**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews, pharmacy interviews and policy review, the facility failed to provide care and services according to accepted standards of clinical practice for 1 of 12 residents reviewed (Residents #6). The facility failed to implement a physician order for a new treatment of Epsom salt foot soaks. The facility reported a census of 29 residents. Findings include: Resident #6's Minimum Data Set (MDS) dated [DATE] assessment identified a Brief Interview for Mental Status (BIMS) score of 14, indicating intact cognition. The MDS identified Resident #6 was independent with bed mobility transfers and ambulation. Resident #6's MDS included diagnoses of hypertension (high blood pressure), cerebral palsy, pain in the right foot, and localized edema. A Progress Note dated 7/10/24 documented Resident #6 saw the Podiatrist, received a new order to apply TAO (triple antibiotic ointment) to the right great toe daily and to call the clinic the following morning to schedule an appointment to have the right great toenail removed. A Progress Note dated 7/15/24 documented Resident #6 returned with post procedure instructions directing staff to soak the right great toe two times daily and then cover with TAO and bandaid. A Progress Note dated 7/29/24 documented Resident #6 returned to the facility from appointment and the right great toenail removal progressing as expected. New orders received to discontinue soaks and twice a day bandaid changes to the right great toe. Apply bandaid and TAO to the right great toe nail bed once daily until healed. A Progress Note dated 9/5/24 at 8:17 AM documented a note text to the Physician reporting Resident #6 had an appointment on Monday to be seen for the right great toe. The note revealed Resident #6's right great toe was red, inflamed and causing resident pain and discomfort. The note requested an order to soak the right great toe in Epsom salt twice a day for 1 week. A Progress Note dated 9/5/24 at 5:07 PM documented the Physician responded yes to the Epsom salt soaks and okay to set up telehealth if an antibiotic needed to be started. The clinical record lacked documentation the Pharmacy was notified of the order for the Epsom salts and lacked follow up documentation regarding the need for the telehealth visit. A Progress Note dated 9/5/24 at 9:29 PM documented Resident #6 had complaints of pain and discomfort to the right big toe. The toe appeared edematous and reddened. The note documented the toe was being dressed twice daily with a bandaid. Review of the September Treatment Administration Record (TAR) 2024 starting on 9/6/24 directed staff to soak Resident #6's right foot in a warm Epsom salt bath twice a day for 7 days for inflammation and pain. A Progress Note dated 9/6/24 at 5:53 AM documented Epsom salt had not been delivered by Pharmacy. A Progress Note dated 9/7/24 at 8:55 PM documented Epsom salt unavailable at this time. A Progress Note dated 9/8/24 at 9:42 AM documented no Epsom salt on hand. A Progress Note dated 9/8/24 at 9:31 PM documented awaiting on Epsom salts. A Progress Note dated 9/9/24 at 5:13 AM documented awaiting on Epsom salts. A Progress Note dated 9/9/24 at 1:16 PM documented Resident #6 returned from appointment with new orders for right great toe infection. The new orders directed staff to soak the right great toe in Epsom salt, apply TAO and cover with bandaid dressing twice a day for 10 days and start Cephalexin (oral antibiotic) 500 mg (milligrams) three times a day for 10 days. A Progress Note dated 9/9/24 at 11:35 PM documented Resident #6's right great toe was reddened and tender. A Progress Note dated 9/9/24 at 11:37 PM documented Epsom salt not available this evening. A Progress Note dated 9/10/24 at 11:35 AM documented Resident #6 continued to complain of soreness to the right great toe and the area remained pink. The note documented a call to the pharmacy to follow up on delivery of the Epsom salt for ordered treatment with delivery planned for that evening. Review of the clinical record from 9/5/24 to the morning of 9/10/24 lacked documentation regarding the follow up on the delivery of the Epsom salt. On 9/19/24 at 9:00 AM, the Director of Nursing (DON) reported the facility had waited on the pharmacy to deliver the Epsom salt. She stated she was not aware of what the hold up was. She stated she had called the pharmacy herself regarding the Epsom salts. The DON acknowledged the clinical record did not reflect the follow up call. The DON reported she was not responsible for ordering the supplies. She verified she would expect the facility to look at other options or ways of obtaining the treatment supply. On 9/19/24 at 9:40 AM, the DON reported she had talked to the Pharmacy. The DON stated the pharmacy did not have the Epsom salts in stock when it was ordered and had to wait for it to come in. When asked if she expected the staff to follow Physician orders, she stated Absolutely. On 9/19/24 at 9:53 AM, a Pharmacy employee reported the facility was billed for Epsom salt on 9/9/24 and it was delivered on 9/10/24. She stated the Epsom Salt was sent out as a stock item and was not on the resident profile. The Pharmacy employee reported she had gone through the refill requests and hard copies and could not locate an order for Epsom salt for Resident #6 on 9/5/24. On 9/19/24 at 10:07 AM, the Pharmacy Manager reported she had gone through faxes, emails, hard copies, deleted emails/faxes for 9/5/24 and 9/6/24 and could not locate an order for Epsom salt for Resident #6. She stated the pharmacy received an order for Epsom salt on 9/9/24. She stated if the facility had called with a verbal request/order, those orders would be written down and scanned in. An undated facility policy titled Physician orders for Medications and Treatments documented all medications would be administered as ordered by a healthcare professional authorized by the state to order medications.

Based on personnel file reviews, facility policy review and staff interview, the facility failed to provide dependent adult abuse recertification training within 3 years for 1 of 5 employees reviewed (Staff A). The facility identified a census of 29 residents. Findings include: The personnel file for Staff A, LPN (Licensed Practical Nurse) documented a hired date of 1/12/24 . Review of the Dependent Adult Abuse Mandatory Reporter Training Certificate documented Staff A completed the 2 hour dependent adult abuse training on 8/17/21. Review of facility policy titled Abuse Policy dated 2023 revealed each employee shall be required to take a 1 hour recertification training within 3 years of the initial 2 hour training and every three years thereafter. On 9/17/24 at 1:33 PM, the Director of Nursing (DON) acknowledged and verified Staff A's Dependent Adult Abuse Mandatory Training was overdue. The DON stated Staff A would be taking the recertification training on 9/17/24.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, facility policy review, resident and staff interviews, the facility failed to provide restorative therapy for 1 of 2 residents reviewed (Resident #15). The facility reported a census of 35 residents. Findings include: The Minimum Data Set (MDS) assessment dated [DATE] for Resident #15 revealed a Brief Interview of Mental Status (BIMS) score of 15 out of 15 possible points indicating intact cognition. The MDS revealed the resident had diagnoses to include dislocation of left hip, osteoarthritis in left hip, and pain in left hip. The MDS revealed the resident required extensive assistance of 1 staff with bed mobility, transfers, and toileting. The MDS revealed the resident had occupational therapy 4 days out of the past 7 days and physical therapy for 2 days out of the past 7 days; the resident did not receive restorative therapy. The Rehab Communication form dated 11/2/22 signed by an Occupational Therapist directed staff to walk patient in the hallway 1-3 times per day with gait belt, FWW, and immobilizer with assist of 2 staff with wheelchair to follow. Distance to patient tolerance. The Restorative Nursing Recommendations form dated 4/24/23 signed by an Occupational Therapist directed staff as follows: 1. NuStep for 9 minutes at a level of 1-2. 2. 1 times per day for 3 days per week: Please stand patient at the sink with front wheeled walker, gait belt, and wheelchair behind for completion of hand hygiene and combing hair. 3. Please encourage group exercise class. 4. Patient is independent with bilateral upper extremity exercises for home exercise program with 1 pound dumbbell while seated in her chair. The Care Plan for Resident #15 listed an intervention dated 11/2/22 directing staff to walk the resident in the hallway 1-3 times per day with a gait belt, front wheeled walker (FWW) and immobilizer with assist of 2 and wheelchair to follow. Distance to resident tolerance. The Care Plan lacked any documentation of any other restorative exercise program. In an interview on 6/19/23 at 10:46 AM, the resident reported that she recently ended physical therapy, that she had exercises to do on her own, and would like to have individual assistance with exercises. The Clinical Record lacked documentation that the resident received NuStep exercise or the handwashing and hair combing activity. The facility Restorative Activities of Daily Living Services policy, undated, documented the following: Policy: Residents of this facility will achieve and maintain the highest practicable level functionality with all Activities of Daily Living. Documentation: The Restorative Flow Sheet will address the goals and interventions in addition to documentation of staff implementation of planned interventions. In an interview on 6/20/23 at 1:35 PM, the Director of Nursing (DON), with Staff A, Registered Nurse (RN), and the Administrator present, reported that it was discovered that the tasks for walking in the hallway, handwashing with hair combing were entered into the clinical record as prn (as needed). This did not trigger staff to document these activities and no other documentation was available for review.

Based on observations and staff interviews the facility failed to ensure food was labeled with dates after opening, labeled with product after removing from original package and discarded after product expiration date. The facility identified a census of 35 residents. Findings include: An initial kitchen tour conducted on 06/19/23 at 9:22 a.m., the following items were stored in the kitchens refrigerator ready for service: a. Individual serving of potato salad in a styrofoam bowl uncovered and not labeled. b. Individual serving of potato salad covered in a styrofoam bowl with no label. c. 2 bottles of salad dressings in a container unlabeled and lacked a date opened. d. Open bottle of honey thickened cranberry juice with an open date of 4/22/23. Label reads discard unused portion after 10 days. Review of the facility provided policy tilted Food Service dated 2023 revealed all foods stored in the refrigerator or freezer will be covered, labeled and dated ( use by date). Interview on 06/19/23 at 9:43 a.m. with the Dietary Manager (DM) revealed she expected the items to be labeled. The DM discarded the items immediately.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, observation, staff interview, and resident interview, the facility failed to treat a resident in a respectful, dignified manner during wound care (Resident #14). The facility reported a census of 31 residents. Findings include: The Minimum Data Set (MDS) assessment dated [DATE] for Resident #14 identified a Brief Interview for Mental Status (BIMS) score of 15 which indicated cognition intact. The MDS revealed the resident required the extensive physical assistance of 2 persons for transfers, bed mobility and personal hygiene. The MDS documented diagnoses that included renal insufficiency, fracture of the right tibia and anxiety disorder. The Care Plan last revised on 2/16/22 showed Resident #14 deficit in activities of daily living (ADL) due to a right ankle fracture, and a wound to the right ankle from a past surgical procedure. The Care Plan informed staff the resident was non-weight bearing and required a hoyer lift for transfers. The Treatment Record dated March 2022 showed Staff I, Registered Nurse (RN), performed dressing changes to Resident #14's right ankle on 3/19/222 and 3/20/22. In an interview on 3/30/22 at 11:30 AM, Staff F, Certified Nursing Assistant (CNA), explained Staff I changed the right ankle dressing of Resident #14 while she sat on the bedpan. When Staff I lifted the resident's leg, the resident responded, ouch. I can lift my leg if you can wait for me to get off the bedpan. Then without warning Staff I released the resident's leg and allowed it to drop onto the bed. Staff I then told the resident, stop whining. I have a job to do. In an interview on 4/4/22 at 9:18 AM, Resident #14 stated, I was on the bedpan when Staff I started to change the bandage. Everyone knew I could lift my own leg but she just grabbed it. It hurt so bad. I told her that I could lift my leg, then she just dropped it, told me to stop being a [NAME]. The Respect and Dignity Policy dated 4/7/22 documented the resident has the right to be treated with respect and dignity including the following: The right to treat each resident with respect and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his/her quality of life, recognizing each resident individuality.The facility must protect and promote the rights of the residents. In an interview on 4/6/22 at 3:40 PM, the Administrator voiced he expected all employees to treat residents with absolute respect and dignity. The Administrator added this employee or any other employee that is disrespectful or would bring harm of any kind does not belong at this facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to notify the family of a fall for 1 of 4 residents reviewed (Resident #32). The facility reported a census of 30 residents. Findings include: According to the Minimum Data Set (MDS) assessment dated [DATE], Resident #32 scored 8 on the Brief Interview for Mental Status (BIMS) indicating moderate cognitive impairment. The resident required supervision for transfer and walking in the corridor, limited assistance with toilet use, and personal hygiene, and independent with ambulation in the room. The resident's diagnoses included chronic obstructive pulmonary disease, heart failure and diabetes. The Progress Notes dated 2/26/21 at 4:02 p.m. documented the Nurse was called to the resident's room by housekeeping. The resident sat on the floor, with her feet directly in front of her and her back leaning against her recliner. Staff faxed the Physician and informed the family. The residents Clinical Resident Profile listed three family member contacts. The Progress Notes dated 7/26/21 at 11:58 a.m. documented the Nurse was called to the resident's room by a Certified Nursing Assistant (CNA). The resident laid on the floor on her back with her legs straight out in front of her. The resident stated she walked to the bath room in a hurry when she lost her balance and fell backwards. She stated she did hit her head but it did not hurt. She did have pain in her mid back. Neuros and vitals were assessed and within normal limits (WNL). No open wounds were noted. The resident did state having pain in her mid back but okay. The resident assisted to a standing position with 2 and a gait belt with out incident. The resident denied pain once brought to a standing position. Reminded the resident to take her time when walking. Staff notified the Physician, and the resident was her own power of attorney (POA) and she understood the situation. The clinical record lacked any documentation the facility notified the family of the fall. On 3/30/22 at 9:13 a.m. the resident's family member stated the facility did not notify them of the fall. She thought they should have notified them of that. On 4/6/22 at 8:24 a.m. the Director of Nursing (DON) stated she thought the resident was her own POA and didn't want her family notified. She did not know if they had any documentation. She did not know when that stopped. The facility policy reviewed and updated 11/9/18 regarding Condition Changes/Managing directed the licensed nurse would notify the Physician and the family or responsible party .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, observation, staff interview, and resident interview, the facility failed to follow policy and protocol when staff failed to report allegations of misconduct to responsible parties. The facility also failed to follow investigative protocols when allegations were reported for 1 out 3 residents reviewed (Resident #4). Findings: 1. The Minimum Data Set (MDS) assessment dated [DATE] for Resident #4 identified a Brief Interview for Mental Status (BIMS) score of 15 which indicated cognition intact. The MDS revealed the resident required no assistance for transfers, bed mobility and dressing and eating. The resident required setup assistance and the help of one staff member for toilet use and personal hygiene. The MDS documented diagnoses that included seizure disorder, cerebral palsy and abnormalities of gait mobility. In an interview on 3/30/22 at 9:37 AM, Resident #4 stated Staff A, Certified Nurses Aide (CNA), asked to borrow $40 because she was broke. Resident #4 further stated, I never did see it back. It happened late last winter. In an interview on 3/30/22 at 10:55 AM, the Director of Nursing (DON), reported the facility did not conduct an investigation that involved an employee asking residents for money. In an interview on 4/4/22 at 1:50 PM, Staff J, Certified Nurses Aide (CNA), stated Resident #4 told me that he borrowed money to Staff A last year. She commented, I don't know how much. I don't remember if I reported it. In an interview on 4/4/22 at 1:51 PM, Staff G, Certified Nurses Aide (CNA), stated Resident #4 told me that he borrowed Staff A money. She stated, I had already heard about it and thought everyone knew so I didn't report it. It was a while ago. In an interview on 4/4/22 at 3:27 PM, the Administrator stated, I had no knowledge of any employee that loaned money from residents. Nothing was reported to me otherwise I would have followed up. I take that kind of thing seriously whether it is employee to resident or resident to resident. The Nursing Facility Abuse Prevention, Identification, Investigation and Reporting Policy (undated) documented all allegations of resident abuse, neglect, exploitation, mistreatment, injuries of unknown origin and misappropriation should be reported immediately to the Charge Nurse. The Charge Nurse is responsible for immediately reporting the allegations of abuse to the Administrator, or designated representative. In an interview on 4/6/22 at 3:44 PM, the Administrator stated he expected employees to follow policy and immediately report allegations. We will reeducate everyone on reporting abuse. 2. In an interview on 3/30/22 at 9:37 AM, Resident #4 stated, the kitchen staff poured water on my head. The resident explained, she said it was a joke, but I thought it was inappropriate. I'm very jumpy and used to have seizures. She would poke my ribs too. I asked her to stop, but she didn't. I moved places, so she couldn't do it so easily. Resident #4 stated, the kitchen staff tell me they are joking and having fun but it feels like they're picking on me. I reported it but as far as I know nothing was done. In an interview on 3/30/22 at 10:55 AM, the DON reported that she knew of this incident. The DON stated, Resident #4 likes to joke. His personality changes. One minute he will joke with the girls and the next he doesn't like it. I didn't take it further than that.The DON failed to initiate an investigation. In an interview on 3/30/22 at 12:51 PM, the Dietary Supervisor stated, yeah I dripped water on Resident #4's head. I did it. I dripped 2 drops and then wiped it off. The Dietary Supervisor explained, Resident #4 told others and thought it was funny, but then about 5-7 days later he reported it. He didn't eat in the dining room for a month after that. The Nursing Facility Abuse Prevention, Idenfiication, Investigation and Reporting Policy (undated) instructed should an incident of suspected resident abuse be reported or observed, the Administrator or he/her will designate a member of management to investigate the alleged incident. In an interview on 4/6/22 at 3:46 PM, the Administrator stated that he expected the DON to initiate an investigation when she became aware that Resident #4 felt the interaction with staff was no longer a joke.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to notify the resident or their representative of the bed hold option for 1 out of 2 residents reviewed for hospitalizations (Resident #1). The facility reported a census of 31 residents. Findings include: 1. A Minimum Data Set (MDS) dated [DATE] for Resident #1 listed diagnoses of heart failure, diabetes, and renal insufficiency. A Brief Interview for Mental Status (BIMS) score of 15 which indicated no cognitive impairment. Review of the Nurse's Progress Note dated 2/20/22 documented the resident was transported to the emergency room and returned to the facility on 2/25/22, was transported to the doctor's office on 3/3/22 and returned to the facility on 3/5/22. Documentation of notification of resident or their representative regarding the bed hold policy was absent from the resident's health record. The Bed Hold and Transfer Notice, undated documented upon admission and when a resident is transferred for hospitalization or for therapeutic leave, a representative will provide information concerning our bed hold policy. When emergency transfers are necessary, the facility will provide the resident or representative with information concerning our bed hold policy within 24 hours of such transfer. In an interview on 4/4/22 at 10:48 AM, the Director of Clinical Services stated the bed hold notifications did not get done. The same Nurse worked both times the bed hold notifications needed to be done, she didn't know she was supposed to do them. In an interview on 4/6/22 at 3:36 PM, the Administrator stated he expected employees to follow policy and that bed hold notifications should be completed as required.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview, the facility failed to assure care plan interventions were in place to prevent 1 resident from falling (Resident #24) and failed to provide adequate supervision to prevent 2 residents from having altercations (Resident #10 and #31), 5 residents reviewed. The facility reported a census of 30 residents. Findings include: 1) According to the Minimum Data Set (MDS) assessment dated [DATE] Resident #24 scored 11 on the Brief Interview for Mental Status (BIMS) indicating moderate cognitive impairment. The resident required extensive assistance for bed mobility, transfer, dressing, toilet use and personal hygiene. The resident's diagnoses included peripheral vascular disease and diabetes. The current Care Plan identified the resident at risk for falls due to general weakness dated 2/10/20. The interventions included the resident had a tab alarm to be on at all times due to falls and self transferring for the resident's safety, initiated 10/14/21. The Progress Notes dated 12/1/21 at 4:03 p.m. documented a housekeeper called the nurse to the resident's room because she heard him fall to the floor. When the nurse entered the room, the resident laid on his right side face down, next to the dresser, with blood coming out of his nose and forehead. After cleaning the resident's face noted a skin tear to his forehead measuring 1.5 centimeters and the bridge of his nose measuring 1 centimeter. He also had an abrasion on the right side area measuring 5.5 centimeters by 4.5 centimeters. The right greater knuckle looked swollen and bruised but the resident denied pain and could move it without issues . The resident complained of his face hurting but no other pain. He moved all extremities within normal limits per his usual. He received acetaminophen for a headache. The resident's family member called and notified and requested he be sent to the emergency room (ER). The intervention initiated at the time of the fall: staff and resident education, the alarm not on at the time of the fall. On 3/31/22 at 3:22 p.m. the resident sat in the wheelchair with the personal alarm attached to the back of his shirt. On 4/4/22 at 9:04 a.m. the Director of Nursing (DON) stated if the resident's Care Plan called for an alarm it should have been on at the time of the incident on 12/1/21. On 4/6/22 at 8:24 a.m. the DON stated all staff working the afternoon of 12/1/21 were written up because the resident did not have the alarm on. 2) According to the MDS assessment dated [DATE] Resident #10 had long and short term memory impairment and severely impaired skills for daily decision making. The resident exibited no behaviors. The resident required limited assistance for ambulation and locomotion. The resident's diagnoses included senile dementia of the brain and a cerebral vascular accident (stroke). According to the MDS assessment dated [DATE] Resident #10 scored 00 on the BIMS indicating severe cognitive impairment. The resident exibited no behaviors. The resident required extensive assistance for ambulation and locomotion. The Care Plan revised 4/22/21 identified the resident had confusion due to dementia. The resident got restless and had difficulty sleeping. The interventions included heart, hands, health (HHH) program instructions located inside of the resident's closet, he enjoyed using the fidget blanket and tool sensory board, visiting with his wife on the phone, watching the Hallmark Channel, CMT and Smokie and the Bandit movies. He preferred quiet settings/individual activities. He usually declined group activitivities. They monitored his behavior and redirected as needed. The Progress Notes dated 9/16/21 at 9:52 a.m. documented the nurse on the phone heard Resident #31 yelling out. The nurse turned around and saw Resident #10 had ahold of Resident #31's wrist.The nurse immediately directed the Certified Medication Aide (CMA) to separate the resident's from each other. The Progress Notes dated 9/16/21 at 4:58 p.m. documented the nurse in the copy room heard Resident #31 scream. She ran out of copy room to see Resident #10 backed up by a CNA in his wheelchair. Resident #31 said he deserved that. The CNA explained she saw Resident #10 had a hold of Resident #31's wrists. Resident #31 stepped back and open handedly smacked Resident #10 in the face. Resident #31 believed Resident #10 was her husband. She often tried to talk to him, and he was not very verbal and it caused her to become very upset. Resident #10 became very upset when Resident #31 touched him as he knew she was not his wife and it made him uncomfortable. The Progress Notes dated 10/1/21 at 3:10 p.m. documented the nurse heard Resident #31 yelling, and the nurse rushed around the desk to the TV room to see what was going on. Upon getting to Resident #10 and Resident #31 a CNA had also ran to see and had already separated them. The nurse asked Resident #10 where Resident #31 grabbed him and he said his neck. The nurse completed a full head to toe assessment of the resident and obtained vital signs. No new skin areas noted and the resident denied any pain. The Progress Notes dated 10/7/21 at 1:29 p.m. documented the nurse called the resident's wife and informed her of another episode in the dining room, between Resident #10 and another resident. The other female resident, who believed Resident #10 was her husband, grabbed his wrist and started yelling that he was hitting her. Resident #10 never laid a hand on her and a CNA witnessed the episode. There were no injuries to either party. The Progress Notes dated 11/25/21 at 12:11 p.m. documented Resident #10 grabbed Resident #31 by the wrist as she walked past. Resident #10 then squeezed and tried to turn Resident #31's wrist in attempt to harm her. They have had incidents in the past where she believed he was her husband. This caused him to be fearful of her. The residents were separated immediately. 3) According to the MDS assessment dated [DATE] Resident #31 scored 4 on the BIMS indicating moderate cognitive impairment. The resident ambulated independently. The resident's diagnoses included non-Alzheimer's dementia. The resident exibited behavioral symptoms not directed towards others (e.g., physical symptoms such as hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, throwing or smearing food or bodily wastes, or verbal/vocal symptoms like screaming, disruptive sounds) 1 to 3 days. The identified symptoms significantly disrupted care or the living environment, impacting others. Wandering occured daily but did not significantly intrude on the privacy or activities of others. The Care Plan initiated 9/15/21 identified the resident had Alzheimer's and delusions. She often thought others were her family. She had a history of wandering without clothing on and had physical aggression towards another resident in the past, with a goal of trying not to hit, undress or hug/touch other residents that she thought were her family. Interventions included assisting the resident with dressing as needed, she liked to feel helpful, please set her up with a folding towel activity, assembling snacks , and she also had a baby doll that she liked to take care of. Offer the resident activities that she can do on her own or in small groups, and occupational therapy to evaluate and treat with a heart hands health program. Tell the resident your name and that you were going to take care of her, the resident had an admission to hope harbor for behaviors and family was looking looking into moving her into an Alzheimer's unit. Redirect with reminiscing, remind the resident that her family was not in the building when she searched for them and assist with using the phone to call her family. When the resident showed signs of aggression give one to one and assist her to another area away from others and offer an activity. The Progress Notes dated 9/16/21 at 9:52 a.m. documented the nurse on the phone heard heard a resident yelling out. The nurse turned around and saw that Resident #10 had ahold of Resident #31's wrist. The nurse immediately directed the Certified Medication Aide (CMA) to separate the resident's from each other. (Staff) performed a full skin assessment, and no skin conditions noted related to the incident. The Progress Notes dated 9/16/21 at 4:58 p.m. documented the nurse in the copy room heard Resident #31 scream. She ran out of copy room to see Resident #10 being backed up by a CNA in his wheelchair. Resident #31 said he deserved that.The CNA explained she saw Resident #10 had ahold of Resident #31's wrists. Resident #31 stepped back and open handedly smacked Resident #10 in the face. Resident #31 believed Resident #10 was her husband. She often tried to talk to him. Resident #10 was not very verbal and this caused Resident #31 to become very upset. Resident #10 became very upset when Resident #31 touched him because he knew she was not his wife and it made him uncomfortable. The Progress Notes dated 10/1/21 at 3:10 p.m. documented the nurse heard Resident #31 yelling, and rushed around the desk to the TV room to see what was going on. Upon getting to Resident #10 and Resident #31, a CNA had also ran to see what was going on and had already separated them. The Progress Notes dated 10/7/21 at 2:35 p.m. documented a CNA in the dining room witnessed Resident #31 grab Resident #10's wrist and started yelling that he was hitting her. It was witnessed that Resident #10 did not lay a hand on Resident #31. The resident's were separated immediately and the male resident was taken to the Administrator's office, as he was afraid of Resident #31. The Progress notes dated 11/25/21 at 1 p.m. documented the nurse was in the TV area talking with two residents. She heard Resident #31 scream out in pain. She looked up to see CNA's separating Resident #10 and #31. Upon speaking with the CNA's they said Resident #31 walked by Resident #10 and he got a mean look on his face and reached out and grabbed her hand and squeezed. Resident #31 had a small bruise present (0.5x 0.4 cm) on her dorsal hand,unsure if related or not. On 4/4/22 at 9:48 a.m. Staff C Certified Nursing Assistant (CNA) stated that Resident #31 thought Resident #10 was her husband. One time she called him sweetie and he wouldn't talk to her so she roll up a newspaper and said she would whack him in the back of the head. Staff C stopped this and redirected Resident #31 away. She said this happened before the first altercation they had. She said one of the interventions was that they would not be in the same room. So Resident #31 sat in the small dining room and Resident #10 sat in the large dining room and they didn't walk them in or out or go in and out where they would be in close proximity to each other. Resident #10 was very uncomfortable when Resident #31 would try to talk to him or get close to him. They tried to keep them separated. Resident #10 started staying in his room more and sitting in his recliner, and Resident #31 continued to wander. On 4/4/22 at 9:56 a.m. the Care Plan Coordinator (CPC) stated she updated the care plans when info came in. She never witnessed any of the events between Resident #10 and Resident #31. She did look at the care plan and was not sure when it was updated but on 10/25 she found one intervention on the care plan but she could not find any others. So she could not say what specific interventions were put in place. She could see that the care plan was revised on 12/10 but also cancelled on 12/10. She did say that Resident #31 was aggressive toward her spouse at home prior to coming into the facility, and that Resident #31 and Resident #10 knew each other before the home. The CPC stated that sometimes if she could see that Resident #31 was exit seeking or restless she would have her come in and visit with her and reminisce, and that would keep her occupied for some time. On 4/4/22 at 10:51 a.m. the Activity Director (AD) stated she averted an interaction right after the resident returned from the hospital stay. She said they had to have someone with Resident #31 if she was out and about and Resident #10 was also out. She said Resident #31 could walk quite fast so she could get to Resident #10 quickly. She said for awhile after Resident #31 returned from the hospital she wasn't walking as well and required assistance of two. She said one of the interventions they did was they both couldn't come out to the same activity they would ask Resident #31 and if she didn't want to come then they would ask Resident #10. If Resident #31 wanted to come out they would ask Resident #10 to come to the later activity. She said she thought that intervention initiated sometime before Halloween so sometime in October. On 4/4/22 at 11:13 a.m. the Administrator stated Resident #31 would visit in his office. Shee had a baby doll that they would give to her and that would take up some of her time. He said they tried to keep the two residents separated. He would bring the other resident in his office he did not like the sound of Resident #31's voice, it agitated him. He the MDS Coordinator, the Quality Assurance nurse, and the DON discussed it and decided they had to do some kind of an intervention, and that was sending her somewhere. The other resident was in a wheelchair and Resident #31 was freely mobile throughout the facility. They did the hearts, hand, health program through occupational therapy as one thing they tried. He said if they didn't get it documented on the care plan the interventions we're a priority, not getting it written down somewhere. Resident #31 transferred to a facility that had a dementia unit. On 4/4/22 at 11:39 a.m. Staff F CNA stated she saw Resident #31 and Resident #10 going to have an altercation and someone intervened and stopped it. They started putting Resident #10 in his recliner in his room instead of in the TV room. They observed the residents to try and assure that they weren't in a position that they could have an altercation. The other resident would come out to the TV room when Resident #31 was gone. Staff F didn't see any of the altercations herself. She said the other resident was kind of grabby anyway. They tried to keep Resident #31 busy. On 4/4/22 at 11:47 a.m. Staff G CNA stated once she saw Resident #31 smack the other resident with her hand and she also had seen the other resident pinch Resident #31's hand on another occasion. She said one of the things they would do would be to keep the other resident in his room and they would keep a close eye on the residents when they were both out of their room. On 4/4/22 at 11:56 a.m. Staff D CNA stated Resident #31 would go up to Resident #10 and one or the other would get aggressive. Resident #31 slapped Resident #10 at least two times. Some of the younger staff would put them too close together and not realize the problems that they'd have. She would say no they cannot be together. They took Resident #10 to his room instead of the TV room to sit in his recliner, so that Resident #31 wouldn't see him out there and start something. She said Resident #31 didn't seem to care if he sat out in the TV room or sat in his room. They put him in the TV room if there's something going on and he couldn't sleep, then he wouldn't miss it. The facility policy Care Plan Frequent Update reviewed and updated 11/9/18 documented the resident care plan would be updated whenever there was a change in the plan of care. The process included whenever a change in physician orders and or nursing interventions occurred the care plan would be reviewed. The care plan would be reviewed to determine which section of the care plan addressed the concern and or problem that the change affected. The update/change to the care plan would be communicated to appropriate staff.

Based on record review, observation and staff interview, the facility failed to ensure dishwashing temperatures and sanitizing solutions were maintained at safe, sanitizing levels. Findings include: 1. A review of the Dishmachine Log revealed only one temperature recorded daily, beginning 2/28/22 thru 3/29/22, for a total of 30 days. A single daily entry consisted of the notation over 160 degrees with a yellow test strip attached with a blackened mark, indicating the correct temperature had been achieved. A joint review of the dishmachine with the Dietary Manager (DM) liquid additives revealed 2 components were attached to the machine. One labeled detergent and one labeled rinse additive. The DM stated the machine is operated as a high temperature sanitizer and does not utilize chemical sanitizing. A review of the manufacturer's attached labeling instructed that during the wash stage, a minimum of 155 degrees F (Fahrenheit), for a minimum of 45 seconds was required for proper operations and sanitizing. The labelling also instructed that a minimum of 180 degrees F for a minimum of 7 seconds, with a dwell time (time spent in the same stage of a process) of 20 seconds was required for proper operations and sanitizing during the rinse stage. A review of the yellow test stripes attached to the daily temperature log revealed the temperature range was marked as obtaining a temperature of 160 degrees F. A review of the undated facility policy titled 'Dish Machine Temperature Log' , directs that staff will be trained to record dish machine temperatures for the wash and rinse cycles at each meal. It further directs the food service manager will spot check this log to assure temperatures are appropriate and staff is actually monitoring dish machine temperatures. It outlines the temperatures for a 'High Temperature Dishwasher' as a wash cycle obtaining 150-165 degrees F and a final rinse temperature for sanitization as 180 degrees F. On 3/29/22 at 10:30 AM, a joint review was conducted with the DM of the red cleaning buckets filled with Multi-QUAT (sanitizing solution). The product is used for the 3-compartment sink sanitizing of large cookware and to refill and replenish buckets of sanitizer for staff to utilize on food contact surfaces and equipment. Testing of the bucket revealed a measurement of 150 ppm. The ECOLAB signage posted over the wash sinks, instructs the user to monitor the solution with a test strip. The test strip indicates a color change when dipped into the solution, to indicate if the solution meets the required range of 150-400 ppm (parts per million) for safe and effective sanitizing. The DM acknowledged this documentation of testing for proper sanitizing levels of product is not documented or monitored on any log, throughout the day. On 3/29/22 at 11:00 AM, an interview with the DM, stated they have never documented the dishmachine temperatures more than once daily, and typically this occurs at the breakfast meal She stated they have never documented the ppm of the Multi-QUAT solution used to sanitize food surfaces and equipment. Stated she believed the kitchen in the assisted living facility did utilize a log that documents those processes. The DM acknowledged a log documenting the dishmachine operating temperatures after each meal and the monitoring of the sanitizing solution strength, would demonstrate safe practices for the kitchen. Stated she plans to implement the new log this week.