Based on observation, interview, record review, review of a police report, and facility policy review, the facility failed to follow its policy for the receipt of a Schedule 4 controlled medication (clonazepam) for 1 of 2 sampled residents, Resident (R) 32. On 01/02/2025, Licensed Practical Nurse (LPN) 2 signed the pharmacy's Delivery Receipt for delivery of R32's 15 tablets of clonazepam (a benzodiazepine, used to treat anxiety). However, review of the facility's Narcotic Sheet revealed R32 did not have an entry for the delivery of the clonazepam on 01/02/2025, and review of R32's Medication Administration Record [MAR] revealed R32 missed five doses of clonazepam because the facility did not have that medication. The findings include: Review of the facility's undated policy titled, 2.0 Receipt of Routine Deliveries, revealed the facility nurse or other facility representative, when routine medication deliveries arrived from the pharmacy, signed the delivery manifest and/or electronic signature pad, noted time of arrival, and took responsibility of the medications. Per the policy, if medications were not correct, for instance missing from the delivered pharmacy tote, the pharmacy must be notified within 24 hours, so the items could be resent. The policy also stated controlled substances were immediately logged into the facility's controlled drug inventory system in compliance with state or local regulations. Review of the facility's policy titled, Medication Storage, dated 08/04/2024, revealed controlled substances (listed as Schedule 2 through 5 of the Comprehensive Drug Abuse Prevention and Control Act of 1976) and other drugs subject to abuse were separately locked in permanently affixed compartments, except when using a single unit package drug distribution system in which the quantity stored was minimal and a missing dose could be readily detected. Review of R32's Physician's Orders, dated 12/26/2024, revealed R32 was ordered clonazepam 0.25 milligrams (mg) orally and daily at bedtime. Review of R32's January 2025 MAR revealed R32 had an order for clonazepam 0.25 mg to be given orally at bedtime. However, the MAR revealed R32 did not receive doses for five nights because of missing medication on 01/03/2025, 01/05/2025, 01/06/2025, 01/07/2025, and 01/08/2025. Review of the facility provided Delivery Receipt, dated 01/02/2025, revealed clonazepam 0.25 mg, 15 tablets, was signed into the facility at 5:07 PM on 01/02/2025, and LPN2 signed the receipt for the delivery. Review of the facility's Narcotic Sheet revealed R32 did not have an entry for the delivery of the clonazepam 0.25 mg on 01/02/2025. Review of the Police Report, filed on 01/08/2025, revealed LPN2 made a statement that clonazepam 0.25 mg was signed into the medication cart on 01/02/2025. However, per the report, there were no entries on the narcotic record that the medication was signed into the cart. The police report stated the resident (R32) complained about not receiving the medication. Observation on 03/19/2025 at 9:07 AM revealed the pharmacy courier delivered medications to the facility in red sealed bags. The courier placed the medication bags at the nurses' station, LPN1 opened the bags, signed the delivery receipt, and kept a copy of the delivery receipt for the facility. Observation on 03/19/2025 at 10:00 AM revealed the Unit Manager (UM) unlocked the medication room, and several medications were noted in the room in plastic containers. When asked if there were any narcotics in the room, the UM stated no. She stated the room was used as a holding area for medications. During an interview with R32 on 03/19/2025 at 1:15 PM, R32 stated she was aware of the missing medication incident. She stated the UM told her the medication was lost. She stated the facility reordered the medication, and she had no further concerns about the incident. During an interview with LPN2 on 03/19/2025 at 11:45 AM, LPN2 stated, on 01/02/2025, she signed for a medication delivery from the pharmacy and placed those medications in the medication room. She stated she did not view the medications. She stated she did not believe the clonazepam was delivered to the facility. During an interview with LPN6 on 03/20/2025 at 10:37 AM, she stated she came to work for the evening shift, on 01/02/2025, and counted the medication cart with LPN2. She stated the medication count was correct. LPN6 stated that due to the facility being overstaffed she went home, but before leaving, she counted the cart with LPN8. LPN6 stated she was called in a week later for drug testing for the missing clonazepam. The State Survey Agency (SSA) Surveyor attempted to interview LPN8 by telephone. Phone calls were made on 03/20/2025 at 10:18 AM, 03/20/2025 at 2:15 PM, and 03/21/2025 at 9:30 AM. There were no answers, and the voice mail was full. During an interview with the Pharmacist on 03/21/2025 at 2:38 PM, he stated the medication (clonazepam) was delivered on 01/02/2025 at 5:07 PM. The Pharmacist stated there were no discrepancies in the count at the pharmacy. The Pharmacist stated the resident was not billed for the missing medication. He stated the medication was reordered on 01/08/2025 and required prior authorization. During an interview with the Director of Nursing (DON) on 03/20/2025 at 2:00 PM, he stated he had been working at the facility since 12/26/2024. He stated he reported to the Administrator. He stated he had been trained by the Regional Director. He stated narcotics were to be signed directly into the cart and verified with two nurses. He stated he could not verify the medications were delivered to the facility. He stated he was in training at this time. During an interview with the Administrator on 03/19/2025 at 11:35 AM, he stated he was notified the medication was missing on 01/08/2025. He stated he started a facility investigation that included, calling the police, filing a police report, taking witness statements, and initiating drug screens for three employees, LPN2, LPN6, and LPN8. He stated all three employees were given a drug test and placed on leave until the drug test results came back. He stated none of the three tested employees came back positive for any traces of clonazepam. He stated LPN8 and LPN6 were no longer employed at the facility. He stated he could not verify that the clonazepam was delivered to the facility, and as a result, came to the conclusion that the medication was never in the building.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2.a. Review of R62's admission Record revealed the facility admitted R62 on 02/24/2022 with diagnoses of end stage renal disease, obstructive uropathy, and cerebral infarction. Review of R62's quarterly MDS, with an ARD of 03/09/2024, revealed the facility assessed the resident to have a BIMS score of 99, indicating R62 was unable to complete the interview. Review of R62's Progress Note, dated 04/02/2024 revealed an indwelling urinary catheter was inserted with standing orders in place at this time (for the indwelling urinary catheter). Review of R62'S Care Plan, dated 04/02/2024, revealed a focus of indwelling urinary catheter placement with an intervention to provide a privacy bag. Review of R62's Physician Orders, dated 04/04/2024, revealed an order for an indwelling urinary catheter to be placed for the diagnosis of neurogenic bladder. Observation on 04/23/2024 at 1:52 PM of R62 revealed his catheter bag hanging on the side of the bed frame did not have a dignity bag covering it. Observation on 04/25/2024 at 8:47 AM and again at 3:29 PM of R62 revealed his catheter bag hanging on the side of the bed frame did not have a dignity bag covering it. In an interview with R62's Family (F) 6 on 04/25/2024 at 3:29 PM, F6 stated she visited R62 regularly, usually once a week, and could not recall a dignity bag covering the catheter bag. Further interview revealed F6 was unfamiliar with the term, product, or purpose of a dignity bag. In an interview with the Infection Preventionist/Licensed Practical Nurse (IP/LPN) on 04/25/2024 at 3:44 PM, she stated she was working as the care nurse assigned to the 400 Unit, and she cared for R62 on that date. The IP/LPN stated she was unaware there was not a dignity bag on R62's catheter bag. Further interview revealed R62 had gone out of the facility to dialysis, and she thought the dignity bag was removed while R62 was at the dialysis clinic. The IP/LPN further stated it was important to provide a dignity bag for residents to give them dignity and prevent any embarrassment related to bodily functions. b. Review of R41's admission Record revealed the facility admitted R41 on 10/26/2023 with diagnoses of traumatic brain injury, paraplegia, and neuromuscular dysfunction of the bladder. Review of R41's significant change MDS, with an ARD of 03/04/2024, revealed the facility assessed the resident to have a score of 15 out of 15, indicating intact cognition. Observation of R41 on 04/23/2024 at 11:00 AM revealed his catheter bag hanging on the side of the bed frame did not have a dignity bag covering it. Observation of R41 on 04/25/2024 at 8:28 AM and again at 12:23 PM revealed his catheter bag hanging on the side of the bed frame did not have a dignity bag covering it. In an interview with R41 on 04/25/2024 at 12:23 PM, he stated he had used a catheter since a traumatic injury occurred six years ago. R41 stated he was a paraplegic and had no control over bowel or bladder elimination. Further interview revealed R41 was familiar with a dignity bag covering, and sometimes the covering was on the catheter bag and other times it was not. In an interview with State Registered Nurse Aide (SRNA) 5 on 04/25/2024 at 1:07 PM, she stated she had been caring for R41 since he arrived in October 2023. SRNA5 stated sometimes R41 would refuse care, including staff putting a dignity covering over his catheter bag, and other times he allowed it. SRNA5 stated since R41 was on hospice care, he received care from that team as well as facility staff. She stated she was unaware of whose responsibility it was to place the dignity bag covering on the catheter bag. In an interview with LPN6 on 04/25/2024 at 3:36 PM, she stated she was assigned to care for R41 on that date. She stated R41 was difficult to care for because he often refused care. LPN6 stated she was unable to recall if R41 was care planned for refusal to use the dignity bag. During an interview with the Administrator on 04/27/2024 at 5:01 PM, he stated it was his expectation staff followed the facility's policy and protected the residents' right to privacy and dignity. Based on observation, interview, record review, and review of the facility's policy, the facility failed to ensure residents were treated with dignity and respect related to privacy when transporting to a communal bath for 1 of 63 sampled residents (Resident (R) 88) and providing a privacy/dignity bag to cover indwelling urinary catheter bags for 2 out of 6 sampled residents with indwelling urinary catheters (R41 and R62). The findings include: Review of the facility's policy titled, Resident Rights, not dated, revealed the resident had the right to be treated with consideration, respect, and full recognition of their dignity, including privacy in treatment and in care of personal needs. Additionally, the policy stated the resident had the right to receive services in his/her plan of care. Review of R88's admission Record revealed the facility admitted the resident on 03/14/2024 with diagnoses to include unspecified dementia, bipolar disorder,and major depressive disorder. Review of the R88's admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 03/16/2024, revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of 13 of 15, which indicated the resident was cognitively intact. Review of R88's Comprehensive Care Plan (CCP), no date, revealed the facility identified the resident was at risk for decreased ability to perform activities of daily living (ADL) in bathing with interventions to include limited assist of one for bathing. Further review revealed R88 was at risk for impaired/decline in cognitive function or impaired thought processes. Interventions included 1) observe and evaluate types of changes in cognitive status including confusion, forgetfulness, decision making ability, and notify physician as needed; and 2) to allow R88 to make daily decisions and staff to use verbal clues, gestures, and demonstrations to assist R88 in decision making if needed. Observation of R88 in room [ROOM NUMBER] on 04/24/2024 at 8:16 AM, revealed State Registered Nurse Aide (SRNA) 4 assisted R88 out of room [ROOM NUMBER] to the communal bathroom located two rooms away from the resident's room. R88 ambulated per self with a walker, and SRNA4 was at R88's side. SRNA4 was carrying clothing and bath linens, and R88 was wearing a top, briefs, and slippers. Per observation, the resident's back was visible to anyone behind her, and her brief and bare legs were fully visible. When SRNA4 noticed the State Survey Agency (SSA) Surveyor, she quickly took the towel in her hand and attempted to cover the resident's backend. Additionally, the SRNA did not turn the privacy sign on the outside of the bathroom door to Occupied when she entered the communal bathroom to provide privacy for R88. During an interview with R88 on 04/24/2024 at 8:45 AM, she stated when the SSA Surveyor asked if she walked out of the room in her briefs, she nodded her head up and down. When asked if she refused to wear pants out of the room, she pursed her lips. When asked if she felt embarrassed, she again pursed her lips and nodded up and down. When asked if she was saying yes, she was embarrassed that she was walked to the communal bath wearing only briefs on her lower body, R88 stated, Yes. During an interview with SRNA4 on 04/24/2024 at 8:30 AM, she stated upon hire, the facility educated her on resident rights and that residents had the right to refuse. She stated that the resident refused to wear pants out of the room. SRNA4 did not comment about failing to turn on the Occupied sign. During an interview with Licensed Practical Nurse (LPN) 1, on 04/24/2024 at 8:50 AM, she stated staff should ensure that residents were always clothed when taking them to the communal bathroom. She further stated staff needed to make sure the sign on the outside of the door was turned to Occupied to indicate the bathroom was in use and to protect the privacy and dignity of the residents. During an interview with the DON on 04/26/2024 at 1:05 PM, she stated residents should always be properly clothed or covered during transportation to the communal bathrooms. The DON further stated providing for resident privacy during activities and bathing provides for and protects the residents' right to privacy and dignity.

Based on interview, record review, and review of the facility's policy, the facility failed to ensure each resident exercised the right to formulate an advance directive for 1 of 63 sampled residents, Resident (R) 47. The findings include: Review of the facility's policy titled, Advance Directives, revision date 12/2016, revealed advance directives would be respected in accordance with state law and facility policy. The policy stated, upon admission, the resident would be provided with written information concerning the right to refuse or accept medical or surgical treatment and to formulate an advance directive if he or she chose to do so. Review of R47's admission Record revealed the facility admitted the resident on 11/25/2023 with diagnoses of hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting the left non dominant side, unspecified convulsions, and atherosclerotic heart disease. Review of R47's admission Minimum Data Set Assessment (MDS), with an Assessment Reference Date (ARD) of 03/02/2024, revealed the facility assessed the resident to have a Brief Interview for Mental Status Score (BIMS) of 15 out of 15, indicating intact cognition. Review of R47's Social Services Assessment and Documentation in the electronic medical record, dated 11/29/2023, revealed the questions involving advance directives being in place, information being offered, the opportunity to complete advance directives, and provision of educational materials for advance directives had all been checked No. During an interview on 04/25/2024 at 2:55 PM with the Infection Preventionist/Licensed Practical Nurse (IP/LPN), she stated she could not locate R47's advance directive document in Point Click Care (PCC), the facility's electronic medical record and charting system. The IP/LPN requested assistance from MDS Nurse2, and neither were able to locate the document. Both nurses stated the subject of advance directives was reviewed on admission by either the Admissions Director (AD) or the Social Services Director (SSD). During an interview on 04/25/2024 at 2:10 PM with the AD, she stated R47's advance directives paperwork would have been completed by the previous SSD who was no longer at the facility. She stated, under the new management, all residents were in the process of having their advance directive forms reviewed and redone, using the new management's documentation. She stated that process was planned and in place prior to the State Survey Agency (SSA) Surveyors arriving for survey and was placed on hold so annual survey duties could have her full attention. She stated she felt every resident should have the opportunity to be offered, discuss, and have help in formulating an advance directive if they wished. During an interview on 04/26/2024 at 5:45 PM with the Director of Nursing (DON) and the Regional Nurse Consultant (RNC), they stated resident advance directives were and should be addressed on admission and with changes in resident condition as needed. During an interview on 04/26/2024 at 5:52 PM with the Administrator in the presence of the Regional [NAME] President (RVP), he stated it was his expectation advance directives be discussed with residents or their responsible person on admission and as needed with changes in a resident's condition, and documentation of this should be placed in the resident's medical record.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of R56's Face Sheet revealed the facility admitted the resident on [DATE] with diagnoses of unspecified intellectual disabilities, intermittent explosive disorder, and personal history of other mental and behavioral disorders. Review of R56's quarterly MDS, with an ARD of [DATE], revealed the facility assessed the resident to have a BIMS score of 11 of 15, indicating the resident had moderate cognitive impairment. Review of R56's Care Plan, revised on [DATE], showed R56 was care planned for interventions to decrease episodes of verbal behaviors such as cursing staff and making false accusations toward other residents and staff. She also was care planned for interventions to decrease episodes of physical behaviors. Review of R50's Face Sheet revealed the facility admitted the resident on [DATE] with diagnoses of unspecified dementia, severe, without behavioral disturbance; psychotic disturbance; and schizophrenia. Review of R50's quarterly MDS, with an ARD of [DATE], revealed the facility assessed the resident to have a BIMS score of six of 15, indicating the resident had severe cognitive impairment. Review of R50's Care Plan, last revised on [DATE], revealed R50 was care planned for interventions to help improve her mood state as she was at risk for distressed and fluctuating mood symptoms related to paranoid schizophrenia and advanced dementia. Review of the the facility's Internal Investigation, undated, revealed R56 was holding R50 by the collar of her blouse and making physical contact with her closed hand. Further review showed that R56 was on 15 minute monitoring from [DATE] at 2:30 AM until 9:30 PM that day. The investigation revealed resident interview responses indicated all residents interviewed felt safe at the facility, and no other resident had experienced verbal or physical abuse. Review of the local Police Report, dated [DATE], revealed R56 hit R50 and then became violent with staff. It revealed that R56 was escorted by the local police for admission to a state psychiatric hospital located 27 miles from the facility, according to www.mapquest.com. Observation on [DATE] at 9:21 AM revealed R56 and R50 had rooms adjacent to one another, and the nurses' station was around the corner from the 200 Hall, which both residents resided in. In an attempted interview with R56 on [DATE] at 11:03 AM, she did not answer questions with appropriate responses, and the interview was not completed. In attempted interviews with R50 on [DATE] at 9:21 AM and on [DATE] at 9:23 AM, she could not hold a conversation or answer questions, and the interviews were not completed. In an interview with R50's Family Member (F) 3 via phone on [DATE] at 6:07 PM, he stated R50 told him she was defending herself because R56 pushed her, and she then pushed R56 back. He stated R56 scratched R50. He stated the next day he visited R50, and she had a large scratch on her left arm. F3 stated he felt his mother was safe in the facility. In an interview with R56's F1 via phone on [DATE] at 2:17 PM, she stated she had been told R56 had grabbed R50 by the collar and held R50 while hitting her. She stated the nurse who reported the incident to her stated R56 became angry and jealous of R50 and that was why R56 hit R50. She stated F56 had behaviors. F1 stated R56 cursed and spat at nursing staff. In an interview via phone with Licensed Practical Nurse (LPN) 2 on [DATE] at 8:10 AM, she stated on the evening of [DATE], she was at the nurses' station with LPN9, and they both heard a weird noise. She stated they followed the noise down the hallway to where the altercation was occurring, in R50's room. LPN2 stated she witnessed R56 holding R50 by the collar and hitting her in the head. She stated they separated the residents. LPN2 stated she placed R50 with an SRNA in her room. She stated R56 would not calm down and became violet toward LPN2 and shook LPN2. She stated R56 also was violent toward and spat on another SRNA, but LPN2 could not remember who it was. She stated R56 also spat on LPN9. LPN2 stated she assessed R50 after separating the two residents, and R56 was taken to the front of the facility. LPN2 stated the local police were called, and they transported R56 to a state psychiatric hospital. However, LPN2 stated R56 was not admitted and was back at the facility the following day. LPN2 stated R56 was placed on 15 minute checks when she returned, which lasted for several days. LPN2 stated, before this incident, she had never seen R56 be aggressive or violent. LPN2 stated R56 got angry when she did not get enough attention, and when R56 got angry, she threw tantrums. LPN2 stated staff had tried having R56 count or removing her from the situation, but neither were effective. LPN2 stated, after this incident, the APRN for the facility had R56's hormone levels tested, and her medications were altered. In an interview with LPN3 on [DATE] at 8:57 AM, she stated R50 had never had violent outbursts with any other residents nor had she been the victim of abuse of any other resident. She stated R50 had never put her hands on anyone else, but she had done things to instigate behaviors in other residents. She stated R56 had medication changes, and the APRN had gotten R56's medications for dementia and schizophrenia regulated. LPN3 stated R56 had aggressive behaviors and had acted out since arriving at the facility. She stated R56 cursed, spat, and hit staff. In an interview with LPN9 via phone on [DATE] at 2:06 PM, she stated on the night of [DATE], she and LPN2 were sitting at the nurses' station, and both heard R56 talking, and she was agitated. She stated she and LPN2 ran down the hall to find R56 had R50 by the collar of her shirt and had pulled R50's head down into her lap. She stated R50's hooded sweatshirt was pulled over her head, and R56 was wailing on Resident #50. She stated she and LPN2 separated them, and R50 was taken to a safe space. She stated staff tried to calm R56, but R56 got violent with the two nurses and two SRNAs. She stated staff notified the Director of Nursing (DON), and the DON came to the facility. She stated the DON took R56 to the front of the facility, and the DON looked for a psychiatric facility to take R56 for assessment and treatment. She stated staff members were working with R56 to keep her away from R50 and to learn calming techniques so she would not have violent outbursts. LPN9 stated R56 had her medications altered and dosing increased to help with her behaviors. In an interview via phone with the APRN on [DATE] at 2:55 PM, she stated she was notified by staff of the incident involving R56 and R50. She stated R56 was given Haldol (an antipsychotic) to calm her down the night of the alleged abuse. The APRN stated that she was unaware of any other altercations between R56 and other residents. She stated both residents had medications altered and had visits with the psychiatric provider. The APRN stated nursing staff had reported behaviors exhibited by R56 to her, and they were now able to manage the behaviors with her medication and behavioral interventions. The APRN stated R50 was confused but not aggressive. She stated the psychiatric provider came to the facility to see the residents, and that provider made recommendations for a plan of care. The APRN stated she put in the orders for the medications changes and interventions. In an attempted phone interview with Psychiatric Provider #23 on [DATE] at 1:56 PM and on [DATE] at 2:02 PM, a voicemail was left requesting a return call. However, no return call was received. In an interview with the DON on [DATE] at 2:20 PM, she stated she was called the evening of the incident came to the facility immediately and notified the Administrator. She stated staff who witnessed the incident had already separated the residents. She stated R56 had been removed from the 200 Hall and was placed in the dining room with one-to-one supervision when she arrived. She stated R50 was in her room, was assessed, and was found to have a skin tear on her arm, which had been cleaned and bandaged. She stated staff did not send R50 to the hospital for any scans or treatment but did do neurological checks for her throughout the night. She stated she pursued getting R56 admitted to the state psychiatric hospital for observation and treatment. She stated R56 was sent to the psychiatric hospital via the local police. However, she stated the psychiatric hospital would not accept R56 for admission. She stated when R56 came back to the facility, staff placed her on one-to-one observation for several hours to make sure she remained calm. She stated then staff changed R56 to 15 minte checks to observe her mood for calmness. The DON stated it would not have done any good to move one of the residents to another hall because both were mobile and left the hallway. She stated since the incident R50 and R56 had interacted with no problems. She stated R50 did not even remember being hit in the head. She stated if there was resident to resident abuse, the residents were separated and monitored to keep them apart. The DON stated the facility gave staff training on how to de-escalate R56. She stated staff members were taught to not surround R56 if she became agitated and to talk calmly and remain calm with R56. In an interview with the Administrator on [DATE] at 1:44 PM, he stated R50's and R56's rooms did not change (they were side by side) because there were no other open rooms to move one of the individuals to. He stated staff attempted to get R56 admitted to a psychiatric facility for assessment and treatment, but R56 was not accepted. He stated after R56 returned to the facility, her behaviors settled down. He stated staff had been taught R56's triggers and good ways to de-escalate her. He stated both R50 and R56 were seen by psychiatry. The Administrator stated every allegation of abuse was taken seriously and was investigated thoroughly and in a timely manner. He stated he oversaw all investigations but other staff such as the DON did help him investigate. The Administrator stated staff were given education on abuse at hire and were re-educated on it daily. Based on observation, interview, record review, review of the facility's investigation reports, review of the local police report, review of the Mapquest website, and review of the facility's policy, it was determined the facility failed to protect 4 out of 10 sampled residents from physical abuse involving resident to resident altercations, Resident (R) 50, 73, 547 and 548. 1. On [DATE], R73 was in his bathroom on the toilet when R296 entered the bathroom and grabbed R73's arm and attempted to hit R73. R73 received scratches to her right chest, and her right arm had bruising. 2. On [DATE], R56 pulled R50's head into her lap using the collar of R50's hooded sweatshirt. The hooded sweatshirt was pulled over R50's head, and R56 was hit R50 in the head with her fists. This resulted in a skin tear on R50's arm. 3. On [DATE], R547 entered R548's room, and R547 smacked R548. R548 responded by punching R547 in the face. The altercation resulted in no injuries. The findings include: Review of the facility's policy titled, Abuse, Neglect, Exploitation and Misappropriation Prevention Program, revised [DATE], revealed residents had the right to be free from physical abuse, and the facility was responsible for identifying and investigating all possible incidents of abuse. Review of the facility's policy titled, Notice of Resident Rights and Responsibilities, revised [DATE], revealed the resident had the right to be free from mental or physical abuse. 1. Review of R73's Face Sheet revealed the facility admitted the resident on [DATE] with diagnoses to include chronic kidney disease, chronic hepatitis, and type 2 diabetes. Review of R73's quarterly Minimum Data Set (MDS), with an assessment reference date (ARD) of [DATE], revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of 15 of 15, indicating intact cognition. Review of R73's Care Plan, initiated on [DATE] with a revision date of [DATE] and after the incident occurred, revealed R73 was identified as at risk for complications related to a resident-to-resident altercation. Continued review revealed R73's goal was to report feelings of being safe in the center. Additional review revealed interventions included for staff to be sensitive to privacy and confidentiality, maintain communication, and to respect and listen to R73. Review of R296's Face Sheet revealed the facility admitted the resident on [DATE] with diagnoses to include acute respiratory failure, pneumonia, and cerebral infarction. Review of R296's admission MDS, with an ARD of [DATE], revealed the facility assessed the resident to have a score of nine of 15 on the BIMS, indicating moderate cognitive impairment. Review of R296's Care Plan, initiated on [DATE] and revised on [DATE], revealed the resident exhibited physical behaviors related to dementia. Additional review revealed a goal stated was for a decrease in physical behaviors. Continued review revealed interventions included every 15 minute checks, Nurse Practitioner to perform medication review, psychiatric evaluation, and obtain labs. Review of the facility's Internal Investigation, dated [DATE], revealed the incident was witnessed by State Registered Nurse Aide (SRNA) 11. The investigation revealed SRNA11 confirmed through a typed statement, when she entered the R73's bathroom, she found R296 scratching R73's arm. The investigation stated the facility moved R296 to a private room, and an x-ray of R73's arm was negative for fracture or dislocation. Continued review revealed in Registered Nurse (RN) 1's typed statement, dated [DATE], she stated SRNA11 reported to her the incident and upon that information, she interviewed R73. RN1's statement documented that R73 was sitting in the hallway in a wheelchair during the interview, and R73 confirmed R296 had come into the bathroom and began grabbing and scratching R73s arm and chest. Additional review of RN1's statement revealed she notified the Director of Nursing (DON), Administrator, and the Advanced Practice Registered Nurse (APRN), who gave an order for an x-ray of R73's right arm. Review of R73's skin assessment performed by RN1, dated [DATE], revealed R73 had scratches to her right chest and right arm with bruising. In an interview with R73 on [DATE] at 8:30 AM, she stated she had no memory of any altercation with another resident since admission to the facility. R296 was deceased and unable to be interviewed. During an interview with SRNA21 on [DATE] at 3:00 PM and SRNA18 on [DATE] at 3:10 PM, they stated they could not recall R296. The State Survey Agency (SSA) Surveyor attempted to reach SRNA11 by phone on [DATE] at 1:55 PM, and a message was left for a return call. However, a return call was not received. During a phone interview with RN1 on [DATE] at 12:03 PM, she stated she could not recall the incident between R73 and R296. During an interview with the APRN on [DATE] at 2:09 PM, she stated she could not recall the incident between R73 and R296, but according to her notes, around that timeline she had made some medication adjustments for R296 for behaviors. During an interview with the Administrator on [DATE] at 9:35 AM, he stated he performed the investigation and R296 had not had any behavior prior to this incident. He stated the facility was unable to identify any cause for R296's behavior. He stated the facility assured the safety of other residents by providing closer monitoring of R296 and moved R296 to a private room. He stated R296's care plan was updated, and an x-ray was performed on R73's arm just to be cautious. He added the nurse had contacted him immediately. 3. Review of R547's Face Sheet revealed the resident was admitted to the facility on [DATE] with diagnoses to include unspecified dementia severe with agitation, and polyarthritis unspecified. Review of R547's admission MDS, with an ARD of [DATE], revealed the facility assessed the resident as significantly cognitively impaired, and the BIMS was not able to be conducted. Review of R547's Progress Note, dated [DATE], revealed the resident was assessed with no injury following an altercation with R548, and the resident was sent to a local hospital behavioral health unit for evaluation. Review of R548's Face Sheet revealed the facility admitted the resident on [DATE] with diagnoses to include dementia in other diseases classified elsewhere without behavioral disturbance and chronic obstructive pulmonary disease (COPD). Review of R548's admission MDS, with an ARD of [DATE], revealed the facility assessed the resident to have a BIMS score of 13 of 15, indicating no cognitive impairment. However, R548's BIMS score had fallen to 6 of 15, indicating severe cognitive impairment, on a discharge MDS, dated [DATE]. Review of R548's Progress Note, dated [DATE], revealed the resident was assessed with no injury following an altercation with R547. Review of the Final Report/5 Day Follow Up, dated [DATE], revealed SRNA12 witnessed R547 enter R548's room, on [DATE] at approximately 2:00 PM, and was on her way to remove R547 when she overheard R548 tell R547 this was not your room. The report stated R547 smacked R548, and R548 responded by punching R547 in the face. In an attempted phone interview with SRNA12 on [DATE] at 3:17 PM, a voicemail was left requesting a return call. However, no return call was received. In an interview with SRNA17 on [DATE] at 9:23 AM, he stated R547 had advanced dementia and could not form sentences and could barely walk when he first got to the facility. However, he stated, after a while, it was difficult to keep up with R547 when he used his rolling walker. SRNA17 described R548 as nice, although she had increasing confusion. He stated he did not witness the incident, but an aide from the hall where R548 resided came and got him and other aides from the hall where R547 resided. He stated those staff members were able to redirect R547 to the dining room. SRNA17 stated R547 was placed on 15 minute checks upon return from the hospital for behavioral health, and shortly after that, he became wheelchair bound. In an interview with SRNA18 on [DATE] at 9:34 AM, she stated both R547 and R548 were sweet. She stated R548 frequently thought she was on a ship and wanted to know when the [NAME] was going to to get to the other side. SRNA18 stated R547 had wandered to the 400 Hall, and she and another aide had been alerted by a worker from that hall that there had been an altercation. SRNA18 stated R547 went to the dining room with a memory book his spouse had made. SRNA18 stated she did not recall there being any injuries, and both residents were fine after that. She stated R548 was initially a little shaken up, but only for a short while. She stated she recalled keeping R547 within sight after that. In an interview with MDS Nurse2 on [DATE] at 8:51 AM, she stated R548 was alert and oriented with some confusion, and R547 was a very confused resident with dementia that wandered into R548's room. She stated she did not recall who struck first, only that there had been an altercation between the two of them. She stated the residents were separated and assessed to have no injuries following the incident. She stated R547 was sent out for behavioral health. In an interview with the DON on [DATE] at 2:45 PM, she stated she was not employed at the facility during the time of the incident. She stated the facility provided training to staff on abuse, and the training included to first assure the safety of the residents by separating them and recognizing and reporting abuse immediately. In an interview with the Administrator on [DATE] at 10:31 AM, he stated he was present when the incident occurred between R547 and R548. He stated R547 started to move into R548's room; R548 said no and tried to close the door; and R547 pushed it back open, at which point R548 punched R547. The Administrator stated R547 was confused, R548 less so, and neither were injured. He stated it was unclear who was the aggressor, and who was the victim. The Administrator stated he did not consider this to be an abuse situation when he conducted the investigation as R547 was entirely too confused to understand going into R548's room was inappropriate. He stated he considered R548's actions to be self-defensive. The Administrator stated abuse was not tolerated, and staff members were trained on abuse, neglect, and reporting, and understood their responsibility in monitoring for signs and reporting any suspicions immediately.

Based on interview, record review, and review of the facility's policy, the facility failed to review and revise the comprehensive care plan (CCP) to include refusals of care for 1 of 63 sampled residents (Resident (R) 45). Per staff interview, R45 had a history of refusals of turning and repositioning, refusals of offers to be transferred out of bed into a Broda chair, refusals of participation in one-to-one activities, and refusals of having her hand splints applied. The findings include: Review of the facility's policy titled, Care Plans, Comprehensive Person-Centered, revised March 2022, revealed the resident had the right to refuse to participate in the development of his/her care plan and medical and nursing treatments. Such refusals would be documented in the resident's clinical record in accordance with established policies. Review of R45's Face Sheet revealed the facility admitted R45 on 09/10/2020 with diagnoses of cerebral infarction, acute and chronic respiratory failure, tracheostomy, and pneumonitis due to inhalation of food or vomit. Review of R45's quarterly Minimum Data Set (MDS), with an assessment reference date (ARD) of 03/01/2024, revealed the Brief Interview for Mental Status (BIMS) score was not able to be completed because R45 rarely/never understood. Review of R45's CCP revealed R45 was care planned for activities of one-to-one sensory visits, and she liked music and television (TV). Further review revealed no care plan for documentation of refusals of care when it was reviewed on 04/24/2024. During an interview with R45 on 04/24/2024 at 8:10 AM, when asked if staff at the facility did activities with her, she indicated they did not by shaking her head no and then indicated she liked music by nodding her head yes. During further interview with R45 on 04/26/2024 at 8:26 AM, she indicated she did not want to be out of bed and did not want her hand splints on for that day. During an interview with R45's spouse on 04/25/2024 at 9:17 AM, he stated R45 had a stroke and had been at the facility for five years. He stated she had not been out of bed in a long time but could not say exactly how long. He further stated she used to have a wheelchair, but it had disappeared. R45's spouse stated R45 indicated by nodding her head if she would like to get out of bed and do things because she was tired of lying in the bed. During an interview with R45's brother-in-law on 04/25/2024 at 9:35 AM, he stated he had observed R45 refusing staff offers to get her out of bed and reposition her at times. During an interview with the Activities Director (AD) on 04/25/2024 at 4:30 PM, she stated R45's activities included one-to-one visits with sensory stimulation to include touch, smell, and vision, and she visited with R45 one to two times a week. The AD stated she did not document visits in the computer, and sometimes R45 would refuse to participate in activities by shaking her head no. The AD explained nodding for yes or no and blinking were the ways R45 communicated with staff. She stated R45 enjoyed staff talking to her but did not always want to participate in the other sensory activities. She also stated R45 liked to watch TV and listen to the radio. The AD stated she did her activity assessments under the tab labeled recreation in the computer which were completed for residents on admission, with an annual assessment, and with a change of condition. She further stated sometimes she did an evaluation if she felt the resident's preferences had changed, and R45's last recreation assessment was completed on 01/15/2024. During an interview with MDS Nurse1 and MDS Nurse2 on 04/26/2024 at 1:46 PM, they stated R45 had a history of refusing to have her hand splints applied and to be turned and repositioned, and they thought that was on her CCP. They stated care plans were updated by MDS Nurses with quarterly reviews and as needed with changes in resident need or condition, but any licensed nurse could add or update a care plan. They further stated MDS Nurses usually resolved care plans with all reviews. During an interview with the Infection Preventionist (IP) on 04/26/2024 at 5:20 PM, she stated R45 had a history of refusals of care for getting up to the Broda chair (a wheelchair that provided supportive positioning) and being repositioned, and it should be on her care plan. She stated the MDS Nurses usually updated the resident care plans during morning meetings. During an interview with the Director of Nursing (DON) and the Regional Nurse Consultant (RNC) on 04/26/2024 at 5:45 PM, they stated the CCP was updated by MDS Nurses with quarterly reviews, as needed, and with changes in resident need or condition. They stated any licensed nurse could add or update a care plan, and MDS Nurses usually resolved any care plans that were no longer in effect with reviews. During an interview with the Administrator on 04/25/2024 at 4:45 PM, he stated R45 did not and never had a wheelchair at the facility, but she did have a Broda chair she used to be out of bed, which she refused at times. He stated the Broda chair was stored in the shower room when not in use to maximize space in the room, but the chair had been returned to the residen'st room, and staff would get her out of bed as she wished. During an additional interview with the Administrator on 04/26/2024 at 5:20 PM, he stated it was his expectation the CCP be updated with changes in resident condition, resident events, or changes in medications. He further stated the CCP should be reviewed during Monday through Friday clinical meetings with review of incidents, events, admissions, and orders for need of an update. The Administrator stated refusals of care should be care planned as well as documented in the resident's record.

Based on observation, interview, record review, and review of the facility's policy, the facility failed to ensure a resident received the correct tube feeding rate for 1 of 4 sampled residents, Resident (R) 17. R17 was ordered to be on a tube feeding rate of 70 milliliters (ml)/hour to maintain the resident's nutritional status. However, observation on 04/24/2024 revealed R17's tube feeding rate was 65 ml/hour. The findings include: Review of the facility's policy titled, Enteral Nutrition, revised 2018, revealed the nurse confirmed that orders for enteral nutrition (liquids given through the intestine through a tube) were complete. Complete orders included the enteral nutrition product, volume, rate of administration, and instructions for flushing. Review of R17's admission Record revealed the facility admitted the resident on 10/31/2017 with diagnoses of diverticulosis, bipolar disorder, and dysphagia. Review of R17's Physician's Orders, dated 03/11/2024 revealed an enteral feed order for Jevity 1.5 CAL every 12 hours to be administered continuously via pump at 65 ml/hour. Review of an additional order, dated 03/27/2024, revealed the same except it added to replace the Jevity with Osmolyte when Jevity was not available. Additional review revealed another order, dated 04/14/2024, for Jevity 1.5 CAL to be administered continuously via pump at 70 ml/hour for 22 hours or until the total nutrient was delivered. Review of the R17's Medication Administration Record (MAR), dated 03/01/2024, revealed Jevity 1.5 CAL at 65 ml per hour was discontinued on 03/27/2024, and Osmolyte replaced Jevity 1.5 CAL from 03/27/2024 until 03/29/2024. The MAR revealed Jevity 1.5 CAL at 65 ml/hour continued form 04/01/2024 until 04/13/2024. Additional review of the MAR, dated 04/14/2024 to 04/25/2024, revealed the enteral feed order, dated 04/14/2024, of Jevity 1.5 CAL at 70 ml per hour for 22 hours was signed off as given at the new rate. Observation on 04/25/2024 at 9:10 AM, revealed R17's enteral nutritional product was Jevity 1.5 CAL, with a rate running at 65 ml/hour. Interview with Registered Dietitian Licensed Dietitian (RD, LD) on 04/25/2024 at 3:36 PM she stated she made recommendation for tube feeding rate to increase to 70 ML/hour to meet residents nutritional needs. She stated the order was changed to 70 ml/hour due to need for weight gain. In an interview with Licensed Practical Nurse (LPN) 3 on 04/25/2024 at 4:00, she stated she was on day shift and turned off the tube feeding, and the night nurse turned on or changed the tube feeding. In an interview with LPN8, the night shift nurse, on 04/25/2024 at 4:57 PM, she stated the current rate for R17's tube feeding was 65 ml/hour, and she was not aware of any change in rate. She stated in report no increase of the tube feeding rate was discussed. In an interview with the Director of Nursing (DON) on 04/26/2024 at 4:19 PM, she stated nursing staff was responsible to pass on in end of shift report any changes, and the physicians' orders should be checked against the MAR. In an interview with the Administrator on 04/26/2024 at 4:36 PM, he stated it was important to read the MAR, check the pump rate against the MAR, and not to depend on the end of shift report.

Based on observation, interview, record review and review of the facility's policies, the facility failed to ensure the services provided or arranged by the facility, as outlined by the physician orders and the comprehensive care plan met professional standards of quality for 1 of 63 sampled residents, Resident (R) 45. R45 had an active order for oxygen at three liters via tracheostomy mask/collar continuously, and the setting on the oxygen concentrator was observed to be set at between 3.5 liters (3.5L) and 4 liters (4L) on 04/23/2024, 04/24/2024, and 04/25/2024. The findings include: Review of the facility's policy titled, Physician Medication Orders, dated 08/01/2013 revealed medications shall be administered only upon the order of a person duly licensed and authorized to prescribe such medications in this state. Review of the facility's policy titled, Oxygen Administration, revised 10/2010, revealed the purpose of the procedure was to provide guidelines for safe oxygen administration. Further review revealed staff was to verify there was a physician's order for the procedure and to review the physician's orders or facility protocol for oxygen administration. The policy instructed staff to turn on the oxygen and start the flow of oxygen at two to three liters per minute unless otherwise ordered. Review of R45's Face Sheet revealed the facility admitted the resident on 09/10/2020 with diagnoses of cerebral infarction, acute and chronic respiratory failure, tracheostomy, and pneumonitis due to inhalation of food or vomit. Review of R45's quarterly Minimum Data Set (MDS), with an assessment reference date (ARD) of 03/01/2024, revealed the Brief Interview for Mental Status (BIMS) was not able to be completed because R45 rarely/never understood. Review of R45's Physician's Orders, revealed an active order, dated 06/09/2022, for oxygen at 3 liters per minute via aerosol/tracheostomy (trach) mask/collar continuously every shift. Observation on 04/23/2024 at 10:33 AM revealed R45's oxygen flow was being delivered via the oxygen concentrator and was set at between 3.5 and 4 liters per minute via trach collar. Observation on 04/24/2024 at 8:00 AM revealed R45's oxygen flow was being delivered via the oxygen concentrator and was set at between 3.5 and 4 liters per minute via trach collar. Observation on 04/25/2024 at 8:33 AM revealed R45's oxygen flow was being delivered via the oxygen concentrator and was set at between 3.5 and 4 liters per minute via trach collar. During an interview on 04/25/2024 at 11:24 AM with the Infection Preventionist (IP) in R45's room, she stated she was not sure what the oxygen setting on the concentrator needed to be to deliver the ordered 3L/trach collar with all the tubing from the humidified water and the hose to the R45's trach collar being taken into account. She stated she was not sure how all that worked and agreed it was important to know that information for resident care. During an interview on 04/26/2024 at 5:45 PM with the Director of Nursing (DON) in the presence of the Regional Nurse Consultant (RNC), she stated it was her expectation physician orders be followed and charted as ordered for resident care standards and safety. During an interview on 04/26/2024 at 5:20 PM with the Administrator in the presence of the Regional [NAME] President (RVP), he stated it was his expectation all practitioner orders be followed and charted as completed in the resident record.

Based on interview, record review, review of the Centers for Medicare and Medicaid Services (CMS) Quality, Safety and Oversight (QSO) QSO-21-19-NH Memo, and review of the facility's policies, the facility failed to maintain documentation of screening, education, offering, and current Coronavirus Disease 2019 (COVID-19) vaccination status for 1 of 1 sampled staff (State Registered Nurse Aide (SRNA) 2). This failure placed the residents and staff at increased risk for communicable diseases and healthcare-associated infections (HAI). The findings include: Review of the CMS QSO QSO-21-19-NH Memo, dated 05/01/2021, revealed Long-term Care (LTC) facilities must offer staff vaccination against COVID-19 when vaccine supplies were available to the facility. Per the memo, LTC facilities must screen staff prior to offering the vaccination for prior immunization, medical precautions, and contraindications to determine whether they were appropriate candidates for vaccination. Per the guidance, the vaccine might be offered and provided directly by the LTC facility or indirectly, such as through an arrangement with a pharmacy partner, local health department, or other appropriate health entity. Review of the facility's policy titled, Coronavirus Disease (COVID-19)-Vaccination of Staff, revised 06/2023, revealed the facility would educate staff about the benefits, risks, and potential side effects of the COVID-19 vaccine. Per the policy, before providing care, treatments, or other services for the facility or its residents, staff would comply with any state or local requirements or facility practices that required COVID-19 vaccination to staff. Additionally, staff members would provide documentation of vaccination. Further review of the policy revealed the facility would educate each staff member on the benefits, risks, and potential side effects associated with the vaccine and provide the Federal Drug Administration (FDA) Emergency Use Authorizations (EUA) fact sheet before being offered the vaccine. Review of the facility's policy titled, Infection Control, dated 10/2018, revealed the purpose of the policy was to maintain a safe, sanitary, and comfortable environment to help prevent and manage the transmission of diseases and infection. According to the policy, leadership was responsible for ensuring the implementation and adherence to infection control practices. Review of SRNA2's employee file revealed no documented evidence noting the SRNA had received the COVID-19 vaccination, or that it was offered to the employee. Additionally, there was no documentation that education regarding the benefits, risks, and potential side effects of the vaccine was provided to the employee. During an interview with SRNA2, on 04/23/2024 at 10:24 AM, he stated he had been employed at the facility for a few days. and it was his second day on the floor providing care to residents. SRNA2 stated he was not provided education related to the COVID-19 vaccine and was not offered the vaccine by the facility. He further stated he did not sign a COVID-19 declination form. During an interview with the Infection Preventionist (IP), on 04/25/2024 at 3:55 PM, she stated the facility followed the Centers for Disease Control and Prevention's (CDC) recommendations for all immunizations and vaccines. The IP stated she did not have complete vaccination records for all employees due to missing employee files or the inability to locate the files after a change in facility ownership. She stated the facility provided vaccine education to staff on hire. She further stated the facility did not offer the COVID-19 vaccine to its staff members, but they were given a list of local pharmacies that provided the vaccine. She further stated the facility stocked the COVID-19 vaccine, and it could be provided to the employee. In continued interview with the IP on 04/25/2024 at 3:55 PM, she stated she did not know why SRNA2's file did not have his COVID-19 vaccine education documentation. However, she stated it was important for the facility to educate staff about COVID-19 and offer the vaccine, and for their immunization or declination to the facility to be documented in their files. She also stated it was important to follow the CDC's recommendations for infection prevention and control to prevent the spread of diseases and infections. During an interview with the Director of Nursing (DON) on 04/26/2024 at 1:05 PM, she stated the facility followed infection control guidelines as per the CDC to include recommendations for staff immunizations and vaccines. She further stated it was important for staff members to be educated about and offered the COVID-19 vaccine, and for their immunization or declination to be documented in their files as part of a comprehensive infection control program. During an interview with the Administrator on 04/27/2024 at 5:01 PM, the Administrator stated the facility followed the CDC's recommendations and guidelines related to infection control. The Administrator further stated it was his expectation that all staff followed the CDC guidelines and facility policies. He stated it was the responsibility of every individual to ensure that the infection control procedures were carried out effectively, providing a safe environment for both the residents and staff.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and review of the facility's documents, the facility failed to ensure resident rooms measured 80 square feet per resident in multiple resident rooms. Twenty-three dual occupancy rooms on Unit 1 and Unit 2 were measured at 152 square feet, eight feet short of the 160 square feet required for dual occupancy resident rooms. The findings include: Previous observation on 06/14/2017 revealed nine dual occupancy resident rooms on Unit 1, to include rooms 103, 104, 105, 106, 111, 112, 113, 114, and 115, and 14 dual occupancy resident rooms on Unit 2, to include rooms 202, 204, 204, 205, 206, 208, 209, 210, 211, 212, 213, 214, 215, and 217, measured less than 80 square feet per resident. Observation on 04/24/2024 revealed no new construction had been completed on the affected rooms, although two rooms, rooms [ROOM NUMBERS], did not have residents assigned. Review of the Notice of Room Size Variations forms created by the facility revealed all residents and/or responsible parties residing in the affected rooms were alerted to the facility's failure and were offered the opportunity to be assisted in moving to another room when one was available, or assistance in finding alternate placement should they desire. The forms were signed by residents or responsible parties with dates ranging from 02/07/2024 through 02/20/2024. Review of the Larger Room Wait List revealed one resident had been on the list as of 02/07/2024 and was relocated to a room on Unit 3 on 02/14/2024. In an interview with Resident (R) 19 on 04/25/2024 at 9:00 AM, she stated she was on a waiting list previously, but when she was relocated to a different room, the resident stated it was more noisy there, and she decided she did not want to move. R19 further stated it was difficult getting around in her room, as both she and her roommate had wheelchairs. In an interview with the Minimum Data Set (MDS) Nurse2 on 04/26/2024 at 8:51 AM, she stated she knew the facility used to have a waiver, and staff would go around every year to interview residents on Units 1 and 2 to see if they were comfortable, and if they or their responsible party wanted them to move to a larger room. She stated staff would do their best to get residents who were interested moved to Unit 3 or 4. She further stated it was never a long waiting list, as most residents were comfortable where they were. MDS Nurse2 stated the new ownership company of the facility was planning to revamp the facility, although she was not sure what that would consist of. In an interview with the Administrator on 04/26/2024 at 10:31 AM, he stated at this point there was no plan to address the discrepancy in room sizes. The new ownership company had only owned the facility for approximately three months, and he was not sure what their plans were. He stated he would always advocate for building a new facility, but he did not know if that was financially feasible. He further stated the facility would continue to do quarterly reviews with residents regarding the room size discrepancy, and the admissions director discussed that with residents and families at the time of admission. The Administrator stated most residents did not want to move, as they were accustomed to their staff on those hallways. Regarding the two rooms identified as not in use by residents, he stated room [ROOM NUMBER] had been turned into a medical records office, but it was still a certified room if it were needed, and room [ROOM NUMBER] was undergoing renovation following damage to the floor and would be turned back into a resident room.

Based on observation, interview, and review of the facility's documents and policies, the facility failed to ensure residents had a clean environment for 46 of 46 residents who resided on the 100 and 200 Halls. The findings include: Review of the facility's policy titled, Homelike Environment, revised February 2021, stated residents were provided with a safe, clean, comfortable, and homelike environment. Review of the facility's policy titled, Notice of Resident Rights and Responsibilities, revised March 2017, stated the resident had a right to a safe, clean, comfortable, and homelike environment. Review of the facility's document Daily Cleaning Schedule revealed common area bathrooms and resident bathrooms were to be cleaned daily. However, it was not a sign off sheet for the housekeeping staff to make an entry when the task was completed. Observation on 04/24/2024 at 8:04 AM revealed the communal bathroom on the 200 Hall smelled of urine. The floors and toilets were not clean, and the floor had a black buildup. The toilets had a dark brown/black substance on them. Observation on 04/24/2024 at 8:15 AM showed that the communal bathroom on the 100 Hall had soiled wash clothes on both sinks. The floor was dirty and had a brown/black substance on it. Both toilets had feces on the seats. The plastic cabinet with drawers located beside the back toilet had feces on the top and front sides. Observation on 04/25/2024 at 9:00 AM of the 200 Hall communal bathroom revealed it had a faint urine odor. There was a stronger odor of urine in the 200 Hall than there was in the bathroom. Observation on 04/25/2024 at 9:05 AM of the 100 Hall communal bathroom revealed it smelled strongly of urine. The hallway odor outside this bathroom smelled faintly of urine. Observation on 04/25/2024 at 12:17 PM revealed the 200 Hall communal bathroom had feces on the toilet seat on the front toilet of the two toilets and smelled of urine. The floor had a toilet paper wrapper and scraps of toilet paper on it. Observation on 04/26/2024 at 7:56 AM revealed the 100 Hall communal bathroom smelled strongly of urine. The 100 Hall outside the bathroom smelled faintly of urine. Observation on 04/26/2024 at 9:57 AM revealed the 200 Hall communal bathroom smelled of urine. Observation on 04/26/2024 at 9:59 AM of the 100 Hall communal bathroom revealed a wheelchair stored by the back toilet. Both toilets had feces on the seats and feces in the bowls. The bathroom smelled strongly of urine and feces. In an interview with Housekeeper (HK) 7 on 04/25/2024 at 8:45 AM, she stated each housekeeper was assigned to a specific hallway to clean for the day. She stated the communal bathrooms on the 100 and 200 Halls were cleaned one to three times per day, or anytime there was a mess, and at night nursing staff cleaned up any messes. She stated that her orientation consisted of her touring the facility with her manager instructing her on what and how to clean. In an interview with the Housekeeping Director (HD) on 04/25/2024 at 9:07 AM, she stated she had been the HD for the past two to three months, and her staff consisted of four housekeepers. She stated housekeepers had a list of daily tasks, but they did not sign a paper stating the work they performed. She stated the 100 and 200 Hall bathrooms were cleaned once a day, but if they were soiled, nursing staff knew to contact them and they would come and reclean it. The HD stated there were housekeepers there daily, including the weekend. Also, she stated one housekeeper stayed each day until 6:00 PM and would take care of any messes made in the communal bathrooms. She stated if there was a mess made in the bathrooms during the night, nursing staff would clean it up during the overnight hours. In an interview with Licensed Practical Nurse (LPN) 1 and LPN3 on 04/25/2024 at 3:24 PM, they stated nursing staff cleaned the bathrooms in the evenings if they became soiled or dirty. In an interview with State Registered Nurse Aide (SRNA) 17 on 04/26/2024 at 10:00 AM, the SRNA stated 28 residents lived on the 200 Hall, and 11 of those regularly used the communal bathroom. In an interview with SRNA10 on 04/26/2024 at 10:05 AM, the SRNA stated 18 residents resided on the 100 Hall, and eight of those regularly used the communal bathroom. In an interview with Resident (R) 64 on 04/26/2024 at 2:35 PM, she stated the 200 Hall bathroom was not kept clean. She stated she had an issue with the smell in the bathroom sometimes. She stated before using the toilet, she would wash it off with soap and water. In an interview with R92 and R56 on 04/26/2024 at 2:41 PM, both stated the 200 Hall bathroom had a bad odor. R92 stated the bathroom was dirty and needed to be cleaned more often. R92 stated it bothered her to use the bathroom at times because of the smell. R92 stated she often held her urine until she absolutely had to go. R92 also stated the hallway smelled of urine all the time, and the smell was sometimes worse than others. R56 stated the 200 Hall bathroom smelled, and she did not like to use it. In an interview with the Director of Nursing (DON) 1 on 04/26/2024 at 5:26 PM, she stated she had not recently been inside either of the communal bathrooms on the 100 and 200 Halls. She stated she had been outside both bathrooms in both hallways, and she agreed they smelled of urine. She stated she did not think it was related to the hallway but was due to residents that lived in those hallways. She stated she did not know what the facility was doing to remedy the bad odors and told the State Survey Agency (SSA) Surveyor to talk with the Administrator about that issue. In an interview with the Administrator and the Regional [NAME] President of Operations (RVPO) on 04/26/2024 at 5:23 PM, they stated they were both aware of the constant odor of urine in the 100 Hall and its communal bathroom and the 200 Hall and its communal bathroom. The Administrator stated he was working on getting renovations for the facility. He stated he hoped that once the old flooring in the bathrooms and the carpet in the halls were removed and replaced the odor would go away. The RVPO stated when her employer bought the facility she came to the facility and scrubbed the communal bathrooms on the 100 and 200 Halls. She stated the smell was better after the scrubbing, but it still smelled like urine because urine was soaked into and under the linoleum flooring. The Administrator stated the reason the halls smelled like urine was the carpet. He stated he had the carpet cleaned, and it did not make the smell better. The Administrator stated he did not feel the strong smell of urine and feces on the toilets frequently created a homelike, clean environment.

Based on observation, interview, review of the package insert/product label for tubersol tuberculin (TB) purified protein derivative (PPD), and review of the facility's policy, the facility failed to have an effective system to ensure open TB PPD skin test solution vials were not expired in 1 of 2 medication refrigerators, with the potential to affect 46 of 46 residents on the 100 and 200 Halls. On 04/23/2024, one expired vial of PPD was found in the 100/200 Hall medication refrigerator. The vial of skin test solution had an opened date of 03/19/2024. The findings include: Review of the facility's policy titled, Medication Labeling and Storage, revised 02/2023, revealed the nursing staff was responsible for maintaining medication and to ensure that outdated medications or biologicals were returned to the pharmacy or destroyed. Per the policy, multi-dose vials that had been opened were dated and discarded within 28 days unless otherwise indicated by the manufacturer. Review of the package insert/product label revealed PPD was used as an aid in the detection of infection with mycobacterium. Further review revealed a multi-dose vial of PPD, which had been opened and used, should be discarded after 30 days. Observation of the 100/200 Hall medication storage room refrigerator on 04/23/2024 at 10:43 AM, revealed one multi-dose vial of PPD 5 Units/0.1 milliliter (mL) had an opened date of 03/19/2024, revealing the opened vial of PPD had expired five days prior. During an interview with Licensed Practical Nurse (LPN) 1 on 04/23/2024 at 10:43 AM, she stated that once opened, a multi-dose vial of PPD should be discarded after 30 days. She further stated that nurses were responsible for labeling the vial with an opened date. LPN1 stated the nursing staff monitored refrigerators routinely to check for outdated or expired medications and vaccines. She stated when a medication was expired it should be sent back to pharmacy or discarded. LPN1 stated it was important to discard the PPD per manufacturer's instruction to ensure the effectiveness of the TB testing. During an interview with the Infection Preventionist (IP) on 04/24/2024 at 8:25 AM, she stated nurses working the medication cart were responsible for checking the medication carts and refrigerators for expired medications. She stated nursing leadership, to include the Unit Managers, the DON, and the IP, conducted audits of the medication carts and refrigerators; however, she did not have documentation of those audits. She emphasized the importance of discarding all expired medications to ensure their efficacy. During an interview with the DON on 04/26/2024 at 1:05 PM, she stated it was her expectation that medications in the medication cart and refrigerator were to be stored according to the facility's policy and manufacturer's guideline. She stated multi-dose vials should be dated when opened and discarded according to labeling instructions. She further stated it was important to discard all expired medications to ensure their efficacy. During an interview with the Administrator on 04/27/2024 at 5:01 PM, he stated it was his expectation staff followed all the facility's policies.

Based on observation, interview, and review of the facility's document and policies, the facility failed to store food in a safe, clean environment. This affected 85 residents that were provided meals from the kitchen. Observation of the kitchen, on 04/23/2024, revealed ingredient bins were visibly soiled, with a lid left open; utility carts were soiled; and the two spatulas were melted or appeared broken. Observation of the 300 Hall residents' refrigerator, on 04/23/2024, revealed a gelatin salad in a Christmas box and left over salad in a clear container with no resident name, date, or room number. The findings include: Review of the facility's policy titled, Sanitation and Infection Control, revised 2023, revealed the procedure for cleaning utility carts was to clean with a hot soapy water solution. Per the policy, the process was to brush wheels to remove dirt and then scrub them; wash carts and wheels; rinse; use dry paper towels for drying; and polish carts with stainless steel polish. Review of the facility's policy titled, Foods Brought by Family/Visitors, dated 2001, revealed food brought by family/visitors for residents to consume later was labeled and stored in a manner that was clearly distinguishable from facility-prepared food. Per the policy, perishable foods were stored in re-sealable containers with tightly fitting lids in a refrigerator, and containers were labeled with the resident's name, the item, and the use by date. Review of the facility's document, Dietary Cleaning Schedule, not dated, revealed it had no documentation area to record the daily cleaning when completed. Continued review revealed Sunday through Saturday the utility carts were scheduled to be cleaned daily and after every use. Further review revealed cleaning of the ingredient bins was not scheduled. 1. Observation on the initial kitchen tour, on 04/23/2024 at 9:20 AM, revealed, hanging from the utensils rack above the production area, were two kitchen plastic spatulas. One black spatula appeared melted, and one soft white spatula had the appearance of missing pieces almost like teeth marks. Tour of the dry storage revealed an ingredient bin with cereal, and the cover was left open. Further, the outside of the bins appeared dusty on all four bins, including the lids. Observation of five utility carts, three white and two black, revealed they were worn and soiled. During interview with the Dietary Manager on 04/26/2024 at 2:50 PM, she stated the day and night shift have their own areas of cleaning assigned and would check the cleaning list every morning. She stated the black utility carts were cleaned daily and served as snack carts, but the white utility carts were not used. She stated the ingredient bins were cleaned daily, and staff kept the tops closed to prevent anything falling into the bins to prevent a source of physical contamination. She stated the two plastic spatulas should not be used in the kitchen because they could melt or break and get into the food. She stated she checked daily for the cleaning to be completed. During interview with Cook1 on 04/26/2024 at 3:08 PM, she stated the dietary aides were responsible to clean and sanitize the utility carts, before and after use. She stated the ingredient bins were cleaned daily, and the lids closed to keep something from dropping into the bin. She stated metal instead of plastic utensils should be used for cooking because metal does not melt. She stated plastic utensils could melt into the food. During interview with Dietary Aide1 on 04/26/2024 at 3:15 PM, he stated the utility cart was cleaned with soap and water after every use, and then sanitized. During interview with the Director of Nursing (DON) on 04/26/2024 at 4:19 PM, she stated her expectation was for the kitchen to be clean and sanitary. During interview with the Administrator on 04/26/2024 at 4:39 PM, he stated his expectation was for the dietary staff to clean the assigned areas. 2. Observation of the 300 Hall Nourishment Room, on 04/23/2024 at 10:40 AM, revealed one container of green congealed gelatin salad with a layer of sour cream in a Christmas box and a partially eaten tossed salad in a clear container with no date, room number, or resident name. During interview with the Dietary Manager on 04/26/2024 at 2:50 PM, she stated she checked the nourishment refrigerator daily, and food should be labeled and dated. During interview with State Registered Nurse Aide (SRNA) 20 on 04/26/2024 4:00 PM, she stated the resident's food should have the resident name, date, and room number. SRNA20 stated all food should be cleaned out of the nourishment refrigerator on Fridays. During interview with the DON on 04/26/2023 at 4:19 PM she stated resident food in the nourishment refrigerator should be labeled with the resident's name and date. She stated the resident's food should be thrown out in three days. During interview with the Administrator on 04/26/2024 at 4:30 PM, he stated the nourishment refrigerator should be checked for dates and resident names daily during restock of the refrigerator.

Based on observation, interview, review of the facility's policy, and review of the Plan of Correction (POC) submitted for the 04/26/2024 survey the facility failed to ensure it was administered in a manner that enabled it to use its resources effectively and efficiently to attain and maintain the highest practicable physical, mental, and psychosocial well-being of each resident. The facility failed to have an effective process to address systemic failures through the Quality Assurance Performance Improvement (QAPI) process. As a result, the facility failed to ensure standards for quality of care regarding performance improvement measures were achieved and sustained. This had the potential to affect all 92 current residents. The State Survey Agency (SSA) identified continued non-compliance in the areas of 42 CFR 483.10 Resident Rights (F550); 42 CFR 483.21 Comprehensive Resident Centered Care Plan (F657); 42 CFR 483.45 Pharmacy Services (F761); and 483.80 Infection Control (F880). Review of the facility's POC revealed the facility's Administration failed to have an effective process to address systemic failures. As a result, the facility failed to ensure standards for quality of care regarding performance improvement measures were achieved and sustained. The facility was cited again at the highest scope and severity (S/S) of an E for the 06/21/2024 first revisit. (Cross-reference F550, F657, F761, and F880) The findings include: Review of the facility's policy titled, Administrator, dated 03/2021, revealed the Administrator was responsible for the day-to-day functions of the facility. The Administrator's responsibilities included ensuring each resident's right to fair and equitable treatment, self-determination, individuality, and privacy; implementing established resident care policies, personnel policies, safety and security policies; and, the Administrator was responsible to ensure the facility remained in compliance with current laws, regulations, and guidelines governing long term care facilities. Review of the facility's acceptable POC, for the Standard Recertification/Abbreviated/Extended Survey concluded on 04/26/2024, revealed the Administrator failed to ensure the facility achieved substantial compliance. The facility remained out of compliance with repeat deficiencies following the first revisit, concluded on 06/21/2024. 1. During an observation of the 300 Hall on 06/21/2024 at 9:34 AM, the door was open, and staff had not closed the privacy curtain, allowing a full view of resident (R) 67 while she was in bed. The resident was lying in bed without clothing or covering on her upper torso with her breasts exposed. 2. Review of R67's Comprehensive Care Plan (CCP), not dated, revealed the facility identified the resident as requiring assistance for Activities of Daily Living (ADL) care, including dressing. A goal for the resident was that she would maintain the highest capable level of ADL ability through the next review. Additional review revealed at the time of the observation, the CCP had not been updated to include interventions related to the resident preferring to be unclothed to sleep. 3. Observation of the 100/200 Hall medication room refrigerator on 06/20/2024 at 9:56 AM, revealed one opened vial of tuberculin purified protein derivative (TB PPD) with no opened date. Observation of the 300/400 Hall medication storage room refrigerator on 06/20/2024 at 10:13 AM, revealed one opened vial of TB PPD with no opened date and two boxes of R13's Ozempic semaglutide injections were being stored in the door of the refrigerator. 4. Observation on the 300 Hall on 06/18/2024 at 9:12 AM, revealed Licensed Practical Nurse (LPN) 4 failed to perform hand hygiene (HH) before donning gloves and entering R1's room. Observation on the 400 Hall on 06/20/2024 at 9:38 AM, revealed a wheelchair gel seat pad and two wheelchair leg rests were observed on the floor in R70's room. Observation on 06/20/2024 at 9:42 AM, revealed LPN4 was in an Enhanced Barrier Precaution (EBP) room. LPN4 was wearing gloves but no gown. Observation revealed LPN4 was using R67's suction tubing equipment. When LPN4 saw the State Survey Agency (SSA) Surveyor, she came out of the room, pulled a gown out of the PPE container while still wearing the contaminated gloves, and went back into R67's room. Observation of the 400 Hall on 06/21/2024 at 4:00 PM, revealed Registered Nurse (RN) 2 was walking down the hall wearing gloves and holding a used elastic wrap in his hands. During an interview with the Director of Nursing (DON) on 06/21/2024 at 3:19 PM, she stated she, the Administrative Nurse (AN), Minimum Data Set (MDS) Coordinators, and the Infection Preventionist/Staff Development Nurse (IP/SD) were trained by the Regional Nurse Consultant (RNC) to provide education to staff as part of the POC. She stated all staff, including new hires and agency staff were trained and tested on residents' rights and dignity, care plan timing and revision, medication storage and labeling, and infection control practices. She stated audits were on-going. The DON stated leadership had not identified any concerns, and she believed the staff was doing well and following the facility's policy. She stated she assisted nursing leadership to maintain a safe environment for the staff and residents. Furthermore, the DON stated it was her expectation that all staff adhered to the facility's policies and procedures. During an interview with the Administrator on 06/21/2024 at 4:25 PM, he stated he had been in the position of Administrator since 10/2023. He stated he was responsible for directing the day-to-day functions of the facility in accordance with federal, state, and local standards, guidelines, and regulations that governed nursing facilities to assure the highest degree of quality care could be provided to residents at all times. He stated he was responsible for ensuring issues were addressed to include monitoring, audits, and completion of rounds, as per the facility's POC for deficiencies cited during surveys. Additionally, the Administrator stated he was responsible for reviewing and checking the competence of the work force and making necessary adjustments and corrections as required, and to ensure all facility personnel, to include residents and visitors, followed established regulations, to include infection control. The Administrator stated he took an active role in the POC audit process, by delegating to nurse leadership, reviewing completed audits, and making multiple daily rounds to ensure residents needs were met. He stated during rounding he monitored staff members to ensure they were performing their duties and knew how to do their jobs. He stated nurse leaders were trained by the RNC to provide education to staff as part of the POC and performed daily audits of staff performance. He stated all staff, including new hires and agency staff, were trained and tested on resident rights and dignity, care plan timing and revision, medication storage and labeling, and infection control practices. The Administrator stated it was his expectation that all staff followed the facility's policies to ensure a safe environment for the residents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, review of the Centers for Disease Control and Prevention (CDC) guidelines, review of the manufacturers' directions for use for the glucometer (blood glucose monitoring device) and disinfectant wipes, review of the facility's policies, the facility failed to identify and correct problems related to infection prevention practices for 7 out of 63 sampled residents, Resident (R) 2, R4, R19, R39, R71, R72, and R44. In addition, the facility failed to provide a safe and sanitary environment to help prevent the development and transmission of communicable diseases and infections for 1 of 6 residents that received enteral nutrition through tube feedings, R45. Observation of R2, in contact precautions, on 04/25/2024 and 04/26/2024 revealed staff failed to properly dispose of R2's contaminated bodily fluids and failed to properly don (put on) and doff (take off) personal protective equipment (PPE), including performing hand hygiene. Observation of R71, R72, and R44, on 04/23/2024 revealed staff failed to perform hand hygiene and clean and disinfect a portable vital sign before and after use on these residents. Observation of R19 on 04/24/2024 revealed staff failed to clean the glucometer (shared equipment) after use on R19 according to the Environmental Protection Agency (EPA) registered disinfectant manufacturer's instruction. Observation of room [ROOM NUMBER], where R4 and R39 resided, on 04/23/2024 revealed staff failed to perform hand hygiene between care for each resident. In addition, staff failed to pass ice and refreshments using Standard Precautions and in a clean and sanitary manner for R4 and R39. Observation on the 100 Hall on 04/24/2024 revealed staff failed to use a urinal with a cap when transporting urine to the communal bathroom for disposal which required staff to walk down the hall. Observation on 04/23/2024, 04/24/2024, 04/25/2024, and 04/26/2024 revealed R45's enteral feeding tubing and water flush bag with tubing were undated. On 04/23/2024, 04/25/2024, and 04/26/2024 the State Survey Agency (SSA) Surveyor requested the facility provide the required appropriate infection surveillance related to the building's water system. However, the facility was unable to produce the documents. The findings include: Review of the CDC's Guidelines provided by the facility and titled, Core Infection Prevention and Control Practices for Safe Health Care Delivery in all Settings, reviewed 11/29/2022, revealed that reusable or shared medical equipment should be cleaned and disinfected before use on another resident or when soiled. The guidelines stated facilities should maintain separation between clean and soiled equipment to prevent cross-contamination. Further review of the guidelines revealed personnel should be trained in the correct steps for cleaning and disinfection of shared equipment and competencies should be assessed and documented initially upon assignment, whenever there was new equipment, and periodically thereafter. Review of the facility's policy titled, Infection Control, dated 10/2018, revealed the purpose of the policy was to maintain a safe, sanitary, and comfortable environment to help prevent and manage the transmission of diseases and infection. According to the policy, department heads and managers were responsible for ensuring the implementation and adherence to infection control practices, which included guidelines for implementing isolation precautions such as standard and TBPs, maintaining records of incidents and corrective actions related to infections, and ensuring the safe cleaning and reprocessing of reusable resident care equipment. In addition, all personnel would receive training on infection prevention and control practices (IPCP) during their hiring process and periodically thereafter. Review of the facility's policy titled, Healthcare-Associated Infections [HAI], dated 09/2017, revealed a facility goal was to prevent the further spread of infection (resident-to-resident and staff-to-resident) through the initiation of appropriate isolation precautions where warranted and to identify and to correct breaches in infection control practices that may contribute to the spread of an HAI. Review of the facility's policy titled, Cleaning and Disinfection of Resident-Care Items and Equipment, dated 09/2022, revealed the purpose of the policy was to ensure that reusable items and durable medical equipment would be cleaned and disinfected according to current CDC recommendations for disinfection of health care facilities and the Occupational Safety and Health Administration (OSHA) bloodborne pathogen standard. Further review of the policy revealed non-critical items required cleaning followed by either a low or intermediate level disinfection following the manufacturer's instructions. Further, the policy stated disinfection was performed with an EPA registered disinfectant labeled for use in healthcare settings. Review of the facility's policy titled, Handwashing/Hand Hygiene, dated 10/2023, revealed the facility considered hand hygiene (HH) the primary means to prevent the spread of healthcare-associated infections (HAI). Per the policy, HH was indicated immediately before touching a resident; after touching a resident; after touching the resident's environment; and immediately after glove removal. Additionally, the policy stated wearing gloves did not replace handwashing or HH. Review of the facility's policy titled, Employee Training on Infection Control, dated 01/2012, revealed staff and personnel would complete orientation and training on preventing the transmission of HAIs. It stated the Infection Preventionist (IP) or designee would maintain appropriate records of content and attendance for all training in-service programs. Further review revealed the infection control training program would include a return demonstration and a competency checklist. Review of the facility's policy titled, Bedpan/Urinal, Offering/Removing, dated 02/2018, revealed after assisting the residents, staff should empty the urinal into the commode and flush the commode. The policy stated the urinal was then cleaned, wiped dry with a clean paper towel, and stored off the floor. Review of the cleaning and disinfecting instructions for the Assure Prism Blood Glucose Monitoring System, no date, revealed to minimize the risk of transmitting bloodborne pathogens, the exterior of the glucometer should be cleaned of all dirt, blood, and bodily fluids before performing the disinfection procedure, which would prevent the transmission of bloodborne pathogens. Per the instructions, the exterior of the glucometer should remain wet for the appropriate contact time according to the disinfectant's instructions. Review of the cleaning and disinfecting instructions for the Sani-Cloth Germicidal Disposable Wipe revealed, to clean and disinfect non-porous surfaces, the user would use one or more wipes as necessary to wet surfaces sufficiently and thoroughly to clean the surface. Further review revealed the user was to unfold a clean wipe to thoroughly wet the surface and allow the treated surface to remain wet for a full two minutes to ensure complete disinfection of all pathogens, and then allow the treated surface to air dry. Review of the cleaning and disinfecting instructions for the Sani-Cloth Bleach Wipes revealed the user would use one wipe to remove visible soil first and clean the surface. Further review revealed the user was to unfold another wipe and thoroughly wet the surface and allow the treated surface to remain wet for a full four minutes to ensure complete disinfection of all pathogens, and then allow the treated surface to air dry. Review of the facility's policy titled, Legionella Water Management Plan, undated, revealed the facility would document all aspects of the water management system and maintain maintenance logs. Per the policy, the facility would have a water management program in place to prevent, detect, and control water-borne contaminants and ensure water was safe for consumption and use. Furthermore, documentation for all aspects of the water management program would be maintained within the maintenance logs. Review of R2's Face Sheet revealed the facility admitted the resident on 10/19/2022 with diagnoses to include sepsis, resistance to multiple antibiotics, type 2 diabetes mellitus, and paralytic syndrome. Review of the R2's annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 03/09/2024, revealed the resident had a Brief Interview for Mental Status (BIMS) score of 15 of 15, which indicated the resident was cognitively intact. Review of R4's Face Sheet revealed the facility admitted the resident on 01/17/2024 with diagnoses to include encephalopathy, anemia, and heart failure. Review of the R4's annual MDS, with an ARD of 04/06/2024, revealed the resident had a BIMS score of three of 15, which indicated the resident was severely cognitively impaired. Review of R19's Face Sheet revealed the facility admitted the resident on 09/23/2023 with diagnoses to include type 2 diabetes mellitus, cerebral infarction, and atrial fibrillation. Review of R19's quarterly MDS, with an ARD of 03/22/2024, revealed the resident had a BIMS score of 15 of 15, which indicated the resident was cognitively intact. Review of R39's Face Sheet revealed the facility admitted the resident on 08/05/2020 with diagnoses to include iron deficiency anemia, atrial fibrillation, and major depressive order. Review of the R39's quarterly MDS, with an ARD of 02/15/2024, revealed the resident had a BIMS score of 13 of 15, which indicated the resident was cognitively intact. Review of R44's Face Sheet revealed the facility admitted the resident on 01/03/2024 with diagnoses to include chronic systolic congestive heart failure, other specified disorders involving the immune mechanism, and respiratory disorders. Review of the R44's quarterly MDS, with an ARD of 03/31/2024, revealed the resident had a BIMS score of 15 of 15, which indicated the resident was cognitively intact. Review of R71's Face Sheet revealed the facility admitted the resident on 12/13/2022 with diagnoses to include type 2 diabetes mellitus, atrial fibrillation, and malignant neoplasm of the central nervous system. Review of the R71's quarterly MDS, with an ARD of 02/27/2024 revealed the resident had a BIMS score of 9 of 15, which indicated the resident had moderate cognitive impairment. Review of R72's Face Sheet revealed the facility admitted the resident on 03/30/2023 with diagnoses to include occlusion and stenosis of the left coronary artery and dysphasia following non-traumatic internal cerebral hemorrhage. Review of R72's annual MDS, with an ARD of 03/07/2024, revealed the resident had a BIMS score of 99, which indicated the resident was severely cognitively impaired. Review of R45's Face Sheet revealed the facility admitted the resident on 09/10/2020 with diagnoses of cerebral infarction, acute and chronic respiratory failure, tracheostomy, and pneumonitis due to inhalation of food or vomit. Review of R45's quarterly MDS, with an ARD of 03/01/2024, revealed the BIMS was not able to be completed because R45 rarely/never understood. 1. On 04/26/2024 at 3:15 PM, SRNA18 was observed to have entered room [ROOM NUMBER], R2's room, without properly donning PPE. Although there was a PPE bag outside the room, it did not contain any gloves. SRNA18 put on a gown outside the room, but only put on gloves after entering the room. She did not perform Hand Hygiene (HH) before donning gloves. R2 was in contact precautions due to a diagnosis of extended-spectrum beta-lactamases (ESBL), which was an antibiotic-resistant bacteria that commonly causes infections in healthcare settings. R2's urine collection bag was lying flat on the floor. SRNA18 took a urinal from the bedside table and placed it directly on the floor without first putting a barrier under it. She then placed the catheter drain tube into the urinal, which touched the inside of the neck of the urinal. SRNA18 drained the urine, which almost filled the container. She did not wipe the drain tube or holder with alcohol before closing the bag. When SRNA18 picked the urinal up, she discovered that the urinal had a hole in the bottom, and it was dripping on the floor. She left the urine collection bag on the floor and put the urinal in the trash can. She untied her gown at the neck with contaminated gloves and then took off both gown and gloves together. She did not perform HH before placing on a new pair of gloves. SRNA18 then took the urinal in a single plastic trash bag to the communal bathroom and disposed of the bag containing the urinal in the trash. During an interview with SRNA18 on 04/26/2024 at 3:37 PM, she stated she normally flushed the urine down the toilet but did not know the way to do it when the urinal began to leak. She stated she did not don gloves before going in the room because the PPE container was not supplied with gloves. She stated that for contact precautions, PPE was put on before going in the room to protect the resident and staff. She stated the urinal should be rinsed out and put back in the resident's room. She stated she did not clean and disinfect each time she disposed of R2's contaminated urine. When asked if she had received Infection Prevention and Control Practices (IPCP) training, she stated, Yes. She further stated that it included training on HH, PPE, and TBPs, including Enhanced Barrier Precautions (EBP). She stated following the facility policy was important for everyone's safety and to prevent the spread of infection. During an interview with Licensed Practical Nurse (LPN) 3 on 04/25/2024 at 3:10 PM, she stated she disposed of contaminated urine by placing it in a red biohazard bag and then throwing it in the trash. She stated the aides carried these red bags with them to ensure safe transportation of contaminated urine. LPN3 stated she received IPCP training upon hire and annually, and all staff received in-service training as needed. She stated following IPCP was During an interview with the Wound Care Nurse (WCN) on 04/25/2024 at 11:35 AM, she stated staff collected urine contaminated with ESBL, took it to the communal bathroom, and disposed of it down the commode. She stated the urinal should be rinsed out and taken back to the resident's room. She stated she was not aware if the commode should be disinfected each time staff disposed of contaminated urine. During a telephone interview with the Infectious Disease Branch's (Region 3) Infection Preventionist (IP) on 04/26/2024 at 3:55 PM, she stated urine with ESBL did not need to go in a red biohazard bag or be double bagged unless it was leaking. She stated the double bag would be a barrier against leakage during transport to the communal bathroom. She stated urine with ESBL could be flushed in the toilet. However, she stated the urinal would need to be disposed of in the trash, and the commode would require immediate cleaning and disinfecting. The State IP stated PPE should be worn when emptying urinals to protect against splashing. She stated containers filled with urine should not be disposed of into the trash. 2. Observation on 04/25/2024 at 11:10 AM, revealed the WCN did not don gloves before entering R2's room where contact precautions (transmission based precaution (TBP)) were needed. Although there was a PPE bag outside the room, it did not contain any gloves. The room was found to have contaminated PPE spilling out over the sides of the trash can near R2's bed. Furthermore, there was no trash receptacle near the door for staff to dispose of contaminated PPE, which meant staff had to walk back to the resident's bed to dispose of doffed PPE. The resident's urine collection bag was resting in a plastic basin on the floor. During the observation, the WCN provided a wound care dressing change to R2. After care, the WCN used her contaminated gloved hands to untie her gown behind her head and removed her gloves. She touched several items on the bedside table before she performed HH and gathered up supplies. Inn an interview with the WCN on 04/25/2024 at 11:35 AM, she stated she did not don gloves prior to entering the contact precaution room because there were no gloves in the PPE container on the outside of the room. She stated she should have restocked the PPE. The WCN stated R2 was in contact precautions due to ESBL in his urine. The WCN further stated trash should be disposed of when the receptacle was full. She stated the trash receptacle should be by the door to dispose of PPE, but the resident liked it by the bedside. In an additional interview with the WCN on 04/26/2024 at 4:45 PM, she stated she had worked at the facility for three years. She stated she received ICPC training upon hire and annually. She stated staff received in-service trainings as needed to keep up to date with current recommendations. She stated it was important to follow IPCP for the safety of residents and staff and to prevent the spread of infection. 3. Observation on the 400 Hall on 04/23/2024 at 9:13 AM, revealed State Registered Nurse Aide (SRNA) 1 walked into room [ROOM NUMBER] with a portable vital sign machine. SRNA1 performed a vital signs assessment on R71 using a blood pressure cuff, pulse oxygen monitor, and digital forehead thermometer. She then went to the other side of the room with the portable vital sign machine and obtained a blood pressure, temperature reading, and pulse oxygen on R72. SRNA1 did not clean and disinfect the shared equipment after use between R71 and R72. Furthermore, SRNA1 did not perform HH between the residents after providing care. SRNA1 then walked from room [ROOM NUMBER] to room [ROOM NUMBER] and obtained vital signs on R44. She did not clean the shared portable vital sign machine or perform HH before leaving room [ROOM NUMBER]. She left the portable vital sign machine outside of room [ROOM NUMBER] and entered room [ROOM NUMBER]. SRNA1 did not perform HH before entering the room. During an interview with SRNA1 on 04/23/2024 at 9:26 AM, she stated she had been working at the facility for one year. She stated she had never seen anyone cleaning shared equipment between residents. Additionally, she mentioned that she only performed hand hygiene if she had used gloves or if her hands were soiled. She stated, although she received infection prevention training when hired, she had not attended any in-service or training sessions since. She stated performing HH and cleaning equipment was important to stop the spread of germs. During an interview with the facility's IP on 04/24/2024 at 11:00 AM, she stated all clinical staff were educated upon hire and annually regarding IPCP. She stated staff members were taught to use standard precautions with all residents unless it was posted otherwise. The IP stated all shared equipment should be cleaned and disinfected between each resident's use. 4. Observation of LPN1 perform R19's blood glucose monitoring (BGM) on 04/24/2024 at 11:10 AM, revealed the LPN performed the treatment using an Accu-Chek Prism glucometer. When she cleaned the glucometer, she used one germicide wipe to clean the monitor. She then laid the monitor on a tissue barrier to dry. She did not take a second wipe to wrap the glucometer to stay wet for the four minute dwell time per the manufacturer's instructions for the SaniCloth Bleach Wipes. Once the glucometer was dry, LPN1 stored the glucometer in a plastic container on top of other testing strips and lancets. During an interview with LPN1 on 04/24/2024 at 11:23 AM, she stated she had been a nurse for a long time, knew how to clean and disinfect the glucometers, and followed facility policies related to IPCPs. She stated the Director of Nursing (DON), or the IP provided education and in-services on IPCP. When asked, she stated she did not know what the manufacturer's cleaning and disinfection instructions were for the Assure Prism glucometer. LPN1 stated the glucometer had to be cleaned and left to air dry. She stated the SaniCloth Bleach Wipe had a two minute dwell time. During an interview with the DON on 04/26/2024 at 1:05 PM, she stated nurses should adhere to the facility's policy while performing point-of-care finger sticks. Additionally, she stated staff should follow the guidelines concerning the cleaning and disinfection of shared equipment. She stated cleaning and disinfecting between residents was important to ensure staff disinfected the equipment correctly, per the manufacturer's instructions. 5. Observation on the 100 Hall on 04/23/2024 at 10:24 AM, revealed SRNA2 passed ice in room [ROOM NUMBER] without performing HH or following IPCP. SRNA2 entered room [ROOM NUMBER] and took R4's pitcher and emptied the remaining liquid into the sink. He then touched the straw and lid. Without any barrier, he placed the straw and lid directly on the top of the ice cooler cart. After filling the pitcher, he returned it to R4. Further observation revealed SRNA2 took R39's pitcher from the room without performing HH and placed the pitcher lid with the straw directly on the top of the ice cooler cart. SRNA2 exited the room without performing HH and started moving the hydration cart down the hall. During an interview with SRNA2 on 04/23/2024 at 10:34 AM, he stated it was his first day working in the facility as an SRNA. He stated he was nervous and forgot about HH. He stated he did not think that placing the straw and lid on the cart would contaminate it. He stated he received infection control training during his orientation upon hire. He stated following infection control policies was important, so disease did not spread. When asked if he received any orientation on the floor or if he was shadowing anyone, he stated, No. He stated he and one other SRNA were caring for the residents. During an interview with SRNA7 on 04/24/2024 at 11:45 AM, she revealed that the facility educates staff regarding infection prevention and control upon hire and annually. SRNA7 stated that staff should gel in and out of each room using hand sanitizer or wash hands with soap and water if they come in contact with bodily fluid. She stated further that she received infection control training upon hire to include HH, PPE, and TBPs. She stated staff should remind each other of IPCP if they see another co-worker breach protocols or fail to perform hand hygiene. During and interview with the IP on 04/24/2024 at 8:25 AM, she revealed new staff was oriented to the floor with an experienced aide. She stated SRNA1 was just hired, and this was his second day on the floor. She stated that she and other nurse leaders monitor staff for adherence to IPCPs. She stated she was on the 100 Hall to monitor SRNA2. 6. Observation on the 100 Hall on 04/24/2024 at 8:37 AM, revealed SRNA2 walked out of room [ROOM NUMBER] wearing gloves and carrying an uncapped urinal filled with urine. The SRNA walked with the urinal down the hall into the communal bathroom. He came out of the bathroom, still wearing gloves, and returned the urinal to room [ROOM NUMBER]. There was no name or date on the urinal. During an interview with SRNA2 on 04/24/2024 at 8:50 AM, he stated there were no private bathrooms in the residents' room in the 100 Hall, and staff emptied urinals in the communal bathroom. When asked if he was educated regarding the transportation of urine, he stated he was told to dispose of it in the communal bathroom. When he was asked why the urinal did not have a cap on it, he stated he could not find the cap. He further stated urinals should be dated with the resident's name as per policy. He stated urinals were changed once weekly. During an interview with SRNA4 on 04/25/2024 at 8:30 AM, she stated urine was transported to the communal bathroom and flushed down the commode. She stated the urinal should have a lid on it when transporting. She stated contaminated gloves should not be worn in the hall, and HH should be performed after emptying urinals. During an interview with the IP on 04/24/2024 at 11:00 AM, she stated resident rooms on the 100 Hall did not have private bathrooms, and residents shared a communal bath and shower. She stated, for those residents who used urinals, the staff needed to empty the urinal in the communal bathrooms. She stated staff members were to carry the urinal wearing clean gloves. She stated urinals were to be rinsed out and dried before taking them back to the resident's room. Furthermore, she stated urinals should have the resident's name and date it was changed. The IP stated urinals should be capped with a lid during transportation. The IP stated staff should not transport the urinal without a lid. 7. Observation on 04/23/2024 at 10:33 AM revealed R45's tube feeding tubing and water bag were not dated. Observation on 04/24/2024 at 8:00 AM revealed R45's tube feeding tubing and water bag were not dated. Observation on 04/25/2024 at 8:33 AM revealed R45's tube feeding tubing and water bag were not dated. Observation on 04/26/2024 at 8:15 AM revealed R45's tube feeding tubing and water bag were not dated. During an interview on 04/26/2024 at 5:20 PM with the IP, she stated the tube feeding bottle, tubing, and water were changed every 24 hours as a unit and the bottle, tubing and water bag should be dated and timed when the new unit was placed. During an interview on 04/26/2024 at 5:45 PM with the DON in the presence of the Regional Nurse Consultant (RNC), she stated it was her expectation all tube feeding administration equipment be labeled with the date and time they were set up and/or changed. During an interview on 04/26/2024 at 5:20 PM with the Administrator in the presence of the Regional [NAME] President (RVP), he stated it was his expectation all tubing for enteral feedings should be dated and timed when initially set up and/or changed. 8. During the facility's task for infection control, the facility was asked to provide a water system process flow diagram of the facility for monitoring water management related to minimizing the risk of Legionnaire's disease. The SSA Surveyor requested the flow diagram on 04/23/2024 at 1:40 PM, 04/25/2024 at 9:10 AM, and on 04/26/2024 at 5:01 PM. The facility did not provide the required documentation. During an interview with the Director of Maintenance (DOM) on 04/23/2024 at 1:40 PM, he stated he started with the facility in 10/2023. He stated he believed the facility did not have a water system process flow diagram, and the previous owners took the documentation at the time of ownership transfer. The DOM stated he requested a schematic of the building from the city through an open records request but had not received any documentation to date. He stated he was in touch with the Regional DOM, who he stated was hopeful that he might have a source to obtain the documentation. During an interview with the Regional DOM on 04/25/2024 at 9:10 AM, the SSA Surveyor requested a water system process flow diagram. The Regional DOM stated the former owners of the company did not leave the water flow diagram. He stated he had called and requested the document from the former maintenance supervisor and was told it would be emailed to him by 04/26/2024. During an interview with the Administrator on 04/27/2024 at 5:01 PM, he stated the Regional DOM could not obtain a water systems flow diagram for the facility and he could not provide the requested documentation to the SSA Surveyor. Additionally, the Administrator stated that while the corporate office was in the process of developing a Water Management policy, the facility was currently using the policy of the former owners. He stated the importance of having a facility water management plan as part of the overall infection control plan was to reduce the risk of Legionnaires disease and to identify potential areas where legionella could grow and spread. During an additional interview with the IP on 04/24/2024 at 11:45 AM, she stated the facility followed CDC guidelines and recommendations related to infection control. The IP stated in addition to having the role of IP, she was also the Staff Development Coordinator and worked as a floor nurse several shifts during the week. However, she stated she was in the role of IP at least part time and could perform her duties as an IP. She stated while she did not keep documentation, she and nursing leadership monitored staff members to ensure they were following the facility's policies and at a minimum, standard precautions. She stated it was her expectation that all staff followed the facility's infection control policies and procedures. The IP stated it was important to prevent the spread of infection. During an interview with the DON on 04/26/2024 at 1:05 PM, she stated the facility followed IPCP guidelines as per the CDC. She stated she reviewed reports related to infection surveillance and assisted the IP and nursing leadership to maintain a safe environment for the staff and residents. The DON stated the IP was employed in that role at least part time and could perform her duties as an IP in addition to having the role of the Staff Development Coordinator and working the floor several shifts during the week. The DON stated staff had access to all policies and procedure guidelines through the facility's shared One-Drive. She stated nurses could access the latest nursing care standards on the same shared drive. In the continued interview with the DON on 04/26/2024 at 1:05 PM, she stated when a resident was admitted requiring TBP, the facility followed guidelines to protect the residents and staff from the spread of infection. She stated staff members were trained on how to don and doff PPE and should follow the guidelines outlined on the sheets located on each door with precautions. She stated it was important to follow the facility's policy for HH, and her expectation was that staff performed HH prior to and immediately after providing resident care. She stated staff should empty trash cans when they were full and take them to the proper receptacle for disposal. She stated there was no special bagging for contact precautions. She stated staff should follow the facility's policy and procedure when emptying urinary catheter bags and disposing of urine. The DON further stated that urinal containers should be changed once weekly and should be labeled with the name of the resident and dated at time of change. She stated urinals needed to be capped when transporting to the communal bathroom and emptied in the commode. She stated urinals should be rinsed out or replaced before returning them to the residents. Furthermore, the DON stated it was her expectation that all staff members were responsible for infection control and followed the facility's infection control policies and procedures. She stated having an infection control and prevention program was important to prevent infectious and communicable diseases. During an interview with the RNC on 04/26/2024 at 3:43 PM, she stated staff received IPCP training upon hire, annually, and through periodic in-service training. The RNC, along with the DON and the IP, had educated staff on HH, donning and doffing PPE, and TBPs. She stated staff should not reach back to untie the back of the gown while still wearing gloves. During the continued interview with the Administrator on 04/27/2024 at 5:01 PM, he stated he had been in the position of Administrator since 10/2023. The Administrator stated infection prevention and control education was provided upon hire for all staff, and it was based on job duties. He stated the facility followed the CDC's recommendations and guidelines related to IPCP, HH, and TBPs. The Administrator stated it was his expectation that all staff followed the CDC guidelines and facility policies. A[TRUNCATED]

Based on interview, record review, review of the facility's local health department inspection, and review of the local health department's website, the facility failed to provide education to food handlers related to safe food handling practice to enable food handlers to effectively carry out the functions of the food and nutrition service department. This deficient practice affected 85 residents receiving meals from the kitchen. The findings include: Review of the local health department's Health Department Inspection, dated 02/05/2024, revealed the facility was cited for improper glove use, hand hygiene, and staff needing food handlers' cards. Further review revealed these citations should be corrected as soon as possible or by the next routine inspection for appropriate employees and the provider to have food handler training and certification. Review of the local county health department's website, https://fchd.org/foodsafetycertification, revealed that all food handlers and managers were required to complete a course in food safety and maintain a valid and current certification. Further review revealed a basic Food Handler Certification course was required for all persons working in the county through the local health department. Review of the dietary staff's personnel records revealed none of the 10 staff had current food handler's cards or certifications. During interview with Cook1 on 04/26/2024 at 3:08 PM, she stated all dietary staff attended education for food safety with new employee orientation. Cook1 stated she did not have a food handler's card. During interview with Dietary Aide 1 on 04/26/2024 at 3:15 PM, he stated he had training with armed services for culinary and had a food handlers' card, which had expired. During interview with the Dietary Manager on 04/26/2024 at 2:50 PM, she stated she had a Safe Food Handling Certificate. She stated she talked with new staff concerning safe food handling. She stated unless there was a problem identified with safe food handling, she did not provide any education with dietary staff other than the new hires. During interview with the Director of Nursing (DON) on 04/26/2024 at 4:19 PM, she stated her expectations for dietary staff would be that they be trained in safe food handling and handled food in a safe manner. During interview with the Administrator on 04/26/2024 at 4:36 PM, he stated he was not aware kitchen staff required food handlers training and certification.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, review of the facility's investigation reports, and review of the facility's policy, it was determined the facility failed to protect the resident's right to be free from abuse for two (2) of four (4) sampled residents reviewed for abuse and the right to be free from abuse, Resident #187 and #11. On 09/05/2022, Resident #187 stated he/she was sexually harassed and made to feel uncomfortable with a Physical Therapy Assistant (PTA) when the PTA looked at the resident unclothed while taking a bath, kissed the resident on the cheek, and made comments about the resident's physical appearance. On 10/25/2022, Resident #45 hit Resident #11 with his/her walker causing discoloration to Resident #11's leg. The findings include: Review of the facility's policy titled, Abuse Prohibition, dated 10/24/2022, revealed, Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, injury or mental anguish. The policy further revealed, It includes verbal abuse, sexual abuse, physical abuse, and mental abuse. The policy defined sexual abuse as non-consensual sexual contact of any type with a patient. It includes but is not limited to sexual harassment, sexual coercion, or sexual assault. The policy stated that if the abuse was resident-to-resident, the resident who had threatened or attacked another resident would be removed from the setting or situation. Per the policy, after it was determined the residents were safe, an investigation would be completed. 1. Review of Resident #187's medical record revealed the facility admitted the resident, on 07/29/2022, with diagnoses that included Left Tibia Fracture, Cirrhosis, Opioid Abuse, Type II Diabetes Mellitus, Alcohol Abuse, and Psychosis not due to a substance or known physiological condition. The record further indicated Resident #187 was discharged from the facility on 11/16/2022. Review of the admission Minimum Data Set (MDS) Assessment, dated 07/31/2022, revealed Resident #187 had a Brief Interview for Mental Status (BIMS) score of twelve (12) of fifteen (15), indicating the resident was moderately cognitively impaired. Further review revealed Resident #187 had not exhibited any physical, verbal, or other behavioral symptoms during the assessment look back period. The MDS Assessment indicated Resident #187 required limited one (1) person assistance with dressing and personal hygiene. Review of Resident #187's Care Plan, initiated on 09/05/2022, revealed a focus area of reporting past experience of trauma as evidenced by a sexual harassment allegation. Interventions included reporting allegation to the state; to maintain communication that was consistent, open, respectful, and compassionate; to respect concerns and questions; and to involve Resident #187 in decision making. Review of the Self-Reported Incident Form, dated 09/05/2022, indicated Resident #187 alleged the PTA entered his/her room when the curtain was drawn while performing his/her own bed bath. Per the report, the resident stated the PTA peeked his head around the privacy curtain and saw Resident #187 unclothed. The report documented the resident stated the PTA had made comments to Resident #187 in the past about being attractive, and Resident #187 stated he kissed him/her on the cheek in the hallway after a therapy session. Per the report, Resident #187 further stated the PTA made him/her feel uncomfortable during therapy sessions because he stood too close and made uncomfortable comments to Resident #187. Per the report, the facility unsubstantiated the allegation following an investigation, which included suspending and terminating the PTA, staff interviews, resident interviews, and resident skin assessments. The report stated the facility provided education to all employees on identifying abuse, sexual harassment, and resident respect and dignity following the allegation. Interview with the PTA, on 01/11/2023 at 12:22 PM, revealed Resident #187 would make comments about how he/she was ugly, fat, and no one liked him/her, so he had hugged Resident #187 in the past to make the resident feel better about him/herself and kissed the top of the resident's head. The PTA further stated he had never said anything inappropriate to Resident #187 and did not think telling a resident he/she was not ugly was inappropriate. The PTA stated that on 09/05/2022, he knocked on Resident #187's door to get the roommate's walker and walked past Resident #187's pulled curtain. He stated when he noticed Resident #187 was naked in bed, the PTA apologized and left the room. The PTA then stated he was suspended for a couple of days and then terminated following the incident. The PTA stated his supervisor told him that he had been educated previously on proper customer service following a previous allegation from a female resident, and the facility opted to terminate him following the incident that occurred on 09/05/2022. Interview with Licensed Practical Nurse (LPN) #4, on 01/11/2023 at 1:10 PM, revealed Resident #187 approached him with concerns regarding an incident where the PTA came into his/her room and intentionally peeked around the pulled privacy curtain to see Resident #187 unclothed, giving him/herself a bed bath. LPN #4 further stated Resident #187 told him the PTA routinely flirted with the resident, telling Resident #187 that he/she had pretty eyes and would touch his/her shoulders and hair during therapy. Resident #187 stated this made the him/her uncomfortable. LPN #4 stated Resident #187 told him the resident was scared, so he/she came to LPN #4 to report his/her concerns. LPN #4 then stated he immediately took Resident #187 to the Administrator to explain the situation. LPN #4 stated the PTA was suspended and did not return to the facility. Interview with the Certified Occupational Therapy Assistant (COTA), on 01/11/2023 at 2:30 PM, revealed she was on leave when the incident between the PTA and Resident #187 occurred, but Resident #187 told her about it when she returned to work. The COTA stated Resident #187 told her the PTA rubbed his/her back and kissed his/her cheek, and this made the resident uncomfortable. The COTA stated Resident #187 was worried this would happen to other residents if the resident did not say anything. The COTA further stated the PTA received education previously on sexual harassment in the past due to incidents with other therapy staff. The COTA then stated once Resident #187 verbalized his/her concerns, the PTA was suspended and terminated following an investigation. Interview with the Social Services Director (SSD), on 01/11/2023 at 2:42 PM, revealed she spoke with Resident #187 following the resident's allegation and had him/her complete a witness statement regarding the incident. The SSD further stated she conducted safe resident surveys on all cognitively intact residents (BIMS score of eight (8) and greater) and followed up with Resident #187 daily to ensure he/she felt safe and comfortable in the building. The safe resident surveys revealed other residents felt the PTA touched them more than needed during therapy and was creepy overall, but none verbalized any allegations against him prior to 09/05/2022. The SSD then stated that once the PTA was terminated, he came to the facility, was escorted to collect his belongings, and then was escorted off the property. Interview with the Director of Nursing (DON), on 01/11/2023 at 4:25 PM, revealed Resident #187 reported to LPN #4 that the PTA intentionally peeked around the resident's privacy curtain to see him/her naked. The DON stated the PTA was immediately suspended pending investigation, and administrative staff interviewed the floor staff and all cognitively intact residents. The PTA's supervisor interviewed him following the incident and decided to terminate him due to a similar allegation made months ago that was found to be unsubstantiated. The DON further stated that when a resident made an allegation, she expected her staff to take it seriously, ensure resident safety, and to immediately report it to her or the Administrator. Interview with the Clinical Operator Area Director ([NAME]) for the Therapy Department, on 01/11/2023 at 6:13 PM, revealed the PTA was immediately suspended pending investigation after the incident with Resident #187 was reported. The [NAME] reported there was a similar allegation against the PTA in March 2022 that was unfounded. The [NAME] stated, at that time, the [NAME] provided the PTA with additional education on customer service and resident rights. The [NAME] stated after Resident #187 verbalized his/her concerns with the PTA on 09/05/2022, and following all staff and resident interviews, it was determined that it was best to terminate the PTA for resident comfort and safety. Additional interview with the DON, on 01/12/2023 at 9:30 AM, revealed there had been a previous sexual abuse allegation against the PTA in March 2022 that was unsubstantiated. The DON stated the PTA was friendly and gave compliments to residents regarding their hair and eyes that sometimes made them feel uncomfortable, but nothing sexual in nature. The DON further stated she knew residents enjoyed hugs from staff but thought a kiss was inappropriate. The DON stated if the PTA was not in the building, it would have prevented the incident with Resident #187. The DON then stated the facility had policies and procedures in place, and it was important to follow them to protect residents and to help them feel safe in the facility. Interview with the Administrator, on 01/12/2023 at 11:20 AM, revealed Resident #187 reported to LPN #4, on 09/05/2022, that the PTA intentionally peeked around his/her privacy curtain and saw the resident unclothed while he/she was giving him/herself a bed bath. The Administrator then stated that during the investigation, Resident #187 told him the PTA had kissed the resident on the cheek after a therapy session, and it made the resident feel uncomfortable. Once notified, the Administrator stated he obtained the PTA's statement and suspended him pending an investigation. The Administrator stated the administrative staff obtained staff and resident interviews, and he had follow-up conversations with Resident #187 to ensure resident safety. The Administrator stated staff interviewed all alert and oriented residents with a BIMS score of eight (8) or greater and did skin assessments on residents with a BIMS score of seven (7) or below. The Administrator further stated he considered a staff member kissing a resident to be inappropriate. The Administrator stated there had been a previous sexual abuse allegation against the PTA in March 2022, which was unsubstantiated. However, he stated with the second allegation from Resident #187, the PTA's company decided to terminate him. The Administrator then stated it was important to implement the facility's policies and procedures to ensure resident safety and to prevent any incidents from occurring in the first place. 2. Review of Resident #45's medical record revealed the facility admitted the resident, on 10/13/2021, with diagnoses that included Cerebral Infarction, Psychoactive Substance Abuse, Vascular Dementia, Aphasia, and Anxiety. Review of Resident #45's Annual Minimum Data Set (MDS) Assessment, dated 08/30/2022, revealed Resident #45 had a Brief Interview for Mental Status (BIMS) score of fourteen (14) of fifteen (15), indicating the resident was cognitively intact. Further review revealed Resident #45 had physical, verbal, and other behavioral symptoms directed towards others on one (1) to three (3) days during the assessment period. The MDS Assessment further indicated Resident #45 ambulated independently with setup assistance only, using a walker. Review of Resident #45's Care Plan, initiated on 10/25/2021 and revised on 11/29/2021, indicated Resident #45 exhibited physical behaviors related to cognitive loss and dementia. The care plan indicated on 10/25/2022, Resident #45 hit another resident with his/her walker. Interventions included to evaluate the need for a behavioral health consult, observe for any non-verbal signs of physical aggression, and to remove Resident #45 from the environment as needed while speaking in a calm, reassuring voice. Further review of the care plan revealed a focus area initiated on 10/25/2022 that indicated Resident #45 exhibited psychosocial distress with his/her well-being and social relationships related to wandering. The care plan indicated another resident reported he/she was struck by Resident #45's walker. Interventions included one-to-one (1:1) supervision initiated from 10/25/2022 to 10/27/2022; every fifteen (15) minute checks from 10/27/2022; every thirty (30) minute checks from 10/30/2022 to 11/02/2022; and to assist with processing feelings to find positive outcomes. Review of Resident #11's medical record revealed the facility admitted the resident, on 06/07/2016, with diagnoses that included Heart Failure, Type II Diabetes Mellitus, and Dementia without Behavioral Disturbance. Review of Resident #11's Quarterly MDS Assessment, dated 10/26/2022, revealed Resident #11 had a BIMS score of seven (7) of fifteen (15), indicating severe cognitive impairment. Further review revealed Resident #11 had physical, verbal, and other behavioral symptoms on one (1) to three (3) days during the assessment period and used a wheelchair for mobility assistance. Review of Resident #11's Care Plan, initiated on 03/02/2017, indicated a focus of impaired cognitive function related to a condition other than delirium, and his/her cognitive function varied throughout the day and from day-to-day. Interventions included to observe for and evaluate types of changes in cognitive status and to evaluate behavioral symptoms for underlying causes. Review of a Resident-to-Resident Incident Report, dated 10/25/2022 at 11:00 PM, revealed Resident #11 stated to Certified Nursing Assistant (CNA) #1 that Resident #45 kicked at him/her and hit him/her with Resident #45's walker. The incident report indicated Resident #45 was placed on one-to-one (1:1) observation following the incident, and Resident #11 had discoloration to his/her left lower leg. The incident report indicated the incident was unwitnessed, and no other injuries were noted. Additional review of a Resident-to-Resident Incident Report, dated 10/26/2022 at 12:11 AM, revealed Resident #45 stated to Licensed Practical Nurse (LPN) #2 he/she hit Resident #11 with his/her walker. Per the report, Resident #45 was placed on one-to-one (1:1) observation following the incident, and there were no injuries noted post incident. Review of the Self-Reported Incident Form, dated 10/26/2022, indicated Resident #11 told Resident #45 to get away from Resident #11's doorway, and Resident #45 responded by taking his/her walker and hitting Resident #11 on the leg. Per the report, staff intervened and separated the residents, and Resident #45 was placed on increased supervision until Resident #45 could be reviewed by psychiatric services. The report indicated Resident #45 admitted to contacting Resident #11's leg with his/her walker but did not respond to any questions related to the intent of the contact. Interview with Licensed Practical Nurse (LPN) #5, on 01/11/2023 at 11:10 AM, revealed Resident #11 and Resident #45 were both confused at times and used to reside in adjacent rooms on the same hall. The LPN stated the residents were moved after an altercation and were now on different halls separated by a large common area and two (2) sets of double doors. Interview with Certified Nursing Assistant (CNA) #3, on 01/11/2023 at 1:00 PM, revealed both Resident #11 and Resident #45 used to reside on the same hall but were now on separate halls, following their altercation in October 2022. CNA #3 stated Resident #45 had no prior history of physical behaviors towards other residents but was placed on one-to-one (1:1) supervision following the altercation. Interview with the Director of Nursing (DON), on 01/12/2023 at 9:25 AM, revealed Resident #45 used his/her walker to hit Resident #11's leg in the hallway, and the incident occurred around 11:00 PM on 10/25/2022. The DON stated the evening CNA reported it to the nurse, who then notified her shortly after the incident. The DON then stated she immediately notified the Administrator. Interview with the Administrator, on 01/12/2023 at 11:12 AM, stated Resident #45 hit Resident #11's leg with Resident #45's walker in the hallway. Resident #11 and Resident #45 had no history of physical aggression toward others, and there had been no incidents since.

Based on interview, record review, review of the facility's investigation reports, and review of the facility's policy, it was determined the facility failed to report an allegation of sexual abuse to local authorities for one (1) of four (4) residents reviewed for abuse, Resident #187. In addition, the facility failed to report an allegation of abuse within two (2) hours to the State Survey Agency (SSA) for one (1) of three (3) abuse allegations reviewed involving Resident #11 and Resident #45. The findings include: Review of the facility's policy titled, Abuse Prohibition, dated 10/24/2022, revealed staff was to report allegations involving abuse no later than two (2) hours after the allegation was made. Per the policy, facilities must coordinate with their state and local law enforcement entities to determine what actions were considered crimes. The policy stated the individual reporting the suspicion was not responsible for determining whether the incident was a crime but was required to report the suspicion that a crime occurred. 1. Review of Resident #187's medical record revealed the facility admitted the resident, on 07/29/2022, with diagnoses that included Left Tibia Fracture, Cirrhosis, Opioid Abuse, Type II Diabetes Mellitus, Alcohol Abuse, and Psychosis not due to a substance or known physiological condition. The record further indicated Resident #187 was discharged from the facility on 11/16/2022. Review of the admission Minimum Data Set (MDS) Assessment, dated 07/31/2022, revealed Resident #187 had a Brief Interview for Mental Status (BIMS) score of twelve (12) of fifteen (15), indicating the resident was moderately cognitively impaired. Review of the Self-Reported Incident Form, dated 09/05/2022, indicated the SSA was notified of the abuse allegation on 09/05/2022 at 2:53 PM. The form indicated Resident #187 alleged the Physical Therapy Assistant (PTA) entered his/her room when the curtain was drawn while he/she was performing his/her own bed bath. Per the report, the PTA peeked his head around the privacy curtain and saw Resident #187 unclothed. The report stated the PTA had made comments to Resident #187 in the past about being attractive, and Resident #187 stated he had kissed him/her on the cheek in the hallway after a therapy session. The report stated Resident #187 stated the PTA made him/her feel uncomfortable during therapy sessions because he stood too close and made uncomfortable comments to Resident #187. Interview with the PTA, on 01/11/2023 at 12:22 PM, revealed on 09/05/2022, he knocked on Resident #187's door to get his/her roommate's walker and walked past Resident #187's pulled privacy curtain. The PTA stated when he noticed Resident #187 was naked in bed, the PTA apologized and left the room. The PTA then stated he was suspended for a couple of days and then terminated following the incident. Interview with Licensed Practical Nurse (LPN) #4, on 01/11/2023 at 1:10 PM, revealed Resident #187 approached him with concerns regarding an incident where the PTA came into the resident's room and intentionally peeked around the pulled privacy curtain to see Resident #187 unclothed, while he/she was giving him/herself a bed bath. LPN #4 stated Resident #187 told him the resident was scared so he/she came to LPN #4 to report his/her concerns. LPN #4 then stated he immediately took Resident #187 to the Administrator to explain the situation. Interview with the Director of Nursing (DON), on 01/11/2023 at 4:25 PM, stated Resident #187 reported to LPN #4 that the PTA intentionally peeked around the resident's privacy curtain to see him/her naked. The DON further stated that when a resident made an allegation, she expected her staff to take it seriously, ensure resident safety, and to immediately report it to her or the Administrator. Addition interview with the DON, on 01/12/2023 at 9:10 AM, revealed Resident #187 told the DON he/she would not allow the facility to notify the police and would not say anything to the authorities if they were notified. Interview with the Administrator, on 01/12/2023 at 11:20 AM, revealed Resident #187 reported to LPN #4 on 09/05/2022 that the PTA intentionally peeked around his/her privacy curtain and saw him/her unclothed, while he/she was giving him/herself a bed bath. The Administrator further stated he did not notify the police of the sexual abuse allegation because Resident #187 was embarrassed and did not want to talk to them. The Administrator then stated it was important to implement the facility's policies and procedures to ensure resident safety and to prevent any incidents from occurring in the first place. 2. Review of Resident #11's medical record revealed the facility admitted the resident, on 06/07/2016, with diagnoses that included Heart Failure, Type II Diabetes Mellitus, and Dementia without Behavioral Disturbance. Review of Resident #11's Quarterly MDS Assessment, dated 10/26/2022, revealed Resident #11 had a BIMS score of seven (7) of fifteen (15), indicating severe cognitive impairment. Review of Resident #45's medical record revealed the facility admitted the resident, on 10/13/2021, with diagnoses that included Cerebral Infarction, Psychoactive Substance Abuse, Vascular Dementia, Aphasia, and Anxiety. Review of Resident #45's Annual Minimum Data Set (MDS) Assessment, dated 08/30/2022, revealed Resident #45 had a Brief Interview for Mental Status (BIMS) score of fourteen (14) of fifteen (15), indicating the resident was cognitively intact. Review of the Resident-to-Resident Incident Report, dated 10/25/2022 at 11:00 PM, revealed Resident #11 stated to Certified Nursing Assistant (CNA) #1 that Resident #45 kicked at him/her and hit him/her with Resident #45's walker. Per the report, Resident #11 had discoloration to their left lower leg. Per the report, the incident was unwitnessed, and no other injuries were noted. Additional review of the Resident-to-Resident Incident Report, dated 10/26/2022 at 12:11 AM, revealed Resident #45 stated to LPN #2 that he/she hit Resident #11 with his/her walker. Review of the Self-Reported Incident Form, dated 10/26/2022, indicated the SSA was notified of the abuse allegation on 10/26/2022 at 8:54 AM, approximately ten (10) hours after it was first reported by Resident #11 to CNA #1. Interview with the DON, on 01/12/2023 at 9:25 AM, revealed Resident #45 used his/her walker to hit Resident #11's leg in the hallway, and the incident occurred around 11:00 PM on 10/25/2022. She stated the evening CNA reported it to the nurse, who then notified her shortly after the incident. The DON stated she notified the Administrator immediately that night, and the Administrator was responsible for reporting the incident to the SSA, which should have been done within two (2) hours of the incident occurring. The DON further stated it was important to report timely any incidents between residents to the SSA, so they were aware of the allegation and knew the facility was appropriately addressing the resident-to-resident altercation. Interview with the Administrator, on 01/12/2023 at 11:12 AM, revealed Resident #45 hit Resident #11's leg in the hallway with Resident #45's walker. The Administrator then stated the nurse notified him of the incident around midnight on 10/25/2022, and he reported the incident to the SSA on 10/26/2022 at 8:54 AM. He further stated he knew the incident needed to be reported to the SSA within two (2) hours and had no excuse as to why it was not completed until later that morning. The Administrator then stated it was important to report any allegations of abuse timely to ensure resident safety and because the regulations required facilities to report allegations within two (2) hours.