**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and interviews, the facility failed to ensure two (#19 and #44) of four residents out of 51 sample residents had the right to a dignified existence. Specifically, the facility failed to: -Ensure Resident #19 was provided dignity and privacy while removing medication patches; and, -Ensure Resident #44 was not placed in the hallway facing the wall by facility staff. Findings include: I. Facility policy and procedure The Residents' Rights and Dignity policy and procedure, dated November 2023, was provided by the nursing home administrator (NHA) on 12/10/24 at 9:00 p.m. It read in pertinent part, To be treated with consideration, respect, and full recognition of his or her dignity and individuality. II. Resident #19 A. Resident status Resident #19, age greater than 65, was admitted on [DATE]. According to the December 2024 computerized physician orders (CPO), the diagnoses included dementia with anxiety and cognitive communication deficit (difficulty communicating related to attention and memory issues). The 9/25/24 minimum data set (MDS) assessment revealed the resident had severe cognitive impairments with a brief interview for mental status (BIMS) score of two out of 15. B. Observations On 12/5/24 at 3:33 p.m. certified nurse aide with medication authority (CNA-Med) #1 entered the dining room during a group activity. Resident #19 was sitting in the dining room near other residents. CNA-Med #1 approached Resident #19 and asked her to lean forward in her wheelchair. CNA-Med #1 lifted her sweater and shirt which exposed her lower back and removed a lidocaine patch. On 12/9/24 at 3:32 p.m. CNA-Med #1 entered the dining room during a group activity, where Resident #19 was sitting near other residents. CNA-Med #1 approached Resident #19 and asked her to lean forward in her wheelchair. CNA-Med #1 then lifted her sweater and shirt which exposed her lower back and removed a lidocaine patch. C. Staff interviews The director of nursing (DON) was interviewed on 12/10/24 at 6:24 p.m. The DON said that a medication patch underneath clothing should not be removed in the dining room. He said Resident #19 should have been taken back to their room and provided privacy prior to having a medication patch underneath her clothing removed. III. Resident #44 A. Resident status Resident #44, age greater than 65, was admitted on [DATE]. According to the December 2024 CPO, the diagnoses included Alzheimer's disease, dementia and generalized muscle weakness. The 9/11/24 MDS assessment revealed the resident had short term and long term memory impairment with severe impairment in making decisions regarding tasks of daily life. She was dependent on staff for all mobility and used a wheelchair and was unable to self propel. B. Observations On 12/4/24 at 9:06 a.m. Resident #44 was sitting in her wheelchair in the back hallway, facing the wall. Resident #44 was faced away from other residents, the nurses station and the jazz music playing. On 12/5/24 at 10:38 a.m. Resident #44 was assisted to the back hallway and left in the corner, partially facing the wall, away from the nurses station and the common area where other residents were participating in a Christmas [NAME] sing-along activity with the chaplain. On 12/9/24 at 12:55 p.m. Resident #44 was sitting in her wheelchair in the back hallway, facing the wall, away from other residents. Christmas music played at the nurses station in the common area for residents. C. Record Review The communication care plan, dated 7/2/2020, read in pertinent part, be conscious of Resident #44's position when in groups, activities, dining room, to promote proper communication with others. D. Staff interviews The DON was interviewed on 12/10/24 at 6:24 p.m. The DON said a residents' placement in the hallway depended on their ability to propel themselves. He said Resident #44 was not able to propel herself. He said Resident #44 being placed in the back hallway or with the wheelchair faced toward the wall was not ideal. He said he preferred Resident #44 to be near others and be brought to the common area to be part of the Christmas music activity.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to prevent abuse for one (#68) of three sample residents reviewed for abuse out of a sample of 51 residents. Specifically, the facility failed to ensure Resident #22 was free from physical abuse from Resident #68. Findings include: I. Facility policy and procedure The Abuse Prevention policy and procedure, revised July 2019, was provided by the clinical nurse resource (CNR) on 12/10/24 at 9:00 p.m. It read in pertinent part, It is the policy of this facility that each resident has the right to be free from abuse, neglect, misappropriation of resident property and exploitation. All employees of our facility will take action to protect and prevent abuse and neglect from occurring within the facility by ensuring the staff has the knowledge of individual residents' care needs, ensuring supervision of staff to identify inappropriate behaviors, assess residents, care plan and monitor residents with history of aggressive behaviors (such as entering other resident rooms, self-injurious behavior, communication disorders and resident totally dependent on staff). II. Incident of physical abuse between Resident #68 and Resident #22 on 9/2/24 The 9/2/24 abuse investigation documented there was a physical altercation between two residents. The residents were separated and assessed. Resident #22 had a red mark on her neck. The residents were interviewed and placed on 72-hour monitoring. Resident #68 was interviewed on 9/2/24 and she did not recall the incident but said she needed to pack. She said that she felt safe and was not fearful. Resident #22 was interviewed on 9/2/24 and said she had a disagreement with a lady about her jewelry. She said she felt safe and was not fearful. Resident #22 had a small scratch on the right side of her neck that did not require medical interventions. Four staff members were interviewed. Licensed practical nurse (LPN) #3 said she was at the nursing station when she heard the two residents talking. She did not see what happened but she heard Resident #22 say, No, it isn' t your room and then she rushed in to separate the residents. Five residents were interviewed on the unit and were not able to provide any additional information. III. Resident #22 - victim A. Resident status Resident #22, age [AGE], was admitted on [DATE]. According to the December 2024 computerized physician's orders (CPO), diagnoses included unspecified dementia, type 2 diabetes and muscle weakness. The 11/13/24 minimum data set (MDS) assessment documented the resident had severe cognitive impairments with a brief interview for mental status (BIMS) score of six out of 15. She required supervision with eating, dressing, bathing, toileting and walking. B. Record review The care plan, initiated on 6/10/24 and revised on 12/7/24, documented Resident #22 was at risk for depression and behavior problems related to dementia, disease process and depression. Interventions included discussing with the family/caregivers about any concerns (initiated 6/10/24), encouraging the resident to express her feelings (initiated 6/10/24), following the Level II pre-admission screening and resident review program (PASARR) recommendations (which included psychiatric case management, social interactions once settled into new facility and the resident had hearing aids (initiated 6/25/24), observing and documenting any signs and symptoms of depression to the nurse (initiated 6/10/24), offering the resident a piece of chewing gum (initiated 12/7/24), offering the resident to call a friend (initiated 9/6/24), offering the resident to go outside for a walk in the courtyard (initiated 9/6/24), reminding the resident to put her light low if she was reading when others were sleeping (initiated 12/7/24) and stopping and talking to resident when passing by (initiated 9/6/24). The interdisciplinary team (IDT) note, dated 9/3/24, documented that the IDT reviewed the incident from 9/2/24 around 8:50 p.m. It documented Resident #68 wandered into Resident #22's room. Resident #68 began packing up Resident #22's clothing. Resident #22 got frustrated and asked Resident #68 to leave but Resident #68 reported it was her room. Resident #22 told Resident #68 it was not her room. Resident #68 then scratched Resident #22 on the neck. The residents were immediately separated by staff. The nursing progress note, dated 9/3/24 documented Resident #22 was on follow-up for the altercation with another resident and no new concerns were identified. IV. Resident #68 - assailant A. Resident status Resident #68, age [AGE], was admitted on [DATE]. According to the December 2024 CPO, diagnoses included Alzheimer's disease, muscle weakness, cognitive communication deficit and hypertension (high blood pressure). The 9/25/24 MDS assessment documented the resident had severe cognitive impairments with a BIMS score of two out of 15. She required supervision with eating, dressing, bathing, toileting and walking. The assessment documented that she had other behaviors not directed toward others (physical symptoms such as hitting or scratching, self-pacing, rummaging, public sexual acts, disrobing in public, throwing or smearing food or bodily wastes or verbal/vocal symptoms like screaming) one to three times a week. B. Record review The care plan, initiated on 3/6/23 and revised on 9/26/24, documented the resident had potential for a behavior problem related to dementia. The goal was to be able to explore the neighborhood in a safe manner. The pertinent interventions included offering her to read her Bible, providing the resident with activities, putting the television on to the gospel channel, redirecting her away from other's space, reminding her where her room was, redirecting her with one-on-one time and reorienting what belongings were hers. The nurse progress note, dated 3/3/23, documented Resident #68 was wandering around the neighborhood and was not able to recall where her room was. The note documented when she was wandering into others spaces, this was agitating others. The staff continued to reorient her to new surroundings and assisted her with adjusting. The nurse progress note, dated 3/18/23, documented, Resident #68 continued to wander into other residents' rooms which irritated some residents. Resident #68 became aggressive with redirection from other rooms. Resident #68 also attempted to not let her roommate in. The staff redirected her and let her in but she was upset. The activities progress note, dated 7/3/24, documented Resident #68 continued to get agitated and territorial when others went in her room. The note documented that at times she did not let anyone go in her room. The nurse progress note, dated 7/18/24, documented Resident #68 was packing up her roommate's belongings and staff would redirect her to her side of the room and that those items were not hers. The resident became verbally agitated. The note documented that eventually she stopped packing and calmed down. The note documented the resident returned back to her baseline. The nurse progress note, dated 9/2/24, documented Resident #68 and Resident #22 had a fight. Resident #68 walked into Resident #22's room and started the argument. Staff ran in to separate the residents. Resident #68 scratched Resident #22 on her neck. The medical doctor (MD), the director of nursing (DON) and both families were notified. Both residents were stable and safe at the time of the documentation. One-on-one protocol was initiated for both residents. The social services progress note, dated 9/3/24, documented social services checked in with Resident #68 following the incident on 9/2/24. Resident #68 did not recall the incident, however, she did say that her son was coming to pick her up so she needed to pack. Resident #68 reported that she felt safe and was not fearful. The note documented social services would continue to follow and provide support as needed. V. Staff interviews Certified nurse aide (CNA) #12 was interviewed on 12/10/24 at 9:50 a.m. CNA #12 said when residents had altercations it was important to keep them separated and to keep an eye on them. CNA #12 said the unit kept activities and movies or shows going in the common area to keep the residents busy. CNA #12 said Resident #68 went into a lot of different rooms. CNA #12 said Resident #22 did not like it when people entered her room. CNA #12 said Resident #68 always thought she needed to pack up and get home to her children, so Resident #68 began packing up Resident #22's belongings. CNA #12 said the closets on the unit were all locked, but that Resident #68 was packing up the items that were on Resident #22's nightstand and bed. CNA #12 was interviewed a second time on 12/10/24 at 1:02 p.m. CNA #12 said Resident #68 was always trying to find a way out of the facility. CNA #12 said Resident #68 would get confused and agitated and go into another resident's room. CNA #12 said Resident #68 entered other residents' rooms a few times a week. CNA #12 said she could redirect Resident #68 by talking about religion or offering to call Resident #68's son. CNA #12 said when Resident #68 wandered into another resident's room, she would get agitated with that resident. CNA #12 said Resident #68 was fine when she first got to the facility but started wandering later on. Social worker (SW) #1 was interviewed on 12/10/24 at 1:55 p.m. SW #1 said Resident #68 knew where her room was when she first moved in and when her dementia started progressing, she started to wander around the unit more and into other residents' rooms. SW #1 said she would do this about three to four times a week. She said Resident #68 would exit seek and pack her belongings because she thought her son was coming to pick her up. She said the staff would intervene if they witnessed this occurring by offering for her to call her son, offering for her to read the Bible, redirect her to the chaplain, and listening to gospel music. She said in August 2024, she got into an altercation with another resident. She said because of that incident and the progressing dementia, she was moved into a different unit more suited for her needs. She said she was doing a lot better in terms of behaviors in the new unit. The DON and the CNR were interviewed together on 12/10/24 at 5:00 p.m. The DON said Resident #68 liked to walk around the unit and at one point started to wander into other residents' rooms. He said staff reported to him that Resident #68 would rummage through other residents' belongings. He said when residents start to wander, it could become a trigger for an altercation. He said the resident was redirected by staff and they utilized red stop signs banners that would be placed across a doorway. He said after the altercation between Resident #68 and Resident #22, the two residents were immediately separated and assessed. The DON said the residents were placed on 72-hour monitoring. He said Resident #68 had not shown any aggressive behaviors prior to this incident. -However, review of the resident's electronic medical record (EMR) revealed the Resident #68 had a history of behaviors (see record review above).

Deficiency Text Not Available

Deficiency Text Not Available

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interviews, the facility failed to ensure supervision and interventions to prevent accidents for one (#88) of twelve residents reviewed for accidents of 51 sample residents. Specifically, the facility failed to ensure fall interventions were implemented for Resident #88 who had experienced several falls. Findings include: I. Facility policy and procedure The Fall Monitoring and Management policy and procedure, revised March 2024, was received from the clinical nurse resource (CNR) on 12/10/24 at 9:00 p.m. It documented in pertinent part, It is the policy of this facility that residents are assessed and evaluated to identify risks for injury due to falls, residents receive necessary treatment and monitoring after a fall and interventions are implemented to minimize risks for injury due to falls. The interdisciplinary team (IDT) will place a fall IDT note in the computer with verification of interventions or new interventions. II. Resident #88 A. Resident status Resident #88, age [AGE], was admitted on [DATE]. According to the December 2024 computerized physician orders (CPO), diagnoses included unspecified dementia, history of falling, cognitive communication deficit, lack of coordination, unsteadiness on feet and muscle weakness. According to the 9/25/24 minimum data set (MDS) assessment, the resident had severe cognitive impairments with a brief interview for mental status (BIMS) score of three of 15. The resident suffered one fall without injury since the previous MDS assessment. She required partial/moderate assistance for hygiene, toileting, showering, dressing and transferring. She required supervision or touching assistance (helper provides verbal cues and/or touching/steadying and/or contact guard assistance) for walking. She used a walker regularly in the past seven days. B. Observations During a continuous observation on 12/4/24, beginning at 9:15 a.m. and ending at 12:10 p.m. the following was observed: Resident #88 was in the dining room with a group of residents for an exercise activity. She wandered out of the dining room and into the hallway. She walked three laps in the hallway at 9:15 a.m. without a walker. A certified nursing aide (CNA) walked past her and did not offer a walker or assistance with ambulation. She sat down on a couch in the living room at 9:25 a.m. She was not wearing a soft helmet. During a continuous observation on 12/4/24, beginning at 1:30 p.m. and ending at 4:30 p.m., the following was observed: At 2:31 p.m. Resident #88 was sitting on a couch in the hallway. She got up by herself and walked toward another resident's room. She turned around and walked down the hallway. There was an unidentified CNA taking vital signs in the hallway and she did not offer to get Resident #11's walker or offer assistance with ambulation. She was not wearing a soft helmet. During a continuous observation on 12/9/24, beginning at 8:30 a.m. and ending at 12:40 p.m., the following was observed: At 8:45 a.m. Resident #88 was walking around the unit without a walker. CNA #6 walked past her and did not offer assistance with ambulation or a walker. She was not wearing a soft helmet. At 8:50 a.m. Resident #88 was walking around the hallway without her walker or assistance. She was not wearing her helmet. At 10:05 a.m. Resident #88 was observed holding onto a side railing in the hallway. A nurse was with and calling out for someone to get her a wheelchair. A CNA brought a wheelchair and they assisted the resident into a seated position into the chair. She was not wearing a soft helmet. At 12:30 a.m. Resident #88 was observed walking around the unit. There was an unidentified CNA that walked past the resident without offering a walker, wheelchair or assistance with ambulation. She was not wearing a soft helmet. C. Record review The care plan for falls, initiated 4/3/24 and revised 9/25/24, identified the resident had a history of dementia, seizure disorder, used high risk medications, had poor safety awareness, had muscle weakness, difficulty walking, unsteadiness on her feet, lack of coordination and history of falling. Interventions included ensuring the resident was wearing appropriate footwear when ambulating or wheeling in wheelchair (initiated 4/3/24), keeping needed items (water) in reach (initiated 4/3/24), maintaining a clear pathway free of obstacles (initiated 4/3/24) and, offering a soft helmet and hipsters (padded shorts) as resident allows (4/3/24). -However, observations revealed the resident was not wearing the soft helmet (see observations above). An additional fall care plan, initiated on 9/5/24 and revised on 11/28/24, revealed the resident had a fall related to poor balance and poor communication/comprehension. Interventions for the fall documented on 9/4/24 (initiated 9/5/24) included physical therapy (PT) to screen the resident, offering toileting after meals and routine blood work ordered for hyperthyroidism. Interventions for the fall documented on 9/26/24 (initiated 9/30/24) included PT to assess for new pain and report to floor nurse, recommended labs and medication review and to continue therapy. Interventions for the fall documented on 10/11/24 (initiated 10/14/24) included therapy to screen as indicated and offering rest periods after meals to address fatigue that may occur post-lunch. Interventions for the fall documented on 10/25/24 (initiated 10/28/24) included to continue PT/occupation therapy (OT)/speech therapy (ST) and to anticipate needs and assist to bed post lunch time as indicated. Interventions for the fall documented on 11/23/24 (initiated 11/25/24) included to assist with frequent repositioning in her wheelchair and to continue PT/OT/ST. Interventions for the fall documented on 11/27/24 (initiated 11/28/24) included to check for labs or urinary analysis (UA) and to continue PT/OT to address mobility and activities of daily living (ADLs). The December 2024 CPO indicated Resident #11 had an order to encourage to wear a soft helmet as the resident would allow, every shift for safety, ordered on 4/3/24. The CNA [NAME] (instructions for care) identified that the resident required supervision and up to one staff participation using a gait belt for transfer and walking. It was documented to provide verbal cues for initiation and safe sequencing and to walk to/from meals and bathroom as the resident was willing. 1. Fall incident on 9/4/24 - unwitnessed The progress note on 9/4/24 documented that therapy reported to the nurse that the resident was sitting in the hallway on the floor. Prior to the incident she was walking around the unit. The resident had poor safety awareness with diagnosis of dementia. The 9/4/24 fall investigation documented the immediate action that was taken included the registered nurse (RN) assessed the resident and there were no visible injuries noted. A wheelchair was close to where the resident was sitting. The note documented the resident could have been attempting to sit in the wheelchair and missed it and ended up sitting on the floor. The resident had non-slip socks on, the floor around the resident was dry and free of clutter and there was adequate lighting. Initial vital signs were stable, neurological checks were initiated and the guardian and the provider were notified. The fall assessment from 9/4/24 documented the resident was oriented to person, Predisposing factors contributing to the fall included confusion, impaired memory, incontinence and wandering behavior. 2. Fall incident on 9/26/24 - unwitnessed The progress note on 9/26/24 documented that staff notified the resident sitting in the hallway, prior to that she was walking/wandering around the unit. She had dementia that made her have a poor sense of safety. The 9/26/24 fall investigation documented immediate action taken included the RN assessed the resident while she was sitting on the floor. The area was clean with no clutter and she was wearing non-slip socks. She appeared to be tired with generalized weakness. There were no neurological changes from baseline. There were no visible injuries noted. She was assisted by two staff members to a wheelchair. The provider and guardian were notified. Lab tests and medication review were recommended and neurological checks were initiated. The fall assessment from 9/26/24 documented the resident was oriented to person, predisposing factors contributing to the fall included gait imbalance, impaired memory, incontinence and wandering behavior. 3. Fall incident on 10/11/24 The progress note on 10/11/24 documented the staff last saw the resident sitting on a chair in the hallway. The staff heard a noise and observed the resident sitting on the floor. The resident was assisted by two staff members back into a wheelchair and sat by the television. The resident got up again after a couple hours and fell again. The 10/11/24 fall investigation documented immediate action taken included the resident was assessed by a nurse and helped up by two staff. No injuries were noted. All range of motion (ROM) were active, the resident was wearing non-slip socks, hipsters and the floor was free from clutter. Neurological checks were initiated and stable. The family and provider were notified. The fall assessment from 10/11/24 documented the resident was oriented to person, predisposing factors contributing to the fall included confusion and wandering behavior. 4. Fall incident on 10/25/24 - unwitnessed The progress note on 10/25/24 documented the resident was found sitting on the floor during rounds. The resident was unable to describe the incident due to unspecified dementia. A head to toe assessment was completed by the RN supervisor. The resident was stable and had no signs of pain or discomfort. The 10/25/24 fall investigation documented immediate action taken included a head to toe assessment. The resident had a black eye. She was assisted into the wheelchair with a gait belt. Neurological checks were initiated and vital signs were normal. She was at baseline for ROM. Responsible parties were notified. The fall assessment from 10/25/24 documented the resident was oriented to person, predisposing factors contributing to the fall included confusion, gait imbalance, impaired memory, incontinence, ambulating without assistance and wandering behavior. 5. Fall incident on 11/23/24- witnessed The progress note on 11/23/24 documented the resident had a witnessed fall. Before the fall, the resident was sitting in a wheelchair close to the couch in the common area watching television. The fall occurred while the resident was attempting to self-transfer to a nearby couch. The staff were unable to prevent the fall due to its unexpected and sudden nature. The RN was notified and assessed the resident. There were no visible injuries noted. Neurological checks were initiated and vital signs were normal. Responsible parties were notified. The 11/23/24 fall investigation documented the immediate action taken included notifying the RN, injury assessment by the RN and assisting the resident into a safe sitting position. The fall assessment from 11/23/24 documented the resident was oriented to person, predisposing factors contributing to the fall included confusion, incontinence, and wandering behavior. 6. Fall incident on 11/27/24 - unwitnessed The progress note on 11/23/24 documented the resident was found sitting next to her bed. The nurse went in to check on the resident and the resident had already gotten up by herself. A complete head to toe assessment was done by the RN supervisor. The resident denied any pain or discomfort. The room was well lit, free from clutter and the resident was wearing non-slip socks. The 11/27/24 fall investigation documented the immediate action taken included a head to toe assessment, neurological checks were initiated and vital signs were normal. Responsible parties were notified. The fall assessment from 11/27/24 documented the resident was oriented to person, predisposing factors contributing to the fall included confusion, incontinence, impaired memory, ambulating without assistance and wandering behavior. D. Staff interviews CNA #4 was interviewed on 12/9/24 at 2:45 p.m. CNA #4 said nobody on the unit wore a soft helmet on the unit where Resident #88 resided. He said Resident #88 needed assistance getting dressed daily and the staff assisted her in putting her hipsters on. CNA #13 was interviewed on 12/9/24 at 3:45 p.m. CNA #13 said Resident #88 was a high fall risk. She said she could walk but gets weak sometimes and the staff would get her a wheelchair. Licensed practical nurse (LPN) #2 was interviewed on 12/9/24 at 4:20 p.m. LPN #2 said Resident #88 was a high fall risk. She said interventions to prevent falls for her included offering hipsters, offering a wheelchair or walker, staff to supervise her,and for the staff to walk with her. She said the nurses and the CNAs were responsible for offering the resident to wear a soft helmet and hipsters. She said she could not find Resident #88's soft helmet. The director of nursing (DON) and the CNR were interviewed together on 12/10/24 at 5:00 p.m. The DON said Resident #88's mood and activity level fluctuated from day to day. He said sometimes she wanted to be left alone and other times she engaged in activities with others. He said she was working with therapy and used a walker and required the assistance of one to two staff members for ambulation. He said she got up on her own often and the staff were expected to intervene and walk with her when this occurred. He said based on assessment and previous falls, she was considered a high fall risk. He said fall interventions for her included wearing hipsters, a soft helmet, a fall mat beside her bed and ensuring her bed was in the lowest position. He said with the acuity of the resident population on the unit Resident #88 lived on, the staff were not able to keep an eye on everybody at all times. He said fall interventions were continually assessed and new ones were added if old ones were no longer working.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interviews, the facility failed to ensure four (#366, #370, #27 and #43) of 12 residents out of 51 sample residents were provided the appropriate care and services of activities of daily living (ADL) to maintain or improve his or her abilities. Specifically, the facility failed to ensure Resident #366, Resident #370, Resident #27 and Resident #43 received cueing or assistance while eating. Findings include: I. Facility policy and procedure The Assisting Diners policy and procedure, revised May 2019, was provided by the nursing home administrator (NHA) on 12/11/24 at 9:26 a.m. It read in pertinent part It is the policy of this facility that dependent diners will be assisted with all meals in a manner that meets the individual resident's needs, promotes self-esteem and the highest practical level of independence. If verbal prompts are needed to initiate eating, opening mouth, swallowing, do these in a calm, pleasant manner. Offer drinks of beverages throughout the meal. Offer alternatives if foods refused. II. Resident #366 A. Resident status Resident #366, age [AGE], was admitted on [DATE]. According to the December 2024 computerized physician orders (CPO) diagnoses included aphasia (disorder affecting ability to understand and express language), dysphagia (difficulty swallowing) and dementia. The 11/24/24 minimum data set (MDS) assessment revealed the resident had severe cognitive impairments with a brief interview for mental status (BIMS) score of seven out of 15. Resident #366 needed set up and clean up assistance with meals as well as partial assistance with planning regular daily activities. B. Observations During a continuous observation on 12/9/24, beginning at 9:46 a.m. and ending at 1:00 p.m., the following was observed: At 12:20 p.m. Resident #366 was served a room tray for lunch of orange chicken, rice, mixed vegetables, and a cookie. An unidentified certified nurse aide (CNA) who served her the lunch tray did not offer or encourage the resident to go to the dining room. The resident took a few bites. The staff did not provide cueing or physical assistance to Resident #366 during the meal. The resident ate less than 25% of her meal. During a continuous observation on 12/9/24, beginning at 3:30 p.m. and ending at 7:00 p.m., the following was observed: At 6:28 p.m. Resident #366 was served a room tray for dinner. An unidentified CNA did not encourage the resident to eat dinner in the dining room. The staff did not provide cueing or physical assistance to Resident #366 during the meal. The resident ate about 50% of her meal. During a continuous observation on 12/10/24, beginning at 11:45 a.m. and ending at 1:00 p.m., the following was observed: At 11:58 a.m. Resident #366 entered the dining room. At 12:16 p.m. she was served a plate of mashed potatoes, mixed vegetables, roast beef and fruit for lunch. At 12:21 p.m. Resident #366 had not taken a bite of lunch. The staff did not provide any physical assistance or cueing for the resident to eat. At 12:36 p.m. Resident #366 was asked by an unidentified nurse if she was going to eat. Resident #366 responded yes, however she still did not take a bite of food. The unidentified nurse walked away and did not provide any further cueing or assistance. At 12:48 p.m. Resident #366 was assisted back to the unit. She did not eat any of her meal. C. Record review The ADL care plan, revised on 11/22/24, documented Resident #366 had an ADL self-care performance deficit due to a recent fall and a diagnosis of dementia, which impacted her cognition. The interventions included providing set-up and physical assistance of one staff member with eating and encouraging the resident to eat her meals in the dining room. -However, according the observations during the survey process, Resident #366 was not provided the level of assistance in which the care plan documented she required. The nutritional risk care plan, revised on 12/1/24, documented Resident #366 was malnourished according to a mini-nutritional assessment conducted at the facility. The interventions included inviting the resident to attend activities that promote additional intakes, eating meals in the dining room, monitoring and reporting to the physician if the resident had any signs or symptoms of a decreased appetite, monitoring the resident's weights per facility policy, providing and serving supplements as ordered (Ensure Plus one carton, three times daily) and reviewing the resident's nutritional status in the nutrition at risk meeting as needed. The 12/1/24 dietitian progress note documented Resident #366's meal intake was sporadic, between zero to 75%. The meal percentage documentation record revealed from 11/21/24 to 12/10/24, Resident #366 ate zero to 25% on 19 occasions and refused to eat on three occasions. III. Resident #370 A. Resident status Resident #370, age [AGE], was admitted on [DATE]. According to the December 2024 CPO, diagnoses included encephalopathy (brain disorder that causes brain dysfunction), dysphagia, dementia and moderate protein calorie malnutrition. The 11/17/24 MDS assessment revealed the resident had severe cognitive impairments with a BIMS score of three out of 15. Resident #370 required set up and clean up assistance with meals as well as partial assistance with planning regular daily activities. B. Observations During a continuous observation on 12/4/24, beginning at 9:45 a.m. and ending at 1:30 p.m., the following was observed: At 12:23 p.m. Resident #370 was served lunch of fish, green beans, rice and corn bread. Resident #370 was unable to find his silverware that was tucked in his napkin on his right hand side. He was eating with his hands. At 12:42 p.m. the food and nutrition resource (FNR) asked Resident #370 if he was doing okay. She did not offer any encouragement or cueing and did not offer to assist him with his silverware Resident #370 ate a few bites of his food. At 1:15 p.m.Resident #370 was assisted back to the common area. He had eaten less than 25% of his meal. During a continuous observation on 12/9/24, beginning at 3:30 p.m. and ending at 7:00 p.m., the following was observed: At 6:15 p.m. Resident #370 was served a room tray for dinner. He was sitting up in bed at about 80 degrees and slouched over. He took a few bites of food. The staff was not observed checking on the resident, providing cueing or any physical assistance. During a continuous observation on 12/10/24, beginning at 11:45 a.m. and ending at 1:00 p.m., the following was observed: At 12:00 p.m. Resident #370 was sitting in the dining room for lunch, sleeping in his wheelchair. At 12:15 p.m. Resident #370 received lunch of roast beef, mashed potatoes, mixed vegetables and fruit. He began to scoop up the food and eat with his knife. He did not receive any cueing or assistance from the facility staff observed in the dining room. Resident #370 finished his plate and began to scrape the plate in an attempt to get more food. Staff did not offer him any additional food. C. Record review The alteration in neurological status care plan, revised on 11/14/24, documented Resident #370 had a history of chronic microvascular ischemic (small blood vessels become damaged in the brain), dementia and a seizure disorder. The interventions included providing cueing and reorientation as needed. The ADL care plan, revised 11/17/24, documented Resident #370 had an ADL self-care performance deficit due to the diagnoses of encephalopathy, seizures and dementia which impacted his strength, balance, coordination, cognition and mobility. It indicated he required set up and one staff physical assistance with meals. The interventions included encouraging the resident to eat all meals in the dining room. The nutritional risk care plan, revised on 11/20/24, documented Resident #370 was malnourished according to a mini-nutritional assessment conducted at the facility. The interventions included inviting the resident to activities that promoted additional intakes, encouraging the resident to eat all meals in the dining room, monitoring and reporting to the physician if the resident had any signs or symptoms of decreased appetite; monitoring weights per the facility policy and reviewing as needed, providing and serving supplements as ordered (Ensure Plus one carton, three times daily, evening snack every night) and reviewing the nutritional status in the nutrition at risk meeting as needed. The meal intake documentation revealed Resident #370 ate 76% to 100% the majority of the time. It documented on 12/4/24, he ate 76% to100% during lunch, however this documentation was inaccurate as observations during the survey process showed Resident #370 had eaten less than 25% (see observations above). IV. Resident #27 A. Resident status Resident #27, age [AGE], was admitted on [DATE]. According to the December 2024 CPO, diagnoses included fracture (break) of the upper left femur (thigh bone), fracture of the lower left ulna (bone in the arm) bone, stroke, dementia, dysphagia and moderate protein calorie malnutrition. The 11/4/24 MDS assessment revealed the resident had severe cognitive impairments with a BIMS score of seven out of 15. Resident #27 required substantial to maximal assistance with eating as well as partial assistance with planning regular daily activities. B. Observations During a continuous observation on 12/4/24, beginning at 9:45 a.m. and ending at 1:00 p.m. the following was observed: At 12:33 p.m. Resident #27 was in the dining room with a plate of fish, rice, green beans and corn bread. She was eating her corn bread. She did not receive any cueing or encouragement from staff. During a continuous observation on 12/9/24, beginning at 9:46 a.m. and ending at 1:00 p.m., the following was observed: At 12:12 p.m. Resident #27 was observed sitting in the dining room, drinking her water. At 12:18 p.m. she was served lunch, which consisted of orange chicken, rice, vegetables and a cookie. Resident #27 ate small bites of her meal. At 12:28 p.m., Resident #27 took a small bite of her chicken and was still chewing on that same bite of chicken at 12:33 p.m. The staff did not provide Resident #27 any cueing or encouragement during the meal. Resident #27 ate less than 25% of her meal. At 3:27 p.m. an unidentified CNA removed Resident #27's meal tray. During a continuous observation on 12/10/24 beginning at 11:45 a.m and ending at 1:00 p.m. the following observations were made: At 12:13 p.m. Resident #27 was served lunch which consisted of mashed potatoes, mixed vegetables, pot roast and fruit. At 12:19 p.m. Resident #27 had eaten only the mashed potatoes. At 12:35 p.m. Resident #27 ate some fruit. At 12:46 p.m. an unidentified nurse asked Resident #27 if she was going to eat. Resident #27 responded, no and the nurse walked away. At 12:49 p.m. Resident #27 was returned to the unit. She had eaten less than 25% of her meal. C. Record review Review of the record revealed that Resident #27 was malnourished according to the 11/7/24 mini nutritional assessment (MNA). The meal intake documentation revealed Resident #27 ate 51% to75% the majority of the time. -However, observations on 12/4/24, 12/9/24 and 12/10/24 showed Resident #27 ate 25% or less of her meals (see observations above). V. Resident #43 A. Resident status Resident #43, age [AGE], was admitted on [DATE]. According to the December 2024 CPO, diagnoses included dementia, protein-calorie malnutrition, cognitive communication deficit and dysphasia. The 11/7/24 MDS assessment revealed Resident #43 had severe cognitive impairments with a BIMS score of three out of 15. TResident #43 required set up and clean-up assistance with meals. B. Observations During a continuous observation on 12/4/24, beginning at 9:45 a.m. and ending at 1:30 p.m., the following was observed: At 11:49 a.m. Resident #43 was in the dining room with the unidentified speech therapist. Resident #43 was served fish, green beans, rice and corn bread. -However, based on her dislikes documented in the electronic medical record (EMR), Resident #43 did not like fish. She was not offered a meal replacement. At 12:26 p.m. the unidentified speech therapist left the dining room. Resident #43 ate less than 25% of her lunch. The resident was not provided any cueing or assistance during the meal. On 12/9/24 during a continuous observation, beginning at 9:46 a.m. and ending at 1:00 p.m., the following was observed: At 12:17 p.m. she was served lunch which had mechanical soft orange chicken, mixed vegetables, rice and a cookie. At 12:32 p.m. Resident #43 spit out a mouthful of food onto her plate. She was moving the food around her plate but did not take any bites. The staff did not provide Resident #43 with cueing or encouraged her to eat. At 12:54 p.m. Resident #43 was removed from the dining room. She had eaten less than 25% of her meal. During a continuous observation on 12/9/24, beginning at 3:30 p.m. and ending at 7:00 p.m., the following was observed: At 6:01 p.m. Resident #43 was in her room sleeping. At 6:13 p.m. an unidentified CNA delivered the resident's dinner tray to her room. Once she delivered the tray, the CNA closed the bedroom door after exiting her room. During a continuous observation, on 12/10/24, beginning at 11:45 a.m. and ending at 1:00 p.m., the following was observed: At 11:55 a.m. Resident #43 was assisted to the dining room for lunch. At 12:11 p.m. the resident was served her meal which consisted of mashed potatoes, mixed vegetables and pot roast. She had a few bites of her vegetables and had a couple sips of her beverage. At 12:18 p.m. Resident #43 stopped eating after taking a couple bites of her vegetables and roast beef. She did not receive any cueing from staff. At 12:33 p.m. an unidentified CNA provided a cue, the resident took one bite and the CNA walked away. She did not provide Resident #43 any additional cueing. At 12:50 p.m. she was wheeled from the dining room to the common area. Resident #43 ate less than 25% of her meal. C. Record review The ADL care plan, revised 11/21/24, documented Resident #43 had a self-care deficit due to her diagnoses of dementia, protein-calorie malnutrition, cognitive communication deficit, and dysphasia. It indicated the resident required set up and one person physical assistance with meals. The interventions included encouraging the resident to eat all the meals in the dining room. The nutritional risk care plan, revised on 12/3/24, documented Resident #43 was malnourished according to the mini-nutritional assessment completed at the facility. The interventions included offering a meal replacement if she ate less than 50%, offering snacks in between meals, monitoring and reporting to the physician if the resident had any signs or symptoms of decreased appetite, monitoring weights per facility policy and reviewing as needed, providing and serving supplements as ordered (Ensure Plus one carton, three times daily, evening snack every night) and reviewing the resident's nutritional status in the nutrition at risk meeting as needed. It also documented her food preferences, such as dislike of fish and likes of mashed potatoes, fruit, ice cream, Coke, cookies, chocolate, scrambled eggs, fried potatoes, tortillas and bacon. The resident was prescribed a mechanical soft diet. The 12/3/24 nutrition progress note documented Resident #27's meal intake was sporadic and accepted 25 to 50% of supplements. It documented the resident's family said she was overwhelmed by large amounts of food and it would be beneficial to provide smaller meal portions. The meal intake documentation revealed from 11/11/24 to 12/10/24, Resident #27 ate zero to25% on 30 occasions and refused meals on 18 occasions. VI. Staff interviews CNA #14 was interviewed on 12/10/24 at 12:58 p.m. CNA #14 said the unit that Resident #366, Resident #370, Resident #27 and Resident #43 resided on, was a memory care and rehabilitation unit. She said some of the residents on the unit were independent and some needed full care. She said the CNAs got their information on the residents and the type of care that they need from the report at the beginning of their shift. She said the CNAs got some of their information from the computer and the therapy department/ She said a one person assist meant that the resident needed someone to stand by them or to give them cues either by touch or verbally. She said the amount of assistance that a resident might need can change from day to day. She said for dining assistance, the meal tickets had all the information on them which includes how much assistance they need, preferences and type of diet. She said they also watched to see who was not eating or was struggling and they would give them encouragement. CNA #5 was interviewed on 12/10/24 at 5:00 p.m. CNA #5 said Resident #366, Resident #370, Resident #27 and Resident #43 all needed assistance in the dining room. She said that if she saw a resident struggling with eating she would go over to help them. She said sometimes Resident #43 would refuse any help or encouragement. The director of nursing (DON) was interviewed on 12/10/24 at 6:23 p.m. He said the CNAs were scheduled on the same unit every shift so that there was continuity for the residents and the staff. He said the staff should have encouraged residents to eat their meals. He said that a one person assist meant that the resident needed cueing, encouragement, cutting up their meat and assisting the resident with eating.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** IV. Resident #364 A. Resident status Resident #364, age [AGE], was admitted on [DATE]. According to the December 2024 CPO, diagnoses included displaced intertrochanteric fracture of the left femur (break of the left upper thigh bone), history of falling, cognitive communication deficit and dementia. The 11/19/24 MDS assessment revealed Resident #364 had short term and long term memory problems and her cognitive skills for daily decision making was severely impaired per staff assessment. The assessment revealed she was dependent on staff or needed substantial to maximal assistance with the majority of her ADLs. The MDS assessment further revealed that it was very important to her to do her favorite activities, to go outside and get fresh air and keep up with the news. B. Observations On 12/4/24 at 3:06 p.m. an unidentified activities staff member was asking the residents if they wanted to go and play Bingo. The unidentified activities staff member did not ask Resident #364. At 3:54 p.m. Resident #364 was seen placing her forehead on the bedside table in the common area. The television was still playing in the common area, no other activities had been offered to her. During a continuous observation on 12/5/24, beginning at 10:30 a.m. and ending 5:00 p.m., the following was observed: At 10:50 a.m. Resident #364 was in bed and has tried to get up multiple times, each time staff has laid her back down in her bed. No one offered the resident a meaningful activity. During a continuous observation on 12/9/24, beginning at 3:30 p.m. and ending at 7:00 p.m., the following was observed: At 4:26 p.m. an unidentified activities staff member invited residents to do a word search. Resident #364 was not invited to participate. C. Record review The activities care plan, revised on 11/22/24 documented Resident #364 was dependent on staff for activities, cognitive stimulation and social interaction. The care plan documented that she preferred to watch sports, listen to music, go outdoors, gardening, conversing with others and her preferred hobby was to go shopping at the grocery stores. Interventions included inviting the resident to all scheduled activities and providing her with materials for individual activities as desired. The activities admission evaluation, dated 11/22/24 indicated that the resident was interested in exercise groups, sports, music, singing, shopping, going outside, and being around animals. According to the one on one activity tracker (11/15/24 to 12/10/24), Resident #364 had been provided one, one on one activity which was nail care on 12/6/24. According to the independent activity tracker, Resident #364 was active in exploring the environment, observing her surroundings, and walking/wheeling. D. Staff interviews CNA #14 was interviewed on 12/10/24 at 12:58 p.m. CNA #14 said that after the residents had been at the facility for a while the staff got to know them. She said when sundowning began to happen in the afternoon it was important to have activities to help redirect the residents. She said Resident #364 changed from day to day, she said that yesterday (12/9/24) she was up and wanted to get up and go but today she wanted to be left alone. The activities supervisor (AS) was interviewed on 12/10/24 at 1:15 p.m. The AS said all of the residents were on a one-to-one engagement program, which was when the residents were taken out of their room and the activities staff would sit with them and play games or whatever the resident liked to do. She said for residents that were really confused, they tried to find things that really connected with them, such as with Resident #364. She said that they were still trying to figure out what she was interested in. The AS said they also asked the CNAs and the residents family members what they had noticed that the resident liked. The AS said she expected her staff to invite all of the residents to the different activities that were occurring. The DON was interviewed on 12/10/24 at 6:23 p.m. The DON said that both the activities staff and the CNAs should have invited all of the residents to activities. He said when residents were exit seeking due to their confusion that staff should constantly be redirecting the resident. He said the staff should be taking the residents to activities as a redirection, even if the resident was confused. III. Resident #11 A. Resident status Resident #11, age [AGE], was admitted on [DATE]. According to the December 2024 CPO, diagnoses included unspecified dementia, cognitive communication deficit, muscle weakness and chronic respiratory failure with hypoxia. The 10/22/24 MDS assessment revealed the resident had moderate cognitive impairments with a BIMS score of seven out of 15. She required partial/moderate assistance with hygiene, showering and dressing. She required supervision or touching assistance with walking and transferring. The MDS assessment documented that having books, magazines, and newspapers to read, listening to music, keeping up with the news, doing things with groups of people, doing her favorite activities, going outdoors and participating in religious services was very important to Resident #11. B. Observations During a continuous observation on on 12/4/24, beginning at 1:30 p.m. and ending at 4:30 p.m. the following was observed: At 1:30 p.m. Resident #82 was lying in her bed with the television turned on. AA #2 was walking around asking residents to attend a coloring activity in the dining room. Resident #11 was not offered to attend the activity. During a continuous observation on 12/5/24, beginning at 8:37 a.m. and ending at 11:00 a.m., the following was observed: At 8:37 a.m. Resident #11 was lying in bed with the television turned on and the door closed. AA #2 was offering hand massages to residents sitting in the living room. She did not offer a massage to Resident #11. At 10:22 a.m. the chaplain came to the unit and began a sing along with Christmas music. Resident #11 was not invited to the activity. During a continuous observation on 12/9/24, beginning at 8:30 a.m. and ending at 11:00 a.m., the following was observed: At 8:37 a.m.Resident #11 was lying in bed with her eyes closed and the door was closed. At 9:00 a.m. AA #2 was passing out daily chronicles and did not offer Resident #11 one. At 9:33 a.m. AA #2 started doing an exercise group with the residents sitting in the living room. Resident #11 was not offered to join. At 9:55 a.m. AA #2 was passing out snacks and did not offer resident #11 a snack. At 10:15 a.m. an unidentified chaplain started a church service in the living room. Resident #11 was not invited to attend. The chaplain finished the church service at 10:42 a.m. C. Resident interview and observation Resident #11 was interviewed on 12/9/24 at 2:00 p.m. Resident #11 was sitting up in bed with the television turned on and said she was hungry for a pizza. She said she liked to draw, color and watch movies. She said she loved animals and listening to music. She said she did not have time for church, but she enjoyed it. She started yelling out that she was hungry. There was an activity going on in the dining room where residents were coloring, eating snacks, listening to music and folding towels. -However, based on observations, Resident #11 was not invited to the activities going on in the dining room. D. Record review The quarterly activity assessment, completed 10/2/24, documented Resident #11's favorite activities were taking a nap, staying in her room and having a snack every hour, listening to music, playing bingo, balloon volleyball, sing-along, trivia, special events including holiday related activities, animal related activities, church services, community outreach, outside activities and coloring pictures. It was documented in the resident tasks that Resident #11 participated in a sing along and a drawing/painting activity on 12/4/24 at 4:08 p.m. -However, observations revealed Resident #11 was lying in her bed with the door closed alone at this time (see observations above). It was documented in the resident tasks that Resident #11 participated in religious services on 12/9/24 at 11:15 a.m. -However, observations revealed Resident #11 was lying in her bed with the door closed alone at the time of the religious service (see observations above). It was documented in the resident tasks that Resident #11 accepted a snack on 12/4/24 at 2:20 p.m., 12/5/24 at 9:04 a.m. and on 12/9/24 at 10:00 a.m. -However, Resident #11 was lying in bed with the door closed at this time. Staff was not observed offering a snack to Resident #11 at any of these times. It was documented in resident tasks that Resident #11 participated in watching television with others, a men's/women's/focus groups/wellness activity, meal/food/snack social, exercise group and abilities care on 12/4/24 at 4:08 p.m. -However, Resident #11 was lying in her bed with the door closed alone at this time. E. Staff interviews CNA #13 was interviewed on 12/9/24 at 3:45 p.m. CNA #13 said Resident #11 liked to participate in activities. She said she was able to walk by herself with supervision from staff and was forgetful and needed reminders from staff. AA #2 was interviewed on 12/9/24 at 4:15 p.m. AA #2 said Resident #11 used to be on a one to one program for activities but ended because staff were encouraging her to participate in group activities. She said she was actively participating in group activities and enjoyed bingo, coloring, music and church. She said she had refused the activity offered today because she wanted to take a nap. The AD was interviewed on 12/10/24 at 3:15 p.m. The AD said if a resident refused an activity, she would expect the staff to offer a different activity. She said if residents were not willing to participate in a group activity, staff should offer independent or one on one activities. She said Resident #11 participated in group activities lately and enjoyed music, bingo, pets and watching movies. She said if a resident refused an activity, she would expect staff to document refusals. The DON and the CNR were interviewed together on 12/10/24 at 5:00 p.m. The DON said Resident #11 mostly liked to be alone. The DON said she enjoyed some one to one activities, group activities and watching television. He said if she refused to participate in an activity offered, staff should document the refusal. Based on observations, record review and interviews, the facility failed to implement an activities program that met the interests of and supported the physical, mental, and psychosocial well-being of each resident for three residents (#79, #364 and #11) out of eight residents reviewed for activities of 51 sample residents. Specifically, the facility failed to: -Establish activity preferences and meet the socialization needs of Resident #79 and Resident #364; and, -Invite Resident #11 to group activities and ensure accurate activity documentation. Findings include: I. Facility policy and procedure The Activity Policy and Procedure Manual, revised November 2017, was received from the clinical resource nurse (CNR) on 12/10/24 at 9:00 p.m. It read in pertinent part, Should a resident be considered medically or mentally incompetent, or physically unable to participate in such programs, an entry will be made in the resident's medical record (chart) stating fully the reason(s) for the restriction(s). Such an entry will be signed and dated by the person recording such data. Some activities can be adapted to accommodate the resident's change in functioning due to physical or cognitive limitations: Cognitive impairment (task segmentation, settings that recreate past experiences, smaller groups without interruption, one-to-one); Language barrier (translation tools, audio/video in the resident's language) Residents on a formal one-to-one program will have documentation in medical records regarding the type and length of the visit and the individual's response to the visit. Daily activities, including those on weekends and holidays, are provided, as well as scheduled religious and social activities. However, residents are free to choose whether or not they wish to attend any activity or other scheduled event(s). II. Resident #79 A. Resident status Resident #79, age [AGE], was admitted on [DATE]. According to the December 2024 computerized physicians orders (CPO), diagnoses included Alzheimer's disease, traumatic brain compression and cognitive communication deficits. The 9/18/24 minimum data set (MDS) revealed the resident was severely cognitively impaired and was unable to perform a brief interview for mental status (BIMS) assessment. The assessment revealed the resident's preferred language was Spanish and he needed an interpreter to communicate with health care staff. The 12/21/23 MDS revealed the resident had been interviewed to determine his activity preferences. The resident indicated it was somewhat important for him to have books, newspapers, and magazines to read, to listen to music he liked, to be around animals, to keep up with the news, to do things with groups of people, to go outside to get fresh air, to participate in religious services or practices, and to do his favorite activities. B. Resident representative interview Resident #79's representative was interviewed on 12/10/24 at 9:16 a.m. Resident #79's representative said Resident #79 did not really do much aside from sit in his wheelchair. Resident #79's representative said the facility staff assisted Resident #79 to a position in the common area next to a table by the television and sometimes gave him activities he could do like going through the newspaper. Resident #79's representative said the physical therapy team gave him puzzles he could do and provided him with therapy. Resident #79's representative said she did not think the activities staff spent time with Resident #79 and that he was mostly on his own. Resident #79's representative said Resident #79's first language was Spanish. Resident #79's representative said Resident #79 used to understand a small amount of English but due to his disease process, he had forgotten it. Resident #79's representative said most of the facility staff spoke English but some of the staff spoke Spanish when communicating with Resident #79 and he appeared to understand them. C. Observations On 12/4/24 at 10:07 a.m. Resident #79 was sitting in his wheelchair at a table in the common area. Resident #79 was sitting under the common area television and had his back turned to the rest of the residents in the common area. An unidentified certified nurse aide (CNA) offered the resident a stack of newspapers which were all written in English. Resident #79 was groaning and quietly crying out. At 4:16 p.m. Resident #79 was sitting in his wheelchair at a table in the common area. Resident #79 was sitting under the common area television and had his back turned to the rest of the residents in the common area with no meaningful activities observed. On 12/5/24 at 8:47 a.m. Resident #79 was sitting in his wheelchair at a table in the common area. Resident #79 was sitting under the common area television and had his back turned to the rest of the residents in the common area. At 8:58 a.m. activities assistant (AA) #3 entered the common area and began interacting with residents. Resident #79 was sitting in his wheelchair at a table in the common area in the same position. Resident #79 was intermittently quietly crying out. -AA #3 did not interact with Resident #79. At 9:15 a.m. Resident #79 was sitting in the same position in the common area asleep. At 9:28 a.m. Resident #79 was sitting in the same position in the common area asleep. AA #3 announced to the common area she was going to do exercises in the dining room and invited multiple residents to join her. -AA #3 did not invite Resident #79 to join her in the activity. At 9:37 a.m. licensed practical nurse (LPN) #4 assisted Resident #79 to his room for a nap. Resident #79 was observed during a continuous observation, beginning at 2:45 p.m. and ending at 4:15 p.m. The following was observed: At 2:45 p.m. Resident #79 was sitting in his wheelchair in the common area with his wheelchair angled away from the television and his back turned to the rest of the residents in the common area. At 3:01 p.m. AA #3 set up a table under the television in the common area so Resident #79 could look at magazines. Resident #79 was still sitting in his wheelchair angled away from the television. AA #3 told Resident #79 he could look at magazines after his shower and left him in his wheelchair approximately three feet away from the table. AA #3 announced to the common area she was going to do puzzles in the dining room and asked if anyone wanted to join her. -AA #3 did not directly invite Resident #79 to the puzzle activity nor wait for the resident's response when she announced the activity to the common area to see if Resident #79 would be interested in participating At 3:07 p.m. Resident #79 propelled himself in his wheelchair so that he was facing the television and table in the common room. Resident #79's head was down and he was groaning and intermittently crying out. CNA #10 was in the common area helping another residents but did not assist or address Resident #79. At 3:15 p.m. Resident #79 was slowly propelling himself toward the table and intermittently groaning and crying out. CNA #10 was sitting and doing computer work in the common area approximately ten feet away from Resident #79 but did not address Resident #79. At 3:18 p.m. Resident #79 reached the table and began picking up and looking at magazines which were published in English. At 3:22 p.m. Resident #79 was grabbing the edge of the table and trying to pull himself closer to the table. At 3:34 p.m. Resident #79 had propelled himself away from the table and was looking at the wall with no meaningful activity happening. AA #3 was sitting in the common area next to the resident conducting a word game. AA #3 did not attempt to include Resident #79 or interact with him. At 3:35 p.m. Resident #79 began to grasp the edge of the table and tried to pull the table to himself. At 4:05 p.m. Resident #79 was sitting in the same position in his wheelchair. An activity was being conducted in the dining room. -AA #3 did not invite Resident #79 to the activity in the dining room. At 4:06 p.m. Resident #79 was crying and grabbing the edge of the table. An unidentified CNA was sitting in the common area doing computer work. At 4:07 p.m. another resident was standing next to Resident #79, rubbing his back and talking to him. Resident #79 began crying louder. The unidentified CNA called the other resident's name and told her to stop but did not address Resident #79. At 4:10 p.m. the other resident was still rubbing Resident #79's back. Resident #79 was crying intermittently. At 4:15 p.m. the other resident left Resident #79's side. Resident #79 was sitting in his wheelchair approximately two feet away from the table and looking at the floor. Resident #79 was intermittently crying. The unidentified staff member was sitting in the common area approximately ten feet away from the resident doing computer work. On 12/9/24 at 8:49 a.m. Resident #79 was sitting in his wheelchair with his head down at a table in the common area. Resident #79 was sitting under the common area television and had his back turned to the rest of the residents in the common area. At 2:15 p.m. Resident #79 was sitting in the same position in the common area at the table. Resident #79 was tracing his finger along a blank piece of paper. On the table next to him were several newspapers, all written in English, and one coloring book page. At 2:23 p.m. AA #4 delivered the daily newspaper to Resident #79. The newspaper was written in English. Resident #79 was sitting in his wheelchair in the same position and crying out intermittently. -AA #4 did not read the newspaper or offer to translate the newspaper. At 2:57 p.m. Resident #79 was looking at the newspaper. At 3:03 p.m. Resident #79 was sitting in his wheelchair an arm's length away from the table. Resident #79 was looking vacantly away with no meaningful activity occurring. At 3:23 p.m. Resident #79 was sitting in his wheelchair in the same position sleeping. At 5:54 p.m. Resident #79 was assisted in his wheelchair from the dining room after dinner to the table in the common area. Resident #79 was crying out and tracing his finger on a magazine. The magazine was published in English. On 12/10/24 at 9:41 a.m. Resident #79 was sitting at the table under the television in the common area in his wheelchair. Resident #79 was staring at the daily newspaper from the day prior, written in English. At 10:07 a.m. Resident #79 was sitting with CNA #11 in the back corner of the hallway while CNA #11 worked on the computer. Spanish music was playing. At 10:08 a.m. CNA #11 left the hallway and the Spanish music stopped. At 10:09 a.m. AA #4 invited residents sitting a few feet away from Resident #79 to join her in a stretching activity. -AA #4 did not speak with nor invite Resident #79 to the activity. At 10:14 a.m. CNA #11 returned to her computer next to Resident #79 and the Spanish music resumed playing. At 10:16 a.m. CNA #12 spoke with Resident #79 in Spanish and the resident responded but the response was not audible. Resident #79 was smiling as he listened to the music. At 10:22 a.m. AA #4 was handing out coloring pages in the common area. Resident #79 was still sitting in his wheelchair in the corner of the hallway listening to music. At 10:28 a.m. Resident #79 was asleep in his wheelchair by the CNA's computer. The music was no longer playing. At 10:30 a.m. AA #4 assisted Resident #79 to the dining room in his wheelchair to participate in the coloring activity. D. Record review The communication care plan, revised 9/20/24, revealed Resident #79 was at risk for communication problems due to his traumatic brain injury and because he primarily spoke Spanish. Pertinent interventions included anticipating and meeting his needs, providing a translator as necessary and being conscious of the resident's position when in groups, activities, and the dining room in order to promote proper communication with others. The activities care plan, revised 1/27/24, revealed Resident #79's preferred activities were few and included listening to music, going outdoors, watching movies, and reading the daily newspaper. Pertinent interventions included providing Resident #79 with materials for independent activities, inviting and encouraging the resident to participate in all scheduled activities, and that Resident #79 liked to sit in the common area with his peers and observe others. An activities progress note on 8/29/24 revealed Resident #79 was asleep so a formal one-on-one engagement could not be conducted. An activities progress note on 9/3/24 revealed Resident #79 went outside with an unidentified activities staff member to enjoy the nice weather as part of a formal one-on-one engagement. An activities progress note on 9/8/24 revealed Resident #79 was asleep so a formal one-on-one engagement could not be conducted. An activities progress note on 9/19/24 revealed Resident #79 listened to Spanish music with an unidentified activities staff member as part of a formal one-on-one engagement. An activities progress note on 10/3/24 revealed Resident #79 was asleep so a formal one-on-one engagement could not be conducted. A quarterly activity progress note, dated 10/22/24, revealed Resident #79 continued to not show interest in scheduled activities. Resident #79 sat in the common area with his peers, watched television and observed his surroundings. Resident #79 was part of the formal one-on-one engagement program with the activities staff. During the one-on-one engagements, Resident #79 enjoyed listening to music, talking about his family, and going outside. The formal one-on-one engagements took place at least three times per week. Resident #79 had shown interest in holiday-related social activities and going outside. Resident #79 would continue to be encouraged to join scheduled activities and be provided with materials for independent activities. An activities progress note on 10/24/24 revealed Resident #79 had a formal one-on-one activity in which the resident and the unidentified activities personnel listened to music and colored together. -Review of the resident's electronic medical record (EMR) on 12/9/24 did not reveal further documentation that Resident #37 consistently received three one-on-one activity visits per week. Review of Resident #79's social activity task log from 11/10/24 to 12/9/24 revealed the following: -On 11/11/24 at 11:36 a.m. the resident was watching television with others and participated in a snack social; -On 11/26/24 at 10:56 a.m. the resident was watching television with others and participated in a snack social; -On 12/2/24 at 11:48 a.m. the resident was watching television with others and participated in a snack social; and, -On 12/9/24 at 12:17 p.m. the resident was watching television with others and participated in a snack social. -No other activities of this kind were documented at the time of review. Review of Resident #79s mental activity task log from 11/10/24 to 12/9/24 revealed the following: -On 11/11/24 at 11:36 a.m. the resident was participating in a self-esteem workshop and reading; -On 11/26/24 at 10:55 a.m. the resident was participating in a self-esteem workshop; -On 12/2/24 at 11:47 a.m. the resident was participating in a self-esteem workshop; and, -On 12/9/24 at 12:16 p.m. the resident was participating in a self-esteem workshop and reading. Review of Resident #79's independent activity task log from 11/10/24 to 12/9/24 revealed the following: -On 11/11/24 at 11:37 a.m. the resident was actively participating in independent activities; -On 11/26/24 at 10:55 a.m. the resident was actively participating in independent activities; -On 12/2/24 at 11:49 a.m. the resident was actively participating in independent activities; and, -On 12/9/24 at 12:16 p.m. the resident was actively participating in independent activities. E. Staff interviews CNA #10 was interviewed on 12/9/24 at 6:14 p.m. CNA #10 said Resident #79 mostly spoke Spanish but spoke some English. CNA #12 was interviewed on 12/10/24 at 9:50 a.m. CNA #12 said Resident #79 loved to eat and it was his favorite thing to do. CNA #12 said Resident #79 liked to listen to Spanish music because the resident only spoke Spanish. CNA #12 said the activities staff brought Resident #79 a newspaper published in Spanish and the resident liked to look at the newspaper. -However, observations revealed the resident was provided a newspaper in English (see observations above). The activities supervisor (AS) was interviewed on 12/10/24 at 3:16 p.m. The AS said the facility had a daily newspaper that was able to be printed in Spanish for the facility's Spanish-speaking residents. The AS said the facility had five staff members that spoke Spanish and were able to read the daily newspaper aloud and translate it for any Spanish speaking residents. The AS said the activities assistants did a lot of one-on-one engagement with residents in Spanish, including listening to music and watching videos and movies in Spanish. The AS said most of the Spanish speaking residents also understood English and that they were able to participate in group activities in English. The AS said Resident #79 went outside three times a day when the weather was nice and the activities staff did one-on-one engagements with him. The AS said Resident #79 liked to talk and watch videos with the activities staff. The AS said Resident #79 liked to be in the common area, watch television, listen to music and read the newspaper. The AS said they were having issues with their daily newspaper account and had to switch to a different publication the last five days that could only be printed in English. The AS said the activities staff had been printing out the publication and reading it aloud in Spanish for the last five days. The AS said the activities staff also printed out news articles in Spanish for Resident #79. The AS said the activities staff documented their one-on-one interactions in the mental activity task log. The AS said Resident #79 was invited to all activities. The AS said Resident #79 was on a formal one-on-one program, which meant he received one-on-one engagements three times per week. The AS said the activities staff would document any refusals in the activity log. The nursing home administrator (NHA) was interviewed on 12/10/24 at 6:35 p.m. The NHA said the AS and her team did the activities assessments for the residents and made them resident centered. The NHA said he was not sure how often the activities team updated their assessments. The NHA said everyone should be invited to group activities. F. Additional information Beginning 12/10/24 at 4:38 p.m., multiple late entry formal one-on-one activity progress notes were entered into Resident #79's progress notes, starting on 12/7/24 and going through 8/15/24.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** II. Failed to ensure appropriate infection control standards were followed during meals A. Professional reference The CDC (2024), Clinical Safety: Hand Hygiene for Healthcare Workers, was retrieved on 12/11/24 from https://www.cdc.gov/clean-hands/hcp/clinical-safety/index.html. It read in pertinent part, Perform hand hygiene before touching a patient, after touching a patient or their surroundings, immediately after glove removal. According to Treas, L.S., [NAME], K.L., & [NAME], M.H. (2022.) Basic Nursing: Thinking, Doing and Caring, (Third edition), pages 1601, 1604-1605, Use standard precautions to prevent the transmission of infection. Implement measures to prevent healthcare-associated infections (HAIs). HAIs are the leading complication of healthcare and one of the ten leading causes of death in the United States. Hand hygiene can remove transient flora (microbes acquired by touching objects or people). B. Observations On 12/5/24 at 3:00 p.m. CNA #3 opened a cookie from a cellophane package for Resident #24. CNA #3 handled the cookie with his bare hands as he handed it to Resident #24. CNA #3 had not performed hand hygiene prior to this interaction. On 12/5/24 at 3:28 p.m. CNA #3 was charting on a touch screen computer. When he was finished, he walked over to a table where Resident #54 was seated. He did not perform hand hygiene. Resident #54 had been eating peanut butter filled cheese crackers and some had fallen off of the plate onto the table. CNA #3 picked up the crackers off the table, with a bare hand, and placed them back onto the plate. CNA #3 attempted to remove the plate from the table, however Resident #54 prevented him from taking the plate as she was not finished eating. Resident #54 continued to eat the crackers. During a continuous observation that began on 12/9/24 at 8:20 a.m. and ended at 10:15 a.m. the following was observed: At 8:30 a.m. Resident #60 left the dining room leaving her plate on the table. At 9:03 a.m. after Resident #58 had finished his meal he propelled himself over to the table where Resident #60's plate remained. Resident #58 began to eat food from the plate and then left the dining room. -The staff did not redirect Resident #58 from eating off of Resident #60's plate. At 9:06 a.m. Resident #47 entered the dining room and sat in a chair which had Resident #60's partially eaten meal still on the table. Resident #47 began to eat the fruit from the bowl, then pushed the bowl and plate away. At 9:08 a.m. CNA #1 walked into the dining room and told Resident #47 that her plate had been placed on the table next to her. Resident #47 did not move from her seat and CNA #1 walked away without assisting the resident to move to the other table, or bring her plate to her where she was seated. At 9:13 a.m. the DON entered the dining room. After greeting Resident #47, the DON offered her a cup of coffee and a cookie. Unaware that the plate near Resident #47 was not hers, he encouraged her to eat more food, she declined. During a continuous observation that began on 12/9/24, at 5:33 p.m. and ended at 6:45 p.m., the following was observed: At 5:45 p.m. Resident #60 entered the dining room and was seated at a table. Resident #60 requested that the staff serve her only dessert. At 5:47 p.m. Resident #60 was served a cookie pudding dessert garnished with a wafer cookie. Resident #60 removed the wafer cookie and placed it on the table in front of her. At 5:58 p.m. after Resident #60 finished her first dessert and was offered a second by a staff member. Again, Resident #60 removed the wafer cookie garnish and placed it on the table in front of her. At 6:23 p.m. Resident #58 seated at the next table wheeled himself over to Resident #60 and took the two wafer cookies from her table and ate them. Resident #58 had been seated at a table with Resident #74 who had received feeding assistance from an unidentified staff member during his departure from the table. The unidentified staff member did not intervene when Resident #60 took the two wafer cookies off the table. At 6:26 p.m. Resident #58 was redirected back to his table and meal by the unidentified staff member providing feeding assistance to Resident #74. C. Staff interviews The IP was interviewed on 12/10/24 at 1:28 p.m.The IP said hand hygiene should be performed before and after handling food. The IP said food should not be touched with bare hands, especially if hand hygiene had not been performed. The IP said residents should not eat from other resident's plates. The IP said there was a potential for a negative outcome related to food texture, food allergies and the spread of potential infection. The DON was interviewed on 12/10/24 at 6:24 p.m. The DON said resident food should not be handled with bare hands. The DON said a clean, gloved hand could have been used to remove food from a package or the package could have been opened to allow the resident to take the food from the package. The DON said residents should not eat from each other's plates. The DON said there was a potential negative outcome in consuming the wrong diet texture for a resident along with potential food allergies and potential spread of an infection. The DON said residents consuming other resident food could alter the accuracy of documentation of meal intake percentages of food consumed by residents that required intake monitoring for weight loss or gain. The DON said the facility staff had the responsibility to serve a resident where they were seated or move their plate for them if it was on a different table. Based on observation and interviews, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the possible development and transmission of infectious diseases. Specifically, the facility failed to: -Ensure staff followed appropriate hand hygiene during resident care; -Ensure shared vital signs equipment was sanitized between use; and, -Ensure appropriate infection control standards were followed during meals. Findings include: I. Ensure staff followed appropriate hand hygiene during resident care and ensure shared vital signs equipment was sanitized between use A. Professional reference According to the Centers for Disease Control and Prevention (CDC) Recommendations for Hand Hygiene for Healthcare Workers, (2024), retrieved on 12/11/24 from https://www.cdc.gov/clean-hands/hcp/clinical-safety/index.html, CDC provides the following recommendations for hand hygiene in healthcare settings. Know when to clean your hands: immediately before touching a patient and after touching a patient or a patient's surroundings. According to the CDC Recommendations for Disinfection and Sterilization in Healthcare Facilities, (2024), retrieved on 12/11/24 from https://www.cdc.gov/infection-control/hcp/disinfection-sterilization/summary-recommendations.html#:~:text=Ensure%20that%2C%20at%20a%20minimum,once%20daily%20or%20once%20weekly, Clean medical devices as soon as practical after use. Perform either manual cleaning or mechanical cleaning. Perform low-level disinfection for noncritical patient-care surfaces and equipment (blood pressure cuffs) that touch intact skin. B. Facility policy and procedure The Hand Hygiene policy and procedure, revised October 2022, was received from the clinical nurse resource (CNR) on 12/10/24 at 9:00 p.m. It documented in pertinent part, Hand hygiene is one of the most effective measures to prevent the spread of infection. Use an alcohol-based hand rub containing at least 62% alcohol or soap and water for the following situations: before and after direct contact with residents, after contact with resident's intact skin, after handling used dressings and contaminated equipment and after contact with objects (medical equipment). C. Observations Certified nursing aide (CNA) #5 was observed on 12/5/24 during a continuous observation from 2:30 p.m. until 4:30 p.m. At 2:50 p.m. CNA #5 was walking around the Lavender unit with the vital signs cart. She walked into the dining room where the residents were sitting watching a movie. She measured vital signs on the first resident and documented it on a clipboard. She moved the cart to the second resident in the dining room and measured vital signs. She documented it on a clipboard and moved the cart to a third resident in the dining room. She measured vital signs on the resident and documented it on a clipboard. CNA #5 moved the vital signs cart into the hallway and measured vital signs on a fourth resident sitting in the hallway. She documented the vital signs and walked away from the cart. -CNA #5 did not sanitize her hands after each resident care before moving to the next resident -CNA #5 did not sanitize the vital signs cart between residents D. Staff interviews The infection preventionist (IP) was interviewed on 12/10/24 at 1:00 p.m. The IP said she provided hand hygiene education to staff multiple times a year. She said hand hygiene should be done before and after providing resident care, including taking vital signs. The IP said shared medical equipment, including a vital signs cart should be sanitized before and after resident use. The director of nursing (DON) and the clinical nurse resource (CNR) were interviewed together on 12/10/24 at 5:00 p.m. The CNR said it was expected that staff sanitize hands before and after resident care. She said this included when the staff were measuring vital signs. The DON said this was important to ensure germs did not spread from one resident to another. The CNR said she would expect staff to sanitize medical equipment before and after resident use. The DON said this was important to ensure germs did not spread from one resident to another.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to establish an effective antibiotic stewardship program to monitor for antibiotic use for one (#40) of one resident reviewed for antibiotic use out of 51 sample residents. Specifically, the facility failed to: -Have an effective antibiotic stewardship program by mapping infections timely; and, -Have an effective antibiotic stewardship program to ensure Resident #40 was not given an antibiotic unnecessarily. Findings include: I. Failure to have an effective antibiotic stewardship program by mapping infections timely A. Professional reference According to The Centers for Disease Control and Prevention (CDC) Core Elements of Antibiotic Stewardship for Nursing Homes, (2024), retrieved on 12/11/24 from https://www.cdc.gov/antibiotic-use/hcp/core-elements/nursing-homes-antibiotic-stewardship.html Track the amount of antibiotic used in your nursing home to review patterns of use and determine the impact of new stewardship interventions. Antibiotic use data from nursing homes to improve antibiotic stewardship is important both for individual facility improvements and for public health action. B. Facility policy and procedure The Antibiotic Stewardship Program policy and procedure, revised November 2024, was received from the clinical nurse resource (CNR) on 12/10/24 at 9:00 p.m. It documented in pertinent part, The purpose of the program is to optimize the treatment of infections while reducing the adverse events associated with antibiotic use. At least one measure associated with antibiotic use will be tracked monthly, as prioritized from the facility ' s infection control risk assessment and other infection surveillance data. C. Record review Record of the infection mapping for the month of December 2024 was requested from the IP on 12/10/24 at 1:00 p.m. The infection preventionist (IP) said she was unable to provide the infection mapping as she did not complete it until the end of the month (see interviews below). D. Staff interviews The IP was interviewed on 12/10/24 at 1:00 p.m. The IP said the facility had a monthly infection control meeting and a monthly quality assurance and performance improvement (QAPI) meetings with the medical director to discuss house-acquired infections, trends in illnesses and some antibiotic review if clarification was needed. She said at the end of each month, she mapped out all the infections from that month to identify trends in infections. The director of nursing (DON) and the CNR were interviewed together on 12/10/24 at 5:00 p.m. The DON said infections should be mapped out as soon as they were identified. He said this was important so the facility can determine if there was a pattern in infections. II. Failure to have an effective antibiotic stewardship program to ensure Resident #40 was not given an antibiotic unnecessarily. A. Resident #40 1. Resident status Resident #40, age [AGE], was admitted on [DATE]. According to the December 2024 computerized physicians orders (CPO), diagnoses included dementia, cognitive communication deficits and generalized muscle weakness. The 10/9/24 minimum data set (MDS) revealed the resident was moderately cognitively impaired with a brief interview for mental status (BIMS) assessment score of 11 out of 15. The assessment revealed the resident was always continent of bowel and bladder and required supervision or touching assistance for toileting hygiene. The assessment did not indicate Resident #40 was on an antibiotic. 2. Record review The incontinence care plan, dated 6/3/2020, revealed Resident #40 was at risk for complications associated with incontinence and had a history of urinary tract infections (UTIs). Pertinent interventions included encouraging fluids during the day, checking the resident as required for incontinence and observing the resident for any signs or symptoms of a UTI. A provider note, dated 11/5/24 at 3:40 p.m., revealed Resident #40 was seen by the physician per her representative ' s request. The note revealed the representatives had recently visited and noted a cognitive decline with Resident #40 and were concerned about a UTI. Resident #40 denied any urinary symptoms that day, said she felt well and appeared to be at baseline. In the assessment and plan, the note documented that the provider suspected the cognitive decline was due to the progression of Resident #40 ' s dementia but ordered bloodwork to rule out concern for an infection or electrolyte disturbance given the representative ' s concern. A progress note, dated 11/26/24 at 11:18 a.m,. revealed Resident #40 had a change in condition. Resident #40 had a functional decline and altered mental status. Resident #40 ' s vitals were taken at that time and were within normal limits and did not have a fever. Resident #40 ' s provider and representative were notified. A progress note, dated 11/26/24 at 1:10 p.m., revealed there was a lab sample waiting for pickup for Resident #40. A progress note, dated 11/26/24 at 1:45 p.m., revealed Resident #40 ' s provider had assessed the resident and a new order to obtain a urinalysis via a straight catheter was obtained and to perform a culture and sensitivity if indicated. -However, Resident #40 did not meet the McGeer criteria to obtain a urine sample. Resident #40 had an acute onset of altered mental status, but did not have fluctuating behavior, altered level of consciousness, or inattention during her assessment (see below). Additionally, Resident #40 did not have a three point decrease in functional ability in her activities of daily living (ADLs), was afebrile, and did not yet have current bloodwork results available for review for elevated white blood cell counts. A provider note, dated 11/26/24 at 3:40 p.m., revealed Resident #40 was evaluated by the facility nurses ' request due to increased confusion and altered gait. Resident #40 was pouring sugar packets onto the table at breakfast instead of into her coffee. An unidentified certified nurse aide (CNA) reported to the provider Resident #40 was having new urinary incontinence and frequency. There was concern for infection or possible reaction to a vaccine Resident #40 had received the day prior. In her exam, Resident #40 was more confused than usual and denied any suprapubic tenderness or pain. The provider ordered bloodwork as well as a urinalysis with urine culture to evaluate further. A progress note dated 11/27/24 at 8:34 a.m. revealed Resident #40 ' s functional ability had improved, appetite increased, and confusion had decreased. A progress note dated 11/27/24 at 11:45 a.m. revealed Resident #40 ' s urinalysis results were received and reviewed by the provider. A new order was received from the provider for Bactrim (antibiotic) twice a day for five days. A progress note dated 11/27/24 at 11:55 a.m. revealed a change of condition form for Resident #40. The note documented Resident #40 had a UTI and vitals were assessed at that time. All vitals were within normal limits and no fever was reported. The provider and Resident #40 ' s representatives were both notified. An infection surveillance report dated 11/27/24 at 1:18 p.m. revealed which criteria Resident #40 met when reviewing the resident for antibiotic stewardship. For constitutional criteria, it was documented that Resident #40 had an acute change in mental status from baseline and an acute functional decline in ADLs. For ADLs, Resident #40 was marked mostly dependent for all areas for both baseline and current, and did not have any functional decline indicated. In the surveillance by body systems section, it was noted that Resident #40 had a UTI, acute dysuria (painful or uncomfortable urination), suprapubic pain, and a new or marked increase in urinary urgency. In the section for provider review, it was indicated that the antibiotic was reviewed with the provider to ensure it was a true infection, the right antibiotic, right dose, right route, and right duration. The infection preventionist note revealed it was a healthcare acquired infection and met criteria for infection. Additional notes revealed Resident #40 had a change of condition on 11/26/24 with increased confusion and decrease in functional ability. A urinalysis was ordered and the results showed +1 leukocyte esterase with a urine culture pending. The provider was notified and a new order received. Resident #40 was to start on an oral antibiotic for a UTI until 12/2/24. Bloodwork results for Resident #40 were reported to the facility on [DATE] at 8:44 a.m. A review of the bloodwork results revealed two abnormal values: -Nine hundred and ninty seven cells per microliter (uL) absolute monocytes, with a normal reference range of 200-950 cells per uL; and, -Twelve cells per uL absolute eosinophils, with a normal reference range of 15-500 cells per uL. Urinalysis and urine culture results for Resident #40 were reported to the facility on [DATE] at 10:11 a.m. A review of the urinalysis results revealed four abnormal values: -One plus leukocyte esterase, with a normal reference range of zero; -Six to ten white blood cells per high power field (HPF), with a normal reference range of zero to five; -Six to ten squamous epithelial cells per HPF, with a normal reference range of zero to five; and, -One plus ketones, with a normal reference range of zero. The urine culture did not have any bacterial growth. -However, Resident #40 remained on antibiotics after the urine culture results were received by the facility despite there being no bacterial growth on the urine culture (see interview below). Review of the November 2024 and December 2024 medication administration records (MAR) revealed Resident #40 received one tablet of Bactrim Ds 800-160 milligrams twice daily, starting at 7:00 p.m. on 11/27/24 and ending at 6:00 a.m. on 12/2/24. 3. Staff interviews The infection preventionist (IP) was interviewed on 12/10/24 at 1:08 p.m. The IP said the facility followed the McGeer criteria for determining infections in the facility. The IP said she spoke with the provider that ordered the antibiotic if said antibiotic was not meeting criteria, not the medical director (MD). The IP said she met with the MD once a month for an infection control meeting but would call the MD if she had any concerns. The IP said she did not call the MD to go over every antibiotic, but would get called if she had concerns and could not get ahold of the ordering provider. The IP said the MD did not review every antibiotic during their quality assessment meetings, only the antibiotics with which the IP had concerns. The IP said Resident #40 had a change of condition on 11/26/24, at which point the provider ordered a urinalysis. The IP said the urinalysis results came back on 11/27/24 and Resident #40 was started on Bactrim that day prior to her urine culture results coming in. The IP said Resident #40 met McGeer ' s criteria to collect a urinalysis as she had one plus leukocytes and altered mental status. The IP said Resident #40 ' s urine culture results were reviewed on 11/28/24. The IP said when a urine culture came back with no growth, they needed to discontinue the antibiotic. The IP said she was not sure how Resident #40 ' s urine culture was missed. The IP said the provider should wait for the urine culture results prior to using antibiotics so that the provider knows what bacteria has grown, if any, and so that the resident does not take an antibiotic unnecessarily. The IP said in reviewing the infection surveillance note the area indicating Resident #40 was having suprapubic pain may have been clicked by accident, as the resident did not have any pain. The IP clarified Resident #40 only had altered mental status, but did not meet any other criteria to collect a urinalysis. The IP said if Resident #40 did not meet criteria, a urinalysis should not have been ordered. The director of nursing (DON) and the clinical nurse resource (CNR) were interviewed on 12/10/24 at 5:12 p.m. The DON said the facility followed the McGeer criteria for determining infections in the facility. The CNR said if a physician ordered a urinalysis but the resident did not meet the McGeer criteria, the IP would notify the physician that they did not meet criteria and would document this in the medical record. The CNR said the resident had to meet McGeer ' s criteria in order to obtain a urine sample for a urinalysis. The DON said the IP reviewed residents ' lab work and communicated with the residents ' providers. The DON said the IP and the prescribing physician worked to make a determination with regard to the resident being on an antibiotic or if they should discontinue its use. The CNR said a culture and sensitivity were part of the McGeer criteria and that the provider needed to wait to see the culture results prior to starting an antibiotic. The CNR said the IP needed to look at the criteria the resident met and see if a urinalysis was indicated. The CNR said after the lab work was received, the IP needed to communicate with the resident ' s physician and tell them the labwork results and see if they could discontinue the antibiotic.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and staff interviews the facility failed to provide services for one (#3) out of 12 residents reviewed for professional standards of practice out of 47 sample residents. Specifically, the facility failed to ensure Resident #3's vital signs were monitored prior to the administration of a blood pressure medication. Findings include: I. Professional reference Kiziior, R. J., [NAME], K. J. (2023). Lisinopril. [NAME] Nursing Drug Handbook. Elsevier. P. 704. Obtain blood pressure, apical pulse immediately before each dose in addition to regular monitoring (be alert to fluctuations). II. Resident #3 A. Resident status Resident #3, age [AGE], was admitted on [DATE]. According to the July 2023 computerized physician orders (CPO), the diagnoses included dementia, diabetes mellitus and hypertensive (high blood pressure) chronic kidney disease. The 6/1/23 minimum data set (MDS) assessment revealed the resident had severe cognitive impairment with deficits in long and short term memory. The resident required the extensive assistance of one person for most ADLs. B. Observations On 7/26/23 at 7:03 a.m. certified nurse aide with medical authority (CNA/MA) #2 was observed dispensing and administering Lisinopril (blood pressure medication) 2.5 milligrams (mg) of Resident #3. CNA/MA #2 did not check for the resident's vital signs on the medical record, including the resident's blood pressure and pulse, prior to the administration. C. Record review The July 2023 CPO documented a physician order of Lisinopril 2.5 mg once a day for hypertension, ordered on 11/1/21. -The CPO did not document any vital sign parameters for when to hold the medication or when to notify the physician of irregular vital sign results. The July 2023 medication and treatment administration record (MAR/TAR) documented the resident's blood pressure and pulse was to be taken every morning and evening. III. Staff interviews CNA/MA #2 was interviewed on 7/26/23 at 7:06 a.m. She said the residents had vital signs taken first thing in the morning. She said she did not check for the vital signs because there were no parameters ordered. Registered nurse (RN) #2 was interviewed on 7/26/23 at 1:10 p.m. She said blood pressures and pulses should be obtained and checked prior to the administration of a blood pressure medication. She said, if there were no blood pressure parameters ordered, then the physician should be notified if the blood pressures were fluctuating outside of the resident's baseline vital signs. The director of nursing (DON) was interviewed on 7/27/23 at 1:45 p.m. He said the blood pressure and pulse should be monitored prior to the administration of a blood pressure medication.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interviews, the facility failed to ensure one (#52) of two residents with limited range of motion received appropriate treatment and services out of 47 sample residents. Specifically, the facility failed to ensure Resident #52's palm splint was in place as ordered by the physician to prevent skin breakdown. Findings include: I. Resident #52 status Resident #52, age [AGE], was admitted on [DATE]. According to the July 2023 computerized physician orders (CPO) revealed the following diagnoses dysphagia (swallowing difficulty), history traumatic brain injury, contracture of muscle right upper arm, contracture or right hand, contracture of right shoulder, hemiplegia and hemiparesis following cerebral infarction affecting right dominant side (right sided weakness related to a stroke), dementia with behavioral disturbance and cognitive communication deficit. The 6/15/23 minimum data set (MDS) assessment revealed the resident had severe cognitive impairment with a brief interview for mental status with a score of three of 15. She required extensive assistance of one person for bed mobility, transfers, locomotion on and off the unit, dressing, eating, toileting and personal hygiene. The assessment revealed Resident #52 had limited range of motion to one upper extremity and limited range of motion to two lower extremities. She was receiving occupational therapy. A. Observations During a continuous observation on 7/24/23 beginning at 11:45 a.m. and ended at 1:01 p.m. Resident #52 was in the dining room without a splint to her right hand. Resident #52's fingers on her right hand were slightly bent, her thumb in between her fingers and her hand was held up to her chest. During a continuous observation on 7/25/23 beginning at 11:18 a.m. and ended at 12:29 p.m. Resident #52 was in the dining room without a splint to her right hand. On 7/26/23 the following was observed: -At 10:18 a.m. Resident #52 was in the dining room without a splint to her right hand. -At 10:33 a.m. Resident #52 had a splint on her right hand (see interview below). -Upon interviewing certified nurse aide (CNA) #4, he went to Resident #52's room, got the brace out of Resident #52's nightstand and applied it on Resident #52's right hand. B. Record review The musculoskeletal care plan, initiated on 7/9/19 and revised on 7/20/23, revealed Resident #52 had a history of fracture of the right humerus (leg fracture), history of a stroke, history of stroke with right elbow, right hand, right wrist and shoulder contractures and bilateral knee contractures. The interventions included: anticipating and meeting the residents needs, following physician orders for weight bearing status, following physician orders for therapy or treatment plans, providing pain medications as ordered by the physician and monitoring for side effects and effectiveness, monitoring for risk of falls, monitoring and documenting complications related to arthritis, providing position changes, providing occupational and physical therapy as needed and providing a right balm protector for day use as tolerated. The skin integrity care plan, initiated on 6/25/19 and revised on 3/19/21, revealed Resident #52 had potential impairment to her skin related to fragile skin and impaired safety awareness. The interventions included: performing daily skin checks during cares, encouraging good nutrition and hydration, following facility protocols for treatment of injury, keeping the skin clean and dry, monitoring and documing location, size and treatment of skin injury, reporting failure to heal, signs of symptom of infection and providing pressure relieving/reducing mattress and pillows to protect skin while in bed and out of bed. The July 2023 CPO revealed the following physician order: -Provide right palm protector during the day as tolerated, ordered 7/19/21 and discontinued on 7/27/22. -Provide right palm protector as tolerated every day shift, ordered 7/27/23 (during the survey, the order was clarified). The [NAME] (staff directive) indicated the staff were to provide a right hand palm protector for day use as tolerated, conduct a skin check pre and post use and notify therapy if there are signs or symptoms of intolerance. -A review of the resident's medical record on 7/26/23 at 3:00 p.m. did not reveal documentation that the brace was being applied to the resident's right palm as directed in the physician's order (see interview below). II. Staff interviews CNA with medication authority (CNA/MA) #2 was interviewed on 7/26/23 at 10:17 a.m. CNA/MA #2 said she was not sure where Resident #52's splint was located. CNA #4 was interviewed on 7/26/23 at 10:19 a.m. CNA #4 said Resident #52's splint was in her room. CNA #4 said Resident #52's splint should have been applied when she got ready for the day. CNA #4 said a CNA or a licensed nurse could apply the splint. Registered nurse (RN) #3 was interviewed on 7/26/23 at 3:09 p.m. RN #3 said occupational therapy was responsible for placing and taking off Resident #52's hand splint. The director of rehabilitation (DOR) was interviewed on 7/27/23 at 9:52 a.m. She said the CNAs or licensed nurses were responsible for applying the splint to Resident #52's hand. The DOR said the brace was in place to prevent skin breakdown. The DOR acknowledge the point of care documentation did not reveal Resident #52's splint had been offered to her. The DOR said the point of care documentation was not prompting the correct documentation for the staff and she would fix it. The DOR said Resident #52 was currently receiving occupational therapy for contracture management. The director of nursing (DON) was interviewed on 7/27/23 at 11:01 p.m. The DON said typically if a resident had a splint or brace a task was created on the point of care system. The DON said the CNAs are then able to document if the resident tolerated or refused the brace or splint. The DOR and the clinical resource (CR) were interviewed on 7/27/23 at 12:13 p.m. The CR said she would obtain a new order and ensure the electronic medical record prompted the correct documentation for Resident #52's splint. The CR said the electronic medical record should populate a question to the floor staff to document if the resident tolerated the splint or refused the splint. The CR acknowledge Resident #52's medical record did not have documentation indicating Resident #52's hand splint had been offered or refused.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to ensure residents maintained acceptable parameters of nutritional status for two (#20 and #76) of five reviewed for nutrition status out of 47 sample residents. Specifically, the facility failed to ensure -Resident #76, who had a downward trending weight loss and was identified with pressure ulcers was provided nutritional interventions in a timely manner; and, -Resident #20 was identified with a continued weight loss and completed a timely quarterly nutrition assessment. Findings include: I. Professional reference [NAME], S., [NAME], A. (June 2022). The Impact of Nutrition on Pressure Ulcer Healing. British Journal of Nursing. https://www.britishjournalofnursing.com/content/nutrition/the-impact-of-nutrition-on-pressure-ulcer-healing/ retrieved on 8/2/23. A high-calorie diet and protein fortified foods or oral supplements are recommended for all patients at risk for developing a pressure ulcer and who are at risk of developing malnutrition. These supplements must be prescribed on an individual basis following a full risk assessment. II. Facility policy and procedure The Weights policy and procedure, reviewed May 2022, and provided by the nursing home administrator on 7/27/23 at 12:06 p.m. It read in pertinent part, The registered dietician (RD) or designee will review all significant/severe weight losses monthly or as needed; this may also be completed during the Nutrition at Risk (NAR) meeting. As part of this review, nutrition status will be assessed. The RD or designee will document the specific interventions used and determina monitoring system to evaluate the success of the interventions initiated. Nutrition at Risk (NAR) committee will meet weekly by the interdisciplinary team (IDT) (at least consisting of representation from nutrition and nursing), the RD or designee will determine and provide a list of residents to be discussed at the meeting. Progress notes from the meeting will be documented in each resident's EMR. The following residents may be included in the NAR list, at the RD's discretion: a. New admission/readmission, b. Tube feedings, c. Significant weight changes, d. Pressure ulcers, e. Fluid imbalance, f. TPN (total parenteral nutrition), g. Dialysis, h. Change of Condition. III. Resident #76 A. Resident status Resident #76, age [AGE], was admitted on [DATE]. According to the July 2023 computerized physician orders (CPO), the diagnoses included dementia, osteoporosis, hip fracture and diabetes mellitus. The 6/2/23 minimum data set (MDS) assessment revealed the resident had severe cognitive impairment with deficits in short and long term memory. He was totally dependent with the assistance of two people for toileting and required the extensive assistance of one person for bed mobility, transfers, dressing, eating and personal hygiene. It indicated that he was at risk for pressure ulcers but failed to indicate resident had unhealed pressure ulcers stage one or higher. B. Record review The nutritional risk care plan, initiated on 4/2/21 revised 12/23/22, indicated he was at a nutritional risk related to dementia, weight loss and generalized weakness. Interventions included diet as ordered by physician, honor resident rights to make personal dietary choices, invite to activities to promote additional intake, monitor and report as needed for signs of decreased appetite nausea and vomiting, unexpected weight loss, monitor to physician signs of malnutrition and emaciation, muscle wasting, significant weight loss, obtain and monitor lab work as ordered, occupational and speech therapy screen and evaluate for diet and self feeding, provide assistance and cueing with meals, provide supplements as ordered, RD to evaluate and make diet change recommendations and monthly weights if stable. The pressure ulcer care plan, initiated 6/28/23 revised on 7/10/23, indicated he had pressure wound to coccyx, right ischium, left heel and the right heel. Interventions included bunny boots for bilateral lower extremities, frequent repositioning in bed, up in the care foam chair as tolerated, monitor pressure areas for color, sensation, temperature, monitor and document wounds, monitor for signs and symptoms of infection, monitor for changes in wound, treat wounds per facility protocol. -A comprehensive review of the care plan failed to reveal personalized nutritional interventions to help prevent or promote wound healing after the development of pressure ulcers on 6/16/23 or address his downward trending weight loss. The resident's weight was documented as follows: -1/19/23 130.4 lbs (pounds) -3/22/23 130.2 lbs -4/17/23 129.9 lbs -5/17/23 126.5 lbs -6/6/23 124.4 lbs -6/23/23 121.2 lbs -A comprehensive review of the resident's weights revealed a weight loss of 4.19% in one month (5/17/23-6/23/23) and a loss of 6.19% in three months (3/22/23 -6/23/23). A comprehensive review of diet and supplementation orders revealed: -Mighty shakes three times a day for malnutrition, ordered 12/7/21 and discontinued on 7/4/23. -Regular diet, mechanical soft texture, thin liquids consistency, ordered 5/29/23. -Liquid protein every day for wound healing, ordered 7/3/23. -A comprehensive review of diet and supplementation orders revealed no new supplementation orders were put in place after the resident's weight started trending downward after April 2023. -A comprehensive review of diet and supplementation orders revealed that new interventions were not ordered until 7/4/23 after the development of four pressure ulcers (see below). In addition, the resident's Mighty Shake was discontinued on 7/4/23 that provided additional calories/protein. The July 2023 CPO revealed a physician order of admit to hospice, ordered on 7/4/23. The annual nutritional evaluation, effective 3/1/23, revealed the resident was on a regular diet with regular texture and thin liquids. His desirable weight was 136 lbs with a weight range of 123-149 lbs and had an estimated caloric need of 1680-1920 calories per day, with estimated protein needs 60-72 grams of protein per day. It documented his intake at meals were between 51-100%. A 4/23/23 nutrition progress note revealed the resident was reviewed in the NAR meeting and no concerns were noted. The RD recommendation included continuing the current diet and supplements as ordered and continue to monitor. -A comprehensive review of the nutrition progress notes revealed no further documentation after 4/23/23. A comprehensive review of the wound physician progress notes revealed a coccyx pressure ulcer identified on 6/16/23; right heel pressure ulcer identified on 6/26/23; left heel pressure ulcer identified on 6/26/23; right ischium was identified on 6/27/23; right lateral ankle was identified on 7/4/23; and the right lateral knee was identified on 7/25/23 (during survey). D. Staff interviews The RD was interviewed on 7/27/23 at 11:31 a.m. She said the RD monitored weights and monitors weekly reports and pulls the weight loss summary if there has been a significant weight loss trigger. She said the system they have in place triggers for significant weight loss if it was greater than 5% in 30 days. She said that if a significant weight loss has not been triggered than they monitor monthly weight loss reports for trending weight loss or rely on nursing to notify if there was a weight loss or pressure ulcer concern. She said that she was not aware of Resident #76's pressure ulcers until 7/27/23, during the survey. The director of nursing (DON) was interviewed on 7/27/23 at 1:42 p.m. He said when a pressure wound was identified the wound nurse or staff nurses notified the RD and placed them on a wound list so that these residents could be tracked, assessed and monitored. IV. Resident #20 A. Resident status Resident #20, age above 70, was admitted on [DATE]. According to the July 2023 computerized physician orders (CPO), the diagnoses included unspecified dementia, unspecified protein-calorie malnutrition, dysphagia (difficulty swallowing) and major depressive disorder. The 5/12/23 minimum data set (MDS) assessment revealed, the resident was unable to complete the brief interview for mental status (BIMS). His cognitive skills for daily decision making were severely impaired. He had no behaviors and did not reject care. He required extensive assistance with all of his activities of daily living. He held food in his mouth/cheeks after the meal. He received an altered diet. B. Record review The weight record revealed he had a 7.68% weight loss in four months: -On 2/5/23 the resident's weight was recorded at 153.6 lbs (pounds). -3/30/23 at 151.4 lbs. -4/28/23 at 145.0 lbs. -5/31/23 at 143.6 lbs. -6/24/23 at 141.8 lbs., which was a 11.8 lbs weight loss in four months. The nutrition care plan, revised 2/10/23, documented the resident had a potential nutritional risk related to altered mental status, Alzheimer's, chewing/swallowing difficulties and difficulty self feeding which required staff to assist with eating. Pertinent interventions were to follow the diet ordered by the physician, feeding assistance, monitor and report to physician as needed for decreased appetite and unexpected weight loss, offer and encourage snacks and fluids between meals, provide supplements as ordered, and registered dietician (RD) to evaluate and make recommendations. -The nutritional care plan had not been updated since the resident's weights were trending down. The July 2023 CPO included an order, dated 10/3/21, to provide a supplemental shake one time a day for mild protein calorie malnutrition. Review of a nutrition progress note dated 2/9/23 revealed: -Diet retained regular/puree/thin liquids. -Intake at meals were 50-100% most recently. -No new labs. -No new skin issues. -Continued on supplemental shake once a day. -Weights were currently stable. Recommendations: -Continue diet as ordered. -Continue supplemental shake once a day for now, offer and encourage fluids/snacks between meal. -Monitor intakes, weights, and adjust as needed. -This progress note was the last RD documentation and assessment for Resident #20. The resident's nutritional status had not been addressed for five months with his weight loss over four months. C. Staff interviews Certified nurse aide (CNA) #1 was interviewed on 7/26/23 at 2:28 p.m. She said Resident #20 needed assistance with eating. She said the CNA was responsible for getting the resident's weight and documenting the weight in the resident's medical record. Registered nurse (RN) #2 was interviewed on 7/27/23 at 8:47 a.m. She said the CNA was responsible for obtaining a resident's weight. She said if the CNA was too busy, the nurse would obtain the weight. She said the resident's weight was then documented in the resident's medical record. She said the RD had access to the medical records and was responsible for following up on the residents' weight loss. She said she was not sure how often the RD reviewed the weights. The RD was interviewed on 7/27/23 at 11:32 a.m. She said the RD was responsible for obtaining a weekly report on weights for the NAR (Nutrition at Risk) meeting. She said she would add a resident to the NAR if they had a quarterly/annual assessment due or if a weight loss was triggered in the resident's medical record. She said Resident #20 did not trigger in the medical record and that was why he probably was missed. She said his weight loss and quarterly assessment should have triggered when due. She said she should have caught the weight changes. She said she would look into the computer based medical record to find out why he did not trigger.

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 one of three ice machines was clean and sanitary; and, -Ensure glassware was handled properly in two of four dining rooms. Findings include: I. Failure to ensure the ice machine was clean and sanitary A. Professional reference The Colorado Department of Public Health and Environment (2019) The Colorado Retail Food Establishment Rules and Regulations, https://www.colorado.gov/pacific/sites/default/files/DEHS_RetailFd_6CCR10102_RFFC_EffJan2019.pdf. It revealed, in pertinent part, Equipment food-contact surfaces and utensils shall be clean to sight and touch. The food-contact surfaces of cooking equipment and pans shall be kept free of encrusted grease deposits and other soil accumulations. Non food contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris. Non food-contact surfaces of equipment shall be cleaned at a frequency necessary to preclude accumulation of soil residues. (Retrieved 8/1/23) B. Facility policy and procedure The Cleaning Instructions: Ice Machine policy, undated, was provided by the registered dietitian (RD) on 7/27/23 at 12:38 p.m. It revealed in pertinent part, The ice machine and equipment (scoops) will be cleaned on a regular basis to maintain a clean, sanitary condition. If available, follow the manufacturer's cleaning and sanitizing procedures. C. Observations On 7/27/23 at 9:16 a.m. the following was observed on the Larkspur unit alongside the RD and the administrator in training (AIT): -The ice machine had brown build-up where the ice was dispensed into the ice holding tank and served to residents. -A piece of the machine in the back right hand corner had built-up brown debris. A rusted nail was holding the piece of the machine to the side of the machine. The RD and the AIT acknowledged the ice machine was not sanitary. The AIT said they would call the maintenance department to have the machine cleaned and serviced. D. Staff interviews The RD and the AIT were interviewed on 7/27/23 at 11:47 p.m. The RD said the maintenance department cleaned the machine monthly and an outside company came to the facility every six months to clean and service the machine. The RD said the last time the machine was serviced by the outside company was in May 2023. The RD said the facility maintenance department cleaned the machine on 6/26/23 and did not notice any abnormalities. The AIT said the ice machine was taken out of use and a service request was made. The AIT said the part of the machine that was rusted would be replaced or the facility will get a new ice machine. II. Failure to ensure glassware was handled properly A. Professional reference The Colorado Department of Public Health and Environment (2019) The Colorado Retail Food Establishment Rules and Regulations, https://www.colorado.gov/pacific/sites/default/files/DEHS_RetailFd_6CCR10102_RFFC_EffJan2019.pdf. It revealed in pertinent part, single-service and single-use articles and cleaned and sanitized utensils shall be handled, displayed, and dispensed so that contamination of food and lip-contact surfaces is prevented. (Retrieved 8/1/23). B. Facility policy and procedure The Handling of Clean Utensils and Equipment policy and procedure, dated August 2017, was provided by the RD on 7/27/23 at 12:38 p.m. It revealed in pertinent part, Clean equipment and utensils will be handled to prevent contamination. When handling cleaned and sanitized equipment and utensils, staff will avoid touching the parts that will come in contact with the food or the mouth (especially with silverware). C. Observations During a continuous observation on 7/24/23 beginning at 11:45 a.m. and ended at 1:01 p.m. the following was observed: -At 11:50 a.m. certified nurse aide (CNA) #4 took glasses off a tray and created two stacks of glasses with the top of the glasses facing up. CNA #4 held the two stacks of glasses against her scrubs. CNA #4 then went to each table in the dining room and put her fingers into the glasses and pinched to pick up two glasses at a time. CNA #4 touched the inside of the glasses and the part of the glass that residents drank out of. CNA #4 then moved a stool. CNA #4 went back to the tray of clean glasses and created two stacks of cups and held them against her scrubs again. CNA #4 began putting her fingers into the cups, pinching them to pick them up and placing them on the tables for the residents to use. -At 11:51 a.m. CNA #4 touched her ponytail and then began stacking cups against her scrubs and placing them on the table from the drinking rim. -At 12:01 p.m. CNA #4 grabbed a stack of styrofoam cups and picked them up from the drinking rim. CNA #4 picked up a plastic cup from the clean tray and put her fingers into the cup and then placed it on the table for a resident to drink. On 7/25/23 at 11:12 a.m. the following was observed: -An unidentified dietary staff member was holding a stack of cups. The cups were upside down and he was touching the rim of the cup that was on the bottom of the stack and had his other hand on other cups rims as he was stabilizing the stack of cups. As he was setting the cups on the table, he was touching the rims of the glasses that residents would drink out of. D. Staff interviews CNA #5 was interviewed on 7/27/23 at 11:44 a.m. She said cups should be held from the bottom to prevent contamination of the cup. The RD and the AIT were interviewed on 7/27/23 at 11:47 a.m. The RD said cups and glasses should be handled from the bottom of the cup. The RD said where a resident's mouth would touch the item should not be touched as it could contaminate the cup or utensil.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews the facility failed to notify the physician timely for one (#2) of three residents reviewed out of seven sample residents. Specifically, the facility failed to notify the physician when the resident began refusing wound treatments to his bilateral lower extremities routinely. Findings include: I. Facility policy and procedure The Change of Condition Reporting policy and procedure, revised October 2020, provided by the director of nursing (DON) on 4/25/23 at 6:46 p.m. It revealed in pertinent part, It is the policy of this facility that all changes in resident condition will be communicated to the physician. All symptoms and unusual signs will be communicated to the physician promptly. Routine changes are a minor change in physical and mental behavior, abnormal laboratory and x-ray results that are not life threatening. The nurse in charge is responsible for notification of physician prior to end of assigned shift when a significant change in resident's condition is noted. All attempts to reach the physician and responsible party will be documented in the nursing progress notes. Documentation will include time and response. II. Resident #2 A. Resident status Resident #2, age [AGE], was admitted on [DATE] and readmitted on [DATE]. According to the April 2023 computerized physician orders (CPO), the diagnoses included dementia with behavioral disturbance, bipolar disorder, localized edema, hypertension (high blood pressure), dysphagia (swallowing difficulty), depression, alcohol abuse with alcohol induced disordered and altered mental status. The 3/16/23 minimum data set (MDS) assessment revealed the resident had severe cognitive impairment with a brief interview for mental status score of two out of 15. He required limited assistance of one person for bed-mobility, dressing and toileting. He required supervision of one person for transfers, locomotion off unit and personal hygiene. He required supervision with set-up assistance for walking on the corridor and eating. The MDS assessment documented the resident was at risk for developing pressure ulcers/injuries and had two venous and arterial ulcers. It documented he had open lesion(s) on the foot. B. Record review The skin care plan, initiated on 1/8/23 and revised on 2/10/23, revealed Resident #2 had actual impairment to his skin related to fragile skin, skin discolorations, unsteadiness on his feet, altered mental status and unspecified psychosis. The interventions included: avoiding scratching and keeping hands and body parts from excessive moisture, keeping his fingernails short, encouraging good nutrition and hydration to promote healthy skin, floating heels as tolerated, following facility protocols for treatment of injury, having the wound team and provider following the resident and had provided monitoring and treatment orders, monitoring for side effects of antibiotics and over-the-counter medications, monitoring and documenting the location, side and treatment of skin injury, reporting abnormalities, failure to heal, signs or symptoms of infection or maceration to the physician, providing a pressure relieving/reducing cushion to protect the skin while in a chair, providing a pressure relieving/reducing mattress to protect the resident's skin when in bed, providing a diuretic for bilateral lower extremity edema, encouraging the resident to allow cares as tolerated as he often refuses care and skin checks, continuing to offer and encourage care as the resident often refused cares and using caution during transfers and bed mobility to prevent hitting arms, legs and hands against any sharp or hard surface. The 4/17/23 physician visit progress note documented staff had requested for the physician to see the resident today. The note documented the resident had essentially been refusing lower extremity dressing changes for three months. The note documented the physician was made aware of the extent of the issue last week. The nurse practitioner (NP) attempted to change the dressings on Friday (4/14/23) and there was no odor present. The note documented the physician entered Resident #2's room. Resident #2 was standing at the sink. The physician could not stay in the room more than 10 seconds due to the malodor (unpleasant smell) from the resident's bilateral lower extremities. The progress note documented multiple staff had tried to convince the resident to let them change the dressings but the resident refused and recently was combative. The resident refused to be sent to the hospital. Ativan (anti anxiety medication) was ordered prior to dressing removals and Cipro (antibiotic) twice a day for seven days. The note documented the resident may need stronger medications or to be sent to the hospital. The resident may need to be started on Zyprexa (antipsychotic medication) as his behavior was harmful to himself and his roommate. The 4/20/23 nurse practitioner progress note documented the facility staff requested the NP to see Resident #2. The complaint was related to Resident #2 refusing lower extremity dressing changes for over two weeks. The note documented many attempted had been made to change the dressings, but Resident #2 refused. The resident was ordered to be sent to the hospital as he was posing a risk to himself. A review of the April 2023 CPO revealed the following wound orders: -Wound treatment: Clean venous wounds to LLE (left lower extremity) with N (normal saline), pat dry, apply Xeroform (gauze dressing), Alginate (wound dressing), ABD (ointment), wrap with Kerlex (gauze bandage) and AC wrap (ace wrap) in the morning every other day., ordered 1/15/23 and discontinued on 4/19/23. -Wound treatment: Clean venous wounds to RLE (right lower extremity) wounds with N (normal saline), pat dry, apply Xerofrom (gauze dressing), Alginate (wound dressing), ABD (ointment) wrap with Kerlex (gauze bandage) and AC wrap (ace wrap) in the morning every other day, ordered 1/15/23 and discontinued on 4/24/23. A review of the March 2023 treatment administration record (TAR) revealed the resident accepted wound treatments to both his LLE and RLE on the following dates: -3/13, 3/19, 3/21, 3/23, 3/25, 3/27, 3/29 and 3/31/23. A review of the April 2023 TAR from 4/1/23 through 4/19/23 revealed the resident refused all wound treatments to his LLE and RLE. -Review of the resident's medical record revealed the physician was not notified of the resident's increased refusals of wound care until the physician saw the resident on 4/17/23. III. Staff interviews The NP was interviewed on 4/25/23 at 1:30 p.m. She said Resident #2 developed weeping edema and cellulitis in January 2023. She said the resident had refused wound care on and off, but began refusing all treatments in April 2023. She said she was unsure of when the physician was notified of the resident's increased refusals. The DON was interviewed on 4/25/23 at 5:28 p.m. He said Resident #2 developed bilateral lower extremity venous ulcers in January 2023. He said Resident #2 had refused wound care on and off for several months. The DON said Resident #2 received wound care treatment on 3/31/23 and then started refusing all wound treatments. He said the facility had tried multiple interventions to encourage the resident to allow wound treatments. The DON said Resident #2 was sent to the hospital on 4/20/23 as he became a danger to himself, since Resident #2 was not allowing staff to change his wound dressings.