Based on observations, record review and interviews, the facility failed to keep resident medical records in a secure and confidential manner. Specifically, the facility failed to ensure resident meal tickets were stored privately and not accessible to guests to review in order to protect the confidentiality of resident information. Findings include: I. Observations During a continuous observation on 3/25/25, beginning at 11:10 a.m. and ending at 12:37 p.m., the following was observed during the meal preparation and service in the main kitchen and dining room: At 11:10 a.m. resident meal trays were being assembled in the main kitchen by cook (CK) #1. Resident meal tickets were observed in two separate places in the service window between the kitchen and main dining room. The meal tickets were on the left side of the serving counter and on the right side on top of the steam table. The meal tickets contained resident names and physician prescribed diet orders. At 11:37 a.m. a resident representative approached the service window in the dining room and picked up the resident meal tickets on the left side of the serving counter and looked through them. The resident's representative then picked up the resident meal tickets on the right side of the team table and looked through them. At 11:38 a.m. the resident's representative asked CK #1 if he had seen a resident's meal ticket. The resident's representative said usually when she looked through the resident meal tickets she could find the resident's meal ticket sooner because it was located closer to the top. -Facility staff failed to ensure the resident meal tickets were kept in a secure and confidential manner in the dining room and not accessible to guests of the facility. II. Staff interviews Certified nurse aide (CNA) #2 was interviewed on 3/25/25 at 11:46 a.m. CNA #2 said a guest at the facility should not look through resident meal tickets because the meal tickets contained protected information that included the residents names, room numbers and diet orders. The dietary director (DD) and the nursing home administrator (NHA) were interviewed together on 3/26/25 at 12:00 p.m. The DD said the resident's representative should not have looked through resident meal tickets because the residents privacy was not maintained. The NHA said it had not been previously brought to his attention that a resident's representative had previously looked through the meal tickets. The regional clinical resource (RCR) was interviewed on 3/25/25 at 12:00 p.m. The RCR said facility staff were trained on resident privacy but she was unsure if resident meal tickets were included in the training.

**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 one (#62) of nine residents reviewed for abuse out of 36 sample residents. Specifically, the facility failed to report an incident of potential sexual abuse involving Resident #62 to the State Survey Agency (SSA). Findings include: I. Facility policy and procedure The Abuse, Neglect, Exploitation and Misappropriation Prevention Program policy, revised April 2021, was provided by the nursing home administrator (NHA) on 3/23/25 at 12:41 p.m. It read in pertinent part, Residents have the right to be free from abuse. The facility will identify and investigate all possible incidents of abuse, neglect, mistreatment, or misappropriation of resident property. The facility will investigate and report any allegations within timeframes required by federal requirements. II. Resident #62 A. Resident status Resident #62, age [AGE], was admitted on [DATE]. According to the March 2025 computerized physician orders (CPO), diagnoses included sexual dysfunction and major depressive disorder. The 12/17/24 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 13 out of 15. The resident needed setup or cleanup assistance for most activities of daily living (ADL). The MDS assessment documented the resident did not have physical or verbal behaviors directed toward others or other behavioral symptoms not directed toward others. B. Record review The behavioral care plan, initiated 7/17/2020 and revised 4/14/23, revealed Resident #62 made verbally explicit comments and suggestions toward staff, masturbated in front of staff, asked female staff members if he could touch them or if the staff could touch him in a sexually inappropriate way. Pertinent interventions included explaining or reinforcing why his behavior was inappropriate or unacceptable, administering medications as ordered, educating staff on the importance of respecting Resident #62's wishes and emphasizing sexual outlet was a normal function, monitor behavioral episodes and attempt to determine an underlying cause, redirecting any inappropriate public exposure and intervening as necessary to protect the rights and safety of others. The antipsychotic medication care plan, revised 12/30/24, revealed Resident #62 required an antipsychotic medication as evidenced by inappropriate sexual behavior, delusions and hallucinations. Pertinent interventions included administering antipsychotic medications as ordered, observing Resident #62's mood and response to the medication, and observing and recording the effectiveness of the drug treatment as indicated. A progress note, dated 3/21/25 at 12:39 p.m., revealed an unidentified CNA witnessed Resident #62 masturbating in another resident's room. The other residents slept through the situation and did not wake up. The CNA relocated Resident #62 away from the room and told the resident he could not perform those actions in others' rooms. The director of nursing (DON) spoke with Resident #62 and gave him choices to ensure his safety and the safety of others, and the resident agreed to relocate to the all-male secured unit. The nursing staff were to continue to monitor Resident #62 for hypersexual behaviors. The facility's incident investigation, undated, was provided by the NHA on 3/24/25 at 4:21 p.m. The investigation included a statement from certified nurse aide (CNA) #4, which revealed on 3/21/25 between 1:30 a.m. and 2:00 a.m., CNA #4 observed Resident #62 as he was halfway into Resident #39 and Resident #59's room. Resident #62 had exposed his genitals and was masturbating in the room. CNA #4 took Resident #62 back to his room and told him he could not be in other residents' rooms. Resident #39 was interviewed by the NHA on 3/21/25. Resident #39 said she did not have any incidents of abuse to report. Resident #39 said she felt safe in the facility. Resident #39 said she did not notice any disturbances during her sleep. Resident #39 said there was nothing else she wanted to share. Resident #59 was interviewed by the NHA on 3/21/25. Resident #59 said she did not have any incidents of abuse to report. Resident #59 said she felt safe in the facility. Resident #59 said she did not notice any disturbances during her sleep. Resident #59 said there was nothing else she wanted to share. -However, the facility failed to report the sexual abuse incident to the State Agency. III. Staff interviews The DON was interviewed on 3/26/25 at 4:40 p.m. The DON said the incident involving Resident #62 happened overnight on 3/21/25. The DON said he received a call from CNA #4 who told him she was in another resident's room, heard a noise, and saw Resident #62 halfway in the doorway of Resident #59 and Resident #39's shared room. CNA #4 said Resident #62 had his genitals exposed and was masturbating. The DON said when he came in later on the morning of 3/21/25, the facility staff interviewed Resident #62 and discussed what his next steps would be. The DON said he notified the NHA of the incident immediately. The NHA was interviewed on 3/26/25 at 5:15 p.m. The NHA said any allegations of abuse needed to be reported to him regardless of the time. The NHA said if he was not available, abuse allegations should be reported to the nurse on-call. The NHA said any abuse allegations needed to be reported to the State Agency within 24 hours. The NHA said after reporting the allegation, the facility staff would launch an investigation, ask for staff statements, and interview any residents within the vicinity of the incident. The NHA said he was notified the morning of 3/21/25 about Resident #62's incident the night prior. The NHA said he got a statement from the CNA who witnessed the incident and that he interviewed Resident #59 and Resident #39 and they were both asleep. The NHA said he asked both of the residents if they felt safe and if they had witnessed any abuse, and neither resident expressed any knowledge of the situation. The NHA said he had not reported the incident to the State Agency as he had reached out to one of the facility's clinical consultants and was told the incident was not abuse.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to document resuscitation choices accurately in the medical record for one (#50) of three residents reviewed for advanced directives out of 36 sample residents. Specifically, the facility failed to document Resident #50's refusal to complete a medical orders for scope of treatment (MOST) form (a legal document that allows individuals to outline their wishes for medical interventions and end-of-life care, ensuring their preferences are followed in the event of a serious illness or decline in health) upon admission to the facility or that the resident's resuscitation choices were discussed with the resident or the resident's representative. Findings include: I. Resident #50 A. Resident status Resident #50, age greater than 65, was admitted on [DATE]. According to the [DATE] computerized physician orders (CPO), diagnoses included chronic obstructive pulmonary disease (COPD - a lung disease with airway obstruction), chronic respiratory failure, type 2 diabetes mellitus, opioid dependence, history of venous thrombosis and embolism (condition involving blood clots), hypertension and stage 2 and stage 3 pressure ulcers. The [DATE] minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 13 out of 15. The resident was dependent on care for hygiene and bed mobility and needed set-up assistance for eating. B. Record review A review of Resident #50's [DATE] CPO revealed Resident #50 had a physician's order for full code (resuscitation status indicating cardiopulmonary resuscitation (CPR) should be conducted if the resident's heart stopped beating), ordered [DATE] (during the survey). A review of Resident #50's [DATE] interdisciplinary team (IDT) care conference summary documented Resident #50 attended the care conference. The care conference summary revealed a section of preferred intensity of care and advanced directives with the following options to review: advanced directives, current wishes and physicians orders for life sustaining treatment. -The advanced directives, current wishes and physician's orders for life-sustaining treatment sections were not documented to indicate whether or not the facility had discussed them with the resident or the resident's representative during the care conference. Additionally, the care conference summary included a progress note section which documented a summary of Resident #50's overall care and progress. The progress note section documented Code status. -However, the facility failed to document what Resident #50's actual code status (CPR versus no CPR) was in the progress note summary. -Review of Resident #50's electronic medical record (EMR) failed to reveal documentation to indicate the resident refused to sign a MOST form upon his admission to the facility on [DATE]. II. Staff interviews The director of nursing (DON) and the regional clinical resource (RCR) were interviewed together on [DATE] at 10:30 a.m. The DON said Resident #50 declined to initiate a MOST form upon his admission to the facility ([DATE]) and the residents' declination was documented in his care conference notes. -However, review of the care conference notes did not reveal that the resident's declination to sign the MOST form or the resident's resuscitation choices had been discussed (see record review above). The RCR said the default physician's order for a resident who did not have a completed MOST form would include an order for a full code (all life sustaining treatments) status. III. Facility follow up On [DATE] at 5:26 p.m. an email was received from the RCR confirming the facility did not have documentation that specifically mentioned Resident #50's refusal to review or sign a MOST form or that the resident's resuscitation choices had been discussed with the resident or the resident's representative.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to ensure one (#1) of one resident received treatment and care in accordance with professional standards of practice out of 36 sample residents. Specifically, the facility failed to obtain a physician's order and provide routine maintenance and care for a peripherally inserted central catheter (PICC) for Resident #1. Findings include: I. Professional reference According to The National Institutes of Health (NIH) PICC Line Placement (1/10/24), retrieved on 4/2/25 from https://www.ncbi.nlm.nih.gov/books/NBK573064/, Dressings should be changed at least once weekly or per policy and manufacturer's guidelines. After each use, the PICC line should be flushed with normal saline and heparin solution. Nurses are responsible for day-to-day care, education, and monitoring of patients with PICC lines, reporting any concerns promptly. Careful monitoring and maintenance of these lines are paramount in preventing procedural complications. II. Resident #1 A. Resident status Resident #1, age greater than 65, was admitted on [DATE]. According to the March 2025 computerized physicians orders (CPO), diagnoses included schizoaffective disorder, vascular dementia and cellulitis of the left lower limb. The 2/7/25 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 13 out of 15. The resident required supervision to maximum assistance for most activities of daily living (ADL). B. Resident representative interview Resident #1's representatives were interviewed on 3/23/25 at 10:33 a.m. The resident's representatives said Resident #1 had an infection in her leg which became swollen and was treated with antibiotics. The resident's representatives said the facility placed a PICC line for the antibiotics. C. Resident interview and observations Resident #1 was interviewed on 3/24/25 at 9:38 a.m. Resident #1 said she had a shower earlier that morning (3/24/25). Resident #1's PICC line dressing was pulling away from her skin around the top and sides and was visibly soiled with brown material. A date was written on the bandage, but the date was mostly washed away and it was difficult to read the date. Resident #1 was interviewed again on 3/25/25 at 8:53 a.m. Resident #1 said the dressing on her PICC line had not been changed that morning (3/25/25) or the day prior (3/24/25). Resident #1's PICC line dressing was pulling away from her skin around the top and sides and was visibly soiled with brown material. A date was written on the bandage, but the date was mostly washed away and it was difficult to read the date. Resident #1 was interviewed a third time on 3/26/25 at 9:37 a.m. Resident #1 said the nursing staff had changed her PICC line dressing that morning (3/26/25). Resident #1 said the nursing staff flushed her PICC line once a day. D. Record review Review of the comprehensive care plan, revised 3/24/25, did not reveal any focus or interventions related to Resident #1's PICC line or maintenance of the PICC line. Review of the March 2025 CPO revealed the following physician's orders: Midline intravenous (IV) placement, ordered 3/7/25. Radiographs to check for midline (PICC) placement, ordered 3/7/25. Normal saline flush solution, with instructions to use 10 milliliters (ml) intravenously two times a day for cellulitis/pneumonia. Flush before and after medication, ordered 3/7/25. Vancomycin IV solution 750 milligrams (mg) per 150 ml, with instructions to use 750 mg intravenously every 12 hours for cellulitis for ten days, ordered 3/6/25 and discontinued 3/13/25. Vancomycin IV solution 500 mg per 150 ml, with instructions to use 1000 mg intravenously every 12 hours for cellulitis until 3/17/25, ordered 3/6/25. PICC line dressing change every seven days, ordered 3/25/25 (during the survey). A progress note, dated 3/7/25 at 10:14 a.m., revealed Resident #1 was ordered to receive an IV antibiotic and a PICC line was requested. A progress note, dated 3/7/25 at 12:58 p.m., revealed a PICC line was placed in Resident #1's right arm. The nurse requested a physician's order for radiographs to check the placement of the PICC line and a physician's order to flush the PICC line. -The progress note did not indicate the nurse requested a physician's order for PICC line dressing changes. A progress note, dated 3/10/25 at 1:05 p.m., revealed Resident #1 was able to receive her antibiotics IV since she had been cleared to use the PICC line for medication administration. Resident #1's PICC line did not show any signs or symptoms of redness, swelling or infection. A progress note, dated 3/18/25 at 11:19 p.m., revealed Resident #1 had completed her course of IV antibiotics. Resident #1's PICC line was still in place, had been flushed, and did not have any redness noted to the area. -There was no documentation in the resident's electronic medical record (EMR) to indicate Resident #1's PICC line dressing had been changed since it was initially inserted on 3/7/25. E. Staff interviews Licensed practical nurse (LPN) #1 was interviewed on 3/26/25 at 10:34 a.m. LPN #1 said Resident #1 was on IV antibiotics in early March 2025 to treat her cellulitis. LPN #1 said Resident #1's physician thought the resident should have her PICC line in place for a few more days following the end of her antibiotic treatment on 3/17/25, but she said it would likely be discontinued that day (3/26/25). LPN #1 said Resident #1's PICC line dressing was changed the night prior (3/25/25), and had been changed every week. LPN #1 said Resident #1 still needed a physician's order for the PICC line dressing. LPN #1 said the resident should have a physician's order in place to change the PICC line dressing each week. -However, there were no dressing changes documented in Resident #1's EMR from 3/7/25 through 3/25/25 (see record review above). -Additionally, there was no physician's order to change the PICC line until 3/25/25, during the survey (see record review above). The director of nursing (DON) was interviewed on 3/26/25 at 7:11 p.m. The DON said Resident #1 had her PICC line in place for at least two weeks. The DON said the resident needed to have an order from the physician for a PICC line prior to the line being placed. The DON said the facility usually put in a physician's order for weekly PICC line dressing changes at the same time as the physician's order for the PICC line itself. -However, the order for weekly PICC line dressing changes was not added to Resident #1's CPO until 3/25/25, during the survey (see record review above).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interviews, the facility failed to ensure one (#50) of three residents out of 36 sample residents received the care and services necessary to meet their nutrition needs to maintain their highest level of physical well-being. Specifically, the facility failed to weigh Resident #50, who was identified to have potential nutrition problems, upon admission to monitor the resident's nutritional status. Findings include: I. Facility policy and procedure The Weight Assessment and Interventions policy, revised March 2022, was provided by the nursing home administrator (NHA) on 3/26/25 at 9:09 a.m. It read in pertinent part, Residents weights are monitored for undesirable or united weight loss or gain. Residents are weighed upon admission and at intervals established by the interdisciplinary team (IDT). Weights are recorded in each unit's weight record chart and in the individual's medical record. Any weight change of 5% or more since the last weight assessment is retaken the next day for confirmation. If the weight is verified, nursing will immediately notify the dietitian in writing. Care planning for weight loss or impaired nutrition is a multidisciplinary effort and includes the physician, nursing staff, the dietitian, the consultant pharmacist and the resident or resident's legal surrogate. If a resident declines to participate in a weight loss goal, the dietitian will document the resident's wishes and those wishes will be respected. II. Resident #50 Resident #50, age greater than 65, was admitted on [DATE]. According to the March 2025 computerized physician orders (CPO), diagnoses included chronic obstructive pulmonary disease (COPD - a lung disease with airway obstruction), chronic respiratory failure, type 2 diabetes mellitus, opioid dependence, history of venous thrombosis and embolism (condition involving blood clots), hypertension and stage 2 and stage 3 pressure ulcers. The 2/14/25 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 13 out of 15. The resident was dependent on care for hygiene and bed mobility and needed set-up assistance for eating. The MDS assessment documented the resident did not refuse care. The MDS assessment did not have a recorded weight. III. Resident interview Resident #50 was interviewed on 3/25/25 at 3:35 p.m. Resident #50 said he had lost weight and used to be overweight. He said he could not remember anyone asking to weigh him at the facility. IV. Record review Resident #50's nutritional care plan, documented the resident had potential nutritional problems due to a diagnosis of diabetes mellitus type 2 with a medication in place, a diagnosis of COPD, history of a right above knee amputation and wounds. Pertinent interventions included to notify the physician of significant or severe weight loss or weight gain, initiated 2/17/25. According to the March 2025 CPO the resident had a physician's order to be weighed weekly times four weeks, ordered 2/10/25. The 2/17/25 nutritional risk assessment documented the resident weighed 186 pounds (lbs) in the hospital on 2/1/25 (prior to admission). The assessment documented the resident refused an admission weight. It documented to obtain a weight as the resident allowed and to monitor the residents weights for trends. The resident's usual body weight (UBW) was documented as unknown and the resident's estimated protein needs of 102 grams (g) of protein were calculated to support wound healing. The assessment also documented diet alone was not enough to meet the resident's estimated calorie and protein needs and the resident's meal intakes were varied. The goal was for the resident to meet estimated nutritional needs and for healing and weight stabilisation was acceptable, and to monitor weight for trends and follow up for significant changes. The assessment documented recommendations to add liquid protein 30 milliliters (ml) twice a day. -However, a review of Resident #50's electronic medical record (EMR) revealed no additional recorded weights or attempts to obtain a weight for Resident #50 until 3/24/25 (during the survey) when the facility documented the resident refused to be weighed. The only documented refusal of weight by Resident #50 was in the 2/17/25 nutritional risk assessment. V. Staff interviews Licensed practical nurse (LPN) #1 was interviewed on 3/25/25 at 3:22 p.m. LPN #1 said when a resident was admitted to the facility they should be weighed the first three days per facility protocol. LPN #1 said if a resident's weights were stable then they would be weighed monthly after that. LPN #1 said that a provider could put in an order for more frequent weights based on the resident's initial weights. Certified nurse aide (CNA) #3 said she tried to weigh Resident #50 and he refused to be weighed. CNA #3 said it was difficult to weigh the resident because they needed two staff members to lift him and the resident said it was painful for him. CNA #3 said if a resident refused to be weighed the CNA told a nurse so the nurse could follow up with the resident before documenting the resident refused. -However, review of Resident #50's EMR did not include documentation indicating the facility had attempted to weigh the resident other than the 2/17/25 nutrition assessment (see record review above).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interviews, the facility failed to ensure residents with a feeding tube received appropriate treatment and services for one (#96) of three residents reviewed out of 36 sample residents. Specifically, the facility failed to ensure Resident #96 was assessed to ensure her safety while self-administering her tube feedings. Findings include: I. Facility policy and procedure The Enteral Nutrition (feeding tube) policy, revised November 2018, was provided by the nursing home administrator (NHA), on 3/26/25 at 11:43 a.m. It read in pertinent part, Adequate nutritional support through enteral nutrition is provided to residents as ordered. Staff caring residents with feeding tubes are trained on how to recognize and report complications associated with the insertion and/or use of a feeding tube, such as aspiration, skin breakdown around the insertion site, and clogging of the tube. Residents receiving enteral nutrition are periodically reassessed for the continued appropriateness and necessity of the feeding tube. Results of these assessments are documented and any changes are made to the care plan. II. Resident status Resident #96, age less than 65, was admitted on [DATE]. According to the March 2025 computerized physician orders (CPO), the diagnoses included moderate protein-calorie malnutrition, eating disorder and adult failure to thrive. The 2/18/25 minimum data set (MDS) assessment revealed the resident had moderate cognitive impairments with a brief interview status (BIMS) score of 12 out of 15. The resident was independent for eating and required supervision or touching assistance for all other activities of daily living (ADL). The assessment documented the resident was receiving 51% or more of her calories through a feeding tube and 501 cubic centimeters (cc) a day of fluid through a feeding tube. III. Observations and resident interview On 3/25/25 at 9:16 a.m. Resident #96 said she administered her own bolus tube feedings. Resident #96 was administering her tube feeding by herself and no staff were present in the room. At 5:28 p.m. Resident #96 had just depressed the plunger of a syringe into her feeding tube. No staff were present in Resident #96's room. IV. Record review The enteral nutrition care plan, initiated 2/17/25 and revised 3/4/25, revealed Resident #96 required enteral nutrition related to her eating disorder. Pertinent interventions included checking the tube placement every shift and prior to feeding or administering medications, providing enteral nutrition as ordered, flushing the tube with 30 milliliters (ml) of water before and after medication administration and monitoring the resident for any nausea, vomiting, or discomfort with each feeding. The ADL care plan, initiated 3/4/25, revealed Resident #96 had a self-care performance deficit due to her eating disorder and failure to thrive. Resident #96 was very private but needed supervision for safety. Pertinent interventions included Resident #96 administered her own tube feeding as she did not eat by mouth and providing/encouraging fluids. The nutrition care plan, initiated 2/17/25 and revised 3/4/25, revealed Resident #96 had a nutritional problem due to her eating disorder, malnutrition and anxiety. The care plan documented Resident #96 refused to allow staff to administer her tube feedings. Pertinent interventions included providing enteral nutrition and water flushes per physician's order. Review of the March 2025 CPO revealed the following physician's orders for Resident #96: Tube Feeding: Nutren 2.0 (enteral feeding formula) or equivalent, give one carton four times per day via bolus per PEG (percutaneous endoscopic gastrostomy) tube, ordered 2/17/25. Check PEG tube placement before use, ordered 2/13/25; Keep head of bed elevated at least 30 degrees during tube feedings and for at least thirty minutes after tube feed administration, ordered 2/13/25; G-tube (feeding tube) site: cleanse with normal saline, pat dry and apply split gauze every shift. Notify provider if signs or symptoms of infection occur, ordered 2/13/25; and, Enteral feed: flush 30 ml of water before and after tube feeding administration four times daily, ordered 2/17/25. The nutritional risk assessment, dated 2/15/25 at 4:58 p.m., revealed Resident #96 said she had been self-administering her tube feeding for three weeks prior to admitting to the facility, was taught how to do so when she was in the hospital and had no questions regarding her tube feeding. The nursing staff reported Resident #96 was particular with her treatments, as she did not allow the staff to administer her tube feedings and often refused to have her PEG tube checked. The registered dietitian (RD) recommended offering snacks between meals and having staff monitor Resident #96 as she self-administered her tube feeding and water flushes. -Review of Resident #96's electronic medical record (EMR) did not reveal any assessments indicating Resident #96 was evaluated and safe to self-administer her tube feedings or physician's orders for the resident to self-administer. V. Staff interviews Licensed practical nurse (LPN) #1 was interviewed on 3/26/25 at 9:42 a.m. LPN #1 said Resident #96 did not let the nursing staff provide her with any treatment and wanted to do her treatments herself. LPN #1 said the nursing staff should be at Resident #96's bedside to monitor the resident during her tube feedings to ensure the resident was administering the feeding and water flushes correctly and according to the physician's order. LPN #1 said there should be a physician's order for Resident #96 to self-administer her tube feedings. LPN #1 said Resident #96's physician was aware she was administering her own tube feedings. LPN #1 said there had not been any formal assessment completed or documented in Resident #96's EMR indicating she was able to self-administer her tube feedings. LPN #1 said Resident #96's tube feeding care and self-administration of tube feedings should be on her care plan. The director of nursing (DON) was interviewed on 3/26/25 at 11:00 a.m. The DON said the nursing staff should be in the room with Resident #96 whenever she administered her own tube feeding. The DON said Resident #96 should not have been self-administering her tube feedings independently and without supervision from the nursing staff. The DON said Resident #96 should be evaluated to ensure she was completing all of the steps involved in administering her tube feeding correctly. The DON said Resident #96's physician had watched her self-administer her tube feeding and did not have any concerns at the time. The DON said Resident #96's self-administration and staff supervision should be on her care plan.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interviews, the facility failed to ensure the medication administration error rate was not greater than five percent (%). Specifically, the facility's medication administration error rate was 6.06%, or two errors out of 33 opportunities for error. Findings include: I. Professional reference According to [NAME], P.A., [NAME], A.G., et.al., Fundamentals of Nursing, 10 ed., E.[NAME], St. Louis Missouri, pp. 606-607. Take appropriate actions to ensure the patient receives medication as prescribed and within the times prescribed and in the appropriate environment. Professional standards such as nursing scope and standards of practice apply to the activity of medication administration. To prevent medication errors, follow the seven rights of medication administration consistently every time you administer medications. Many medication errors can be linked in some way to an inconsistency in adhering to these seven rights: 1. The right medication 2. The right dose 3. The right patient 4. The right route 5. The right time 6. The right documentation 7. The right indication. II. Observations On 3/25/25 at 8:56 a.m. licensed practical nurse (LPN) #3 was preparing and administering medications for Resident #52. The resident had physician's orders for the following medications: Omeprazole delayed release oral capsule 40 mg (milligram), give one capsule via percutaneous endoscopic gastrostomy tube (PEG) tube two times a day for gastroesophageal reflux disease (GERD), ordered 1/20/25. -LPN #3 administered omeprazole 20 mg, not omeprazole 40 mg as indicated in the physician's order. Lidocaine 4% external patch, apply topically (to the skin) to the left shoulder every morning and at bedtime for pain, ordered 3/19/25. -LPN #3 applied the lidocaine patch to Resident #52's right shoulder, not the left shoulder as indicated in the physician's order. III. Staff interviews LPN #3 was interviewed on 3/25/25 at 11:56 a.m. LPN #3 said she thought she had put the lidocaine patch on Resident #52's left shoulder, but she said because of the position the resident was lying in, she accidentally placed it on the resident's right shoulder instead. She said she gave one capsule of omeprazole 20 mg to Resident #52 and she should have given two capsules because she needed 40 mg. She said she should have given the resident another 20 mg capsule of omeprazole. The director of nursing (DON) was interviewed on 3/26/25 at 4:15 p.m. The DON said physician's orders should be double-checked when administering medications.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to meet all the requirements for the provision of hospice care for one (#26) of five residents out of 36 sample residents. Specifically, the facility failed to ensure the hospice agency notes regarding Resident #26's care were easily accessible to the facility staff in an attempt to effectively coordinate care with the hospice agency. Findings include: I. Facility-Hospice contract The contract between the facility and the hospice services company, dated 7/10/23, was provided by the nursing home administrator (NHA) on 3/25/25 at 3:08 p.m. It read in pertinent part, The hospice and nursing facility shall each prepare and maintain complete and detailed clinical records concerning each residential hospice patient receiving services under this agreement. Each clinical record shall completely, promptly, and accurately document all services provided to, and events concerning, each hospice patient. The hospice and the nursing facility shall each retain such records. Each such record shall be readily available and systematically organized to facilitate retrieval by either party. II. Resident #26 A. Resident status Resident #26, age [AGE], was admitted on [DATE]. According to the March 2025 computerized physician orders (CPO), diagnoses included respiratory failure, vascular dementia and adult failure to thrive. The 12/31/24 minimum data set (MDS) assessment documented the resident had both short-term and long-term memory impairments and had severely impaired daily decision-making skills, per staff assessment. The resident was dependent on staff for most activities of daily living (ADL). The MDS assessment indicated the resident was receiving hospice services. B. Record review The March 2025 CPO revealed a physician's order for Resident #26 indicating the resident was admitted to hospice services on 9/25/24. The end of life care plan, revised 10/15/24, revealed Resident #26 required hospice care and was at risk for rapid decline in ADLs. Pertinent interventions included coordinating Resident #26's needs with hospice staff. A hospice notebook was provided by licensed practical nurse (LPN) #1 on 3/25/25 at 4:09 p.m. Review of the notebook revealed three visits from the hospice social worker dated 1/13/25, 2/12/25 and 3/14/25. -However, the notebook did not reveal any documentation from the hospice nursing staff regarding their visits and the care they provided. -Review of Resident #26's electronic medical record (EMR) failed to reveal any progress notes from the hospice services provider. Hospice nursing notes, dated 12/23/24 through 3/26/25, were provided by the director of nursing (DON) on 3/26/25 at 6:06 p.m. The hospice notes documented the care that was provided to Resident #1 at each hospice visit. -However, the hospice nursing notes were not in the hospice binder accessible to the facility staff. III. Staff interviews LPN #1 was interviewed on 3/25/25 at 4:12 p.m. LPN #1 said when the hospice staff visited residents, their notes should be placed in the hospice notebook. LPN #1 said the hospice documents did not get uploaded anywhere into the residents' EMRs. LPN #1 said hospice certified nurse aides (CNAs) visited Resident #26 two to three days per week. LPN #1 was interviewed again on 3/26/25 on 10:34 a.m. LPN #1 verified there were no notes from any hospice CNA visits in Resident #26's hospice binder. LPN #1 said there should be notes from each visit from the hospice staff in the resident's hospice binder. -However, there were no notes documented from the hospice CNAs in Resident #26's hospice notebook (see record review above). CNA #5 was interviewed on 3/26/25 at 9:30 a.m. CNA #5 said the hospice staff reported to the CNA or nurse on duty after each visit to let them know what care they performed with Resident #26. CNA #5 said this information was also written down in the hospice binder. CNA #5 said the hospice staff communicated what care they performed so the facility's nursing staff could chart it in the resident's EMR, or attend to the resident if they needed medications or were not feeling well. CNA #2 was interviewed on 3/26/25 at 10:13 a.m. CNA #2 said some of the hospice CNAs did not tell the facility staff what care they provided for Resident #26 during their visits or if his incontinence brief needed to be changed. CNA #2 said the facility had a binder in which the hospice staff recorded everything they did when they came to assist Resident #26. CNA #2 said the hospice staff communicated with the facility staff to note any changes with Resident #26, ensure he was not left soiled and to make sure he got the care he needed. The DON and the regional clinical resource (RCR) were interviewed together on 3/26/25 at 4:40 p.m. The DON said the hospice staff emailed the facility recommendations after each visit. The DON said the hospice CNA visits and documentation were the social services department's responsibility. The DON said the hospice binders for each resident should contain the resident's plan of care and nursing recommendations from hospice. The RCR said the hospice binders for each resident should also contain visit summaries, chaplain notes and the hospice CNA visits. -However, Resident #26's hospice binder did not contain the plan of care, CNA visits or any documentation aside from the hospice social worker visits (see record review above).

II. Failed to provide residents on the Aspen unit with non-disposable beverage cups at meals. A. Observations On 3/25/25 at 11:30 a.m. the residents in the Aspen women's secured unit were served their meals. The residents were served their milk, punch and coffee in paper and styrofoam cups instead of plastic cups. On 3/25/25 at 5:00 p.m. the residents on the Aspen women's secured unit were served their meals. The residents were served their beverages in paper and styrofoam cups instead of plastic cups. On 3/26/25 at 11:30 a.m. the residents in the Aspen women's secured unit were served their noon meals. The residents were again served all of their beverages in paper and styrofoam cups instead of plastic cups. B. Staff interviews Certified nurse aide (CNA) #10 was interviewed on 3/25/25 at 12:00 p.m. CNA #10 said the residents on the women's secured unit always received both paper and styrofoam cups for their beverages. She said it had something to do with the kitchen, however she said she was not sure of the exact reason. Licensed practical nurse (LPN) #2 was interviewed on 3/26/25 at approximately 12:00 p.m. LPN #2 said the kitchen always sent paper cups for the residents' beverages on the women's secured unit. She said she was not sure of the reason. She said the men's secured unit received washable non-disposable plastic cups. Based on observations, record review and interviews, the facility failed to ensure residents were treated with respect and dignity by providing care in a dignified, respectful and individualized manner for one (#26) of four residents reviewed out of 36 sample residents and on one of three units. Specifically, the facility failed to: -Ensure residents who were prescribed a puree diet received the menu options as listed on the main menu or according to their preference and prescribed diet order; and, -Provide residents on the Aspen unit with non-disposable beverage cups at meals. Findings include: I. Failed to ensure residents who were prescribed a puree diet, received the menu options as listed on the main menu or according to their preference and prescribed diet order A. Facility policy and procedure The Resident Food Preferences policy, revised July 2017, was provided by the nursing home administrator (NHA) on 3/26/25 at 11:32 a.m. It read in pertinent part, Individual food preferences will be assessed upon admission and communicated to the interdisciplinary team. Modifications to diet will only be ordered with the resident's or representative's consent. When possible, staff will interview the resident directly to determine current food preferences based on history and life patterns related to food and meal times. Nursing staff will document the resident's food and eating preferences in the care plan. B. Resident representative interview Resident #26's representative was interviewed on 3/24/25 at 2:42 p.m. The resident representative said she could never find the puree diet menu. The resident representative said she had tried sitting down with Resident #26 and selecting things from the menu he would like, but when Resident #26 received his tray, he did not receive the menu items he had ordered. The resident's representative said she never knew what food items were on Resident #26's plate, so she would have the resident guess what he was eating. C. Observations and test tray During a continuous observation on 3/25/25, beginning at 11:10 a.m. and ending at 12:37 p.m., the following was observed during the meal preparation and service in the main kitchen: The posted menu was beef tostada with shredded lettuce and tomato and fruit crisp. At 11:12 a.m. cook (CK) #1 assembled a meal plate with mashed potatoes and puree meat and placed the meal in the serving window. The resident's meal ticket documented the resident was on a mechanical soft diet with puree meat and' cheeseburger' was written on the ticket. Restorative aide (RA) #1 looked at the meal and told CK #1 the resident ordered a cheeseburger and walked away from the serving window. At 11:13 a.m. RA #1 picked up the meal plate from the serving window and delivered it to the resident without a cheeseburger on the plate. At 12:35 p.m. a puree test tray was provided. The puree texture test tray consisted of puree beef, mashed potatoes, pureed peas and carrots and chocolate pudding for dessert. -The puree test tray did not include puree fruit crisp or puree noodles as documented on the diet modification spreadsheet. D. Record review The facility menus and puree daily standards were provided by the NHA on 3/24/25 at 3:24 p.m. The puree daily standards documented high quality leftovers from the previous meal/day would be saved and pureed to proper consistency following International Dysphagia Diet Standardization initiative IDDSI) standard for the next meal period. Lunch was pureed and served for dinner and dinner for lunch (the following day). Breakfast would be pureed fresh daily and the puree items were tossed after each meal period. The menu diet modification spreadsheet was provided by the dietary director (DD) on 3/26/25 at 5:00 p.m. The spreadsheet documented that for the lunch meal served on 3/25/25 the puree lunch included puree beef and noodles with sauce, and a puree fruit crisp and puree green chili stew. -However, the residents were served puree beef, mashed potatoes, puree peas and carrots and chocolate pudding. E. Staff interviews RA #1 was interviewed on 3/25/25 at 11:45 a.m. RA #1 said she did not know why the resident did not receive a cheeseburger with his meal. She said she thought maybe it was because the resident would also have puree bread with puree meat (of his cheeseburger). The DD and the NHA were interviewed together on 3/26/25 at 12:00 p.m. The DD said the staff pureed leftover food served at the previous meal for residents prescribed a puree diet. The DD said the test tray consisted of roast beef, mashed potato and peas and carrots. The DD said he did talk to the dietary staff after lunch on 3/25/25 and educated the staff to serve the resident a puree burger if that was the resident's preference. The DD said the resident had a mechanical soft diet order with an additional order for puree texture meat. The NHA said he thought the dietary staff pureed food from the previous meal so the staff could have the puree items ready to go ahead of time. The NHA said he had not previously heard any concerns about the puree food items.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interviews, the facility failed to ensure four (#59, #39, #97 and #42) of nine residents out of 36 sample residents were kept free from abuse. Specifically, the facility failed to: -Protect Resident #59 and Resident #39 from sexual abuse by Resident #62; -Protect Resident #97 and Resident #34 from physical abuse by each other; and, -Protect Resident #42 from physical abuse by Resident #58. Findings include: I. Facility policy and procedure The Abuse, Neglect, Exploitation and Misappropriation Prevention Program policy, revised April 2021, was provided by the nursing home administrator (NHA) on 3/23/25 at 12:41 p.m. It read in pertinent part, Residents have the right to be free from abuse. The facility will implement measures to address factors that may lead to abusive situations. The facility will identify and investigate all possible incidents of abuse, neglect, mistreatment, or misappropriation of resident property. The facility will investigate and report any allegations within timeframes required by federal requirements. II. Incident of sexual abuse of Resident #59 and Resident #39 by Resident #62 on 3/21/25 A. Facility investigation The facility's incident investigation, undated, was provided by the NHA on 3/24/25 at 4:21 p.m. The investigation included a statement from certified nurse aide (CNA) #4, which revealed on 3/21/25 between 1:30 a.m. and 2:00 a.m., CNA #4 observed Resident #62 as he was halfway into Resident #39 and Resident #59's shared room. Resident #62 had exposed his genitals and was masturbating in the room. CNA #4 took Resident #62 back to his room and told him he could not be in other residents' rooms. Resident #39 was interviewed by the NHA on 3/21/25. Resident #39 said she did not have any incidents of abuse to report. Resident #39 said she felt safe in the facility. Resident #39 said she did not notice any disturbances during her sleep. Resident #39 said there was nothing else she wanted to share. Resident #59 was interviewed by the NHA on 3/21/25. Resident #59 said she did not have any incidents of abuse to report. Resident #59 said she felt safe in the facility. Resident #59 said she did not notice any disturbances during her sleep. Resident #59 said there was nothing else she wanted to share. The investigation included a secure neighborhood placement evaluation, dated 3/21/25, for Resident #62. -The documents did not include a formal abuse investigation, interviews with any other residents in the vicinity, an interview with Resident #62 or any other interviews with staff members. B. Resident #62 (assailant) 1. Resident status Resident #62, age [AGE], was admitted on [DATE]. According to the March 2025 computerized physician orders (CPO), diagnoses included sexual dysfunction and major depressive disorder. The 12/17/24 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 13 out of 15. The resident needed setup or cleanup assistance for most activities of daily living (ADL). The MDS assessment documented the resident did not have physical or verbal behaviors directed toward others or other behavioral symptoms not directed toward others. 2. Record review The behavioral care plan, initiated 7/17/2020 and revised 4/14/23, revealed Resident #62 made verbally explicit comments and suggestions toward staff, masturbated in front of staff, asked female staff members if he could touch them or if the staff could touch him in a sexually inappropriate way. Pertinent interventions included explaining or reinforcing why his behavior was inappropriate or unacceptable, administering medications as ordered, educating staff on the importance of respecting Resident #62's wishes and emphasizing sexual outlet was a normal function, monitoring behavioral episodes and attempting to determine an underlying cause, redirecting any inappropriate public exposure and intervening as necessary to protect the rights and safety of others. The activities care plan, revised 3/18/25, revealed Resident #62 was part of an activities work reward program in which he passed out news bulletins on the South neighborhood as it gave him purpose and satisfaction to speak with his peers and staff daily. Pertinent interventions included ensuring Resident #62 had the appropriate leisure material in order to be set up for success and having staff remind and encourage Resident #62 to participate in the work reward program. The antipsychotic medication care plan, revised 12/30/24, revealed Resident #62 required an antipsychotic medication as evidenced by inappropriate sexual behavior, delusions and hallucinations. Pertinent interventions included administering antipsychotic medications as ordered, observing Resident #62's mood and response to the medication and observing and recording the effectiveness of the drug treatment as indicated. A progress note, dated 1/16/25 at 9:56 p.m., revealed Resident #62 was being inappropriate in his room and masturbating during medication pass. -However, the incident was not documented in the behavior tracking software or in the resident's treatment administration records (TAR). A progress note, dated 1/29/25 at 9:54 p.m., revealed Resident #62 was asking an unidentified nurse and CNA to come into his room. When the nursing staff members responded and asked Resident #62 what he needed, he did not respond. When the nurse was in Resident #62's room assisting his roommate, Resident #62 began looking at the nurse inappropriately and grunting. When the nurse exited the room, Resident #62 told her he loved her. -However, the incident was not documented in the behavior tracking software or in the TAR. A progress note, dated 3/21/25 at 12:39 p.m., revealed an unidentified CNA witnessed Resident #62 masturbating in another resident's room. The other residents slept through the situation and did not wake up. The CNA relocated Resident #62 away from the room and told the resident he could not perform those actions in others' rooms. The director of nursing (DON) spoke with Resident #62 and gave him choices to ensure his safety and the safety of others, and the resident agreed to relocate the resident to the all-male secured unit. The nursing staff were to continue to monitor Resident #62 for hypersexual behaviors. -However, the incident was not documented in the behavior tracking software or in the TAR. A quarterly interdisciplinary team (IDT) conference, initiated 3/20/25 at 12:21 p.m. and finalized 3/23/25 at 9:09 p.m., revealed Resident #62 was independent in his activities of choice. Resident #62 participated in the work therapy program by passing out the daily bulletin. Resident #62 enjoyed watching television (TV), visiting with his peers, and going out for scheduled smoke breaks. Resident #62 was re-educated on places in which it was appropriate to masturbate. Resident #62 was re-educated on not going into other residents' rooms. An IDT note, dated 3/25/25 at 9:30 a.m., revealed that on 3/21/25 at 1:30 a.m. Resident #62 was observed by a CNA masturbating in the doorway of Resident #39 and Resident #59's room. When confronted, Resident #62 said he did not know what they were talking about. Interventions implemented included moving Resident #62 back to the all-male secured unit. Risk factors included Resident #62's history of sexually inappropriate behavior and mental illnesses. A change in condition note, dated 3/26/25 at 3:33 p.m., revealed Resident #62 had a change in condition due to behavioral symptoms. The note documented the facility staff said Resident #62's behaviors were still present with masturbation in public view. No new interventions or orders were documented. Behavior tracking through the facility's behavior tracking software was reviewed from 9/24/24 through 3/25/25 and revealed the following: On 11/14/24 at 11:40 a.m. Resident #62 asked a CNA to wash his private area while she was assisting him with his shower and Resident #62 told the CNA he could see down her shirt as she was assisting him with putting on his socks. On 1/19/25 at 8:08 p.m. a CNA reported to the nurse that Resident #62 was masturbating and saying to her I know you're over there baby, come on over here repeatedly. The nurse educated Resident #62 that he could masturbate in his room privately but it was unacceptable to ask any staff members to help him. -However, the 1/19/25 incident was not documented in the progress notes or in the TAR. C. Resident #59 (victim) 1. Resident status Resident #59, age [AGE], was admitted on [DATE]. According to the March 2025 CPO, diagnoses included dementia and generalized muscle weakness. The 12/20/24 MDS assessment revealed the resident was severely cognitively impaired with a BIMS score of six out of 15. The resident was dependent or required maximal assistance with most ADLs. 2. Record review A progress note, dated 3/21/25 at 1:30 a.m., revealed a CNA reported she saw a resident in Resident #59's room sitting in his wheelchair exposing his genitals. The CNA moved the other resident out of Resident #59's room. Resident #59 remained asleep and did not appear to wake up or be aware of the incident. All parties were notified per facility protocol by the DON. A progress note, dated 3/23/25 at 11:55 p.m., revealed Resident #59 was resting in bed and did not voice any concerns to the nurse on staff. The nurse would continue to monitor the resident. An IDT note, dated 3/25/25 at 10:07 a.m., revealed on 3/21/25 at 1:30 a.m. a CNA observed a male resident in the doorway of Resident #59's room exposing his genitals. The resident was quickly removed from the room. Resident #59 was sleeping and was not aware of the man's presence. The NHA, the DON, the resident, and the resident's responsible party were notified. Interventions were put into place to prevent any recurrences. -However, the note did not specify what interventions were put into place to prevent recurrence. D. Resident #39 (victim) 1. Resident status Resident #39, age less than 65, was admitted on [DATE]. According to the March 2025 CPO, diagnoses included generalized anxiety disorder, insomnia and depression. The 1/7/25 MDS assessment revealed the resident was cognitively intact with a BIMS score of 14 out of 15. The resident was dependent or required maximal assistance with most ADLs. 2. Record review A progress note, dated 3/21/25 at 1:30 a.m., revealed a CNA reported she saw a resident in Resident #39's room sitting in his wheelchair exposing his genitals. The CNA moved the other resident out of Resident #39's room. Resident #39 remained asleep and did not appear to wake up or be aware of the incident. All parties were notified per facility protocol by the DON. An IDT note, dated 3/25/25 at 9:43 a.m., revealed on 3/21/25 at 1:30 a.m. a CNA observed a male resident in the doorway of Resident #39's room exposing his genitals. The resident was quickly removed from the room. Resident #39 was sleeping and was not aware of the man's presence. The NHA, the DON, the resident, and the resident's responsible party were notified. Interventions were put into place to prevent any recurrences. -However, the note did not specify what interventions were put into place to prevent recurrence. E. Staff interviews CNA #6 was interviewed on 3/25/25 at 9:02 a.m. CNA #6 said Resident #62 had sexually inappropriate behaviors sometimes but never towards her. CNA #6 said she never personally witnessed any sexual behaviors from Resident #62. CNA #6 said Resident #62 was able to be redirected when he was having sexually inappropriate behaviors. CNA #6 said she knew Resident #62 had been inappropriate and masturbated in front of other CNAs. CNA #6 said Resident #62 had sexually inappropriate behaviors day and night, but was only interested in women. CNA #6 said she documented any behaviors Resident #62 exhibited into their behavior monitoring software and would notify the nurse and the social services director (SSD) if she saw any behaviors. CNA #6 said the activities department employed Resident #62 to deliver the daily bulletin to each resident's room. CNA #6 said Resident #62 would peek into residents' rooms while he delivered the news. CNA #5 was interviewed on 3/25/25 at 9:18 a.m. CNA #5 said she tried to avoid working with Resident #62 as much as possible because she had heard from other CNAs that he was inappropriate and would masturbate in front of them. CNA #5 said Resident #62 had not been inappropriate with her, but she said if he had been, she would have let the nurse know. CNA #5 said when Resident #62 distributed the daily bulletin he would slowly put them in the female residents' rooms and linger in their doorways peeking in. CNA #5 said she would close the residents' doors or redirect Resident #62 if she saw him lingering. CNA #7 was interviewed on 3/25/25 at 9:34 a.m. CNA #7 said Resident #62 would go into other residents' rooms and have sexually inappropriate behaviors. CNA #7 said Resident #62 had previously stayed in his room and not bothered anyone but after moving to a different unit, he began having behaviors. CNA #7 said Resident #62 had sexually inappropriate behaviors every two days or so and would masturbate in his room. Licensed practical nurse (LPN) #1 was interviewed on 3/25/25 at 9:58 a.m. LPN #1 said she never witnessed Resident #62 having inappropriate behaviors but she knew he would masturbate in front of staff. LPN #1 said Resident #62 had sexually inappropriate behaviors in front of ladies and was able to be redirected easily for a short time. LPN #1 said Resident #62 was moved back to the all-male secured unit for the safety of other residents after he masturbated in front of two female residents in their doorway. CNA with medication authority (CNA-Med) #1 was interviewed on 3/25/25 at 10:10 a.m. CNA-Med #1 said Resident #62 was very different in the all-male secured unit than he was in the unsecured unit. CNA-Med #1 said Resident #62 was mellow on the secured unit and spent his time hanging out in his room and playing dominos. CNA-Med #1 said Resident #62 was having sexually inappropriate behaviors on the South unit with staff and other residents approximately once per week. CNA-Med #1 said Resident #62 was able to be redirected when he was having sexually inappropriate behaviors. CNA-Med #1 said Resident #62 never had any sexually inappropriate behaviors when he lived in the secured unit previously. CNA-Med #1 said Resident #62 had a job with the activities department to go door to door and pass out the daily bulletins. CNA-Med #1 said behaviors were charted in the facility's behavior monitoring software or in the TAR. The DON was interviewed on 3/26/25 at 4:40 p.m. The DON said the incident involving Resident #62 happened overnight on 3/21/25. The DON said he received a call from CNA #4 who told him she was in another resident's room, heard a noise, and saw Resident #62 halfway in the doorway of Resident #59 and Resident #39's room. CNA #4 said Resident #62 had his genitals exposed and was masturbating. The DON said when he came in later on the morning of 3/21/25, the facility staff interviewed Resident #62 and discussed what his next steps would be. The DON said the facility did a trial move with Resident #62 out of the secured unit because he did not exhibit any hypersexual behaviors when he was on the secured unit. The DON said he notified the NHA of the incident immediately. The DON said Resident #62 was mellow and redirectable on the secured unit and had never displayed any sexually inappropriate behaviors when he was on the secured unit. The NHA was interviewed on 3/26/25 at 5:15 p.m. The NHA said any allegations of abuse needed to be reported to him regardless of the time. The NHA said if he was not available, abuse allegations should be reported to the nurse on-call. The NHA said any abuse allegations needed to be reported to the State Agency within 24 hours. The NHA said after reporting the allegation, the facility staff would launch an investigation, ask for staff statements and interview any residents within the vicinity of the incident. The NHA said he was notified later in the morning on 3/21/25 about Resident #62's incident on 3/21/25. The NHA said when CNA #4 reported the incident, the facility staff explained Resident #62's options to him and the resident elected to go back into the secured unit. The NHA said he got a statement from the CNA who witnessed the incident and that he interviewed Resident #59 and Resident #39 and they were both asleep. The NHA said he asked both Resident #59 and Resident #39 if they felt safe and if they had witnessed any abuse and neither resident expressed any knowledge of the situation. The NHA said he had not reported the incident to the State Agency as he had reached out to one of the facility's clinical consultants and was told the incident was not abuse. Cross-reference F609 for failure to report an allegation of abuse to the State Agency. The NHA said he did not interview any other residents, as CNA #4 said no other residents were in the hallway because the incident occurred overnight. The NHA said he did not feel the need to interview any other residents as they had not seen Resident #62 that night.III. Incident of physical abuse between Resident #97 and Resident #34 on 2/28/25 A. Facility investigation The facility's investigation was provided by the NHA on 3/25/25 at 1:00 p.m., revealed the following: On the morning of 2/28/25, a physical altercation was witnessed between Resident #34 and Resident #97. The altercation occurred in the hallway near Resident #34's bedroom. LPN #6 immediately separated the two residents and both residents were placed on 15-minute checks for the investigation period. LPN #6 assessed both residents and no injuries were present. Resident #34 said he could not recall the altercation with Resident #97. Resident #97 could not communicate any recollection of the incident to staff. Other residents from the unit and staff witnesses were interviewed and revealed the following: Other residents from the same unit stated that they got along with Resident #34 and Resident #97 and did not have any instances of abuse to report. The staff witnesses stated that Resident #97 was walking down the hallway and Resident #34 was in his way. Resident #34 was facing away from Resident #97. Resident #97 attempted to move Resident #34 from behind when Resident #34 reached back and made contact with Resident #97, without looking to see who was behind him. CNA #9 said that on 2/8/25 at approximately 9:30 a.m., she heard a loud noise in the hall and saw Resident #34 and Resident #97 fighting. She said she did not see any contact between the residents, but saw Resident #97 attempt to pick up his walker to hit Resident #34. She said she told Resident #97 everything was okay and tried to re-direct him away from Resident #34. She said when Resident #97 returned and walked near Resident #34 again another staff member re-directed Resident #97 back to his room and he laid down for a nap. LPN #6 said that on 2/8/25 at approximately 9:30 a.m., there was an altercation between Resident #34 and Resident #97. The altercation occurred in the hallway near Resident #34's bedroom. LPN #6 said that Resident #97 attempted to pass by Resident #34 in the hall and pushed Resident #34 aside. LPN #6 said Resident #34 became upset and attempted to hit Resident #97. LPN #6 said the situation did not escalate because the residents were separated. LPN #6 said the residents were assessed and no injuries were found. The NHA and the residents' representatives were notified. Care plans were reviewed and no changes were made. The altercation was unsubstantiated as an act of abuse. -However, abuse occurred because Resident #97 attempted to hit Resident #34 with his walker and Resident #34 retaliated and made physical contact with Resident #97. B. Resident #34 (assailant and victim) 1. Resident status Resident #34, age [AGE], was admitted on [DATE] and readmitted on [DATE]. According to the March 2025 CPO, diagnoses included unspecified dementia with behavioral disturbances. The 2/4/25 minimum data set (MDS) assessment revealed the resident had severe cognitive impairment with a BIMS) of three out of 15. He walked independently but was dependent on staff assistance for all ADLs. The assessment indicated the resident had fluctuating inattention and disorganized thinking. He had delusions and physical behavioral symptoms directed toward others on one to three days during the assessment look-back review period. He had behavioral symptoms not directed toward others on a daily basis. 2. Record review Resident #34's medication care plan, revised 6/14/22, identified the resident was at risk of complications related to antipsychotic medication use for diagnoses of insomnia and dementia with behavioral disturbances. Resident #34's trigger behaviors for mood stabilizer use were impulsiveness and erratic/irrational response to stimuli. His trigger behaviors for antipsychotic use were physical aggression and erratic/irrational responses to stimuli. Interventions included administering antipsychotic medications as ordered and monitoring for any adverse side effects of medication use, consulting with pharmacy and the physician to consider dosage reduction when clinically appropriate, at least quarterly, and monitoring and documenting the resident's trigger behaviors (revised 2/18/23), giving the resident space when he was aggressive or upset, not approaching the resident from behind or the side due to the resident's visual impairments (revised 6/13/23), leading Resident #34 back to areas where staff were positioned in order to keep him visible, encouraging him to stay clear of door ways (revised 7/27/23) and keeping Resident #34 in line of sight if possible (revised 3/28/24). Resident #34's care plan for behaviors, initiated 4/13/22, revealed Resident #34 had behaviors including aggressiveness towards peers and staff and poor impulse control related to dementia, traumatic brain injury, post-traumatic stress disorder (PTSD) and a history of work as a prison guard. The resident had a history of attempting to, or threatening to hit staff. He hallucinated (reached for things that were nonexistent), had poor safety awareness and attempted to self-transfer. Resident #34's triggers included others speaking to him or about him and others approaching or touching him from the back or side and surprising him. Pertinent interventions included monitoring behavior episodes and attempting to determine the underlying cause, documenting behavior and potential causes, praising any indication of progress/improvement in behavior (initiated 4/13/22), performing frequent checks for 72 hours following any verbal or physical aggression observed or reported and providing opportunities for positive interaction and attention re-evaluation of medication management due to the resident's continued behaviors (revised 2/18/23), de-escalation by sitting with him with his back against a wall, when agitated, staff should offer him fluids and his preferred snacks (revised 3/13/23) and frequent checks and back scratches. He enjoyed being called gorgeous while having his back scratched (revised 2/26/24). A review of Resident #34's March 2025 CPO revealed the following physician's orders: Behavior monitoring for antipsychotic medication use every shift, ordered 12/12/24. Monitoring effectiveness of interventions for behaviors, ordered 12/12/24. Monitor resident every shift due to physical aggression initiated, monitor physical aggression until 2/11/25 at 11:59 p.m., ordered 2/9/25. A change in condition progress note, dated 2/8/25, revealed Resident #34 initiated an act of physical aggression. Resident #34's vital signs were within normal limits, and he had no changes in mental or physical status. The resident's representative was notified of the incident. An interdisciplinary team (IDT) progress note, dated 2/10/25, revealed Resident #34 had risk factors that contributed to his behavior, including a traumatic brain injury, dementia, poor situational and safety awareness. Interventions included separating the two residents, and for staff to ensure that other residents did not approach Resident #34 from behind. C. Resident #97 (victim and assailant) 1. Resident status Resident #97, age [AGE], was admitted on [DATE], re-admitted on [DATE] and discharged on 3/2/25. According to the March 2025 CPO, diagnoses included unspecified dementia with behavioral disturbances. The 1/21/25 MDS assessment documented the resident had severely impaired cognition with a BIMS score of zero out of 15. He required partial or maximum assistance for transfers and used a walker for mobility. He required touching assistance or supervision with walking. The assessment indicated the resident had daily behaviors that were not directed toward others. 2. Record review Resident #97's behavioral care plan, revised 2/3/25, revealed the resident had a behavior problem related to his dementia, language and cultural barrier and he made nonsensical statements. He had a history of physical aggression towards females and was also possessive and overprotective of his belongings, peers and partners. The resident paced and sometimes inadvertently ran into others while walking. Pertinent interventions included providing frequent checks following any verbal or physical aggression, intervening as necessary to protect others, approaching him and speaking in a calm manner, diverting his attention, removing him from the situations to an alternate location if needed, monitoring behavior episodes and attempting to determine the underlying cause, documenting behavior and potential causes, praising any indication of progress/improvement in behavior and staff to ensure the resident was not too close to others while walking in the hallway. A progress note, dated 2/8/25, revealed an altercation between Resident #34 and Resident #97 occurred in the hallway. Resident #97 attempted to pass by Resident #34, pushing Resident #34 aside. Resident #34 got upset and swung at Resident #97. The two residents were separated. No injuries were found. The NHA and Resident #97's legal guardian were notified. An IDT progress note, dated 2/10/25, revealed on 2/8/25 at 12:41 p.m. there was a physical altercation between Resident #97 and another resident (Resident #34) while passing in the hallway. Resident #97 inadvertently pushed Resident #34 aside while walking past his wheelchair. Resident #34 swung at Resident #97 in response. The residents were immediately separated. No injuries were noted. The NHA was notified. Staff was to monitor for Resident #97 to have a path clear of wheelchairs while walking in the hallway. A progress note, dated 3/11/25 at 11:59 p.m., revealed completion of 72 hours of frequent 15-minute checks for Resident #97. No problems were reported. D. Staff interviews LPN #2 was interviewed on 3/26/25 at 3:28 p.m. LPN #2 said she could not remember who the aggressor was in the altercation between Resident #34 and Resident #97. She said what she remembered was that Resident #97 used to pace the hall with his walker. She said he was usually calm and collected, but at times the halls got crowded with residents. She said Resident #34 did sometimes have aggressive behaviors. CNA-Med #1 was interviewed on 3/26/25 at 3:45 p.m.CNA-Med #1 said she was not working the day of the altercation between Resident #97 and Resident #34. She said when she returned to work two days later, Resident #34 and Resident #97 were both being documented on frequently due to the altercation. She said she was told by the previous nurse that Resident #97 had been in a bad mood that day (2/8/25) and rammed his walker into the back of Resident #34's wheelchair. She said Resident #34 was easily triggered, sometimes mean, and had previously attempted to hit staff. She said staff normally walked away and let Resident #34 calm down when he was agitated, or staff who had good rapport with him would calm him down. She said she did not know if contact was made during the altercation on 2/8/25, but staff were told to keep an eye on both of the residents. She said she did not think the police were called, but families/representatives and the physician were notified. IV. Incident of physical abuse of Resident #42 by Resident #58 on 3/10/25 A. Facility investigation The facility's investigation was provided by the NHA on 3/25/25 at 1:00 p.m. revealed the following: On 3/10/25 an incident occurred between Resident #58 and Resident #42. Resident #58 allegedly made contact with another resident (Resident #42). Resident #58 attempted to kick Resident #42. The incident was witnessed by staff. Residents and staff from the unit were interviewed, statements were obtained from staff and the victim (Resident #42) was interviewed. The DON assessed Resident #42 and found no injuries. The assailant (Resident #58) was discharged to the hospital because he was unable to be redirected. Resident #42 (victim) had a history of delusions, and verbal aggression towards peers and staff. Resident #42 had a BIMS of 15 and had not been involved in any other occurrences in the past year. Resident #58 had a BIMS of three, required assistance for ADLs, and had a history of verbal and physical aggression towards staff and residents. Resident #58 had become physically aggressive towards other residents when they had food he wanted. When staff attempted to re-direct him, he sometimes attempted to hit staff. Resident #58 wandered into other residents' rooms. There was a care plan for his behaviors, including a communication board, anticipating his needs, offering snacks and redirecting. Resident #58 had been involved in other occurrences of physical abuse on 11/19/24, 1/18/25, 1/20/25. Staff stated that Resident #58 had been having more behavioral episodes recently. They were unable to identify why, except that the resident had a history of being physically aggressive towards others. There were no interactions between the victim (Resident #42) and Resident #58 leading up to the incident on 3/10/25. Care plans and documentation were reviewed. The conclusion was that there was contact made but that it did not rise to the definition of abuse. -However, abuse occurred because Resident #58 willfully kicked Resident #42 (see witness statements below). Changes were made to Resident #58's plan, including discharging him to the hospital with possible re-evaluation at a future date. The police, ombudsman, family/guardian, and physician were notified. Interviews during the investigation revealed the following: On 3/10/25, CNA-Med #1 reported that she saw Resident #58 open his bedroom door, quickly walk over to the dining room and start kicking Resident #42, who was sitting in the dining room watching television. CNA-Med #1 said she separated the residents and Resident #58 shoved her into the medication cart. Other staff intervened quickly and re-directed Resident #58 back to his bedroom to lay down. Both residents were assessed and no injuries were noted. The physician, ombudsman and the corporate support person were called. Resident #58 was transferred to the hospital non-emergently. When the emergency medical technicians (EMTs) arrived, Resident #58 had to be restrained and sedated. Resident #58 was taken to the emergency room because he had become a danger to himself and others and he could not be redirected. Resident #42 was interviewed on 3/10/25 by the DON, immediately after the incident. Resident #42 said he was sitting in the dining room watching television when Resident #58 started kicking him. Resident #42 said he was fine and did not get hurt and just went back to watching television.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** IV. Resident #249 A. Resident status Resident #249, age [AGE], was admitted on [DATE]. According to the March 2025 CPO, diagnoses included dementia with severe agitation, insomnia and alcohol dependence with alcohol induced persisting. The 3/4/25 MDS assessment revealed the resident had severe cognitive impairments with a BIMS score of three out of 15. The resident required supervision or touching assistance with most ADLs. The assessment documented the resident was prescribed several high-risk medications including antidepressants, antipsychotic, and opioids. B. Record review Review of Resident #249's comprehensive care plan, revised 3/19/25, did not reveal any focus or interventions related to her diagnosis of insomnia. Review of the March 2025 CPO revealed the following orders: Trazodone 50 mg oral tablet, instructions to give one tablet by mouth at bedtime for insomnia associated with depression, ordered 3/6/25. C. Staff interviews LPN #2 was interviewed on 3/26/25 at 12:45 p.m. LPN # 2 confirmed Resident #249 received trazadone for insomnia. She said her sleep hours were tracked. She said due to her dementia diagnosis, she sundowned and she was up at night at times. The MDSC was interviewed on 3/26/25 at 3:30 p.m. The MDSC reviewed the care plan for Resident #249 and confirmed there was no care plan for insomnia. She said a care plan to help with interventions for sleep should be written. Based on record review and interviews, the facility failed to develop a comprehensive care plan for three (#1, #75 and #249) of six residents out of 36 sample residents for services to attain or maintain the resident's highest practicable physical, mental and psychosocial well-being. Specifically, the facility failed to: -Ensure a comprehensive care plan was developed to address Resident #1's use of supplemental oxygen and a peripherally inserted central catheter (PICC); and, -Ensure a comprehensive care plan was developed to address Resident #75 and Resident #249's insomnia. Findings include: I. Facility policy and procedure The Comprehensive Person-Centered Care Plans policy, revised March 2022, was provided by the nursing home administrator (NHA) on 3/26/25 at 6:42 p.m. The policy read in pertinent part, The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment. Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change. The interdisciplinary team reviews and updates the care plan when there has been a significant change in the resident's condition and at least quarterly. II. Resident #1 A. Resident status Resident #1, age greater than 65, was admitted on [DATE]. According to the March 2025 computerized physicians orders (CPO), diagnoses included schizoaffective disorder (mental illness), vascular dementia and cellulitis of the left lower limb. The 2/7/25 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 13 out of 15. The resident required supervision to maximum assistance for most activities of daily living (ADL). B. Resident and resident representative interview Resident #1 and her representatives were interviewed together on 3/23/25 at 10:33 a.m. The resident's representatives said Resident #1 had an infection in her leg which became swollen and was treated with antibiotics. The resident's representatives said the facility placed a PICC line for the antibiotics. The resident's representatives said Resident #1 usually had her nasal cannula on and that she had been treated for pneumonia the week prior. Resident #1 said she needed supplemental oxygen all the time. C. Record review The end of life care plan, initiated 3/24/25 (during the survey process), revealed Resident #1 was receiving hospicare care. Pertinent interventions included providing supplemental oxygen as ordered. -Review of the comprehensive care plan, revised 3/24/25, did not reveal any focus or other interventions related to Resident #1's use of supplemental oxygen. -Review of the comprehensive care plan, revised 3/24/25, did not reveal any focus or interventions related to Resident #1's PICC line or maintenance of the PICC line. Review of the March 2025 CPO revealed the following physician's orders: Midline intravenous (IV) placement, ordered 3/7/25; Radiographs to check for midline (PICC) placement, ordered 3/7/25; Normal saline flush solution, with instructions to use 10 milliliters (ml) intravenously two times a day for cellulitis/pneumonia. Flush before and after medication, ordered 3/7/25; Vancomycin IV solution 750 milligrams (mg) per 150 ml, with instructions to use 750 mg intravenously every 12 hours for cellulitis for ten days, ordered 3/6/25 and discontinued 3/13/25; Vancomycin IV solution 500 mg per 150 ml, with instructions to use 1000 mg intravenously every 12 hours for cellulitis until 3/17/25, ordered 3/6/25; PICC line dressing change every seven days, ordered 3/25/25 (during the survey process); and, Oxygen 4 liters per minute (LPM) via nasal cannula. Check oxygen saturation each shift and as needed. Notify healthcare provider if saturation is less than 90%, ordered 3/23/25 (during the survey process). A progress note, dated 3/5/25 at at 10:14 a.m., revealed Resident #1 was receiving supplemental oxygen. A progress note, dated 3/7/25 at 10:14 a.m., revealed Resident #1 was ordered to receive an IV antibiotic and a PICC line was requested. A progress note, dated 3/13/25 at 3:44 p.m., revealed Resident #1 was receiving continuous supplemental oxygen via nasal cannula. D. Staff interviews The MDS coordinator (MDSC) was interviewed on 3/26/25 at 3:30 p.m. The MDSC said she reviewed the care plan and confirmed Resident #1's care plan did not address her use of oxygen or the use of the PICC line. The MDSC said the care plan should have interventions to elevate the head of the bed, ensure they were following physician's orders and also to check oxygen saturation levels. The MDSC said the care plan needed to include interventions for the PICC line that included keeping the line patent and monitoring for infections and directions for flushing. III. Resident #75 A. Resident status Resident #75, age [AGE], was admitted on [DATE]. According to the March 2025 CPO, diagnoses included dementia with anxiety, adult failure to thrive, insomnia and depression. The 2/11/25 MDS assessment revealed the resident was cognitively intact with a BIMS score of 14 out of 15. The resident required supervision or touching assistance with most ADLs. The assessment documented the resident took several high-risk medications including antidepressants, antianxiety, antipsychotic, anticonvulsants, and opioids. B. Record review Review of Resident #75's comprehensive care plan, revised 2/25/25, did not reveal any focus or interventions related to her diagnosis of insomnia or use of medications to treat her insomnia. Review of the March 2025 CPO revealed the following orders: Trazodone 100 mg oral tablet, instructions to give one tablet by mouth at bedtime for insomnia associated with depression, ordered 2/5/25; Melatonin 3 mg oral tablet, instructions to give two tablets by mouth one time a day for insomnia, ordered 2/5/25 and discontinued 3/25/25 (during the survey process); and, Melatonin 3 mg oral tablet, instructions to give one tablet by mouth at bedtime for insomnia, ordered 3/25/25. C. Staff interviews Licensed practical nurse (LPN) #1 was interviewed on 3/26/25 at 12:45 p.m. LPN #1 said Resident #75 received trazadone for insomnia. She said the resident complained of not being about to sleep. She said the resident's hours of sleep were tracked. She said she slept during the day and that could affect her sleeping at night. She said the care plans were updated by the MDSC. The MDSC was interviewed on 3/26/25 at 3:30 p.m. The MDSC said each resident had a plan of care. She said the plan of care began on the admission with a baseline care plan. She said she was responsible to complete the care plan, however, the nurses and other departments were responsible to update the care plan as needed. The MDSC reviewed the care plan for Resident #75 and confirmed there was not a care plan for insomnia. She said a care plan to help with interventions for sleep should be written.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to ensure three (#95, #75 and #249) of five residents out of 36 sample residents were as free from unnecessary medications as possible. Specifically, the facility failed to: -Ensure consents were obtained that included the risks versus benefits for psychotropic medications for Resident #95, Resident #75 and Resident #249; and. -Ensure Resident #95 and Resident #75 had behavior monitoring in place for the use of psychotropic medications. Findings include: I. Facility policy and procedure The Psychotropic Medication Use policy, revised July 2022, was provided by the nursing home administrator (NHA) on 3/26/25 at 6:24 p.m. It revealed in pertinent part, Drugs in the following categories are considered psychotropic medications and are subject to specific prescribing, monitoring, and review requirements: anti-psychotics, anti-depressants, anti-anxiety medications and hypnotics. Residents, families and/or the representative are involved in the medication management process, including: indications for use, dose, duration, adequate monitoring for effectiveness and adverse consequences, and preventing, identifying and responding to adverse consequences. Residents who have not used psychotropic medications are not prescribed or given these medications unless the medication is determined to be necessary to treat a specific condition that is diagnosed and documented in the medical record. Use of psychotropic medications may be appropriate in specific circumstances, such as for enduring conditions and/or new admissions where the resident is already on a psychotropic medication. Residents receiving psychotropic medications are monitored for adverse consequences and residents (and/or representatives) have the right to decline treatment with these medications. The staff and physician will review with the resident/representative the risks related to not taking the medication as well as appropriate alternatives. II. Resident #95 A. Resident status Resident #95, age [AGE], was admitted on [DATE]. According to the March 2025 computerized physician's orders (CPO), diagnoses included acute and chronic respiratory failure and major depressive disorder. The 2/7/25 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. The resident required supervision or touching assistance with most activities of daily living (ADL). The assessment documented the resident took several high-risk medications including antidepressants, hypnotics and anticonvulsants. B. Resident and representative interview Resident #95 was interviewed on 3/26/25 at 12:26 p.m. Resident #95 said her representative signed all of her documents on admission. Resident #95 said she was not sure what documents her representative signed. Resident #95's representative was interviewed on 3/26/25 at 3:19 p.m. The representative said she did not think the facility staff reviewed any medication side effects with her. The representative said she did not remember signing any medication consent forms. C. Record review The antidepressant care plan, initiated 2/20/25, revealed Resident #95 was taking an antidepressant medication to treat her diagnosis of major depressive disorder. Pertinent interventions included educating Resident #95 and her representatives on the risks, benefits, and side effects of the drugs being given, giving the antidepressant medication as ordered, monitoring and documenting ongoing signs or symptoms of depression, and monitoring and documenting medication side effects. The hypnotic care plan, initiated 2/20/25, revealed Resident #95 was taking a hypnotic medication to treat her insomnia (difficulty sleeping). Pertinent interventions included administering the medication as ordered and monitoring and documenting medication side effects. Review of the March 2025 CPO revealed the following physician's orders: Mirtazapine 30 milligram (mg) tablets instructions to give 30 mg by mouth at bedtime for depression, ordered 1/31/25; Venlafaxine extended release 150 mg oral tablet, instructions to give 150 mg by mouth one time a day for depression, ordered 2/1/25; Venlafaxine extended release 37.5 mg oral tablet, instructions to give 37.5 mg by mouth one time a day for depression, ordered 2/1/25; and, Zaleplon 5 mg oral capsule, instructions to give 5mg by mouth at bedtime for insomnia, ordered 1/31/25 and discontinued 3/12/25. -Review of the March 2025 CPO, as well as Resident #95's electronic medical record (EMR), did not reveal any orders for antidepressant or hypnotic medication side effect monitoring or monitoring of target behaviors for depression. -Review of Resident #95's EMR did not reveal any psychoactive medication consent forms. III. Resident #75 A. Resident status Resident #75, age [AGE], was admitted on [DATE]. According to the March 2025 CPO, diagnoses included dementia with anxiety, adult failure to thrive, insomnia and depression. The 2/11/25 MDS assessment revealed the resident was cognitively intact with a BIMS assessment score of 14 out of 15. The resident required supervision or touching assistance with most ADLs. The assessment documented the resident took several high-risk medications including antidepressants, antianxiety, antipsychotic, anticonvulsants, and opioids. B. Resident and representative interview Resident #75 and her representative were interviewed together on 3/26/25 at 12:25 p.m. Resident #75 said she did not remember signing any consent forms for her anxiety medications. Resident #75 and her representative said did not remember signing any forms with any medication side effect information. C. Record review The antianxiety medication care plan, initiated 2/25/25, revealed Resident #75 was taking an antianxiety medication to treat her anxiety disorder. Pertinent interventions included monitoring and documenting medication side effects, and observing Resident #75's mood and response to the medication. The antidepressant care plan, initiated 2/25/25, revealed Resident #75 was taking an antidepressant medication. Pertinent interventions included administering the medication as ordered, monitoring and documenting medication side effects and observing Resident #75's mood and response to the medication. The antipsychotic care plan, initiated 2/25/25, revealed Resident #75 was taking an antipsychotic to treat her depression. Pertinent interventions included administering the medication as ordered, monitoring and documenting medication side effects and monitoring target behaviors. Review of the March 2025 CPO revealed the following physician's orders: Olanzapine 5mg oral tablet, instructions to give one tablet by mouth at bedtime for depression, ordered 2/5/25; Trazodone 100mg oral tablet, instructions to give one tablet by mouth at bedtime for insomnia associated with depression, ordered 2/5/25; Fluoxetine 60mg oral tablet, instructions to give 60mg by mouth one time a day for depression, ordered 2/6/25; Melatonin 3mg oral tablet, instructions to give two tablets by mouth one time a day for insomnia, ordered 2/5/25 and discontinued 3/25/25 (during the survey process); and, Melatonin 3mg oral tablet, instructions to give one tablet by mouth at bedtime for insomnia, ordered 3/25/25. -Review of the March 2025 CPO, as well as Resident #75's EMR, did not reveal any orders for antidepressant or hypnotic medication side effect monitoring or monitoring of target behaviors for depression. -Review of Resident #75's EMR did not reveal any psychoactive medication consent forms. IV. Staff interviews Licensed practical nure (LPN) #1 was interviewed on 3/26/25 at 10:34 a.m. LPN #1 said Resident #75 was on several sleep medications and one of them was recently discontinued. LPN #1 said Resident #75's physician had just lowered her dose of melatonin from 6 mg to 3 mg. -However, review of Resident #75's EMR did not reveal any psychoactive consent forms pertaining to any sleep aides or changes in sleep aide doses. LPN #1 was interviewed again on 3/26/25 at 1:13 p.m. LPN #1 said when a resident started a new psychoactive medication the nursing staff would monitor their behaviors and for any side effects for two weeks. LPN #1 said this was monitored in the treatment administration record (TAR). LPN #1 said residents needed to have a signed consent form for any psychoactive medications prior to the medication being administered. LPN #1 said Resident #95 was on a few psychoactive medications for her depression. LPN #1 reviewed Resident #95's EMR and said she did not see any antidepressant side effect or behavior monitoring in her TAR. LPN #1 said she did not see any orders for antidepressant side effect or behavior monitoring in Resident #95's EMR. LPN #5 was interviewed on 3/26/25 at 2:46 p.m. LPN #5 said when a resident was prescribed psychotropic medications the staff monitored the resident's behavior and for any side effects. LPN #5 said this was usually documented in the resident's TAR, and a physician's order was obtained for side effects and behavior monitoring was usually in the CPO. LPN #5 said behavior and side effect monitoring were performed for psychotropic medications as the nursing staff and physicians wanted to ensure the medications were working appropriately, ensure the resident's symptoms are not worsening, and ensure the medication is not causing any side effects. LPN #5 said behavior and side effect monitoring was performed so the practitioner could adjust the medication dose as needed or stop the medication altogether. LPN #2 was interviewed on 3/26/25 at 3:30 p.m. LPN #2 said when she received an order for a new psychotropic medication or a change in dosage she confirmed the order before documenting it on a list at the nurse's station. LPN #2 said the list was used to notify the nurse on the next shift to monitor the resident for adverse reactions and behavior monitoring and document it in their EMR. LPN #2 said she had never obtained consent for a new medication or a change in medications. The director of nursing (DON) was interviewed on 3/26/25 on 3:35 p.m. The DON said the facility nurses did not obtain the consent forms when a resident had orders for a new psychoactive or change in a psychoactive medication/dosage. The DON said the unit managers and nursing leadership, including himself, obtained consent either from the resident or the resident representative before the initiation of the medication. The DON said the psychoactive medication consent was a form that is filled out on the EMR. The DON said if the consent form was not in the EMR it was not obtained. The DON was interviewed again on 3/26/25 at 4:40 p.m. The DON said behavior and side effect monitoring were initiated on admission or within 24 hours of starting a psychoactive medication. The DON said target behavior monitoring was used to see if the treatment was effective and to find the lowest effective dose of medication interventions. The DON reviewed Resident #95's orders and said she was not able to find any orders for behavior or side effect monitoring.IV. Resident #249 A. Resident status Resident #249, age [AGE], was admitted on [DATE]. According to the March 2025 CPO, diagnoses included severe unspecified dementia with agitation and Wernicke's encephalopathy (severe neurological disorder caused by thiamine deficiency). The baseline care plan, initiated 2/28/25, revealed the resident was cognitively impaired due to a diagnosis of dementia. It documented she had a history of falls, was taking psychoactive medications and needed assistance with ADLs. B. Record review The psychoactive drug care plan, initiated on 3/19/25, documented the resident required an antipsychotic medication related to dementia with behaviors (delusions and inappropriate behaviors in public). Interventions included administering antipsychotic medications as ordered, attempting gradual dose reductions as indicated/ordered or if condition improved, utilizing non-pharmacological approaches prior to medication administration, such as providing a quiet and dark environment, assessing pain/discomfort, providing back rubs, offering warm beverages, encouraging out of room activity, providing activity materials of choice, going outdoors, encouraging family/friend visitation and encouraging her to verbalize feelings. Observe for and document the effectiveness of treatment, and report signs of medication side effects (including insomnia) or adverse reactions. The anti-depressant care plan, initiated on 3/19/25, documented the resident was prescribed an antidepressant medication related to anxiety and post-traumatic stress disorder (PTSD). Pertinent interventions included administering anti-depressant medications as ordered, monitoring/documenting side effects and effectiveness, educating family/caregivers about risks, benefits, side effects and/or toxic symptoms of the anti-depressant medications, and monitoring/documenting/reporting to the physician any ongoing signs and symptoms of depression unchanged by medication use. Review of the March 2025 CPO revealed the following physician's orders: Trazadone hydrochloride (hcl) oral tablet 50 mg, give one tablet by mouth at bedtime for insomnia, may use half of a 100 mg tablet, ordered 3/6/25; and, Zyprexa oral tablet 10 mg (Olanzapine), give 0.5 tablet by mouth in the afternoon for dementia with agitation for four days and give one tablet by mouth in the afternoon for dementia with agitation, ordered 3/20/25. -Review of Resident #249's EMR did not reveal documentation indicating consent forms were obtained prior to the administration of the trazadone and Zyprexa. C. Staff interviews LPN #2 was interviewed on 3/26/25 at 3:30 p.m. She said when she received a physician's order for a new psychotropic medication or a change in dosage, she confirmed the order. She said she notified the oncoming nurse to monitor and document adverse reactions and behaviors. She said she had never obtained consent for a new medication or a change in medications. The DON was interviewed on 3/26/25 on 3:35 p.m. He said when a resident was prescribed a new psychoactive drug or a change in a psychoactive medication/dosage, the nurses did not obtain consent. He said the unit managers and nursing leadership, including himself, obtained consent either from the resident or the resident's representative before the initiation of the change. He said the consent was a form that was filled out in their EMR system for informed consent for psychoactive medication. He said if it was not there, it was not done.

Based on observations, record review and interviews, the facility failed to ensure residents received food and fluids prepared in a form designed to meet his or her needs. Specifically, the facility failed to ensure residents who were prescribed mechanically altered diets had food prepared according to their diet orders of puree and mechanical soft as indicated on their meal tray cards. Findings include: I. Facility policy and procedure The Therapeutic Diets policy, undated, was provided by the nursing home administrator (NHA) on 3/26/25 at 11:32 a.m. It read in pertinent part, Diet orders should match the terminology used by the food and nutrition services department. A therapeutic diet is considered a diet ordered by a physician, practitioner, or dietitian as part of treatment for disease or clinical condition, to modify specific nutrients in the diet, or to alter the texture of a diet, for example: altered consistency diet. If a mechanically altered diet is ordered, the provider will specify the texture modification. The dietitian, nursing staff and attending physician will regularly review the need for, and resident acceptance of, prescribed therapeutic diets. II. Record review The menu extensions and modifications for modified texture diets were provided by the dietary director (DD) on 3/26/25 at 5:00 p.m. The menu extensions documented the following modifications for the mechanically altered food items served during lunch meal service on 3/25/25: -The regular diet included beef tostadas, shredded lettuce and tomato, ground green chili stew and fruit crisp. -The mechanically altered diet included puree beef tostadas, no lettuce and tomato, ground green chili stew and sliced peaches. -However, the modified texture diet menu extensions did not specifically state a mechanical soft altered diet as listed on the resident's meal tickets, but listed a mech altered diet. The extensions also included IDDSI mince and moist level five and soft and bite size level six which the facility had not yet transitioned to use (see the interviews below). III. Meal service observation and test tray During a continuous observation on 3/25/25, beginning at 11:10 a.m. and ending at 12:37 p.m., the following was observed during the meal preparation and service in the main kitchen: The posted menu was beef tostada with shredded lettuce and tomato and fruit crisp. At 11:21 a.m. a resident's lunch plate was assembled by cook (CK) #1 with a crisp, fried tostada shell topped with ground beef and a fruit crisp was placed on the tray by dietary aide (DA) #1. The meal ticket on the tray documented a mechanical soft-ground texture and the tray was placed in a cart for delivery. -However, according to the meal extensions, the resident should have received a pureed beef tostada. (see meal extensions above) All 11:22 a.m. a residents meal tray was assembled by CK #1. DA #1 placed a fruit crisp on the tray. The meal ticket on the tray documented a mechanical soft-ground texture and the tray was placed in a cart for delivery. -However, according to the meal extensions, the resident should have received peach slices, not fruit crisp (see meal extensions above). At 11:33 a.m. a resident's lunch plate was assembled by CK #1 with a crisp, fried tostada shell topped with ground beef. The meal ticket on the tray documented a mechanical soft-ground texture. -However, according to the meal extensions, the resident should have received a pureed beef tostada. (see meal extensions above) At 12:00 p.m. a puree plate was prepared and served to a resident. The plate consisted of puree meat, mashed potatoes and a puree green vegetable. The resident's meal ticket documented a puree diet texture. -The puree vegetable served to the resident included peas which should not have been pureed (see interview below). At 12:16 p.m. the DD said to CK #1 that the fried tostada shells were a choking hazard. At 12:20 p.m. the DD removed the puree meat from the steam table and placed the puree meat in a food processor to blend the food. The DD said he wanted to make sure the food was the right consistency. The puree meat was placed back in the steam table for meal service. At 12:00 p.m. a puree plate was prepared and served to a resident. The plate consisted of puree meat, mashed potatoes and a puree green vegetable. -The puree vegetable served to the resident included peas which should not have been pureed (see interview below). At 12:31 p.m. The DD said to CK #1 that for a mechanical soft diet texture the tortilla should always be bite size and soft while he cut a soft flour tortilla and placed the pieces on a plate. The DD said he had not reviewed the modified texture diet menu extensions. -However, according to the meal extensions, the resident should have received a pureed beef tostada and not a cut-up soft flour tortilla. (see meal extensions above) At 12:35 p.m. a puree test tray was provided. The puree texture test tray consisted of puree beef, mashed potatoes, pureed peas and carrots and chocolate pudding for dessert. -The puree vegetable served to the resident included peas which should not have been pureed (see interview below). -The peas and carrots provided on the test tray had visible pieces of carrots and peas in the puree peas and were not smooth. The puree meat had small visible lumps. IV. Staff interviews CK #1 and the DD were interviewed together on 3/25/25 at approximately 12:30 p.m. (during meal service). CK #1 said the facility had a book of modified texture diet menu extensions in the kitchen. The DD said the facility had modified texture diet menu extensions but he needed to check with the registered dietitian (RD) to see if the modified texture diet menu extensions were correct. The DD and the NHA were interviewed together on 3/26/25 at 12:00 p.m. The DD said the facility was transitioning to IDDSI and was in the process of training the staff to the proper standards on IDDSI. The DD said the residents prescribed a puree diet had received puree peas and carrots for lunch on 3/25/25. The DD said the staff should not have pureed the peas and he noticed the puree peas after the meals had been sent to residents. The DD said a food with a hull, such as peas, should not be pureed. The DD said the facility would transition to minced and moist level five and soft and bite size level six diet textures (of IDDSI diets) to replace the mechanical soft diet texture the facility used. The DD said he was notified during lunch by facility staff the modified diet textures were incorrect, but it was too late to do anything about it. The DD said if modified textures were served incorrectly the residents were at risk for choking. The NHA said all staff were trained during their initial onboarding on how to recognize modified textures.

Based on record review and interviews, the facility failed to ensure the facility's binding arbitration agreement was thoroughly and accurately explained to the residents and or resident representatives before signing the agreement for three (#54, #85 and #96) of four residents out of 36 sample residents. Specifically, the facility failed to: -Thoroughly explain the binding arbitration agreement in a form and in a manner to ensure Resident #54, Resident #85 and Resident #96 and/or their representatives understood the agreement before signing the arbitration agreement; and, -Ensure the facility staff provided evidence Resident #54, Resident #85 and Resident #96 and/or their representatives acknowledged understanding of the components of the agreement. Findings include: I. Facility policy and procedure The Binding Arbitration Agreement policy, November 2023, was provided by the nursing home administrator (NHA) on 3/26/25 at 6:24 p.m. The policy read in pertinent part, Residents (or representatives) are informed of the nature and implications of any proposed binding arbitration agreements so as to make informed decisions on whether to enter into such agreements. Residents (or their representatives) have the right to make informed decisions about the important aspects of their health, welfare and safety. The terms and conditions of a binding arbitration agreement are explained to the resident (or representative) in a way that ensures his or her understanding of the agreement, including that the resident may be giving up his or her right to have a dispute decided in a court proceeding. The terms and conditions of a binding arbitration agreement are explained to the resident (or representative) in a form and manager that he or she understands, taking into consideration the resident's (or representative's) language, literacy and stated preference for learning. After the terms and conditions of the agreement are explained, the resident or representative must acknowledge that he or she understands the agreement before being asked to sign the document. A signature alone is not sufficient acknowledgement of understanding. The resident (or representative) must verbally acknowledge understanding, and the verbal acknowledgement documented by the staff member who explains the agreement. II. Resident interviews Resident #54 and Resident #85 were interviewed during a group interview on 3/25/25 at 10:30 a.m. Resident #54 and Resident #85 said they did not know what an arbitration agreement was and did not remember signing an arbitration agreement. Resident #96 was interviewed on 3/25/25 at 3:00 p.m. Resident #96 said she did not remember signing an arbitration agreement when she signed her paperwork upon admission. Resident #96 said she did not know what an arbitration agreement was and that she had no difficulties or disputes with the facility. IV. Record review The NHA provided a list of residents who signed arbitration agreements on 3/23/25 at 10:55 a.m. -The list documented Resident #54 and Resident #85 signed an arbitration agreement. However, the list of residents was created in June 2024 and not updated to include residents that had admitted since. The admissions coordinator (AC) provided an additional list of residents who signed arbitration agreements on 3/25/25 at approximately 2:00 p.m. Resident #96 signed the arbitration agreement on 2/13/25 IV. Staff interviews The AC and the business office manager (BOM) were interviewed together on 3/26/25 at 12:20 p.m. The AC said she reviewed and read aloud to the resident or the responsible party that signed the admission paperwork and the arbitration agreement. -However, the facility failed to provide documentation of acknowledgement by the residents or their representatives that they understood the arbitration agreement.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** II. Failure to identify and follow EBP A. Professional reference The Centers for Disease Control and Prevention (CDC) Implementation of Personal Protective Equipment (PPE) Use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDROs) (4/2/24), was retrieved on 4/2/25 from https://www.cdc.gov/long-term-care-facilities/hcp/prevent-mdro/PPE.html. It read in pertinent part, Enhanced Barrier Precautions (EBP) are an infection control intervention designed to reduce transmission of resistant organisms that employs targeted gown and glove use during high contact resident care activities. EBP may be indicated (when contact precautions do not otherwise apply) for residents with wounds or indwelling medical devices, regardless of MDRO colonization status. B. Observations On 3/24/25 at 9:22 a.m. restorative aide (RA) #1 was sitting on Resident #1's bed while Resident #1 was doing a physical therapy exercise in her chair. Resident #1 had a peripherally-inserted central catheter (PICC) line hanging from her right arm. RA #1 removed a gait belt from around her waist and put the gait belt around Resident #1. RA #1 grabbed the gait belt and assisted Resident #1 to a standing position from her recliner so the resident was standing in front of her walker. RA #1 grabbed Resident #1's arm at her PICC site to support the resident as she walked. RA #1 quickly let go of the resident's arm but continued holding onto the gait belt around the resident's waist. -RA #1 failed to wear a gown or gloves when she was working with Resident #1. -Additionally, there was no PPE observed in Resident #1's room or outside the resident's room for staff to put on when providing high contact care with the resident. C. Staff interviews Certified nurse aide (CNA) #2 was interviewed on 3/26/25 at 10:13 a.m. CNA #2 said residents that needed EBP had a bag containing PPE on their door and a sign indicating what precautions they were on. CNA #2 said nursing staff needed to wear a gown and gloves when entering the room of any residents on EBP. CNA #2 said residents were on EBP when they had a urinary catheter or needed tube feeding. CNA #2 said she was not sure if Resident #1 needed EBP, but she said no one told her about the resident needing any precautions. Licensed practical nurse (LPN) #1 was interviewed on 3/26/25 at 10:34 a.m. LPN #1 said EBP were used for residents with urinary catheters, tube feedings and PICC lines. LPN #1 said nursing staff needed to wear a mask, gown and gloves when working with residents who needed EBP. RA #1 was interviewed on 3/26/25 at 2:36 p.m. RA #1 said she needed to wear a gown and gloves when working with residents on EBP and disinfect her hands between working with each resident. RA #1 was not sure what the reasons were which caused a resident to require EBP. The infection preventionist (IP) was interviewed on 3/26/25 at 5:53 p.m. The IP said that EBP should be used with any resident that had an indwelling device, such as a PICC line, gastrostomy tube or urinary catheter. She said EBP should additionally be used for residents with wounds or multi-drug resistant organisms (MDROs) in their urine. She said every shift the nurse was required to document that EBP was in place for their residents who were on EBP. The IP said she put in the initial physician's order for EBP for residents, which consisted of wearing a gown and gloves any time staff performed direct care with a resident, such as when they changed dressings, performed incontinence care or bathed a resident. She said EBP was to prevent transmission of infectious organisms. The IP said she did not think that Resident #1 had a PICC line anymore. The director of nursing (DON) was interviewed on 3/26/25 at 7:11 p.m. The DON said Resident #1 had EBP in place when the facility was accessing her PICC line to administer antibiotics, but she said the resident had not had EBP in place since the resident completed her antibiotics and the staff were no longer administering medications through the PICC line. The DON said Resident #1 still needed EBP during dressing changes for the PICC line. Based on observations, interviews and record review, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of disease on three of three units. Specifically, the facility failed to: -Ensure housekeeping staff followed appropriate hand hygiene processes when cleaning resident rooms; -Ensure high touch surfaces in residents' rooms were cleaned; -Ensure housekeeping staff followed proper cleaning techniques when cleaning residents' bathrooms; and, -Ensure enhanced barrier precautions (EBP) were followed for Resident #1, who had a peripherally inserted central catheter (PICC). Findings include: I. Housekeeping failures A. Professional references According to the Centers for Disease Control and Prevention (CDC), CDC Clinical Safety, Hand Hygiene for Healthcare Worker (2/17/24), retrieved on 4/1/25 from https://www.cdc.gov/clean-hands/hcp/clinical-safety, Know when to clean your hands: immediately before touching a patient, before performing an aseptic task such as placing an indwelling device 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 patient's surroundings, after contact with blood, body fluids or contaminated surfaces and immediately after glove removal. According to Assadian O, Harbarth S, Vos M, et al. Practical Recommendations for Routine Cleaning and Disinfection Procedures in Healthcare Institutions: A Narrative Review. The Journal of Hospital Infection, (July 2021) 113:104-114, retrieved on 3/21/25 from https://www.journalofhospitalinfection.com/article/S0195-6701(21)00105-5/fulltext, High-touch surfaces are usually close to the patient, are frequently touched by the patient or nursing staff, come into contact with the skin and, due to increased contact, pose a particularly high risk of transmitting pathogens (virus or microorganism that can cause disease). Contaminated surfaces, particularly those that are touched frequently, act as reservoirs for pathogens and contribute towards pathogen transmission. Therefore, healthcare hygiene requires a comprehensive approach. This approach includes hand hygiene in conjunction with environmental cleaning and disinfection of surfaces and clinical equipment. B. Observations During a continuous observation on 3/26/25, beginning at 9:40 a.m. and ending at 10:27 a.m., the following was observed: The housekeeper (HK) sanitized her hands and donned (put on) gloves. The HK took her keys out of her pocket and opened the top of the supply cart. She grabbed a spray bottle of sanitizer and entered the bathroom in room [ROOM NUMBER], a double-occupancy room. She sprayed the surfaces of the toilet and sink. -The HK contaminated her clean gloves by touching her keys. -The HK failed to lift up the toilet seat and spray the rim of the toilet bowl with sanitizer. The HK cleaned the surfaces of the furniture on side B of the bedroom, changing gloves before each new cloth was used. She swept side B, changed gloves, then swept side A. She mopped half of side A, changed gloves, and cleaned the surfaces and handles of the dresser, bedside table and the door handles. She entered the bathroom and wiped down the vanity and fixtures with a clean towel. -The HK failed to sanitize her hands in between glove changes. At 9:58 a.m. the HK took a bucket with a scrub brush from underneath the supply cart. She poured sanitizer into the toilet bowl and flushed it. She scrubbed the inside of the toilet bowl with the brush. She then used the brush to scrub the top and outsides of the toilet bowl and finished by scrubbing the inside of the toilet again. -The HK failed to use proper cleaning technique by cleaning from a dirty area to a clean area and back to a dirty area. After cleaning the toilet, the HK put the scrub brush back into the bucket and returned it to the cart. She donned new gloves and mopped the bathroom floor. She changed gloves again and mopped the rest of side A, turned off the bedroom lights and exited the room. -The HK failed to sanitize her hands in between glove changes. -The HK failed to clean and sanitize the high touch areas in room [ROOM NUMBER], including door knobs, light switches and call lights. At 10:08 a.m., the HK entered the bathroom of the adjacent room, room [ROOM NUMBER]. She followed the same procedure, spraying the surfaces in the bathroom, then cleaning side B and side A separately, changing gloves in between each step. At 10:21 a.m, she took the same bucket and scrub brush from underneath the supply cart. She poured sanitizer into the toilet bowl and flushed it, using the same technique to clean the toilet. She scrubbed the inside of the toilet bowl with the brush. She then used the brush to scrub the top and outsides of the toilet bowl and finished by scrubbing the inside of the toilet bowl again. After cleaning the toilet, she put the scrub brush back into the bucket and returned it to the cart. -The HK failed to sanitize her hands in between glove changes. -The HK again failed to use proper cleaning technique by cleaning from a dirty area to a clean area and back to a dirty area. -The HK failed to clean and sanitize the high touch areas in room [ROOM NUMBER], including door knobs, light switches and call lights, and used the same scrub brush for multiple residents' toilets. C. Staff interviews The HK was interviewed in Spanish on 3/26/25 at 10:27 a.m. The HK said she used the same toilet scrub brush for all the rooms in the hallway. The housekeeping supervisor (HKS) was interviewed on 3/26/25 at 12:46 p.m. The HKS said she started her position a month ago and she had scheduled a meeting for the following day (3/27/25) to discuss policies, procedures and expectations. She said she told staff that when they were in doubt, they should change them out (their gloves). The HKS said every time gloves were taken off, the hands should be sanitized. The HKS said high touch surfaces should be cleaned daily as part of the regular cleaning procedures. She said toilet scrub brushes were only used for the inner toilet bowl and cleaning cloths should be used on the outside of the toilet bowl. She said currently, there was only one toilet scrub brush per unit. The HKS said she wanted each room to have their own separate toilet brush/plunger combination.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and interviews, the facility failed to provide a safe, functional, sanitary and comfortable environment for residents, staff and the public. Specifically, the facility failed to ensure resident rooms, bathrooms, dining room furniture and hallways received necessary maintenance repairs. Findings include: I. Facility policy and procedure The Safe and Homelike Environment policy, undated, was provided by the nursing home administrator (NHA) on 3/25/25 at 1:53 p.m. The policy read in pertinent part, The facility will provide a safe, clean, and comfortable homelike environment. This ensures that the resident can receive care and services safely and that the physical layout maximizes resident independence and does not pose a safety risk. Environment refers to any location in the facility that is frequented by residents. A homelike environment is one that de-emphasizes the institutional character of the setting. Housekeeping and maintenance services will be provided as necessary to maintain a sanitary, orderly, and comfortable living environment. Furniture in disrepair will be reported to maintenance promptly. II. Aspen common/dining area On 3/23/25 at 9:15 a.m. the following observations were made of the Aspen common area: -Nine dining room chairs had seat cushions that were ripped and peeling; and, -Four of the six dining room tables had scratched and peeling surfaces and the underlying particle board was exposed. III. Ceiling and door frame in the Mountain View hallway On 3/23/25 at 9:30 a.m. the following observations were made in the Mountain View hallway: -There was rotted wood along the bottom of the double doorway frame in the hallway; and, -The ceiling near the exit sign above the double doorway had water spots and was bowing downward. IV. Resident rooms and bathrooms A. Observations On 3/24/25 at 9:46 a.m. room [ROOM NUMBER] was observed. One of the residents who resided in the room was lying in bed. There were four raised and rough patches on the wall next to his bed, approximately three inches in diameter. There was a pink spot on the wall approximately 18 inches long and three inches high next to a vertical wall light approximately the same size. There were two round quarter inch holes in the wall and multiple scuff marks. There was a health shake container on the floor and two wet wipes next to a small trash can on the floor under a tray table. On 3/24/25 at 9:55 a.m. room [ROOM NUMBER] was observed. The walls on the opposite side of one of the residents' beds had multiple lines where a light brown liquid had spilled down and dried on the walls. There were seven spots of a yellow chunky substance splattered on the corner of the wall directly adjacent to the dried spill. On 3/24/25 at 2:37 p.m. room [ROOM NUMBER] was observed. There was a hole in the wall approximately four inches long by one inch tall, surrounded by peeling paint and broken plaster. On 3/25/25 at 5:36 p.m. room [ROOM NUMBER]'s bathroom was observed. There was hard water staining covering several square inches of the floor to the left of and behind the toilet. The baseboard was separating from the wall and had approximately a one centimeter gap between the baseboard and the wall. The area where the water inlet for the toilet met the wall had several inches of corrosion and hard water buildup, and the wall showed signs of water damage where several inches of paint were peeling away from the wall. On 3/25/25 at 5:42 p.m. room [ROOM NUMBER]'s bathroom was observed. There was a towel folded up and placed over a section of the floor to the left of the toilet. The flooring around the towel had areas of hard water buildup and several gnats were flying in the area of the towel. On 3/25/25 at 5:52 p.m. the maintenance director (MTD) lifted the towel on the floor in room [ROOM NUMBER]'s bathroom to examine the flooring underneath. Approximately 15 to 20 gnats flew out from between the floor and the towel. On 3/26/25 at 8:57 a.m. room [ROOM NUMBER] was observed. The room had no curtains on the windows. There were three large brown stains on the tile floor near bed A. The heating vent along the far wall was broken with brown stains and portions of the metal covering were falling off. On 3/26/25 at 10:10 a.m., the lid to the toilet tank in room [ROOM NUMBER] was observed. The toilet tank lid did not fit and was the wrong shape for the tank. It was half-off, leaving an opening into the tank. The wall next to the toilet had an area approximately three feet long with peeling paint and cracks. The wall under the sink had a large horizontal crack extending from the toilet tank to the plumbing. There were large yellow/brown water stains on the wall under the sink. Yellow caulking lined the top of the white vanity and wall, partially covering cracks in the paint. B. Resident interviews One of the residents who resided in room [ROOM NUMBER] was interviewed on 3/24/25 at 9:46 a.m. The resident said he was unable to see his trash basket and so he dropped his trash on the floor. The resident who resided in room [ROOM NUMBER] was interviewed on 3/24/25 at 9:55 a.m. The resident said he was unable to see the wall in his room that had drips on it. He said he had asked for a dead [NAME] moth to be removed from the overhead light in his room and it never happened. One of the residents who resided in room [ROOM NUMBER] was interviewed on 3/26/25 at 9:00 a.m. The resident said she used to have curtains on her windows, but she said the facility had taken them off a while ago and never replaced them. She said the room was always cold and the curtains might have helped keep it warmer. She said the heat vent looked like it was broken and unused, but she said it worked. V. Staff interviews The NHA was interviewed on 3/25/25 at approximately 3:40 p.m. The NHA said housekeeping could clean spills on the walls as well as other staff, such as a certified nurse aide (CNA), if they were in a resident's room. The NHA said he was not aware of the maintenance concerns items and holes in the walls in rooms #46, #47 and #54. The MTD was interviewed on 3/25/25 at 5:52 p.m. The MTD said he had not been made aware of any issues with the bathroom in room [ROOM NUMBER]. The MTD said he had not gone into the room since he started at the facility, as he had not received any work orders for that room or otherwise been invited into the room by the residents. The MTD said there was not any standing water under the towel in room [ROOM NUMBER] but there was a definite issue with the toilet leaking. The MTD was interviewed again on 3/26/25 at 1:29 p.m. The MTD said there was no standing water near the toilet in room [ROOM NUMBER] but that the area had significant staining. The MTD said room [ROOM NUMBER]'s bathroom was being decontaminated by the housekeeping staff. The MTD was interviewed a third time on 3/26/25 at 5:00 p.m. The MTD said he knew about all of the maintenance repair issues in room [ROOM NUMBER], room [ROOM NUMBER], in the Mountain View hallway and the furniture in the Aspen unit dining room. He said the building was old and every time he started to fix one issue, another major and more important issue arose.

Based on observations, record review and interviews, the facility failed to store, prepare, distribute, and serve food in a sanitary manner in the main kitchen and in three of three unit nourishment refrigerators. Specifically the facility failed to: -Ensured the nourishment room refrigerators were maintained at a safe temperature; -Ensure health shakes were labeled in the unit nourishment refrigerators; and, -Ensure the floor, walls and ice machine in the main kitchen were maintained in a clean and sanitary condition. Findings include: I. Ensure safe cold food holding temperatures were maintained and health shakes were labeled in the nourishment refrigerators A. Professional reference The Colorado Retail Food Establishment Rules and Regulations, (3/16/24), retrieved on 4/2/25, read in pertinent part, Except during preparation, cooking, or cooling, or when time is used as the public health control time/temperature control for safety food shall be maintained at 135 degrees fahrenheit (F) or above at 41 F or less. (3-501.16) B. Observations On 3/23/25 at 10:30 a.m. the following was observed in a south unit nourishment refrigerator and freezer: -Six health shake cartons; the directions printed on the side of the carton read to use the thawed product within 14 days. There was no pull date or written expiration date on the thawed health shakes; -There was brown liquid splattered on the sides and spilled on the bottom of the freezer and inside the door shelf; and, -A box of turkey pot pie was in the freezer with an expiration date of 12/21/23 with a name written on the box. On 3/23/25 at 2:25 p.m. the following was observed in the south unit nourishment refrigerator: -There was brown liquid splattered on the sides and spilled on the bottom of the freezer and inside the door shelf; -A box of turkey pot pie in the freezer with an expiration date of 12/21/23; and, -Nine health shake cartons; the directions printed on the side of the carton read to use the thawed product within 14 days. There was no pull date or written expiration date on the thawed health shakes. The March 2025 (3/1/25 to 3/25/25) temperature log for the south unit nourishment refrigerator was reviewed. The temperatures were recorded as follows: -On 3/11/25 the temperature was 42 F. -On 3/12/25 the temperature was 46 F. -On 3/15/25 the temperature was 42 F. -On 3/17/25 the temperature was 45 F. -On 3/18/25 the temperature was 48 F. -On 3/19/25 the temperature was 45 F. -On 3/21/25 the temperature was 43 F. -The recorded refrigerator temperatures were above the acceptable cold holding temperature of 41 F and there was no evidence to indicate the temperature was corrected (see professional reference above). An unidentified certified nurse aide (CNA) looked at the frozen turkey pot pie with the expiration date of 12/21/23 and said the resident whose name was written on the box was no longer at the facility and placed the expired product back in the freezer. On 3/25/25 at 2:40 p.m. the following was observed in the men's secured unit nourishment refrigerator: -Three health shake cartons; the directions printed on the side of the carton read to use the thawed product within 14 days. There was no pull date or written expiration date on the thawed healthsakes. On 3/25/25 at 2:45 p.m. the following was observed in the Aspen unit nourishment refrigerator : -Seven health shake cartons; the directions printed on the side of the carton read to use the thawed product within 14 days. There was no pull date or written expiration date on the thawed healthsakes. The March 2025 (3/1/25 to 3/25/25) temperature log for the aspen unit nourishment refrigerator was reviewed. The temperatures were recorded as follows: -On 3/11/25 the temperature was 42F. -On 3/14/25 the temperature was 42 F. -On 3/15/25 the temperature was 42 F. -On 3/17/25 the temperature was 48 F. -On 3/18/25 the temperature was 46 F. -The recorded refrigerator temperatures were above the acceptable cold holding temperature of 41 F and there was no evidence to indicate the temperature was corrected (see professional reference above). C. Staff interviews The director of nursing (DON) was interviewed on 3/25/25 at approximately 3:25 p.m. The DON said the dietary staff managed the unit nourishment refrigerators. CNA #2 was interviewed on 3/25/25 at approximately 2:30 p.m. CNA #2 said the overnight nursing staff checked the nourishment refrigerator temperatures and removed expired products. Certified nurse aide with medication aide (CNA-Med) #1 said the night shift usually checked the nourishment refrigerator temperatures and she said she would check the temperatures of the nourishment refrigerators again for accuracy. The dietary director (DD) and the nursing home administrator (NHA) were interviewed together on 3/26/25 at 12:00 p.m. The NHA said the dietary department was responsible for recording the nourishment refrigerators temperatures and checking for expired products. The NHA said the nourishment refrigerator in the south unit was running a high temperature (out of range) because the thermometer was in the door but they moved the thermometer back inside the refrigerator. She said when they moved the thermometer the temperature was reading within normal limits. The DD said that unit refrigerator temperatures and maintenance of the product would be corrected. The DD said since the refrigerator temperatures were running high, the staff should take the temperature of the food in the refrigerator to ensure it was a safe temperature, and if the food was not a safe temperature after 30 minutes the food would be discarded. The DD said he was going to go through the product in the unit refrigerators and clean them out. The NHA said he was not sure if the facility provided education to the CNAs on refrigerator temperature maintenance so they would notice if the temperature was out of range during their use of the refrigerators. II. Maintain a clean and sanitary kitchen environment A. Professional reference The Colorado Retail Food Establishment Rules and Regulations, (3/16/24), retrieved 4/2/25 read in pertinent part, Materials for indoor floor, wall, and ceiling surfaces under conditions of normal use shall be: smooth, durable, and easily cleanable for areas where food establishment operations are conducted; and nonabsorbent for areas subject to moisture such as food preparation areas, walk-in refrigerators, warewashing areas, and areas subject to flushing or spray cleaning methods. (6-101.11) B. Facility policy and procedure The Sanitization policy, revised November 2022, was provided by the NHA on 3/26/25 at 11:32 a.m. It read in pertinent part, All kitchens, kitchen areas and dining areas are kept clean, free from garbage and debris and protected from rodents and insects. All equipment, food contact surfaces and utensils are cleaned and sanitized using heat or chemical sanitizing solutions. Ice machines and ice storage containers are drained,cleaned and sanitized per manufactures instructions. C. Observations The initial kitchen tour was conducted on 3/23/25 at 9:10 a.m. The following was observed: -Approximately ten missing coving tiles (a curved tile that transitions the floor to the wall) behind the ice machine extending under the clean side of the dish machine table. The pipe extending from the back of the ice machine was dripping onto the floor instead of the drain and created standing water that pooled into the grout between the existing floor tiles. Four coving tiles were damaged and separated from the wall. The wall behind the ice machine was bowed out into the kitchen; -The aluminum filter on the back of the ice machine was caked with brown debris; and, -A large section extending approximately ten feet long and a foot wide revealed an exposed, uneven and rough concrete floor that was missing kitchen floor tiles. A kitchen walk through was conducted in the main kitchen on 3/25/25 from 11:10 a.m. through 1:30 p.m. The following was observed: -Approximately ten missing coving tiles behind the ice machine and extending under the clean side of the dish machine table (a curved tile that transitions the floor to the wall) were missing. The pipe extending from the back of the ice machine was dripping onto the floor instead of the drain and created standing water that pooled into the grout between the existing floor tiles. Four coving tiles behind the ice machine were damaged and separated from the wall. The wall behind the ice machine was bowed out into the kitchen; -The aluminum filter on the back of the ice machine was caked with brown debris; and, -A large section extending approximately ten feet long and a foot wide revealed an exposed, uneven and rough concrete floor that was missing kitchen floor tiles. D. Staff interviews The NHA was interviewed on 3/25/25 at approximately 3:30 p.m. The NHA said he was not aware that the filter on the back of the ice machine had not been cleaned and had not seen the tiles behind the dish machine. He said he was not aware the ice machine was dripping onto the floor. The NHA said the kitchen floor was missing tiles because a broken pipe had been repaired and the facility would repair the floor in house. The DON was interviewed on 3/25/25 at approximately 3:30 p.m. The DON said it looked like the ice machine had been moved from where it usually sat The DD and the NHA were interviewed together on 3/26/25 at 12:00 p.m. The NHA said he was not sure if the ice machine filter had been assigned to anyone to clean. He said it was possible the ice machine filter should have been cleaned as part of the regular clean performed by their contacted vendor. E. Facility follow up On 3/26/25 at 11:32 a.m. the NHA provided documentation that the facility reached out to a local vendor on 2/20/25 for a quote on epoxy chip coating (seamless) the kitchen floor. No further documentation was provided if the local vendor provided the quote.

Based on record review and interviews, the facility failed to ensure the facility's binding arbitration agreement contained the required components. Specifically, the facility failed to: -Ensure the arbitration agreement presented to residents contained language that provided for the selection of a venue that was convenient to both parties; and, -Provide for the selection of a neutral arbitrator agreed upon by both parties. Findings include: I. Facility policy and procedure The Binding Arbitration Agreement policy, dated November 2023, was provided by the nursing home administrator (NHA) on 3/26/25 at 6:24 p.m. The policy read in pertinent part, Residents (or representatives) are informed of the nature and implications of any proposed binding arbitration agreements so as to make informed decisions on whether to enter into such agreements. Residents (or their representatives) have the right to make informed decisions about the important aspects of their health, welfare and safety. Arbitration agreements provide for the selection of a neutral arbitrator, which is agreed upon by both parties. A neutral arbitrator is an impartial, unbiased party decision maker, without the appearance of any conflicts of interest, contracted with and agreed to by both parties to resolve their dispute. Residents (or representatives) are given the opportunity to suggest an arbitrator and venue. If the facility disagrees with the resident's suggested arbitrator(s) and/or venue, the facility will document the reason and provide that documentation to the resident (or representative). Arbitration agreements provide for the selection of a venue that is both convenient to and suitably meets the needs of both parties. The venue will be agreed upon by both parties. When selecting a venue for consideration, ' convenience' for the resident (or representative) may be determined by his or her ability to get to the venue. II. Facility's binding arbitration agreement A copy of the facility's binding arbitration agreement was provided by the NHA on 3/23/55 at 10:55 a.m. The agreement read in pertinent part, The arbitration shall be administered and conducted by a contracted provider in accordance with its comprehensive arbitrations rules and procedures. Within 15 days after a claim for arbitration is made, the demand shall be filed by the contracted provider (dispute resolution specialist) and a single arbitrator will be selected from a list provided by the named provider pursuant to its rules to conduct the arbitrations. The arbitrator shall have the jurisdiction to decide whether the claims may be arbitrated pursuant to this agreement. The hearing arising under this voluntary arbitration agreement shall be held in the county where the facility is located. -The facility's binding arbitration agreement failed to include the selection of a neutral arbitrator agreed upon by both parties and failed to contain language that provided for the selection of a venue that was convenient to both parties. III. Staff interviews The admission coordinator (AC) was interviewed on 3/26/25 at 12:20 p.m. The AC said the facility's arbitration agreement did not include information indicating a resident could speak with federal, state, local, surveyors or ombudsman. She said the information was included in the facility's admission agreement (a separate document) instead. The AC said there was no language in the facility's arbitration agreement regarding a selection of venue by both parties.

Based on observations, record review and interviews, the facility failed to ensure one of three units were free from accident hazards. Specifically, the facility failed to ensure the alarm on the door to the outside secured patio was functioning properly. Findings include: I. Facility policy and procedure On 1/13/25 at 12:49 p.m. the director of nursing (DON) said the facility followed the state guidelines for the secured unit. The DON provided a copy of the state guidelines, which read read in pertinent part, Any facility that has one or more resident care units that are secured to prohibit free egress of residents shall comply with the standards in this section in addition to all other applicable requirements of this chapter. Staff in the secure environment shall be experienced and trained in the particular needs and care of its residents. The facility shall identify its method for securing the area and establish and implement procedures for monitoring the effectiveness of the security system. II. Observations On 1/13/25 at 12:15 p.m. the back door on the all-male secured unit was observed. The back door was not visible from the nurse's station. There were no cameras near the door to transmit a live visual for the staff at the nurse's station. The alarm on the door was broken and did not audibly alert staff if the door was opened. The back door provided direct access to a courtyard with uneven surfaces. When standing inside there was a keypad on the right side of the door. The keypad was used to reset the door lock and turn off the alarm. Above the door was a long thin green flashing light. When the door arm was pushed on the green light flashed from green to red several times. During this time the door could be pushed open. When the door was closed, it was locked from the outside. The courtyard had a covered smoking area. The courtyard also had a wooden gate which opened to a field. The wooden gate had an alarm system that the facility staff nor facility management knew how to operate, nor where to turn off the gate alarm and reset it (see interviews below). On 1/13/25 at 12:15 p.m. certified nurse aide (CNA) #2 pushed on the door crossbar and when the lights flashed from red to green, the door was able to be pushed open. CNA #2 stepped outside into the courtyard and no alarms sounded to notify the staff that the door had been opened. Three male residents noticed the door open and quickly attempted to walk through the opened door. On 1/13/25 at 4:10 p.m., CNA #4 was seated next to the door to the outside patio on the secured unit. CNA #4 said they were assigned to stay by the door until 10:00 p.m. and then another staff member was to take her place for the next shift. On 1/14/25 at 3:00 p.m. the corporate consultant nurse (CCN), the nursing home administrator (NHA) and the DON demonstrated that the door was fixed. The alarm sounded loudly when the door was opened. III. Staff interviews CNA #1, CNA #2 and CNA #3 were interviewed together on 1/13/25 at 12:20 p.m. CNA #1 said the alarm had not sounded when the door was opened by a resident for several months. CNA #1 said the staff rounded hourly on the 35 residents and tried to keep an eye on the three residents who often pushed on the door crossbar and attempted to get outside. CNA #1 said to keep an eye on three men meant to hope to know where they were located at all times. CNA #1 said they had never been trained on how to set or reset the egress door in the secured unit. CNA #1 said the residents in the male secured unit must be supervised when outside because the ground was uneven, which had concrete walk ways, and rock gardens that could be tripped on. CNA #2 said about 10 out of the 35 men in the secured unit went out to smoke seven times per day. CNA #2 said the men were escorted outside by two staff members, while one staff member walked up and down the hallway in front of the egress door to keep men from pushing on the door to follow the smokers outside. CNA #2 said it was difficult to keep an eye on everything on the secured unit and to make sure no one escaped. CNA #2 said they were never trained how to set or reset the door so that it locked. CNA #2 said the alarm did not work to notify the staff if a resident opened the door. CNA #3 said the alarm and door system had not worked properly for several weeks. CNA #3 said the old maintenance director was told many times but the door was never fixed. CNA #3 said a previously facility ownership company had trained staff how to use the door and its alarm, but there had been no training with the new company. CNA #5 was interviewed on 1/13/25 at 3:50 p.m. CNA #5 said in the seven months of working in the facility on the memory care unit the alarm never sounded to alert the staff if a resident went out the door from the secured unit to the outside. CNA #4 said one time a few weeks prior she found two residents sitting unattended outside in the courtyard and she brought them back inside. She said the alarm did not sound to warn staff that the door was opened. The DON was interviewed on 1/13/25 at 4:00 p.m. The DON said the courtyard to the male resident's secured unit should never have residents in it unsupervised. The DON said he was unaware the alarm was broken to the egress door on the secured unit. The NHA, the CCN and the DON were interviewed together on 1/13/25 at 4:05 p.m. The NHA, the CCN and the DON said the corporate plant operations manager (CPOM) and the facility environmental service director (ESD) had begun a plan to immediately fix whatever was broken on the door, as well as the alarm that was identified during the survey. The NHA said until the door was fixed correctly a CNA would sit next to the door to ensure the resident's safety. The NHA said the staff would be placed outside the door until the alarm was fixed and had been tested several times. The NHA was interviewed on 1/14/25 at 9:30 a.m. The NHA said the door and alarm had been fixed. He said a CNA would sit outside the door until the door had several safety inspections. The NHA said an action plan was created for the door on the memory care unit. The NHA said the action plan included how the facility staff would be trained on how the doors and alarms operated. (see action plan below). The NHA said none of the 35 men on the secured unit should be in the courtyard unsupervised. The ESD was interviewed on 1/14/25 at 2:15 p.m. The ESD said he started working at the facility seven days ago. The ESD said he was part of the team that fixed the door the previous night on 1/13/25. The ESD said the alarm had not sounded and a part was ordered. He said the part arrived today on 1/14/25and was immediately put in the alarm system. The ESD said the egress door and alarm worked correctly now. He said he would check the door daily for a week to make sure the door alarm worked correctly. The ESD said the NHA had an action plan for the door to be checked weekly. He said he used a computer system to enter maintenance orders. The ESD said today he and the NHA implemented that the NHA would receive work orders also from the maintenance system. The ESD said he had an assistant who came in today to learn about the security systems for the door in the secured unit. The NHA was interviewed on 1/14/25 at 2:20 p.m. The NHA said no one told him that the door on the secured unit had not operated correctly, nor did anyone inform him about the alarm not sounding. The NHA said he assumed the staff verbally told the prior maintenance director and that person never told anyone or fixed the situation. The NHA said he reviewed the electronic work order system and did not see any maintenance requests for the door. The NHA said the gate in the courtyard was also updated at the time the egress door alarm was fixed. D. Facility follow-up The facility action plan was provided via email on 1/14/25 at 10:27 a.m. from the NHA. It revealed in pertinent part, The identification of the problem: The exit door on the Mountain View unit (men's secured unit) to the outside courtyard no longer alarms. When the door was pushed the red/green light would blink back and forth. The door was not secured and could be opened. The alarm to the outside gate would only alarm when pressure was being applied. Once the magnet disengaged it stopped alarming. Identification of other potential problems/concerns: This could be a potential hazard due to residents attempting to exit seek going unnoticed. This could also have caused a potential concern if a resident was able to leave the facility, enter into the courtyard and then would be unable to get back into the facility. Corrective action or systemic changes: Upon knowledge of the issue with the door, a staff member was placed next to the door going to the courtyard. The staff member that monitored the exit, was responsible to to log any residents that attempted to exit seek out the door. On 1/13/25 the regional director of plant operations (RDPO) upon assessment utilized the alarm to gate (the) secure door. The courtyard door was functioning during testing. The door would continue to be monitored until the QAPI (quality assurance and performance improvement meeting) was completed. Upon resolving the door, the staff would monitor the residents who went outside for smoking and would be marked on roster upon entering the courtyard and again at completion of smoke break to verify resident count. This will remain in place until the gate is secured, and the alarm is functioning. An alarm part was ordered on 1/13/2025 to repair the alarm system. The part is scheduled to arrive at the facility on 1/14/25. On 1/14/25 the ESD will reach out to (company name) to address the gate. The goal is for it to function with an alarm until code was entered to resolve the alarm. NHA was added to (name) computer work order system, the program where maintenance requests and other facility information is stored. Education was provided to staff on door process and utilizing (maintenance requests) work order communications and informing the ESD. Responsible party and corrective action/completion: The NHA and the ESD would be responsible for ensuring completion and repair of the alarm system at the door. The completion date for repairing the door alarm is 1/15/25. -However, the action plan was not created until 1/13/25, during the survey.

Based on observations, record review and interviews, the facility failed to provide an effective pest control program to ensure the facility was free of pests. Specifically, the facility failed to take the appropriate measures to control a fly infestation in the kitchen and dining room. Findings include: I. Professional reference According to the Center for Disease Control (CDC) Guidelines for Environmental Infection Control in Health-Care Facilities, pp. 95 (updated 1/8/24), retrieved on 7/25/24 from https://www.cdc.gov/infection-control/hcp/environmental-control/environmental-services.html#cdc_generic_section_6-6-pest-control, Cockroaches, spiders, and mice are among the typical pest populations found in health-care facilities. Insects and rodents can serve as agents for the mechanical transmission of microorganisms, or as active participants in the disease transmission process by passing pathogens from one source to another. Insects and rodents should be kept out of all areas of a health-care facility. From a public health and hygiene perspective, pests should be eradicated from all indoor environments. Approaches to institutional pest management should focus on eliminating food sources, indoor habitats, and other conditions that attract pests, excluding pests from entering the indoor environments; and applying pesticides as needed. Insect habitats are characterized by warmth, moisture, and availability of food. Cockroaches, in particular, and anywhere in the facility where water or moisture is present. II. Facility policy and procedure The Pest Control policy, revised November 2022 was provided by the nursing home administrator (NHA) on 7/23/24 at 2:15 p.m. It read in pertinent part, The facility shall maintain an effective and ongoing pest control program to ensure that the building is kept free of insects and rodents. III. Observations and interviews A. Resident interviews and observations Resident #7 was interviewed on 7/23/24 at 11:53 a.m. Resident #7 was seated in the dining room eating her lunch. Several flies were landing on the table where the resident's food was placed. One fly landed on the resident's hand as she held her fork. Another fly was hovering around her head and shoulder area. Resident #7 said the flies bothered her all the time and she did not like it. She said she had complained about the flies to the management, however, she said the facility seemed unable to prevent flies from entering the dining room. She said she did not appreciate that the flies walked on her skin. Resident #7 said the flies were getting on her last nerve and they were gross. Resident #5 was interviewed on 7/23/24 at 12:00 p.m. Resident #5 self-propelled himself into the dining room. The resident had a green fly swatter across his lap. He said he did not like that there were so many flies in the dining room bothering him when he was trying to eat his meal. He said he brought a fly swatter with him all the time. Resident #8 was interviewed on 7/23/24 at 12:20 p.m Resident #8 said the flies were taking over the facility's dining room. The resident said he hurried through eating his lunch to avoid flies touching his food. Resident #8 was finishing his coffee in the dining room. Resident #8 said he and other residents had reported the issue several times to the staff and it seemed the facility was unable to prevent the flies from coming into the dining room. B. Kitchen and dining room observations On 7/23/24 at 10:34 a.m. there were several flies in the main kitchen where lunch was being prepared. The back door of the kitchen, leading to the area where trash dumpsters were kept, had no screens and was open, enabling flies into the kitchen area and the dining room. There were several flies hanging on the kitchen ceiling and flying all over the kitchen and the dining room. At 11:45 a.m., the staff started serving beverages to the residents who had arrived in the dining room. There were flies on several dining room tables flying from one table to the other. Flies were observed walking on residents' bodies. IV. Staff interviews Dietary aide (DA) #1 was interviewed on 7/23/24 at 12:39 p.m. DA #1 said the back door of the kitchen was opened to allow steam from the beef pot pie to evaporate. She said there were several flies in the kitchen and they had been a problem. The dietary manager (DM) was interviewed on 7/23/24 at 12:45 p.m. The DM said the flies continued to be a problem in the kitchen and dining room area. The DM said there were several flies flying around the kitchen and walking on the ceiling. He said the flies were unsanitary and they could contaminate the food preparation surfaces, which could cause illness to residents and staff. The DM said the facility was aware of the fly infestation and had implemented several measures, such as insect zappers and a frequent exterminator, however, he said the flies continued to be an issue. The NHA and the director of nursing (DON) were interviewed together on 7/23/24 at 12:59 p.m. The NHA said flies were still a problem at the facility. The NHA said the facility had been dealing with flies due to the location of the facility. He said the facility was located in a cattle community which made it difficult to eradicate the fly infestation. The NHA said he had implemented several interventions, such as an electrical insect control system by the back door of the kitchen and several places throughout the facility and using a professional exterminator, which had helped reduce the number of flies in the building but had not completely resolved the issue. The NHA said he received an estimate for the introduction of screen doors in the kitchen and the dining room and was working on getting screen doors. The DON said Resident #5 enjoyed roaming around with his fly swatter in his hands. The NHA said the maintenance and housekeeping managers were recently terminated and the facility was working on hiring their replacements. The NHA said he was initiating education for the kitchen staff to ensure the kitchen's back door remained closed at all times to prevent flies from entering the kitchen through it.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview, record review and staff interviews the facility failed to ensure one (#81) of five residents reviewed out of 35 sample residents receive proper foot care and treatment according to standards of practice. Specifically, the facility failed to ensure Resident #81 was seen by the podiatrist timely for toenail care. Findings include: I. Facility policy The Referral Agreements policy, revised October 2008, was provided by the nursing home administrator (NHA) on 7/27/23 at 1:07 p.m. It read in pertinent part, To facilitate referrals, the facility has entered into referral agreements with agencies that will provide services to residents. The scope of agencies and the agreements are consistent with the needs of the facility's resident population. Inquiries concerning the availability and use of referral agencies should be directed to social services or to the Administrator. II. Resident status Resident #81, age under age [AGE], was admitted on [DATE]. According to the July 2023 computerized physician orders (CPO), diagnoses included traumatic brain injury, left side paralysis and fractures of the third and fourth lumbar vertebra (back). The 6/27/23 minimum data set (MDS) assessment revealed the resident was cognitively intact with brief interview for mental status (BIMS) 15 out of 15. She was totally dependent on staff and needed assistance from two people for hygiene and bathing. She needed extensive assistance from two people for dressing. III. Resident interview and observation Resident #81 was interviewed on 7/24/23 at 2:30 p.m. She said she needed to see a podiatrist and staff looked at her feet every day when they changed the wraps on her feet. She said it had been three to four months since a podiatrist had last visited. She said the social services department could put her name on a list to be seen by the podiatrist. Resident #81's feet were wrapped and her toes were exposed. Her toenails were observed to be thick, yellow and had ridges. Two toenails on her left and one toenail on her right foot had dark brown color and were raised off the toenail bed. IV. Record review The ancillary services care plan, was initiated 10/6/22 and revised 11/25/22, documented Resident #81 was acceptable to see podiatry. Pertinent interventions included Resident #81 was to be offered ancillary services as needed, social services to follow up with Resident #81 quarterly and as needed for any ancillary services, initiated 10/6/22 and revised 2/18/23. A review of Resident #81's podiatry visits revealed podiatry visits were attempted for Resident #81 on 1/11/23, 3/28/23 and 7/17/23. All visits were documented as the resident was not in her room and unavailable to be seen. An 2/14/23 IDT (interdisciplinary team) progress note documented Resident #81 had a podiatry visit on 1/11/23 and the progress note was located in the resident's medical record. -However, the note documented the resident was not in her room for the visit. -A review of Resident #81's progress notes did not reveal refusals of podiatry care by Resident #81. There was no documentation that Resident #81 was out of the building during podiatry visits. V. Staff interviews Registered nurse (RN) #1 was interviewed on 7/27/23 at 11:18 a.m. She said she would check Resident #81's skin assessment to see if there were any notes on Resident #81's toes. She said a certified nurse aide (CNA) should tell a nurse if they think something was wrong with a resident's toes and a skin assessment including the resident's toe nails should have been completed on shower days. She said usually a nurse changed the wraps on Resident #81's feet. The social services director (SSD) and social services assistant (SSA) #2 were interviewed on 7/27/23 at 11:45 a.m. The SSD said Resident #81 was very vocal and advocated for her needs. She said Resident #81 was unable to propel herself in her wheelchair and staff would pass her concerns to the social services staff. She said the nurses came directly to the office and then the social services staff sent a message to podiatry and or other visiting ancillary services for other appointments. She said the CNA and nurse being the first point of contact should notify the SSD if there were any concerns with resident toes. SSA #2 said the podiatrist went door to door and knocked on resident doors and let her know which residents refused and which residents were not in their room. She said the podiatrist did knock on all residents' doors at least twice and if a resident refused care the podiatrist wrote refused in the visit notes. She said podiatry visits used to be listed on the facility bulletin that was passed out daily to the residents and any residents who had needs were added to the list. She said Resident #81 had a history of refusing care. -Documentation of Resident #81 refusal of podiatry care was requested and not provided. CNA #2 was interviewed on 7/27/23 at 1:35 p.m. She said a shower aide would typically check the resident's nails in the shower. She said if there were any issues with a resident's nails she would report to the nurse. She said the Resident #81 had fungus on her toenails and the resident had previously told her that two of her toenails fell off. CNA #2 said she reported that Resident #81's toenails had fallen off to a nurse. She was unsure how long ago it was. She said she could see the resident's exposed toes when she cared for her. -A review of the progress notes and skin assessments did not reveal any documented regarding Resident #81's toenails falling off.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review the facility failed to provide timely dental services to meet resident needs for one (#10) of three residents reviewed for dental services out of 35 sample residents. Specifically, the facility failed to assist Resident #10 schedule a consultation for an oral surgeon to have his remaining teeth removed and to get fitted for dentures after the facility received the referral. Findings include I. Facility policy The Availability for Dental Services policy, revised August 2007, was provided by the nursing home administrator (NHA) on 7/27/23 at 12:00 p.m. and read in pertinent part: Oral healthcare and dental services will be provided for each resident; -Social services will be responsible for making necessary dental appointments; -All requests for routine and emergency dental services should be directed to social services to assure that appointments can be made in a timely manner. II. Resident status Resident #10, age [AGE], was admitted on [DATE]. According to the July 2023 computerized physician order diagnoses included depression, gastro-esophageal reflux disease without esophagitis (stomach contents that come back up through the throat to the mouth without swelling) and dementia with other behavioral disturbances. The 6/29/23 minimum data set (MDS) assessment showed the resident had no cognitive impairment with a brief interview for mental status (BIMS) score of 14 out of 15. Resident #10 had no dental issues identified. III. Resident interview Resident #10 was interviewed on 7/24/23 at 2:29 p.m. He said he asked the facility to have all of his teeth pulled to receive dentures. Resident #10 showed he was missing multiple teeth and had a lot of rotten teeth. Resident #10 said it was hard to eat certain foods. He said the facility told him he had to pick if he wanted top or bottom dentures. He said the facility never explained why he would not be able to receive dentures for the top and bottom of his mouth. Resident #10 said he was angered and frustrated the facility would not assist with a full set of dentures. IV. Record review Medical record review revealed Resident #10 was seen at the dentist on 3/7/23 and the facility uploaded the dental order to the facility's charting system on 3/8/23. The dental order read in pertinent part: New patient exam. Multiple decayed and necrotic (rotten) teeth. Patient is interested in replacing teeth. Conversation with patient concerning recommended treatment for FMX (removal of all remaining teeth) and F/F (full top and full bottom set of dentures). Patient to be seen by oral surgeon for FMX and placed back on schedule for follow-up and F/F fabrication once complete. V. Staff interview Social services director (SSD) #2 was interviewed on 7/26/23 at 10:38 a.m. She said all dental requests were received by herself for the unit she oversaw. She looked up Resident #10's dental documentation and said it must have been entered when she was off of work for a period of time. SSD #2 said she was not aware Resident #10 needed an appointment scheduled to see an oral surgeon. She said the facility dropped the ball and she was going to get the order entered into the charting system and an appointment scheduled. SSD #1 and SSD #2 were interviewed on 7/27/23 at 12:35 p.m. SSD #1 said she recently took over the position but was not aware of the oral surgeon referral needed for Resident #10. SSD #2 told SSD #1 the order was entered into the charting system and an oral surgeon would be contacted. SSD #2 said she was not aware the facility's dental policy showed the social services staff were responsible for scheduling dental appointments but she would follow up.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and observation the facility failed to ensure resident food preferences for one (#24) out of five sample residents were honored out of 35 sample residents. Specifically, the facility failed to provide Resident #24 with the preferred vegetarian diet. Findings include: I. Facility policy and procedure The Resident Food Preferences policy and procedure, revised 2017, was delivered by the nursing home administrator (NHA) on 7/26/23 at 12:40 p.m. It read in pertinent part: Upon the resident's admission the dietitian or nursing staff will identify a resident's food preferences. Nursing staff will document the resident's food and eating preferences in the care plan. The Food Services Department will offer a variety of foods at each scheduled meal, as well as access to nourishing snacks throughout the day and night. The facility's Quality Assessment and Performance Improvement (QAPI) committee will periodically review issues related to food preferences and meals to try to identify more widespread concerns about meal offerings, food preparation. II. Resident #24 A. Resident status Resident #24, over age [AGE], was admitted to the facility on [DATE]. According to the July 2023 computerized physician orders (CPO) the diagnoses include major depressive disorder, and hypothyroidism. The 5/23/23 minimum data set (MDS) assessment documented the resident had no cognitive deficit with a brief interview for mental status (BIMS) score of 15 out of 15. B. Resident interview Resident #24 was interviewed on 7/2423 at 10:42 a.m. The resident said she was vegetarian and the facility used to provide her with food choices to her preference but they had stopped. She said she usually only ate the oatmeal or nothing at all because the other options made her feel sick. C. Observations On 7/27/23 at 11:12 a.m. the resident was observed to receive jello and apple slices for lunch rather than the offered meal. The resident was not offered another choice for a meal. D. Record review The care plan for nutrition documented the resident had minimal nutritional risk despite her preferred pattern of meal skipping and multiple food restrictions and avoidances. Interventions include Obtain food preferences and offer as able. Offer resident the vegetarian options as well and provide daily preference. III. Menu extensions The menu failed to show a specific vegetarian diet. IV. Staff interview The social services director (SSD) and social services assistants (SSA) #1 were interviewed on 7/27/23 at 11:43 a.m. The SSD said the facility attempted to purchase resident #24 food items that suited her preferences but have been unable. SSA #1 said the staff has not been able to obtain a list of items to purchase for the resident. The dietary supervisor (DS) was interviewed on 7/27/23 at 1:54 p.m. The DS said for the vegetarian meals the staff would take the meat out of the meal. The DS said Resident #24 liked baked potatoes or peanut butter and jelly sandwiches. The DS said the facility ordered gluten free items for another resident but did not purchase items specifically for Resident #24.

Based on observations, interviews and record review, the facility failed to ensure resident's had the right to a dignified existence. Specifically, the facility failed to provide a dignified living experience adequate by answering resident call lights timely in two of three units that resulted in call light response times up to two hours and 55 minutes. Findings include: I. Facility policy The Answering the Call Light policy, revised October 2010, was provided by the nursing home administrator (NHA) on 7/27/23 at 1:07 p.m. It read in pertinent part, When the resident is in bed or confined to a chair, be sure the call light is within easy reach of the resident. Report all defective call lights to the nurse supervisor promptly. Answer the resident's call light as soon as possible. Be courteous in answering the resident's call. Steps in the procedure: turn off the signal light; identify yourself and call the resident by his or her name; list to the resident's request; do what the resident asks of you if permitted; if uncertain ask the nurse supervisor for assistance. II. Resident census and conditions According to the 7/24/23/23 Resident Census and Conditions of Residents report, the resident census was 93 and the following care needs were identified: -55 residents needed assistance of one or two staff with bathing and 35 residents were dependent. Three residents were independent. -60 residents needed assistance of one or two staff members for toilet use and three residents were dependent; 30 residents were independent. -68 residents needed assistance of one or two staff members for dressing and two were dependent; 23 residents were independent. -55 residents needed assistance of one or two staff members and seven were dependent for transfers; 31 residents were independent. -58 residents needed assistance of one or two staff members with eating and 35 were independent. III. Resident interviews and observations Resident #12 was interviewed on 7/24/23 at 11:28 a.m. He said there were not enough staff and a registered nurse was needed on Mountain View. He said the facility used a lot of agency nurses and CNAs. Resident #25 was interviewed on 7/24/23 at 1:46 p.m. She said she waited one to one and a half hours for staff to answer her call light. Resident #57 was interviewed on 7/24/23 at 1:56 p.m. He said he waited up to two hours for his call light to be answered and CNAs told him there were problems with the call lights and the lights turned off by themselves before the staff could respond. He said sometimes he used his cellphone to call the front desk for help. He waited two hours for his light to be answered once and had an incontinence episode as a result. He said there were more issues having a call light answered timely after dinner. Resident #79 was interviewed on 7/24/23 at 2:30 p.m. He said he waited at least an hour to have his call light answered and in the morning he was not able to get out of bed because the staff were too busy to help him. He said staff told him he had to wait in the morning because the staff were busy helping with breakfast service. Resident #81 was interviewed on 7/24/23 at 2:30 p.m. She said she waited up to two hours for her call light to be answered. She said she thought the wait had to do with the timing of the duties staff had to complete. Resident #46 was interviewed on 7/24/23 at 3:49 p.m. He said there were not enough staff to take care of all the residents in the facility. IV. Record review Call light response times from 7/19/23 to 7/26/23 were provided by the nursing home administrator on 7/26/23 at 2:30 p.m. The staff response times longer than 20 minutes to Resident #57's room after he pushed his call button for assistance were as follows: -On 7/19/23 26 minutes. -On 7/20/23 26 minutes. -On 7/20/23 55 minutes. -On 7/21/23 one hour and six minutes. -On 7/22/23 44 minutes. -On 7/23/23 25 minutes. -On 7/24/23 24 minutes. -On 7/25/23 53 minutes. The staff response times longer than 20 minutes to Resident #79 and Resident #81's shared room after the residents pushed the call button for assistance were as follows: -On 7/20/23 one hour and nine minutes. -On 7/21/23 at 6:27 a.m. 44 minutes. -On 7/21/23 at 8:38 a.m. 40 minutes. -On 7/21/23 at 8:03 p.m. 26 minutes. -On 7/22/23 one hour and 23 minutes. -On 7/23/23 one hour and 55 minutes. -On 7/24/23 at 4:01 a.m. 35 minutes. -On 7/24/23 at 8:29 a.m. 57 minutes. -On 7/24/23 at 3:18 p.m. two hours and 55 minutes. -On 7/26/23 at 5:00 a.m. 49 minutes. -On 7/26/23 at 5:56 a.m. 35 minutes. The staff response times longer than 20 minutes to Resident #72's room after she pushed his call button for assistance were as follows: -On 7/19/23 35 minutes. -On 7/20/23 32 minutes. -On 7/21/23 one hour and 20 minutes. -On 7/22/23 47 minutes. -On 7/23/23 at 2:55 p.m. 57 minutes. -On 7/23/23 at 4:24 p.m. one hour. -On 7/25/23 one hour. V. Staff interviews Registered nurse (RN) #2 was interviewed on 7/26/23 at 2:00 p.m. She said the CNAs used pagers but the nurses did not and she was unsure if both of the CNAs on that unit had pagers on them, but she thought at least one CNA did. She said staff used the computer monitor in the office to see if a resident had pushed their call button and staff should be checking the monitor. She said not all the residents on the Aspen unit used their call lights. CNA #8 was interviewed on 7/26/23 at 2:35 p.m. She said call lights were triggered on a computer screen at the nurses' station and the computer made a noise the CNAs responded to. She said the CNAs did not carry pagers on the unit. CNA #3 was interviewed on 7/27/23 at 12:41 p.m. and said the CNAs did not carry pagers although they were supposed to. She said the pagers did not work most of the time. CNA #3 said the CNAs listened for noise from the computer when they walked by the nurses' station or they looked at the computer screen to see if a call light was triggered. The NHA and infection preventionist (IP) were interviewed on 7/27/23 at 11:00 a.m. The NHA said the CNAs should all have pagers. She said she did review the call light logs and saw some extended wait times. She said two of the residents required a hoyer and extensive care and the facility had issues in which staff provided resident care and call lights were left on. She said she could not speak to any of the extended wait times as to the exact reason but there were a couple residents that have staff cell phone numbers for concerns. She said the call lights were only able to be shut off on the wall in the resident's room and staff were to walk by the monitor at the nurses station to see if any residents pushed their call button. She said the monitor made a sound when a resident pushed their call button. The NHA said if there was a concern regarding long response time to call lights, an audit was done but not on a regularly scheduled basis. If a concern was found a grievance was filled out. She said there were times the facility did not have enough pagers and consequently new pagers were ordered. That one person missing a pager could have been an agency staffing or additional staff issue to grab. The IP said if the facility did not have enough pagers for each CNA, management would would make sure each unit had at least one pager. She said if a resident needed assistance from two staff members, a call light in a resident's room should stay on until the second staff person entered the room to assist but the process was not consistent. She said staff were able to silence the pagers but the pagers still flashed if a resident's call light was on, and the pagers had vibrate as well as a sound option. She said the staff did take the pagers home occasionally.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to ensure freedom from resident-to-resident abuse for three (#71, #43 and #10) of six residents reviewed out of 35 sample residents. Specifically the facility failed to ensure Residents #71, #43 and #10 were free from abuse by Resident #39. All four residents lived in the secure unit. Cross-reference F744, dementia care services. Findings include: I. Facility policy The Abuse, Neglect, Exploitation, and Misappropriation Prevention Program policy, last revised in April 2021, was provided by the nursing home administrator (NHA) on 7/24/23. It read in pertinent part: Protect residents from abuse by anyone including, but not limited to: other residents. Develop and implement policies and protocols to prevent and identify: abuse or mistreatment of residents. Identify and investigate all possible incidents of abuse. II. Abuse incidents involving Resident #39 against other residents Facility investigation reports and medical record documentation revealed the following: A. Physical abuse incident #1 on 6/11/23 at 9:20 a.m.-Resident #39 (assailant) and Resident #71 (victim) On 6/11/23 at approximately 9:20 a.m. Resident #71 and Resident #39 were observed by a certified nurse aide (CNA) as they stood by the locked door in the secure unit. The CNA was on the opposite side of the locked door and was not able to intervene because the door was blocked by the residents and it would not open. The CNA witnessed a fist fly and Resident #71 hit the wall. Resident #39 grabbed Resident #71. The CNA attempted to get another staff's attention to help. Resident #71 was sent to the emergency room 6/11/23 after an altercation with Resident #39. The after visit summary listed the reasons for Resident #71's treatment as assault victim. Resident #71 was diagnosed and treated for a scalp laceration.The discharge summary from the hospital read: Your vital signs were reassuring. There is no evidence of traumatic injury on the CT (computerized tomography which includes a series of x-ray images taken from different angles) of your head, C-spine, chest abdomen pelvis. There was an incidental finding of an aortic aneurysm. There was a very small laceration on your scalp that did not require sutures or staples. Keep the area clean and dry. It is okay to wash with shampoo. No hydrogen peroxide. Tylenol up to 650 mg every four to six hours as needed for pain. Return to the ER (emergency room) for new or worsening concerns and otherwise follow-up with your primary care doctor. An interdisciplinary team (IDT) note was entered for Resident #71 in the facility's charting system on 6/12/23 at 8:39 p.m. by the NHA. The behavior observed was documented as physical aggression received. The interventions were resident (#71) was sent to the emergency room for evaluation and treatment. No head injury identified. The risk factors were resident (#71) with confusion and intrusive behaviors observed prior to other resident (#39) responding by pushing resident (#71) back causing this resident (#71) to fall. -The IDT note was inaccurate based on the hospital report which documented a closed head injury and scalp laceration (above). An IDT note was entered for Resident #39 on 6/12/23 at 8:45 p.m. by the NHA. The behavior observed was documented as physical aggression towards other resident. The interventions were staff maintained distance between residents. Re-direction and police contacted. Frequent checks. The risk factors were resident (#39) highly responsive to others. Resident responsive to other resident's intrusive behaviors as resident (#71) in close proximity and reaching down to touch him (#39) resident (#39) responds by pushing hand back causing other resident (#71) to lose balance and fall. The summary of the investigation read in pertinent part: incident was witnessed by a staff member on the other side of the door. Video was reviewed. The facility documented abuse was unsubstantiated. -However, abuse should have been substantiated because the incident was witnessed and documented accordingly and Resident #71 was injured according to the hospital report. B. Physical and verbal abuse incident #2 on 6/11/23 at 4:25 p.m.-Resident #39 (assailant) and Resident #10 (victim) On 6/11/23 at 4:25 p.m. Resident #39 and Resident #10 were in the dining room. The registered nurse (RN) witnessed Resident #10 say something to someone behind him as he approached the medication cart. As Resident #10 received his medications Resident #39 snuck up behind Resident #10 and kicked him on the right thigh. The RN placed herself between the residents. Resident #39 was angry and said I will kill you and I do not care, I will kill him. Resident #10 told the RN he had not said anything to Resident #39 when she asked Resident #10 what he said when he approached the medication cart. Immediate actions taken by the RN were documented as ensuring both residents were separated and attempting to calm the situation by talking to both residents. An internal investigation was initiated 6/11/23 and police were contacted. The summary of the investigation said although physical contact was observed video monitoring reviewed showed resident (#39) kicking motion in response to (#10) flickering lights. No pain, injury, or fear identified. An interdisciplinary team (IDT) note was entered for Resident #10 on 6/12/23 at 9:29 p.m. by the NHA. The behaviors observed were documented as resident received physical aggression from another resident. The interventions were documented as staff immediately maintained separation of residents. Frequent checks. Police contacted. The risk factors were documented as resident (#10) observed flickering lights on and off in the dining room. Other resident (#39) observed to respond to this resident's (#10) behavior by kicking foot out to try to get this resident (#10) to stop turning light on and off. An IDT note was entered for Resident #39 on 6/12/23 at 9:36 p.m. by the NHA. The behaviors observed were documented as physical aggression toward another resident. The interventions were documented as residents immediately separated. Frequent checks continue for this resident. The risk factors were documented as resident highly responsive to behaviors of others. Resident appeared agitated by other resident (#10) flickering lights on and off in dining room. Resident (#39) observed to kick leg out making contact with other resident (#10). The facility unsubstantiated abuse. -However, abuse should have been substantiated as it was witnessed and documented accordingly (above). C. Physical and verbal abuse incident #3 on 6/13/23 at 8:30 p.m.-Resident #39 (assailant) and Resident #43 (verbal assailant, victim of physical abuse) On 6/13/23 at 8:30 p.m. Resident #43 stood up out of his wheelchair. The licensed practical nurse (LPN) who witnessed the incident asked Resident #43 to sit so he would not fall. Resident #43 refused to sit down. Resident #39 told Resident #43 he needed to sit down because he would fall. Resident #43 was angered and called Resident #39 an (expletive). Resident #39 was upset and kicked Resident #43 in the thigh. Resident #43 told the LPN he kicked me. The LPN approached Resident #39 and he said he deserved to be kicked. The residents were separated, checked for injuries, and 15 minute checks were initiated. The LPN noted no injuries to either resident. The summary of the investigation was not documented by the facility. An IDT note for Resident #39 was entered by the social services director (SSD) #2 on 6/19/23 at 10:38 p.m. The behavior observed was Resident (#39) was observed attempting to assist staff with redirecting another resident (#43), the other resident (#43) became upset with Resident #39. Resident #39 then attempted to kick out at the other resident (#43). The interventions were documented as staff intervened, frequent checks, and anticipate needs. Staff re-education provided. The risk factors were poor safety awareness and lacks insight to his current condition. An IDT note for Resident #43 was entered by the SSD #2 on 6/19/23 at 10:42 a.m. The behavior observed was entered as staff were trying to have Resident #43 sit down so he would not fall. Resident #43 was refusing to sit down when another resident (#39) stated that he needed to sit down because he would fall. Resident #43 became angered and was cursing at the resident (#39), which upset the resident (#39) and he attempted to kick out at Resident #43. The interventions were anticipate his needs, staff to be proactive when behaviors are being observed, frequent checks, redirect or remove from situations as needed. The risk factors were documented as lack of insight to his current condition, poor safety awareness, difficult to redirect at times. The facility unsubstantiated abuse. -However, verbal abuse and physical abuse should have been substantiated as it was witnessed. III. Record review A. Resident #39 status Resident #39, age [AGE], was admitted on [DATE]. According to the July 2023 computerized physician orders (CPO) diagnoses included senile degeneration of the brain (decreased ability to think, concentrate, or remember), mood disorder due to known physiological condition (traumatic brain injury), anxiety disorder, depression, and dementia with other behavioral disturbance. The 5/17/23 minimum data set (MDS) assessment showed the resident had severe cognitive impairment with a brief interview for mental status (BIMS) score of five out of 15. Resident #39 had hallucinations, verbal aggression toward others, and behavioral symptoms not directed toward others (hitting himself, screaming out, rummaging) that occurred daily. These behaviors were documented as putting others at risk for receiving physical aggression, significant intrusion of other residents' privacy or activities, and significantly disruptive to the living environment. Resident #39's care plan, last revised on 3/13/23, identified a behavioral problem and was aggressive toward peers and staff due to his traumatic brain injury and dementia. Resident #39 had poor impulse control and had a potential to be physically aggressive toward staff and other residents. His triggers were listed as he reacted to how others spoke to him, spoke about him, curse words, and being approached from behind. -Resident #39's care plan was not revised after the two abuse incidents on 6/11/23 and the abuse incident on 6/13/23. B. Resident #71 status Resident #71, age [AGE], was admitted on [DATE]. According to the July 2023 CPO diagnoses included dementia with other behavioral disturbance. The 6/26/23 MDS assessment showed the resident had a severe cognitive impairment with a BIMS score of four out of 15. The resident had delusions, other behavioral symptoms not directed toward others, disorganized thinking and inattention (difficulty focusing). Resident #71's care plan, last revised on 4/5/23, identified risk for impaired communication due to English not being his primary language. The facility provided a translation device for the resident to communicate what he needed to staff, however Resident #71 could not communicate with other residents who did not speak other languages. The care plan said Resident #71 was at risk for injuries or altercations related to his cognition and he was unable to understand other residents' boundaries. C. Resident #43 status Resident #43, under age [AGE], was admitted on [DATE]. According to the July 2023 CPO diagnoses included sequelae of cerebral infarction (residual effects or conditions produced by a stroke), dysarthria and anarthria (severe motor speech disorder), depression, personal history of a traumatic brain injury, and unspecified head injury. The 4/21/23 MDS showed the resident had mild cognitive impairment with a BIMS score of 11 out of 15. Resident #43 had other behavioral symptoms not directed at others however it was not documented that he put himself or others at risk due to the behaviors. Resident #43's care plan, last revised on 5/2/23, said he had poor safety awareness and attempted to self transfer from his wheelchair or walk. He became verbally aggressive toward other residents and wandered into other residents' rooms. -Resident #43's care plan was not updated after the abuse incident on 6/13/23. D. Resident #10 Resident #10, age [AGE], was admitted on [DATE]. According to the July 2023 CPO diagnoses included depression and dementia with other behavioral disturbances. The 6/29/23 MDS showed the resident had no cognitive impairment with a BIMS score of 14 out of 15. Resident #10 had other behavioral symptoms not directed at others however it was not documented that he put himself or others at risk due to the behaviors. Resident #10's care plan, last revised on 6/13/23, identified the resident had a behavioral problem related to his diagnosis of dementia. Resident #10 was very intrusive toward residents and staff. He was at risk of receiving physical or verbal aggression from other residents since he approached residents from behind and touched them playfully. -Resident #10's care plan was not revised regarding the abuse incident on 6/11/23. IV. Family/guardian interview Resident #10's guardian was interviewed over the phone on 7/25/23 at 2:29 p.m. He said this was the only facility to not kick (Resident #10) out due to his physical aggression. He said Resident #10 was very unpredictable and his behaviors were hard to address. V. Staff interviews SSD #2 was interviewed on 7/26/23 at 10:38 a.m. She said Resident #10 was hit and miss every day. She said sometimes he participated in activities and interacted with other residents in a positive manner and other days he was physically or verbally aggressive to other residents. SSD #2 said the CNAs provided consistency for Resident #10 but he was still unpredictable. If other residents bumped into Resident #10 or if he perceived them as being mean to him then he would be triggered and act out. She said Resident #71 was a people watcher and enjoyed observing other residents while walking around. Resident #71 was not aware of other residents' boundaries or personal space due to his diagnoses and language barrier. The SSD #2 said Resident #10 was very playful and had a lack of safety awareness which sometimes upset other residents. She said Resident #43 was verbally aggressive at times but usually forgot which room was his or had a lack of safety awareness which caused other residents to physically or verbally attack him. The director of nursing (DON) was interviewed on 7/27/23 at 12:14 p.m. She said the facility had daily huddles and IDT meetings so the facility could come together as a team and then staff received the details of the huddles and IDT meetings. If necessary the DON provided one-on-one training to the floor staff for assistance with residents who had physical aggression. The DON said, We (the staff) cannot change their (residents) behaviors but we can change our reactions to the behaviors. She said Resident #39 had poor vision and staff were trained to stay in front of him and use a normal tone of voice. She said staff were instructed to give Resident #39 an option of where he sat so he could come and go as he pleased. The CNAs kept the hallway traffic to a minimum so the hallways remained open. A CNA stayed around the area Resident #39 was in to keep a close eye on him. The DON said the CNAs were told to move the victim after an altercation because Resident #39 would not move and both the victim and aggressor were placed on 15 minute checks. She said when Resident #39 and Resident #71 had an altercation it happened really fast. Resident #39 attempted to go through the unit's locked door and Resident #71 got in Resident #39's space and attempted to assist Resident #39 open the door. Resident #39 appeared to feel threatened and attacked him. The facility provided more training for the staff. If Resident #39 did not leave the locked door alone staff were asked to just open the door and let Resident #39 go on a big walk around the facility but she said she was unsure if staff walked with Resident #39 around the facility or if he used his wheelchair and propelled himself alone. However the DON said there was a nurses' station in the middle of the facility and the staff that worked there would keep an eye on Resident #39 as he propelled himself. She said it was an expectation for staff to watch Resident #39 when he was around other residents he had previous issues with. CNA #3 was interviewed on 7/27/23 at 12:41 p.m. She said after an altercation it was easier to have the victim removed from the area because the aggressor attacked her when she attempted to redirect them somewhere else. CNA #3 said, Resident #39 does not have any triggers that I know of. We (the CNAs) just have to tell based on his mood or behavior. If Resident #39 states he is not [NAME] then we know it will be a rough day. She said the care plans were not printed on the unit and the facility's charting system was not a reliable method to access care plans. She said the CNAs tried to keep a close eye on Resident #39 but they were not always fast enough to prevent altercations. VI. Facility follow-up documentation The NHA provided follow-up documentation on 7/28/23 at 10:05 p.m. via email which included the following: Significant attempts made to consider resident behaviors to prevent risk to self and others monthly. Medical director, behavioral health services, and ombudsman involvement utilized to reduce risks. Resident's (#39) son actively involved and in agreement with all efforts of facility. Three occurrences reviewed in survey facility found to be unsubstantiated based on occurrence manual guidelines. First occurrence no physical contact made. Fall occurred based on startle response. No physical contact made. Second and third occurrences although physical contact was made there was no pain, fear, or injury identified per occurrence reporting guidelines did not meet criteria for abuse. -However, the findings including staff witness statements, medical record documentation and hospital report, did not support the NHA's statement that abuse was unsubstantiated.

Based on record review and interview, the facility failed to conduct yearly certified nurse aide (CNA) performance reviews and provide training based on the annual reviews for five (#2, #4, #5, #6 and #7) of five CNA training files reviewed. Specifically, the facility failed to provide performance evaluation reviews annually and provide 12 hours of regular in-service education on the outcome of these reviews for CNAs hired prior to July 2022. Findings include: I. Record review Upon review of five CNA training files, it was identified none of the five CNAs had evidence a performance review was completed and annual competencies or associated training totaling 12 hours per year was completed. CNAs reviewed included CNA #2, CNA #4, CNA #5, CNA #6 and CNA #7. The inservice records were reviewed starting July 2022 and documented the title of the inservice and date of completion, but failed to show total hours completed. II. Staff interview The nursing home administrator (NHA) was interviewed on 7/27/23 at 12:30 p.m. She said the competencies were included in the online inservice as post inservice questions required before the inservice itself was considered completed. -The post in-service questions and answers were not able to be printed or viewed for verification. The NHA acknowledged the inservice records did not show staff completed 12 hours of in-services, only inservice titles and dates of completion. She said during morning meeting management determined what areas staff needed more competency training in. An all staff meeting agenda was then created and the all staff meeting was used for in-services and staff competencies. The NHA said a new inservice program documented the hours for each in-service for each employee that was going to be utilized in the future.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews the facility failed to ensure three (#39, #10 and #71) of six residents reviewed for dementia care of 32 sample residents received the appropriate dementia care treatment and services to maintain their highest practical physical, mental, and psychosocial well-being. Specifically the facility failed to: -Assess, identify and implement measures to engage Residents #39, #10 and #71 activities to help prevent resident-to-resident altercations; -Update care plans following resident to resident abuse incidents for Resident #39, #10 and #71; and, -Ensure interventions were implemented to prevent Resident #39 from abusing other residents further. Findings include: I. Resident #39 A. Resident status Resident #39, age [AGE], was admitted on [DATE]. According to the July 2023 computerized physician orders (CPO) diagnoses included senile degeneration of the brain (decreased ability to think, concentrate, or remember), mood disorder due to known physiological condition (traumatic brain injury), anxiety disorder, depression, and dementia with other behavioral disturbance. The 5/17/23 minimum data set (MDS) assessment showed the resident had severe cognitive impairment with a brief interview for mental status (BIMS) score of five out of 15. Resident #39 had hallucinations, verbal aggression toward others, and behavioral symptoms not directed toward others (hitting himself, screaming out, rummaging) that occurred daily. These behaviors were documented as putting others at risk for receiving physical aggression, significant intrusion of other residents' privacy or activities and significantly disruptive to the living environment. B. Record review Resident #39's care plan, last revised on 3/13/23, identified a behavioral problem and was aggressive toward peers and staff due to his traumatic brain injury and dementia. Resident #39 had poor impulse control and had a potential to be physically aggressive toward staff and other residents. His triggers were listed as he reacted to how others spoke to him, spoke about him, curse words, and being approached from behind. The care plan documented Resident #39 lived on a secured unit due to his diagnosis of dementia. Interventions on his care plan said: Staff to intervene preventatively separating resident from others in common areas as observed to prevent future unprovoked response, -Staff to intervene promptly when in dining room if resident is in close proximity to others or grabs other residents' items to prevent escalation of behaviors, -Staff to be proactive when hearing or witnessing verbal aggression from others toward Resident #39, or visa versa, and intervene immediately, -Staff to be present when resident is located in the dining room to protect the resident's rights and rights of other residents, -Frequent checks following any verbal or physical aggression observed or reported for 72 hours. -However the facility failed to have a care plan specifically for Resident #39's dementia care. Specific interventions were not documented regarding engaging Resident #39, identifying unmet needs, identifying potential triggers and therefore effectively avoiding and intervening before aggressive behavior began. Resident #39 was involved in a resident-to-resident incident with Resident #10 on 6/11/23. Resident #39 was involved in a resident-to-resident incident with Resident #71 on 6/11/23. Resident #39 was involved in a resident-to-resident incident with Resident #34 on 6/13/23. (See below and cross-reference F600 freedom from abuse.) -Resident #39's care plan was not revised after the two abuse incidents on 6/11/23 and the abuse incident on 6/13/23. Resident #39 was still involved in altercations with the interventions in place. According to pertinent interdisciplinary progress notes in the resident's medical record: On 4/18/23 at 1:00 p.m. Resident #39 had a physical altercation with another resident at lunch. He attempted to kick and punch the other resident. No injuries were noted and the residents were separated. Resident #39 was counseled and agreed to not show verbal or physical aggression going forward. On 4/20/23, at an unidentified time, Resident #39 received physical aggression from another resident. On 4/24/23, at an unidentified time, Resident #39 was identified as the aggressor with another resident. On 5/5/23 at 1:09 p.m. Resident #39 was sitting in the hallway in his wheelchair when another resident came up to Resident #39 and cursed at him. The resident grabbed at Resident #39's wheelchair. Resident #39 swung at the other resident and made contact with him. The resident also made contact with Resident #39, hitting him in the shoulder a couple of times. The residents were separated and no injuries were noted. On 5/8/23 at 3:34 p.m. Resident #39 intermittently became angry and attempted to open the door to leave the locked unit many times. He blocked the door and hallway. Staff attempted distraction techniques and Resident #39 said you are trying to deceive me. Resident #39 would often block the door and pathway. Staff monitored him to ensure there was no physical altercation with other residents. On 5/23/23 a progress note documented a decrease in Resident #39's Ativan (anti-anxiety medication) and an increase in Risperdal (antipsychotic medication). On 5/26/23 at 6:05 p.m. Resident #39 tried to escape through the door to another unit. When staff tried to help him he started attacking the certified nurse aide (CNA) several times. On 5/26/23 at 8:48 p.m. staff documented the resident seemed to be easily angered and argumentative under a charting note for the decrease of Ativan and increased Risperdal. On 5/27/23 at 3:59 p.m. under a charting note for the decrease of Ativan and increased Risperdal Resident #39 was observed being combative with staff and threatening other residents. On 5/31/23 at 12:25 a.m. under a charting note for the decrease of Ativan and increased Risperdal Resident #39 was easily agitated at times with care. On 5/31/23 at 11:50 p.m. under a charting note for the decrease of Ativan and increased Risperdal Resident #39 was easily agitated at times. On 6/11/23 at approximately 9:20 a.m. Resident #39 initiated verbal and physical aggression toward another resident. Interdisciplinary (IDT) notes documented the victim entered Resident #39's space which caused Resident #39 to react which caused the other resident to fall. On 6/11/23 at 4:25 p.m. Resident #39 initiated physical aggression toward another resident. IDT notes documented the other resident flickered the lights in the dining room on and off which angered Resident #39 and led to physical aggression. On 6/13/23 Resident #39 initiated physical aggression toward another resident. The IDT notes documented the other resident called Resident #39 a name that led to physical aggression. On 7/2/23 at 11:14 a.m. Resident #39 attempted to open the unit's locked door and said he needed to go home. He blocked the door and made verbal threats. II. Resident #71 A. Resident status Resident #71, age [AGE], was admitted on [DATE]. According to the July 2023 CPO diagnoses included dementia with other behavioral disturbances. The 6/26/23 MDS assessment showed the resident had a severe cognitive impairment with a BIMS score of four out of 15. The resident had delusions, other behavioral symptoms not directed toward others, disorganized thinking and inattention (difficulty focusing). B. Record review Resident #71's care plan, last revised on 4/5/23, identified risk for impaired communication due to English not being his primary language. The facility provided a translation device for the resident to communicate what he needed to staff, however Resident #71 could not communicate with other residents who did not speak other languages. The care plan said Resident #71 was at risk for injuries or altercations related to his cognition and he was unable to understand other residents' boundaries. -However, Resident #71 did not have a care plan specifically regarding dementia care. Specific interventions were not documented regarding engaging Resident #39, identifying unmet needs, assisting with communicating with other residents and keeping Resident #71 safe from other residents' potentially aggressive behaviors. III. Resident #10 A. Resident status Resident #10, age [AGE], was admitted on [DATE]. According to the July 2023 CPO diagnoses included depression and dementia with other behavioral disturbances. The 6/29/23 MDS showed the resident had no cognitive impairment with a BIMS score of 14 out of 15. Resident #10 had other behavioral symptoms not directed at others however it was not documented that he put himself or others at risk due to the behaviors. B. Record review Resident #10's care plan, last revised on 6/13/23, identified the resident had a behavioral problem related to his diagnosis of dementia. Resident #10 was very intrusive toward residents and staff. He was at risk of receiving physical or verbal aggression from other residents since he approached residents from behind and touched them playfully. His interventions were listed as the following: Caregivers provide an opportunity for positive interaction and attention. Stop and talk with him as passing by. -Firm limits with the resident regarding touching other residents. Staff to intervene immediately to prevent others from responding reactionary or aggressively towards this resident. -The resident was provided with fidget spinners and he is to be encouraged to have him in his pocket when he is walking in the hallway and in the dining room to prevent him from touching his peers. -Staff to set firm limits and boundaries to protect the rights of others. -Intervene as necessary to protect the rights and safety of others. -Resident #10's care plan was not revised regarding the abuse incident on 6/11/23 (see above). The care plan also did not have detailed interventions for how staff should handle the behaviors associated with his dementia. According to pertinent interdisciplinary progress notes in the resident's medical record: On 1/16/23 Resident #10 started Risperdal. On 1/16/23 at 1:13 p.m. Resident #10 said inappropriate words to the nurse and reached out to touch people. On 1/16/23 at 2:41 p.m. a note documented no bathing activity documented in seven days. Staff to continue to offer bathing options of the resident's choice and continue to re-approach. On 1/24/23 at 6:50 p.m. the resident continued to be intrusive to others and continued to attempt to touch other residents. On 1/26/23 at 12:19 a.m. the resident continued to be intrusive to others and continued to attempt to touch other residents. On 1/27/23 at 3:26 a.m. the resident continued to be intrusive to others and continued to attempt to touch other residents. On 3/20/23 at 10:22 a.m. Resident #10 refused to shower. Staff continued to re-approach the resident throughout the day and offered shower alternatives and encouraged good hygiene. On 4/18/23 at 10:04 a.m. Resident #10 had been hoarding expired foods, medicine cups and other items he refused to show staff. The CNA threw away a couple of bags of expired chips. On 4/25/23 at 10:39 a.m. Resident #10 occasionally touched other residents jokingly to which the resident was counseled not to do it. On 4/26/23 at 6:00 a.m. Resident #10 occasionally touched other residents jokingly to which the resident was counseled not to do it. On 4/26/23 at 9:44 p.m. a note was documented for monitoring the resident's increase in Risperdal that said there was no change to the resident's behaviors. He continued to grab out at other people and was argumentative with staff at times when staff tried to redirect him. On 4/28/23 at 12:17 a.m. a note was documented for monitoring the resident's increase in Risperdal that said there was no change to the resident's behaviors. Resident #10 continued to attempt to grab out at other people. On 4/29/23 at 11:23 p.m. the resident was up at times during the evening. At approximately 9:15 p.m. Resident #10 acted like he was going to throw something at another resident. Resident #10 walked by the resident and flicked him in the ear which angered the other resident. 05/16/23 at 7:42 p.m. Resident #10 walked to the nurse's medication cart and proceeded to remove used medication cups, which were used by other residents, out of the trash can. The nurse educated Resident #10 on unsafe practice and the resident said I do not care and walked back to his room with the used medication cups. On 5/23/23 at 6:19 a.m. Resident #10 refused a shower and all shower alternatives. On 6/11/23 at 6:55 p.m. Resident #10 was the victim of a resident-to-resident incident. The IDT notes documented the video cameras on the unit were reviewed. Resident #10 was seen flickering the dining room lights on and off which angered Resident #39 and led to the incident. IV. Staff interviews Social services director (SSD) #2 was interviewed on 7/26/23 at 10:38 a.m. She said Resident #39 was hit and miss every day. She said sometimes he participated in activities and interacted with other residents in a positive manner and other days he was physically or verbally aggressive to other residents. SSD #2 said the CNAs provided consistency for Resident #39 but he was still unpredictable. If other residents bumped into Resident #39 or if he perceived them as being mean to him then he would be triggered and act out. She said Resident #71 was a people watcher and enjoyed observing other residents while walking around. Resident #71 was not aware of other residents' boundaries or personal space due to his diagnoses and language barrier. SSD #2 said Resident #10 was very playful and lacked safety awareness which sometimes upset other residents. -However SSD #2 did not discuss dementia care training or methods to engage the residents following person-centered dementia care guidelines. The director of nursing (DON) was interviewed on 7/27/23 at 12:14 p.m. She said the facility had daily huddles and IDT meetings so the facility could come together as a team and then staff received the details of the huddles and IDT meetings. If necessary the DON provided one-on-one training to the floor staff for assistance with residents who had physical aggression. The DON said, We (the staff) cannot change their (residents') behaviors but we can change our reactions to the behaviors. She said Resident #39 had poor vision and staff were trained to stay in front of him and use a normal tone of voice. She said staff were instructed to give Resident #39 an option of where he sat so he could come and go as he pleased. The CNAs kept the hallway traffic to a minimum so the hallways remained open. A CNA stayed around the area Resident #39 was in to keep a close eye on him. The DON said the CNAs were told to move the victim after an altercation because Resident #39 would not move and both the victim and aggressor were placed on 15 minute checks. The DON said when Resident #39 and Resident #71 had an altercation, it happened quickly. Resident #39 attempted to go through the unit's locked door and Resident #71 got in Resident #39's space and attempted to assist Resident #39 open the door. Resident #39 appeared to feel threatened and attacked him. The facility provided more training for the staff. If Resident #39 did not leave the locked door alone staff were asked to just open the door and let Resident #39 go on a big walk around the facility but she said she was unsure if staff walked with Resident #39 around the facility or if he used his wheelchair and propelled himself alone. However, the DON said there was a nurses' station in the middle of the facility and the staff that worked there would keep an eye on Resident #39 as he propelled himself. She said it was an expectation for staff to watch Resident #39 when he was around other residents he had previous issues with. -However the DON did not discuss dementia care training or methods to engage the residents following the person-centered dementia care guidelines. CNA #3 was interviewed on 7/27/23 at 12:41 p.m. She said after an altercation it was easier to have the victim removed from the area because the aggressor attacked her when she attempted to redirect them somewhere else. CNA #3 said, Resident #39 does not have any triggers that I know of. We (the CNAs) just have to tell based on his mood or behavior. If Resident #39 states he is not [NAME] then we know it will be a rough day. She said the care plans were not printed on the unit and the facility's charting system was not a reliable method to access care plans. She said the CNAs tried to keep a close eye on Resident #39 but they were not always fast enough to prevent altercations.

Based on observation and interviews, the facility failed to ensure that each resident received food that was palatable, attractive, and an appetizing temperature. Specifically, the facility failed to: -Ensure food was palatable and attractive when delivered to residents; -Ensure food was served at a safe and appetizing temperature; and, -Provide condiments with meals. Findings include: I. Resident interviews Resident #56 was interviewed on 7/24/23 at 10:13 a.m. The resident said she had received burnt eggs. The resident said lunch was usually yucky and the food was runny and cold. Resident #25 was interviewed on 7/24/23 at 10:18 a.m. Resident #25 said the food was horrible and she tried not to eat what they had available at the facility. She said her daughter brought in food because the facility's food was very bad. Resident #45 was interviewed on 7/24/23 at 10:31 a.m. The resident said the food was bad and the bananas were overripe. Resident #24 was interviewed on 7/24/23 at 10:42 a.m. The resident said the food was bad and she would not eat it. She said if she ate the food she felt sick afterward. Resident #31 was interviewed on 7/24/23 at 11:09 a.m. The resident said he avoided the food and he had found a hair in the food. II. Test tray A test tray of the lunch meal was performed on 7/26/23. The tray left the kitchen at 11:43 a.m. and was delivered to the unit and was served after the last resident was served at 12:21 p.m. The meal was Western omelet, hash browns, toast and apple crisp. The meal test tray for palatability was tried by four surveyors: -The omelet was 112 degrees F (farenheit); the eggs were overcooked, rubbery, cold and bland. -The hash browns were 104 degrees F; the hash browns were bland, cold, plain and dry. -The toast was 89 degrees F; the toast was cold and soggy. -The tray did not come with apple crisp. -The tray did not come with condiments, salt, pepper, butter or jelly. III. Observation During continuous kitchen observation 7/26/23 from 10:12 a.m. to 11:43 a.m. There were not enough plates prepared for use and the last 10-15 plates went out without being on the plate heater. Some of the plates had been sitting on the metal holding tray. IV. Staff interview The dietary supervisor (DS) was interviewed on 7/27/23 at 1:54 p.m. He said the facility had a problem with not having enough dishes.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review, the facility failed to maintain an effective program of pest management to ensure the facility was free of pests. Specifically, the facility failed to ensure the main kitchen, dining rooms, resident rooms and hallways were free from flies on three out of three units. Findings include: I. Professional references According to the Colorado Retail Food Establishment Rules and Regulations (last amended 1/1/19) retrieved on 8/1/23 from https://cdphe.colorado.gov/environment/food-regulations, The premises shall be maintained free of insects, rodents, and other pests. The presence of insects, rodents, and other pests shall be controlled to eliminate their presence on the premises by routinely inspecting incoming shipments of food and supplies, routinely inspecting the premises for evidence of pests, using methods, if pests are found, such as trapping devices or other means of pest control, and eliminating harborage conditions. If the windows or doors of a food establishment, or of a larger structure within which a food establishment is located, are kept open for ventilation or other purposes or a temporary food establishment is not provided with windows and doors as specified, the openings shall be protected against the entry of insects and rodents by properly designed and installed air curtains to control flying insects According to the Center for Disease Control's (CDC) Guidelines for Environmental Infection Control in Health-Care Facilities, last updated July 2019 and retrieved on 8/1/23 from https://www.cdc.gov/infectioncontrol/guidelines/environmental/index.html, Insects can serve as agents for the mechanical transmission of microorganisms, or as active participants in the disease transmission process by serving as a vector (route) passing pathogens from one source to another. From a public health and hygiene perspective, arthropods (insects) and vertebrate pests should be eradicated from all indoor environments, including health-care facilities. II. Facility policy The Pest Control policy, revised May 2008, was provided by the nursing home administrator (NHA) on 7/27/23 at 1:07 p.m. It read in pertinent part, This facility maintains an on-going pest control program to ensure that the building is kept free of insects and rodents. Windows are screens at all times. Maintenance services assist, when appropriate and necessary in providing pest control services. III. Resident interviews and observations On 7/23/23 at 11:32 a.m. residents sat in the dining room with their lunches. A resident told certified nurse aide (CNA) #3 These darn flies! CNA #3 said, I know, they are horrible. Flies were everywhere as meals were served. The meal cart doors were opened and flies were in the meal cart as CNAs were delivering trays to residents' rooms. A resident swatted flies on the dining room table with his baseball hat and a magazine. At 12:34 p.m. flies were observed around the dining room as the residents played bingo. On 7/24/23 at 11:45 a.m. the back door to a patio was opened several times and left open. The NHA attempted to close the outside door however, residents continued to go in and out the door and did not latch it. Flies were observed throughout the dining room and hallways, while residents were served lunch. At 12:03 p.m. a family member exited a resident's room and informed CNA #3 flies landed in the resident's food while he was eating. Resident #57 was interviewed on 7/24/23 at 1:30 p.m. He said flies were a real problem at the facility, the flies would get into the food and there was a dead fly on the window sill (the dead fly was observed on the window sill). He said he wanted the dead fly removed and the window sill cleaned. Residents #79 and #81 were interviewed in their shared room on 7/24/23 at 2:30 p.m. Resident #79 said flies were bad in the facility. He said he had spoken to the facility management about the flies. Resident #79 and Resident #81 had flyswatters during the interview. Resident #79 said the fly swatters were provided by another resident. Resident #81 said the flies were in their room all the time. During the interview, the Resident #79 and Resident #81 were observed using their flyswatters during the interview to swat away flies. There were two flies in the room that landed on the bed and the residents. On 7/25/23 at 2:00 p.m. the door to the outdoor smoking patio was observed to be accessed from the main dining room and had an air curtain (air blowing device to prevent insects) installed above it. Upon entering the outdoor smoking patio from the dining room, the air curtain did not turn on and the air curtain did not turn on upon return inside to the dining room from the outdoor smoking patio. During continuous observation of the kitchen and lunch tray delivery on 7/26/23 from 10:12 a.m. until 12:21 p.m. there were multiple flies in the kitchen and hallways. There were flies on clean and sanitized items such as plates, small plates, inside of plate cover, cups, juice pitchers and serving utensils that were hanging over the prep tables. At 12:03 p.m. a resident sitting at the nurses station was swatting at flies with a fly swatter. At 12:13 p.m. licensed practical nurse (LPN) #2 was swatting away flies with her hand while at the medication cart. At 12:15 p.m. CNA #1 said the flies were terrorizing the staff. On 7/26/23 at approximately 1:30 p.m. Resident #81 was observed sitting in the dining room and used a fly swatter to swat away a fly that was flying around her. At 2:00 p.m. flies were observed in the locked unit's kitchenette. During the survey from 7/24/23 to 7/27/23 it was observed there were flies throughout the three facility units and three facility dining rooms. IV. Staff interviews Social services director (SSD) #2 was interviewed on 7/26/23 at 10:38 p.m. She said the facility was located in between some farms and the flies were a problem every summer. She said some of the residents who smoked propped the outside door open and staff would have to close it but that was how the flies got into the locked unit of the facility. She said the facility was informed they could not use fly glue strips so they used fly swatters and a spray on the door frames that deterred flies from going near it. SSD #2 said nothing worked for the flies and they dealt with it every year. Cook (CK) #2 was interviewed on 7/26/23 at 11:20 a.m. CK #2 said the number of flies was worse than before. She said it was due to the back door, located off the dining room, had been left open and the flies came to get to the heat and the food. She said the facility could not get rid of them. The dietary supervisor (DS) was interviewed on 7/27/23 at 1:54 p.m. The DS said the flies were the worst the staff had ever seen. He said the facility had a hard time keeping the back door shut off the dining room, so the flies kept coming in. The maintenance supervisor was not available during the survey to be interviewed. The nursing home administrator (NHA) was interviewed on 7/27/23 at 12:31p.m. She said the facility had fly issues for some time and the issue resolved temporarily when visitation was limited because of less door traffic in the facility. She said there was a cow pasture next to the facility and the door was left open or propped for frequent trips to the smoking area outside the dining room. She said there were air curtains on the east side of the building and at the door to the smoking patio. She said the air curtains were not blowing the day before and the facility called someone to look at the air curtains. She said there were fly lights in the hallways, the facility had monthly pest control visits and more frequently if needed and the facility had outside fly traps. She said during summer the flies were very difficult to manage. V. Facility follow-up The NHA provided pest control records on 7/28/23 that showed a pest control company provided service to the facility twice a month from July 2022 through February 2023 and on 7/27/23 (the last day of survey). The record from 7/27/23 revealed the following facility conditions with corresponding recommendations: -On 2/20/23 the kitchen insect light was not working or bulbs needed to be replaced; the recommendation was to replace the bulbs. -On 3/31/23 food debris and crumbs were in the kitchen corner; the recommendation was to remove the debris and crumbs. -On 4/18/23 cracks and holes were found in an exterior wall; the recommendation was to seal cracks and holes to deny pest entry and harborage. -On 5/2/23 tall weeds or grass should be kept mowed low to deny harborage to rodents, spiders and insects; the recommendation was to [NAME] tall weeds or grass to deny harborage to rodents, spiders and insects. -On 5/2/23 kitchen doors were left open; the recommendation was to keep the door closed when not in use. The pest control record from 7/27/23 revealed the previous conditions still existed during the inspection on 7/27/23 and the recommendation was to address the documented contributing conditions to support the pest management program.