**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to ensure three (#47, #9 and #42) of five residents were free from chemical restraints were receiving the least restrictive approach for their needs out of 39 sample residents. Specifically, the facility failed to: -Ensure Resident #47 and Resident #9 behavior care plans included resident specific non-pharmacological care approaches;-Document consistent behaviors for Resident #47 and Resident #9 to justify the continued use of psychotropic medications; -Document resident-specific care approaches, to include medication specific target behaviors and person-centered intervention for Resident #47 and Resident #9's psychotropic medications; and,-Ensure gradual dose reductions (GDR) were attempted for Resident #42's psychotropic medications. Findings include: I. Facility policy and procedure The Use Of Psychotropic Medications policy, revised 4/28/25, was provided by the regional clinical resource (RCR) on 7/24/25 at 5:12 p.m. It read in pertinent part, “It is the intent of this policy to ensure that residents only receive psychotropic medications when other nonpharmacological interventions are clinically contraindicated. Additionally, these medications should only be used to treat the resident’s medical symptoms and not used for discipline or staff convenience, which would deem it a chemical restraint. “A psychotropic drug is any drug that affects brain activities associated with mental processes and behavior. Psychotropic drugs include, but are not limited to the following categories: antipsychotics, antidepressants, anti-anxiety, and hypnotics. “The indications for initiating, maintaining, or discontinuing medications(s), as well as the use of non-pharmacological approaches, will be determined by evaluating the resident’s physical, behavioral, mental, and psychosocial signs and symptoms in order to identify and rule out any underlying medical conditions, including the assessment of relative benefits and risks, and the preferences and goals for treatment. “Non-pharmacological approaches must be attempted, unless clinically contraindicated, to minimize the need for psychotropic medications, use the lowest possible dose, or discontinue the medications. “The resident’s response to the medication(s), including progress towards goals and presence/absence of adverse consequences, shall be documented in the resident’s medical record. “Residents who use psychotropic drugs shall receive gradual dose reductions, unless clinically contraindicated, in an effort to discontinue these drugs.” II. Resident #47 A. Resident status Resident #47, age [AGE], was admitted on [DATE]. According to the July 2025 computerized physician orders (CPO), diagnoses included Alzheimer’s disease, anxiety disorder, depression and cognitive communication deficit. The 7/23/25 minimum data set (MDS) assessment revealed the resident was severely cognitively impaired with a brief interview for mental status (BIMS) score of two out of 15. She required set up assistance with eating, was dependent on staff for oral hygiene, toileting, showering, dressing and personal hygiene. The MDS assessment revealed the resident wandered on one to three days and exhibited physical behavioral symptoms, such as hitting, kicking, and pushing, directed toward others during the assessment look back period. B. Record review Resident #47’s dementia care plan, revised 12/30/24, revealed the resident had potential to be physically aggressive related to dementia. Interventions included analyzing times of day, place, circumstances, triggers and what de-escalated the resident’s behavior and documenting, assessing and addressing the resident for contributing sensory deficits, assessing and anticipating residents needs, monitoring any signs and symptoms of the resident posing a danger to self or others, offering ambulation for resident in hallway and redirecting the resident when she appeared to introduce in others’ space. Resident #47’s elopement care plan, revised 10/25/24, revealed the resident was a risk for wandering and elopement related to Alzheimer’s disease. Resident #47 wandered aimlessly, significantly intruding on the privacy or activities of others. -Review of Resident #47’s dementia and elopement care plans revealed there were no person centered non-pharmacological interventions. Review of Resident #47’s July 2025 CPO revealed the following physician’s orders: Ativan (antianxiety medication) 0.5 milligrams (mg). Take 0.25 mg by mouth at bedtime for anxiety, ordered 1/2/25. Ativan 0.25 mg. Take 0.25 mg by mouth in the afternoon for anxiety, ordered 1/2/25. Olanzapine (antipsychotic medication) 10 mg. Take 5 mg by mouth at bedtime for dementia, ordered 7/7/25. Trazodone (antidepressant medication with an off label use for insomnia) 50 mg. Take two tablets by mouth at bedtime for dementia with insomnia, ordered 12/26/24. Trazodone 50 mg. Take 25 mg by mouth twice a day for dementia and anxiety, ordered 1/8/25. Behavior monitoring - anti-depressants. Withdrawn, loss of appetite, crying, lack of interest, apathy, feeling of helplessness, feelings of worthlessness, suicidal ideations or insomnia. Interventions: document in progress note, ordered 3/4/25. Behavior monitoring - anti-anxiety. Document intervention attempted and effectiveness. Target behavior: avoidance and restlessness. Intervention: redirection, one-on-one, activity, low stimulation environment, toileting, offer snack, offer fluid, position change, assess pain or other intervention documented in progress note. Effective yes or no, ordered 3/4/25. -The behavior monitoring physician’s order failed to include Resident #47’s identified behaviors of physical aggression and wandering. -Resident #47’s physician orders did not include behavior monitoring for the resident’s antipsychotic medication. Review of Resident #47’s April 2025 (from 4/1/25 to 4/30/25) medication administration record and treatment administration record (MAR/TAR) revealed there was one incident of anti-depressant behavior documented on 4/9/25. It indicated the resident was withdrawn. -However, there was no documentation to indicate what intervention was offered and if the intervention was effective. The April 2025 MAR/TAR revealed there were two incidents where anti-anxiety behavior was observed for Resident #47 on 4/4/25 and 4/24/25. -However there was no documentation to indicate what behavior was observed, what interventions were offered and if the interventions were effective. -Review of Resident #47’s May 2025 (from 5/1/25 to 5/31/25), June 2025 (from 6/1/25 to 6/30/25) and July 2025 (from 7/1/25 to 7/23/25) MAR/TAR revealed there was no documentation to indicate the had resident exhibited antidepressant, antianxiety or antipsychotic behaviors during the month. -Review of Resident #47’s electronic medical record (EMR) from 4/1/25 to 7/23/25 revealed there was no documentation to indicate the resident exhibited any behaviors, if interventions were offered and if the interventions were effective. III. Resident #9 A. Resident status Resident #9, age [AGE], was admitted on [DATE] . According to the July 2025 CPO, diagnoses included Alzheimer’s disease, rheumatoid arthritis (chronic autoimmune disease attacks the joints), atrial fibrillation (heart beats irregularly and often too fast) and insomnia. The 6/17/25 MDS assessment documented the resident was severely cognitively impaired with a BIMS score of zero out of 15. Resident #9 required set up assistance with eating, partial assistance with oral hygiene and substantial assistance with toileting and personal hygiene. She required a walker and wheelchair. The MDS assessment indicated the resident exhibited verbal behavior directed toward others on one to three days during the assessment look-back period. B. Record review Resident #9’s psychotropic medication care plan, revised 4/18/25, revealed the resident used a psychotropic medication, Risperdal. Interventions included monitoring for effectiveness every shift and monitoring and recording target behavior symptoms including pacing, wandering, disrobing, inappropriate response to verbal communication, violence/aggression towards others and documenting, per facility protocol. Resident #9’s antidepressant medication care plan, revised 3/18/25, revealed the resident used an antidepressant medication, Trazodone. -Review of Resident #9’s psychotropic and antidepressant medication care plans revealed there were no person centered non-pharmacological interventions for the resident’s anti-psychotic and antidepressant medication use. Review of Resident #9’s July 2025 CPO revealed the following physician’s orders: Risperidone (antipsychotic medication) 0.25 mg. Take one tablet by mouth two times a day for Alzheimer’s disease, ordered 7/3/25. Trazodone 50 mg. Take 25 mg by mouth at bedtime for depression, ordered 6/15/25. Behavior monitoring - antidepressants. Withdrawn, loss of appetite, crying, lack of interest, apathy, feeling of helplessness, feelings of worthlessness, suicidal ideations, insomnia. Interventions: document in progress note, ordered 5/11/25. Behavior monitoring - antidepressants. Document interventions attempted and effectiveness. Intervention redirection, one-on-one, diversional activity, offering to call family or friend or other. Effective yes or no, ordered 5/11/25. -There was no physician’s order to monitor for behaviors related to Resident #9’s antipsychotic medications. -Review of Resident #9’s April 2025 (from 4/1/25 to 4/30/25), May 2025 (from 5/1/25 to 5/31/25), June 2025 (from 6/1/25 to 6/30/25) and July 2025 (from 7/1/25 to 7/23/25) MAR/TAR revealed there was no documentation to indicate the resident had exhibited antidepressant or antipsychotic behaviors during the month. The 6/20/25 nurse note revealed Resident #9 was awake and yelling at the top of her voice from 10:30 p.m. to 1:00 a.m. No matter what the staff did for the resident, she was not satisfied. -The progress note failed to include what interventions the staff attempted to use to redirect the resident’s behaviors. The 6/27/25 nurse note revealed the resident was up all day in the common areas for meals and was loud to other residents with unspecific meaning. The resident was easily redirected but only for a short time and then repeated again. -The progress note failed to include what interventions the staff attempted to use to redirect the resident’s behaviors. The 7/2/25 nurse note revealed Resident #9 called out for a specific person’s name after breakfast and was very loud and demanding to go see that person. The resident was redirected without difficulty and was quieter after that. -The progress note failed to include what intervention the staff used to effectively redirect the resident’s behaviors. The 7/19/25 morning nurse note revealed Resident #9 continued to call out “Help” and “I can not do this anymore.” The resident was swearing and disrupting other residents. -The progress note failed to include what interventions the staff attempted to use to redirect the resident’s behaviors. IV. Staff interviews Certified nurse aide (CNA) #2 was interviewed on 7/24/25 at 11:36 a.m. CNA #2 said she knew what behaviors to monitor for residents based on their care plans. CNA #2 said she did not document what interventions were used and if the interventions were effective. She said she was familiar with Resident #47 and Resident #9. She said she did not know of any non-pharmacological interventions to use for Resident #47 or Resident #9’s behaviors. Licensed practical nurse (LPN) #3 was interviewed on 7/24/25 at 3:49 p.m. LPN #3 said she would document if she observed a resident’s behavior. She said she did not document if an intervention was used or if the intervention was effective. LPN #3 said was familiar with Resident #47 and Resident #9. She said the behavior Resident #47 had was pacing. She said she did not know what interventions worked Resident #47’s pacing behavior. During the interview, Resident #9 was yelling off and on in the common area in the secured unit. The resident yelled “I get so scared” and “help.” LPN #3 said the behavior Resident #9 had was being loud and wanting help. She said Risperdal, talking calmly and softly and coloring were effective interventions. She said food was not an effective intervention for the resident. The director of nursing (DON) and regional clinical resource (RCR) were interviewed together on 7/23/25 at 3:39 p.m. The RCR said the interdisciplinary team (IDT) determined what behaviors needed to be monitored for residents and social services was responsible for entering the behavior monitoring in the residents’ chart after the IDT discussion. The RCR said the IDT reviewed the incoming notes from the facility or hospital where the resident transferred from and from the 24-hour communication bar in the medical record. The DON said nursing staff knew what interventions to use for each resident based on the behavior tracking on the residents’ TARs. She said CNAs told the nurses when residents had behaviors. The DON said nursing staff entered a progress note or used the TAR. She said nursing staff should use the TAR and then document a progress note about the behavior. The DON said she knew what interventions worked for residents based on verbal reports from the nursing staff. The DON said if the interventions did not work, she would reach out to the resident’s physician and family. The DON said the residents’ families shared what worked for them. The social services director (SSD) was interviewed on 7/24/25 at 12:34 p.m. The SSD said at admission, she went through the admission paperwork for residents to see if there was any behavior to monitor. She said she knew what interventions to use for a resident because there was an IDT discussion about the behaviors. She said if there was an event where a behavior was exhibited, she worked with the IDT team to find out what triggered the behavior. She said non-pharmacological interventions were used prior to a resident starting a psychotropic medication. She said nursing staff was responsible for documenting if a resident exhibited a behavior, what interventions were used and if the intervention used was effective. She said she was not sure how nursing staff documented residents’ behavior monitoring. The SSD said she was familiar with Resident #9. She said the resident had auditory behaviors because she did not hear well. She said she yelled for her daughter. She said snacks and fluids were interventions that worked for her. -However, according to LPN #3, food was not an effective intervention for Resident #9 (see interview above). The SSD said she was familiar with Resident #47. She said the resident wandered. She said interventions that worked with her were specific redirection like talking to her about her past life, such as where she lived and about her career. The DON and the RCR were interviewed together again on 7/24/25 at 4:27 p.m. The DON said non-pharmacological interventions should be offered when residents’ behaviors were elevated. She said she was familiar with Resident #9 and said she yelled for her daughter. She said interventions that worked for Resident #9 were changing the resident to a different seat at a different table, a one-on-one conversation with the resident, coffee and a snack. -However, according to LPN #3, food was not an effective intervention for Resident #9 (see interview above). The DON and the RCR said the documentation of behavior monitoring, including what interventions to use could use improvement. V. Resident #42 A. Resident status Resident #42, age [AGE], was admitted on [DATE] and readmitted on [DATE]. According to the July 2025 CPO, diagnoses included chronic respiratory failure, dementia, bipolar 2 disorder, borderline personality disorder, generalized anxiety disorder and depressive episodes. The 7/7/25 MDS assessment revealed the resident was cognitively intact with a BIMS score of 13 out of 15. The MDS assessment indicated the resident had delusions. The assessment documented the resident had not had any other behavioral symptoms during the assessment look-back period. The MDS assessment documented a gradual dose reduction (GDR) had been attempted on 9/27/24. The assessment indicated a physician documented a GDR was contraindicated for the resident on 4/28/25. B. Resident interview and observations On 7/21/25 at 10:04 a.m. Resident #42 was talking with her physician in her room. Resident #42 said she did not want to take her Seroquel in the middle of the day because it made her so tired. -The physician’s response was not able to be heard. Resident #42 was interviewed on 7/21/25 at 10:15 a.m. Resident #42 said she had talked with her physician earlier and told them she did not want to be on so many medications because they made her so tired. Resident #42 said her physician told her as long as he was her doctor she had to take all of her medications. Resident #42 said she felt like she was on too many medications. C. Record review The antipsychotic medication care plan, revised 7/14/25, revealed Resident #42 took an antipsychotic medication for her bipolar disorder. Pertinent interventions included administering her medications as ordered and observing for side effects and effectiveness each shift, consulting with the pharmacy and physician to consider dose reduction when clinically appropriate for the resident at least quarterly, and discussing with the physician and family the need for ongoing medication use with the resident. The anxiety care plan, revised 7/12/24, revealed Resident #42 had an anxiety disorder. Pertinent interventions included moving Resident #42 to a calm, safe environment when conflict arose, allowing the resident time to answer questions and verbalize her feelings, and encouraging participation from the resident. The depression care plan, revised 7/14/25, revealed Resident #42 took an antidepressant medication for her depression. Pertinent interventions included administering her medications as ordered and observing for side effects and effectiveness each shift. The bipolar care plan, revised 11/8/24, revealed Resident #42 had bipolar disorder. Pertinent interventions included administering medications as ordered, assisting the resident to develop appropriate methods of coping and interacting, intervening as necessary to protect the rights and safety of others, and observing the resident’s behavioral episodes and attempting to determine their underlying cause. The cognitive care plan, revised 12/10/24, revealed Resident #42 had impaired cognitive function. Pertinent interventions included administering medications as ordered, cueing and reorienting the resident as needed, approaching the resident in a gentle friendly manner, and reviewing the resident’s medications and recording possible causes of cognitive deficits. Review of Resident #42's July 2025 CPO revealed the following physician's orders: Clonazepam 1 mg oral tablet, give one tablet by mouth at bedtime for bipolar disorder, ordered 9/26/24. Clonazepam 1 mg oral tablet, give one tablet by mouth in the afternoon for bipolar disorder, ordered 9/26/24. Clonazepam 1 mg oral tablet, give one tablet by mouth in the morning for bipolar disorder, ordered 9/26/24. Lamotrigine 200 mg oral tablet, give 200 mg by mouth at bedtime for bipolar disorder, ordered 11/21/24. Lamotrigine 200 mg oral tablet, give 200 mg by mouth in the morning for bipolar disorder, ordered 11/21/24. Melatonin 1mg oral capsule, give 1 mg by mouth at bedtime for insomnia, ordered 1/31/25. Seroquel 25 mg oral tablet, give one tablet by mouth in the afternoon for bipolar disorder, ordered 1/1/25 and discontinued 7/17/25. Seroquel 25 mg oral tablet, give one tablet by mouth in the morning for bipolar disorder, ordered 1/1/25 and discontinued 7/17/25. Seroquel 25 mg oral tablet, give one tablet by mouth in the morning for bipolar disorder, ordered 7/17/25. Seroquel 25 mg oral tablet, give one tablet by mouth in the afternoon at 2:00 p.m. for bipolar disorder, ordered 7/17/25. Seroquel 25 mg oral tablet, give four tablets by mouth at bedtime for bipolar disorder, ordered 1/1/25 and discontinued 7/17/25. Seroquel 25 mg oral tablet, give four tablets by mouth at bedtime for bipolar disorder, ordered 7/17/25. Venlafaxine 150 mg extended release oral tablet, give one tablet by mouth in the morning daily with breakfast for bipolar disorder, ordered 9/26/24. Review of Resident #42's MARs and TARs, from 3/1/25 to 7/24/25, revealed the following: The March 2025 (from 3/1/25 to 3/31/25) MAR/TAR revealed there was no documentation to indicate Resident #42 exhibited behaviors during the month. The April 2025 (from 4/1/25 to 4/30/25) MAR/TAR revealed there was no documentation to indicate Resident #42 exhibited behaviors during the month. The May 2025 (from 5/1/25 to 5/31/25) MAR/TAR revealed there was no documentation to indicate Resident #42 exhibited behaviors during the month. The June 2025 (from 6/1/25 to 6/30/25) MAR/TAR revealed there was no documentation to indicate Resident #42 exhibited behaviors during the month. The July 2025 (from 7/1/25 to 7/24/25) MAR/TAR revealed there was no documentation to indicate Resident #42 exhibited behaviors related to anxiety or depression during the month. A psychotropic meeting review form, dated 3/31/25, revealed Resident #42’s psychotropic medications were being reviewed by the medical director, the psychiatrist, the DON, the assistant director of nursing (ADON), the SSD and the NHA. The section on the form that asked if a GDR was contraindicated was marked as not applicable. The committee recommended Resident #42’s Seroquel be increased to 50 mg in the mornings and afternoons and 100 mg in the evenings. The committee further recommended the resident’s venlafaxine be decreased from 150 mg to 75mg. A progress note, dated 4/17/25 at 10:26 a.m., revealed the psychopharmacological medication committee recommended Resident #42’s Seroquel be increased and to decrease her venlafaxine. Resident #42’s physician was aware of the recommendation and was in disagreement with the recommendation. -However, the physician did not document a rationale for why changing Resident #42’s medications would not be recommended. The May 2025 pharmacy medication regiment review revealed Resident #42 was due for a GDR on her psychotropic medications. The pharmacy review documented if a GDR was contraindicated, the pharmacist recommended the physician document it as such in Resident #42’s EMR. A physician’s progress note, dated 5/30/25 at 5:45 p.m., revealed it was contraindicated for Resident #42 to undergo a GDR at that time as the resident was on the lowest effective dose of her medications for adequate symptom management. The note further documented that attempting a GDR at that time would place Resident #42 at high risk for symptoms decompensating to unmanageable levels. A psychotropic meeting review form, dated 6/30/25, revealed Resident #42’s psychotropic medications were being reviewed. The section on the form that asked if a GDR was contraindicated was marked as not applicable. The committee recommended Resident #42’s medications go unchanged and a GDR contraindication was signed by her physician. -However, the physician did not document a rationale for why changing Resident #42’s medications would not be recommended. A psychiatric follow-up note, dated 7/15/25 at 8:00 a.m., revealed Resident #42’s medications were reviewed by her physician. Resident #42 said she would like to GDR her Seroquel, and the physician recommended discussing her medications at the next psychopharmacological medication meeting. -However, according to Resident #42, the physician told her she had to take all of her medications (see resident interview above). D. Staff interviews The DON and the RCR were interviewed together on 7/24/25 at 2:42 p.m. The DON said for psychotropic medications, the nursing staff monitored the residents for side effects and efficacy. The DON said the IDT spoke about residents’ medication regimens during their psychopharmacological medication meetings. The DON said the pharmacy sent the facility recommendations and recommended GDRs and the physician would fill out risk/benefit forms as needed. The DON said Resident #42’s last GDR attempt was on 3/31/25. The DON said the facility attempted to GDR psychotropic medications every three months. The RCR said Resident #42’s venlafaxine was decreased from 150 mg to 75 mg per day on 3/31/25. -However, the decrease of the resident’s venlafaxine was the recommendation made by the psychopharmacological medication committee to the physician on 3/31/25, but the physician disagreed with the recommendation and the resident’s medication was not decreased (see record review above). The DON was interviewed a second time on 7/24/25 at 4:54 p.m. The DON said she found a progress note that documented Resident #42’s physician disagreed with the GDR recommended by the psychopharmacological medication committee on 3/31/25. The DON said Resident #42’s physician did not fill out any documentation to indicate the rationale for not changing the resident’s recommendations.

Based on observations, record review and interviews, the facility failed to ensure residents who were unable to carry out activities of daily living (ADLs) received the necessary services to assistance items for one (#49) of two residents reviewed for ADLs out of 39 sample residents. Specifically, the facility failed to ensure Resident #49, who was dependent on staff for care, received her preferred communication device during ADLs. Findings include: I. Resident #49A. Resident statusResident #49, age less than 65, was admitted prior to 2020. According to the July 2025 computerized physician orders (CPO), diagnoses included paraplegia (paralysis of the lower half of the body including the legs and sometimes the abdomen), muscle weakness, dysphagia (difficulty swallowing) and aphasia (difficulty speaking). The 5/8/25 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. She was dependent on staff assistance for toileting hygiene, upper and lower body dressing, rolling, sitting to lying and lying to sitting, chair to bed transfers and toilet transfers. The resident was non ambulatory and was dependent on the use of a manual highback wheelchair.The MDS assessment indicated the resident used communication devices. B. Resident interview and observationsResident #49 was interviewed via her tablet on 7/21/25 at 3:46 p.m. Resident #49 said she used a communication board. She said the staff never gave her the communication board and she said that violated her rights. She said she could use her tablet but the typing took her longer. The resident's communication board was in a basket on top of her dresser and was not within reach for the resident.C. Resident observation During a continuous observation on 4/22/25, beginning at 8:30 a.m. and ending at 12:49 p.m., the following was observed:At 9:10 a.m. certified nurse aide (CNA) #1 entered Resident #49's room to inform her it was her shower day and she would come back later to give her her shower. CNA #1 did not utilize the communication device or offer it to the resident for use. At 9:45 a.m. CNA #1 assisted Resident #49 into the shower room. CNA #1 asked the resident to let her know if the water was too warm during her shower. The resident did not have a communication device in hand to inform CNA #1 if the resident was too warm or too cold. At 9:58 a.m. Resident #49 was assisted back to her room. CNA #1 told the resident she had to obtain the Hoyer lift (mechanical lift) to transfer her back to bed. At 10:02 a.m. CNA #3 entered Resident #49's room to assist CNA #1 with putting Resident #49 in her wheelchair. She was not provided the communication boardAt 10:16 a.m. CNA #1 asked Resident #49 what she wanted to wear. Resident #49 responded by nodding her head. -CNA #1 did not provide Resident #49 with a communication device. At 10:20 a.m. CNA #1 asked Resident #49 which color hair accessories she wanted. Resident nodded her head, CNA #1 picked a color. CNA #1 and asked what color glasses she wanted to wear. The resident nodded her head, CNA #1 picked a pair of glasses. -CNA #1 did not provide Resident #49 with a communication device. At 10:28 a.m. Resident #49 requested her tablet by pointing at it. CNA #1 gave her her tablet. CNA #1 did not offer her the communication board. At 10:57 a.m. all the staff left the room without giving Resident #49 her communication board. At 11:30 a.m. The resident was observed sitting in her wheelchair in her room watching television. Her communication board was observed on top of her dresser. At 12:30 a.m. The resident was sitting in her wheelchair in her room watching television. CNA #1 asked the resident if she needed anything. The resident did not respond. Her communication board was on top of her dresser. D. Record reviewThe care plan dated 10/21/15 identified the resident required substantial/maximal assistance with shower/bathing, and her preferred communication method was her tablet and communication board. Pertinent interventions included the resident requiring a communication board to communicate, ensuring the availability and functioning of adaptive communication equipment, the resident communicated well through email (initiated 10/21/15), evaluating the resident's dexterity/ability to use communication board,writing, use computer or use of sign language as alternate communication to speech (initiated 10/21/15), ensuring her adaptive equipment was provided, present, and functional including wheelchair and communication board (date initiated 9/26/23).II. Staff interviews CNA #3 was interviewed on 7/22/25 at 2:30 p.m. CNA #3 said she did not know how to communicate with Resident #49 and relied on the assistance of other staff. CNA #3 said she had not received any education from the facility about how to communicate with Resident #49. CNA #3 said Resident #49 has had a tablet that she used to play games on but did not use it to communicate with the nursing staff.CNA #1 was interviewed on 7/23/25 at 2:00 p.m. CNA #1 said the resident liked to use her tablet to communicate with the staff. CNA #1 said she only used yes or no questions when communicating with the resident. -However CNA #1 was observed using open ended questions regarding clothing choices and did not offer the resident her communication devices to reply to her questions (see observations above). Registered nurse (RN) #1 was interviewed on 7/22/25 at 2:00 p.m. RN #1 said there was no preferred communication method for Resident #49. RN #1 said she did not really communicate with Resident #49 because she just administered medications. RN #1 said there was no communication method in the resident medical record listed or her care plan. -However the residents comprehensive care plan indicated the resident preferred communication method was her tablet and communication board (see above). The director of nursing (DON) was interviewed on 7/23/25 at 1:15 p.m. The DON said Resident #49 had a tablet and a communication board available for the staff to use. She said the staff needed to use Resident #49's preferred communication device. The DON said the communication devices were listed on her care plan so that all staff were aware of how to properly communicate with Resident #49.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interviews, the facility failed to ensure residents received care consistent with professional standards of practice to prevent pressure injuries from occurring or worsening for one (#14) of four residents reviewed out of 39 sample residents. Specifically, the facility failed to ensure staff provided consistent interventions to Resident #14, who had a pressure ulcer.Findings include:I. Professional reference According to the National Pressure Injury Advisory Panel, European Pressure Injury Advisory Panel and Pan Pacific Pressure Injury Alliance Prevention and Treatment of Pressure Injuries: Clinical Practice Guideline, third edition, [NAME] Haesler (Ed.), EPUAP/NPIAP/PPPIA (2019), retrieved on 7/29/25 from https://www.internationalguideline.com/guideline, Pressure ulcer classification is as follows:Category/Stage 1: Nonblanchable Erythema (discoloration of the skin that does not turn white when pressed, early sign of tissue damage)Intact skin with nonblanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have visible blanching; its color may differ from the surrounding area. The area may be painful, firm, soft, warmer or cooler as compared to adjacent tissue. Category/Stage 1 may be difficult to detect in individuals with dark skin tones. May indicate at risk individuals (a heralding sign of risk).Category/Stage 2: Partial Thickness Skin LossPartial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum filled blister. Presents as a shiny or dry shallow ulcer without slough or bruising. This Category/Stage should not be used to describe skin tears, tape burns, perineal dermatitis, maceration or excoriation.Category/Stage 3: Full Thickness Skin LossFull thickness tissue loss. Subcutaneous fat may be visible, but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. The depth of a Category/ Stage 3 pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have subcutaneous tissue and Category/ Stage 3 ulcers can be shallow. In contrast, areas of significant adiposity can develop extremely deep Category/Stage 3 pressure ulcers. Bone/tendon is not visible or directly palpable.Category/Stage 4: Full Thickness Tissue LossFull thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often include undermining and tunneling. The depth of a Category/Stage 4 pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have subcutaneous tissue and these ulcers can be shallow. Category/ Stage 4 ulcers can extend into muscle and/ or supporting structures (fascia, tendon or joint capsule) making osteomyelitis possible. Exposed bone/tendon is visible or directly palpableUnstageable: Depth UnknownFull thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed. Until enough slough and/or eschar is removed to expose the base of the wound, the true depth, and therefore Category/ Stage, cannot be determined. Stable (dry, adherent, intact without erythema or fluctuance) eschar on the heels serves as the body's natural (biological) cover' and should not be removed.Suspected Deep Tissue Injury: Depth UnknownPurple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. Deep tissue injury may be difficult to detect in individuals with dark skin tones. Evolution may include a thin blister over a dark wound bed. The wound may further evolve and become covered by thin eschar. Evolution may be rapid, exposing additional layers of tissue even with optimal treatment.III. Resident #14A. Resident statusResident #14, age less than 65, was admitted on [DATE]. According to the July 2025 computerized physician orders (CPO), diagnoses included spinal stenosis (a condition where the spaces within the spinal canal narrow, putting pressure on the spinal cord and nerve roots), cerebral infarction (stroke), chronic pain and generalized muscle weakness. The 6/9/25 minimum data set (MDS) assessment revealed the resident was moderately cognitively impaired with a brief interview for mental status (BIMS) score of nine out of 15. The resident was dependent on staff for most activities of daily living (ADL). The assessment documented the resident was dependent on staff for rolling left and right in bed.The assessment indicated the resident was at risk of developing pressure ulcers. The assessment indicated the resident had a stage three pressure ulcer. The assessment indicated the resident was not on a turning or repositioning program.B. ObservationsDuring a continuous observation on 7/22/25, beginning at 1:19 p.m. and ending at 5:03 p.m., the following was observed:At 1:19 p.m. Resident #14 was lying on his air mattress on his back with his weight shifted partially to his right side. A pillow was placed under his left side and his legs were curled in slightly.At 2:46 p.m. the resident aide stepped into Resident #14's room briefly before retrieving an item from the nurses' station for Resident #14. The resident aide left the room immediately afterward. Resident #14 was lying in the same position.At 3:49 p.m. licensed practical nurse (LPN) #4 entered Resident #14's room to pass medications to the resident's roommate. Resident #14 was still lying partially on his right side with a pillow under his left side with his legs curled in slightly. LPN #4 left the room within three minutes of entering it and did not engage with Resident #14.At 4:01 p.m. certified nurse aide (CNA) #3 entered Resident #14's room and closed the door.At 4:02 p.m. CNA #3 left Resident #14's room. Resident #14 continued to lie partially on his right side with the pillow under his left side.-CNA #3 did not attempt to reposition Resident #14 during this time (see interviews below).At 4:35 p.m. Resident #14 continued lying partially on his right side with the pillow under his left side.At 5:03 p.m. CNA #3 entered Resident #14's room, removed the pillow from below the resident's left side and pulled Resident #14's body to the side slightly so he was lying completely flat. CNA #3 adjusted Resident #14's bed so he was sitting upright and prepared his bedside table to make room for his dinner tray.-Resident #14 was lying in the same position for almost four hours during the continuous observation.On 7/23/25 at 12:55 p.m. Resident #14's pressure injury was observed with LPN #6. The skin on Resident #14's coccyx was pink, intact and non-blanchable. Resident #14 did not express pain while Resident #14 applied the topical Triad cream.At 1:21 p.m. Resident #14 was lying in bed on his back with his weight shifted slightly to the right. Resident #14's legs were curled slightly inward and he had a pillow between his legs at his heels.C. Record reviewThe skin impairment care plan, initiated 12/27/24 and revised 6/11/25, revealed Resident #14 had potential impairments to skin integrity and had a stage three pressure injury to his coccyx. Interventions implemented on 12/27/24 included ensuring good nutrition and hydration, following facility protocols for treatment of injuries, identifying and documenting potential causative factors and eliminating them where possible and using caution during resident transfers. Interventions initiated on 5/12/25 included Resident #14 not wearing a brief while in bed.-The care plan did not include an intervention for frequent turning and repositioning of the resident.The ADL care plan, revised 12/27/24, revealed Resident #14 had an ADL self-care performance deficit. Pertinent interventions included ensuring Resident #14's air mattress was inflated and functioning. The care plan documented Resident #14 was totally dependent on staff for bed mobility and used a hoyer lift for transfers.Review of Resident #14's July 2025 CPO revealed the following physician's orders:Treatment to coccyx and left buttocks: clean with wound cleanser, pat dry, and apply Triad cream, ordered 7/1/25.ProSource oral liquid nutritional supplement, instructions to give 30 milliliters (ml) by mouth two times daily, ordered 7/3/25 and revised 7/17/25.Ensure air mattress is inflated and functioning with weight set at 200 to 210 lbs (pounds), ordered 4/10/25.No brief while in bed, only chux pads (incontinence pad), ordered 1/5/25.A Braden scale (pressure sore assessment risk) assessment, dated 3/11/25, revealed Resident #14 was at moderate risk for pressure ulcers with a score of 13 out of 18.A Braden scale assessment, dated 6/7/25, revealed Resident #14 was at risk for pressure ulcers with a score of 14 out of 18.A progress note, dated 5/6/25 at 8:49 a.m., revealed the wound care physician (WCP) found a stage three pressure injury on Resident #14's coccyx during wound rounds that day. The wound was cleansed and dressed and all responsible parties were notified.An interdisciplinary team (IDT) note, dated 5/7/25 at 7:31 p.m., revealed Resident #14 had a new pressure injury as of 5/6/25. The root cause was Resident #14 refusing to be repositioned at times due to the resident enjoying watching his television (TV). Treatments put into place included cleansing the wound with wound cleanser, patting dry, applying skin prep to the peri-wound area, applying a honey-based gel to the wound bed, and covering with border foam. Interventions put into place included Resident #14 not wearing a brief while in bed. The WCP visit note, dated 5/26/25, revealed Resident #14's coccyx wound was a stage three pressure ulcer. The wound measured 0.1 centimeters (cm) in length, 0.1cm in width and 0.1 cm in depth. Previous measurements, taken 5/12/25, revealed the wound had measured 0.3 cm in length, 0.3 cm in width and 0.1cm in depth. The wound bed was 50% granulation (new connective tissue and microscopic blood vessels that form on the surfaces of a wound during the healing process) and 50% epithelialization (a crucial part of wound healing, allowing the body to repair and close wounds by forming a new layer of skin or tissue). The wound was improving. Orders included cleansing the wound with wound cleanser, protecting the peri-wound skin with skin protectant, applying a honey-based gel to the wound bed and applying bordered foam three times per week and as needed. Additional orders included turning and repositioning Resident #14 frequently while he was in bed or in his chair and shifting his weight frequently.-However, observations revealed staff did not reposition Resident #14 for nearly four hours on 7/22/25 (see observations above).The WCP visit note, dated 6/2/25, revealed Resident #14 had a stage three pressure ulcer to the coccyx and moisture-associated skin damage (MASD) to the sacrum. The coccyx wound measured 0.1 cm in length, 0.1cm in width and 0.1 cm in depth. The wound bed was 90% granulation and 10% slough (a type of tissue that is not actively healing and can delay the wound healing process and typically appears as yellow or white, soft, and moist material in the wound bed). There was no change noted in the wound progression. The peri-wound area exhibited maceration (a condition where the skin becomes soft, white, and wrinkled due to prolonged exposure to moisture). Orders included cleansing the wound with wound cleanser and applying Triad cream twice per day and as needed. Additional orders included turning and repositioning Resident #14 frequently while he was in bed or in his chair and shifting his weight frequently.-However, observations revealed staff did not reposition Resident #14 for nearly four hours on 7/22/25 (see observations above). The WCP visit note, dated 6/9/25, revealed Resident #14 had a stage three pressure ulcer to the coccyx and MASD to the sacrum. The coccyx wound measured 0.1 cm in length, 0.1cm in width and 0.1 cm in depth. The wound bed was 90% granulation and 10% slough. There was no change noted in the wound progression. Orders included cleansing the wound with wound cleanser and applying Triad cream twice per day and as needed. Additional orders included turning and repositioning Resident #14 frequently while he was in bed or in his chair and shifting his weight frequently.-However, observations revealed staff did not reposition Resident #14 for nearly four hours on 7/22/25 (see observations above). The WCP visit note, dated 6/16/25, revealed Resident #14 had a stage three pressure ulcer to the coccyx and MASD to the sacrum. The coccyx wound measured 0.1 cm in length, 0.1cm in width and 0.1 cm in depth. The wound bed was 50% granulation and 50% epithelialization. There was no change noted in the wound progression. The peri-wound area exhibited maceration. Orders included cleansing the wound with wound cleanser and applying Triad cream twice per day and as needed. Additional orders included turning and repositioning Resident #14 frequently while he was in bed or in his chair and shifting his weight frequently. -However, observations revealed staff did not reposition Resident #14 for nearly four hours on 7/22/25 (see observations above).The WCP visit note, dated 6/23/25, revealed Resident #14 had a stage three pressure ulcer to the coccyx. The coccyx wound measured 0.2 cm in length, 0.2 cm in width and 0.3 cm in depth. There was a small amount of serous drainage (a thin, watery fluid, typically clear or pale yellow, that is a normal part of the wound healing process) noted. The wound bed was 100% epithelialization. The wound was deteriorating. Orders included cleansing the wound with wound cleanser and protecting the peri-wound area with skin protectant, packing the wound with iodoform packing and applying bordered gauze to the wound every day and as needed. Additional orders included turning and repositioning Resident #14 frequently while he was in bed or in his chair and shifting his weight frequently. -However, observations revealed staff did not reposition Resident #14 for nearly four hours on 7/22/25 (see observations above).The WCP visit note, dated 6/30/25, revealed Resident #14 had a stage three pressure ulcer to the coccyx and MASD to the left buttock. The coccyx wound measured 0.2 cm in length, 0.2 cm in width and 0.3 cm in depth. There was a small amount of serous drainage noted. The wound bed was 80% granulation and 20% epithelialization. The peri-wound skin exhibited maceration. There was no change noted in the wound progression. Orders included cleansing the wound with wound cleanser and applying Triad cream twice per day and as needed. Additional orders included turning and repositioning Resident #14 frequently while he was in bed or in his chair and shifting his weight frequently. -However, observations revealed staff did not reposition Resident #14 for nearly four hours on 7/22/25 (see observations above).The WCP visit note, dated 7/7/25, revealed Resident #14 had a stage three pressure ulcer to the coccyx and MASD to the left buttock. The coccyx wound measured 1.0 cm in length, 1.0 cm in width and 0.5 cm in depth. There was a small amount of serous drainage noted. The wound bed was 50% granulation and 50% epithelialization. The wound was deteriorating. Orders included cleansing the wound with wound cleanser and applying Triad cream twice per day and as needed. Additional orders included turning and repositioning Resident #14 frequently while he was in bed or in his chair and shifting his weight frequently. -However, observations revealed staff did not reposition Resident #14 for nearly four hours on 7/22/25 (see observations above).The WCP visit note, dated 7/14/25, revealed Resident #14 had a stage three pressure ulcer to the coccyx and MASD to the left buttock. The coccyx wound measured 1.0 cm in length, 1.0 cm in width and 0.5 cm in depth. The wound bed was 100% epithelialization. There was no change noted in the wound progression. The peri-wound skin exhibited maceration. Orders included cleansing the wound with wound cleanser and applying Triad cream twice per day and as needed. Additional orders included turning and repositioning Resident #14 frequently while he was in bed or in his chair and shifting his weight frequently. -However, observations revealed staff did not reposition Resident #14 for nearly four hours on 7/22/25 (see observations above).The WCP visit note, dated 7/21/25, revealed Resident #14 had a stage three pressure ulcer to the coccyx and MASD to the left buttock. The coccyx wound measured 1.0 cm in length, 1.0 cm in width and 0.5 cm in depth. The wound bed was 100% epithelialization. There was no change noted in the wound progression. The peri-wound skin exhibited maceration. Orders included cleansing the wound with wound cleanser and applying Triad cream twice per day and as needed. Additional orders included turning and repositioning Resident #14 frequently while he was in bed or in his chair and shifting his weight frequently. -However, observations revealed staff did not reposition Resident #14 for nearly four hours on 7/22/25 (see observations above).Review of the CNA repositioning task records,from 6/25/25 through 7/24/25, revealed there were no refusals of repositioning documented for Resident #14 during the time period.IV. Staff interviewsCNA #3 was interviewed on 7/22/25 at 5:08 p.m. CNA #3 said she had entered Resident #14's room earlier that evening only to empty his catheter bag, as she had changed his brief earlier that day. CNA #3 said she had only emptied Resident #14's catheter bag and had not provided or attempted to provide any other care.CNA #1 was interviewed on 7/23/25 at 2:10 p.m. CNA #1 said Resident #14 was in pain. CNA #1 said Resident #14 was supposed to be up for every meal, so they assisted him up and into the dining room. CNA #1 said the nursing staff went in and repositioned Resident #14 every two to two and a half hours. CNA #1 said Resident #14 could move slightly and wiggle his limbs but could not fully reposition himself onto his side.-However, observations revealed staff did not reposition Resident #14 for nearly four hours on 7/22/25 (see observations above).CNA #1 said Resident #14 previously had a bad sore on his coccyx but it had gotten a lot better. CNA #1 said whenever the nursing staff went into Resident #14's room they also checked his incontinence brief. CNA #1 said they did not use an incontinence brief when Resident #14 was in bed when Resident #14 had the wound on his coccyx, but now the wound was better so he was able to wear a brief throughout the night.-However, the physician's order to not have Resident #14 wear briefs while in bed was in place as of 1/5/25 (see physician's orders above).CNA #4 was interviewed on 7/23/25 at 2:56 p.m. CNA #4 said Resident #14 was supposed to be up and out of bed for every meal. CNA #4 said Resident #14 was in pain all the time and it did not improve unless he was up. CNA #4 said Resident #14's bottom was raw and bled sometimes, but was not doing so as much as it used to. CNA #4 said she took Resident #14's brief off whenever he was in bed. CNA #4 said she applied Triad cream to his bottom whenever it was bleeding. CNA #4 said she was not sure if she was supposed to do that or if the nurses were supposed to do that, but Resident #14's bottom was dry and bleeding so she applied the Triad cream. CNA #4 said Resident #14 was not able to turn over on his own, so the nursing staff turned and repositioned him every two hours. CNA #4 said the nursing staff tried to put pillows under Resident #14 but he just fell back over, so he mostly laid on his back. CNA #4 said when the wound on Resident #14's bottom was bad he would fall back onto the wedge pillows and it looked as if he was never moved.Registered nurse (RN) #1 was interviewed on 7/24/25 at 9:06 a.m. RN #1 said Resident #14 liked to lean to the right and was supposed to be repositioned every few hours. RN #1 said repositioning residents every two hours redistributed their body weight. RN #1 said Resident #14 was not very mobile, so he would lie on his back all day if not repositioned by the nursing staff.-However, observations revealed staff did not reposition Resident #14 for nearly four hours on 7/22/25 (see observations above).LPN #5 was interviewed on 7/24/25 at 9:46 a.m. LPN #5 said the nursing staff were supposed to turn and reposition Resident #14 every two hours since he could not reposition himself. LPN #5 said Resident #14 did not have any skin issues that she knew of, but knew she applied cream to his hips. LPN #5 said repositioning Resident #14 changed the location of the pressure on his body so he would not get pressure ulcers.The WCP was interviewed on 7/24/25. The WCP said he did not have an exact timeframe for repositioning or turning frequency but said Resident #14 needed to be turned or repositioned at least every three hours. The WCP said Resident #14 had had wounds on and off since he started working at the facility. The WCP said the facility's interventions for Resident #14 included using Triad cream, as there were some macerations around his buttocks. The WCP said the facility staff had been turning Resident #14 and had been using wedge pillows, which were important to reduce heat and pressure on the skin. The WCP said sweat was a contributing factor for the wounds Resident #14 had at the time. The WCP said the nursing staff also used pillows between Resident #14's legs for comfort and positioning.-However, Resident #14 was not observed using wedge pillows during the survey process.The director of nursing (DON) was interviewed on 7/24/25 at 2:42 p.m. The DON said Resident #14 had a stage three pressure ulcer to his coccyx and MASD to his left buttock. The DON said the pressure ulcer on Resident #14's coccyx was first noted on 5/5/25. The DON said Resident #14's interventions at the time included using an air mattress and not wearing a brief in bed. The DON said she thought Resident #14 was also on a program for frequent turning/repositioning at the time but she was not sure. -However, observations revealed staff did not reposition Resident #14 for nearly four hours on 7/22/25 (see observations above) and the care plan did not indicate the resident was on a turning/repositioning program (see record review above).The DON said Resident #14 was assessed to be at moderate risk for developing pressure ulcers on 3/11/25. The DON said Resident #14 was limited in his ability to self-reposition and could not roll onto his side independently but could move his arms and legs and readjust himself. The DON said Resident #14 was currently receiving the ProSource nutritional supplement twice a day and was being seen by the WCP. The DON said she thought Resident #14 was on a repositioning program but said she could not find any information about it in his electronic medical record (EMR). The DON said Resident #14 had been refusing repositioning, and refusal notes would be in his EMR.-However, review of Resident #14's EMR did not reveal any documentation about him refusing repositioning.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to ensure residents with limited mobility received appropriate services, equipment, and assistance to maintain or improve mobility for one (#18) of two residents reviewed for mobility out of 39 sample residents. Specifically, the facility failed to ensure Resident #18's hand splint was applied as ordered to help maintain the resident's limb function and mobility.Findings include:I. Facility policy and procedureThe Prevention of Decline in Range of Motion policy and procedure, undated, was provided by the regional clinical resource (RCR) on 7/24/25 at 5:21 p.m. It read in pertinent part, The facility will provide treatment and care in accordance with professional standards of practice. This includes appropriate equipment, including braces or splints. A nurse with responsibility for the resident will monitor for consistent implementation of the care plan interventions. Refusals of care or problems associated with range of motion exercises will be documented in the medical record.II. Resident #4A. Resident statusResident #18, age [AGE], was admitted on [DATE] and readmitted on [DATE]. According to the July 2025 computerized physician orders (CPO), diagnoses included hemiplegia (weakness on one side of the body) and hemiparesis (paralysis on one side of the body), wound on the right ankle, contracture of muscles on the right lower leg, gait and mobility abnormalities and generalized muscle weakness.The 7/9/25 minimum data set (MDS) assessment revealed the resident was severely cognitively impaired with a brief interview for mental status (BIMS) score of four out of 15. The resident was dependent on staff for most activities of daily living (ADL).B. Resident interview and observationsResident #18 was interviewed on 7/21/25 at 10:46 a.m. Resident #18 said he did not wear a splint for his hand. Resident #18's right hand had several fingers that were contracted and pointing downward.On 7/22/25 at 11:25 a.m. Resident #18 was sitting in his wheelchair in his room. Resident #18's right hand was contracted and resting in his lap. Resident #18 was not wearing a splint on his right hand.At 11:57 a.m. licensed practical nurse (LPN) #4 left Resident #18's room after applying a dressing to his right ankle. -However, LPN #4 did not apply a splint to Resident #18's right hand.At 11:59 a.m. Resident #18 was sitting in his wheelchair in his room. Resident #18's right hand was contracted and resting in his lap. Resident #18 was not wearing a splint on his right hand. Certified nurse aide (CNA) #3 entered Resident #18's room and gave him his lunch tray but did not apply a splint to the resident's hand.At 1:20 p.m. Resident #18 was sitting in his wheelchair in his room. Resident #18's right hand was contracted and resting in his lap. Resident #18 was not wearing a splint on his right hand.At 3:25 p.m. Resident #18 was lying on his bed on his back. Resident #18 was not wearing a splint on his right hand.On 7/23/25 at 8:26 a.m. Resident #18 was sitting in his wheelchair in his room. Resident #18's right hand was contracted and resting in his lap. Resident #18 was not wearing a splint on his right hand.At 1:10 p.m. Resident #18 was sitting in his wheelchair in his room. Resident #18's right hand was contracted and resting in his lap. Resident #18 was not wearing a splint on his right hand.At 1:35 p.m. Resident #18 was lying on his back in bed. Resident #18 was not wearing a splint on his right hand.On 7/24/25 at 8:39 a.m. Resident #18 was sitting in his wheelchair in his room. Resident #18's right hand was contracted and resting in his lap. Resident #18 was not wearing a splint on his right hand.On 7/24/25 at 9:55 a.m. LPN #5 entered Resident #18's room and asked him if he had a splint for his right hand, to which Resident #18 said he did. LPN #5 found a splint on Resident #18's bedside table and applied it to the resident's right hand.C. Record reviewReview of the comprehensive care plan, revised 7/22/25, did not reveal any care plan focus regarding Resident #18's hand contractures or therapeutic devices.Review of Resident #18's July 2025 CPO revealed the following physician's orders:Apply right upper extremity wrist cockup splint (a type of orthotic device designed to immobilize and support the wrist in a slightly extended (or cocked-up) position) and c-grip (a type of hand splint designed to support the wrist and encourage finger extension, particularly for managing contractures) hand splint daily as tolerated per restorative therapy, ordered 9/27/22. Resident will don (put on) right resting hand splint as tolerated per restorative, along with skin checks, sensation and movement, ordered 10/3/24.Review of the splint task documentation, which documented the amount of minutes Resident #18's splint was applied, revealed the resident wore his splint for 240 minutes on 7/24/25 (during the survey process). -However, there was no documentation to indicate Resident #18 had worn his splint from 6/24/25 through 7/23/25.D. Staff interviewsCNA #1 was interviewed on 7/23/25 at 2:10 p.m. CNA #1 said Resident #18 did not have any splints for his hands that she had seen.CNA #4 was interviewed on 7/23/25 at 2:56 p.m. CNA #4 said Resident #18 got out of bed first thing in the mornings and sat in his chair from morning until after lunch. CNA #4 said she did not think Resident #18 used any splints or restorative devices for his hands. CNA #4 said she thought she saw a splint for Resident #18's wrist at one point, but she said she was not told to do any restorative care for him. CNA #4 said if Resident #18 refused his splint, she would tell the nurse about the refusal.Occupational therapist (OT) #1 was interviewed on 7/23/25 at 3:45 p.m. OT #1 said Resident #18 was no longer on the occupational therapy caseload and was discharged from therapy on 1/10/25. OT #1 said Resident #18 had been on the therapy caseload for upper extremity management. OT #1 said Resident #18 had a resting hand splint with orders for the splint to be applied in his electronic medical record (EMR). OT #1 said Resident #18 was a little bit resistant to the resting hand splint and he was able to say whether he wanted the splint on or off. OT #1 said the resting hand splint was to maintain the functional grasp for his right hand for tasks, such as self-feeding or holding objects and to prevent further contracture of his hand. OT #1 said Resident #18 was not able to apply his resting hand splint himself and needed staff to do so for him. OT #1 said Resident #18's hand splint would be kept in his room. OT #1 said the nursing staff should have offered to apply Resident #18's hand splint for him. She said she had educated the nursing staff on applying the hand splint. OT #1 said the CNAs knew how to apply Resident #18's hand splint and should document his refusals.Registered nurse (RN) #1 was interviewed on 7/24/25 at 9:06 a.m. RN #1 said the therapy team left the nursing staff notes that indicated they needed to use a splint for residents with contractures. RN #1 said residents' splints were kept in their rooms. RN #1 said the nurses needed to make sure they followed the orders in the residents' CPO for when they needed to apply or take off the splints. She said hand splint application was typically marked in the treatment administration record (TAR).LPN #5 was interviewed on 7/24/25 at 9:46 a.m. LPN #5 said she had not seen Resident #18 wearing any splints. LPN #5 said she did not think Resident #18 would have enough nobility to don a hand splint by himself. LPN #5 said the CNAs applied residents' splints if they had them. LPN #5 said if Resident #18 refused any of his treatments she would mark the refusal in the TAR.LPN #5 was interviewed a second time on 7/24/25 at 9:55 a.m., after assisting Resident #18 with his splint (see observation above). LPN #5 said she usually checked to see if residents were wearing their braces or splints. LPN #5 said she had no idea Resident #18 had a splint and had never seen him wear it. The director of nursing (DON) was interviewed on 7/24/25 at 2:42 p.m. The DON said Resident #18 had a splint he wore on his right hand. The DON said the nursing staff should have been offering Resident #18 his splint each shift. The DON said Resident #18 could not don his splint by himself. The DON said offering of the splint and any resident refusals should have been documented in Resident #4's TAR or progress notes.-However, Resident #18 was not observed wearing a splint on his right hand during the survey period (see observations above).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interviews, the facility failed to ensure residents with indwelling catheters received the appropriate care and services according to professional standards for one (#7) of three residents reviewed for catheter care out of 39 sample residents.Specifically, the facility failed to:-Use privacy bag for Resident #7's catheter drainage bag;-Ensure Resident #7's catheter was placed appropriately to ensure the urine could flow freely; -Ensure Resident #7's catheter bag was emptied timely; and,-Consistently monitor Resident #7's intake and output per physician's orders. Findings include: I. Facility policy and procedure The Catheter Care policy and procedure, implemented 5/24/25, was provided by the regional clinical resource (RCR) on 7/24/25 at 9:11 a.m. It read in pertinent part, It is the policy of this facility to ensure that residents with indwelling catheters receive appropriate catheter care and maintain their dignity and privacy when indwelling catheters are in use. Catheter care will be performed every shift and as needed by nursing personnel. Privacy bags will be available and catheter drainage bags will be covered at all times while in use. Privacy bags will be changed out when soiled, with a catheter change or as needed. Empty drainage bags when bag is half-full or every three to six hours. Ensure drainage bag is located below the level of the bladder to discourage backflow of urine. Document care and report any concerns noted to the nurse on duty. IlI. Resident #7A. Resident statusResident #7, age greater than 65, was admitted on [DATE]. According to the July 2025 computerized physician orders (CPO), diagnoses included type 2 diabetes mellitus, urinary tract infection (UTI), and obstructive and reflux uropathy (a condition where urine flow is blocked and urine flows backward from the bladder into the kidneys).The 6/23/25 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. He was dependent with toileting hygiene, bathing/showers, lower body dressing, personal hygiene and bed to chair transfers. He was non ambulatory and used a wheelchair for mobility.The MDS assessment indicated he had an indwelling catheter and was always incontinent of bowel and bladder.B. Resident interview and observationsResident #7 was interviewed on 7/21/25 at 1:48 p.m. Resident #7 said he had penis pain around his catheter insertion site. Resident #7 said he told the staff today (7/21/25) and they should be taking care of it. Resident #7 said he got the catheter put in while he was at the hospital prior to admission. Resident #7 said he was trying to increase his intake of water because he had been told he was dehydrated. During the interview the resident's catheter bag was hooked to the side of his bed. Resident #7 was interviewed on 7/22/25 at 3:15 p.m. Resident #7 said that his pain was much better and mostly gone today. He said the UTI medication was working. Resident #7 was resting comfortably in his bed and the catheter bag was hanging on the side of the bed. Resident #7 said the care staff had not emptied his catheter bag yet today. The resident's catheter bag was full or urine. On 7/22/25 at 3:44 p.m. certified nurse aide (CNA) #3 was in Resident #7's room. CNA #3 emptied dark yellow urine from Resident #7's catheter bag without donning (put on) gloves or a gown. On 7/23/25 at 1:23 p.m. CNA #1 and CNA #4 assisted Resident #7 with getting dressed, out of bed and into a wheelchair. The resident was assisted to the hallway. Resident #7's catheter bag was under his chair with no privacy bag covering the catheter bag. The catheter tubing was coming up and out of the top of Resident #7's pants at the waistband to the front right side. C. Record reviewThe indwelling catheter care plan, initiated 4/11/25 revealed the resident had a catheter. The interventions included monitoring for signs and symptoms of discomfort on urination and frequency, monitoring and documenting for pain/discomfort due to the catheter and monitoring/recording/reporting to medical doctor for signs and symptoms of a UTI: pain, burning, blood tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temperature, urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior and change in eating patterns.The EBP care plan, initiated 6/6/25, revealed the resident was on EBP to prevent the spread of multi-drug resistant organisms.The antibiotic therapy care plan, initiated 7/21/25 revealed the resident was on an antibiotic. Pertinent interventions included administering antibiotic medications as ordered by physician, monitoring/documenting side effects and effectiveness, monitoring/documenting/reporting as needed and adverse reactions to antibiotic therapy: diarrhea, nausea, vomiting, anorexia, and hypersensitivity/allergic reactions (rashes, welts, hives, swelling face/throat) and monitoring/documenting/reporting as needed any signs and symptoms of secondary infection related to antibiotic therapy: oral thrush (white coating in mouth, tongue), persistent diarrhea, and vaginitis/itchy perineum/whitish discharge/coating of the vulva/anus.-The antibiotic therapy care plan was not initiated for five days following the new UTI diagnosis on 7/16/25.-The care plans were not updated after the resident was diagnosed with a UTI on 7/16/25.The lab results, dated 7/15/25 at 7:12 p.m., revealed the resident had a UTI due to abnormal urinalysis (UA) results. The culture and sensitivity test revealed positive for Escherichia coli.The 7/16/25 nursing progress note documented at 11:09 a.m. revealed the primary care physician was aware of recent lab results, new orders for antibiotics.The 7/16/25 antibiotic monitoring note documented at 9:57 a.m. revealed the resident had his first dose of rocephin (injectable antibiotic) IM (intramuscular) on day shift. The 7/18/25 nurse practitioner (NP) note revealed the reason for the visit was follow-up on UTI. The UA was positive and white blood count was high. The note documented the resident had been on Rocephin IM for two days.The NP ordered Macrobid (antibiotic) 100 milligrams (mg) twice a day for seven days and may need to adjust based on sensitivity results.The 7/19/25 nursing progress note documented at 3:34 p.m. revealed in pertinent part that the resident was eating and drinking without difficulty. He had 800 mL (milliliters) of urine output that morning and oral fluids were being encouraged per orders. The 7/23/25 nursing progress note documented at 4:55 p.m. revealed in pertinent part that fluids were encouraged throughout shift today. The note documented that the resident had accepted two 600 ml containers of water during the shift, and accepted coffee this morning that was approximately 180 ml and approximately 240 ml of juice at lunch. The nurse drained 800 ml of urine from the foley catheter at this time. Review of the July 2025 CPO revealed the following physician's orders:Apply a dignity bag, check for placement each shift, ordered 4/8/25.Catheter bag to gravity drainage, every shift for foley catheter, ordered 4/8/25.16 French foley with 10 milliliter (ml) balloon to bedside drainage via gravity. Change every month, as needed leakage or dislodged every shift for foley catheter, ordered 5/29/25.Push 750 cubic centimeters (cc) water three times a day, three times a day for urinary issues, ordered 7/16/25.Macrobid Oral Capsule 100 mg (Nitrofurantoin Monohyd Macro). Give 1 capsule by mouth two times a day for UTI, for seven days, ordered 7/18/25.Encourage Oral Fluids, Monitor Intake and output, document urine characteristics, every shift for change of condition, ordered 7/19/25.-Review of Resident #7's electronic medical record (EMR) did not reveal documentation that the facility was consistently monitoring the residents intake and output of fluids (see interviews below).III. Staff interviews CNA #5 was interviewed on 7/23/25 at 2:00 p.m. CNA #5 said she had not received any catheter care training while at the facility but had learned about catheters during her CNA training. CNA #5 said when the catheter bags were emptied gloves and gown should be worn. CNA #5 said when getting a resident dressed who had a catheter the tubing went through the resident's pant leg so that it came out the pant leg at the bottom. CNA #5 said she would hook the catheter bag under the chair and put a privacy bag over the catheter bag.LPN #1 was interviewed on 7/23/25 at 2:06 p.m. LPN #1 said when completing catheter care, she checked that it was patent, unobstructed and draining properly. LPN #1 said she also checked that it was below the bladder level for proper draining. LPN #1 said she had received no catheter care training at the facility. LPN #1 said if a resident had a physician's order for monitoring fluid intake and output,the nurses would document how many cc‘s of fluid the resident consumed and the amount of urine that was output. LPN #1 said the nurses would also monitor the color and odor of the urine. LPN #1 said if there was a physician's order for monitoring intake and output the nurse was responsible for monitoring and documenting. LPN #1 said if there was a physician's order for monitoring input and output the nurse would document that information on the medication administration record/treatment administration record (MAR/TAR). LPN #1 said when the CNAs got a resident dressed that had a catheter, the catheter went down the pant leg and came out the bottom of the pant leg and then hook under the wheelchair. She said it was important to ensure the catheter did not touch the ground. LPN #1 said the catheter bag should always be covered with a privacy bag to ensure the resident's dignity. The director of nursing (DON) and the infection preventionist (IP) were interviewed together on 7/23/25 at 3:17 p.m. The IP and the DON said it was important for staff to follow EBP to help prevent the development of UTIs. The DON said when there was a physician's order to monitor the resident's input, output and urine characteristics, the nurse would document that information in the progress notes. She said this would be something the nurses would assess. She said this would also be documented on the MAR/TAR since it was a physician's order. The DON said it was important to monitor the urine characteristics by looking at the color, odor and clarity to make sure there were no signs of infection. She said monitoring the resident's inputs and outputs could also signal hydration levels. The DON said when a resident got dressed the catheter bag went down the leg of the pants and came out the bottom and hooked under the chair, covered with a privacy bag, which was important for the resident's dignity. The DON said she found that the nurses were documenting the physician's order of monitoring the resident's input and output urine characteristics each shift (twice per day) in the progress notes. The DON said there should be two notes per day since the order started on 7/19/25 at 6:00 a.m. The DON said she checked the progress note and saw a note on 7/19/25 at 3:34 p.m. but said there was not a second note monitoring the resident. The DON said she checked the progress notes on 7/20/25 and 7//21/25 and said there was no documentation at all that day monitoring the resident. The DON checked the progress notes on 7/22/25 and said there was one note addressing urine characteristics but none that day addressing input and output. The DON said she checked the progress notes on 7/23/25 at 3:17 p.m. and there were no progress notes at all. The DON said the failure may be how the physician's orders were put in and made it difficult for the nurses to document. The DON said the urinalysis results said escherichia coli was the bacteria that caused Resident #7's UTI and not using gloves could have contributed to that or it could be improper perineal care. The DON said the catheter that was observed coming out Resident #7's waistband was improperly placed and could create a blockage and risk of not having the catheter drain properly with the tube coming up out of the pants. The DON said she would begin staff education on catheter care, EBP and perineal care today.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interviews, the facility failed to ensure residents with a feeding tube received appropriate treatment and services for one (#22) of two residents reviewed out of 39 sample residents.Specifically, the facility failed to ensure Resident #22's feeding tube was in place prior to administering a bolus feeding per physician's orders.Findings include: I. Facility policy and procedureThe Care and Treatment of Feeding Tubes policy and procedure, undated, was provided by the regional nurse consultant (RNC), on 7/24/25 at 5:34 p.m. It read in pertinent part, In accordance with facility protocol, licensed nurses will monitor and check that the feeding tube is in the right location. Tube placement will be verified before beginning a feeding and before administering medications.II. Resident statusResident #22, age less than 65, was admitted on [DATE] and readmitted on [DATE]. According to the July 2025 computerized physician orders (CPO), the diagnoses included hemiplegia (weakness on one side of the body) and hemiparesis (paralysis on one side of the body) and dysphagia (difficulty swallowing).The 7/22/25 minimum data set (MDS) assessment revealed the resident had moderate cognitive impairments with a brief interview status (BIMS) score of ten out of 15. The resident required substantial to maximal assistance from staff with most activities of daily living (ADL).The assessment documented the resident had coughing or choking during meals or when swallowing medications. The assessment documented the resident was receiving 51% or more of her calories through a feeding tube and 501 cubic centimeters (cc) a day of fluid through a feeding tube. III. Resident observations and interviewResident #22 was interviewed on 7/21/25 at 9:23 a.m. Resident #22 said she was unable to eat, drink or take medications by mouth. Resident #22 said she received tube feeds five times per day. On 7/24/25 at 11:34 a.m. licensed practical nurse (LPN) #5 performed hand hygiene, donned (put on) a gown and gloves and entered Resident #22's room. LPN #5 removed a stopper from Resident #22's percutaneous endoscopic gastrostomy (PEG) tube, inserted the barrel of a syringe into the tube, poured a small splash of water from a plastic cup into the syringe and watched it drain into the PEG tube. LPN #5 then poured the entire contents of one 237 milliliter (ml) carton of Glucerna nutritional supplement into the syringe barrel slowly, allowing the contents to feed by gravity into the PEG tube. Once finished with the Glucerna, LPN #5 flushed the PEG tube again by pouring the remaining contents of the cup of water into the syringe barrel, disconnected the syringe and replaced the stopper.-However, LPN #5 did not check Resident #22's PEG tube to ensure it was placed and functioning properly prior to administering the bolus feeding and water flushes (see interviews below).IV. Record reviewThe nutrition care plan, revised 5/14/25, revealed Resident #22 was at a nutritional risk due to her dysphagia and had a PEG tube in place. Pertinent interventions included providing nocturnal feedings by administering Glucerna at a rate of 55 ml per hour over 12 hours, and flushing with 120 ml of water before and after feeding and every four hours.-However, the care plan did not reflect the updated physician's orders for Resident #22's bolus feeding amount and frequency.The gastrointestinal care plan, revised 5/25/25, revealed Resident #22 had an alteration in her gastrointestinal status due to her PEG tube. Pertinent interventions included avoiding snacks that aggravated her condition and administering medications as ordered.Review of the July 2025 CPO revealed the following physician's orders for Resident #22:-Enteral feed order: enteral tube placement will be checked each shift. Hold enteral feeding and notify physician if tube migration is suspected, ordered 6/28/25; and,-Enteral order: give 220 ml of 1.5 Glucerna bolus with 75 ml water before and after feeding five times per day, ordered 7/10/25.Review of the July 2025 treatment administration record (TAR) revealed the order to check Resident #22's enteral tube placement was marked completed twice daily from 7/1/24 through 7/24/25.V. Staff interviewsLPN #5 was interviewed on 7/24/25 at 11:34 a.m. LPN #5 said she used approximately 60 ml of water to flush Resident #22's PEG tube before her bolus and about 75 ml of water to flush after her bolus. LPN #5 said she measured it using a measuring cup at her medication cart and poured it into the plastic water cup, so she would pour about half of the cup before the bolus and a little bit over half of the cup after the bolus. LPN #5 said she did not know how to check to see if Resident #22's PEG tube was correctly positioned. LPN #5 said if Resident #22's PEG tube was migrating the facility staff would have to send her to the hospital.LPN #5 was interviewed a second time on 7/24/25 at 12:22 p.m. LPN #5 said she had checked Resident #22's PEG tube placement and marked it accordingly on the TAR as she saw the water flush went into Resident #22's PEG tube at an appropriate speed and her bolus feeding went in. LPN #5 said the physician's order to check PEG tube placement may have had something to do with aspirating the PEG tube but she would need to ask the director of nursing (DON) to clarify. LPN #5 reviewed Resident #22's CPO and said her enteral feed order specified she needed 75 ml of water flushed before and after each bolus feeding.The DON was interviewed on 7/24/25 at 2:42 p.m. The DON said for each bolus feeding, the nurse needed to have the resident's head of bed elevated and ensure their orders matched what feed they were going to administer. The DON said the nurse would then ensure the tube was placed correctly and was patent, flush the gastric tube with water, provide the feeding, flush again and clamp the tube. The DON said PEG tube placement was determined by visually examining the tube and making sure it looked secure, using a stethoscope to hear the air going into the stomach and making sure the site looked presentable and did not look infected. The DON said the PEG tube needed to be assessed to see if it was in place each shift and prior to each feeding. The DON said LPN #5 should have checked the placement of Resident #22's PEG tube prior to administering her feeding.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interviews, the facility failed to ensure residents who displayed or were diagnosed with dementia received the appropriate treatment and services to attain or maintain his or her highest practical physical, mental, and psychological well-being for one (#47) of two residents reviewed for dementia care out of 39 sample residents. Specifically, the facility failed to develop and implement effective dementia management-focused interventions to prevent Resident #47 from wandering into other residents' rooms, shower rooms, the nurses' station and standing over the top of other residents. Findings include: I. Resident #47 A. Resident status Resident #47, age [AGE], was admitted on [DATE]. According to the July 2025 computerized physician orders (CPO), diagnoses included Alzheimer's disease, anxiety disorder, depression and cognitive communication deficit. The 7/23/25 minimum data set (MDS) assessment revealed the resident was severely cognitively impaired, with a brief interview for mental status (BIMS) score of two out of 15. She required set up assistance with eating, was dependent on staff for oral hygiene, toileting, showering, dressing and personal hygiene. The MDS assessment revealed the resident wandered one to three days and exhibited physical behavioral symptoms, such as hitting, kicking, and pushing, directed toward others during the look back assessment period. B. Observations During a continuous observation on 7/22/25, beginning at 9:09 a.m. and ending at 11:01 a.m., the following observations were made in the facility's secured unit: There were ten resident rooms and five of the ten rooms had their doors open. The doors of room [ROOM NUMBER], #24, #25, #27 and #29 were open. The shower room door was additionally open. Five residents were sitting at various dining tables in the dining room. Resident #47 was sitting in a chair across from the nurses' station, sleeping. At 10:04 a.m. Resident #47 woke up. At 10:11 a.m., activities assistant (AS) #1 started a ball activity with four residents at a dining table.From 10:13 a.m. to 11:01 a.m. Resident #47 was observed continuously walking up and down the one hallway in the secured unit. Resident #47 stood at the door to the main unit, standing over the top of residents who were sitting in their wheelchairs or chairs at the dining room tables and trying to push a resident in their wheelchair. -However, staff did not attempt to redirect or distract Resident #47 in order to reduce the resident's repetitive exit-seeking behavior, standing over the top of other residents sitting down and trying to push other residents in their wheelchairs. During a continuous observation on 7/23/25, beginning at 1:29 p.m. and ending at 2:54 p.m., the following observations were made in the facility's secured unit:Nine of the ten resident room doors were open. The doors of room [ROOM NUMBER], #21, #23, #24, #25, #26, #27, #28 and #29 were open. At 1:35 p.m. Resident #47 was observed entering room [ROOM NUMBER]. She closed the door once she entered the room.From 1:46 p.m. to 2:54 p.m., Resident #47 was observed standing over the top of a resident sitting in a chair at a dining table, walking in and out of room [ROOM NUMBER], looking at the door handles on the door to the facility's main unit and on the door to the facility's courtyard and touching a resident's wheelchair handles. -However, staff did not attempt to redirect or distract Resident #47 in order to reduce the resident's repetitive exit-seeking behavior, standing over the top of other residents sitting down and touching other residents' wheelchair handles. C. Record review Resident #47's elopement care plan, revised 10/25/24, revealed the resident was a risk for wandering and elopement related to Alzheimer's disease. Resident #47 wandered aimlessly, significantly intruding on the privacy or activities of others. The 2/1/25 nurse note revealed Resident #47was very agitated and restless. She continued to take food and drinks from other residents. She was unable to be redirected. The 2/8/25 nurse note revealed the resident was easily agitated when trying to redirect her. She continued to take other residents' drinks and snacks. The 2/11/25 nurse note revealed Resident #47 continued to ambulate, went into other residents' rooms and picked up other residents' belongings and moved furniture around. The 2/16/25 nurse note revealed the resident continued to ambulate up and down the hallway. She frequently stood over other residents and would attempt to squeeze into small spaces. She was difficult to redirect and became angry with the staff. The 2/18/25 nurse note revealed Resident #47 continued to ambulate up and down the hallway, going in and out of other residents' rooms. She was unable to redirect with offers of food, drink, activity, toileting. The 3/8/25 nurse note revealed the resident continued to ambulate up and down the hallways and in and out of other residents' rooms. She became angry when trying to redirect. The 3/9/25 nurse note revealed Resident #47 went into another resident's room, causing some aggravation to other residents. Fifteen-minute checks were started and no skin issues were noted. She continued to ambulate up and down the hallway with staff frequently redirecting. The 3/25/25 nurse note revealed the resident continued to go into other residents' rooms, going to the door whenever it opened, and was unable to be redirected. The 4/25/25 nurse note revealed Resident #47 was redirected multiple times because she was entering other residents' rooms, attempting to push other residents in their wheelchairs, attempting to move chairs and getting into the trash. Snacks, coloring books, cooking shows and reading a book were offered. The resident followed for a few minutes before getting up and needed to be redirected again. The 5/10/25 nurse note revealed the resident continued to ambulate up and down the halls and went into other residents' rooms. The resident was combative with staff when they tried to redirect the resident. The 6/21/25 nurse note revealed Resident #47 continued to wander and went into other residents' rooms, taking other residents' food and belongings. She continued to push other residents in their wheelchairs even though they did not want her to push them. -Review of Resident #47's progress notes revealed there was no consistent documentation regarding what interventions were used to redirect the resident and/or which interventions were effective when the resident's wandering was observed. Review of Resident #47's behavior monitoring and intervention task record, from 6/25/25 to 7/24/25, revealed the resident wandered, pushed, grabbed, and had repetitive movement. -There was no documentation in the behavior task record from 6/25/25 to 7/24/25 to indicate if interventions were used and if the interventions were effective. II. Staff interviewsCertified nurse aide (CNA) #2 was interviewed on 7/24/25 at 11:36 a.m. CNA #2 said she knew a resident wandered based on the resident's care plan. She said if she saw a resident wandered, she made sure the resident was safe by ensuring they wore the right footwear. She said she intervened if the wandering was not safe. She said wandering was not safe if the resident was exit seeking, tried to go into the nurses' station or tried to go into the shower room and other residents' rooms. CNA #2 said it was hard to keep the residents from going into other residents' rooms. She said some residents liked to lay in other residents' beds. CNA #2 said it was not okay for residents to stand close to other residents because it could escalate the other resident's behavior and she said she never knew what behavior might happen. She said interventions were important for the safety of the resident wandering and the other residents. She said she documented if the resident wandered in the resident's electronic medical record (EMR) under a behavior task. She said she did not document if she used an intervention and if the intervention was effective. CNA #2 said she was familiar with Resident #47. She said Resident #47 wandered everywhere including into the nurses' station, shower room and other residents' rooms. She said the resident also tried to leave the secured unit. She said Resident #47 got into another resident's space because she was unaware of other peoples' personal space. She said Resident #47 would sometimes get stuck and she did not know where to move. She said Resident #47 needed to be directed on where she needed to move. CNA #2 said successful interventions for Resident #47 included moving her away from other residents, talking to her about where she should go and letting her know that she was upsetting other residents. She said the resident liked the feeling of the handlebars on the wheelchairs and she needed redirection and reminders about her safety. CNA #2 said there were activities that had velcro and fabric for Resident #47 to use. She said Resident #47 had a short attention span and it was hard to find an activity to keep the resident engaged.Licensed practical nurse (LPN) #3 was interviewed on 7/24/25 at 3:49 p.m. LPN #3 said she knew a resident wandered based on a main communication board in the EMR system. She said she saw the communication board when she first logged into the EMR system. She said wandering was not safe if the resident was exit seeking, tried to go into the nurses' station, tried to go into the shower room, in other residents' rooms and in other residents' personal space. LPN #3 said if a resident wandered, she would redirect the resident to eating food, drinking fluid, listening to music or watching an animal show. She said she did not document if the resident wandered, if interventions were used or if the interventions were effective. She said interventions were important because it could alleviate anxiety, calm the resident down and reduce or eliminate aggressive behavior. LPN #3 said she was familiar with Resident #47. She said the resident wandered. She said it was important to keep the doors closed when leaving the secured unit because Resident #47 would try to leave the unit. She said she redirected the resident by telling the resident to walk a different direction and offer her something to do. She said a soft approach was an effective way to talk to the resident.The director of nursing (DON) was interviewed on 7/24/25 at 4:27 p.m. The DON said if a resident wandered, the resident had multiple interventions for nursing. The DON said the same intervention did not work every day for residents who had dementia. The DON said the resident's family helped develop the interventions. The DON said one-on-one, activities, board games, snack, rest and going outside were used to redirect the resident from what they were doing to something else like music therapy or socializing. The DON said moving the resident to a less stimulating area could also be effective. The DON said nursing should document if the resident was wandering more than what their baseline was and if their behavior changed. The DON said she was familiar with Resident #47. She said the resident wandered. She said the resident's baseline wandering was not documented. She said she did not know why the nursing staff was not documenting what interventions were used and what interventions were effective when Resident #47 wandered into other residents' rooms and the shower room or when the resident stood too close to other residents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to ensure drug regimens were free from unnecessary medications for two (#61 and #42) of five residents reviewed for unnecessary medications out of 39 sample residents. Specifically, the facility failed to ensure Resident #61 and Resident #42 were monitored for hours of sleep for insomnia (difficulty sleeping) medications.Findings include: I. Facility policy and procedureThe Use of Psychotropic Medications policy and procedure, revised 4/28/25, was provided by the regional clinical resource (RCR) on 7/24/25 at 5:08 p.m. It read in pertinent part, The effects of the psychotropic medications on a resident's physical, mental, and psychosocial well-being will be evaluated on an ongoing basis and in accordance with nurse assessments and medication monitoring parameters consistent with clinical standards of practice, manufacturer's specifications, and the resident's comprehensive plan of care.II. Resident #61A. Resident statusResident #61, age [AGE], was admitted on [DATE]. According to the July 2025 computerized physician's orders (CPO), diagnoses included anxiety disorder, insomnia, dementia and mood disorder.The 7/3/25 minimum data set (MDS) revealed the resident was severely cognitively impaired with a brief interview for mental status (BIMS) assessment score of five out of 15.B. Record reviewReview of the comprehensive care plan, revised 7/10/25, did not reveal any focus related to Resident #61's insomnia or use of medications to treat his insomnia.Review of the July 2025 CPO revealed the following orders:-Melatonin 3 milligram (mg) oral tablet. Give 3 mg by mouth at bedtime for insomnia, ordered 1/23/25 and discontinued 7/11/25; and,-Trazodone HCl 50mg oral tablet with instructions to give 25mg by mouth in the evening related to insomnia, ordered 5/30/25.-However, there were no physician's orders to monitor or document the number of hours Resident #61 slept each shift.Review of the Resident #61's medication administration records (MAR) from7/1/25 through 7/23/25 revealed Resident #61 had been administered melatonin and trazodone as ordered each day throughout the period.Review of the resident's electronic medical record (EMR) did not reveal any documentation of the number of hours Resident #61 slept each day during that period.III. Resident #42A. Resident statusResident #42, age [AGE], was admitted on [DATE] and readmitted on [DATE]. According to the July 2025 CPO, diagnoses included chronic respiratory failure, dementia, bipolar 2 disorder, borderline personality disorder, generalized anxiety disorder and depressive episodes.-Resident #42 did not have a documented diagnosis of insomnia.The 7/7/25 minimum data set (MDS) assessment revealed the resident was cognitively intact with a BIMS score of 13 out of 15. B. Resident interviewResident #42 was interviewed on 7/21/25 at 10:15 a.m. Resident #42 said she had talked with her physician earlier and told them she did not want to be on so many medications because they made her so tired. Resident #42 said her physician told her as long as he was her doctor she had to take all of her medications. Resident #42 said she felt like she was on too many medications.C. Record reviewReview of the comprehensive care plan, revised 7/8/25, did not reveal any focus for Resident #42's insomnia or use of medications to treat insomnia.Review of the July 2025 CPO revealed a physician's order for melatonin 1 mg oral capsules with instructions to give one capsule at bedtime for insomnia, ordered 1/31/25.-However, there were no physician's orders to monitor or document the number of hours Resident #42 slept each shift.Review of the Resident #42's MAR from 3/1/25 through 7/23/25 revealed Resident #42 had been administered melatonin 1 mg each eveningReview of the resident's EMR did not reveal any documentation of the number of hours Resident #42 slept each day during that period.IV. Staff interviewsLicensed practical nurse (LPN) #4 was interviewed on 7/23/25 at 4:47 p.m. LPN #4 said residents on psychotropic medications should be monitored for side effects and medication efficacy to see if they were effective. LPN #4 said for medications for insomnia, the nursing staff monitored the number of hours of sleep at night and if the residents were sleeping during the day. LPN #4 said the nursing staff monitored the hours the residents slept to see if the sleep medication was working or to see if they were taking too much medication and were too sleepy during the day. LPN #4 said she documented the number of hours slept in the TAR. LPN #4 said a physician's order was obtained to monitor the number of hours the resident slept whenever a resident was receiving insomnia medications.Registered nurse (RN) #1 was interviewed on 7/24/25 at 9:06 a.m. RN #1 said the nursing staff monitored behaviors and side effects for residents on psychotropic medications. RN #1 said insomnia medications could cause residents to appear drowsy or tired, so the nursing staff monitored the residents' number of hours slept and documented it in the TAR. RN #1 said there were also physician's orders to monitor hours of sleep for residents on insomnia medications. RN #1 said the nursing staff monitored the number of hours slept so they could ensure residents were not sleeping all day and that their medications were balanced. RN #1 said she reviewed the CPO for Resident #61 and said she found an order for trazodone for insomnia. RN #1 said she could not find a physician's order to monitor Resident #61's hours of sleep. RN #1 reviewed the physician's orders for Resident #42 and said she could not find a physician's order for sleep monitoring. RN #1 said she thought both residents had a physician's order to monitor their number of hours slept.LPN #5 was interviewed on 7/24/25 at 9:33 a.m. LPN #5 said she could not find a physician's order to monitor Resident #61's hours of sleep. LPN #5 said she reviewed the physician's orders for Resident #42 and said she could not find a physician's order for sleep monitoring. LPN #5 said she thought both residents had an order to monitor their number of hours slept.The director of nursing (DON) was interviewed on 7/24/25 at 2:42 p.m. The DON said residents receiving psychotropic medications were monitored for any potential side effects and the medication's efficacy. The DON said for residents receiving medications to treat insomnia, the nursing staff monitored the number of hours the residents slept each shift. The DON said if a resident slept through the whole day they were not receiving the proper medication dose, so sleep monitoring helped the facility staff find the correct insomnia medication and dose. The DON said there would be a physician's order for sleep monitoring and the number of hours slept would be documented in the TAR.The DON said she did not see any physician's orders for sleep monitoring for Resident #61. The DON said Resident #42 did not have a diagnosis of insomnia. The DON said she did not see any physician's orders for sleep monitoring in Resident #42's CPO but said she would obtain one.

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 disease. Specifically, the facility failed to ensure the staff followed proper infection control procedures for Resident #7, who was on enhanced barrier precautions (EBP).Findings include: I. Professional reference The Centers for Disease Control and Prevention (CDC) Implementation of Personal Protective Equipment (PPE) Use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDROs) (4/2/24), was retrieved on 3/20/25 from https://www.cdc.gov/long-term-care-facilities/hcp/prevent-mdro/PPE.html. It read in pertinent part,Enhanced Barrier Precautions (EBP) are an infection control intervention designed to reduce transmission of resistant organisms that employs targeted gown and glove use during high contact resident care activities.EBP may be indicated (when contact precautions do not otherwise apply) for residents with wounds or indwelling medical devices, regardless of MDRO colonization status.II. Facility policy and procedureThe Catheter Care policy and procedure, implemented 5/24/25, was provided by the regional clinical resource (RCR) on 7/24/25 at 9:11 a.m. It read in pertinent part, Catheter care will be performed using EBP or additional precautions as directed. Perform hand hygiene. [NAME] (put on) gloves and gown.III. ObservationsOn 7/22/25 at 3:44 p.m. certified nurse aide (CNA) #3 was in Resident #7's room. CNA #3 emptied dark yellow urine from Resident #7's catheter bag without donning gloves or a gown.IV. Staff interviewsCNA #5 was interviewed on 7/23/25 at 2:00 p.m. CNA #5 said she had not received any catheter care training while at the facility. She said when she was emptying catheter bags, she should wear gloves and a gown. The director of nursing (DON) and the infection preventionist (IP) were interviewed together on 7/23/25 at 3:17 p.m. The IP and the DON said CNAs needed to follow EBP when providing care to a resident with a catheter. The DON said this included when the CNAs were emptying the resident's catheter bag. The DON said it was improper for the CNAs to empty Resident #7's catheter bag without putting on a gown and gloves.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to take steps to protect four (#67, #39, #36 and #31) of five residents reviewed for abuse out of 39 sample residents. Specifically, the facility failed to protect Resident #67, Resident #39, Resident #36 and Resident #31 from physical abuse by Resident #17.Findings include: I. Facility policy and procedureThe Abuse, Neglect and Exploitation policy and procedure, revised 4/11/25, was provided by the regional clinical resource (RCR) on 7/21/25 at 10:19 a.m. It read in pertinent part, Abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish, which can include resident-to-resident altercations. It includes physical abuse.II. Incident of physical abuse between Resident #17, Resident #67 and Resident #39 on 6/19/25A. Facility investigationThe 6/19/25 nurse note revealed the nurse was in the nurses' station when a certified nurse aide (CNA) called for help in the hallway. The nurse went to assist and found three residents in a physical altercation. Resident #17 was hitting Resident #39 in the face and then pulled Resident #67's hair. The CNA and the nurse separated all three residents. The CNA told the nurse that Resident #17 took Resident #39's walker. Fifteen minute checks were initiated. Cares and monitoring for the residents were ongoing. The facility's conclusion of the internal investigation was the incident was substantiated. III. Incident of physical abuse between Resident #17 and Resident #36 on 6/22/25A. Facility investigationThe witness statement by the housekeeper, dated 6/23/25, documented the housekeeper was cleaning Resident #36's bathroom in room [ROOM NUMBER]. Resident #36 was standing by her bed and the housekeeper noticed the resident go to the door. Resident #17 entered the room. The housekeeper came out of the restroom and asked Resident #17 to leave because Resident #36 did not like anyone in her room. Resident #17 became verbal and started to push Resident #36. The housekeeper tried to separate the two residents but Resident #17 immediately pushed Resident #36 down. Resident #36 said she was fine. Resident #17 continued to curse at Resident #36 and grabbed Resident #36's sweater cuffs and did not let go. The housekeeper called for help and a CNA immediately came in and tried to separate the two residents. The CNA took Resident #17 out of the room. The nurse came in and checked Resident #36 for any possible injuries and blood. Resident #36 appeared to be okay. The witness statement by CNA #6, dated 6/22/25, documented CNA #6 saw Resident #36 attacked by Resident #17. She heard yelling and hitting. CNA #6 quickly rushed over to see what was going on. Resident #17 was hitting Resident #36 and the housekeeper and CNA #6 immediately tried to separate the residents from each other. Resident #17 did not want to let go until CNA #6 loosened her grip on Resident #36's shirt. CNA #6 took Resident #17 out of the room. The facility's investigation summary revealed a housekeeper was in Resident #36's room and attempted to intervene and de-escalate. Resident #17 pushed Resident #36 to the floor. The housekeeper called for help, and a CNA came to separate the two residents. The facility's conclusion of the internal investigation was the incident was substantiated. IV. Incident of physical abuse between Resident #17 and Resident #31 on 6/23/25A. Facility investigation of the altercation on 6/23/25The victim's statement (Resident #31), dated 6/23/25, documented Resident #31 was sitting on her bed watching television. Resident #17 (assailant) came over and grabbed her arm. Resident #31 said she did not like that. Resident #31 said Resident #17 grabbed her arm so Resident #31 pulled her arm away and Resident #31 slipped off the bed. The 6/23/25 nurse incident note revealed a nurse heard yelling from Resident #31's and Resident #17's room. Resident #31 was on the floor with Resident #17 standing nearby. Resident #31 said Resident #17 pushed her down when she told Resident #17 to get off of her bed. The facility's conclusion of the internal investigation was the incident was substantiated. The facility's investigation summary revealed Resident #17 had one-on-one supervision from a previous incident in the last week. The interventions included continuing one-on-one supervision for at least one month, Resident #17 moved to a new room, a new medication was added to Resident #17's medication regimen and hospice increased nurse visit frequency. The facility's investigation revealed Resident #17 had two incidents with other residents prior to the incident with Resident #31 on 6/23/25 (see incidents above). The investigation revealed Resident #17 had one-on-one supervision from a previous incident. The conclusion of the internal investigation revealed there was a breakdown in the shift change system that led to substantiating the incident. Resident #17 had an incident on 6/19/25 and 6/22/25 with other residents. The intervention for the 6/19/25 incident was a medication review and 15-minute checks. The intervention for the 6/22/25 was one-on-one supervision. -Review of Resident #17 electronic medical record (EMR) and the facility incident investigation revealed the facility failed to have continuous one-on-one supervision, which led to the 6/23/25 incident.V. Resident #67 - victimA. Resident statusResident #67, age [AGE], was admitted on [DATE]. According to the 6/19/25 July 2025 computerized physician orders (CPO), diagnoses included multiple sclerosis (a chronic disease of the central nervous system), cerebral infarction (blood flow to a part of the brain is blocked), and memory deficit. According to the 6/12/25 minimum data set (MDS) assessment, the resident was severely cognitively impaired with a brief interview mental status (BIMS) score of four out of 15. She required a wheelchair. She required supervision with oral hygiene and showering and required set-up assistance for eating and toiletingThe MDS assessment identified the resident had delusions and other behaviors on one to three days in the look-back period. The behaviors placed the resident at significant risk for physical illness or injury and significantly interfered with the resident's participation in activities or social interactions. The MDS assessment further revealed the resident's behavior had an impact on others, including putting others at significant risk for physical injury, significantly intruding on the privacy or activity of others and significantly disrupting the care or living environment of others. B. Record reviewThe 6/19/25 nurse note revealed the nurse went to assist and found three residents in a physical altercation. Resident #17 was hitting Resident #39 in the face and then pulled Resident #67's hair. The CNA and the nurse separated all three residents. The CNA told the nurse Resident #17 took Resident #39's walker. Fifteen minute checks were initiated. Cares and monitoring were ongoing. VI. Resident #39 - victim A. Resident statusResident #39, age greater than 65, was admitted on [DATE]. According to the July 2025 CPO, diagnoses included cerebral infarction and unspecified dementia. According to the 6/22/25 MDS assessment, the resident was severely cognitively impaired with a BIMS score of three out of 15. She required a wheelchair and wheelchair. She required supervision with eating, substantial assistance with oral hygiene, toileting and was dependent on staff for showering and personal hygiene. The MDS assessment identified the resident had physical behaviors towards others one to three days in the look-back period. The behaviors did not place the resident at significant risk for physical illness or injury and significantly interfered with the resident's participation in activities or social interactions. The MDS assessment further revealed the resident's behavior did not have an impact on others, including putting others at significant risk for physical injury, significantly intruding on the privacy or activity of others and significantly disrupting the care or living environment of others.B. Record reviewThe 6/19/25 physician's order revealed 15-minute checks for the victim of aggression from another resident every shift for three days. VII. Resident #36 - victimA. Resident status Resident #36, age greater than 65, was admitted on [DATE]. According to the July 2025 computerized physician orders (CPO), diagnosis included Alzheimer's disease, chronic kidney disease stage three, psychotic disturbance, mood disturbance, anxiety and depression. According to the 6/5/25 MDS assessment, the resident was severely cognitively impaired with a BIMS score of three out of 15. She required set up assistance with eating, oral hygiene and was independent with toileting, dressing and personal hygiene. She required substantial assistance with showering. The MDS assessment did not identify the resident displayed behaviors during the assessment look-back period. B. Record review Review of Resident #36's physically aggressive care plan, revised 3/14/25 revealed the resident had the potential to be physically aggressive related to dementia. Interventions included anticipating the resident's need for food, thirst, toileting and comfort level. The 6/22/25 nurse note revealed the CNA said Resident #36 was in her room when another resident (Resident #17) entered her room and pushed her onto the floor. Resident #36 was assessed by a registered nurse (RN) for injuries. Resident #36 was noted to have a reddened area approximately three centimeters (cm) to her lower right side of back. The resident was able to move all extremities without difficulty. The 6/25/25 interdisciplinary team (IDT) note revealed Resident #36 received physical aggression on 6/22/25. The root cause was the aggressor (Resident #17) disregarded several verbal attempts to redirect. The intervention in place was one-on-one supervision for the aggressor. VIII. Resident #31 - victimA. Resident status Resident #31, age [AGE], was admitted on [DATE]. According to the July 2025 CPO, diagnoses included atherosclerotic heart disease of native coronary artery (build up of fat, cholesterol and other substances in and on the walls of the heart arteries), type 2 diabetes mellitus with hyperglycemia (a condition of too much sugar in the bloodstream), tobacco use, dementia with anxiety, major depressive disorder, and mood disorder. The 5/21/25 MDS assessment revealed the resident was severely cognitively impaired with a BIMS score of five out of 15. She was independent with oral hygiene and toileting, required set-up assistance for eating, and was dependent for showering. The MDS assessment did not identify the resident displayed behaviors during the assessment look back period. B. Record review Resident #31's behavior care plan, revised 11/25/24, revealed the resident had the potential and history of becoming verbally aggressive and confrontational with staff and other residents. The resident preferred not to have visitors in her room and preferred to be alone at times in her room. Interventions included remaining calm and using a soft reassuring voice to prevent further escalation and offering to go for a walk or eat a snack. The 6/23/25 nurse note revealed Resident #31 said she was grabbed on her right arm by her roommate while sitting on her bed. The resident was heard yelling from her room. The resident was seen sitting on her floor with her roommate, Resident #17, standing nearby. Resident #31 said that Resident #17 pushed her down when she told her to get off her bed. The 6/24/25 IDT note revealed Resident #31 received physical aggression on 6/23/25. The root cause was the roommate had behaviors. The interventions in place were the resident's roommate (Resident #17) had one-on-one supervision, the roommate had a medication review from hospice and provider, the roommate moved rooms away from the resident and nursing staff were educated on one-on-one supervision hand-off procedures. IX. Resident #17 - assailant A. Resident status Resident #17, age [AGE], was admitted on [DATE]. According to the July 2025 CPO, diagnoses included Alzheimer's disease, chronic obstructive pulmonary disease (a lung condition that makes it hard to breathe) and occlusion and stenosis of unspecified carotid artery (plaque buildup narrows the artery, potentially leading to stroke). The 6/9/25 MDS assessment revealed the resident was severely cognitively impaired with a BIMS score of five out of 15. She required partial assistance with toileting, supervision for oral hygiene and set up assistance with eating. The MDS assessment revealed the resident had delusions and had physical and verbal behavior symptoms towards others for one to three days during the look-back period. It revealed the behavior had an impact on the resident, including putting the resident at significant risk for physical illness or injury, significantly interfering with the resident's care and significantly interfering with the resident's participation in activities or social interactions. The MDS assessment further revealed the resident's behavior had an impact on others, including putting others at significant risk for physical injury, significantly intruding on the privacy or activity of others and significantly disrupting the care or living environment of others. B. Record review Resident #17's physically aggressive care plan, revised 6/24/25, revealed the resident had the potential to be physically aggressive. Interventions included one-on-one supervision, medication review and giving the resident as many choices as possible about care and activities.-However, the care plan failed to identify what triggered Resident #17's physically aggressive behaviors and include person-centered interventions in order to prevent further physically aggressive altercations from occurring with other residents.The 6/19/25 nurse note revealed the nurse went to assist and found three residents in a physical altercation. Resident #17 was hitting Resident #39 in the face and then pulled Resident #67's hair. The CNA and the nurse separated all three residents. The CNA told the nurse Resident #17 took Resident #39's walker. Fifteen-minute checks were initiated. Cares and monitoring were ongoing.The 6/23/25 nurse note revealed Resident #17 was sitting on her bed with a CNA. The resident held a towel to her left forearm and said she was bleeding. The nurse removed the towel and observed the resident's arm with a one-inch skin tear. The resident denied pain and did not remember the incident. The resident was easily redirected at this time. The resident sat with the nurse until she said she was ready for bed. One-on-one supervision was in place at this time, accompanying the resident at all times. The 6/24/25 IDT note revealed Resident #17 initiated physical aggression on 6/23/25. The root cause was aggressive behavior, Alzheimer's disease, hospice, past history of prior trauma. The treatment required was one-on-one supervision. X. Staff interviewsCNA #2 was interviewed on 6/23/25 at 10:05 a.m. CNA #2 said she was not present when Resident #17 had physical altercations with other residents. She said the resident's behavior escalated when staff and others moved fast or if she was around a lot of people. She said Resident #17 was de-escalated by removing the resident from the environment, offering a snack, providing one-on-one supervision and distracting the resident. CNA #2 said if she suspected abuse, she would protect the residents by separating the residents if it was a resident-to-resident altercation and she would tell the nurse and the director of nursing (DON) or the nursing home administrator (NHA). She said the nurse was responsible for writing an incident report and she would write a statement if she saw the incident. CNA #2 said the entire facility would be trained on what new interventions were put in place to prevent further abuse. Licensed practical nurse (LPN) #3 was interviewed on 6/23/25 at 10:20 a.m. LPN #3 said she was not present when Resident #17 had a physical altercation with other residents. She said if she suspected abuse, she would separate the residents to protect the residents and report the incident to the NHA. She said she started the incident report, wrote a progress note and notified the physician and the resident's representative. The resident aide was interviewed on 6/24/25 at 12:53 p.m. The resident aide said he was not present when Resident #17 had a physical altercation with other residents. He said if he suspected abuse, he would ask CNAs or nurses to come help him separate the residents. He said his main responsibility was providing one-on-one supervision to Resident #17. He said the purpose of one-on-one supervision was to help anticipate the needs of the resident, monitor the resident and report any behaviors to nursing. The NHA, the DON and the RCR were interviewed together on 7/23/25 at 3:39 p.m The NHA said the 6/19/25, 6/22/25 and 6/23/25 incidents involving Resident #17 as the aggressor were substantiated as physical abuse. He said after the 6/19/25 altercation, the interventions were a medication review and 15-minute checks for Resident #17. He said after the 6/22/25 altercation, the intervention was revised to one-on-one supervision of Resident #17. The DON and the RCR said the medication review and the 15-minute check interventions were not effective because Resident #17 was not on the new medication long enough to see the effects. The NHA said the one-on-one supervision intervention was not effective because staff did not follow the intervention, and there was a 90-minute gap in coverage. He said all nursing staff were trained on one-on-one supervision coverage, including education not to leave Resident #17 in order to prevent future altercations.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interviews, the facility failed to ensure activities designed to support the residents' physical, mental and psychosocial well-being were provided for three (#17, #36 and #42) of four residents reviewed for activities out of 39 sample residents. Specifically, the facility failed to to offer and provide personalized activity programs for Resident #17, Resident #36 and Resident #42. Findings include: I. Facility policy and procedure The Activities policy, dated 4/11/25, was provided by the regional clinical regional clinical resource (RCR) on 7/24/25 at 5:12 p.m The policy read in pertinent part, “It is the policy of this facility to provide an ongoing program to support residents in their choice of activities based on their comprehensive assessment, care plan, and preferences. Facility-sponsored group, individual, and independent activities will be designed to meet the interests of each resident, as well as support their physical, mental, and psychosocial well-being. Activities will encourage both independence and interaction within the community. “Each resident’s interest and needs will be assessed on a routine basis. Activities will be designed with the intent to: -Enhance the resident’s sense of well-being, belonging, and usefulness; -Create opportunities for each resident to have a meaningful life; -Promote or enhance physical activity; -Promote or enhance cognition; -Promote or enhance emotional health; -Promote self-esteem, dignity, pleasure, comfort, education, creativity, success and independence; -Reflect resident’s interests and age; -Reflect cultural and religious interests of the residents; and, -Reflect choices of the residents. Special considerations will be made for developing meaningful activities for residents with dementia and/or special needs. These include, but are not limited to, considerations for: -Residents who exhibit unusual amounts of energy or walking without purpose; -Residents who engage in behaviors not conducive with a therapeutic home like environment; -Residents who exhibit behaviors that require a less stimulating environment to discontinue behaviors not welcomed by others sharing their social space; -Residents who go through others’ belongings; -Residents who have withdrawn from previous activity interest/customary routines, and isolates self in room/bed most of the day; -Residents who excessively seek attention from staff and/or peers; -Residents who lack awareness of personal safety; and, -Residents who have delusional and hallucinatory behavior that is stressful to themselves.” II. Resident #17 A. Resident status Resident #17, age [AGE], was admitted on [DATE]. According to the July 2025 computerized physician orders (CPO), diagnoses included Alzheimer’s disease, chronic obstructive pulmonary disease (a lung condition that makes it hard to breathe) and occlusion and stenosis of unspecified carotid artery (plaque buildup narrows the artery, potentially leading to stroke). The 6/9/25 minimum data set (MDS) assessment revealed the resident was severely cognitively impaired with a brief interview for mental status (BIMS) score of five out of 15. She required partial assistance with toileting, supervision for oral hygiene and set up assistance with eating. The assessment revealed the resident preferred reading books, newspapers or magazines, listening to music, being around animals such as pets, participating in favorite activities and spending time outdoors. The assessment revealed the resident did not refuse care. B. Resident’s representative interview Resident #17’s representative was interviewed on 7/21/25 at 9:53 a.m. The representative said staff told her activities were offered to Resident #17 but the resident refused. She said she thought the resident would participate in some activities. She said she would engage in watching old television shows. She said she wished the television in the resident’s room worked because it could help with the resident’s behavior. C. Observation During a continuous observation on 7/22/25, beginning at 1:51 p.m. and ending at 3:00 p.m., the following observations were made: The activities calendar in the secured unit revealed pet therapy was scheduled at 2:00 p.m. At 1:51 Resident #17 was in her room with the door closed. At 2:04 p.m. activity assistant (AA) #1 walked into the secured unit with a therapy dog. AA #1 went to multiple residents in the common area to see if they wanted to pet the dog. AA #1 sat down in the common area with residents sitting on both sides of her and across from her. At 2:53 p.m. AA #1 and the therapy dog left the unit. -However, the therapy dog was not directed to go into Resident #17’s room, despite the resident’s interest in dogs (see care plan below). At 3:06 p.m. Resident #17’s room was observed. There was a television above the foot of Resident #17’s bed. The television was not plugged in. There was no television remote in the resident’s room. Certified nurse aide (CNA) #7 was in the room and she said did not know where the remote was for the television. D. Record review Resident #17’s activities care plan, revised 6/12/25, revealed the resident loved dogs and she had two dogs when she lived at home. The resident and the dogs had sat together and birdwatched every afternoon. The care plan goal was for the resident to participate in two to three group activities per week until the next review. Interventions included assisting the resident to group activities if she chose to attend and inviting the resident to participate in activities of interest. A review of Resident #17’s electronic medical record (EMR) revealed the resident did not attend any emotional activities from 6/24/25 to 7/24/25 and she attended seven intellectual activities from 6/24/25 to 7/24/25. -There was no further documentation to indicate the resident had participated in or been offered the opportunity to participate in any other activities during the timeframe. III. Resident #36 A. Resident status Resident #36, age greater than 65, was admitted on [DATE]. According to the July 2025 CPO, diagnosis included Alzheimer’s disease, chronic kidney disease stage three, psychotic disturbance, mood disturbance, anxiety and depression. The 6/5/25 MDS assessment revealed the resident was severely cognitively impaired with a BIMS score of three out of 15. She required set up assistance with eating, oral hygiene and was independent with toileting, dressing and personal hygiene. She required substantial assistance with showering. The 12/17/24 MDS revealed it was somewhat important for the resident to have books, newspapers and magazines to read, to be around animals such as pets, and it was very important to do her favorite activities. B. Observations During a continuous observation on 7/22/25, beginning at 9:09 a.m. and ending at 11:01 a.m., the following observations were made in the facility’s secured unit: At 9:09 a.m. Resident #36 was observed in her room. At 10:07 a.m. AA #1 arrived at the unit. From 10:11 a.m. to 10:40 a.m. AA #1 engaged eight residents in the common area with a ball activity. At 10:14 a.m. an unidentified staff member said Resident #36 and her roommate were going to participate in the ball activity. At 10:15 a.m. Resident #47 interfered with Resident #36 walking towards the activity which caused Resident #36 to walk back to her room. -No staff members attempted to get Resident #36 to participate in the ball activity again. C. Record review Resident #36’s activities care plan, revised 6/8/25, revealed the group activities goal was for the resident to participate in activities two to three times a week. She likes to snack on cookies and chips, magazines with eye-catching pictures, reading a book, or reminiscing with activity staff. She enjoys lotion therapy, aromatherapy, working on simple puzzles, and word searches. She loves animals and really enjoys pet therapy. Her favorite activities are going out on the patio when the weather is warm and reminiscing with select residents and staff. Interventions included offering independent leisure activity materials, offering pet visits when in the building and visit three times a week for 20 to 30 minutes per week. -A review of Resident #17’s EMR revealed the resident did not attend any social activities from 6/24/25 to 7/24/25 and she attended six intellectual activities from 6/24/25 to 7/24/25. -There was no further documentation to indicate the resident had participated in or been offered the opportunity to participate in any other activities during the timeframe. IV. Staff interviews The nursing home administrator (NHA) was interviewed on 7/23/25 at 3:39 p.m. The NHA said if a resident had it on their care plan that they liked animals and the animal was part of the scheduled pet therapy, the activities staff should try to engage the resident with the pet therapy. He said he did not know when pet therapy was scheduled on 7/22/25 or why the pet therapy was not offered to Resident #17. He said he would talk to the activity director (AD) to ensure residents in their room were offered activities such as pet therapy. The AD was interviewed on 7/24/25 at 2:00 p.m. The AD said she had worked at the facility for the past year. She said she was fully staffed with herself, one full-time activities coordinator and two part-time activities staff. She said one staff member worked eight hours on Saturdays and AA #1 worked 15 hours per week, from 1:00 p.m. to 4:00 p.m. She said AA #1 was responsible for covering the activities in the secured unit. She said when AA #1 was not scheduled, she or the full-time staff covered the activities in the secured unit. The AD said if residents were in the secured unit at the dining room tables, the nursing staff should offer independent activity supplies. She said she had a closet full of activity supplies in the secured unit as well as crossword puzzles and other games next to the television. She said word searches, coloring and a sewing kit should be offered every day. She said the independent activities should be offered because residents in the secured unit could not express themselves so staff should offer individual activities. She said everyone should be invited and encouraged to participate in an activity. The AD said she documented if a resident attended or refused to attend the activity in the resident’s EMR under tasks. She said activities were important because activities could make a difference in residents’ lives and change how they felt about living in a facility. She said the residents needed to be in the facility so she wanted to make it fun for them. She said if a resident participated in pet therapy, it would be documented as an emotional activity in the resident’s chart and if it was a ball activity, it should be documented as a social activity. The AD said she was familiar with Resident #17. She said the resident was a really good artist and she liked fresh air. She said the resident liked to color and participate in pet therapy. She said she did not know that when pet therapy was an activity on 7/22/25 that Resident #17 did not get invited to participate. She said she did not know Resident #17’s activities participation record only documented that she participated in intellectual activities. The AD said she was familiar with Resident #36. She said the resident had her days when she did not participate in anything. She said sometimes she participated in activities in the main unit. She said if Resident #36 agreed to attend the ball activity and was distracted by Resident #47, staff should have attempted to invite her back to attend the activity. She said did not know Resident #36’s activities participation record only documented that she participated in intellectual activities. V. Resident #42 A. Resident status Resident #42, age [AGE], was admitted on [DATE] and readmitted on [DATE]. According to the July 2025 CPO, diagnoses included chronic respiratory failure, dementia, bipolar 2 disorder, borderline personality disorder, generalized anxiety disorder and depressive episodes. The 7/7/25 MDS assessment revealed the resident was cognitively intact with a BIMS score of 13 out of 15. B. Resident interview and observations Resident #42 was interviewed on 7/21/25 at 10:15 a.m. Resident #42 said she wanted to start going to more activities. Resident #42 said she had gone to bingo one time but she could not see the numbers on the bingo cards. Resident #42 reiterated that she wanted to start going to more activities. On 7/22/25 at 3:07 p.m. AA #1 came into the facility with her dog. AA #1 went up and down Resident #42’s hallway and stopped into rooms to greet the residents with her dog and allow the residents to socialize with her dog. -However, AA #1 did not knock on Resident #42’s door or otherwise offer to socialize with Resident #42. Resident #42 was in her room at the time of the observation. On 7/23/25 at 2:20 p.m. an activity was being conducted in the main dining room. Resident #42 was in her room lying in her bed with no meaningful activity occurring. C. Record review The activity care plan, revised 1/2/25, revealed Resident #42 enjoyed independent activities and would participate in group activities if food or drinks were involved. Pertinent interventions included having care staff invite and encourage Resident #42 to participate in programs of interest such as food groups and to remind and encourage the resident to participate in group activities. The nutritional care plan, revised 3/28/25, revealed Resident #42 was at risk for nutritional problems due to her dementia. Pertinent interventions included inviting and encouraging Resident #42 to participate in physical activity and offer her activities of choice to help divert her attention away from food. Review of Resident #42’s one-on-one activity task log from 6/24/25 to 7/24/25 revealed the following: -No one-to-one activities were documented for the resident during the time frame. No activity refusals were documented. Review of Resident #42’s emotional activity task log from 6/24/25 to 7/24/25 revealed the following: -No emotional activities were documented for the resident during the time frame. No activity refusals were documented. Review of Resident #42’s outing activity task log from 6/24/25 to 7/24/25 revealed the following: -No outing activities were documented for the resident during the time frame. No activity refusals were documented. Review of Resident #42’s physical activity task log from 6/24/25 to 7/24/25 revealed the following: -No physical activities were documented for the resident during the time frame. No activity refusals were documented. Review of Resident #42’s social activity task log from 6/24/25 to 7/24/25 revealed the following: -No social activities were documented for the resident during the time frame. No activity refusals were documented. Review of Resident #42’s special event activity task log from 6/24/25 to 7/24/25 revealed the following: -No special event activities were documented for the resident during the time frame. No activity refusals were documented. Review of Resident #42’s spiritual activity task log from 6/24/25 to 7/24/25 revealed the following: -No spiritual activities were documented for the resident during the time frame. No activity refusals were documented. Review of Resident #42’s intellectual activity task log from 6/24/25 to 7/24/25 revealed the following: -On 6/26/25 at 3:49 p.m. Resident #42 participated in independent leisure. -On 6/27/25 at 1:42 p.m. Resident #42 participated in independent leisure. -On 7/1/25 at 2:41 p.m. Resident #42 participated in independent leisure. -On 7/7/25 at 3:07 p.m. Resident #42 participated in independent leisure. -On 7/22/25 at 8:20 a.m. Resident #42 participated in independent leisure. -On 7/23/25 at 3:43 p.m. Resident #42 participated in independent leisure. -On 7/24/25 at 11:53 a.m. Resident #42 participated in independent leisure. The intellectual activity task log did not document any refusals from Resident #42. E. Staff interviews Certified nurse aide (CNA) #4 was interviewed on 7/23/25 at 2:56 p.m. CNA #4 said Resident #42 went to her birthday party activity in March 2025 and went to an activity two weeks prior. CNA #4 said Resident #42 had not left her room between those two activities. CNA #4 said the activities staff brought Resident #42 supplies for individual activities but Resident #42 did not want to leave her room. The AD was interviewed on 7/24/25 at 1:45 p.m. The AD said she visited every resident every day and invited and encouraged them to come to activities that day. The AD said refusals of each activity offered each day were documented in the residents’ EMRs under tasks. The AD said residents were assessed on admission to see what their life was like before they were admitted to the facility and see what their interests were. The AD said activities were important because they changed how the residents felt about being in a facility and allowed them to be comfortable and have fun. The AD said pet therapy, provided by AA #1, was considered an emotional activity. The AD said AA #1 should go to each resident’s room and usually went room to room with her dog. The AD said the facility provided three to four activities per day every day of the week. The AD said she tried to have residents attend activities at least twice per week. The AD said the activities assistants would document refusals for each resident in their tasks. The AD said she wanted the activities assistants to document refusals so she had proof the resident was invited to the activity. The AD said she had seen issues with the activities assistants’ documentation. The AD said she had tried implementing different color coding methods for charting.

Based on interviews and record review, the facility failed to ensure residents had the right to choose his or her preferred attending physician for four ( #1, #2, #3 and #4) of six residents out of 12 sample residents. Specifically, the facility failed to assist residents to make an informed choice for selecting their attending physician when the facility changed medical provider groups. Findings include: I. Facility policy and procedure The Resident Rights policy, revised December 2016, was provided by the regional nurse consultant (RNC) on 10/16/24 at 2:48 p.m. It read in pertinent part, Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident ' s right to be informed about his or her rights, be informed of, choose an attending physician, and participate in decision-making regarding his or her care. II. Resident interviews Resident #4, who was cognitively intact based on facility assessment, was interviewed on 10/16/24 at 1:12 p.m. Resident #4 said she was aware her attending physician had changed. She said she was not offered a choice for a new physician and did not recall the facility obtaining her consent to select the attending physician of her choice. Resident #4 said she was not informed she had the right to select her preferred attending physician and the facility had not informed her which physicians would be covered by her insurance. Resident #2, who was cognitively intact based on facility assessment, was interviewed on 10/16/24 at 1:24 p.m. Resident #2 said she was aware her physician had changed. She said she was offered a choice of a new physician but not the physician she preferred. Resident #2 said she was not informed she had the right to select the attending physician of her choice. She said she did not recall the facility notified which physicians would be covered by her insurance. III. Record review The electronic medical records (EMR) for Resident #1, #2, #3 and #4 were reviewed. There was an undated and unsigned provider choice document in each of the residents ' EMRs. The document read in pertinent part, We are proud to announce we have two new medical providers for you to choose from, please see below. Please let us know which provider you would like to have as your physician. I, (resident name), have decided I would like to have, one of the two physicians on the form, as my selected physician. Each of the forms were completed by the facility ' s social services director (SSD) and were not signed by the residents or the residents ' legal representatives. -The facility was unable to provide documentation the Residents #1, #2, #3, and #4 and/or their responsible parties had been informed about the change in attending physician and the residents' permission was obtained with informed consent to change the attending physicians. IV. Staff interviews The nursing home administrator (NHA) was interviewed on 10/17/24 at 8:20 a.m. The NHA said the previous facility owner contracted with a new medical group to provide primary care for the facility ' s residents around July 2024. The NHA said the previous owner would not allow residents to choose a physician outside of the newly contracted medical group. The NHA said the facility changed ownership on 9/1/24 and ended the contract with the previous medical group. The NHA said in September 2024, the facility arranged to have two new physicians assume primary care for the residents. The SSD was interviewed on 10/17/24 at 8:46 a.m. The SSD said in September 2024 she and her assistant met with each resident and assisted them in choosing a new attending physician. The SSD said, when she met with the residents, she told each resident they had a right to select a physician of their choice but did not include information for which physicians were covered by their insurance. She said if the resident was undecided which physician to choose, she reviewed the provider choice document with them and then the residents made their choice of one of the two listed physicians. The SSD said she completed the provider choice forms for each resident and the form reflected each residents ' choice for attending physician.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to ensure residents were free from resident to resident abuse for two (#48 and #52) of four residents reviewed for physical abuse out of 32 sample residents. Specifically the facility failed to ensure Resident #48 was free from physical abuse from Resident #52. Cross reference F744, dementia care. Findings include: I. Facility policy and procedure The Abuse Policy was provided by the nursing home administrator (NHA) on 8/28/23 at 12:47 p.m. It read in pertinent part, Communities do not condone resident abuse and shall take every precaution possible to prevent resident abuse by anyone, including staff members and other residents. Residents have the right to be free from abuse, neglect, misappropriation of residents property, and exploitation. Identification of abuse shall be the responsibility of every employee. Physical abuse is defined as abuse that results in bodily harm with intent. It includes hitting, slapping, pinching and kicking. Willful means the individual must have acted deliberately, not that he/she must have intended to inflict injury or harm. Adverse event is an untoward, undesirable, and usually unanticipated event that causes death or serious injury, or the risk thereof. II. Resident to resident physical altercation between Resident #48 and Resident #52. The 8/20/23 facility incident report which involved Resident #48 and Resident #52 was provided by the NHA on 8/29/23 at approximately 10:00 a.m. It revealed in pertinent part: The investigation showed the date of the incident was 8/20/23 at 9:38 a.m. The investigation showed Resident #52 hit Resident #48 in the face. The incident was unwitnessed. The investigation did not have staff interviews about the incident. The physician, police department, and all appropriate parties were notified. Both residents were ambulatory and independently mobile. Both residents did not express any fear. Plan of action was taken for Resident #52 with one-on-one observation while awake. A stop sign was placed on Resident #52 ' s door to prevent Resident #48 from entering Resident #52 ' s room. Resident #48 said the incident did not happen although the 8/21/23 nurse's note was documented (see below). The resident was asked what happened. The resident pointed at another resident (#52) and said she had been hit. Resident #52 said she did not know if the incident had happened but if the staff said it happened she guessed it did. She then said she did not think she had done this. The investigation failed to show Resident #48 had bleeding and swelling to the right side of the face next to the nose as indicated in the 8/21/23 nurse's note (see below). The abuse investigation dated 8/20/23 substantiated the abuse. III. Resident #48 A. Resident status Resident #48, age [AGE], was admitted to the facility on [DATE]. According to the August 2023 computerized physician orders (CPO), diagnoses included traumatic subdural (between the brain and the outermost layer) hemorrhage (bleeding), Alzheimer ' s disease, dementia, personality disorder, adjustment disorder with disturbance of conduct, migraine, and cognitive communication disorder. The 8/16/23 minimum data set (MDS) assessment documented the resident had a severe cognitive deficit with a brief interview for mental status (BIMS) score of one out of 15. The resident required limited one person physical assistance with bed mobility, transfers, walking in room, walking in corridors, dressing, and toileting. The resident required extensive one person assistance with personal hygiene. B. Record review The care plan for safety initiated on 5/1/23 and revised on 5/30/23 documented the resident struggled to maintain safe boundaries from others and often entered others' rooms without permission. The resident was at risk due to other residents becoming upset if the resident entered their rooms without permission. The resident was also at risk due to not maintaining safe boundaries from other residents who may become upset if she was invading their personal space. Interventions included staff would encourage the resident to utilize appropriate boundaries such as knocking on doors and to wait for permission to enter. Staff would encourage the resident to visit with others in public spaces. Staff would offer a variety of activities. The nurse's note dated a late entry on 8/21/23 at 9:14 a.m. documented the resident was observed by the staff to have bleeding and swelling to the right side of her face next to the nose. The resident was asked what happened. The resident pointed at another Resident (#52) and said she had been hit. IV. Resident #52 A. Resident status Resident #52, age [AGE], was admitted to the facility on [DATE]. According to the August 2023 CPO, diagnoses include reduced mobility, bipolar disorder, generalized anxiety disorder, dementia, disorientation, alcohol abuse, and cognitive communication deficit. The 7/17/23 MDS assessment documented the resident had moderate cognitive impairment with a BIMS score of nine out of 15. The resident required supervision with set up help only for bed mobility, transfers, walking in room and corridors, dressing, and toileting. The resident required supervision with one person assistance with personal hygiene. B. Record review The care plan for physical aggression initiated on 3/13/23 revised on 3/16/23 documented the resident had the potential to be physically aggressive (pushing others) related to anger, dementia, and poor impulse control. Interventions included analyzing key times, places, circumstances, triggers and what de-escalated behaviors, communication and provide physical and verbal cues to alleviate anxiety, and place on one-to-one monitoring and every 15 minute checks at night while sleeping. The initial evaluation and re-evaluation for secure neighborhood placement dated 5/31/23 documented the resident was evaluated by the interdisciplinary team (IDT) and found: Less restrictive alternatives have been unsuccessful in preventing harm to self or others; Resident is serious danger to self or others; Resident has behavioral disturbances that seriously disrupt the rights of other residents. The nurse's note dated 8/20/23 at 10:46 a.m. documented the resident had behavior toward another resident and continued on every 15 minute checks and one-on-one monitoring. The nurse's note dated 8/20/23 at 10:56 a.m. documented the resident had physical behavior toward another resident. The nurse's note dated 8/21/23 at 9:32 a.m. documented the nurse was notified Resident #48 was in the hall outside of Resident #52 ' s room holding her face and Resident #48 said that Resident #52 had hit her because Resident #48 was attempting to get into her bed. Resident #52 was on every 15 minute checks and one-on-one care. One-on-one/every 15 minute check notes dated 8/21/23 between 8:30 a.m. and 10:00 documented the resident was in her room. The nurse practitioner note dated 8/21/23 at 7:16 p.m. documented a report from staff that the resident had hit another resident on 8/20/23. The certified nurse aide (CNA) had reported Resident #48 went into Resident #52 ' s room and attempted to get into Resident #52 ' s bed. V. Interviews Registered nurse (RN) #1 was interviewed on 8/31/23 at 9:32 a.m. RN #1 said Resident #52 was on 15 minute checks and one-on-one supervision. She said the staff was unable to watch the resident all the time. She said the facility did not have someone to supervise the residents in the evenings and at night when the residents were asleep. She said incidents happened mostly in the evenings and at night when there were fewer staff in the facility. She said the facility put a stop sign up for Resident #48 so she would not go into Resident #52 ' s room, however Resident #48 liked to walk around, and did enter other resident rooms. The director of nursing (DON) was interviewed on 8/31/23 at 2:04 p.m. The DON said residents on the memory care unit had monitoring interventions. She said the CNAs and nurses were the point of care for behaviors. Monitoring behaviors of residents with dementia should be charted and reported at the beginning and end of each shift.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and interviews, the facility failed to offer sufficient fluid intake to sustain hydration and ensure each resident was able to maintain the highest practical level of health and wellbeing for two residents (#21and #25) of 5 reviewed for hydration. Specifically, the facility failed to ensure: -Resident #21 and Resident #25 were provided with sufficient hydration in accordance with the resident's plan of care. Findings include: I. Facility policy The Hydration Policy, revised November 2019, was received from the nursing home administrator on 8/30/23. It read in pertinent part,Residents are provided with sufficient fluid intake to maintain proper hydration and health. Resident's identified at risk for fluid volume deficit will be assessed timely and provided appropriate interventions to promote adequate hydration. Residents identified with potential/actual hydration issues will be reviewed/assessed by the interdisciplinary team (IDT) for contributing risk factors/conditions. These risk factors and preventive interventions will be documented in the care plan and nursing notes in the medical record. II. Failure to ensure hydration needs were met 1. Resident #10 A. Resident status Resident #10, age [AGE], was admitted on [DATE]. According to the August 2023 computerized physicians orders (CPO) diagnoses included muscular sclerosis (disabling disease of the brain and spinal cord), and inflammatory polyneuropathy (a disorder that involves progressive weakness and reduced sense in the arm and legs), The 7/20/23 minimum data set (MDS) assessment revealed the resident had moderately impaired cognition with a brief interview for mental status (BIMS) score of ten out of fifteen. The resident was dependent on two staff members for activities of daily living.The resident did not have a swallowing disorder. The August 2023 CPO showed the resident was prescribed a regular diet, regular texture, and thin consistency diet/fluid and required the assistance of one staff member with eating. B. Resident interview The resident was interviewed on 8/30/23 at 9:52 a.m. The resident said she liked orange juice to drink in the morning but had yet to receive it. The resident said she lacked the strength to pick up the water pitcher to drink and needed staff assistance to drink fluids included with her meals. The resident said she often felt nauseated, tired, and restless, and preferred to sleep rather than eat or drink. C. Observations On 8/28/23 at 10:05 a.m., the resident's lips were dry and cracked. There was a pitcher of water filled with water & ice on the resident ' s bedside table, the pitcher was out of the resident's reach. 8/29/23 -At 8:15 a.m., the resident was lying upright in bed with the overbed table over her lap. There was half eaten toast & uneaten eggs on a plate and no fluid/drinks included with the resident ' s morning meal. The water pitcher remained out of reach. -At 9:01 a.m., the resident's water pitcher was on the floor at the resident's bedside. water the resident's bedding and pajama top were wet and the resident was shivering, asking for help -At 2:02 p.m., an unidentified certified nurse aide (CNA) entered the resident ' s room, the resident had an untouched 120 ml of a red fluid on her bedside. The resident told the CNA she was nauseated. The CNA left the room however did not encourage the resident to drink. 8/30/23 -At 8:09 a.m., A certified nurse aide (CNA) assisted the resident with breakfast. The resident was served 50 ml of orange juice. She did not have any other beverage. The CNA offered the resident a sip of orange juice, however, when the resident spoke, the orange juice ran out onto the resident ' s chest. At the completion of the meal, the resident consumed approximately 50 ml of the juice. The cup of juice remained half full and the CNA did not offer the resident anything -At 10:12 a.m. to 11:05 am., during continuous observations, no staff member entered the resident ' s room to offer the resident fluids to drink -At 11:55 a.m., an unidentified CNA assisted the resident with lunch. There was a cup of red juice on the resident's tray containing 120 ml. The resident drank three small separate sips. The CNA did not offer additional sips of the fluid D. Record review The care plan dated, 8/23/23 identified the resident required assistance of one person with eating. The hydration status evaluation dated 6/26/23 showed the resident had no underlying factors affecting hydration nor inadequacy of fluid intake. The calculation of fluid needs based on clinical condition (body mass index, weight, and height) revealed the resident's fluid needs were 1475-1770 milliliters daily. The fluid intake records from August 2023 failed to show the resident's fluid consumed was tracked and monitored. E. Interviews Restorative certified aide (RCA) #1 was interviewed on 8/30/23 at 2:40 p.m. RCA#1 said the role of a restorative certified aide was to pass ice water to each resident, check water pitchers for refills. RCA#1 said the resident's fluid intake was not documented. Certified nurse aide (CNA) #1 was interviewed on 8/30/23 at 3:45 p.m. CNA #1 said the resident drank coke for lunch and orange juice in the morning. CNA#1 said the resident could lift the water pitcher unassisted, as well as, other drinks in cups without assistance, although the resident had spilled drinks in the past. CNA #1 said she was not aware of the need to monitor how much the resident drank and had not been advised to monitor and document the resident ' s fluid intake. Certified nurse aide (CNA) #2 was interviewed on 8/30/23 at 4:05 p.m. CNA #2 said fluid intake was not monitored unless the resident was on a fluid restriction. Registered nurse (RN) #3 was interviewed on 8/30/23 at 4:21 p.m. RN #3 said the resident's lips were often dry and staff would offer chapstick or ask the resident if she was thirsty. RN #3 said there was not an assessment to include hydration. Regional clinical consultant (RCC) was interviewed on 8/31/23 at 3:42 p,m. The RCC said the facility underwent a merger recently and the tools have not been completely rolled out and only new admissions have been assessed for hydration versus dehydration using the hydration status evaluation on admission tool. The director of nursing (DON) was interviewed on 8/30/23 at 4:00 p.m. The DON said fluid intake monitoring was in the resident's care plan and occurred with each meal and was documented after each meal. The DON said if the resident showed signs and symptoms of dehydration, for example diarrhea or vomiting, the physician would be notified and the nurses would deliver intravenous fluids. The DON further stated every time a staff member entered the resident's room they should offer the resident something to drink. 2. Resident #21 A. Resident status Resident #21, age less than 60 years, was initially admitted [DATE] and readmitted on [DATE]. According to the August 2023 computerized physicians orders (CPO) diagnosis included quadriplegia. The 8/28/23 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of fifteen out of fifteen. The resident was dependent on two staff members for activities of daily living and was dependent on a wheelchair for mobility. The resident did not have a swallowing disorder nor dental issues. The August 2023 CPO showed the resident was prescribed a regular diet, regular texture diet/fluid. B. Resident interview The resident was interviewed on 8/29/23 at 12:52 p.m. The resident said he was unable to use his upper and lower extremities and was dependent on staff members to assist him with eating and drinking. The resident said he had to use the call light to request assistance to drink. The resident said his favorite drink was coke. The resident said he was dependent on staff to assist him with drinking fluid, at times he felt dry and did not always get enough to drink. C. Observations 8/29/23 -At 9:19 a.m. The resident's lips were dry and cracked, his tongue was dry and had a slight white film atop. -At 12:13 p.m., the resident's lunch tray arrived at 12:13 p.m. A certified nurse aide returned to the resident's room [ROOM NUMBER] minutes later to assist the resident with lunch There were no fluids included on the resident's lunch tray. A water pitcher was sitting atop the overbed table that was not touched nor did the CNA offer the resident a drink. 8/30/23 -At 8:26 a.m. the resident received assistance to eat from a CNA. The resident ate 90% of his meal and drank approximately 180 ml of coke. The resident received 240 ml of both milk and juice on the meal tray went untouched nor was it offered to the resident. D. Record review The August 2023 hydration status evaluation the resident had a history of cerebral vascular accident as an underlying factor affecting hydration. The calculation of fluid needs based on clinical condition (body mass index, weight, and height) revealed the resident ' s fluid needs were 1925- 2310 milliliters daily (Eight to nine cups a day). There were no mechanisms in place within the facility to consistently monitor the resident's fluid intake nor staff actions to promote the resident's fluid intake. The fluid intake records from July 2023 through August 2023 showed, the resident's average fluid intake was 550 ml a day, which was five cups short. E. Interviews Certified nurse aide (CNA) #2 was interviewed on 8/29/23 at 9:01 a.m. CNA #2 said charting for fluid intake only occurs if the resident was on fluid restrictions. CNA #2 said the resident required full assistance with meals and drinks and helped the resident drink as the resident eats his meal. CNA #2 confirmed the resident used the call light to ask for a drink at least six times a day and offered the resident sips before and after incontinence care. III. Additional interviews Registered nurse (RN) #4 was interviewed on 8/30/23 at 4:00 p.m. RN #4 said the signs and symptoms of dehydration are dry skin, poor urine output, confusion, and skin tenting. RN #4 said if the CNA noticed any of these signs and symptoms of dehydration, the CNA was required to report the findings to the nurse. Assistant director of nursing (ADON) was interviewed on 8/30/23 at 4:05 p.m. The ADON said fluid intake was monitored at meals only and is documented by the CNA documentation. The ADON said the dietician completes the hydration status evaluation form and shares it with the interdisciplinary team in the morning huddle only if there are concerns. The ADON further said, the resident requires complete assistance with meals and hydration. The ADON said fluid intake was monitored daily for the resident at meals and would determine whether the resident was drinking enough fluids in the point of care documentation entered by CNA staff. The ADON said the majority of care plans were completed by the previous DON and was updated by the previous MDS coordinator. Certified nurse assistant (CNA) #2 was interviewed on 8/30/23 at 1:48 pm. CNA #2 said it would help if CNAs had consistent assignments for resident care to monitor fluid intake. CNA #2 said she has documented other resident's fluid intake in point of care (POC) but with meals only. Licensed practical nurse (LPN) #1 was interviewed on 8/30/23 at 2:39 pm. LPN #1 said fluid intake was monitored only at meals by the CNA staff and was documented in point of care (POC). LPN #1 said she was not aware of any other times fluid intake was monitored and/or documented. LPN #1 reaffirmed CNA staff know to report changes in resident status to the nurse. LPN #1 said there had been no reports of residents showing signs of dehydration but could not say whether or not all CNAs would recognize signs of dehydration.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to prevent significant medication errors for two (#41 and #49) of five residents reviewed for medication errors out of 32 sample residents. Specifically, the facility failed to ensure: -Resident #41 received prescribed daily doses of Vraylar (antipsychotic) and Trazodone (antidepressant), as ordered by the resident's physician; and -Resident #49 received a prescribed daily dose of Abilify (antipsychotic) and Lialda (anti-inflammatory agent used to treat ulcerative colitis), as ordered by the resident's physician. Findings include: I. Professional standards According to [NAME], P.A. and [NAME], A.G. et.al., (2021), Fundamentals of Nursing, 10 edition, pp 599 - 609. Nurses play an important role in patient safety, especially in the area of medication administration. The safe administration of medications is also an important topic for current nursing researchers. As a nurse you need to know how to calculate medication doses accurately and understand the different roles that members of the health care team play in prescribing and administering medications. The National Coordinating Council for Medication Error Reporting and Prevention (2018) defines a medication error as any preventable event that may cause inappropriate medication use or jeopardize patient safety. Medication errors include inaccurate prescribing, administering the wrong medication, giving the medication using the wrong route or time interval, administering extra doses, and/or failing to administer a medication. -Preventing medication errors is essential. -Because nurses play an essential role in preparing and administering medications, they need to be vigilant in preventing errors. Professional standards such as scope of nursing and standards of practice apply to the activity of medication administration. To prevent medication errors follow the seven rights of medication administration consistently every time you administer medication. -The right medication; the right dose; the right patient; the right route; the right time; the right documentation; and right indication. II. Facility policy and procedure The Medication Administration policy, revised November 2019, was provided by the nursing home administrator (NHA) on 8/21/23 at 8:45 a.m. It revealed in pertinent part, Medications are administered in accordance with written orders of the attending physician. Record the results of medications administered per facility policy and procedure. III. Resident #41 A. Resident status Resident #41, age [AGE], was admitted on [DATE]. According to the August 2023 computerized physician orders (CPO), the diagnoses included multiple sclerosis, depression, bipolar disorder, and hypertension. The 3/21/23 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for a mental status (BIMS) score of 15 out of 15. He required two person assistance with bed mobility, transfers, toileting, personal hygiene and dressing. B. Record review The August 2023 CPO documented: -Vraylar capsule 1.5 mg. Give one capsule by mouth one time a day for bipolar disorder, current episode, mild or moderate severity. Start 2/3/23. - Trazodone HCl tablet 50mg. Give one table by mouth at bedtime related to depression. Start 2/3/23. A. Vraylar medication errors The care plan on 1/16/23 documented the resident was prescribed the antipsychotic medication Vraylar related to depression. Interventions included: -Administer psychotropic medications as ordered by the physician. Monitor for side effects and effectiveness every shift; -Consult with pharmacy, doctor to consider dosage reduction when clinically appropriate at least quarterly; -Discuss with doctor, family regarding the ongoing need for use of medications. Review behaviors, interventions and alternate therapies attempted and their effectiveness as per facility policy; and -Monitor/document/report as needed any adverse reactions of psychotropic medications such as depression and suicidal ideations. The progress note on 6/21/23 at 10:07 a.m. documented Vraylar was not administered because the medication was on order. The progress note on 6/22/23 at 10:19 a.m. documented Vraylar was not administered because the medication was on order. The progress note on 7/24/23 at 7:39 a.m. documented Vraylar was not administered because the medication was on order. The progress note on 8/26/23 at 12:42 p.m. documented Vraylar was not administered. The medication was reordered from the pharmacy and currently on order. The progress note on 8/27/23 at 12:49 p.m. documented Vraylar was not administered. The pharmacy was called regarding the medication status. The pharmacy said the medication would be delivered on the next delivery window. The progress note on 8/28/23 at 11:49 a.m. documented Vraylar was not administered because the medication was on order. B. Trazodone medication errors The care plan on 1/16/23 documented the resident was prescribed the antidepressant medication trazodone due to insomnia. Interventions included: -Administer antidepressant medications as ordered by the physician. Monitor and document side effects and effectiveness every shift; -Monitor, document and report as needed adverse reactions to antidepressant therapy including change in behavior, mood and cognition, hallucinations, social isolation, withdrawal, and insomnia. The medication administration record (MAR) for April and May 2023 revealed the resident refused trazodone on 4/16/23 through 4/19/23, 4/23/23 through 4/26/23, 4/30/23, 5/1/23 through 5/3/23, 5/7/23, 5/10/23, 5/17/23, 5/18/23, and 5/20/23 through 5/24/23. -The progress notes for April and May 2023 did not document why the resident refused the medication. There were no progress notes to show that the physician or family were notified that the resident refused the medication. C. Resident Interview The resident was interviewed on 8/29/23 at 10:11 a.m. He said he took Vraylar to help with his bipolar disorder. He said when he did not take his Vraylar it made him feel depressed. He confirmed that he did not take his Vraylar for the last couple of days. He did not know why he had not taken the medication but was told by the facility staff that they were working on an alternative medication. He said when he did not take Vraylar, it made him feel trapped. He said he felt like he lived in Groundhog Day because everything felt the same every day. IV. Resident #49 A. Resident Status Resident #49, under the age of 65, was admitted on [DATE]. According to the August 2023 CPO, the diagnoses included type two diabetes, hypertension, ulcerative colitis, bicondylar fracture of right tibia, post traumatic stress disorder, major depressive disorder and chronic pain syndrome. The 8/3/23 MDS assessment revealed the resident was cognitively intact with a BIMS score of 15 out of 15. He required supervision in bathing and was independent in bed mobility, transfers, toileting, personal hygiene and dressing. B. Record Review The August 2023 CPO documented: -Abilify tablet 5mg. Give one tablet by mouth in the morning related to post traumatic stress disorder. Start 5/1/23. -Lialda 1.2 mg. Give one tablet by mouth two times a day related to ulcerative colitis. Start 5/1/23. A. Abilify medication errors The care plan on 5/9/23 documented the resident was prescribed Abilify related to major depression. Interventions included: -Administer medications as ordered by the physician. Monitor for side effects and effectiveness every shift; -Educate the resident, family and caregiver about risks, benefits and the side effects and toxic symptoms of Abilify. The medication administration record (MAR) for August 2023 documented that Abilify was not administered on 8/11/23 through 8/16/23 and 8/19/23 through 8/21/23 because the medication was on order. There were no progress notes that the physician was notified the resident did not take the medication. B. Lialda medication errors The care plan did not document why the resident took Lialda. The physician's history and physical on 5/4/23 documented the resident was stable with ulcerative colitis. The assessment and plan said to monitor for symptoms. The medication administration record (MAR) for July and August 2023 documented that Lialda was not administered on 7/6/23 through 7/9/23 and 8/8/23 through 8/10/23 and 8/24/23 because the medication was on order. There were no progress notes that the physician was notified the resident did not take the medication. V. Interviews Licensed practical nurse (LPN) #3 was interviewed on 8/30/23 at 3:45 p.m. She said if a medication was out of stock, she would let the resident know why they were not taking the medication. She would call the doctor and the pharmacy. She would document why the medication was not administered in a progress note. She was not aware Resident #41 refused Trazodone in April 2023 and May 2023. She said the resident never refused Trazodone when she administered his medications. The director of nursing (DON) was interviewed on 8/31/23 at 1:55 p.m. The DON said if a medication was out of stock, the nurse should go to their back up medication storage to see if the medication was available there. If the medication was not available in the medication storage, the nurse should call the doctor to inform the doctor the medication was not available and ask if the medication could be held until the medication was available. She said that if a resident refused medication for several days the doctor should be notified.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review, the facility failed to provide a therapeutic diet as prescribed by the physician to two Residents (#69 and #67) of 16 sample residents for a therapeutic diet, out of a total sample of 32 residents. Specifically, the facility failed to follow the physician orders for Resident #69 and Resident #67 to receive a carbohydrate controlled diet (CCD: meals that contain carbohydrate-rich foods in fairly equal amounts to help control the blood sugar levels). Findings include: I. Facility policy and procedure The Diabetic Management Policy and Procedure, dated 7/28/23, was received from the nursing home administrator (NHA) on 8/30/23 at 2:17 p.m. It read in pertinent part, Diabetic management involves both preventative measures and treatment of complications. From admission, the interdisciplinary team works together to implement a plan of care to minimize complications. The Therapeutic Diets Policy and Procedure, dated 1/12/16, was received by the NHA on 8/30/23 at 4:56 p.m. It read in pertinent part, Therapeutic diets must be prescribed by the attending physician. When a therapeutic diet is ordered, it is served correctly. Therapeutic diets are physician orders and must be followed. Regularly check the service of diets to be sure what is served on the menu matches the meal on the tray. Observe staff reading the menu extension to proper compliance. II. Resident #69 A. Resident status Resident #69, age [AGE], was admitted on [DATE]. According to the August 2023 computerized physician orders (CPO), diagnoses included paraplegia (paralysis of the legs and lower body), severe protein-calorie malnutrition (low energy intake, weight loss, loss of subcutaneous fat, loss of muscle mass), and type 2 diabetes mellitus. The 6/19/23 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. He required extensive assistance with two persons for transfers. He required extensive assistance with one person for bed mobility, dressing, toilet use, and personal hygiene. He required supervision with setup help for eating. B. Resident interview Resident #69 was interviewed on 8/28/23 at 2:27 p.m. Resident #69 said that he was concerned that he did not receive the proper food due to his type II diabetes. He said for breakfast he received a glazed cinnamon roll which he said he was not supposed to eat due to being diabetic, however the kitchen did not give him anything in its place when he did not eat it. He said he should have had one piece of toast with diet jelly. He said that he did not receive enough protein with his breakfast meal. Resident #69 was interviewed a second time on 8/30/23 at 10:14 a.m. He said for breakfast the kitchen forgot his eggs and he was supposed to receive a double portion. He said the breakfast on the regular menu was scrambled eggs but he was supposed to receive over-easy eggs. He also said he did not receive diet jelly for his toast, only regular grape jelly. He said his biggest frustration was the kitchen was closed before dinner was over so he could not get any substitutions. He said the dinner on Monday was sweet and sour chicken, but he did not receive the bread or watermelon cubes that was listed on his meal ticket, instead they gave him chocolate cake which was not on his CCD diet. C. Observations The tray line was observed on 8/30/23 at 7:09 a.m. The menu showed scrambled eggs, one slice of toast, one diet jelly and 1 margarine should of been served for the CCD diet, however, the tray line showed that regular jelly was served with all meals. Meal tickets that said double portions were served the same amount of a regular diet. A regular diet was one fourth cup of scrambled eggs, one slice of toast, one jelly and one margarine. D. Record Review The August 2023 CPO revealed orders related to diet included the following: CCD diet, regular texture, regular/thin consistency, double protein for all meals. order date 3/27/23. Pro Stat supplement, three times a day for wound healing protein liquid 30 mls (milliliters) three times a day; code percentage consumed. order date 3/29/23. The care plan related to type 2 diabetes mellitus and the required use of insulin, initiated 4/1/23, revealed interventions related to diet and included, dietary consult for nutritional regimen and ongoing monitoring; identify areas of noncompliance or other difficulties in resident diabetic management. Modify the problem area so that it may be more manageable for the resident/family. Provide and document teaching to resident/family/caregiver address identified roadblocks to compliance; Monitor/document/report PRN (as needed) compliance with diet and document any problems; Offer substitutes for foods not eaten. -However, the care plan interventions were not consistently followed and there was no reference to the residents CCD diet or double protein for all meals. The care plan related to nutritional problems, revised 7/27/23, revealed interventions related to diet and included, Resident does like to have his brother bring in food from the community per his choice; Invite the resident to activities that promote additional intake; Provide and serve supplements as ordered; Provide, serve diet as ordered. Monitor intake and record every meal; Registered dietician to evaluate and make diet change recommendations PRN (as needed); Snacks per orders. -However, the care plan interventions were not consistently followed and there was no reference to the residents CCD diet or double protein for all meals. III. Resident #67 A. Resident status Resident #67, age [AGE], was admitted on [DATE], and readmitted [DATE]. According to the August 2023 CPO, diagnoses included cerebral infarction (stroke), hemiplegia and hemiparesis (paralysis and muscle weakness on one side of the body) affecting the right dominant side, and diabetes mellitus due to underlying condition with hyperglycemia. The 7/12/23 MDS assessment revealed the resident was cognitively intact with a BIMS score of 15 out of 15. He required extensive assistance with one person for transfers, dressing, and toilet use. He required limited assistance with one person for bed mobility, bathing and personal hygiene. Eating required supervision with set-up help. B. Resident interview Resident #67 was interviewed on 8/28/23 at 2:49 p.m. He said he had a lack of protein in his diet and had lost weight. Resident #67 said he was diabetic but the kitchen was serving him pancakes (Saturday), french toast (Sunday) and a glazed cinnamon roll (Monday) . Resident #67 said he told the CNAs that he cannot eat the pancakes/french toast, so the CNA took it back to the kitchen but the kitchen said they were out of substitutes and had no more eggs. Resident #67 said the kitchen was not following his meal tickets and in addition the facility had not provided a menu. Resident #67 said he was bedridden, so if the facility posted the menu he could not view it. Resident #67 said he was supposed to receive snacks but they brought him marshmallow oatmeal cookies, goldfish crackers, but rarely a sandwich or banana which he would prefer and would be more suitable for his diabetic diet. Resident #67 was interviewed on 8/30/23 at 9:50 a.m. He said for breakfast that morning he had toast but the jelly served was not diet, it was regular jelly. He said he preferred meat and eggs and wanted a double portion but he was not receiving that. He said for snacks the facility only offered Trix brand yogurt, but he did not like it because the sugar content was not suitable for his diabetic diet but the facility had not offered another option. C. Record review The August 2023 CPO revealed orders related to diet included the following: Snack BID (twice a day), prefers half sandwich or yogurt when available. order date 7/12/23. CCD diet, regular texture, regular/thin consistency, for diet no salt packet. Large portions all meals. order date 6/1/23. The care plan related to diabetes mellitus, revised 6/19/23, revealed interventions related to diet included, Dietary consult for nutritional regimen and ongoing monitoring. -There was no reference to the residents CCD diet or large portions. The care plan related to nutritional problems, revised 8/25/23, revealed interventions related to diet included, Provide and serve diet as ordered; Snacks, as ordered. -There was no reference to the residents CCD diet or large portions. IV. Staff interview The cook #1 was interviewed on 8/29/23 at 1:43 p.m. She said that she did not make any meals for CCD/diabetics. She showed the production list for the upcoming dinner meal. She said the menu instructed what each meal, and she followed it. The production list had columns for the different types of meals like regular diet and pureed diet. [NAME] #1 said there was not a column for CCD. The registered dietitian (RD) was interviewed on 8/30/23 at 2:17 p.m. She said the meal tickets indicated the diet ordered by the physician and must be followed. She said the nutritional spreadsheets (extensions) included the different diet types and what needed to be served. She said if the physician prescribed a special diet such as CCD it was important to follow because the principal was consistent carbohydrates which keeps the blood sugar stable. She said there was a substitution sheet such as vegetable for vegetable or fruit for fruit. The RD said chocolate cake would not be an appropriate nutritional substitute for watermelon. She said if the physician ordered double portions it was absolutely important to follow to prevent weight loss and help with wound healing and nutrition. She said it would be questionable if the Trix yogurt was ok for the CCD diet since it was higher in sugar than those that were light. The RD said that regular Welch's grape jelly was not considered a diet jelly and was not appropriate for CCD diets. The dietary director of operations (DOO) was interviewed on 8/31/23 at 9:04 a.m. She said the kitchen manager was terminated two weeks ago but there was an assistant kitchen manager. She said the purpose of the meal ticket was so residents could get the nutrition they needed and if the physician ordered a CCD and double portions it should be followed. She said the nutritional spreadsheet (extensions) outlines what each diet can have and the cook was in charge of making sure the diet served was correct. The DOO said if a resident had a CCD diet it was important to be accurate because it's based on the amount of sugar and was ordered by the doctor. She said if not served correctly it could cause the residents' glucose to rise and be off. The DOO said cinnamon rolls should not have been served to residents on a CCD diet and also said they should be served diet jelly not regular. The DOO said the cooks needed some extra training and better communication for not knowing the Resident #69, and #67 had a therapeutic diet. The DOO said that both cooks were new. The director of nursing (DON) and NHA were interviewed on 8/31/23 at 2:04 p.m. They said if there was a special diet ordered by the physician it should be followed. The DON said it was important to follow the CCD diet for diabetic residents because blood sugar levels could be affected either too high or too low. They said if a physician ordered double portions at meals it should be followed. The DON said it would be important for wound healing, and to prevent weight loss. V. Facility follow-up On 8/31/23 at 3:35 p.m. the NHA provided the following information related to therapeutic diets after being brought to the facility's attention. The information was corrective action that the facility identified that residents with therapeutic diets were not followed as ordered specifically CCD diets, dietary preferences were not followed with options to request an alternative, and resident meal palatability was not met. Sixteen residents were identified as on CCD therapeutic diet and all residents would be affected for palatability and preference. Dietary completed meal tracker and computer audit of CCD diet to ensure tray card accuracy. One resident identified and updated. Dietary staff education provided on CCD diet and components to include preference. Preferences were updated for residents identified. Care plan reviewed to ensure therapeutic diet was indicated. Whole house resident preferences would be completed and the care plan updated. Random meals would be audited to ensure appropriate diet had been followed five times per week. Five residents per week would be interviewed to be sure preferences were being met. Test tray daily five days per week random meals and textures. Test tray offered to staff and residents and interviewed for food quality.

Based on observations, record review and interviews, the facility failed to ensure menus were followed to meet the residents' nutritional needs. Specifically, the facility failed to: -Follow the correct portion sizes to ensure adequate nutrition was provided to the residents; and, -Ensure the correct items were served in accordance with the posted menu. Findings include: I. Facility policy and procedure The Meal Distribution policy and procedure, revised September 2017, was received from the Regional Clinical Consultant (RCC) on 8/31/23 at 3:39 p.m. It read in pertinent part, All meals will be assembled in accordance with the individualized diet order, plan of care, and preferences. The dining services department staff will assemble the meal in accordance with the individual meal card. II. Failure to follow the correct portion sizes to ensure adequate nutrition was provided to the residents Observations and record review During a continuous observation during the breakfast meal tray line on 8/30/23 starting at 7:09 a.m. and ending at 8:40 a.m., cook #2 and dietary service aide (DSA) #1 did not follow the meal tickets in the following ways: -Meal tickets that said double portions had single servings of each breakfast item; and, -Meal tickets that said cold cereal were not measured and poured into a black round bowl. The menu revealed cold cereal should be one serving. III. Failure to ensure the correct items were served in accordance with the posted menu Observations and record review During a continuous observation during the breakfast meal tray line on 8/30/23 starting at 7:09 a.m. and ending at 8:40 a.m., cook #2 did not follow the meal tickets in the following ways: -Meal tickets that said regular diet received toast; and -Meal tickets that said CCD (calorie controlled diet) had regular jelly on their trays. The menu revealed residents who were prescribed regular diets should have received one English muffin. The menu revealed residents who were prescribed a CCD diet should have received diet jelly. IV. Staff interviews Cook #2 was interviewed on 8/30/23 at 8:40 a.m. He said that he ran out of English muffins. He said that was why some residents received toast. He said he kept the kitchen open for about 15 minutes after the last meal was served so that if residents wanted more, they would be open. The registered dietitian (RD) was interviewed on 8/30/23 at 2:17 p.m. She said the meal tickets indicated the diet ordered by the physician and must be followed. She said if the physician ordered double portions it was important to follow to prevent weight loss and help with wound healing and nutrition. The RD said that regular Welch's grape jelly was not considered a diet jelly and was not appropriate for CCD diets. The RD said one serving of cereal was the individual size cereal boxes or one half a cup. The dietary director of operations (DDO) was interviewed on 8/31/23 at 9:04 a.m. She said the kitchen manager was terminated two weeks ago but there was an assistant kitchen manager. She said the purpose of the meal ticket was so residents could get the nutrition they needed and if the physician ordered a CCD and double portions it should be followed. The DDO said she thought one serving of cereal was six ounces but she would double check. She said a double portion was considered twice the amount of each item listed on the menu. She said that the cook followed the facility's direction to provide a single serving to all residents regardless of what the meal ticket said and then the nursing staff would come back to ask for the second serving. The director of nursing (DON) and NHA were interviewed on 8/31/23 at 2:04 p.m. They said if there was a special diet ordered by the physician it should be followed. The DON said it was important to follow the CCD diet for diabetic residents because blood sugar levels could be affected either too high or too low. They said if a physician ordered double portions at meals it should be followed. The DON said it would be important for wound healing and to prevent weight loss.

Based on observations and staff interviews, the facility failed to ensure the dietary department followed safe practices to prevent the potential contamination of food and spread of food-borne illness. Specifically, the facility failed to ensure food items removed from their original packaging and opened had a dating system. Findings include: I. Professional reference The Colorado Department of Public Health and Environment (2019) Colorado Retail Food Establishment Rules and Regulations, retrieved on 9/10/23 from: https://www.colorado.gov/pacific/sites/default/files/DEHS_RetailFd_6CCR10102_RFFC_Eff Jan2019.pdf revealed in pertinent part: A date marking system may include: Using a method approved by the Department for refrigerated, ready-to eat potentially hazardous food (time/temperature control for safety food) that is frequently rewrapped, such as lunch meat or a roast, or for which date marking is impractical, such as soft serve mix or milk in a dispensing machine; Marking the date or day of preparation, with a procedure to discard the food on or before the last date or day by which the food must be consumed on the premises, sold, or discarded; Marking the date or day the original container is opened in a food establishment, with a procedure to discard the food on or before the last date or day by which the food must be consumed on the premises, sold, or discarded; or Using calendar dates, days of the week, color-coded marks, or other effective marking methods, provided that the marking system is disclosed to the Department upon request. II. Observations On 8/28/23 at 9:30 a.m. the main kitchen had the following items: -In the refrigerator, there was an unknown item that looked like chicken in a container that was not labeled and not dated. There was a food item that looked like macaroni and cheese covered with aluminum foil that was not labeled and not dated. There was tomato paste in the original can that opened and was not dated. There were sliced orange cheese wrapped in plastic wrap that was not labeled and not dated. There were several eggs in a measuring cup that did not have a date. There was sliced turkey outside of its original packaging that was not labeled or dated. There were several hot dogs in a plastic container that was not labeled or dated. In the pantry, an unknown item was in its original packaging bag that was brown and looked like flakes. The food item did not have an expiration date or opened date. On 8/29/23 at 1:43 p.m. the main kitchen refrigerator had several Sysco imperial chocolate health shakes on a tray that had a ripped piece of cardboard that served as a sign on top of the shakes. The cardboard sign had a date that it was placed in the refrigerator. The individual shakes did not have expiration dates written on them. 3. Interviews The assistant dietary service manager (ADSM) was interviewed on 8/28/23 at 9:45 a.m. She did not know what the unlabeled item in the pantry was and threw the item away. The registered dietitian (RD) was interviewed on 8/30/23 at 3:04 p.m. She said when food was out of its original packaging, the food should be dated and labeled with what the item was. She said that dietary shakes should be individually dated with the pull date and the shakes were good for 14 days from when the shakes were thawed. The dietary director of operations (DDO) and nursing home administrator (NHA) were interviewed on 8/31/23 at 9:04 a.m. The DDO said when food was out of its original packaging, the food should be dated and labeled with what the item was. The DDO said that dietary shakes should be individually dated with the pull date and the shakes were good for 14 days from when the shakes were thawed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, observations and record review, the facility failed to consistently serve food that was palatable, attractive and at the appropriate temperature. Specifically, the facility failed to ensure resident food was palatable in taste, texture, temperature and appearance. Findings include: I. Resident group interview A group interview was conducted on 8/29/23 at 3:26 p.m. with five cognitively independent residents (#29, #42, #44, #49, and #65). All the residents in the group interview said that the food was not palatable. Residents said the hot food came cold. II. Individual resident interviews Resident #62 was interviewed on 8/28/23 at 9:34 a.m. She said the meat served at dinner was sour and bland. She said the meat would have been better with salt and pepper. She did not know if there was salt and pepper served on the tray. Resident #42 was interviewed on 8/28/23 at 2:15 p.m. The resident said the meals were too salty. He said he did not ask for an alternative because it was too late to order an alternative. Resident #66 was interviewed on 8/28/23 at 2:23 p.m. He said the meat served was hard to slice and difficult to chew because it was tough. He said the food did not taste good and did not taste right. Resident #69 was interviewed on 8/28/23 at 2:27 p.m. He said if the menu said the cheese was supposed to be melted, the cheese was not melted. One example he gave was a tuna melt sandwich. He said the cheese was not melted. He said the pork loin served for lunch was overcooked. Resident #67 was interviewed on 8/28/23 at 2:49 p.m. The resident said the pork loin served for lunch was overcooked. Resident #49 was interviewed on 8/28/23 at 2:52 p.m. He said some meals were served with meat that was unidentifiable. He said his roommate and him called it mystery meat because neither of them knew what the meat was. He also said that the hot meals were served cold. Resident #29 was interviewed on 8/28/23 at 4:14 p.m. He said the French fries were served cold. He said he mentioned it to the facility management and the response was that fries were hard to serve warm and he was not the only resident who complained about cold fries. Resident #21 was interviewed on 8/29/23 at 9:14 a.m. He said he was one of the last residents served in his room, hot food was served cold and the food was not good. He was unable to explain further on what made the meals not taste good. He said the hot food was not served hot. Resident #41 was interviewed on 8/29/23 at 10:16 a.m. He said his meals were served in his room and the hot food was served cold. III. Meal service observations Meal tray pass was observed for one lunch in one unit. -The meal tray pass for the east unit was observed on 8/28/23 at 12:40 p.m. The dinner roll was served on the same plate with a dijon pork loin, scalloped potatoes and broccoli which made the roll soggy. The kitchen was observed for breakfast for all units. -The breakfast meal was observed on 8/29/23 at 7:28 a.m. The English muffins and toast were in a metal container on a shelf above the food steamers. The pureed bread was in a metal container on the same shelf as the English muffins and toast. There was not a mechanism to keep the food warm. IV. Test tray A regular diet test tray was evaluated on 8/29/23 at 12:22 p.m. by four surveyors. The menu was meat sauce, pasta noodles, Caesar salad, garlic bread and deluxe fruit salad. The following was observed: - All hot menu items were served on one plate with the garlic bread on top. - The meat sauce had too many green peppers and tasted like vinegar. It lacked Italian seasoning. - The pasta noodles were crunchy and not al [NAME]. - The toast was not toasted. It tasted like bread and there was no garlic flavor. - The Caesar salad was not Caesar salad but iceberg lettuce with an Italian dressing. V. Interviews The registered dietitian (RD) was interviewed on 8/30/23 at 3:04 p.m. The RD said there should be a heating mechanism for the toast, English muffins and pureed bread. The RD said toast and pureed bread should be served warm. She said biscuits, rolls and bread should not be served on the same plate as wet foods like spaghetti with meat sauce. She said that pasta noodles should be served al [NAME]. She said meat sauce should taste like garlic, oregano and basil. She said that pork loin should not be tough and if cheese was supposed to be melted, it should be served melted. The dietary director of operations (DDO) and nursing home administrator (NHA) were interviewed on 8/31/23 at 9:04 a.m. The DDO said toast should be served warm. The DDO said if the main meal was saucy, biscuits, rolls and bread should not be served on the same plate. She said pasta noodles should be served al [NAME]. The NHA said meat sauce should taste like tomatoes and Italian seasoning.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interviews, the facility failed to complete a comprehensive and accurate assessment of functional capacity after a significant change of condition for one (#70) of 36 sample residents. Specifically, the facility failed to comprehensively assess changes of condition in multiple areas of the resident's physical condition. Findings included: I. Resident #70 Resident #70, under age [AGE], was admitted on [DATE]. According to the October 2019 computerized physician orders, diagnoses included schizoaffective disorder and muscle weakness. Record review revealed Resident #70 made improvements in bed mobility, transfers, locomotion on the unit, dressing, eating, toileting, and hygiene. The resident also had an increase in verbal and physical behaviors and refusing care. The resident also had significant weight loss. Review of the initial minimum data set (MDS) assessment, dated 2/2/19 revealed the resident was coded as follows: -Bed Mobility- 3/2 (limited assist of one person) -Transfer-3/2 (limited assist of one person) -Locomotion on Unit-8/8 (activity occurred once or not at all) -Dressing-8/8 (activity occurred once or not at all) -Eating-3/2 (limited assist of one person) -Toilet Use-3/2 (limited assist of one person) -Personal Hygiene-2/2 (limited assist of one person) -Section E documented no behaviors for rejecting care and physical or verbal aggression. -The resident's weight was recorded at 130 pounds Review of the quarterly MDS, dated [DATE], revealed the resident had improvements coded as follows: -Bed Mobility-1/1 (supervision with setup help) -Transfer-1/2 (supervision with one person physical assist) -Locomotion on Unit-1/2 (supervision with one person physical assist) -Dressing-1/2 (supervision with one person physical assist) -Eating-1/2 (supervision with one person physical assist) -Toilet Use-1/2 (supervision with one person physical assist) -Personal Hygiene-1/2 (supervision with one person physical assist) -Urinary Continence -1/2 (supervision with one person physical assist) -Section E documented the rejection of care and physical and verbal behaviors. -The resident's weight was recorded at 106 pounds. Review of the quarterly MDS, dated [DATE], revealed the resident had improvements coded as follows: -Bed Mobility-1/0 (supervision) -Transfer-1/0 (supervision) -Locomotion on Unit-1/0 (supervision) -Dressing-1/0 (supervision) -Eating-1/1 (supervision with setup help) -Toilet Use-1/1 (supervision with setup help) -Personal Hygiene-1/0 (supervision) -Urinary Continence -1/0 (supervision) -Section E documented the rejection of care and verbal behaviors. -The resident's weight was recorded at 101 pounds. The MDS coding, from 2/2/19 through 10/1/19, indicated an improvement in bed mobility, transfers, locomotion on the unit, dressing, eating, toilet use, personal hygiene, urinary continence, an increase in physical and verbal behaviors and rejection of care and weight loss. B. Observations The resident was observed on 10/9/19, 10/10/19, 10/14/19, 10/15/19 and 10/16/19. During this time she observed using a front support walker to move around the facility, was independent in eating and drinking and could sit and stand without assistance. During the observations, no behaviors were observed by the resident. C. Interviews The MDS coordinator (MDSC) was interviewed on 10/16/19 at 8:39 a.m. The MDSC said each section was completed by a different department. She said she was responsible for the overall MDS. She said the facility had a program which triggered quarterly and annual evaluations. She said the significant change evaluations were not triggered in the program. She said significant change evaluations were discussed and tracked during the interdisciplinary team (IDT) meeting. She said the IDT met daily to discuss the electronic care management care board. She said the electronic care management care board was where the resident's condition changes and falls were tracked. She said the changes for Resident #70 should have been caught in the daily IDT meetings and a significant change assessment should have been completed for the resident. She said the resident's behaviors fluctuated between assessments and might not have been captured within the seven day observation period. She said a behavior note should have been included in the MDS assessment. She confirmed after review of the MDSs that a significant change assessment should have been completed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review, the facility failed to provide assistance for four (#2, and #44) of four residents reviewed for activities of daily living (ADLs) assistance of 36 sample residents. Specifically, the facility failed to: - Ensure Resident #2 received assistance with communicating her needs; and -Ensure Resident #44 received assistance with meals. Findings include: I. Communication A. Facility policies and procedures The Communicating with Persons with Limited English Proficiency policy, revised October 2015, was provided by the nursing home administrator(NHA) on 10/16/19 at 1:03 p.m. It reads, in pertinent part .It is facility policy to ensure that persons with limited english proficiency are identified and that the facility is capable of communicating information to such persons efficiently . B. Resident #2 1. Resident status Resident #2 over the age of 90, was admitted on [DATE].According to the October 2019 computerized physician orders (CPO), diagnoses included vascular dementia with behavioral disturbance, generalized anxiety disorder, and major depressive disorder. The 10/3/19 minimum data set (MDS) assessment, revealed the resident had severe cognitive impairment with a brief interview for mental status (BIMS) score of 0 out of 15. Resident #2 required extensive assistance of two for activities of daily living (ADL) and limited one person assist for eating. Resident #2 spoke Polish, and wanted an interpreter to communicate with doctors and healthcare staff. 2. Resident observations Resident #2 was first observed on 10/9/19 at 10:15 a.m. She was seated in her wheelchair muttering and then screaming. Several staff were observed to walk by her and not attempt to use a communication board or google translator. Resident #2 was observed on 10/9/19 at 11:46 a.m. to 12:30 p.m., she was in her wheelchair in hallway near the nursing desk yelling in Polish Staff were observed to walk by the resident without any attempts to communicate with her to find out what she needed. Resident #2 was observed on 10/10/19 to 10/16/19. She was observed to be yelling in Polish at staff as well as other residents for several days no staff were observed to use google translator or communication board with resident. 3. Record review The care plan, initiated on 7/11/19, revealed the resident had a history of yelling for police related to diagnosis of vascular dementia with behavioral disturbance. The interventions included staff would anticipate cares, allow ample time for responses, ask one command at a time, use gentle touch and soft voice, and use communication board. Resident preferred to communicate in polish. Progress notes The interdisciplinary progress notes were reviewed from 6/13/19 through 10/16/19. There were no documented of communication board or google translate used with Resident #2 for interactions. Speech Therapy notes The speech evaluation and plan of treatment on 9/19/19 revealed short term goals included resident #2 will increase ability to make needs known with 80%percent of attempts with google translate with staff education in place in order to communicate basic wants, needs and successfully participate in functional, social communication exchanges with familiar listeners. Speech therapy progress report from 9/19/19 to 10/3/19 revealed resident required extra time with use of translation by son or google translation in Polish. Speech therapy discharge summary 10/12/19 revealed resident very poor ability to communicate her needs. Resident#2 requires support in polish with staff support using google translate when possible. Resident also required increased support from staff for interactions. 4. Staff interviews An unidentified certified nurse aide (CNA)was interviewed on 10/9/19 at approximately 12:15 p.m. The CNA said the resident did not speak English, she said she spoke Polish, but she was unable to understand her. The CNA said the resident only understood, smiles and love. Certified nurse aide (CNA) #2 was interviewed on 10/16/19 at 11:15 a.m. She said, she never saw the communication board for Resident#2. She said she just tried to talk to resident in english and see if she would express her needs by facial expressions. She said, I do not use google translate because I was not taught how to use it. She said she was told the resident did not know English or Polish. CNA#17 was interviewed on 10/16/19 at 2:00 p.m. CNA #17 she never saw a communication board for Resident #2. She said she used the google translator on her personal cell phone, however, she did not know if she understood. Licensed practical nurse (LPN) #2 was interviewed on 10/16/19 at 10:05 a.m. LPN #2 said she was not aware that Resident #2 did not have a communication board. She said the staff tried to anticipate the resident wishes, however, she was told the resident communication in English and/or Polish was difficult and did not really make sense. She said she would benefit on training on communication with Resident #2 Activities Manager (AM) was interviewed on 10/16/19 at 2:30 p.m. She said she never saw a communication board for Resident #2. She said Resident #2 knew some words in English. She said she had not used google translator with resident, and was told the resident ' s English and Polish language were garbled. She said staff tried to see facial expressions to know how to talk with the resident. II. Meal assistance A. Resident #44, age [AGE], was admitted on [DATE]. According to the October 2019 CPO diagnoses included, vascular dementia, and dysphagia. The 8/8/19 minimum data set (MDS) assessment revealed the resident ' s cognitive status was moderately impaired with a brief interview for mental status (BIMS) score of three out of 15. She required extensive assistance with eating, bed mobility, transfers, dressing, toilet use, and personal hygiene. B. Observations 10/10/19 -At 8:42 a.m., the resident was served her meal of pancakes and sausage. The certified nurse aide (CNA) who served the meal left the table before cutting up the pancakes. -At 8:44 a.m., Resident #44 continued to wait for someone to help her eat. She then closed her eyes. -At 8:45 a.m., the CNA walked up to the resident and asked her to wake up. The CNA put butter on the pancakes and cut them up for the resident. The CNA assisted the resident to eat a few bites of pancake. -At 8:50 a.m., the CNA left the table without offering the resident anything else to eat or drink. -At 9:02 a.m., the resident was not receiving any assistance by staff to eat. She was not eating on her own. The resident was observed to sit at the table, and watch the happenings during the meal service. -At 9:06 a.m., the CNA came back to the table. The resident said she did not like the breakfast. The CNA asked if she would like a banana. The resident said yes. A few minutes later a dietary staff member came to the table and said the kitchen did not have any bananas. The CNA informed the resident no banana was available. The resident made a frown face. 10/14/19 noon meal -At 12:58 p.m., the resident was served her meal. The resident was served mashed potatoes, pudding and a sandwich. -At 1:02 p.m., Resident #44 was sitting at the table with no assistance from staff. The CNA then got up and left assisting Resident #44 to find a tray for another resident. -At 1:05 p.m., the resident received no assistance from staff. The resident did pick up her milk glass and took a drink. -At 1:06 p.m., the CNA came over, and sat with her, the resident said she itched. The CNA told the resident that she would tell the nurse. -At 1:09 p.m., she was assisted away from the table to see the nurse. The CNA covered her food. -At 1:25 p.m., the resident was in her room lying down. The CNA said the nurse put a cream on the resident. -At 1:33 p.m., the resident's tray remained at the table covered. -At approximately 1:45 p.m., the tray was picked up by the dietary staff and thrown away. The resident was not provided her noon lunch tray after she received treatment for the itching. Staff did not offer to get the resident a room tray or substitute meal as hers was left in the dining room. C. Record review The 5/6/19 nutrition note documented the resident's intakes were variable. The resident received a nutrition supplement and fortified foods at meals. The 10/10/19 restorative dining note documented the resident required frequent cueing and reminding to finish task. The resident ' s progress varied from day to day. The care plan dated last updated 8/8/19. identified the resident was at risk for weight loss. Pertinent interventions were the meal assistance as needed, and determine individual likes and dislikes. D. Interview Registered nurse #1 was interviewed on 10/16/19 at approximately 1:30 p.m. The RN said the resident sat at the restorative table and she required assistance with eating. She said that she was at risk for weight loss. The RN said alternatives should be offered when the resident did not like what she was served.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to ensure two (#4) of 36 sample residents who were unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming and personal and oral hygiene. Specifically, the facility failed to provide timely incontinent care to Resident #4 Findings include I Facility Policy The Incontinence Management policy revised on December 2018 was provided by the director of nurses (DON) on 10/15/19 at 3:00 p.m., it read in pertinent part; . Moisture-associated skin damage and infection may result from incontinence II.Resident #4 A. Resident #4, age [AGE], was admitted on [DATE]. According to the October 2019 computerized physician orders (CPOs), diagnosis included dementia. The 8/14/19 minimum data set (MDS) assessment revealed, Resident #4 was rarely understood and therefore a brief interview for mental status (BIMS) assessment was not attempted. The resident required extensive assistant with two persons for bed mobility, transfers, dressing and toileting. The resident was incontinent of bowel and bladder. He was dependant on all activities of daily living. B.Observations Continuous observations for Resident #4 on 10/14/19 was from 9:13 a.m. to 2:13 p.m. showed the resident did not receive incontinence care for five hours. -At 9:13 a.m., Resident #4 sat in his wheelchair (W/C) in a dark room talking to himself. -At 9:53 a.m., the resident continued to sit in his room. -At 10:25 a.m., he remained in his room and talked to himself. He leaned to the right side of his W/C and the call light was attached to his shirt At 10:34 a.m., RN #3 went into the residents room to ask him if he wanted to lie down and he said yes She told him said she would get help to lie him down and left the room. -At 10:51a.m., he remained in the W/C talking to himself. RN #3 stood in the hallway and tried to get help from a certified nursing aide (CNA) to assist him to bed. -At 11:02 a.m., CNA #2 and CNA #31 assisted him with repositioning, however, did not provide incontinence care. -At 11:14 a.m., the activity manager (AM) knocked on his door to see if he wanted to go to stretch class and he said yes. However, she did not assist him to the activity -At 11:51 a.m., the resident remained in the W/C in his room. -At 11:57 a.m., CNA #2 assisted the resident to the dining room, to watch TV. -At 12:25 p.m., CNA #32 assisted the resident to the dinner table. -At 1:20 p.m., CNA #31 assisted him to finish his meal and then assisted him back to his room -At 1:23 p.m., RN #3 was notified by the surveyor that the resident had not received any incontinent care in over four hours. -At 2:13 p.m., CNA #31 assisted him into bed with the help of CNA #2. The resident had been incontient of urine. The resident ' s bottom was red. C. Record review The care plan for activities of daily living (ADLs) for Resident #4 dated 10/3/19 read in pertinent part: .He had an ADL self care performance deficit related to the dementia. The interventions read the resident needed extensive assist by two persons for toileting care . The situation background assessment recommendation (SBAR) nurse note dated 9/23/19 read in pertinent part; .Resident #4 was noted during cares to have moisture related skin damage. Cream was applied and the resident needed to be checked for incontinence every two hours and as needed . D. Interviews Registered nurse (RN) #3 was interviewed on 10/14/19 at 1:46 p.m. RN #3 said incontinent care needed to be completed for every resident every two hours and as needed. She said she would get a CNA to change his incontinent brief for Resident #4 at that time. The director of nurse (DON) was interviewed on 10/16/19 at 4:31 p.m. The DON said residents were to be checked for incontinent care before and after each meal. She said the facility had regular meetings with the team of medical staff discuss changes with residents on their care and then a care plan was created.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interviews the facility failed to ensure sufficient fluid intake to maintain proper hydration and health for one (#60) out of six residents out of 36 sample residents reviewed. Specifically the facility failed to: -Ensure Resident #60 met his hydration needs Findings include: I. Facility policy The Hydration Management policy revised date July 2017 provided by the director of nurses (DON) on 10/15/19 at 3:00 p.m. read in pertinent part; .Residents are provided with sufficient fluid intake to maintain proper hydration and nutritional status. Residents hydration status will be monitored on a regular basis . II. Resident #60 A. Resident #60, age [AGE], was admitted on [DATE]. According to the October 2019 computerized physician orders (CPOs), diagnoses include dementia and diabetes. The 9/7/19 minimum data set (MDS) assessment revealed, Resident #60 was able to complete the assessment with had moderate cognitive impairments with a brief interview for mental status (BIMS) score of 00 out of 15. The resident required extensive assistant with two persons for bed mobility, transfers, dressing and toileting. The resident was coded as a high risk for skin breakdown. He required extensive meal assist of one. B. Observations On 10/10/19 at 8:28 a.m., the life engagement coordinator (LEC) #2 was observed to assist Resident #60 with 240 cubic centimeter (cc) of apple juice. The resident had his eyes closed and leaned to the right side of his wheelchair. He took a few sips of juice throughout the breakfast meal. The glass was 210 cc full after the meal was over. Continuous observations for Resident #60 on 10/14/19 was from 9:13 a.m. to 2:00 p.m. Throughout the five hours of continuous observations, the resident received only approximately 160 cc to drink. -At 9:13 a.m. the resident laid in bed the room was darkened and his bed was in the low position. His water pitcher was full and was on his bedside table. -At 10:06 a.m., he remained in bed no cares given, no fluids offered -At 10:53 a.m., he remained in bed no cares given, no fluids offered -At 11:07 a.m., he remained in bed no cares given, no fluids offered -At 11:14 a.m., the activities manager (AM) went into his room and then left the room, the resident was asleep in his bed, no cares given, no fluids offered. -At 11:18 a.m. the certified nurse aide (CNA) #31 entered his room to check on him, he was asleep in his bed, no cares given and no fluids offered. -At 11:52 a.m., CNA #31 went into the room with the mechanical lift to assist him out of bed. CNA #2 assisted CNA #31 to transfer him from the bed to the chair. The resident was then assisted to the dining room. During the care he was not offered any fluids. -At 12:17a.m., CNA #31 was observed to put a 240 cc glass of lemonade in front of him on the table. He was only provided one 240 cc glass of lemonade. He was not offered any fluids and was unable to drink on his own. -At 12:30 p.m., the resident was asleep while he sat at the dining table -At 12:42 p.m.,CNA #31 received his meal which consisted of mashed potatoes, meatloaf, peas and a fruit cup. The CNA assisted him with a sip of his lemonade, however he was asleep and CNA tried to wake him up but then she put the glass of lemonade down and went to assist Resident #4 with his meal. -At 12:48 p.m., the assistant director of nurses (ADON) assisted him to wake up and then fed him two bites of the mashed potatoes and meatloaf, and he consumed approximately 40cc of the lemonade. -At 1:00 p.m., the ADON assisted him with the lemonade and the resident held the glass. However, he could not drink it by himself, she set the glass down when she was not with him to help. -At 1:13 p.m., he had only consumed approximately 120cc of the 240 cc glass of lemonade. -At 1:18 p.m., CNA #31 and the ADON repositioned him in his wheelchair. CNA #31 then assisted him out of the dining room. When he was assisted out of the dining room, he was not encouraged and assisted to drink the rest of his lemonade. He consumed approximately 40 cc of the lemonade. -At 1:56 p.m., he continued to sit in his wheelchair in the hallway next to his room. -At 2:00 p.m. CNA #31 and CNA #30 assisted the resident to bed. During his care CNA # 2 entered the room to fill his water pitcher with ice. The CNAs failed to offer and assist the resident with any fluid during cares. then the life engagement coordinator (LEC) #2 knocked and said he had to type out a report and needed to talk to the resident, he said he would come back after cares. CNA # 17 knocked and entered the room to talk to CNA #31 about the staffing schedule. Finally RN #3 knocked and said she would come back later after care C. Record review Nutritional registered dietitian assessment note dated 8/19/19 read Resident #60's nutritional estimated needs for fluid intake was 1956 cc per day. The care plan dated 8/19/19 read Resident #60 had a potential fluid deficit related to the need for encouragement and assistance with fluid intake at all times. The goal was to be free of symptoms of dehydration and maintain moist mucous membranes, good skin turgor. Pertinent approaches included, encourage and assist the resident with fluids of choice. D. Interviews CNA #4 was interviewed on 10/15/19 at 4:26 p.m. CNA #4 said Resident #60's routine was to eat in the dining room for breakfast and lunch, then stay in bed for dinner. The CNA said the resident ate and drank well with assistance. The registered dietitian (RD) was interviewed on 10/16/19 at 5:11 p.m. The RD said he would see residents on a yearly basis, new admissions, or with a significant change of condition. He said he saw Resident #60 recently due to weight loss. He recommended in his nutritional assessment that Resident #60 had fluid intake of 1575- 1890 cc per day. He calculated that by multiplying 30 cc per kilogram of body weight. The residents weight was 138lbs. He said unless there was a medical condition or fluid restriction that was the average. The RD said the resident was unable to drink on his own, and therefore he should be encouraged more often throughout the day. The director of nurses (DON) was interviewed on 10/15/19 at 3:14 p.m. The DON said residents were checked for incontinence before and after each meal and fluids were offered at that time. She said water was at the bedside for the CNAs to offer and assist residents to drink during all cares. Resident #60 had a recent change of condition so he declined more food, fluids and activities. The facility had regular meetings with the team to include the RD when a weight change occurred so a plan was put into place. The DON said that at each meal, the resident should receive at a minimum 480 cc of fluid.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and interviews the facility failed to ensure one (#49) out of one out of 36 sampled residents reviewed for quality of care received treatment and care in accordance with the comprehensive person-centered care plan. Specifically, the facility failed: -To implement person-centered care plan treatment and care resulting in self injurious behaviors of biting and chewing on arms and hands; -To provide preferred activities to the resident; and -To communicate with the resident while providing care. Findings include: I. Failed the facility failed to implement person-centered care plan treatment and care due to her anxiety and related self injurious behaviors of biting and sucking. II. Facility Policy and Procedure A copy of the policy Skin Management was provided by the director of nursing (DON) on 10/15/19 at 5:33 p.m. It read in pertinent part .Residents receive care to aid in the prevention or worsening of wounds and/or pressure ulcers. Individuals at risk for skin compromise are identified, assessed and provided treatment to promote healing, prevent infection and prevent new ulcers from developing. Ongoing monitoring and evaluation are provided for optimal resident outcomes III. Resident #49 ' s status Resident #49, below the age of 70, was admitted [DATE]. According to the October 2019 computerized physician orders (CPO), diagnoses included dementia with behavioral disturbance, cerebral palsy, anxiety, deafness, and blindness. The 8/16/19 minimum data set (MDS) assessment revealed the resident had severe cognitive impairment with a brief interview for mental status (BIMS) of 00 out of 15. She exhibited verbal behavioral symptoms directed towards others, required extensive assistance with transfers and hygiene, required limited assistance with eating, and received scheduled pain and anxiety medications. IV. Observations The resident was observed throughout the survey and was found to bite herself, and was not provided with the interventions as directed by the care plan. The resident did not receive any redirection, was not wearing any protective sleeves, or provided any touch stimulation items, her baby dolls or squeaky toys as the interviews showed. 10/9/19 -Lunch was continuously observed from 11:46 a.m. to 1:27 p.m. Continuous lunch observations revealed the resident did not receive any assistance with her meal and remained alone at her table. Before receiving her lunch she was observed chewing on her fingers and the nursing staff that passed her did not stop to interact with her or try to redirect her. Her fingers appeared red but she did not make any gestures of being in pain. The nursing staff were observed to place her lunch in front of the resident with out communication to the resident as to what was served. Throughout the meal no assistance was provided to the resident. She was observed feeling around the table for her food, utensils and beverages. No nursing staff stopped to assist the resident as she tried to eat with her spoon held backward in her hand or when she was licking out the food from the bowl. A CNA was observed to stop to open the resident ' s soda and put it on the table in front of her instead of putting it in her hand. The resident remained sitting alone at the dining room table after she finished her meal. She sat alone at the table until she started to yell out and then a CNA assisted her out of the dining room. 10/10/19 -At 9:00 a.m. the resident was observed sitting alone at the dining table. She was observed to lick the food out of the bowl rather than use a utensil as multiple nursing staff walked past her. None of the staff stopped to offer assistance. -At 9:08 a.m., the resident had finished her breakfast and was sitting alone at the table. She was observed chewing and sucking on her arm while sitting in the dining room. She was observed chewing and sucking on herself for five minutes. The areas she was chewing on were red with the skin intact. Throughout the observation, no staff checked in with or redirected her as they passed by her in the dining room. The resident did not have any arm protectors on her arms. The resident was not provided any touch stimulation items for the resident as the care plan directed. -At 9:57 a.m. the resident remained alone for the duration of the meal. She was finished with her meal and was feeling around the table for something. The nursing staff walked by without offering assistance or attempting to communicate with her. She had to cry out before assistance was given from the nursing staff. -At 12:00 p.m. the resident was observed to sit alone in the dining room. When the CNA served her meal tray, it was sat in front of her, however, they did not show her where the bowls were to let her know where they were located. -At 2:11 p.m., the resident did not have any wounds observed on her arms or hands. 10/14/19 -At 9:25 a.m., CNA #19 and #12 assisted the resident with incontinence care. The resident was crying and holding her face. CNA #19 told the resident verbally she was going to assist her to bed in response to her crying. However, the resident was deaf and unable to understand. The CNAs proceed to assist her into bed and tucked her in. No communication about activities or 1:1 time from the staff was observed before laying her down in bed. The resident did not have sleeve protectors on and was not offered to put any on. -At 10:00 a.m. the resident was napping. -At 10:34 a.m. the resident was napping -At 11:42 a.m. the staff roused the resident, and assisted her into her wheelchair and took her out into the hall. She sat there briefly before being assisted into the dining area for lunch. -At 12:51 p.m. the resident was eating her mashed potatoes with her fingers and licking out the bowl. -At 1:07 p.m., the resident was observed sitting alone at the dining table and was sucking on her fingers and arms. Small red areas were observed on her arms and fingers. No staff interacted or redirected her until she started yelling. Nursing staff did not respond to her cries for 20 minutes. - At 1:20 p.m., when nursing staff responded to her she was assisted back to her room and put her in bed. The staff did not try to communicate afternoon activities or offer her 1:1 interaction. -At 1:23 p.m., Resident #49 was in her room and wounds were observed closely, two wounds on her right and left forearm were newly scabbed over, the wounds on her hands and fingers where opened and raw. -At 4:10 p.m. the resident was asleep. -At 5:50 p.m. the resident was still in her room. Staff had transferred her into her wheelchair, then left her alone in the dining room. -At 6:40 p.m., the resident was observed sucking on her fingers and arms while waiting for dinner to be served. She was observed sucking on her fingers and arms for ten minutes with no intervention from the five nursing staff in the dining area. She had opened a wound on her left finger. -At 6:50 p.m. the resident was sitting alone at the dining room table waiting for dinner. When the CNA served her dinner they set it down on the table in front of her and did not show her where it was or let her know it was there. -At 7:10 p.m. the resident was observed licking out one of her food bowls. No staff offered her assistance. -At 7:15 p.m. the resident was crying out and was moving around her food bowls. She ate her turkey and roll and did not eat her broccoli, which did not have ranch on it, or rice. She was able to open her supplemental nutrition ice cream cup but could not find her spoon and began to lick it and use her hands to get the ice cream out. A staff member handed her a spoon. On 10/15/19 -At 10:30 p.m. the resident was sitting alone in the hallway. Multiple nursing staff walked by her and offered no interaction. -At 1:30 p.m. the resident was napping. -At 4:30 p.m., registered nurse (RN) #5 was notified about the wounds on her arms and hands. The RN confirmed the wounds on her right arm, right thumb, left knuckle, left thumb and left arm. -At 6:45 p.m., the resident was observed sitting alone at the dining room table biting on her fingers and arms while waiting for dinner. A licensed nurse walked by the resident and did not interact or redirect her from biting herself. V. Family interview Resident #49 ' s sister was interviewed on 10/16/19 at 1:45 p.m. She said her sister would bite herself when her needs were not being met. She said when the resident lived with her she would pat her hand to redirect her to stop when she found the resident biting herself. She said she believed the biting was behavioral possibly being linked to her anxiety. She said the resident and the family had created the signs she used to communicate. She said the resident and her would spell things out to each other when they were kids and continued to communicate this way as they grew up. She said the touch sign language the resident understood were signs they made up. She said the resident had always been able to feed herself, but needed to know where the food bowls were at. She said the resident would smell her food to know if she wanted to eat it. She said that if she did not like the smell of the food she would not eat it. She said she the resident told her to tell the facility that she wanted ranch with all her veggies. VI. Record review The head to toe skin assessment completed on 10/10/19 documented the resident ' s skin was intact. The behavior tracking form from October 2019 failed to show any interventions for behavior techniques described in the plan of care were used. The last documented behavior of biting or chewing was 10/6/19. The treatment administration record (TAR) from 10/6/19 only documented the behavior had occurred, it did not specify the duration or extent of the behavior. The 10/16/19 at 4:48pm the dinner meal ticket documented a packet of ranch would be included when vegetables were served. VII. Care Plans The 2/5/18 nutrition progress note documented the resident ' s risk for nutrition deficiencies. An intervention documented the resident liked ranch poured on all her veggies. The 6/21/19 revised care plan identified the resident was at risk for non-pressure skin issues related to her biting her hands and arms. She also received antianxiety medications to aid her behavioral disturbances, which included biting self. The goal was for the resident was to decrease her number of anxiety episodes, engage in 1:1 sessions with staff doing sensory activities and minimize her potential for skin issues through the review date.Interventions included the use of protective sleeves, the care plan documented, the resident was able to remove them independently. If she expressed dislike, by biting self, crying out or yelling staff were to cease the activity immediately. It was documented to report behaviors to the physician and to track them on the daily track log in the treatment administration record (TAR). The care plan documented the nurse would assess skin weekly for new bites and signs and symptoms of infection. The 6/21/19 revised care plan documented the resident had behaviors related to inability to fully communicate her needs and make herself understood. The resident would bite herself on her hands and arms when she was upset or agitated; she would chew on sticks, would place herself on the floor from her wheelchair, cried outs, chewed her fingernails and bit her own arms. The goal for the resident was to demonstrate effective coping skills through the review date. The documented interventions included redirection of the resident when behaviors occur with activities, preferred food or drink, giving her one of her baby dolls of stuffed animals that she liked to take care of, to allow the resident to make her own choices, check for pain or discomfort, provide her privacy, reassure her with calm gentle touch and redirection. The 6/21/19 revised care plan revealed the resident experienced joint pain and osteoporosis, which the resident expressed as grimacing, moaning, and crying. The goal was for the resident to have pain alleviated with medication and non-pharmaceutical interventions. A documented intervention was to provide diversion activities such as positioning, giving her a doll or squeaky toy and offering food or fluids of choice. The situation, background, assessment, recommendation (SBAR) completed on 10/15/19 at 5:11 p.m. documented Resident #49 had self-inflicted wounds on her right arm, right thumb, left knuckle, left thumb and left arm. The wounds were attributed to the resident biting, scratching, pinching and grabbing self out of anger, frustration, and anxiety. The nurse documented no signs or symptoms of infection and no distress or pain from the resident. The resident ' s physician and sister were notified. The head to toe skin check completed on 10/15/19 at 5:34 p.m. documented three small scabs on the resident ' s right arm that were 100% scabbed over with no drainage.In addition a second head to toe skin check completed on 10/15/19 at 10:51 p.m. documented a scabbed over sore on the resident ' s right thumb, a wound to the left knuckle and thumb, and wounds to the left arm. All wounds noted as, self-inflicted, scabbed over with no drainage or signs or symptoms of infection. The resident ' s physician and sister were notified. VII. Staff interviews CNA #12 was interviewed on 10/14/19 at 9:36 a.m. CNA #12 she said the resident ' s sister taught her how to communicate with the resident through signs communicated from the resident. She said the resident would pat the side of her leg if she was wet, folded her hands by her head if she wanted to lay down, drive an invisible steering wheel if she wanted to go and pinch her nose if she had a bowel movement. She said the resident was blind, deaf and could not communicate verbally. Registered nurse (RN) #5 was interviewed on 10/15/19 at 5:00 p.m. RN #5 said Resident #49 self inflicted harm to herself by biting and sucking on her skin. She said the resident chewed her fingernails to the soft flesh under her nails and has done it for years. She said staff was instructed to redirect her by patting her arm or giving her candy. She said the resident harmed herself some days and some days she did not. She said the resident ' s biting can get worse depending on her anxiety level. RN #5 confirmed Resident #49 had multiple wounds on her right and left fingers, hands, and arms. She said they do weekly skin assessments but if wounds were found before the designated weekly assessment nursing staff should do an updated assessment, SBAR, and progress notes. She said the physician and wound team should be notified as well. The social services director (SSD) was interviewed on 10/15/19 at 5:35 p.m. The SSD said Resident #49 had a behavior of biting herself. She said that redirection was used to intervene in the behavior. She said the resident was redirected with her sensory toys, touch and one-to-one interaction with staff. She said the sensory toys were in her room and it should be in the care plan to use them as a redirection. She said the staff were aware of the baby doll and sensory toys for Resident #49. She said although the resident was blind and deaf, she did have the ability to feel touch. She said Resident #49 communicated through touching, direction and feeling. RN #1 was interviewed on 10/16/19 at 9:45 a.m. RN #1 said she has worked with Resident #49 since she started a month ago. She said redirection was used when the resident was observed biting herself. She said redirections which were successful included, handing the resident her back scratcher, toys or dolls. She said she notified the physician when she saw the resident biting herself and it was recorded on the TAR. CNA #12 was interviewed on 10/16/19 at 9:55 a.m. She said when she saw Resident #49 biting herself she would go to her and gently rub her arms, shoulders, and face to comfort her. She said she got very upset when her sister left from visits and then she needed redirection and engagement. The social services director (SSD) was interviewed 10/16/19 at 2:07 p.m. She said the resident used limited sign language. She said the resident understood when her sister wrote on her skin. She said there were certain things they had learned from the resident to communicate and how she expressed herself. She said it was difficult to assess the resident for pain. She said the resident had limited communication to tell the nursing staff where she was in pain. She said the two staff who knew sign language recently left the facility. She said there were no sign language classes for staff. The activity manager was interviewed on 10/16/19 at 2:46 p.m. She said she has one assistant who became full time a month ago after her last assistant left the facility. She said they worked seven days a week between all the units. She said there was always an activities person in the house. She said she feels the activity needs of the residents were being met. She said she wished they could have the same ratios on the other units that were in place on the memory unit. She said Resident #49 did not like her routine messed with. She said the resident would cry, scream and punch her hand to communicate she did not want to be bothered. She said the resident knows where all her stuff is in her room and can reorganize her room on her own. She said they communicated activities to the resident by touching the bottom of her cheek. She said said sometimes writing on her arm and feeling signs in her palm works for communication. She said when the resident sits by the wall in the hallway she is relaxing. She said if anyone tried to move her it was game over. She said the staff does sensory things with the resident, such as play with the squishy toys with her. She said when she saw the resident biting herself she would lightly place her hand there but sometimes that would make the resident more upset. She said the resident bites herself to calm herself. She said activities staff conduct one on one sessions with the resident. She said the sessions where a minimum of 15 minutes twice a week. She said if the resident was engaged the staff would hold a longer sessions. She said the 15 minute sessions was suggested/recommended in a class she took about one-one sessions. She said the resident ' s attention span tended to lessen if sessions were longer than 15 minutes. She said it is tailored to residents. She said they do other little things in between the documented sessions. She said activities staff check in with all residents daily. The director of nursing (DON) was interviewed on 10/16/19 at 4:15 p.m. The DON said the weekend staff should have done a skin assessment and followed the skin policy. She said that was her expectation of the nursing staff. She said when Resident #49 bit herself the staff should attempt to intervene to keep her safe to the best they can and monitor areas for infection. She said they might not be able to stop her but staff should address and intervene when they can. She said they should try long sleeves and skin protecting sleeves and touch stimulation items as the care plan directs. She said sometimes she bites to self-sooth and we still try to intervene. She said they work with the sister for information about how to communicate with the resident. She said everyone knows the resident liked ranch on her veggies. The dietary manager was interviewed on 10/16/19 at 4:48 p.m. She said the kitchen included a packet of ranch on top of the residents veggies and the staff should open the packet and pour the ranch on top for the resident.

Based on observations, record review and interviews the facility failed to ensure infection control practices were followed to prevent the spread of infection. Specifically, the facility failed to: -Follow proper hand hygiene with glove uses when working between dirty and clean processes; and -Follow proper sanitization of equipment is between resident use. Finding include: I. Hand washing II. Facility policy The hand hygiene policy revised on February 2018 was provided by the director of nurses (DON) on 10/15/19 at 3:00 p.m. read in pertinent part; .To decrease the risk of transmission of infection by appropriate hand hygiene . III. Observations Certified nurse aide (CNA) #12 was observed on 10/14/19 at 9:28 a.m.to remove the mechanical lift and sling from Resident #49. The CNA left that in the hallway and did not disinfect that after resident use. Registered nurse (RN) #5 was observed on 10/09/19 at 11:47 a.m. to push the wound treatment cart into Resident # 63s room and wound care was completed for the resident. The treatment cart was then pushed out of the room into the hallway. The cart was not disinfected when it was pushed out of the room. The assistant director of nurses (ADON) was observed on 10/09/19 at 3:11 p.m. to carry a full sharps container in the hallway to the dirty supply room with her bare hands. She failed to wear gloves. Licensed practical nurse (LPN) #1 was observed on 10/15/19 at 11:19 a.m. to do wound care for Resident #63. CNA #2 assisted the LPN to turn the resident to her side to expose her wound on her bottom for the dressing change. The LPN donned gloves and opened the sterile gauze supplies and put that on the bed next to the resident. She then took off the old dressings that were on the resident and sprayed the wound with wound cleanser. She then used a peri wipe to clean the residents peri area and bottom. Without changing her gloves she put the clean gauze on the wound. She had to push the new gauze into the wound and she did that with the same gloved fingertips. After that, she took off her gloves, cleaned up the area and washed her hands. She failed to wash hand and change gloves in between dirty to clean procedure. Interviews CNA #32 was interviewed on 10/15/19 at 1:29 p.m. CNA #32 said she would plug the mechanical lift in after each use. She said the residents had their own slings so the facility did not share in between residents. She was trained a few months ago in a classroom to practice. Staff development coordinator (SDC) was interviewed on 10/16/19 at 2:08 p.m. The SDC said if there was an infection in the building they would contact the public health department and then isolate the source. She educated the facility staff to wash their hands with soap and water or use alcohol based hand rub (ABHR). She had a demonstration in a classroom to show them how to change their gloves between dirty and clean procedures at least one time a year with all staff. She said the equipment would be cleaned per manufacturer's directions. She said the mechanical lift should be disinfected after each resident use.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** III. Chemicals sprayed on tables A. Observation After breakfast on 10/10/19 at 9:17 a.m.in the secured unit, the residents were still seated at the dining table when the housekeeper (HK) #1 walked to the table where Resident #57 and Resident #65 were sitting after finishing their meal. HK #1 did not introduce herself to the residents, she did not talk to them about the process with what she was about to carry out and neither did she offer to transfer the residents prior to removing the table cloth and subsequently sprayed the sanitizer on the table while the residents continued to sit at the table. B. Staff interviews The nursing home administrator (NHA) was interviewed on 10/16/19 at 8:59 a.m. The NHA stated in order to ensure residents were treated in a dignified manner, staff should introduce themselves to the residents, and also explain the process they were going to carry out on or around the residents. The NHA stated housekeeping personnel should wait till residents vacate the dining area before they commence cleaning. She added that the alternative was for housekeeping to seek the assistance of nursing staff to safely transfer residents to a secured area while they clean. The NHA concluded that it was derogatory to any resident to have chemical sprayed around them and also to not be spoken to. She added that she would provide education to the housekeeping staff going forward. The infection preventionist (IP) was interviewed was interviewed on 10/16/19 at 9:24 a.m. The IP stated spraying sanitizing chemicals the dining area while residents still sat at the dining table was not an acceptable practice. She stated housekeeping personnel should clean only when residents were not in the area. She concluded that the facility would provide education to staff going forward. Based on observations, record review and interviews, the facility failed to ensure that three (#15, #57 and #65) out of three residents reviewed for dignity out of 36 sample residents, were treated in a dignified manner Specifically, the facility failed to ensure: -Resident #57 and Resident #65 were informed and/ or offered to be assisted away from the table prior to housekeeping personnel sprayed sanitizing chemical on the tables, while residents were still seated at the dining table; and -Ensure resident #15 wishes were honored around going to bed. -Ensure resident #15 wishes around plugging in motor scooter were honored. Findings include: I. Facility policy The Resident Dignity and Personal Privacy policy, with a revision date of June 2007, was provided by the director of nursing (DON) on 10/15/19 at 5:37 p.m. It reads, in pertinent part .Dignity means that when interacting with residents, staff carries out activities that assist the resident in maintaining and enhancing his or her self-esteem and self-worth. The facility provides care for residents in a manner that respects and enhances each resident ' s dignity . II. Resident #15 A. Resident status Resident #15, over the age of 60, was initially admitted on [DATE], and readmitted on [DATE]. According to the October 2019 computerized physician order(CPO), diagnoses included displaced intertrochanteric fracture of left femur, acute pain due to trauma, dementia, and hemiplegia. The 7/3/19 minimum data set (MDS) coded resident as cognitively intact with a brief interview for mental status (BIMS) score of 14 out of 15. Resident #15 required extensive one person physical assistance with dressing, transfers, bed mobility, and personal hygiene. Resident #15 was frequently incontinent of bowel and bladder. B. Record review The care plan, initiated 6/27/17, revealed the resident had a minor communication problem of not understanding what was being relayed to her and behavior problem related to making false allegations toward others The interventions included anticipate and meet resident's needs. Communication allow adequate time to respond, do not rush, request clarification from the resident to ensure understanding, face when speaking, make eye contact, and allow choices within individual's decision making abilities. C. Observation -On 10/9/19 at 11:38 a.m. to 12:00 p.m., Resident #15was observed in her wheelchair calling for assistance Licensed practical nurse (LPN) #2 was observed to go to Resident #15's room door. Resident #15 was heard to say, Can you please put me in bed? I'm tired. LPN #2 was observed to not make eye contact with Resident #15 and said, I don't have any certified nurse aides (CNAs).She then proceeded to walk back to the medication administration cart at the end of the hall. LPN#2 was observed to not look or call for any CNAs. Resident #15 was observed to begin to cry. She said, The nurse rushed with me, and did not honor my choice. I want to lay down but the staff will not help me. -On 10/15/19 at 1:55 p.m., Resident #15 was observed on her motorized scooter by her bedroom door. Resident #15 was sitting on the scooter with it unplugged into wall socket. Resident #15 said, Can you plug my scooter into the wall socket? An unknown nurse was observed to quickly walk by resident #15 ' s room door and not give any eye contact. The unknown nurse said, I can not help you now. I do not have a CNA. Resident #15 was observed to cry. She said, Why will she not help me? She could have stopped and plugged my scooter into the wall. D. Resident interview Resident #15 was interviewed on 10/9/19 at 11:08 a.m. She said LPN #2 did not explain the rationale behind making her wait to get in bed. She said she did not know why the nurse could not call for help. She said she did not know why LPN#2 could not take the time to talk to her. She said there were several staff walking up and down her hallway who could have helped. Resident #15 was interviewed a second time on 10/15/19 at 2:10 p.m. Resident #15 said the unknown nurse did not use brief, consistent words with her and did not explain the reason she could not help her. She said she was not treated in a dignified manner. E. Staff interviews CNA #2 was interviewed on 10/16/19 at 11:15 a.m. She said staff should always attempt to help residents go to bed and it was not okay to not assist them. She said the facility halls had numerous staff to assist resident cares if CNAs were busy. She said Resident's #15's scooter was parked in front of a wall socket all the time. She said she was not familiar with resident #15 care plan around communication because she was new working there. She said, But I would ask the nurse if there was an issue with communication with residents. LPN #2 was interviewed on 10/16/19 at 10:05 a.m. She said she was not aware that she did not treat resident #15 with respect and dignity. She said she had to return to her medication administration cart and did not have any CNAs available. She said she did not think to call other staff or inform resident of how long it may take. She said she did not know if it was the resident having a behavior or in need. She said, I should have taken the time to see to resident #15 needs. I did not mean to make her feel disrespected.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and interviews the facility failed to provide a clean, comfortable and homelike environment. Specifically, the facility failed: -To provide clean hand towels and wash clothes to the residents, and; -Maintain clean dining room floors. Findings include: I. Towels A.Resident council A resident council meeting was conducted on 10/15/19 at 10:30 a.m. with six residents selected by the facility. The residents said they had to ask for towels from the certified nurse aides or grab extras from the shower rooms when they showered. The resident said towels were not passed out on a daily basis. B. Observations The resident ' s rooms were observed on 10/15/19 at 12:30 p.m. During these observations, the resident ' s shared restrooms were sparsely supplied with towels, some restrooms having none at all. Towels not found in rooms on 10/15/19 at 12:30 p.m. The observations were as follows: room [ROOM NUMBER] had one towel for two residents. room [ROOM NUMBER] had one towel for two residents. room [ROOM NUMBER] had no towels. room [ROOM NUMBER] had no towels room [ROOM NUMBER] had no towels. room [ROOM NUMBER] had one washcloth. room [ROOM NUMBER] had no towels. room [ROOM NUMBER] had no towels. room [ROOM NUMBER] had no towels. room [ROOM NUMBER] had no towels. room [ROOM NUMBER] had no towels. room [ROOM NUMBER] had one dirty towel. room [ROOM NUMBER] had no towels. room [ROOM NUMBER] had no towels. room [ROOM NUMBER] had no towels and two dirty wash clothes. room [ROOM NUMBER] had no towels. room [ROOM NUMBER] had no towels. room [ROOM NUMBER] had no towels. room [ROOM NUMBER] had no towels. room [ROOM NUMBER] had no towels. room [ROOM NUMBER] had no towels. room [ROOM NUMBER] had no towels. room [ROOM NUMBER] had one towel for two residents. room [ROOM NUMBER] had no towels. C. Interviews A licensed practical nurse (LPN) was interviewed on 10/15/19 at approximately 4:00 p.m. The LPN said towels needed to be passed out each shift. She toured a few random rooms and verified towels were not in the rooms. The housekeeping manager (HM) was interviewed on 10/15/19 at 430 p.m. He said towels and sheets had a 24-hour turnaround and personal laundry had a 24-48 hour turnaround. He said personal laundry was delivered in the morning and they fill the towels and linen carts throughout the day. He said he filled a laundry cart with towels at night and left it in the hallway. He said the certified nurse aides pass out the towels to the residents. The director of nursing (DON) was interviewed on 10/15/19 at 5:13 p.m. She said the certified nurse aides (CNA) pass towels out daily and towels were available on the linen cart at night. The linen cart was stored in the locked shower rooms. She said she was not aware of the towels not being passed out and residents not having towels. She said everyone should have a hand towel and washcloth. II. Dining room floors A. Resident council A resident council meeting was conducted on 10/15/19 at 10:30 a.m. The residents said some residents spit on the dining room floors, crumbs and food were always on the floors and the cleaning staff did not clean the floors after meals. B. Observations 10/9/19 The dining room floors were observed at 1:00 p.m. There was a dried juice spill under one of the tables and food on the floor under the tables. At 6:00 p.m. the dining room was observed after dinner. There were plates still on the table and food on the floor. 10/10/19 At 9:24 a.m. the dining room was observed after breakfast. There were spills on the floor and food under the tables. 10/14/19 At 11:45 a.m. before lunch was served, food was observed under the tables and drink spills were seen. C. Staff interview The housekeeping assistant manager (HKAM) was interviewed on 10/16/19 at 10:44 p.m. HKAM said, we try to clean the floors when residents are in the dining room but it is hard to clean when residents are sitting at the table. The housekeeping manager (HM) was interviewed on 10/16/19 at 10:24 a.m. He said housekeeping did not have a specific time when to clean the dining room so they were usually cleaned before dietary staff cleaned the table off. He also said activities started right after the meal and it was hard to get the dining room cleaned quickly. The dietary manager (DM) was interviewed on 10/16/19 at 11:44 p.m. The DM said the residents could eat later than posted meal times so dietary staff did not clean until residents were done.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview, the facility failed to ensure two (#67 and #15) of two out of 36 sample residents were without restraints. Specifically, the facility failed to ensure: -Resident #67's legs was not propped up on an electric recliner that resident was not able to remotely control; and -Resident #15 had an assessment that justified the use of a wander guard. Findings Include: I. Facility policy The Restraint Management System policy with a revision date of November 2017 was provided by the life engagement coordinator (LEC) on 10/14/19 at 10:17 a.m. The policy documented in pertinent part that .Restraints are implemented in accordance with State and Federal regulations. If indicated, the least restrictive restraint is used for the least amount of time. Restraints are not used as a disciplinary action or for the convenience of the facility to control behavior. The policy further defined physical restraint and reported that it is any manual method, physical or mechanical device, material, or equipment attached or adjacent to the resident's body that the resident cannot remove easily, which restricts freedom of movement or normal access to one ' s body . II. Electric recliner A. Resident #67 Resident #67, age [AGE], was admitted on [DATE]. According to the October 2019 computerized physician orders, diagnoses included unspecified dementia without behavioral disturbance, other lack of coordination, low back pain, and other insomnia. The 9/12/19 minimum data set (MDS) documented no brief interview for mental status (BIMS) was completed with the resident. The resident required one person physical assistant with bed mobility, transfers, walking, locomotion on and off the facility, dressing, eating and personal hygiene. Resident also required two persons physical assistant with toilet use. The resident resided on the secured unit. B. Observation - On 10/9/19 at 1:15 p.m., the resident was sitting in an electronically controlled recliner in the common area of the memory unit of the facility. The leg rest of the recliner was propped up such that resident could not get off the recliner as she wanted to. - On 10/10/19 at 9:07 a.m., a nursing staff assisted Resident #67 to the common area, placed the resident on the electronically controlled recliner, propped up the leg rest of the recliner electronically and then left. Resident #67 was observed as she struggled to get off the recliner as she was unable to put the foot rest down. - On 10/14/19 at 10:16 a.m., the resident was sitting on the electronically controlled recliner in the common area, the leg rest of the recliner was propped up. The resident was not napping and was also reaching and stretching out her hands each time anyone walked by. C. Interviews Certified nurse aide (CNA) #19 was interviewed on 10/14/19 at 9:36 a.m. CNA #19 stated she was familiar with Resident #67 because she provided care to the resident. The CNA added Resident #67 liked to walk up and down the hallway and had experienced falls in the past hence the need to sit her in the recliner. The CNA verified the resident was not able to use the remote control to the recliner. The CNA said since the resident was not able to use the remote control she was not able to get out of it when she wished. The CNA added that she did not know to utilize the free standing ottoman while Resident #67 was seated in the recliner rather than extending the foot rest on the recliner. Licensed practical nurse (LPN) #3 was interviewed on 10/14/19 at 9:47 a.m. The LPN stated Resident #67 was not able to use the remote control to lower the leg rest of the recliner and as such was unable to independently get out of the recliner when she wished. The LPN stated when a resident was unable to undo a physical barrier put in place by nursing staff, she would call it a restraint. The life engagement coordinator (LEC) was interviewed on 10/14/19 at 9:52 a.m. The LEC stated Resident #67 was not able to get out of the recliner because it is electronically controlled. Specifically, the LEC stated the recliner required to be remotely controlled to prop the leg rest up and down such that resident can get out of it. The LEC verified that Resident #67 was unable to remotely control the recliner. The LEC added that nursing staff should not prop the leg rest from the recliner, but utilize ottoman for the resident when she sat on the recliner because resident was able to push the ottoman away if she needed to get out of the recliner. The LEC concluded that education would be provided to nursing staff going forward. Follow-up 10/14/19 at 10:17 a.m., the life engagement coordinator provided a copy of the facility's updated care plan for Resident #67, the care plan documented in pertinent part Resident #67 chooses to sit on electric recliner in common area for napping. The goal of the care plan documented the resident would remain free of falls and would be offered repositioning and ambulation every two hours or as needed (PRN). The intervention documented as follows: -Allow resident the right to limit or decline where she would like to take her naps; -Due to Resident #67's inability to operate electric recliner, please utilize ottoman to prop her legs while napping in recliner; and -Staff will offer repositioning The facility also provided a copy of a follow-up in-service provided on restraint management following and the LEC verified that the facility knew to put such plan in place because they agreed with the survey team findings of the situation with Resident #67. III. Wander guard A. Facility policy in regards to the wander guard The Restraint Management policy, revised November,2017 was provided by the nursing home administrator(NHA) on 10/20/19 at 11:06 a.m. via email. It reads, in pertinent part .Restraints are implemented in accordance with State and Federal regulations. If indicated , the least restrictive restraint is used for the least amount of time. Restraints are not used as a disciplinary action or for the convenience of the facility to control behavior . B. Resident #15 1. Resident status Resident #15, over the age of 60, was initially admitted on [DATE], and readmitted on [DATE]. According to the October 2019 computerized physician order(CPO), diagnoses included displaced intertrochanteric fracture of left femur,, acute pain due to trauma, dementia, and hemiplegia. The 7/3/19 minimum data set (MDS) coded resident as cognitively intact with a brief interview for mental status (BIMS) score of 14 out of 15. Resident #15 required extensive one person physical assistance with dressing, transfers, bed mobility, and personal hygiene. The resident used a wheelchair and scooter for mobility. She had mood symptoms of trouble falling asleep and having little energy, She had no behaviors of wandering, and slight hallucinations. The MDS did not code the resident as elopement risk. She was not documented for a daily wander/elopement alarm. 2. Observation Resident #15 was observed on 10/9/19, 10/10/19, 10/13/19, 10/14/19, 10/15/19, and 10/16/19 to have wanderguard bracelet on her ankle. Resident #15 was not observed to have exit-seeking behaviors on 10/9/19, 10/10/19, 10/13/19, 10/14/19, 10/15/19, and 10/16/19. 3. Record review The 9/29/19 Nursing Monthly Summary documented the resident had no restraint was used for resident #15. The 9/29/19 elopement risk assessment provided by the facility read the resident was 120 days without elopement and no history of elopement in past six months. The safety awareness care plan, initiated 11/10/17, and revised on 1/5/18 revealed the resident was an elopement risk related to impaired safety awareness. The interventions included distract resident from wandering by offering pleasant diversions, structured activities, food, conversation. Observed location at regular and frequent intervals, and document wandering behavior and attempted diversional interventions. The October 2019 CPOs did not show a physician's order for use of the wander guard and also the function and placement of the wanderguard bracelet. Review of progress notes from 4/16/19 to 10/16/19 revealed: -The 9/14/19 nurse progress note revealed the resident attempted to leave via the front door. Staff able to redirect resident, and medical doctor updated to behaviors. -The resident had no further exit-seeking behavior documented during 4/16/19 to 10/16/19. -There was no progress note discussing the wanderguard alarm had been reassessed for use after the resident no longer exhibited exit-seeking behaviors. There were no other assessments or care conference documentation from 4/16/19 to 10/16/19 which discussed the resident's continued use and necessity of the wanderguard alarm bracelet or exit-seeking behavior. 4. Staff interviews Certified nurse aide (CNA) #2 was interviewed on 10/16/19 at 11:15 a.m. CNA #2 said the resident had a wander guard bracelet, however, she had not witnessed resident #15 trying to elope from the facility. She said she did not know why resident #15 still had an wanderguard on her ankle. She said all changes with resident care would be told to CNAs from the charge nurse. Licensed practical nurse (LPN) #2 was interviewed on 10/16/19 at 10:05 a.m. LPN#2 said Resident #15 used a motorized scooter for mobility. She said she had not seen Resident #15 attempt to elope from the facility. She said a wanderguard were used for residents who are elopement risk and for their safety. She said she did not know why Resident #15 still had a wanderguard on her ankle. The social services director (SSD) was interviewed on 10/16/19 at 2:25 p.m. The SSD said social services did not complete the elopement risk assessments, however, did provide input regarding behaviors to the nursing staff. The SSD said the resident had not had any exit-seeking behaviors recently. The director of nursing (DON) was interviewed on 10/16/19 at 5:23 p.m. The DON said the facility policy was for the wanderguard alarm bracelet to be reassessed based on resident behaviors that were constantly monitored. The DON said the need for the alarm bracelet would be discussed at a care conference and interdisciplinary team (IDT) meeting. The DON reviewed the medical record and confirmed there had not been an assessment completed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** III. PICC line A. Professional reference Nursing licensure requirements in Colorado (2019) https://www.nursinglicensure.org/state/nursing-license-colorado.html#lpn (retrieved on 10/15/19). It read in pertinent part; A licensed practical nurse (LPN) who completed an intravenous (IV) training should get transcripts and course descriptions from the training center; the candidate should also secure a competency checklist from a former instructor or registered nurse (RN) supervisor. The LPN license in Colorado does not automatically grant IV authority. An IV certification course for LPNs was required to perform any IV procedures on residents within their scope of practice. B. policy The administration of an intermittent infusion policy revised May 2016 provided by the director of nurses (DON) on 10/15/19 at 2:00 p.m. read in pertinent part; The nurse is responsible and accountable for obtaining and maintaining competence with infusion therapy within his or her scope of practice. IV. Resident #277 A. Resident #277, age [AGE], was admitted on [DATE]. According to the October 2019 computerized physician orders (CPO), diagnosis included osteomyelitis of the vertebrae. The minimum data set (MDS) assessment has not been completed for Resident #277 as of 10/15/19. B. Record Review The computerized physician orders (CPOs) for Resident #277 dated 10/5/19 read in pertinent part; .Change the PICC dressing every seventh day and flush with 10 milliliters (ml) of normal saline one time a day . Record review on 10/15/19 showed LPN #4 wrote her initials to document she changed the PICC dressing for Resident #277 and flushed the PICC line with 10ml of normal saline on 10/12/19 at 10:00 a.m. Record review on 10/15/19 from The department of regulatory agency ([NAME]) revealed no IV certification on file for LPN #4. C. Interviews LPN #1 was interviewed on 10/15/19 at 10:19 a.m. She said the registered nurses (RNs) were allowed to work on the PICC lines for residents and LPNs could work on them when they were IV certified. She said she called the house supervisor RN when a resident had a PICC line. The DON was interviewed on 10/16/19 at 4:15 p.m. The DON said RNs and IV certified LPNs were qualified to assist with the PICC lines. She reviewed the record and confirmed the LPN #4 had signed off as completing the order on the PICC line. She was not aware the reason LPN #4 had done this without being IV certified. She said the facility checked the licenses of LPNs on the date of hire. She said the facility had yearly training on PICC lines. Based on interviews, and record review, the facility failed to ensure that two (#45 and #277) out of four residents reviewed out of 36 sample residents, received services by a qualified person who had the proper licensure to perform a specific task. Specifically, the facility failed to ensure: -- Resident #45 received a complete assessment by a registered nurse (RN) following an unwitnessed fall on 6/29/19; and --Ensure one licensed practical nurse (LPN) #4 had an intravenous (IV) certificate to work on peripherally inserted central catheter (PICC) for Resident #277. Findings include: I. Fall without assessment A. Facility policy The Fall Management System policy, with a revision date of July 2017, was provided by the director of nursing (DON) on 10/15/19 at 5:37 p.m. It reads, in pertinent part .the facility assists each resident in attaining/maintaining his or her highest practicable level of function by providing the resident adequate supervision, assistive devices and /or functional programs as appropriate to minimize the risk of falls. When a fall occurs, the resident is assessed for injury by the nurse . -The policy failed to specify that all post fall assessments were to be conducted by a registered nurse (RN). B. Professional reference Colorado Department of Regulatory Agencies, (2018), Board of nursing: Laws, rules and policies. Colorado revised statutes. (2018). Title 12 Professions and occupations. Article 38. Retrieved from https://www.colorado.gov/pacific/[NAME]/Nursing_Laws. It read in part, The practice of practical nursing, is defined as the performance, under the supervision of a dentist, physician, podiatrist, or professional nurse authorized to practice in the state of Colorado (Nurse Practice Act, 2018). Furthermore, of those services and skills include, caring for the ill, injured, teaching & promoting preventive health measures, acting to safeguard life and health, administering treatments & medications prescribed by a legally authorized dentist, podiatrist, physician or a physician assistant. II. Resident #45 A. Resident status Resident #45, age [AGE], was admitted on [DATE]. According to the October 2019 computerized physician order, diagnoses included pain, unspecified muscle weakness, other lack of coordination, other abnormalities of gait and mobility (generalized). The 8/9/19 minimum data set (MDS) documented that the resident was severely cognitively impaired with a brief interview for mental status (BIMS) score of seven out of 15. The MDS inaccurately documented resident has had no fall in the six months or prior to the assessment. B. Record review A review of the 6/29/19 progress note revealed LPN #6 documented Resident #45 came to nursing station stating that she fell in her room when she was reaching for her walker and slid off the bed onto the floor. Resident #45 denied hitting her head, denied any pain, resident was able to move all extremities, neuros were within normal limit (WNL), Optum on-call notified and message left for power of attorney ( POA), will continue to monitor. The fall incident report dated 6/29/19 revealed a full assessment was completed by LPN #6 there was no additional documentation that showed evidence that an RN completed an assessment following the fall. A review of the progress notes dated 6/29/19 revealed a change of condition assessment post Resident #45 ' s fall was conducted by LPN #6, there was no additional documentation that showed evidence that an RN completed an assessment. C Staff interviews LPN #3 was interviewed on 10/15/19 at 11:49 a.m. LPN #3 stated if a resident had a fall, an assessment of the resident was completed that consisted of vital signs and assessing for injuries. If the resident was injured, the RN was notified. If the fall was unwitnessed or the resident reported hitting his/her head, neurological checks were initiated and continued for 72 hours after the incident. Both the physician and family were notified. An incident report and a progress note were completed with details of the incident. The LPN stated any nurse on the floor could complete a full assessment post resident fall regardless of their type of license. LPN #7 was interviewed on 10/15/19 at 3:52 p.m. She said an assessment, consisting of pain level, if the resident was injured, if he/she hit their head, and the ability to move their extremities. If the fall was unwitnessed or the resident said he/she hit their head, neurologicals were initiated and continued for 72 hours after the incident. Both the physician and family were notified. A fall assessment and progress note detailing the incident were completed. The LPN stated any nurse on the floor could complete a full assessment post resident fall. The director of nursing (DON) and consultant nurse (CN) were interviewed on 10/16/19 at 9:32 a.m. The DON reviewed Resident #45 medical record and verified she was not assessed by an RN post the 6/29/19 fall. The DON stated the standard practice after a fall was to conduct a post fall assessment which would include taking vital signs and assessing the resident ' s entire body particularly the head for any sign of injuries. The DON clarified that neurological checks were to be conducted for a witnessed and unwitnessed fall where a resident had hit their head. The DON further clarified that this full assessment was only to be completed by an RN. The DON further clarified the verbiage Nurse as used in the facility ' s policy denotes an RN.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interviews the facility failed to ensure licensed nurses had competencies. Specifically the facility failed ensure the licensed nurses were trained on the crash carts. Finding include: I. Facility policy The nasotracheal suctioning policy revised December 2018 provided by the director of nurses (DON) on 10/15/19 at 3:00 p.m. read in pertinent part; .Tracheal suctioning involves the removal of secretions from the trachea or bronchi by means of a catheter inserted through the mouth or nose. The procedure helps maintain a patent airway to promote optimal exchange of oxygen and carbon dioxide and to prevent pneumonia that can result from pooling of secretions . II. Observations and interviews The facility had three crash carts in the building, one for each station. The licensed nurses were interviewed in regards to how to operate the crash carts, in the event of an emergency. However, the observations and interviews showed, the nurses had not been trained on how to operate. The interviews and observations were as follows: Licensed practical nurse (LPN) #7 was observed and interviewed on 10/14/10 at 3:30 p.m. The crash cart on the secured unit was observed with the LPN #7. As she looked at the crash cart she was observed to fumble through the packages of cannulas and tubing that were on the cart. She was observed to look at the sealed packages to determine which package was the yankauer and the extension tubing was set up so she could hook up the suction machine. As she looked at the packages, she was talking out loud and trying to figure out which tube went where. The cart had two suction machines on the cart and the LPN said there were two of them in case one of them did not work. She said it had been a long time since she had to used a crash cart. She said the RN would be the one to suction in the event a resident required suctioning. She said suctioning was was not in her scope of practice as an LPN. She said she had not been trained at that facility on how to use the crash carts. RN #4 was observed and interviewed on 10/14/19 at 5:54p.m. The crash cart near room [ROOM NUMBER] was observed with RN #4. She said she had crash cart training when she worked at the emergency room but had not official been trained at the facility. She was observed to fumble trying to hook the suction machine up, she plugged it in and turned the machine on. She did not know the suction setting amount and said the doctor would have to be there to use the machine when someone required suctioning. III. Interviews The LPN # 8 was interviewed on 10/15/19 at 4:36 p.m., she said she had no training on crash carts at that facility. The staff development coordinator (SDC) was interviewed on 10/15/19 at 5:26 p.m. The SDC said the facility had a nurse meeting last month and they talked about crash carts but she was not specific as to what they talked about. She said she had not trained the nurses on the rash carts however, she said she would start to train on that going forward. The director of nurses (DON) was interviewed on 10/15/19 at 1030 a.m. The DON said the extra suction machine on the secured unit ' s crash cart had been removed. She said the facility would start to train the licensed nurses on how to use the crash carts immediately. She said most of the residents that were at that facility were no codes (do not resuscitate) so the crash cart may not be used often. However, the crash cart could be used if a resident was choking because the suction machine assisted to get the object or food out of the airway. IV. Facility follow up On 10/18/19, after survey exit, the facility provided a performance improvement project (PIP) dated 9/1/19., which read in pertinent part, .The action plan item was to educate nurses on code blue and to include crash carts. The start date to do that training started on 9/25/19 and the actual completion date said 9/25/19 with resources of the emergency management pip . Although there was a performance improvement plan in place for crash carts in the facility, it was not currently being implemented and was identified over a month ago, and at the time of the crash cart observations and interviews the staff continued to not be trained.

Based on observation, record review and interviews the facility failed to ensure it was free of a medication error rate of five percent (%) or greater. Specifically, the medication pass observation error rate was 46.15 %, or 12 errors out of 26 opportunities for error. Findings include: I. Facility policy The Medication Administration policy, revised date of June 2008, provided by the director of nurses (DON) on 10/15/19 at 1:00 p.m., read in pertinent part: Administer medications within 60 minutes of the scheduled time. Unless otherwise specified by the physician. II. Medication errors A. Resident #24 1. Observation Registered nurse (RN) #4 was observed on 10/14/19 at 4:15 p.m. looking at the MAR (medication administration record) for Resident # 24. The electronic MAR showed the medication highlighted in a red color, to indicate they were late. The medications were scheduled to be given at 3:00 p.m. The RN said she did not administer the medications because the resident wanted to take them when she ate dinner. 2. Record review The computerized physician orders (CPO), dated 8/1/19, included the following medications that were supposed to be administered to Resident #24 at 3:00 p.m.: -Aspirin (anti-inflammatory) enteric coated (EC) 81 milligrams (mg) take one tablet by mouth daily -Calcium (supplement) 500-200 mg take one tablet by mouth daily -Lisinopril (antihypertensive) 10 mg take one tablet by mouth daily -Medroxyprogesterone acetate (hormone) 10 mg take one tablet by mouth daily -Metoprolol succinate (antihypertensive) extended release (ER) 100 mg take one tablet by mouth daily -Senna plus (laxative) 8.5 mg-500 mg take two tablets by mouth daily -Triamterene hydrochlorothiazide (HCTZ) (diuretic) 37.5-25 mg take one tablet by mouth daily. The care plan, dated 7/13/19, identified the resident had hypertension and the goal was to remain free of signs and symptoms of high blood pressure. The approaches included; give anti hypertensive medications as ordered and observe for side effects such as orthostatic hypotension and increased heart rate and effectiveness. 3. Staff interviews RN #4 was interviewed at 10/14/19 at 6:20 p.m. She said she had not given the medications to Resident #24 as of 6:20 p.m., which made them a minimum of three hours and 20 minutes late. She said she waited for the resident to tell her when she was ready to take them with dinner. She said she did not call the physician to advise him the resident did not want to take her medication at 3:00 p.m. The DON was interviewed on 10/14/19 at 6:13 p.m. She said she called the physician for Resident #24 to let him know the resident did not want to take her medications at 3:00 p.m. She said the physician usually called back within 30 minutes to receive new orders or make any changes and he had not called yet. B. Resident #276 1. Observation Licensed practical nurse (LPN) #1 was observed on 10/15/19 at 9:33 a.m., preparing and administering medications for Resident #276. The electronic MAR showed the medication highlighted in a red color, to indicate they were late. The medications were scheduled to be given at 8:00 a.m. The LPN administered the medications at 9:33 a.m., which was one hour and 33 minutes late. 2. Record review The CPO, dated 10/1/19, included the following medications that were supposed to be administered to Resident #276 at 8:00 a.m.: -Amlodipine (antihypertensive) 10 mg take one tablet by mouth two times a day -Apixaban (anticoagulant) 5 mg take one tablet by mouth two times a day -Glardine insulin 8 units subcutaneously daily -Senna 8.5 mg-50 mg take one tablet by mouth daily -Torsemide (antihypertensive, diuretic) 10mg take one tablet by mouth daily. 3. Interviews LPN #1 was interviewed on 10/15/19 at 9:50 a.m. She said the medications were to be given one hour before and one hour after the due time. She said the facility had recently started to change the timed medication to be scheduled to give upon awakening in the morning and when the resident wanted to take them. She said they had not changed the medication times yet for the unit she worked on that day. The DON was interviewed on 10/15/19 at 1:35 p.m., and she said she had a plan of correction for the medication (med) pass errors. She said it was a person centered liberalized med pass which gave the residents more freedom on what time to take their medications. She had a draft of The Person Centered Medication Administration Policy in her hand. She said the facility did a trial to see how well the program would work and they had implemented that policy on one of the nursing units already. III. Facility follow up On 10/18/19, after survey exit, the facility provided a nursing note dated 10/14/19 at 6:41 p.m., which read in pertinent part; A message was left for the physician that read (Resident #24) requested that her medications, scheduled at 3:00 p.m. be given after dinner. That nurse note also read, waiting for a return call. -At 7:22 p.m. the physician called back and gave an order to request a liberalized medication schedule be implemented. Although there was a performance improvement plan in place on other neighborhoods in the facility, it was not currently being implemented for Resident #24 or #276 at the time of the medication pass observations.

Based on interviews, observations and record review, the facility failed to consistently serve food that was palatable and attractive at the appropriate temperatures. Specifically, the facility failed to ensure: -Resident food was palatable in taste, texture, appearance, and temperature Findings include: I. Policy and procedures The Food Quality and Palatability policy, revised September 2017 was provided by the dietary regional manager (DRM) on 10/16/19 at 1:03 p.m. It read in pertinent part, Food will be prepared by methods that conserve nutritive value, flavor, and appearance. Food will be palatable, attractive and served at a safe and appetizing temperature. The cook will be responsible for food preparation techniques which minimize the amount of time that food items are exposed to temperatures greater than 41Fahrenheit (F) and/or less than 135F. II. Group interview A group interview was conducted on 10/15/19 at 10:30 a.m. with six alert and oriented residents selected by the facility, who were all active in the resident council monthly meetings. All of the residents in the group interview said that the food was not palatable. Some of the comments were as follows: - The food was often cold when they received it at the tables. - The food was not seasoned well. - The meals were repetitive and were given rice too often. III. Food committee minutes Review of the Food Committee Minutes from May 2019 to September 2019 revealed the following concerns about the palatability of food: -The meat was often tough. -The kitchen served too much rice, pork and couscous. -The food was not seasoned well. -The kitchen served too much cheese pizza with no other topping choices. IV. Observations -On 10/9/19 the lunch meal was continuously observed from 11:00 a.m. to 2:00 p.m. -On the tables were condiment baskets. Of the seven baskets observed, two were empty and the other five were meagerly filled with various condiments. -At the end of lunch, 60% of the plates remained 75% uneaten. -At the completion of the 10/14/19 lunch meal, 60% of the plates on the tables remained 60% uneaten. -On 10/14/19 the dinner meal service was continuously observed from 4:03 p.m. to 7:40 p.m. The meal consisted of hot options of citrus glazed turkey, seasoned couscous, broccoli florets, and the alternative meal consisted of honey dijon pork chop, baked sweet potatoes, and sauteed green beans. -At the completion of the dinner meal, 75% of the plates remained with 50% or more uneaten. - On 10/15/19 at 1:00 p.m. the regular textured diet test tray was evaluated after the last resident was served. --The rice was cool to the palate at 104.7 degrees F and bland in taste. --The chicken breast was cool to the palate at 112.0 degrees F. The chicken was brown in color and was dry. --The meatball was bland in taste. A test tray, regular diet was evaluated immediately after the last resident had been served in the dining room. The entire meal could not not be tasted as the kitchen had run out of the vegetable. -During the 10/15/19 11:45 a.m. to 1:00 p.m. lunch meal service, two residents who ate in their rooms said they did not receive their previously ordered salads as documented on their meal order tickets. This was brought to the staff's attention. V. Staff interviews The dietary manager (DM) and the dietary supervisor (DS) were interviewed on 10/16/19 at 2:30 p.m. The DS that the food complaints had been brought up at the food committee recently. The DS said she had heard the pork chops and the chicken were dry and a little tough. The DM said she would work with the DS to evaluate the food and ensure good food was put out. The DS said alternatives were to be offered to residents, when they did not like what was served, or when a request was made.

Based on observations and staff interviews, the facility failed to ensure food items were served under sanitary conditions in the main kitchen. Specifically, the facility failed to ensure warm food items were held at the proper temperature to reduce the potential risk of food borne illness; and sanitary conditions were maintained in the kitchen. Findings include: I. Ensure hot food items were held at the proper temperature to reduce the risk of food borne illness. A. Professional reference The Colorado Department of Public Health and Environment (2019) The Colorado Retail Food Establishment Rules and Regulations, https://www.colorado.gov/pacific/sites/default/files/DEHS_RetailFd_6CCR10102_RFFC_EffJan2019.pdf. It read in pertinent part; The food shall have an initial temperature of 41ºF (Fahrenheit) or less when removed from cold holding temperature control or 135°F or greater when removed from hot holding temperature control. B. Facility policy and procedure The Food Preparation policy, revised September 2017 was provided by the dietary regional manager (DRM) on 10/16/19 at 1:03 p.m. It read in pertinent part, All staff will practice proper hand washing techniques and glove use. All utensils, food contact equipment, and food contact surfaces will be cleaned and sanitized after every use. The cook will be responsible for food preparation techniques which minimize the amount of time that food items are exposed to temperatures greater than 41degrees Fahrenheit (F) and or less than 135 degrees F per state regulations. 1. Observation On 10/14/19 the dinner meal service was continuously observed from 4:03 p.m. to 7:40 p.m. The meal consisted of hot options of citrus glazed turkey, seasoned couscous, broccoli florets, and the alternative meal consisted of honey dijon pork chop, baked sweet potatoes, and sauteed green beans. The dietary cook (DC) #1 obtained temperatures of the menu items after they were put on the steam table, and room trays, and seven dining room trays had been made for residents. The holding temperatures of the citrus glazed turkey and honey dijon pork chop were 123 F, which was below the safe holding temperature range of 135 F. 2. Staff interviews DC #1 was interviewed on 10/14/19 at 6:34 p.m. After being informed of the above observations, DC#1 said she was aware that she should have checked the holding temperatures of the food to prevent foodborne illness. The dietary manager (DM) was interviewed on 10/14/19 at 6:44 p.m. After being informed of the above observations, the DM said the temperatures of the citrus glazed turkey and honey dijon pork chops were not within the safe temperature zone of 135 F. She said it was due to DC#1 left prepared food uncovered on the steam table and the temperatures were not held appropriately. The DRM was interviewed on 10/16/19 at 10:24 a.m. She said that all food should have temperatures taken after preparation, before service and after service. She said the staff would be trained to follow safe holding temperatures and proper kitchen sanitation. II. Ensure sanitary conditions were maintained in the kitchen A. Professional reference The Colorado Department of Public Health and Environment (2019). The Colorado Retail Food Establishment Rules and Regulations, https://www.colorado.gov/pacific/sites/default/files/DEHS_RetailFd_6CCR10102_RFFC_EffJan2019.pdf. It read in pertinent part, Equipment food-contact surfaces and utensils shall be cleaned. 1. Observation On 10/14/19 the dinner meal service was continuously observed from 4:03 p.m. to 7:40 p.m. DC#1 put on one glove, touched the dirty, and stained table top, touched her uniform, and then used the same glove hand to reach into a bag of hotdog buns and pull out two buns. DC#1 then put on another glove touched the dirty, and stained table, her dirty, and stained uniform, and then used the same glove hand to reach into a sandwich bread bag and pull out two slices of bread. DC#1 touched her dirty and stained uniform with bare hands, then with unwashed hand picked up a dinner plate, touched the inside eating surface and put glazed turkey, seasoned couscous, and broccoli florets. DC#1 then rubbed metal tongs against the dirty and stained uniform then used them to put meat on meal room trays. DC#1 then stuck her bare hand in the middle of a plate, took off a piece of lettuce, walked over to the three compartment designated for food sink, used hand with lettuce in it to turn on dirty water handle, rinse lettuce, and turned off the faucet with hand with lettuce in it to make the dinner sandwich. DC#1 then used metal tongs lying against brown stained kitchen wall to prepare a meal tray. 2. Staff interviews DC#1 was interviewed on 10/14/19 at 6:34 p.m. After being informed of the above observations, DC#1 said she knew she should have performed proper kitchen sanitation to prevent foodborne illness such as to wash her hands before glove use, not lay clean utensils on dirty surfaces, and wash her hands before applying gloves, and before touching several different types of food. The DM was interviewed on 10/14/19 at 6:44 p.m. The DM said the staff should not stick dirty hands on the eating surface of plates, staff should not rub clean utensils against dirty uniforms, and against food to be served to prevent foodborne illness. She said routine training consisted of kitchen sanitation, proper glove use, and routine daily cleaning of the kitchen. The DRM was interviewed on 10/16/19 at 10:24 a.m. She said that all kitchen utensils should be cleaned, and kitchen sanitation done according to food regulations. She said staff would be educated and trained to follow safe holding temperatures, and proper kitchen sanitation.