**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interviews, the facility failed to provide reasonable accommodations necessary to accommodate mobility and accessibility in the resident's environment for one (#26) of one resident reviewed for accommodation of needs out of 53 sample residents. Specifically, the facility failed to ensure Resident #26's bed side rails were installed as requested by the resident and as recommended by the rehabilitation services department staff. Findings include: I. Resident #26 A. Resident status Resident #26, age less than 65, was admitted on [DATE]. According to the January 2025 computerized physician orders (CPO), diagnoses included paraplegia (inability to voluntarily move the lower parts of the body), pressure ulcer to the right buttock, neuromuscular dysfunction of the bladder (condition where the nerves controlling bladder function are damaged), anxiety and depression. The 12/28/24 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. Resident #26 required set up assistance for eating and oral hygiene and was dependent on staff for toileting and showering. The resident required substantial assistance from staff for dressing, rolling from left to right and moving from a sitting to a lying position in bed. B. Resident observation and interview Resident #26 was interviewed on 1/27/25 at 2:42 p.m. Resident #26 was sitting in her wheelchair. There were no side rails on Resident #26's bed. Resident #26 said she was able to move her arms. Resident #26 said she needed bed side rails near the head of her bed in order to be able to move in the bed without significant assistance. Resident #26 said she asked staff for bed side rails on 11/15/24 (the date she was admitted to the facility) and had asked for side rails several times since then. Resident #26 said when someone was paraplegic, the lack of side rails was a restraint, because it did not allow for independence and movement. Resident #26 said if there were side rails on the bed, she would be able to move side to side and would be more independent. C. Record review Resident #26's therapy notes were provided by the regional director of clinical services (RDCS) on 1/29/25 at 10:41 a.m. The therapy notes revealed the following: On 11/16/24, occupational therapy notes documented the resident would benefit from bilateral bed rails for increased independence with bed mobility and repositioning. On 11/30/24, the short term physical therapy goals documented the resident would be able to roll in bed left to right (and back) with bed mobility rails and minimum assistance for pressure relief. D. Staff interviews Registered nurse (RN) #1 was interviewed on 1/28/25 at 3:55 p.m. RN #1 said Resident #26 needed help to reposition in bed. RN #1 said Resident #26 could likely move herself better in bed if there were side rails on the bed. RN #3 was interviewed on 1/29/25 at 9:29 a.m. RN #3 said it could be helpful for Resident #26 to have side rails for her bed. RN #3 said Resident #26 could use her upper arms and the side rails would allow her to turn easier. Certified nurse aide (CNA) #1 was interviewed on 1/30/25 at 12:18 p.m. CNA #1 said Resident #26 asked at the beginning of December 2024 for bed side rails so she could reposition herself in bed. CNA #1 said she told the nurse on duty of the resident's request. CNA #1 said all staff, including the therapy department, knew Resident #26 wanted side rails for her bed. CNA #1 said Resident #26 would be able to reposition herself much better and would gain more independence if she had the side rails on her bed. The physical therapy assistant (PTA) and the occupational therapist (OT) were interviewed together on 1/30/25 at 12:21 p.m. The OT said Resident #26 had requested side rails for her bed. The OT said after the initial OT evaluation, she documented in the resident's electronic medical record (EMR) and sent a text message to the director of rehabilitation to request side rails for Resident #26's bed on 11/16/24 at 11:25 a.m. The PTA said bed rails would allow Resident #26 to reposition herself in bed and would promote her independence. The PTA said she thought Resident #26 would feel more confident in her abilities with the side rails present. The assistant director of rehabilitation (ADOR) was interviewed on 1/30/25 at 12:36 p.m. The ADOR said he did not know whether the bed rails were requested for resident #26. He said the director of rehabilitation (DOR) would know, but was not available. The ADOR said the process to determine if it was safe for a resident to use bed side rails, and then approve and install the bed side rails should take no more than a few days. The director of nursing (DON) was interviewed on 1/30/25 at 1:45 p.m. The DON said she was not aware Resident #26 had requested, nor that therapy had recommended, the side rails. The DON said she would expect the DOR to enter a communication note and to bring a bed side rail request to a daily morning Skilled Review meeting. The DON said the DOR had not entered this request. The DON said Resident #26 could have benefited from bed side rails, as it could assist her with repositioning and independence. The DON said there was a lack of communication which led to the request not being processed. The DON said a request for bed rails could be approved and installed within a few hours. The DON said she was going to confirm that Resident #26 could safely have side rails, and the side rails would be installed on 1/30/25 (during the survey).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to honor resident choices for one (#30) of one resident reviewed for self-determination out of 53 sample residents. Specifically, the facility failed to promote, facilitate and support a room change for Resident #30, per her preference. Findings include: I. Facility policy and procedure The Resident Self-Determination and Participation policy and procedure, revised August 2022, was provided by the regional director of clinical services (RDCS) on 1/29/25 at 6:35 p.m. It read in pertinent part, Our facility respects and promotes the right of each resident to exercise his or her autonomy regarding what the resident considers to be important facets of his or her life. In order to facilitate resident choices, the administration and staff inform the residents and family members of the residents' right to self-determination and participation in preferred activities, gather information about the residents' personal preferences on initial assessment and periodically thereafter, and document these preferences in the medical record, including information gathered about the resident's preferences in the care planning process. Residents are encouraged to make choices about aspects of their lives in the facility, including rooming with the person of their choice and providing both individuals consent to the choice. II. Resident #30 A. Resident status Resident #30, under age [AGE], was admitted on [DATE]. According to the January 2024 computerized physician orders (CPO), diagnoses included cerebral palsy (a disorder that affects ability to move and maintain balance and posture caused by brain damage), thoracic scoliosis, pain in the right hip and depression. The 12/16/24 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. She was dependent on staff assistance with toileting, bathing, dressing, personal hygiene and transfers. She used a motorized wheelchair for mobility. The MDS assessment indicated the resident did not have behaviors or rejection of care during the review period. B. Resident interview Resident #30 was interviewed on 1/27/25 at 2:47 p.m. Resident #30 said her roommate had sundowning (late-day confusion affecting people with dementia) and was loud and her neighbor across the hall yelled out all night due to dementia. Resident #30 said she needed to wear her headphones in order to sleep at night. Resident #30 said it seemed like many of the residents around her had significant cognitive issues and she was not sure her room location and her roommate was the best fit for her since she was younger and had no cognitive issues. Resident #30 said when she first admitted to the facility, she was in the rehabilitation unit and her room was great but later she was moved to her current room. Resident #30 said the last time she talked to the unnamed social worker (SW), the SW had said if she put in a request for a new roommate she may get a worse one. Resident #30 said she knew four other younger residents and thought they may be a better match for her and mainly not to have her sleep disturbed. Resident #30 said the SW had discouraged her from pursuing a formal request for a room/roommate change. Resident #30 said she had had a care conference last month (December 2024) and voiced her wishes but said there had been no follow up from the meeting. C. Record review The respite stay care plan, initiated 9/16/24 and revised 10/8/24, revealed Resident #30 was originally admitted for a 21-day respite stay but later made the decision to stay for long-term care related to 24/7 (twenty-four/seven) care needs. Interventions included to provide an arena such as IDT (interdisciplinary team) care conference for resident, family and/or interested parties to address plans for discharge and participate in the discharge planning process as indicated, social services to document changes to discharge goals per resident preference as indicated and social services to schedule IDT care plan meetings upon admission, quarterly and as needed. -However there were no updates to the care plan interventions following Resident #30's decision to remain in the facility for long-term care. Review of the IDT conference summary, dated 12/5/24, revealed it was a quarterly conference. The activities comment revealed the resident continued to be active and attend groups of interest weekly such as church, bingo, music, entertainment and social. The resident used an electric wheelchair for mobility but needed staff assistance to take her to and from groups of interest and she could make her needs known. The care conference summary revealed that the resident attended the care conference but the social services progress note summary was blank. -Resident #30 said she had told social services of her room/roommate concerns during the IDT case conference, however, the care conference summary note failed to reveal documentation from social services regarding the resident's concerns or any follow up. III. Staff interviews The social services director (SSD) was interviewed on 1/29/25 at 1:54 p.m. The SSD reviewed the care conference summary note dated 12/5/24 and said she could not tell from the note what concerns were discussed in the meeting and what were the outcomes because the social services portion of the progress note had not been documented and was blank. The SSD said typically the social services assistant (SSA) would write in the progress note section at the bottom of the form. The SSD said since the SSA did not document anything from the meeting, she did not know what was talked about and discussed. The SSD said she would want social services to write a progress note in the care conference summary because it was important to document what was talked about in the care conference and indicate the facility was discussing ancillary services or any resident concerns. She said social services should additionally document the plan to follow up on residents' concerns, depending on what the concerns were, in a progress note. The SSD said it was important to know what the follow up plan was so she could follow up and make sure the residents were getting the care they needed. The SSD said she had not heard anything about Resident #30 wanting to move to a different room. The SSD said she knew of a good place/room that Resident #30 could move to that might meet her needs better. The SSD said residents were always permitted to request a room change that would better meet their needs. The SSD said the social services department recently made some changes to the department's staff. IV. Facility follow up On 1/29/25 at 2:40 p.m. the SSD said she had spoken with Resident #30 and arranged for a room change for the resident. She said Resident #30 toured the new room and was quite happy with the new room and location. The social services progress noted, dated 1/29/25 at 3:06 p.m. revealed the social services department had spoken with Resident #30 about a room move. The resident verbalized she would like to move to a different room. Available rooms were discussed and the resident toured and chose a new room. The resident was introduced to her new roommate and it was decided that the room move would happen first thing in the morning (1/30/25). Resident #30 verbalized understanding and gave consent for the room change.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interviews, the facility failed to ensure residents were free from abuse for two (#88 and #54) of four residents reviewed for abuse out of 53 sample residents. Specifically, the facility failed to protect Resident #88 and Resident #54 from physical abuse from Resident #144. Findings include: I. Facility policy and procedure The Abuse, Neglect and Exploitation policy, revised April 2021, was provided by the regional director of clinical services (RDCS) on 1/28/25. It read in pertinent part, Protect residents from abuse and neglect by anyone including but not necessarily limited to: facility staff and other residents. Develop and implement policies and protocols to prevent and identify: abuse or mistreatment of residents. Provide staff orientation and training/orientation programs that include topics such as abuse prevention, identification and reporting of abuse, and handling verbally or physically aggressive resident behavior. Implement measures to address factors that may lead to abusive situations, for example, adequately prepare staff for caregiving responsibilities. Identify and investigate all possible incidents of abuse, neglect or mistreatment., Investigate and report any allegations within timeframes required by federal requirements. Protect residents from any further harm during investigations. Establish and implement a quality assurance and performance improvement (QAPI) review and analysis of reports, allegations or findings of abuse, neglect, or mistreatment. II. Incident of resident to resident physical altercation between Resident #144 and Resident #88 on 1/17/25. A. Facility investigation The facility's investigation revealed a physical altercation between Resident #144 and Resident #88 occurred in Resident #88's room on 1/17/25. Staff heard verbal commotion down the hall. When staff reached Resident #88's room, Resident #144 was standing next to Resident #88's bed. Staff did not witness any physical action, but Resident #88 stated Resident #144 hit him. Immediately, the nurse removed Resident #144 from the room and placed him on one-to-one supervision and behavior monitoring for the next 72 hours. Staff redirected Resident #144 away from Resident #88's room. Resident #144 was assessed and found to have a skin tear on his right ring finger. The local police department, ombudsman, the residents' physicians and both residents' representatives were notified. Resident #88 was interviewed by staff on 1/17/25 at 3:45 p.m. Resident #88 said Resident #144 came into his room and hit him on his left temple, cheek, side of his chin and several places on his left arm. Resident #88 was assessed after the incident and had no bruising, redness or scratches. The resident denied fear or distress. He was placed on one-to-one observation and psychosocial wellbeing monitoring for the next 72 hours. Resident #144 was interviewed by staff on 1/17/25 at 4:00 p.m. and had no recollection of the incident. Resident #144's psychiatrist initiated medication changes, and the facility initiated referrals to other facilities. Resident #144 was sent to the emergency department for evaluation. Five other residents were interviewed and reported no concerns with Resident #144 or being fearful of the resident. The witness statements were as follows: Certified nurse aide (CNA) #7 said he heard yelling down the hall. When he arrived to Resident #88's room he saw Resident #144 standing over Resident #88 and Resident #88 yelled that Resident #144 had hit him. CNA #7 approached Resident #144 and noticed he had a bleeding cut on his hand. CNA #7 asked Resident #144 what happened and the resident said that Resident #88 was also hitting him. CNA #7 tried to escort Resident #144 out of the room but the resident got agitated and aggressive and started pushing CNA #7 and yelling. CNA #7 said he put gloves on and gently escorted Resident #144 to the day room. He notified nursing staff of the incident and the resident's injured hand. Licensed practical nurse (LPN) #2 said she was told by CNA #7 that Resident #144 and Resident #88 were fighting. She said she saw Resident #144 try to hit CNA #7. She said she approached Resident #144 and tried to redirect him to the recliner. She assessed Resident #144 and cleaned his right hand ring finger, which had a small skin tear. She asked Resident #88 what happened and he said that Resident #144 hit him three times on his face. She said that Resident #88 pointed to the left side of his face, told her that Resident #144 hit him up and down his arm, and then pointed to his left arm. Resident #88 denied pain, and said Resident #144 needed to go. LPN #2 noted no evidence of injury to Resident #88. B. Resident #144 (assailant) 1. Resident status Resident #144, age less than 65, was admitted on [DATE]. According to the January 2025 computerized physician's orders (CPO), diagnoses included cerebral infarct (blocked blood flow to the brain/a stroke), Alzheimer's disease with early onset and unspecified dementia with behavioral and psychotic disturbances. The 12/30/24 minimum data set (MDS) assessment revealed the resident had short term and long term memory problems and had severely impaired cognition and decision making, per staff assessment. He walked independently but was dependent on assistance for bathing and required assistance for all other activities of daily living (ADLs). The assessment indicated the resident had wandered one to three days during the seven-day assessment look-back period. 2. Resident interview An attempt was made to interview Resident #144 on 1/28/25 at 10:43 a.m., however, the resident was not interviewable due to his cognitive impairment. 3. Record review Resident #144's psychosocial care plan, revised 12/12/24, identified the resident was at risk for poor impulse control and decreased well-being related to his adjustment to long-term care. The care plan further identified that the resident had aggressive behaviors and then forgot what happened. It identified his wife's visits as triggers for behaviors. Interventions included assessing clinical issues that may have contributed to the resident's mood pattern, maintaining a calm, slow, understandable approach with the resident and redirecting and reorienting the resident to his environment and routine. The psychosocial care plan further revealed Resident #144 had the potential to be physically and verbally aggressive related to dementia. Interventions included redirecting the resident with snacks and a calm environment when he was yelling, cussing, and balling his fist (initiated 11/28/24), attempting de-escalation techniques, such as providing the resident space and a calm environment (initiated 11/30/24) and having the resident evaluated by his psychiatrist (initiated 11/30/24). -Review of Resident #144's behavior care plan failed to reveal new interventions put into place to prevent further resident to resident altercations after the 1/17/25 incident with Resident #88. Review of Resident #144's pharmacy care plan, revised 12/12/24, revealed the resident required antipsychotic medication related to psychosis. Interventions included administering antipsychotic medications as ordered and gradually reducing the doses as indicated/condition improves, administering non-pharmacological approaches prior to medication administration, providing a quiet and dark environment, assessing the presence of pain/discomfort, keeping the resident as comfortable as possible, providing back rubs as needed, offering warm beverages and observing and reporting signs of hallucinations. A review of Resident #144's January 2025 CPO revealed the following physician's orders: Behavior monitoring for antidepressant every shift as evidenced by combative with cares, anxiety, agitation and self-isolation, ordered 10/7/24. Monitor behaviors for antipsychotic use as evidenced by hitting walls and inanimate objects. Document every shift in behavior progress note any behaviors observed and any nonpharmacological interventions utilized, ordered 12/10/24. 72-hour monitoring related to aggressive behaviors with staff and agitation, ordered 1/7/25 through 1/10/25. One-to-one monitoring for 72 hours related to a resident to resident incident, ordered 1/17/25. 72-hour behavior monitoring for increase in agitation and/or aggression, ordered 1/17/25 through 1/20/25. A change in condition report, dated 1/17/25 at 4:22 p.m., revealed Resident #144 had altered mental status and behavioral symptoms, including psychosis or agitation. He was noted to have new/worsening memory loss and increased confusion. Behavior changes included physical and verbal aggression. The report indicated the resident was a danger to himself or others. Review of Resident #144's electronic medical record (EMR) revealed the following progress notes: A behavior monitoring progress note, dated 12/29/24, revealed Resident #144 banged and slammed another resident's door and was yelling and cussing. A behavior monitoring progress note, dated 1/7/25, revealed Resident #144 tried to hit a CNA. Another progress note, dated 1/18/25, revealed Resident #144 continued on one-to-one monitoring. The resident was started on Seroquel 12.5 milligrams (mg) every afternoon for severe, unspecified dementia with psychotic disturbance, ordered 1/17/25. A progress note, dated 1/19/25, revealed Resident #144 still had one-to-one monitoring due to incidents of agitation, restlessness and irritability. The resident had episodes when he could not verbalize his needs or make full complete sentences. The resident denied pain and was assisted by staff when walking in the hallway. The resident could not keep his clothing on for long periods, and could not void independently in the bathroom, he voided on the bedroom floor. Staff continued to offer all non-pharmalogical interventions, monitor him, and assist him with all his needs. A progress note, dated 1/20/25, revealed that Resident #144 was asked immediately after the altercation with another resident on 1/17/25 and found to have no recollection of the incident. Interventions included initiation of referrals to two other facilities. The physician initiated medication changes, one-to-one supervision was provided for 72 hours and the resident was sent to the emergency room for evaluation and treatment. The care plan was updated to reflect interventions. Monitoring was ongoing. -However, there were no updated interventions documented on Resident #144's behavior care plan following the incident with Resident #88 on 1/17/25 (see care plan above). C. Resident #88 (victim) 1. Resident status Resident #88, age [AGE], was admitted on [DATE]. According to the January 2025 CPO, diagnoses included Alzheimer's disease. The 11/17/24 MDS assessment documented the resident had mild cognitive impairment with a brief interview for mental status (BIMS) score of eight out of 15. He used a wheelchair or walker for mobility. The assessment indicated the resident had no behaviors. 2. Resident interview Resident #88 was interviewed on 1/28/25 at 9:32 a.m. Resident #88 said he had no issues with other residents and had had no fights. He said he did not want to talk and everything was fine. 3. Record review The comprehensive care plan, revised 12/5/24, identified a psychosocial/behavior focus. The resident exhibited or was at risk for behavioral symptoms, such as grabbing others, being combative, verbally or physically abusive and inappropriately disrobing due to Alzheimer's disease. The resident had a history of sexually inappropriate behaviors and yelling at other residents. Interventions included staff were to attempt de-escalation if these behaviors were seen, intervening before agitation escalated, guiding the resident away from the source of distress, engaging the resident calmly in conversation, walking away calmly and reapproaching the resident later if his response was aggressive, separating, redirecting, distracting and other appropriate methods for ensuring safety of both parties, placing the resident on one-to-one observation until the situation was resolved if de-escalation attempts were unsuccessful, observing and documenting changes in behavior, including frequency of occurrence and potential triggers, including a high stimuli environment and offering a low stimuli environment during meals. A physician's progress note, dated 12/5/24, revealed Resident #88's behaviors were discussed during the interdisciplinary team review (IDT) meeting. Resident #88 had significant and frequent inappropriate sexual behaviors towards staff. He had been physically and verbally inappropriate on a daily basis. He had also been verbally abusive toward at least one other resident and a police report was filed as a result of his behaviors. III. Incident of resident to resident physical altercation between Resident #144 and Resident #54 on 1/27/25 A. Facility investigation The facility's investigation, which was in-progress, for the incident between Resident #144 and Resident #54 on 1/27/25, was received from the director of nursing (DON) on 1/30/25 at 1:00 p.m. The investigation revealed the incident occurred in Resident #54's room. Resident #144 was interviewed by staff immediately after the incident and his responses were unintelligible. Resident #54 was interviewed by staff immediately after the incident and she said she was hit in the face (by Resident #144), but had no injuries she was aware of. She said she did not feel safe with Resident #144 there. Resident #54 was observed lying in bed at the time of her interview, with baseline confusion. On 1/27/25, a witness statement was received from CNA #7. CNA #7 said he was helping another resident when he heard yelling coming out of another room. He saw Resident #144 walking in the hallway. He said by the time he got there, Resident #144 was walking into Resident #54's room. He said he ran down the hall and as soon as he got to Resident #54's door, Resident #144 was yelling and hitting the side of Resident #54's bed. CNA #7 said he told Resident #144 to stop. Resident #144 then hit Resident #54 five times in the rib cage area. CNA #7 said he escorted Resident #144 out of the room and brought him to the day room. He said he notified the nurse and nursing supervisor and then checked on Resident #54. Resident #54 was interviewed again by staff on 1/27/25 at 4:00 p.m. Resident #54 said Resident #144 came into her room and punched her in the face on the right cheek area. She then said he hit her once and left the room. Resident #144 was interviewed again by staff on 1/27/25 at 4:10 p.m. Resident #144 had no recollection of the incident. Five additional residents were interviewed. No other residents said they had been treated roughly by Resident #144 nor were they afraid of him. The investigation revealed the local police department was notified to complete the investigation. Staff and resident interviews revealed Resident #144 entered Resident #54's room and a physical altercation resulted. There were no precipitating signs or behaviors that would have predicted this incident. Resident #144 was calm and cooperative and engaging with staff prior to the incident. -However, Resident #144 had been the assailant in another resident to resident physical altercation 10 days prior, on 1/17/25 (see 1/17/25 incident above). While the investigation was being conducted, Resident #144 was placed on one-to-one monitoring. Resident #54 was offered an immediate room change off the unit, however the resident and her representative declined. The caregiver that regularly visited Resident #54 was noted to be scheduled for a visit that night (1/27/25). Staff continuously rounded to ensure safety on the unit. Social services visits with Resident #54 continued. The local police department, Adult Protective Services (APS), the residents' physicians and the residents' representatives were notified. Resident #54 was assessed by LPN #2 after the incident and no skin changes were noted. The resident reported pain to her left arm. Her psychosocial well-being was assessed and noted to be different from her baseline. A follow-up assessment revealed Resident #54 had returned to her baseline and did not remember the details of the event. She continued to have no skin alterations and no pain. The resident was engaged in activities and socializing with staff and residents. Resident #54 was interviewed multiple times regarding the incident and continued to say that Resident #144 hit her, but the location changed with each interview. The resident said she had no injuries. B. Resident #144 (assailant) 1. Record review -Review of Resident #144's behavior care plan failed to reveal new interventions put into place to prevent further resident to resident altercations after the 1/27/25 incident with Resident #54. Review of Resident #144's January 2025 CPO revealed the following physician's order following the resident's incident with Resident #54: One-to-one monitoring for 72 hours related to a resident to resident incident, ordered 1/28/25. 72-hour behavior monitoring for increased agitation and aggression related to the incident, ordered 1/28/25 through 1/31/25. C. Resident #54 (victim) 1. Resident status Resident #54, age [AGE], was admitted on [DATE]. According to the January 2025 CPO, diagnoses included severe unspecified dementia with psychotic disturbance. The 11/27/24 MDS assessment documented the resident had short term and long term memory problems and had moderately impaired cognition and decision making per staff assessment. She used a walker or wheelchair for mobility. The assessment indicated the resident had intermittent inattention, constant disorganized thinking and altered level of consciousness, but no behaviors. 2. Resident interview Resident #54 was interviewed on 1/29/25 at 3:56 p.m. Resident #54 was not fully interviewable due to cognitive impairment, but she said she thought someone hit her yesterday (1/28/25) on her shoulders. She said she thought it was a man and said it did not hurt. She said she felt safe. 3. Record review Review of the social services care plan, revised 12/12/24, identified Resident #54 was at risk for decreased psychosocial well-being, adjustment issues, emotional distress, ineffective coping skills, poor impulse control and adverse effects on function and wellbeing related to diagnosis of post-traumatic stress disorder (PTSD). She had severe, unspecified dementia, with psychotic disturbance. The resident had cognitive loss related to dementia. Interventions included anticipating her needs and meeting them promptly, explaining all care before providing them to reduce resident tension and promote a comfortable experience, approaching her in a calm, reassuring manner, assessing the resident's coping strategies and respecting the resident's wishes, to the extent possible to address the resident's anxiety disorder (initiated 12/12/24). Review of Resident #54's EMR revealed the following progress notes: A change in condition progress note, dated 1/27/25, revealed Resident #54 had been hit by another resident. The resident's physician recommended to continue monitoring Resident #54 and notifying the physician of any further changes. A psychosocial progress note, dated 1/27/25 (after the incident), revealed Resident #54 appeared calm with no visible signs of distress. The resident reported that she was doing better and wanted to get some rest. A physician's progress note, dated 1/28/25, revealed the physician spoke with Resident #54 the day before (1/27/25) and she was confused (her baseline) about the incident on 1/27/25 and said it did not happen. Her representative requested five days of skin checks every shift. The resident appeared tired and was laying in her bed and said she did not wish to get up at the time of the interview. The physician performed a skin check on her torso. There were no abnormalities found. Review of Resident #54's January 2025 CPO revealed a physician's order for five days of skin monitoring. Monitor for redness or bruising on the right side/rib area and to write a progress note if anything appeared abnormal, ordered 1/27/25. IV. Staff interviews CNA #8 was interviewed on 1/29/25 at 4:05 p.m. CNA #8 said she had worked at the facility since October 2024 and had worked with Resident #144 for a while. CNA #8 said when Resident #144 was first admitted to the facility, he was nice and did not have many behaviors, but he declined quickly. She said she thought the resident now got over-stimulated, and then got angry and lashed out. She said he got over-stimulated from noise, people and his surroundings. CNA #8 said toileting Resident #8 had become challenging. She said he forgot where he was at times and needed to be reassured often. CNA #8 said Resident #144 wandered and went in/out of other residents' rooms so staff had to redirect him. She said he probably needed one-to-one supervision permanently now and thought so far it had made a big difference in terms of the altercations he had. She said she thought Resident #144 had had increased supervision for a few weeks following his altercations. She said she was not working during the altercations, but she heard they were resident to resident contact situations and he was going into other residents' rooms. Said a night shift agency CNA had to chase Resident #144 down the hallway. She said she heard that the resident punched Resident #54 in the ribs. She said she heard there was another incident a few weeks prior where he made contact with another male resident (Resident #88). CNA #9 was interviewed on 1/29/25 at 5:28 p.m. CNA #9 said Resident #144 could not be left alone because his incidents came out of nowhere and could not be anticipated. She said she knew some of his triggers, for example, if he started getting agitated in the shower, she knew to step back and give him a minute. But she said other residents wouldn't necessarily know to do that. The DON was interviewed on 1/30/25 at 11:27 a.m. The DON said she had talked with the psychiatrist regarding Resident #144's decline. She said the psychiatrist said Resident #144's decline was much faster due to his diagnoses of both Alzheimer's disease and Parkinson's disease. The DON said the facility was trying to find a good medication regimen for him. The DON said Resident #144 had problems with impulse control and had poor short-term memory. She said the facility had eliminated some things that triggered the resident's behaviors, such as his wife visiting. She said meeting with his wife virtually had helped some with his behaviors. The DON said she had heard him in the past sitting in his recliner and then he suddenly started to throw dishes. She said she would check on him and ask what was going on and if he was okay. She said Resident #144 never had any recollection of what happened and would say he was fine. The DON said Resident #144 was in the military, so it was possible he had some PTSD which contributed to his outbursts. The DON said Resident #144 had an incident a few weeks ago (1/17/25) with Resident #88. She said there was no contact witnessed between the residents, but Resident #88 said Resident #144 hit him in the face/arm. She said Resident #88 had no evidence of being hit. The DON said Resident #88's memory recall was a little better than Resident #144's and the two residents had never had an issue before. She said the 1/17/25 incident with Resident #88 was Resident #144's first physical altercation incident with another resident. She said Resident #88 was eventually moved to another hallway at his representative's request. The DON said after the 1/17/25 incident with Resident #88, Resident #144 was immediately placed on one-to-one monitoring with documentation being completed every 15 minutes for 72 hours. She said according to the 72-hour documentation, Resident #144 was back to baseline, had no unsafe wandering and no behaviors. She said since a resident to resident physical altercation had only happened once for Resident #144 and the fact that the resident's psychiatrist changed some of his medications soon after, the facility decided to trial the resident off of the one-to-one monitoring. She said the facility had still been tracking his behaviors every shift. She said she thought Resident #144 had started to get more agitated again, but he was doing it all in his room and not coming out of his room. The DON said the facility still had not been able to identify any additional triggers for Resident #144's behaviors. She described his behavior as impulsive and said she had not seen any precipitating behaviors that would have led to the second incident with Resident #54. The DON said after the incident with Resident #54, Resident #144 was probably going to have a full-time one-to-one supervision sitter, unless another medication helped improve the situation. She said the facility had sent referrals for Resident #144 to other facilities due to his behaviors. She said the facility had tried different caregivers for Resident #144 to see if that made any difference for him and it did not.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 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 and assistance for bathing for two (#48 and #77) of four residents reviewed out of 53 sample residents. Specifically, the facility failed to provide complete grooming with shower/bed bath for Resident #48 and Resident #77 in order to maintain personal hygiene, including shaving of beard, washing of hair and trimming of fingernails. Findings include: I. Facility policy and procedure The Activities of Daily Living, Supporting policy and procedure, revised March 2018, was provided by the regional director of clinical services (RDCS) on 1/29/25 at 6:35 p.m. It read in pertinent part, Residents who are unable to carry out activities of daily living (ADL) independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene. Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with hygiene (bathing, dressing, grooming, and oral care). II. Resident #48 A. Resident status Resident #48, age [AGE], was admitted on [DATE]. According to the January 2025 computerized physician orders (CPO), diagnoses included disorders of bladder, paralytic syndrome following cerebrovascular (CVA) disease affecting left dominant side (stroke), paraplegia (paralysis of the lower half of body) and emphysema. The 11/11/24 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. He was dependent on staff assistance with oral hygiene, toileting hygiene, bathing, upper/lower body dressing, personal hygiene (including combing hair and shaving), bed mobility and all transfers. He used a motorized wheelchair for mobility. The MDS assessment indicated the resident did not have behaviors or rejection of care during the review period. B. Resident interviews and observations Resident # 48 was interviewed on 1/28/25 at 9:48 a.m. He had long jagged fingernails on both hands with brown matter visible underneath the nails. Resident #48 said he preferred to have a shower twice a week but the staff did not have time for it. Resident #48's hair was greasy and uncombed. Resident #48 said the staff usually combed his hair and he relied on them to do it. Resident #48 had a full bushy beard, mustache and side burns. Resident #48 said he preferred to have a clean shave since being in the military. Resident #48 said the staff did shave him occasionally, maybe once a week. Resident #48 said he did not know which days he could expect a shower or a shave, as it occurred whenever the staff got around to it. Resident #48 was interviewed a second time on 1/29/25 at 5:12 p.m. Resident #48's hair was long, messy and unkempt. Resident #48 said it had been hectic around his unit. Resident #48 said he was promised a shave but the staff member who promised him the shave never came back to do it. Resident #48 had a full unkempt beard and his fingernails continued to be long and jagged with visible brown matter underneath the nails. C. Record review Review of the bathing care plan, revised 10/4/23, revealed Resident #48 required assistance and was dependent for ADL care related to impaired mobility/cognition due to paralytic syndrome following CVA, chronic pain and muscle weakness. Resident #49's shower preference was for two times per week and he had no caregiver preference. -The care plan failed to include shaving the resident's beard or providing nail care. Review of Resident #48's bathing record from 12/31/24 to 1/28/25 revealed the resident had received six showers over the 30-day period with no resident refusals. The bathing record revealed the resident was dependent on staff for bathing. -However there was no documentation that indicated the resident's fingernails were trimmed or his beard was shaved. III. Resident #77 A. Resident status Resident #77, age [AGE], was admitted on [DATE]. According to the January 2025 CPO, diagnoses included pressure ulcer of sacral region, heart disease, hemiplegia (paralysis on one side of the body) affecting right dominant side, contracture (permanent shortening and stiffening of muscles and other tissue) of the right hand and major depressive disorder. The 12/3/24 MDS assessment revealed the resident had moderate cognitive impairment with a BIMS score of 12 out of 15. She was dependent on assistance with bathing, chair/toilet/bed transfers, and sit-to-stand transfers. She required partial/moderate assistance with bed mobility, oral hygiene, toileting hygiene, upper/lower body dressing and personal hygiene (including combing hair). She required a manual wheelchair for mobility. The MDS assessment indicated the resident did not have behaviors or rejection of care during the review period. B. Resident interviews and observations Resident #77 was interviewed on 1/27/25 at 11:58 a.m. Resident #77's hair was dirty and greasy and was not combed. The resident's fingernails were long with brown matter visible under the nails. The resident's right hand was contracted and her fingernails touched into her palm. Resident #77 said she preferred her fingernails short. Resident #77 said she had not been getting out of bed, per her choice, so she had only received bed baths, not showers. Resident #77 was interviewed a second time on 1/29/25 at 5:08 p.m. Resident #77's hair was greasy and unkempt. Resident #77 said she should be getting her hair washed tomorrow (1/30/25), however, she said when the staff did the bed bath, they did not offer to wash her hair unless she insisted they go get the waterless shampoo cap. Resident #77's fingernails were long with brown matter visible under the nails. Resident #77 said she liked her nails short, but the staff had been really busy. Resident #77 said she would ask the staff to trim her nails since they had been too busy to offer. C. Record review Review of the ADL care plan, revised 6/2/24, revealed Resident #77 had an actual self-care deficit and was at risk for further ADL/mobility decline and required assistance related to contractures, history of CVA with hemiparesis, recent hospitalization, weight loss and failure to thrive. -The ADL care plan failed to include bathing or nail care for the resident. Review of Resident #48's bathing record from 12/31/24 to 1/28/25 revealed the resident had received seven bed baths over the 30-day period with one resident refusal. The bathing record revealed the resident was dependent on staff for bathing. -However, there was no documentation that the resident's fingernails were trimmed or her hair was washed. IV. Additional observation On 1/29/25 beginning at 5:46 p.m. the director of nursing (DON) interviewed and observed Resident #48 and Resident #77. The DON confirmed that both residents had long jagged fingernails with brown matter visible under their nails and their hair was greasy and uncombed. The DON said a lack of care with the nails and hair could cause skin infections and skin integrity problems. The DON confirmed with both residents that they wanted to have short, clean fingernails. Resident #48 verified with the DON that he would like his beard shaved and he would like to keep his mustache. The DON acknowledged the residents' grooming concerns and said she would make sure the residents received the necessary services right away. V. Staff interviews Licensed practical nurse (LPN) #3 was interviewed on 1/29/25 at 5:17 p.m. LPN #3 said residents should receive a shower two to four times per week, per their preference. LPN #3 said the certified nurse aides (CNA) would tell her if a resident refused grooming, and she would encourage them. LPN #3 said the CNAs charted the residents' showers in the electronic medical record (EMR). LPN #3 said it was important for the residents to receive a shower to keep skin clean, prevent skin break down and promote good hygiene. The DON was interviewed on 1/29/25 at 5:36 p.m. The DON said she recommended a shower at least two times per week. The DON said a shower/bath was important for cleanliness, good hygiene and to minimize risk of infection. The DON said the facility used to have a shower aide but she left, so now the CNAs were doing the showers. The DON said the process for fingernail care was to offer during activities with a manicure, if the resident was not diabetic or the CNAs would offer and ask the residents if they would like their fingernails trimmed during the bathing task. The DON said the bathing task, whether a shower or bed bath, included hair shampoo, nail care, soap and water clean, face washing and teeth/oral care. The DON said beard shaving could be part of the bathing task or some residents had an electric razor, or the CNA would do the shaving upon the residents' request.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interviews, the facility failed to ensure proper treatment and services to maintain vision abilities for one (#137) of three residents reviewed for vision services out of 53 sample residents. Specifically, the facility failed to ensure Resident #137's new eyeglasses were obtained in a timely manner. Findings include: I. Facility policy and procedure The Hearing and Vision Services policy (undated), was provided by the regional director of clinical services (RDCS) on 1/28/25 at 5:10 p.m. It read in pertinent part, It is the policy of this facility to ensure that all residents have access to hearing and vision services and receive adaptive equipment as indicated. The social worker/social services designee is responsible for assisting residents, and their families, in locating and utilizing any available resources for the provision of the vision and hearing services the resident needs. II. Resident #137 A. Resident status Resident #137, age [AGE], was admitted on [DATE]. According to the January 2025 computerized physician orders (CPO), diagnoses included dementia, heart disease, hypothyroidism (thyroid gland did not produce enough hormone) and chronic pain. The 12/24/24 minimum data set (MDS) assessment revealed a brief interview for mental status (BIMS) assessment was not completed. The resident had a memory problem and his cognitive skills were severely impaired. The resident required substantial assistance from staff for oral hygiene, toileting, dressing, personal hygiene and required supervision for transferring. The MDS assessment documented the resident had adequate vision and did not require corrective lenses. -However, documentation from an eye consult office visit revealed the resident required glasses (see record review below). B. Resident observation and resident representative interview On 1/27/25 at 3:00 p.m. Resident #137 was sitting in the dining room. The resident was not wearing glasses. Resident #137's representative was interviewed on 1/28/25 at 11:10 a.m. The representative said Resident #137 had worn eyeglasses since he was a child. The representative said Resident #137's eyeglasses had been missing for several months. The representative said Resident #137 saw an optometrist and was provided a prescription for eyeglasses but the eyeglasses were never ordered. The representative said he had asked a facility representative about the eyeglasses on several occasions and was not provided updates regarding the status of Resident #137's eyeglasses. C. Record review The 8/5/24 eye exam note, entitled Summary Ocular Progress Note, was provided by the RDCS on 1/30/25 at 1:05 p.m. The eye exam note included instructions to deliver Resident #137's prescribed eyeglasses two weeks from the receipt of payment. A nursing progress note, dated 10/1/24 at 7:37 p.m., revealed Resident #137's representative was notified that the resident's glasses were on order and management had reached out to the eye doctor for an estimated time for when they would be delivered. -Review of Resident #137's electronic medical record (EMR) on 1/30/25 did not reveal documentation to indicate the resident had received his new eyeglasses. D. Staff interviews The social services director (SSD) was interviewed on 1/30/25 at 12:09 p.m. The SSD said Resident #137 should have received his eyeglasses. The SSD said the facility changed vision providers and said this could have contributed to the delay. The SSD was interviewed a second time on 1/30/25 at 12:49 p.m. The SSD said she was responsible for ensuring Resident #137 received his eyeglasses in a timely manner. The SSD said she had been trying to catch up with residents' ancillary needs since she started in her position at the facility in April 2024. The director of nursing (DON) and the RDCS were interviewed together on 1/30/25 at 1:52 p.m. The DON said Resident #137's eyeglasses were ordered on 1/30/25 (during the survey). The RDCS said there were gaps in the process to order the eyeglasses for Resident #137. The RDCS said she would expect the process to obtain new eyeglass prescriptions to not take longer than six to eight weeks.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interviews, the facility failed to ensure residents received adequate supervision to prevent accidents for one (#4) of three residents out of 53 sample residents. Specifically, the facility failed to ensure staff were aware of and following the care planned interventions for Resident #4 in order to prevent further falls. Findings include: I. Resident #4 A. Resident status Resident #4, age greater than 65, was admitted on [DATE]. According to the January 2025 computerized physician orders (CPO), diagnoses included unspecified dementia, osteoporosis, muscle weakness, unspecified lack of coordination and left artificial hip. The 11/25/24 minimum data set (MDS) assessment revealed the resident had severe cognitive impairments. The resident could not complete the cognitive assessment therefore a staff assessment was completed. The staff assessment revealed the resident had short and long term memory deficits, impaired decision making, and was only oriented to herself. The MDS assessment documented the resident used a wheelchair for mobility and required moderate assistance from staff for bed mobility and transfers. The MDS assessment indicated the resident required supervision and hands-on assistance with ambulation. The MDS assessment indicated the resident had not had any falls since the prior assessment. B. Resident observations On 1/27/25 at 11:30 a.m. Resident #4 was ambulating in the hallway with sock-like slippers on. She was pushing another resident in their wheelchair. She was observed with a raised, large hematoma (a pool of blood under the skin or in the body caused by a broken blood vessel) on the left side of her forehead with bruising to the left forehead area and under her left eye. Registered nurse (RN) # 4 walked past Resident #4, but did not discourage the resident from ambulating on her own or pushing the other residents' wheelchair. At 11:34 a.m., four minutes after initially walking past Resident #4, RN #4 returned and asked the resident not to push other residents' wheelchairs. RN #4 took Resident #4's hand and guided the resident away from the other resident's wheelchair. On 1/28/25 at 11:20 a.m. Resident #4 was ambulating independently with an unsteady gait and sock-like slippers on her feet. Several staff members were present in the area but did not provide ambulation assistance to the resident. On 1/29/25 at 11:51 a.m. Resident #4 was ambulating independently with an unsteady gait and sock-like slippers on her feet. Several staff members were present but did not provide ambulation assistance to the resident. On 1/29/25 at 4:46 p.m. Resident #4 was ambulating independently with sock-like slippers on her feet and holding another resident's hand while pulling the other resident in their wheelchair. The memory care director (MCD) came up to Resident #4 and asked to hold her hand so she would stop pulling the other resident in their wheelchair. C. Record review Resident #4's fall care plan, revised 10/17/24, revealed the resident was at risk for falls due to dementia, gait/balance problems, history of falls and history of femur fracture and rib fracture. Interventions included anticipating and meeting the resident's needs (initiated 9/21/23), encouraging and assisting the resident to use a wheelchair for ambulation (initiated 10/30/23), ensuring the resident was wearing non-skid socks or non-skid footwear (initiated 5/13/24), educating the staff to keep the resident in line of sight (initiated 1/14/25) and ordering a therapy evaluation for the use of a four-wheel walker (FWW) (initiated 1/20/25). A post-fall review assessment, dated 1/15/25, revealed the resident had a fall on 1/14/25. A post-fall review assessment, dated 1/20/25, revealed the resident had a fall on 1/20/25. A review of Resident #4's progress notes from 1/14/25 through 1/30/25 revealed the following: A 1/14/25 change of condition assessment progress note revealed Resident #4 had a fall. The physician ordered a new prescription for as needed pain medication. A 1/14/25 change of condition fall progress note dated revealed a housekeeper had found Resident #4 lying on the floor at the end of a hallway in her unit. When the nurse arrived to assess the resident, the resident was standing up and screaming out. She was observed to be holding the hand of another resident who had helped her stand up. No injuries were observed by the nurse. A 1/15/25 interdisciplinary team (IDT) fall note dated revealed the new interventions put into place for the 1/14/25 fall included educating the staff to keep Resident #4 within sight in common areas and to update the care plan. A 72-hour charting note, dated 1/17/25, revealed Resident #4 was observed walking the unit unassisted and constantly attempting to engage with the nursing staff, however, the resident was unable to articulate herself. -The note did not indicate if staff attempted to assist the resident with ambulation. A 1/20/25 change of condition assessment progress note revealed Resident #4 had suffered a fall after ambulating in the hallway and letting go of a hand rail which caused her to fall. The resident was observed with discoloration to her forehead and the physician ordered the resident be sent out to the hospital for a contusion to her head. A 1/20/25 nursing note revealed the resident had returned from the hospital with a hematoma to her scalp, was grimacing and verbally complaining of pain and pointing at her right hip. A 1/21/25 IDT skin note revealed Resident #4 had a contusion to the left forehead with edema and discoloration. A 1/21/25 resident safety note revealed occupational therapy issued a FWW for Resident #4 to use. The staff were provided education to watch the resident while the new device was being initiated. The resident demonstrated good results for use. A 72-hour charting note, dated 1/21/25, revealed physical therapy worked with the resident on her use of the FWW. This was effective until the resident saw another resident she liked to hold hands with and then she let go of the walker. Redirection with the resident was effective. -However, staff were not observed during the survey to be assisting Resident #4 with ambulation, redirecting the resident when she was ambulating unassisted or encouraging the resident to utilize the FWW (see observations above). II. Staff interviews RN #4 was interviewed on 1/27/25 at 11:30 a.m. RN #4 said Resident #4 used to be a nurse and thought she was working. She said the resident liked to assist and push other residents in their wheelchairs. RN #4 said the resident's fall interventions were to keep her within their line of sight when she was out of her room. RN #4 said she thought the resident's walker was in her room but the resident did not use it. Certified nurse aide (CNA) #3 was interviewed on 1/29/25 at 11:58 a.m. CNA #3 said Resident #4 could ambulate independently without a walker or wheelchair. -However, according to the resident's 11/25/24 MDS assessment, care plan and progress notes, Resident #4 required hands-on assistance with ambulation or the use of a wheelchair or FWW (see resident status and record review above). The director of nursing (DON) was interviewed on 1/30/25 at 12:54 p.m. The DON said when a resident had a fall, the nurses were to complete an assessment of the resident's condition. The DON said an immediate new fall intervention was determined and the managers attempted to identify the root cause of the fall. The DON said once a new intervention was put into place, a manager was assigned to monitor the intervention's implementation. The DON said the new interventions for Resident #4's fall on 1/14/25 were to educate the staff regarding keeping her in their line of sight and monitoring her for 72 hours. The DON said the new interventions put into place post fall on 1/20/25 were to have the therapy department evaluate the resident for a FWW. The DON said she did not know why the staff were not encouraging the resident to use her walker for ambulation. The DON said she was unaware Resident #4 had been wearing slipper-like socks instead of non-skid socks or footwear.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interviews, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the possible development and transmission of infectious disease on three of nine units. Specifically, the facility failed to: -Ensure housekeeping staff wore gloves and performed appropriate hand hygiene while cleaning residents' rooms; -Ensure housekeeping staff wore masks appropriately while the facility was in a flu outbreak; and, -Ensure staff sanitized dining tables and the floor prior to the next meal. Findings include: I. Housekeeping failures A. Facility policy and procedure The Cleaning and Disinfecting Residents' Rooms policy, revised August 2013, was provided by the regional director of clinical services (RDCS) on 1/30/25 at 2:39 p.m. It read in pertinent part, Use heavy-duty gloves and other personal protective equipment (PPE), as indicated, for housekeeping tasks. Gloves, protective eyewear and masks may be indicated to reduce exposure levels to disinfectant chemicals as well as to protect employees from exposure to blood and OPIM (other potentially infectious materials) while cleaning or disinfecting. Perform hand hygiene after removing gloves. B. Observations On 1/29/25 at 8:42 a.m. housekeeper (HK) #1 was observed cleaning room [ROOM NUMBER]. HK #1 reached her ungloved hand into a clean bucket, retrieved a mophead and applied the mophead to her mop. After using the mop, HK #1 removed the dirty mophead and disposed of it with ungloved hands. -HK #1 did not perform hand hygiene after removing the dirty mophead with her ungloved hands. HK #1 proceeded to empty the trash can with her ungloved hands. -HK #1 did not perform hand hygiene after emptying the trash can. HK #1 licked her fingers and opened a clean trash bag with her ungloved hands, which she had not sanitized after removing the dirty mophead with her ungloved hands or emptying the trash can. HK #1 did not perform hand hygiene after licking her fingers. On 1/29/25 at 8:50 a.m., HK #1 was observed cleaning room [ROOM NUMBER]. HK #1 reached her ungloved hand into a clean bucket, retrieved a mophead and applied the mophead to her mop. After using the mop, HK #1 removed the dirty mophead and disposed of it with ungloved hands. -HK #1 did not perform hand hygiene after removing the dirty mophead. HK #1 proceeded to reach her ungloved hand into the bucket of clean mopheads again to retrieve another mophead. C. Staff interviews HK#1 was interviewed on 1/29/25 at 9:00 a.m. HK #1 said she should have worn gloves to obtain and dispose of the mophead. She said she should have used hand sanitizer after touching the dirty mophead. HK #1 said some residents' trash cans looked clean so she did not always wear gloves. HK #1 said she should have worn gloves to empty the trash. -During the interview, HK#1 was observed wearing a mask under her nose, despite the fact that the facility was in a flu outbreak during the survey. The housekeeping supervisor (HKS) was interviewed on 1/29/25 at 9:30 a.m. The HKS said HK#1 should have worn gloves and changed gloves between tasks when cleaning the residents' rooms, including when removing trash from the rooms and when she discarded the dirty mopheads. The HKS said HK #1 should have used hand sanitizer before applying gloves and between changing gloves. The infection preventionist (IP) was interviewed on 1/29/25 at 1:55 p.m. The IP said HK #1 should have worn gloves at all times while cleaning the residents' rooms and changed gloves and performed hand hygiene between dirty and clean tasks. The IP said HK#1 should have washed her hands with soap and water after licking her fingers. The IP said HK #1 should have covered her nose when wearing her mask. II. Failure to sanitize dining tables and the floor between meals A. Observations On 1/27/25 at 11:32 a.m. the dining room in the 100 hallway was observed. There were five tables in the dining room. There were bread/dessert crumbs on three dining tables and beverage cup liquid markings and other stains present on four of the dining tables. At 12:09 p.m. stains and crumbs were still present on the 100 hallway dining tables and there were four residents sitting at the tables waiting for lunch and drinking beverages. At 12:43 p.m. meal service began and the dining tables in the 100 hallway dining room had not been cleaned. On 1/28/25 at 9:15 a.m. the dining room on the 100 hallway was observed again. There were crumbs on the floor and dirty marks/dried beverage spots on two of the four dining tables after the breakfast meal. At 12:26 p.m. there were still crumbs on the floor and the same spots on the tables in the 100 hallway dining room. Three residents were sitting at the dining tables awaiting lunch. On 1/29/25 at 11:30 a.m. the dining room on the 100 hallway was observed. There were bread/dessert crumbs on three of the dining tables, crusty substances on three of the dining tables' edges and beverage spots on one dining table. The dining table closest to the entrance of the dining room still had liquid spots in the same locations observed on 1/27/25 and 1/28/25 (see above). Crumbs were present on a chair and on the floor under the dining tables. A plastic cup lid was on the floor. At 11:55 a.m. a housekeeper was cleaning the 100 hallway and walked with the housekeeping cart past the dining room. The housekeeper did not clean the dining room. At 12:41 p.m. the 100 hallway dining room was observed in the same condition. The dining tables, chair and floor had not been cleaned. At 12:56 p.m. two residents were observed in the 100 hallway dining room. They sat at a dining table and began drinking coffee. The dining tables had not been wiped/sanitized and the room was in the same condition. At 12:57 p.m. a resident sat at another dining table that had not been wiped/sanitized. At 12:59 p.m. meal service began in the 100 dining room and the dining tables had not been cleaned. At 3:49 p.m. the dining tables were in the same condition with crumbs and dried beverage stains. In addition, there were two plastic beverage cup lids on the floor and additional crumbs on the floor. At 5:15 p.m. two of the beverage stains on a dining table were able to be partially removed when wiped with a wet paper towel. At 5:31 p.m. two residents were observed eating at a dining table which had not been cleaned. B. Resident interview Resident #40 was interviewed on 1/30/25 at 10:30 am. Resident #40 said many times the dining room was not cleaned after meals. Resident #40 said she had gone into the dining room for Bingo at 2:30 p.m. on several occasions and there was still food on the tables or trays with food stacked in racks in the dining room. C. Staff interview The dietary manager (DM) was interviewed on 1/29/25 at 5:39 p.m. The DM said the dietary aides were responsible for cleaning the dining room tables and serving areas in the 100 hallway dining room. He said the dietary aides were supposed to clean the dining rooms after every meal. The DM said there were cleaning logs for the other dining rooms, however, he said he did not think there was a cleaning log for the 100 hallway dining room. The DM said there should be a cleaning log for the 100 hallway dining room. The DM said the staff should ensure the tables were clear of food debris and stains and remove trash so residents would feel comfortable sitting at the tables. The DM said the cleaning of the 100 hallway floor was the responsibility of the dietary aides and housekeeping was also responsible for cleaning the floors. The DM said he was going to communicate with the nursing staff to assist with cleaning the 100 hallway dining room. The DM said he would also communicate with the housekeeping supervisor to establish a 100 hallway dining room cleaning schedule for the housekeeping department.

Based on observations, record review and interviews, the facility failed to provide a safe, sanitary, functional and comfortable environment for residents, staff and the public. Specifically, the facility failed to ensure necessary kitchen equipment was maintained in a safe, sanitary and working condition. Findings include: I. Observations On 1/27/25 at 9:30 a.m. the initial kitchen tour was conducted and the following was observed: -An approximate twelve-inch by twenty-four inch puddle of water was observed coming from underneath the kitchen employee's hand washing sink. -Under the three compartment dishwashing sink, a large silver mixing bowl was observed directly underneath the water pipes. The mixing bowl was collecting the drops of water from a leak in one of the pipes. -Two broken floor tiles by the sink were detached from the floor and floating on top of an accumulation of water. On 1/28/25 at 11:18 a.m. observations of the kitchen revealed there were no changes to the condition of the leak coming from underneath the kitchen employee's hand washing sink, the leak coming from the pipe underneath the three compartment dishwashing sink or the broken floor tiles that were floating on top of an accumulation of water. On 1/28/25 at 1:52 p.m. observations of the kitchen revealed there were no changes to the condition of the leak coming from underneath the kitchen employee's hand washing sink, the leak coming from the pipe underneath the three compartment dishwashing sink or the broken floor tiles that were floating on top of an accumulation of water. II. Staff interviews The dietary manager (DM) was interviewed on 1/28/25 at 1:26 p.m. The DM said the facility used an electronic work order system to enter work orders to the maintenance department for repairs. The DM said the kitchen staff were to notify him or one of his night supervisors to put repair orders into the system. The DM said he had been aware of the leaking pipe underneath the three compartment dishwashing sink for at least a week. He said he told someone in maintenance about it but could not recall who he had told or when he had done this. -The DM entered a work order to repair the leak, after it was observed during the survey. The DM said he was unaware of the leak and puddle of water underneath the employee's hand washing sink. He did acknowledge it was the main employee hand washing sink when the staff first came into the kitchen. He said his expectation was for the staff to go to the sink and wash their hands before performing any tasks in the kitchen. He said the outcome for leaks that were not addressed was water damage, resulting in the potential for mold in the kitchen. An environmental tour of the kitchen was conducted with the maintenance director (MTD) and the nursing home administrator (NHA) on 1/28/25 at 1:52 p.m. The MTD said he had ordered the part to repair the pipe leak underneath the three compartment dishwashing sink on 1/27/25 (during the survey). He said prior to the survey, he was unaware of the leak and had not received a work order from the DM. The MTD said the leak coming from underneath the employee's hand washing sink was due to a disconnected drain pump from the ice machine next to the sink. He said the disconnected drain pump was causing the water leak to come from underneath the ice machine and travel underneath the hand washing sink. It was observed the material at the base of the hand washing sink was soft and warped consistent with water damage. The MTD said he would reconnect the drain pump and repair the warped base of the sink. The NHA said a work order should have been submitted in the electronic work order system in order for the MTD or the maintenance assistant (MTA) to repair the leaks. The MTD said during new hire employee orientation, he provided education to staff on the electronic work order system and how to enter work orders. -During the interview, the work order system training for the DM was requested from the MTD and the NHA, along with the agenda for the new hire orientation section on work orders. III. Facility follow up On 1/28/25 at 2:20 p.m. the regional director of clinical services (RDCS) provided an email with an attached document titled Maintenance Education. The document included instructions on how to enter a work order, the contact numbers for the MTD and the MTA, the maintenance problems to direct to the MTD and MTA and the fire alarm code. -However, the Maintenance Education document was not dated with the date the education was provided and did not include any staff signatures to identify who received the education.

Based on observations, record review,and interviews, the facility failed to maintain a system of documenting grievances and demonstrating prompt action for residents for four (#135, #40, #37 and #51) residents out of seven residents reviewed for grievances out of 53 sample residents. Specifically, the facility failed to effectively address, resolve and demonstrate the facility's response to individual grievances for Resident #135, Resident #40, Resident #37 and Resident #51. Findings include: I. Resident group interviews and observations A group interview was conducted on 1/30/25 at 10:30 a.m. with four residents (#135, #40, #37 and #51). The residents were interviewable per the facility and assessment. Resident #135 said when he had a concern , he provided the grievance to a member of the social service staff. He said many times he had not received a follow up on how his grievance was resolved or if it was resolved. Resident #40 said she had filled out two formal grievance forms and provided the forms to staff but received no follow up from social services or administration. She said she was aware of the grievance process and was aware the staff should have spoken with her after she submits a grievance form. Resident #37 said it took approximately two weeks for her to receive any notification of follow up to her grievances and many times she did not receive any follow up at all. She said due to her visual deficits, she required staff to assist her in completing a grievance form. She said this was difficult for her because she must trust the staff were filling the form out correctly and submitting it on her behalf. She said the staff did not read back to her what they had written on her grievance form. Resident #37 said several times she had asked staff to help her fill out a grievance form, was told they were too busy at the time and no one ever returned to complete the form with her. Resident #51 said he submitted a formal grievance to the maintenance assistant regarding a clog in his sink several weeks ago and had not received any follow up. On 1/30/25 at approximately 11:30 a.m. Resident #51's bathroom sink was observed to begin to fill up if the water ran for more than approximately three minutes continuously. II. Record review Facility grievances for the last six months were reviewed. Individual grievances were provided by the social services director (SSD) on 1/30/25. The grievances revealed the following; A grievance dated 11/3/24, was submitted by Resident #37. The grievance pertained to oxygen and medication administration. The date the resolution was discussed with the resident was 12/5/24. -The grievance was not reviewed with the resident for more than 30 days from the date she had initiated the grievance. A grievance dated 9/28/24, was submitted by Resident #37. The grievance pertained to dietary concerns. The date the resolution was discussed with the resident was 9/30/24. -However, the resident did not sign the resolution, the registered dietitian consultant (RDC) signed in the resident's place. A grievance dated 1/10/25, was submitted by Resident #135. The grievance pertained to resident dignity. The date the staff followed up with the resident after he submitted his grievance was not until 1/20/25. -The grievance was not reviewed with the resident for 10 days after he filed his grievance. No grievances were located by the SSD for a six month look back period for Residents #51 or Resident #40. III. Staff interviews The SSD was interviewed on 1/30/25 at 2:23 p.m. The SSD said she explained the grievance process to new employees during general orientation. She said she expected staff to assist residents who need assistance with completing a grievance form or to locate a member of social services to assist. She said the staff were to provide residents with a grievance form if they could not complete it independently and turn the form in for them if the resident needs assistance. The SSD said during the morning management meeting, the SSD would pass out grievances to the appropriate department to follow up on. She said she requested status updates on outstanding grievances. The SSD said she expected a follow up to be made to the resident within 24 to 48 hours to provide a resolution or to provide an acknowledgment the grievance was being worked on. She said if it took more than a week to resolve, she said the resident was to continue to receive updates. She said once resolved, the department manager would go back and let the resident know the resolution and have the resident sign on the form the resolution was satisfactory. The SSD said she had not received grievances in the last six months for Resident #51 or Resident #40.

Based on record review and interviews, the facility failed to complete a performance review of every nurse aide at least once every 12-months and provide regular in-service education based on the outcome of these reviews for three of three certified nurse aides (CNA). Specifically, the facility failed to complete annual performance reviews and/or provide regular in-service education based on the outcome of the reviews for CNA #4, CNA #5 and CNA #6. Findings include: I. Facility policy and procedure The Performance Evaluations policy and procedure, revised September 2020, was provided by the regional director of clinical services (RDCS) on 1/30/25 at 3:33 p.m. It read in pertinent part, The job performance of each employee shall be reviewed and evaluated at least annually. A performance evaluation will be completed on each employee at the conclusion of his/her 90-day probationary period and at least annually thereafter. II. Record review Annual performance reviews were requested on 1/29/25 at 4:05 p.m. The facility was unable to provide annual performance evaluations for 2024 for CNA #4 (hired on 12/9/23), CNA #5 (hired on 12/26/23 ) and CNA #6 (hired on 10/7/2020). -CNA #4, CNA #5 and CNA #6 did not have an annual performance review completed and did not have an in-service education plan based on the outcome of the review. III. Staff interviews The RDCS was interviewed on 1/30/25 at 3:25 p.m. The RDCS said the facility did not have the performance reviews for CNA #4, CNA #5 and CNA #6. The RDCS said she understood the importance of performing annual performance evaluations so that proper in-services could be conducted following the reviews. The director of nursing (DON) was interviewed on 1/30/25 at 4:05 p.m. The DON said she was new to her role of DON as of 11/15/24. The DON said performance reviews needed to be completed for CNAs annually, but she said she did not know where the former DON kept the records for the staff. The DON said she would start the performance reviews of the CNAs as soon as possible and then provide them with the in-service training they may need.

Based on record review and interviews, the facility failed to report alleged violations of potential abuse to the State Survey and Certification Agency in accordance with state law for three (#1, #9 and #2) of four residents reviewed for abuse out of 10 sample residents. Specifically, the facility failed to report incidents of physical abuse involving Resident #1 to the State Survey Agency (SSA). Findings include: I. Facility policy and procedure The Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating policy and procedure, revised September 2022, was provided by the nursing home administrator (NHA) on 9/17/24 at 12:31 p.m. It revealed in pertinent part, All reports of resident abuse (including injuries of unknown origin), neglect, exploitation, or theft/misappropriation of resident property are reported to local, state and federal agencies (as required by current regulations) and thoroughly investigated by facility management. Findings of investigations are documented and reported. The administrator or the individual making the allegation immediately reports his or her suspicion to the following persons or agencies: the state licensing/certification agency responsible for surveying/licensing the facility. II. Record review A. Incident of verbal abuse toward Resident #9 on 7/8/24 The 7/8/24 nursing progress note documented, at lunch at approximately 12:20 p.m. in the dining room, Resident #1 was sitting at a table and Resident #9 was sitting at another table. Resident #1, yelled at Resident #9, You are a [expletive] [expletive] that needs to leave. He gets on my nerves making that sound with his [expletive] tongue hanging out. The progress note documented Resident #1 was told by the nursing staff that while he was in the dining room, he needed to be respectful, however Resident #1 continued making statements towards the other resident. The nurse documented she moved Resident #9 closer to her and engaged him in watching the television so he would not hear Resident #1's comments. The facility was unable to provide documentation that the incident of verbal abuse was reported to the SSA. B. Incident of physical abuse toward Resident #2 on 7/8/24 The 7/8/24 interdisciplinary team (IDT) progress note documented the nurse watched as the aggressor (Resident #1) was talking to another nurse on the unit. Resident #2 tapped Resident #1 on the shoulder, as sometimes she does to other residents on the unit. Resident #1 turned around and shoved Resident #2 into the wall with his left arm on her chest before the nurse could stop him. Resident #2 hit the wall with the back of her head. The facility was unable to provide documentation that the incident of verbal abuse was reported to the SSA. C. Incident of physical abuse toward Resident #2 on 7/20/24 The 7/22/24 nursing progress note in Resident #1's medical record documented there were no issues post altercation on 7/20/24 with a female resident. The facility was unable to provide documentation that the incident of verbal abuse was reported to the SSA. D. Incident of physical aggression toward another resident on 8/8/24 The 8/8/24 nursing progress note documented Resident #1 was seen by staff attempting to kick and hit another resident throughout the day. The facility was unable to provide documentation that the incident of verbal abuse was reported to the SSA. III. Staff interviews The clinical consultant (CC) and the director of nursing (DON) were interviewed on 9/16/24 at 12:45 p.m. The CC said, during the survey process, the facility had realized they did not have a good amount of abuse investigations, which were requested. She said there had been turnover in the NHA and the DON position recently and they were unable to determine if some incidents of abuse had been investigated. The CC said some of the incidents of abuse that were requested during the survey process were not reported to the state survey agency. The CC said the incidents involving Resident #1 on 7/8/24, 7/20/24 and 8/8/24, 8/7/24 should have been reported to the SSA. The CC said she had called the NHA, who was not at the facility, and provided over the phone education on the process of reporting abuse to the SSA. The CC said all incidents of abuse or allegation of abuse should be reported to the SSA.

Based on record review, the facility failed to investigate incidents of physical aggression involving one (#1) of four residents reviewied out of 10 sample residents. Specifically, the facility failed to conduct investigations of physical abuse involving Resident #1. Findings include: I. Facility policy and procedure The Resident to Resident Altercations policy and procedure, revised September 2022, was provided by the nursing home administrator (NHA) on 9/17/24 at 12:31 p.m. It revealed in pertinent part, All altercations, including those that may represent resident to resident abuse, are investigated and reported to the nursing supervisor, the director of nursing services and to the administrator. II. Incidents of abuse A. Incident of verbal abuse toward Resident #9 on 7/8/24 The 7/8/24 nursing progress note documented, at lunch at approximately 12:20 p.m. in the dining room, Resident #1 was sitting at a table and Resident #9 was sitting at another table. Resident #1, yelled at Resident #9, You are a [expletive] [expletive] that needs to leave. He gets on my nerves making that sound with his [expletive] tongue hanging out. The progress note documented Resident #1 was told by the nursing staff that while he was in the dining room, he needed to be respectful, however Resident #1 continued making statements towards the other resident. The nurse documented she moved Resident #9 closer to her and engaged him in watching the television so he would not hear Resident #1's comments. An abuse investigation was requested on 9/16/24, during the survey process. The facility was unable to provide documentation that an investigation had been completed following the verbal abuse incident by Resident #1 toward Resident #9 on 7/8/24. There was no further documentation of the incident. B. Incident of physical abuse toward Resident #2 on 7/8/24 The 7/8/24 interdisciplinary team (IDT) progress note documented the nurse watched as the aggressor (Resident #1) was talking to another nurse on the unit. Resident #2 tapped Resident #1 on the shoulder, as sometimes she did to other residents on the unit. Resident #1 turned around and shoved Resident #2 into the wall with his left arm on her chest before the nurse could stop him. Resident #2 hit the wall with the back of her head. An abuse investigation was requested on 9/16/24, during the survey process. The facility was unable to provide documentation that an investigation had been completed following the physical abuse incident by Resident #1 toward Resident #2 on 7/8/24. There was no further documentation of the incident. C. Incident of physical abuse toward Resident #2 on 7/20/24 The 7/22/24 nursing progress note in Resident #1's medical record documented there were no issues post altercation on 7/20/24 with a female resident. -There was no further documentation in Resident #1's medical record of the incident. An abuse investigation was requested on 9/16/24, during the survey process. The facility was unable to provide documentation that an investigation had been completed following the physical abuse incident by Resident #1 toward Resident #2 on 7/20/24. D. Incident of physical aggression toward another resident on 8/8/24 The 8/8/24 nursing progress note documented Resident #1 was seen by staff attempting to kick and hit another resident throughout the day. -Resident #1's medical record did not include any further documentation of the incidents. An investigation was requested on 9/16/24, during the survey process. The facility was unable to provide documentation that an investigation had been completed following the incident of physical aggression by Resident #1 toward another resident. III. Staff interviews The clinical consultant (CC) and the director of nursing (DON) were interviewed on 9/16/24 at 12:45 p.m. The CC said, during the survey process, the facility had realized they did not have a good amount of abuse investigations, which were requested. She said there had been turnover in the NHA and the DON position recently and they were unable to determine if some incidents of abuse had been investigated. The CC said some of the incidents of abuse that were requested during the survey process were not investigated. The CC said the incidents involving Resident #1 on 7/8/24, 7/20/24 and 8/8/24, 8/7/24 should have been investigated. The CC said she had called the NHA, who was not at the facility, and provided over the phone education on the process of investigating abuse and reporting abuse to the SSA. The CC said all incidents of abuse or allegation of abuse should be investigated. The assistant director of nursing (ADON) was interviewed on 9/16/24 at 2:59 p.m. The ADON said she had reported the incident on 7/20/24 involving Resident #1 and Resident #2 to the DON and the NHA. She said she had documentation on her cell phone that she contacted the former DON on 7/20/24 at 4:35 p.m. and the current NHA at 4:38 p.m.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interviews, the facility failed to ensure residents received necessary respiratory care and services per physician orders for four (#2, #10, #12 and #13) of four residents reviewed for respiratory care out of 13 sample residents. Specifically, the facility failed to: -Ensure physician's orders for oxygen were obtained for Resident #2 and Resident #10 prior to administering oxygen; -Ensure oxygen saturation levels (SpO2) were being monitored consistently for Resident #2, Resident #10 and Resident #12; -Ensure Resident #12's physician's order for oxygen accurately identified the correct oxygen flow rate; and, -Ensure staff were providing the correct flow rate of oxygen per the physician's order to Resident #13. I. Facility policy The Oxygen Administration policy, revised October 2010, was received by the director of nursing (DON) on 3/14/24 at 12:30 p.m. It read in pertinent part, Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration. Before administering oxygen, and while the resident is receiving oxygen therapy, assess . vital signs. After completing the oxygen setup or adjustment, the following information should be recorded in the resident's medical record: date and time that the procedure was performed . The rate of oxygen flow, route, and rationale. II. Resident #2 A. Resident status Resident #2, age [AGE], was admitted to the facility on [DATE] and passed away at the facility on 2/12/24. According to the March 2024 computerized physician orders (CPO), diagnoses included acute and chronic respiratory failure, chronic congestive heart failure, emphysema and end stage renal disease. The 1/16/24 minimum data assessment (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 13 out of 15. The resident required supervision and assistance with most activities of daily living. B. Record review The 12/19/23 care plan identified Resident #2 was at risk for respiratory complications due to congestive heart failure, emphysema and chronic respiratory failure with hypoxia (low levels of oxygen in the body's tissues). Pertinent interventions included supplying oxygen therapy as ordered and monitoring for signs and symptoms of hypoxia. The 1/18/24 care plan identified Resident #2 had behavior problems. Pertinent interventions included spot checking Resident #2's SpO2 as needed. The March 2024 CPO revealed physician's orders to spot check the SpO2 for Resident #2 as needed. -The physician's order did not specify parameters/indications for when Resident #2's SpO2 should be spot checked. -There was no physician's order for supplemental oxygen for Resident #2. -The January 2024 and February 2024 medication administration records (MAR) for Resident #2 did not reveal any SpO2 documentation. The 12/19/23 physician notes revealed Resident #2 was on chronic supplemental oxygen at 3 liters per minute (LPM). -However, there was no physician's order for supplemental oxygen in Resident #2's electronic medical record (EMR). The 2/6/24 notes from the MDS coordinator revealed Resident #2 was wearing oxygen via nasal cannula and denied having any shortness of breath. -However, there was no physician's order for supplemental oxygen in Resident #2's EMR. C. Staff interview The director of nursing (DON) was interviewed on 3/14/24 at 1:59 p.m. The DON said physician orders to spot check SpO2 as needed should be checked once per shift unless the resident had an acute change of condition or if they showed signs or symptoms of being hypoxic. The DON said the facility did not have a clear process for identifying when as needed SpO2 levels should be obtained. The DON said oxygen required a physician's order to administer. III. Resident #10 A. Resident status Resident #10, age [AGE], was admitted to the facility on [DATE]. According to the March 2024 CPO, diagnoses included congestive heart failure, hypertension and atherosclerotic heart disease. B. Observations On 3/13/24 at 2:40 p.m., Resident #10 was lying in bed. He was receiving oxygen via an oxygen cannula. The oxygen concentrator was set at 4 LPM of oxygen. On 3/13/24 at 4:28 p.m., with LPN #2 present, the resident continued to receive 4 LPM of oxygen via nasal cannula. C. Record review The 11/19/23 care plan identified Resident #10 had congestive heart failure. Pertinent interventions included checking breath sounds and monitoring for labored breathing and oxygen therapy as ordered or as indicated. The 3/8/24 care plan identified Resident #10 required pulmonary hygiene interventions due to acute complication of the respiratory system. Pertinent interventions included assessing pulse, respirations and oxygen saturation as ordered. -The March 2024 CPO did not reveal any orders for supplemental oxygen or measuring SpO2. The 12/30/23 progress notes revealed Resident #10 was on 2 LPM of supplemental oxygen via nasal cannula. -However, there was no physician's order for supplemental oxygen in Resident #10's EMR. The 1/12/24 progress notes revealed Resident #10 was on 4 LPM of supplemental oxygen via nasal cannula. -However, there was no physician's order for supplemental oxygen in Resident #10's EMR. Physician notes from 3/2/24 revealed Resident #10 received supplemental oxygen via nasal cannula. -However, there was no physician's order for supplemental oxygen in Resident #10's EMR. -The physician's note did not specify the rate of oxygen flow Resident #10 should receive. D. Staff interviews The DON was interviewed at 4:42 p.m. on 3/13/24. The DON said she could not find Resident #10's physician's order for supplemental oxygen. The DON said there were issues with the process for oxygen management. Licensed practical nurse (LPN) #2 was interviewed on 3/13/24 at 4:28 p.m. LPN #2 identified Resident #10's supplemental oxygen flow rate was set at 4 LPM. LPN #2 could not find a physician order for this oxygen, and said she was going to call the doctor to verify Resident #10's orders. LPN #2 said that oxygen was considered a medicine and required a physician's order to administer. IV. Resident #12 A. Resident status Resident #12, age [AGE], was admitted to the facility on [DATE]. According to the March 2024 CPO, diagnoses included dementia and liver disease. B. Observation On 3/13/24 at 2:45 p.m., Resident #12 was lying in bed. She was receiving oxygen via an oxygen cannula. The oxygen concentrator was set for 3 LPM of oxygen. On 3/13/24 at 4:35 p.m., with LPN #1 present, the resident continued to receive 3 LPM of oxygen. C. Record review The March 2024 CPO revealed the following: -An order for supplemental oxygen at 2 to 4 LPM via nasal cannula to keep SpO2 above 90%, initiated 1/29/24; -An order to do spot checks of SpO2 as needed, initiated 1/29/24; and, -An order for supplemental oxygen at 2 LPM via nasal cannula as needed for shortness of breath related to COVID-19, initiated on 1/28/24. The March 2024 MAR revealed a scheduled treatment for supplemental oxygen at 2 LPM via nasal cannula as needed for shortness of breath related to COVID-19. -The treatment was scheduled as needed, and was not signed off as being administered for any days in March 2024. Resident #12's vital signs were taken on 3/3/24 at 7:37 p.m. Her SpO2 was 94% on 2 LPM of oxygen -The last documentation of the resident's SpO2 levels, prior to 3/3/24, was 2/6/24. D. Staff interview LPN #1 was interviewed at 4:18 p.m. on 3/13/24. LPN #1 identified Resident #12 was receiving supplemental oxygen at 3 LPM. LPN #2 said the order for the 2 LPM oxygen was old, and that the 2 to 4 LPM order was the one that should be followed for Resident #12. LPN #2 said for as needed SpO2 checks, the nursing staff measured vital signs at random times of the day. LPN #2 said she took Resident #12's vitals that morning, but that Resident #12's measurements were not showing up in the vital signs section of the EMR or on her MAR. LPN #1 said oxygen was considered a medication and required a physician's order. V. Resident #13 A. Resident status Resident #13, age [AGE], was admitted to the facility on [DATE]. According to the March 2024 CPO, diagnoses included anemia, liver cirrhosis and thrombocytopenia. B. Observations On 3/13/24 at 2:40 p.m., Resident #13 was lying in bed. He was receiving oxygen via an oxygen cannula. The oxygen concentrator was set for 4.5 LPM of oxygen. On 3/13/24 at 4:45 p.m., with LPN #2 present, the resident continued to receive 4.5 LPM of oxygen. C. Record review The 2/21/24 care plan, revised 3/8/24, identified Resident #13 was at risk for respiratory complications due to a history of hypoxia and anemia. Pertinent interventions included providing oxygen therapy as ordered and assessing the resident for signs and symptoms of hypoxia. Resident #13's vital signs revealed the resident's SpO2 was measured at least once a day over the previous thirty days. The March 2024 CPO revealed Resident #13 had a physician's order for supplemental oxygen to be administered at 2 LPM. -However, observations revealed the resident was receiving oxygen at 4.5 LPM (see observations above). D. Staff interview LPN #2 was interviewed at 4:28 p.m. on 3/13/24. LPN #2 identified Resident #13 was receiving supplemental oxygen at 4.5 LPM. LPN #2 reviewed Resident #13's orders and confirmed that the physician's order stated the resident was to receive 2 LPM of oxygen. LPN #2 said she knew there were orders to titrate Resident #13's oxygen flow rate but could not find them. LPN #2 said Resident #13's oxygen should be on 2 LPM as ordered but as a nurse she was authorized to turn it up if needed. LPN #2 said oxygen was considered a medicine.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to ensure the resident's responsible party was notified when a change in medication occurred for one (#2) out of three residents reviewed for notification out of 13 sample residents. Specifically the facility failed to: -Ensure the responsible party was notified when a psychotropic medication was ordered and administered for Resident #2. Findings include: I. Resident #2 A. Resident status Resident #2, age [AGE], was admitted on [DATE]. According to the November 2023 computerized physician orders (CPO), diagnoses included failure to thrive, and anxiety. The 11/15/23 minimum data set (MDS) assessment revealed that the resident had severe cognitive impairment with a brief interview for mental status (BIMS) score of 99 out of 15. The resident was dependent on staff for assistance with all activities of daily living (ADLs) B. Record review The October 2023 CPO showed an order for Abilify (an antipsychotic medication) 2 mg (milligrams) to be given at bedtime for agitation. The start date of the order was 10/23/23. -The electronic medical record (EMR) failed to show the resident's responsible party was notified of the start of the Ability. -The EMR failed to show a psychotropic medication consent form was obtained from the resident's representative. C. Interview The director of nurses (DON) was interviewed on 11/29/23 at 11:00 a.m. The DON said the licensed nurse taking the order was responsible for ensuring the resident's responsible party was notified of the medication change and obtaining the signed consent. The DON reviewed the EMR and could not find documentation indicating the resident's responsible party was notified of the medication order or that a signed consent was obtained. The charge nurse (CN) was interviewed on 11/29/23 at 3:00 p.m. The CN said the nurse obtaining the order was responsible for ensuring the resident's responsible party was notified of the change of medication. She said a signed consent should be obtained from the resident's responsible party. She said if a signed consent could not be obtained the same day, then two licensed nurses were to sign after receiving a verbal consent. D. Follow up The DON provided a psychotropic medication administration disclosure on 11/29/23 at approximately 4:00 p.m. The disclosure was dated 11/29/23 for verbal consent from Resident #2's responsible party for the psychotropic medication.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interviews, the facility failed to provide written notification of room changes and roommate changes for two (#3 and #1) of three residents reviewed for notifications out of 13 sample residents. Specifically, the facility failed to provide timely written and/or verbal notification of room and/or roommate changes to Resident #3 and Resident #1 and/or their representatives. Findings include: I. Facility policy and procedure The Transfer Room to Room policy, dated December 2016, was provided by the nursing home administrator (NHA) on 11/29/23 at 4:00 p.m. The policy read in pertinent part, The purpose of this procedure guidelines for safely transferring residents from one room to another when such transfer has been approved in accordance with facility policies. Preparation Orient the resident to the transfer in a form and manner that the resident can understand. Provide the resident with the following information: where the room is located, who the resident ' s new roommate is, who will be providing care and why the transfer is taking place. The following information should be recorded in the resident ' s medical record: -Date and time the room transfer was made; -The name and title of the individual(s) who assisted in the move; and, -All assessment data obtained during the move. -The policy failed to instruct the room change needed to be in writing. II. Resident #3 A. Resident status Resident #3, age [AGE], was admitted on [DATE]. According to the November 2023 computerized physician orders (CPO), diagnoses included hemiplegia (paralysis of one side of the body), and hemiparesis (one sided muscle weakness) following cerebral infarction affecting left dominant side, muscle weakness, dysphagia and vascular dementia. The 10/11/23 minimum data set (MDS) assessment showed the resident had moderate cognitive deficit with a brief interview for mental status (BIMS) score of six out of 15. The resident was dependent on staff for personal hygiene. B. Record review Review of Residents #3 ' s electronic medical record (EMR) revealed no documentation of the room roommate change which occurred on 10/12/23. C. Responsible party interview Resident #3 ' s daughter was interviewed on 11/27/23 at 2:30 p.m. The daughter said Resident #3 received a roommate a few days prior to his discharge to the hospital. She said neither she nor Resident #3 received any notification of a new roommate. She said on 10/13/23, in the early morning, a resident to resident altercation occurred between Resident #3 and his new roommate which resulted in facial injuries and hospitalization for Resident #3 (cross-reference F657 for care planning). III. Resident #1 A. Resident status Resident #1, age [AGE], was admitted on [DATE]. According to the November 2023 CPO, diagnoses included Alzheimer ' s disease with late-onset, chronic pain and dysphagia. The 9/20/23 MDS assessment showed the resident had severe cognitive impairment with a BIMS score of 99, which indicated he was not able to recall any of the answers. The MDS assessment coded the resident as independent in mobility and as having no behaviors. B. Record review Review of Resident #1 ' s EMR revealed no written documentation of the room change or a reason for the room change which occurred on 10/12/23. The progress note dated 10/12/23 read in pertinent part, This writer called residents POA to update her about moving the resident ' s room. She is completely onboard. I advised POA to call me with any concerns or complaints. She states she has none. -The progress note did not document the POA was informed of the reason for the room change or if the POA was given written notification of the room change. III. Interview The social services director (SSD) was interviewed on 11/29/23 at 3:05 p.m. The SSD said that she reviewed the record for both Resident #1 and Resident #3 and confirmed there was no information in the record for the reason for the room change and no notification. She said that she had only been with the facility for two days prior to this room change so she was not familiar with the residents and reasons. The SSD said that each resident needed to receive written documentation prior to the change, which included the reasons for the room change or the new roommate.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interviews, the facility failed to ensure the self-administration of medications was clinically appropriate for one (#13) of three out of 70 sample residents. Specifically, the facility failed to ensure Resident #13 was assessed for clinical appropriateness of self administration of medication and medications left at the bedside were secured. Findings include: I. Facility policy and procedure The Medication Self-Administration facility policy and procedure, revised on 3/1/22, was provided by the nursing home administrator (NHA) on 8/17/23 at 6:30 p.m. It revealed, in pertinent part, Patients who request to self-administer medications will be evaluated for safe and clinically appropriate capability based on the patient's functionality and health condition. If it is determined that the patient is able to self-administer a physician/advanced practice provider order (APP) is required. Self-administration and medication self-storage must be care planned. When applicable, patients must be provided with a secure, lock area to maintain medications. Patients must be instructed in self-administration. Evaluation of capability must be performed initially, quarterly, and with any significant change in condition. II. Resident #13 A. Resident status Resident #13, age [AGE], was admitted on [DATE]. According to the August 2023 computerized physician orders (CPO), the diagnoses included asthma (a disease that affects your lungs, causing repeated episodes of wheezing, breathlessness, chest tightness) and sleep apnea (sleep disorder in which breathing repeatedly stops and starts). The 5/4/23 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status score of 15 out of 15. He required the supervision of one staff member for transfers, dressing, eating, toileting and personal hygiene. B. Observations and resident interview On 8/14/23 at 4:00 p.m. a triangle shaped object, gray in color, with a label reading Wexla fluticasone propionate and salmeterol inhalation powder, USP -Salmeterol (asthma inhaler) was observed on the bedside table belonging to Resident #13. On 8/15/23 at 12:00 p.m. the same medications were observed on the resident ' s bedside table. Resident #13 identified the object as a medicated inhaler he used for his asthma diagnosis. He said the facility was aware he kept the medication at his bedside. He said the facility ordered the inhaler for him from a pharmacy. Resident #13 said he preferred to keep medications on his bedside table. C. Record review The August 2023 CPO revealed a physician ' s order for Wixela Inhub Inhalation Aerosol Powder Breath Activated (Fluticasone-Salmeterol) 1 puff inhaled orally two times a day for asthma unsupervised self administration. The 5/31/23 care plan revealed Resident #13 was at risk of respiratory complications related to sleep apnea asthma. The interventions included administering medications as ordered, monitoring of the effectiveness, observing for signs and symptoms of side effects and reporting to the physician. -The comprehensive care plan did not indicate Resident #13 had been assessed and approved by the physician to self administer the Wixela inhaler, nor did it address safe storage of medication. A review of Resident #13's medical record did not reveal an assessment had been conducted to determine if the resident was able to safely administer medications. V. Staff interviews Registered nurse (RN) #6 was interviewed on 8/16/23 at 1:09 p.m. She said the electronic medical record (EMR) that nursing staff used to pass medication indicated which residents could self-administer and what medication could be self administered. She reviewed the EMR for Resident #13. She did not see any indication that Resident #13 could self administer his Wexla. The director of staff development (DSD) was interviewed on 8/16/23 at 1:37 p.m. She said residents needed to be assessed for ability to self administer prior to permitting them to do so. She said residents who were assessed and found capable of self administering medications could store those medications in their rooms in a safe location. She said the drawer of a bedside table or a locked box on a bedside table would be a safe location. She said keeping the medication out in the open on a bedside table was not considered a safe location for storage. The assistant director of nursing (ADON) was interviewed on 8/16/23 at 1:40 p.m. He said residents who wished to self administer medications needed to be assessed prior to doing so. He said once assessed and found capable to self administer medications the orders in EMR needed to reflect the information. He said medications left in resident rooms should be stored in a safe location such as a nightstand drawer. He said the bedside table, out in the open, was not a safe location for storage of medications. -On 8/17/23 at 3:58 p.m. ADON provided documentation a facility audit had been conducted to include Resident #13 being provided a lock box or opting to store medications at bedside in a locked drawer. The audit included on the spot training conducted by DSD addressing medication self administration assessment, facility policy, storage, safety maintaining and orders.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** III. Incident of physical abuse between Resident #64 and Resident #52 A. Resident #64 1. Resident status Resident #64, under the age of 65, was admitted on [DATE] and readmitted on [DATE]. According to the August 2023 CPO the diagnoses included depression, vascular dementia with agitation, psychotic disorder with delusions, vascular dementia with mood disturbance and nicotine dependence. The 6/2/23 MDS assessment revealed the resident had moderate cognitive impairment with a brief interview for mental status with a score of 11 out of 15. She required supervision for bed mobility, transfers, walking in her room and in the corridor and locomotion on and off the unit. She required extensive assistance of one person for toileting, personal hygiene, eating and dressing. The MDS assessment revealed she had verbal behaviors directed towards others one to three times in the review period. She had behavioral symptoms not directed towards others one to three times in the review period. 2. Record review The behavior care plan, initiated on 4/18/19, revealed Resident #64 made allegations of verbal abuse related to staff commenting on her smoking habits. The interventions included: ensuring Resident #64 was taken out on her smoke breaks and monitoring complaints and let management or social services know of any issues. Another behavior care plan, initiated on 10/18/23 and revised on 5/19/21, revealed Resident #64 exhibited or had the potential to exhibit physical behaviors related to cognitive loss and dementia. Resident #64 became argumentative or verbally aggressive with other residents (7/24/23), especially when she perceived their actions as being hostile or directed towards others. Resident #64 has been involved in resident to resident physical altercations. Resident #64 attempted to provide care or push other resident's wheelchairs even when redirected not to by staff. Some of Resident #64's behaviors were centered around smoking when she perceived she missed a smoke break. The interventions included: diverting the resident by giving her alternative objects or activities (10/18/18), attempting to de-escalate the situation if Resident #64 becomes physically aggressive to ensure the safety of both parties (7/24/23), reminding Resident #64 when she has been out to smoke (6/11/19), removing the resident from her environment (10/18/18), encouraging Resident #64 to seek staff support when she was distressed (10/18/18), removing Resident #64 from the environment if needed and gently guiding the resident into a different environment (10/18/18), observing for non-verbal signs of physical aggression (10/18/18), listening to the resident and trying to calm her (10/18/18), allowing time for expression of feelings (10/18/18), approaching Resident #64 in a calm manner (10/18/18), providing consistent caregivers (10/18/18) and providing Resident #64 with opportunities for choice during care and activities to provide a sense of control (10/18/18). The 7/23/23 change in condition assessment documented in Resident #64's medical record revealed Resident #64 had behavioral symptoms. Resident #64 was admitted for long term care and had a diagnosis of chronic obstructive pulmonary disease (COPD) and diabetes. The assessment documented there were no mental or functional status changes observed. Resident #64 had physical and verbal aggression. The assessment documented a skin or pain evaluation was not needed. The resident's representative and physician were notified of the incident. The 7/23/23 progress note documented in Resident #64's medical record revealed Resident #64 was involved in a resident to resident altercation. Resident #64 told Resident #52 to stop yelling out. Resident #52 hit Resident #64 on her right forearm with a book. Resident #64 slapped Resident #52 across the cheek. Resident #52 grabbed Resident #64's arm. The progress note documented that the nurse and the CNA intervened and separated the residents. Resident #64 was calm and did not require redirection. The progress note documented staff would continue to monitor with frequent checks to ensure the resident was safe. The NHA and the DON were notified of the incident. -A review of Resident #64's medical record revealed a skin check was completed on 7/24/23. A skin check was not completed after the incident of physical abuse on 7/23/23. B. Resident #52 1. Resident status Resident #52, age [AGE], was admitted on [DATE]. According to the August 2023 CPO the diagnoses included vascular dementia, anxiety disorder, altered mental status, dementia and vascular dementia with psychotic disturbance. The 8/2/23 MDS assessment revealed the resident had severe cognitive impairment with a brief interview for mental status with a score of five out of 15. She required supervision with bed mobility, transfers, eating, walking in her room and in the corridor and locomotion on the unit. She required extensive assistance of one person for dressing, toileting and personal hygiene. The MDS revealed the resident had verbal behavior directed towards others one to three days in the review period. 2. Record review The behavior care plan, initiated on 5/3/23 and revised on 8/5/23, revealed Resident #52 exhibited verbal behaviors related to dementia. Resident #52 had episodes of cursing at staff and other residents. Resident #52 had episodes of yelling, throwing items and throwing water at staff. Resident #52 had episodes of being accusatory towards staff related to her belongings. Resident #52 had verbal aggression towards her daughter, staff and other residents. The interventions included: attempting to de-escalate the situation and ensuing the safety of both parties (7/24/23), monitoring medications for side effects that could contribute to verbal behaviors (5/3/23), evaluating the nature of the circumstance (5/3/23), evaluating the need for behavioral health consultation (5/3/23), providing consistent caregivers and a structured environment (5/3/23), postponing cares or activities if resident became combative or resistant (5/3/23) and allowing time for expression of feelings (5/3/23). The 7/23/23 change in condition assessment documented in Resident #52's medical record revealed Resident #52 had behavioral symptoms. Resident #52 was admitted for long term care and had a diagnosis of dementia and diabetes. The assessment documented Resident #52 had physical and verbal aggression. The assessment documented a skin, pain or neurological evaluation was not needed. The resident's representative and physician were notified of the incident. The 7/23/23 progress note documented in Resident #52's medical record revealed Resident #52 was involved in a resident to resident altercation. Resident #52 was carrying her belongings and was yelling out that she needed to leave. Staff attempted to redirect and calm the residents. The progress note documented as Resident #52 passed Resident #64 in the hallway, Resident #64 told Resident #52 to stop yelling. Resident #52 slapped Resident #64 with a book on her right forearm. Resident #64 slapped Resident #52 on the face. Resident #52 grabbed Resident #64 on the right forearm. The progress note documented the nurse and the CNA intervened and separated the residents. Resident #52 was taken to her room to calm down and listen to music with staff. The progress note documented the staff would continue to monitor with frequent checks to ensure the residents safety. The administrator and the DON were notified. The 7/24/23 progress note documented in Resident #52's medical record revealed Resident #52 entered the dining room at breakfast and apologized to Resident #64 regarding the altercation that occurred on 7/23/23. -A review of Resident #52's medical record revealed a skin check was completed on 7/29/23, seven days after the incident of physical abuse on 7/23/23. C. Resident to resident altercation The 7/23/23 abuse investigation revealed the interdisciplinary team (IDT) team reviewed the resident to resident altercation on 7/24/23. The investigation documented safety measures were put into place for the residents and there were no injuries noted upon nursing assessments. The care plans were updated to include de-escalation and physical and verbal behaviors. The abuse investigation included a statement that was dated 7/24/23 from CNA #10 who was present at the time of the resident to resident altercation on 7/23/23. The statement revealed on Sunday 8/23/23 CNA #10 helped the nurses with a resident to resident conflict. CNA #10 was exiting a resident room when she heard registered nurse (RN) #4 yelling to stop. CNA #10 documented she was unsure of what exactly occurred, since she was around the corner. CNA #10 approached the situation and helped RN #4 separate the residents. At that time Resident #52 was holding onto Resident #64's arm with a firm grip. Resident #54's glasses were on the floor and her hair was disheveled. CNA #10 said in an attempt to calm Resident #54 she took her to her room. CNA #10 documented as she assisted Resident #54 back to her room, she was making claims that Resident #64 started it and Resident #64 was making rude comments to Resident #52 and that was why she went after her. CNA #10 documented she assisted Resident #52 in turning on music and looking at a photo album, which helped calm her down. Resident #64 did not want to return to her room and returned to pacing the hallways. The 7/23/23 abuse investigation revealed the NHA interviewed Resident #52 on 7/25/23. Resident #52 said she did not remember the incident from 7/23/23. The NHA asked Resident #52 if she was in distress, upset or had feelings of being unsafe and Resident #52 denied. Resident #52 said she had never grabbed or hit anyone and did not recall being hit herself. Resident #52 said she felt safe in the facility and had no concerns. The 7/23/23 abuse investigation revealed the NHA interviewed Resident #64 on 7/25/23. Resident #64 did not remember the resident to resident altercation on 7/23/23. Resident #64 appeared calm and without distress at the time of the interview. Resident #64 said she was not fearful of other residents. The interview documented the NHA observed Resident #64 being pleasant with other residents. D. Staff interviews RN #4 was interviewed on 8/17/23 at 12:21 p.m. RN #4 said she had worked on the 900 unit for several years and was very familiar with Resident #64. RN #4 said Resident #64 did not like when other residents entered her space. RN #4 said Resident #64 enjoyed smoking and had supervised smoke breaks three times a day. RN #4 said Resident #64 had a history of becoming verbally or physically aggressive if she thought her smoke breaks were missed or late. RN #4 said Resident #64 could be redirected. RN #4 said Resident #64 enjoyed pacing the hallways during the day. RN #4 said Resident #52 had only been at the facility for a couple of months. RN #4 said Resident #52 was easily escalated. RN #4 said Resident #52 often became more agitated in the afternoon. RN #4 said she was present on 7/23/23 when Resident #64 and Resident #52 had a resident to resident altercation. RN #4 said Resident #52 was upset because her daughter was late to visit her. RN #4 said she attempted to help Resident #52 call her daughter, but her daughter did not answer. RN #4 said this upset Resident #52. RN #4 said Resident #64 was waiting by the nurses station to smoke. RN #4 said Resident #52 began yelling and screaming by the nurses station. RN #4 said Resident #64 asked Resident #52 to stop yelling. RN #4 said Resident #52 was carrying around a book and some personal belongings when she turned and hit Resident #64 on the right forearm. RN #4 said Resident #64 then swung and slapped Resident #52 in the face. RN #4 said herself and the unidentified CNA on duty separated the residents. RN #4 said the resident to resident altercation occurred near the shift change. RN #4 said she notified the oncoming shift of what occurred and the NHA. RN #4 said the skin assessments for both residents should have been documented under the change of condition assessment. -However, a review of Resident #64's and Resident #52's medical records revealed in the change of condition assessments that it was marked a skin assessment was not needed. The NHA was interviewed on 8/17/23 at 2:21 p.m. The NHA said he started working at the facility on 7/20/23. The NHA said the resident to resident altercation on 7/23/23 was witnessed by RN #4. The NHA said he did not substantiate abuse because both residents involved had a diagnosis of dementia. The NHA said he was unable to prove the residents had intent to hurt each other because they had cognitive impairments. The NHA said no concerns were noted after he conducted the abuse investigation. The NHA said he did not interview any other residents on the unit since it was a dementia unit. The NHA said he interviewed the two staff members that were present at the time of the alteration. The NHA said he initiated frequent checks to ensure the residents were safe. The NHA said there were no time parameters on the frequent checks. The NHA said when he initiated frequent checks he expected staff to check on the residents more frequently than the usual two hours. The NHA said he did not have staff document the frequent checks. The NHA said the residents had a childlike reaction by hitting each other, which stemmed from frustration. The NHA said the IDT team reviewed the residents' care plans, but did not put any new interventions into place. The SSD was interviewed on 8/17/23 at 5:10 p.m. The SSD said she was not involved in the investigation regarding the 7/23/23 resident to resident altercation. The SSD said she did not follow up with either resident after the altercation. Based on interviews and record review, the facility failed to ensure three (#56, #64 and #52) out of 70 sample residents were kept free from abuse. Specifically, the facility failed to: -Ensure Resident #56 was kept free from physical abuse by Resident #188; and, -Ensure resident to resident altercation, which started with yelling, did not result in physical abuse with Resident #64 and Resident #52. Findings include: I. Facility policy and procedure The Abuse Prohibition policy and procedure, reviewed February 2021, was provided by the nursing home administrator (NHA) on 8/17/23 at 6:15 p.m. It read, in pertinent part, (The facility) prohibits abuse, mistreatment, neglect, misappropriation of property, and exploitation of all residents. This includes, but is not limited to, freedom from corporal punishment, involuntary seclusion, and any physical or chemical restraint not required to treat the patient's medical symptoms. Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, injury, or mental anguish. Physical abuse includes hitting, slapping, pinching, kicking, as well as controlling behavior through corporal punishment. If the suspected abuse is resident to resident, the resident who has in any way threatened or attacked another will be removed from the setting or situation and an investigation will be completed. The (facility) will provide adequate supervision when the risk of resident to resident altercation is suspected. The (facility) is responsible for identifying residents who have a history of disruptive or intrusive interactions or who exhibit other behaviors that make them more likely to be involved in an altercation. II. Incident of physical abuse between Resident #56 and Resident #188 A. Resident #56 1. Resident status Resident #56, age [AGE], was admitted on [DATE] and readmitted on [DATE]. According to the August 2023 computerized physician orders (CPO), the diagnoses included vascular dementia with behavioral disturbance. The 7/7/23 minimum data set (MDS) assessment revealed the resident had severe cognitive impairment with a brief interview for mental status score of five out of 15. He required extensive assistance of one person with bed mobility and transfers and extensive assistance of two people with dressing and toileting. It indicated the resident did not exhibit any behaviors during the assessment period. 2. Record review The behavioral care plan, initiated on 2/16/23 and revised on 7/14/23, documented the resident had the potential to exhibit physical behaviors related to impaired cognition due to vascular dementia. It indicated the resident had been involved in an altercation with another resident on 2/13/23 and 7/13/23. The interventions included evaluating the nature and circumstances of the physical behavior with the resident and/or resident representative; discussing the findings with the resident and family members; adjusting care delivery appropriately; evaluating the need for a behavioral health consult; observing for non-verbal signs of physical aggression such as a rigid body position and clenched fists; removing the resident from the environment; guiding the resident from the environment while speaking in a clam and reassuring voice; providing social services visits to provide support; and diverting the resident by giving alternative objects or activities. B. Resident #188 1. Resident status Resident #188, age [AGE], was admitted on [DATE], readmitted on [DATE] and discharged on 7/13/23. According to the July 2023 CPO, the diagnoses included dementia with behavioral disturbance and Alzheimer's disease. The 6/20/23 MDS assessment revealed the resident had short term and long term memory impairment and had severe impairment in making decisions regarding tasks of daily life. He required extensive assistance of one person with bed mobility, transfers, dressing, toileting and personal hygiene. It indicated the resident exhibited physical and verbal behaviors directed towards others one to three days during the seven day assessment period. 2. Record review The behavioral care plan, initiated on 2/15/23 and revised on 7/20/23, documented the resident exhibited physical behaviors related to dementia and had a history of harming others. It indicated the resident hit another resident in the face when the other resident walked past his room on 2/13/23 and grabbed another resident's hand and squeezed it on 6/10/23. The interventions included evaluating the nature and circumstances of the physical behavior with the resident and/or resident representative; discussing the findings with the resident and family members; adjusting care delivery appropriately; evaluating the need for a behavioral health consult; observing for non-verbal signs of physical aggression such as a rigid body position and clenched fists; removing the resident from the environment; guiding the resident from the environment while speaking in a calm and reassuring voice; providing social services visits to provide support; and diverting the resident by giving alternative objects or activities. -Upon review of the resident's medical record, the interventions documented on Resident #188's care plan were the same interventions documented on Resident #56's care plan. The interventions were not person-centered. C. Resident to resident altercation The 7/13/23 nursing progress note documented Resident #188 was found by a certified nurse aide (CNA) on top of Resident #56 on the ground. It took three staff members to get Resident #188 off of Resident #56. Once Resident #188 was removed, blood was observed all over the bed and on the wall. Resident #56 had a baseball sized hematoma on his left eye and it was completely swollen shut. The resident was bleeding from three small lacerations above his left eye. Emergency services was contacted and Resident #56 was transported to the hospital. Resident #188's hospice agency was notified of the incident and it was determined by the family that the resident would be moved to the hospice inpatient facility. The police were contacted to assist the transport agency with transferring the resident. The 7/17/23 nursing progress note documented Resident #56 returned to the facility with bruises to the face, neck and arms with a hematoma on the left forehead. The 7/13/23 abuse investigation did not document any changes made to Resident #188's care plan and documented as a conclusion that Resident #188 was transferred to another facility. It indicated the allegation of physical abuse was substantiated due to witness statements and the injuries sustained to Resident #56. D. Staff interviews The program director (PD) was interviewed on 8/17/23 at 12:50 p.m. She said she was not at the facility the day of the altercation between Resident #188 and Resident #56, but she was told by the staff. She said the staff were rounding when they saw Resident #188 in Resident #56's room. She said they were hitting each other. She said Resident #188 entered Resident #56's room and started the altercation. She said Resident #188 had a history of physically aggressive behavior. She said he would have outbursts and act out, however staff were usually around to intervene. Licensed practical nurse (LPN) #3 was interviewed on 8/17/23 at 1:15 p.m. She said prior to the incident, Resident #188 had been wandering in and out of rooms on the unit. She said she had redirected the resident out of a room and he had punched her on the arm. She said Resident #188 had a history of head butting other people and becoming violent. She said Resident #188 would hit anyone, it did not matter if the person was male or female. She said Resident #56 did not like it when other residents entered his room. She said he would yell at people to leave his room. She said he would yell at people but did not get physical. CNA #7 was interviewed on 8/17/23 at 1:32 p.m. She said she went to Resident #56's room and saw him with a lot of blood on his face. She said they called emergency services and the police. She said some staff took Resident #188 back to his room and a few other staff members stayed with Resident #56 to protect him. She said Resident #188 had a history of being physically aggressive. The director of nursing (DON) was interviewed on 8/17/23 at 6:02 p.m. She said the nurse working on the floor was responsible for initiating an abuse investigation when an incident occurred or an allegation made. She said she was aware of the incident between Resident #188 and Resident #56. She said Resident #188 had been transferred to a hospice in patient care center and Resident #56 returned to the facility after being seen at the hospital. She said she was not aware of either residents' behavioral history. She said the unit manager handled specifics on each unit.

Based on observations and interviews, the facility failed to provide services in accordance with currently accepted professional principles. Specifically, the facility failed to ensure medications were not dispensed and stored in medication cups in the top drawer of the medication cart. Findings include : A. Professional references Nursing rights of medication administration last updated on 9/5/22, was retrieved from https://www.ncbi.nlm.nih.gov/books/NBK560654/ on 8/31/23 at 8:50 a.m. It read in pertinent part: ' Right time '-administering medications at a time that was intended by the prescriber. Often, certain drugs have specific intervals or window periods during which another dose should be given to maintain a therapeutic effect or level. A guiding principle of this ' right ' is that medications should be prescribed as closely to the time as possible, and nurses should not deviate from this time by more than half an hour to avoid consequences such as altering bioavailability or other chemical mechanisms. I. Facility policy and procedure The Medication Storage policy was requested from the NHA on 8/17/23 at 4:15 p.m. but was not provided. II. Observations and record review On 8/17/23 at 11:26 a.m., the medication cart on the 400 hall were inspected with the licenced practical nurse (LPN) #. The following items were found: -A medicine administration cup with pudding and pieces of crushed medication mixed in it and written on the side was 407a. -A medicine administration cup with multiple medications in it and written on the side was 402b. III. Staff Interviews LPN #1 was interviewed on 8/17/23 at 10:50 a.m. She said the medication mixed in with the pudding was for a resident that had refused to take the medication earlier that morning and she was keeping it in the cart so she could make more efforts to try to get the resident to take the medication. She said the medications in the other cup were medications she had prepared for a resident but then was unable to find the resident. She said she was from an agency and did not know if she could store the medication in the cart if the resident refused or was not available. The DON was interviewed on 8/17/23 at 6:18 p.m. She said dispensed medications in medicine cups were not to be stored in the drawers of the medicine cart. She said medications that were refused or unable to be administered to a resident should be disposed of properly.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observations, and interviews the facility failed to ensure one resident (#63) reviewed for activities of daily living (ADLs) received the necessary care and services to maintain their abilities in ADLs out of 70 sample residents. Specifically, the facility failed to provide language communication tools in order for Resident #63 to effectively communicate her needs, requests, opinions and participate in social conversation. Findings include: I. Resident status Resident #63, age [AGE], was admitted on [DATE]. According to the August 2023 computerized physician orders (CPO), the resident's diagnoses included pneumonia, unspecified organism and acute respiratory failure with hypoxia (low oxygen). The 7/3/23 minimum data set (MDS) assessment revealed the resident was severely impaired with a brief interview for mental status score of zero out of 15. She required extensive assistance with bed mobility, transfers, locomotion on and off unit, dressing and toilet use. II. Observation The staff were not able to communicate with the resident consistently due to her primary language being Vietnamese. On 8/16/23 at 9:38 a.m. the resident in the dining room held her empty cup of chocolate milk and said ah, ah, ah. Staff asked if she would like more and the resident gave staff her cup to fill up. At 1:19 p.m. the staff used hand gestures with the resident and staff pointing to their mouth and told the resident if she was ready to eat. At 2:20 p.m. the resident opened the door to her room and made a hand gesture to her mouth. A staff member said to the resident if she wanted her lipstick and the resident puckered her lips and the staff put her lipstick on. At 2:30 p.m. the resident's room had a sign for the language line. She had no communication board (as indicated by the director of nursing, see interview below). III. Record review The communication care plan, revised on 8/16/23, documented the resident had impaired communication as evidenced by language barrier, impaired hearing and had bilateral hearing aids. Primary language is Vietnamese. Communicating with the resident by translation apps, calling family for assistance and have attempted communication boards in the past. Interventions included using short phrases that require yes or no answers, speaking in normal tone voice clearly and slowly, stressing key words and pausing between statements, reducing external noise when communicating with resident (turn off television or radio), providing preferred language interpreter services such as language line as indicated, using personal cell phone translator, utilizing family when available, speaking facing the resident, using touch to help convey your message as tolerated by resident/patient and validating meaning of nonverbal communication. IV. Staff interviews Certified nurse aide (CNA) #7 was interviewed on 8/17/23 at 4:47 p.m. She said when speaking to the resident she would point to things and make hand gestures and the resident made hand gestures back. She said she understood what the resident was saying but not sure if the resident understood what the staff was saying. Licensed practical nurse (LPN) #3 was interviewed on 8/17/23 at 4:31 p.m. She said she was not able to hold a long conversation with the resident. She said she kept her conversations short and simple. She said she had a translator application on her phone and used it if needed or she would ask another staff member to find out what resident needed. She said she downloaded the translator application on her phone on her own. She said she had not seen the translation line posted on the unit nor has she been trained on how to use the translation line. The program director of activities was interviewed on 8/17/23 at 5:40 p.m. She said staff have an application on their phone to use for translation but not all the staff used it. She said staff sang with the resident, did prayers with her and used family for translation. She said the facility used to have a translator line but no longer had access and they were working on getting the staff access to the language line. The director of nursing (DON) was interviewed on 8/17/23 at 6:02 p.m. She said for residents who speak a different language there were communication boards for them. She said they had a language line that staff used. She said staff used their personal phones to interpret. She said using hand or body gestures was not the appropriate way to communicate with residents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** III. Resident #335 A. Resident status Resident #335, under the age of 65, was admitted on [DATE]. According to the August 2023 CPOs diagnoses included disease of the spinal cord, displaced fracture of the fifth cervical vertebra, attention-deficit hyperactivity disorder, anxiety disorder, bipolar disorder, and insomnia. The 8/10/23 MDS assessment documented the resident had mild cognitive impairment with a brief interview for mental status (BIMS) score of 11 out of 15. He also needed extensive assistance with eating and personal hygiene. It indicated the resident did exhibit any behavioral symptoms during the assessment period. B. Observations During a continuous observation on 8/15/23 beginning at 9:50 a.m. and ended at Resident #335 was observed lying in bed in his room with the television (TV) on and his eyes open. -At 10:50 a.m., an unidentified licensed medical provider left the resident's room after spending 18 minutes with him. The resident remained in the same position on his back in his bed with the head of the bed slightly elevated and the TV still on. -At 11:30 p.m. the resident was still lying in his bed in the same position, watching TV. -At 12:45 p.m. the resident was served lunch and was assisted with eating. -At 1:55 p.m. an unidentified certified nurse aide (CNA) entered the resident's room and removed the resident's lunch tray from the bedside table and exited the room. -At 3:15 p.m. the resident remained lying on his back with the TV on, and his eyes were closed. -At 4:07 p.m. the resident remained in the same position -At 5:15 p.m. the resident activated his call light. The facility staff had not yet answered the resident's call light when observations ended at 5:30 p.m. The resident was not offered or provided any meaningful activities during the observation. During a continuous observation on 8/16/23 beginning at 9:22 a.m. and ended at 4:05 p.m. Resident #335 was observed lying in bed, on his back with the head of the bed slightly elevated, a breakfast tray on his bedside table, the television was turned on and his eyes were open. -At 9:36 a.m. the resident activated his call light. -At 9:43 a.m. an unidentified CNA spoke to the resident from the hall for a few seconds, entered the room and repositioned the resident's head. -At 9:48 a.m. the resident activated his call light. -At 9:49 a.m. an unidentified CNA went into the resident's room and turned off the call light. -At 9:51 a.m. the resident turned the call light on. An unidentified CNA entered the resident's room and turned off the light. -At 10:25 a.m. the resident turned the call light on. An unidentified CNA saw the light and told the resident from the hall to give her a few minutes. -At 10:35 a.m. licesnsed practical nurse (LPN) #2 and an unidentified CNA entered the resident's room to reposition the resident's upper torso as he began to shift to the side. -At 11:01 a.m. the resident remained lying on his back, in his bed with the TV on. -At 11:07 a.m. the resident turned his call light on. -At 11:19 a.m. an unidentified CNA turned off the call light and repositioned the resident's head. The resident remained laying on his back. -At 12:17 p.m. the resident was lying in bed, on his back with the TV on. -At 1:40 p.m. the resident was served a lunch tray and was assisted with eating. -At 2:40 p.m. the resident was lying in bed watching tv. -At 3:01 p.m. CNA #2 and CNA #1 entered the resident's room to provide incontinence care for a bowel movement. -At 4:01 p.m. the resident turned on his call light. -At 4:02 p.m. CNA #2 turned off the call light and exited the room. The resident was not offered or provided any meaningful activities throughout the observation. C. Resident interview Resident #335 was interviewed on 8/14/23 at 11:25 a.m. He said that he would like to participate in activities but he was not able to leave his room due to his condition. He said the only thing he does is lay in his bed and watch television or look out of the window. Resident #335 said he was sad and lonely. D. Record review The activity care plan, initiated on 8/5/23 and revised on 8/11/23, revealed Resident #335 was at risk for or was experiencing adjustment issues related to a change in customary lifestyle and routines, difficulty accepting placement in the center, coping with a decline in overall health status and a functional decline. The care focus goal documented the resident would demonstrate improved coping skills to adjust to changes in circumstances or the new environment. The interventions included providing the resident with opportunities for choices during care/other activities to provide a sense of control. -The care plan did not address the resident's activity preferences nor provide person-centered approaches to meet the resident's socialization needs. -The facility was unable to provide documentation of a one to one activity program for Resident #335 upon request during the survey process. E. Staff interview AA #1 was interviewed on 8/17/23 at 5:24 p.m. She said the facility developed a one to one activity program for residents that were unable to leave their rooms to address their socialization needs. She said she did not know Resident #335. She said Resident #335 was not placed on a one to one activity schedule. She said she did not know the resident's activity preferences. The activity director was unavailable for an interview during the survey process. The NHA was interviewed on 8/17/23 at 6:45 p.m. He said he had recently taken over as the NHA of the facility. He said he was aware the activity department was not staffed appropriately, which caused a deficit in the activities of the facility. He said the facility was in the process of hiring another three activities assistants to meet the socialization needs of the residents. Based on observations, record review and interviews, the facility facile to ensure activities designed to support residents physical, mental and psychosocial well-being were provided for two (#21 and #335) of 10 residents reviewed for activities out of 70 sample residents. Specifically, the facility failed to ensure Resident #21 and #335 were provided activities and developed a comprehensive care plan which addressed each resident's socialization and activity needs. Findings include: I. Facility policy and procedure The Program Components policy, dated 7/1/14, was provided by the nursing home administrator (NHA) on 8/17/23 at 5:09 p.m. It revealed in pertinent part, The Recreation Department will create a program environment that supports resident/patient well being. Purpose: to provide experiences for each resident/patient which address the domains of wellbeing: identity, growth, autonomy, security, connectedness, meaning, and joy. The Program design policy, dated 7/1/14, was provided by the NHA on 8/17/23 at 5:09 p.m. It revealed in pertinent part, Recreation services will be designed to meet residents'/patients' interests, abilities, and preferences through group and individual programs and independent leisure activities. Purpose: to provide residents/patients with a wide variety of experiences that are available on a regularly scheduled basis consistent with their assessed life routines and patterns of engagement. II. Resident #21 A. Resident status Resident #21, under the age of 65, was admitted on [DATE]. According to the August 2023 computerized physician orders (CPO) the diagnoses included Parkinson's disease (brain disorder causing unintentional movements), major depressive disorder and adjustment disorder. The 7/5/23 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) with a score of 15 out of 15. He required supervision with set-up assistance for bed mobility, transfers, walking in his room and in the corridor, locomotion on and off the unit, dressing, toileting and personal hygiene. He required supervision with one person assistance for eating. The 4/10/23 MDS assessment revealed it was somewhat important for the resident to have books to read, keep up with the news, do things with groups of people and do his favorite activities. It was very important to listen to music and be around animals, get fresh air and participate in religious activities. B. Observations and resident interview Resident #21 was interviewed on 8/15/23 at 10:29 a.m. Resident #21 said he did not have any reading material in his room. Resident #21 said there was a common area room where he was able to read books. Resident #21 said he was not sure if he was able to take the books out of the common room. Resident #21 said he would like to read in his room sometimes. Resident #21 said he enjoyed attending group activities occasionally. Resident #21 said he enjoyed going outside for fresh air. Observations at that time revealed Resident #21 had a television in his room, but the walls were blank and there were no independent activities in his room. During a continuous observation on 8/16/23 beginning at 9:30 a.m. and ended at 10:40 a.m. the following was observed: -At 10:31 a.m. activities assistant (AA) #1 entered Resident #21's room. AA #1 handed Resident #21 the daily chronicle and left the room at 10:31 a.m. AA #1 did not provide any meaningful conversation to the resident. On 8/17/23 at 10:07 a.m. AA #1 was on the 600 unit, where Resident #21 resided. AA #1 went into several rooms on the hallway and invited residents to the coffee talk that was occurring in the north unit dining room. AA #1 did not enter Resident #21's room to invite him to the coffee talk. Resident #21 was interviewed again on 8/17/23 at 11:28 a.m. Resident #21 said no staff invited him to the coffee talk activity that morning. Resident #21 said he was frequently bored because he had nothing to do. Resident #21 said he tried to go for a daily walk outside to keep himself busy. C. Record review The activities plan of care, initiated on 6/24/21 and revised on 4/24/23, revealed Resident #21 enjoyed reading, listening to music, watching television, the news, meditating, pet visits and socializing with staff. Resident #21 enjoyed going outside for walks and sitting in the common room reading and relaxing. Resident #21 attended a church across the street. Resident #21 occasionally participated in room socials, but stated that he liked to be left alone and would ask for assistance when needed. Resident #21 used a wheelchair for mobility. The interventions included: encouraging and facilitating Resident #21's activity preferences, assisting Resident #21 in picking out his clothing items, allowing Resident #21 to take care of his personal belongings, offering Resident #21 bathing preferences, offering Resident #21 snacks between meals, offering Resident #21 to eat in his room or outside, allowing Resident #21 to pick his bedtime, allowing Resident #21 to wake up early, allowing Resident #21 to take a nap as desired, including family or close friends in decisions regarding the residents' care, providing Resident #21 fresh air when he became upset, providing Resident #21 with a private place to use his phone, providing a place to lock up his personal belongings, providing reading materials such as religious books, providing music, providing pet vitists, allowing to watch the television as desired, encouraging Resident #21 to participate in church activities, providing a place to mediated, engaging Resident #21 in his favorite activities such as spending time outside and with his church friends, encouraging Resident #21 to go outside when the weather is good, offering religious activities and ensuring Resident #21 had his walker and glasses. The 4/10/23 recreation assessment documented Resident #21 was able to express his ideas and wants. Resident #21 preferred to be called by his first name. The assessment documented Resident #21 said it was very important to him to choose the clothes he wears, use his phone in private, listen to music, get outside when the weather is good, have pet visits and have his friends/family involved in his care. Resident #21 said it was somewhat important to him to take care of his personal belongings, choose between a tub bath, shower, bed bath or sponge bath, have snacks available between meals, have a place to lock his personal belongings, have things to read, choose where he ate and choose his own bedtime. Resident #21 said his friends from his church and the pastor at his church were important people in his life that visited him in person. The assessment documented Resident #21 enjoyed going for walks. Resident #21 enjoyed being with the church family and bible studies. The assessment summary documented Resident #21 remained the same this year. Resident #21 enjoyed the comfort of his room by reading, listening to music, watching television and news, mediating, pet visits and socializing with staff. Resident #21 enjoyed going on walks outside. Resident #21 attended church across the street. Resident #21 was very vocal about his opinion, could make his needs known and had no activity issues. D. Staff interviews Certified nurse aide (CNA) #4 was interviewed on 8/17/23 at 1:45 p.m. CNA #4 said Resident #21 was a religious man. CA #4 said Resident #21 enjoyed reading the Bible, spending time with his friends from church and going outside for walks. The NHA was interviewed on 8/17/23 at 2:21 p.m. The NHA said the facility currently had three full time activity employees. The NHA said the facility needed seven to eight full time activity employees in order to develop and conduct appropriate activities for the entire facility. The dementia program coordinator (DPC) was interviewed on 8/17/23 at 5:39 p.m. The DPC said she used to be the activities director, but transitioned into a new role that focused on dementia care. The DPC said the activities director was out sick but she knew all of the residents well. The DPC said Resident #21 preferred to do activities on his own. The DPC said Resident #21 was involved in the church across the street. The DPC said communion was canceled on 8/16/23. The DPC said the cancellation was not posted throughout the facility to notify the residents. The DPC said the facility only had three activities staff members and they needed several more to provide activities to all of the residents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observations and interviews, the facility failed to provide the necessary treatment and services to treat and prevent pressure injuries from occurring for two (#1 and #335) of two residents out of 70 sample residents. Specifically, the facility failed to: -Ensure timely identification of a stage 2 pressure injury, notify the physician, receive a treatment order and update the comprehensive care plan for Resident #335; -Ensure treatment orders were in place from a licensed medical provider before a treatment was applied for Resident #335; and, -Ensure timely identification of Stage 1 deep tissue injury (DTI) for Resident #1. Findings include: I. Professional reference According to the National Pressure Injury Advisory Panel (NPIAP) Pressure Injury Stages, the National Pressure Injury Advisory Panel - NPIAP web. (2/4/18) accessed 8/24/23 from http://www.npiap.org/resources/educationaland-clinical-resources/npuap-pressure-injury-stages. read in pertinent part: A pressure injury is localized damage to the skin and/or underlying soft tissue, usually over a bony prominence as a result of pressure, or pressure in combination with shear. The updated staging system includes the following definitions: Category/Stage 2: Partial Thickness Skin Loss Partial 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. Bruising indicates suspected deep tissue injury. Deep Tissue Pressure Injury: Persistent non-blanchable deep red, maroon or purple discoloration. Intact or non-intact skin with localized areas of persistent non-blanchable deep red, maroon, purple discoloration or epidermal separation revealing a dark wound bed or blood-filled blister. Pain and temperature change often precede skin color changes. Discoloration may appear differently in darkly pigmented skin. This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface. The wound may evolve rapidly to reveal the actual extent of tissue injury, or may resolve without tissue loss. If necrotic tissue, subcutaneous tissue, granulation tissue, fascia, muscle or other underlying structures are visible, this indicates a full-thickness pressure injury (Unstageable, Stage 3 or Stage 4). Do not use DTPI (deep tissue pressure injury) to describe vascular, traumatic, neuropathic, or dermatologic conditions. II. Facility policy and procedure The Skin Integrity and Wound Management policy, revised 2/1/23, was provided by the nursing home administrator (NHA) on 8/16/23. It read in the pertinent part: A comprehensive initial and ongoing nursing assessment of intrinsic and extrinsic factors that influence skin health, skin/wound impairment, and the ability of a wound to heal will be performed. The plan of care for the patient will be reflective of assessment findings from the comprehensive patient assessment and wound evaluation. Staff will continually observe and monitor patients for changes and implement revisions to the plan of care as needed. III. Resident #335 A. Resident status Resident #335, under the age of 65, was admitted on [DATE]. According to the August 2023 computerized physician orders (CPO) diagnoses included disease of the spinal cord, displaced fracture of the fifth cervical vertebra, attention-deficit hyperactivity disorder, anxiety disorder, bipolar disorder and insomnia. The 8/10/23 minimum data set (MDS) assessment documented the resident had moderate cognitive impairment with a brief interview for mental status (BIMS) score of 11 out of 15. He also needed extensive assistance with eating and personal hygiene. -It did not indicate that the resident had a pressure injury. B. Observations During a continuous observation on 8/15/23 beginning at 9:50 a.m. and ended at 1:00 p.m., Resident #335 was observed lying in bed on his back with the television (TV) on and his eyes open. -At 10:50 a.m., an unidentified licensed medical provider left the resident's room after spending 18 minutes with him. The resident remained in the same position on his back in his bed with the head of the bed slightly elevated and the TV still on. -At 11:30 p.m. the resident was still lying in his bed in the same position. -At 12:45 p.m. the resident was served lunch and was assisted with eating. During a continuous observation on 8/15/23 beginning at 1:55 p.m. and ended at 5:30 p.m. Resident #335 was observed lying in bed, on his back. The television was turned on. -At 1:55 p.m. an unidentified certified nurse assistant (CNA) entered the resident's room and removed the resident's lunch tray from the bedside table and exited the room. The CNA did not offer to reposition the resident and he remained in the same position. -At 3:15 p.m. the resident remained lying on his back with the TV on and his eyes were closed. The resident remained in the same position. -At 4:07 p.m. the resident remained in the same position -At 5:15 p.m. the resident activated his call light. The facility staff had not yet answered the resident's call light when observations ended at 5:30 p.m. During a continuous observation on 8/16/23 beginning at 9:22 a.m. and ended at 4:05 p.m. Resident #335 was observed lying in bed, on his back with the head of the bed slightly elevated, a breakfast tray on his bedside table, the television was turned on and his eyes were open. -At 9:36 a.m. the resident activated his call light. -At 9:43 a.m. an unidentified CNA spoke to the resident from the hall for a few seconds, entered the room and repositioned the resident's head. The resident remained on his back. -At 10:25 a.m. the resident turned the call light on. An unidentified CNA saw the light and told the resident from the hall to give her a few minutes. -At 10:35 a.m. licensed practical nurse (LPN) #2 and an unidentified CNA entered the resident's room to reposition the resident's upper torso as he began to shift to the side. The resident remained lying on his back. -At 11:19 a.m. an unidentified CNA turned off the call light and repositioned the resident's head. The resident remained laying on his back. -At 1:40 p.m. the resident was served a lunch tray and was assisted to eat by an unidentified CNA. After he was finished eating, the CNA left the room. The CNA did not offer to reposition the resident and he remained lying on his back. -At 2:40 p.m. the resident was lying in bed on his back with the TV on and he was watching it. -At 2:42 p.m. the resident turned his call light on. -At 2:51 p.m. CNA #2 turned off the call light and spoke to the resident. -At 3:01 p.m. CNA #2 and CNA #1 entered the resident's room to provide incontinence care for a bowel movement. -At 3:07 p.m. CNA #2 and CNA #1 exited the resident's room. The resident remained positioned lying on his back after being provided incontinence care. -At 4:01 p.m. the resident turned on his call light. CNA #2 entered the room, turned off the call light and then exited the room. The resident had activated it by mistake. The resident remained lying on his back. C. Record review The Braden scale completed on 8/12/23 documented that the resident was at moderate risk for pressure ulcers with a score of 14 out of 23. A nursing progress note dated 8/5/23 documented redness to the resident's sacrum. The comprehensive care plan created on 8/5/23 did not address the resident having a deep pressure tissue injury that was present on arrival to the facility. A review of the August 2023 CPO did not reveal a physician's treatment order for wound care, turning/repositioning or skin checks. The skin check documented on 8/12/23 identified surgical incisions to the residents neck. -It did not identify that the resident had any other skin issues. D. Wound observation On 8/17/23 at 4:30 p.m. Resident #335's skin was observed with registered nurse (RN) #2. When the resident's brief was removed and he was rolled to the side, a bandage was present over his sacrum. It was not dated or initialed. RN #2 removed the dressing and the wound color was purple and black with an open area. There was also a small amount of drainage. It had progressed from a DTI to a stage 2 pressure injury. E. Staff interviews RN #2 was interviewed on 8/17/23 at 5:15 p.m. RN #2 said Resident #335 had developed a stage 2 pressure injury on the sacrum, had redness on both sides of the scrotum and redness on the inner thigh of the left leg. RN #2 said she would start treating the resident on her daily rounds. RN #2 said the wound was not documented in the resident's medical record and a treatment had not been obtained from the physician. She said she was the nurse who had placed a treatment on Resident #335's sacrum. She said she did not recall when she was informed the resident had an open wound. CNA #3 was interviewed on 8/17/23 at 5:35 p.m. CNA #3 said he had seen the bandage on the resident's sacrum when he provided incontinence care to the resident earlier that day. He said had not previously seen the wound itself. He said it was the CNA's responsibility to report skin condition changes to the nursing staff. CNA #3 said he was not aware of any turning or repositioning orders for Resident #335. The director of nursing (DON) was interviewed on 8/17/23 at 6:18 p.m. The DON said residents who had limited mobility and/or were incontinent should have weekly skin checks and orders for turning and repositioning every two hours. She said the CNAs should report any changes in a resident's skin to nursing. She said residents who were unable to reposition themselves should be placed on a turning and repositioning schedule to prevent pressure injuries. She said treatments should not be completed without a physician's order. She said any changes to the resident's skin should initiate an assessment with a description, measurements and staging. III. Resident #1 A. Resident status Resident #1, age [AGE], was admitted on [DATE]. According to the August 2023 CPO, diagnoses included type 2 diabetes mellitus with diabetic chronic kidney disease, chronic obstructive pulmonary disease, heart failure, chronic respiratory failure with hypoxia, and depression. According to the 7/31/23 MDS assessment, the resident was cognitively intact with a brief interview for mental status of 14 out of 15. The resident required extensive assistance with bed mobility and transfers. It indicated that the resident had an unstageable pressure injury presenting as a deep tissue pressure injury. B. Record review The Braden scale completed on 7/29/23 showed the resident was at high risk for developing pressure ulcers with a score of 18 out of 24. The skin integrity care plan, revised on 7/31/23, identified that the resident had the potential for pressure ulcer development related to impaired mobility, type 2 diabetes, and incontinence of bowel and bladder. The interventions included providing a pressure redistribution surface to bed and wheelchair; providing quarter rails to bed to help with mobility and to relieve pressure to prevent skin breakdown; utilizing pillows to assist the resident with turning/positioning to reduce friction/shearing; conducting weekly skin checks by a licensed nurse and weekly wound assessments to include measurements and description of the wound status; and observing skin condition daily with ADL (activities of daily living) care and report abnormalities. The August 2023 CPO documented orders for the following: -Apply antifungal powder to groin and perineum area twice daily and with brief changes as needed - ordered 8/3/23. -Wound care to sacral abrasion: Cleanse with wound cleanser, pat dry, apply Triad paste twice a day and as needed, leave open to air in brief. Report any new skin changes to wound care team and monitor and treat for pain as needed before dressing changes - ordered 8/3/23. -Ensure barrier cream is applied with each incontinent episode - ordered 2/23/23. The skin check on 8/2/23 identified the wound as an other type of wound to the coccyx. -It did not provide any additional information such as measurements, a description and staging. -However, the nursing progress notes from 7/27/23 through 8/2/23 described the wound on the coccyx as open. The skin check on 8/9/23 identified the wound as an other type of wound to the coccyx. -It did not provide any additional information. The skin and wound assessment dated [DATE] documented an abrasion to the coccyx with 100% of the wound bed covered and skin intact. Review of the record on 8/17/23 revealed no measurement and no changes to wound orders when it was identified the resident had a stage 1 pressure ulcer with two open areas (see RN #2 interview below). C. Wound Observation On 8/17/23 at 5:05 p.m., Resident #1's skin was observed with RN #2. Upon being rolled to the side, the resident's skin was observed.The wound was red and had two small open areas. There was not a dressing in place or signs of barrier cream having been applied as ordered. D. Staff interviews RN #2 was interviewed on 8/17/23 at 5:15 p.m. RN #2 said Resident #1 had a stage 1 pressure injury on the sacrum with two open areas. RN #2 said she would start treating the resident on her daily rounds. CNA #6 was interviewed on 8/17/23 at 5:30 p.m. CNA #6 said she had seen the wound on the resident a couple of days prior and had reported it to the nurse. She said residents should be repositioned every two hours. She said if she saw any changes in the resident's skin then she would report the change to the nurse. The DON was interviewed on 8/17/23 at 6:18 p.m. The DON said residents who had limited mobility and were incontinent should have weekly skin checks and orders for turning and repositioning every two hours. She said CNAs should report any changes to the resident's skin to the nurse.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interviews the facility failed to ensure one (#62) of four residents reviewed were provided with services or treatments to prevent the reduction in range of motion out of 70 sample residents. Specifically, the facility failed to ensure Resident #62 was provided with preventative measures for his contracture. Findings include: I. Resident status Resident #62, age [AGE], was admitted on [DATE]. According to the August 2023 computerized physician orders (CPO), the diagnoses included hemiplegia (complete paralysis) and hemiparesis (partial weakness) following cerebrovascular disease (stroke) affecting unspecified side and major depressive disorder. The 6/6/23 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for a mental status score of 15 out of 15. He required supervision from one person for bed mobility, dressing, toileting and personal hygiene. He had an upper extremity impairment on one side and he had five days of occupational therapy. II. Resident interview Resident #62 was interviewed on 8/14/23 at 10:27 a.m. He said that when he was first admitted he was seen by therapy but shortly after they told him there was nothing they could do for him and the therapy stopped. He said he was never provided any devices for his contracture. III. Observations On 8/14/23 at 10:27 a.m. Resident #62 was observed sitting in his wheelchair in his room. He was not wearing any contracture therapy devices on his left hand to protect his palm. His left hand was balled up with his fingers touching his palm. On 8/15/23 at 10:00 a.m. the resident was observed sitting in his wheelchair in the common area waiting to go outside to smoke. He did not have any splints or preventative measures in place. On 8/16/23 at 12:30 p.m. the resident was observed sitting in his wheelchair in the common area waiting to go outside to smoke. He did not have any splints or preventative measures in place. IV. Record review -Review of the resident ' s comprehensive care plan did not address the resident's hand contracture or any interventions and preventative measures to be put into place to prevent the worsening of the contractures. -Review of the August 2023 CPO revealed no orders for orders related to contracture management. V. Staff interviews The director of rehabilitation (DOR) was interviewed on 8/17/23 at 2:45 p.m. She said she did not have a contracture management program in place for Resident #65. She said there should be orders in the care plan and the MDS assessment. The DOR said that the resident refused therapy in 2021 and no staff had approached the resident regarding therapy or contracture management since then.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to have scheduled physician visits for two residents (#297 and #295) out of five newly admitted residents reviewed for physician visits out of 65 sample residents. Specifically, the facility failed to ensure the physician evaluated Resident #297 and Resident #295 timely upon admission. Findings include: I. Facility policy and procedure The Physician Visits policy, dated April 2013, was provided by the nursing home administrator (NHA) on 9/5/23 at 2:29 p.m. It revealed in pertinent part, The Attending Physician will visit residents in a timely fashion, consistent with applicable state and federal requirements and depending on the individual ' s medical stability, recent and previous medical history, and the presence of medical conditions or problems that cannot be handled readily by phone. II. Resident #297 A. Resident status Resident #297, under age [AGE], was admitted on [DATE]. According to the August 2023 CPO, the diagnoses included mood disorder with depressive features, dementia, major depressive disorder and insomnia. The MDS assessment was in progress during the survey. The 8/15/23 progress note revealed the resident was not alert and oriented to person, place, time or situation. The 6/5/23 functional status provided by her previous facility revealed Resident #297 was dependent on one staff member for toileting, dressing, personal hygiene and needed maximal assistance with eating. She was able to walk independently with supervision or light touch. B. Record review A review of Resident #297's electronic medical record revealed the physician first saw the resident on 9/1/23, 16 days after the resident was admitted to the facility. III. Resident #295 A. Resident status Resident #295, age [AGE], was admitted on [DATE]. According to the August 2023 CPO, the diagnoses included dementia with behavioral disturbances and anxiety. The MDS assessment was in progress during the survey. The 8/16/23 care plan revealed Resident #295 had impaired cognitive function related to dementia. She required minimal assistance with transfers, dressing, toilet needs and personal hygiene. She could ambulate independently. B. Record review A review of Resident #295's electronic medical record revealed the physician first saw the resident on 8/30/23, 15 days after the resident was admitted to the facility. IV. Staff interviews The director of nursing (DON) was interviewed on 9/5/23 at 1:52 p.m. The DON said residents should be seen timely within admission to the facility. The DON said Resident #297 and Resident #295 were not seen for 15 or 16 days after their admission to the facility. The DON said Resident #297 and Resident #295 were transferred from a different facility and still had the same primary care physician. -However, Resident #297 and Resident #295 were admitted to a new facility and were transferred to a non secured unit. The NHA was interviewed on 9/5/23 at 2:40 p.m. The NHA acknowledged Resident #297 and Resident #295 were not seen by the physician in a timely manner. The NHA said they had an opportunity for improvement for timely physician visits.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** III. Resident #14 A. Resident status Resident #14, age [AGE], was admitted on [DATE]. According to the August 2023 CPO, the diagnoses included arthritis (inflammation or swelling of one or more joints) and obesity (disease involving having too much body fat). The 5/25/23 MDS assessment revealed the resident was cognitively intact with a brief interview for mental status score of 15 out of 15. B. Resident interview and observation Resident #14 was interviewed on 8/15/23 at approximately 3:00 p.m. She said she followed a vegetarian diet. She said she was not provided many vegetarian options aside from grilled cheese or a cheese quesadilla. She said she was not provided a vegetarian menu by the facility. She said she would eat fish or meat alternatives such as vegetarian burgers or chicken substitutes. She said she was served mainly starches for side dishes. On 8/16/23 Resident #14's lunch included an egg salad sandwich on white bread, with potato and steamed broccoli on the side. On 8/17/23 Resident #14's lunch included a grilled cheese sandwich on white bread, white rice and mashed potatoes. Resident #14 was interviewed again on 8/17/23 at 5:44 p.m. She said the kitchen manager speaks with her every six months regarding menu selections to accommodate her vegetarian preferences. She said she had discussed wanting more options in vegetarian burgers and chicken substitutes. C. Record review The 7/31/23 nutritional assessment revealed Resident #14 followed a lacto-ovo vegetarian diet (a diet that excludes meat, poultry and fish but includes eggs and dairy products) that included fish, but not seafood. The assessment revealed Resident #14 did not eat the facility's food, ate junk food instead and expressed dissatisfaction with meal options at the facility and received tuna/egg salad sandwiches, grilled cheese, quesadillas or fish dishes as entrees. The 5/31/23 care plan revealed Resident #14 had a focus on nutritional risk related to morbid obesity, was at risk for altered nutritional status related to very limited facility meal acceptance, and followed a lacto-ovo vegetarian diet (will eat fish, no seafood). The care plan had a goal of weight loss being appropriate. Interventions included Resident #14's meal and snack requests were honored as much as possible and alternative choices were offered as needed. D. Staff interview Certified nurses aide (CNA) #6 was interviewed on 8/17/23 at 12:54 p.m. She said residents received a weekly menu and if they wanted something different than the menu items they had to let the kitchen staff know. She did not know if Resident #14 was provided a vegetarian menu. The dietary manager (DM) was interviewed on 8/17/23 at 5:00 p.m. He said residents were provided a weekly food menu and had to inform kitchen staff if they wanted something other than a menu item. He said the facility had a vegetarian menu. He said Resident #14 was not provided a vegetarian menu. He said he met with Resident #14 every two weeks to discuss her food preferences from a menu they developed. The DM provided copy of menu discussed with Resident #14 consisting of one week of lunch and dinner items. Out of the 14 meals, fish options were displayed four times, two out of the four being tuna fish sandwiches and vegetarian nuggets were displayed once. The menu did not include vegetarian burgers as an option nor did it list side options for meals. Based on observations, record review and interviews, the facility failed to provide each resident with a nourishing, well-balanced diet that meets his or her daily nutritional and special dietary needs, taking into consideration the allergens and preferences of each resident for two (#118 and #14) of two residents out of 70 sample residents. Specifically, the facility failed to: -Ensure Resident #118's allergen to gluten was not served to her; and, -Ensure Resident #14 requests, preferences, and options for a vegetarian diet were served to her. I. Facility policy and procedure The Selective Menus policy, dated 5/1/23, was provided by the nursing home administrator (NHA) on 8/17/23 at 1:15 p.m. It revealed in pertinent part, Personal Choice Menus are distributed to the residents based on the facility plan. Personal Choice Menu selections are reviewed for appropriateness for the resident's diet. Inappropriate selections that are high risk and unsafe may include: allergy to food or ingredient, selected food contains gluten on the Gluten Free diet; selected food is in conflict with the ordered diet consistency and, do not serve selected food and communicate the rationale of the inappropriate choice with the resident. II. Resident #118 A. Resident status Resident #118, age [AGE], was admitted on [DATE]. According to the August 2023 computerized physician orders (CPO), the diagnoses included sepsis (infection of the blood), history of malignant neoplasm of the stomach (stomach cancer), nutritional deficiency, unspecified protein-calorie malnutrition, gastro-esophageal reflux disease (GERD), anxiety, dementia and dysphagia (difficulty swallowing). The 7/28/23 minimum data set (MDS) assessment revealed the resident had short-term and long-term memory impairment. The resident was severely impaired making decisions regarding tasks of daily life. The resident was on a mechanically altered diet. B. Resident observation During a continuous observation on 8/16/23 beginning at 11:26 a.m. and ended at 1:06 p.m. the following was observed: -Dietary aide (DA) #2 was serving lunch. DA #2 placed a scoop of pureed ham, pureed broccoli, mashed potatoes and pureed bread. -An unidentified DA told DA #2 that bread contained gluten. DA #2 said it was alright and served the meal to Resident #118. -Resident #118's meal ticket read she was on a pureed diet and had a gluten allergy. C. Record review The nutritional plan of care, initiated on 6/13/22 and revised on 7/13/23, revealed Resident #118 was at nutritional risk related to unavoidable weight loss with advancing dementia. The resident had declining oral intakes related to the progression of her disease. Resident #118 received a texture modified diet for comfortable and effective oral intakes. Resident #118 was dependent on staff for assistance with foods and fluids and has a history of intolerance to gluten without a diagnosis of celiac disease. The interventions included: providing a house shake supplement once a day, evaluating the resident for proper consistency of diet, offering fluids of choice, discontinuing facility weights, monitoring for changes in nutritional status, monitoring intake of all meals, providing diet as ordered by observing gluten restriction and providing assistance at meals. The August 2023 CPO had the following physician order for Resident #118's diet: -Gluten Free diet, dysphagia puree texture for prevention of aspiration, ordered 7/11/23. A review of Resident #118's electronic medical record on 8/16/23 at 2:00 p.m. revealed Resident #118 had an allergy to gluten. D. Staff interviews The registered dietitian (RD) and the dietary manager (DM) were interviewed on 8/17/23 at 11:59 a.m. The DM said the facility put regular slices of bread in the food processor to make the pureed bread for the residents who were on a pureed diet. The RD said Resident #118 should have not received the pureed bread, since she was allergic to gluten.

Based on interviews and record review, the facility failed to ensure prompt action was taken upon the filing of a grievance of a group. Specifically, the facility failed to follow up with residents' concerns regarding meals that were brought up by the food committee. Findings include: I. Facility policy and procedure The Grievance/Concern policy, dated 7/19/23, was provided by the nursing home administrator (NHA) on 8/17/23 at 6:30 p.m. It revealed in pertinent part, The patient/resident has the right to voice grievances to the Center or other agency or entity that hears grievances without fear of discrimination or reprisal. Such grievances include those with respect to care and treatment which has been furnished as well as that which has not been furnished, the behavior of staff and of other patients, and other concerns regarding their Center stay. Purpose: to ensure that any patient or patient representative has the right to express a grievance/concern without fear of restraint, interference, coercion, discrimination, or reprisal in any form and to assure prompt receipt and resolution of patient or representative grievance/concern. II. Resident interviews Residents were identified by the facility and assessment as interviewable. Resident #5, #43, #109, #32, #47, #89, #51, #90, #114 and #53 were interviewed on 8/16/23 at 10:02 a.m. They said during the food committee meetings they brought up that the meals were served late every month. They said they did not feel their concerns were being addressed. Resident #5 was interviewed on 8/17/23 at 4:30 p.m. Resident #5 said she was the vice president of the resident council. Resident #5 said she attended the food committee meetings. Resident #5 said the food committee often brought up the same concerns month after month. Resident #5 said they often voiced concerns on menu options and late meals. Resident #5 said she did not feel the facility was addressing the concerns of the food committee. Resident #43 was interviewed on 8/17/23 at 5:05 p.m. Resident #43 said she was the resident council president. Resident #43 said she attended the monthly food committee meetings. Resident #43 said the same concerns were often brought up more than once. II. Record review The May 2023 Food Committee Minutes revealed the residents reported they did not receive what was ordered on their meal tickets, they wanted coffee always available, the food on the posted menus was not consistent with what they ordered and the meal tickets were delivered to them dirty. The June 2023 Food Committee Minutes revealed the residents reported they did not like the fish, they were receiving foods they did not order, food was always cold, meals were often served late, snacks and drinks were not being offered, they wanted more fresh fruit and a cleaner dining room. Record review revealed food committee was not held in July 2023. The August 2023 Food Committee Minutes revealed the residents reported they wanted more salads, the pork was dry, they requested to have bacon lettuce and tomato sandwiches, they requested more egg options, they requested more fried foods, they requested chicken salad, they requested beef tacos, the meals were consistently served late, they asked why they no longer had a meal of the month and they were concerned they were being fed leftovers. A request for all grievances related to the concerns brought up in the food committee in June, July and August 2023 was requested on 8/17/23. The NHA said the facility did not have any grievance forms for that time related to the food committee. Cross reference F803: the facility failed to follow the menu and provide the documented potion sizes to meet the residents nutritional needs. III. Staff interviews The social services director (SSD) was interviewed on 8/17/23 at 5:10 p.m. The SSD said all concerns that were brought up in the food committee should be documented on a grievance form. The SSD said the grievance process had not been concrete for a couple months due to staff turnover. The SSD said she was currently responsible for ensuring all of the grievances were logged and distributed to the correct department. The SSD said grievances were handled by the department it pertained to. The SSD said grievances should be reviewed with the resident or residents to ensure they were happy with the resolution. The dietary manager (DM) was interviewed on 8/17/23 at 4:53 p.m. The DM said he did not fill out grievance forms for concerns brought up in the food committee. The DM said the food committee did not have any concerns. The DM acknowledged after reading the food committee minutes grievance forms should have been filled out to ensure the concerns brought up during the meetings were addressed.

Based on record review and interviews the facility failed to ensure that the personal funds accounts were managed adequate for seven (#21, #92, #65, #79, #34, #12 and #97) of seven residents reviewed for personal funds out of 70 sample residents. Specifically the facility failed to: -Ensure Resident #21 was assisted in applying for financial benefits and setting up an account so he could access money; and, -Ensure Resident #92, #65, #79, #34, #12 and #97 were notified and assisted in spending down their bank accounts. Findings include: I. Facility policy and procedure The Resident Funds policy, dated 1/16/23, was provided by the nursing home administrator (NHA) on 8/17/23 at 6:30 p.m. It revealed in pertinent part, Purpose: to ensure that residents have ready and reasonable access to their personal funds and to comply with state and federal regulations and other governmental guidelines which indicated what can and cannot be charged to a resident's fund. During the admission conference, the Admissions Director or designees will inform the resident/representative of the Resident Fund Management System (RFMS). If a resident chooses to participate in the RFMS service: complete the RFMS authorization agreement form and present to the resident/representative for signature prior to or at the time of admission (follow state specific requirements regarding competency). Items covered under Medicaid or Medicare payment cannot be charged against resident person funds. In accordance with state and federal regulations, all Medical Assistance residents must be notified monthly when the resident's account reaches $200 of the state's asset level for Medicaid eligibility. II. Ensure Resident #21 was assisted in setting up a bank account A Resident interview Resident #21 was interviewed on 8/15/23 at 10:35 a.m. Resident #21 said he was unsure how his room and board was paid at the facility, because he had no money. Resident #21 said he did not receive quarterly statements. Resident #21 was interviewed again on 8/17/23 at 11:28 a.m. Resident #21 said the facility had set up a bank account for him about a week ago. Resident #21 said no staff at the facility had approached him about setting up a bank account previous to last week. B. Record review A review of Resident #21's bank statement on 8/16/23 revealed Resident #21 had zero balance. III. Ensure Resident #92, #65, #79, #34, #12 and #97 were notified and assisted in spending down their bank accounts A review of Resident #92's bank account on 8/16/23 revealed he had 2,250.76 dollars. The resident had 250.76 dollars over the Medicaid eligibility limit of 2,000 dollars. A review of Resident #65's bank account on 8/16/23 revealed he had 2434.69 dollars. The resident had 434.69 dollars over the Medicaid eligibility limit. A review of Resident #79's bank account on 8/16/23 revealed she had 2519.60 dollars. The resident had 519.60 dollars over the Medicaid eligibility limit. A review of Resident #34's bank account on 8/16/23 revealed she had 2292.19 dollars. The resident had 292.19 dollars over the Medicaid eligibility limit. A review of Resident #12's bank account on 8/16/23 revealed she had 2120.34 dollars. The resident had 120.34 dollars over the Medicaid eligibility limit. A review of Resident #97s bank account on 8/16/23 revealed she had 2016.21 dollars. The resident had 16.21 dollars over the Medicaid eligibility limit. IV. Staff interviews The business office manager (BOM) was interviewed on 8/16/23 at 4:30 p.m. The BOM said she assisted Resident #21 in setting up a bank account at the beginning of August 2023. The BOM said Resident #21 had been admitted to the facility for over two years. The BOM said she was unsure why Resident #21 was not assisted in setting up a bank account upon admission. The BOM was interviewed again on 8/17/23 at 10:54 a.m. The BOM said she did not provide letters notifying residents that they were within $200 of the Medicaid eligibility limit or above it in July 2023. The BOM said she did not have the residents sign an acknowledgement that they received the letter regarding the amount of money in their bank account and the need to spend down their money when they were their own representative. The BOM said she sent letters to resident representatives when residents' bank accounts were within $200 or over the $2000 Medicaid eligibility limit, but did not send it certified mail. The BOM said she was unable to confirm that the resident representatives received the letter. The BOM said at times the facility was the residents' representative and it was their responsibility to assist the resident in spending down their money. The BOM said she had assisted Resident #12 in purchasing some new personal items in January 2023. The BOM said she was considering sending some of Resident #12's money back to Medicaid, since she did not need anything else. The BOM said she was not aware of how the residents' money could be utilized to help spend down their money. The NHA was interviewed on 8/17/23 at 2:21 p.m. The NHA said Resident #21 should have had a bank account set up upon admission. The NHA said it was normal practice to assist residents in setting up bank accounts upon admission if needed. The NHA acknowledged that some of the residents were above the Medicaid eligibility limit. The social services director (SSD) was interviewed on 8/17/23 at 5:10 p.m. The SSD said she worked alongside the BOM to help residents spend down their money. The SSD said she had not reviewed the different options that could be utilized to help spend down the residents money.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** II. Timely interventions were in place following falls A. Resident #25 1. Resident status Resident #25, age [AGE], was admitted on [DATE]. According to the August 2023 CPO, the resident ' s diagnoses included unspecified dementia, severe, with mood disturbance and dementia in other diseases classified elsewhere severe, with other behavioral disturbance. The 7/3/23 MDS assessment revealed the resident was severely impaired with a BIMS score of zero out of 15. She required extensive assistance with bed mobility, transfers, dressing, toilet use and personal hygiene. 2. Observations On 8/15/23 at 3:36 p.m. the resident was by the nurses station hunched over walking around and picking at her right pant leg. -At 4:17 p.m. the resident took one of her socks off, had it in her hand and was walking around the unit. -At 5:58 p.m. the resident was in another resident ' s room and then wandered into another resident ' s room. The resident was continuously observed on 8/16/23 from 9:29 a.m. to 2:51 p.m. Observations revealed: -At 9:29 a.m. resident sitting at the dining room table. -At 9:40 a.m. the resident slumped over/leaned over to the right side of her chair. -At 9:43 a.m. the resident repositioned herself to an upright position in the chair in the dining room. -At 12:52 p.m. the resident got out of the chair on her own in the television room and walked slowly hunched over with her head down. A staff member then assisted the resident by holding her hand to help assist her to the dining room for lunch. -At 1:08 p.m. the resident was sitting at the dining room table and slumped over/leaned over to the right side of her chair. -At 1:20 p.m. the resident repositioned herself and was sitting upright in the chair. -At 2:27 p.m. the resident was slumped over/leaned over the right side eating her sandwich. -At 2:29 p.m. a staff member asked the resident if she was doing ok and the resident said yeah. However, the resident was not repositioned so she was not slumped over. -At 2:51 p.m. a staff member assisted the resident from the dining room to the television room. 3. Record review The care plan for falls revised on 3/31/23 documented the resident was at risk for falls due to advanced dementia with behaviors, unsteady gait/balance, poor safety awareness, medication side effects and history of falls. Interventions included assisting resident to and from dining room at mealtime when needed for safety, assisting resident with toileting and assisting to place of comfort after meals, bed in low position, encouraging proper footwear at all times, manual wheelchair for locomotion, tends to get up to ambulate independently, observing for changes in medical status, pain status, mental status, and medication side effects that may contribute to cognitive loss/dementia/delirium and can lead to increase fall risk, reporting to medical doctor (MD) as indicated, repositioning items as needed to location within visual field, therapy services as ordered, and assisting resident/caregiver to organize belongings for a clutter-free environment in the resident's room and consistent furniture arrangement. The care plan for restorative ambulation revised on 6/5/23 documented the resident demonstrated a deficit in ambulation. Interventions included cuing the resident to look up and stand upright while ambulating and encouraging singing as this helps the resident to participate in ambulation and exercises. The resident will walk with intermittent hand hold for 300-500 feet with cues to increase step length daily as tolerated through this review period. Providing verbal cueing and walking along with the resident. The physician orders revised on 7/31/23 documented physical therapy (PT) evaluation and treatment for three times per week for four weeks for gait treatment, group therapy, manual therapy for treatment diagnosis muscle weakness. The long term goal was to improve strength, balance, posture and gait in order to avoid falls for four weeks. The resident had multiple falls since being admitted on [DATE]: Progress note dated 3/31/23 read the resident observed sitting on the floor in her room with blood on the back of her head (left side). There was blood on the floor next to the resident. Resident unable to state what happened. The fall was not witnessed, so she was sent to the hospital for evaluation and had a CT scan of the brain, cervical spine, abdomen, chest and pelvis which were essentially unremarkable. The resident had labs done which were reviewed. Progress note dated 4/5/23 read nursing staff observed the resident loose her footing and fell in the hallway. Resident found on her left side and was assisted into a wheelchair, but the resident was ready to be up walking immediately. Resident refused vital signs and refused to sit still for her blood pressure. Neurological checks were within normal limits and the resident obtained a small hematoma to her left forehead, no other injuries noted. Progress note dated 5/11/23 read staff heard the resident fall and hollered. The resident was found sitting on her bottom on the floor by the dining room. Another resident ' s family witnessed the fall and said that another resident was encouraging her to sit in a chair and pushed one towards the resident and the resident fell. The family who witnessed the fall said that the resident did not hit her head. The resident refused vitals and no injuries noted. The resident assisted up and began walking independently. Physician progress note dated 5/11/23 read the resident ambulated with a forward flexion bend of the upper and middle spine with her head bent low. The resident was able to stand nearly upright at times, but could not maintain this posture. Gait was slow and unsteady. The resident utilized rails against the walls and furniture for stabilization or stand by assist from nursing staff. Progress noted dated 5/17/23 read the fall was witnessed by the activity staff member. Staff stated the resident was up walking around the television room when she tripped over her feet and fell. Resident fell onto her bottom, but hit the back of her head on the floor on the way down. Full range of motion, no signs of acute pain or discomfort, neuro check initiated, vital signs, at cognitive baseline. Progress note dated 5/30/23 read the nurse was called to assess the resident as she was sitting on the floor in front of the television room right in front of the red recliner. Range of motion within normal limits, she was assisted up and was able to walk to the dining room without complaints. Fall risk assessment dated [DATE] read the resident was at a high fall risk due to advanced dementia with cognitive and physical decline. The resident has the strength to attempt to walk and transfer but lacks the balance, coordination, and strength to do so safely and effectively. There have been multiple interventions attempted with various levels of success. Will continue to monitor closely and care plan, non-pharmacologic fall prevention interventions. Medications that may lead to increased fall risk have been minimized, and the risk/benefit of each of her medications has been reviewed by physician and the interdisciplinary treatment (IDT) team. Progress note dated 7/23/23 read the CNA informed the nurse the resident was found on the floor. Head to toe assessment completed, range of motion to all extremities, within normal limits, neuros within normal limit, vital signs within normal limits, and no apparent injury noted. The resident assisted to her chair. Progress note dated 7/30/23 read the resident was found by CNA scooting and crying inside another resident ' s room. Laundry basket tipped over near the resident with stuffed toys scattered on the floor. No apparent physical injuries except redness to resident ' s right back. The resident assisted and transferred to a chair in the living room area for close monitoring. Progress note dated 8/1/23 read the CNA called for RN to come to the hallway next to the dining room due to the resident on the ground. RN completed a head to toe assessment with all findings within normal limits. The fall was unwitnessed, CNA stated that another resident pulled on the resident, causing the resident to fall onto the floor. Progress note dated 8/9/23 read the resident had a witnessed fall around lunch time. The resident was assessed and helped up and no signs or discomfort or injury noted. The resident refused vitals and immediately up walking around independently. 4. Staff interviews RN #7 was interviewed on 8/17/23 at 4:24 p.m. She said the resident was normally steady when she walked. She said she was not sure why the resident had been falling. She said if the resident was in a wheelchair that she would not stay in it because she was capable of walking around on her own. She said the resident would have more falls if she were using a wheelchair. She said she was not sure if the resident was receiving physical therapy. She said anytime residents had a fall physical therapy would assess to find out what was happening and see if they would benefit from physical therapy. CNA #7 was interviewed on 8/17/23 at 4:42 p.m. She said the resident was able to walk on her own and preferred to walk. She said the staff watched the residents to make sure they were safe from falls. She said when a resident was tired or sleepy staff would notice a resident needing help with walking. The director of nursing (DON) was interviewed on 8/17/23 at 6:32 p.m. She said staff should be putting in interventions after every fall. She said that therapy should assess the resident after each fall but it depended on how busy they were. B. Resident #130 1. Resident status Resident #130, age [AGE], was admitted on [DATE]. According to the August 2023 CPO, the resident ' s diagnoses included Parkinson ' s disease, dementia in other diseases classified elsewhere, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety. The 7/26/23 MDS assessment revealed the resident was severely impaired with a BIMS score of one out of 15. He required extensive assistance with bed mobility, transfers, dressing and toilet use. 2. Observations On 8/15/23 at 5:35 p.m. resident in the hallway by his room in his wheelchair. The resident attempted two times to get out of his wheelchair and stand. A staff member redirected the resident to sit back down in his wheelchair. On 8/16/23 at 2:33 p.m. the resident was having difficulty getting around in his wheelchair and was getting himself stuck in tight spots, so the staff had to assist him. On 8/17/23 at 11:44 a.m. the resident was in the doorway of his room and he attempted to stand up out of his wheelchair and then sat back down. At 11:46 a.m. the resident was in the doorway of his room and he stood up and was holding onto the door handle and then sat back down in his wheelchair. 3. Record review The physician orders revised 7/23/23 documented physical therapy and occupational therapy to evaluate and treat status post fall. The physician orders revised 7/21/23 documented physical therapy clarification order, physical therapy evaluate and treatment for four times a week for four weeks for gait training, wheelchair mobility training, manual therapy, groups therapy in order to improve functional mobility including long term goal the resident would self-propel in wheelchair for 150 feet with supervision, one time only for four weeks. The care plan for falls revised on 8/9/23, documented the resident was at risk for falls, cognitive loss, and lack of safety awareness. Interventions included bedding/mattress perimeter reminder lipped mattress, fall mat, providing resident/caregiver education for safe techniques (including when to use call light) of transfers, providing verbal cues for safety and sequencing when needed, providing resident/caregiver education for safe techniques of transfers, and implementing safety precautions when appropriate. The resident had multiple falls since his admission on [DATE]: Progress note dated 7/20/23 read the resident had a fall early in the morning without any apparent injury. CNA informed the nurse that the resident was on the floor. The resident stated that he was attempting to ambulate to the bathroom. Head to toe assessment completed, skin intact, range of motion to all extremities within normal limits. Care of pain to RUE (right upper extremity), analgesic (pain medication) refused and neurological checks were within normal limits. Progress note dated 7/20/23 read the RN supervisor notified of resident fall, completed head to toe assessment. Neurological checks within normal limits. Resident stated that he was attempting to ambulate to the bathroom. Progress note dated 7/21/23 read the RN assessed resident for injuries, none were noted or observed, resident had no verbal complaints of pain; resident alert and oriented. Progress note dated 7/23/23 read the CNA witnessed a fall by resident. Nurse notified the resident was on the floor in his room. The resident was lying on his back in the middle of the floor in his room. No injuries noted. Progress note dated 7/24/23 read the staff was notified the resident had fallen out of his wheelchair by the dining room. He was found lying on the floor on his left side. The resident was assessed, vital signs and neuro checks were within normal limits. The resident had no discomfort and no new injuries noted. Staff only noted old bruising. The resident assisted back into the wheelchair. Progress note dated 7/27/23 read the CNA was doing rounds and the resident could be heard calling out for his wife. When the CNA went to check on the resident he was on the floor on the fall mat that was placed beside his bed. When asked what happened the resident could not say what happened. Vital signs obtained which were within normal limits. Progress note dated 7/28/23 read the CNA alerted the nurse that the resident was on the floor next to his bed on the floor mat. Resident appeared to have rolled off of bed and landed on the mat next to his bed. Resident was assisted by four staff members back into bed. No injuries noted. Progress note dated 8/1/23 read the resident rolled out of his bed onto the mat that was on the floor next to his bed. No injuries reported, vital signs and neurological checks were within normal limits. Progress note dated 8/7/23 read the resident was seen by the nurse sliding out of his wheelchair in the dining room. The resident did not hit his head or have any injury noted. The hoyer (mechanical) lift was used to get resident backup in the wheelchair and ready for bed. 4. Staff interviews RN #7 was interviewed on 8/17/23 at 4:17 p.m. She said the resident was on the north side of the building and recently moved to the secured memory unit as he was attempting to exit. She said the resident was able to do things on his own but did not know how to use the call light when he needed something. She said when a resident was in bed he had a fall mat placed on the floor next to his bed in case he got up on his own. She said his bed was in the lowest position and he had his call light within reach. She said his wheelchair was kept at the foot of his bed. She said when the resident was up he was in a public area so staff were able to watch him. She said she did not think the resident was able to walk by himself. She said therapy was working with him. She said the resident since he was weak and unsteady and it was safer for him to be in a wheelchair. She said she was not sure how many falls resident had since he transferred over the secured memory unit. CNA #7 was interviewed on 8/17/23 at 4:42 p.m. She said the resident was able to stand up on his own but he has the blue mat in his room in case he fell. She said staff have to use the hoyer lift to assist the resident in his wheelchair. She said the resident had not had any falls during the day shift but most of his falls occurred during the nights when he was already in bed. The DON was interviewed on 8/17/23 at 6:32 p.m. She did not know the resident's care plan and interventions were not updated with each fall he had. Based on observations, interviews and record review, the facility failed to provide an environment as free of accident hazards as possible and ensure residents received adequate supervision and assistance devices to prevent accidents for eight (#285, #297, #286, #295, #296, #125, #25 and #130) of nine residents reviewed for accident hazards out of 70 sample residents. Specifically, the facility failed to: -Identify elopement/wander risk, implement wander guard and develop a comprehensive wander risk care plan based on knowledge of previous secure placement and elopement evaluations for Resident #285, #297, #286, #295, #296 and #125; and, -Ensure timely interventions were put into place following falls for Resident #25 and #130. Findings include I. Identify elopement/wander risk, implement wander guard and develop a comprehensive wander risk care plan A. Facility policy and procedure The Elopement of Patient policy, revised 10/24/23, was received by the nursing home administrator on 8/17/23 at 6:30 p.m. It read in pertinent parts: Resident ' s will be evaluated for elopement risk upon admission, readmission, quarterly, and with a change of condition as part of the clinical assessment process. Those determined to be at risk will receive appropriate interventions to reduce risk and minimize injury. B. Resident #285 1. Resident status Resident #285, age [AGE], was admitted on [DATE]. According to the August 2023 computerized physician orders (CPO), the diagnoses included dementia with severe psychotic disturbances, insomnia and psychotic disorders with hallucinations. The 8/10/23 minimum data set (MDS) assessment revealed the resident had severe cognitive impairment and a brief interview for mental status was not conducted. She required extensive assistance with transfers, dressing, toilet use and personal hygiene. She used a wheelchair for mobility which she was able to self propel. 2. Record review On 8/4/23 a restrictive device consent was signed by the residents representative for the use of a wander guard (a monitoring device to help ensure an alarm is activated and staff respond when a resident attempts to leave a safe area) to include the risks vs the benefits of the device. The 8/10/23 elopement evaluation revealed Resident #285 had a history of an actual or attempted elopement, a history of wandering that placed her at significant risk of getting to a potentially dangerous place, such as stairs or outside the facility, she had a history of wandering that significantly intruded on the privacy and/or activity of others, and she exhibited one or more emotional state or behavior that could result in exit-seeking behavior being impulsiveness, restlessness and/or agitation. The August 2023 CPO revealed Resident #285 had an order for a wander guard with a start date of 8/17/23 on her right wrist, due to poor safety awareness. -A review of the resident's comprehensive care plan did not reveal a focus for wander risk or use of wander guard. -A consent for the use of a restrictive device was not in the resident ' s medical record. Resident #285 was admitted to the facility on [DATE] from a secure memory care facility. 3. Observation and interview On 8/17/23 at approximately 9:30 a.m. licensed practical nurse (LPN) #5 said Resident #285 had an order for wander guard placement on right wrist and did not have a wander guard on her right wrist. LPN #5 said a wander guard for Resident #285 was not placed on an extremity (arms and legs) different from the right wrist. C. Resident #297 1. Resident status Resident #297, under age [AGE], was admitted on [DATE]. According to the August 2023 CPO, the diagnoses included mood disorder with depressive features, dementia, major depressive disorder and insomnia. The MDS assessment was in progress during the survey. The 8/15/23 progress note revealed the resident was not alert and oriented to person, place, time or situation. The 6/5/23 functional status provided by her previous facility revealed Resident #297 was dependent on one staff member for toileting, dressing, personal hygiene and needed maximal assistance with eating. She was able to walk independently with supervision or light touch. 2. Record review The 8/17/23 elopement evaluation revealed Resident #297 was able to ambulate (walk) independently, had a history of an actual or attempted elopement, had a history of wandering that placed her at significant risk of getting to a potentially dangerous place, such as stairs or outside the facility, she had a history of wandering that significantly intruded on the privacy and/or activity of others, and exhibited one or more emotional state or behavior that could result in exit-seeking behavior being impulsivity, shadowing staff or other resident ' s, and hyperactivity (restless walking pattern). The August 2023 CPO revealed Resident #297 had an order for a wander guard placement, with a start date of 8/17/23, to be placed on her right wrist due to poor safety awareness. -A review of the resident ' s comprehensive care plan did not reveal a focus for wander risk or use of wander guard. -A consent for the use of a restrictive device was not in the resident ' s medical record. Resident #297 was admitted to the facility on [DATE] from a secure memory care facility. D. Resident #286 1. Resident status Resident #286, age [AGE], was admitted on [DATE]. According to the August 2023 CPO, the diagnoses included major depressive disorder and dementia with behavioral disturbances. The MDS assessment was in progress during the survey. The 8/11/23 nursing progress note revealed the resident had severe cognitive impairment and she was alert and oriented to self only. She required an unknown amount of staff assistance for transfers, dressing, toilet needs and personal hygiene. Her primary mobility device was a wheelchair. She was able to self propel herself in her wheelchair. 2. Record review The 8/11/23 progress note revealed Resident #286 was newly admitted to memory care at the facility and a wander guard device was in use. The 8/14/23 elopement evaluation revealed Resident #286 was able to self-propel in her wheelchair independently, had a diagnosis of dementia, had a history of an actual or attempted elopement and expressed a desire to leave, go home, talked about going on a trip, or attempted to pack belongings. The August 2023 CPO for Resident #286 revealed an order for a wander guard device be placed on the right wrist of Resident #286 due to poor safety awareness with a start date of 8/17/23. -A review of the resident ' s comprehensive care plan did not reveal a focus for wander risk or use of wander guard. -A consent for the use of a restrictive device was not in the resident ' s medical record. Resident #286 was admitted to the facility on [DATE] from a secure memory care facility. 3. Observation and interview LPN #5 was interviewed on 8/17/23 at approximately 9:30 a.m. She [NAME] Resident #286 had an order for wander guard placement on right wrist and did not have a wander guard on her right wrist. LPN #5 said a wander guard for Resident #286 was not placed on an extremity (arms and legs) different from the right wrist. E. Resident #295 1. Resident status Resident #295, age [AGE], was admitted on [DATE]. According to the August 2023 CPO, the diagnoses included dementia with behavioral disturbances and anxiety. The MDS assessment was in progress during the survey. The 8/16/23 care plan revealed Resident #295 had impaired cognitive function related to dementia. She required minimal assistance with transfers, dressing, toilet needs and personal hygiene. She could ambulate independently. 2. Record review The 8/17/23 elopement evaluation revealed Resident #295 was able to ambulate independently, had a diagnosis of dementia, a history of actual or attempted elopement, a history of wandering that placed her at significant risk of getting to a potentially dangerous place (stairs or outside facility), a history of wandering that significantly intruded on the privacy and/or activity of others, she had a sleep pattern disturbance that caused increased confusion, exhibited one or more emotional state or behavior that may result in exit-seeking behavior, being that she hovered near exits, was hyperactive (restless walking patterns) and impulsive. -The August 2023 CPO did not reveal an order for a wander guard device for Resident #295. Resident #295 was admitted to the facility on [DATE] from a secure memory care facility. 3. Observation and interview On 8/17/23 at approximately 9:30 a.m. wrists and hands were visible for Resident #295. A wanderguard was not observed on either wrist. LPN #5 was interviewed immediately after and said Resident #295 was an elopement risk. LPN #5 placed a wander guard on the right wrist of Resident #295. F. Resident #296 1. Resident status Resident #296, over age [AGE], was admitted on [DATE]. According to the August 2023 CPO, the diagnoses included dementia, anxiety and insomnia. The MDS assessment was in progress during the survey. The 8/15/23 care plan revealed Resident #296 had cognitive impairment related to a diagnosis of dementia and staff needed to anticipate her needs related activities of daily living (ADL). She used a wheelchair primarily for mobility and was able to self-propel. 2. Resident review The 8/17/23 elopement evaluation revealed Resident #296 was able to self-propel her wheelchair independently, she had a diagnosis of dementia, a history of actual elopement or attempted elopement, a history of wandering places that put her at a significant risk of getting to a potentially dangerous place (stairs or outside facility), she had a history of wandering that significantly intruded on the privacy and/or activity of others, she had a sleep pattern disturbance that caused increased confusion, she had expressed the desire to leave (go home, talked about going on a trip, attempted to pack belongings), She was unable to locate significant landmarks without assistance (bathroom, dining room and her own room), she exhibited one or more emotional state or behavior that may result in exit-seeking behavior (hovering near exits, frustration, restlessness and/or agitation and impulsivity). -The August 2023 CPO did not reveal an order for a wander guard for Resident #296. Resident #296 was admitted to the facility on [DATE] from a secure memory care facility. 3. Observation and interview On 8/17/23 at approximately 9:30 a.m. wrists and hands were visible for Resident #296. A wanderguard was not observed on either wrist. LPN #5 was interviewed immediately after and said Resident #296 was an elopement risk. LPN #5 placed a wander guard on the left wrist of Resident #296. G. Resident #125 1. Resident status Resident #125, age [AGE], was admitted on [DATE]. According to the August 2023 CPO, the diagnoses included dementia, anxiety and depression. The 5/31/23 MDS assessment revealed the resident was cognitively impaired with a brief interview for mental status score of 10 out of 15. She required extensive assistance with transfers, dressing, toilet use and personal hygiene. She used a wheelchair for mobility and was able to self-propel. 2. Record review The 8/4/23 room transfer form revealed Resident #125 moved from a secure unit in the facility to a non secure unit since the resident was not exit seeking and would benefit from being off a secured unit. The 8/14/23 elopement evaluation revealed Resident #125 was able to self-propel her wheelchair independently, had a diagnosis of dementia and exhibited one or more emotional state or behavior that may result in exit-seeking behavior being hyperactivity. The August 2023 CPO revealed an order for a wander guard to placed on the right wrist of Resident #125 with a start date of 8/7/23, due to poor safety awareness. The care plan, initiated 8/9/23, revealed a focus for Resident #125 at risk for elopement related to impaired cognition/wandering, with a goal that she would not attempt to leave the facility without an escort. An intervention to achieve the goal was use and monitoring of a wander guard. 3. Observation and interview On 8/17/23 at approximately 9:30 a.m. Resident #125 was wearing a quarter length sleeved shirt exposing both wrists. A wanderguard was not observed on either wrist. LPN #5 was interviewed immediately after and said Resident #125 had an order for a wander guard and one was not currently present on her wrist. LPN #5 placed a wander guard on the right wrist of Resident #125. H. Staff interviews The assistant director of nursing (ADON) was interviewed on 8/14/23 at 10:33 a.m. He said an elopement evaluation had been completed prior to admission of residents moving from another secure memory care facility which were Residents #285, #297, #286, #295 and #296. He said all residents who were identified as risk to wander had wander guards. He said the residents admitted from the other secured facility were not automatically moved to their secured unit. The director of nursing (DON) was interviewed 0n 8/17/23 at approximately 10:00 a.m. She said residents who were identified as an elopement risk need an order for the placement of a wander guard and for the wander guard to be placed on the resident. She said she was informed by ADON all residents admitted from another secured facility had elopement assessments completed, orders for wander guard and placement of wander guard.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and interviews, the facility failed to ensure a resident diagnosed with dementia, received the appropriate treatment and services to attain or maintain his or her highest practicable physical, mental, and psychosocial well-being for three (#64, #52 and #116) of four residents reviewed for dementia care out of 70 sample residents. Specifically, the facility failed to: -Provide a person-centered approach, individualized approach and treatment to Resident #116's dementia care to address her increased confusion prior to moving her to a new room within facility; -Provide a person-centered approach to Resident #64 and Resident #52's dementia care services to address their physically aggressive behavior in order to prevent physical altercations with each other and; -Have consistent, purposeful and meaningful activity programming for one of two secured units. Findings include I. Facility policy and procedures The Dementia policy and procedure, revised 6/1/21, was provided by the nursing home administrator (NHA) on 8/17/23 at 6:30 p.m. It read in pertinent part: It is expected that the approach to care for a patient with dementia follows a systematic care process in order to gather and analyze information necessary to provide appropriate care and services, and that the patient and/or family or representative is engaged throughout the process. The patient's record will reflect the implementation of the following care process: recognition and assessment; cause identification and diagnosis; development of care plan; individualized approaches and treatment; monitoring, follow up and oversight of care plan implementation; and quality assurance and performance improvement. Patients will be evaluated as part of the nursing assessment process for the presence of cognitive loss/dementia upon admissions/readmission, quarterly, with changing condition or changing cognitive status, and/or per state regulations. And your disciplinary assessments of the person's abilities and backgrounds are completed in order to provide care and assistance that is tailored to his or her individual need. Staff will receive education on the care and needs of the patient with dementia. Purpose: To provide dementia care programs that are individualized, person-centered and relationship-based. To maintain the highest level of cognitive, physical, and activities of daily living (ADL) function. To [NAME] Independence and promote non-pharmacological interventions. Practice standards: Review pre-admission information to plan for patients needs prior to admission. Complete nursing assessment to determine patients cognitive status. If the assessment shows cognitive loss/dementia, review the care plan triggers. Consult with social services and recreation to review and evaluate assessments regarding cognition, mood, social history, and previous life patterns/routines, choices, cultural patterns, preferences. Evaluate behavioral symptoms for underlying causes: toilet needs, pain, positioning. Evaluate need for psych/behavioral health consult. Obtain rehabilitation screen to determine if rehabilitation services are indicated. Collaborate with the interdisciplinary team and family/healthcare decision maker to develop individualized care plans. Implement care plans and communicate to staff. The interdisciplinary team, and collaboration with the patient or family/representative, reviews the results of the assessment and cause identification in order to develop individualized, person-centered interventions. Communicate and consistently implement the care plan with all staff and across all shifts. Monitor conditions that may contribute to cognitive loss/dementia such as delirium diabetes electrolytes and balance. Change in cognitive status (confusion, orientation, ability to self express). Medications, especially new/changed/discontinued, for side effects and patient response contributing to cognitive loss/dementia, pain, elopement risk, safety to self and others (swallowing objects, environmental factors, intrusive wandering). Decline in physical and/or ADL function refer to therapy if decline in ADL noted. If a patient exhibits behavioral symptoms, implement behavioral monitoring and intervention flow records. Review non pharmacological approaches for effectiveness. Notify physicians, advanced practice providers, if applicable. II. Resident #116 A. Resident status Resident #116, under age [AGE], was admitted on [DATE]. According to the August 2023 computerized physician orders (CPO), the diagnoses included early onset Alzheimer disease and anxiety disorder. The 7/19/23 minimum data set (MDS) assessment revealed the resident had severe cognitive impairment with a brief interview for mental status score of zero out of 15. She required only supervised assistance with transfers, dressing, toileting, personal hygiene and eating. She was experiencing psychosis with hallucinations and delusions, She displayed behavioral symptoms of rummaging and pacing, she rejected care that was necessary to achieve goals for health and well-being, and she had wandered. B. Observations During a continuous observation on 8/14/23 beginning at 10:00 a.m. and ending at 1:30 p.m. Resident #116 was observed tearful throughout the duration. She approached an unidentified staff member at 11:00 a.m., was tearful and said she wanted to go home and she did not want to be there. The staff member encouraged Resident #116 to call her family and said he could not help her to go anywhere because he was working. The staff member did not assist Resident #116 to call family. Resident #116 paced the hallway looking in rooms and approached the staff member again, was tearful and asked for help getting home. She was advised to call her family and not assisted to use her personal cell phone she was holding. At 1:00 p.m. Resident #116 was tearful in the hallway and said she did not want to be where she was and paced the hall looking in rooms. On 8/14/23 at 3:30 p.m. Resident #116 was observed approaching licensed practical nurse (LPN) #5, the resident was tearful and said she wanted to go home and asked for help. LPN #5 said she was unable to help her to leave because she needed to be in the building to help other people. On 8/15/23 at 2:00 p.m. Resident #116 was tearful and asking for help. She was approached by the medical recorders director (MRD) who asked how to help. Resident #116 was crying and said she did not know what to do and she was scared. The MRD offered to get Resident #116 cookies. Resident #116 declined. The MRD asked Resident #116 what she needed and Resident #116 continued to cry and repeatedly said she did belong where she was at and she needed to leave. The MRD again offered Resident #116 a cookie, she declined. The MRD offered to walk with Resident #116 around inside of the building. During a continuous observation on 8/16/23 beginning at 12:30 p.m. and ending at 4:00 p.m. Resident #116 was tearful, she was pacing to and from an activity in the dining area down the hallway past her room and back again. She was approached by certified nurse aide (CNA) #13, Resident #116 said she was scared and did not belong where she was. CNA#13 suggested Resident #116 call her family and walked Resident #116 to her room. CNA #13 did not stay with Resident #116 to assist with call. At 1:54 p.m. Resident #13 exited her room and approached registered nurse (RN) #8, she was tearful, stated she was scared and asked for help. RN #8 suggested Resident #116 to lie down and take a nap. Resident #116 was tearful and approached CNA #13, said she was scared and asked for help and said she was not where she needed to be. Resident #116 was unable to communicate what was scaring her, she continued to pace the hallway, tearful, looking into rooms. At 3:30 p.m. Resident #116 was approached by activities assistant (AA) #2 who offered to sit with Resident #116 in her room and read to her. Resident #116 remained with AA #2 for 30 minutes reading her room. C. Record review 1. Progress notes The 6/17/23 progress note revealed staff observed Resident #116 pacing up and down the hall, standing at the door exiting to the parking lot, looking into rooms and standing in the hallway looking around. Staff noted Resident #116 had increased confusion. The 7/19/23 progress note revealed Resident #116 was restless the previous night until midnight, she had piled her belongings on her bed and she was looking into the hallway from her room door repeatedly. Progress note indicated Resident #116 normally keeps her room tidy. She was increasingly confused and could not hold a conversation, she approached staff asking what should be done with her cell phone cord and could not identify an outlet as an outlet on her wall. The 7/20/23 progress note revealed Resident #116 was sorting her clothing all day and came out of her room with her pajamas wrapped around her left arm. She had clothing items on the floor and was unable to complete a sentence and had difficulty expressing her needs or wants. She needed cuing for reminders to eat. The 7/21/23 progress note revealed Resident #116 had increased confusion, needed constant redirection from staff related to increased confusion. Medical provider was informed and indicated no new orders The 7/22/23 progress noted revealed Resident #116 was experiencing anxiety about surroundings, she continued to empty her drawers and closet looking for pajamas that had been provided to her multiple times by staff. She was unable to express her needs and had difficulty with word finding. The 7/23/23 progress note revealed Resident #116 was removing her clothes from her dresser and closet and putting them on her bed over the duration of weekend and was looking for her pajamas that she was holding in her hands. The 7/31/23 room transfer form revealed Resident #116 transferred to a wanderguard unit. The 8/5/23 progress note revealed Resident #116 was escorted by an unidentified nurse to the social services office related to physical aggression towards staff and others. Resident #116 was extremely tearful and unable to explain the situation. Resident #116 said she was scared, but was unable to express why or about what. Resident #116 expressed sadness, she had been crying all day and not sleeping well. She was confused about where she should be and the circumstances involved and she had hit other residents and staff. The medical provider was informed and recommended a one time dose of seroquel (antipsychotic used to improve mood, thoughts, and behaviors) 25 milligrams (MG) be given. No other recommendations were made by the provider. The August CPO revealed an order for citalopram hydrobromide (antidepressant) tablet 20 milligrams (mg), to be given one time a day for depression, with a start date of 8/5/23. On 8/5/23 Resident #116 was evaluated for a change in condition, specifically, behavioral symptoms to include agitation or psychosis and increased confusion. The behavioral changes were described as physical (biting, hitting, kicking or spitting) and verbal (cursing or screaming) aggression, personality changes, and depression. She had been crying non-stop and kicked a CNA in the chest. The medical provider was notified and gave a recommendation for a one time dose of seroquel (see above). The 8/8/23 progress note revealed Resident #116 had been tearful and continued to wander into other resident rooms, went through their belongings and removed clothing from their closet. She had cried when redirected by nursing staff. The intervention implemented was for Resident #116 to walk with nursing staff until the resident was ready for bed. The 8/11/23 behavioral note revealed Resident #116 wandered daily, was experiencing anxiety about surroundings, displayed impulsive behavior and was not adjusting to transfer well. An elopement evaluation was completed on 8/14/23 and revealed Resident #116 was able to ambulate (walk) independently, she had a history of wandering that placed her at significant risk for getting into potentially dangerous places, being stairs or outside facility, she had a history of wandering that significantly intruded on privacy or activities of others, she was unable to locate landmarks, such as, bathroom, dining room, or her own room with assistance, and she exhibited one or more emotional state or behavior that could result in exit-seeking behavior, being shadowing staff or other resident and hyperactivity (restless walking patterns). Resident #116 was moved to a wanderguard unit on 7/31/23, however, an elopement evaluation was not conducted until 8/11/23. A restrictive device consent form was signed by the resident representative on 7/31/23. 2. Care plan The care plan, last reviewed 8/2/23, revealed Resident #116 exhibited distressed or fluctuating mood symptoms related to anxiety. Interventions included she be observed for signs and symptoms of worsening sadness, depression, fear, anxiety, fear, agitation and anger. Psychosocial cause was to be determined for resident's sadness, depression, anxiety, fear, anger or agitation. She was to be encouraged to seek staff support for distressed mood, redirected to something positive, staff was to facilitate contact with her support system, allow time for expression of feeling and provide empathy, she was to be encouraged to participate in an activity. The care plan, last reviewed 8/2/23, revealed Resident #116 was involved with identifying interventions to help reduce anxiety and discomfort for her without the use of medications. The interventions included hand massage, chaplain visit, relaxing music or sound machine, quiet time, pet therapy, essential oils, and walking. She identified the use of a fan, warm shower or stretching to promote comfort. She identified books, magazines, movies, puzzle books, coloring books, board games, arts and crafts and television as forms of entertainment. Staff was to assist her with the interventions listed. The care plan, initiated 8/11/23, revealed Resident #116 was at risk for or experiencing adjustment issues related to a room change. Interventions included encouraging family and friends to visit with her for support, staff was to encourage Resident #116 to express thoughts and feelings associated with the change and loss of customary lifestyles or routines and she was to continue her psychiatric and counseling services. 3. Behavior tracking The point of care response history revealed Resident #116 was to be monitored for distressing hallucinations. -However, the behavior tracking did not provide staff an option in the tracking to record information. Interventions for behaviors were not obtained or not documented. Behaviors were documented as follows. Anxiety or restlessness was displayed on 7/21/23, 7/25/23, 7/26/23, 7/27/23, 7/28/23, 7/31/23, 8/3/23, 8/8/23 and 8/12/23. Agitation was displayed on 7/25/23, 8/2/23, 8/11/23 and 8/12/23. Rummaging was displayed on 7/26/23 and 7/31/23. -However, progress notes on 7/20/23, 7/22/23, 7/23/23 and 8/8/23 revealed Resident #116 was observed rummaging on these days. (see above) Entering other resident rooms or personal space was displayed on 8/5/23 and 8/8/23. Expressing frustration or anger at others was displayed on 8/2/23, 8/5/23, 8/8/23 and 8/12/23 Cursing at others was displayed on 8/5/23. Accusing others was displayed on 8/2/23. Kicking others was displayed on 8/5/23. 4. Therapy notes The 8/14/23 and 8/24/23 therapy notes from an outside provider revealed Resident #116 had struggled with anxiety most of her life and was struggling with memory and concentration issues lately. She reported some adjustment issues related to adjusting to her new surroundings at her current facility. It revealed Resident #116 had cognitive impairment that did not interfere with her ability to participate in and benefit from psychotherapy. The therapy assessment identified the primary reason for referral was related to anxiety diagnosis. The treatment plan included Resident #116 be monitored for changes in mood and behavior which include cognitive functioning, psychosis, depression, sleep disturbance, irritability, low frustration and stress tolerance, sensory dysregulation, mental and physical fatigue and behavioral disturbance. Encouragement to adhere to a daily schedule and opportunities during the day for cognitive and mental stimulation was recommended. The 8/14/23 therapy note revealed a discussion was had with the unit social worker regarding the importance of monitoring and documenting symptoms and mood states. Staff reported no major concerns regarding mood or behavior. -However, the 8/5/23 progress note revealed Resident #116 was evaluated for a change in condition, specifically, behavioral symptoms to include agitation or psychosis and increased confusion. (see above) The 8/24/23 therapy note revealed staff reported concerns regarding visual hallucinations and bizarre behavior. She presented with difficulty in word finding and was incoherent with the therapist at times. Resident #116 initially denied any concerns regarding visual hallucinations but when she was asked specifically about seeing spiders in the hallway over the weekend, she informed the therapist that it was [NAME] and if you leave him alone he would not bother you. D. Staff interviews CNA # 11 was interviewed on 8/15/23 at 1:20 p.m. She said Resident #116 has become more confused and tearful since she moved rooms. She said Resident #116 approached staff and visitors and told them she wanted to go home. She said Resident #116 was sad, anxious and was tearful multiple times a day. She said she required constant redirection from staff. She said she Resident #116 moved rooms because of increased confusion. She said the move had not helped her confusion. She said Resident #116 enjoyed going on walks and being social. She said, recently, Resident #116 had difficulty with word finding and did not socialize much but still enjoyed walking and being spoken to. AA #2 was interviewed on 8/16/23 at 4:00 p.m. She said Resident #116 moved rooms related to worsening of cognition and increased confusion. She said Resident #116 had displayed an increase in confusion and sadness since she was moved. She said Resident #116 enjoyed passive activities that did not require her to be conversational as she had more difficulty with word finding recently. She said Resident #116 enjoyed being read to, listening to music or walking. LPN #5 was interviewed on 8/17/23 at 10:30 a.m. She said Resident #116 moved rooms because of increased confusion. She said the area of the building she was in now had more staff oversight and Resident #116 had become an elopement risk. She said Resident #116 had not adjusted well to the move, she had become tearful and anxious. The director of nursing (DON) and the assistant director of nursing (ADON) were interviewed on 8/17/23 at 2:00 p.m. The ADON said Resident #116 had a rapid cognitive decline and had become more confused. The ADON said her room move was related to a more robust activity program in the location of her current room. The ADON said when she was moved on 7/31/23 the hallway she resided on had only four residents and was easier for her to navigate. He said there was an influx of residents moving to the hallway she resided on and she was having difficulty adjusting. The ADON said no other interventions to address Resident #116's were attempted prior to a room move. The ADON said the facility did not consider a move back to her previous room. The DON said Resident #116 was moved to a room in the secure memory care on that day (8/17/23). The DON said Resident #116 would benefit from the structure a secure unit provided. The social services director (SSD) was interviewed on 8/17/23 at 4:30. She said Resident #116 moved rooms because she was getting lost and going into other resident rooms. She said Resident #116 was moved again on that day (8/17/23) to the secure memory care unit in the facility. She said multiple moves would not benefit someone with increased confusion. She said no other interventions were implemented to address confusion prior to moving Resident #116 to a new room. She said moving Resident #116 back to her previous room had not been an option. III. Resident #64 A. Resident status Resident #64, under the age of 65, was admitted on [DATE] and readmitted on [DATE]. According to the August 2023 CPO the diagnoses included depression, vascular dementia with agitation, psychotic disorder with delusions, vascular dementia with mood disturbance and nicotine dependence. The 6/2/23 MDS assessment revealed the resident had moderate cognitive impairment with a brief interview for mental status with a score of 11 out of 15. She required supervision for bed mobility, transfers, walking in her room and in the corridor and locomotion on and off the unit. She required extensive assistance of one person for toileting, personal hygiene, eating and dressing. The MDS assessment revealed she had verbal behaviors directed towards others one to three times in the review period. She had behavioral symptoms not directed towards others one to three times in the review period. The resident resided on a secured unit. B. Record review The behavior care plan, initiated on 4/18/19, revealed Resident #64 made allegations of verbal abuse related to staff commenting on her smoking habits. The interventions included: ensuing Resident #64 was taken out on her smoke breaks and monitoring complaints and let management or social services know of any issues. The cognitive impairment plan of care, initiated on 4/13/18, revealed Resident #64 had impaired cognitive function and thought process related to vascular dementia. Resident #64 often forgot when she had smoked and made comments that staff did not take her out to smoke. The interventions included: allowing the resident to make daily decisions, redirecting and reorienting the resident using external cues as needed, providing consisted caregivers and structured daily routine, personalizing the resident's room with familiar items to assist in identifying her room, facilitating the family to participate in the residents care and providing opportunities to the resident to reminisce. Another behavior care plan, initiated on 10/18/23 and revised on 5/19/21, revealed Resident #64 exhibited or had the potential to exhibit physical behaviors related to cognitive loss and dementia. Resident #64 became argumentative or verbally aggressive with other residents, especially when she perceives their actions as being hostile or directed towards others. Resident #64 has been involved in resident to resident physical altercations. Resident #64 attempted to provide care or push other resident's wheelchairs even when redirected not to by staff. Some of Resident #64's behaviors were centered around smoking when she perceived she missed a smoke break. The interventions included: diverting the resident by giving her alternative objects or activities, attempting to de-escalate the situation if Resident #64 becomes physically aggressive to ensure the safety of both parties, reminding Resident #64 when she has been out to smoke, removing the resident from her environment, encouraging Resident #64 to seek staff support when she was distressed, removing Resident #64 from the environment if needed and gently guiding the resident into a different environment, observing for non-verbal signs of physical aggression, listening to the resident and trying to calm her, allowing time for expression of feelings, approaching Resident #64 in a calm manner, providing consistent caregivers and providing Resident #64 with opportunities for choice during care and activities to provide a sense of control. IV. Resident #52 A. Resident status Resident #52, age [AGE], was admitted on [DATE]. According to the August 2023 CPO the diagnoses included vascular dementia, anxiety disorder, altered mental status, dementia and vascular dementia with psychotic disturbance. The 8/2/23 MDS assessment revealed the resident had severe cognitive impairment with a brief interview for mental status with a score of five out of 15. She required supervision with bed mobility, transfers, eating, walking in her room and in the corridor and locomotion on the unit. She required extensive assistance of one person for dressing, toileting and personal hygiene. The MDS assessment revealed the resident had verbal behavior directed towards others one to three days in the review period. The resident resided on a secured unit. B. Record review The cognitive impairment care plan, initiated on 5/1/23, revealed Resident #54 had impaired cognitive function related to vascular dementia with agitation. The interventions included: observing and evaluating for changes in cognitive status, monitoring medications for side effects, monitoring for decline in function, evaluating behavioral symptoms for underlying causes, evaluating the need for behavioral health consult if indicated, breaking down tasks to support short-term memory deficits and provide cueing as needed, explaining all cares prior to initiating, calling Resident #54 by her preferred name and providing opportunities to reminisce. The behavior care plan initiated on 5/3/23 and revised on 8/5/23, revealed Resident #52 exhibited verbal behaviors related to dementia. Resident #52 had episodes of cursing at staff and other residents. Resident #52 had episodes of yelling, throwing items and throwing water at staff. Resident #52 had episodes of being accusatory towards staff related to her belongings. Resident #52 had verbal aggression towards her daughter, staff and other residents. The interventions included: attempting to de-escalate the situation and ensuing the safety of both parties, monitoring medications for side effects that could contribute to verbal behaviors, evaluating the nature of the circumstance, evaluating the need for behavioral health consultation, providing consistent caregivers and a structured environment, postponing cares or activities if resident became combative or resistant and allowing time for expression of feelings. -The facility failed to identify person-centered interventions to address the resident's behaviors which ultimately led to a resident to resident altercation with Resident #64. V. Observations During a continuous observation on 8/15/23 beginning at 4:39 p.m. and ended at 5:55 p.m. the following was observed: -At 4:39 p.m. Resident #52 was at the nurses station holding a stack of papers. -At 4:56 p.m. Resident #52 left the television room holding a stack of papers. During a continuous observation on 8/16/23 beginning at 9:47 a.m. and ended at 10:11 a.m. the following was observed: -At 9:48 a.m. Resident #64 was pacing the hallways. -At 10:07 a.m. Resident #64 was pacing the hallways. RN #4 went outside with Resident #64 to smoke. On 8/17/23 at 1:39 p.m. RN #4 was painting Resident #64's nails. -Throughout the observations, the residents had no meaningful activity and were wandering around. The residents had been in an altercation on 7/23/23 (see below). VI. Resident to resident altercation on 7/23/23 Resident #52 and Resident #64 were involved in a resident to resident altercation on 7/23/23 in which Resident #64 told Resident #52 to stop yelling. Resident #52 hit Resident #64 on the right forearm with a book and Resident #64 slapped Resident #52 on the face. Resident #52 then grabbed Resident #64 on the arm. VII. Failure to have consistent, purposeful and meaningful activity programming A. Observations During a continuous observation on 8/15/23 beginning at 4:39 p.m. and ended at 5:55 p.m. the following was observed: -At 4:40 p.m. seven residents were sitting and watching television. The television was on the news channel and was discussing a recent fire that resulted in fatalities. -At 4:47 p.m. Resident #110 was pacing the hallway. -At 4:50 p.m. RN #5 asked the residents in the common area if they were hungry. -At 4:54 p.m. a female resident attempted to touch Resident #64. RN #4 told the resident not to touch Resident #64 because she did not like to be touched. -At 4:54 p.m. RN #5 grabbed Resident #110's hand and guided him to the television room and told him to sit down. Resident #110 was unable to see the television where he was sitting and had no meaningful activity in front of him. -At 5:04 p.m. Resident #110 was bent over playing with his shoe laces. -At 5:06 p.m. RN #5 and CNA #5 began assisting residents to the dining room. There was no music playing in the dining room. During a continuous observation on 8/14/23 beginning at 11:30 a.m. and ended at 12:57 p.m. the following was observed on the 900 unit. -At 12:04 p.m. several residents were sitting in the television room. -At 12:08 p.m. Resident #128 was observed crying and saying she did not know what to do. Resident #128 stood up and walked to a different chair in the television room and sat back down. -At 12:22 p.m. Resident #128 stood back up and said she was going to go see what was happening. Resident #128 took a couple steps and then sat back down. -At 12:23 p.m. an unidentified CNA brought another resident to the television room and left. -At 12:57 p.m. an unidentified activities staff member passed out printed activities calendars. The unidentified activities staff member did not interact with any residents on the unit. -Several residents were pacing up and down the hallway. -During this time there were no meaningful or purposeful activities provided to the residents on the 900 unit. The activity calendar listed the following activities as occurring: -11:45 a.m. [NAME] Facts -12:00 p.m. daily chronicle -None of these activities were observed being offered or occurring on the 900 unit. During a continuous observation on 8/16/23 beginning at 9:47 a.m. and ended at 10:11 a.m. the following was observed: -Several residents were watching television. The television was on the news channel and had a segment playing on suicide rates of veterans. -At 10:07 a.m. an unidentified activities staff member entered the 900 unit. The unidentified activities staff member passed out a daily chronicle to the residents in the television room. She did not engage in any purposeful or meaningful activities with the residents. The activity calendar listed the following activities as occurring: -10:00 a.m. Catholic communion -Catholic communion was not observed being offered on the 900 unit. B. Record review A review of the activity calendar posted throughout the facility revealed there was one activity calendar for the entire facility (eight units, two secured memory units). The activities for 8/14/23 to 8/17/23 were as follows: 8:14/23: -9:30 a.m. 300 hall manicure -11:00 a.m. Music with [NAME] -10:00 a.m. Bible Study in the television room -11:45 a.m. [NAME] Facts -12:00 p.m. Daily chronicle -2:30 p m. Bingo -4:00 p.m. Mail/Package delivery 8/15/23: -9:30 a.m. Fun Cart -10:30 a.m. Arts and Crafts -11:30 a.m. Relaxation Facts -12:00 p.m. Daily Chronicle -12:30 p.m. taco Bell luncheon -2:30 p.m. Food Committee -4:00 p.m. Mail/Package delivery 8/16/23: -9:30 a.m. Fun Cart -10:00 a.m. Catholic Communion -11:30 a.m. Poet's Facts -12:00 p.m. Daily Chronicle -12:00 p.m. Piano Music (north dining room/900) -2:30 p.m. Music Trivia -4:00 p.m. Mail/Package Delivery -7:00 p.m. Happy Hour 8/17/23: -9:30 a.m. Fun Cart -10:30 Coffee Talk -11:30 a.m. Vacation Word Search -11:45 Vacation Facts -12:00 Daily Chronicle -2:30 p.m. Resident's Board of Directors Meeting -4:00 p.m. Mail/package Delivery C. Staff interviews RN #4 was interviewed on 8/17/23 at 12:21 p.[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, 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 administration observation error rate was 32% or 18 errors out of 56 opportunities for error. Findings include: I. Professional reference According to [NAME], P.A., [NAME], A.G., et.al., Fundamentals of Nursing, 10 ed. (2020), E.[NAME], St. Louis Missouri, pp. 606-607, retrieved on 2/13/23, Take appropriate actions to ensure the patient receives medication as prescribed and within the times prescribed and in the appropriate environment. Professional Standards such as nursing scope and standards of practice apply to the activity of medication administration. To prevent medication errors, follow the seven rights of medication administration consistently every time you administer medications. Many medication errors can be linked in some way to an inconsistency in adhering to these seven rights: 1. The right medication 2. The right dose 3. The right patient 4. The right route 5. The right time 6. The right documentation 7. The right indication. II. Facility policy and procedure The Administration of Medications and Treatments policy, revised 8/1/16, was provided by the nursing home administrator (NHA) on 8/17/23 at 4:53 p.m. It read in the pertinent part, Residents shall receive only the medications ordered by his or her duly authorized licensed practitioner in the correct dose, at the correct time, and by the correct route of administration consistent with pharmaceutical standards. III. Observations On 8/17/23 at 9:42 a.m. licensed practical nurse (LPN) #1 was observed preparing and administering medications to Resident #114. The resident's orders were for: -Buspirone HCI oral tablet. Scheduled for 8:00 a.m. -Lyrica oral capsule. Scheduled for 8:00 a.m. On 8/17/23 at 9:57 a.m. LPN #1 was observed preparing and administering medications to Resident #14. The resident's orders were for: -Buspirone HCI oral tablet. Scheduled for 8:00 a.m. -Trelegy Ellipta Inhalation Aerosol Powder Breath Activated. Scheduled for 8:00 a.m. On 8/17/23 at 10:25 a.m. LPN #1 was observed preparing and administering medications to Resident #27. The resident's order was for: -Effexor oral tablet. Scheduled for 8:00 a.m. -Klor-con oral tablet. Scheduled for 8:00 a.m. -Apixaban oral tablet. Scheduled for 8:00 a.m. -Senna oral tablet. Scheduled for 8:00 a.m. -Neurontin oral tablet. Scheduled for 8:00 a.m. -Systane eye drops. Scheduled for 8:00 a.m. -Levetiracetam oral tablet. Scheduled for 8:00 a.m. On 8/17/23 at 10:35 a.m. LPN #1 was observed preparing and administering medications to Resident #11. The resident's order was for: -Esomeprazole oral tablet. Scheduled for 8:00 a.m. -Myrbetriq oral tablet. Scheduled for 8:00 a.m. -Topiramate oral tablet. Scheduled for 8:00 a.m. III. Interviews LPN #1 was interviewed on 8/17/23 at 3:40 p.m. LPN #1 said she was aware of the medications being administered late but the facility expectation was that they still be given as soon as possible. The director of nursing (DON) was interviewed on 8/17/23 at 4:02 p.m. The DON said it n was extremely important that residents receive their medications on time. An acceptable expectation was for medications to be administered within one hour before up to one hour after the actual ordered time. She said she would speak with LPN #1 and find out why the medications were being given late.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review, the facility failed to ensure drugs and biologicals were labeled and stored in accordance with accepted professional standards, in five of five medication carts reviewed out of nine medication carts and two of two medication rooms reviewed out of five medication rooms. Specifically, the facility failed to: -Label and date insulin when opened; -Dispose of medications beyond the manufacturer use by date once opened; and, -Ensure medications and vaccines were not stored with resident food. Findings include: I. Manufacturer's recommendations Insulin Glargine (lantus) package insert read in pertinent part: Insulin Glargine pen should be stored at room temperature, below 86°F and must be used within 28 days or be discarded. Insulin Lispro package insert read in pertinent part: Insulin Lispro pen should be stored at room temperature, below 86°F and must be used within 28 days or be discarded. Insulin Levemir Vial package insert read in pertinent part: Insulin Lispro pen should be stored at room temperature, below 86°F and must be used within 28 days or be discarded.Throw away all opened Levemir vials after 42 days, even if they still have insulin left in them. Insulin Novolog Flexpen package insert read in pertinent part: Insulin Lispro pen should be stored at room temperature, below 86°F and must be used within 28 days. Insulin Tresbiba Flextouch insulin pen package insert read in pertinent part: Insulin Tresbiba pen should be stored at room temperature, and must be used within 56 days. II. Facility policy and procedure The Storage of Medication policy, dated November 2020, was received from the quality assurance nurse (QAN) on 11/7/23 at 12:26 p.m. The policy document in pertinent part, Discontinued, outdated, or deteriorated drugs or biologicals are returned to the dispensing pharmacy or destroyed. Medications are stored separately from food and are labeled accordingly. III. Improper medication storage on medication carts and in refrigerators 1. Little Bear medication cart The Little Bear medication cart was reviewed with registered nurse (RN) #1 on 11/6/23 at 10:16 a.m. The top drawer of the cart contained a Glargine insulin pen dated as opened 8/29/23 and a Lantus insulin pen, undated. RN #1 removed the pens and said the pens should not have been used more than 30 days after it was opened or if the insulin pen was not dated when opened. The Kit [NAME] medication cart was reviewed with licensed practical nurse (LPN) #7 at 11:22 a.m. The top drawer of the cart contained an open Trebisa insulin pen with no date of when it was opened, an open Novalog insulin pen with no date and an open Lantus insulin pen with no date. LPN #7 said she did not know how long the insulin pens were good after they were opened, but she said she knew they were supposed to be dated when opened. The Pyramid mediation cart was reviewed with LPN #2 at 11:30 a.m. The top drawer of the cart contained an open Lispro insulin pen with no date. LPN #2 removed the pen and said the insulin pen and said the insulin should be dated when opened and should not be used for more than 30 days. He removed the insulin pen from the cart. The 600 hall medication cart was reviewed with LPN #1 at 11:42 a.m. The top drawer of the cart contained an open Glargine pen with no date of when it was opened. The medication room near the 600 hall was reviewed with LPN #1 at 11:45 a.m. The resident nourishment refrigerator in the medication room contained an intravenous (IV) antibiotic, Ceftrixine. There were five boxes of prefilled influenza syringes, 10 syringes per box. The refrigerator contained food items in clear cups which appeared to be yellow pudding, sandwiches and other supplements. LPN #1 said the medication was only in the nourishment refrigerator temporarily because there was no room in the medication refrigerator. She did not remove the medication or vaccines. The [NAME] medication cart #1 was reviewed with with LPN #1 at 12:01 p.m. The top drawer of the cart contained a vial of Levemir insulin dated 8/26/23 and an undated Glargine insulin pen. LPN #1 said the insulin pen should have been dated and was good for a month after opening. She said the Levemir insulin vial was good for a month after opening, She removed the items for disposal. The [NAME] medication room refrigerator was reviewed with LPN #1. The medication refrigerator contained multiple medications. The refrigerator contained opened containers of liquid supplements for residents. LPN #1 said the supplements should not be kept in with the medication because they could contaminate each other. VI. Administrative interviews The dietary manager (DM) was interviewed on 11/7/23 at 8:42 a.m. She said she did not check the nourishment refrigerators in the medication rooms. She said it was the nurse's responsibility. She said she did not think medications should be stored with food. The QAN was interviewed on 11/7/23 at 3:28 p.m. She said she did not know what the policy was for keeping resident food or supplements with medications such as IV medications and vaccines. She said insulin was good for 30 days after opening.

Based on observations, record review, and interviews, the facility failed to maintain an infection control program designed to prevent the spread of infection for one of three neighborhoods. Specifically, the facility failed to perform appropriate hand hygiene during medication administration. Findings include: I. Professional standard According to the Centers for Disease Control and Prevention (CDC) Hand Hygiene in Healthcare Settings, last up updated 1/8/21, retrieved from https://www.cdc.gov/handhygiene/providers/index.html on 8/29/23, included the following recommendations: Multiple opportunities for hand hygiene may occur during a single care episode. Following are the clinical indications for hand hygiene: Use an alcohol-based hand sanitizer immediately before touching a patient, before performing an aseptic task (placing an indwelling device) or handling invasive medical devices, before moving from work on a soiled body site to a clean body site on the same patient, after touching a patient or the patient's immediate environment, after contact with blood, body fluids or contaminated surfaces, and immediately after glove removal. Wash with soap and water when hands are visibly soiled, after caring for a person with known or suspected infectious diarrhea, and after known or suspected exposure to spores. When using alcohol-based hand sanitizer, put the product on hands and rub hands together. Cover all surfaces until hands feel dry. This should take around 20 seconds. II. Facility policy and procedure The Hand Hygiene policy was requested from the nursing home administrator on 8/17/23 at 4:15 p.m. but it was not provided. III. Observations and interviews On 8/17/23 at 9:35 a.m. LPN #1 was observed preparing and administering medications to Resident #113. She entered the residents room without performing hand hygiene and handed the resident a cup with his medications. She then asked the resident to lay on his side so she could administer the suppository. She donned clean gloves and proceeded to open the suppository and insert it in the residents rectum. LPN #1 removed her gloves and exited the residents room without performing hand hygiene. At 9:42 a.m. LPN #1 was observed preparing and administering medications to Resident #114. She did not perform hand hygiene. She could not locate the vitamin D so she went to the medication room, opened the locked door and looked. She returned to the medication cart and continued collecting the remaining ordered medications without performing hand hygiene. LPN #1 entered the residents room and handed the medication cup and water to the resident. LPN #1 left the resident's room and did not use hand sanitizer or wash her hands. At 9:57 a.m. LPN #1 was observed preparing and administering medications to Resident #14. LPN #1 carried the medications into the resident's room and moved the bedside table out of her way. She offered the medication cup to the resident but the resident refused to take them without applesauce. LPN #1 returned to the medication cart and placed all the medications in the top drawer and locked it, then went to the kitchen to get applesauce. She opened the kitchen door and asked for applesauce. It was given to her and she returned to the medication cart. She did not perform hand hygiene and collected the medications previously prepared from the medication cart and went back to the residents room. LPN #1 put the medications on the residents bedside table. She donned clean gloves without performing hand hygiene. She handed the resident a tissue, asked her to look up, and placed one eye drop in the resident's eye. She removed her gloves and gave the resident each medication with a spoon. She exited the resident's room and did not perform hand hygiene. At 10:25 a.m. LPN #1 was observed preparing and administering medications to Resident #27. LPN #1 entered the residents room and gave her the medications to be taken by mouth, then she donned clean gloves, handed the resident a tissue, asked her to look up and placed one eye drop in each of her eyes. LPN #1 exited the resident's room and for the first time used hand sanitizer at 10:30 a.m. IV. Staff interviews The infection preventionist (IP) was interviewed on 8/17/23 at 3:32 p.m. She said there should be hand sanitizer on each medication cart and nurses should perform hand hygiene before and after every resident interaction including and especially during medication pass. The director of nursing (DON) was interviewed on 8/17/23 at 6:18 p.m. She said nurses should be washing their hands or using hand sanitizer between every resident during medication pass.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to ensure the antibiotic stewardship program included antibiotic use protocols addressing documentation of the indication and duration of the antibiotic and a system to monitor antibiotic use for prophylactic antibiotics for five (#52, #74, #43, #45 and #76) of five residents reviewed for antibiotic use out of 70 sample residents. Specifically, the facility failed to evaluate and monitor the use of current prophylactic antibiotic usage for Residents #52, #74, #43, #45 and #76. Findings include: I. Professional reference The Centers for Disease Control and Prevention (2019) The Core Elements of Antibiotic Stewardship for Nursing Homes APPENDIX A: Policy and Practice Actions to Improve Antibiotic Use, retrieved 8/28/23 from: https://www.cdc.gov/antibiotic-use/core-elements/pdfs/core-elements-antibiotic-stewardship-appendix-a-508.pdf It read in pertinent parts: Reduce prolonged antibiotic treatment courses for common infections. A large study of antibiotic prescribing practices in nursing homes demonstrated that over 50% of antibiotic treatment courses extended beyond a week with no correlation with resident characteristics or type of infection being treated. Given the growing body of evidence that short courses of antibiotics are effective for common infections,interventions designed to decrease antibiotic duration among nursing home residents may reduce the complications and adverse events associated with antibiotic exposure. II. Resident #52 A. Resident status Resident #52, age [AGE], was admitted on [DATE]. According to the August 2023 computerized physicians orders (CPO), diagnoses included septicemia (blood poisoning by bacteria). The 5/4/23 minimum data set (MDS) assessment revealed the resident had moderate cognitive impairment with a brief interview for mental status (BIMS) score of eight out of 15. The resident required supervision and set up only for toilet use and personal hygiene. B. Record review The order listing report, received on 8/16/23 at 5:00 p.m. by the infection preventionist (IP) revealed Resident #52 had an order for macrobid oral capsule 100 milligrams (mg) (antibiotic used to treat bladder infections) once daily by mouth for urinary tract infections (UTI) prevention. III. Resident #74 A. Resident status Resident #74, age [AGE], was admitted on [DATE]. According to the August 2023 CPO, diagnoses included presence of a colostomy bag and urge incontinence (sudden urges to void resulting in involuntary leakage of urine). The 5/20/23 MDS assessment revealed the resident was cognitively intact with a (BIMS) score of 14 out of 15. The resident required extensive assistance from staff for toilet use and personal hygiene. B. Record review The order listing report, received on 8/16/23 at 5:00 p.m. by the IP revealed Resident #74 had an order for nitrofurantoin monohydrate macro oral capsule 100 mg once daily for prophylaxis (intended to prevent disease). IV. Resident #43 A. Resident status Resident #43, age [AGE], was admitted on [DATE]. According to the August 2023 CPO, diagnoses included UTI. The 6/16/23 MDS assessment revealed the resident was cognitively intact with a BIMS score of 15 out of 15. The resident required extensive assistance from staff for toilet use and personal hygiene. B. Record review The order listing report, received on 8/16/23 at 5:00 p.m. by the IP revealed Resident #43 had an order for macrobid oral capsule 50 mg twice daily for UTI prophylaxis. V. Resident #45 A. Resident status Resident #45, over age [AGE], was admitted on [DATE] According to the August 2023 computerized physician orders (CPO), diagnoses included neurogenic bladder (name given to a number of urinary conditions in people who lack bladder control due to a brain, spinal cord or nerve problem). The 6/22/23 MDS assessment revealed the resident was cognitively intact with a BIMS score of 15 out of 15. The resident required extensive assistance from staff for toilet use and personal hygiene. He had an indwelling catheter. B. Record review The order listing report, received on 8/16/23 at 5:00 p.m. by the IP revealed an order for methenamine hippurate (urinary antiseptic used as preventive treatment for recurrent UTI) oral tablet 1 gram (gm) twice daily for UTI prevention. VI. Resident #76 A. Resident status Resident #76, age [AGE], was admitted on [DATE]. According to the August 2023 CPO, diagnoses included obstructive uropathy (a disorder of the urinary tract that occurs due to obstructed urinary flow). The 6/22/23 MDS assessment revealed the resident was cognitively intact with a BIMS score of 15 out of 15. The resident required extensive assistance from staff for toilet use and limited assistance for personal hygiene. She had an indwelling catheter. B. Record review The order listing report, received on 8/16/23 at 5:00 p.m. by the IP revealed an order for doxycycline hyclate (antibiotic treating only bacterial infections) tablet 100 mg once daily for prophylactic for knee hardware. VII. Staff interview The IP was interviewed on 8/16/23 at 5:00 p.m. She said the medical director and a urologist discussed residents who used antibiotics for prophylactic use. She said the medical director received guidance from urology on if antibiotic use should be continued. She said there was no current system for tracking residents using antibiotics as prophylaxis. She was unable to provide documentation of urology recommending prophylactic use of antibiotics for Residents #52, #74, #43, #45 and #76.

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. I. Facility policy and procedure The Food Service Quality Indicators policy, dated 5/1/23, was provided by the nursing home administrator (NHA) on 8/17/23 at 1:15 p.m. It revealed in pertinent part, Portion sizes of foods served are correct according to the written menu for each diet. Meals are served according to the Diet Guides: recipes are followed, portion sizes are correct, all items are present non-specified items are included and preferences are honored if not contraindicated by diet restriction. II. Follow the correct portion sizes to ensure adequate nutrition was provided to the residents A. Observations and record review During a continuous observation during the dinner meal on 8/15/23 starting at 4:39 p.m. and ended at 5:55 p.m. on the 900 unit dietary aide (DA) #3 used the following scoop sizes: A two ounce (oz) scoop for the pureed meat; and, A 3.2 oz scoop for the mashed potatoes The two oz scoop used for the pureed meat was 1.2 ounces less than the 3.2 oz portion size specified on the menu extension for the pureed barbeque pork for the pureed diet. The 3.2 oz scoop used for the mashed potatoes was 0.8 ounces less than the four oz portion size specified on the menu extension for the seasoned whipped potatoes for the pureed diet. The menu revealed residents who were prescribed a pureed diet should have received two ounces of pureed green peas. DA #3 said he did not have pureed green peas to serve to the residents, so he only served them pureed meat and seasoned mashed potatoes. During a continuous observation during the lunch meal on 8/16/23 beginning at 11:26 a.m. and ended at 1:06 p.m. in the main kitchen DA #2 used the following scoop sizes: A two oz scoop for the dysphagia advanced ham; A two oz scoop for the pureed ham; and, A 2.67 oz scoop for the pureed broccoli. The two oz scoop used for the dysphagia advanced ham was one oz less than the three oz portion size specified on the menu extensions for the ham for the dysphagia advanced diets. The two oz scoop used for the pureed ham was 1.2 oz less than the 3.2 oz portion size specified on the menu extensions for the ham for the pureed diets. The 2.67 oz scoop used for the pureed broccoli was 0.53 oz less than the 3.2 oz portion size specified on the menu extension for the broccoli for the pureed diets. DA #2 said she was serving the 600 and 700 units out of the main kitchen. The 600 and 700 unit had 18 residents who were on a dysphagia advanced diet and six residents on a pureed diet. DA #1 requested DA #2 to plate three pureed plates for residents on the 900 unit. III. Ensure the correct items were served in accordance with the posted menu A. Observations and record review During a continuous observation on 8/15/23 on the 900 unit starting at 4:39 p.m. and ended at 5:55 p.m. the following was observed: -At 4:50 p.m. registered nurse (RN) #5 read the menu to the resident on the 900 unit. RN #5 said dinner was barbeque pork on a bun, watermelon, french fries and green peas. -At 5:23 p.m. RN #5 said DA #3 was serving tater tots and creamed corn to the residents who were prescribed a regular texture diet. DA #3 said he did not have any green peas. -The menu specified residents who were prescribed a regular diet should have received barbeque pork on a bun, watermelon, french fries and green peas. -The menu specified the residents who were prescribed a pureed diet should have received pureed barbeque pork with sauce, pureed watermelon, seasoned whipped potatoes and pureed green peas. DA #3 and RN #5 said the three residents on the 900 unit who were prescribed a pureed diet did not receive pureed watermelon or pureed peas. DA #3 said he served applesauce to the residents prescribed a pureed diet. III. Staff interviews DA #3 was interviewed on 8/15/23 at 5:48 p.m. DA #3 said the pureed residents did not receive a pureed vegetable for the dinner meal on 8/15/23. RN #5 was interviewed on 8/15/23 at 5:50 p.m. RN #5 said she was surprised the residents on the pureed diet did not receive a vegetable. RN #5 said the vegetable on the menu was green peas, but the residents received creamed corn. RN #5 said residents on a pureed diet could not have creamed corn. The RD was interviewed on 8/17/23 at 11:45 a.m. The RD said when the cooks substituted a menu item, they were supposed to write it on the substitution log and notify her. The RD said the french fries and creamed corn were not on the substitution log. The RD said the DAs needed to follow the meal extensions to ensure adequate nutrition was being provided to all of the residents. The RD said the residents who received a pureed diet on 8/15/23 on the 900 unit were not provided the correct portion sizes. The DM joined the interview at 11:59 a.m. The DM acknowledged the residents were not served the correct portion sizes for the pureed diet on the 900 unit. The DM and the RD said the residents who received a mechanically altered diet on the 600 and 700 units did not receive the correct amount of meat for lunch on 8/16/23. The DM and the RD said the residents on a pureed diet on the 600, 700 and 900 units did receive the correct amount of vegetables or meat for lunch on 8/16/23. The DM said the facility typically did not serve french fries, since they did not have a deep fat fryer in the oven. The DM said the facility switched french fries for tater tots at dinner on 8/15/23. The DM said they did not have a process in place to notify residents of menu changes. The DM said he would educate the dietary staff on the process of utilizing the substitution log.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review the facility failed to store, prepare, distribute, and serve food in a sanitary manner in the main kitchen, the north serving kitchen and four out of four nourishment rooms. Specifically, the facility failed to: -Ensure food was labeled and dated and disposed of timely in the walk-in refrigerators, dry storage and reach-in refrigerator in the main kitchen and in four nourishment rooms; -Ensure the main kitchen and four unit nourishment rooms were clean and sanitary; -Ensure garbage was covered and disposed of in the main kitchen; -Ensure appropriate hand hygiene when staff were assisting residents with meals; -Ensure temperatures were taken of refrigerators in the main kitchens and the nourishment rooms; -Have a system in place to monitor the internal temperature of the dishwasher to ensure the functioning of the dishwasher; -Ensure the food delivery order was put away timely and not stored on the ground; and, -Ensure cooked food items were monitored and cooled properly. Findings include: I. Ensure food was labeled and dated and disposed of timely in the walk-in refrigerators, dry storage and reach-in refrigerator in the main kitchen and in four nourishment rooms A. Professional reference The Colorado Department of Public Health and Environment (2019) The Colorado Retail Food Establishment Rules and Regulations, retrieved from: https://www.colorado.gov/pacific/sites/default/files/DEHS_RetailFd_6CCR10102_RFFC_EffJan2019.pdf. It revealed in pertinent part, A date marking system that meets the criteria stated in (1) and (2) is of this section may include: Using a method approved by the Department for refrigerated, ready-to eat potentially hazardous food (time/temperature control for safety food) that is frequently rewrapped, such as lunch meat or a roast, or for which date marking is impractical, such as soft serve mix or milk in a dispensing machine; Marking the date or day of preparation, with a procedure to discard the food on or before the last date or day by which the food must be consumed on the premises, sold, or discarded as specified in (a) of this section; Marking the date or day the original container is opened in a food establishment, with a procedure to discard the food on or before the last date or day by which the food must be consumed on the premises, sold, or discarded as specified in (b) of this section; or Using calendar dates, days of the week, color-coded marks, or other effective marking methods, provided that the marking system is disclosed to the Department upon request. The day or date marked by the food establishment may not exceed a manufacturer's use-by-date if the manufacturer determined the use-by date based on food safety. (Retrieved 8/22/23). The Hormel Code Date and Handling Information 2022, retrieved from https://www.hormelhealthlabs.com/wp-content/uploads/HHL-Code-Date_Handling-Sheet-11_2022.pdf. It revealed in pertinent part, Hormel Vital Cuisine Might Shakes, Great Shake Plus, and Nutritious Juice Drink, Shelf Life: unopened: 15 months frozen, refrigerated: 14 days thawed, bedside: up to two hours. B. Facility policy and procedure The Food Handling policy, dated 5/1/23, was provided by the nursing home administrator (NHA) on 8/17/23 at 1:15 p.m. It revealed in pertinent part, Foods that are marked with the manufacturer's 'use by' date that are properly stored can be used until that date as long as the product has not been combined with any other food or prepared in any way including portioning. Once a product has been prepared or portioned, a new 'use by' date is established. The Guidelines for Food Brought in For Individual Patients/Residents policy, dated 5/1/23, was provided by the NHA on 8/17/23 at 1:15 p.m. it revealed in pertinent part, Food may be stored in refrigerators outside of the Food and Nutrition Services Department on the nursing unit. Food items that require refrigeration must be labeled with patient's/resident's name and date the food was brought in. The Guidelines for Food Brought in For Individual Patients/Residents policy, dated 5/1/23, was provided by the NHA on 8/17/23 at 1:15 p.m. It revealed in pertinent part, Food considered unsafe for consumption or beyond the expiration date will be discarded by staff upon notification to patient/resident. Food will be held in refrigerator for three days following date on label and will be discarded by staff upon notification to patient/resident. C. Observations During the initial kitchen tour on 8/14/23 at 9:09 a.m. the following was observed: -In the main walk-in refrigerator, there were three opened bags of mixed salad that were undated and unlabeled. -In the reach-in refrigerator, there was an opened bag of mozzarella cheese without a label or date. During a continuous observation on 8/16/23 beginning at 11:26 a.m. and ended at 1:06 p.m. the following was observed: -In the reach-in drink refrigerator, there was an opened container of thickened water that expired on 4/20/23 and two containers of thickened cranberry juice that expired on 7/22/23. -In the main walk-in refrigerator, there was a container of italian dressing that did not have a label, a metal bowl of prepared egg salad that was labeled 10/16, a large piece of pork that did not have a label or date on it. -In the main kitchen, the cereal dispensers that had [NAME] Krispies, Cheerios and Corn Flakes were not labeled or dated. A pitcher that had Raisin Bran in it was left open to air and did not have a label or date. -In the reach-in refrigerator, there was a package of opened hot dogs without a label or date, four hard boiled eggs sitting in liquid with no label or date, two half gallon jugs of lemon juice that expired on 6/9/23, an opened bag of mozzarella cheese that did not have a label and the manufacture date was rubbed off, a packaged of sliced cheese wrapped in plastic wrap with no label or date and appeared to be slightly melted and another packaged of sliced cheese wrapped in plastic wrap with no label or date. On 8/16/23 at 2:29 p.m. the following was observed in the main kitchen: -In the reach-in refrigerator, there was a package of opened hot dogs without a label or date, four hard boiled eggs sitting in liquid with no label or date, two half gallon jugs of lemon juice that expired on 6/9/23, an opened bag of mozzarella cheese that did not have a label and the manufacture date was rubbed off, a packaged of sliced cheese wrapped in plastic wrap with no label or date and appeared to be slightly melted and another packaged of sliced cheese wrapped in plastic wrap with no label or date. The dietary manager (DM) disposed of the hard boiled eggs, two half gallon jugs of lemon juice, the melted sliced cheese and wrapped and labeled the other package of sliced cheese. -In the main walk-in refrigerator, the DM said the pork did not have a pull-date, use-by date or have a label for what it was. The DM said he would label the pork. The DM said the pork came in thawed last week. On 8/16/23 at 2:45 p.m. on the 600 unit the following was observed: -On the snack and beverage cart there were containers of snacks including pretzels and cookies that were packaged by the facility. The snacks did not have a label or date. The DM said he would educate the staff on labeling the individual containers of snacks. -In the nourishment room refrigerator there were two thawed nutritional shakes that did not have a pull-date. On 8/16/23 at 2:48 p.m. in the north unit serving kitchen the following was observed: -In the reach-in refrigerator, there was a gallon of milk that expired on 8/10/23 and four thawed nutritional shakes that did not have a pull date. On 8/16/23 at 2:53 p.m. in the north unit nourishment room the following was observed: -In the freezer, there was a frozen pizza with no date, two bags of opened burritos with no open date and two popsicles with no label or date. -In the refrigerator, there were two individual containers of tartar sauce that were not labeled, a rotten radish in a reusable grocery bag that was soaked in liquid, three nutritional shakes, four jugs of coffee creamer without an open date, three individual containers of thickened juice that expired on 7/27/23, two bags of take-out Chinese food that was not labeled or dated, three boxes of [NAME] probiotic pouches that expired on 4/12/23, two boxes of [NAME] probiotic pouches that expired on 4/8/23, an opened container of thickened apple juice that expired on 5/25/23, a plate of cottage cheese and fruit that was not labeled or dated, a jug of soda that was not labeled or dated, a cheese and meat stick that expired on 12/16/22, two opened containers of thickened juice that expired on 7/27/23, a togo container of Mexican rice dated 8/8/23, a container of cranberry juice that expired on 4/4/23, an opened container of cranberry juice that expired on 4/4/23 and an opened container of thickened apple juice that expired on 5/25/23. -The refrigerator was 50ºF (degrees fahrenheit). -At the nurses station there was a container of water with three nutritional shakes with no pull-date. The DM disposed of the tartar sauce, thickened beverages, Chinese food, nutritional shakes, Mexican rice, cottage cheese and fruit plate, meat and cheese stick and the jug of soda. The DM placed the expired Gtuz probiotic pouches and placed them on the counter in the nourishment room. On 8/16/23 at 3:23 p.m. in the 900 unit nourishment room the following was observed: -In the refrigerator, there was an opened container of thickened cranberry juice with no date. -In the freezer, there was a bag of frozen wontons with ice build-up with no label or date and a container of unidentifiable frozen food with no label or date. -In the cupboards, there was a loaf of bread that expired on 8/1/23, a loaf of bread that expired on 8/5/23 and a loaf of bread that expired on 8/10/23, a container of prepackaged crackers with no use-by date and a container of instant coffee that expired on 4/6/23. -The DM disposed of the thickened cranberry juice, the frozen wontons, unidentifiable frozen food and the loaves of bread. On 8/17/23 on the north unit nursing station the following was observed: -At 11:20 a.m. five boxes of [NAME] probiotic pouches remained on the counter. The DM placed them on the counter on 8/16/23. -At 2:07 p.m. there were four nutritional shakes that were thawed and in a pool of water on the nurses desk. The shakes did not have a pull date on them. D. Staff interviews The NHA was interviewed on 8/16/23 at 3:42 p.m. The NHA said the north, 600, 700 and 900 units needed a better system in place to ensure temperatures were being taken regularly from the refrigerators. The NHA said some nourishment rooms had temperature logs, but had several missing days. The NHA said he was unable to decipher what temperatures were taken when. The DM was interviewed on 8/17/23 at 11:59 a.m. The DM said all foods should be labeled with an open date and a use-by date. The DM said all foods should be discarded when they are past their expiration date. The DM said the nursing department would need to provide education to the nursing staff on how to label and date foods properly in the nourishment room refrigerators. Dietary aide (DA) #1 was interviewed on 8/17/23 at 2:07 p.m. DA #1 said he was provided training on 8/16/23 regarding labeling and dating of foods. DA #1 said all foods should be labeled with the open date and the use-by date. DA #1 said whoever opened the item was responsible for labeling and dating it. The infection preventionist (IP) was interviewed on 8/17/23 at 4:42 p.m. The IP said it was very important to ensure foods were labeled and dated correctly. The IP said expired foods should be disposed of timely. II. Ensure the main kitchen and four unit nourishment rooms were clean and sanitary A. Professional reference The Colorado Department of Public Health and Environment (2019) The Colorado Retail Food Establishment Rules and Regulations, https://drive.google.com/file/d/18-uo0wlxj9xvOoT6Ai4x6ZMYIiuu2v1G/view Revealed in pertinent part, Equipment food-contact surfaces and utensils shall be clean to sight and touch. The food-contact surfaces of cooking equipment and pans shall be kept free of encrusted grease deposits and other soil accumulations. Non food contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris. Non food-contact surfaces of equipment shall be cleaned at a frequency necessary to preclude accumulation of soil residues. (Retrieved 8/22/23) B. Observations During the initial kitchen tour on 8/14/23 at 9:09 a.m. the following was observed: -The reach-in drink refrigerator had a red sticky substance on the bottom. -The toaster was covered in crumbs and burnt toast. During a continuous observation on 8/16/23 beginning at 11:26 a.m. and ended at 1:06 p.m. the following was observed: -In the reach-in refrigerator, the bottom of the refrigerator was covered in a red sticky substance. -Behind the three compartment sink, the white pipe had black build-up on it. -Underneath the coffee maker there was a container of pre packaged condiments that had liquid coffee and coffee grounds spilt in it. -The counter that had the coffee maker and cereal dispenser had coffee grounds, trash and cereal spilt all over the counter. Underneath the table the floor was sticky and had dirty dishes and trash underneath it. -The toaster had pieces of burnt toast in it and had several pieces of bread open to air around the toaster and spilling onto the steam table. The toaster had bread crumbs in it. On 8/16/23 at 2:31 p.m. the DM said the table with the coffee and the cereal dispensers was dirty and needed to be cleaned and said the toaster and the surrounding area were dirty and needed to be cleaned. On 8/16/23 at 2:48 p.m. in the north unit serving kitchen the following was observed: -The reach-in refrigerator had a wet broken box of individual packaged margrines. On 8/16/23 at 2:53 p.m. in the north unit nourishment room the following was observed: -The freezer had sticky pink and orange substances. -The refrigerator had a towel that was soaked in liquid. Liquid was dripping out of the refrigerator. There was a reusable grocery bag and three cartons of beverages that were soaked in the liquid. On 8/16/23 at 3:13 p.m. in the 700 unit serving kitchen the following was observed: -The refrigerator and freezer had spilled food debris in them. The DM said both the refrigerator and the freezer need to be cleaned. On 9/16/23 at 3:23 p.m. in the 900 unit nourishment room the following was observed: -There was spilled food debris in the refrigerator. C. Staff interviews The NHA was interviewed on 8/16/23 at 3:42 p.m. The NHA said the nourishment rooms were dirty and needed a lot of attention. The DM was interviewed on 8/17/23 at 11:59 a.m. The DM said he was unsure of who was responsible for cleaning the nourishment room refrigerators. The DM said the main kitchen should be cleaned regularly. The DM said the hoods and ovens should be free from grease. The DM said the floors should be clean and free from debris. The DM acknowledged the kitchen needed to be thoroughly cleaned. The IP was interviewed on 8/17/23 at 4:42 p.m. The IP said the kitchen and nourishment rooms should be clean and sanitary to prevent cross contamination. The director of nursing (DON) was interviewed on 8/17/23 at 6:46 p.m. The DON said she was unsure who was responsible for ensuring the nourishment rooms were clean and sanitary. III. Ensure garbage was covered and disposed of in the main kitchen A. Professional reference The Colorado Department of Public Health and Environment (2019) The Colorado Retail Food Establishment Rules and Regulations, https://www.colorado.gov/pacific/sites/default/files/DEHS_RetailFd_6CCR10102_RFFC_EffJan2019.pdf. It read in pertinent part, -Receptacles and waste handling units for refuse, recyclables, and returnables and for use with materials containing food residue shall be durable, cleanable, insect- and rodent-resistant, leak-proof, and nonabsorbent. -Receptacles and waste handling units for refuse, recyclables, and returnables shall be kept covered: Inside the food establishment if the receptacles and units contain food residue and after they are filled. (Retrieved 8/22/23) B. Observations During a continuous observation on 8/16/23 beginning at 11:26 a.m. and ended at 1:06 p.m. the following was observed: -Next to the table that had the coffee maker and cereal dispenser, there were two empty boxes of juice on the ground. -Next to the preparation table in the main kitchen, there was a trash can that did not have a lid and was full. DA #2 was transferring cooked potatoes next to the full trash can. On 8/16/23 at 2:29 p.m. the following was observed in the main kitchen: -The trash can next to the preparation table was still full. The DM said he would order lids for all of the trash cans in the main kitchen. C. Staff interviews The DM was interviewed on 8/17/23 at 11:59 a.m. The DM said the trash cans in the main kitchen did not have lids. The DM said the trash can was full and close to a food preparation table. The DM said he would get with the maintenance director and order lids for the trash cans, because he was unable to locate them within the facility. IV. Ensure appropriate hand hygiene when assisting residents with meals A. Professional reference The Colorado Retail Food Establishment Rules and Regulations revised January 2019, read in pertinent part, Employees prevent bare hand contact with ready-to-eat food by properly using suitable utensils such as deli tissue, spatulas, tongs, single-use gloves, or dispensing equipment. If used, single-use gloves shall be used for only one task, such as working with ready-to-eat food. Single-use gloves shall be used for no other purpose, and discarded when damaged, when interruptions occur in the operation, or when the task is completed. Food employees shall clean their hands and exposed portions of their arms immediately before engaging in food preparation including working with exposed food, clean equipment and utensils, and unwrapped single-service and single-use articles and before handling or putting on single-use gloves for working with food, and between removing soiled gloves and putting on clean gloves. (Retrieved 8/23/23) B. Observations During a continuous observation on 8/15/23 starting at 5:04 p.m. and ended at 5:55 p.m. the following was observed: -At 5:15 p.m. the first meal was delivered to a resident. -At 5:36 p.m. two residents sitting next to each other were served their meals. -Certified nurse aide (CNA) #5 assisted the resident on her left in cutting her sandwich. CNA #5 handed the spoon to the resident. CNA #5 sat down and began using her right hand to help feed the resident on her right. CNA #5 then used her right hand to help the resident with her meal on her left without performing hand hygiene. CNA #5 assisted a resident on her left with another bite and then assisted the resident on her right with a bite. -CNA #5 got up and assisted another resident in the dining room and then sanitized her hands and sat back down. -CNA #5 went back to helping the resident on her right with her right hand and then used her right hand to assist the resident on her left. CNA #5 assisted the resident on her right with another bite using her right hand and the resident on her left with her right hand. She did not perform hand hygiene between residents. -At 5:48 p.m. CNA #5 continued to assist both residents using her right hand and not performing hand hygiene between residents. During a continuous observation on 8/16/23 beginning at 11:26 a.m. and ended at 5:55 p.m. the following was observed: -At 11:59 p.m. DA #2 had gloves on. She was using her hands and a spatula to scoop potatoes off a cookie sheet and into a pan. DA #2 dropped a pair of tongs onto the floor. DA #2 picked the tongs up and put them with the dirty dishes. DA #2 did not perform hand hygiene or change her gloves and went back to scooping the potatoes into the pan. On 8/16/23 at 1:13 pm. registered nurse (RN) #8 was walking around the north dining room assisting, cueing and encouraging several residents. RN #8 did not perform hand hygiene between residents. C. Staff interviews CNA #9 was interviewed on 8/17/23 at 11:17 a.m. CNA #9 said hand hygiene should be performed frequently in the dining room. CNA #9 said residents should be assisted with eating one at a time. Licensed practical nurse (LPN) #4 was interviewed on 8/17/23 at 11:24 a.m. LPN #4 said hand hygiene should be conducted upon entering the dining room. LPN #4 said only one resident should be assisted with eating at a time. The DM was interviewed on 8/17/23 at 11:59 a.m. The DM said staff should wash their hands between all tasks. The DM said staff should wash their hands after assisting a resident and before assisting another resident. The IP was interviewed on 8/17/23 at 4:42 p.m. The IP said hand hygiene should be conducted when entering the dining room. The IP said staff should only assist one resident at time with eating. The IP said hand hygiene should be performed after assisting a resident. The IP said a staff member should not use the same hand to assist two residents at the same time without performing hand hygiene between the two residents. The DON was interviewed on 8/17/23 at 6:29 p.m. The DON said staff should perform hand hygiene before and after assisting a resident in the dining room. The DON said staff members should only assist one resident with eating at a time. V. Ensure temperatures were taken of refrigerators in the main kitchens and the nourishment rooms A. Professional reference The Colorado Retail Food Establishment Rules and Regulations, revised January 2019, Each mechanically refrigerated food storage unit storing potentially hazardous food (time/temperature control for safety food) shall be provided with a numerically scaled indicating temperature measuring device. -Time/temperature control for safety of food prepared and held in a food establishment for more than 24 hours shall be clearly marked to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded when held at a temperature of 41º (degrees) F (Farenheit) or less for a maximum of 7 days. The day of preparation shall be counted as Day 1. The day or date marked by the food establishment may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on food safety. -In a mechanically refrigerated storage unit, the sensor of a temperature measuring device shall be located to measure the air temperature or a simulated product temperature in the warmest part of a mechanically refrigerated unit. (Retrieved 8/22/23) B. Observations During the initial kitchen tour on 8/14/23 at 9:09 a.m. the following was observed: -The logs for two refrigerators in the main kitchen had several missing temperatures. The registered dietitian (RD) said the temperatures should be taken three times a day. The RD said multiple days were missing temperature monitoring. On 8/16/23 at 2:48 p.m. in the north unit serving kitchen the following was observed: -The DM said there was not a temperature log for the reach-in refrigerator or the chest freezer. -At 2:48 p.m. the temperature in the refrigerator was 50º C. Record review A request was made for the documented temperature logs for the nourishment room refrigerators on 8/16/23. The NHA said the temperature logs were not organized and he was unable to decipher what the logs meant (see interview below). D. Staff interviews On 8/16/23 at 3:23 p.m. RN #4 said she worked on the 900 unit. RN #4 said they did not take the temperatures of the dining room refrigerator. The NHA was interviewed on 8/16/23 at 3:42 p.m. The NHA said there was not a system in place that determined who was responsible for labeling and dating resident's food, cleaning the refrigerators and monitoring the temperatures. The RD and the DM were interviewed on 8/17/23 at 11:59 a.m. The DM said the nursing department was responsible for monitoring the temperatures of the nourishment room refrigerators. The DM said all refrigerators in the main kitchen and in the nourishment rooms should be monitored twice a day for the temperature. The DM said the temperature should be documented on a log. The IP was interviewed on 8/17/23 at 4:42 p.m. The IP said the nourishment room refrigerators should be checked regularly to ensure the temperature was within the correct limit. The DON was interviewed on 8/17/23 at 6:46 p.m. The DON said she was unsure of which department was responsible for monitoring and documenting the temperature of the nourishment room refrigerators. VI. Have a system in place to monitor the internal temperature of the dishwasher to ensure the functioning of the dishwasher A. Professional reference According to the Food and Drug Administration Food Code (2022) https://www.fda.gov/media/164194/download?attachment read in pertinent part, Water temperature is critical to sanitization in warewashing operations. This is particularly true if the sanitizer being used is hot water. A temperature measuring device is essential to monitor manual warewashing and ensure sanitization. Effective mechanical hot water sanitization occurs when the surface temperatures of utensils passing through the warewashing machine meet or exceed the required 160°F (Fahrenheit). Parameters such as water temperature, rinse pressure, and time determine whether the appropriate surface temperature is achieved. Although the Food Code requires integral temperature measuring devices and a pressure gauge for hot water mechanical warewashers, the measurements displayed by these devices may not always be sufficient to determine that the surface temperatures of utensils are reaching 160°). The regular use of irreversible registering temperature indicators provides a simple method to verify that the hot water mechanical sanitizing operation is effective in achieving a utensil surface temperature of 160ºF. (Retrieved 8/22/23) B. Record review A request was made for the dish machine temperature log on 8/14/23. DA #4 said the facility did not utilize temperature logs (see interview below). C. Staff interviews DA #4 was interviewed on 8/14/23 at 9:15 a.m. DA #4 said the dishwasher was a high temperature dishwasher. She said the facility did not have logs to document the temperature of the dishwasher on a regular basis. DA #4 said the temperature gauge on the outside of the machine was difficult to read. DA #4 said she was not aware of a device to take the temperature of the inside of the machine. DA #4 said the dish machine was on its last leg and she was unsure how to test it to ensure it was working properly. The RD was interviewed on 8/14/23 at 9:17 a.m. The RD said the facility did not have a waterproof thermometer or test strips to test the internal temperature of the machine. The DM was interviewed on 8/17/23 at 11:59 a.m. The DM said they did not have a mechanism to ensure the internal temperature of the dishwasher was functioning appropriately. The DM said he would order a thermometer to check the internal temperature of the dishwasher. The DM said he would provide education to the dietary staff on how to take the internal temperature of the dishwasher and where to document it. The DM said the dishwashing monitor log was typically hung on a nail in the dishwashing room. The DM said the nail broke that held the clipboard for the dishwashing monitor log and the clipboard was moved to a different spot. The DM said the staff that was present during the initial kitchen tour did not know where the dishwashing monitor log had been moved to since the nail broke. The DM was interviewed on 8/16/23 at 2:29 p.m. The DM said the dishwasher was old and needed to be replaced. The DM said he had bids out to two separate companies to replace the dishwasher. The DM said the facility needed to be testing the internal temperature of the dishwasher with another device to ensure it was working properly. The NHA was interviewed on 8/16/23 at 3:42 p.m. The NHA said he would help the DM order a new dish machine and ensure the kitchen was adequately stocked with items to check the functioning of the dishmachine. The IP was interviewed on 8/17/23 at 4:42 p.m. The IP said there should be a system in place to ensure the dishwasher was working properly. VII. Ensure the food delivery order was put away timely and not stored on the ground A. Professional reference The Colorado Department of Public Health and Environment (2019) The Colorado Retail Food Establishment Rules and Regulations, https://www.colorado.gov/pacific/sites/default/files/DEHS_RetailFd_6CCR10102_RFFC_EffJan2019.pdf. It revealed in pertinent part, Employees are visibly observing foods as they are received to determine that they are from approved sources, delivered at the required temperature,s protected from contamination, unadulterated, and accurately presented, by routined monitoring the employees observations and periodically evaluating the foods upon their receipt. Employees are verifying that foods delivered to the food establishment during non-operating hours are from approved sources and are placed into appropriate storage location such that they are maintained at the required temperatures, protected from contamination, unadulterated, and accurately presented. Time/temperature control for safety food shall be at a temperature of 41F (degrees fahrenheit) or below when received. Food shall be protected from contamination by storing the food, in a clean dry location, where it is not exposed to splash, dust or other contamination and at least 15 centimeters (six inches) above the floor. (Retrieved 8/22/23) B. Observations During a continuous observation on 8/16/23 beginning at 11:26 a.m. and ended at 1:06 p.m. the following was observed: -At 11:26 a.m. in the main kitchen, dry goods were stored directly on the ground. -At 11:30 a.m. in the preparation room the cold food from the delivery was stored directly on the ground at room temperature. -At 11:45 a.m. the DM said the food delivery was delivered around 9:00 a.m. and was put directly onto the floor. -At 11:48 p.m. the DM took the temperature of the bucket of hard boiled eggs that was delivered at 9:00 a.m. and had not been refrigerated. The temperature was 50.7º F. C. Staff interviews The DM was interviewed on 8/17/23 at 11:59 a.m. The DM said the food delivery was often delivered at different times each week. The DM said the food delivery should be put away within two hours. The DM said the food delivery should have been put away more timely and not stored on the floor. The DM said food should not be stored on the floor and should be stored on a palate until it can be properly put away on the shelves. The IP was interviewed on 8/17/23 at 4:42 p.m. The IP said food should be put away timely and food should never be stored on the ground. VIII. Ensure cooked food items were monitored and cooled properly 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.<[TRUNCATED]

Based on record review and staff interviews, the facility failed to conduct and document a facility-wide assessment to determine what resources are necessary to care for its residents competently during both day-to-day operations and emergencies. Specifically, the facility failed to develop a facility assessment which included all resources, staff education, staff competencies and facility based risk assessments. Findings include: I. Facility policy and procedure The facility assessment policy, dated October 2018, was provided by the nursing home administrator (NHA) on 9/5/23 at 2:29 p.m. It revealed in pertinent part, A facility assessment is conducted annually to determine and update our capacity to meet the needs of and competently care for our residents during day-to-day operations. Determining our capacity to meet the needs of and care for our residents during emergencies is included in this assessment. Once a year, and as needed, a designated team conducts a facility wide-assessment to ensure that the resources are available to meet the specific needs of our residents. The facility assessment includes a detailed review of the resident population. The facility assessment also includes a detailed review of the resources available to meet the needs of the resident population. The facility assessment is intended to help our facility plan for and respond to changes in the needs of our resident population and helps to determine budget, staffing, training, equipment and supplies needed. It is separate from the Quality Assurance and Performance Improvement evaluation. II. Record review The facility assessment was last reviewed on 6/7/23 by the previous NHA and the interdisciplinary team. The facility assessment failed to include the following: -Include staff competencies that were necessary to provide the level and types of care needed for the resident population or include the staff training program to ensure any training needs are met for all new and existing staff; -Include staff trainings/education necessary to provide the level and types of support and care needed for the resident population; -Identify facility resources needed to provide competent resident support during day to day operations and emergencies; -Include the facility-based and community-based risk assessment, utilizing an all-hazards approach. III. Staff interviews The NHA was interviewed on 9/5/23 at 12:33 p.m. The NHA said the previous NHA and the interdisciplinary team developed the facility assessment. The NHA said the facilities interdisciplinary team was new. The NHA reviewed the facility assessment and confirmed the assessment did not have specific training staff needed to help the residents at the facility. The NHA said the assessment did not include a facility-based risk hazard approach. The NHA confirmed after review the assessment did not include, all of the resources which the facility utilized were on the facility assessment or direction where the contracts were maintained. The NHA said the interdisciplinary team and himself would review the facility assessment and create a new one. The NHA said the current facility assessment was missing several pieces and was more of a shell to create a facility assessment.

Based on interviews and record review, the facility failed to ensure an effective quality assurance program to identify and address facility compliance concerns was implemented, in order to facilitate improvement in the lives of nursing home residents, through continuous attention to quality of care, quality of life and resident safety. Specifically, the quality assurance performance improvement (QAPI) program committee failed to develop and implement effective action plans to address repeat deficiencies and ensure systemic and lasting improvement for quality of care issues. Findings include: I. Facility policy The Quality Assurance Process Improvement Program (QAPI) policy, revised March 2020, was received from the nursing home administrator (NHA) on 11/9/23 at 8:57 a.m. The policy documented in pertinent part, The QAPI program, overseen by the QAPI committee is designed to identify and address quality deficiencies through the analysis of the underlying cause and actions targeted at correcting systems at a comprehensive level. The methodology for analysis and action is guided by a written QAPI plan that includes: Definition of the problem, based on information obtained through data, self-assessment and feedback systems. An analysis of the root cause of the problem from a systems perspective. Establishing measurable goals or benchmarks for improvement. Specific interventions aimed at correcting the problem and achieving the stated goals or benchmarks. Methods and frequency of monitoring performance improvement objectives. The QAPI committee is responsible for analyzing identified problems, establishing corrective actions, measuring progress against the established goals and benchmarks, communicating information to staff and residents, and reporting findings to the Administrator and governing board. II. Cross-referenced citations Cross-reference F565: The facility failed to follow up on resident grievances reported during group meetings regarding food. Cross-reference F658: The facility failed to follow professional standards of practice regarding storing medications poured into medication cups in the medication cart. Cross-reference F838: The facility failed to develop a comprehensive facility assessment which included all resources, education, competency and training for staff and facility and community risk assessments. Cross-reference F880: The facility failed to implement practices to help prevent the possible development and transmission of Coronavirus (COVID-19). III. Review of the facility's regulatory record revealed it failed to operate a QAPI program in a manner to prevent repeat deficiencies and initiate a plan to correct. F565 Grievances During the recertification survey on 9/5/23, F565 was cited at an E scope and severity. During the revisit survey on 11/7/23, the facility was cited at an E scope and severity. F658 Professional standards During the recertification survey on 9/5/23, F565 was cited at a D scope and severity. During the revisit survey on 11/7/23, the facility was cited at a D scope and severity. F838 Facility Assessment During the recertification survey on 9/5/23, F565 was cited at a F scope and severity. During the revisit survey on 11/7/23, the facility was cited at a F scope and severity. F880 Infection Control During the recertification survey on 9/5/23, F565 was cited at a D scope and severity. During the revisit survey on 11/7/23, the facility was cited at an E scope and severity. IV. Interviews The assistant director of nursing (ADON) was interviewed on 11/2/23 at 10:01 a.m. He said the director of nursing (DON) and NHA were not in the facility and he was in charge. The ADON said he knew there were a number of items missing from the facility's binders with corrective action. He said the QAPI committee had reviewed what had been cited on 9/5/23 but not in detail. The NHA was interviewed via phone on 11/2/23 at 11:36 a.m. He said he knew the facility binders with proof of corrective action were missing items. He said the staff would do what they could to find the information the facility had. The NHA was interviewed again on 11/7/23 at approximately 3:00 p.m. He said the QAPI committee had reviewed what had been cited on the 9/5/23 survey in general but had not looked at the details of each citation and whether corrective action was implemented. The NHA said some of the leadership team members were new and that could have been why there were gaps in corrective activity for the previous citations. He said the facility should have assigned alternate team members to ensure deficiency corrections were ongoing during any staff position transition gap. He said he trusted many corrections were being completed without verifying for himself they were done. The NHA said there were many training opportunities and knowledge gaps, including infection control.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure a Preadmission Screening and Resident Review (PASARR) Level I screening was completed within thirty days of admission for one (Resident #89) of one residents reviewed for PASARR. Findings included: A review of the facility policy, revised 01/15/2021, titled, Preadmission Screening for Mental Disorder and/or Intellectual Disability Patients, revealed, Purpose: To ensure that all individuals are screened for a MD [Mental Disorder] and/or ID [Intellectual Disability] prior to admission. A review of the Centers for Medicare and Medicaid (CMS) COVID-19 Emergency Declaration Blanket Waivers for Health Care Providers, updated 05/24/2021, revealed, Waive Pre-admission Screening and Annual Resident Review (PASARR). CMS is waiving 42 CFR 483.20 (k), allowing nursing homes to admit new residents who have not received Level 1 or Level 2 Preadmission Screening. Level 1 assessments may be performed post-admission. On or before the 30th day of admission, new patients admitted to the nursing homes with a mental illness (MI), or intellectual disability (ID) should be referred promptly by the nursing home to State PASARR program for Level 2 Resident Review. A review of Resident #89's admission Record revealed the resident was admitted to the facility on [DATE] with diagnoses that included bipolar disorder, major depressive disorder, anxiety, and post-traumatic stress disorder. A review of Resident #89's quarterly Minimum Data Set (MDS) assessment, dated 04/16/2022, revealed a Brief Interview for Mental Status (BIMS) score of 14 out of 15, indicating intact cognition. A review of Resident #89's care plan, dated 06/09/2022, revealed the resident met the PASARR Level II determination secondary to a diagnosis of serious mental illness, including bipolar disorder and major depressive disorder. A review of facility-provided undated and untitled list of PASARR notifications to state authorities revealed Resident #89's PASARR Level I screening was submitted on 05/09/2022. This was over four months since the resident's admission to the facility. An interview on 06/09/2022 at 3:12 PM with Social Worker (SW) #1 revealed she started at the facility in February 2022. SW #1 stated she had been playing catch up since then. SW #1 stated the PASARR was supposed to be done within a few weeks of admission but submitted Resident #89's towards the end of May 2022. During a follow up interview on 06/10/2022 at 10:08 AM, SW #1 stated she completed PASARR training in April 2022 and started doing PASARRs in May 2022. An interview on 06/10/2022 at 1:42 PM with the Director of Nursing (DON) revealed the DON did not participate in the PASARR process and that it was usually social services that handled PASARR. An interview on 06/10/2022 at 12:00 PM with the Administrator revealed there was a CMS waiver regarding PASARR. The Administrator stated they went a few months without a staff member that had access to the state system. It was the Administrator's understanding that each facility could only have one person with access. The Administrator stated in a perfect world they would always have someone with access.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. A review of Resident #32's admission Record revealed the facility admitted the resident on 02/28/2020 with diagnoses which included chronic obstructive pulmonary disease (COPD) and vascular dementia without behavioral disturbance. A review of Resident #32's annual Minimum Data Set (MDS), dated [DATE], indicated the resident was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 15 out of 15. A review of Resident #32's care plan, dated 03/21/2021, revealed the resident exhibited or was at risk for respiratory complications related to COPD, with goals that the resident would have no sign/symptoms of respiratory distress during this treatment period. The interventions included to monitor and report oxygen (O2) saturation levels via pulse oximetry as ordered and prn (pro re nata; as needed) and administer O2 as ordered via nasal cannula. Further review of Resident #32's care plan revealed no interventions addressing the resident changing oxygen settings. A review of Resident #32's physician's orders revealed an order dated 04/23/2022 for staff to administer oxygen at 4 liters per minute (LPM) via nasal cannula. A review of Resident #32's progress notes from 04/01/2022 through 06/06/2022 revealed no documentation related to the resident changing their oxygen settings. Observation of Resident #32 on 06/06/2022 at 2:17 PM revealed the resident reclined in bed with his/her oxygen set at 4.5 LPM. An interview with Registered Nurse (RN) #3 on 06/07/2022 at 4:50 PM revealed she reviewed care plans routinely and reported any changes to the interdisciplinary team for discussion. An interview with Licensed Practical Nurse (LPN) #8 on 06/08/2022 at 11:05 AM revealed she checked oxygen concentrators to make sure the LPMs were correct, but stated the residents were bad about adjusting it themselves. LPN #8 stated Resident #32 may change the oxygen settings, but she had not personally seen the resident change them. She stated Resident #32's oxygen order was for 4 LPM. She noted this was a dementia unit and they had some residents who changed their concentrator settings, though she tried to educate them. LPN #8 stated she did not know if Resident #32 was care planned for this issue but, if not, it should be care planned. An interview with Certified Nursing Assistant (CNA) #5 on 06/09/2022 at 9:55 AM revealed Resident #32 would roll around in his/her wheelchair and change oxygen settings. Per CNA #5, in the past, the oxygen concentrator was next to the bed and Resident #32 would change it. CNA #5 stated now the resident could not reach it from the bed, but could reach it when the resident got up in the wheelchair. During an interview on 06/09/2022 at 10:02 AM, LPN #8 identified the risk of a resident changing his/her oxygen setting included the resident getting too much or too little oxygen. She stated the facility needed to care plan such an issue and provide education. LPN #8 stated she was not sure if care plan interventions had been developed to prevent Resident #32 from changing the settings on his/her oxygen concentrator. She stated she could make changes to a care plan, but she usually passed on any needed changes to the MDS Nurse. An interview with MDS RN #2 on 06/09/2022 at 10:20 AM revealed that, when a resident was admitted , a baseline care plan was completed and then the nurses on the floor updated the care plan with any changes. The MDS Nurse stated if revisions were mentioned to her, she updated the care plan, but noted it was the floor nurse's responsibility. She said she expected staff to document and inform nursing staff if a resident was changing the settings on their oxygen. She said the nurse could then add interventions and update the care plan. An interview with the Director of Nursing (DON) on 06/09/2022 at 2:29 PM revealed her expectation was for staff to make sure oxygen was on the resident at the correct setting based on physician orders. She stated she knew Resident #32 would remove their oxygen, walk to the bathroom, come back, and would turn up the oxygen settings because the resident was then out of breath. The DON stated the care plan should be updated about the resident changing their oxygen and include interventions to try to prevent it. The DON stated she expected staff to follow the care plan for each resident and report any changes immediately to the nurse, DON, or Administrator. Additionally, the DON stated she expected nursing staff to update and revise the care plan as needed. An interview with the Administrator on 06/09/2022 at 2:29 PM revealed that staff were to check oxygen concentrators and report any problems to a nurse. The Administrator stated it was the expectation for staff to make sure it was care planned to keep residents safe and try to prevent them from having any issues with their oxygen. During an interview on 06/10/2022 at 7:55 AM, the DON confirmed Resident #32 was not care planned related to the resident changing his/her oxygen settings. Based on record review, observation, interviews, and facility policy review, the facility failed to ensure care plans were revised for one (Resident #103) of three sampled residents with an indwelling urinary catheter and for one (Resident #32) of three sampled residents with a change in oxygen administration settings. Findings included: A review of the facility's policy and procedure, titled Person-Centered Care Plan, dated 11/28/2016, revealed, The interdisciplinary team, in conjunction with the patient and/or resident representative, as appropriate, will establish the expected goals and outcomes of care, the type, amount, frequency, and duration of care, and any other factors related to the effectiveness of the plan of care. The care plan will be reviewed and revised by the interdisciplinary team after each assessment. 1. A review of Resident #103's admission Record revealed the facility admitted the resident on 02/10/2022 with diagnoses of non-pressure chronic ulcer of the buttock limited to breakdown of skin, acute kidney failure, and anemia. A review of a quarterly Minimum Data Set (MDS), dated [DATE], revealed the resident was cognitively intact as evidenced by a Brief Interview for Mental Status score of 14 out of 15. The MDS identified Resident #103 was always incontinent of bowel and bladder. There was no notation of the use of an indwelling urinary catheter or any other bladder appliance in the MDS. A review of Resident #103's care plan, last revised on 06/07/2022, revealed no mention of the need for or the care of an indwelling urinary catheter. On 06/06/2022 at 10:08 AM, during an initial tour of the facility, the surveyor observed Resident #103 lying in bed with a urinary catheter drainage bag hanging on the side of the resident's bed. The resident reported he/she was not aware of the reason for the indwelling urinary catheter. A review of an Order Summary Report, dated 06/01/2022 through 06/30/2022, revealed no physician's order to initiate an indwelling urinary catheter. During an interview on 06/09/2022 at 12:08 PM, Certified Nursing Assistant (CNA) #1 indicated she was not aware of the date the indwelling urinary catheter was placed, but she thought it had been in place for a few weeks. She indicated she thought the hospital had returned the resident to the facility with the catheter in place and that the resident needed the catheter to stay dry. During an interview on 06/09/2022 at 12:09 PM, Registered Nurse (RN) #5 indicated the resident had been in the hospital with Clostridium Difficile (C. diff) from 04/12/2022 until the facility readmitted the resident on 04/18/2022. She indicated the nursing staff noted the resident to have skin irritation when he/she returned to the facility, and the indwelling urinary catheter had been placed for wound healing. During an interview on 06/10/2022 at 11:13 AM, the Director of Nursing (DON) indicated care plan revisions were the responsibility of all the nurses and the care plan should have been revised by the nurse placing the catheter, the unit manager, or the DON. During an interview on 06/10/2022 at 11:21 AM, the Administrator indicated she had a meeting last night with the staff, at which time the staff members were instructed that all care plans are to be revised and updated daily.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, record review, and review of the facility policy, the facility failed to provide appropriate treatment and care for 1 of 2 residents (Resident #96) with alterations in skin integrity. Specifically, Resident #96 had a rough patch of skin with open cracks in the skin that had not been identified by the facility. Findings included: A review of the facility policy titled, Skin Integrity Management, with a revision date of 06/01/2021, revealed, The implementation of an individual patient's [resident] skin integrity management occurs within the care delivery process. Staff continually observes and monitors patients for changes and implement revisions to the plan of care as needed .3. Identify patient's skin integrity status and need for prevention intervention or treatment modalities through review of all appropriate assessment information. 3.3 Perform wound observations and measurements and complete Skin Integrity Report (Forms on Demand (FOD) #GHC-692R) upon initial identification of altered skin integrity. A review of Resident #96's admission Record indicated the resident had diagnoses that included diabetes, obesity, acquired absence of right leg above knee, and a history of a pressure ulcer to the buttock. A review of Resident #96's quarterly Minimum Data Set (MDS), dated [DATE], revealed Resident #96 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition. The MDS indicated Resident #96 needed extensive assistance of two or more staff for bed mobility, toilet use, and personal hygiene. Further review of the MDS revealed the resident had frequent urine and bowel incontinence. According to the MDS, Resident #96 had no pressure ulcers at the time of the assessment but was at risk for developing pressure ulcers/injuries. A review of Resident #96's care plan revealed the facility revised the care plan on 04/29/2022 to address the resident's history of skin breakdown related to decreased activity, frail fragile skin, history of pressure ulcers, and impaired sensation. The goal for Resident #96 was not to show signs and symptoms of skin breakdown through the review period. The facility developed interventions that included applying a barrier cream with each cleansing; observing the resident's skin for signs/symptoms of skin breakdown i.e. (that is), redness, cracking, blistering, decreased sensation, and skin that does not blanch easily; evaluating for any localized skin problems i.e. dryness, redness, pustules, or inflammation; observing the resident's skin condition daily with activities of daily living (ADL) care and reporting abnormalities; and the licensed nurse would conduct a weekly skin check. A review of Skin Check forms for Resident #96, dated 05/31/2022 and 06/07/2022, indicated a skin check was conducted and the resident had no skin injury/wound(s). An interview with Resident #96 on 06/06/2022 at 2:54 PM indicated the sore on my butt is irritating. It's between my buttock and upper leg. During an interview on 06/08/2022 at 4:41 PM, Resident #96 stated that one of the nurses called the area a boil that had a head. According to Resident #96, staff were not conducting weekly skin assessments. The resident stated, Nobody is coming to check my skin once a week, that is not happening. An observation of Resident #96's skin on 06/08/2022 at 10:07 AM, after obtaining the resident's permission, revealed skin breakdown on the right ischium (just below the buttocks). The skin appeared to be open with a rough patch of skin that had open cracks in the skin. An interview with Certified Nursing Assistant (CNA) #3 during the observation revealed the nurse said it was a boil. An interview with CNA #3 on 06/08/2022 at 10:20 AM revealed when they identified skin breakdown, they usually reported to the resident's nurse and documented their findings in nurse aide charting. A review of Resident #96's Progress Notes from 06/03/2022 through 06/09/2022 at 6:24 PM revealed no documentation regarding the skin observation on 06/08/2022 at 10:07 AM. An interview with Licensed Practical Nurse (LPN) #7 on 06/08/2022 at 5:15 PM revealed the LPN was not aware Resident #96 had an open area. LPN #7 stated the CNAs had not reported any skin concerns for the resident. During a follow up interview at 5:39 PM, LPN #7 revealed she documented the skin assessment for Resident #96 on 05/31/2022. The LPN stated she remembered helping turn the resident and seeing the resident's buttocks. According to LPN #7, the resident had no redness to the buttocks at that time. On 06/09/2022 at 8:32 AM, an interview with CNA #3 revealed the open area observed on Resident #96 comes and goes and had been there every day. According to CNA #3, about one month ago, Resident #96 stated the area was irritated and asked for cream. The CNA stated a nurse practitioner assessed the area last week. CNA #3 stated she did not report the area to nursing staff on 06/08/2022, because nursing staff already knew it was there. On 06/09/2022 at 1:00 PM, an interview with LPN #6, the nurse who documented a skin assessment was completed for Resident #96 on 06/07/2022, revealed it was a quick skin check because the resident had an appointment that day and really wanted to get ready to go. LPN #6 stated she did not look thoroughly at the resident's buttocks. However, according to LPN #6, she had heard the wound team was following the resident for a boil in the resident's perineal area. On 06/09/2022 at 3:25 PM, a telephone interview conducted with Nurse Practitioner (NP) #1 revealed the week before, a staff member asked the NP to look at Resident #96's right buttock because they saw something that looked like a boil. NP #1 stated at that time, the area looked like a scar from an old chronic wound. A follow up interview with NP #1 on 06/10/2022 at 10:00 AM, after the NP had examined Resident #96's skin, revealed she observed an open area to the right inner buttock area that measured 1 centimeter (cm) long by 1 cm wide with redness measuring 5.0 cm long x 4.0 cm wide. NP #1 stated she believed the area was shearing or chronic irritation from wearing an incontinence brief (shearing is soft tissue damage). NP #1 stated the area had opened since she saw the area the week before. On 06/09/2022 at 2:57 PM, an interview conducted with the Director of Nursing (DON) revealed if a CNA observed an open area, her expectation was for the CNA to notify the nurse right away. The nurse should assess the wound, call the resident's doctor, notify the DON, and complete a change in condition report. In addition, the DON stated that if a resident had any kind of open area, the resident was seen on wound rounds; however, the DON stated she was not aware Resident #96 had an open area to the buttock.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, interviews, and policy review, the facility failed to ensure an indwelling urinary catheter was utilized with adequate justification for one (Resident #103) of three residents sampled with indwelling urinary catheters. Findings included: A review of the facility's policy and procedure, titled NSG209 Catheter: Urinary - Justification for Use, last revised on 03/01/2022, revealed: Patients who enter the Center without an indwelling catheter will not be catheterized unless the patient's clinical condition demonstrates that catheterization was necessary. Indwelling catheter criteria: Contamination of Stage III or IV wound with urine which has impeded healing despite appropriate personal care for the incontinence. Purpose .To ensure there is a valid medical justification for use of an indwelling catheter and that the catheter is discontinued as soon as clinically warranted. A review of Resident #103's admission Record revealed the facility admitted the resident on 02/10/2022 with diagnoses of non-pressure chronic ulcer of the buttock limited to breakdown of skin, acute kidney failure, and anemia. A review of a quarterly Minimum Data Set (MDS), dated [DATE], revealed the resident was cognitively intact as evidenced by a Brief Interview for Mental Status score of 14 out of 15. The MDS identified Resident #103 was always incontinent of bowel and bladder. There was no notation of the use of an indwelling urinary catheter or any other bladder appliance in the MDS. A review of physician's progress documentation, titled Acute Visit and dated 05/27/2022, revealed, Patient reports [he/she was] seen by wound doctor this week, that [the wound] is getting better, still with Foley [indwelling urinary] catheter because of the wound. A review of Resident #103's care plan, last revised on 06/07/2022, revealed no mention of the need for or the care of an indwelling urinary catheter. On 06/06/2022 at 10:08 AM, during an initial tour of the facility, the surveyor observed Resident #103 lying in bed with a urinary catheter drainage bag hanging on the side of the resident's bed. The resident reported he/she was not aware of the reason for the indwelling urinary catheter. A review of an Order Summary Report, dated 06/01/2022 through 06/30/2022, revealed no physician's order to initiate an indwelling urinary catheter. During an interview on 06/09/2022 at 12:08 PM, Certified Nursing Assistant (CNA) #1 indicated she was not aware of the date the indwelling urinary catheter was placed, but she thought it had been in place for a few weeks. She indicated she thought the hospital had returned the resident to the facility with the catheter in place and that the resident needed the catheter to stay dry. During an interview on 06/09/2022 at 12:09 PM, Registered Nurse (RN) #5 indicated the resident had been in the hospital with Clostridium Difficile (C. diff) from 04/12/2022 until the facility readmitted the resident on 04/18/2022. She indicated the nursing staff noted the resident to have skin irritation when he/she returned to the facility, and the indwelling urinary catheter had been placed for wound healing. RN #5 looked at Resident #103's physician's orders and was unable to find an order for the catheter. During an interview on 06/09/2022 at 12:20 PM, the Director of Nursing (DON) indicated she was not aware of facility staff having initiated Resident #103's indwelling urinary catheter. She indicated that RN #5 entered the physician's order for the indwelling urinary catheter that very day. During an interview on 06/09/2022 at 12:24 PM, RN #5 indicated that on 04/21/2022 she had received a verbal order from a physician to initiate the indwelling urinary catheter, and she had forgotten to enter the order into the computer on the day she received the order. Therefore, she entered the information into the computer that day, on 06/09/2022. During an interview on 06/10/2022 at 11:13 AM, the DON indicated the resident had been in the hospital for C. Diff, but she was not able to locate an acceptable reason for the use of the indwelling urinary catheter in the facility health record, and the facility would discontinue the catheter if it were determined that the resident did not need it. During an interview on 06/10/2022 at 11:21 AM, the Administrator indicated she expected the staff members to follow the policy and procedure pertaining to the placement/justification of all catheters.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, policy review, and record review, it was determined the facility failed to maintain an infection control program to help prevent the transmission of communicable diseases for two (Resident #154 and Resident #159) of 32 sampled residents. Observations revealed staff did not wear appropriate personal protective equipment (PPE) when entering the rooms of Resident #154 and Resident #159 and there was not appropriate signage posted on the residents' doors about infection prevention precautions. Findings included: Review of the policy titled, Infection Control Policies and Procedures, dated 06/07/2021, revealed, In addition to Standard Precautions, Contact and Airborne Precautions will be implemented for patients suspected or confirmed to have Covid19 based on the Centers for Disease Prevention and Control (CDC) guidance. For the purposes of this policy, Airborne Precautions is defined as wearing an N95/approved KN95 respirator upon entry into the patient's room, in addition to the recommended PPE, keeping the door to the patient's room closed, and no negative pressure room required. Purpose- To prevent the development and transmission of Covid19 .General Standard Precautions- Implement universal use of facemasks/respirators and eye protection while in the Center. Follow the Personal PPE: Use, Reuse, and Extended Use of PPE for All Healthcare Staff and Providers guidelines. Transmission Based Precautions: 12. For patients with an undiagnosed respiratory infection, staff follow Standard/Contact/Droplet Precautions (example-facemask, gloves, isolation gown) with eye protection when caring for a patient unless the suspected diagnosis requires Airborne Precautions. 1. A review of the admission record revealed the facility admitted Resident #159 on 05/17/2022. A review of Progress Notes revealed a nursing documentation note dated 06/08/2022 at 2:51 PM indicating the resident continued on isolation precautions due to positive COVID-19 results. A review of the care plan, dated 06/08/2022, revealed Resident #159 had a COVID-19 infection and interventions including patient-specific contact plus droplet precautions. Observations of Certified Nursing Assistant (CNA) #2, on 06/06/2022 at 9:30 AM, revealed the CNA entered Resident #159's room without wearing goggles or gloves. Continued observation revealed the resident's door did not have signage related to isolation precautions; however, a PPE cart was present. Interview with Licensed Practical Nurse (LPN) #6, on 06/06/2022 at 10:05 AM, revealed residents who were newly admitted to the facility went into about a 10-day isolation period, and these residents would have isolation carts outside of their doors. She stated staff would recognize a resident was in isolation from the presence of the cart. The LPN revealed she depended on the isolation carts outside of a resident's room in order to determine which residents were in isolation. An interview with CNA #2, on 06/10/2022 at 10:43 AM, revealed she was aware if an isolation cart was in front of a resident's door that it meant the resident was on isolation precautions. She revealed some of the resident's who were in isolation had signs on their doors, and others did not, primarily because the signs may fall. 2. A review of the admission record revealed the facility admitted Resident #154 on 06/02/2022 with a diagnosis of COVID-19. A review of Progress Notes revealed a general note dated and timed for 06/06/2022 at 10:30 AM by LPN #6, who documented that a physician assistant had seen the resident and decided to send the resident to a local hospital for evaluation due to worsening COVID-19 symptoms. An observation on 06/06/2022 at 10:45 AM revealed two Emergency Medical Technicians (EMTs) were in Resident #154's room with a stretcher. The resident was awake, alert, talkative, and coughing. An isolation cart was observed outside of the resident's room, however, there was no signage observed on his/her door related to isolation procedures. An interview on 06/06/2022 at 10:50 AM with EMT #1 revealed staff had informed him the resident was post-isolation due to COVID-19, but the resident was still having respiratory issues. Observation of Resident# 154's door on 06/06/2022, at 5:46 PM revealed the entrance door to the resident's room had no signage prompting the use of PPE or an isolation cart. A review of a History and Physical for Resident #154, dated 06/07/2022, revealed the resident had COVID-19 pneumonia and chronic obstructive pulmonary disease (COPD). Further review of the history and physical revealed the resident was reassessed in an emergency department on 06/06/2022 for respiratory distress and was ordered to receive antibiotics for seven days. The history and physical further noted that on 06/07/2022 a trial of dexamethasone for acute hypoxic respiratory failure due to COVID-19 was to be initiated. An interview on 06/07/2022 at 5:05 PM with Registered Nurse (RN) #1 revealed Resident #154 had returned to the facility on [DATE] with post-COVID-19 pneumonia with a worsened cough. RN #1 stated the resident had a difficult time being in quarantine and had more behaviors, described as the resident needed more attention and feedback. He stated he did not believe the resident should have remained in quarantine at this time. Observation on 06/07/2022 at 5:46 PM revealed Resident #154 was in bed in his/her room. Observation revealed a visitor was sitting in a chair in the resident's room without any form of PPE in place except a facial mask. A staff member was observed to leave the resident's room and wore only goggles and a mask. Continued observation revealed Resident #154 did not have signage on his/her door or a PPE cart outside the room. Interview with Family Member (FM) #1 on 06/07/2022 revealed he/she had only been required to wear a mask while visiting Resident #154. FM #1 stated he/she had not been asked by staff or required to don a gown or gloves in the past two and a half weeks while Resident #154 had been at the facility. An interview on 06/07/2022 at 9:16 AM with RN #6 and the Director of Nursing (DON) revealed that, on 06/06/2022, it was thought Resident #154 had experienced worsening symptoms of COVID-19. They agreed nursing staff would not have necessarily put the resident back into isolation if he/she remained behind the double doors of the unit. The DON and RN #6 also agreed that they did not know whether the resident should have been in isolation; however, when the resident came back into the facility, he/she should have been placed back into quarantine for at least seven days. They agreed an isolation cart and signage should be observed anytime a resident was in isolation. An interview on 06/10/2022 at 12:45 PM with the DON revealed staff needed to wear PPE appropriately as they entered an isolation room. She stated the facility did not want to put anyone in harm's way and the facility desired to protect staff, residents, and families. During the interview, she stated an ineffective infection control program could spread COVID-19. An interview with the Administrator on 06/10/2022 at 1:27 PM revealed she expected staff to follow the facility's infection control policies and procedures in order to protect staff and residents against cross-contamination. She went on to state isolation carts and signage helped educate staff regarding isolation precautions. She revealed the failure to follow infection control practices could result in infections within the building, and the elderly were a vulnerable group of people.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on document review, record review, observations, interviews, and facility policy review, the facility failed to prevent potential accidents by failing to: 1. ensure hot water temperatures were maintained at safe temperatures between 105 - 115 degrees Fahrenheit (F) in 1 (700 Hall; secured memory care unit) of 8 halls in the facility. 2. complete a smoking assessment for one (Resident #260) of one newly admitted residents who smoked tobacco products and required such an assessment prior to smoking. Findings included: 1. A review of a document titled, Direct Supply TELS, printed 06/10/2022, revealed, Water temps [temperatures]: test and log the hot water temperatures .Ensure patient room water temperatures are between 105 [degrees] and 115 [degrees] Fahrenheit. On 06/07/2022 at 9:39 AM, the hot water in the sink of room [ROOM NUMBER], room [ROOM NUMBER] and room [ROOM NUMBER] felt hot to the touch. The rooms were located on the secured memory unit. The temperature of the water in room [ROOM NUMBER] was checked with an uncalibrated thermometer and the temperature registered at 121.8 degrees F. On 06/07/2022 at 3:23 PM, Maintenance Staff (MS) #1 was asked to check the hot water temperatures on the 700 Hall and an interview was conducted at that time. MS#1 indicated he did not calibrate the thermometer he used. MS #1 then placed the tip of the thermometer in a cup of ice. The thermometer registered 34.5 degrees F. A sticker located on the handle of the thermometer indicated Extech Calibrated. It was dated 05/29/2020 and next due for calibration on 05/29/2021. On 06/07/2022 at 3:31 PM, MS #1 was observed to turn the hot water on in room [ROOM NUMBER]. At 3:35 PM, the hot water temperature registered 86.6 degrees F. On 06/07/2022 at 3:32 PM, the hot water in room [ROOM NUMBER] was turned on. At 3:37 PM, the water temperature registered 116.5 degrees F. On 06/07/2022 at 3:33 PM, the hot water in room [ROOM NUMBER] was turned on. At 3:39 PM, the water temperature registered 115.8 degrees F. On 06/07/2022 at 3:33 PM, the hot water in room [ROOM NUMBER] was turned on. At 3:40 PM, the water temperature registered 116.7 degrees F. MS #1 was interviewed on 06/07/2022 at 3:44 PM. MS #1 stated the water temperature should not be over 120 degrees F or less than 102 degrees F. MS #1 indicated they checked the water temperatures weekly. MS #1 indicated there were two maintenance staff who checked water temperatures. MS #1 stated he used the thermometer he was currently utilizing and his assistant used a different thermometer. The hot water temperature logs were reviewed for 04/15/2022. The logs indicated the water in room [ROOM NUMBER] was 136.0 degrees F, room [ROOM NUMBER] was 143.0 degrees F, and room [ROOM NUMBER] was 146.0 degrees F. The comments at the bottom of the form indicated, Turned down mixing valve. Temp [temperature] on mixing valve was extremely high. The temperature monitoring logs dated 04/22/2022, 05/13/2022, 05/21/2022, 05/30/2022 and 06/03/22 were reviewed. All temperatures were less than 120 degrees F, but there were several instances when the temperature was above 115 degrees F. On 06/08/2022 at 10:44 AM, MS #2 was asked to check the hot water temperatures on the 700 Hall. MS #2 was observed to calibrate the thermometer and the thermometer registered 32.1 degrees F. MS #2 was observed to check the hot water temperature in room [ROOM NUMBER]. The water registered 128.4 degrees F. MS #2 then went to the back and checked the temperature at the boiler. MS #2 returned at 11:05 AM and stated he and the other maintenance staff had stayed last night and put in new filters in the boiler system. He stated the mixing valve for the cold water was halfway open, so he had to open it all the way. At 11:06 AM, MS #2 continued to check hot water temperatures and obtained the following temperatures: - room [ROOM NUMBER] was 116.6 degrees F, - room [ROOM NUMBER] was 119.5 degrees F, - room [ROOM NUMBER] was 117.3 degrees F; and - The hot water in the shower room on the 700 Hall was 123.2 degrees F. At 11:16 AM, the hot water temperature was rechecked in room [ROOM NUMBER]. The temperature registered 109.6 degrees F. Facility incident reports were reviewed for the period of January 2022 until current. There were no incident reports of burns. 2. A review of an undated facility policy titled, [Facility Name] Smoking Policy, revealed, All Residents who choose to smoke are required to have a smoking evaluation. This will determine if supervision is required and re-evaluation on quarterly basis or with a change of condition. The policy also noted, Independent smoking will be on a case-by-case basis and No oxygen equipment is permitted within the designated smoking area. Per the policy, supervised smoking occurred under the direct supervision of staff or a family member. A review of Resident #260's undated admission Record revealed the resident was initially admitted to the facility on [DATE] and was readmitted to the facility on [DATE]. The resident's diagnoses included tobacco use, diabetes mellitus with diabetic nephropathy, weakness, unqualified right eye visual loss, and dependence on a wheelchair. A review of Resident #260's admission Minimum Data Set (MDS), dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 13 out of 15, indicating intact cognition. Observation on 06/06/2022 at 9:30 AM of the facility's outdoor inner patio area revealed there were four residents, including Resident #260, smoking. Nursing staff was observed passing out the residents' cigarettes and lighters. Observation on 06/08/2022 at 2:10 PM revealed residents, including Resident #260, were outside smoking in the patio smoking area. No staff were present. During an interview on 06/09/2022 at 3:37 PM, Licensed Practical Nurse (LPN) #5 revealed she had not looked for a smoking assessment for Resident #260. LPN #5 stated that, due to an incident that had occurred that morning involving Resident #260, the Director of Nursing (DON) had asked LPN #5 to conduct a smoking assessment for Resident #260. LPN #5 described the incident in question, noting that Resident #260 was seen outside in the smoking area going through discarded cigarette butts and lighting them while sitting next to a resident wearing oxygen. LPN #5 noted this occurred outside of the time for a scheduled smoke break. An interview on 6/10/2022 at 1:42 PM with the DON revealed there was no smoking assessment for Resident #260 prior to 06/09/2022. The DON stated the expectation was for a smoking assessment to be completed upon admission. An interview on 06/10/2022 at 12:00 PM with the Administrator revealed smoking assessments were done prior to a resident starting to smoke. The Administrator explained that, initially, Resident #260 was on another unit where there was no smoking. The Administrator stated that once Resident #260 moved to a different unit, the resident should have been assessed for smoking prior to being allowed to smoke.