**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to conduct a preadmission screening resident review (PASRR) for two (#20 and #10) of two residents reviewed for PASRR out of 28 sample residents. Specifically, the facility failed to submit a new PASRR Level I after Resident #20 and Resident #10 were admitted to the facility with a provisional PASRR and remained in the facility for more than 30 days. Findings include: I. Facility policy and procedure The Pre-admission Screening and Resident Review (PASRR) policy, revised [DATE], was provided by the regional director of clinical services (RDCS) #1 on [DATE] at 2:10 p.m. It read in pertinent part, Ensure the Level I PASRR screening has been completed on potential admissions prior to admission. A negative Level I screen permits admission to proceed and ends the PASRR process unless a possible serious mental disorder or intellectual disability arises later. A record of the pre-screening should be retained in the resident's medical record. A positive Level I screen necessitates an in-depth evaluation of the individual by the state-designated authority, known as PASRR Level II, which must be conducted prior to admission to a nursing facility. When a Level II PASRR screening is warranted it must be obtained as well as a determination letter prior to admission. The Level II PASRR cannot be conducted by the nursing facility. The Level II PASRR determination and the evaluation report specify services to be provided by the facility or specialized services defined by the state; and, Recommendations from PASRR Level II determination and PASRR evaluation report are to be incorporated into the person-centered care plan as well as in transitions of care. II. Resident #20 A. Resident status Resident #20, age over 65, was admitted on [DATE]. According to the [DATE] computerized physician orders (CPO), diagnoses included generalized anxiety disorder, depression, bipolar disorder, cognitive-communication deficit, other symptoms and signs involving cognitive functions and awareness and adjustment disorder with depressed mood. The [DATE] minimum data set (MDS) assessment revealed Resident #20 was cognitively intact with a brief interview for mental status (BIMS) score of 14 out of 15. Resident #20 was documented as not having any behavioral symptoms. B. Record review Resident #20's care plan, revised [DATE], documented she received Sertraline (antidepressant medication) for her depression and she received Abilify (antipsychotic medication) for behavior management with Resident #20's bipolar disorder. Resident #20's behavioral care plan, revised [DATE], documented the resident had chronic depression and generalized anxiety disorder. Interventions included administering medications as ordered, discussing the resident's fears or concerns as needed, encouraging Resident #20 to talk about her life, offering the resident music, offering one-on-one attention and monitoring for signs and symptoms of depression. A provisional (temporary) PASRR was uploaded into Resident #20's electronic medical record (EMR) on [DATE]. The provisional PASRR read in pertinent part, The review of the submitted PASRR Level I screen resulted in a finding of a known or suspected mental illness and there were indicators for a qualifying provisional admission. The facility is responsible for submitting a new Level I PASRR screen if the member (resident) is anticipated to reside in the facility beyond the approved provisional admission timeline as noted below. Exempted hospital discharge: The need for a nursing home regarding convalescent (recovery) care due to a discharge from an acute care hospital where the rehabilitation care relates to the reason for the hospitalization and has been certified by the attending physician to likely require fewer than 30 days of nursing services. -However, the facility failed to submit a new Level I PASRR screen when the resident remained in the facility longer than 30 days. A PASRR Level I screen was approved for Resident #20 on [DATE] (over six months after the provisional PASRR expired) and documented the resident needed a PASRR Level II due to evidence of a known or suspected PASRR condition which required further evaluation. A PASRR Level II was approved for Resident #20 on [DATE] (during the survey). It documented the following specialized services were required or recommended for Resident #20: Medication review, individual therapy and a further neurocognitive test to verify the diagnosis of a neurocognitive disorder and to establish a baseline. -However, the facility's delay in submitting a new Level I PASRR screen when the resident remained in the facility after 30 days, resulted in a nine-month delay of Resident #20 receiving the recommended individual therapy and neurocognitive testing. III. Resident #10 A. Resident status Resident #10, age over 65, was admitted on [DATE]. According to the [DATE] CPO, diagnoses included generalized anxiety disorder, unspecified disorder of the brain, dementia with anxiety and unspecified symptoms and signs which involved cognitive functions and awareness. The [DATE] MDS assessment revealed Resident #10 had a severe cognitive impairment with a BIMS score of six out of 15. Resident #10 did not have documented behaviors. B. Record review Resident #10's activity care plan, revised on [DATE], documented the resident had little to no activity involvement due to her anxiety, depression and disinterest. Interventions included the resident preferred to watch television, listen to music, socialize with her hearing aids, family visits and stay up-to-date on current events. Resident #10's care plan, revised on [DATE], documented Resident #10 used Escitalopram (antidepressant medication) for her dementia with anxiety. Interventions included administering antidepressant medication as ordered and monitoring for side effects and effectiveness and educating the resident and family about the risks and benefits of the medication. A provisional PASRR was uploaded into Resident #10's EMR on [DATE]. The provisional PASRR read in pertinent part, The review of the submitted PASRR Level I screen resulted in a finding of a known or suspected mental illness and there were indicators for a qualifying provisional admission. The facility is responsible for submitting a new Level I PASRR screen if the member (resident) is anticipated to reside in the facility beyond the approved provisional admission timeline as noted below. Exempted hospital discharge: The need for a nursing home regarding convalescent (recovery) care due to a discharge from an acute care hospital where the rehabilitation care relates to the reason for the hospitalization and has been certified by the attending physician to likely require fewer than 30 days of nursing services. -The resident's EMR did not reveal that a new PASRR Level I had been submitted by the facility after Resident #10 remained in the facility longer than 30 days. A PASRR Level I screen was submitted for Resident #10 on [DATE] (during the survey). IV. Staff interview The social services director (SSD) was interviewed on [DATE] at 4:25 p.m. The SSD said when residents were admitted to the facility a Level I PASRR screen was completed by the hospital. She said recently the hospital was only completing provisional PASRR screens instead of a Level I PASRR. She said the admissions coordinator reviewed the PASRRs during the time of the resident's admission. The SSD said the provisional PASRR gave her 30 days to submit a new Level I PASRR screen if the resident was not going to be discharged by the end of the 30 days. The SSD said Resident #20 was admitted in [DATE] and she did not have a social services assistant at the time to help her with PASRRs. The SSD said she missed submitting a new Level I PASRR for Resident #20 when the resident remained in the facility longer than 30 days. The SSD said Resident #10 was readmitted to the facility in [DATE]. The SSD said she missed submitting a new Level I PASRR for Resident #10 when the resident remained in the facility longer than 30 days. She said she submitted the new PASRR Level I screen earlier that day ([DATE]). The SSD said she completed an audit of the rest of the residents in the facility (during the survey) and did not find any other PASRRs that were not completed correctly. The SSD said she planned to complete weekly audits to ensure residents had the appropriate PASRRs submitted in a timely manner.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interviews, the facility failed to ensure one (#24) of two residents reviewed for assistance with activities of daily living (ADL) out of 28 sample residents received appropriate treatment and services to maintain or improve his or her abilities. Specifically, the facility failed to ensure Resident #24 was repositioned timely Findings include: I. Resident #24 A. Resident status Resident #24, age greater than 65, was admitted on [DATE]. According to the August 2024 computerized physician orders (CPO), diagnoses included Alzheimer's disease, dysphagia (difficulty swallowing), prediabetes and chronic kidney disease stage 3. According to the 8/5/24 minimum data set (MDS)assessment the resident had severe cognitive impairments with a brief interview for mental status (BIMS) score of four out of 15. Resident #24 required substantial to maximum assistance with mobility and transfers. B. Observations During a continuous observation on 8/28/24, beginning at 8:47 a.m. and ending at 1:10 p.m. the following was observed: At 8:46 a.m. the resident was assisted away from the table. She was assisted to her room in her tilt back wheelchair. She was sitting in an upright position in her room. At 8:55 a.m. the resident continued to sit in her tilt back wheelchair. The wheelchair was in the upright position. At 9:23 a.m. the resident continued to sit in the same position. Certified nurse aide (CNA) #4 was talking with the resident. CNA #4 did not offer to reposition the resident. At 9:49 a.m. the resident remained in the same position and was sleeping in her chair. At 9:51 a.m. the resident continued to stay in her room in an upright position in her tilt back wheelchair. At 11:05 a.m. CNA #4 asked the resident if she wanted to go to trivia. -She did not offer to reposition Resident #24. The resident continued sitting in the wheelchair in the upright position. At 11:50 a.m. the resident was assisted to the dining room table. At 12:26 p.m. the resident was assisted back to her room. -The resident was not repositioned. At 12:29 p.m. the resident asked CNA #1 to help lay her down. CNA #1 said she would have to wait a bit as she needed to get some help. At 1:10 p.m. CNA #1 assisted the resident to the shower. -Resident #24 was not repositioned from 8:55 a.m. until 1:10 p.m. C. Resident's representative interview Resident #24's representative was interviewed on 8/29/24 at 11:30 a.m. The resident's representative said she had a special chair made which tilted back for Resident #24. She said it tilted back so that way her positioning was changed. D. Record review The skin care plan, revised on 8/18/24, revealed the resident was at risk for break in skin integrity including pressure related injury related to impaired mobility and function, weakness, incontinence, cognitive deficits and risk for malnutrition. Pertinent interventions included assisting Resident #24 with repositioning every two hours and as needed. The [NAME] (staff directive for person centered care), dated 8/29/24, documented the resident required extensive assistance of one to two staff members for transfers with the mechanical hoyer lift. E. Staff interviews Registered nurse (RN) #1 was interviewed on 8/28/24 at 12:30 p.m. RN #1 said Resident #24 was unable to move on her own. He said she required assistance from two staff members to transfer and reposition. He said the resident was at risk for skin breakdown because she had lack of mobility and was also incontinent of urine. RN #1 said Resident #24 needed to be repositioned every two hours. The director of rehabilitation (DOR) was interviewed on 8/29/24 at approximately 1:00 p.m. The DOR said Resident #24 had a tilt back wheelchair which was specially ordered. The DOR said titting the wheelchair back helped with the repositioning of the resident and relieved pressure.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** IV. Resident #1 A. Resident status Resident #1, over the age of 65, was admitted on [DATE] and readmitted on [DATE]. According to the August 2024 CPO, diagnoses included urinary incontinence, chronic kidney disease and chronic pain. The 8/2/24 MDS assessment revealed the resident was cognitively intact with a BIMS score of 15 out of 15. She required maximum assistance with lower body dressing, toileting and bathing. The assessment documented Resident #1 had no rejections of care. B. Record review The bladder incontinence plan of care, initiated 2/28/24 and revised 8/12/24, revealed interventions including observing for urinary tract infection (UTI) symptoms, including pain, burning, blood tinged urine, cloudiness, dark urine color, no urine output, urinary frequency, foul-smelling urine, fever, chills, changes in behavior, or changes in eating patterns and reporting potential causes of incontinence, including bladder infections. A progress note dated 6/1/24 documented that nursing staff spoke to Resident #1's family members because the resident had experienced an open area on her skin in the perineal area (patch of skin between the anus and the genitals) and the resident appeared to need more assistance with perineal hygiene. A progress note dated 6/3/24 documented that Resident #1's urine culture had no growth in the first 48 hours. The progress note documented that the resident was experiencing several UTI symptoms, including burning and blood, protein and leukocytes (white blood cells) in urine. The progress note further documented the nurse spoke to medical doctor (MD) #1 who informed nursing staff to discuss the matter with MD #2. Nursing staff documented a message was left for MD #2. A fax order request/notification form was documented on 6/3/24 at 6:33 p.m. The fax order documented MD #2 was notified that Resident #1 continued to experience burning while voiding. The form requested a reply from MD #2. -However, review of Resident #1's EMR failed to reveal documentation to indicate MD #2 provided a response to the facility's request. -Additionally, Resident #1's EMR failed to reveal documentation to indicate the facility followed up again with MD #2 when they did not receive a response to their request or contact the medical director when MD #2 did not respond A progress note dated 6/6/24 documented that Resident #1 was experiencing pain with urination, and the resident's skin near the perineal area was excoriated. -Resident #1's EMR failed to reveal documentation to indicate the facility attempted to notify MD #2 again or contact the medical director when MD #2 did not respond. A progress note dated 6/8/24 documented Resident #1 continued to experience pain and burning with urination. The progress note documented a urine dipstick was collected and leukocytes, protein and blood were found in Resident #1's urine. The progress note documented the on-call physician was called four times that day (6/8/24) for nursing staff to obtain an order to send Resident #1's urine to the lab, however, the nursing staff was unable to reach the on-call physician. The progress note documented that nursing staff encouraged Resident #1 to drink water. -Review of Resident #1's EMR revealed there was no further documentation regarding the resident's UTI symptoms or follow-up with a physician from 6/8/24 until 7/6/24. A provider visit note dated 7/6/24 documented that Resident #1 had experienced UTIs chronically. The provider visit note documented Resident #1 reported urinary burning symptoms and the nursing staff reported that the resident had been complaining of burning upon urination. The provider note documented the resident's skin excoriation could also be a cause for the burning pain. -However, a urinalysis completed two days after this visit (on 7/8/24) documented the resident had two different types of bacteria present in her urinary tract (see final urinalysis results below). A progress note dated 7/8/24 documented a urinalysis was completed for Resident #1. The progress note documented the resident had many indications of a urinary tract infection, including an elevated white blood cell count, elevated leukocytes and the presence of mucus, bacteria and epithelial (skin) bacteria. A progress note dated 7/10/24 documented that Resident #1's urinalysis contained two separate bacterial colonies. These colonies included Klebsiella Pneumoniae and another unidentified bacteria. The progress note documented the results were faxed to MD #1. A progress note dated 7/11/24 documented that Resident #1's final urinalysis results were completed and the resident had a Klebsiella Pneumoniae infection and an Escherichia coli (E. coli) infection in her urine. The progress note documented that the results were reviewed by MD #3, who ordered an antibiotic. A review of the July 2024 revealed a physician's order for Cefpodoxime Proxetil (antibiotic) oral tablet 100 milligrams (mg), give 100 mg by mouth two times per day for UTI for 7 (seven) days, ordered 7/12/24 at 7:00 p.m. A progress note dated 7/13/24 documented that Resident #1 was started on antibiotic therapy on 7/13/24 for a UTI. -The facility failed to ensure appropriate physician follow-up was provided between 6/3/24 and 7/6/24 to appropriately address Resident #1's UTI symptoms in a timely manner. C. Staff interviews RN #1 was interviewed on 8/27/24 at 3:58 p.m. RN #1 said Resident #1 had experienced several infections in the last year . RN #1 said Resident #1's infections had mostly been UTIs and nursing staff knew to report the resident's symptoms to the physician when Resident #1 felt pain or burning with urination. Certified nurse aide (CNA) #1 was interviewed on 8/28/24 at 1:22 p.m. CNA #1 said Resident #1 required maximal assistance with toileting and perineal care. CNA #1 said Resident #1 had experienced several UTIs in the past year (2023 to 2024) and nursing staff was watching her closely for any signs or symptoms of UTIs. CNA #1 said Resident #1 had no rejections of care. The IP and the DON were interviewed together on 8/29/24 at 3:19 p.m. The IP said it was important for nursing staff to recognize signs and symptoms of infection and report them to the physician. The DON said she expected physicians and nursing staff to communicate when nursing staff identified new symptoms of infection in residents. The DON said the facility had experienced difficulties with physician communication and the facility was currently transitioning to work with a new group of physician partners in the future. The DON said she was unsure why it took more than a month for a provider to further investigate Resident #1's UTI symptoms. Based on observations, record review and interviews, the facility failed to ensure two (#37 and #1) of two residents out of 28 sample residents received treatment and care in accordance with professional standards of practice. Specifically, the facility failed to ensure Resident #37 and Resident #1 received quality care when the residents' physicians did not respond timely after both residents experienced a change of condition. Findings include: I. Professional reference [NAME], P.A., [NAME], A.G., Fundamentals of Nursing, 10 ed. (2020), Elsevier, St. Louis Missouri, pp. 1115, read in pertinent part: Effective communication and teamwork are essential for the delivery of high-quality, safe patient care. To avoid communication failures that can lead to unanticipated adverse events in patients, nurses must speak up when they have concerns and take the necessary steps to communicate assertively and collaboratively with the healthcare team. II. Facility policy and procedure The Changes in Resident's Condition or Status policy, revised 8/9/23, was provided by regional director of clinical services (RDCS) #1 on 8/29/24 at 2:10 p.m. It read in pertinent part, This facility will notify the resident, his or her primary care provider and resident representative of changes in the resident's condition or status. III. Resident #37 A. Resident status Resident #37, age greater than 65, was admitted on [DATE]. According to the July 2024 computerized physician orders (CPO), diagnoses included dementia, chronic obstructive pulmonary disease (COPD), occlusion and stenosis of the right carotid artery, cognitive-communication deficit, dysphagia and heart failure. The 5/16/24 minimum data set (MDS) assessment revealed the resident had a moderate cognitive impairment with a brief interview for mental status (BIMS) score of nine out of 15. Resident #37 had an impairment to both arms and both legs. B. Record review Resident #37's Medical Orders for Scope of Treatment (MOST) form revealed the resident had a do not resuscitate status, however, the resident was okay with medical treatment at the hospital except for a breathing machine or being admitted into the intensive care unit (ICU). A health status note dated 7/3/24 documented a message was left with the resident's representative and physician because the resident tested positive for COVID-19 and isolation precautions were started. The physician ordered Paxlovid (medication used to treat COVID-19) 150 milligrams (mg). A communication with physician note dated 7/3/24 at 2:43 p.m. documented the nurse left a message for the physician because Resident #37 was unable to take Paxlovid because the resident required her medications to be crushed. According to the facility's pharmacist, Paxlovid could not be crushed. The nurse requested the physician to advise the nurse what the next step was. An infection note dated 7/4/24 documented the resident was on isolation precautions due to being positive for COVID-19. The resident denied pain at the time of the assessment and her vital signs were within her normal limits. The staff provided all care in her room and the plan of care was ongoing. An infection note dated 7/5/24 documented Resident #37 continued on isolation precautions for COVID-19. The resident denied pain at the time of the assessment and her vital signs were within her normal limits. The staff provided all care in her room, placed her call light within reach and the plan of care was ongoing. Another infection note dated 7/5/24 documented the resident continued on alert charting for isolation due to a positive COVID-19 test and all care was provided in her room. The resident's vital signs were within normal limits for the resident. Her vital signs were as follows: blood pressure 121/65, temperature 98.0 degrees Fahrenheit (F), pulse 99, respirations 20 and oxygen saturation 88 percent (%) on room air. A third infection note dated 7/5/24 documented the resident continued on alert charting because she was COVID-19 positive. Resident #37 was weak and on contact isolation precautions. When tolerated by the resident, fluids were offered by staff. The resident was on oxygen at 2 liters per minute (LPM) via nasal cannula and her oxygen saturation was 91%. The resident had an occasional moist cough. -There was no documentation to indicate the physician had been notified Resident #37 was now requiring oxygen and she was exhibiting a moist cough. Review of the July 2024 medication administration record (MAR) revealed Resident #37's morning medications were marked as not administered on 7/6/24 due to the resident appearing to be actively passing (dying). -However, the facility failed to obtain a physician's order to withhold or discontinue Resident #37's medications. An infection note dated 7/6/24 documented the resident continued on alert charting for isolation due to a positive COVID-19 test and all care was provided in her room. The resident's vital signs were within normal limits for the resident. Her vital signs were as follows: blood pressure 137/76, temperature 98.2 degrees Fahrenheit (F), pulse 105, respirations 25 and oxygen saturation 91% on 2 LPM of oxygen. A health status note dated 7/6/24 documented the licensed practical nurse (LPN) spoke to the resident's representative and asked if she wanted the facility to begin comfort medications. The resident's representative refused and requested Tylenol suppositories be given to the resident. -There was no documentation to indicate the physician had been notified that Resident #37 was continuing to decline. another health status note dated 7/6/24 documented the LPN spoke to the resident's representative again and informed the representative it looked like Resident #37 was passing. -There was no documentation to indicate the physician had been notified that Resident #37 was continuing to decline. A third health status note dated 7/6/24 documented the registered nurse (RN) called the resident's representative and informed her the resident continued to decline. -There was no documentation to indicate the physician had been notified that Resident #37 was continuing to decline. Review of the July 2024 MAR revealed Resident #37's evening medications were marked as not administered on 7/6/24 due to the resident appearing to be actively passing. -However, the facility failed to obtain a physician's order to withhold or discontinue Resident #37's medications. Review of the July 2024 MAR revealed Resident #37's morning medications were marked as not administered on 7/7/24 due to the resident appearing to be actively passing. -However, the facility failed to obtain a physician's order to withhold or discontinue Resident #37's medications. An infection note dated 7/7/24 documented the resident was still on active charting due to a positive COVID-19 test. The LPN documented the resident was actively passing away at the time of the note and all care was being provided in her room. Another infection note dated 7/7/24 documented the resident was declining and mouth care was provided in her room. Repositioning and mouth care was provided every two hours and the resident was on scheduled Tylenol via suppository for comfort. -There was no documentation to indicate the physician had been notified that Resident #37 was continuing to decline. Review of the July 2024 MAR revealed Resident #37's evening medications were marked as not administered on 7/7/24 due to the resident appearing to be actively passing. -However, the facility failed to have a physician's order to withhold or discontinue Resident #37's medications. Review of the July 2024 MAR revealed Resident #37's morning medications were marked as not administered on 7/8/24 due to the resident appearing to be actively passing. -However, the facility failed to have a physician's order to withhold or discontinue Resident #37's medications. An infection note dated 7/8/24 documented Resident #37 was actively passing away. Her oxygen saturation was 82% on 5 liters of oxygen and her heart rate was 128 beats per minute. -There was no documentation to indicate the physician had been notified that Resident #37 was actively passing away. A progress noted dated 7/8/24 at 10:20 a.m. documented Resident #37 passed away. C. Staff interviews Registered nurse (RN) #2 was interviewed on 8/29/24 at 12:25 p.m. RN #2 said when a medication was ordered and the resident was unable to take the medication, the nurse needed to continue calling the physician until a response was received. RN #2 said she would not have administered the Paxlovid to Resident #37 because it was a choking hazard for the resident to swallow it whole. She said she was not the nurse who took care of Resident #37 so she was not involved when the resident began to decline. RN #2 said if a resident was actively passing away, the nurse needed to call the physician and request an order to withhold or discontinue the resident's medications. RN #2 said a physician's order was needed to hold a resident's medications no matter what the reason was. The director of nursing (DON), infection preventionist (IP) and RDCS #1 were interviewed together on 8/29/24 at 3:47 p.m. RDCS #1 said the nurses were supposed to keep calling the physician until they received guidance or a physician's order. She said the nurse was able to call the facility's medical director if the resident's physician was unable to be reached. The DON said the staff should only withhold residents' medications with a physician's order. The DON said she was unable to explain why a physician's order was not obtained to discontinue Resident #37's medications. Resident #37's primary care physician (PCP) was interviewed on 8/29/24 at 5:35 p.m. The PCP said he received a message from the facility on 7/3/24 which informed him Resident #37 was positive with COVID-19. He said he was informed the resident was unable to take Paxlovid because it was unable to be crushed. He said he discontinued the order for Paxlovid. The PCP said if Resident #37 was unable to take the Paxlovid the facility could have sent her to the emergency room to receive intravenous (IV) Paxlovid but he said he did not recall staff requesting that. -However, review of Resident #37's EMR did not reveal a physician's order to discontinue the Paxlovid or documentation of further communication with the physician after the facility left a message with the PCP informing him Resident #37 could not take Paxlovid because it could not be crushed in order for the resident to swallow the medication (see record review above) The PCP said he was informed on 7/6/24 that Resident #37 appeared to be passing away and the nurses were withholding her medications. He said he usually sent orders for the medications to be discontinued but he was unable to locate the order and was unsure why he could not find the order. -However, review of Resident #37's EMR did not reveal further documentation to indicate the physician had been informed of the resident's continued decline (see record review above).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interviews, the facility failed to ensure proper treatment and assistive devices to maintain hearing abilities for one (#26) of one resident reviewed for hearing and vision problems out of 28 sample residents. Specifically, the facility failed to ensure Resident #26 was assisted to receive a replacement hearing aid after her right hearing aid was lost. Findings include: I. Resident #26 A. Resident status Resident #26, age greater than 65, was admitted on [DATE]. According to the August 2024 computerized physician orders (CPO), diagnoses included hearing loss of both ears, macular degeneration and anxiety disorder. The 6/10/24 minimum data set (MDS) assessment revealed the resident had no cognitive impairment with a brief interview for mental status (BIMS) score of 14 out of 15. The assessment documented the resident had moderate difficulty hearing and required the use of hearing aides. B. Resident Observations On 8/26/24 at 3:51 p.m. Resident #26 was wearing one hearing aid in her left ear and no hearing aid in her right ear. On 8/27/24 at 9:41 Resident #26 was wearing one hearing aid in her left ear and no hearing aid in her right ear. On 8/28/24 at 1:44 p.m. Resident #26 was wearing one hearing aid in her left ear and no hearing aid in her right ear. C. Resident interview Resident #26 was interviewed on 8/26/24 at 3:51 p.m. Resident #26 said she only had one hearing aid in her left ear. Resident #26 said her right hearing aid was lost by the facility a long time ago. Resident #26 said the facility told her they would replace it but the facility never replaced it. Resident #26 said she had low vision and having low vision with one missing hearing aid made it very difficult for her to interact with other residents, family members and staff. Resident #26 said she was frustrated the facility had not assisted her in replacing her hearing aid. D. Record review A facility incident report form was provided by the nursing home administrator (NHA) on 8/27/24 at 3:11 p.m. The facility incident report form documented that Resident #26 reported her hearing aid was missing on 6/27/24 at 8:55 a.m. The incident report form documented that the facility would replace one lost hearing aid. The incident report form documented that this information was shared with Resident #26 on 8/8/24. -However, Resident #26 reported the facility had not replaced the hearing aid as of 8/26/24. (see interview above) A progress notes dated 8/29/24 (during the survey) documented a staff member spoke to the audiology clinic and Resident #26's hearing aid would be replaced. -However, the facility failed to attempt to replace the hearing aid for more than two months after it was reported missing. E. Staff Interviews The social service director (SSD) was interviewed on 8/27/24 at 1:25 p.m. The SSD said she was not involved in Resident #26's investigation concerning her hearing aid. The SSD said the NHA completed all investigations of missing property and would only involve the SSD upon request. The SSD said she did not know the current status of replacing Resident #26's hearing aid that was lost. The NHA was interviewed on 8/27/24 at 1:44 p.m. The NHA said Resident #26 was missing one hearing aid and the facility offered to replace it. The NHA said she completed the investigation into the hearing aid. The NHA said the hearing aid had not been replaced yet because the facility was experiencing logistical problems with reaching the audiology clinic. The NHA said she did not have documentation that the facility attempted to get Resident #26's hearing aid replaced. The NHA was interviewed again on 8/29/24 at 3:41 p.m. The NHA said the facility's transportation driver was able to get ahold of the audiology clinic today (8/29/24) to discuss replacing Resident #26's hearing aid. The NHA said the facility would implement a call log so the facility could document when calls were made to other care partners on behalf of resident care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interviews, the facility failed to ensure that residents who entered the facility without limited mobility and range of motion received appropriate services and assistance to maintain or improve mobility with the maximum practicable independence unless a reduction in mobility was demonstrated as unavoidable for one (#24) of four residents out of 28 sample residents. Specifically, the facility failed to ensure Resident #24 received passive range of motion (PROM) to prevent potential decline in her mobility. Findings include: I. Facility policy The Restorative policy, revised 8/7/21, was received on 8/28/24 at 5:44 p.m. from regional director of clinical services (RDCS) #2. It read in pertinent part, To promote the resident's optimum function, a restorative program may be developed by proactively identifying, care planning and monitoring a resident's assessments and indicators. Nursing assistants must be trained in techniques that promote resident involvement in restorative activities. Based on the comprehensive assessment of a resident and consistent with the resident's needs and choices, the facility must provide the necessary care and services to ensure that a resident's abilities on activities of daily living do not diminish, this includes the facility ensuring that a resident is given the appropriate treatment and services to maintain or improve their ability to carry out activities of daily living. A resident may be started on a restorative nursing program when he or she is admitted with restorative needs. Restorative nursing functions can be within one of the following categories: range of motion (active and passive), splint or brace assistance, bed mobility, transfers, walking, dressing and or grooming, eating and or swallowing, amputation/prosthesis care, communication, toileting program, bladder retraining. II. Resident #24 A. Resident status Resident #24, age greater than 65, was admitted on [DATE]. According to the August 2024 computerized physician orders (CPO), diagnoses included Alzheimer's disease, dysphagia (difficulty swallowing), prediabetes and chronic kidney disease stage 3. The 8/5/24 minimum data set (MDS) assessment revealed the resident had severe cognitive impairments with a brief interview for mental status (BIMS) score of four out of 15. The resident required substantial to maximum assistance with mobility and transfers. The MDS assessment revealed Resident #24 was not on a restorative program and was not receiving range of motion. B. Observations On 8/28/24 at 1:10 p.m. Resident #24 was transferred from the wheelchair to the shower chair with a hoyer mechanical lift. C. Resident representative interview The resident's representative was interviewed on 8/29/24 at 11:30 a.m. The representative said she had been asking for the resident to receive therapy and range of motion. She said Resident #24 had declined in her mobility. She said when the resident was admitted to the facility she was able to walk. The representative said the resident recently had a decline in mobility and was now being transferred from bed/wheelchair using a mechanical lift. The representative said she knew there had been some orders for therapy but she said she was never invited to come and be with the resident and encourage her participation in therapy when the therapists approached her. She said Resident #24 was responsive to her. D. Record review Resident #24's activities of daily living (ADL) care plan, updated 8/13/24, revealed the resident had a self-care performance deficit related to encephalopathy, weakness and cognitive deficits. The resident required extensive assistance of two staff members with personal hygiene. Pertinent interventions included having Resident #24 participate to the fullest extent possible with each interaction -The care plan did not indicate the resident was receiving range of motion exercises for her upper or lower extremities. The [NAME] (tool utilized by staff to provide consistent resident care)dated 8/29/24 documented the resident required extensive assistance of one to two staff members for bed mobility. The [NAME] directed extensive assistance by two staff members for transfers with a mechanical hoyer lift. A physical therapy (PT) note dated 4/30/24 documented PT services were offered but the resident said she wanted to wait until tomorrow. -The note failed to document if more than one attempt was made to offer the resident PT. A PT note dated 5/9/24 documented the resident was offered PT and the resident refused. -The note failed to document if more than one attempt was made to offer the resident PT. A nurse progress note dated 6/11/24 documented the resident was using the mechanical hoyer lift for transfers. The resident was no longer able to use the sit to stand lift for transfers. A therapy progress note, dated 8/8/24 and written by the director of rehabilitation (DOR), documented Resident #24 was offered therapy to improve her transfers but the resident said she wanted to sleep. -The note failed to document if more than one attempt was made to offer the resident therapy. -Review of Resident #24's electronic medical record (EMR) failed to reveal the resident had a restorative program plan which was individualized and included passive range of motion for both lower and upper bilateral extremities for her limited range of motion. -The EMR further revealed there were no baseline assessments of the resident's range of motion of either her upper and lower extremities. E. Staff interviews The director of nursing (DON) was interviewed on 8/29/24 at approximately 1:00 p.m. The DON said Resident #24 had had a decline in mobility and she was being transferred using a hoyer mechanical lift. She said the resident was not on a restorative program. She said that there was no PROM program for the resident because one would have to be written by the therapy program. She said the resident's arms were extended when she was dressed. The director of rehabilitation (DOR) was interviewed on 8/29/24 at 1:15 p.m. The DOR said Resident #24 was not on any restorative program. He said he could not develop a restorative program unless the resident was seen by a licensed therapist. He said the resident had declined therapy services in the past when they attempted. He said he had asked for the resident's representative to come to the facility when the resident was offered therapy and she had declined. -However, the representative said she had not been invited to come to the facility when the therapist approached the resident (see resident's representative interview above). -Additionally, there was no documentation in Resident #24's EMR to indicate the DOR had asked the resident's representative to come to the facility when the therapists attempted to provide therapy for the resident. -The DOR said the therapy department only did baseline assessments for range of motion on residents who had been on therapy services. He said he did not know who completed the baseline range of motion assessments for residents who were not on therapy services. The physical therapist assistant (PTA) was interviewed on 8/28/24 at 11:51 a.m. The PTA said the facility did not have a restorative program. Certified nurse aide (CNA) #6 was interviewed on 8/28/24 at 4:25 p.m. CNA #6 said the facility did not have a restorative program. She said there were no individual plans for PROM for residents. She said physical therapy worked with the residents. CNA #1 was interviewed on 8/28/24 at 4:28 p.m. CNA #1 said she did not know anything about a restorative program but did say that residents who went to activities would sometimes play with pool noodles for exercise. CNA #7 was interviewed on 8/28/24 at 4:29 p.m. CNA #7 said she did not perform range of motion with residents. She said there were not any residents who had individualized restorative program plans. She said only therapy was involved with range of motion for residents. The director of nursing (DON) was interviewed on 8/28/24 at 4:41 p.m. The DON said the facility did not have a restorative program anymore. She said the facility would like to reinstate it at some time but the facility currently did not have enough staff to complete restorative programs.

Based on record review and interviews, the facility failed to complete a performance review of every nurse aide at least once every 12 months and provide regular in-service education based on the outcome of these reviews for one out of five staff reviewed. Specifically, the facility did not complete an annual performance review and/or provide regular in-service education based on the outcome of the review for certified nurse aide (CNA) #2. Findings include: I. Record review CNA #2 (hired on 6/22/22) did not have an annual performance review completed. CNA #2 did not have an in-service education plan based on the outcome of the review. II. Staff interviews The nursing home administrator (NHA) was interviewed on 8/29/24 at 10:11 a.m. The NHA said she completed performance evaluations for CNAs in the facility. The NHA said CNA #2 had been out of the country between January 2024 and April 2024 and was currently a PRN (as needed) employee. The NHA said CNA #2 had worked in the facility in April 2024 after returning to the United States on 4/19/24. The NHA said CNA #2 had not had a performance evaluation or in-service education based on the outcome of that review. The NHA said she would do monthly audits moving forward to ensure all CNAs in the facility received timely annual evaluations.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interviews, the facility failed to ensure that one (#241) of five residents out of 28 sample residents were free from unnecessary medications. Specifically, the facility failed to ensure as needed (PRN) physician's orders for psychotropic drugs were limited to 14 days unless the physician provided a rationale for extended use. Findings include: I. Resident #241 A. Resident Status Resident #241, age [AGE], was admitted on [DATE]. According to the August 2024 computerized physician orders (CPO), diagnoses included displaced intertrochanteric fracture of left femur (break in the femur), unspecified dementia, severe, unspecified osteoarthritis (arthritis) and history of falling. The 7/5/24 minimum data set (MDS) assessment revealed the resident had moderate cognitive impairments with a brief interview for mental status (BIMS) score of nine out of 15. The resident required setup and clean up assistance for meals, partial assistance with bathing, toileting and upper body dressing and needed substantial assistance with lower body dressing. B. Observations On 8/26/24 at 10:09 a.m. Resident #241 was heard calling out, Please help me. On 8/27/24 during a continuous observation, beginning at 12:41 p.m. and ending at 3:18 p.m., the resident did not exhibit any behaviors or calling out. On 8/28/24 at 9:01 a.m. Resident #241 was heard calling out, I have to go to the bathroom, I can't do this, oh dear God please help me, this is too much! An unidentified certified nurse aide (CNA) walked by but did not check on the resident. On 8/28/24 at 9:05 a.m. the resident stopped calling out. On 8/28/24 at 9:22 a.m. the resident was heard calling out, Please help, I can't do this anymore, please don't ignore me! An unidentified CNA and nurse went into her room and closed the door. C. Record review Review of Resident #241's comprehensive care plan, initiated 7/15/24, revealed a care plan focus area for the use of anti-anxiety medications. Pertinent interventions included administering anti-anxiety medications as ordered by the physician, monitoring/documenting side effects and effectiveness of the medication every shift, monitoring/documenting/reporting as needed any adverse reactions to anti-anxiety therapy, changes in behavior/mood/cognition and hallucinations/delusions. The August 2024 CPO revealed the following physician's order for Lorazepam: Lorazepam oral concentrate 2 milligrams (mg)/milliliter (ml) every eight hours as needed for anxiety until 11/1/24, ordered 8/27/24. Review of Resident #241's electronic medical record (EMR) failed to reveal documentation for physician's rationale for the extended use of the PRN lorazepam beyond 14 days. II. Staff interview The director of nursing (DON) was interviewed on 8/29/24 at p.m. The DON said she was aware PRN psychotropic drugs were to not be given past 14 days without a documented physician's rationale. She said she was not aware there was no rationale documented by the physician for the extended use of Resident #241's PRN lorazepam.

Based on interviews and record review, the facility failed to ensure certified nurse aides (CNA) received at least 12 hours of annual in-service training that also included dementia management training and resident abuse prevention training to ensure continued competence for two out of five certified nurse aides (CNA) reviewed. Specifically, the facility failed to ensure CNA #2 and CNA #3 received 12 hours of continuing education annually. Findings include: I. Training record review Five randomly selected CNA training records were reviewed on 8/27/24. Of the five CNAs reviewed, CNA #2 and CNA #3 did not receive 12 hours of annual training. A. CNA #2 -CNA #2, hired on 6/22/22, had participated in 10 hours and 30 minutes of training during the annual training year. B. CNA #3 -CNA #3, hired on 6/11/14, had participated in 10 hours and 30 minutes of training during the annual training year. II. Staff interviews The nursing home administrator (NHA) was interviewed on 8/28/24 at 11:27 a.m. The NHA said she kept the records for the annual staff training and verified that all of the staff members received appropriate training in the facility. The NHA said she had recorded 10.5 hours of CNA training for CNA #2 and CNA #3, which also included dementia and abuse training. The NHA said it was important for CNAs to complete their annual training to stay updated on current bedside skills and education. The NHA said she would conduct an audit in the facility to ensure all staff had completed training appropriately moving forward.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interviews, the facility failed to ensure residents had the right to a dignified existence for three (#6, #27 and #4) of three residents out of 28 sample residents reviewed. Specifically, the facility failed to: -Provide Resident #6 and Resident #27 with a dignified dining experience; -Provide Resident #4 with privacy and dignity while he used his urinal in his room; and, -Ensure residents were not discussed by staff in areas where the conversations could be overheard by others. Findings include: I. Facility policy and procedure The Dignity policy and procedure, dated 5/16/19, was provided by regional director of clinical services (RDCS) #2 on 8/29/24 at 2:10 pm. It revealed in pertinent part, Each resident has the right to be treated with dignity and respect. Interactions and activities with residents by staff, temporary agency staff, or volunteers must focus on maintaining and enhancing the resident's self-esteem, self-worth, and incorporating the resident's goals, preferences, and choices. Staff must respect the resident's individuality as well as honor and value their input. Promote resident independence and dignity while dining, such as avoiding: -Staff standing over residents while assisting them to eat; and, -Staff interacting /conversing only with each other rather than with residents while assisting with meals. Staff should not discuss residents in settings where others can overhear private or protected information or document in charts/electronic health records where others can see a resident's information. II. Resident #6 A. Resident status Resident #6, age [AGE], was admitted on [DATE]. According to the August 2024 computerized physician order (CPO), diagnoses included major depressive disorder, other Alzheimer's disease, restlessness and agitation. The 6/5/24 minimum data set (MDS) assessment revealed the resident had severe cognitive impairments and was unable to complete the brief interview for mental status (BIMS). Resident #6 required set up and clean up assistance with meals and was dependent on staff for the rest of her activities of daily living (ADL). B. Observations On 8/26/24 at approximately 12:15 p.m. Resident #6 was sitting at a dining room table awaiting her meal. The resident was served her meal in four individual bowls and a small dessert bowl. The registered dietitian (RD) walked up to Resident #6's table and pushed all but one of the bowls to the top of the table, out of reach of the resident. The RD did not explain what she was doing or speak to Resident #6 prior to moving the bowls. Resident #6 was left with one bowl but did not get the choice of which food items she wished to eat. On 8/28/24 during a continuous observation of the breakfast meal, beginning at 8:28 a.m. and ending at 8:41 a.m., the following was observed: At 8:28 a.m. Resident #6 had four individual bowls of food in front of her. She was eating from two of the bowls. At 8:41 a.m. the RD walked up to the resident and removed all but one of the bowls. The other bowls were put out of reach for the resident. The RD did not speak to the resident as she moved the bowls. Resident #6 was not provided a choice of which food items she wanted to eat. C. Record review Resident #6's dietary care plan, revised on 3/12/24, revealed Resident #6 could dine independently if needed due to agitation and, at times, disruptive behavior. Resident #6 needed supervision, some assistance and encouragement at times and adequate time to eat. -The care plan failed to indicate Resident #6 needed to have her meal served in individual bowls and only be given one bowl at a time. D. Staff interviews The RD was interviewed on 8/29/24 at approximately 10:00 a.m. The RD said Resident #6 did better eating her meal when all of the bowls were not directly in front of her. She said having all of the bowls at once made the resident more agitated. The RD said she would work on ensuring that she spoke to the resident prior to moving the bowls. -However, observations of Resident #6 did not reveal that the resident was agitated while eating her meal with all of the bowls sitting directly in front of her (see observations above). The director of nursing (DON) was interviewed on 8/29/24 at approximately 4:00 p.m. The DON said Resident #6 was cognitively impaired. She said providing only one bowl at a time for the resident was better for the resident. The DON said the RD moving the bowls so Resident #6 only had one bowl at a time was not disrespectful or discourteous to the resident. III. Resident #27 A. Resident status Resident #27, age less than 65, was admitted on [DATE]. According to the August 2024 CPO, diagnoses included Down's syndrome, unspecified convulsions, Parkinson's disease with dyskinesia (involuntary movements of the body), dysphagia of oral phase (difficulty swallowing), generalized anxiety disorder, panic disorder, dementia with anxiety and mood disturbances and visual hallucinations. The 6/28/24 MDS assessment revealed Resident #27 had a severe cognitive impairment with a BIMS score of four out of 15. B. Resident representative interview Resident #27's representative was interviewed on 8/27/24 at 7:33 p.m. The resident's representative said Resident #27 would benefit from one-on-one activities and conversations with staff because he had a hard time socializing after his Parkinson's disease progressed. She said the resident needed someone to spend time with him throughout the day when the family was unable to visit. The resident's representative said Resident #27 told her, on 8/25/24, that he wanted the staff to sit in his room with him. The resident's representative said the resident had told her that the staff did not need to talk to him, he just wanted someone's companionship. The resident's representative said Resident #27 ate well during meals when the person assisting him socialized with him. She said she observed some meals and the CNAs assisted two residents at a time. She said the CNAs did not interact with the residents. She said the nurses communicated with Resident #27 when assisting him at meals. The resident's representative said Resident #27 was a very social person but his medical issues affected how he communicated and he was lonely because the CNAs failed to socialize with him throughout the day and at meals. C. Observations During a continuous observation on 8/28/24, beginning at 11:40 a.m. and ending at 12:24 p.m., the following was observed: At 11:40 a.m. Resident #27 was in his wheelchair in the middle of the dining room. At 11:43 a.m. an unidentified certified nurse aide (CNA) assisted Resident #27 to his seat at the resident assistance table in the dining room. At 11:48 a.m. Resident #27 was sitting by himself and the staff were interacting with all of the residents at the table except for Resident #27. At 11:56 a.m. CNA #1 put a clothing protector on Resident #27 and sat next to him. CNA #1 did not socialize with Resident #27. CNA #1 was interacting with a female resident at the table. At 11:57 a.m. Resident #27 tried talking to CNA #1. CNA #1 listened to the resident for 10 seconds and looked around the room which ended the conversation. At 11:58 a.m. an unidentified dietary aide (DA) served drinks to the residents at the resident assistance table. The DA provided Resident #27 milk and gatorade but did not ask the resident what he wanted to drink. The DA did not interact with the resident but spoke to CNA #1 in Spanish. At 12:00 p.m. CNA #1 was not socializing or offering drinks to Resident #27. At 12:02 p.m. CNA #1 moved Resident #27's legs in his wheelchair without asking if he wanted to move or notifying the resident. CNA #1 put the cup's spout to Resident #27's lips without asking if he wanted a drink and did not interact with the resident. At 12:03 p.m. CNA #1 gave Resident #27 a drink while she talked to another resident at the resident assistance table and did not interact with Resident #27. At 12:10 p.m. Resident #27 told CNA #1 something and motioned to his left hand. CNA #1 held his hand and massaged his palm as she interacted with other staff in the dining room. At 12:12 p.m. CNA #1 assisted Resident #27 with eating and rubbed her left hand along his back but she did not talk to the resident. At 12:19 p.m. CNA #1 was assisting Resident #27 with his meal and closing her eyes for a few seconds. She repeatedly blinked her eyes to wake herself up. At 12:20 p.m. CNA #1 closed her eyes for a few seconds while she had the spoon up to Resident #27's mouth. At 12:21 p.m. CNA #1 again closed her eyes for a few seconds. She opened her eyes and rubbed her face before feeding Resident #27 another bite of his lunch. At 12:22 p.m. CNA #1 had her head on her hand while she provided Resident #27 another bite of food and she closed her eyes. At 12:24 p.m., the DON asked CNA #1 to complete a different task outside of the dining room. The DON took over assisting Resident #27. D. Record review Resident #27's activity care plan, revised on 7/26/24, revealed, due to his physical limitations, he was dependent on staff to meet his emotional, intellectual, physical and social needs. The intervention was providing the resident with one-on-one activities because he liked to converse. Resident #27's activities of daily living (ADL) care plan, revised on 9/11/21, revealed Resident #27 required extensive assistance from one staff member while eating. Resident #27's communication care plan, revised on 2/26/24, revealed the resident had a communication problem which referred to his fear or shyness and Down's syndrome. Interventions included being conscious of Resident #27's position when in groups, activities and the dining room to promote proper communication with others, allowing the resident adequate time to respond, repeating as necessary, not rushing the resident, requesting clarification from the resident to ensure understanding, facing the resident when speaking and making eye contact, encouraging Resident #27 to continue stating his thoughts even if he was having difficulty, keeping communication with the resident focused on the resident and being conscientious of what was talked about within listening distance because Resident #27 has excellent hearing and internalized and was stressed by conversations overheard. A review of Resident #27's [NAME] (a staff directive tool) revealed the resident needed extra time to respond to questions and instructions, the resident occasionally needed to be asked yes or no questions to determine his needs and Resident #27 needed to be offered gatorade and his favorite drink of choice during and in between meals to promote hydration. E. Staff interviews The nursing home administrator (NHA) was interviewed on 8/29/24 at 4:42 p.m. The NHA said the incident with CNA #1 falling asleep while she assisted him at lunch was going to be investigated. The NHA said she reminded all of the staff that if they felt tired while assisting a resident at a meal to inform another staff member and switch duties. The NHA said it put the Resident #27 at a higher risk of choking when CNA #1 fell asleep while she assisted him. She said CNA #1 was not paying attention and the resident had a hard time communicating. She said the staff needed to communicate with all of the residents, but especially the residents that were being assisted at meals. Registered nurse (RN) #2 was interviewed on 8/29/24 at 12:25 p.m. RN #2 said when she assisted residents with meals she socialized with the residents. IV. Resident #4 A. Resident status Resident #4, age greater than 65, was admitted on [DATE]. According to the August 2024 CPO, diagnoses included bilateral conductive hearing loss, legal blindness, difficulty in walking and muscle weakness. The 6/19/24 MDS assessment revealed Resident #4 had moderate cognitive impairments with a BIMS score of 12 out of 15. B. Observations During a continuous observation on 8/28/24, beginning at10:30 a.m. and ending at 12:45 p.m., the following was observed: At 10:30 a.m. Resident #4 was lying on his bed with his window curtains and the bedroom door open. At 10:34 a.m. an unidentified CNA answered Resident #4's call light. The unidentified CNA provided the resident with his urinal and said You are welcome as she left the room. The unidentified CNA left his bedroom door and window curtains open. At 10:35 a.m. Resident #4 pulled down his pants and had the urinal in his left hand. Resident #4 used his right hand to expose his penis and put it inside the opening of the urinal. Resident #4 used the urinal while he laid in his bed with his pants pulled down and his window curtain and door were left open. At 10:38 a.m. the same unidentified CNA walked by Resident #4's door and saw he was still using his urinal in his bed and walked by without closing his door. At 10:41 a.m. the same unidentified CNA walked by Resident #4's door and kept walking down the hallway. Staff were observed in the living room of the dementia unit across the courtyard through Resident #4's window. At 10:42 a.m. the physical therapy assistant (PTA) walked by Resident #4's room. He told Resident #4 How about some privacy and closed the privacy curtain in the bedroom. The PTA left the room but left the resident's window curtains open. At 11:09 a.m. Resident #4 activated his call light. RN #3 answered his call light and brought the resident a glass of water. RN #3 left Resident #4's privacy curtain closed but left his window curtains open. At 11:25 a.m., Resident #4 was observed with his privacy curtain closed and his pants were pulled up while laying in bed. He was waiting to go to the dining room for lunch. C. Record review Resident #4's ADL care plan, revised on 3/12/24, revealed the resident had an ADL self-care deficit due to impaired balance, visual deficits, generalized weakness and a history of a rotator cuff tear. Resident #4 was able to self-propel independently using his wheelchair, he required limited assistance by one staff member to turn and reposition in bed, he required one person assistance with toileting and he was able to transfer with one person assistance. D. Staff interviews The regional vice president (RVP) and the NHA were interviewed together on 8/28/24 at 1:55 p.m. The RVP said privacy needed to be provided to the residents anytime care was provided, which included when Resident #4 used a urinal in bed. The NHA said privacy was important because Resident #4 did not need to be exposed to other residents and other residents did not need to be exposed to Resident #4 while he was using the urinal. The NHA was interviewed again on 8/29/24 at 4:42 p.m. The NHA said when a resident used the restroom, the door and the curtains needed to be closed to provide the resident with privacy and dignity. RN #2 was interviewed on 8/29/24 at 12:25 p.m. RN #2 said when a resident used the urinal, the privacy curtain or the bedroom door needed to be closed. She said she never thought about closing the window curtains but she said the curtains probably needed to be closed as well. The RVP and the NHA were interviewed together again on 8/29/24 at 7:55 p.m. The NHA said the leadership team met once a month to discuss areas of improvement within the facility to better serve the residents. The NHA said the facility had not identified privacy or dignity as an area for improvement. V. Failure to ensure residents were not discussed by staff in areas where the conversations could be overheard by others A. Observations On 8/26/24 during a continuous observations of the dining room, beginning at 12:00 p.m. and ending at 12:30 p.m., the following was observed: The main dining room had approximately ten tables. During the meal service, approximately 18 residents were in the dining room. At approximately 12:00 p.m. an unidentified resident asked for creamer. for their coffee. The RD was heard telling the resident You don' t like creamer, you like your coffee black. -The RD did not provide the resident with creamer as requested. At 12:15 p.m. an unidentified certified nurse aide (CNA) was observed standing while assisting Resident #24 with eating their meal. At approximately 12:30 p.m. the RD was heard talking loudly about other residents ' decline and needing to change their diet orders. The RD was heard asking multiple residents about their dentures and why they did not want to wear them. The RD was heard talking about different resident's preferences to other residents' family members. The RD could be overheard throughout the dining room. -Throughout the continuous observation, the RD was walking from resident to resident and assisting them with their meals while standing up. The RD conversed with other employees instead of the residents while she was assisting them to eat their meals. B. Staff interviews The RD was interviewed on 8/29/24 at approximately 10:00 a.m. The RD said she knew her voice was loud. She said she had been told she was loud before. She said when she was in the kitchen she had to speak loudly because of the overhead fans. She said she viewed the facility as a family and she wanted to help everyone and that was why she would talk to all of the residents. The social services director (SSD) was interviewed on 8/29/24 at 3:51 p.m. The SSD said the facility had provided staff with education on dignity and respect. She said staff received the education when new employees were hired and then annually thereafter. She said all residents were to be treated with respect and dignity. The SSD said she would review the resident rights with all staff.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to ensure four (#241, #242, #36, and #239) of five residents out of 28 sample residents had a completed baseline care plan within 48 hours of admission. Specifically, the facility failed to ensure that Resident #241, Resident #242, Resident #36 and Resident #239 had baseline care plans completed within 48 hours of admission and/or baseline care plans which addressed all of the minimum requirements, including initial goals based on admission orders, physician orders, dietary orders, therapy services, social services, preadmission screening and resident review (PASARR) recommendation, if applicable. Findings include: I. Facility policy and procedure The Baseline Care Plan policy, revised 8/11/23, was provided by the regional director of clinical services (RDCS) #1 on 8/29/24 at approximatly 2:00 p.m. It revealed in pertinent part, A baseline care plan will be developed for every resident within 48 hours of admission to provide an initial set of instructions needed to provide effective and person-centered care of the resident that meet professional standards of care. The baseline care plan must include, but is not limited to: -Initial goals based on admission orders; -Physician orders; -Dietary orders; -Therapy services; -Social services; and, -PASARR recommendation, if applicable The facility may develop a comprehensive care plan in place of the baseline care plan if the comprehensive care plan is developed within 48 hours of admission and meets the requirements listed above. II. Resident #241 A. Resident status Resident #241, age [AGE], was admitted on [DATE]. According to the August 2024 computerized physician orders (CPO), diagnoses included displaced intertrochanteric fracture of left femur (break in the femur), unspecified dementia, severe, unspecified osteoarthritis (arthritis), unspecified urinary incontinence and history of falling. The 7/5/24 minimum data set (MDS) assessment revealed the resident had moderate cognitive impairments with a brief interview for mental status (BIMS) score of nine out of 15. The MDS assessment further revealed Resident #241 needed set up and clean up assistance for meals, partial assistance with bathing, toileting and upper body dressing and substantial assistance with lower body dressing. B. Record review -Review of Resident #241's electronic medical record (EMR) revealed the facility failed to complete a baseline care plan for the resident within 48 hours of the resident's admission. -Additionally, the facility failed to develop a comprehensive care plan in place of a baseline care plan within 48 hours of admission. -The care plan for antidepressant, antipsychotic and anti-anxiety medications was not initiated until 7/15/24 and the dietary care plan was not initiated until 7/23/24. III. Resident #242 A. Resident status Resident #242 age [AGE], was admitted on [DATE]. According to the August 2024 CPO, diagnoses included displaced trimalleolar fracture of right lower leg (fracture of the ankle), unspecified fracture of the lower end of the right radius (fracture of the lower right arm), cervicalgia (neck pain), rotator cuff tear or rupture of left shoulder, rotator cuff tear or rupture of right shoulder, chronic kidney disease stage 3, fibromyalgia (widespread body pain and tiredness). The 8/23/24 MDS assessment revealed the resident was cognitively intact with a BIMS score of 14 out of 15. The MDS assessment further revealed Resident #242 needed set up and clean up assistance for meals, oral hygiene and partial assistance for bathing and upper body dressing and needed substantial assistance with toileting and lower body dressing. B. Record review -Review of Resident #242's EMR revealed a baseline care plan, dated 8/21/24, failed to include advance directives, COR status, dietary orders and therapy services, which were ordered. IV. Resident #36 A. Resident status Resident #36, age [AGE], was admitted on [DATE]. According to the August 2024CPO, diagnoses included muscle weakness, Raynaud's syndrome (parts of the body feel numb and cool due to small arteries constricting blood flow) without gangrene, dorsalgia unspecified (back pain), history of malignant neoplasm (cancer) of unspecified site of lip, oral cavity, and pharynx, facial weakness, cognitive communication deficit and pneumonitis (lung infection) due to inhalation of food and vomit. The 8/2/24 MDS assessment revealed the resident had severe cognitive impairment with a BIMS score of seven out of 15. The MDS assessment further revealed that Resident #36 needed supervision or touching assistance with personal hygiene and upper body dressing and needed partial to moderate assistance with bathing/showering and lower body dressing. B. Record review -Review of Resident #36's EMR revealed that the baseline care plan, dated 7/31/24, failed to document advance directives, COR (resuscitation) status, dietary orders (the resident was to receive nothing by mouth and received nutrition and hydration through a tube feeding), or therapy services, which were ordered. -The dietary care plan was not initiated until 8/5/24. The baseline care plan failed to address the resident's activities of daily living self-care deficit until 8/12/24. V. Resident #239 A. Resident status Resident #239, age [AGE], was admitted on [DATE]. According to the August 2024 CPO, diagnoses included pneumonia, sleep related hypoventilation, hypertension and hepatitis C. B. Record review -Review of Resident #239's EMR revealed that a baseline care plan was not completed for the resident. The comprehensive care plan, initiated on 8/7/24, initiated activities of daily living and discharge plan within 48 hours of the resident's admission to the facility. -However, a fall and history of falls care plan was not initiated until 8/12/24, a dietary care plan was not initiated until 8/20/24 and a therapy services care plan was not initiated VI. Staff interviews Registered nurse (RN) #2 was interviewed on 8/29/24 at 8:54 a.m. RN #2 said when a resident was admitted to the facility, the RN had to initiate the care plan and enter the pertinent information about continence care and other pertinent care plan areas. RN #2 said the MDS coordinator (MDSC) completed the rest of the care plan. The MDSC was interviewed on 8/29/24 at approximately 1:00 p.m. The MDSC said the baseline care plan needed to be completed within 48 hours. She reviewed the EMRs for Resident #241, #242, #36, and #239. She said the baseline care plans for each resident were incomplete or had not been completed at all. She said the care plans were not completed within 48 hours of the residents's admissions to the facility. The MDSC said she would begin an audit to ensure the baseline care plans for all residents were completed timely following admission to the facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interviews, the facility failed to ensure that three (#16, #14 and #17) of three residents out of 28 sample residents received necessary respiratory care. Specifically, the facility failed to: -Ensure portable oxygen tanks were refilled timely for Residents #16, #14, and #17; -Ensure oxygen tubing was changed routinely and dated; and, -Ensure staff were using the appropriate personal protective equipment (PPE) while filling residents' oxygen tanks. Findings include: I. Facility policy and procedure The Oxygen Administration policy and procedure, revised on 2/27/24, was received from the regional vice president (RVP) on 8/29/24 at 6:50 p.m. It read in pertinent part, To assure that oxygen is administered and stored safely within the healthcare centers or in an outside storage area. Change oxygen supplies weekly and when visibly soiled. Equipment should be labeled with resident name and dated when setup or changed out. Cryogenic (relating to or involving very low temperatures) safety gear (face shield, gloves, apron) are required in the oxygen filling room for staff to use when filling portable units. II. Failure to ensure portable oxygen tanks were filled timely and oxygen tubing was changed routinely and dated A. Resident #16 1. Resident status Resident #16, age [AGE], was admitted on [DATE]. According to the August 2024 computerized physician orders (CPO), diagnoses included hemiplegia (paralysis) and hemiparesis (muscle weakness or partial paralysis) following cerebral infarction (stroke) affecting left non-dominant side, vascular dementia with psychotic disturbance. The 6/25/24 minimum data set (MDS) assessment revealed Resident #16 was cognitively intact with a brief interview for mental status (BIMS) score of 14 out of 15. She had limited range of motion on one side of her upper extremity and both sides of her lower extremities. The resident was dependent on staff assistance for bed mobility, transfers and most of her activities of daily living (ADL). The assessment indicated the resident was receiving oxygen therapy. 2. Observations On 8/27/24 at 3:15 p.m. Resident #16 was in her room and was using her portable oxygen tank. -There was no date labeled on her oxygen tubing. On 8/27/24 at 6:02 p.m., the resident's portable oxygen tank was observed with certified nurse aide (CNA) #5. -The nasal cannula was in the resident's nose, however, the portable oxygen tank hanging on the resident's wheelchair was empty. CNA #5 took the resident's portable oxygen tank to go fill it in the oxygen room. 3. Record review Review of the August 2024 CPO revealed the following physician's order for oxygen: Oxygen at 2 liters per minute (LPM) to keep saturations (level of oxygen in the blood) at 90% (percent) or above, ordered 8/26/24. Resident #16's respiratory care plan, updated 3/18/24, revealed the resident was on 2 LPM of oxygen via nasal cannula as needed. Pertinent interventions included tracking the resident's oxygen levels daily. -Review of the August 2024 treatment administration record (TAR) failed to show Resident #16's oxygen tubing was changed. B. Resident #14 1. Resident status Resident #14 age [AGE], was admitted on [DATE]. According to the August 2024 CPO diagnoses included chronic obstructive pulmonary disease (COPD), altered mental status and stroke. The 6/7/24 MDS assessment revealed Resident #14 had severe cognitive impairments with a BIMS score of four out of 15 The assessment indicated the resident was receiving oxygen therapy. 2. Observations On 8/27/24 at approximately 5:50 p.m. Resident #14, who had been observed at various activities throughout the day, was sitting in the hallway. He had his nasal cannula in his nose and his portable oxygen tank was hanging on the back of his wheelchair. -There was no date labeled on his oxygen tubing. The resident's portable oxygen tank was observed with CNA #5. -The portable oxygen tank was empty. CNA #5 took the resident's portable oxygen tank and went to fill it in the oxygen room. 3. Record review Review of the August 2024 CPO revealed the following physician's order for oxygen: Oxygen at 1 to 3 LPM to keep saturations at 90% or above, ordered 3/4/24. Resident #14's respiratory care plan, updated 3/18/24 revealed the resident was to be on 1 to 3 LPM of oxygen and needed to have oxygen levels monitored each shift to maintain oxygen levels of 90% or greater. Pertinent interventions included monitoring the resident's oxygen levels daily and changing out the oxygen tubing every Sunday during the night shift. C. Resident #17 1. Resident Status Resident #17, age [AGE], was admitted on [DATE]. According to the August 2024 CPO, diagnoses included unspecified dementia, adult failure to thrive, heart failure unspecified and shortness of breath. The 6/3/24 MDS assessment revealed the resident had moderate cognitive impairments with a BIMS score of eight out of 15. The MDS assessment revealed the resident was on oxygen therapy and required moderate assistance with bathing and dressing and needed maximal assistance with toileting. 2. Observations On 8/27/24 at 6:02 p.m. Resident #17 was in the dining room with her nasal cannula in her nose and her portable oxygen tank on the back of her wheelchair. -There was no date labeled on her oxygen tubing. The portable oxygen tank was observed with the infection control preventionist (IP). -The resident's portable oxygen tank was empty. The IP filled the tank. The IP took the resident's portable oxygen tank and went to fill it the oxygen room. 3. Record Review Review of the August 2024 CPO revealed the following physician's order for oxygen: Oxygen at 2 LPM via nasal cannula for shortness of breath, ordered 8/13/24. Resident #17's respiratory care plan, updated 3/6/24, revealed the resident was to be on 1 to 2 LPM of oxygen as needed for disorientation. Pertinent interventions included changing the oxygen tubing every Sunday during the night shift. D. Staff interviews CNA #5 was interviewed on 8/27/24 at 5:45 p.m. CNA #5 said the residents' portable oxygen tanks were checked on the night shift and after lunch. -However, observations of Resident #16's, #14's and #17's oxygen tanks following CNA #5's interview revealed all three residents' portable oxygen tanks were empty (see observations above). The director of nursing (DON) was interviewed on 8/27/24 at 6:15 p.m. The DON said portable oxygen tanks were to be checked every two hours. She said the tanks should also be checked prior to meals or if the resident was on the portable tanks for an extended period of time. The DON was interviewed a second time on 8/29/24 at approximately 4:00 p.m. The DON said she provided education (during the survey) to the certified nurse aides during the CNA huddles. She said the education included checking the portable oxygen tanks every couple of hours, before meals and when residents were brought out of their rooms for activities. III. Failure to wear appropriate PPE while filling residents' oxygen tanks A. Observations The facility's oxygen room was located on the Brother Ben's hallway. The oxygen room had three liquid oxygen tanks. The PPE staff was supposed to use to fill the portable oxygen tanks was hanging on the wall just inside the room. The PPE provided included a pair of goggles, heavy gloves that went to the elbows, ear protection and a heavy yellow apron. On 8/27/24 at approximately 6:15 p.m. three different employees, CNA #5, IP, and the NHA were observed filling portable oxygen tanks. The NHA was wearing the appropriate PPE provided for safety. -CNA #5 and the IP failed to use the appropriate PPE while filling portable oxygen tanks. The DON) was interviewed on 8/29/24 at approximately 4:00 p.m. The DON said proper PPE needed to be worn when filling the portable oxygen tanks for the safety of the staff. She said the appropriate PPE included an apron, eye protection and heavy gloves.

Based on observations, record review and interviews, the facility failed to consistently serve food that was palatable in taste, texture, appearance and temperature. Specifically, the facility failed to ensure food was palatable and served at the appropriate temperature. Findings include: I. Resident interviews Resident #12 was interviewed on 8/26/24 at 10:44 a.m. Resident #12 said she ate her meals in the dining room and had received cold food several times. She said she did not eat meat and the vegetables were overcooked or undercooked and the food was bland. Resident #30 was interviewed on 8/26/24 at 2:00 p.m. Resident #30 said she ate her meals in her room and her food was often served at a lukewarm temperature or cold. She said her food was edible but never arrived in her room hot. Resident #1 was interviewed on 8/26/24 at 2:48 p.m. Resident #1 said she ate her meals in her room and received cold food on her room tray. II. Resident group interview The resident group was interviewed on 8/28/24 at 2:07 p.m. with Resident #23, Resident #30, Resident #31, Resident #26, Resident #1, Resident #32, Resident #12 and Resident #5. The residents were identified as alert and oriented through facility and assessment. Resident #26 said she received cold food at meal times. Resident #23 said he received cold food at meal times. Resident #5 said she received cold food at meal times. III. Observations A test tray for a regular diet was evaluated by four surveyors immediately after the last resident had been served dinner on 8/28/24 at 5:34 p.m. The test tray consisted of parmesan crusted tilapia, tartar sauce, pea salad, dinner roll and corn kernels. -The parmesan crusted tilapia was 111.8 degrees Fahrenheit (F) and tasted bland; -The pea salad was 64.5 degrees F and had a strong onion taste; -The corn was 122.3 degrees F, was tough, greasy and tasted like oil; and, -The tartar sauce was 70.3 degrees F and was acidic. IV. Resident council notes The 6/12/24 resident council notes revealed a resident requested to have her meals served warmer. -There was no documentation indicating how the facility took steps to address the resident's request of wanting warmer food. V. Staff interviews The registered dietitian (RD), the nursing home administrator (NHA) and the regional vice president (RVP) were interviewed together on 8/29/24 at 10:37 a.m The RD said the residents had not informed her that the meals were not served at the correct temperature or that the food did not taste good. The RD said cold foods were on ice during service and served at 41 degrees F. The RD said hot foods were served between 120 degrees F and 145 degrees F after the initial cooking temperature was reached. The NHA said she had not heard anything from the residents regarding the temperatures or taste. The NHA said the residents wanted to have food committee meetings during resident council meetings and the facility planned to combine the meetings in September 2024. The RVP said the facility was going to take a look at what was going on with the temperatures and taste of the food. The RD said it was important to serve food at the correct temperature and hot so the meal was enjoyable and safe to eat.

Based on observations, record review and interviews, the facility failed to store, prepare, distribute and serve food in a sanitary manner in the main kitchen. Specifically, the facility failed to: -Ensure a dietary aide's (DA) medication was not stored in the walk-in refrigerator; -Ensure appropriate hand hygiene was performed for staff and residents during meal service; and, -Ensure dietary staff removed their jewelry before serving meals. Findings include: I. Failure to ensure staff medications were not stored in the walk-in refrigerator A. Professional reference The Colorado Department of Public Health and Environment (2024) The Colorado Retail Food Establishment Rules and Regulations, was retrieved on 9/6/24 from https://drive.google.com/file/d/18-uo0wlxj9xvOoT6Ai4x6ZMYIiuu2v1G/view, revealed in pertinent part, Medicines belonging to employees that require refrigeration and are stored in a food refrigerator shall be stored in a package or container and kept inside a covered, leakproof container that is identified as a container for the storage of medicines. B. Observations and staff interviews During the initial tour of the kitchen on 8/26/24 at 9:32 a.m. the walk-in refrigerator had a gallon plastic bag on the top shelf next to the resident's food. The bag was marked with cook (CK) #2's name. Inside the plastic bag was an insulin pen. At 9:48 a.m. CK #2 said the insulin pen was his and he sometimes placed the insulin pen in the walk-in refrigerator. At 9:49 a.m., the registered dietitian (RD) said the employees were not supposed to store personal medications in the walk-in refrigerator. The RD said the insulin pen needed to be moved to the employee refrigerator. C. Additional staff interview The nursing home administrator (NHA), the RD and the regional registered dietitian (RDD) were interviewed together on 8/28/24 at 1:55 p.m. The RD said she provided education to the kitchen staff about personal belongings and personal medications being stored in the walk-in refrigerator. D. Facility follow-up The nutritional services huddle, completed on 8/28/24 (during the survey), was provided by the RD on 8/28/24 at 1:00 p.m. It read in pertinent part, All personal items must be kept in the employee refrigerator in the employee break room or in the employee closet. No food, drinks or medications can be stored in the refrigerator in the kitchen. II. Failure to ensure hand hygiene was conducted appropriately in the dining room A. Professional reference According to The Colorado Department of Public Health and Environment (2024) The Colorado Retail and Food Establishment Rules and Regulations, retrieved on 9/6/24 from https://drive.google.com/file/d/1kEtv4f6YciFXXzLEu6amUc9Anu9uWGYn/view, Food employees shall clean their hands and exposed portions of their arms immediately before engaging in food preparation including working with exposed food, clean equipment and utensils, and unwrapped single-service and single-use articles and: after touching bare human body parts other than clean hands and clean, exposed portions of arms; after using the toilet room; after coughing, sneezing, using a handkerchief or disposable tissue; after handling soiled equipment or utensils; before donning gloves to initiate a task that involves working with food; and, after engaging in other activities that contaminate the hands. B. Facility policy and procedure The Hand Hygiene policy, reviewed on 5/29/24, was provided by the regional vice president (RVP) on 8/29/24 at 6:44 p.m. It read in pertinent part, The hands are the conduits for almost every transfer of potential pathogens from one patient to another, from a contaminated object to a patient and from a staff member to a patient. Because of this, hand hygiene is the single most important procedure to prevent infection. To protect patients from healthcare-associated infection, hand hygiene must be performed routinely and thoroughly. The Centers for Disease Control and Prevention (CDC) recommends performing hand hygiene with soap and water before eating. Teach patients and their families about the importance of hand hygiene in preventing the spread of infection. C. Observations During a continuous observation on 8/26/24, beginning at 11:30 a.m. and ending at 12:49 p.m., the following was observed: At 11:49 a.m. an unidentified resident completed an activity and was immediately brought into the dining room. An unidentified staff member assisted the resident into the dining room and did not offer hand hygiene to the resident. The resident ate her entire meal with her hands after throwing balls with other residents and sharing pool noodles. At 11:50 a.m. an unidentified resident had completed an activity throwing balls with other residents and sharing pool noodles. The resident wheeled himself from the activity to the hallway and touched his wheels. Hand hygiene was not offered to the resident and the resident ate his lunch with his hands. At 11:57 p.m. an unidentified DA served residents their drinks in the dining room. The DA did not complete hand hygiene in between handing out drinks, touching residents and touching resident's wheelchairs. During a continuous observation on 8/27/24, beginning at 4:50 p.m. and ending at 5:43 p.m., the following was observed: At 4:50 p.m. hand hygiene was only offered to the residents at the assistance table. Approximately five independent residents entered the dining room via their personal walkers and three independent residents self-propelled in their wheelchairs. Hand hygiene was not offered to the residents once they were seated. At 5:43 p.m. an unidentified resident was assisted from his room to the dining room and was not offered hand hygiene. The resident ate a tuna salad sandwich and potato chips with his hands. During a continuous observation on 8/28/24, beginning at 11:29 a.m. and ending at 12:46 p.m., the following was observed: At 11:51 a.m. an unidentified DA served drinks to the residents in the dining room. The DA did not complete hand hygiene in between handing out drinks, touching residents and touching resident's wheelchairs. At 12:00 p.m. an unidentified resident was sitting at a dining room table and not offered hand hygiene. The resident rearranged fake flowers that sat on the table then ate her food with her hands. D. Staff interview The RD was interviewed on 8/29/24 at 10:37 a.m. The RD said she was concerned with making sure hand hygiene was offered to the residents who ate in their rooms and she did not realize the residents in the dining room were not being offered hand hygiene. The RD said the DA needed to complete hand hygiene after she touched anything other than the clean drink she was handing out. III. Failure to ensure dietary staff did not wear jewelry while preparing food A. Professional reference According to The Colorado Department of Public Health and Environment (2024) The Colorado Retail and Food Establishment Rules and Regulations, retrieved on 9/6/24 from https://drive.google.com/file/d/1kEtv4f6YciFXXzLEu6amUc9Anu9uWGYn/view revealed in pertinent part, Except for a plain ring, such as a wedding band, while preparing food, food employees may not wear jewelry including medical information jewelry on their arms and hands. B. Observations During a continuous observation of the dinner service on 8/28/24, beginning at 4:30 p.m. and ending at 5:34 p.m., the following was observed: At 4:30 p.m. DA #2 was wearing a corded bracelet on her left wrist with strings hanging from the bracelet. At 4:44 p.m. DA #2 opened individual packets of butter and placed them on the tray line. DA #2 grabbed a butter packet and the strings to her bracelet dragged through other opened packets of butter. At 4:53 p.m. DA #2 grabbed another packet of butter and the strings to her bracelet drug through the other opened butter. She placed the butter packet on a plate and the strings of her bracelet dragged across the food she was plating for a resident. At 5:13 p.m. DA #2 reached over to grab an individual container of ketchup on the service line and the strings of her bracelet drug through the opened butter containers. C. Staff interviews The RVP was interviewed on 8/29/24 at 1:00 p.m. The RVP said staff were not allowed to wear jewelry in the kitchen and she was unaware it was occurring. The RVP said education was going to be provided to the dietary staff.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interviews, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the possible development and transmission of infectious diseases. Specifically, the facility failed to: -Ensure housekeeping staff cleaned high touch areas in residents' rooms; and, -Ensure staff followed appropriate hand hygiene practices. Findings include: I. Housekeeping failures A. Professional reference The Centers for Disease Control and Prevention (CDC) Environment Cleaning Procedures, (3/19/24) was retrieved on 9/5/24 from https://www.cdc.gov/healthcare-associated-infections/hcp/cleaning-global/appendix-c.html. It read in pertinent part, High-Touch Surfaces: The identification of high-touch surfaces and items in each patient care area is a necessary prerequisite to the development of cleaning procedures, as these will often differ by room, ward and facility. Common high-touch surfaces include: bed rails, IV (intravenous) poles, sink handles, bedside tables, counters, edges of privacy curtains, patient monitoring equipment (keyboards, control panels), call bells and door knobs. Proceed from cleaner to dirtier areas to avoid spreading dirt and microorganisms. Examples include: during terminal cleaning, clean low-touch surfaces before high-touch surfaces, clean patient areas (patient zones) before patient toilets, within a specified patient room, terminal cleaning should start with shared equipment and common surfaces, then proceed to surfaces and items touched during patient care that are outside of the patient zone, and finally to surfaces and items directly touched by the patient inside the patient zone. In other words, high-touch surfaces outside the patient zone should be cleaned before the high-touch surfaces inside the patient zone and clean general patient areas not under transmission-based precautions before those areas under transmission-based precautions. B. Facility policy The Daily Room Cleaning policy, reviewed 6/12/24, was received from the regional director of clinical services (RDCS) #1 on 8/29/24 at 2:10 p.m. It read in pertinent part, The facility must provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior. -The policy did not specify that high touch surface areas should be cleaned C. Observations On 8/27/24 at 8:37 a.m. housekeeper (HSKP) #1 was observed cleaning room [ROOM NUMBER]. -The call light cords in the resident's room and the resident's bathroom were not cleaned by HSKP #1 during the room cleaning process. -the door handles to the resident's room and the resident's bathroom were not cleaned by HSKP #1 during the room cleaning process. On 8/29/24 at 9:14 a.m. HSKP #2 was observed cleaning room [ROOM NUMBER]. -The call light cords in the resident's room and the resident's bathroom were not cleaned by HSKP #2 during the room cleaning process. -The door handles to the resident's room and the resident's bathroom were not cleaned by HSKP #2 during the room cleaning process. D. Staff interviews HSKP #1 was interviewed on 8/27/24 at 8:55 a.m. HSKP #1 said call light cords and door handles should be cleaned daily because they were high touch surfaces. HSKP #1 said she cleaned the call light cords during the room cleaning she completed in room [ROOM NUMBER]. -However, HSKP #1 failed to clean either residents' call light, the bathroom call light or the door handles to the room or the bathroom in room [ROOM NUMBER] (see observation above). -Additionally, the director of housekeeping (DHK) said HSKP #1 reported to her she had not cleaned the resident call lights during the room cleaning in room [ROOM NUMBER] on 8/27/24 (see DHK interview below). HSKP #2 was interviewed on 8/29/24 at 9:35 a.m., utilizing a spanish-speaking interpreter. HSKP #2 said she did not clean the residents' call lights , the call light in the bathroom or the room and bathroom door knobs in room [ROOM NUMBER]. The DHK was interviewed on 8/29/24 at 12:40 p.m. The DHK said call light cords, door handles, drawer handles and cabinet handles were high-touch surface areas that should be cleaned everyday. The DHK said she had previously spoken to housekeeping staff about the importance of cleaning high-touch surfaces as part of the daily cleaning. The DHK said HSKP #1 told her she did not clean the resident's call light cords or the call light cord in the bathroom during the room cleaning observation that occurred on 8/27/24 in room [ROOM NUMBER]. The infection preventionist (IP) and the director of nursing (DON) were interviewed together on 8/29/24 at 3:19 p.m. The IP said the resident call lights and door handles should be cleaned because they were considered high touch surfaces that could transmit infections. The IP said resident call light cords and door handles should be cleaned every day. The DON said call lights and door handles should be cleaned daily. II. Hand hygiene failures A. Professional reference The CDC Clinical Safety: Hand Hygiene for Healthcare Workers, (2/27/24) was retrieved on 9/5/24 from https://www.cdc.gov/clean-hands/hcp/clinical-safety/index.html. It read in pertinent part, Hand hygiene protects both healthcare personnel and patients. Hand hygiene means cleaning your hands by handwashing with water and soap (plain soap or with an antiseptic), using an antiseptic hand rub (alcohol-based foam or gel hand sanitizer), or performing surgical hand antisepsis. Cleaning your hands reduces the potential spread of deadly germs to patients, the spread of germs, including those resistant to antibiotics, and the risk of healthcare personnel colonization or infection caused by germs received from the patient. Some healthcare personnel may need to clean their hands as often as 100 times during a work shift to keep themselves, patients and staff safe. B. Facility policy The Hand Hygiene policy, reviewed 8/19/24, was received from the regional vice president (RVP) on 8/29/24 at 6:49 p.m. It read in pertinent part, Hand hygiene using an alcohol-based hand rub is appropriate before direct patient contact and after contact with inanimate objects in the patient's environment. C. Observations On 8/28/24 at 9:49 a.m, registered nurse (RN) #1 entered room [ROOM NUMBER]. RN #1 knocked on the door, opened the door and touched the resident's call light in the room. RN #1 left the room and began to prepare medications for another resident at the medication cart. -RN #1 failed to perform hand hygiene before entering room [ROOM NUMBER]. -RN #1 failed to perform hand hygiene after interacting with the resident's environment in room [ROOM NUMBER]. On 8/28/24 at 10:45 a.m., certified nurse aide (CNA) #1 was observed assisting Resident #33 to the restroom. -CNA #1 failed to offer Resident #33 hand hygiene after assisting her in the bathroom. On 8/29/24 at 10:31 a.m., CNA #2 was passing clean water cups to residents in their rooms. CNA #2 entered several residents' rooms and replaced the residents' used water cups with clean cups. CNA #2 performed hand hygiene after passing clean water to several rooms. -However, CNA #2 failed to perform hand hygiene before entering and after exiting each residents' rooms. -CNA #2 failed to perform hand hygiene after her hands became contaminated by touching used resident water cups. D. Staff interviews The IP and the DON were interviewed together a second time on 8/29/24 at 3:19 p.m. The IP said staff should perform hand hygiene before entering a resident's room, when they were leaving a resident's room and in between cares in the resident's room as appropriate. The IP said staff should offer to wash a resident's hands after assisting the resident to the bathroom. The IP said staff should wash their hands after interacting with a resident's environment in their room. The DON said nursing staff should offer hand hygiene to residents after they were assisted to the bathroom for toileting. The IP said it was important to promote hand hygiene to prevent the spread of infection in the facility.

Based on record review and interviews, the facility failed to ensure an effective quality assurance program to identify and address facility compliance concerns was implemented, in order to facilitate improvement in the lives of nursing home residents, through continuous attention to quality of care. Specifically, the quality assurance performance improvement (QAPI) program committee failed to identify and address multiple concerns related to quality of care. Findings include: I. Facility policy and procedure The Quality Assurance and Performance Improvement (QAPI) Plan, revised 1/18/24, was provided by the nursing home administrator (NHA) on 8/26/24 at 1:00 p.m. It read in pertinent part, The QAPI Program is to utilize an ongoing, data-driven, proactive approach to advance the quality of life and quality of care for all residents at the facility. All facility associates, families and residents will be encouraged to be involved in identifying opportunities for improvement, partake in QAPI teams, imbed QAPI activities in all core processes and provide ongoing feedback. The facility will put in place systems to monitor care and services, drawing data from multiple sources. Feedback systems will actively incorporate input from staff, residents, families and others as appropriate. It will include using performance indicators to monitor a wide range of care processes and outcomes and reviewing findings against benchmarks and/or goals the facility has established for performance. It also includes tracking, investigating and monitoring adverse events every time they occur, and action plans implemented through the plan, do, study, act cycle of improvement to prevent recurrences. II. Cross-referenced citations Cross-reference F550 dignity: The facility failed to ensure care for residents in a manner and in an environment that maintains or enhances each resident's dignity and respect. Cross-reference F655 baseline care plans: The facility failed to develop and implement acute/baseline care plans. Cross-reference F677 activities of daily living for dependent residents: The facility failed to provide appropriate treatment and services to maintain or improve residents' ability to perform activities of daily living. Cross-reference F688 range of motion: The facility failed to ensure residents with limited mobility reviewed for range of motion (ROM) received appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion. Cross-reference F692 nutrition and hydration: The facility failed to ensure effective interventions were in place to address weight loss timely. Cross-reference F695 respiratory: The facility failed to ensure residents received proper respiratory treatment and care. Cross-reference F880 infection control: The facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of diseases and infection. Cross-reference F758 unnecessary psychotropic medications: The facility failed to ensure residents were as free from unnecessary psychotropic drugs as possible. Cross-reference F684 quality of care: The facility failed to ensure that residents received treatment and care in accordance with professional standards of practice. Cross-reference F685 treatment or devices to maintain hearing and vision: The facility failed to ensure proper treatment and services to maintain hearing. Cross-reference F645 Preadmission Screening and Resident Review (PASRR) Level I: The facility failed to ensure a PASRR Level I screening was completed within thirty days of admission. Cross-reference F804 palatable food: The facility failed to ensure residents were provided with food cooked and served in a manner that conserved nutritive value, flavor, appearance, texture and at an appetizing temperature. Cross-reference F812 kitchen sanitation: The facility failed to prepare and serve food in a sanitary manner. III. Staff interviews The nursing home administrator (NHA) and regional vice president (RVP) were interviewed together on 8/29/24 at 7:43 p.m. The NHA said the facility did not invite floor staff, residents or family members to their QAPI meetings or for feedback but the facility wanted to. She said the facility had not accomplished getting others involved in the QAPI meetings. The NHA said dignity, baseline care plans, positioning residents, restorative services, weight loss, oxygen canisters, as-needed psychotropic medications, PASRR Level I screens, palatable food and kitchen sanitation were not identified by the QAPI team as areas for improvement. The NHA said hand hygiene and infection control were always watched as an area for improvement but resident hand hygiene and appropriate cleaning of resident rooms were not identified as an area for improvement until the annual recertification survey. The NHA said the QAPI team needed to create a performance improvement plan (PIP) and complete audits to better identify areas for improvement. The NHA said the facility completed random spot checks with staff and she wanted to increase spot checks. She said the facility needed more eyes on the floor to identify areas for improvement. She said the facility focused on bigger areas of concern for improvement and the little areas were missed. The NHA said there was a lot of turnover in leadership which caused a breakdown in the system. She said the QAPI system worked but the QAPI team needed to re-evaluate, not just focusing on the bigger areas of concern but all areas that could affect the care the facility provided the residents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observations and interviews, the facility failed to provide dementia care services for five (#1, #2, #3, #4 and #5) out of seven sample residents to ensure they reached their highest practicable well-being. Specifically, the facility failed to identify and implement effective approaches to engage Resident #1 in life in the facility and ensure her psychosocial needs were met and aggressive behavioral symptoms did not affect and harm others. The facility further failed to ensure Residents #2, #3, #4 and #5 received personalized dementia care services in an environment where they were engaged and safe in their home. Cross-reference F600 free from abuse Findings include: I. Facility policy and procedures The Care of the Cognitively Impaired (Dementia Care) policy, provided by the nursing home administrator (NHA) at 5:30 p.m. on 7/5/23, included the following: The facility will provide dementia treatment and services which may include but are not limited to the following: -Ensuring adequate medical care, diagnosis, and supports based on diagnosis; -Ensuring that the necessary care and services are person-centered and reflect the resident's goals, while maximizing the resident's dignity, autonomy, privacy, socialization, independence, choice and safety; and -Utilizing individualized, non-pharmacological approaches to care (e.g. purposeful and meaningful activities). Meaningful activities are those that address the resident's customary routines, interests, preferences, and choices to enhance the resident's well-being. II. Resident #1 A. Resident status Resident #1, age [AGE], was admitted on [DATE] and readmitted on [DATE]. According to the July 2023 computerized physician orders (CPO), diagnoses included Alzheimer ' s disease with early onset, dementia moderate with agitation, anxiety disorder, restlessness and agitation, and other conduct disorder (behavioral and emotional disorders with onset that occurred in childhood or adolescence). The 5/26/23 minimum data set (MDS) assessment showed the resident had cognitive impairment with a brief interview for mental status (BIMS) score that was undetermined due to the assessment not being able to be completed by the resident. The resident had short-term and long-term memory impairment and the resident was severely impaired to make decisions regarding tasks of daily life. B. Abuse incidents Resident #1 was involved in five documented abuse incidents within three months (cross-reference F600). She abused Resident #4 on 3/31/23, was abused by registered nurse (RN) #2 on 5/15/23, abused Resident #2 and Resident #3 in two incidents on 5/26/23 and abused Resident #5 on 6/9/23. C. Observations Resident #1 was observed with one-to-one supervision from a physical therapy assistant (PTA) on 7/5/23 between 10:45 a.m. to 6:00 p.m. At 10:47 a.m. Resident #1 approached another female resident who was lying back in her recliner but the PTA intervened before she got too close. At 11:05 a.m. she was lying on mattresses on her bedroom floor trying to nap. At 12:24 p.m. she was asleep and had not been served lunch. Her nurse said she had a late breakfast and they would assist Resident #1 with lunch when she woke up. Staff said in interviews (see below) that she was on one-to-one supervision indefinitely due to resident-to-resident abuse incidents. Resident #1 was pacing the hallways on the morning of 7/5/23 and lying in bed sleeping off and on during the afternoon. D. Record review Resident #1's care plan, initiated on 3/24/2020 and revised on 5/27/23, identified behaviors of exit seeking/wandering, restlessness, verbal aggression, physical aggression, resistance to care, agitation, frustration with others, unprovoked aggression towards residents and staff and generalized anxiety related to depression and dementia with behaviors. Interventions were: -One-to-one (1:1) supervision for safety during the daytime hours (initiated 5/27/23); -Administer medications as ordered; -Anticipate and meet Resident #1's needs; -Assist Resident #1 to develop more appropriate methods of coping and interacting during hours of peak behaviors. Encourage Resident #1 to express feelings appropriately; -Follow up with neurology and psychiatric care (6/15/23); -Finger foods when she won't tolerate sitting for meals (6/16/23); -Intervene as necessary to protect the rights and safety of others. Approach/Speak in a calm manner. Divert attention. Remove from situation and take to alternate location as needed; -Resident #1 triggers for tearfulness, exit seeking, restlessness are sun-downing hours, other residents' lack for personal space. Resident #1's behavior is de-escalated by individual space, snacks/coffee, sometimes activities are helpful; -Minimize potential for Resident #1's disruptive behaviors of restlessness by offering tasks which divert attention such as folding laundry, individual space and down time; -Observe for behavior episodes and attempt to determine underlying cause. Consider location, time of day, persons involved, and situations; -Provide a program of activities that is of interest and accommodates resident's status; -Provide reassurance of safety; -Redirect Resident #1 from other residents when wandering in the hall; -Request personal photos/memories from family to build visual activities for Resident #1 (6/16/23); -Take Resident #1 for a walk-outside if appropriate; -Utilize I-pad (held by staff) for country music, visual entertainment such as horses, ranches, scenic videos, animals, old country music, cowboys (6/16/23); and, -Walk outdoors one time per day as weather permits. Start walk in courtyard to see how Resident #1 will tolerate (6/16/23). Nursing progress notes, reviewed for the past six months, documented successful non-pharmacological interventions were documented on 2/15/23 as one-to-one, playing country music and distracting with dancing, offering snacks and drinks, engage in an activity and walk the hall with Resident #1 and engage her in conversation. Resident #1 was physically aggressive with staff during care, was exhibiting mouth pain, approached a certified nurse aide (CNA) to punch them on 3/12/23 and became aggressive with other residents starting on 3/31/23 at 2:30 p.m. She was seen by an activity aide (AA) pulling on another resident's right foot while the other resident was sleeping in a recliner in the dining room. Resident #1 then pulled off the other resident's blanket and smacked her right thigh. The smack was loud enough to hear. The AA alerted the nurse immediately and when the nurse tried to redirect Resident #1 she grabbed the nurse's hand and twisted the nurse's index finger. The physician and family were notified. On 4/2/23 at about 8:00 p.m. the CNA called the nurse into the resident's room. Resident #1 had tightly encircled the privacy curtains in the room around herself and appeared to be stuck. The nurse and CNA lifted and unwrapped the curtains. The resident was slightly flushed but quickly regained her baseline color. Furniture was rearranged in her room so the curtains were planted against the wall by tables, making it difficult for her to access them and wrap herself. She was checked on frequently and sleeping since the incident; staff would continue to monitor. On 4/3/23 Resident #1's family gave consent to install a camera in the resident's room for monitoring and curtains were removed from her room. She had slept through the previous night. Recliners were moved to other placement in the dining/day room since that was what appeared to aggravate Resident #1. The resident was wandering during activity sessions and staff were educated to encourage her to tidy or fold blankets when she was fidgeting in the day room and unable to redirect to the hallway. On 4/23/23 at 4:43 p.m. Resident #1 lightly hit another resident's hand. The other resident was sitting at the table and tapping it with her hand. Resident #1 walked by, hitting the other resident's hand with light force. There was no verbal exchange or further signs of agitation or injury. The residents were separated and redirected with no further issues. On 4/23/23 at 5:21 p.m., the above incident was clarified. Resident #1 approached the table of another resident and pushed it. The other resident pushed Resident #1's hand away and Resident #1 pushed the other resident's and away. Staff intervened as soon as the table wash pushed, separating the two residents. On 5/3/23 at 5:51 p.m., Resident #1 approached another resident's table and grabbed her dinner plate. A CNA held the plate from her and Resident #1 punched the CNA in the arm three times. The nurse steered Resident #1 away from the other resident. The CNA was not injured. On 5/4/23 at 5:14 p.m., Resident #1 was documented as punching and kicking staff members during toileting, stealing food from other residents. On 5/14/23 at 1:10 p.m. Resident #1 lifted another resident's right leg up. Staff asked her to stop so she put it down. The other resident had no complaints of it hurting. On 5/15/23 at 1:55 p.m. a CNA reported that Resident #1 pushed another resident's wheelchair out of the way and sat on the end of the recliner of the resident's lower legs and feet. The other resident did not yell out or show any distress. The CNA gently coaxed Resident #1 off the recliner. Resident #1 then went to the dining/day room couch and sat down. On 5/15/23 at 2:15 p.m., Resident #1 was combative with personal care and afterwards walked into the dining room and sat on the couch. While the nurse was attempting to put her sock back on, Resident #1 stood up and punched the nurse in the chest and stabbed the CNA with a cardboard nail file. Neither staff had any notable injury. The nurse called and asked the receptionist to send someone to assist with escalating behavior. The social services director (SSD) and another staff came to the unit to assist. Staff shut the dining room doors to protect other residents who were with the AA in activities. The SSD walked the hallway with Resident #1 for about 10 minutes until the resident was calm and laughing. At 3:06 p.m., Resident #1 was pacing the hallways and smiling. -There was no documentation of how the nurse responded abusively to Resident #1 on 5/15/23 (cross-reference F600). On 5/17/23 at 1:37 p.m., the resident was pacing and touched the pant leg of another resident who was sleeping on the couch. When this startled him awake, Resident #1 put her hands up in the air in an apologetic gesture and said oops. The other resident went back to sleep immediately and Resident #1 sat in a chair in the day room and was napping intermittently. On 5/25/23 at 7:30 a.m. the resident was pacing the hallways and in and out of the day room. She repeatedly touched another resident's feet, toes and blanket who was sleeping on the sofa, then startled the resident by grabbing his toes. Staff redirected the resident and she punched the nurse in the chest three times. On 5/26/23 at 7:33 p.m., Resident #1 hit another resident in the upper lip. She had been pacing in the day room and stopped and stood over a recliner where another resident was lying. Resident #1 pointed at the other resident's feet and the other resident slapped Resident #1's arm. Resident #1 then punched the other resident in the upper lip, causing bleeding, swelling and bruising. No signs of injury to Resident #1 were found. She was transferred to the local hospital emergency department (ED) for psychiatric evaluation. Her physician and family were notified. On 5/26/23 at 9:55 p.m., the nurse received an update on Resident #1's status from the ED staff. They said Resident #1 was doing well. Her urine test revealed a urinary tract infection. Resident #1 was given an antibiotic prescription which was started at the hospital. Upon her return from the hospital, Resident #1 began alternately hitting and hugging staff and was kept away from other residents. A late entry behavior note on 5/29/23 at 5:47 p.m. documented Resident #1 was on alert charting for two incidents of aggression on 5/26/23. Multiple incidents of verbal and physical aggression towards CNA staff today as well as two incidents lunging toward fellow residents attempting to hit them, but prevented from contact by CNA maintaining one-on-one supervision for this entire shift. At 1:30 p.m. Resident #1 yelled and lunged at fellow resident, prevented from contact by CNA. At 12:50 p.m. tried to slap and punch a fellow resident, prevented by CNA. On 5/26/23 at 8:25 p.m. the AA witnessed Resident #1 walk by another resident and slap her on the back. The other resident was seated in her wheelchair facing the television in the day room at the time. The nurse was dispensing medications at the time of the incident and the CNA was assisting another resident in the bathroom. The AA separated the residents as soon as possible and alerted the nurse. The residents were separated and supervised. Head to toe evaluations revealed no injuries. On 5/30/23 at 10:47 a.m., a nurse documented the resident remained on alert charting for aggressive behaviors and physical aggression, both initiated against another resident and also received from a different resident. She continued to pace the hallways and day rom, with one-to-one supervision, staff supervising resident had to intervene multiple times thus far during day shift to prevent physical aggression toward other residents. Resident #1 had physical contact with staff members in the form of shoving her shoulder into their shoulders when walking past. On 5/30/23 at 12:02 p.m., the nurse documented in a physician communication note the resident continued to display aggressive behaviors despite high dose of Sertraline (antidepressant), maybe a dose reduction would be beneficial. Recommendations from nursing were trial decrease of Sertraline and utilize PRN (as needed) Abilify (antipsychotic) dose if/when behaviors exhibited. Called PCP and left message discussing the above, awaiting return call. On 5/31/23 at 1:27 p.m., the resident was seen in-house by the primary care physician (PCP) following up on recent agitation and aggression as well as UTI treated with Keflex for seven days, started on 5/27/23. The plan was to decrease Sertraline to 100mg daily. Res(ident) has PRN Abilify 10mg in addition to scheduled 10mg daily dose, to be utilized for agitation and aggression. On 6/1/23 at 7:11 a.m. Resident #1 was on alert charting for aggression where she received contact from another resident and injured/contacted two other residents. She has been in bed since beginning of shift and has not gotten up. Will continue to have 1:1 supervision. On 6/1/23 at 11:57 a.m. the nurse documented aggressive behaviors toward staff and attempted physical behaviors toward another resident and their visitor. The resident continued with one-to-one safety monitoring at all times. On 6/1/23 at 12:51 p.m. Resident #1 was given PRN Abilify 10 mg for agitation/aggression which was documented as effective. On 6/3/23 at 6:11 p.m. Resident #1 remained on one-to-one due to recent behaviors. At times she made attempts to reach at other residents' blankets on them but one-to-one (staff) kept distance between residents. She continued to exhibit aggressive behaviors towards staff. On 6/5/23 at 2:54 p.m. Resident #1 had near misses throughout the shift with CNA needing to restrain her arms when near other residents to prevent her from striking at them. Most of the time resident is smiling but at times has been preoccupied with pulling cushions off the couch and attempting to push or throw another resident's walker left at recliner's side. On 6/5/23 at 4:22 p.m. Resident #1 attempted to punch two different residents during a music activity while walking past them. She was restrained by the one-to-one CNA to prevent injury. She became aggressive with staff trying to restrain and redirect her. On 6/9/23 at 10:44 a.m. and event note documented Resident #1 initiated physical aggression towards two residents with contact with one of them. She started walking quickly toward a resident in a recliner. The CNA assigned to one-to-one caught up to her and blocked her from having contact with the other resident. She punched and kicked the CNA who stood between the residents, then saw another resident who was reclining on the couch nearby and quickly turned toward that resident and grabbed the blanket covering him and kicked him in the shin as the CNA was trying to get between them. The nurse arrived and with the CNA was able to redirect Resident #1 to the hallway. No injuries were noted to either resident. The fire doors to the day room were closed to protect other residents from Resident #1's aggression. The family and physician were notified. On 6/9/23 at 1:15 p.m. Resident #1 was given a PRN dose of Abilify, effectiveness unknown. She was later observed by a CNA to be apparently hallucinating approximately 45 minutes after the PRN Abilify, bending over to pick up objects on the floor that were not there and then kicking and punching into the air when a CNA was a distance away. Does appear to be more sleepy at this time, but when encouraged to lay down or sit down, immediately stands up and continues pacing, frowning. So effectiveness of PRN is unclear at this time. -There was no evidence the physician was notified of this adverse effect of the PRN antipsychotic. On 6/9/23 at 5:15 p.m. a physician communication note documented physical aggression toward fellow residents continued requiring one-to-one, and with history of aggressive physical actions, placement at another facility was recommended which could be done at the local hospital ED. Urgent transport requested. A behavior note at 5:33 p.m. documented multiple events of punching and kicking at staff during cares and while one-to-one quietly walking with resident. Incidents at 7:45 a.m., 9:15 a.m. and 9:30 a.m. (with another resident), 11:00 a.m., 11:30 a.m., 12:35 p.m. and 12:55 p.m. Pacing and restless so far this shift, any attempts at getting her to rest last only a few minutes. Given PRN Abilify at 12:45 p.m. with little effectiveness. On 6/9/23 at 5:45 p.m. Resident #1 left the facility with the local fire department and police escort for urgent transport to the local hospital ED. The resident was admitted to an acute care unit, slept all night, and was evaluated for psychiatric evaluation and possible transfer to a geri-psych facility on 6/10/23. On 6/15/23 at 1:40 p.m. Resident #1 was returned to the facility via ambulance and taken to her room on a stretcher in a gown and a heavily wet, soiled brief. Nursing staff transferred her to bed where clean clothing and a clean brief were applied. She then attempted to self-transfer out of bed so staff assisted her to ambulate safely in the hallway. She received one-to-one assistance and her demeanor was calm with episodic aggression exhibited during care. Plan of care will be for resident to remain with 1:1 staff assist for the safety of herself and others, until if/when she can be transferred to a higher LOC (level of care) facility for geri-psych. On 6/15/23 at 5:31 p.m. the nurse documented new orders from the hospital for Zyprexa and Seroquel (both antipsychotics). A behavior note at 6:15 p.m. documented Resident #1 had physically aggressive behaviors toward staff and attempted toward other residents, staff intervened. On 6/16/23 at 5:03 p.m., she was sleeping quietly during the night shift. She slept late that morning and as she as she woke up started pacing. She was on one-to-one (supervision), ate meals while pacing with a CNA giving a bite at a time as she walked by the tray. No aggressive behavior so far this shift. At 3:10 p.m. nursing documented, Currently resident is a 1:1 due to behavioral symptoms. Resident wanders and paces most of her waking hours and requires frequent redirection. Requires full assistance for meals and snacks. Resident will at times sit to eat but mostly she paces while eating. Every drink or bite is prompted by staff. Resident requires full assistance with showering and elimination as well. Resident is mostly non-verbal, garbled speech when vocal. Resident requires constant supervision for safety. On 6/16/23 at 4:33 p.m., a behavior and administration note documented a 50 mg dose of Seroquel was given for agitation. Resident his this nurse when she was trying to redirect her from another residents walker that she was trying to move. On 6/17/23 at 2:22 p.m., a behavior note documented Resident #1 continued to be aggressive toward staff with a grim expression on her face. She frequently bent over to pick invisible things off the floor, possibly hallucinating. She was observed punching the linen closet door with both fists three times. She punched and kicked at staff since she awoke at 11:00 a.m. Most aggression is related to occasions when staff is attempting to do cares or to guide her away from another resident or another resident's room. On 6/17/23 at 5:21 p.m. she was drowsy all shift, slept until 11:00 a.m. and ate lunch and accepted supplements, paced hallway with one-to-one (staff) until 2:45 p.m. when she became visibly tired, walking with closed eyes, staggering and bumping into walls. Helped to her bed by staff where she has remained so far this shift. Brief changes in her bed by staff without protest at approximately 4:30 p.m., showed no interest in dinner tonight. -There was no documentation the physician was notified of the resident's adverse reactions to her medications. The nurses continued to chart Resident #1's physical aggression toward staff, punching doors or hard objects with her fists, redirecting her away from other residents and at times closing the day room off behind the fire doors to protect other residents. On 6/28/23 at 11:24 a.m. a nurse documented one-to-one supervision during waking hours for safety of Resident #1 and other residents. Sleeping more than usual during the daytime, may be in response to recent psychotropic med changes, nursing will continue to monitor. Resident awoke this morning in a combative mood and has been pacing the hallways. She approached (housekeeping) staff and grabbed the housekeeping cart, shaking it back and forth. Resident has calmed at this time so no PRN Seroquel administered, will utilize med (medication) if resident becomes physically aggressive again this shift. On 7/4/23 at 12:19 p.m., a nurse documented in a behavior note that Resident #1 utilized Mirtazapine (antidepressant) 15 mg daily for appetite stimulant, Zoloft (antidepressant) 100mg daily for Alzheimer's disease/dementia with behavioral disturbance, Zyprexa (antipsychotic) 5 mg twice daily for dementia with agitation, Seroquel 50 mg PRN for dementia with agitation and has used once, and Valium 5 mg rectally PRN for diagnosis of seizures. Since readmission on new medications she has had 23 episodes of physical aggression during cares, 6 episodes of pacing, 1 episode of resisting care, 1 episode of agitation, 2 episodes of frustration with others, and 1 episode of hallucinations. In the last 2 weeks (Resident #1) no longer gets up to ambulate, is changed and fed in bed. She will have a telehealth with (psychiatrist) in October. POA (power of attorney) consent to the use of psychotropics. -See interviews below, the psychiatrist visit was moved up to July 2023. On 7/4/23 at 12:34 p.m., a nurse further documented Res (resident) sleeping much of this DAY shift thus far, becoming physically aggressive toward staff during cares and ADLs (activities of daily living). Res ate well only when fed by staff. Res has oral pain and occasional difficulty chewing, PRN viscous Lidocaine (pain medication) to gums is available PRN and has noted therapeutic effect. Res is totally dependent on staff for feeding assistance at this time. Offered supplements in addition to meals, accepted all supplements today. Scheduled APAP (acetaminophen) for chronic pain, PRN viscous lidocaine for oral pain. Difficult to assess response to interventions due to resident level of dementia. Resident has one-on-one staff member watching her to avoid conflicts with other residents. Has spent virtually the entire shift asleep in her room. Mattresses have been placed on most of her room's floor so that she can roll in her sleep without injury, which she does often. She is toileted and fed by staff, does not participate in her own care. Able to ambulate without devices when awake/alert enough. Res up to recliner for lunch and is sleeping in recliner at this time. E. Staff interviews The SSD was interviewed on 7/5/23 at 12:30 p.m. in her office within the secure unit. She said when Resident #1 moved into the facility in February of 2020 she had been leaving her home and getting lost, was diagnosed with early onset Alzheimer's disease and needed close supervision. She started becoming combative with care early in her stay at the facility and she was not on any medications. She wandered the halls, and might walk up to a door and push on it but she did not seem to be trying to get out. She would go to the SSD's office frequently and they would visit, and Resident #1 would smile and hug the SSD. She could sometimes answer questions appropriately with yes or no, but mostly Resident #1 talked in word salad (confused or unintelligible mixture of seemingly random words and phrases), sometimes mentioning her family members. The SSD said before when Resident #1 approached other residents, it was in a loving way but just since February 2023 she started approaching other residents in an aggressive manner. The resident's physician and facility staff had discussed in psychotropic committee meetings why Resident #1 was being aggressive with other residents and how to respond. The SSD said they moved the recliners to one path because she would walk by and bump into their foot rests if they were reclined and startle them. The SSD said she recalled one incident where Resident #1 bumped into Resident #2's foot rest, Resident #2 said something to her and Resident #1 pointed her finger and then got slapped so in turn Resident #1 defended herself. Regarding Resident #1's background and any trauma she may have experienced, the SSD said Resident #1's relatives said her mother died of cancer which was traumatic for Resident #1 who was living in the family home at the time. She was divorced and her significant other who admitted her to the facility died in January 2022. He visited when Resident #1 first moved in and she was always excited to see him, then got to where she kind of did not know who he was and as he was dealing with his own health he was unable to come out for visits. The SSD said Resident #1 was sent to the hospital and when she returned she was on the PRN Seroquel. She thought it had been given once and they were supposed to discuss her psychotropics again on 7/6/23 (the next day). She had a telehealth appointment arranged with the only nearby psychiatrist that she knew of, who did not typically see residents with Medicaid (her payor source). Before her hospitalization she was taking Abilify, came back with Zyprexa and PRN Seroquel, and was already on Zoloft (decreased to 100 mg from 200 mg) and then she was on the Mirtazapine as an appetite stimulant because she got to where she was not eating at all and after that her appetite started picking up a little bit. When she first came back to us from the hospital she'd still pace, then sit down and rest, but it seems like she slowly was sleeping more, so I was glad (the psychiatrist) agreed to have the telehealth appointment with her today. The SSD said she was anxious to talk about Resident #1 in psychotropics to get the pharmacist's and medical director's view, because after her ED visit and medication changes she's just not the same. The SSD said Resident #1 had always been combative with care but some staff were able to talk her through it and she would allow them to assist her. The SSD said she had been asked to assist which was helpful to staff and the resident during care and staff were good about passing information along from one to another. She said they tried to have consistent staffing as much as possible. When discussing Resident #1's medications and her response to them, the SSD said, I don't like PRN antipsychotics. She confirmed there was no stop date or frequency documented in the order and that it was given as needed for agitation but specific behaviors for specific medications were not defined in her behavior tracking. The SSD said her psychiatrist telehealth appointment was scheduled for 11:00 a.m. today (7/5/23) and she hoped it happened because Resident #1 needed it. I was concerned she was on Zyprexa with it showing she's sleeping a lot. She'll still eat; we've had to feed her for a long time. Sometimes she'd eat walking down the hallway. Before her medication changes, she was sleeping a lot, I just don't like that. The SSD said Resident #1 had never been aggressive with her and although she was pacing a little bit with the PTA that morning, she still smiled and gave the SSD a hug. She said the facility provided dementia training, corporate came and did dementia training and the SSD continued with that training during every orientation. She said during the training she provided she talked with staff about alerting other staff regarding combative behavior and if they needed a break to tell somebody. During orientation I tell them I'm here for the residents and for you. You need to vent, you need to de-escalate, whatever, feel free to come to my office. The SSD said she did not see any behavioral changes or fear from Resident #1 after the abuse incident with RN #2 (cross-reference F600). She said Resident #2 was the only resident who had been injured by Resident #1 when Resident #1 punched her in the mouth. She did not have to go to the hospital but she had a bruised and swollen lip. She did not show any fear. The SSD said their plan going forward for meeting Resident #1's needs and keeping other residents safe was trying to figure out what she needed and just being more aware. She loved country music, sometimes would watch videos of dogs or horses and talking about ranch kind of things because she grew up on a ranch. She resisted going outside for walks, which surprised the SSD. Before her medication changes, she enjoyed having the freedom to pace in the hallways, having staff play music for her while she was pacing, a lot of the staff and nurses were good about putting Resident #1's favorite music on their phone to play for her. I always have music going here and of course we can put music on the TV (television). Some residents like jigsaw puzzles, art, having outside time and reminiscing, doing nails, I've noticed the men are usually talking about something with hunting, they hold up pictures of states and see if the residents can name the states, trivia games. She said activity staff were in the secure unit full time to engage the residents. III. Resident #2 A. Resident status Resident #2, age [AGE], was admitted to the facility on [DATE]. According to the July 2023 CPO, diagnoses included dementia with unspecified severity. The 4/7/23 MDS assessment showed the resident had severe cognitive impairment with a BIMS score of four out of 15. B. Observations Resident #2 was observed on 7/5/23 spending most of her day sleeping in a recliner in the dining/day room common area. Although some other residents were engaged in activities and she was invited, she did not participate. C. Record review Review of nursing progress notes revealed the incident with Resident #1 on 5/26/23 at 7:56 p.m. was described as follows: Resident #2 was

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews, the facility failed to timely investigate a potential allegation of abuse involving two (#29 and #43) of seven residents reviewed for abuse out of 26 sample residents. Specifically, the facility failed to: -Timely investigate all allegations of potential abuse for Residents #29; and, -Implement immediate interventions to prevent potential future abuse from Resident #43. Findings include: I. Facility policies and procedures The Abuse - Reporting and Response policy, dated 10/4/22, was provided by the facility on 2/9/23. The policy read in pertinent part: The facility will report alleged violations related to mistreatment, exploitation, neglect, or abuse including injuries of unknown source and misappropriation of resident property and report the results of all investigations to the proper authorities within prescribed time frames. According to the reporting and response policy, the facility would ensure that all staff were aware of reporting requirements and to support an environment in which staff and others report all allegations of mistreatment, exploitation, neglect, or abuse including injuries of unknown source and misappropriation of resident property. The individual reporting the alleged violation did not have to explicitly characterize the situation as abuse, neglect, mistreatment or exploitation in order to trigger the facility to investigate. The policy read: Rather if the facility staff could reasonably conclude that the potential exists related to mistreatment, exploitation, neglect, or abuse, including injuries of unknown source, and misappropriation of property, then it would be considered to be reportable and require action. The policy identified all alleged or suspected violations should be reported to the administrator and/or director of nursing. The Abuse - Conducting an Investigation policy, dated 10/4/22, was provided by the facility on 2/9/23. The policy read in pertinent part: It is the policy of the facility that allegations of abuse are promptly and thoroughly investigated. The facility will prevent further abuse, neglect, exploitation and mistreatment from occurring while the investigation is in process; and take the appropriate corrective action, as a result of the investigation findings. Residents have the right to live at ease in a safe environment without fear of retaliation when allegations are reported. II. Resident status 1. Resident #29 Resident #29, age [AGE], was admitted on [DATE]. The resident resided in the secured memory care unit. According to the February 2023 computerized physician orders (CPO), diagnoses included unspecified dementia, unspecified severity, with agitation, cognitive communication deficit, anxiety disorder, major depressive disorder, muscle weakness, chronic pain, osteoporosis. The 11/30/22 minimum data set (MDS) assessment indicated the resident had severe cognitive impairment with a brief interview for a mental status score of four out of 15. She did not exhibit delusions or hallucinations. The MDS assessment identified the resident required extensive physical assistance from one person with bed mobility, transfers, dressing and locomotion on and off the unit. She needed extensive physical assistance of more than two staff with toileting. The psychosocial well-being care plan, revised 12/15/21, identified Resident #29 was dependent on staff for meeting her emotional, intellectual, physical, and social needs related to her cognitive deficits, immobility, and depression. 2. Resident #43 Resident #43, age [AGE], was admitted on [DATE]. The resident resided in the secured memory care unit. According to the February 2023 CPO, diagnoses included Alzheimer ' s disease with early onset; and, dementia in other diseases classified elsewhere, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. The 1/20/23 MDS assessment indicated the resident had severe cognitive impairment with a brief interview for a mental status score of five out of 15. He did not exhibit inattention or disoriented thinking. The MDS assessment identified the resident was independent with bed mobility, transferring, and walking in his room. According to the MDS assessment, he needed supervision with walking in the corridor and locomotion on and off the unit. The behavior care plan, last revised on 1/20/23, identified Resident #43 had the potential to be verbally aggressive. According to the care plan, the resident had hallucinations and believed he was a caregiver to assist other residents. The behavior care plan, revised on 2/3/23, identified Resident #43 had the potential to be physically aggressive towards staff and other residents related to anger, dementia, and poor impulse control. Cross-reference F600 physical abuse. III. Observations Observations on the memory care secured unit between 2/6/23 and 2/9/23, identified several resident rooms had a stop sign banner strung across the residents' doorways. The stop sign banner was velcroed to each side of the doorway frame. Throughout the observation period, Resident #29 had the stop sign in place across her doorway. IV. Record review The 2/4/23 behavior note, documented in the medical record of Resident #43 by registered nurse (RN) #3, read a resident informed RN #3 that there was a female resident in distress down the hall. The RN observed Resident #43 kneeling at the bedside of Resident #29 and talking to her. Resident #43 said he had told Resident #29 to get up and get out of the room. The note read Resident #29 was frightened to the point of almost crying. According to the note, Resident #29 said she was so scared. The RN reassured the resident that she was safe and the staff was watching out for her. Resident #43 was escorted out of her room. The note identified the RN went back into Resident #29 ' s room to administer medication and the resident still sounded frightened. The resident told the nurse to keep Resident #43 out of her room. The note identified Resident #29 took a while to get calmed down. According to the note, the stop sign across the Resident #29 ' s doorway was down and it was undetermined if Resident #43 pulled the sign down to go into Resident #29 ' s room. The note indicated the RN explained to Resident #43 that the stop signs were meant to keep people out of each other's rooms and he should not enter any residents ' rooms. The staff monitored Resident #43 to ensure he did not go into anyone's room before he went to bed. The review of the medical record for Resident #29 identified the 2/4/23 incident was not documented in her record on 2/4/23 identifying the incident, the resident reactions, interventions put in place and monitoring of the resident following the incident. The review of the medical record for Resident #29 identified there was not a head to toe check assessment completed to determine if there were injuries associated with the incident. The education log for RN #3 was provided by the interim nursing home administrator (INHA) on 2/8/23 at 5:44 p.m. The education log identified RN #3 had recently completed an abuse education on 1/31/23 regarding mandatory reporting. V. Staff interview RN #2 was interviewed on 2/8/23 at 9:25 a.m. She said Resident #43 would pace, become restless and delusional. She said Resident #43 had altercations with other residents and would go into other resident rooms. She said stop signs were put up and staff would attempt to redirect him. RN #2 said Resident #29 was afraid of Resident #43 since the 2/4/23 incident. She said she did not know if there was a reason Resident #29 was afraid of Resident #43 when he was in her room or if it was just her perception. The RN said his medication changes seemed to help Resident #43 ' s behaviors. Staff would redirect Resident #43 if he attempted to enter the room of Resident #29 or other residents. The INHA was interviewed on 2/8/23 at 1:48 p.m. The INHA said all allegations and incidents of resident to resident altercations, or any other types of potential abuse, including if a resident exhibited or expressed fearfulness of another person/situation, the facility would report and investigate. The INHA said she was new to the facility but she had already informed all staff that they needed to immediately report to her any incidents and concerns of potential abuse. The above 2/4/23 behavior note documented in the medical record of Resident #43 was reviewed with the INHA. The INHA said she was not aware of the documented incident and no staff reported it to her. She said she would follow up. The INHA was interviewed again on 2/8/23 at 5:03 p.m. with the corporate consultant (CC). The INHA said Resident #43 had prior history of entering resident rooms and thought the stop sign intervention was effective until she became aware of the behavior note on the 2/4/23 regarding Resident #29. The INHA said the director of nursing (DON) knew of the incident but was not aware that Resident #29 was afraid. She said Resident #43 was now (as of 2/8/23) on one-to-one supervision, the incident had now been reported to the appropriate parties including the State Agency, and an investigation was now in process, including staff and resident interviews. The INHA said the incident was reported on 2/8/23 to the State agency after she became aware of the incident. She said the nurse who observed and documented the 2/4/23 should have directly reported it so the facility could start an investigation and implement interventions right away. The CC confirmed a head to toe assessment was not conducted following the incident but RN #3 should have completed the assessment to ensure there were no injuries from the incident. The INHA said she had started an all staff abuse education on 2/8/23 following her knowledge of the 2/4/23 incident. The DON was interviewed on 2/9/23 at 11:06 a.m. The DON said she said was aware of the incident but had not reviewed the note or was aware that Resident #29 was fearful during and following the 2/4/23 incident. She said she received a report in the Monday (2/6/23) morning meeting rounds that Resident #43 was in the room of Resident #29. The DON said it was reported to her that Resident #29 was surprised. The DON said the nurse (RN #3) who witnessed and documented the incident, should have reported the incident directly and immediately to the DON and not just passed it on to the oncoming day shift nurse. The DON said an investigation was not conducted when it was reported to her. She said if the incident was reported to her timely and directly, she would have known the resident felt scared, and then she would have started the investigation immediately and addressed the concern right away. The DON said Resident #43 would have been immediately placed on one-on-one supervision because he went into resident rooms regardless if there was a stop sign across the doorway. The DON said stop signs had not been effective for Resident #43 because he would duck under them. The INHA was interviewed on 2/9/23 at 12:51 p.m. She said the facility was still investigating the 2/4/23 incident but learned other residents on the memory care unit were not expressing fear of Resident #43. She said Resident #43 had been accepted to another facility who could appropriately manage his mental health needs. The INHA said RN #3 would be educated on reporting abuse and completing an head to toe assessment to ensure there were no injuries following a resident to resident incident. The INHA said the RN would be educated before she returned to work. IV. Facility follow-up A 2/8/23 staff education was provided by the INHA on 2/9/23 at 12:50 p.m. The education included the Suspected Resident Abuse Assessment policy for long-term care, revised 9/19/22. The policy included the types of abuse and the procedures the facility must take to protect residents from abuse. According to the policy, the facility must immediately report all alleged violations involving mistreatment, neglect, and abuse to the facility administrator and other officials including the State Agency. The facility must have evidence of a thorough investigation of all alleged violations and must take precautions to prevent further potential abuse while the investigation was in progress. Resident #43 was observed on 2/9/23 at 9:34 a.m. receiving one-to-one supervision by a physical therapist assistant (PTA.) The PTA said he was assigned to watch Resident #43 all day on 2/9/22 and another staff member would watch Resident #43 during the night. He said he was monitoring Resident #43 ' s behaviors and would redirect him as needed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to take steps to protect two (#8 and #32) of seven residents reviewed for abuse out of 26 sample residents. Specifically, the facility failed to ensure Resident #8 was free from physical abuse by Resident #18 and Resident #43 and Resident #32 was free from physical abuse from Resident #15. Findings include: I. Facility policy and procedure The Abuse - Identification of Types policy, dated 10/4/22, was provided by the director of nursing (DON) on 2/6/23 at approximately 11:00 a.m It revealed, in pertinent part, Abuse: is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Abuse also includes deprivation by an individual, including a care, of goods or service that are residents from abuse, necessary to attain or maintain physical, mental, or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology. Physical abuse includes, but not limited to, hitting, slapping, punching, biting, and kicking. II. Incident of physical abuse of Resident #8 by Resident #18 on 2/2/23 A. Incident on 2/2/23 The 2/2/23 behavior note documented in Resident #18's electronic medical record (EMR), Resident #18 was in his room watching television and talking on the phone. Resident #8 entered Resident #18's room. Resident #18 started yelling for Resident #8 to get out of his room. The note documented a certified nurse aide (CNA) ran into Resident #18's room to escort Resident #8 out of his room. Resident #18 came up behind Resident #8 and the CNA with his walker. The note document Resident #18 punched Resident #8 in the back. The note documented if the CNA did not have a hold of Resident #8, she would have fallen. Resident #18 was screaming at Resident #8 that she did not belong there. The note documented Resident #18 was out of control for about 30 minutes and woke up another resident who was sleeping in the common room. The note documented the minimum data set coordinator (MDSC) spoke with Resident #18 on the phone and told him to go to his room. The note documented all parties were notified. The MDSC and the nursing home administrator (NHA) instructed the staff to move Resident #18 off the secured unit to room [ROOM NUMBER]. The 2/2/23 event note documented in Resident #18's EMR by the MDSC, the registered nurse (RN) was contacted regarding a resident to resident altercation that ended in one resident physically hitting the other resident in the back. Resident #18 was noted screaming in the background while the hall nurse was explaining the situation on the phone. The MDSC spoke to Resident #18 on the phone and explained to the resident she understood his frustration. The MDSC listened to Resident #18's side of the story and then encouraged the resident to go to his room to relax. The note documented Resident #18 agreed and handed the phone back to the unit nurse. The MDSC requested to move Resident #18 to the 200 hall to diffuse the situation and for the safety of both residents. The police, director of nursing (DON) and the executive director were notified. Resident #8 was checked for injuries and none were noted. The families and physicians of both residents were notified. The 2/3/23 event note documented in Resident #18's EMR, Resident #18 was visibly upset when a facility staff member discussed the event from 2/3/23. The note documented Resident #18 said what about her? Is she going to have to pay for her actions? The writer documented Resident #8 did nothing wrong. Resident #18 said she went into his room and she needed to be punished for that. The writer explained that Resident #8 was not aware and not able to understand that she could not enter his room. The writer explained to Resident #18 that he should have kept his door closed like he was encouraged to do, so Resident #8 would not enter his room. The note documented the writer explained this was a serious issue and that it was still under investigation. Resident #18 apologized to the writer about everything that happened on 2/2/23 and thanked the writer for listening. B. Resident #18 1. Resident status Resident #18, age [AGE], was admitted on [DATE]. According to the February 2023 computerized physician orders (CPO), the diagnosis included Parkinson's disease (progressive brain disorder that causes uncontrolled movements of the body), personal history of transient ischemic attack (a small stroke), diabetes mellitus due to underlying condition, vascular dementia, unspecified severity with agitation, depression and anxiety. The 1/21/23 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) with a score of 14 out of 15. He required set-up supervision for bed mobility, transfers, walking in his room and coorider, locomotion on and off the unit and eating. He required extensive assistance of one person for dressing and toileting and limited assistance of one person for personal hygiene. The MDS revealed the resident did not have any verbal or physical behaviors directed towards others during the review date and he did not have any wandering behaviors during the review period. 2. Record review The elopement care plan, initiated on 7/24/2020 and revised on 10/7/22, documented Resident #18 was at risk for elopement due to wandering and exit seeking behaviors. Resident #18 was very protective of his space and did not want others entering his room or touching him. The interventions included providing one on one supervision as needed to divert him when he was exit seeking. The cognitive care plan, initiated on 11/1/2020 documented the resident had a history of a transient cerebral ischemic attack (a small stroke) affecting his cognition. The interventions included: assisting the resident with activities of daily living, encouraging the resident to do what he is capable of doing, giving medications as ordered by the physician, obtaining orders from speech therapy to consult and evaluate if the resident was presenting with cognitive function problems. C. Resident #8 1. Resident status Resident #8, age [AGE], was admitted on [DATE]. She resided in the secured/memory care unit. According to the February 2023 CPO, diagnoses included unspecified dementia with unspecified severity without behavioral disturbances, insomnia, pain, osteoarthritis, age related nuclear bilateral cataracts, presence of an artificial knee joint, muscle weakness and muscle spasms. The 2/3/23 minimum data set (MDS) assessment identified a staff assessment for mental status was conducted and identified the resident had severe cognitive impairment. The resident exhibited short and long term memory loss and inattention. Resident #8 required extensive physical assistance from more than two staff for transferring, walking in her room and walking in the corridor, and toileting. The resident required extensive physical assistance on one person for dressing, bed mobility, and personal hygiene. The MDS identified the resident needed one person physical assistance for locomotion on and off the unit. The behavior care plan, revised 11/16/21, for Resident #8 read the resident paced the halls, was restless and at times would agitation related to other resident's behaviors. According to the care plan goal, Resident #8 would not experience behaviors that were harmful to herself or others. The risk for elopement care plan, revised 2/17/21, read Resident #8 was often found in other resident's rooms. The care plan intervention, dated 2/17/21, instructed staff to direct Resident #8 away from male residents when she walked up to them. The care plan intervention, dated 4/29/22, instructed staff to redirect Resident #8 from other residents when she was wandering. 2. Record review The review of the Resident #8's progress notes did not identify Resident #8 was involved in a resident to resident altercation. The behavior care plan, revised 11/16/21, for Resident #8 read the resident paced the halls, was restless and at times would agitation related to other resident's behaviors. According to the care plan goal, Resident #8 would not experience behaviors that were harmful to herself or others. The risk for elopement care plan, revised 2/17/21, read Resident #8 was often found in other resident's rooms. The care plan intervention, dated 2/17/21, instructed staff to direct Resident #8 away from male residents when she walked up to them. The care plan intervention, dated 4/29/22, instructed staff to redirect Resident #8 from other residents when she was wandering. III. Incident of physical abuse between Resident #43 and Resident #8 on 1/11/23 A. Resident #43 status Resident #43, age [AGE], was admitted on [DATE]. The resident resided in the secured memory care unit. According to the February 2023 CPO, diagnoses included Alzheimer's disease with early onset; and, dementia in other diseases classified elsewhere, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. The 1/20/23 MDS assessment indicated the resident had severe cognitive impairment with a brief interview for a mental status score of five out of 15. He did not exhibit inattention or disoriented thinking. The MDS assessment identified the resident was independent with bed mobility, transferring, and walking in his room. According to the MDS assessment, he needed supervision with walking in the corridor and locomotion on and off the unit. The behavior care plan, last revised on 1/20/23, identified Resident #43 had the potential to be verbally aggressive. According to the care plan, the resident had hallucinations and believed he was a caregiver to assist other residents. The behavior care plan, revised on 2/3/23, identified Resident #43 had the potential to be physically aggressive towards staff and other residents related to anger, dementia, and poor impulse control. B. Record review The 1/11/23 event note documented in the medical record of Resident #8, identified Resident #8 was involved in a resident to resident altercation on 1/11/23. According to the note, the nurse was in the medication room when she heard a commotion in the hallway. The nurse came out of the medication room and heard a CNA telling Resident #43 to move away from Resident #8 and informing him that he could not touch her like that. Resident #43 replied to the CNA that Resident #8 would not leave him alone. The Resident #43 then walked to his room. The CNAs report to the nurse, Resident #8 was self ambulating in the hallway outside of the Resident #43's room, Resident #43 shoulder shoveled Resident #8 three times and used profanity towards Resident #8. According to the note, the CNAs attempted to separate the residents when Resident #43 became more agitated and defensive, yelling that she won't leave me alone, she won't get off my back, and she came at me. Resident #43 later said I had to shove her or she wouldn't stop, and Maybe I took things a bit too far. The event indicated the Resident #43 calmed down and staff kept him away from Resident #8. The 1/11/23 abuse investigation packet was provided by the facility on 2/6/23. The packet included an incident narrative of the resident to resident altercation on 1/11/23 between Resident #8 and Resident #43, witness reports, family, staff and resident interviews and an investigation recapitulation. The 1/11/23 incident narrative under physical abuse read on 1/11/23 at 4:15 p.m. a certified nurse aide (CNA) observed Resident #8 standing in middle of the hallway near Resident #43's room. Resident #43 came out of his room and shoulder shoved Resident #8 as she walked towards the nurses' station and away from Resident #43. Resident #43 followed Resident #8 to nurses' station and yelled out a profanity and shoulder shoved Resident #8. The CNA went to get another CNA to assist in separating residents. When both CNAs were with Resident #43 and Resident #8, Resident #43 shoulder shoved Resident #8 again and stated she keeps bugging me and walked back to his room. The witness statement from the nurse aide in training (NA) #2 identified in above notes as a CNA, read she observed Resident #43 shoved Resident #8 with his shoulder in the hallway, twice and the nurses' station. NA #2 said the Resident #8 was not instigating the altercation. The witness statement from the nurse aide in training (NA) #1 identified in above notes as a CNA, read she observed Resident #43 pushing Resident #8 with his right shoulder into the nursing station. The resident interview with Resident #43 read the resident said the other resident (Resident #8) was in his bubble and kept coming close to him. The investigation recapitulation read Resident #43 yelled belligerent language to Resident #8. Staff provided extra supervision after the incident and both residents were kept separated. The physician was notified and adjusted Resident #43's medication. C. Family interview The family of Resident #8 was interviewed on 2/7/23 at 9:24 a.m. She said she was concerned about abuse towards Resident #8. She said Resident #8 was hit by Resident #18. She said she felt he was not appropriate for the memory care unit but was not moved of the unit until after the 2/2/23 resident to resident altercation with Resident #8. She said Resident #18 expressed frequent displays of discontent towards Resident #8. The family member said Resident #18 would sometimes rush at Resident #8, draw his hand back at her and yell at her. She said the facility was aware of these behaviors towards Resident #8 because Resident #8 would wander into Resident #18's room. The family member said the interventions she was told the staff was attempting to do was to put up the stop signs over the doors and keep an eye on the residents. She said on 2/2/23, Resident #18 hit Resident #8 on the back. The family member said another incident occurred on 1/11/23 with another male resident. She said she was informed a CNA saw the male resident (Resident #43) shoulder check Resident #8. She said she was thinking about moving the Resident #8 out of the facility because of the abuse towards Resident #8. IV. Staff interview RN #2 was interviewed on 2/8/23 at 9:32 a.m. The RN said to prevent resident to resident altercations, staff tried to redirect and de-escalate resident behaviors. Staff tried to avoid potential causes of altercations such as residents wandering into other resident rooms. She said the stop signs have helped sometimes. The RN described the behaviors of Resident #18, Resident #8 and Resident #43. RN #2 said Resident #8 would often go into resident rooms but the stop signs seemed to divert some of that behavior. The RN said on 2/2/23, Resident #8 followed Resident #18 into his room when his stop sign across the doorway was still down and not put immediately back up. Resident #18 then hit Resident #8. RN #2 said Resident #18 was assessed about six months ago to determine if he was still appropriate for the secured memory care unit. He had dementia but was high functioning. He had a bad temper and would yell at residents if they came into his room. She said staff thought he would do better off the unit where he could socialize with other residents at more of his level and ability. The RN said the Resident #8 liked the memory care unit and said he did not want to move so he remained on the memory care unit. The resident was not moved until after the 2/2/23 resident physical altercation with Resident #8. RN #2 said Resident #43 would pace, become restless and delusional. She said Resident #43 had altercations with other residents and would go into other resident rooms. She said stop signs were put up and staff would attempt to redirect him. The RN said his medication changes seemed to be helping his behaviors and he would be redirected away from other resident rooms. The interim nursing home administrator (INHA) was interviewed on 2/8/23 at 1:48 p.m. She said was new to the facility but had recently identified the facility had concerns with the abuse/resident to resident altercation process and was working towards identifying and correcting the concerns beginning on 2/6/23 (first day of survey). She said staff would be educated again on abuse on 2/8/23 following additional concerns reported to her on 2/8/23. Cross-reference F610 investigating/correcting allegations of abuse. The INHA was interviewed again on 2/8/23 at 5:03 p.m. She said physical abuse was substantiated following the abuse investigation after resident to resident altercation on 1/11/23 between Resident #43 and Resident #8. Nurse aide in training (NA) #1 was interviewed on 2/9/23 at 9:59 a.m. She said she saw Resident #43 push Resident #8 twice with his body. She said she went to get another staff member and when she returned, Resident #43 bumped Resident #8 into the nurse's station. The INHA was interviewed again on 2/9/23 at 11:48 a.m. She said Resident #43 would receive one-to-one supervision 24 hours/seven days a week until he transferred to another facility. The director of nursing (DON) was interviewed on 2/9/23 at 11:04 a.m. She said stop signs were implemented in the middle of January 2023 because Resident #8 would enter the rooms of Resident #18 and Resident #43. The DON said to attempt to prevent potential resident to resident altercations, staff would also try to redirect Resident #8 and keep her separated from Resident #43 and Resident #18. She said staff encouraged Resident #43 to use his call light or ask for staff assistance with Resident #8. Staff continued to monitor the residents to try to know where each resident was. Resident #8 would be directed to the nursing station if she was up and wandering into other resident rooms. The DON said Resident #18 had a history of raising his voice to Resident #8 because she would enter his personal space or go into his room. She said the incident had not yet been reviewed in the interdisciplinary team (IDT) meeting to review all the details of the incident or conduct staff interviews. The DON said to prevent future resident to resident incidents on the memory care unit, the facility has ordered additional stop signs to be placed over the rest of the resident room doorways. She said a stop sign was not placed in front of Resident #43 because it would increase his agitation. The DON said Resident #8 should have had someone walking with Resident #8. She said staff thought she was independent with walking and not aware they should walk with her. She said having someone walk with Resident #8 could help prevent her from going to other resident rooms. The DON said she would review the staffing schedule with the staff scheduler to identify if another staff member could be added to the memory care unit so they staff could walk with Resident #8. She said Resident #43 was placed on one-to-one supervision to prevent future resident to resident altercations. The director of nursing (DON) was interviewed again on 2/9/23 at 12:00 p.m. She said Resident #18 had resided in the secured unit for awhile. She said the facility had offered for the resident to move off the secured unit, but Resident #18 did not want to move. The DON said Resident #18 was moved off the secured unit after the incident on 2/2/23 and would not be returning to the secured unit. The DON said Resident #18 was interacting with other residents on the 200 unit and was enjoying the activities. She said Resident #18 had not had any other resident to resident altercations since he was moved to the 200 unit. The central supply director (CSD) was interviewed 2/9/23 at 2:51 p.m. The CSD was identified as the staff scheduler. The CSD said she was looking into adding a CNA to the secured memory care unit soon now that the resident census had increased. IV. Physical abuse incident involving Residents #15 and #32 on 1/29/23 A. Resident status 1. Resident #15, age [AGE], was admitted on [DATE]. According to the February 2023 CPO, diagnoses included dementia with agitation, cognitive communication deficit, history of falling, and personal history of transient ischemic attack (stroke). According to the 12/12/22 MDS assessment, he had severe cognitive impairment with a BIMS score of five out of 15. No behavioral symptoms were documented. He used a wheelchair and needed extensive assistance for most activities of daily living (ADLs). 2. Resident #32, age [AGE], was admitted on [DATE]. According to the February 2023 CPO, diagnoses included hypertensive heart disease with heart failure, history of transient ischemic attack, dementia without behavioral disturbance, history of falling, major depressive disorder, anxiety disorder and spinal stenosis. According to the 12/8/26 MDS assessment, he had severe cognitive impairment with a BIMS score of five out of 15. No behavioral symptoms were documented. He used a wheelchair pushed by others, and needed extensive to total assistance for most ADLs. B. Facility investigation The facility's investigative report and nursing progress notes in Resident #15's medical record were reviewed. The documentation revealed on 1/29/23 a CNA walked into Resident #15's room and witnessed him hitting Resident #32's legs with his shoe while Resident #32 was lying in bed. Resident #15 was asked what he was doing and he stated, He wouldn't tell me if he was my roommate or not. The staff immediately separated the residents, assessed Resident #32 for injuries and none were found, and Resident #32 was moved to a different hallway and room. The police were called. The day before, 1/28/23, the nurse had noticed Resident #15 was more confused and his urine had a strong odor. An order was received for urine culture and sensitivity for cloudy and foul-smelling urine and increased confusion. After the incident the physician was called and would not give an order for antibiotics, but requested the resident be sent out to the emergency room. Resident #15's son wanted him to stay and not be transferred to the hospital. On 1/30/23, when the urine culture and sensitivity came back, Resident #15 was placed on an antibiotic, Bactrim DS twice daily for seven days. Social services followed up with Resident #32 on 1/30, 1/31 and 2/2/23. He did not show any signs of being in distress or fearful of anyone at the center. He had no injury to his leg. Social services also conducted follow-up interviews with staff and other residents and none had any concerns to report. The facility documented physical abuse was substantiated per federal regulations. C. Record review Review of the resident's care plan revealed a history of physical aggression by Resident #15 directed toward his roommates and others. The care plan, initiated on 11/12/2020, identified a behavior problem regarding physical aggression, socially inappropriate, verbal aggression, sexually inappropriate, aggression toward roommates, resists care and medications related to dementia. The goal was for Resident #15 to not experience behaviors that were harmful to himself and others. Interventions included: -Intervene as necessary to protect the rights and safety of others. Approach/Speak in a calm manner. Divert attention. Remove from situation and take to alternate location as needed. -Investigate/observe need for psychological/psychiatric support. Provide services if desired by resident's son and as ordered by the physician. Resident and his son have refused counseling services. -Resident #15 moved to a private room on 11/12/2020. -There were no corresponding nurses' or interdisciplinary notes in Resident #15's medical record, reviewed for the prior six months, to describe incidents of aggression. -Although Resident #15 was moved to a private room on 11/12/2020, potentially following an incident with a previous roommate, his care plan was not updated after the abuse incident with Resident #32 when he was again moved to a private room. -There were no progress notes in Resident #32's medical record regarding the 1/29/23 abuse incident. D. Staff interviews The NHA was interviewed on 2/7/23 at 4:50 p.m. She said staff thought the incident was a result of Resident #15's urinary tract infection and related confusion. She said he was doing much better now and there had been no aggression from Resident #15 for a long time before this incident, or since the incident. The NHA was interviewed a second time on 2/8/23 at 9:05 a.m. She said Resident #15 was still in a private room, partly because of his history of aggression before the urinary tract infection. She said the facility had developed a process improvement plan (PIP) regarding abuse, because she was new to the facility and was not satisfied with where they were with the issue of identifying and investigating abuse. She said staff would be updating care plans and monitoring due to Resident #15's history, and wanted to ensure Resident #32 was not abused by a roommate again. V. Facility follow-up A 2/8/23 staff education was provided by the facility on 2/9/23. The education included the Suspected Resident Abuse Assessment policy for long-term care, revised 9/19/22. The policy included the types of abuse and the procedures the facility must take to protect residents from abuse. The Suspected Resident Abuse Assessment policy read Abuse occurred when someone actively or neglectfully caused harm to another person or put that person at risk for harm. According to the policy, residents in a long-term care facility were at risk for abuse because of their limited ability to protect themselves due to dependency, multiple health conditions, and advanced age. The policy identified the facility must implement written policies and procedures that prohibit mistreatment, neglect, and abuse.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and interviews, the facility failed to ensure a resident diagnosed with dementia, received the appropriate treatment and services to attain or maintain his or her highest practicable physical, mental, and psychosocial well-being for four (#8, #15, #43 and #32) of seven residents reviewed for dementia care out of 26 sample residents. Specifically, the facility failed to identify effectively and implement person-centered approaches for dementia care to prevent resident-to-resident altercations for Resident #8, #15, #43 and #32. Cross-reference: F600 for failure to prevent resident abuse. Findings include: I. Facility policy and procedure The Care of the Cognitively Impaired (Dementia Care) policy and procedure, dated 8/29/22, was provided by the facility on 2/9/23. According to the policy, the facility will provide dementia treatment and Services to include Ensuring that the necessary care and services are person-centered and reflect the residents goals, while maximizing the resident ' s dignity, autonomy, privacy and socialization, independence, choice and safety. The policy identified staff should develop and implement person-centered care plans that support dementia care needs; and, review and revise care plans that have not been effective and/or when the residents have had a change of condition. II. Resident #8 A. Resident status Resident #8, age [AGE], was admitted on [DATE]. She resided in the secured/memory care unit. According to the February 2023 computerized physician orders (CPO), diagnoses included unspecified dementia with unspecified severity without behavioral disturbances, insomnia, pain, osteoarthritis, age related nuclear bilateral cataracts, presence of an artificial knee joint, muscle weakness and muscle spasms. The 2/3/23 minimum data set (MDS) assessment identified a staff assessment for mental status was conducted and identified the resident had severe cognitive impairment. The resident exhibited short and long term memory loss and inattention. Resident #8 required extensive physical assistance from more than two staff for transferring, walking in her room and walking in the corridor, and toileting. The resident required extensive physical assistance on one person for dressing, bed mobility, and personal hygiene. The MDS assessment identified the resident needed one person physical assistance for locomotion on and off the unit. B. Resident to resident altercations The record review for Resident #8 identified the resident was involved in two resident to resident altercations. Facility investigations following the altercations identified Resident #8 was a victim of physical abuse from Resident #43 on 1/11/23 and again was was a victim of physical abuse from Resident #18 on 2/2/23. Cross-reference F600. 1. Incident #1 Physical abuse between Resident #43 and Resident #8 on 1/11/23 The 1/11/23 event note documented in the medical record of Resident #8, identified Resident #8 was involved in a witnessed resident to resident altercation on 1/11/23. Resident #8 was witnessed to by the room of Resident #43 when Resident #43 shoulder shoveled in the hallway Resident #8 three times and used profanity towards Resident #8 before the staff was able to separate them. The note identified Resident #43 felt Resident #8 would not leave him alone and he felt he had to shove her to get her to leave him alone. The resident interview of Resident #43 identified the 1/11/23 investigation of alleged physical abuse was provided by the facility on 2/6/23. According to the resident interview, Resident #43 said Resident #8 was in his bubble and kept moving close to him. C. Record review The risk for elopement care plan, revised 2/17/21, read Resident #8 was often found in other resident's rooms. The care plan intervention, dated 2/17/21, instructed staff to direct Resident #8 away from male residents when she walked up to them. The care plan intervention dated 11/17/23, directed staff to provide staff wandering. The care plan intervention, dated 4/29/22, instructed staff to redirect Resident #8 from other residents when she was wandering. The care plan intervention, dated 2/17/21, read to direct Resident #8 away from male resident when she walks up to them. The elopement care plan identifying the resident wandered and walks up to male residents was not updated after the 1/11/23 resident to resident altercation with Resident #43. -The care plan did not include monitoring the resident when she wandered to the resident to help prevent potentially unsafe behaviors such as wandering near male residents or into resident rooms. The behavior care plan, revised 11/16/21, for Resident #8 read the resident paced the halls, was restless and at times would show agitation related to other resident ' s behaviors. According to the care plan goal, Resident #8 would not experience behaviors that were harmful to herself or others. The care identified the last care interventions to assist in resident pacing and restless behaviors were initiated in 2019. According to the care plan, staff were to anticipate and meet the Resident ' s needs. The dementia care plan, revised on 5/9/23 read Resident #8 had impaired cognitive ability and impaired thought processes. The dementia care plan did not identify how to provide safe wandering until 1/17/23 when the intervention stop signs were put in place in resident rooms. -The care plan did not include monitoring the resident when she wandered to the resident to help prevent potentially unsafe behaviors such as wandering near male residents or into resident rooms. D. Resident observation Observations throughout the survey between 2/6/23 and 2/9/23 identified the Resident #8 walked independently throughout the hallway, common areas and her room. III. Resident #43 A. Resident status Resident #43, age [AGE], was admitted on [DATE]. The resident resided in the secured memory care unit. According to the February 2023 CPO, diagnoses included Alzheimer ' s disease with early onset; and, dementia in other diseases classified elsewhere, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. The 1/20/23 MDS assessment indicated the resident had severe cognitive impairment with a brief interview for a mental status score of five out of 15. He did not exhibit inattention or disoriented thinking. The MDS assessment identified the resident was independent with bed mobility, transferring, and walking in his room. According to the MDS assessment, he needed supervision with walking in the corridor and locomotion on and off the unit. B. Resident to resident altercations The record review for Resident #43 identified the resident was involved in two resident to resident altercations. Facility investigations following the altercations identified Resident #8 was a victim of physical abuse from Resident #43 on 1/11/23 (See above) and potential resident to resident altercation on 2/4/23 with Resident #29. Cross-reference F610 failed to timely investigate an allegation of potential abuse. 1. Incident #1 Resident to resident altercation between Resident #43 and Resident #8 -see above. 2. Incident #2 Resident to resident altercations between Resident #43 and Resident #29 The 2/4/23 behavior note, documented in the medical record of Resident #43 by registered nurse (RN) #3, read a resident informed RN #3 that there was a female resident in distress down the hall. The RN observed Resident #43 kneeling at the bedside of Resident #29 and talking to her. Resident #43 said he had told Resident #29 to get up and get out of the room. The note read Resident #29 was frightened to the point of almost crying. According to the note, Resident #29 said she was so scared. The RN reassured the resident that she was safe and the staff was watching out for her. Resident #43 was escorted out of her room. The note identified the RN went back into Resident #29 ' s room to administer medication and the resident still sounded frightened. The resident told the nurse to keep Resident #43 out of her room. The note identified Resident #29 took a while to get calmed down. According to the note, the stop sign across the Resident #29 ' s doorway was down and it was undetermined if Resident #43 pulled the sign down to go into Resident #29 ' s room. The note indicated the RN explained to Resident #43 that the stop signs were meant to keep people out of each other's rooms and he should not enter any residents ' rooms. The staff monitored Resident #43 to ensure he did not go into anyone's room before he went to bed. C. Record review The behavior care plan, last revised on 1/20/23, identified Resident #43 had the potential to be verbally aggressive. According to the care plan, the resident had hallucinations and believed he was a caregiver to assist other residents. Interventions initiated on 1/4/23 included: -Administer medications as ordered. -Analyze of key times, places, circumstances, triggers, and what de-escalates behavior and document. -Assess and anticipate resident's needs: food, thirst. toileting needs, comfort level, body positioning, pain etc. -Assess resident's coping skills and support system. -Assess resident's understanding of the situation. Allow time for the resident to express self and feelings towards the situation. -Give the resident as many choices as possible about care and activities. The 1/11/23 behavior care plan, identified Resident #43 had the potential to be physically aggressive towards staff and other residents related to anger, dementia, and poor impulse control. Interventions initiated on 1/11/23 included when the resident became agitated, staff should intervene before Resident #43 ' s agitation escalated. Staff should guide him away from the source of distress; Engage calmly in conversation; If response is aggressive, staff were to walk calmly away, and approach later. IV. Staff interviews Registered nurse (RN) #2 was interviewed on 2/8/23 at 9:25 a.m. She said Resident #43 would pace, become restless and delusional. She said Resident #43 had altercations with other residents and would go into other resident rooms. She said stop signs were put up and staff would attempt to redirect him. Staff would redirect Resident #43 if he attempted to enter the room of Resident #29 or other residents. The social service director was interviewed on 2/8/23 at 9:51 a.m. She said to help prevent behaviors related to dementia care she tried to help staff figure out non-pharmological interventions and tried to intervene by diverting residents from the unit exit door and offering residents food, drinks and support visits. She said she tried to offer resident support visits when possible but she had not had as much time as she used to. The interim nursing home administrator (INHA) was interviewed on 2/8/23 at 5:03 p.m. with the corporate consultant (CC). The INHA said Resident #43 had prior history of entering resident rooms and thought the stop sign intervention was effective for until she became aware of the behavior note on the 2/4/23 regarding Resident #29. She said Resident #43 was now (as of 2/8/23) on one-to-one supervision.The INHA said she had started an all staff abuse education on 2/8/23 following her knowledge of the 2/4/23 incident. RN #2 was interviewed again on 2/8/23 at 9:32 a.m. The RN said to prevent resident to resident altercations, staff tried to redirect and de-escalate resident behaviors. Staff tried to avoid potential causes of altercations such as residents wandering into other resident rooms. RN #2 said Resident #8 would often go into resident rooms but the stop signs seemed to divert some of that behavior. The interim nursing home administrator (INHA) was interviewed on 2/8/23 at 1:48 p.m. She said was new to the facility but had recently identified the facility had concerns with the abuse/resident to resident altercation process and was working towards identifying and correcting the concerns beginning on 2/6/23 (first day of survey). She said staff would receive additional education on 2/8/23. The director of nursing (DON) was interviewed on 2/9/23 at 11:04 a.m. She said stop signs were implemented in the middle of January 2023 because Resident #8 would enter the rooms including Resident #43. The DON said to attempt to prevent potential resident to resident altercations, staff would also try to redirect Resident #8 and keep her separated from Resident #43. She said staff encouraged Resident #43 to use his call light or ask for staff assistance with Resident #8. Staff continued to monitor the residents to try to know where each resident was. Resident #8 would be directed to the nursing station if she was up and wandering into other resident rooms. The DON said to prevent future resident to resident incidents on the memory care unit, the facility has ordered additional stop signs to be placed over the rest of the resident room doorways. She said a stop sign was not placed in front of Resident #43 because it would increase his agitation. The DON said Resident #8 should have had someone walking with Resident #8 to help prevent her from going to other resident rooms. The DON said she would review the staffing schedule with the staff scheduler to identify if another staff member could be added to the memory care unit so they staff could walk with Resident #8. She said Resident #43 was placed on one-to-one supervision to prevent future resident to resident altercations. The DON was interviewed on 2/9/23 at 11:06 a.m. The DON said Resident #49 went into resident rooms regardless if there was a stop sign across the doorway. The DON said stop signs had not been effective for Resident #43 because he would duck under them. The INHA was interviewed again on 2/9/23 at 11:48 a.m. She said Resident #43 would receive one-to-one supervision 24 hours/seven days a week until he transferred to a facility. The INHA was interviewed again on 2/9/23 at 12:51 p.m. She said Resident #43 had been accepted to another facility who could appropriately manage his mental health needs related to the limited mental health resources near his current facility. The central supply director (CSD) was interviewed 2/9/23 at 2:51 p.m. The CSD was identified as the staff scheduler. The CSD said she was looking into adding a CNA to the secured memory care unit soon now that the resident census had increased. V. Residents #15 and Resident #32 A. Resident status 1. Resident #15, age [AGE], was admitted on [DATE]. According to the February 2023 CPO, diagnoses included dementia with agitation, cognitive communication deficit, history of falling, and personal history of transient ischemic attack (stroke). According to the 12/12/22 MDS assessment, he had severe cognitive impairment with a BIMS score of five out of 15. No behavioral symptoms were documented. He used a wheelchair and needed extensive assistance for most activities of daily living (ADLs). 2. Resident #32, age [AGE], was admitted on [DATE]. According to the February 2023 CPO, diagnoses included hypertensive heart disease with heart failure, history of transient ischemic attack, dementia without behavioral disturbance, history of falling, major depressive disorder, anxiety disorder and spinal stenosis. According to the 12/8/26 MDS assessment, he had severe cognitive impairment with a BIMS score of five out of 15. No behavioral symptoms were documented. He used a wheelchair pushed by others, and needed extensive to total assistance for most ADLs. B. Record review Review of progress notes and a facility investigative report revealed Resident #15 was observed hitting his roommate Resident #32 in the legs with his shoe on 1/29/23. (Cross-reference F600, free from abuse.) Both residents had severe dementia and were vulnerable, but neither resident had care plans regarding dementia care or vulnerability. Resident #15's care plan dated 11/20/22 identified a history of aggression with his roommates, but his care plan was not revised after the incident with Resident #32 on 1/29/23. Resident #15 was moved to a private room after the 1/29/23 incident. -There were no progress notes in Resident #32's medical record regarding the 1/29/23 abuse incident. C. Staff interviews The director of nursing (DON) was interviewed on 2/9/23 at 3:40 p.m. She said they did not want that interaction to occur again, so Resident #15 would continue to have a private room at this time. She said Resident #15's previous roommate (before Resident #32) shared the bathroom and television which created conflict. She said Resident #15 had a private room for a while. They thought Residents #15 and #32 would not have those conflicts, but then the abuse incident occurred on 1/29/23. They had not seen further behavior like that since then. The DON said Resident #15 was a very quiet person, and they tried to include him in activities. He was usually not the initiator of a conversation but he enjoyed being around people and observing group activities. Regarding Resident #32, the DON said he spent a lot of his time alone but he enjoyed having conversations with staff. She said she had educated the nurses that if there was an aggressor incident, the information needed to be documented in both residents' medical records, to include progress notes, documentation of follow-up regarding potential psychosocial changes, evidence of reporting, and care plan updates should be done. The DON acknowledged neither Resident #15 nor Resident #32 had vulnerability or specific dementia care plans, and it was important to do so. The DON and NHA were interviewed on 2/9/23 at 4:30 p.m. regarding quality assurance. They said they did not have action plans regarding abuse and dementia care, but they would be developing them. The NHA said they would be having an outside dementia care expert to come out and educate all their staff.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to perform COVID-19 testing and documentation of the testing schedules for staff after an identification of a positive tested COVID-19 staff member who exhibited signs/symptoms of the infection while at the facility. Specifically, the facility failed to: -Perform a COVID-19 viral test on an employee as soon as possible with exhibited symptoms of COVID-19; -Investigate details on when the employee started exhibiting signs/symptoms of COVID-19 on 2/5/23; and, -Follow a testing schedule when the employee exhibited signs/symptoms of COVID-19. Findings include: I. Professional reference According to the Centers for Disease Control (CDC) COVID-19 guidance website, Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html, updated 9/23/22, accessed on 2/9/23: Perform SARS-CoV-2 Viral Testing: Anyone with even mild symptoms of COVID-19, regardless of vaccination status, should receive a viral test for SARS-CoV-2 as soon as possible. Asymptomatic patients with close contact with someone with SARS-CoV-2 infection should have a series of three viral tests for SARS-CoV-2 infection. Testing is recommended immediately (but not earlier than 24 hours after the exposure) and, if negative, again 48 hours after the first negative test and, if negative, again 48 hours after the second negative test. This will typically be at day 1 (where day of exposure is day 0), day 3, and day 5. II. Interviews and observations The director of nurses (DON), who was also the infection preventionist, was interviewed on 2/8/23 at 2:00 p.m. She said that on 2/6/23, dietary aide (DA) #6 reported to work with signs and symptoms of COVID-19. The DON said DA #6 reported her symptoms to the dietary manager (DM) who then notified her of the symptoms. The DON said she instructed the DM to have the DA #6 perform a COVID-19 point of care (POC) antigen test. After the test results were positive, DA #6 was sent home. The DON said that she did not have any documentation of contact tracing or an employee POC testing log, she stated that the DM was keeping up with it, because it was only the dietary staff. She stated four dietary staff members were potentially affected. She said that she would start following up with the employee testing, and, going forward she was going to document and track testing with a spreadsheet. The DON and DM were interviewed on 2/8/23 at 2:45 p.m. The DM said she had no documentation for contact tracing or point of care (POC) testing. The DM said six dietary staff members were affected (potentially exposed by DA #6) and were having POC testing. The DM said that: -Cook #1, POC test was negative on 2/6/23, and that she would notify cook #1 of testing today, 2/8/23. -DA #5, had no testing, had worked today, 2/8/23 and was not tested,the DM would contact DA #5 of testing today. -Cook #2, had no testing, had worked today, 2/8/23 and was not tested, the DM would notify cook #2 of testing today. -DA #2, had no testing, last worked on 2/5/23, not scheduled back to work until 2/11/23, DM would notify DA #2 of testing today, 2/8/23. -Cook #3, had no testing, last worked on 2/5/23, would be tested on [DATE] before starting their shift. -DA #3, she said she did not know if DA #3 tested yesterday, 2/7/23, she said she would have DA #3 test today, 2/8/23, if DA #3 was not tested on [DATE]. The POC Testing Log-for Associates documentation was created 2/8/23 was received from the DON on 2/8/23 at 5:34 p.m. It revealed that the DM, activity director (AD), and DA #6 were not added to the log. The DON was interviewed again on 2/8/23 at 5:34 p.m. She said she did not know the approximate time when DA #6 symptoms began, but they started on 2/5/23. She said the facility contact traced 22 residents, and testing on those residents began on 2/7/23, she said secondary to the fact that she was unable to enter orders for the testing until 2/6/23 at approximately 8:00 p.m. to 9:30 p.m. because of being too busy. She said all residents that have tested have had negative results. She said DA #6 reported to work symptomatic at 6:00 a.m. on 2/6/23. She said she was made aware of DA #6 ' s symptoms from the AD, who translated for DA #6. She was unaware if DA #6 informed anyone of her symptoms when she arrived at work at 6:00 a.m. She said she did not know where the COVID-19 testing took place. She said the testing took place either outside or in a room next to the reception ' s office. She said DA #6 gave her positive COVID-19 results to the AD. She said DA #6 went home 30-45 minutes after she received the positive test results. -The DON provided documentation of the timeline of events during this interview. It revealed that on 2/6/23 between 9:30 a.m. and 10:00 a.m., she was notified of DA #6 symptoms, she instructed DA #6 to test, the test was positive, and DA #6 was sent home. The POC Testing Log-for Associates documentation, updated on 2/9/23, was received from the DON on 2/9/23 at 8:00 a.m. It revealed DA #6 was still not being tracked and was not added to the log. It also revealed that DA #3, cook #3, cook #2, and DA #5 were not notified of exposure to the COVID-19 team member until 2/8/23. It also revealed DA #5, the DM, and the AD were exposed on 2/6/23, and should have been tested on [DATE], instead they were tested on [DATE]. Also, it revealed that the DA #3, cook #3 and cook #2 were exposed on 2/5/23, but none were tested on [DATE]. The AD was interviewed on 2/9/23 at 11:20 a.m. She said that on 2/6/23 at approximately 9:00 a.m., she was in the dishwashing area talking with DA #6. She said she told DA #6 that she sounded congested, and DA #6 said she did not feel well. The AD stated that she went to the DON around 9:15 a.m. and notified her of DA #6 ' s symptoms. She said the DON told her that DA #6 would need to take the COVID-19 POC test. The AD said she also notified the DM. The DM was interviewed on 2/9/23 at 12:56 p.m. She said that on 2/6/23 at approximately 7:20 a.m. with the AD present, she was informed that DA #6 did not feel well, she was congested. She said DA #6 was directed to take a COVID-19 test around 9:00 a.m. She did not know who instructed DA #6 to take the test or where she took the test. She stated the AD notified her of the positive test results and at this point she instructed DA #6 to go home.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and staff interviews, the facility failed to ensure infection control practices were maintained to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of communicable diseases and possible transmission of Coronavirus (COVID-19) infection. Specifically, the facility failed to: -Follow proper infection control practices following an employee who exhibited signs/symptoms of COVID-19, entered the facility and began working, then was later confirmed to have COVID-19 from a positive COVID-19 antigen test; and, -Practice proper hand hygiene during meal service with resident assistance. Findings include: I. Infection control practices regarding a COVID-19 positive staff member A. Facility policy and procedures 1. The Infection Prevention and Control Program and Plan, last revised on 9/20/22, was received on 2/6/23 from the director of nurses (DON). It read in pertinent part, in bold print, Remind healthcare personnel not to report to work when ill. It also read to Reinforce adherence to standard infection prevention control measures including hand hygiene. It also read as part of routine practice, to ask healthcare personnel to regularly monitor themselves for fever and symptoms consistent with COVID-19. 2. The COVR staff text notification program policy and procedure , created by human resources on 3/23/22, received from the DON on the morning of 2/7/23, documented that COVR should NOT be used as a method of education. B. Interviews and observations The DON who was also the infection preventionist, was interviewed on 2/8/23 at 2:00 p.m. She said that on 2/6/23, dietary aide (DA) #6 reported to work with signs and symptoms of COVID-19. The DON said DA #6 had reported her symptoms to the dietary manager (DM) who then notified the DON of DA #6's symptoms. The DON said she instructed the DM to have DA #6 perform a COVID-19 point of care (POC) antigen test. After the test results were positive, DA #6 was sent home. The DON did not have any documentation of contact tracing or an employee POC testing log. She stated that the DM was keeping up with it, because it only involved dietary staff. She stated four dietary staff members were potentially affected. She said that she would start following up with employee testing, and going forward, she was going to track testing with a spreadsheet. She said she did informal education regarding hand hygiene and infection prevention. She said she used COVR, a text messaging software program that delivered text messages to employees via their cell phones. The DON and DM were interviewed on 2/8/23 at 2:45 p.m. The DM said that she had no documentation for contact tracing or point of care (POC) testing. The DM said that six dietary staff members were affected (potentially exposed by DA #6) and were having POC testing. The DON was interviewed again on 2/8/23 at 5:34 p.m. She provided a timeline of events from 2/6/23 at 9:30 a.m. through 2/8/23 at 4:00 p.m. She said DA #6 reported to work symptomatic at 6:00 a.m. on 2/6/23. She said Spanish was DA #6's primary language, and she was first notified about DA #6's symptoms from the activity director (AD), who translated for DA #6. She was unaware if DA #6 informed anyone of her symptoms when she arrived at work at 6:00 a.m. on 2/6/23. She said she did not know where the COVID testing took place, but it was probably either outside or in a room next to the receptionist's office. She said DA #6 gave her positive COVID-19 results to the AD. She said DA #6 went home 30-45 minutes after she received the positive test result. She said that they had a passive screening process posted at facility entrances, although not in Spanish. She said that they did not ask DA #6 why she came into work with symptoms. She said she did not know the approximate time when DA #6's symptoms began, but they started on 2/5/23. She said DA #6 was a dishwasher, and she was informed by the DM that DA #6 had served meal trays on 2/5/23 in the main dining room. She also stated that on 2/6/23, per the DM, DA #6 did not deliver any trays to residents and she would not have handled any clean dishes. She stated that the DM, who was excluded from the staff point of care (POC) testing, should be added to the testing log, and that she would add her. She said the last staff education training about not coming to work if having COVID-19 symptoms was in September 2022. -Although requested, no documentation of the September 2022 training was provided. Observations on 2/9/23 at 10:26 a.m. revealed COVID signage outside the facility entrance was in English only, without Spanish translation for Spanish-speaking staff and visitors. Observations on 2/9/23 at 11:09 a.m. revealed COVID signage outside of the employees' entrance door was in English only. The AD was interviewed on 2/9/23 at 11:20 a.m. She said that on 2/6/23 at approximately 9:00 a.m., she was in the dishwashing area talking with DA #6. She said she told DA #6 that she sounded congested, and DA #6 said she did not feel well. The AD said DA #6 told her she did not have a fever because she walked down to [NAME] Hall and had a registered nurse (RN #2) take her temperature. The AD also stated that she went to the DON around 9:15 a.m. and notified her of DA #6's symptoms. She said the DON told her that DA#6 would need to take the COVID-19 POC test. The AD said she also notified the DM. The DON was interviewed on 2/9/23 at 11:43 a.m. She said that in October 2022, education was provided regarding a change to the COVID-19 screening process; it had guidance of a passive screen in process on entering the facility. It was sent to employees via a text messaging system, through a software program called COVR. She said that it was not sent out in Spanish. She said that staff was educated on COVID-19 symptoms, how it was transmitted, self monitoring for symptoms and work exclusions. She said that they were educated through the COVR software messaging program. She said she did not recall if DA #6 delivered the food cart to [NAME] Hall on 2/6/23. She said that she would be doing education with employees about not walking through the facility if they had signs/symptoms of COVID-19. The DM was interviewed on 2/9/23 at 12:56 p.m. She said that on 2/6/23 at approximately 7:20 a.m. with the AD present, she was informed that DA #6 did not feel well, she was congested. She said DA #6 walked to [NAME] Hall to get her temperature taken. She said she was not for sure who told DA #6 to go to [NAME] Hall. She said that DA #6 was directed to take a COVID-19 test around 9:00 a.m. She did not know who instructed DA #6 to take the test or where she took the test. She stated that the AD notified her of the positive test results, and at that point she instructed DA #6 to go home. She stated that DA #6 probably delivered the food cart to [NAME] Hall on 2/5/23 and 2/6/23. She said that DA #6 pushed the cart into [NAME] Hall then dropped it off and walked away. She said DA #6 would have been wearing a surgical mask at all times, which was the facility protocol. She said that on 2/8/23 she performed COVID-19 education with DA #6 with the AD's translation assistance. The DON was interviewed on 2/9/23 at 2:35 p.m. regarding the POC testing log. After discussion with the DON and DM on 2/8/23 at 2:45 p.m., the DM stated that DA #2 had not had further POC testing, and would not return to work until 2/11/23. The POC testing log that was received 2/8/23 at 5:34 p.m. listed DA #2 with a POC test date of 2/6/23. The DON said that she had talked with the DM on 2/8/23 at approximately 6:00 p.m. and she was notified that DA #2 was tested on [DATE]. The DON was asked why DA #6 was not included on the POC testing log. She said she would add DA #6 to the log. II. Failure to perform proper hand hygiene in the dining room A. Facility policy and procedure The Hand Hygiene policy, revised 7/15/22, was provided by the corporate consultant (CC) on 2/9/23 at 3:08 p.m. It revealed, in pertinent part, Handwashing/hand hygiene is generally considered the most important single procedure for preventing nosocomial infections. Unless hands are visibly soiled, an alcohol-based hand rubs (ABHR) is preferred over soap and water in most clinical situations due to evidence of better compliance compared to soap and water. It is important to make sure that hand hygiene is performed at the appropriate times before and after touching a resident, between residents and frequently during care. Health care professionals should perform hand hygiene by using ABHR with 60-95% (percent) alcohol or washing hands with soap and water for at least 20 seconds. B. Observations During a continuous observation on 2/6/23 beginning at 11:44 a.m. and ending at 12:40 p.m. in the dining room the following was observed: -At 12:00 p.m. an unidentified certified nurse aide (CNA) assisted a resident in putting on a clothing protector. She applied ABHR to her hands and when they were still visibly wet she moved the menu and assisted another resident in putting on a clothing protector. -At 12:01 p.m. an unidentified CNA placed ABHR on her hands and rubbed them together for five seconds. She picked up a clothing protector and asked the resident if they would like to put on the clothing protector. The resident refused. -At 12:06 p.m. an unidentified CNA applied hand sanitizer, began rubbing her hands, when they were still visibility wet she picked up a stool and moved it, then sat down on the stool and finished rubbing her hands together. -At 12:07 p.m. CNA #6 touched her face mask and tucked her hair behind her hair. She then began assisting a resident with eating. -At 12:11 p.m. an unidentified CNA sanitized her hands for five seconds with ABHR. While her hands were still visibly wet, she placed her hand on the back of a resident and encouraged the resident to eat. -At 12:13 p.m. CNA #6 sanitized her hands with ABHR for two seconds, she placed the sanitizer bottle into her pocket. She placed her hand on a resident's back and encouraged them to eat. She then reached back into her pocket, grabbed the bottle of hand sanitizer, sanitized her hands for ten seconds and then began assisting another resident with eating. -At 12:20 p.m. CNA #6 itched her head and then picked up a spoon and began assisting a resident with eating without performing hand hygiene. During a continuous observation on 2/7/23 beginning at 11:50 a.m. and ending at 12:41 p.m. the following was observed: -At 12:19 p.m. CNA #6 touched her face mask then began assisting a resident with eating. -At 12:22 p.m. CNA #6 was assisting a resident with eating without sanitizing her hands then she assisted another resident to take a bite of his food. -At 12:24 p.m. CNA #6 used both of her hands to help a resident eat her melon. -At 12:27 p.m. CNA #6 used her right hand to help feed another resident. She did not perform hand hygiene between residents. -At 12:29 p.m. CNA #6 continued to assist a resident to eat his meal with both of her hands. -At 12:30 p.m. CNA #6 then assisted a resident to eat. She did not perform hand hygiene between residents. C. Staff interviews CNA #5 was interviewed on 2/9/23 at 9:29 a.m. She said when performing hand hygiene with ABHR she first applied the sanitizer and then rubbed her hands together to get all surfaces for about 30 seconds. CNA #5 said hand hygiene should be performed when entering the dining room and between any tasks. Registered nurse (RN) #5 was interviewed on 2/9/23 at 10:23 a.m. She said when performing hand hygiene with ABHR she first applied the solution to her hands, then rubbed her hands together for about 10 seconds or until fully dry. She said nothing should be touched when hands were still wet from ABHR. The registered dietitian (RD) was interviewed on 2/9/23 at 10:50 a.m. She said hand hygiene should be performed between assisting residents. She said if a staff member assisted a resident with eating or putting on a clothing protector they should perform hand hygiene prior to helping another resident. The RD said ABHR could be used in the dining room. She said ABHR should be applied to the hands and rubbed together until it was dry. She said staff should not touch anything prior to fully completing hand hygiene. The director of nursing (DON) was interviewed on 2/9/23 at 12:00 p.m. She said hand hygiene should be performed frequently. The DON said all staff should perform hand hygiene after assisting a resident and before assisting another resident. She said if a staff member was assisting two residents at the same time, they should use one hand for one resident and the other hand for the other resident or use ABHR between residents. The DON said hand hygiene should always be performed after touching a face mask. The DON said ABHR could be used in the dining room. She said staff should apply hand sanitizer on their hands, rub their hands together vigorously over all surfaces until their hands were dry. She said staff should not touch residents or other items until their hands were fully dry after using ABHR.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to ensure that individuals identified with a mental disorder (MD) or intellectual disability (ID) were screened and evaluated and received care and services in the most integrated setting appropriate to their needs for one (#43) of two residents reviewed for preadmission screening and resident review (PASARR) services of 28 sample residents. Specifically, the facility failed to ensure Resident #43 received a second level one PASARR within 30 days after admission to the facility as directed in the initial screening assessment. Findings include: I. Facility policy and procedure The Pre-admission Screening (PASARR) Policy, revised 8/7/21, was provided by the case manager (CM) on 10/25/21 at an unknown time. The policy read in pertinent part: PASARR is a federal requirement to help ensure that individuals who have an MD or ID diagnosis are not inappropriately placed in nursing homes for long term care. PASARR requires that all applicants to a Medicaid-certified nursing facility be evaluated for serious MD/ID, be offered the most appropriate setting for their needs, and receive the services they need. II. Resident status Resident #43, age under 50, was admitted on [DATE]. According to the October 2021 computerized physician orders (CPO), diagnoses included Down syndrome, major depressive disorder, anxiety, and Parkinson's disease. The 9/7/21 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. Resident #43 was taking antidepressant medications. III. Record review A Level 1 PASARR dated 8/30/21 documented that Resident #43 was approved for short term treatment at the facility with provisional admission. The PASARR documented in pertinent part the following under the provisional admission determination section: The review of the submitted Level 1 PASARR screening resulted in a finding of a known or suspected mental illness, or intellectual/developmental disability, or related condition, and there were indicators for a qualifying provisional admission. The facility was responsible for submitting a new Level 1 PASARR screening if the member was anticipated to reside in the facility beyond the approved provisional timeline (30 days). The resident had a baseline care plan, initiated 9/7/21 and revised 9/23/21, that read in pertinent part: Resident #43 was dependent on staff for meeting emotional, intellectual, physical, and social needs. His goal was to maintain involvement in cognitive stimulation and social activities. The resident was at risk for a change in mood or behavior and desired to be consulted with for decisions related to his care. Resident #43 was on antidepressant medications and required monitoring for adverse effects, such as change in behavior/mood/cognition, hallucinations/delusions, social isolation, suicidal thoughts, and withdrawal. His discharge plan was to return home with his family. A patient health questionnaire (PHQ)-9 was documented as conducted verbally by the CM in the resident's room at 11:30 a.m. on 9/7/21. Resident #43 scored a 2/27 on the PHQ-9 indicating minimal depression. A psychotropic note, dated 9/14/21 by the social services director (SSD), read in pertinent part: Resident #43 was admitted to the facility for short term rehab and utilized Lexapro for depression. Since admission, he had not had any recorded behaviors. Effective non-pharmacological interventions include sitting with the resident one on one, engaging in an activity, encouraging him to go to therapy, encouraging family visits, and taking for a walk outside. Resident #43's father consented to the use of psychotropic medications and understood the risks and side effects. A CPO dated 8/30/21 documented that the resident was to be monitored for side effects of antidepressant medication, such as sedation, drowsiness, dry mouth, blurred vision, urinary retention, tachycardia (fast heart rate), muscle tremors, agitation, headache, skin rash, photosensitivity (skin), and excess weight gain. A CPO dated 8/31/21 documented Lexapro 10mg was to be given by mouth once daily. IV. Staff interviews The CM was interviewed on 10/25/21 at 3:57 p.m. She stated that she was responsible for updating the PASARR screenings when required. She acknowledged that she did not look at the provisional assessment from Resident #43's Level I PASARR and did not complete the second screening due within 30 days after admission. She said that she would do another screening for Resident #43 to determine if he needed a Level II PASARR assessment. The nursing home administrator (NHA) was interviewed on 10/26/21 at 2:59 p.m. He stated that the social work assistant (SSA) was responsible for completing the short term Medicare A and B insurance plans and the staff development coordinator (SDC) was responsible for the long term care residents and Medicaid. He stated that both the SSA and SSD had a system in which new admissions would go through an initial approval process. Once approved, the SSA or SSD would enter the resident into a tickler file (future reminder) in the electronic health record (EHR). He said he did remember asking the SSA and SSD to look into Resident #43's care, but could not pinpoint a timeframe of when he asked them to do that. V. Facility follow-up The SSA provided an updated Level 1 PASARR screening application for Resident #43 on 10/25/21 at 4:24 p.m. On 10/27/21 at 3:45 p.m. the NHA provided a form from the Colorado Department of Health Care Policy and Financing that documented the resubmitted screening application was approved and Resident #43 required a Level II screening.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interviews, the facility failed to ensure one (#24) of two residents observed for limited range of motion, out of 28 sample residents, was provided appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion. Specifically, the facility failed to ensure Resident #24's hand splint was in place as ordered. Findings include: I. Facility policy The Alignment and Pressure-Reducing Device Application policy, revised 10/11/21, provided by the facility on 10/26/21 at 1:34 p.m., read in pertinent part: The facility will provide Alignment and Pressure-Reducing Device Application in accordance with professional standards of practice. According to the policy, the services provided were outlined in the comprehensive care plan. II. Resident status Resident #24, age [AGE], was admitted on [DATE]. According to the October 2021 computerized physician orders (CPO), diagnoses included hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, old myocardial infarction, abnormalities of gait and mobility, and muscle weakness. The 7/22/21 minimum data set (MDS) assessment revealed Resident #24 had moderate cognitive impairment with a brief interview for a mental status score of eight out of 15. He required extensive assistance of two or more persons physical assistance with bed mobility, transferring, dressing, and toileting. He required extensive physical assistance by one person for personal hygiene. The MDS indicated Resident #24 had impairment to his upper extremities on one side. No hours were recorded for restorative or range of motion services. III. Resident observation and interview Resident #24 was observed sitting in his wheelchair in his room watching television on 10/20/21 at 10:51 a.m. He did not wear a splint to his left hand. -At 11:25 p.m. Resident #24's left hand, balled into a fist, rested on his lap. The resident said he used to have a splint for his hand but was told it was missing. On 10/21/21 at 2:39 p.m. Resident #24 was observed in his room, his splint was not on his hand. He said he had not been informed by staff on the status of the splint. He said he was not bothered by the use of the splint. -At 4:33 p.m. the resident was observed watching television in his room. His splint was not in place. On 10/25/21 at 9:52 a.m. Resident #24 was in his room. His splint was not in place. -At 1:29 p.m. the resident was observed in his room, his splint was not in place. -At 10/25/21 at 3:15 p.m. Resident #24's splint was not in place. IV. Record review The October 2021 CPO identified Resident #24 had an active order for a splint, with a start date of 4/9/21. According to the order, staff were to apply the split to his left arm once a day and then remove as scheduled. The October 2021 care plan for activities of daily living (ADLs) read Resident #24 had an ADL self-care performance deficit related to hemiplegia and limited mobility. According to the care plan, staff were to splint his left hand between each meal until dinner. The 10/8/21 administration note read Resident #24's splint was missing from his room. The note indicated therapy was notified. The 10/9/21 administration note read Resident #24's splint was not in his room. The note indicated therapy was notified. V. Staff interviews The rehabilitation director (RD) was interviewed on 10/26/21 at 12:13 p.m. The RD said therapy introduced the splint to prevent increased muscle tone to the resident's contracting hand. The RD said splint use would be monitored by the restorative staff. He said the facility did not have a complete restorative program in place for ongoing monitoring at the time of the interview. The RD said staff should have notified the therapy department so they could have assessed the resident for use of a carrot (hand contracture orthosis), until a splint could be located or reordered. The RD was interviewed again on 10/26/21 at 1:01 p.m. He said he located the splint and placed it on the resident. According the RD, he determined the splint was still a proper fit and placed it on Resident #24's hand. The RD said he would provide staff education on communication and application of the splint. Certified nurse aide (CNA) #3 was interviewed on 10/26/21 at 1:03 p.m. She said she had not been able to locate the resident's splint to apply it to his hand. She said she had not seen the splint for a couple of months. The CNA said she thought she informed the rehabilitation director when she first identified it was missing but was not sure how long ago. Registered nurse (RN) #6 was interviewed on 10/26/21 at 1:32 p.m. She said she was not informed the splint was not in place or that it was missing. The director of nursing (DON) was interviewed on 10/26/21 at 2:58 p.m. She confirmed Resident #24 had active orders to apply the splint to his hand daily. She said staff did not report to her the splint was missing or that staff were not placing it on the resident as ordered. She said CNAs should have reported the missing splint to the nurse so the nurse could have communicated the concern during the morning rounds meeting. CNA #2 and the nurse aide (NA) were interviewed on 10/26/21 at 4:12 p.m. CNA #2 said she had not seen Resident #24's splint for months. The NA identified herself as the facility bath aide. She said she had not seen a splint available for use after the resident's shower in a long time. Neither staff member said they reported the missing splint to management or the nurse. VI. Facility follow up On 10/26/21 at 1:27 p.m. the RD provided a copy of a sign to be placed in the room of Resident #24, an interim care plan for Resident #24, and the Lippincott procedure for rigid splint application. -The provided sign reminded staff of the daily splint use to his left hand with removal at meals and storage in his dresser. According to the sign, staff should report to therapy if the splint was missing or in the wash. -The interim care plan directed staff to report refusals to therapy. -The splint application procedure guide read in part: Collaborate with practitioner, physical therapist, or occupational therapist about splint application and removal schedule, permitting activities, and recommended range of motion and strengthening exercises. An education acknowledgement form with staff signatures, dated 10/26/21, was provided by the RD on 10/26/21 at 3:07 p.m The form indicated staff were educated on communication and the daily use of Resident 24's splint on 10/26/21.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interviews, the facility failed to ensure supervision and assistive devices to prevent accidents for one (#12) of six residents reviewed for falls out of 28 sample residents. Specifically, the facility failed to: -Complete a thorough and complete investigation after unwitnessed falls to ensure all risks and interventions to prevent additional falls were considered; -Implement effective and updated staff communication to prevent falls; and -Provide and follow effective interventions to prevent falls. Findings include: I. Facility policy The Fall Management policy, revised 8/2/21, was provided by the medical records director on 10/26/21. According to the policy, the purpose of fall management was: To promote patient (resident) safety and reduce patient falls by proactively identifying, care planning and monitoring of patients' fall indicators. The facility will assess the resident upon admission/readmission, quarterly, with change in condition, and with any fall event for any fall risks and will identify appropriate interventions to minimize the risk of injury related to falls. The policy identified measures to prevent accidents. The measures included: -Identify environmental hazards and/or assess individual resident risk of an accident including the need for supervision and or assistive devices. -Evaluate/analyze the hazards and risks and eliminate them, if possible, or, if not possible, identify and implement measures to reduce the hazard risk as much as possible. - Implement interventions, including adequate supervision and assistive devices, consistent with residents needs, goals, care plan and current professional standards of practice in order to eliminate the risk, if possible, and, if not, reduce the risk of accident. - Monitor the effectiveness of the interventions and modify the care plan as necessary, in accordance with current professional standards of practice. II. Resident status Resident #12, age [AGE], was admitted on [DATE]. According to the October 2021 computerized physician orders (CPO), diagnoses included normal pressure hydrocephalus (NPH), muscle weakness, difficulty in walking, cognitive communication deficit and unspecified dementia without behavioral disturbances. According to the 10/7/21 minimum data set (MDS) assessment, the resident had moderate cognitive impairment with a brief interview for mental status (BIMS) score of 12 out of 15. She required extensive assistance of one person with bed mobility, transferring, locomotion, dressing, personal hygiene and toileting. The MDS indicated the resident did not have a steady balance. The MDS identified Resident #24 was only able to stabilize with staff assistance when moving from a seated to standing position, moving on and off the toilet, and moving surface-to-surface in transfers. The MDS revealed resident #12 had a fall prior to the 10/7/21 MDS assessment. III. Resident interview Resident #12 was interviewed on 10/21/21 at 2:42 p.m. She said she slid out of her wheelchair when she was asked about her recent falls. The resident did not provide additional details of the falls. IV. Observations Observations between 10/20/21 and 10/21/21 and 10/25/21 and 10/26/21 throughout each day during the survey, did not identify specific fall interventions were in place for Resident #12. The bed was not placed in a lower position, a fall mat was not on the side of the bed. The resident was observed alone in her room watching television from her wheelchair and her bed. Observations of the resident indicated that she spent most time in her room. Her room was located towards the end of the hall from the nursing station. On 10/21/21 at 3:07 p.m. Resident #12 was in bed watching television. Her call light push pad was on her bedside table, not within the resident's reach. V. Record Review A. Documented staff communication The October 2021 care plan for falls, last revised 10/18/2020, read Resident #12 was at risk for falls, had balance problems, was incontinent, and unaware of safety needs secondary to her dementia and normal pressure hydrocephalus (NPH). Interventions directed staff to: -Anticipate and meet Resident #12's needs. -Assist with ADLs as needed. -Call light within reach. -Complete fall risk assessment. -Provide appropriate footwear. -Physical therapy to evaluate and treat as ordered. -The review of the fall care plan did not identify any new interventions that were incorporated in the resident's care plan to prevent falls since 10/18/2020. The [NAME], a certified nurse aide (CNA) communication sheet, for Resident #24 directed CNAs to provide the following directions for safety pertaining to falls: -Call light within reach -Provide appropriate footwear -Provide an unobstructed path to the bathroom. B. Resident falls 1. 8/11/21 unwitnessed fall The 8/11/21 event note read Resident #12 was found on the floor by a CNA. According to the note, the resident informed the staff she slid off her wheelchair. According to the note, the resident was assessed for injuries and placed back into her wheelchair with the assistance of three staff members. The event note did not identify what immediate interventions staff put in place to prevent another fall from her wheelchair. The 8/11/21 fall assessment identified the 8/11/21 fall as unwitnessed, with neurological checks initiated. The resident did not present any injuries. The fall assessment revealed the resident had a history of sliding out of her wheelchair. The assessment did not identify interventions to prevent future falls based on her history of sliding out of her chair. The fall risk evaluation, completed on 8/12/21, identified the resident's increased risk for falls with a score of 10 or above. According to the fall risk evaluation the resident had a risk score of 11. The 8/17/21 interdisciplinary team note (IDT) read that the resident wanted to stay in her wheelchair as opposed to lying down in bed. The note read that there was not a malfunction with her wheelchair. The intervention suggested by the IDT was to instruct staff to reduce the resident's sitting time in her wheelchair when she was in her room. -The intervention was not added to the care plan or the [NAME] to inform staff. The intervention did not clarify how staff would attempt to reduce her sitting time in her wheelchair to prevent a fall if the resident did not want to go to bed. The note did not identify that the IDT members reviewed the cause or potential cause of her historical and current factor of sliding out of a wheelchair that was in good repair. Additional review of the resident's medical record did not identify other departments such as activities were incorporated in the resident's fall prevention plan. 2. 10/13/21 unwitnessed fall 10/13/21 event note read a CNA found Resident #12 on the floor in her room. According to the note, the resident was on her left side with her feet facing the bed, and her wheelchair was in front of her also facing the bed. The resident was unable to describe the circumstances surrounding the fall. The event note revealed the resident was incontinent with bowel at the time of the fall. -The note did not identify if the call light was on at the time of the fall. The resident was assisted to the restroom after the fall, according to the note. -The event note did not identify if other interventions were put in place to prevent Resident #12 from falling again. The note did not identify if the resident was in her wheelchair or her bed prior to the fall. The note did not identify what the resident was doing that contributed to the fall. The 10/13/21 fall assessment identified the 10/13/21 fall as unwitnessed and neurological checks were initiated. The resident did not present any injuries. The fall assessment identified predisposing physiological factors of confusion, incontinence, gait balance and impaired memory. The fall assessment did not identify additional fall findings other than what was recorded in the above event note. The 10/13/21 fall risk assessment identified Resident #12 was at high risk for falls with a score of 18. -The review of the documentation did not identify the fall on 10/13/21 was reviewed by the IDT staff members or was reviewed at all. The documentation did not identify new interventions were put in place to prevent Resident #12 from falling again in her room. The documentation did not identify an investigation was completed after the resident had her second fall in two months. The documentation did not show how or if staff were educated or directed in the attempt to prevent future falls based on the limited information gathered on the 8/11/21 and 10/13/21 fall. VI. Staff interviews The director of nursing (DON) was interviewed on 10/26/21 at 1:51 p.m. The DON said residents' fall risk was reviewed on admission, quarterly, and if risk management was initiated after a fall. She said that identifying the resident's fall risk would determine the need for interventions in fall prevention. The DON said if fall risk was deemed high, the facility would incorporate prevention measures such as resident placement near the nurse's station, add a foam mat on the side of their bed, place the bed in its lowest position, and ensure the call light was within reach. She said staff ensured the type of call light device was appropriate for the ability of the resident with resident education on use. The DON said person-centered interventions would also be incorporated based on risk and fall history. The DON described the steps staff taken after a resident fall. She said when a resident falls, a fall huddle would occur immediately after to assess the situation. She said the huddle would include the floor CNAs, nurses, and available members of the IDT. She said if the resident fell during the off hours when the IDT management members were not present, the nursing staff would ask staff from other halls to help assess the fall for another perspective. The DON said the nurse would then document the findings in their risk management documentation. The DON said the IDT would review the findings the next day or as soon as possible, determining other environmental factors, fall causation, why the resident was prompted to move and what contributed to the fall. She said the IDT review would assess and determine if the needs of the resident were met, if fall interventions were in place at time of fall, if staff and resident education was necessary and introduce new interventions based on the findings of the IDT review. The DON said the interventions would be added to the care plan and the CNA [NAME] for floor staff communication and implementation. She said the IDT would do a second review in a weekly meeting as a fall wrap-up and document the review of the fall, findings, and interventions, in an IDT note. The DON reviewed the resident's fall on 8/11/21. The DON said the resident wanted to stay up in her wheelchair instead of going to bed after dinner. She said the resident then fell from her wheelchair. The DON said the IDT determined staff should offer her activities in the common area if she did not want to lie down in bed. She said the intervention was not planned or documented on the [NAME] to ensure staff were aware of the intervention. The DON reviewed the fall on 10/13/21. The DON said the resident was found on the floor between the sink and her bed. The DON said she thought the resident was trying to take herself to the restroom because the resident was incontinent when she was found. The DON said staff offer residents toileting when they wake, before and after meals and before bed. She said staff were educated to offer Resident #12 increased frequency of toileting to ensure she did not have the urgency to get up. The DON reviewed the documentation and could not confirm that all nursing staff who worked were aware of the intervention. The DON confirmed the intervention was not in the care plan or the [NAME]. The DON revealed that the IDT team did not review the 10/13/21 fall. She said the nursing home administrator (NHA) was part of the IDT fall review meeting but was on leave at the time the review would have been conducted so the review did not occur without him. She said because the review of the fall in an IDT meeting did not occur, interventions were not added to the care plan, [NAME] or other notes for staff communication. The DON said in hindsight, all factors of a fall needed to be reviewed and documented for a thorough fall investigation. She said interventions needed to be communicated and added to the care plan to ensure the intervention was performed and staff were aware of her needs to prevent future falls. The DON revealed that she needed an increase in fall training and time for fall review to ensure fall risk management was thorough and complete in the event the NHA was not present to assist in fall review. She said she needed to improve staff communication after a resident fell. The DON said moving forward, the IDT fall review would be conducted even if the NHA was not present, and they would document and communicate findings and interventions to prevent future falls for Resident #12. The DON said the facility, with assistance from their corporation, determined a need for fall management improvement in review of the fall program during the recertification survey. Certified nurse aide (CNA) #2 was interviewed on 10/26/21 at 4:12 p.m. She said Resident #12 was at high risk for falls, so she had been instructed to ensure the resident had her call light within reach and attempt to answer her call lights quickly. CNA #2 said she was not aware of additional precautions, interventions or instructions to prevent falls for Resident #12.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interviews, the facility failed to provide an ongoing program to support residents in their choice of activities, designed to meet their interests and support their physical, mental and psychosocial well-being, for two (#39 and #3) of 12 residents who resided in the [NAME] Hall memory care neighborhood, potentially affecting all the residents who resided in [NAME] Hall. Specifically, the facility failed to: -Ensure resident centered activity programs were offered and participation was encouraged for all 12 residents in the [NAME] Hall, including both individual and group activities; -Ensure the activity staff assessed and consistently documented the activities provided to the residents; and -Ensure the facility provided an activity program during COVID-19 outbreaks in [NAME] Hall. Findings include: I. Facility policy and procedure The Individual Programming policy, revised 5/18/2020, was provided by the medical records director (MDR) on 10/25/21. The policy documented, in pertinent part, Individual programming ensures that all residents who are unable to participate in group programs have consistent, goal-oriented and individualized recreation opportunities. All residents have a need for engagement in meaningful activities. Regularly scheduled programming will be provided to all residents who are unable to or decline to attend group activities. Structured individual interventions will be developed based on each resident's assessed needs. Each resident's individual program will include interventions that meet the resident's assessed social, emotional, physical, spiritual and cognitive functioning needs. These approaches will reflect the resident's lifestyle and interests and will be incorporated into the interdisciplinary care plan. The Group Programming policy, revised 5/18/2020, was provided by the MDR on 10/25/21. The policy documented, in pertinent part, Group programming ensures each resident the opportunity for active participation in group programming designed to accommodate his or her social and/or cognitive abilities and to promote quality of life. The resident population will be assessed according to each resident's present cognitive capability, physical function and endurance as it relates to his or her social functioning to determine a level of programming in which each resident would best function. The Group Programming During a Public Health Crisis or Pandemic policy, revised 4/29/21, was provided by the MDR on 10/25/21. The policy documented in pertinent part, Group recreational and therapeutic programming ensures each resident has the opportunity for active participation in recreational/therapeutic activities designed to accommodate his or her social and/or cognitive abilities and to promote quality of life. Find new ways to help residents remain physically, mentally and socially active and connected, such as play live or recorded music outside in a courtyard where residents can watch and listen. verbally and visually cue residents to participate in as much of their care as possible. II. Activities on [NAME] Hall A. Observations On 10/25/21 at 2:00 p.m., the activity director (AD) was observed providing activities for three residents seated at the same table in [NAME] Hall: one was looking at a book of pictures, one was working with the AD on a word search puzzle and the last resident was looking at a magazine. On 10/26/21 at 1:55 p.m., the activity assistant (AA) was observed playing an animal trivia game with three residents. Residents #3 and #39 were not observed participating. The other nine residents residing in [NAME] Hall were not engaged with an activity or with a staff member at this time, except one resident was visiting with the social services director (SSD) in her office. On 10/26/21 at 3:45 p.m., the SSD and AA were observed beginning to play a game of Bingo with five residents. Neither Resident #39 nor Resident #3 were observed attending this activity. The three above observations were the only observations of organized activities of any type, group or individual, seen in [NAME] Hall between 10/20/21 at 10:30 a.m. and 10/26/21 at approximately 4:00 p.m. The following observations are examples of a typical day on [NAME] Hall during the survey conducted from 10/20/21 through 10/26/21: On 10/26/21, from 8:30 a.m. to 9:04 a.m., two residents were observed finishing their breakfast (one was Resident #39), two residents were looking at the newspapers, Resident #3 was by herself looking at an animal magazine, three residents were napping in recliners, one resident was receiving ADL care and the other three residents were in their rooms. On 10/26/21 at 11:15 a.m., Resident #3 was observed at a dining room table by herself, with a newspaper open, but she was not looking at the paper. No staff were interacting with her. Resident #39 was observed napping in a recliner in the [NAME] Hall common area. Four additional residents were napping or resting in recliners. The television was turned on to a western. One male resident just returned from his shower. Two female residents were socializing together at a table. One female was sitting in the office with the SSD. One male resident was seated on a couch outside of the SSD office. No staff was interacting with him. One female resident was wandering the halls with no staff interaction. The AA was observed standing in the common area, but not interacting with the residents in a meaningful manner or encouraging any activity. She was overheard telling the residents their lunch would be there in about 30 minutes. A receptionist came back into [NAME] Hall and said lunch would be delivered soon, said hello to a few residents and left the unit a short time later. The television was usually tuned to an animal program or Bewitched reruns. Often there was no music playing softly in the background for other residents. There were two magazines on a counter in the dining area left out for residents to look at, one with pictures of New Hampshire and the other with pictures of animals. Several copies of the local newspaper were on the counter. There were no coloring supplies or crafts accessible for residents to access. The weather outside was nice with comfortable temperatures during three of the four days during the recertification survey. No staff were observed taking the [NAME] Hall residents outside, despite the fact there was a secured patio available for the residents to enjoy. The following monthly activity schedule was posted on the large, white dry-erase board located in the dining area of [NAME] Hall. Every day documented the same activity schedule: 9:00 a.m. News and Coffee 9:30 a.m. Snacks and Hydration 10:00 a.m. Group activity 11:45 a.m. Lunch 1:00 p.m. Physical/cognitive 2:00 p.m. Snacks and Hydration 3:00 p.m. Bingo There was a note at the bottom of the dry erase board, which read Activities may include going out to the patio. There was a secured patio with three locking fire doors off of [NAME] Hall. B. Staff interviews A registered nurse (RN) was interviewed on 10/20/21 at 11:00 a.m. She said the facility did not provide many activities to the residents residing in [NAME] Hall. She said the residents played Bingo on Thursdays from 3:00 to 4:00 p.m. She said they also watched some movies on occasion. She said the AD usually came back to provide one on one activities with some residents, but not often. She said there was an AA to provide some services at times, but not often. She said the CNAs would try to do some activities with the residents if time permitted. She said she felt there should be more activities for the residents residing in [NAME] Hall. The AD was interviewed on 10/25/21 at 3:30 p.m. She said she used to come back to [NAME] Hall and provide activities, but she had not been back herself for months. She said the SSD would play Bingo with the residents and one employee would visit her mother, but only visited and provided activities for her mother. She said the therapy receptionist, the main receptionist and a new certified nurse aide (CNA) would assist on [NAME] when they had time. She said she learned that a few previous AAs had not been accurately documenting activity records during the COVID-19 outbreak during July 2021, and they had not been providing activities for the residents. She said she did not feel comfortable documenting the activities that she did not personally provide. She said she was the only full-time activity person in the facility until a few weeks ago when the facility hired an AA. She said she had hired some assistants that no longer worked in the facility. She said she had been concentrating her time providing activities to residents on the main unit. RN #3 was interviewed on 10/26/21 at 9:50 a.m. She said, in relation to activities in [NAME] Hall, We miss them and need them to occur more often. She said the facility had not had a full activity team for at least a year. She said, due to decreased staffing and a lower number of residents residing in [NAME] Hall, they did not have enough staff to take the [NAME] Hall residents outside as much as she would like. CNA #1 was interviewed on 10/26/21 at 10:00 a.m. She said she worked four days per week and was dedicated to [NAME] Hall. She said the facility needed to provide more activities to the residents of [NAME] Hall. She said she was able to assist with activities right after 10:00 a.m. and also after 3:00 p.m. She said she would read to the residents, as well as play basketball and dance with them. She said she felt it was so important for the residents to engage in physical activity and exercises so they did not stiffen up and get bored. The SSD, whose office was located in [NAME] Hall, was interviewed on 10/26/21 at 10:15 a.m. She said she was bothered by the lack of activities provided to the residents of [NAME] Hall. She said she would assist with activities in [NAME] Hall when she had time and would help find other staff, like the receptionists, to assist often. She said she felt that both staffing for activities and training for activity staff was an issue. She said the facility only had the current AD, one new AA and one AA who had been out of the facility for a few weeks. She said the lack of activities in [NAME] Hall led to boredom, which led to increased behaviors. She said she did not understand why there was a lack of documentation with activity participation, as she would write down the activity and attendees for any activity she provided and gave that information to the AD. She said on 10/25/21 at approximately 4:00 p.m., she noticed the residents were bored before dinner and spontaneously began singing songs; she said both Resident #39 and Resident #3 joined in. She said she had not seen residents going outside or engaging in any physical exercises or activities recently and the male residents, especially, who resided on [NAME] needed that physical activity to decrease their levels of anxiety and agitation. She said she felt the residents were just placed in the recliners in front of the televisions too much. The medical records director (MRD) was interviewed on 10/26/21 at 11:45 a.m. She said she had been doing the activity preference assessments for the AD since 10/1/21. She said the MDS nurses had been helping her with the assessments prior to that date. The MDS director was interviewed on 10/26/21 at 2:15 p.m. She said she had not been helping with activities so much the last few weeks since the other MDS worker left the facility. She said the other MDS person helped with the activity preferences section of the MDS (Section F) more than she did. She said she had concerns about activities in the building and lack of consistent activity staff. She said the MCU nursing staff and the SSD whose office was in [NAME] Hall tried to assist with activities when they could, but they all had their own jobs to do. She said a lack of activities in [NAME] Hall resulted in more resident behaviors, especially during the early to late afternoons when some residents started sun-downing. She said, as a team, the facility was having current and past issues with the activity programming in the building and it was a work in progress. III. Failure to meet the individual needs of residents A. Resident #39 1. Resident status Resident #39, age [AGE], was admitted on [DATE]. According to the October 2021 computerized physician orders (CPO), diagnoses included Alzheimer's disease, major depressive disorder, anxiety disorder and insomnia. The 8/19/21 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. It indicated snacks between meals and listening to music were very important to her. 2. Observations Resident #39 was initially observed on 10/20/21 at 11:10 a.m. She was napping with her eyes closed in a brown leather recliner in the common area in [NAME] Hall, covered with a blanket with cats on it. At this time two certified nurse aides were observed transferring her to her wheelchair. The resident began unzipping the male CNA's jacket and would not let go of him. She was gently redirected away from the male CNA and taken to her table in the dining room to await lunch. -At 4:18 p.m., the resident was observed calmly propelling herself down the [NAME] Hall hallway in her wheelchair. On 10/21/21 at 9:14 a.m., Resident #39 was observed napping in her recliner in the [NAME] Hall common area. The social services director said this resident usually spent her mornings napping. -At 11:55 a.m., Resident #39 was seated in her recliner with a bedside table set up for her lunch. She was eating independently at this time. On 10/25/21 at 9:45 a.m., Resident #39 was napping in her recliner with her glasses on. CNA # 1 said the resident had woken up in a good mood, ate about 50% of her breakfast, then settled into the recliner to nap. -At 3:00 p.m., this resident was observed to be still napping in her recliner. Between 10/20/21 at 11:10 a.m. and 10/26/21 at approximately 5:00 p.m., Resident #39 was not observed engaged in any facility activity, either group or individual. She was not observed listening to music on an MP3 player with headphones, as another resident residing in [NAME] Hall was, although MDS documentation (see above) revealed that listening to music was very important to this resident. 3. Interviews A family member of Resident #39 was interviewed via telephone on 10/21/21 at 1:11 p.m. The family member stated she was concerned about activities in [NAME] Hall and wondered if the residents just sat around in recliners sleeping all day. She said she thought her mother had been bored and was more lethargic since COVID-19 hit the facility in September 2021. The activity director (AD) was interviewed on 10/25/21 at 3:30 p.m. She said Resident #39 had been sleeping a lot lately. She said this resident was hard to arouse. She said she knew most of the residents from working in the occupation therapy department prior. She said Resident #39 would only participate passively with activities such as listening to music and being read to. She could not say what Resident #39's favorite types of music or books were. She said Resident #39 had not been issued an MP3 player with headphones, as another resident in [NAME] Hall had, although the facility staff was aware this resident enjoyed music. She said the resident did not really have any interest in looking at picture binders. She said she had interviewed Resident #39's family recently and they did not have anything new to share with her related to activity interests. She said the facility had been working with the resident on adjusting her medications and changing her sleep hygiene program. She said the facility did not have an activity director for a few months before she accepted the position in March 2021. She said there used to be two activity staff: one for the main unit and one for [NAME] Hall. She said activities were not provided in [NAME] Hall when COVID-19 was in that hall. She said it was an uphill battle getting staff hired to help with activities because of the staffing shortage nationwide. She said the facility needed to hire two more full-time activity staff. She said the facility had not been able to provide consistent activities for the residents for some time now. She said something always came up, but the plan was to have dedicated activity personnel in [NAME] Hall seven days a week. She said she had not been completing the resident preferences related to activities for Section F of the MDS and that the MDS nurse had been completing that portion of the assessment for her. She said it had been a long year and due to COVID-19, there were no musicians or family visiting the [NAME] Hall. 4. Record review The care plan, initiated on 8/20/2020 and revised on 8/19/21, identified risk for alteration in psychosocial well-being related to restrictions on visitation and reduced activities/communal dining due to COVID-19. Interventions included Resident #39 should be taken outside for fresh air and sunshine. -Except for encouraging alternative communication with visitors, there were no other activity interventions included in this care plan. -There was no specific care plan related to activity programming in Resident #39's medical record. The record of one to one activities was documented as initiated for this resident on 7/7/21. Nothing was documented on this form until 9/5/21. The document read: -9/5/21: Very little response. -9/6/21: Very little response. -9/13/21: Helped feed after she woke up: 20 minutes. -9/19/21: Helped feed: 10 minutes. -9/20/21: Helped feed: 10 minutes. -9/26/21: Helped feed: 20 minutes. The individual resident daily participation record for July 2021 documented that the resident actively participated in no activities for the month. It documented she passively participated in current events once, watching movies twice and listening to music once. There were no activity daily participation records completed for Resident #39 for August, September or October 2021. B. Resident #3 1. Resident status Resident #3, age [AGE], was admitted on [DATE]. The October 2021 CPO documented the resident's diagnoses included Alzheimer's disease, insomnia, major depressive disorder and dementia with behavioral disturbance. The annual MDS assessment, dated 12/10/2020, documented staff conducted Resident #3's assessment for activity preferences, but the section was left blank. The previous annual MDS assessment, dated 12/12/19, documented it was very important for Resident #3 to have snacks between meals, have things to read or written print/pictures to look at, to do things with groups of people, to engage in her favorite activities and to get outside often for fresh air. It documented it was somewhat important to Resident #3 to listen to music and keep up with news and current events. 2. Observations On 10/21/21 at 11:55 a.m., Resident #3 was observed seated at the dining room table by herself and was eating well. On 10/25/21 at 9:45 a.m., the AD was observed reading the newspaper to Resident #3 and another male resident. On 10/26/21 at 8:30 a.m., Resident #3 was observed looking at an animal picture book by herself. There was no staff encouragement or attention to the resident at this time. (Also see general [NAME] Hall observations above.) 3. Record review The care plan, initiated on 9/10/2020 and revised on 9/9/21, identified the resident was dependent on staff encouragement for meeting emotional, intellectual, physical and social needs. Interventions included Resident #3 would attend and participate in her choice of activities once or twice each day/ she should be invited to scheduled activities; and she enjoyed live music, puzzles and Bingo. The documented record of one to one activities was initiated for this resident on 7/7/21. Nothing was documented on this form until 9/5/21. The document read: -9/5/21: Relatively alert, non-responsive to stimuli: five minutes. -9/6/21: Not coherent to stimuli: five minutes -9/13/21: OK to comfort: time not documented -9/19/21: Played bingo: one hour -9/21/21: Paper and snacks: 10 minutes -9/26/21: Paper and snacks, little chat: five minutes -10/24/21: Passively listened to music, imitated dance moves, content: 15 minutes. The individual resident daily participation record for July 2021 documented the resident actively participated in ball toss twice and putting together a puzzle once. It documented the resident passively observed bingo twice that month and refused bingo twice. It documented passive participation in current events six times, educational programs once, group discussion three times, music once, television once and putting together a puzzle once. It documented she refused bingo twice and taking a walk outside once. It documented the resident was unable to participate in board games once, group discussion once, watching movies twice, listening to music once and watching television. There were no activity daily participation records completed for Resident #3 for August and September 2021. The individual resident daily participation record for October 2021 documented Resident #3 actively participated in bingo once, playing a board game once and watched television once. It documented passive participation in a board game once, current events once, group discussion twice, music once, being read to once and watching television once. She refused arts and crafts once. Resident #3 was unable to participate in arts and crafts one time and current events once. IV. Nursing home administrator (NHA) interview The nursing home administrator (NHA) was interviewed on 10/26/21 at 4:04 p.m. He said he was very aware the facility had issues with their activity program and they currently were working on the issue. He said they ran into a huge snag with activity staff and had 90% staff turnover in the past year or so. He said the previous AD resigned and the facility had a gap of a few months when they did not have an AD. He said the current AD took over that position in March 2021. He said several AAs had recently quit and one AA was terminated. He said they were now aware of the current documentation issues and would be working on training the current staff on how to document activity participation. He said the MRD would be obtaining her AD certification so she could begin assisting with some administrative tasks related to activities. He said the facility would be working with the Colorado Activity Professionals Association (CAPA) on suggestions on training activity staff. He said he would be having staff from other departments routinely helping with facility activities until they could get the actual activity department running efficiently. He said the MRD would begin by conducting interviews with residents or their representatives about preferred activity preferences. He also plans on creating an activity calendar binder for training and would be meeting with the AD on a weekly basis for supervision and training, including how to approach and encourage residents to participate in facility activities.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to establish a system of record of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation on three of three halls (200, 300, and [NAME] Hall/memory care) reviewed for narcotic administration. Specifically, the facility failed to ensure narcotic removal documentation in the narcotic log matched the dates of narcotic administration in the electronic medical record (EMR). Findings include: I. Facility policies and procedures The Pain Assessment and Management Policy, revised [DATE], provided by the nursing home administrator (NHA) on [DATE]at 1:20 p.m., read in pertinent part: The facility must ensure that residents receive the treatment and care in accordance with professional standards of practice. The Disposal/Destruction of Expired or Discontinued Medication Policy, last revised on [DATE], provided by the NHA on [DATE] at 1:12 p.m., read in pertinent part: The facility staff should destroy and dispose of medications in accordance with facility policy and applicable law, and applicable environment regulations. The facility should record destruction of controlled substances on the medication destruction log book, and in the presence of a registered nurse and a licensed professional. The recording should contain signatures of both the registered nurse and the witnessing licensed professional along with the quantity destroyed and the date of destruction. The Controlled Substance Destruction Process, revised on [DATE], provided by the NHA on [DATE] at 1:12 p.m., read in pertinent part: If a pharmacy consultant is not required to assist with the destruction of controlled substances, the facility should destroy Schedule II-V controlled substances in the presence of a registered nurse (preferably a member of nursing administration) and another licensed professional. II. Record review The 200 hall narcotic sheets and electronic medical record (EMR) revealed the following discrepancies: On the following dates oxycodone was recorded as being removed from the narcotic supply, however was not recorded as being given in the medication administration record (MAR): - [DATE] at 8:25 p.m. - [DATE] at 3:38 a.m. - [DATE] at 3:20 p.m. - [DATE] at 7:25 a.m. On the following dates tramadol was recorded as being removed from the narcotic supply, but was not recorded as being administered in the MAR: - [DATE] at 11:15 a.m. - [DATE] at 7:05 p.m. - [DATE] at 12:10 a.m. - [DATE] at 10:40 a.m. - [DATE] at 3:40 a.m. - [DATE] at 1:30 a.m. - [DATE] at 4:00 a.m. On the following dates tramadol was recorded as being administered in the MAR, however was not documented as being removed from the narcotic supply: - [DATE] at 12:10 a.m. - [DATE] at 3:49 p.m. - [DATE] at 11:57 p.m. The 300 hall narcotic sheets and EMR revealed the following discrepancies: On the following dates hydrocodone-acetaminophen (NORCO) was recorded as being removed from the narcotic supply, however was not recorded as being given in the MAR: - [DATE] at 12:03 a.m. - [DATE] at 10:38 p.m. - [DATE] at 9:00 a.m. - [DATE] at 9:00 a.m. On the following dates tramadol was recorded as being removed from the narcotic supply, but was not recorded as being administered in the MAR: - [DATE] at 7:45 a.m. - [DATE] at 12:15 a.m. - [DATE] at 9:20 p.m. - [DATE] at 9:00 p.m. On the following date lorazepam was recorded as being removed from the narcotic supply, but was not recorded as being administered in the MAR: - [DATE] at 2:45 a.m. On the following dates morphine sulfate was recorded as being removed from the narcotic supply, but was not recorded as being administered in the MAR: - [DATE] at 1:11 a.m. - [DATE] at 5:18 a.m. On the following dates hydrocodone- acetaminophen (NORCO) was recorded as being administered in the MAR, however was not documented as being removed from the narcotic supply: - [DATE] at 12:03 a.m. - [DATE] at 10:15 a.m. - [DATE] at 7:32 a.m. On the following dates tramadol was recorded as being administered in the MAR, however was not documented as being removed from the narcotic supply: - [DATE] at 7:45 p.m. - [DATE] at 12:46 a.m. - [DATE] at 3:28 p.m. - [DATE] at 5:51 a.m. - [DATE] at 7:06 p.m. - [DATE] at 4:01 p.m. - [DATE] at 4:22 p.m. On the following date lorazepam was recorded as being administered in the MAR, however was not documented as being removed from the narcotic supply: - [DATE] at 2:45 a.m. The memory care hall narcotic sheets and EMR revealed the following discrepancies: On the following date hydrocodone-acetaminophen (NORCO) was recorded as being removed from the narcotic supply, but was not recorded as being administered in the MAR: - [DATE] at 2:00 p.m. None of the medications reviewed were documented as being wasted in the Drug Buster Record provided by the medical record assistant on [DATE] at 11:00 a.m. III. Staff education An Education Acknowledgement Form, dated [DATE] (during the survey), was provided by the staff development coordinator (SDC) on [DATE] at 3:32 p.m., and documented the following: Type of training requested/needed: Proper protocol on signing out narcotics and notify on-call with any discrepancies. Summary of training: Narcotics are required to be signed out upon every administration and pull from narcotic box. Always notify On-Call with any discrepancies and questions, no matter the time of day or day of the week. ATTN: NURSES: Purpose: Narcotics have not been properly documented on both PCC (point click care) and Narcotic administration records. Nurses must ensure both of these are kept updated for patient safety. Always refer to the '6 medication rights' prior to administering medications: Right Patient- Refer to patient's photo on profile if you are unfamiliar with resident. Please also note we may have patient's on 'name alert' due to having same name and/or last name. SHARING MEDICATIONS FROM RESIDENT TO RESIDENT IS NEVER ACCEPTABLE UNDER ANY CIRCUMSTANCE! Right medication- Please ensure resident does have a current order of medication you are about to administer. If narcotic is unavailable, please request a pull from the Emergency Omni-Cell Kit in Med Room. Again, sharing narcotics from resident to resident is never acceptable. If medication is unavailable in omni-cell, please notify infection control nurse and she will request from (the pharmacy). Right dose- Ensure medication on cart has current and correct dose compared to order on PCC, most up to date. Right time- Most Narcotic orders are PRN (as needed), please ensure proper amount has passed from last administration of medication. Please also ensure you correctly DOCUMENT the date and time you are administering on both records, PCC and Narcotic Administration Record. Right route- ensure all medications are administered through correct route. Right Documentation- Please ensure narcotics are documented at the time of administration so we do not have any med errors/discrepancies. Document on both PCC and narcotic administration record what time and date you have administered medication, and follow up with proper assessment. Please review these rights and ensure proper documentation is happening with every med pass, this includes narcotics and non-narcotics. Narcotics do have separate sign out sheets that MUST BE KEPT UP TO DATE AT ALL TIMES TO AVOID DISCREPANCIES! This form had been signed by three nurses at the time the training was provided. IV. Staff interviews Registered nurse (RN) #7 was interviewed on [DATE] at 8:26 a.m. She acknowledged the discrepancies noted above in the 200 hall narcotic book. She stated that she was not sure what had happened on those dates. She said that if a medication was dropped, refused, or wasted (disposed of) for any reason that two nurses would sign off in the narcotic log, the EMR, and would destroy the medication together in the medication destroyer solution. RN #3 was interviewed on [DATE] at 8:51 a.m. She acknowledged that there was a discrepancy in the memory hall narcotic book. She stated that she was the nurse the day prior and that she did give the medication, however she forgot to document that it was administered in the MAR. She entered a late entry to verify the medication was administered. The NHA was interviewed on [DATE] at 2:59 p.m. He stated that it was his understanding that during narcotic medication administration, the nurses were to verify the medication in the MAR and document administration, verify the 6 rights of medication administration, and then document in the narcotic log. He stated that if a medication was not given and was not able to be returned to the narcotic supply, then the medication should have been destroyed, and documented as such in the EMR and on the narcotic sheet. He acknowledged that there were discrepancies between the narcotic log and MARs. He said that the director of nursing (DON) and SDC assisted with narcotic documentation audits at least once a week. He said that the facility did perform training on medication diversion and how to report medication errors for all nurses. This training documentation was requested at the time of the interview, but was not provided before the survey ended. The SDC nurse was interviewed on [DATE] at 3:32 p.m. She stated that weekly audits were performed for narcotic medication administration. After reviewing the discrepancies she stated, It has been a long time since we've done it. She said that she did not have an explanation for the discrepancies and asked the surveyor to talk to the DON. The DON was interviewed on [DATE] at 4:29 p.m. She stated that she did not have any records showing why the medication discrepancies occurred. She said that the pharmacist that was responsible for providing reconciliation of narcotic medications had just resigned. She said she would reach out to the other pharmacy contact they had and see if they could provide anything, however no documentation was provided before the survey ended.