**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a resident was free from staff to resident verbal abuse for one (R1) of five residents reviewed for abuse in the sample of five. Findings include: R1's Face Sheet documented an admission Date of 5/22/23 and listed diagnoses including Major Depressive Disorder, Hypertension, and Cerebral Infarction by history. R1's Minimum Data Set, dated [DATE] documented a Brief Interview for Mental Status Score of 14, indicating R1 has minimal deficits in cognition. R1's Care Plan dated 9/6/24 documented problem areas, (R1) may display short-term and long-term memory problems. R1's Nurses Notes, all authored by V7, Licensed Practical Nurse (LPN), documented the following: 11/8/24, 5:00pm, This nurse was called down to (R1's) room for a complaint of a skin tear. When I arrived I noted a large skin tear (to the) left forearm with large amount of bleeding. Pressure was applied to get bleeding to slow down. (V3, Certified Nursing Assistant/CNA) stated resident was in bedside table and he pulled resident wheelchair back and resident got a skin tear from arm being between bed and bedside table. Resident states, 'He grabbed my arm.' Noticing such a large skin tear, asked other nurse to look at it since it didn't look like it could be approximated with (trade name wound closure strips).Decision was made to send to ER (Emergency Room) for treatment. Notified (V10, Physician/Medical Director) per fax. Called (V5, R1's Power of Attorney) and made aware. Called and gave report to ER. Called (local medical transport company) for transportation. Resident was confused earlier, asking this nurse to take him to get his truck from his wife. An Abuse Investigation Witness Statement dated 11/8/24 at 7:45pm, signed by V3, CNA, stated, Upon entering (R1's) room, he was reaching down trying to pick something up off the floor. Trying to move the wheelchair to pick up what he was after and I noticed the chair was wedged between the bed, nightstand, and recliner. I lifted the rear of the wheelchair to get him unstuck. I was able to get him turned around and that's when I noticed the injury. Freaking out over the size of it. I hurried to find another CNA to grab a nurse. I found (V6, CNA) in another resident's room and asked her to get (V7). I went back to (R1's) room and he was starting to mess with the skin tear, with a loud, panicked voice I stated, Stop messing with it, grabbed his hands and rested them on the arms of the wheelchair, slowly and gently. (R1) started to blame me for the injury, saying, 'If you didn't twist my arm, that wouldn't have happened.' I stated, I didn't freaking do it, I didn't grab on your arm til you was messing with the laceration, being accused for a second time of causing it, being flustered and overwhelmed by the size of the skin tear. I also said, I wouldn't be that fu**ing stupid. I would not grab your arm and twist it. I apologized for cursing, it just slipped out due to the overwhelmingness of the situation. (V7 and V6) then arrived and took over. An Abuse Investigation Witness Statement dated 11/8/24 at 8:15pm, signed by V6, stated,(V8, LPN) asked me to take a package to a resident on the North Hall. I was talking to the resident and (V3) came running in and told me to grab (V7) because (R1) had a skin tear. On my way up to the nurses station, I heard (V3) yelling at (R1). (V3) said, 'I didn't fu**ing do it. You fu**ing did it .stupid.' (V7) and I went down to (R1's) room and (V3) said he didn't know what happened. (V3) asked if we needed help and (V7) told him that her and I could handle it. (V3) left the room. (V7) tried to dress the wound but since it was bleeding so much, she decided to send him to the ER. On 11/13/24 at 9:50am, R1 was awake and alert to himself, he could not name the facility, nor the current President. He was able to state it was November 2024 but could not give the date or day of the week. R1 exhibited evidence of significant cognitive slowing, in part evidenced by very delayed verbal responses. The Surveyor asked R1 if any staff at the facility had ever hurt him, and R1 stated, Yes, a few days ago, that guy who works here, with R1 pointing to his left forearm which was bandaged, saying, He twisted it.' R1 was unable to state the name of the staff member, but told the Surveyor to look at the report. R1 stated he does not know why the staff member did this, but the staff member was looking through R1's greeting cards, and R1 told him to stop looking at them, and then he twisted R1's arm. R1 stated he was sent to the ER for treatment and came back to the facility the same night. R1 stated he has not seen the staff member since the event occurred. R1 stated the arm is not painful, and he denied having any lasting emotional effects from the incident. R1 stated he did not recall this staff member yelling at him, or calling him names. On 11/13/24 at 10:45am,V7 corroborated the events of 11/8/24 as outlined above in her Nurses Notes. V7 stated V3 reported that R1 was leaning forward in his wheelchair and V3 was afraid he would fall forward, so V3 pulled the wheelchair backward, with the left forearm making contact with something, causing the skin tear. V7 stated R1 told her that V3 was looking through R1's greeting cards and R1 told him to stop doing it. V7 stated she did not report the allegation of abuse to V1, Administrator, because what V3 said happened made sense, and R1 had been confused earlier in the day. V7 stated she was later told by V1 that V7 should have contacted V1 immediately after the allegation was made. V7 stated staff also received re-education on the Abuse Policy. On 11/13/24 at 12:40pm, V3 stated he was working 7am to 7pm on 11/8/24. V3 stated he went into R1's room around 5pm to take him to the dining room, and saw R1, sitting in his wheelchair, wedged between the bed, the nightstand, and the recliner. V3 stated R1 was leaning forward and V3 was afraid he would fall. V3 stated he grabbed the wheelchair and pulled it back. V3 stated there were greeting cards scattered on the floor, and V3 bent over to pick them up. V3 stated R1 then accused V3 of stealing his cards, and at that point V3 saw a large skin tear on R1's left forearm. V3 stated he picked up R1's arm to examine it, and R1 said, You twisted my arm. V3 stated he went to get help, and when he came back, R1 was messing with the skin tear which was then bleeding profusely. V3 stated he told R1 not to touch the area. V3 stated, I get freaked out when I see a lot of blood. (R1) kept saying I twisted his arm, and I was arguing with him, and I said,' 'I'm not that fu**ing stupid, to grab and twist your arm ' V3 stated he did not yell at R1 or call him stupid. V3 stated at that point, V7 came in to deal with the wound, so he went to take care of other residents. V3 stated he worked the remainder of his shift and left at 7:00pm. V3 stated R1 was sent to ER and V3 had no further contact with him. V3 stated he had no previous issues with R1 prior to this event. On 11/13/24 at 1:20pm, V6 corroborated the details of 11/8/24 as per her interview statement as referenced above. V6 stated within minutes of hearing V3 yell at R1, she told V8, LPN, about it, and, (V8) said she would investigate it. On 11/14/24 at 10:25am, V1 confirmed she is the facility's Abuse Coordinator. V1 stated she found out about the abuse allegation on 11/8/24 in the evening when V12, Director of Administrative Services, called her to say the police had called the facility, wanting to come interview residents and staff about an abuse allegation. V1 stated she then began an immediate abuse investigation. V1 stated after the interviews and the incident re-creation, the physical abuse allegation will be unfounded. V1 stated since V3 admitted to cursing in front of R1, which is a violation of the facility's Abuse Policy, verbal abuse will be substantiated and V3 will be terminated from employment. The facility's Freedom from Abuse, Neglect, Exploitation and Misappropriation of Resident Property, Facility Abuse Management Policy and Procedures dated November 2024 stated, (The facility) affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of their personal property, corporal punishment and/or involuntary seclusion. (The facility) therefore; prohibits abuse, neglect, exploitation, misappropriation of resident property, corporal punishment, voluntary seclusion, use of physical or chemical restraints not required to treat the resident's medical symptoms, and has attempted to establish a resident sensitive and resident secure environment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to immediately report an allegation of staff to resident verbal and physical abuse to the facility's Abuse Coordinator for one resident (R1) of five residents reviewed for abuse in the sample of five. Findings include: R1's Face Sheet documented an admission Date of 5/22/23 and listed diagnoses including Major Depressive Disorder, Hypertension, and Cerebral Infarction by history. R1's Minimum Data Set, dated [DATE] documented a Brief Interview for Mental Status Score of 14, indicating R1 has minimal deficits in cognition. R1's Care Plan dated 9/6/24 documented problem areas, (R1) may display short-term and long-term memory problems, (R1) has potential for skin breakdown. At present is on aspirin therapy which may increase his potential for bruising and bleeding, and (R1 has) potential for falls related to unsteady gait, weakness and fatigue. (R1 has a) history of falls. (R1 is) alert and oriented with occasional confusion. R1's Nurses Notes, all authored by V7, Licensed Practical Nurse (LPN), documented the following: 11/8/24, 5:00pm, This nurse was called down to (R1's) room for a complaint of a skin tear. When I arrived I noted a large skin tear (to the) left forearm with large amount of bleeding. Pressure was applied to get bleeding to slow down. (V3, Certified Nursing Assistant/CNA) stated resident was in bedside table and he pulled resident wheelchair back and resident got a skin tear from arm being between bed and bedside table. Resident states, 'He grabbed my arm.' Noticing such a large skin tear, asked other nurse to look at it since it didn't look like it could be approximated with (trade name wound closure strips).Decision was made to send to ER for treatment. Notified (V10, Physician/Medical Director) per fax. Called (V5, R1's Power of Attorney) and made aware. Called and gave report to ER. Called (local medical transport company) for transportation. Resident was confused earlier, asking this nurse to take him to get his truck from his wife. 11/8/24, no time noted: Pressure dressing applied to slow bleeding. 11/8/24, 5:30pm: (Transport company) here to transfer to ER. 11/8/24,10:30pm:Returned to facility via facility van. Complaining of right knee pain. Tylenol given. Eating evening meal. Alert. (V5) here. (V5) states (trade name wound closure strips) were applied to the area with (trade name gauze bandage) wrap (at the ER). An Emergency Department Note dated 11/8/24 documented, (R1) is a [AGE] year old male with a past history of Constipation, Cerebral Vascular Accident, Depression, Gastroesophageal Reflux Disease, Hypertension, Serum Lipids high, and Weakness who presents for evaluation of skin tear to left arm. Patient reports that Aid was in room going through his birthday cards when patient told him it was then out of his business to be in his birthday cards. The Aid reached for patient's arm and jerked it away in a twisting manner, causing a skin tear. Medical decision making: [AGE] year old who presents with a skin tear. X-ray shows no acute fractures. Rest, Tylenol, dressing changes twice a day. Return if worsening symptoms. No questions or concerns at this time. A (State Agency) Facility Reported Incident dated 11/8/24 documented,(R1): Date of Occurrence: 11/8/24 at 5:00pm. Large laceration-skin tear. Left forearm, greater than 5cm (centimeters). Bleeding. Sent resident to ER (Emergency Room) for sutures. Met with (local) Police Officer this evening around 7:30pm. He informed me he was called to the hospital related to (R1), reporting a staff member twisting his arm. An Abuse Investigation Witness Statement dated 11/8/24 at 7:45pm, signed by V3, CNA, stated, Upon entering (R1's) room, he was reaching down trying to pick something up off the floor. Trying to move the wheelchair to pick up what he was after and I noticed the chair was wedged between the bed, nightstand, and recliner. I lifted the rear of the wheelchair to get him unstuck. I was able to get him turned around and that's when I noticed the injury. Freaking out over the size of it. I hurried to find another CNA to grab a nurse. I found (V6, CNA) in another resident's room and asked her to get (V7 Licensed Practical Nurse/LPN). I went back to (R1's) room and he was starting to mess with the skin tear, with a loud, panicked voice I stated, Stop messing with it, grabbed his hands and rested them on the arms of the wheelchair, slowly and gently. (R1) started to blame me for the injury, saying, 'If you didn't twist my arm, that wouldn't have happened.' I stated, I didn't freaking do it, I didn't grab on your arm til you was messing with the laceration, being accused for a second time of causing it, being flustered and overwhelmed by the size of the skin tear. I also said, I wouldn't be that fu**ing stupid. I would not grab your arm and twist it. I apologized for cursing, it just slipped out due to the overwhelmingness of the situation. (V7 and V6) then arrived and took over. An Abuse Investigation Witness Statement dated 11/8/24 at 8:15pm, signed by V6, stated,(V8, LPN) asked me to take a package to a resident on the North Hall. I was talking to the resident and (V3) came running in and told me to grab (V7) because (R1) had a skin tear. On my way up to the nurses station, I heard (V3) yelling at (R1). (V3) said, 'I didn't fu**ing do it. You fu**ing did it .stupid.' (V7) and I went down to (R1's) room and (V3) said he didn't know what happened. (V3) asked if we needed help and (V7) told him that her and I could handle it. (V3) left the room. (V7) tried to dress the wound but since it was bleeding so much, she decided to send him to the ER. On 11/13/24 at 9:50am, R1 was awake and alert to himself, he could not name the facility, nor the current President. He was able to state it was November 2024 but could not give the date or day of the week. R1 exhibited evidence of significant cognitive slowing, in part evidenced by very delayed verbal responses. The Surveyor asked R1 if any staff at the facility had ever hurt him, and R1 stated, Yes, a few days ago, that guy who works here, with R1 pointing to his left forearm which was bandaged, saying, He twisted it.' R1 was unable to state the name of the staff member, but told the Surveyor to, 'Look at the report.' R1 stated he does not know why the staff member did this, but the staff member was looking through R1's greeting cards, and R1 told him to stop looking at them, and then he twisted R1's arm. R1 stated he was sent to the ER for treatment and came back to the facility the same night. R1 stated he has not seen the staff member since the event occurred. R1 stated the arm is not painful, and he denied having any lasting emotional effects from the incident. R1 stated he did not recall this staff member yelling at him, or calling him names. On 11/13/24 at 10:45am, V7 corroborated the events of 11/8/24 as outlined above in her Nurses Notes. V7 stated V3 reported that R1 was leaning forward in his wheelchair and V3 was afraid he would fall forward, so V3 pulled the wheelchair backward, with the left forearm making contact with something, causing the skin tear. V7 stated R1 told her that V3 was looking through R1's greeting cards and R1 told him to stop doing it. V7 stated she did not report the allegation of abuse to V1, Administrator, because what V3 said happened made sense, and R1 had been confused earlier in the day. V7 stated she was later told by V1 that V7 should have contacted V1 immediately after the allegation was made. V7 stated staff also received re-education on the Abuse Policy. On 11/13/24 at 12:40pm, V3 stated he was working 7am to 7pm on 11/8/24. V3 stated he went into R1's room around 5pm to take him to the dining room, and saw R1, sitting in his wheelchair, wedged between the bed, the nightstand, and the recliner. V3 stated R1 was leaning forward and V3 was afraid he would fall. V3 stated he grabbed the wheelchair and pulled it back. V3 stated there were greeting cards scattered on the floor, and V3 bent over to pick them up. V3 stated R1 then accused V3 of stealing his cards, and at that point V3 saw a large skin tear on R1's left forearm. V3 stated he picked up R1's arm to examine it, and R1 said, You twisted my arm. V3 stated he went to get help, and when he came back, R1 was messing with the skin tear which was then bleeding profusely. V3 stated he told R1 not to touch the area. V3 stated, I get freaked out when I see a lot of blood. (R1) kept saying I twisted his arm, and I was arguing with him, and I said,' 'I'm not that fu**ng stupid, to grab and twist your arm ' V3 stated he did not yell at R1 or call him stupid. V3 stated at that point, V7 came in to deal with the wound, so he went to take care of other residents. V3 stated he worked the remainder of his shift and left at 7:00pm. V3 stated R1 was sent to ER and V3 had no further contact with him. V3 stated he had no previous issues with R1 prior to this event. On 11/13/24 at 1:20pm, V6 corroborated the details of 11/8/24 as per her interview statement as referenced above. V6 stated within minutes of hearing V3 yell at R1, she told V8, LPN, about it, and, (V8) said she would investigate it. On 11/13/24 at 1:40pm, V5 stated some time in the evening on 11/8/24, she was notified by V7 that R1 had sustained a skin tear. V5 stated she was then called by an ER nurse, who said that R1 was there, and, They were calling in a report of elder abuse because he said that one of the staff twisted his arm. V5 stated later that evening, V1 had spoken to her and said the facility was starting an abuse investigation. On 11/13/24 at 2:50pm, V8 stated on 11/8/24 at about 5pm she was alerted by V7 that R1 had a skin tear, and they worked together to assess the wound and control the bleeding. V8 stated R1 told V8, 'He (V3) grabbed my arm. V8 stated V6 reported to V8, 'That she heard (V3) yelling at (R1) but doesn't recall telling (V6) she would investigate it.' V8 confirmed she did not notify the Administrator about the incident. V8 stated after the event, staff were retrained on the Abuse Policy, and V1 told V8 she should have notified V1 immediately of R1's abuse allegation. On 11/14/24 at 9:40am, V2, Director of Nurses, stated R1 has very fragile skin and is prone to skin tears. V2 stated she has heard no complaints from residents or staff about V3, and she has only disciplined V3 for occasional tardiness. V2 stated abuse is to be reported immediately to V1. V2 stated she does not think V7 or V8 violated the abuse policy by not reporting to V1, because they thought the skin tear was an accident, and that R1 was confused when he said V3 hurt him. On 11/14/24 at 10:25am, V1 confirmed she is the facility's Abuse Coordinator. V1 stated she found out about the abuse allegation on 11/8/24 in the evening when V12, Director of Administrative Services, called her to say the police had called the facility, wanting to come interview residents and staff about an abuse allegation. V1 stated she then began an immediate abuse investigation. V1 stated after the interviews and the incident re-creation, the physical abuse allegation will be unfounded. V1 stated since V3 admitted to cursing in front of R1, which is a violation of the facility's Abuse Policy, verbal abuse will be substantiated and V3 will be terminated from employment. V1 stated she did not believe V7 and V8 failed to follow the Abuse Policy by not immediately reporting it to her, because they believed it was an accident and not abuse. The facility's Freedom from Abuse, Neglect, Exploitation and Misappropriation of Resident Property, Facility Abuse Management Policy and Procedures dated November 2024 stated, It is the policy of (the facility) to encourage and support all residents, staff, families, visitors, volunteers and resident representatives in reporting any suspected acts of abuse, neglect, exploitation, involuntary seclusion or misappropriation of resident property from abuse, neglect, misappropriation of resident property, and exploitation Any employee of (the facility) or volunteer who becomes aware of abuse, mistreatment, neglect, exploitation or misappropriation shall immediately report to the nursing home administrator. A), Definitions: Verbal Abuse is the use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to residents or families, or within their hearing distance, regardless of their age, ability to comprehend, or disability. Examples of verbal abuse include, but are not limited to, threats of harm, saying things to frighten a resident, such as telling a resident that he/she will never be able to see his/her family again (42CFR 483.13b Interpretive Guidelines).

Based on observation, interview, and record review the facility failed to follow enhanced barrier precautions for 8 of 12 residents (R5, R6, R8, R12, R18, R25, R35 and R41) reviewed for infection control in the sample of 25. The Findings Include: On the initial tour of the facility on 07/23/2024 beginning at 9:25 AM, there was one resident (R21) observed in the facility with signage indicating enhanced barrier precautions. During the tour of the facility R5, R6, R8, R12, R18, R25, and R35 were all observed to have indwelling catheters. On 07/23/2024 a Matrix for Providers (Form CMS 802) was provided by the facility with no residents marked for transmission-based precautions. On the same form documented under number 5 under pressure ulcers, R12 and R21 are the only two residents listed. On 07/23/2024 at 1:26 P.M., V3 (Minimum Data Set/Infection Preventionist) stated they have one resident on Enhanced Barrier Precautions. V3 stated R21 was on Enhanced Barrier Precautions for having MRSA (Methicillin-Resistant Staphylococcus Aureas) of the wound. On 07/23/2024 at 1:56 P.M., a tour of north hall noted to have one resident (R21) had signage on their door indicating they were on Enhanced Barrier Precautions (EBP). On 07/23/2024 2:00 P.M., no rooms were observed to have signage on the door indicating they were on EBP on the south hall. On 07/24/2024 at 12:48 P.M., V4 (Registered Nurse) stated a resident on enhanced barrier precautions you have to don gloves to go in the resident room. V4 stated she is unsure of what Enhanced Barrier Precautions are. On 07/24/2024 at 12:52 P.M., V5 (Licensed Practical Nurse) stated that she is not for sure what Enhanced Barrier Precautions means. On 07/24/2024 at 1:36 P.M., V2 (Director of Nursing) stated she was unaware the Enhanced Barrier Precautions are for residents with wounds and indwelling medical devices. V2 stated that V3 writes the polices for isolation and infection control practices. On 07/24/2024 at 2:24 P.M., V3 (Minimum Data Set/Infection Preventionist) stated she was unaware of wounds and indwelling medical devices were part of Enhanced Barrier Precautions. V3 stated she has started educating the nurses and the rest of the staff on Enhanced Barrier Precautions. R5's Resident Face Sheet documented an admission date of 08/31/2023. R5's Resident Face Sheet documented diagnoses including retention of urine and urinary tract infection. R5's Physician Order Form with a date of July 2024 documented an order for a 16 FR (French) indwelling catheter. R6's Resident Face Sheet documented an admission date of 04/13/2021. R6's Resident Face Sheet documented the following diagnoses: pneumonia, acute respiratory failure, weakness, chronic obstructive pulmonary disease, insomnia, chronic pain, chronic combined systolic and diastolic heart failure, vitamin d deficiency, hyperlipidemia, hypokalemia, constipation, arthroplasty, osteoarthritis, gastro-esophageal reflux disease without esophagitis, hypothyroidism and essential hypertension. R6's Physician Order Form dated July 2024 documented an order for a 16 FR indwelling catheter. R8's Resident Face Sheet documented an admission date of 11/10/2023. R8's Resident Face Sheet documented diagnoses including gross hematuria. R8's Physician Orders dated July 2024 documented an order for a 16 French indwelling catheter. R12's Resident Face Sheet documented an admission date of 02/15/2021. R12's Resident Face Sheet documented diagnoses including acute kidney failure, urinary tract infection, neuromuscular dysfunction of bladder, retention of urine, and chronic kidney disease. R12's Physician's Order Form with a date of July 2024 documented an order for a 16 Fr indwelling catheter. R18's Resident Face Sheet documented an admission date of 01/23/2019. R18's Resident Face Sheet documented the following diagnoses: cerebral infarction, dysphagia, hemiplegia and hemiparesis following cerebral infarction, lump in right breast, hypothyroidism, vitamin d deficiency, hyperlipidemia, essential primary hypertension and insomnia. R18's Physician Order Form for July 2024 documented an order for a 16 Fr indwelling catheter. R25's Resident Face Sheet documented an admission date of 08/14/2020. R25's Resident Face Sheet documented diagnoses including neuromuscular dysfunction of bladder. R25's Physician's Order dated July 2024 documented an order for 16 fr indwelling catheter. R35's Resident Face Sheet documented an admission date of 06/19/2023. R35's Resident Face Sheet documented diagnoses including retention of urine. R35's Physician Order Sheet documented an order for a 16 fr indwelling catheter. R41's Resident Face Sheet documented and admission date of 06/27/2024. R41's Resident Face Sheet documented the following diagnoses: anemia, syncope and collapse, hypercholesteremia, vitamin deficiency, generalized anxiety disorder, restless leg syndrome, allergic rhinitis, gastro-esophageal reflux disease, and constipation. R41's Physician Orders documented an order to apply santyl on left outer calf, Apply to necrotic skin / tissue daily then apply nonadherent dressing, and wrap with gauze until healed. According to Centers for Disease Control at https://www.cdc.gov/long-term-care-facilities/hcp/prevent-mdro/ppe.html?CDC_AAref_Val=https://www.cdc.gov/hai/containment/PPE-Nursing-Homes.html, Enhanced Barrier Precautions (EBP) are an infection control intervention designed to reduce transmission of resistant organisms that employs targeted gown and glove use during high contact resident care activities. EBP may be indicated (when Contact Precautions do not otherwise apply) for residents with any of the following: Wounds or indwelling medical devices, regardless of MDRO (Multidrug Resistant Organisms) colonization status and Infection or colonization with an MDRO.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to add fall prevention interventions for a resident at high risk for falls for 1 of 2 (R8) residents reviewed for falls in the sample of 25. Findings include: R8's Face Sheet documented an admission date of 10/05/20, with diagnoses including old Myocardial Infarction, Gastro-esophageal Reflux Disease, and Unspecified Dementia without Behavior Disturbance. A Minimum Data Set, dated [DATE] documented that R8 requires extensive assistance from at least two staff members for transfers. A 2/20/21 Physicians Order documented an order for,(trade name weighted lap cushion) while up to wheelchair for proper posture and safety. A 1/14/23 Fall Risk Assessment documented a score of 12, indicating R8 is at high risk for falls. A January 2023 Incident Study Form documented that on 1/22/23, on the 7:00am to 3:00pm shift, R8 sustained a fall while in her room. A 1/22/23 Fall Investigation authored by V2, Director of Nurses, documented, Factors contributing to the fall: (R8) had slid down in chair and continued sliding until on the floor. Resident activity at the time of the fall: Preparing for transfer. Action Plan/Intervention if Warranted: (Left blank). A Nurses Note dated 1/22/23 at 12:45pm documented,Resident slid to floor during transfer after lunch. No injuries noted. Didn't hit head. Family aware. Doctor faxed. R8's Care Plan dated 1/21/23 documented a problem area, (R8) has a potential for falls related to confusion and weakness. Transfers per two assist. (Weighted lap cushion) while up to wheelchair to promote safety and a proper sitting position. No new fall interventions had been added to the Care Plan after R8's 1/22/23 fall. On 6/6/23 at 10:40am, R8 was observed in her room sitting in her recliner. R8 was alert only to self. On 6/8/23 at 1:48pm, V5, Registered Nurse/Care Plan Coordinator, acknowledged no new Care Plan interventions had been added following R8's 1/22/23 fall. V5 stated staff felt as though R8's existing fall interventions were effective. V5 stated R8 is not at high risk for falls. On 6/9/23 at 8:17am, V2 stated that on 1/22/23, she and another staff member were preparing to transfer R8 from the wheelchair to the recliner. V2 stated the other staff member went to retrieve the sitting to standing mechanical transfer lift, and V2 then removed R8's weighted lap cushion, which is used for positioning R8 in the wheelchair. V2 stated R8 began sliding out of the wheelchair, coming to a stop when with her buttocks made contact with the floor. V2 stated by herself, she was unable to stop R8 from sliding. V2 stated R8 sustained no injuries. V2 stated no new fall interventions were added to R8's plan of care, as staff felt the existing interventions were working. An undated Fall Prevention Policy and Procedure documented,The interdisciplinary team will .develop interventions to address residents identified as at risk for falling and implement an interdisciplinary plan of care if necessary. Interventions should be based on the level of risk. Post Fall Management: The interdisciplinary team will .review fall prevention interventions and modify the plan of care as necessary.

Based on observation, interview, and record review, the facility failed to administer prescribed medication per physicians orders and manufacturers directions for two residents of ten residents (R9, R8) reviewed for medication errors in the sample of 25. There were thirty medication opportunities observed with a total of three administration errors, making the error rate 10 percent. Findings include: 1. R9's June 2023 Physicians Order Sheet(POS) and June 2023 Medication Administration Record (MAR) documented an order for Fluticasone 50 microgram spray, directions-two sprays in each nostril daily at 8:00am. On 6/7/23 at 7:16am,V3, Registered Nurse (RN) was observed administering medications to R9. V3 read aloud the directions on the MAR as referenced above. V3 did not shake the medication prior to administration. V3 administered one spray per each nostril, washed her hands, returned the medication to the medication cart, documented the administration, and began looking at the MAR for medication orders on the next resident for administration. When the surveyor pointed out the discrepancy between the order and the administration, V3 re-checked the MAR and acknowledged she should have given two sprays to each nostril. V3 then administered the remaining one spray to each nostril. On 6/8/23 at 11:55am, the Surveyor asked V3 if the Fluticasone should have been shaken before administration. V3 stated she was not sure. The Surveyor and V3 checked the directions on the Fluticasone manufacturers packaging which stated, Shake gently before administration. 2. R2's June 2023 POS and June 2023 MAR documented an order for, Humalog 100 units per milliliter Kwikpen, inject 8 units three times daily before meals. If premeal blood glucose is less than 120 mg/dl(Milligrams per Deciliter), inject 4(additional) units. If pre-meal blood glucose is less than 80 mg/dl, hold insulin. If premeal blood glucose is 250-300mg/dl, inject 2(additional) units. If premeal blood glucose is 301-350mg/dl, inject 3(additional) units. If premeal blood glucose is 351-400mg/dl, inject 4 (additional) units. If greater than 400 mg/dl, inject 5(additional) units. Diagnosis: Insulin Dependent Diabetes Mellitus. On 6/7/23 at 11:15am,V4, RN, was observed administering medications for R2. V4 checked R2's blood glucose level, which was 286. V4 retrieved R2's Humalog Kwikpen, and administered 8 units subcutaneously. V4 performed hand hygiene, left the room, and returned the Kwikpen to the medication cart. On 6/7/23 at 11:25am, the Surveyor approached V4 for clarification about the discrepancy between the order and the administration observation. V4 rechecked the order and acknowledged R2 should have had a total of 10 units of Humalog. V4 then administered the remaining 2 units to R2. A Medication Administration Policy dated 5/19/22 documented, Responsibility of the nursing professional is to be aware of the correct dosage prior to administration of medications .The nurse should always be knowledgeable of the medications they have prepared prior to administration .Read and follow any special instructions written on the labels.

Based on observation, interview and record review, the facility failed to maintain aseptic technique during wound care and perineal care for two (R49 and R7) of 13 residents reviewed for infection control in the sample of 31. Findings include: 1. On 06/15/22 at 2:10pm, a sign reading Contact Isolation was observed on R49's door. At that time, V3 (Licensed Practical Nurse/LPN) was observed performing wound care for R49's knee wound. V3 performed handwashing and donned gown and gloves. V3 placed extra gloves and a tube of a trade name antibiotic ointment onto the overbed table with no barrier underneath. After providing the treatment, V3, without doffing her contaminated gloves, picked up the extra gloves and placed them on the sink counter of the bathroom that R49 shares with two other residents. V3 then doffed the contaminated gloves, picked up the trash can and placed a liner in it, then picked up the tube of ointment and placed it back in the treatment cart. V3 then doffed her gown. Without washing her hands or performing hand hygiene, V3 then pushed the treatment cart back to the nurses' station. R49's Lab Report Wound Culture Left Knee dated 5/18/22 documented, Final Report (positive for) Rare Methicillin Resistant Staphylococcus Aureus. 2. On 06/16/22 at 10:15am, a sign reading Contact Isolation was observed on R7's door. At that time, V4 and V5 (both Certified Nursing Assistants/CNAs) were observed providing perineal care for R7. Both performed handwashing and donned gown and gloves. After cleansing the perineal area, V5, without doffing her contaminated gloves, touched R7's clean gown and underwear, the bed linens, R7's oxygen tubing, and R7's call light. R7's 6/2/22 Lab Report Urine Culture documented,Final Report: (Positive for) Escherichia Coli ESBL (Extended Spectrum Beta-Lactamase). An undated Contact Isolation Policy documents Hands must be washed after touching the patient or potentially contaminated articles and before taking care of another resident .articles contaminated with infected material .should be disposed of as infectious waste. On 06/16/22 at 11:00am, V2 (Director of Nurses/DON) acknowledged the above observations represented a breach in infection control protocols. V2 stated V5 had approached her after the observation and reported to V2 that V5 had realized after the fact that she had breached infection control protocols during the above observation.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation and record review, the facility failed to provide range of motion for one (R49) of one resident reviewed for risk of contractures/range of motion in the sample of 31. Findings include: On 06/15/22 at 1:32pm, V6 (Certified Nursing Assistant/CNA), was observed providing range of motion (ROM) services for R49. R49 was alert but oriented only to herself, displaying word salad and non sensical answers. V6 stated the facility has Restorative Program CNAs, but due to staffing issues, they work the floor now, so CNAs are responsible for doing restorative programming for their own residents. V6 stated as an example, today was his day off, but he got called in to work because two CNAs called in. V6 was asked how often R49 is getting ROM, to which V6 replied, Well, we do the best we can, she's supposed to be getting it daily, she gets it when we have time. V6 stated ROM is documented by the CNAs in a binder which contains the resident's restorative goals. V6 stated R49 is very stiff in the lower extremities and has a lot of pain with movement, so they usually focus on her upper extremities. V6 performed passive ROM to R49's shoulders, arms, and elbows for ten repetitions, but did not exercise the neck, hands, fingers, or wrists. R49's legs were noted to both be very stiff with limited ROM bilaterally. V6 extended R49's right leg slightly twice, and R49 complained of pain so V6 stopped. V6 made no attempt to try any of the other joints below the waist on either side of the body. R49's Minimum Data Set (MDS) dated [DATE] documented that R49 has impairment to both sides of the body of both the upper and lower extremities. R49's Care Plan dated 06/10/22 documented a problem areas, Requires 2 staff assist for transfers, poor weight bearing. Non ambulatory. Uses wheelchair for mobility. Noted spinal deformities with poor posture, limited ROM to all extremities, with a corresponding intervention, Complete voluntary movement/ROM assessment upon admission and review quarterly. Make recommendations to restorative nursing for appropriate placement in program as needed, and (R49) is not consistently active on her own. Some days she is very mobile and other days she does not initiate mobility on her own. An undated Restorative Program Guidelines Policy documented, Goals: Promote resident wellness and prevent decline and loss of independence whenever possible . Each resident on admission will be informally screened by admitting staff as to whether a resident will benefit from placement into a restorative/maintenance program all residents will be (re) assessed quarterly On 06/16/22 at 08:12am, V2 (Director of Nurses/DON) stated she is the staff member responsible for the facility's restorative nursing program. V2 acknowledged R49's lower legs are very stiff with limited ROM. V2 stated R49 does not have a formal program of restorative nursing at this time, so there is no documentation of her getting it. V2 acknowledged R49 needs to be reassessed regarding receiving ROM to prevent decline in level of functioning and contractures, and that she will assess R49 and develop a restorative nursing program for R49.

Based on observation, interview and record review, the facility failed to provide oxygen therapy humidification for 3 (R47, R38, R3) of 3 residents reviewed for oxygen therapy services in the sample of 31. Findings Include: 1. On 06/14/22 at 11:11 AM, R47 was observed wearing O2 (oxygen) via NC (nasal cannula) at 3L (liters). R47 stated she has resided in the facility for a couple weeks, and never wore O2 prior to admitting to the facility after having a fall and heart attack while at home. R47 stated her nose gets awfully dry and stated she has experienced minor nose bleeds which she has not reported to nursing staff. R47's O2 concentrator was observed as having a humidity bottle that was empty and dated 6/3. R47 is alert and oriented to person, place, and time. On 06/15/22 at 12:46 PM, R47 was observed as having a full humidity bottle in place on her O2 concentrator. R47 stated she asked the nurse to replace the empty bottle yesterday to help keep her nose from drying out, in which the nurse did. R47's Physician Orders for June 2022 documents an order for O2 2-5L PRN (as needed). R47's Treatment Sheet for June 2022 documents the treatment of Change O2 cannula and humidity bottle wkly (weekly) and PRN. This treatment is documented as being completed on 6/10/22, although the bottle observed in place on 6/14/22 was dated 6/3. 2. On 06/14/22 at 11:19 AM, R38 was observed utilizing O2 per NC at 4L. R38's O2 humidity bottle was observed as being empty and dated 6/3. R38 stated during the night last night he had a nosebleed that he didn't report to nursing staff. R38 was alert and oriented to person and place. On 06/15/22 at 10:43 AM, R38's humidity bottle on the O2 concentrator was observed as being empty with the bottle dated 6/3. R38 was observed as having O2 on per NC at 4L. On 06/16/22 at 09:22 AM, R38's humidity bottle on the O2 concentrator was observed as being empty with the bottle dated 6/3. R38 was observed as having O2 on per NC at 4L. R38's Physician Orders for June 2022 documents an order for O2 2-5L PRN. R38's Treatment Sheet for June 2022 documents the treatment of Change O2 cannula and humidity bottle wkly and PRN. This treatment is documented as being completed on 6/3/22, and next due on 6/10/22 with no initials present, indicating the treatment was not completed. 3. On 06/14/22 at 10:20 AM, R3 was observed with O2 on per NC at 2L. The humidity bottle connected to the O2 concentrator was observed as being empty. The date written on the bottle was 6/3. R3 was alert and oriented to person, place, and time. On 06/15/22 at 12:50 PM, R3 was observed as having a full humidity bottle on her O2 concentrator. R3 stated she had noticed it was empty, so asked for a new one yesterday, which the staff then replaced. R3's Physician Orders for June 2022 document an order for O2 2-5 L PRN. R3's Treatment Sheet for June 2022 documents the treatments of, Change O2 tubing and Humidity bottle wkly and PRN. This is documented as being completed on 6/3/22 and next scheduled for 6/10/22 with the initials circled, indicating the change was not completed. On 06/16/22 at 09:50 AM, V2 (Director of Nursing) stated that the facility had experienced a supply shortage with obtaining humidity bottles for oxygen concentrators after changing companies. V2 stated the facility has changed back to their former supply company and will get the humidity bottles changed on the concentrators. V2 acknowledged that the humidity bottles were not changed weekly by nursing staff in accordance with R47, R38 and R3's Treatment Sheets. V2 confirmed the O2 humidity bottles should have been replaced when empty. The facility policy titled Oxygen Therapy-Mask and Nasal Cannula with a date of 3/17/22 states, Humidification is used in all cases unless ordered otherwise. The same policy goes on to state, Humidity bottles and tubing are changed at least every two weeks and dated by the nurse on duty.