**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interviews, the facility failed to ensure two (#6 and #9) of three residents reviewed for abuse out of 11 sample residents were kept free from abuse. Specifically, the facility failed to protect Resident #6 and Resident #9 from physical and verbal abuse from Resident #7. Findings include: I. Facility policy and procedure The Abuse policy, dated 5/3/23, was provided by the nursing home administrator (NHA) on 2/11/25 at 5:55 pm. It read in pertinent part, The facility does not condone resident abuse and shall take every precaution possible to prevent resident abuse by anyone, including other residents. Residents have the right to be free from abuse. Providing a safe environment for the resident is one of the most basic and essential duties of our facility. Identification of abuse shall be the responsibility of every employee. Residents at risk for abusive situations are identified and appropriate care plans are developed. If a resident experiences a behavior change resulting in aggression toward other residents, the community will implement interventions for protection of the alleged assailant and other residents. The resident's care plan is revised to include new approaches to reduce or eliminate any further chance of abuse. If abuse happens, separate the assailant from the victim, isolate the assailant to protect others, assess and treat the victim and notify the abuse coordinator. II. Incident of physical abuse between Resident #9 and Resident #7 on 10/1/24 A. Facility investigation The facility's investigation revealed there was a resident to resident altercation between Resident #7 and Resident #9 in the residents' shared room on 10/1/24. Resident #7 became upset when his roommate (Resident #9) called him crazy. Resident #7 punched Resident #9. Resident #9 punched Resident #7 back and they began to hit each other multiple times. Immediately, the residents were separated and Resident #7 was placed on one-to-one supervision with a staff member and a room change for Resident #7 was initiated. Resident #9 was assessed and found to have sustained an abrasion to his right arm and a headache from hitting his head on the door frame. Resident #9 was sent to the hospital for evaluation and further assessment to rule out a head injury. He was sent back to the facility from the hospital with negative results for a head injury. The local police department, the ombudsman, the residents` physicians and both residents` representatives were notified. B. Resident #7 (assailant) 1. Resident status Resident #7, age less than 65, was admitted on [DATE]. According to the February 2025 computerized physician orders (CPO), diagnoses included personal history of traumatic brain injury (TBI), post-traumatic stress disorder unspecified, schizoaffective disorder bipolar type, unspecified intellectual disabilities, nicotine dependence and anxiety disorder. The 1/21/25 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. He was able to ambulate independently and required supervised smoking assistance and minimal assistance with personal hygiene. The MDS assessment indicated the resident had hallucinations and delusions but did not exhibit physical or verbal symptoms. 2. Resident observations On 2/11/25 the following was observed: At 11:26 a.m. Resident #7 was sitting in the dining room rocking back and forth in his seat with his head in his hands being closely monitored by a staff member sitting beside him providing one-to-one supervision. At 11:35 a.m. Resident #7 let out a loud noise and stood up telling the staff member I can't be in here anymore and walked towards his room while being followed by the one-to-one supervision staff member. At 4:55 p.m. Resident #7 was pacing the hallway talking to himself and responding to internal stimuli (talking back to voices he was hearing in his head) and singing to himself. 3. Resident interview Resident #7 was interviewed on 2/11/25 at 4:57 p.m. Resident #7 was exhibiting paranoid behavior and was distracted by internal stimuli during questioning, but remained calm and pleasant. He said he made attempts to prevent altercations by being non-violent. He said staff were sometimes helpful in helping him control his urges. He said the interventions were sometimes helpful. Resident #7 said he was better now than when he had past altercations with other residents and said he tried to avoid the people who caused him problems. 4. Record review The behavior care plan, initiated 10/7/24 and revised 2/2/25, revealed Resident #7 had the potential to be physical toward other residents when he believed another resident had disrespected him and must defend himself. Pertinent interventions included one-on-one monitoring following an occurrence as needed (PRN), administering medications as ordered and documenting and monitoring side effects and effectiveness, reminding Resident #7 to seek out staff support to de-escalate the behavior, monitoring and documenting observed behaviors and attempted interventions PRN, monitoring, documenting and reporting PRN any signs or symptoms of the resident posing a danger to himself or others when Resident #7 became agitated, intervening before agitation escalated, guiding the resident away from the source of distress and engaging him calmly in conversation and if the resident responded aggressively, staff should calmly walk away and approach later. -The resident's behavior care plan was not initiated until 10/7/24, six days after the resident's altercation with Resident #9 (see investigation above). The psychotropic medication care plan, revised 10/3/24, revealed Resident #7 was prescribed antidepressant medication for trouble sleeping, an antihistamine and an anxiolytic medications for anxiety and antipsychotic medication for symptoms and behaviors associated with the diagnosis of schizoaffective disorder bipolar type. Pertinent interventions included monitoring, documenting and reporting changes in behavior, mood or cognition, hallucinations and delusions, monitoring and documenting side effects and efficacy of medications, administering medications as ordered and reviewing alternate therapies attempted and effectiveness. -The resident's psychotropic care plan was not updated with any new interventions after the resident's altercation with Resident #9 on 10/1/24. The auditory hallucinations and delusions care plan, initiated 12/31/24 and revised 2/2/25, revealed Resident #7 paced the halls most of the day, responded to internal stimuli and believed he was part African American and would say the N word as he believed he had a right to do so since it was socially acceptable for African Americans to say it to each other and staff had difficulty redirecting this delusion. Additional pertinent interventions included allowing Resident #7 to express how he felt and what he was talking about, offering psychiatric services and offering to take him out for a cigarette to assist in re-directing him. -The resident's auditory hallucinations and delusions care plan was not initiated until 12/31/24, almost three months after the resident's altercation with Resident #9 (see investigation above) and over a month after the resident's second altercation with Resident #6 (see investigation below). A progress note, dated 10/1/24 at 11:53 p.m., documented Resident #7 came out of his room and reported his roommate (Resident #9) was being mean to him and calling him names. Resident #9 then came out of the room and called Resident #7 crazy. Resident #7 told Resident #9 he was not crazy and started hitting Resident #9. The residents continued hitting each other and both residents fell to the floor. The residents were separated and assessed for injury and no injuries were noted. A nurse progress note, dated 10/3/24 at 10:16 p.m., documented Resident #7 continued to be monitored post physical altercation with another resident. The resident continued to be on one-to-one monitoring. -There was no further documentation related to the 10/1/24 incident with Resident #9 in Resident #7's electronic medical record (EMR). C. Resident #9 (victim) 1. Resident status Resident #9, age less than 65, was admitted on [DATE]. According to the February 2025 CPO, diagnoses included schizophrenia, hypertension, cognitive communication deficit and major depressive disorder, recurrent severe, without psychotic features. The 12/6/24 MDS assessment revealed the resident was cognitively intact with a BIMS score of 13 out of 15. The resident was independent for all activities of daily living (ADL). The MDS assessment indicated the resident was taking antipsychotic and antidepressant medications. The MDS assessment documented the resident did not have physical or verbal behaviors directed at others or other behavioral symptoms not directed toward others. 2. Resident interview Resident #9 was interviewed on 2/11/25 at 2:30 p.m. Resident #9 said he felt safe in the facility. He said he did not remember the altercation with Resident #7. 3. Record review The behavior care plan, initiated 10/7/24, revealed Resident #9 had the potential to become verbally and physically aggressive toward other residents and staff members at the facility. He presented anger problems, history of harm to others and poor impulse control. Resident #9 had the potential to become physically aggressive toward other residents when he was physically or verbally instigated by others. Pertinent interventions included administering medications as ordered, monitoring and documenting for side effects and effectiveness, providing physical and verbal cues to alleviate anxiety, giving positive feedback, assisting the resident's verbalization of the source of agitation, assisting the resident to set goals for more pleasant behavior, encouraging the resident to seek out staff members when agitated, offering the resident choices about his care and activities, providing psychiatric consultation, intervening before agitation escalated and guiding Resident #9 away from source of distress and engaging the resident calmly in conversation and walking away if the response was aggressive. A nursing progress note, dated 10/1/24 at 11:05 p.m, revealed a physical altercation occurred between Resident #9 and Resident #7 in the residents' room. The note documented Resident #7 became upset when his roommate (Resident #9) called him crazy and Resident #7 punched Resident #9. Resident #9 punched Resident #7 back and they began to hit each other multiple times. Immediately, the residents were separated and Resident #7 was placed on one-to-one supervision with a staff member and a room change was initiated for Resident #7. Resident #9 was assessed and found to have sustained an abrasion to his right arm and a headache from hitting his head on the door frame. Resident #9 was sent to the hospital for evaluation and assessment to rule out a head injury. He was sent back to the facility from the hospital with negative results for a head injury. Resident #9 felt safe in the facility and continued with his usual activities. He denied feeling fear. D. Staff interviews Certified nurse aide (CNA) #1 was interviewed on 2/11/25 at 1:30 p.m. CNA #1 said she had not witnessed Resident #7 acting aggressively toward other residents but knew he was capable when triggered. She said he would talk to himself frequently. She said the tone of his voice could sound aggressive and other residents might mistakenly believe Resident #7 was talking to them offensively. CNA #1 was interviewed a second time on 2/11/25 at 4:45p.m. She said she would de-escalate Resident #7 by talking to him in a calm voice. She said she would redirect him by talking to him about a different topic or offer other distractions. She said Resident #7 was able to tell staff if he was being triggered. She said he would ask the CNAs to remove him from the situation before being triggered. She said staff were required to take mandatory online and in-person training on de-escalation of residents. She said her last in-person training was in October 2024. She said she would make behavior notes in residents' EMR which the nurses could see. She said new orders and intervention changes for residents would be sent to staff via text message from management. CNA #2 was interviewed on 2/11/25 at 12:30 p.m. CNA #2 said Resident #7 had frequent mood swings and could show physical and verbal aggression toward others. She said he paced and appeared to be agitated often. She said he often talked to the personalities inside his head. CNA #2 was interviewed a second time on 2/11/25 at 4:45p.m. She said she would approach him in a calm manner during an altercation and would offer choices, such as going outside or going to another area in the facility. She said she would redirect by taking Residen #7 out of the altercation. She said she received mandatory ongoing de-escalation training with computer based training. She said CNAs would chart behavior notes in the residents' EMRs and report the behaviors to the nurse. CNA #2 said interventions or new orders would be communicated from the admission office upon admission and via mass text to staff. III. Incident of physical and verbal abuse of Resident #6 by Resident #7 on 11/20/24 A. Facility investigation The facility's investigation revealed that on 11/20/24 at 5:00 p.m., Resident #7 and Resident #6 were sitting in the dining room. Resident #7 was responding to internal stimuli. Resident #6 thought he was talking to him so he stood holding up a fist. Resident #7 then stood up, held up his fist, said okay and pushed Resident #6 against the wall. The immediate safety measures put into place to protect Resident #6 included separating the residents from one another, placing each resident on 15-minute checks for 72 hours and on a psychosocial follow up scheduled for one week following the incident. The investigation documented that the police, the residents' representatives, the ombudsman and the residents' physicians were notified. The investigation indicated that Resident #6 was assessed by the licensed practical nurse (LPN) on duty during the incident and he was found to have no pain or sign of injury. Resident #6 was interviewed during the investigation (date and time unknown). Resident #6 said Resident #7 was talking to no one about demons. When Resident #6 told Resident #7 to shut up, Resident #7 then told Resident #6 to shut up twice and asked Resident #6 if he wanted to fight. Resident #6 said Resident #7 got up and put two fists up so Resident #6 got up and put two fists up. Resident #6 said Resident #7 then pushed him and he tripped over his chair backwards and hit the wall. The investigation indicated that Resident #7 was interviewed by management during the investigation (date and time unknown). Resident #7 said Resident #6 said he (Resident #7) was talking to demons. Resident #7 said he told Resident #6 he was not talking to demons. Resident #7 said Resident #6 got up and put two fists up so Resident #7 got up and pushed him. Three resident witnesses of the occurrence were interviewed by management. Witness #1 said she looked up and saw Resident #7 push Resident #6. She said Resident #6 then fell against the wall. Witness #2 said Resident #7 stood up and then Resident #6 stood up. Witness #2 said both residents put two fists up and Resident #7 pushed Resident #6. Witness #3 said Resident #7 and Resident #6 had an argument and Resident #6 fell against the wall. Staff interviews conducted during the investigation revealed that no staff witnessed the occurrence. Record review revealed Resident #7 had a potential to be physical towards other residents when he felt he had been disrespected and had to defend himself. B. Resident #7 (assailant) 1. Record review Review of Resident #7's revealed there were no interventions updated on the resident's behavior, psychotropic medications or auditory hallucinations and delusions care plans following the resident to resident altercation with Resident #6 on 11/20/24 (see investigation above). A nursing progress note, dated 11/20/24 at 6:19 p.m., documented that the nurse was at the nursing station when a concierge ran up saying a nurse was needed in the dining room because Resident #6 and Resident #7 were fighting. The nurse ran to the dining room as the concierge said it was over now. The nurse asked Resident #7 what happened. Resident #7 said he was defending himself because Resident #6 started yelling at him and stood up with his fist in the air, so Resident #7 stood up to defend himself and pushed Resident #6. Staff removed Resident #7 for safety and placed him on 15-minute checks until further notice. Resident #7 was assessed for injury and the nurse found no bruising or signs of injury. The nurse educated Resident #7 on controlling his emotions and physical impulsions and instructed him on walking away and deep breathing exercises. Resident #7 said he understood, although he was just trying to defend himself. He denied feeling fearful towards Resident #6. The nurse notified the manager on call, the physician and the residents' representative. The November 2024 progress notes revealed that one nursing progress note and two alert notes, all dated 11/21/24, were charted in the 72-hour period following the incident with Resident #6. The alert notes documented that the nurse would have the social worker talk with Resident #7. -There were no behavior monitoring notes regarding the incident documented on 11/22/24 or 11/23/24. The November 2024 treatment administration record (TAR) revealed staff failed to document Resident #7's targeted behaviors of anxiety and psychosis on 11/20/24. -However, according to the facility investigation of the incident with Resident #6 on 11/20/24, Resident #7 was exhibiting symptoms of psychosis as evidenced by him responding to internal stimuli (see investigation above). The interdisciplinary team (IDT) risk management review note, dated 11/29/24 at 6:35 a.m., documented that the abuse allegation for the 11/20/24 physical aggression incident was found to be unsubstantiated. -However, abuse occurred because Resident #7 willfully pushed Resident #6 (see investigation above). The behavior note, dated 1/27/25 at 5:57 p.m., revealed Resident #7 had an incident with his roommate following a psychotic episode of loudly responding to stimuli and yelling and using racial slurs. When the roommate responded, Resident #7 began to yell derogatory words louder and more directly. Staff intervened by moving Resident #7 to a new room not far from Resident #6's room. -However, Resident #7 had already had an abuse incident with Resident #6 on 11/20/24 (see investigation above). The behavior note, dated 2/10/25, documented that Resident #7 had an episode of loud yelling and talking to himself, was very restless and refused to talk with the nurse. -The note failed to indicate whether interventions were attempted or if the physician or the social worker were notified. The 11/20/24 frequent check form revealed close monitoring of Resident #7 every 15 minutes was conducted between the hours of 5:00 p.m. (prior to the incident) and 12:00 a.m. -The 11/21/24 frequent check form revealed staff failed to closely monitor the resident between the hours of 6:15 a.m. to 9:45 p.m. -The 11/22/24 frequent check form revealed staff failed to closely monitor the resident between the hours of 6:15 a.m to 12:00 a.m. -The facility was unable to provide a frequent check form for 11/23/24. -The facility failed to perform frequent checks on Resident #7 during the 72-hour alert monitoring timeframe following the resident's incident with Resident #6 on 11/20/24. D. Resident #6 (victim) 1. Resident status Resident #6, age greater than 65, was admitted on [DATE]. According to the February 2025 CPO, diagnoses included psychoactive substance abuse with psychoactive substance-induced psychotic disorder unspecified, antisocial personality disorder, drug-induced subacute dyskinesia (movement disorder that develops over days or weeks after taking certain drugs or medications) and schizophrenia unspecified. The 12/10/24 MDS assessment revealed the resident was cognitively intact with a BIMS score of 13 out of 15. He was independent and required minimal assistance with showers and hygiene. 2. Resident interview Resident #6 was interviewed on 2/11/25 at 1:04 p.m. Resident #6 said that during the incident on 11/20/24 with Resident #7, Resident #7 was running his mouth so he told him to shut up and Resident #7 started calling people names so they got in a fight and he (Resident #6) fell out of his chair. Resident #6 said he felt staff did not handle the situation well because Resident #7 still had the same behaviors. He said Resident #7 was a menace. He said sometimes Resident #7 saw him and apologized and told him he loved him, however, Resident #6 said Resident #7 was dangerous. Resident #6 said it was harder for him to avoid Resident #7 recently because Resident #7 had a fight with his roommate and he now lived upstairs closer to his (Resident #6) room. Resident #6 said he would feel safer if staff managed Resident #7's, and other problematic residents', behaviors better. 3. Record review The nursing progress note, dated 11/20/24 at 10:25 p.m., revealed that the nurse was alerted that a fight broke out in the dining room where she rushed to find Resident #6 sitting at the dining room table with no visible injuries. At that time, Resident #6 said Resident #7 was yelling at him so he had to defend himself. The nurse manager and the physician were notified and both residents were placed on 15-minute checks until further notice. The November 2024 progress notes revealed one alert note, dated 11/21/24 at 9:15 a.m., was documented following the 11/20/24 incident. -The facility failed to ensure 72-hour follow-up monitoring was documented for Resident #6. E. Staff interviews LPN #1 was interviewed on 2/11/25 at 12:25 p.m. LPN #1 said Resident #7 had been talking to himself and pacing but had not been violent lately. She said if there was a resident-to-resident altercation, she would intervene by separating the residents for safety and notify the administrator, the supervisor and sometimes the police. LPN #1 said Resident #7's behaviors had not changed since he was admitted to the facility. She said when he first admitted to the facility he moved downstairs after an altercation with his roommate, then he was moved upstairs again after another altercation with another roommate. LPN #1 said the staff were offered crisis intervention training frequently in the form of meetings and in-services, but they were not mandatory. She said when management implemented new interventions for new behaviors, staff was notified via group messages. Registered nurse (RN) #1 was interviewed on 2/11/25 at 1:21 p.m. RN #1 said social services and management were highly involved in crisis intervention and prevention training. She said staff were provided mandatory online training that included informative videos on de-escalation and managing difficult resident behaviors. RN #1 said that new or unwanted resident behaviors were charted in the residents' EMR under the task documentation system for CNAs and in the residents' behavior progress notes for nurses. She said behaviors were also documented in a 24-hour nursing report. She said a mass text was sent out to nursing staff by management or social services for residents needing one-to-one supervision or frequent checks. She said behavior notes were mandatory for residents on 15-minute checks. LPN #2 was interviewed on 2/11/25 at 1:38 p.m. LPN #2 said that crisis intervention and prevention training was organized by the NHA. She said when Resident #7 had an altercation with his roommate, staff intervened by separating them, providing one-to-one supervision for him for 72 hours and placing the residents involved on frequent 15-minute checks for 72 hours. She said Resident #7 had had several resident to resident altercations and the same interventions were put into place. She said that Resident #7 was usually easily redirected and he liked snacks. She said he talked to himself and he paced a lot. LPN #2 said at one time, Resident #7 was attending a day program but had to stop going due to his behaviors and the facility was working on a new plan for him because he liked to socialize. The social services director (SSD) was interviewed on 2/11/25 at 3:42 p.m. The SSD said residents' behavior interventions were to be documented in care plans and progress notes and were updated based on whether staff had found new effective interventions or when there was an incident. The SSD said interventions implemented for verbally and physically aggressive behaviors included redirecting and relocating the resident, ensuring safety and communicating with the resident to find the root of the problem. She said following Resident #7's incident with Resident #6, the police were notified but the facility did not send him out to the hospital as he was not a threat to himself or others at the time. The SSD said to keep other residents safe when Resident #7 experienced an episode of aggression, staff coordinated a room change and provided one-to-one supervision, frequent checks and medication review. She emphasized that he was usually very sweet, he just had mental anguish and got very upset at times. She said Resident #7's behaviors were not a daily concern and they were not unprovoked. The NHA was interviewed on 2/11/25 at 3:42 p.m. The NHA said staff huddles at nursing stations were implemented in 2024 and were intended to highlight residents' targeted behaviors and other pertinent incidents and changes in condition. She said a binder on huddle discussions was available at the nursing station for staff to review. The NHA said interventions for targeted behaviors were put into place by the director of nursing (DON) and the nurses and they were to be documented in the treatment administration record (TAR). The NHA said in the event of physical or verbal aggression, staff would move the resident to a new room, if deemed necessary, and conduct frequent 15-minute checks and one-to-one supervision would be implemented. The NHA said she was working on getting crisis prevention intervention (CPI) training for all staff. She said staff had monthly meetings, including how to manage verbally and physically aggressive behaviors, and said she felt staff were sufficiently trained on the subject. She said the training was also provided at the annual skilled nursing facility (SNF) competency training, as well as in verbal and written education materials. The NHA said staff was last trained on TBI behavior management around November 2024. She said Resident #7 had auditory hallucinations and responded to internal stimuli frequently. She said he would often go into the bathroom to yell, wander the halls and talk to himself. She said he would let staff know if he felt troubled by his mental state and needed to go to the hospital. She said a very effective de-escalation intervention was to take Resident #7 on walks or to smoke a cigarette. The NHA said Resident #7 often used derogatory language when responding to internal stimuli and this had been ongoing since he was first admitted to the facility. She said the care plan reflected his belief that he was half African American and felt he had the right to use the N word. The NHA said the intervention for Resident #7, after the incident with Resident #6, was to speak with staff regarding his concerns and place both residents on frequent checks. She said she was under the impression that Resident #6 was the assailant and Resident #7 was the victim in the incident. The NHA said, after the most recent incident involving Resident #7 on 1/27/25, Resident #7 was placed on one-to-one supervision with a staff member for 24 hours and relocated to a room upstairs. She said she did not acknowledge Resident #6 as the victim in the 11/20/24 occurrence. The NHA said she did not have any concerns about Resident #6 or Resident #7's safety, even though their rooms were now in closer proximity.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to provide the necessary behavioral health care and services to attain and maintain the highest practicable physical, mental and psychosocial well-being for one (#1) of two residents reviewed out of 11 sample residents. Specifically, the facility failed to implement person centered interventions to address Resident #1's pattern of escalating behaviors. Findings include: I. Facility policy and procedure The Behavior Monitoring policy, dated 2/29/24, was provided by the nursing home administrator (NHA) on 2/11/25 at 4:23 p.m. It read in pertinent part, The purpose of behavior monitoring is to establish an accurate pattern of resident targeted behaviors as determined by the resident's history, evaluation, assessment. The goal is to determine appropriate behavior interventions such as counseling, behavior management plan including non-pharmacological interventions, and psychoactive medication management. When a resident displays targeted and/or inappropriate behavior, facility staff will implement behavioral interventions to assure the safety of the resident and/or other residents and staff/visitors. The behavior monitoring records of those residents under review will be discussed at the psychotropic drug committee for review and recommendations. IDT (interdisciplinary) members and/or designee will review behavior monitoring daily and as needed to follow up on any changes in behaviors. II. Resident #1 A. Resident status Resident #1, age less than 65, was admitted on [DATE]. According to the February 2025 computerized physician orders (CPO), the diagnoses included traumatic brain injury, mood disorder and mild cognitive impairment. The 12/20/24 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status score (BIMS) score of 15 out of 15. He required moderate to extensive assistance with dressing, bathing, transfers, and bed mobility. He used a wheelchair for ambulation. The assessment indicated the resident had behaviors of physical and verbal aggression directed towards others. The MDS assessment indicated the resident did not experience hallucinations or delusions. The MDS assessment indicated the resident participated in the discharge assessment and there was no active discharge plan for the resident. B. Resident interview and observations Resident #1 was interviewed on 2/11/25 at 2:30 p.m. He said he did not recall any physical altercations between himself and other residents. Resident #1 said he struggled with anxiety and anger. Resident #1 said he had been in the facility for close to a year but did not feel the facility tried to understand his brain injury. He said the facility did not do anything to work with him regarding his brain injury or provide any type of rehabilitation for him to become more cognitively independent. Resident #1 said he would like to go to a facility that specialized in the care of brain injuries but no one at the facility has talked to him about helping locate a different facility. He said he had a difficult time with the other residents who suffer from mental illness and it was hard for him to handle being around them. He said he expressed this frustration with anger. C. Record review The social services care plan, revised 9/3/24, revealed the resident exhibited behaviors of cursing and yelling at staff and peers, name calling, and poor money management with the potential to be reduced with the implementation of a positive reinforcement/incentive program. The care plan documented therapy, social services, and activities would work with the resident on implementation of a reinforcement/incentive program utilizing cigarettes and lottery tickets to reward positive behavior. Interventions included providing consistent reinforcement and incentives to maintain motivation (initiated 6/27/24), regularly assessing progress towards goals and the effectiveness of reinforcement strategies (initiated 6/27/24), adapting reinforcement strategies to accommodate individual preferences and learning styles (initiated 6/27/24), being open to adjusting the resident's goals and incentives based on progress (initiated 6/27/24) and breaking down larger goals into smaller more manageable milestones (initiated 6/27/24). The psychosocial care plan, revised 10/6/24, revealed the resident exhibited behaviors of verbal and physical aggression towards others, displayed as the use of racial slurs, verbal aggression, spitting and striking out physically at others. The care plan indicated the residents identified triggers included: feeling the staff were not moving fast enough, believing others had wronged him and when he or his wheelchair were accidentally touched. Interventions included allowing the resident to verbalize his frustration (initiated 7/7/24), educating the resident on what is appropriate behavior (initiated 7/7/24), completing a medication review requested by the pharmacist and the medical director (initiated 9/6/24), reminding the resident to verbalize his dislike of being moved without his permission to avoid physical aggression (initiated 10/6/24), setting clear and strict boundaries (initiated 7/7/24) and weekly follow ups from the NHA/IDT team following an occurrence (initiated 9/6/24). The behavior care plan, revised 2/5/25, revealed the resident had the potential to be verbally and physically aggression related to poor impulse control and a traumatic brain injury. The care plan indicated the resident would swing at other residents, use derogatory language and spit at the staff. Interventions included administering medications as ordered (initiated 6/27/24), analyzing key times, places, circumstances, triggers, and what de-escalated the resident's behavior and document this (initiated 6/27/24), assessing the resident's coping skills and support systems (initiated 6/27/24), assessing the resident's understanding of the situation (initiated 6/27/24), behavior monitoring (initiated 6/27/24), providing positive feedback for good behavior (initiated 6/27/24) and intervening before agitation escalates when the resident becomes agitated escalates (initiated 6/27/24). The discharge care plan, revised 6/27/24, revealed the resident would remain in the facility for long term care related to a history of a traumatic brain injury. Interventions included discussing the resident's current living arrangement and desire for discharge to the community with the power of attorney/family periodically or as needed (initiated 6/18/24). -The facility failed to update the care plan to include person centered interventions to address the residents escalated behavior after resident to resident altercations on 9/29/24, 10/14/24, 10/18/24, 11/2/24, 11/13/24 and 2/1/25 (see record review below). The February 2025 CPO revealed the following physician's orders: -Behavior monitoring for behaviors of hallucinations/expressing delusions, verbal/physical aggression, and hypersexualized comments, ordered on 8/16/24. A review of the monthly psychoactive pharmacological meeting notes from 9/15/24 to 1/27/25 did not reveal the resident's behaviors were reviewed or interventions were implemented to address the resident's aggressive behaviors. A review of the progress notes in resident's electronic medical record (EMR) from 9/29/24 to 2/10/25 revealed documented behaviors of verbal or physical aggression towards others occurred on 9/29/24, 10/1/24, 11/14/24, 11/17/24, 11/18/24, 11/19/24, 12/2/24, 12/23/24 and 1/26/25. -There were no descriptions of the non-pharmological interventions that had been tried to address the behaviors or if the interventions were effective in the resident's progress notes. The NHA provided the facility's investigations of the resident to resident altercations pertaining to Resident #1 on 2/11/25 at approximately 11:00 a.m. A review of the investigations revealed the following: The 9/29/24 incident revealed Resident #1 and Resident #11 were arguing. Resident #1 attempted to spit in Resident #11's face. Both residents were separated with no injuries reported. Interventions put into place to prevent a recurrence included providing education to Resident #11 to talk to staff if she was having problems with another resident. The 9/29/24 incident revealed Resident #2 tried to move Resident #1's wheelchair out of the walkway and Resident #1 hit him in the stomach. Resident #2 responded by hitting Resident #1 in the back. Both residents were separated with no injuries reported. Interventions put into place to prevent a recurrence included reminding Resident #1 to verbalize his dislike for being moved without his permission to avoid physical aggression. The 10/14/24 incident revealed Resident #1 believed Resident #4 was trying to cut in line to go into the social services office and Resident #1 attempted to hit Resident #4. When he was unable to hit him, Resident #1 kicked Resident #4's wheelchair. Both residents were separated with no injuries reported. Interventions put into place to prevent a recurrence included putting Resident #1 on frequent checks, reviewing his behaviors and medications in the monthly psychoactive pharmacological meeting and continuing to seek alternative placement for Resident #1 due to increasing behaviors. The 10/18/24 incident revealed Resident #3 accidentally cut in line in front of Resident #1. Resident #1 cursed at him and kicked him in the leg. Both residents were separated with no injuries reported. Interventions put into place to prevent a recurrence included putting Resident #1 on frequent checks, reviewing his behaviors and medications in the monthly psychoactive pharmacological meeting and to continue to seek alternative placement for Resident #1 due to increasing behaviors. -However, frequent checks and reviewing medications were existing implemented interventions. Upon record review, there was no evidence the facility made efforts to find alternative placement. The 11/2/24 incident revealed Resident #4 was passing Resident #1's wheelchair and Resident #1 became upset. Resident #1 began to hit Resident #4 in the arm and Resident #4 attempted to hit him in return. Both residents were separated with no injuries reported. Interventions put into place to prevent a recurrence included putting Resident #1 on frequent checks for 72 hours and for the psychoactive pharmacological team to review medications and behaviors during monthly meetings. -However, frequent checks and reviewing medications were existing implemented interventions. The 11/13/24 incident revealed Resident #1 hit Resident #5 in the face after cutting in front of Resident #5 in line and Resident #5 attempting to hit him. Both residents were separated with no injuries reported. Interventions put into place to prevent a recurrence included putting Resident #1 on 15 minute checks for 72 hours and for the psychoactive pharmacological team to review medications and behaviors during monthly meetings. However, frequent checks and reviewing medications were existing implemented interventions. The 2/1/25 incident revealed Resident #10 was trying to pass Resident #1 to exit the smoking area and accidentally hit his wheelchair with hers. Resident #1 hit Resident #10 in the left arm twice. Both residents were separated with no injuries reported. Interventions put into place to prevent a recurrence included putting both residents involved on 15-minute checks and escorting Resident #1 to and from the smoking area. -However, review of Resident #1's comprehensive care plan did not reveal the intervention of escorting Resident #1 to and from the smoking area (see care plan above). -Review of Resident #1's EMR did not reveal any psychological and psychiatric behavior health provider notes. -Review of the resident's medication administration records (MAR) and treatment administration records (TAR) from 9/1/24 to 2/10/25 did not reveal any behaviors had been documented. III. Additional resident interview Resident #10 was interviewed on 2/11/25 at 2:19 PM. Resident #10 said the incident between herself and Resident #1 happened so fast she did not even see it coming. She said it occurred outside of the facility in the designated smoking area. She said she had tried to go past Resident #1 to get back into the facility and he reached out and hit her in the arm. She said she now tried to avoid him and not go out to smoke when he was out there. She said she had not seen the staff do anything different with Resident #1 in regards to his escalating behaviors. IV. Staff interviews Licensed practical nurse (LPN) #1 was interviewed on 2/11/25 at 12:25 p.m. LPN #1 said if there was an incident between two residents, she would separate them, call the NHA, the SSD, her supervisor and the police. She said when a resident had behaviors, she would chart in the behavior progress notes. LPN #1 said if the IDT team put new interventions in place to address a resident's behaviors, the staff were notified in the twice weekly huddles. LPN #1 said Resident #1 displayed behaviors such as arguing with other residents, yelling at others who walked past him and demanding the staff's attention. LPN #1 said the staff redirected the resident when he had these behaviors. Certified nurse aide (CNA) #2 was interviewed on 2/1/25 at 1:00 p.m. CNA #2 said Resident #1 had behaviors of demanding staff attention and becoming impatient with the staff. CNA #2 said these behaviors could trigger physical and verbal aggression from the resident. She said the interventions the CNAs tried were to speak to him in a calm voice or offer him a soda. CNA #2 was interviewed on 2/1/25 at 1:15 p.m. She said Resident #1 was inpatient and was physically aggressive. She said the interventions she tried with the resident were to speak in a calm voice, remove him from the situation or redirect him to an activity. Registered nurse (RN) #1 was interviewed on 2/11/25 at 1:21 p.m. She said Resident #1 expressed behaviors when he did not get his way, such as being told he had to wait for staff assistance. She said this would trigger him to become verbally and physically aggressive. She said the resident would apologize sometimes and acknowledge his behavior was inappropriate. She said the staff attempted to redirect Resident #1 and would try to resolve the concern he had. RN #1 said the CNAs charted behaviors in the CNA electronic charting system and the nurses charted behaviors in the progress notes. She said if the IDT team put a new intervention into place, the nurses were notified via text message. LPN #2 was interviewed on 2/11/25 at 1:38 p.m. She said Resident #1 had behaviors of attention seeking and using his call light frequently for staff attention. She said he was verbally and physically abusive towards the staff, so the staff had to provide care in pairs (two people providing care at all times). -However, review of Resident #1's comprehensive care plan did not identify the intervention of cares in pairs. LPN #2 said the interventions for Resident #1's behavior included redirection. She said his behaviors were documented on the behavior tracking order in the TAR. She said when new interventions were implemented, the management team put an alert into the EMR to alert the nurses. RN #2 was interviewed on 2/11/25 at 2:46 p.m. She said Resident #1 had behaviors of lashing out at other residents and staff and becoming physically aggressive. She said Resident #1 was triggered when other residents or staff were in his personal space when he would prefer they not be. She said the non-pharmological interventions for his behaviors consisted of assisting him back and forth to the smoking area and providing care in pairs. However, review of Resident #1's comprehensive care plan did not identify the intervention of cares in pairs or escorting the resident back and forth to the smoking area. She said when the resident displayed behaviors, the nurse wrote a progress note, as well as documented the behavior on his behavior tracking order in the TAR. RN #2 said she was not sure why there was no documentation on the resident's behavior sheet on the TAR from 9/1/24 to 2/11/25. She said she had access to view the resident's care plans but she did not look at the care plan for target behaviors or non-pharmacological interventions. She said the nurses got their information regarding behaviors and interventions from the behavior tracking order and verbal instructions from the administration. RN #2 said the CNAs did not have access to view the resident's care plans. The social services director (SSD) and the NHA were interviewed together on 2/11/25 at 3:45 p.m. The SSD said she expected nursing staff to document the resident's behaviors in a progress note and to let social services know if there were behavior concerns. The SSD said the IDT team also conducted twice a week huddles at each nursing station to address any concerns the staff had with any of the departments. She said this meeting included discussing behavioral issues with residents. The SSD said there was a behavior tracking order on Resident #1's TAR. She said the behavior tracking order included the behaviors the nurses were to observe for and the non-pharmological interventions the nurses were to attempt. She said the nurses could either document behaviors on the TAR or in the progress notes. She said the CNA's documented behaviors on their task sheet in their own electronic system which was separate from the nurses. She said if there were specific interventions the SSD wanted the staff to try with the resident, she would tell the staff during a huddle or the IDT would send out a text message to the staff. She said all updated behaviors and interventions were included in the resident's care plan which the staff, including the CNAs, had access to review. The SSD said when a resident had a change in condition regarding behaviors or non-pharmological interventions, the staff provided feedback on interventions they had tried, or there was an occurrence involving a resident it would trigger an update to the resident's behavior tracking order and care plan. She said if a resident was having behaviors of physical or verbal aggression towards others some of the behavior interventions that would be tried would be redirection, changing the environment, determining the psychosocial trigger, frequent checks, and one-on-one supervision. The SSD said r Resident #1 displayed impulsive reactions when feeling strong emotions such as anger or frustration. She said the resident had a short temper and if another resident bumped into him or his wheelchair, he would respond immediately and could become verbally and physically aggressive. The SSD said the IDT reviewed the resident in the psychoactive pharmacology monthly meeting. She said during the meeting, the residents' behaviors and occurrences were discussed as well as reviewing medication changes and behavior interventions for efficacy. The SSD said she was not aware these meetings were not documented. The SSD said some of the interventions tried with Resident #1 included monitoring him when he went back and forth to the smoking area and moving his room to a calmer and quieter area of the building without the disruptions of other residents coming and going from the smoking area. She said additional interventions included locating a facility specializing in traumatic brain injuries for Resident #1. The SSD said she had sent out several referrals but had not had facilities show interest due to the aggressive behaviors. She said her efforts to find him placement were documented in the progress notes as well as on paper documentation within her office. She said when Resident #1 began displaying behaviors of verbal and physical aggression, the staff tried to redirect him from the environment and would try talking to him about his feelings. The SSD said Resident #1 could show insight into his behavior at times. She said the resident had told her he was not always the way he was currently, as far as his behaviors in relation to his traumatic brain injury. She said he currently saw the facility's psychological and psychiatric behavior health provider and that was documented in his progress notes. -However, review of Resident #1's EMR did not reveal documentation that the resident was seen by the behavior health provider (see record review above). The NHA said the facility kept other residents safe from Resident #1's behaviors by monitoring Resident #1 to ensure he did not get too physically close to other residents, initiating room changes if necessary, reviewing his medications and behaviors in the psychoactive pharmacological meeting and discussing new interventions with the care staff in the huddles. She said the expectation of the nursing staff was to either document the resident behaviors on the behavior tracking order on the TAR or to make a progress note in the chart. The NHA said the progress note included the same information found on the behavior tracking order such as non-pharmological interventions the staff were to use and whether the interventions were effective or not. The NHA said she was unsure why the behavior progress notes did not include the intervention attempted to address Resident #1's behaviors or the effectiveness of the non-pharmalogical intervention. The NHA said whenever the facility developed new interventions for Resident #1, the interventions were added to his care plan and the care plan was updated after every occurrence the resident was involved in. -However, review of Resident #1's comprehensive care plan did not reveal new person centered interventions to address the resident's aggressive behaviors after the 10/14/24, 10/18/24, 11/2/24, 11/13/24 and 2/1/25 resident to resident altercations (see record review above). The NHA said the behavior care plan was updated after the resident to resident altercations. -However the updates made were to the focus behaviors and there had been no updates to the interventions since initiated on 6/27/24. The NHA said she reviewed the resident to resident altercations involving Resident #1. She acknowledged the facility implemented the same interventions that were put into place to prevent a recurrence on several occasions and were not person centered. V. Facility follow up The NHA provided documentation of one psychological visit note for Resident #1 on 2/11/25 at approximately 4:45 p.m. The note was dated 9/18/24 and revealed the resident had been discharged from services on 9/11/24 due to verbally aggressive behaviors during the therapist. The NHA said the psychological provider said the facility could attempt to put him back on services, but from 9/11/24 to 2/11/25 (the time of the survey) the resident was not receiving psychological services. No additional psychiatric visit notes were provided. The NHA provided documentation on 2/11/25 at approximately 4:45 p.m. that indicated the SSD had sent out referrals to 22 other skilled nursing facilities on 9/7/24 with six denials and sixteen facilities not responded. There were no additional documented efforts to find alternative placement provided by the NHA or SSD. -However, review of Resident #1's EMR did not reveal any other evidence of efforts to find alternative placement or a specialized facility for Resident #1 was provided (see record review above).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to ensure each resident was being screened for a mental disorder prior to admission or that residents identified with a mental disorder were evaluated to receive care and services in the most integrated setting to meet their needs for one (#9) of four residents reviewed out of 27 sample residents. Specifically, the failed failed to: -Notify the State Mental Health Agency Resident #9 had exceeded the 60 day convalescent preadmission screening and resident review (PASRR) period; and, -Submit a new PASRR to the State Mental Health Agency for Resident #9 to determine if a level II evaluation was needed. Findings include: I. Facility policy and procedure The PASRR (Pre-admission Screen and Resident Review) policy, dated [DATE], was provided by the nursing home administrator (NHA) on [DATE]. It revealed in pertinent part, Provisional Approval: Provisional approvals permit nursing facilities (NF) to accept a resident without a full level II evaluation (mental health evaluation) in certain circumstances that are time-limited or where the need for NF is clear. This determination is made by the State Mental Health Agency after review of the level I and other supporting documentation. These exemptions include: Convalescent Care: convalescent care is due to discharge from an acute care hospital. A physician determines that the resident will likely require fewer than 30 days of nursing services. A level I screen shall be submitted to the State Mental Health Agency if the resident remains at the facility past 30 days. II. Resident #9 A. Resident status Resident #9, age under 65, was admitted on [DATE]. According to the [DATE] computerized physician orders (CPO), the diagnoses included epilepsy and an intellectual disability. The [DATE] minimum data set (MDS) assessment revealed the resident was unable to participate in the brief interview for mental status (BIMS) due to being never or rarely understood. A staff assessment was never completed. The PASRR section on the assessment was blank. B. PASRR level II notice of determination for MI (mental illness) evaluation and facility failures The resident's pre-admission level I PASRR dated [DATE] revealed the resident was approved under a convalescent care admission. The PASRR included the end date of [DATE] for the convalescent care admission. It documented if the resident stayed past the end date, the facility would need to contact the State Mental Health Agency to have the resident evaluated for a level II. -There were no additional level I PASRR screens in the resident's chart to indicate the State Mental Health Agency was notified the resident had resided in the facility past the 60 day end date. This failure resulted in the resident not being screened for a level II PASRR and not being identified for any specialized services or needs. C. Record review The comprehensive care plan, revised on [DATE], revealed the resident had severe cognitive and communication deficits. He benefited from 24 hour nursing care and his guardians had no plans to move him. The resident was anticipated to remain for long term care. Progress notes reviewed from [DATE] to [DATE] revealed no social service notes were located documenting a new PASRR had been submitted. III. Staff interviews The resident care director (RSC) was interviewed on [DATE] at 11:15 a.m. The RSC said she completed the resident PASRR after admission, the hospital or sending facility completed the preadmission PASRR. If the preadmission PASRR indicated a time limit, the RSC would be responsible for sending in the update once the time limit had expired. She said residents who required a level II PASRR were residents with a major mental illness or a diagnosis of an intellectual or developmental disability. Resident #9 had a diagnosed intellectual disability and met the criteria for a level II PASRR. The importance of completing the level II PASRR was to receive a notice of determination from the State Mental Health Agency with instructions for specialized services and needs for the resident. She said she was not aware Resident #9 did not have a level II PASRR in his medical record. She said she would look for this, however she did not provide the PASRR. IV. Facility follow up On [DATE] at 2:42 p.m. a level II PASRR for Resident #9 was requested from the NHA. By time of survey exit on [DATE] at 2:00 p.m., no level II PASRR was provided by the facility for Resident #9.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to notify the state mental health agency promptly after a significant change in the mental condition of two (#45 and #128) of five residents out of 27 sample residents. Specifically, the facility failed to: -Notify the State Mental Health Agency of Resident #128 necessity for inpatient psychiatric hospitalizations; and, -Notify the State Mental Health Agency of Resident #45's suicide attempt and physical aggression towards others. Findings include: I. Facility policy and procedure The PASRR (Pre-admission Screen and Resident Review) policy, dated 9/26/23, was provided by the nursing home administrator (NHA) on 1/8/24. It revealed in pertinent part, If a resident's psychiatric status changes after admission, the social services staff are responsible for contacting the State Mental Health Agency via completion and submission of a PASRR level I screen and indicate the reason for referral as a change in mental health status or psychiatric diagnosis. Status change level I screens should be submitted in the following circumstances: significant deterioration in mental health condition; significant increase in psychiatric symptoms or psychiatric hospitalization, regardless of whether there is a change in diagnosis or medications. II. Resident #45 A. Resident status Resident #45, age [AGE], was admitted on [DATE]. According to the January 2024 computerized physician orders (CPO), the diagnoses included schizophrenia. The 10/9/23 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. The MDS assessment section for identification of a level II PASRR for a serious mental illness had not been completed. The depression screen and behavior section of the MDS assessment were incomplete. B. Record review The comprehensive care plan, revised on 10/27/23, revealed the resident had a level II PASRR due to a diagnosis of schizophrenia. He exhibited behaviors of throwing away his personal belongings and accidently taking his roommates belongings. The resident had impaired vision and was not aware he was taking others belongings. He also would give personal belongings and money away. Interventions include monitoring the resident's room for unfamiliar belongings, providing positive interaction and reminding the resident to maintain his personal property. -The care plan did not reflect behaviors of harm to self or others. Progress notes dated 12/4/23 through 1/4/24 revealed in pertinent part, Psychiatric follow up progress note dated 12/6/23 at 10:00 a.m. documented the resident had a depression assessment and scored nine out of 27 indicating mild depression. No reported or observed signs of suicidal or homicidal ideations. Nursing progress note dated 12/6/23 at 3:58 p.m. documented the resident had a trash can and a staff member attempted to take the trash can from him. The resident pulled the trash can from the staff and hit the staff member in the side of the face. Medical provider long term care follow up note dated 12/7/23 documented the provider was following up with the resident due to the assault on 12/6/23. The resident had punched the staff member in the face. The staff had been instructed to monitor the resident. The resident appeared stable during the provider visit. Medical provider long term care follow up note dated 12/10/23 documented the provider was following up due to increased behaviors. It was recommended there would be an increase in the resident's antipsychotic medication, perphenazine, due to worsening behaviors. Psychiatric follow up progress note dated 12/19/23 documented the resident appeared disheveled, underweight and guarded during the visit. He was irritable, uncooperative and avoided eye contact. No reported or observed signs of suicidal or homicidal ideations. Order administration note dated 1/1/24 documented the resident was found by staff with a gait belt (transfer belt) around his neck. No injury was noted. Medical provider long term care follow up note dated 1/5/24 documented the provider was following up due to worsening behaviors. The staff had reported finding the resident with a gait belt around his neck and was put on one-on-one staff supervision for concern of suicidal intent. The resident told the provider he did not remember how the gait belt got around his neck. -No progress notes were found documenting the State Mental Health Agency had been updated on the new behaviors the resident had displayed; the physical assault and a suicide attempt. The resident's pre-admission level II PASRR was reviewed. The level II notice of determination dated 6/1/18 identified the resident as meeting the criteria for PASRR mental illness. -The level II evaluation dated 6/1/18 did not show the resident had a history of harming self or others. III. Resident #128 A. Resident status Resident #128, age under 65, was admitted on [DATE]. According to the January 2024 CPO, the diagnoses included schizoaffective disorder bipolar type and paranoid personality disorder. The 10/9/23 MDS assessment revealed the resident had not been assessed for a BIMS. The MDS assessment section for identification of a level II PASRR for a serious mental illness had not been completed. The depression screen and behavior section of the MDS assessment were incomplete. B. Record review The comprehensive care plan, revised on 12/26/23, revealed the resident had a level II PASRR due to a diagnosis of schizophrenia and paranoid personality disorder. He exhibited behaviors suicidal ideations or interpreted behaviors such as verbalizations, statements of means and calling 911. Interventions included reporting all suicidal or homicidal ideations to management and educating the resident on appropriate communication methods. According to the January 2024 CPO, the resident had orders dated 12/18/23 to transfer to the hospital for expressions of suicidal ideations. Progress notes dated 12/4/23 through 1/4/24 revealed in pertinent part, Nursing progress note dated 12/18/23 documented the resident was transferred to the hospital after calling 911 and expressing intent to kill himself. Behavior note dated 12/19/23 documented the resident was showing signs of hallucinating and psychomotor agitation. Social services quarterly assessment dated [DATE] documented the resident was cognitively intact with a history of suicidal and homicidal ideations. The resident PASRR level II and recommendations were reviewed during the assessment. Nursing progress note dated 1/1/24 documented the resident was transported to the hospital after calling 911 and expressing suicidal ideations. Nursing progress note dated 1/4/24 documented the resident had called 911 and expressed he wanted to kill himself. The resident had a plan to hit his head or jump off of a table. The resident was handcuffed and taken to the hospital. -No progress notes were found documenting the State Mental Health Agency had been updated on the resident's worsening symptoms and repeated expressions of suicidal ideations. Psychiatric history and physical dated 11/27/23 documented the resident had readmitted to the facility on [DATE] after a mental health hold to a psychiatrist inpatient stay in the hospital post statements of suicidal ideations, threats to others and public masturbation. The resident's pre-admission level II PASRR was reviewed. The level II notice of determination dated 10/6/22 identified the resident as meeting the criteria for PASRR mental illness. The level II evaluation dated 10/6/22 showed the resident had a long history of psychiatric inpatient stays for stabilization and an inpatient stay for suicidal ideations. IV. Staff interview The resident care director (RSC) was interviewed on 1/8/24 at 11:15 a.m. She said a status change was sent into the State Mental Health Agency if a resident had new or worsening symptoms. She said new or worsening symptoms could be a resident exhibiting suicidal attempts or ideations when this was not a baseline behavior. If a resident had an inpatient psychiatric hospitalization due to needing to be stabilized, a status change update would be completed. She did not know why an update had not been sent for Resident #45 or Resident #128 but said the updates should have been sent in.

Based on observation, record review and interviews, the facility failed to ensure one (#3) of six residents reviewed for medication administration received treatment and care in accordance with professional standards of practice out of of 27 sample residents. Specifically, the facility failed to ensure that Resident #3 was not administered an expired inhaler as identified by the manufacturer's directions. Findings include: I. Professional references According to the Centers for Disease Control (CDC) website, retrieved on 1/18/24 from https://www.cdc.gov/wtc/prescriptionsafety.html#:~:text=You%20should%20dispose%20of%20any,or%20misusing%20the%20medication%20intentionally. included the following recommendations, You should dispose of any unused or expired prescription medicine as soon as possible. Timely disposal of prescription medicine can reduce the risk of others taking the medication accidentally or misusing the medication intentionally. According to the Food and Drug Administration (FDA) website, retrieved on 1/18/24 from https://www.fda.gov/drugs/special-features/dont-be-tempted-use-expired-medicines#:~:text=Expired%20medicines%20can%20be%20risky&text=Once%20the%20expiration%20date%20has,expired%2C%20do%20not%20use%20it. included the following recommendations, Once the expiration date has passed there is no guarantee that the medicine will be safe and effective. If your medicine has expired, do not use it. II. Manufacturer recommendations According to the Severent Diskus inhaler manufacturer guidelines, revised 10/22, retrieved on 1/9/24 from https://gskpro.com/content/dam/global/hcpportal/en_US/Prescribing_Information/Serevent_Diskus/pdf/SEREVENT-DISKUS-PI-MG-IFU.PDF on 12/28/23 included the following recommendations, Storage and handling Severent Diskus should be stored inside the unopened moisture-protective foil pouch and only removed from the pouch immediately before initial use. Discard Severent Diskus six weeks after opening the foil pouch or when the counter reads ' 0 ' (after all blisters have been used), whichever comes first. The inhaler is not reusable. Do not attempt to take the inhaler apart. III. Observations and interviews On 1/8/24 at 9:25 a.m., licensed practical nurse (LPN) #3 reviewed the Severent Diskus inhaler for Resident #3 from the medication cart. The inhaler had a written open date of 11/9/23. LPN #3 said the inhaler had expired. He said he had administered the inhaler for the morning dose. He said he would order a new one. On 1/9/24 at 9:20 a.m., LPN #3 identified the same inhaler from the previous day in the medication cart. He said he was going to order a new inhaler later that day and he had not removed the inhaler from when the inhaler was identified as expired. IV. Record review The computerized physician orders for Resident #3 identified he was ordered the Serevent Diskus inhaler twice a day, once in the morning and once in the evening. The January 2024 medication administration record (MAR) for Resident #3 had documentation that the resident had received the evening dose of the Serevent Diskus inhaler after the inhaler had been identified as expired. The evening nurse administered an expired inhaler after the medication had been identified as expired on 1/8/24 with LPN #3 (see above). The provider was not notified of the expired medication being administered twice on 1/8/24. V. Staff interviews The director of nursing (DON) was interviewed on 1/9/24 at 9:50 a.m. She said when a medication was ordered it usually would arrive in the afternoon or evening. She said the nurses had been trained how to order a medication if needed. She said when the inhaler had been identified as expired, it should have been removed from the medication cart and re-ordered. She said she did not want an expired medication to be administered to a resident for the safety of the medication. She said she would remove the inhaler from the medication cart immediately to ensure the safety of the resident and provide education to the nurse on duty.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interviews, the facility failed to provide appropriate treatment and services to maintain or improve the ability to perform activities of daily living (ADLs) for one (#3) of two residents reviewed for ADLs out of 27 residents. Specifically, the facility failed to provide supervision, oversight, encouragement and cueing with personal hygiene for Resident #3. Findings include: I. Resident status Resident #3, age [AGE], was admitted on [DATE]. According to the January 2024 computerized physician orders (CPO), diagnoses included schizoaffective disorder bipolar type and major depressive disorder recurrent. The 7/28/23 minimum data set (MDS) assessment documented the resident was cognitively impaired with a brief interview for mental status (BIMS) score of eight out of 15. The resident required supervision to one person assistance with personal hygiene and dressing. The assessment documented no behaviors of refusals of care. II. Observations and interview On 1/3/24 at 10:05 a.m. the resident was sitting in the common area. The resident's hair appeared to be greasy. The resident's shirt had what appeared to be stains from food or liquids on it. His teeth were discolored with debris. The resident was wearing shorts and a short sleeve shirt despite the weather ranging from 18 degree Fahrenheit (F) to 40 degree F. On 1/4/24 at 12:36 p.m. the resident was in his room. He was sitting on his bed. The resident's hair appeared to be greasy. The resident's shirt had what appeared to be stains from food or liquids on it. Holes could be seen in his shorts and his socks. The resident was wearing the same shorts from 1/3/24. The weather ranged from 25 degree F to 35 degree F on 1/4/24. On 1/8/24 at 9:38 a.m the resident was exiting the facility to the outside smoking section. He was wearing a jacket, a shirt and a pair of shorts. The temperature at the time was 22 degrees F. The resident passed licensed practical nurse (LPN) #3 who acknowledged the resident but did not say anything to him about his clothing. III. Record review The comprehensive care plan, revised 5/6/23, revealed the resident had impaired decision making abilities and required assistance to make safe, good decisions. The resident had poor safety awareness related to cognitive deficits and a traumatic brain injury. The resident had an ADL self care performance deficit related to cognitive impairments. Interventions included providing the resident with verbal cues and prompting. The resident had oral/dental health problems related to poor dentition. The resident required assistance with his ADLs and required staff to complete his oral care. Interventions included to assist with mouth care as per ADL self care personal hygiene. IV. Staff interview Certified nurse aide (CNA) #5 was interviewed on 1/8/24 at 8:30 a.m. She said Resident #3 did not refuse showers, changing his clothes or brushing his teeth. The CNAs provide cueing, prompting and stand by assistance for showers and dressing and one person assistance for brushing teeth. LPN #3 was interviewed on 1/8/24 at 8:54 a.m. He said Resident #3 was cooperative with care staff. The resident did not have a preference for shorts and was agreeable to receiving help from staff with changing clothes. The resident was independent physically in ADLs but had cognitive deficits requiring curing, prompting and stand-by assistance with showers, dressing and personal hygiene. The director of nursing (DON) and nursing home administrator were interviewed on 1/8/24 at 2:03 p.m. The DON said the resident required cueing up to one person assistance with personal hygiene tasks. She said the resident would refuse to change his clothes and choose clothing inappropriate for the weather. The DON was unaware the staff failed to document those behaviors. The staff interviews did not reveal the resident had these behaviors. The NHA said when she saw the resident wearing shorts, she would ask him if he would like to change into pants and he declined. -No further prompting or encouragement was provided per the NHA or risk-benefit education regarding wearing clothing not appropriate for the weather.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** V. Resident #3 A. Facility policy The Traditional Tobacco and Electronic Smoking Device policy, dated 3/10/23, was provided by the nursing home administrator (NHA) on 1/8/24 at 8:42 a.m. It read in pertinent part: Supervised smokers will have their smoking supplies secured at the nursing station. Staff will be responsible for distributing smoking materials during designated smoking times. Supervised smokers shall not be permitted to smoke without the direct supervision of a designated staff member, family member or volunteer. Direct supervision will be provided throughout the entire smoking period. B. Resident status Resident #3, age [AGE], was admitted on [DATE]. According to the January 2024 CPO, diagnoses included schizoaffective disorder bipolar type and major depressive disorder recurrent. The 10/20/23 MDS assessment documented the resident was cognitively impaired with a BIMS score of eight out of 15. The assessment documented no behaviors. C. Observation On 1/8/24 at 9:38 a.m. the resident was exiting the facility to the outside smoking section. He removed a lighter and cigarette from his jacket and began smoking unsupervised. The resident was standing two feet from the building. At 9:43 a.m. the resident threw his still lit cigarette on the floor next to the building and went back inside the facility. D. Record review The comprehensive care plan, revised 1/8/24, revealed the resident exhibits impaired decision making abilities and required assistance to make safe decisions. The resident was a supervised smoker due to being unable to manage his cigarettes independently. The resident was to wear a smoking apron due to lack of safety awareness. Interventions included to supervise the resident while smoking, monitor and observe the resident for unsafe smoking practices and keep the resident's smoking supplies in a box. The smoking/vaping risk evaluation dated 10/10/23 revealed: The resident was unable to light a cigarette with a lighter or match without difficulty and handle it securely and safely, he could not keep a lighter in personal possession, he would endanger himself or others when smoking, he would burn skin, clothing, or other, he did not extinguish cigarettes safely and completely when he had finished smoking get all his ashes in the ashtray. Behavior progress note dated 1/8/24 documented the resident was observed by staff smoking at 10:30 a.m. and staff reported this to the resident services director (RSD). The RSD obtained consent from the resident to search his room and person. One cigarette and a lighter were found in the resident's room. The RSD was unable to determine where the resident obtained a cigarette and lighter. The facility policy was provided to the resident along with a resident agreement to not violate the policy. E. Staff interview The RSD was interviewed on 1/8/24 at 11:08 a.m. The RSD was responsible for doing smoking assessments at admission and quarterly. She would observe the residents and conduct an interview with the resident to determine if the resident was safe to smoke independently. A list was provided to the floor staff and posted at the nurses station. The list included which residents could smoke unsupervised and which residents needed staff supervision to be taken out at smoke break times. No residents were allowed to keep lighters and had to request a lighter from the nurse designated to the resident's hall. Unsupervised smokers kept cigarettes but had to request a lighter and return the lighter to the nurse. Supervised smokers had to wait for designated smoking times and a staff escort to be given smoking materials. The RSD said a staff member had reported to her seeing Resident #3 smoking independently at 10:30 a.m. and she educated the resident on the policies. She was unaware the resident had been outside smoking unsupervised at 9:38 a.m. The resident was a supervised smoker and was supposed to wear a smoking apron due to decreased safety awareness. Based on observations, record review and interviews, the facility failed to ensure three (#60, #25 and #3) out of 27 sample residents remained free of accident hazards and received adequate supervision to prevent accidents. Specifically, the facility failed to: -Assess Resident #60 and #25's bolstered mattresses to ensure they remained free of accident hazards; and, -Provide supervision to Resident #3, who was a supervised smoker. Findings include: I. Resident #60 A. Resident status Resident #60, age [AGE], was admitted on [DATE]. According to the January 2024 computerized physician orders (CPO), diagnoses included dementia, depression and chronic systolic congestive heart failure. According to the 11/22/23 minimum data set (MDS) assessment, the resident had no cognitive impairment with a brief interview for mental status (BIMS) score of 14 out of 15. The resident had verbal behaviors toward others. The MDS revealed the resident had no falls since admission. B. Observations From 1/3/24 to 1/8/24 from 8:00 a.m. through 6:30 p.m. there was a bolstered mattress on Resident #60's bed. C. Record review The care plan, initiated 10/10/22 and revised 11/22/23, identified the resident had activities of daily living (ADL) self-care due to performance deficit related to poor endurance, vascular dementia, and chronic pain. Interventions include the resident was usually independent with his activites of daily living (ADLs). The resident may require some assistance. The resident was independent with bed mobility. -Resident #60 did not have a physician order for bolstered mattress. -Resident #60 did not have a care plan identifying use of bolstered mattress. -The facility did not complete a bolstered mattress assessment to identify the need for the mattress for Resident #60. D. Staff interview Certified nurse aide (CNA) #4 was interviewed on 1/4/24 at 10:12 a.m. She said she did not know why Resident #60 had a bolstered mattress as he was not a fall risk. She said he was independent of all ADLs. She said she would find out and return with an answer. CNA #4 returned. Licensed practical nurse (LPN) #3 was interviewed on 1/8/24 at 3:34 p.m. She said the resident had a bolstered mattress so the resident would not fall out of bed. II. Resident #25 A. Resident status Resident #25, age under 65, was admitted on [DATE]. According to the January 2024 CPO, diagnoses included multiple sclerosis, dementia, alcohol abuse and depression. According to the 11/28/23 MDS assessment, the resident had moderate cognitive impairment with a brief interview for mental status (BIMS) score of 11 out of 15. The resident had no behavioral symptoms. The MDS revealed the resident had no falls since admission. B. Observations From 1/3/24 to 1/8/24 from 8:00 a.m. through 6:30 p.m. there was a bolstered mattress on Resident #60's bed. C. Record review The care plan, initiated 8/23/23 and revised 11/28/23, identified the resident had an ADL self-care performance deficit related to history of hemiplegia affecting left side non dominant side and diagnosis of MS causing limited range of motion (ROM), contracture to left hand. Interventions including the resident require extensive assistance. The resident requires total assistance of One to two staff in order to dress his upper and lower body and to manage footwear. The resident requires total assistance with Hoyer (mechanical lift) transfer. Physical therapy and occupational therapy evaluation and treatment as per medical doctor (MD) orders. -A request was made on 1/8/23 at 1:09 p.m. for assessment for the bolstered mattress, risk benefit statement, care plan, consent to use bolstered mattress and physicians order lipped mattress. -At time of exit on 1/9/24 no requested documentation was provided. D. Staff interview CNA #8 was interviewed on 1/8/24 at 9:08 a.m. She said Resident #25 had the mattress so he would not fall out of bed. She said she did not know if he was a fall risk. LPN #4 was interviewed on 1/8/24 at 9:15 a.m. She said the reason Resident #25 had a lipped mattress so he would not fall out of the bed. IV. Administrative interview The director of nursing (DON) and the nursing home administrator (NHA) were interviewed on 1/8/24 at 1:09 p.m. The DON and NHA were told of the observations of Resident #60 and Resident #25's beds having bolstered mattresses. The NHA said that Resident #60 was moved from the second floor to the 100 hundred hall and staff did not bring his original mattress from the second floor. Resident #25 should not have a bolstered mattress on their bed. The NHA said the mattresses would be removed immediately.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** III. Resident #62 A. Resident status Resident #62, age [AGE], was admitted on [DATE]. According to the January 2024 CPO, diagnoses included schizoaffective, major depression, shortness of breath, history of falling and insomnia. According to the 12/6/23 MDS assessment, the resident had moderate cognitive impairment with a BIMS score of 12 out of 15. The resident had no behavioral symptoms. The MDS revealed the resident had two or more falls after admission. -It documented the resident was not receiving oxygen therapy. B. Observation and interview On 1/3/24 at 2:43 p.m. the resident was lying in bed sleeping and was not wearing his oxygen cannula. Resident #62's oxygen concentrator was set at one liter per minute (LPM). On 1/4/24 at 2:00 p.m. the resident was sleeping and he did have his oxygen cannula on. The resident's concentrator was set at one LPM. On 1/8/24 at 10:07 a.m. Resident #62 was sitting in his wheelchair slumped forward. The resident was observed to be short of breath and was struggling to catch his breath. He was not wearing his oxygen cannula. The oxygen concentrator was set to one LPM. LPN #5 observed Resident #62 sitting in his wheelchair with his oxygen cannula off. LPN #5 asked Resident #62 if it was okay to check his oxygen. Resident #62 gave LPN #5 his finger and LPN #5 checked his oxygen saturation level. The pulse oximeter read 86. LPN #5 located the resident's oxygen cannula at the foot of the bed and placed it back on the resident. LPN #5 said the resident's oxygen was at one LPM, should have been set at two LPM and he adjusted the resident oxygen level. He said oxygen was a medication and the physician order should have been followed. C. Record review -A review of the comprehensive care plan revealed he did not have a care plan for the use of oxygen. The January 2024 CPO included an oxygen order for O2 at 2 liters per minute (LPM) via nasal cannula continuous. May titrate liter flow to maintain saturation of 90 percent or above. Start date 12/30/23. D. Staff interview The DON was interviewed on 1/8/24 at 1:15 p.m. She said oxygen was a medication. She said Resident #62's oxygen should have been administered as the provider ordered it. The DON said a negative outcome from not being administered oxygen when ordered could be altered mental status, dizziness, falls and hypoxic (low blood oxygen) events and could have put the residents in respiratory distress. Based on observations, record review and interviews, the facility failed to ensure residents who needed respiratory care were provided such care, consistent with professional standards of practice for one (#33 and #62) of three residents reviewed for the use of supplemental oxygen of 27 sample residents. Specifically, the facility failed to: -Have an oxygen order in place for an individual requiring supplemental oxygen to include correct liter flow for Resident #33; and, -Ensure oxygen was provided as ordered for Resident #62. Findings include: I. Facility policy The Oxygen policy, dated 4/14/23, was provided by the nursing home administrator (NHA) on 1/8/24 at 11:51 a.m., included, Oxygen is administered under orders of a physician, except in the case of an emergency. In such cases, oxygen is administered and orders for oxygen are obtained as soon as practicable when the situation is under control. Staff shall document the initial and ongoing assessment of the resident's condition warranting oxygen and the response to oxygen therapy. Staff shall notify the physician of any changes in the resident's condition, including changes in vital signs, oxygen concentrations, or evidence of complications associated with the use of oxygen. II. Resident #33 A. Resident status Resident #33, age over 65, was admitted on [DATE]. According to the January 2024 computerized physician orders (CPO), diagnoses included hypertension and insomnia. The 12/14/23 minimum data set (MDS) assessment revealed the resident's mental status was moderately impaired with a brief interview for mental status (BIMS) score of nine out of 15. The use of oxygen was not identified in the assessment. B. Observations Resident #33 was in his room on 1/3/24 at 10:25 a.m. with the nasal cannula (NC) on with the concentrator set to three liters. Resident #33 was in his room on 1/8/24 at 10:55 a.m. with the nasal cannula on and the concentrator set to two liters. C. Record review -Review of the resident's comprehensive care plan revealed it did not address the use of oxygen. -Review of the January 2024 CPO revealed the resident did not have an order for oxygen. D. Staff interviews Certified nurse aide (CNA) #2 was interviewed on 1/8/24 at 10:55 a.m. She said Resident #33 had only been in the facility for a couple of weeks. She said he was on two liters of oxygen. She said the liter flow was reported to her by other CNAs. Licensed practical nurse (LPN) #3 was interviewed on 1/8/24 at 10:57 a.m. He said Resident #33 was on two liters of oxygen. He said he could not locate an order for the oxygen. He said the resident had been on oxygen since he had been admitted . He said he did not know if two liters was correct if the resident had the concentrator set to three liters the previous week. He said oxygen was a medication, but he did not need an order to have the resident on the oxygen. The director of nursing (DON) was interviewed on 1/8/24 at 11:05 a.m. She said oxygen was considered a medication and required a physician's order. She said Resident #33 did utilize oxygen. She said she was not aware the resident did not have an order for the use of oxygen. She said he should have had an order to ensure he was receiving the correct liter flow.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to ensure one (#45) of three residents diagnosed with a mental disorder or psychosocial adjustment difficulty received appropriate treatment and services to attain the highest practicable mental and psychosocial wellbeing out of 27 sample residents. Specifically, the facility failed to ensure Resident #45 who expressed suicidal ideations was assessed and provided psychosocial support. Findings include: I. Resident #45 A. Resident status Resident #45, age [AGE], was admitted on [DATE]. According to the January 2024 computerized physician orders (CPO), the diagnoses included schizophrenia. The 10/9/23 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. The mood assessment showed the resident denied any symptoms of depression. B. Resident observation and interview On 1/3/24 at 10:00 a.m. the resident was interviewed in his room. He said he did not remember the incident of trying to harm himself. The resident appeared unkempt and disheveled. He did not have any sheets, shoes or personal items visible. C. Record review The comprehensive care plan, revised on 10/27/23, revealed the resident exhibited behaviors of throwing away his personal belongings and accidentally taking his roommates belongings. The resident had impaired vision and was not aware he was taking others belongings. He also would give personal belongings and money away. Interventions include monitoring the resident's room for unfamiliar belongings, providing positive interaction and reminding the resident to maintain his personal property. -The care plan did not reflect behaviors of harm to self or others. The January 2024 CPO revealed the following physician orders: Perphenazine (antipsychotic) 2 MG (milligrams)- give 1 MG tablet one time a day for schizophrenia to take with 2 MG to equal 3 MG-ordered on 6/18/22 and discontinued on 12/11/23. Perphenazine 4 MG- give one time a day for schizophrenia -ordered on 12/11/23. Document behaviors observed and interventions in progress notes-ordered on 9/13/22. Progress notes dated 1/1/24 through 1/5/24 revealed in pertinent part, Order administration note dated 1/1/24 at 6:19 a.m. documented the resident was found by staff with a gait belt (transfer belt) around his neck. No injury was noted. Order administration note dated 1/1/24 at 9:36 p.m. documented the resident was spending an extended amount of time in his bathroom. Medical provider long term care follow up note dated 1/5/24 documented staff had reported finding the resident with a gait belt around his neck and the facility believed it was a suicide attempt. The resident had been put on one-on-one staff supervision. -The medical record failed to reveal an assessment for suicide lethality or psychosocial follow up. II. Staff interviews The concierge (CCE) was interviewed on 1/3/24 at 9:48 a.m. She was sitting outside of the resident's room. She said she was told the resident tried to hang himself with a gait belt. She was to provide one-on-one supervision to the resident. The resident service director (RSD) was interviewed on 1/8/24 at 11:08 a.m. She said a resident showing suicidal ideations or attempts had a suicide lethality assessment completed the same day as the incident. Once the assessment had been done, a safety plan was created with the resident. The resident's care plan was updated to reflect the incident and safety plan. The resident would have a sitter put into place for 72 hours and then transition to 15 minute checks if needed. The RSD said Resident #45 should have had an assessment done and updates to his care plan. -However, the medical record did not have an assessment, safety plan and the care plan was not updated. III. Facility follow-up The facility completed a suicide/homicide risk evaluation on 1/8/24 at 11:52 p.m. (during the survey). The resident did not express current thoughts of self harm and the facility would develop a safety plan with him per the evaluation. -The evaluation was completed seven days after the suicide attempt. -The facility did not provide a safety plan.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and staff interviews, the facility failed to maintain a sanitary, orderly and comfortable environment for residents in 14 of 40 resident rooms in six hallways. Specifically, the facility failed to ensure walls, floors, baseboards, doors and ceilings were properly maintained and rooms were free of trash and floors deep cleaned. Findings include: I. Initial observations Observations of the resident living environment were conducted on 1/8/24 at 9:18 a.m. revealed: room [ROOM NUMBER]: The wall next to the resident's bed had sticker residue from four large picture adhesive tape on the wall. The wood chair molding was missing a section approximately seven inches long by four inches wide. The closet door was off the rails and leaning against the wall. The floors had trash and debris underneath the resident's bed. The edges of the whole room and under the baseboard heater had a large build of dirt. The transition strip at the entrance door was missing which had approximately a one-fourth inch lip. The ceiling outside of room [ROOM NUMBER] had a large water stain approximately four feet wide by three feet wide. room [ROOM NUMBER]: The wall next to the resident's headboard had chipped and peeling paint. There were nine pea sized holes above the toilet paper dispenser. The caulking around the sink had an area approximately 17 inches long that was missing and there was caulking on the other side of the sink that had black matter on it. The floors had trash and debris underneath the resident's bed. The edges of the whole room and under the baseboard heater had a large build of dirt. The transition strip at the entrance door was missing which had approximately a one-fourth inch lip. room [ROOM NUMBER]: The restroom had an area approximately four feet by four feet with water damaged tiles which were discolored and brown. The wall next to the restroom had scratched and chipped paint from the wheelchair hitting the wall. There were four large nails sticking out of the wall behind the resident's recliner. The floors had trash and debris underneath the resident's bed. The edges of the whole room and under the baseboard heater had a large build of dirt. The transition strip at the entrance door was missing which had approximately a one-fourth inch lip. room [ROOM NUMBER]: The wall next to the restroom had 16 pea sized holes. The room had a strong odor of urine. The floor in the restroom was sticky and had yellow stains. The baseboard cove next to the restroom was falling off the wall. The resident's oxygen concentrator was plugged into a non-medical grade power strip. The floors had trash and debris underneath the resident's bed. The edges of the whole room and under the baseboard heater had a large build of dirt. room [ROOM NUMBER]: The wall in the middle of the room had three dime sized holes. The door had deep chips and splintering wood approximately three feet high. The floors had trash and debris underneath the resident's bed. The edges of the whole room and under the baseboard heater had a large build of dirt. room [ROOM NUMBER]: The resident's wall had 17 metal picture clips on the wall. The door had deep chips and splintering wood approximately three feet high. The resident's oxygen concentrator was plugged into a non-medical grade power strip. The edges of the whole room and under the baseboard heater had a large build of dirt. The shower room on the 100 hundred hall had water damage with the sheetrock being soft and crumbly due to the absorption of water. The floor tile outside of the shower room had white water spots approximately 15 feet along the west wall and 10 feet toward the dining room. room [ROOM NUMBER]: The bathroom floor tiles had brown water stains from a water leak. The edges of the whole room and under the baseboard heater had a large build of dirt. room [ROOM NUMBER]. The resident's window blinds were broken. The laminate underneath the sink was chipped and missing a section approximately four inches long by two inches wide. The corner next to the sink had chipped and damaged sheet rock approximately 13 inches high by two inches wide from the wheelchair hitting the corner. The floor tiles were damaged and broken approximately 12 inches long by two inches thick. The floors had trash and debris underneath the resident's bed. The edges of the whole room and under the baseboard heater had a large build of dirt. The wall in the dining room had a corner wall approximately five feet high by five inches wide with bubbling and peeling paint. The wall underneath the table had an area approximately seven feet long by four feet high with chipped and peeling paint. The corner behind a cabinet had trash and debris and the edges of the whole dining room and under the baseboard heater had a large build of dirt. The elevator had a chipped and broken panel approximately seven inches high by five inches wide which was falling off. The elevator floor had yellow stains and the corners of the floor with built up dirt. The second floor common area floors were stained from various liquids which had been spilled. The edges of the whole common area, behind the furniture and under the baseboard heater had a large build of dirt. The wood edging was chipped and splintering. The ceiling had several tiles which were missing and another area of water damage on the ceiling tile had water stains approximately 12 inches wide by seven inches wide. room [ROOM NUMBER]: The wall next to the resident's bed had six pea sized holes. The wall next to the resident's sink had an area approximately three feet wide by two feet high which had chipped and peeling sheetrock. The corner next to the sink had chipped and peeling sheetrock approximately 14 inches high by three inches wide with the metal corner strip visible. The closet door behind the entrance door had a large hole from the door knob slamming into it. The floors had trash and debris underneath the resident's bed. The edges of the whole room and under the baseboard heater had a large build of dirt. The tile outside of the phone room had a white discolored paint stain approximately 12 inches by 12 inches. room [ROOM NUMBER]: The floors had trash and debris underneath the resident's bed. The edges of the whole room and under the baseboard heater had a large build of dirt. The entrance had a missing transition strip with a one-fourth inch lip. Room # 201: The floors were sticky and stained from unknown liquid. The floor tiles next to the 200 hall were damaged, chipped and had medium brown stains approximately 16 feet long by three feet inches wide with a one-fourth inch lip. The sheetrock outside of the shower room had water damage approximately four feet high by six feet long with the sheetrock soft and crumbly from the water damage. room [ROOM NUMBER]: The resident's restroom floor was sticky and had yellow stains on the floor. The floors had trash and debris underneath the resident's bed. The edges of the whole room and under the baseboard heater had a large build of dirt. room [ROOM NUMBER]: The wall next to the resident's bed had an area approximately four feet by five feet of peeling and chipped sheetrock. II. Environmental tour and staff interview The environmental tour was conducted with the maintenance supervisor (MS) and environmental regional director ([NAME]) on 1/9/24 at 9:44 a.m. The above detailed observations were reviewed. The MS documented the environmental concerns. The MS said staff had not been utilizing the work orders, had recently been educated on the work order process and how to fill out requisition requests for repairs in the facility, which were located at each nursing station. The MS said he did not have any repair requisition requests for the above-mentioned items. The MS said the above-mentioned damage should have been repaired and addressed in a timely manner.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to ensure five (#56, #34, #3, #45 and #128) of six residents were free from unnecessary psychotropic medications out of 27 sample residents. Specifically, the facility failed to: -Implement effective individualized behavior monitoring in the medical record and follow physician orders to determine the efficacy of psychoactive medications for Residents #56, #34, #3 and #128; -Track behaviors of sexual aggression for Resident #128; and, -Update behavior tracking to reflect an increase in an antipsychotic medication for Resident #45. Findings include: I. Facility policy The Behavior Monitoring policy, dated 3/10/23, was provided by the nursing home administrator (NHA) on 1/8/24 at 8:42 a.m. It read in pertinent part: Specific behavior(s) documentation will be utilized to monitor residents and behaviors. Identify the potential cause of the behavior(s), Attempt to eliminate or decrease the behavior(s) through interventions, Document the specific and observable behaviors such as continuous pacing, biting, kicking, crying, grabbing, hitting, repetitive questions/concerns, hallucinations, paranoia or verbalizations of delusions. The Psychopharmacological policy, dated 3/10/23, was provided by the NHA on 1/8/24 at 8:42 a.m. It read in pertinent part: Licensed nurses and additional staff will monitor and document any targeted behaviors that occur. These behaviors will be documented on one or more of the following: Point of Care (POC), Progress Notes, or on a Risk Management Incident Report II. Resident #56 A. Resident status Resident #56, age under 65, was admitted on [DATE]. According to the January 2024 computerized physician order (CPO), diagnoses included paranoid schizophrenia. The 12/20/23 minimum data set (MDS) assessment documented the resident was cognitively intact with a brief interview of mental status (BIMS) score of 15 out of 15. The behavior section of the MDS assessment had not been completed. B. Record review The comprehensive care plan, initiated 6/8/21, revealed the resident experienced hallucinations, delusions and behaviors of self harm. The resident frequently heard voices and if he became overwhelmed by the voices, he would bang his head against the wall. The resident had a history of banging his head against the wall and causing a traumatic brain injury. Interventions included to redirect the resident to independent activities of interest such as video games or putting on Beatles music for him. Staff were to monitor behavior episodes and attempt to determine the underlying cause. The January 2024 CPO revealed the following physician orders: Clozapine (antipsychotic) 50 milligram (MG)- give one time a day for paranoid schizophrenia-ordered on 9/27/22. Clozapine 100 MG- give two times a day for paranoid schizophrenia-ordered on 9/27/22. Clozapine 200 MG- give two times a day for paranoid schizophrenia-ordered on 9/27/22. Document behaviors observed and interventions in progress notes-ordered on 9/13/22. A review of the resident's medication administration records (MAR) and treatment administration records (TAR) from 12/1/23 to 1/7/24 revealed: Behaviors indicated as occurring on 12/3/23, 12/9/23, 12/10/23, 12/16/23, 12/23/23, 12/25/23, 1/6/24 and 1/7/24. -There were no descriptions of the behaviors observed indicated in the resident's progress notes, the interventions tried to address the behaviors or if the interventions were effective. III. Resident #34 A. Resident status Resident #34, age [AGE], was admitted on [DATE]. According to the January 2024 CPO, diagnoses included dementia, depression and epilepsy. According to the 10/20/23 MDS assessment, the resident had severe cognitive impairment with a BIMS score of four out of 15. The resident had no behavioral symptoms. B. Record review The care plan, initiated 5/26/2020 and revised 11/10/23, identified the resident was receiving psychotropic medications for the symptoms of behaviors. The resident's current medication was Risperdal. The resident had a history of gradual dose reduction (GDR) with this Risperdal and had become physically aggressive towards peers during the GDR trials. Do not GDR this medication. Interventions include utilizing non-pharmacological interventions as possible. Medication reductions and or risk benefit assessments as indicated. Monitor for medication effectiveness, behaviors, administer medications per physician order, quarterly medication management review, labs per physician orders, abnormal involuntary movement (AIMS) quarterly or as needed, and assess for side effects as needed. Monitor for dermatologic reactions during lamotrigine therapy and monitor for symptoms of immune system reactions-fever, rash blood dyscrasias (blood disorder) any are noted-notify the prescriber for possible discontinue and initiation of alternative anticonvulsant therapy. The care plan, initiated 5/26/20 and revised 11/10/23, identified the resident had behaviors of agitation, physical and verbal aggression toward others and making false allegations. The resident can become physically aggressive (pushing, hitting others with his fists or objects) related to neurocognitive disorder with aggression, traumatic brain injury (TBI), paranoid and delusional disorder. Interventions include analyzing the times of day, places, circumstances, triggers and what de-escalates behaviors and documents. Medication monitoring; document paranoid statements every shift (Q shift), document verbal aggression q shift, was resident paranoid regarding money q shift and were paranoid statements regarding staff or peers made. The January 2024 CPO included: -Ativan 0.5 mg tab by mouth two times a day for anxiety related to dementia. Start date 9/26/23. -Risperidone 1 mg tab by mouth two times a day related to unspecified dementia, unspecified severity with other behavioral disturbance. Start date 8/15/23. -Please document behaviors observed and interventions in progress note every shift related to unspecified dementia with behavioral disturbance. Start date 9/13/22. -Behavior documentation for Ativan and Risperidone revealed there were no behaviors documented for November 2023 to 1/8/24. A written request was made for behavior tracking in the Foresight behavior tracking was requested on 1/8/24 at 1:29 p.m. -At time of exit on 1/9/24, no requested documentation was provided. IV. Resident #3 A. Resident status Resident #3, age [AGE], was admitted on [DATE]. According to the January 2024 CPO, diagnoses included schizoaffective disorder bipolar type and major depressive disorder recurrent. The 10/20/23 MDS assessment documented the resident was cognitively impaired with a BIMS score of eight out of 15. The assessment documented no behaviors. B. Record review The comprehensive care plan, revised 5/16/23, revealed the resident had a history of sexually inappropriate behaviors and a history of wandering. The resident had delusions and a potential for suicidal ideations or self harm. Interventions included to report inappropriate behaviors to nursing and track on behavior tracking log. Staff were to engage the resident in activities of interest, provide education on boundaries, and follow the facility self harm protocol. The January 2024 CPO revealed the following physician orders: Clozapine 200 MG- give two tablets one time a day for schizoaffective disorder bipolar type-ordered on 8/11/21. Clozapine 50 MG- give one time a day for schizoaffective disorder bipolar type-ordered on 9/8/21. Document behaviors observed and interventions in progress notes-ordered on 9/13/22. A review of the resident's MAR and TAR from 12/1/23 to 1/7/24 revealed: Behaviors indicated as occurring on 12/2/23, 12/3/23, 12/9/23, 12/10/23, 12/16/23, 12/23/23,12/24/23, 1/6/24 and 1/7/24. -There were no descriptions of the behaviors observed in the resident's progress notes, the interventions tried to address the behaviors or if the interventions were effective. V. Resident #128 A. Resident status Resident #128, age under 65, was admitted on [DATE]. According to the January 2024 CPO, the diagnoses included schizoaffective disorder bipolar type and paranoid personality disorder. The 10/9/23 MDS assessment revealed the resident had not been assessed for a BIMS. The behavior section of the MDS assessment had not been completed. B. Record review The comprehensive care plan, revised on 12/26/23, revealed the resident had sexually inappropriate behaviors such as making verbally explicit comments or suggestions, attempting to follow staff or other residents making others uncomfortable with a history of sexually assaulting women. The resident had shown no interest in alternative ways to satisfy his sexual needs and needed continual reminders of acceptable public behavior. Interventions included to redirect the resident's sexual feelings, expressions, and needs to appropriate outlets. The resident had behaviors of anger manifestations displayed as excessive or unrealistic anxiety. Interventions included assisting the resident in learning relaxation techniques as a coping skill. He exhibited behaviors of suicidal ideations or interpreted behaviors such as verbalizations, statements of means and calling 911. Interventions included reporting all suicidal or homicidal ideations to management and educating the resident on appropriate communication methods. The January 2024 CPO revealed the following physician orders: Clozapine 250 MG- give one time a day for schizoaffective disorder bipolar type-ordered on 11/10/23 and discontinued 12/12/23. Clozapine 200 MG- give two tablets one time a day for schizoaffective disorder bipolar type-ordered on 12/12/23. Depakote (mood stabilizer) 1000 MG-give one time a day for schizoaffective disorder bipolar type-ordered on 11/10/23 and discontinued 12/12/23. Fluphenazine (antipsychotic) injection 25 MG/milliliter (ML)-give 0.75 ML intramuscular (IM) injection one time a day every 21 days for schizoaffective disorder bipolar type-ordered on 12/12/23 and discontinued 12/14/23. Fluphenazine injection 25 MG/ML-give 0.75 ML IM injection one time a day every 21 days for schizoaffective disorder bipolar type-ordered on 12/14/23. Depakote 500 MG- give one tablet two times a day for schizophrenia- ordered on 12/12/23 and discontinued on 12/14/23. Depakote 125 MG- give one tablet two times a day for a total of 375 MG a day for schizoaffective disorder bipolar type-ordered on 12/14/23. -There was no physician order for behavior monitoring. The admission packet from the psychiatric inpatient unit dated 9/4/21 documented the resident had a history of self mutilation, biting himself and banging his head. He had a history of physical and verbal aggression along with unwanted touching of female staff members and exposing his penis. It was recommended by the hospital he be discharged to a secure locked all male unit. The level II preadmission screening and resident review (PASRR) evaluation dated 10/6/22 showed the resident had a long history of psychiatric inpatient stays for suicidal ideations and sexual aggression. At the time of the evaluation, staff had reported hypersexual behavior and verbal aggression toward female staff. The resident frequently displayed verbal aggression and threats of sexual violence towards female staff and residents. The resident had not acted on threats but had a history of incarceration due to perpetration in a sexual assault. The facility placed the resident on one-on-one supervision to ensure staff and resident safety. Psychiatric history and physical dated 11/27/23 documented the resident had readmitted to the facility on [DATE] after a mental health hold to a psychiatrist inpatient stay in the hospital post statements of suicidal ideations, threats to others, and public masturbation in front of peers and staff. A review of progress notes from 11/25/23 to 1/7/24 revealed: Nursing progress note dated 11/25/23 documented the resident was transported to the hospital after calling 911 and expressing suicidal ideations. Nursing progress note dated 12/12/23 documented the resident had returned from the hospital. Nursing progress note dated 12/17/23 documented the resident had refused to take his psychotropic medications. Nursing progress note dated 12/18/23 documented the resident was transferred to the hospital on [DATE] after calling 911 and expressing intent to kill himself. Nursing progress note dated 12/18/23 documented resident had returned from the hospital at 9:50 a.m. Nursing progress note dated 12/18/23 at 9:24 p.m. documented the resident had refused to take his psychotropic medications. Behavior note dated 12/19/23 documented the resident was showing signs of hallucinating and psychomotor agitation. Behavior note dated 12/21/23 at 11:28 a.m. documented the resident approached staff and stated he no longer wanted to be in the facility and wanted to go to a sex lodge. He explicitly explained he needed to have oral sex performed on him. The resident was offered visual stimulation videos and personal masturbation devices which he refused. He repeated he needed to go to a sex lodge. Behavior note dated 12/21/23 at 11:30 a.m. documented the resident went to the NHA and director of nursing (DON) and asked to go to a sex lodge. He again explicitly explained he needed to have oral sex performed on him. The resident was offered visual stimulation videos and personal masturbation devices which he refused. The social worker was informed and the resident was placed on 15 minute checks from staff. Social services quarterly evaluation dated 12/25/23 documented the resident occasionally expressed sexual ideations. Nursing progress note dated 12/31/23 documented the resident had refused to take his psychotropic medications. Nursing progress note dated 1/1/24 documented the resident was transported to the hospital after calling 911 and expressing suicidal ideations. Behavior note 1/2/24 documented the resident had been responding to internal stimuli (voices) and stated his head was getting louder. The resident refused his medications. He was pacing and attempted to elope from the facility but was redirected. Nursing progress note dated 1/4/24 documented the resident had called 911 and expressed homicidal and suicidal thoughts. The resident had a plan to hit his head or jump off of a table. The resident was handcuffed and taken to the hospital. VI. Resident #45 A. Resident status Resident #45, age [AGE], was admitted on [DATE]. According to the January 2024 CPO, the diagnoses included schizophrenia. The 10/9/23 MDS assessment revealed the resident was cognitively intact with a BIMS score of fifteen out of 15. The behavior section of the MDS assessment had not been completed. B. Record review The comprehensive care plan, revised on 8/10/23, revealed the resident took antipsychotic medications related to his diagnosis of schizophrenia. Interventions included to monitor behaviors related to antipsychotic medications. Review behaviors/interventions and alternative therapies attempted and effectiveness according to facility policy. The January 2024 CPO revealed the following physician orders: Perphenazine (antipsychotic) 2 MG- give 1 MG tablet one time a day for schizophrenia to take with 2 MG to equal 3 MG-ordered on 6/18/22 and discontinued on 12/11/23. Perphenazine 4 MG- give one time a day for schizophrenia -ordered on 12/11/23. Document behaviors observed and interventions in progress notes-ordered on 9/13/22. Progress notes dated 12/6/23 through 1/4/24 revealed in pertinent part, Nursing progress note dated 12/6/23 documented the resident had a trash can and a staff member attempted to take the trash can from him. The resident pulled the trash can from the staff and hit the staff member in the side of the face. No further details were documented. Medical provider long term care follow up note dated 12/10/23 documented the provider followed up due to increased behaviors. It was recommended the resident's antipsychotic medication be increased, perphenazine, due to worsening behaviors. Psychiatric follow up progress note dated 12/19/23 documented the resident appeared disheveled and guarded during the visit. He had been irritable and uncooperative with the provider. No reported or observed signs of homicidal ideations. The resident's pre-admission level II PASRR was reviewed. The level II evaluation dated 6/1/18 did not show the resident had a history of harming others. VI. Staff interviews Certified nurse aide (CNA) #2 was interviewed on 1/8/24 at 8:30 a.m. She said Resident #34 did not have any behaviors and the resident stayed in his room and sat in his recliner and watched television. She said if a resident had a behavior she would tell the nurse what was going on. Licensed practical nurse (LPN) #3 was interviewed on 1/8/24 at 8:54 a.m. LPN #3 said the nursing track behaviors on the resident's TAR. The specific behaviors and interventions were to be charted in the resident's progress note. He did not know where the certified nursing aides (CNA) documented residents' behaviors. If the social worker or the director of nursing (DON) wanted to communicate particular target behaviors or interventions, it would be put in the communication section of the resident's electronic medical record but only remained there for a few days. He did not know how this information was communicated to staff who had missed the notification in the electronic medical record. LPN #3 said he did not look in the resident's care plan for target behaviors or non-pharmacological interventions. He said Resident #56 did not have behaviors. He did not know what type of medication the resident's Clozaril was or why specifically it was being administered. Resident #128 had behaviors of calling 911, refusing medications, suicidal and homicidal ideations. LPN #3 was not aware of any sexually inappropriate history to monitor Resident #128 for. Resident #3 was cooperative with staff and had no behaviors. LPN #4 was interviewed on 1/8/24 at 9:09 a.m. She said Resident #45 had behaviors of tearing his clothes, sheets and blankets apart. LPN #4 said nursing track behaviors on the TAR and then progress note the specific behaviors and interventions. CNAs track behaviors in a separate tracking system called Foresight. It was a computer tracking program separate from the resident medical record. The nurse could track in Foresight as well, however LPN #4 said she could not recall her login information. CNA #5 was interviewed on 1/8/24 at 9:15 a.m. She said resident behaviors were in the resident [NAME] (abbreviated care plan) but the behaviors were generic and not individualized. If CNAs wanted to document resident specific behaviors, the CNAs used Foresight. CNA #5 attempted to login but could not recall her login information. CNA #6 was interviewed on 1/8/24 at 9:25 a.m. He said Resident #45 had behaviors of tearing up his clothes and his roommate's belongings. CNAs track resident behaviors in Foresight. LPN #2 was interviewed on 1/8/24 at 9:50 a.m. She said the nurses track behaviors on the TAR and in Foresight. -However, she was unable to locate the login website and could not recall her login information. LPN #2 said she documented on the resident's TAR only. CNA #1 was interviewed on 1/8/24 at 9:55 a.m. He said Foresight was only on the CNA computers on the first floor of the facility. He said CNAs tracked in Foresight only and not on the [NAME]. LPN #4 and CNA #6 were interviewed again on 1/8/24 at 10:00 a.m. CNA #6 did not have his login information to get into Foresight. LPN #4 said the facility had been using Foresight for five years to track behaviors but she used the resident's TAR. LPN #4 and CNA #6 did know how behaviors marked in Foresight were incorporated into the resident's electronic medical record. CNA #9 was interviewed on 1/8/24 at 10:05 a.m. She was able to login into Foresight. She said CNAs use the [NAME] for behaviors and if the behaviors were more serious, the CNAs would document in Foresight. The resident care director (RSC) was interviewed on 1/8/24 at 11:15 a.m. Resident #3 and Resident #56 did not have behaviors. Resident #128 had behaviors of expressing suicidal ideations in order to be sent out to the hospital. Resident #128 had not had any inappropriate sexual behaviors towards female staff or residents since RSC started working at the facility in June of 2023. The facility had not initiated behavior tracking for this behavior because it was not an active behavior of his and he had not exhibited any sexual ideations, despite documentation showing sexual ideations as recent as November and December 2023. Licensed practical nurse (LPN) #5 was interviewed on 1/8/24 at 1:07 p.m. She said Resident #34 spent the majority of his time in his room watching television. She said the resident was compliant with taking his medication and never really had any behaviors to speak of. She said the resident would yell things throughout the day but that was just typical of Resident #34. The director of nursing (DON) was interviewed on 1/8/24 at 1:09 p.m. The DON said the problem with documenting Resident #34's behavior was that staff would see his behaviors as typical baseline behaviors and his behaviors were not being tracked correctly. She said the facility needed to change how staff were documenting behaviors for all residents. The DON said a negative outcome for not correctly identifying behaviors for a resident could be isolation, paranoia, added depression and the use of unnecessary medications. The RSC, the NHA and the DON were interviewed on 1/8/24 at 1:34 p.m. The NHA said the facility used the tracking on the TAR in the electronic medical record and Foresight program. The staff were more accustomed to using Foresight but the goal was to integrate tracking to just the electronic medical record. The nurses made a progress note after marking a behavior on the TAR. The RSC and DON had just started putting the quarterly summaries from Foresight into the electronic medical record as a progress note. -However, these summaries were not in the progress notes for Residents #56, #35, #3, #45 or #128. The DON said the behavior tracking on the TAR were not personalized because the severity of the mental illness amongst the facility's residents on psychoactive medications would require too many behaviors listed on the tracker. The NHA and RSC were responsible for entering the behaviors into Foresight to be tracked. The NHA said the nurses should be checking the residents' care plan and reading the psychotropic drug committee notes to find target behaviors and non-pharmacological interventions. The nurses should be able to determine the behaviors to track based on the resident's diagnosis alone. She was not aware the staff were not utilizing Foresight and nurses were not making supplemental progress notes to explain behaviors indicated. CNA #6 was interviewed on 1/8/24 at 1:55 p.m. She said Resident #34 yelled all day and he was now trying to kiss female CNAs when he got a chance. She said the resident would yell out all day long. She said his yelling gets out of control at times but staff just go in and check to see if he needs anything. She said when a resident would have behaviors she would report them to the nurse on duty. She said she did not use foresight but would tell the nurse on duty of the resident's behaviors. V. Facility follow-up On 1/8/24 at 11:25 a.m. six months of behavior tracking were requested from the NHA for Resident #45, #56, #3 and #128. On 1/8/24 at 11:56 a.m. only behavior tracking from Foresight was provided by the NHA for Resident #45, #56, #3 and #128. Behavior tracking for 8/1/23 to 12/31/23 for Resident #45 was provided. -No tracking for January 2024 was provided to show tracking of physical aggression are behaviors related to antipsychotic usage. Behavior tracking for 8/1/23 to 12/31/23 for Resident #56 was provided. -There were no dates on the tracker to confirm what time frame it was from. Behavior tracking for 8/1/23 to 12/31/23 for Resident #3 was provided. -There were no dates on the tracker to confirm what time frame it was from. Behavior tracking for 8/1/23 to 12/31/23 for Resident #128 was provided and only had one behavior incident listed on 8/29/23 the resident had been staring at two other residents who reported he was making them uncomfortable. -The tracker failed to have targeted behaviors.

Based on observation and staff interviews, the facility failed to provide a safe, functional and comfortable environment for residents, staff and the public. Specifically, the facility failed to ensure a backflow prevention device was installed on the hand held shower in the shower on the 100 hall, increasing the risk of contamination to the facility's main water supply. Findings include: I. Observation Observations of the resident living environment conducted on 1/8/24 at 9:18 a.m. revealed: The hand held shower head in the 100 hall shower room did not have a backflow prevention valve on it. The hand held shower was long enough to sit on the side on the floor next to the drain. There was visible standing water at the base of the shower pan. II. Staff interview The maintenance supervisor (MS) was interviewed on 1/9/24 at 9:44 a.m. He said he was familiar with the backflow valve protocol. The MS stated the hand held shower should have a backflow prevention valve on. He said he would install one immediately.

Based on observations, record review and staff interviews, the facility failed to ensure food was stored, prepared and served under sanitary conditions in one kitchen. Specifically, the facility failed to ensure: -Cutting boards were free from deep scratches and stains; -Frozen food thawing process was followed; and, -Beard restraints were worn in kitchen areas while preparing food. Findings include: I. Cutting boards A. Professional reference According to the State Board of Health Colorado Retail Food Establishment Rules and Regulations (updated 1/1/19), page 132, retrieved 1/16/24 from https://cdphe.colorado.gov/environment/food-regulations, Cutting surfaces that are scratched and scored must be resurfaced so as to be easily cleaned, or be discarded when these surfaces can no longer be effectively cleaned and sanitized. B. Observation The initial kitchen tour conducted on 1/3/24 at 8:29 a.m. revealed five large cutting boards and the cutting board on the serving line. There was one green, one blue, one red, one large white, and one yellow cutting board. All cutting boards were heavily scored and stained. On 1/4/24 at 10:30 a.m., the cook was slicing the ham on the red cutting board that was heavily scored and stained (see above). On 1/8/24 at 8:36 a.m., the cook was cutting up vegetables on the green cutting board that was heavily scored and stained (see above). C. Staff interview The dietary manager (DM) was interviewed on 1/9/24 at 8:36 a.m. The DM was told of the observations of the cutting boards in the kitchen. He said the cutting boards were visibly stained and showed wear. He said he would replace them immediately. He said the deep scratches could be a potential for bacteria to grow. II. Frozen food thawing A. Professional reference According to the Colorado Retail Food Establishment Rules and Regulations (effective 1/1/19) pg.88-89, retrieved 1/16/24 from https://cdphe.colorado.gov/environment/food-regulations, Time/temperature control for food safety shall be thawed: Under refrigeration that maintains the food temperature at 41 degrees F or less; or completely submerged under running water: at a water temperature of 70 degrees F, with sufficient water velocity to agitate and float off loose particles in an overflow, and for a period of time that does not allow thawed portions of ready-to-eat food to rise above 41 degrees F, or for a period of time that does not allow thawed portions of a raw animal food requiring cooking as specified under 3-401.11or to be above (41 degrees F), for more than 4 hours including: the time the food was exposed to the running water and the time needed for preparation for cooking, ort he time it takes under refrigeration to lower the food temperature to 41 degrees F. B. Observations A tour of the kitchen was completed on 1/3/24 at 8:29 a.m. and revealed the following: The three compartment sink had approximately five large rolls of frozen hamburger thawing in the sink. The rolls of hamburger were in a metal container filled with water. The water was warm to the touch. A second observation of the kitchen was conducted on 1/9/24 at 8:25 a.m. There were four large frozen packages of chili con carne sitting in a metal pan with warm water. C. Staff interview The DM was interviewed on 1/9/24 at 8:32 a.m. The DM said when staff were thawing out any food item they needed to place it in the two compartment sink. The DM was told of the observations of the hamburger being thawed in a metal pan in the three compartment sink. The DM said the hamburger and chili con carne should have been thawing in the two compartment sink as the three compartment sink was for sanitizing. The DM said a negative outcome could be the buildup of harmful bacteria. III. [NAME] restraints A. Professional reference According to the Colorado Retail Food Establishment Rules and Regulations (updated 1/1/19) pg. 51, food employees shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed food; clean equipment, utensils, and linens; and unwrapped single service and single-use articles. B. Observations and interviews On 1/4/24 at 8:21 a.m. the DM had a beard that was approximately two inches in length. He was in the kitchen area without wearing a beard restraint. The DM was preparing individual entrees for the residents. The DM had a beard was approximately two inches in length On 1/8/24 at 10:15 a.m. the DM was in the kitchen area not wearing a beard restraint. The DM was preparing several cups of smoothies for the lunch meal. The DM was scooping the ice cream into several cups and then mixing other ingredients into the smoothie. The DM was interviewed on 1/9/24 at 8:36 a.m. The DM stated all kitchen staff were required to wear hair restraint and should have all hair covered. The DM said he had beard guards on order and had not yet received them. He said all male staff who had facial hair should be wearing proper beard restraints while in food preparation areas.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** III. Resident #274 A. Resident status Resident #274, age [AGE] was admitted to the facility 9/2/22. According to the 9/2/22 plan of care, diagnoses included, weight loss, chronic kidney disease, gastro-esophogeal reflux disease (GERD), anxiety, nausea, shortness of breath, malignant rectal cancer, malignant bladder cancer, and insomnia. The minimum data set (MDS) was not completed for this resident. The 9/7/22 social services assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 14 out of 15. According to the computerized physician's orders (CPOs), Resident #274 had a potential for activities of daily living (ADL) self-care performance deficit related to a terminal illness. B. Resident interview and observations Resident #274 was interviewed on 9/12/22 at 3:00 p.m. The resident was aware that he was receiving hospice services. He said his stay was not going well and it was stressful as he was used to doing things his way. The resident's large flat screen television (TV) was observed sitting on the floor next to the window. The resident said he was unhappy his television was still on the floor and he was unable to watch it. He said no staff talked to him about when his TV could be mounted. The resident was sitting on his bed on top of the bare mattress. He said nurses would not allow him to have any linens or blanket on the mattress because it was an air mattress. He said he slept in his clothes since he did not have linens. He said he was unhappy sleeping on a bare mattress and was not offered any linens for his bed. Resident #274 was interviewed on 9/12/22 at 3:00 p.m. This resident's television was on the side of his bed on the floor. This resident's mattress was bare and had no sheets or bedding. The same observations were noted on 9/13, 9/14, and 9/15/22. C. Record review The computerized physician orders CPO) revealed Resident #274 was admitted to hospice care on 9/3/22. The care plan initiated 9/5/22 identified that Resident #274 had potential for activities of daily living (ADL) self-care performance deficit related to a terminal illness. Interventions included assisting the resident with set up for all ADLs and encouraging him to participate to the fullest extent possible for each one. The care plan initiated 9/5/22 identified that Resident #274 will be staying long term in the facility due to terminal illness. The care plan recorded goal was for Resident #274 to be comfortable in his environment. The care plan interventions for Resident #274 included hanging and arranging personal items the way the resident and family wished in order to create a home like environment. The 9/8/22 grievance form submitted by the resident read that resident's TV was not set up within reasonable time and he did not receive any help arranging his belongings. The follow up on 9/12/22 (survey time) read that the resident was offered a TV stand but he was too tired to maintain the conversation. The progress notes dated 9/9/22 revealed Resident #274 expressed frustration that staff had not unpacked his belongings so that he could easily find them. He furthermore became tearful, stating he was being ignored. On 9/14/22 the note read Resident responded in favor of ordering a TV stand. D. Staff interviews Certified nurse aide (CNA) #3 was interviewed on 9/14/22 at 9:08 a.m. She said all residents on admission were helped with arranging belongings in their room. She said the resident's TV was on the floor because it was too big for any stands that were in the room. She said the resident was not allowed to have any linens on his bed because he had an air mattress. She said that was the instruction from the nurse. Licensed practical nurse (LPN) #1 was interviewed on 9/14/22 at 2:09 p.m. She said she was not aware the resident wanted his TV to be set up. She did not know why the TV was on the floor next to the window. Regarding the linens, she said the resident could not have any linens because he was using an air mattress. She said the recommendation was coming from the director of nursing. The director of nursing (DON) was interviewed on 9/15/22 at 1:20 p.m. She said she was aware of the grievance that the resident submitted on 9/8/22. She said the facility was in the progress of ordering a mount for the TV. She provided a note indicating that the TV mount was ordered 9/15/22 (during the survey process). Regarding the linen, she said the resident was on the air mattress and therefore could not use any linens. -However, a flat sheet that was not fitted could be utilized on an air mattress. Based on observations and interviews, the facility failed to ensure care for residents was provided in a manner and in an environment that maintained or enhanced the residents' dignity and respect in full recognition of their individuality for two (#3 and #274) residents of five residents reviewed for dignity out of 36 sample residents. Specifically, the facility failed to: -Ensure Resident #3 had the right to a dignified existence and the ability to exercise self-determination by neglecting to support and honor the resident's status as a transgender female; and, -Assist Resident #274 with the organization of his personal items. Two weeks after admission, the resident's television (TV) was not properly mounted and he was not able to use it. In addition, he was not offered any linens for his mattress, and slept on top of the uncovered mattress. Findings include: I. Facility policy and procedure The Dignity policy, revised February 2021, was provided by the regional clinical resource (RCR) on 9/15/22. It read in pertinent part, The facility culture supports dignity and respect for residents by honoring resident goals, choices, preference, values, and beliefs. This begins with the initial admission and continues throughout the resident's facility stay. II. Resident #3 A. Resident status Resident #3, aged 62, was admitted on [DATE]. According to the September 2022 computerized physician orders (CPO), diagnoses included hemiplegia (paralysis) and hemiparesis (partial paralysis) following nontraumatic subarachnoid hemorrhage (brain bleed) affecting the right side and expressive aphasia (loss of understanding or expressing speech). The 6/14/22 minimum data set (MDS) assessment documented that the resident had not been interviewed for the brief interview for mental status. The assessment documented the resident had intact short term and long term memory. The resident had also been identified as alert and oriented to location, time, event, and person and independent in her decision making. Her communication was documented as unclear speech but able to respond adequately to simple, direct communication and understood what was being said to her without impairment. The patient health questionnaire (PHQ-9) score was zero indicating no depression evident. B. Resident interview and observations Resident #3 was interviewed on 9/12/22 at 8:42 a.m. She said that she had been identifying as a transgender woman for the last 16 years but had been living as a man. She started hormone treatments at the facility within the last year and had come out as transgender. She shared that she no longer used her birth name but a new name and that her pronouns were she/her. She expressed she was not comfortable having a male roommate and would had preferred to live alone at the facility. Reident #3 hair was shoulder length and her nails were painted. She wore makeup, jewelry, and a dress. Resident #3 was interviewed a second time on 9/12/22 at 12:27 p.m. She said the facility did not ask her how she had felt about living with a man. She also said the facility did not offer support for transgender individuals. Throughout the survey, when out of her room, the resident was always observed in a dress, with makeup and jewelry on. C. Record review The psychiatric physician (PSY) visit note dated 6/14/22 documented the resident was a male assigned at birth but identifying as a woman undergoing transition with plans to surgically transition in the future. Preferred pronouns were she/her. Her active problems indicated were inadequate social support, psychosocial stressors, inadequate community resources, and transgender. The September 2022 CPO revealed the resident started medication for testosterone suppression on 10/26/21 and started feminizing hormone therapy medication on 10/27/21. The comprehensive care plan initiated on 1/5/21, referred to the resident by birth name and by pronouns he/him. -There was no care plan focus for the resident's transgender status or needs. The room and/or roommate change authorization form in the medical record dated 2/16/22 documented that the resident was advised she was receiving a new roommate. The roommate was male and there was no note on form Resident #3 was transgender. There was no documentation on the form that the care team coordinator (CTC) had a conversation with the resident about identifying as a woman and if she felt comfortable with a male roommate. The social services progress note dated 2/16/22 documented that Resident #3 was educated on receiving a new roommate. Stated that the resident was not happy but was receptive to education. -There was no documentation as to why Resident #3 was unhappy with new roommate or that a discussion was held with Resident #3 about her preference to have or not have a male roommate. The first mention of resident's gender status was not until 3/21/22 in the care team progress note where it stated the resident would like to talk to hormone doctor about potential referrals to surgery for gender affirming. The resident was referred to as he/him in the progress note. The first physician/medical provider visit note to identify resident as transgender was not until 5/12/22. The resident's preferred pronouns of her/she were not used in documentation in the progress notes until 7/19/22. The only social service progress note to document the resident expressing her preferred pronouns was on 8/29/22. -No other social service notes regarding the resident's psychosocial wellbeing or preferences. All care team progress notes in the resident's chart by the social services department referred to the resident as he/him. The patient health questionnaire (PHQ-9) dated 9/8/22, documented a score of five out of 27 indicating mild depression. The attending physician progress note dated 9/16/22 referred to the resident as a male with gender dysphoria on hormone therapies. D. Staff interviews Licensed practical nurse (LPN) #4 was interviewed on 9/14/22 at 10:26 a.m. LPN #4 said that she was the resident's regular nurse. The resident had been able to express themselves verbally to the LPN. The resident was alert and oriented and could answer yes or no questions and write things down. -LPN #4 referred to the resident as he/him the entire interview. The CTC was interviewed on 9/14/22 at 3:03 p.m. She said Resident #3 as being on her caseload for social services. She said that the resident was cognitively intact and able to effectively communicate their needs. She said for psychosocial support, the facility took the resident to the mall or to the store to buy makeup. She said on one occasion, the prior care team coordinator had taken the resident to a transgender support group. She was not aware if it was care planned that resident was transgender. She said that the resident had expressed that they preferred to have a male roommate and that was documented on the room change form in the medical record. -During the entire interview, the CTC referred to the resident as he/him. E. Facility follow-up The RCR provided follow up documentation on 9/15/22 at 9:37 a.m. A care plan focus for transitioning dated 9/14/22 (time of the survey). It stated the resident was transitioning from male to female and her preferred pronouns were under naming focus. A care plan focus for roommate dated 9/14/22 (time of the survey). It stated that the resident was happy with the current roommate and the resident's preference was for a male roommate. Roommate focus referred to Resident #3 as him. A care plan focus for naming dated 9/14/22 (time of the survey). It stated the resident preferred to use a new name and not her full name. It also stated the resident's pronouns were she/her. A scanned copy of a flyer for an in-person transgender women support group dated for 8/25/22. -There was no sign in or attendance included with the flyer to show the resident had attended.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** III. Resident #275 A. Resident status Resident #275, age [AGE], was admitted on [DATE]. According to the January 2022 computerized physician orders (CPO), the diagnoses included stroke, epilepsy, heart disease, and left sided weakness. The 7/15/22 minimum data set (MDS) revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. He required supervision for walking within his room, and required a one person assist for all other activities of daily living (ADLs). His MDS revealed he had unclear speech. Resident interview and observation An interview was attempted with Resident #275. The resident did not follow the questions and was slow to respond. His fingernails were observed to be grown way past the tips of his fingers. B. Record review The care plan for ADLs and self-care performance deficit related to stroke and left side weakness was initiated 1/14/22. Interventions included extensive assistance with bathing and showering; check nail length, and trim and clean nails on bath day and as necessary; report any changes to the nurse. The care plan for potential impairment to skin integrity related to fragile skin was initiated 1/14/22. Interventions included to avoid scratching, and keep hands and body parts from excessive moisture; keep fingernails short. The resident task sheet reviewed 9/13/22 nail care task was assigned to the certified nursing assistant (CNA) as needed. The daily nail care task response tracking was not completed for 30 days prior to 9/13/22. The nursing progress notes were reviewed for Resident #275 from 3/17/22 to 9/15/22: The 6/18/22 entry revealed the resident declined to have his nails trimmed. The 4/22/22 entry revealed the resident requested his left thumb and first fingernails not be cut. -Additional interventions and approaches were not documented in the progress notes or care plan. C. Staff interview Registered nurse (RN) #1 was interviewed on 9/13/22 3:30 p.m. She stated she was not regular staff at the facility. She said normally the CNA was responsible for nail care and the nurse oversaw the CNA. She stated the resident nails ideally should be trimmed once a week. Certified nurse aide (CNA) #1 was interviewed on 9/13/22 at 3:32 p.m. She stated a restorative aide did the nail trimming. CNA #1 said she trimmed nails when she could, but she was sometimes afraid to trim their nails too short. She said the staff should be looking at residents' nail length in the shower, and if the staff are unable to trim nails, they report it to the director of nursing (DON) or a nurse. The director of nursing (DON) was interviewed on 9/14/22 at 1:55 p.m. She stated the CNA provided the nail care during shower time and nurses during the weekly skin evaluation. The DON stated that Resident #275 pulled away when staff tried to provide nail care and she was unaware if this was documented. Based on observations, record review, and interviews, the facility failed to provide necessary care and services for residents who were unable to carry out activities of daily living for two (#41 and #275) of six residents reviewed for activities of daily living of 36 sample residents. Specifically, the facility failed to: -Establish an effective communication system for Resident #41 in order to provide him with services; and, -Provide nail care to Resident #275. Findings include: I. Facility policy and procedure The Activities of Daily Living (ADLs), Supporting policy, revised in 2018, was provided by the regional clinical resource (RCR) on 9/15/22. It read in pertinent part, residents will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs). Residents who are unable to carry out activities of daily living 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). If residents with cognitive impairment or dementia resist care, staff will attempt to identify the underlying cause of the problem and not just assume the resident is refusing or declining care. Approaching the resident in a different way or at a different time, or having another staff member speak with the resident may be appropriate. II. Resident #41 A. Resident status Resident #41, age [AGE], was admitted on [DATE]. According to the September 2022 computerized physician orders (CPO), the diagnoses included type two diabetes mellitus, history of stroke, weakness on the right side, dysphagia (swallowing difficulty) and dementia with behavioral disturbance. The 8/4/22 minimum data set (MDS) assessment revealed the resident was cognitively impaired, he was rarely understood, and a brief interview for mental status score was not conducted. He required extensive assistance for most activities of daily living (ADLs). The resident did not have aggressive behaviors and did not reject the care. B. Resident interview and observation Resident #41 was interviewed on 9/13/22 at 12:30 p.m. The resident was asked open ended questions in English. He nodded his head up and down and said yes to all questions including open ended. The resident's appearance was disheveled. He was unshaved and had at least a week old beard. His nails were long and unclean. The resident was observed on 9/14 and 9/15/22. His appearance did not change from the initial observation. C. Record review The care plan for activities, revised on 4/27/21 revealed the resident spoke Polish language, and he understood and spoke some English. Resident had an interpreter listed on his care plan who was contacted over the phone and occasionally visited him. The care plan for communication, revised on 9/20/21 revealed the resident had cognitive deficits due to dementia. He had difficulty processing information, understanding, following directions and making decisions. Interventions included to provide the other means of communication when interpreter was not available. -The care plan did not specify what the alternative means of communication were. The care plan for mood/behavior, revised on 3/2/21, revealed the resident was impatient and had verbal outbursts. When a resident felt that his needs were not met, he would yell and push staff away with his hands. Interventions included to administer psychotropic medication for behaviors associated with his diagnosis of dementia. Additional interventions included to monitor behaviors, and quarterly review of psychotropic medications. The ADLs care plan, revised on 10/22/19, revealed the resident was resistive to care at times, and he liked to be independent. The resident would become frustrated if he doesn't know what is being communicated to him. The resident had an order for antidepressant medication. Interventions included to administer medication as ordered. -The resident did not have a care plan for preferences describing his individual preferences regarding daily care. -The care plan did not include documentation for the resident's nail care and shaving preference and assistance. -The resident's progress notes were reviewed from August 2022 to 9/13/22 and revealed no notes regarding resident's refusals, re-approaches or any alternatives that were offered to the resident. D. Staff interviews Certified nurse aide (CNA) #3 was interviewed on 9/14/22 at 9:08 a.m. She said the resident did not speak English and she never understood what he was saying. She said she would use gestures and objects to communicate with the resident. She said he liked his coffee and pretty much wanted to be left alone for the day. She said he did not have any aggressive behaviors but would get upset and would yell when staff did not understand what he wanted. She said watching TV and drinking coffee were his daily activities. Licensed practical nurse (LPN) #1 was interviewed on 9/14/22 at 2:09 p.m. She said Resident #41 did not communicate in English and mostly demanded things by yelling incoherent words. She said he would get upset when staff would not understand what he needs. She said the resident had an interpreter and staff called her when the resident was upset. She said he did not refuse the care but gave preference to certain staff members because they had different approaches. She said the resident preferred to watch TV in his room and was mostly pleasant and cooperative. The interpreter was contacted on 9/15/22 at 11:20 a.m. She said Resident #41 had a stroke and had difficulty communicating since then. She said he spoke Polish and was able to answer questions when prompted, he did not speak English. She said the resident did not have any relatives and she assisted him with communication and occasionally brought food items that he liked. She said due to aphasia (loss of ability to understand or express speech) and dementia it was difficult to understand the resident. She said she has known the resident for more than 10 years. She said Resident #41 was not a morning person, he liked to sleep late and was more active in the afternoon. She said he liked his coffee and TV and mostly would stay in his room or sit on the patio outside. She said he did not like to be assisted in the bathroom and did not like when staff woke him up early in the morning. She said his verbal outburst were driven by misunderstanding between him and staff members. He was not able to express himself due to aphasia and staff could not understand him. The director of nursing (DON) was interviewed on 9/15/22 at 1:20 p.m. She said nurses and CNAs were responsible for providing nail care and shaving to the resident. She said the care should have been offered during showers and as needed. She did not answer any questions regarding alternative means of communication with the resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to ensure one (#274) out of 36 sample residents reviewed for fecal incontinence and constipation received appropriate treatment and services to maintain normal bowel function as much as possible. Specifically, the facility failed to follow bowel protocol for Resident #274 who was at risk for constipation. Findings include: I. Facility policy and procedure The facility policy and procedure for Bowel and Bladder management were requested at the time of the survey. It was not provided prior to the exit on 9/15/22. II. Resident status Resident #274, age [AGE], was admitted to the facility on [DATE]. According to the 9/3/22 computerized physician orders (CPO), diagnoses included human immunodeficiency virus (HIV), weight loss, chronic kidney disease, gastro-esophogeal reflux disease (GERD), anxiety, nausea, shortness of breath, malignant rectal cancer, malignant bladder cancer, and insomnia. The MDS assessment was not completed for this resident. The 9/7/22 social services assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 14 out of 15. III. Resident interview Resident #274 was interviewed on 9/12/22 at 3:00 p.m. He said his stay was not going well and it was stressful as he was used to doing things his way. He said since he was admitted to the facility all his medications were managed by nurses and he was not in agreement how they were administered. Specifically, his bowel medication was not given to him as often as he needed. IV. Record review According to the clinical physician orders (CPO), Resident #274 was admitted to hospice care on 9/3/22. According to the care plan dated 9/5/22, Resident #274 had potential for activities of daily living (ADL) self-care performance deficit related to a terminal illness. Interventions included assisting the resident with set up for all ADLs and encouraging him to participate to the fullest extent possible for each one. The care plan initiated 9/5/22 recorded Resident #274 as having GERD related to hyperacidity. Interventions included giving medications as ordered, and monitor for effectiveness and side effects such as headache, diarrhea, constipation, abdominal pain, flatulence, vomiting, and diarrhea. -The resident did not have a care plan for bowel management related to his terminal diagnosis. The 9/3/22 CPO for Resident #274 revealed the resident was receiving following medications: Senna 8.6 milligram (mg), two tablets every 12 hours, for constipation, initiated on 9/2/22; Methadone 10 mg, one tablet twice a day, for pain, initiated 9/3/22; Trazodone 100 mg, 2 tablets by mouth at bedtime, for pain, initiated 9/3/22. Two additional pain medications were ordered : Fentanyl patch, 72 hours 100 micrograms per hour, for pain, initiated 9/4/22; and, Dilaudid 4 mg, one tablet by mouth every six hours as needed for pain scale one to five (out of 10, with 10 being the worst on the scale) initiated 9/8/22 two tablets by mouth every six hours as needed for pain scale six to ten, initiated 9/9/22; and, Dilaudid 4 mg, two tablets by mouth every six hours as needed for pain scale six to ten, initiated 9/9/22. -There were no changes in resident's medications for constipation after his pain medications increased. The CPO for Resident #274 did not include a standing order for bowel management such as milk of magnesia, suppository or enema. Resident #274's recorded history for bowel elimination between 9/2/22 and 9/14/22 revealed the resident had no bowel movement for three days, from admission date 9/2/22 to 9/5/22. The resident's first recorded bowel movement was 9/6/22 at 4:17 p.m. (four days after admission). Nurses progress notes were reviewed from 9/2/22 to 9/15/22. There were no documented notes regarding the resident's bowel assessment and interventions. The progress notes 9/9/22 from the physician recorded Resident #274 is at very high risk for constipation due to this patient's pathology and current narcotic regimen. -There were no documented interventions on the resident's care plan or the nurses progress notes to address the resident's high risk of constipation. V. Staff Interviews Licensed practical nurse (LPN) #1 was interviewed on 9/14/22 at 11:37 a.m. She stated the certified nursing assistant (CNA) records for resident bowel movements was in point click care (the electronic charting system). She said facility protocol was to offer milk of magnesia (MOM) if a resident has not had a bowel movement within three days, and if MOM ineffective they could offer a suppository or enema as long as they had physician's orders for them. Certified nurse aide (CNA) #2 was interviewed on 9/14/22 at 11:50 a.m. She stated she recorded resident bowel movements in point click care and confirmed resident bowel movement by observation. She said if a resident was constipated she informs the nurse and it was recorded. The director of nursing (DON) was interviewed on 9/14/22 at 1:55 p.m. The DON stated if a resident has not had a bowel movement in three days they will issue MOM or whatever was ordered and monitor for effectiveness. She said if MOM is not effective the nurse will offer a suppository and monitor for results. She said if the suppository was not effective the nurse would offer an enema and if the enema was not effective the facility would notify the physician. She said there should be standing orders for MOM, suppositories and enemas in the clinical physician's orders. LPN #1 was interviewed second time on 9/15/22 at 1:30 p.m. She was not able to locate the Resident #274's bowel records in the electronic medical records. She reviewed the resident's orders and stated she did not know why the resident did not have a standing order for laxatives upon admission. She said the facility had a standing order for bowel management that should be initiated on admission by admitting nurses. She was not able to locate a copy of bowel management standing orders at the nurses station. The DON was interviewed a second time on 9/15/22 at 1:50 p.m. She said the facility did not have standing bowel management orders. She said the facility identified this during the survey and provided education to nurses on duty to assess resident's bowel status on admission and daily. She said when the resident was admitted , the physician should be contacted regarding bowel management orders for specific residents based on their needs. She provided a copy of education.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interviews, the facility failed to establish a communication process with the hospice provider, including how the communication would be documented between the facility and the hospice provider for one (#274) resident reviewed for hospice care and services out of 36 sample residents. Specifically, the facility failed to collaborate with hospice for the development, implementation and revision of the coordinated plan of care for Resident #274. Findings include: I. Resident status Resident #274, age [AGE], was admitted to the facility on [DATE]. According to the 9/3/22 computerized physician orders (CPO), diagnoses included human immunodeficiency virus (HIV), weight loss, chronic kidney disease, gastro-esophogeal reflux disease (GERD), anxiety, nausea, shortness of breath, malignant rectal cancer, malignant bladder cancer, and insomnia. The MDS assessment was not completed for this resident. The 9/7/22 social services assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 14 out of 15. II. Resident interview Resident #274 was interviewed on 9/12/22 at 3:00 p.m. The resident was aware that he was receiving hospice services. He said that he never met the hospice physician and was unhappy with the way his care was managed. III. Record review According to the clinical physician orders (CPO), Resident #274 was admitted to hospice care on 9/3/22. According to the care plan dated 9/5/22, Resident #274 had potential for activities of daily living (ADL) self-care performance deficit related to a terminal illness. Interventions included assisting the resident with set up for all ADLs and encouraging him to participate to the fullest extent possible for each one. The resident's comprehensive care plan was reviewed and the care plan for hospice was initiated on 9/5/22. The care plan interventions included to notify hospice nurse of changes in condition timely for input and evaluation; hospice nurse to visit 1-2 times per week; hospice certified nursing assistant (CNA) to visit twice weekly to assist with showers/bathing, grooming, hygiene; hospice Chaplain and social worker to visit monthly and as needed for support; facility interdisciplinary team (IDT) to invite hospice staff to participate in care plan meetings quarterly; refer to hospice care plan and collaborate with hospice staff regarding patient care; work cooperatively with hospice team to ensure the resident's spiritual, emotional, intellectual, physical and social needs are met. -The care plan did not include resident specific information. The care plan lacked names and contact information for hospice personnel involved in hospice care of the resident. It did not include instructions on how to access the hospice's 24-hour on-call system. A hospice plan of care for the resident was requested during the survey. The plan of care was not provided. The interdisciplinary notes were reviewed from 9/2/22 to 9/15/22. There was no evidence of communication with the hospice care team. IV. Staff interviews Licensed practical nurse (LPN) #1 was interviewed on 9/14/22 at 11:37 a.m. She stated the hospice provider was supposed to leave a binder at the facility, but she did not see one. She did not know who was a contact person at the hospice. She said she has not seen nurses or certified nurses aides (CNAs) from hospice during her shift. The director of nursing (DON) was interviewed on 9/14/22 at 11:46 a.m. She said the hospice provider was supposed to leave a binder with a plan of care specific for the resident and contact information. She said she was not able to locate the binder. She said she would reach out to hospice for clarification. -The DON did not follow up with the survey team regarding the hospice binder before survey exit on 9/15/22.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** V. Resident #273 A. Resident status Resident #273, age [AGE], was admitted on [DATE]. According to the 8/30/22 computerized physician orders (CPO), the diagnoses included urinary tract infection and asthma. The 9/6/22 minimum data set (MDS) revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. She required set-up and one person assistance for all activities of daily living (ADLs). B. Resident interview An interview with Resident #273 was attempted on 9/12/22 at 11:10 a.m. The resident did want to be interviewed. C. Record review Resident #273's MOST form was not in the binder at the nurses containing resident MOST forms. The form was not signed by the resident and/or the medical power of attorney. The 9/1/22 clinical physician orders (CPO) listed Resident #273's status as cardiopulmonary resuscitation (CPR), full code. D. Staff interview LPN #3 was interviewed on 9/13/22 at 2:09 p.m. She confirmed Resident #273's MOST form was not signed and Resident #273's family was going to sign the form in person. She said Resident #273's family member was not here to sign the MOST form, and acknowledged the MOST form should be signed within 24 hours of admission. She said Resident #273 wanted a do not resuscitate (DNR) status but when the MOST form was not signed, the resident's status is ordered as a full code. She confirmed Resident #273's preferred status of DNR was not documented. IV. Residents #43 A. Resident status Resident #43, age [AGE], was admitted on [DATE]. According to the September 2022 CPO, the diagnoses included vascular dementia without behavioral disturbances, major depressive disorder, altered mental status, and disorientation. The 8/9/22 MDS assessment revealed the resident scored a seven out of 15 on his BIMS. The resident did exhibit behaviors of inattention and disorganized thinking during the assessment period. B. Record review The September 2022 CPO revealed the following physician orders: Order dated 7/26/22 for Full code. This matches dashboard of resident's chart. When reviewing MOST form, it showed the resident indicated do not resuscitate status. The document signed by resident representative and physician. C. Interviews LPN #8 was interviewed on 9/13/22 at 1:19 p.m. LPN #8 stated that the resident advanced directive MOST forms were not scanned into their electronic medical record but kept in a binder at the nurses station. LPN #8 stated that if there was an emergency with a resident, the nurse would check the dashboard of their electronic chart for their code status to determine if they need to perform CPR or not.Based on record review and interviews, the facility failed to ensure the resident had the right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive for five (#67, #34, #43, #41, and #273) of nine out of 36 sample residents. Specifically, the facility failed to: -Have accurate physician orders regarding code status for Resident #67, #43 and #41; -Indicate code status, and have physician orders, in the electronic medical record (EMR) for Resident #34; and, -Obtain Resident #273's advance directive wishes regarding his resuscitation status. Findings include: I. Facility policy and procedure The Advanced Directive policy, reviewed 5/12/22, was provided by the nursing home administrator (NHA) on 9/13/22 at 4:16 p.m. It read in pertinent part, If the resident has executed any advance directive documents, or if he/she executes any such documents while living in the community, a copy will be requested and placed in the resident's record. If the resident has such documents, and has provided a copy to the community, the community will place a copy of the document in the resident's record so the community can readily access such documents. The advance directive and CPR decisions will be reviewed at least annually, but also when a change of condition occurs or when requested by the Resident. All MOST (medical orders for scope of treatment) forms shall be kept in a binder at the nurses station. II. Resident #67 A. Resident status Resident #67, age [AGE], was admitted on [DATE], with readmission 1/2/22. According to the September 2022 computerized physician orders (CPO), diagnoses included depressive disorder, dementia with behavioral disturbance, and human immunodeficiency virus (HIV) disease. The 8/23/22 minimum data set (MDS) assessment revealed the resident had moderate cognitive impairment with a brief interview for mental status (BIMS) score of 11 out of 15. He required limited assistance with one person for dressing and supervision with set up help only for bed mobility, toilet use, and locomotion off the unit. He was independent with set up help only for transfers, walking in room, locomotion on unit, and eating. B. Record review and interview Review of the clinical resident profile page in the resident's EMR, viewed on 9/12/22 at 11:31 a.m., revealed COR Status: DNR, full treatment, use antibiotics, long-term artificial nutrition by tube to be discussed with power of attorney (POA) at time of need. The MOST form was filled out as Yes CPR, Full treatment but not signed or dated by physician or resident. On the back of the MOST form it was dated at the top 5/4/2020 as the date prepared, at the bottom there were review dates of 5/4/2020, 11/12/2020, 2/27/21, 4/28/21, and 10/18/21. All were marked as no change except for the 5/4/2020 form was marked as a new form completed. The MOST form was found in the MOST binder at the nurses station on the second floor. C. Staff interviews LPN #11 was interviewed on 9/12/22 at 2:55 p.m. She said to review a resident's code status in the computer for the fastest access during an emergency. LPN #11 said a copy of the resident's MOST forms were not uploaded to the EMR She said there was a MOST book at the nurses station. The director of nursing (DON) was interviewed on 9/13/22 at 2:21 p.m. She viewed Resident #67's MOST form and said there was no medical doctor (MD) signature on the form. The DON said in an emergency she would start cardiopulmonary resuscitation (CPR) however the staff were not using the MOST form at all because it was not signed. -However, according to the resident's physician orders documented the resident was DNR. The DON said the staff tried to get MD signatures immediately when processing a MOST form. The DON said she would notify the MD to come in and sign the MOST form to correct the situation. The DON said she would also call the POA and conduct an audit of the resident's MOST forms and code status to ensure their accuracy. D. Facility follow-up The DON provided an updated MOST form for Resident #67 on 9/14/22 at 9:46 a.m. It was dated 9/14/22 and signed by the POA for Yes CPR, Full treatment. -However, it was not signed by the MD yet. The CPO was updated for Resident #67 on 9/13/22 and revealed orders for COR Status: CPR, Full Code. III. Resident #34 A. Resident status Resident #34, age [AGE], was admitted on [DATE], readmitted on [DATE]. According to the September 2022 computerized physician orders (CPO), diagnoses included myocardial infarction (heart attack), schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly), and parkinson's disease (a disorder that affects movement, often including tremors). The 8/1/22 minimum data set (MDS) assessment revealed the resident was cognitively with a brief interview for mental status (BIMS) score of 14 out of 15. He required limited assistance with one person for personal hygiene, and bathing. He was independent with no set up or physical help from staff for bed mobility, transfers, walking in room/corridor, locomotion on/off the unit, dressing, toilet use and eating. B. Record review Review of the clinical resident profile page in the resident's EMR, viewed on 9/12/22 at 2:33 p.m. revealed, Code status: none it was blank. Review of the CPO revealed there were no MD orders related to Resident #34's desired code status. The current MOST form was filled out as Yes CPR, Full treatment and signed 5/2/22 by Resident #34 and signed by MD on 5/4/22. The MOST form was found in the MOST binder at the nurses station on the second floor. C. Staff interview The DON and the regional clinical resource (RCR) were interviewed on 9/13/22 at 2:09 p.m. The DON said the advanced directive process began at the resident's admission. The DON said the MOST forms were the type of advanced directives used at the facility. The DON said in an emergency the staff would look for the resident's MOST form in the MOST form book because the MOST forms were not uploaded to the resident's EMR chart. The DON said in point click care (PCC, the electronic charting system) there was no section for code status or indication of the resident's code wishes. The DON acknowledged the clinical resident profile page in the EMR after viewing the code status was blank. The DON said the primary source was to use the MOST book, however she would want to get MD orders to match the MOST form and have this indicated in the code status section in the EMR. D. Facility follow-up The CPO was updated for Resident #34 on 9/13/22 and revealed orders for COR Status: CPR, Full Code. III. Resident #41 A. Resident status Resident #41, age [AGE], was admitted on [DATE]. According to the September2022 computerized physician orders (CPO), the diagnoses included type two diabetes mellitus, history of stroke, weakness on the right side, dysphagia (swallowing difficulty) and dementia with behavioral disturbance. The 8/4/22 minimum data set (MDS) assessment revealed the resident was cognitively impaired, he was rarely understood, and a brief interview for mental status score was not conducted. He required extensive assistance for most activities of daily living (ADLs). B. Record review The code status for Resident #41 was not listed on the front page of the electronic medical record. The binder at the nurses station contained a paper copy of the MOST form for Resident #41. The form read no CPR for the resident and only selective treatments. The form was not signed by the resident. It was signed by a proxy physician on 3/10/21. The resident did not have a copy of advanced directives in his chart, and did not have listed medical power of attorney or proxy physician who signed his MOST form. The resident was listed as a self responsible party. The resident's care plan revised on 4/27/21 revealed the resident spoke Polish language, and he understood and spoke some English. The resident had an interpreter listed on his care plan who was contacted over the phone and occasionally visited him. The care plan for communication, revised on 9/20/21 revealed the resident had cognitive deficits due to dementia. He had difficulty processing information, understanding, following directions and making decisions. Interventions included to provide the other means of communication when interpreter is not available. C. Staff interview CNA #3 was interviewed on 9/14/22 at 9:08 a.m. She said the resident did not speak English and she never understood what he was saying. She said she would use gestures and objects to communicate with the resident. She said he liked his coffee and pretty much wanted to be left alone for the day. LPN #1 was interviewed on 9/14/22 at 2:09 p.m. She said the resident did not communicate in English and mostly demanded things by yelling. She said he would get upset when staff would not understand what he needs. She said the resident had an interpreter that staff conducted when the resident was upset. She said all MOST forms were kept at the nurses station and updated in the computer from the binder. She said the resident did not have any family members and the only contact he had was his interpreter. The interpreter was contacted on 9/15/22 at 11:20 a.m. She said Resident #41 had a stroke and had difficulty communicating since then. She said he spoke Polish and was able to answer questions when prompted, he did not speak English. She said the resident did not have any relatives and she was not his power of attorney. She assisted him with communication and occasionally brought food items that he liked. She said due to aphasia (loss of ability or express speech) and dementia it was difficult to understand the resident. The director of nursing (DON) was interviewed on 9/15/22 at 1:20 p.m. She said the physical MOST form should match the CPO. She said she did not know a cognitive status for Resident #41 and did not know who signed his MOST form. She said she will look into it and provide more information later. She did not come back with more information. Family nurse practitioner (FNP ) #1 was interviewed on 9/15/22 at 2:34 p.m. She said she did not know the cognitive status of the resident and she did not know the physician who signed the resident's MOST form on his behalf. The RCR was interviewed on 9/15/22 at 3:10 p.m. She said they would contact the interpreter to see if they can obtain the resident's wishes regarding his advanced directives, meanwhile the resident's status will be full code.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to ensure six (#47, #27, #30, #41, #43, and #50) of eleven residents were free from unnecessary psychotropic medications out of 36 sample residents. Specifically, the facility failed to: -Identify and monitor targeted behaviors for psychotropic medications for Resident #47, #27, #30, #41, #43, and #50; and, -Ensure consents were obtained and contained black box warnings for the usage of psychotropic medications for Resident #47, #27, #30, #41 and #43. Findings include: I. Facility policy and procedure The Psychopharmacological Medications policy and procedure,revised 1/10/19, was provided by the regional clinical resource (RCR) on 9/15/22 at 3:25 p.m. It revealed in pertinent part, A licensed nurse will review admission medication orders and ensure appropriate diagnosis for use of each medication from the primary care physician. If the information was not obtained prior to admission, the licensed nurse and/or social services director will make every effort to determine if there are any possible behavior symptoms that may require special monitoring and/or care planning. The licensed nurse or designee will document any known target behaviors and potential interventions on the Kardex. This will help to assure certified nursing assistants receive communication related to the initial plan of care as appropriate. The licensed nurse or social services director will initiate behavior monitoring within the first twenty-four hours of admission. Behavior monitoring is mandatory for all residents who take psychotropic medications. The primary physician, psychiatrist, and/or consultant pharmacist will monitor residents who are prescribed psychopharmacological drugs at least quarterly to assure these drugs are utilized according to State and Federal regulations and for the appropriate treatment of the resident diagnosis. Licensed nurses and additional staff will monitor and document any target behaviors that occur. These behaviors will be documented on one or more of the following: the Medication Administration Record, the Treatment Administration Record, Behavior Monitoring Chart form, or on a Behavior Incident Report. Psychopharmacological drugs have appropriate corresponding diagnosis and rationale for continued use (Risk vs Benefit statement). II. Resident #47 A. Resident status Resident #47, age [AGE], was admitted on [DATE]. According to the September 2022 computerized physician orders (CPO), the diagnoses included unspecified dementia with behavioral disturbances, traumatic brain injury, encephalopathy (disease where the brain is affected), and epilepsy. The 8/12/22 minimum data set (MDS) assessment revealed the resident was not assessed for cognition and a brief interview for mental status (BIMS) was not done. The patient health questionnaire (PHQ-9) documented the resident was not assessed for depression and a staff interview was not conducted to identify depression. B. Record review The comprehensive care plan, initiated on 1/15/15, revealed the resident exhibited impaired decision making abilities with impaired understanding of the consequences of his actions. The resident was taking anti-depressant medications related to obsessive compulsive behaviors and antipsychotic medications for symptoms/behaviors related to diagnosis of behavior management. The interventions included administering medications per physician orders, educating the resident/family/caregiver about risks, benefits, and side effects, PHQ-9 assessment quarterly, annually, and with change of condition and to offer positive reinforcements and encouragement to divert behaviors. The September 2022 CPO revealed the following physician orders for psychotropic medications: -Zoloft 100 MG (milligrams)-give one tablet by mouth one time a day for anxiety related to traumatic brain injury-ordered on 7/4/22; -Olanzapine (Zyprexa) 5 MG-give one tablet by mouth one time a day for encephalopathy-ordered on 7/4/22; and, -Abilify 10 MG-give one tablet by mouth on time a day for traumatic brain injury-ordered on 7/4/22. The resident's medical record was reviewed on 9/13/22 at 1:19 p.m. There was no evidence the facility had identified behaviors for the Zoloft, Olanzapine, or Abilify medications to track targeted behaviors for use of the medications ordered. On 9/13/22 at 2:00 p.m. (during survey) an order to document behaviors observed and interventions in the progress notes was entered. No specific medications, behaviors, interventions, or outcomes were indicated. The consent for the Abilify, Zyprexa, and Zoloft was documented in the medical record under progress notes dated 7/21/22 with no signature by the resident or the resident's representative. The progress note stated that the resident had consented to continue the medications. -It did not document that the resident and/or resident's representative had been informed of the black box warnings for those medications. C. Facility follow-up Documentation of behavior tracking was requested from the RCR on 9/13/22 at 4:00 p.m. The RCR provided a behavior tracking print out from the facility's Foresight system on 9/14/22 at 11:53 a.m. Resident #47 had one incident of behaviors documented for the timeframe of 6/13/22-9/14/22. Behaviors displayed on 6/25/22 were disorganized thinking, elopements, and wandering. Interventions of notifying the nurse, verbal redirection, and one on one validation were effective. There were no associated progress notes or behavior notes in the medical record from the social services director (SSD) or nurse. Documentation of attempted gradual dose reductions (GDR) of the resident's Abilify, Olanzapine, and Zoloft for the months of September, August, July, and June 2022 were requested from the RCR 9/13/22 at 12:38 p.m. On 9/14/22 at 9:58 a.m. the RCR provided an IDT risk benefit statement dated 1/12/22 electronically signed by family nurse practitioner (FNP) #2 for Abilify, Zyprexa (Olanzapine), and Zoloft with no dosages. No proof that GDR's were attempted was received. III. Resident #27 A. Resident status Resident #27, age [AGE], was admitted on [DATE]. According to the September 2022 CPO, the diagnoses included unspecified dementia with behavioral disturbances, cerebral palsy, encephalopathy and epilepsy. The 7/22/22 MDS assessment revealed the resident was not assessed for cognition and a BIMS was not done. Last MDS to reflect his cognition was 6/21/2022. He was marked as rarely to never understood with short and long term memory problems. His decision making was severely impaired with behaviors of inattention fluctuating during the assessment period. The PHQ-9 documented the resident was unable to participate as he was rarely to never understood. Staff completed the assessment and indicated the resident displayed no signs or symptoms of depression. B. Record review The comprehensive care plan, initiated on 1/1/2020 revealed the resident exhibited impaired cognitive status. The resident was taking anti-depressant medications related to anxiety and anti-anxiety medications related to anxiety disorder. The resident was also taking antipsychotic medications for symptoms and behaviors associated with the diagnosis of physical and verbal aggression and behavior management. The interventions included administering medications per physician orders, educating the resident about risks, benefits, and side effects, PHQ-9 assessment quarterly, annually, and with change of condition and removing the resident from over-stimulated environments. The September 2022 CPO revealed the following physician orders for psychotropic medications: -Risperidone 1 MG-give one tablet by mouth two times a day related to unspecified dementia with behavioral disturbances-ordered on 11/3/21; -Olanzapine (Zyprexa) 20 MG-give one tablet by mouth one time a day related to unspecified dementia with behavioral disturbances-ordered on 5/11/22; -Lorazepam 0.5 MG-give one tablet by mouth at bedtime for anxiety-ordered 3/4/22; and, -Trazodone 150 MG- give one tablet by mouth in the evening for behavior (no specific behavior indicated on order or appropriate diagnosis)-dated 11/3/21. The resident's medical record was reviewed on 9/13/22 at 1:15 p.m. There was no evidence the facility had identified behaviors for the Risperidone, Olanzapine, Lorazepam, or Trazodone medications to track targeted behaviors for use of the medications ordered. On 9/13/22 at 2:00 p.m. (during survey) an order to document behaviors observed and interventions in the progress notes was entered. No specific medications, behaviors, interventions, or outcomes were indicated. There was no consent located in the medical record for Risperidone, Olanzapine, Lorazepam, or Trazodone. In the resident's medical record was a court document dated 7/31/22 that the resident had a court ordered guardian. No documentation found in the medical record that consent for the psychotropic drugs were obtained from the guardian. -The medical record did not document that the resident and/or resident's representative had been informed of the black box warnings for those medications. C. Facility follow-up Documentation of behavior tracking was requested from the RCR on 9/15/22 at 12:38 p.m. Documentation was never provided. Psychotropic drug consent for resident #27 was requested from RCR on 9/14/22 at 3:37 p.m. The RCR emailed document identified as Resident #27's consent form on 9/15/22 at 9:37 a.m. The form was an IDT care conference summary dated 6/13/19. There was no psychotropic consent included in the summary. Documentation of GDR's of the resident's Lorazepam, Olanzapine, Risperidone, and Trazodone for the months of September, August, July, and June 2022 were requested from the RCR 9/13/22 at 12:38 p.m. On 9/14/22 at 9:58 a.m. the RCR provided an IDT risk benefit statement dated 3/9/22 electronically signed by FNP#2 for Zyprexa (Olanzapine) and Risperdal (Risperidone) only with no dosages. No proof that GDR's were attempted was received. IIII. Resident #30 A. Resident status Resident #30, age [AGE], was admitted on [DATE]. According to the September 2022 CPO, the diagnoses included unspecified dementia with behavioral disturbances, depressive episodes, and epilepsy. The 7/26/22 MDS assessment revealed the resident was able to participate and scored a three out of 15 on his BIMS indicating severe cognitive impairment. The resident did not exhibit any behavioral symptoms during the assessment period. The PHQ-9 documented the resident was not assessed for depression due to being rarely to never understood. A staff interview was conducted and scored the resident's depression as a five out of 27 indicating mild depression. B. Record review The comprehensive care plan, initiated on 6/21/17 revealed the resident exhibited cognitive deficits with impaired understanding of the consequences of his actions. The resident had difficulty processing information, following directions and making decisions with short and long term memory loss. The resident was taking anti-depressant medications related to depression and an anti-anxiety medication related to anxiety. The interventions included administering medications per physician orders, educating on the risks, benefits, and side effects, and conducting a PHQ-9 assessment quarterly, annually, and with change of condition. The September 2022 CPO revealed the following physician orders for psychotropic medications: -Lorazepam 0.5 MG-give one tablet by mouth two times a day for anxiety-ordered on 6/30/22; -Trazodone 50 MG-give one tablet by mouth at bedtime for depression-ordered on 6/29/22; and, -Risperidone 1 MG-give two tablets by mouth at bedtime related to unspecified dementia with behavioral disturbances-ordered on 12/8/21. The resident's medical record was reviewed on 9/13/22 at 1:10 p.m. There was no evidence the facility had identified behaviors for the Lorazepam, Trazodone, or Risperidone medications to track targeted behaviors for use of the medications ordered. On 9/13/22 at 2:00 p.m. (during survey) an order to document behaviors observed and interventions in the progress notes was entered. No specific medications, behaviors, interventions, or outcomes were indicated. The consent for the Lorazepam, Trazodone, and Risperidone was documented in the medical record in the progress notes dated 7/21/22 with no signature by the resident or the resident's representative. The progress note stated that the resident had consented to continue the medications. -It did not document that the resident and/or resident's representative had been informed of the black box warnings for those medications. C. Facility follow-up Documentation of behavior tracking was requested from RCR 9/13/22 at 4:00 p.m. The RCR provided a behavior tracking print out from the facility's tracking system on 9/14/22 at 11:53 a.m. Resident #30 had two incidents of behaviors documented for the timeframe of 6/13/22-9/14/22. Behaviors displayed on 6/17/22 were verbal aggression and physical aggression. The resident was upset that the smoking times had ended for the day. Interventions of redirection, snacks, water, and toileting were effective. Behaviors displayed on 6/30/22 were repetitive statements. The resident was repeating he needed the restroom and wanted a coffee. Intervention of one-on-one was effective. There were no associated progress notes or behavior notes in the medical record from SSD or nurse for 6/17/22. Documentation of GDR's of the resident's Lorazepam, Trazodone and Risperidone for the months of September, August, July, and June 2022 were requested from the RCR 9/13/22 at 12:38 p.m. This documentation was not provided. IV. Residents #43 A. Residents #43 Resident #43, age [AGE], was admitted on [DATE]. According to the September 2022 CPO, the diagnoses included vascular dementia without behavioral disturbances, major depressive disorder, altered mental status, and disorientation. The 8/9/22 MDS assessment revealed the resident scored a seven out of 15 on his BIMS which indicated severe cognitive impairment. The resident did exhibit behaviors of inattention and disorganized thinking during the assessment period. The PHQ-9 documented the resident scored a two out of 27 indicating mild depression. B. Record review The comprehensive care plan, initiated on 10/19/21 revealed the resident had a diagnosis of dementia which affected his cognition. He was also at risk for behavioral problems related to increased confusion, decreased safety awareness and a history of aggressive behaviors. The resident was taking antipsychotic medications for symptoms/behaviors associated with the diagnosis of major depressive disorder, vascular dementia, and behavior management. The interventions included administering medications per physician orders, educating the resident/family/caregiver about risks, benefits, and side effects, and reporting side effects. The September 2022 CPO revealed the following physician orders for psychotropic medications: -Quetiapine (Seroquel) 50 MG- take one tablet by mouth at bedtime for behaviors (order does not specify behaviors or appropriate diagnosis)-ordered 9/30/21. The interdisciplinary team (IDT)-psych pharm management meeting recommendations for 7/11/22 showed the resident's Seroquel was to be changed from 50 MG one time a day to 25 MG in the a.m. and 25 MG in the p.m. The attendance for the meeting showed the nursing home administrator (NHA), director of nursing (DON), resident services director (RSD) and pharmacist (PHR). In the resident's medical record there was a preadmission screening and resident review (PASRR) progress note made by the RSD dated 8/14/22 documented it was recommended that the resident's Seroquel was to be changed from 50 MG one time a day to 25 MG in the a.m. and 25 MG in the p.m. -However, there were no changes to the resident's orders by his physician. The resident's medical record was reviewed on 9/13/22 at 1:00 p.m. There was no evidence the facility had identified behaviors for the Seroquel medication to track targeted behaviors for use of the medications ordered. On 9/13/22 at 2:00 p.m. (during survey) an order to document behaviors observed and interventions in the progress notes was entered. No specific medications, behaviors, interventions, or outcomes were indicated. The consent for the Seroquel was documented in the medical record in the progress notes dated 8/14/22 with no signature by the resident or the resident's representative. The progress note stated that the resident had consented to continue the medications. -It did not document that the resident and/or resident's representative had been informed of the black box warnings for those medications C. Facility follow-up Documentation of behavior tracking was requested from the RCR 9/13/22 at 4:00 p.m. The RCR provided a behavior tracking print out from the facility's tracking system on 9/14/22 at 11:53 a.m. Resident #43 had one incident of behaviors documented for the timeframe 7/14/22-9/14/22. Behaviors displayed on 9/4/22 were mood issues and verbal aggression. The resident was upset that the snack store was out of a specific item. Intervention of verbal redirection and limit setting was effective. There were no associated progress notes or behavior notes in the medical record from SSD or nurse. Documentation of GDR's of the resident's Seroquel for the months of September, August, July, and June 2022 were requested from the RCR 9/13/22 at 12:38 p.m. On 9/14/22 at 9:58 a.m. the RCR provided an IDT risk benefit statement dated 4/13/22 electronically signed by FNP#2 for Seroquel with no dosage. No proof that GDR's were attempted was received. V. Staff interviews The RSD was interviewed on 9/13/22 at 3:30 p.m. He identified himself as the department head for the social services department and had been in the department for 18 months. He explained the interdisciplinary team (IDT) met every month with the pharmacist, medical director, and psychologist and/or psychiatrist to review psychotropic medications and behavior changes. During this meeting, behavior tracking was used to determine if a medication warranted a GDR, needed to increase, or needed to remain the same. The process in which staff report behavior changes with residents was to contact the social services department directly. The IDT reviewed resident behaviors during their morning meeting which includes the NHA and DON. During the morning meeting, the social services department advised the DON what interventions they want the nursing staff to use for a specific resident displaying behaviors. To document the resident's behaviors, the facility used an electronic program. This was a separate computerized program from the resident's electronic medical record. The RSD would input the target behaviors, interventions and desired outcomes into the program. He stated that the nursing staff had access to the system on their computers at the nurses stations. Nurses were to document behaviors, interventions, and outcomes every shift as indicated for the residents. Certified nursing assistant (CNA) #6 was interviewed on 9/13/22 at 3:40 p.m. She said that if a resident displayed behaviors, the CNAs reported them directly to the nurse responsible for that resident to document. The CNA did not know how social services communicated target behaviors, desired interventions or outcomes to nursing. Registered nurse (RN) #1 was interviewed on 9/13/22 at 3:45 p.m. RN #1 said a resident's behavior tracking will show up on their medication administration record (MAR) and provided the nurses an option to make an additional progress note after marking if a behavior occurred. RN #1 did not know how social services communicated target behaviors, desired interventions or outcomes to nursing. Licensed practical nurse (LPN) #9 was interviewed on 9/13/22 at 3:49 p.m. She said that the nursing staff will send the social services department a message regarding a resident's behaviors through the dashboard in the electronic medical record and then make a nursing progress note. LPN #9 did not know how social services communicated target behaviors, desired interventions or outcomes to nursing. LPN #3 was interviewed on 9/13/22 at 4:26 p.m. LPN #3 said that the DON had recently implemented an electronic 24 hour reporting system in the last two days and this was to be used to document behaviors to notify the IDT. She said the prior system was to write on a large white board in the nurses stations the resident and their behaviors to communicate to IDT and other nurses. She said that the nurses were not using the MAR to track behaviors. LPN #3 did not know how social services communicated target behaviors, desired interventions or outcomes to nursing. The SSD was interviewed on 9/13/22 at 4:31 p.m. The SSD explained the use of the behavior tracking system and that nursing staff have access to the program to document behaviors on their computers at nurses stations. She said training on behavior tracking, interventions and outcomes for nursing staff was done by the DON not the SSD. She was not sure who entered the resident profile (behaviors, interventions, outcomes) into the behavior tracking system. The DON was interviewed on 9/13/22 at 4:38 p.m. She said to document behaviors, nurses select the custom note type behavior note in the resident's electronic medical record under progress notes. She said the nurses enter the behaviors in a behavior note and add a notification on the dashboard in the resident's electronic medication record. She said the social services department followed up with a social services progress note. She said the IDT had recently added behavior tracking to the MAR. She said this decision was made between nursing and the social services department to add an additional method to capture behaviors. The RCR was interviewed on 9/14/22 at 1:56 p.m. The RCR explained that it is the facility's practice to obtain consents for psychotropic medications verbally and make a progress note in the resident's chart. There was no paper or electronic document with the consent or the risk/benefit for the resident or responsible party to sign. The medical director (MD) was interviewed on 9/15/22 at 10:20 a.m. He explained that the monthly meeting to review psychotropic drug use in the facility is referred to as psych pharm. The corporate medical director (CMD) reviews the medications and makes decisions on changes, the MD makes recommendations sometimes. If a resident was taking psychotropic medications and nonverbal, the MD would collect information from the resident's nurse to determine the resident's psychological and behavioral status. He explained that monitoring resident's behaviors in the medical record was very important. The MD said he did not know what the facility was disclosing when they went over the risks, benefits, and side effects for the psychotropic drug consents with residents or their representatives, he stated he could only assume what was being disclosed. The family nurse practitioner (FNP) #1 was interviewed 9/15/22 at 12:56 p.m. She said that she followed Residents #47, #30, #43, and #27. FNP#1 said that Resident #47 was alert and oriented to self and staff. He had limited understanding of the treatments he received or the medications he was taking. To understand the risk, benefits, and side effects for him would be challenging. Stated she had not discussed his care or medications with his family or representative. FNP #1 said that Resident #30 had impaired cognition and could not fully comprehend his medications or their risk, benefits, and side effects. She stated she had not discussed his care or medications with his family or representative. FNP #1 said that Resident #43 had cognition challenges and he did not understand the risk, benefits, or side effects of his psychotropic medication. She said she was not aware that there was an order recommendation made in his medical record to split the dosage of his Seroquel and she could not explain why it was recommended initially in July 2022 but not followed to date. FNP #1 said that Resident #27 had very poor cognition and was not able to comprehend his medications or their risk, benefits, and side effects. She stated she had not discussed his care or medications with his family or guardian. VI. Facility training follow-up Training materials and behavior monitoring documentation were requested from DON on 9/14/22 at 9:38 a.m. Staff training on behavior health for older adults was provided by the RCR on 9/15/22 at 9:37 a.m. The training reviewed behavior health symptoms but did not include interventions or behavior monitoring. The NHA provided staff training for the behavior tracking system on 9/15/22 at 9:32 a.m. The training was all staff in-service conducted 9/13/22, which was during the survey process. VIII. Resident #50 A. Resident status Resident #50, age [AGE], was admitted on [DATE], and readmitted [DATE]. According to the September 2022 computerized physician orders (CPO), diagnoses included dementia without behavioral disturbance, hemiplegia (muscle weakness) affecting the right dominant side, and personal history of traumatic brain injury. The 8/6/22 minimum data set (MDS) assessment revealed the resident was unable to complete the brief interview for mental status (BIMS). The staff assessment for mental status revealed short-term and long-term memory problems, he was able to recall staff names and faces. Daily decision making regarding tasks of daily life were severely impaired. The staff assessment of resident mood (patient health questionnaire-PHQ-9) revealed a score of 30, indicating severe depression. No behavioral symptoms present, no rejection of care or wandering present. The resident received antipsychotic and antidepressant medications during the last seven days of the review period. The antipsychotics were received on a routine basis only. No gradual dose reduction (GDR) had been attempted. No physician documented GDR as clinically contraindicated. He required limited assistance with one person for bed mobility, transfers, locomotion off unit, and dressing. He required extensive assistance with one person for personal hygiene, toilet use, and total dependence for bathing. B. Record review Review of the September 2022 CPO related to antipsychotic medications revealed orders for Abilify tablet 5 mg (aripiprazole). Give one tablet by mouth one time a day related to vascular dementia without behavioral disturbance. Start date 9/22/21. -The CPO failed to have orders to ensure the targeted behaviors were tracked and documented. Review of the comprehensive care plan related to use of antipsychotic medication, revised 9/22/21, revealed to use for the symptoms/behaviors associated with the diagnosis of major depressive disorder/behavior management. Goal: residents risk for psychotropic drug related complications, including movement disorder, discomfort, hypotension, gait disturbance, constipation/impaction or cognitive/behavioral impairment would be minimized through the next review date. Interventions included administering psychotropic medication as ordered by physician and monitor for side effects and effectiveness every shift. AIMS assessment quarterly or as needed. Behavioral monitoring for antipsychotic medication, date initiated 9/22/21. Consult with a pharmacy, medical doctor (MD) to consider dosage reduction when clinically appropriate at least quarterly. Discuss with MD, power of attorney (POA)/family regarding ongoing need for use of medication. Review behaviors/intentions and alternate therapies attempted and their effectiveness as per facility policy. Educate and inform the resident of the current medication regimen and change recommendations. Medication reducations and/or risk benefit assessments as indicated. Monitor/document/report as needed (PRN) any adverse reactions of psychotropic medications: unsteady gait, tardive dyskinesia, EPS (shuffling gait, rigid muscles, shaking), frequent falls, refusal to eat, sedation, difficulty swallowing, dry mouth, depression, extrapyramidal reaction, weight gain, edema, suicidal ideations, social isolation, blurred vision, diarrhea, fatigue, insomnia, loss of appetie, weight loss, constipation, muscle cramps, nausea, vomiting, behavior symptoms not usual to the person. Utilize non-pharmacological: cold, range of motion, massage, relaxation and breathing techniques, imagery and distraction techniques, reposition, aromatherapy, therapeutic touch and massage. Date interventions initiated 9/22/21. -There was no documentation in the record of offering or implementing non-pharmacological approaches. -There was no documentation in the record of behavior monitoring in a measurable and objective manner related to the targeted behaviors with goals and parameters for monitoring the resident's condition related to use of antipsychotic medication. Behavior monitoring records were requested from the facility at the time of the survey but not provided by exit of the survey on 9/15/22. C. Interview The psychiatric (PSY) physician was interviewed on 9/15/22 at 9:49 a.m. He said he no longer follow Resident #50 (as of 6/13/22) but that the attending physician would. The PSY said the facility social worker would be who keeps track and records the target behaviors and the social worker would communicate that with their case workers. The family nurse practitioner (FNP) #1 was interviewed on 9/15/22 at 1:18 p.m. She said she was familiar with Resident #50. FNP #1 said the caregivers had some recent challenges with the resident agreeing to accept dental care. FNP #1 said it would be helpful to have behavior tracking at the facility and it would be great during a review to see if behaviors were increasing or decreasing. FNP #1 said the facility had just put it in place today she had noticed. FNP#1 said that other facilities she works at have the behaviors show up on the dashboard in the resident's electronic medical record where the nurses documented their behaviors. FNP #1 said that today she had approved orders for the nurses to note/document resident behaviors. The FNP #1 said it was more of a notification that nurses would document behaviors as they occur. D. Facility follow-up After being brought to the facility's attention, new CPOs were added on 9/13/22 to document behaviors observed and interventions in the progress notes every shift related to the resident's diagnosis. VII. Resident #41 A. Resident status Resident #41, age [AGE], was admitted on [DATE]. According to the September 2022 computerized physician orders (CPO), the diagnoses included type two diabetes mellitus, history of stroke, weakness on the right side, dysphagia (swallowing difficulty) and dementia with behavioral disturbance. The 8/4/22 minimum data set (MDS) assessment revealed the resident was cognitively impaired, he was rarely understood, and a brief interview for mental status score was not conducted. He required extensive assistance for most activities of daily living (ADLs). The resident did not have aggressive behaviors and did not reject the care. The patient health questionnaire (PHQ-9) for depression was not conducted as the resident was rarely understood. B. Record review The care plan for activities, revised on 4/27/21 revealed the resident spoke Polish language, and he understood and spoke some English. Resident had an interpreter listed on his care plan who was contacted over the phone and occasionally visited him. The care plan for communication, revised on 9/20/21 revealed the resident had cognitive deficits due to dementia. He had difficulty processing inf[TRUNCATED]

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. Specifically, the facility failed to: -Ensure food was labeled and dated; and, -Ensure holding temperatures of food were within the safe range. Findings include: I. Failure to ensure food was labeled and dated correctly 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. It revealed in pertinent part, A date marking system that meets the criteria stated in (1) and (2) 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. (Retrieved 9/15/22). B. Observations On 9/12/22 at 7:30 a.m. the initial kitchen tour was conducted and the following was observed: -In the dry-storage in the main kitchen, there was a box of red potatoes that had sprouted and were no longer firm. There was also a small box of onions and several appeared to have black spots present. -In the main walk-in cooler, there were four pitchers of what appeared to be juice with no labels or dates. -In a reach-in freezer refrigerator in the main kitchen, there were four Ziploc freezer bags without labels or dates containing what appeared to be raw pork chops. There were also two Ziploc freezer bags without labels or dates containing what appeared to be raw chicken thigh. There was also a tray containing several small dessert bowls with an unidentified substance that appeared to be pudding unwrapped, without a label or date. On 9/15/22 at 1:30 p.m an additional kitchen tour was conducted and the following was observed: -In the dry-storage in the main kitchen, there was a box of red potatoes that had sprouted and were no longer firm. There was also a small box of onions and several appeared to have black spots present. -In the main walk-in cooler several items were found: a container of blueberry filling dated 9/12/22, a container of carnitas meat dated 9/11/22, a container of ham dated 9/9/22, and a container of salsa dated 9/9/22. Shredded iceberg lettuce sitting immersed in a container of water dated 9/14/22, and a container of hardened bacon grease dated 9/13/22. There was a tray of lasagna without a date. II. Failure to ensure holding temperatures of food were within the correct range A. Professional reference The Colorado Department of Public Health and Environment (2019) The Colorado Retail Food Establishment Rules and Regulations, https://www.colorado.gov/pacific/sites/default/files/DEHS_RetailFd_6CCR10102_RFFC_EffJan2019.pdf. It read in pertinent part; The food shall have an initial temperature of 41ºF (fahrenheit) or less when removed from cold holding temperature control or 135°F or greater when removed from hot holding temperature control. (Retrieved 9/15/22) B. Facility policy and procedure The Food Wholesomeness policy, revised December 2021, was provided by the registered dietitian nutritionist (RDN) on 9/15/22 at 2:59 p.m. It revealed in pertinent part, -Cold foods are kept between 34-41 degrees prior to serving and frozen foods are kept at 0 degrees or below. -Hot food are cooked to above 165 degrees or per USDA Food Code and held at least 140 degrees until service. -Foods not in original containers are labeled and dated with opening and suggested to have been used by date. -Service temperatures are acceptable, below 50 degrees for cold, and above 125 degrees for hot food. US Food/Blue Print Menu Production Recipe for salad garden was provided by the registered dietary nutritionist (RDN) on 9/15/22 at 2:59 p.m. It revealed in pertinent part, -Hold temperature 40 degrees or below. US Food/Blue Print Menu Production recipe for brussel sprouts was provided by the registered dietary nutritionist (RDN) on 9/15/22 at 2:59 p.m. It revealed in pertinent part, -Minimum internal temperature 140 degrees. -Hot or serve hot food at or above 140 degrees. C. Observations During a continuous observation on 9/14//22 beginning at 4:47 p.m. and ended at 6:24 p.m. the following was observed: -A tray of prepared garden salad was sitting on the serving line next to the hot entree (chili con carne) and hot sides (brussel sprouts and corn bread). It did not appear to be on ice. -At 4:47 p.m. the dietary supervisor (DS) took the temperature of the garden salad and it read 60F. The puree cornbread was 105F. The brussel sprouts were 130F -The DS did not take the temperature of the alternative dinner option, stuffed bell peppers, prior to serving. -The salad was served on the plate with the hot entree and hot sides. -The serving plates and bowls for dinner were colder than room temperature. -At 5:40 p.m. the DS got additional clean bowls for serving that had come from the dishwasher that were too hot to touch. -At 6:24 p.m. the DS took temperatures after serving dinner. The entree temperature was 132F, the hot side was 118F, the salad remained 60F, the puree chili was 118F, and the puree cornbread was 92F. During observation on 9/15/22 at 2:16 p.m. yogurts were found in an insulated container on a nurses cart. The temperature was 66F. III. Staff interviews The DS was interviewed on 9/15/22 at 1:32 p.m. She stated that her expectation of the temperature for the brussel sprouts was above 140F. She said she was aware that she should have put them back into the oven after discovering the temperature was below 140F. She stated it was her normal practice to put cold items, like salads, in separate bowls from the hot foods served instead of on the same plate.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interviews, the facility failed to develop and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of disease and infection for three out of four units. Specifically, the facility failed to: -Ensure proper hand hygiene was offered to residents prior to meals; and, -Ensure proper wearing of masks for staff. Findings include: I. Hand hygiene A. Professional reference The Centers for Disease Control (CDC) Hand Hygiene Guidance, reviewed 1/30/2020, retrieved on 9/20/22 from: https://www.cdc.gov/handhygiene/providers/guideline.html, read in pertinent part, The core infection prevention and control practices for safe care delivery in all healthcare settings recommendations of the Healthcare Infection Control Practices Advisory Committee (HICPAC) include the following strong recommendations for hand hygiene in healthcare settings. Healthcare personnel should use an alcohol-based hand rub or wash with soap and water for the following clinical indications: Immediately before touching a patient Before performing an aseptic task (e.g., 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 Immediately after glove removal Healthcare facilities should: Require healthcare personnel to perform hand hygiene in accordance with Centers for Disease Control and Prevention (CDC) recommendations. Ensure that healthcare personnel perform hand hygiene with soap and water when hands are visibly soiled. Ensure that supplies necessary for adherence to hand hygiene are readily accessible in all areas where patient care is being delivered. Unless hands are visibly soiled, an alcohol-based hand rub is preferred over soap and water in most clinical situations due to evidence of better compliance compared to soap and water. Hand rubs are generally less irritating to hands and, in the absence of a sink, are an effective method of cleaning hands. The Centers for Disease Control and Prevention (CDC) Interim Infection Prevention and Control Recommendations to Prevent SARS-CoV-2 Spread in Nursing Homes (updated 2/2/22), retrieved on 9/20/22 from https://www.cdc.gov/coronavirus/2019-ncov/hcp/long-term-care.html, read in pertinent part, Educate residents and families through educational sessions and written materials on topics, including information about SARS-CoV-2, actions the facility is taking to protect them and their loved ones from SARS-CoV-2, and actions they should take to protect themselves and others in the facility, emphasizing when they should wear source control, physically distance, and perform hand hygiene.Facilities should provide instruction, before visitors enter the patient ' s room, on hand hygiene, limiting surfaces touched, and use of PPE according to current facility policy. B. Facility policy The COVID-19 Prevention, Response and Testing policy, revised 8/22/22, was provided by the nursing home administrator (NHA) on 9/15/22 at 12:55 p.m. It read in pertinent part, Interventions to prevent the spread of respiratory germs within the facility: Keep residents and employees informed by answering questions and explaining what they can do to protect themselves and their fellow residents (i.e., social distancing, respiratory hygiene/cough etiquette, handwashing). Support hand hygiene and respiratory/cough etiquette by residents and employees by making sure tissues, soap, paper towels and alcohol-based hand rubs are available. C. Observations On 9/12/22 lunch service was observed from 11:35 a.m. to 12:45 p.m. in the supervised dining room. Seven residents ate lunch in the supervised dining room. Six of seven residents in the supervised dining room were not offered hand hygiene before the meal. Five staff members present. Spray bottles of alcohol based hand rub were available in the supervised dining room. On 9/13/22 at 12:40 p.m., meal delivery to room [ROOM NUMBER] was observed. The residents in room [ROOM NUMBER] were not offered hand hygiene before the meal was set up in their room. On 9/14/22 at 6:08 p.m. the resident room trays arrived on the 100 floor. Certified nurse aide (CNA) #3 entered room [ROOM NUMBER] and she did not offer hand hygiene prior to the meal being served. -At 6:12 p.m., CNA #3 then entered room [ROOM NUMBER] and delivered the meal tray. She failed to offer hand hygiene prior to the meal being served. -At 6:16 p.m., an unidentified CNA delivered the room tray to resident in room [ROOM NUMBER]. No hand hygiene was offered to the resident. -At 6:18 p.m., an unidentified staff member delivered the room tray room [ROOM NUMBER] and failed to offer hand hygiene to the resident. On 9/15/22 at 12:27 p.m. meal delivery was observed on the west second floor hallway. CNA #9 pushed the room tray cart to the elevator, and then stated she forgot something, and walked to the dining room, brought a spray bottle of alcohol based hand rub and placed it on the room tray cart. The bottles of alcohol based hand rub were in a tub on a three tier cart in the dining room. At 12:58 p.m., meal delivery was observed in the west first floor hallway, and the east first floor hallway. Four out of five residents were not offered hand washing before the meal in the west first floor hallway. There was no alcohol based hand rub on the meal delivery cart. The staff member delivering meal trays did not wash their hands in between each meal delivery to the residents rooms. The resident in room [ROOM NUMBER] was not offered hand hygiene before the meal. The resident in room [ROOM NUMBER] was not offered hand hygiene before the meal. The resident in room [ROOM NUMBER] was not offered hand hygiene before the meal. The resident in room [ROOM NUMBER] was not offered hand hygiene before the meal. D. Record review The Infection Control Observations Checklist was provided by the nursing home administrator (NHA) on 9/14/22 at 5:13 p.m. The infection control observation checklist documented in pertinent part, to complete random observations throughout the community of general infection control practices. Infection control observations were completed on 9/5/22, 9/9/22, 9/10/22, 9/11/22 and 9/14/22, and included hand hygiene completed with residents before meals and alcohol based hand rub in staff pockets. E. Staff interview CNA #9 was interviewed on 9/15/22 at 12:31 p.m. She stated she passed meal trays on the same hallway that she works her shift. She said it was typical that staff deliver meals to resident rooms in the hall they worked. She said when a resident refused the alcohol based hand rub that she offered, one particular resident had their own hand sanitizer they preferred. She said all the residents accepted the alcohol based hand rub she offered. II. Personal protective equipment (PPE) A. Professional reference The Centers for Disease Control and Prevention (CDC), (updated 2/2/22) Interim Infection Prevention and Control Recommendations for Healthcare Personnel (HCP) During the Coronavirus Disease 2019 (COVID-19) Pandemic, retrieved on 9/20/22 from https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html , read in pertinent part, Implement universal use of personal protective equipment for HCP (healthcare personnel). If SARS-CoV-2 infection is not suspected in a patient presenting for care (based on symptom and exposure history), HCP should follow Standard Precautions (and Transmission-Based Precautions if required based on the suspected diagnosis). Additionally, HCP working in facilities located in counties with substantial or high transmission should also use PPE as described below: -To simplify implementation, facilities in counties with substantial or high transmission may consider implementing universal use of NIOSH-approved N95 or equivalent or higher-level respirators for HCP during all patient care encounters or in specific units or areas of the facility at higher risk for SARS-CoV-2 transmission. -Eye protection (i.e., goggles or a face shield that covers the front and sides of the face) should be worn during all patient care encounters. The healthcare community transmission levels for the facility's county of residence, obtained from https://covid19.colorado.gov/healthcare-providers/long-term-care-facilities/healthcare-community-transmission-levels, were reviewed for the time of survey 9/12/22-9/15/22 and found to be in Substantial levels of transmission. B. Facility policy and procedure The COVID-19 Prevention, Response and Testing policy, revised 8/22/22, was provided by the nursing home administrator (NHA) on 9/15/22 at 12:55 p.m. It read in pertinent part, educate staff on proper use of personal protective equipment and application of standard, contact, droplet, and airborne precautions, including eye protection. C. Observation On 9/14/22 at 12:30 p.m. CNA#10 was observed in the dining room with his mask down to his chin. When he realized he was observed, he pulled the mask back over his face in the proper position. -At 1:00 p.m. CNA#10 was in the hallway with his mask down to his chin. When he realized he was observed, he pulled the mask back over his face in the proper position. -At 6:04 p.m., licensed practical nurse (LPN) #7 was at the medication cart in the hallway. Residents were all around in the hallway, along with other staff. LPN #7 was not wearing her mask. The mask was hanging off one of her ears. She was not wearing eye protection as required. -At 6:06 p.m., the MDS coordinator was alerted and observed LPN #7 without her mask, she then told her to put the mask on as she was in a resident area. On 9/15/22 at 2:16 p.m. CNA#10 was standing next to the nurses station near residents with his mask down to his chin. When he realized he was observed, he pulled the mask back over his face in the proper position. D. Facility follow-up The facility provided in-service training documentation dated 9/14/22 it revealed that employee (LPN #7) had been identified as without her N95 mask and goggles while in a patient care area. III. Staff interview The director of nursing (DON), the NHA and regional clinical resource (RCR) were interviewed on 9/15/22 at 11:20 a.m. The NHA reported that the current facility COVID-19 outbreak began 7/7/22 with two staff members and then two residents became positive on 8/2/22 and then 14 residents became positive on 8/5/22. The last positive was a staff member on 8/5/22. The DON and NHA said the facility did have enough PPE. The RCR said the staff did not have hand sanitizer in or outside of every room based on population assessment and there were concerns that the facility had residents with alcohol abuse issues and the facility did not want them drinking it. The RCR said the staff need to wear eye protection based on the transmission rate in the community. The RCR said after the facility was informed that staff were not wearing masks, or wearing under chin, in resident care areas, the facility provided instructions on how to wear a mask correctly. The DON said they had not been trending to see the root cause even though the DON acknowledged over 14 residents became COVID-19 positive and it showed something was wrong with the facility's implementation of transmission based precautions. The DON said when she saw a staff member not wearing a mask, she provided verbal education to the staff member. The DON said she provided training on PPE and identified/educated when staff were not wearing masks properly. The DON said the staff should use hand hygiene before entering/exiting a room, and in between passing meal trays. The DON said hand hygiene should be offered to residents before every meal with towelettes or hand gel.

Based on observations, record review and interviews, the facility failed to develop and implement a COVID-19 staff vaccination process to address all facility staff, including agency staff who provided care, treatment and other services to facility and/or residents. Specifically, the facility failed to obtain the vaccination status of other outside providers. The facility did not have the vaccination status for all of the outside providers. The facility was unable to provide a listing of the vaccination status of all contracted providers/staff who enter the facility on a regular basis and provide direct care to residents. Cross-reference F886 (COVID-19 testing), and F880 (Infection control). Findings include: I. Record review Staff vaccination matrixes were provided by the facility. The vaccination matrix failed to ensure all staff and providers who provided resident care were listed on the vaccine matrix. -Review of the matrix provided by the facility failed to include medical providers, which included psychiatric physician (PSY) and two staff, one who scribed (SC) and a case manager (CM), and failed to include contract agencies certified nurse aide (CNAs), licensed practical nurse (LPNs), and registered nurse (RNs). II. Staff interviews The NHA and DON were interviewed on 9/15/22 at 11:20 a.m. The NHA said she was responsible for entering all staff into the COVID-19 immunization matrix. The NHA said they catch new employees and add as hired. The NHA said they add agency staff as they come in and give their immunization cards. The NHA checked on the matrix and and verified that many staff members had not been added to the matrix and many were contract agency staff. The NHA acknowledged that the following sample staff members were not added to the matrix: LPN #5, CNA #8, CNA #7, CNA #6, LPN #6, psychiatric physician and two of his workers (SC and CM), LPN #10, CNA #3, and CNA #4. The regional clinical resource (RCR) was interviewed on 9/15/22 at 2:32 p.m. The RCR said she reviewed records and was able to locate the vaccination cards on some of the missing staff. The RCR did confirm that the staff names which were provided in an earlier meeting were not on the matrix. LPN #7, the nurse who did not wear the mask the day before on the unit (cross-reference F880), had COVID-19 in June 2022 so was in the 90 day period and did not have to test. -However, she was not listed on the matrix. The RCR also verified she did not have the vaccination status for the psychiatric physician and his two workers (SC and CM) who were in the building on 9/14/22. III. Facility follow up The facility provided the vaccine cards for those sample staff members not listed on the vaccine matrix. -CNA #6 primary vaccinations. -LPN #5 primary vaccinations plus one booster dose. -CNA #7 primary vaccinations plus one booster dose. -LPN #6 primary vaccinations. -LPN #7 primary vaccinations. -CNA #3 primary vaccinations plus one booster dose. IV. Facility COVID-19 status The facility had been in COVID-19 outbreak status since 7/7/22. The facility had no current confirmed positive cases of COVID-19 in residents and had one positive agency staff member who tested positive 9/6/22. The facility was located in Denver county, and was in substantial community transmission levels for healthcare communities.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to test residents, facility staff, and individuals providing services under arrangement and volunteers, for COVID-19. This had the potential to affect all 77 residents residing in the facility at the time of the survey. Specifically, the facility failed to ensure: -Rapid point-of-care (POC) tests for COVID-19 were consistently conducted and documented on staff prior to the start of their shift, based on the facility's county positivity rate and outbreak status; and -Polymerase chain reaction (PCR) testing was conducted on all staff based on the county positivity rate and outbreak status. Cross reference F888 (COVID-19 staff vaccination matrix) and F880 (Infection control). Findings include: I. Professional references The healthcare community transmission levels for the facility's county of residence, obtained from https://covid19.colorado.gov/healthcare-providers/long-term-care-facilities/healthcare-community-transmission-levels, were reviewed for the time of survey (9/12/22-9/15/22) and found to be in Substantial levels of transmission. The Centers for Disease Control and Prevention (CDC), (updated 2/2/22) Interim Infection Prevention and Control Recommendations to Prevent SARS-Co-V-2 Spread in Nursing Homes, retrieved on 9/20/22 from https://www.cdc.gov/coronavirus/2019-ncov/hcp/long-term-care.html#anchor_1631031062858 , documented the following, Expanded screening testing of asymptomatic HCP (healthcare personnel) should be as follows: Fully vaccinated HCP may be exempt from expanded screening testing. In nursing homes, unvaccinated HCP should continue expanded screening testing based on the level of community transmission as follows: In nursing homes located in counties with substantial to high community transmission, unvaccinated HCP should have a viral test twice a week. If unvaccinated HCP work infrequently at these facilities, they should ideally be tested within the 3 days before their shift (including the day of the shift). Per recommendations above, these facilities should prioritize resources to test vaccinated and unvaccinated symptomatic people and all close contacts, as well as be prepared to initiate outbreak response immediately if a nursing home-onset infection is identified among residents or HCP. II. Facility policy The COVID-19 Prevention, Response and Testing Policy, revised 8/22/22, was provided by the nursing home administrator (NHA) on 9/15/22 at 12:55 p.m. It read in pertinent part, Surveillance testing: The facility will conduct testing in a manner that is consistent with current standards of practice and CDC guidance for conducting COVID-19 testing including use of droplet precaution personal protective equipment (PPE). For each instance of testing: Document that testing was completed and the results of each staff test. The facility will follow Center for Medicare and Medicaid Services (CMS) guidance for surveillance testing based on community transmission rates. Outbreak testing: Upon identification of a single new case of COVID-19 infection in any staff or residents, all staff and residents should be tested. Staff will continue to be tested per guidelines from the CDC and local and state health departments. III. POC and PCR COVID-19 testing Review of the staffing schedule on 9/14/22 revealed the facility had staff who were working that were not up to date on their vaccination status and failed to complete the POC tests prior to shift. Certified nurse aide (CNA) #5 was not up to date on vaccination. CNA #5 worked on 9/13/22. -Records failed to show CNA #5 had POC testing prior to their shift and no PCR test on 9/12/22 or 9/13/22. Licensed practical nurse (LPN) #8 was not up to date on vaccination. LPN #8 worked on 9/12/22, 9/13/22, 9/14/22, and 9/15/22. -Records failed to show LPN #8 had POC testing prior to their shifts. The SSD was not up to date on vaccination. The SSD worked the week of 9/12/22. -Records failed to show the SSD had POC testing prior to shifts for the month of September 2022 and also no PCR testing documentation for the month of September 2022. Dietary aide (DA) #1 was not up to date on vaccination. DA #1 had worked the week of 9/12/22. -Records failed to show DA #1 had POC testing prior to their shift for the entire month of September 2022 and she also had no PCR testing documentation for her for the month of September 2022. The dietary supervisor (DS) was not up to date on vaccination. The DS worked the week of 9/12/22. -Records failed to show the DS had POC testing prior to shifts for the month of September 2022. The DA #2 was not up to date on vaccination. The DA #2 worked the week of 9/12/22. -Records failed to show the DA #2 had POC testing prior to shifts for the month of September 2022. IV. Staff interviews The NHA and director of nursing (DON) were interviewed on 9/15/22 at 11:20 a.m. She said they had an agency staff person test positive for COVID-19 on 9/6/22. The NHA said the current outbreak began 7/7/22 and began with a staff member., verified by PCR test. The NHA said they test staff on Monday/Tuesdays and on Thursday/Fridays and they get results in two days. The NHA said during the outbreak two residents became positive 8/2/22 and on 8/5/22 the facility had 14 positive residents. The NHA said when staff were not up to date on vaccination the staff were doing rapid (POC) tests before their shift. The NHA said the staff did daily rapid tests and twice a week PCR. The NHA said she was responsible for entering everyone into the matrix. The NHA said that CNA #5 completed a rapid test on 9/14/22 and was PCR tested 9/8/22 but had no further PCR testing. The NHA said if CNA #5 was working then CNA #5 should have had a PCR test on 9/12 or 9/13/22. -According to the daily staffing schedule CNA #5 worked the evening shift on 9/13/22. The NHA said she had no rapid test records for LPN #8. The NHA said she had no rapid test records for the DS but had PCR testing for the DS on 9/12/22, and 9/8/22, but none for 9/5/22 or 9/6/22. The NHA said that perhaps DS had been on vacation. The NHA said she had no rapid test records in the month of September 2022 for the SSD and she also had no PCR testing documentation for the month of September 2022 for the SSD. The NHA said she had no rapid test records for the month of September 2022 for DA #1 and she also had no PCR testing documentation for her for the month of September 2022. The NHA said she had no rapid test records for the month of September 2022 for DA #2 but she had a record of PCR testing on 9/12, 9/8, 9/5 and 9/1/22. The NHA said it was part of the facility policy that staff get tested twice a week with PCR testing and get daily rapid testing if they were not up to date on vaccine boosters. The NHA said she would not want the staff to come in if they had not tested. The NHA said the DON) and registered nurse (RN) supervisor were responsible for tracking and verifying that staff testing was completed. The NHA and DON said they reviewed together to verify if testing had been done. The DON said the system was broken in the lack of follow through. The regional clinical resource (RCR) was interviewed on 9/15/22 at 2:32 p.m. The RCR said she reviewed records and was able to locate the vaccination cards on some of the missing staff. The RCR did confirm that the staff names which were provided in an earlier meeting were not on the vaccine matrix (cross-reference F888). The RCR said the DS was fully vaccinated and she did not have to do a rapid test. She said that the facility did recognize that there was a problem with point of care (rapid) testing, as not everyone was testing as indicated. The RCR provided a written statement from CNA #3, CNA #5 and CNA #4 which attested that they have completed the PCR testing as ordered. However, their names were not on the printed list. -However, when the specimen was picked up by the lab, the specimen was disposed of because they did not have printed labels which was required by the lab. So therefore, the individuals were not tested, as their specimen was never processed. The RCR said that the facility was currently providing inserving to all staff in regards to COVID-19 testing. She said everyone will be educated before the next shift. The RCR said they were waiting for staff outside to provide them training. V. Facility follow-up The facility provided staff attestation that PCR testing was completed since the facility had no record of it being conducted. -CNA #3, To whom it may concern, I (CNA #3) had been testing on the days I am scheduled here unless working multiple shifts. If I have three plus shift, I fall in line with the regular staff testing schedule and test two times a week on Monday and Thursday I have tested on the following days, 8/12/22, 8/18/22, 8/16/22, and 9/12/22. If you have any questions or concerns I can be reached at this phone number. -CNA #4, To whom it may concern, I (CNA #4) tested on the sixth and the 12th of September due to the fifth being a holiday, signed and dated 9/15/22. -CNA #5, I have been testing but forgot to put label on testing kit I have been writing my name on the label for two weeks, signed and dated 9/15/22. -However the facility had no documentation or lab record of CNA #3, #4, and #5's testing, as the test was discarded at the lab as it was not prepared correctly. Staff education documentation on proper COVID-19 testing requirements for staff was provided by RCR on 9/15/22 at 2:30 p.m. It read in part, the staff were to complete testing twice a week and daily rapid test if not up to date. If over [AGE] years old a rapid test daily until the booster had been received. Test when you come into work. Inservice dated 9/15/22 and signed by 20 staff members. The second in-service document read in part, COVID-19 testing was to be sent to the lab twice a week. Test when you come into work. Inservice dated 9/15/22 and signed by 20 staff members. The RCR provided COVID-19 PCR positive testing results for the SSD, test collected 6/7/22. The RCR provided an action plan for POC testing of not up-to-date staff and residents during outbreak, date identified 9/15/22. Identified concern: It was identified that the point of care testing was not occurring per Colorado department of public health and environment (CDPHE) regulation, daily prior to the beginning of the shift and for not up-to-date residents during the outbreak.