Every finding on record at Uptown Care Center

Based on observations, record review and interviews, the facility failed to provide resident care in a dignified and respectful manner for one (#1) of four residents reviewed for dignity out of 10 sample residents.Specifically, the facility failed to ensure that Resident #1 was allowed to sit on the floor per his request.Findings include:Record review and interviews confirmed the facility corrected the deficient practice prior to the onsite investigation on 4/27/26, 4/28/26, and 4/29/26, resulting in the deficiency being cited as past noncompliance with a correction date of 3/13/26.I. Situation of lack of dignityOn 3/12/26 at approximately 11:40 p.m. Resident #1, who lived on the second floor of the facility, was in his wheelchair on the first floor of the building. Staff observed Resident #1 slide out of his wheelchair to sit on the ground, according to his own wishes. When staff asked to assist Resident #1 to get back into his wheelchair, Resident #1 refused. At 11:45 p.m. licensed practical nurse (LPN) #1 told certified nurse aide (CNA) #3 to contact CNA #2 to come help put Resident #1 back into his wheelchair. LPN #1 told CNA #2 and CNA #3 to place a blanket underneath Resident #1 so that he could be dragged while he laid on the blanket because he would not get in his wheelchair. Resident #1 said I tried to fight them like crazy. CNA #3 approached the resident's back and put their arms under his armpits. CNA #2 held the resident's pants at his ankles, while LPN #1 pulled on the blanket with Resident #1 on it. The three staff members then dragged the blanket onto the elevator with the resident on the blanket. When the elevator reached the second floor, the staff members pulled Resident #1 off the elevator and onto the second floor, where he lived. When Resident #1 was on the blanket on the second floor, he agreed to have two staff members help him sit in his wheelchair. -LPN #1, CNA #2 and CNA #3 failed to treat Resident #1 with dignity and respect by not allowing to remain seated on the floor, per his resident right, and dragging him across the floor on a blanket to the second floor.On 3/13/26 Resident #1 told the nursing home administrator (NHA) about the incident that occurred on 3/12/26. Resident #1 told the NHA that he had wanted to sit on the floor. The NHA reviewed the facility's video surveillance footage, which revealed Resident #1 had been dragged across the floor to the elevator and onto the second floor by LPN #1, CNA #2 and CNA #3.II. Facility plan of correctionOn 3/13/26 the NHA and the facility's management team met to develop a plan of action in response to Resident #1's lack of dignity situation, in order to ensure safety and dignity for all of the residents in the facility.A. Immediate actionOn 3/13/26 all three staff members (LPN #1, CNA #2 and CNA #3) were suspended immediately pending an investigation. Resident #1 had a fall protocol initiated, a skin assessment was given and a trauma interview was provided. B. Identification of other residentsOn 3/13/26 all residents in the facility were interviewed to assess any concerns related to resident rights, safety, dignity and safe practices. All staff members who worked the night of 3/12/26 (staff not involved in the incident) were interviewed as part of the investigation.C. Systemic changeOn 3/13/26 all staff were educated on the following, with all staff notified that education must be completed before working in the facility: -Fall policy/management training;-Competency of using lifts and the sit to standing position lifts;-Abuse and Mandatory reporting in the facility training;-Resident Rights training;-CNA - Safely Moving Residents - lifting and transferring; and, -Reporting incidents on time, (including) fall and abuse, chain of command, compliance line. D. Monitoring The NHA would be responsible for monitoring.The CCO (chief clinical officer)/designee in conjunction with the interdisciplinary team (IDT) would review progress notes and behavior monitoring daily Monday through Friday.The DON (director of nursing)/designee would conduct random observations of staff assisting residents with transfers to ensure that transfer instructions in resident care plans were being followed during care delivery.All incident reports and fall documentation would be reviewed by the DON/designee to ensure timely reporting per facility policy.The SSD (social service director)/designee would conduct random rounds with residents to ensure residents felt safe and received their care in a dignified manner.Monitoring would continue for a minimum of 90 days or until substantial compliance was achieved.A monthly review in the QAPI (quality assurance and performance improvement) committee would continue until substantial compliance was achieved, or 90 days.The above corrective actions and monitoring began on 3/13/26.III. Facility policy and procedureThe Dignity policy, revised February 2021, was provided by the clinical resource (CR) #2 on 4/29/26 at 12:30 p.m., via email. It revealed in pertinent part, Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem. Residents are treated with dignity and respect at all times. The facility culture supports dignity and respect for residents by honoring resident goals, choices, preferences, values and beliefs. This begins with the initial admission and continues throughout the resident's facility stay. Individual needs and preferences of the resident are identified through the assessment process. Residents may exercise their rights without interference, coercion, discrimination or reprisal from any person or entity associated with this facility. Demeaning practices and standards of care that compromise dignity are prohibited. Staff are expected to promote dignity and assist residents. Staff are expected to treat cognitively impaired residents with dignity and sensitivity; for example, addressing the underlying motives or root causes for behavior; and not challenging or contradicting the resident's beliefs or statements.IV. Resident #1A. Resident statusResident #1, age [AGE], was admitted on [DATE]. According to the April 2026 computerized physician orders (CPO), diagnoses included Parkinson's disease, depression, unspecified intellectual disabilities, traumatic brain injury (TBI), seizures and chronic kidney disease stage 3.The 1/21/26 minimum data set (MDS) assessment revealed the resident had severe cognitive impairments with a brief interview for mental status (BIMS) score of three out of 15. The resident had continuous disorganized thinking and inattention. The resident was able to self-ambulate in a wheelchair. B.Resident interviewResident #1 was interviewed on 4/29/26. Resident #1 said he remembered the day the staff pulled him on a blanket. Resident #1 said he tried to fight them like crazy. He said the staff members got a sheet or blanket to put him on and dragged him. He said he did not like it.C. Record reviewThe fall care plan, initiated 1/17/26, documented Resident #1 was a high fall risk. Resident #1's fall interventions were to educate Resident #1 as needed on transfer safety, transfer recommendations and to ask for staff assistance as needed.The 2/20/25 fall care plan goal revealed Resident #1 was to be treated with dignity and autonomy, and that was to be maintained at the highest level.The 3/13/26 trauma assessment (conducted the day after the incident) revealed Resident #1 had not had a traumatic event as a result of the incident on 3/12/26. The nursing progress note, dated 3/13/26 at 7:01 a.m. (the day after the incident) and written by LPN #1, documented Resident #1 remained on the first floor until 11:00 p.m. (3/12/26) and the resident refused to talk with staff, refused care from staff, declined snacks, fluids and redirection. Resident #1 was provided education with difficulty.-However, the note failed to document how Resident #1 was relocated to the second floor by LPN #1, CNA #2 and CNA #3 (see situation above). V. Staff interviewsThe NHA and clinical resource #2 were interviewed together on 4/28/26 at 11:30 a.m. The NHA and clinical resource #2 said due to the situation with Resident #1 having been pulled on a blanket instead of Resident #1 being provided with his right to sit on the floor, an investigation immediately began (on 3/13/26). The NHA said the day after the incident (on 3/13/26), Resident #1 came to her and told her how he was dragged across the floor on a blanket because he would not get back in his wheelchair. The NHA said shortly after Resident #1 told her what happened, CNA #2 came to her to tell her what had happened. The NHA said CNA #2 told her the same story and details that Resident #1 told her. The NHA said CNA #2 told the NHA that she knew better, and she had been trained to let a resident sit on the floor if that was what the resident wanted to do. The NHA said the IDT was immediately notified to begin an investigation into the incident. The NHA said all three staff members involved (LPN #1, CNA #2 and CNA #3) in the incident were suspended pending the investigation. Clinical resource #2 said staff education began immediately on 3/13/26, with no staff members being allowed to work a shift until they had completed the education. CNA #2 was interviewed on 4/29/26 at 12:00 p.m. CNA #2 said she worked the night shift 3/12/26 on the second floor. She said at approximately 11:45 p.m. LPN #1 asked CNA #3 to come and get her (CNA #2) to come help to get Resident #1 up into his wheelchair. CNA #2 said she and CNA #3 went to the first floor and expected to help with a two-person transfer to lift Resident #1 up and place him back into his wheelchair. CNA #2 said they thought the staff wanted CNA #2 because Resident #1 liked her. CNA #2 said Resident #1 was seated on the floor. CNA #2 said LPN #1 told CNA #2 that Resident #1 slid out of his chair, sat on the floor but did not fall. CNA #2 said the other two staff members (CNA #3 and LPN #1) retrieved a blanket to put under Resident #1 as he sat on the floor, and they moved him from side to side to get the blanket under him. CNA #2 said LPN #1 instructed CNA #3 to move to Resident #1's back side and put her arms through his arm pits as he sat on the blanket. CNA #2 said she was told by LPN #1 to grab the resident's pants at his ankles. CNA #2 said Resident #1 scratched both LPN #1 and CNA #3's arms, but CNA #2 pulled away and did not get scratched. CNA #2 said Resident #1 was somewhat reclined as he was pulled across the floor and onto the elevator. CNA #2 said she knew what had happened was not how they were trained to care for the residents.CNA #2 said LPN #1 yelled at her and CNA #3 to pull the blanket towards the elevator, and instructed them to pull him into the elevator along with the help of LPN #1. CNA #2 said when the elevator stopped at the second floor, LPN #1 instructed the CNAs to pull the resident off the elevator. CNA #2 said at that time, Resident #1 was asked if it was okay to put him in his wheelchair, to which he responded yes. CNA #2 said they went back downstairs to get his wheelchair, and then CNA #2 and CNA #3 performed a two-person transfer under his arms to lift Resident #1 off of the floor and back into this wheelchair. CNA #2 said she did what LPN #1 told her because in the moment, LPN #1 yelled at the CNAs. CNA #2 said she did not report the incident to the supervisor on duty that night, who was on another floor, because CNA #2 was afraid of retaliation from LPN #1. CNA #2 said Resident #1 seemed calm after he was back in his wheelchair. CNA #2 said she knew it was wrong and she felt bad because the residents had rights. CNA #2 said Resident #1 should have been allowed to sit on the floor and the staff should have checked on him. She said she felt badly for not respecting his rights. She said she went to the NHA the next day (on 3/13/26) and told the NHA what had happened. The NHA was interviewed again on 4/29/26 at 1:00 p.m. The NHA said most of the incident with Resident #1 was verified by the facility's video footage that she reviewed. The NHA said CNA #2 was re-educated and was kept on staff, but the other two staff members (LPN #1 and CNA #3) involved in the incident were terminated. The NHA said no other incidents of that type had happened since the incident with Resident #1.

Based on record review and interviews, the facility failed to ensure residents were free from significant medication errors for two (#59 and #69) of six residents reviewed for medication errors out of 38 sample residents. Specifically, the facility failed to:-Ensure Resident #59 was administered her blood pressure medication per the physician orders; and, -Ensure Resident #69 was administered her rescue seizure medication per the physician order. Findings include: I. Facility policy and procedure The Medication administration policy, dated 8/4/25, was provided by the nursing home administrator (NHA) on 8/7/25 at 11:55 a.m. It read in pertinent part, Resident medications are administered in an accurate, safe, timely, and sanitary manner. Medications are administered in accordance with written orders of the attending physician or physician extender. If a dose is inconsistent with the resident's age and condition or a medication order is inconsistent with the resident's current diagnosis or condition, contact the physician for clarification prior to the administration of the medication. Document the interaction with the physician in the nursing progress notes and elsewhere in the medical record, as appropriate. Procedure: verify the medication label against the medication administration record (MAR) for accuracy of drug frequency, duration, strength, and route. Be sure to check the bottle's label against the physician's order. Double-check the amount of medication to be administered. Medication is to be given in compliance with physician orders and or manufacturer's recommendations. II. Resident #59 A. Resident status Resident #59, age less than 65, was admitted on [DATE]. According to the August 2025 computerized physician orders (CPO), diagnoses included schizoaffective disorder (psychosis and mood disorder), Type 2 diabetes mellitus (insulin disorder), mild chronic kidney disease, stage two and hypertension (elevated blood pressure). The 7/9/25 minimum data set assessment (MDS) revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. She was independent with hygiene, bed mobility, transfers, and ambulation. She required set up assistance with eating. B. Observations and interviews During a continuous observation on 8/6/25 beginning at 8:31 a.m. and ending at 9:40 a.m. the following was observed: On 8/6/25 at 8:31 a.m., licensed practical nurse (LPN) #1 was checking the second floor medication cart for Resident #59's Metoprolol succinate (blood pressure medication) extended release (25 milligram (mg) tablets. LPN #1 was unable to find the medication in the medication cart or the overstock medications located in the second floor medication storage room. LPN #1 said she would need to get the medication from the facility's Nexsys (automated medication dispensing) machine. At 9:14 a.m., LPN #1 was in the third floor medication storage room retrieving Resident #59's Metoprolol from the Nexsys machine. LPN #1 typed the first three letters of Resident #59's last name, scrolled to the resident's name and verified her date of birth before selecting her profile. LPN #1 searched for the medication by typing in the first three letters of the Metoprolol. LPN #1 scrolled to Metoprolol and selected Metoprolol tartrate (immediate release) 25 mg tablets. LPN #1 selected Metoprolol tartrate 25 mg tablets and dispensed two individually packaged tablets. LPN #1 selected the Metoprolol tartrate (immediate release), instead of the resident's ordered Metoprolol succinate ER 25 mg tablet (see order below). LPN #1 said she pulled an extra tablet from the machine so the nurse on the next shift would have the medication to administer. At 9:24 a.m. LPN #1 was at the second floor medication cart. LPN #1 dispensed one of the Metoprolol tartrate 25 mg tablets and the tablet fell onto the floor. LPN #1 discarded the pill in a medication destruction container located inside the medication cart. LPN #1 dispensed the second tablet of Metoprolol tartrate 25 mg and poured it into a medication cup. -LPN #1 did not verify the physician's order and medication prior to administering the medication to Resident #59. At 9:31 a.m. LPN #1 placed the medication cup, containing one Metoprolol tartrate 25 mg tablet on the table in front of Resident #59. Resident #59 took the medication presented to her. After returning to the medication cart, LPN #1 confirmed the resident's order was for Metoprolol succinate ER 25 mg, not Metoprolol tartrate 25 mg. LPN #1 stated a medication error had occurred. LPN #1 said she was unsure what the process was for medication errors. LPN #1 sent a text message to the unit manager (UM) and reported the error. C. Record review A review of Resident #59's August 2025 CPO revealed the following physician's order: Metoprolol succinate ER oral 25 mg tablet. Take one tablet by mouth in the morning for hypertension. Hold for systolic blood pressure less than 100 millimeters of mercury (mmHg) and a heart rate less than 60 beats per minute (bpm), ordered 1/13/25. The cardiovascular status care plan, initiated 12/29/21, documented Resident #59 had altered cardiovascular status due to diagnoses of hypertension and hyperlipidemia (elevated cholesterol). Interventions included assessing the resident for chest pain, monitoring the resident's vital signs daily, monitoring/documenting/reporting any signs and symptoms of coronary artery disease (narrowing of the vessels supplying blood to the heart). A nurse note, dated 8/6/25 at 10:30 a.m., documented Resident #59's nurse practitioner (NP) was notified of the incident and frequent neurologic assessments were initiated per policy. It documented an order was obtained to complete frequent checks with neurologic assessment. A medication regimen review note, dated 8/6/25, documented the pharmacist recommendation was to administer one dose of Metoprolol tartrate 25 mg the evening on 8/6/25. It documented to resume Metoprolol succinate ER 25 mg once daily on 8/7/25. D. Additional staff interviews The UM was interviewed on 8/6/25 at 9:56 a.m. The UM said the medication error process included notifying the resident's provider, having a registered nurse (RN) perform an assessment and initiating 15-minute checks with neurologic assessments. The UM said the treatment plan would be adjusted depending on the provider's recommendations. The director of nursing (DON) was interviewed on 8/6/25 at 10:20 a.m. The DON said the nurses were responsible for verifying the rights of medication administration for all residents. The DON said the potential consequences of not verifying the correct medication was being administered included experiencing side effects, serious harm, change in condition or death. III. Resident #69 A. Resident status Resident #69, age less than 65, was admitted on [DATE]. According to the August 2025 CPO, diagnoses included dementia, major depressive disorder, epilepsy (seizure disorder), history of traumatic brain injury (TBI), unsteadiness on her feet, abnormal posture and a history of falling. The 4/21/25 MDS assessment revealed the resident was cognitively intact with a BIMS score of 13 out of 15. She needed set up assistance for meals and was dependent on assistance with all other activities of daily living (ADL). The assessment documented the resident had a seizure disorder or epilepsy. B. Record review Resident #69's seizure care plan, revised 8/25/23, documented she had a seizure disorder and Resident #69 saw an outside neurology provider. Resident #69, although she had increased medication doses, continued to have seizures and falls. Pertinent interventions included to ask the resident about the presence or absence of auras prior to a seizure (revised 3/26/18); and give seizure medication as ordered by a doctor and monitor and document the side effects (revised 5/16/23). A review of Resident #69's August 2025 CPO revealed the resident had a physician's order for the following medication: Midazolam HCl (hydrochloride -sedative) Injection Solution 5 mg/5 milliliter (ml). Inject 5 ml intramuscularly (directly into the muscle) every 30 minutes as needed for an acute seizure. Give 5 ml intramuscularly every 30 min for up to three doses for an acute seizure as needed, ordered 1/3/25. Review of resident #69's electronic medication administration record (MAR) revealed the following: A 6/26/25 administration note documented at 4:30 a.m. a Midazolam HCl Injection Solution 5 mg/5 ml was administered; the resident had a seizure. A 6/26/25 administration note documented at 7:59 a.m. the administration of Midazolam HCl Injection Solution 5 mg/5 ml was effective. A 6/26/25 nursing note documented at 8:20 revealed that at approximately 4:15 a.m. Resident #69 had a seizure for approximately two minutes. A midazolam hcl injection solution 5 mg/5 ml was administered. The nurse who administered the medication documented an actual administration of 2 ml midazolam hcl and reported the administration to the provider who gave follow up orders to monitor and check the resident's oxygen. The resident denied pain or discomfort and vital signs were at baseline. The resident said she was fine and felt no pain. A RN was notified and the RN assessed the resident. Vital signs and neurological checks were implemented for every 15 minutes with seizure protocol. The supervisor and assistant director of nursing (ADON) were notified. A 6/27/25 nursing note documented at 8:00 a.m. revealed that the incident initially documented as an overdose medication error had been reassessed and identified as an underdose medication error. The nurse reported administering 2 ml of medication; however, upon review, the full vial contained only 1 ml in total. Inspection of the used vial revealed 0.6 ml of medication remained, indicating that approximately 0.4 ml was actually drawn and administered. The remainder of the 2 ml syringe was filled with air, leading to the mistaken belief that 2 ml had been given. The resident was assessed and was stable with no adverse effects noted. No further treatment or monitoring was required at that time in regards to the medication error per the provider's assessment. The resident continued on monitoring related to post seizure policy. The 6/27/25 interdisciplinary Team (IDT) note documented at 8:37 a.m. revealed that on 6/26/25 a medication error occurred in which the nurse did not give a large enough dose. The root cause was the nurse did not check the label and pull the medication correctly. The intervention put into place was education was provided to the nurse. C. Staff interviews The DON, the assistant director of nursing (ADON) and quality mentor were interviewed together on 8/6/25 at 2:00 p.m. The DON said Resident #69's post seizure mediation was supposed to decrease seizure activity. The DON said the resident could be administered one dose initially after a seizure. The DON said if the first dose was effective an additional dose of the medication did not have to be administered. The DON said after administration, the nurse would monitor to see if the seizure symptoms were reducing and talk to the resident to see if the medication was effective. The DON said if the resident's vital signs or symptoms were getting worse after the first dose of the post seizure medication the facility would call and notify the provider. The quality mentor said if the first dose of the post seizure medication was not effective to decrease seizure activity the facility would call emergency services. The ADON said after the nurse administered the medication she called the RN, the RN looked at the vial and asked her how many vials she used. The nurse responded that she used 2 ml and the RN realized it was a 1 ml vial, the RN saw there was some medication left in the vial. The ADON said that was when she realized it was an underdose and they could not administer any additional medication to the resident because the seizure had already stopped. The ADON said the facility then reported back to the provider it was an underdose. The ADON said the nurse who administered the medication reported they did an overdose of the medication initially and reported that to the provider. The incident was then reported to the ADON immediately. The ADON said the nurse did not compare the order to the supply that she used and that the supply was stronger than what the doctor had ordered. The ADON said there was no error by the pharmacy, the nurse needed to do the calculation. The ADON said the resident's seizure was completely stopped by the time the RN arrived. The ADON said the facility completed post seizure monitoring for 72 hours and because they reported an overdose the physician gave monitoring instructions. The ADPN said the RN did provide education to the LPN immediately and then after that the ADON provided education multiple times. Nurse practitioner (NP) #1 was interviewed on 8/7/25 at 8:44 a.m. NP #1 said the potential consequences of underdosing a rescue seizure medication included the potential to prolong the seizure since the resident would have to wait 30 minutes until she could receive her next dose. The pharmacist was interviewed on 8/7/25 at 4:28 p.m. The pharmacist said the potential consequences of underdosing a rescue seizure medication included potentially delaying the seizure in progress. D. Facility follow up Education provided to the nurse who administered the incurred dose of medication was provided by the NHA on 8/6/25 at approximately 11:00 a.m. It read in pertinent part, On June 26th, 2025 you made a medication error in which you administered an underdose of medication to a resident due to failure to perform proper dosage calculations. It was noted that the strength/concentration of the medication on hand was not verified against the provider's order prior to administration. This deviation from protocol resulted in the resident receiving a lower dose than prescribed. Moving forward, you will make sure to strictly follow the following steps before administering any medications to ensure patient safety and compliance with nursing standard: Review the providers order carefully, including the prescribed dosage and route; check the strength/concentration of the medication on hand and perform accurate calculations to determine the correct volume or amount to administer; double-check the calculations, especially for high-risk medications or when the dosage requires conversion such as mg to ml. The education was signed by the employee on 6/28/25.

Based on record review and interviews, the facility failed to ensure one (#6) of six residents reviewed for abuse out of 38 sample residents were free from abuse.Specifically, the facility failed to protect Resident #6 from abuse by Resident #60. Findings include:I. Facility policy and procedureThe Abuse Policy and procedure, dated 5/3/23, was provided by the nursing home administrator (NHA) on 8/4/25 at 9:00 a.m. It read in pertinent part, This facility does not condone resident abuse and shall take every precaution possible to prevent resident abuse by anyone, including staff members, other residents, volunteers, and staff of other agencies serving the resident, family members, legal guardians, resident representative, sponsors, friends or any other individuals. Residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse, and physical or chemical restraints not required to treat the resident's symptoms. Resident abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation or punishment of a resident resulting in physical harm or pain, mental anguish, deprivation of goods or services that are necessary to attain or maintain physical, mental or psychosocial well-being. Physical abuse is defined as abuse that results in bodily harm with intent. It includes hitting, slapping, pinching, kicking and controlling behavior through corporal punishment and willful neglect of the resident's basic needs. If abuse happens, separate the assailant from the victim, isolate the assailant to protect others, assess and treat the victim and notify the abuse coordinator.II. Physical abuse of Resident #6 by Resident #60 on 7/20/25A. Facility investigationThe facility investigation was provided by the NHA on 8/6/25 at 1:00 p.m.The investigation documented Resident #6's and Resident #60's roommate was interviewed on 7/22/25. He stated he was in the room on 7/20/25 when the incident occurred and heard what he thought was joking around, and when he looked over, he saw Resident #60 hit Resident #6 in the face. He went to alert the staff.The investigation included a written statement from licensed practical nurse (LPN) #1. LPN #1's statement documented that Resident #6 said that guy hit me and he had a small laceration on the bridge of his nose. Resident #60 was mumbling under his breath, I am going to kick his (explicit word). Resident #60 was separated from Resident #6. LPN #1 cleaned Resident #6's nose wound, notified the director of nursing (DON), the physician and the residents' responsible parties.The investigation documented certified nurse aide (CNA) #3 stated she was at the nursing station when a resident asked her to go to their room. When CNA #3 entered the room she said Resident #60 was seated on Resident #6's bed and the two residents seemed to be arguing. CNA #3 immediately separated the residents and asked the nurse for assistance. CNA #3 did not see a physical altercation between the residents but she did see marks on Resident #6's face.The facility substantiated Resident #60 hit Resident #6 in the face.B. Resident #60 (assailant)1. Resident statusResident #60, age greater than 65, was admitted on [DATE]. According to the August 2025 computerized physician orders (CPO), diagnoses included chronic obstructive pulmonary disease (COPD- a lung condition making it difficult to breathe), dementia and respiratory failure. The 5/15/25 minimum data set (MDS) assessment revealed the resident was moderately cognitively impaired with a brief interview for mental status (BIMS) score of 12 out of 15. He needed set-up assistance with meals and bathing and was independent with all other activities of daily living (ADL).The assessment did not document the resident had physical or verbal behaviors toward others.2. Record reviewResident #60's behavior care plan, revised 7/28/25, documented he had a behavior problem (agitation, confusion) related to a head injury. Resident #60 had the potential for confusion secondary to a dementia diagnosis. He had a history of making statements related to his past and believed those things to be current. At times, the resident would clean areas repetitively despite redirection or education on infection control practices. Resident #60 had a history of physical altercations with others.Pertinent interventions included intervene as necessary to protect the rights and safety of others, approach and speak in a calm manner, divert attention, remove from the situation and take to an alternate location as needed (initiated 3/1/23) and complete a clinical and psychiatric workup as indicated; orders and recommendations to be followed as indicated (revised 8/6/25).A review of Resident #60's electronic medical record (EMR) documented the following:The 7/20/25 progress note, documented at 5:40 a.m., revealed the resident continued on observation for a new prescription Zoloft (antidepressant) and continued on every 15-minute safety checks. The resident had recently increased verbal aggression noted towards staff during care.The 7/20/25 progress note, documented at 3:05 p.m., revealed the resident had new skin concerns with a scattered bruise on the back of his right hand.The 7/20/25 progress note, documented at 3:21 p.m., revealed Resident #60 was moved to a different room.The 7/20/25 progress note, documented at 5:27 p.m., (after the altercation) revealed Resident #60 had earlier become agitated about being moved to a new room and threatened his new roommate. The DON requested that Resident #60 be sent to the emergency room. The 7/20/25 progress note, documented at 5:43 p.m., revealed Resident #60 hit his roommate (Resident #6) on his left eye and nose. Resident #6 had a blackened eye and gash on the nasal bridge. Resident #60 was moved to the fourth floor and the decision was made to send him to the hospital for an evaluation (see previous note).The 7/21/25 interdisciplinary team (IDT) note documented the IDT team discussed on 7/20/25 the alleged incident with Resident #6. Resident #60 was found on his roommate's (Resident #6) side of the room, suggesting increased confusion. The IDT again discussed Resident #60 prior to his return from the hospital after receiving a report for his return. Resident #60 was to be placed on increased monitoring as indicated upon return from the hospital related to roommate dynamics and a recent change of condition. The IDT discussed the option of one-to-one monitoring; however, it was determined that this approach may increase agitation. The note documented it was decided not to implement one-to-one monitoring at this time and instead to monitor for any concerns related to roommate dynamics.C. Resident #6 (victim)1. Resident statusResident #6, age less than 65, was admitted on [DATE]. According to the August 2025 CPO, diagnoses included anoxic (lack of oxygen) brain damage, moderate protein calorie malnutrition, COPD, dementia, depressive disorders, schizoaffective disorder (mental illness) and cognitive communication deficit. The 7/10/25 MDS assessment revealed the resident was moderately cognitively impaired with a BIMS score of nine out of 15. He was dependent on assistance with (ADL)The assessment documented the resident had verbal behaviors toward others that occurred daily.2. Record reviewResident #6's behavior care plan, revised 8/25/23, documented he had potential behavior challenges due to a traumatic brain injury and schizoaffective disorder. He had a history of bar fighting prior to admission and a history of verbal and physical altercations with others. He liked to ambulate up and down the hallways and at times would go into other residents' rooms. The care plan documented redirection could be helpful at times.Pertinent interventions included to intervene as necessary when behaviors occurred to protect the rights and safety of others, approach and speak in a calm manner, divert attention. remove from the situation and take to an alternate location as needed (revised 5/16/23); provide education to the resident as needed on keeping his hands to himself and personal boundaries (initiated 5/23/23); a clinical workup to be completed and orders and recommendations to be followed as indicated (7/28/25) and to encourage the resident to participate in visits with mental health providers as indicated (revised 8/6/25).A review of Resident #6's EMR documented the following:The 7/20/25 weekly skin note, documented at 3:06 p.m., revealed Resident #6 had new skin concerns with a bruised left eye approximately 4 centimeter (cm) by 3 cm and ecchymosis (flat, purple bruise) over the nasal bridge approximately 2.5 cm by 2 cm with a 0.4 cm superficial abrasion at the center. Dried blood was noted on and around the nostrils and no active bleeding was observed. Mild swelling was present around the eye and nasal bridge.The 7/20/25 progress note, documented at 4:42 p.m., revealed Resident #6 was laying in bed and said that guy hit me. He had black/purple discoloration to the left periorbital (eyelids to eye brown) region, also a small gash on the upper bridge of his nose. Resident #60 admitted he hit Resident #6 in the face. Resident #60 had several small bruises on his anterior hand. Resident #6 was lying in bed hollering at no one in particular when Resident #60 became irritated and punched Resident #6 in the left eye and nose. The physician was contacted and if the resident had any increased pain, he became drowsy and hard to arouse, and if any bleeding would not stop to call for an order to send the resident for a scan of the left eye and nose. The 7/21/25 progress note, documented at 5:45 a.m,. revealed the resident continued on observation and neurological checks related to a resident-to-resident altercation. Resolving and intact bruising was noted to the left eye, periorbital area, and nasal bridge. No other injury or adverse effects were noted. The 7/23/25 progress note, documented at 10:02 a.m., revealed Resident #6 was monitored for physical aggression he received. His roommate punched him in the left eye. The left eye had periorbital bruising, purple, blue and greenish/yellow and was beginning to resolve. He had a small gash on the bridge of his nose that was dry and left open to the air. The resident's vital signs and neurological checks continued and were within normal limits. The 7/24/25 IDT note, documented at 3:49 p.m., revealed the IDT team discussed Resident #6. He appeared to be at baseline with no changes in behavior observed. A referral was sent for additional psychosocial support. The resident continued to display impulsivity and verbal agitation at times, such as yelling out. While he enjoyed activities of interest, he had difficulty sustaining attention and active participation.III. Staff interviewsLPN #2 was interviewed on 8/7/25 at 1:50 p.m. LPN #2 said she could sometimes hear Resident #6 yelling in his room but more often he yelled when he was sitting up in his chair and in the hallway. LPN #1 said sometimes Resident #6 also swore. LPN #1 said she had not seen any issues between Resident #6 and Resident #60 prior to the incident on 7/20/25.The DON and the NHA were interviewed on 8/6/25 at 2:00 p.m. The NHA said the resident who overheard the incident reported that he said Resident #60 hit Resident #6 in the face and that he was a roommate of Resident #6 and Resident #60. The NHA said initially he did not tell the staff anything but later he did say he saw Resident #60 hit Resident #6. The NHA said the staff were not aware that Resident #6 was yelling prior to the incident. The NHA said Resident #6 would yell for help instead of using his call light.The NHA said Resident #60 said that Resident #6 was yelling although the staff did not hear yelling. The NHA said that Resident #6 told the nurse that guy hit me. The NHA said that when Resident #60 came back from the hospital, she thought with his increased confusion that his memory was poor. The NHA said Resident #6's roommates were not bothered by Resident #6 yelling out. The NHA said after the incident, Resident #60 was placed on frequent checks. The NHA said that Resident #60 had a change in behavior prior to the incident where he displayed increased confusion and was cleaning things repeatedly. The NHA said staff were trying to redirect his behavior and discussed his behavior in morning meetings. The NHA said they did not see agitation from Resident #60 toward other people until the incident on 7/20/25. The DON said Resident #6 said that Resident #60 hit him. The DON said Resident #60 went to the hospital after the incident but Resident #6 did not. The DON said Resident #6 was assessed by the nurse practitioner and registered nurse at the facility. The DON said the assailant had a bruise on his right hand that was not indicated on previous skin documentation. The DON said when CNA #3 walked in after the incident, Resident #60 was sitting on Resident #6's bed and Resident #6 was laying on his bed. The DON said Resident #60 used a cane and did not need assistance to transfer.

Based on record review and interviews, the facility failed to revise and implement an effective discharge plan for one (#81) of four residents reviewed for discharge planning out of 38 sample residents. Specifically, the facility failed to: - Ensure that Resident #81's discharge care plan was updated when the resident's discharge plan changed; -Notify the facility's ombudsman in writing of Resident #81's against medical advice (AMA) discharge; and -Notify Resident #81's physician of the resident's AMA discharge.Findings include: I. Resident #81A. Resident statusResident #81, age less than 65, was admitted on [DATE] and discharged back to the community AMA on 5/18/25. According to the August 2025 computerized physician orders (CPO), diagnoses included chronic obstructive pulmonary disease (COPD), encephalopathy (brain dysfunction) and depression. According to the 4/28/25 minimum data set (MDS) assessment, the resident was cognitively intact with a brief interview mental status (BIMS) score of 15 out of 15. He was independent with eating and toileting and required set-up assistance with oral hygiene and showering. He required supervision with personal hygiene.The 4/28/25 MDS assessment revealed the overall goal for discharge was to discharge to the community. The information was provided by the resident. There was not an active discharge plan already occurring for the resident to return to the community. The resident answered yes to wanting to talk to someone about the possibility of leaving the facility and returning to live and receive services in the community. B. Record reviewThe discharge care plan, initiated 4/25/25, revealed Resident #81's discharge goal was to move to another state to live with his daughter. Interventions included establishing a pre-discharge plan with the resident and family, evaluating progress and revising plans as needed, providing the resident with written instructions as required to ensure care continuity post-discharge and making arrangements with the required community resources to support independence post-discharge. The 4/23/25 initial discharge planning review revealed the discharge plan provided by the resident and his family was for the resident to be discharged to the community, and the anticipated length of stay was unknown and preferred to be about a month. The 4/25/25 interdisciplinary team (IDT) care conference note revealed the IDT met with the resident and his son. The notes revealed the son wanted the resident to discharge in the next month to another state with the resident's son and home health services.-However, the care plan identified the resident was to move to another state with his daughter (see above).The 4/30/25 social services note revealed Resident #81 would no longer be discharged to live in another state with his daughter. The son indicated that the daughter denied any desire to be involved in the resident's care. According to the note, the son wanted the resident to remain at the facility for long-term care. -However, the resident's discharge care plan was not updated after 4/30/25 once the discharge plan changed to the resident remaining at the facility for long-term care. The 5/17/25 nurse progress note revealed Resident #81 asked the nurse why he was in the facility. The nurse provided the resident with information regarding his current health condition and his need for care at the facility. The resident expressed understanding of the provided information. The resident was observed with no behavioral issues or concerns during care, was easy to redirect and accepted the care provided. The 5/18/25 nurse progress note revealed at approximately 8:00 p.m., a certified nurse aide (CNA) reported Resident #81 was unable to be located in the building and the elopement protocol was initiated. The director of nursing (DON) and the assistant director of nursing (ADON) were notified. Staff searched the building while other staff searched the surrounding community. Left notification message for son, emergency contact to return call at 8:38 p.m. The nurse for the resident notified the provider at this time. The 5/19/25 IDT note, documented by the NHA, revealed Resident #81 was located on 5/19/25 at a local hotel that he was familiar with. The resident indicated he preferred to remain at the hotel and not return to the facility. The son was notified and voiced no concerns. The resident was educated on leaving the facility AMA and was offered assistance obtaining medications and contact information for local shelters. Resident #81 voiced understanding of the AMA information, but reiterated his preference to remain at the hotel. The resident declined assistance from the facility and the NHA documented the resident left the facility AMA on 5/18/25. The against medical advice (AMA) form, dated 5/18/25, revealed Resident #81 refused to sign the form but stated understanding of the AMA information provided.-A review of Resident #81's EMR did not reveal documentation to indicate the ombudsman was notified of the resident's AMA discharge in writing (see frequent visitor interview below). -A review of Resident #81's EMR did not reveal documentation to indicate the physician was notified of the resident's AMA discharge. C. Frequent visitor interviewA frequent visitor, with knowledge of the facility, was interviewed on 8/6/25 at 10:30 a.m. The frequent visitor said she had been a frequent visitor since April 2025. She said she was not aware that Resident #81 was discharged from the facility due to leaving AMA. The frequent visitor checked her records during the interview, and she said she did not have any documents in writing or in an electronic (e-mail) format from the facility which informed her that Resident #81 was discharged from the facility due to leaving AMA. The frequent visitor said she did not receive a monthly report of discharges from the facility. II. Staff interviewsSocial services assistant (SSA) #1 was interviewed on 8/7/25 at 11:25 a.m. SSA #1 said the social services director (SSD) position had been open for a couple of months. She said she had worked with the NHA in place of the SSD since the previous SSD left the facility. She said social services was responsible for discharge planning and worked with the resident, the guardian, and the family. She said discharge planning was discussed at admission. She said discharge planning was reviewed at admission with the resident, the guardian and the family to set up goals and expectations to see if there was a viable plan for discharge. She said the discharge plan was then care planned. SSA #1 said discharge planning was reviewed quarterly and as needed. She said if something changed with the discharge plan, the care plan was updated. She said most of the time, residents requested a care conference and discharge planning was discussed at that time. She said the conversation was documented as a progress note or as a care conference summary. She said discharge planning covered if the resident wanted to stay in the facility long term or if they wanted to return to the community. She said the majority of residents stayed in the facility long term. She said if a resident wanted to return to the community, she talked to the decision maker, reviewed the risks and barriers, talked to the physician, set up durable medical equipment (DME) and located a pharmacy. She said the IDT team was responsible for discharge planning. SSA #1 said she would involve the ombudsman if she ran into issues with the resident. She said she would recommend the resident to have a good relationship with the ombudsman. She said she involved the ombudsman if the discharge plan was an unsafe discharge plan. She said the physician was involved in the discharge planning. She said the discharge planning was documented in a progress note, an assessment and in the resident's care plan. She said the physician was notified of the discharge and she was unsure if the ombudsman was notified when a resident was discharged . SSA #1 said if a resident left the facility AMA, the NHA and the director of nursing (DON) were responsible for the notification to the ombudsman and the physician. She said the physician was notified if the resident went AMA and she was unsure if the ombudsman was notified if the resident went AMA. SSA #1 said she was familiar with Resident #81. She said the former SSD had worked with the resident and his family related to his discharge plan and she was not part of his discharge. The NHA was interviewed on 8/7/25 at 2:52 p.m. The NHA said social services was responsible for discharge planning. She said discharge planning was discussed at admission, quarterly and as needed. She said goals were discussed for discharge planning with the resident and representatives at care conferences. She said the primary goal was if the resident wanted to stay at the facility long term or if they wanted to go back to the community. She said the ombudsman could be part of discharge planning. She said the facility had not had a consistent ombudsman for the past couple of months. The NHA said the physician was part of discharge planning. She said discharge planning was documented in the care conference notes, care plan, the progress notes, the quarterly assessment and the MDS assessment. She said the day the resident was discharged , multiple IDT team members were responsible for different aspects of the discharge. She said the nurse worked to ensure the resident had their medications and social services knew who their home health agency was and transportation She said the physician was notified if it was a planned discharge and if it was AMA. She said it was documented the physician provided an order for planned discharges and if the resident left AMA, it was documented in a file that was not part of the resident's chart. She said the ombudsman was notified, depending on the type of discharge. The NHA was familiar with Resident #81. She said the resident's care plan was not updated when the resident's discharge plan changed to long-term care because there were a lot of different stories from the resident and the son about what the actual discharge plan was. The NHA said she would provide documentation to demonstrate the ombudsman was notified in writing that Resident #81 left AMA. The NHA said she would provide documentation to demonstrate the physician was notified the resident left AMA.-However, no documentation to indicate the ombudsman or the physician were notified of Resident #81's AMA discharge was provided by the survey exit on 8/7/25.

Based on record review and staff interviews, the facility failed to ensure the resident environment remained as free of accident hazards as possible for one (#69) of four residents reviewed for accident hazards out of 38 sample residents.Specifically, the facility failed to ensure Resident #69 did not sustain a fall during an assisted transfer and implement effective fall interventions. Findings include:I. Facility policy and procedureThe Fall Management policy, 2/29/24, was provided by the quality mentor on 8/7/25 at 6:00 p.m. It read in pertinent part, The purpose of this fall management policy is to modify or eliminate risk factors as applicable and thereby attempt to reduce the likelihood of falls with significant injury. Research has shown that structured fall reduction programs can substantially reduce the rate of falls and related injuries in nursing facilities; however, falls may likely occur. Identifying risk factors, followed by timely and appropriate interventions, is the key to a successful program. Each resident will be reevaluated quarterly, annually and when a significant change occurs. Individualized care plan interventions will be implemented for these residents found to be at high risk for falls. The following interventions may be considered after identification of root cause: Assess the environment and make appropriate changes, such as bed in the lowest position, placement of furniture, lighting, personal items within reach, non-slip footwear, night light, walker, wheelchair within reach if applicable. Complete a thorough analysis of the fall-time of day, location of fall, causative factors. Identify whether the interventions were in place at the time of the fall.II. Resident statusResident #69, age less than 65, was admitted on [DATE] and readmitted on [DATE]. According to the August 2025 computerized physician orders (CPO), diagnoses included dementia, major depressive disorder, epilepsy, history of traumatic brain injury (TBI), unsteadiness on her feet, abnormal posture and a history of falling.The 4/21/25 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 13 out of 15. She needed set up assistance for meals and was dependent on assistance with all other activities of daily living (ADL).II. Record reviewResident #69's ADL care plan, revised 8/7/24, documented she had an ADL self-care performance deficit related to post neurological surgery. Resident #69 used a wheelchair for mobility, wore a helmet when she was out of bed, and had decreased activity tolerance and safety awareness with ambulation related to seizures, impulsivity and balance impairment. Pertinent interventions, initiated 5/16/23, included to apply nonslip strips to her chair to prevent sliding out of the chair; Resident #69 had a helmet she was to wear when she was out of bed, and required assistance of one person for toileting.Resident #69's mobility care plan, revised 8/25/23, documented she had limited physical mobility related to a limited range of motion, seizure disorder, and left eye blindness. Pertinent interventions, revised 5/16/23, included Resident #69 used a wheelchair for ambulation and required assistance from one person. Resident #69's fall care plan, revised 8/7/24, documented she was at risk for falls related to poor safety awareness, impulsivity, poor judgement, seizure disorder, left-eye blindness, and a history of falling. She also had impaired mobility. Pertinent interventions included to not leave Resident #69 alone in the bathroom or shower (revised 5/16/23), to educate staff on the use of a gait belt for all transfers and encourage the resident to allow staff to utilize the belt (revised 6/5/25).Resident #69's fall risk evaluation, 4/30/25, categorized her as a high risk for falls and documented the following: the resident was wheelchair bound, the resident had three or more diagnoses that could contribute to falls and was not able to perform a gait evaluation (how a person walks).A review of Resident #69's electronic medical record (EMR) revealed the resident experienced falls on 4/30/25, 6/4/25 and 7/22/25.A 5/1/25 interdisciplinary team (IDT) note documented Resident #69 had an assisted fall on 4/30/25. The root case was weakness. The interventions put into place included orders and recommendations to be followed as indicated and therapy to screen the resident. Staff education was provided on utilizing gait belts as needed.The 6/4/25 progress note documented Resident #69 was sitting on the floor and a certified nurse aide (CNA) said the resident stood up from the toilet, went to sit down and misjudged where the wheelchair was and was eased to the floor by the CNA.The 6/5/25 IDT note documented Resident #69 had an intercepted fall and the root cause was poor safety awareness and impulsivity. Interventions put into place included to re-educate staff to utilize gait belts with residents that used assistive devices.The 7/22/25 progress note documented at 6:00 p.m. revealed the nurse was notified of a fall by the second floor nurse. Resident #69 was sitting in a wheelchair next to the nursing station (post fall). The resident was assessed and had a 0.7 by 0.5 centimeter (cm) laceration on the back of her head and a new forming bruise on the top of her right knee. The resident reported nine out of ten pain and the resident had regular neurological checks initiated.The 7/22/25 progress note documented at 6:10 p.m. revealed that a CNA reported that Resident #69 fell in the bathroom after being changed. The resident was lying down on the floor after her fall. After having her vital signs taken, the resident was assisted to a sitting position. During assessment the resident was alert and oriented with a 0.7 by 0.5 cm laceration on the back of her head, but not bleeding, and potential bruise on the top of the right knee noted. The resident stated I was dizzy when I tried to sit and slid down from the wheelchair to the floor.The 7/25/25 IDT note documented the resident had a witnessed fall on 7/22/25 at 5:40 p.m. The root cause was poor safety awareness and poor impulse control. Interventions put into place included staff education on fall preventions, a therapy screen and resident education on fall safety. The resident verbalized understanding.-However, Resident #69 had sustained two previous falls on 4/30/25 and 6/4/25. Post fall interventions for each fall prior to the resident's 7/22/25 fall included a therapy screening of the resident and staff education was provided on utilizing gait belts as needed.III. Staff interviewsCNA #4 was interviewed on 8/7/25 at 1:35 p.m. CNA #4 said Resident #69 was unable to transfer independently. CNA #4 said she used a gait belt to transfer Resident #69, and prior to transferring would ask the resident if she was able to stand up. CNA #4 said if she needed a second CNA to transfer Resident #69 she would ask and they would both transfer the resident to and from her chair as needed. CNA #4 said Resident #69 could turn her feet and take a step but the resident would not try to transfer herself independently. CNA #4 said Resident #69 did not try to shift herself in her chair or adjust in her chair. CNA #4 said Resident #69 was compliant wearing her helmet.The director of nursing (DON) was interviewed on 8/7/25 at 3:00 p.m. The DON said Resident #69 fell in the bathroom connected to the shower room on 7/22/25. The DON said a CNA had taken the resident to the bathroom and the resident fell during the transfer from the toilet to the wheelchair. The DON said the CNA assisted the resident during the transfer. The DON said the CNA thought the resident was in her chair, but she was not all the way in her wheelchair and then the resident slid down to the floor on her bottom. The DON said the resident's only injury was to her head. The DON said the resident hit her head, but the CNA who transferred the resident did not see what the resident hit her head on. The DON said the resident wore her helmet while out of bed and she was wearing her helmet during the fall. The DON said the resident was assessed by a registered nurse (RN) and an licensed practical nurse (LPN) on staff. The DON said they provided education with the certified nurse aide post fall.The administrator in training was interviewed on 8/7/25 at 3:00 p.m. The administrator in training said staff should have used the gait belt during Resident #69's transfer. The administrator in training said the facility changed the cushion on Resident #69's chair the day after the fall on 7/22/25 so Resident #69 was able to move herself back in her chair better.IV. Facility follow upThe NHA provided documentation of education on 8/11/25 at 2:00 p.m. The education was provided individually to facility staff from 7/25/25 to 8/1/25. The education documented in pertinent part, If a resident falls while staff is present and no interventions was attempted, it becomes a serious concern for resident safety and facility liability. Use gait belts when appropriate and position yourself in a way that allows you to intervene immediately if a resident begins to lose balance. In cases where a fall is truly unavoidable, assisting the resident safely to the floor is the best option to prevent more severe injury. This is acceptable only if all other efforts to prevent the fall were attempted and failed and the staff demonstrated that appropriate inventions were made.The facility staff signed and dated the education provided.

Based on observations, record review and interviews, the facility failed to ensure two (#1 and #2) of nine residents reviewed for abuse out of 10 sample residents were kept free from physical abuse. Resident #1 admitted to the facility on [DATE] with diagnoses of hemiplegia (paralysis affecting one side of the body) affecting the right dominant side, aphasia (a partial loss of language skills due to brain damage) and nicotine dependence. According to Resident #1's care plan, he had a history of reaching out and grabbing others. Resident #2 was admitted to the facility on [DATE] with a diagnosis of schizoaffective disorder bipolar type (mental health condition with symptoms of hallucinations and delusions and mood disorder), attention-deficit hyperactivity disorder (ADHD) and cognitive communication deficit. On 2/17/25 Resident #1 and Resident #2 were standing in line waiting to go outside for their smoking break. The residents were standing in a line close to one another. Resident #1 kicked Resident #2 and then, as a result, Resident #2 punched Resident #1 in the face. Both of the residents fell to the ground. Resident #1 sustained a laceration to his face which required him to be sent to the hospital for stitches. Findings include: I. Facility policy and procedure The Abuse policy, dated 2/29/24, was provided by the nursing home administrator (NHA) on 3/25/25 at 5:57 p.m. It read in pertinent part, The facility does not condone resident abuse and shall take every precaution possible to prevent resident abuse by anyone, including staff members, other residents, volunteers, and staff of other agencies serving the resident, family members, legal guardians, resident representative, sponsors, friends, or any other individuals. Residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. Providing a safe environment for the resident is one of the most basic and essential duties of our facility. Physical abuse is defined as abuse that results in bodily harm with intent. It includes hitting, slapping, pinching, kicking, and controlling behavior through corporal punishment and willful neglect of the resident's basic needs. If a resident experiences a behavior change resulting in aggression toward other residents, the facility will implement interventions for protection of the alleged assailant and other residents. The facility conducts further assessment and arranges for appropriate psychiatric evaluation for further screening. The resident's care plan is revised to include new approaches to reduce or eliminate any further chance of abuse. Recommendations for appropriate intervention, up to and including hospitalization , can then be implemented. II. Resident-to-resident physical altercation between Resident #2 and Resident #1 on 2/17/25 A. Facility investigation The 2/17/25 facility abuse investigation report was provided by the NHA on 3/24/25 at 3:07 p.m. The investigation documented that on 2/17/25 at 7:41 p.m., Resident #1 and Resident #2 were both waiting in the dining room to go outside to smoke. Resident #1 kicked Resident #2. Staff immediately intervened and as the staff were separating the two residents, Resident #2 hit Resident #1 in the face with a closed hand. This resulted in both residents falling onto the floor. The report documented that both residents were immediately separated and placed on frequent checks. The registered nurse (RN) did a skin assessment for both residents. Both residents sustained injuries. Resident #2 sustained a two centimeter crescent shaped cut on his right hand that potentially was from Resident #2's rings and Resident #1 sustained a two to three centimeter laceration under his left eye, resulting in him being sent to the hospital for stitches. Resident #2 was placed on increased monitoring for safety. The facility investigation documented that the RN on duty went to check on Resident #2 in his room and that Resident #1 continued to try to enter Resident #2's room. Resident #1 was then placed on one-to-one supervision. The investigation documented the interventions that were put in place for Resident #1 included speech therapy to provide treatment to help with his communication skills and he was referred to behavioral health counseling services. The facility implemented increased monitoring for Resident #2. Additionally, Resident #2's behavioral health counselor was notified and his medication regime was reviewed B. Resident #1 1. Resident status Resident #1, age less than 65, was admitted on [DATE]. According to the March 2025 computerized physician orders (CPO), diagnoses included hemiplegia affecting the right dominant side, aphasia and nicotine dependence. The 2/5/25 minimum data set (MDS) assessment revealed the resident had moderate cognitive impairments with a brief interview for mental status (BIMS) score of nine out of 15. The MDS assessment indicated the resident was independent with all activities of daily living (ADL) and used a manual wheelchair independently. The assessment revealed he had no behavioral symptoms directed toward others. He had exhibited rejection of care for one to three days during the assessment review period. 2. Record review Resident #1's care plan, initiated 11/21/24 and revised 3/13/25, identified the resident had behavior issues related to refusing care and had a history of reaching out and grabbing onto others. Pertinent interventions included behavioral monitoring (initiated 11/21/24), praising the resident's progress in improvement in behavior (initiated 1/2/25), encouraging the resident to communicate verbally with others to ensure personal boundaries as needed (initiated 3/13/25). -The care plan was not updated after the 2/17/25 resident-to-resident altercation to indicate that the resident had a tendency to kick at others who were close. The 2/17/25 nursing note documented that the nurse was called down to the dining room by a certified nurse aide (CNA) because of an altercation between two residents. The note documented that the nurse found Resident #1 in his wheelchair with blood on the left side of his face and a two to three centimeter laceration below his left eye. The 2/17/25 nursing note documented that Resident #1 continually tried to enter Resident #2's room even after being encouraged to return to his own room. The note documented that the nurse had to have a CNA remain in the hallway to prevent Resident #1 from entering Resident #2's room. The note documented that both residents were on 15-minute checks. The 2/17/25 nursing note documented that they received a physician's order to send Resident #1 to the emergency department for evaluation and treatment of the laceration under his left eye. The 2/17/25 after-visit summary from the hospital, documented Resident #1 had a contusion of the face and a facial laceration that needed three sutures. The 2/18/25 nursing note documented that Resident #1 returned from the emergency department with stitches under his left eye and the area had moderate swelling. The note documented the stitches were to be removed on 2/25/25 and the emergency department doctor suggested bactrim ointment (antibiotic) and told the facility that all the testing was clear. C. Resident #2 1. Resident status Resident #2, age less than 65, was admitted on [DATE]. According to the March 2025 CPO, diagnoses included schizoaffective disorder bipolar type, attention-deficit hyperactivity disorder and cognitive communication deficit. The 1/20/25 MDS assessment revealed the resident was cognitively intact with a BIMS score of 15 out of 15. The MDS assessment documented the resident was independent with all ADLs and walked independently without assistive devices. The assessment revealed the resident had no behavioral symptoms directed towards others and no rejection of care. 2. Resident observation and interview Resident #2 was interviewed on 3/25/25 at 11:18 a.m. Resident #2 said he remembered the incident with Resident #1, which occurred on 2/17/25. He said Resident #1 kicked him and therefore he punched Resident #2 in the face. He said they had since apologized to each other and had not had any further incidents. The resident had large rings on all of his fingers on both hands. 3. Record review Resident #2's care plan, initiated 3/18/24 and revised 3/24/25 (during the survey), documented Resident #2 had auditory and visual hallucinations which could cause him to have paranoia and delusions. The care plan documented that he had a history of impulsiveness and physical altercations. Pertinent interventions included providing a behavioral consult with his mental health providers (initiated 5/29/24), behavioral monitoring (initiated 11/9/24), providing frequent checks (initiated 9/20/24), monitoring the resident's behaviors and attempting to determine underlying cause (initiated 12/24/24) and intervening as necessary when behaviors occurred (initiated 4/26/24). The 2/17/25 nursing note documented Resident #2 was outside smoking when the nurse approached him and asked him what had happened. Resident #2 told the nurse that Resident #1 had kicked him on his left leg so he had punched him. The 2/17/25 nursing follow-up note documented Resident #2 had said Resident #1 had been kicking at him for the past few days, but he had not told anyone about the previous incidents. He told the nurse it was not a big deal at the time. The 2/18/25 nursing note documented Resident #2 remained on 15-minute checks and remained on one-to-one supervision for safety from Resident #1. The 2/20/25 interdisciplinary team (IDT) note documented Resident #2 continued to have delusions. The resident continued to be on one-on-one supervision for continued safety of others. III. Staff interviews CNA #1 was interviewed on 3/35/25 at 3:54 p.m. CNA #1 said the staff were trained on abuse every month through an online portal. She said she had not seen any recent altercations between Resident #1 and Resident #2. She said she always kept an eye on Resident #2 since the altercation with Resident #1. The social services director (SSD) was interviewed on 3/25/25 at 4:45 p.m. The SSD said the social services department was responsible for completing abuse investigations, reporting of the abuse and completing the facility abuse packet. The SSD said the abuse coordinator was the NHA. The SSD said when abuse happened, the facility investigated to determine the root cause. She said the facility also completed an analysis for any triggers such as hunger, thirst or any environmental stressors. She said a lot of the residents that resided at the facility had major mental illness with behaviors, which caused them not to understand social cues and they were socially inappropriate. The SSD said Resident #1 had a history of reaching out and grabbing other residents. She said the facility continued to monitor and intervene with his behavior. The director of nursing (DON) was interviewed on 3/25/25 at 5:04 p.m. The DON said a resident-to-resident altercation occurred between Resident #1 and Resident #2 on 2/17/25, which was substantiated as abuse. He said the licensed nurses and the CNAs would notify him of any abuse and then he would notify the NHA and the SSD. He said the RN who was working the floor would do a skin assessment after the incident occurred. He said the facility discussed the incident during their IDT meeting. He said it was recommended, after the 2/17/25 incident, that the residents needed to be spread out from each other while they waited to go outside to smoke. The NHA was interviewed on 3/25/25 at 5:30 p.m. The NHA said since the abuse incident between Resident #1 and Resident #2, the facility had moved around the smoking times and asked the residents to wait further away from the smoking door. She said the facility separated the smoking times by floor and each floor was separated by 15 minute intervals.

Based on observations and interviews the facility failed to ensure one out of two medication refrigerators stored narcotic medications in accordance with accepted professional standards and that only licensed staff had access to resident-prescribed medications. Specifically, the facility failed to: -Ensure the treatment carts were locked when left unattended; and, -Ensure controlled medications were in a locked storage container permanently secured to the refrigerator. Findings include: I. Facility policy and procedure The Storage of Medications policy and procedure, revised November 2020, was provided by the nursing home administrator (NHA) on 11/28/23 at 1:36 p.m. It read in the pertinent part, Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes) containing drugs and biologicals are locked when not in use. Unlocked medication carts are not left unattended. Schedule II-V controlled medications are stored in separately locked, permanently affixed compartments. II. Observations On 11/27/23 at 9:05 a.m. the treatment cart on the second floor was unlocked and unattended. Several residents were in the hall and walked past the cart. The treatment cart contained prescription creams, ointments, over-the-counter creams and supplies for wound care. Licensed practical nurse (LPN) #2 was notified after she came out of a resident's room and several minutes had passed. At that point, she locked the cart. At 9:10 a.m. the medication room on the second floor was unlocked and unattended. Inside the medication room were multiple over-the-counter medications on open shelves, prescription cards with medications that were no longer being used and a medication refrigerator that was unlocked. The medication refrigerator contained multiple injectable medications, suppositories and other medications that required refrigeration. On 11/28/23 at 2:14 p.m. the treatment cart on the third floor was unlocked and unattended. Several residents were in the hall and passed the cart. The treatment cart contained prescription creams, ointments, over-the-counter creams and supplies for wound care. The director of nursing (DON) noticed the treatment cart was unlocked and he locked it at 2:33 p.m. On 11/30/23 at 11:14 a.m. the medication room on the fourth floor was observed with LPN #1. There was a medication refrigerator that contained three vials of liquid Ativan (a benzodiazepine and a schedule IV controlled substance used to treat agitation that tranquilizes the patient) and an influenza vaccine. The schedule IV controlled medications were in a ziploc bag on the bottom of the refrigerator next to the influenza vaccine. III. Staff interviews LPN #2 was interviewed on 11/27/23 at 9:15 a.m. She said the treatment cart should always be locked. She said residents could get into treatments that were not safe. She said the medication room should always be locked for the same reason. The DON was interviewed on 11/30/23 at 11:00 a.m. He said the treatment carts and medication rooms should be locked at all times. He said leaving either unlocked could result in a Health Insurance Portability and Accountability Act (HIPAA) violations, financial exploitation, missing medications and unauthorized staff or residents getting into the treatment cart and overdosing. He said he was not aware that the Ativan needed to be in a secured permanently affixed compartment in the refrigerator. The nursing home administrator (NHA) was interviewed on 11/30/23 at 1:40 p.m. The NHA said treatment carts and medication rooms should be locked at all times when not attended by a licensed nurse.

Based on observations, record review and interviews, the facility failed to ensure menus were followed. Specifically, the facility failed to ensure food items served were consistent with the daily menu. Findings include: I. Resident interview A group of residents (#63, #40, #64, #22 and #2) were interviewed on 11/28/23 at 4:00 p.m. Resident #63 said the meals served often did not match the posted menu. She said it bothered her when she thought she was getting fried chicken and it was baked instead or if enchiladas were on the menu but everyone received burritos instead. The resident group agreed with the statement provided. II. Lunch on 11/28/23 The 11/28/23 lunch menu revealed residents were to be served chicken fried chicken, mashed potatoes with gravy, broccoli salad, biscuits and peach cobbler for dessert. During a continuous observation on 11/28/23 beginning at 11:30 a.m. and ending at 2:30 p.m., the lunch being served was baked chicken breast, wings and thighs, mashed potatoes with gravy, green beans, biscuits and peach cobbler for dessert. At 12:10 p.m. the regional dietary consultant (RDC) substituted green beans for broccoli salad because the broccoli salad remained above a temperature of 41 degrees. At 2:00 p.m. the dietary manager (DM) delivered a tray of breaded and cooked cutlets to cook (CK) #1. The DM was interviewed at 2:00 p.m. She said the facility did not receive enough chicken fried chicken cutlets from a delivery and she substituted with baked chicken. She said she had intended to serve the chicken fried chicken first but accidentally sent out the baked chicken first. The DM was interviewed again on 11/28/23 at 3:12 p.m. She said she was unsure if the breaded cutlets served for lunch were made of chicken or steak. She said it looked like chicken fried steak. She said she did not look at the box it came in to confirm what protein was being served. At 3:00 p.m. the RDC produced a box that revealed the cutlets served for lunch were chicken fried steak and were made from steak and not chicken. III. Additional DM interview The DM was interviewed again on 11/30/23 at 2:00 p.m. The DM said she opened the box of chicken fried steak and cooked the lunch served on 11/28/23. She said she thought the cutlets looked odd for being chicken. She said she did not check the box to confirm the ingredients prior to serving the residents. She said it was problematic to serve a different type of protein than what the menu advertised because of allergies, dietary needs and cultural preferences.

Based on observations and interviews, the facility failed to label and date stored food items and distribute and serve food in a sanitary manner in two of three food storage units reviewed. Specifically, the facility failed to: -Ensure food was labeled and dated in the freezers in the main kitchen; and, -Ensure food that left the kitchen was covered. Findings include: I. Failure to ensure food was labeled and dated A. Professional reference The Colorado Department of Public Health and Environment (2019) The Colorado Retail Food Establishment Rules and Regulations, retrieved 12/11/23 from: https://drive.google.com/file/d/18-uo0wlxj9xvOoT6Ai4x6ZMYIiuu2v1G/view, revealed in pertinent part, A date marking system that meets the criteria stated in (2) of this section may include: Marking the date or day of preparation, with a procedure to discard the food on or before the last date or day by which the food must be consumed on the premises, sold, or discarded as specified in (a) of this section; Marking the date or day the original container is opened in a food establishment, with a procedure to discard the food on or before the last date or day by which the food must be consumed on the premises, sold, or discarded as specified in (b) of this section; or Using calendar dates, days of the week, color-coded marks, or other effective marking methods, provided that the marking system is disclosed to the Department upon request. B. Facility policy and procedure The Food Wholesomeness policy, dated 11/29/23, was provided by the nursing home administrator (NHA) on 11/29/23 at 11:42 a.m. It revealed in pertinent parts: Frozen foods are cooked per manufacturer's instructions or thawed with dates of use and meal item. Foods not in original containers are labeled and dated with opening and suggested to have a use by date. C. Observations During an initial kitchen tour on 11/27/23 beginning at 9:20 a.m. and ending at 10:00 a.m., the following was observed: In the freezer of the main kitchen there was a plastic bag, blue in color, with circular pea sized objects inside with no label or date, two clear plastic bags of breaded items that were square in shape and beige in color, one clear plastic bag of chicken and a clear plastic bag containing burritos. -None of the items were labeled or dated. The ice chest freezer in the secondary storage area of the kitchen had three bags of collard greens, two bags of asparagus and one bag of broccoli out of the original box. -None of the items were dated. At 10:00 a.m. the dietary manager (DM) said the food item in the blue plastic bag of the main freezer could be peas, however, she was unable to locate a label or date. The DM was unable to locate labels and dates on the other unlabeled and undated items observed in the main kitchen freezer. -The DM was unable to locate dates on the undated items observed in the ice chest freezer. On 11/28/23 at 3:30 p.m., during an observation of the fourth floor refrigerator, a tray with five sandwiches in clear plastic bags was observed. There was no date or label on the bags or tray. An unknown staff member said kitchen staff was responsible for labeling and dating food they provided to the units for resident consumption. On 11/29/23 at 10:30 a.m. the following was observed: In the freezer of the main kitchen there was a plastic bag, blue in color, with circular pea sized objects inside with a second blue plastic bag on top of it, two clear plastic bags of breaded items square in shape, one clear plastic bag of chicken and a clear plastic bag containing burritos. -None of the items were labeled or dated. In the ice chest freezer of a secondary storage area of the kitchen there were three bags of collard greens, two bags of asparagus and one bag of broccoli out of the original box. -None of the items were dated. II. Failure to cover food leaving the kitchen A. Observations During a continuous observation on 11/28/23 beginning at 11:30 a.m. and ending at 2:30 p.m. cook (CK) #1 was observed handing an uncovered plate of baked chicken to an unknown staff member out of the kitchen to be delivered to an unknown resident in an area other than the dining room. -The unknown staff member did not cover the plate prior to leaving the dining room to deliver the food to a resident. III. Staff interviews The DM was interviewed on 11/29/23 at 10:23 a.m. She said the kitchen staff was responsible for dating sandwich trays delivered to individual units. She said if the floor staff removed the sandwiches from the tray they were responsible for dating individual sandwich bags. She did not know who was responsible for labeling the type of sandwich each bag contained. She said it was important to label the contents of individual sandwiches because of food allergies, dietary restrictions and cultural preferences. She said it was important to date individual bags to ensure freshness. She said education would be provided to kitchen staff to label and date individual bags. The nursing home administrator (NHA) was interviewed on 11/29/23 at 10:36 a.m. She was unable to locate labels or dates for items in the main kitchen freezer or dates on items out of the original box in the secondary storage area. She said items without labels or dates should be thrown out immediately. She said unlabeled food items presented concerns with dietary needs and food allergies. She said food that was labeled without a date of when it was removed from the original box presented concerns for quality of freshness. The regional dietary consultant (RDC) and DM were interviewed together on 11/30/28 at 2:00 p.m. The DM said plated food being served from the kitchen and delivered to an area other than the dining room should be covered. She said this ensured food stayed warm and prevented the potential for contamination. The DM said food items without labels or dates were problematic because not knowing ingredients impacted food allergies, dietary restrictions, cultural preferences and freshness of the food being served. She said all items found without labels or dates in the refrigerators and ice chest freezer had been discarded and education was being provided to staff. IV. Facility follow up At 1:00 p.m. the NHA said that all foods found without labels and dates had been removed from the refrigerators and ice chest freezer and staff education was provided.

Based on observations and interviews, the facility failed to maintain an infection control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of diseases and infection for two out of three units at the facility. Specifically, the facility failed to: -Ensure residents were provided with an opportunity to participate in hand hygiene before and after meals; -Ensure proper infection control measures for housekeeping were followed; and, -Ensure appropriate hand hygiene was performed during medication administration. Findings include: I. Failure to ensure residents were provided with an opportunity to participate in hand hygiene before and after meals. A. Professional reference The Center for Disease Control (CDC) Hand Hygiene in Healthcare Settings: Patients, retrieved on 12/4/23 from: https://www.cdc.gov/handhygiene/patients/index.html revealed in part, Clean Hands Count for Patients: As a patient in a healthcare setting, you are at risk of getting an infection while you are being treated for something else. Patients and their loved ones can play a role in asking and reminding healthcare providers to clean their hands. Your hands can spread germs too, so protect yourself by cleaning your hands often. When should you clean your hands: -Before preparing or eating food; -Before touching your eyes, nose, or mouth; -Before and after changing wound dressings or bandages; -After using the restroom; -After blowing your nose, coughing, or sneezing; and, -After touching hospital surfaces such as bed rails, bedside tables, doorknobs, remote controls, or the phone. How should you clean your hands: With an alcohol-based hand sanitizer: Put the product on your hands and rub your hands together Cover all surfaces until hands feel dry This should take around 20 seconds With soap and water: Wet your hands with warm water. Use liquid soap if possible. Apply a nickel- or quarter-sized amount of soap to your hands. Rub your hands together until the soap forms a lather and then rub all over the top of your hands, in between your fingers and the area around and under the fingernails. Continue rubbing your hands for at least 15 seconds. Need a timer? Imagine singing the 'Happy Birthday' song twice. Rinse your hands well under running water. Dry your hands using a paper towel if possible. Then use your paper towel to turn off the faucet and to open the door if needed. B. Facility policy The Hand Hygiene policy, revised August 2019, was provided by the nursing home administrator (NHA) on 11/29/23 at 2:02 p.m. It read in pertinent part, This facility considers hand hygiene the primary means to prevent the spread of infections. The policy interpretation and implementation included: 1. All personnel shall be trained and regularly in-serviced on the importance of hand hygiene in preventing the transmission of healthcare-associated infections. 2. All personnel shall follow the hand washing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors. 3. Residents, family members, and/or visitors will be encouraged to practice hand hygiene. 4. Use an alcohol-based hand rub containing at least 60% or soap and water for the following situations: Before and after coming into contact with residents, before and after eating or handling food. C. Observations On 11/27/23 at approximately 9:30 a.m., during breakfast, approximately 16 residents in the main dining room were not provided the opportunity to perform hand hygiene. -The meal trays were passed out without the staff offering hand hygiene to the residents. -There were no hand sanitizing wipes provided on the resident's dining table. -Some of the residents were in their wheelchairs and had wheeled themselves to the dining room, touching the dirty wheels of their wheelchairs prior to eating. -The menu for breakfast included toasted bread which the resident's ate with their fingers. On 11/28/23 at approximately 4:55 p.m. room trays arrived on unit three for five of the residents who stayed back and did not dine in the main dining room. -The staff passed the dinner trays and did not offer any of the resident's hand hygiene. -There were no hand sanitizer packets provided on the resident's trays. On 11/29/23 at 12:00 p.m., the staff started serving lunch in the first floor main dining room. -There was no hand sanitizer in the dining area and staff did not offer hand sanitizer wipes to the residents. -Approximately twelve residents in the dining room were not provided the opportunity to perform hand hygiene. II. Failure to ensure housekeeping followed proper infection control measures. A. Facility policy The Infection Control policy, dated 7/28/2023, was provided by the nursing home administrator (NHA) on 11/30/23 at 10:00 a.m. It read in pertinent part, An infection prevention and control program (IPCP) is established and maintained to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. The program is based on accepted national infection prevention and control standards. The infection prevention and control program is a facility-wide effort involving all disciplines, and individuals and is an integral part of the quality assurance and performance improvement program. The elements of the infection prevention and control program consist of coordination, policies and procedures, surveillance, data analysis, antibiotic stewardship, outbreak management, prevention of infections, and employee health and safety. B. Housekeeping observations On 11/29/23 at 10:35 a.m. housekeeper (HSKP) #1 was observed cleaning resident room [ROOM NUMBER]. There were three residents living in the room. room [ROOM NUMBER] was on enhanced barrier precautions ( infection control interventions designed to reduce transmission of resistant organisms). HSKP #1 started cleaning the room by donning gloves. She sprayed a disinfectant solution on the surfaces of the television stand and bedside stands of the two residents on the same side of the room. HSKP #1 cleaned one stand belonging to the resident at bed A and continued cleaning with the same cleaning rag to the area of bed B. HSKP #1 returned to the cleaning cart to pick up a mop stick. She started mopping the floor around the resident in bed A and proceeded to mop the area of the resident in bed B with the same mop pad. HSKP #1 continued to mop the shared bathroom inside the resident's bedroom with the same mop pad and proceeded to mop the floor of the resident in bed C, all with the same mop pad. HSKP #1 left room [ROOM NUMBER] after completing her cleaning routine. HSKP #1 did not clean the door knob and the side rails in the hallway which wereboth high touch areas for staff and residents. III. Staff interviews Certified nurse aide (CNA) #6 was interviewed on 11/29/23 at 2:30 p.m. CNA #6 said there were hand sanitizer dispensers on the walls for staff and residents to perform hand hygiene, however, most of the residents refused to utilize them. CNA #6 said hand hygiene was important to prevent the spread of infectious diseases. CNA # 6 said the resident's room trays did not have sanitizing wipes for hand hygiene. The director of nursing (DON) was interviewed on 11/29/23 at 4:25 p.m. The DON said the housekeeping staff were trained on infection control as well as all the other departments. The DON said disinfecting high-touch areas such as door knobs and side rails and offering each resident the opportunity to perform hand hygiene were important to prevent the transmission of infectious diseases. The DON said staff should encourage all residents to perform hand hygiene before and after meals. The infection control preventionist (ICP) was interviewed on 11/30/23 at 11:00 a.m. The ICP said the facility staff were to wash their hands before and after each resident contact, after performing a task, and when their hands were visibly dirty. Hand sanitizers were readily available throughout the facility for the staff to encourage all residents to perform hand hygiene before and after each meal service. The ICP said her focus was on staff education which included education on infection control measures and hand hygiene for all staff and residents. 47960 IV. Failure to ensure hand hygiene was performed during medication administration On 11/28/23 at 11:00 a.m., licensed practical nurse (LPN) #1 got up from his desk where he had been typing on the computer and began preparing medications for a resident. -He did not use hand sanitizer or wash his hands before he began preparing medications. LPN #1 dispensed the medication from a bottle into a medication cup and carried the medication to a resident in room [ROOM NUMBER]. The resident took the medication and LPN #1 returned to the medication cart and began preparing medications for the next resident. -He did not use hand sanitizer or wash his hands prior to beginning preparation of the next resident ' s medications. At 11:10 a.m., LPN #1 dispensed medication from a bottle into a medication cup, retrieved a Boost (nutritional supplement) from the kitchenette and carried the items to a resident in room [ROOM NUMBER]. The resident took the medication and LPN #1 returned to the medication cart and began preparing medications for a third resident. -He did not use hand sanitizer or wash his hands prior to beginning preparation of the next resident ' s medications. At 11:15 a.m., LPN #1 dispensed medication from the controlled substance lock box in the medication cart into a medication cup and poured a powdered medication into a cup of water. He carried the medications to a resident in room [ROOM NUMBER] and she took the medications. -LPN #1 returned to the nurses station desk without using hand sanitizer or washing his hands. V. Additional interviews The DON was interviewed on 11/30/23 at 11:00 a.m. He said that staff should wash their hands or use hand sanitizer before and in between each resident during the medication pass. He said in some situations the nurses may also need to wear gloves. He said failure to perform hand hygiene could lead to a spread of viruses or infections in the facility. The infection control preventionist (ICP) was interviewed on 11/30/23 at 11:07 a.m. She said each nurse should use hand sanitizer before administering medications to residents to ensure they were not passing potential infections from resident to resident.

Based on observations and interviews, the facility failed to provide a comfortable and homelike environment for the residents of the facility on two out of three units. Specifically, the facility failed to ensure: -Residents were provided with hand towels and washcloths; and, -Residents' room windows and electrical outlets were properly maintained. Findings include: I. Lack of washcloths and hand towels in resident rooms A. Observations On 11/27/23 at 10:16 a.m. the following shared rooms had no hand towels and washcloths: -room [ROOM NUMBER], #308 and #312. On11/28/23 at 9:45 a.m: -room [ROOM NUMBER] had one washcloth in a shared room, otherwise no towels; -room [ROOM NUMBER] had no towels;and, -room [ROOM NUMBER] had no hand towels and washcloths for a three resident shared bathroom. On 7/29/23 at 3:28 p.m: -room [ROOM NUMBER] had one towel hanging in a shared bathroom of four residents; -room [ROOM NUMBER] had no towels in a four resident shared bathroom; -room [ROOM NUMBER] had no towels; -room [ROOM NUMBER] had no hand towels and washcloths; -room [ROOM NUMBER] had one used washcloth in a shared bathroom for three residents; -room [ROOM NUMBER] had no towels; -room [ROOM NUMBER] had only one used washcloth in a shared room; and, -room [ROOM NUMBER] had no towels. On 7/30/23 at 10:05 a.m.: -room [ROOM NUMBER] had no towels in a shared bathroom of four residents; -room [ROOM NUMBER] had no towels; -room [ROOM NUMBER] had no towels. One towel holder was not labeled with a resident name;. -room [ROOM NUMBER] only had one wash rag in a shared bathroom of four residents; -room [ROOM NUMBER] had no towels; -room [ROOM NUMBER] had no towels and washcloths in a shared room; and, -room [ROOM NUMBER] had no towels in a four resident shared bathroom. B. Resident interview Resident #19 was interviewed on 11/30/23 at 10:15 a.m. Resident #19 said staff were not providing washcloths and towels except when a resident requested them. The resident said he used a paper towel to wash his face or he would just go to the clean linen closet and get them himself. He said when the staff removed the used towels and washcloths the staff did not replace them unless the resident asked the staff to do so. II. Resident room windows and electrical power outlet not properly maintained. A. The Maintenance Service Policy was received on 11/29/23 at 4:01 p.m. from the nursing home administrator (NHA). The policy read in pertinent part, Maintenance service shall be provided to all areas of the building, grounds, and equipment. The maintenance department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times. B. Observations On 11/27/23 at 10:25 a.m. Resident #56 was sitting on his bed in room [ROOM NUMBER] with a blanket covering both knees. The resident was painting on a piece of paper. -The left side window over bed C in room [ROOM NUMBER] did not close all the way. There was a blanket covering the space that would not close. On 11/28/23 at 2:15 p.m., the window in room [ROOM NUMBER] bed C had the left side cracked from top to bottom. The top of the ceiling has a dark brown color and the ceiling appears to be wet. On 11/29/23 at 10:14 a.m., an electrical outlet in the resident's common area on the fourth floor was open, exposing electrical cables. Three residents were sitting in the open area watching television. C. Resident interviews Resident #56, who resided in room [ROOM NUMBER], said he was cold even though he had the blanket covering his knees. Resident #56 said the left side window in his room did not shut all the way so it got really cold in his room. The resident said he reported it to staff and the staff used a blanket to cover the opened space. Resident #19, who resided in room [ROOM NUMBER], said the left side window had been cracked for over three years. He said he had e reported it to staff several times but it had not been fixed. The resident said there had been a leakage from the ceiling several times. III. Staff interviews The maintenance supervisor (MS) was interviewed on 11/29/23 at 12:03 p.m. The MS said he received reports about the cracked window in room [ROOM NUMBER] over three years ago and reported it to his superiors. The MS said the facility had still not allocated funds to maintain the window. The MS said it was a safety concern and it needed to be addressed. The MS said he was able to repair the window over bed B in room [ROOM NUMBER], however, the resident could not open and close the window until he received the parts needed to repair the window. The MS said he was able to fix the leakage on the ceiling and had replaced the wet ceiling tile. Housekeeper (HSKP) #1 was interviewed on 11/29/23 at 1:45 p.m. HSKP #1 said the housekeeping department ensured towels and linens were frequently sent to the floor throughout the day. She said the housekeeping department locked the towels in closets on each unit and it was up to the certified nurse aides (CNA) to ensure each resident room was supplied with hand towels and washcloths. CNA #5 was interviewed on 11/29/23 at 1:50 p.m. The CNA said most of the rooms had no towels. CNA #5 said linens were locked in closets in each unit's clean linen rooms. She said CNAs on both day and night shifts were responsible for supplying residents' rooms with towels and washcloths. The director of nursing (DON) was interviewed on 11/29/23 at 2:53 p.m. The DON said housekeeping and nursing staff were responsible for ensuring each resident had adequate towels and washcloths. The DON said the housekeepers washed dried and stored linens in the linen closet. The DON said it was important for each resident to have clean hand towels and washcloths each day for the resident's dignity and infection control. The DON said some rooms had no towels due to the cognitive level of the residents. He said the interdisciplinary committee would discuss and come up with ways to provide each resident with clean towels and linens without other residents touching them.

Based on observations, record review and interviews, the facility failed to provide the assistance needed to maintain the ability to complete activities of daily living (ADLs) for one (#62) of two residents out of 35 sample residents. Specifically, the facility failed to identify and develop an intervention for the staff to assist Resident #62 with her ADLs effectively due to the resident's diagnosis of mental illness. Findings include: I. Facility policy The ADL policy, revised 8/2018, was provided by the nursing home administrator (NHA) on 11/30/23 at 10:05 a.m. It read in pertinent part, Residents will be provided with care, treatment, and services as appropriate to maintain or improve their ability to carry out activities daily living. Residents who are unable to carry out activities of daily living independently will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene. Interpretation: The existence of a clinical diagnosis or condition does not alone justify a decline in a resident's ability to perform ADLs. If residents with cognitive impairment or dementia resist care, staff will attempt to identify the underlying cause of the problem and not just assume the resident is refusing or declining care. Approaching the resident in a different way or at a different time, or having another staff speak with the resident may be appropriate. II. Resident #62 A. Resident status Resident #62, under the age of 65, was admitted on [DATE] and readmitted on [DATE]. According to the November 2023 computerized physician orders (CPO), diagnoses included schizoaffective disorder, post-traumatic stress disorder, chronic obstructive pulmonary disease (COPD), morbid (severe) obesity, need for assistance with personal care and muscle weakness. The 11/15/23 minimum data set (MDS) assessment revealed the resident's cognitive status was intact with a brief interview for mental status (BIMS) score of 14 out of 15. She had no identified behaviors and rejection of care behaviors were not exhibited. B. Resident observation and interview On 11/27/23 at 1:54 p.m., Resident #62 was sitting on her bed. She had mid-length hair which was matted all around her head and unkempt in appearance with pink and brown unidentified substances extending to the bottom tips of her hair. Resident #62 said she would like to have her washed to get the stains out and untangle it, however she said she did not feel safe getting into the shower because she was fearful of falling. Resident #62 said staff had not offered her the use of a shower chair for her to sit down on during a shower to prevent her from falling. C. Record review The ADL care plan initiated, on 1/22/22 and revised on 12/22/22 revealed Resident #62 had an ADL self-care performance deficit and was a high risk for falls. -The resident did not have an individualized person-centered care plan addressing her shower needs, measures, and approaches for the facility staff to follow to assist Resident #62 with showers. The interdisciplinary team (IDT) assessment document titled The Story of Me, dated 12/21/21, revealed Resident #62 preferred showers over other forms of bathing such as tub baths and bed baths. -Progress notes date 3/16/23/, 6/7/23 and 8/22/23 documented Resident #62 was independent with showers. -On 10/2/23, occupational therapy treatment encounter notes documented Resident #62 was agreeable to participate in a restorative nursing program (RNP) and have help from restorative to shower to ensure she wouldn't fall. The licensed occupational therapy (OT) note documented that nursing should address and implement a RNP which included showers three times per week with the help of restorative. -There was no documentation indicating the RNP was implemented after Resident #62 agreed to participate on 10/2/23. -The progress note documented on 11/27/23 from Adult Spectrum Care (ASC) indicated Resident #62 appeared to be in poor hygiene. D. Staff interviews Certified nurse aide (CNA) #5 was interviewed on 11/29/23 at 1:50 p.m. CNA #5 said Resident #62 had expressed fear of falling in the shower. She said the resident often applied hair glue and other substances to her hair and did not wash it. She said the resident's hair appeared matted for a long period. CNA #5 said Resident #62 was independent with showers. The director of nursing (DON) was interviewed on 11/29/23 at 2:53 p.m. The DON said Resident #62 needed assistance with personal care, however, the resident declined showers due to the fear of falling and losing her baby. The DON said Resident #62 was currently not involved in any RNP that she is aware of. The restorative registered nurse (RRN) was interviewed on 11/30/23 at 11:45 a.m. She said Resident #62 was currently not involved in any RNPs. The RRN said the resident's previous restorative program was terminated on 5/16/23 and she had since not been involved in any restorative care. She said she was not aware of any new recommendations from the OT department and she was going to follow up with the OT. The RRN said she was informed by the nursing staff about Resident #62's decline with ADLs. E. Facility follow-up The facility provided additional documentation on 12/1/23, a day after the survey exit. A review of the documentation revealed the following: The facility updated Resident #62's care plan to include the resident's preference for a bed bath with wipes. -The facility did not address the reason the resident was uncooperative with taking showers and the resident's continued poor hygiene. -There were no person-centered interventions updated on the resident's care plan. The facility provided a 30-day record of Resident #62's bed baths. The resident had nine bed baths in 30 days. -The facility did not provide documentation to indicate a resolution occurred for Resident #62's matted hair. The facility provided evidence of the OT treatment and evaluation for Resident #62 that resulted in the 10/2/23 OT recommendation for the resident to participate in a restorative nursing program for her shower, which the resident had agreed to. -The facility did not provide evidence the recommendation was implemented.

Based on observations, interviews and record review, the facility failed to ensure one (#43) of four residents reviewed for dementia care out of 35 sample residents received the appropriate treatment and services to attain or maintain the highest practicable physical, mental and psychosocial well-being. Specifically, the facility failed to develop a comprehensive plan of care, to include person-centered interventions to address Resident #43's behaviors. Findings include: I. Facility policy and procedure The Care of Resident with Dementia policy and procedure, revised October 2017, was provided by the nursing home administrator (NHA) on 11/30/23 at 7:02 p.m. It revealed, in pertinent part, Residents who display symptoms or are diagnosed with dementia should receive the appropriate treatment and services to attain or maintain their highest practicable physical, mental and psychosocial wellbeing. Providing care and services for residents living with dementia or dementia-like symptoms is an integral part of the person-centered care environment. This environment supports quality of life, meaningful relationships, and positive engagement. The facility provides treatment and services that include, but are not limited to: medical care, diagnosis, and support based on diagnosis including evaluation of sudden changes or worsening of behavioral expressions or indications of distress and subsequent care and/or intervention, and appropriate pharmacological interventions, when clinically indicated. Necessary person-centered care and services should reflect the resident's goals, choices, and preferences while maximizing their dignity, autonomy, privacy, socialization, independence, choice and safety. Individualized, non-pharmacological approaches to care that are purposeful and meaningful to the resident to enhance their well-being. The facility follows a systematic care process that includes an assessment of the resident's strengths and care needs, and development and implementation of an individualized, holistic care plan that includes input from the resident, the resident's family and/or representative, to the extent possible, and the interdisciplinary team. II. Resident status Resident #43, age 66, was admitted on [DATE]. According to the November 2023 computerized physician orders (CPO), diagnoses included vascular dementia, cognitive social or emotional deficiency following cerebral infarction, mood disorder due to know physiological condition with depressive features and generalized anxiety disorder. According to the 10/12/23 minimum data (MDS) assessment, the resident was unable to complete the brief interview for mental status (BIMS) and was identified as moderately impaired in his cognitive skills for daily decision making. The resident had disorganized thinking, delusions and behavioral symptoms directed towards others. Resident #43 resided on secured unit. III. Observation On 11/27/23 at 11:20 a.m. Resident #43 using profanity at Resident #44 and putting his middle finger about one foot away from her face. Certified nurse aide (CNA) #1 redirected Resident #43 back to his room. At 11:26 a.m. Resident #43 left his room and went back to the corner where Resident #44 was sitting and using profanity at her. There was not any staff in the vicinity that witnessed this interaction. Resident #43 returned to his room. Resident #44 stood up from her chair and looked down the hall to see where he went, then went back to reading her book. At 11:32 a.m. Resident #43 used profanity toward Resident #44. CNA #1 witnessed this and followed Resident #43 back to his room. At 11:33 a.m. CNA #1 returned to the main room and asked Resident #44 if she was ok. Resident #44 responded saying she was but she moved away from the corner because Resident #43 yelled at her. At 1:26 p.m. in the dining room, Resident #43 moved a chair at the table so he was positioned about eight feet to the left of Resident #44 and then he used profanity directed at her. Staff were present in the dining room and did not intervene. At 1:29 p.m. Resident #43 used profanity directed towards Resident #44. Staff were present in the dining room and did not intervene. At 1:31 p.m. Resident #43 used profanity directed towards Resident #44. Staff were present in the dining room and did not intervene. At 1:37 p.m. Resident #43 used profanity directed towards Resident #44. Staff was present in the dining room and did intervene but did not remove either resident from each other's proximity. The nursing home administrator (NHA) was made aware of Resident 43's behavior at 4:15 p.m. and the NHA said she would look into it. At 4:37 p.m. the regional vice president said Resident #43 was put on one-to-one staff observation. On 11/29/23 at 11:21 a.m. Resident #43 used profanity directed toward Resident #44 in the hallway on the secured unit while she was waiting to use the main bathroom. Resident #43 was on one-to-one observation and was redirected to his room and Resident #44 was directed to use the bathroom in her room. IV. Record review The resident's comprehensive care plan, revised 10/12/23, identified the resident could be verbally and physically aggressive due to cognitive deficits from his stroke, ineffective coping skills and poor impulse control. The care goal documented the resident's risk for verbally aggressive episodes would be minimized through the review date. Interventions included psychiatric/psychogeriatric consult as indicated, intervene before agitation escalated and guide away from source of distress. The rejection of care from the staff care plan, initiated 9/30/2020, revealed the resident had the potential to reject care from staff when required. The interventions included the staff would give the resident time and ask again. The activity care plan, revised on 11/18/22, revealed the resident was dependent upon staff for meeting his emotional, intellectual, physical and social needs due to the resident's cognitive deficits. It documented the resident enjoyed watching movies, reading, trivia, exercise and sitting outside. The interventions included: encouragement of ongoing family involvement; ensure activities the resident attended were compatible with the resident's mental capabilities and known interests; introduce him to residents with similar interests; and provide a program of activities that was of interest and empowered the resident allowing the resident a choice, self expression and responsibility. -The facility failed to develop a comprehensive care plan that addressed the resident's behaviors and psychosocial needs to include person-centered approaches. A review of progress notes from September 2023 to November 2023 revealed the resident was verbally aggressive on 20 occasions and physically aggressive on two occasions: On 9/18/23 an incident note documented Resident #43 initiated verbal aggressive behavior towards another resident in the dining room. Staff separated the residents. On 9/20/23 a nurse note documented the resident continued on 15 minute checks for his behaviors. He was observed to throw an incontinence brief at the certified nurse aide, a verbal altercation with Resident #44 and yelling at staff members. The primary care physician (PCP) was notified and no new orders were given. On 9/21/23 an interdisciplinary team note documented the discussion of behavioral changes. It was determined these behaviors were within baseline. On 9/22/23 a nurse note documented the resident continued on 15 minute checks for his behaviors. On 9/22/23 a physician visit progress note documented the resident was very agitated and kicked the physician and chased her out of the room. A registered nurse (RN) told the physician that his behaviors were a significant problem. The physician noted that the resident was a danger to staff, was frequently combative and his behaviors were uncontrolled. The physician documented the oxycodone (pain medication) was resumed twice a day last month due to the resident having pain in his scrotum. She opted to continue the narcotic pain medication noting his behaviors seemed to improve when it was taken regularly. On 9/23/23 a nurse note documented the resident continued on 15 minute checks for his behaviors and monitoring for increased oxycodone dose. On 9/29/23 a nurse note documented the resident was on 15 minute checks for a verbal altercation with his roommate which he initiated. Resident #43 cursed and yelled at his roommate. On 9/29/23, a nurse note documented the resident continued on monitoring for increased oxycodone from 2.5 milligrams (mg) twice a day to 2.5 mg four times a day. On 10/1/23 an alert note documented the resident had been verbally lashing out all day and continues on monitoring for increased oxycodone dose and frequency. On 10/25/23 a nurse note documented the resident was on charting for his behavior. The resident yelled and screamed toward other residents in the hallway. On 10/26/23 an interdisciplinary team note documented the resident appeared to have increased agitation. On 10/31/23 a nurse note documented the resident continued on 15 minute checks for his behaviors. The resident continued to yell in the hall using profanity and he was not easy to redirect. On 11/1/23 a nurse note documented the resident continued on 15 minute checks for his behaviors and continued to yell in the hallway. He was redirected to the dining room. On 11/2/23 an interdisciplinary team follow up note documented the resident continued to be at baseline without any behavioral changes observed. On 11/5/23 a nurse note documented the resident continued on 15 minute checks for his behaviors. The resident was yelling in the hallway and using profanity. On 11/8/23 a nurse note documented the resident had made physical contact with his roommate, Resident #65 and yelled at him on multiple occasions. Resident #65 was offered a room change and he agreed. Resident #43 continued on 15 minute checks for his behaviors. On 11/8/23 a nurse note documented the resident was yelling and calling two other residents names, one of which was Resident #44. He was redirected to his room and continued on monitoring for his behaviors. On 11/10/23 an interdisciplinary team follow-up note documented the resident continued to be at baseline without any changes observed. On 11/10/23 a nurse's note documented the resident was pointing and cussing Resident #44 and Resident #65 during breakfast. On 11/11/23 a nurse's note documented the resident continued on monitoring for his behaviors. He was observed yelling at Resident #44 and was redirected to stop with his behavior. On 11/12/23 a nurse note documented the resident was screaming at staff. Staff were able to redirect and escorted him to the smoking patio. On 11/13/23 a nurse's note documented the resident was screaming at staff and was redirected. He continued on 15 minute checks for his behaviors. On 11/15/23 an interdisciplinary team note documented the resident had shown increased agitation. On 11/15/23 a nurse note documented the resident was agitated in the morning, screamed at lunch and was redirected. He continued on 15 minute checks for his behaviors. On 11/17/23 a nurse note documented the resident continued on 15 minute checks for his behaviors and had verbal aggression and yelling towards staff. On 11/23/23 a nurse note documented the resident continued on 15 minute checks for his behaviors and had been screaming in the hallway. On 11/24/23 a nurse note documented the resident continued on 15 minute checks for his behaviors and was screaming in his room. On 11/25/23 a nurse note documented the resident continued on 15 minute checks for his behaviors and continued to yell when approached by staff. On 11/27/23 an incident note documented Resident #43 had called Resident #44 names while in the TV room. He was redirected to his room and the supervisor was notified and the social services department. On 11/28/23 a physician visit note documented the resident needed to be seen due to ongoing verbal aggression on the unit. He was noted to be on one-to-one monitoring. She documented the possibility of a trial of Zyprexa (a mood stabilizer) if he demonstrates more aggressive behaviors. V. Staff interviews CNA #1 was interviewed on 11/30/23 at 10:08 a.m. She said that all staff were responsible for separating residents involved in altercations and did their best to prevent altercations when possible. She said they redirected the residents and reported the incidents to their supervisor. She said they document the behaviors in a custom alert in the resident's electronic record and that all staff who witness behaviors were responsible for documenting that behavior. She said Resident #43 could have aggressive behavior toward other residents and staff members. She said she was not sure of any person-centered interventions that were successful for Resident #43, other than redirection. She said that behaviors were common on the secure unit. The NHA was interviewed on 11/30/23 at 1:40 p.m. She said if there was a safety concern after behavior incidents staff should separate the residents. She said staff should watch for behavior changes in general and residents acting out of their baseline to avoid escalating behaviors. She said in the situation with Resident #43, his behaviors were perceptional. She said Resident #43 might yell and cuss at someone as they walk by him but that behavior was not directed towards that resident, that is just how he is. She said each resident's comprehensive care plan should include person-centered interventions and approaches. She said each resident's behavior should be described and interventions included in the comprehensive care plan. She said the comprehensive care plan was part of the dementia care program. She said the comprehensive care plan should be a plan to provide care to all residents and dementia care services.

Based on interviews, document review, record review, and facility policy review, it was determined that the facility failed to ensure residents, their representatives and families of residents residing in the facility were notified of a confirmed positive COVID-19 result in the facility by 5:00 PM the following calendar day. This had the potential to affect all residents. The facility's Daily Census, dated 08/22/2022, indicated there were 72 active residents. Findings included: A review of the facility's policy titled, Communication During Covid Policy, dated 02/01/2022, revealed, Upon receiving a new Covid positive test result from a care partner or resident, the Administrator or designee will provide communication to Care Partners, Community Partners, Family members, and Residents. The policy further stated the information will be communicated no later than by 5:00 PM the next calendar day. A review of laboratory results for Resident #71, dated 08/20/2022, revealed the resident tested positive for COVID-19. During an interview on 08/22/2022 at 9:26 AM, the Director of Nursing (DON) indicated Resident #71 tested positive for COVID-19 on Saturday, 08/20/2022. During an interview on 08/22/2022 at 11:35 AM, the Administrator indicated she had received an email of the positive results on 08/20/2022. The Administrator indicated she had notified the DON, staff, and Resident #71's guardian. When asked if all families and/or guardians had been notified, the Administrator indicated she had not sent out the notification. The Administrator indicated the notification should have been sent out by 5:00 PM on 08/21/2022. During a follow-up interview on 08/22/2022 at 12:10 PM, the Administrator indicated the notification normally would have been done. On 08/25/2022 at 10:39 AM, the Administrator indicated the messaging system included all residents, families and/or guardians, and staff members. During an interview on 08/25/2022 at 9:20 AM, the DON indicated notification related to a positive COVID-19 case should be done by 5:00 PM the next day to staff, residents, and family and/or guardians.

Based on observations, interviews, facility document review, and facility policy review, the facility failed to prepare, distribute, and serve food in accordance with professional standards for food service safety. Specifically, the facility failed to: 1. Ensure a staff member performed hand hygiene after touching her mask/eye wear during pureed food preparation. This had the potential to affect two (Residents #21 and #44) of two residents who were to be served a pureed diet; and 2. Ensure the dishwasher sanitizer concentration was within the required range and failed to test/document the dish machine wash cycle temperature and sanitizer concentration per their policy. This had the potential to affect 71 of 72 residents in the facility who were served food from the kitchen. (One resident had a feeding tube and received no nourishment/hydration per mouth.) Findings included: 1. A review of the facility's Handwashing policy and procedure, revised 10/24/2018, revealed, All dining service workers must wash their hands the right way frequently with antibacterial soap and warm water for at least 20 seconds. Be sure to wash hands with soap and warm water for at least 20 seconds.after touching or scratching areas of the body, such as ears, mouth, nose, or hair. On 08/23/2022 at 11:40 AM, Dietary Aide (DA) #1 was observed as she prepared pureed diets for two residents. On 08/23/2022 at 11:42 AM, DA #1 pulled her mask down from her nose to reposition the mask. She proceeded with the process to puree the food without washing her hands. At 11:44 AM, DA #1 then adjusted the position of her mask and proceeded with the process to puree the food without washing her hands. Further observations revealed at 11:49 AM, DA #1 touched her mask as she walked into the serving area across the hall. She returned to the kitchen and, without washing her hands, proceeded with the process to puree the food. At 11:50 AM, DA #1 then pulled her mask down from her face to taste broth and, without washing her hands, proceeded with the process to puree the food. Further observations revealed at 11:52 AM, DA #1 adjusted her protective eye wear and mask and proceeded with the process to puree the food without washing her hands. At 11:53 AM, DA #1 touched her mask with her right hand. Without washing her hands, she proceeded with the process to puree the food. At 11:58 AM, DA #1 touched her protective eye wear and mask. Without washing her hands, she proceeded with the process to puree the food. In a few more seconds, DA #1 touched her protective eye wear again and proceeded with the process to puree the food without washing her hands. On 08/23/2022 at 12:18 PM, DA #1 was interviewed. She stated a mask and protective eye wear being worn would be considered to be contaminated. She stated touching a mask and protective eye wear would contaminate one's hands. When the above observations were reviewed with DA #1, she stated she should have washed her hands after touching her mask and/or protective eye wear before she continued the process of preparing the pureed food. During an interview on 08/24/2022 at 12:03 PM, the Dietary Manager (DM) stated a staff member's hands would be considered contaminated after they touched their mask and/or eye wear. He stated he would expect staff to wash their hands after the staff touched their mask or eye wear. An interview with the DM on 08/25/2022 at 9:19 AM revealed two residents received a pureed diet, Resident #21 and Resident #44. A review of the Diet Type Report, dated 08/25/2022, verified that Resident #21 and Resident #44 were to receive a pureed diet. On 08/24/2022 at 1:40 PM, the Registered Dietitian (RD) was interviewed. The above observations were reviewed with the RD. She stated a staff member who touched their face would have contaminated their hands. On 08/25/2022 at 7:22 AM, the Administrator was interviewed. The above observations regarding DA #1's failure to perform hand hygiene during pureed diet preparation. She stated staff should wash their hands after touching their face and before continuing with food preparation. 2. A review of the facility's Dishwashing Machine Use, policy and procedure, revised 03/2010, revealed, Food service staff required to operate the dishwashing machine will be trained in all steps of dishwashing machine use by the supervisor or a designee proficient in all aspects of proper use and sanitation. Dishwashing machine chemical sanitizer concentrations and contact times will be as follows: Chlorine Maximum Concentration 50-100 ppm Contact time 10 seconds. A supervisor will check the dishwashing machine for proper concentrations of sanitizer solution (measured as parts-per-million [PPM]) after filling the dishwashing machine and once a week thereafter. Concentrations will be recorded in a facility approved log. Corrective action will be taken immediately if sanitizer concentrations are too low. If hot water temperatures or chemical sanitation concentrations do not meet requirements, cease use of dishwashing machine immediately until temperatures or PPM are adjusted. A review of an undated facility document titled, Dishwasher Job Descriptions During Covid revealed the following schedule: -6:00 AM Set up sanitizer water and soapy water for dishwashers' area and cooks' area. Make sure to document PPMs. Make sure to document dishwasher temperatures. -12:00 PM Change all sanitation waters and soapy water, test all waters for PPM documentation. -12:15 PM Fill out the dishwasher temperatures for 12:00 PM. -4:00 PM Set up sanitizer water and soapy water for dishwasher area and cooks' area. Make sure to document PPMs and document dishwasher temperatures. -6:00 PM Set up sanitizer water and soapy water for dishwashers' area and cooks' area. Make sure to document all PPMs. Observation and interview in the kitchen on 08/24/2022 at 12:05 PM revealed the Dietary Manager stated the dishwasher was a low temperature, chemical sanitizing machine. When asked to run the dishwasher to test the sanitizer concentration, he was unable to find a bottle of test strips and left the dishwasher area to obtain a bottle. When he returned, he was asked how often the dishwasher should be checked to ensure proper concentration of sanitizer. He stated test strips were to be used to check the sanitizer in the dishwasher three times daily at mealtimes. When asked if there was documentation of the testing, he presented a document titled, Dish Machine Log - Low Temp. The log had documentation of the wash temperature and sanitizer concentration check for the month of August 2022 as follows: -08/01/2022 - breakfast and lunch, 50 PPM; no documentation for supper -08/02/2022 - breakfast and lunch, 50 PPM; no documentation for supper -08/03/2022 - breakfast, 50 PPM; no documentation for lunch or supper -08/04/2022 - breakfast, 50 PPM; no documentation for lunch or supper -08/05/2022 - No documentation -08/06/2022 - breakfast and lunch, 50 PPM; no documentation for supper -08/07/2022 - breakfast and lunch, 50 PPM; no documentation for supper -08/08/2022 through 08/10/2022 - No documentation -08/11/2022 - breakfast, 50 PPM; no documentation for supper -08/12/2022 - No documentation -08/13/2022 - breakfast and lunch, 50 PPM; no documentation for supper -08/14/2022 - breakfast and lunch, 50 PPM; no documentation for supper -08/15/2022 through 08/19/2022 - No documentation -08/20/2022 - breakfast and lunch, 50 PPM; no documentation for supper -08/21/2022 - breakfast and lunch, 50 PPM; no documentation for supper -08/22/2022 through 08/22/2022 - No documentation On 08/24/2022 at 12:09 PM, the DM tested the dishwasher chlorine concentration to be 10 PPM. The DM stated the concentration should be at 50-100 PPM. He then noticed the chlorine sanitizer container under the dishwasher machine was low and left the dishwasher room. He returned with a full five-gallon container of Chlorine Sanitizer and changed it out with the empty sanitizer container. On 08/24/2022 at 1:11 PM, the DM tested the sanitizer concentration of the dishwasher to be 100 PPM. On 08/24/2022 at 1:40 PM, the Registered Dietitian (RD) was interviewed. The above observations were reviewed with the RD. The RD stated the facility's policy was to test the dishwasher sanitizer concentration at each meal. On 08/25/2022 at 7:22 AM, the Administrator was interviewed. The above observations regarding the dishwasher low sanitizer concentration and documentation of sanitizer concentration were reviewed with the Administrator. She stated the failure of the dietary staff to test the dishwasher sanitizer concentration three times daily was a problem.

Based on observations, record review and interviews, the facility failed to establish and maintain an infection control program designed to prevent the spread of the novel Coronavirus (COVID-19) in three of three neighborhoods. Specifically: Observations, record review and interviews revealed the facility failed to conduct active screening of staff in a manner to prevent the spread of COVID-19. Staff reported self-screening and one staff member, who worked one-to-one with a resident, had no screening forms available for review. Both the staff member and the resident developed COVID-19. Further review of screening forms and staff interviews revealed no system to ensure all staff were screened, that screening forms were completed, and finally, that these forms were reviewed timely. Observations and interviews revealed additional infection control failures, including staff's failure to follow appropriate donning and doffing procedures for residents on isolation precautions. The above failures in infection control practices created an immediate jeopardy situation with the likelihood of serious harm to residents in three of three neighborhoods, staff, and others, if not corrected immediately. Findings include: I. Immediate jeopardy A. Findings of immediate jeopardy Observations, record review and interviews revealed the facility failed to conduct active screening of staff in a manner to prevent the spread of COVID-19. Staff reported self-screening and one staff member, who worked one-to-one with a resident, had no screening forms available for review. Both the staff member and the resident developed COVID-19. Further review of screening forms and staff interviews revealed no system to ensure all staff and visitors were screened, that screening forms were completed, and finally, that these forms were reviewed timely. Observations and interviews revealed additional infection control failures, including staff's failure to follow appropriate donning and doffing procedures for residents on isolation precautions. The above failures in infection control practices created an immediate jeopardy situation with the likelihood of serious harm to residents in three of three neighborhoods, staff, and others, if not corrected immediately. On 7/13/2020 at 5:52 p.m., the nursing home administrator (NHA), quality improvement coordinator (QIC), and director of nursing (DON) were notified the failures above created an immediate jeopardy situation that placed all residents in the facility at risk for serious harm (COVID-19). B. Facility plan to remove immediate jeopardy On 7/14/20 at 2:13 p.m., the facility submitted an action plan to abate the immediate jeopardy. The abatement plan read: The community was not following CDC guidance regarding thorough screening of employees consistently as well as donning and doffing PPE. Immediate action and ongoing monitoring Admission hold for new residents Fourteen day isolation hold for any hospital readmissions Employee reeducation on donning and doffing of PPE Dedicated staff to man front entrance for staff screenings during day hours. Identified staff to receive more education for staff screening off hours, after doors locked. QI(C), NHA, and DON reeducation for staff on proper donning and doffing of PPE. QI(C) to perform daily review of all employee COVID-19 entrance screening forms. QI(C) to perform daily virtual facility tours for compliance. Corporate call to facility on 7/14/20 to reiterate compliance. Facility to return to weekly staff and resident COVID-19 testing. C. Removal of immediate jeopardy On 7/14/20 at 3:05 p.m. the NHA, QIC, regional consultant (RC), and DON were informed that the immediate jeopardy had been abated, based on the facility's implementation of the above plan. However, deficient practice remained at F level (widespread with the potential for more than minimal harm). II. The facility failed to conduct active screening of staff in a manner to prevent the spread of COVID-19. A. Professional references 1. The Centers for Disease Control and Prevention (CDC) updated 6/25/2020, retrieved from https://www.cdc.gov/coronavirus/2019-ncov/hcp/long-term-care.html, reads: Actively screen everyone for fever and symptoms of COVID-19 before they enter the healthcare facility. Screen all healthcare personnel at the beginning of their shift. Actively take their temperature and document the absence of symptoms consistent with COVID-19. 2. The Centers for Medicare and Medicaid Services (CMS) (4/2/2020) COVID-19 Long-Term Care Facility Guidance. Retrieved from: https://www.cms.gov/files/document/4220-covid-19-long-term-care-facility-guidance.pdf. It read in pertinent part, Long-term care facilities should immediately implement symptom screening for all. Facilities should limit access points and ensure that all accessible entrances have a screening station. B. Screening process On 7/13/2020, observations of the facility's screening area for all healthcare personnel and other visitors who entered the facility revealed the screening area was located at the receptionist's office at the facility's main entrance and secured with a keypad code. Staff could access the building using the code and, thereafter, enter the facility for screening. Visitors pushed the doorbell and allowed, selectively, entrance into the screening area. 1. Observations and interviews a. Interviews and observations revealed deficiencies in the facility's screening process. On 7/13/20 at 8:55 a.m., the survey team entered the facility. The receptionist (REC) #1 asked the team to complete a screening questionnaire, stating, go ahead and screen yourselves and then someone will take your temperature. The social services assistant (SSA) took the team members' temperatures; neither REC #1 nor the SSA reviewed the team's responses on the questionnaires prior to the team entering the building. In addition, no education was provided and the bottle of hand sanitizer located at the screening desk was empty. At approximately 9:00 a.m., the NHA entered the facility for the first time that day and did not complete the screening process. She walked past the screening area and down the hallway. At 5:40 p.m., REC #1 was interviewed regarding the staff screening process. She said she normally worked the second shift of the day, but was covering another receptionist on this day. She said all staff enter through the front door and she has them fill out the screening form. She then takes the staff's temperature, and makes sure it is accurate. She said if a temperature was above 99 degrees Fahrenheit, she contacts administration. She said management would handle the screening process from there. When asked how she documented that she had contacted administration for any staff screenings that had occurred, she said it had not yet come up for discussion. She said she checked to make sure the staff name was on the form, the date, and that the temperature was documented accurately. She said she looked to make sure the rest of the screening form was completed with checkmarks, but she did not look at the responses specifically, just that they were completed. b. Staff interviews confirmed the deficiencies in the facility's screening process. In multiple interviews, staff reported they often self-screened prior to starting their shifts. Cook #2 was interviewed on 7/13/20 at 5:35 p.m. She said she always entered the facility through the front door. She said that if staff was present, she would have them watch her screen herself in the morning. However, she said she could not wait around in the morning because she had to start cooking; therefore, she often completed the screening form herself and took her own temperature. Licensed practical nurse (LPN) #2 was interviewed on 7/14/2020 at 12:45 p.m. She said she works the morning shift and every morning when she comes in, she checks her own temperature, answers all the questions, and sanitizes her hands. She said she usually is in the screening area by herself. Certified nurse aide (CNA) #4 was interviewed at the same time as LPN #2. He said all CNAs check and record their own temperature prior to the morning shift. He said they have been doing it for months, ever since the facility started to screen staff prior to their shift. He said no one was usually there to screen them; they all completed the screening themselves. CNA #1 was interviewed on 7/14/2020 at 12:33 p.m. She said, with regard to self-screening in the morning, We fill (out) the paper (form), check our own temperature, preferably confirming it with another nurse or CNA who is in line for screening. There is usually a line of people waiting and we confirm each other's temperature. 2. Record review revealed additional deficiencies in the facility's screening process. a. Review of the screening form, last updated 5/28/20, titled Respiratory Disease Screening, revealed the instructions read, Must be completed with any person entering (the) building. It further read, if a person had a new onset of fever, coughing, or shortness of breath/difficulty breathing, the person must speak to management prior to entering the community. If the person had two of the following symptoms, the person must speak to management prior to entering: Sore throat, congestion, runny nose, nausea/vomiting/diarrhea, new loss of sense of taste and/or smell, chills/shaking with chills, headache, fatigue, or muscle/body aches. The bottom of the form asked if the person had washed their hands or used alcohol-based hand rub (ABHR) on entry, and if they did not, please ask them to do so. The form did not include a space to document who provided the screening, the time the screening was completed, or any follow up conducted if the person had symptoms. b. Staff daily screening sheets from 6/1/2020 to 7/13/2020 were reviewed and many were found incomplete. Of the several hundred staff screening forms reviewed, approximately half were either incomplete, had responses which should have triggered additional screening questions, or indicated no under the bottom of the form where it asked if the person had washed their hands or used ABHR. Sixty-seven (67) staff screening forms reviewed were undated, eight screening forms had no recorded temperature, and more than half had no additional signature to indicate the temperature had been witnessed by another staff member. C. Potential adverse outcome related to the facility's screening deficiencies 1. Resident #7 and CNA #5 Resident #7 was admitted to the secured memory unit of the facility on 2/1/19. The resident's care plan was updated on 10/11/19 to include he should have one-to-one staff monitoring to ensure safety of others until such time as risk was mitigated. The record revealed CNA #5 had worked as a one-to-one aide with Resident #7 on 6/4/2020, 6/5/2020 and 6/6/2020. A nurse progress note, dated 6/9/2020, read Resident #7's oxygen saturation level had decreased to 68 percent on room air. He was transported to the hospital and subsequently tested positive for COVID-19. The facility tested all staff and residents on 6/12/2020 and confirmed that CNA #5 was positive for COVID-19 on 6/15/2020. According to the facility's line listing, seven residents and two staff members had positive results. 2. CNA #5's screening forms could not be located in the facility's records for 6/4/2020, 6/5/2020 and 6/6/2020. The facility could not confirm that the CNA had completed a screening prior to working on these dates. 3. The DON was interviewed on 7/13/2020 at 9:36 a.m. She said the facility had educated staff that they needed to have another staff person witness them take their temperature. She said if another staff member was not at the door when the staff member completed the screening at the start of their shift, he or she needed to get someone to witness their temperature. She said that all staff utilized the entrance where the screening area was located. She said that, usually, if any staff member had a temperature over 99 degrees, the staff member would bring that to the attention of the administration. 4. The NHA and DON were interviewed together on 7/13/2020 at 3:10 p.m. The DON said that based on the facility's investigation of the outbreak, it was identified that CNA #5 was likely patient zero, the initial person who was positive in the facility. D. Action taken to address the facility's screening deficiencies on and after notification of immediate jeopardy on 7/13/2020 at 5:52 p.m. 1. On 7/13/2020 at 5:52 p.m., the NHA, QIC, and DON were interviewed regarding the screening failures identified above. The NHA said the facility had not been able to locate daily screening documentation for the identified staff member (CNA #5) who most likely brought COVID-19 to the facility in early June. They were going to continue to look for it, but the search had been unsuccessful. The QIC said that he had reviewed the staff screening forms, as well, and would make sure that going forward, the forms would be filled out completely. 2. On 7/14/20 at 12:37 p.m., a meeting was held with the NHA, QIC, and DON. The QIC said an in-service education on the importance of staff screening was conducted the night of 7/13/20. Every staff member had been educated overnight. The QIC said he had provided this education himself. He said they had held a corporate call on the morning of 7/14/20 for all company facilities. All facilities were educated that either someone would be manning the facility front doors or the doors would be locked. Someone would have to unlock the facility door to allow staff to enter after hours. The QIC said they were going to reformat the facility's employee screening forms, as they had seen some of them filled out incorrectly. The NHA said they were considering putting answers to necessary follow-up questions on the back of the form to show that concerns had been reviewed. Staff would not be permitted to go to the floor until concerns were noted. Dedicated staff were educated on the full staff screening process. After hours, all registered nurses (RNs) would be educated, as they would be the staff doing the off-hour staff screenings. The QIC said he had reviewed all of the staff screening forms and would be reviewing them each day. He said he would also be doing virtual tours each day to address any concerns. III. Additional infection control failures - Failure to properly apply mask and failure to follow appropriate donning and doffing procedures for residents on isolation precautions. A. Professional references and facility policies 1. Professional references The Centers for Disease Control and Prevention, Preparing for COVID-19 in Nursing Homes, retrieved from: https://www.cdc.gov/coronavirus/2019-ncov/hcp/long-term-care.html (updated 6/25/2020) read, in pertinent part: Create a Plan for Managing New Admissions and Readmissions Whose COVID-19 Status is Unknown. Depending on the prevalence of COVID-19 in the community, this might include placing the resident in a single-person room or in a separate observation area so the resident can be monitored for evidence of COVID-19. HCP (health care providers) should wear an N95 or higher-level respirator (or facemask if a respirator is not available), eye protection (i.e., goggles or a disposable face shield that covers the front and sides of the face), gloves, and gown when caring for these residents. Residents can be transferred out of the observation area to the main facility if they remain afebrile and without symptoms for 14 days after their admission . Residents with known or suspected COVID-19 should be cared for using all recommended PPE (personal protective equipment), which includes use of N95 or higher level respirator (or facemask if a respirator is not available), eye protection (i.e., goggles or a disposable face shield that covers the front sides of the face), gloves, and gown. The Centers for Disease Control, How to Safely Wear and Take off a Cloth Face covering, https://www.cdc.gov/coronavirus/2019-ncov/prevent-getting-sick/diy-cloth-face-coverings.html reads in pertinent part, put (the mask) over your nose and mouth and secure it under your chin. 2. Facility policy A copy of the Personal Protective Equipment policy, dated 4/2020, was provided by the DON on 7/14/2020, read in part, Protocol for removing and reprocessing eye protection. Outside of goggles or face shield are contaminated! If your hands get contaminated during google or face shield removal, immediately wash your hands or use an alcohol-based hand sanitizer. Remove goggles or face shield from the back by lifting headband or ear pieces. If the item is reusable, place it in a designated receptacle for reprocessing. A copy of the Coronavirus Disease -Infection Prevention and Control Measures, dated 4/2020, was provided by the DON on 7/14/2020. It read in part, For a resident with a known or suspected COVID-19: Staff wear gloves, isolation gown, eye protection and an N95 or higher level respirator if available (a facemask is an acceptable alternative if a respirator is not available); and resident is placed in a private room with a dedicated bathroom (if available) and close the door; or resident cohorted per national, state, or local public health authority recommendations. B. Improper use of PPE 1. Mask The dietary manager (DM) was observed on 7/13/20 at 1:20 p.m., in the first floor common area. Two residents were observed in close proximity, wearing surgical masks. The DM had her surgical mask positioned below her nose. 2. Isolation room interviews and observations a. Isolation room [ROOM NUMBER] on 7/13/2020 CNA #2 was interviewed on 7/13/2020 at 9:42 a.m. She said the resident in room [ROOM NUMBER] was admitted two days ago and he was on quarantine because he was new to the facility. She further stated, if you do not touch the resident, you need only to wear gloves and a mask when in his room, nothing else. CNA #1 was observed at 9:45 a.m. entering room [ROOM NUMBER] with a breakfast tray. The sign on the door to the room read Droplet precautions. The CNA did not wear any PPE when she entered the room except for gloves and a surgical mask. After delivering the tray, she removed her gloves in the hallway, threw them into trash at the nurses' station and sanitized her hands. The DON was interviewed on 7/13/2020 at 10:40 a.m. She confirmed the newly admitted resident in room [ROOM NUMBER] was on droplet precautions. She said this meant nurses and CNAs should always wear a facemask, gloves, and a face shield; a gown should only be worn when providing direct resident care and touching the resident. She said she was following guidelines from the CDC found on a printed flyer, which she said did not mention the use of a gown with residents in isolation. In addition, she said resident in room [ROOM NUMBER] had two negative COVID-19 tests prior to admission. CNA #1 was interviewed 7/13/2020 at 1:02 p.m. She, too, acknowledged the resident in room [ROOM NUMBER] was admitted recently and was on isolation precautions. She said, since she did not touch the resident, she did not need to wear anything but gloves. She said she was aware the sign on the door read Droplet precautions, and she said other PPE were necessary only when staff provided direct care to the resident. LPN #1 was interviewed on 7/13/2020 at 1:20 p.m. He said the resident in room [ROOM NUMBER] was on droplet isolation precautions because he was newly admitted to the facility and his COVID-19 status was unknown. He said for droplet precautions, everyone entering the room should wear a gown, N95 mask or equivalent, gloves, and face shield. He said isolation precautions were followed for two consecutive weeks. CNA #2 was present during the interview with LPN #1. She said the DON instructed her not to wear full PPE, rather, only gloves, when in an isolation room. She said this was the practice followed earlier on the fourth floor when there was an outbreak of COVID-19. b. Isolation room [ROOM NUMBER] on 7/14/2020 The DON was interviewed on 7/14/2020 at 11:05 a.m. She said there was confusion on what PPE to wear for new admitted residents, but said she clarified for all staff members (during survey) that full PPE should be worn at all times when entering an isolation room, including gown, even though it had not been mentioned in the CDC flyer. CNA #1 was observed leaving room [ROOM NUMBER] on 7/14/2020 at 12:33 p.m. CNA #1 was wearing a surgical mask, face shield, gown, and gloves. She took all the PPE off in the room and hung the face shield on the wall on a hook outside the room. She did not sanitize her hands after removing PPE and she did not clean the face shield prior to hanging it on the hook outside the room. She said the face shield was not labeled and she just hoped no one would take it. At 1:05 p.m., room [ROOM NUMBER] was updated with a new sign that read to wear full PPE when entering the room - gown, gloves, face shield and N95 mask. CNA #3 was observed entering room [ROOM NUMBER] at 1:30 p.m When she approached the room, she was already wearing a N95 mask on top of a surgical mask. CNA #3 donned gloves first, then a gown and a face shield that was on the hook outside the door and delivered a lunch tray to the resident. As the CNA exited the room, the DON approached her and said she would walk the CNA through what PPE needed to be taken off first. The DON read the sign on the wall that she just posted, and told the CNA what to take off first. There was no hand sanitizer in the room and DON went to get it. Upon doffing the face shield, the CNA placed the shield back on the hook outside the room without cleaning. The DON was interviewed about the face shield left unsanitized on the hook outside room [ROOM NUMBER]. She confirmed that face shields were not assigned to individual staff members, not labeled, and not cleaned prior to hanging them on the wall outside the room. She also said a N95 mask should not be worn on top of the surgical mask. She acknowledged that PPE donning and doffing was not done correctly and stated she would work on it more. Regarding resident in isolation room [ROOM NUMBER], the DON said that she could not locate the test results showing the resident was tested for COVID prior to admission and, therefore, his COVID-19 status was unknown. C. Actions taken on and after the facility was notified of immediate jeopardy 1. On 7/13/2020 at 5:52 p.m., the NHA, QIC, and DON were interviewed about PPE use and care. The DON said that they had been using the CDC (Center for Disease Control) guidelines for everybody in the facility. The DON said that all staff had been educated on the use of gowns, and that they were to be worn at all times in isolation rooms. She said they had N95 masks, gowns, gloves, and face protection for any staff member going into the new resident admit room. 2. On 7/14/20 at 12:37 p.m., a meeting was held with the NHA, QIC, and DON on PPE use and care. The QIC said staff restrictions would be in place for resident isolation rooms. The QIC said the readmission process for residents would not change. He said all residents returning from the hospital would be on 14 days of isolation. He said there had been some readmission confusion, and they had thought they could relax precautions. All staff was now educated on PPE usage. The DON said all donning signs now included the N95 mask. She said she also looked at the resident vital signs every day. She said she looked at every resident with a temperature above 99 Fahrenheit. She said she would reeducate staff on ensuring temperatures were retaken due to any concerns with temperatures outside normal parameters.

Based on observations, record review and interviews, the facility failed to provide the appropriate treatment and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being for one unit of 17 dementia residents out of 74 total residents. Specifically, the facility failed to ensure: -Necessary care and services were person-centered and reflected the resident goals, while maximizing Resident #1 ' s dignity, privacy, socialization, choice and safety. -The facility identified person-centered approaches to utilize, including purposeful and meaningful activities addressing the residents customary routines, interests, preferences, and choices to enhance the residents well-being. Cross-reference: F600 Failure to prevent abuse and neglect Findings include: I. Facility policy and procedure The Dementia Clinical Protocol policy and procedure, revised November 2018, was provided by the quality insurance specialist (QIS) #1 on 3/9/2020 at 1:30 p.m. The policy read in pertinent part: Direct care staff will support the resident in initiating and completing activities and tasks of daily living. A. Bathing, dressing, mealtimes, and therapeutic and recreational activities will be supervised and supported throughout the day as needed. II. Resident #1 status Resident #1 age 80, was admitted on [DATE]. According to the March 2020 computerized physician orders [REDACTED]. The 1/28/2020 minimum data set (MDS) assessment revealed the resident had a moderate cognitive deficit with a brief interview for mental status (BIMS) score of eight out of 15. She had no verbal behaviors marked as daily and no rejection of care marked. For functional status, the resident was independent for bed mobility, transfers, toileting, and eating. She was supervision for personal hygiene. A. Resident interview Resident #1 was interviewed on 3/5/2020 at 11:45 a.m. She said, she did some activities like singing and reading but was currently bored. She said, she got into a disagreement with Resident #2 over a book she was holding. She said she would like to do more of what she liked to do instead of just sitting in a chair. B Observations Residents in the memory care unit were observed on 3/9/2020 between 8:00 a.m. and 2:35 p.m. During this time, three unknown residents were observed on unit in their wheelchairs going up and down the hallway not engaged by staff. Four other unknown residents were observed sitting in the television room of the unit. The residents were not engaged by staff. Several other unknown residents in the unit were in their bedrooms. The unit had the television on but no residents were observed watching. The residents on the unit did not socialize with other residents or engage in any specialized activities. The 9:30 a.m. daily chronicles, and 9:45 a.m. uptown downtown band activities were conducted, however most of the residents stayed on the unit. At 10:30 a.m. to 2:30 p.m. no activities were conducted. Resident #1 was observed during this time sitting in a chair on the wall on the side of the television room just looking around. III. Record review The activity care plan, revised 4/29/19, did not reveal how Resident #1 spent most of her time. According to the care plan, the resident enjoyed sharing stories, reading, social groups, live entertainment, singing in the uptown band, trivia, socializing with peers and staff. The care plan identified Resident #1 had impaired cognitive function and impaired thought process related to [MEDICAL CONDITION] disorder [MEDICAL CONDITION] type, and unspecified dementia without behavioral disturbance. Interventions included: engage the resident in simple structured activities that avoid overly demanding tasks and elopement attempts. Staff invite, encourage, and assist resident with getting to and from all activities of her interest. Review of the progress notes revealed the following: -1/14/2020: Nursing Note Resident#1 often checks the doors, trying to get out of the facility to go home. The nursing note did not show any attempts by staff to avoid elopement attempts or engage in activities. -1/21/2020: Nursing Note Resident#1 paces between doors checking to see if they are unlocked so she can get out of the facility to go home. The nursing note did not show any attempts by staff to avoid elopement attempts or engage in activities. -2/18/2020: Nursing note Resident #1 accused people of talking about her this shift, told staff member that she was going to kick her in the ass this shift, resident easily redirected. The nursing note did not show any attempts by staff to avoid behavior concerns or engage in activities. -2/20/2020: Nursing note Resident #1 was sitting reading a book and Resident #2 came up to her and insisted that she give it to her. Resident #1 got agitated and stood up and pushed Resident #2 to the floor. The two residents were separated and Resident #1 was taken to a different floor. Resident #1 was unharmed by the incident. The director of nursing(DON), medical doctor (MD), and family were notified. There was no documentation of attempts to engage the residents in activities. -2/22/2020: Nursing note Resident #1 followup for an altercation with another resident: Resident remains on 15 minute checks. No increased agitation noted. Resident #1 was noted sitting next to Resident #2 and having a calm conversation. Resident #1 was observed walking up and down the hall checking doors to see if they were locked. The nursing note did not show any attempts by staff to avoid elopement attempts. There was no documentation of attempts to engage the residents in activities. Activities calendar According to the review of the February 2020, and the March 2020 activity calendar, revealed the residents were scheduled for five to six activities from 9:30 a.m. to 7:30 p.m. daily, primarily the activities conducted were daily chronicles, country cart, and bingo. However most of the activities were from thirty to forty minutes and no activities were conducted in between. IV. Staff interviews Activities assistant (AA) was interviewed on 3/9/2020 at 12:15 p.m. She said there was not enough activity staff to conduct all of the activities on every floor all day long. She said it was very hard to work with residents with dementia and had not gone to every room to see if residents wanted to participate in activities. She said there were no specialized activities for the residents in the memory care unit. She said residents would benefit from more activities geared to dementia residents such as music or do one-to-ones with residents. She said it was a team effort and staff on the unit can also do activities. Certified nurse aide (CNA) #1 was interviewed on 3/9/2020 at 10:58 a.m. She said she had completed some dementia training for the facility. She said the activities staff do not do enough with the residents to keep them busy and decrease behaviors. She said she felt more training would be helpful for staff to decrease residents physical, mental, and wandering behaviors. Registered nurse (RN) #1 was interviewed on 3/9/2020 at 11:05 a.m. She said she sometimes will try to do some activities with a couple of the residents. However she said, not enough activities are offered to the residents. She also said more comprehensive activities would decrease residents from wandering the units and decrease behaviors. Activities director was interviewed on 3/9/2020 at 12:25 a.m. He said he had worked at the facility only a couple of months. He said a lot of activities were not conducive to benefit the residents in the memory care unit. He said, he knew dementia was related to behavior care including purposeful and meaningful activities addressing the residents interests, and preferences. He said most of the activities on the schedule were not geared to that, but he was working hard to correct that. The nursing home administrator (NHA) was interviewed on 3/9/2020 at 1:45 p.m. She confirmed the residents were not receiving appropriate activities for dementia care on the units from staff. She said, this can be seen in residents not engaging in activities and having behaviors. She also said there was a plan in place to increase meaningful activities for the residents on the units. However she could not show me the plan at that time.

Based on record review, and interviews, the facility failed to ensure two (#1, and #2) of two out of six residents who were investigated were free from abuse. Specifically, the facility failed to prevent resident to resident altercation between Residents #1 and #2. Cross-reference: F744 the facility failed to provide services to residents with dementia Findings include: I. Facility policies and procedures The Abuse policy and procedure, revised November 2019, was provided by the quality insurance specialist (QIS) #1 on 3/9/2020 at 1:30 p.m. The policy read in the pertinent part: 1. Providing a safe environment for the resident is one of the most basic and essential duties of our facility. 2. Employees have a unique position of trust with vulnerable residents. 3. This facility promotes an atmosphere of sharing with residents and staff without fear of retribution. Residents must not be subjected to abuse by anyone, including but not limited to facility staff, other residents, consultants, volunteers, staff of other agencies serving the residents, family members or legal guardians, friends, or other individuals. 4. Identification of abuse shall be the responsibility of every employee. II. Resident #1 A. Resident status Resident #1 age 80, was admitted on [DATE]. According to the March 2020 computerized physician orders [REDACTED]. The 1/28/2020 minimum data set (MDS) assessment revealed the resident had a moderate cognitive deficit with a brief interview for mental status (BIMS) score of eight out of 15. She had no verbal behaviors marked as daily and no rejection of care marked. For functional status, the resident was independent for bed mobility, transfers, toileting, and eating. She was supervision for personal hygiene. Record review and staff interviews revealed the facility was aware of Resident #1 had verbal and physical behaviors against others. The facility had interventions such as have resident do activities she liked throughout the day, medication management and redirection; however, Resident #1 behaviors continued to escalate based on nursing progress notes, and staff interviews with no positive response to the interventions. The facility did not ensure Resident #1 was safe from escalating behaviors. The facility did not ensure the resident did not negatively interact with other residents, and continued to try exit doors to leave the facility. B. Record review The behavior care plan, revised 4/29/19, revealed, Resident #1 had impaired cognitive function and impaired thought process related to [MEDICAL CONDITION] disorder [MEDICAL CONDITION] type, and unspecified dementia without behavioral disturbance. Interventions included: engage the resident in simple structured activities that avoid overly demanding tasks and elopement attempts. Discuss concerns about confusion, and disease processes. Staff invite, encourage, and assist resident with getting to and from all activities of her interest. She enjoyed sharing stories, reading, social groups, live entertainment, singing in the uptown band, trivia, socializing with peers and staff. Review of the abuse investigation revealed the following: -Date of incident: 2/20/2020. Time of incident: 2:30 p.m. -Date the investigation initiated: 2/20/2020. Time investigation was initiated: 2:30 p.m. -Residents involved: Resident #1, and Resident #2. Type of investigation: Physical abuse. -Suspected perpetrator: Resident #1 -Description: Resident #1 and resident #2 engaged in an altercation over a book. Resident #1 was holding the book. Resident #2 grabbed the book. Resident #2 fell to the floor. Immediate safety measures implemented: The residents were redirected and placed on increased monitoring. Both residents were evaluated by a nurse. Resident#1 and Resident #2 are at risk individuals and the police were notified. -Staff interviewed: three staff were interviewed but were not at the facility during the survey. -Residents interviewed: seven residents were listed including Resident #1, and #2. -Summary: There were conflicting stories about the severity of what happened. However, the facility took into account, that Resident #2 was on the floor and the incident was substantiated. -Action: Immediate safety measures implemented: The residents were redirected and placed on increased monitoring. Both residents were evaluated by a nurse. Resident#1 and Resident #2 are at risk individuals and the police were notified. Review of the progress notes revealed the following: -1/14/2020: Nursing Note Resident #1 often checks the doors, trying to get out of the facility to go home. The nursing note did not show any attempts by staff to avoid elopement attempts, engage or redirect the resident. -1/21/2020: Nursing Note Resident#1 paces between doors checking to see if they are unlocked so she can get out of the facility to go home. The nursing note did not show any attempts by staff to avoid elopement attempts, engage or redirect the resident. -2/20/2020: Nursing note Resident #1 was sitting reading a book and Resident #2 came up to her and insisted that she give it to her. Resident #1 got agitated and stood up and pushed Resident #2 to the floor. The two residents were separated and Resident #1 was taken to a different floor. Resident #1 was unharmed by the incident. The director of nursing (DON), medical doctor (MD), and family were notified. -2/22/2020: Nursing note Resident #1 follow-up for an altercation with another resident: Resident remains on 15 minute checks. No increased agitation noted. Resident #1 was noted sitting next to Resident #2 and having a calm conversation. Resident #1 was observed walking up and down the hall checking doors to see if they were locked. The nursing note did not show any attempts by staff to avoid elopement attempts, engage or redirect the resident. Medication Administration Record [REDACTED] The MARreviewed from 1/6/2020 to 3/5/2020 revealed monitoring of Resident #1 ' s behaviors or interventions for her behaviors was not documented. C. Resident interview Resident #1 was interviewed on 3/5/2020 at 11:45 a.m. She said, she was not fearful of Resident #2. She said she would like to do more of what she liked to do. V. Staff interviews Activities assistant (AA) was interviewed on 3/9/2020 at 12:15 p.m. She said she was not present when Resident #1 and Resident #2 had the altercation. She said she knew how to report abuse allegations. She said she knew resident #1 liked activities, and they calmed her behaviors. She also said there was not enough activity staff to conduct all of the activities on every floor all day long. She said it was very hard to work with residents with dementia and had not gone to every room to see if residents wanted to participate in activities. She said there were no specialized activities for the residents in the memory care unit. She said residents would benefit from more activities geared to dementia residents such as music or do one-to-ones with residents. She said it was a team effort and staff on the unit could also provide activities. Certified nurse aide (CNA) #1 was interviewed on 3/9/2020 at 10:58 a.m. She had been a CNA for [AGE] years. She said she knew how to report allegations of abuse. She said she was not working when Resident #1 and Resident #2 had an altercation. She said she had completed some dementia training for the facility. She said the activities staff do not do enough with the residents to keep them busy and decrease behaviors. She said she felt more training would be helpful for staff to decrease residents physical, mental, and wandering behaviors. She also said, Resident #1 will sit by the television room and will often look bored. Registered nurse (RN) #1 was interviewed on 3/9/2020 at 11:05 a.m. She said she knew how to report allegations of abuse and the different types of abuse. She said she sometimes would try to provide some activities with a couple of the residents. However she said, not enough activities are offered to the residents. She also said more comprehensive activities would decrease residents from wandering the units and decrease behaviors. The activities director was interviewed on 3/9/2020 at 12:25 a.m. He said he had worked at the facility only a couple of months. He said he knew the different types of abuse. He said a lot of activities were not conducive to benefit the residents in the memory care unit. He said, he knew dementia was related to behavior care including purposeful and meaningful activities addressing the residents interests, and preferences. He said most of the activities on the schedule were not geared to that, but he was working hard to correct that. He also said, Residents who are bored and have nothing to interest themselves will often have behaviors. He said I am working hard in his department to create meaningful activities for residents. The nursing home administrator (NHA) was interviewed on 3/9/2020 at 1:45 p.m. She said she was the abuse coordinator for the facility. She said staff can call her phone 24 hours a day with allegations of abuse. She said appropriate activities could decrease abusive behaviors on the units. She confirmed the residents were not receiving appropriate activities for dementia care on the units from staff. She said this could be seen in residents not engaging in activities and having behaviors. She also said there was a plan in place to increase meaningful activities for the residents on the units. However, she could not show me the plan at that time during survey. Findings include: III. Resident #2 A. Resident status Resident #2, less than [AGE] years of age, was admitted on [DATE]. The March 2020 computerized physician orders [REDACTED]. According to the 1/7/2020 minimum data set (MDS) assessment she had severe cognitive impairment to the extent in which she could not understand nor complete the brief interview for mental status (BIMS). She experienced delusions and had no adverse moods. B. Observation An observation made on 3/5/2020 at 11:30 a.m. revealed Resident #2 was standing in her room not engaged in a person-centered activity at this time; there was no staff member in her room providing a one-to-one activity for her. An observation made on 3/9/2020 at 12:24 p.m. revealed Resident #2 sat across from Resident #1 in the common area, neither of them engaged in a person-centered activity, and there was no staff offering person-centered activities for them. C. Resident interview Resident #2 was interviewed on 3/5/2020 at 11:01 am. She said she was safe, other residents were nice to her, and staff were respectful. She did not recall when Resident #1 pushed her to the floor; when she wanted a book back from her. She said she wanted to go to church but the facility told her it was too far to take her. She felt she did not belong on the secured floor because she had more knowledge than the other residents who lived on there. D. Record review According to the March 2020 CPOs, it reflected she had an order to be on the secured floor since 8/27/2019 due to she was a high risk for elopement. The care plan, initiated and revised on 12/9/2019, identified she had dementia behavior verbal and physical combativeness. Interventions included to anticipate her needs. The care plan, initiated on 4/19/2019 and revised on 2/4/2020, identified she had a communication problem related to her significant memory impairment due to dementia. Interventions included to anticipate and meet her needs. The care plan, initiated and revised on 4/24/2019, identified she wanted more independence, to make her own decisions; she wanted to join a book club with the activities department. She was intellectual, was very emotional about living in the facility and having lost her independence, and wanted to have a volunteer job to have a sense of purpose in life. Interventions included to assist and arrange community activities. The care plan, initiated on 11/29/2019 and revised on 12/09/19, identified she had behaviors of verbal and physical aggression due to dementia and ineffective coping skills. Interventions included to give her as many choices as possible about activities. According to the Resident #2 ' s activity tasks for February 2020 and March 2020, there was no documentation of regularly structured activities which reflected her interests or her participation. According to the 2/20/2020 at 3:10 p.m. incident note, it reflected Resident #1 stood up and pushed her to the floor. She sustained a scrape to her right elbow. She was placed on 15 minute checks; protocol for a neurological assessment. According to the 2/20/2020 at 3:54 p.m. incident note, it reflected Resident #2 said in her interview that she tried to get a book back from Resident #1; a book she lent to Resident #1. Resident #1 got upset, pushed her, she fell to the floor, and hit her right elbow. She denied pain or discomfort. According to the February 2020 progress notes, it reflected the facility completed their neurological assessment of her, the assessments were within normal limits, the facility monitored her mood and behavior and she did not display adverse moods or behaviors after the incident. E. Staff interviews The certified nurse aide (CNA) #2 was interviewed 3/9/2010 at 10:45 a.m. She said Resident #2 was not aggressive, she was forgetful, and confused. She said she and Resident #1 were good friends and they did not interact every day. She said if staff observed behaviors they were to immediately report to the nurse if there were any behaviors between residents. CNA #1 and registered nurse (RN) #1 were interviewed on 3/9/2010 at 10:45 a.m. they said Resident #2 could be inpatient, required redirection, and there was no tension between her and Resident #1. The activities assistant (AA) was interviewed on 3/9/2020 at 12:05 p.m. She said she heard Resident #1 and Resident #2 yelling and saw a nurse go to them. They were fine today on the elevator; neither of them recalled the incident and had no tension between them. Some days they interacted with each other appropriately. She said when there was a resident-to-resident incident, she would redirect them to calm them down, separate them, get help from staff, distract them, alert staff, and notify the NHA. I would have staff stay with residents or I would take one with me, we do this to keep them safe and protect them. The social service director (SSD) was interviewed on 3/9/2020 at 12:00 p.m. She said Resident #1 resided in the secured unit because she was an elopement risk. She refused to wear a wander guard but was not physically aggressive. Resident #2 told her Resident #1 pushed her and she got a scratch. She said staff were responsible to keep residents safe, separate them when necessary for their safety, immediately report concerns of abuse, and do 15 minute checks or 1:1 monitoring when necessary. The NHA was interviewed on 3/9/2020 at 1:24 p.m. She was notified the day of the allegation of physical abuse in the hallway which involved Resident #1 and Resident #2; who were not roommates. Staff protected both residents through redirection and increased monitoring. As the abuse coordinator she monitored residents for potential for abuse. She or staff intervened if they observed a potential for an argument; they knew their residents ' tendencies. Her number was easily accessible, she was available 24/7, or staff could report abuse concerns to the director of nursing (DON). The activity department were the eyes and ears of the facility and were going to start a program (which did not exist at this time) designed to engage the residents who lived on the secured floor to address the time between organized activities. She did not want residents who lived on the secured floor to just watch television. She expected the staff to identify boredom amongst them and get them engaged in an activity of their choice. The interdisciplinary team continued to discuss whether Resident #2 was appropriately placed on the secured floor. She planned to have the activities department provide spiritual services for Resident #2.

Based on record review and interview, the facility failed to ensure an effective training program for all staff included training on abuse, neglect, exploitation, and misappropriation of resident property. Specifically, the facility failed to ensure five employees received abuse training in the last 12 months after their initial training upon being hired. Findings include: I. Facility policy and procedure The Abuse Training policy, undated, was provided by the nursing home administrator (NHA) on 8/29/19 at 3:00 p.m. It documented in pertinent part, -Training programs are completed upon hire on abuse and neglect, The Elder Justice Act and resident rights. -Abuse prevention and The Elder Justice Act training for all staff is to be completed semi-annually. II. Record review Review of the course training data from 8/28/18 to 8/28/19 revealed that five staff had not had abuse and neglect training in the past 12 months: -Staff development coordinator (SDC) #2 hired on 9/4/12; -Laundry worker (LW) #1 hired on 6/14/18; -Certified nurse aide (CNA) #1 hired on 1/13/11; -Housekeeper (HK) #1 hired on 3/6/12; and -Licenced practical nurse (LPN) #5 hired on 1/20/14. III. Staff interviews The SDC #2 was interviewed on 8/28/19 at 9:19 a.m. She said she had started her position about a month previous but had worked in the facility in another capacity. She said since starting her role she ensured the nursing staff had their competency training which included an inservice about the types of abuse and reporting requirements. She said in addition to her training the nursing staff completed computer based training at a minimum annually but she did not have access to the system. She said she did not keep track of other staff ' s abuse and neglect training and she said the director of nursing (DON) would know who kept track of it. The DON was interviewed on 8/28/19 at 9:30 a.m. She said she did not keep track of all staff training of abuse and neglect training but the social service director (SSD) kept track of it and provided the abuse and neglect trainings at their all staff meetings. The SSD was interviewed on 8/28/19 at 9:35 a.m. She said she presented abuse and neglect training at all staff meetings. She said the staff who attended, signed in as being present, but she overall, did not keep track of who attended each meeting. The NHA was interviewed on 8/28/19 at 9:38 a.m. She said she thought the SDC kept track of all employee abuse and neglect training. She said she was going to keep track of the abuse and neglect training moving forward to ensure all staff had received the training wither in their all staff meetings held monthly, on the computer based system or any other abuse and neglect training provided by department managers.

Based on observations, interviews and record review, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of disease and infection. Specifically, the facility failed to: -Follow appropriate surface contact times with a disinfectant and perform hand hygiene with routine cleaning; and -Implement appopriate hand hygiene during medication pass. Findings include: I. Follow appropriate surface contact times with a disinfectant and perform hand hygiene with routine cleaning. [NAME] Professional reference The Centers for Disease Control and Prevention (2019) Healthcare Environmental Infection Prevention and Control, retrieved from: https://www.cdc.gov/hai/prevent/environment/index.html. It read in pertinent part, -Throughout healthcare, the physical environment represents an important source of pathogens that can cause infections or carry antibiotic resistance.Sometimes, the healthcare environment is a primary source of germs. Consider that molds can be present on wet or damp surfaces or materials, and bacteria can be present in plumbing fixtures including sink drains or ice machines. -The way that humans interact with the healthcare environment also plays a role. For example, when a healthcare worker fails to wash their hands, they might touch and contaminate a piece of equipment or environmental surface; in turn the equipment or surface could wind up exposing a patient to pathogens. -These examples illustrate the importance of environmental infection prevention and control in the healthcare setting. Water and environmental surfaces are two intersecting parts of the healthcare environment that contribute to the spread of antibiotic resistance and healthcare associated infections. B. Manufacturer recommendations for directions of use of the disinfectant spray The manufacturer's recommendation for directions of use for the disinfectant spray, undated, was provided by the quality improvement specialist (QIS) on 8/29/19 at 4:22 p.m. It read in pertinent part, To clean and disinfect hard, non-porous surfaces: For heavily soiled areas, clean before disinfecting. Thoroughly wet hard, non-porous for 10 minutes, then rinse and wipe clean. C. Observations of housekeeping staff on 8/29/19 At 11:24 a.m. housekeeper (HK) #1 was observed cleaning room [ROOM NUMBER]. She donned gloves without performing hand hygiene previously and went into the bathroom with two clean rags. There was a brown substance on the base of the right side of the toilet. She sprayed the disinfectant directly onto the toilet seat, under the seat and base of the toilet. She immediately wiped the disinfectant with a rag starting on the toilet seat, the bowl rim and then cleaned the base of the toilet. The brown substance still remain at the base of the toilet even after she cleaned the toilet. She took the rag out of the bathroom and disposed of it on her cart. She doffed her gloves and donned new gloves without performing hand hygiene to clean the rest of the room. She did not follow the manufacturer's instructions to spray disinfectant directly on the surface ensuring thorough saturation to remain wet for 10 minutes (see manufacturer recommendation above) before wiping up it up. After cleaning room [ROOM NUMBER], she doffed her gloves and placed them in the trash and proceed to clean another residents room without performing hand hygiene. At 11:35 a.m. HK #1 was observed cleaning room [ROOM NUMBER]. She donned gloves without performing hand hygiene previously and went into the bathroom with two rags. She cleaned the sink area of the bathroom with one rag and left it on the counter after cleaning. She sprayed the disinfectant directly onto the toilet seat, under the seat and base of the toilet. She immediately wiped the disinfectant with a rag starting on the toilet seat, the bowl rim and then cleaned the base of the toilet. She then placed the rag she cleaned the toilet with onto the sink area where she had just cleaned to take the trash out of the bathroom. She took the two rags out of the bathroom once she emptied the trash and placed them in a bag on her cart. She did not change her gloves and proceeded to clean room [ROOM NUMBER]. After cleaning the room, she doffed her gloves and placed them in the trash and proceeded to clean another resident room without performing hand hygiene. D. Staff interviews The maintenance service director (MSD) was interviewed on 8/29/19 at 12:31 p.m. He said he managed the housekeeping, laundry and maintenance departments. He said the housekeeping manager was on vacation and he was not available. He said the previous housekeeping manager worked in medical records currently so she would be able to answer procedural questions on how to clean the room. He said the representative from the chemical company came in once a month to check the chemicals the facility was using to disinfect and clean the resident rooms. He said most of the housekeepers had been working at the facility for several years so they did not require additional training on how to clean and use the chemicals. He said when a housekeeper started, during initial training they were provided competency based training on how to clean the resident rooms. The health information manager was interviewed on 8/29/19 at 12:41 p.m. She said previous to starting her position in medical records, she was the housekeeping manager for about five years. She said the correct procedure to clean the room was to start in the bathroom where two rags were used, one for sink area and one for the toilet. She said after the sink was cleaned the rag was discarded into a bag and then the toilet was cleaned with disinfectant sprayed directly on it and wiped immediately. She said the rag to clean the toilet was placed in the bag and removed from the room. She said after the bathroom was cleaned and disinfected, the housekeepers were to change their gloves with performing hand hygiene in between before proceeding to clean the rest of the room. She said once the room was cleaned then the housekeepers doffed their gloves and performed hand hygiene before cleaning the next room. She said when she managed the department she would provide on the spot training if she saw the rooms were not being cleaned correctly but did not document or provide competency based training after the initial training. She said she did not know what the surface contact time was the disinfectant chemical the housekeepers used and it was being used when she was supervising the department. The staff development coordinator #1 was interviewed on 8/29/19 at 1:02 p.m. She said she was the infection control preventionist for the facility and oversaw the program. She said she had started a month previous in the position. She said she tracked the infections of the facility and had provided training to staff during monthly all staff meetings and skills fair training held every three months on hand hygiene, specifically when to use alcohol based hand rub or wash their hands. She said she did not know the surface contact time for the chemical used by the housekeepers. She said based on the observations (see above) that there could be a potential for spread of a healthcare associated infection. She said moving forward she would be working with all the departments to provide education on infection control prevention. II. Failed to implement appropriate hand hygiene during medication administration. [NAME] Professional standards The Centers for Disease Control and prevention (CDC) Hand Hygiene in Healthcare Settings, last updated 4/29/19, retrieved from https://www.cdc.gov/handhygiene/providers/index.html, included the following recommendations : Multiple opportunities for hand hygiene may occur during a single care episode. Following are the clinical indications for hand hygiene: Use an alcohol-based hand sanitizer (ABHS) immediately before touching a patient, before performing an aseptic task or handling invasive medical devices, before moving from work on a soiled body site to a clean site on the same patient, after touching a patient or a patient's immediate environment, after contact with blood, body fluids or contaminated surfaces, and immediately after glove removal. Wash with soap and water when hands are visibly soiled, after caring for a person with known or suspected infectious diarrhea, or after known or suspected exposure to spores. B. Facility policy and procedure The Hand Hygiene policy and procedure, revised (MONTH) (YEAR), provided by the quality improvement specialist (QIS) on 8/29/19 at 4:30 p.m. documented the following: All personnel shall be trained and regularly in-serviced on the importance of hand hygiene in preventing the transmission of healthcare-associated infections. Single use disposable gloves should be used before an aseptic procedure, when anticipating contact with blood or body fluids; and when in contact with a resident, or the equipment or environment of a resident who is on contact precautions. Wash hands before applying non-sterile gloves and after removing them. The Medication Administration policy and procedure, dated 9/30/13, provided by the QIS on 8/29/19 at 4:30 p.m. documented the following: Wash hands or use hand sanitizer prior to medication preparation for each medication pass. If direct resident contact is made, the nurse must wash hands. Do not touch oral medications, topical medications, ointments or creams. C. Observation Registered nurse (RN) #1 was observed on 8/28/19 at 7:18 a.m. during medication pass. RN #1 used alcohol-based hand sanitizer (ABHS) and then donned gloves. She said she wore gloves because she had a hard time popping the pills out of the cardboard bubble pack. She removed the medication cart keys from her scrub top pocket. She touched the computer, the mouse, the top of the cart, the medication cart handles and medication cards. She removed the residents medication cards from the cart and laid them on top. She then held the blister pack and popped the medication out in to her gloved hand, which was contaminated by previous touched items. She them placed the medication into a souffle cup. She followed the same technique for the next three medications. She then locked the medication cart and asked the resident if he would like milk to take his medications. With the same gloved hands, she removed the keys from her pocket and unlocked the nourishment room door. She opened the refrigerator and poured a cup of milk for the resident. She removed the gloves in the nourishment room, and did not perform hand hygiene. She grabbed the cup around the lip of the drinking surface and gave it to the resident. RN #1 was observed again on 8/28/19 at 7:46 a.m. She used ABHS and then donned gloves. She used her gloved hand to remove the keys from her pocket. She touched the computer, the mouse, the top of the cart, the medication cart handles and medication cards. She removed the residents medication cards from the cart and laid them on top. She then held the blister pack and popped the medication out in to her gloved hand, which was contaminated by previous touched items. She them placed the medication into a souffle cup. She followed the same technique for the second medication. She then locked the cart and walked to the residents room. With the same gloved hands she knocked on the residents door. She entered the room and removed her gloves at the bedside before giving medications to the resident. She did not perform hand hygiene until after the medications were administered to the resident. RN #1 was observed a third time on 8/28/19 at 5:01 pm. While she was preparing to check a resident's blood sugar. She donned gloves and removed an alcohol wipe and a 4x4 gauze from the cart. She walked to the common area where the resident was sitting. She used her gloved hand to push her glasses on to her nose and then scratched her arm with the same gloved hand. Without changing gloves or performing hand hygiene, she wiped the residents finger with the alcohol wipe and used the gauze to wipe away the first drop of blood. She then held the residents finger and collected the sample. She again used gauze to apply pressure to the bleeding finger. She failed to do hand hygiene and don new gloves after touching her glasses and scratching her arm. D. Record review The RN training log was provided by the QIS on 8/29/19 at 4:30 p.m. It documented RN #1 had received hand hygiene training on 8/14/19. The skills check off form was provided by the QIS on 8/29/19 at 4:30 p.m. It documented that RN #1 was trained on handwashing, hand gel and glove use on 8/14/19 with satisfactory results. The document was signed and dated by RN #1. E.Staff Interviews The director of nursing (DON) and the QIS were interviewed on 8/29/19 at 12:00 p.m. The DON said when a nurse was preparing medications they should wash their hands and not touch the medication with their bare hands. The QIS said if a nurse chose to wear gloves, the only surface they should be touching was the medication card while the pill was being removed from. The QIS said if they touch any other surface they were to remove the gloves and perform hand hygiene before donning new gloves. The QIS said he would have to talk to the nurse in question and ask her why she was wearing gloves to pass medications. He said the nurse should not have worn gloves for the medication pass. The staff development coordinator (SDC), who was also the infection control preventionist, was interviewed on 8/29/19 at 1:30 p.m. She said the facility did hand hygiene training with the annual competencies, during the skills fair every three months, and during spot checks. She said staff should be washing their hands before and after donning gloves. She said if a nurse chooses to wear gloves the nurse should only be touching the medication card and nothing else.