**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to ensure three (#86, #48 and #93) of six residents reviewed for abuse out of 35 sample residents were free from abuse. Specially, the facility failed to: -Protect Resident #48 from physical abuse by Resident #86; -Protect Resident #86 from physical abuse by Resident #48; and, -Protect Resident #93 from physical abuse by Resident #84. Findings include: I. Facility policy and procedure The Abuse Prevention policy, revised 6/17/24, was received from the nursing home administrator (NHA) on 5/1/25 at 11:15 a.m. It read in pertinent part, The facility must develop and implement written policies and procedures that identify, assess, and care plan for appropriate interventions, and monitor residents with needs and behaviors which might lead to conflict or neglect such as verbally aggressive behavior, physically aggressive behavior, sexually aggressive behavior, taking, touching, or rummaging through other's property, or wandering into other rooms/space. II. Incidents of physical abuse between Residents #86 and #48 A. Facility investigation of physical abuse on 2/18/25 The 2/18/25 facility investigation documented a nurse, who was at the nurses' station, heard yelling. The nurse came out of the nurses' station and witnessed Resident #48 sitting in the doorway of Resident #86's room. Resident #86 and Resident #48 had grabbed each other's shirts and were slapping each other on the forearms, open handed. The two residents were separated by staff and assessed for injuries and no injuries were noted. When interviewed by staff, Resident #86 recalled being involved in a negative interaction with another resident but thought that it may have been a male resident. Resident #48 could not recall the event when interviewed. The residents resided on the same secured unit of the facility. Resident #48 was provided a one-on-one caregiver for 72-hours, a medication review was requested and a room move to another unit was completed, per the facility reported incident. The facility unsubstantiated the abuse investigation due to the residents' cognitive impairments. -However, abuse occurred due to Resident #86 and Resident #48 being observed slapping each other. B. Facility investigation of physical abuse on 2/19/25 The 2/19/25 incident investigation documented an altercation occurred between Resident #86 and Resident #48 in the hallway of the secured unit that both of the residents resided on. Resident #48 had been assigned a one-on-one caregiver for supervision after the incident between Resident #86 and Resident #48 on 2/18/25. The one-on-one caregiver took a break and advised the nurse on shift. However, the nurse did not find a replacement to supervise Resident #48, while the one-on-one caregiver took a break. When the nurse looked up from the desk at the nurses' station, she observed Resident #86 pushing Resident #48 in her wheelchair down the hallway. The nurse called for another staff member to come and assist. Before the other staff member or nurse could intervene, Resident #48 swung her arm back and punched Resident #86 in the back causing her to fall. The two residents were separated by staff and assessed for injuries. Resident #86 had redness to her knees and elbows. When interviewed by staff, Resident #86 recalled falling down and hitting her elbow and knee but could not recall further details. Resident #48 could not recall the event when interviewed. The residents resided on the same secured unit of the facility. Resident #48 was to continue with the one-on-one caregiver for 72-hours and to be moved to another unit within the facility. The staff were provided education on intervening promptly to possible altercations between residents. -The investigation did not indicate the staff were provided education regarding not leaving a resident who was required to have a one-on-one unsupervised. The investigation documented abuse was substantiated. C. Resident #86 (victim and assailant) 1. Resident status Resident #86, age [AGE], was admitted on [DATE]. According to the May 2025 computerized physician orders (CPO), diagnoses included unspecified dementia with mood disturbance. The 3/19/25 minimum data set (MDS) assessment documented Resident #86 had severe cognitive impairments with a brief interview of mental status (BIMS) score of four out of 15. She ambulated without a wheelchair or walker. She required one-person moderate assistance with showers, dressing and personal hygiene. The MDS assessment indicated Resident #86 had behaviors of being physically abusive, verbally abusive, and behaviors not directed at others, which included physical symptoms such as scratching self, pacing, smearing bodily fluids or food, disrobing, public sexual acts, screaming, or distruptive sounds. 2. Record review Resident #86's elopement care plan, revised 9/18/24, revealed she was at risk for elopement related to verbalizations of wanting to leave the facility and would wander into other residents' rooms. Interventions included providing the resident with structured activities such as toileting, walking inside and outside, or reorientation strategies including signs, pictures and memory boxes. Resident #86's behavior care plan, initiated 9/24/24, revealed she used antipsychotic medications for behavior management. Interventions, initiated 9/24/24, included providing non-pharmacological interventions such as active listening, offering a snack or drink, providing positive distraction, reassurance of safety and reapproaching and assisting to a quiet area. Resident #86's mood care plan, revised 2/21/25, revealed she was at risk for changes in mood. She would often take things from various locations on the unit or from other residents or their rooms. Resident #86 would claim the items were hers and could be verbally and physically aggressive towards staff and other residents. Interventions, initiated 2/21/25, included providing physical and verbal cues to alleviate anxiety, giving positive feedback, assisting with encouraging verbalization of the source of her agitation, assisting to set goals for more pleasant behavior, and encouraging her to seek out staff members when agitated. -Review of the resident's comprehensive care plan did not indicate the facility implemented person-centered interventions after the resident was involved in two resident-to-resident altercations. Review of Resident #86's electronic medical record (EMR) from 1/1/25 to 2/19/25 revealed the resident had a history of wandering into other residents' rooms. An event note, dated 2/18/25, revealed Resident #86 had been the victim in an altercation with Resident #48. Resident #86 and Resident #48 were separated by staff and assessed for injuries and no injuries were noted. An event note, dated 2/19/25, revealed Resident #86 had been the victim in an altercation with Resident #48. Resident #48 was to have a one-on-one caregiver and at the time, the caregiver had gone on a break and notified the nurse. The nurse failed to replace the one-on-one caregiver. The nurse looked up from the nurses' station and observed Resident #86 pushing Resident #48's wheelchair down the hallway. Before the nurse could intervene, Resident #48 turned and punched Resident #86 in the back, causing Resident #86 to fall. The residents were separated and assessed for injuries. Resident #86 had redness to her knee and elbow. D. Resident #48 (victim and assailant) 1. Resident status Resident #48, age greater than 65, was admitted on [DATE]. According to the May 2025 CPO, diagnoses included unspecified dementia and depression. The 1/29/25 MDS assessment revealed Resident #48 had severe cognitive impairments with a BIMS score of five out of 15. She had verbal aggression and behaviors not directed at others such as physical symptoms such as scratching self, pacing, smearing bodily fluids or food, disrobing, public sexual acts, screaming, or distruptive sounds. Her behaviors impacted her ability to receive care, socialize and participate in activities. Resident #48 required a wheelchair for mobility and required one-person maximum assistance with toileting and bathing. 2. Record review The behavior care plan, revised 12/17/24, revealed Resident #48 used antipsychotic medications for behavior management. Interventions, initiated 12/17/24, included providing non-pharmacological interventions such as active listening, offering the resident a snack or drink, providing positive distraction, providing reassurance of safety, reapproaching and assisting the resident to a quiet area. The mood care plan, revised 2/21/25, revealed Resident #48 had a diagnosis of unspecified dementia with mood disturbance. She struggled at times with excessive tearfulness, increased isolation and changes in mood and appetite. Resident #48 was verbally aggressive and paranoid towards others. She could be territorial of her room and the area around her and would sit in other residents' doorways. Resident #48 presented with delusions and hallucinations and physical aggression towards others such as grabbing and hitting others. Interventions, initiated 2/24/25, included redirecting her to the activities room, offering for the resident to listen to Elvis music and providing coloring or crossword puzzles. -Review of Resident #48's comprehensive care plan did not indicate the resident had been involved in a resident-to-resident altercation. An event note, dated 2/18/25, revealed the director of nursing (DON) was called to the unit by the floor nurse due to an altercation between two residents. The incident occurred in the hallway where Resident #48 and another resident (Resident #86) were observed to be pulling on each other's sleeves and slapping each other on the forearms open handed. The two residents were separated. A behavior note, dated 2/19/25, revealed Resident #48 had been put on one-on-one supervision. A physician note, dated 2/19/25, revealed if behaviors persisted, the physician would increase Resident #48's antipsychotic medication again. A communication note, dated 2/19/25, revealed the DON advised the responsible party that Resident #48 would be moved to another unit again due to the altercation. III. Resident to resident physical altercation by Residents #84 towards and Resident #93 A. Facility investigation of physical abuse by Resident #84 towards Resident #93 The 3/24/25 facility investigation documented the altercation occurred in Resident #84's room. Both Resident #93 and Resident #84 resided in the secured unit. The staff heard yelling coming from Resident #84's room and upon entering the room, the staff observed Resident #84 standing over Resident #93 who was lying on the floor. The two residents were separated and assessed for injuries. Resident #93 sustained a scratch to the right side of his eye, redness to the right side of his face, a cut to his bottom lip and bumps to the forehead and the back of his head. When interviewed by staff, Resident #93 could not recall the event and said something hit his face. When interviewed, Resident #84 initially denied hitting Resident #93, but eventually admitted to hitting him in the face because Resident #93 had wandered into his room and touched Resident #84's belongings. Resident #84 was provided a one-on-one caregiver for 72-hours and moved rooms to another unit. The facility substantiated the abuse investigation. B. Resident #93 (victim) 1. Resident status Resident #93, age [AGE], was admitted on [DATE]. According to the May2025 CPO, diagnoses included unspecified dementia with behavioral disturbances. The 4/9/25 MDS assessment revealed Resident #93 had severe cognitive impairments with a BIMS score of three out of 15. He ambulated without a wheelchair or walker. He required one-person maximum assistance with shower, dressing and personal hygiene. The MDS assessment indicated Resident #93 had behaviors of being physically abusive, wandering, and behaviors not directed at others such as physical symptoms such as scratching self, pacing, smearing bodily fluids or food, disrobing, public sexual acts, screaming, or distruptive sounds. 2. Record review The elopement care plan, revised 3/27/25, revealed Resident #93 would often wander into other resident's rooms to use their bathroom, relieve himself on their floor or touch their personal belongings. Resident #93 had made attempts to break windows in order to climb out of them. The care plan documented at times, he could be redirected easily and other times, Resident #93 could become aggressive, both verbally and physically towards staff. Interventions, initiated 3/27/25, included providing Resident #93 with activities or objects to help keep him busy to prevent him from touching others belongings. The behavior care plan, initiated 8/24/24, revealed Resident #93 used antipsychotic medications for behavior management. Interventions, initiated 8/24/24, included providing non-pharmacological interventions such as active listening, offer snack or drink, provide positive distraction, offering reassurance of safety, helping the resident become more comfortable by assessing physical needs, offering validation, assisting with difficult tasks, assisting to a quiet area, providing the resident with a distracting conversation by talking about interest, and reapproaching the resident. -The care plan did not document the resident was a victim of a resident-to-resident altercation on 3/24/25. Review of Resident #93's EMR from 3/1//25 to 4/29/25 revealed the following progress notes: An event note, dated 3/24/25, revealed the staff heard a loud noise and immediately went to the room where staff observed Resident #93 kneeling on the floor with one hand holding the heater on the wall trying to get up. The nurse did a head to toe assessment and observed a scratch to the right side of the resident's eye that was 0.3 centimeters (cm) by 0.1 cm, redness to the right and left side of the resident's cheek bone area, a cut to the left eye that was 1 cm by 0.1 cm, a cut to the resident's bottom lip that was 0.2 cm by 0.2 cm, a bump to the forehead that was 2 cm by 1.5cm and a bump to the back of the resident's head that was 3 cm by 2 cm and blood was coming out from the lip. Both residents were immediately separated. -The note did not document how Resident #93 sustained the injuries. C. Resident #84 (assailant) 1. Resident status Resident #84, age [AGE], was admitted on [DATE]. According to the May 2025 CPO, diagnoses included unspecified dementia with psychotic disturbances, delusional disorder, alcohol abuse and anxiety. The 2/5/25 MDS assessment revealed Resident #84 had severe cognitive impairments with a BIMS score of seven out of 15. He ambulated without a wheelchair or walker and was independent in his activities of daily living. The MDS assessment indicated Resident #84 had behaviors of being verbally abusive, wandering, and behaviors not directed at others such as physical symptoms such as scratching self, pacing, smearing bodily fluids or food, disrobing, public sexual acts, screaming or distruptive sounds. 2. Record review The behavior care plan, revised 11/8/24, revealed Resident #84 used antipsychotic medications for behavior management. Interventions, initiated 12/16/24, included non-pharmacological interventions such as active listening, offering snack or drink, positive distraction, reassurance of safety, reapproach, and assist to a quiet area. The mood care plan, revised 3/27/25, revealed Resident #84 had a diagnosis of dementia with psychotic disturbance and had a history of alcohol abuse. He struggled with paranoid thoughts regarding his brother and former girlfriend stealing from him. Resident #84 could become agitated and frustrated with staff when paranoid, causing him to become aggressive. Resident #84 would perseverate on objects and other residents. He enjoyed doing arts, crafts, and coloring but could become physically aggressive if others touched his art supplies or belongings. Resident #84 would become agitated and aggressive when others entered his room uninvited. Interventions, initiated 11/8/24, included assessing his understanding of the situation and allowing time to express self and feelings towards the situation. -Review of Resident #84's comprehensive care plan did not indicate the resident had been involved in a resident-to-resident altercation on 3/24/25. An event note, dated 3/24/25, revealed the DON was called to Resident #84's unit. Resident #84 was sitting on his bed in his room and told the DON he was not doing alright. He told the DON that he punched another resident (Resident #93) in the mouth because he came into his room and touched his belongings. Resident #84 was moved to a different unit and a one-on-one caregiver for 72-hours was put into place. V. Staff interviews Certified nurse aide (CNA) #2 was interviewed on 4/30/25 at 9:18 a.m. CNA #2 said Resident #86 had behaviors of thinking everyone else had her belongings. She said Resident #86 could be redirected to her room. CNA #2 said Resident #48 did not have behaviors and did not have physical aggression towards staff or other residents. Licensed practical nurse (LPN) #2 was interviewed on 4/30/25 at 9:25 a.m. LPN #2 said Resident #48 had behaviors of becoming tearful and confused but did not have behaviors of aggression towards staff or other residents. She said she did not know why Resident #48 was moved to her current unit. LPN #2 said she was not aware of any behaviors for Resident #86 except wandering. CNA #3 was interviewed on 4/30/25 at 1:49 p.m. She said the CNAs did not have access to the residents' care plans. She said the CNA behavior monitoring task displayed a list of generic, template behaviors to choose from and a list of generic, template interventions to choose from. She said the CNAs were unable to personalize the behaviors or interventions when documenting. CNA #3 said if the resident had a specific behavior or an individualized intervention that was not included in the generic list, the CNAs did their best to select an appropriate choice. CNA #3 said Resident #84 had moved around the building to different units because of behavioral issues or because he did not get along with his roommates. CNA #3 said Resident #84 had behaviors of agitation, paranoia and delusions regarding people stealing from him or items being missing. She said the non-pharmacological interventions that worked were to provide him one-on-one attention in his room to calm down, talk to him about his artwork, or take him outside to color. She said if the CNAs used an intervention like offering coloring, it would be documented as meaningful activity in the behavior monitoring, but there was no way to identify what the meaningful activity was. CNA #3 said she believed Resident #84 had been aggressive toward other residents but she did not know for sure. She said she had observed Resident #84 become agitated if other residents touched his belongings but he was now in a unit where there were less wandering residents going into his room. CNA #3 said Resident #93 had behaviors of wandering and disrobing but he was redirectable by offering him activities of interest to distract him. Registered nurse (RN) #3 was interviewed on 4/30/25 at 2:05 p.m. She said the nurses documented resident behaviors and non-pharmacological interventions attempted in EMR progress notes. RN #3 said the nurses found the resident specific behaviors and interventions in the resident's care plan. She said Resident #84 did not have behaviors of aggression towards staff or other residents. RN #3 said Resident #84 did not like other residents to touch his belongings but he was redirectable. RN #3 said she was not aware of why Resident #84 was moved to his current unit. The DON and the social services director (SSD) were interviewed together on 5/1/25 at 2:00 p.m. The SSD said the residents' individualized behaviors and resident specific non-pharmacological interventions were located in the resident care plan and the nurses were expected to look there for the information. The DON said the process for the nurses to apply interventions for resident behaviors were to first attempt standard, non-specific interventions such as redirecting, offering food or fluids or taking the resident to activities. She said if those interventions were unsuccessful, the nurse would then look at the resident's care plan for the identified resident specific interventions. The SSD said the method described by the DON had the potential to cause residents to escalate if the identified interventions were not tried first. She said the resident specific interventions in the care plan were developed with the assistance of the residents' families and the use of the residents' history in order to mitigate negative behaviors. The DON said the immediate interventions for the altercation between Resident #48 and the Resident #86 on 2/18/25 were to implement a one-on-one caregiver and move Resident #48's room. She said the CNA providing the one-on-one supervision went on her lunch break and advised the nurse she was leaving. The DON said the nurse failed to implement a replacement one-on-one staff member and instead, the nurse was going to keep Resident #48 in her line of sight. The DON said the expectation was to replace the CNA with another dedicated one-on-one caregiver and she did not know why the nurse chose not to follow that process. The DON and the SSD said they did not know why Resident #48 had not been moved on 2/18/25, as it was recommended by the facility after the altercation. The DON and the SSD said Resident #48 remained on the same unit as Resident #86 (the victim), providing an opportunity to attack Resident #86 a second time on 2/19/25. The DON said, other than moving units and 72-hour one-on-one supervision, no additional interventions or training were provided to the staff to ensure the residents were safe from abuse. The SSD said after the incident on 3/24/25 between Resident #93 and Resident #84, Resident #84 was moved to a new unit. She said the staff identified he would do better on a unit with residents who did not wander into each other's rooms as often. The SSD said she could not recall what interventions had been used to prevent Resident #93 from wandering into Resident #84's room and avoiding an altercation. The DON said Resident #93 had behaviors of wandering into other residents' rooms but she was not aware of what interventions had been used to prevent Resident #93 from wandering into Resident #84's room and avoiding an altercation.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observations and interviews, the facility failed to ensure that one (#79) of three residents out of 35 sample residents were free from involuntary seclusion and were receiving the least restrictive approach for their needs. Specifically, the facility failed to ensure Residents #79, residing on the secure locked unit, had the required documentation to justify such restrictions including a consent from the resident's responsible party for placement, documentation reflecting secure/locked placement was the least restrictive approach possible. Findings include: I. Facility policy and procedure The Secure Unit policy, revised 1/2/24, was provided by the nursing home administrator (NHA) on 5/1/25 at 11:15 a.m. It read in pertinent part, Upon determination that the resident may benefit from placement on a secure unit, the facility must obtain consent from the resident's representative, as indicated on the Secure Unit Placement, Admission, Evaluation and Authorization form and file that consent in the medical record. The resident's medical record should reflect the following: Documentation of the clinical criteria met for placement in the secure/locked area by the resident's physician, along with information provided by members of the interdisciplinary (IDT) team; Documentation that reflects the resident/representative's involvement in the decision for placement in the secure/locked area; Documentation that reflects whether placement in the secure/locked area is the least restrictive approach that is reasonable to protect the resident and assure his/her health and safety; Documentation by the IDT team of the impact and/or reaction of the resident, if any, regarding placement on the unit; Ongoing documentation over the review and revision of the resident's care plan as necessary, including whether he/she continues to meet criteria for remaining in the secure/locked area, and if interventions continue to meet the needs of the resident. II. Resident #79 A. Resident status Resident #79, age [AGE], was admitted on [DATE]. According to the April 2025 computerized physician orders (CPO), diagnoses included unspecified dementia. The 4/7/25 minimum data set (MDS) assessment documented the resident was cognitively intact with a brief interview of mental status (BIMS) score of 15 out of 15. She did not have behaviors that affected herself or others and she did not have behaviors of wandering. She required a wheelchair for mobility and was unable to walk. The resident required one-person maximum assistance with showering, toileting, dressing, transfers and bed mobility. B. Resident interview Resident #79 was interviewed on 5/1/25 at 9:15 a.m. She said prior to admitting to the facility she lived with her son. She said she asked her son to take her to the emergency room because she was not feeling well. She said she was discharged from the hospital to the facility. She said she did not know why she was at the facility. She said the facility's doors were locked. Resident #79 said she did not have a history of leaving her home or getting lost. She said it was never explained to her why she needed to be in a locked area. She said no one had spoken to her about her interest in discharging to a lower level of care or back to her home with support. Resident #79 said she hated living in the facility and missed her pets, her friends and her neighbors. She said she did not socialize with the other residents within the facility because the other residents did not seem to know how to socialize. Resident #79 said she would like to start a book club, but did not think the other residents could participate. She said she had tried to attend activities, but the activities were not stimulating for her so she stayed in her room. She expressed feelings of sadness because she enjoyed socializing with her friends prior to admission and now had no one to talk to. C. Record review The cognition care plan, initiated 4/8/25, revealed the resident had an impaired cognitive ability or impaired thought processes related to a diagnosis of dementia with short term memory impairment. Interventions initiated on 4/8/25 included administering medications as ordered, allowing the resident extra time to respond to questions and instructions, and asking the resident yes or no questions. -The care plan did not include a focus for secure unit placement. The April 2025 CPO revealed the following physician orders: Admit to skilled insurance services on 4/6/25. A brief cognitive assessment tool (BCAT) examination for memory and cognitive functioning was conducted at the facility with the resident on 4/7/25. Her score reflected mild stage dementia with no deficits in the areas of verbal recall, visual recognition, abstraction, or language. Progress notes were reviewed from 4/6/25 to 5/1/25 revealed: A physician note, dated 4/7/25, revealed the resident admitted to the facility for a gastrointestinal hemorrhage and was to receive physical and occupational therapy. Her judgment and insight were fair and she had a diagnosis of cognitive impairments but the physician noted, the resident did not have a diagnosis of dementia. A psychosocial note, dated 4/7/25, revealed a baseline care plan meeting had been held with the family but the resident was not included. The decision was made that the resident would transition to long term care after her therapy services ended. A behavior note, dated 4/11/25, revealed the resident was tearful and expressed that she was ready to go home. A psychosocial note, dated 4/16/25, revealed there had been a care conference meeting with the family on 4/16/25. The note documented the resident had not been invited to attend. -Review of Resident #79's electronic medical record (EMR) did not reveal any further documentation that indicated the resident had exit seeking behaviors or least restrictive alternatives were attempted and failed. On 4/30/25 at 11:26 a.m. documentation indicating a consent form was completed by the resident or her responsible party for placement on a secure unit and an initial evaluation for the necessity for secure unit placement was requested from the NHA. An email was received from the unit manager (UM) on 5/1/25 at 6:24 p.m. It revealed the facility did not have a consent or an evaluation for Resident #79's placement in a secure/locked facility. III. Staff interviews Certified nursing assistant (CNA) #4 was interviewed on 5/1/25 at 9:25 a.m. She said Resident #79 did not have any exit-seeking behaviors. CNA #4 said the resident did not show behaviors of elopement attempts, interest in exiting the facility or attempting to enter other residents' rooms. Licensed practical nurse (LPN) #2 was interviewed on 5/1/25 at 9:42 a.m. Resident #79 did not show behaviors of elopement attempts, interest in exiting the facility, or attempting to enter other residents' rooms. She said the resident primarily stayed in her room but appeared sad and tearful. LPN #2 said she did not know why the resident was sad. The director of nursing (DON) and the social services director (SSD) were interviewed together on 5/1/25 at 2:00 p.m. The SSD said the process to evaluate the appropriateness of the residents for admission and continued stay in a locked facility involved the initial review of the referral. The SSD said she looked for a history of behaviors of wandering, elopement, or getting lost in the community. She said the criteria to remain in the facility was to have a diagnosis of dementia and to be at risk for leaving the facility. The SSD said the facility's evaluation process for continued stay did not include record review, staff interviews, or an assessment for the appropriateness of remaining in a secure/locked facility but the process should include these things. She said she was not sure why Resident #79 was admitted and remained in the facility. The DON said she thought if the resident had a diagnosis of dementia and the family wanted the resident placed in the facility, that was enough justification to admit the resident. The DON was unaware once a resident was admitted , if they did not exhibit behaviors of wandering or elopement attempts, the resident should be considered for discharge to a less restrictive environment. She said she could not explain why Resident #79 was admitted and remained in the facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and interviews, the facility failed to ensure one (#57) of two residents out of 35 sample residents received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan. Specifically, the facility failed to ensure staff provided wound care per physician's order for Resident #57. Findings include: I. Facility policy The Physician Orders policy, revised February 2024, was provided by the nursing home administrator (NHA) on 5/1/25 at 10:46 a.m. It read in pertinent part, A physician must personally approve in writing a recommendation that an individual be admitted to the facility. A physician, physician assistant or nurse practitioner must provide orders for the resident's immediate care and ongoing care of the resident. The facility is obligated to follow and carry out the orders of the prescriber in accordance with all applicable state and federal guidelines. Orders must be authenticated, signed and dated, by the provider who gave the order. Signatures may be manual or electronic and may be accepted if faxed. II. Resident #57 A. Resident status Resident #57, age greater than 65, was admitted on [DATE]. According to the April 2025 computerized physician orders (CPO), diagnoses included moderate unspecified dementia (cognitive decline) with mood disturbance, unspecified protein-calorie malnutrition, generalized muscle weakness, Stage 3 pressure ulcer of the sacral region and need for assistance with personal care. The 3/26/25 minimum data set (MDS) assessment revealed the resident had severe cognitive impairment with a brief interview for mental status (BIMS) score of four out of 15. She required partial assistance with bed mobility and transfers. She required substantial assistance with personal and toileting hygiene and showering. She was frequently incontinent of bowel and bladder, and she was at risk for developing pressure ulcers/injuries. B. Observations During a continuous observation on 4/29/25, beginning at 1:40 p.m. and ending at 1:55 p.m., the following was observed: The facility's wound care nurse (WCN) prepared to do wound care for Resident #57. She verified the resident's wound care orders by checking the physician's orders listed in the resident's electronic medical record (EMR). She went to the unit's medication storage room and removed a zip lock bag from a storage cart. The bag was labeled with Resident #57's name and contained the resident's specific wound care supplies. The WCN said she put the wound care supply bags together for staff to use when needed. The WCN said Resident #57's wound orders included applying Medihoney gel (a moist antibacterial dressing) to the resident's sacral wound daily, and as needed if the dressing was soiled. The WCN revealed that Medihoney gel was in Resident #57's wound care supply bag. The WCN attempted to perform wound care on Resident #57 using the wound care supplies in the zip lock bag, however, the resident was too sleepy and the WCN said she would re-attempt the wound care dressing change later in the afternoon (on 4/29/25). C. Record review A review of Resident #57's April 2025 CPO revealed the following physician's order for wound care: Cleanse wound with wound cleanser, apply Medihoney to wound on coccyx, then cover with bordered gauze, daily in the afternoon, ordered 4/2/25. Review of Resident #57's wound care physician (WCP) visit notes revealed the following: The 4/8/25 WCP visit note, revealed the WCP discontinued Resident #57's daily Medihoney dressings, and changed the wound treatment order to calcium alginate with silver dressing (a highly absorbent antibacterial dressing) once daily for 30 days. The 4/16/25 WCP visit note documented to continue applying calcium alginate with silver dressing to Resident #57's sacral pressure wound. The 4/23/25 WCP visit note documented to continue applying calcium alginate with silver dressing to Resident #57's sacral pressure wound. -However, a review of the April 2025 CPO revealed Resident #57's wound care orders were not updated to reflect the wound care dressing change ordered on 4/8/25 or after the subsequent WCP visits on 4/16/25 and 4/23/25 (see physician's order above) A review of Resident #57's April 2025 medication administration record (MAR) revealed Medihoney gel was applied to the resident's sacral pressure wound on the following dates: 4/9/25, 4/10/25, 4/11/25, 4/12/25, 4/13/25, 4/14/25, 4/15/25, 4/16/25, 4/17/25, 4/18/25, 4/20/25, 4/21/25, 4/22/25, 4/23/25, 4/24/25, 4/25/25, 4/26/25, 4/27/25, 4/28/25, 4/29/25, and 4/30/25. -There was no documentation on 4/19/25 to indicate a treatment to the sacral pressure wound was completed. -However, the WCP visit notes indicated the WCP discontinued the Medihoney gel treatment order on 4/8/25 (see WCP visit notes above). III. Staff interviews The WCN was interviewed on 5/1/25 at 8:58 a.m. The WCN said she was primarily responsible for providing wound care to residents and entering/updating wound care orders in the residents' EMRs. The WCN said she would access the WCP's EMR portal, download his wound care visit notes and make any necessary changes to the physician's orders. Registered nurse (RN) #1 was interviewed on 5/1/25 at 10:21 a.m. RN #1 said the WCN was primarily responsible for obtaining wound care orders and putting them into the residents' EMRs. RN #1 said she would verify a resident's wound orders by contacting the WCN and asking if the physician's orders in the EMR were accurate or if any changes were made. The WCN was interviewed a second time on 5/1/25 at 10:56 a.m. The WCN removed Resident #57's wound care supply bag from the medication storage room. The WCN confirmed Medihoney gel was in Resident #57's wound care supply bag. The WCN reviewed the treatment plan from Resident #57's 4/8/25 WCP visit note. She confirmed the wound care orders indicated to add calcium alginate with silver dressings and discontinue the Medihoney gel. The WCN confirmed that facility staff were still applying Medihoney gel to Resident #57's sacral pressure injury, instead of the calcium alginate with silver that was ordered by the WCP on 4/8/25. The director of nursing (DON) was interviewed on 5/1/25 at 2:15 p.m. The DON said the WCP came to the facility one day per week to round on residents requiring wound care. The DON said the WCP and the WCN did wound rounds together. She said the WCP would either give the WCN verbal treatment orders or he would enter orders into his visit progress notes. The DON said it was the WCN's responsibility to enter the treatment orders into the residents' EMRs. The DON said the facility did not currently have a process to circle back and verify the accuracy of wound orders entered into the EMR. The WCP was interviewed on 5/1/25 at 2:27 p.m. The WCP said when he rounded at the facility, he would give the WCN verbal wound care orders after assessing a resident's wound. The WCP said he sometimes made changes to his treatment plans after he left the facility. The WCP said his official treatment plan and wound care orders were documented in his visit note and it was his expectation that the treatment orders in his visit notes were followed. The WCP said he was unaware Medihoney gel was still being applied to Resident #57's sacral wound until he was notified of it by facility staff on 5/1/25. The WCP said his normal process was to see the resident, remove the old wound dressing, cleanse the wound and then measure it. He said once completed, he would give the WCN verbal treatment orders and then leave the resident's room to finish documenting before moving on to the next resident. The WCP said while he documented, the WCN would stay in the resident's room to apply the ordered wound dressings. The WCP said he would sometimes stay in the room to assist the WCN if she needed help with positioning the resident, however, he said he did not consistently double check the placement of certain dressings if a resident had multiple wounds. The WCP said he did not recall having a specific conversation with the WCN regarding Resident #57's wound care orders when he last rounded on 4/23/25. The WCN was interviewed a third time on 5/1/25 at 2:44 p.m. The WCN said she was given a verbal order by the WCP on 4/8/25 to continue applying Medihoney gel to Resident #57's sacral pressure wound. The WCN said she reviewed the WCP's 4/8/25 wound visit note on 4/9/25 and saw the treatment order to switch wound care dressings from Medihoney gel to calcium alginate with silver, however, she said she did not follow up with the WCP to clarify the order because she had just verified it with him the day before. The WCN said the WCP assisted her with Resident #57's wound care on 4/23/25. The WCN said she believed the WCP could see, and was aware of, the Medihoney gel dressing she applied to Resident #57's sacral pressure wound, however, she acknowledged the WCP did not specifically tell her what wound dressing to use.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interviews, the facility failed to ensure that its medication error rate was not greater than five percent (%). Specifically, the facility had a medication error rate of 8%, which was two errors out of 25 opportunities for error. Findings include: I. Professional reference According to [NAME], P.A., [NAME], A.G., et.al., Fundamentals of Nursing, 10 ed., E.[NAME], St. Louis Missouri, pp. 606-607. Take appropriate actions to ensure the patient receives medication as prescribed and within the times prescribed and in the appropriate environment. Professional Standards such as nursing scope and standards of practice apply to the activity of medication administration?. To prevent medication errors, follow the seven rights of medication administration consistently every time you administer medications. Many medication errors can be linked in some way to an inconsistency in adhering to these seven rights: 1. The right medication 2. The right dose 3. The right patient 4. The right route 5. The right time 6. The right documentation 7. The right indication. II. Facility policy and procedure According to the Administration of Medications policy, revised 9/16/24, was received from the nursing home administrator (NHA) on 5/1/25 at 10:46 a.m. It revealed in pertinent part, The facility will ensure medications are administered safely and appropriately per physician order to address residents' diagnoses and signs and symptoms. Medication error, means the observed or identified preparation or administration of medications or biological which is not in accordance with: the prescriber's order, manufactures specifications regarding the preparation and administration of the medications or biological, and the accepted professional standards and principals which apply to professionals providing services. Medication administration is the responsibility of those individuals who through certification and licensure are authorized in their state to administer medications in a skilled nursing facility. Staff who are responsible for medication administration will adhere to the 10 rights of medication administration: right drug, right resident, right dose, right route, right time and frequency, right documentation, right assessment, right to refuse, right evaluation/response and right education and information. III. Observation and staff interviews On 4/30/25 at 7:42 a.m. registered nurse (RN) #1 was administering medications to Resident #8. The physician's order read sennoside-docusate sodium (anti constipation medications containing two different medications in one tablet) 8.6-50 milligrams (mg), administer one tablet daily for constipation. RN #1 dispensed one tablet of senna 8.6 mg into the medication cup. -RN #1 dispensed a medication which contained sennoside, however, the medication did not contain docusate sodium as the physician's orders instructed. RN #1 then began to dispense polyethylene glycol powder (anti constipation medications). The physician's order read polyethylene glycol powder 17 gram (gm) by mouth one time a day for constipation, hold for loose stool, stir and dissolve 17 grams in four to eight ounces (oz) of water or beverage of choice. RN #1 dispensed the medication from a multidose bottle into a medication cup. RN #1 dispensed the powder to between 15 to 20 milliliters (ml) line on the medication cup. RN #1 said the order was for 17 gm so she dispensed that much into the medication cup. -Review of the medication cup that RN #1 revealed the measurements on the cup were ml and not gm like the order specified. RN #1 was stopped to review orders to the administration of the polyethylene glycol powder to the resident. RN #1 said she did not identify any concerns with the medications she had dispensed. Review of the polyethylene glycol powder bottle with RN #1 it revealed the medication was to be measured with the cap of the container for the 17 gm dose. RN #1 then took the medication cup with the powder she had already dispensed and poured it into the cap of the bottle. The powdered medication was observed to be spilling over the cap and medication was observed falling onto the floor and some powder still remained in the medication cup. -RN #1 had dispensed too much medication than ordered due to using the incorrect measuring device. IV. Additional staff interviews RN #1 was interviewed on 4/30/25 at approximately 8:00 a.m. She said she was taught in nursing school to measure the medication in a medication cup. RN #1 said too much of the polyethylene glycol powder could lead to the resident having loose stools or irregular bowel movements. RN #1 said the Senna 8.6 mg she initially dispensed was incorrect because the physician had ordered a combination medication and had she given the incorrect medication the resident could have become constipated. The director of nursing (DON) was interviewed on 5/1/25 at 2:00 p.m. She said the nurses were expected to follow all the rights of medication administration to ensure no medication errors were made. The DON said nurses were to compare the order to the packaging to ensure the correct medication was dispensed and administered to the residents. The DON said when measuring polyethylene glycol powder, the nurse was to measure using the cap from the bottle as a measuring tool as per manufactures recommendations.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to develop and implement policies and procedures related to COVID-19 immunizations for one (#69) of five residents reviewed for immunizations out of 35 sample residents. Specifically, the facility failed to follow up with a resident and/or the resident's representative to offer and administer COVID-19 vaccination for Resident #69. Findings include: I. Professional reference According to the Centers for Disease Control and Prevention (CDC), COVID-19 guidelines (revised 1/7/25), retrieved on 45/7/25 from https://www.cdc.gov/covid/vaccines/stay-up-to-date.html. Everyone ages six months and older should get a 2024-2025 COVID-19 vaccine. The COVID-19 vaccine helps protect you from severe illness, hospitalization, and death. It is especially important to get your 2024-2025 COVID-19 vaccine if you are age [AGE] and older, are at risk for severe COVID-19, or have never received a COVID-19 vaccine. Vaccine protection decreases over time, so it is important to get your 2024-2025 COVID-19 vaccine. II. Facility policy and procedure The COVID-19 (SARS-CoV-2) Vaccination Program policy and procedure, revised 11/27/24, was provided by the nursing home administrator (NHA) on 4/28/25 at 3:39 p.m. It read in pertinent part, The facility will ensure that residents are offered the COVID-19 vaccine unless the immunization is medically contraindicated, or the resident has already been immunized. The facility will educate residents or resident representatives regarding the benefits and potential side effects associated with the COVID-19 vaccine and offer the vaccine unless it is medically contraindicated, or the resident has already been immunized. Once screening is completed, the facility should offer residents vaccination against COVID-19 when vaccine supplies are available to the facility. III. Resident #69 A. Resident status Resident #69, age [AGE], was admitted on [DATE]. According to the April 2025 computerized physician orders (CPO), diagnoses included methicillin resistant staphylococcus aureus infection (MRSA - bacterial infection), pneumonitis (infection of the lungs), esophagitis (infection of the throat), dementia and schizoaffective disorder (mental illness). According to the 3/24/25 minimum data set (MDS) assessment revealed the resident had severe cognitive impairments with a brief interview for a mental status (BIMS) score of one out of 15. He required assistance of one person with bed mobility, transfers, bathing and toileting. The assessment revealed the resident did not reject care. B. Record review A review of Resident #69's electronic medical record (EMR) did not reveal documentation indicating the resident had been offered, declined or had received the COVID-19 vaccination. IV. Staff interviews The director of nursing (DON) and the infection preventionist (IP) were interviewed on 5/1/25 at 2:07 p.m. The IP said the facility conducted COVID-19 vaccine clinics frequently and reviewed the state immunization portal to determine when the residents were due for their next vaccine dose. The IP said when a resident was admitted to the facility, they reviewed the resident' vaccine history. The IP said they did not receive consent from Resident #69's representative after several attempts were made. -However, review of Resident 369's EMR did not reveal documentation that indicated attempts had been made to obtain consent to administer the COVID-19 vaccine to the resident. The IP said Resident #69 was admitted to the facility in January 2024. The IP said the facility staff had not followed up with the resident and/or responsible party to obtain consent for the COVID-19 vaccination after the initial attempt was unsuccessful. The IP said Resident #69 had not received the COVID-19 vaccine. The DON said the facility staff should have followed up with the resident and/or representative regarding the COVID-19 vaccination and obtained consent to administer the vaccination. The DON said there was no documentation indicating the facility had offered the vaccination or evidence that the facility provided education to the residents or their legal representative of the risk and benefit of not receiving the COVID-19 vaccine. She said Resident #69 had not been offered any additional COVID-19 vaccines since the resident was admitted to the facility. The IP said she would reach out to the resident's representative in a formal manner and document her response in the resident's EMR.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to ensure that three (#57, #10 and #51) of five residents out of 35 sample residents were free from chemical restraint and were receiving the least restrictive approach for their needs. Specifically, for Residents #57, #10 and #51, the facility failed to: -Adequately identify and monitor target behaviors for psychotropic medications; -Identify resident specific interventions for behaviors; and, -Provide adequate documentation to justify the addition of new psychotropic medications, the increase in dosage of psychotropic medications and/or the continued use of psychotropic medications. Findings include: I. Facility policy and procedure The Unnecessary Medication policy, revised 4/22/25, was provided by the nursing home administrator (NHA) on 5/1/25 at 11:14 a.m. It read in pertinent part, The facility will ensure only medications required to treat the resident's assessed condition are being used, reducing the need for and maximizing the effectiveness of medications are important considerations for all residents.Therefore, as part of medication management (especially psychotropic medications), it is important for the interdisciplinary team (IDT) to implement non-pharmacological approaches designed to meet the individual needs of each resident. The facility will assess the resident's underlying condition, current signs, symptoms, and expressions, and preferences and goals for treatment. This will assist the facility in determining if there are any indications for initiating, withdrawing, or withholding medications as well as the use of non-pharmacological approaches. II. Resident #57 A. Resident status Resident #57, age greater than 65, was admitted on [DATE]. According to the April 2025 computerized physician orders (CPO), diagnoses included unspecified dementia, anxiety, major depressive disorder, and insomnia. The 3/26/25 minimum data set (MDS) assessment revealed the resident had severe cognitive impairments with a brief interview for mental status (BIMS) score of four out of 15. The resident required one-person maximum assistance with showering, toileting, dressing, personal hygiene and transfers and required a wheelchair for mobility. The MDS assessment indicated the resident had behaviors not directed at others (physical symptoms such as scratching self, pacing, smearing bodily fluids or food, disrobing, public sexual acts, screaming or distruptive sounds). B. Record review Resident #57's elopement care plan, initiated 4/15/25, revealed the resident would often ask her family about taking her home, or would often state that her family was going to come and get her. Interventions, initiated 4/22/25, included providing structured activities: toileting, walking inside and outside, or reorientation strategies including signs, pictures and memory boxes. Resident #57's behavior care plan, revised 12/16/24, revealed the resident used antipsychotic medications for behavior management. Interventions, initiated 12/16/24, included non-pharmacological interventions such as active listening, offering snack or drink, positive distraction, reassurance of safety, reapproaching and assisting to a quiet area. -The care plan did not identify target behaviors to monitor for Resident #57's prescribed antipsychotic medications or resident specific non-pharmacological interventions. Resident #57's April 2025 CPO revealed the following physician's orders: Trazodone (antidepressant medication) 100 milligram (mg) tablet. Give one tablet at bedtime for insomnia, ordered 12/11/24. Sertraline (antidepressant medication) 100 mg tablet,. Give one tablet a day for depression, ordered 12/12/24. Sertraline 50 mg. Give 0.5 (half) tablet a day for major depressive disorder for seven days with 100 mg dosage to equal 125 mg, ordered 4/1/25 and discontinued 4/8/25. Sertraline 50 mg tablet. Give one tablet a day for depression with 100 mg dosage to equal 150 mg, ordered 4/10/25 (an increase in dosage). Document number of hours resident sleeps, ordered 2/4/25. Risperdone (antipsychotic mediation) 1 mg tablet. Give 0.5 mg one time a day for unspecified dementia, ordered 4/1/25. Risperdone 1 mg tablet. Give one tablet at bedtime for dementia with agitation and anxiety, ordered 4/1/25. -Review of Resident #57's April 2025 CPO revealed there were no physician's orders for behavior tracking/monitoring. Review of Resident #57's electronic medical record (EMR) from 3/1/25 to 4/29/25 revealed the following progress notes: A psychotropic medication meeting note, dated 1/31/25, did not identify what behaviors were exhibited by Resident #57 or what resident specific interventions were effective when the resident was exhibiting behaviors. -Additionally, the psychotropic meeting note did not document the justification for continuing Resident #57's antipsychotic and antidepressant medications. A behavior note, dated 3/10/25, revealed Resident #57 displayed obsessive behaviors regarding wanting to call her family to have them take her home. The resident began asking her roommate to help her call and was becoming increasingly anxious. When in her room, the resident attempted to walk and the staff attempted to take her to a common area so the staff could supervise her to prevent falls. This caused the resident to become argumentative with the staff. A behavior note, dated 3/11/25, revealed Resident #57 continued behaviors of obsessing over calling her family and asking her roommate to help her make a call. The resident was encouraged to stay in the common area to prevent falls but the resident became argumentative with staff. Interventions of distraction and snacks were offered but the resident's behavior continued. A behavior note, dated 3/12/25, revealed Resident #57 continued to be restless and requested to call her family. The resident continued to want to go to her room alone. Later in the shift, the resident was found by staff on the floor of her bedroom doorway, with her wheelchair behind her. She told the staff she was trying to go to her room to call her family. -The non-pharmological interventions identified in the care plan for Resident #57's behaviors of obsessing over her family taking her home to prevent agitation (providing structured activities: toileting, walking inside and outside, or reorientation strategies including signs, pictures and memory boxes) were not indicated as being used when the resident was wanting to call her family on 3/10/25, 3/11/24 and 3/12/25 (see care plan and progress notes above). A communication note, dated 4/1/25, revealed a call was made to Resident #57's representative to notify her that the physician had increased the resident's risperidone (antipsychotic medication) due to behaviors at night where the resident refused to be changed which caused her to be wet throughout the evening. -Review of Resident #57's EMR revealed there was no physician's progress note or nursing documentation to indicate the resident refused to be changed. Review of the certified nurse aide (CNA) behavior monitoring task for Resident #57, from 3/1/25 to 4/29/25, revealed the following: The resident had eighteen episodes of repetitive motions where the intervention used was marked as not applicable. The resident had four episodes of anxiety, agitation, restlessness and frustration where the intervention used was marked as not applicable. The resident had seven episodes of anxiety, agitation, restlessness and frustration where the interventions used were marked as either redirect or reapproach. -The CNA behavior monitoring task did not identify what the term not applicable indicated or what resident specific redirection or reapproach interventions were attempted. A review of Resident #57's hours of sleep documented from 2/1/25 to 4/30/25 revealed she slept an average of 10 to 12 hours per day. A review of Resident #57's EMR from 1/20/25 to 3/18/25 revealed she had fallen five times. III. Resident #10 A. Resident status Resident #10, age greater than 65, was admitted on [DATE]. According to the April 2025 computerized CPO, diagnoses included unspecified dementia with psychotic disturbance and anxiety. The 2/5/25 MDS assessment revealed the resident had severe cognitive impairments with a BIMS score of zero out of 15. The resident used a wheelchair for mobility and required one-person maximum assistance with eating, personal hygiene, showering, toileting, dressing, bed mobility and transfers. The MDS assessment indicated the resident had no behaviors of physical or verbal aggression, rejection of care, disrobing, pacing or wandering. B. Record review Resident #10's elopement care plan, revised 11/18/24, revealed the resident had behaviors of wandering related to a diagnosis of dementia with anxiety. The resident would often forget where her room was and was at risk for exit seeking. Interventions, initiated 11/18/24, included providing structured activities: toileting, walking inside and outside, or reorientation strategies including signs, pictures and memory boxes. Resident #10's behavior care plan, initiated 12/16/24, revealed the resident used antipsychotic medications for behavior management. Interventions, initiated 12/16/24, included non-pharmacological interventions such as active listening, offering snack or drink, positive distraction, reassurance of safety, reapproaching and assisting to a quiet area. -The care plan did not identify target behaviors to monitor for Resident #10's prescribed antipsychotic medications or resident specific non-pharmacological interventions. Resident #10's April 2025 CPO revealed the following physician's orders: Olanzapine (antipsychotic medication) 5 mg. Give one tablet a day for dementia with psychotic features, ordered 2/3/25. Citalopram (antidepressant medication) 10 mg. Give one tablet a day for depression, ordered 2/3/25 and discontinued 3/6/25. Citalopram 20 mg. Give one tablet a day for depression, ordered 3/6/25 (an increase in dosage). Document number of hours resident sleeps, ordered 3/25/25. -Review of Resident #10's April 2025 CPO revealed there were no physician's orders for behavior tracking/monitoring. Review of Resident #10's EMR from 1/1/25 to 4/29/25 revealed the following progress notes: A behavior note, dated 1/4/25, revealed Resident #10 had been restless, pacing the halls and going into other residents' rooms on the evening shift. A progress note, dated 3/4/25, revealed Resident #10 had been crying and requesting to go home so the family picked her up to take her home to spend the night. A physician's note, dated 3/5/25, revealed the physician increased Resident #10's antidepressant medication (citalopram) after nursing staff reported she had an episode of crying uncontrollably and wanting to go home. The physician noted the resident's mental status appeared to be at baseline. -The non-pharmological interventions identified in Resident #10's care plan for her behaviors of wandering (providing structured activities: toileting, walking inside and outside, or reorientation strategies including signs, pictures and memory boxes) were not indicated as being used when the resident was wandering on 1/4/25 and crying and wanting to go home on 3/5/25 (see care plan and progress notes above). A psychotropic medication meeting note, dated 3/25/25, did not identify what behaviors Resident #10 exhibited or what resident specific interventions were effective when the resident was exhibiting behaviors. -Additionally, the psychotropic meeting note did not document the justification for continuing Resident #10's antipsychotic and antidepressant medications. Review of the CNA behavior monitoring task for Resident #10, from 1/1/25 to 4/30/25 revealed the following: The resident had five episodes of repetitive motions where the intervention used was marked as not applicable. The resident had four episodes of anxiety, agitation, restlessness and frustration where the intervention used was marked as not applicable. The resident had eight episodes of anxiety, agitation, restlessness and frustration where the interventions used were marked as either redirect or reapproach. The resident had four episodes of pacing and wandering where the interventions were marked as either redirect or reapproach. The resident had five episodes of entering other residents' rooms where the intervention used was marked as not applicable. The resident had four episodes of entering other residents' rooms where the interventions were marked as either redirect or reapproach. The resident had one episode of disrobing, tearfulness, hitting others and screaming at others where the interventions used were marked as either redirect or reapproach. -The CNA behavior monitoring task did not identify what the term not applicable indicated or what resident specific redirection or reapproach interventions were attempted. A review of Resident #10's hours of sleep documented from 3/25/25 to 4/29/25 revealed she slept an average of 10 to 12 hours per day. IV. Resident #51 A. Resident status Resident #51, age greater than 65, was admitted on [DATE]. According to the April 2025 computerized CPO, diagnoses included unspecified dementia. The 3/21/25 MDS assessment revealed the resident had severe cognitive impairments with a BIMS score of one out of 15. The resident used a wheelchair for mobility and was dependent on staff for personal hygiene, toileting, showering, dressing, bed mobility and transfers. The MDS assessment indicated the resident had no behaviors of physical or verbal aggression, rejection of care or wandering. B. Resident interview Resident #51 was interviewed on 4/28/25 at 12:15 p.m. Resident #51 inquired about purchasing a plane ticket to [NAME]. When she was advised of the cost of a one-way ticket to [NAME], she asked if there were any sales. When the resident was advised there might be a summer sale on plane tickets, she said she would like to wait for the sale. The resident did not display any agitation and accepted the explanation. C. Record review Resident #51's elopement care plan, initiated 4/28/25 (during the survey), revealed the resident was at risk for elopement due to her diagnosis of dementia with agitation. The resident would often ask the staff about going home and propel herself in her wheelchair to the exit doors. Interventions, initiated 4/28/25 (during the survey), included providing structured activities: toileting, walking inside and outside, or reorientation strategies including signs, pictures and memory boxes. Resident #51's behavior care plan, initiated 3/24/24, revealed the resident used antipsychotic medications related to a diagnosis of dementia with psychosis. Interventions, initiated 3/24/24, included non-pharmacological interventions such as active listening, offering snack or drink, positive distraction, reassurance of safety, reapproaching and assisting to a quiet area. -The care plan did not identify target behaviors to monitor for Resident #51's prescribed antipsychotic medications or resident specific non-pharmacological interventions. Resident #51's April 2025 CPO revealed the following physician's orders: Lorazepam (anti-anxiety medication) 1 mg. Give one tablet every twelve hours as needed for anxiety/restlessness, ordered 4/26/25 and discontinued 5/1/25 (during the survey). Risperdone 0.5 mg. Give one tablet twice a day for dementia with psychotic disturbances, ordered 3/19/25. Document number of hours resident sleeps, ordered 4/1/25. Seroquel (antipsychotic medication) 12.5 mg. Give one tablet at bedtime for dementia with behaviors, ordered 3/19/25 and discontinued 4/1/25. Seroquel 25 mg. Give one half tablet (or 12.5 mg) at bedtime for unspecific dementia, ordered 4/3/25. -Review of Resident #51's April 2025 CPO revealed there were no physician's orders for behavior tracking/monitoring. Review of Resident #51's EMR from 3/19/25 to 4/29/25 revealed the following progress notes: A psychotropic medication meeting note, dated 3/25/25, did not identify any behaviors exhibited by Resident #51 since her admission on [DATE]. A communication note, dated 4/2/25, revealed Resident #51's representative was unaware the resident's Seroquel (antipsychotic medication) had been discontinued and was upset she had not been contacted. The medication was restarted per the representative's request. A skilled nursing note, dated 4/5/25, revealed Resident #51 had behaviors of anxiety and tried to transfer herself to a chair near the nurses station. The note did not indicate if non-pharmacological interventions were attempted to decrease the resident's anxiety. A behavior note, dated 4/7/25, revealed Resident #51continued to be restless throughout the day, propelling herself around the unit, going into all the rooms, attempting to get up from her chair or transferring herself from her wheelchair unassisted. The resident was obsessed with purchasing a ticket for a train. Positive distraction, snacks, drinks and a fake train ticket were provided, but the interventions were not effective. A behavior note, dated 4/8/25, revealed Resident #51 continued to be restless throughout the day, propelling herself around the unit, going into rooms, attempting to get up from her chair or transferring herself from her wheelchair unassisted. The resident was obsessed with purchasing a ticket for a train. Positive distraction, snacks, drinks and a fake train ticket were provided, but the interventions were not effective. A behavior note, dated 4/13/25, revealed Resident #51 displayed confusion, requesting to go home, attempting to walk independently and exit-seeking. The note documented attempts to redirect the resident were successful for short periods of time, however, the note did not document the interventions that were attempted. A skilled nursing note, dated 4/14/25, revealed Resident #51 had behaviors of wandering, decreased safety awareness, unsafe attempts to self transfer and was obsessed over having a bill, money being taken by staff and needing to catch a bus. The interventions were not always successful, including positive distraction, snacks and drinks. A behavior note, dated 4/20/25, revealed Resident #51 had behaviors of exit-seeking and asking to go home. She required frequent redirection (watching television (TV), reading or attending church services) that were only successful for short periods of time. A behavior note, dated 4/25/25, revealed Resident #51 was observed pacing the unit frequently, restless and anxious and verbalizing concerns intermittently about not being able to find her bag. The note documented that redirection was attempted multiple times with no effectiveness, however, the note did not document the interventions that were attempted. A communication note, dated 4/26/25, revealed the nurse contacted the physician requesting an order for lorazepam as needed for agitation due to Resident #51 not sleeping well the previous two evenings, attempting to get up at night and requiring frequent redirection. A behavior note, dated 4/26/25, revealed Resident #51 was observed pacing the unit frequently, restless and anxious and verbalizing concerns intermittently about not being able to find her bag. The note documented that redirection was attempted multiple times with no effectiveness, however, the note did not document the interventions that were attempted. A behavior note, dated 4/27/25, revealed Resident #51 was observed pacing the unit frequently, restless and anxious and verbalizing concerns intermittently about not being able to find her bag. The note documented that redirection was attempted multiple times with no effectiveness, however, the note did not document the interventions that were attempted. A behavior note, dated 4/29/25, revealed Resident #51 was restless throughout the day, impulsive, continuously getting up and self-transferring without assistance. Redirection (activities, snacks and positive distraction) worked only briefly. -The non-pharmological interventions identified in the care plan for Resident #51's behaviors of wandering (providing structured activities: toileting, walking inside and outside, or reorientation strategies including signs, pictures and memory boxes) were not initiated until 4/28/25 (during the survey). A communication note, dated 5/1/25, revealed the nurse and the director of nursing (DON) called Resident #51's representative to confirm she was aware of the lorazepam order obtained on 4/26/25 (see physician's orders above). The nurse documented that the representative said she was aware and had consented. Review of the CNA behavior monitoring task for Resident #51 from 4/28/25 to 4/30/25 revealed the following: On 4/28/25 Resident #51 had behaviors of making disruptive sounds, disrobing in public, agitation, anxiety and exit-seeking. Interventions included redirection, removal from the environment, offering meaningful activity and providing a calm environment without success. On 4/29/25 Resident #51 had behaviors of disrobing in public, agitation, anxiety and restlessness. Interventions included redirection and removal from the environment without success. On 4/30/25 Resident #51 had behaviors of repetitive motions and agitation. The interventions were marked as not applicable. -The CNA behavior monitoring task did not identify what the term not applicable indicated or what redirection or reapproach interventions were attempted. -The CNA behavior monitoring task was not initiated until 4/28/25 (during the survey). V. Staff interviews Registered nurse (RN) #3 was interviewed on 4/30/25 at 1:49 p.m. RN #3 said the nurses documented behaviors and interventions attempted in the residents' progress notes. She said the residents'specific behaviors and residents'specific interventions were documented in the residents' care plans. RN #3 said the nurses had to check every resident's care plan during their shift. She said the nurses did not document behaviors associated with specific psychotropic medications, such as antipsychotics medications. She said the nurses only documented behaviors for 14 days after a medication change and then stopped monitoring. RN #3 said if there were new behaviors or interventions identified in the facility's 24-hour meeting in the mornings, it would be verbally communicated to the nurses, but she said the new behaviors and interventions were not documented. CNA #3 was interviewed on 4/30/25 at 2:05 p.m. CNA #3 said the CNAs documented behaviors in a separate documentation system from the nurses and the CNAs did not have access to the residents' care plans. She said the CNA behavior monitoring tasks displayed a list of behaviors to choose from and a list of interventions to choose from, but the CNA could not personalize the behaviors or interventions. CNA #3 said if the resident had a specific behavior or intervention that was not included in the generic list, the CNAs did their best to select an appropriate choice. She said if the interventions were not included on the list, the CNA would document not applicable and report the interventions to the nurse to document in the progress notes. RN #1 was interviewed on 5/1/25 at 9:45 a.m. RN #1 said Resident #51 had behaviors of agitation and wandering. She said the resident was triggered when others raised their voices and the staff had to remove her from the unit or lay her down. RN #1 said if the resident tried to get up out of bed or her chair repeatedly, the nurses would administer her an as needed lorazepam dose. RN #1 said Resident #57 had behaviors of propelling herself to her doorway and waiting for staff, but she said the resident had no other behaviors. She said the staff would offer her books or magazines. RN #1 said Resident #10 had behaviors due to her language deficits because she spoke only Romanian and the staff had to read her body language. RN #1 said the resident became anxious due to her lack of ability to communicate and there were no specific interventions for her. CNA #4 was interviewed on 5/1/25 at 10:07 a.m. CNA #4 said Resident #51 had behaviors of standing up sometimes and the only intervention that worked was to walk with her. CNA #4 said Resident #57 has behaviors of anxiety and she was not aware of specific behaviors or interventions for her. CNA #4 said Resident #10 did not have any behaviors. The DON and the social services director (SSD) were interviewed together on 5/1/25 at 2:00 p.m. The SSD said the efficacies of the residents' psychotropic medications were reviewed in the psychotropic medication meeting quarterly or as needed. She said the nurses documented behaviors in the progress notes and the CNAs reported behaviors to the nurses as well as documented behaviors in their own behavior monitoring system. She said the nurses notes and the CNA behavior monitoring tasks should match. She said she could not customize the CNA behavior monitoring to be person-centered or individualized. She said the expectation was that the nurses looked for the individualized behaviors and resident specific non-pharmological interventions in the resident care plan. The SSD said the behavior monitoring was used to identify residents' behaviors and effective interventions. She said if the documentation was inconsistent, the information brought to the psychotropic medication meeting was inaccurate and this affected medication decisions. The SSD said the psychotropic medication meeting was intended to be for the interdisciplinary team (IDT) to discuss with the physician and providers the efficacy of psychotropic medications, the effectiveness of the interventions and any changes in residents' behaviors. The DON said if the resident was having behaviors, the nurses would first try generic interventions, such as redirection, offering food or fluids and taking residents to activities. She said if those interventions were unsuccessful, the nurse would look at the resident's care plan for the identified resident specific interventions. The DON said the nurses did not have time to look at every resident's care plan during their shifts unless the generic interventions were unsuccessful. She acknowledged this practice did not demonstrate that individualized, person-centered interventions were being attempted for residents' behaviors. The DON said she was not happy when she discovered Resident #57 had risperidone added to her medication regimen. She said the physician had come into the building and the staff reported the resident was refusing care so the physician prescribed the risperidone. The DON said the physician declined to discontinue the medication when she requested it be discontinued, but she said she had not reached out to the medical director to assist further in getting the medication discontinued. The DON said Resident #51's Seroquel medication was discontinued on 4/1/25 by the physician but consent to discontinue the medication was not obtained from the resident's representative so the medication had to be reinstated on 4/3/25. She said she contacted the representative on 5/1/25 to confirm the lorazepam order had been approved by the representative due to the DON being unable to find documentation that a consent had been obtained. She said the representative informed her that she had never been contacted or asked to start this medication. -However, the nurse who documented the 5/1/25 note regarding the call placed to the resident's representative about the lorazepam indicated the representative was aware of the new physician's order prior to the 5/1/25 call and had given consent for the medication (see 5/1/25 communication progress note above). The SSD said the risperidone for Resident #57 was inappropriate to treat provoked behaviors. She said the behavior monitoring for the resident did not reflect a necessity for the medication. The SSD said Resident #10 went out to the hospital and returned with the olanzapine medication and prior to that, she had been taking Seroquel for hallucinations. She said the hallucinations were not being tracked and when the CNAs documented not applicable on their behavior monitoring task, she thought that indicated no interventions were attempted. The SSD said Resident #51's lorazepam was requested by the overnight nurses because the resident was restless and having trouble sleeping. She said she was not able to say the facility was attempting individualized resident specific nonpharmacological interventions or that the facility was not using psychotropic medications for staff convenience. -An attempt was made to interview the medical director on 5/1/25 at approximately 5:30 p.m. via phone, however, the medical director was unable to be reached.

Based on observations and interviews, the facility failed to ensure medications and biologicals were stored and labeled properly according to professional standards in one of three medication storage rooms. Specifically, the facility failed to ensure vaccinations were not stored in dormitory style fridges. Findings include: I. Professional reference According to the Vaccine Storage and Handling Tool-kit, dated 3/29/24, retrieved on 5/5/25 from https://www.cdc.gov/vaccines/hcp/downloads/storage-handling-toolkit.pdf, it revealed in pertinent part, Do not store any vaccine in a dormitory-style or bar-style combined refrigerator/freezer unit under any circumstances. These units have a single exterior door and an evaporator plate/cooling coil, usually located in an icemaker/freezer compartment. These units pose a significant risk of freezing vaccines even when used for temporary storage. II. Facility policy and procedure The Medication Storage in Refrigerator/Freezer policy, reviewed 9/16/24, was received from the nursing home administrator (NHA) on 5/1/25 at 10:46 a.m. It revealed in pertinent part, The facility will ensure that medications which require refrigeration were stored appropriately per manufacturer's instructions. Safe temperatures for refrigeration were between 36 degrees and 46 degrees Fahrenheit (F). The facility should monitor the temperature for vaccine storage twice a day. If there is excessive ice built up in the freezer, the maintenance department should be notified to defrost the unit to ensure proper functioning. III. Observations and staff interviews On 5/1/25 at 9:46 a.m. the west medication room was observed with the infection preventionist (IP). The IP said the facility stored all vaccinations in the west medication refrigerator. The IP said the refrigerator temperature was 34 degrees F. The west medication refrigerator contained 13 doses of 2024/2025 influenza vaccines and eight doses of pneumococcal 21 valent conjugate vaccine. The IP said the refrigerator temperature should be between 36 to 46 degrees F. The temperature at time of observation revealed the temperature was 34 degrees F. The IP said the temperature was too cold for the vaccines. -The IP did not adjust the medication fridge temperature at time of observation. IV. Additional interviews The IP was interviewed on 5/1/25 at approximately 9:55 a.m. She said there was not a concern for the vaccines to be stored in a dormitory style refrigerator as long as there were no temperature fluctuations. The IP said the current refrigerator temperature was just below the refrigerator temperature ranges. The director of nursing (DON) was interviewed on 5/1/25 at 2:00 p.m. She said the temperature for medication refrigerators needed to be between 36 to 40 degrees F. The DON said if a refrigerator was found to not maintain temperature the nurse who identified it should adjust the temperature and check back to see if it was corrected or if further intervention was required. The DON said she has the nurses defrost the freezers to ensure ice does not build up. The DON said she did not know if vaccines should not be stored in dormitory style refrigerators.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and interviews, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of diseases and infection for three out of five units in the facility. Specifically, the facility failed to: -Ensure housekeeping staff engaged in hand hygiene and change gloves between resident rooms and between different areas in each resident room (bathroom and bedroom); -Ensure housekeeping staff changed cleaning towels between different areas in a resident rooms (bedroom and bathroom); -Ensure housekeeping staff disinfected high frequency touch areas in resident rooms and shared spaces; -Ensure surface disinfectant times were adhered to for disinfecting products by all staff; -Ensure nursing staff disinfected shared equipment (vitals machines and lifts) between residents; and, -Ensure nursing staff engaged in infection control practices during wound care. Finding include: I. Infection control failures A. Professional reference Assadian O, Harbarth S, Vos M, et al. Practical recommendations for routine cleaning and disinfection procedures in healthcare institutions: a narrative review. The Journal of Hospital Infection. 2021 Jul;113:104-114 was retrieved on 9/20/23 revealed, in pertinent part: High-touch surfaces, on the other hand, are usually close to the patient, are frequently touched by the patient or nursing staff, come into contact with the skin and, due to increased contact, pose a particularly high risk of transmitting pathogens (virus or microorganism that can cause disease) Healthcare-associated infections (HAIs) are the most common adverse outcomes due to delivery of medical care. HAIs increase morbidity and mortality, prolonged hospital stay, and are associated with additional healthcare costs. Contaminated surfaces, particularly those that are touched frequently, act as reservoirs for pathogens and contribute towards pathogen transmission. Therefore, healthcare hygiene requires a comprehensive approach. This approach includes hand hygiene in conjunction with environmental cleaning and disinfection of surfaces and clinical equipment. The Centers for Disease Control (CDC) Environment Cleaning Procedures https://www.cdc.gov/hai/prevent/resource-limited/cleaning-procedures.html# retrieved on 9/20/23 read in pertinent part, High-Touch Surfaces: The identification of high-touch surfaces and items in each patient care area is a necessary prerequisite to the development of cleaning procedures, as these will often differ by room, ward and facility. Common high-touch surfaces include: -bedrails -IV (intravenous) poles -sink handles -bedside tables -counters -edges of privacy curtains -patient monitoring equipment (keyboards, control panels) -call bells -door knobs Proceed From Cleaner To Dirtier Proceed from cleaner to dirtier areas to avoid spreading dirt and microorganisms. Examples include: -During terminal cleaning, clean low-touch surfaces before high-touch surfaces. -Clean patient areas ( patient zones) before patient toilets. -Within a specified patient room, terminal cleaning should start with shared equipment and common surfaces, then proceed to surfaces and items touched during patient care that are outside of the patient zone, and finally to surfaces and items directly touched by the patient inside the patient zone. In other words, high-touch surfaces outside the patient zone should be cleaned before the high-touch surfaces inside the patient zone. -Clean general patient areas not under transmission-based precautions before those areas under transmission-based precautions. B. Facility policy and procedure The Housekeeping Services Infection Control policy and procedure, undated, was provided by the director of housekeeping (DOH) on 9/14/23 at 2:09 p.m. It read in pertinent part, It is the policy of this facility to require effective environmental sanitation to lessen the hazards of exposure to contaminated air, dust, furnishings, equipment and other fomites. Frequent cleaning of the facility's interior will aid in physically removing and reducing microorganisms' potential contribution to the incidence of health-associated infections (HAI); The housekeeping supervisor will work closely with the infection control team to establish and maintain consistent practices and high standards of cleanliness; Periodic inspection of the facility will be made by the housekeeping supervisor or as a joint exercise with the infection control team; Cleaning shall be performed in a manner to minimize the spread of pathogenic organisms;dust high places before dusting lower areas light fixtures, tops of closets, tops of door casings, window coverings, TV's (televisions), pictures and other wall hangings tables, beds, medical apparatus, window sills; straighten displayed resident personal belongings (no gloves on); Wipe down with disinfectant soaked rag all touched surfaces in room, allow to air dry; door knobs, TV remotes, bed controllers, phones, bed-side tables, light switches,closet doors/dresser drawers medical apparatus like oxygen concentrators, clean heavily soiled restroom fixtures and porcelain surfaces using disinfectant and a rag or brush clean restroom walls with disinfectant; clean mirror with glass cleaner; Wipe down with disinfectant soaked rag all touched surfaces in room, allow to air dry; remove trash and re-line the receptacle, clean the receptacle as needed using disinfectant to disinfect sweep entire room including under beds; mop floors with dispensed solution of floor cleaner. C. Manufacturer recommendations The disinfectants in the facility were identified as: Oxivir TB The product label was reviewed which read in pertinent part, Ready-to-use disinfectant cleaner based on proprietary hydrogen peroxide technology to deliver fast, effective cleaning performance. Disinfects in 60 seconds. Virucide, bactericide, tuberculocide, fungicide and non-food contact sanitizer. Kills MRSA (Methicillin-resistant Staphylococcus aureus is a group of gram-positive bacteria that are genetically distinct from other strains of Staphylococcus aureus. MRSA is responsible for several difficult-to-treat infections in humans) and Norovirus. Meets bloodborne pathogen standards for decontaminating blood and body fluids. Colorless with a characteristic scent. Oxivir Five-16 Concentrate Cleaner The product label was reviewed which read in pertinent part, A one-step disinfectant cleaner based on proprietary Accelerated Hydrogen Peroxide technology to deliver fast, effective cleaning performance. At 1:16 dilution, disinfects in five minutes. Virucide, bactericide, fungicide, mildewcide and non-food contact sanitizer. Kills MRSA, Norovirus and Canine parvovirus. Concentrate delivers economical performance. Meets bloodborne pathogen standards for decontaminating blood and body fluids. Colorless with a characteristic scent. Sani Cloth Bleach Germicidal Wipes The product label was reviewed which read in pertinent part, Effective against 50 microorganisms in 4 minutes. Ideal for disinfecting high risk areas contaminated with Clostridioides difficile (C. difficile or C. diff.) spores and Norovirus. Now effective against SARS-CoV-2, the virus that causes COVID-19. D. Observations LPN #1 was observed on the east hall 9/11/23 at 8:05 a.m. She was taking vital signs of residents while passing medications. LPN #1 took a blood pressure reading then used the same machine on a second resident. She cleansed the machine after the second resident with Sani cloth hand wipes (not a disinfectant) and continued to use the machine on a third resident. -She failed to clean the vitals machine used between each resident and the one time she cleaned the vitals machine she failed to use the proper disinfecting wipe for medical equipment. An unidentified CNA in the 200 hallway was observed on 9/11/23 at 2:40 p.m. She entered a resident room with vital machine equipment and took the resident's vitals. The CNA exited and entered another resident's room and took the second resident's vitals. -There were no disinfecting wipes on the vitals machine carts. -The CNA failed to properly disinfect vitals machine equipment between residents. During continuous observation on 9/12/23 from 8:57 a.m. to 9:28 a.m. housekeeper (HSK) #1 failed to engage in proper hand hygiene and failed to disinfect high frequency touch areas. HSK #1 moved from resident room [ROOM NUMBER] to #306 without changing gloves after spraying the disinfectant cleaner in the bathroom. She changed the trash bags in the second room then moved back to the first room to continue cleaning. HSK #1 changed gloves after cleaning the bathroom, however failed to perform hand hygiene before putting on new gloves. HSK #1 took a clean cloth to dust the dressers and television then wet the same cloth to clean the sink, vanity, soap and towel dispensers. HSK #1 failed to clean the chair and recliner in the room. HSK #1 failed to disinfect any of the horizontal surfaces (bedside tables, vanity and window ledge) in the room. HSK #1 moved to the next room without changing gloves, walked out of the room and down the hall to the nurse station, then back to the room without changing gloves. During continuous observation on 9/13/23 from 9:00 a.m. to 11:00 a.m. HSK #2 failed to adhere to the surface disinfectant time according to the manufacturer's recommendations (see above) and failed to disinfect high frequency touch areas. HSK #2 was observed cleaning room [ROOM NUMBER], # 202 and #203. HSK #2 changed gloves and engaged in hand hygiene after each room but not across different areas in the rooms such as the bathroom and the resident room. HSK #2 did not change gloves and did not change the disinfectant soaked cloths between cleaning two separate sections of a shared room between two residents. HSK #2 touched high frequency touch areas with dirty gloves worn throughout the room and not changed even after cleaning the bathroom. HSK #2 did not disinfect high frequency touch areas in the room that included call lights, light switches and bathroom rails. Horizontal surfaces (bedside tables, vanity and window ledge) in the room were wiped with a disinfectant soaked cloth but the dwell time was not adhered to of five minutes for the disinfectant Oxivir five 16. HSK #2 wiped the surface in a single motion for two seconds per surface. The surface was no longer wet within 30 seconds. During continuous observation on 9/13/23 from 1:00 p.m. to 1:30 p.m. HSK #3 failed to adhere to the surface disinfectant time listed for Oxivir TB and failed to change gloves throughout cleaning room [ROOM NUMBER]. HSK #3 was observed spraying the disinfectant on a horizontal surface (vanity and bedside table) and then wiped it off immediately with a dry cloth. The surface was no longer wet within five seconds of application. HSK #3 was observed cleaning the room shared between two residents using the same pair of gloves throughout the entire cleaning. HSK #3 did not disinfect high frequency touch areas that included call lights, bathroom call light, light switches and bathroom rails. The door handles were wiped with a disinfectant soaked cloth however the surface disinfectant time was not adhered to and therefore the surface was not disinfected. During continuous observation on 9/13/23 from 1:45 p.m. to 2:20 p.m. CNA #4 and CNA #5 failed to disinfect shared medical equipment between two residents. CNA #5 placed back a lift into storage but did not disinfect the machine. CNA #4 brought back a sit to stand machine and cleaned the machine with a bleach cleaner wipe (four minute dwell time). CNA #4 wiped the surfaces for approximately 15 seconds. The surface was no longer wet within 30 seconds. The surface disinfectant time was not adhered to. The sit to stand machine was observed after CNA #4 cleaned it, however the sit to stand still had brown and red streaks of hardened liquid on the handles. The cushions on the leg area had dried brown liquid on them. The surface where a person would stand had approximately one inch of crusted black, yellow and brown pieces of dirt. The shower chair was observed in storage, the shower chair had dried streaks of yellow, brown and black liquid on the chair. E. Interviews HSK #1 was interviewed on 9/12/23 at 9:04 a.m. The HSK said the Clorox cleaner should sit for two to three minutes and high touch items of door handles and call buttons should be cleaned. -However, the HSK failed to spray high touch areas including the door handles, call buttons, and television remote. The HSK said she would come back and clean those items later. HSK #2 was interviewed on 9/13/23 at 11:05 a.m. HSK #2 said surface disinfectant time meant to use a soaked wiping cloth and just wipe the area. HSK #2 was unsure what high frequency touch areas were. She said she did not keep track of time for surface disinfectant times but she just did her cleaning process and enough time should pass for the surface disinfectant time after she completed other housekeeping tasks in the room. HSK #2 said she used the same process to clean every room. HSK #2 said she would change gloves at times if they were dirty but only use hand hygiene at the end of the cleaning and not between glove changes. HSK #3 said she did not consider call lights a high frequency touch area. HSK #2 said she would only use Oxivir disinfectant soaked cloths to clean the room and she only used water to mop the floors because using a cleaning product on the floor would make the floor sticky. HSK #3 was interviewed on 9/13/23 at 1:33 a.m. HSK #3 said she used Oxivir TB, Clorox at times and sometimes Oxivir five depending on how she felt She said the surface disinfectant time was 10 to 15 minutes. She said she would spray the surface first then wipe it with a dry rag but she did not track time to make sure the surface disinfectant time was adhered to. HSK #3 was unable to identify high touch areas. She said she did not keep track of time for the surface disinfectant times to ensure enough time had passed before she wiped the surfaces. CNA #4 was interviewed on 9/13/23 at 1:40 p.m. He said he was uncertain if he was responsible for cleaning the shared medical equipment. CNA #4 said he believed the housekeeping department was responsible for cleaning shared medical equipment. CNA #4 said he did not know what the surface disinfectant time meant and or what product should be used to clean shared medical equipment. CNA #5 was interviewed on 9/13/23 at 1:43 p.m. She said shared medical equipment should be cleaned before the equipment was stored. CNA #5 said the surface disinfectant time for the bleach wipes were one minute and it meant she should clean the surface using a single pass and let it dry for a minute. The housekeeping and laundry manager (HLM) was interviewed on 9/13/23 at 1:48 p.m. The HLM said housekeeping staff should clean all the resident rooms daily. The process to clean the room was to start by emptying the trash and then use four rags per room. First, they start on the right and do light dusting of the window sills, blinds, dresser and desk. Second, they should ring the rag and wipe surfaces, once done they change the rag and then go to the next side and wipe the mirror, counters, sink, paper towel and soap dispenser. Third, they checked if there were paper towels and soap in there. Fourth, they went to the bathroom and wiped all the rails, toilet and inside the bowl with the brush. Lastly, they swept the floors in the room and bathroom then mopped after it and then wiped the window ledge. All high touch areas were to be cleaned such as: call lights, blinds, light switches, door knobs, closet doors and use a duster for the blinds. The HLM said based on the observation of the housekeeping staff hand hygiene was not adhered to, cleaning methods were not correct with the facility's procedure and the surface disinfectant times were not followed. The HLM observed the shared medical equipment in storage and said it was dirty. The HLM said she would train all housekeeping staff again on the process of cleaning rooms, surface disinfectant times, high frequency touch areas, universal cleaning procedures, following manufacturer's recommendations for the cleaning products used and appropriate hand hygiene practices. The infection preventionist (IP) was interviewed on 9/14/23 at approximately 11:00 a.m. The IP said she was not involved yet with the housekeeping department in regards to infection control. The IP was unsure of the cleaning products used at the facility without observing a list of the cleaning products which had to be obtained from the HLM. The IP said she was unaware of the surface disinfectant times of the cleaning products used without asking the HLM. The IP said surface disinfectant times meant the surface must stay wet for the disinfectant time listed on the label of the disinfecting product; if the product did not stay wet for the time listed then the disinfectant would be ineffective. The IP identified high touch areas in the resident room as over the bed table and everything on it, call lights, sink area, faucets, toilet area, everything the resident touched, grab bars, door knobs and light switches. The IP said the shared medical equipment was dirty, however, was cleaned during the survey process and moving forward all staff will be provided with education related to surface disinfectant times, approved cleaning agents and responsibilities of utilizing shared medical equipment. II. Wound care failures A. Professional reference According to [NAME], P.A., [NAME], A.G., et.al., Fundamentals of Nursing, 10 ed. (2022), Elsevier, St. Louis Missouri, pg. 1265. After applying a solution to sterile gauze, clean away from the wound. Never use the same piece of gauze to clean across an incision or wound twice. B. Facility policy and procedure The Treatment of Wounds policy and procedure, revised 9/3/21, received from the NHA on 9/14/23 at revealed in pertinent part, provide comprehensive treatment plan designated to meet the individual resident's goals utilizing a multidisciplinary approach. Intent of this center that a resident having a wound receive necessary medical treatment to prevent infection, deterioration or development of wounds. A resident received care, consistent with professional standards of practice. C. Observations RN #1 was observed on 9/13/23 at 11:27 a.m. providing wound care to a Resident #90. During wound care, RN #1 cleaned the resident's right heel wound with saline and gauze. She wiped over the open wound bed with the same piece of gauze two times. RN #1 continued with wound care for the same resident on the left heel. She obtained a new piece of gauze, added saline to the gauze and wiped the open left heel wound three times with the same piece of gauze. -RN #1 failed to use a new piece of gauze for each wipe over the wound bed during cleaning. D. Staff interviews RN #1 was interviewed on 9/13/23 at 11:45 a.m. She said she should have used a new piece of gauze for each wipe over the wound bed during cleaning. RN #1 said using the same piece over and over again could contaminate the wound. The DON was interviewed on 9/14/23 at 11:00 a.m. She said during wound treatment a new piece of gauze should be used for each wipe over the wound to prevent contamination in the wound bed. The IP was interviewed on 9/14/23 at approximately 11:00 a.m. The IP said when a wound was cleaned a new gauze pad should be used after each pass, or the gauze pad should be folded in between each pass. The same gauze pad should not be used because the infection and or bacteria would be reapplied to the wound and the wound would not be clean.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to ensure residents were free from abuse for two (#3 and #4) out of four residents reviewed for abuse out of seven sample residents. Specifically, the facility failed to prevent an incident of physical abuse by Resident #4 toward Resident #3. Findings include: I. Facility policies and procedures The Abuse - Protection of Residents policy, initiated on 10/4/22, was provided by the nursing home administrator (NHA) on 3/21/23 at 1:42 p.m. The policy revealed the facility would ensure all residents were protected from physical and psychosocial harm during and after an investigation. The following methods were to ensure the protection of residents during an investigation, might include but were not limited to; responding immediately to protect the alleged victim and integrity of the investigation; examining the alleged victim for any sign of injury, including a physical examination or psychosocial assessment if needed; immediate notification of the alleged victim's practitioner and the family or responsible party; removal of access by the alleged perpetrator to the alleged victim, assurance that ongoing safety and protection was provided for the alleged victim and, was appropriate, for other residents; notification of the alleged violation to other agencies or law enforcement authorities; evaluation of whether the alleged victim felt safe and if he/she did not feel safe, taking immediate steps to alleviate the fear, such as a room relocation, increased supervision; providing emotional support and counseling to the resident during and after the investigation, as needed; protection from retaliation; monitor the alleged victim and other residents at risk, such as conducting unannounced management visits at different times and shifts. II. Incident of resident to resident abuse A. Record review Incident report dated 3/1/23 at 7:20 p.m., revealed a certified nurse aide (CNA) entered Resident #3 and #4's room to find Resident #3 was bleeding on his forehead and Resident #4 holding a belt. The incident was not observed but it was concluded that Resident #3 caused resident #4 emotional distress which led Resident #4 to believe Resident #3 was trying to kill him. Resident #4 said he struck out at Resident #3 to protect himself. Upon discovery the CNA discovering the injured resident reported the incident to the nurse on duty. The nurse on duty and the registered nurse (RN) supervisor on duty responded to assess the resident and determine the cause of the resident to resident altercation. Both residents believed and reported that the other was trying to kill them. Immediate response after the residents were assessed for injury was to separate the residents to a safe space. Resident assessments revealed: Resident #3 had a skin tear that measured 1.5 centimeters (cm) and was cleaned with normal saline. A band aide was applied and an ice pack was also applied to the area. The resident was administered, as needed, Tylenol 650 milligrams for his complaint of pain (3 out of 10, with 10 being the worst pain). It was determined to be caused by being hit by Resident #4 with the resident's belt. Resident #4 had a skin tear on his forearm, the cause of the injury was unknown; but determined to have occurred during the resident to resident altercation. The residents were immediately separated and an investigation was started. The resident's physician and power of attorney (POA), NHA and director of nursing (DON) were notified (read below for more information). Fifteen minute checks were started on 3/1/23 at 8:00 p.m., and continued to 3/5/23 at 5:45 p.m. Event note dated 3/1/23 at 9:45 p.m., by the DON revealed after the incident, Resident #3 was assessed by an RN and Resident #4 was moved (with official room change) to another unit with close monitoring. Neurological assessments were started per facility protocol. Event note dated 3/1/23 at 10:47 p.m., by registered nurse (RN) #2 revealed according to a unit nurse, a physical altercation occurred between two residents (Resident #3 and Resident #4) on 3/1/23 at 7:20 p.m. Resident #3 was found lying in bed on his back holding the right temple of his head. Upon assessment, Resident #3 had a bump on the right temple of his head that measured 3 centimeters (cm) by 2 cm with surrounding emerging bruises that measured 3 cm by 4 cm with a small opening in the skin. RN #2 cleaned the site with wound cleanser and a small ice pack was applied for five to ten minutes to reduce the swelling and discomfort. Neurological assessments were initiated. The resident was unable to explain his pain lever at this time, but no facial grimacing was observed. Resident #3 was resting in his bed without any signs or symptoms of distress. Resident #3 was placed on close monitoring and placed on the 24-hour report for future follow up. Event note 3/1/23 at 11:04 p.m., by RN #2 revealed Resident #4 was found sitting on his bed holding a leather belt in his right hand. RN #2 tried to remove the belt from Resident #4's hand, the resident became aggressive and said the belt was needed for protection. Resident #4 was assessed and observed to have a skin tear on the resident's left dorsal forearm that measured approximately 3 cm by 3 cm. The site was cleaned with a wound cleanser and covered with a bandage. Neurological assessments were initiated. The resident laid down on his left side on the bed and did not exhibit any discomfort or behaviors. The resident rested in bed without any signs or symptoms of distress. The resident was placed on close monitoring and placed on the 24-hour report for future follow up. Event note dated 3/1/23 at 11:25 p.m., by the DON revealed the interdisciplinary team (IDT) post fall huddle note and care plan were reviewed. After the (resident to resident ) incident, Resident #4 was confused, upset, and agitated. The resident tried to self-transfer from his bed to his wheelchair, missed the wheelchair and fell. The resident was assessed by a RN and was moved to the Center Unit. A one-to-one sitter was provided immediately for close monitoring of the resident. Event note dated 3/2/23 at 2:17 a.m., by a licensed practical nurse (LPN) revealed Resident #3 was on follow up for a resident to resident altercation. Resident #3 had a cut and a bump to the right side of his forehead. The resident was on neurological assessments and had no signs of pain or discomfort. The resident did not exhibit any behaviors. A nurse practitioner (NP) note dated 3/2/23 at 4:34 a.m., revealed Resident #3 was seen for involvement in a physical resident or resident altercation. The resident had no acute distress and did not appear to be in any significant discomfort. The staff told the NP that the Resident #3 had gotten into an altercation with his roommate yesterday. Resident #4 hit Resident #3 with a belt on his left forearm (however, it was Resident's #3's forehead that was injured per other documentation). Resident #3 had a small laceration to his left forearm with no active bleeding. Health status note dated 3/3/23 at 3:34 a.m., by a RN revealed Resident #4 continued on monitoring for resident to resident altercation. The resident did not exhibit any aggressive behaviors. A staff sitter was at the resident's bedside during the shift. Health status note dated 3/3/23 at 5:35 p.m., by an LPN revealed Resident #3 was on follow up for a resident to resident altercation. He had a cut on the right side of his forehead and was at baseline for neurological assessments. Health status note dated 3/3/23 at 10:31 p.m., by a LPN revealed Resident 34 was able to make his needs known and continued on 15-minute checks for a recent resident to resident altercation. The resident did not exhibit any aggressive behaviors. B. The social service director (SSD) typed/signed notes The SSD note dated 3/2/23 (not timed) revealed the SSD followed up with Resident #3 regarding his current mood. Resident #3 expressed he did not know English and his daughter was called to translate. The daughter translated that Resident #3 did not remember the altercation and was not afraid of anyone in the facility. The resident had no change in his mood, behavior or affect. The SSD note dated 3/2/23 (not timed) revealed the SSD spoke with Resident #4 regarding the resident to resident altercation. Resident #4 could not recall the altercation but did mention he did not like his roommate. The SSD asked him how he liked his new unit, and he said he was okay. Resident #4 had not officially met his new roommate at this time but sat with him for lunch. The SSD asked him how he felt his mood was today, he said he felt alright. Resident #4 had no change in his mood, behavior or affect at this time. III. Resident #3 A. Resident status Resident #3, age [AGE], was admitted on [DATE]. According to the March 2023 computerized physician orders (CPO), pertinent diagnoses included dementia of unspecified severity with other behavioral disturbances, Alzheimer's disease, wandering, and history of transient ischemic attack (stroke). The 2/27/23 minimum data set (MDS) assessment revealed the resident had severe cognitive impairment with a brief interview for mental status (BIMS) score of three out of 15. The resident had disorganized thinking. The resident's thinking was disorganized or incoherent (rambling or irrelevant conversation, unclear or illogical flow of ideas, and/or unpredictable switching from subject to subject). This behavior was present and fluctuated (came and went and changed in severity). The resident required extensive staff assistance for dressing, toileting, and personal hygiene. The resident required staff supervision for bed mobility, transfers, and eating. B. Resident observations On 3/21/23 at 9:51 a.m., the resident laid on the bed in his private room. He answered yes that he was feeling good and yes he liked his private room. He then did not want to talk any more. C. Record review Care plan for change in mood or behavior due to a medical condition was initiated on 3/1/23. The pertinent goals revealed the resident would not harm himself or others through the next review. The resident desired to be consulted with decisions related to his/her care through the next review. The intervention was to consult with the resident on preferences regarding customary routine. Care plan for the resident being at risk for elopement related to a diagnosis of dementia with wandering behavior was initiated on 3/1/23. The pertinent interventions included provide the resident with safe wandering. The resident was an elopement risk and staff were to encourage the resident to participate in activities to divert from exit seeking behavior. Care plan for the potential for decreased life satisfaction and psycho-social well-being subject to dementia and a change in environment was initiated on 3/2/23. The pertinent interventions were when conflicts arose, remove the residents to a calm safe environment and allow them to vent/share their feelings. Encourage participation from the resident, who depended on others to make their own decisions. Allow the resident time to answer questions and to verbalize feelings, perceptions, and/or fears. [NAME] for Resident #3 revealed under mood/behavior to encourage the resident to participate in activities to divert him from exit seeking. Offer redirection orientation to the current place and provide for safe wandering; the resident was an elopement risk. Use translator services as needed with care if the resident exhibited confusion resulting in aggression. IV. Resident #4 A. Resident status Resident #4, age [AGE], was admitted on [DATE]. According to the March 2023 CPO, pertinent diagnoses included Parkinson's disease, depression, psychosis, dementia without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety. The 2/6/23 MDS assessment revealed the resident was severely cognitively impaired with a BIMS score of six out of 15 with no behaviors. The resident required extensive staff assistance for dressing and personal hygiene. The resident required staff supervision for bed mobility, transfers, and toileting. B. Resident observations On 3/21/23 at 3:45 p.m., the resident sat in a wheelchair by the nurse cart on the Center Unit. He was interacting with the nurse related to his medications. He did not express any verbal or physical agitation or aggression. C. Record review Care plan for the potential to become physically aggressive with the roommate and also the potential to exhibit changes in orientation related to current level of dementia resulting in changes in behavior (walking down the hall unsafely, and delusions) was initiated on 3/6/23. The pertinent interventions were for staff to analyze times of day, places, circumstances, triggers, and what de-escalated behavior and document. Staff were to provide physical and verbal cues to alleviate anxiety; give positive feedback, assist verbalization of source of agitation, assist to set goals for more pleasant behavior, and encourage seeking out of staff members when agitated. If the resident communicated or demonstrated issues with the roommate, notify social services to assess and intervene as necessary. When the resident became agitated; staff were to intervene before agitation escalated; guide away from the source of distress; and engage calmly in conversation. If the response was aggressive, staff were to walk calmly away, and approach later. The resident's triggers for physical aggression were changes in the environment, including staff. The resident's behaviors were de-escalated by offering the resident to speak with family and allowing the requested space was initiated on 3/15/23. [NAME] for Resident #4 revealed for behavior monitoring and interventions for communication the staff were to provide physical and verbal cues to alleviate anxiety; give positive feedback, assist verbalization of source of agitation, assist to set goals for more pleasant behavior, and encourage seeking out of staff members when agitated. If the resident communicated or demonstrated issues with the roommate, notify social services to assess and intervene as necessary. The resident's triggers (stimulations/provokes) for physical aggression were changes in the environment, which included staff. The resident's behaviors were de-escalated by offering residents to speak with family, allowing him to have the space requested. When the resident became agitated: staff were to intervene before agitation escalated; guide the resident away from source of distress; engage the resident calmly in conversation; and if the resident's response was aggressive, staff were to walk away and approach later. V. Staff interviews The SSD and the social service assistant (SSA) were interviewed on 3/21/23 at 12:31 p.m. They said Resident #4 hit Resident #3 with a belt. They said Resident #4 had dementia and Alzheimer's disease and Resident #4 had dementia. They said at the time of the altercation, they shared a room on the North Unit. They said Resident #4 was moved to the Center Unit after the altercation. They said neither resident remembered the altercation when interviewed. They said this was the first altercation between these residents. They felt the altercation occurred, because Resident #3 came into the personal space of Resident #4. CNA #1 was interviewed on 3/21/23 at 2:48 p.m. CNA #1 said she was working on the North Unit at the time of the altercation. It was around 7:00 p.m. on 3/1/23, after dinner, the incident occurred , but she did not witness the altercation. CNA #1 said Resident #3 went into another resident's room and was looking for a bathroom. She redirected the resident back to his room and took him to the bathroom. CNA #1 said Resident #3 was taking a long time in the bathroom and she told him to pull the call light and wait for her when he had finished. CNA #1 said when she returned back to the room; both of the residents were bloody. Resident #3 was standing and Resident #4 was seated on his bed. She said Resident #3 had blood on the right side of his head. She said Resident #4 was bleeding from a skin tear from an old bruise on his forearm. Resident #3 said that Resident #4 was trying to kill him. CNA #1 said she asked Resident #4 if he had hit Resident #3 with a belt and Resident #4 said that Resident #3 was trying to kill him; both residents stated that the other one was trying to kill them. CNA #1 said she believed Resident #4 hit Resident #3 with the buckle on the belt. She said Resident #4 was holding a belt and did not want to give it to her because Resident #4 felt he needed the belt for protection from Resident #3. CNA #1 said she reported the incident to the nurse on duty. The residents were separated and Resident #3 was started on 15 minute checks. CNA #1 said Resident #3 said he did not like Resident #4; this was the first time she heard this statement. This was the first altercation between these two residents and the first altercation for either resident. LPN #2 was interviewed on 3/21/23 at 3:19 p.m. LPN #2 said CNA #1 reported that Resident #3 was bleeding from the right temple after a resident to resident altercation between Resident #3 and #4 on 3/1/23 at 7:20 p.m., LPN #2 said when she went into the room, Resident #3 was standing and Resident #4 was seated on his bed; holding a belt. LPN #2 said she reported the incident to the RN on duty and gathered first aid supplies. Pressure and an ice pack was applied to Resident #3's wound. Resident #3's vital signs were assessed and neurological assessments were started. LPN #2 said Resident #4 had a skin tear to his forearm and did not say how he got the skin tear. Neither resident complained of pain. The RN on duty also conducted a full assessment on both residents. LPN #2 said Resident #4 said he hit Resident #3 for personal protection. LPN #2 did not see any blood on the belt or the buckle. Resident #4 was assisted to a neighboring unit for his protection. LPN #2 said to her knowledge, this was the first altercation between these two residents. RN #2 was interviewed on 3/22/23 at 9:00 a.m. RN #2 said on 3/1/23 at approximately 7:30 p.m, she entered resident #3 and #4's room. Resident #4 was seated in the middle of his bed holding a belt and was agitated and yelling. Resident #4 would not give up the belt, saying he needed to keep the belt for protection from Resident #3. Resident #4 had a skin tear to his forearm and would not let RN #2 touch him to assess the injury. RN #2 said she continued to talk with Resident #4 and he finally calmed down and allowed her to clean and bandage the skin tear. Then he allowed staff to take him to a room in the Center Unit. Resident #4 eventually allowed her to complete a head to toe assessment Resident #4's vital signs were found to be within normal range. RN #2 said Resident #3 was very quiet and was found laying in his bed holding on to the right temple area of his head. Resident #3 had a bump on the right temple but showed no signs or agitation or symptoms of being in pain. Pain level was assessed by facial expressions because he was not able to give verbal indication of pain.RN #2 said she completed the initial neurological assessments; all vital signs were in normal range. An ice pack covered with a wash cloth was applied to the resident's temple. The RN had to hold the ice pack in place because the resident kept trying to remove it. RN #4 said she concluded that Resident #4 hit Resident #3 with the buckle of his belt on the right temple area. RN #2 said both residents were separated after discovery of the physical altercation. The NHA and the DON were interviewed on 3/22/23 at 2:24 p.m. They said the residents had been roommates for approximately two weeks. They said they had not exhibited any signs of aggressive behaviors towards each other, prior to this altercation. They said Resident #3 had a tendency to stare at Resident #4. They said Resident #3 was close to Resident's #4 bed and was staring at him. Resident #4 felt he needed to defend himself with the belt and said he did hit Resident #3 with the belt. They said they were unsure if Resident #3 was struck with the buckle of the belt. They said Resident #4 was placed on 15-minute checks with a one-to-one sitter. They said after the altercation, Resident #4 was moved to the Center Unit. VI. Staff in-service for Resident #3 and Resident #4's altercation In-service dated 3/6/23 and 3/7/23 (both not timed) revealed one of the concerns that was discussed pertained to the altercation between Resident #3 and Resident #4. The inservice document that staff intervention when residents were involved in abuse altercations were a priority and all staff that were working on the floor were responsible to intervene and prevent any altercation if possible. Staff were to refer to the resident's [NAME] (computerized information system for quick references) or consult with the nurse on duty for appropriate and effective interventions. If an altercation occurred, it needed to be reported to the DON and NHA immediately; timely reporting was crucial. .

Based on observation, interview, record review, and facility policy review, the facility failed to ensure dignity was provided by failing to cover a urinary catheter drainage bag for one (Resident #14) of two residents reviewed for urinary catheters. Findings included: A review of the facility policy titled, Dignity, dated 08/03/2021, revealed, Policy: Each resident has the right to be treated with dignity and respect. Interactions and activities with residents by staff, temporary agency staff, or volunteers must focus on maintaining and enhancing the resident's self-esteem, self-worth, and incorporating the resident's goals, preferences and choices . Examples of treating residents with dignity and respect include, but are not limited to: 7. Refraining from practices demeaning to residents, such as leaving urinary catheter bags uncovered. A review of a 04/06/2022 quarterly Minimum Data Assessment (MDS) revealed Resident #14 had a Staff Assessment of Mental Status indicating the resident had severe cognitive impairment. Per the MDS, the resident had diagnoses including dementia, obstructive uropathy, benign prostatic hyperplasia, and retention of urine. The MDS noted Resident #14 did not walk, used a wheelchair for locomotion, and required an indwelling urinary catheter. An observation of Resident #14 on 06/27/2022 at 11:37 AM revealed the resident sat in a wheelchair in the dining room with a visible catheter drainage bag containing urine. An observation on 06/27/2022 at 1:40 PM revealed Resident #14 sat in a wheelchair in a hallway near the nurses' station with a visible catheter drainage bag containing urine. An observation on 06/27/2022 at 3:58 PM revealed Resident #14 rested in bed with an uncovered catheter drainage bag visible from the open doorway. The catheter drainage bag contained urine. An observation on 06/28/2022 at 10:22 AM revealed Resident #14 sat in a wheelchair in a hallway near the nurses' station with a visible catheter drainage bag containing urine. An observation on 06/28/2022 at 12:05 PM revealed Resident #14 sat in a wheelchair in a hallway near the nurses' station with a transparent plastic bag covering the catheter drainage bag with urine visible in the bag. An observation on 06/28/2022 at 2:09 PM revealed Resident #14 sat in a wheelchair in the dining room with a transparent plastic bag covering the catheter drainage bag, with urine visible in the bag. An observation on 06/28/2022 at 3:02 PM revealed Resident #14 sat in a wheelchair in the resident's room with a transparent plastic bag covering the catheter drainage bag, with urine visible in the bag. An observation on 06/28/2022 at 4:07 PM revealed Resident #14 sat in a wheelchair in the dining room with a transparent plastic bag covering the catheter drainage bag, with urine visible in the bag. An observation on 06/29/2022 at 9:52 AM revealed Resident #14 sat in a wheelchair in the dining room with a transparent plastic bag covering the catheter drainage bag, with urine visible in the bag. An observation on 06/29/2022 at 12:21 PM revealed Resident #14 sat in a wheelchair in a hallway near the nurses' station with a transparent plastic bag covering the catheter drainage bag, with urine visible in the bag. During an interview on 06/30/2022 at 10:06 AM, Certified Nursing Assistant (CNA) #1 stated the catheter drainage bag should be covered while Resident #14 was in the wheelchair and bed, noting an uncovered bag is a dignity issue. During an interview on 06/30/2022 at 10:13 AM, Recreation Staff #2 stated a resident's catheter drainage bag should be covered for respect and dignity. During an interview on 06/30/2022 at 10:15 AM, Licensed Practical Nurse (LPN) #3 noted Resident #14's catheter bag should be covered so it did not look offensive. LPN #3 stated, We don't want people to walk by and see the urine. It is a dignity issue. During an interview on 06/30/2022 at 12:05 PM, the Director of Nursing (DON) stated her expectation was for staff to cover a resident's catheter bag because it was a dignity issue. During an interview on 06/30/2022 at 12:09 PM, the Administrator stated a resident's catheter bag should not be visible and should be covered as an aspect of dignity.

Based on observations, interviews, record review, and facility policy and document review, the facility failed to: 1. Conduct a thorough visitor screening for COVID-19 for three of four days of the survey; and 2. Prevent possible contamination of one resident's catheter drainage bag by allowing it to rest on the floor for one (Resident #14) of two residents sampled for catheter care. Findings included: A review of a facility policy titled, Visitor - Screening/Communication/Visitation/Education, updated 05/19/2022 revealed, Visitors will be screened for COVID-19 in accordance with current CDC [Centers for Disease Control], CMS [Centers for Medicare and Medicaid Services], and local and state guidelines. This screening will include: -Symptoms of COVID-19, or -Have a positive viral test for COVID-19, or -Close contact with someone with SARS-COV-2 infection . Education should be provided to visitors on the following: -COVID-19 -Visitor restrictions -Actions the facility is taking to protect them, the residents, and associates -Actions they can take to protect themselves while in the facility -The important role of social distancing -How to properly don and doff appropriate PPE [Personal Protective Equipment] -Hand Hygiene, respiratory hygiene, and cough etiquette -Wearing a face covering or mask during presence in the facility as a means of source control -Performing hand hygiene immediately before and after any contact with their facemask or cloth mask. A review of a General - Visitor COVID Screening form, updated 02/08/2022, listed the following signs and symptoms for visitor screening: 1. Fever = Temperature of greater than 100.0. If yes do not allow visit. 2. S/S [signs/symptoms] of COVID-19 = Chills, repeated shaking with chills, New/Change in Cough, Shortness of breath, difficulty breathing, Fatigue, Muscle or body aches, Headache, New loss of taste or smell, Sore throat, Congestion, Runny nose, Nausea, Vomiting, Diarrhea, New sputum production, Hemoptysis = If Yes do not allow visit. 3. Have you been diagnosed with COVID-19 and have not completed the time/symptom-based requirements to come out of isolation = If Yes, do not allow visit. 4. In the last 10 days have you had close personal contact with a person with a + [positive] COVID-19 diagnosis and been asked to quarantine by a public health authority (Y/N) = If Yes, do not allow visit. 5. Visitor Acknowledgement: I understand that during my visit, I should wear a face mask and other PPE as directed by the facility, perform hand hygiene before and after my visit, and practice social distancing (6 [feet]) between myself and other residents and staff. The facility had a main entrance, and each hall including the main or Center hall had a keypad lock. In addition to Central, each of the other units, North, South, East, and West, had individual keypad locks to enter and exit the units. 1. An observation of visitor screening on 06/27/2022 at 9:01 AM revealed the Business Office Assistant (BOA) was at the entry desk. She measured and recorded the visitor's temperature and asked the visitor, Do you have any symptoms? The signs and symptoms of COVID were not asked or described nor was a list provided of the symptoms, and the visitor was not educated on infection control practices while they were in the building. The visitor was allowed entrance into the facility. An observation of a visitor on 06/28/2022 at 7:51 AM revealed the Business Office Manager (BOM) was at the entry desk. The BOM measured and recorded the visitor's temperature. No other information was requested, and education was not provided. An observation on 06/29/2022 at 8:09 AM revealed both the BOA and the BOM were at the entry desk. The BOM measured a visitor's temperature and asked the visitor, Do you have any symptoms? When asked what the symptoms were, the BOM used a list to read the symptoms to the visitor. The BOA then clarified the symptom list was on the General - Visitor COVID Screening form and the BOM was reading incorrectly from the staff's screening form. The BOM stated she was supposed to ask the screening questions of new visitors who had not previously entered the building. The BOM acknowledged the visitor had not been asked any questions or provided infection control education during three of three days of entry to the building. During an interview on 06/29/2022 at 8:14 AM, the Infection Control Preventionist (ICP) acknowledged staff did not ask questions about signs and symptoms of COVID for three of three days of building entry. The ICP stated staff should have asked about vaccination status, fever, the signs and symptoms listed on the form, and known exposure to COVID for all visitors every time they enter for a visit. The ICP stated visitors should be educated on personal protective equipment (PPE), handwashing, and social distancing while in the building. The ICP stated staff should use the General - Visitor COVID Screening form and ask the questions listed on the form. The ICP stated, They [staff] have been trained to ask about signs and symptoms; we have gotten away from it a bit. During an interview on 06/30/2022 at 12:01 PM, the Director of Nursing (DON) stated her expectation was for staff to do the screening for visitors and ask the questions for signs and symptoms of COVID. The DON stated visitors may not know what the signs and symptoms were and needed to be informed and given direction on social distancing, PPE, and handwashing. During an interview on 06/30/2022 at 12:09 PM, the Administrator stated it was his expectation the staff reviewed the signs and symptoms of COVID for visitors. 2. A review of a 04/06/2022 quarterly Minimum Data Assessment (MDS) revealed Resident #14 had a Staff Assessment of Mental Status indicating the resident had severe cognitive impairment. Per the MDS, the resident had diagnoses including dementia, obstructive uropathy, benign prostatic hyperplasia, and retention of urine. The MDS noted Resident #14 did not walk, used a wheelchair for locomotion, and required an indwelling urinary catheter. An observation on 06/27/2022 at 3:58 PM revealed the resident rested in bed. A urinary catheter bag hung from the bed frame and rested on the floor. An observation on 06/30/2022 at 9:37 AM revealed the resident slept in bed with the catheter drainage bag hanging from the bed frame and resting on the floor. During an interview on 06/30/2022 at 10:06 AM, Certified Nursing Assistant (CNA) #1 stated the catheter drainage bag should not touch the floor. CNA #1 stated they usually placed a towel under the bag for infection control purposes. An observation was conducted on 06/30/2022 at 10:10 AM with CNA #1, who confirmed the catheter bag was touching the floor. During an interview on 06/30/2022 at 10:15 AM, Licensed Practical Nurse (LPN) #3 stated catheter bags should be covered to be protective. LPN #3 stated the catheter bag should not touch the floor for sanitary reasons and due to possible risk of infection. During an interview on 06/30/2022 at 10:48 AM, the Infection Control Nurse (ICP) stated the catheter bag should not be on the floor, stating, Of course there is a possible risk of infection. During an interview on 06/30/2022 at 12:05 PM, the Director of Nursing (DON) stated the expectation was for staff not to allow catheter bags to touch the floor because it was a potential infection control issue with a risk for possible infection of a resident. During an interview on 06/30/2022 at 12:09 PM, the Administrator stated there may be infection control issues associated with a catheter bag being on the floor and a risk of possible resident infection.