**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, facility documentation, staff interviews, and policies and procedures, the facility failed to ensure one resident (#166) was free from resident to resident abuse, which resulted in physical harm as evidenced by a 5 x 4 cm bruise on the resident's right wrist. The deficient practice could result in other residents being abused. Findings include: -Regarding Resident #166 Resident #166 (alleged victim) was admitted to the facility on [DATE] with diagnoses that included chronic kidney disease, anxiety disorder, major depressive disorder, and schizoaffective disorder. A neurological care plan initiated on July 13, 2019 indicated that the resident has an alteration in neurological status related to dementia. Goals included: resident will be able to communicate daily needs, and will maintain optimal status and quality of life within limitations imposed by neurological deficits. Interventions included give medications as ordered, monitor/document for side effects and effectiveness, evaluate and treat as ordered. Review of a care plan initiated on July 25, 2019 revealed that the resident demonstrated physical behaviors related to his impaired cognition. The goal was resident will not harm self or others. Interventions included to analyze key times, place, circumstances, triggers, and what deescalates behavior and document. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 3, which indicated the resident had severe cognitive impairment. The MDS assessment indicated that at the resident was negative for psychosis, behavioral symptoms, rejection of care, and wandering. A nursing note dated November 4, 2021 revealed that the resident presented to the nursing office and showed a nurse a bruise to his right wrist. The nursing note stated that the resident reported that his roommate punched him causing the bruise which measured 5 x4 cm. The note documented that resident #166 stated that he was going to his room when his roommate grabbed then punched him. A follow-up nursing note dated November 4, 2021 indicated that resident #166 demonstrated exit seeking behavior after the incident. The note also noted that the resident wanted to talk to someone and kicked the exit door. The note documented that this occurred twice within a 30-minute period. A Health Status note dated November 4, 2021 indicated that during conversation with the resident regarding the incident, the resident stated that the man who hit him was standing next to him. Review of a progress note dated November 5, 2021 revealed that the incident which left a bruise on the resident's wrist was reported to Adult Protective Services (APS), non-emergency police, and the ombudsman. The note also stated that the residents were separated into different rooms. A weekly skin assessment dated [DATE] indicated that resident #166 had a new skin condition. It was described as right wrist bruise. Further review of the resident's clinical notes revealed a nursing note dated November 8, 2021 which indicated that resident had presented to the nurse's station multiple times stating he was being beat up in his sleep. The note indicated that the resident was reassured, redirected, and monitored. -Regarding resident #5 Resident #5 (alleged perpetrator) was initially admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses that included dementia without behavioral disturbance/psychotic disturbance/mood disturbance/anxiety, altered mental status, cerebrovascular disease, vascular dementia, anxiety disorder, and major depressive disorder. A cognition care plan initiated on April 30, 2018 revealed that the resident has impaired cognitive function/impaired thought process related to dementia. Interventions included to communicate with resident/family/caregivers regarding resident's capabilities and needs, review medications and record possible cause of cognitive deficit. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 5 indicating that the resident has severe cognitive impairment. Additionally, the MDS indicated that the resident has not exhibited psychosis or behavioral symptoms during the assessment period. A Health Status Note dated November 4, 2021 revealed that the resident # 5 was moved to another room in the secured unit. Review of a behavior note dated November 4, 2021 revealed that resident #5 stated that he did grab his roommate's arm and punched him with his fist. The note indicated that the incident occurred in the hallway and that the Director of Nursing (DON) was notified of the incident. A Social Services Progress note dated November 5, 2021 documented that per the DON, an Adult Protective Services (APS) report was submitted about a claim of a resident hitting roommate. The note indicated that residents have been separated into different rooms. It also noted that the incident was reported to the non-emergency police and that the ombudsman was notified. Review of the facility's investigation report dated November 9, 2021 revealed that according to Registered Nurse's statement, she was signing out medications in the nurse's office when resident #166 approached her and showed her his right wrist with a recent bruise. The report indicated that residents involved were unable to recall the event when interviewed. The investigation concluded that the allegation of abuse could not be substantiated due to lack of witnesses and inconsistency in resident statements. An interview with a Licensed Practical Nurse (LPN/staff #3) was conducted on December 7, 2023 at 1:52 p.m. Staff #3 stated that residents are supervised in order to mitigate resident to resident altercations. However, if it occurs, the staff will separate the residents immediately and report the incident. She indicated that she has not experienced such incidents in the facility. However, if it happens, it is reported to the Director of Nursing (DON), the social worker, physician, and family. Notification to the state and police is also done and the facility has to follow its protocol regarding abuse reporting and it is reported immediately. An interview with a Certified Nursing Assistant (CNA/staff #51) was conducted on December 7, 2023 at 2:08 pm. Staff #51 indicated that when they see a potential or actual resident to resident altercation, they try to redirect the residents. She noted that they get assistance to make sure the residents are separated and safe. Then they let the nurse know about the incident so it can be reported/documented. Staff #51 said that staff are provided abuse training. She said that it is provided as needed, when they do in-service training, and it is discussed during monthly meetings. An interview with the Director of Nursing (DON/staff #100) was conducted on December 7, 2023 at 3:07 p.m. Staff #100 stated that her expectation is for her staff to notify her immediately if an allegation of abuse occurs. She noted that she expects her staff to ensure that the resident(s) is safe. Notification regarding the allegation of abuse will then be accomplished by either the DON or the Executive Director (ED). The investigation is also usually done by the DON or the ED. Social Services assist with safety questions. The investigation involves interviewing anyone randomly where the incident occurred, interview the residents to see if they feel safe. With regards to the incident between residents #166 and #5, staff #100 noted that she remembers it. She noted that the incident was investigated and residents were assessed. Staff #100 noted that the residents were safe. She said to her recollection they were unable to unsubstantiated or substantiate due to the residents involved being in the dementia unit. The alleged victim was out in the hallway and it the timeframe could not be determined. Residents were not reliable historians. Regardless, she noted that the facility still must investigate, assess, separate the residents, and try to find out what happened. Review of facility policy titled Abuse Policy version dated 06/2022 indicated that the facility strive to prevent the abuse of all their residents. Furthermore, it noted that their objective is to provide a safe haven for our residents through preventive measures.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record reviews, staff interviews and facility policy and procedures, the facility failed to ensure that a Preadmission Screening and Resident Review (PASRR) level I was completed accurately and a level II was sent to the state for determination for one resident (#2). The deficient practice could result in specialized services not being identified and provided to residents. Findings include: Resident #2 was initially admitted to the facility on [DATE] and was re-admitted on [DATE] with diagnoses that included acute stress reaction, and suicidal ideations. A cognition care plan revised on November 7, 2019 revealed that the resident has impaired cognitive function or impaired thought process. Interventions indicated to use residents name and identify yourself at each interaction. Review of a medication care plan revised on November 4, 2019 revealed that the resident is on psychotropic medications related to schizoaffective disorder. Interventions included administer medications as ordered, monitor/record occurrence of target behavior symptoms, monitor/record/report to physician side effects and adverse reaction to medication, and psychiatric/psychological consult as ordered. A medication care plan initiated on September 23, 2020 indicated that the resident is on antidepressant medication related to depression. Interventions included to monitor/document/report to physician as needed ongoing signs/symptoms of depression that is unaltered by medication, give antidepressant medications as ordered by physician, and refer for psychiatric/psychological consult as ordered. Review of the resident's face sheet revealed the following new diagnoses and date of onset: major depressive disorder dated July 11, 2021, anxiety disorder dated September 26, 2020, and schizoaffective disorder dated August 21, 2021. A medication care plan revised on September 28, 2020 revealed that the resident is on anti-anxiety medication related to anxiety disorder. Interventions included to give anti-anxiety medications as ordered, monitor/record occurrence of target behavior symptoms, and psychiatric/psychological consult as ordered. Review of the PASRR Level I Screening Tool dated March 9, 2021 revealed the form was not adequately filled out. Section B. Mental Illness was left blank. The symptoms portion under the area interpersonal with the question has the individual exhibited interpersonal symptoms or behaviors was left unanswered. Additionally, the concentration/task related symptoms portion was left answered. The portion pertaining to History of Psychiatric Treatment was also left blank. The area titled Psychotropic Medications was also left blank. A communication care plan revised April 25, 2022 revealed that the resident has impaired hearing. Interventions included to be conscious of the resident's position when in groups, activities, and dining room to promote proper communication with others. It also recommended to use communication techniques which enhance interaction and to allow adequate time to respond. A care plan revised on April 25, 2022 indicated that the resident has a potential to demonstrate physical and verbal behaviors and refusal of care related to dementia. The goal was for resident not to injure self or others. Interventions included to administer and monitor the effectiveness of medications, assess and anticipate needs, evaluate for side effects of medication, intervene as needed to protect the rights and safe of others, remove from situation, when agitated-ensure safety and re-approach at a later time when less agitated. A medication care plan revised on February 17, 2023 revealed that the resident is on anti-psychotic medicates related to schizoaffective disorder. Interventions included to administer medications as ordered, and monitor for side effects. A behavioral care plan revised on July 26, 2023 revealed that the resident has behavior problems related to striking/swinging at staff during nursing care. Interventions included to administer medications as ordered, anticipate and meet needs, encourage to follow the care plan but respect choices, and explain all procedures to him before starting, allow time to adjust to changes. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 99, indicating that the resident was unable to complete the assessment. Section I. Active Diagnoses indicated the resident's diagnoses included dementia, anxiety disorder, depression, and schizophrenia. Further review of the clinical record did not reveal a PASRR Level I after the PASRR Level I dated March 9, 2021. An interview with the Resident Relations Manager who functions as Social Services (staff #107) was conducted on December 7, 2023. Staff #107 stated that when a resident first comes into the facility, they come in with a PASRR which she reviews/updates. After the resident is here after 40-day admission they review and will do a PASRR or hospital stay or change they do a level II PASRR. Staff #107 noted that if there is a mental illness and intellectual disability they will do a new PASRR and initiate a level II. PASRR audit is accomplished by corporate and they check PASRR. However, the audit does not include residents that have been in the facility over 40-days, so long term care residents are not part of the PASRR audit complete by corporate. Staff #107 stated that every single spot of the PASRR sheet should be completed and that included section B. She noted that if schizoaffective disorder is a new diagnosis after a PASRR is completed then a new PASRR will be triggered. Staff #107 noted that if a new PASRR is not accomplished following a new mental illness/disorder diagnoses then the facility will not be able to provide effective care for the resident. She stated that a new PASRR is a great identifier to provide care for what a resident need so if it is not completed then it can be a problem. Staff #107 verified that the most recent PASRR for resident #2 was dated March 9, 2021. She stated that with the diagnoses of schizoaffective disorder in August 21, 2021, it should have triggered a new PASRR I and should include the medications that is related to the pertaining diagnosis. An interview with the Director of Nursing (DON/staff #100) was conducted on December 7, 2023 at 2:12 p.m. Staff #100 stated that her expectation is that PASRR is completed for each resident. She said that she also expects that when there is a new diagnosis related to mental illness/disorder a new PASRR is accomplished. Staff #100 stated that she has been made aware that a new PASRR should have been completed for resident #2 and that one will be done for him. Staff #100 stated that if a PASRR is not updated then the facility will not know how to properly care for the resident. Review of the facility's policy titled Pre-admission Screening and Resident Review [PASRR]) version 0920 stated that the facility will strive to verify that a Level 1 PASRR screening has been conducted, in order to identify serious mental illness (MI) and/or an intellectual disability (ID) prior to initial admission of individual to the facility. Additionally, it stated that PASRR Level I screenings are used to determine whether the individual has a diagnosis or other presenting evidence that suggests the for MI or ID. If the resident is positive for potential MI or ID, a Level II PASRR referral must be submitted. The policy indicated that it is the responsibility of the facility to make referrals for a Level II PASRR, or that a referral is made by the ALTCs case manager, if a Level II is determined to be necessary. The policy also indicated that the facility will strive to submit an updated Level I Screening and Level II evaluation request within 14 days after the facility determines through the MDS assessment that there has been a significant change in the resident's physical or mental condition which may indicate the need for specialized MI or ID services, according to the Criteria for Level II Referrals. Furthermore, the policy stated that an updated Level I screening must be conducted for each resident of the facility who has serious mental illness or intellectual disability not less than annually.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, clinical record review, interviews, and policy review, the facility failed to ensure one resident (#23) received the necessary services to maintain good bathing and grooming hygiene. This deficient practice could result in bathing and grooming needs not being met. Findings include: Resident #23 was admitted on [DATE] with diagnosis including Parkinson's Disease, unspecified dementia, psychotic disturbance, mood disturbance, anxiety, arthritis, major depressive disorder, muscle weakness and need for assistance with personal care. A review of the MDS (minimum data set) dated November 07, 2023 revealed a BIMS (brief interview of mental status) of 5 and further noting that for personal hygiene the resident requires one-person physical assistance. A review of the care plan for resident #23 revealed that the resident is at risk for functional selfcare deficits and that facility staff is to communicate the resident and or family regarding the resident's needs. A observation was conducted on December 07, 2023 at 1:54 P.M. Resident #23 was observed to be seated in the communal area of the unit watching television. The resident was not clean shaven and was observed to exhibit facial hair. A telephone interview with the representative, Individual #203, of resident #23. She stated that the resident likes to be shaved but had not been. Individual #203 stated that the resident's presonal razor had been brought to the facility and it was requested that staff shave the resident; however, based on the representatives statement and per observation, the resident had not been shaven. An interview was conducted on December 7, 2023 at 2:02 P.M. with resident #23. The resident stated that he did not like facial hair and would like to have a shave. The CNA (certified nursing assistant), staff #31, had walked into the room and stated that the resident had not been shaven for 3 to 4 days, because she can't find his personal razor. She stated that facility razors were available but they tend to cause 'nicks' and that is why she had not shaved the resident. When asked about an electric razor, staff #31stated that the facility does have one but she would have to track it down; however, neither a bladed or electric razor had been utilized to shave the resident. She stated that the last time the resident had received a shower was on December 06, 2023. She further stated that anytime a resident wants to be shaved that he should be shaved. An interview was conducted with 2 additional CNA's, staff #94 and staff #202, on December 07, 2023 at 2:06 P.M. CNA #202 stated that residents generally bring their own razors, but if not, a facility razor would be utilized and CNA #94 if a resident prefers to be shaven, staff would shave the resident on a daily basis. An interview was conducted on December 07, 2023 at 2:27 P.M. with LPN (licensed practical nurse) staff #3. Staff #3 stated that personal hygiene tasks such as shaving are generally completed twice a week during showers and as needed. Staff #3 reviewed the shower schedule for the resident and stated that it was noted that the last documented shower was on November 15, 2023. An interview was conducted on December 07, 2023 at 2:39 P.M. with the DON (director of nursing) staff #100. Staff #100 stated that shaving is contingent on whether a resident would like to be shaved or not and that it is most frequently offered during showers twice weekly. However, staff #100 stated that the last documented time the resident had received a shower was on November 15, 2023 and the facility expectation is 2 showers per week; however, per facility documentation, the last reported shower had been approximately 3 weeks ago which did not meet the facility's expectation. A review of the facility's Activities of Daily Living (ADL) policy, with a revision date of March 2018, revealed that appropriate care and services would be provided to residents who are unable to carry out ADL's independently to include bathing and grooming. The bath and shower policy dated 2022 revealed that staff are to document the date and time that the shower/ bath had been performed and further document skin related observations and or refusals; however, the last documented shower was noted to be on November 15, 2023.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on documentation, staff and resident interviews, and the facility policy and process, the facility failed to ensure one resident (#40) had access to activities. The deficient practice could impact the psychosocial well-being of residents. Findings include: Resident #40 was admitted to the facility on [DATE] with diagnoses that included a displaced intertrochanteric fracture of the left femur, chronic obstructive pulmonary disease, dependence on oxygen, major depressive disorder and an anxiety disorder. The activities care plan dated October 10, 2023 stated that the resident enjoys being in his room watching TV and looking outside his window getting sunlight and included one intervention to offer a variety of activity types and locations. Note: resident #40 shares a room and his roommate's bed is located on the side of the room where the window is located. The minimum data set (MDS) dated [DATE] included a brief interview for mental status score of 14 indicating the resident was cognitively intact. Review of the clinical record did not reveal any documentation of activities that the resident attended or refused to attend. During the initial interview conducted on December 4, 2023 at 1:07 p.m. with resident #40, he stated that he is not invited to activities and doesn't know what activities are being offered. An activity calendar was observed hanging on wall directly across from the resident's bed and was dated November 2023. An interview was conducted on December 7, 2023 at 2:07 p.m. with the Activities Manager (#staff 61), who stated that the purpose of activities is to get the residents out of their rooms, to distract them. She makes an activities calendar each month for the residents, so they know what activities are being offered. She stated that she goes to the residents' rooms and invites them to activities and she memorizes which residents are not participating. She stated that resident #40 usually doesn't want to attend activities because he is not interested. She stated that the prior Activities Manager trained her, which included tracking and documenting resident participation, but she has not done this. An interview was conducted on December 7, 2023 at 2:27 p.m. with the Executive Director (ED/staff #11), who stated that he supervises the Activities Manager (staff #61) and he has never required her to track resident participation in activities. He stated that there is a large activities calendar posted in the hallway, so residents know what activities are scheduled. During a second interview conducted on December 7, 2023 at 2:47 p.m. with resident #40, he stated that he can't get out of bed by himself, so he would need assistance to attend an activity. He also stated that he can read, but he can't see the activities calendar hanging on the wall across the room. The facility's policy Activity Programs dated January 2011 states that the activity programs are designed to encourage maximum individual participation and are geared to the individual resident's needs. Activities participation for each resident is approved by the Attending Physician based on information in the resident's comprehensive assessment. Scheduled activities are posted on the resident bulletin board. Activity schedules are also provided individually to residents who cannot access the bulletin board (e.g. bed bound or visually impaired residents).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical documentation, staff interviews, and the facility policy and process, the facility failed to complete baseline vital assessments upon one resident's (#116) admission. The deficient practice result in a change of condition not being recognized. Findings include: Resident #116 was admitted to the facility on [DATE] with diagnoses that included displaced intertrochanteric fracture of the left femur, hypothyroidism, and depression. The admission evaluation dated May 26, 2023 at 3:25 p.m. did not include vitals. An admission summary progress note dated May 26, 2023 at 7:38 p.m. revealed that the resident arrived at the facility around 1:30 p.m. The resident was admitted for a displaced intertrochanteric fracture of the left femur, subsequent encounter for a closed fracture with routine healing. The resident's weight was 158 pounds. Review of the weights and vitals summary revealed that the resident's blood pressure was 129/68 and temperature was 97.6 F. at 4:00 p.m. A health status progress note dated May 26, 2023 at 5:37 p.m. revealed that the resident felt warm and her temperature was 99.5 F. The resident was offered Tylenol and declined stating that it gives her diarrhea. The resident was checked again at 8:58 p.m. and stated that she was having chest pain and that she had called her husband and told him to call 911. The ambulance arrived at 9:05 p.m. to transport the resident to the hospital as per the resident's request. Saturation of peripheral oxygen (SPO2) was 95%. Staff attempted other vitals, but the emergency staff arrived and took vitals. The discharge/transfer assessment dated [DATE] at 9:23 p.m. did not include vital signs. An interview was conducted on December 6, 2023 at 10:14 a.m. with the reporting source (#200), he stated that the resident had surgery and was treated for infection at the hospital. He stated that the resident called him and said that she was hot and sweaty, warm to the touch, and having heart palpitations. He was concerned because staff did not take the resident's vitals when she was admitted and her temperature baseline was below average. He called 911 and had the resident transported to the hospital. An interview was conducted on December 6, 2023 at 11:17 a.m. with the Director of Nursing (DON/staff #100), she stated that when a resident is admitted , the staff establish a baseline, which includes: mentation, vitals, skin check, heart and lung sounds, and pedal pulses and the results are documented in the initial evaluation or could be found in a progress note. It is her expectation that the vitals are done within the first hour of the resident being admitted . She referred to the admission evaluation and acknowledged that the vitals were not included. Then, she referred to the clinical record and stated that the resident was admitted at 1:30 p.m., blood pressure was taken at 4:00 p.m., and temperature was taken at 4:00 p.m. She stated that if the vitals were not taken when the resident was admitted , we wouldn't have a baseline and then we wouldn't know if there was a change of condition. She also stated that she thinks it is common for the elderly to have a lower temperature. An interview was conducted on December 6, 2023 at 2:12 p.m. with a licensed practical nurse (LPN/staff #18), who stated that when a resident is admitted , the nurse completes a head-to-toe assessment, which includes a full set of vitals and the documented in the clinical record. She stated that the facility doesn't have a policy regarding vitals.

Based on staff interviews, and review of facility documentation and policies, the facility failed to ensure that the QAA (quality assessment and assurance) committee collected data and monitored it's performance regarding adverse events for performance improvement. Findings include: An interview was conducted on December 7, 2023 at 3:21 P.M. with the administrator, staff #11, and the director of nursing, staff #25. Staff #11 stated that the QAA comittee meets at least quarterly and that data for performance improvement is obtained from a variety of sources to include audits, staff and resident feedback. Some of the topics for PIP's (performance improvement plans) had included the facility census, pressure ulcers, weight loss, falls, psychotropic medications, call-light response and showers. Staff #11 stated that the data for each PIP is reviewed the following month during the QAPI (quality assurance and performance improvement program) meeting. Staff #11 stated that staff #25 utilizes audit forms and that data is kept in a specific binder. Status updates are then shared forward with staff and residents as applicable. She stated that two of the PIP's tracked included call-light response, which were stated to be ongoing and showers, which were stated as a completed PIP; however, when asked about the data tracking, the facility was unable to provide evidence of data tracking for either PIP. The administrator stated that both analysis of data and graphing of the data would be an expectation for any PIP. He stated that the risk of not tracking and appropriately documenting the data could include that the problem would not actually get fixed. A review of the Quality Assurance and Performance Improvement Meeting policy with a copyright date of 2016 revealed that the purpose of QAPI is to establish data-driven, facility-wide processes that improve the quality of care; however, for 2 of the performance measures, there was no evidence of data trend tracking for the identified PIP's.

Based on personnel file reviews, staff interviews, and the facility policy and procedures, the facility failed to provide evidence that 3 out of 10 staff (#98, #26, and #27) were provided resident rights training. The deficient practice could result in residents not being afforded their rights. Findings include: Review of the personnel file for staff #98, a physical therapist, revealed a hire date of June 1, 2023. Further review of the personnel file revealed no evidence that staff #98 had received training on resident rights. -Review of the personnel file for staff #26, a occupational therapist, revealed a hire date of June 1, 2023. Further review of the personnel file revealed no evidence that staff #26 had received training on resident rights. -Review of the personnel file for staff #27, a speech therapist, revealed a hire date of June 1, 2023. Further review of the personnel file revealed no evidence that staff #26 had received training on resident rights. An interview was conducted on December 6, 203 at 9:19 a.m. with the human resources (staff #201) all staff are required to complete training on resident rights. An interview was conducted on December 6, 2023 at 3:27 p.m. with a certified occupational therapy assistant (COTA)/Area Manager (staff #111. She stated that she doesn't have a sign-in sheet to show that staff (#98, #26, and #27) attended resident rights training. The facility policy Staff Development Program states all personnel must participate in initial orientation and regularly scheduled in-service training classes. DHS Mandatory topics include resident's rights.

Based on personnel file review, staff interviews, and the facility policy and procedures, the facility failed to provide evidence that 1 out of 10 staff (#98) was provided dementia training. The deficient practice could result in residents with dementia not receiving the care needed. Findings include: Review of the personnel file for staff #98, a physical therapist, revealed a hire date of June 1, 2023. Further review of the personnel file revealed no evidence that staff #98 had received dementia training. An interview was conducted on December 6, 203 at 9:19 a.m. with the human resources (staff #201) all staff are required to complete dementia training. An interview was conducted on December 6, 2023 at 3:27 p.m. with a certified occupational therapy assistant (COTA)/Area Manager (staff #111. She stated that she doesn't have a sign-in sheet to show that staff (#98) attended dementia training. The facility policy Staff Development Program states all personnel must participate in initial orientation and regularly scheduled in-service training classes. Topics did not include dementia training.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews, and the facility policy and procedures, the facility failed to ensure that adequate documentation for one resident's (#40) nutritional intake was completed. The deficient practice could result in nutritional deficiencies not being monitored. Findings include: Resident #40 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included unspecified protein-calorie malnutrition, iron deficiency, chronic obstructive pulmonary disease, and acute kidney failure. Review of the care plan dated October 10, 2023 revealed that the resident is at risk for nutritional and hydration problems as evidenced by a low mini nutritional assessment (MNA) score of 6: malnourished. Interventions included fortified cereal, Med Pass nutritional shake two times daily, and to encourage intake. A mini nutritional assessment (MNA) dated October 11, 2023 revealed the resident's height was 68 inches and weight was 142 lbs and had a moderate decrease in food intake and lost more than 6.6 pounds over the last three months. The minimum data set (MDS) dated [DATE] included a brief interview for mental status score of 14 indicating the resident was cognitively intact. The order summary revealed an order dated October 10, 2023 for a regular diet, regular texture, thin liquids consistency and fortified cereal. A progress note by the dietician dated November 12, 2023 revealed that the resident's weight was 133.5 lbs on November 3, 2023 and he had a 5.6% weight loss over the last 30 days. The resident is on a regular diet with 67% intake times one week, variable intake of fortified cereal, and an appetite stimulant is in place. The resident's weight is trending down despite interventions and will add Med Pass nutritional shake twice a day to maximize nutrition. Review of task for cereal intake revealed that there was no documentation on November 2, and 6, 2023 and documented as not applicable on November 10, 11, 12, 17, 18, 19, 23, 24, 25, 26, and December 1, 2, and 3, 2023. An interview was conducted on December 7, 2023 at 12:52 p.m. with a certified nursing assistant (CNA/staff #36), who stated that the percentage of food intake for every meal is documented for all the residents. She stated that if a resident refuses to eat, she documents the refusal on the task sheet and reports it to the nurse. She knows that the resident eats fortified cereal with a protein shake for breakfast and if it is a standing order, he should received the cereal every morning. She stated that if there is no documentation regarding the percentage of cereal eaten, it may mean that the cereal was not sent to the resident. During an interview conducted on December 7, 2023 at 1:14 p.m. with a registered nurse (RN/staff #81), she referred to the cereal order and stated that it was part of the dietary order, but was not sure how often the resident was supposed to receive it. She went to check with the Director of Nursing (DON/staff #100) and stated the DON told her the order for the fortified cereal was for every day shift. Then, staff #81 reviewed the task sheet for the fortified cereal and stated that some of the documentation was missing, and there were multiple times that not applicable was documented. She was not able to state why the staff hadn't documented the amount of cereal eaten and did not know what was meant by not applicable. An interview was conducted on December 7, 2023 at 1:24 p.m. with the Director of Nursing (DON/staff #100), who stated that it was the same CNA who documented not applicable on the task sheet and needed to be reeducated on how to complete the task sheet accurately. Then, staff #100 reviewed the progress notes and stated that she couldn't find anything showing that the resident refused to eat cereal on the days that the data was marked not applicable. She stated that there is a risk to not documenting the percentage of meal intake or the refusal to eat because we are not able to see if the resident is benefiting from the cereal. The facility's policy Resident Nutrition Services dated November 2015 states that the multidisciplinary staff, including nursing staff, the attending physician and the dietitian will assess each resident's nutritional needs, food likes, dislikes and eating habits. They will develop a resident care plan based on this assessment. Nursing personnel will evaluate food and fluid intake in residents with, or at risk for, significant nutritional problems. Nursing staff will assess and document the amounts eaten as indicated for individuals with, or at risk for, impaired nutrition.

Based on observations, staff interviews, and policy reviews, the facility failed to ensure a sanitary kitchen with regards to peeling paint over the tray line counter. The deficient practice could increase the risk of foodborne illness. Findings include: An observation was conducted of the kitchen on December 6, 2023 at 12:13 p.m. During this observation, peeling ceiling paint was noticed above the tray line counter. A follow-up observation was conducted on December 6, 2023 at 3:00 p.m. It was observed that the cracked and peeling ceiling paint spanned the length of the 3 vents on top of the tray line counter. An interview with the Nutrition Services Manager (staff #55) was conducted on December 6, 2023 at 2:55 p.m. Staff #55 stated that there are plans for a kitchen renovation. He said that the facility knows about the cracked/peeling ceiling paint in the kitchen but no action has been taken. He stated that the facility has assessed but nothing has been done. Staff #55 stated that it does bother him and that the crack/peeling ceiling paint is around the 3 vents. He said that potentially particles can get in the food they are preparing. Staff #55 noted that over 6-months ago, he placed a work order about the ceiling but it still has not been fixed. An interview was conducted with the Executive Director (ED/staff #11) inside the kitchen on December 6, 2023 at 3:02 p.m. Staff #11 admitted that all the times he has been at the kitchen he has never looked up. Now looking at it, he admitted that it is a concern that there is cracked/peeling ceiling paint over the tray line. Staff #11 stated that it has probably been months that the ceiling has cracked/peeling paint. He indicated that renovations for the kitchen is supposed to start next week. Staff #11 agreed that having cracked/peeling ceiling paint over the tray line is an issue. Review of the TELS work order log with the timeframe of May 1, 2023 through December 5, 2023 did not reveal a work order request regarding the peeling ceiling paint in the kitchen. On December 7, 2023 at 9:16 a.m., the ED (staff #11) and the Nutrition Services Manager (staff #55) showed the surveyor that the kitchen ceiling was fixed. Review of the facility policy titled Sanitation revised October 2008 indicated that the food service area shall be maintained in a clean and sanitary manner. The facility policy titled Maintenance Service revised December 2009 indicated that the maintenance department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times. Furthermore, the policy stated that the functions include maintaining the building in good repair and free from hazards. The policy noted that the Maintenance Director is responsible for maintaining a schedule of maintenance service to assure that the buildings, grounds, and equipment are maintained in a safe and operable manner.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interviews, clinical record reviews, and review of policy and procedure, the facility failed to ensure one resident who was identified with serious mental illness (#44) and one presumed short-stay resident (#26) who remained in the facility for longer than 40 days were referred to the State-designated authority for Level II pre-admission screening and resident review (PASRR) evaluation and determination. The sample size was 2. The deficient practice may result in residents being inappropriately placed into nursing homes and/or not receiving services they need. Findings include: -Resident #44 was admitted to the facility on [DATE] with diagnoses that included systemic lupus erythematosus, schizophrenia, and major depressive disorder, recurrent. Review of the Level I PASRR screening dated 02/04/21 indicated the resident had not been admitted for 30-day convalescent care and did not have a primary diagnosis of serious mental illness. However, the section of the assessment which would include whether or not a referral was necessary for Level II determination had not been completed. The screening was signed by a Nurse Care Manager (NCM). Another Level I PASRR dated 03/12/21 was identified in the clinical record which included the resident's relevant diagnoses. However, a referral for a Level II evaluation and determination was not made. A physician order dated 12/30/21 revealed for Trazodone HCl (antidepressant) 100 milligrams (mg) once daily for major depressive disorder, recurrent. Review of a physician order dated 03/01/22 included duloxetine HCl (antidepressant) delayed release particles 20 mg once daily for depression related to major depressive disorder, recurrent. A physician order dated 07/16/22 included behavior monitoring for the number of episodes per shift the resident exhibited drug seeking behaviors related to a history of aggressive behaviors. Review of the July 16 through 31, 2022 Medication Administration Record (MAR) revealed the resident displayed drug seeking behaviors for 26 out of 49 shifts. However, review of the care plan did not include drug seeking and/or aggressive behaviors. Further review of the July 2022 MAR revealed psychotropic medications were administered per physician orders, and that the resident displayed inability to sleep/stay asleep for 10 out of 31 nights. The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident scored 15 on the brief interview for mental status, indicating intact cognition. The assessment indicated the resident displayed no behaviors or symptoms of psychosis, and required supervision/set-up for most activities of daily living. The August 2022 MAR revealed the resident displayed drug seeking behaviors for 49 out of 94 shifts. The resident displayed inability to sleep/stay asleep for 12 out of 31 nights. Per review, medications were administered in accordance with the physician's orders. A health status progress note dated 09/06/22 at 3:33 a.m. included the 2:00 - 10:00 p.m. shift reported the resident had an increase in self-isolation episodes. The note stated the isolation episodes were difficult to gauge at that time due to the resident resting in bed with eyes closed. Review of the September 1 through 7, 2022 MAR revealed the resident displayed drug seeking behaviors for 15 out of 21 shifts, and an inability to fall asleep/stay asleep for 5 out of 7 nights. However, per review of the clinical record, a referral for a PASRR Level II evaluation and determination had not been done. -Resident #26 admitted to the facility on [DATE] with diagnoses that included type 2 diabetes mellitus with hyperglycemia, panic disorder (episodic paroxysmal anxiety), and post-traumatic stress disorder, chronic. A PASRR Level I screening document dated 10/04/21 revealed the resident was admitted to the facility from the hospital after receiving acute inpatient care, and that the physician had certified before admission that the resident required 30 days or less of nursing facility services. The document indicated that no referral for Level II services was necessary. However, further review of the clinical record did not reveal the PASRR Level 1 was updated and/or that the resident was referred to the State authority for Level II evaluation and determination after the resident continued to reside in the facility for longer than 40 days. On 09/08/22 at 11:13 a.m., an interview was conducted with the Social Services Director (SSD/staff #52). She stated that PASRR screening must be completed before residents are admitted to the facility or that she will complete the screening if the hospital has not provided it. She stated if the resident comes to the facility for 30-day convalescent care, but needs to stay longer, she will complete another Level I PASRR which would be good until the resident was discharged . She stated the resident would still be considered a Level I unless they were considered to be a danger to themselves or others. She stated that the clinical team is responsible to review for accuracy of diagnoses. She stated that she thought the MDS coordinator was responsible for making referrals to the State agency for Level II evaluation. She stated that the facility would not be appropriate for residents with Level II designation. She stated that she was not really aware of the PASRR screening process and that she would be sure to correct it as soon as she could. An interview was conducted on 09/08/22 at 11:44 a.m. with the Director of Nursing (DON/staff #27). She stated that upon admission the resident will have a PASRR which would be completed by the discharging facility/hospital. She stated that either she or the MDS coordinator will review it for accuracy. She stated that if the resident was admitted for a 30-day convalescent stay, but stayed for a longer period of time, a PASRR Level II must be completed upon day 40 by the SSD (staff #52). She stated that when a resident is identified as having an evident or possible mental disorder, intellectual disorder, or related condition staff #52 must make a referral. She stated that it would not meet her expectations not to screen the residents appropriately. The facility policy titled Pre-admission Screening and Resident Review, dated 2020 stated the facility will strive to verify that a Level I PASRR screening has been conducted, in order to identify serious mental illness (MI) and/or intellectual disability (ID) prior to initial admission of individuals to the facility. A new PASRR Level I screening is not required for readmission to the facility. PASRR Level I screenings are used to determine whether the individual has a diagnosis or other presenting evidence that suggests the potential for MI or ID. If the resident is positive for MI or ID, a PASRR Level II referral must be submitted. It is the responsibility of the facility to make referrals for a Level II PASRR.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, resident and staff interviews, and the facility's policies and procedures, the facility failed to assist one resident (#3) in obtaining hearing aids. The sample size was 2. The deficient practice could result in residents not being provided with devices to maintain hearing ability. Findings include: Resident #3 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included chronic obstructive pulmonary disease, and acquired absence of right leg above the knee. Review of physician orders dated April 10, 2021 included the resident may be seen by a podiatrist, dentist, eye doctor, wound care consultant, psychiatrist, and audiologist as needed. Review of the audiological record dated March 9, 2022 stated minimal response levels for pure tone. Review of the pure tone audiogram revealed a downward slope in hearing frequency. The audiological record included a prescription that stated to consider hearing aids if dementia, and also stated severe hearing loss bilaterally. Review of a quarterly Minimum Data Set, dated [DATE] revealed a Brief Interview of Mental Status score of 7, which indicated the resident had severe cognitive impairment. The MDS stated the resident had adequate ability to hear (with hearing aid or hearing appliances if normally used), understood verbal and non-verbal expressions, and understood verbal content (with hearing aid or device if used). An interview was conducted with the resident on September 9, 2022 at 12:57 p.m. Resident #3 was lying in bed looking at the television. Resident #3 answered interview questions appropriately but had to be spoken to loudly. Resident #3 stated she was hard of hearing in both ears. An interview was conducted on September 8, 2022 at 8:42 a.m. with a social service (staff #52). Staff #52 stated this was the first time she heard about the resident needing hearing aids, and that she did not know anything about the audiology recommendation. Staff #52 stated the process when a resident returns from an audiology appointment included the driver handing the doctor's paperwork to the receptionist who was also responsible with scheduling appointments. Staff #52 stated the nurses input the orders, then give the paperwork to the medical records to be scanned to resident's electronic records. Staff #52 stated she would follow up and make the appointment happen. An interview was conducted on September 8, 2022 at 1:50 a.m. with the DON (director of nurses/staff #27). Staff #27 stated the process when a resident returns from an audiology appointment includes giving the physician paperwork to the nurse, who inputs the physician orders, then the family or the facility can make arrangements for transportation. Staff #27 stated social services was responsible for following up on hearing aids prescriptions. The DON stated if a resident did not get the recommended hearing aids, the resident could have difficulty with communication. A facility policy, Hearing Impaired Resident, Care of, stated staff will assist hearing impaired residents to maintain effective communication with clinicians, caregivers, other residents and visitors. The policy also stated the staff will assist the resident (or representative) with locating available resources, scheduling appointments, and arranging transportation to obtain needed services.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, observations, resident and staff interviews, and policy and procedure, the facility failed to ensure a suprapubic catheter was secured and positioned below the level of the bladder for one resident (#46). The sample size was 2. The deficient practice could result in adverse effects to residents. Findings include: Resident #46 was admitted to the facility on [DATE] with diagnoses that included sepsis, unspecified organism, urinary tract infection, and reflux uropathy, unspecified. Review of the nursing admission summary dated [DATE] at 6:22 p.m., stated the resident was admitted following urosepsis with a suprapubic catheter related to chronic obstructive urinary issues. Review of the care plan initiated on August 8, 2022 included a problem for obstructive uropathy, and stated the resident was at risk for developing complications due to the catheter. The interventions included keeping the catheter drainage bag below the level of the bladder. Review of the admission Minimum Data Set assessment dated [DATE] revealed a Brief Interview of Mental Status score of 10, which indicated the resident had moderately impaired cognition. The assessment also revealed the resident had an indwelling catheter. An observation was conducted on September 6, 2022 at 9:42 a.m. The resident was observed lying in bed, eyes closed, the head of the bed was flat, and the resident's head was resting on a white pillow. Resident #46 was observed with a urinary catheter bag attached on the middle part of the bed frame, aligned with the resident's left hip, not below the bladder. A second observation was conducted on September 8, 2022 at 8:30 a.m. The resident was lying in bed with the head of the bed slightly elevated to approximately 20 degrees. A urinary catheter was observed hung on the upper right side of the bed, on the movable frame. The urinary catheter had approximately 1300 cc (cubic centimeter) of urine, and the tubing had visible sediments. An immediate interview was conducted with resident #46 who stated he had just finished eating breakfast. The resident stated the urinary catheter was emptied by the nurses once a day. Resident #46 exposed the urinary catheter, and stated he did not know if the nurse emptied it last night because he was asleep. The urinary catheter tubing was not secured on the resident's body, and the drainage bag was not placed below the resident's bladder. An interview was conducted with the resident on September 8, 2022 at 11:00 a.m. The resident stated he was showered and a nurse put a new dressing on the catheter. The resident exposed the suprapubic catheter site and it was observed the stoma was covered with a 4X4 gauze. However, further observation of the urinary catheter revealed the urinary tubing was not secured. An interview was conducted on September 8, 2022 at 1:50 a.m. with the DON (director of nurses/staff #27). Staff #27 stated her expectation related to the placement of a supra pubic catheter included the collection bag being placed below the level of the bladder, and securely anchored to prevent tugging. The facility policy, Urinary Continence and Incontinence-Assessment and Management revealed urinary catheters will be used sparingly, for appropriate indications only. The policy also revealed the staff and physician will treat symptoms of urinary tract infections or urosepsis as indicated but that eradication of all bacteria may not always be feasible (e.g., in a resident who has an indwelling urinary catheter). The policy did not include catheter placement and securement to prevent potential injury and recurrent urinary tract infections.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, observations, staff interviews, and review of policy, the facility failed to provide oxygen as ordered for one resident (#3). The sample size was 2. The deficient practice could result in residents not receiving ordered oxygen. Findings include: Resident #3 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included chronic obstructive pulmonary disease (COPD), absence of right leg above the knee, and osteoarthritis. Review of the physician order dated May 5, 2020 revealed an order for oxygen at 0-5 liter per minute as needed to keep saturation above 95% every shift for oxygen therapy related to chronic obstructive pulmonary disease, unspecified. Review of the care plan problem with a revision date of December 9, 2021, stated the resident had oxygen therapy as needed related to COPD. The interventions stated to provide oxygen therapy per physician order. Review of the weights and vital signs records dated August 2022 revealed resident #3's oxygen saturation ranged between 90%-95% approximately 60 times. Review of the treatment administration record (TAR) for August 2022, revealed checked marks for all shifts which indicated oxygen was administered. Review of quarterly Minimum Data Set assessment dated [DATE] revealed a Brief Interview of Mental Status score of 07, which indicated the resident had severe cognitive impairment. The assessment did not reveal the resident had received oxygen therapy. Further record review of weight and vital signs records dated September 5, 2022 at 10:28 a.m. revealed the resident's oxygen saturation was 90%, and at 5:33 p.m. it was 93%. The record for September 6, 2022 revealed at 1:55 p.m. and 6:28 p.m., the resident's oxygen saturation was 95%. The record also revealed that on September 7, 2022 at 1:46 a.m., the oxygen saturation was 90%. Review of TAR dated September 2022 revealed checked marks for all shifts which indicated oxygen was administered. An observation of resident #3 was conducted on September 6, 2022 at 12:57 p.m. Resident #3 was lying in bed and was able to participate with the interview when spoken to loudly. It was noted that the resident's room did not include oxygen set up to administer oxygen, including concentrator, emergency oxygen tank, and nasal cannula. The resident was not observed wearing oxygen. On September 8, 2022 at 8:53 a.m., a registered nurse (RN/staff #69) visited resident #3's room and stated the resident did not have oxygen on. The RN reviewed the TAR and stated the nurses signed off on the oxygen administration but the resident did not have oxygen on. A follow up interview was conducted with the RN (staff #69) on September 8, 2022 at 8:58 a.m. Staff #69 stated resident #3 has not received oxygen for a while, and the last time oxygen was used was when it was ordered in 2020, when the resident had respiratory episodes. Staff #69 stated the nurses signed off on oxygen administration indicating it was administered but there is no oxygen concentrator or oxygen set up in the resident's room. The RN stated the nurses were signing the oxygen administration on the TAR because they were used to providing oxygen to maintain the resident's saturation greater than 90%. An interview was conducted on September 8, 2022 at 1:50 a.m. with the DON (director of nurses/staff #27). Staff #27 stated resident #3 has an oxygen order in point click care (PCC). Staff #27 stated the staff documents the oxygen administration in PCC if ordered, and her expectation is for staff to follow the order. The DON stated if a resident with an oxygen order is not followed, the resident could be at risk for hypoxia or shortness of breath. A facility policy, Medication and Treatment Orders, stated orders for oxygen will be prescribed and managed according to the physician's order and in accordance with safety procedures in the facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews, and review of facility policy, the facility failed to ensure advance directive information was consistent for 2 of 16 sampled residents (#4 and #65). The deficient practice could result in residents receiving or not receiving emergent services which are not in accordance with their wishes. Findings include: -Resident #4 was admitted on [DATE] with diagnoses that included acute chronic diastolic heart failure, type 2 diabetes, acute kidney failure, and hypertensive heart disease with heart failure. Review of the clinical record revealed an Advance Directive signed by the resident on [DATE] which the resident marked DNR (Do Not Resuscitate) indicating the resident did not want cardiopulmonary resuscitation (CPR). The admission Minimum Data Set (MDS) assessment dated [DATE] and the quarterly MDS assessment dated [DATE] included the resident scored a 15 on the Brief Interview for Mental Status, indicating the resident was cognitively intact. A physician's order dated [DATE] stated Full Code CPR. However, further review of the clinical record did not reveal that the resident had changed the advance directive. -Resident #65 was admitted on [DATE] with diagnoses that included chronic respiratory failure with hypoxia, congestive heart failure, and peripheral vascular disease. Review of the clinical record revealed an Advance Directive signed by the resident's representative on [DATE] which was marked DNR indicating the resident should not receive CPR. Continued review of the clinical record revealed an additional Advance Directive signed by the resident's representative on February 16, 2020 which was also marked DNR. A physician's order dated [DATE] stated Full Code- CPR. A care plan was revised on [DATE] and stated the resident had a Full Code status and the resident wishes will be honored as a Full Code. However, continued review of the clinical record did not reveal the resident's representative signed a new advance directive or indicated the resident or representative expressed a desire to change the advance directive. The quarterly MDS assessment dated [DATE] revealed the resident scored a 5 on the BIMS, indicating the resident had severe cognitive impairment. An interview was conducted on [DATE] at 1:08 pm with the social services director (staff #69). Staff #69 stated admissions is responsible for the initial advance directives, and that any nurse can provide residents with the form to change an advance directive. Staff #69 stated there used to be one staff member who was responsible for auditing the advance directives, but that person was no longer employed at the facility and no one had been assigned that duty. An interview was conducted on [DATE] at 2:07 pm with the Director of Nursing (DON/staff #47). The DON stated the admissions nurse is responsible for advance directives, and that any nurse can provide information to the physician to initiate a different code status. She stated audits of advance directives are completed by medical records in the facility. She stated a corporate audit was competed quarterly as well. The DON stated she thought resident #4 had recently indicated in a care conference that he wanted to change his code status, and that might be why the order was changed. She stated resident #65 had been in and out of the hospital several times recently and resident #65 code status must have been missed. The DON stated she would expect the order for a resident's code status to match the signed Advance Directives that were in the clinical record. The facility's policy Advance Directives included information about whether or not a resident has executed an advance directive shall be displayed prominently in the medical record. It also included the plan of care for each resident will be consistent with his or her advance directives.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, resident and staff interviews, clinical record review, and review of facility documents, the facility failed to ensure a venetian blind was repaired/replaced in one resident's room (#7). The census was 63. The deficient practice could result in residents' room not having a homelike environment. Findings include: Resident #7 was admitted to the facility on [DATE] with diagnoses of Type II diabetes mellitus and transient ischemic attack and cerebral infarction. The quarterly MDS (Minimum Data Set) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating the resident had no cognitive impairment. During an interview conducted with the resident on 05/03/21 at 12:47 PM, a venetian blind was observed on the floor near the window. The resident stated the venetian blind fell off when an aide tried to open the blinds about two weeks ago. The resident stated maintenance needs work orders for everything and that the repairs take too long. The resident also said that he had spoken to EVS (Environmental Services) Manager (staff #60) about the blinds. At 9:40 AM on 05/04/2021 and at 9:36 AM on 05/05/2021, the venetian blind was observed on the resident's room floor. The resident's window faced a vacant lot. A valance was above the window but there were no curtains. An interview was conducted with a Certified Nursing Assistant (CNA/staff #77) on 05/05/2021 at 10:41 AM. Staff #77 stated that she has worked at the facility for a year and knows most of the residents. The surveyor and the CNA went to resident #7's room. The CNA removed the broken blind and placed it in the trash. Staff #77 stated that she had not noticed the broken blind as she works part time. The CNA stated the work orders are computerized and any staff can enter a work order. The CNA also stated repairs are backed up. The resident who was also present stated he had spoken with staff and that staff #60 knows there is a work order for the blind. At 01:42 PM on 05/05/21, an interview was conducted with staff #60. When asked about the process for maintenance and repairs, staff #60 stated work orders must be entered into the new computerized work order entry system by the nursing staff. He stated that he can access the order from his cell phone, which he then accessed. Staff #60 showed the cell phone screen to the surveyor; an 0 was observed. Staff #60 stated that the 0 indicated there were no outstanding work orders that had not been completed. An observation conducted of the resident's room on 5/6/2021 at 8:31 AM, revealed the venetian blind had not been replaced. Another interview was conducted with staff #60 on 5/6/21 at 09:33 AM. When asked specifically about resident #7 blind, staff #60 stated that he had not received a work order for the blind and did not know about the blind. Staff #60 further stated there were extra blinds in stock. He stated that if the nurses or CNAs do not enter the work order on the computer, he would not know a blind is needed. In an interview conducted with the Administrator (staff #88) on 05/06/21 at 10:03 AM, the Administrator stated that new employees have to be trained on the new work order system. The Administrator stated that they may have the mindset that work orders could just be verbalized or put on paper. The Administrator also stated the request regarding the blind was lost in translation. Review of Resident Council Grievance Log revealed resident #7 had stated on 01/21/2021 new blinds were needed. Under the heading Resolutions Reviewed with Person Stating Concern, blinds ordered was documented. A review of paper generated work orders for January 2021 through March 2021 revealed no request for blind repair. A review of the computerized work orders from March 1, 2021 to May 5, 2021 revealed no outstanding work orders and no request for the replacement of a broken blind for resident #7.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, observations, staff interviews, and review of facility policy, the facility failed to ensure one resident (#14) who was receiving oxygen had an order for oxygen therapy. The deficient practice could result in residents receiving oxygen without a provider's order. Findings include: Resident #14 was admitted on [DATE] with diagnoses that included emphysema, dementia without behavioral disturbance, major depressive disorder, and anxiety disorder. The quarterly Minimum Data Set (MDS) assessment dated [DATE] included the resident scored a 4 on the Brief Interview for Mental Status (BIMS) indicating the resident had severe cognitive impairment. The MDS assessment also included the resident did not use oxygen during the look back period. The monthly nursing summary dated April 10, 2021 included the resident did use oxygen. Oxygen saturation documentation for resident #14 from April 17, 2021 through May 4, 2021 included the saturation was taken while the resident was using oxygen via nasal cannula for 34 occasions, and while on room air for 7 occasions. However, further review of the clinical record revealed resident #14 did not have a physician's order for oxygen. Resident #14 was observed on May 3, 2021 at 12:47 pm in her room. The resident was not using oxygen at that time, but there was an oxygen concentrator and tubing labeled with resident #14's name next to the bed. An observation was conducted of resident #14 on May 4, 2021 at 9:02 am. The resident was in the bed asleep. The oxygen concentrator in the room was set to 2 liters per minute (2 LPM) and the resident was wearing the attached nasal cannula. Another observation of resident #14 was conducted on May 5, 2021 at 8:38 am. The resident was sitting up in the bed, eating breakfast. The resident was observed receiving oxygen at 2 LPM via nasal cannula from the oxygen concentrator in the room. An interview was conducted on May 5, 2021 at 10:11 am with the MDS nurse (staff #51), who stated if a resident is receiving oxygen, she would expect to see orders for oxygen, and it would be included on the Medication Administration Record (MAR). Staff #51 stated resident #14 did not have an order for oxygen in the facility's system prior to May 5, 2021, even though the resident was receiving oxygen. An interview was conducted with the Director of Nursing (DON/staff #47) on May 5, 2021 at 10:19 am. She stated a resident who is receiving oxygen should have an order that specifies the liter flow and what the resident's oxygen saturations should be. The DON stated there should have been an order for resident #14 to use oxygen. The facility's policy Oxygen Administration included that prior to administering oxygen, staff should verify that there is a physician's order for the procedure.

Based on visitor and staff interviews, observation, facility documents, policy review, and the Centers for Disease Control (CDC) guidance, the facility failed to ensure infection control standards were followed regarding visitation. The deficient practice could result in the spread of infection including COVID-19. Findings include: An interview was conducted with a visitor (#45) on May 6, 2021 at 10:12 AM, who said that she calls and schedules the times to visit, and that the times are a half hour to an hour depending on the day. The visitor stated that she does not go inside so she is not screened. She said that the staff do not ask her any questions or require her to wear a mask. The visitor stated that she had visited with another lady earlier so she had two visits with residents that day. Visitor #45 was observed sitting next to a resident in a small patio area in front of the facility lobby. The visitor and the resident were observed wearing masks. A review of the visitor screening logs for May 6, 2021 revealed that visitor #45 had not been screened. An interview was conducted on May 6, 2021 at 2:13 PM with a Receptionist (staff #79), who said that she had seen visitor #45 sitting in front of the facility. Staff #79 reviewed the visitor screening log and stated that she might be in our other book. She said that visitor #45 is one of their peer support people that comes weekly, and that this visitor might not have known that visitors have to be screened in. Staff #79 reviewed the visitor screening log again and searched the reception area, then said, I'm not seeing her in here so she must not have known. She said that whenever anyone comes into the facility they have to have a mask on, have their temperature taken and answer the questions, and use hand sanitizer before they are walked back to the resident's room. The receptionist said If they are outside they still have to go through the same process because they are still in contact with the residents. An interview was conducted on May 6, 2021 at 3:37 PM with the Director of Nursing (DON/staff #47), who said that her expectation is that everyone that comes into the facility be screened including that they are asked all the questions, wash or sanitize their hands, and that the screener contact the Assistant Director of Nursing or herself and report if one of the screening questions has a yes answer. The DON said that it does not meet her expectations that a visitor would not be screened. A policy's policy titled Facility Visitation revealed that this policy outlines resident visitation by family members, friends, guests and other third parties as well as other individuals who enter the community for other approved reasons. This policy included that this policy follows and is consistent with guidance provided by the CDC, Arizona Department of Health Services, CMS (the Centers for Medicare and Medicaid Services), local health departments and other established policy. The policy stated all visitors and third parties are required to comply with the following requirements for any type of visitation. Visitors will be subject to a mandatory health screening, visitors will be subject to attestation or confirmation forms, and visitors will follow all infection control policies and procedures as established and as instructed by a staff team member. A CDC guidance titled Interim Infection Prevention and Control Recommendations to Prevent SARS-CoV-2 Spread in Nursing Homes, Nursing Homes & Long-Term Care Facilities updated Mar. 29, 2021 revealed that even as nursing homes resume normal practices and begin relaxing restrictions, nursing homes must sustain core infection prevention and control practices and remain vigilant for SARS-CoV-2 infection among residents and health care providers in order to prevent spread and protect residents and health care providers from severe infections, hospitalizations, and death. The guidance included facilities should ask visitors to inform the facility if they develop a fever or symptoms consistent with COVID-19 within 14 days of visiting the facility, screen for symptoms of COVID-19, fever of 100.0 °F or higher or report feeling feverish, and who have had close contact to someone with COVID-19 during the prior 14 days.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews, and facility policy, the facility failed to ensure that immunizations were administered per facility policy and professional standards for one resident (#59). The deficient practice could result in residents not receiving immunizations. Findings include: Resident #59 was admitted on [DATE] with diagnoses of unspecified injury at unspecified level of cervical spinal cord, muscle weakness and cerebral palsy. A physician order dated April 8, 2021 included Pneumonia 0.5 ml (milliliters) vaccine unless previously received or unless contraindicated. A Consent for Influenza and Pneumococcal Vaccines dated April 11, 2021 revealed that the resident consented to receiving the Influenza and Pneumococcal Vaccinations. However, a review of the resident's vaccination record revealed the resident did not receive a pneumococcal vaccination. An interview was conducted on May 5, 2021 at 01:26 PM with a Registered Nurse (RN/staff #23), who said that when they admit a resident, they normally ask the resident if they have had the Influenza, Pneumonia and COVID-19 vaccinations. The RN said that the admissions nurse (staff #73) will follow up and ask the resident if they have had the vaccines or if they want them, and if so will have the resident sign a consent on her tablet. Staff #23 stated that for the residents that want the vaccines, the nurses will make sure everything is ordered, administered and put into Point Click Care. The RN stated that vaccines are recorded in the resident's profile under Immunizations in the electronic health records. During an interview conducted on May 6, 2021 at 12:51 PM with the Infection Preventionist (IP/staff #57), the IP stated it is the residents' choice if they want to get the Pneumococcal or Influenza vaccine. The IP said they have an electronic consent form for the resident to sign if they want a vaccine. She said that if the residents' consent, they should receive the vaccines. An interview was conducted on May 6, 2021 at 02:25 PM with a RN (staff #45). The RN reviewed the resident's clinical record and said that she does not see where a pneumococcal vaccine was given. The RN stated that if the resident consented, record of the vaccine being given should be in the clinical record. An interview was conducted on May 6, 2021 at 3:37 PM with the Director of Nursing (DON/staff #47), who stated consents for vaccines are obtained with the admission paperwork and once the consents are obtained, they can give the vaccines. The DON said the timing regarding when the resident receives the vaccine depends on if they have the vaccine readily available. Staff #47 stated that she would expect the vaccine to be administered within 24 hours, as the Pneumonia vaccines are available. The DON said it would not meet her expectations that the resident had not received the vaccine they had consented for. A facility's policy titled Pneumococcal Vaccine revealed that all residents will be offered pneumococcal vaccines to aid in preventing pneumococcal infections. The policy included that Pneumococcal vaccines will be administered to residents (unless medically contraindicated, already given, or refused) per the facility's physician-approved pneumococcal vaccination protocol. The policy also included that residents who receive the vaccines; the date of vaccination, lot number, expiration date, person administering, and the site of vaccination will be documented in the resident's medical record.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, clinical record review, resident and staff interviews, and facility policies, the facility failed to ensure one of 16 sampled residents (#49) received the necessary services to maintain good grooming and personal hygiene. The census was 63. The deficient practice could result in residents not receiving Activities of Daily Living (ADL) care. Findings include: Resident #49 was admitted to the facility on [DATE] with diagnoses of unspecified dementia without behavioral disturbance, peripheral vascular disease and acquired absence of other right toes. Review of the care plan initiated on September 30, 2020 revealed resident #49 had an ADL self-care performance deficit related to weakness. The goal was that the resident would improve current level of function in bed mobility, transfers, dressing, and toilet use. Interventions included the resident required the assistance of 2 staff participation for toilet use, transfer, and mobility; and required the assistance of one staff participation with bathing, personal hygiene and oral care, and dressing. The quarterly Minimum Data Set assessment dated [DATE] revealed a Brief Interview for Mental Status score of 8, indicating the resident had moderate cognitive impairment. The assessment also revealed the resident was total dependent for bathing and transfers, and required the assistance of two persons. The assessment included the resident required extensive assistance of two persons for bed mobility, dressing, personal hygiene, toilet use and bathing. A review of the POC (Point of Care) Legend Reports and Shower Sheets for February 20, 2021 through May 6 2021 revealed the resident was offered bathing care once a week February 22 through 28, March 8 through 14, March 29 through April 4, April 5 through 11, and April 12 through 18. This report also revealed the resident did not receive bathing care the weeks of March 1 through 7, and April 26 through May 2. During an interview conducted with the resident on May 3, 2021 at 12:03 PM, the resident was observed to have a white flaky and crusty appearance on his face, scalp and neck; and very dry flaky skin on his arms. The resident stated that he does not receive bathing assistance on a daily basis. The resident stated he was due for bathing and was sure how often he is supposed to get bathed or showered. In an interview conducted with a Certified Nursing Assistant (CNA/staff #76) on May 5, 2021 at 9:12 AM, the CNA stated sometimes they are unable to provide all the showers during their shift and that they will put that on the shower sheet and hand it off to the evening shift. Staff #76 stated residents' showers are documented in their electronic health records. During an interview conducted with a Registered Nurse (RN/staff #23) on May 5, 2021 at 1:26 AM, the RN stated that CNAs mostly handle bathing and that nurses only get involved with showers when they are asked. She said the CNAs will ask the nurse for assistance if the resident refused bathing, and that the nurse will go talk to the resident about bathing. An interview was conducted on May 6, 2021 at 2:07 AM with a CNA (staff #53), who stated residents are scheduled twice a week for bathing. She stated that there are not enough staff and that she would not be surprised to hear that a resident did not receive their showers. The CNA said that they try to get the showers done but sometimes it is just the two CNAs for this long hall. Staff #53 said that if a resident had refused the shower, it would be documented. The CNA stated the CNAs chart resident bathing in the resident electronic health record. An interview was conducted on May 6, 2021 at 3:37 PM with the Director of Nursing (DON/staff #47), who stated most residents receive their showers twice a week, however they can receive a shower 3 times a week if they want. She stated that she thinks twice a week is the standard. The DON said this resident should have been offered a shower twice a week. She stated that when the staff reported that showers were not able to be given, the management team would go and give residents showers. The DON stated if the shower sheet was out, then she would document the shower. The DON further stated that she was not always great about documenting and that was her fault. Review of the facility's policy titled Shower/Tub Bath revised October 2010 stated the purpose of the procedure is to promote cleanliness, provide comfort to the resident and to observe the condition of the resident's skin. The policy also stated the following information should be recorded on the resident's ADL record and/or in the resident's medical record: the date and time the shower/tub bath was performed, the name and title of the individual(s) who assisted the resident with the shower/tub bath, all assessment data obtained during the shower/tub bath, how the resident tolerated the shower/tub bath, if the resident refused the shower/tub bath, the reason(s) why and the intervention taken, and the signature and title of the person recording the data.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On May 5, 2021 at 2:06 p.m., a phone interview was conducted with a member of the nursing staff (staff #71). Staff #71 stated that there was no night nurse on the SCU and that there was only one CNA scheduled to work the night shifts. Staff #71 stated that the night CNA would leave the door to the SCU open every night. Staff #71 stated that two nights prior, one of the residents got up and assaulted the CNA that was assigned to the unit. Staff #71 stated that it was a good thing the door had been left open otherwise no one would have heard the CNA when she yelled for help. A phone interview was conducted on May 6, 2021 at 10:15 a.m. with a member of the nursing staff (staff #31). Staff #31 stated that on the night shift the CAN would leave the door open because it is kind of creepy back there and also so that someone else could hear if one of the residents assaulted them. Staff #31 stated that the CNA from the SCU helps the CNA on the Medicare hall, because it is hard for one CNA to do the whole hall by themselves. Staff #31 stated that they leave the secured unit door open and a nurse from another unit will watch the hall through the open door. Staff #31 stated that the CNAs place a medication cart in the doorway and lock the wheels, so if a resident did get up in the middle of the night, the resident would not be able to move it. Staff #31 stated that they thought that if someone were really strong, they could move the cart. Staff #31 stated that the doors to the two units open in opposite directions, and that the cart does not block the doors from opening or closing. Staff #31 stated the cart just blocks the doorway so someone would have a difficult time getting out. A phone interview was conducted on May 6, 2021 at 12:16 p.m. with a member of the nursing staff (staff #80). Staff #80 stated that it has been the practice of the CNA to leave the door open with the cart in the doorway on the SCU because they do not feel safe with the aggressive resident that resides on the unit. Staff #80 stated that the SCU door stays open because the CNAs assist each other during rounds. Staff #80 stated that on the previous night, there had been only one CNA on the 200 and the 300 halls to care for about 40 residents. Staff #80 stated that was too many residents for one CNA. A phone interview was conducted on May 6, 2021 at 1:31 p.m. with a member of the nursing staff (staff #4). Staff #4 stated that the nurse covers two halls when the door to the SCU is left open. Staff #4 stated that if they have to leave the area, they try to time it when the CNAs have come back from their rounds and are back on the unit. Staff #4 stated that they personally had never left the area unsupervised. On May 6, 2021 at 2:26 p.m., an interview was conducted with the Assistant Director of Nursing (ADON/staff #57). The ADON stated she had seen the SCU door open herself when she had come in in the morning. She stated that she has told the nursing staff to close the door, and that she did not know that it was still going on. The ADON stated that leaving the secured unit door open was a safety risk and that the practice did not meet her expectations. An interview was conducted on May 6, 2021 at 3:23 p.m. with the Director of Nursing (DON/staff #47). She stated that it would not meet her expectation for the secure unit door to be left open for extended periods, including an entire shift. She stated that a nurse or another CNA needs to be on the unit for observation purposes. She stated that resident safety would be at risk. She said that she was not aware of the SCU door being left open. The facility policy titled Safety and Supervision of Residents stated that the facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities. The policy included that safety risks and environmental hazards are identified on an ongoing basis through a combination of employee training, employee monitoring, and reporting processes: QAPI (Quality Assurance and Performance Improvement) reviews of safety incident/accident data; and a facility-wide commitment to safety at all levels of the organization. Individualized, resident-centered approach to safety included addressing safety and accident hazards for individual residents, and the interdisciplinary care team shall analyze information obtained from assessments and observations to identify any specific accident hazards or risk for individual residents. Resident supervision is a core component of the systems approach to safety. The types and frequency of resident supervision is determined by the individual resident's assessed needs and identified hazards in the environment. Based on clinical record review, resident family and staff interviews, and policy review, the facility failed to ensure adequate supervision was provided on the secured dementia unit/Special Care Unit (SCU) including for two residents (#5 and #27) who were involved in a resident to resident altercation that resulted in an injury to resident #5. The secured unit census was 13. The facility census was 63. The deficient practice could result increased risk for accidents or hazards related to inadequate resident supervision. Findings include: -Resident #5 was admitted to the facility on [DATE], and re-admitted on [DATE], with diagnoses that included schizoaffective disorder, anxiety disorder, and muscle weakness. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) score of 2, which indicated that the resident had severe cognitive impairment. The assessment included the resident had rejection of care and wandering 1 to 3 days of the assessment period. Review of the behavior Care Area Assessment (CAA) revealed the resident was noted to be exit seeking, wanting to go home and for the staff to have measures in place to keep the resident safely within the facility. A fall report dated February 4, 2021 revealed the resident was found on the floor in an adjacent, empty room and was looking for an exit. The report included that wandering was a predisposing situation factor. A care plan revised February 9, 2021 (initiated 1/23/2021) revealed: The resident was at risk for falls related to impaired gait/balance, weakness, wandering, and impaired cognition. Review of the Care Unit Evaluation for the Special Care Unit dated April 13, 2021 revealed the resident had diagnoses of schizoaffective disorder and anxiety. The evaluation included the resident had wandering on 4-6 days and required the Special Care Unit (SCU). Review of the quarterly MDS assessment dated [DATE] revealed the resident had a BIMS score of 3, which indicated the resident had severely impaired cognition. The assessment included the resident wandered on 1 to 3 days of the assessment period. Review of a nursing progress note dated April 26, 2021 at 6:34 p.m. revealed the resident continued with exit-seeking behavior and wandering into other residents' rooms. Redirected. Continue to monitor. A nursing note dated April 27, 2021 at 3:22 a.m. revealed the resident had a fall that occurred in the TV/Dining area of the SCU. The note included the resident was assessed, assisted to a standing position, and that the resident was able to ambulate to bed. Review of an IDT (Interdisciplinary Team) fall review note dated May 1, 2021 at 10:38 a.m. revealed the resident sustained a fall on May 1, 2021 at 12:00 a.m. and sustained a laceration to the head. Review of a nursing progress dated May 3, 2021 at 6:00 a.m. revealed: Screaming was heard coming from a resident's room (resident #27). Both resident #27 and this resident are in the room standing, Certified Nursing Assistant (CNA) staff reports as she entered the room she witnessed a physical altercation and this resident fell backward onto her head. Resident #27 continued to yell at this resident while receiving care, this resident is slid out into the hallway. Resident is having a hard time opening her eyes and has noticeable weakness to her left grip, pain in left lower extremity with range of motion. Respirations are even and unlabored. Hematoma is felt on the back of patient's scalp. Emergency Medical Services was contacted to transport the resident related to head injury with neurological deficits. Review of a nursing progress note dated May 3, 2021 stated that since returning from the hospital, the resident is very restless, wandering the hallways, into other residents' rooms and hallucinating. Continue to monitor. A physical incident report dated May 3, 2021 revealed the patient had wandered into a resident's room and the CNA reported hearing arguing and entered the room. The CNA witnessed resident #27 placing her hands on resident #5 and resident #5 fell backwards. The CNA described it as a push. Predisposing factors included resident #5 was an active exit seeker and ambulating without assist. Review of a provider note dated May 3, 2021 included that nursing reported the resident with disturbed sleeping patterns, insomnia, exit-seeking behavior and wandering. The patient was in an altercation today May 3, 2021, and fell and hit the back of her head. Nurse reports to patient having a hematoma. Patient is poor historian. Monitor behavior and redirect as needed. A care plan initiated on May 4, 2021 included the resident had impaired decision making and was at risk for altercations related to wandering and impaired cognitive function. The goals included that the resident would be able to communicate basic needs on a daily basis. The interventions included to keep the resident's routine consistent and try to provide consistent care givers as much as possible in order to decrease confusion. Goals for wandering and altercations with other residents, and interventions to decrease the risks with wandering and altercations were not included. -Resident #27 was admitted to the facility on [DATE] with diagnoses that included schizophrenia. A care plan that was initiated on August 4, 2016 stated the resident had the potential to demonstrate physical behaviors related to anger and had threatened staff with a walking stick. The goal was that the resident would not injure self or others. Interventions included to analyze key times, places, circumstances, triggers, and what de-escalated behavior and to document; to establish limits for inappropriate behaviors; to intervene as needed to protect the rights and safety of others; monitor and modify environment for external contributors to behavior including other residents. An annual MDS assessment dated [DATE] revealed the resident had a BIMS score of 99 as the resident was unable to complete the interview. The staff assessment for mental status included the resident had short- and long-term memory problems and poor decisions requiring cues/supervision. The assessment included that the resident had delusions and hallucinations, daily rejection of care, and wandering. Review of a Care Unit Evaluation dated April 13, 2021 for the Special Care Unit revealed the resident had a diagnosis of Schizophrenia. The eval included the resident had daily behavioral symptoms not directed toward others, that the resident was unaware of her own safety needs, and required the Special Care Unit. A provider progress note dated May 3, 2021 revealed the nurse reported that the resident had an altercation with another resident who walked into the resident's room. The police were notified and spoke with the resident as the other resident fell and hit their head. Resident #27 denied pushing the resident per nurse. Review of a Social Services Progress note dated May 3, 2021 at 9:00 a.m. revealed that social services was informed of a resident to resident altercation that morning at approximately 5:15 in the secured unit. It was reported that that this resident's neighbor wandered into her room while she was sleeping and began touching her table and her papers and the resident asked the other resident to leave. This resident speaks Korean and the other resident speaks Spanish. The other resident would not leave her room. Resident stated that she tried to get her out and when she finally turned to leave, she lost her balance and fell. Resident stated that she did not push her or try to hurt her, just that she wanted her out of her room. The other resident hit her head and was sent to the hospital for treatment and observation. Social services notified case management and non-emergent police. The resident called the CNA staff a liar for saying that she pushed the other resident. Review of a physical incident report dated May 3, 2021 revealed that resident #5 wandered into the resident #27 room. A verbal argument was heard. A CNA reported resident #27 pushed resident #5. Review of the Nurses Station Scheduling Reports for April 1 through April 30, 2021 and May 1, 2021 revealed one Certified Nursing Assistant (CNA) worked the night shift (10:00 p.m. to 6:00 a.m.) on the Secured Dementia Unit (SCU). No nurses were assigned to work the SCU on the night shift. An interview was conducted on May 3, 2021 at 12:55 p.m. with a Registered Nurse (RN/staff #70). She stated that there had been an altercation between resident #5 and resident #27. She stated that resident #27 does not let anyone into her room and that resident #5 wandered into resident #27's room that morning. She stated that resident #27 pushed resident #5 down and resident #5 hit her head. An interview was conducted on May 4, 2021 at 8:54 a.m. with a family member of resident #5. The family member stated the facility stated that resident #5 wandered into another resident's room and that the other resident pushed resident #5 down. The family member stated that resident #5 had a hematoma and had to be sent to the hospital for Magnetic Resonance Imaging (MRI). An interview was conducted on May 6, 2021 at 10:56 a.m. with a CNA (staff #34). She stated that resident #27 had really bad trust issues and no one was allowed in her room, she stated that when staff delivers the meal tray they have to stand by the door and the resident would come to the door to get it. Staff #34 stated that if someone went into her room she would probably hit them with a stick. She stated that the resident had a stick that she used to chase other residents out of her room. She stated that she shakes the stick in the air but had not hit anyone with it. The CNA stated that there were three residents on the secured unit that wander, which included resident #5, and that those residents wander into other residents' rooms. She stated that only resident #27 would react badly to residents wandering into her room. Staff #34 stated that resident #5 and another resident had wandered into resident #27's room before. She stated that she heard that resident #5 wandered into resident #27's room on Monday (May 3, 2021) and was pushed to the floor. The CNA stated that when she is not in the nursing station that she walks up and down the hall as a lot of the residents are in the hallway. The CNA stated that she can look at the mirrors mounted outside of the station and see if anyone is in the hall but that she cannot visualize resident #27's room from the mirror. Staff #34 stated that she works from 6 a.m. to 2 p.m. She stated that there was only one CNA on the hall and that it would be nice to have another CNA on the unit because sometimes the residents were wandering or fighting each other and the nurse was busy. She stated that when she arrives to the unit at 6:00 a.m., the door to the secured unit had been propped open a couple of times, but that it was usually closed. She stated that there was no nurse on the unit at night and only one CNA. She stated the CNA would prop open the door when she had to leave the secured unit to go to help in other areas of the facility. She stated that the door would be propped so that the nurse working the Medicare hall could supervise the secured unit. An interview was conducted on May 6, 2021 at 11:21 a.m. with a RN (staff #5). She stated that resident #27 had been there for a long time and that the staff all know her. She stated that resident #27 was very private, spoke Korean, and did not speak English. The RN stated that resident #27 was delusional and hallucinates, did not take any medication, and that she did not know if the resident had any psychiatric care. The RN stated that resident #27 is sometimes scary to the other residents and had been on 15-minute checks since she pushed resident #5 down. She stated that resident #27 was not a danger to other residents if the other residents stayed out of her room, or if the other residents left her room when she told them to/warned them, or staff pulled the other resident out. She stated that resident #27 would say hey hey hey or get out, and that staff would respond quickly if they heard that. She stated that, mostly, staff had to keep up with residents that wander. Staff #5 stated that this was the first time she can think of that resident #27 had become physical with anyone. The RN stated that in her opinion they did not have enough staff on the secured unit to give the supervision to meet the needs/care for the clientele there. The RN stated that if any resident needed two people to assist them with care there would be no supervision on the unit while the nurse and CNA were doing the task. She stated that it was a constant worry related to the population served on the secured unit and that many of the residents acted spontaneously. Staff #5 stated that she had asked the Director of Nursing (DON) for more staff related to the concerns that she had and was told that the facility did not staff according to acuity, that the facility staffed by numbers. A phone interview was conducted on May 6, 2021 at 12:30 p.m. with a RN (staff #54) He stated that he was the nurse working at the time of the altercation between resident #27 and resident #5 on May 3, 2021. He stated that resident #27 resided on the secured unit and that she would freak out if someone entered her room. He stated that resident #5 was up wandering/pacing the hall and the CNA (identified as staff #50) on the hall was in a room caring for a resident. Staff #54 stated that the CNA heard yelling and when she got to the room she saw resident #27 push resident #5 and that resident #5 fell. He stated that resident #27 called the CNA a liar and made a hand motion to show that she was trying to guide resident #5 out of the room, not push her. The RN stated that he could not say if resident #27 was a reliable reporter but that he felt that she had the right to defend herself. He stated that he could recall one prior instance when resident #5 was in the doorway of resident #27's room and resident #27 made noise so the CNA was able to redirect resident #5. The RN stated that resident #27 considers her room her personal space and that she would be a physical risk to other residents if they were to wander into her room. Staff #54 stated that when a resident is up wandering, the staff usually sit outside of the doorway near the dining room to supervise the hall and re-direct the residents. He stated that at night he is the nurse for the Medicare hallway and that there is a CNA on each hallway. The RN stated that there would be times at night when the CNA from the secured unit (SCU) is needed to help in other areas and the door to the secured unit would be propped open so that he can try to supervise both units. He stated he thought the point of the secured unit was for wandering residents, but that he felt that they had some geriatric psychiatric residents back there. He stated that the staff ratio for the secured unit is right but that those residents have more skilled needs than other residents, and are ambulatory and wander. The RN stated that he thought two permanent staff on each hall would be beneficial on the night shift. An interview was conducted on May 6, 2021 at 1:41 p.m. with a Licensed Practical Nurse (LPN/staff #66). She stated that resident #27 did not like people in her room. Staff #66 stated that resident #27 would only be considered a danger to other residents if they went into her room. The LPN stated that other residents sometimes wander into resident #27's room and that resident #27 chases them out of her room with a broomstick. She stated that she had never seen resident #27 do anything physical to anybody. She stated that they used to have another CNA on the secured unit before the COVID pandemic but they were shorthanded so they were unable to provide a second CNA. The LPN stated that there was no nurse scheduled on the secured unit for the 7:00 p.m. to 7:00 a.m. shift, but that there was always a CNA there who will get the nurse if something happens. The LPN stated that one of the other nurses voiced a concern to the DON regarding the staffing on the secured unit and that she agreed, but that they were told that the ratio did not allow for another CNA on the secured unit. A call was placed to the CNA (staff #50) on May 6, 2021 at 2:02 p.m. Message left. No call back received. An interview was conducted on May 6, 2021 at 2:47 p.m. with the DON (staff #47). She stated that she had not had any behavior concerns with resident #27 except for refusal of care. Staff #47 stated that resident #27 was on 15-minute checks since she had a resident to resident altercation with resident #5. She stated that when facility staff interviewed resident #27 about the resident to resident incident, resident #27 stated that she did not harm resident #5 and was trying to shoo her out her door. She stated that, by diagnoses, the resident was Schizophrenic and not cognitively impaired. She stated that there was a language barrier present between the two residents. The DON stated that she had not been able to talk to the CNA witness to get her report. The DON stated that with resident #27's reaction to anyone entering her room, she could be a danger to other residents/wandering residents if they were to enter her room. She stated that when she was in talking to resident #27 today, the resident was tapping her stick but was not threatening with it. She stated that a CNA was on the secured unit at all times during the night. The DON stated that if the CNA were to leave for break or to help on other units, another staff member should go to the secured unit. The DON stated that the secured unit would not be able to be adequately supervised from Medicare nursing station, that the staff would need to be physically on the unit. She stated that staff were not permitted to prop open the secure unit door so that they would not need to go onto the secure unit. The DON stated that staff would not be able to adequately visualize the secure unit with the door propped because they would not be able to fully visualize the unit. The DON stated that patient safety was at risk if a staff member was not physically on the secured unit.

Based on resident and staff interviews, facility documentation, and policy review, the facility failed to ensure there was sufficient nursing staff to meet the needs of residents, by failing to utilize all avenues available including exhausting registry agencies and/or transferring residents to another facility due to being unable to meet the cares of the residents. The deficient practice resulted in residents' needs not being met. The census was 63. Findings include: During the initial phase of the survey, 4 out of 24 residents identified concerns of not having enough staff. Residents reported that they have waited up to 2-3 hours for call lights to be answered, for assistance with a Hoyer lift and slide board, and being incontinent due to the wait and feeling frustrated and embarrassed. Residents stated staffing was worse on the evening shift, and on the night shift on the weekends. Review of the Resident Council Grievance Log revealed that on January 21, 2021 residents complained that call lights were not answered quickly. On March 18, 2021, residents complained showers were missed. On April 6, 2021, residents complained of not having showers for two weeks, waiting up to an hour for call lights to be answered, and being left incontinent in the bed for over an hour. A Resident Council interview was conducted on May 5, 2021 at 9:58 a.m. The residents stated there was a shortage of Certified Nursing Assistants (CNAs). They stated that on the evening shift which might have been on the weekend, there were only 2-3 CNAs working in the entire building. One resident stated they had waited so long for assistance that they tried to transfer themselves and fell. The residents stated that the residents that are unable to care for themselves are frustrated. They stated showers have been missed and they have waited more than 30 minutes for call lights to be answered. They also stated that call lights have been answered immediately today. Review of the facility assessment updated March 19, 2021 stated that to meet the needs of the resident population, the required number of direct staff included 7 licensed Nursing Assistants (NAs) or CNAs for the day shift and the evening shift, and 4 for the night shift. The assessment included an average daily census of 60-65. A review of the Nurses Station Scheduling Reports for April 2021 revealed there were less than 7 CNAs for all the evening shifts and less than 4 CNAs for 9 of the night shifts. In an interview conducted with a CNA on May 3, 2021 at 11:51 a.m., the CNA stated that there were more than 35 staff call-offs for April 2021. The CNA stated that they had worked most of the month as the only CNA on the hall, providing care to 22 or more residents. The CNA stated they complained to management several times but nothing has been done. On May 5, 2021 at 8:51 a.m., an interview was conducted with a CNA who stated that if there is only one CNA on a hall, most often the residents will not receive showers. The CNA stated that she tries to provide at least two incontinence changes per shift. The CNA also stated that at the beginning of the shift, residents were found soaking wet because they were not changed during the prior shift. On May 5, 2021 at 1:31 p.m., an interview was conducted with the Executive Director (ED/staff #88) and the Human Resources Director/Staffing Coordinator (staff #46). They stated that the Nurses Station Scheduling Reports dated April 1 through April 30, 2021 included administrative staff that had worked the floor as nursing and CNA staff. The ED stated that the facility was within the staffing guidelines, and within the guidelines of their facility assessment. Staff #88 stated that the information provided the complete picture of all staff, in total, that had worked the floor and that there was no further documentation. Another interview was conducted with a CNA on May 5, 2021 at 1:36 p.m., who stated that prior to this year, the Long-Term Care (LTC) Unit/300 hall was staffed with 3 CNAs for the day and evening shifts. The CNA stated that usually the LTC hall has approximately 40 residents, more or less. The CNA stated that there have been multiple instances of only one CNA providing care for all the residents on the hall. The CNA said that the Medicare Unit/100 hall was supposed to be staffed with 2 CNAs, and that the Secured Unit/200 hall should also have 2 CNAs. The CNA stated that since January, staffing has sometimes been half that. The CNA stated that the results of inadequate staffing included residents having to wait a long time, sometimes an hour or more, for their call lights to be answered, resident care is rushed, incontinence care may not always be provided, and that residents may not always have the assistance they need to get out of bed in the mornings. On May 5, 2021 at 2:06 p.m., an interview was conducted with another CNA. The CNA stated that there had been a shortage of direct care staff since the beginning of the year, and that the other day there had been one CNA providing care to the entire LTC/300 hall (approximately 30 residents). The CNA stated that on the night shift the CNAs have to work together to provide care, and that the CNA from the secured unit will leave that unit to assist the other CNAs. The CNA further stated that on the night shift, there is only one CNA on the secured unit and there is no nurse. The CNA also stated that now that State is in the facility, all of a sudden there is staff helping out on the floor. On May 6, 2021 at 3:28 p.m., an interview was conducted with the DON (staff #47). She stated that the administrative staff had approached the lack of staffing by taking on the Temporary Nursing Assistant (TNA) program, and that they have hired valets to do simple things such as answering call lights and getting the resident drinks, and did radio advertising for jobs. She stated that they had called the county, and that emails had been initiated/sent in January. She stated she was not sure if their Quality Assurance and Performance Improvement (QAPI) had addressed the staffing shortage. She stated the facility had tried calling other sister facilities, but that they did not call registry. She stated she was told that they had tried to call registry, but were told they did not have any staff available. She stated that additional interventions had included a group CNA text line, offering extra shifts, and bonuses - creative staffing strategies. An interview was conducted on May 6, 2021 at 4:03 p.m. with the ED (staff #88) and the ADON (staff #57). Staff #88 stated that staffing issues had been identified in their last QAPI meeting held on April 23, 2021. He stated that it had been an ongoing challenge. He said actions taken to correct the issues had included recruiting and retention activities. Staff #88 stated that he had reached out to the county on December 27, 2020, contacted a nurse staffing agency in December 2020. The ED stated he reached out to sister facilities on a monthly basis, and that he had reported staffing shortages to CMS (Centers for Medicare and Medicaid) in April 2021. The ED stated that the issue has not been corrected. He stated that they had one agency CNA that had just started working in the facility this week. When asked to provide documentation that the facility had implemented its Emergency Staffing policy and procedures, staff #88 stated he would do so. The facility's emergency staffing plan included utilizing registry staff and staff from other facilities. However, the facility had not demonstrated that this plan was implemented to address staffing shortages. The facility's policy titled Staffing stated that the facility would provide adequate staffing to meet needed care and services for the resident population. The facility maintains adequate staffing on each shift to ensure that the resident's needs and services are met. Licensed registered nursing and licensed nursing staff are available to provide and monitor the delivery of resident care services. Certified Nursing Assistants/Nursing Assistants are available on each shift to provide the needed care and services of each resident as outlined on the resident's comprehensive care plan. The facility's policy titled Employee Staffing Procedures and Resources - Temporary Emergencies stated that in the event of a situation that results in a temporary emergency including events like a natural disaster, pandemic, public health crisis, or similar situations, the facility will take the following steps in order to review staffing needs in the event that the situation warrants immediate additional staff members. Based on the evaluation, the following efforts would then be taken including relying on previously contracted registry agencies to contract clinical staff members to fill any necessary shifts. The policy stated that after the facility leadership reviews the availability of additional staff and support members and, depending on the circumstances and resident needs, the facility may review the need to the transfer of residents to another location where current economies of scale and operational and clinical conditions would allow the receiving location to more effectively care for residents. The policy also included that resident transfers shall not be necessary unless the facility clinically and operationally cannot adequately provide care for residents under the circumstances.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews, the facility assessment, and review of policy and procedure, the facility failed to ensure that the necessary behavioral health care and services were provided to one resident (#51). The deficient practice could result in residents not receiving the necessary behavioral health care and services. Findings include: Resident #51 was readmitted to the facility on [DATE] with diagnoses that included fracture of an unspecified part of neck of left femur, subsequent encounter for closed fracture with routine healing, Alzheimer's disease, unspecified, and dementia in other diseases classified elsewhere without behavioral disturbance. The admission assessment dated [DATE] at 5:56 p.m. included the resident required 2-person physical assistance and was totally dependent upon staff for activities of daily living (ADLs). The resident was assessed to be alert to person, able to express ideas and wants, and sometimes understood verbal content. A physician's order dated April 3, 2021 included the resident may be seen by a psychiatrist of choice as needed. Review of a nursing progress note dated April 4, 2021 at 6:46 p.m. revealed the resident had demonstrated poor acclimation to the skilled nursing facility environment due to confusion and had struck a Certified Nursing Assistant (CNA) while she was providing care. The note stated that the Assistant Director of Nursing (ADON) and the physician had been made aware, and that a new order had been received for lorazepam (anti-anxiety) 0.5 milligram every 6 hours as needed for agitation. Further review of the clinical record revealed a Psychotropic Medication Informed Consent dated April 5, 2021 had been obtained for lorazepam. Review of the care plan initiated on April 5, 2021 revealed the resident used antianxiety medications (lorazepam) related to an anxiety disorder. The goal was that the resident would be free from discomfort or adverse reactions related to antianxiety therapy. Interventions included to give anti-anxiety medications ordered by the physician, monitor and document side effects and effectiveness, monitor/record occurrence of target behavior symptoms per facility protocol, and psychiatric/psychological consult as ordered. However, review of the physician's orders did not reveal an order for lorazepam. A nursing progress note dated April 5, 2021 at 4:50 a.m. included the resident was combative with a bedtime brief change at the start of the shift, and that around midnight the resident was heard yelling out. The note stated that the resident began requesting a knife, motioned toward the bed control and said he needed to cut the wire. The note stated that nursing was unable to reorient the resident to time and location, and that the resident continued to argue with staff. The note did not include the physician was notified. The admission Minimum Data Set assessment dated [DATE] revealed a score of 3 on the Brief Interview for Mental Status, indicating the resident had severely impaired cognition. The assessment included the resident displayed physical behavioral symptoms directed toward others (i.e., hitting, kicking, pushing, scratching and grabbing) and verbal behaviors directed toward others (i.e., threatening others, screaming at others, and cursing at others). These behaviors occurred 1-3 days during the 7-day lookback period and significantly interfered with the resident's care and put others at significant risk for physical injury. The assessment also included the resident displayed rejection of care for 1-3 days of the 7-day lookback period. Diagnoses included Alzheimer's Disease, Non-Alzheimer's Dementia, and anxiety disorder. However, review of the care plan did not include for physical or verbal behaviors directed towards others, or rejection of care. Review of the Medication Administration Record (MAR) for April 2021 revealed the resident was administered lorazepam 0.5 mg on April 18, 2021 at 4:18 p.m. Per a nursing progress note dated April 20, 2021 at 2:54 p.m., a verbal order had been received from the physician to renew lorazepam 0.5 mg every 6 hours as needed, was noted and carried out. However, review of the physician's orders did not reveal an order for lorazepam. A nursing progress note dated April 20, 2021 at 8:17 p.m. stated the resident required redirection 4 times during the shift to refrain from entering other resident's rooms. Review of a nursing progress note dated April 22, 2021 at 12:49 a.m. revealed the resident was transferred to the secured unit on the previous shift. The note stated that the resident agreed to the room change. A nursing progress note dated April 23, 2021 at 2:01 p.m. included the resident had behavioral issues, such as wanting to be in charge and giving staff orders. The note stated that the resident had a rude attitude towards the staff. A physician's order dated April 23, 2021 revealed for lorazepam 0.5 mg by mouth every 6 hours as needed for anxiety/agitation for 14 days. A nursing progress note dated April 24, 2021 at 1:57 p.m. included the resident had been belligerent and argumentative per his normal behavior. The note stated that the resident's behaviors had disrupted most everyone in the resident's path, and that the resident had no boundaries thinking he was entitled to do and take everything and go anywhere he pleased. A nursing progress note dated April 24, 2021 at 8:03 p.m. included the resident continued to disrupt his neighbors on the unit, had no boundaries or respect for anyone other than his roommate, who was a much larger male. The note stated that the resident was very confrontational and seemed to delight in confrontation. Review of a nursing progress note dated April 25, 2021 at 10:07 a.m. revealed the resident had been uncooperative with the staff when staff attempted to assist with toileting. The note stated the resident had attempted to take control of the toilet and would not get off for the roommate. The note included that the resident was very stubborn and could be verbally abusive towards staff. The note stated that when the Registered Nurse (RN) tried to convince the resident to get off the toilet, the resident threatened to smack the RN in the face. A nursing progress note dated April 27, 2021 at 6:17 a.m. included the resident was combative with hygiene, required 2 staff members to change his brief, and was swinging and grabbing at staff. Review of a nursing progress note dated April 28, 2021 at 6:08 p.m. revealed the resident had attempted to come near the nurse's station multiple times and was redirected by nursing. The note stated the resident grabbed the RN's wrist on one occasion and was threatening. Review of the nursing note dated April 29, 2021 at 7:31 p.m. revealed the resident had been into everyone's business, giving orders to other residents, and attempting to give orders to staff. The note stated that the resident had difficulty following directions from staff and always wanted to argue. The note included that when staff attempted to assist the resident with toileting, the resident will become argumentative and will threaten the staff with violence, stating that he will strike the staff's face or slap the snot out of them. Review of the April 2021 MAR for Target Symptoms/Behavior Tracking regarding anxiety disorder as evidenced by restlessness revealed the behaviors were documented for three instances on April 5, one instance on April 19, five instances on April 24, and one instance in the evening and one instance during the night on April 30. Additional review of the MAR for April 2021 revealed the resident was administered lorazepam twice on April 24 and 25, and once on April 30 and that the lorazepam was effective. A nursing progress note dated May 1, 2021 at 6:16 p.m. stated that the resident started to be disrespectful and demanding of the staff during dinner. The note stated that the resident tried to grab the nurse's hand a couple of times and was talking in a threatening manner. The note stated the resident was medicated per physician's orders. Review of the nursing progress note dated May 3, 2021 at 5:55 p.m. stated the resident had eaten dinner with another resident without problems, until he took the other resident's cookie. The resident was redirected, ate some of the cookie, then threw the rest of the cookie at the other resident. The note stated the resident was educated and apologized to the other resident. The note stated the resident had proceeded to his room, began irritating his roommate, and became verbally abusive. The note included the resident had been redirected as best as possible. A nursing progress note dated May 5, 2021 at 7:30 p.m. stated a CNA had reported the resident had shown aggression towards her, and had pulled her hair during care. Review of a nursing progress note dated May 6, 2021 at 6:40 a.m. revealed that CNA staff had reported the resident had been thrashing around during morning brief change and that the CNA had been struck in the left forearm. A nursing progress note dated May 6, 2021 at 12:54 p.m. revealed the resident got into a verbal altercation with another resident before lunch. The resident was in another's resident's room. The note included the other resident requested resident #51 leave the room, and resident #51 refused. A nursing progress note written by the Director of Nursing (DON) dated May 6, 2021 at 1:29 p.m. revealed the DON was notified around 7:30 a.m. that morning about the resident having behaviors toward staff. The note included the DON asked the nurse to request a psych eval for the resident. Review of the May 2021 MAR for Target Symptoms/Behavior Tracking regarding anxiety disorder as evidenced by restlessness revealed the resident had displayed behaviors once on the day shift and once on the evening shift on May 1, 2021. Further review of the MAR for May 2021 revealed the resident was administered lorazepam on May 1 at 5:37 p.m. and May 3 at 6/10 p.m. and that the lorazepam was ineffective. During an interview conducted with Human Resources (staff #46) on May 6, 2021 at 10:59 a.m., staff #46 stated that when an assaultive resident has been identified, the ADON (Assistant Director of Nursing) and the DON would be notified and alternate placement may be considered depending on the situation. Staff #46 stated that they would try to find out what the trigger might be for a resident assaulting staff. Staff #46 further stated that she was not aware of a resident assaulting staff on a regular basis. She said that the staff have been educated to report to the nurses when they have been assaulted and that the nurses will notified the ADON and the DON who will investigate further. On May 6, 2021 at 11:23 a.m., an interview was conducted with the Resident Relations Manager/Social Services Director (staff #69). Staff #69 stated the facility is not equipped for residents with aggressive behaviors. She stated that if a resident starts exhibiting behaviors, the DON will order a psychiatric consult, and medications or medication changes would be tried. She stated that typically that works. Staff #69 stated there have been a few times when that has not worked, and she has contacted the resident's case manager for placement outside of the facility. She stated that if there was an incident of resident-to-resident abuse, an emergency discharge would be facilitated otherwise the time of the transfer would be up to the physician. Staff #60 stated that staff have not been trained to handle residents with aggressive behaviors. She stated that this was not the type of facility for residents who displayed daily, known violence. She stated that she has not been made aware of any instances of resident to staff abuse. Staff #69 stated staff have been trained to notify the charge nurse on duty, the DON, or Executive Director (ED). Staff #69 said the CNAs are to report behaviors to the nurse and the nurse is to document it. She said the DON would be the one responsible to address it. A phone interview was conducted with staff #80 on May 6, 2021 at 12:16 p.m. Staff #80 admitted to feeling unsafe with resident #51. Staff #80 stated that at least three nurses were notified about staff #80 being assaulted by the resident and that the nurses were supposed to document it. Staff #80 stated being assaulted by resident #51 occurred pretty much every night staff #80 worked. Staff #80 stated that the resident stalks the CNAs and sneaks upon them quietly. Staff #80 stated the CNAs feel there is not much they can do about it. Staff #80 stated that they avoid talking with the DON and ED because they had been dismissive in the past. Staff #80 stated that when a former resident had severely assaulted a member of the nursing staff, the ED and DON called a staff meeting and asked everyone what they could have done to prevent the incident. Staff #80 stated that since then they have felt that anything said to management has fallen on deaf ears. On May 6, 2021 at 12:33 p.m., a phone interview was conducted with staff #54. Staff #54 stated this was the resident's second admission and that there was aggressive during the prior admission as well. Staff #54 stated that when administrative staff were approached regarding aggressive residents before, they were told they needed to get better with geri psych (geriatric psychiatry). Staff #54 stated that the nursing staff received on-line training on how to approach residents with dementia, and that they also had a skills fair on April 9, 2021 with a section on geri psych. Staff #54 stated the care plans are initiated by admissions and nursing staff. Staff #54 stated they had been taught to document, then notify the administrative staff. Staff #54 reported notifying administrative staff on one occasion within the past month, but did not know the outcome. An interview was conducted on May 6, 2021 at 1:07 p.m. with staff #38. Staff #38 stated resident #51 had a history of following the staff around and being assaultive, and had personally witnessed the resident pulling hair, hitting, and kicking. Staff #38 stated that the resident is aggressive on and off, and that staff have not been able to figure out what triggers him. Staff #38 stated the resident does not usually assault other residents, but does go into their rooms. Staff #38 stated the physician was notified on prior occasions, but could not recall whether or not the calls were documented in the resident's clinical record. Staff #38 stated staff #38 reported the aggressive behaviors to the DON and ADON on at least one or two occasions. On May 6, 2021 at 3:53 p.m., an interview was conducted with the ADON (staff #57). She stated that if a resident displayed aggressive or assaultive behaviors, nursing would be expected to alert the physician, administrative staff, and perhaps initiate an emergency psychiatric consultation. She stated the resident would be placed on 15-minute checks and/or transferred to a different facility that would be safer for the resident. She stated she had just spoken with the nurses on the unit regarding the lack of behavior documentation on the MARs. The ADON stated that when the nurses do not document the behaviors on the MAR, the pharmacy suggests a decrease in medication based upon that information. She stated that then they end up increasing the medications again because it was not a good plan. The ADON stated that her expectations included for nursing to document the resident's behaviors, notify the physician, and that it would be a good idea to revise the care plan. The ADON stated that if nursing did not make the administrative staff aware of the behaviors, the MDS nurse or the DON would not be alerted to revise the care plan. She stated that if the behaviors continued and it was not communicated, it would not meet the resident's needs. The Facility Assessment completed January 1, 2021, and updated February 18, 2021 and March 19, 2021 stated the purpose of the assessment was to determine what resources were necessary to care for residents competently during both day-to-day operations and emergencies. The assessment was to be utilized to make decisions about direct care staff needs as well as the capabilities to provide services to the residents in the facility. Using a competency-based approach focuses on ensuring that each resident was provided care that allows the resident to maintain or attain their highest practicable physical, mental, and psychosocial well-being. The intent of the facility assessment was for the facility to evaluate its resident population and identify the resources needed to provide the necessary person-centered care and services the residents require. The assessment stated that the facility accepted residents with, or that residents may develop, the following common diseases, conditions, physical and cognitive disabilities, or combinations of conditions that require complex medical care and management. The assessment included under the category of psychiatric/mood disorders residents with non-aggressive behaviors that needs interventions for psychiatric/mood disorders. The facility's policy titled Behavior Management Program included the facility leadership is required to review all residents in an effort to review behaviors and manage their psychotropic medication regimen. Psychotropic medications shall only be utilized with a physician's order and shall never be used for the convenience of staff. If new behaviors are noted or existing behaviors have worsened, prior to initiating or increasing any psychotropic medication, the following interventions must occur: contact the ADON, place the resident on alert charting, obtain a urine sample to dipstick to rule out urinary tract infection, review the resident for factors which may be causing the behaviors including: physical concerns, environmental conditions, psychosocial stressors, and medical conditions which require treatment. If a resident is in immediate danger of harm to self or others, notify the Medical Doctor (MD) for possible hospitalization or an emergency order may be initiated as follows, including notifying the MD for possible hospital referral, and notify the family of the situation and possible physician order. The facility's policy titled Behavioral Assessment, Intervention and Monitoring included behavioral symptoms will be identified using facility-approved behavioral screening tool and behavioral symptoms will be managed appropriately. As part of the initial assessment, the nursing staff and attending physician will identify individuals with a history of impaired cognition, altered behavior, or mental illness. As part of the comprehensive assessment, staff will evaluate based on input from the resident, family and caregivers; review of the medical record and general observations: the resident's usual patterns of cognition, mood, and behavior, the resident's usual method of communicating things like pain, hunger, thirst, and other physical discomforts, and the resident's typical or past responses to stress, fatigue, fear, anxiety, frustration, and other triggers. The nursing staff will identify, document, and inform the physician about specific details regarding changes in an individual's mental status, behavior, and cognition. The interdisciplinary team will evaluate behavioral symptoms in residents to determine the degree of severity, distress, and potential safety risk to the resident, and develop a plan of care accordingly. Safety strategies will be implemented immediately if necessary to protect the resident and others from harm. The care plan will incorporate findings from the comprehensive assessment and be consistent with current standards of practice.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Review of the facility work orders revealed a work order #338 for cockroach problem in the resident's room with completed on the top of the page from the computerized program. There was no date. There was a copy of a receipt for two ORTHO HD MAX 1.33-GAL ET, purchased on 4/28/21. Invoices reviewed revealed monthly visits from a professional pest control company. On 05/05/21 at 01:42 PM, an interview was conducted with the Environmental Services Director (EVS director/staff 60). Staff #60 stated there were no outstanding work orders. The EVS director then displayed a computerized entry system (TELS) which he had accessed with his phone. The number 0 was observed, indicating there are no incomplete tasks. He stated the computerized work orders is a new system for the facility. Another interview was conducted with the EVS (staff #60) on 05/06/21 at 09:31 AM. Staff #60 stated that he does not know about problems with roaches in residents' rooms. He stated the problem areas were the laundry room. Staff #60 stated that about a week and a half ago, he sprayed the building for 3 days in a row. He stated he did not document the times that he sprayed between the professional pest control treatments. Staff #60 stated that he bought chemicals himself to spray. He stated the pest control company did not leave chemicals for him to use. On 05/06/21 at 10:03 AM, an interview was conducted with the Administrator (staff #91). He stated that the new employees have to be trained on the new work order system. He said they may have the mindset that work orders can just be verbalized or put on paper, and that it may become lost in translation. The Administrator stated the pest control company is scheduled to treat monthly and have dropped off chemicals so that the facility can spray themselves in between if needed. He stated that there are construction areas nearby and a nearby apartment building was infested. Staff #91 stated the sewer system was probably the problem, and that there was a recent sewer repair. Review of the facility's Pest Control policy revealed the facility maintains an effective pest control program to ensure the building is kept free of insects and rodents. The policy stated only EPA and FDA insecticides and rodenticides are permitted in the facility. The policy also stated that maintenance services will assist when appropriate and necessary in providing pest control services. Based on observation, resident and staff interviews, facility documents, and policy review, the facility failed to maintain an effective pest control program to ensure the facility was free of pests. The deficient practice could result in ongoing pest problems. Findings include: On May 5, 2021 at 2:06 p.m., an interview was conducted with a Certified Nursing Assistant (CNA/staff #71). The CNA stated that there had been a roach infestation on the Secured Dementia Unit (SCU) for about a year, and that the roaches seemed to be most concentrated in one resident's room. The CNA stated that they had gone into the resident's room the other evening to check the resident and observed roaches crawling on the floor, on the resident's bedside table, in the resident's water cup, and in the resident's bed. The CNA stated that they reported it to the nurse on duty. An interview was conducted on May 6, 2021 at 10:15 a.m. with a CNA (staff #31). The CNA stated that they had seen cockroaches in the resident's room for months. The CNA stated that the roaches do not really come out in the daytime, however, they were in the resident's drawers. The CNA stated that during the night, roaches will be all over the floor, on the dressers, behind the resident's pictures, and crawling up the walls. The CNA stated they would [NAME] the cockroaches out of the resident's bed using their fingers. The CNA stated that all the nurses know about the roaches. Staff #31 also stated that a week or so ago maintenance had come in and sprayed the resident's room. On May 6, 2021 at 10:46 a.m., an interview was conducted with the Director of Maintenance (staff #60). He stated that he went to the store to buy pesticide and that he had sprayed the whole facility himself three times after staff had made him aware of the roaches. Staff #60 stated that the last time he heard there was a problem was the week before last. An observation was conducted of the resident's on May 6, 2021 at approximately 10:50 a.m. with the Director of Maintenance (staff #60). With the resident's permission, staff #60 looked through the resident's drawers and closet. Staff #60 stated he saw one cockroach in the resident's drawer. Upon further observation by the surveyor, two cockroaches were observed behind one of the resident's dressers, one cockroach was observed in the bottom of the resident's closet, and one was observed on the side of the closet behind the resident's clothes. All of the roaches were observed to be alive. The resident that resided in the room stated that the cockroaches were everywhere and hoped they could catch them. An interview was conducted on May 6, 2021 at 11:00 a.m. with the Human Resources Director (HR/staff #46). She stated that when staff have a concern they may text, email, leave a note, or call her directly. She stated that she has a drop-box in the front of her office and that staff will sometimes slip a note under her door as well. Staff #46 stated that she did recall there had been a note from a member of the staff regarding the cockroaches in the facility. She stated that she had informed the Executive Director (ED/staff #88) and the Director of Nursing (DON/staff #47) after she had received the note. Staff #46 also stated that she did not remember exactly when she had notified them. She stated that the ED had gone on rounds with maintenance, checked all the rooms, and that they had sprayed twice weekly, or every day, during the month of April. She stated that the Infection Preventionist and the DON are responsible to educate staff on what to do when they see cockroaches. Staff #46 stated that once she let the ED and the DON know, it was out of her hands. On May 6, 2021 at 12:16 p.m., an interview was conducted with a CNA (staff #80). The CNA stated they had seen cockroaches all over the resident's room, especially at night. The CNA stated the roaches had been seen in the resident's bed on more than one occasion. An interview was conducted on May 6, 2021 at 12:33 p.m. with a member of the nursing staff (staff #54). Staff #54 stated that cockroaches were seen in the resident's room and that the roaches were not directly reported by staff #54. Staff #54 also stated that the facility had a couple of new hires recently, and that one CNA had only stayed for 1.5 hours because she had seen a cockroach in the building and did not like how unclean the building was.