**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** III. Resident #21 A. Resident status Resident #21, age greater than 65, was admitted on [DATE]. According to the July 2024 CPO, diagnoses included dementia without mood disturbances, anemia (not enough oxygen in the cells to fuel the body), and a history of COVID-19 and stroke (blocked blood flow to the brain). The 6/7/24 MDS assessment documented the resident had severe cognitive impairment with a BIMS score of three out of 15. The resident required substantial assistance with personal hygiene, showering, bathing, toileting and dressing her lower body. She required moderate assistance for dressing her upper body and supervision and/or touching assistance with eating. She required substantial assistance for rolling in bed and for most transfers. The assessment documented the resident was on oxygen. B. Observations On 7/25/24 at 9:55 a.m. Resident #21's nasal cannula (tubing device that supplies oxygen through the nose) was not in her nose properly (only one of two nasal prongs was in her nose). At 10:07 a.m. the resident's nasal cannula was completely out of her nose. At 2:35 p.m. CNA #1 assisted the resident in her wheelchair to an activity. CNA #1 carried the portable oxygen on her back but the nasal cannula was not in the resident's nose. On 7/29/24 at 9:14 a.m. Resident #21 was lying flat in bed. The nasal cannula was not in her nose but was laying on her bed. At 11:29 a.m. Resident #21 was awake, lying flat in bed. The nasal cannula was not in her nose. C. Family member interview Resident #21's representative was interviewed on 7/30/24 at 11:05 a.m. Resident #21's representative said a few days prior to the survey, the resident called at night with a confusing question. He said he came to the facility the next morning and said the resident was more confused than normal. He said the resident's nasal cannula was not in her nose and was on top of the oxygen machine by the closet. The representative said he assumed that meant she did not get her oxygen overnight. He said he thought a CNA noticed in the morning and told the NHA because the NHA called the family later that day. He said there had been a few times he had noticed the nasal cannula had not been in her nose and the resident did not have the dexterity to put it back in herself. He said the staff did check her oxygen levels but he was not sure how often. The representative said the staff told him that even when she was not wearing her oxygen, her saturations were within normal limits. D. Record review The July 2024 CPO revealed the resident had a physician's order that indicated to administer oxygen at a rate of two liters per minute via nasal cannula every shift for hypoxia, ordered 4/12/24. The care plan, revised on 9/19/23, revealed the resident had oxygen therapy related to ineffective gas exchange. The oxygen was ordered at two liters per minute continuously. Interventions included changing her position often to ease movement and drainage of fluid in the lungs, positioning the resident to facilitate breathing and oxygenation by assisting her into an upright position whenever possible. The care plan revealed if the resident was on her side, her good side should be down (damaged lung facing up). The care plan indicated the resident should be monitored for signs and symptoms of respiratory distress and, if noted, reported to the physician. -The care plan did not address interventions to ensure the resident was wearing her nasal cannula and getting her oxygen as ordered. A review of the resident's electronic medical record (EMR) revealed between 7/1/24 and 7/29/24, the resident's oxygen saturations were documented three times per day and were 90% or above. On 7/12/24, they were not documented in the morning check. E. Staff interviews CNA #8 was interviewed on 7/30/24 at 12:44 p.m. CNA #8 said the CNAs and the nurses checked Resident #21's nasal cannula to make sure it was in. She said the resident sometimes took off the cannula to blow her nose and forgot to put it back in. She said the resident could not put it back in herself. CNA #8 said for the past three weeks she had been working at the facility and it had always been in. LPN #2 was interviewed on 7/30/24 at 12:56 p.m. LPN #2 said Resident #21 was on two liters of oxygen continuously but sometimes she took it off. LPN #2 said the resident could not put the nasal cannula back in her nose herself so staff frequently checked on her to make sure it was in. LPN #3 was interviewed on 7/30/24 at 3:20 p.m. LPN #3 said the staff frequently checked on Resident #21 at night to make sure her nasal cannula was in because she had a history of removing it. She said she noticed it was not in her nose sometimes. She said if she noticed it was out of her nose she would put it back in. She said oxygen saturation levels were checked every shift for all residents on oxygen and more often if their oxygen had not been on consistently. Based on observations, record review and interviews, the facility failed to ensure two (#56 and #21) of five residents reviewed for oxygen therapy was provided respiratory care consistent with professional standards of practice out of 51 sample residents. Specifically, the facility failed to: -Ensure Resident #56's CPAP (continuous positive airway pressure) machine was working appropriately and used as ordered by the physician; and, -Ensure Resident #21 was wearing oxygen as ordered by the physician. Findings include: I. Facility policy and procedure The Oxygen Administration policy and procedure, reviewed June 2023, was provided by the nursing home administrator (NHA) on 7/30/24 at 4:43 p.m. It read in pertinent part, Oxygen is administered under orders of the physician. Staff shall document the initial and ongoing assessment of the resident's condition warranting oxygen and the response to oxygen therapy. -The policy did not include any pertinent information for the use of CPAP/biPAP (bilevel positive airway pressure) machines. II. Resident #56 A. Resident status Resident #56, age [AGE] , was admitted on [DATE]. According to the July 2024 computerized physician orders (CPO), diagnoses included acute and chronic respiratory failure with hypoxia (decreased oxygen levels), chronic obstructive pulmonary disease (COPD) and dependance on supplemental oxygen. The 6/27/24 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 13 out of 15. She was receiving oxygen therapy. -CPAP therapy was not documented on the assessment. B. Observations and resident interview Resident #56 was interviewed on 7/24/24 at 3:11 p.m. Resident #56 was wearing oxygen via nasal cannula. At the bedside, a CPAP machine was observed on the table. Resident #56 said she had not used the CPAP machine for at least three months. She said the machine was broken. She said the staff were aware that it was broken. She said the staff would come and tell her that they would take care of it but no one did. She said the facility had new staff every day and she could not remember the names of all the staff who knew about the broken machine. C. Record review The oxygen therapy care plan, initiated 5/21/24, indicated Resident #56 required a CPAP machine for effective symptom management of COPD. Interventions included administering supplemental oxygen as ordered, ensuring the oxygen tubing was connected to the CPAP unit and verifying the liter flow prior to CPAP mask placement. -The care plan referred to machine BIPAP or CPAP interchangeably and the specific settings were not documented. -Review of the July 2024 CPO revealed Resident #56 did not have a physician's order for the use of a CPAP or BiPAP. Review Resident #56's physician progress notes between 5/1/2424 and 7/30/24 revealed a note on 5/20/24 that documented the resident was not using the CPAP machine because it was leaking water on her face when she was using it. The physician recommended service or replacement of the CPAP as soon as possible. -However, there was no additional documentation indicating the facility had attempted to service or replace the CPAP machine. D. Staff interviews Certified nurse aide (CNA) #10 was interviewed on 7/25/24 at 2:30 p.m. CNA #10 said she did not know if the resident used a CPAP or BiPAP machine. She said she worked the morning shift and she had not observed the resident wearing the mask early in the morning. Registered nurse (RN) #2 was interviewed on 7/25/24 at 2:43 p.m. RN #2 said she did not know if the resident should or should not use the CPAP machine. She reviewed the physician's orders and said the resident did not have a physician's order for the CPAP machine. She said she was an agency nurse and did not know the resident well enough to know if the resident used the machine in the past. Licensed practical nurse (LPN) #1 was interviewed on 7/25/24 3:36 p.m. LPN #1 said she was a unit manager. She said she was new to the unit and today (7/25/24) was her eighth day of work on the unit. She said she remembered from the recent care conference that the resident was not using the CPAP machine but she did not know why and she did not ask the resident about it. The director of nursing (DON) was interviewed on 7/25/24 at 3:57 p.m. The DON said she did not know if the resident was using the CPAP machine. She reviewed the physician's orders and said the resident did not have a physician's order for the use of a CPAP machine. She said she was not aware that the machine was broken and did not know why it was not serviced since the physician's recommendation in May 2024. The DON said she would clarify the need for the CPAP machine with the physician and find out what needed to be fixed.

Based on observations, record review and interviews, the facility failed to ensure residents were treated with dignity in two out of four dining rooms. Specifically, the facility failed to: -Ensure an adequate system was in place to provide meal service in a timely fashion to residents waiting to be served their meals in the Aspen and Pine Ridge dining rooms, which resulted in some residents at the same table receiving their meals 40 to50 minute after other residents; and, -Ensure residents were treated with respect and dignity by staff in the dining rooms, including engaging with residents and addressing residents by his/her preferred name. Findings include: I. Facility policies and procedure The Quality of Life - Dignity policy, revised February 2020, was requested and received from the nursing home administrator (NHA) on 7/30/24. It read in pertinent part, Residents are treated with dignity and respect at all times. Staff speak respectfully to residents at all times, including addressing the resident by his or her name of choice. The Assistance with Meals policy, revised March 2022, was requested and received from the nursing home administrator (NHA) on 7/30/24. It read in pertinent part, All residents will be encouraged to eat in the dining room. Residents who can not feed themselves will be fed with attention to safety, comfort and dignity, for example, not standing over residents while assisting them with meals and keeping interactions with other staff to a minimum while assisting residents with meals. II. Dining room meal times The posted meal times for the facility's dining rooms were scheduled to begin as follows: breakfast began at 6:45 a.m., lunch began at 11:30 a.m. and supper began at 4:20 p.m. III. Aspen dining room observations During a continuous observation of the lunch meal in the Aspen dining room on 7/24/24, beginning at 11:54 a.m. and ending at 12:53 p.m., the following observations were made: At 11:54 a.m. eight residents were present and seated at tables in the dining room. One of the residents spilled water that ran all over the table and the floor. -No staff were present in the dining room and the water spill went unnoticed. At 12:00 p.m. lunch meal trays were delivered on a cart to the dining room by the dietary staff. At 12:04 p.m. staff started to pass the lunch meal trays to the residents seated at the tables. At 12:08 p.m the spilled water was noticed by an unidentified certified nurse aide (CNA) who cleaned up the spill. Another unidentified CNA was overheard telling two other staff members You guys will be feeding them (referring to residents) today before leaving the dining room. At 12:14 p.m. one of the CNAs was standing up next to a resident and assisting her with eating lunch. -The CNA failed to sit down next to the resident while assisting her to eat her lunch. At 12:20 p.m. five of the eight residents present in the dining room had received their meals. At 12:24 p.m. more meal trays were delivered to the Aspen dining room, however the lunch meal trays were for residents who chose to eat in their rooms and not for the three remaining residents in the dining room who had not yet received their meals. At 12:44 p.m. a third cart of lunch meal trays was delivered to the Aspen dining room. The three other residents in the dining room received their lunch meals, 40 minutes after lunch service began and at least 20 minutes after the other five residents had received their meals. At 12:53 p.m.one of the residents at the front right dining room table was heard asking if she could have toast. CNAs walking by the table ignored her request. A resident who was sitting next to her at the table said They told me they don't make toast. Staff members in the middle of the dining room were discussing another resident and were overheard saying She already ate, all she wanted was a sandwich and we offered her everything. -The staff members did not refer to the resident by name. During a continuous observation of the lunch meal in the Aspen dining room on 7/25/24, beginning at 12:00 p.m. and ending at 12:52 p.m., the following observations were made: At 12:00 p.m. The first lunch meal trays were delivered on a cart to the dining room. Two of the eight residents in the dining room received lunch meal trays from the first meal cart delivery. At 12:40 p.m. the second cart of meal trays was delivered to the dining room, however, the meal trays on the cart were for residents who were eating in their rooms and not for the remaining six residents in the dining room who had not yet received their meals At 12:52 p.m. the third cart of lunch trays was delivered to the Aspen dining room. The six other residents in the dining room received their lunch meals, 52 minutes after the other two residents in the dining room had received their meals. During a continuous observation of the lunch meal in the Aspen dining room on 7/29/24, beginning at 12:01 p.m. and ending at 12:47 p.m., the following observations were made: At 12:01 p.m. a housekeeper pushed a resident in a wheelchair into the dining room and was overheard asking a CNA Where do you want her? The CNA responded Put her with (resident name), she gets along with her. -The housekeeper and the CNA failed to refer to the resident in the wheelchair by her name. At 12:06 p.m. the first lunch meal tray cart arrived in the dining room. One out of seven residents present in the dining room received a lunch meal tray. The other meal trays on the cart were served to residents who were eating in their room. At 12:09 p.m. a second meal tray cart was delivered to the dining room. One of three residents, who were sitting at the same table, were served their lunch meal. At 12:21 p.m. a third meal cart was delivered to the Aspen dining room. All of the lunch meal trays on the cart were for residents who were eating in their rooms. At 12:30 p.m. a fourth lunch meal tray cart arrived in the dining room. Four of the remaining residents in the dining room received their meals. One resident in the dining room, who was sitting next to a resident who had received her meal tray at 12:00 p.m., still had not received her lunch meal. At 12:39 p.m. a fifth meal cart of lunch trays was delivered. All of the meal trays went to residents in their rooms. At 12:46 p.m. an unidentified CNA sat next to the resident with the face mask who required assistance with eating and started assisting the resident (21 minutes after she had received her meal). The resident's mask was still touching her lower lip. The CNA began helping another resident on her other side as well as the resident with the mask. The CNA did not remove the resident's mask or lower it below her chin. At 12:47 p.m. a sixth cart of lunch meal trays was delivered to the Aspen dining room and the last resident in the dining room was served (41 minutes after the first resident received their lunch meal tray). IV. Pine Ridge dining room observations During a continuous observation of the lunch meal in the Pine Ridge dining room on 7/24/24, beginning at 11:31 a.m. and ending at 12:42 p.m., the following observations were made: The Pine Ridge dining room had two round tables which accommodated five residents each and bistro seating for two residents. From 11:31 a.m. to 11:40 a.m., nine residents were assisted to the dining room for meal time. Four additional residents were seated by 11:52 a.m., for a total of 12 residents seated in the dining room. At 12:04 p.m. the first meal tray cart arrived at the Pine Ridge dining room. Two meal trays were delivered to two residents in the dining room. No other residents received a meal tray. At 12:08 p.m. an unidentified staff member told a resident that the food was coming. At 12:22 p.m., five additional meal trays arrived on a cart and were passed to residents. At 12:30 p.m., 38 minutes after the last residents were seated, five residents did not have meal trays. Two residents from each of the two dining tables and one of the two residents seated at the bistro counter waited to receive their meal tray while the other seven residents in the dining room were eating their lunch. An unidentified staff member said to a resident who was waiting for their meal tray, You are getting sleepy waiting for your lunch huh. Between 12:31 p.m. and 12:42 p.m., the remainder of the lunch meal trays were delivered and at 12:42 p.m. the last resident seated at the bistro counter in the dining room received his meal tray, 50 minutes after the last resident was initially seated for lunch. -The facility failed to ensure residents seated at the same table were served their meals in a timely manner during the lunch meal. During a continuous observation of the lunch meal in the Pine Ridge dining room on 7/25/24, beginning at 11:15 a.m. and ending at 12:50 p.m., the following observations were made: At 11:42 a.m. eight residents were seated in the dining room with four residents each seated at the two round tables. At 11:45 a.m. Resident #38 was just brought to the dining room and seated at the bistro counter. Three additional residents were seated in the dining room for a total of twelve residents. All residents had drinks in front of them but no food. At 12:02 p.m. Resident #38 made a short, low groaning sound. Registered nurse (RN) #3 approached Resident #38 and asked her if she was okay. Resident #38 replied she was okay and RN #3 asked Resident #38 if she was getting hungry. Resident #38 replied yes she was. At 12:07 p.m. four meal trays arrived and were delivered to residents seated in the dining room. Resident #38 continued to make a short, low groaning sound while seated in the dining room. At 12:14 p.m. Resident #38 was sitting with her eyes closed in the dining room. At 12:15 p.m. CNA #11 escorted a resident from the dining room and no other facility staff were present in the dining room. At 12:22 p.m. five more meal trays had been delivered to residents seated in the dining room. Three residents seated at the round dining table did not have a meal tray while the remainder of the residents in the dining room had received meal trays and were eating their lunch. At 12:37 p.m. three residents had not yet received a meal tray. A resident who received her meal tray first finished eating, while the resident seated next to her had not received a meal yet and watched her eat her meal. At 12:42 p.m a cart of additional meat trays was delivered to the dining room. At 12:49 p.m. the final resident without a meal tray was given her lunch. RN #3 set up her tray and said to the resident, You look hungry. -The facility failed to ensure residents seated at the same table were served their meals in a timely manner during the lunch meal. V. Main dining room observations During a continuous observation of the dinner meal in the main dining room on 7/30/24, beginning at 4:16 p.m and ending 5:54 p.m., the following observations were made:: At 5:04 p.m. CNA #9 was observed standing next to a table in the dining room. A resident was seated in her wheelchair next to CNA #9. CNA #9 was eating out of a clear plastic container while standing in the dining room during meal service. -Dietary aide (DA) #1 was interviewed at 5:05 p.m. DA #1 said CNA #9 was employed at the facility and assisted feeding residents at meal time. At 5:07 p.m. CNA #9 sat down at the table and set his cell phone on the dining room table in front of him. CNA #9 offered the resident a drink with his left hand while looking down at his cell phone on the table. CNA #9 continued to hold the drink glass in front of the resident while he looked at his phone for approximately 45 seconds. CNA #9 put down the drink glass and continued to look at his phone instead of looking at the resident and engaging with her At 5:14 p.m. CNA #9 was looking down at his phone on the table while sitting with the resident, not making eye contact with her or engaging with her. -The dietary manager (DM) was interviewed at 5:17 p.m. The DM confirmed CNA #9 was an employee of the facility and the DM asked if CNA #9 was on his phone again in the dining room. The DM said she told CNA #9 to get off his phone at lunch and he was not happy he was told to put his phone away. The DM said in the orientation for new employees, she reviewed staff should not have their personal cell phones in the dining room. The DM said CNA #9 was not a new staff member and did not have an orientation with her but she said he should still know cell phones were not allowed in the dining room. At 5:31 p.m. CNA #9 was observed checking his hands and not looking at or engaging with the resident during meal time. -CNA #9 failed to assist and engage with the resident while assisting her during meal service. VI. Staff training The DON provided an inservice on 7/30/24 at 1:25 p.m. The course title was nursing meeting and dated 4/11/24. The description of the education included addressing weight concerns (of residents), dining services, meal orders and encouraging residents to come to the main dining room. CNA #9 signed the inservice on 4/11/24. -However, the inservice did not provide details that specifically addressed resident meal time assistance. VII. Staff interviews CNA #12 was interviewed on 7/30/24 at 10:35 a.m. CNA #12 said the residents could choose which dining room they preferred to dine in and what menu items they preferred to eat. CNA #12 said, after facility staff took resident meal orders, the orders were given to the dietary staff. CNA #12 said she was unsure why resident meal trays were served so far apart for one dining room instead of being served together. CNA #12 said the facility staff usually had the residents seated in the dining room around 11:30 a.m. for lunch (however lunch was served between 11:30 a.m. and 1:00 p.m.) CNA #12 said residents expressed frustration about waiting too long for their meal trays to be delivered and dietary staff were aware of the resident's concerns. The DM and the nursing home administrator were interviewed together on 7/30/24 at 11:00 a.m. The NHA said the timing of meal delivery was an issue the facility was working on. The NHA said the facility only sent a few trays to one dining room at a time so the food was served hot. The NHA said the CNAs spent three days with another staff member for their initial training. The NHA said resident meal assistance, as well as feeding the residents, was part of the CNAs initial training. The DM said the goal was for staff to be able to pass some meal trays before sending more so the food stays hot. The DM said the dietary staff did not always know where the residents preferred to eat and where to send the meal trays. The DM said meal service usually took almost an hour. CNA #9 was interviewed on 7/30/24 at 11:30 a.m. CNA #9 said he was a full time CNA and was working occasionally at nights and on the weekends. He said dining room assignments for CNAs were not clear as far as which CNA needed to present in which dining room. He said sometimes CNAs were told to go to the main dining room and sometimes they were to go to the small dining room. He said the facility had new agency staff coming daily and those staff members were not aware of the resident's preferences and had a tendency to ask questions about personal care in front of the residents. CNA #9 said the general rules of meal assistance were to sit next to the resident and assist the resident with the meal until the resident was finished eating. He said all residents should be referred to by name and personal care and needs should not be discussed in front of other residents. CNA #9 said the kitchen always delivered meal trays in random order and there was no system to who received the first meal or which resident received the last meal. Licensed practical nurse (LPN) #1 was interviewed on 7/30/24 at 11:45 a.m. LPN #1 said she was not sure if there was an order for meal tray delivery. She said the kitchen delivered the trays randomly and it was unclear if there was any system to it. LPN #1 said when staff assisted residents in the dining room they should refer to residents by name, be attentive to their needs and help residents until they were finished with the meal. The NHA and the director of nursing (DON) were interviewed together on 7/30/24 at 12:45 p.m. The DON said the facility provided a meal service education in April 2024 to encourage residents to come to the dining room and CNA assistance with meals. She said staff were talked to about not being on their phones. The DON said meal service was something the facility had been working on and they were trying to get residents into a type of seating arrangement. -However, the inservice did not provide details that specifically addressed resident meal time assistance (see staff training above). The NHA said a cart of meal trays was delivered to the Pine Ridge dining room, and then another cart of meal trays was delivered to a different dining room so the CNAs had time to get trays set up for residents and the residents were not waiting too long. The NHA said the facility was trying to improve socialization with residents at meal time and improve overall meal service. The NHA said the facility had not yet considered staggering the start times of meals in the different dining rooms. CNA #11 was interviewed on 7/30/24 at 2:00 p.m. CNA #11 said the residents sometimes expressed concern they felt hungry while waiting for lunch. CNA #11 said the staff did their best to offer residents a drink or something small to eat while waiting for meal trays to be delivered at mealtime. CNA #11 said the late arrival of lunch meals could disrupt the resident's afternoon schedules. CNA #11 said longer mealtimes made it difficult to manage if residents were eating and needed assistance and another resident had to use the restroom, which caused the staff to leave the dining room to assist a resident with continence care. CNA #11 said she was trained how to assist a resident at meal time and a personal cell phone should not be used while assisting a resident. CNA #11 said staff should be seated and make eye contact with the residents because it was respectful to the resident and helped the residents trust the staff. The DON was interviewed again on 7/30/24 at 5:24 p.m. The DON said while assisting a resident at meal time, staff should sit so they were at eye level with the residents. The DON said staff's hands should be clean, staff should talk to the resident, inform the resident what menu items were on their plates and cue or assist them to eat as needed. The DON said cell phones were not acceptable to use while assisting a resident at meal time, nor were conversations about other residents. The DON said residents should be discussed on the side and resident's personal matters should not be discussed in front of other residents. The NHA was interviewed again on 7/30/24 at 5:50 p.m The NHA said all residents were to be treated with respect and dignity. He said CNAs should be seated next to the residents when they were providing meal assistance and remain with the resident until the resident finished his or her meal. He said staff should not discuss any personal information in front of other residents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to honor resident choices for three (#56, #6 and #65) of five residents reviewed for activities of daily living (ADL) out of 51 sample residents. Specifically, the facility failed to: -Ensure Resident #56, Resident #6 and Resident #65 received two showers a week per their preferences; and, -Ensure Resident #65 was assisted with a leg catheter bag on Sundays when he was attending church. Findings include: I. Resident #56 A. Resident status Resident #56, age [AGE], was admitted on [DATE]. According to the July 2024 computerized physician orders (CPO), diagnoses included acute and chronic respiratory failure with hypoxia (decreased oxygen levels), chronic obstructive pulmonary disease (COPD) and dependance on supplemental oxygen. The 6/27/24 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 13 out of 15. She required substantial maximal assistance with showers and did not reject the care. B. Resident interview Resident #56 was interviewed on 7/24/24 at 3:28 p.m. Resident #56 said she had not had a shower in a week. She said her preference was to receive two showers a week. She said there were new staff members working at the facility every day and they were not familiar with the shower schedule. She said the staff would come into her room and say they would come back. She said the staff never returned to her room to assist her with a shower. She said sometimes the staff said there was not enough staff so they could not help with showers. C. Record review The care plan, initiated 11/15/23, identified Resident #56 had impaired balance and limited mobility. Interventions included staff to assist with showers. -A review of the care plan revealed the care plan did not address Resident #56's current shower preferences. The care plan, initiated on 5/24/24, revealed that the resident was resistive to bathing, and would decline showers and bed baths at times. Interventions included allowing the resident to make decisions about treatment regimens, providing a sense of control and if possible negotiating a time for showers so that the resident participated in the decision making process. A review of the certified nurse aide (CNA) shower task for July 2024 revealed Resident #56 was to receive showers on Tuesdays and Thursdays on the evening shift. -The shower logs for 6/23/24 to 7/26/24 revealed the resident received one bed bath on 7/6/24 (Saturday), and one shower on 7/10/24 (Wednesday). The resident refused care on 7/5/24 (Friday) and 7/12/24 (Friday). -Resident #56 was supposed to receive nine showers a month and she received only one. -Review of the progress notes from 6/23/24 to7/26/24 revealed no documented notes for resident refusals of showers. II. Resident #6 A. Resident status Resident #6, age [AGE], was admitted on [DATE]. According to the July 2024 CPO, diagnoses included COPD and hypertension (high blood pressure). The 6/26/24 MDS assessment revealed the resident was cognitively intact with a BIMS score of 14 out of 15. She required substantial/maximal assistance with showers and did not reject care. B. Resident interview Resident #6 was interviewed on 7/29/24 at 1:28 p.m. Resident #6 said she received showers inconsistently. She said her preference was to receive showers twice a week. She said the agency staff did not know what the shower schedule was and who was to provide showers. She said the staff frequently said they were understaffed and could not provide showers. She said the facility used to have a shower aide, but with the new management, that position was eliminated. She said it was impossible to get a shower per her preference or at all. C. Record review The care plan, initiated 2/24/23, identified Resident #6 had impaired balance and decreased mobility. Interventions included assisting the resident with showers. -A review of the care plan revealed the care plan did not address Resident #6's current shower preferences. A review of the CNA shower task for July 2024 revealed the resident was to receive showers on Mondays and Thursdays on the day shift. -The shower logs for 7/1/24 to 7/30/24 revealed the resident received a total of five showers out of nine scheduled opportunities for showers. -Review of the progress notes from 7/21/24 to 7/30/24 revealed no documented notes for resident refusals of showers. III. Resident #65 A. Resident status Resident #65, age [AGE], was admitted on [DATE]. According to the July 2024 CPO, diagnoses included hypertension, heart disease and diabetes. The 5/10/24 MDS assessment revealed the resident was cognitively intact with a BIMS score of 14 out of 15. He required substantial moderate assistance with showers and did not reject care. B. Resident interview Resident #65 was interviewed on 7/25/24 at 1:28 p.m. Resident #65 said showers were provided inconsistently. He said his preference was to receive showers twice a week on assigned days. He said the agency staff did not know the shower schedule or who was to provide the showers. He said his showers were frequently skipped or not offered at all. Resident #65 said when he voiced his concerns to staff they would say they were too busy. He said every Sunday around 10:30 a.m. he went to church. He said he told staff that his regular catheter bag needed to be replaced with a leg catheter bag prior to attending church. He said the agency staff did not know what a leg catheter bag was. He said the prior Sunday when he was getting ready to go to church, the agency nurse did not know what a leg catheter bag was and it took 30 minutes to find someone who was able to help. He said every Sunday he had to find a nurse who knew what a leg catheter bag was. He said since there was no consistent staff working on the unit, his leg catheter bag was never ready in time for him to go to church. He said he was very frustrated with care. C. Record review The care plan, initiated 11/27/22, identified Resident #65 had impaired balance and decreased mobility. Interventions included assisting the resident with showers. -A review of the care plan revealed the care plan did not address Resident #65's current shower preferences. -The care plan for the urinary catheter, initiated on 11/27/22, did not mention resident's preference for a leg catheter bag on Sundays for church. A review of the CNA shower task for July 2024 revealed the resident was to receive showers on Tuesdays and Fridays on the day shift. -The shower logs for 7/1/24 to 7/30/24 revealed the resident received six out of nine scheduled opportunities for showers. -Review of the progress notes from 7/21/24 to 7/30/24 revealed no documented notes for resident refusals of showers. IV. Staff interviews Licensed practical nurse (LPN) #5 was interviewed on 7/30/24 at 10:45 a.m LPN #5 said the facility was understaffed especially on the Aspen unit where resident care was more heavy than on other units. LPN #5 said she was aware of Resident #65's preference for the leg catheter bag on Sundays. She said when she worked on the weekends she would help him with it. She said she did not know how agency staff could be aware of personal preferences since it was not documented anywhere. LPN #5 said on most days the facility did not have shower aides and CNAs were responsible for providing showers. She said she did not know shower preferences for any of the residents who had shower concerns. She said it was the CNAs responsibility to locate a binder at the nurses station and figure out who was due for showers. CNA #9 was interviewed on 7/30/24 11:47 a.m. CNA #9 said he used to be a shower aide at the facility but since a full time position as shower aide was eliminated with the new management, he was working as a CNA on various shifts. He said, on some rare occasions like today (7/30/24), he was assigned to work as a shower aide. CNA #9 said the facility used to have a schedule for showers where he and other CNAs were assigned to complete the showers. However, he said with new changes and new agency staff in the building, the old schedule did not work because agency CNAs would tell the facility staff what they would do and would not do. He said the rest of the staff would have to scramble and do extra work to provide the care that agency staff would not do. He said agency staff were frequently late or did not show up for work at all and that compromised the care for residents. He said he was certain many showers were missed for residents due to late arrivals and call offs by agency staff. Registered nurse (RN) #2 was interviewed on 7/30/24 at 11:59 a.m. RN #2 said she was an agency nurse and worked in the building on several occasions on different shifts, including weekends. She said she did not know about shower preferences as it was CNAs responsibility to provide showers. RN #2 said she did not know anything about Resident #65's routine on Sundays. She said her orientation to the unit consisted of shift to shift reports from nurses. She said all preferences residents could communicate directly to staff. She said when residents could not communicate, staff could call family and ask about preferences. CNA #11 was interviewed on 7/30/24 12:23 p m. CNA #11 said she was new to the unit and worked different shifts. She said she did not know when residents were to receive showers. She said she looked at the roster the facility provided to her before shifts and said showers or any specific resident preferences were not mentioned on that roster. The director of nursing (DON) was interviewed in the presence of a nursing home administrator (NHA) on 7/30/24 at 5:20 p.m. The DON said the facility had identified that shower preferences were missed, and they were actively working on implementing a new system to ensure showers were provided per preferences. She said unit managers were working to ensure that agency staff had easy access to residents' preferences and would be updating it on the rosters that staff received at the beginning of the shift. The DON said she was not aware of Resident #65's leg catheter bag preference. The DON said the facility did employ agency staff and all staff were provided with the policies and expectations of the facility.

Based on record review and interviews, the facility failed to ensure residents were provided prompt efforts by the facility to resolve any grievances for six (#65, #6, #81, #92, #58 and #87) of ten residents reviewed for grievances out of 51 sample residents. Specifically, the facility failed to ensure grievances regarding competency of agency staff were followed up timely with a satisfactory resolution for Residents #65, #6, #81, #92, #58 and #87. Findings include: I. Facility policy The Grievance policy, dated 5/8/23, was provided by the nursing home administrator (NHA) on 7/30/24 at 5:15 p.m. It read in pertinent part, To provide residents and responsible parties with information on the facility grievance procedure. To ensure that residents are afforded their right to file a grievance without discrimination or reprisal and that such grievance shall be responded promptly and in written form. Upon the receipt of a grievance and complaint report or complaint concern form, the social service director or designee will begin an exploration into the allegations/concerns. The appropriate department director will be notified of the nature of the complaint that follow up is necessary. The resident or person acting on behalf of the resident will be informed of the findings of the investigation, as well as any corrective actions recommended within 10 working days of the filing of the grievance or complaint. II. Resident interview Resident #87 was interviewed on 7/24/24 at 3:45 p.m. She said agency staff were inconsiderate. She said she took her medications only with hot water because her tooth was sensitive and staff frequently came with cold water. She said, regardless of how many times she communicated it to the staff, they never passed the message on and she had to educate every new staff member about her preferences. III. Group interview A group of five, alert and oriented residents( (#65, #6, #81, #92 and #58) was interviewed on 7/29/24 at 1:05 p.m. The residents were deemed interviewable per the facility and assessment. Residents said agency nursing staff was working in the building and they were unaware of resident's preferences and daily routines. Resident #65 said showers were provided inconsistently. He said the agency staff did not know the shower schedule and who was to provide the showers. He said his showers were frequently skipped or not offered at all. He said when she voiced his concerns to staff, they would say they were too busy. Resident #65 said every Sunday, around 10:30 a.m. he went to church. He said she told staff that his regular catheter bag was supposed to be replaced with a leg catheter bag prior to attending church. He said the agency staff did not know what a leg catheter bag was. He said the prior Sunday when he was getting ready to go to church, the agency nurse did not know what a leg catheter bag was and it took 30 minutes for the nurse to find someone who was able to help. He said every Sunday he had to find a nurse who knew what a leg catheter bag was. Resident #65 said since there was no consistent staff working on the unit, his leg catheter bag was never ready in time for him to go to church. He said he was very frustrated with care. Cross reference F561 for failure to honor resident preferences. Resident #6 said the agency staff did not know what the shower schedule was or who was to provide showers. She said the staff frequently said they were understaffed and could not provide showers. She said the facility used to have a shower aide, but with the new management, the shower aide position was eliminated. She said it was impossible to get a shower per her preference or at all. Resident #81 said she had memory problems and would frequently forget things. She said, in the past, nursing staff would keep a reminder in her room about her shower days, but she said the sign was gone and agency staff did not know when her shower days were. Resident #92 and Resident #58 said agency staff frequently did not show up for work and were late. Resident #92 said staff frequently walked into his room in the middle of the night to check on his roommate and would turn the light on at the sink area instead of next to his roommate and it would frequently wake him up. He said he asked nurses not to turn on the light at the sink area, but it continued to happen. Resident #58 said, during the shift changes, all staff would loudly argue at the nurses station about assignments. IV. Record review Resident council minutes were reviewed for the last six months. The 7/17/24 resident council meeting documented a concern that certified nurse aides (CNA) were not working as a team and showers were not done as scheduled. -Both concerns were marked as resolved, however, there was no added information to explain how the concerns were resolved or if the residents were satisfied with the resolution to the concerns. V. Staff interviews Licensed practical nurse (LPN) #5 was interviewed on 7/30/24 at 10:45 a.m LPN #5 said the facility was understaffed especially on the Aspen unit where resident care was more heavy than on other units. LPN #5 said she was aware of Resident #65's preference for the leg catheter bag on Sundays. She said when she worked on the weekends she would help him with it. She said she did not know how agency staff could be aware of personal preferences since it was not documented anywhere. LPN #5 said on most days they did not have shower aides and CNAs were responsible for providing showers. She said she did not know shower preferences for any of the residents who had shower concerns. She said it was the CNAs responsibility to locate a binder at the nurses station and figure out who was due for showers. CNA #9 was interviewed on 7/30/24 11:47 a.m. CNA #9 said he used to be a shower aide at the facility but since a full time position as shower aide was eliminated with the new management, he was working as a CNA on various shifts. He said, on some rare occasions like today (7/30/24), he was assigned to work as a shower aide. CNA #9 said the facility used to have a schedule for showers where he and other CNAs were assigned to complete the showers. However, he said with new changes and new agency staff in the building, the old schedule did not work because agency CNAs would tell the facility staff what they would do and would not do. He said the rest of the staff would have to scramble and do extra work to provide the care that agency staff would not do. He said agency staff were frequently late or did not show up for work at all and that compromised the care for residents. He said he was certain many showers were missed for residents due to late arrivals and call offs by agency staff. Registered nurse (RN) #2 was interviewed on 7/30/24 at 11:59 a.m. RN #2 said she was an agency nurse and worked in the building on several occasions on different shifts, including weekends. She said she did not know about shower preferences as it was CNAs responsibility to provide showers. RN #2 said she did not know anything about Resident #65's routine on Sundays. She said her orientation to the unit consisted of shift to shift reports from nurses. She said all preferences residents could communicate directly to staff. She said when residents could not communicate, staff could call family and ask about preferences. CNA #11 was interviewed on 7/30/24 12:23 p m. CNA #11 said she was new to the unit and worked different shifts. She said she did not know when residents were to receive showers. She said she looked at the roster the facility provided to her before shifts and said showers or any specific resident preferences were not mentioned on that roster. The director of nursing (DON) was interviewed in the presence of a nursing home administrator (NHA) on 7/30/24 at 5:20 p.m. The DON said the facility had identified that shower preferences were missed, and they were actively working on implementing a new system to ensure showers were provided per preferences. She said unit managers were working to ensure that agency staff had easy access to residents' preferences and would be updating it on the rosters that staff received at the beginning of the shift. The DON said the facility did employ agency staff and all staff were provided with the policies and expectations of the facility. The NHA said the facility had agency staff in the building for some time and recently switched to a different company. He said agency staff received the same orientation to the unit as other new staff. He said staff who were familiar with the unit were expected to help and assist new staff with details of care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interviews, the facility failed to ensure the medication error rate was less than five percent (%). Specifically, the facility had a medication error rate of 16.1%, or five errors out of 31 opportunities for error. Findings include: I. Professional reference According to [NAME], P.A., [NAME], A.G., et.al., Fundamentals of Nursing, 10 ed. (2020), Elsevier, St. Louis Missouri, pp. 606-607, retrieved on 7/31/24, Take appropriate actions to ensure the patient receives medication as prescribed and within the times prescribed and in the appropriate environment. Professional Standards such as nursing scope and standards of practice apply to the activity of medication administration. To prevent medication errors, follow the seven rights of medication administration consistently every time you administer medications. Many medication errors can be linked in some way to an inconsistency in adhering to these seven rights: the right medication, the right dose, the right patient, the right route, the right time, the right documentation and the right indication. II. Facility policy and procedure The Medication Administration policy, revised 2/29/24, was provided by the nursing home administrator (NHA) on 7/30/24 at 5:30 p.m. It read in pertinent part, Medications are to be administered in an accurate, safe, timely, and sanitary manner. Medication is to be given in compliance with physician orders. The Medication Time and Administration Guidelines were provided by the NHA on 7/25/24. The guidelines read in pertinent part, To better comply with our resident's rights, we have adopted the following guidelines for medication passing. Routine medications will be passed according to the following schedule: -EA: early am (6:00 a.m.); -AM: upon arising (6:00 a.m. - 11:00 a.m.); -MD: midday (11:00 a.m. - 1:00 p.m.); -PM: afternoon (4:00 p.m. - 7:00 p.m.); and, -BT: bedtime (7:00 p.m.- 10:00 p.m.). Medications scheduled between 11:00 p.m. and 6:00 a.m. will be documented as time specific. III. Observations On 7/24/24 during a continuous observation, beginning at 9:30 a.m. and ending at 11:30 a.m., registered nurse (RN) #1 was observed passing medications to residents. At 9:30 a.m. RN #1 was administering medications to Resident #87. The medication administration record (MAR) for July 2024 read that Resident #87 was due for the following medications: -Lactaid 3,000 units to be administered at 7:30 a.m. for lactose intolerance; and, -Fluticasone propionate nasal spray, two sprays in each nostril to be given in the morning for allergies. RN #1 could not locate the appropriate dose of Lactaid medication in his cart. He went to the unit manager for help. While RN #1 was trying to locate the appropriate dose of Lactaid medication, he locked all other medications in his cart. At 10:45 a.m., after locating the correct dose of Lactaid, RN #1 returned to his medication cart, added the medication to the medication cup containing Resident #87's other oral medications and proceeded to the resident's room to administer the medications. He did not take the resident's fluticasone propionate nasal spray to the room with the other medications. RN #1 administered the medications and returned to his medication cart. -RN #1 administered Resident #87's Lactaid two hours and 15 minutes after the allowed administration time. -RN #1 failed to administer the nasal spray to Resident #87. On 7/29/24 at 9:23 a.m., licensed practical nurse (LPN #2) was observed during medication administration for Resident #97. LPN #2's medication screen listed three medications that were color-coded red, which indicated the medications were late (see interviews below). The late medications were as follows: -Celecoxib 200 milligrams (mg) two times a day for pain, scheduled at 8:00 a.m.; -Clobazam 20 mg tablet, give 40 mg two times a day for seizures, scheduled at 8:00 a.m.; and, -Lacosamide 50 mg two times a day for seizures, scheduled at 8:00 a.m. -LPN #2 administered the three medications at 9:23 a.m. (23 minutes after the allowed administration time. IV. Staff interviews LPN #4 was interviewed on 7/24/24 at 10:05 a.m. LPN #4 said that when items were color-coded red on the medication administration record (MAR), it meant that something was late or missing. RN #1 was interviewed on 7/24/24 at 10:50 a.m. RN #1 said he was an agency nurse and this was his first day working on the unit. He said he did not know specific preferences for the residents and it took extra time for him to find out what the preferences were. He said, for example, he had to approach Resident #87 three times before he was able to administer her morning medications. RN #1 said initially Resident #87 said she would take her medications only with warm to hot water due to her tooth sensitivity. He said when he came back with warm water she did not like that he had mixed her miralax medication with the hot water and he had to remix the miralax in a separate cup and bring a fresh cup of hot water. He said because he had to approach Resident #87 three times with her medications, he forgot about her nasal spray. LPN #2 was interviewed during medication administration on 7/29/24 at 9:23 a.m. LPN #2 said she had a lot of medications to give and she was behind and did not want to be slowed down by being interviewed. The DON was interviewed on 7/30/24 at 5:14 p.m. The DON said all medications that were labeled as AM could be administered any time between 6:00 a.m. and 11:00 a.m. However, she said medications that were scheduled at a specific time should be administered as scheduled. The DON said because it was not possible to administer all medications at the exact scheduled hour, it was acceptable to administer medications one hour before or one hour after the documented scheduled time. She said she was not aware that medications were not administered on time. She said she would audit the medication administration to ensure all medications were administered on time.

Based on record review and interviews, the facility failed to employ an infection preventionist (IP) who had completed specialized training in infection prevention and control. Specifically, the facility failed to have a qualified IP involved with the facility's infection prevention and control program. Findings include: I. Facility policy and procedure The Infection Control and Surveillance policy, dated 7/28/23, was provided by the nursing home administrator (NHA) on 7/23/24. The policy documented in pertinent part, An infection prevention and control program (IPCP) is established and maintained to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. The IPCP is developed to address the facility-specific infection control needs, requirements identified in the facility assessment and the infection control risk assessment. The elements of the IPCP consist of coordination/oversight, policies/procedures, surveillance, data analysis, antibiotic stewardship, outbreak management, prevention of infection, and employee health and safety. The IPCP is coordinated and overseen by an IP specialist. II. Record review On 7/24/24 at 12:19 p.m. the NHA wrote in an email message that the facility did not have a designated IP and was recruiting to fill the position. III. Staff interview The director of nursing (DON) was interviewed on 7/29/24 at 10:25 a.m. The DON said the facility did not currently have a qualified IP. The DON said she and the unit nurse managers shared the duties and the responsibilities of the IP position, but they had not completed the required specialized education for the IP position.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, and interviews, the facility failed to ensure the resident representative was notified for one (#89) of five residents reviewed out of 37 sample residents. Specifically, the facility failed to ensure Resident #89's representative was notified of his significant weight loss. Findings include: I. Facility policy The Weight Management policy, dated 10/24/22, was provided by the regional clinical resource (RCR) on 3/16/23 at 10:10 a.m. The policy read in pertinent part, Nursing staff were responsible to communicate weight changes to the attending physician and resident's family. The nurse documented the notification in the medical record. Nursing staff was to notify food and nutrition services and the registered dietitian (RD) of a resident's weight change. The Changes in Resident Condition Policy, revised 11/23/19 was provided by the RCR on 3/16/23 at 10:10 a.m. The policy read in pertinent part, The resident, attending physician and legal representative or interested family member were notified when changes in condition or certain events occurred. A facility immediately informed the resident; consulted with the resident's physician; and if known, notified the resident's legal representative or an interested family member when there was: A significant change in the resident's physical, mental, or psychosocial status (such a deterioration in health, mental, or psychosocial status in either life - threatening conditions or clinical); a need that altered treatment significantly ( a need that discontinued an existing form of treatment due to adverse consequences, or to commence a new form of treatment); change in the resident status that affect the problem(s)/goal(s) or approach on the resident's plan of care were documented as revisions and communicated to the interdisciplinary team (IDT) team. Examples of clinical condition changes were such things as a stage II pressure injury, onset or recurrent delirium, recent urinary tract infections, significant weight loss, falls, a significant change in behaviors, a resident was started on antibiotics for any type of infection, any change in the resident from resident's baseline such as an onset of a new concern/incident (such as a skin tear, or bruise). The documentation in the resident's medical record was to include: -The date and time of the change of condition and who (physician/family member/responsible party) was notified regarding the condition change -The information communicated. -The response and/or orders received. -The assessment of the resident's condition and ongoing monitoring of resident condition. -The care provided. -The care plan was updated as needed. -Documented on the 24 Hour report the was resident's name and the condition change and any other pertinent information. II. Resident #89 Resident #89, age [AGE], was admitted on [DATE]. According to the March 2023 computerized physician orders (CPO), the diagnoses included dementia, post traumatic stress disorder, chronic kidney disease stage three, previous head injury with loss of consciousness, left side paralysis following a stroke, epilepsy, prostate enlargement, vitamin D deficiency, urinary incontinence, restlessness and agitation, depression and influenza (flu). The 2/7/23 minimum data set (MDS) assessment revealed the Resident #89 was severely cognitively impaired with a brief interview for mental status (BIMS) score of three out of 15. The MDS assessment revealed the resident needed one person assistance for bed mobility, ambulating in his room, corridor, and on and off the unit, dressing, eating, toilet use and hygiene. He needed two person assistance for transfers. The resident's profile revealed Resident #89's wife was his medical power of attorney (MPOA). III. Resident representative interview Resident #89's wife and MPOA was interviewed on 3/16/23 at 9:26 a.m. She said she could tell Resident #89 was getting thinner, but he did seem to eat when she was there. She said she was at the facility almost daily but she did not go to the medical provider appointments with him. She said she was not contacted about a recent weight loss, and when informed of his weight loss since his admission, she stated she had no idea he had lost so much weight. She stated she was not going to be at the facility later that day or the remainder of the week due to a medical appointment she had planned. IV. Record review Resident #89's admission weight on 1/5/23 was 178 lbs. The initial 1/5/23 admission nutritional assessment signed 1/16/23 did not list a usual body weight or previous weight within the last 30 days. The assessment also revealed the resident was at minimal nutrition risk due to consistent meal intake greater than 50% and a stable weight, with the care plan goal of the resident to maintain weight during admission. Resident #89 showed progressive weight loss through 3/12/23. On 2/26/23 Resident #89 weighed 160.4 lbs, a 17.6 lb and 9.9% weight decrease since admission. On 3/5/23 Resident #89 weighed 157.8 lbs, a 20.2 lb and 11.3% weight decrease since admission. Cross-reference F692 for nutritional status. The 3/2/23 weight change note revealed the resident's most recent weight was 160.4 lbs on 2/26/23 and a re-weigh was pending. -There was no documentation Resident #89's MPOA was notified or was attempted to be notified of the resident's significant weight decrease which was a 9.9% decrease since his admission. The 3/6/23 progress notes revealed Resident #89's MPOA was in the building to visit him. -There was no documentation Resident #89's MPOA was notified or was attempted to be notified of the resident's significant weight decrease. The 3/8/23 weight change note revealed Resident #89's weight was 157.8 lbs on 3/5/23, a loss of 15 lbs in 30 days. This weight change was recommended to be referred to the RD. -There was no documentation the MPOA was notified or attempted to be notified of the resident's significant weight decrease which was an 11.3% decrease since admission and 7.9% decrease in less than 30 days. The 3/15/23 social services progress notes revealed staff attempted to contact Resident #89's spouse to advise her of the care conference on 3/16/23 at11:30 a m. Staff left a voicemail, requested a call back and provided a contact number for a return call. V. Interviews The facility RD, nursing home administrator (NHA), director of nursing (DON and dietary director (DD) were interviewed on 3/16/23 at 10:00 a.m. The facility staff were unable to confirm the MPOA was informed of Resident #89's weight loss. The DON stated she had reached out to the MPOA a couple times but the MPOA did not call her back and the MPOA had some memory issues. The RD stated she thought she saw a note about a care conference and an unidentified staff member stated the care conference was happening that afternoon and there was an attempt to reach his wife. The RD then stated the care conference was happening that day and there had been an attempt to reach his wife. -Care conference notes or sign in sheet were requested for documentation regarding the MPOA being notified of Resident #89's weight loss but was not received by the exit of survey on 3/16/23. V. Facility follow up A 3/16/23 interdisciplinary team (IDT) note was entered and revealed the DD discussed Resident #89's weight with his MPOA.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** III. Resident #29 A. Resident status Resident #29, over the age [AGE], was admitted on [DATE]. According to the January 2023 computerized physician orders (CPO), diagnoses included dementia, history of COVID-19, history of urinary tract infections, chronic kidney disease stage three, high blood pressure, aphasia (speech difficulties), weakness, anemia, gout, vitamin D deficiency, gastroesophageal disease, osteoarthritis, and history of falls. The 2/13/23 minimum data set (MDS) assessment revealed the Resident #29 was moderately impaired with a brief interview for mental status (BIMS) score of 10 out of 15. She needed two person assistance for bed mobility and one person assistance for transfers, walking in her room and corridor, ambulating on and off the unit, dressing, eating, toileting and hygiene. The MDS assessment revealed Resident #29 did not use a hearing aid or other hearing appliance, usually understood or missed some pertinent parts of the message but comprehended most conversation. B. Resident interview and observation Resident #29 was interviewed on 3/13/23 at 10:22 a.m. She said at the start of the interview she was hard of hearing. The resident was unable to hear some questions, and specifically unable to hear questions regarding her use of hearing aids in the past or if she had hearing aids currently. There were no hearing aids or hearing devices observed in the resident's room. The resident appeared to hear better if this speaker was standing within a foot of her while talking. The resident said she was interested in hearing aids. C. Record review A consent form for ancillary services was signed on 6/7/22 by Resident #29's legal representative and a facility representative. Resident #29's care plan for ancillary services was initiated and revised on 6/21/22 for dental, vision, audiology and podiatry. Pertinent interventions initiated 6/21/22 included coordination of arrangements for dental care, and transportation as needed and as ordered. Resident #29's care plan for falls initiated on 6/8/22 and revised on 6/21/22 revealed she was at moderate risk for falls due to generalized weakness, gait and balance problems, a history of falls, incontinence, vision and hearing problems. Resident #29's activities care plan initiated on 6/15/22 and revised on 3/11/23 revealed she enjoyed watching court tv and the news on tv, listening to German and polka music and was hard of hearing. Pertinent interventions included to encourage the resident to sit near a visiting speaker or presenter due to her being hard of hearing. The 9/6/22 provider note revealed Resident #29 had conductive hearing loss of both ears. The 9/11/22 activities progress note revealed Resident #29 was extremely hard of hearing and adaptations were needed for successful participation due to hearing limitations. The 11/21/22 provider notes revealed Resident #29 had conductive hearing loss of both ears. The 12/26/22 activities progress note revealed Resident #29 was extremely hard of hearing and adaptations were needed for successful participation due to hearing limitations The 2/8/23 psychosocial progress note revealed Resident #29 had poor hearing and ancillary needs that needed addressed including dental, visual, auditory and podiatry. -The resident had documented appointments for vision services on 1/24/23 and podiatry on 9/21/22. There was no documentation for audiology services. The 2/10/23 activities progress note revealed Resident #29 was extremely hard of hearing and needed to sit next to speakers. D. Staff interviews The nursing home administrator (NHA) and director of nursing (DON) were interviewed 3/14/23 at 3:35 p.m. The DON said she was not familiar with Resident #29's desire for hearing aids. The NHA said he thought the facility had previously followed up with the resident on a request for hearing aids, but he was going to verify documentation was present that indicated the audiology ancillary services were offered and the resident refused. Certified nurses aide (CNA) #5 was interviewed on 3/15/23 10:00 a.m. She stated she had previously taken care of Resident #29 and she was hard of hearing and did not use hearing aids. The DON was interviewed on 3/16/23 1:00 p.m. She said if a resident requested hearing aids, then a social worker would follow up with the resident. The social services director (SSD) was interviewed on 3/16/23 at 2:20 p.m. He said audiology ancillary services fell under visiting audiology at the facility. He said if the resident benefited the facility offered testing to the resident, but it was up to the resident if they wanted to or not. He said he thought Resident #29 had been offered to see an audiologist in the past but said it might not be documented. He said if he found the documentation he would provide it. E. Facility follow-up The SSD met with Resident #29 on 3/14/23 and placed the resident on a waiting list for an audiology appointment. Based on observations, record review and interviews, the facility failed to ensure proper treatment and assistive device to maintain hearing and vision abilities for two (#32 and #29) of three residents reviewed for vision and hearing out of 37 sample residents. Specifically, the facility failed to: -Provide working hearing aids and repair glasses for Resident #32; and, -Offer Resident #29 audiology services. Findings include: I. Facility policy and procedure The Ancillary policy and procedure, dated 8/19/14, were provided by the nursing home administrator (NHA) on 3/15/23 at 11:35 a.m. It read in pertinent part, Ancillary services, including, but not limited to, dental, vision, audiology, and podiatry will be provided to the resident per state and federal regulatory guidelines; at the resident/responsible family member's request; and as needed. Any resident needing or requesting ancillary services such as dental, vision, audiology or podiatry will have their needs met timely. The facility will keep available a provider for ancillary services and/or assist the resident with utilizing the provider of their choice. Ancillary services are available to all residents requiring routine and emergency ancillary services care. Social services/designee will be responsible for ensuring residents needing ancillary services receive needed/requested services in a timely manner. II. Resident #32 A. Resident status Resident #32, over age [AGE], was admitted on [DATE]. According to the March 2023 computerized physician orders (CPO), diagnoses include stable burst fracture of unspecified lumbar vertebra (back bone), shortness of breath, chronic obstructive pulmonary disease and depression. The 12/21/22 minimum data set (MDS) assessment revealed the resident had no cognitive deficit impairment with a brief interview for mental status (BIMS) with a score of 14 out of 15. The resident required extensive assistance of one person with bed mobility, transfers, how the resident moved between surfaces, walking in the room, walking in the corridor, dressing, toileting, and personal hygiene. B. Resident interview and observation Resident #32 was interviewed on 3/13/23 at 10:20 a.m. The resident said her hearing aids did not work and she could not hear very well and she said that her glasses did not fit, and that she could not see out of them. She said the staff were supposed to schedule her for another hearing test but it had not happened. The resident was interviewed in the presence of her son on 3/13/23 at 4:26 p.m. The son said the resident was very hard of hearing and her hearing aids were not working. He said he had brought in amplifying headphones for her so she would be able to watch television. He said that the staff had to speak very loudly in order for her to be able to hear. Resident #32 was interviewed again on 3/15/23 at 11:32 a.m. The resident said she did not put the hearing aids on unless she had to. She said the hearing aids were not working right and they had not worked right for a while. She said she felt she should be able to hear better with the hearing aids in than she did. She said she could hear about the same with the hearing aids as she does without them. She said that she had asked the facility to have the hearing aids checked, she was told they would look into it and then nothing happened. The resident said she needed to have her glasses looked at too, she was unsure if they were not fitting right or if the prescription was wrong but she did not feel she could see with them. The resident proceeded to put her hearing aids in both ears after taking them out of the charger and putting on her glasses that appeared ill-fitting and smashed onto her face. The resident had difficulty hearing with the aids in. C. Record review The care plan for communication initiated and revised on 9/19/22 documented the resident had a communication problem related to a hearing deficit. Interventions included anticipating and meeting the resident's needs, when communicating allow adequate time to respond and repeat if necessary, and do not rush, monitor effectiveness of communication strategies and assistive devices. Monitor, document and report any changes in ability to communicate. The care plan for ancillary services initiated and revised on 9/19/22 documented the resident will receive ancillary services as needed and required for dental, vision, audiology, and podiatry. Interventions include: coordinate arrangements for dental care; transportation as needed/as ordered. Diet as ordered. Monitor, document, report any sign or symptoms of oral/dental problems needing attention. The nursing admission note dated 9/13/23 at 4:35 p.m. documented the resident was mildly to moderately hearing impaired with difficulty hearing in some environments or the speaker may need to increase volume and the resident had hearing aids for both ears. The social services note dated 1/31/23 at 9:16 a.m. documented an email from an outside agency involved with the resident's care regarding the need for ancillary services, optometry and audiology appointments. -There were no other social services notes regarding the need for ancillary services. The nursing note dated 3/10/23 at 8:44 a.m. documented the resident wore glasses and was very hard of hearing. -The facility failed to document providing or the resident receiving ancillary services at the facility or with the outside agency involved with her care. D. Staff interviews The social services director (SSD) was interviewed on 3/15/23 at 3:53 p.m. The SSD said the facility utilized visiting services for long term care residents including dental, audiology, and podiatry. An initial assessment was performed when the resident was admitted to the facility to learn what services they needed. He said the providers of ancillary services did not take outside insurances. He said the outside agency involved with Resident #32's care had their own preferred provider for ancillary services. He said if he was notified by a nurse that a resident needed services he would investigate to see what the residents' needs were then he would reach out to a scheduler to make appointments for those residents with outside agencies involved with their care. Licensed practical nurse (LPN) #1 was interviewed on 3/16/23 at 10:12 a.m. The nurse said Resident #32 was admitted to be hard of hearing. She said she tried to get the residents to see the facility providers. She said the nurses could put in requests for care and they did not report it to anyone else. The SSD was interviewed again on 3/16/23 at 10:16 a.m. He said he had received an email from the outside agency on 1/31/23 regarding Resident #32 going for appointments for her hearing and vision. There were no follow up emails regarding appointments. Certified nursing assistant (CNA) #1 was interviewed on 3/16/23 at 10:57 a.m. The CNA said Resident #32 was hard of hearing and had hearing aids. He said the resident had stated she was not sure if she could hear better with them or without them. He said if the resident were to say there was a problem the staff would tell the nurse. The CNA said he did not know if there was an appointment for hearing aids, glasses or other services. The NHA was interviewed on 3/16/23 at 11:03 a.m. in the presence of the regional clinical resource (RCR) and the director of nursing (DON). He said if it was found that a resident was supposed to get services through the resident's preferred provider and had not, the facility would follow up with them. He said the facility could call their center director and schedule them for services or follow up with the doctor directly. The NHA said the outside agencies said they would provide services at their centers. The NHA said that if it was found that a resident was not getting the service they needed the facility could call the medical director and have the facility providers give the care the residents need.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and interviews, the facility failed to ensure a resident with limited mobility receives appropriate equipment, and assistance to maintain or improve mobility for one (#26) of three residents reviewed for limited range of motion out of 37 sample residents. Specifically, the facility failed to provide the resident with a hand splint and assistance for right hand contracture. Findings include: I. Facility policy and procedure The Resident Mobility and Range of Motion policy and procedure, 2001 and revised in July 2017, was provided by the director of clinical operations (DCO) on 3/16/23 at 2:48 p.m. In pertinent part, it read: -Residents will not experience an avoidable reduction in range of motion (ROM). -Residents with limited range of motion will receive treatment and services to increase and/or prevent a further decrease in ROM. -Residents with limited mobility will receive appropriate services, equipment and assistance to maintain or improve mobility unless reduction in mobility is unavoidable. -The care plan will be developed by the interdisciplinary team based on the comprehensive assessment, and will be revised as needed. -The care plan will include specific interventions, exercises and therapies to maintain, prevent avoidable decline in, and/or improve mobility and range of motion. II. Resident #26 A. Resident #26 status Resident #26, age [AGE], was admitted to the facility on [DATE]. According to the March 2023 computerized physician orders (CPO), diagnoses included epilepsy, unspecified traumatic brain injury, hemiplegia (paralysis one side) unspecified affecting right dominant side, contracture of right hand and muscle weakness. The 2/2/23 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. He had no behavioral problems, psychosis, or rejection of care. He required extensive assistance of two people with bed mobility, transfers, toilet use and personal hygiene and extensive assistance of one person with dressing. The resident had functional limitations on his right side of both upper and lower extremities. He was receiving restorative nursing services for passive range of motion and transfers. B. Resident interview and observations Resident #26 was interviewed on 3/13/23 at 4:07 p.m. He said he had the contracture to his right hand ever since he had a motorcycle accident over 30 years ago. He said he had a right hand splint that he was supposed to be using. The resident was observed in his room watching television (TV) and visiting with his wife. His right hand was in his lap which had a contracture, his hand was in a fist with his wrist bent inward towards his body. His hand contracture was without a hand splint or washcloth, and he was leaning to his right side. On 3/15/23 at 11:02 a.m., the resident was observed propelling himself down the hall to the dining area. He was leaning to the right side with his right hand in lap; he was using his left hand to propel his wheelchair. Resident #26 was interviewed on 3/15/23 at 1:22 p.m. The resident said he had a splint for his right hand but he did not know where it was. He said the staff should be putting it on him at night but they had not done so recently. He said there was a sign in his room that reminded staff to put his splint on at night. The resident was in his wheelchair. His right hand was in his lap, it was without a hand splint/brace or washcloth, and he was leaning to his right side. On his wall was a sign that reminded staff to put his hand splint on his right hand at night. The hand splint was not observed in the room. Resident #26 was interviewed on 3/16/23 at 10:32 a.m. Resident #26 said staff found his hand splint on the table in his room. He said someone saw him yesterday to look at his hand splint and said they were going to order a new one because this one was worn out. The resident's right hand was in his lap, it was without a hand splint/brace or washcloth. His hand splint was on a small table in the room. C. Record review Occupational therapy evaluation and plan dated 4/28/22 revealed the following: -Resident #26 to work with the occupational therapist (OT) to determine appropriate hand/wrist splint to decrease discomfort and risk of skin breakdown. The resident has a soft, moldable hand splint recently provided by restorative. -Resident #26 will wear a hand/wrist splint for the right hand. OT will determine a wear schedule with staff assistance for 90% of the time. Target date 5/27/22. -Education and training completed for primary caregivers and Resident #26 for positioning/pressure relieving techniques, positioning maneuvers, proper body mechanics and self-care/skin checks, use of assistive devices and use of adaptive equipment. OT treatment encounter notes: -5/6/22 Resident #26 said he was wearing his hand splint when he could remember to remind staff to put it on. OT created a sign to remind staff to put on his hand splint, and placed it on the bulletin board next to his bed. -5/7/22 Resident #26 right hand splint wearing schedule developed and provided to patient and nursing. The recommendation was for him to wear this at night with use of rolled up washcloth as needed for day time. -5/10/22 Resident #26 said he has been using the resting hand splint at night and it was comfortable. -5/19/22 Resident #26 said that the resting hand splint was comfortable and working well. The occupational therapist determined the resident could wear the hand splint at night with a rolled up washcloth in palm during the day. -5/26/22 Resident #26 reported his hand splint program was going well. Goal met. The care plan updated on 5/10/22 identified the resident had self-care performance deficit, right impaired balance, activity intolerance, decreased mobility, weakness, and shortness of breath. Interventions included: wear resting right hand splint, night staff to assist the resident to take off in the morning. Use a rolled washcloth in the palm of his right hand and check hand for potential skin issues. The OT evaluation and plan dated 3/1/23 evaluated toileting skills and did not address range of motion (ROM) or use of hand splint. The resident's treatment administration record from 3/1/23-3/16/23 (TAR) did not include application of hand splint. E. Staff interviews Certified nurses aide (CNA) #4 was interviewed on 3/16/23 at 10:36 a.m. She said worked periodically with the resident on the day shift. She said she had not seen the resident wearing the hand splint and did not think he was using it. Registered nurse #2 was interviewed on 3/15/23 at 1:38 p.m. She said she did not know if Resident #26 had a right hand splint or if he was supposed to be using one. The restorative therapist (RT) was interviewed on 3/15/23 at 1:16 p.m. The RT said Resident #26 loved doing the passive range of motion (PROM) exercises. The RT said he provided massages to the resident's right hand and focused on the resident's right side. He said he did not know anything about a right hand splint or if the resident was using one. The OT was interviewed on 3/16/23 at 10:12 a.m. She said Resident #26 was admitted with a splint for a right hand contracture and had been using it for a long time. She said he was on her caseload in 2022 for his right hand contracture and wheelchair management. About a year ago she assessed the splint for him, monitored his skin and set up a schedule for use of the splint to be applied during the night. The nurses and CNAs were trained on the use of the splint with the resident. As far as she knew it had not been discontinued. The director of rehabilitation (DOR) was interviewed on 3/16/23 at 10:19 a.m. She said an evaluation was completed on 3/15/23 for his contracture. The resident's splint was found on his dresser. The assessment would include determining why the resident was not using his splint; if he was refusing to wear it or if it did not fit properly. The director of nursing (DON) was interviewed on 3/16/23 at 1:12 p.m. She said Resident #26 had used a hand splint since last spring but when he was placed on hospice last year, he declined to wear it. He was discharged from hospice on 4/18/22. The DON said the care plan should have been updated to reflect that he declined to use the hand splint. The posted sign in his room was a reminder to the CNAs, especially the agency staff, to apply the splint nightly. She said the CNAs were primarily responsible for the application of the splint and it should be documented on the resident's TAR. The CNA and nursing staff should have been trained on the application and use of the splint for the resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure inspection and maintenance of a halo safety ring (fixed bed rail assistive device) for one (#29) of two residents using bed halo (type of bed rail) for positioning out of 37 sample residents. Specifically, for Resident #29, the facility failed to: -Inspect and regularly check the mattress and halo safety ring for areas of possible entrapment; -Check bed rail/halo safety ring regularly for ongoing maintenance to make sure device was still installed correctly as rails may shift or loosen over time; and, -Ensured the bedrail/halo safety ring was securely attached to the resident bed frame and prevented unstable movement and wobbling of the assistive device. Findings include: I. Professional standard The U.S. Food and Drug Administration (FDA) Clinical Guidance For the Assessment and Implementation of Bed Rails In Hospitals, Long Term Care Facilities, last updated 2/27/23 and pulled 3/22/23 from https://www.fda.gov/medical-devices/adult-portable-bed-rail-safety/recommendations-health-care-providers-using-adult-portable-bed-rails included bed rail safety guidelines: -Bed rail use for patient's mobility and/or transferring, for example turning and positioning within the bed and providing a hand-hold for getting into or out of bed, should be accompanied by a care plan. -The equipment (beds/mattresses/bed rails) should be inspected, evaluated, maintained, and upgraded to identify and remove potential fall and entrapment hazards and appropriately match the equipment to patient needs, considering all relevant risk factors. -The patient's needs should be re-assessed and the equipment re-evaluated if an episode of entrapment or near-entrapment occurred, with or without serious injury; this was done immediately because fatal repeat events can occur within minutes of the first episode. -The bed, mattress and any accessories should be monitored and maintained on an ongoing basis. II. Facility policy and procedure The Assisted Devices Policy Timeline, revised 2/28/19, was provided by the regional clinical resource (RCR) on 3/16/23 at 10:00 a.m. The policy read in pertinent part, The purpose of this policy is to establish timelines in which assistive devices were reassessed. The facility completed a reassessment of any assistive devices at least annually and with any significant change in resident status. The facility completed quarterly reviews of the assistive device with quarterly MDS (minimum data set) and plan of care reviews. The facility will obtain a written consent for the use of an assistive device at the time the device is initiated and annually thereafter. -The policy did not document that a bed rail/bed halo was assessed for proper fit and safety, or that the bed rail/bed halo was regularly monitored and inspected per the manufacturer's recommendations. III. Assistive device manual The manufacturer's instructions for Resident #29's bed rail/halo ring was provided by the RCR on 3/15/23 at 10:59 a.m. for model number 77121. The manufacturer's instructions provided the information: -Proper patient assessment and monitoring, and proper maintenance and use of equipment was required to reduce the risk of entrapment. -The bed rail/halo ring and bed system should be measured, tested and evaluated for each user individually. -The halo safety ring should be returned to the original position parallel to the bed with the detent (quick release) pins engaged before each use. -The mattress must remain in firm contact with the halo safety ring with no gap on both sides of the bed. If a halo safety ring was only installed on one side of the bed, ensure the mattress remained in firm contact with mounted bracket on the other side of the bed. -The halo device was regularly checked to identify areas of possible entrapment, and immediately ceased use of the device until the bed until entrapment risk was fixed. A gap allowed a resident to become wedged between the bed rail and the mattress. Continuous movement in bed increased mattress compression, gap spaces, and the possibility of injury or death. IV. Resident #29 A. Resident status Resident #29, over the age [AGE], was admitted on [DATE]. According to the January 2023 computerized physician orders (CPO) diagnoses included dementia, history of COVID-19, history of urinary tract infections, chronic kidney disease stage three, high blood pressure, aphasia (speech difficulties), weakness, anemia, gout, vitamin D deficiency, gastroesophageal disease, osteoarthritis and history of falls. The 2/13/23 minimum data set (MDS) assessment revealed the Resident #29's cognition was moderately impaired with a brief interview for mental status (BIMS) score of 10 out of 15. She needed two person assistance for bed mobility and one person assistance for transfers, walking in her room and corridor, ambulating on and off the unit, dressing, eating, toileting and hygiene. She was noted as not steady during transfers from the bed to the chair. The MDS assessment was not marked to indicate a bed rail/halo ring was used. B. Resident observation and interview Resident #29 was interviewed on 3/13/23 at 10:22 a.m. She stated she used the bed rail/halo ring to lift herself up in bed. She stated she was concerned the bed rail/halo ring was loose. Resident #29 was interviewed on 3/14/23 at 1:30 p.m. She said she did not think anyone checked the bed rail/halo ring or tightened it. The bed rail/halo ring turned approximately one inch to the right while parallel to the bed when moved. C. Record review A review of the Resident #29's March 2023 computerized physician orders (CPO) showed an order on 10/24/22 for a bed halo added to the resident's bed and checked for placement and functionality every shift, which was to occur three times daily. The resident's care plan activities of daily living (ADL) care plan self-care performance deficit with impaired balance and limited mobility was initiated on 6/8/22 and revised on 6/21/22. The bed mobility intervention initiated 6/21/22 revealed the resident needed two person assistance and halos on the bed for mobility was added 10/24/22. Resident #29's treatment administration record (TAR) revealed an order to check the bed rail/halo rings placement every shift including placement and functionality, which was to occur three times daily. V. Staff interviews The nursing home administrator (NHA) was interviewed on 3/14/23 at 2:35 p.m. The NHA said that maintenance would check the bed rail/halo ring to see if the halo rings needed to be replaced because due to age but the maintenance staff did not check for stability. The NHA was observed checking both halo rings on Resident #29's bed and stated the halo rings were in the correct position and moved appropriately. Licensed practical nurse (LPN) #2 was interviewed on 3/14/23 at 3:44 p.m. as she was working on Resident #29's hallway. She said she was not aware she needed to check the resident's bed rail/halo ring and was unsure what she was looking for, and she had not checked them at the building previously. Registered nurse (RN) #3 was interviewed on 3/15/23 at 3:30 p.m. as she was working on Resident #29's hallway. She stated she worked as needed at the facility, and did not check the resident's bed rail/halo ring and was not sure what a halo ring was, and was not aware of what to do. The director of nursing (DON) was interviewed on 3/16/23 at 1:00 p.m. in the presence of the NHA and RCR. She stated the nursing staff checking the bed rail/halo ring should be making sure the halo ring was secure to the bed frame and that the halo ring was functional, and the staff would be educated on what that meant. VI. Facility follow up The NHA stated on 3/15/23 at 10:30 a.m. that the bed rail/halo ring was replaced on Resident #29's bed and the resident was very happy with the replacement. The NHA provided a grievance form on 3/15/23 at 12:00 p.m. that a different bed rail/halo ring was installed on Resident #29's bed that the resident was comfortable with. The matching manufacturer's instructions were provided and the instructions for maintenance matched the maintenance instructions on the previous bed rail/halo ring.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interviews, the facility failed to consistently provide activities of daily living (ADL) support for one (#38) of six dependent residents reviewed for ADLs out of 40 sample residents. Specifically, the facility failed to: -Provide timely incontinence care and reposition Resident #38 who was dependent on staff for all care; and, -Provide appropriate assessed level of supervision for Resident #38 while the resident used the toilet. Findings include: I. Facility policy and procedures The Activities of Daily Living (ADLs) Supporting policy, revised March 2018, was provided by the nursing home administrator (NHA) on 1/6/22 at 5:38 p.m. It read in pertinent part, Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: hygiene (bathing, dressing, grooming, and oral care); mobility (transfer and ambulation, including walking); elimination (toileting); dining (meals and snacks); and communication (speech, language, and any functional communication systems). II. Resident #38 A. Resident status Resident #38, age [AGE], was admitted initially on 11/29/18 and re-entry on 10/28/2020. According to the January 2022 computerized physician orders (CPO), diagnoses included Alzheimer's disease, type two diabetes, and chronic kidney disease with heart failure. The 11/1/21 minimum data set (MDS) assessment revealed the resident with severe cognitive impairment with a brief interview for mental status score of seven out of 15. She required extensive assistance with two persons for bed mobility, transfers, and toilet use. Extensive assistance with one person for dressing, and personal hygiene. Supervision of one person for eating. Wheelchair mobility with maximal assistance. Behaviors were not present, no rejection of care. Disorganized thinking and inattention were present. Resident had an ostomy (colostomy) and frequent urinary incontinence. Two falls since prior assessment. The resident was at risk for developing pressure ulcers. B. Resident observations and interview On 1/3/22 a continuous observation was conducted from 9:40 a.m. to 2:10 p.m. Resident #38 was observed seated in her wheelchair, without foot pedals, sitting next to the side of the nurses station. Resident #38 finished her breakfast. The breakfast tray was removed and Resident #38 remained seated in her wheelchair, to the side of the nurses station. No activities, repositioning or incontinence care were offered or provided. Lunch was served at 12:31 p.m. Resident #38 ate her lunch in her same location next to the nurses station seated in her wheelchair. The resident's lunch tray was removed and Resident #38 remained seated in her wheelchair. At 1:44 p.m., Resident #38 was interviewed and Resident #38 said she was achy and hurting all over. At 1:53 p.m. licensed practical nurse (LPN) #4 was notified of Resident #38 achiness and complaints of hurting all over. LPN #4 asked an unnamed certified nurse aide (CNA) to move Resident #38 to her reclining chair in her room to see if that would make her more comfortable. LPN #4 said the Resident #38 may be achy from sitting in the same position for several hours. -No toileting or pressure relief was observed until brought to the staff's attention. Six staff members had walked by Resident #38. There was a total of four hours and 20 minutes when Resident #38 was not provided incontinence care or pressure relief. On 1/4/22 at 2:14 p.m. Resident #38, who was supposed to be in isolation in her room due to recent COVID-19 exposure, was not in her bed or side chair in her room; her whereabouts were unknown. Registered nurse (RN) #3 said she was not sure where the Resident #38 was and entered the room to look in the bathroom for the resident. Resident #38 was left alone in the bathroom, there was a call light but Resident #38 was unable to use it due to cognition, bathroom transfers required two person assistance. There was a change of shift at 2:00 p.m. and the oncoming nursing staff had not been notified by the staff leaving shift that Resident #38 was placed on the toilet and left unsupervised. RN #3 acknowledged Resident #38 was unable to use the call light to call for staff assistance and was not to be left in the bathroom unsupervised. RN #3 left to go get assistance. Resident #38 began calling out for assistance. Certified nurse aide (CNA) #2 arrived to assist RN #3 with Resident #38's care and to get her off of the toilet at 2:20 p.m. RN #3 and CNA #2 were interviewed at 2:16 p.m. after the observation above. RN #3 said that she and CNA #2 each arrived for shift at 2:00 p.m. and neither RN #3 or CNA #2 knew that Resident #38 was left on the toilet or which staff, from the prior shift, had placed the resident on the toilet and then left for the day without telling anyone. C. Record review The resident comprehensive care plan for ADLs, revised 10/30/2020, identified the resident had self-care performance deficits related to cognitive deficits and impaired balance. Interventions for toilet use reveals the resident requires assistance by staff for toileting and colostomy care. Interventions for transfers reveal the resident requires two persons to assist to move between surfaces and due to the resident's severe cognitive loss, she will not use her call light. Staff to anticipate needs. The care plan identified the resident was at risk for falls related to decreased mobility, cognitive deficits, impaired balance, incontinence, and history of falls, revised 10/30/2020. Interventions include to anticipate and meet the resident's needs, offer frequent toileting, lay resident down when fatigued, and frequent wheelchair position changes. Schedule toileting program for fall prevention. Provide assistance with positioning when in a wheelchair and provide safety cues to maintain proper positioning. The care plan identified the resident was at risk for pressure injury development related to decreased mobility, incontinence, and cognitive deficits, revised 12/11/18. Interventions include to encourage and assist with frequent position changes. -The care plans identified the residents' risks but the facility failed to consistently implement the interventions in the care plan for staff to anticipate and meet the resident's needs, offer frequent toileting, lay resident down when fatigued, frequent wheelchair position changes, schedule toileting for fall prevention, provide assistance with positioning when in a wheelchair, and encourage and assist with frequent position changes as indicated in observations above. The point of care documentation completed by CNAs revealed: On 1/3/22 toileting was documented at 12:03 a.m.; 2:29 p.m.; and 6:40 p.m. There was 14.5 hours between the 12:03 a.m. incontinence care and the 2:29 p.m. incontinence care. The ADL task revealed: toilet use, routine check and change, toilet upon rising, before and after meals, at bedtime and as needed. Offer frequent toileting. D. Staff interviews CNA #3 was interviewed on 1/5/22 at 9:45 a.m. She said if a resident needs a two person transfer to the bathroom, they transfer the resident and she leaves the bathroom door cracked to keep an eye on the resident and stand by and wait for them to finish. CNA #3 said if the resident was unable to use the call light and or was a fall risk the CNA needed to stand by and not leave the resident alone. CNA #4 was interviewed on 1/5/22 at 9:58 a.m. She said if a resident needs a two person transfer to the bathroom she would ask a CNA or nurse for help. CNA #4 said she would wait for the resident to finish if they were a fall risk; if not a fall risk she would ask them to push the call light when ready. CNA #4 said if the resident could not push the call light she would stay with them. CNA #4 said she would check on a resident seated in a wheelchair every two hours to see if they need to be changed or repositioned. Especially those residents that could not use a call light for assistance. RN #4 was interviewed on 1/5/22 at 10:06 a.m. She said she assisted the CNAs with two person toilet transfers. She said the CNA would stay with the resident and when they were ready to transfer, the CNA would push a call light for the second staff to come help. RN #4 said if the resident was a fall risk the CNA definitely stays with them. RN #4 said staff should not leave a resident alone if they cannot use the call light. RN #4 said dependent residents should be checked on for repositioning or incontinence care needs at a minimum of every two hours or more often if needed. The director of nurses (DON) was interviewed on 1/6/22 at 5:06 p.m. She said the staff should reposition and check for incontinence care for dependent residents every two hours. The DON said residents that require two person assistance for toilet transfers should be assisted using a gait belt, and the staff should stand by after the resident was seated. The DON said the CNA should stay by the door, partially opened, to give as much privacy as possible, but always stay with the resident. She said at shift changes the nurse and CNA leaving shift should be giving reports to the oncoming nurse and CNAs for continuity of care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure two (#75 and #87) of three residents reviewed for respiratory care out of 40 sample residents were provided respiratory care consistent with professional standards of practice. Specifically, the facility failed to: -Ensure Resident #75 had orders, care plan, and set up and cleaning assistance with use of continuous positive airway pressure (CPAP) machine, and; -Ensure Resident #87 was assisted with the setup of the oxygen concentrator at night. Findings include: I. Facility policy and procedure The CPAP/BIPAP support policy and procedure, revised March 2015, was provided by the corporate nurse consultant (CNC) on 1/6/22 at 5:30 p.m. It read, in pertinent part, Only a qualified and properly trained nurse or respiratory therapist should administer oxygen through a CPAP mask. Review the physician's order to determine the oxygen concentration and flow and the PEEP pressure for the machine. Wipe machine with warm, soapy water and rinse at least once a week as needed. Use clean, distilled water only in the humidifier chamber. Rinse washable filter underst running water once a week to remove dust and debris. Clean (mask) daily by placing in warm, soapy water and soaking/agitating for five minutes. Document the following in the resident's medical record: General assessment prior to the procedure, time CPAP was started and duration of therapy, mode and settings for the CPAP, oxygen concentration and flow. The Oxygen administration policy and procedure, revised October 2010, was provided by the nursing home administrator on 1/6/21 at 1:14 p.m. It read, in pertinent part, Unless otherwise instructed, unplug and/or relocate all electrical devices in the immediate area where oxygen is to be administered. Turn on the oxygen. Place appropriate oxygen device on the resident. II. Resident #75 A. Resident status Resident #75, age [AGE], was admitted on [DATE]. According to the January 2022 computerized physician orders (CPO), diagnoses included rheumatoid arthritis, obstructive sleep apnea, and insomnia. The 12/3/21 minimum data set (MDS) assessment revealed the resident was unable to complete a brief interview for mental status but was coded independent for cognitive skills for daily decision making and short and long term memory okay. The resident was independent with activities of daily living. It did not indicate the resident received respiratory treatments. B. Resident interview and observation Resident #75 was interviewed on 1/3/22 at 10:43 a.m. She said she used a CPAP machine at night and she set it up. She said the machine was not cleaned by staff or herself. She said the facility had provided one gallon of distilled water but she was unable to pour the water into the chamber so she used the CPAP without water. The CPAP machine was observed at the bedside. The mask was on a hook located on the bedside table. C. Record review The physician orders were reviewed and revealed no orders for CPAP were in the medical record. The care plan was reviewed and revealed no care plan for CPAP was in the medical record. D. Staff interviews Registered nurse (RN) #1 was interviewed on 1/5/21 at 3:45 p.m. She said if a resident was on a CPAP machine there would be orders in the chart and a care plan in place. She said CPAP machines were cleaned once a week and distilled water would be used. She said Resident #75 was independent and did the set up and cleaning of her CPAP as far as she knew. Licensed practical nurse (LPN) #1 was interviewed on 1/6/21 at 10:26 a.m. She said Resident #75 was independent with her CPAP machine. She said the resident should use distilled water with her machine and the mask should be cleaned daily. She said if the mask and tube were not cleaned it would have the potential to cause respiratory issues. The director of nursing (DON) was interviewed on 1/6/22 at 4:46 p.m. She said if a resident had a CPAP machine there should be orders, settings, and a care plan in the electronic medical record. She said Resident #75 had been resistant to a self evaluation to ensure the resident was using and caring for the CPAP properly. She said the machine should be cleaned daily in order to reduce the risk of respiratory issues such as infection. She said distilled water should be used with the machine and provided to the resident. The CNC was interviewed on 1/6/22 at 4:50 p.m. He said the resident was present during care conferences and had a preference for using the CPAP independently. He said this should be in the care plan. III. Resident #87 A. Resident status Resident #87, age [AGE], was admitted on [DATE]. According to the January 2022 CPO, diagnoses included type two diabetes, obstructive sleep apnea, and dependence on supplemental oxygen. The 12/10/21 MDS assessment revealed the resident was cognitively intact with a brief interview for mental status score of 15 out of 15. It indicated the resident required supervision for activities of daily living and received oxygen therapy. B. Resident interview and observation Resident #87 was interviewed on 1/3/21 at 10:26 a.m. She said had an evaluation recently and received a breathing apparatus to be used at night. She said the oxygen concentrator had to be unplugged in the morning and moved because it was in the way of her closet. She said she was unable to set up the machine every night and unplug and move it in the morning. She said she used the supplemental oxygen for a week and no longer used it because she cannot complete the set up. She said the staff at the facility do not help her. The oxygen concentrator was observed unplugged with the nasal cannula wrapped and located on top of the concentrator. C. Record review The physician orders, dated 11/9/21, documented nocturnal O2 at 2L continuous at bedtime for nocturnal hypoxemia and OSA. The oxygen therapy care plan, initiated 11/11/21, indicated oxygen settings at two liters per minute via nasal cannula at night. It did not indicate the resident was responsible for daily set-up. D. Staff interviews RN#1 was interviewed on 1/5/21 at 3:45 p.m. She said Resident #87 was independent with her respiratory care. She said the resident should be provided with education and be able to demonstrate understanding in order to be independent. RN #2 was interviewed on 1/6/21 at 9:41 a.m. She said she was unsure if Resident #87 was on supplemental oxygen. She said respiratory care was a part of the evening task for the nurse and the nurse helped with set up. LPN #2 was interviewed on 1/6/21 at 9:45 a.m. She said nurses checked that residents were assisted and wore supplemental oxygen. She said CNAs provided assistance too. LPN #1 was interviewed on 1/6/21 at 10:26 a.m. She said Resident #87 was on two liters of oxygen at night. She said the evening shift would set up the concentrator. DON was interviewed on 1/6/21 at 4:50 p.m. She said if a resident is on supplemental oxygen the nurse or certified nurse aides should assist with set up of the nasal cannula and concentrator. She said she believed Resident #87 was on oxygen therapy and independent with daily set up. She said if a resident was responsible for oxygen therapy care, the resident should be able to complete a return demonstration to a nurse and that should be documented. She said there was no documentation of this for Resident #87.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure the correct installation, use and maintenance of transfer bar, (fixed bed rail assistive device) for one (#62) of two residents using bed canes (type of bed rail) for positioning out of 40 sample residents. Specifically, for Resident #62 the facility did not: -Inspect, evaluate, maintain, and upgrade equipment (beds/mattresses/bed rails) to identify and remove potential fall and entrapment hazards, including: -Ensure the bed cane was securely attached to the resident bed frame prevent unstable movement and wobbling of the assistive device; -Prevent gaps between the bed cane and the mattress large enough for the resident to have a body part become potentially entrapped within; and, -Review the manufacturer's recommendations for installation and ongoing maintenance of the assistive device. Findings include: I. Professional standard The U.S. Food and Drug Administration (FDA) Recommendations for Health Care Providers about Bed Rails, last updated 7/9/18, retrieved on 12/20/21, from https://www.fda.gov/MedicalDevices/ProductsandMedicalProcedures/HomeHealthandConsumer/ConsumerProducts/BedRailSafety/ucm362848.htm; the reference included the following recommendations: -Inspect and regularly check the mattress and bed rails to make sure they are still installed correctly and for areas of possible entrapment and falls. Regardless of mattress width, length, and/or depth, the bed frame, bedside rail, and mattress should leave no gap wide enough to entrap a patient's head or body. -Regularly assess that bed rails remain appropriately matched to the equipment and to the patient's needs, considering all relevant risk factors. -Inspect, evaluate, maintain, and upgrade equipment (beds/mattresses/bed rails) to identify and remove potential fall and entrapment hazards. -Be aware that gaps can be created by movement or compression of the mattress which may be caused by patient weight, patient movement or bed position, or by using a specialty mattress, such as an air mattress, mattress pad or water bed. II. Facility policy and procedure The Assistive Devices policy, revised 2/28/19, was provided by the clinical nurse consultant (CNC) on 1/6/22 at 10:02 a.m., it read in pertinent part: The purpose of this policy is to establish timelines in which assistive devices will be reassessed. 1. The facility will complete a reassessment of any assistive devices at least annually and with any significant change in resident status. 2. The facility will complete quarterly reviews of the assistive device with quarterly minimum data set (MDS) and plan of care reviews. 3. The facility will obtain a written consent for the use of an assistive device at the time the device is initiated and annually thereafter. -The policy did not document that a bed rail/bed cane would be assessed for proper fit and safety per manufactures recommendations or that the resident use based on bed rail type and bed type would be assessed and measured for potential entrapment risk prior to installation and resident use. III. Assistive device manual On 1/6/22 at approximately 9:00 a.m., a request was made for the user manual for Resident #62's specific brand of bed cane/assistive device for reviewing the device recommendations for installation, maintenance and usage instructions. The CNC said the facility did not have the manual for the resident bed cane because it was not a facility provided bed cane. The resident brought the assistive device from her prior living placement. The resident did not have the manual any longer. IV. Resident #62 1. Resident status Resident #62, over the age of 90, was admitted on [DATE]. According to the January 2022 computerized physician orders (CPO) diagnosis included anxiety, Parkinson ' s, and abnormalities of gait and mobility. The 11/19/21 minimum data set (MDS) assessment revealed the resident cognition was intact with a brief interview for mental status (BIMS) score of 15 out of 15. The resident needed limited assistance from one staff member for transfers, bed mobility, bathing and dressing; extensive assistance from one staff member to use the toilet and supervision assistance with personal hygiene tasks. The resident's balance was not steady and was only able to stabilize with human assistance. The resident's main mode of transportation was a manual wheelchair but she was able to walk with the use of a walker. The resident started with occupational therapy on 11/16/21 and did not have a bed rail at the time of the assessment including not indicated under restraints. 2. Resident interview and observations Resident #62's bed and bed cane assistive device were observed on 1/3/22 at 11:23 a.m. The resident had a standard hospital bed with a bed cane attached on the right side of the bed. Resident #62 said the bed cane was her personal property; she brought it with her and asked the facility to install it when she moved in. The device was helpful to help with bed mobility. The bed cane was constructed of a lightweight metal bar with a padded grab bar; the device was in the shape of an upside down U with adjustable rubber tipped legs that extended to the floor. At midline on the assistive device. The device had an attached horizontal bar that was placed between the resident mattress and metal frame of the hospital bed. There was a canvas strap attached from the bed cane to the metal frame intended to prevent the bed cane from disengaging from the resident hospital bed. The bed cane was not securely bolted to the resident bed frame and the rubber feet did not prevent the bed cane from moving. The bed cane easily slid up and down the length of the upper bed frame, and was wobbly rocking to and from the matter's side so that an average sized clenched fist could be placed long ways in between the bed cane and the resident's mattress. 3. Record review The resident care plan, initiated 11/16/21 and revised 12/22/21 revealed Resident #62 had a self-care performance deficit related to decreased mobility affecting ability to perform activities of daily living (ADLs). Interventions initiated 11/15/21 documented: The resident requires assistance by one staff with bed mobility and to move between surfaces. Bed cane to the right side of bed to assist with bed mobility and positioning. Check placement and function. Discuss with the resident/family/power of attorney any concerns related to loss of independence, decline in function. Encourage the resident to participate to the fullest extent possible with each interaction .Transfer program: Facilitate opportunities for functional transfers: wheelchair to .bed. Cuing assistance for forward weight shifting and safety awareness. Resident requires minimal to moderate assistance . Pre restraint assistive device evaluation dated 12/22/21 read in pertinent part: Device to be implemented: bed cane to the right side of the bed. Behavior prompting continued use of restraint: unsteady gait and repartitioning assistance. Resident would like to reposition self while in bed to improve independence. Resident has used this device prior to admission and is aware of its function. Discussed with the resident the potential risk of the bed cane and determined the benefits outweigh the risks. Physical therapy Discharge summary dated [DATE] read in patient part: Resident #62 will safely perform mobility tasks with supervision, without the use of side rails and 10 % verbal cues for correct hand/foot placement and proper sequencing in order to get in and out of bed . Interventions provided: Bed mobility training with and without bed cane to improve safety and independence with mobility .Patient seen for planned discontinuation of services and trial of bed cane. Patient demonstrated improved ability to perform bed transfers . V. Staff interviews Registered nurse (RN) #4 was interviewed on 1/6/22 at 10:21 a.m. RN #4 said prior to installation of a bed cane assistive device the physical therapist would conduct an assessment of the resident need for the assistive device and obtain physician's order for the device. The nurse was to check the devices every shift for functional safety of the rail and place a work order with the maintenance department if the devices became loose or were a danger to the resident. Nursing staff was to conduct a quarterly assessment of the bed rail to assess appropriateness of the resident continued use of the assistive device. The nursing home administrator (NHA) was interviewed on 1/6/22 at 10:33 a.m. The NHA said the nursing department was to alert the maintenance department if a resident bed cane was loose, unstable or posing a danger to a resident. The maintenance department was responsible to make repairs and adjustment on the bed cane/assistive devices and maintenance a record of repairs. The maintenance director (MTD) was interviewed on 1/6/22 at 11:16 a.m. The MTD said the nursing department was responsible for conducting regular checks of assistive devices; if they noticed any issues or had any concerns about the safety of any assistive devices and would pace a work order for repair. The maintenance department would inspect the device and make needed adjustment repairs or recommendations for replacement. The MTD said the maintenance department did not make regular rounds checking bed canes or bed rails but depended on the nurses to let them know when the device needed to be adjusted or repaired. The MTD said Resident #62 came from an assisted living facility with her bed cane device and wanted to use that same bed cane device. The MTD offered and recommended the resident the standard facility provided Halo bed cane but the resident declined. The MTD acknowledged the Halo bed cane was more secure because it could be bolted to the bed frame and would not slide on the bed frame. The minimum data set coordinator (MDSC) was interviewed on 1/6/22 at 12:08 p.m. The MDSC said the physical therapist did the initial assessment for assistive devices including bed canes and then as the restorative nurse, she would conduct ongoing assessment annually and quarterly to make sure the assistive device/bed cane continued to be useful and appropriate for the resident's use. The floor nurses were expected to conduct a daily check of the bed cane to ensure fit and safety. The floor nurse was to notify the MTD of any safety concerns or malfunctions. The MDSC said she had talk to Resident #62 and the family about the risk and benefits of Resident #62 using the bed cane and obtained consent for the resident use of the bed cane. The MDSC provided a user's manual for the Halo brand bed cane and said they will speak to the resident about replacing the resident's Medline bed cane (that came from the assisted living facility) with the Halo bed cane. The NHA was interviewed on 1/6/22 at 4:06 p.m. The NHA said Resident #62 did not have the user's manual for her personal bed cane, but it was insistent that the facility installed the unit anyway. Based on the resident's insistence and request they installed the device. Physical therapy was working with Resident #62 on bed mobility and safe transfers with and without the bed cane device. Due to concerns raised, the facility talked with the resident about bed cane options. The resident reluctantly agreed to permit the facility to remove her bed cane and install a Halo brand bed cane (the Halo safety ring/bed cane is a hospital bed bracket system compatible with hospital beds used in the facility. The device bolts directly to the hospital bed frame. The device would still need to be monitored for functionality.) The director of nursing (DON) was interviewed on 1/6/22 at 5:09 p.m. The DON acknowledged the bed cane assistive devices should be monitored for safety and adjusted if loose or hazardous to the resident. VI. Facility follow-up The facility implemented an Assistive Devices Action Plan which was dated 1/6/22 (identified during the survey). As a part of the plan, the facility conducted a facility wide sweep of all resident rooms to identify all current assistive devices; completed 1/6/22. Nursing staff to be provided education on proper placement of assistive devices and when to notify maintenance for repair, on an ongoing basis.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** III. Incidents of physical abuse between Resident #2 and Resident #91 A. Facility investigation of incident on 12/1/21 The 12/1/21 abuse investigation was provided by the NHA on 1/4/21 at 1:00 p.m. The report was completed by the social services director (SSD). The report indicated the following: On 12/1/21, in the morning, Resident #91 allegedly came up on the side of Resident #2 and asked if she could borrow her phone three times. Resident #2 stated all three times she did not have a phone. Resident #2 said that Resident #91 hit her on her arm seven to eight times. No care partner or other resident witnessed actual contact and video footage was unsuccessful in showing if contact was made and how many times. Both residents were placed on frequent checks for safety. A RN skin assessment was conducted on Resident #2. Resident #91 was severely cognitively impaired. Police department, resident representatives and providers were notified. Both of the residents' care plan and chart review were completed. RN skin assessments were completed with no new marking or discoloration noted. Included in the report were additional interviews completed by the SSD. The interviews revealed the following: Resident #2 was interviewed on 12/1/21 at 9:20 a.m. She stated she was exercising with her ball in the hallway and the crazy lady came up to her and asked her to borrow her phone. She said she did not have a phone. She told Resident #91 no all three times and she hit Resident #2 on her arm seven to eight times. Resident #2 stated she was not scared at the moment but scared of what Resident #91 could do to her. Resident #91 was interviewed on 12/1/21 at 10:00 a.m. Resident #91 said she had no recollection of the event. Witness interview summary: There were no witnesses present for this event. Staff interview, RN #5, 12/1/21 (time not provided). Statement: Resident #2 was very mad and told me that Resident #91 hit her on her arm. I did not see it but I saw them right next to each other and quickly moved Resident #91 to give some space. Staff interview, RN#6, 12/1/21 (time not provided). Statement: I was not on shift at that time. I have not seen Resident #91 hit anyone, she did yell out all day and that was disruptive to the other residents. Staff interview, clinical advocate, 12/1/21 (time not provided). Statement: I was told about the incident but I was told Resident #91 did not make contact. Staff interview, CNA #7 , 12/1/21 (time not provided). Statement: I did not see anything between the two of them. Resident #91 yells out most of the day. Review of the State Agency portal revealed the initial report for the incident had been submitted by the facility on 12/1/21. B. Resident #91 1. Resident status Resident #91, age [AGE], was admitted on [DATE]. According to the January 2022 computerized physician orders (CPO), diagnoses included dementia with behavioral disturbances, chronic kidney disease, and spinal stenosis. The 12/15/21 minimum data set (MDS) assessment revealed the resident with severe cognitive impairment with a brief interview for mental status score of five out of 15. She required extensive assistance with two persons for bed mobility, transfers, dressing, toilet use. Extensive assistant with one person for personal hygiene, and total dependence for bathing. Eating required supervision with one person. Exhibits disorganized thinking and inattention. The MDS was marked as no rejection of care and no physical or verbal behaviors directed toward others. However, there were at least one incident of resident to resident altercations documented on 12/1/21 before completion of MDS on 12/15/21 and a care plan had been established for behavioral problems, resistance to care, and physical aggression. 2. Record review The resident comprehensive care plan for behavior problems, revised 12/29/21, identified the resident had behavior problems related to dementia with behavioral disturbances. History from past assistive living of explosive physical aggression and verbal aggression. The resident will sit and yell out at all times of the day. When going in to assist she can become verbal and physical trying to hit others with shoes, punch, spit, and throw things she can get to. The resident has limited safety awareness and limited boundaries. Interventions for behavioral problems include to anticipate and meet the resident's needs, behavioral monitoring, caregivers to provide opportunities for positive interaction, and attention. Stop and talk with her as passing by. Intervene to protect the rights and safety of others. Approach/speak in a calm manner. Divert attention. Remove from the situation and take her to an alternate location. Minimize potential for the resident's disruptive behaviors yelling out and potentially trying to hit staff and peers by offering tasks which divert attention such as offering a magazine, putting her radio on in her room, giving her pet stuffed cat that was in her room. Offer and document non pharmacological interventions prior to administering medication and as needed: offer range of motion, massage, relaxation and breathing techniques, imagery and distraction techniques, repositioning, aromatherapy, therapeutic touch; offer snack, and drink. Redirect to an activity, offer independent activity supplies, offer to call a loved one, assist outside, sit with the resident as needed, offer shower or a bath, active listening and validation. Offer the resident her busy vest when she was experiencing anxiousness or as needed. Praise any indication of the resident's progress/improvement in behavior. The resident comprehensive care plan for physical aggression, revised 12/29/21, identified the resident had potential to be physically aggressive related to dementia. Poor impulse control, and safety awareness. The resident has a history and potential to be physically aggressive with staff during care. It was reported that she will yell you are raping me or other obscenities while hitting, punching, kicking the staff during cares. She will also sit in the hallway screaming at staff and residents. She can be very hard to redirect. Interventions for physical aggression include analyzing times of day, places, circumstances, triggers, and what de-escalates behavior and document. Provide physical and verbal cues to alleviate anxiety, give positive feedback, assist verbalization of source of agitation, assist to set goals for more pleasant behavior, encourage seeking out of staff members when agitated. Give the resident as many choices as possible about care and activities. When the resident becomes agitated, intervene before agitation escalates. Guide away from the source of distress, engage calmly in conversation. If the response was aggressive, the staff walk calmly away and approach later. -The care plans identified the residents' risks of behavior problems and physical aggression but the facility failed to consistently implement the interventions in the care plan, to anticipate and meet the resident's needs, and to provide opportunities for attention. Stop and talk with resident as passing by and divert attention. Minimize potential for the resident's disruptive behaviors yelling out and potentially trying to hit staff and peers by offering tasks which divert attention such as offering a magazine, putting her radio on in her room, giving her pet stuffed cat that was in her room. Offer and document non pharmacological interventions prior to administering medication and as needed: offer range of motion, massage, relaxation and breathing techniques, imagery and distraction techniques, repositioning, aromatherapy, therapeutic touch; offer snack, and drink. Redirect to an activity, offer independent activity supplies, offer to call a loved one, assist outside, sit with the resident as needed, offer shower or a bath, active listening and validation. Offer the resident her busy vest when she was experiencing anxiousness or as needed, as indicated in observations above. Cross-reference F744. No behavioral monitoring on the January 2022 medication administration/treatment administration records (MAR/TAR). C. Resident #2 1. Resident status Resident #2, age [AGE], was admitted initially on 11/2/15, with re-entry 5/26/2020. According to the January 2022 computerized physician orders (CPO), diagnoses included hypertensive heart and chronic kidney disease with heart failure, and scoliosis. Resident was currently receiving hospice services. The 12/22/21 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status score of 15 out of 15. She required extensive assistance with two persons for bathing, toileting, dressing, bed mobility, and transfers. No disorganized thinking or inattention behavior present. No behavioral symptoms or rejection of care exhibited. 2. Resident observation and interview On 1/5/22 at 9:36 a.m. Resident #2 was observed playing with a ball, that was hanging from a string in the ceiling, in the 400 hallway and seated in her wheelchair. She was very pleasant and said she enjoyed playing with the ball each day for exercise. Resident #2 was interviewed on 1/5/22 at 10:23 a.m. She recalled the incident of Resident #91 hitting her. Resident #2 said that Resident #91 asked to use her phone multiple times and was asking everybody. Resident #2 told her she did not have a phone, then Resident #91 hit her on the shoulder about six times. Resident #2 said it hurt to be hit but she was not physically injured. Resident #2 said she was annoyed more than anything else. Resident #2 said her ball, that hangs from a string from the ceiling, used to be on hall 600 but moved to hall 400 so that Resident #91 did not hurt her again. Resident #91's room was on hall 600. 3. Record review The resident comprehensive care plan, revised 4/12/21, identified the resident had chronic pain related to history of right elbow bursitis, scoliosis, kyphosis, and lower extremity, all joints, contractures. The resident comprehensive care plan, revised 4/26/21, identified the resident had potential for behaviors and can become irritable when her wishes were not met immediately by staff. The resident comprehensive care plan, revised 9/2/21, identified the resident had fragile skin and was at risk for skin tears and bruising. IV. Incidents of physical abuse between Resident #36 and Resident #91 A. Facility investigation of incident on 12/30/21 The 12/30/21 abuse investigation was provided by the NHA on 1/6/21 at 9:00 a.m. The report was completed by the social services director (SSD). The report indicated the following: On 12/20/21 at 7:00 p.m., Resident #91 was being guided down the hall towards her room by staff through the neighborhood. While staff was assisting Resident #91 navigate, Resident #91 left arm was observed outside of the wheelchair and making contact with Resident #36 left wrist. Staff guided Resident #91 back to her room and assisted her to bed. Staff members immediately intervened to separate both residents. Residents were both placed on frequent safety checks. Upon interview, Resident #91 and Resident #36 demonstrated no recall of the event due to severe cognitive impairments. A skin assessment was completed by an registered nurse (RN) with no noted discoloration or marks at this time. Police department, resident representative, providers, and ombudsman notified. Included in the report were additional interviews completed by the SSD. The interviews revealed the following: The witness, clinical advocate, was interviewed 1/5/22 at 2:40 p.m. She said she was walking down the hall and going toward Resident #91 who was very escalated and down by the exit door on 600 hall. The witness redirected and brought her back down the hall towards the nurses station. Resident #36 was in the hall wandering in a circle. The witness tried to guide Resident #91 away from Resident #36. Resident #91 took her hand and swatted with an open hand and made contact with Resident #36's wrist and forearm. Resident #36 pulled her hands up to her chest and said what did I do? Someone took Resident #36 and Resident #91 went to bed shortly after. RN #4 was interviewed on 1/4/21 (no time provided). Statement: I was not here but got in report that they were on frequent checks due to Resident #91 hitting the other resident on the hand. CNA #6 was interviewed on 1/4/21 (no time provided). Statement: Pretty much all I know is that there was an altercation, and did not know what resident. I do not know much about the altercation, I just knew there was one. RN #3 was interviewed on 1/4/21 (no time provided). Statement: I was on shift but I did not see it happen or know about it. CNA #3 was interviewed on 1/5/21 (no time provided). Statement: I do not remember what happened. I may not have been told. Review of the State Agency portal revealed the initial report for the incident had been submitted by the facility on 12/31/21. B. Resident #36 1. Resident status Resident #36, age [AGE], was admitted on [DATE]. According to the January 2022 computerized physician orders (CPO), diagnoses included Alzhiemer's disease, dementia without behavioral disturbance, and anxiety disorder. The 12/21/21 minimum data set (MDS) assessment revealed the facility did not assess the brief interview for mental status (BIMS) due to the resident rarely/never understanding. The staff assessment for mental status revealed short term and long term memory problems, and the resident was unable to recall the current season, location of her room, staff names and faces, and that she was in a nursing home. Cognitive skills for daily decision making are severely impaired. Inattention and disorganized thinking behavior were continuously present. No physical or verbal behavioral symptoms were directed toward others. No rejection of care behaviors. Wandering behavior occurred daily. She required extensive assistance with one person for eating, toileting, bathing, dressing, bed mobility, and transfers. 2. Record review The resident comprehensive care plan for elopement risk/wanderer, revised 7/1/19, identified the resident was an elopement/wanderer related to disoriented to place, and impaired safety awareness.The resident wanders aimlessly. Interventions include providing structured activities, toileting, walking inside and outside, reorientation strategies including signs pictures and memory boxes.Wanderguard placement, and redirect resident. The resident comprehensive care plan for Alzheimer's and dementia without behavioral disturbances, revised 7/22/2020, identified the resident with impaired cognitive functioning, impaired thought processes, difficulty making decisions, impaired decision making, long and short term memory loss. The resident exhibits severe cognitive impairment, and her needs and wishes typically must be anticipated. Interventions include to cue, redirect, and supervise. The care plans identified the residents' risks for elopement/wandering and vulnerability due to severe cognitive impairment. However, the facility failed to consistently implement the interventions in the care plan, to provide structured activities, reorientation strategies, redirect the resident, anticipate residents needs and wishes, cue, and supervise, as indicated in observations above. Cross-reference F744. V. Incidents of physical abuse between Resident #96 and Resident #91 A. Facility investigation of incident on 1/3/22 The 1/3/22 abuse investigation was provided by the NHA on 1/6/21 at 9:00 a.m. The report was completed by the SSD. The report indicated the following: On 1/3/22 at 6:43 p.m. Both Residents #91 and #96 were by the nurses station in the neighborhood. Resident #91 and #96 were talking. Resident #91 propelled herself away from #96 closer to the nurses. Resident #96 followed her. Resident #91 took her left hand making contact with Resident #96 right upper arm. Resident #96 had no fear or no pain. During the skin assessment Resident #96 stated oh, that's nothing, I thought you wanted to see where they gave me a shot, during skin assessment. No injury noted. No complaint of pain or nonverbal signs of pain. Residents were immediately separated. Police Department, Resident Representatives, Providers, and Ombudsman notified. Additional interviews were not conducted yet. Witness and staff interviews were not completed yet. The SSD said the facility investigation was not completed and was in progress. Review of the State Agency portal revealed the initial report for the incident had been submitted by the facility on 1/4/22. B. Resident #96 1. Resident status Resident #96, age [AGE], was admitted on [DATE]. According to the January 2022 computerized physician orders (CPO), diagnoses included fracture of right leg, fracture of right arm, and bipolar disorder. The 12/13/21 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status score of 15 out of 15. She required moderate assistance with one person for bed mobility, and dressing . Maximal assistance of one person for transfers, showers, and toileting. Wheelchair mobility with setup assistance. Inattention and disorganized thinking behavior present intermittently. No physical or verbal behavioral symptoms were directed toward others. No rejections of care behaviors. 2. Resident observation On 1/3/22 at 1:11 p.m. Resident #96 was observed seated in her wheelchair and was independently wheeling around the nurse station and TV/dining room and speaking to various staff members. 3. Record review The resident comprehensive care plan for behavioral problems, initiated 1/3/22, identified the resident had poor boundaries. She will talk for long periods of time even after being politely reminded by care partners they need to go or only have a certain amount of time to meet with her. Interventions include behavioral monitoring. Encourage the resident to respect care partners/resident's time and boundaries. VI. Staff interviews CNA #8 was interviewed on 1/6/22 at 10:35 a.m. She said the process for when a resident altercation occurred was to go tell the nurse but first separate the residents. She said she did not know the residents well enough to know who was at risk or who to keep an eye on. RN #4 was interviewed on 1/6/22 at 10:43 a.m. She said for resident to resident altercations separate first for safety, report it to the NHA, who was the abuse coordinator. She said she was aware of keeping an eye on Resident #91 due to her impulsiveness. She said she had not done the abuse training because when it was offered she was in a different position. She said she had worked for the past few months as a floor nurse, prior she was in a clinical advocate position. LPN #1 was interviewed on 1/6/22 at 10:53 a.m. She said for resident to resident altercations first separate the residents and make sure both are in a safe place. Then ask someone to go get help, assess the resident, notify family and doctor. She said abuse training was reviewed in a recent all staff meeting. The SSD and NHA were interviewed on 1/6/22 at 2:02 p.m. The SSD said there had been three incidents in which Resident #91 had hit another resident (12/1/21, 12/30/21, and 1/3/22). The SSD said she was aware of Resident #91 history of behaviors and that Resident #2 was wheelchair bound, and had a BIMS score of 15. The SSD said the hitting incident of Resident #91 to Resident #2 was not witnessed. She said typically they use open ended questions when doing an interview. The SSD said Resident #91 had hit Resident #36, she said it happened when the clinical advocate was assisting Resident #91 to her room and she reached out and hit Resident #36 and contact was made. The clinical advocate witnessed the incident. The SSD said Resident #91 was screaming at the door, so the clinical advocate tried to bring her up. The SSD said Resident #36 was wandering in a circle and Resident #91 reached out and hit Resident #36 wrist area. The SSD said making contact meant Resident #91 swatted with an open hand. The SSD acknowledged that Resident #36 had pulled her hands to her chest and said what did I do? after being struck. The SSD and NHA said they had not heard of any other incidents between the residents. The SSD said the 1/3/21 incident investigation was just starting. She said Resident #91 had reached out and hit Resident #96 on her arm. The SSD said the two residents were on the side of the fish tank and they were talking, then Resident #91 propelled to the nurse cart. Resident #96 followed and came by Resident #91, and Resident #91 hit Resident #96. The SSD said Resident #96 said to the DON, what's up with that lady, she believed she was crazy. The SSD said she did not have the interviews with her that she had just started, so she did not know what the supervising nurse had said. The NHA said Resident #91's daughter had come in and that helped her behavior and also music in her room. The NHA said he was not 100 percentage sure what the plan was for Resident #91. He had spoken to Resident #91's daughter, low stimulation was helpful and they have discussed going back to the memory care environment. Based on interviews and record review, the facility failed to ensure residents had the right to be free from physical abuse for four (#54, #2, #36 and #96) of seven residents out of 40 sample residents. Specifically, the facility failed to ensure: -Resident #54 was kept free from abuse from Resident #92; -Resident #2 was kept free from abuse from Resident #91; -Resident #36 was kept free from abuse from Resident #91; and, -Resident #96 was kept free from abuse from Resident #91. Findings include: I. Facility policy and procedure The Abuse policy, last revised 10/28/2020, was provided by the nursing home administrator (NHA) on 1/3/22 at 11:53 a.m. It read in pertinent part, This facility does not condone resident abuse and shall take every precaution possible to prevent resident abuse by anyone, including staff members, other residents, volunteers, and staff of other agencies serving the resident, family members, legal guardians, resident representative, sponsors, friends, or any other individuals. Every resident has the right to be free from verbal, sexual, physical and mental abuse, corporal punishment, and involuntary seclusion. Providing a safe environment for the resident is one of the most basic and essential duties of our facility. If a resident experiences a behavior change resulting in aggression toward other residents, the facility conducts further assessment and arranges for appropriate psychiatric evaluation for further screening. The resident's care plan is revised to include new approaches to reduce or eliminate any further chance of abuse. When residents who have been admitted exhibit behavior that presents a danger to others, interventions shall be taken to ensure the safety of other residents and staff. II. Incidents of physical abuse between Resident #54 and Resident #92 A. Facility investigation of incident on 11/7/21 The 11/7/21 abuse investigation report was provided by the NHA on 1/4/21 at 1:00 p.m. The report was completed by the social services director (SSD). The report indicated the following: On 11/7/21 at 2:45 p.m., Resident #92 allegedly entered Resident #54's room and opened and rummaged through draws. Resident #54 asked Resident #92 to leave and Resident #92 called Resident #54 a derogatory name. Resident #92 then hit Resident #54 and pushed a table into her. Resident #54 yelled for her husband who was in the bathroom at the time. Resident #54's husband (Resident #55) exited the bathroom and walked down the hallway to get a nurse. Resident #92 then hit Resident #54 in the back of the head. A nurse and certified nurse aide entered the room, separated the residents, and assisted Resident #92 back to her room. The residents were placed on frequent checks and a skin assessment was completed for Resident #54. A stop sign was placed on Resident #54's door as a deterrent to keep Resident #92 from entering the room. A sticker with Resident #92's room number was placed on her walker to remind her where her room was. The physician, ombudsman, power of attorney, and police department were notified. Included in the report were additional interviews completed by the SSD. The interviews revealed the following: Resident #92 was interviewed on 11/12/21 at 8:45 a.m. She said she did not recall the incident and would not hit anyone. Resident #54 was interviewed on 11/8/21 at 8:30 a.m. She said Resident #92 entered her room, called her a derogatory name, slapped her hand, and pushed a table into her. Resident #54 said she called for her husband to get a nurse. She said Resident #92 looked through her belongings and then sat on the bed. She said the nurse was able get Resident #92 to leave. Resident #55 was interviewed on 11/8/21 at 8:30 a.m. He said he went to get a certified nurse aide and was in the room when nursing staff asked Resident #92 to leave. He said he saw Resident #92 hit his wife on the back of the head. Licensed practical nurse (LPN) #3 was interviewed on 11/8/21. She said she saw Resident #54's husband was in the hallway and he notified her what happened. She said Resident #92 was sitting on Resident #54's bed. She said after several attempts she was able to walk Resident #92 back to her room. Certified nurse aide (CNA) #1 was interviewed on 11/8/21. He said he was approached by Resident #54's husband and he went to her room. He said Resident #92 was sitting on Resident #54's bed. He said the nurse came in and assisted Resident #92 back to her room. Review of the State Agency portal revealed the initial report for the incident had been submitted by the facility on 11/7/21. B. Facility investigation of incident on 12/30/21 The 12/30/21 abuse investigation was provided by the NHA on 1/6/21 at 9:00 a.m. The report was completed by the SSD. The report indicated the following: On 12/30/21 at 9:36 a.m., Resident #92 entered Resident #54's room. Resident #92 allegedly screamed this is my room at Resident #54 and then hit her hand. Resident #92 then screamed in Resident #54's ear. The residents were separated and a skin assessment was completed for Resident #54 without significant findings. A stop sign was to be replaced/re-stuck on Resident #54's door with consent from both she and her husband. They had taken it down and said it would not stick to the wall. Signs were placed in the hallways on bright paper alerting Resident #92 which way her room was located. The physician, ombudsman, power of attorney, and police department were notified of the incident. Video surveillance was reviewed and described in the report. It revealed Resident #92 walked into Resident #54's room and left 21 seconds later. Resident #54 left her room shortly after. Included in the report were additional interviews completed by the social services director, they indicated the following: Resident #54 was interviewed on 12/30/21 at 10:30 a.m. She said Resident #92 came into her room, screamed at her, hit her hand, screamed at her again, and then left her room. Resident #92 was interviewed on 12/30/21 at 8:45 a.m. She had no memory of the event and said she would never hit anyone. Resident #55 was interviewed on 1/2/21. He said he would like for Resident #92 to stop walking into their room. Review of the State Agency portal revealed the initial report for the incident had been submitted by the facility on 12/30/21. C. Resident #54 1. Resident status Resident #54, under 65, was admitted on [DATE]. According to the January 2022 computerized physician orders (CPO), diagnoses included mild intellectual disability and depression. According to the 11/15/21 minimum data set (MDS) assessment, the resident was cognitively intact with a brief interview for mental status score of 15 out of 15. It revealed the resident was independent with activities of daily living. 2. Resident interview and observation Resident #54 was interviewed on 1/3/22 at 1:02 p.m. She said she shared a room with her husband. She said Resident #92 had come into their room on two occasions. She said she did not feel good about the situation. She said she wanted to move to an apartment with her husband. She said staff placed a stop sign on her door to deter Resident #92, she said she was unsure if the stop sign helped. The stop sign was observed on the door. The stop sign was affixed to the door frame with velcro and ran the length of the door horizontally. Resident #54 was interviewed again on 1/5/22 at 10:12 a.m. She said she has preferred to stay in her room to avoid Resident #92. She said she wanted the facility to move Resident #92 so that she will not hurt any other resident. She said she was not currently scared but would be if Resident #92 came into her room again. Observations on survey from 1/3/22 to 1/6/22 revealed that Resident #92 did not wander by Resident #54 and Resident #55's room. 3. Record review A nursing progress note from 11/7/21 revealed the following: Resident #54 reported Resident #92 entered her room, slapped her, pushed a tray table at her, and attempted to slap her husband. Residents were assessed for safety and no injuries were reported. Residents were monitored. A nursing progress note from 12/30/21 revealed the following: Resident #54 reported Resident #92 entered her room, slapped her, and yelled at her. Resident #54 was upset and spoke with social worker. A skin assessment was completed with no injuries. The behavior care plan, revised on 11/12/21, indicated staff affixed a stop sign on Resident #54's door in order deter other residents from wandering into the room. D. Resident #55 1. Resident status Resident #55, age [AGE], was admitted on [DATE]. According to the January 2022 CPO, diagnoses included need for assistance with recital cancer, anxiety, and depression. According to the 11/15/21 MDS assessment, the resident was cognitively intact with a brief interview for mental status score of 15 out of 15. It indicated the resident was independent with activities of daily living. 2. Resident interview Resident #55 was interviewed on 1/3/21 at 12:49 p.m. He said he saw Resident #92 hit Resident #54 during the first incident. He said Resident #92 had come into their room several times since they had lived at the facility. He said the facility staff placed a stop sign on their door after the first event and put signs that pointed Resident #92 to her room. He said he wanted to move due to the events. D. Resident #92 1. Resident status Resident #92, age [AGE], was admitted on [DATE] and readmitted on [DATE]. According to the January 2022 computerized physician orders (CPO), diagnoses included Alzheimer's disease and dementia with behavioral disturbance. The 12/13/21 minimum data set (MDS) assessment revealed that the resident had severe cognitive impairment with a brief interview for mental status (BIMS) of three out of 15. She required one-person extensive assistance for bed mobility, transfers, dressing, and toilet use. She required one-person limited assistance for personal hygiene. She required supervision for ambulation with a walker. The 12/13/21 MDS assessment further documented that the resident had not exhibited any physical or verbal behaviors directed at staff or others during the assessment period. She had not wandered during the assessment period. 2. Record review Review of Resident #92's comprehensive care plan, initiated 12/11/19 and last revised 5/17/21, re[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** III. Resident #91 A. Resident status Resident #91, age [AGE], was admitted on [DATE]. According to the January 2022 computerized physician orders (CPO), diagnoses included dementia with behavioral disturbances, chronic kidney disease, and spinal stenosis. The 12/15/21 minimum data set (MDS) assessment revealed the resident with severe cognitive impairment with a brief interview for mental status score of five out of 15. She required extensive assistance with two persons for bed mobility, transfers, dressing, toilet use. Extensive assistant with one person for personal hygiene, and total dependence for bathing. Eating required supervision with one person. Exhibits disorganized thinking and inattention. The MDS was marked as no rejection of care and no physical or verbal behaviors directed toward others. However, there were at least one incident of resident to resident altercations documented on 12/1/21 before completion of MDS on 12/15/21 and a care plan had been established for behavioral problems, resistance to care, and physical aggression. B. Resident to resident altercations on 12/1/21, 12/30/21, and 1/3/22 The facility investigation summary of the 12/1/21 incident between Resident #2 and Resident #91 documented the following in pertinent part: On 12/1/21 at 1:00 p.m. Resident #91 allegedly came up on the side of Resident #2 and asked if she could borrow her phone three times. Resident #2 stated all three times she did not have a phone. Resident #2 said that Resident #91 hit her on her arm seven to eight times. No care partner or other resident witnessed actual contact and video footage was unsuccessful in showing if contact was made and how many times. Both residents were placed on frequent checks for safety. A registered nurse (RN) skin assessment was conducted on Resident #2. Resident #91 was severely cognitively impaired. Police department, resident representatives and providers were notified. Both of the residents' care plan and chart review were completed. RN skin assessments were completed with no new marking or discoloration noted. Cross reference F600 for abuse. The facility investigation summary of the 12/30/21 incident between Resident #36 and Resident #91 documented the following in pertinent part: On 12/30/21 at 7:00 p.m. Resident #91was being guided down the hall towards her room by staff through the neighborhood. While staff was assisting Resident #91 to navigate, Resident #91 left arm was observed outside of the wheelchair and making contact with Resident #36 left wrist. Staff guided Resident #91 back to her room and assisted her to bed. Staff members immediately intervened to separate both residents. Residents were both placed on frequent safety checks. Upon interview, Resident #91 and Resident #36 demonstrated no recall of the event due to severe cognitive impairments. A skin assessment was completed by an registered nurse (RN) with no noted discoloration or marks at this time. Police department, resident representative, providers, and ombudsman notified. Cross reference F600 for abuse. The facility investigation summary of the 1/3/22 incident between Resident #96 and Resident #91 documented the following in pertinent part: On 1/3/22 at 6:43 p.m. Both Residents #91 and #96 were by the nurses station in the neighborhood. Resident #91 and #96 were talking. Resident #91 propelled herself away from #96 closer to the nurses. Resident #96 followed her. Resident #91 took her left hand making contact with Resident #96 right upper arm. Resident #96 had no fear or no pain. During the skin assessment Resident #96 stated oh, that's nothing, I thought you wanted to see where they gave me a shot, during skin assessment. No injury noted. No complaint of pain or nonverbal signs of pain. Residents were immediately separated. Police Department, Resident Representatives, Providers, and Ombudsman notified. Additional interviews were not conducted yet. Witness and staff interviews were not completed yet. The Social services director (SSD) said the facility investigation was not completed and was in progress. Cross reference F600 for abuse. C. Resident #91 observations On 1/3/22 at 10:42 a.m. Resident #91 was in the television (TV)/dining area unsupervised. She was observed exhibiting verbal expressions sometimes directed toward others, and sometimes just yelling out hey. Resident #91 told another resident to shut up although the unnamed resident did not hear her. Resident #91 was seated in a wheelchair in the TV/dining area and said loudly come and get this. She was referring to her breakfast tray which was still before her. No other staff was observed in the area to hear her call out. Resident #91 said for heaven's sake! Finally after 20 minutes a nurse came and took the breakfast tray and the resident said thank you. On 1/4/22 at 2:13 p.m. Resident #91 was seated in a wheelchair in the hallway with nothing to do. She said hi and today was a good day. Observed Resident #91 with no activities, supervision, or interaction with other staff for more than 25 minutes. She was wandering around in the 600 hallway in her wheelchair. On 1/6/22 at 12:36 p.m. Resident #91 was observed without any activities or materials to keep her occupied. Resident #91 wandered in the halls and common spaces without additional supervision. D. Record review The resident comprehensive care plan for behavior problems, revised 12/29/21, identified the resident had behavior problems related to dementia with behavioral disturbances. History from past assistive living of explosive physical aggression and verbal aggression. The resident will sit and yell out at all times of the day. When going in to assist she can become verbal and physical trying to hit others with shoes, punch, spit, and throw things she can get to. The resident has limited safety awareness and limited boundaries. Interventions for behavioral problems include to anticipate and meet the resident's needs, behavioral monitoring, caregivers to provide opportunities for positive interaction, and attention. Stop and talk with her as passing by. Intervene to protect the rights and safety of others. Approach/speak in a calm manner. Divert attention. Remove from the situation and take her to an alternate location. Minimize potential for the resident's disruptive behaviors yelling out and potentially trying to hit staff and peers by offering tasks which divert attention such as offering a magazine, putting her radio on in her room, giving her pet stuffed cat that was in her room. Offer and document non pharmacological interventions prior to administering medication and as needed: offer range of motion, massage, relaxation and breathing techniques, imagery and distraction techniques, repositioning, aromatherapy, therapeutic touch; offer snack, and drink. Redirect to an activity, offer independent activity supplies, offer to call a loved one, assist outside, sit with the resident as needed, offer shower or a bath, active listening and validation. Offer the resident her busy vest when she was experiencing anxiousness or as needed. Praise any indication of the resident's progress/improvement in behavior. The resident comprehensive care plan for physical aggression, revised 12/29/21, identified the resident had potential to be physically aggressive related to dementia. Poor impulse control, and safety awareness. The resident has a history and potential to be physically aggressive with staff during care. It was reported that she will yell you are raping me or other obscenities while hitting, punching, kicking the staff during cares. She will also sit in the hallway screaming at staff and residents. She can be very hard to redirect. Interventions for physical aggression include analyzing times of day, places, circumstances, triggers, and what de-escalates behavior and document. Provide physical and verbal cues to alleviate anxiety, give positive feedback, assist verbalization of source of agitation, assist to set goals for more pleasant behavior, encourage seeking out of staff members when agitated. Give the resident as many choices as possible about care and activities. When the resident becomes agitated, intervene before agitation escalates. Guide away from the source of distress, engage calmly in conversation. If the response was aggressive, the staff walk calmly away and approach later. -The care plans identified the residents' risks of behavior problems and physical aggression but the facility failed to consistently implement the interventions in the care plan, to anticipate and meet the resident's needs, and to provide opportunities for attention. Stop and talk with resident as passing by and divert attention. Minimize potential for the resident's disruptive behaviors yelling out and potentially trying to hit staff and peers by offering tasks which divert attention such as offering a magazine, putting her radio on in her room, giving her pet stuffed cat that was in her room. Offer and document non pharmacological interventions prior to administering medication and as needed: offer range of motion, massage, relaxation and breathing techniques, imagery and distraction techniques, repositioning, aromatherapy, therapeutic touch; offer snack, and drink. Redirect to an activity, offer independent activity supplies, offer to call a loved one, assist outside, sit with the resident as needed, offer shower or a bath, active listening and validation. Offer the resident her busy vest when she was experiencing anxiousness or as needed, as indicated in observations above. Cross-reference F600 abuse. No behavioral monitoring on the January 2022 medication administration/treatment administration records (MAR/TAR) and no physician orders for behavioral monitoring. IV. Resident #36 A. Resident status Resident #36, age [AGE], was admitted on [DATE]. According to the January 2022 computerized physician orders (CPO), diagnoses included Alzhiemer's disease, dementia without behavioral disturbance, and anxiety disorder. The 12/21/21 minimum data set (MDS) assessment revealed the facility did not assess the brief interview for mental status (BIMS) due to the resident rarely/never understanding. The staff assessment for mental status revealed short term and long term memory problems, and the resident was unable to recall the current season, location of her room, staff names and faces, and that she was in a nursing home. Cognitive skills for daily decision making are severely impaired. Inattention and disorganized thinking behavior were continuously present. No physical or verbal behavioral symptoms were directed toward others. No rejection of care behaviors. Wandering behavior occurred daily. She required extensive assistance with one person for eating, toileting, bathing, dressing, bed mobility, and transfers. B. Resident #36 observations On 1/3/22 at 10:42 a.m. Resident #36 was in the television (TV)/dining area unsupervised. She was observed seated in a chair talking to herself quietly and laughing. She was drinking some juice. She was not able to engage in conversation. Resident #91 was observed seated in a wheelchair, in the same area, ten feet away from Resident #36. Resident #91 told Resident #36 to shut up when she heard her talking and laughing to herself. Resident #36 did not hear Resident #91. There were no staff supervising in the area for more than 20 minutes. On 1/4/22 at 2:26 p.m. Resident #36 was observed walking up and down the 600 hallway. She was talking to herself, and stopped and pats her knees. No activities or staff interaction were observed. Resident #91 was also observed in the 600 hallway, seated in her wheelchair with nothing to do. No activities, supervision, or interaction with staff were observed. C. Record review The resident comprehensive care plan for elopement risk/wanderer, revised 7/1/19, identified the resident was an elopement/wanderer related to disoriented to place, and impaired safety awareness.The resident wanders aimlessly. Interventions include providing structured activities, toileting, walking inside and outside, reorientation strategies including signs pictures and memory boxes.Wanderguard placement, and redirect resident. The resident comprehensive care plan for Alzheimer's and dementia without behavioral disturbances, revised 7/22/2020, identified the resident with impaired cognitive functioning, impaired thought processes, difficulty making decisions, impaired decision making, long and short term memory loss. The resident exhibits severe cognitive impairment, and her needs and wishes typically must be anticipated. Interventions include to cue, redirect, and supervise. -Following the physical abuse incident that occurred on 12/30/21, the comprehensive care plan did not document any new interventions put into place to protect Resident #36 due to her severe cognitive impairment and daily wandering, in order to prevent recurrence of abuse to Resident #36. The last update to the elopement/wanderer care plan was 7/1/19, and the last update to the Alzheimer's/dementia care plan was 7/22/2020. -The care plans identified the residents' risks for elopement/wandering and vulnerability due to severe cognitive impairment. However, the facility failed to consistently implement the interventions in the care plan, to provide structured activities, reorientation strategies, redirect the resident, anticipate residents needs and wishes, cue, and supervise, as indicated in observations above. Cross-reference F600 abuse. V. Staff interviews RN #4 was interviewed on 1/6/22 at 10:43 a.m. She said she kept an eye on Resident #91 due to her impulsiveness. LPN #1 was interviewed on 1/6/22 at 10:53 a.m. She said she completed dementia training when she was first hired about a year ago. The SSD was interviewed on 1/6/22 at 2:02 p.m. She said there had been three incidents in which Resident #91 had hit another resident (12/1/21, 12/30/21, and 1/3/22). The SSD said she was aware of Resident #91 history of behaviors. The SSD said she was aware of Resident #36 wandering around daily and that both residents had severe cognitive impairments. She said the follow up action to protect residents was when care partners were assisting Resident #91 ensure she was not assisted within reach of other residents. The SSD said the follow up action for Resident #36 was to ensure rest chairs are in each hallway for her to utilize. Based on record review and interviews, the facility failed to ensure a resident who displayed or was diagnosed with dementia, received the appropriate treatment and services to attain or maintain his or her highest practicable physical, mental, and psychosocial well-being for three (#92, #91, and #36) of 10 residents out of 40 sample residents. Specifically, the facility failed to effectively identify person-centered approaches for dementia care to prevent resident-to-resident altercations for Residents #92, #91, and #36. Findings include: I. Census and Conditions demographic The 1/3/22 Census and Condition form documented that 96 total residents resided at the facility. The form further documented there were 48 residents with a dementia diagnosis and 34 residents with behavioral healthcare needs. The facility had a secure unit with seven residents residing on it. II. Facility policy and procedure The Dementia Care policy, revised November 2018, was provided by the nursing home administrator (NHA) on 1/6/22 at 5:38 p.m. It read in pertinent part, As part of the initial assessment, the physician will help identify individuals who have been diagnosed as having dementia and those with otherwise impaired cognition. For the individual with confirmed dementia, the interdisciplinary team (IDT) will identify a resident-centered care plan to maximize remaining function and quality of life. The IDT will adjust interventions and the overall plan depending on the individual's responses to those interventions, progression of dementia, development of new acute medical conditions or complications, changes in resident or family wishes, and other relevant factors. II. Resident #92 A. Resident status Resident #92, age [AGE], was admitted on [DATE] and readmitted on [DATE]. According to the January 2022 computerized physician orders (CPO), diagnoses included Alzheimer's disease and dementia with behavioral disturbance. The 12/13/21 minimum data set (MDS) assessment revealed that the resident had severe cognitive impairment with a brief interview for mental status (BIMS) of three out of 15. She required one-person extensive assistance for bed mobility, transfers, dressing, and toilet use. She required one-person limited assistance for personal hygiene. She required supervision for ambulation with a walker. The 12/13/21 MDS assessment further documented that the resident had not exhibited any physical or verbal behaviors directed at staff or others during the assessment period. She had not wandered during the assessment period. B. Resident to resident altercations on 11/7/21 and 12/30/21 The facility investigation summary of the 11/7/21 incident between Resident #92 and Resident #54 documented the following in pertinent part: On 11/7/21 at 2:45 p.m., Resident #92 allegedly entered Resident #54's room and opened and rummaged through draws. Resident #54 asked Resident #92 to leave and Resident #92 called Resident #54 a derogatory name. Resident #92 then hit Resident #54 and pushed a table into her. Resident #54 yelled for her husband who was in the bathroom at the time. Resident #54's husband exited the bathroom and walked down the hallway to get a nurse. Resident #92 then hit Resident #54 in the back of the head. A nurse and certified nurse aide (CNA) entered the room, separated the residents, and assisted Resident #92 back to her room. The residents were placed on frequent checks and a skin assessment was completed for Resident #54. A stop sign was placed on Resident #54's door as a deterrent to keep Resident #92 from entering the room. A sticker with Resident #92's room number was placed on her walker to remind her where her room was. Cross-reference F600 for abuse. The facility investigation summary of the 12/30/21 incident between resident #92 and Resident #54 documented the following in pertinent part: On 12/30/21 at 9:36 a.m., Resident #92 entered Resident #54's room. Resident #92 allegedly screamed this is my room at Resident #54 and then hit her hand. Resident #92 then screamed in Resident #54's ear. The residents were separated and a skin assessment was completed for Resident #54 without significant findings. A stop sign was to be replaced/re-stuck on Resident #54's door with consent from both she and her husband. They had taken it down and said it would not stick to the wall. Signs were placed in the hallways on bright paper alerting Resident #92 which way her room was located. Cross-reference F600. C. Observations and resident interview On 1/4/22 at 10:45 a.m, bright yellow signs were observed posted on either side of the entrance into the common area. Both signs said Room (Resident #92's room number) and had an arrow on them which pointed down the 300 hall. On 1/5/22 at 9:48 a.m, Resident #92, who did not reside on the secure neighborhood, was sitting at a table in the common room eating her breakfast. There was a white sticker on the front bar of her walker with (resident's room number) written on it in black ink. The sticker was partially peeled away at the top. The room number was also written in black ink directly on the walker on the front bar and both lower side bars of the walker. When Resident #92 was asked what the sticker said, she initially said it looked like a heart. The resident was asked about the sticker again after a few minutes. Resident #92 slowly read the numbers correctly. Resident #92 did not know what the numbers meant. Resident #92 said she did not remember what her room number was and said her room was straight ahead out of the common area. Resident #92 pointed in the direction she thought her room was. She pointed to the 100 hall instead of the 300 hall. D. Record review Review of Resident #92's comprehensive care plan, initiated 12/11/19 and last revised 5/17/21, revealed the resident had a history of verbal aggression towards her daughter and had the potential to be verbally aggressive towards staff related to her diagnosis of dementia. She would enter other residents' rooms believing the room was hers, and could get escalated when staff tried to redirect. Pertinent interventions included redirecting her when she was observed approaching other residents personal boundaries, monitoring her behaviors, intervening when she became agitated before her agitation escalated, putting her room number on her walker to help her remember her room number, and redirecting her to her room when she was confused and in the wrong location looking for her room. -The care plan documented the intervention for putting her room number on her walker to direct her towards her room had been initiated on 5/5/2020, over a year prior to the incidents with Resident #54. -Following the physical abuse incidents that occurred on 11/7/21 and 12/30/21, the comprehensive care plan did not document any new interventions put into place to address Resident #92's aggressive behavior or her tendency to become confused and wander into the wrong room in order to prevent recurrence of abuse to Resident #54 or the other residents. Review of Resident #92's electronic medical record (EMR) revealed the following progress notes: 11/7/21 at 6:53 p.m: This nurse was informed that the following unwitnessed event occurred: Resident #54 stated that Resident #92 entered her room, slapped her, pushed her tray table at her, then attempted to slap her husband. Both residents were assessed for safety. No injuries observed. 11/7/21 at 10:01 p.m: Some increased confusion, besides that no further behaviors or change in routine observed. 11/8/21 at 3:39 a.m: Frequent checks by staff. No issues noted tonight. She has been in her room all night but has been restless and awake sporadically through the night. 11/8/21 at 1:12 p.m: Remains on frequent checks for safety. No observed episodes of aggressive behavior this shift. Several incidents of need for redirection to keep Resident #92 out of other residents' private areas. 11/8/21 at 8:15 p.m: Remains on frequent checks for safety. No noted aggressive behaviors this shift. No wandering. cooperative this shift. 11/9/21 at 4:27 a.m: Frequent checks by staff during the night. She has been sleeping in her room all night. No behaviors or issues noted. 11/9/21 at 2:04 p.m: Remains on frequent checks for safety. No noted aggressive behaviors this shift. No wandering. cooperative this shift. 11/10/21 at 4:39 a.m: Resident on 15 minute checks for wandering, no behaviors noted this shift, resting in her bed at this time. 11/10/21 at 1:15 p.m: Resident continues on frequent checks no issues this shift. 12/30/21 at 4:06 p.m: Meeting held today with Resident #92's daughter. Facility presented to the daughter that we believe Resident #92 needs to be in the secured neighborhood. She has been wandering into other resident rooms (sometimes taking things), has hit a resident on two separate occasions after going into their room, can be difficult to redirect, has threatened to kill another resident when she went into their room, has turned off other resident's oxygen due to the noise, and these things happen at all times of the day or night. This facility says this needs to happen to protect Resident #92 and the other residents. The Ombudsman has been informed. Daughter does not want her back there, feeling she is not ready for it. We described what it is like back there now, Resident #92 would get more activity, it's not dark, they have lots of activities, staff are great and consistent. Daughter feels it would not be a problem if staff just watched her; we explained why that isn't possible (we've already been trying that intervention) to catch her all the time at any moment (like being one on one). The facility's position is that she goes to the secured neighborhood or we make referrals. Daughter said if there was just a sign up that pointed to the hall her room is on, that would make the difference. We agreed to try that for the weekend, and be re-evaluated on Monday (1/3/22) for effectiveness. A referral was sent to another facility at the daughter's request. The signs were put up, and shown to the daughter. Nurse was asked to orient Resident #92 to the signs as well. 12/30/21 at 4:26 p.m: Care partner reported to staff that resident went into another resident's room and took other resident's cellphone one room down. Caretaker found the phone and returned it to the resident. 12/31/21 at 4:52 a.m: Frequent checks by staff tonight. She has been sleeping in her room all night tonight. 12/31/21 at 1:16 p.m: Resident on frequent checks no issues with any other residents. 1/1/22 at 2:51 a.m: Resident on frequent checks no issues with any other residents. 1/1/22 at 1:30 p.m: Resident on frequent checks no issues this shift. 1/2/22 at 12:45 p.m: Resident on frequent checks no issues with other residents this shift. -Further review of the resident's EMR did not reveal any additional documentation of ongoing monitoring for Resident #92 to ensure the safety of Resident #54 or the other residents. -In addition, there was no additional follow-up documentation from the facility regarding the effectiveness/ineffectiveness of the signs with her room number, or moving the resident to the secured unit. The Wander/Elopement Risk assessment dated [DATE] documented Resident #92 did not routinely wander, but had wandered into other residents ' rooms. E Interviews CNA #5 was interviewed on 1/5/22 at 10:46 a.m. CNA #5 said Resident #92 could sometimes get agitated, however she was usually redirectable. She said giving her a baby doll would calm her down. CNA #5 said the resident did not wander often. She said she would get confused and go into the wrong room. She said she was aware that Resident #92 had gone into Resident #54's room on 12/30/21 and hit her. CNA #5 said she thought that was the only time the resident had hit another resident. She said she did not think Resident #92 knew what her room number was. She said she just knew where it was located on the hall. She said Resident #92's room was the last room at the end of the hall on the left side of the hall. She said Resident #54's room was located in the same position just on the opposite hallway from Resident #92's room. CNA #5 said she thought Resident #92 got confused which hallway was hers and ended up in Resident #54's room. She said she felt the reason the resident lashed out was because she was startled to find someone in what she thought was her room. Licensed practical nurse (LPN) #2 was interviewed on 1/5/22 at 11:58 a.m. LPN #2 said Resident #92 had occasionally wandered into other residents ' rooms, but it did not happen that often. She said the resident was easily confused. She said she did not believe Resident #92 knew what her room number was, or which hallway it was on. She said the resident only knew where the room was located on the hall. LPN #2 said staff tried to keep an eye on the resident and redirect her to the correct hallway as much as possible. She said the facility had put up yellow signs with her room number on them to direct her to her room, however she said they were probably not effective because she did not think Resident #92 knew what her room number was. The SSD and the NHA were interviewed together on 1/6/22 at 2:50 p.m. The SSD said there had been two incidents in which Resident #92 had wandered into Resident #54's room and hit her. She said the facility placed a stop sign on Resident #54's door to deter Resident #92 from wandering into the room. She said a sticker with her room number was put on Resident #92's walker to remind her of her room number. The SSD said the facility also had a meeting with Resident #92's daughter on 12/30/21 and expressed to her that the facility felt she might be appropriate for the secure neighborhood. She said Resident #92's daughter did not want to move her there and insisted they try the yellow signs with her room number on them and an arrow pointing in the direction of her room. She said the facility agreed to try that and were to re-evaluate the effectiveness of the signs on 1/3/21. The SSD said the facility had not yet re-evaluated to see if the signs were effective. She said Resident #92's daughter said the resident knew what her room number was, so she thought the signs would work. The SSD said she had not actually asked Resident #92 if she knew what her room number was or if she knew what the number on the signs and her walker was for. She said besides the two incidents with Resident #54, there had not been any other recent resident to resident altercations between Resident #92 and other residents. The NHA said the facility had determined during their investigations of the incidents that Resident #92 had gotten confused about where her room was because of her cognition. He said that was why they put the sign with her room number on it on her walker after the first incident. He said after the second incident, the facility requested the meeting with Resident #92's daughter to discuss their safety concerns for the resident and the other residents. He said the daughter insisted the facility try the signs with her room number on them. He said the facility needed to re-evaluate their effectiveness. The NHA said staff tried to redirect Resident #92 to her room as much as possible. He said he did not know if the resident was aware of what her room number was.