**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to ensure two (#4 and #2) of three residents reviewed for abuse were kept free from sexual abuse out of five sample residents. Specifically, the facility failed to: -Protect Resident #4 from sexual abuse by Resident #3; and, -Protect Resident #2 from sexual abuse by Resident #3. Findings include: I. Facility policy and procedure The Abuse policy, dated 1/30/25, was provided by the nursing home administrator (NHA) on 6/23/25 at 4:00 p.m. It read in pertinent part, It is the policy of this facility to maintain an environment free of abuse and neglect. The resident has the right to be free from verbal, sexual, physical and mental abuse, corporal punishment, and involuntary seclusion. Identifying physical or psychosocial indicators of abuse (including injuries from an unknown source), neglect, exploitation, and misappropriation of resident property from situations of verbal, mental, sexual or physical abuse. The distribution of staff on each shift in sufficient numbers to meet the needs of the residents and assure that staff assigned have the knowledge of individual care needs. In cases of abuse, the quality assurance committee will review the circumstances of the abuse to determine if changes in policies and procedures are necessary to provide further preventative measures. II. Incident of sexual abuse towards Resident #4 by Resident #3 on 5/2/25 A. Facility investigation The 5/2/25 facility investigation was provided by the NHA on 6/23/25 at 4:00 p.m. The investigation revealed Resident #3 grabbed Resident #4's shirt and upper chest area. The investigation revealed the NHA interviewed Resident #4 on 5/2/25 at 10:15 a.m. Resident #4 said she went to talk to Resident #3. Resident #1 said Resident #3 shook her hand and with his other hand tried to reach down her shirt. Resident #4 said Resident #3 touched her skin and grazed her breast while holding her other hand. Resident #4 said Resident #3 shook her hand with his right hand and touched her breast with his left hand. Resident #4 said she did not welcome the touch, but was alright. Resident #4 said she felt safe because the nurse saw it and stopped it right away. Resident #4 said she did not feel totally safe because she was unsure what Resident #3 was up to and she did not want him on her unit. Resident #4 said she was not in pain. The investigation documented the director of nursing (DON) interviewed certified nurse aide (CNA) #4 on 5/2/25 at 10:40 a.m. regarding the incident between Resident #3 and Resident #4. CNA #1 said around 10:00 a.m. he was walking from the dining room on the second floor. CNA #1 said he saw Resident #3 near the nurses' station with his hand out towards Resident #4. He said he then saw Resident #3's hand pull at Resident #4's shirt by the collar. CNA #1 said he told Resident #3 that he could not do that. CNA #1 said he alerted one of the three CNAs sitting at the nurses' station. CNA #1 said one of the CNAs immediately took Resident #3 back to the third floor. CNA #1 said Resident #4 told him that Resident #3 was trying to touch her. CNA #1 said when he first saw Resident #3 reaching towards Resident #4 and pulling at her shirt, Resident #4 did not appear to have any reaction. CNA #1 said he immediately reported what happened to the nurse assigned to Resident #4. The assistant nursing home administrator (ANHA) and the DON interviewed a dietary aide (DA) on 5/2/25 at 4:30 p.m. The DA said she was in the dining room taking meal orders. She said Resident #4 was by the ice machine. The DA said she started walking out of the dining room and saw Resident #3 near Resident #4 with his hand on her shirt at the top. The DA said a CNA went to Resident #4 and Resident #3 right away and separated them. The DA said the CNA told Resident #3 that he could not touch other residents. The DA said Resident #4 did not appear to be upset. The DA said the CNA asked if Resident #4 was alright. The DA said Resident #4 said she was fine. The NHA interviewed CNA #1 again on 5/2/25 at 4:36 p.m. CNA #1 said Resident #3 had his hands on Resident #4's breast and her shirt area. The interview said CNA #1 did not specify if Resident #3's hands were in Resident #4's shirt or outside, just that his hands were placed near her breasts. The investigation documented the facility substantiated sexual abuse by Resident #3 towards Resident #4. B. Resident #3 (assailant) 1. Resident status Resident #3, age less than 65, was admitted on [DATE] and discharged to another facility on 6/20/25. According to the June 2025 computerized physician orders (CPO), diagnoses including severe traumatic brain injury (TBI). The 6/11/25 minimum data set (MDS) assessment revealed, through staff assessment, the resident required modified independence in cognitive decisions. The MDS assessment documented the resident did not have physical or verbal behaviors directed at others or other behavioral symptoms not directed toward others. 2. Record review The behavior care plan, revised 5/2/25, revealed Resident #3 had a history of sexually inappropriate behaviors. Pertinent interventions included providing one-to-one staff monitoring, providing frequent checks, providing redirection and maintaining the resident's personal space. C. Resident #4 (victim) 1. Resident status Resident #4, age less than 65, was admitted on [DATE]. According to the June 2025 CPO, diagnoses including moderate intellectual disabilities, delusional disorders, insomnia, generalized anxiety disorder and depression. The 6/13/25 MDS assessment indicated the resident was cognitively intact with a brief interview for mental status (BIMS) score of 14 out of 15. 2. Resident interview Resident #4 was interviewed on 6/23/25 at 10:45 a.m. Resident #4 said she approached Resident #3 to shake his hand. She said in the process, he attempted to reach out and grab her breast. Resident #4 said a staff member intervened and stopped Resident #3 before he could succeed. She said after the incident, Resident #3 returned to the third floor. III. Incident of physical abuse of Resident #2 by Resident #3 on 5/20/25 A. Facility investigation The 5/20/25 facility investigation was provided by the NHA on 6/30/25 at 4:00 p.m. The investigation documented on 5/20/25 at approximately 11:00 a.m., Resident #2 reported an incident involving Resident #3 to the NHA. Resident #2 said after offering Resident #3 a spoonful of pudding, Resident #3 touched her breast twice. Resident #2 said she wanted to avoid Resident #3. The investigation documented later that day (5/20/25) at 11:35 a.m., the NHA and the DON interviewed Resident #3 about the incident. Resident #3 admitted to grabbing Resident #2's breast and stated he was horny. The investigation documented on 5/20/25 at 12:15 p.m. that the NHA interviewed staff members. The staff members reported observing nothing specific, but noted that Resident #2 had assisted Resident #3 with pudding, during which Resident #3 touched Resident #2's breast. The NHA interviewed another resident on 5/22/25 at 12:43 p.m. The resident said they did not witness the event and only saw officers enter Resident #3's room. The resident said she was not afraid of Resident #3 and said Resident #3 was no longer funny. The investigation concluded abuse occurred. Resident #3 was placed on a one-to-one caregiver indefinitely. B. Resident #2 (victim) 1. Resident status Resident #2, age greater than 65, was admitted on [DATE]. According to the June 2025 CPO, diagnoses including anxiety, dementia without behavioral disturbance, psychotic disturbance and mood disturbance. The 6/11/25 MDS assessment revealed Resident #2 had severe cognitive impairments with a BIMS score of seven out of 15. 2. Resident interview Resident #2 was interviewed on 6/23/25 at 11:30 a.m. Resident #2 said Resident #3 reached over and grabbed her breast while she was giving him a bite of ice cream in the dining room area on the third floor. She said after the incident, a staff member separated Resident #3 from Resident #2. IV. Staff interviews CNA #1 was interviewed on 6/23/25 at 1:15 p.m. CNA #1 said on 5/2/25 Resident #3 was in the third floor dining room and appeared to be feeling down. CNA #1 said Resident #4 approached Resident #3 to offer comfort and was touched by Resident #3. CNA #1 said he heard about the incident between Resident #2 and Resident #3 within five minutes of the incident occurring on 5/20/25. CNA #1 said a one-to-one caregiver was implemented following this event. Licensed practical nurse (LPN) #1 was interviewed on 6/23/25 at 2:00 p.m. LPN #1 said Resident #4 told her that Resident #3 grabbed her shirt. LPN #1 said both Resident #4 and Resident #3 were separated. LPN #1 said after the incident with Resident #2 and Resident #3, staff members were assigned to Resident #3 to ensure no other appropriate interactions would occur. The NHA was interviewed on 6/23/25 at 4:00 p.m. The NHA said Resident #3 had a history of sexual behaviors and that the facility had implemented a one-on-one caregiver. She said the facility was aware of Resident #3's history of inappropriate behaviors but had not implemented more restrictive interventions for him before the 5/20/25 incident. The NHA and the DON said they were not aware of Resident #3's sexually aggressive behavior before the incidents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interviews, the facility failed to ensure care for residents in a manager and in an environment that maintains or enhances each resident's dignity and respect, in full recognition of his or her individuality for one of four residents out of 53 sample residents reviewed for respect and dignity. Specifically, the facility failed to ensure a resident was provided privacy while using the restroom. Findings include: I. Resident status Resident #7, age greater than 65, was admitted on [DATE]. According to the January 2025 computerized physician orders (CPO), diagnoses included schizophrenia, post traumatic stress disorder (PTSD) and history of falls. The 12/10/24 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. He was dependent on total assistance from staff for toileting hygiene, transfers, and lower body dressing. He needed substantial to maximal assistance with bed mobility and bathing, and needed set up help only with eating, oral and personal hygiene. II. Record review Resident #7's activities of daily living (ADL) care plan documented Resident #7 haD an ADL self-care performance deficit due to impaired balance, muscle weakness, decreased endurance, poor trunk control, cognitive impairments and decreased motivation to perform tasks. Pertinent interventions included Resident #7 needed assistance from two people for transferring. Resident #7 had incontinent episodes of bowel and bladder and required assistance with incontinence care and clothing management after an episode. Resident #7 transferred onto the toilet for bowel movements occasionally. III. Observations On 1/14/25 at 5:15 p.m. Resident #7 was sitting on the toilet in his room. The door to Resident #7's room and bathroom were both open, and the bathroom was immediately to the left of the room entrance. The bathroom door was opened at an angle so Resident #7 was visible from the hallway. Resident #7 was seated on the toilet, his pants were around his legs and he was holding a grab bar on the wall of the bathroom. Resident #7 grunted loudly twice and then yelled' here it comes' while seated on the toilet. An unidentified certified nurse aide (CNA) walked past Resident #7's room while Resident #7 was on the toilet with the door open, looked at the doors and continued to walk down the hallway. The unidentified CNA did not check on the resident or close the door to the room while the resident was using the restroom and was exposed to the facility hallway. Immediately after the unidentified CNA passed Resident #7's room, CNA #4 exited Resident #7's room with a clear bag of trash in her hand while Resident #7 was still in the bathroom and exposed to the facility hallway. She did not close the door to Resident #7's room, walked across the hallway and placed the clear trash bag inside a refuse container. CNA #4 walked back toward Resident #7's room and closed the door to the room. IV. Staff interviews CNA #5 was interviewed on 1/15/25 at 1:00 p.m. CNA #5 said if a resident was able to independently sit in the bathroom without assistance either the bathroom door or room door should be closed for privacy. CNA #5 said she was trained to ensure the residents' room doors were closed for privacy unless the resident was claustrophobic and needed the door open. CNA #5 said if a resident needed the door open, the resident should still be shielded for privacy. CNA #4 was interviewed on 1/16/25 at 2:15 p.m. CNA #4 said she thought she was in Resident #7's room with his roommate on 1/15/25. CNA #4 said sometimes Resident #7 did use the bathroom himself with the bathroom door open so he could call someone when he needed help. CNA #4 said if a resident wanted the bathroom door open while they used the bathroom then the door to the resident's room should be closed or the resident should be provided another form of privacy. The director of nursing (DON) was interviewed on 1/16/25 at 10:15 a.m. The DON said Resident #7 was fine with his bathroom door open unless his roommate's family or visitors were in the room and then he would want the door closed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and interviews, the facility failed to honor a resident's choice for laundry services, for one (#113) out of 33 residents reviewed out of 53 sample residents. Specifically, the facility failed to ensure Resident #113's laundry was consistently saved and stored for his wife to launder due to his multiple allergies. Findings include: I. Facility policy and procedure The facility's Promoting/Maintaining Resident Self-Determination policy, undated, was provided by the nursing home administrator (NHA) on 1/16/25 at 10:53 a.m. It read in pertinent part, It is the practice of this facility to protect and promote resident rights by promoting and facilitating resident self-determination through support of resident choice. The facility will ensure that each resident has the opportunity to exercise his/her autonomy regarding those things that are important in his/her life such as interests and preferences. Policy compliance guidelines included: -All staff members involved in providing care to residents will promote and facilitate resident self-determination; -Each resident has the right to make choices about aspects of his or her life in the facility that are significant to the resident; -All aspects of care and services will be discussed in the care plan meeting and documented as such; -The care plan will reflect resident choices when applicable; and, -The facility will accommodate the resident's preferences to the extent possible and as agreed upon by the resident's sponsor and physician. II. Resident #113 A. Resident status Resident #113, age greater than 65, was admitted on [DATE]. According to the January 2025 computerized physician orders (CPO), diagnoses included unspecified dementia without behavioral/psychotic/mood disturbance and anxiety, post-traumatic stress disorder (PTSD) and gout (a type of arthritis). The 11/11/24 minimum data set (MDS) assessment revealed the resident was severely cognitively impaired with a brief interview for mental status score (BIMS) of two out of 15. He was independent with bed mobility, transfers and locomotion. He required partial assistance with oral/toileting hygiene and showering, and supervision with dressing. B. Resident representative interview and observations Resident #113's representative was interviewed on 1/13/25 at 2:28 p.m.The representative said a bunch of Resident #113's clothes were previously missing and she was working with one of the facility's social workers regarding the issue. She said Resident #113 was previously exposed to Agent Orange (tactical herbicide) which caused him to develop a lot of allergies. The representative said Resident #113 had gotten rashes in the past if the wrong soap or laundry detergent was used. She said she had requested Resident #113's dirty laundry to be stored and saved for her to launder due to his allergy to most commercial laundry products. She said there was a lot of turnover with the nurses and the certified nurse aides (CNA) in the facility, so she felt like she had to micromanage his care. She said she did not understand why it was so difficult for the facility's staff to ensure his laundry was in his closet for her to collect. There was a sign taped to Resident #113's bathroom door stating he was allergic to aloe and to only use the shampoo that was in his closet. Another laminated sign was taped to Resident #113's closet door stating his wife wanted to do his laundry and facility staff should store his dirty laundry in the laundry basket inside the closet. A laundry basket was inside his closet. C. Record review A grievance form, dated 12/23/24, revealed Resident #113's wife reported the resident was missing pants, pajama pants and multiple shirts. She reported often finding other resident's clothing in Resident #113's room and not his clothing. An investigation was conducted by a facility administrator on 12/23/24, and five pairs of pants and five shirts were found in his closet. The administrator left a voicemail for Resident #113's wife on 12/27/24. The facility administrator reported his clothes were located in the facility laundry and other resident's clothing were removed from Resident #113's room. A review of Resident #113's electronic medical record (EMR) documented he had allergies to hydrocodone (pain medication), valproic acid (seizure medication, penicillins (antibiotics), milk and milk products, pork, aloe, corn and lavender. A skin integrity care plan, initiated on 9/7/22 and revised on 8/6/24, revealed Resident #113 was at risk for impaired skin integrity due to anticoagulant (blood thinner) use. He had fragile skin and poor safety awareness. Interventions included encouraging good nutrition and hydration to promote healthier skin, assessing his risk of skin breakdown quarterly and as needed, and completing skin assessments weekly. -Review of Resident #113's EMR did not reveal documentation addressing his allergies, skin issues with topical products and detergents, or laundry preferences. III. Staff interviews Certified nurse aide (CNA) #1 was interviewed on 1/16/25 at 9:34 a.m. CNA #1 said Resident #113's wife did his laundry. She said he was frequently incontinent and would sometimes go through all of his clean clothes, so his clothes would be sent to the facility's laundry room. She said the laundry department was aware of Resident #113's allergies and did his laundry different from the other residents. Licensed practical nurse (LPN) #2 was interviewed on 1/16/25 at 9:48 a.m. LPN #2 said Resident #113's wife did his laundry. She said his wife did allow the facility to do his laundry when she was sick, but otherwise she wanted to primarily do it. She said she would ask Resident #113's wife to bring additional clothing in for him due to his incontinence. The director of nursing (DON) was interviewed on 1/16/25 at 1:51 p.m. The DON said if a resident's family asked to do their laundry, the facility had signs posted for staff to place on their closet and laundry bins they could put inside the closet. She said it was important to follow a resident's request because it was their right and the facility should honor their preferences, especially if they affect their health. The DON was interviewed again on 1/16/25 at approximately 5:45 p.m The DON said the facility had begun providing education with the facility's staff to discuss the resident's laundry and laundry preferences.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interviews the facility failed to ensure the minimum data set (MDS) assessment accurately reflected the residents'status based on the criteria outlined in the resident assessment instrument (RAI) for one (#83) of 18 residents reviewed out of 53 sample residents. Specifically, the facility failed to ensure Resident #83's MDS accurately indicated the resident was receiving hospice services. Findings include: I. Facility policy and procedure The Documentation of Medical Record policy and procedure, undated, was received from the nursing home administrator (NHA) on 1/16/25 at 1:47 p.m. It revealed in pertinent part, Each resident's medical record shall contain an accurate representation of the actual experiences of the resident and include enough information to provide a picture of the resident's progress through complete, accurate, and timely documentation. Licensed staff and interdisciplinary team members shall document all assessments, observations, and services provided in the resident's medical record in accordance with state law and facility policy. II. Resident #83 A. Resident status Resident #83, age [AGE], was admitted on [DATE]. According to the January 2025 computerized physician's orders (CPO), the diagnoses included chronic obstructive pulmonary disease (COPD) and heart failure. The 11/26/24 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. She was dependent with toileting, personal hygiene, bed mobility and required set up assistance with eating. The assessment indicated Resident #83 was receiving hospice care. -However, review of Resident #83's EMR did not reveal the resident was receiving hospice services (see record review below). B. Record review A comprehensive review of the EMR failed to reveal a physician's order for hospice, progress notes of hospice services or care planned interventions of hospice services being provided. III. Staff interview The NHA was interviewed by email communication on 1/15/25 at 1:20 p.m. She said the hospice services coded for Resident #83 on the MDS assessment was incorrect and would be corrected. The minimum data set coordinator (MDSC) was interviewed on 1/16/25 at 2:15 p.m. The MDSC said she was responsible for completing the MDS assessments for the residents. The MDSC said she would assess a resident in their room and speak with staff about resident cares to complete the MDS assessment. The MDSC said she double checked the MDS assessment and read through alerts at the end prior to signing it. The MDSC said alerts could come from a new change on the MDS assessment that was different from the previous MDS assessment if it was available. She said if an alert came up, she could change the response at that time. The MSDC said the MDS assessment could be modified at any time if an error was found. The MDSC said Resident #83 was not on hospice services and that was coded in error. The MDSC said that the MDS assessment for Resident #83 had been corrected when it was brought to her attention (during the survey). The MDSC said she planned to slow down when reading through the alerts in the future to ensure that MDS assessments were coded correctly.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interviews, the facility failed to ensure two (#45 and and #95) of five residents who required respiratory care received the care consistent with professional standards of practice out of 53 sample residents. Specifically, the facility failed to: -Implement a routine cleaning schedule for the care of Resident #45's continuous positive airway pressure (CPAP) machine; -Ensure a care plan was in place and implemented for Resident #45's CPAP machine to include route of administration, oxygen supplementation, storage, cleaning and machine settings; and, -Ensure a functional continuous positive airway pressure (CPAP) machine was available, cleansed, stored, and maintained for Resident #45 and Resident #95. Findings include: I. Professional reference The Legionella Toolkit (12/26/24) retrieved on 1/22/25 from the Centers for Disease Control (CDC) https://www.cdc.gov/control-legionella/php/toolkit/control-toolkit.html. It read in pertinent part, In the absence of control, Legionella can grow in almost any system or equipment containing non sterile water, such as tap water, at temperatures favorable to Legionella growth. Devices that may grow Legionella in the absence of control include the following: dental and medical equipment such as scalers, CPAP, bronchoscopes, and heater-cooler units. Dental and medical equipment should be cleaned regularly per manufacturer recommendations and use distilled water in respiratory equipment such as CPAP machines, heater-cooler units, and bronchoscopes (page 8). II. Facility policy and procedure The CPAP policy, revised November 2021, was provided by the nursing home administrator (NHA) on 1/16/25 at 1:47 p.m. The policy read in pertinent part, A CPAP or BiPAP's purpose is to improve oxygenation, assist in reducing pulmonary edema, decrease the work of breathing and for use with residents who do not require assistance in maintaining adequate minute volume. Cleaning the CPAP and BiPAP machines: wash the mask daily in fragrance-free soap, mild and warm water or with designated sanitation wipes, then rinse in warm water and air dry. The frame of the mask should be cleaned weekly in warm soapy water or with a designated sanitation wipe. The CPAP/BiPAP humidifier uses distilled water only and should be emptied and refilled daily. The humidification chamber should be washed daily using mild soap and warm water and air dried. III. Resident #45 A. Resident status Resident #45, age greater than 65, was admitted on [DATE]. According to the January 2025 computerized physician orders (CPO), diagnoses included type 2 diabetes, chronic respiratory failure with hypoxia, chronic kidney disease stage 2 and dependence on supplemental oxygen. The 12/3/24 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 was dependent on assistance with transfers and bed mobility and needed substantial assistance with bathing. He needed set up help with upper body dressing and oral hygiene and was independent at meal time. The MDS assessment documented the resident used a non-invasive mechanical ventilator. B. Resident interview and observation Resident #45 was interviewed on 1/13/25 at 11:05 a.m. Resident #45 said his CPAP machine did not get cleaned at the facility and he used his CPAP every night. Resident #45 said he cleaned his own CPAP machine himself. Resident #45's CPAP mask and tubing were on his nightstand during the interview on 1/13/25. C. Record review A review of Resident #45's January 2025 CPO revealed a physician's order to apply the CPAP at bedtime for sleep with two liters of oxygen bled in, one time a day starting 4/23/23. A review of Resident #45's care plan documented he had altered respiratory status and difficulty breathing related to sleep apnea and had coronary heart failure. Pertinent interventions included the use of the CPAP machine as ordered. -However, further review of the resident's electronic medical record (EMR) revealed Resident #45 did not have a physician's order that included the storage of the machine and/or settings of the device. Additionally, review of the resident's EMR revealed Resident #45 did not have a physician's order for cleaning his CPAP machine. -The use of a CPAP machine was not on Resident #45's care plan as an active problem area, and the care plan did not have goals and interventions listed for the CPAP machine, to include route of administration, frequency, oxygen supplementation, storage and/or settings and a cleaning schedule. IV. Resident #95 A. Resident status Resident #95, age greater than 65, was admitted on [DATE] and readmitted on [DATE]. According to the January 2025 CPO, diagnoses included obstructive sleep apnea (OSA), primary pulmonary hypertension (high lung pressure) and chronic obstructive pulmonary disease (COPD). The 12/3/24 MDS assessment revealed the resident was cognitively intact with a BIMSscore of 15 out of 15. She required partial assistance with bed mobility. She was dependent on staff for toileting hygiene, lower body dressing, applying/removing footwear, transfers, and locomotion. The assessment indicated the resident used a non-invasive mechanical ventilator. B. Observations On 1/13/25 at 10:26 a.m. Resident #95's CPAP mask and tubing were hanging over the resident's bed rail. The CPAP mask was on the floor. On 1/14/25 at 9:39 a.m. Resident #95's CPAP mask and tubing were hanging over the resident's bed rail. The CPAP mask was on the floor with a floor fan on top of the mask's two straps. On 1/15/25 at 8:10 a.m. Resident #95's CPAP mask and tubing were hanging over the resident's bed rail. The CPAP mask was on the floor with a floor fan on top of one of the mask's straps. On 1/16/25 at 10:38 a.m. Resident 95's CPAP mask was stored in a plastic bag hanging on the resident's bed rail. C. Resident interviews Resident #95 was interviewed on 1/15/25 at 8:10 a.m. Resident #95 said she had not used her CPAP machine in two to three years. She said her CPAP machine was not functional and the power cord had been lost when she moved to a different room in the facility. She said the unit manager (UM) ordered a new power cord one month ago (December 2024) and she was still waiting for it to arrive. Resident #95 was interviewed on 1/15/25 at 9:05 a.m. Resident #95 said her CPAP mask and machine had not been cleaned since she moved in. Resident #95 was interviewed a second time on 1/16/25 at 10:38 a.m. Resident #95 said she contacted her service provider about the power cord for her CPAP machine and she was told they would provide an update at her next appointment. She said she did not use her CPAP machine the previous night (1/15/25) and she thought the UM stored it in a bag on 1/15/25 after he was looking at her machine. D. Record review A physician's order, dated 11/12/24, revealed staff should cleanse Resident #95's CPAP every night with provided cleansing wipes. A physician's order, dated 10/25/24, revealed staff should bleed in two liters of oxygen, then assist Resident #95 with her CPAP machine at bedtime for OSA. The respiratory care plan, initiated on 6/27/23 and revised on 11/4/24, revealed Resident #95 was at risk of respiratory distress due to COPD and OSA. It documented Resident #95 had a CPAP machine and often declined to use it. Interventions included a mask fitting, on 11/5/24, to promote CPAP compliance, administering medications/inhalers as ordered, cleansing and sanitizing Resident #95's CPAP machine with CPAP wipes as directed and monitoring for signs and symptoms of respiratory distress. A nurse progress note, dated 11/5/24 at 4:22 p.m., revealed Resident #95's provider was notified she was not using her CPAP machine due to mask fit. It documented a new mask was on order and should come soon. -Review of Resident #95's EMR failed to reveal documentation to indicate the facility had addressed the resident's non-functional CPAP machine or what interventions were put in place to repair/replace it. V. Staff interviews Registered nurse (RN) #1 was interviewed on 1/15/25 at 9:42 a.m. RN #1 said the night nurse was responsible for cleaning and storing the CPAP machines/masks for residents. She said she was unsure how CPAP masks should be stored or how often the tubing should be changed. She said she would find the answer by asking the facility's infection control nurse, respiratory therapist, and/or the UM. The respiratory vendor (RV) was interviewed on 1/15/25 at 10:18 a.m. The RV said the respiratory company provided respiratory equipment for residents' needs. He said he came weekly to the facility to service equipment and replace supplies per schedule or as needed. He said if a resident/family used their personal respiratory equipment, the company would service them upon request and bill whoever initiated the request. The RV said the CPAP mask and tubing should be changed every three months. He said the mask should be stored in a bag or a resident's top nightstand drawer. He said it was important to keep it off of the ground. He said the respiratory company recommended CPAP machine supplies to be cleansed daily. UM #1 was interviewed on 1/16/25 at 11:56 a.m. UM #1 said the night shift nurses were responsible for cleaning residents' CPAP masks daily. He said he needed to check the facility's policy and procedure to verify how often CPAP machines should be cleansed. He said CPAP masks should be stored in plastic bags hung at the resident's bedside and the tubing should be draped over the bed rail. He said he requested a power cord for Resident #95's CPAP machine the previous month (December 2024) during a meeting with her care provider. He said he had left multiple voicemails, without a response or update, and advised Resident #95 to ask her care provider for an update. He said he was unsure if the CPAP mask and tubing in the plastic bag at Resident #95's bedside were new. UM #1 said he would discard the mask and tubing at Resident #95's bedside and replace it. -On 11/16/25 at 12:20 p.m., UM #1 was observed in Resident #95's room. He discarded the CPAP mask and tubing at her bedside. He said he would replace supplies with those from the facility's stock and order additional supplies from Resident #95's care provider. The director of nursing (DON) was interviewed on 1/16/25 at 1:51 p.m. The DON said the night nurses were historically responsible for cleansing CPAP supplies, however, the facility had recently given the UMs the ability to adjust the time cleansing occurred. She said the facility bulk-ordered wipes specifically used to cleanse respiratory supplies. She said the cleansing/maintenance schedule and orders/machine settings were resident-specific, and should be documented in the resident's orders and care plan. The DON said she was not sure how often CPAP machines/masks should be cleansed and how often the tubing should be replaced. She said CPAP masks should be stored in a plastic bag hung at the resident's bedside or in a bag in the top drawer of the resident's nightstand. She said she was unaware Resident #95's CPAP machine was non-functional and did not know the length of time since it was last used. The DON said cardiac issues were a potential risk for a resident not using the CPAP machine as ordered and respiratory illnesses were a risk if CPAP masks/machines were not stored and cleansed correctly.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interviews, the facility failed to ensure that a consent and a safety bed rail evaluation was in place for one (#151) of five residents with bed rails out of 53 residents. Specifically, the facility failed to: -Ensure a signed consent was obtained from Resident #151 or the resident's representative prior to the initiation of side rails; -Ensure a physical therapy or occupational therapy (PT/OT) safety evaluation was conducted for Resident #151 prior to the use of half bed rails on a new bed; -Ensure the least restrictive alternatives were tried and documented prior to the use of half rails; and, -Ensure a physician's order was obtained for Resident #151 prior to the use of bed rails. Findings include: I. Professional reference According to the U. S. Food and Drug Administration (FDA) (2023), Recommendations for Health Care Providers Using Adult Portable Bed Rails, retrieved on 1/22/25 from https://www.fda.gov/medical-devices/adult-portable-bed-rail-safety/recommendations-health-care-providers-using-adult-portable-bed-rails, Avoid the routine use of adult bed rails without first conducting an individual patient or resident assessment. Evaluation is needed to assess the relative risk of using the bed rail compared with not using it for an individual patient. II. Facility policy and procedure The Physical Restraint policy and procedure, revised December 2019, was provided by the nursing home administrator (NHA) on 1/16/25 at 3:12 p.m. It read in pertinent part, Physical restraint is any manual method, or physical or mechanical device, material or equipment attached or adjacent to the resident's body that the resident can not easily remove and that restricts freedom of movement or normal access to his/her body part. Does a resident have a device that can be considered a restraint? If yes, complete a physical restraint evaluation form, complete the physical restraint elimination usage form if the resident is a candidate for restraint reduction, elimination or usage. Physical therapy/Occupational therapy (PT/OT) consultation for least restrictive physical restraint. Obtain physician's order for restraint including medical symptoms for restraint usage, type of restraint, time of use and duration. Discuss restraint alternatives, risks and benefits with resident or legal representative upon initiation and annually. Complete physical restraint evaluation upon initial use and quarterly or with significant change. Document on care plan. III. Resident #151 A. Resident status Resident #151, age less than 65, was admitted on [DATE]. According to the January 2025 computerized physician orders (CPO), diagnoses included quadriplegia (paralysis of all four limbs) and pressure ulcers. The 10/14/24 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. He was dependent on staff with toileting, personal hygiene, bed mobility, transfers and required substantial/maximal assistance with eating. The assessment indicated physical restraints, including bed rails were not used. B. Observations and resident interview On 1/13/25 at 2:29 p.m. Resident #151 was lying in bed with two half rails in the up position on the bed. On 1/15/25 at 3:04 p.m. Resident #151 was lying in bed with two half rails in the up position on the bed. On 1/16/25 at 9:22 a.m. Resident #151 was lying in bed with two half rails in the up position on the bed. Resident #151 was interviewed on 1/16/25 at 9:23 a.m. Resident #151 said the nursing staff used the half rails when they were doing wound care in the mornings to prevent him from rolling out and put them down after they were done using them. He said he was able to use the controls on the bed rails to put his head up and down. He said he was not mobile enough to be able to get trapped between the bed rails and the bed. C. Record review The January 2025 CPO revealed a physician's order to put opposite rail for legs up when turning resident in bed and have two people to do any care that required turning in bed, ordered 10/10/24. -However, the physician's order did not indicate that the resident's bed rails were to be in the up position when staff was not repositioning the resident. The 10/30/24 nursing physical restraint evaluation identified the use of half rails needed for positioning and to promote independence. It documented the side rails were not a restraint because the resident was paralyzed. It documented the use of half rails was requested by nursing staff and the resident. -However, Resident #151 was totally dependent on staff for bed mobility and therefore was unable to use the bed rails independently. -However, the evaluation failed to document if a PT/OT screening had been done for the bed rails to assess for safety. The 10/30/24 nursing physical restraint elimination/usage evaluation documented a score of 19 out of 20, which indicated the potential elimination of the restraint and to attempt alternatives for restraint. -However, a comprehensive review of the nursing physical restraint elimination evaluation and Resident #151's electronic medical record (EMR) did not document that potential alternatives to the bed rails had been attempted by the facility or that discussion had taken place regarding the potential elimination of the side rails. The activities of daily living (ADL) care plan, initiated on 10/7/24, indicated Resident #151 was dependent with bed mobility. Interventions included using bed canes to promote independence for repositioning and turning in bed. -However, Resident #151 was totally dependent on staff for bed mobility and therefore was unable to use the bed rails independently. -A comprehensive review of the care plan failed to reveal documentation of the use of bed rails or other least restrictive alternatives. A comprehensive review of Resident #151's EMR failed to reveal documentation of a signed consent, a physical restraint evaluation, a physical restraint elimination evaluation, a PT/OT safety screening or a physician's order prior to the implementation of a new bed and initiation of the half side rails. IV. Staff interviews Licensed practical nurse (LPN) #3 was interviewed on 1/16/25 at 9:30 a.m. LPN #3 said bed rails were a physical restraint and should have an evaluation for risk versus benefit. He said the bed rails should be assessed for proper functioning. He said prior to initiating any physical restraint, a consent needed to be obtained and a physician's order. He said Resident #151 had side rails to help prevent falls out of bed during repositioning. He said Resident #151 also used side rails for safety because he had seizures. -However, there was no documentation in Resident #151's EMR to indicate the resident used the bed rails due to seizures. The NHA was interviewed on 1/15/25 at 3:00 p.m. The NHA said Resident #151 should not have half bed rails up on his bed. She said the bed he was using should have the bed rails zip locked down to prevent their use. She said she was not aware that bed rails were being used for Resident #151. Unit manager (UM) #2 was interviewed on 1/16/25 at 10:20 a.m. UM #2 said she was new to the physical restraint evaluation process. She said before bed rails were used, nursing staff should evaluate the need for them, obtain a consent and a physician's order. She said the nursing staff obtained a consent for the use of Resident #151's bed rails on 1/15/25 (during the survey) on the new bed from the resident. She said Resident #151 had been on a different bed with a dolphin mattress (a pressure redistribution specialty air mattress used to treat pressure wounds) and had recently switched to the current hospital type bed with the half bed rails. She said nursing staff used the bed rails to help with repositioning the resident. She said the resident was able to use the control on the bed rails himself. The director of nursing (DON) was interviewed on 1/16/25 at 3:00 p.m. The DON said that any potential restraint should be assessed to determine if it was a true restraint. She said PT/OT was involved in evaluating bed rails. She said there was a restraint assessment done when Resident #151 was admitted to the facility for his bed rails on the old bed. The DON said therapy had determined there was no benefit to having the side rails up and Resident #151 had agreed to having the side rails zip locked down so they could not be used. The DON said there were other things the facility could try for repositioning the resident, including bolsters, that were not bed rails. She said Resident #151's old bed had a dolphin mattress which he did not like. She said it was discovered, during survey, that Resident #151 had arranged for a new bed from the veterans administration (VA) and had it delivered to the facility. She said she and the NHA had not been aware Resident #151 had a new bed delivered and had been using it since approximately November 2024 or December 2024. The DON said therapy had done an evaluation on the new bed for the bed rails, after it was brought to their attention, during the survey. She said it was not a practice of the facility to use bed rails. She said medical equipment, such as hospital beds, should not be brought into the facility and used by staff and residents without notifying the DON and the NHA.

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 in one of five dining rooms. Specifically, the facility failed to ensure residents who were prescribed mechanically altered diets had food prepared according to the resident's diet orders of mechanical soft as indicated on their meal tray cards. Findings include: I. Facility policy and procedure The Therapeutic Diet Orders policy, undated, was provided by the nursing home administrator (NHA) on 1/16/25 at 4:55 p.m. It read in pertinent part, The facility provides all residents with foods in the appropriate form and/or the appropriate nutritive content as prescribed by a physician, and/or assessed by the interdisciplinary team to support the resident's treatment/plan of care, in accordance with his/her goals and preferences. A mechanically altered diet is one in which the texture or consistency of food is altered to facilitate oral intake. Examples include soft solids, pureed foods, ground meat, and thickened liquids. Therapeutic diets, including mechanically altered diets where appropriate, will be based on the resident's individual needs as determined by the resident's assessment. Therapeutic diets may be considered in certain situations, such as, but not limited to: inadequate nutrition, nutritional deficits, weight loss, medical conditions such as diabetes, renal disease, or heart disease and swallowing difficulty. Dietary and nursing staff are responsible for providing therapeutic diets in the appropriate form and/or the appropriate nutritive content as prescribed. II. Meal service observations Meal Service was continuously observed on 1/15/25 from 4:30 p.m. to 6:00 p.m. The posted menu documented the dinner meal as quiche, zucchini and onions, oven roasted potatoes, an apple cinnamon muffin and a fruit cup. At 5:20 p.m. meal tray assembly started for the long hall. A meal ticket indicated a resident was prescribed a mechanical soft diet order. The plate was assembled with a soft shell taco and ground beef, zucchini and potato wedges. The potato wedges served had skin on the potato. The meal tray was placed in the room delivery cart for service. At 5:45 p.m. a meal was assembled for a resident who's meal ticketed documented a mechanical soft diet. Written on the meal ticket was soft taco and sides. The plate was assembled with a soft shell taco and ground beef and potatoes wedges. The potato wedges served had skin on the potato and the plate was delivered to the resident in the dining room. -However, according to the diet manual description (see below) potato skins were restricted for residents prescribed a mechanically alerted diet. Both plates contained potatoes with the skin on the potatoes. At 5:52 p.m. the human resources director (HRD), who was the previous dietary manager was notified the oven roasted potatoes contained skins and were served to residents on a mechanical soft diet. The HRD said residents on mechanical soft diets should not have potato skins. III. Record review The fall/winter 2024-2025 diet spreadsheets were provided by the NHA on 1/13/25 at 1:00 p.m. The spreadsheet for dinner on 1/15/25 documented oven roasted potatoes could be served to a resident on a mechanical soft diet. -However, according to the diet manual description (see below) potato skins were restricted for residents prescribed a mechanically alerted diet. Both plates contained potatoes with the skin on the potatoes. The Dysphagia Mechanically Altered Diet Consistency Alteration Diet Manual , undated, was provided by the NHA on 1/16/25 at 1:30 p.m. It read in pertinent part, Avoid dry tough meats, or any other whole pieces of meat, cheese slices or cues, peanut butter sandwiches or pizza, potato chips, skins, fried or french fried potatoes. Please pay close attention to the menu extensions provided. Be sure that all planned foods are prepared. It is imperative to post a copy of the current day's menu extension on the tray line for easy reference during meal service. (page 71). The recipe for red fresh oven roasted potatoes, dated 11/7/23, was provided by the NHA on 1/16/25 at 1:30 p.m. The recipe instructions documented the following production steps: 1. Cut the red potatoes into quarters and steam or boil until tender. Drain off the excess liquid. 2. Melt the margarine with garlic and salt and toss the potatoes with seasoned margarine. Bake in the oven at 400 degrees fahrenheit (F) for 35 to 40 minutes or until lightly browned and tender. Hold or serve hot food at or above 135 degrees F. -The recipe did not include any further instructions on how to modify red fresh oven roasted potatoes for mechanically altered diets. IV. Staff interviews The HRD was interviewed on 1/15/25 at 5:56 p.m. The HRD said she was not sure what happened but the potatoes sent and served to the other dining rooms in the building all had potatoes without skins. She said she brought the potatoes without skins to the first floor dining room for service and removed the roasted potatoes with skin from the steam table. The dietary manager (DM) and the NHA were interviewed together on 1/16/25 at 11:30 a.m. The DM said the speech therapy department reviewed food items the residents could or could not have. The NHA said she spoke to the speech therapist for the facility. The NHA said she asked the speech therapist if they had reviewed the recipe for the oven roasted potatoes, and the speech therapist replied to the NHA that residents on a mechanical soft diet could have potato skins. The NHA said she requested a resource from the speech therapist that indicated a resident on a mechanical soft diet was able to have potato skins. -However according to the facility's diet manual (see above) potato skins were restricted from the mechanical soft diet.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to maintain accurately documented medical records for one (#114) of four residents out of 53 sample residents. Specifically, the facility failed to ensure Resident #114's wound orders and treatment records were accurate. Findings include: I. Facility policy and procedure The Documentation of Medical Record policy, undated, was provided by the nursing home administrator (NHA) on 1/16/25 at 4:30 p.m. It read in pertinent part, Licensed staff and interdisciplinary team members shall document all assessments, observations and services provided in the resident's medical record in accordance with state law and facility policy. Documentation may be performed manually or as per the facility's specific electronic medical record software program. Principles of documentation include but are not limited to: Documentation shall be factual, objective and resident centered; documentation shall be accurate, relevant and complete, containing sufficient details about the residents' care and/or responses to care; documentation shall be timely and in chronological order. Record date and time of entry. When documentation occurs after the fact, outside of acceptable time limits, the entry shall be clearly indicated as' late entry.' Corrections to a medical record shall be made to clarify inaccurate information. Contradictory information may be clarified by a new entry in the medical record. II. Resident status Resident #114, age greater than 65, was admitted on [DATE]. According to the January 2025 computerized physician orders (CPO), diagnoses included post surgical aftercare of the skin and subcutaneous tissue and multiple pressure ulcers. The 11/18/24 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. He was dependent on total assistance from staff for toileting hygiene and lower body dressing, needed substantial assistance with bed mobility and bathing, supervision with personal hygiene and set up help only for eating. The MDS assessment documented the resident had one or more pressure ulcers. III. Record review A review of Resident #114's electronic medical record (EMR) revealed the following: A 12/11/24 admission nursing data collection documented in the skin assessment section documented to See wound note. A corresponding note in the resident's EMR documented a skin assessment was completed by the wound nurse, see wound note. -However a skin/wound was not documented until 12/17/24 (see below). A skin/wound note documented on 12/17/24 revealed wound assessments were completed for Resident #114 on 12/13/24, upon admission. The note documented a right upper buttock unstageable pressure injury. A skin/wound note documented on 12/19/24 revealed a left buttock unstageable pressure injury (corrected from previously documented right buttock). A review of Resident #114's treatment administration record (TAR) revealed treatment orders for a right upper buttock pressure ulcer started 12/12/24 and discontinued 1/13/25. The treatment administration record documented treatment was administered or attempted to be administered as ordered on the right buttock during this time. -However, the facility failed to update Resident #114's wound treatment orders until 1/13/25 (during the survey) to indicate Resident #114 had a left buttock wound instead of a right buttock wound. Resident #114's admission wound location chart was provided by the NHA on 1/14/25 at 1:38 p.m. The wound location chart documented Resident #114 had a wound on his right buttock and no wound on his left buttock. The wound location chart was not dated. -However, the resident's wound was on his left buttock (see interview below). IV. Staff interviews The director of nursing (DON) was interviewed on 1/16/25. The DON said she talked to the two nurses who primarily performed Resident #114's wound treatments. The DON said both nurses knew Resident #114's wound was on his left buttock and not his right buttock. The DON said the nurses did not recognize Resident #114's wound treatment orders were incorrect. The DON said she did provide education to the assistant director of nursing (during the survey) on correct wound documentation in the resident's EMR.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to ensure six (#98, #16, #127, #106, #116 and #67) of 33 residents reviewed for abuse out of 53 sample residents were free from abuse. Specifically, the facility failed to: -Prevent resident to resident physical abuse between Resident #98 and Resident #16, who had a history of physically and verbally aggressive behaviors towards other residents and staff; -Protect Resident #67 from physical abuse from Resident #127; -Protect Resident #106 from physical abuse from Resident #127; and, -Prevent a resident to resident physical abuse altercation between Resident #116 and Resident #127. Findings include: I. Facility policy and procedure The Abuse Prevention policy and procedure, revised 12/17/18, was provided by the nursing home administrator (NHA) on 1/13/25 at 1:10 p.m. It read in pertinent part, Residents will not be subjected to abuse by anyone including, but not limited to, facility staff, other residents, consultants or volunteers, staff or other agencies servicing the resident, family members or legal guardians, friends or other individuals. Physical abuse is not limited to hitting, slapping, punching and kicking. Assess, care plan and monitor residents exhibiting needs and behaviors that predispose them to have conflict with others or to subject them to neglect by staff (such as residents with history of aggressive behaviors; residents who enter other residents' rooms, residents with self injury behaviors; residents with communication disorders; resident requiring extensive or total nursing care). II. Incident of physical abuse between Resident #98 and Resident #16 on 1/6/25 A. Facility investigation The 1/6/25 abuse investigation documented a witnessed resident-to-resident physical altercation between Resident #98 and Resident #16. The staff observed Resident #98 entering the third floor dining room and Resident #16 exiting the third floor dining room. Their wheelchairs bumped together when passing each other. Resident #98 reached over and slapped Resident #16 in the face. The staff separated the two residents. Resident #16 said that Resident #98 had slapped him. Resident #98 denied slapping Resident #16 and said Resident #16 had yelled at him. Resident #98 said he had slapped Resident #16 a long time ago because Resident #16 had made him angry. The investigation indicated the two residents were separated and placed on 15-minute checks. The on-duty nurse performed skin and pain assessments on both residents and neurological checks were initiated for Resident #16. It indicated that Resident #16 had denied pain or being afraid of Resident #98. The facility investigation unsubstantiated the allegation of physical abuse at the conclusion of the investigation due to Resident #98's poor impulse control and therefore the slap was unintentional and there was no observed pain, injury or animosity from either Resident #98 or Resident #16. -However, abuse occurred as Resident #98 slapped Resident #16. B. Resident #98 - assailant 1. Resident status Resident #98, age less than 65, was admitted on [DATE]. According to the January 2025 computerized physician orders (CPO), diagnoses included traumatic brain injury (TBI) and dementia. The 11/25/24 minimum data set (MDS) assessment revealed the resident had moderate cognitive impairment with a brief interview for mental status score (BIMS) of ten out of 15. He was dependent with toileting, personal hygiene, bed mobility, transfers and required substantial/maximal assistance with eating. The assessment indicated the resident exhibited verbal behaviors towards others. The assessment did not indicate the resident exhibited physical behaviors towards others. 2. Resident observation and interview On 1/13/25 at 10:00 a.m. Resident #98 declined to be interviewed with difficult to understand speech. On 1/13/25 at 1:04 p.m. Resident #98 was sitting at a table in the dining room. He was sitting alone at a table, feeding himself and cursing, which was not directed to anyone. 3. Record review The behavior care plan, initiated 5/18/21 and revised 11/12/24, indicated Resident #98 had behaviors of being physically and verbally combative with staff, invading other residents' personal space, taking food off of other residents' plates, inappropriate behaviors toward females and poor impulse control related to his TBI. Interventions included trying different activities to increase resident engagement, initiating a behavior chart and reward program, offering to take Resident #98 to his room if his behavior was agitating other residents, encouraging the resident to develop more appropriate methods of coping and interacting, reviewing diet regimen to address his food seeking behaviors and intervening as necessary to protect the rights and safety of others. The 8/13/24 resident to resident physical altercation care plan, initiated 9/5/24, documented a female resident had reported that Resident #98 had hit her. Interventions included separating residents and initiating 15-minute checks with one-to-one support given until calm, moving resident to another floor for decreased stimulation and calmer environment with more activity involvement, following up with behavioral health services, reviewing bowel and pain regimen evaluating for neurology follow up, ruling out a medical cause, during checks noting location, environment and people surrounding him remove him from a highly stimulated, loud or crowded area and assisting as needed. The 1/6/25 resident to resident physical altercation care plan, initiated 1/6/25, indicated that Resident #98 had a resident to resident physical altercation while he was trying to enter the dining area and another resident was exiting the dining area when their wheelchairs bumped. Interventions included separating residents and initiating 15-minute checks, adding a pureed snack at 10:00 a.m. and increasing portions to double portions to reduce behavior of seeking other residents left over food in the dining area, placing a sign at the end of the steam table for staff not to park the hot food holding tower in the dining room entry to prevent resident collisions and reviewing resident mood and behavior with the psych interdisciplinary team (IDT). The facility daily behavior monitoring, from 9/14/24 to 1/14/25, documented Resident #98's physically aggressive behaviors including kicking/hitting, grabbing and pinching/scratching/spitting on 9/23/24, 10/31/24, 11/23/24, 11/24/24, 12/20/24, 12/30/24, 1/5/25, 1/6/25, 1/12/25 and 1/14/25. The 8/31/24 nursing progress note documented Resident #98 and another resident were found with wheelchair wheels entangled in the entrance way of the dining room. The other resident stated that they had been hit by Resident #98. The residents were separated and 15-minute checks were initiated. The 9/11/24 nursing progress note documented Resident #98 was swearing at the nurse on two separate occasions because he was upset that the nurse was not listening to him. The 9/12/24 social services progress note documented Resident #98 could be verbally and physically abusive toward others and that Resident #98 had a recent altercation with another resident. Resident #98 had been moved to another floor which was smaller with more activity involvement. The 12/16/24 behavior progress note documented Resident #98 had been yelling, wandering and exit seeking during the shift. The 12/25/24 behavior progress note documented Resident #98 had been yelling and cursing at staff and other residents. He was assisted out of the dining room and started to attempt to make himself vomit. The 12/25/24 behavior progress note documented Resident #98 was swearing at staff during bedtime care. Resident #98 was also swearing and trying to strike staff when he was in the middle of the hallway and staff asked him to move. The 12/31/24 behavior progress note documented Resident #98 became verbally aggressive with staff when asked to move his wheelchair and kicked staff in the shin twice. He was observed later to be verbally aggressive toward another resident and backed up his wheelchair into the other resident's wheelchair. The 1/3/25 behavior progress note documented Resident #98 attempted to hit staff when he was assisted with bedtime care. The 1/5/25 behavior progress note documented Resident #98 started eating food off of other residents' plates. A certified nurse aide (CNA) attempted to redirect the resident and he kicked her in the shin and spit food out at her. The 1/6/25 nurse progress note documented Resident #98 passed another resident and Resident #98 reached up and slapped them. Resident #98 denied slapping the other resident and said the other resident had yelled at him. He then said he had slapped the other resident a long time ago because he had made him angry. The 1/13/25 social services progress note documented the social worker spoke to Resident #98 regarding the physical altercation with another resident. Resident #98 was asked not to target or approach the other resident and not have any negative interactions with the other resident. C. Resident #16 1. Resident status Resident #16, age [AGE], was admitted on [DATE]. According to the January 2025 CPO, diagnoses included dementia and post traumatic stress disorder (PTSD). The 10/29/24 MDS assessment revealed the resident had severe cognitive impairments with deficits in short and long term memory per staff assessment. He was dependent with toileting, substantial/maximal assistance with personal hygiene, transfers, partial/moderate assistance with bed mobility and set up assistance with eating. The assessment indicated the resident exhibited physical and verbal behaviors towards others. 2. Record review The post traumatic stress disorder (PTSD) care plan, initiated 7/26/24 and revised 9/24/24, documented Resident #16 had a history of PTSD related to his experiences and being wounded as a [NAME] in the Vietnam war. It indicated his triggers might be from lights at night or flood lights. Interventions included administering medications as ordered, encouraging responsible party in plan of care, facilitation referrals to community resources, monitoring resident mood and behaviors. The 12/17/24 resident to resident physical altercation care plan, initiated 12/17/24, documented Resident #16 was a victim in a resident to resident altercation. Resident #16 was being held by the wrist by another resident while the other resident was swinging a hat hitting him in his left shoulder. Interventions included assessing the resident head to toe and keeping the resident in line of sight. The 1/6/25 resident to resident physical altercation care plan, initiated 1/6/25, documented Resident #16 was slapped by another resident when their wheelchairs bumped into each other at the entrance of the dining room. Interventions included placing residents on monitoring, separating and assessing residents every 15 minutes and decongesting the entrance to the dining room. -A review of Resident #16's comprehensive care plan did not reveal personalized interventions to prevent further abuse from aggression by other residents. The 1/6/25 nursing progress note documented Resident #16 was slapped by Resident #98 while they were passing each other in the entry of the dining room. Redness was noted on the left side of his face but he denied pain or being fearful. D. Staff interviews CNA #6 was interviewed on 1/15/25 at 10:27 a.m. CNA #6 said Resident #98 would lash out towards others when he was unable to articulate or make his needs known. He said Resident #98 could get verbally and physically aggressive at times. He said Resident #16 also had difficulties communicating. He said since the recent resident to resident altercation between Resident #98 and Resident #16, Resident #16 did not seem comfortable around Resident #98. He said both residents used to get along but now Resident #16 seemed to want nothing to do with Resident #98. He said when Resident #16 saw Resident #98 he would often shake his finger at Resident #98 and say you, you. He said staff would keep Resident #98 and Resident #16 apart, especially during meals and sat them at different tables. Licensed practical nurse (LPN) #3 was interviewed on 1/16/25 at 9:30 a.m. LPN #3 said Resident #98 was very attention seeking. He said he was not aware of any recent resident to resident physical altercations but Resident #98 was on 15-minute checks for his behaviors and would be summarized and documented in the medical record as a behavior note for each shift. He said Resident #98 did have a previous resident to resident physical altercation on another floor and had been moved to the current floor because of behaviors with another resident. He said if Resident #98 was unable to communicate he would lash out. He said he was unaware of any special interventions that were in place from a recent alteration with another resident. He said when there was a resident to resident physical altercation, staff would immediately separate the residents, placed them on 15-minute monitoring, notified administration and the police. Unit manager (UM) #2 was interviewed on 1/16/25 at 10:20 a.m. UM #2 said Resident #98 had a history of a TBI and had a speech impediment and difficulty in communicating. She said he was originally on another floor and had been moved to the current floor because of behavior issues with others. She said the current floor was a calmer environment for him. She said Resident #98 had a recent physical altercation with Resident #16. She said Resident #98 had reached over and slapped Resident #16 in the face when their wheelchairs bumped at the entrance of the dining room. She said Resident #98 was very impulsive. She said the staff discussed his behaviors once a week in IDT. She said Resident #16 had reacted to Resident #98 by calling out and Resident #98 had come to her office and been upset by this. She said Resident #98 had been told by staff that Resident #16 called out and not to take it personally. She said Resident #98 had been on 15-minute checks continuously for his behaviors. She said the staff had tried to decongest the entry of the dining room to prevent this from happening again. The director of nursing (DON) and the NHA were interviewed together on 1/16/25 at 1:51 p.m. The DON said Resident #98 had a long history of behaviors and physical aggression towards others. She said Resident #98 had been on another floor and had been moved to the current floor for less stimulation. The DON said there had been multiple referrals for Resident #98 for more appropriate placement, including a TBI center. She said Resident #98 was also being followed by psychiatric staff. The DON said both Resident #98 and Resident #16 had their ups and downs. She said both residents had a tendency to call out. She said Resident #98's behavior had improved while on the current floor. She said Resident #98's behaviors seemed to have escalated over the holidays. The DON said the nursing staff notified the provider, obtained a urinalysis, reviewed his chart, checked his bowel and bladder program, limited his caffeinated beverages, reviewed his medications, reviewed his pain levels, obtained a neurology referral and reviewed his diet. The DON said the nursing staff were still trying to regiment Resident #98's day and were looking into a behavioral reward system. The DON said she was not aware of any behavior changes or ongoing tension between Resident #98 and Resident #16 since the altercation. She said CNA #6 worked with Resident #98 and Resident #16 consistently and knew the residents well. She said if CNA #6 had identified there was a behavior change by Resident #16 towards Resident #98 after the physical altercation, he would know. She said if Resident #16 was no longer comfortable around Resident #98 and no longer wanting to interact with Resident #98 since the altercation, that would substantiate the allegation of physical abuse. She said she would do further research into the behavior changes between the two residents.III. Incident of physical abuse between Resident #67 and Resident #127 on 9/23/24 A. Facility investigation The 9/23/24 facility investigation documented Resident #67 was in the dining room yelling obscenities at staff members who were around the corner. Resident #127 became agitated from the obscenities and struck Resident #67. It documented Resident #67 then swung his arms trying to hit Resident #127 back before the staff could intervene. Resident #67 sustained a skin laceration above his right eyebrow, which was treated with normal saline and steri-strips. The investigation documented the residents were separated, staff and residents were interviewed, the resident's care plans were reviewed, and pain/medication reviews were conducted. Fifteen minute checks were initiated and behavioral health services were contacted. Resident #67 was interviewed and said he went to the table that Resident #127 was sitting at and asked him for help opening something. He said Resident #127 initially agreed, but then got mad and hit Resident #67 across the face. He said he hit Resident #127 back three times, but not as hard as Resident #127 hit him. Resident #67 said he felt safe as long as Resident #127 was not around. Resident #127 was interviewed and said Resident #67 was yelling at staff members then came after him. He said he told Resident #67 to stop, which made Resident #67 mad. Resident #127 said he did not physically touch or throw objects near Resident #67. Resident #127 was unable to complete the interview. The investigation documented Resident #127 appeared overstimulated by the environment and kept looking around worried. The investigation documented the staff witnessed Resident #67 and Resident #127 physically fighting each other. Resident #67 was in the dining room angry about his coffee, and started screaming obscenities. The staff member passed him and went into the kitchen. It documented the staff member heard a commotion and witnessed Resident #67 throwing a glass of juice and Resident #127 standing next to him with his right fist drawn back. It documented Resident #127 stated Resident #67 went after him for no reason, and Resident #67 should not be allowed to talk that way. The investigation documented Resident #67 was sent to the hospital days after the altercation due to low oxygen levels and lethargy. It documented a CT scan of the head and cervical spine and a chest x-ray were conducted, all negative for any findings. The results of the investigation documented that abuse was unsubstantiated as both elements of physical abuse were not met. It documented that even though Resident #67 obtained a skin tear, there was a lack of evidence proving Resident #127 intended to harm Resident #67 instead of Resident #127 reacting negatively after becoming overstimulated. Additionally, the conclusion documented although Resident #67 obtained a laceration to his eyebrow, no serious bodily injury occurred. -However, Resident #67 and Resident #127 were witnessed fighting each other and Resident #67 said he was hit by Resident #127. B. Resident #67 - victim 1. Resident status Resident #67, age [AGE], was admitted on [DATE]. According to the January 2025 CPO, diagnoses included Alzheimer's disease with late onset, unspecified dementia with other behavioral disturbance, anxiety disorder and moderate and recurrent major depressive disorder. The 11/20/24 MDS assessment revealed the resident was cognitively impaired with a BIMS score of three out of 15. He required substantial assistance with toileting/personal hygiene and dressing. He was dependent on staff for transfers and locomotion via wheelchair. The assessment indicated the resident exhibited wandering behavior. 2. Record review A behavior care plan, initiated on 5/24/24 and revised on 1/13/25, revealed Resident #67 could be verbally and physically aggressive towards others related to his diagnosis of dementia The resident had a history of delusions and hallucinations. It documented Resident #67 had previously thrown things, wandered into other resident's rooms, made inappropriate sexual comments to others and made inappropriate jokes about being mad at or harming others. Interventions included scheduling pain medication, increasing supervision of Resident #67 through various methods, assessing for verbal and non-verbal signs of pain and offering Resident #67 tasks/activities that focused his attention. A behavioral symptoms care plan, initiated on 9/24/24, revealed Resident #67 could affect others by directing negative physical and verbal behaviors towards them. Interventions included assessing for physiological causes of aggressive behavior, a pain regimen review, providing redirection and/or one-to-one supervision as needed and intervening when Resident #67 exhibited negative behaviors towards others. A nurse progress note, dated 9/23/24 at 6:55 p.m., revealed Resident #67 was in the dining room angry about his coffee when he started screaming obscenities. It documented the nurse heard a commotion and observed Resident #67 throwing a cup of juice. It documented Resident #127 was standing next to Resident #67 with his right fist drawn back. It documented Resident #67 sustained a one and a half centimeter (cm) laceration above his right eyebrow. It documented the laceration was cleansed with normal saline and steri-strips were applied. It documented Resident #67's provider and power of attorney (POA) were notified. C. Resident #127 - assailant 1. Resident status Resident #127, age [AGE], was admitted on [DATE]. According to the January 2025 CPO, diagnoses included Alzheimer's disease, delusional disorders, post-traumatic stress disorder (PTSD), and mild dementia , in other diseases, with other behavioral disturbance. The 12/26/24 MDS assessment revealed the resident was cognitively impaired with a BIMS score of six out of 15. He required supervision with ambulation, transfers, and personal hygiene. He required substantial assistance with toileting hygiene and showering. He experienced hallucinations and delusions. The MDS assessment indicated the resident had symptoms of negative physical and verbal behaviors towards others, and negative behaviors not directed towards others. 2. Record review An altercation care plan, initiated on 9/24/24, revealed Resident #127 was involved in a resident to resident altercation on 9/23/24. It documented Resident #127 could be triggered by overstimulation and direct negative physical and verbal behaviors towards others. Interventions included encouraging a low stimulation dining location, assessing for physiological causes of aggression and providing redirection and/or one to one supervision as needed. The behavior care plan, initiated on 11/4/23 and revised on 1/6/25, revealed Resident #127 was physically and verbally aggressive related to his dementia with paranoia, delusion and PTSD. It documented Resident #127 became overstimulated at times and would strike out at others who made noises or touched him. Interventions included providing a calm environment, administering medications as ordered, keeping the resident near a staff member when at group activities to redirect if he had increased agitation, analyzing triggers and what deescalated the resident's behavior and staff to intervene before the agitation escalated. A nurse progress note, dated 9/23/24 at 7:11 p.m., revealed the nurse overheard Resident #67 scream an obscenity. The nurse entered the dining room and saw Resident #127 standing next to Resident #67 with his right hand raised. It documented Resident #127 said Resident #67 should not be allowed to talk that way. It documented Resident #67 sustained a laceration. It documented Resident #127 sustained no injuries, and his provider and POA were notified. IV. Incident of physical abuse between Resident #106 and Resident #127 on 12/20/24 A. Facility investigation The 12/20/24 facility investigation documented screaming was heard from Resident #127's room. When the staff approached, Resident #106 was on the floor facing into Resident #127's room, indicating she wandered in. It documented Resident #127 was standing over Resident #106. Resident #106 was attempting to kick Resident #127, however no contact was made. The investigation documented no injuries were observed on either resident. The investigation documented the residents were separated, the staff and residents involved were interviewed, and the resident's care plans were reviewed. Fifteen minute checks were initiated and a stop sign was placed on the outside of Resident #127's room to deter wandering residents from entering. The investigation documented laboratory (lab) work was requested for Resident #127. -Stop sign was in place, but was not hung up due to Resident #127 being under one-to-one supervision. His door was closed to deter other residents from entering his room. Resident #106 was interviewed and talked nonsensically when asked about the altercation. She was unable to verbalize the events and she appeared angry. Resident #127 was interviewed and said Resident #106 went into his room. Resident #127 said she did all the time. He said she was not allowed to be in there and she got in his face. He said he went to close his room door and pushed Resident #106 to the ground. -The investigation documented Resident #127 had previously been physically aggressive towards others if he felt they were invading his space and his room door was closed when Resident #106 entered. The results of the investigation documented that abuse was unsubstantiated as it did not meet all of the requirements elements of abuse criteria, even though there was evidence of intent to harm. It documented neither resident sustained physical injuries, reported any pain, or exhibited signs and symptoms of fear or emotional distress. -However, Resident #127 said he pushed #106 and Resident #106 was found lying on the floor attempting to kick Resident #127. B. Resident #106 - victim 1. Resident status Resident #106, age [AGE], was admitted on [DATE]. According to the January 2025 CPO, diagnoses included dementia in other diseases, severity unspecified, with agitation, anxiety disorder and recurrent major depressive disorder. The 12/6/24 MDS assessment revealed the resident was cognitively impaired with a BIMS score of three out of 15. She was independent with eating, ambulating and transfers. The assessment exhibited wandering behavior. 2. Record review An altercation care plan, initiated on 12/20/24 and revised on 12/26/24, revealed Resident #106 was involved in a resident to resident altercation on 12/20/24. She went into another resident's room, which agitated him, and prompted him to push Resident #106 to the ground. Interventions included one-on-one supervision, conducting an activity review and implementing personalized activities and removing the resident to a calm/safe environment to de-escalate as necessary. A behavior care plan, initiated on 1/22/22 and revised on 8/1/24, revealed Resident #106 would often attempt to offer unsolicited help to other residents, and would lean in close to them if they did not respond to her. Interventions included redirecting residents behavior, administering medications as ordered and offering activities that diverted her attention. A nurse progress note, dated 12/20/24 at 2:03 p.m., revealed screaming was heard from Resident #127's room. It documented when the nurse approached, Resident #106 was lying on the floor attempting to kick Resident #127, who was standing over her. It documented Resident #106 was temporarily removed from the unit to calm down, 15-minute checks were initiated on Resident #106. The provider and her POA were notified. C. Resident #127 - assailant 1. Record review An altercation care plan, initiated on 12/20/24 and revised on 12/30/24, revealed Resident #127 had territorial behaviors related to dementia and PTSD and would become aggressive towards others if he felt they were invading his space. Interventions included placing a stop sign and door alarm on Resident #127's door, lab work, administering medications as ordered and intervening as necessary to protect the safety of others. A nurse progress note, dated 12/20/24 at 1:41 p.m., revealed the nurse heard screaming from Resident #127's room and found him standing over Resident #106. It documented Resident #106 appeared to have entered Resident #127's room and she was lying on the floor attempting to kick Resident #127. It documented both residents were immediately separated and 15-minute checks were initiated on Resident #127. It documented Resident #127's provider was notified and lab work was ordered. It documented a voicemail was left for Resident #127's power of attorney. III. Incident of physical abuse between Resident #116 and Resident #127 on 1/3/25 A. Facility investigation The 1/3/25 facility investigation documented Resident #116 was observed falling backwards and landing on his buttocks. When the staff approached Resident #116, Resident #127 was standing over him. The investigation documented Resident #116 did not hit his head. The investigation documented Resident #127 had finger indentations and scratches on his right arm. Resident #127 had full range of motion to the extremity and had no reports of pain. Resident #127 said he was just standing there when Resident #116 grabbed his arm and twisted it trying to push him out of the way. Resident #127 said he had to push Resident #116 to the ground so he would not fall. He said he had to defend himself. The investigation documented the residents were separated, the staff within the vicinity of the incident were interviewed, the residents were interviewed, the resident's care plans were reviewed and behavioral health services was contacted. Fifteen-minute safety checks were initiated. The investigation documented lab work and a urinary analysis (UA) was requested. Resident #116 was interviewed and said he was just standing there and was pushed down. The investigation documented the staff witnessed Resident #116 falling from around the corner. It was unclear which resident pushed first based on the interviews and the altercation being unwitnessed. Resident #127 did have finger indentations and superficial scratches on his arm aligning with the claim of Resident #116 grabbing Resident #127's arm. The results of the investigation documented that abuse was unsubstantiated as it did not meet all of the requirements of abuse because there was no intent to harm, the reddened area to the arm was resolved moments after the event occurred, there were no further injuries and neither resident showed signs of distress. -However, Resident #127 said he pushed Resident #116 and said Resident #116 grabbed his arm. B. Resident #116 - assailant Resident #116, age [AGE], was admitted on [DATE] and readmitted on [DATE]. According to the January 2025 CPO, diagnoses included unspecified Alzheimer's disease, schizoaffective disorder (mental disorder), and dementia, in other diseases, with other behavioral disturbance. The 11/27/24 MDS assessment revealed the resident was cognitively impaired with a BIMS score of three out of 15. He was independent with ambulation, bed mobility, and transfers. He exhibited wandering behavior. 2. Record review An altercation care plan, initiated on 1/3/25, revealed Resident #116 was involved in a physical altercation with another resident. Interventions included 15-minute monitoring, encouraging the resident to participate in meaningful activities, ordering lab work and referring the resident to behavioral health services for medication review. A behavior care plan, initiated on 6/4/24 and revised on 6/19/[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interviews, the facility failed to implement their policy regarding use and storage of foods brought to residents by family and other visitors to ensure safe and sanitary storage, handling and consumption on two of three floors. Specifically, the facility failed to ensure safe and appropriate storage of food items in resident's personal refrigerators. Findings include: I. Professional reference The Colorado Retail Food Establishment Regulations, (3/16/24), retrieved on 1/21/25 read in pertinent part: Ready-to-eat, time/temperature control for safety food prepared and held in a food establishment for more than 24 hours shall be clearly marked to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded when held at a temperature of 41 degrees Fahrenheit (F) or less for a maximum of seven days. The day of preparation shall be counted as day one. The day or date marked by the food establishment may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on food safety. (Chapter 3-28). II. Facility policy and procedure The Safe Handling of Foods From Visitors policy, undated, was provided by the nursing home administrator (NHA) on 1/13/25 at 1:00 p.m. The policy read in pertinent part, Facility staff will request that visitors bringing in food, and or residents that received food, must notify a member of the nursing or activities departments. The responsible facility staff member will determine whether the food item is for immediate consumption or to be stored for later use. When food items are intended for later consumption, the responsible facility staff member will: Ensure that the food is stored separate or easily distinguishable from the facility food in a unit refrigerator/freezer or resident's personal regenerator (sic) in their room and labeled with the resident name and current date. Refrigerators/freezer storage of foods brought in by visitors will be properly maintained and equipped with thermometers, have temperatures monitors daily for refrigerators equal to or less than 41 degrees fahrenheit and equal to or less than ten degrees fahrenheit; daily monitoring for refrigerated storage duration and discard of any food items that have been stored for more three or more days; and cleaned weekly. III. Observations On 1/13/25 at 11:00 a.m. the following observations were made in room [ROOM NUMBER]: Two personal refrigerators each belonging to the residents who resided in room [ROOM NUMBER] were inspected. One refrigerator contained two packages of cheese and two containers of meat were stored in the refrigerator. The refrigerator did not have an internal thermometer. A resident who resided in room [ROOM NUMBER] was interviewed and said facility staff did not check the temperature of her refrigerator but her husband checked the refrigerator daily and kept it clean. The second personal refrigerator in room [ROOM NUMBER] was inspected and did not have an internal thermometer. On 1/13/25 at 1:40 p.m. the personal refrigerator in room [ROOM NUMBER] far was inspected and did not have an internal thermometer. IV. Record review Personal refrigerator monitoring logs from December 2024 (12/1/24 to 12/31/24) and January 2025 (1/1/25 to 1/13/25) were reviewed. On 12/23/25, there were no temperatures recorded for refrigerators in room [ROOM NUMBER], #131, #133, #134, #135, #137, #138 or the two refrigerators in room [ROOM NUMBER]. Temperatures were recorded once daily each day on 12/5, 12/26, and 12/27/25 for residents personal refrigerators and were as follows: A refrigerator in room [ROOM NUMBER] was documented as having temperatures of 42 F, 42 F, and 44 F. A refrigerator in room [ROOM NUMBER] was documented as having a temperature of 42F, 45, and 41 F. A refrigerator in room [ROOM NUMBER] was documented as having temperatures of 41 F, 45 F and 44 F. A refrigerator in room [ROOM NUMBER] was documented as having temperatures of 41 F, 43 F, and 43 F. A second refrigerator in room [ROOM NUMBER] was documented as having temperatures of 42 F, 41 F, and 44 F. -However, neither refrigerator in room [ROOM NUMBER] was labeled to indicate which resident's refrigerator was being monitored or what corrective actions were taken when the temperatures were out of range. Temperature logs for 1/13/25 through 1/16/25 revealed the following: A refrigerator in room [ROOM NUMBER] was documented once daily as having a temperature of 45 F, 45 F, 45 F and 45 F each day. A refrigerator in room [ROOM NUMBER] was documented once daily as having a temperature of 43 F, 43 F, 43 F, 43 F each day. -However, corrective actions were not indicated for the refrigerators in rooms #355 and #358 when they were documented as having temperatures out of the acceptable range. V. Staff interviews Certified nurse aide (CNA) #5 was interviewed on 1/15/25 at 1:00 p.m. CNA #5 said she was not sure who monitored the temperatures of the resident's personal refrigerators. CNA #5 said if a resident's family brought in food and asked facility staff to store the food, she labeled the container with the date food was brought to the facility and then placed the food in the resident's refrigerator. The NHA was interviewed on 1/16/25 at 11:00 a.m. The NHA said the housekeeping staff monitored and recorded the temperatures of resident's personal refrigerators when the rooms were cleaned. The NHA said the housekeeping staff kept a binder of all temperature logs for the residents personal refrigerators. The NHA said she was unsure if the facility staff provided education to the residents or their representatives regarding the food from outside sources policy. The NHA said she talked to the residents and families about the appropriate plugs and placement of the refrigerators. The environmental services director (ESD) and the NHA were interviewed together on 1/16/25 at 1:00 p.m. The ESD said each housekeeper brought a refrigerator monitoring log with them when they cleaned the resident's room. The ESD said there was a monitoring log for each hallway and when a housekeeper cleaned a resident's room, the personal refrigerator was checked and the temperature of the resident's personal refrigerator was recorded on the log. The ESD said if the temperature was above 40 degrees fahrenheit on the thermometer, that meant the refrigerator's temperature was out of range and the housekeeping staff should inform her. The ESD said she recently ordered thermometers and gave them to housekeeping staff on 1/15/25 to replace any refrigerators that needed them. The ESD said housekeeping staff carried extra thermometers with them. The NHA said if a resident's personal refrigerator was out of temperature range the facility would replace the refrigerator and discard the perishable food from the room. VI. Resident interviews and observations The resident who resided in room [ROOM NUMBER] was interviewed on 1/13/25 at 10:29 a.m. The resident said she had lived in the facility for two years and her refrigerator had not been cleaned since she moved in. The refrigerator in room [ROOM NUMBER] was observed. The refrigerator had a small amount of food spills that were red and brown in color and the freezer was half-full of packed ice crystals. A thermometer was found inside that read 40 degrees. Temperature logs were not seen in Resident #66's room. room [ROOM NUMBER]'s refrigerator was observed again on 1/15/25 at 8:09 a.m. The refrigerator had one wrapped, undated, dessert inside. The refrigerator had a small amount of food spills that were red and brown in color and the freezer was half-full of packed ice crystals. The thermometer inside read 42 degrees. The refrigerator in room [ROOM NUMBER] was observed on 1/13/25 at 10:15 a.m. The refrigerator did not have a thermometer inside. There were two open, undated, cups of fluids inside the refrigerator. The refrigerator had a small amount of food spots that were brown in color and had some built up ice-crystals present. The refrigerator in room [ROOM NUMBER] was observed again on 1/15/25 at 8:19 a.m. The refrigerator had a small amount of food spots that were brown in color. There was not a thermometer inside the refrigerator. The freezer had some built-up ice crystals present.

Based on record review and interviews, the facility failed to provide training to their staff that at a minimum educates staff on activities that constitute abuse, neglect, exploitation and misappropriation of resident property as set forth, procedures for reporting incidents of abuse, neglect, exploitation or misappropriation of resident property and resident dementia abuse prevention. Specifically the facility failed to: -Provide annual resident abuse prevention training/education to 46 out of 212 staff members; and, -Provide annual dementia management education/training for 42 out of 212 staff members. Findings include: I. Facility policy and procedure The Abuse Prevention policy and procedure, revised 12/17/18 was received from the nursing home administrator (NHA) on 1/13/25 at 1:10 p.m. It revealed in pertinent part, It is the policy of this facility to maintain an environment free of abuse and neglect. The resident has the right to be free from verbal, sexual, physical and mental abuse, corporal punishment, and involuntary seclusion. Residents will not be subjected to abuse by anyone including, but not limited to, facility staff, other residents, consultants or volunteers, staff or other agencies serving the resident, family members or legal guardians, friends or other individuals. Educating staff on factors related to dementia care and abuse prevention, such as understanding that expressions or indications of distress of residents with dementia are often attempts to communicate an unmet need, discomfort or thoughts that they can no longer articulate with words. However, they may be perceived as challenging behaviors to staff and could increase the risk of resident abuse and neglect. II. Staff training records A request was made for the facility's annual abuse and dementia training records for all active staff members on 1/14/25. On 1/15/25 at 3:32 p.m. the staff development coordinator (SDC) provided the records for all active staff members who had completed annual abuse and dementia training. The records revealed 46 out of 212 staff members had not completed the facility's annual abuse training. Additionally, the records revealed 38 out of 212 staff members had not completed the facility's annual dementia training. On 1/16/25 at 2:35 p.m. the NHA provided a revised copy of all active staff members training records for annual abuse and dementia training (see NHA interview below). The revised records revealed 42 (not 38) of 212 staff members had not completed the facility's annual dementia training. -The facility failed to ensure all active staff members completed the annual training for abuse and dementia. III. Staff interviews The NHA was interviewed on 1/15/25 at 3:13 p.m. The NHA said the facility had acquired a new SDC in May 2024 who was also the infection preventionist (IP) due to the facility identifying issues with training completion. The NHA said the facility put a performance improvement plan (PIP) in place for human resources. However, the NHA said the PIP did not include annual abuse and dementia education. The NHA said the electronic education platform previously used by the facility was not being completed by staff and they had opted into a new training platform that was started on 1/1/25. The NHA said it was important to ensure all staff members were able to provide care and be aware of signs of abuse and dementia care. The NHA was interviewed a second time on 1/16/25 at 12:45 p.m. The NHA said the staff were reviewing employee files to ensure accurate counts for training were given. She said the facility would not be able to provide documentation for all staff members for abuse and dementia training. The NHA said moving forward the SDC would be responsible for auditing and ensuring all abuse and dementia training was completed on hire and annually and it was to be added to the new hire checklist. On 1/16/25 at 3:20 p.m. the director of nursing (DON) was interviewed. The DON said abuse and dementia training for all employees was important for safety and knowledge of how to handle resident situations that could arise, especially with dementia residents in the facility.

Based on observations, record review and interviews, the facility failed to ensure food was prepared, distributed and served under sanitary conditions in five of five nourishment refrigerators. Specifically, the facility failed to ensure safe and appropriate storage of food items in the nourishment refrigerators. Findings include: I. Professional reference The Colorado Retail Food Establishment Regulations, (3/16/24), retrieved on 1/21/25, read in pertinent part, Ready-to-eat, time/temperature control for safety food prepared and held in a food establishment for more than 24 hours shall be clearly marked to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded when held at a temperature of 41 degrees fahrenheit (F) or less for a maximum of seven days. The day of preparation shall be counted as day one. The day or date marked by the food establishment may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on food safety. (Chapter 3-28). The Hormel Handling Information product guide, (2025), retrieved on 1/21/25, read in pertinent part: For Med-Pass products: Shelf life is up to four days refrigerated after opening. (Page 5) II. Facility policy and procedure The Safe Handling of Foods From Visitors policy, undated, was provided by the nursing home administrator (NHA) on 1/13/25 at 1:00 p.m. The policy read in pertinent part, Facility staff will request that visitors bringing in food, and or residents that received food, must notify a member of the nursing or activities departments. The responsible facility staff member will determine whether the food item is for immediate consumption or to be stored for later use. When food items are intended for later consumption, the responsible facility staff member will. Ensure that the food is stored separate or easily distinguishable from the facility food in a unit refrigerator/freezer or resident's personal regenerator in their room and labeled with the resident name and current date. Refrigerators/freezer storage of foods brought in by visitors will be properly maintained and equipped with thermometers, have temperatures monitors daily for refrigerators equal to or less than 41 degrees fahrenheit and equal to or less than ten degrees fahrenheit; daily monitoring for refrigerated storage duration and discard of any food items that have been stored for more three or more days; and cleaned weekly. III. Observations On 1/15/25 at 9:52 a.m. a refrigerator was observed on the first floor behind the nurses station. The refrigerator contained a container of Med-Pass (liquid supplement) approximately a quarter full and an unopened Monster energy drink. A sticky light brown substance with long black hair was in the bottom of the refrigerator. -The facility failed to label the Med-Pass with an opened or expiration date according to the product's handling instructions (see recommendations above) and the Monster energy drink was not labeled with a resident's information to differentiate it from the staff's food. On 1/15/25 at 10:04 a.m. a refrigerator was observed in the second floor dining room. The refrigerator contained a container of Med-Pass approximately a quarter full. -The facility failed to label the Med-Pass with an opened or expiration date according to the products' handling instructions (see recommendations above). On 1/15/25 at 10:09 a.m. a refrigerator was observed on the third floor. The refrigerator contained three Nestle Boost supplements with a use by date of 12/26/24. On 1/15/25 at 10:22 a.m. in the first floor secure unit freezer, there was a clear plastic one ounce (oz) medication cup with a frozen white substance in the cup. There were small light pink pieces on top of the white substance with a small white spoon frozen inside the cup. The cup was not labeled or covered. On 1/15/25 at 10:35 a.m. a refrigerator was observed on the third floor secure unit. The refrigerator contained the following: -A container of Med-Pass approximately a quarter full and the facility failed to label the Med-Pass with an opened or expiration date according to the product's handling instructions (see recommendations above). -A clear plastic container topped with a red lid that contained fresh blueberries was not labeled with a resident's name or date on the container. -An opened, two quart container of coffee mate creamer that was not labeled with a resident's name or expiration date on the container. -One 16 ounce pump bottle of hand sanitizer. -A clear, two quart plastic container of salsa with no resident's name or expiration date on the container. -A disposable Starbucks cup with a sticker dated 1/12/25 at 9:11 a.m. with no residents name on the cup -One can of unopened Red Bull that was not labeled to differentiate it from the staff's food. A typed sign was posted on the refrigerator that read in pertinent part: Residents only. All items must have a resident name and date. All employee items will be removed. IV. Staff interviews Dietary aide (DA) #1 was interviewed on 1/15/25 at 10:05 a.m. DA #1 said a resident's family member could bring and keep a resident's food in the nourishment refrigerator. DA#1 said she asked the family to put the resident's name, room number and date on the item. DA #1 said the nurses used Med-Pass and should label the Med-Pass container upon opening it. Certified nurse aide (CNA) #5 was interviewed on 1/15/25 at 1:00 p.m. CNA #5 said if a resident's family brought in food and asked facility staff to store the food, CNA #5 labeled the container with the date food was brought to the facility and then placed the food in the resident's refrigerator. CNA #5 said if a family brought in food that was placed in a nourishment refrigerator at the nurses station she would label the item with the resident's name also. The NHA and the director of nursing (DON) were interviewed together on 1/16/25 at 11:30 a.m. The NHA said the dietary staff monitored temperatures of the nourishment refrigerators and checked for expired products . The NHA said the nursing staff used the refrigerators as well. The NHA said the nursing staff and the dietary staff could remove expired items from the refrigerators. The DON said the Med-Pass was not a widely used supplement but the containers were usually placed in the refrigerators after being opened. The NHA said a staff drink or food in a resident refrigerator would be discarded because the nourishments refrigerators were for resident food only.

Based on observations and interviews, the facility failed to ensure residents received notices orally and in writing which included a written description of their legal rights. Specifically, the facility failed to: -Include the email address of the State Survey Agency so a resident may file a care complaint; and, -Post the information in a manner accessible and understandable to all residents. Findings include: I. Resident group interview The group interview was conducted on 7/24/23 at 10:36 p.m. with five residents (#10, #68, #91 #104 and #105) identified by assessment and the facility as interviewable. All five residents said they did not know they could file a complaint with the State Agency and they did not know where the facility posted information in regard to pertinent State Agencies' contact information and it was not reviewed in the resident council meeting. III. Staff interviews and observation On 7/19/23 at 10:46 a.m. observation of the mandatory posting for the State Agency was made on the third floor across from the unit manager's office. An eight inch by 11 inch paper was stapled inside a glass bulletin board. The posting was hung approximately six feet up from the floor. The bulletin board contained a paper with the names, addresses and phone numbers of State Agencies. The font of the contact information was approximately size 11 font but it would be hard to read with a visual impairment. The complaint intake email address was not included for the State Survey Agency on the posting. The posting was not accessible at wheelchair height so a resident could not read the sign without assistance. On 7/20/23 at 8:36 a.m. observation of the mandatory posting for the State Agency was made upon entrance to the facility. An eight inch by 11 inch paper was stapled inside a glass bulletin board upon the entrance to the facility on the right hand side. The posting was hung approximately seven feet up from the floor. The bulletin board contained a paper with the names, addresses and phone numbers of State Agencies. The font of the contact information was approximately size 11 font but it would be hard to read with a visual impairment. The complaint intake email address was not included for the State Survey Agency on the posting. The posting was not accessible at wheelchair height so a resident could not read the sign without assistance. The posting was in an area that was not easily accessible to residents that were not mobile. Certified nurse aide (CNA) #1 was interviewed on 7/24/23 at 2:11 p.m. She said she was uncertain where the State Agencies' contact information was located. CNA #2 was interviewed on 7/24/23 at 2:15 p.m. She said she did not know where the State Agencies' contact information was located. Registered nurse unit manager (RNUM) #1 was interviewed on 7/2/423 at 2:19 p.m. She said she did not know where the State Agencies' contact information was located.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews the facility failed to keep two residents (#108 and #133) free from resident to resident physical abuse of two residents reviewed out of 71 sample residents. Specifically, the facility failed to ensure there was an effective plan to monitor, or provide increased oversight and effective interventions to protect, Residents #108 and #133 from Resident #409's behavior. Resident #409 physically abused two residents on 7/9/23. Findings include: I. Facility policy and procedure The Abuse, Neglect, & Exploitation Prevention policy and procedure, revised 12/17/18, documented in pertinent part: It is the policy of this facility to maintain an environment free of abuse and neglect. The resident has the right to be free from verbal, sexual, physical and mental abuse, corporal punishment, and involuntary seclusion. Residents will not be subjected to abuse by anyone including, but not limited to, facilities staff, other residents, consultants or volunteers, staff or other agencies serving the residents, family members or legal guardians, friends or other individuals. Educating staff on factors related to dementia care and abuse prevention, such as understanding that expressions or indications of distress of residents with dementia are often attempts to communicate an unmet need, discomfort or thoughts that they can no longer articulate with words. However, they may be perceived as challenging behavior to staff and could increase the risk of resident abuse and neglect. Expressions or indications of distress can include, but are not limited to aggressiveness, wandering or elopement, agitation, yelling out, or delusions. II. Resident to resident altercation between Resident #409 (assailant) and Residents #108 and #133 The abuse investigation dated 7/9/23 revealed certified nurse aide (CNA) #16 observed Resident #409 grab and punch Resident #133 three times on the head while in the dining area of the secure unit. CNA #16 separated Resident #409 from Resident #133 and Resident #409 fell backwards and landed on the floor. Registered nurse (RN) #2 observed the altercation and witnessed Resident #409 attempting to stand from the floor and strike CNA #16. RN #2 assisted in separating Resident #409 and Resident #133 and assessed both for pain and/or injury. While RN #2 held the hand of Resident #409 and assisted him to walk away from the dining area, Resident #409 hit Resident #108 on the head as she was self propelling her wheelchair past them. CNA #17 observed Resident #409 hit Resident #108 on the head as Resident #409 was being escorted from other residents. III. Resident #409 A. Resident status Resident #409, age [AGE], was admitted on [DATE] and discharged on 7/9/23. According to the July 2023 computerized physician orders (CPO), the diagnoses included dementia with other behavioral disturbances. The 7/7/23 minimum data set (MDS) assessment revealed the resident had severe cognitive impairment with a brief interview for mental status score of four out of 15. He required extensive assistance for transfers, dressing, toilet use and personal hygiene. Resident #409 had behaviors of pacing, exit seeking and wandering. B. Record review The 6/28/23 care plan revealed resident #409 used psychotropic medications (prescription medication that affect a person's mental state). Pertinent interventions included monitoring, documenting, and reporting any adverse events to include behavior symptoms not usual to the person. -Resident #409 did not have a care plan regarding physical aggression. The 6/28/23 progress note revealed Resident #409 was admitted to the facility on this day, he was Spanish speaking only. The 6/30/23 progress note revealed Resident #409 was observed attempting to exit the unit on multiple occasions and was transferred to the secure memory care neighborhood on the first floor of the facility. The 7/2/23 progress note revealed Resident #409 had been wandering into other residents' rooms. The 7/3/23 progress note revealed Resident #409 entered the room of another resident twice and attempted to take their wheelchair and was observed with his suitcase attempting to exit the building. The 7/4/23 progress note revealed Resident #409 fell backwards against a wall while attempting to open a door to the outside. The 7/8/23 progress note revealed Resident #409 was observed trying to hit another resident and nursing staff intervened, Resident #409 then hit the nurse in the face with a napkin. The 7/9/23 progress note revealed at 10:00 a.m., Resident #409 was observed punching the air with closed fists and stating in Spanish (translated by Spanish speaking CNA) I want to kill somebody. A second progress note on the same day was recorded at 2:05 p.m. It revealed Resident #409 had fallen backwards while attempting to swing at a CNA after striking two other residents (Resident #108 and #133). IV. Resident #133 A. Resident status Resident #133, age [AGE], was admitted on [DATE]. According to the July 2023 CPO, the diagnoses included dementia and anxiety. The 6/16/23 minimum data set (MDS) assessment revealed the resident had severe cognitive impairment with a brief interview for mental status score of five out of 15. She was independent with mobility, transfers, dressing, toilet use and personal hygiene. B. Record review The 7/9/23 progress note revealed Resident #133 was being evaluated for pain and any negative emotional outcomes for aggression received by Resident #409. Resident #133 was observed to have increased anxiety, she pointed at Resident #409 and stated, He's also trying to get my pants down; you know the same guy; the idiot. Resident #133 approached the nurses station concerned that food on her plate was not okay to eat; the progress note revealed it to be a familiar behavior and she was observed to be in distress. The 7/10/23 progress note revealed Resident #133 was not able to recall the altercation happening on the previous day. The 7/11/23 through 7/13/23 progress notes revealed Resident #133 was free from pain and distress. The care plan, with a revision date of 7/13/23, revealed Resident #133 had a traumatic life experience with being physically abused by her mother as a child and history of alcohol dependence, and due to the recent event of being hit by Resident #409 she was at risk for potential trauma. Interventions included Resident #133 should be monitored for any ongoing mood and behavioral symptoms and that a referral for counseling support be made if need be. V. Resident #108 A. Resident status Resident #108, age [AGE], was admitted on [DATE]. According to the July 2023 CPO, the diagnoses included dementia, anxiety and depression. The 6/16/23 minimum data set (MDS) assessment revealed the resident had severe cognitive impairment with a brief interview for mental status score of five out of 15. She required extensive assistance from one staff member for dressing, toilet use and personal hygiene. B. Record review The 7/9/23 progress note revealed Resident #108 was struck on the top of her head by another resident and was being evaluated for pain and any negative emotional outcomes. Resident #108 was free from pain and distress. The 7/10/23 and 7/11/23 progress notes revealed Resident #108 was free from pain and distress. The 7/12/23 progress note revealed Resident #108 was observed having anxious behavior, repeatedly telling at staff she wanted out of here. The 7/13/23 progress note revealed the facility was in contact with Resident #108's decision maker and discussed psychological services being offered to Resident #108. The decision maker was in agreement and added that Resident #108 had lived with an abusive son in her past. The care plan, with a revision date of 7/13/23, revealed Resident #108 was at risk for potential trauma related to the recent event of being hit by Resident #409, and that the resident had a history of trauma related to living with an abusive son. Interventions included promoting feelings of safety as much as possible and providing the resident with reassurance when appropriate. VI. Staff interviews Certified nurse aide (CNA) #4 was interviewed on 7/25/23 at 10:29 a.m. She said she was not working on the day of the altercation but had worked with Resident #409 while he was admitted to the secure unit. She said Resident #409 was restless, would wander into other residents' rooms, and would ask her how he could leave. She said she was fluent in Spanish and being that Resident #409 was Spanish speaking only she would inquire about his unmet needs. She said he would respond by asking how he could leave. Licensed practical nurse (LPN) #1 was interviewed on 7/25/23 at 10:29 a.m. She said she was not working on the day of the altercation but had worked with Resident #409 while he was admitted to the secure unit. She said he was restless and needed to be continuously monitored as he would wander into other residents' rooms and try to open every door on the secure unit. CNA #5 was interviewed on 7/25/23 at 11:00 a.m. She said she was working on the day of the altercation but did not witness the event. She said Resident #409 was to be observed by staff every 15 minutes for location and needs. She said she had checked in on Resident #409 as she was fluent in Spanish and he expressed no needs. She said she left for her break and was informed of an altercation upon her arrival. The administrator in training (AIT) was interviewed on 7/25/23 at 2:00 p.m. She said she met with the son of Resident #409 prior to admission. She said the terms of the admission was for Resident #409 to move in on a one month trial period, as there was dissatisfaction with his other facility. The AIT said Resident #409 was first admitted to the third floor of the facility and was quickly moved to the first floor secure unit after he was continuously opening and attempting to leave the unit through the emergency exits. She said the family was asked about any behavioral issues and the family denied any existed. She said she had not reached out to the managed care team of Resident #409 to ask about any behavioral issues.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to provide written information regarding the facility's bed-hold policy to a resident's representative for one (#409) resident reviewed for discharge out of 71 sample residents. Specifically, the the facility failed to provide Resident #409's representative with a written notice of the bed hold policy when he was transferred to the hospital. Findings include: I. Resident status Resident #409, age [AGE], was admitted on [DATE] and discharged to hospital on 7/9/23. According to the July 2023 computerized physician orders (CPO), the diagnoses included dementia with other behavioral disturbances. The 7/7/23 minimum data set (MDS) assessment revealed the resident had severe cognitive impairment with a brief interview for mental status score of four out of 15. He required extensive assistance for transfers, dressing, toilet use and personal hygiene. II. Record review The 7/9/23 nursing progress note revealed Resident #409 was sent to the emergency room to be evaluated for aggressive behaviors. Cross-reference F626 for not permitting a resident to return to the facility. A review of the resident's electronic medical record (EMR) did not reveal documentation to indicate that Resident #409's representative was contacted or provided written information regarding the resident's right to a bed hold at the time of Resident #409's transfer to the hospital. III. Staff interviews The director of nursing (DON) was interviewed on 7/25/23 at 8:00 p.m. She said, because Resident #409 was admitted for social respite, the facility was not obligated to provide written information regarding the facility's bed-hold policy. She said she was unaware of the federal requirement that a notice of bed hold had to be provided to the resident or resident representative upon transfer. IV. Additional information On 7/26/23 at 4:52 p.m. the administrator in training (AIT) provided a copy of the facility's bed hold policy, which was signed upon Resident #409's admission by the resident's representative. -However, the facility failed to provide the notice of the resident's right to a bed hold to Resident #409's representative upon the resident's transfer to the hospital.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to allow a resident to return to the facility after going to the hospital for one (#409) of one resident reviewed for discharge out of 71 sample residents. Specifically, the facility failed to assess Resident #409 when he went to the hospital to be stabilized to return to the facility. Findings include: I. Facility policy and procedure The Involuntary Discharge policy and procedure, revised 2/14/19, was provided by the administrator in training (AIT) on 7/26/23. It read in pertinent part, To assure residents will be transferred or discharged only for the resident's welfare, the resident's needs cannot be met in the facility, the resident's health has improved sufficiently so the resident no longer needs the services provided by the facility, the health and safety of individuals in the facility are endangered or for non-payment. If the resident is being transferred due to the resident being a danger to self or others, there must be documentation to show that interdisciplinary interventions were tried and failed prior to discharge. The resident's physician must document in the medical record when the discharge is because the resident's needs cannot be met or the health of the resident is endangered. The facility will document in the resident's medical record: the basis for the transfer, the specific resident need(s) that cannot be met, facility attempts to meet the resident needs, and the service available at the receiving facility to meet the need(s). II. Resident #409 Resident #409, age [AGE], was admitted on [DATE] and discharged to hospital on 7/9/23. According to the July 2023 computerized physician orders (CPO), the diagnoses included dementia with other behavioral disturbances. The 7/7/23 minimum data set (MDS) assessment revealed the resident had severe cognitive impairment with a brief interview for mental status score of four out of 15. He required extensive assistance for transfers, dressing, toilet use and personal hygiene. Resident #409 had behaviors of pacing, exit seeking and wandering. III. Record review The 6/28/23 care plan revealed resident #409 used psychotropic medications (prescription medication that affect a person ' s mental state). Pertinent interventions included monitoring, documenting, and reporting any adverse events to include behavior symptoms not usual to the person. It also revealed Resident #409 was admitted for a social respite stay (provides short-term relief for primary caregivers) and would return home with family after the respite stay. -The 6/28/23 care plan failed to implement meaningful interventions to address the need for secure placement, use of psychotropic medications or that Resident #409 ' s primary language was Spanish. The July 2023 CPO revealed Resident #409 was to be monitored for agitation/aggression that presented as hitting, kicking, or verbal statements. Observed behaviors were to be documented in progress notes, to include description of behavior, non-pharmacological (medication administration), approaches and how Resident #409 responded. The July 2023 CPO revealed the following orders: Start date of 6/28/23 Seroquel (antipsychotic medication) oral tablet, give 200 milligrams (mg) by mouth one time a day for dementia with behaviors. Notify MD (medical doctor) if adverse effects are observed or reported. Start date of 6/29/23 Seroquel oral tablet, give 50 milligrams (mg) by mouth one time a day for dementia with behaviors. Notify MD if adverse effects are observed or reported. The 6/30/23 progress note revealed Resident #409 was observed attempting to exit the unit on multiple occasions and was transferred to the secure memory care unit on the first floor of the facility. The 7/2/23 progress note revealed Resident #409 had been wandering into other residents' rooms. The 7/3/23 progress note revealed Resident #409 entered the room of another resident twice and attempted to take their wheelchair and was observed with his suitcase attempting to exit the building. The 7/4/23 progress note revealed Resident #409 fell backwards against a wall while attempting to open a door to the outside. The 7/8/23 progress note revealed Resident #409 was observed trying to hit another resident and nursing staff intervened, Resident #409 then hit the nurse in the face with a napkin. -The above progress notes, dated 7/2/23 to 7/8/23, failed to include what interventions were implemented and how Resident #409 responded. The 7/9/23 progress note revealed at 10:00 a.m., Resident #409 was observed punching the air with closed fists and stating in Spanish, translated by a Spanish speaking certified nurse aide (CNA), I want to kill somebody. A female resident had approached the nurse station and stated Resident #409 was trying to get down her pants. The progress note revealed a CNA (unknown) stated Resident #409 believed Resident #133 to be his wife and would follow her. Resident #409 was kept close to the nurses station for one-to-one oversight and placed on 15 minute checks. The medical doctor, director of nursing, responsible party and weekend supervisor were informed. The 7/9/23 progress note revealed at 12:57 p.m., the facility received a one time order for Seroquel 100 milligrams (MG) to be administered for agitation. The 7/9/23 progress note revealed at 2:05 p.m., Resident #409 had fallen backwards while attempting to swing at a CNA after striking two other residents (Residents #108 and #133). Cross-reference F600 abuse. The 7/9/23 progress note revealed at 3:21 p.m., Resident #409 was sent to the emergency room for violent behavior. -However, prior to the facility sending the resident to the hospital, limited interventions were attempted to address his behaviors with him being moved to a secured unit on 6/30/23. The 7/10/23 progress note revealed the responsible party for Resident #409 was contacted by the administrator in training (AIT) and registered nurse (RN) #4 and informed of an interdisciplinary (IDT) facility decision of not accepting Resident #409 back after he was discharged from the facility to the hospital due to violent and aggressive behaviors. The responsible party for Resident #409 informed the AIT and RN #4 he had already been notified of this on 7/9/23 by a nurse on duty. The responsible party informed the facility that Resident #409 remained in the hospital as they were attempting to find a medication regimen that worked with his behaviors. -The facility failed to provide information to the resident on the bed hold policy at the time of transfer (cross-reference F625). The 7/9/23 discharge summary signed by the attending physician on 7/24/23 listed medically defined conditions as admitting diagnoses or current diagnoses to be: vascular dementia, unspecified severity, with other behavioral disturbances, complete loss of teeth, chronic obstructive pulmonary disease (COPD) (diseases that causes airflow blockage and breathing-related problems), vascular disease (condition that affects blood vessels), unspecified benign prostate hyperplasia without lower urinary tract symptoms (enlarged gland in men that carries semen and urine from body), lumbago with sciatica (lower back pain), heart disease, cerebrovascular disease (disease affecting blood flow to brain), hypertension (elevated pressure in blood vessels), personal history of malignant neoplasm of the bladder (bladder cancer). The final diagnoses listed were the same as above. The condition on discharge was listed as worsened, sent to the emergency room (ER); rehabilitation, potential and prognosis was listed as unknown. -The facility failed to have physician documentation in the medical record that Resident #409 ' s needs could not be met and what attempts had been made to meet his needs prior to initiating an involuntary discharge. -The facility failed to reassess the resident for return to the facility when the responsible party notified the facility the hospital was working on his medication regimen. -The facility failed to receive information from hospital on Resident #409 ' s condition and what services the facility would need to provide upon return to meet the resident needs. IV. Staff interviews CNA #4 was interviewed on 7/25/23 at 10:29 a.m. She said Resident #409 was restless at baseline and required constant oversight by staff. She said she he went into other residents ' rooms and tried to open doors to the outside. She said she would redirect by walking with him and asking if she could help. She said she was fluent in Spanish and asked about his needs. She said he would ask how he could leave. She said walking and talking with him in Spanish was the only intervention she implemented with him. CNA #5 was interviewed on 7/25/23 at 11:00 a.m. She said Resident #409 required constant staff oversight as he went into other residents' rooms and tried to open doors. CNA #5 said she was fluent in Spanish and Resident #409 had made comments that he needed to find his wife and would ask where the exit was. She said walking and talking with him was the only intervention she implemented. The AIT was interviewed on 7/25/23 at 2:00 p.m. She said Resident #409 admitted as a social respite, as a trial, to see if facility would be a good fit for permanency. She said she was not aware of behaviors prior to his admission. She said if the facility had knowledge of behaviors associated with diagnoses those behaviors were to be documented in the care plan so that interventions could be implemented. She said she was instructed by the DON and nursing home administrator (NHA) to inform the family and the managed care team of Resident #409 the facility had decided to not readmit the resident from the hospital because of aggressive and violent behaviors. The admission coordinator (AC) was interviewed on 8/8/23 at 11:14 a.m. She said Resident #409 was hospitalized prior to admitting to the facility and the facility had declined to admit him. She said he was hospitalized for throwing a walker at his wife in their home. She said he was discharged back to their home and his managed care sent a referral for a respite stay. She said the managed care team assured her Resident #409 had only been aggressive towards his wife. She said Resident #409, his wife and their son had toured the facility prior to admission. She said Resident #409 was pleasant at this time. She said the facility contacted the managed care team for Resident #409 and they were told Resident #409 would not be readmitted because of violent and aggressive behaviors. She said when a resident was discharged to the hospital the facility awaited a call from the hospital or resident representative regarding readmission. She said she did not hear from the hospital regarding Resident #409 and she did not reach out to the hospital about his return. The DON was interviewed on 8/8/23 at 11:30 a.m. She said the facility was aware Resident #409 had been aggressive towards his wife prior to admitting to the facility. She said she would not expect this information to be added to a care plan. She said she was aware Resident #409 was sent to hospital for violent and aggressive behaviors over the weekend of 7/9/23. She said she received information from the hospital on 7/10/23 that Resident #409 remained unstable and the hospital was informed the facility would not readmit in that conversation. She was unable to provide documentation of a conversation between the facility and hospital regarding readmission. The son of Resident #409 was not available for an interview during the duration of the survey.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and interviews, the facility failed to ensure two of three residents (#41 and #136) reviewed for activities of daily living (ADLs) received the necessary care and services to maintain their abilities in ADLs out of 71 sample residents. Specifically, the facility failed to provide language communication tools in order for Resident #41 and #136 to effectively communicate their needs, requests, and opinions, as well as to participate in social conversation. Findings include: I. Resident #41 A. Resident status Resident #41, over the age of 65, was admitted on [DATE]. According to the July 2023 Computerized Physician Orders (CPO), the resident's diagnoses included unspecified dementia, of unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. The June 2023 minimum data set (MDS) assessment revealed the resident with severe cognitive impairment with a brief interview for mental status score of four out of 15. She required supervised assistance with bed mobility, transfer, walking in room, walking in the corridor, dressing, eating, toilet use, and personal hygiene. B. Observation On 7/20/23 at 12:00 p.m. when an attempt was made to speak with Resident #41, staff reported the resident did not speak English but rather spoke Chinese. A communication board was not observed in the resident's room. On 7/25/23 at 10:30 a.m. another attempt to speak with the resident as she was exiting her room was unsuccessful; the resident kept walking, making hand gestures that could not be interpreted by the surveyor. C. Record review - failures The resident's communication care plan, revised on 6/21/23, documented Resident #41 did not speak the dominant language of the facility. Her primary language was Chinese and her family assisted with communication often. The plan read the resident was able to understand some English. Interventions included encouraging the resident to use signs/gestures(pointing)/sounds, and translator (family) when expressing self. It read the resident will often point to the phone to call her daughter if needed. It further read she had a communication board in her room with pictures to help with communication. -See staff interviews below; no staff indicated they used a communication board to help with communication and the care plan did not identify other means of communication and which means were most effective in addressing the resident's ability to express her needs, requests, opinions and to participate in social conversation. The activity care plan, revised on 6/27/23, documented Resident #41 had the following barriers to activity participation: non-English speaking, as the resident spoke Chinese. Interventions included: Staff using communication tools and family members to speak to the resident; using a direct and positive approach, speaking clearly while facing the resident, and being patient and understanding; using gestures and anticipating needs: respecting the resident's right to choose or refuse invitations to group participation; providing regular visits from activity staff to encourage, socialize, provide comfort and support as needed; referring to diet report and/or consult nurse before involvement in activities with food or drink; assessing individual needs, encourage active participation, escort to groups of choice as needed; assist as needed, and provide materials for independent pursuits. -See staff interviews below; no staff indicated they effectively communicated with the resident by speaking clearly and directly or were able to anticipate her needs or encourage active participation in activities; rather, staff reported communication with the resident was short and primarily through gesturing. An interdisciplinary team meeting note, dated 6/28/23, read the resident was able to answer yes or no questions, spoke only Chinese, but was able to communicate with gestures and make her needs known. D. Staff interviews Staff interviews revealed the facility failed to ensure Resident #41 an effective means of communicating that promoted her ability to communicate her needs, requests, and opinions, as well as to participate in social conversation. Staff were unaware of and did not utilize communication tools to facilitate conversation. 1. The MDS coordinator was interviewed on 7/25/23 at 10:12 a.m. She said the resident communicates with her by pointing at objects. Resident #41 has an iPad (small computer) she uses to communicate with her daughter. She said her iPad is in Chinese. The MDS coordinator said the resident does not have a communication book because she uses her iPad. The MDS coordinator said they have an interpreter line they can use if they need it, but she said she has never used it. She said she was not sure if other staff had used the language line. 2. Certified nurse aide (CNA) #6 was interviewed on 7/25/23 at 10:29 a.m. CNA #6 said Resident #41 shows staff what she wants by pointing to things. She said Resident #41 sits with a male resident in the dining room and she will order whatever he orders. CNA #6 said the resident does not ask staff for anything. She said she has never been shown how to use the interpreter line or the resident's iPad. She said if she had a question about what the resident wanted, she would ask a nurse. 3. CNA #8 was interviewed on 7/25/23 at 11:03 a.m. She said she has not worked with Resident #41. She said if she worked with a resident who needed translation, she would ask other staff how they communicate with the resident. CNA #8 said she has used gestures with other residents and that helped. She also said she would go to the care plan and see what was written. 4. CNA #10 was interviewed on 7/25/23 at 11:15 a.m. She said she cannot understand Resident #41. She said the resident will point at things and they get those things for her. She said Resident #41 does not have a communication book or log. CNA #10 said there was no interpreter line at the facility. She said the staff let the resident do her own thing and if she needed something, she pointed to it. She said having Resident #41 point to things was not the right and effective way for the resident to have to communicate her needs. She said if the resident did not point at things, staff would not do anything for her. 5. The social services director (SSD) was interviewed on 7/25/23 at 11:42 a.m. She said she used gestures to address Resident #41's needs and requests. She said the resident pointed to things and that was how she knew what the resident needed. The SSD said the resident's daughter was available any time if staff had any questions or concerns. She said staff have google translate to communicate with residents who needed it and the CNAs use it more than other staff. She said staff have short interactions with Resident #41 as pothey are not able to communicate with resident. II. Resident #136 A. Resident #136's status Resident #136, age [AGE], was admitted on [DATE]. According to the March 2022 CPO, the resident's diagnoses included unspecified dementia of unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. The June 2023 minimum data set (MDS) assessment revealed the resident was severely impaired with a brief interview for mental status score of zero out of 15. She required total assistance with bed mobility, transfer, toilet use, and personal hygiene. B Observation The resident was continuously observed on 7/24/23 from 8:54 a.m. until 3:24 p.m. Observations revealed: -At 8:54 a.m., the resident sat in a Broda chair (a tilt-in-space positioning wheelchair) in the dayroom. -At 10:33 a.m., the resident sat in the dayroom, sleeping in her Broda chair. -At 10:51 a.m., staff wheeled the resident back to her room. Staff closed the door to her room. At 10:59 a.m., staff left the room with the resident and wheeled her back to the dayroom. -At 11:46 a.m., the resident had a visitor, and staff wheeled the resident in the Broda chair to a table in the dayroom. -At 11:58 a.m., almost three hours since the observation began, the resident had not been heard to talk or ask for anything. -At 12:10 p.m., family members showed up and helped feed the resident her lunch, speaking to the resident in Spanish. -At 3:09 p.m., staff in the dayroom got ready to wheel the resident in the Broda chair back to her room. Staff was overheard telling the resident in English that they were going to take her to her room and change her. At 3:24 p.m. staff wheeled the resident in the Broda chair back to the dayroom. C. Record review - failures The resident's cognitive care plan, revised on 7/3/23, documented the resident had an impaired communication problem as she was non-verbal. Interventions included, anticipating and meeting her needs, ensuring/providing a safe environment, call light in reach, and fall prevention measures in place. Monitoring/documenting physical/ nonverbal indicators of discomfort or distress, and follow-up as needed. -The care plan did not identify how to address her communication problem, did not identify that her primary language was Spanish (see below) or communicated to staff her physical/ nonverbal indicators of discomfort or stress. The activity care plan, revised on 6/20/23, documented barriers to activity participation as extreme ambulation and mobility limitations, language barrier (Spanish Speaking), difficulty understanding and communicating, and short attention span. Interventions included encouraging ongoing family involvement and inviting the resident's family to attend special events, activities, and meals. Staff will inform of activities, provide a calendar, escort to and assist during groups of choice as needed, assess individual needs, develop rapport with the resident, encourage nursing home involvement and group participation, as well as providing materials for independent pursuits. Be aware of limited mobility and endurance. Staff will refer to diet report and/or consult nurse before involvement in activities with food or drink, provide regular visits from activity staff to encourage, socialize, and provide comfort and support as needed. -See staff interviews below; no staff indicated they effectively communicated with the resident by speaking clearly and directly or were able to anticipate her needs or encourage active participation in activities; rather, staff reported communication with the resident was short and primarily through gesturing. D. Interviews Family interviews indicated they spoke to the resident in Spanish and, although minimal, did at times respond. Staff interviews indicated they spoke to the resident in English and were unsure the resident understood them. There was no indication that means to promote effective communication with the resident had been attempted. 1. The resident's husband was interviewed on 7/23/23 at 5:17 p.m. He said he comes in to feed his wife dinner every day. He said there is always a family member who comes in to feed her lunch or dinner. He said his wife does not speak anymore. He stated he talks to his wife in Spanish as he does not speak much English. 2. The resident's brother was interviewed on 7/24/23 at 11:50 a.m. He said he speaks to the resident in Spanish. He said she does not respond to him; stating she stopped talking about a year ago. He said he comes in every day to visit his sister and to feed her lunch. He said he is not sure how staff communicate with his sister as she does not speak. 3. The resident's niece was interviewed on 7/24/23 at 12:45 p.m. She said she speaks to her aunt in Spanish and she understands and will respond to cues like opening her mouth to eat. The niece said the resident would benefit from more Spanish programs on television and listening to Spanish music. 4. Certified nurse aide (CNA) #6 was interviewed on 7/25/23 at 10:29 a.m. CNA #6 said she tells the resident what she is going to do in English and the CNA said she was not sure if the resident comprehends what she has said. CNA #6 said she has never been shown how to use the interpreter line or if they have one. She said would ask the nurse if she had a question. 5. CNA #8 was interviewed on 7/25/23 at 11:03 a.m. She said she has not worked with Resident #136. She said she would ask staff how they communicate with the resident or see what works for them. 6. CNA #10 was interviewed on 7/25/23 at 11:15 a.m. She said Resident #136 did not say anything. She said she speaks in English to the resident and said she did not think the resident understands her. She said she did not think the resident communicates often. She said there is no interpreter line to communicate with residents whose primarily language was not English. 7. The social services director (SSD) was interviewed on 7/25/23 at 11:42 a.m. She said she has tried to talk to the resident in English and Spanish and said each time she has not gotten a response. The SSD said staff, CNAs more than other staff, use google translate to communicate with residents if they do not speak English a

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and staff interviews, the facility failed to provide an ongoing program to support residents in their choice activities, designed to meet the interests of and support the physical, mental and psychosocial well-being of each resident, encouraging both independence and interaction in the community for one (#69) of two residents out of 71 sample residents. Specifically, the facility failed to offer and provide activity programs for Resident #69 to meet her activity needs. Findings include: I. Facility policy and procedure The Federal Resident Right and Facility Responsibilities document, not dated, was provided by the nursing home administrator (NHA) on 7/26/23 at 11:00 p.m. It read in pertinent part: The resident has a right to choose activities, schedules (including sleeping and waking times), health care and provider of health care services consistent with his or her interests, assessments, plan of care and other applicable provisions of this part. II. Resident status Resident #69, age [AGE], was admitted on [DATE]. According to the July 2023 computerized physician orders (CPO) diagnoses included hemiplegia (total or nearly complete paralysis of one side of the body) and hemiparesis (weakness on one side of the body) following cerebral infarction (stroke) affecting left non-dominant side, type two diabetes mellitus with other diabetic kidney complications and polyneuropathy and major depressive disorder. The 7/4/23 minimum data set assessment documented the resident did not have memory or cognitive issues indicated by a score of 14 out of 15 on the brief interview for mental status (BIMS). The resident needed extensive assistance with bed mobility and activities of daily living (ADLs) and total dependence for transferring. The resident did not have any behaviors or rejection of care. It was very important for the resident to get outside to get fresh air when the weather was good and be able to keep up with the news. III. Resident interview Resident #69 was interviewed on 7/19/23 at 12:47 p.m. She said she would like to participate in some of the activities, however, staff would not get her up to participate in activities. She said she has asked multiple times to get up and go outside as this was her favorite thing to do and of utmost importance to her but was always told no because they did not have enough staff for someone to go with her. Instead, they just leave her in the bed. Resident #69 said this makes her very sad. IV. Observations The observations showed the resident was lying in bed with no meaningful activity. The resident resided on the third floor in a room by herself. Her bed was placed parallel to and against the long side of the wall with the head of the bed at the window end of the room disabling her from being able to look out of the window. There were books on a shelf on the opposite wall from the bed and out of the residents' reach. 7/19/23 -At 12:47 p.m. Resident #69 was lying in bed with her eyes open with the television (TV) on. She appeared to be watching TV. -At 1:50 p.m. the resident continued to lay in bed with the TV on. -At 3:05 p.m. she continued to lay in bed with the TV on. -At 5:00 p.m. there were no changes. 7/20/23 -At 11:29 a.m. Resident #69 was lying in bed with the TV on. -At 11:50 a.m. there were no changes. -At 12:38 p.m. there were no changes. V. Record review The 1/9/22 activities assessment showed Resident #69 had general activity preferences of cards and other board games, current events, music, movies, dining out, reading and writing, outdoor games, painting, gardening, talking, cooking, word games, and visiting with animals. The care plan, revised 7/11/23, identified Resident #69 enjoyed cards and other games, music, reading, writing and watching TV (television). The goal documented the resident would participate in offered programs such as outings, personal shopper or restaurant dine-in as desired throughout the month. The resident would pursue independent leisure activities such as reading, watching TV, listening to music and visiting with others as desired. The interventions included: staff will honor references for daily activities and routines, inform of activities, provide calendar, escort to and assist during groups of choice as needed, assess individual needs, develop rapport with resident, encourage nursing home involvement and group participation, provide materials for independent pursuits, be aware of limited mobility and endurance, help locate and clean glasses as needed for all activities. The participation records were requested on 7/25/23 at 5:33 p.m. for Resident #69 and were not provided. VI. Staff interview The activities assistant (AA) was interviewed on 7/25/23 at 5:33 p.m. The AA said he was responsible for providing one-to-one interaction with residents that remain in their beds in their rooms. He said he was supposed to spend 15 minutes two to three times a week with them and the visits were logged. The director of nursing (DON) was interviewed on 7/25/23 at 8:16 p.m. She said residents that stay in their rooms have one-to-one visits in their rooms with the activities department staff. The activities director was interviewed on 8/8/23 at 10:00 a.m. She said she determined which residents needed one-to-one activity time based on criteria such as if they were bedbound or stayed in their room, if the resident was able to self-lead with activities and if the resident had any rejection of one-to-one time in the past. She said if residents refused activity offerings she had the activity staff try to ask what the resident would prefer to do. She said she could not always accommodate the residents ' requests because she did not have the staff to support those requests. She said she started a stroll group on Friday mornings and she tried to get Resident #69 to participate but the resident would typically agree the day before and then refuse on the day of the activity. -However, the AD did not provide documentation showing this pattern. The AD said she had tried to encourage the activity staff to document activity participation including refusals but she did not think they were doing so. The AD said she should provide a one-to-one activity 45 minutes three times a week for the residents with that program but she did not have the staffing to support it, so they provided 15 to 20 minutes two to three times a week to those on one-to-one activities.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, observation and record review, the facility failed to provide treatment and care in accordance with professional standards of practice for one (#7) out of 71 sample residents. Specifically, the facility failed to ensure Resident #7, who was diagnosed with diabetes, had her fingernails cut by a licensed nurse. Resident #7 sustained a laceration on her finger when the certified nurse aide (CNA) cut her nails. Findings include: I. Resident #7 status Resident #7, age [AGE], was admitted on [DATE]. According to the July 2023 computerized physician orders (CPO), the diagnoses included type two diabetes mellitus and Parkinson's disease. The 5/15/23 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status score of 15 out of 15. She required extensive assistance of two people with bed mobility, transfers, toileting and extensive assistance of one person with dressing and personal hygiene. A. Resident interview Resident #7 was interviewed on 7/20/23 at 11:18 a.m. She said she had asked a CNA for someone to cut her fingernails. She said the CNA told her she could do it. She said she did not think the CNA was able to cut her nails because she was diabetic, but believed her. She said the CNA cut her finger when she was cutting her fingernails. B. Record review The diabetes mellitus care plan, initiated on 5/1/19 and revised on 5/29/23, documented the resident had a risk of complications related to elevated blood sugars due to a diagnosis of diabetes mellitus. It indicated the resident utilized insulin daily to manage her diabetes. The 1/27/23 nursing progress note documented the CNA accidentally cut the skin around the resident's nails to the right thumb. The laceration measured 0.6 centimeters (cm) in length. The area was cleansed with normal saline and a treatment was applied. The physician was notified. II. Staff interviews Registered nurse (RN) #3 was interviewed on 7/25/23 at 3:06 p.m. She said CNAs were able to cut resident fingernails, except those who had a diagnosis of diabetes. She said a licensed nurse should cut the fingernails of a diabetic resident and a podiatrist for toenails. She said residents who had a diagnosis of diabetes had a risk of slower healing with lacerations and wounds. The DON was interviewed on 7/25/23 at 3:29 p.m. She said a licensed nurse should be the one to cut the fingernails and provide nail care of a diabetic resident. She said she was unaware a CNA had cut Resident #7's fingernail that caused a laceration. She confirmed Resident #7 had a diagnosis of diabetes. She said lacerations and wounds could be slower to heal and had a higher risk of infections for diabetic residents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to provide the necessary treatment and services to prevent pressure injuries from occurring for two (#23 and #85) of two residents in a sample of 71 residents. Specifically, the facility failed to implement or plan interventions to reduce pressure injury risk factors for Resident #23 and #85, both of whom had been identified at high risk for pressure injuries. Cross-reference F725: Lack of sufficient staffing to meet residents' needs for care and services Findings include: I. Professional reference According to the National Pressure Injury Advisory Panel (NPIAP) Pressure Injury Stages, the National Pressure Injury Advisory Panel - NPIAP web. (2/4/18) accessed 8/2/23 from http://www.npiap.org/resources/educationaland-clinical-resources/npuap-pressure-injury-stages. read in pertinent part: A pressure injury is localized damage to the skin and/or underlying soft tissue, usually over a bony prominence as a result of pressure, or pressure in combination with shear. The updated staging system includes the following definitions: Deep Tissue Pressure Injury: Persistent non-blanchable deep red, maroon or purple discoloration. Intact or non-intact skin with localized areas of persistent non-blanchable deep red, maroon, purple discoloration or epidermal separation revealing a dark wound bed or blood-filled blister. Pain and temperature change often precede skin color changes. Discoloration may appear differently in darkly pigmented skin. This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface. The wound may evolve rapidly to reveal the actual extent of tissue injury, or may resolve without tissue loss. If necrotic tissue, subcutaneous tissue, granulation tissue, fascia, muscle or other underlying structures are visible, this indicates a full-thickness pressure injury (Unstageable, Stage 3 or Stage 4). Do not use DTPI (deep tissue pressure injury) to describe vascular, traumatic, neuropathic, or dermatologic conditions. II. Facility policy and procedure The Prevention and Treatment of Pressure Ulcers policy, revised January 2020, was provided by the nursing home administrator (NHA) on 7/25/23 at 11:06 p.m. It read in pertinent part, To ensure a resident who enters the facility without a pressure ulcer does not develop a pressure ulcer unless the clinical condition demonstrates it was unavoidable. To ensure a resident who has a pressure ulcer receives the necessary treatment and services to promote healing, prevent infection and prevent additional pressure ulcers. The Skin Management policy was provided by the NHA on 7/25/23 at 11:06 p.m. It read in pertinent part, On admission/readmission all residents will have a head-to-toe skin observation completed by a licensed nurse and all skin issues identified, measured and documented on the Nursing admission Data Collection. All skin issues identified will have a treatment plan in place and a care plan formulated for the areas. III. Resident #23 A. Resident status Resident #23, age [AGE], was admitted to the facility on [DATE]. According to the July 2023 computerized physician orders (CPO), diagnoses included dementia, atrial fibrillation, and chronic kidney disease. According to the 5/4/23 minimum data set (MDS) assessment, the resident had a brief interview for mental status (BIMS) score of 14 out of 15 and did not have any cognitive impairments. The resident required extensive assistance with bed mobility, transfers, and toileting. The resident was occasionally incontinent of bladder and frequently incontinent of bowel. The resident had an unstageable pressure injury presenting as a deep tissue pressure injury upon admission in August of 2022 that was coded as a Stage IV pressure ulcer on the May 2023 MDS. The resident did not have any behaviors or refusal of care. B. Record review - history of pressure injury and plans to prevent new pressure injury from developing The Braden scale measuring pressure injury risk completed on 8/13/22 showed the resident was at high risk for pressure ulcers with a score of 17 because of the following risk factors: atrial fibrillation, chronic pain, poor mobility, chronic kidney disease, long-term anticoagulant use, and advanced age. The weekly skin observation tool completed on 8/13/22 did not identify any skin issues. The new admit report and aide checklist dated 8/12/22 identified discoloration to the right heel. The wound care note completed by the wound care provider on 8/18/22 identified an unstageable deep tissue injury to the right heel, healing, and orders to float heels in bed and skin prep once daily for 30 days. The wound care note for 8/24/22 showed the wound was getting larger, evidenced by an increased surface area. The same orders as previously implemented were continued. On 8/30/22, physician orders were entered for Prevalon boots to the heels when in bed if tolerated, otherwise continue to float heels. Wound care notes from 9/7/22 to 10/7/22 showed the wound improved as evidenced by a decrease in surface area. On 10/19/22 the wound care note identified a surgical debridement of the wound to remove necrotic tissue had been performed resulting in an increase in surface area. The orders were changed to use medihoney and cover with a gauze island with the dressing to be cleaned and redressed three times a week and as needed. The wound care note on 11/23/22 documented the wound was resolved as evidenced by epithelialized tissue. The procedure note dated 12/7/22 showed a scabbed area to the right heel without any signs or symptoms of infection and orders were to continue to offload heels at night. The procedure note dated 12/21/22 identified the wound as unstageable without drainage and new orders to cleanse, pat dry and apply puracol every other day with a dry dressing and offload the feet. The wound status was documented as healing. On 1/4/23 the procedure note orders were changed to apply medihoney and calcium alginate three times a week. The wound status was documented as worsening as evidenced by an increase in surface area. The treatment administration record (TAR) was revised March, 2023. This was the first time there was documentation of staff assisting with donning heel boot protectors at bedtime every night shift for skin integrity. The treatment continued until 4/18/23 and then it no longer appeared on the TAR. The wound care notes continued to show the wound worsening from 4/19/23 to 5/24/23 as evidenced by increased surface area. The resident's care plan, last revised on 5/31/23, identified the resident had a risk for impaired skin integrity related to an unstageable deep tissue injury upon admission due to atrial fibrillation, chronic pain, chronic kidney disease, long-time anticoagulant use, impaired mobility, and advanced age. The interventions included encouraging the resident to change positions frequently, shift weight while in the wheelchair and alternate sides while in bed, Prevalon boots provided and floating heels while in bed. C. Observations - failure to implement plans to prevent pressure injury During continuous observations on 7/24/23 that started at 9:40 a.m. and ended at 3:30 p.m., Resident #23 sat in her wheelchair. Notwithstanding her high risk for pressure injury and history of actual pressure injury, need for extensive assistance with mobility, and incontinence, the resident was not approached by staff to toilet or reposition for six hours. -At 10:00 a.m., the resident was sitting in her wheelchair with the TV on. -At 11:30 a.m., the resident sorted through papers on her bedside table. She remained in her wheelchair. -At 12:00 p.m., the resident was taken to the dining room in her wheelchair for lunch. She was not offered toileting, repositioning or reminded to shift her weight. -At 12:15 p.m., an unidentified certified nurse aide (CNA) delivered the resident her lunch in the dining room. She did not remind the resident to shift her weight or offer assistance to reposition. -At 1:00 p.m., the resident was taken back to her room and remained in her wheelchair. She was not offered toileting or incontinence care. She was also not reminded to shift her weight or offered assistance to reposition. -At 1:30 p.m., the resident was in the same position in her wheelchair in her room. She had not been offered to reposition or lay down. IV. Resident #85 A. Resident status Resident #85, age [AGE], was admitted on [DATE]. According to the July 2023 CPO, diagnoses included heart failure, morbid obesity, artificial openings of urinary tract, and renal and ureteral calculous obstruction. According to the 6/26/23 MDS assessment, the resident had a brief interview for mental status (BIMS) score of 14 out of 15 and did not have any cognitive impairments. The resident required extensive assistance with toileting, dressing, and walking. The resident needed limited assistance with bed mobility and transfers. The resident was frequently incontinent of bowel and had an indwelling catheter. The resident did not have any behaviors or refusal of care. B. Record Review - history of pressure injury and plan to address pressure injury risk According to the 6/26/23 MDS, the resident had a stage IV (four) pressure injury to the coccyx upon admission in September of 2022 that was coded as a Stage four pressure ulcer in the June 2023 MDS. The Care Plan initiated on admission on [DATE] identified the resident as being at risk of impaired skin integrity with pertinent interventions to encourage the resident to change positions frequently, shift weight while in wheelchair, and to limit sitting to 60 minutes. The Care Plan, revised in July 2023, showed impaired skin integrity and had pertinent interventions to encourage the resident to change positions frequently, shift weight while in wheelchair, and to limit sitting to 60 minutes. The [NAME] dated 7/25/23, under resident care, showed the resident needed to be limited to sitting for no longer than 60 minutes. C. Observations 1. During continuous observations on 7/20/23 that started at 9:14 a.m. and ended at 1:45 p.m. Resident #85 sat in her wheelchair and was not approached by staff to reposition or to move to the bed or recliner. -At 9:45 a.m., the resident was sitting in her wheelchair in her room with the TV on. -At 11:00 a.m., the resident continued to sit in her wheelchair while watching TV. -At 12:00 p.m., the resident wheeled herself to the dining room for lunch. -At 12:15 p.m. an unidentified CNA served lunch to the resident. She did not offer to reposition the resident. -At 12:45 p.m. the resident returned to her room and remained in her wheelchair. There was no evidence the resident had been repositioned or received incontinence care. At 1:45 p.m. an unidentified CNA assisted the resident to lie down in her bed. At this time, she had been sitting up in her wheelchair for four and one-half hours. 2. During continuous observations on 7/24/23, starting at 9:40 a.m. and ending at 2:30 p.m., the resident sat in her wheelchair and she was not approached to reposition or move to her bed or recliner. -At 9:55 a.m., the resident went downstairs in her wheelchair for an activity in the main dining room. -At 10:55 a.m., the resident returned upstairs to her room and she remained in her wheelchair. -At 11:55 a.m., the resident ambulated to the dining room in her wheelchair for lunch. -At 12:15 a.m., an unidentified CNA delivered the resident her lunch. The CNA did not offer to reposition the resident or remind her to shift her weight. -At 1:00 p.m., the resident went back to her room and picked up a small book from her bedside table. She remained seated in her wheelchair. -At 1:40 p.m., CNA #13 entered the resident's room and assisted the resident to stand. After the resident stood up she sat back down in her wheelchair. -At 2:15 p.m. CNA #13 and licensed practical nurse (LPN) #3 assisted the resident to her recliner chair. At this time, except for standing briefly at 1:40 p.m., the resident had been sitting upright in her wheelchair for five hours. V. Interviews CNA #13 was interviewed on 7/25/23 at 1:45 p.m. She said she had turned in her notice to end her employment with the facility because there was not enough staff to help the residents in a timely manner. She said the facility was always short staffed and she did not have time to remind or help residents turn or reposition because she is always providing care for someone else. (Cross-reference F725) An anonymous nurse was interviewed on 7/25/23 at 1:55 p.m. The nurse said the facility needed more help. The nurse said they did not have time to remind or assist residents to turn or reposition. Tears began to roll down their cheeks as they described often going home and not wanting to come back to work at the facility because the staffing was so short. The nurse said it was not their intention to provide subpar care but they could only do what they had time to do. (Cross-reference F725) The director of nursing (DON) was interviewed on 7/25/23 at 8:16 p.m. She said residents who were unable or do not remember to reposition themselves should be reminded and/or assisted to reposition every two hours and as needed. She said the CNAs knew who needed to be reminded or assisted with repositioning by looking at the [NAME]. She said that residents who are incontinent should be checked every two hours and as needed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** III. Resident #92 A. Resident status Resident #92, age [AGE], admitted to the facility on [DATE]. According to the July 2023 CPO, diagnoses included chronic kidney disease, anemia in chronic kidney disease and morbid obesity. The 5/26/23 minimum data set (MDS) assessment, showed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 14 out of 15. She required total dependence for bed mobility and extensive assistance from two or more staff members for transfers and toilet use. The resident was independent with eating. B. Resident interview Resident #92 was interviewed on 7/19/23 at 11:00 a.m. She said she only received water with her meals and she was not offered water outside of meal times. She said she had to push her call light and wait over an hour to ask for water and most of the time she would not get it until the meal was served anyway. (Cross-reference F725) C. Observations During the continuous observation period on 7/24/23 at 9:00 a.m. to 11:40 a.m. and at 12:30 p.m. to 3:30 p.m. the resident was not offered water or other hydration. -At 9:00 a.m. the resident was laying in her bed. She did not have any fluids available at her bedside. -At 11:40 a.m. an unidentified CNA answered the resident's call light but did not offer the resident any water or other hydration. -At 12:45 p.m. an unidentified CNA removed the resident's lunch tray but did not offer the resident any additional beverages or water. -At 1:30 p.m. the resident did not have any water in her cup on the bedside table. -At 2:45 p.m. the resident did not have any water in her cup on the bedside table. -At 3:30 p.m. the resident did not have any water within reach. During the continuous observation period on 7/25/23 at 1:35 p.m. to 5:33 p.m. the resident was not offered any fluids outside of meal time. -At 1:35 p.m. the resident was in bed and she did not have any water in her cup on her bedside table. -At 3:00 p.m. her water cup remained empty. -At 5:30 p.m. an unidentified CNA served the resident a 240 ml cup of a red drink and a 240 ml cup of another beverage. The resident had not had any fluids since lunch. D. Record review The nutrition assessment dated [DATE] indicated the resident was on a 3500 ml fluid requirement daily. The care plan initiated 6/14/23 had a focus for risk of nutrition deficit due to diuretic use and had an intervention to encourage fluid intake with and in between meals. For the month of July 2023 the fluid intake response form for Resident #92 showed the resident consumed anywhere from 340 milliliters (ml) of fluid to 1920 ml of fluid. Most days the resident consumed less than 1000 ml of fluid. The hydration sheets showed the following for July 2023: 7/1/23 600 ml 7/2/23 800 ml 7/4/23 1920 ml 7/5/23 400 ml 7/6/23 800 ml 7/7/23 340 ml 7/8/23 960 ml 7/9/23 350 ml 7/10/23 980 ml 7/11/23 600 ml 7/13/23 680 ml 7/14/23 780 ml 7/16/23 960 ml 7/17/23 520 ml 7/19/23 960 ml 7/22/23 1200 ml 7/23/23 720 ml 7/24/23 600 ml E. Staff interviews CNA #13 was interviewed on 7/25/23 at 1:45 p.m. She said she did not have time to provide residents with water unless they asked for it. She said there was not enough staff and she spent her entire shift answering call lights. (Cross-reference F725) The RD was interviewed on 7/25/23 at 6:31 p.m. She said residents should be offered fluids not only during meal times but in between meals to meet their individual hydration needs. Based on observations, record review and interviews, the facility failed to ensure two (#130 and #92) of three out of 71 sample residents received the care and services necessary to meet their nutrition needs and to maintain their highest level of physical well-being. Specifically, the facility failed to: -Ensure Resident #130 received assistance to meet her nutrition and hydration needs; and, -Ensure Resident #92 received sufficient hydration. Findings include: I. Facility policy and procedure A. The Hydration policy and procedure, revised January 2020, was provided by the director of nursing (DON) on 7/25/23 at 6:30 p.m. It read in pertinent part, Purpose: to identify residents at risk for dehydration. To evaluate the fluid requirement of each resident. To identify risk factors which lead to dehydration and develop an appropriate preventative care plan. To provide sufficient fluid intake to maintain proper hydration and health. B. The Facility Nutrition Program policy and procedure, revised April 2007, was provided by the DON on 7/25/23 at 6:30 p.m. It read in pertinent part, Direct care staff, assisted by the facility's clinical dietician, will evaluate each individual's physical, functional, and psychosocial factors that affect eating and nutritional intake and utilization. A facility dietician will help assess the nutritional needs and risks of all residents and patients in the facility, and help the facility assure that it provides appropriate meals and other nutritional interventions. II. Resident #130 A. Resident status Resident #130, age [AGE], was admitted on [DATE]. According to the July 2023 computerized physician orders (CPO), the diagnoses included Alzheimer's disease, anxiety disorder, macular degeneration and legal blindness. The 5/29/23 minimum data set (MDS) assessment revealed the resident had severe cognitive impairment with a brief interview for mental status score of one out of 15. She required extensive assistance of two people with bed mobility, transfers, dressing, toileting and personal hygiene. The resident required extensive, one person physical assistance with eating. It indicated the resident did not have weight loss of 5% or more in the last month or 10% or more in the past six months. B. Resident representative interview Resident #130's representative was interviewed on 7/19/23 at 4:05 p.m. He said he did not think the facility staff encouraged the resident to drink enough. He said she had two beverage containers, one filled with cranberry juice and the other with Sprite (soda) each day and when he arrived almost every day around 2:00 p.m. the containers were still filled to the top and not within her reach when she was sitting in the recliner. He said Resident #130 required assistance with drinking and eating, as well as encouragement. He said when she was thirsty she would call out for help, but she would only receive assistance when someone was around in the hallway, which was not very often. He said when he arrived at the facility, more often than not, her lunch was sitting on the over bed table, not within reach and still covered in clear wrapping. He said Resident #130 did not like going to the dining room to eat, because she was not a very social person. He said she needed to be assisted in her room, but he felt the staff were too busy or did not care to ensure she ate, because she required more attention. He said he felt that the resident did not get assistance with eating unless a family member was present. He said the facility often gave the resident food items that were not cut up. He said the resident was not able to cut up her food for her and he had made it clear that when possible to cut up items. He said sandwiches could be cut up into small sections to make it easier for the resident to handle. He said the resident was not able to pick up a whole hamburger or sandwich to eat. C. Observations During a continuous observation on 7/20/23 beginning at 9:30 a.m. and ending at 2:15 p.m., Resident #130 was observed sitting in the recliner chair, sleeping. A water pitcher (24 ounces) was observed filled to the top with ice and another beverage tumbler (26 ounces) with a red liquid (cranberry juice) filled to the top sitting on top of the over bed table. The table was not within reach of the resident, who was reclined in the recliner chair. The hospice certified nurse aide (CNA) was fixing the resident's blanket and then left the room. -At 9:48 a.m. the hospice CNA told the nurse she had provided a bed bath to Resident #130 and then left the facility. -At 10:09 a.m. two unidentified activity staff members entered the resident's room for the donuts and coffee activity. They entered the room and then immediately exited. One staff member said, she is sleeping, just mark passive down cause she is asleep. The other staff member said, well, they can't say we didn't offer her anything. -At 11:34 a.m. the over bed table was in the same position and not within reach of the resident. Staff were not observed entering the resident's room to offer her a drink. -At 11:51 a.m. an unidentified nurse entered the resident's room. She woke the resident up to take her medications. The resident said she was thirsty and the nurse held the drink tumbler containing the cranberry juice for the resident as she drank. The resident said, thank you, I was so thirsty. -At 12:34 p.m. CNA #19 entered the resident's room with her lunch. The resident was served a cheeseburger, not cut up and the plate was wrapped in clear plastic. She did not wake up the resident to eat lunch. She placed it on the over bed table, which was still not within reach of the resident, who remained in the recliner chair. She did not provide any additional beverages for the resident. -At 2:07 p.m. the resident remained in the same position and her food was still wrapped, on the over bed table and not within reach of the resident. The facility staff had not returned to assist the resident with eating or set up her meal. Her water pitcher remained at the same level (full) and the tumbler with cranberry juice had been reduced by approximately six ounces. During a continuous observation on 7/24/23 beginning at 10:00 a.m. and ended at 2:50 p.m. Resident #130 was observed laying in the recliner chair. The hospice CNA exited the room after providing incontinence care and personal hygiene. The hospice CNA informed the nurse of the care she provided and then left the facility. -At 10:30 a.m. the resident was lying in the recliner chair with a water pitcher filled to the top on the over bed table, not within reach of the resident. -At 11:57 a.m. registered nurse (RN) #3 entered the room to administer medications. She entered with a cup of cranberry juice (six ounces). The resident took the medication and drank the entire cup. -At 12:57 p.m. a visitor entered the room and played music for the resident. The resident's water pitcher remained on the over bed table, not within reach. -At 1:06 p.m. CNA #19 entered the room and delivered her lunch, shrimp pasta. -At 1:13 p.m. an unidentified CNA entered the room with an eight ounce (oz) cup of cranberry juice and placed it on the over bed table. He did not move the table within reach of the resident. -At 1:23 p.m. RN #3 entered the room with a six oz cup of cranberry juice and medications. The resident drank the entire cup of cranberry juice. The nurse did not move the over bed table within reach of the resident. -At 1:46 p.m. CNA #19 was observed in the hallway cleaning off plates after residents were finished eating. She informed the nurse that she needed to feed Resident #130. The nurse said she needed her to lay another resident down before she assisted Resident #130 with her meal. -At 2:49 p.m. Resident #130 was observed sleeping in the recliner chair. The resident's lunch was observed on the over bed table, not within reach. The resident was served shrimp noodles with large pieces of cantaloupe on the side. It appeared as though the resident had eaten one to two bites of the shrimp noodles, the cantaloupe was untouched and still covered with plastic. The water pitcher was filled to the top and two glasses of cranberry juice were filled to the top, untouched. D. Record review The memory impairment care plan, initiated on 11/10/21 and revised on 6/1/23, documented the resident had impaired short term and long term memory. The interventions included offering gentle cueing, reminders and redirection as needed; providing comfort when the resident is confused and does not know where she is; and contacting the family for assistance as needed. The dehydration care plan, initiated and revised on 6/12/23, documented the resident had a potential for dehydration or fluid deficits related to care needs and Alzheimer's disease. The interventions included encouraging the resident to drink fluids every shift and ensuring the resident had access to fluids. The nutrition care plan, initiated on 11/11/21 and revised on 6/12/23, documented the resident was at nutritional risk due to a diagnosis of Alzheimer's disease, advanced age and weight loss. It indicated the resident was receiving hospice care. The interventions included providing the resident's diet as ordered, offering meal alternatives if the resident's intake is poor, providing reminders that items are available from the a la carte menu, providing meal assistance as needed, putting the food into bowls so it is easier for the resident to hold/eat, monitoring weights monthly, encouraging fluids in between meals, and providing supplements as ordered. The comprehensive care plan documented that the resident often preferred to sit in her recliner chair, partially reclined when she was eating or drinking. It indicated she had been provided education about the risks associated with improper alignment, however because of the resident's dementia, it was unclear how much she was able to retain. It indicated she would often decline assistance with meals. The interventions included ensuring the resident has the diet necessary to make eating as safe as possible, raising the head of the recliner as much as she will allow, setting up the resident's meal and providing feeding assistance. The activities of daily living (ADL) care plan, initiated on 11/11/21 and revised on 6/12/23, documented the resident had a self-care performance deficit related to impaired balance, decreased endurance, blindness and dementia. It indicated the resident was unable to meet her own self care needs and was dependent upon staff for care. It indicated the resident had varying levels of feeding herself and staff should set up her meals and assist as needed (last revised 11/16/21). The 2/25/23 nutrition assessment documented Resident #130 received a regular, mechanical soft diet and had an average meal intake of 50-75% (percent). The resident received Ensure three times per day with an average intake of 50-100%. It indicated the resident required limited assistance with eating. The resident's estimated needs were documented as approximately 1500 calories, approximately 63 grams of protein and 1700-2100 ml (milliliters) of fluids. The July 2023 meal intakes documented the resident had a variable intake, but primarily between 50-75%, however, on multiple occurrences (11 out of 24), meal intakes were only documented once per day. Resident #130's weights were documented as follows: -1/13/23: 146.5 lbs (pounds) -2/10/23: 147.4 lbs -3/16/23: 143 lbs -4/3/23: 144.2 lbs -5/1/23: 142.4 lbs -6/5/23: 138.7 lbs (loss of 5.26% in six months); and -7/11/23: 134.4 (loss of 3.10% in one month). -A review of the resident's electronic medical record did not reveal any further nutrition documentation or interventions. E. Staff interviews CNA #19 was interviewed on 3:15 p.m. She said Resident #130 required total assistance with all ADLs. She said the resident required assistance with eating. She said the resident could not pick up the food by herself. She said the resident required a lot of cueing and encouragement to eat. She said the resident was not able to pick up the water pitcher or tumbler by herself. She said staff should be offering her a beverage every one to two hours, but she got too busy and would forget. (Cross-reference F725 for insufficient staffing). She confirmed the resident's over bed table was not within reach of the resident. She said it was easier for the resident to eat her meals if it was cut up. She confirmed, during the survey process, the resident's food has sat in her room for an extended periods of time. She said she got really busy and it was hard to be able to assist her with her meal timely. (Cross-reference F725) She confirmed the shrimp noodles were cold when she tried to assist the resident. She said she did not think it probably tasted good cold and that could be why the resident did not take very many bites. The registered dietitian (RD) was interviewed on 7/25/23 at 6:15 p.m. She said Resident #130 was not her radar for weight loss. She said the resident received Ensure three times per day and had an average meal intake of 50-75%. She agreed the resident had a gradual weight loss over the past few months. She said the resident had lost 8% in the past six months. She said she had not been notified of the gradual weight loss because it was not considered significant. She said Resident #130 required assistance with eating and required a lot of cueing and encouragement. She said she conducted observations of feeding in the dining room, but did not observe residents in their rooms. She said she had not assessed the resident since May 2023. She said she did not have any additional interventions in place to address the resident's weight loss. She said the resident should be assisted when her meal was delivered to her room. She said the resident's meal should not be sitting in her room, not within reach and still covered. She said beverages should be offered to the residents throughout the day. She said she would recommend the resident receive 50 to 60 ounces of fluids per day (1479 ml to 1775 ml). -However, the amount the RD recommended varied from the 2/25/23 nutrition assessment where it was recommended she receive 1700-2100 ml. The DON was interviewed on 7/25/23 at 3:29 p.m. She said beverages should be offered throughout the day and night, every couple of hours. She said beverages should be placed within reach of the resident. She said any residents who required assistance and ate in their rooms, should have their meal trays passed at the same time to maintain food temperature. She said once their tray has been delivered, the staff member should sit and assist the resident with her meal. She said she was unsure of how much care Resident #130 required. She said the RD was responsible to identify weight loss trends and put interventions into place.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interviews, the facility failed to ensure one (#108) resident who required respiratory care received the care consistent with professional standards of practice out of 71 sample residents. Specifically, the facility failed to ensure a portable oxygen concentrator was in working condition for Resident #108. Findings include: I. Resident status Resident #108, age [AGE], was admitted on [DATE]. According to the July 2023 computerized physician orders (CPO), the diagnoses included dementia, chronic obstructive pulmonary disease (COPD), emphysema (lung disease that causes breathlessness) and anxiety. The 6/16/23 minimum data set (MDS) assessment revealed the resident had severe cognitive impairment with a brief interview for mental status score of five out of 15. She required extensive assistance from one staff member for dressing, toilet use and personal hygiene. She required oxygen therapy. II. Observations and interviews On 7/24/23 at 12:34 p.m. certified nurse aide (CNA) #3 approached Resident #108 with a rag and wiped a clear, liquid substance off the floor located directly under the portable oxygen tank hanging from back of wheelchair of Resident #108. On 7/25/23 at 10:02 a.m. Resident #108 was observed sitting in a wheelchair in her personal room, two puddles of a clear, liquid substance was observed on the floor under the wheelchair and portable oxygen tank, approximately four to six inches in diameter. CNA #3 entered the room, observed the clear, liquid substance and wiped it up. CNA #3 checked the portable oxygen tank level for fullness, the tank level was less than a quarter of the way full. CNA #3 used a pulse oximeter (device placed on fingertip to measure oxygen levels) to measure the oxygen level of Resident #108. Reading on the pulse oximeter revealed an oxygen level of 89 percent, she then provided Resident #108 with a nasal cannula (a device used to administer supplemental oxygen to those in need of oxygen therapy) from a stationary oxygen tank in the room. CNA #3 said she noticed a clear liquid substance dripping from the portable oxygen tank on 7/24/23 at 12:34 p.m. She said she took no further action past cleaning the substance from the floor. She said she was aware it had came from the portable oxygen tank of Resident #108. CNA #5 was entered the room of Resident #108. CNA #5 said she had filled the oxygen tank at 7:00 a.m. that morning (7/25/23). CNA #3 used the pulse oximeter for a second time 10:13 a.m. to check the oxygen levels of Resident #108, oxygen level was 96 percent. III. Record review Resident #108 had a physician's order to receive oxygen via nasal cannula at 2 liters. The care plan with a revision date or 6/28/23 revealed Resident #108 required oxygen use for emphysema and COPD. IV. Staff interviews CNA #3 was interviewed on 7/25/23 at 10:24 a.m. She said she noticed a liquid dripping from Resident #108's portable oxygen tank on 7/24/23. She said she did not inspect the tank for further defects. She said oxygen tanks not in good working condition should be switched out for equipment that was in working condition. CNA #5 was interviewed on 7/25/23 at 10:24 a.m. She said she was not aware Resident #108's portable oxygen tank had been dripping liquid. She said oxygen tanks not in good working condition should be switched out for equipment that was in working condition. The director of nursing was interviewed on 7/25/23 at 8:00 p.m. She said if a portable oxygen tank was observed to be leaking fluid it should be replaced by one in working condition. The facility took the concentrator that Resident #108 was using out of circulation.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews the facility failed to develop and implement an antibiotic stewardship program that included antibiotic use protocols and a system to monitor antibiotic use for one (#143) resident reviewed for antibiotic stewardship out of 71 sample residents. Specifically, the facility failed to thoroughly assess and document clinical signs and symptoms of an infection to ensure the criteria of the infection was met prior to the administration of an antibiotic for Residents #143. Findings include: I. Professional reference The Centers for Disease Control and Prevention (2019) The Core Elements of Antibiotic Stewardship for Nursing Homes APPENDIX B: Measures of Antibiotic Prescribing, Use and Outcomes, retrieved 7/27/23 https://www.cdc.gov/antibiotic-use/core-elements/pdfs/core-elements-antibiotic-stewardship-appendix-a-508.pdf. It read in pertinent part, Incomplete assessment and documentation of a resident's clinical status, physical exam or laboratory findings at the time a resident is evaluated for infection can lead to uncertainty about the rationale and/or appropriateness of an antibiotic. Ongoing audits of antibiotic prescriptions for completeness of documentation, regardless of whether the antibiotic was initiated in the nursing home or at a transferring facility, should verify that the antibiotic prescribing elements have been addressed and recorded. II. Facility procedure A Synopsis of McGeer's Definitions of Infection: Constitutional Criteria in Residents of Long-Term Care Facilities (LTCFs) was received by the infection (IP) preventionist on 7/26/23, it read in pertinent part: Fever Single oral temperature >37.8°C (>100°F) OR Repeated oral temperatures >37.2°C (99°F) or rectal temperatures >37.5°C (99.5°F) OR Single temperature >1.1°C (2°F) over baseline from any site (oral, tympanic, axillary) Leukocytosis Neutrophilia (>14,000 leukocytes/mm3) OR Left shift (>6% bands or =1,500 bands/mm3) Acute change in mental status from baseline (all criteria must be present) Acute onset Fluctuating course Inattention AND Either disorganized thinking or altered level of consciousness Acute functional decline A new 3-point increase in total activities of daily living (ADL) score (range, 0-28) from baseline, based on the following 7 ADL items, each scored from 0 (independent) to 4 (total dependence)14 Bed mobility Transfer Locomotion within LTCF Dressing Toilet use Personal hygiene Eating. III. Resident status Resident #143, over age [AGE], was admitted on [DATE]. According to the July 2023 computerized physician orders (CPO), diagnoses included dementia. The 5/20/23 minimum data set (MDS) assessment revealed the resident had severe cognitive impairment with a brief interview for mental status (BIMS) score of one out of 15. The resident required extensive assistance from staff for toilet use and personal hygiene. IV. Record review The 7/13/23 progress note revealed Resident #143 had a temperature of 96.9, she was observed to have increased weakness while ambulating (walking) and she was incontinent with dark yellow urine that had an odor. The facility placed a call to the resident's nurse practitioner and received orders to obtain UA (urine analysis), C&S (culture and sensitivity test, to check which medicine would work best on germ if found), CMP (complete blood count lab) and CBC (complete blood count lab). -However, she did not meet the criteria for a urine analysis due her not meeting the McGreer's criteria. Although she had weakness and odor with her urine, she did not have the presence of a temperature or other symptoms to warrant further testing. The 7/13/23 lab results revealed Resident #143 had urine that was amber in color and cloudy in clarity with presence of bacteria. Resident #143 tested negative for leukocyte esterase (leukocyte esterase test is a urine test for the presence of white blood cells and other abnormalities associated with infection) and a further culture was not indicated (a culture would identify what type of bacteria may be causing an infection). -However, the resident was subsequently started on an antibiotic even though she did not meet the McGreers criteria. The 7/14/23 progress note revealed the nurse practitioner was notified on results for labs and a new order to start antibiotic Nitrofurantoin 100 milligram (mg) twice daily (TID) for urinary tract infection (UTI) for five days. The July 2023 CPO revealed the following order: -Nitrofurantoin Macrocrystal oral capsule 100 mg give 1 capsule by mouth two times a day for UTI for five days from 7/15/23 to 7/18/23. V. Staff interviews The infection preventionist was interviewed on 7/25/23 at 5:30 p.m. He said the facility used the McGeer Criteria for determining the need for a urinary analysis (UA) in regards to a urinary tract infection (UTI). He said Resident #143 displayed dark urine and foul smelling odor in her brief. He said, according to the McGeer Criteria, Resident #143 did not meet criteria for further testing. In addition, he acknowledged the resident was not supposed to be started on an antibiotic when she did not meet the McGreer criteria.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and interviews, the facility failed to ensure residents had safe, clean, comfortable and homelike environments in multiple areas of the facility. Specifically, the facility failed to ensure resident rooms and facility hallways. Findings include: I. Initial observations The following was observed during the initial walkthrough of entering the facility on [DATE] at 9:00 a.m. until [DATE] at 4:00 p.m. The third floor memory care was observed to have bugs (deceased ) in multiple ceiling light fixtures throughout the unit. room [ROOM NUMBER] and #17: The window blinds were observed to be broken, bent and missing. room [ROOM NUMBER]: The electrical outlet on wall behind head of bed was observed to be dislodged from wall and unusable. room [ROOM NUMBER]: Multiple holes and tears, ranging from approximately one inch to four inches were observed in the screen to the window. room [ROOM NUMBER]: Two vertical holes, approximately three inches in length and half an inch wide were observed in the wall behind the head of the bed; pieces of drywall and dust was observed on the floor below the holes. room [ROOM NUMBER]: Ants were observed on the floor nearest the window. II. Environmental tour and staff interview The environmental tour was conducted on [DATE] at 3:21 p.m. with the maintenance director (MTD). The above observations were reviewed and documented by the MTD. He said he did not know if it was the responsibility of the maintenance or housekeeping department to clean bugs from light fixtures on the ceiling, he said he would discuss with the housekeeping department. He said he was aware of the damaged blinds in room [ROOM NUMBER] and #17 and was awaiting delivery of more blinds. He said he was unaware of the damaged electrical outlet in room [ROOM NUMBER]. He said he was unaware of the damage to the screen window in room [ROOM NUMBER] and suspected it was [NAME] damage from a recent storm. He said he was unaware of the damage to the wall in room [ROOM NUMBER] but was familiar with the problem. He said it occurred with the bariatric beds and the design when the residents raise and lower the head of the bed. He said he was aware of the ants in room [ROOM NUMBER] and the problem has been resolved. He said the staff submitted work tickets through a web-based communication system to inform the maintenance department of needed repairs. He said the same system was used to track and complete general maintenance rounds in the facility. He said he would attend to repairs as soon as possible.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review, the facility failed to ensure seven (#19, #69, #90, #92, #25, #98 and #75) residents were provided prompt efforts by the facility to follow up on grievances out of 71 sample residents. Specifically, the facility failed to ensure grievances were followed up timely with a resolution in regards to missing property. Findings include: I. Facility policy and procedure The Complaints and Grievances policy, revised 2/8/19, was provided by the nursing home administrator (NHA) on 7/26/23 at 11:03 p.m. It read in pertinent part This facility encourages and requests that staff, residents, families, visitors, express their concerns, complaints and grievances. The facility will review, investigate and respond to all such concerns. A resident, his or her representative, family member, visitor or advocate may file a verbal or written grievance or complaint concerning treatment, abuse, neglect, harassment, medical care, behavior of other residents or staff members, theft of property, without fear of threat or reprisal in any form. II. Resident interviews All residents were identified by facility and assessment as interviewable. Resident #19 was interviewed on 7/19/23 at 1:54 p.m. She stated she lost one of her favorite clothing items shortly after coming to the facility. She said she filed a grievance and went directly to the laundry to try to locate the missing item but was unable to find it. She said she was not reimbursed for the item or offered any other kind of resolution. She said no staff or management had followed up with her. Resident #69 was interviewed on 7/19/23 at 12:47 p.m. She said she had several bras when she first admitted to the facility on [DATE]. She said she no longer had any bras at all. She had reported the missing items to the certified nurse aides (CNA) and nurses; however, she had not heard anything back. Resident #69 said the facility had not located or replaced any of the missing bras resulting in her not having any bras to wear and this makes her uncomfortable. Resident #90 was interviewed on 7/19/23 at 1:41 p.m. He said he had a watch when he was in his initial room approximately one month ago, however, when he moved to his current room the watch did not make it there. He said he filed a grievance and one of the CNAs said she looked for it in his old room but did not see it. Resident #90 was not offered any compensation or a replacement watch. Resident #92 was interviewed on 7/19/23 at 11:00 a.m. Resident #92 said she ordered items online and often did not receive them. Most recently she said she ordered some Easter cards and two puzzles that she did not receive. She did file a grievance and although there was writing on the grievance that the items were found in her room, they were not located. She said the items were still missing and she was not offered any replacement items or reimbursement. Resident #25 was interviewed on 7/19/23 at approximately 12:00 p.m. She said her clothing went missing on 7/4/23 after she requested her clothing to be laundered; prior to the clothes being laundered the resident ensured her clothing was labeled to prevent them from getting lost. She notified a CNA on 7/4/23 that upon receipt of her clean laundry she was missing her husband's polo shirt and her shirt with ruffled sleeves. The resident said the CNA told her she would let laundry know and they would keep looking for the missing items until they showed up. The resident said no grievance and or complaint form was filled out and the resident has not received any resolution since 7/4/23 (21 days since verbal complaint was made to staff). Resident #98 was interviewed on 7/19/23 at 2:05 p.m. She said she had two blankets go missing shortly after her sister brought them to her approximately six months ago. She said she filed a grievance but the missing blankets were not found and she was not offered reimbursement or a replacement. She said if you have nice things at the facility they go missing. Resident #75 was interviewed on 7/20/23 at 9:49 a.m. She said within the last six months her clothes have gone missing. She said her phone has been missing for over a week. Resident #75's daughter was interviewed on 7/26/23 at 4:30 p.m. She said the facility staff threw clothes away all the time. She said she went to the laundry room asking about her mother's clothing and the laundry staff showed her that the floor staff constantly threw clothes away that were not marked. She said she brought in a bag of clothes for the resident and labeled it with the resident's name and room number. She said the clothes never made it to Resident #75. She said three weeks ago, Resident #75's bed spread went missing. She said she had physically taken it to the laundry room and handed it to the staff. She said they told her if the label fell off, then it would be thrown away. She said the laundry staff would not allow her to take the clothing out of the trash can for fear they would get into trouble. She said she has seen personal items and clothes go missing often and the facility did not ever replace them. III. Observations and record review On 7/24/23 at approximately 11:30 a.m. the laundry room was observed. The laundry room contained a lost and found section which contained approximately 50 items of missing clothing. The grievances were requested from the facility on 7/24/23 for the residents (see above) and only one grievance was provided for Resident #92. However, according to Resident #92 the items were not located (see above). IV. Staff interviews CNA #2 was interviewed on 7/25/23 at approximately 3:00 p.m. She said she would not fill out a complaint form if a resident complained about missing property. The director of nurses (DON) was interviewed on 7/25/23 at approximately 7:30 p.m. The DON said if a resident told a CNA property was missing then the staff should immediately fill out a grievance form. If staff were unable to locate the missing item then the resident would be reimbursed monetarily if they had a receipt or the missing items needed to be replaced.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interviews, the facility failed to consistently provide activities of daily living (ADL) support for three (#27, #98 and #106) of six dependent residents reviewed for ADL care out of 71 sample residents. Specifically, the facility failed to: -Provide repositioning adjustments for Resident #27 and Resident #98 who were unable to reposition themselves; and, -Provide timely incontinence care for Resident #27 and Resident #106. Cross-reference F725: Lack of sufficient staffing to meet residents' needs for care and services Findings include: I. Facility policy and procedures A turning and repositioning document not dated or titled as a policy was provided by the nursing home administrator (NHA) on 7/26/23 at 11:05 p.m. It read in pertinent part, Evaluate bed mobility and develop a turning schedule based on identified risk. Individualized positioning regime and repositioning schedule must be documented and displayed. If the patient is able to make large body movements easily and frequently: Monitor bed mobility and ensure adequate turning every 3-4 hours. If the patient is able to make small body shifts but is unable to make large body movements: Reposition every 2 hours. Use positioning devices to position the patient in a 30-degree laterally inclined position when repositioned to either side (see picture below). Avoid 90-degree side-lying position. If the patient is unable to make any independent movement: Turn every 2 hours or more frequently if indicated. May require therapeutic pressure management mattress. Please note that a patient on a therapeutic pressure management mattress should still be turned and repositioned regularly as per individualized positioning regime. Use positioning devices to prevent contact between bony prominences and completely relieve heel pressure when in bed. Support length of legs with a pillow and allow heels to drop off pillow. II. Resident #27 A. Resident status Resident #27, age [AGE], was admitted to the facility on [DATE] and readmitted on [DATE]. According to the July 2023 computerized physician orders (CPO), diagnoses included hypertensive heart disease with heart failure, diabetes mellitus type 2, morbid obesity, and chronic obstructive pulmonary disease. The 6/21/23 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 13 out of 15. She required extensive assistance with two persons for bed mobility, toileting and transfers, and total dependence with one person for locomotion on unit, dressing and bathing. There were not any rejection of care behaviors exhibited. B. Record review The resident's care plan, revised June 2023, revealed the resident had a self-care performance deficit related to muscle weakness, activity intolerance, decreased endurance, left knee pain, vision impairments and upper extremity tremors. The interventions revealed bed mobility required the assistance of one to two staff to sit up, lie down, turn, and reposition in bed. Pertinent interventions were to encourage and assist the resident to change positions frequently as tolerated, encourage her to shift her weight when in the wheelchair and to alternate from side to side while in bed using pillows and wedges for support. -However, see below; observations on 7/20, 7/24 and 7/25/23 revealed this was not being done. C. Resident observations 1. On 7/20/23 at 9:14 a.m., Resident #27 was observed in her bed, which had an air mattress, lying on her back and her call light was on outside of the room. She said she had pushed her call light at 8:30 a.m. to request to be cleaned up after an incontinence episode and was waiting for assistance. At 9:35 a.m. certified nurse aide (CNA) #13 and CNA #15 entered the room to reposition the resident. The CNAs moved the resident up further toward the head of the bed and more toward the center of the bed. They did not use any pillows or wedges for positioning or offloading the resident's heels and left the resident in the same position she had been in prior to being moved toward the head of the bed. Once the repositioning was completed, CNA #13 and CNA #15 started to leave the room. With prompting, Resident #27 said she had been waiting to be cleaned up after having an incontinence episode since she activated her call light at 8:30 a.m. During the observation, CNA #13 and CNA #15 had not asked Resident #27 why she had activated her call light. CNA #13 said she had to wait for another CNA to help her. CNA #15 said he could assist so they began the task at that time. CNA #14 entered the room and told CNA #15 he could leave and she would continue assisting. Resident #27 was placed back on her back, the same position she had been in since first observed at 9:14 a.m. 2. During a continuous observation on 7/24/23 that started at 9:40 a.m. and ended at 2:30 p.m., Resident #27 was observed in her bed lying on her back. The resident was not offered assistance with repositioning for five hours. -At 11:00 a.m., the resident remained in the same position, lying on her back in bed, looking out the window. The resident turned on the television (TV). -At 12:15 p.m., an unidentified CNA entered the resident's room and served her lunch. She did not offer to reposition the resident. -At 1:15 p.m., an unidentified CNA entered the resident's room and removed the resident's lunch tray. She did not offer to reposition the resident. -At 1:30 p.m., the resident began reading a magazine and writing with a pen. The resident remained in the same position. -At 2:30 p.m., the resident remained in the same position and was observed sleeping. 3. During a continuous observation on 7/25/23 that started at 9:35 a.m. and ended at 3:00 p.m. Resident #27 was observed in her bed lying on her back with her head elevated. The resident was not offered assistance with repositioning for seven hours. -At 9:45 a.m., the resident was talking on her phone while in her bed lying on her back with her head elevated. -At 11:15 a.m., the resident began reading a book and was in the same position as above. -At 12:30 p.m., the resident was served a lunch tray in her room while she lay in bed on her back. The CNA did not offer to reposition the resident. -At 1:15 p.m., an unidentified CNA entered the resident's room and removed the lunch tray. The CNA did not offer to reposition the resident. -At 2:30 p.m., the resident had the TV on and was in the same position as above . -At 4:00 p.m., the resident was talking on the phone and was in the same position as above. Resident #27 remained in the same position throughout the remainder of the day until the last observation at 4:30 p.m. D. Resident interview Resident #27 was interviewed on 7/20/23 at 9:55 a.m. Resident #27 said she frequently waited over an hour after she pushed her call light to get assistance. She said the CNAs rarely repositioned her unless she asked. This made her worry about her likelihood of developing a pressure injury. III. Resident #98 A. Resident status Resident #98, age [AGE], was admitted on [DATE]. According to the July 2023 CPO, diagnoses included type 2 diabetes mellitus with diabetic neuropathy, paroxysmal atrial fibrillation, morbid obesity, and chronic kidney disease. The 5/29/23 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. She required extensive assistance with two people for bed mobility and dressing. She required extensive assistance from two people for transfers. She did not have any rejection of care or verbal behaviors exhibited. B. Record review The care plan revised 6/8/23, revealed self-care performance deficits related to muscle weakness, morbid obesity, activity intolerance and impaired mobility. The interventions revealed the resident required limited to extensive assistance to turn over, reposition and sit up in bed. C. Resident observations During a continuous observation on 7/20/23 that began at 10:40 a.m. and ended at 1:30 p.m., Resident #98 was observed lying in her bed, which had an air mattress, on her back with the head of the bed slightly elevated. She was not repositioned or offered to be assisted with repositioning for three hours. -At 11:00 a.m., the resident turned her TV on and remained in the same position on her back with the head of the bed slightly elevated. -At 12:15 p.m., an unidentified CNA entered the resident's room with a lunch tray. She did not offer to preposition the resident. -At 1:00 p.m., an unidentified CNA entered the resident's room and removed the lunch tray. She did not offer to reposition the resident. -At 1:30 p.m., the resident remained in the same position with her TV on and her eyes closed. D. Resident interview Resident #98 was interviewed on 7/24/23 at 3:35 p.m. She said the staff did not come in to remind her to reposition or assist her with repositioning. She said she was unable to reposition herself. This made her very worried about her skin and the status of her current pressure injuries. E. Staff interviews CNA #13 was interviewed on 7/25/23 at 1:45 p.m. She said she turned in her notice to end her employment with the facility because there was not enough staff to help the residents in a timely manner. She said the facility was always short staffed and she did not have time to remind or help residents turn or reposition because she was always providing care for someone else. (Cross-reference F725) An anonymous nurse was interviewed on 7/25/23 at 1:55 p.m. The nurse said the facility needed more help. The nurse said they did not have time to remind or assist residents to turn or reposition. Tears began to roll down their cheeks as they described often going home and not wanting to come back to work at the facility because the staffing was so short. The nurse said it was not their intention to provide subpar care but they could only do what they had time to do. (Cross-reference F725) The director of nursing (DON) was interviewed on 7/25/23 at 8:16 p.m. She said residents who were unable or did not remember to reposition themselves should be reminded and/or assisted to reposition every two hours and as needed. She said the CNAs knew who needed to be reminded or assisted with repositioning by looking at the [NAME] (a directive for care). IV. Resident #106 A. Resident status Resident #106, age [AGE], was admitted to the facility on [DATE]. According to the July 2023 CPO, diagnoses included dementia and benign prostatic hyperplasia with lower urinary tract symptoms (frequent need to urinate). According to the 5/17/23 MDS assessment, the resident was severely cognitively impaired with a brief interview for a mental status score of zero out of 15. The resident required extensive assistance of two persons with bed mobility, transfers, dressing, toileting, and personal hygiene. The resident was incontinent of bowel and bladder and was at risk of pressure ulcers. B. Record review The resident's care plan, revised on 5/30/23, revealed Resident #106 had an activity of daily living (ADL) self-care performance deficit for toileting related to cognitive and memory impairments. He required extensive assistance with toileting tasks and had incontinent episodes with urine and bowels. Interventions included assistance with toileting frequently and as needed. The care plan, revised on 5/30/23, revealed ResidentResient #106 had daily episodes of bladder and bowel incontinence related to confusion and diminished awareness of personal needs related to dementia. Interventions included assistance with toileting frequently, as he would allow and as needed. The care plan, revised 5/30/23, revealed Resident #106 had the potential for impaired skin integrity related to incontinence. Interventions failed to include assistance with incontinence care. C. Observations On 7/19/23, during a continuous observation beginning at 10:30 a.m. and ending at 3:30 p.m., Resident #106 was observed in a Broda chair (wheelchair that can tilt, recline, and has adjustable footrest) in the main dining area with staff and other residents. At 2:30 p.m., Resident #106 was assisted to his room by CNA #5, positioned in his wheelchair, to look out the window and the care staff exited the room. Incontinence care for Resident #106 was not observed for five hours. On 7/20/23, during a continuous observation beginning at 10:00 a.m. and ending at 2:30 p.m., Resident #106 was observed in a Broda chair in the main dining area. At approximately 2:00 p.m., Resident #106 was assisted to his room by CNA #4 and CNA #5. Incontinence care was provided and Resident #106 returned to the main dining room. CNA #5 said the resident had been incontinent of urine. Incontinence care for Resident #106 was not observed for four and on-half hours. On 7/24/23, during a continuous observation beginning at 9:30 a.m. and ending at 3:00 p.m., Resident #106 was observed in a Broda chair in the dining room area. At approximately 1:30 p.m. Resident #106 was assisted to his room by CNA #3 and CNA #5 and was provided with incontinence care. The resident's brief was observed to be soiled with urine and yellow in color. Incontinence care for Resident #106 was not observed for four hours. D. Staff interview CNA #3 was interviewed on 7/25/23 at approximately 11:00 a.m. She said she had worked in the building for only a couple days. She said Resident #106 was provided incontinence care after breakfast and lunch on the shift she worked. CNA #5 was interviewed on 7/25/23 at approximately 11:00 a.m. She said residents fully dependent on staff for incontinence care are assisted twice a shift. She said depending on the resident, incontinence care could be provided more or less often. She said Resident #106 was provided incontinence care after breakfast and lunch on her shifts. She said he was consistently incontinent of urine. The unit manager (UM) was interviewed on 7/25/23 at 2:48 p.m. She said for assisting fully dependent residents with incontinence care, it was provided after every meal, as needed and during overnight rounds. She said it was dependent on the resident's output, lack thereof, and tolerance of care provided. She said providing Resident #106 with incontinence care after meals during day shift hours was acceptable for his incontinence needs. -But see findings above; the resident had multiple risk factors for skin breakdown and interviews revealed he was consistently incontinent of urine. The director of nursing (DON) was interviewed on 7/25/23 at 8:16 p.m. She said that residents who were incontinent should be checked every two hours and as needed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** III. Resident #127 A. Material Safety Data Sheet for chemicals 1. Ajax all purpose cleaning powder Hazard Identification Health Hazards (Acute and Chronic): This product contains a small amount of crystalline silica, a naturally occurring impurity in calcium carbonate. NTP has listed crystalline silica as an carcinogen. IARC has found limited evidence for carcinogenicity in humans. However, under normal conditions of product use, no significant health risk to humans is expected. Signs and Symptoms: Eye-Direct exposure to large amounts may cause eye irritation, but no permanent eye injury is expected. Skin-May cause irritation upon prolonged and excessive contact. However, no skin irritation is expected with normal use. Ingestion-May be harmful if swallowed. Inhalation-Overexposure to dust may cause respiratory tract irritation. Medical Conditions Generally Aggravated by Exposure: None known. 2. Scrubbing bubbles bathroom cleaner Hazard identification: Principle routes of exposure: Eye contact. Skin contact. Inhalation. Eye contact: Severe eye irritation. Skin contact: Moderately irritating to the skin. Inhalation: May be irritating to nose, throat, and respiratory tract. Ingestion: May be irritating to mouth, throat and stomach. B. Resident status Resident #127, age [AGE], was admitted on [DATE]. According to the July 2023 CPO diagnoses included anxiety, depressive episodes and malignant neoplasm (cancer) of the colon. According to the most recent MDS dated [DATE] the resident had moderate cognitive impairment with a score of nine out of 15 for the BIMS. The resident was primarily independent with activities of daily living and required setup help by staff. C. Observations and interviews Resident #127 was interviewed on 7/19/23 at approximately 11:00 a.m. Resident #127 said housekeeping staff brought him cleaning supplies and left them in his room and told him you should clean the (explicit word) in the toilet yourself and you should clean your room yourself. The resident's room contained Scrubbing Bubbles (bathroom cleaner) and Ajax (all purpose powder cleaner). D. Staff interviews Housekeeper (HSKP) #2 was interviewed on 7/19/23 at 2:35 p.m. She said Ajax and Scrubbing Bubbles were accidentally left there by her. She said housekeeping supplies should never be left in the room because a resident could eat or drink the chemicals or get the chemicals in their eyes. The environmental director (ED) was interviewed on 7/19/23 at approximately 3:00 p.m. She said she always had to correct and remind HSKP #2 that housekeeping supplies should never be left in a resident's room. Housekeeping supplies should never be given to a resident to clean their own room. Housekeeping staff were responsible for cleaning the room and not the resident. Housekeeping supplies should never be left in the room because it could potentially be harmful to a resident if they used it incorrectly. The ED said the facility's policies and procedures were not adhered to and that she had to educate all her staff. The director of nurses (DON) was interviewed on 7/25/23 at approximately 7:30 p.m. The DON said cleaning supplies should not be left in the resident's room. Cleaning supplies should enter the room with housekeeping staff and be secured by housekeeping staff upon exit of a resident's room. II. Resident #89 A. Professional reference According to [NAME], P.A., [NAME], A.G., et.al., Fundamentals of Nursing, 10 ed. (2022), Elsevier, St. Louis Missouri, pg 812. If a patient was unable to cooperate or does not have sufficient upper or lower body strength, use ceiling, hydraulic floor, or power driven lift to transfer the patient from bed to chair. Use a minimum of two to three caregivers. B. Facility policy and procedure The Mechanical Lift policy, reviewed 2/21/2020, was provided by the director of nursing (DON) on 7/25/23 at 11:06 p.m. It read in pertinent part, Mechanical lifts should ALWAYS be used with two (2) or more trained staff members assisting in lift procedure from start to finish (including the placement of and removal of the sling). C. Resident status Resident #89, age [AGE], was admitted on [DATE]. According to the July 2023 computerized physician order (CPO) diagnoses included hemiplegia (total or nearly complete paralysis of one side of the body) and hemiparesis (weakness on one side of the body) following cerebral infarction (stroke) affecting left non-dominant side, type two diabetes mellitus and acquired absence of right and left leg above the knee. The 5/14/23 minimum data set (MDS) assessment showed the resident did not have cognitive impairment with a score of 15 out of 15 on the brief interview for mental status (BIMS). The resident required extensive assistance with bed mobility, transfers and all activities of daily living. The resident did not have any behaviors or rejection of care. D. Record review The care plan updated on 5/29/23 identified the resident required two person assist with the mechanical lift for all transfers. E. Observations and interviews On 7/25/23 at 10:27 a.m., Resident #89 was observed in his wheelchair in his room with the call light on because he needed to use the restroom. CNA #2 brought the mechanical hoyer lift into the room, closed the door and turned off the call light. CNA #2 exited the room with the mechanical hoyer lift five minutes later at 10:23 a.m. with Resident #89 following her in his wheelchair. The resident was transferred via the mechanical lift with one CNA. Resident #89 was interviewed on 7/25/23 at 10:32 a.m. Resident #89 said CNA #2 used the mechanical hoyer lift by herself and no other staff were in the room when she moved him from his wheelchair to the toilet and back again. He said the CNAs transfer him by themselves more often than not. He said it was unusual for two CNAs to use the hoyer lift with him. CNA #2 was interviewed on 7/25/23 at 10:35 a.m. CNA #2 said she used the mechanical hoyer lift by herself when she transferred Resident #89 from the wheelchair to the toilet and then back to the wheelchair. She said she did not always remember who needs to be transferred with specific equipment so she often asked the nurses for guidance. She said she knew there was supposed to be two people using the hoyer lift but there was not always help available when it was needed so she did it by herself especially with residents that were able to help themselves some. (Cross-reference F725 for insufficient staffing) CNA #19 was interviewed on 7/25/23 at 3:15 p.m. She said she used the mechanical lift to transfer residents that were totally dependent on staff for care. She said she often transferred residents by herself using the mechanical lift because she was unable to find help. She said she was unaware that two staff members should be present when using a mechanical lift. (Cross-reference F725). The director of nursing (DON) was interviewed on 7/25/23 at 8:16 p.m. She said when the mechanical hoyer lift was used, it was always a two-person assist device and it was never authorized for only one CNA to use it. She said the staff had been provided training on proper use of the hoyer lift and the two person requirement as the facility had recently been cited for the same thing. Based on observations, record review and interviews, the facility failed to ensure three (#78, #89 and #127) of five out of 71 sample residents received adequate supervision to prevent accidents. Specifically, the facility failed to: -Ensure Resident #78 did not receive another resident's medications; -Ensure Resident #89 was transferred with a mechanical lift according to professional standards of practice; and, -Ensure cleaning chemicals were not left in Resident #127's room unsecured. Findings include: I. Resident #78 A. Resident status Resident #78, age [AGE], was admitted on [DATE]. According to the July 2023 computerized physician orders (CPO), the diagnoses included hypertension and depression. The 6/19/23 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status score of 14 out of 15. She was independent with all activities of daily living. B. Resident interview and observations Resident #78 was interviewed on 7/19/23 at 3:34 p.m. She said the nurse came into her room and tried to give her pain medication. She said she told the nurse she did not get any pain medication, but that she was waiting for her Eliquis medication. She said the nurse had called her another resident's name. She said this was not the first time a nurse had tried to give her someone else's medication. She said she was glad she was of sound mind so she did not take the wrong medications, but was concerned for those residents who were not. During the interview, licensed practical nurse (LPN) #6 approached Resident #78 at the medication cart. Resident #78 asked LPN #6 why she called her by another resident's name and why she tried to give her the wrong medications. LPN #6 responded she was sorry and thought Resident #78 was another resident in the hallway. She said she had attempted to give Resident #78 a pain medication that was meant for another resident. C. Record review The anticoagulant therapy care plan, initiated and revised on 6/29/23, documented the resident used anticoagulant therapy due to a diagnosis of atrial fibrillation (irregular and often very rapid heart rhythm). The interventions included administering anticoagulant medication as ordered by the physician. A review of the July 2023 CPO did not reveal a physician's order for Resident #7 to receive pain medication. D. Staff interviews Registered nurse (RN) #3 was interviewed on 7/25/23 at 3:06 p.m. She said prior to administering medication, each nurse should review the rights of medication use, which included ensuring the right patient, the right drug, the right time, the right dose and the right route. She said it could be very dangerous if a nurse administered medications without first verifying the rights of medication use. The director of nursing (DON) was interviewed on 7/25/23 at 3:29 p.m. She said prior to administering medications, the nurse should review the rights of medication use. She said administering the incorrect medication could be dangerous depending on the resident, their conditions and any other medications they may be taking. She said Resident #78 should have not had to tell the nurse that those were the wrong medications. She said the nurse should have verified who the resident was prior to attempting to administer medications. She said, if the nurse was new to that hallway, then she should have asked another staff member to verify who the resident was prior to attempting to administer medications.

Based on record review and interview the facility failed to ensure certified nurse aides (CNAs) received 12 hours of training per year for seven (CNA #20, CNA #21, CNA #22, CNA #23, CNA #7, CNA #24, and CNA #25) out of 49 CNAs. Specifically, the facility failed to provide 12 hour training for CNA #20, CNA #21, CNA #22, CNA #23, CNA #7, CNA #24 and CNA #25. Findings include: I. Record review The facility was unable to provide documentation CNA #20 (hire date of 1/11/19) , CNA #21 (hire date of 8/22/22), CNA #22 (hire date of 6/6/17), CNA #23 (hire date of 8/1/19), CNA #7 (hire date of 1/21/22), CNA #24 (hire date of 9/15/2020) and CNA #25 (hire date of 9/29/22) had completed 12 hours of training during the survey process. II. Staff interview The infection preventionist (IP) interviewed on 8/8/23 at 2:10 p.m. He said the system they use for tracking training records was through a computer based program. He said he had his own tracking spreadsheet for education. He said he did not have a list of mandatory training for the CNAs to complete. He said he would look at the list of classes from last year and go off of whatever was in the system. He said he was not sure what would happen if the CNAs did not meet their training expectations as he said he had not done it. He said he would give the CNAs a timeframe to get their training done.

Based on observations and interviews the facility failed to ensure three out of four medication refrigerators stored narcotic, non-narcotic medications and biologicals in accordance with accepted professional standards. Specifically, the facility failed to ensure controlled medications were in a locked storage area that was permanently secured to the refrigerator. Findings include: I. Facility policy and procedure The Medication Storage policy was requested from the director of nursing (DON) on 7/25/23 but was not provided. II. Observations 7/25/23 -At 10:34 a.m. the third floor medication room medication refrigerator was observed with licensed practical nurse (LPN) #4. The refrigerator was not locked and it contained a locked box to hold controlled medications needing refrigeration that could be picked up and removed from the refrigerator. The narcotic locked box was not permanently affixed to the refrigerator. The nurse confirmed the controlled substance locked box inside of the refrigerator contained Lorazepam. -At 10:50 a.m. the second floor medication room medication refrigerator was observed with registered nurse (RN) #1. The controlled medication box was not permanently affixed to the refrigerator. The nurse confirmed the controlled substance locked box inside of the refrigerator contained Lorazepam. -At 11:11 a.m. the first floor medication room medication refrigerator was observed with LPN #1. The controlled medication box was not permanently affixed to the refrigerator. The nurse confirmed the controlled substance locked box inside of the refrigerator contained Lorazepam. III. Staff interviews The director of nursing (DON) was interviewed on 7/25/23 at 8:05 p.m. The DON said the narcotic boxes in the refrigerators were in a locked box in a locked room and she was not aware the narcotic boxes needed to be permanently affixed to the refrigerator itself. She said the most commonly refrigerated controlled substance in the facility was Lorazepam.

Based on observations, record review and interviews; the facility failed to provide food that accommodated resident preferences for four (#13, #78, #79 and #86) of four residents out of 71 sample residents. Specifically the facility failed to offer food choices according to resident preferences for Residents #13, #78, #79 and #86. Findings include: I. Observations and record review On 7/25/23 the noon kitchen line was observed continuously from 12:00 p.m. to 1:00 p.m. The trays were prepared using a resident list, which had the resident's preferences (likes and dislikes) and what the resident wanted to eat for their meal. At approximately 12:30 p.m. Resident #13 was served half of a serving of carrots. -Tray card for Resident #13 indicated that the resident disliked carrots. At approximately 12:30 p.m. Resident #78 was served a full serving of carrots. -Tray card for Resident #78 indicated that the resident disliked carrots. At approximately 12:30 p.m. Resident #79 was served gravy. -Tray card for Resident #79 indicated that the resident disliked gravy. At approximately 12:30 p.m. Resident #86 was served a full serving of carrots. -Tray card for Resident #86 indicated that the resident disliked carrots. II. Resident interviews Resident #13 was interviewed on 7/24/23 at 1:36 p.m. The resident said she did not like carrots although she was served them and she would not eat them. Resident #78 was interviewed on 7/24/23 at 1:40 p.m. The resident said she was bothered that she was served carrots because she did not like them at all. The resident said her meal ticket documented she did not like them. The resident said she only wanted potatoes but she always got carrots. Resident #79 was interviewed on 7/24/23 at 1:47 p.m. The resident said she received gravy on her potatoes but she did not want gravy and she did not like it and therefore she did not eat her potatoes. Resident #86 was interviewed on 7/24/23 at 1:50 p.m. The resident said he was bothered that he was served carrots because he did not like them at all, especially since they were half cooked and he could not stab them with a fork. The resident said the facility did not listen to the resident's preferences and it made him frustrated and angry. III. Staff interviews The dietary manager (DM) was interviewed on 7/24/23 at 7:04 p.m. The DM said the dietary staff were supposed to review the tray card prior to serving the resident. The tray card included hand written preferences, likes and dislikes and selections a resident would make prior to receiving their meal. Dietary staff should serve residents according to the tray card when they were plating the meal to ensure the residents were served what they ordered and to take into account the resident's preferences. The tray card listed the resident's preferences and the facility was supposed to honor the resident's preferences.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and staff interviews, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Specifically, the facility failed to ensure: -Housekeeping staff engaged in appropriate infection control practices when cleaning a resident room; -Residents were provided with proper hand hygiene prior to meals; -Proper hand hygiene was conducted during medication pass; and, -Shared equipment was consistently sanitized between resident uses. Findings include: I. Facility policy and procedure A. The Infection Control policy and procedure manual, revised August 2015, was received by the administrator in training (AIT) on 7/26/23. It read in pertinent parts: This facility considers hand hygiene the primary means to prevent the spread of infections. All personnel shall be trained and regularly in-serviced on the importance of hand hygiene in preventing the transmission of healthcare-associated infections. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors. Hand hygiene products and supplies (sinks, soap, towels, alcohol-based hand rub) shall be readily accessible and convenient for staff use to encourage compliance with hand hygiene policies. Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: before preparing or handling medications and before and after assisting a resident with meals. B. The Infection Prevention Manual for Long-Term Care, specific to housekeeping services, was received by the AIT on 7/26/23. It read in pertinent parts: To promote a safe and sanitary environment which is maintained by a contracted service, by employees of the facility, or a combination of both. Thorough scrubbing will be used for all environmental surfaces that are being cleaned in resident care areas. II. Failure to ensure housekeeping staff maintained infection control practices when cleaning a resident room. A. Resident interview and observation Resident #127 was interviewed on 7/19/23 at 10:38 p.m. The resident said housekeeping staff have had trouble cleaning the toilet, especially the dried fecal matter in the bowl. Housekeeping staff used an eating utensil (fork) and a toilet brush to clean the toilet bowl. The resident complained that the fork and toilet brush had been left in his bathroom on top of his plastic organizer for three weeks and both cleaning tools were left with dried fecal matter. At 10:45 p.m. a fork and a toilet brush with dried fecal matter were observed in the resident's bathroom on top of a plastic organizer by the toilet. B. Staff Interview Licensed practical nurse (LPN) #5 was interviewed on 7/19/23 at 11:01 a.m. She said she did not know why the fork with the dried fecal was in the resident's bathroom on top of the resident's plastic organizer. She said that she has never seen a fork before used as a cleaning tool and it was an infection control issue to leave the fork with fecal matter in the bathroom. Fecal matter harbored bacteria and other pathogens that could be potentially harmful to a person. The LPN removed the fork by disposing of it in the trash receptacle. -However, the LPN did not dispose of the toilet bowl cleaner with dried fecal matter on the resident's plastic organizer and or disinfect the surface where the fork was resting. The environmental director (ED) was interviewed on 7/19/23 at 2:52 p.m. She said the area where the fork was kept should have been disinfected after the LPN removed it and the housekeeping staff should have been notified. The resident needed a new brush and the brush should not have been kept on top of the plastic organizer but should have been stored in the appropriate container. The ED said the bathroom was not clean and needed to be cleaned by a housekeeping staff member. The ED said she would provide education to her housekeeping staff related to appropriate practices related to bathroom cleaning and cleaning tool storage. Registered nurse unit manager (RNUM) #1 was interviewed on 7/19/23 at 3:08 p.m. She said that the LPN should have called the housekeeping staff after she witnessed the fork situation and notified them to clean the room. The fork with the fecal matter was an infection control issue and it may cause many gastrointestinal problems if touched by the resident and he touched his face or if he accidently used the fork to eat. The toilet brush was an infection control issue to be left out with fecal matter and not stored in the appropriate storage container. RNUM #1 said she would have the toilet bowl cleaner thrown out, replaced with a new one and the entire bathroom would be disinfected. RNUM #1 said she would provide education to the LPN. The infection preventionist (IP) was interviewed on 7/25/23 at 5:19 p.m. He said the fork with dried fecal matter was an infection control issue. The fork should have never been used to clean the toilet. Staff should use appropriate cleaning materials and the cleaning materials should leave the room after the room was cleaned. The surface of the organizer in the resident's room should have been cleaned after the fork was removed. The toilet bowl cleaner should have been placed back into the housekeeping cart after it was used and if the resident wanted their own in the room then it should have been stored in the holder after it was used. III. Failure to ensure residents were provided with an opportunity to participate in hand hygiene prior to meals On 7/19/23 at 11:57 a.m. the dining room on the third floor was observed. Hand sanitizer was not offered to any of the seven residents in the dining room at any point prior to or during the meal. The resident room meal trays were delivered at 12:45 p.m. to the third floor and residents were not offered or encouraged hand hygiene prior to eating their meal. -At 12:45 p.m., a certified nurse aide (CNA) #2 delivered a room tray to room [ROOM NUMBER] and did not offer hand hygiene to the resident. No hand sanitizer and or cleaning wipes were provided on the meal trays. -At 12:47 p.m., CNA #1 delivered a room tray to a resident in room [ROOM NUMBER] and did not offer hand hygiene to the resident. No hand sanitizer and or cleaning wipes were provided on the meal trays. -At 12:50 p.m., CNA #2 delivered a room tray to a resident in room [ROOM NUMBER] and did not offer hand hygiene to the resident. No hand sanitizer and or cleaning wipes were provided on the meal trays. The third floor memory care dining room was observed continuously from 4:30 p.m. to 5:45 p.m. Nine residents were observed eating dinner in the dining room. The meal consisted of a hamburger or a ham and cheese sandwich. -88% of residents ate using their hands. -100% of residents were not offered or encouraged to engage in hand hygiene. Throughout the dinner meal service, no hand hygiene was offered by staff. Hand hygiene products were not available on any dining table. On 7/20/23 at 11:51 a.m. the dining room on the third floor was observed. There were six residents present for lunch service and hand sanitizer was not offered prior to or during the meal. On 7/24/23 at 11:48 a.m. the dining room on the third floor was observed. A resident was blowing his nose into the open air without a tissue while he was sitting at a dining table. Then he began wiping his nose with his bare hand and the sleeve of his shirt. At 11:50 a.m. trays began to be passed out and hand sanitizer was not offered to any residents. At 11:56 a.m. multiple staff were observed washing their hands at a sink in the dining room. Posted above the handwashing sink was a sign identifying the process for staff to wash their hands for at least 20 seconds. An unidentified CNA was observed washing her hands for six seconds. Another unidentified staff member washed her hands for 12 seconds. An unidentified CNA was observed washing her hands for three seconds. Another unidentified CNA was observed washing her hands for eight seconds. At 1:05 p.m. 11 resident room meal trays were delivered to the first floor and residents were not offered or encouraged hand hygiene prior to eating their meal. The meal consisted of fried chicken, carrots, mashed potatoes and gravy. -100% of the residents were not offered or encouraged to engage in hand hygiene prior to their meal for lunch. On 7/25/23 the lunch kitchen line was observed continuously from 12:00 p.m. to 1:00 p.m. At 12:15 p.m. 14 residents were observed in the dining room for lunch. -50% of the residents were eating their meals with their hands. -64% ate cookies with their hands. -100% of residents in the dining room were not offered or encouraged to engage in hand hygiene. Throughout the lunch meal service no hand hygiene was offered by staff. Hand hygiene products were not available on any dining table. IV. Failure to ensure hand hygiene was performed during medication pass On 7/25/23 at 9:57 a.m. the certified nurse aide with medication authority (CNA/MA) #1 was observed for medication pass. CNA/MA #1 exited a resident room and did not perform hand hygiene. CNA/MA #1 walked to the medication cart and unlocked the drawers with her keys that were on a key ring in her pocket. She unlocked her computer by typing on the keypad and unlocked the narcotic box and pulled medication from the drawer. She was confused about the expiration date so she closed the narcotic box, the medication cart drawer and took the medication in the box to show the unit manager who was in her office down the hall. After getting clarification, CNA/MA #1 returned to the medication cart, did not perform hand hygiene and unlocked the drawer to gather the remaining medications. CNA/MA #1 carried the medications to the resident's room and handed the medication cup to the resident. CNA/MA #1 put a syringe of oral morphine in the resident's mouth and administered it then she gave the resident the medicine cup of remaining medications for her to take. CNA/MA #1 returned to the medication cart without performing hand hygiene after exiting the resident's room and wrote in the narcotic log book on top of the medication cart with her pen that she removed from her pocket. V. Failure to ensure shared equipment was sanitized On 7/24/23 at approximately 10:30 a.m. LPN #1 was observed approaching Resident #143 with a portable vitals sign machine (vital signs measure the body's basic functions by objectively measuring body temperature, pulse rate, respiration rate, and blood pressures) and obtained vitals. At 12:34 p.m. CNA #3 approached Resident #108 with the same portable vital signs machine to check her oxygen levels (how much oxygen is in the blood). The portable vitals sign machine was not wiped down before or after it was used to obtain vitals for Resident #143 and Resident #108. CNA #3 was interviewed on 7/24/23 at 12:34 p.m. She said the portable vital signs machine was used on multiple residents throughout the day. She said cleaning between uses was necessary if the machine was visibly dirty. VI. Administrative interviews The IP was interviewed on 7/25/23 at 5:30 p.m. He said hand hygiene should be offered before meals staff should either offer residents to wash their hands or use hand sanitizer. The IP said he never saw any hand sanitizer wipes at the facility. He said staff were to perform hand hygiene (sanitizer) when entering and exiting resident rooms, while passing meal trays, and during medication passes. He said hand sanitizer gel should be rubbed over all surfaces of hands and fingers until the hands were dry. He said this duration should be 20-30 seconds. He said direct care staff are responsible for cleaning portable vital machines. He said machines were to be cleaned after each use and as needed. The director of nursing (DON) was interviewed on 7/25/23 at 8:00 p.m. She said all staff members should be performing when entering and exiting resident rooms, while passing meal trays and during medication pass. She said residents should be offered hand sanitizer prior to meals. She said hand sanitizer gel should be rubbed over all surfaces of hands and fingers until the hands were dry. She said this duration should be 20-30 seconds. She said direct care staff were to clean equipment (portable vitals machine and mechanical lifts) between each use.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observations, and interviews, the facility failed to provide sufficient nursing staff to ensure the residents received the care and services they required per their comprehensive plans of care, to achieve and maintain their highest practicable physical, mental and psychosocial well-being. Specifically, the facility failed to consistently provide adequate nursing staff given the acuity and diagnoses of the facility's population, resident census, and the residents' daily need for care and services. Cross-reference citations: -F677 for the failure to provide timely incontinence care and reposition to residents; -F686 for the failure to provide repositioning for residents with pressure injuries; -F689 for the failure to ensure two staff were utilized when transferring residents with mechanical lifts; and, -F692 for the failure to provide timely eating assistance and consistently provide fluids to residents between meals. Findings include: I. Resident census and conditions According to the 7/19/23 Resident Census and Conditions of Residents report, the resident census was 158 and the following care needs were identified: -110 residents needed assistance of one or two staff members for bathing and 37 residents were dependent;11 residents were independent. -135 residents needed assistance of one or two staff members for dressing and seven residents were dependent;16 residents were independent. -134 residents needed assistance of one or two staff members for transferring and no residents were dependent; 24 residents were independent. -129 residents needed assistance of one or two staff members for toilet use and 11 residents were dependent; 18 residents were independent. -60 residents needed assistance of one or two staff members for eating and six residents were dependent; 92 residents were independent. II. Staff requirements for each floor/unit A. 1st Floor rehab- 18 residents Two licensed nurses for 12 hours for the day shift and four certified nurse aides (CNAs); The night shift had one licensed nurse from 6:00 p.m. to 6:00 a.m. and three CNAs. B. 2nd Floor - 25 residents Two licensed nurses 12 hours for the day shift and five CNAs; The night shift had one licensed nurse from 6:00 p.m. to 6:00 a.m. and three CNAs. The unit had a CNA medication aide who worked from 6:00 p.m. to 6:00 a.m. C. 3rd Floor - 23 residents Two licensed nurses 12 hours for the day shift and three CNAs; The night shift had one licensed nurse from 6:00 p.m. to 6:00 a.m. and two CNAs. D. 3rd Floor Memory Care - 12 residents One licensed nurse 12 hours for the day shift and one CNA; The night shift had one licensed nurse from 6:00 p.m. to 6:00 a.m. and one CNA. E. Memory unit- 27 residents One licensed nurse 12 hours for the day shift and three CNAs; The night shift had one licensed nurse from 6:00 p.m. to 6:00 a.m. and two CNAs. III. Resident Council minutes The Resident Council minutes were reviewed on 7/24/23 at 4:42 p.m. A. Resident Council minutes dated 2/8/23 revealed residents complained staff said showers were being skipped because the staff did not have time. B. Resident Council minutes dated 5/10/23 revealed residents miss their old CNAs and have mixed reviews on agency staff; it was discussed the whole country was in a CNA shortage. C. Resident Council minutes dated 7/12/23 revealed residents complained about staff administering wrong medications or not receiving their medications and the nurses do not want to double check or they do not have time; the nurses just drop off the medications and leave them on the table where they are not seen, and therefore, are not being taken. The minutes further read, showering schedules were a mess. Residents complained the facility would not pay overtime for reliable CNAs but will pay for agency staff who leave early. IV. Observations A. Resident #130 was observed on 7/19/23 at 4:44 p.m. According to the comprehensive care plan, the resident needs more attention as she was not able to make her needs known. She cannot use the call light as she did not know what it is. B. Resident #25 was observed continuously on 7/24/23 from 1:10 p.m. to 3:00 p.m. -At 1:15 p.m. Resident #25 engaged the call light and requested for her husband (Resident #110) to be transferred from his wheelchair to his recliner. -At 1:18 p.m. CNA #12 responded and said she would be back in 10 minutes. The CNA turned off the call light; she did not address the resident's request. -At 2:15 p.m. Resident # 25 engaged the call light, 60 minutes later. Her husband continued to sit in his wheelchair and Resident #25 again requested for her husband to be moved from his wheelchair to the recliner. Staff turned off the call light and at time transferred Resident #25's husband to his recliner. V. Resident interviews Resident interviews revealed delays, from 20 minutes to over an hour, in staff providing them requested assistance. A. Resident #127 was interviewed on 7/19/23 at 11:13 a.m. According to computerized physician's orders (CPO), the resident admitted on [DATE] and assessed on 6/8/23 as moderately impaired. The resident said he had to wait 45 minutes for his call light to be answered when there were fewer staff working. He said around 4:00 p.m. or 5:00 p.m. there were not a lot of staff working on the floor He said the evening and middle of the afternoon and weekends were the worst. B. Resident #43 was interviewed on 7/19/23 at 12:06 p.m. According to CPO, the resident was admitted on [DATE] and assessed on 6/21/23 as cognitively intact. She said during the evening shift, if you push your call light, you can wait a long time, anywhere from 30-45 minutes. She said this happened often and mainly in the evening. C. Resident #104 was interviewed on 7/19/23 at 1:16 p.m. According to CPO, the resident was admitted on [DATE] and assessed on 4/9/23 as cognitively intact. He said there was not enough staff here. He said he had had to fill his own cups with ice every day as staff did not offer to do so. D. Resident #98 was interviewed on 7/19/23 at 1:20 p.m. According to CPO, the resident was admitted on [DATE] and assessed on 5/29/23 as cognitively intact. He said he had never waited less than an hour for help when pushing the call light. E. Resident #130 was interviewed on 7/19/23 at 4:44 p.m. According to CPO, the resident was admitted [DATE] and assessed on 5/29/23 as moderately impaired. She said this past Monday her sister pushed the call button and no one came for an hour and 15 minutes. F. Resident #7 was interviewed on 7/20/23 at 10:44 a.m. According to CPO, the resident was admitted [DATE] and assessed on 5/15/23 as cognitively intact. She said she requires assistance from two staff with toileting, transfers, and bed mobility, and sometimes there was only one staff working the hallway and it was hard to get the care she needed. She said she had had to wait around 20 minutes to get help. She said two CNAs worked the hallway and she required a two person assist. She said sometimes they only have one CNA and it was hard for her to get the care she needs. G. Resident #85 was interviewed on 7/25/23 at 2:00 p.m. Record review revealed the resident was admitted [DATE] and assessed on 6/26/23 as cognitively intact. She requires, per MDS, extensive assistance with toileting. She said she had had to wait over an hour at times to get assistance to use the restroom for a bowel movement and she believed it was due to a lack of available staff. VI. Staff interviews Staff interviews indicated staffing expectations (see above) were not being consistently met. Staff reported they had too many duties and it was difficult to keep an eye on all the residents. A. CNA #9 was interviewed on 7/23/23 at 5:47 p.m. She said she had been employed at the facility since 4/12/19 and usually worked the weekends. She said every weekend and especially on Sundays, the facility was very, very short-staffed. She said most of the time, the facility did not have enough staff coverage, so the facility had been working with agency staff most of the time, call-off. CNA #9 said this morning, they only had two CNAs for the second floor. She said at 10:00 a.m. a third CNA came in but she was a shower aide. B. CNA #11 was interviewed on 7/23/23 at 5:50 p.m. She said she had been employed at the facility since 7/2/13 and usually worked weekdays. She said due to staffing shortages, the residents do not get the care they need. She said the facility had only one Sara lift on the second floor and the majority of the residents on the second floor require a Sara lift. C. CNA #7 was interviewed on 7/24/23 at 9:55 a.m. She said she had been employed at the facility since 1/21/22 and usually worked weekdays. She said staffing issues were horrible and the weekends were the worst. She said the weekend supervisor did not tell anyone anything. She said this morning there were three CNAs because a CNA picked up an extra shift. She said there used to be five CNAs on the second floor and now, because the census was low, they pulled the fifth CNA and there were only four CNAs on the first shift. She said when the facility changed the schedule, reducing the number of CNAs each shift, a lot of staff left. She said the facility was using a lot of agency staff. D. CNA #12 was interviewed on 7/24/23 at 3:36 p.m. She said she had been employed at the facility since 6/5/23 and usually worked weekdays. She said the third floor Memory Care usually had three CNAs and two registered nurses (RNs) who worked the floor and it was not enough staff. She said it was difficult to keep an eye on all the residents in Memory Care, especially those with wandering behaviors and were a fall risk. She said sometimes the RN will help her with transfers but some of the other staff would not help. She said she could not provide the appropriate care with the amount of staff they currently have. She said since the survey began, there had been more staff help but after the survey, staff would get the help they need and the facility will be short-staffed again. She said she had never seen the director of nursing (DON) in the Memory Care unit except when the survey was going on. E. CNA #2 was interviewed on 7/24/23 at 3:47 p.m. She said she had been employed at the facility since 6/5/23 and usually worked weekdays. She said they usually have three CNAs and two RNs a shift who sometimes help her out. She said sometimes there was not enough staff, especially when two CNAs were helping a resident out, leaving one CNA to attend to the other residents. G. CNA #1 was interviewed on 7/24/23 at 3:59 p.m. She said she had been employed at the facility since 1/13/22 and usually worked weekdays. She said there were three CNAs and two RNs on her shift. She said depending on the day and how many requests the residents have, it would be helpful to have an extra CNA. She said when there were too few facility staff, the facility had agency staff come in to fill in for staffing shortages. H. CNA #13 was interviewed on 7/25/23 at 1:45 p.m. She said she had turned in her notice to end her employment with the facility because there was not enough staff to help the residents in a timely manner. She said the facility was always short staffed and she did not have time to remind or help residents turn or reposition because she was always providing care for someone else. Cross-reference F686. I. An anonymous nurse was interviewed on 7/25/23 at 1:55 p.m. The nurse said the facility needed more help. The nurse said they did not have time to remind or assist residents to turn or reposition. Tears began to roll down their cheeks as they described often going home and not wanting to come back to work at the facility because the staffing was so short. The nurse said it was not their intention to provide subpar care but they could only do what they had time to do. J. The DON was interviewed on 7/25/23 at 7:52 p.m. She said she had been employed at the facility since February 2023. She said the facility did not have a shortage of staff because the facility uses agency staff to supplement staffing. She said, on the first floor, they have three to four CNAs and two RNs and on the second floor, they have two RNs and anywhere from four to six CNAs. She said on the third floor, they have two RNs and three to four CNAs. She said every floor had a nurse manager. She said the nursing home administrator (NHA), DON, and scheduler were responsible for staffing concerns. She said she and the scheduler meet daily to discuss staffing concerns or issues. She said they staff according to the census, acuity level and medical necessity. The DON said if the acuity requires three-person assistance, then they would add another staff aide or nurse to make sure there was enough staff. The DON said if there was not enough staff to address residents' needs, then their needs would not be addressed. She said they try to staff as adequately as they can, but there was nobody jumping into health care and everyone was tired of doing this kind of work. She said they have tried to put out bonuses and did not work. She said they were competitive in their salaries and no one was jumping at the opportunity. She said they offered to pay training for new CNAs and no one had applied. K. The scheduler was interviewed on 8/8/23 at 2:30 p.m. She said she had received a directive from management to staff the units by census or she will get in trouble. She staffing should be as follows: The first floor should have three CNAs for day shift and night shift, two nurses on day shift and from 6:00 p.m. to 10:00 p.m. and 6:00 p.m. to 6:00 a.m., one nurse. The second floor should have four CNAs and two nurses. The first floor Memory Care unit should have one nurse and three CNAs. The third floor should have three CNAs and two nurses on day shift and from 6:00 p.m. to 10 :00 p.m., one nurse and two CNAs. The third floor Memory Care should have one CNA and one nurse on day shift. She said on the night shift, one nurse floats back and forth. The scheduler was interviewed again on 8/8/23 at 3:00 p.m. She said they have several CNA and nurse positions open. She said: -The first floor had open positions of three morning CNAs and one CNA at night. There was one full time nurse position open. -The second floor had six CNA positions open, one on day shift, two on night shift and two-part time CNAs. There were three nurse positions on day shift and two full time nurse positions open on night shift. -The third floor had one morning and one night CNA position open. There are three nurse positions open on day shift and two nurse positions open on night shift. The Memory Care unit on the third floor had two CNA positions open for an eight hour shift and one-part time CNA needed. There was one nurse position open for the night shift. She said the facility was not offering any hiring bonus. She said the facility would pay for new CNAs included $1500.00 toward training classes. The scheduler said they used to have PRN as needed when staff called off but she said staff do not answer their phones, so she said she stopped calling them. She said she had increased the bonus to $15.00 an hour for CNAs and $60.00 an hour for nurses. She said she was not supposed to increase the bonus as the bonuses need to be approved by the NHA. She said when there was a call-off, she would put a message to staff in care communication and it went out to all the staff. She said the call-offs vary on the weekdays, but there were more call-offs on the weekends. She said they changed the staff's schedule so staff rotate every other weekend off and every weekend on. She said they use agency staff to fill the gaps in open positions. She said if the agency staff called off they were suspended from care for seven days. She said she gave staff three chances to call-ff and if they continue to call-off she took them off the schedule and off the list for rehire. VII. Additional information The facility staffing policy was received on 8/8/23 at 2:35 p.m. It read, in pertinent part, it was the goal of the facility to operate at the optimal level to meet the standards of care for our residents. The facility's daily staffing HPPD (hours per patient day) changes routinely, however, the facility will never operate below a minimum of 2.0 HPPD. The state of Colorado had no minimum staffing ratio for long-term care. However, the facility adhered to all state and federal regulations related to staffing and the guidance provided by such entities. The facility will adjust its staffing as needed based on census, acuity and the needs of the residents. The AIT was interviewed on 8/8/23 at 2:36 p.m. She said the policy was given to her by the DON and printed off by the DON today. The scheduler was interviewed on 8/8/23 at 2:45 p.m. She said she did not recognize the staffing policy when shown. The AIT was interviewed on 8/8/23 at 3:00 p.m. She said when she was not able to find a policy she would go to the DON and provide the copy. She said the policy that was provided was what the DON had printed off.

Based on observations and interviews, the facility failed to prepare and serve food in a sanitary manner. Specifically, the facility failed to have a system in place to monitor the internal temperature of the dishwasher to ensure the functioning of the dishwasher. Findings include: I. Professional reference According to the Food and Drug Administration Food Code (2022) accessed on 8/16/23 from https://www.fda.gov/media/164194/download?attachment read in pertinent part, Water temperature is critical to sanitization in warewashing operations. This is particularly true if the sanitizer being used is hot water. A temperature measuring device is essential to monitor manual warewashing and ensure sanitization. Effective mechanical hot water sanitization occurs when the surface temperatures of utensils passing through the warewashing machine meet or exceed the required 160°F (Fahrenheit). Parameters such as water temperature, rinse pressure, and time determine whether the appropriate surface temperature is achieved. Although the Food Code requires integral temperature measuring devices and a pressure gauge for hot water mechanical warewashers, the measurements displayed by these devices may not always be sufficient to determine that the surface temperatures of utensils are reaching 160°). The regular use of irreversible registering temperature indicators provides a simple method to verify that the hot water mechanical sanitizing operation is effective in achieving a utensil surface temperature of 160ºF. II. Observations On 7/19/23 at 8:53 p.m. an unidentified dietary aide put a load of dishes through the dishwasher. She said the dishwasher was high temperature and indicated that the external display read 180 degrees F (Fahrenheit). She said she did not know how to check the internal temperature of the dishwasher to ensure the outside display was correct. She said the facility did not keep a log of the temperature of the dishwasher. III. Record review The facility was unable to provide documentation that the internal temperature of the dishwasher was being monitored to ensure functionality. IV. Staff interviews The dietary manager was interviewed on 7/19/23 at 11:35 p.m. He said the facility did not have a way to check the internal temperature of the dishwashing machine. He said the outside gauge was sufficient. He said he would not know how to begin to check the internal temperature of a dishwasher. He said he did not have a waterproof thermometer and had never heard of temperature testing strips. He said he could not be certain the outside gauge was correct, but felt it probably was fine. He said he did not understand why he needed to ensure the internal temperature and the outside gage matched, when he felt as though it most likely did match. He said he did not have a policy on the dishwasher. He said he would not know where to look to even obtain a policy on the use of the dishwasher.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to ensure one (#2) out of three sample residents reviewed out of 12 sample residents were provided prompt efforts by the facility to resolve a grievance. Specifically the facility failed to ensure Resident #2's concerns regarding incontinence care were resolved timely by the facility. Findings include: I. Facility policy and procedure The Grievance policy and procedure, revised 2/8/19, was provided by the director of nursing (DON) on 3/29/23. It read in pertinent part, A resident, family member, staff member or visitor may file a grievance at any time with an appropriate staff member or supervisor. A resident, or person filling the grievance will be informed of the findings of the investigation within five (5) days and the actions that will be taken to correct the identified problems. The Grievance official who is responsible for overseeing the grievance process, receiving and tracking grievances through to their conclusions; leading any necessary investigations by the facility and issuing written grievance decisions to the resident. All residents or persons acting on a resident's behalf that initiate a grievance are to be offered a written Resolution Summary. II. Resident #2 A. Resident status Resident #2, age [AGE], was admitted on [DATE]. According to the March 2023 computerized physician orders (CPO), diagnoses included unspecified dementia without behavioral disturbance and malignant neoplasm (cancer) of the lung. The 2/20/23 minimum data set (MDS) assessment revealed the resident was cognitively impaired with a brief interview for mental status (BIMS) score of three out of 15. The resident required one person physical assistance with all activities of daily living (ADLs) including toileting and personal hygiene. The resident was receiving hospice services. B. Resident representative interview Resident #2's power of attorney (POA) was interviewed on 3/23/23 at 1:25 p.m. The resident's POA said she visited almost daily and on several occasions she witnessed Resident #2 with a smell of urine because she was not changed for long periods of time. She said she had brought up concerns with several staff members on numerous occasions and had not received any written results of the investigation or plan how the care concerns would be resolved. She said she brought all concerns during the care conference and the response she received was that the facility was challenged by staffing shortage, and employed agency staff who were not familiar with residents' needs. She said this was given as an excuse for the care that Resident #2 did not receive daily. There was no resolution for the concerns she brought up to the management (Cross-reference to F677 incontinence care). C. Record review Review of the facility concern forms revealed one concern for Resident #2, dated 2/22/23. The concern form stated that POA reported to the hospice nurse that staff at the facility were not meeting the Resident #2's needs. Specifically, she was not changed timely and frequently found in dirty clothes. As a response from the facility, the care conference was scheduled for 3/2/23. Below the form was dated 3/2/23 the family was notified of the resolution and the family was satisfied with the resolution. D. Staff interview Unit manager #1 was interviewed on 3/23/23 at 3:45 p.m. She said Resident #2's POA approached her on many occasions with many nursing concerns, such as the resident not getting assistance with meals and not getting incontinence care. She said she explained to the POA that they were doing their best with the staff they got. She said she passed POA's concerns to other team members during daily meetings. She said she did not recall if she filled out the grievance form. The social service director (SSD) was interviewed on 3/28/23 at 10:15 a.m. He said he did recall the resident bringing up concerns about several different things, but was unsure of the time and date. She said since the change in the administration a few months ago the process of grievances changed. She said the grievances were no longer mainstreamed to her, but were submitted to any supervisors and then reviewed by the administrator. She said all grievances were investigated by the heads of the departments that they were pertinent to. After all the investigations and administrator's review, she logged the grievance. She said due to many agency nurses in the building the grievance process was not very smooth in the nursing department. She said it was the responsibility of DON to investigate grievances related to nursing care and the administrator was responsible for review and family communication. The DON was interviewed on 3/28/23 at 12:05 p.m. She said she was aware of the family concerns with care and believed all the concerns were resolved to the family satisfaction. The NHA was interviewed over the phone on 3/28/23 at 12:41 p.m. He said Resident #2's POA frequently visited the facility and he spoke with her about all the concerns she brought. He believed all her concerns were resolved. -However, according the the resident's POA interview (see above) the concerns with Resident #2 incontinence care were not resolved.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to permit resident to remain in the facility, and not transfer or discharge the resident from the facility for one (#6) of three residents reviewed for discharge out of 12 sample residents. Specifically, the facility failed to provide Resident #6 and their responsible parties, an appropriate notice of discharge that included: -The reason for transfer or discharge; -The effective date of transfer or discharge; -A statement of the resident's appeal rights, including the name, address (mailing and email), and telephone number of the entity which receives such requests; -Information on how to obtain an appeal form and assistance in completing the form and submitting the appeal hearing request; and, -The name, address (mailing and email) and telephone number of the Office of the State. Findings include: I. Facility policy and procedure The Involuntary discharge policy and procedure, revised 2/14/19, was provided by the director of nursing (DON) on 3/28/23 at 12:40 p.m. It read in pertinent part, To assure residents will be transferred or discharged only for the residents welfare. Elements include a thirty day transfer/discharge notice. If the resident is being transferred due to the resident being a danger to self or others, there must be documentation to show that interdisciplinary interventions were tried and failed prior to discharge. The resident physician must document in the medical record. The facility will document in the residents medical record: The basis for the transfer, the specific residents need(s) that cannot be met, facility attempts to meet the resident needs, and the service available at the receiving facility to meet the need(s). The facility must send a copy of the notice of transfer or discharge to the representative of the Office of the State Long-term care (LTC) Ombudsman. Notice to the Office of the State LTC ombudsman must occur before or as close as possible to the actual time of a facility-initiated transfer or discharge. A copy of the notice sent to the Ombudsman will be maintained in the medical record. The notice provided to the resident, family member, or representative must contain an explanation of the right to appeal the transfer to the state as well as the name, address, and phone number of the Ombudsman. The Thirty Day Transfer/Discharge notice, Nursing Home Notice of Involuntary Transfer or Discharge paperwork, dated 2/14/19, was provided by the DON on 3/28/23 at 12:40 p.m. It read in pertinent part, This notice is for involuntary discharge or transfer. Fill out this notice for the resident you want to move. Give these papers to the resident - and to his or her representative. Also, send these pages to the State long term care (LTC) Ombudsman, and the Local LTC Ombudsman. A nursing home can move a resident 30 days after it gives this page to the resident, provided a safe discharge has been arranged. The nursing home must document the exception. The doctor must also sign the fourth page or the nursing home must attach the doctor's written order. The nursing home must tell you why they want you to move. Here is what they said, about the situation, their efforts to resolve the situation and other important information. You can appeal this. You can get help with your appeal. You have the right to appeal the nursing home's decision to transfer or discharge you. II. Frequent visitor interview A frequent visitor, with knowledge of the facility, was interviewed on 3/23/23 at 4:00 p.m. He said he was not aware of facility initiated discharge for Resident #6. He said he was not notified verbally or in writing about this discharge. III. Resident #6 A. Resident status Resident #6 age [AGE], was admitted on [DATE] and discharged [DATE]. According to the February 2023 computerized physician orders (CPO) diagnoses include Parkinson's disease, depressive episodes, dementia with other behavioral disturbances, and insomnia. The 12/20/22 minimum data set (MDS) assessment revealed the resident had moderate cognitive impairment deficit with a brief interview for mental status (BIMS) score of 10 out of 15. The resident required one person supervision for walking in the room, in the corridors, locomotion on and off the unit, toileting, and personal hygiene. There were no behaviors noted in the MDS assessment. B. Record review The comprehensive care plan documented discharge was not feasible. Interventions include providing the resident with daily opportunities to participate in activities of interest, social services will assist the resident in finding safe and appropriate placement where which the resident can transfer, if the resident and/or responsible party indicates a desire to discharge. The care plan for behaviors documents the resident being verbally aggressive, such as yelling, can be combative, threatening to others with physical and/or invade others personal space related to dementia. Interventions included administering medications as ordered, analyzing key times, places, circumstances, triggers and what de-escalates behaviors, assess residents' coping skills and support system, and assess residents' understanding of the situation. The care plan for activities documents the resident enjoyed going outside, gardening, exercise, trips, and outdoor games. Interventions included provide a program of activities that is of interest and empowers the resident by encouraging/allowing choice, self-expression, and responsibility and to honor preferences. C. Progress notes Nursing note dated 1/30/23 at 3:06 a.m. documented the resident was up and wandering the hallways and was in slight distress. -No additional information was in the note on why the resident was in distress and what was done to help the resident. Nursing note dated 1/24/23 at 7:00 a.m. documented the resident crying and banging on the window with her hands. -No additional documentation on potential causes of behavior or what was done to help the resident with behavior. Behavior note dated 2/4/23 at 1:50 p.m. documented staff hearing the door alarm at 11:30 a.m. and found the resident running outside the building. When the resident saw the staff she picked up a large rock, the staff intervened. Two certified nurse aides (CNAs) escorted the resident back into the building while she resisted. Once the resident was back in the building the resident obtained a leather belt and wrapped it around a handrail in the shower and tried to pull it off the wall. Behavior note dated 2/4/23 at 2:00 p.m. documented the resident behavior of yelling, cussing, attempting to hit staff members with a belt. After staff obtained the belt the resident attempted to hit her head on the window. Three CNAs prevented the resident from hurting herself. The resident left the facility at 12:30 p.m. via ambulance. The power of attorney (POA) was notified. Nursing note dated 2/4/23 at 1:16 p.m. documented that the resident's POA was notified over the phone that Resident #6 would not be accepted back to the facility, the POA did not agree but was aware. A discharge summary from the nurse practitioner, dated 2/3/23 (a day prior to behaviors documented above), and signed on 2/21/23 documented the condition on discharge was: unstable at time of discharge, sent to the emergency room (ER) and not allowed to return to the facility. -The note did not include reasons or clarification why the resident was not allowed to return to the facility. Cross-reference F626 for permitting a resident to return from the hospital. -The POA was not given a written notice of the resident's discharge to include the information for the resident and/or representative to appeal the discharge from the facility. An after-visit summary from the hospital dated 2/4/23 document the resident was stable and medically cleared to return to assisted living. -No documentation of interdisciplinary team (IDT) or social services notes was in the medical record. There was no documentation of the exact time of discharge to the hospital or physician order for discharge. -There were no additional notes by a primary care physician or medical director regarding discharge. There were no documented notes on what was done to manage resident's behavior in the facility. III. Staff interviews Certified nurse assistant (CNA) #1 was interviewed on 3/27/23 at 2:21 p.m. The CNA said the resident was known to fixate on the doors and tried to get out of the unit. The CNA said the resident had tried to use a dinner knife to pry the doors open. She said the resident was known to get violent and the staff would give her space or contact family to help de-escalate the situation. The CNA said the resident had been discharged from the facility due to an elopement and being a danger to herself and others. Registered nurse (RN) #1 was interviewed on 3/28/23 at 10:26 a.m. The RN said Resident #6 always had some behaviors and sometimes one--one walking would help but not usually. The RN said the resident did not have triggers that would set her off. She said staff usually kept track of triggers so they could be avoided. The social services director (SSD) was interviewed on 3/28/23 at 11:02 a.m. The SSD said she was not familiar with Resident #6's triggers or the incident that caused the resident to be discharged from the facility. She said the DON and nursing home administrator (NHA) made the decision to discharge the resident and she was not part of the discharge process. The SSD said a note regarding the incident should be documented in the resident's medical record. The SSD said the social services department was not informed or involved with the discharge of Resident #6. The DON was interviewed on 3/28/23 at 11:19 a.m. The DON said in most resident discharges to the hospital there was no paperwork and it was done on an individual basis. The DON said Resident #6 had a history of behaviors. The DON said she and the NHA made the decision to transfer the resident to the hospital and not allow her to be readmitted to the facility. The DON said the family requested the resident be allowed to return to the facility and the request was considered by the IDT team. The DON said the IDT decided the resident was too dangerous to return based on her condition in the facility prior to being discharged to the hospital. The NHA was interviewed on 3/28/23 at 12:33 p.m. The NHA said the discharge of Resident #6 was facility initiated. He said he reviewed the situation and made the decision to not let the resident back. He said after the resident had been cleared by the hospital to return that the facility had no indication that she was stable and he did not think the hospital could stabilize her. He said the medical director was involved in the decision and there should be documentation of the decision. -However, there was no documentation provided from the medical director by the exit of the survey on 3/28/23.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, record review and observation the facility failed to allow resident to return to the facility after going to the hospital for one (#6) of three residents reviewed for discharge out of 12 sample residents. Specifically, the facility failed to allow the resident to return to the facility once stabilized at the hospital. Findings include: I. Facility policy and procedure The Involuntary discharge policy and procedure, revised 2/14/19, was provided by the director of nursing (DON) on 3/28/23 at 12:40 p.m. It read in pertinent part, To assure residents will be transferred or discharged only for the residents welfare. If the resident is being transferred due to the resident being a danger to self or others, there must be documentation to show that interdisciplinary interventions were tried and failed prior to discharge. The resident's physician must document in the medical record. The facility will document in the residents medical record: The basis for the transfer, the specific residents need(s) that cannot be met, facility attempts to meet the resident needs, and the service available at the receiving facility to meet the need(s). The notice provided to the resident, family member, or representative must contain an explanation of the right to appeal the transfer to the state as well as the name, address, and phone number of the Ombudsman. II. Resident #6 A. Resident status Resident #6 age [AGE], was admitted on [DATE] and discharged on 2/4/23 to the hospital. According to the February 2023 computerized physician orders (CPO) diagnoses include Parkinson's disease, depressive episodes, dementia with other behavioral disturbances, and insomnia. The 12/20/22 minimum data set (MDS) assessment revealed the resident had moderate cognitive impairment deficit with a brief interview for mental status (BIMS) with a score of 10 out of 15. The resident required one person supervision for walking in the room, in the corridors, locomotion on and off the unit, toileting, and personal hygiene. There were no behaviors coded on the MDS assessment. III. Record review The care plan for long term care (LTC) documented discharge was not feasible. Interventions include providing the resident with daily opportunities to participate in activities of interest, social services will assist the resident in finding safe and appropriate placement where which the resident can transfer, if the resident and/or responsible party indicates a desire to discharge. The care plan for behaviors documents the resident being verbally aggressive, such as yelling, can be combative, threatening to others with physical and/or invade others personal space related to dementia. Interventions include administering medications as ordered, analyzing key times, places, circumstances, triggers and what de-escalates behaviors, assess residents' coping skills and support system, and assess residents' understanding of the situation. A. Nursing notes Behavior note dated 2/4/23 at 2:00 p.m. documented the resident behavior of yelling, cussing, attempting to hit staff members with a belt. After staff obtained the belt the resident attempted to hit her head on the window. Three CNAs prevented the resident from hurting herself. The resident left the facility at 12:30 p.m. via ambulance. The power of attorney (POA) was notified. Nursing note dated 2/4/23 at 1:16 p.m. documented the resident's power of attorney (POA) would not be accepted back to the facility, the POA did not agree but was aware. Cross-reference F623 for discharge notice. A Discharge summary dated [DATE] (dated a day prior to the resident's discharge to the hospital), signed on 2/21/23 documented the condition on discharge as: unstable at time of discharge, sent to the emergency room (ER) and not allowed to return to the facility. An after-visit summary from the hospital dated 2/4/23 document the resident was stable and medically cleared to return to assisted living. -The resident was not accepted back to the facility for readmission after completion of hospital treatment where she was medically stable and cleared. IV. Staff interviews The social services director (SSD) was interviewed on 3/28/23 at 11:02 a.m. The SSD said she was not familiar with Resident #6's triggers or the incident that caused the resident to be discharged from the facility. She said the DON and nursing home administrator (NHA) made the decision to discharge the resident and she was not part of the discharge. The SSD said a note regarding the incident should be documented in the resident's medical record. The SSD said that social services was not informed or involved with the discharge of Resident #6. The DON was interviewed on 3/28/23 at 11:19 a.m. The DON said in most discharges to the hospital there was no paperwork and paperwork was done on an individual basis. The DON said Resident #6 had a history of behaviors. She and the NHA made the decision to transfer the resident to the hospital and not allow her to be readmitted to the facility. The DON said the family requested the resident be allowed to return to the facility and the request was considered by the facility. The DON said the interdisciplinary team (IDT) decided the resident was too dangerous to return based on her condition in the facility prior to being discharged to the hospital. The NHA was interviewed on 3/28/23 at 12:33 p.m. The NHA said the discharge of Resident #6 was facility initiated. He said he reviewed the situation and made the decision to not let the resident back. He said after the resident had been cleared by the hospital to return that the facility had no indication that she was stable and he did not think the hospital could stabilize her. He said the medical director was involved in the decision and there should be documentation of the decision. -However, there was no documentation provided from the medical director by the exit of the survey on 3/28/23.

Based on observations, and interviews, the facility failed to provide services in accordance with currently accepted professional principles. Specifically, the facility failed to ensure medications were not left at the bedside in a resident's room. Findings include: I. Observations On 3/23/23 at 3:46 p.m. in room # 261 a medication cup with two orange medications (that were identified as Senna S) observed on the table. The resident was not in his room. The above observation was communicated to the licensed practical nurse (LPN) #2. II. Staff interviews LPN #2 was interviewed on 3/23/23 at 3:55 p.m. She said she left medications at the bedside because the resident wanted to take medications later. She said she was not sure how to handle the situation since the resident was alert and wanted to take medications later. Unit manager (UM) #2 was interviewed on 3/23/23 at 4:05 p.m. She said medications should not be left at the bedside. She said if a resident wanted medications later, the nurse should have taken medications back and provided it to the resident when he was ready for it. The director of nursing (DON) was interviewed on 3/28/23 at 12:15 p.m. She said medications should not be left at the bedside for safety reasons. She said if a resident wanted to self administer medications he or she should be assessed for self administration of medications.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and interviews, the facility failed to provide necessary care and services for residents who were unable to carry out activities of daily living for one (#2) out of three sample residents reviewed out of 12 sample residents. Specifically, the facility failed to provide incontinence care to Residents #2 after the meal. Findings include: I. Facility policy and procedure The Incontinence Management policy, revised 8/20/29, was provided by the director of nursing (DON) on 3/29/23. The policy included a Passway to Incontinence Management. The passway read in pertinent part: When a resident has no memory recall and is extensively dependent, manage the incontinence care with frequent changes. II. Resident #2 A. Resident status Resident #2, age [AGE], was admitted on [DATE]. According to the March 2023 computerized physician orders (CPO), diagnoses included unspecified dementia without behavioral disturbance and malignant neoplasm (cancer) of the lung. The 2/20/23 minimum data set (MDS) assessment revealed the resident was cognitively impaired with a brief interview for mental status (BIMS) score of three out of 15. The resident required one person physical assistance with all activities of daily living (ADLs) including toileting and personal hygiene.Resident was always incontinent. The resident was receiving hospice services. B. Observations Resident #2 was observed on 3/22/23 between 11:50 a.m. and 4:10 p.m. -At 11:50 a.m. the resident was brought to the dining room and served a meal. -At 12:55 p.m. the resident was taken by a certified nurse aide (CNA) to her room and put to bed without being provided incontinence care. -At 4:10 p.m. the resident was still in bed sleeping. According to the CNA toileting task documented in the resident's record, the resident was last toileted at 9:02 a.m. on 3/22/23. C. Resident representative interview Resident #2's power of attorney (POA) was interviewed on 3/22/23 at 1:25 p.m. The resident's POA said she visited almost daily and on several occasions she witnessed Resident #2 with a smell of urine because she was not changed for long periods of time. She said she brought all concerns during the care conference and the response she received was that the facility was challenged by staffing shortage, and employed agency staff who were not familiar with residents' needs. She said this was given as an excuse for the care that Resident #2 did not receive daily (Cross-reference to F585 grievances). D. Record review The comprehensive care plan for the bowel and bladder was initiated on 5/5/21 and last revised on 5/31/22, revealing the resident was incontinent of bowel and bladder. Interventions included to observe patter of incontinence, and initiate toileting schedule if indicated. -The care plan did not include any specifics about the resident's individual needs. The resident's [NAME] (a directive for CNAs) included the following interventions: offer toileting upon rising, before and after meals and before bed time. III. Staff interviews CNA #2 was interviewed on 3/22/23 at 3:26 p.m. She said she was agency CNA and she was not familiar with Resident #2's needs. She said she was not assigned to the unit where Resident #2 was residing, but she was helping on the unit to answer the call lights. CNA #3 was interviewed on 3/22/23 at 3:30 p.m. She said she was agency CNA and she was not familiar with Resident #2's needs. She said she was not assigned to the unit where Resident #2 was residing, but she was helping on the unit with call lights and transfers. Unit manager (UM) #1 was interviewed on 3/22/23 at 3:40 p.m. She said CNA #4 was assigned to the unit where Resident #2 was residing. She said she was not sure where CNA #4 was at the moment. CNA #4 was interviewed on 3/22/23 at 4:00 p.m. She said she was an agency CNA and took over the shift at 2:00 p.m. from the other CNA. The previous CNA was an agency CNA and she did not recall her name. She said she did not receive a report from her on which resident was toileted and which residents were not. She said sometimes a report was given and sometimes not. She said she was not familiar with residents on the unit. She said she was given a printed page with resident's names and their transfer status. She said she was also assigned to provide showers to four residents on another unit and was absent from her assigned unit for a significant amount of time. She said she did not check on Resident #2 since her shift started and she did not provide any care to the resident. UM #1 was interviewed a second time on 3/22/23 at 4:10 p.m. She said the facility was fully staffed. The unit had three CNAs who were agency CNAs and she was helping them with transfers and care to make sure the care was provided. The DON was interviewed on 3/28/23 at 12:10 p.m. She said the incontinence care should be offered to all residents prior and after the meals. She said agency CNAs were working the unit, but they all received printed instructions for all residents in their care. She said Resident #2 should have been provided incontinence care after the meal prior to the nap.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews, the facility failed to ensure two (#9 and #10) residents reviewed out of 12 sample residents received treatment and care in accordance with professional standards of practice. Specifically, the facility failed to administer morning medications to Resident #10 and afternoon insulin to Resident #9. Findings include: I. Resident #10 A. Resident status Resident #10, age [AGE], was admitted on [DATE]. According to the March 2023 computerized physician orders (CPO), diagnoses included dementia, heart failure, and depression. The 2/8/23 minimum data set (MDS) assessment revealed the resident was cognitively impaired with a brief interview for mental status (BIMS) score of zero out of 15. B. Medication administration observations Licensed practical nurse (LPN) #3 was continuously observed on 3/23/23 from 10:58 a.m. to 1:00 p.m. LPN #3 was approached at 10:58 a.m. He said he was an agency nurse, it was his first time working on the unit and he was a bit late with his morning meds. He said Resident #10 was his last resident that he had to pass morning medications to. He pulled blister cards out of medication card and pulled the following medications: -Vitamin D 3 1,000 international units (IU) -Vitamin B 12 500 milligrams (mg) -Tylenol 650 mg for pain -Lasix 10 mg for edema -Sertraline 125 mg for depression -Oxycodone 5 mg for chronic pain LPN #3 put all medications in a plastic sleeve and crushed them. He could not locate an order for administering crushed medications and reached out to unit manager (UM) #2. The UM #2 reviewed the resident's orders and could not locate the order to crush medications. He instructed LPN #3 to dispose of crushed medications and went to clarify the orders. LPN #3 disposed of all crushed medications at 11:32 a.m. LPN #3 was observed until 1:00 p.m., he never re-approached the Resident #10 who was sitting in the dining room, and never administered morning medications when the observation was stopped at 1:00 p.m. C. Record review According to the March 2023 CPO, the resident had the following medications to be administered in the morning: -Vitamin D 3 1,000 international units (IU) -Vitamin B 12 500 milligrams (mg) -Tylenol 650 mg for pain -Lasix 10 mg for edema -Sertraline 125 mg for depression -Oxycodone 5 mg for chronic pain The medication administration record (MAR) was marked with LPN's signature and number 5 code, meaning hold/see progress note. The progress note by UM #2 on 3/23/23 at 8:49 p.m. read Spoke earlier with nurse practitioner, requesting order to retime medication and to crush meds (medications) unless contraindicated. Nurse practitioner was okay with this. However, on further review, timing change was not necessary per documentation by the nurse. Informed on-call nurse practitioner of morning medication and noon medication. Okay to resume medications at their normal times. No further concerns noted at this time. -The note did not clarify if morning medications were given or not. II. Resident #9 A. Resident status Resident #9, age [AGE], was admitted on [DATE]. According to the March 2023 computerized CPO, diagnoses included type one diabetes mellitus and vascular dementia. The 3/20/23 MDS assessment revealed the resident was cognitively impaired with a BIMS score of five out of 15. B. Medication administration observations LPN #3 was continuously observed on 3/23/23 from 10:58 a.m. to 1:00 p.m. -At 11:59 a.m. LPN #3 entered Resident #9's room to check her blood sugar. The blood sugar was 366. LPN #3 exited the room, documented blood sugar and drew four units of humalog per sliding scale. -At 12:03 p.m. LPN #3 entered Resident #9's room and administered four units of insulin in the presence of UM #2. Resident #9 asked the nurse where her second dose of insulin was before lunch. LPN #3 said it was coming later. -At 12:20 p.m. LPN #3 exited the room and proceeded to administer medications to other residents. LPN #3 never entered Resident #9's room between 12:20 p.m. and 1:00 p.m. Resident #9 was served coffee with cream and cranberry juice at 12:05 p.m. and her lunch was delivered to her room at 12:30 p.m. C. Record review According to the March 2023 CPO, the resident had the following orders: -Humalog Solution 100 units/ml (Insulin Lispro), inject as per sliding scale before meals at 11:00 a.m.; and, -Humalog Solution 100 units/ml (Insulin Lispro), inject six units with meals at 12:00 a.m. The MAR administration times were reviewed with UM #2 at 1:15 p.m. The MAR timestamp indicated that LPN #3 signed four units of insulin (scheduled at 11:00 a.m.) and six units of insulin (scheduled at 12:00 p.m.) were both given to Resident #9 at 12:20 p.m. -This was contrary to observations above, as LPN #3 never entered Resident #9's room to administer six units of humalog between 12:20 and 1:00 p.m. He only administered four units of humalog per sliding scale at 12:20 p.m. The above findings were reported to the director of nursing (DON) on 3/23/22 at 1:20 p.m. III. Staff interviews UM #2 was interviewed on 3/23/23 at 1:15 p.m. He said the MAR timestamp indicated that both doses of insulin were given to the Resident #9 at 12:20 p.m. He said all medications were administered an hour before and an hour after scheduled times. He said this rule applied to all medications without exclusions. He said if medication was given late or was not given on time, the nurse should call the doctor to notify about missed medication. He said based on MAR review for Resident #9 all medications were administered on time, including insulin. Regarding Resident #10, he said all morning medications were signed as given, and he said LPN #3 confirmed to him that all morning medications were administered. The DON was initially interviewed on 3/23/23 at 1:20 p.m. She said she would investigate reported findings. She said all medications were administered an hour before and an hour after scheduled times for all residents. She said she was not aware of any time sensitive medications that should be administered at a specific time. Primary care physician (PCP) #1 was interviewed on 3/27/23 at 10:51 a.m. She was a PCP for Resident #9. She said she did not receive any calls from the facility on 3/23/23 about missed or late insulin administration for Resident #9. She said insulin should be administered as scheduled and it was important to give insulin before the meals. She said late or missed insulin administration would result in high blood sugars. The pharmacy consultant was interviewed on 3/28/23 at 9:30 a.m. She said she reviewed medications on monthly bases and occasionally observed medication administrations. She said she did not identify any concerns with medication administration in the facility. She said she could not comment on whenever missed medications for Resident #10 and late/missed insulin administration for Resident #9 were significant medication errors. She said she would need to review the medical record and get back with her comments. She said she was not certain that insulin or any other medications should be given at a specific time. She said nurses always had a two hour window to administer all medications. -The pharmacy consultant did not return the call with further clarifications by the exit of the survey on 3/28/23. Nurse practitioner (NP) #1 was interviewed on 3/28/23 at 10:45 p.m. She said she was on call NP for Resident #10. She said she was off on 3/23/23 but she checked with other NP who was covering for her and she said covering NP received a call on 3/23/23 to clarify if Resident #10's medications could be crashed. She said there was no mention that morning medications were not given to Resident #10. She read a progress note by UM #2 on 3/23/23 and said she could not determine from the note if medications were given or not. She said some medications such as insulin, antibiotics and Parkinson's medications were time sensitive medications and should be given as scheduled (not an hour before or after scheduled time). She said the reasons for that were different for every medication. She said it was important to administer insulin on time as it was affecting an individual's blood sugar and was influenced by meal intake. She said insulin scheduled prior to meal should be given prior to meal. The DON was interviewed a second time on 3/28/23 at 12:20 p.m. She said on 3/23/23 after above observations were reported to her, she initiated facility wide training for all nurses on proper medication administrations. She said she contacted PCP #1 on 3/23/23 regarding insulin administration for Resident #9. She said her investigation did not show that medications were not given to Resident #9 and Resident #10. She said her investigation included an interview with LPN #3 who said that he administered morning medications to Resident #10 and both insulin doses to Resident #9 on time. She said since MAR was signed timely and LPN denied not administering medications she had no evidence of improper medication administration. She said she reported the above concerns to the medical director and facility wide training was initiated on 3/23/23 with random audits of medication administrations.

Based on observations and staff interviews, the facility failed to maintain an infection control and prevention program designed to provide a sanitary environment to help prevent the development and transmission of communicable diseases and infections in one out of three units. Specifically, the facility failed to clean and sanitize the water pitcher that Resident #11 dropped on the floor. Findings include: I. Observations Resident #11 was observed on 3/23/23 between 2:50 p.m and 4:15 p.m. He was strolling in a wheelchair in the hallway of the second floor unit. He was holding an empty water pitcher with a straw in it. -At 3:45 p.m. Resident #11 dropped his water pitcher on the floor, the lid and straw were in contact with the floor. The passing by certified nurse aide (CNA) picked up the pitcher and gave it back to the resident. -At 4:10 p.m. Resident #11's pitcher was observed on the floor. The resident strolled to the door with the sign medication room and kicked the door. Passing by unit manager (UM) #1 picked up an empty pitcher off the floor and gave it back to the resident. II. Staff interview UM #1 was interviewed on 3/23/23 at 4:20 p.m. She said she did recall picking up a pitcher off the floor and giving it back to the Resident #11. She said Resident #11 wanted his soda drink and this was why he was kicking the door to the medication room (where soda was stored) and kept dropping his pitcher. She said she did not have time to refill his pitcher with a soda drink. She said she told him he should be patient. She said she should have washed the pitcher before giving it to the resident, but she forgot to do so. The director of nursing (DON) was interviewed on 3/28/23 at 12:15 p.m. She said nurses and CNAs should have cleaned the pitcher that was dropped on the floor prior to giving it back to the resident.

Based on observations, interviews and record review, the facility failed to provide sufficient nursing staff with the appropriate competencies and skills to ensure the residents received the care and services they required as determined by resident assessments and individual plans of care for one (Unit 2) out of three units. Specifically, the facility failed to consistently provide adequate nursing staff which considered the acuity and diagnoses of the facility's resident population in accordance with the facility assessment, resident census and daily care required by the residents. As a result of inadequate staffing, the facility failed to ensure residents were treated with respect and dignity. Cross-reference F550 Respect and Dignity. Findings include: I. Resident census and conditions According to the 12/13/22 census and conditions report for the second floor, the census was 52 residents. Of those 52 residents: -29 residents required one or two staff member assist with bathing, 14 were totally dependent, and 9 were independent. -42 residents required one or two staff member assist with dressing, 2 were totally dependent, and 8 were independent. -36 residents required one or two staff member assist with transferring, 7 were totally dependent, and 9 were independent. -40 residents required one or two staff member assist with toileting, three were totally dependent, and seven were independent. -8 residents required one or two staff member assist with eating, 3 were totally dependent and 41 were independent. II. Staffing requirements The staff scheduler (SS) was interviewed on 12/9/22 at 11:50 a.m. He stated the goals for staffing for the second floor were six certified nurse aides (CNAs) and two nurses on the day shift and two nurses from 6:00 to 10:00 p.m. and four CNAs at night. He stated after 10:00 p.m. one licensed nurse was sufficient on night shift. He stated the facility has many staff who work 12 hour shifts 6:00 a.m. to 6:00 p.m., though also have many staff that work eight hour shifts of 6:00 a.m. to 2:00 p.m., 2:00 p.m. to 10:00 p.m. and some work 10:00 p.m. to 6:00 a.m. He stated staffing to the ideal numbers has been a big challenge. He stated the crisis level staffing during the day was four CNAs and two nurses. He stated the night shift was difficult to staff with three or four CNAs and there were frequently only two, which was not enough to provide timely care to all of the residents on the second floor. III. Working schedules Review of the working schedules for the facility from 11/1/22 to 12/9/22 revealed: On 11/3/22 the second floor day shift had two nurses and four CNAs until 2:00 p.m. when one CNA left until another CNA came in at 6:00 p.m. On night shift there was one nurse and four CNAs until 10:00 p.m. when two CNAs left and there were two left from 10:00 p.m. to 6:00 a.m. On 11/5/22 the second floor had two nurses and three CNAs on day shift. On 11/11/22 the second floor had two nurses and three CNAs until 10:00 p.m. on night shift. After 10:00 p.m. a nurse and a CNA left and the staffing dropped to one nurse and two CNAs. On 11/13/22 the second floor had two nurses and three CNAs until 10:00 p.m. on night shift. After 10:00 p.m. a nurse and a CNA left and the staffing dropped to one nurse and two CNAs. On 11/17/22 the second floor had two nurses and four CNAs on day shift until 6:00 p.m. The night shift had three nurses and two CNAs until 10:00 p.m. then dropped to one nurse and two CNAs from 10:00 p.m. to 6:00 a.m. On 11/18/22 the second floor had two nurses and four CNAs from 6:00 a.m. to 2:00 p.m. when they dropped to three CNAs from 2:00 p.m. to 6:00 p.m. On night shift the second floor had two nurses and three CNAs until 10:00 p.m. when they dropped to one nurse and two CNAs until 6:00 a.m. On 11/19/22 the second floor had two nurses and four CNAs from 6:00 a.m. to 6:00 p.m. On night shift, the floor had two nurses and four CNAs from 6:00 p.m. to 10:00 p.m. then dropped to one nurse and two CNAs until 6:00 a.m. On 11/23/22 the second floor had one nurse and four CNAs from 6:00 a.m. to 2:00 p.m. when they dropped to one nurse and three CNAs from 2:00 p.m. to 6:00 p.m. The night shift had two nurses and two CNAs from 6:00 p.m. to 10:00 p.m. and then dropped to one nurse and two CNAs from 10:00 p.m. to 6:00 a.m. On 11/24/22 the second floor had one nurse and three CNAs on night shift from 6:00 p.m. to 10:00 p.m. and then dropped to one nurse and two CNAs from 10:00 p.m. to 6:00 a.m. On 11/25/22 the second floor had two nurses and three CNAs from 6:00 a.m. to 6:00 p.m. on day shift. On 12/1/22 the second floor had two nurses and two CNAs on night shift from 6:00 p.m. to 10:00 p.m. and dropped to one nurse and two CNAs from 10:00 p.m. to 5:00 a.m. when one of the CNAs left and resulted in one nurse and one CNA. On 12/2/22 the second floor had three nurses and one CNA from 6:00 p.m. to 10:00 p.m. At 10:00 p.m. two of the nurses left and one more CNA arrived leaving one nurse and two CNAs from 10:00 p.m. to 6:00 a.m. IV. Resident interviews Resident #2 was interviewed on 12/5/22 at 2:24 p.m. He stated the call lights had been taking a very long time to answer, sometimes close to an hour at night when there were only two CNAs (certified nurse aides) at night. He stated the facility was frequently short staffed and it made him upset and feel forgotten or worthless when the call light took a long time. He stated the staff worked hard and tried, but there just weren't enough of them to care for all of the people on the floor. He stated he was not only concerned for himself and his care, but for the other residents on the floor who needed more help than he did. Resident #4 was interviewed on 12/7/22 at 8:32 a.m. She stated the facility was short staffed regularly, especially at night. She stated the CNAs on the second floor work very hard and treat the residents well but they can only do so much when there are two of them at night. She stated she has had to wait for 30 minutes to an hour for her call light to be answered at night and had gotten herself out of bed on more than one occasion to go out in the hall to look for someone and it took 45 minutes to see any staff come by her room. She stated she frequently heard other residents on the hall calling out for help and waiting for a long time to receive assistance. She stated the long wait times make her feel afraid that she will not receive assistance if something bad happened to her or if she fell. Resident #6 was interviewed on 12/7/22 at 9:30 a.m. She stated the facility did not have enough staff. She stated the call lights and cares took a long time because there was not always enough staff on the floor to get to everyone. She stated there were a lot of people who needed a lot of help on the unit and she worried they were not getting the help they needed timely. VI. Additional record review Resident council minutes were reviewed for November 2022. One of the residents in attendance complained that her call light was not being answered and that she called out for the nurse by name who did not come in and help her. The notes revealed the resident reported feeling very sad and scared when this happened. The resident reported staff were rushed and stressed when the facility was short staffed. One resident stated she was given a bell for emergencies to add to call light but did not receive a prompt response. Another resident stated that CNAs say wait a minute and do not return. A resident stated that she understands the building has been short staffed and that CNAs have a lot of people to get to. Another resident stated she was told they were short staffed on a day they were fully staffed. Grievances for September 2022, October 2022, November 2022, and December 2022 to date were reviewed, and five grievances were filed related to long call light times related to insufficient staffing numbers. Follow up from the facility was to educate staff regarding timely call light response and to complete call light audits. The call light audits were requested, though were not provided and residents continued to experience long call light response times (see above). VII. Staff interviews Licensed practical nurse (LPN) #1 was interviewed on 12/8/22 at 12:15 p.m. She stated there was not always enough staff on the floor and it was difficult to get everything done when the facility was short staffed. She stated the resident call lights should be answered within five minutes, though this was very difficult to accomplish especially when the facility was not fully staffed and during meal times and shift changes. LPN #2 was interviewed on 12/9/22 at 1:25 p.m. She stated there was not enough staff to answer call lights timely for the residents. She stated they tried, though call lights were often longer during the day when there were four CNAs caring for all the residents on the unit. She stated the CNAs and nurses had difficulty getting to all the residents timely when multiple staff were caring for those residents who needed two or more staff for care tasks. CNA #1 was interviewed on 12/9/22 at 1:35 p.m. She stated four staff was the very minimum the unit could have to care for residents during the day and evening. She stated it was difficult to get to all resident call lights timely when multiple staff were providing care for residents who required two-person assistance. She stated she had worked the night shift on many occasions and two CNAs was not enough to provide timely care to the residents. CNA #2 was interviewed on 12/9/22 at 1:40 p.m. She stated she always worked day shift and it was difficult to provide timely care to all residents and answer the call lights timely when there were only four CNAs. She stated when there were only two CNAs on night shift, the morning shift could be chaotic because the night shift staff could not get to everything and everyone the night before. The director of nursing (DON) was interviewed on 12/9/22 3:02 p.m. She stated the facility tried to reach their ideal staffing levels. She stated staffing was based on acuity and numbers. She stated they tried to keep staffing during the day and evening to 1:12 (ratio of staff to residents) but it was not always possible. She stated when the second floor dropped to three CNAs during the day or evening shifts, the unit managers would help out with resident care. She stated three CNAs would not be enough alone on the second floor. She stated it was difficult having only two CNAs on night shift for the amount of residents on the second floor. She stated once resident call lights go past 10 or 15 minutes, the residents could start getting upset and worried.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interview, record review, and policy review, the facility failed to ensure over-the-counter medications were secured for 1 (Resident #115) of 8 sampled residents who resided on the third floor. Findings included: A review of the facility policy titled, Bedside Storage of Medications Self Administration of Drugs, revised 03/14/2018, revealed, Purpose: To provide a safe environment for self-administration of drugs .Procedure: .2. Assess the resident's ability to self-administer medications if the resident so chooses by completing the Self-Administration Pretest .5. Storage of the medications should de only in lockable drawers, cabinets or boxes to prevent access by other residents. A review of the admission Record revealed Resident #115 was admitted to the facility with a diagnosis of vascular dementia with behavioral disturbance. A review of the quarterly Minimum Data Set (MDS), dated [DATE], revealed the resident scored a 10 on the Brief Interview for Mental Status (BIMS), which indicated the resident was moderately cognitively impaired. An observation and interview with Resident #115 on 05/16/2022 at 10:32 AM revealed two open tubes of Aspercreme, one bottle of artificial tears, and one medication unit dose pack containing two tablets labeled Day on the resident's bedside table. Resident #115 indicated the two tablets were daytime cold medicine and the resident got it from a shopping center. During an interview on 05/16/2022 at 11:10 AM, Licensed Practical Nurse (LPN) #1 stated medications should not be in the resident rooms. A review of the Order Summary Report, dated 04/30/2022, revealed a physician's order for Refresh Tears solution, but no physician's order for artificial tears, Aspercreme, or cold medication. There was also no physician's order for self-administration of medications. A review of the care plan revealed Resident #115 did not have a care plan related to self-administration of medications. A review of Resident #115's medical record revealed there was no assessment for self-administration of medications for the resident. During an observation in Resident #115's room on 05/16/2022 at 3:40 PM, the one medication dose pack with two tablets and the bottle of artificial tears remained on the bedside table. During an observation and interview on 05/16/2022 at 3:43 PM, the Registered Nurse (RN) Third Floor Unit Manager indicated no self-administration assessment had been completed for Resident #115. She indicated Resident #115 failed the self-administration assessment that was done that day. The RN Third Floor Unit Manager stated she had removed the medications (Aspercreme) and talked with a family member who indicated they had not brought in any medications. The RN Third Floor Unit Manager was asked if she removed the cold medications, and she indicated she did not see any. Upon observation in Resident #115's room, she picked up the cold medication and was shown the bottle of artificial tears eye drops. RN Third Floor Unit Manager indicated she was not sure if the bottle of artificial tears eye drops was considered a medication, but she removed it from the room. During an interview on 05/18/2022 at 2:55 PM, Certified Nursing Assistant (CNA) #1 indicated she had seen medications in Resident #115's room and thought the nurse had put them on the bedside table. During an interview on 05/18/2022 at 3:10 PM, LPN #2 stated if a resident could keep medications in their room, there would be an order. LPN #2 reviewed Resident #115's physician's orders and stated there was no order for the resident to keep medications in their room and there was also no order indicating the resident could self-administer medications. LPN #2 indicated in order for a resident to self-administer medications, the RN Third Floor Unit Manager would have to do an assessment. During an interview on 05/19/2022 at 10:12 AM, the Director of Nursing (DON) stated the medication was not supposed to be in Resident #115's room. The DON stated the expectation was if the resident passed the self-administration test, the medications would be locked up and if the resident did not pass, medications would not be in the room. If the resident passed, that would be documented and care planned as well. During an interview on 05/19/2022 at 12:39 PM, the Administrator stated the expectation was for the resident to be assessed and deemed safe to self-administer prior to the medications being left in the room.