Based on interview, record review, facility document review, and facility policy review, the facility failed to protect the residents' right to be free from abuse other residents for 2 (Resident #10 and Resident #38) of 5 residents reviewed for abuse.Findings included: A facility policy titled, “Abuse, Neglect, Misappropriation and Exploitation Policy,” revised 01/2018, indicated, “Our facility does not condone or tolerate resident abuse (this includes verbal abuse, sexual abuse, physical abuse and mental abuse), neglect, misappropriation or exploitation under any circumstances by anyone, including staff members, other residents, consultants, volunteers, staff of other agencies serving or visiting the resident, family members, legal guardians, sponsors, friends, or other individuals.” 1. Record review revealed a document titled “admission Record” indicated the facility admitted Resident 10 on 04/03/2024. According to the admission Record, the resident had a medical history that included diagnoses of anxiety disorder and major depressive disorder. An annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 03/04/2025, revealed Resident 10 had a Brief Interview for Mental Status (BIMS) score of 11, which indicated the resident had moderate cognitive impairment. Resident 10’s “Care Plan Report,” included a focus area initiated 12/10/2024, that indicated the resident had a potential for alteration in sleep cycle due to a history of insomnia for which the resident received medication. Interventions directed staff to provide a calm environment for the resident as much as possible. Record review of a document titled “admission Record” indicated the facility admitted Resident #19 on 07/23/2021. According to the admission Record, the resident had a medical history that included diagnoses of Parkinson’s disease, major depressive disorder and insomnia. An annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 01/08/2025, revealed Resident 19 had a Brief Interview for Mental Status (BIMS) score of 7, which indicated the resident had severe cognitive impairment. The MDS also indicated Resident #19 had no wandering behaviors and exhibited no physical behaviors directed toward others. Resident 19’s “Care Plan Report,” included a focus area initiated 11/07/2023 that indicated the resident had a physical altercation with another resident. Interventions directed staff to move the resident to another room where the bathroom had only one entrance to avoid any confusion. Record review of a facility document titled, “Initial Report,” dated 03/28/2025, revealed an alleged incident of resident-to-resident physical abuse that occurred on 03/28/2025 at 5:35 AM. Per the Initial Report, Resident 19 was in an adjoining bathroom and got confused and exited out the wrong bathroom door into Resident 10’s room, where Resident 10 was sleeping. The Initial Report revealed Resident 19 hit Resident #10. The Initial Report revealed Resident 10 had a small laceration above their right eyelid. The Initial Report revealed both residents were evaluated for any injuries and sent to emergency room (ER) for an evaluation. A facility document titled, “Final Report/5 Day Follow-up,” dated 04/02/2025, revealed Resident 19 was assessed in the ER and reviewed by psychiatry, who felt that the incident was due to ongoing confusion as a result of the resident’s dementia. The report revealed the facility placed Resident 19 on one-on-one (1:1) supervision and moved the resident to new room where they did not have to share a bathroom with another resident/room. Per the report, Resident 19 was seen by in-house psychiatry and medication changes were made. The report revealed Resident 10 had a superficial laceration and bruising to the left eyebrow that did not require repair. During an interview on 08/20/2025 at 9:30 AM, Resident 10 stated they remembered being hit in the face, but they did not remember any other information, just that they were punched. During an interview on 08/20/2025 at 9:48 AM, Registered Nurse (RN) 7 stated he understood that Resident 19 thought Resident 10 was in Resident 19’s bed. RN 7 stated Resident 19 then punched Resident 10 in the face. During a telephone interview on 08/20/2025 at 12:49 PM, RN 15 stated that when Resident 19 was in their bathroom, the resident must have gotten confused and went out the wrong bathroom door into Resident 10’s room and thought Resident 10 was in Resident 19’s bed. During a telephone interview on 08/20/2025 at 1:35 PM, State Registered Nurse Aide (SRNA) 16 stated she was completing rounds and heard Resident 19 in the bathroom and went down to the room and found Resident 19 in Resident 10’s room. SRNA 16 stated it appeared that Resident 19 got confused while in the adjoining bathroom and came out into Resident 10’s room and thought Resident 10 was in Resident 19’s bed. SRNA 16 stated she then saw Resident 10’s eye had a small laceration/scratch on the eyebrow area. SRNA 16 stated both residents were sent to the ER for an evaluation. During an interview on 08/20/2025 at 3:52 PM, RN 17 stated that she was notified by SRNA 16 that Resident 19 was found in Resident 10’s room. RN 17 stated when she entered the room, she found Resident 10 had a small amount of blood on their face, and the resident said that someone had hit them in the face. RN 17 stated Resident 10 had a laceration on their eyebrow. During an interview on 08/22/2025 at 3:35 PM, the Administrator stated she knew the incident happened between Resident 10 and Resident 19 but believed Resident 19 was confused and thought someone was in their bed. 2. An “admission Record” revealed the facility admitted Resident 71 on 01/30/2023. According to the admission Record, the resident had a medical history that included diagnoses of dementia, mild intellectual disability, and depression. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 06/04/2025, revealed Resident 71 had a Brief Interview for Mental Status (BIMS) score of 5, which indicated the resident had severe cognitive impairment. Resident 71's “Care Plan Report,” included a focus area initiated 04/04/2024, that indicated the resident had the potential for an alteration in mood/behavior and was noted with physical aggression, screaming, threatening, cursing, and frustration. Interventions directed staff to administer medications as ordered, observe and record any alterations in mood/behaviors, psychiatric consult as ordered, if resistant to care allow the resident to calm down and then reapproach, and invite the resident to activities of choice. An “admission Record” revealed the facility admitted Resident 38 on 12/30/2005. According to the admission Record, the resident had a medical history that included diagnoses of bipolar disorder, dementia, major depressive disorder, and anxiety disorder. A quarterly MDS, with an ARD of 08/11/2025, revealed Resident 38 had a BIMS score of 10, which indicated the resident had moderate cognitive impairment. An “Initial Report” dated 07/19/2025 revealed an allegation of resident-to-resident abuse that occurred on 07/19/2025 at 11:40 AM between Resident 71 and Resident 38. The report revealed the incident was witnessed by State Registered Nurse Aide (SRNA) 3. The report revealed Resident 71 slapped Resident 38 on the right side of their face and knocked their glasses off. Per the report, Resident 71 was immediately removed to their room by Registered Nurse (RN) 4 to calm down. During an interview on 08/20/2025 at 9:49 AM, SRNA 3 stated that she had witnessed the altercation between Resident 71 and Resident 38. She stated that the residents were in front of the nursing station on the [NAME] Unit. SRNA 3 stated that Resident 71 appeared to get upset that their chair was touching Resident 38’s chair and they were unable to go around the other resident. She stated Resident 71 backed up a little and slapped Resident 38 in the face. SRNA 3 stated Resident 38’s glasses fell off their face as a result. During an interview on 08/20/2025 at 10:23 AM, RN 4 stated that Resident 71 had episodes of anger. He stated that he did not directly witness the slap but removed Resident 71 to the resident’s room after the incident. During an interview on 08/20/2025 at 10:38 AM, LPN 5 stated that she was present during the altercation between Resident 38 and Resident 71 but did not witness Resident 71 making contact with Resident 38. She stated that she checked Resident 38’s jaw, which was a little red, but the redness went away in approximately an hour. She stated Resident 38 did not have a bruise, and there were no scratches. She stated that R 71 had a history of cursing when they did not get what they wanted. She stated that she reported the incident to the Director of Nursing (DON). Resident 71 was observed ambulating independently in their wheelchair on 08/20/2025 at 11:50 AM on the [NAME] Unit. During an interview on 08/20/2025 at 11:54 AM, R 71 indicated they did not recall the incident that involved hitting R 38 but did know a resident by that name. R 71 denied ever striking another resident. During an interview on 08/18/2025 at 2:21 PM, R 38 indicated that they recalled R 71 hitting them. R 38 indicated that they did not feel safe in the facility because of that. The DON was interviewed on 08/20/2025 at 11:19 AM. She stated that she recalled the incident with Resident 38 and Resident 71, and the abuse had been verified.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, document review, and facility policy review, the facility failed to ensure staff reported an allegation of abuse timely to the Director of Nursing and/or Administrator for 2 (Resident #38 and Resident #81) of 4 sampled residents reviewed for abuse.Findings included: The facility policy titled, “Abuse, Neglect, Misappropriation and Exploitation Policy,” revised 01/2018, indicated, “All allegations involving suspected abuse, neglect, misappropriation or exploitation including injuries of an unknown source or misappropriation of resident property shall be reported immediately, but not later 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do no result in serious bodily injury, to the Director of Nursing and/or the Administrator of the facility. The Director of Nursing, Administrator or Designee shall report such allegations to appropriate state and federal agencies, including law enforcement, as required.” 1. An “admission Record” revealed the facility admitted Resident #81 on 09/12/2022. According to the admission Record, the resident had a medical history that included a diagnosis of atherosclerotic heart disease. An annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/27/2024, revealed Resident #81 had a Brief Interview for Mental Status (BIMS) of 12, which indicated the resident was cognitively intact. A review of progress notes dated 07/06/2025 at 2:57 AM indicated, “[Resident #81] stated to CNA (State Registered Nurse Aide [SRNA] #1) that hospital staff was mean to [Resident #81] during [Resident #81’s] admission and asked CNA where [Resident #81] could purchase a gun.” The progress note was entered by Registered Nurse (RN) #2. During an interview on 08/21/2025 at 8:43 AM, SRNA #1 stated she took care of Resident #81 on 07/05/2025. She stated Resident #81 told her that something had happened to Resident #81 at the hospital, and Resident #81 had a bruise on the top of their left hand. Resident #81 stated they wanted a gun for protection, and she told Resident #81 the resident did not need a gun for protection, and she would keep Resident #81 safe. Resident #81 then said to her, “Look at my hand and look at what they did to me at the hospital.” She reported it to RN #2, who was the nurse on duty that night, as soon as Resident #81 made the allegation to her. She could not remember what time it was when Resident #81 made the allegation of something happening at the hospital. During an interview on 08/20/2025 at 10:15 AM, RN #2 stated a SRNA came and told her what Resident #81 had said. Resident #81 told the SRNA that Resident #81 had been abused at the hospital. She made sure Resident #81 was safe, then she called the on-call nurse and told her what Resident #81 had reported as well. She could not remember who the SRNA was or who the on-call nurse was to whom she talked. The on-call nurse told her to leave a nurse's note for the social worker, and the social worker would talk to Resident #81. She stated she had received abuse training. She stated she would report any allegation of abuse to the on-call nurse or to a supervisor. She stated she was always supposed to report it immediately. She stated the on-call nurse told her just to make the note since the allegation of abuse did not involve any of their staff nor did it happen in the facility. During an interview on 08/20/2025 at 10:55 AM, MDS #11 could not remember what time RN #2 had called her on the night of 07/05/2025 and vaguely remembered what RN #2 had told her that Resident #81 had reported. She stated it was something about Resident #81 wanting a gun for protection because Resident #81 was worried about being robbed and about something that occurred at the hospital. She stated RN #2 told her that she had ensured Resident #81 was safe. She told RN #2 if Resident #81 was okay just to watch Resident #81 and make Resident #81 feel safe and comfortable. She did not report it to anyone else at that time. She could not remember if she ever reported it to anyone else. MDS #11 stated she had received abuse training. She stated she was supposed to report any allegation of abuse immediately by contacting the DON and/or Administrator. During an interview on 08/19/2025 at 2:20 PM, the Director of Social Services stated the allegation of abuse was reported to her by a staff member on July 8th. She stated a progress note dated 07/06/2025 at 2:57 AM revealed Resident #81 had reported the allegation to a CNA who reported it to RN #2 at that time. She talked to Resident #81 on 07/08/2025 sometime that morning, and Resident #81 told her that Resident #81 was at the hospital, and a man and two women came into the resident’s room, and the man held him down while the two women hit him on the hand over and over. She called the hospital on [DATE] and reported the allegation to a case manager. During a follow-up interview on 08/20/2025 at 10:46 AM, Director of Social Services stated they were reviewing the nurse’s note during their morning meeting on 07/08/2025 when they came across the note RN #2 had entered regarding Resident #81. The Administrator and Director of Nursing (DON) became aware during the morning meeting of the allegation of abuse made by Resident #81. She stated she had received abuse training, and she was to report abuse immediately. She stated she would report any allegation of abuse to the DON or Administrator. During an interview on 08/22/2025 at 1:51 PM, the DON stated they expected all staff to report abuse as soon as it happened. They had two hours to report abuse to the state in their initial report. When the allegation Resident #81 had made came to her that Resident #81 had been abused at the hospital, they wanted to know who, so she sent the Director of Social Services to talk to Resident #81 and get details while she started their initial report. She stated she was made aware of the allegation on 07/10/2025 and did not remember what time exactly. She stated there was obviously a breakdown somewhere, and staff did not report it properly on the morning of 07/06/2025. She did not remember becoming aware of the allegation on 07/08/2025 during the morning meeting. She would expect any allegation of abuse to be reported immediately and within two hours to the state. During an interview on 08/22/2025 at 2:18 PM, the Administrator stated that once abuse was reported the residents were protected first. They separated them, assessed them, and made sure they were safe. If it was reported to or witnessed by an aide, the aide would report it to the nurse, and the nurse would report it to a supervisor. It would then get reported to the Administrator or the DON. All staff should report any allegation of abuse immediately. After any allegation of abuse was reported, they had two hours to submit their initial report to the state survey agency and five days before the final report. She stated she could not remember when she was made aware of the allegation made by Resident #81. After she reviewed Resident #81’s file, she stated she was out sick during that time. She stated the DON had called her, but she did not recall any details. She would expect every staff member to report any allegation of abuse immediately so they could start their investigation. She did not know why the allegation made by Resident #81 was not reported timely. 2. An admission Record revealed the facility admitted Resident #71 on 01/30/2023 with diagnoses that included dementia, mild intellectual disability, and depression. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 06/04/2025, revealed Resident #71 had a Brief Interview for Mental Status (BIMS) score of 5, which indicated the resident had severe cognitive impairment. An admission Record revealed the facility admitted Resident #38 on 12/23/2024 with diagnoses that included bipolar disorder, dementia, major depressive disorder, and anxiety disorder. A quarterly Minimum Data Set (MDS), with an ARD of 05/13/2025, revealed Resident #38 had a BIMS score of 12, which indicated the resident had moderate cognitive impairment. Review of the “Long Term Care Facility – Self-Reported Incident Form Initial Report” indicated an allegation of resident-to-resident abuse was witnessed by State Registered Nurse Aide (SRNA) #3 on 07/19/2025 at 11:40 AM between Resident #71 and Resident #38. The incident was reported to the Administrator on 07/19/2025 at 2:39 PM. The facility reported the incident to the state agency on 07/19/2025 at 3:49 PM, which was not within the two-hour regulatory timeframe. During an interview on 08/20/2025 at 9:49 AM, SRNA #3 stated that she had witnessed the altercation between Resident #71 and Resident #38. She stated it was in front of the nursing station on the [NAME] Unit. Resident #71 appeared to get upset that they were unable to get around the other resident, so repositioned their own wheelchair and slapped Resident #38 in the face. Resident #38’s glasses fell off their face as a result. The event occurred during meal time, and several other staff were present offering feeding assistance to various residents and passing trays. She stated she made the nurse aware of the incident. During an interview on 08/20/2025 at 10:23 AM, Registered Nurse (RN) #4 stated that Resident #71 had episodes of anger. He stated that he did not directly witness the slap, but removed Resident #71 to the resident’s room. He stated that he let the assigned nurse, Licensed Practical Nurse (LPN) #5, process the situation and handle reporting the abuse to administration. In an interview on 08/20/2025 at 10:38 AM, LPN #5 stated that she was present during the altercation between Resident 38 and Resident #71 but did not witness the Resident #71’s hand make contact with Resident #38’s face. She stated that she checked Resident #38’s jaw, which was a little red, but the redness went away in approximately an hour. It did not bruise and there were no scratches. She stated that Resident #71 had a history of cursing when they did not get what they wanted. She stated that she did report the incident to the Director of Nursing (DON), but it may have been over an hour after the incident occurred. She stated that she did receive abuse training and had been educated to report abuse immediately. She stated the reason she took longer to report was due to becoming occupied with another person. Resident #71 was observed ambulating independently in their wheelchair on 08/20/2025 on the [NAME] Unit. Resident #71 was interviewed on 08/20/2025 at 11:54 AM. They indicated they did not recall the incident that involved hitting Resident #38 but did know a resident by Resident #38’s name. Resident #71 denied ever striking another resident. Resident #38 was interviewed on 08/18/2025 at 2:21 PM. Resident #38 indicated that they did recall Resident #71 hitting them. During an interview on 08/22/2025 at 1:51 PM, the DON stated that she expected all staff to report abuse as soon as it happened. She stated the facility had two hours to report abuse to the state in their initial report. She would expect any allegation of abuse to be reported immediately and within two hours to the state. In a follow-up interview on 08/22/2025 at 3:16 PM, the DON stated that the incident with Resident #71 and Resident #38 was reported to her late, so she informed the Administrator (ADM) that she would be unable to report the incident timely. The nurse who reported to her was educated after the fact about reporting. She reiterated that she expected staff to report immediately. In an interview on 08/22/2025 at 2:18 PM, the ADM stated that once abuse was reported, the resident was protected first; they separated the residents, assessed them, and made sure they were safe. If abuse was reported to or witnessed by an aide, the aide would report it to the nurse, and the nurse would report it to a supervisor. It would then get reported to the ADM or the DON. After any allegation of abuse was reported, the facility had two hours to submit the initial report to the state agency and five days to submit the final report. She stated she would expect every staff member to report any allegation of abuse immediately so they could start their investigation. In a follow-up interview on 08/22/2025 at 3:58 PM, the ADM stated that it did not meet expectations for an incident that occurred and was witnessed at 11:40 AM to be reported to the state agency at 3:49 PM the same day. She stated she was not sure why the allegation was reported late.

Based on interview, record review, and facility document and policy review, the facility failed to provide evidence of a thorough abuse investigation for an allegation of resident-to-resident abuse involving 1 (Resident #71) of 4 residents reviewed for dementia care and 1 (Resident #38) of 6 residents reviewed for abuse. Specifically, after staff witnessed Resident #71 slap Resident #38 on the face on 07/19/2025, the facility failed to ensure all potential witnesses to the incident were identified and interviewed and interviews or assessments of other residents who may have had contact with Resident #71 were conducted during the investigation to determine if other residents may have also been affected.Findings included: A facility policy titled, Abuse, Neglect, Misappropriation and Exploitation Policy, last revised on 01/2018, indicated, ABUSE AND/OR RESIDENT NEGLECT INVESTIGATION 1) When an incident or suspected incident of resident abuse or neglect is reported, the Administrator or Director of Nursing will appoint a representative to investigate the incident. 2) A thorough investigation shall be completed. 3) Results of the investigation may be documented in an Investigative Summary report format or on a Resident Abuse Investigation Report Form. 4) For resident to resident altercations: -Separate and ensure both residents are protected from further harm -Assess both residents for injuries -Provide appropriate medical attention as needed -Contact family, doctor, Administrator -Interview both residents, if interviewable, and document in an Investigative Summary report format -Review the resident's medical record for signs that led up to the event -Interview any witnesses to the incident.During an interview on 08/22/2025 at 2:18 PM, the Administrator (ADM) stated that during an abuse investigation, facility staff would also conduct interviews with other residents who had a Brief Interview for Mental Status (BIMS) score of 8 or above (those with moderate cognitive impairment and those that were cognitively intact) and conduct skin assessments on residents with a BIMS score below 8 (those with severe cognitive impairment).An admission Record revealed the facility admitted Resident #71 on 01/30/2023. According to the admission Record, the resident had a medical history that included diagnoses of dementia, mild intellectual disability, and depression.A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 06/04/2025, revealed Resident #71 had a Brief Interview for Mental Status (BIMS) score of 5, which indicated the resident had severe cognitive impairment.Resident #71's Care Plan Report included a focus area, initiated 04/04/2024, that indicated the resident had the potential for an alteration in mood/behavior and was noted with physical aggression, screaming, threatening, cursing, and frustration. Interventions directed staff to administer medications as ordered, observe and record any alterations in mood/behaviors, psychiatric consult as ordered, if resistant to care allow the resident to calm down and then reapproach, and invite the resident to activities of choice.An admission Record revealed the facility admitted Resident #38 on 12/30/2005. According to the admission Record, the resident had a medical history that included diagnoses of bipolar disorder, dementia, major depressive disorder, and anxiety disorder. A quarterly MDS, with an ARD of 08/11/2025, revealed Resident #38 had a BIMS score of 10, which indicated the resident had moderate cognitive impairment.An Initial Report, dated 07/19/2025, revealed an allegation of resident-to-resident abuse occurred on 07/19/2025 at 11:40 AM between Resident #71 and Resident #38. The report revealed Resident #71 slapped Resident #38 on the right side of their face and knocked their glasses off. The report revealed the incident was witnessed by State Registered Nurse Aide (SRNA) #3. The report did not reflect any other identified witnesses.A Final Report/5 Day Follow-Up revealed the facility's investigation included an interview with one witness (SRNA #3), an interview with the alleged perpetrator (Resident #71), and an interview with the alleged victim (Resident #38). The 5 Day Follow-Up report indicated that the altercation occurred in an area utilized by some residents for meals and was within sight of any staff coming and going through the area; however, the facility's investigation documentation revealed no evidence of attempts to identify or interview additional potential witnesses. The investigation documentation further revealed there was no evidence that interviews or skin assessments of other residents who may have had contact with Resident #71 were conducted during the investigation to determine if other residents may have also been affected.During an interview on 08/20/2025 at 9:49 AM, SRNA #3 stated that she had witnessed the altercation between Resident #71 and Resident #38. She stated the incident occurred in front of the nursing station on the [NAME] Unit during mealtime, and several other staff were present, offering feeding assistance to various residents and passing trays.During an interview on 08/20/2025 at 10:23 AM, RN #4 stated that at least five other staff were present as witnesses to the altercation that occurred on 07/19/2025.The Director of Nursing (DON) was interviewed on 08/20/2025 at 11:19 AM. The DON stated that she recalled the incident with Resident #38 and Resident #71. She further stated that she did not interview or assess other residents who may have had contact with the alleged perpetrator.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and review of the facility's policies, the facility failed to provide a safe, clean, comfortable, and homelike environment for two of nine sampled residents (Resident (R)8, and R42). Observations revealed the shared bathrooms in rooms 226, 228, 227, 221, and 223 had strong urine odor and two sampled residents complained of urine odors in their bathrooms. The findings include: Review of the facility's Protocol for Housekeeping Services (PHS) policy, not dated, revealed the housekeeping and maintenance services would ensure to maintain a sanitary, orderly, and comfortable interior environment. Review of the facility's Resident Rights (RR) policy, not dated, revealed residents had a right to share concerns regarding their stay at the facility. During observation on 08/14/2024, at 9:13 AM, room [ROOM NUMBER]'s bathroom presented with a strong urine odor. The private bathroom had a commode and shower, with a strong urine odor. During observation on 08/16/2024, at 9:15 AM, room [ROOM NUMBER]'s bathroom presented with a strong urine odor. Residents in room [ROOM NUMBER] shared a bathroom with residents in room [ROOM NUMBER]. Resident's in room [ROOM NUMBER] shared a bathroom with residents in room [ROOM NUMBER] and the bathroom presented with a strong urine odor. Record review revealed Resident(R)8 was admitted to the facility on [DATE] with diagnoses of chronic obstructive pulmonary disease, vascular dementia, anxiety and osteoarthritis. Record review of R8's brief interview of mental status (BIMS) was 15/15, indicating no cognitive impairment. During an interview on 08/16/2024 at 10:20 AM, with R8, she stated that her bathroom smelled bad. R8 stated she had reported the smell to housekeeping and the aides. R8 continued to state that housekeeping would come every day to clean the bathroom, but it still smelled bad. She further stated the bathroom stinks, and it had smelled bad for months. She rated the smell a ten on a scale of one to ten with ten being the worst she had ever smelled. Record review revealed R42 had been admitted to the facility on [DATE], with diagnoses of gout, dementia, hypertension, adjustment disorder for depression after the passing of his wife. Record review of R42's BIMS was 15/15 indicating no cognitive impairment. During interview on 08/13/2204 at 10:12 AM, with R42 he stated that he used the bathroom all the time and the bathroom smelled. He further stated he was used to the smell. He stated housekeeping cleaned every day and the bathroom still smelled of urine. On 08/15/2024 at 2:54 PM, during the interview with housekeeping/ laundry supervisor (HLS) she stated she was aware of the urine odors coming from the bathrooms. During further interview she stated she would try to find the cause of odors and address them, because she knew the strong urine smell would make residents uncomfortable and they would complain. HLS further stated urinals cause a lot of odors and were discarded as needed. She further stated other causes of urine odor could be the high-rise commode may need changed to a low rise commode, a commode seal might leak, or a high-rise screw on top commode extender may need changed. HLS continued to state that she was responsible to take any issue she had with needed repairs to the Administrator and the Administrator would let maintenance know to do needed repairs. She further stated there was no cleaning log, she went through and checked the rooms herself and would re-clean the rooms if she found odors. However, she further stated it could be hard to get rid of the urine odor despite trying several cleaning and disinfecting chemicals. 08/15/2024 at 3:25 PM, interview with Maintenance Director (MD) he stated he had replaced the seals, with a rubber gasket on the commode in room [ROOM NUMBER] last week, and when a seal leaked it would smell of urine. He further stated that HLS would let the Administrator know when a commode seal would need replaced and then the Administrator would let him know to replace it. 08/16/2024 at 10:30 AM interview with Administrator she stated she would visit residents but did not usually go into the restrooms and was not aware of the odors. The Administrator was taken to the bathrooms with odors, and she stated the bathrooms had a strong urine odor. She further stated her expectations were to have a homelike environment free of urine odors.

Based on observation, interview, record review and facility policy review, the facility failed to label and store drugs and biologicals in accordance with accepted principles. Observations, on 08/13/2024 at 3:49 PM, 08/14/2024 at 3:39 PM, 3:43 PM, and 4:05 PM, revealed a medication cart on the [NAME] Hall unlocked during medication pass. Residents, staff and visitors were observed passing by the cart. Additional observation, on 08/14/2024, revealed a medication cart on the [NAME] Hall with multi-dose bottles without an open date. The findings include: Review of the facility's policy titled Medication Storage in the Facility, dated June 2023 revealed medications and biologicals were to be stored safely, securely, and properly, following the manufacturer's recommendations or those of the supplier. The medication supply should be accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. Observation on 08/13/2024 at 3:49 PM, on 08/14/2024 at 3:39 PM, 3:43 PM, and 4:05 PM noted a medication cart on the [NAME] Hall, unlocked and unattended by staff during medication pass. Residents, staff, and visitors were observed to be passing by the medication cart. Licensed Practical Nurse #1 ( LPN1) was noted to be responsible for the medication cart. Observation of the medication cart on 08/13/2024 at 9:23 AM on the [NAME] Back Hall revealed Simply Thick an easy mix (a thickener) without an open date, Lactulose (a laxative) 10g/15mL (10 gram/15 milliliter) 32-ounce bottle opened without an open date; and, a 10g/15mL 16-ounce bottle opened without an open date. Further observation revealed Lidocaine Gel (an oral numbing gel) not labeled with a resident's name or open date. Observation of the medication room on 08/14/2024 at 2:29 PM on the East Hall revealed viral transport tubes/swabs dated 06/02/2024; 3 central line dressing kits dated 09/30/2019; 24-gauge intravenous (IV) with an expiration date of 06/03/2023; and, 1 sixteen ounce bottle of hydrogen peroxide, with an expiration date of 11/2023. During interview with Licensed Practical Nurse #1 (LPN1) on 08/14/2024 at 5:33 PM, she stated she realized she had failed to lock the medication cart. She further stated she did not realize she left the medication cart unlocked 4 times. LPN1 stated that failing to lock the medication cart could allow someone to get the medications from the cart (residents, staff, and/or visitors) and could cause harm if they took the medications. She further stated not labeling medications when opened could possibly cause harm to residents by giving expired medications. LPN1 stated that multi-dose medications could only be kept for thirty days after opening. Interview on 08/14/2024 at 5:55 PM with Nurse Consultant 1, she stated the facility did not have a policy for multi-dose bottle storage, but they should always be dated when opened. During an interview with RN3 on 08/15/2024 at 2:29 PM she stated she was not sure who was responsible for ensuring medical supplies were discarded when expired. She stated the supplies may not be as effecttive for use if expired. During interview with the Director of Nursing (DON) on 08/16/2024 at 4:47 PM, she stated it was very important for all medication and treatment carts to be locked when unattended due to the risk of a resident getting into the cart and getting medications which they could be allergic to and cause them harm. The DON further stated it was important to not use expired products as it also cause harm. She stated she expected anything opened to have a date on it so other staff knew when it had been opened to prevent harm to the residents. The DON stated she expected all nurses to lock the carts when unattended. During interview with the Administrator on 08/16/2024 at 5:16 PM, she stated she expected all staff to date medications or supplements when opened to prevent risks to the residents. The Administrator stated she expected all nurses to lock medication carts when they leave the cart to prevent residents, other staff, or visitors from getting into the medication carts. The Administrator stated she expected all nursing staff to look at the expiration dates on supplies and to discard any expired supplies due to the possibility of the supplies not being sterile. She further stated it could cause harm if residents, staff, and/or visitors got into unlocked medication carts.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review and facility policy, the facility failed to maintain proper infection control to prevent the development and transmission of communicable diseases and infections. The facility failed to use enhanced barrier precautions when providing personal resident care and wound care. Staff failed to clean shared resident equipment. In addition, the facility failed to ensure residents' urinals were stored in a clean matter to prevent contamination. The findings include: Review of the facility's policy, titled Protocol for Enhanced Barrier Precautions, revised 03/2024, revealed enhanced barrier precautions (EBP) were indicated for nursing home residents who have an infection or known colonization with a multi-drug resistant organism (MDRO) when contact precautions did not otherwise apply. Continued review of the policy revealed EBP included the use of a gown and gloves during high-contact resident care activities, including dressing, bathing or showering, performing transfers, changing linens, providing hygiene, changing a resident's brief or assisting them with toileting, direct care of an indwelling medical device, such as a central line, urinary catheter, feeding tube, or tracheostomy, and when performing wound care on any skin opening that requires a dressing. 1. Observation on 08/16/2024 at 9:12 AM of R1's wound care, by Licensed Practical Nurse (LPN) 2 revealed no gown was donned (put on) during the wound care. Continued observation revealed State Registered Nursing Assistant #12 (SRNA12) provided urinary catheter care without donning a gown. Further observation revealed SRNA13 assisted with turning and repositioning the resident during care without donning a gown. During an interview on 08/16/2024 at 9:42 AM, with SRNA12, she stated she realized immediately that she forgot to wear a gown and I was nervous. SRNA12 stated she had been trained on infection control by the Infection Preventionist (IP) and knew that a gown was required with any contact care being provided to a resident in enhanced barrier precautions. She stated by not following precautions she could contaminate other residents, and the reason for precautions was to keep residents and staff safe. During an interview on 08/16/2024 at 9:49 AM with LPN 2 who provided the wound care, she stated she had been trained on EBP, by the Infection Preventionist. She stated she was aware she should have worn a gown while providing hands on care to a resident in EBP, as well as gloves. She stated that they were very nervous with State Survey Agency (SSA) observing and forgot to gown. LPN2 stated she had been trained by the IP on all infection control precautions. She stated they must follow precautions to prevent cross contamination to other residents and or staff. During an interview on 08/16/2024 at 4:00 PM with the Infection Preventionist (IP), she stated staff were aware that a yellow tag by the name on the door alerted them that the resident was on EBP precautions and Personal Protective Equipment (PPE) was on the backside of door, which included gowns and gloves. The IP stated staff had been educated that for hands on care for residents in EBP they must use a gown and gloves. She stated EBP were implemented when a resident had a Foley (brand of indwelling catheter) wound, and/or a gastrostomy tube, or essentially any artificial opening or wound of the skin. The IP stated she provided in-services quarterly and/or as needed. She stated she did not have any formal audits in place and if she was rounding on the floor and saw an infection control issue she addressed it verbally at that time. The IP stated she made rounds when she had the opportunity, but there was no set time. She stated that her expectation was for the staff to always follow infection control measures. The IP stated she did track infections using the McGreer (is a set of guidelines used to identify infections in long term care facilities) criteria and tracks antibiotics. She further stated she was responsible for oversight for infection prevention, including education, tracking of antibiotic use, and cleaning of reusable equipment. She stated that by not following appropriate infection control it could cause a risk to the residents by cross contamination. 2. During an interview with Administrator on 08/16/2024 at 5:17 PM she stated the facility did not have a policy outlining the protocol for cleaning residents' care items after use. Observation on 08/13/2024 at 3:05 PM of SRNA5 (State Registered Nurse Aide) 5 and SRNA 6 removing the Hoyer (brand of mechanical lift) from the nurse's station on the 100 Hall and moving it into R83's room to assist the resident from the bed to the wheelchair. Observation revealed staff did not clean the Hoyer lift prior to use. After transferring the resident to his wheelchair, SRNA5 removed Hoyer lift from R 83's room and rolled it back to the 100 Hall nurse's station. The SRNA placed it next to the armoire and walked away from the Hoyer lift without cleaning the equipment. During an interview on 08/13/2024 at 3:31 PM with SRNA6 he stated the policy for cleaning equipment was to wipe down with Purple Top wipes after each use Observation on 08/13/2024 at 3:42 PM of SRNA 7 and SRNA 8 using the In-Bed scale to weigh R 16 in her bed. The IN-Bed scale was brought into R 16's room. A mat was removed from the side of the scale and was placed under R 16 without cleaning prior to use. SRNA 7 and SRNA 8 weighed R 16, returned her to her bed, removed the mat from underneath her, rolled the mat up without cleaning it, and placed it back onto the mobile bed scale. The scale was then removed from R 16's room and place in the 100 Hall nurse's station, behind the Hoyer lift. SRNA 7 and SRNA 8 went to assist another resident without cleaning the In-Bed scale. During an interview on 08/13/2024 at 4:09 PM with SRNA 7, she stated she was not aware of a policy that required staff to clean the In-Bed scale after each use. She stated, I have only been working here a month. They may have talked about it during orientation. I can go and ask someone, if you need me to. She stated if the mat gets soiled, we will wipe it down before placing it on the scale. She also stated by not cleaning the mat and equipment, it would not keep residents safe. Observation on 08/16/2024 at 10:12 AM revealed SRNA14 and SRNA2 taking the Hoyer lift from the nurse's station on the 100 Hall, assisting a resident, and returning the lift to the nurse's station without cleaning it. During an interview on 08/16/2024 at 10:34 AM with SRNA14 she stated she had only been working at the facility for a couple of weeks. She stated she did not know about a policy for cleaning the Hoyer lift or In-Bed scale either before or after use. During an interview on 08/16/2024 at 2:37 PM with the Infection Control (IP)/Staff Development Coordinator (SDC) she stated, We do not provide training for staff on cleaning the Hoyer lift or the In-Bed scale. She stated to her knowledge, the facility did not have a policy for cleaning the Hoyer lift or In-Bed scale. The IP/SDC stated there was not a cleaning schedule for equipment. She stated the lack of cleaning could put residents at risk for becoming exposed to infectious organisms. The IP/SDC stated employees were required to pass a skills test before providing resident care. She stated competency skills were assessed yearly. During an interview on 08/16/2024 at 4:45 PM with the Director of Nursing (DON) she stated the facility did not have a policy for cleaning the Hoyer lift of In-Bed scale currently. She stated she has discussed this with the Administrator, and they are working to develop an equipment cleaning policy. During an interview on 08/16/2024 at 5:17 PM with the Administrator, she stated her expectation of staff using Hoyer lifts and In-Bed scale would be they properly use them to assist residents and the equipment was properly cleaned after use with each resident. She also stated the implications of staff not properly cleaning equipment could endanger residents to possible germs and bacteria. She stated the facility did not currently have a cleaning policy for the Hoyer lift or In-Bed scale. 3. During initial tour of the facility on 08/13/2024, observations of bathrooms in rooms [ROOM NUMBERS] revealed unbagged bedpans and urinals sitting on the floor with no names on the devices. Continued tour of the facility on 08/13/2024 revealed the bathroom in room [ROOM NUMBER] had 2 unbagged urinals with dark color urine hanging on the rail. During an interview with the Director of Nursing (DON) on 08/16/2024 at 4:47 PM, she stated it was very important for the residents to have a homelike environment. The DON stated the bedpans and urinals should be cleaned after each use and changed at least weekly. The DON stated bedpans and urinals should be in a bag and not stored on the floor as the risk for the residents could be the spread of bacteria. During an interview with the Administrator on 08/16/2024 at 5:16 PM, she stated she expected any bedpans or urinals would be stored in a bag and not on the floor. She stated the risk would be the spreading of bacteria. The Administrator stated she expectation was if a bedpan or urinal was on the floor, then the staff would throw that item away and get another one.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and review of the Resident Assessment Instrument (RAI) User's Manual, it was determined the facility failed to ensure the Minimum Data Set (MDS) assessment accurately reflected the resident's status for one (1) of twenty-seven (27) sampled residents (Resident #49). Resident #49 was admitted to hospice services on 04/25/19. However, review of the resident's Minimum Data Set (MDS) assessment dated [DATE] revealed hospice services was not coded on the assessment. The findings include: Interview with the Director of Nursing (DON) on 06/27/19 at 3:38 PM, revealed the facility utilized the Long Term Care Facility Resident Assessment Instrument 3.0 User's Manual, dated October 2018, as a resource for completion of MDS assessments. Review of the Long Term Care Facility Resident Assessment Instrument 3.0 User's Manual revealed the facility had to complete a Significant Change in Status Assessment when a terminally ill resident enrolled in a hospice program and remained a resident in the facility. Further review of the manual revealed the facility had to complete the assessment within fourteen (14) days from the date hospice services was elected. Continued review of the manual revealed the facility must code the Significant Change in Status Assessment to reflect that the resident had elected to receive hospice services. A review of Resident #49's medical record revealed the facility admitted the resident on 06/28/11, with diagnoses including Chronic Obstructive Pulmonary Disease (COPD), Alzheimer's Disease, Seizure Disorder, Diabetes Mellitus, and Atrial Fibrillation. Review of physician's orders for Resident #49 revealed an order dated 04/24/19, for the resident to be admitted to hospice services. Review of hospice communication sheets revealed Resident #49 continued to receive hospice services as of 06/27/19. Although review of a Significant Change in Status MDS assessment for Resident #49, dated 05/01/19, revealed the facility completed the assessment, the facility failed to code the assessment to indicate the resident was receiving hospice services. Interview on 06/27/19 at 3:52 PM with the MDS Nurse that completed the Significant Change in Status MDS assessment dated [DATE] revealed the hospice selection should have been coded, stating it was human error, a typo. Interviews on 06/27/19 at 3:18 PM with the MDS Coordinator and at 3:38 PM with the Director of Nursing (DON) revealed the assessment should have been coded to reflect that the resident was receiving hospice services. The DON further stated she and a corporate staff member randomly audit MDS assessments, but have not identified any concerns related to accuracy.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review and policy review it was determined the facility failed to ensure one (1) of twenty-seven (27) (Residents were free from significant medication errors. Observation of medication administration on 06/26/19 revealed staff mixed Lantus and NovoLog insulins in the same syringe and administer to Resident #99. The findings include: Review of facility's policy titled Medication Administration Policy, not dated, revealed should there be any doubt concerning the administration of medication to a resident, the physician's order must be verified before the medication is administered. Review of the Lantus insulin (a long acting insulin) package insert revealed, Do not dilute or mix Lantus with any other insulin or solution. In addition, review of the NovoLog insulin package insert revealed, NovoLog may be mixed with neutral protamine [NAME] (immediate acting insulins) insulin preparations ONLY. Review of Resident #99's medical record revealed the facility admitted the resident on 05/10/19 with diagnoses of Heart Failure, Diabetes, Dementia, and Chronic Obstructive Pulmonary Disease. Review of Resident #99's physician orders dated 07/01/19 revealed the resident had physician orders for Lantus insulin to be administered subcutaneously twice daily at 8:00 AM and at 4:00 PM. In addition, the resident had physician orders for NovoLog insulin to be administered per sliding scale (the amount administered is based on the resident's blood glucose level). Review of Resident #99's Minimum Data Set (MDS), dated [DATE], revealed the resident had a Brief Interview for Mental Status (BIMS) score of 14, indicating the resident was cognitively intact. Observation and interview on 06/25/19 at 9:07 AM with Resident #99 revealed the resident sitting on the edge of the bed watching television. Interview with Resident #99 revealed the resident voiced no concerns with insulin administration. Observation on 06/26/19 at 8:35 AM of Licensed Practice Nurse (LPN) #2 preparing medication for Resident #99 revealed the LPN removed fifteen (15) units of Lantus from the medication vial via syringe, and then utilized the same syringe to remove six (6) units of NovoLog insulin from the vial, mixing the insulins together. The LPN was then observed to administer the mixed insulins to Resident #99. Interview on 06/26/19 at 3:56 PM with LPN #2 revealed she realized that she had made a mistake with the insulin right about lunchtime. She stated she called the physician and received orders to check the resident's blood sugar every hour for the next six hours. Continued interview with the LPN revealed the resident's blood sugar had been monitored as ordered, and no concerns had been noted. LPN #2 stated she was nervous and got confused when mixing the insulin. She said, I do realize I made a mistake by mixing the insulins, and will never mix Lantus with anything again. A subsequent interview with Resident #99 on 06/26/19 at 4:03 PM revealed the resident was lying in bed with eyes open watching television. When asked how he/she was feeling the resident responded, I'm feeling fine; I don't know why everyone keeps asking me that. Interview on 06/27/19 at 4:06 PM with the Director of Nursing (DON) revealed she expected nurses to follow physician orders and give insulin as ordered. The DON stated the physician was notified of the incident and Resident #99 had suffered no ill effects.