**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to cover a urinary catheter bag with a privacy bag for one of one resident (R21) reviewed for dignity in the sample of 28. Findings include: R21's current computerized medical record, documents R21 was admitted to the facility on [DATE] with diagnoses which included Cerebral Infarction, Hemiplegia and Hemiparesis Following Cerebral Infarction Affecting Right Dominant Side, Chronic kidney Disease, Retention of Urine, Other Specified Disorders of Bladder, and Type 2 Diabetes Mellitus. R21's MDS (Minimum Data Set) assessment dated [DATE] documents a BIMS (Brief Interview for Mental Status) Score of 12/15, indicating (moderate cognitive impairment) and R21 has an indwelling urinary catheter. R21's Physicians Order dated 1/9/24 documents R21 has an (indwelling) catheter for diagnosis of Urinary Retention. On 11/24/24 at 9:46 AM, R21 was sitting in the recliner in his room. R21's urinary catheter bag was attached to R21's walker. There was no cover on the urinary catheter bag. The bag was half full of urine. The catheter bag with urine was visible from the hallway. On 11/25/24 at 10:43 AM, R21 was sitting in his recliner in his room. The urinary catheter bag was attached to R21's walker and the urine in the bag was visible from the hallway. On 11/26/24 at 8:48 AM, R21 was sitting in his recliner in his room. The catheter bag was attached to R21's walker and the uncovered catheter bag was visible from the hallway. On 11/26/24 at 10:05 AM, V2/Director of Nursing stated that urinary catheter bags are to be covered with a privacy bag. At 11:26 AM, V2 verified that R21's urinary catheter bag had not been covered and a privacy bag had been applied. The Resident Rights Booklet dated 11/18, documents Your facility must treat you with dignity and respect and must care for you in a manner that promotes your quality of life. Your facility must be safe, clean, comfortable, and homelike.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure the call light was in reach for one resident (R2) out of 12 residents reviewed for call lights in the sample 28. Findings include: R2's Current Medical Record documents that R2 was admitted to the facility on [DATE] with diagnoses that included Dementia, Urinary Tract Infection, Type 2 Diabetes Mellitus, Essential (Primary) Hypertension, Acute and Chronic Respiratory Failure with Hypoxia, Chronic Kidney Disease (stage 3), Neuromuscular Dysfunction of Bladder, and Chronic Obstructive Pulmonary Disease. R2's Minimum Data Set assessment dated [DATE] documents R2 has a BIMS (Brief Interview of Mental Status) of 3 (severe cognitive impairment). On 11/24/24 at 10:10 AM R2 was lying in bed wearing oxygen. R2 was asked if she had her call light. R2 pulled down the covers and stated, I can't find it. V6/Licensed Practical Nurse came to R2's room and found the call light draped across the bedside table that was not within R2's reach. On 11/26/24 at 10:03 AM V2/Director of Nursing stated that all residents should always have their call light in reach. The Call Light policy (not dated) documents Procedure To respond promptly to resident's call for assistance. 8. When providing care to the residents be sure to position the call light conveniently for the resident to use. Tell the resident where the call light is and show him/her how to use the call light. 11. Be sure all call lights are placed on the bed at all times, never on the floor or bedside table.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to ensure a resident's Physician Order and Practitioner Order for Life-Sustaining Treatment (POLST) DNR (Do Not Resuscitate) code status was updated and accurate within the resident's care plan for one of 12 residents (R35) reviewed for Advanced Directives in the sample of 28. Findings include: R35's State Agency Uniform Practitioner for Lift-Sustaining Treatment (POLST) form dated 11-9-24 and signed by (V11/R35's Family Representative) documents No CPR (Cardiopulmonary Resuscitation): DNR. R35's Physician's Order dated 11-10-24 and signed by V13 (Physician) documents, Code Status: DNR. R35's Current Advanced Directive Care Plan documents, I am not at or approaching end of life at this time. My wishes for advanced directives and end of life care will be honored. Full Code-full treatment. On [DATE] at 10:23 AM V10 (Social Service Director) stated, (R35) decided to change his advanced directives from a full code to a DNR on 11-9-24. I did not update (R35's) Advanced Directive's Care Plan to indicate (R35's) change to a DNR. The Advanced Directives policy dated 11/2024 documents 1. The facility defines the following in accordance with current OBRA (Omnibus Budget Reconciliation Act) definitions and guidelines: a. Advance care planning- a process of communication between individuals and their healthcare agents to understand, reflect on, discuss, and plan for future healthcare decisions for a time when individuals are not able to make their own healthcare decisions. b. Advanced Directive- a written instruction, such as a living will or durable power of attorney for health care, recognized by state law (whether statutory or as recognized by the courts of the state), relating to the provisions of health care when the individual is incapacitated. 3. Do Not Resuscitate (DNR)- indicates that, in case of respiratory or cardiac failure, the resident, legal guardian, health care proxy, or representative (sponsor) has directed that no cardiopulmonary resuscitation (CPR) or other life-sustaining treatments or methods are to be used. If the Resident Has an Advanced Directive 1. If the resident or the resident's representative has executed one or more advanced directive(s), or executes one upon admission, copies of these documents are obtained and maintained in the same section of the resident's medical record and are readily retrievable by any facility staff. 2. The director of nursing services or designee notifies the attending physician of the advanced directives (or changes in advanced directives) so that appropriate orders can be documented in the resident's medical record and plan of care. 4. The plan of care for each resident is consistent with his or her documented treatment preferences and/or advanced directive.

Based on observation, interview, and record review the facility failed to develop and implement restorative range of motion programs for two of two residents (R4 and R6) reviewed for functional limitations in range of motion in the sample of 28. Findings include: 1. R4's MDS (Minimum Data Set) Assessments dated 10/6/24 and 7/7/24 document R4 is cognitively intact, has functional limitations in range of motion to one side of the upper and lower extremities, and does not receive therapy, range of motion, splint/brace assistance, or any restorative programs. R4's current Care Plan documents R4 has the diagnoses of Hemiplegia affecting the left nondominant side and Pain. This same Care Plan does not address R4's limitations in range of motion to the left upper and lower extremities. On 11/24/24 at 10:07 AM R4 was sitting in his wheelchair. R4's left hand was in a closed fist with his fingers facing inward towards his palm with no splint or assistive device. R4 was unable to open his left hand. R4 stated he does not receive any range of motion exercises and the staff do not put a roll or splint in his left hand. R4 stated he would like to receive range of motion exercises. 2. R6's MDS Assessments dated 11/10/24 and 8/11/24 document R6 is cognitively intact, has functional limitations in range of motion to both sides of the upper extremities, does not receive therapy, range of motion, splint/brace assistance, or any restorative programs. R6's current Care Plan documents R6 has the diagnoses of Rheumatoid Arthritis and Limited Mobility. This same Care Plan does not address R6's limitations in range of motion to the upper extremities. On 11/24/24 at 10:09 AM R6 was sitting in her recliner in her room watching television. Both of R6's hands were in closed fists with her fingers facing inward towards her palms with no splint or assistive devices. R6 stated she has not had exercises in over a year and would like staff to do exercises with her. On 11/25/24 at 11:34 AM V4 (Agency CNA/Certified Nursing Assistant) stated, (R4 and R6) do not receive range of motion or any type of restorative programs that I am aware of. I take care of (R4 and R6) full time. On 11/25/24 at 12:05 PM V2 (Director of Nursing) stated, We (the facility) have not had a restorative nurse or CNA for a few months now. (R4) and (R6) do not receive any restoratives or range of motion and probably should. The Restorative Nursing Services policy dated 11/2024 documents Residents will receive restorative nursing care as needed to help promote optimal safety and independence. Policy Interpretation and Implementation: 1. Restorative nursing care consists of nursing interventions that may or may not be accompanied by formalized rehabilitative services (e.g. (example) physical, occupational or speech therapies). 3. Restorative goals and objectives are individualized and resident-centered and are outlined in the resident's plan of care. 5. Restorative goals may include, but not limited to supporting and assisting the resident in: a. adjusting or adapting to changing abilities; b. developing, maintaining or strengthening his/her physiological or psychological resources; c. maintaining his/her dignity, independence and self-esteem; and d. participating in the development and implementation of his/her plan of care. The ROM (Range of Motion) Contracture Care Policy and Procedure dated 11/2024 documents It is the policy of this facility that residents will be assessed on admission and quarterly, or more often as a change of condition warrants, for risk factors for development of contractures. An individualized ROM program may be developed based on the resident's unique assessed risk factors and involve formalized therapy and/or restorative nursing, as applicable. This program will be reflected in the interdisciplinary care plan and will be systematically and consistently followed. Key Points Formalized therapy will work closely with nursing staff, as appropriate, communicating and planning for goals and approaches so the team can be consistent in providing the care and services for maintaining joint mobility and for contracture care. An individualized plan will be based upon the comprehensive assessment and resident/representative input after discussion on risks and benefits to include interventions for staff to follow for prevention of contractures. If the purpose of ROM is other than prevention 1.e.(example), building muscle strength, Physical Therapy may assist in determining the repetition program. The program will also be modified for those residents that for whatever reason are unable to tolerate the recommended repetitions. 3. A physician's order will be obtained for physical or occupational therapy to evaluate and treat if there is any indication that the resident could benefit from these services. 4. Nursing orders can be initiated to start a preventative ROM movement program if there is no indication for formalized therapy or if there is no contradiction to the ROM movements. When in doubt, consult with physician and therapy for limitations and precautions for specific movements. 5. The nurse will review functional assessment to assure specific risk factors for contractures and contracture care are identified, addressed, and planned for. 7. When a resident has been identified as at risk for contractures and there is no indication to involve formalized therapy, the resident's name and ROM interventions will be added to the nursing tracking tool for Restorative, goals and approaches determined and care planned, and a restorative nursing flow sheet implemented. 8. When a resident has a contracture or contractures already present, formalized therapy will evaluate and work with nursing department in setting up goals and approaches for the plan that specifically addresses this individual's unique needs. 10. Individual plans for preventive ROM and contracture care will be followed as planned seven days a week or as indicated based upon assessed needs. 14. Initial flow sheet or document in the electronic health record daily.

Based on interview and record review the facility failed to ensure physician ordered daily weights were obtained for a resident with congestive heart failure for one of one resident (R1) reviewed for hydration in the sample of 28. Findings include: R1's current care plan, dated 11/8/24, documents R1 has diagnoses including but not limited to: Edema, Retention of Urine, Atherosclerotic Heart Disease of Native Coronary Artery, Heart Failure, Atrial Fibrillation, Presence of Cardiac Pacemaker, Volume Depletion, Dehydration (history), Chronic Diastolic Congestive Heart Failure (CHF), Hypertensive Heart and Chronic Kidney Disease. This care plan documents I have diagnosis of Hypertension with routine medication to treat. Intervention: Weigh me as ordered. This same care plan also documents I am at risk for dehydration. I receive a diuretic medication two times a day for edema. Intervention: Weigh me as ordered 5/02/24, Daily weight for CHF. R1's Current Physician Order sheet, dated 11/26/24, documents an order for Daily weight everyday shift for CHF. This order has a start date of 5/3/2024. R1's Treatment Administration Record (TAR), dated September 2024 documents 17 scheduled daily weights were not completed. Of the 17 undocumented weights, this same TAR documents R1's weights were not completed from 9/17/24-9/25/24, totaling of nine consecutive missed weights. R1's TAR, dated October 2024, documents nine scheduled daily weights were not completed throughout the month. R1's TAR, dated November 1st-24th, 2024, documents ten scheduled daily weights were not completed over 24 days. On 11/26/24 at 10:40 AM, V3 (Certified Nursing Assistant) confirmed the CNA staff are the ones who complete resident weights. V3 stated To be honest we have a lot of nursing assistants who are agency and don't always know the routine. They may be responsible for vitals but not realize that weights are included in that. If the weight isn't done, then the nurse should be notified. I know (R1) can sometimes refuse weights or be difficult but not all of the time. I know sometimes her weights have been missed in error. On 11/26/24 at 12:20 PM, V2 (Director of Nursing) confirmed that R1 does not have daily weights documented every day, as ordered. V2 stated that if R1 is refusing to be weighed or the facility staff miss a weight then documentation and physician notification should be completed and R1's medical record does not reflect that documentation related to R1's missed daily weights from September- November 2024. The facility's Weight Measurement policy, dated 11/2018, documents It is the policy of (the facility) that resident's weights are taken upon admission, re-admission, monthly and as indicated. Residents with congestive heart failure will be weighed as ordered by physician. Ordering physician will be notified of weight gains and losses of two pounds or greater in one day or five pounds or greater in one week unless other parameters are specified by their physician.

Based on Observation, Interview and Record Review, the facility failed to document a diagnosis and identify target behaviors to warrant the use of Risperidone (antipsychotic medication), complete a psychotropic medication assessment, and attempt a gradual dose reduction of Risperidone for one of three residents (R31) with a diagnosis of Dementia, reviewed for antipsychotic medications in the sample of 28. Findings include: 1. On 11/24/24 at 11:40 PM R31 was sitting in the facility's dining room in a wheelchair awaiting lunch. R31 was quiet, looking forward, smiled and did not exhibit any behaviors. On 11/25/24 at 9:15 AM, R31 was sitting in his wheelchair being pushed through the hallway of the facility. R31 was cooperative with mobility assistance throughout the building and was not exhibiting any behaviors. R31's current Physician Order sheet, dated 11/26/24, documents R31 has an order for Risperidone 0.25 milligrams (antipsychotic medication), Give one tablet by mouth two times a day for Dementia with behavioral disturbance. R31's current Care Plan, dated 11/21/24, documents R31 has diagnoses of Non-traumatic Chronic Subdural Hemorrhage, Cognitive Communication Deficit, Major Depressive Disorder, Unspecified Dementia and Insomnia. This same care plan documents I (R31) take psychotropic medication(s) related to dementia with behavioral disturbances. Interventions/Tasks: I am on behavior tracking for my verbal aggression, including but not limited to outburst of yelling out directed at others. R31's behavior summary reports for November 1-26th, 2024 document R31 is being monitored for behaviors of insomnia, verbal aggression, getting up on his own, resisting care, physical aggression, threats to staff, inappropriate verbal behaviors, depression, exit seeking and agitation. These weekly summary reports document R31 has exhibited zero behaviors for the month. On 11/26/24 at 10:08 AM, V2 (Director of Nursing) stated Since admission in February 2024, (R31) has been resistive to cares. For a while he wanted to leave. He is not harmful to other residents or himself. (R31) has not had any dose reduction of his Risperidone due to the Psychiatrist (V17) not allowing it. We (the facility) do not have psychotropic medication assessments. I wasn't aware they needed to be done. On 11/26/24 at 10:30 AM, V3 (Certified Nursing Assistant) stated (R31) has some behaviors depending on your approach and patience that you give him. (R31) doesn't like to be told what to do. He can be aggressive with cares when staff are trying to help or get him to do something. (R31) will get up on his own and walk when he's not supposed to. He's not a threat to himself and hasn't shown signs of aggressive or psychotic behaviors towards other residents. (R31's) behaviors get more increased in the evenings as with typical dementia. When his family leaves, he wants to also leave and do the things he used to do. (R31) has more confusion in the evening. On 11/26/24 at 11:12 AM, V10 (Social Service Director) stated When (R31) came to us he was placed on all of his home medications. He admitted in February 2024 and has been on the Risperidone since just after his admission. (R31) had a procedure done in May 2024 for bleeding in his brain and his behaviors are better since the surgery. At first (R31) was just angry. He would not get angry with other residents; it was mainly only with hands on care. (R31) was confused but he's gotten better and is more stable now. V10 then confirmed that aggression towards staff with cares, getting up on his own and exit seeking are not behaviors of psychosis and correlate to typical behaviors of dementia. On 11/26/24 at 12:04 PM V2 (Director of Nursing) confirmed R31 had surgery in May and since then, his behaviors have lessened. V2 stated Since the procedure he's actually more tired now and he has leveled off with behaviors. The Psychotropic Medication Program policy (not dated) documents Facility staff will ensure that all psychotropic mediations are properly ordered, monitored for effectiveness, and side effects. Physicians will be notified for review of medications for possible dosage reduction according to current guidelines: the entire psychotherapeutic regimen will be taken into account when reductions are made. Purpose: To prevent the use of unnecessary psychotropic medications. To prevent adverse effects to all residents receiving psychotropic mediations. Procedures and Key Points 1. Resident Assessment - Assessment will begin when facility staff determines the resident is exhibiting untoward behaviors that place the resident, or their peers in danger. The social service department shall be alerted when noting any untoward behavior. Upon the noting of behaviors focus charting will be initiated for ongoing assessment. The nursing staff along with the IDT will attempt to identify any potential causes for the untoward behavior. This may include but not limited to, acute health conditions, social settings, personal choices and interests, etc. (etcetera). Screening for depressive symptoms will be formally completed by 14-day assessment, quarterly, as needed, by the social services department or nursing. The family or responsible party will be notified of all significant behaviors. Behavior tracking will be instituted at this time to provide documentations of the frequency and intensity or the behavior occurrence. 2. Alternatives - The initial plan for treatment of behaviors will include such alternatives as; diversional activities, change in environment, psycho-social programming, treatment of acute medical conditions, etc. Treatment will be added to care plan. When all alternatives have been exhausted, the use of a psychotropic may be deemed necessary by the attending physician. When possible, the expertise of a psychologist or psychiatrist will be consulted. 9. Dose Reduction - Gradual dose reductions are to occur unless documented by physicians/psychiatrist that they are clinically contraindicated. (Many mental illnesses require the use of psychotropic medications). The Psychotropic Medication Policy and Procedure (not dated) documents Psychotropic medications will be utilized appropriately by working with the physicians and the interdisciplinary team through evaluations and monitoring. Standards 1. The facility will make every effort to comply with state and federal regulations related to the use of psychopharmacological medications in long term care to include regular review for continued need, appropriate dosage, side effects, risks and/ or benefits. Primary Care Physician 1. Orders for psychotropic medication only for the treatment of specific medical and/or psychiatric conditions or wen the medication meets the needs of the resident to alleviate significant distress for the resident not met by the use of non-pharmacologic approaches. 2. Documents rationale and diagnosis for use and identifies target symptoms. 5. Attempt a gradual dose reduction (GDR) decrease or discontinuation of psychotropic medications after no more than 3 (three) months unless clinically contraindicated. Gradual dose reduction must be attempted for 2 (two) separate quarters (with at least on month between attempts). Gradual dose reduction must be attempted annually thereafter or as the resident's clinical condition warrants, unless the physician has documented at least annually that this would not be indicated or in the patient's best interest. Nursing 3. Review the use of the medication with the physician and interdisciplinary team on a quarterly basis to determine the continued presence of target behaviors and /or the presence of any adverse effects of the medication use.

Based on observation, interview, and record review the facility failed to implement Enhanced Barrier Precautions (EBP) and Universal Standard Precautions while providing incontinence cares to a resident with a pressure ulcer for one of 12 residents (R35) reviewed for Infection Control in the sample of 28. Findings include: R35's current Care Plan documents R35 has a stage two pressure ulcer to his coccyx. On 11/24/24 at 9:40 AM R35's door had a sign on his door that stated, Stop. Enhanced Barrier Precautions. Everyone must clean their hands, including before entering and when leaving the room. Providers and staff must also wear gloves and a gown for the following high-contact resident care activities: Dressing, bathing/showering, transferring, changing linens, providing hygiene, changing briefs, or assisting with toileting, during device care or use, and during wound care. R35 was lying in bed and had a four-by-four gauze covering a pressure ulcer to his coccyx. During this time V3 (CNA/Certified Nursing Assistant) and V4 (CNA) were providing incontinence cares to R35. During these cares V3 and V4 were not wearing gowns. V4 applied gloves, removed R35's soiled adult brief, and washed R35's buttocks and groin area. Using the same soiled gloves opened R35's restroom door and opened R35's side table drawer looking for incontinence cream. V3 and V4 then proceeded to roll R35 over to his left side and V4 placed her soiled gloves on the back of R35's shirt while rolling R35, applied a clean adult brief, and rolled R35 to his back while using the same soiled gloves. V3 and V4 then removed their gloves, placed the gloves in a trash bag, and exited R35's room without washing their hands. On 11/25/24 at 11:00 AM V4 stated, I did not change my gloves after providing incontinence cares to (R35) and I did not wash my hands before leaving (R35's) room after doing incontinence cares. I did not wear a gown while doing (R35's) incontinence cares. I realized what I did but it was too late. On 11/25/24 at 12:05 PM V2 (Director of Nursing) stated, (V3 and V4) should have worn gowns and gloves when providing incontinence cares to (R35) since (R35) is supposed to have enhanced barrier precautions due to having a pressure ulcer. (V4) should have changed her gloves after providing incontinence care and should have washed her hands before leaving (R35's) room. The Enhanced Barrier Precautions policy dated 4/2024 documents Enhanced Barrier Precautions (EBPs) are utilized to reduce the transmission of multi-drug resistant organisms (MDROs) to residents. Policy Interpretation and Implementation 1. EBPs are used as an infection prevention and control intervention to reduce the transmission of multi-drug resistant organisms (MDROs) to residents. 2. EBPs employ targeted gown and glove use in addition to standard precautions during high contact resident care activities when contact precautions do not otherwise apply. a. Gloves and gown are applied prior to performing the high contact resident care activity (as opposed to before entering the room). b. Personal protective equipment (PPE) is changed before caring for another resident. c. Face protection may be used if there is also a risk of splash or spray. 3. Examples of high-contact resident care activities requiring the use of gown and gloves for EBPs include: a. dressing; b. bathing/showering; c. transferring; d. providing hygiene; e. changing linens; f. changing briefs or assisting with toileting; g. device care or use (central line, urinary catheter, feeding tube, tracheostomy/ventilator, etc. (etcetera); and h. wound care (any skin opening requiring a dressing). 5 EBPs are indicated (when contact precautions do not otherwise apply) for residents with wounds and/or indwelling medical devices regardless of MDRO colonization. a. Wounds generally include chronic wounds (i.e.(example), pressure ulcers, diabetic foot ulcers, venous stasis ulcers, and unhealed surgical wounds), not shorter-lasting wounds like skin breaks or skin tears. EBPs remain in place for the duration of the resident's stay or until resolution of the wound or discontinuation of the indwelling medical device that places them at increased risk. The Standard (Universal) Precautions policy dated 11/2008 documents Basic Responsibility: All Staff Standard precautions are based on the principle that all blood, body fluids, secretions, excretions except sweat, non-intact skin, and mucous membranes may contain transmissible infectious agents. The purpose of this policy is to provide guidelines to decrease the risk of occupational exposure to blood or body fluids. These precautions are based on the current CDC (Center for Disease Control) guidelines. Handwashing 1. Hands should be washed before, after, and between contact with persons and after touching intimate objects likely to be contaminated by blood and body. 2. Hands should be washed after removing gloves. 3. Hands should be washed if contaminated with blood or body fluids as soon as possible. 4. Hands should be washed for 10-15 seconds under running water with soap using vigorous mechanical friction. 5. An alcohol based antiseptic hand cleaner may be used to decontaminate hands following thorough hand washing with soap and water. Gloves the use of gloves will vary according to the procedure involved. The use of disposable gloves is indicated for procedures where body fluids are handled. 1. Gloves should be worn in the following circumstances: a. If the worker has cuts, broken skin, chapped hands, dermatitis, or other breaks in skin b. During invasive procedures c. During cleaning of body fluids and decontaminating procedures d. If worker judges that hand contamination with blood or body fluids may occur e. During contact with mucous membranes. 2. Gloves should be worn when handling soiled linens. 3. Gloves should be changed after contact with each person when body fluids are present and between clean and dirty procedures. Gowns flood resistant or flood proof gowns should be worn during procedures that are likely to generate splashes of blood or body fluids to skin or clothing.

Based on observation, interview and record review, the facility failed to ensure use of an effective sanitation solution and prevent spread of potential contamination to food and food preparation surfaces in the kitchen. This failure has the potential to affect all 35 residents residing in the facility. Findings include: On 11/24/24 at 11:45 AM V7 (Dietary Manager) and V8 (Dietary Cook) were in the kitchen preparing to serve lunch. At this time V8 removed a food thermometer from a storage cup containing other kitchen utensils. V8 then retrieved a folded kitchen cloth from the kitchen's storage closet and soaked the cloth in the kitchen's quaternary (bleach) sanitation bucket. V8 proceeded to wipe down the thermometer and began taking temperatures of hot food on the kitchen's steam table. V8 used the same wet cloth to clean the thermometer between each hot food item including roasted pork, sweet potatoes, mixed vegetables, and ground pork. After completing temperatures of hot items, V8 used the same cloth to clean the thermometer and checked the temperature of cold lettuce salad mixed with ranch dressing. Upon competition of all temperatures, V8 took the same wet cloth and wiped down the kitchen's metal food preparation table which contained crumbs and food particles from lunch preparation. At this time V7 (Dietary Manager) used a testing strip and checked the kitchens quaternary sanitation bucket and the result was ten PPM. At this time V8 stated I haven't changed that (sanitation solution) yet. V7 confirmed the chemical solution concentration needs to be at 50-100 PPM to be used in the kitchen when cleaning. V7 confirmed the sanitation solution at only ten PPM concentration was used to sanitize the kitchen's thermometer during the steam table food temperature checks. V7 stated We normally would use an alcohol wipe when doing the steam table temperatures, but we are out of those until more come in. That is why (V8) used the cloth. The bleach solution needs changed though because ten PPM is not effective for sanitation. The facility's (undated) Cleaning For Kitchen Staff policy, documents Basic responsibility- all dietary staff: To maintain clean worked environment. To keep work areas sanitary for food production. To inhibit the growth of bacteria and food born illness. This policy also documents Use general guidelines made by manufacturers when using chemicals. A sanitizing solution is made using water and bleach to reach a 50 PPM (Part Per Million) ratio. Check with test strips. The facility's Sanitation policy, dated 11/2022, documents The food service area is maintained in a clean and sanitary manner. All equipment, food contact surfaces and utensils are cleaned and sanitized using heat or chemical sanitizing solutions. Service area wiping cloths are cleaned and dried or placed in a chemical sanitizing solution of appropriate concentration. The facility's Long Term Care Application for Medicare and Medicaid, dated 11/24/24 and signed by V1 (Administrator) documents 35 residents reside in the facility.

Based on observation, interview and record review the facility failed to ensure hand hygiene was performed during a dressing change for one of one resident (R182) reviewed for pressure ulcers in a sample of 20. Findings include: The CDC (Center for Disease Control website documents Keep PPE (Personal Protective Equipment) available in all sizes for staff and providers. Wear gloves during all stages of wound care including when applying new dressings. [NAME] gloves after performing hand hygiene. During an individual resident's wound care, doff gloves every time when going from dirty to clean surfaces or supplies. On 09/06/23 at 11:30AM V7 Licensed Practical Nurse (LPN) entered R182's room, put gloves on, took keys out of shirt pocket, unlocked cart, opened multiple drawers and removed supplies. V7 removed dressing from resident's right heel, sprayed gauze 4x4 with normal saline and rubbed in a circular motion. V7 removed gloves, put new gloves on, removed dressing from packaging, cut approximate amount and returned the rest to the package, and applied new dressing. On 9/6/23 at 11:38 AM V7 (LPN) stated I should have washed my hands before I started, used hand sanitizer in between and I shouldn't have touched the clean gauze with my gloves that had just taken off the dirty dressing.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. The Facility's Fall Prevention Program dated 8/1/2008 documents It is the policy of (this facility) that the resident's environment remain free of accident/fall/injury hazards as possible and that each resident receive appropriate assessment, supervision and assistance to prevent accidents/falls/injuries with the implementation of a fall prevention program. The program will include environmental/safety precautions, generic resident care strategies, resident specific assessment, quality assurance review and staff education. R18's Nurse's Notes dated 6/20/23 document resident was observed with legs and partial buttocks off bed and was assisted to the floor by staff. R18's Current care plan dated 7/4/23 does not address any incident on 6/20/23. R18's Nurse's Notes dated 7/18/2023 document R18 was found lying on the floor next to his bed. R18's Current care plan dated 7/4/23 documents keep my bed in low position with wheels locked when not attending to me. R18's Current care plan with an update dated 7/18/23 documents maintain bed in low position. On 9/6/23 at 11:30 AM V2 (Director of Nursing) stated I don't know why (staff) repeated an intervention that was already in place, they shouldn't have. R18's Nurse's Notes dated 7/19/23 document R18 was found face down on the floor in his room. R18's Current care plan dated 7/18/23 does not include any intervention regarding fall on 7/19/23. R18's Nurse's Notes dated 7/29/23 document R18 was observed sliding out wheelchair while sitting in his room. R18's Current care plan dated 7/18/23 does not include any new intervention regarding R18 sliding out of his wheelchair on 7/29/23. R18's Nurse's Notes dated 8/4/23 document R18 was found on the floor in his room. R18's Current care plan dated 7/18/23 does not include any new interventions regarding R18 being found on the floor on 8/4/23. Throughout the survey, R18 had a fall alarm on his wheelchair. R18's medical record does not include any mention of R18 having a fall alarm. On 9/6/23 at 11:30 AM V2 (Director of Nursing) confirmed that she did not have any investigations into any of R18's fall to determine why he continues to fall or any new interventions after each fall. V2 stated she didn't know where the fall alarm intervention came from. Based on observation, interview, and record review the facility failed to ensure two staff members were present and a safety transfer (gait) belt was used during a resident transfer for one resident (R27), and failed to ensure falls were thoroughly investigated to determine a root cause of the falls and develop new fall prevention interventions for one resident (R18) of two residents (R27, R18) reviewed for accidents in a sample of 20. Findings include: 1. A Resident Handling Policy (Limited Lift Policy) dated 11/1/2008 states, Mandatory gait (safety transfer belt) belt usage for all resident handling with the exception for bed mobility (and) medical contraindications. R27's Minimum Data Set (MDS) assessment dated [DATE] documents R27 requires the extensive assistance of two staff to transfer between surfaces including to or from bed, chair, wheelchair and standing position. R27's fall risk assessment dated [DATE] documents R27 is at high risk for falling because of risk factors that include a balance problem while standing or walking, has decreased muscular coordination, and requires use of assistive devices. On 9/5/23 at 11:31a.m. V5 (Certified Nurse Aide/CNA) was in R27's room preparing to transfer R27 from the recliner to the wheelchair. Without calling for a second staff member to assist or placing a safety transfer belt around R27's waist, V5 placed R27's walker in front of R27, then assisted R27 to stand. R27 appeared unsteady on her feet and required extensive assistance and cueing to take a few steps from the recliner to the wheelchair before V5 assisted R27 to sit back down. At 11:40a.m. V5 verified V5 transferred R27 from the recliner to the wheelchair without the assistance of a second staff member and without using a safety transfer belt. V5 stated she usually uses a safety transfer belt for all resident transfers. On 9/6/23 at 10:55a.m. V2 (Director of Nurses) stated that if a resident is assessed as requiring extensive assistance, a safety transfer belt should be used by staff to transfer that resident from place to place.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to identify adverse target behaviors or document a diagnosis to warrant the use of an antipsychotic medication for one of four residents (R27) reviewed for psychoactive medication use in a sample of 20. Findings include: A Psychotropic Medication Program policy (undated) gives as its purpose, To prevent the use of unnecessary medications. Under procedures and key points, this policy states, Assessment will begin when facility staff determines the resident is exhibiting untoward behaviors that place the resident, or their peers in danger. The social services department shall be alerted when noting any untoward behavior. Upon the noting of behaviors focus charting will be initiated for ongoing assessment. The nursing staff along with the IDT (interdisciplinary team) will attempt to identify any potential causes for the untoward behavior. This may include but not limited to, acute health conditions, social settings, personal choices and interests, etc. (etcetera). In addition, this policy states, The initial plan for treatment of behaviors will include such alternatives as: diversional activities, change in environment, psycho-social programming, treatment of acute medical conditions, etc. Treatment will be added to care plan. When alternatives have been exhausted, the use of a psychotropic may be deemed necessary by the attending physician. R27's list of current diagnoses includes Unspecified Dementia, Unspecified Severity, Without Behavioral Disturbance, Psychotic Disturbance, Mood Disturbance, and Anxiety; and Dementia in Other Diseases Classified Elsewhere, Unspecified Severity, Without Behavioral Disturbance, and Urinary Tract Infection (UTI). R27's physician's orders (POS) dated 5/10/23 documents R27 was prescribed the antipsychotic medication Olanzapine 5mg (milligrams) daily at bedtime for the diagnosis of Dementia without behavioral disturbance. R27's admission Minimum Data Set (MDS) assessment dated [DATE] and quarterly MDS dated [DATE] document R27 is severely cognitively impaired and has exhibited no indicators of psychosis and no behavioral symptoms. R27's care plan dated 5/17/23 documents R27 has behavior tracking for the behavior of depression, feeling down or hopeless, and trouble with sleep. R27's nursing progress notes dated 6/5/23 to 8/10/23 document R27 had three behaviors during that time. R27's first Behavior nursing progress note dated 6/5/23 documents that R27 refused pain medication and scheduled medications by stating, Those aren't my pills. R27's second Behavior nursing progress note dated 8/1/23 documents that R27 was found situated sideways in her recliner because R27 tried to get up without assistance. R27's third Behavior nursing progress note dated 8/10/23 stated that R27 was anxious, suspicious of staff, and spit out her medications. This note also documents R27 read the nurse's name tag and asked, What is this? In addition, this note documents that R27 refused to eat her supper stating, I don't know what this is. I don't know what any of this is! R27's nursing progress note dated 8/12/23 documents that at that time R27 was being administered the antibiotic Keflex 500mg three times daily for the diagnosis of UTI. R27's Pharmacy Consultation Report dated 7/18/23 under the comment section states, (R27) receives an antipsychotic, Olanzapine 5mg at bedtime, for a potentially inappropriate indication: dementia without behavioral disturbance-medication was initiated at recent hospital admission. This report does not indicate that R27's physician ever reviewed or signed this recommendation. R27's Pharmacy Consultation Report dated 8/8/23 under the comment section states, (R27) receives an antipsychotic, Olanzapine 5mg at bedtime, for a potentially inappropriate indication: dementia without behavioral disturbance-medication was initiated at recent hospital admission. In addition, this report recommended that R27's Olanzapine be reduced to 2.5mg at bedtime. R27's physician's response was to agree to the reduction in Olanzapine, however, R27's physician did not provide an indication to warrant the use of this medication. On 9/5/23 at 11:00a.m. R27 was in her room seated in a recliner. R27 was pleasantly confused and unable to make conversation. V5 (Certified Nurse Aide) entered R27's room and assisted R27 to transfer from the recliner to the wheelchair so R27 could go to the dining room for lunch. Once R27 was seated in the dining room, she sat quietly at her table while being fed by staff. During these observations, R27 did not exhibit any behaviors including behaviors that placed R27 or her peers in danger. At 11:10a.m. V5 stated that R27 does not usually have any behaviors. V5 stated that R27 does not have any behaviors that place herself or her peers in danger. At 11:17a.m. V4 (Registered Nurse) stated she is R27's nurse. V4 stated that R27 gets more confused in the evening. V4 stated that when R27 is more confused, R27 is in her own world. V4 stated that R27 is not a danger to herself or her peers. On 9/6/23 at 9:30a.m. V3 (Assistant Director of Nurses/ADON) stated that she manages psychoactive medications for the facility. V3 stated she is new to this position. V3 stated that R27's diagnosis indicating the need for an antipsychotic medication is Dementia without behavioral disturbance. V3 was not sure what behaviors R27 exhibited to warrant the use of an antipsychotic medication. V2 (Director of Nurses/DON), who was in the same office, stated that Dementia without behavioral disturbance isn't a diagnosis which warrants the use of an antipsychotic medication. V2 stated that target behaviors are determined by V9 (Social Services). V2 and V3 were unable to provide documentation of what non-pharmacological measures were attempted or exhausted before R27 was prescribed and administered Olanzapine. On 9/6/23 at 1:27p.m. V9 stated she does not determine what target behaviors warrant the use of an antipsychotic medication. V9 stated that is V3's responsibility. V9 stated she just adds behaviors to the care plan based on nurses' behavior tracking progress notes. V9 stated R27 has had few behaviors since she was admitted to the facility in 5/2023. V9 stated none of the behaviors R27 does have seem to be distressing to R27. V9 stated she believes any behaviors R27 has had were related to R27's recent UTI.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure their infection prevention antibiotic stewardship program addressed prophylactic antibiotic use. This has the potential to affect all 34 residents in the facility. Findings include: An Antibiotic Stewardship Program policy excerpt dated 1/1/2018 instructs, Providers will utilize the Loeb Criteria when considering initiation of antibiotics. An excerpt of this policy dated 12/1/2017 states, At 72 hours after antibiotic initiation or first dose in the facility, each resident will be reassessed for consideration of antibiotic need, duration, appropriateness, and de-escalation potential. Within the Antibiotic Stewardship policy is the Loeb Criteria for determining presence of UTI. The Loeb Criteria instructs that residents with indwelling catheters are appropriate for antibiotic therapy if they demonstrate one of the following: a fever of 100 degrees Fahrenheit (100F) or repeated temperatures of 99F; new back pain or flank pain; acute pain; rigors/shaking chills; new dramatic change in mental status; hypotension (significant change from baseline blood pressure or a systolic (top number) of less than 90 mmHg (millimeters of mercury). For residents without catheters, this policy instructs the criteria for antibiotic use are met if residents demonstrate one of three situations: 1. acute dysuria (pain and/or burning during urination), 2. a single temperature of 100F and at least new or symptoms of worsening urgency, frequency, back or flank pain, suprapubic pain, gross hematuria (blood in urine), or urinary incontinence; 3. no fever, but two or more of the following symptoms: urgency, frequency, incontinence, suprapubic pain, gross hematuria. This Loeb Criteria policy documents that if any of the above criteria are not met, the resident does not need an immediate prescription for an antibiotic but may need additional observation because the resident's symptoms are insufficient to indicate an active Urinary Tract Infection. A Center's for Disease Control and Prevention recommendation guide titled Limited Prolonged Antibiotic Prophylaxis for Urinary Tract Infection (undated) states, Antibiotics are frequently prescribed for prolonged duration for the prevention of infection or prophylaxis in nursing homes. 1. While antibiotic prophylaxis may reduce recurrent UTIs in specific population, 2-3 there is no clear evidence on prevention of recurrent UTIs among nursing home residents with asymptomatic bacteriuria. 4 Furthermore, antibiotic use carries the risk of harm to residents, including adverse drug events and increased antibiotic resistance, which argue against the use of prolonged antibiotic therapy in nursing home residents. 1. On 9/5/23 at 11:00a.m. R27 was seated in a recliner in her room. R27 was pleasantly confused but did not complain of symptoms of pain or urgency to urinate and did not have a urinary catheter in place. R27's Physician Order Sheet dated 8/21/23 documents Keflex 250mg capsule in the morning for prophylactic (preventive), to start 8/29/23. This same order does not include a duration or stop date for this antibiotic. R27's nursing progress notes dated 8/21/23 to 9/7/23 do not include R27 had any symptoms listed on the Loeb Criteria which meets the criteria for antibiotic use. R27's log of temperatures documents that R27 has not had a fever of 100F or greater. On 9/6/23 at 1:47p.m. V3 (Assistant Director of Nurses/ Infection Preventionist) stated that she monitors residents for signs of infection and for appropriateness of physician's orders for antibiotics. V3 stated that R27 was prescribed the antibiotic Keflex as a preventive measure because of recurring Urinary Tract Infections. V3 stated she does not believe there is any reason to prohibit the use of antibiotics prescribed for prophylactic use. V3 verified that R27 was not exhibiting any symptoms or criteria listed on the Loeb Criteria for antibiotic use. 2. R12's Physician Order Sheet dated September 2023 documents Cephalexin 250 mg (milligram) every day for reoccurring urinary tract infections. R12's Nurse's Notes document R12 was admitted to the facility on [DATE] with prophylactic antibiotic for reoccurring urinary tract infections. On 9/7/23 at 11:00 AM V2 (Director of Nursing) stated (R12) has not had any urinary tract infections since she has been here. We are trying to get the doctor to quit ordering prophylactic antibiotics. V2 stated that currently there are only two residents on prophylactic antibiotics. The Centers for Medicare and Medicaid Resident Census and Condition of Residents form 672 dated 9/5/23 and signed by V1 (Administrator) documents that at the time of the survey 34 residents resided in the facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to prevent occurrences of physical and verbal abuse for one of three residents (R5) reviewed for abuse in a total sample of 15. Findings Include: The Facility's Abuse, Neglect, Mistreatment and Misappropriation of Resident Property Policy dated 2/2018 documents the definition of Abuse as, The willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Abuse includes verbal abuse, sexual abuse, physical abuse and mental abuse, including abuse facilitated or enabled through the use of technology. Willful, as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. The Abuse, Neglect, Mistreatment, and Misappropriation of Resident Property Policy defines verbal abuse as, The use of oral, written or gestured language that willfully includes disparaging and derogatory terms to residents or their families, or within their hearing distance, regardless of their age, ability to comprehend, or disability. The Abuse, Neglect, Mistreatment, and Misappropriation of Resident Property Policy defines physical abuse as, Hitting, slapping, pinching, and kicking. R5 and R6's Medical Records document that they are a married couple who were both admitted on [DATE], both with a diagnosis of Alzheimer's Dementia. R5's MDS (Minimum Data Set) assessment dated [DATE] documents a BIMS (Brief Interview for Mental Status) Score of 4/15, which indicates severe cognitive impairment. R6's MDS (Minimum Data Set) assessment dated [DATE] documents a BIMS (Brief Interview for Mental Status) Score of 6/15, which indicates severe cognitive impairment. R5's Progress Notes (7/29/22 at 11:23 AM) document R5 was noted to have blood running down his arm. These notes document, Wife (R6) said to husband (R5), 'Honey what happened. 'He (R5) replied, 'You scratched me.' Areas measure 0.5 x 0.3 (centimeters), 0.2 x 0.4 (centimeters), and 0.4 (centimeters) x 0.3 (centimeters). R5's Physician Order Sheet dated July 2022 documents Apply TAO (Triple Antibiotic Ointment) to areas daily until healed. R6's Progress Notes document that on 6/3/22 R6 was, Being verbally abusive to her husband (R5). R6's Abuse Investigation dated 6/5/22 documents that V5 (R5 and R6's family member/Healthcare Power of Attorney) reported that R6 slapped R5 on the leg, a couple of times while he was toileting. The Investigation documents that V5 stated, We can tell (R6) is frustrated with (R5) when he (R5) doesn't do something she is asking him to do. R6's Abuse Investigation dated 6/23/22 documents that a CNA (Certified Nursing Assistant) witnessed R6 become frustrated with R5 because he was not responding to her, so she pinched his arm and removed his plate of food from in front of him. R6's Progress Notes dated 6/28/22 at 7:33 AM document R6 Yelling aggressively to husband (R5) at dining room table. (R6) Kicked foot at him (R5) when was slow to respond. R6's Progress Notes dated 7/5/22 at 11:30 PM document, (R6) grabbed husband's (R5) arm aggressively trying to get him to follow her. Nurse asked her (R6) to not grab him (R5) like that, she (R6) stated, 'Just go on and don't worry about it'. On 8/17/22 at 10:30 AM V2 (Interim Director of Nursing) stated, I do believe it (the occurrences between R5 and R6) is abuse, but they are married. On 8/17/22 at 11:20 AM V1 (Administrator) stated Yes these instances (6/3/22, 6/28/22, 7/5/22 and 7/29/22) would be physical and verbal abuse.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to report allegations of physical and verbal abuse to the Administrator for one of three residents (R5) reviewed for abuse in a total sample of 15. Findings Include: The Abuse, Neglect, Mistreatment, and Misappropriation of Resident Property Policy dated 2/2018 documents all employees will be trained on, Communication of reports of resident mistreatment, neglect, and/or abuse, including injuries of unknown source and misappropriation of property. This policy also documents, Employees must always report any abuse or suspicion of abuse immediately to the Administrator. R5 and R6's Medical Records document that R5 and R6 are a married couple who were both admitted on [DATE], both with a diagnosis of Alzheimer's Dementia. R5's MDS (Minimum Data Set) assessment dated [DATE] documents a BIMS (Brief Interview for Mental Status) Score of 4/15, which indicates severe cognitive impairment. R6's MDS (Minimum Data Set) assessment dated [DATE] documents a BIMS (Brief Interview for Mental Status) Score of 6/15 , which indicates severe cognitive impairment. R5's Progress Notes (7/29/22 at 11:23 AM) document R5 was noted to have blood running down his arm. These notes document, Wife (R6) said to husband (R5), 'Honey what happened. 'He (R5) replied, 'You scratched me.' Areas measure 0.5 x 0.3 (centimeters), 0.2 x 0.4 (centimeters), and 0.4 (centimeters) x 0.3 (centimeters). R5's Physician Order Sheet dated July 2022 documents Apply TAO (Triple Antibiotic Ointment) to areas daily until healed. R6's Progress Notes document that on 6/3/22 R6 was, Being verbally abusive to her husband (R5). R6's Progress Notes dated 6/28/22 at 7:33 AM document R6 was, Yelling aggressively to husband (R5) at dining room table and kicked foot at him (R5) when was slow to respond. R6's Progress Notes dated 7/5/22 at 11:30 PM document, (R6) grabbed husband's (R5) arm aggressively trying to get him to follow her. Nurse asked her to not grab him (R5) like that, she (R6) stated, 'Just go on and don't worry about it'. On 8/17/22 at 10:30 AM V2 (Interim Director of Nursing) stated I do believe it is abuse, but they are married. On 8/17/22 at 11:20 AM V1 (Administrator) stated Yes, these instances (6/3/22, 6/28/22, 7/5/22 and 7/29/22) would be physical and verbal abuse. On 8/17/22 at 11:00 AM V1 (Administrator) stated I was not notified of these instances (6/3/22, 6/28/22, 7/5/22, and 7/29/22) and I should have been.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to investigate allegations of physical and verbal abuse for one of three residents (R5) reviewed for abuse in a total sample of 15. Findings Include: The Facility's Abuse, Neglect, Mistreatment and Misappropriation of Resident Property Policy dated 2/2018 defines verbal abuse as, The use of oral, written or gestured language that willfully includes disparaging and derogatory terms to residents or their families, or within their hearing distance, regardless of their age, ability to comprehend, or disability. This policy further documents physical abuse as, Hitting, slapping, pinching, and kicking. This policy also documents, It is the policy of (This Facility) that reports of abuse are promptly and thoroughly investigated. R5 and R6's Medical Record document that the married couple were both admitted on [DATE] both with a diagnosis of Alzheimer's Dementia. R5's Progress Notes (7/29/22 at 11:23 AM) document R5 was noted to have blood running down his arm. These notes document, Wife (R6) said to husband (R5), 'Honey what happened. 'He (R5) replied, 'You scratched me.' Areas measure 0.5 x 0.3 (centimeters), 0.2 x 0.4 (centimeters), and 0.4 (centimeters) x 0.3 (centimeters). R5's Physician Order Sheet dated July 2022 documents Apply TAO (Triple Antibiotic Ointment) to areas daily until healed. R6's Progress Notes document that on 6/3/22 R6 was, being verbally abusive to her husband (R5). R6's Progress Notes dated 6/28/22 at 7:33 AM document R6 was, Yelling aggressively to husband (R5) at dining room table and kicked foot at him (R5) when was slow to respond. R6's Progress Notes dated 7/5/22 at 11:30 PM document, (R6) grabbed husband's (R5) arm aggressively trying to get him to follow her. Nurse asked her to not grab him (R5) like that, she (R6) stated, 'Just go on and don't worry about it'. On 8/17/22 at 10:30 AM V2 (Interim Director of Nursing) stated I do believe it (the 6/3/22, 6/28/22, 7/5/22 and 7/29/22 occurrences) is abuse, but they are married. On 8/17/22 at 11:20 AM V1 (Administrator) stated Yes, these instances (6/3/22, 6/28/22, 7/5/22 and 7/29/22) would be physical and verbal abuse. On 8/17/22 at 11:00 AM V1 (Administrator) confirmed that she had no investigations regarding the documented occurrences between R5 and R6 on 6/3/22, 6/28/22, 7/5/22, and 7/29/22.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to identify and remove a fall hazard for one resident (R5) of four residents reviewed for falls in the sample of 15. Findings include: The facility's (undated) Fall Prevention and Follow up policy, documents, Staff will follow the procedures as outlined in this policy in attempts to limit and/or prevent the occurrence of falls. A fall is defined as an unintentional change in position, coming to rest on the ground, floor or onto the next lower surface. This policy also documents, Post Fall Management will include: b. Registered Nurse will investigate fall circumstances and check to see that all prescribed interventions are in place and working properly. On 8/16/22 at 10:35 AM, R5 was sitting in a chair in his room with a walker at R5's bedside. R5 was confused with conversation and was unable to form sentences to communicate. R5's current care plan, dated 6/17/22, documents that R5 was admitted to the facility on [DATE]. This care plan also documents, I have impaired cognitive function/Dementia and impaired decision making. I scored a 4 (severely cognitively impaired) on my BIMS (Brief Interview for Mental Status) assessment and did not show any signs of delirium. Due to my Dementia, I often get up without assistance, I am on behavior tracking. This same care plan also documents, I am at high risk for falling due to having history of falling at home and having falls in past 60 days. R5's electronic medical record documents R5 suffered a fall on 3/2/22, 3/7/22, 5/15/22, 5/16/22, 5/18/22, 5/23,22, 5/30/22, and 6/9/22. All of these documented falls were unwitnessed by staff. R5's record also documents that R6 (R5's spouse) was in the room with R5 or was the person who notified staff of R5 falling for each of the documented occurrence. R5's Progress Notes dated 4/9/22 at 1:00 AM, documents, Resident is alert and sleeps well through the night. Spouse (R6) tries to assist resident with ADLs (Activities of Daily Living). (R5) requires one staff assist with ADLs. (R5) has history of falls. (Fall) alarm in use. (R6) often removes the alarm. R5's Progress Notes dated 4/15/22 at 8:46 AM, documents (R5) alert per his baseline. He is slow to respond and speaks in one-two word answers. Ambulates in hallway, usually holding (R6's) hand. Gait slow and steady. (Fall) alarm is to be in place while (R5) is in recliner or bed as he has a history of falls. (R6) has been noted to be removing alarm at times. R5's Progress Notes dated 5/16/22 at 12:58 AM, documents, Entered (R5's) room when someone was heard yelling, 'Help Me' from inside the resident's room. (R5) was found lying on the floor behind the door in his room. (R5) was assessed by this nurse and was found to have a small skin tear to his right elbow. No other injuries noted. (R5) was then assisted to sit on the bed and Neurological checks were started. Neurological checks WNL (within normal limits) per (R5's) baseline. Resident was then assisted to get ready for bed. Resident's wife (R6) was also found on the floor sitting beside the bed. Both were fully dressed with all their belongings packed to leave. R5's Progress Notes dated 5/23/22 at 1:18 PM, documents, Resident's wife (R6) was in their doorway yelling, 'Help, Help'. (R5) observed sitting in front of his closet with his legs extended and his back against the drawers. (R6) said, 'He just kind of slid down'. (R5) was wearing tennis shoes and the floor was dry. He was not wearing his glasses. (R6) had clothes on the bed that she was packing up and a small side table was sitting a few feet in front of the closet. R5's Progress Notes dated 6/9/22 at 4:48 PM, documents, Resident's wife (R6) came to the desk and asked if we could help get (R5) off the floor. (R5) noted to be laying on his left side on the floor in front of the closet. Electric razor cord on the floor by the outlet and razor sitting on table running. (R5) assessed and hematoma noted to left elbow with 1 cm (centimeter) skin tear to bottom edge, no other injury noted. On 8/18/22 at 9:27 AM, V2 (Interim Director of Nursing) stated, We never really gave it a thought that (R6) may be the reason for (R5) falling related to her aggression. Honestly, when we would go into the room after (R5's)falls, there were hazards that (R6) had created. (R6) would turn off nightlights, cover the fall alarm and pack up items and then leaves them on the floor in areas he would trip over. (R6) was a safety hazard for (R5). (R6) was moved out of (R5')s room June 14th, 2022, due to his falls, her aggression and (R6) being possibly the cause of (R5's) falls. (R5) has had no falls since (R6) was moved. On 8/18/22 at 10:12 AM, V1 (Administrator) confirmed that R6 was causing R5 to fall multiple times. V1 stated, During that 6/9/22 fall that was completely (R6), trying to get (R5) to shave or help him shave. Which resulted in the cord being on the floor and (R5) falling. (R5) would not have gotten up and done those things on his own. (R6) was for sure his hazard. (R6) would tell him to get up and get ready and start packing items up in his room. We separated them after more aggressive behaviors were seen (from R6). Since (R6) has been moved, (R5) has not fallen (over two months' time).