**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, observation, and interview, the facility failed to ensure proper infection control practices related to hand hygiene were followed by 1 staff member during meal service and failed to offer hand hygiene assistance to 1 resident (Resident #48) of 10 residents observed during meal tray distribution on 1 of 3 hallways. The findings include: Review of the facility's policy titled, Infection Control, revised 1/31/2025, revealed .facility infection control policies and practices are intended to facilitate maintaining a safe, sanitary, and comfortable environment and to help prevent and manage transmission of diseases and infections . Review of the medical record revealed Resident #48 was admitted to the facility on [DATE] with diagnoses including Parkinson's Disease, Dementia, Muscle Weakness, and Need for Assistance with Personal Care. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #48 scored a 12 on the Brief Interview for Mental Status (BIMS) assessment which indicated the resident was moderately cognitively impaired. Further review revealed the resident required setup or clean up assistance with eating and personal hygiene. Review of the comprehensive care plan for Resident #48 revised 4/24/2025, revealed .self care deficit .need for staff assistance for adequate completion of ADL [activities of daily living] care .care guide .assist resident with [meal] tray set up . During an observation on 5/5/2025 at 12:44 PM, Certified Nursing Assistant (CNA) C pushed the meal service cart down the 100 hallway, opened the plastic, clear covering to the meal cart, and removed Resident #48's tray. CNA C took the meal tray into Resident #48's room, opened the resident's silverware, picked up Resident #48's glass of tea to move closer to the resident, opened a straw to place inside the glass of tea, and opened the plate warming dome from the plate of food. Resident #48 picked up her fork and began eating her meal. Continued observation revealed CNA C failed to sanitize his hands before directly touching the resident's meal tray to include the eating and drinking utensils. CNA C failed to offer Resident #48 hand hygiene assistance prior to the resident eating the lunch meal. During an interview on 5/5/2025 at 12:46 PM, Resident #48 stated the staff did not offer hand hygiene assistance prior to the lunch service on 5/5/2025 and stated the staff had not offered her hand hygiene assistance .all day . During an interview on 5/5/2025 at 12:47 PM, CNA C confirmed he failed to complete hand hygiene prior to serving and touching Resident #48's meal tray and confirmed he had not offered hand hygiene assistance to Resident #48 prior to the lunch meal service. During an interview on 5/7/2025 at 9:32 AM, the Director of Nursing (DON) stated the staff were to complete hand hygiene before assisting a resident with the meal tray setup and to offer hand hygiene assistance to all residents before serving the meal. The DON confirmed infection prevention and control practices were not maintained during the lunch meal service on 5/5/2025 when CNA C failed to sanitize his hands prior to touching Resident #48's tray for the resident's consumption and failed to offer Resident #48 hand hygiene assistance prior to the lunch meal service.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, observation and interview the facility failed to prevent abuse for 1 resident #22 of 8 residents reviewed for abuse of 29 sampled residents The findings include: Review of the facility policy, Abuse, Neglect and Misappropriation of Property revised 5/8/19 revealed It is the organization's intention to prevent the occurrence of abuse .Abuse .includes physical abuse .willful .means non-accidental .Willful as used in the definition of abuse' means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm . Medical record review revealed Resident #22 was admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses including Chronic Obstructive Pulmonary Disease, Peripheral Vascular Disease, Neuromuscular Dysfunction of the Bladder, Generalized Anxiety Disorder, Mood Disorder and Dementia. Medical record review of Resident #22's Quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #22 had a Brief Interview for Mental Status (BIMS) score of 5 indicated the resident had severe cognitive impairment and required extensive assistance for bed mobility, toileting, transfer, dressing and toileting. Medical record review revealed Resident #173 was admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses including Chronic Obstructive Pulmonary Disease, Cognitive Communication Deficit, Alcohol Abuse with Alcohol Induced Mood Disorder, and Wernick's Encephalopathy. Medical record review of Resident #173's Significant Change MDS dated [DATE] revealed the resident had a BIMS score of 7, indicated the resident had severe cognitive impairment, coded with hallucinations and delusions, required extensive assistance for dressing, limited assistance for toileting and hygiene and supervision for locomotion, bed mobility, transfer and locomotion. Medical record review of Resident #173's care plan dated 2/12/19 revealed .Resident is a threat to self and/others .history of physical and verbal abuse . rejection of care, urinates in inappropriate places R/T [related to] Dementia, Depression, history of Alcohol Abuse .Goal .Resident will not harm self or others . Medical record review of Resident #173's nurse's note dated 7/4/19, revealed at 9:50 PM, Certified Nursing Assistant (CNA) was summoned to the room by resident (#173), who told him that he had beat up his roommate (#22). Roommate (Resident #22) said resident had hit him twice in the face and roommate's urinary catheter was pulled out. No injuries were noted to resident. Residents were separated and monitored. Contacted Director of Nursing (DON), MD (Medical Doctor), new orders to send out for behavioral modification and psych evaluation. Contacted both families. Resident had on roommates's shoes and refused to remove them, saying they were his. Resident left facility via EMS (Emergency Medical Services) at 11:18 PM. Medical record review of Resident #173's Psychiatric note dated 7/15/19, revealed the resident had continued inappropriate and bizarre behavior and had to move his roommate (Resident #22) out because of the resident's behavioral disturbances. Interview with CNA #1 on 10/1/19 at 2:20 PM, in the conference room, confirmed she was working as a CNA on the 200 hall on 7/3/19. Continued interview confirmed another CNA called for her and she went into the room while the other CNA separated Resident 173 and Resident #22. Further interview confirmed staff took Resident #173 out of the room and staff cleaned up Resident #22 because his catheter had been pulled out and and there was blood on Resident #22. Further interview confirmed Resident #22 told the CNA that Resident #173 had hit him in the face. Continued interview confirmed she was not aware of any other incidents of aggression. Further interview confirmed it was at the end of her shift and she left shortly after the incident. Interview with CNA #2 on 10/1/19 at 3:10 PM by phone, revealed he worked from 6 PM-10 PM on the day of the incident (7/3/19). Further interview confirmed he was passing ice and went in to resident's room and the lights were off, he turned the lights on and saw Resident #173 standing by Resident #22 in his bed. Further interview confirmed blood was on Resident #22's sheet and the urinary catheter had been removed from Resident #22. Continued interview confirmed Resident #173 stated that he had beat the hell out of him (resident #22). Further interview confirmed Resident #22 stated to the CNA that Resident #173 had hit him. Continued interview confirmed Resident #22 was checked for any injuries and no marks or injuries were found. Further interview confirmed the residents were separated he was unsure what room the residents were sent to. Further interview confirmed he was not aware of either residents having aggressive behavior prior to this event. Review of a statement by the DON dated 10/2/19 revealed .This nurse spoke with resident [#173] the next day on 7/4/19 about incident the night before. He had told me that his roommate left because he beat him up & there was blood all over the place but didn't remember much about the night except he went to jail & they released him . I had also spoke to the other resident [Resident #22]who stated to just forget it ever happened .I spoke with [Resident #173]'s daughter on 7/5/19 from home in regards to his behaviors & explained he may be more appropriate in a behavior unit if his behaviors continued with refusing care, etc .