Based on interviews and record review, the facility failed to develop a comprehensive person-centered care plan for 1 (#113) of 5 (#14, #20, #91, #113, and #119) residents reviewed for unnecessary medications by failing to ensure: 1. Resident #113 care plan addressed her use of antidepressant and psychotropic medications; and 2. Resident #113's care plan addressed her suicidal ideations. Findings: Review of Resident #113's clinical record revealed an admission date of 10/11/2024. Further review revealed Resident #113 had diagnoses, which included Alzheimer's Disease and Anxiety Disorder. Review of Resident #113's Medication Administration Records from 10/11/2024 to 11/14/2024 revealed the following, in part: Seroquel 25 mg Give 0.5 mg by mouth at bedtime was administered from 10/11/2024 to 10/31/2024; Seroquel 25 mg Give 1 tablet by mouth at bedtime was administered from 11/01/2024 to 11/11/2024; Seroquel 50 mg Give 1 tablet by mouth at bedtime was administered from 11/12/2024 to 11/13/2024; and Lexapro 20 mg Give 1 tablet by mouth in the morning was administered from 10/12/2024 to 11/14/2024. Review of Resident #113's Progress Notes revealed the following, in part: 10/23/2024 at 4:06 p.m., .therapy came to Social Services and spoke about Resident #113 constantly saying she is going to kill herself. 11/04/2024 at 11:03 a.m., Therapy came to talk to Social Services and explained that Resident #113 stated that If I could get a gun and kill myself I would. Review of Resident #113's current Care Plan revealed it did not reflect Resident #113's use of antidepressant and psychotropic medications nor her suicidal ideations. On 11/14/2024 at 12:24 p.m., an interview was conducted with S9LPN. S9LPN reviewed Resident #113's orders and confirmed the resident received Lexapro and Seroquel. S9LPN confirmed the resident received antipsychotic and antidepressant medications. On 11/14/2024 at 12:34 p.m., an interview was conducted with S8MDS. S8MDS reviewed Resident #113's care plan and confirmed Resident #113 was not care planned for psychotropic and antidepressant medications nor suicidal ideations. S8MDS confirmed Resident #113's suicidal ideation on 10/23/2024 should have been care planned. On 11/14/2024 at 12:49 p.m., an interview was conducted with S2DON. S2DON reviewed Resident #113's care plan and confirmed the resident was not care planned for suicidal ideations, antidepressants nor psychotropic medications. S2DON confirmed Resident #113 should have been care planned for psychotropic and antidepressant medication use. S2DON confirmed Resident #113's suicidal ideation from 10/23/2024 should have been care planned by 11/06/2024.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary environment to help prevent the development and transmission of infection for 1 (#80) of 6 (#4, #24, #33, #68, #80, and #84) residents reviewed for infection control. The facility failed to ensure staff wore proper Personal Protective Equipment (PPE) while providing catheter care to a resident who was on Enhanced Barrier Precautions (EBP). Findings: Review of the facility's policy titled Enhanced Barrier Precautions, revised on 03/2024, revealed the following, in part: Enhanced Barrier Precautions involve gown and glove use during high-contact resident care activities for residents known to be colonized or infected with a MDRO as well as those at increased risk of MDRO acquisition (e.g. indwelling medical devices). For residents for whom EBP are indicated, EBP is employed when performing the following high-contact resident care activities: Device care or use: urinary catheter Review of Resident #80's clinical record revealed she was admitted to the facility on [DATE] with diagnoses, which included personal history of urinary tract infections. Review of Resident #80's current physician's orders revealed the following, in part: Start Date 08/30/2024: Enhanced Barrier Precautions - gown and gloves to be worn during high contact resident care activities (urinary catheter). Start Date: 11/09/2024: Catheter, indwelling, 16FR Foley Catheter On 11/12/2024 at 12:55 p.m., an observation was made of the Enhanced Barrier Precautions sign posted on Resident #80's door. The sign revealed the following, in part: Providers and staff must also: Wear gloves and a gown for the following high-contact activities. Device care or use: urinary catheter On 11/12/2024 at 12:45 p.m., an observation was made of S10CNA performing catheter care for Resident #80 without wearing a gown. On 11/12/2024 at 1:00 p.m., an interview was conducted with S10CNA. S10CNA confirmed Resident #80 was on EBP and she did not wear a gown while performing catheter care and should have. She stated she did not wear a gown because she was busy performing other tasks. On 11/13/2024 at 11:50 a.m., an interview was conducted with S11LPN. S11LPN confirmed Resident #80 was on EBP. S11LPN confirmed S10CNA should have worn a gown while performing catheter care for Resident #80. On 11/13/2024 at 12:16 p.m., an interview was conducted with S2DON. S2DON confirmed staff should wear a gown while performing catheter care for a resident who is on EBP.

Based on observations and interview, the facility failed to store, prepare, and distribute foods under sanitary conditions. The facility failed to ensure: 1. Food was dated after opening; 2. Ice machine was properly cleaned and sanitized; and 3. Ice machine rolling table was properly cleaned and sanitized. This deficient practice had the potential to affect 137 out of 142 facility residents who were provided meals and beverages from the facility's kitchen. Findings: Review of the facility's undated policy titled, Storage Of Refrigerated Food revealed the following, in part; Policy: The facility ensures the quality and safety of refrigerated foods through accepted storage practices. Procedure: 4. Food taken out of original containers is put in a clean sanitized container with tight fitting lid. 5. All non-hazardous, opened food are labeled with name of food, date stored. 6. All hazardous foods are labeled with name of food and date stored. During the initial tour of the facility's kitchen on 11/07/2024 at 8:40 a.m. with S4DM, the following observations were made: Walk in Refrigerator: 1-opened gallon of milk with no open date. 1-opened thickener mix with no open date. 1-opened package of turkey meat with no open date. 2-opened cheese blocks with no open date. 2-opened salad dressing bottles with no open dates. Ice Machine: A pink sticky substance was noted on the ice machine rolling table cart. The ice machine's ice dispenser tray was completely covered with round fuzzy greenish/black particles. The fuzzy greenish/black particles were also noted to be floating in standing water in the ice machine. On 11/07/2024 at 8:40 a.m., an interview was conducted with S4DM. S4DM confirmed the above aforementioned findings. S4DM confirmed all opened items should be labeled with an open date. On 11/12/2024 at 9:46 a.m., S4DM confirmed the ice machine and table should be clean and sanitary and were not. On 11/12/2024 at 11:18 a.m., an interview was conducted with S5MS who stated he was responsible for cleaning all ice machines. On 11/13/2024 at 4:45 p.m., an interview was conducted with S1ADM. He stated S5MS was responsible for scheduled cleanings of all ice machines. He confirmed the ice machine and table should be clean and sanitary and was not. S1ADM confirmed on 11/07/2024 at 4:50 p.m. all opened items should be labeled with an open date.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure adequate monitoring for effectiveness and side effects of psychotropic medication was completed for 1 (#1) of 3 (#1, #2, and #3) residents reviewed for unnecessary medications. Findings: Review of the facility's policy titled Psychotropic Medications dated 10/2022 revealed the following: The use of PRN psychotropic medications require a screen pre and post administration. Documentation should include behavior the drug is intended to reduce, physiological, environmental and pharmacological interventions. As well as post administration behavior and side effects. A pre and post administration screen should be completed for each use of PRN Psychotropic medications. Residents that use psychotropic medications shall have side effect monitoring. Review of the facility's policy titled Drug Administration and Documentation dated 12/2023 revealed the following: PRN medications will be documented on the MAR and the reason for giving as well as the result/response for each dose given will be noted in the clinical record. Review of Resident #1 clinical record revealed Resident #1 was admitted to the facility on [DATE] with diagnoses of Other Non-traumatic Intracerebral Hemorrhage, Chronic pain syndrome, Other Specified Anxiety Disorders, Other Specified Depressive Episodes, Pulmonary Fibrosis, and Raynaud's Syndrome. Review of Resident #1's physician orders dated May 2024 revealed, in part, an ordered dated 05/27/2024 for Xanax 0.25 mg 1 tablet by mouth twice daily as needed for feeling agitated or Panic disorder for 14 days. Review of Resident #1's MAR dated May 2024 and June 2024 revealed, in part, Resident #1 received the above medication on the following dates: 05/27/2024 at 9:17 p.m.; 05/28/2024 at 8:00 p.m.; 05/30/2024 at 4:00 a.m.; 05/31/2024 at 8:00 a.m.; 05/31/2024 at 8:00 p.m.; 06/01/2024 at 5:05 p.m.; 06/02/2024 at 4:00 a.m.; 06/03/2024 at 3:45 a.m.; and 06/03/2024 at 9:20 a.m. There was no documentation of a screen performed pre administration or reason for administering the above medication on the following dates: 05/28/2024 at 8:00 p.m.; 05/30/2024 at 4:00 a.m.; 05/31/2024 at 8:00 a.m.; 05/31/2024 at 8:00 p.m.; and 06/03/2024 at 3:45 a.m. There was no documentation of a screen performed post administration or response to the above medication on the following dates: 05/28/2024 at 8:00 p.m.; 05/31/2024 at 8:00 p.m.; and 06/03/2024 at 3:45 a.m. On 07/18/2024 at 11:35 a.m., an interview was conducted with S2DON. She reviewed the policy titled Psychotropic Medications. She stated a pre and post administration screen should be completed for each use of as needed psychotropic medication. She reviewed Resident #1's MAR for administration of the above medication and reviewed Resident #1's nurse's notes for the dates and times of administration. She confirmed there was no documentation a pre-administration or post-administration screen had been performed on Resident #1 for the aforementioned dates.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview the facility failed to ensure medication Carts were locked when unattended for 1 (Cart F) of 6 (Cart A, Cart B, Cart C, Cart D, Cart E, and Cart F) medication carts observed. Findings: Review of the facility's policy titled Drug Administration and Documentation dated 12/2023 revealed the following: The medication cart is not to be taken into the resident's room, and therefore, is to be locked whenever unattended. On 07/17/2024 at 8:01 a.m., an observation was made of Cart F unlocked and unattended near room [ROOM NUMBER]. On 07/17/2024 at 10:15 a.m., an interview was conducted with S4LPN. She stated the medication cart should be locked at all times and confirmed Cart F was not locked when it was left unattended near room [ROOM NUMBER]. On 07/18/2024 at 11:35 a.m., an interview was conducted with S2DON. She stated medication carts should be locked when left unattended, and confirmed the surveyor should not have observed Cart F unlocked if it was left unattended.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record reviews, the facility failed to ensure a resident's call light was within reach for 2 (R1 and R2) of 5 (#1, #2, #3, R1, R2) residents reviewed. Findings: Review of the facilities policy, Call Light/Bell, dated 01/2024, revealed the following, in part: Purpose: To provide the resident a means of communication with staff members Procedure 1. Ensure resident has call light in reach when in resident room 7. Place the call light within the resident's reach before leaving the room. Resident R1 A review of Resident R1's Clinical Record revealed the resident was admitted to the facility on [DATE] with diagnoses, which included the following, in part: Alzheimer's disease, Urinary Tract Infections, and Cognitive Communication Deficit. A review of Resident R1's current Care Plan revealed the following: Onset: 05/30/2019 Problem: Resident was at risk for injury from falls. Interventions: Place call light within reach. On 05/20/2024 at 9:40 a.m., an observation was conducted of Resident R1. She was observed resting in her bed with her call light noted on the floor and not in reach. Resident R2 A review of Resident R2's Clinical Record revealed the resident was admitted to the facility on [DATE] with diagnoses, which included the following, in part: Systemic Lupus, Cognitive Communication Deficit, and Dementia. A review of Resident R2's current Care Plan revealed the following: Onset 04/02/2023 Problem: Resident was at risk for falls. Interventions: Place call light within reach. 06/14/2023- Call don't fall sign placed in bathroom and room; 06/22/2023- Staff in-serviced on keeping call light within reach and clipped to bed or recliner; and 07/21/2023- Educated resident on importance of using the call light. On 05/20/2024 at 10:02 a.m., an observation was conducted of Resident R2. She was observed sitting up in her wheelchair with her call light behind her on the floor and not in reach. On 05/20/2024 at 10:02 a.m., an interview was conducted with Resident R2. She stated she was not able to transfer without assistance. She stated she would press the button for assistance, but she was not able to reach the call light. She stated would like to get in her recliner but was not able to call for assistance. On 05/20/2024 at 10:29 a.m., an observation was conducted of Resident R2. She was noted sitting in her wheelchair and her call light was not in reach of the resident. On 05/20/2024 at 10:29 a.m., an interview was conducted with S5LPN. She confirmed Resident R2 utilized her call light and it should be within reach. She further confirmed the call light was on the floor and Resident R2 was not able to reach it. On 05/21/2024 at 10:39 a.m., an interview was conducted with S3ADON. She stated she was not sure if Resident R1 would use the call light because she normally would yell out but the call light should be placed within reach. She confirmed Resident R2 was able to use her call light and it should be placed within reach when staff exited the room. On 05/21/2024 at 1:00 p.m., an interview was conducted with S4ADON. She stated she was not sure if Resident R1 would use the call light but the call light should be placed within reach. She confirmed Resident R2 was able to use her call light and it should be placed within reach when staff exited the room. On 05/21/2024 at 1:26 p.m., an interview was conducted with S2DON. She stated she expected when staff exited the residents room to leave the call light within reach.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to ensure an injury of unknown origin was reported immediately, but not later than 2 hours after the incident, to the facility Administrator and to the State Survey Agency within the specified timeframe for 1 (#1) of 3 (#1, #2, and #3) residents reviewed for accidents. Findings: Review of the facility's policy titled, Incident Investigation and Reporting, reviewed on 05/21/2024, dated 10/2022, revealed in part: Purpose: To provide guidance to the facility for investigation and reporting incidents of abuse, neglect, exploitation, misappropriation of property and/or reportable incidents as required by state and federal requirements. 2. Relevant Terms: Injury of unknown origin: a. Source of injury was not observed by any person and b. The source of injury could not be explained by the resident and c. The injury is suspicious due to the extent or location of the injury or the number of injuries at one time or the incidence of injury over time. 3. The administrator shall report no later than 2 hours after forming the suspicion, if the events that cause the suspicion involve abuse or result in serious bodily injury 5. Additional incidents that must have a thorough investigation and may require reporting . D. Unwitnessed Falls-consider abuse or neglect Review of Resident #1's clinical record revealed, resident was admitted to the facility on [DATE] with diagnosis which included Parkinson's Disease, Dementia, Cognitive Communication Deficit, Hallucinations, Fracture of Upper Left Humerus and Fracture of Superior Right Rim of Left Pubis. Review of Resident #1's Quarterly MDS with an ARD of 05/14/2024 revealed the provider assessed Resident #1 as having a BIMS of 11, indicated resident exhibited moderate cognitive impairment. Further review of the facility's assessment revealed Resident #1 required total dependence for all ADLs and transfer. Review of Resident #1's nurse's note dated 02/12/2024 by S6LPN revealed, in part, S6LPN was summoned to Resident #1's room when CNA found Resident #1 on the floor. Further review revealed, upon entering Resident #1's room, Resident #1 was noted to be face down on the floor to the right side of the bed with her head next to the foot of the bed and her feet towards the head of the bed. S6LPN's assessment revealed Resident #1 had a protruding knot above the left eyebrow with bruising noted to the left side of the scalp; abrasions to the left knee, the left lateral great toe, and the smaller toes on the right foot; Resident #1 complained of pain to the left arm; the left shoulder appeared increased in size with some surrounding edema; and Resident #1 was unable to lift the left arm without crying. Further review also revealed, Resident #1 was confused and unable to answer direct, simple questions. A review of Resident #1's Incident/Accident report dated 02/12/2024 at 4:00 p.m. revealed, in part: Incident Type: found on floor Incident Level: Non-Witnessed Reported to Supervisor: Yes Resident Condition at Time of incident: Mobility-bedfast, no independent movement; Mental-disoriented-not follow commands Review of Resident #1's hospital records dated 02/15/2024 revealed the following X-Ray results: Pelvis: acute left superior and inferior pubic rami fracture. Left shoulder: acute displaced/impacted surgical neck proximal humeral fracture. On 05/21/2024 at 12:34 p.m., an interview was conducted with S6LPN. S6LPN stated she was the floor nurse for Resident #1 on 02/12/2024. S6LPN further stated she had not observed Resident #1 attempting to transfer out of the bed independently prior to the incident. S6LPN stated prior to the unwitnessed fall, Resident #1 had a temperature of 100.7F and was very confused. S6LPN stated she was called to Resident #1's room by a CNA when Resident #1 was found on the floor. S6LPN stated she reported the incident to S4ADON immediately. S6LPN stated Resident #1 had altered mental status prior to the incident. S6LPN stated Resident #1 was confused and could not verbalize how she got on the floor. On 05/21/2024 at 1:24 p.m., an interview was conducted with S2DON. S2DON confirmed she was immediately made aware Resident #1 had an unwitnessed fall, resulting in an injury with fractures on 2/12/2024. She stated S1ADM was made aware of that incident the day of the incident or within 24 hours during morning meetings. On 05/21/2024 at 1:45 p.m., an interview was conducted with S1ADM. S1ADM stated he was aware Resident #1 had an unwitnessed fall, resulting in injuries on 2/12/2024. He verified he did not report the unwitnessed incident which resulted in fractures to the state agency. He stated it was his understanding that unwitnessed falls did not need to be reported.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews, the facility failed to protect the residents' right to be free from physical abuse by Resident #39 for 1 (#17) of 3 (#17, #41 and #137) residents reviewed for abuse. The facility implemented corrective actions which were completed prior to the State Agency's investigation, thus it was determined to be a Past Noncompliance Citation. Findings: Review of the facility's policy titled, Incident Investigation and Reporting revealed the following, in part: Purpose: 1. Each resident residing in this facility has the right to be free from any type of abuse including: physical abuse. Physical Abuse: this includes but is not limited to hitting, slapping, pinching and kicking. Resident #39 Review of Resident # 39's Clinical Record revealed she was admitted to the facility on [DATE] and had diagnoses which included Cerebrovascular Disease, Traumatic Hemorrhage of Cerebrum without Loss of Consciousness, Lack of Coordination, Recurrent Depressive Disorders, Delusional Disorders, Bipolar Disorder, Dementia, Alzheimer's Disease and Cognitive Communication Deficit. Review of Resident #39's Quarterly MDS with an ARD of 07/04/2023 revealed the provider assessed the resident as having a BIMS of Blank, indicating the resident was unable to be assessed. Review of Resident #39's Care Plan revealed the following, in part: Problem: Resident has physical behavioral symptoms directed towards others. Problem: Resident has verbal behaviors directed towards others including staff: Resident threatens to falsely accuse staff of physical harm to her. Review of Resident #39's Nurse's Notes dated June - July 2023 revealed the following, in part: 06/10/2023 at 1:34 a.m. At approximately 1:00 a.m. Resident #39 begin hitting at me with a closed fist. She is fidgeting and restless. Approximately 1:15 a.m. Notified on call provider. Send to Behavior Health Unit for evaluation if behaviors continue per Nurse Practitioner. Signed by S5LPN. 07/10/2023 at 2:50 p.m. Late Entry at 1:38 p.m. Notified S2DON Resident #17 reported Resident #39 struck her to her left eye. Resident #39 sitting in room, did not respond verbally when asked did she hit or touch another person this morning. She only looked at me and shook her head no, and continued to play with her doll. Signed by S6LPN. Review of the facility's Incident Investigation for Resident #39 revealed the following, in part: Incident type: Contact-Resident Date/Time: 07/10/2023 at 1:38 p.m. Type of injury: None apparent Location: Hallway on unit Incident reported by S6LPN Narrative: 1:38 p.m. Notified by S2DON that Resident #17 reported Resident #39 struck her on her left eye. Resident #39 sitting in her wheelchair at this time. She did not respond verbally when asked did she hit or touch another resident this morning. She only looked at me and shook her head no. Resident #17 Review of Resident #17's Clinical Record revealed she was admitted to the facility on [DATE] and had a diagnosis which included Spastic Quadriplegic Cerebral Palsy. Review of Resident #17's Quarterly MDS with an ARD of 10/25/2023 revealed, in part, a BIMS of 15, which indicated she was cognitively intact. Review of Resident #17's Medication Administration Record dated July 2023 revealed the following, in part: Monitor discoloration under left eye daily times 7 days. Report any significant changes to doctor, such as increased swelling, redness or pain. Initialed by the nurse indicating task was completed 07/11/2023 - 07/17/2023. Review of the facility's Incident Investigation for Resident #17 revealed the following, in part: Incident type: Contact-Resident Date/Time: 07/10/2023 at 1:39 p.m. Type of injury: Pain, Bruise, Localized tissue edema, Reddened . Location: Hallway Incident reported by S6LPN Narrative: 1:38 p.m. Notified by S2DON that Resident #17 reported Resident #39 struck her on her left eye. Resident #17 sitting in her wheelchair at this time. Noted redness to left corner of eye with small amount of swelling. When asked about incident, Resident #17 stated while sitting in hallway Resident #39 struck her on her left eye. The corner of Resident #17's left eye was red with bruising and below left eye had minimal swelling. Review of Resident #17's 24-hour follow up investigation documented by S3ADON revealed the following, in part: No swelling noted, small amount of redness noted under left eye. Review of the facility's Self-Reported Incident Report revealed the following, in part: Resident #17 - Victim Resident #39 - Accused Accused Allegation - Physical Abuse Allegation Findings: Substantiated Date/Time - 07/10/2023 at 7:38 a.m. Type of Injury - Redness, Swelling Incident reported by S1ADM Incident Description: Resident #17 reported to S2DON Resident #39 hit her in the eye. Camera footage reviewed, which suggested Resident #39 plucked, with her finger, Resident #17 in the head while passing in her wheelchair. An interview was conducted on 12/12/2023 at 9:30 a.m. with Resident #17. She said on 07/10/2023 at 7:30 a.m., she and Resident #39 were sitting in their wheelchairs on Hall A waiting for the CNA staff to transport them to the dining room. She said Resident #39's wheelchair was parked behind her in the hallway. She said Resident #39 reached from behind her and hit her on the left side of her head near the corner of her left eye. She said her left eye was swollen and red after the incident. She said she had a bruise under her left eye for a few days. An interview was conducted on 12/12/2023 at 12:40 p.m. with S3ADON. She said on 07/10/2023 at 1:30 p.m. she was informed by S6LPN that Resident #17 accused Resident #39 of hitting her to the left side of her face near her left eye. She said she assessed Resident #17's left eye 24-hours after the incident and observed a small amount of redness noted under her left eye. An interview was conducted on 12/12/2023 at 1:15 p.m. with S6LPN. She said on 07/10/2023 at 1:30 p.m., S2DON informed her Resident #17 accused Resident #39 of hitting her on the left side of her face. She said she assessed Resident #17 and found dark colored bruising to the corner of her left eye. She said Resident #17 told her Resident #39 rolled past her on Hall A and hit her on the left side of her head near her left eye. An interview was conducted on 12/12/2023 at 2:00 p.m. with S2DON. She said on 07/10/2023 at 1:30 p.m., Resident #17 reported that Resident #39 hit her on the left eye. She said she watched video surveillance of the incident which occurred on 07/10/2023 at 7:38 a.m. between Resident #39 and Resident #17. She said Resident #39's wheelchair was parked right behind Resident #17's wheelchair on Hall A. She said Resident #39 propelled herself forward, reached around and plucked with her finger the left side of Resident #17's face near her left eye. She said after assessing Resident #17's eye, a red mark was observed under her left eye. An interview was conducted on 12/13/2023 at 3:00 p.m. with S1ADM. He said he was made aware of the incident on 07/10/2023 at 1:38 p.m. involving Resident #17 and Resident #39. He said the facility's video surveillance revealed Resident #39 plucked Resident #17 to the left side of her head near the corner of her left eye. He said the incident was substainated as physical abuse. The facility had implemented the following actions to correct the deficient practice: 1.I mmediate actions taken are as follows: a. Administrator immediately reviewed camera footage upon notification of incident by Resident #17. b. Alleged victim was assessed by floor nurse and Director of Nursing. A small discolored area was noted to Resident #17's left eye. Cold compress was ordered to left eye as needed. c. Local authorities were notified per Elder Justice Act d. Incident reports were opened on both the alleged victim and accused: -Physician notified at 2:11 p.m. -Resident representatives notified at 2:40 p.m. e. Alleged Accused immediately placed under direct staff supervision and monitored one on one. f. Alleged Accused was sent to local hospital for evaluation and treatment and possible admit to Geri-psych at 4:30 p.m. on 07/10/2023 due to behaviors. Accused returned to the facility at 10:22 p.m. and was monitored one on one, when in public spaces, for greater than 24 hours upon return from hospital. g. In-service conducted immediately with all nurses and aides regarding being observant of residents who have behaviors and not leaving residents with physically aggressive behaviors near other residents. h. Psych NP consultation initiated for accused. i. Social Services began reaching out to nursing facilities for alternate placement for Resident #39 on 07/12/2023 in order to attain an accepting facility. j. Received order to increase dose of Seroquel from 25mg to 50mg for Resident #39 on 07/13/2023. k. Social services discussed room change with accused resident representative and resident representative was in agreeance with room change due to accused interest in alleged victim. l. Urinary Analysis collected on accused with negative results 07/14/2023. m. Relocated Resident #39 to Hall B, due to bed on another hall becoming available on 07/14/2023. n. Accused seen by Psych Nurse Practitioner on 07/20/2023. 2. Residents who have the potential to be affected by residents who make physical contact with others include all residents. 3. Measures taken to reduce the likelihood of an event such as this occurring in the future are as follows: a. In-service conducted immediately with all nurses and aides regarding being observant of residents who have behaviors and not leaving residents with physically aggressive behaviors near other residents. b. Facility initiated 30 day discharge process, hearing was scheduled and discharge to accepting facility was denied by Administrative Law judge. c. Quality Assurance plan initiated requiring S2DON/designee to monitor high traffic areas for residents exhibiting escalated behaviors and staffs' ability to respond appropriately. Audits are to be conducted 3 times per week for no less than 4 weeks. d. QA rounds conducted on residents daily for two weeks ending on 07/24/2023 and twice per week for an additional two weeks ending on 08/07/2023 to ensure there is no evidence of abuse of any type. No evidence of abuse has been observed. e. Quality Assurance plan initiated requiring S2DON/designee to monitor all resident's emotional wellbeing, including Resident #17, daily for two weeks until 07/24/2023 then twice per week for two additional weeks ending 08/07/2023 f. Abuse/neglect training conducted quarterly and as needed including providing care to difficult/combative. Resident's education is conducted as needed. 4. The following Quality Assurance measures were put in place: a. Quality Assurance Plan audits are to be captured on a special care form. Results of audits to be discussed in the daily stand-up meeting with the interdisciplinary team. Negative outcomes are to result in education/discipline. The Quality Assurance Committee to meet weekly to assure substantial compliance is maintained. 5. Substantial compliance attained 07/14/2023. Throughout the survey from 12/11/2023 to 12/13/2023, observations, interviews, and record reviews revealed the above listed actions were implemented. Random staff interviews revealed staff received training on the facility's abuse policy and procedure. Observations were made throughout the survey with no abuse identified. Observations, interviews, and record review, revealed monitoring had begun with no further issues identified.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record review, the facility failed to implement appropriate infection control practices during resident care as evidenced by failing to ensure staff implemented proper hand hygiene and glove usage during wound care for 1 (#60) of 3 (#13, #34, and #60) residents reviewed for wound care. Findings: Review of the facility's policy titled, Hand Hygiene revealed the following In part: Policy: To cleanse hands to prevent transmission of infection or other conditions Indications for Hand Washing: 3.) Before and after procedures 4.) Before and after applying gloves 5.) When hands are visibly soiled 9.) Wearing gloves does not replace the need to perform hand hygiene Review of the Clinical Record for Resident #60 revealed the resident was admitted to the facility on [DATE] with diagnoses, which included Pressure Ulcer Stage 3, with an onset date of 09/13/2022. An observation was conducted on 11/17/2022 at 1:30 p.m. of S2WC providing wound care for Resident #60. S2WC cleaned an abrasion noted on Resident #60's right under arm with wound cleanser on a gauze. S2WC removed her soiled gloves and applied a pair of clean gloves without performing hand hygiene. S2WC grabbed a clean dressing and scissors, and then applied the dressing to the abrasion. She removed her soiled gloves and applied a pair of clean gloves without performing hand hygiene, S2WC applied medication to an open wound noted on resident #60's sacrum with her gloved finger. Her gloves were visibly soiled at that time. S2WC removed her soiled gloves, touched her scrubs, Resident #60's bedside table, and placed trash in the biohazard bag located in her hand. S2WC placed the biohazard bag on Resident #60's bedside table and sanitized her hands. An interview was conducted with S2WC on 11/17/2022 at 1:40 p.m. S2WC confirmed she did not perform hand hygiene after removing soiled gloves and before applying clean gloves and should have. An interview was conducted with S3ADON on 11/18/2022 at 10:40 a.m. She confirmed S2WC should have performed hand hygiene between glove changes.

Based on observation and interview, the facility failed to store food in accordance with professional standards for food safety by failing to ensure: 1. Canned goods did not have a compromised seal; and 2. Food products had not exceeded their expiration date. This deficient practice had the potential to affect any of the 135 residents who consumed meals prepared in the facility's kitchen. Findings: An observation was conducted on 11/15/2022 at 8:45 a.m. during the initial kitchen tour with S1DM revealed the following: 1 black Pepper seasoning container with an expiration date of June 2022 3 loaves of bread with green fuzzy substance 1 can of pinto beans with dents 1 can of vanilla pudding with dents 2 cans of mandarin oranges with dents An interview was conducted on 11/15/2022 at 9:00 a.m. with S1DM. She verified the above observation. She verified expired products as well as dented cans as being a possibility of food contamination. She confirmed these products were available for use and should not have been.