**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to ensure one (#1) of five residents was kept free from abuse out of five sample residents. Specifically, the facility failed to ensure Resident #1 was kept free from sexual abuse by Resident #2. Findings include: I. Facility policy and procedure The Abuse, Neglect and Exploitation policy and procedure, revised 2024, was provided by the nursing home administrator (NHA) on 2/4/25 at 12:33 p.m. It read in pertinent part, It is the policy of this facility to provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. Abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish which can include staff to resident abuse and resident to resident altercations. The facility will make efforts to ensure all residents are protected from physical and psychosocial harm, as well as additional abuse, during and after the investigation. Examples include, but are not limited to, responding immediately to protect the alleged victim and integrity of the investigation, examining the alleged victim for any sign of injury, including a physical examination or psychosocial assessment if needed, increased supervision of the alleged victim and residents, room or staffing changes, if necessary, to protect the resident(s) from the alleged perpetrator, protection from retaliation, providing emotional support and counseling to the resident during and after the investigation, as needed and revision of the resident's care plan if the resident's medical, nursing, physical, mental or psychosocial needs or preferences change as a result of an incident of abuse. II. Incident of sexual abuse between Resident #1 and Resident #2 on 1/4/25 The 1/4/25 abuse investigation documented Resident #1 had wandered into Resident #2's room and fell asleep on Resident's #2's roommate's bed. When Resident #2 returned to his room, he laid down next to Resident #1 and touched her in a sexual manner. During the rounds, certified nurse aide (CNA) #1 found the residents and immediately separated them. Both residents were placed on 15-minute checks. Resident #2 was placed on one-to-one observations. Later the same day, Resident #2 was moved to a unit on the second floor where his one-to-one continued and he was around more alert and oriented residents. The facility investigation documented that the sexual abuse was substantiated. II. Resident #2 - assailant A. Resident status Resident #2, age greater than 75, was admitted on [DATE]. According to the February 2025 computerized physician orders (CPO), diagnoses included dementia with other behavioral disturbance and cognitive communication deficit. The 12/13/24 minimum data set (MDS) assessment documented the resident had severe cognitive impairments per staff assessment. He required minimal assistance with all activities of daily living (ADL), and ambulated with a walker. The assessment indicated the resident did not have physical or verbal behaviors towards other residents. B. Record review The behavioral care plan, revised on 1/7/25, documented Resident #2 had displayed sexually inappropriate behaviors and touched other residents. Interventions included administering medications as ordered, monitoring and documenting for side effects and effectiveness of medications, behavioral monitoring every shift, providing firm redirection and two-person care, providing one-to-one supervision for the resident every shift, notifying the unit manager or director of nursing (DON) and the NHA if Resident #2 was seen alone without one-to-one supervision and if any inappropriate behavior occurred and providing a program of activities of interest to the resident. III. Resident #1 - victim A. Resident status Resident #1, age [AGE], was admitted on [DATE]. According to the February 2025 CPO, diagnoses included dementia with behavioral disturbance and major depressive disorder. The 12/2/24 MDS assessment revealed the resident had severe cognitive impairments per staff assessment. She required supervision and minimal assistance with ADLs. She ambulated without assistance. B. Record review The behavioral care plan, initiated on 12/30/24 and revised on 1/6/25, documented Resident #1 was at risk for behavioral symptoms such as getting in other resident's beds or biting once agitated due to dementia. Interventions included maintaining a calm and slow approach, observing and documenting changes in behavior, providing reminders and checking on the resident every 15 minutes. A 1/4/25 nursing progress note documented Resident #1 was sleeping in Resident #2's roommate's bed. Resident #2 was noted to have his hands in Resident #1's pants pocket and was touching her on her hip and thigh. The residents were immediately separated. IV. Staff interviews Licensed practical nurse (LPN) #1 was interviewed on 2/3/25 at 10:40 a.m. LPN #1 said she was the nurse working on the unit with Resident #1. She said she was an agency nurse and did not know much about Resident #1. She said Resident #2 did not reside in the same unit. She said the unit did not have any residents with sexually inappropriate behaviors. CNA #2 was interviewed on 2/3/25 at 11:05 a.m. CNA #2 said Resident #1 liked to walk and she occasionally entered rooms of other residents where she would fall asleep. She said Resident #1 was not aggressive and easily redirectable. She said the staff checked on her every 15 minutes, however she was very quick and could be anywhere at any time. CNA #2 said Resident #2 no longer resided on the same unit as Resident #1. LPN #2 was interviewed on 2/3/25 at 4:30 pm. LPN #2 said she was the unit manager for the unit where Resident #1 currently resided. She said Resident #1 wandered around the unit and occasionally entered other residents' rooms. She said the staff checked on the resident every 15 minutes to ensure that she was not in someone else's room. LPN #2 said after the incident on 1/4/25, Resident #2 was moved to the second floor where he could be around more alert and oriented residents. She said in addition, Resident #2 was placed on one-to-one monitoring for sexually inappropriate behaviors. The NHA was interviewed on 2/3/25 at 4:50 p.m. The NHA said Resident #2 had a history of sexually inappropriate behaviors and was previously placed on one-to-one monitoring in the past. He said after being on one-to-one for several weeks, he did not display sexually inappropriate behaviors, his medications were adjusted and he was removed from one-to-one monitoring. The NHA said after the incident on 1/4/25, the interdisciplinary (IDT) team decided that one-to-one monitoring was necessary for Resident #2 and it was initiated for an indefinite period. He said, Resident #2 was moved to a different unit where he would be around more alert and oriented residents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, 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 one (#1) of five residents out five sample residents. Specifically, the facility failed to develop and implement effective dementia management focused interventions to prevent Resident #1 from wandering into other resident's rooms. Findings include: I. Facility policy and procedure The Dementia Care policy and procedure, undated, was provided by the nursing home administrator (NHA) on 2/4/25 at 12:33 p.m. It read in pertinent part, It is the policy of this facility to provide the appropriate treatment and services to every resident who displays signs of, or is diagnosed with dementia, to meet his or her highest practicable physical, mental, and psychosocial well-being. The facility will assess, develop, and implement care plans through an interdisciplinary team (IDT) approach that includes the resident, their family, and/or resident representative, to the extent possible. Care and services will be person-centered and reflect each resident's individual goals while maximizing the resident's dignity, autonomy, privacy, socialization, independence, choice, and safety. II. Resident #1 A. Resident status Resident #1, age [AGE], was admitted on [DATE]. According to the February 2025 computerized physicians orders (CPO), diagnoses included dementia with behavioral disturbance and major depressive disorder. The 12/2/24 minimum data set (MDS) assessment revealed the resident had severe cognitive impairments per staff interview. She required supervision and minimal assistance with activities of daily living (ADLs). She ambulated without assistance. B. Record review The behavioral care plan, initiated on 12/30/24 and revised on 1/6/25, documented Resident #1 was at risk for behavioral symptoms such as getting in other resident's beds or biting once agitated due to dementia. Interventions included maintaining a calm and slow approach, observing and document changes in behavior, providing reminders and checking on the resident every 15 minutes. A 1/4/25 nursing progress note documented Resident #1 was sleeping in Resident #2's roommate's bed. Resident #2 was noted to have his hands in her pants pocket and touching her on her hip and thigh. Resident #1 showed no fear or anxious behavior. Resident #1 appeared comfortable. The residents were immediately separated. Cross reference F600 failure to protect Resident #1 from sexual abuse. A 12/26/24 nursing note documented Resident #1 was lying down in the (other) resident bed. The resident tried to get Resident #1 out of her bed and Resident #1 bit her on her left forearm. Residents were separated. Resident #1 was placed on 15 min checks. -No person centered dementia interventions were provided to Resident #1. C. Observations On 2/3/25 at 10:30 a.m. observations on the first floor unit were conducted. Resident #1 was not in her room. The resident's room did not have any personal pictures, items or signs to help the resident identify her room. At 10:35 a.m. Resident #1 was located by certified nurse aide (CNA) #2. Resident was asleep in another resident's room. The room belonged to two gentlemen who were not in the room. Resident #1 was woken up and taken to her room by CNA #2. III. Staff interviews Licensed practical nurse (LPN) #1 was interviewed on 2/3/25 at 10:25 a.m. LPN #1 said she was an agency nurse and did not know much about Resident #1. She said she could look up the care plan in her medical record. She said she did not know what Resident #1 looked like or where she was at the moment. She said she would ask the CNAs, because they knew residents well. CNA #2 was interviewed on 2/3/25 at 10:30 a.m. She said Resident #1 was not in the common area and not in her room. She said the resident probably fell asleep in someone else's room (see observations above). CNA #2 was interviewed a second time on 2/3/25 at 11:05 a.m. She said Resident #1 liked to walk and she occasionally entered rooms of other residents where she would fall asleep. She said Resident #1 was not aggressive and easily redirectable. She said the staff checked on her every 15 minutes, however she was very quick and could be anywhere at any time. She said she was aware of one altercation that Resident #1 had with other residents that occurred on 1/4/25. LPN #2 was interviewed on 2/3/25 at 4:30 pm. LPN #2 said she was the unit manager for the unit where Resident #1 currently resided. She said Resident #1 wandered around the unit and occasionally entered other resident's rooms. She said the staff checked on the resident every 15 minutes to ensure that she was not in someone else's room. She said some rooms had a stop sign at the entrance to prevent wandering residents from wandering. The NHA was interviewed on 2/3/25 at 4:50 p.m. The NHA said Resident #1 was on 15 minute checks by staff. He said he was aware that Resident #1 was found in another resident's room earlier today (2/3/25). He said the interdisciplinary team would review the interventions to identify why they were not being effective and would consider additional one to ensure Resident #1 was sleeping in her personal room.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to ensure two (#2 and #3) of five residents out of nine sample residents were kept free from abuse. Specifically, the facility failed to ensure Resident #2 was kept free from abuse by Resident #3. Findings include: I. Facility policy and procedure The Abuse, Neglect and Exploitation policy and procedure, revised October 2024, was provided by the nursing home administrator (NHA) on 10/23/24 at 12:33 p.m. It read in pertinent part, It is the policy of this facility to provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. Abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish which can include staff to resident abuse and resident to resident altercations. The facility will make efforts to ensure all residents are protected from physical and psychosocial harm, as well as additional abuse, during and after the investigation. Examples include but are not limited to, responding immediately to protect the alleged victim and integrity of the investigation, examining the alleged victim for any sign of injury, including a physical examination or psychosocial assessment if needed, increased supervision of the alleged victim and residents, room or staffing changes, if necessary, to protect the resident(s) from the alleged perpetrator, protection from retaliation, providing emotional support and counseling to the resident during and after the investigation, as needed and revision of the resident's care plan if the resident's medical, nursing, physical, mental or psychosocial needs or preferences change as a result of an incident of abuse. II. Incident of physical abuse between Resident #2 and Resident #3 on 3/21/24 A 3/21/24 nursing progress note documented Resident #2 informed the nurse that Resident #3 pushed him on the chest and knocked him backwards, causing him to fall and hit his head on the floor. Upon a nursing assessment, a hematoma (pool of clotted blood that forms in an organ, tissue, or body space caused by a broken blood vessel) was identified on the right side of Resident #2's head. The progress note further documented Resident #3 indicated that Resident #2 came into his room and punched him in the left eye. Resident #3 made a gesturing motion to indicate that he pushed Resident #2 which caused Resident #2 to fall to the floor. Resident #3 said he went boom and then pointed to the floor. The nurse assessment revealed a small 1 centimeter (cm) by 1 cm hematoma to Resident #3's left lower eye and an abrasion to his left cheek. The 3/21/24 situation, background and review (SBAR) assessment documented a change in condition to the appearance of Resident# 3 with the noted bruise to the left lower eye and an abrasion. The interventions included frequent checks every 15 minutes, neurological checks and to separate the residents. The 3/21/24 abuse investigation documented Resident #2 said Resident #3 pushed him on his chest, knocked him down on his back and made him hit his head on the ground. Upon assessment completed by the nurse, Resident #2 was noted to have a small hematoma to the right side of the head. Resident #3 said Resident #2 entered his room and hit him in the face, for which Resident #3 responded by pushing Resident #2 in the chest, causing him to fall to the ground. Upon assessment, Resident #3 sustained a bruise and abrasion to the right eye. -The facility documented that the physical abuse was unsubstantiated because there was not a witness to the altercation, however both Resident #2 and Resident #3 had corresponding injuries that were consistent with their story. III. Resident #2 A. Resident status Resident #2, age less than 65, was admitted on [DATE]. According to the October 2024 computerized physician orders (CPO), diagnoses included dementia with other behavioral disturbance and cognitive communication deficit. The 3/21/24 minimum data set (MDS) assessment documented the resident had severe cognitive impairment with a brief interview for mental status (BIMS) score of three out of 15. He was independent with all activities of daily living (ADL). B. Record review The behavioral care plan, revised on 10/22/24 (during the survey), documented Resident #2 had a behavior problem of sexually inappropriate behaviors and touching other residents. He sometimes thought other residents were his wife. Interventions included administering medications as ordered, monitoring and documenting for side effects and effectiveness of medications, behavioral monitoring every shift, providing firm redirection and two person care, one-to-one supervision for the resident every shift, notifying the unit manager or director of nursing (DON) and the NHA if Resident #2 was seen alone without one-to-one supervision and if any inappropriate behavior occurred and providing a program of activities of interest to the resident. IV. Resident #3 A. Resident status Resident #3, age [AGE], was admitted on [DATE]. According to the October 2024 CPO, diagnoses included dementia with moderate agitation, vascular dementia without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety. The 6/11/24 MDS assessment revealed the resident was moderately cognitive impairment with a BIMS score of four out of 15. He required extensive to moderate assistance with ADLs. B. Record review The behavioral care plan, initiated on 5/31/23 and revised on 11/29/23, documented Resident #3 had episodes of being physically combative and abusive when he felt other residents were too close to him or invading his space. Resident #3 had hit or pushed others to get them away from him. Interventions included documenting behavioral episodes, maintaining a calm, slow and understanding approach, monitoring and reporting an increase in behaviors, monitoring Resident #3 when other residents were in close proximity as necessary and removing other residents if needed and notifying the physician and responsible party of episodes of aggression and abusive behavior. V. Staff interviews The NHA and the regional clinical consultant (RCC) were interviewed on 10/23/24 at 11:17 a.m. The NHA said he was the abuse coordinator for the facility and was responsible for directing the investigation for any allegation of abuse. He said physical abuse occurred when there was actual physical contact made. The NHA said he directed the physical abuse investigation between Resident #2 and Resident #3 on 3/21/24. He said he thought that the conclusion of unsubstantiated had been reached because there was no staff witness of the event. The NHA said, upon review of the investigation and the physical assessments conducted at the time of the incident, both resident's sustained injuries that were consistent with their version of the event that occurred on 3/21/24. He said based on his review of the investigation that day (10/23/24), he should have substantiated that physical abuse had occurred between Resident #2 and Resident #3 on 3/21/24.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to report alleged violations of potential abuse to the State Survey and Certification Agency in accordance with state law for two (#2 and #8) of five residents reviewed for abuse out of nine sample residents. Specifically, the facility failed to report two incident of potential sexual abuse involving Resident #2 and Resident #8 to the State Agency. Findings include: I. Facility policy and procedure The Abuse, Neglect, Exploitation or Misappropriation - Reporting and Response policy and procedure, revised October 2024, was provided by the nursing home administrator (NHA) on 10/23/24 at 12:33 p.m. It revealed in pertinent part, Reporting of all alleged violations to the administrator, state agency, adult protective services and to all other required agencies ( law enforcement when applicable) within specified times frames is required for all types of abuse, neglect, misappropriation of resident property and exploitation (including injuries of unknown origin), and thoroughly investigated by facility administrator. Findings of investigations are documented and reported. The administrator or the individual making the allegation immediately reports his or her suspicion to the following persons or agencies: the state licensing/certification agency responsible for surveying/licensing the facility. II. Resident #2 A. Resident status Resident #2, age less than 65, was admitted on [DATE]. According to the October 2024 computerized physician orders (CPO), diagnoses included dementia with other behavioral disturbance and cognitive communication deficit. The 3/21/24 minimum data set (MDS) assessment documented the resident had severe cognitive impairment with a brief interview for mental status (BIMS) score of three out of 15. He was independent with all activities of daily living (ADL). B. Record review The behavioral care plan, revised on 10/22/24 (during the survey), documented Resident #2 had a behavior problem of sexually inappropriate behaviors and touching other residents. He sometimes thought other residents were his wife. Interventions included administering medications as ordered, monitoring and documenting for side effects and effectiveness of medications, behavioral monitoring every shift, providing firm redirection and two person care, one-to-one supervision for the resident every shift, notifying the unit manager or director of nursing (DON) and the NHA if Resident #2 was seen alone without one-to-one supervision and if any inappropriate behavior occurred and providing a program of activities of interest to the resident. III. Resident #8 A. Resident status Resident #8, age less than 65, was admitted on [DATE]. According to the 9/3/24 CPO, diagnoses included bipolar disorder, dementia with psychotic disturbance, other symptoms and signs involving cognitive functions and awareness, unspecified psychosis not due to a substance or known physiological condition and unspecified convulsions The 9/18/24 MDS assessment revealed the resident had short and long-term memory deficits and her daily decision making skills were severely impaired based on the staff assessment for mental status. She was dependent on staff for all ADLs. B. Record Review The care plan, revised on 9/23/24, documented that Resident #8 had altered cognition related to dementia with psychotic disturbance, bipolar disorder and psychosis manifested by impaired short and long term memory, safety awareness and decision making. The resident had a communication deficit that indicated the inability for Resident #8 to make her needs known. IV. Incident involving Resident #8 on 9/14/24 The 9/14/24 nursing progress note documented that at approximately 5:37 p.m., Resident #2 had used his hands to hold Resident #8's hands. Resident #2 kissed Resident #8's hands and then sat down next to her for about 45 minutes. Resident #2 was later observed going into Resident #8's room to see her. -The facility was unable to provide documentation that the incident had been investigated for potential sexual abuse. Cross reference F610 for failure to investigate potential abuse. -The facility was unable to provide documentation that the incident of potential sexual abuse was reported to the State Agency. V. Incident involving Resident #8 on 9/17/24 The 9/17/24 nursing progress note documented the nurse observed Resident #2 holding and rubbing the hand of the Resident #8. The nurse tried to redirect Resident #2 a few times. Resident #2 got upset and stated she is my wife. A certified nurse aide (CNA) observed Resident #2 touching Resident #8's leg and Resident #2 refused to move away from Resident #8. Resident #2 was separated from Resident #8 and a CNA arranged the table so that Resident #2 would not be able to come near her. The nurse practitioner visited on 9/17/24 and was provided an update of the incident. -The facility was unable to provide documentation that the incident had been investigated for potential sexual abuse. -The facility was unable to provide documentation that the incident of potential sexual abuse was reported to the State Agency. VI. Staff interviews The NHA was interviewed on 10/22/24 at 2:03 p.m. The NHA said the incidents involving Resident #2 and Resident # 8 on 9/14/24 and 9/17/24 should have been reported by staff and to the State Agency. The regional clinical consultant (RCC) was interviewed on 10/23/24 at 9:35 a.m. The RCC said an additional action item had been added to the facility's recent performance improvement plan (PIP) on 10/22/24 (during the survey) following the identification of the two unreported incidents involving Resident #2 and Resident #8. The RCC said the interdisciplinary team (IDT) would be reviewing progress notes five times a week to ensure no unreported incidents of potential abuse were documented. The NHA and the RCC were interviewed together on 10/23/24 at 10:53 a.m. The RCC said, prior to the survey, the facility had realized that facility staff had an issue with the understanding of what constituted neglect, abuse or exploitation and what a thorough investigation process should look like, including interviewing and reporting. She said a PIP was initiated on 10/11/24. -However, according to the RCC's previous interview (see above), the facility had implemented a new action item to the PIP, during the survey. The NHA said there were two abuse allegations involving Resident #2 which were not reported timely. The NHA said the abuse allegations were reported to the State Agency on 10/22/24 (during the survey). The NHA said abuse should be reported/investigated and responded to within 24 hours unless serious injury occurred. He said if a serious injury occurred, potential abuse must be reported within two hours.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, the facility failed to investigate incidents of abuse involving two (#2 and #8) of five residents reviewed for abuse out of nine sample residents. Specifically, the facility failed to conduct investigations of two incidents of potential sexual abuse involving Resident #2 and Resident #8. Findings include: I. Facility policy and procedure The Abuse, Neglect and Exploitation policy and procedure, revised October 2024, was provided by the nursing home administrator (NHA) on 10/23/24 at 12:33 p.m. It revealed in pertinent part, An immediate investigation is warranted when suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur, including those that may represent resident to resident abuse, and reported to the administrator immediately. II. Resident #2 A. Resident status Resident #2, age less than 65, was admitted on [DATE]. According to the October 2024 computerized physician orders (CPO), diagnoses included dementia with other behavioral disturbance and cognitive communication deficit. The 3/21/24 minimum data set (MDS) assessment documented the resident had severe cognitive impairment with a brief interview for mental status (BIMS) score of three out of 15. He was independent with all activities of daily living (ADL). B. Record review The behavioral care plan, revised on 10/22/24 (during the survey), documented Resident #2 had a behavior problem of sexually inappropriate behaviors and touching other residents. He sometimes thought other residents were his wife. Interventions included administering medications as ordered, monitoring and documenting for side effects and effectiveness of medications, behavioral monitoring every shift, providing firm redirection and two person care, one-to-one supervision for the resident every shift, notifying the unit manager or director of nursing (DON) and the NHA if Resident #2 was seen alone without one-to-one supervision and if any inappropriate behavior occurred and providing a program of activities of interest to the resident. III. Resident #8 A. Resident status Resident #8, age less than 65, was admitted on [DATE]. According to the 9/3/24 CPO, diagnoses included bipolar disorder, dementia with psychotic disturbance, other symptoms and signs involving cognitive functions and awareness, unspecified psychosis not due to a substance or known physiological condition and unspecified convulsions. The 9/18/24 MDS assessment revealed the resident had short and long-term memory deficits and her daily decision making skills were severely impaired based on the staff assessment for mental status. She was dependent on staff for all ADLs. B. Record Review The care plan, revised on 9/23/24, documented that Resident #8 had altered cognition related to dementia with psychotic disturbance, bipolar disorder and psychosis manifested by impaired short and long term memory, safety awareness and decision making. The resident had a communication deficit that indicated the inability for Resident #8 to make her needs known. IV. Incident involving Resident #8 on 9/14/24 The 9/14/24 nurse progress note documented that at approximately 5:37 p.m. Resident #2 had used his hands to hold Resident #8's hands. Resident #2 kissed Resident #8's hands and then sat down next to her for about 45 minutes. Resident #2 was later observed going into Resident #8's room to see her. An investigation related to the incident on 9/14/24 was requested on 10/22/24, during the survey process. -The facility was unable to provide documentation that an investigation had been completed following the abuse incident with Resident #2 and Resident #8 on 9/14/24. V. Incident involving Resident #8 on 9/17/24 The 9/17/24 nurse progress note documented the nurse observed Resident #2 holding and rubbing the hand of the Resident #8. The nurse tried to redirect Resident #2 a few times. Resident #2 got upset and stated she is my wife. A certified nurse assistant (CNA) observed Resident #2 touching Resident #8's leg and Resident #2 refused to move away from Resident #8. Resident #2 was separated from Resident #8 and a CNA arranged the table so that Resident #2 would not be able to come near her. The nurse practitioner visited on 9/17/24 and was provided an update of the incident. An investigation related to the incident on 9/17/24 was requested on 10/22/24, during the survey process. -The facility was unable to provide documentation that an investigation had been completed following the incident between Resident #2 and Resident #8 on 9/17/24. VI. Staff interviews The NHA was interviewed on 10/22/24 at 2:03 p.m. The NHA said the incidents involving Resident #2 and Resident # 8 on 9/14/24 and 9/17/24 should have been investigated. The regional clinical consultant (RCC) was interviewed on 10/23/24 at 9:35 a.m. The RCC said an additional action item to the facility's recent performance improvement plan (PIP) on 10/22/24 (during the survey) following the identification of two unreported incidents involving Resident #2 and Resident #8. The RCC said the interdisciplinary team (IDT) would be reviewing progress notes five times a week to ensure no unreported incidents of potential abuse were documented. The NHA and regional clinical consultant (RCC) were interviewed on 10/23/24 at 10:53 a.m. The RCC said, prior to the survey, the facility had realized that facility staff had an issue with the understanding of what constituted neglect, abuse or exploitation, the thorough investigation process including interviewing and reporting, and a performance improvement plan was initiated on 10/11/24. -However, according to the RCC's previous interview (see above), the facility had implemented a new action item to the PIP, during the survey. The NHA said all incidents of abuse or allegations of abuse should be investigated timely and he had initiated the investigation process of the 9/14/24 and 9/17/24 incidents and reported the incidents to the State Agency as well as contacted law enforcement.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interviews, the facility failed to ensure one (#3) of three residents received treatment and care in accordance with professional standards of practice out of 15 sample residents. Specifically, the facility failed to: -Investigate, treat, and implement interventions to prevent wounds to the resident's knees; and, -Complete routine weekly skin assessments. Findings include: I. Facility policy and procedure The policies for skin management and accidents and injuries were requested from the director of nursing (DON) on 5/21/24 at 12:00 p.m. and were not received by the end of the survey (on 5/21/24). II. Resident #3 A. Resident status Resident #3, age less than 65, was admitted on [DATE] and readmitted on [DATE]. According to the May 2024 computerized physician orders (CPO), diagnoses included Huntington's disease (progressive breakdown of nerve cells in the brain leading to inability to control movement and cognitive changes), anxiety and a history of falls. The 2/14/24 minimum data set (MDS) assessment revealed the resident had moderate cognitive impairment with a brief interview for mental status (BIMS) score of nine out of 15. He was dependent on staff for personal hygiene, toileting and dressing. He required moderate to partial assistance with transferring and bed mobility. B. Observation and interview On 5/20/24 at 11:13 a.m. Resident #3 was observed with certified nurse aide (CNA) #2. Resident #3 was sitting in his recliner. CNA #2 said the resident had a history of falls and she was concerned about his knees. She said he slid out of his recliner continuously and got up to walk without assistance frequently. CNA #2 rolled up the resident's sweat pants to reveal Resident #3's knees. The resident's right knee had a redness discoloration with three round scabbed areas approximately 1 cm (centimeter) in size around the knee cap. The outer right knee had a new appearing abraded area which was red and approximately 2 cm in size. The resident's left anterior knee had three scattered, round scabbed areas approximately 1 cm in size. CNA #2 said she had seen the resident bang his legs on the dining room table. She said she did not know what the plan was to prevent the skin injuries. CNA #2 went to her computer to check the [NAME] for a plan to prevent injuries to the resident's knees. She said there was no plan to prevent the injuries. CNA #2 said the nurse was aware of the injuries. Unit manager (UM) #1 was interviewed on 5/20/24 at 11:30 a.m. UM #1 said she was aware of the injuries on Resident #3's knees. She said she was unsure how the injuries occurred. She said the resident could be impulsive with uncontrolled movements. C. Record review Resident #3's skin assessments were reviewed for May 2024. -The 5/9/24 skin assessment was incomplete and did not document whether the skin was intact or there were injuries. -There was no skin assessment for the week of 5/16/24. -The resident's progress notes and evaluations were reviewed. There was no record of the skin injuries to the resident's knees. -There was no documentation to indicate the physician, resident, or medical durable power of attorney (MDPOA) were notified of the injuries to the resident's knees. The skin care plan, initiated 8/19/20, was reviewed. The care plan documented the resident was at risk of pressure injuries and abrasions and bruising due to uncontrolled movement and poor safety awareness. Interventions included educating the resident, family and caregivers as to causes of skin breakdown including transfers, positioning requirements, importance of taking care during ambulation and mobility, good nutrition and frequent repositioning,iInforming the resident, family, caregivers of any new area of skin breakdown, providing a pressure relieving mattress, monitoring nutritional status, monitoring and documenting any changes to the skin status, Obtaining laboratory or diagnostic work as ordered and performing weekly skin checks by a licensed nurse. -However, the change in the resident's skin status was not documented, the resident, family and provider were not notified of the injuries and the weekly skin assessments were not completed as ordered. D. DON interview The DON was interviewed on 5/20/24 at 12:01 p.m. The DON said Resident #3 was impulsive and she was aware of his knee injuries. She said the resident was supposed to wear knee pads to prevent injuries to his knees but he refused the knee pads. -However, The DON said she had reviewed the resident's progress notes and there was no documentation knee pads had been offered and refused. The DON said the nurses should have completed a risk management form and notified the provider and family of the skin injuries to the resident's knees. She said she was not aware that had not been completed. The DON said she had reviewed Resident #3's orders and care plan and there were no orders and no care plan for the knee pads. The DON said there was no skin assessment done for the week of 5/16/24. She said she thought the problem was with the electronic medical record system. She said she had audited the skin assessments today (5/20/24), when it was brought to her attention, and there were four residents who had missed skin assessments. IV. Facility follow up On 5/21/24 at 11:44 a.m. the DON provided a performance improvement plan (PIP) titled Nursing Weekly Skin Summaries, dated 5/21/24 (during the survey). The PIP documented education was to be completed for all nursing staff by 5/24/24. Nursing management was to audit 5 (five) times per week for 30 days and would review in upcoming QAPI (Quality Assurance Performance improvement) meetings. After 30 days, nursing management would review weekly and continue to report findings in QAPI until substantial compliance had been met. Skin assessments would be done every week on each resident by a licensed nurse in the facility. Education would be provided to nursing staff to put any injury/scab into risk management and the content of skin assessment. Daily monitoring orders would be put in the treatment administration record (TAR) until healed. The DON and the unit managers would meet with all nursing staff to provide education regarding the weekly skin summaries and the nursing teams obligation to complete them when they were scheduled. Nursing managers were to have a list of residents and when the residents' skin assessments were due. Nursing management was to audit the skin assessments everyday before the end of their shift to ensure that they had been completed. After 30 days, an audit would be conducted weekly until compliance had been met. The facility would continue to discuss the findings in QAPI meetings. -The PIP did not address investigating the cause of skin injuries.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to incorporate recommendations from the preadmission screening and resident review (PASRR) level II determination and evaluation from the State Mental Health Agency in the case of residents with serious mental illness or a related condition for one (#63) of three residents reviewed for PASRR out of 42 sample residents. Specifically, the facility failed to arrange and incorporate recommendations from the PASRR level II notice of determination for Resident #63. Findings include: I. Resident status Resident #63, age [AGE], was admitted on [DATE]. According to the March 2024 computerized physician orders (CPO), diagnoses included cerebral infarction due to embolism of right cerebellar artery (stroke), schizophrenia, unspecified and vascular dementia. The 8/2/24 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status score of 13 out of 15 and a patient health questionnaire (PHQ-9) score of seven, indicating mild depression. II. PASRR level II notice of determination for mental illness (MI) evaluation and facility failures The PASRR level II, dated 5/12/23, revealed the resident had been evaluated for mental illness (MI) due to a qualifying diagnosis of schizophrenia disorder. Specialized services were recommended included psychiatric case consultation and behavior management/therapy. III. Record review The behavioral care plan, revised 12/11/23, revealed Resident #63 has a behavior problem related to diagnosis of dementia, schizophrenia and history of cerebral infarction. The resident can become agitated quickly when being redirected. She will yell and scream, has grabbed at nursing staff or others and has been noted to kick on doors to get out of here. The resident has made the comment, I'll just shoot myself in the head when she was not allowed to smoke at one in the morning. Interventions included minute checks as indicated, giving the resident as many choices as possible about care and activities; monitoring for and documenting observed behavior and attempted interventions; keeping other residents out of the resident's way when she is agitated; suicide evaluation completed, the resident does not have access to a gun, when the resident becomes agitated; intervene before agitation escalates; guide away from source of distress; engage calmly in conversation; if response is aggressive, staff to walk calmly away, and approach later; when redirecting, if the resident becomes agitated, give her space and allow her time to calm down, keeping her and other resident's safe, reapproach at a later time, approach in a calm manner; document behaviors and resident response to interventions. The March 2024 CPO revealed the following physician orders: -Risperdal 3 MG (milligrams)-give one tablet by mouth at bedtime for schizophrenia ordered on 8/16/23. -No orders for individual therapy or psychiatric case consultation were located. -A review of progress notes dated 7/6/23 to 3/12/24 failed to reveal any PASRR progress notes. -No social services notes were located regarding PASRR or recommendations. No PASRR progress notes showing communication with the State Mental Health Agency regarding a delay or inability to follow the recommendations were located. IV. Staff interviews The social service director (SSD) and social service assistant (SSA) were interviewed on 3/12/24 at 9:47 a.m. The SSA said admissions initiated the PASSR if a resident needed one. She said sometimes the hospital would start the PASSR but if it was not completed then admissions would initiate the PASSR. She said if the resident needed a PASSR level II then it would need to be completed within 180 days. She said once there were recommendations in place the SSD or the SSA were responsible for setting up services for the residents. The SSA could not find where the services were requested for Resident #63. The SSA said the facility physician was providing the necessary care for Resident #63. She said psych pharm evaluations were done regularly and the resident was being seen every three months. Licensed practical nurse (LPN) #5 was interviewed on 3/12/24 at 10:40 a.m. He said Resident #63 needed motivation to take her medications as she would refuse her medications often. He said the resident did not like anyone to approach her and sometimes she would get up and run away from staff. He said he approached the resident from a distance and would talk nicely. He said the resident would sometimes scream at him when he approached her. He said if the resident told him no then he would move on. He said the resident was verbally aggressive but had not been physical towards others. He said the resident would benefit from therapy services and talking to someone. Certified nurse aide (CNA) #4 was interviewed on 3/12/24 at 10:50 a.m. She said the resident could have an outburst at any time. She said the resident was easily angered and had frequent mood swings. She said the resident would scream or yell and say whatever was on her mind and then walk away. She said if the resident missed her cigarette break she would get mad. She said the resident had not been physical. She said sometimes the resident did not want to talk. She said it depended on the resident's mood if she would talk to a therapist. Nurse practitioner (NP) #1 was interviewed on 3/12/24 at 1:45 p.m. He said he came to the facility every two weeks to see residents. He said he did talk therapy and made medication changes. He said Resident #63 was not on his case load of residents to see. He said he spoke with the SSD and the SSA and they said they were going to send a referral for Resident #63. He said residents who were cognitively intact and had psychiatric trouble did well with talk therapy. He said some residents did not have family support and said behavioral support would be beneficial for residents needing it. He said he could introduce coping skills, decrease any behaviors and provide better validation. The director of nursing (DON) was interviewed on 3/12/24 at 3:32 p.m. She said a PASSR should be completed before the resident arrived at the facility. She said if the resident needed a PASSR level II completed then it would be completed once they were at the facility. She said the SSD or the SSA was responsible for making the appropriate referrals. She said the facility used behavioral health solutions or mental health partners for mental health services. She said she spoke with the SSD and the SSA today and they mentioned they were making a referral for Resident #63. The DON said the recommendations should have been implemented previously. She said it was concerning that the recommendations were not being followed from May 2023. The DON said she did not know how Resident #63 got missed and did not realize the resident was not being followed by anyone. She said the resident's primary doctor was monitoring and managing the medications for the resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** II. Resident #92 A. Resident status Resident #92, over the age of 65, was admitted on [DATE]. According to the March 2024 CPO, diagnoses included bipolar disorder, generalized anxiety disorder and glaucoma (damage to the eye, leading to loss of vision). The 12/7/23 MDS assessment revealed the resident was cognitively intact with a BIMS score of 15 out of 15. B. Resident interview Resident #92 was interviewed on 3/11/24 at 3:09 p.m. Resident #92 said she enjoyed watching movies, reading, walking outside and listening to music. She said she did not enjoy the group activities because her vision was impaired which made participating in the activities difficult and she did not get along with other residents. She said she enjoyed going to the front entrance of the building to talk with the receptionist. She said staff members from the activity department rarely assisted her there from the fourth floor where she lived. She said she felt that it was dangerous with her vision impairment and she did not feel comfortable going by herself to visit the receptionist. She said she was able to call for help when she needed it. She said there were activities she would enjoy that the staff had not provided to her such as reading to her, going outside and talking with staff. Resident #92 said she had talked to the nursing and activities staff about activities she would enjoy. She said there was a recent outing that she expressed interest to the activities staff in attending. She said she was told by the activities staff there was not enough room on the bus for her to go. She said she was very disappointed she was not able to go on the outing. C. Record review Resident 92's care plan, initiated on 11/20/2020 and revised 2/18/24, documented the resident enjoyed reading, sewing, doing puzzles, animals and spending time outside when the weather was nice. She enjoyed group activities such as bingo, trivia and the Game of Things. According to Resident #92's Interview for Daily and Activity Preferences, dated 10/5/22, it was very important for the resident to go outside to get fresh air when the weather was good. The activity logs from January 2024 and February 2024 were received by the AD on 3/12/24 at 11:30 a.m. According to the logs, resident #92 received no outside strolls in either month. D. Staff interviews LPN #1 was interviewed on 3/12/24 at 9:30 a.m. LPN #1 said Resident #92 stayed in her room most of the day but she had a resident job to post the menu daily. She said the resident had a vision impairment that required assistance to walk around outside her room and with activities. She said she enjoyed going to the first floor to talk with the receptionist, reading, listening to music and going outside. The AD was interviewed on 3/12/24 at 10:45 a.m. The AD said the activities staff offered group activities to all residents daily. She said Resident #92 had a vision impairment and enjoyed staying in her room to read and listen to music. She said group outings were limited depending on how many staff members there were to accompany the residents. III. Resident #97 A. Resident status Resident #97, over the age of 65, was admitted on [DATE]. According to the March 2024 CPO, diagnoses included acute pancreatitis (inflammation of the pancreas), dementia and seizures. The 12/16/23 MDS assessment revealed the resident had moderately impaired cognition with a BIMS score of 11 out of 15. B. Resident interview Resident #97 was interviewed on 3/6/24 at 2:54 p.m. Resident #97 said sculpting and glass blowing were his life's work and he would like to be able to work on his artwork daily. He said when he first got to the facility he brought tools with him to work on his artwork. He described the tool as something that heated up the material to sculpt with. He said the administrator took them away for safety concerns due to his seizure disorder and he had been asking for them back. Resident #97 said he was very frustrated and felt like they were treating him like a child. He said the activity staff used to offer supervision while he used his tools to heat up the sculpting material and work on his artwork but they did not come in and allow him to do that anymore. He said the only other activity he enjoyed was going outside to smoke. He said the activities staff members had never offered other tools or for him to work on the art outside of his room. C. Record review The activity logs from January 2024 and February 2024 for Resident #97 were received from the AD on 3/12/24 at 11:30 a.m. According to the logs, Resident #97 received a one on one activity for offering and providing activity materials one time in January 2024 and one time in February 2024. D. Staff interviews LPN #1 was interviewed on 3/12/24 at 9:30 a.m. LPN #1 said Resident #97 liked to go outside to smoke and stay in his room to work on artwork. She said the activity staff used to sit with him in his room while he worked on the artwork. She said she had not witnessed him working on his artwork with activity supervision in a while. She said he had a tool to use for his artwork that was taken away due to safety concerns with his seizure disorder. The AD was interviewed on 3/12/24 at 10:45 a.m. The AD said Resident #97 liked to work on sculpting and go outside to smoke. She said she kept his sculpting tool in her office and she often went into his room to set up a time to sit with him while he did his sculpting. She said he was often agreeable at first but when she went back to sit with him so he could do his artwork he often refused. She said she had not offered him a different kind of tool to meet his needs.Based on observations, record review and interviews, the facility failed to ensure meaningful activities designed to support residents physical, mental, and psychosocial well-being were provided for four (#100, #92, #97 and #70) of six residents out of 42 sample residents. Specifically, the facility failed to provide meaningful activities, including activities of personal choice, for Resident #100, Resident #92, Resident #97 and Resident #70. Findings include: I. Resident #100 A. Resident status Resident #100, age under 65, was admitted on [DATE]. According to the March 2024 computerized physician orders (CPO), diagnoses included benign neoplasm of the brain, supratentorial (brain tumors), schizoaffective disorder and mild neurocognitive disorder. The 9/6/23 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. She required dependent assistance with chair/bed to chair transferred and tub/shower transferred. She required substantial/maximal assistance with sit to standing and toilet transferring. The assessment documented it was very important to the resident to be able to listen to music, be around animals such as pets, keep up with the news, do things with groups of people, do her favorite activities, go outside to get fresh air when the weather was good and participate in religious services or practices. B. Resident interview Resident #100 was interviewed on 3/07/24 at 10:06 a.m. Resident #100 said activities at the facility had not occurred at all in December 2023 and January 2024. She said activities did hand out the chronicle for residents to read every day but that was it. Resident #100 said activities started occurring again in February 2024 activities. Resident #100 said the facility had some activities scheduled in the evenings at 6:00 p.m., however, she said the activity staff were not around to lead the evening activities because they left for the day around 3:00 p.m. or 4:00 p.m. every day. She said the only big group activity that occurred was Bingo, which was scheduled twice a week, on Mondays and Fridays. Resident #100 said the activities staff used to take the residents out to the movies. She said the new activity director (AD) changed things and the residents did not get to go out to the movies anymore. She said the residents asked to go to Sonic for half price shakes and the new activity director told the resident's that there was no money to go and get shakes. She said the activities in the facility had not gotten better since the new AD started. Resident #100 was interviewed again on 3/7/24 at 2:30 p.m. Resident #100 said the facility told residents that activities and resident council could not occur during December 2023 and January 2024 because of a COVID-19 outbreak in the facility, however, she said residents had been allowed to eat their meals in the dining room and did not have to quarantine to their rooms during the outbreak. Resident #100 said the coloring activities that were provided were for kids. She said the activities staff had residents coloring a dog, cat, sun or something else simple Resident #100 said she did not think the AD did much all day for the residents' activities during the week. She said the activities assistant (AA) who worked the weekends did an amazing job with the activities. C. Record review Resident #100's activity care plan, revised on 2/23/24, documented the resident enjoyed going outside when the weather was nice, she enjoyed socializing with others and enjoyed eating ice cream. The resident also enjoyed participating in art though she needed assistance in doing so. The resident enjoyed participating in walks in her wheelchair. The resident went to church services from time to time. She enjoyed watching a variety of shows. She enjoyed going on outings to the movies and going to group activities like bingo, socials, participating in scrabble and chair yoga. She enjoyed watching TV (television) in her room and sitting in the hallways visiting with staff and others. She was part of the resident council and part of the facility's work program. The interventions included the activities team would give the resident a monthly calendar, activities team would make sure to invite the resident to group activities of interest and respect her right to refuse. D. Staff interviews Licensed practical nurse (LPN) #3 was interviewed on 3/12/24 at 10:15 a.m. LPN #3 said the activity staff handed out the daily chronicle to the residents in the morning. She said the activity staff also handed out snacks like ice cream and coffee to the residents. She said she had never been asked to help out with the activities. Certified nurse aide (CNA) #6 was interviewed on 3/12/24 at 10:21 a.m. CNA #6 said she saw the activity staff once a day passing out snacks or drinks to the residents. She said she had seen them handing out the daily chronicle. She said activities did not spend a lot of time with the residents on the unit. She said she had never been asked to help out with activities if they needed help. She said when they did not have enough help for activities the activity was canceled. The AD and AA #1 were interviewed together on 3/12/24 at 12:44 p.m. The AD said each floor of the building had different activities. She said activities were happening seven days a week. She said activities were scheduled in the afternoon and the last activity happened around 2:45 p.m. She said staff on the unit could do the evening activities. She said CNAs helped out with the activities at least once a day. The AD said evening activities should be happening more often. She said it was a work in progress to figure out what schedule of activities worked and what did not work. She said there were no outings on the weekends because there were not enough staff to help out. She said there were only two activities staff working in activities and AA #1 would help cover the weekend activities. The AD said activities were put on hold the week before Christmas 2023 and resumed in February 2024. She said in the morning both she and AA #1 went around with a cart with snacks, puzzles, reading books and games and then in the afternoon they did the same thing. The AD said residents needed to have their own money if they were going to go out for lunch. She said the facility did not provide a free lunch out to restaurants. She said activities had offered free things for residents to do, such as going to the park and on van rides. She said activities planned outings for residents twice a month. She said activities would provide a morning ride and an afternoon ride so more residents could get out. She said the residents pick the outings. The AD said she was trying to offer more activities but was in a staffing crisis as there were only two of them for the whole facility. She said she was trying to do what she could with what she had.IV. Resident #70 A. Resident status Resident #70, age [AGE], was admitted on [DATE]. According to the March 2024 CPO, diagnoses included anxiety and depression. The 1/11/24 MDS assessment revealed the resident had severe cognitive impairment with a BIMS score of three out of 15. He was independent with all activities of daily living (ADL). B. Observation and resident interview Resident #70 was interviewed on 3/6/24 at 11:00 a.m. Resident #70 said the facility did not offer any activities. He said he enjoyed socializing when he could but he watched a lot of television because there was nothing to do. He said he liked hanging out in the hallway outside his room and talking to people or playing Bingo. On 3/11/24 at 9:30 a.m., Resident #70 was in the hallway near his room while a scheduled activity of Bingo was occurring in the communal dining area. He said he was unaware of the Bingo game and would have joined if he had known. Resident #70 walked to the communal area of the Bingo game but did not join in because he said he did not want to join in the middle of the game. C. Record review Resident #70's activity care plan, initiated on 10/12/2020 and revised on 1/24/24, revealed Resident #70 preferred independent leisure, spending time outside, smoking, going to socials, watching television and listening to music. He enjoyed reading mystery books and playing Bingo from time to time. The resident would participate in one to three structured groups of interest each week and continued being independent and structured his day with leisure activities of his choosing such as spending time outdoors, reading, socializing with peers or watching something on television. Pertinent interventions included staff inviting the resident to activities, reminding and encouraging the resident to participate in activities of interest and providing the resident with resources for independent activities. The 1/24/24 quarterly activity participation review indicated Resident #70 was participating in leisure and group activities. Resident #70 enjoyed reading, smoking, watching television, socials and playing Bingo. The March 2024 activity calendar indicated Bingo was played every Monday and Friday at 9:45 a.m. -The March 2024 activity tracking form indicated Resident #70 engaged in playing Bingo on 3/9/24. The tracking form was blank on Friday (3/1/24), Monday (3/4/24) and Monday 3/11/24. The tracking form did not indicate Resident #70 was invited and declined the activity. D. Staff interview CNA #5 was interviewed on 3/11/24 at 10:30 a.m. CNA #5 said she had not informed Resident #70 of the Bingo game scheduled that morning (3/11/24). She said she was not aware he enjoyed Bingo.

Based on observations, interviews and record review, the facility failed to store, prepare, distribute and serve food in a sanitary manner in three of five nourishment rooms. Specifically, the facility failed to: -Ensure food was labeled and dated in the nourishment rooms; and, -Ensure personal food items belonging to staff were not kept in facility nourishment refrigerators. Findings include: I. Facility policy and procedure The Refrigerators and Freezers policy, revised November 2022, was provided by the director of nursing (DON) on 3/11/24 at 1:30 p.m. It read in pertinent part, This facility will ensure safe refrigerator and freezer maintenance, temperatures, and sanitation, and will observe food expiration guidelines. Policy Interpretation and Implementation All food is appropriately dated to ensure proper rotation by expiration dates. 'Received' dates (dates of delivery) are marked on cases and on individual items removed from cases for storage. 'Use by' dates are completed with expiration dates on all prepared food in refrigerators. Expiration dates on unopened food are observed and 'use by' dates are indicated once food is opened. A. Observations and interviews During an initial building tour on 3/6/24 at 9:30 a.m., the nourishment refrigerator and freezer on the Three [NAME] unit contained the following items without labels or dates: Refrigerator: -A clear plastic bag containing six to eight peeled hard boiled eggs; -Five small red apples with visible wrinkles; and, -Several packets of ketchup, mustard and mayonnaise. Freezer: -A commercial brand burrito was labeled with the name of certified nurses aide (CNA) #2. Registered nurse (RN) #2 was interviewed on 3/6/24 at 10:00 a.m. RN #2 said it was acceptable for staff to use the resident nourishment refrigerators on the units because there was not a separate refrigerator for staff to store personal food at the facility. Licensed practical nurse (LPN) #4 was interviewed on 3/6/24 at 10:05 a.m. LPN #4 said staff were to put personal food in the staff refrigerator. She said nourishment refrigerators were used for storing resident food only and should be labeled with resident name and dated with when the food item was put in the refrigerator. LPN #3 was interviewed on 3/6/24 at 10:15 a.m. LPN #3 said facility staff had their own refrigerator and freezer in the break room of the East unit to store personal food items. On 3/12/24 at 9:00 a.m., the second floor nourishment refrigerator and freezer contained the following items: Refrigerator: -Two plates covered with clear plastic containing eggs, a meat patty and a bread item; -A bowl covered with clear plastic wrap containing oatmeal; -Two bowls covered with clear plastic wrap containing two hard boiled eggs each; and, -Two individual servings of Yoplait brand yogurt. Freezer: -One pint size ice cream container; -One gallon size ice cream container; -Two bags of Egglife egg white wraps; -One freezer popsicle (orange flavor); and, -One dish covered with a paper towel displaying an illegible word and that was dated 3/6. -Items were not dated or labeled to indicate who they belonged to or what the items were. Nurse manager (NM) #1 was interviewed on 3/12/24 at 9:00 a.m. NM #1 said the nourishment refrigerators on the units were used for storing food items belonging only to the residents and not staff. She said there was a designated staff refrigerator on the third floor in the staff breakroom. NM #1 was able to identify the egg white wraps as belonging to a resident, the two plates and one bowl covered with clear plastic, and two bowls containing hard boiled eggs as breakfast items from the morning of 3/12/24. NM #1 said she believed the ice cream and popsicle were from an activity but could not confirm that and the items were thrown in the trash along with the dish covered by a paper towel. On 3/12/24 at 9:15 a.m., the third floor nourishment refrigerator contained a bag displaying the word Lululemon. CNA #2 was interviewed on 3/12/24 at 9:15 a.m. She said the Lululemeon bag belonged to a staff member and contained food. CNA #2 said staff were allowed to use the nourishment refrigerators on the units to store personal food items. She said there was not a designated staff refrigerator. On 3/12/24 at 9:30 a.m., the fourth floor nourishment refrigerator contained the following: Refrigerator items: -Two reusable Walmart grocery bags; -One disposable plastic Safeway grocery bag; dated ?; -A box of microwave popcorn; -A plate covered with plastic wrap containing an english muffin and bacon, dated 3/11; -A small jar of hot sauce which had been opened but was undated; -A plastic bottle of french vanilla coffee creamer; -A pink transparent, reusable Blender Bottle; and,six -Six individual serving size Yoplait yogurts. Freezer items: -Two squeezable fruit pouches; -A small plastic container with a blue lid; and, -A frozen pizza. -Not all of the items were dated or labeled to indicate who they belonged to or what the items were. CNA #3 was interviewed on 3/12/24 at 9:30 a.m. CNA #3 said she believed the two Walmart bags belonged to staff members. She said the nourishment refrigerator was to be used for resident items only and staff had a designated refrigerator in the breakroom. She said she would attempt to find the owners of the items and if unsuccessful the items should be thrown out. D. DON Interview The DON was interviewed on 3/13/24 at 3:00 p.m. The DON said staff had their own refrigerator located in the break room for personal food items. She said staff should not use the nourishment refrigerators or freezers on any floor for storing personal food items. The DON said facility staff would be re-educated on the location of the staff refrigerator and that personal items were not to be stored in the nourishment refrigerators. She said employees would also be re-educated on the importance of labeling and dating all food items placed in nourishment refrigerators and freezers.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to ensure two (#99 and #11) of five out of 44 sample residents had the right to formulate an advanced directive. Specifically, the facility failed to ensure Resident #99 and Resident #11's advanced directives matched the physician's orders. Findings include: I. Facility policy and procedure The Advanced directives policy and procedure, reviewed [DATE], was provided by the nursing home administrator (NHA) on [DATE] at 4:44 p.m. It documented, in pertinent part, The Community shall ask residents whether they have executed any advance directives. This includes health care powers of attorney, living wills, or other documents which describe the amount, level or type of health care each Resident would want to receive when he/she can no longer communicate those decisions directly to a doctor or other health care professional. It also includes documents to which a Resident names another person who has the legal authority to make healthcare decisions for him/her. If the Resident has executed any advance directive documents, or if he/she executes any such documents while living in the Community, a copy will be requested and placed in the Resident's record. The advance directive and CPR (cardiopulmonary resuscitation) decisions will be reviewed at least annually, but also when a change of condition occurs or when requested by the Resident. This is required so that the Community can assist the Resident in ensuring that his/her health care choices are properly communicated to health care professionals. II. Resident #99 A. Resident status Resident #99, age [AGE], was admitted on [DATE] and was readmitted on [DATE]. According to the [DATE] computerized physician orders (CPO), the resident's diagnoses included unspecified dementia with behavioral disturbances, Wernicke's encephalopathy (degenerative brain disorder), and blindness in the left eye. According to the [DATE] minimum data set (MDS) assessment, the resident was unable to complete the brief interview for mental status(BIMS); however, it showed that he had short-term and long-term memory impairment with severe impairment in making decisions regarding tasks of daily life. He required extensive assistance of one person with bed mobility, transfers, dressing, toileting and walking and set up for personal hygiene and bathing. B. Record review The medical order for scope of treatment (MOST) form dated [DATE] showed that Resident #99 did not want to receive CPR and did not want resuscitation attempted. According to [DATE] computerized physician orders (CPO), the resident was coded as full code, and CPR. III. Resident #11 A. Resident status Resident #11, age [AGE], was admitted on [DATE]. According to the [DATE] computerized physician orders (CPO), the resident's diagnoses included unspecified dementia with behavioral disturbances, traumatic brain injury, anxiety and depressive episodes. According to the [DATE] minimum data set (MDS) assessment the resident had severe impairment with a brief interview for a mental status score (BIMS) of seven out of 15. He required one-person assistance with set up only with bed mobility, transfers, dressing, toileting, personal hygiene and bathing. B. Record review The MOST form dated [DATE] showed that Resident #11 did not want to receive CPR and did not want resuscitation attempted. According to [DATE] computerized physician orders (CPO), the resident was coded as full code, and CPR. IV. Staff interviews Licensed practical nurse (LPN) #5 was interviewed on [DATE] at 2:32 p.m. He confirmed that Resident #99's and #11's MOST forms documented DNR and the CPO orders said full code and CPR. He said in the event of cardiac arrest, the nurses reviewed the resident's electronic medical record in order to determine the resident's resuscitation order or the MOST form if they did not have the computer open at the time. The regional clinical resource (RCR) was interviewed in the presence of the NHA on [DATE] at 3:00 p.m. The RCR confirmed that Resident #99's and Resident #11's CPO orders did not match the MOST form. The RCR said that the MOST form should match the electronic medical record. The RCR said staff would complete a building audit of the MOST forms for all residents to make sure they have accurate information. -After being brought to the facility's attention, Resident #99 and Resident #11's orders remained the same on [DATE].

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to ensure one (#89) out of five residents reviewed for grievances out of 44 sample residents were provided prompt efforts by the facility to resolve grievances. Specifically, the facility failed to provide a resolution to Resident #89's grievances, for which was communicated to staff on multiple occasions. Findings include: I. Facility policy and procedure The Grievance policy, revised 10/10/19, was provided by the regional clinical resource (RCR) on 12/1/22 at 3:14 p.m. It revealed, in pertinent part, Purpose: to provide residents and responsible party 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. The Grievance and Complaint Investigation Report must be filed with the administrator within five (5) working days of the receipt of the grievance or complaint form. II. Resident #89 status Resident #89, under the age of 65, was admitted on [DATE]. According to the December 2022 computerized physician orders (CPO), the diagnoses included injury at C5 level of cervical spinal cord (spinal cord injury), quadriplegia (paralysis of all four limbs) and needs for assistance with personal care. The 10/18/22 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) with a score of 15 out of 15. He required extensive assistance of two people for bed mobility and extensive assistance of one person for eating. He required total dependence of two people for transfers, dressing and toileting. He required total dependence of one person for personal hygiene. III. Resident interview Resident #89 was interviewed on 11/28/22 at 11:19 p.m. He said he preferred to have showers. He said the occupational therapist who no longer worked at the facility ordered him a shower chair that did not work for him. He said the shower chair was ordered when he was admitted to the facility five months ago. He said the shower chair was too big. He said the facility had not addressed his concern regarding receiving showers over bed baths. Resident #89 said he had a catheter for many years. He said the facility ordered locks that attached the catheter bag to his leg. He said he did not like the locks that were ordered, because they often broke which caused yanking on the catheter tubing. Resident #89 said he had notified the nursing staff on multiple occasions that he would prefer to have a different catheter lock. He said he had not received a resolution to his concern. Resident #89 said his urologist had ordered him to take a cranberry pill as he was contracting urinary tract infections frequently (UTIs). He said the urologist wanted him to take a name brand cranberry pill. Resident #89 said he had notified the nursing staff that the urologist ordered him to take the name brand cranberry pill. He said the facility had not addressed his concern and had not been providing him the name brand cranberry capsule. IV. Record review A request was made for the documentation of Resident #89's grievances regarding his showers, catheter locks and the cranberry pills on 12/1/22. The RCR said the facility did not have documentation regarding Resident #89's grievances. The 7/20/22 occupational therapy progress note documented the resident was in need of a shower chair that provided adequate trunk support for bathing. The note documented the occupational therapist determined a tilt in space (reclining) shower chair was needed for the resident. The progress note documented the nursing home administrator (NHA) approved for the shower chair to be purchased. The 7/29/22 occupational therapy progress note documented occupational therapy discharged the resident from the caseload and the shower chair was on order. A request was made for the documentation for the education provided to Resident #89 that therapy had recommended the specialized shower chair for his safety on 11/30/22. The RCR said the facility did not have documentation regarding the education. V. Staff interviews Licensed practical nurse (LPN) #2 was interviewed on 11/30/22 at 10:35 a.m. He said Resident #89 preferred to take showers. He said Resident #89 did not like the shower chair that was ordered by the therapy department. LPN #2 said Resident #89 had mentioned he did not like the catheter locks the facility was providing or the generic cranberry capsule. LPN #2 said he attempted to resolve the residents' concerns on his own. LPN #2 said he had not filled out a grievance form regarding Resident #89's concerns. He said filling out a grievance form would have been beneficial to show how the facility had attempted to resolve the resident's concerns. The restorative aide (RA), physical therapist (PT) and the occupational therapist (OT) were interviewed on 11/30/22 at 3:19 p.m. The OT said she had just started working at the facility recently and was not involved in the residents shower chair determination. She said she had not provided the resident education on trunk safety when using the specialized shower chair. The PT said she had also recently started working at the facility. She said she was not aware of the therapy department trialing the shower chair with Resident #89. The RA said when the shower chair arrived at the facility the resident refused to use it. He said Resident #89 did not like the shower chair because it was pink. The RA said Resident #89 was embarrassed to use the shower chair because it was too big and fancy. The unit manager (UM) was interviewed on 12/1/22 at 10:19 a.m. He said Resident #89 wanted a specific shower chair that the facility did not have. He said the facility had ordered a shower chair for Resident #89 when he first admitted to the facility. He said Resident #89 did not like the shower chair that was ordered for him, because it was pink. The UM said he was not aware Resident #89 did not like the catheter locks that the facility was providing. He said he would provide a list of other locks that could be ordered to the resident. The UM said he was not aware Resident #89 had requested to have the name brand cranberry capsules. He said the facility carried a generic cranberry capsule. He said he would notify the resident he was able to purchase his own cranberry capsules and keep them in the medication cart with his name on them. The UM said residents or staff members could fill out grievance forms. The social services assistant (SSA) #1 was interviewed on 11/30/22 at 3:03 p.m. She said when Resident #89 admitted to the facility, the director of rehabilitation who no longer worked at the facility, ordered the resident a shower chair. The SSA said when the shower chair arrived to the facility Resident #89 refused to use the shower chair, because he said it was too big. The SSA said a grievance had not been filled out regarding Resident #89's concern with the shower chair. The SSA said anyone could fill out a grievance form. She said if a resident needed help filling out the form a staff member could assist them. She said the grievance form was then given to her. The SSA said she then gave the grievance form to the director of the department the grievance involved. She said the department director was then responsible for following up with the resident and resolving the resident's concern. She said the resident then signed off on the grievance form to acknowledge their agreement with the resolution. The SSA said the grievance form was then given to the NHA for approval. She said she was responsible for logging the grievance in a binder when they were completed. The director of rehabilitation (DOR) and the RCR were interviewed on 12/1/22 at 11:28 a.m. The DOR said she had recently started working at the facility and was not involved in ordering the shower chair for Resident #89. She said occupational therapy had recently started working with Resident #89 again in the last week. The DOR said the OT was working with the resident on becoming independent with eating. The DOR said Resident #89 wanted a basic shower chair, but she did not feel Resident #89 would be safe in one with his trunk control. The RCR said the facility had not filled out a grievance form to help address the resident's concerns regarding the shower chair. He said he would fill one out and speak to the resident to address his concerns. Certified nurse aide (CNA) #4 was interviewed on 12/1/22 at 1:26 p.m. She said if a resident voiced a concern she did not fill out a grievance form. She said she notified the licensed nurses of any concerns voiced by the residents. The director of nursing (DON), NHA and RCR were interviewed on 12/1/22 at 2:46 p.m. The DON said residents were able to fill out grievance forms for any concerns they had. She said staff could help residents fill out the forms if they needed. The DON said the grievance form was then distributed to the correct department director for follow-up. She said the department director was responsible for resolving the grievance with the resident and obtaining a signature of approval from the resident. The NHA said he signed off on the grievance to ensure the correct steps were taken. The DON said the social services department logged the grievance forms in a binder. The DON said she was not aware Resident #89 had concerns regarding the cranberry capsules and his catheter lock. She said she would fill out a grievance form and address the resident's concern immediately. The DON said grievance forms should have been filled out for Resident #89's concerns.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to have a completed discharge summary that included a recapitulation of the stay for one (#144) of three residents reviewed for discharge out of 44 sample residents. Specifically, the facility failed to ensure the facility accepting Resident #144 for admission received a discharge summary to include all required components; including: -An accurate and current description of the clinical status of the resident and sufficiently detailed, individualized care instructions, to ensure that care was coordinated and the resident transitioned safely from one setting to another; -Detailed and accurate information to reduce or eliminate confusion among the various facilities, agencies, practitioners, and caregivers involved with the resident's care; and, -Recapitulation of the resident's stay describes the resident's course of treatment while residing in the facility. The recapitulation (summary) includes, but is not limited to, diagnoses, course of illness, treatment, and/or therapy, and pertinent lab, radiology, and consultation results, including any pending lab results. An accurate final summary of the resident's status which includes the items from the resident's most recent comprehensive assessment identified and additional summary of the resident's status regarding: customary routine; cognitive patterns; communication; vision; mood and Behavior patterns; psychosocial well-being; physical functioning and structural problems; continence; disease diagnoses and health conditions; dental and nutritional status, skin condition; activity pursuit; medications; documentation of participation in assessment; other pertinent information and additional assessments. I. Facility policy The Discharge Summary and Plan policy and procedure, revised December 2016, provided by the regional clinical director (RCD) 12/1/22 at 3:21 p.m. It read in pertinent part, When the facility anticipates a resident ' s discharge to a private resident, another nursing care facility, a discharge summary and a post-discharge plan will be developed which will assist the resident to adjust to his or her new living environment. The discharge summary will include a recapitulation of the resident ' s stay at this facility and a final summary of the resident information and as permitted by the resident. Every resident will be evaluated for his or her discharge needs and will have an individualized post-discharge plan. The post-discharge plan will be developed by the care planning interdisciplinary team with the assistance of the resident and his or her family. A copy of the following will be provided to the resident and receiving facility and a copy will be filed in the resident ' s medical record: an evaluation of the resident ' s discharge needs; the post-discharge plan; and the discharge summary. II. Resident #144 A. Resident status Resident #144, age [AGE], was admitted on [DATE] and discharged on 10/5/22. According to the October 2022 computerized physician orders (CPO), diagnoses included alcohol use, diabetes mellitus with diabetic neuropathy (nerve damage), and anemia (lacking healthy red blood cells to carry adequate oxygen to body ' s tissues). The 10/5/22 discharge (return not anticipated) minimum data set (MDS) assessment revealed the brief interview for mental status was not conducted and the staff assessment for mental status revealed the resident had memory problems, made decisions regarding tasks of daily life with modified independence. Inattention and disorganized thinking, and altered level of consciousness were not present. There was no acute onset of mental status change. Physical behavioral symptoms directed toward others were present one to three days. No rejection of care or wandering exhibited. He was independent with all activities of daily living. B. Record review Review of all the progress notes revealed no basis for the transfer, or the specific resident needs that could not be met, the facility attempted to meet the resident needs, and the services available at the receiving facility to meet the needs. The 10/5/22 administration note read, Resident was transferred to another facility. The 10/5/22 nursing note read the resident was transferred to another facility that morning at 10:30 a.m., willing using a wheelchair to walk. He was taken by driver with facility van. Resident took all his belongings with him and his medication was packed with all his paperwork. At 11:43 a.m. the nurse called the other facility to give a report on the resident. -There was no documentation by the resident ' s physician regarding the necessity of the transfer or discharge, and no discharge orders. -Review of the resident ' s electronic medical record including the assessment/evaluation section, social services notes, and miscellaneous section revealed there was no documentation of the information provided to the receiving provider such as contact information of the practitioner responsible for the care of the resident; resident representative information including contact information; advanced directives information; all special instructions or precautions for ongoing care as appropriate; comprehensive care plan goals; and all other necessary information, including a copy of the resident ' s discharge summary and any other documentation to ensure a safe and effective transition of care. -The care plan revealed there was no resident centered discharge or long term care plan to describe the resident's goals at the facility. III. Interviews The director of nursing (DON) was interviewed on 12/1/22 at 12:16 p.m. She said Resident #144 had been there for long term care. The DON viewed Resident #144 ' s care plan but said she was unable to locate any goals related to the residents goals at the facility or discharge plans. The DON looked in the resident ' s EMR and said she was unable to locate a discharge summary, there were no physician discharge orders, there were no social services notes concerning Resident #144 ' s discharge. The DON acknowledged the discharge paperwork was not in the resident ' s EMR. The DON said the discharge procedure was to get physician orders, and complete a discharge evaluation, with an interdisciplinary team (IDT) evaluation. The DON said the evaluation should have all the information about the resident so the receiving facility would have the necessary information regarding the new resident. The DON said the nurse should put in a note and the facility should have evidence of the information packet that was sent to the new facility, but the facility did not. -At 2:42 p.m. the DON said she checked further and was unable to locate any further discharge information regarding Resident #144. The DON said the RCR had called the facility that Resident #144 had been discharged and they were unable to locate the discharge paperwork either.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interviews, the facility failed to ensure activities designed to support residents physical, mental, and psychosocial well-being were provided for one (#89) out of six reviewed for activities of 44 sample residents. Specifically, the facility failed to ensure activities that met Resident #89's interests were offered. Findings include: I. Facility policy and procedure The Activity Schedule policy, revised 11/7/22, was provided by the regional clinical resource (RCR) on 12/1/22 at 3:14 p.m. It revealed, in pertinent part, (Facility name) understands the value and importance of structured and unstructured activities within the community. The importance of activities touches not only the participants' lives, but the lives of the family members, care partners and organization as a whole. Activities provides meaning, purpose and independence, all of which are necessary to maintain a positive quality of life. (Facility name) understands that all activities can be therapeutic, regardless of what population is being served. The community will provide daily activities that not only meet the requirements of state and federal guidelines, but also the interests, preferences, hobbies and the culture of the participants and community. Daily activities include community sponsored group and individualized activities, in addition to assistance with independent daily activities. Activities will create opportunities for each participant to have a meaningful life by supporting their domains of wellness. Activities will be designed to meet the participants' best ability to function, incorporating their strengths and abilities. II. Resident #89 status Resident #89, under the age of 65, was admitted on [DATE]. According to the December 2022 computerized physician orders (CPO), the diagnoses included injury at C5 level of cervical spinal cord (spinal cord injury), quadriplegia (paralysis of all four limbs) and needs for assistance with personal care. The 10/18/22 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) with a score of 15 out of 15. He required extensive assistance of two people for bed mobility and extensive assistance of one person for eating. He required total dependence of two people for transfers, dressing and toileting. He required total dependence of one person for personal hygiene. The 7/13/22 MDS assessment documented it was very important to the resident to choose what clothes he wore, to take care of his personal belongings, to choose the type of shower he received, to have snacks available during meal times, to choose his bedtime and to use his phone in private. III. Resident interview Resident #89 was interviewed on 11/28/22 at 11:07 a.m. He said he did not enjoy going to group activities. He said he was often in his room bored. He said he wanted to be on a one-on-one program, as he wanted help making beaded jewelry. He said he was tired of watching movies and playing on his phone all day. IV. Observations During a continuous observation on 11/29/22 beginning at 11:01 a.m. and ended at 2:00 p.m. Resident #89 was in his room. Resident #89 was not offered one-on-one activities during this time. V. Record review The activities care plan initiated on 7/13/22 documented Resident #89 used to enjoy biking, kayaking and other outdoor activities. Resident #89 enjoyed spending time with his dog. Resident #89 also enjoyed listening to metal music and was interested in making beaded necklaces. The interventions included: offering Resident #89 the activities calendar monthly and providing Resident #89 with supplies to complete activities of his interest. The 7/13/22 activities initial review assessment documented the resident enjoyed listening to music and was interested in beaded necklaces. The assessment documented the resident wished to participate in group activities and wanted to go on outings. It also documented the resident did not want one-on-one attention from staff. A review of Resident #89s activity log in his medical record on 12/1/22 at 2:15 p.m., revealed the resident had refused one-on-one activities from 11/15/22 through 12/1/22. (see staff interviews below). A request was made for the documentation of when Resident #89 participated in activities or received one-on-one activities. The facility did not have any documentation to show the residents participation or refusals of activities. Activities assistant (AA) #1 said they did not have documentation, since Resident #89 did not participate in group activities and he was not on a one-on-one activities program. VI. Staff interviews AA #1 was interviewed on 11/30/22 at 3:44 p.m. She said Resident #89 did not enjoy coming to group activities. She said he preferred one-on-one activities in his room. She said he enjoyed making beaded necklaces. AA #1 said there was not enough staff in the activities department to provide one-on-one activities for Resident #89. She said Resident #89 needed to be placed on the therapeutic one-on-one program to provide entertainment and stimulation to the resident. AA #1 said Resident #89 would be the perfect candidate to be on the one-on-one program. She said there was only one other activities assistant and she had not been trained on the therapeutic one-on-one program yet. AA #1 said she would try to get Resident #89 on the one-on-one program by January 2023. AA #1 said Resident #89 did not like to come out of his room because the hallways were too cold for his preference. Cross references: F584 failure to maintain comfortable temperatures for the residents. Certified nurse aide (CNA) #3 was interviewed on 12/1/22 at 2:00 p.m. She said Resident #89 stayed in his room all day. She said Resident #89 often watched movies or played on his phone throughout the day. She said she had never observed the activities department visiting with the resident. AA #1, AA #2 and driver #1 were interviewed on 12/1/22 at 2:00 p.m. AA #2 said she documented under the one-on-one activities point of care task in the resident's medical record as refused when he did not accept the daily chronicle. She said Resident #89 refused the daily chronicle almost every day. AA #2 said she had not been trained on the one-on-one program, so she had not conducted any one-on-one activities with Resident #89. AA #2 said Resident #89 did not like group activities and wanted help making beaded necklaces as an activity. Driver #1 said he documented in Resident #89's medical record under one-on-one activities program when he took the resident to appointments. He said he did not visit the resident in his room. The nursing home administrator (NHA), director of nursing (DON) and regional clinical resource (RCR) were interviewed on 12/1/22 at 2:46 p.m. The DON said Resident #89 preferred to stay in his room during the day.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interviews, the facility failed to maintain a comfortable environment for residents on three of five units. Specifically, the facility failed to ensure comfortable room temperature levels for Unit #1, Unit #2 and Unit #4. Findings include: I. Facility policy and procedure The Homelike Environment policy, revised February 2021, was provided by the regional clinical resource (RCR) on 12/1/22 at 3:14 p.m. It revealed, in pertinent part, The facility and management maximizes, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include: comfortable and safe temperatures 71°F (farenheit)-81°F. II. Resident interview Resident #89 who was identified as interviewable by facility assessment was interviewed on 11/28/22 at 11:14 a.m. He said he was often very cold in his room. He said he had notified the maintenance department, but the issue had not been resolved. Resident #89 said he did not like to leave his room because the hallways were very cold. During the interview, Resident #89 was covered in two blankets. III. Observations During a continuous observation on 11/29/22 beginning at 11:01 a.m. and ended at 12:29 p.m. the following was observed: -At 11:36 a.m. the resident in room [ROOM NUMBER] said to an unidentified staff member that she was uncomfortable, because her room was cold. On 11/30/22 at 9:37 a.m. a tour of the building was completed with the maintenance associate (MA). The following was observed throughout the facility. A. The first unit -The hallway near room [ROOM NUMBER] registered at 61.9°F. -Inside room [ROOM NUMBER] registered at 70.2°F. -Above the double doors that lead to the outside smoking area was a two inch gap. B. The second unit -The hallway near room [ROOM NUMBER] registered at 57°F. -Inside room [ROOM NUMBER] registered at 64.2°F. -Inside room [ROOM NUMBER] registered at 70.7°F. C. The fourth unit -The hallway near room [ROOM NUMBER] registered at 70.7°F. -Inside room [ROOM NUMBER] registered at 63°F. IV. Staff interviews The MA was interviewed on 11/29/22 at 11:01 a.m. during the tour of the facility. He said the gap over the doors on the first unit likely led to the cool temperatures on the unit. He said he was going to fill the gap to help regulate the temperature of the unit. The MA said he noticed staff on the second floor unit often left the door to the outside smoking area open, which likely caused the unit to be cold. He said the staff needed to be educated on keeping the doors closed when the temperature outside was low to help regulate the temperature of the building. The MA said the building should be between 75°F and 80°F. The MA was interviewed again on 11/30/22 at 4:31 p.m. he said he was aware the temperatures of the building were sometimes low. He said he had not checked the temperature of the building prior to the tour of the facility on 11/29/22. The MA said he was aware a couple of residents had voiced concerns regarding the temperature of the building. The MA said he had suggested to move Resident #89 to a different room that might have been warmer than the room he was in. The MA said he had contacted an outside company to check the heating system in the last few weeks, but they did not show up to the appointment. The RCR, director of nursing (DON) and the nursing home administrator (NHA) were interviewed on 12/1/22 at 2:53 p.m. The NHA said the temperature of the building should be comfortable for the residents. THe DON said the interdisciplinary team had discussed moving Resident #89 to a different room that may be warmer, but it had not been completed yet.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, observations and record review, the facility failed to ensure three (#99, #11 and #77) of seven residents reviewed for activities of daily living of 44 sample residents were provided the necessary care and services to maintain or improve their level of functioning. Specifically, the facility failed to: -Ensure that Resident #99 and Resident #11 received regular showers; and, -Ensure that Resident #99 and Resident #77 received nail care. Findings include: I. Facility policy and procedure The Activity of Daily Living policy and procedure, revised March 2018, was provided by the nursing home administrator (NHA) on 12/01/22 at 4:44 p.m. It documented, in pertinent part, Residents will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs). Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene. 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: a. hygiene (bathing, dressing, grooming, and oral care); b. mobility (transfer and ambulation, including walking); c. elimination (toileting); d. dining (meals and snacks); and e. communication (speech, language, and any functional communication systems). If residents with cognitive impairment or dementia resist care, staff will attempt to identify the underlying cause of the problem and not just assume the resident is refusing or declining care. Approaching the resident in a different way or at a different time, or having another staff member speak with the resident may be appropriate. Interventions to improve or minimize a resident's functional abilities will be in accordance with the resident's assessed needs, preferences, stated goals and recognized standards of practice. The resident's response to interventions will be monitored, evaluated and revised as appropriate. II. Resident #99 A. Resident status Resident #99, age [AGE], was admitted on [DATE] and readmitted on [DATE]. According to the November 2022 computerized physician orders (CPO), the diagnoses included unspecified dementia with behavioral disturbances, Wernicke's encephalopathy (degenerative brain disorder) and blindness in the left eye. According to the 9/21/22 minimum data set (MDS) assessment, the resident was unable to complete the brief interview for mental status (BIMS); however it showed that he had short-term and long-term memory impairment with severe impairment in making decisions regarding tasks of daily life. He required extensive assistance of one person with bed mobility, transfers, dressing, toileting and walking and set up for personal hygiene and bathing. He did not reject care. B. Observations On 11/28/22 at 2:20 p.m. Resident #99 hair was tangled and appeared greasy. His fingernails were long and jagged and had brown matter under them. On 11/29/22 at 1:09 p.m. the resident had the same appearance to his hair and nails. On 11/30/22 at 9:00 a.m. the resident had the same appearance to his hair and nails. On 12/1/22 at 11:03 a.m. CNA #3 confirmed that his hair was tangled and greasy and that his nails were long and had brown matter under his fingernails. C. Record review The activities of daily living (ADL) care plan, revised 10/12/22, documented the resident had a self-care deficit related to previous history of homelessness. It indicated that the resident may refuse showers if he needs encouragement and set up and limited assistance when he agrees to bathe. On bath day nails should be checked, cleaned and trimmed and as needed. Any changes should be reported to the nurse. Shower documentation for the month of November 2022 showed one refusal and zero indications of a shower received. The resident requested to have two showers a week. D. Staff interviews CNA #3 was interviewed on 12/1/22 at 11:05 a.m. She said the nurses performed resident nail care. She said that Resident #99 gets showered in the evenings. She said that staff documents all refusals and showers given in the resident's electronic medical record. Licensed practical nurse (LPN) #3 was interviewed on 12/1/22 at 10:45 a.m. She said the activities department did resident nails or the CNAs. She said Resident #99 needed coaching and cueing but he would participate in ADLs with staff persistence. The director of nursing (DON) was interviewed on 12/1/22 at 2:47 p.m. She said CNAs should perform resident nail care including trimming and cleaning, unless the resident was diabetic. She said showers should be performed twice a week unless the resident asked to shower more and it would be documented in the resident's record. She said Resident #99 was not diabetic and CNAs should perform nail care and set up showers and document refusals and showers in the resident's electronic medical record. III. Resident #11 A. Resident status Resident #11, age [AGE], was admitted on [DATE]. According to the November 2022 CPO, the diagnoses included unspecified dementia with behavioral disturbances, traumatic brain injury, anxiety and depressive episodes. According to the 9/22/22 minimum data set (MDS) assessment revealed the resident had severe impairment with a brief interview for a mental status score of seven out of 15. He required one-person assistance with set up only with bed mobility, transfers, dressing, toileting, personal hygiene and bathing. B. Observations On 11/28/22 at 12:29 a.m. Resident #11 was unkempt, he had greasy hair, he had crumbs on his face and clothing had stains on them and had a distinct smell. On 11/30/22 a.m. Resident #11 appeared the same and in the same clothes. On 12/1/22 a.m. he was to be wearing the same clothes. His hair was greasy and his face had dark brown matter on it. C. Record review The activities of daily living (ADL) care plan, revised on 8/8/22, documented the resident had a self-care deficit related to dementia, brain damage, and seizure disorder. It indicated that the resident may refuse showers; he may need encouragement and set up and limited assistance when he agrees to bathe. Shower documentation for the month of November 2022 showed a refusal on 11/19/22 and 11/26/22. The resident requested two showers a week. -There was no other documentation showing when showers were performed or if resident was re-approached. D. Staff interviews CNA #3 was interviewed on 12/1/22 at 11:05 a.m. She said Resident #11 gets showered in the evenings. She said the staff documents all refusals and showers given in the resident's electronic medical record. Licensed practical nurse (LPN) #3 was interviewed on 12/1/22 at 10:45 a.m. She said that Resident #11 was easy to redirect and almost always participates in ADLs. She said CNAs were responsible for giving showers and documenting refusals and showers that were given in the resident's electronic medical record. The director of nursing (DON) was interviewed on 12/1/22 at 2:47 p.m. She said showers should be performed twice a week unless the resident asked to shower more and was documented in the resident's electronic medical record. She said CNAs should follow the care plan when assisting with showers. IV. Resident #77 A. Resident status Resident #77, age [AGE], was admitted on [DATE]. According to the December 2022 computerized physician orders (CPO), the diagnoses included alcohol use with alcohol-induced persisting dementia, post-traumatic stress disorder, anxiety, cognitive communication deficit, depression and acquired absence of the right upper limb above the elbow (right arm amputation). The 9/9/22 MDS assessment revealed the resident had severe cognitive impairment with a BIMS with a score of five out of 15. He was independent with all ADLs. B. Observations and resident interview On 11/28/22 at 2:58 p.m. Resident #77 was sitting on his bed in his room. His fingernails were a half inch extended past the tip of his finger. There was black debris built-up under his five fingernails on his left hand. On 12/1/22 at 10:02 a.m. certified nurse aire (CNA) #8 confirmed Resident #77 had long fingernails that needed to be trimmed and cleaned. CNA #8 asked Resident #77 if he would like his fingernails trimmed and cleaned. Resident #77 responded yes. CNA #8 said she would notify the nurse to help Resident #77 clean and trim his fingernails. C. Record review The ADL care plan, initiated on 10/2/2020 and revised on 9/19/22, documented Resident #77 had the potential for self-care performance deficit related to alcohol induced dementia, post-traumatic stress disorder, anxiety, depression, macular degeneration to the right eye (vision impairment) and a right arm amputation. The interventions included, in pertinent part: resident #77 was able to complete his grooming and hygiene independently, but needed reminders and cueing. A review of Resident #77's nail care log in his medical record on 11/30/22 at 4:00 p.m., revealed the resident had not received nail care in the last 30 days. D. Staff interviews CNA #8 was interviewed on 12/1/22 at 10:02 a.m. She said the nurses were responsible for cutting the resident's fingernails. CNA #8 said when assisting residents with their showers she would help clean their fingernails. Licensed practical nurse (LPN) #6 was interviewed on 12/1/22 at 10:08 a.m. She said the CNAs were responsible for cutting the resident's fingernails. She said Resident #77 should have received help trimming and cleaning his fingernails. The director of nursing (DON), regional clinical resource (RCR) and nursing home administrator (NHA) were interviewed on 12/1/22 at 2:53 p.m. The DON said CNAs were responsible for trimming the resident's fingernails. The DON said Resident #77 was unable to trim his fingernails independently as he was missing his right arm. The DON said his nails should be kept trimmed and cleaned.

Based on interviews, observations and record review, the facility failed to consistently serve food that was palatable, attractive at the appropriate temperatures and meet the nutritional needs of the residents. Specifically, the facility failed to: -Ensure the resident food was palatable in taste, texture and appearance; and, -Ensure the resident food met the nutritional needs of the residents. Findings include: I. Resident food was palatable A. Observations A test tray for a pureed diet was evaluated immediately after the last resident had been served their room tray for lunch on 11/30/22 at 1:00 p.m.by four surveyors. The test tray consisted of pureed green beans and a pureed hamburger. -The green beans were salty and runny. It did not taste like green beans. -The meat in the hamburger was gritty and bitter. It did not taste like beef. -The bread was bitter. The bread was thick like a dough. B. Record review The second floor resident council meeting minutes from 7/19/22 documented a resident said the meatballs were bad, soggy and tasted poorly. The minutes documented a resident requested more chocolate desserts and coffee. The third floor resident council meeting minutes from 7/19/22 documented the residents reported the meat was tasteless and tough. They also said the waffles were soggy, the grilled cheese was burnt. The residents said the food was not cooked enough and they wanted a food council meeting. The fourth floor resident council meeting minutes from 7/19/22 documented the residents said the food was bad and the food was over salted. The food council minutes from 8/9/22 documented the residents who attended said the scrambled eggs were too tough the past few days, the vegetables were overcooked and they were not always receiving the side salads when ordered. The third floor resident council minutes from 8/16/22 documented the food had been too salty a few times. The third floor resident council minutes from 9/20/22 documented the food was still too salty, the fish was not cooked enough and the pork was overcooked. The third floor resident council minutes from 10/18/22 documented the residents said the french toast on the weekends looked soggy and the waffles were too hard. C. Resident interview Resident #89 was interviewed on 11/28/22 at 11:07 a.m., who was identified as interviable by the facility staff. He said he no longer consumed the food at the facility. He said the food was so salty he was unable to eat it. Resident #89 said his family provided food for him. D. Staff interviews The registered dietitian (RD) was interviewed on 11/30/22 at 3:34 p.m. She said she had not completed a test tray in a while. She said her and the food and nutrition director (FND) should complete test trays more frequently to taste the food served to residents. The RD said they had recently started conducting a food council. She said they completed a meeting in August 2022 and the plan was to complete the meeting every three months. The RD said Resident #89 did not like the facility food and his family provided all of his food. The FND was interviewed on 12/1/22 at 10:38 a.m. She said there were a couple residents who complained about the saltiness of the food. The FND said she had not tasted the pureed food recently. She said the pureed food should taste similar to the regular foods. The FND said the pureed food should be the consistency of pudding. The director of nursing (DON), regional clinical director (RCR) and the nursing home administrator (NHA) were interviewed on 12/1/22 at 2:53 p.m. The DON said pureed foods should be similar to a pudding consistency. She said it was important to have the correct consistency for the safety of the residents. II. Met the nutritional needs of the residents A. Observations During a continuous observation on 11/30/22 beginning at 11:00 a.m. and ended at 12:40 p.m. the following was observed: -At 11:20 a.m. cook #2 prepared three puree plates. She placed a scoop of pureed bread in a bowl, placed a scoop of pureed meat on top and then layered it with another scoop of pureed bread. She placed a scoop of pureed vegetables in a bowl. -At 11:40 a.m. cook #1 plated five plates of macaroni and cheese and green beans for residents who preferred to be vegetarian. He said the macaroni and cheese was the protein source for the residents. The FND said the macaroni and cheese did not contain enough protein. -At 11:46 a.m. the FND called the RD. The RD said to give the vegetarian residents a half a cup of peas to provide additional protein. -The FND got a box of frozen mixed peas and carrots and placed them in a metal pan and into the steamer. -At 12:08 p.m. cook #1 used a metal mixing spoon and placed a spoonful of mixed peas and carrots on the plates. -At 1:00 p.m. four surveyors sampled a pureed test tray meal. They did not receive mashed potatoes (see test tray above). B. Record review The menu extension for the 11/30/22 lunch meal was reviewed. It revealed, the vegetarian residents were to receive two veggie burgers, half a cup of french fries, half a cup of creamy southern coleslaw, a two by three square of applesauce swirl cake, eight fluid ounces of 2% milk and eight fluid ounces of a beverage of choice. -The five vegetarian residents did not receive the menu items that were to be served per the vegetarian menu extension (see interviews below). The pureed menu extension for the 11/30/22 lunch meal was reviewed. It revealed, the residents who were on a pureed diet should have received half a cup of mashed potatoes. -The observations revealed the residents did not receive the mashed potatoes who were served out of the main kitchen for lunch on 11/30/22. C. Staff interviews The registered dietitian (RD) was interviewed on 11/30/22 at 3:34 p.m. She said five residents in the facility were vegetarian per their preference. She said the kitchen staff knew what the residents liked and often cooked to their preference. The RD said she should ensure that the residents are meeting their nutritional needs with the meals that are being provided. She said since the residents on the pureed diets did not receive mashed potatoes for lunch on 11/30/22 they were not provided with the adequate nutrition. The FND was interviewed on 12/1/22 at 10:38 a.m. She said the menu extensions had a vegetarian extension. She said the kitchen usually had alternative protein items such as vegetarian burgers and tofu, but the kitchen was currently out. She said the vegetarian residents should have received a vegetarian burger for lunch on 11/30/22. The FND said the residents who were on a pureed diet should have received mashed potatoes as the alternative to french fries. She said it was important for the cooks to follow the menus to ensure the residents were provided with adequate nutrition. The director of nursing (DON), regional clinical director (RCR) and the nursing home administrator (NHA) were interviewed on 12/1/22 at 2:53 p.m. The RCR said the staff in the kitchen should follow the menus and recipes. He said this ensured the residents were being provided with the correct amount of nutritional needs.

Based on observations, interviews and record review the facility failed to store, prepare, distribute, and serve food in a sanitary manner in the main kitchen and five out of five satellite kitchens. Specifically, the facility failed to: -Ensure food was labeled and dated in the walk-in refrigerators in the main kitchen and dry storage; -Ensure the main kitchen was clean and sanitary; -Ensure five unit refrigerators were clean and sanitary; -Ensure garbage was covered and disposed of in the main kitchen; -Ensure food was properly cooled; and, -Ensure holes were fixed timely in the main kitchen. Findings include: I. Food was labeled and dated in the main kitchen A. Professional reference The Colorado Department of Public Health and Environment (2019) The Colorado Retail Food Establishment Rules and Regulations, retrieved from: https://www.colorado.gov/pacific/sites/default/files/DEHS_RetailFd_6CCR10102_RFFC_EffJan2019.pdf. It revealed, in pertinent part, A date marking system that meets the criteria stated in (1) and (2) of this section may include: Using a method approved by the Department for refrigerated, ready-to eat potentially hazardous food (time/temperature control for safety food) that is frequently rewrapped, such as lunch meat or a roast, or for which date marking is impractical, such as soft serve mix or milk in a dispensing machine; Marking the date or day of preparation, with a procedure to discard the food on or before the last date or day by which the food must be consumed on the premises, sold, or discarded as specified in (a) of this section; Marking the date or day the original container is opened in a food establishment, with a procedure to discard the food on or before the last date or day by which the food must be consumed on the premises, sold, or discarded as specified in (b) of this section; or Using calendar dates, days of the week, color-coded marks, or other effective marking methods, provided that the marking system is disclosed to the Department upon request. (Retrieved 12/8/22) B. Facility policy and procedure The Food Wholesomeness policy, dated 1/12/16, was provided by the regional clinical resource (RCR) on 12/1/22 at 1:52 p.m. It revealed, in pertinent part, Foods not in original containers are labeled and dated with opening and suggest to have a use by date. C. Observations On 11/28/22 at 8:22 a.m. the initial kitchen tour was conducted and the following was observed: -In the main walk-in coolers, there was a container of prepared egg salad, a container of pureed vegetables dated 11/25/22, a container of pureed ham dated 11/25/22, and a container of gravy labeled 11/26/22, but no use by date. -In the main walk-in coolers, an opened container of relish was labeled 10/3, an opened bag of blue cheese opened and labeled 11/17 and an opened container of mayonnaise was labeled 11/24. -In the main walk-in coolers a container of sliced deli turkey and a bag of shredded cheese were opened and not labeled. -In the reach-in refrigerator in the main kitchen, there were five green salads prepared and not labeled and a container of jelly labeled 10/31. -In the reach-in freezer there was a tiramisu cake left open to air with no label and an opened bag of garlic bread not labeled or dated. -A quinoa container opened and labeled 5/10, bag of captain crunch, fruit loops, corn flakes not labeled or dated. -In the dry storage, a container of quinoa, a bag of fruit loops and a bag of corn flakes were not labeled or dated. During a continuous observation on 11/30/22 beginning at 11:00 a.m. and ended at 12:40 p.m. the following was observed: -In the main walk-in coolers a container of hard boiled eggs was opened and not labeled. D. Staff interviews The food and nutrition director (FND) and the registered dietitian (RD) were interviewed on 11/30/22 at 1:20 p.m. The FND said foods should contain a label that had the preparation date. The FND said the kitchen did not have a system in place that determined when food items expired. She said most foods needed to be thrown away in three days, but some were seven days and some were several months. The RD said the kitchen should have a system in place to ensure expired foods were discarded timely. The FND said she would immediately educate the dining department staff regarding labeling and dating. II. Main kitchen was clean and sanitary A. Professional reference The Colorado Department of Public Health and Environment (2019) The Colorado Retail Food Establishment Rules and Regulations, https://www.colorado.gov/pacific/sites/default/files/DEHS_RetailFd_6CCR10102_RFFC_EffJan2019.pdf. It revealed, in pertinent part, Equipment food-contact surfaces and utensils shall be clean to sight and touch. The food-contact surfaces of cooking equipment and pans shall be kept free of encrusted grease deposits and other soil accumulations. Non food contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris. Non food-contact surfaces of equipment shall be cleaned at a frequency necessary to preclude accumulation of soil residues. (Retrieved 12/8/22) B. Facility policy and procedure The Food Wholesomeness policy, dated 1/12/16, was provided by the regional clinical resource (RCR) on 12/1/22 at 1:52 p.m. It revealed, in pertinent part, Kitchen and serving areas are clean at all times. C. Observations On 11/28/22 at 8:22 a.m. the initial kitchen tour was conducted and the following was observed: -Behind the two compartment preparation sink the floor had black build up that covered the tile. There was dust debris and food particles that were on the ground. Behind the sink wall and underneath the sink there were food splatters brown and orange on the wall. -Behind the juice dispenser was a sign that explained how to make pureed foods which was covered in orange, green, and brown food splatters. -Behind the three compartment sink the tiles were covered in a black film. The white pipe underneath the sink was coated in a black debris. During a continuous observation on 11/30/22 beginning at 11:00 a.m. and ended at 12:40 p.m. the following was observed: -Underneath the three compartment sink remained dirty with food debris. Behind the sink on the wall remained dirty with splatters of food. There was yellow debris underneath the sink next to the floor cleaner. -The coffee cart had drips of dried coffee on the sides. -Behind the preparation table, the wall was full of green food splatters. The food splatters were crusted and dried over. A sign was hung over the preparation table that was covered in crusted food debris. -The side of the spice rack was covered in brown food splatters that were crusted and dried. -The floor in front of the spice rack had salt spilt. -To the left of the reach-in freezer was a wall that was covered in black food debris. -The flat top griddle had dried scrambled eggs in the grease catcher. -The knobs on the steam table were covered in a black residue. -Behind the stove, flat top and oven there were multiple broken plates, disposable dishes, food debris and trash piled up. -Underneath the two compartment sink the drain had pink, brown and black build-up. -Underneath the sink the tiles were turning black from build-up and there was a large amount of gray dust built-up. The tiles going up the wall beneath the sink had food dried food splatters. -Around the perimeter of the kitchen walls the tiles had black build-up that was going up the walls. D. Staff interviews The FND and the RD were interviewed on 11/30/22 at 1:20 p.m. The FND and the RD said they were aware the kitchen was not clean and sanitary, where food preparation occurred. The RD said they had worked on a list to ensure the kitchen was cleaned in a timely manner, but it had not been implemented yet. The director of nursing (DON), nursing home administrator (NHA) and the RCR were interviewed on 12/1/22 at 2:53 p.m . The DON, NHA and RCR said they had not recently been in the kitchen to observe the lack of cleanliness. The RCR said the kitchen should be clean and sanitary. III. Unit refrigerators were clean and sanitary A. Professional reference The Colorado Department of Public Health and Environment (2019) The Colorado Retail Food Establishment Rules and Regulations, https://www.colorado.gov/pacific/sites/default/files/DEHS_RetailFd_6CCR10102_RFFC_EffJan2019.pdf. It read in pertinent part; -Time/temperature control for safety of food prepared and held in a food establishment for more than 24 hours shall be clearly marked to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded when held at a temperature of 41º (degrees) F (Farenheit) or less for a maximum of 7 days. The day of preparation shall be counted as Day 1. The day or date marked by the food establishment may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on food safety. -In a mechanically refrigerated storage unit, the sensor of a temperature measuring device shall be located to measure the air temperature or a simulated product temperature in the warmest part of a mechanically refrigerated unit. (Retrieved 12/8/22) B. Observations On 11/30/22 at 10:32 a.m. the following was observed in the fourth floor unit nourishment room refrigerator: -A tupperware of food, a blender bottle with liquid in it and an opened container of half and half was unlabeled. -Two grocery bags full of food were labeled 10/28. -A grocery bag full of take-out food and a take-out salad was not labeled. -Two staff lunch boxes were not labeled -The freezer had brown frozen liquid on the bottom shelf. -Four opened containers of ice cream, frozen quart container of berries and three opened boxes of popsicles were not labeled. At 1:36 p.m. the following was observed in the third floor east unit nourishment room refrigerator: -An opened jar of thousand island dressing, an opened jar of pepperoncinis, an opened container of nectar thick orange juice (see interview below), an opened container of nectar thick apple juice, an opened container of nectar thick cranberry juice, an opened container of honey thick cranberry juice, and a personal tupperware of food were unlabeled or dated in the refrigerator. At 1:45 p.m. the following was observed in the third floor west unit nourishment room refrigerator: -Six unlabeled peanut butter and jelly sandwiches were in the freezer. -An opened loaf of bread, an opened tub of butter and a take-out pizza were unlabeled in the refrigerator. At 1:50 p.m. the following was observed in the second floor east unit nourishment room refrigerator: -One opened container of nectar thick cranberry juice was unlabeled in the refrigerator. -One frozen smoothie was unlabeled in the freezer. At 1:53 p.m. the following was observed in the first floor unit nourishment room refrigerator: -A container of take-out Chinese food was labeled 11/25/22 in the refrigerator. -The freezer had brown frozen liquid on the bottom shelf. C. Staff interviews The FND was interviewed on 11/30/22 at 2:01 p.m. She said the certified nurse aides (CNA) were responsible for ensuring the unit refrigerators were clean. The FND said the CNAs were responsible for ensuring the food that was placed in the unit refrigerators was labeled properly. The FND said thickened liquids should be discarded seven days after it was opened. IV. Garbage was covered and disposed of in the main kitchen A. Professional reference The Colorado Department of Public Health and Environment (2019) The Colorado Retail Food Establishment Rules and Regulations, https://www.colorado.gov/pacific/sites/default/files/DEHS_RetailFd_6CCR10102_RFFC_EffJan2019.pdf. It read in pertinent part, -Receptacles and waste handling units for refuse, recyclables, and returnables and for use with materials containing food residue shall be durable, cleanable, insect- and rodent-resistant, leak-proof, and nonabsorbent. -Receptacles and waste handling units for refuse, recyclables, and returnables shall be kept covered: Inside the food establishment if the receptacles and units contain food residue and after they are filled. (Retrieved 12/8/22) B. Facility policy and procedure The Disposal of Garbage policy, dated 1/12/16, was provided by the RCR on 12/1/22 at 1:52 p.m. It revealed, in pertinent part, Garbage is bagged and tied before removing placing in trash receptacle. Garbage receptacle is closed at all times. The Sanitization policy, revised October 2008, was provided by the regional clinical resource (RCR) on 12/1/22 at 1:52 p.m. It revealed, in pertinent part, Kitchen wastes that are not disposed of by mechanical means shall be kept in clean, leakproof, nonabsorbent, tightly closed containers and shall be disposed of daily. C. Observations On 11/28/22 at 8:22 a.m. the initial kitchen tour was conducted and the following was observed: -Next to the three compartment sink a trash can was filled to the top and was not covered. -The trash can underneath the handwashing sink did not have a cover During a continuous observation on 11/30/22 beginning at 11:00 a.m. and ended at 12:40 p.m. the following was observed: -A trash can was next to the three compartment sink that was filled to the top and without a cover. -The trash can next to the hand washing sink was overflowing. Paper Towels were on the ground in the surrounding area. -At 11:56 a.m. cook #2 picked up the trash surrounding the hand washing sink trash can and placed them in the bin. She then used her hands to push the trash down to fit in the trash can and then washed her hands. The trash can did not have a lid. D. Staff interviews The FND and the RD were interviewed on 11/30/22 at 1:20 p.m. The FND said she was not aware the trash cans in the kitchen needed to be covered. The FND said she would speak with the NHA regarding ordering new trash cans. V. Food was properly cooled A. Professional reference The Colorado Department of Public Health and Environment (2019) The Colorado Retail Food Establishment Rules and Regulations, https://www.colorado.gov/pacific/sites/default/files/DEHS_RetailFd_6CCR10102_RFFC_EffJan2019.pdf. It revealed in pertinent part, Maintain the records required to confirm that cooling and cold holding refrigeration time/temperature parameters are required as part of the HACCP (hazard analysis critical control point) plan. (Retrieved 12/8/22) B. Facility policy and procedure The Food Wholesomeness policy, dated 1/12/16, was provided by the regional clinical resource (RCR) on 12/1/22 at 1:52 p.m. It revealed, in pertinent part, Leftover foods are chilled with HACCP (hazard analysis and critical control points) guidelines if product is acceptable. C. Observations During a continuous observation on 11/30/22 beginning at 11:00 a.m. and ended at 12:40 p.m. the following was observed: -At 11:01 a.m. a colander of cooked noodles was in the three compartment sink. Steam was coming off of the noodles. -At 11:25 a.m. the noodles were placed in a plastic bag and placed directly in the refrigerator. -A casserole was warm to the touch in the main kitchen walk-in refrigerator. -A bag of cooked scrambled eggs, a container of pureed ham and a container of pureed vegetables were in the main kitchen walk-in refrigerator. D. Record review A request was made for the documented cooling monitor system on 11/30/22. The FND said the facility did not have a documented cooling monitor system in place (see interview below). E. Staff interviews The FND and the RD were interviewed on 11/30/22 at 1:20 p.m. The FND said food must be cooled properly to prevent the growth of bacteria that could cause food borne illness. The FND said the macaroni should have been cooled properly prior to it being placed in the refrigerator. The FND said she did not have documentation that food that was in the walk-in refrigerators were cooled properly. The FND said she would implement a food cooling and logging system immediately. VI. Holes were patched timely in the main kitchen A. Professional reference The Colorado Department of Public Health and Environment (2019) The Colorado Retail Food Establishment Rules and Regulations, retrieved from: https://www.colorado.gov/pacific/sites/default/files/DEHS_RetailFd_6CCR10102_RFFC_EffJan2019.pdf. It read in pertinent part, -Utility service lines and pipes may not be unnecessarily exposed. -Except in areas used only for dry storage, concrete, porous blocks, or bricks used for indoor wall construction shall be finished and sealed to provide a smooth, nonabsorbent, easily cleanable surface. (Retrieved 12/8/22) B. Observations On 11/28/22 at 8:22 a.m. the initial kitchen tour was conducted and on the back kitchen wall, across from the two walk-in refrigerators were five holes in the wall that were approximately three inches by three inches. C. Staff interviews The FND and the RD were interviewed on 11/30/22 at 1:20 p.m. The FND said she was aware there were several holes in the kitchen wall. The RD said holes in the kitchen could let pests into the kitchen. The RD and the FND said they planned to begin a deep clean and renovation of the kitchen in the future. The FND said she was not sure if the maintenance department had been notified of the holes in the wall. The maintenance associate (MA) was interviewed on 12/1/22 at 3:46 a.m. He said he was not aware of the holes in the kitchen wall. He said holes should be fixed immediately, so pests such as mice did not get into the kitchen. The MA said he would fix the wall immediately. The DON, NHA and RCR were interviewed on 12/1/22 at 2:53 p.m. The RCR said he would speak with the regional RD for her to address the holes in the kitchen wall.

Based on observations, record review and interviews, the facility failed to implement their policy regarding use and storage of foods brought to residents by family and other visitors to ensure safe and sanitary storage, handling and consumption on four of five units. Specifically, the facility failed to: -Ensure food that was kept in resident's refrigerators had safe and sanitary storage; -Ensure resident refrigerators had a thermometer to continuously monitor the internal temperature; and, -Ensure documentation monitored daily refrigerator temperatures. Findings include: I. Facility policy The Food From Outside Sources policy, revised 3/27/17, was provided by the director of nursing (DON) on 11/28/22 at 10:19 a.m. It revealed, in pertinent part, All foods may be permitted from outside sources if deemed safe and wholesome per state and federal guidelines and within medical advice. If food is not consumed upon arrival, it may be stored in a suitable container and labeled with date, resident name and item description if needed. II. Resident interview and observation On 11/30/22 at 4:36 p.m. Resident #89's personal refrigerator was inspected. Resident #89 who was identified as interviewable by the facility assessment, said there was not a thermometer in the refrigerator. He said foods were not labeled when placed in the refrigerator. There was brown residue on the bottom shelf of the refrigerator. There was cut-up fresh fruit, condiments and cut-up fresh vegetables that were in the refrigerator not labeled. III. Record review A request was made for the documentation of the personal refrigerators monitoring logs on 11/30/22. The facility did not have any documentation that the personal refrigerators in the resident rooms were being monitored. The regional clinical resource (RCR) provided a list of residents who had a personal refrigerator in their room on 11/30/22 at 3:54 p.m. It revealed, zero residents on the first floor unit had a personal refrigerator, five residents on the second floor unit had personal refrigerators, three residents on the third floor east unit had personal refrigerators, eight residents on the third floor west unit had personal refrigerators and 12 residents on the fourth floor unit had personal refrigerators. IV. Staff interviews Licensed practical nurse (LPN) #3 was interviewed on 11/30/22 at 1:45 p.m. She said she was unsure of who was responsible for monitoring the resident's personal refrigerators. She said she had reviewed the log book, but was unable to locate the temperature logs for the personal refrigerators. Registered nurse (RN) #1 was interviewed on 11/30/22 at 1:50 p.m. She said she was not aware of who was responsible for monitoring the residents personal refrigerators. She said she was unable to locate the logs for the personal refrigerators. LPN #2 was interviewed on 11/30/22 at 2:07 p.m. He said he did not know who was responsible for monitoring the residents personal refrigerators. The RCR and DON were interviewed on 11/30/22 at 2:49 p.m. The RCR said he was unable to locate the temperature monitoring logs for the resident's personal refrigerators. The DON said the night shift certified nurse aides (CNAs) were responsible for monitoring the temperatures of the refrigerators. The RCR was interviewed again on 11/30/22 at 3:54 p.m. He said the facility had begun an immediate audit of residents who have personal refrigerators. He said the food and nutrition director (FND) was ordering thermometers to be placed in each refrigerator. He said the night shift staff would be responsible for monitoring the temperature of the refrigerators, cleaning the refrigerators and ensuring all foods were labeled and dated correctly. The FND was interviewed on 12/1/22 at 10:38 a.m. She said the CNAs were responsible for monitoring the resident's personal refrigerators twice a day. She said the CNAs were responsible for ensuring the refrigerators were cleaned and the food was labeled and dated properly.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and interviews the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of disease and infection in two of five units. Specifically, the facility failed to: -Provide and encourage hand hygiene to residents at meal times; and, -Staff did not follow proper hand hygiene during meal assistane. Findings include: I. Professional reference The Centers for Disease and Prevention (CDC) Hand Hygiene in Healthcare Settings, last reviewed 1/30/2020, retrieved on 12/5/22 from https://www.cdc.gov/handhygiene/providers/guideline.html included the following recommendations, in pertinent part for hand hygiene, Use an alcohol-based hand sanitizer immediately before touching a patient, before performing an aseptic task or handling invasive medical devices, before moving from work on a soiled body site to a clean body site on the same patient, after touching a patient or the patient's immediate environment, after contact with blood, body fluids or contaminated surfaces, and immediately after glove removal. II. Facility policy and procedure The COVID-19 Prevention, Response and Testing policy and procedure, revision date 11/4/22, provided by the director of nursing (DON) on 11/28/22 at 11:36 a.m. via email, it read in pertinent part, Interventions to prevent the spread of respiratory germs within the facility: Keep residents and employees informed by answering questions and explaining what they can do to protect themselves and their fellow residents (social distancing, respiratory hygiene/cough etiquette, handwashing). Residents are reminded to perform frequent hand hygiene and are assisted as necessary. Support hand hygiene and respiratory/cough etiquette by residents and employees by making sure tissues, soap, paper towels, and alcohol-based hand rubs are available. III. 400 unit A. Observations During a continuous observation on 11/29/22 beginning at 11:01 a.m. and ended at 1:35 p.m. the following was observed: -At 12:41 p.m. an unidentified certified nurse aide (CNA) delivered a room tray to rooms 427a and 427b, she did not encourage or offer hand hygiene to the residents. -At 12:42 p.m. an unidentified CNA delivered a room tray to room [ROOM NUMBER], she did not offer or encourage hand hygiene to the resident. -At 12:43 p.m. an unidentified CNA delivered a room tray to room [ROOM NUMBER]a, she did not encourage or offer hand hygiene to the resident. -At 12:44 p.m. an unidentified CNA delivered a room tray to room [ROOM NUMBER], she did not encourage or offer hand hygiene to the resident. -At 12:44 p.m. an unidentified CNA delivered a room tray to room [ROOM NUMBER]b, she did not encourage or offer hand hygiene to the resident. -At 12:45 p.m. an unidentified CNA delivered a room tray to room [ROOM NUMBER]b, she did not encourage or offer hand hygiene to the resident. -At 12:55 p.m. an unidentified CNA delivered a room tray to room [ROOM NUMBER], she did not encourage or offer hand hygiene to the resident. -At 12:55 p.m. an unidentified CNA delivered a room tray to room [ROOM NUMBER], she did not encourage or offer hand hygiene to the resident. -At 12:56 p.m. an unidentified CNA delivered a room tray to room [ROOM NUMBER], she did not encourage or offer hand hygiene to the resident. B. Staff interviews CNA #4 was interviewed on 12/1/22 at 1:26 p.m. She said CNAs were responsible for encouraging or offering hand hygiene to all residents prior to the meal. The DON was interviewed on 12/1/22 at 3:50 p.m. She said the CNAs were responsible for encouraging hand hygiene to the residents prior to meals. She said there were sanitizer wipes and hand sanitizer liquid available for the CNAs to offer to the residents. The DON said she expected the CNAs to encourage independent residents to wash their hands as well. IV. 100 unit A. Observations Lunch observations on 11/28/22 from 11:15 a.m to 12:55 p.m. -At 11:15 a.m. twelve residents were observed in the dining room completing coloring activity. -At 12:28 p.m. the meal cart was delivered to the unit. The coloring supplies were taken away by CNAs and meals were served to residents. The residents were not offered hand hygiene prior to the meal. -At 12:38 p.m. CNA #2 was observed redirecting a wandering resident from the meal cart by holding his both hands and walking with him away from the meal cart. After she redirected the resident, she did not wash or sanitize her hands and went on assisting with meals to other residents. -At 12:43 p.m. CNA #9 observed serving meals to residents wearing gloves. She grabbed a trash bin by the top rim and moved it out of the way to clear a space for the resident. After the resident was seated at the table she grabbed plates from the meal cart, placed it in front of the resident and assisted the resident with the meal without changing her gloves. B. Staff interview The director of nursing (DON) was interviewed on 12/1/22 at 4:30 p.m. She said residents should be offered hand hygiene prior to meals. She said CNAs should not wear gloves during meal service and must wash or sanitize their hands after touching unclean surfaces. She said she would provide education to all CNAs to make sure they were following proper hand hygiene.

Based on observations and interviews, the facility failed to follow proper testing procedures and infection control measures to prevent potential cross-contamination and spread of SARS-CoV-2 COVID-19, during testing procedures on staff and residents. Specifically, the facility failed to ensure proper disinfection of the testing area (a facility bathroom) between staff self-tests; and that the entire testing area and all items in the testing area (within six feet of the testing) were properly disinfected every hour during the testing period. Findings include: I. Professional reference According to Centers for Disease Control (CDC) guidance, Guidance for SARS-CoV-2 Point-of-Care and Rapid Testing, updated 4/4/22, available from https://www.cdc.gov/coronavirus/2019-ncov/lab/point-of-care-testing.html#anchor_1615506986947, viewed 12/8/22, - Rapid point-of-care tests provide results within minutes (depending on the test) and are used to diagnose current or detect past SARS-CoV-2 infections in a variety of settings, such as: Long-term care facilities and nursing homes. Specimen Collection & Handling of Rapid Tests in a Point-of-Care Setting: -Proper specimen collection and handling are critical for all COVID-19 testing, including those tests performed in point-of-care settings. A specimen that is not collected or handled correctly can lead to inaccurate or unreliable test results. For personnel collecting specimens or working within 6 feet of patients suspected to be infected with SARS-CoV-2, maintain proper infection control and use recommended personal protective equipment (PPE), which could include an N95 or higher-level respirator (or face mask if a respirator is not available), eye protection, gloves, and a lab coat or gown. Disinfect surfaces within 6 feet of the specimen collection and handling area before, during, and after testing and at these times: -Before testing begins each day -Between each specimen collection -At least hourly during testing -When visibly soiled -In the event of a specimen spill or splash -At the end of every testing day CDC recommends the following practices when performing tests point-of-care setting: Before the Test -Perform a risk assessment to identify what could go wrong, such as breathing in infectious material or touching contaminated objects and surfaces. -Implement appropriate control measures to prevent these potentially negative outcomes from happening. After the Test -Decontaminate the instrument after each use. Follow the manufacturer's recommendations for using an approved disinfectant, including proper dilution, contact time, and safe handling. CDC guidance, Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, updated 9/23/22, available from: https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html , accessed on 12/8/22. It read in pertinent part, This guidance is applicable to all U.S. settings where healthcare is delivered. Employers should be aware that other local, state, and federal requirements may apply, including those promulgated by OSHA. Ensure everyone is aware of recommended IPC practices in the facility. Optimize the use of engineering controls to reduce or eliminate exposures by shielding health care professionals (HCP) and other patients from infected individuals physical barriers at reception / triage locations and dedicated pathways to guide symptomatic patients through waiting rooms and triage areas). -Procedures that could generate infectious aerosols should be performed cautiously and avoided if appropriate alternatives exist. -AGPs should take place in an airborne infection isolation room (AIIR), if possible. -The number of HCP present during the procedure should be limited to only those essential for patient care and procedure support. Visitors should not be present for the procedure. Environmental Infection Control -Routine cleaning and disinfection procedures (e.g., using cleaners and water to pre-clean surfaces prior to applying an EPA-registered, hospital-grade disinfectant to frequently touched surfaces or objects for appropriate contact times as indicated on the product's label) are appropriate for SARS-CoV-2 in healthcare settings, including those patient-care areas in which aerosol generating procedures are performed. II. Sanitizing the COVID-19 testing room On 11/29/22 at 10:38 a.m. the testing area for polymerase chain reaction (PCR) and antigen rapid testing was observed. The testing area was in the first floor public facility bathroom used by visitors and staff. There were no was no cleaning or sanitizing products in the room or signage with instructions concerning sanitization. There were no gloves or gel hand sanitizer. There was a red biohazard trash can in the bathroom with a lid. The signage on the wall described washing hands with soap and water before and after the procedure, and the testing procedure. There was no information on cleaning the surfaces in the bathroom before or after testing (an aerosol producing procedure). Multiple staff members and guests were observed using the bathroom throughout the testing day. III. County positivity rate The facility was located in Boulder county where the level of community transmission rate was high the week of 11/18/22 to 11/24/22, retreived from https://covid19.colorado.gov/healthcare-providers/long-term-care-facilities/healthcare-community-transmission-levels. The facility was currently in outbreak status. IV. Staff interviews The infection preventionist (IP) was interviewed on 11/30/22 at 11:21 a.m. She said the facility was currently in outbreak status and they were testing twice per week, on Tuesdays and Fridays. The IP said the procedure for staff testing was to go to the bathroom on the first floor area and test there. The staff member shut the door, completed the test, put it in a bag, and put it in the refrigerator. The staff should wash hands with soap and water prior to the test, dry hands and apply gloves. After the staff completed the test, they should wash hands. The IP acknowledged that COVID-19 testing was an aerosol producing procedure. The IP said the facility used clorox wipes or spray on anything the staff member touched. The IP said the staff member should wipe and clean the area after testing. The IP said there should be cleaning instructions posted but acknowledged there was not. The IP said she needed to put up signage about cleaning. The IP said housekeeping cleaned the bathroom two times a day and should wear full PPE including gloves, gowns, masks and eye protection to protect themselves. The IP said guests using the bathroom should use a surgical mask and wash their hands. The DON was interviewed on 12/1/22 at 2:06 p.m. The DON said the IP reported to her and she was her supervisor. The DON said she was aware that the staff were COVID-19 testing in the guest/staff bathroom. The DON said testing supplies were at the receptionist desk then the staff member tests in the bathroom. The DON said as an aersoling producing procedure (testing) there should be cleaning between staff member testing. The DON said there should be cleaning of the door knobs, counter and sink in the testing room with sanitizing wipes. The DON said that other guests or staff were using that bathroom. The DON acknowledged there was no record of cleaning between testing on 11/29/22, no signage with instructions on cleaning the bathroom, and there were no cleaning or sanitizing supplies in the bathroom. V. Additional information On 12/1/22 at 9:57 a.m. the testing area bathroom was viewed. There were three new unopened boxes of gloves placed in the bathroom and an unopened box of disinfecting wipes. On 12/1/22 the facility reported two new COVID-19 positive residents and two staff members from the testing conducted on 11/29/22.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to prevent misappropriation of property for one (#111) of three residents reviewed out of 59 sample residents. Specifically, the facility failed to keep Resident #111's four wedding rings safe. Findings include: I. Facility policy The Personal Property policy, revised in September 2012, was provided by the regional nurse consultant (RNC) on 8/19/21 at 12:30 p.m., it read in pertinent part: Residents are permitted to retain and use personal possessions and appropriate clothing, as space permits. A representative of the admitting office will advise the resident, prior to or upon admission, as to the types and amount of personal clothing and possessions that the resident may keep in his or her room. The resident personal belongings shall be inventoried and documented upon admission and as such items are replenished. The facility will promptly investigate any complaints of misappropriation or mistreatment of residents' property. The Misappropriation of Property policy, developed on 11/4/13, was provided by the RNC on 8/19/21 at 12:30 p.m., it read in pertinent part: The purpose of the policy was to ensure residents' property was not misappropriated. Residents' property will not be misappropriated (pattern of deliberate misplacing or exploiting or wrongful use of resident property). If a resident, family member or legal responsible party alleges the resident property is missing or has been misappropriated, a complaint and concern form, missing item form or grievance form shall be completed according to the complaint or concern policy and procedure. An investigation to find the missing item(s) shall be completed by the designated department. If the investigation locates the missing item(s), the item(s) shall be returned to the resident. If the investigation finds that the resident property was misappropriated in a deliberate and wrongful manner, the social services director shall report the misappropriation according to the occurrence reporting guideline policy and procedure. If the investigation finds there is another explanation for the missing item (i.e. resident misplaced it and due to their memory loss cannot remember where they placed the item), these findings will be documented on the complaint and concern form where indicated and investigation will be completed. All allegations of misappropriation will be discussed with the administrator. II. Resident #111 A. Resident status Resident #111, age [AGE], was admitted on [DATE]. According to the August 2021 computerized physician orders (CPO), diagnosis included cerebral vascular disease, seizure disorder and anxiety. The 7/21/21 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 12 out of 15. Resident #111 required limited assistance of one person for bed mobility, transfers and toileting. She needed extensive assistance with dressing. Her preference in asking how important it was to take care of her personal belongings and having a place to lock those personal belongings up to keep them safe was very important to her. B. Resident and family interview Resident #111 was interviewed on 8/16/21 at 10:30 a.m. She said she had her family bring the rings to her and she wore them for about a month. She said the facility lost her wedding rings and the facility staff tried to find them but they did not. She said she really loved her rings and she wanted them back. Resident #111's family member was interviewed on 8/16/21 at 6:00 p.m. The family member said he brought the resident her wedding rings a few months ago and the resident wore her rings for a while and then the rings were put in a bag for safe keeping. The family member said the resident wanted her rings back to wear and the facility could not find them. The family member said the facility looked for the rings and could not find them. The family member was told by the facility that a claim was started for reimbursement and he had not heard anything else. The family member said they gave the facility a description of the rings and an estimate of the value. See nurse note 4/13/21, bag was placed in nurse cart C. Record review An investigative report dated 8/17/21 at 2:30 p.m. for Resident #111 was provided by the nursing home administrator (NHA), it read in pertinent part: Investigation was started on 8/4/21 for Resident #111. The family and resident reported on 7/15/21 at 10:28 a.m. to the social service assistant (SSA) that her wedding rings were missing but the official report started on 8/4/21. On 8/13/21 the director of nurses (DON) was notified by the family with a description of the rings and an estimate for the cost of the rings. The police were notified and the investigation report read the investigation was ongoing. A nurse note dated 4/13/21 for Resident #111 read the resident's rings, four of them were in the nurse cart and the resident was aware of the placement of the rings for safe keeping within a double locked box within the medication cart. -Record review on 8/17/21 at 1:30 p.m. revealed no inventory sheet for Resident #111. III. Interviews Registered nurse (RN) #1 was interviewed on 8/17/21 at 1:30 p.m. She said the facility was not sure if Resident #111 had the rings or not. She said she had no record of any rings in the locked drawer. She said the inventory sheet determined any personal items brought into the facility. -The inventory sheet was not available during record review (see above). She said when items were missed a report was filed in the 24 hour book and the management followed up with an investigation. She said she looked for the rings with the resident in her room and no rings were found. The social service director (SSD) was interviewed on 8/17/21 at 2:55 p.m. She said when a resident moved into the facility an inventory sheet was filled out that listed the residents' belongings. She said an occurrence form was filled out for any missing items and an investigation was started. Resident #111 and the family reported some missing rings to the SSA on 7/15/21. The facility looked for the missing rings in the residents room but could not find them. The facility asked the family to describe the rings and give them a value of the rings. The family did give this information to the facility but it took a few weeks. The SSD said there was a nurse note that read the rings were placed in an envelope and put in the locked nurse cart but no one could find the envelope. She said typically the facility replaced missing items such as clothes but they had never replaced wedding rings before so they were not sure what the follow-up was for missing rings. The nursing home administrator (NHA) was interviewed on 8/19/21 at 11:00 a.m. She said she started the investigation for Resident #111 missing rings on 8/4/21. She said the investigation included a room search of the items, which included laundry, pockets and the nurse cart. She said the rings were not found. There was a nurse note that showed documentation that Resident #111's four rings were placed into an envelope and put in the locked drawer of the medication cart. The nurse who documented that no longer worked at the facility. She said she asked the family to give them a description of the rings and a dollar amount of the rings. She said they completed a police report and the investigation was ongoing because the family took a few weeks to get them the information about the rings. She said she educated the nursing staff on missing items, especially jewelry. She said the facility's plan was to reimburse the resident for the missing rings. -Documentation was requested for specific education on missed items and none was provided before the survey exit on 8/19/21. V.Facility follow-up The NHA emailed on 8/19/21 at 6:48 p.m. the following information: The SSD and director of nurses (DON) searched Resident #111's room and interviewed staff. The unit manager reviewed progress notes that stated a nurse had locked the rings up in the medication cart. The cart was searched and the envelope containing the rings was not located. The DON and unit manager proceeded to search the medication room. The envelope was not located. Upon receiving a description of the rings, the police were notified of the missing rings. It is not certain if the rings were given to the family and they forgot. The unit manager had asked the family to look for the envelope at home.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation record review and interviews, the facility failed to ensure that all residents were free from abuse, neglect, and exploitation, for five (#55, #50, #6, #87 and #73) of seven residents reviewed in three out of eight facility reported incidents reviewed of abuse out of 59 sample residents. Specifically, the facility failed to provide adequate supervision and effective interventions to prevent resident-to-resident altercations for occurring on the dementia care unit (cross-reference F744 for dementia care). The facility failed to prevent the following physical altercations between residents: -Resident #50 being physically aggressive towards Resident #55; -Resident #6 being physically aggressive towards Resident #87; and, -Resident #73 being physically aggressive towards Resident #6. Findings include: I. Facility policy The Abuse Policy, revised 5/15/18, was provided by the interim nursing home administrator (INHA) on 8/16/21 at 12:24 p.m. It read in pertinent part: The facility does not condone resident abuse and shall take every precaution possible to prevent resident abuse by anyone, including staff members, other residents .Standards: Providing a safe environment for the resident is one of the most basic and essential duties of our facility. The Resident-to-Resident Altercations policy, revised December 2016, was provided by the regional nurse consultant (RNC) on 8/19/21 at 12:28 p.m. It read in pertinent part: Facility staff will monitor residents for aggressive/inappropriate behavior towards other residents, family members, visitors, or to the staff. Occurrences of such incidents shall be promptly reported . If two residents are involved in an altercation, staff will: -Separate the residents, and institute measures to calm the situation; -Identify what happened, including what might have led to aggressive conduct on the part of one or more of the individuals involved in the altercation; -Review the events with the nursing supervisor and director of nursing, and possible measures to try to prevent additional incidents; -Consult with the attending physician to identify treatable conditions such as acute psychosis that may have caused or contributed to the problem; -Make any necessary changes in the care plan approaches to any or all of the involved individuals; -Document in the resident's clinical record all interventions and their effectiveness; -Consult psychiatric services as needed for assistance in assessing the resident, identifying causes, and developing a care plan for intervention and management as necessary or as may be recommended by the attending physician or interdisciplinary care planning team . II. Facility reported incidents (FRI) A. FRI dated 8/4/21, allegation of physical abuse between Resident #50 and Resident #55. According to the facility investigation and progress notes the social service director (SSD) heard a loud disturbance when the SSD when to investigate the SSD observed Resident #50 pushing Resident #55; causing Resident #55 to lose balance and fall. The residents were separated at that point and evaluated for signs and symptoms of injury. Neither resident was able to explain what happened between them and there was no signs of physical injury or psychosocial distress. The SSD was interviewed on 6/17/21 at 4:00 p.m. The SSD said she said she was in her office when she heard Resident #50 voices in a lower tone than usual he seemed angry. In response the SSD exited her office and saw Resident #55 standing very close to Resident #50. Resident #50 pushed Resident #55 and she lost her balance and fell. The SSD did not know why Resident #50 pushed Resident #55 but thought it had to due with how close Resident #55 was standing to Resident #50. Resident #55 had a tendency to get too close to others, invading their space, this behavior upset many of the residents on the unit. Staff were responsible to monitoring Resident #55's wandering to keep her from getting too close to other residents and causing other residents distress and anxiety. The SSD said Resident #55 would benefit from activities programming geared towards her interests. B. FRI dated 7/26/21, allegation of physical abuse between Resident #6 and Resident #87. According to the facility investigation and progress notes, facility staff were escorting Resident #6 from the hall after an unrelated behavioral episode, Resident #6 was being aggressive towards staff. When they passed Resident #87 in the hall Resident #6 reach out and hit the resident in the face. Resident #87 was assessed and there were no apparent injuries. C. FRI dated 7/16/21, allegation of physical abuse between Resident #73 and #6. According to the facility investigation and progress notes, the SSD was in her office and heard a resident say stop it. The SSD went to investigate and observed Resident #73 with his arm wrapped around Resident #6's chest, neck and shoulder area. The SSD told Resident #73 to let go of Resident #6; Resident #73 complied and walked away. Upon further investigation it was discovered that Resident #6 had Resident #73's glasses in his possession. The SSD ensured both residents safety and returned Resident #73's glasses to the resident. Neither resident had physical signs or symptoms of injury. The SSD was interviewed on 6/17/21 at 4:00 p.m. The SSD said Resident #6 frequently wandered into other resident rooms and picked up their personal items, he would usually set those items down as he wandered, never seeming to intentionally take or keep the items of others. Resident #6's wandering behavior would upset other residents when he went into their rooms and touched their things. Staff should be redirect Resident #6 from going into other resident rooms. III. Resident #50 A. Resident status Resident #50, age [AGE], was admitted on [DATE]. According to the August 2021 computerized physician orders (CPO), diagnoses included dementia with behavioral disturbance, depression, and chronic obstructive pulmonary disease (COPD). According to the 6/21/21 minimum data set (MDS) assessment the resident had severely impaired cognition and scored a zero out of 15 on the brief interview for mental status (BIMS) exam. The MDS identified the resident had not shown signs of verbal or physical aggression during the time of the assessment. The resident was not wandering and did not reject care. The resident required supervision, oversight, cuing and encouragement with bed mobility, transfers; and was able to walk with supervision (oversight and cuing). The resident was taking daily antipsychotic and antidepressant medication. B. Observation and interview Resident #50 was observed on 8/16/21 at 10:02 a.m. and 8/18/21 at 3:12 p.m.; on both occasions the resident was seated at a table in the common area. He was not engaged in any activity at the time of the observation just sitting and staring into space. Resident #50 did not answer questions but gestured an acknowledgment of hello. C. Record review Progress notes revealed Resident #50 had several physical aggressive interactions towards other residents; documented as follows: Nursing note dated 11/23/2020 at 5:18 p.m., read in part: Resident's order for Seroquel was recently discontinued. Since stopping the use of Seroquel, resident's negative and aggressive behaviors have slowly returned. resident starting with exit-seeking behavior .Resident is also aggressive with other resident's- was overheard saying that bitch right there is going to get it! referring to another resident . Nursing note dated 11/24/2020 at 6:16 p.m., read: Resident was in bed most of shift. Every time staff tried to assist this resident with care, the resident refused, each time and grew increasingly more combative. Resident walked into the room, and started getting visibly agitated with other resident's trying to push and slap them, but staff intervened prior to physical contact. Nursing note dated 1/23/21 at 5:38 p.m., read in part: Resident was witnessed pushing another resident who walked past him in the dining room. Resident is calm at this time with no aggression toward others noted. Resident shows no further signs or symptoms of pain or distress. The resident who was pushed was uninjured . Physicians note dated 6/7/21, read in part: Report of acute episode. Chief complaint: Resident #50 has been irritable and agitated today. He has been difficult to manage or redirect all day. Resident #50 needs follow up of chronic medical conditions that require timely monitoring and titration of medications with care plan adjustments. Psychiatric condition and cognitive disorder makes regular visits essential to avoid delayed problem identification and intervention. Nursing note dated 6/14/21 at 10:12 p.m., read in part: This nurse reporting and assistant director of nursing (ADON) watched the incident via facility camera. While resident eating at the dining table, another resident came to the table grabbing Resident #50's dinner plate. Resident #73 then threw his cup of cranberry juice at the other resident's face. Resident responded ' I don't know ' when asked about the incident. This writer and certified nurse aide (CNA) immediately separated both residents. Nurse walked with the other resident towards the patio. No injury noted. Resident was calm and continued to eat his dinner at the dining table, No distress observed. Fifteen minutes check initiated for safety. Nursing note dated 6/21/21 at 11:45 a.m., read: CNA reports that as she was walking toward another resident, Resident #50 opened the door and hit the other resident on the right side of her head. CNA reports she told Resident #50 not to hit, and as CNA was walking toward residents in an attempt to redirect the other resident from the situation, Resident #50 hit the other resident again on the right side of her head. Nursing note dated 6/21/2021 at 2:18 p.m., read: Camera reviewed: noted Resident #50 came out of a room and was standing in front of the door. Observed the CNA in the hallway a little far by them. Observed Resident #55 was passing by, and then observed, Resident #50 making a ' soft ' physical contact on the head of Resident #55 with his knuckle. Observed, CNA intervened but resident was able to make another physical contact hitting Resident #55 on the left side of the head which appears to have been a light knuckle touch. Per CNA statement Resident #50 was laughing after the incident when both residents were separated. Resident #55 does not have any signs or symptoms of injuries on her head, noted no signs of non-verbal pain. Resident #55 went back to normal pacing and wandering in the hallway. Resident #50 was placed on the frequent safety checks. Nursing note dated 6/21/21 at 6:08 p.m., read: Resident's physician ordered to increase Seroquel 25 milligram (mg) daily to twice daily due to increased aggressions and behavior of agitation. Nursing note 8/3/21 at 10:30 a.m., read: Heard a loud commotion down the hall, immediately went to see the concern. Noted resident standing in place and another resident on the floor. Received a report from a staff member that this resident pushed the other resident and the resident stumbled, falling onto the floor. Immediately assisted, abuse packet initiated. Appropriate parties notified. Behavior tracking documentation for 7/21/21 through 8/19/21 revealed Resident #50 had a variety of aggressive behaviors. Occurrence of behavioral episode in that 30-day period included: Seven episodes of hitting others; Eight episodes of grabbing others; Nine episodes of pushing others; Fourteen episodes of physical aggression towards others; Eleven episodes of cursing at others; Nineteen episodes of expressing frustration or anger at others; Six episodes of screaming at others; Eight episodes of threatening others; Twelve episodes of enter other resident rooms or personal space; and, Nine episodes of being agitated. The comprehensive care plan documented in part, the following needs: Behavior care focus, revised 1/28/21: Resident #50 has a behavior problem related to dementia, anxiety and depression. Resident #50 often has exit seeking behaviors and will push on the locked doors. Resident #50 has an Alzheimer's cat that he carries around with him which helps with his anxious behaviors. Goal: Resident #50's behavioral episodes will be minimized. Interventions: -Administer medications as ordered; -Monitor/document for side effects and effectiveness; -Anticipate and meet the resident's needs; -Caregivers to provide opportunities for positive interaction, attention. Stop and talk with him/her as passing by; -Monitor behavior episodes and attempt to determine underlying cause. Consider location, time of day, persons involved, and situations. Document behavior and potential causes. Communication care focus, revised 6/30/21: Resident #50 has a communication problem related to dementia. He usually does not understand what is being said to him. He is able to communicate his basic needs. Wandering care focus, revised 6/30/21: Resident #50 is an elopement risk/wanderer related to dementia. He has poor insight into his deficits and poor safety awareness. Interventions: -Monitor location frequently. Document wandering behavior and allow to wander safely. -As of 8/18/21, the resident's care plan, did not identify the resident's known aggressive behaviors; linking the resident behavioral expressions to potential physical aggressive resident-to-resident altercation which could putting other resident at risk of harm; or provide interventions to prevent the resident form engaging in resident-to-resident altercations or being a victim of physical abuse. Physicians note documented the following treatment recommendation and findings: IV. Resident #55 A. Resident status Resident #55, age [AGE], was admitted on [DATE]. According to the August 2021 CPO, diagnoses included Alzheimer's disease, dementia with behavioral disturbance, anxiety, and repeated falls. According to the 6/29/21 MDS assessment the resident had severely impaired cognition and scored a zero out of 15 on the BIMS exam. The MDS identified the resident did not show signs of verbal or physical aggression during the time of the assessment. The resident was not wandering and did not reject care. The resident required limited assistance form one staff with transfers; and non-weight bearing guided assistance while walking around the unit. The resident was taking daily antipsychotic and antianxiety medication. The MDS indicated Resident #55 enjoyed books and magazines; being around animals; going outside when the weather was good; participating in religious activities or practices; and doing her favorite activities. Music was somewhat important to the resident. B. Observation and interview Resident #55 was observed in the common area on 8/16/21 from at 9:02 a.m. until 12:55 p.m. Resident #55 was wandering the entire observation going up and down the hall and walking throughout the common area /dining room. The resident was observed touching numerous surfaces, rearranging chairs and items on the dining table. She approached several residents standing very close to them, touching their person appearing to pat them on the shoulder or wiping something from their person. Staff had to provide continuous supervision and redirection to prevent Resident #55 from getting in her peers' personal space and away from residents telling her to go away. Resident #55 was easily annoyed and agitated by staff's redirection attempts. She would yell at staff when they tried to make her sit in one place. Resident #55 ignored interview questions and was focused on busy work of wiping tables with her hands and rearranging chairs. C. Record review Progress notes revealed Resident #55 was subject to several physical aggressive interactions from other residents; documented as follows: Weekly nursing note dated 1/17/21at 1:32 p.m., read in part: Resident is alert and oriented to self, poor memory and recall is baseline. Confusion is baseline. Speaks English. Resident is able to verbalize very few wants and needs. Most wants and needs anticipated by staff per cueing and prompts. Vision and hearing adequate. Communication/behaviors: Resident remains very intrusive of others and their space and belongings. Resident irritating other residents due to intrusiveness. Resident also paces hallways often. Resident will sometimes begin to remove pants and use a chair in the dining room as a toilet. Redirected and assisted to the bathroom when noted. These behaviors remain baseline . Nursing note dated 1/23/21 at 5:32 p.m., read: CNA reported that this resident was pushed by another resident while she was walking in the dining room and got close to the other resident. CNA reports that she was able to help guide the fall and keep resident from hitting her head. Resident was assessed and no injuries were noted . Nursing note dated 1/24/21 at 2:08 p.m., read: Resident continues on follow up related to physical aggression received .Resident occasionally noted engaging with other resident's, causing them to grow irritated . Nursing note 4/4/21 at 6:03 p.m., read: Registered nurse (RN) heard resident scream and looked to see resident resting on the floor in the hallway on her bottom. A CNA was right next to resident and witnessed event. Resident #55 was talking to another resident and was really close to the other residents That resident pushed Resident #55 she lost her balance due to being pushed by other resident and she fell down onto her bottom. The other resident walked away without any further altercation. Resident #55 did not hit her head when she fell per the CNA witness. Resident #55 was assisted up. Resident range of motion was with in normal limits . Risk management review note dated 4/7/21 at 2:55 p.m., read: Date of incident: 4/4/21 at 4:20 p.m. Type of incident: staff witnessed this resident being pushed by another resident and this resident fell on her bottom and did not hit her head. Root cause: this resident was right in the face of another resident and was talking too close. Treatment required: no injuries evident. Interventions put into place: frequent checks. Nursing note dated 6/21/21 at 11:50 a.m., read: CNA reports that .another resident hit this res. on the right side of her head with his fist . CNA was attempting to assist this resident away from the situation; the other resident hit this resident again on the right side of her head. (See note dated the same date above in Resident #50's record review section). Risk management review note dated 6/23/21 at 6:20 p.m., read: Date of incident: 6/21/21. Type of incident: this resident received a physical tough (hit) from another male resident in the hallway on her head when she was pacing. Root Cause: this resident paces in the hallway, babbles and says things. Treatment required: this resident has no signs or symptoms of pain or injury. Interventions put into place: placed frequent checks on the alleged assailant. Weekly nursing note dated 7/11/21 at 2:02 p.m., read in part: Mentation: Resident alert and oriented to self only. Resident is confused to time, place and people. Resident cannot hold a conversation, resident tends to just blurt out .Resident is constantly pacing the halls during the shift. Resident tends to upset other residents by blurting out. Nursing note dated 8/3/21 at 10:31 a.m., read in part: Heard loud commotion down the hall, immediately ran to find the concern, and noted resident down the hall near the door laying on the floor on the left side. Staff states that she was pushed onto the floor by another resident. No injury. Resident given routine scheduled Tylenol for possible pain. CNAs advised to watch the dining room and hallway more closely. Behavior tracking documentation for 7/20/21 through 8/17/21 revealed Resident #55 had a variety of aggressive behaviors. Occurrence of behavioral episode in that 30-day period included: Seven episodes of hitting others; Twenty episodes of grabbing others; Fourteen episodes of pushing others; Twelve episodes of physical aggression towards others; Twenty-one episodes of cursing at others; Twenty-four episodes of expressing frustration or anger at others; Fourteen episodes of screaming at others; Nine episodes of threatening others; Twenty-three episodes of enter other resident rooms or personal space; and, Eighteen episodes of being agitated. The comprehensive care plan documented in part, the following needs: Behavior care focus, revised 5/27/21: Resident #55 is intrusive at times, reaches out to other residents, grabs their walker or touches them. This kind of behavior instigates physical altercations with other resident at times. Recently, Resident #55 slapped other person in face when the other resident did not allow Resident #55 to take her walker. Interventions: -Behavior monitoring and medication; -Review behaviors/interventions and alternate therapies attempted and their effectiveness as per facility policy; -Redirection by walking arm to arm with resident effectively; constant redirection is required for resident to minimize being intrusive to other resident's personal space. -As of 8/18/21, the resident's care plan did not identify the resident's known aggressive behaviors; linking the resident behavioral expressions to potential physical aggressive resident-to-resident altercation which could putting other resident at risk of harm; or provide interventions to prevent the resident form engaging in resident-to-resident altercations or being a victim of physical abuse. V. Resident #6 A. Resident status Resident #6, age [AGE], was admitted on [DATE]. According to the August 2021 CPO, diagnoses included dementia with behavioral disturbance, diabetes mellitus, and hypotension. According to the 5/16//21 MDS annual assessment a BIMS could not be completed. The MDS identified the resident had severe cognitive impairment with a short term and long-term memory deficit. The MDS did not identify that the resident had signs of symptoms of delirium, disorganized thinking or inattention. The MDS identified the resident had no shown signs of verbal or physical aggression during the time of the assessment. The resident was not wandering and did not reject care. According to the MDS, the resident was short tempered and easily annoyed. The resident required extensive assistance form one staff to transfers form surface to surface; and supervision, oversight and cuing while walking around the unit. The resident was taking daily antipsychotic and antidepressant medication. B. Observation and interview Resident #6 was observed on 8/18/21 from 2:30 p.m. to 3:30 p.m. Resident #6 was engaged in continual wandering the main hall of the unit back and forth. Resident #6 took possession of another resident walker, who was not actively using the walker at the time. Resident #6 pushed the walker from the side and from the back, using it inappropriately, up and down the hall several times without staff guidance or redirection. Resident #6 approached another resident on a couple of occasions and verbalized something to the other resident but his language was not nonsensical. C. Record review Progress notes revealed Resident #6 had been subject to physical aggressive interactions by other residents and had been physically aggressive towards other residents; documented as follows: Nursing note dated 5/22/21 at 6:28 p.m., it read: CNA came to this writer with concern that resident had been hit while in another residents room after hearing resident yell ' Oh, you b**** ' . Resident was seen walking out of room [ROOM NUMBER] with his right hand over the right side of his face. Resident assessed for injury, none observed, placed on 15-minute checks and neuro checks. Writer spoke with the assailant who verbally confirmed that they had struck the patient with a closed fist to the face after seeing resident attempt to take another resident's shoes. This writer explained to resident that it is not appropriate to put their hands on another resident to which resident replied ' oh, f*** off. Nursing note dated 5/23/21 at 1:15 p.m., read: Resident on follow up related to receiving physical aggression.Resident has been wandering throughout the unit majority of the shift. Resident continues to wander into other residents ' rooms despite consistent redirection from staff. Resident becomes combative when the staff tries to redirect . Nursing note dated 7/16/21 at 1:01 p.m., read: Heard staff yell for assistance, immediately left nurses station and noted Resident #50 was standing behind Resident #6 with his arm around his chest and neck area as Resident #6 was yelling and cursing ' get off me ' . Resident #6 had no signs or symptoms of trouble breathing or voicing. Staff immediately separated both residents. Assessed Resident #6 for injuries, no noted injuries . Physician note dated 7/16/21 at 5:56 p.m., read in part: Medical necessity of visit: report of acute episode. Chief complaint: Resident #6 is seen at the request of nursing after an altercation with another resident on the unit. Resident #6 has dementia. He has impulsive behavior and wanders in and out of other resident's rooms. Today he went into another resident's room and picked up glasses from a bedside table. The other resident put Resident #6 in a ' choke hold ' . Staff were able to separate the two residents and Resident #6 returned to his room. He had no soft tissue or other injury from the incident .Plan: continue to monitor, may need adjustment in medications if he continues to get into physical altercations with other residents. Nursing note dated 7/19/21 at 12:13 p.m., read in part: Resident is alert and oriented to self only. Resident has confusion related to time, situation and people. Resident is able to express some needs, some needs are anticipated by staff. Resident has adequate hearing and vision. Communication/Behaviors: Resident at times paces the hallway. Resident at times will get into other residents personal space. Resident at times will take items belonging to other residents. Resident is combative toward staff at times . Nursing note dated 7/26/21 at 6:29 p.m., read: This nurse was in the dining room getting all resident's set up for dinner. This resident came out of a room pushing a wheelchair. Myself and two CNA's took the wheelchair and tried redirecting. Resident became very combative .While CNA was redirecting the resident down the hall and passed another resident and reached out and slapped the other resident in the face . Behavior tracking documentation for 7/21/21 through 8/19/21 revealed Resident #6 had a variety of aggressive behaviors. Occurrence of behavioral episode in that 30-day period included: Twenty-seven episodes of hitting others; Thirteen episodes of grabbing others; Fourteen episodes of kicking others; Nine episodes of pushing others; Nineteen episodes of physical aggression towards others; Eleven episodes of cursing at others; Twenty-three episodes of expressing frustration or anger at others; Four episodes of screaming at others; Ten episodes of threatening others; Sixteen episodes of enter other resident rooms or personal space; and, Twenty-one episodes of being agitated. The comprehensive care plan documented in part, the following needs: Behavior care focus, revised 3/8/21: Resident #6 has a behavior problem related to dementia with behavioral disturbance. Goal: Resident #6's number of behavioral episodes will be minimized. Interventions: -Caregivers to provide opportunities for positive interaction, attention. Stop and talk with him/her as they pass by. -Monitor behavior episodes and attempt to determine underlying cause. Consider location, time of day, persons involved, and situations. Document behavior and potential causes. -Praise any indication of the resident's progress/improvement in behavior. Communication care focus, revised 3/8/21: Resident #6 has a communication problem related to dementia with behavioral disturbance. His speech is difficult to understand at times due to word salad when he talks. He does make clear, concise, short statements at times. Interventions: -Anticipate and meet needs. -Encourage resident to continue stating thoughts even if the resident is having difficulty. -As of 8/18/21, the resident's care plan did not identify the resident's known aggressive behaviors; linking the resident behavioral expressions to potential physical aggressive resident-to-resident altercation which could putting other resident at risk of harm; or provide interventions to prevent the resident form engaging in resident-to-resident altercations or being a victim of physical abuse. VI. Resident #73 A. Resident status Resident #73, age [AGE], was admitted on [DATE]. According to the August 2021 CPO, diagnoses included hallucinations, lewy body dementia and atherosclerotic heart disease. According to the 7/1/21 MDS annual assessment the resident had moderately impaired cognition with a BIMS score of 12 out of 15. The MDS identified the resident had not shown signs of physical aggression towards others and did not reject care. The resident did display verbal aggression towards others, was wandering and displayed other behavioral expressions not director towards other one to three day during the week. The assessment did not document how the resident behavior affected other resident on the unit. The resident had no signs of delirium or psychosis. The resident required supervision, oversight and cuing form one staff to transfers from surface to surface; and used a walker device to walk around the unit. The resident was taking any antipsychotic medication. B. Observation and interview Resident #73 was observed on 8/16/21 at 9:30 a.m. and 8/18/21 at 4:06 p.m. On both occasions the resident was in his room lying down in his bed. On 8/18/21 at 3:32 p.m., Resident #59 exited his room to walk the hallway for about 10 minutes before returning to his room, during that time he did not engage with other residents on the unit. Resident #73 was not very talkative and did not answer any questions asked of him. C. Record review Progress notes revealed Resident #73 had been physical aggressive towards another resident on one occasion; documented as follows: Nursing note dated 7/16/21 at 12:55 p.m., read: Heard staff yell for assistance, immediately left nurses station and noted Resident #73 standing behind Resident #6 with his arm around Resident #6's chest and neck area. Resident #6 was yelling and cursing ' get off me ' . Physician's note dated 7/16/21 at 6:10 p.m., read in part: Nursing requested that I see the patient today. Chief complaint: Resident #50 is seen at the request of nursing for involvement in a physical altercation with another resident earlier today. Resident #73 has dementia and is in the secured unit. Earlier today, he was in an altercation with another resident on the unit. Per staff report, the other resident entered Resident #73's room and picked up his glasses. Resident #73 felt the other resident was going to steal his glasses so he put him in a choke hold. Staff intervened and he let the other resident leave the room without further incident. Resident #73 is currently on quetiapine twice daily for behaviors . Assessment and Plan: Other[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interviews, the facility failed to ensure three (#50. #55 and #6) of seven residents reviewed for dementia care of 59 sample residents, received the appropriate treatment and services to maintain their highest practicable physical, mental and psychosocial well-being. Specifically, the facility failed to ensure Residents #50, #55, and #6 received: -Personalized care plans with focused interventions to meet the resident assessed needs including; developed individualized interventions; non-pharmacological approaches to care were utilized; developed person centered purposeful and meaningful activities addressing the resident's past customary routines, interests, preferences, and choices to enhance the resident's well-being; and the provision of meaningful activities thought the day; -Personalized care plans which identified tracked behavioral expressions linked to a potential for physical aggressive episodes with the potential for resident-to-resident altercation or result in potential harm or provide interventions to prevent the resident form engaging in resident-to-resident altercations or being a victim of physical abuse; and, -The benefits of residing in a home-like environment that was void of negative resident-to-resident interactions that caused the residents distress resulting in physically abusive interactions. Findings include: I. Facility policy and procedure The Dementia Clinical Protocol policy, last revised November 2018, was provided by the regional nurse consultant (RNC) on 8/19/21 at 12;28 P.M., it read in part: The IDT (interdisciplinary team) will evaluate individuals with new or progressive cognitive impairment and help identify symptoms and findings that differentiate dementia from other causes .The physician will identify individuals taking cholinesterase inhibitors or other medications used to try to stabilize cognitive function, or medications such as antipsychotic medications and mood stabilizers that are commonly ordered to try to manage problematic behavior and disturbed mood. The staff and physician will evaluate individuals with new or worsening cognitive impairment and behavior and differentiate dementia from other causes (see policy on Delirium/Altered Mental States) The staff and physician will collaborate to stage dementia and identify prognosis .The staff and physician will collaborate to stage dementia and identify prognosis. -Direct care staff will support the resident in initiating and completing activities and tasks of daily living. Bathing dressing, mealtimes, and therapeutic and recreational activities will be supervised and supported throughout the day as needed. -The IDT will identify and document the resident's condition and level of support needed during care planning and review changing needs as they arise. -Resident needs will be communicated to direct care staff through care plan conferences, during change of shift communications and through written documentation (nurses' notes and documentation tools). -Progressive or persistent worsening of symptoms and increased need of staff support will be reported to the IDT. -The physician will help define potential benefits and risks of medical interventions . - The physician will order appropriate interventions to address significant behavioral and psychiatric symptoms, based on pertinent clinical guidelines and consistent with regulatory requirements. - The staff will monitor the individual with dementia for changes in condition and decline in function and will report these findings to the physician. -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. -The physician and staff will review the effectiveness and complications of medications used to try to enhance cognition and manage behavioral and psychiatric symptoms and will adjust, stop, or change such medications as indicated. II. Resident census and conditions The facility Resident Census and Condition of Residents dated 8/18/21, was provided by the director of nursing. The document revealed the facility's total census of 136 residents with 50 residents were diagnosed with dementia of Alzhiemer's disease; 57 residents were diagnosed with a psychiatric diagnosis other than dementia and depression; and 67 residents had behavioral healthcare needs requiring a care plan to support them. III. Resident #50 A. Resident status Resident #50, age [AGE], was admitted on [DATE]. According to the August 2021 computerized physician orders (CPO), diagnoses included dementia with behavioral disturbance, depression, and chronic obstructive pulmonary disease (COPD). According to the 6/21/21 minimum data set (MDS) assessment the resident had severely impaired cognition and scored a zero out of 15 on the brief interview for mental status (BIMS) exam. The MDS identified the resident had not shown signs of verbal or physical aggression during the time of the assessment. The resident was not wandering and did not reject care. The resident required supervision, oversight, cuing and encouragement with bed mobility, transfers; and was able to walk with supervision (oversight and cuing). The resident was taking daily antipsychotic and antidepressant medication. B. Record review Progress notes, dated 11/23/2020 through 8/5/21, and behavioral tracking records revealed Resident #50 had several physical aggressive interactions towards other residents; where Resident #50 was the aggressor acting out with verbal and physical aggression. Behavior tracking documentation for 7/21/21 through 8/19/21 revealed Resident #50 had over nineteen days where he expressed his frustration and anger directed towards other individuals, including staff and other residents. These emotions present as aggressive behaviors directed towards other individuals in the community on a frequent basis. Behaviors included hitting, grabbing, pushing, cursing, screaming, threatening, invading personal space and other physical acts of aggression and anger. The comprehensive care plan revised 6/30/21 documented several care needs related to the resident diagnosis of dementia. The care planned focus care areas for: -Behaviors related to anxiety and depression displayed as exit seeking attempts. -Communication difficulties steaming from an inability to understand what others are saying. -Wandering and elopement attempts, which were problematic due to the resident's poor insight into his deficits and poor safety awareness. -Need for secured unit placement due to an inability to safely care for himself in the community. and behaviors. -Activity preferences for some group activities; coloring; spending time outdoors; gardening; working with his hands; watching television and listening to music. -Sexual intimacy with a female peer. The care plan document that a sexual intimacy consent was conducted with Resident #50 and partner, but there was no guidance to identify the partner or give staff guidance to the outcome results of the assessment. -The care plan did not identify a care plan focus to address the resident aggressive nature director towards other individual or give staff guidance for interventions to prevent Resident #50 from taking out his anger and frustration against his peers. The care plan lacked non-pharmaceutical resident specific interventions to address resident care needs. C. Activity interventions The initial activities assessment dated [DATE] revealed the resident had previously enjoyed gardening and taking care of his own lawn, working with his hands and watching old television (TV) shows. All activities offered needed to be modified to accommodate the resident's cognitive deficit, communication deficit, sensory deficits and the resident benefited from personal invites and encouragement to attend activities with a seat by group leader. The activities care plan was provided by the NHA on 8/19/21 at 10:10 a.m., The activities detail was dated for a review start date of 9/14/21, it documented Resident #50 enjoys independent leisure and may enjoy group activities from time to time, such as coloring. Resident #50 enjoys spending time outdoors and used to enjoy gardening and taking care of his lawn. He enjoys working with his hands. Resident #50 enjoys spending time in his room to rest and watch classic TV shows. He enjoys supervised smoke breaks from time to time. [NAME] also enjoys listening to music. Goal Resident #50 will participate in 1-3 structured activities of interest each week, as available. Resident #50 will remain independent in structuring his day with leisure of his choosing and will engage in at least one independent leisure pursuit each day such as watching classic TV shows or spending time outside. Interventions: -Staff are aware that resident may stay up late at night and need time to rest the following day -Staff will create a record of resident's independent leisure and structured group participation to establish a baseline and monitor for any change. -Staff will invite, remind, and encourage resident to participate in group activities that may be of interest -Staff will offer and provide resident with independent leisure resources as needed. -Staff will offer resident an activity calendar each month. According to the activities participation records he resident participated in seven group activities from April 2021 through July 2021. Including karaoke, trivia, dancing, folding towels, chair yoga and ice coffee; none of which met his assessed interests. The resident participated in eleven one-to-one activities in his room from 7/22/21 to 8/17/21; no detail of level of participation was given. D. Resident altercations The resident was involved in an altercation on 8/3/21 where Resident #50 was observed in the hall pushing Resident #55 causing Resident #55 to fall backwards onto the floor. Per the social services director (SSD) Resident #50 appeared to be angry. The SSD attributed resident #50's anger to the close proximity that Resident #55 was in his personal space. Resident #55's record documented that she could be intrusive, getting too close to other resident in their personal space; this behavior distressed and upset other residents when staff were not present to redirect Resident #55 from invading their space. (Cross-reference F600 for abuse). The facility failed to provide personalized care interventions to meet the resident's dementia care needs to prevent resident to resident altercations. IV. Resident #55 A. Resident status Resident #55, age [AGE], was admitted on [DATE]. According to the August 2021 CPO, diagnoses included Alzheimer's disease, dementia with behavioral disturbance, anxiety, and repeated falls. According to the 6/29/21 MDS assessment the resident had severely impaired cognition and scored a zero out of 15 on the BIMS exam. The MDS identified the resident was not shown signs of verbal or physical aggression during the time of the assessment. The resident was not wandering and did not reject care. The resident required limited assistance form one staff with transfers; and non-weight bearing guided assistance while walking around the unit. The resident was taking daily antipsychotic and antianxiety medication. The MDS indicated Resident #55 enjoyed books and magazines; being around animals; going outside when the weather was good; participating in religious activities or practices; and doing her favorite activities. Music was somewhat important to the resident. B. Record review Progress notes, dated 1/17/21 through 8/3/21, and behavioral tracking records revealed Resident #55 had several physical aggressive interactions towards other residents. The progress note revealed the resident's intrusive behaviors contributed to her involvement as either the aggressor and/or the victim of another resident's aggressive behavior. Behavior tracking documentation for 7/20/21 through 8/17/21 revealed Resident #55 had over twenty-four days where she expressed frustration and anger directed towards other individuals, including staff and other residents. These emotions present as aggressive behaviors directed towards other individuals in the community. Behaviors included hitting, grabbing, pushing, cursing, screaming, threatening, and invading the personal space of other resident's. The comprehensive care plan revised 6/28/21 documented several care needs related to the resident diagnosis of Alzheimer's disease. The care planned focus care areas for: -Behavioral disturbances related to resident intrusiveness, reaching out to touch or grab other residents and or their belongings and then getting agitated and physically combative when the other resident resists her taking their assistive devices and other personal belongings. One of the care planned interventions was Redirection by walking arm to arm with resident effectively; constant redirection is required for resident to minimize being intrusive to other residents personal space. While their intervention may be effective initially, the intervention also causes the resident distress, anger and anxiety (see unit observation below) there was no other alternative intervention listed when this technique starts to fail. -Communication difficulties steaming from frustration and difficulties expressing needs and wants. -Wandering and elopement risk. -Need for secured unit placement due to wandering and behaviors. -Activity preferences for walking, singing and engaging in helpful activities. Intervention included only offer group activities and failed to provide intervention for meaningful activities the resident could engage in in between group activities. -The care plan did not identify a care plan focus to address the resident aggressive nature director towards other individual or give staff guidance for interventions to prevent Resident #55 being intrusive with other residents except for the arm and arm redirection. (see care plan above) C. Activity interventions The initial activities assessment dated [DATE] revealed the resident had previously enjoyed teaching, being outdoors, walking and singing. All activities offered needed to be modified to accommodate the resident's cognitive deficit, communication deficit, and the resident benefited from personal invites and encouragement to attend activities with a seat by group leader. Resident #55 was usually walking the halls, and was easily redirected. She would benefit from a seat by the group leader. Resident #55 may not understand a complex activity. Provide simple things to do like throwing a balloon, folding towels or singing. The activities care plan was provided by the NHA on 8/19/21 at 10:10 a.m., The activities detail was dated for a review start date of 7/13/21, it documented Resident #55 enjoys walking in the hallway during the day. She also enjoys singing while she walks. Resident liked to be helpful to others; at times other residents may perceive her helpfulness as distracting and resident can be redirected with a sucker and a walk. While walking Resident #55 enjoys talking (has limited vocabulary) to care partners and peers in the neighborhood. Resident has a family that she received regular visits from, as they are available, or phone calls. Resident previously enjoyed teaching and helping at home. Resident #55 enjoyed coloring and doodling, currently she enjoys holding and taking care of her doll. Resident enjoyed reading the Daily Chronicle, listening to music ([NAME] Diamond/[NAME]), using, being around cats, being outdoors on nice days and son stated, she always said the Lord's Prayer before bed. Goal: Resident will participate in independent leisure on a daily basis by walking around the neighborhood, playing with her doll, talking to care partners and peers and/or listening to music. Resident will participate, actively or passively, in 1-3 structured activities of interest each week, as available. Interventions: -At times Resident may confuse her doll with another Residents doll in the neighborhood. Care partners will intervene and make sure both Residents have dolls accessible (will search for dolls if needed) to decrease frustration and agitation. -Care partners will remind and show Resident of the activity calendar in the neighborhood to remind/orient Resident to the groups of the day. -Staff will invite, encourage, and remind resident of structured activities that may be of interest -Staff will offer and provide resident with independent leisure supplies as needed, such as her doll she enjoys taking care of. -Staff will offer resident a lollipop as a redirection when she is trying to be helpful to other residents and they become agitated; staff will offer resident to help with tasks as available. -Staff will provide simplified directions for resident during group activities to encourage active participation. New Intervention New Custom Intervention -Distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television and books. -Provide structured activities: toileting, walking inside and outside, reorientation strategies including signs, pictures. According to the activities participation records the resident participated in twelve group activities from April 2021 through July 2021. Including karaoke, trivia, dancing, price is right, folding towels, chair yoga and ice coffee, relaxing videos; none of which met his assessed interests. The resident participated in thirteen one to one activities in his room from 7/20/21 to 8/17/21; no detail of level of participation was given. Activity note dated 6/28/21 at 8:39 a.m., read in part: Resident benefits from constant reminders due to her poor memory, verbal cuing, visual demonstration, and hand in hand direction from staff to participate in activities. Resident can communicate in a few clear words but many can still be indecipherable; staff should determine her enjoyment of activities based on her facial expressions and laughter or no laughter.Activities staff can encourage her to participate, even just for seconds to a few minutes. Resident can still often get into other residents ' personal space and try to help them, which can lead to other residents becoming angry and even aggressive with her. Activities staff should redirect her with the activity or give her a lollipop and direct her to walk down the hallway. Participation: Resident continues to still achieve at least one of her goals of engaging in independent leisure on a daily basis, where she walks around the hallway, cleans tables, sings, plays with her baby doll, and socializes with some staff and peers every day still.Regarding the goal of engaging structured activities per week, Resident often walks into the dining room when a group is occurring; then walks out or has to be redirected as she will get in other residents ' personal space. She has recently participated in karaoke/trivia, where she sat down for a little during it and watched. Activities staff will continue to invite her to structured activities and encourage her to participate, even just for a short span of time. There are no changes to note related to participation in leisure activities. D. Resident altercations The resident was involved in an altercation on 8/3/21 where Resident #55 became intrusive with Resident #50, getting to close into Resident #50's personal space. Per the investigative report Resident #55's behavior angered Resident #50 when there was no staff to redirect her away from him. Resident #50 was observed pushing Resident #55 causing her to fall backwards onto the floor. (Cross-reference F600). The facility failed to provide personalized care interventions to meet the resident's dementia care needs to prevent resident to resident altercations. V. Resident #6 A. Resident status Resident #6, age [AGE], was admitted on [DATE]. According to the August 2021 CPO, diagnoses included dementia with behavioral disturbance, diabetes mellitus, and hypotension. According to the 5/16/21 MDS annual assessment a BIMS could not be completed. The MDS identified the resident had severe cognitive impairment with a short term and long-term memory deficit. The MDS did not identify that the resident had signs of symptoms of delirium, disorganized thinking or inattention. The MDS identified the resident had no shown signs of verbal or physical aggression during the time of the assessment. The resident was not wandering and did not reject care. According to the MDS, the resident was short tempered and easily annoyed. The resident required extensive assistance form one staff to transfers form surface to surface; and supervision, oversight and cuing while walking around the unit. The resident was taking daily antipsychotic and antidepressant medication. B. Record review Progress notes, dated 5/22/21 through 8/1/21, and behavioral tracking records revealed Resident #6 had several physical aggressive interactions towards other residents. The progress note revealed the resident's intrusive behavior and wandering into other resident rooms, taking the belongings of others contributed to his involvement as either the aggressor and/or the victim of another resident's aggressive behavior. Behavior tracking documentation for 7/21/21 through 8/19/21 revealed Resident #6 had over nineteen episodes of physical aggressions towards others. Behaviors included hitting, grabbing, kicking, pushing, cursing, screaming, threatening, and invading the personal space of other resident's. The comprehensive care plan revised 8/9/21 documented several care needs related to the resident diagnosis of dementia with behavioral disturbance. The care planned focus care areas for: -Behavioral disturbances related to refusal of care. combativeness, and the need for positive reinforcement and ability to have control over as much of his routine as possible. -Communication: speech was difficult to understand due to nonsensical language and the use of wrong words. -Wandering and elopement risk. -Need for secured unit placement due to poor memory, judgment and safety awareness. -Activity preferences for singing, dancing, picture books or magazines. engaging in helpful activities. Intervention included only offer group activities and failed to provide intervention for meaningful activities the resident could engage in in between group activities. Staff to create a record of resident's independent leisure and group activity participation to establish a baseline and monitor for any change. -The care plan did not identify a care plan focus to address the resident aggressive nature director towards other individual or give staff guidance for interventions to prevent Resident #6 from being intrusive with other residents, taking their belongings and risking a resident to resident to resident physical alteration. C. Activity interventions The initial activities assessment dated [DATE] revealed the resident used to sing in a gospel choir and liked a variety of music, particularly the oldies. The resident liked to dance and was a very social person. The resident was catholic and would occasionally attend church. Based on assessments done by other staff members, Resident #6 can be combative towards staff and engage in inappropriate behaviors related to dementia. Activities staff should provide choice and give him as much control as possible. Based on assessments done by other staff members, Resident can have difficulty communicating related to dementia. Activities staff should practice active listening with him asking simple questions and encourage him to verbally express himself and ask him simple questions and encourage him to verbally express himself. The activities care plan was provided by the NHA on 8/19/21 at 10:10 a.m., The activities detail was dated for a review start date of 8/11/21, it documented Resident #6 is a very sociable person and used to sing in a Gospel choir. [NAME] also likes a variety of music, particularly rhythm and blues and the oldies, and likes to dance. Lastly, if he is in the mood, he would enjoy looking at reading material with pictures. Goal: Resident will continue to be independent in structuring his day with leisure of his choosing and will engage in at least one independent leisure pursuit each day such as spending time watching television. Resident will participate in 1-3 structured activities of interest in a period of two weeks, as available. Interventions: -Staff will create a record of resident's independent leisure and group activity participation to establish a baseline and monitor for any change. -Staff will direct resident to groups of interest, as well as assisting residents to and from group activities as needed, and will ensure the resident is able to find his room following a group activity if he chooses to attend. -Staff will invite, remind, and encourage resident to participate in group activities of interest. According to the activities participation records the resident participated in twelve group activities from April 2021 through August 2021. Including karaoke, trivia, price is right, chair yoga and ice coffee, movies, bingo, music. The resident participated in nine one to one activities in his room from 7/20/21 to 8/17/21; no detail of level of participation was given. Activity note dated 8/5/21 at 11:21 a.m., read in part: Resident #6 is able to communicate but still has mumbled speech and is difficult to understand. Staff need to get close to him and ask concrete or yes/no questions to facilitate understanding. Resident ambulates independently. Resident has dementia, so staff need to remind him of activities coming up and staff should ensure to bring him into the area where the activity will be so he may participate. Resident can be verbally and sometimes physically aggressive towards his peers and staff if he is having a mood disturbance, where staff need to redirect him and leave him alone. Resident appears to be accomplishing his independent leisure activities and structured, group activities goal. Independently, he continues to walk through the halls, watch TV in the dining room, listen to music, sometimes socialize with staff and peers, and look through the Daily Chronicle. He has also participated in various groups over two weeks passively and participates in music and dance groups actively, dancing to the music, particularly rhythm and blues music. He has also accepted some snacks, particularly ice coffee. Activities staff will continue to invite the resident to groups, especially music and dance groups. Resident appears to be more on his feet in this quarter and has participated in more activities, particularly music and dance activities. Care plan has been reviewed and updated to reflect Resident currently, particularly updating her focus. D. Resident altercations The resident was involved in an altercation on 7/6/21 where Resident #6 wandered into Resident #73's room and picked up his glasses. Resident #73 tried to get his glasses back but Resident #6 would not give them back. Resident #73 physically restrained Resident #6 in a and on 7/16/21 Resident #6 took a resident's wheelchair when staff intervene and redirect Resident #6 away form the other resident's wheelchair Resident #6 became combative. As staff were redirecting the resident down the hall Resident #6 reached out and slapped Resident #87 in the face as he passed by her in the hall. (Cross-reference F600). The facility failed to provide personalized care interventions to meet the resident's dementia care needs to prevent resident to resident altercations. VI. Observations The secured dementia care unit was observed on 8/16/21 at 10:00 a.m. to 11:55 a.m. The residents were pacing the unit, Resident #55 was wiping the tables moving chairs and wandering the unit; as Resident #55 wandered she got very close to several residents and had to be redirected away for the residents. Staff redirection was making her agitated and she yelled at staff to get away from her. There were no activities occurring during the observation. The secured dementia care unit was observed on 8/17/21 at 11:00 a.m. Several residents were observed walking up and down the hall; walking to the end of the hall looking out the patio door trying to get outside. The door was locked and they were unable to get outside at that time. There were no activities occurring at the time of the observation. The secured unit was observed on 8/18/21 at 4:06 p.m. eight residents were seated in the common area with no activity. The television was on but the volume was down and no residents were paying attention to it. One male resident was vigorously rubbing his pant leg and chair armrest. Resident #6 took possession of another resident walker and was pushing it down the hall back and forth from the patio door to the dining area. Resident #87 was wandering the hall in her wheelchair and getting caught in other resident's wheelchair while singing to herself. Another female resident said she wish Resident #87 would stop singing that same song. Another make resident was pacing the hall back and forth to the patio door and the dining room. He tried to exit the unit several times but was unsuccessful. Resident tried to get out the main door and was unsuccessful. At 4:19 p.m. staff turned on the radio but did not engage with the resident's about the music. Resident #55 was trying to move furniture in the dining room. Staff tried to get her to sit down but she refused and started to wander the unit; touching another resident who told her to go away. Staff tried to redirect Resident #55 when she became agitated. The INHA came to the unit at 4:22 p.m. and instructed staff to provide an activity for the residents. At 4:43 p.m., staff started a ball toss and work recall activity; ten residents gathered in a circle and actively participated in the activity and appeared to be having a good time. VII. Interviews The social services director (SSD) was interviewed on 8/17/21 at 4:00 p.m. The SSD said the residents on the secured dementia care unit were frequently in resident to resident altercations. There had been an increase in incidents since the COVID pandemic when group activities were put on hold. The residents need distraction, frequent redirection through activities to prevent boredom and aggressive behavior. Activities staff were on the unit to provide group activities and mostly one-to-one activity programming but activity programming needed to occur in-between the activities present on the unit. There was no staff assigned to provide activities in between the scheduled activities and in the evening. The SSD said she tried to engage the residents in activities and give them meaningful activities because the unit did not have regular activities programming and since the decrease in activities programming there had been an increase in resident to resident altercations and reported incidents. The activities director (AD) was interviewed on 8/18/21 at 4:45 p.m. The AD said they recently hired two activities staff this past month and the facility was fully staffed for activities staff. Current activities programming included one-to-one activities like coloring, word puzzles, magazines and books that residents could keep and not share. They could not use any of the activity supplies on the activity shelving like building blocks, puzzles, busy boards. because there was not a way to sanitize the items. Instead the activities program consisted of snacks, movies, television watching, trivia and music to divert the resident from getting bored and engaging in negative behaviors. The activities assistant (AA) #1 was interviewed on 8/19/21 at 4:00 p.m. The AA said she was new to the facility and was getting to know the residents[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review the facility failed to prepare foods using methods that conserve nutritive value, flavor, temperature, and appearance for meals served to the residents on four of four floors. Specifically, the facility failed to conserve the flavor and nutritional value of food served to residents. Findings include: I. Failure to conserve flavor and nutritional value of foods A. Professional reference The Difficulty Chewing: Diet and Eating Tips, September 2019, retrieved on 8/23/21, from:https://www.cancer.net/coping-with-cancer/physical-emotional-and-social-effects-cancer/managing-physical-side-effects/difficulty-chewing reads, moisten dry foods with broth, sauce, butter, or milk. B. Facility policy The Baked Tilapia recipe was received from the interim nursing home administrator (INHA) on 8/19/21 at 1:41 p.m. it read in pertinent part, For any of the above-modified texture diets: Add small amounts of gravy, sauce, vegetable juice, cooking water, fruit juice, milk, or half and half to meet desired consistency. Based on type and amount of liquid/thickener added in the texture modification process, nutrition information may vary. C. Observations Breakfast meal preparations were observed on 8/17/21 from 5:30 a.m. to 8:00 a.m. -At 5:30 a.m. the food and nutrition supervisor (FNS) was observed making breakfast. -At 5:40 a.m. the FNS retrieved a bag of hard-boiled eggs from the refrigerator. He put them into a blender. He added water and 13 pieces of bread to the blender and started it. He blended the eggs, bread, and water until it was the right consistency for a pureed diet (blenderized diet). -At 6:00 a.m. the FNS pureed white bread for the pureed diets. He pureed two and a half loaves of white sandwich bread and added water to the blender before turning the blender on to puree the bread. -At 6:35 a.m. the FNS put sausage into the blender, added water to the sausage, and blended it until smooth. The FNS said he used to use milk to blend the pureed foods. He said the building had some lactose intolerant residents and he stopped using milk and switched to water. He did not know what else he could use to blend pureed foods. -The toast being sent to the floors for meal service was visibly burnt around the edges. The toast was on the steam table and waiting for service at 5:30 a.m. when meal preparation observations began. The toast was not dry but it was burnt and soft from being in the steam table so long prior to meal service. The meals for the fourth floor and the west side of the third floor were plated and wrapped in plastic in the kitchen then sent to the floors in a hot box. D. Test trays A test tray of the regular lunch meal and the pureed lunch meal was provided on 8/17/21 at 1:00 p.m. The meal was served from the steam table on the second floor. The meal was retrieved from the serving cart at 12:55 p.m. after all residents received their lunch meals. The meal consisted of rice (115 F), breaded fish filet (115 F), and mixed vegetables (113 F), soup (142), and mashed potatoes (129 F) pureed diet. All of the meals were served on Styrofoam plates and wrapped in plastic wrap. The rice was dry and flavorless, the fish was dry and three bones were found on the test tray, the pureed fish tasted like the gravy on top of it, the mixed vegetables were unseasoned and were bland, the pureed vegetables were unseasoned and flavorless, the pureed mashed potatoes where bland tasting like no oil or seasoning was used in their cooking, and the soup, vegetable soup with pasta, tasted like tomato paste. A regular lunch meal and a mechanical soft lunch meal tray were retrieved on 8/18/21 at 1:10 p.m. The meal was served from the steam table in the kitchen on the fourth floor. The meal was retrieved from the serving cart at 1:10 p.m. after all residents received their lunch meals. All of the meals were served on Styrofoam plates and wrapped in plastic wrap. The lunch meal consisted of a hot dog in a bun (85 F), mashed potatoes (117.8 F) (mechanical soft), three-bean salad (64 F), and canned peaches (70.5 F). The hot dog was cold, hard to chew, and the bun was soggy, the mechanical soft hot dog was salty and smothered in gravy with no bun and or condiments like ketchup, the mashed potatoes were flavorless and tasted as if they were cooked without oil or seasonings, the three-bean salad tasted like vinegar and could not taste the beans themselves, the mechanical soft three-bean salad tasted like the beans, not vinegar and was salty, and the peaches tasted like canned peaches. E. Resident interviews Residents were identified by facility and assessment as interviewable. Resident #51 was interviewed on 8/16/21 at 11:16 a.m. She said the food was awful and since it was served on paper plates it was always cold. She said most days she threw out her meals without tasting them because they looked so bad. She said sometimes it was spiced too much and was too spicy to eat. Resident #56 was interviewed on 8/16/21 at 12:28 p.m. He said the food received at lunch and dinner was cold every day. He said the waffles from that morning were not cooked all the way and were cold in the middle. He said occasionally the meals were good but most days they were not appealing. He said he usually ate his own food and threw away the food provided by the kitchen. On 8/17/21 at 8:47 a.m. a female resident on the second floor appeared around the corner from the steam table and told the servers that her egg was so fried she could not cut it with her plastic fork and spoon. She accepted scrambled eggs as a replacement. Resident #113 was interviewed on 8/17/21 at 2:00 p.m. He said the lunch was no good and had no flavor. He said he did not find any bones in his fish. Two male residents were interviewed outside on the smoking patio on 8/17/21 at 2:10 p.m. They said their lunches were late and tasted [NAME]. They said the only edible thing on the plate was the fish and it was hard on the edges and only edible in the middle. They said they did not find any bones in the fish at lunch. Resident #56 was interviewed again on 8/17/21 at 2:37 p.m. He said he did not like fish and was not offered any alternatives. He said he pulled the plastic off of his lunch tray and knew he did not want it. He said the eggs from that morning's breakfast were hard and he could not cut them with his plastic silverware. A male resident was interviewed on 8/17/21 at 3:00 p.m. He said the fish was terrible and the rice did not taste right. A resident group meeting of six residents was held on 8/18/21 at 2:00 p.m. The residents in the meeting said the food was bad. They said none of them ordered the fish and on fish days they ordered something else. They said the only issue they had with the facility using paper plates was how they affected the temperature of the food. They said the food always came to them cold. F. Staff interviews The food and nutrition supervisor was interviewed on 8/17/21 at 7:00 a.m. He said he had not received food complaints from residents lately. He said most of the complaints he received were about food being cold when meal trays were delivered to resident rooms. He said when they received the temperature complaints they switched to serving from the steam table and directly from the kitchen for half of the third floor and the fourth floor. The registered dietitian was interviewed on 8/18/21 at 11:00 a.m. She said she had not received any food complaints since they switched food vendors a month ago. She said up until the change of vendors they were receiving multiple food complaints. She said during the COVID outbreak they received complaints about meals being cold when received in rooms and they changed their meal service set up to accommodate temperature and the residents seemed happy with the new setup. The corporate dietitian was interviewed on 8/18/21 at 2:15 p.m. She said water should not be used for pureed foods. She said broth, cooking water, or milk would be better alternatives for pureed foods. She said the facility recently changed food vendors and that had helped improve the number of complaints received from residents.

Based on interviews, observations, and record review, the facilitated failed to store, prepare, distribute, and serve food in accordance with professional standards. Specifically, the facility failed to: -Follow sanitary food service procedures during food service; -Monitor and clean refrigerators in four of five satellite kitchens; and, -Maintain temperature logs for meal service. Findings include: I. Facility policy The Food Wholesomeness policy, updated 1/12/16, was received from the quality improvement specialist (QIS) on 9/19/21 at 12:08 p.m. It read in pertinent part, Store, prepare, distribute, and serve food under sanitary conditions. Food is handled properly with frequent handwashing and proper sanitation guidelines. The kitchen and serving areas are clean at all times. A cleaning schedule is followed and initialed when tasks are done. Food temperatures are taken for serving at every meal and at the point when a resident is served a meal on a regular basis. Food temperatures are recorded and records maintained for three months. Food temperatures are taken prior to service and after service, if a sufficient amount of food is available. Staff is in proper clothing, preferably uniforms, and has hair restraints on at all times. The Refrigerators and Freezers policy, updated December 2014, was received from the QIS on 8/19/21 at 12:08 p.m. It read in pertinent part, This facility will ensure safe refrigerator and freezer maintenance, temperatures, and sanitation, and will observe food expiration guidelines. Monthly tracking sheets for all refrigerators and freezers will be posted to record temperatures. Monthly tracking sheets will include time, temperature, initials, and action taken. The last column will be completed only if temperatures are not acceptable. Foodservice supervisors or designated employees will check and record refrigerator and freezer temperatures daily with the first opening and at closing in the evening. All food shall be appropriately dated to ensure proper rotation by expiration dates. Received dates (dates of delivery) will be marked on cases and on individual items removed from cases for storage. Use by dates will be completed with expiration dates on all prepared food in refrigerators. Expiration dates on unopened food will be observed and use by dates indicated once the food is opened. Supervisors will be responsible for ensuring food items in pantry, refrigerators, and freezers are not expired or past parish dates. Refrigerators and freezers will be kept clean, free of debris, and mopped with sanitizing solution on a scheduled basis and more often as necessary. The Handwashing/Hand Hygiene policy, updated August 2019, was received from the QIS on 8/19/21 at 12:08 p.m. It read in pertinent part, Use an alcohol-based hand rub containing at least 60% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: After removing gloves. II. Meal time observations The first floor breakfast meal was observed on 8/16/21 from 7:30 a.m.-8:00 a.m. The human resources staff (HRS) was serving breakfast out of a plugged-in steam table. The HRS was not wearing a hairnet. The HRS was wearing gloves and a surgical mask while serving breakfast to the residents. As she was plating breakfast she was touching utensil handles to serve the eggs, meat, and waffles. As the HRS plated a meal she took two waffles out of the steam table, using gloved hands that had just touched serving handles and the surfaces of the steam table, and put them onto the plate, which was wrapped in plastic for a resident. The HRS said she helped the dietary department by serving meals from the steam table on three floors. The HRS said she received unofficial dietary training from the food and nutrition supervisor (FNS) to serve meals to the residents. The third, first, and second-floor lunch meals were observed on 8/16/21 from 12:00 p.m. to 1:30 p.m. -At 12:00 p.m. the HRS was wearing a hairnet, preparing to serve the third-floor lunch from the steam table. She took temperatures of the food items before meal service; Mechanical soft meat 140.1 degrees Fahrenheit (F), mashed potatoes 141 F, gravy 142 F. Food temperatures were not documented into a temperature log. -At 12:12 p.m. meal service began after the HRS performed hand hygiene. She plated the mechanical soft meals. -At 12:15 p.m. the HRS doffed her gloves and donned new gloves, no hand hygiene was performed. After donning new gloves, she placed her used gloves into an empty tray on the steam table. The empty tray was directly above the lunch stew and directly to the right of the regular texture mixed vegetables. The used gloves were left in the tray on the steam table and the HRS continued food service. -The HRS took the temperature of the regular textured food items; mixed vegetables, 140 F, chicken sausage, and potato stew 151.4 F, no documentation of the temperature in a log. The thermometer was sanitized between each food item. The HRS did not perform hand hygiene before donning new gloves and plating the regular texture meals. -At 12:24 p.m. the HRS placed additional dirty gloves and discarded plastic wrap into the tray, where the previous dirty gloves still were. -At 12:28 p.m. the steam table was taken to the first floor for lunch meal service. The HRS plugged the steam table into the wall, performed hand hygiene. She took the temperatures of the pureed foods; vegetables 161 F and stew 163 F, not documented. After HRSsanitized the thermometer between food items she placed the dirty alcohol wipes into the steam table tray with the dirty gloves and discarded plastic wrap. The HRS discontinued lunch service. -At 12:38 p.m. the HRS doffed her gloves and added them to the tray on the steam table, did not perform hand hygiene, and donned new gloves to take the temperatures of the mechanical soft foods; meat 140 F, potatoes 141.6 F, gravy 150.5 F. The temperatures were not documented. She doffed her gloves after taking the temperatures and added them to the tray on the steam table. -At 12:40 p.m. the HRS gathered the multiple pairs of used gloves, the discarded plastic wrap, and the numerous alcohol wipes, placed it all into a styrofoam bowl, and set it on the shelf underneath the steam table. The discarded items were on the steam table for 35 minutes and from two floors. The HRS did not perform hand hygiene before donning new gloves and continuing food service, plating the mechanical soft meal. -At 12:48 p.m. the HRS took the temperatures of the regular texture food items; vegetables 141 F and stew 141.6 F. No temperatures were documented. The HRS doffed her gloves, did not perform hand hygiene, and donned new gloves. The HRS continued meal service. -At 12:55 p.m. the steam table was brought to the second floor. A dietary staff member brought additional food items for the second-floor meal service and took away the empty food trays. The HRS added the new wrapped regular diet food items to the steam table, performed hand hygiene, and donned new gloves. She took the temperatures of the mechanical soft foods; vegetables 142 F, meat 142 F. No temperatures were documented. HRScontinued with meal service. -At 1:14 p.m. the HRS placed the scoop back into the mechanical soft meat tray. The handle of the scoop fell into the mechanical soft meat. The HRS picked the scoop out of the meat by the handle and put the meat onto another plate for a resident. After serving all the mechanical soft meals, the HRS doffed her gloves, did not perform hand hygiene and donned new gloves. -At 1:15 p.m. the HRS added the remaining stew to the new stew brought from the kitchen and took the regular food temperatures; vegetables 148.2 F and stew 147.8 F. No temperatures were documented. -At 1:30 p.m. the HRS completed meal service and returned the steam table and remaining food items to the kitchen. No temperatures were documented during the meal service. III. Failure to monitor and clean satellite refrigerators 1. Observations and record review The fourth-floor nourishment refrigerator was observed on 8/17/21 at 9:10 a.m. Two breakfasts from the day before (8/16/21) were dated and observed on a shelf in the refrigerator. The interior was clean and the thermometer displayed 40F. The August 2021 temperature log was complete. The June and July 2021 temperature logs were requested on 8/18/21 but were not provided by the facility. The third floor west hallway nourishment refrigerator, freezer, and room were observed on 8/17/21 at 9:20 a.m. Breakfast meals were piled on the counter, breakfast was served at 7:00 a.m. A gallon of milk was left on the counter from breakfast. The inside of the refrigerator was dirty and there was a large dried beverage spill on the bottom and the shelves were dirty. An open container of juice had indecipherable brown writing on it and no date. The container had visibly expanded from build-up. An open container of thickened juice was undated. An open container of thickened lemon water was not dated. Open soy milk was labeled for garbage and the manufacture expiration date documented October 2020. Inside the freezer, an unsealed bag of frozen blueberries was labeled with a name but no date. The thermometer in the refrigerator displayed 40 F and the thermometer in the freezer displayed 1 F. The temperature log revealed temperatures were recorded on 8/6/21 (30 F), 8/13/21 (32 F), and 8/17/21 (36 F). All other dates for August 2021 were blank and no freezer temperatures were documented. The temperature logs for June and July 2021 were complete and within the safe range, however, no freezer temperatures were documented for either June or July 2021. The third-floor east hallway nourishment refrigerator was observed on 8/17/21 at 9:25 a.m. There was no thermometer in the refrigerator or freezer. Two meals from the kitchen were dated 8/16/21. An opened container of thickened lemon water was updated. The interior of the refrigerator was clean. The temperature logs for the east refrigerator were requested on 8/18/21 but were not provided by the facility. The second-floor nourishment refrigerator was observed on 8/17/21 at 9:30 a.m. A sticky liquid was spilled and had dried in the bottom of the refrigerator. A pizza box was unlabeled and not dated. A bowl of hard-boiled eggs from the kitchen was not dated. Juice belonging to a resident was open and undated. A deli sandwich wrapped in paper was dated 8/10/21. The thermometer in the refrigerator displayed 40 F. There was a dried puddle of spilled juice in the bottom of the refrigerator and on the bottom shelf. There was no thermometer in the freezer. A large container of ice cream was not dated. An uncovered bowl of frozen fruit was not labeled or dated. The temperature log for this refrigerator revealed temperatures taken and logged on 8/3/21, 8/4/21, 8/5/21, 8/6/21, 8/7/21, 8/8/21, 8/9/21, 8/10/21, 8/11/21, 8/12/21, and 8/14/21. The rest of the dates were blank and no freezer temperatures were documented. The temperature log sheet for July 2021 revealed temperature were recorded on 7/1/21 (36F), 7/5/21 (36F), 7/9/21 (38F), 7/9/21 (38F), 7/10/21 (38F), 7/11/21 (38F) 7/12/21 (38F), 7/16/21 (38F), 7/18/21 (38F), 7/19/21 (38F), 7/21/21 (38F), 7/23/21 (39F), 7/26/21 (40F), 7/28/21 (50F, maintenance was notified and fixed the refrigerator), and 7/29/21 (40F). The rest of the dates were blank and no freezer temperatures accompanied the refrigerator temperatures. The temperature log sheet for June 2021was requested on 8/18/21 and was not provided by the facility. The first floor nourishment room was observed on 8/17/21 at 9:40 a.m. The thermometer displayed 40 F and the thermometer on the freezer was broken. Inside the refrigerator was an opened container of lemonade that was not dated. In the bottom of the refrigerator, there was a bag of an unknown homemade food product that was unlabeled and not dated. The temperature log for August 2021 revealed temperature were recorded on 8/3/21 (38F, -20F), 8/4/21 (40F, -10F), 8/5/21 (40F, -18F), 8/6/21 (38F, -20F), 8/7/21 (38F, -14F), 8/8/21 (40F, -20F), 8/11/21 (38F, -20F), 8/12/21 (35F, -20F), 8/13/21 (35F, -20F), 8/14/21 (35F, -18F), and 8/16/21 (35F, -12F). The rest of the dates were blank. The logs for June and July 2021 were complete and within the normal range. IV. Failure to maintain temperature logs at meal service 1. Observations At 6:20 a.m. the FNS took the temperatures of the food items to be sent to the steam table that traveled the floors. The cream of wheat was at 190 F, the scrambled eggs were at 160 F, the ham for mechanical soft breakfast was 156 F, and the pureed sausage was 150 F. The pureed eggs and bread were retrieved from the refrigerator to be served cold, no temperatures were taken before they were put into the steam table to be sent to the floors, bacon was at 150 F, fried eggs were at 160 F, and the gravy was at 160 F. No temperatures were entered into a temperature log. 2. Record review The facility food temperature logs were reviewed on 8/17/21 at 10:00 a.m. The logs revealed there were no breakfast temperatures documented for June 2021, July 2021, and August 2021. V. Staff interviews The FNS was interviewed on 8/17/21 at 7:00 a.m. He said he provided training to the HRS to provide meal service to the residents. He said it was unofficial but covered hand hygiene, safe temperatures, when to take temperatures, safe food handling practices, serving sizes, and what to wear while serving meals. He said hair nets should be worn by any staff serving meals to residents. He said hand hygiene should be performed between glove changes and that gloves were not needed during food service but she chose to wear them. He said the temperatures for food were taken before the food was sent to the floor and that the HRS should take the food temperatures on each floor before beginning food service. He said the night shift nursing staff was responsible for maintaining the nourishment refrigerators on the floors. The registered dietitian (RD) was interviewed on 8/18/21 at 11:00 a.m. She said hairnets should be worn at every meal service. She said hand hygiene should be performed between glove changes if hands were visibly soiled, and before meal service. She said staff serving meals did not have to wear gloves. She said the HRS was more comfortable wearing gloves while serving meals. She said the handles of serving utensils should be propped on the side of the food tray and if the handle were to fall into the food should be sent back to the kitchen and something new prepared and sent up. She said she would provide training to the HRS about hand hygiene and sanitary serving techniques. She said the night shift nursing staff was responsible for cleaning the nourishment refrigerators on each floor. She said the cleanliness of those refrigerators had been an issue lately and it was hard to keep tabs on because of kitchen duties. She said the HRS was trained to serve meals by the FNS. She said the training was informal. She said food temperatures were not recorded outside of the kitchen during meal service. She said food temperatures should be logged into the temperature log for each meal before they are sent to the residents. The corporate dietitian was interviewed on 8/18/21 at 2:15 p.m. She said the training provided to the HRS was informal and quick so she could assist the dietary staff serves meals to residents. She said the training included taking temperatures of food, hand hygiene, and reading the diet cards of each resident. She said discarded gloves and trash should not be put into a tray on the steam table during meal service and should be kept away from food items. She said nourishment refrigerators should be checked and cleaned out nightly by the nursing staff. She said the temperatures should be documented daily on the logs. She said each refrigerator should have a dedicated thermometer inside the refrigerator and freezer all the time. She said if the open food was three days old it should be thrown away. She said dates and names should be on all food in the nourishment refrigerators. She said there should be no expired products in the nourishment refrigerators. She said meals for residents should be kept in the refrigerator not left on the counter. She said food temperatures should be documented in the log before meal service in the kitchen and while on the floor.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interviews, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the possible development and transmission of Coronavirus (COVID-19) and infection for two out of four floors. Specifically, the facility failed to: -Ensure housekeeping staff cleaned high-touch surfaces during routine daily room cleaning; and, -Ensure housekeeping staff followed the appropriate procedure when cleaning resident bathrooms. Findings include: I. Professional standards The Centers for Disease Control and Prevention (2020) Preparing for COVID-19 in Nursing Homes, updated 4/5/21, retrieved on 8/23/21 from: https://www.cdc.gov/coronavirus/2019-ncov/community/disinfecting-building-facility.html/, revealed in part For environmental cleaning and disinfection: develop a schedule for regular cleaning and disinfection of shared equipment, frequently touch surfaces in resident rooms and common areas. Clean high-touch surfaces at least once a day or as often as determined is necessary. Examples of high-touch surfaces include: pens, counters, shopping carts, tables, doorknobs, light switches, handles, stair rails, elevator buttons, desks, keyboards, phones, toilets, faucets, and sinks. II. Facility policy and procedure The Cleaning and Disinfecting Residents' Rooms policy, revised August 2013, was provided by the regional nurse consultant (RNC) on 8/19/21 at 12:28 p.m. It read, in pertinent part, When cleaning residents' rooms, clean horizontal surfaces daily with a cloth moistened with disinfectant solution. Do not use feather dusters. III. Observations Housekeeper (HK) #1 was observed on 8/19/21 at 10:38 a.m. preparing to clean room [ROOM NUMBER]. -She used alcohol based hand sanitizer (ABHR) and donned gloves. She removed the bathroom disinfectant spray and the toilet brush from the cleaning cart and entered room [ROOM NUMBER]. She placed the toilet brush, in its container, on the floor and sprayed the surfaces in the bathroom with the disinfectant spray. She returned the disinfectant spray to the cart. -She removed a rag and sprayed it with Windex. She used the rag to wash the mirror. She placed the soiled rag into a bag on the cleaning cart and placed the windex back on the cart. -She entered the bathroom and used the toilet brush to clean the inside of the toilet bowl. She placed the toilet brush back into its holder and used a rag to wipe under the toilet seat, the rim of the toilet and then the toilet seat. She returned the rag to the cart and removed her gloves. -She performed hand hygiene and donned clean gloves. She removed a rag and the disinfectant spray bottle for the bedroom. -She sprayed the overbed table and the dresser. She returned the disinfectant to the cart. -She used the clean rag to wipe off the overbed table and the dresser. She placed the soiled rag in the bag on the cleaning cart. -She removed the broom from the cart and swept the room. She used the dust pan to pick up the debris at the door and removed her gloves. She did hand hygiene and donned clean gloves. -She removed a mopping pad from the mop bucket and dropped it on the floor. She placed the mop handle on top of the mop pad and mopped the bedroom. -She replaced the mop pad with a clean one and mopped the bathroom. She placed the dirty mop pad in the linen bag and placed the mop handle on the cart. She removed her gloves and performed hand hygiene. She proceeded to the next room. -HK #1 failed to clean and disinfect high touch areas such as the door knobs, light switches, closet handles, night stand, call light, phone, television remote, and bed controller. She failed to clean the toilet from top to bottom and clean to dirty. HK #1 was observed on 8/19/21 at 10:48 a.m. -She used ABHR and donned gloves. She removed the bathroom disinfectant spray and the toilet brush from the cleaning cart and entered room [ROOM NUMBER]. She placed the toilet brush, in its container, on the floor and sprayed the surfaces in the bathroom with the disinfectant spray. She returned the disinfectant spray to the cart. -She used the toilet brush to scrub the top of the toilet seat. She lifted the toilet seat and used the toilet brush to clean the inside of the toilet bowl. She placed the toilet brush back into its holder and used a rag to wipe under the toilet seat, the rim of the toilet and then the toilet seat. She returned the rag to the cart and removed her gloves. -She performed hand hygiene and donned clean gloves. She removed a rag and the disinfectant spray bottle for the bedroom. -She sprayed the overbed table and the dresser. She returned the disinfectant to the cart. -She used the clean rag to wipe off the overbed table and the dresser. She placed the soiled rag in the bag on the cleaning cart. -She removed the broom from the cart and swept the room. She used the dust pan to pick up the debris at the door and removed her gloves. She did hand hygiene and donned clean gloves. -She removed a mopping pad from the mop bucket and dropped it on the floor. She placed the mop handle on top of the mop pad and mopped the bedroom. -She replaced the mop pad with a clean one and mopped the bathroom. She placed the dirty mop pad in the linen bag and placed the mop handle on the cart. She removed her gloves and performed hand hygiene. -HK #1 failed to clean and disinfect high touch areas such as the door knobs, light switches, closet handles, night stand, call light, phone, television remote, and bed controller. She failed to clean the toilet from top to bottom and clean to dirty. IV. Staff interviews HK #1 was interviewed on 8/19/21 at 10:58 a.m. laundry aide (LA) #1 interpreted for HK #1, who was Spanish speaking. HK #1 said she cleaned all the rooms the same way. She said she knew she should not use the toilet brush outside the toilet bowl. However, she said the male residents urinate on the seat and that was how she cleaned their seats because the urine was hard to remove. She said she forgot that she should clean the toilet from top to bottom. She said she had been trained to clean high touch areas but was in a hurry and did not have time to clean those items. She said she was responsible for cleaning the rooms on the first and second floor. The housekeeping supervisor (HKS) was unavailable for an interview. The infection preventionist (IP) was interviewed on 8/19/21 at 12:16 p.m. She said housekeeping staff had their last COVID-19 training in January 2021. She said the toilet brush should only be used to clean the inside of the toilet bowl. She said the toilet should be cleaned from top to bottom. She said all high touch surfaces and items the residents touch should be cleaned daily. She said she would immediately educate the housekeeping staff on the proper cleaning techniques. The interim nursing home administrator (INHA) was interviewed on 8/19/21 at 2:09 p.m. She said the toilet brush should never be used outside the toilet bowl. She said all high touch surfaces should be cleaned daily. She said she would immediately call the chemical company and have them provide training to the housekeepers on the proper cleaning procedure. V. Facility COVID-19 status There were no COVID-19 positive nor presumptive cases in the facility.