**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to ensure two (#1 and #2) of eight residents reviewed for abuse out of eight sample residents were free from abuse. Specifically, the facility failed to ensure Resident #1 and Resident #2 were free from abuse by each other. Findings include: I. Facility policy and procedure The Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating policy, revised September 2022, was provided by the nursing home administrator (NHA) on 7/7/25 at 11:00 a.m. It read in pertinent part, All reports of resident abuse (including injuries of unknown origin), neglect, exploitation, or theft/misappropriation of resident property are reported to local, state and federal agencies (as required by current regulations) and thoroughly investigated by facility management. Findings of all investigations are documented and reported. If resident abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source is suspected, the suspicion must be reported immediately to the administrator or to other officials according to state law. The individual conducting the investigation as a minimum reviews the documentation and evidence, reviews the resident's medical record to determine the resident's physical and cognitive status at the time of the incident and since the incident, reviews all events leading up to the alleged incident and documents the investigation completely and thoroughly. The follow up investigation report will provide sufficient information to describe the results of the investigation, and indicate any corrective actions taken if the allegation was verified. II. Physical abuse between Resident #1 and Resident #2 on 5/12/25. A. Facility investigation The facility investigation was provided by the NHA on 7/7/25 at 12:30 p.m. The investigation documented the NHA responded to a commotion from staff that occurred in the entrance of the front dining room. When the NHA arrived, the registered nurse (RN) on duty was standing by Resident #2 at the dining room entrance holding his glasses. At this time, Resident #1 was sitting at the table nearest to the dining room entrance. The NHA asked what happened. The staff present, including one certified nurse aide (CNA), one dietary aide and a RN , said that they did not witness the event but there was an event that occurred between Resident #1 and Resident #2. The NHA interviewed both residents following the event. Resident #1 said that he was walking to the dining room for dinner and Resident #2 kicked his shin when he walked by, then grabbed at his shirt and hit his chest. The NHA asked what happened next and Resident #1 said that he acted in self defense and hit Resident #2 to stop Resident #2 from grabbing his shirt. The NHA asked Resident #1 if he remembered if he hit Resident #2 with an open or closed hand. Resident #1 said he did not remember that detail. Resident #2 said he did not fully remember what happened and that Resident #1 came at him. The investigation documented the event was not caught on the facility's camera. The RN present said Resident #1 told her the same things that he communicated to the NHA but he told the RN he slapped Resident #2. B. Resident #1 1. Resident status Resident #1, age less than 65, was admitted on [DATE]. According to the July 2025 computerized physician orders (CPO), diagnoses included dementia, obesity, hypertension (high blood pressure), restlessness and agitation. The 2/22/25 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 14 out of 15. He was independent with mobility and for meals and needed moderate assistance with hygiene and set up assistance with other activities of daily living (ADL). 2. Record review Resident #1's dementia care plan, initiated 8/7/24, documented he had impaired cognitive function and dementia or impaired thought processes. Pertinent interventions, initiated 8/7/24, included to monitor, document and report to the physician any changes in cognitive function, specifically decision making ability, memory, recall and general awareness, difficulty expressing self, difficulty understanding others and mental status. Resident #1's psychotropic medication care plan, revised 12/16/24, documented he received psychotropic medications due to dementia with behaviors. Pertinent interventions, revised 5/20/25, included to monitor for agitation as evidenced by verbal and physical outbursts and monitor and record occurrences of target behavior symptoms (specify: pacing, wandering, disrobing, inappropriate response to verbal communication, violence/aggression towards staff/others) and document per facility protocol; administer medications as ordered; and monitor and document for side effects and effectiveness. Resident #1's antidepressant medication care plan, revised 12/20/24, documented he received antidepressant medication for dementia with behaviors and insomnia. Pertinent interventions, revised 12/20/24, included to monitor, document and report to the physician as needed ongoing signs and symptoms of depression: sadness, irritation, anger, crying, negative mood and/or comments, not enjoying usual activities, changes in cognition, unrealistic fears, attention seeking, and constant reassurance. A 5/13/25 alert note documented that on 5/12/25 at approximately 5:00 p.m., Resident #2 was in the dining room doorway when Resident #1 entered the dining room and as he was passing by, Resident #2 kicked Resident #1 on his shin, grabbed him and hit him on his chest. Resident #1 hit Resident #2 back in self defense on the left side of the head. A nurse was at the nurses'station and heard the slap and something fall to the ground. The nurse went to check on the commotion and found Resident #2's glasses on the floor and the left arm of the glasses was broken. Resident #2 was assessed. Resident #2 said Resident #1 hit him and broke his glasses. Resident #1 said he hit Resident #2 back in self defense so that Resident #2 would leave him alone. Resident #1 said he hit Resident #2 with a slap on the left side of his face and head. The NHA was notified. C. Resident #2 1. Resident status Resident #2, age greater than 65, was admitted on [DATE]. According to the July 2025 CPO, diagnoses included chronic respiratory failure, type 2 diabetes mellitus, Parkinson's disease (disease that causes unwanted movements), cognitive communication deficit and dementia. The 4/11/25 MDS assessment revealed the resident had moderate cognitive impairment with a BIMS score of nine out of 15. He needed set up assistance for meals and was dependent on staff assistance for his ADLs. 2. Record review Resident #2's behavior care plan, revised 2/4/25, documented he frequently made uninvited sexual advances toward female staff and explicit sexual comments towards female staff. Pertinent interventions included to administer medications as ordered and monitor and document for side effects and effectiveness (initiated 5/28/24) and staff were to assist Resident #2 to an appropriate table in the dining room to prevent collision with other residents (initiated 5/13/25). Resident #2's antipsychotic medication care plan, revised 2/4/25, documented he was on prescribed antipsychotic medications for dementia with behavioral disturbance and to monitor for: uninvited sexual advances towards others; hallucinations; and verbal outbursts Pertinent interventions, revised 9/3/24, included observing for behavior associated with anti-psychotic medications including delusions, paranoia and hallucinations. Resident #2's Kardex (care plan summary), as of 7/7/25, documented to monitor behavior episodes and attempt to determine the underlying cause, and consider the location, time of day, persons involved and solutions and document the resident's behavior and potential causes. -However, the Kardex failed to list a care planned intervention for staff to assist Resident #2 to an appropriate table in the dining room to prevent collision with other residents (see above). A 5/13/25 nursing note documented that at 5:20 a.m. a CNA reported a bruise above Resident #2's left eye. During the assessment Resident #2 said he got the bruise from the previous day's incident where he was in a fight with another resident. The nurse assessed the site, which was a minor bruise to the left eyelid, and the resident denied having pain. The previous day shift nurse reported Resident #2 was engaged in a physical fight with another resident which broke the left side of Resident #2's eyeglasses. III. Staff interviews CNA #1 was interviewed on 7/7/25 at 2:45 p.m. CNA #1 said she was aware of an incident between Resident #1 and Resident #2, but did not witness the incident. CNA #1 said all residents were monitored for behaviors in the building and she said residents had different interventions based on their behavior. CNA #1 said she could not could not recall any issues between Resident #2 and other residents prior to 5/12/25 and he was easily redirectable. CNA #1 said she could document a resident's behavior in the electronic medical record (EMR) multiple times a day if behaviors occurred. CNA #1 said if a resident had behaviors, she reported them to the nurse and also reported them to the CNA during the shift change so the other staff were aware. CNA #1 said she could find a resident's behaviors in the Kardex and could look up Resident #2's interventions in the Kardex, but she was not sure of Resident #2's exact interventions for his behavior. -However, a review of Resident #2's Kardex on 7/7/25 revealed the 5/13/25 care planned intervention for staff to assist Resident #2 to an appropriate table in the dining room to prevent collision with other residents was not on the resident's Kardex. Licensed practical nurse (LPN) #1 was interviewed on 7/7/25 at 2:52 p.m. LPN #1 said behavior monitoring was generally the same for all residents but if there was a different behavior than the resident's baseline, he would document that in a progress note. The NHA and the assistant director of nursing (ADON) were interviewed together on 7/7/25 at 4:20 p.m. The NHA said on 5/12/25, the nurse was at the nurses'station and heard something fall on the floor and determined it was Resident #2's glasses. The NHA said the nurse heard what she thought was an open handed slap. The NHA said Resident #1 consistently reported that Resident #2 reached out and kicked him. The NHA said Resident #2 was able to kick and self propel in his wheelchair if motivated. The NHA said Resident #2 reported that he was unable to remember what he did and he said Resident #1 attacked him. The NHA said after the incident, she let staff know that Resident #2 preferred to eat in his room at breakfast but if Resident #1 and Resident #2 were going to be in the dining room, the residents should be separated and not eat at the same table and Resident #2 should be assisted to the dining room because he was wheelchair ambulatory. The NHA said Resident #2's assistance to the dining room was added to his care plan and Kardex so the staff could see it. -However, a review of Resident #2's Kardex revealed the 5/13/25 care planned intervention for staff to assist Resident #2 to an appropriate table in the dining room to prevent collision with other residents was not on the resident's Kardex. The ADON said the CNAs were not able to see a resident's care plan but did use the Kardex. The ADON said Resident #2's Kardex had not been updated with the intervention for staff to assist Resident #2 to an appropriate table in the dining room to prevent collision with other residents. The ADON said she added the intervention to Resident #2's Kardex during the survey.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to ensure four (#2, #3, #6 and #9) of nine residents reviewed for abuse out of 13 sample residents were kept free from abuse. Specifically, the facility failed to: -Protect Resident #2 from physical abuse by Resident #3; -Protect Resident #6 and Resident #3 from physical abuse from each other; and, -Protect Resident #9 from physical abuse by Resident #3. Findings include: I. Facility policy and procedure The Abuse, Neglect, Exploitation and Misappropriation policy and procedure, revised April 2021, was provided by the nursing home administrator (NHA) on 3/24/25 at 2:00 p.m. The policy read in pertinent part, Residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. The resident abuse program consists of a facility-wide commitment and resource allocation to support protecting residents from abuse by: -Developing and implementing policies and protocols to prevent and identify abuse, neglect and exploitation, ensure adequate staffing and oversight to prevent burnout, stressful working situations and high turnover rates; -Conduct employee background checks; -Establishing and maintaining a culture of compassion and caring for all residents; -Providing staff education and training on abuse; -Implementing measures to address factors that lead to abuse; -Identifying and investigating all possible incidents of abuse; -Protecting residents from further harm during investigations; -Reviewing allegations of abuse during monthly quality assurance and performance improvement (QAPI) meetings; and, -Involving the resident council in monitoring and evaluating the facility's abuse prevention program. II. Facility investigations of abuse incidents A. Incident of physical abuse by Resident #3 towards Resident #2 on 2/13/25 The 2/13/25 abuse investigation report was provided by the clinical resource nurse (CRN) on 3/24/25 at 9:50 a.m. It documented there was a witnessed, physical altercation between two residents (Resident #2 and Resident #3). The residents were separated, assessed, placed on frequent checks and their care plans were updated with new interventions. The staff assisted Resident #2 to the Red Rocks unit for an activity. The staff took turns watching Resident #3 on the Columbine (co-ed) unit. Resident #2 sustained an abrasion and bruise to her left eyebrow but declined care. Resident #3 was interviewed by the NHA on 2/13/25 at 2:28 p.m. Resident #3 was unable to answer the NHA's questions appropriately. Resident #2 was interviewed by the NHA on 2/13/25 at 2:47 p.m. Resident #2 made a punching motion and pointed to her face when asked if any of her fellow residents had ever physically harmed her. Resident #2 was unable to appropriately answer the NHA's other questions. Eight additional residents were interviewed and did not have additional information. Housekeeper (HK) #1, who witnessed the altercation, said she was sweeping the dining room and Resident #2 was in a dining room chair. Resident #3 was sitting on a pink sofa chair. Resident #3 stood up and walked over to Resident #2. With a closed fist, Resident #3 hit Resident #2 three times on the eye. HK #1 separated the two residents and Resident #3 tried to hit her. A therapist and certified nurse aide (CNA) responded and the situation was de-escalated. The business office manager (BOM) took Resident #2 up front to the Valentine's Day party and Resident #3 grabbed the broom and started sweeping the hallway. The facility substantiated the incident. B. Incident of physical abuse between Resident #3 and Resident #6 on 2/16/25 The 2/16/25 abuse investigation was provided by the CRN on 3/24/25 at 9:50 a.m. It documented there was a witnessed physical altercation between Resident #3 and Resident #6. The residents were separated and assessed. Resident #6 was assisted to his room and Resident #3 stayed with a CNA in the dining room until he went to bed. The residents's care plans were updated with new interventions. Resident #3 had a new, small abrasion on his elbow upon assessment. Resident #3 was interviewed by the BOM on 2/17/25 at 11:08 a.m. Resident #3 was unable to answer the BOM's questions appropriately. Resident #6 was interviewed by the BOM on 2/17/25 at 11:37 a.m. He answered no when asked if he had recently been upset by an interaction with a fellow resident at the facility, had felt uncomfortable, threatened or fearful by any fellow residents or had been harmed by any fellow residents. He had nothing additional to say. Eight residents were interviewed and had no additional information. CNA #5 made a witness statement on 2/16/25 at 10:56 p.m. CNA #5's witness statement documented that she was in the dining room. She said Resident #3 got up from his nap and came to the dining room. She said she was standing by a table. She said Resident #6 was sitting at another table but got up and began wandering. She said Resident #3 wandered over in the direction of where Resident #6 was wandering. The residents ran into each other and began arguing and yelling. Resident #3 pushed Resident #6 away. Resident #6 then grabbed at Resident #3 and pushed him hard. She said this caused Resident #3 to fall to the floor on his buttocks and tailbone. The nurse and another CNA helped the witness separate the two residents. The assisting CNA helped Resident #6 to his room where he remained for the rest of the night. The witness (CNA #5) stayed with Resident #3 until the nurse assessed him and got him up from the ground. Resident #3 did not hit his head but scraped his elbow on the wall. The facility substantiated the incident. C. Incident of physical abuse by Resident #3 towards Resident #9 on 3/24/25 On 3/24/25 at 9:55 a.m. (during the survey), Resident #3 was walking around while pushing a dining room chair in the Columbine unit. Resident #9 walked in front of the chair and sat down in the chair. Resident #3 tried pushing the chair forward and was not able to. Resident #3, with an open palm, slapped Resident #9 on the right side of the head. This incident was reported to licensed practical nurse (LPN) #1 on 3/24/25 at 9:57 a.m. and reported to the NHA on 3/24/25 at 10:02 a.m. LPN #1 separated the two residents and assessed each resident. The NHA said she would start an internal abuse investigation. III. Resident #3 - assailant and victim A. Resident status Resident #3, age [AGE], was admitted on [DATE]. According to the March 2025 computerized physician's orders (CPO), diagnoses included unspecified dementia with agitation, chronic obstructive pulmonary disease, low back pain and weakness. According to the 12/11/24 minimum data set (MDS) assessment the resident had short term and long term memory problems and his cognitive skills for daily decision making were severely impaired through staff assessment. He was dependent on staff for toileting and dressing. He was independent with ambulation. The MDS assessment documented Resident #3 had physical behavior symptoms directed towards others, verbal behavioral symptoms directed toward others and other behavioral symptoms not directed at others every one to three days. B. Record review Resident #3's cognitive impairment care plan, initiated 12/18/24, revealed he had impaired cognitive function related to dementia with behaviors. Interventions included monitoring and reporting changes in cognitive function to his physicians, reviewing medications and using task segmentation to support short term memory deficits. Resident #3's behavior care plan, initiated 12/23/24 and revised 3/21/25, revealed he had the potential to be verbally and physically aggressive related to dementia. Interventions added after the 2/13/25 incident included for staff to provide Resident #3 with meaningful activities, including sweeping with supervision and reading the menus that were posted. Interventions added after the 2/16/25 incident included encouraging Resident #3 to participate in goal oriented tasks, offering snacks and drinks throughout the day and referring Resident #3 to therapy for sensory integration. The skin assessment completed on 2/16/25 documented Resident #3 had a new bruise on his left elbow. The 2/13/25 nursing note documented the nurse was notified that Resident #3 was aggressive towards another resident (Resident #2). Resident #3 was unable to explain what happened. The residents were separated and frequent checks were initiated. Resident #3's representative was notified of the incident. The 2/16/25 nursing note documented that a CNA notified the nurse that Resident #3 and another resident were yelling in each other's faces. Resident #3 pushed the other resident so that resident (Resident #6) retaliated and pushed Resident #3 to the floor. Resident #3 hit his left elbow on the ground. The CNA called the nurse and they separated both residents and the nurse assessed both residents. Resident #3 denied pain and the nurse assisted him to lift himself from the floor. Resident #3 sustained light bruising to his left elbow and a dry dressing was applied on it. The nurse notified the physician, the director of nursing (DON) and the NHA. IV. Resident #2 - victim A. Resident status Resident #2, age [AGE], was admitted on [DATE]. According to the March 2025 CPO, diagnoses included unspecified dementia with behavioral disturbances, chronic kidney disease, mood disorder and chronic pain. The 2/5/25 MDS assessment revealed the resident had short and long term memory impairment and her cognitive skills for daily decision making were moderately impaired, per staff assessment. Resident #2 was independent with ambulation and required supervision with transfers, hygiene, dressing and toileting. The MDS assessment documented Resident #2 had physical behavior symptoms directed towards others, verbal behavioral symptoms directed toward others and other behavioral symptoms not directed at others every one to three days. B. Record review Resident #2's behavior care plan, initiated 2/14/25, revealed the resident had verbal aggression. The interventions included administering medications as ordered, letting Resident #2 clean-up after meals, allowing the resident choices regarding her care, analyzing key times and triggers and what de-escalated her, assessing and anticipating the resident's needs, assessing coping skills and support systems, offering evening activities, providing sensory integration from occupational therapy, redirecting the resident away from high-stimulus areas, completing sleep tracking, speech therapy to work on communication and intervening when resident became agitated. The skin assessment completed on 2/13/25 documented Resident #2 had a new bruise and abrasion to her left eyebrow. The 2/13/25 nursing progress note documented that the nurse was notified that Resident #2 was the non-aggressor in a resident-to-resident altercation. Resident #2 was unable to describe what happened. The residents were separated for safety. Resident #2's representative, the DON, the physician and the NHA were notified. Frequent checks were initiated. V. Resident #6 - assailant and victim A. Resident status Resident #6, age less than 65, was admitted on [DATE] and passed away on 3/12/25. According to the March 2025 CPO, diagnoses included cerebral infarction (disrupted blood flow to the brain), unspecified dementia with psychotic disturbance, muscle weakness and type 2 diabetes. The 2/14/25 MDS assessment revealed the resident was not assessed for a brief interview for mental status or cognitive skills for daily decision making. He was dependent on staff for eating, hygiene, toileting and dressing. He could ambulate independently. The MDS assessment indicated Resident #6 did not have any physical or verbal behaviors. B. Record review Resident #6's behavior care plan, initiated 2/17/25, revealed Resident #6 had the potential to be physically aggressive related to dementia and poor impulse control. He had vision deficits which contributed to his wandering and spatial awareness. Interventions included administering medications as ordered, analyzing times of the day and triggers that contributed to his behaviors, assessing for the residents needs, assessing the resident for sensory deficits, providing occupational therapy for communication and sensory integration, providing physical therapy, providing speech therapy, giving the resident choices and activities, modifying the environment to make Resident #6 comfortable and reducing agitation and intervening when Resident #6 got agitated before the behavior escalated. The 2/16/25 nursing note documented that a CNA noticed Resident #6 and another resident yelling in each other's faces. Resident #3 pushed Resident #6. Resident #6 retaliated and pushed Resident #3 on the floor. Resident #3 hit his left elbow on the ground. The CNA called the nurse and they separated both residents. The physician, the DON and the NHA were notified. VI. Resident #9 - victim A. Resident status Resident #9, age less than 65, was admitted on [DATE]. According to the March 2025 CPO, diagnoses included paranoid schizophrenia, osteoarthritis and dementia with behavioral disturbances. The 1/16/25 MDS assessment revealed the resident's cognitive skills for daily decision making were moderately impaired and he had short term and long term memory problems, through staff assessment. He was dependent on staff for hygiene, toileting, showering and dressing. He could ambulate independently. The MDS assessment indicated Resident #9 did not have any physical and verbal behaviors. B. Record review Resident #9's behavior care plan, initiated 6/16/23 and revised 8/28/23, documented Resident #9 had the potential for behavior problems related to his dementia. He had a history of physical aggression and redirection could be difficult at times. Interventions included a chart review from the pharmacist as needed, providing distraction with pleasant activities, encouraging Resident #9 to wear his eyeglasses, completing frequent rounding, providing individual activities, such as watching movies and providing a resident-specific activity box. VII. Staff interviews CNA #4 was interviewed on 3/24/25 at 1:40 p.m. CNA #4 said Resident #3 was very aggressive when he was first admitted to the facility. She said medication adjustments seemed to have started to calm his behaviors down. She said he still acted aggressive often and he was physically aggressive towards the residents that got in his personal space. She said that Resident #3 hit everybody and he did not target certain residents. CNA #4 said he sundowned (behavior changes caused by dementia) around 3:00 p.m. and that was usually when his behaviors got worse. The DON, the CRN and the NHA were interviewed together on 3/24/25 at 3:30 p.m. The NHA said she verbally educated staff on Resident #3's behavior interventions each time he got new interventions added. She said he was reviewed at monthly psychology pharmaceutical (psych pharm) meetings, weekly at-risk meetings and at the monthly QAPI meetings with the interdisciplinary (IDT) team. She said the facility identified that one of Resident #3's triggers was when he was woken up in the morning. She said the facility implemented interventions to let him sleep as long as he wanted and to wake on his own. The DON said the facility was working with the pharmacist and Resident #3's physician to adjust his medications and get him on the right medication regimen to ensure he maintained his quality of life while keeping his behaviors stable. The NHA said she had sent a referral for Resident #3 to work with a psychiatrist and that Resident #3 had been unable to participate. Resident #3's physician (PHY) was interviewed on 3/25/25 at 11:25 a.m. The PHY said he thought Resident #3's diagnosis was frontal lobe vascular dementia which was consistent with his behaviors and he would update the resident's diagnosis. He said he had been working with Resident #3 to get him on the right medication regimen since he was admitted . He said Resident #3 was gradually getting better with his behaviors. He said the staff that worked with him full-time knew him well and were able to redirect him. The PHY said he received calls from the agency staff regarding Resident #3's behaviors because they did not know him as well. The medical director (MD) was interviewed on 3/25/25 at 11:45 a.m. He said Resident #3 had dementia and would never be cured of his disease. He said just like other diseases, he had exacerbations with his behaviors. He said the staff were working with him to get him on the right medication regimen and the right interventions that worked for him. The MD said the goal was to minimize Resident #3's behaviors without sedating him to the point he had no behaviors. CNA #2 was interviewed on 3/25/25 at 8:35 a.m. CNA #2 said Resident #3 was not having any behaviors so far that morning (3/25/25). She said he refused his shower and they let him refuse because he could get aggressive. She said he got aggressive when other people got in his way or took his food off his plate. She said Resident #9 took food from other resident's plates in the dining room, so they had to keep Resident #3 and Resident #9 separated in the dining room. She said the two residents (Resident #9 and Resident #3) did not get along. CNA #2 said the staff redirected Resident #3 when he got aggressive with snacks, books and reading menus. The DON was interviewed a second time on 3/25/25 at 1:43 p.m. The DON said she felt like the facility was progressing with Resident #3 in the right direction. She said it had been a process to figure out Resident #3's triggers and what he responded well too. She said the facility had been working on getting information from staff and educating the staff regarding Resident #3. She said the staff kept other residents free from harm while residing with Resident #3 by knowing when Resident #3 was up and active, keeping an eye on him, redirecting him with reading material or activities when he was aimlessly wandering, being aware of his stimuli and keeping a close eye on him when he was in the dining room. She said she had not noticed any of the victims of Resident #3's incidents having any changes in their behaviors or mood. The DON said she educated the agency staff about Resident #3's patterns and triggers and also had them review a binder prior to their shift with the facility's policies.

Deficiency Text Not Available

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interviews, the facility failed to ensure that its medication error rate was less than five percent (%). Specifically, the facility had a medication error rate of 6.45%, which was two errors out of 31 opportunities for error. Findings include: I. Professional reference According to [NAME], P.A., [NAME], A.G., et.al., Fundamentals of Nursing, 10 ed., E.[NAME], St. Louis Missouri, pp. 606-607. Take appropriate actions to ensure the patient receives medication as prescribed and within the times prescribed and in the appropriate environment. Professional Standards such as nursing scope and standards of practice apply to the activity of medication administration. To prevent medication errors, follow the seven rights of medication administration consistently every time you administer medications. Many medication errors can be linked in some way to an inconsistency in adhering to these seven rights: 1. The right medication 2. The right dose 3. The right patient 4. The right route 5. The right time 6. The right documentation 7. The right indication. According to the Instructions for use Humalin R KwikPen, retrieved on 11/23/24 from: https://pi.lilly.com/ca/humulin-n-r-ca-ifu-kp.pdf It revealed in pertinent Priming your pen. Prime before injections. Priming your Pen means removing the air from the needle and cartridge that may collect during normal use and ensure the pen is working correctly. If you do not prime the pen before injections, you may get too much or too little insulin. According to the How to Use Voltaren Gel instructions, retrieved on 12/23/24 from: https://www.voltarengel.com/arthritis-pain-gel/ It reveled in pertinent part Dosage: using the dosing care, apply the following amounts: Upper body areas (hand, wrist, elbow: 2.25 inches. Lower body areas (foot ankle, knee): 4.5 inches II. Facility policy and procedure The Administering Medications policy and procedure, revised April 2019, was received from the nursing home administrator (NHA) on 12/19/24 at 1:29 p.m. It revealed in pertinent part, Medications are administered in a safe and timely manner, and as prescribed. The individual administering medications checks the label three times to verify the right resident, right medication, right dose, right time, and right method (route) of administration before giving the medications. III. Observations On 12/17/24 at 11:40 a.m. registered nurse (RN) #1 was administering medications for Resident #3. The medication ordered was Humalin R U-500 Kwik pen 500 units/milliliter (ml) inject 125 units subcutaneously before meals for diabetes. RN #1 collected the Humalin R pen from the medication cart, applied a new needle to the tip and dialed the insulin pen to 125 units. RN #1 then identified Resident #3, applied gloves, cleansed the site with an alcohol swab and administered the injection via pen into the resident's right lower abdomen. -RN #1 failed to prime the insulin pen for the correct dose of medications ( see professional reference above). On 12/19/24 at 8:27 a.m. RN #1 was administering medications for Resident #10. The medication ordered was Volataren arthritis pain external gel one percent, apply to the right hip topically three times a day for osteoarthritis. RN #1 obtained a tube of Voltaren gel one percent from the treatment cart. He opened the tube and poured out about a quarter in diameter gel directly into a medication cup. RN #1 then identified Resident #10 applied gloves and applied the gel to the resident's right hip. -RN #1 failed to identify the medication order did not have a dose indicated (see professional reference above) in order to administer the correct dose to the resident. IV. Staff interviews RN #1 was interviewed on 12/17/24 at 12:41 p.m. RN #1 said insulin vials needed to be cleansed with an alcohol swab prior to inserting a needle to draw up the insulin. RN #1 was not aware he needed to cleanse the top of the insulin pen prior to applying the needle. RN #1 said he was did not know he needed to prime an insulin pen before dialing to the ordered dose. RN #1 said priming would waste the insulin. RN #1 said he would need to find out what the facility protocol on insulin pens was. Licensed practical nurse (LPN) #1 was interviewed on 11/17/24 at 12:56 p.m. LPN #1 said insulin pens did not need to be primed after applying a new needle. The director of nursing (DON) was interviewed on 12/18/24 at 3:09 p.m. The DON said insulin pens should be cleaned prior to applying the needle and the pen should be primed prior to dialing up the dose. The DON said priming was important to ensure the correct dose was administered, not priming could lead to too much or too little insulin being administered. RN #1 was interviewed again on 12/19/24 at 9:40 a.m. RN #1 said he administered the Voltaren gel as ordered for Resident #10. He said after reviewing the Voltaren gel order he was able to identify the order was missing a dose. He said he was not aware he needed to use the dosing card inside the Voltaren gel box. RN #1 said he would call the physician immediately to get the dose added to the order. The DON was interviewed again on 12/19/24 at 10:20 a.m. The DON said an order should include the right person, medication, dose, frequency and route. The DON said if the order was missing one of the five rights it was to be corrected immediately to prevent medication error. The DON said her charting system did not allow for the dose to be put in and she would have to figure out how it can be added. The DON said Voltaren gel had a dosing card that should be used to ensure the correct dose is being administered.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interviews the facility failed to ensure residents were kept free of significant medication errors for one resident (#3) out of 29 sample residents. Specifically the facility failed to ensure insulin pens were primed prior to medication administration for Residents #3. Cross-reference F759 failure to ensure the medication error rate was less than five percent (%). Findings include: I. Professional reference According to the Instructions for use Humalin R KwikPen, retrieved 12/26/24 from: https://pi.lilly.com/ca/humulin-n-r-ca-ifu-kp.pdf It revealed in pertinent Priming your pen. Prime before injections. Priming your Pen means removing the air from the needle and cartridge that may collect during normal use and ensure the pen is working correctly. If you do not prime the pen before injections, you may get too much or too little insulin. II. Facility policy and procedure The Administering medications policy and procedure, revised April 2019, was received from the nursing home administrator (NHA) on 12/19/24 at 1:29 p.m. It revealed in pertinent part, Medications were administered in a safe and timely manner, and as prescribed. The individual administering medications checks the label three times to verify the right resident, right medication, right dose, right time, and right method (route) of administration before giving the medications. III. Resident #3 A. Resident status Resident #3, age greater than 65, admitted on [DATE]. According to the December 2024 computerized physician orders (CPO) diagnoses included type one diabetes (abnormal glucose control), obesity and paranoid schizophrenia (abnormal thinking process). The 11/22/24 minimum data set (MDS) assessment revealed the resident had severe cognitive impairments with a brief interview for mental status (BIMS) score of three out of 15. He required set up assistance with personal hygiene. He was independent for eating, dressing, toileting and transfers. The MDS assessment revealed the resident received insulin injections for the past seven days. B. Physician's orders The December 2024 CPO documented a physician's order for Resident #3. The order read: Humalin R U-500 kwikPen, Inject 125 units subcutaneously before meals for diabetes. C. Observations On 12/17/24 at 11:40 a.m. registered nurse (RN) #1 was administering medications for Resident #3. The medication ordered was Humalin R U-500 Kwik pen 500 units/milliliter (ml) inject 125 units subcutaneously before meals for diabetes. RN #1 collected the Humalin R pen from the medication cart, applied a new needle to the tip and dialed the insulin pen to 125 units. RN #1 then identified Resident #3, applied gloves, cleansed the site with an alcohol swab and administered the injection via pen into the resident's right lower abdomen. -RN #1 failed to prime the insulin pen for the correct dose of medications (see professional reference above). III. Staff interviews RN #1 was interviewed on 12/17/24 at 12:41 p.m. RN #1 said insulin vials needed to be cleansed with an alcohol swab prior to inserting a needle to draw up the insulin. RN #1 said he was not aware he needed to cleanse the top of the insulin pen prior to applying the needle. RN #1 said he did not know he needed to prime an insulin pen before dialing to the ordered dose. RN #1 said priming would waste the insulin. RN #1 said he would need to find out what the facility protocol on insulin pens was. Licensed practical nurse (LPN) #1 was interviewed on 11/17/24 at 12:56 p.m. LPN #1 said insulin pens did not need to be primed after applying a new needle. The director of nursing (DON) was interviewed on 12/18/24 at 3:09 p.m. The DON said insulin pens should be cleaned prior to applying the needle and the pen should be primed prior to dialing up the dose. The DON said priming was important to ensure the correct dose was administered, not priming could lead to too much or too little insulin being administered.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and interviews, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of diseases and infection. Specifically, the facility failed to: -Ensure housekeeping staff followed proper cleaning techniques for cleaning and disinfecting resident rooms and high frequency touched areas (call lights, door handles and handrails); -Ensure housekeeping staff used the correct surface disinfectant products; -Ensure enhanced barrier precautions (EBP) were in place for a resident with a stage IV pressure injury prior to wound care; and, -Ensure washing machine temperatures were checked daily and lint traps were emptied timely. Findings include: I. Housekeeping A. Professional reference Assadian O, Harbarth S, Vos M, et al. Practical Recommendations for Routine Cleaning and Disinfection Procedures in Healthcare Institutions: A Narrative Review. The Journal of Hospital Infection, (July 2021) 113:104-114, was retrieved on 12/21/24 from https.//pubmed.ncbi.nlm.nih.gov. It revealed in pertinent part, High-touch surfaces, on the other hand, are usually close to the patient, are frequently touched by the patient or nursing staff, come into contact with the skin and, due to increased contact, pose a particularly high risk of transmitting pathogens (virus or microorganism that can cause disease). Healthcare-associated infections (HAIs) are the most common adverse outcomes due to delivery of medical care. HAIs increase morbidity and mortality, prolonged hospital stays, and are associated with additional healthcare costs. Contaminated surfaces, particularly those that are touched frequently, act as reservoirs for pathogens and contribute towards pathogen transmission. Therefore, healthcare hygiene requires a comprehensive approach. This approach includes hand hygiene in conjunction with environmental cleaning and disinfection of surfaces and clinical equipment. The Centers for Disease Control and Prevention (CDC) Environment Cleaning Procedures, (revised 3/19/24) was retrieved on 12/21/24 from https://www.cdc.gov/healthcare-associated- infections/hcp/cleaning-global/procedures.html?CDC_AAref_Val=https://www.cdc.gov/hai/pre ent/resource-limited/cleaning-procedures.html#cdc_generic_section_2-4-1-general-environmental-cleaning-techniques. It read in pertinent part, High-Touch Surfaces: The identification of high-touch surfaces and items in each patient care area is a necessary prerequisite to the development of cleaning procedures, as these will often differ by room, ward and facility. Common high-touch surfaces include: bed rails, IV (intravenous) poles, sink handles, bedside tables, counters, edges of privacy curtains, patient monitoring equipment (keyboards, control panels), call bells and door knobs. Proceed from cleaner to dirtier areas to avoid spreading dirt and microorganisms. Examples include: during terminal cleaning, clean low-touch surfaces before high-touch surfaces, clean patient areas (patient zones) before patient toilets, within a specified patient room, terminal cleaning should start with shared equipment and common surfaces, then proceed to surfaces and items touched during patient care that are outside of the patient zone, and finally to surfaces and items directly touched by the patient inside the patient zone. In other words, high-touch surfaces outside the patient zone should be cleaned before the high-touch surfaces inside the patient zone and clean general patient areas not under transmission-based precautions before those areas under transmission-based precautions. B. Facility policy and procedure The Daily Room Cleaning policy, undated, was provided by the nursing home administrator (NHA) on 12/19/24 at 1:19 p.m. It read in pertinent part, Throughout the cleaning process, you must be thorough as germs are everywhere. In corners, small openings, grooves, and the underside of objects. Dip the cleaning cloth into the disinfectant and hand wring. Wipe the headboard, the bed controls and the foot board. Disinfect the night stand top, the sides, the front, the back and the legs. Wipe the telephone paying close attention to the receiver. Clean the over bed table and clean it thoroughly, working from the upper surfaces to the lower surfaces. Wipe clean the pedestal, base and the casters. Disinfect the toilet bowls, flush before cleaning. Apply toilet bowl cleaner and disinfectant to the inside of the toilet. Clean the rim, spray the outside and bottom surfaces with disinfectant solution and wipe and spray the toilet seat with the disinfectant. Spray a small amount of cleaner in the sink and rub the cleaner around the top and inside of the sink. Wipe the sink and the top dry. Dampen a cloth in disinfectant and wipe the counter top, being careful to clean under personal items left by the resident. Clean under the personal items left by the resident. Clean under the items and place them back in a neat arrangement. Clean the counter front, inside sink doors, the piping, and all exposed surfaces of the entire unit. Use pre-measured disinfectant floor cleaning chemicals for mopping. Before leaving the room, inspect the room according to the checklist and to make sure all required cleaning tasks were performed. C. Observations During a continuous observation on 12/18/24 at 10:06 a.m. housekeeper (HSK) #1 was observed cleaning room [ROOM NUMBER], room [ROOM NUMBER] and room [ROOM NUMBER]. HSK #1 pushed the cleaning cart to the door way of room [ROOM NUMBER]. She donned (put on ) gloves and removed a disinfectant spray bottle and the toilet brush from the cart. She entered room [ROOM NUMBER]'s bathroom. She sprayed the inside of the toilet bowl and scrubbed it with the toilet brush. She placed the toilet brush back into the cart and removed her gloves. She used hand sanitizer and put on clean gloves. She removed a small container of a soap solution and a scrubbing pad. She washed the inside of the sink. She placed the container with the scrub pad back into the cart. She removed the broom and swept the room. She placed the broom and dust pan back onto the cart and removed a green rag. She placed the green rag on the sink and splashed water onto the mirror. She used a paper towel from the dispenser to wash the mirror. She turned on the sink and wet the green rag. She wiped out the inside of the sink, the top of the sink and the faucet. -HSK #1 did not use a disinfectant while cleaning the sink. HSK #1 washed her hands and donned clean gloves and removed the disinfectant spray bottle and a green rag from the cart. She sprayed the toilet. She used the green rag to wipe the seat of the toilet, the rim, the toilet seat a second time, the back of the seat, the side of the toilet, the front of the toilet tank and the top of the tank. She sprayed the two grab bars, on each side of the toilet, with the disinfectant spray and used the same rag to clean the grab bars. She placed the spray bottle and rag back onto the cart. She removed her gloves, used hand sanitizer, and donned clean gloves. She removed a mop pad from the water bucket and sprayed it with a cleaner. She dropped the mop pad on the floor and placed the mop handle on top. She mopped the room first and then the bathroom. She pushed the cleaning cart to room [ROOM NUMBER]. -HSK #1 failed to use the correct cleaning techniques to clean the toilet and the grab bars. -HSK #1 said there was no disinfectant in the mop pad bucket and it only contained plain water. -HSK #1 did not disinfect high touch areas such as the door knobs, light switches, call light and bed controller. HSK #1 used hand sanitizer and donned gloves and entered room [ROOM NUMBER]. She removed the container of a soap solution and a scrubbing pad and washed the inside of the sink. She returned the container to the cart and removed the disinfectant spray. She sprayed the leather recliner and used a green rag to wipe it down. She placed the soiled rag on the cart. She removed a clean green rag from the cart and walked to the sink. She used her gloved hand to splash water onto the mirror. She wiped it dry with a paper towel. She sprayed disinfectant onto the rag and wiped the top of both of the night stands. She placed the soiled rag on the cart and removed the broom. She then swept the room. She placed the broom back on the cart and removed a mop pad from the water bucket. She sprayed the mop pad with cleaner and mopped the bedroom floor. The bathroom was shared with room [ROOM NUMBER]. She pushed the cleaning cart to room [ROOM NUMBER]. -HSK #1 said there was no disinfectant in the mop pad bucket and it only contained plain water. -HSK #1 did not disinfect high touch areas such as the door knobs, light switches, call light and bed controller. HSK #1 used hand sanitizer, donned gloves and entered room [ROOM NUMBER]. She removed the toilet brush from the cart and proceeded to the bathroom. The toilet seat had feces on it and there was feces in the toilet bowl. She did not flush the toilet. She used the toilet brush to clean the inside of the toilet bowl and then used the brush to clean the feces off the seat. She placed the toilet brush back onto the cart and removed her gloves. She used hand sanitizer and donned clean gloves. She removed the broom from the cart and began sweeping the room. She moved the night stand and swept behind it. A comb and tube of toothpaste was in the debris. She picked up the items and shook them off. She placed both items back onto the night stand. There was still debris in the comb. She swept the rest of the debris to the doorway and picked it up with the dust pan. She removed the disinfectant and a green rag from the cart. She wet the rag at the sink and proceeded to the bathroom. She sprayed the toilet with disinfectant and used the rag to wipe it. She first wiped the tank, the seat, under the seat, the rim, the side of the toilet and the sides. She sprayed the window sill and used a clean rag to wipe it. She returned the spray bottle and the soiled rags to the cart. She removed her gloves, used hand sanitizer and donned clean gloves. She removed a mop pad from the water bucket and sprayed it with a cleaner. She dropped the mop pad on the floor and placed the mop handle on top. She mopped the room and emptied the trash. She removed the soiled mop pad and replaced it with a clean mop pad from the water bucket. She did not spray the second mop pad with a cleaner. She then mopped the bathroom floor. She placed the mop pad and handle back onto the cart. She removed a small container of a soap solution and a scrubbing pad. She washed the inside of the sink. She again splashed water onto the sink top and mirror and wiped them dry with a paper towel. She placed a wet floor sign at the door entrance and exited the room. -HSK #1 failed to use the toilet brush only on the inside of the toilet and use a disinfectant on the toilet. She failed to discard the comb and tooth paste into the trash and placed them back on the night stand to be used. She failed to use a disinfectant when mopping the bathroom floor and failed to use a disinfectant while cleaning the sink. She failed to clean horizontal surfaces and high touch surfaces. D. Staff interviews HSK #1 was interviewed on 12/18/24 at 10:37 a.m. HSK #1 said she used the container of dish soap and water, with the scrub pad, to clean the sink in all the resident's rooms. She said she changed the scrub pad once a week and used the dish soap because she felt it was the best product to disinfect with. She said the toilet brush should only be used for the inside of the toilet bowl, but since there was dried feces on the seat she had to use the toilet brush to clean the seat. She said the toilet should have been cleaned from top to bottom. She said she used the toilet brush to clean the seat, because she did not have another rag. She said high touch areas, such as door knobs, grab bars, sink handles and call lights should be cleaned daily. She said there was only water in the mop bucket, but she sprayed the mop with a cleaner to rid the room of odors. The housekeeping and laundry manager (HLM) was interviewed on 12/18/24 at 11:09 a.m. The HLM said a multipurpose cleaner should have been used for the cleaning of the floors. He said there was a chemical dispensing system in the janitor closet. He said when the HSK filled the mop bucket they should have pushed the button on the dispenser to add the cleaner to the water. He said the cleaner spray was only used to give the room a clean smell and did not disinfect. He said the toilet brush should never be used outside of the toilet bowl. He said the toilet should be cleaned with a disinfectant and wiped with a clean rag from top to bottom. He said high touch surfaces should be disinfected daily as well as the sink and any frequently touched surfaces. He said HSK #1 should not have cleaned the grab bars after the toilet with the same rag. He said the toilet should always be cleaned last. He said HSK #1 should have thrown the comb and tooth paste in the trash so it could not be used. He said he would reeducate HSK #1 on the room cleaning process and procedures. The infection preventionist (IP) was interviewed on 12/19/24 at 10:47 a.m. The IP said a resident's room should be cleaned from top to bottom and cleanest to dirtiest. She said the bathroom should always be cleaned last. She said the grab bars should have been cleaned prior to the toilet. She said the toilet should be cleaned from top to bottom and the toilet bowl last. She said the toilet brush should only be used inside the toilet. She said a disinfectant should have been used to clean the sink, high touch surfaces and when mopping the floor. She said if items were on the floor, they should have been thrown away. She said she would immediately reeducate the housekeeping staff on the correct room cleaning process and the use of the correct cleaning chemicals. II. Enhanced barrier precautions A. Facility policy and procedure The Enhanced Barrier Precautions policy, revised March 2024, was provided by the NHA on 12/19/24 at 1:19 p.m. It read in pertinent part, Enhanced barrier precautions were utilized to reduce the transmission of multi-drug resistant organisms (MRDOs) to residents. Gown and glove use in addition to standard precautions should be used during high contact resident care activities when contact precautions do not apply. High-contact resident care activities requiring the use of gown and gloves for EBPs include dressing, bathing, transferring, changing linen, changing brief or toileting, device care and wound care. EBPs are indicated for residents with wounds and/or indwelling medical devices regardless of MRDO colonization. Wounds generally include chronic wounds such as pressure ulcers, diabetic foot ulcers, venous stasis ulcers and unhealed surgical wounds. EBPs remain in place for the duration of the resident's stay or until resolution of the wound or discontinuation of the indwelling medical device that places them at increased risk. Staff are trained prior to caring for residents on EBPs. Signs are posted in the door or wall outside the resident room indicating the type of precautions and PPE required. PPE is available outside of the resident rooms. Residents, families and visitors are notified of the implementation of EBPs throughout the facility. B. Observations On 12/18/24 at 12:19 p.m. Resident #35 was laying in bed waiting for the wound physician to perform wound care. The wound care physician and registered nurse (RN) #1 used hand sanitizer and donned gloves. They entered Resident #35's room and began her wound care. -The facility failed to identify the need for Resident #35 to be placed on EBPs for her chronic stage IV pressure injury. C. Staff interviews RN #1 was interviewed on 12/18/24 at 1:43 p.m. RN #1 said he was not sure what enhanced barrier precautions were or when they should be put into place. The director of nursing (DON) was interviewed on 12/18/24 at 1:44 p.m. The DON said there were no residents in the facility, at the time of the survey, that required EBPs. She said she would check to see if any residents needed to be on EBP. When she returned, she said Resident #35 should have been placed on EBPs and was not sure why she was not. She said she would immediately get a physician's order and place Resident #35 on EBPs. She said when a resident was on EBP the staff needed to wear a gown, gloves and mask prior to completing wound care. III. Laundry A. Facility policy and procedure The Soiled Laundry and Bedding policy, revised September 2022, was provided by the nursing home administrator (NHA) on 12/19/24 at 1:19 p.m. It read in pertinent part: Laundry equipment (washing machines and dryers) are used and maintained according to the manufacturer's instructions for use to prevent microbial contamination of the system. Laundry processed in hot water temperatures is 160 degrees F (fahrenheit) for 25 minutes. Laundry that is not hot water compatible, low temperature washing at 71 degrees to 77 degrees F (22-25 degrees celcius) plus chlorine or oxygen-activated bleach can reduce microbial contamination. The Cleaning Lint in Laundry policy, undated, was provided by the NHA on 12/19/24 at 1:19 p.m. It read in pertinent part: The policy statement was to maintain a safe, efficient, and sanitary laundry environment, lint must be regularly cleaned from laundry machines, lint traps, and surrounding areas. THis reduces the risk of fire, ensures proper machine function and maintains hygiene standards in the facility. The purpose was to establish a consistent procedure for cleaning lint in laundry facilities to promote safety, improve equipment performance and ensure compliance with applicable regulations. Remove the lint trap from the machine carefully after every load of laundry. Use a lint brush or hand to remove accumulated lint. Place the lint into a designated trash receptacle. Inspect the lint trap for tears or damage. Report any issues to the supervisor immediately. Maintain a log of daily, weekly, and monthly lint cleaning activities. Note any issues, repairs, or maintenance required in the log. B. Observations The laundry room was observed on 12/18/24 at 2:34 p.m. There were two washing machines. C. Record review A request was made for the temperature log for the washing machines. The facility was unable to provide a temperature log for the two washing machines. D. Staff interviews The HLM was interviewed on 12/18/24 at 2:34 p.m. He said he did not know he needed to check the temperature on the washing machines. The regional director of plant operations (RDPO) was interviewed on 12/18/24 at 10:47 a.m. He said the washing machine temperatures should reach 160F and tested daily with a thermometer to disinfect the laundry properly. The IP was interviewed on 12/19/24 at 10:47 a.m. The IP said she did not know how often the washing machine temperatures should be checked or what the temperature should be at.

Based on observations, record review and interviews, the facility failed to ensure food items were stored, prepared, distributed and served under sanitary conditions in the main kitchen. Specifically, the facility failed to have a system in place to monitor the internal water temperature and concentration (parts per million-ppm) of hypochlorite of the dish machine in the main kitchen to ensure tableware, drinkware and cookware were effectively sanitized. Findings include: I. Professional reference The Colorado Retail Food Establishment Rules and Regulations, revised March 2024, retrieved on 12/26/24, read in pertinent part: A test kit or other device that accurately measures the concentration in MG/L (milligrams per liter) of sanitizing solutions shall be provided. (page 125) A chemical sanitizer used in a sanitizing solution for a manual or mechanical operation at contact times shall meet the criteria specified in accordance with the EPA- registered label use instructions . A chlorine solution shall have a minimum temperature based on the concentration and PH of the solution as listed in the following chart: The concentration range minimum temperature chart indicated if the MG/L was 25 to 49 and the PH (potential of hydrogen) was 10 or less or the PH was eight or less the temperature of the water needed to be 120F. If the MG/L was 50 to 99 and the PH was 10 or less or eight or less the water needed to be 100F. If the MG/L was 100 and the PH was 10 or less or eight or less the water needed to be 55F. The temperature of the wash solution in spray-type warewashers that use chemicals to sanitize may not be less than 120°F. (page 129 to 130) II. Facility policy and procedure The Dishwashing Machine Use policy and procedure, revised March 2010, was received from the nursing home administrator (NHA) on 12/19/24 at 1:29 p.m. It revealed in pertinent part, Food Service staff required to operate the dishwashing machine will be trained in all steps of dishwashing machine use by the supervisor or a designee proficient in all aspects of proper use and sanitation . Dishwashing machine chemical sanitizer concentrations and contact times will be as follows: If the solution is chlorine the minimum concentration is 50 to 100 ppm with a contact time of 10 seconds. If the solution is iodine the minimum concentration is 12.5 ppm with a contact time of 30 seconds. If the solution is quaternary ammonium the minimum concentration is 150 to 200 ppm and the contact time is per the manufacturer's instructions. A supervisor will check the dishwashing machine for proper concentrations of sanitizer solution (measured as parts-per-million [PPM] or mL/L) after filling the dishwashing machine and once a week thereafter. Concentrations will be recorded in a facility approved log. Corrective action will be taken immediately if sanitizer concentrations are too low. The operator will check temperatures using the machine gauge with each dishwashing machine cycle, and will record the results in a facility approved log. The operator will monitor the gauge frequently during the dishwashing machine cycle. Inadequate temperatures will be reported to the supervisor and corrected immediately. The supervisor will check the calibration of the gauge weekly by running a secondary thermometer through the machine to compare temperatures; or using commercial temperature test strips following manufacturer's instructions. If hot water temperatures or chemical sanitation concentrations do not meet requirements, cease use of dishwashing machines immediately until temperatures or ppm are adjusted. III. Observations and staff interviews On 12/16/24 at 9:08 a.m. the kitchen dish machine was in use after the breakfast meal. The dietary manager (DM) said the dish machine used chemicals for sanitization. There were no test strips available to test the chemical solution. The DM said they ran out of test strips two or three days prior. The DM said the staff were using the temperature on the machine for monitoring the effectiveness of disinfecting until the test strips were delivered. The dish machine was 130F. On 12/18/24 at 1:25 p.m. the dishwasher was in use. The DM said he still had not received test strips to check the dishwashing machines chemical use. The dish washer temperature was 130F. Dietary aide (DA) #1 was interviewed on 12/18/24 at 1:30 p.m. She said she checked the temperature on the dish machine once per meal. DA #1 said she recorded the temperature on the log sheet. The November 2024 (11/1/24 to 11/30/24) and December 2024 (12/1/24 to 12/19/24) machine log sheets were reviewed with DA #1 and she confirmed there were days that were missing temperature monitoring of the dish machine. DA #1 said she did not know what was an acceptable temperature. DA #1 said she had never tested the dishwasher chemicals. IV. Record review The dishwasher temperature log from 11/28/24 to 12/19/24 was reviewed on 12/19/24 at 1:58 p.m. it documented the following: -On 11/28/24 there was not a temperature logged for the dinner service; -From 11/30/24 to 12/5/24 there were no temperatures logged; -On 12/7/27 there were no temperatures logged for the lunch or dinner service; -On 12/8/24 the temperature was 115F for breakfast service with no corrective action documented; -From 12/9/24 to 12/12/24 there were no temperatures logged; -On 12/13/24 there were no temperatures logged for the lunch or dinner service; -On 12/14/24 the temperature was 110F for breakfast and 100F for lunch. There was no temperature logged for dinner services. -On 12/15/24 the temperature was 100F for breakfast service. -On 12/16/24 the temperature was 110F for breakfast and there was no temperature logged for dinner service. -On 12/17/24 there was no temperature logged for dinner service. -The dishwasher machine log had no place to document the ppm was being monitored. The dishwasher log failed to consistently document the temperature of the dishwasher, along with no testing of the ppm for chemical sanitization. The log documented several days with temperatures out of range (see professional reference above). V. Additional staff interviews DA #2 was interviewed on 12/18/24 at 1:51 p.m. He said from time to time he would assist with washing dishes. DA #2 said the temperature on the dishwashing machine should be between 35 and 45 degrees fahrenheit. DA #2 said they were to use the dip sticks in the dishwasher to ensure the proper amount of chemical was being used for disinfecting purposes. DA #2 said the dip stick should be a green to dark green color to be in the correct range. DA #2 said he did not know the ppm levels the dishwasher should read during testing. The infection preventionist (IP) was interviewed on 12/19/24 at 10:27 a.m. The IP said the dishwasher chemicals were dispensed from a machine. The IP said she did not know what the chemical concentration needed to be to ensure proper sanitization. The IP said the dish machine was a low temperature dishwasher that used chemicals to sanitize the dishes. The IP said she needed to check with the DM for the correct intervals the dishwasher should be checked, but she believed it was every four hours. The IP said it was important for the dish machine to be functioning appropriately to ensure proper sanitization of dishes to prevent spread of infection. The DM was interviewed on 12/19/24 at 1:16 p.m. He said he had been educated to ensure the dishwasher temperature was at least 120F and the ppm should be between 50 and 100 for chlorine. The DM said he would call the chemical servicing company if they discovered the chemical dispensing was inaccurate based on testing strips. The DM said if the dishwasher was not working the dietary staff would washing dishes manually in the sink and the ppm would be checked of the sanitizer in the sink to ensure it was effectively sanitizing. The DM said he had testing strips the whole time during the survey. The DM said he did not know he could use the same testing strips he used on his sanitization buckets. The DM said the staff were responsible for documenting the ppm and the temperatures for all areas that chemicals were used in the kitchen. The DM said the manager on duty was responsible for checking the logs on the weekends or when he was not in the facility to ensure they were filled out daily. The DM said he was not sure why the logs were not being completed or how the log sheet did not have a section for ppm to be recorded. The DM said he would be completing education to the staff. He said he would change the log sheets immediately to ensure the temperatures and ppm could be recorded appropriately. The DM said he tested the ppm on the dishmachine once he learned he could use the same strips and it was above 50 ppm.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and interviews, the facility failed to ensure residents resided in a sanitary and comfortable environment for two of two units observed for cleanliness. Specifically the facility failed to: - Ensure resident rooms, dining rooms, hallways, kitchen floors and furniture were free from debris, food and mice droppings (cross reference F 925 pest control); -Ensure resident furniture and hand rails in common areas were in good repair; and, -Ensure the resident's courtyard was free of hundreds of cigarettes extinguished and disposed of on the ground. Findings include: I. Facility policy and procedures The Common Area Cleaning policy, undated, was received from the nursing home administrator (NHA) via email on 1/25/24 at 12:02 p.m. It read in pertinent part, The lobby and hallways. Damp wipe and disinfect the furniture by damp-wiping the top, inside the drawers, the pulls, the sides, the front and back, and the legs. Clean wall splash marks. Clean walls with your cloth dampened in disinfectant cleaner. Clean only the wall areas that need to be cleaned. If the wall needs thorough cleaning, clean the whole wall. Spot clean walls. Remove spots on the wall with your cloth dipped and wrung in your disinfectant-detergent solution as you move around the room. For a stubborn spot, wet your cloth with the disinfectant-detergent solution and then rub the spot with the saturated part of your cloth. Before you dust mop, check the floor for obstructions like gum stuck to the floor. Use your scraper to remove the gum before you begin dust mopping. Wet mop floor. Remember, it is important that the entire floor surface be mopped, including corners and behind fixtures, being careful not to splash or rub against the baseboards. II. Observations Conference room On 1/25/24 at 10:30 a.m., the conference room was observed. The conference room had a chair with two large pizza boxes. The boxes contained half eaten dried out pizza. The pizza was left over from a staff meeting the previous day, almost 24 hours prior (see below). Front lobby On 1/25/24 at 10:32 a.m., six black, vinyl chairs faced the front door entrance to the building. Five of the six chairs were missing pieces of upholstery on the arm rests. The missing upholstery pieces were several inches in diameter. Under the missing sections of upholstery was a white fabric which had become brown in many of the areas. Residents were observed sitting in the chairs with their arms on the torn upholstery. The floors of the lobby were dirty in the corners with visible grime, crumbs and layers of debris. On 1/25/24 at 10:33 a.m., a door leading to a courtyard was observed off the lobby. The door had a large gap at the left side and toward the bottom with sunlight coming through. Red Rocks dining room On 1/25/23 at 10:40 a.m., the Red Rocks unit dining room was observed. The dining room had caked orange, brown and white food splatters and chunks on the walls. Along the floors, under the heat register and in the corners of the dining room, the floors were blackened or brown with layers of debris including numerous crumbs, cheese, crackers, a ground meat substance which had dried, hair and mouse droppings. In a cabinet with the table cloths, on the bottom shelf, were crumbs, hair and mouse droppings. In the white activity closet in the dining room there were mouse droppings and dried fluids trailing back behind the supplies. Food and debris were observed under the ice machine. Kitchen On 1/25/23 at 10:46 a.m., the kitchen was observed. The kitchen floor, around the trash cans and hallway, had pieces of dried meat, hair and other dried unrecognizable food debris. Mice droppings were observed within the debris. The top of the dishwasher was covered in crumbs, dust, and mouse droppings. Red Rocks unit hallways On 1/25/24 at 11:02 a.m. the Red Rocks unit hallways were observed. The handrails were painted white and the paint was peeling on the handrails throughout the unit.The handrails were taped together with large strips of silver tape which was peeling at the corner of the two hallways. An isolation cart on the hallway was missing a wheel and leaning. The cart had a brown discolored dried substance along the entire right side and bottom of the cart. The brown substance had dust and debris dried in it. Resident room [ROOM NUMBER], at the end of the hallway on the right, had crumbs, hair, and mouse droppings in the room on the floor to the right of the entry. The edges and corners of the hallway floors were darkened and caked with layers of debris, food, crumbs, dust, hair and mouse droppings. Columbine unit dining room and hallways On 1/25/24 at 11:15 a.m., the dining room and hallways on the Columbine unit were observed. The edges and corners of the dining room and hallway floors were darkened and caked with layers of debris, food, crumbs and chunks, dust, hair and mouse droppings. Courtyard On 1/25/24 at 11:28 a.m., the courtyard off the front lobby of Red Rocks unit had grass with a sidewalk through the grass and sitting areas. The grass had hundreds of cigarette butts littering the ground. Some cigarette butts were new and sitting on top of the grass, and some were faded and shredded and embedded in the grass. The cigarette butts ran along the sidewalk edge in the grass and some were out further in the center of the grass.The concrete sitting areas and sidewalks contained approximately 100 cigarette butts. Some of the cigarette butts were new with black soot still sitting under them where they had been extinguished. Some of the cigarette butts were older and fading. III. Observation and interview with NHA On 1/25/24 at 11:50 a.m., the front lobby, Red Rocks unit dining room and hallways were observed with the NHA. The NHA looked at the torn furniture in the front lobby. She said she would like to replace it but did not have the money for it. She said she had no plan to replace the furniture. The Red Rocks unit dining room was observed. The NHA looked at the floors, mouse droppings on the floors and in the cabinets. She said the housekeeping staff should clean the dining room and wipe food off the walls. She said there was no schedule or plan for cleaning the common areas and halls. The NHA said the facility had been without a maintenance director for several weeks. She said the housekeeping staff reported to the maintenance director. The NHA said the housekeeping staff did not speak any English and therefore she thought maybe there was a communication issue about cleaning the common areas. The NHA did not comment on the dirty floors in the halls, or chipped and taped handrails. The NHA said the regional maintenance person had been trying to come to the facility weekly since the facility maintenance director left. The NHA said she had seen the cigarette butts in the courtyard and she had picked some up when she had time but she said she could not do it everyday. The NHA said she had reports of mice from the night shift who heard them in the ceiling and had the pest control company come out. The NHA said the pizza in the conference room was from a staff meeting the previous day at 1:00 p.m. IV. Additional interviews Resident #1 was interviewed on 1/25/25 at 11:31 a.m. He lived in room [ROOM NUMBER]. He said he had seen at least one mouse in his room. The director of nursing (DON) was interviewed on 1/25/24 at 12:39 p.m. She said she did not know who was responsible for ensuring the isolation carts were cleaned and in good working order. She said she did have additional isolation carts but did not feel the isolation cart on the Red Rocks unit with the missing wheel and dried brown substance and debris (see above) needed to be changed because it was already stocked with supplies. The regional maintenance director (RMD) was interviewed via telephone on 1/25/24 at 12:44 p.m. He said he was out of the state this week and would not be able to come to the facility. He said he tried to come to the facility weekly since the facility lost their maintenance director several weeks ago. He said he thought the cleaning issues in the facility were due to a lack of supervision. The RDM said he would create a common area cleaning schedule for the facility. He said he was aware of the rodent issue in the facility and an outside pest company had come monthly.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interviews, the facility failed to provide an effective pest control program to ensure the facility was free of pests. Specifically, the facility failed to: -Take the appropriate measures to control a mice problem in the facility including failing to eliminate or minimize food sources; and, -Attempt to eliminate the mice from entering the facility through door gaps and holes. Findings include: I. Professional reference According to the Center for Disease Control (CDC) revised July 2019 Guidelines for Environmental Infection Control in Health-Care Facilities, retrieved from:https://www.cdc.gov/infectioncontrol/guidelines/environmental/index.html Mice are among the typical pest populations found in health-care facilities. Insects and rodents can serve as agents for the mechanical transmission of microorganisms, or as active participants in the disease transmission process by passing pathogens from one source to another. Insects and rodents should be kept out of all areas of a health-care facility. From a public health and hygiene perspective, pests should be eradicated from all indoor environments. Approaches to institutional pest management should focus on: -Eliminating food sources, indoor habitats, and other conditions that attract pests; -Excluding pests from entering the indoor environments; and -Applying pesticides as needed. Rodents can transmit viruses such as Lymphocytic choriomeningitis, bacteria such as Campylobacteriosis, Leptospirosis, Plague, Salmonellosis, Tularemia, Yersiniosis, and fungi such as Dermatophytosis. II. Facility policy and procedure The facility's policy on pest control was requested from the nursing home administrator (NHA) on 1/25/23 at 12:00 p.m. -The policy was not provided by the end of the survey. II. Observations and interviews Conference room On 1/25/24 at 10:30 a.m., the conference room was observed. The conference room had a chair with two large pizza boxes. The boxes had half eaten, dried pizza. The pizza was left over from a staff meeting the previous day, almost 24 hours prior (see NHA interview below). Front Lobby On 1/25/24 at 10:32 a.m., the floors of the front lobby were dirty in the corners with grime, food crumbs and layers of debris. On 1/25/24 at 10:33 a.m., a door leading to a courtyard was observed off the lobby of the Red Rocks unit. The door had a large gap on the left side and toward the bottom. Sunlight was visible through the large gap. Red Rocks unit dining room On 1/25/23 at 10:40 a.m., the Red Rocks unit dining room was observed. The dining room had caked food which was orange and brown on the walls. Along the floors, under the heat register and in the corners of the dining room, the floors were blackened or brown with layers of debris including numerous crumbs, cheese, crackers, a ground meat substance which had dried, hair and mouse droppings. In a cabinet with the table cloths, on the bottom shelf, were crumbs, hair and mouse droppings. In the white activity closet in the dining room, there were mouse droppings and dried fluids trailing back behind the supplies. Food and debris were observed under the ice machine. Kitchen on Red Rocks unit On 1/25/23 at 10:46 a.m., the kitchen was observed. The kitchen floor around the trash cans and hallway had pieces of dried meat, hair and other dried unrecognizable food crumbs. Mouse droppings were observed within the debris. The top of the dishwasher was covered in crumbs, dust, and mouse droppings. Dietary aide (DA) #1 was interviewed on 1/25/24 at 10:48 a.m. DA #1 said he had seen packages torn open in the kitchen but he had not seen the mice himself. Red Rocks unit hallways On 1/25/24 at 11:02 a.m., the hallways were observed. The edges and corners of the hallway floors were darkened and caked with layers of debris, food, crumbs, dust, hair and mouse droppings. Certified nurse aide (CNA) #1 was interviewed on 1/25/23 at 12:26 p.m. CNA #1 said mice would run across the dining room under the ice machine, past the door that went outside and to the far wall under the heat registers. She said she had also seen mice entering through the gap in the door leading to the courtyard. CNA #1 pointed to the hole in the door to the courtyard with the sunlight coming through the gap. She said she had also seen mice run across the hall between resident rooms #10 and #11 at the end of the hall Resident room [ROOM NUMBER], at the end of the hallway on the right side, had crumbs, hair, and mouse droppings in the room on the floor to the right of the entry. Resident #1 was present in the room and said he had seen at least one mouse in his room. Columbine unit dining room and hallways On 1/25/24 at 11:15 a.m., The dining room and hallways were observed. The edges and corners of the dining room and hallway floors were darkened and caked with layers of debris, food, crumbs and chunks, dust, hair and mouse droppings. Licensed practical nurse (LPN) #1 was interviewed on 1/25/24 at 11:16 a.m. LPN #1 said she had heard about the concerns with mice from the other staff. She said the night nurse told her the night shift staff could hear the mice running around in the ceiling at night. III. Observation and interview with the NHA On 1/25/24 at 11:50 a.m., the front lobby, Red Rocks unit dining room and hallways were observed with the NHA. The NHA looked at the mouse droppings on the floors and in the cabinets of the dining room. She said the housekeeping staff should clean the dining room and wipe food off the walls. She said there was no schedule or plan for cleaning the common areas and hallways. The NHA said the facility had been without a maintenance director for several weeks. She said the housekeeping staff reported to the maintenance director. The NHA said the housekeeping staff did not speak any English and therefore she thought maybe there was a communication issue about cleaning the common areas. The NHA said she had not looked at points of entry or considered the amount of food available on the floors in relation to the facility's issue with mice. The NHA looked at the gap in the doorway leading to the courtyard and said the facility had not considered these areas as potential entries for the mice (see below). -However, the pest control company advised the facility multiple times to replace and repair door sweeps and patch holes (see below). The NHA said the regional maintenance person had been trying to come to the facility weekly since the facility maintenance director left. The NHA said she had reports of mice from the night shift who heard them in the ceiling and had the pest control company come out. She said the pest control company did not come to the facility unless the facility called them. She said she did not recall when she called them but they had come to the facility on 1/17/24. The NHA said the pizza in the conference room was from a staff meeting the previous day at 1:00 p.m. The regional maintenance director (RMD) was interviewed via telephone on 1/25/24 at 12:44 p.m. He said he was out of the state this week and would not be able to come to the facility. He said he tried to come to the facility weekly since the facility lost their maintenance director over weeks ago. He said he thought the cleaning issues in the facility were due to a lack of supervision. He said he was aware of the rodent issue in the facility and an outside pest company had come monthly. The RDM said he had not investigated or inspected the facility for areas where the mice may be entering. He said he would have the pest company start coming out every two weeks. The RDM said he did not check any of the mouse traps due to the poison in them. He said that had to be done by a pest control company. IV. Record review A report from the outside pest control agency, dated 1/17/24, was received from the NHA on 1/25/24 at 11:24 a.m. The report documented the cafeteria, dining area, and front area of the facility needed to have the door sweeps replaced or repaired. The report documented the recommendations were previously made on 12/27/24. It further documented there was evidence of mice feeding at the exterior rat station. -However, the facility had not addressed the access points including door sweeps according to the NHA and RDM (see interviews above). V. Facility follow up On 1/25/24 at 5:25 p.m., after the survey, additional reports from the outside pest control company were received from the NHA. The additional reports revealed the following: -On 11/15/23 the pest control company documented there was evidence of mice feeding in the cafeteria and exterior rat stations. -On 11/18/23 the pest control company report documented the facility's exterior condition included branches and vegetation touching walls or roof allowing pests easy access. The report documented the facility condition with cracks around windows, doors, air conditioning lines and hose faucets which may permit entry and should be sealed. Items in the laundry room should be lifted off the floor. The 11/18/23 report documented the recommendations for these conditions was created on 9/29/23. The 11/18/23 report further documented, in the cafeteria area, cracks in the floor could allow water and debris to accumulate. The manager was notified of the recommendation to repair the area. The report further documented holes in the walls of the cafeteria would provide access for rodents and other pests. The facility manager was notified to seal the cracks and holes in the wall.The report documented to address these contributing conditions to the exterior, cafeteria and laundry room. -On 12/27/23 the pest control company documented there was evidence of mice in the cafeteria and exterior. Door sweeps were again mentioned in the report as needing repair or replacement. The report documented the facility management was made aware. The pest control report further documented on 12/27/23 there was evidence of mice feeding in the cafeteria and a dead mouse in a trap in the cafeteria. The exterior traps had evidence of mice eating. Door sweep repair or replacement was recommended again for the interior of the facility and cafeteria. -The 1/17/24 pest control report again documented the need for door sweep repair or replacement (see above). -On 1/25/24, after the survey, a new pest control company report documented again that door sweeps in the cafeteria, dining area and front area needed to be repaired or replaced to prevent pest entry. The recommendation was documented as made on 12/27/23 to the facility manager. It further documented wall damage and holes should also be repaired to prevent entry. The report documented several rooms were checked for mice and no activity was seen. The technician documented he did not think the facility was infested but documented concerns with holes in walls and around pipes. Additionally, the report documented doors to the outside had door sweep issues. -The facility had a pest control company place traps and poison for mice but failed to eliminate food sources and ports of entry to maintain a pest free environment as recommended by the pest control company.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to ensure residents had a right to participate in the development and implementation of their person-centered plan of care for two (#9 and #23) of two out of 27 sample residents. Specifically, the facility failed to invite and conduct regular care conferences to review the resident's plan of care with Resident #9 and Resident #23. Findings include: I. Resident #9 A. Resident status Resident #9, age [AGE], was admitted on [DATE] and readmitted on [DATE]. According to the July 2023 computerized physician orders (CPO) the diagnoses included type two diabetes mellitus, anxiety and schizoaffective disorder. The 6/19/23 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) with a score of 15 out of 15. She required supervision of two people for bed mobility and locomotion on the unit. She required supervision of one person for transfers and walking in her room. She required supervision with set-up assistance for walking in the corridor, locomotion off the unit, dressing, eating and toileting. She required limited assistance of two people for personal hygiene. B. Resident interview Resident #9 was interviewed on 7/10/23 at 11:22 a.m. She said the facility did not schedule care conferences on a regular basis to review her plan of care. Resident #9 said she was not sure the last time she had a care conference. C. Record review -A review of the resident's medical record on 7/11/22 at 12:00 p.m. revealed no documentation in the progress notes that a care conference has occurred with the resident since his admission to the facility on 1/24/23. The 7/11/23 social services progress note documented a care conference was completed today with Resident #9 and staff (during the survey process). II. Resident #23 A. Resident status Resident #23, age [AGE], was admitted on [DATE]. According to the July 2023 CPO the diagnoses included dementia, anxiety disorder and post-traumatic stress disorder (PTSD). The 4/5/23 MDS assessment revealed the resident had moderate cognitive impairment with a BIMS with a score of nine out of 15. He required supervision of one person for bed mobility, transfers, walking in his room and in the corridor and locomotion on the unit. He required limited assistance of one person for dressing and eating. He required extensive assistance of one person for toileting and personal hygiene. B. Resident interview Resident #23 was interviewed on 7/10/23 at 12:20 p.m. Resident #23 said the facility used to hold care conferences, but he had not had one in a long time to discuss his care goals. C. Record review -A review of the resident's medical record on 7/11/23 at 12:30 p.m. did not reveal documentation any additional care conferences had been conducted or the resident and/or responsible party had been invited since the resident's care conference on 2/28/23. The 7/12/23 social services progress note documented a care conference was scheduled with Resident #23's guardian for 7/26/23 at 11:30 a.m. (scheduled during the survey process). III. Staff interviews The social services director (SSD) was interviewed on 7/11/23 at 2:07 p.m. She said care conferences followed the MDS schedule and were held monthly. The SSD said residents and resident representatives were invited to the care conferences. The SSD was interviewed again on 7/13/23 at 10:04 a.m. The SSD said Resident #9 was wanting to move to Maine to be closer to her son. The SSD said Resident #9 signed the admission paperwork to a secured unit herself. The SSD was interviewed again on 7/13/23 at 10:04 a.m. She said she took over scheduling care conferences at the end of 2022. The SSD acknowledged that Resident #9 and Resident #11 had not had a care conference in approximately six months. The SSD said care conferences should be held every three months. Nursing home administrator (NHA) #1 said Resident #9 was planning her own discharge to Maine and did not want any assistance. NHA #1 acknowledged that Resident #9 and Resident #23 had not received quarterly care conferences.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, observations, and record review, the facility failed to take steps to protect three (#27, #47 and #40) of seven residents reviewed for abuse out of 27 sample residents. Specifically, the facility failed to ensure: -Resident #47 was free from physical abuse from Resident #40; -Resident #40 was free from physical abuse from Resident #47; and, -Resident #27 was free from physical abuse from Resident #12. Findings include: I. Incident of physical abuse between Resident #47 and Resident #40 The 6/23/23 abuse investigation documented it was reported to the DON and the NHA that alleged abuse had occurred on the back unit. Resident #47's state appointed guardian said that the alleged assailant (Resident #40) pinched Resident #47. This led Resident #47 to punch Resident #40 and then Resident #40 pulled Resident #47's hair. A facility housekeeper was present at the time and said Resident #47 got angry and took a fast swing towards Resident #40, which lead Resident #40 to pull Resident #40's hair. Both residents were placed on 15 minute checks until a room move was arranged. The NHA spoke with floor staff and found an appropriate room to move Resident #47 to. -However, documentation of the 15 minute safety checks was requested on 7/13/23 and the NHA #1 said she was unable to locate the documentation. Resident #47's guardian reported Resident #40 was standing in the doorway as Resident #47 and herself were entering the room. Resident #40 pinched Resident #47, which led Resident #47 to punch Resident #40, then Resident #47 pulled Resident #40's hair. The housekeeper that witnessed the altercation was interviewed and said Resident #47 grabbed Resident #47's arm. The housekeeper said Resident #40 looked upset and took a fast swing and hit Resident #47 in the face. Resident #47 reacted by pulling Resident #40's hair. After the investigation was conducted, the facility determined the altercation was substantiated due to being witnessed by a visitor and housekeeping staff, however due to diagnoses of dementia for both residents abuse was unsubstantiated. -However, physical abuse occurred because Resident #40 pinched and pulled Resident #47's hair and Resident #47 punched Resident #40. II. Resident #47 A. Resident status Resident #47, age [AGE], was admitted on [DATE]. According to the July 2023 computerized physician orders (CPO) the diagnoses included major depressive disorder and vascular dementia with behavioral disturbance. The 5/9/23 minimum data set (MDS) assessment revealed the resident had short-term and long-term memory impairment. The resident was severely impaired making decisions regarding tasks of daily life. She required supervision of one person for bed mobility, transfers, walking in her room and in the corridor and for locomotion on and off the unit.She required extensive assistance of one person for dressing, toileting and personal hygiene. She required limited assistance of one person for eating. It indicated the resident did not have any behaviors. B. Record review The behavior care plan, initiated on 8/10/22 and revised on 5/24/23, revealed Resident #47 had potential behavior problems. Resident #47 had a history of being physically aggressive related to her diagnosis of dementia. Resident #47 had a history of sexual behaviors towards other females and males. Resident #47 responded to redirection from Spanish speaking staff. The interventions included: analyzing the times of day, places, circumstances, triggers, and what de-escalated behavior and document, providing physical and verbal cues to alleviate anxiety, giving positive feedback, assisting verbalization of source of agitation, assisting to set goals for more pleasant behavior, encouraging seeking out of staff member when agitated, giving the resident as many choices as possible about care and activities, monitoring and documenting any signs or symptoms of resident posing danger to self and other and intervening before agitation escalates by guiding the resident away from the source of distress and engaging in calm conversation, III. Resident #40 A. Resident status Resident #40, age [AGE], was admitted on [DATE]. According to the July 2023 CPO the diagnoses included Alzheimer's disease, vascular dementia with behavioral disturbance and post-traumatic stress disorder (PTSD). The 7/11/23 MDS assessment revealed the resident had severe cognitive impairment with a brief interview for mental status (BIMS) with a score of seven out of 15. She required supervision of one person for bed mobility and locomotion off the unit. She required limited assistance of one person for transfers. She required supervision of two people for walking in her room and walking in the corridor. She required supervision with set-up assistance for locomotion on the unit and eating. She required extensive assistance of one person for dressing and personal hygiene. She was totally dependent on two staff for toileting. The MDS assessment documented the resident had physical and verbal behaviors directed towards others one to three days in the review period. She did not have physical or behavior symptoms not directed at others. B. Record review The cognitive impairment care plan, initiated on 7/20/21 revealed Resident #40 had impaired thought processes related to dementia. Resident #40 was often confused and forgetful. The interventions included: administering medications as ordered, asking yes or no questions in order to determine the resident's needs, communicating with the resident and family regarding the residents capabilities and needs, using the residents preferred name, identifying yourself during each interaction, reducing any interactions, cueing and reorienting the resident as needed, supervising the resident as needed, presenting one thought, idea, questions or command at a time, providing a program of activities that accommodates the resident's abilities and usingtask segmentation to support short term memory deficits. The behavior care plan, initiated on 8/23/21 and revised on 7/11/23 (during the survey process) revealed Resident #40 had behavior concerns related to her diagnosis of dementia with behaviors. Resident #40 had a history of being verbally aggressive towards others when they were in her room or around her baby dolls. Resident #40 had a history of refusing cares. Resident #40 preferred to wash her feet in the sink per her cultural preferences. Resident #40 had a history of refusing to eat unless her food was presented in plastic bags. Resident #40 had a history of becoming easily agitated over her own personal space in the common areas and could escalate to physical aggression. Resident #40 had a history of sitting and lying on the fall mat next to her bed per her choice. Resident #40 had a history of refusing housekeeping services. The interventions included: administering medications as ordered, allowing the resident to make decisions about treatment to provide her sense of control, anticipating and meeting the residents needs, providing the opportunity for positive interactions, encouraging participation by the resident during cares, explaining all procedures to the resident before starting, intervening as necessary to protect the rights and safety of others, providing a program of activities that were of interest and accommodated the resident's status, offering music to the resident, providing redirection during times of agitation and offering the same spot in the dining room for all meals. IV. Staff interviews Licensed practical nurse (LPN) #1 was interviewed on 7/12/23 at 3:40 p.m. LPN #1 said Resident #47 often wandered around the unit and took other residents' personal belongings. LPN #1 said Resident #40 did not like other residents near or touching her belongings. LPN #1 said she knew Resident #47 and Resident #40 had an altercation and she attempted to keep the two residents separated. The SSD was interviewed on 713/23 at 10:04 a.m. The SSD said she was not a witness to the resident to resident altercation on 6/23/23. The SSD said she helped move Resident #40 to a different room. The SSD said Resident #40 and Resident #47 both had a history of physical aggression towards others, but had not had physical aggression directed at each other previously. The activities director (AD) was interviewed on 7/13/23 at 11:43 a.m. The AD said she spent a lot of time with Resident #47. The AD said she was not aware that Resident #40 and Resident #47 had a resident to resident altercation. The clinical resource nurse (RCR) and NHA #1 were interviewed on 7/13/23 at 12:46 p.m. NHA #1 said Resident #47 grabbed Resident #40's arm. NHA #1 said Resident #40 then punched Resident #47 and Resident #47 pulled Resident #40's hair. NHA #1 said a housekeeper and Resident #47's guardian witnessed the altercation. NHA #1 said Resident #40 and Resident #47 were placed on 15 minute safety checks. NHA #1 said they were unable to find documentation that the 15 minute safety checks had been completed. NHA #1 said she would begin educating all staff on documenting 15 minute checks when they were implemented. The RCR said skin assessments were completed. The RCR said Resident #40 and Resident #47 did not sustain injuries from the altercations. NHA #1 said the facility substantiated that the altercation occurred. NHA #1 said the facility was unable to prove willfulness due to the residents' diagnoses of dementia, therefore abuse was unsubstantiated. VI. Incident of physical abuse between Resident #27 and #12 A. Incident report The facility incident report dated 7/10/23 at 8:26 p.m., identified Resident #27 was walking by Resident #12. Resident #12 thought that Resident #27 was going to step on his foot. Resident #12 stood up and pushed Resident #27 down. Resident #27 received a hematoma to his right forehead and had a small amount of blood from his nose. Resident #27 did not lose consciousness and picked himself up from the floor. Resident #27 was not able to describe the incident. The resident was not in any pain and did not realize what had happened. The resident was confused, had impaired memory and dementia. The facility received physician orders to send him to the hospital emergency department for evaluation with a computerized tomography (CT) scan. The families of both residents were notified. The investigation reported to the state reporting portal revealed the incident occurred on 7/10/23 at 9:00 p.m. The incident was witnessed by two staff members. Resident #27 was anxiously walking down the front hallways of the unit at 9:00 p.m. He was pacing to each door down the hallways. Resident #12 sat in a chair in the common area by the front nurse's station, when Resident #27 accidently stepped on Resident #12's toes. Resident #12 cried out that this hurt, stood up and pushed Resident #27. This caused Resident #27 to fall to the floor. Resident #27 stood up and started to interact with staff. The charge registered nurse (RN) observed a cut to Resident #27's upper right forehead, just above the eyebrow and edema to the right eye. The resident's vital signs were taken and within normal limits. The resident appeared to be at his baseline (normal) status. Resident #27 was moved away from Resident #12 by the floor staff and emergency services. The floor staff de-escalated Resident #12 by talking to him. Resident #12 sat back down in a chair and no aggressive behaviors were observed. There were no other residents in the common area at this time, due to lateness of the hour. Resident #27 was taken to the hospital by the paramedics. Resident #12 was interviewed immediately after the event and was unable to recall any events. He asked if he could help Resident #27 get up from the floor. He did not verbalize any injuries, pain and he felt safe. Resident #12 was placed on 15-minute checks and per his preference, he remained in his room. The resident was offered activities, snacks and beverages on a regular basis. The police were notified and a case number was assigned. The conclusion of the investigation revealed, this event was substantiated and injuries were observed. When it occurred to the willful actions of Resident #12, there needed to be an understanding of the resident's current significant change in his medical condition. In June 2023 the resident had a newly developed squamous cell carcinoma protruding from his left cheek. The staff observed that the resident had become increasingly guarded in his behaviors to his immediate surroundings. The resident has been admitted to hospice services due to his rapid decline. The facility's medical director (MD) felt that this event was more of a medical issue rather than an outward behavior issue. B. Resident interviews by staff The charge registered nurse (RN) interviewed Resident #12 on 7/10/23 at 9:45 p.m. The resident was unable to recall what had happened and asked if he could help Resident #27 from off the floor. He said he had no pain or injuries. He said he felt safe in the facility. NHA #1 interviewed Resident #27 on 7/11/23 at 7:00 a.m. The resident was unable to tell the NHA what had happened. He said he was not injured and he had a little bit of pain in his chest area. He said he always felt safe in the facility. C. Charge RN typed phone statement Typed charge RN statement to the NHA #1 dated 7/10/23 at 9:08 p.m., during a phone conversation, the RN said Resident #27 was walking back and forth due to being more anxious and he stepped on Resident #12's foot. Resident #12 yelled out that this hurt, stood up form a chair and shoved Resident #27. Resident #27 fell to the ground, his head and then got up from off the floor. Resident #27 had a cut on his right frontal area and his vital signs were within normal limits. This RN and a certified nurse aide (CNA) de-escalated Resident #12 and he sat back down in a chair. The residents were a good distance from each other at this time. An ambulance was notified immediately related to the hematoma to Resident #27's head. Resident #27 was neurologically intact. The DON, NHA, physician, police and emergency services were notified and a police case number was assigned to this event. D. Abuse Investigation Statements Abuse Investigation Statements (AIS) dated and signed on 7/10/23 at 10:30 p.m., by a RN, revealed she witnessed the event. The RN last provided cares to Resident #27 at 8:30 p.m. during medication administration. The RN overheard Resident #12 say ouch that hurt my foot to Resident #27, who had accidently stepped on Resident #12's foot. Resident #12 impulsively pushed Resident #27 which caused him to fall and hit his head. This resulted in a right forehead hematoma, ecchymosis, and periorbital edema to the right eye. She saw Resident #12 push Resident #27 which caused him to fall and hit his head. Resident #27's vital signs were taken and a neurological assessment was started. Emergency services was called to take Resident #27 to the hospital for evaluation. She wrote that both residents had advanced dementia with behaviors. Abuse Investigation Statement (AIS) dated and signed on 7/10/23 at 10:30 p.m., by a CNA, revealed she witnessed the event. The last time she provided care to Resident #27 was at 6:30 p.m., while taking vital signs. The CNA heard Resident #12 yelling at Resident #27 for stepping on his toes. Resident #12 proceeded to stand up from a chair and push Resident #27 to the ground. She witnessed Resident #27 fell and hit his head causing a hematoma on the right side followed by a light nose bleed. The residents were separated and vital signs were taken on Resident #27. VII. Resident #12 A. Resident status Resident #12, age [AGE], was admitted to the facility on [DATE] and readmitted on [DATE]. According to the July 2023 CPO, the diagnoses included dementia and unspecified severity with other behavioral disturbances, squamous cell carcinoma (cancer) of the face and exophthalmos (protrusion of the eye). The 5/15/23 MDS assessment revealed the resident had severe cognitive impairment with a BIMS score of six out of 15. The resident had disorganized thinking. The resident's thinking was disorganized or incoherent (rambling or irrelevant conversation, unclear or illogical flow of ideas, or unpredictable switching from subject to subject). This behavior was present and fluctuated (came and went, changed in severity). The resident had hallucinations (perceptual experiences in the absence of real external sensory stimuli). The resident had delusions (misconceptions or beliefs that are firmly held, contrary to reality). The resident had physical behavioral symptoms directed towards others (hitting, kicking, pushing, scratching, grabbing, abusing others sexually). This behavior occurred one to three days during the seven-day assessment. The resident had verbal behavioral symptoms directed towards others (threatening others, screaming at others, cursing at others). This behavior occurred one to three days during the seven-day assessment. The resident wandered. This behavior occurred one to three days during the seven-day assessment. The staff provided limited assistance for dressing, toileting, and personal hygiene. The staff provided supervision for bed mobility, transfers, and eating. The resident received antipsychotic medications on a routine basis, for seven consecutive days during the assessment period. B. Resident observation Resident #12 was observed seated on his bed on 7/13/23 at 1:20 p.m. He had a bed over table in front of him and his lunch was on the table. He wore white socks on both feet and his shoes were to the left of the bed, on the floor. He said the food was good and he was having a good day. The door to the room was partially open and he was the only person in the room. C. Record review Physician order dated 12/15/22 at 1:24 p.m., revealed that the resident was to reside at the facility (secure unit) due to a history of wandering and would not be able to find his way back. A least restrictive alternative would be unsuccessful in preventing wandering. The resident could have behaviors that might be disruptive to himself and others. He would benefit with a more structured environment. The resident had a diagnosis of dementia. Care plan for impaired thought processes related to dementia was initiated on 9/10/21 and revised on 7/11/23 (during the survey), revealed the resident was often confused and forgetful. The resident did not like others to walk in front of him or beside him. The resident thought that others might step on and/or roll over his toes. The pertinent interventions included to administered medications as physic ordered (9/10/21), keep the resident's routine consistent and try to provide consistent care givers as much as possible in order to decrease confusion (9/10/21) and encourage the resident to sit out of the way of wheelchairs (7/11/23). Care plan for concerns regarding dementia was initiated on 9/10/21 and revised on 5/21/23. The resident had a history of physical aggression toward others and staff were to redirect him to a [NAME] space was helpful at times. The resident had a history of delusions and hallucinations of being back in the Navy. Facility staff were to redirect him to a less stimulated location, which might be helpful. He had a history of unpredictable outbursts that were not triggered at times. The pertinent interventions dated 9/10/21 revealed to administer medications as physician ordered, allow the resident to make decisions about treatment regime to provide a sense of control, anticipate and meet the resident's needs, intervene as necessary to protect the rights and safety of others, approach and speak in a calm manner, remove the resident from a situation and take to an alternate location as needed. Nurse note dated 7/9/23 at 10:25 a.m., by the director of nursing (DON) revealed the on call for (manage care provider) was contacted by a facility nurse voicing a concern that the morning dose of Seroquel (antipsychotic medication) was not helping the resident with his new aggressive behaviors towards others. The resident had an appointment with (the managed care provider) on 6/27/23 regarding the cancer that was reoccurring on his left check that had become quite large. With the resident's dementia, it was hard to tell if he was in pain and creating new anxieties. The on call was not listening to the nurse and ordered more Seroquel that made him lethargic. A message was sent to another physician in relation to this concern. The resident's family was aware of the cancer and wanted the resident to be comfortable. The resident had new behaviors of being aggressive to residents in the halls with fists up and telling them to get to work or to not walk here. The resident was not redirectable, which was new for him. Incident note dated 7/10/23 at 10:57 p.m., by the DON revealed this resident was seated in the hallway, when another resident walked by. The resident's perception was that the other resident was going to step on his foot. Resident #12 pushed Resident #27 and Resident #27 fell on his forehead. Resident #12 did not recall what happened due to his dementia. The resident's family was notified, as well as his physician. Resident #12 had frequent outbursts and did have Ativan available. Resident #12 has a new cancer growth on the left side of his face. Resident #12 was ambulatory, but has been more confused lately. Nurse note dated 7/10/23 at 11:12 p.m., by the DON revealed that 15 minute checks were in progress for Resident #12 and both of the residents were separated in different halls. Resident #12's was started on 7/10/23 at 8:30 p.m., and continued during the survey. VIII. Resident #27 A. Resident status Resident #27, age [AGE], was admitted to the facility on [DATE]. According to the July 2023 CPO, the diagnoses included dementia and unspecified severity with other behavioral disturbances, depression, epilepsy and muscle weakness. The 6/16/23 MDS assessment revealed the resident had both short and long term memory problems. The resident was severely impaired with cognitive skills for daily decision making. The resident had an acute onset mental status change as evidenced by an acute change in mental status from the resident's baseline. The resident had inattention with difficulty focusing his attention; for example, being easily distractible or having difficulty keeping track of what was said. This behavior was continuously present, and did not fluctuate. The resident had disorganized thinking or incoherent (rambling or irrelevant conversation, unclear or illogical flow of ideas, or unpredictable switching from subject to subject). This behavior was continuously present, and did not fluctuate. The resident required extensive staff assistance for bed mobility, transfers, dressing, toileting and personal hygiene. B. Record review Care Plan for impaired cognition function with dementia or impaired through process related to dementia was initiated on 2/15/23 and revised on 6/22/23. The interventions included to administer medications as physician ordered, monitor for mediation side effects/effectiveness, ask yes or no questions to determine resident needs, and cue/reorient/supervise as needed. Care plan for exhibiting behavior problems due to a history of wandering into others' rooms and responding with physical aggression when asked to leave related to a diagnosis of dementia was initiated on 2/15/23 and revised on 5/4/23. The resident was a security guard for his career and would check all doors daily to ensure all were safe and secure. Staff intervention, redirection or distraction might be helpful. Staff were to offer the resident a binder with papers to look through, activities, and items to sort; this might help. The pertinent interventions were to administer medications as physician ordered, monitor for mediation side effects/effectiveness, create an activity binder for him, because he liked to look at binders related to his old job, provide an afternoon sitter for the resident's high anxiety and wandering when other residents were out in the hallways, if the resident became agitated the staff were to intervene before he agitation escalated, guide the resident away for the source of distress, staff were to calmly engage the resident in conversation and if his response was aggressive; the staff were to walk away calmly and approach later, staff were to divert his attention, staff were to remove the resident from the situation and take him to an alternate location as needed and intervene as necessary to protect the rights/safety of others. eINTERACT situation background, assessment recommendation (SBAR) note dated 7/10/23 at 10:14 p.m., by the DON revealed the change of condition was due to a fall. Resident #27 walked by Resident #12 who thought the resident was going to step on his foot. Resident #12 stood up and pushed Resident #27 down. Resident #27 received a hematoma to his right forehead and a small amount of blood came from his nose. Resident #27 did not lose consciousness and picked himself off the floor. Physician orders were received to send Resident #27 to the emergency room for evaluation with a CT scan. Families of both residents were notified. Incident note by the DON dated 7/10/23 at 10:33 p.m., revealed Resident #27 was walking by Resident #12 and Resident #12 through Resident #27 was going to step on his foot. Resident #12 stood up and pushed Resident #27 down. Resident #27 received a hematoma to his right forehead and a small amount of blood came from his nose. Resident #27 did not lose consciousness and picked himself off the floor. Physician orders were received to send Resident #27 to the emergency room for evaluation with a CT scan. Families of both residents were notified. Fall risk assessment dated [DATE] at 10:33 p.m., revealed a score of score of 11 or high risk. Pain assessment dated [DATE] at 10:40 p.m., revealed no indicators of pain were observed. Head to toe skin assessment dated [DATE] at 10:41 p.m., revealed a right forehead hematoma. Nurse note dated 7/10/23 at 11:10 p.m., by the DON revealed Resident #27 returned from the emergency room by stretcher and the paramedics stated the CT scan was negative. The resident had a hematoma to the left (should be right) forehead and eye black. The resident was alert and his baseline dementia. The resident did not present with pain and was smiling. The hospital CT scan dated 7/10/23 revealed the reason for the scan was facial trauma with a right frontal scalp hematoma. There was no acute intracranial abnormality or fracture. The resident's right frontal encephalomalacia (softening of the brain's tissue) was stable. Nurse note dated 7/10/23 at 11:12 p.m., by the DON revealed neurological assessments were in place upon the resident's return to the facility. Physician order dated 7/10/23 at 2:13 a.m., may transfer to the emergency room for CT scan and evaluation. Social services note dated 7/11/23 at 3:54 p.m., by the social services director (SSD) revealed Resident #27 was interviewed today and did not recall the event. He said he felt safe and had no nonverbal signs/symptoms of fear at this time. Staff would continue to monitor. Nurse note by the DON dated 7/11/23 at 6:41 p.m., revealed the resident had a hematoma to right forehead and right eye black. There was no further swelling observed and the resident was ambulating well. Nurse note dated 7/12/23 at 4:47 a.m., by an RN revealed the resident was awake for the majority of the night. He was ambulating back and forth nonstop. He had a right forehead hematoma that remained unchanged. He had ecchymosis (discoloration of skin usually due to bleeding) to the right eye. The resident denied pain. The resident was cooperative and redirectable throughout the shift. IX. Staff interviews The DON and the assistant director of nursing (ADON) were interviewed on 7/12/23 at 3:07 p.m. The DON said Resident #12 had depth perception issues. She said when you passed him, he thought you were right on top of him and he became very anxious and started yelling. She said this was the reason the facility placed a plant in the corner of the hall (by the chairs) to try to get residents to go around him a little further distance, so he would perceive they were not going to step on him. The DON said she was in her office at the time of the altercation. She said Resident #12 was seated in a chair (third chair from the door) in the common area by the nurse's station. She was unable to see this area because she was in her office. She said she heard the yelling Ow, get away from me and heard Resident #27's head hit the floor. The DON said herself, the RN and CNA both heard him yelling out and quickly went to see what was going on. She said Resident #27 was on his right side on the floor and his right eye was starting to swell. Resident #12 was standing over Resident #27 and was not exhibiting any threatening behaviors. Resident #27 was trying to get up, and we kept him on the floor during the assessment. The CNA took Resident #12 back to his room. The RN called 911, Resident #27's physician and family. The decision was made to send the resident to the hospital based on the swelling on his head. He was at his usual baseline and did not lose consciousness. Resident #27 got up from off the floor and was assessed by the paramedics. The resident was taken to the emergency room at the hospital for evaluation of a possible head injury related to the swelling on his head was getting bigger. The CT scan from the hospital was negative for fractures. The DON said Resident #12 had a lot of misperception and anticipated that people were going to step on his feet when they got too close, reacted accordingly, became very anxious about it and yelled out. She said the resident was pretty calm during the day and became more anxious in the evening. The DON said Resident #27's care plan intervention to an afternoon sitter was initiated at admission related to some behavioral issues and the adjustment of his medications. He did not have a sitter at this time and this should have been discontinued. She said Resident #27 was a lot calmer at this time. The SSD was interviewed on 7/13/23 at 10:36 a.m. She said Resident #12 had cancer on his face and did not like people in his space. She said his vision and depth perception were diminished. The resident saw objects closer than they were. She said when people walked near him, he feared that they were too close and would step on his toes or bump into him. She said he thought people were disrespecting him by being too close to him and he could be territorial. NHA #1, CRN and regional director of rehabilitation (RDR) were interviewed on 7/17/23 at 9:30 a.m. They said Resident #27 received a right frontal scalp hematoma for the altercation with Resident #12. NHA #1 said Resident #27 and Resident #12 have not expressed or demonstrated any fears regarding any residents or staff. NHA #1 said Resident #27 was unable to recall the event. NHA #1 said Resident #12 did not know he had pushed a resident down and did offer to help pick Resident #27 from off the floor. NHA #1 reviewed Resident #27's care plan intervention that was initiated on 4/4/23, which revealed that an afternoon sitter was to be provided for the resident's high anxiety and wandering at times when other residents are out and about. NHA #1 said afternoon was interpreted as 2:00 p.m., to 6:00 p.m. NHA #1 said the incident occurred around 8:00 p.m. NHA #1 said this intervention needed to be discontinued. NHA #1 said to her knowledge, there had not been any other incidents between these two residents. NHA #1 and the CRN were interviewed on 7/13/23 at 2:36 p.m. NHA #1 said this was a witnessed event on 7/10/23 at approximately 8:00 p.m., by the charge RN on the night shift and a CNA. Resident #27 was pacing and was anxious that night and was making his rounds down the hallways. He was a night security guard as part of his work history. Resident #12 was seated in a chair in the front common area by the nu[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interviews, the facility failed to ensure residents were as free from unnecessary psychotropic drugs as possible for one (#14) of five residents reviewed out of 27 sample residents. Specifically, the facility failed to: -Consistently track behaviors to justify the use of an antipsychotic medication for a resident with dementia for Resident #14; and, -Attempt an annual gradual dose reduction (GDR) of an antipsychotic medication for a resident with dementia, as is required unless it is clinically contraindicated, for Resident #14. Findings include: I. Facility policy and procedures The Psychotropic Medication Use policy, revised July 2022, was provided by the director of nursing (DON) on 7/13/23 at 3:30 p.m. It read in pertinent part, Residents will not receive medications that are not clinically indicated to treat a specific condition. A psychotropic medication is any medication that affects brain activity associated with mental processes and behavior. An antipsychotic medication is considered a psychotropic medication and is subject to prescribing, monitoring, and review requirements specific to psychotropic medications. Psychotropic medication management includes indications for use, dose, duration, adequate monitoring for efficacy and adverse consequences and prevention, identifying and responding to adverse consequences. Consideration of the use of any psychotropic medication is based on comprehensive review of the resident. This includes evaluation of the resident's signs and symptoms in order to identify underlying causes. Residents on psychotropic medications receive gradual dose reductions unless clinically contraindicated, in an effort to discontinue these medications. II. Resident #14 Resident #14, age younger than 65, was admitted on [DATE] and readmitted on [DATE]. According to the July 2023 computerized physician orders, diagnoses included alcohol-induced dementia and dementia with behavioral disturbance. The 6/20/23 minimum data set (MDS) assessment revealed that the brief interview for mental status (BIMS) was not assessed because the resident was rarely understood. The staff assessment for mental status revealed the resident had a problem with short and long term memory and his cognitive skills for daily decision making were severely impaired. He required supervision with bed mobility. He required one-person extensive assistance for transfers. He was totally dependent on one staff member for dressing, toilet use and personal hygiene. Resident #14 did not exhibit any potential indicators of psychosis such as delusions or hallucinations. He did not exhibit any physical or verbal behaviors, rejection of cares during the seven day MDS assessment look-back period. He exhibited wandering behaviors daily during the seven day MDS assessment look-back period. He received an antipsychotic medication daily. III. Observations On 7/10/23 at 11:48 a.m., Resident #14 was sitting in the dining room at a table. There was a female resident sitting at the table next to him. He had a bag of chips in his hand. He was busy crushing some chips in his hand. He appeared to be content and was not exhibiting any aggression or behaviors other than crushing the potato chips. On 7/11/23 at 12:07 p.m., Resident #14 was wandering in the halls of the secure unit. He was not exhibiting any behaviors or aggression toward other residents or staff members. On 7/12/23 at 2:23 p.m., Resident #14 was again wandering in the halls of the secure unit. He was calm and was not exhibiting any behaviors or aggression toward other residents or staff members. C. Record review Review of Resident #14's July 2023 CPO revealed a physician's order for Risperdal (an antipsychotic medication) tablet 1 milligram (mg). Give 1.5 tablets by mouth one time a day for alcohol related dementia with behaviors. The order had a start date of 4/18/22. Review of Resident #14's history of physician orders for Risperdal revealed the resident was initially started on Risperdal 1 mg on 12/3/19. The medication was increased to 1.5 mg on 3/10/21. The facility attempted a gradual dose reduction (GDR) of the medication by reducing the medication to 1.5 mg on Monday, Tuesday, Wednesday, Thursday, Friday and Saturday and 1 mg on Sundays on 2/3/22. The facility documented the GDR failed and the resident was restarted on 1.5 mg of the medication daily on 4/18/22. -There had been no other GDRs for the medication, as is required annually unless it is clinically contraindicated, since 4/18/22. Review of Resident #14's antipsychotic medication use care plan, initiated 2/23/21 and revised on 11/4/22, revealed the resident received antipsychotic medications for alcohol related dementia with behavioral disturbance. Pertinent interventions included consulting with pharmacy and physician to consider dosage reduction when clinically appropriate at least quarterly, monitoring for behavior associated with antipsychotic medication due to dementia with behaviors such as unprovoked physical aggression, verbal aggression toward others and repetitive speech and using non-pharmacological interventions such as redirection, repositioning, offering snacks, offering fluids, adjusting room temperatures and distraction/offering activities. Resident #14's medication administration records (MAR) were reviewed for 1/1/23 through 7/12/23. The MARs revealed the following: -January 2023: There were no behaviors documented for the entire month; -February 2023: There were no behaviors documented for the entire month; -March 2023: There were no behaviors documented for the entire month; -April 2023: There were no behaviors documented for the entire month; -May 2023: There were no behaviors documented for the entire month; -June 2023: There were no behaviors documented for the entire month; and, -July 2023: There were no behaviors documented for the entire month. -The facility did not attempt a GDR despite the MARs documenting the resident did not have any behaviors documented from 1/1/23 through 7/12/23. -Review of the certified nurse aide (CNA) behavior documentation from 6/14/23 through 7/13/23 revealed there was no behavior documentation completed by the CNAs for Resident #14. Review of Resident #14's electronic medical record (EMR) revealed a behavior note dated 3/21/23. The progress note read in pertinent part, Resident was observed urinating in the hallway next to the nurses station. Staff was able to redirect and get the resident to his room and changed. -There were no other progress notes regarding behaviors documented from 1/1/23 through 7/12/23. The quarterly IDT Psychotropic Medication Review assessment dated [DATE] documented Resident #14 was on the antipsychotic medication Risperdal and had a failed GDR on 4/18/22. The behavior review documented in pertinent part, (Resident #14) has a history of interacting with hallucinations. Staff continues to monitor and follow up as needed. -The review did not document that the resident was continuing to experience hallucinations or exhibit aggressive behaviors. A Psychotropic Medication Review Risk versus Benefit form dated 3/9/23 documented the following in pertinent part as a rationale for not conducting a GDR of Resident #14's Risperdal, Improved quality of life and history of hallucinations. -The form was not signed by the physician. -There was not a clinically contraindicated rationale for why any attempted dose reduction at that time would be likely to impair the resident's function or exacerbate an underlying medical or psychiatric disorder. Review of Resident #14's EMR revealed the following provider visit notes documented by the nurse practitioner (NP) in pertinent part: 3/9/23 Resident is seen today for follow up. Resident has a diagnosis of dementia with behaviors. Discussed resident in psychotropic/pharmacy meeting and recommendations. No changes in current Risperdal dose because he has failed a previous GDR. Will continue to monitor. -The NP did not document a clinically contraindicated rationale for why any attempted dose reduction at that time would be likely to impair the resident's function or exacerbate an underlying medical or psychiatric disorder. 5/4/23: Resident is seen today for follow up. Resident has a diagnosis of dementia with behaviors. Stable mood and no behaviors reported on current medications. Continue current medications at current dose and schedule. Will continue to monitor. -The NP did not document a clinically contraindicated rationale for why any attempted dose reduction at that time would be likely to impair the resident's function or exacerbate an underlying medical or psychiatric disorder. 6/8/23: Resident is doing well and has a stable mood with no behaviors on his current medications. His quality of life is improved on his current dose of Risperdal and the benefits outweigh the risks with him taking the medication. -The NP did not document a clinically contraindicated rationale for why any attempted dose reduction at that time would be likely to impair the resident's function or exacerbate an underlying medical or psychiatric disorder. Review of Resident #14's EMR revealed a provider visit note dated 6/19/23 documented by the physician. It read in pertinent part: Resident is doing well and has a stable mood with no behaviors on his current medications. His quality of life is improved on his current dose of Risperdal and the benefits outweigh the risks with him taking the medication. -The physician did not document a clinical rationale for why any attempted dose reduction at that time would be likely to impair the resident's function or exacerbate an underlying medical or psychiatric disorder. C. Interviews Licensed practical nurse (LPN) #2 was interviewed on 7/11/23 at 1:25 p.m. LPN #2 said she had never seen Resident #14 exhibit any behaviors. She said he was not aggressive with other residents and did not become agitated when staff provided him with cares. LPN #2 said the resident was easily redirectable when he was near the exit doors and did not become aggressive. LPN #1 was interviewed on 7/12/23 at 11:13 a.m. LPN #1 said Resident #14 did not have any behaviors. She said he would wander in the hallways, however, she said she had never seen him become aggressive with staff or other residents. The DON and the assistant director of nursing (ADON) were interviewed together on 7/12/23 at 3:30 p.m. The ADON said Resident #14 did not exhibit any aggressive behaviors. She said she had not seen him have any hallucinations or delusions. She said the resident wandered but was easy to redirect if the need to redirect him arose. The DON said GDRs should be attempted for all psychotropic medications. She said if a resident exhibited behaviors, staff should be documenting those behaviors on the MAR and in the progress notes. She said if there were no behaviors documented for the resident there was no justification to keep him on the same dose of antipsychotic medication. She said a GDR should have been attempted again for Resident #14. The DON said she would discuss the need for a GDR for the resident's Risperdal with the physician and the interdisciplinary team (IDT) at the next psychotropic medication review meeting which was scheduled for 7/13/23. Certified nurse aide (CNA) #1 was interviewed on 7/13/23 at 1:42 p.m. CNA #1 said Resident #14 did not have behaviors. She said he would wander on the unit and constantly pace, however, she said she had never seen him display any aggression toward other residents. CNA #1 said the resident occasionally resisted cares, however, she said if he was left alone for a few minutes staff could come back and he would allow them to finish his cares. She said he was very redirectable and easy to take care of.

Based on observations and staff interviews the facility failed to ensure all drugs and biologicals were properly stored, secured, and labeled in accordance with accepted professional standards for one of two medication carts and one of one medication storage rooms. Specifically the facility failed to: -Remove expired medications from medication carts and medication storage rooms to prevent the use of expired medications; -Date insulins, eye drops and inhalers when opened; and, -Ensure the medication storage refrigerator temperature was within acceptable parameters. Findings include: I. Professional references The United States Food and Drug Administration (USFDA) (2/8/21) Don't Be Tempted to Use Expired Medicines, retrieved on 7/25/23 from https://www.fda.gov/drugs/special-features/dont-be-tempted-use-expired-medicines, read in pertinent part, Expired medical products can be less effective or risky due to a change in chemical composition or a decrease in strength. Certain expired medications are at risk of bacterial growth and sub-potent antibiotics can fail to treat infections, leading to more serious illnesses and antibiotic resistance. Once the expiration date has passed there is no guarantee that the medicine will be safe and effective. If your medicine has expired, do not use it. II. Facility policy and procedures The Storage of Medications policy, not dated, was provided by the director of nursing (DON) on 7/11/23 at 4:16 p.m. It read in pertinent part, The facility stores all drugs and biologicals in a safe, secure, and orderly manner. Drugs and biologicals used in the facility are stored in locked compartments under controlled temperature, light and humidity controls. Discontinued, outdated or or deteriorated drugs and biologicals are returned to the dispensary pharmacy or destroyed. Medications requiring refrigeration are stored in a refrigerator located in the drug room at the nurses station or another secured location. -The policy did not address labeling or dating of medications when opened. III. Observations, interviews and record review A. Back unit medication cart On 7/11/23 at 12:19 p.m., the back unit medication cart was observed with licensed practical nurse (LPN) #2 and the assistant director of nursing (ADON). The following items were found: A bottle of Simbrinza 1%-0.2% eye drops was open, however, the bottle was not labeled with the date it was opened. The ADON said the bottle should have been labeled at the time it was opened as there was not a way to know when it was opened and when it should be disposed of. The ADON removed the medication from the cart and said it would need to be disposed of and reordered for the resident. -According to the package insert instructions for Simbrinza 1%-0.2% eye drops, the medication should not be used for more than 125 days after opening the bottle. A bottle of Timolol Maleate ophthalmic solution 0.5% eye drops was open, however, the bottle was not labeled with the date it was opened. The ADON said the bottle should have been labeled at the time it was opened as there was not a way to know when it was opened and when it should be disposed of. The ADON removed the medication from the cart and said it would need to be disposed of and reordered for the resident. -According to the package insert instructions for Timolol Maleate ophthalmic solution 0.5% eye drops, the medication should be discarded four weeks after opening. A Lantus Solostar insulin pen 100 units/milliliter (ml) had been used by a resident, however the pen was not labeled with the date that the pen was first removed from the refrigerator. The ADON said the insulin pen would need to be disposed of because the insulin was only good for 28 days once the pen had been removed from the refrigerator. She said there was no way to tell when the insulin pen should be disposed of because the pen had not been labeled when it was removed from the refrigerator. The ADON removed the insulin pen from the medication cart and said she would dispose of it. -According to the package insert instructions for Lantus Solostar insulin pen 100 units/ml, the medication should be discarded 28 days after removing it from the refrigerator. A Serevent Diskus 50 mcg inhaler was open, however, the inhaler was not labeled with the date it was opened. The counter on the inhaler read there were nine doses remaining out of 60 doses. The ADON said the inhaler was good for six weeks after it was opened. She said there was no way to tell when the inhaler should be disposed of because it had not been labeled when it was removed from the package. The ADON removed the inhaler from the medication cart and said she would dispose of it. -According to the package insert instructions for Serevent Diskus 50 mcg inhaler, the medication should be discarded six weeks after removal from the moisture-protective foil overwrap pouch or after all the medication blisters have been used (when the dose indicator reads 0), whichever comes first. A tube of Lidocaine cream 5% was open and had been used, however the tube was not labeled with an individual resident's name. The ADON said the tube of cream should only be used for one resident. She said the cream should have been labeled with a specific resident's name to ensure staff did not use the same tube of cream for more than one resident. She removed the tube of cream from the cart and said she would dispose of it. A stock bottle of 1000 milligram (mg) fish oil capsules had an expiration date of March 2023. The ADON said the medication should have been removed from the cart when it expired. She removed the bottle of medication from the cart and said she would dispose of it. B. Medication storage room On 7/11/23 at 12:45 p.m., the medication storage room was observed with LPN #2 and the ADON. The following items were found: On initial observation of the medication storage refrigerator no thermometer was visible in the refrigerator. The ADON moved a plastic box which contained medications that were available for emergency use. The medications in the box required refrigeration. The label on the box documented the emergency medications should have been replaced by the pharmacy in May 2023 (see emergency medication box contents and ADON interview below). The ADON located the refrigerator thermometer behind the plastic box of emergency medications and removed it from the refrigerator. The thermometer had a light film of frost on it. The temperature on the thermometer read 22 degrees fahrenheit. LPN #2 and the ADON confirmed the temperature on the thermometer. The plastic box containing the emergency medications had a label which documented the medications should have been replaced by the pharmacy in May 2023. The box contained the following: -One Lantus Solostar 100 units/ml insulin pen; -One 3 ml 100 units/ml vial of Humulin 70/30 insulin; -One 3 ml 100 units/ml vial of Humulin N insulin; -One 3 ml 100 units/ml vial of Humulin R insulin; and, -Two 1 ml 2 mg/ml vials of Lorazepam. The ADON said nursing staff should have called the pharmacy in May 2023 to have the medications replaced. She said expired medications should not be used for residents. -According to the package insert instructions for Lantus Solostar insulin pen 100 units/ml, the medication could be kept at 36 degrees fahrenheit to 46 degrees fahrenheit until first use. The medication should not be allowed to freeze. -According to the package insert instructions for Humulin 70/30 insulin, the medication should not be frozen and should not be used after it had been frozen. -According to the package insert instructions for Humulin N insulin, the medication should not be frozen and should not be used after it had been frozen. -According to the package insert instructions for Humulin R insulin, the medication should not be frozen and should not be used after it had been frozen. -According to the package insert instructions for Lorazepam, the medication should be stored in a refrigerator (not a freezer). The ADON said the medication refrigerator temperature should be between 36 degrees fahrenheit and 46 degrees fahrenheit. She said there was no way to determine how long the refrigerator temperature was below the acceptable temperature ranges. She said the night shift nurses monitored the temperature of the medication refrigerator daily. She said the medications would need to be disposed of because the efficacy (ability to produce a desired or intended result) of the medications was potentially compromised due to the medications being stored below the acceptable temperature ranges. The ADON removed all of the medications from the refrigerator in order to dispose of them. The ADON provided the medication refrigerator logs for the months of May, June and July 2023. The medication refrigerator logs were documented daily, however, the temperature had been recorded each day as a consistent 39 degrees since 5/1/23. The ADON said the temperatures had not been monitored appropriately because the thermometer was found behind the plastic box of emergency medications which should have been replaced in May 2023. In addition to the above emergency medications, the refrigerator also contained the following unopened medications: -Two vials of Flucelvax quadrivalent influenza vaccine which expired 6/30/22; -Nine Lantus Solostar 100 units/ml insulin pens; -Two Humulin R 500 units/ml insulin kwikpens; -Three Trulicity 1.5 mg/0.5 ml insulin pens; -One 3 ml 100 units/ml vial of novolog insulin; -Five 3 ml 100 units/ml vials of Lantus insulin; and, -One bottle of Latanoprost ophthalmic solution .0005%. -According to the package insert instructions for Flucelvax quadrivalent influenza vaccine, the medication should be kept at 36 degrees fahrenheit to 46 degrees fahrenheit. The medication should be discarded if frozen. -According to the package insert instructions for Lantus Solostar insulin pen 100 units/ml, the medication could be kept at 36 degrees fahrenheit to 46 degrees fahrenheit until first use. The medication should not be allowed to freeze. -According to the package insert instructions for Humulin R 500 units/ml insulin kwikpens, the medication should not be frozen and should not be used after it had been frozen. -According to the package insert instructions for Trulicity 1.5 mg/0.5 ml insulin pens, the medication should be kept at 36 degrees fahrenheit to 46 degrees fahrenheit. The medication should not be frozen and should not be used after it had been frozen. -According to the package insert instructions for the Novolog insulin 3 ml 100 units/ml vial, the medication should be kept at 36 degrees fahrenheit to 46 degrees fahrenheit. The medication should not be frozen and should not be used after it had been frozen. -According to the package insert instructions for the Lantus insulin 3 ml 100 units/ml vial, the medication should not be frozen and should not be used after it had been frozen. -According to the package insert instructions for Latanoprost ophthalmic solution .0005%, the medication should be kept at 36 degrees fahrenheit to 46 degrees fahrenheit. IV. The director of nursing (DON) interview The DON was interviewed on 7/12/23 at 9:42 a.m. The DON said all medications, such as insulin, eye drops and inhalers which expired a certain amount of time after opening, should be labeled with the date the medication was opened. She said medications should not be used past the expiration date as the medication may not be as effective. She said expired medications should be removed from the medication cart or medication storage room and disposed of appropriately. The DON said multiple use items such as creams and ointments should be used by an individual resident only and should be labeled with the resident's name when opened. The DON said the medication storage refrigerator temperature was supposed to be checked daily and the temperature recorded accurately. She said medications that had been frozen should be discarded as the freezing temperature could have affected the efficacy of the medications. V. Facility follow-up On 7/12/23 at 11:25 a.m. the DON provided a copy of the medication refrigerator and expired medications performance improvement plan (PIP). The PIP was dated 7/12/23. The PIP read in pertinent part: Problem: Refrigerator temperatures not being done daily. Root Cause Analysis: Daily temperature log not being filled out correctly, staff not understanding the importance of this task. Interventions: Education needing to be done to nursing staff on daily temperature logs. The nurse managers need to verify the temperatures two times per week. Problem: Expired medications in refrigerator. Root Cause Analysis: Medications not being checked for expiration dates. Interventions: Medications in the refrigerator need to be checked weekly for expired medications, nurse managers to double check. -The PIP did not address the expired medications in the medication carts. Problem: Refrigerator not being defrosted. Root Cause Analysis: Nurses not knowing the policy for defrosting the medication refrigerator monthly. Interventions: Monthly cleaning/defrosting schedule.

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 and one out of two nourishment rooms. Specifically, the facility failed to: -Ensure one unit nourishment room was clean and sanitary; -Ensure the kitchen ceiling was free from debris and dust; -Ensure appropriate hand washing occurred in the main kitchen; and, -Ensure dishes were dried appropriately. Findings include: I. Ensure the unit nourishment room 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 read in pertinent part; -Time/temperature control for safety of food prepared and held in a food establishment for more than 24 hours shall be clearly marked to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded when held at a temperature of 41º (degrees) F (Farenheit) or less for a maximum of 7 days. The day of preparation shall be counted as Day 1. The day or date marked by the food establishment may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on food safety. Food shall be protected from contamination by storing the food, in a clean dry location, where it is not exposed to splash, dust or other contamination and at least 15 centimeters (6 inches) above the floor. (Retrieved 7/19/23). B. Facility policy and procedure The Food Receiving and Storage policy, revised November 2022, was provided by the regional director of rehabilitation (RDR) on 7/12/23 at 3:24 p.m. It revealed in pertinent part, Food in designated dry storage areas are kept at least six (6) inches off the floor (unless packaged for handling, for example, dollies, pallets, racks and skids) and clear of sprinkler heads, sewage/waste disposal pipes and vents. Foods and Snacks Kept on Nursing Units: All food items to be kept at or below 41°F (degrees fahrenheit) are place in the refrigerator located at the nurses' station and labeled with a 'use by' date; all food belonging to residents are labeled with the resident's name, the item and the 'use by' date; Refrigerators must have working thermometers and are monitored for temperature according to state-specific guidelines; beverages are dated when opened and discarded after twenty-four (24) hours; other opened containers are dated and sealed or covered during storage; partially eaten food is not kept in the refrigerator; and, medications, blood or blood products are not stored in the same refrigerator with food. C. Observations On 7/12/23 at 4:34 p.m. the following was observed in the back unit nourishment room: -In the refrigerator there was an opened matcha drink with no name or expiration date, an opened container of creamer that expired on 5/13/23, a container of pudding with no label or date, a half gallon of chocolate milk that expired on 7/11/23, two individual yogurts that expired on 6/14/23, one individual yogurt that expired on 6/12/23 and a bag of four rolls that did not have a use by label and the rolls were hard. -The refrigerator had smears of chocolate pudding and food debris at the bottom of the refrigerator. -In the freezer there was a frozen pizza that expired on 11/22/22, a frozen salisbury steak meal that expired on 6/28/23 and a container of lactose free ice cream with no open or use-by date. -The freezer had built-up ice and had built-up food brown food debris on the bottom shelf. -Next to the refrigerator were boxes of Boost (nutritional supplement) stored directly on the ground. On 7/13/23 at 11:05 a.m. the following was observed in the back unit nourishment room with the dietary supervisor (DS): -In the refrigerator there was an opened matcha drink with no name or expiration date. The DS said the drink might have been a nurse's drink and left it in the refrigerator. He said he was not sure how long the opened drink had been in the refrigerator. -A container of pudding with no label or date, a half gallon of chocolate milk that expired on 7/11/23, two individual yogurts that expired on 6/14/23, one individual yogurt that expired on 6/12/23. The DS said these items needed to be disposed of and threw them out. -A bag of four rolls that did not have a use by label and the rolls were hard. The DS said the rolls belonged to a resident and he was unsure of how long they had been in the refrigerator. The DS left the bag of rolls in the refrigerator. -In the freezer there was a frozen pizza that expired on 11/22/22, a frozen salisbury steak meal that expired on 6/28/23. The DS said these items likely belonged to residents and he said they needed to be disposed of and threw them away. -In the freezer there was a container of lactose free ice cream with no open or use-by date. The DS said the lactose free ice cream belonged to a resident and he was unsure of how long it had been in the freezer. -The DS said the refrigerator and the freezer had food debris built-up and were dirty. The DS said he would have a dietary staff member clean the refrigerator and freezer on 7/13/23. -The DS said there was Boost stored directly on the floor in the nourishment room and said food items needed to be stored off of the ground. D. Staff interviews The DS was interviewed on 7/13/23 at 11:05 a.m. He said the nourishment room refrigerator and freezer should be clean and free from debris. The DS said foods should be labeled and dated. The DS said foods should be thrown away if they were past the expiration date. The DS said he was not sure who was responsible for cleaning the nourishment refrigerators, but he would have a dietary staff member clean the refrigerator on 7/13/23. The DS said foods such as Boost should not be stored on the ground. The infection preventionist (IP) was interviewed on 7/13/23 at 11:34 a.m. She said all foods should be discarded on their expiration date. The IP said food should not be stored on the ground for pest control. II. Ensure the kitchen ceiling was free from debris and dust 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 7/18/23) B. Facility policy and procedure The Sanitization policy, revised November 2022, was provided by the director of nursing (DON) on 7/13/23 at 4:07 p.m. It revealed in pertinent part, All kitchens, kitchen areas and dining areas are kept clean, free from garbage and debris, and protected from rodents and insects. C. Observations During the initial kitchen tour on 7/10/23 at 9:34 a.m. the following was observed: -The ceiling above the preparation table, two compartment sink and oven had built-up gray dust. The dust was hanging from the ceiling and the two vents that were in the area. During a continuous observation on 7/12/23 beginning at 11:26 a.m. and ended at 1:35 p.m. the following was observed: -The ceiling above the preparation table, two compartment sink and oven had built-up gray dust. The dust was hanging from the ceiling and the two vents that were in the area. -DA #1 portioned cooked apple crisp under the dust and the DS prepared the mechanically altered foods under the dust. D. Staff interviews The registered dietitian (RD) was interviewed on 7/13/23 at 10:59 a.m. She acknowledged the ceiling was dirty and needed to be cleaned. The DS was interviewed on 7/13/23 at 11:05 a.m. The DS said the kitchen ceiling should be cleaned. The DS said he was unsure of who was responsible for cleaning the ceiling. He said he would speak with the maintenance director and get the ceiling cleaned. The IP was interviewed on 7/13/23 at 11:34 a.m. She acknowledged the dust on the ceiling could become a contaminant in foods. III. Ensure appropriate hand washing occurred in the main kitchen A. Professional reference The Colorado Department of Public Health and Environment (2019) The Colorado Retail Food Establishment Rules and Regulations, https://www.colorado.gov/pacific/sites/default/files/DEHS_RetailFd_6CCR10102_RFFC_EffJan2019.pdf. Food employees shall clean their hands and exposed portions of their arms immediately before engaging in food preparation including working with exposed food, clean equipment and utensils, and unwrapped singled service and single-use articles and: after touching bare human body parts other than clean hands and clean, exposed portions of arms; after using the toilet room; after caring for or handing service animals or aquatic animals, after coughing, sneezing, using a handkerchief or disposable tissue, using tobacco, eating or drinking; after handling soiled equipment or utensils; during food preparation, as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks; when switching between working with raw food and working with ready-to-eat food; before dining gloves to initiate a task that involves working with food; and, after engaging in other activities that contaminate the hands. Food employees shall clean their hands in a handwashing sink or approved automatic handwashing facility and may not clean their hands in a sink used for food preparation or warwashing or in a service sink or a curbed cleaning facility used for the disposal of mop water and similar liquid waste. (Retrieved 7/18/23). B. Facility policy and procedure The Handwashing/Hand Hygiene policy, dated August 2019, was provided by the RDR on 7/12/23 at 3:24 p.m. It revealed in pertinent part, The facility considers hand hygiene the primary means to prevent the spread of infections. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors. The Preventing Foodborne Illness - Employee Hygiene and Sanitary Practices policy, dated November 2022, was provided by the RDR on 7/12/23 at 3:24 p.m. It revealed in pertinent part, Food and nutrition services employees follow appropriate hygiene and sanitary procedures to prevent the spread of foodborne illness. Employees must wash their hands: after personal body functions; after using tobacco, eating or drinking; whenever entering or reentering the kitchen, before coming in contact with any food surfaces; after handling raw meat, poultry or fish and when switching between working with raw food and working with ready-to-eat food; after handling soiled equipment or utensils; during food preparation, as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks; and/or, after engaging in other activities that contaminate the hands. C. Observations During a continuous observation on 7/12/23 beginning at 11:26 a.m. and ended at 1:35 p.m. the following was observed: -At 12:06 p.m. dietary aide (DA) #1 loaded a rack of dirty dishes into the dish machine. DA #1 touched his phone, grabbed a towel and began drying clean dishes with the towel. -At 1:12 p.m. DA #1 was putting away clean dishes. DA #1 picked up dirty dishes, loaded them into a dish rack and sprayed the dishes off. He loaded the rack of dirty dishes into the dishwasher. He then used the dish sprayer to spray one hand then used the dish sprayer to spray the other hand. DA #1 went to the other side of the dish room where the clean dishes came out of the dishwasher and began putting away clean dishes. DA #1 put away two metal pans that were visibly wet. -DA #1 used his hands to adjust his hair net. DA #1 got his tablet and a speaker and went to the dishwasher. He opened the dish machine and pulled the clean dishes out. DA #1 went to the dirty side of the dishroom and began loading dirty dishes. He loaded the rack of dishes into the dishmachine and started it. DA #1 turned music on his speakers. DA #1 began putting away clean dishes without washing his hands. DA #1 used the same dish towel that had been in the dish room to dry off the food processor. DA #1 put the food processor away. DA #1 used the same towel to dry utensils and plates. He left the dish room and put away some clean utensils. -DA #1 went back into the dish room without washing his hands and put plates on a rack to dry. -DA #1 went back to the dirty side of the dish room and began loading dishes onto a rack and spraying them off. DA #1 opened the dishmachine and pulled clean dishes out. DA #1 loaded the dirty dishes into the dish machine. DA #1 used the dirty dish sprayer to spray off both of his hands. DA #1 began putting away clean dishes without washing his hands. DA #1 left the dish room and put clean dishes away. DA #1 entered the dining room and began picking up dirty dishes from the lunch meal. -DA #1 came back into the kitchen and without washing his hands he pulled out a rack of clean dishes from the dish machine. -DA #1 began rinsing and racking dirty dishes. DA #1 pushed a rack of dirty dishes into the dish machine. DA #1 touched his smart watch and then began putting away clean dishes without washing his hands. D. Staff interviews Nursing home administrator (NHA) #2 and the DS were interviewed on 7/12/23 at 1:52 p.m. The DS said there was not a hand washing sink in the dish room. The DS said staff needed to leave the dishroom and come to the main part of the kitchen to wash their hands appropriately. The DS said staff should wash their hands after handling dirty dishes and before handling clean dishes. The DS said staff should run three racks of dishes through the dish machine, then wash their hands, then begin putting away clean dishes. The infection preventionist (IP) was interviewed on 7/13/23 at 11:34 p.m. The IP said it was important to conduct proper hand hygiene after handling dirty dishes to prevent the spread of bacteria. IV. Ensure dishes were dried appropriately A. Professional reference The Colorado Department of Public Health and Environment (2019) The Colorado Retail Food Establishment Rules and Regulations, https://www.colorado.gov/pacific/sites/default/files/DEHS_RetailFd_6CCR10102_RFFC_EffJan2019.pdf. It read in pertinent part, Unless used immediately after sanitization, all equipment and utensils shall be air-dried. (Retrieved 7/19/23). B. Facility policy and procedure The Sanitization policy, revised November 2022, was provided by the DON on 7/13/23 at 4:07 p.m. It revealed in pertinent part, Drying food preparation equipment and utensils with a towel or cloth may increase risks for cross contamination. C. Observations During a continuous observation on 7/12/23 beginning at 11:26 a.m. and ended at 1:35 p.m. the following was observed: -At 11:59 p.m. DA #1 was using a towel to dry off the food processor pieces. -At 12:06 p.m. DA #1 loaded a rack of dirty dishes into the dish machine. DA #1 touched his phone, grabbed a towel and began drying clean dishes with the towel. -At 1:12 p.m. DA #1 put away two metal pans that were visibly wet. -At 1:15 p.m. DA #1 used the same dish towel that had been in the dish room to dry off the food processor. DA #1 put the food processor away. DA #1 used the same towel to dry utensils and plates. -DA #1 began rinsing and racking dirty dishes. DA #1 moved to the clean side of the dishroom and used the same towel to dry dishes. D. Staff interviews DA #1 was interviewed on 7/12/23 at 1:32 p.m. He said he used a towel to dry dishes to speed up the process. NHA #2 and the DS were interviewed on 7/12/23 at 1:52 p.m. The DS said the dietary staff used a clean towel for drying pots and pans. The DS said those items were used more frequently and they needed them to be cleaned and dried quickly. The DS said it was important for dishes to be dried appropriately, so bacteria did not start growing. The RD was interviewed on 7/13/23 at 10:59 a.m. She said dishes should not be dried with a towel. The RD said drying dishes with a towel could introduce bacteria.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interviews, the facility failed to ensure residents were free from resident-to-resident abuse for four residents (#1, #2, #3 and #4) of six residents reviewed out of eight sample residents. Specifically, the facility failed to prevent: -Resident #1 from physical abuse from Resident #2. Resident #2 had documented aggressive behaviors prior to the incident with Resident #1 on 2/19/23; and, -Resident #3 from physical abuse from Resident #4. Resident #4 had documented aggressive behaviors prior to the incident with Resident #3 on 2/28/23. Findings include: I. Resident census and conditions demographic The Resident Census and Condition was provided by the nursing home administrator (NHA) on 3/20/23 at 9:00 a.m. It revealed in pertinent part that 50 residents resided in the facility,44 of the 50 residents had dementia; 28 of the 50 residents had behavioral healthcare needs. The facility had two secured units. The secured units were called the front unit which had all male residents. The other unit was called the back unit which had men and women residents. II. Professional reference According to the Centers for Disease Control (CDC) website, Preventing Elder Abuse https://www.cdc.gov/violenceprevention/elderabuse/fastfact.html 6/2/21, (Retrieved 3/27/23), Elder abuse is an intentional act or failure to act that causes or creates a risk of harm to an older adult. Common types of elder abuse include: physical abuse, sexual abuse, emotional or psychological abuse, neglect and financial abuse. Physical abuse is when an elder experiences illness, pain, injury, functional impairment, distress, or death as a result of the intentional use of physical force and includes acts such as hitting, kicking, pushing, slapping, and burning. III. Facility policy and procedure The Abuse, Neglect, Exploitation, and Misappropriation Prevention Program policy and procedures, not dated, was provided by the nursing home administrator (NHA) via email on 3/23/23 at 8:27 a.m. It revealed in pertinent part, Residents have the right to be free from abuse, this includes but is not limited to physical abuse. The resident abuse, neglect and exploitation prevention program consists of a facility wide commitment and resource allocation to support the following objectives: Protect residents from abuse, neglect, exploitation or misappropriation of property by anyone including, but not necessarily limited to: other residents. IV. Physical abuse between Resident #1 and Resident #2 The 2/19/23 facility incident report which involved Resident #1 and Resident #2 was provided by the NHA on 3/20/22 at 11:00 a.m. It revealed in pertinent part, On 2/19/23 Resident #1 was seated in the facility dining room. The staff observed Resident #2 push Resident #1 from his chair. (The NHA interview below said Resident #2 stood over Resident #1 and pushed him down into his chair while he tried to stand up). The report read Resident #1 and #2 were unable to provide interviews because of their diagnosis of dementia. The report documented that staff were interviewed about the incident and educated. The facility was unable to provide any staff interviews or any type of education provided to the staff after the incident. The facility documented that because both Resident #1 and Resident #2 had a diagnosis of dementia, and because of their inability to understand the outcomes, the facility was unable to find the allegation of abuse substantiated. -However, the physical abuse should have been substantiated due to the willful action of Resident #2 push Resident #1. Interventions after the physical abuse: Resident #1 had no changes/interventions implemented after the altercation. Resident #2 would be provided with continued education (although facility documented due to dementia he could not recall the incident) and he would be provided with alternate places to sit in the dining room. -Staff were to be educated on redirecting residents and their dining room seats, but the NHA said the facility was unable to provide proof of staff being educated after the incident. -The facility incident report left blank the section for remarks of any predisposing environmental factors, psychosocial factors, or situation factors about the incident. V. Resident #1 A. Resident status (victim) Resident #1, age [AGE], was admitted on [DATE]. According to the March 2023 computerized physician orders (CPO), the diagnoses included Alzheimer's disease, dementia with other behavioral disturbances, epilepsy and depression. The 3/7/23 minimum data set (MDS) assessment revealed the resident had severe cognitive impairment with a brief interview for mental status score of one out of 15. He required extensive assistance with toilet use, and personal hygiene. He was independent with bed mobility, transfers, walking in his room and corridors. He had inattention, was easily distractible, had unclear or illogical flow of ideas, and was unpredictable. He switched from subject to subject, had an altered level of consciousness, and startled easily to any sound or touch. The resident had delusions, misconceptions of beliefs that were firmly held contrary to reality. The resident did not reject care provided by staff. B. Record review The 6/17/22 and revised 1/10/23 comprehensive care plan revealed, Goal: Resident #1 had communication problems with his diagnosis of dementia. He needed staff to help anticipate some of his needs. He had a potential mood problem with a history of dementia with behaviors. He had a lack of situational safety awareness and personal space of others. He had invasive behaviors. Interventions: Staff were to be conscious of where Resident #1 sat when (he was) in groups, activities, and the dining room, to promote proper communication with others. He was to be spoken to on an adult level, spoken to clearly and slower than normal. Staff were to anticipate and meet his needs. -Staff were to intervene as necessary to protect the rights and safety of others. He was to be approached/spoken to in a calm manner. Divert attention (as needed). Remove him from (a) situation (s) and take to an alternate location as needed. - Attempt non-pharmacological interventions: 1. Redirect to (a) calm environment.2. Respond calmly. 3. Distract and redirect. 4. Use consistent direction to make calm changes gradually. (5. Was not listed) 6. Distract with calm conversation. 7. Offer simple explanations. 8. Modification of (the) environment. 9. Walking. 10 Responded well to positive statements. The certified nurse aide (CNA) communication/organization sheets to be used for resident care as of 3/21/23 (during survey) was provided by the corporate resource person (CRP) on 3/21/23 at 11:30 a.m. It revealed in pertinent part, -Ask yes/no questions in order to determine the resident's needs. -Communication: Allow adequate time to respond, repeat as necessary, do not rush, request clarification from the resident to ensure understanding. Use simple, brief, consistent words/cues. Use alternative communication tools as needed. -Cue, reorient, and supervise as needed. -Encourage him to continue stating thoughts even if he had difficulty. Focus on a word or phrase that makes sense, or responds to the feeling he was trying to express. -Use task segmentation to support short term memory deficits. Break tasks into one step at a time. VI. Resident #2 A. Resident status (perpetrator) Resident #2, age under 70, admitted [DATE], and readmitted [DATE]. According to the March 2023 computerized physician orders (CPO), the diagnoses included dysarthria (difficulty speaking following cerebrovascular disease), dementia with behavioral disturbances, cognitive communication deficit, restlessness and agitation. The 1/25/23 annual minimum data set (MDS) revealed the resident was cognitively intact with a brief interview for mental status score of 15 out of 15. The resident had delusions, misconceptions or beliefs that were firmly held, contrary to reality. He did not reject care provided by the staff. He was independent with bed mobility, transfers, walking in his room and corridors, eating, toilet use, and personal hygiene. B. Resident interview Resident #2 was interviewed on 3/20/23 at 12:00 p.m. He said he had never had an altercation with anyone in the facility. He said he was homeless and in prison and he got along with everybody. C. Record review The 6/17/22 and revised on 1/10/23 comprehensive care plan revealed, -The resident had a history of physical aggression. He wandered into others' personal spaces and/or room. Redirection was often helpful and effective. Interventions: (Staff were to) intervene as necessary to protect the rights and safety of others. Approach/speak (to) in a calm manner. Divert (his) attention. Remove (him) from situation and take to alternate location as needed. The 4/3/22 behavioral progress note revealed, Resident #2 became physically aggressive with a staff member during a supervised cigarette smoking session. He was told by a nurse that he could not hit staff or anyone else. The staff member reported the resident hit her glasses off her face and then Resident #2 attempted to step on the glasses while the glasses were on the floor, and then (he) began to flip the outside tables. The 4/26/22 physician note revealed the resident was seen by the physician because the resident had physical aggression. The resident had triggered episodes where he had flipped tables. The 12/2/22 physician note revealed the resident was seen by the physician because the resident was the aggressor and had an altercation with another resident. The 2/19/23 progress note documented by the director of nursing (DON), Thinks that chair is his and has done this in the past. Each time we explained to him and he is unable to comprehend. He has aggression issues. Staff saw him pick up the back of (Resident #1's) chair and tried to stop him but could not. Immediate action taken was to explain to the resident that there was not assigned seating, and everyone can sit where they want. He had done this same behavior in the past. The 2/20/23 progress note revealed, Resident #2 was observed to tip a chair over that another patient was sitting in. This behavior was unprovoked by (a) fellow patient. The 2/20/23 DON progress note documented Resident #2 did not want someone to sit in his chair that he usually sat in. Resident #2 picked up the back of the chair (that Resident #1 was seated in) and slid the resident out of his chair. -The facility incident report documented Resident #1 was pushed from his chair by Resident #2. The DON documented Resident #2 picked up the back of Resident #1's chair and slid him out of it. The NHA said in an interview that Resident #2 pushed Resident #1's shoulders so that he would sit down in his chair and that he did not come out of his chair. The CNA communication/organization sheets to be used for resident care as of 3/21/23 (during survey) was provided by the CRP on 3/21/23 at 11:30 a.m. It revealed in pertinent part, -Monitor behavior episodes and attempt to determine underlying cause. Consider location, time of day, persons involved, and situations. Document behavior and potential causes. -If reasonable, discuss the resident's behavior. Explain/reinforce why behavior is inappropriate and/or unacceptable to the resident. -Intervene as necessary to protect the rights and safety of others. Approach/speak to in a calm manner. Divert attention. Remove from (the) situation and take to (an) alternate location as needed. VII. Staff interviews The director of nursing (DON) was interviewed on 3/20/23 at 9:00 a.m. She said the front unit area was where Resident #1 and Resident #2 lived and had only male residents. She said most of the men on the unit had some sort of domestic violence in their past. She said Resident #2 wanted Resident #1's chair in the dining room. She said the incident was witnessed by the staff. She said both residents in the incident had a diagnosis of dementia. She said the incident was witnessed by staff. She said she thought maybe the resident to resident physical abuse that happened was reported as unsubstantiated because if it was reported as substantiated it would go on an administrator's professional license. VIII. Physical abuse between Resident #3 and Resident #4 The 2/28/23 facility incident report which involved Resident #3 and Resident #4 was provided by the NHA on 3/20/23 at 11:00 a.m. It revealed in pertinent part, Resident #3 was seated in the dining room and Resident #4 slapped Resident #3 in the face. Due to both residents with a diagnosis of dementia and both were unable to recall the event, the facility was unable to find the allegation of abuse substantiated. The facility documented it was unable to identify abuse or intent to harm. (see CNA #2 interview below about the incident) -However, physical abuse should have been substantiated due to Resident #4 slapping Resident #3 in the face. -Agency registered nurse (ARN) #1 documented immediately after the incident that Resident #4 showed impulsive and aggressive behavior slapping Resident #3. ARN #1 did not document (left blank on the incident report) any predisposing environmental, physiological, physiological, and situation factors. IX. Resident #3 A. Resident status (victim) Resident #3, age over 90, was admitted on [DATE]. According to the March 2023 computerized physician orders (CPO), the diagnoses included Alzheimer's Disease, history of falling, and other specified depressive episodes. The 2/7/23 minimum data set (MDS) assessment revealed the resident was not assessed for a mental status score (BIMS). The resident had delusions, misconceptions or beliefs that were firmly held, contrary to reality. She had verbal behavioral symptoms directed towards others, threatening others, screaming at others, or cursing at others. She required extensive assistance with transfers, dressing, toilet use, and personal hygiene. The resident utilized a wheelchair. B. Record review The 11/2/22 and revised 11/22/22 comprehensive care plan revealed, -The resident received psychotropic medications for behavior management and depression. The 2/17/23 behavioral progress note revealed the resident was very agitated since lunch, yelling, and screaming in the hallway. It took multiple attempts to stabilize her mood by redirection and offering snacks. X. Resident #4 A. Resident status (perpetrator) Resident #4, age [AGE], was admitted on [DATE]. According to the March 2023 computerized physician orders (CPO), the diagnoses included dementia with behavioral disturbances, other specified depressive episodes, and epilepsy. The 2/8/23 minimum data set (MDS) assessment revealed the resident was not assessed for a brief interview for mental status score (BIMS). The resident had short and long term memory problems. He had severe impairment for cognitive skills for daily decision making. The resident had delusions, misconceptions or beliefs that were firmly held, contrary to reality. The resident had continual inattention, and disorganized thinking. He was independent with bed mobility, transfers, and walking in his room and corridors. He required extensive assistance with dressing, toilet use, and personal hygiene. Resident #4 was admitted to the facility on [DATE] to the front all male secured unit. On 2/24/23 Resident #4 was moved to the back secured unit where males and females resided. (See DON interview) After the incident on 2/28/23 the resident was moved again back to the all male front unit on 3/1/22. B. Record review On 2/2/23 the secured unit placement evaluation revealed that the resident was a serious danger to himself and others. He had significant behavior problems that seriously disrupted the rights of others. He had a history of wandering, physical and verbal aggression, and was exit seeking. The 2/15/23 and updated 3/6/23 comprehensive care plan revealed, -The resident had a history of physical aggression. Interventions: Intervene before agitation escalates. Intervene as necessary to protect the rights and safety of others. The 2/16/23 nurse practitioner (NP) progress note revealed the resident had a history of aggressive behaviors with violence towards other residents and staff. The CNA communication/organization sheets to be used for resident care as of 3/21/23 (during survey) was provided by the CRP on 3/21/23 at 11:30 a.m. It revealed in pertinent part, If the resident became agitated to intervene before agitation escalated, guide away from the source of distress, and engage calmly in conversation. Intervene as necessary to protect the rights and safety of others. Divert his attention. XI. Staff interviews The DON was interviewed on 3/20/23 at 1:30 p.m. She said Resident #4 had been at another facility in the area and had perpetrated physical abuse while he was there. She said Resident #4 went to the hospital from that local facility and then the facility refused to take him back. She said she made the decision to admit him because she believed with some medication management he could do well in the facility. She said he was admitted to the front all male secured unit due to his physically aggressive behavior. She said she made the decision to put him into the male/female secured unit because of the need for his bed with a new admission. She said that was the only reason she moved him. She said she thought because he wandered the hallway the back unit residents were more accustomed to that behavior. She said after he hit Resident #3 she then moved him back to the all male secured unit. She said the physical abuse situation was observed by CNA #2. ARN #1 was interviewed on 3/21/23 at 10:10 a.m. She said she was the charge nurse on duty on the back secured unit when the the incident happened between Resident #3 and Resident #4. She said she did not see anything and could not give any insight into the physical abuse that happened. She said she did fill out the report that day after the incident. She said CNA #2 saw it all and CNA #2 separated the two residents. She said she could not discuss the physical abuse that occurred because she did not see or hear anything. CNA #2 was interviewed on 3/21/23 at 2:27 p.m. She said she was the only who witnessed the physical abuse with Resident #3 and Resident #4. She said she was walking down the back secured unit hallway with Resident #4 who was pushing Resident #3 while she was in her wheelchair. She said she was overseeing Resident #4 as he pushed Resident #3's wheelchair. She said the three of them walked from the dining room and up a hallway which led to the nurse's station next to the secured doors. She said she began talking to another resident in the area and looked away from Resident #3 and Resident #4. She said when she looked back she saw Resident #4 slap Resident #3 across her face which knocked Resident #3's glasses to the ground. CNA #2 said she had surgery on her arm and was unable to separate the residents due to her limitations. She said the facility was aware of her physical limitations. She said the agency nurse (ARN #1) who was seated at the nurse's station in front of her, got up and separated the two residents. CNA #2 said she had only met Resident #4 one other time and did not know a lot about him. CNA #2 said she was unaware of his behaviors so that she could have prevented the situation. She said sometimes a resident would get a certain look in their face or eyes and that was how she knew if something was going to happen negatively. She said they were not in the middle of the dining room when this situation occurred. She said her dementia training was primarily online training with videos not hands on return demonstration training. She said she did the best she could to redirect residents after something went wrong. She said she did not receive training about Resident #3 and #4 after the incident. XII. Administrative interviews The CRP was interviewed on 3/21/23 at 11:00 a.m. She said she was aware that many years ago a resident's intent to do physical harm was considered but that was not the way the regulations read any longer. She said resident-to-resident physical abuse was witnessed by staff for both incidents with Resident #1 and Resident #2, and Resident #3 and Resident #4. Activity assistant (#2) was interviewed on 3/21/23 at 2:00 p.m. She said if she wanted to know how to work with any of the dementia residents she could ask other staff members. She said she took the required online video training that the company made all employees take. She said she had watched the required staff videos of dementia training to learn how to work with dementia residents. She said with some residents she could see their mood changes by the look in their eyes. She said the resident may look wild and that was how she knew they might get aggressive. She said Resident #4 sometimes had a cranky mood and if he did she kept her body at a distance from him. She said Resident #4 hit the plant supervisor (PS) after Resident #4 moved back to the all male unit about two weeks ago. The (PS) was interviewed on 3/21/23 at 2:50 p.m. He said about two weeks ago he was at the front door getting ready to go outside and do snow removal when Resident #4 came up to him. He said he told Resident #4 that he could not go outside because of the bad weather. He said, I didn't see it coming, Resident #4 used a closed fist and upper cut me under my chin. Bam, it was hard and it hurt. He said he did not anticipate that aggressive behavior with Resident #4. He said where he had previously worked the staff had hands-on training to learn how to handle people with dementia. He said at the facility they were only required to watch videos about dementia. He said he had never received any specific education about how to handle Resident #4. The NHA was interviewed on 3/21/23 at 4:00 p.m. She said she was the abuse coordinator for the facility. She said the incident report between Resident #1 and Resident #2 meant that Resident #2 used his hands and pushed on the shoulders of Resident #1 and made him sit down in his chair when he tried to stand up. She said Resident #1 was not pushed out of his chair. She said Resident #4 did slap Resident #3 on the back secured unit. She said both incidents involved physical aggression. She said she documented both incidents and reported them to the State Agency. She said both incidents which involved all four residents, were reported as unsubstantiated even though there were eyewitnesses to the resident-to-resident physical abuse. She said all four of the residents had dementia therefore they could not recall the physical abuse after the incidents occurred. She said even though the altercations did occur, all four residents had dementia, so she did not document that the two incidents were substantiated. She said she did not have documentation proof that any staff were educated after the two different incidents. She said she had no documented proof that the incidents were even discussed in a group huddle type education environment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview, record review and staff interviews, the facility failed to inform a resident, of the facility's bed hold policy, for one (#18) resident reviewed for hospitalization out of 29 sample residents. Specifically, the facility failed to ensure Resident #18 was informed, verbally and in writing, of the bed hold policy while on leave from the facility when he transferred to the hospital. Findings include: I. Facility policy and procedure The Bed hold policy, revised in December 2016, was provided by the nursing home administrator (NHA) on 10/29/19 at 1:40 p.m. It read in pertinent part: -A post-discharge plan is developed for each resident prior to his or her discharge. -This plan will be reviewed with the resident, and/or his or her family, at least twenty-four (24) hours before the resident's discharge or transfer from the facility. -The facility staff is responsible for obtaining orders for discharge, transfer, and providing the resident or representative (sponsor) with required documents (i.e., discharge summary and plan, readmission appeal rights, bed-holding policies, etc.). II. Resident #18 A. Resident status Resident #18, age [AGE], was admitted on [DATE] and readmitted on [DATE]. According to the October 2019 computerized physician orders (CPO) diagnoses included chronic obstructive pulmonary disease with acute exacerbation, pulmonary hypertension due to lung disease and hypoxia. The 8/18/19 minimum data set (MDS) assessment indicated the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. The resident had a reentry date of 8/11/19 from an acute care hospital. B. Record review The 8/1/19 nurse progress note documented the resident had diminished lung sound and low pulse oxygenation, the resident was transported to the emergency room and was admitted to the hospital. He returned to the facility on 8/11/19. A review of progress notes and the transfer/discharge paperwork failed to reveal the resident was notified by the facility of bed hold policy when he transferred to the hospital on 8/1/19. III. Staff interviews The director of clinical operation (DOCO) was interviewed on 10/29/19 at 1:05 p.m. She said when a resident was sent to the hospital, the E-interact Transfer/Discharge form was sent with the resident, including the bed hold policy. The complete packet was given to Emergency Medical Technician-EMT (physician order, discharged /transfer form, assessment, face sheet, medication list, Medical Orders for Scope of Treatment-MOST form, and bed hold policy) should be copied and filed in medical records. She was unable to locate the admission agreement signed by the resident when admitted , or any of the transfer/discharge forms which indicated the bed hold agreement was provided to Resident #18. She said she was going to reeducate the staff on the paperwork/documentation required during the discharge/transfer process of the residents to the hospital from the facility.

Based on observations and staff interview, the facility failed to provide adequate outside ventilation by means of windows or mechanical ventilation, or a combination of the two. Specifically, the facility failed to ensure resident bathroom exhaust fans were functioning properly to ensure good air circulation and minimize unpleasant odors. Findings include: A. Observations An observation of the resident environment was completed on 10/28/19 at 3:30 p.m. Exhaust fans were installed in the ceilings/walls of each bathroom. Bathroom fans in rooms located on the south hall were not audible and did not create air movement with the switch in the on position. As a measure of checking the function of each fan, a small square of single-ply toilet paper was placed against the vent. The exhaust fans were unable to hold the toilet tissue in place which indicated the fans did not function properly. Urine odors were smelled during multiple observations in the south hallway, on 10/28/19 and 10/29/19. The bathroom exhaust fans in rooms #11, #17 and #18 were not functioning. B. Staff interview The nursing home administrator (NHA) and plant supervisor (PS) were informed of the above findings on 10/29/19 at 10:50 a.m. The PS provided facility audits at 11:15 a.m., and identified eight of 24 bathroom fans were non-functional in the facility. He said the motors were not functioning correctly and the ventilation fans in every resident bathroom should be in good working condition. The NHA on 10/29/19 at 2:00 p.m. said the replacement part (electric motors) were ordered and they will be replaced as soon as possible. The PS said the system was checked monthly, however, his log did not identify specific room numbers. He will improve the preventive maintenance log and add room numbers for his monthly checks.