**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and review of Resident Identifier (RI) #202's medical record, the facility's policy titled Abuse, Neglect, Misappropriation, Exploitation Policy and the facility's investigation file, the facility failed to ensure Employee Identifier (EI) #7, a Nurse Aide (NA) did not mentally abuse RI #202 on 2/21/2021. This deficient practice affected RI #202; one of four residents reviewed for abuse. Findings include: The facility's policy titled, Abuse, Neglect, Misappropriation, Exploitation Policy dated January 2019, documented Purpose: To prohibit and prevent abuse . Definitions: Abuse: The willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish . It includes . mental abuse . Willful, as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm . Mental Abuse: is the use of verbal or nonverbal conduct which causes or has the potential to cause the resident to experience humiliation, intimidation, fear, shame, agitation, or degradation . On 2/22/2021, the facility reported an allegation of mental abuse to the State Survey Agency. According to the report, (RI #202) reported on 02/22/2021 at 12:45pm that yesterday nurse aide (EI #7) made comments about (his/her) (spouse) seeing another (man/woman). Resident stated it upset (him/her) and (he/she) was unable to sleep last night, but was feeling much better at the time. (He/She) stated it embarrassed (him/her). The facility's investigation summary signed by EI #1, the facility's Administrator, documented (RI #202) stated the day before at the resident smoke break that (EI #7) Nurse Aide saw (his/her) (spouse) and best friend come to the facility. (RI #202) said (EI #7) stated to (him/her) Are you sure they aren't f ing. (RI #202) said she (EI #7) embarrassed (him/her) in front of the other residents and (he/she) could not sleep because of the comment she (EI #7)made. (EI #7) was interviewed and stated that she did ask (RI #202) if (his/her) (spouse) was sleeping with (his/her) best friend. I asked (EI #7) if she used the word sleeping and she admitted that no she used the f word. She stated that she was just joking with (RI #202) and later apologized. I am substantiating abuse in this matter. (EI #7) will be terminated . RI #202 was admitted to the facility on [DATE]. In an interview on 6/2/2021 at 9:07 AM, RI #202 was asked what happened involving EI #7 on 2/21/2021. RI #202 stated, We were all in the front lobby because we were going to go out and smoke and my (spouse) pulled up out front to bring me some clothes and one of my good friends rode with (spouse). Out of the blue (EI #7), one of the aide, said out loud, Are they fucking?, and I said no and left. When asked how the resident felt about what EI #7 said, RI #202 said It embarrassed me in front of the friends that I had made in the facility because I didn't want them to think something like that was going on. According to RI #202, the resident could not sleep night, but after that he/she shrugged it off because he/she knew it wasn't true. In a telephone interview on 6/3/2021 at 9:38 AM, EI #7, a NA was asked what she could recall about an incident that occurred on 2/21/2021 with RI #202. EI #7 stated she doesn't know why she said it, it was stupid thing to say and she now knows that she should not have said it. During an interview on 6/3/2021 at 5:00 PM, EI #1, the Administrator was asked about the incident between RI #202 and EI #7. EI #1 stated they were at the front door and RI #202's spouse came to the facility. EI #7 looked at RI #202 and asked the resident how long has your spouse been fucking your friend. RI #202 didn't respond, but was embarrassed. EI #7 stated she knew it embarrassed RI #202 and later apologized. The resident didn't report it to anyone when it occurred, but finally told someone the next day. When asked if she felt occurred was abuse, EI #1 said yes mental abuse due it embarrassing the resident. ************************* Once the facility became aware of the allegation of mental abuse, the following corrective actions were taken: EI #7 was suspended and not allowed back to work pending the investigation findings. EI #7's employment with the facility was terminated on 3/1/2021. The facility timely reported the allegation and the subsequent findings to the State Survey Agency, the facility's Medical Director and RI #202's representative. RI #202 was assessed by the licensed nursing staff. Beginning 2/23/2021 until 3/14/2021, the facility conducted staff in-service regarding Diversicare Service Standards How to Talk to a Resident ************************* After review of the facility's investigation file, in-service/education records, staff and resident interviews, the facility implemented corrective actions from 2/22/2021 to 3/14/2021; thus past noncompliance was cited. This deficiency was cited as a result of the investigation of complaint/report number AL00041258.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and review of Potter and [NAME] Clinical Nursing Skills and Techniques, the facility failed to ensure: 1.) a licensed nurse administering medications washed her hands or used hand sanitizer between each resident during medication administration, this affected Resident Identifier (RI) #81 and RI #95, and 2.) a licensed nurse did not place gloves and a plastic bag containing RI #87's nasal spray on a potentially contaminated surface without a barrier prior to applying the gloves to administer RI #87's nasal spray and placing the plastic bag back into the medication cart. These deficient practices affected three of seven residents observed during medication administration. Findings include: 1.) A review of Potter and [NAME] Clinical Nursing Skills and Techniques, 8th Edition, Chapter 7, pages 168 and 169 revealed, .Hand Hygiene .The most important and basic technique in preventing and controlling transmission of infection is hand hygiene. Hand hygiene is a general term that applies to handwashing, . antiseptic hand rub, . Follow these guidelines for hand hygiene .: 1. Wash hands with either plain soap and water or an antibacterial soap and water when hands are visibly dirty, . 3. If hands are not visibly soiled, use an alcohol-based hand rub for routinely decontaminating hands in the following clinical situations: a. Before and after having direct contact with patients. f. After contact with inanimate objects . in the immediate vicinity of the patient . On 6/2/21 at 4:53 PM, during observation of medication administration with Employee Identifier (EI) #5, a Registered Nurse (RN), the surveyor entered RI #81's room with EI #5. The surveyor observed RI #81 standing up in front of a wheelchair. EI #5 touched the wheelchair and RI #81's right arm to assist RI #81 to sit in the wheelchair. When RI #81 was sitting, EI #5 administered medications and held a cup of water for RI #81 to drink from. EI #5 placed the cup of water on RI #81's bedside table and returned to the medication cart and threw the medication cup out at the medication cart. EI #5 did not wash her hands or cleanse hands with hand sanitizer. EI #5 then touched her pen, touched the computer mouse, unlocked the medication cart and prepared medications for RI #95 by dispensing medications into a medication cup. EI #5 then poured RI #95 a cup of water, touching the paper cup, water pitcher and a wrapped straw. EI #5 unwrapped the straw and touched the center of the straw and put the straw in the cup of water for RI #95. EI #5 and the surveyor entered RI #95's room. EI #5 placed the medication cup containing medications on the bedside table. Touching the bedside table EI #5 moved the table out of the way, elevated the head of the bed by using the remote attached to the bed rail. Touching RI #95's medication cup EI #5 administered the medications, touched the cup of water, held the straw with her bare hands, gave RI #95 a drink of water, lowered the head of the bed using the bed remote, returned to the medication cart, touched her pen, touched the computer mouse, all without washing her hands or using hand sanitizer. On 6/2/21 at 5:04 PM, an interview was conducted with EI #5. EI #5 was asked, when she finished giving medications to RI #81, what did she forget to do. EI #5 replied, she did not know. EI #5 was asked, when did she wash her hands or use hand sanitizer. EI #5 replied, she used hand sanitizer before she gave medications to RI #81 and that she washed her hands after every third resident. EI #5 was asked, how often did she wash her hands during medication administration. EI #5 replied, it depended on if she was wearing gloves and she would wash her hands after removing gloves. EI #5 was asked, when should she use hand sanitizer during medication administration. EI #5 replied, she would use hand sanitizer after every third resident or if she came in contact with a surface they had touched, like a water cup or medication cup. EI #5 was asked, when did RI #81 have contact with the water cup or medication cup. EI #5 replied, RI #81's lips touched the top of cup but she had touched the bottom of the cup. EI #5 was asked, how she handled RI #95's cup. EI #5 replied, she held the cup and straw and held the bottom of the cup. EI #5 was asked, when was handwashing indicated. EI #5 replied, before starting her shift, anytime she came in contact with something contaminated, after every third resident, if visibly soiled, before eating and after using the restroom. EI #5 was asked, what did she touch in RI #81's room that was contaminated. EI #5 replied, the wheelchair. EI #5 was asked, what did she touch that was contaminated in RI #95's room. EI #5 replied, she moved the bedside table and touched the bed control. EI #5 was asked when should she have washed her hands or used hand sanitizer. EI #5 replied, after RI #81 and before RI #95 and then after RI #95. On 6/3/21 at 8:36 AM, an interview was conducted with EI #3, the Infection Preventionist/Clinical Educator. EI #3 was asked, when was hand hygiene indicated. EI #3 replied, when coming into the building, before entering a resident room, anytime hands were visibly soiled, after touching something contaminated and after providing care. EI #3 was asked, when should a nurse perform hand hygiene during medication administration. EI #3 replied, before entering the room and after administering medications. EI #3 was asked, when should a nurse perform hand hygiene between every third resident during medication administration. EI #3 replied, as long as they don't touch anything and use hand sanitizer in between each resident. EI #3 was asked, why would a nurse not perform hand hygiene between each resident during medication administration. EI #3 replied, they should use hand sanitizer between each resident. EI #3 was asked, when are hands considered contaminated. EI #3 replied, if visibly soiled or if anything in a resident's room or a resident is touched. EI #3 was asked, what should nurses do when their hands become contaminated. EI #3 replied, wash their hands. EI #3 was asked, what should nurses use to sanitized their hands with between residents during medication observation. EI #3 replied, hand sanitizer. EI #3 was asked, what was the risk to the residents when contaminated hands were not cleansed between residents. EI #3 replied, cross contamination and spread of infection. 2.) A review of POTTER AND [NAME], FUNDAMENTALS OF NURSING, NINTH EDITION, UNIT V Foundations for Nursing Practice, CHAPTER 32 Medication Administration, page 632, documented: . Correct Administration.Use aseptic technique and proper procedures when handling and giving medications . On 6/3/21 at 8:00 AM during medication administration, EI #6, a Licensed Practical Nurse (LPN), was observed placing gloves and a plastic bag containing nasal spray on RI #87's overbed table, a potentially contaminated surface, next to RI #87's breakfast tray. EI #6 picked the gloves up off the table and applied them to administer RI #87's nasal spray. She placed the nasal spray back into the plastic bag, returned to the medication cart and placed the nasal spray in the bottom drawer without wiping off the plastic bag. In an interview on 6/3/21 at 3:37 PM, EI #6, LPN, was asked what was important when she used gloves to administer medications. EI #6 stated to place a barrier on the table before laying the gloves down. EI #6 was asked where she placed her gloves when she entered RI #87's room. EI #6 said on RI #87's bedside table. EI #6 was asked if she placed a barrier before she put the gloves on the table. EI #6 replied no. EI #6 was asked should she have placed a barrier. EI #6 said yes. EI #6 was asked where she placed RI #87's nasal spray. EI #6 stated, on RI #87's table in a plastic bag. EI #6 was asked what was the concern with placing items to be used during medication administration on a potentially contaminated surface prior to use. EI #6 said it contaminated the items and she may transfer viruses or bacteria to the resident. EI #6 was asked what she did when she took the nasal spray back to the medication cart. EI #6 stated, placed it in the bottom drawer. EI #6 was asked if she wiped the bag off before she placed it back in the drawer. EI #6 said no. EI #6 was asked should she have wiped off the bag. EI #6 stated yes, because it had been on the bedside table. EI #6 was asked what was the concern with those things. EI #6 said, infection control. On 6/3/21 at 4:03 PM an interview was conducted with EI #1, Registered Nurse (RN)/Administrator. EI #1 was asked where should gloves be placed prior to use during medication administration. EI #1 said there should be a barrier put down and the gloves placed on the barrier. EI #1 was asked should gloves be laid on an overbed table without a barrier prior to applying them to administer nasal spray. EI #1 replied no. EI #1 was asked why not. EI #1 said, cross-contamination. EI #1 was asked should a plastic bag containing nasal spray be placed on an overbed table without a barrier and then returned to the medication cart. EI #1 said no. EI #1 was asked why. EI #1 stated the bag should be cleaned with a bleach wipe first or the bag should be changed. EI #1 was asked why. EI #1 said, to avoid cross-contamination to other items in the medication drawer. EI #1 was asked what was the concern with those things occurring during medication administration. EI #1 stated, infection control.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, record review, and review of a facility policy titled, Daily Clinical Start-Up Process, the facility failed to ensure an order for the use and care of a urinary Foley catheter was obtained for Resident Identifier (RI) #98 upon admission to the facility on [DATE] and readmission on [DATE]. This affected RI #98, one of two residents for whom catheter admission orders were reviewed. Findings Include: A review of a facility policy titled, Daily Clinical Start-Up Process, dated February 2019, revealed the following: . Purpose . Ensure communication to physicians . is in place . Ensure documentation is thorough and reflective of care delivered . Items to review daily: . All new admission and re-admission documentation is reviewed including: Physician orders reviewed for transcription accuracy . RI #98 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included Obstructive and Reflux Uropathy, unspecified and Bladder-neck Obstruction A review of RI #98's baseline care plan, dated 12/4/19, revealed the following: . 7. Special Treatments/Procedures g. Catheter . Resident admitted . from home .Foley cath (catheter) . intact . A review of RI # 98's comprehensive care plan, dated 12/12/19, revealed the following: . I have a Foley cath r/t (related to) bladder neck obstruction . However, review of RI #98's Physician's Orders for December 2019, January 2020 and February 2020, revealed no orders for the use and care of a urinary Foley catheter for RI #98. On 2/5/20 at 4:00 PM, the surveyor observed RI #98 with a catheter. On 2/5/20 at 4:59 PM, an interview was conducted with Employee Identifier (EI) #2, Registered Nurse (RN), Director of Nursing (DON). EI #2 was asked if RI #98 had a catheter. EI #2 stated yes. EI #2 was asked if RI #98 had a physician's order for the catheter. EI #2 replied that she did not see a current order. EI #2 was asked if RI #98 was admitted to the facility with a catheter. EI #2 replied yes, RI #98 was admitted on [DATE] and readmitted on [DATE] with a Foley catheter. When asked why there was not an order for the catheter, EI #2 said the order was missed on admission and readmission. EI #2 was asked what was the potential negative outcome of not having an order for a catheter. EI #2 stated resident possibly not receiving the care that was needed.