**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and interviews, the facility failed to ensure one (#36) out of one of 20 sample residents received food and fluids prepared in a form designed to meet his or her needs. Specifically, the facility failed to ensure Resident #36 received nectar thick liquids per physician's orders. Findings include: I. Manufacture's recommendations The Simply Thick Easy Mix packet was provided by the director of nursing (DON) on 5/1/25 at 11:05 a.m., the directions read: add to four fluid ounces (oz) (120 milliliters - ml) of liquid. Stir briskly for 30 seconds. II. Facility policy and procedure The Dysphagia Clinical Protocol was provided by the nursing home administrator (NHA) on 5/1/25 at 2:14 p.m. It read in pertinent part, The staff and physician will identify individual with a history of swallowing difficulties or related diagnoses such as dysphagia, as well as individuals who currently have difficulty chewing or swallowing food. If a swallowing problem is identified or suspected, a healthcare practitioner, in conjunction with nursing and the speech pathologist (SLP) will identify and document pertinent information: level of consciousness, ability to swallow three ounces of water without drooling, coughing, or choking, previous and recent history of swallowing capability and difficulty. The staff and physician will first try to identify and implement simple interventions to manage the situation for example: cutting food into smaller pieces, allowing the resident to eat more slowly. If a modified consistency diet or other restrictions are indicated, nursing will obtain an order for such restrictions from the physician. II. Resident #36 A. Resident status Resident #36, age greater than 65, admitted on [DATE]. According to the May 2025 computerized physician order (CPO) diagnoses, included Alzheimer's disease, dysphasia (difficulty swallowing), gastro-esophageal reflux disease (GERD) and depression. The 2/5/25 MDS assessment revealed Resident #36 had moderate cognitive impairments with a brief interview for mental status (BIMS) score of nine out of 15.The MDS assessment documented she required partial to moderate assistance activities of daily living (ADLs). The MDS assessment documented Resident #36 did not have a swallowing disorder but was on a mechanically altered diet. B. Observations During a continuous observation on 4/28/25 beginning at 11:34 a.m. and ending at 11:45 a.m. the following was observed: At 11:34 a.m. an unidentified certified nurse aide (CNA) gave Resident #36 juice and water at the dining room table for lunch. The unidentified CNA filled the eight ounce (oz) cups to the top . The unidentified CNA added one package of a liquid thickener to each beverage and then stirred each glass for approximately five seconds. -The unidentified CNA failed to follow the manufacturer's recommendations (see observations above). At approximately 11:45 a.m. the unidentified CNA gave Resident #36 a sip of her beverage. The thickener had settled at the bottom of the glass and the liquid at the top was thin. The unidentified CNA did not stir the beverage again. Resident #36 was holding her chin up in the air with her head tilted back and took a sip of her drink. She then coughed five times, the unidentified CNA reminded her to put her chin down. On 4/29/25 at 11:37 a.m. an unidentified CNA added one packet of powdered thickener to Resident #36's lemonade and one packet of liquid thickener to her water and stirred each drink for approximately five seconds. The cups were filled to the top of the eight oz cup. On 4/29/25 at 12:10 p.m., an unidentified CNA gave Resident #36 a sip of each of her drinks. The unidentified CNA did not stir the drink again. Both drinks had been sitting since being served. The thickener had settled to the bottom of the glasses. The liquid at the top of her drink was thin like regular liquid. On 4/29/25 at 12:39 p.m, an unidentified dietary aide (DA) poured Resident #26's leftover beverages out. The consistency was thin. On 4/30/25 at 11:27 a.m. CNA #10 filled two eight oz glasses and added one packet of liquid thickener to her red juice and one packet of liquid thickener to her water. She stirred the drinks for approximately five seconds. On 4/30/25 at 12:30 p.m., an unidentified CNA offered to assist Resident #36 with her drinks, Resident #36 took a sip of her juice and coughed twice. On 4/30/25 at 1:00 p.m., the water pitcher in Resident #36's room was regular thin water. C. Record review Review of the May 2025 CPO indicated the resident was prescribed a pureed diet texture and nectar thick liquids, ordered on 3/24/25. The nutritional care plan, initiated on 2/14/25 and revised on 4/15/25, revealed Resident #36 was at increased nutritional risk due to poor intake. Interventions included following swallow precautions, providing assistance with meals, serving meals with appropriate sauces on the side for starch foods, alternating foods and liquids, checking the resident's mouth for pocketing intermittently during meals and providing and serving the residents diet as ordered (mechanical soft consistency, regular fluids and fortified foods). -However, the care plan was not updated when the resident's diet was downgraded to a pureed diet with nectar thick liquids until 4/30/25 (during the survey) The 3/16/25 nursing progress note documented the nurse had spoken to Resident #36's family when they had come in to visit her. The note documented on 3/14/25 during dinner Resident #36 had coughed and had emesis (threw up) and on 3/15/25 she had coughed with emesis during evening medication pass while swallowing her medications with water. Family members sat down with Resident #36 and began to assist her with her meal. They gave her mashed potatoes and Resident #36 demonstrated a similar cough with emesis. The note documented the nurse recommended a bedside swallow screen and the family was supportive of the concept and was willing to support the diet and liquids per rehabilitation orders. The 3/22/25 nursing progress note documented Resident #36 was doing much better since she started on a three day diet trial . The note documented she had not had any coughing since the downgrade of diet and liquids The 3/23/25 nursing progress note documented Resident #36 oral intake had increased since her diet was changed to pureed and nectar thick liquids. She had not had any coughing. III. Staff interviews CNA #10 was interviewed on 4/30/25 at 11:30 a.m. CNA #10 said she used one packet of the instant liquid food thickener per glass. She said Resident #36 had been drinking a lot more since she was placed on thickened liquids. CNA #10 was interviewed again on 4/30/25 at 1:00 p.m. CNA #10 said when she discarded the resident's water glass, the water towards the top was thinner like regular thin liquid and she said it was thicker towards the bottom of the glass. She said it probably separated because it sat too long. She said if they did not stir the thickener for long enough, the drink became lumpy at the bottom. She said the water in Resident #36's room should be thickened as well. She said when she went to Resident #36's room, she said her water was not thickened, but it should have been. She said the glasses used in the dining room were 240 ml and the water bottles in the rooms were 350 ml. She said after reading the instructions on the back of the thickener packet, she said the packet was for four ounces (120 ml). She said the instructions indicated to stir the drink for 30 seconds and the liquid should be nectar thick. She said she only got a quick training on thickened liquids on the day that Resident #36 was switched. She said if Resident #36 were to get thin liquids, she could cough or choke. CNA #11 was interviewed on 4/30/25 at 3:30 p.m. He said the hydration aide had not come by that shift to change Resident #36's water bottle in her room. He said that he had added two packets of thickener to her water bottle. He said at dinner they used one packet of thickener per glass and the drinks should be stirred for 30 seconds. CNA #4 was interviewed on 5/1/25 at 9:57 a.m. She said the nurse let the CNAs know if someone was on thickened liquids or had had any type of diet change. She said she did not know how long to stir a beverage when she added the thickener into a beverage. She said she was able to look at the drink to know when to stop stirring. She said she got a quick walk-through training when Resident #36 was switched to nectar thick liquids. She said if Resident #36 got regular liquids she could cough and it would take her a long time to stop coughing. Registered nurse (RN) #4 was interviewed on 5/1/25 at 10:20 a.m. She said the nurses got the orders for thickened liquids or diet changes from the speech therapist, dietary staff,and the physician. She said it had been a while since she had made thickened liquids. She said she would stir the beverage until she got the consistency she was looking for. She said if Resident #36 got thin liquids it could put her at risk for aspiration, choking and she could get pneumonia. The DON was interviewed on 5/1/25 at 11:05 a.m. She said Resident #36 was prescribed thickened liquids on 3/23/25 and before that was put on a three-day trial, which was initiated by nursing staff due to the resident not eating well and coughing to the point of vomiting. She said since the change, she had not seen the resident coughing. She said speech therapy did not see Resident #36 because she was on hospice, which was why they did the three-day trial. She said the diet downgrade was discussed by nursing staff and her physician. She said the CNAs should be using two packets in each eight-ounce glasses and stirring for 30 seconds. She said the water bottle in her room should be thickened as well. She said the staff working on the floor have been educated on the proper steps of using the thickener packets. CNA #6 was interviewed on 5/1/25 at 4:05 p.m. She said she had only been at the facility since March of 2025 and had not been trained on thickened liquids. She said there was a container of powdered thickener in the main kitchen that she used. She said she would use the scoop and pour a little in and stir until it was nectar thick. She said she had not heard of the packets until someone had trained her that day. She said she was to use two packets for an eight-ounce glass and stir for 30 seconds. CNA #12 was interviewed on 5/1/25 at 4:10 p.m. She said she had worked at the facility for two years and was unaware of any thickening packets. She said she used the thickening powder from the kitchen. She said she would add the powder and then check the thickness. She said the care plan had all of the dietary requirements for each resident and should indicate if they need nectar thick liquids. She said she was shown the packets and trained on them that day (5/1/25). DA #3 was interviewed on 5/1/25 at 4:42 p.m. He was observed pointing to a black container on the counter in the kitchen preparation area labeled thickener for liquids. He said there were no instructions for thickening on the container. The dietary manager (DM) was interviewed on 5/1/25 at 4:48 p.m. She said she ordered pre-bottled nectar thick water, nectar thick lemon flavored water and a nectar thick kiwi strawberry flavored water. She said she also ordered nectar thick packets as well as a thickening pump that had instructions for how many pumps to add to liquids for nectar thick, honey thick and pudding thick liquids. She said this was what the CNAs should be using when they were making drinks for the residents who were on thickened liquids. She said the CNAs should be using the pre-bottled nectar thick drinks unless the resident wanted a different flavor or a different drink then they should be using the pump or the packets. She said she did not know why they had been using the powder in the kitchen because that was for cooking. She said she had told the CNAs that she had put the pre-bottled nectar thick drinks in the refrigerator that morning (5/1/25). The dietary consultant (DC) was interviewed on 5/1/25 at approximately 5:00 p.m. The DC said Resident #36 was an aspiration risk which was why the three day diet trial was done. He said it was very important that the CNAs prepared her drinks correctly because if the drinks were too thin or too diluted she could choke. He said he was not involved with training the CNAs on thickened liquids or how to prepare the thickened liquids. The DON was interviewed again on 5/1/25 at 5:14 p.m. The DON said all of the nursing should use the pre-bottled nectar thick liquids when possible. She said if they were not able to use the pre-bottled, they should use the pump provided by the DM or use the packets and they should follow the directions on the pump and the packets. She said the CNAs should not be using the thickening powder in the kitchen to thicken liquids.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interviews, the facility failed to ensure four (#29, #32, #35 and #36) out of 14 received activities to meet the needs and interests of the residents out of 20 sample residents. Specifically, the facility failed to: -Provide person-centered activities for Resident #29, Resident #32, Resident #35 and Resident #36; and, -Ensure Resident #32 and Resident #36 were assisted to a group activity when they requested to attend. Findings include: I. Facility policy and procedure The Activities policy, revised June 2018, was provided by the nursing home administrator (NHA) on 5/1/25 at 5:29 p.m. It read in pertinent part, Attendance and participation is recorded for every resident in group and individual activities on a daily basis. Records are reviewed on a regular basis, and at least quarterly, to determine any changes in resident participation that might indicate a change in condition and lead to reassessment and care plan review. Attendance records are used when completing residents' progress notes to determine their participation as it relates to their activity plan. Residents are encouraged to participate in all group activities, especially those that are best suited for their interests and physical, mental, and emotional needs. Activities calenders are posted in high-visibility and high-traffic areas in the facility at a height that is readable from a wheelchair. Individual activities are provided for individuals who have conditions or situations that prevent them from participating in group activities, or who do not wish to do so. For those residents whose condition or situation prevents participation in group activities, and for those who do not wish to participate in group activities, the activities program provides individualized activities consistent with the overall goals of an effective activities program. Individualized activities are reflective of the resident's activity interests, as identified in the activity assessment, progress notes and the resident's comprehensive care plan. Activities for residents with behavioral or emotional problems who cannot participate in group activities include: uncomplicated activities that can be adapted to the level of the individual's behavioral or attention function, activities requiring short periods of of concentration to reduce frustration, and activities tailored to address specific underlying causes of the individual's behavioral or attention limitations. Residents who choose not to attend group activities are encouraged to participate in independent activities. It is the responsibility of the facility and activity staff to make regular contact with residents who choose to pursue independent activities, maintain appropriate records, and offer supplies, as needed. II. Posted activities calendar The daily activities posting was observed hanging on the wall in a plastic wall sign holder in the special care unit. The posting was changed daily by the activities director (AD). The daily calendar documented the following activities: On 4/29/25: -10:00 a.m. Strawberry Crunch cookies -12:00 p.m. Daily Devotion in the main dining room -2:00 p.m. Stuck in the Mud On 4/30/25: -10:00 a.m. Butterflies -12:00 p.m. Daily Devotion in the main dining room -2:00 p.m. Bingo On 5/1/25: -10:00 a.m. May Day Coloring -12:00 p.m. Daily Devotion in the main dining room -2:30 p.m. Bible Study -3:15 p.m. May Day III. Resident #29 A. Resident status Resident #29, age [AGE], was admitted on [DATE]. According to the May 2025 computerized physician's orders (CPO), diagnoses included unspecified dementia, type two diabetes, age-related cognitive decline and generalized anxiety disorder. The 4/1/25 minimum data set (MDS) assessment revealed Resident #29 was unable to complete the brief interview for mental status (BIMS). The staff assessment revealed she had short-term and long-term memory deficits. The staff assessment further revealed she was severely impaired in her daily decision-making. The MDS assessment revealed Resident #29 required partial to moderate assistance when wheeling in her wheelchair and needed substantial to maximal assistance with most of her activities of daily living (ADL). The 12/30/24 MDS assessment revealed Resident #29 was rarely/never understood. The staff assessment documented Resident #29 preferred reading books, newspapers or magazines, listening to music, being around animals, doing things with groups of people, participating in her favorite activities and participating in religious activities. B. Observations On 4/28/25 at 11:05 a.m. Resident #29, who resided on the special care unit, was sleeping at the table in the common room. The television was playing country music. There were no other activities going on. Observations of the unit revealed there were no individual activities available such as books or magazines, puzzles. During a continuous observation on 4/29/25, beginning at 11:15 and ending at 2:19 p.m., the following was observed: At 11:15 a.m. Resident #29 was sitting in the common area with other residents. No activities were being conducted. At approximately 1:30 p.m. Resident #29 was assisted to her recliner after lunch. At 2:19 p.m. Resident #29 continued to sit in the recliner. She was not invited to the activity that started at 2:00 p.m. per the posted activities calendar (see calendar above). During a continuous observation on 4/30/25, beginning at 9:09 a.m. an ending at 1:30 p.m., the following was observed: At 9:09 a.m. the AD was in the special care unit and told the staff that she was going to do the butterfly activity (craft) on the special care unit. She switched the activities schedule to the correct date. At 9:17 a.m. the AD entered Resident #29's room. She did not invite Resident #29 to the butterflies activity. At approximately 1:30 p.m. Resident #29 was assisted to her recliner after lunch. The AD was inviting residents on the special care unit to Bingo, she did not invite Resident #29. C. Record review The activities care plan, initiated on 4/3/25 and revised on 4/28/25, revealed Resident #29 liked pizza, enchiladas, card games, drawing, painting, old western movies and black and white movies. She enjoyed reading biographies and true stories. She enjoyed listening to blue grass and Spanish music. Pertinent interventions were providing the resident with independent activities of interest when requested, inviting and providing assistance to activities of interest, helping the resident turn on the television when requested. The care plan documented the activities staff would provide one-on-one social conversation if she chooses to stay in her room. According to the activity participation logs for February 2025 (2/1/25 to 2/28/25) March 2025 (3/1/25 to 3/31/25) and April 2025 (4/1/25 to 4/30/25), Resident #29 participated in activities several days a week. IV. Resident # 32 A. Resident status Resident #32, age [AGE], was admitted on [DATE]. According to the May 2025 CPO, diagnoses included unspecified dementia, type two diabetes, other depressive episodes and other anxiety disorders. The 2/6/25 MDS assessment revealed the resident was unable to complete the BIMS assessment. The staff assessment revealed she had short-term and long-term memory deficits. The staff assessment revealed she was moderately impaired in her daily decision-making. The assessment revealed Resident #32 needed partial to moderate assistance with most of her ADL and needed supervision or touching assistance when wheeling in her wheelchair. The 11/6/24 MDS assessment revealed the resident preferred reading books, magazines and newspapers, listening to music, being around animals, doing things with groups of people, participating in favorite activities, and participating in religious activities or practices. B. Observations During a continuous observation on 4/30/25, beginning at 8:49 a.m. and ending at 2:22 p.m., the following was observed: At 8:49 a.m. Resident #32 was in the common area. An unidentified CNA was sitting with the resident. The unidentified CNA was assisting the resident with drinking an oral nutritional supplement. The unidentified CNA was not talking to the resident. At 9:24 a.m. the AD engaged in a short conversation with Resident #32 and told her about the butterfly activity while she changed the television station to 50's music. At 10:12 a.m. Resident #32 was sleeping through the butterfly activity, she was cued by the AD once but fell back to sleep. At 2:22 p.m. the AD invited Resident #32 to attend Bingo. Resident #32 said she wanted to go. -However, Resident #32 was not assisted to Bingo. C. Record review Resident #32's quarterly activities assessment, dated 2/4/25 documented Resident #32 enjoyed visits with family, watching television and listening to music as her independent activities. The assessment documented Resident #32 required reminding of activities and needed assistance going to activities as well as with her independent activities. Resident #32's activity care plan, initiated on 2/4/25 and revised on 4/28/25, revealed Resident #32 enjoyed board games, card games and gardening before her cognitive decline. She enjoyed balloon activities. She enjoyed watching the Denver Broncos, classic television shows and listening to classic country music. She also enjoyed doing activities with children. Pertinent interventions included providing the resident assistance to activities of interest, providing the resident with independent activities of interest, redirecting the resident on days that she might be having a bad day and having the activities department provide visits. Review of the April 2025 (4/1/25 to 4/30/25) activity participation log revealed Resident #32 was actively passive during arts and crafts on 4/30/25. -However, observations revealed she slept through the craft on 4/30/25 (see observations above). Further review of the April 2025 activity participation log revealed Resident #32 refused to go to Bingo on 4/30/25. -However, observations revealed Resident #32 did want to go to Bingo, but the staff did not take her. V. Resident #35 A. Resident status Resident #35, age [AGE], was admitted on [DATE]. According to the May2025 CPO, diagnoses included Parkinson's disease (disease that causes tremors), psychotic disorder and neurocognitive disorder with Lewy Bodies (type of dementia). The 4/18/25 MDS assessment revealed Resident #35 was unable to complete the BIMS assessment. The staff assessment revealed she had short-term and long-term memory deficits. The staff assessment revealed she was severely impaired in her daily decision-making. The assessment revealed Resident #35 needed partial to moderate assistance with the majority of her ADL as well as with her wheelchair mobility. The 10/16/24 MDS revealed it was somewhat important for Resident #35 to have books, magazines and newspapers to read, to do things with groups of people and to go outside when the weather was good. B. Observations During a continuous observation on 4/30/25, beginning at 8:49 a.m. and ending at 2:22 p.m., the following was observed: At 2:17 p.m., Resident #35 was sleeping in the dining area with potato chips and a soda in front of her. She was not asked if she wanted to go to Bingo. C. Record review The activity care plan, initiated on 4/15/25 and revised 4/28/2,5 revealed Resident #35 enjoyed listening to pop music, reading the daily newspaper, watching the Denver Broncos, being around cats and dogs and having her hair curled. The April 2025 (4/1/25 to 4/30/25) activity participation log revealed Resident #35 refused to go to Bingo on 4/30/25. -However, observations revealed that staff did not invite Resident #35 to go to Bingo (see observations above). VI. Resident #36 A. Resident status Resident #36, age greater than 65, admitted on [DATE]. According to the May 2025 CPO diagnoses, included Alzheimer's disease, dysphasia (difficulty swallowing), gastro-esophageal reflux disease and depression. The 2/5/25 MDS assessment revealed Resident #36 had moderate cognitive impairments with a BIMS score of nine out of 15. The MDS assessment revealed she required partial to moderate assistance with her ADLs. The assessment revealed it was very important for Resident #36 to be around animals, to do her favorite activities and to go outside when the weather was nice. B. Observations During a continuous observation on 4/30/25 beginning at 8:49 a.m. and ending at 2:50 p.m., the following was observed: At 2:43 p.m. the AD invited Resident #36 to go to Bingo, she told the AD that she wanted to go. The staff did not assist her to Bingo. Resident #36 was trying to get up out of the recliner and was calling out. CNA #11 continued to tell her to sit back down and to lie back. He did not offer her any other activities. C. Record review The activities care plan, initiated on 4/28/25, revealed Resident #36 enjoyed listening to short stories, watching football, listening to Hawaiian and country music. She also enjoyed activities that involved children and animals. Pertinent included providing the resident assistance to activities of interest, providing independent activities of interest and providing one one-on-one social conversation through the activities department if the resident chose to stay in her room. -However, observations revealed that staff did not provide assistance to activities of interest. The April 2025 (4/1/25 to 4/30/25) activity participation log documented that Resident #36 refused to go to Bingo on 4/30/25. -However, observations revealed Resident #36 did want to go to Bingo, but the staff did not assist her to the activity (see observations above). VII. Staff interviews CNA #10 was interviewed on 5/1/25 at 9:26 a.m., CNA #10 said the AD would come around and let the staff know what activities were going on that day. She said the AD and the CNAs would invite the residents to the different activities. She said if the residents did not want to go to the activity, they would just hang out on the unit in the common area. SShe said movies were played for the residents between activities and the staff would sometimes take the residents outside. She said puzzles, magazines, books and coloring materials were not kept in the special care unit. She said all the residents were able to use those materials. She said the staff would get the residents on the special care unit those materials if they requested them. CNA #4 was interviewed on 5/1/25 at 9:57 a.m. CNA #4 said the AD hung up the daily schedule and hung the monthly calendar in the residents' rooms. She said the AD invited the residents to the activities. She said the staff would put out coloring sheets between activities. She said the staff would also put on music and style the resident's hair between scheduled group activities. The AD was interviewed on 5/1/25 at 4:00 p.m. She said nursing staff would help with the time in between activities by doing manicures, arm massages and putting on movies for the residents. She said some of the activities were more focused for the residents who had dementia, such as aroma therapy, arm massage, trivia, old-time magazines and old-time music. She said she individualized activities by getting to know the residents and adapting to their needs. She said the staff should have gotten Residents #36 and Resident #32 up and assisted them to Bingo as requested. She said she tried to communicate with staff when a resident wanted to join in the activity. The director of nursing (DON) was interviewed on 5/1/25 at 4:18 p.m. The DON said it was important for the residents on the special care unit to have activities that enrich their lives.

Based on observations and interviews, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety in the main kitchen. Specifically, the facility failed to develop a maintenance program to ensure environmental concerns in the kitchen, entrance to the dish room and the dish receiving room were identified and corrected in a timely manner. Findings include: I. Facility policies and procedures The Floors policy, revised December 2009, was provided by the nursing home administrator (NHA) on 5/1/25 at 11:51 a.m. The policy revealed all floors should be mopped, cleaned and or vacuumed daily in accordance with the facility's established procedures. The environmental services director (ESD) maintained floor-cleaning procedures. Inquiries concerning floor care should be directed to the director of housekeeping services. The Maintenance Service policy, revised December 2009, was provided by the NHA on 5/1/25 at 11:45 a.m., the policy revealed maintenance services should be provided to all areas of the facility, ground and equipment. The maintenance department was responsible for maintaining the facility, grounds, and equipment in a safe and operable manner at all times. The department should maintain the facility in good repair and free from hazards. The department should routinely schedule maintenance services to all areas of the facility. The ESD was responsible for developing and maintaining a schedule of maintenance services to assure that the facility, grounds, and equipment were maintained in a safe and operable manner. The ESD was responsible for maintaining work order requests and maintenance schedules. II. Observations An environmental tour of the kitchen and dish washing room was conducted on 4/28/25 at 9:30 a.m. Observations revealed multiple rags were on the floor under the three compartment sink and there were multiple rags wrapped around two of the feet attached to the steamer unit.There were several cut marks on the linoleum floor in the dishwashing room and one hole in the linoleum floor under the reach in freezer. A second environmental tour of the kitchen and dish room was conducted on 4/28/25 3:46 p.m. The rear entrance room to the dishwashing room revealed bubbled paint on two of the walls and there was separation of the seam in the linoleum floor. There was also a corner of the room where the cove base was not caulked. There was debris in the corner of the room.There was approximately four inches of linoleum floor adjacent to the room's cove base that was discolored. The transition strip was missing at the rear entrance to the dishwashing room. The dishwashing room had several cut marks in the linoleum floor. There were multiple brown spots on the ceiling and an unfinished sheet rock area on one wall. There was debris in the corners of the room and there was separation of the cove base along one room wall. There was approximately four inches of soiled/discolored linoleum floor adjacent to the room's cove base. There was a hole in the wall above the cove base on one wall, lint/debris on the white plastic water drain pipes, and torn/separated linoleum floor adjacent to the floor drain. There was an approximately four inch hole in the wall near the dishwashing unit and standing water under the dishwashing unit. There were four missing wall tiles, black discoloration with lint in the stainless steel hood exhaust vent over the dishwashing machine and black discoloration in multiple areas in the stainless steel hood over the dishwashing machine. There was approximately eight feet of brown/black discolored caulk at the interface of the stainless steel and the wall tile along the entrance to the dishwashing machine. The dish receiving room that was adjacent to the dishwashing room had several cut marks in the linoleum floor. There was sheet rock damage on the ceiling, three six-inch black discoloration circles on the ceiling and multiple brown discoloration stains on the ceiling. The grout had brown stains on it. There was an approximately four inch hole in the linoleum floor and brown/black discoloration on the 3/4 inch grout at the end of the stainless steel dishwasher discharge table. A third environmental tour was conducted 4/29/25 at 8:45 a.m. Kitchen observations revealed sheet rock damage with cove base separation on one wall and debris on the floor under the three-compartment sink. There was missing cove base under the second hand-washing sink located under the kitchen windows. There was debris on the floor behind the steamer unit and the spice rack. There was sheet rock damage under the fire extinguisher. III. Staff interviews and observations On 5/1/25 at 3:23 p.m., a fourth environment tour was conducted with the dietary manager (DM) and the ESD. They observed and documented each of the above items. The ESD said he did not have any work orders in the last six months of the items observed. The ESD said that staff filled out work orders on a tri-carbon form and placed them in a box on the wall outside his office. The ESD said he reviewed this box several times a day. He said the staff could also call him for any environmental issues. The DM said the kitchen staff deep cleaned the kitchen, dish room and the dish receiving room each month. She said by the above observations, the staff were not cleaning all the way up to the baseboard in these areas. She said the deep cleaning should include all of the floor and the baseboards.

Based on observations, record review and interviews the facility failed to maintain an effective pest control program so the facility was free from pests and cockroaches, in one of one kitchen and one of two dining rooms. Specifically, the facility failed to: -Ensure an effective pest control program that eliminated the presence of live and dead cockroaches in the kitchen and dining room, food preparation area, storage area, serving and eating areas; -Ensure dead and decaying roaches were removed from the dining room lower cupboard space; and, -Ensure heavily occupied sticky pest traps, containing a large amount of trapped dead and decaying cockroaches were removed timely and when the traps were full. Findings include: I. Professional references According to the Colorado Department of Public Health and Environment, Colorado Retail Food Establishment Regulations, effective 3/16/24, was retrieved on 9/25/24 from https://cdphe.colorado.gov/dehs Controlling Pests. The premises shall be maintained free of insects, rodents, and other pests. The presence of insects, rodents, and other pests shall be controlled to eliminate their presence on the premises by: routinely inspecting incoming shipments of food and supplies; routinely inspecting the premises for evidence of pests; using methods, if pests are found, such as trapping devices or other means of pest control; eliminating harborage conditions; and, removing dead or trapped insects and other pests. Dead or trapped insects and other pests shall be removed from control devices and the premises at a frequency that prevents their accumulation, decomposition, or the attraction of pests. According to the National Pest Management Association (NPMA) The Truth About Cockroaches and Health, 2024, was retrieved on 9/25/24 from https://www.pestworld.org/news-hub/pest-health-hub/the-truth-about-cockroaches-and-health/# Cockroaches have many negative consequences for human health because certain proteins (called allergens) found in cockroach feces, saliva and body parts can cause allergic reactions or trigger asthma symptoms. Cockroaches can also passively transport microbes on their body surfaces including pathogens that are potentially dangerous to humans. Cockroaches have been implicated in the spread 33 kinds of bacteria, including E. coli and Salmonella species, six parasitic worms and more than seven other types of human pathogens. E. coli and Salmonella are classic causes of food poisoning or gastroenteritis. Common symptoms include belly pain, severe stomach cramps and tenderness, diarrhea which can sometimes be bloody, nausea and vomiting. Some people can experience severe diarrhea, which will cause dehydration and may require hospitalization. In rare cases, the bacteria can spread to the bloodstream and cause life threatening infections. According to Terminix What to do if you find dead roaches, 2024, was retrieved in 9/25/24, from: https://www.terminix.com/cockroaches/why-cockroaches-die-on-their-backs/#:~:text=Dead%20cockroaches%20are%20typically%20not,contaminate%20surfaces%20near%20food%20areas. Dead cockroaches are typically not directly harmful but can pose risks. Their body parts, droppings, and shed exoskeletons can trigger allergies and asthma. They may also carry bacteria and pathogens that contaminate surfaces near food areas. Additionally, a dead cockroach can attract more roaches because they are scavengers. II. Facility policy and procedure The Pest Control policy, revised May 2008, was provided by the nursing home administrator (NHA) on 9/20/24 at 11:30 a.m. It read in pertinent part: Our facility shall maintain an effective pest control program. Maintenance services assist, when appropriate and necessary, in providing pest control services. III. Observations and interview On 9/19/24 at 2:38 p.m. the kitchen and main resident dining room were observed. The kitchen had several pest control sticky traps on the floor underneath and behind the counters and kitchen equipment. All of the traps were full of cockroaches and other insects. There was a live cockroach underneath the shelving in the dry storage room and one on the wall. All of the cupboards in the main dining room underneath the counters where dinnerware, condiments, snacks and drinks were stored and set up were full of several dead and live cockroaches. The dead cockroaches were in different stages of decay. There was one live cockroach observed on the wall behind the drink machine next to the lemonade dispenser. The dietary manager (DM) said the facility had eliminated the mice but were still dealing with cockroaches and flies. The DM said the facility had to increase the frequency of pest control from once a week to twice a week to try to get the problem under control. The DM said she had extra sticky traps so that she could replace the full traps in the kitchen. She said she had to replace the traps almost daily. The DM said they had the light-up traps to manage the flies but they still had flies in the kitchen. The cook and the serving staff had to monitor the uncovered foods so that flies would not land on the food. VI. Record review Pest control records were reviewed on 9/19/24. The documents revealed the facility had received services for pest management twice a month from March 2024 through the month of the survey (September 2024). The pest control company treated the facility for ongoing problems with German roaches, oriental roaches and a few other insect pests. The consistent monthly pest control treatment provided was to treat the presence of German roaches. Areas treated included the kitchen, the resident dining room, resident rooms (bathrooms and closets), the facility entrance, offices and the facility exterior. The treatments provided varied depending on the provider's recommendations. The most focused areas targeted for pest control treatment were the kitchen and the resident dining room. The last day of treatment was on 9/18/24, the day before the survey started (9/19/24). The pest control provider replaced six glue board stick traps. -However, all the stick glue traps observed during the survey on 9/19/24 were full of cockroaches. -There were no sticky (glue) traps placed in the cupboards under the service area counters in the resident dining room. V. Staff interviews The NHA was interviewed on 9/19/24 at 4:58 p.m. The NHA said the facility increased the frequency of pest control visits to twice a month to address the ongoing issues with insect presence. She said the pest control provider was in the building yesterday (9/18/24). The NHA said she just observed the stick traps and did not think they had been changed in a while due to the amount of bugs in the trap and she was not sure if the maintenance department or the DM changed the traps in between pest control visits. The NHA said the usual pest control treatment was for the provider to spray the facility with the prescribed pest control product and place stick traps throughout the building where problems were identified. She said did not know the details of the products used. The NHA was not aware of the presence of cockroaches in the cabinets under the serving areas in the resident's dining room. The NHA said she provided staff training on keeping all areas of the dining room clean and free of cockroach remains.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to coordinate changes to the preadmission screening and resident review (PASRR) level II determination and evaluation report promptly with the State Mental Health Agency in the case of residents with serious mental illness or a related condition for one (#8) of four residents reviewed for PASRR out of 24 sampled residents. Specifically, the facility failed to notify the State Mental Health Agency when recommendations had not been met for Resident #8. Findings include: I. Facility expectations Pre-admission Screen and Resident Review training provided to the social services director (SSD) on 3/29/22 was provided by the nursing home administrator (NHA) on 8/23/23. It read in pertinent part: Specialized services: If a nursing facility cannot arrange or provide specialized services, it must transfer the resident to an appropriate nursing home. Psychiatric case consultation is defined as the addition of a psychiatrist or psychiatric prescriber to a resident's medication review treatment team, quarterly when stable and monthly when not stable. II. Resident status Resident #8, age [AGE], was admitted on [DATE]. According to the August 2023 computerized physician orders (CPO), diagnoses included major depressive disorder and dementia. The 6/23/23 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 12 out of 15. III. Pre-admission Screen and Resident Review (PASRR) level II notice of determination for MI (mental illness) evaluation and facility failures: The PASRR level II, provided to the facility on 8/8/22, included the evaluation which revealed the resident had been evaluated for MI due to a qualifying diagnosis of major depressive disorder. MI was ruled out, however specialized services were recommended. The resident was to receive psychiatric case consultation. IV. Resident interview Several attempts were made to interview the resident between 8/21/23 and 8/24/23. The resident was either unavailable or sleeping. V. Record review The mood care plan, revised 6/29/22, revealed the resident used antidepressant medication related to major depressive disorder. She had a psychosocial well-being problem related to admission. The resident was in assisted living and required a higher level of care. The interventions were for staff to anticipate and respond to needs promptly. The resident was to receive a familiar routine with monitoring for changes in mood, depression, or behaviors. The August 2023 CPO revealed the following physician orders: -Duloxetine (Cymbalta) 20 MG (milligrams)-give one tablet by mouth one time a day for depression - ordered on 5/17/23. A review of progress notes dated 8/22/23 revealed: -Social service progress notes dated 8/22/22 documented the social worker discussed the recommendations with the resident from the PASRR evaluation. The resident declined but agreed to allow the facility to schedule if she felt more depressed. No further social services notes were located regarding PASRR or recommendations. No PASRR progress notes showing communication with the State Mental Health Agency regarding a delay or inability to follow the recommendations were located. VI. Staff interviews The SSD was interviewed on 8/23/23 at 11:53 a.m. She did not recall the PASRR recommendations for Resident #8. She stated psychiatric case consultation was the same as individual therapy services. She said there was not a psychiatrist available in the area. The SSD had not notified the State Mental Health Agency the recommendations made for Resident #8 were not provided. The NHA was interviewed on 8/23/23 at 12:38 p.m. Her expectations of the SSD included completing PASRRs and following through on PASRR recommendations. The NHA said there was a psychiatrist available in the area to satisfy PASRR recommendations for psychiatric case consultations.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to ensure each resident was being screened for a mental disorder prior to admission or that residents identified with a mental disorder were evaluated to receive care and services in the most integrated setting to meet their needs for two (#12 and #24) of five residents reviewed out of 24 sample residents. Specifically the failed failed to: -Obtain a level I screening for Resident #12 who suffered from mental illness (MI) prior to admission so a level II evaluation and determination could be completed by the State Mental Health Agency; -Notify the State Mental Health Agency Resident #24 had exceeded the 30 day provisional preadmission screening and resident review (PASRR) period; and -Submit a new PASRR to the State Mental Health Agency for Resident #24 to determine if a level II evaluation was needed. Findings include: I. Resident #24 A. Resident status Resident #24, age [AGE], was admitted on [DATE]. According to the August 2023 computerized physician orders (CPO), the diagnoses included post traumatic stress disorder, alcohol induced dementia, and depression. The 7/12/23 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 13 out of 15. The resident's depression screen revealed a score of 14 out of 27 indicating moderate depression. No behaviors were indicated. B. PASRR level II notice of determination for MI (mental illness) evaluation and facility failures The resident's pre-admission level I PASRR dated 4/19/23 revealed the resident was approved under a provisional admission. The PASRR included the definition of a provisional admission. It documented a provisional admission resident as one who had either a known or suspected mental illness or related condition. The facility was responsible to submit a new level I screen if the resident was anticipated to remain in the facility past 30 days. There were no additional level I PASRR screens in the resident's chart to indicate the State Mental Health Agency was notified the resident had resided in the facility for four months. This failure resulted in the resident not being screened for a level II PASRR and not being identified for any specialized services. C. Resident interview Resident #24 was interviewed on 8/22/23 at 9:52 a.m. The resident stated he struggled with depression and adjustment issues at the facility. After returning from the Vietnam war, he coped with drugs and alcohol and isolated himself from his family. He stated he attempted suicide seven times in his life, the last time being ten years ago. He denied current thoughts of self harm. His post traumatic stress disorder (PTSD) gave him flashbacks and hallucinations of things he saw and did when in Vietnam. He said he was still trying to process those feelings. Some of his triggers were when people came up behind him and not having a safe place to go to process. D. Record review The comprehensive care plan, initiated on 5/10/23, revealed the resident had PTSD with nightmares related to military service. Interventions included to reorient the resident, allow him to verbalize his feelings and anticipate the resident's needs. The resident had the potential to be verbally aggressive related to mental and emotional illness. Interventions included analyzing triggers, monitor effectiveness of medications, anticipate needs, give the resident choices, provide positive reinforcement for good behavior, and ensure the resident had independent activities he enjoyed The resident took antidepressant medications related to depression and PTSD. The resident took anti psychotics related to PTSD, nightmares, and flashbacks. Interventions included administering medications as ordered, monitor for adverse reactions, and educate the resident on risks/benefits and side effects of medications. The August 2023 CPO revealed the following physician orders: -Abilify (Aripiprazole, an antipsychotic medication) 10 milligrams (MG)- give one tablet by mouth one time a day for PTSD- ordered on 6/7/23. -Trazodone (antidepressant) 100 MG- give one tablet by mouth for depression- ordered on 4/20/23. -Venlafaxine (Effexor, antidepressant) 75 MG- give three capsules by mouth two times a day for PTSD- ordered on 4/27/23. Progress notes reviewed from 4/22/23 to 8/24/23 revealed no social service notes were located documenting a new PASRR had been submitted. II. Resident #12 A. Resident status Resident #12, age [AGE], was admitted on [DATE]. According to the August 2023 CPO, the diagnoses included bipolar, depression, and anxiety. The 7/5/23 MDS assessment revealed the resident was cognitively intact with a BIMS score of 12 out of 15. No behaviors were indicated. The resident was marked as having a PASRR level II condition of mental illness on the MDS. B. PASRR level II notice of determination for MI evaluation and facility failures A pre-admission level I PASRR was not located. Additionally, there was no evidence the facility had received a level II PASRR, level II evaluation or notice of determination. This failure resulted in the resident not being screened for appropriateness of placement setting and possible required recommendations for the facility to provide. C. Resident interview Several attempts were made to interview the resident between 8/21/23 and 8/24/23. The resident was sleeping each time. D. Record review The comprehensive care plan, revised on 7/11/21, revealed the resident had bipolar disorder with anxiety. The resident had been stable over the past year and no longer required services from the mental health provider. Interventions included to keep the physician, mental health provider, and family informed of any changes in mood, depression, and behaviors. The resident would maintain a daily routine, be provided with calm environments if conflicts arose, and be encouraged to participate in activities of choice. The resident took Lithium (a psychiatric mood stabilizer) and Cymbalta (an antidepressant) for depression. Interventions included monitoring for behaviors and adverse reactions. Provide activities of choice and provide a safe environment. The resident took Risperdal (an antipsychotic) for bipolar as evident by inappropriate verbal comments and resistance to care. Interventions included monitoring for behaviors and adverse reactions. When manic, the resident would display excessive talking, seeking out men, wandering, expressing a desire to smoke, and decreased sleeping. Staff to assist with distractions and encourage participation in activities. The August 2023 CPO revealed the following physician orders: -Cymbalta (antidepressant) 30 MG- give one by mouth once a day for bipolar- ordered on 4/8/21. -Lithium carbonate (mood stabilizer)150 MG- give one by mouth once a day for bipolar- ordered on 5/7/21. -Risperdal (antipsychotic) 1 MG- give one by mouth once a day for dementia with behaviors- ordered on 12/21/22. -Lorazepam (Ativan, anti-anxiety) 0.5 MG- give one tablet by mouth at bedtime for other specified anxiety disorders- ordered on 7/18/23. -Lorazepam 0/25 MG- give one tablet two times a day for anxiety- ordered on 7/19/23. Progress notes reviewed from 12/31/22 to 8/24/23 revealed no social service notes were located documenting a pre-admission PASRR had been requested or a level II evaluation request had been submitted. III. Staff interviews The SSD was interviewed on 8/23/23 at 11:53 a.m. She did not know the timeframe for a provisional PASRR for Resident #24. She stated she had been sending in status change PASRRs for Resident #12 and was told there was nothing else she needed to do. She was not aware of what was needed regarding a new admission with MI and the importance of the level II PASRR process. She did not have a preadmission screen level I, a level II evaluation or letter of determination with mental health recommendations for Resident #12. The nursing home administrator (NHA) was interviewed on 8/23/23 at 12:38 p.m. Her expectations of the SSD included completing PASRRs and following through on PASRRs ensuring the resident's medical records had complete PASRRs. IV. Facility follow up On 8/23/23 at 3:00 p.m. (during the survey), the NHA provided documentation the SSD submitted an updated PASRR for Resident #24 to the State Mental Health Agency.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident observations, record review and staff interviews, the facility failed to ensure residents received proper respiratory treatment and care for two (#27 and #28) of two residents reviewed for supplemental oxygen use out of 24 sample residents. Specifically, the facility failed to administer oxygen in accordance with the physician's order for Residents #27 and 28. Findings include: I. Facility policy The Oxygen Administration Policy, revised October 2010, was provided on 8/23/23 at 2:47 p.m. by the nursing home administrator (NHA). It read in pertinent part, The purpose of this procedure is to provide guidelines for safe oxygen administration. II. Resident # 27 A. Resident status Resident #27, age [AGE], was admitted on [DATE]. According to the August 2023 computerized physician orders (CPO), diagnoses included schizophrenia, heart failure, left bundle-branch block, schizoaffective disorder, and hypoxia. According to the 7/31/23 minimum data set (MDS) assessment, the resident had moderate cognitive impairment with a brief interview for mental status (BIMS) score of 10 out of 15. The resident had verbal symptoms directed toward others. She required limited assistance for bed mobility, transfers, grooming and toilet use. The resident received oxygen therapy. B. Record review The resident did not have a care plan addressing the titration or monitoring of Resident #27's needs. The August 2023 CPO included an order dated 3/27/23 to titrate oxygen via nasal cannula to keep SaO2 (oxygen saturation levels) above 89% for congestive heart failure (CHF). C. Observation On 8/21/23 at 12:54 p.m. Resident #27 was lying down in bed sleeping. Resident #27 had her oxygen cannula on the side of her face. The resident's oxygen concentrator was set on three liters per minute (LPM). On 8/22/23 at 10:04 a.m. Resident #27 was in her room sitting in her wheelchair, she did not have her oxygen on. The resident's oxygen concentrator was set on three LPM. The activity director entered Resident #27's room and asked Resident #27 how she was doing. The activity director exited the resident's room and did not remind Resident #27 to put on her oxygen. D. Staff interviews Licensed practical nurse (LPN) #1 was interviewed on 8/22/23 at 10:10 a.m. She said oxygen was a medication. She said the resident was supposed to be on two LPM continuously. LPN #1 went to the resident's room and stated the resident was not wearing her oxygen cannula correctly as it was on the side of her face. LPN #1 helped Resident #27 put on her cannula and exited the resident's room. She said she would have to check Resident #27's order to see what the physician's orders stated on LPM. LPN #1 was shown Resident #27's order. She said she would contact Resident #27's provider because the order was not clear on where to start with LPM and when and how long titration was required. She said a negative outcome could be the resident receiving too much oxygen causing hypercapnia (too much carbon dioxide in the bloodstream). The DON was interviewed on 8/22/23 at 3:42 p.m. The DON said oxygen was a medication. The DON was told of the observation above. She said Resident #27's order should have been clarified with the physician to show what the initial LPM was to be and how titration was to be monitored. She said the facility needs to consult with the physician to get the order changed. III. Resident #40 A. Resident status Resident #28, age [AGE], was admitted on [DATE] and readmitted [DATE]. According to the August 2023 computerized physician orders (CPO), diagnoses included schizophrenia, anxiety, depression, chronic obstructive pulmonary disease (COPD), and chronic kidney disease. According to the 7/4/22 minimum data set (MDS) assessment, the resident had no cognitive impairment with a brief interview for mental status (BIMS) score of 15 out of 15. The resident had no behavioral symptoms. He required supervision for bed mobility, transfers, grooming and toilet use. The resident received oxygen (02) therapy. B. Record Review The resident did not have a care plan for his oxygen use. The August 2023 CPO included an order dated 6/11/23 oxygen five LPM via nasal cannula, may titrate to keep oxygen saturation above 90%. C. Observation and interview On 8/21/23 at 2:10 p.m., the resident was sitting in his recliner in his room. His room concentrator was set to three LPM and he was wearing his oxygen cannula. On 8/22/23 at 3:00 p.m., the resident was sitting in his recliner and was not wearing his oxygen. Certified nurse aide (CNA) #6 walked into Resident #28's room to check his vitals. CNA #6 was asked to check the resident's oxygen saturation. CNA #6 placed the resident's oxygen cannula on the resident and checked his oxygen saturation, which was 84%. CNA #6 had Resident #28 take in several deep breaths and continued to have Resident #28 take deep breaths. Resident #28 was able to get his oxygen saturation up to 92%. CNA #6 reeducated Resident #28 to always have his oxygen cannula on. CNA #6 was asked to check LPM on the room concentrator which was set to three LPM. D. Staff interview CNA #6 was interviewed on 8/22/23 at 3:09 a.m. CNA #6 said Resident #28 had been wearing oxygen ever since she started working at the facility, which had been approximately one year. The DON was interviewed on 8/22/23 at 3:42 p.m. She said oxygen was a medication. She said Resident #28's oxygen should have been administered as the provider ordered it. The DON said a negative outcome from not being administered oxygen when ordered could be altered mental status, dizziness, falls, and hypoxic events and could have put the residents in respiratory distress.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to ensure residents were provided medically related social services to attain and maintain the highest practicable mental and psychosocial wellbeing for three (#24, #12, and #9) of five residents reviewed out of 24 sample residents. Specifically, the facility failed to ensure: -Social services was providing and arranging needed mental and psychosocial counseling services for Residents #24 and #9; -Social services was meeting the needs of residents who were having difficulty with change, loss, and adjustment for Residents #24, #12 and #9; and -Social services was meeting the need for emotional support for residents suffering from suicidal ideations and changes in mental health symptoms for Residents #24 and #12. Findings include: I. Facility description of medically related social services The resident services director (social services director) job description signed by the social services director (SSD) on 10/6/2010 was provided by the nursing home administrator (NHA) on 8/24/23. It read in pertinent part: The primary purpose of this position is to plan, organize, and direct the operation of psychosocial programs for elders including social services. To include: Assure the coordination of outside services of outside agencies occur, assisting residents with financial and legal matters, and assure counseling and support for elders (residents) and families occur. II. Resident #24 A. Resident status Resident #24, age [AGE], was admitted on [DATE]. According to the August 2023 computerized physician orders (CPO), the diagnoses included post traumatic stress disorder, alcohol induced dementia, and depression. The 7/12/23 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 13 out of 15. The resident's depression screen revealed a score of 14 out of 27 indicating moderate depression. No behaviors were indicated. C. Resident interview Resident #24 was interviewed on 8/22/23 at 9:52 a.m. The resident stated it was difficult for him to adjust to people younger than him providing personal care when he first admitted to the facility. He said he knew he gave the nurses and certified nursing aides (CNAs) hell. When he struggled with depression and adjustment issues, he would talk to his nurses. The SSD did not come to talk to him. He stated he attempted suicide seven times in his life, the last time being ten years ago. He denied current thoughts of self harm. His post traumatic stress disorder (PTSD) gave him flashbacks and hallucinations of things he saw and did when in Vietnam. He said he was still trying to process those feelings. Some of his triggers were when people came up behind him and not having a safe place to go to process. Resident #24 was interviewed again on 8/22/23 at 1:23 p.m. He stated he had thoughts he would be better off dead in the last thirty days but he tried to stay positive. He had requested a mental health appointment through the Veterans Administration (VA) but it was canceled for some reason. He was not sure if the SSD was making him a new appointment or if he was expected to make the appointment himself. The SSD had not talked to him about it. He said he received psychosocial support from the nurses when he was having flashbacks and was distressed. D. Record review The comprehensive care plan, initiated on 5/10/23, revealed the resident had PTSD with nightmares related to military service. Interventions included to reorient the resident, allow him to verbalize his feelings and anticipate his needs. The resident had the potential to be verbally aggressive related to mental and emotional illness. Interventions included analyzing triggers, monitoring effectiveness of medications, anticipating needs, giving the resident choices, providing positive reinforcement for good behavior, and ensuring the resident has independent activities he enjoys. The resident took antidepressant medications related to depression and PTSD. The resident took antipsychotics related to PTSD, nightmares, and flashbacks. Interventions included administering medications as ordered, monitor for adverse reactions, and educate the resident on risks/benefits and side effects of medications. The August 2023 CPO revealed the following physician orders: -Abilify (Aripiprazole, antipsychotic) 10 milligram (MG)- give one tablet by mouth one time a day for PTSD- ordered on 6/7/23. -Trazodone (antidepressant) 100 MG- give one tablet by mouth for depression- ordered on 4/20/23. -Venlafaxine (Effexor, antidepressant) 75 MG- give three capsules by mouth two times a day for PTSD- ordered on 4/27/23. Progress notes reviewed from 4/21/23 to 8/24/23 revealed: -Nursing progress notes dated 4/21/23 at 3:48 p.m. revealed the resident displayed agitation when having physical difficulty feeding himself. He became angry and threw his plate on the floor. The resident stated he was leaving the facility and wanted staff to find his scooter so he could leave. The resident eventually went to sleep. -Behavior notes dated 4/22/23 at 3:29 p.m. revealed the resident had been uncooperative with care and stated he was going to leave the facility to return home. He again asked the facility to get his electric scooter for him (this was not at the facility). When the nurse tried to explain this, the resident stated his property had been stolen and he was going to call the Los Angeles police department. -Behavior notes dated 4/22/23 at 4:05 p.m. revealed the resident had escalated to screaming continuously. He again demanded the staff help him to discharge home and retrieve his scooter. The registered nurse (RN) supervisor had to calm the resident down. -Nursing progress notes dated 4/22/23 at 5:03 p.m. revealed nursing placed a call to the local mental health provider to have the resident assessed for suicidal ideations due to making verbal threats of self harm. The mental health provider informed the facility the resident required medical clearance first. -Nursing notes dated 4/22/23 at 6:48 p.m. revealed nursing placed a call to the resident's primary care provider to inform the provider of the resident's behaviors. -Order administration notes dated 4/23/23 at 10:09 p.m. revealed the resident was experiencing delusions the staff had not showered him with despite having been showered. The resident became agitated and verbally aggressive. -Nursing notes dated 4/23/23 at 3:09 p.m. revealed the resident stated to the nurse he wanted to return home but understood he was in the facility for therapy. -Order administration notes dated 4/24/23 at 2:21 p.m. revealed the resident had been yelling at his family during their visit. He told his family he was unhappy and to take him home. -Order administration notes dated 4/25/23 at 2:33 p.m. revealed the resident had become withdrawn and remained agitated. -Nutrition dietary notes dated 4/26/23 at 10:26 a.m. revealed the resident had not been adjusting well to placement and wanted to return home. -Order administration notes dated 4/26/23 at 3:29 p.m. revealed the resident was resistant to care and wanting to leave the facility. -Social services progress notes dated 4/27/23 at 3:15 p.m. revealed the social services director (SSD) met with the resident to complete the MDS and social history. The resident scored a 2 on his depression screen indicating no depressive symptoms. The note did not indicate the SSD had followed up with the resident regarding his behaviors, suicidal ideations, or demands to discharge. -Behavior notes dated 4/28/23 at 1:02 a.m. revealed the resident continuously was found to be crawling across his floor. When staff tried to educate him on using his call light and not crawling out of bed, he became belligerent. He yelled obscenities at the CNAs and woke up other residents. The other residents began to yell obscenities at him, and it went back and forth until the CNAs got him to return to bed. -Nursing progress notes dated 4/28/23 at 4:12 p.m. revealed the resident was screaming and using obscenities. The resident stripped off all of his clothing and was pulling on his catheter tubing. The tubing was adjusted and the resident eventually calmed down. -Nursing notes dated 4/28/23 at 7:12 p.m. revealed the resident's son had brought in his electric scooter but was told by the nurse the resident could not keep it. The resident became agitated and threatened to get into his scooter and leave. The son left with the scooter. -Order administration notes dated 4/28/23 at 9:03 p.m. revealed the resident was experiencing delusions he had lost four phones in four days. -Behavior notes dated 4/29/23 at 3:49 a.m. revealed the resident was experiencing visual hallucinations of people in a kitchen within his room. The resident had been yelling out for help. -Order administration notes dated 4/30/23 revealed the resident had been yelling throughout the day and was irritable. -Nursing notes dated 5/2/23 at 7:27 p.m. revealed the resident was experiencing visual hallucinations of a woman in his room trying to kidnap him. The resident had been yelling out for help. He claimed the woman was trying to kidnap him and make him use drugs. -Nursing notes dated 5/2/23 at 9:29 p.m. revealed the resident was experiencing visual hallucinations and speaking to someone in his room who was not there. -Incident notes on 5/3/23 at 3:20 a.m. revealed the resident had crawled out of bed and pulled out his catheter. He refused to allow staff to reinsert it. He was experiencing hallucinations of men in his room yelling at him. -Order administration notes dated 5/3/23 at 1:09 p.m. revealed the resident was experiencing delusions he had his sister's car at the facility and needed to return it to her. -Order administration notes dated 5/3/23 at 3:29 p.m. revealed the resident was experiencing delusions he had his sister's car at the facility and needed to return it to her. -Behavior notes dated 5/4/23 at 3:31 p.m. revealed the resident was yelling for staff assistance. He had ripped his call light from the wall and tried to self transfer so he could have a bowel movement. The resident ended up having a bowel movement in his bed. He also had thrown his water on the floor and nursing was unable to redirect his behaviors. -Behavior notes dated 5/6/23 at 4:06 p.m. revealed the resident had pulled his call light from the wall and was yelling for staff. He was refusing to use his urinal and instead used cups, his trash can, or the floor. The resident poured his water on the floor twice and stripped his clothes off twice. -Order administration notes dated 5/10/23 at 2:31 p.m. revealed the resident was experiencing confusion and agitation with increased anxiety. -Order administration notes dated 5/11/23 at 8:46 p.m. revealed the resident was experiencing delusions and hallucinations he was instructing troops he said who were not following his instructions. -Order administration notes dated 5/21/23 at 2:03 a.m. revealed the resident was experiencing delusions and hallucinations. He said there were sheriffs outside his window and he had been talking to a sergeant. -Order administration notes dated 5/22/23 at 12:51 a.m. revealed the resident was experiencing delusions asking the staff when chow was. He had become withdrawn with increased agitation. -Nursing progress notes dated 5/29/23 at 1:25 p.m. revealed the resident was experiencing delusions telling the nurse he had magical powers and his daughter had once brought him a dead baby with a hole in its skull. His daughter visited him by coming through the walls. -Order administration notes dated 6/2/23 at 11:03 p.m. revealed the resident was experiencing anxiety and came to the nurse stating he was going crazy. He was aware some of the things he saw were not real and expressed interest in seeing a psychiatrist. -Social services progress notes dated 6/6/23 at 10:09 a.m. revealed the physician had ordered mental health consultation for the resident. The SSD was attempting to schedule it through the resident's insurance. The note did not indicate the SSD had followed up with the resident regarding his behaviors, hallucinations, or delusions. -Behavior notes dated 6/9/23 at 8:26 p.m. revealed the resident had been found in his room yelling and swinging suspenders around the room. The resident was experiencing delusions and hallucinations where someone else was in the room. -Nursing progress notes dated 6/9/23 at 8:33 p.m. revealed the resident was to be referred to the mental health provider for counseling. -Nursing notes dated 6/26/23 at 7:22 p.m. revealed the resident had been out of the facility for his mental health appointment but when he arrived, the appointment had been canceled. The resident was to have a rescheduled appointment. -Social services progress notes dated 7/14/23 at 10:41 a.m. revealed the resident's MDS was completed. His depression score had increased to 14, indicating moderate depression. He had negative thoughts about himself and thoughts he would be better off dead but said he would not harm himself. The SSD had not been able to reschedule his mental health appointment yet. No suicidal ideation screen was conducted and the note did not indicate the SSD discussed with the resident his behaviors and hallucinations. -Behavior notes dated 7/24/23 at 7:50 p.m. revealed the resident was tearful and talked to the nurse about having to serve his son with eviction papers to leave his home. He stated his son hated him. -Order administration notes dated 7/25/23 at 2:23 a.m. revealed the resident had expressed depression related to the situation with his son. -Order administration notes dated 7/29/23 at 5:54 p.m. revealed the resident was having behaviors of yelling, using obscene language, anxiety, and irritability. -Medical appointment scheduling notes written by the business office assistant (BOA) dated 8/23/23 at 2:11 p.m. (during survey) revealed the BOA was notified by the SSD the resident needed a mental health appointment scheduled. A message was left with the VA. From 4/21/23 to 8/23/23, eighteen progress notes were documented concerning aggressive, depressive, or adjustment related behaviors. Fourteen progress notes were documented concerning hallucinations, delusions, and flashbacks. There were only two social service progress notes in this time frame and neither reflected the SSD addressed with the resident directly his behaviors or adjustment issues. II. Resident #12 A. Resident status Resident #12, age [AGE], was admitted on [DATE]. According to the August 2023 CPO, the diagnoses included bipolar, depression, and anxiety. The 7/5/23 MDS assessment revealed the resident was cognitively intact with a BIMS score of 12 out of 15. No behaviors were indicated. The resident was marked as having a PASRR level II condition of mental illness on the MDS. B. Resident interview Several attempts were made to interview the resident between 8/21/23 and 8/24/23. The resident was sleeping each time. C. Record review The comprehensive care plan, revised on 7/11/21, revealed the resident had bipolar disorder with anxiety. The resident had been stable over the past year and no longer required services from the mental health provider. Interventions included to keep the physician, mental health provider, and family informed of any changes in mood, depression, and behaviors. The resident would maintain a daily routine, be provided with calm environments if conflicts arose, and be encouraged to participate in activities of choice. The resident took Lithium (a psychiatric mood stabilizer) and Cymbalta (an antidepressant) for depression. Interventions included monitoring for behaviors and adverse reactions. Provide activities of choice and provide a safe environment. The resident took Risperdal (an antipsychotic) for bipolar as evident by inappropriate verbal comments and resistance to care. Interventions included monitoring for behaviors and adverse reactions. When manic, the resident would display excessive talking, seeking out men, wandering, expressing a desire to smoke, and decreased sleeping. Staff to assist with distractions and encouraging participation in activities. The August 2023 CPO revealed the following physician orders: -Cymbalta 30 MG- give one by mouth once a day for bipolar- ordered on 4/8/21. -Lithium carbonate 150 MG- give one by mouth once a day for bipolar- ordered on 5/7/21. -Risperdal 1 MG- give one by mouth once a day for dementia with behaviors- ordered on 12/21/22. -Lorazepam (Ativan) 0.5 MG- give one tablet by mouth at bedtime for other specified anxiety disorders- ordered on 7/18/23. -Lorazepam 0/25 MG- give one tablet two times a day for anxiety- ordered on 7/19/23. Progress notes reviewed from 12/31/22 to 8/24/23 revealed: -Nursing notes dated 6/20/23 at 7:07 p.m. revealed the resident had a fall in her bathroom and was unable to move her left leg and complained of pain in her leg and hip. An ambulance was called to take the resident to the hospital. -Nursing notes dated 6/20/23 at 8:27 p.m. revealed the resident was admitted to the hospital with a left hip fracture. -Nursing notes dated 6/22/23 at 5:30 p.m. revealed the resident was readmitted to the facility post surgery for a left hip fracture. -Social services progress notes dated 7/5/23 at 11:56 a.m. revealed the resident's MDS was completed. -Nursing progress notes dated 7/6/23 at 3:49 p.m. revealed the resident stated to the nurse the prior day's storm had made her feel nervous and voiced increased anxiety before and after the storm. Twice during the shift, the resident had attempted to transfer and ambulate herself, needing to be reminded to call for assistance. The daughter was contacted and the daughter informed the nurses the resident had sounded confused and had slurred speech when on the phone. The physician was notified. -Nursing progress notes dated 7/8/23 at 2:04 p.m. revealed the resident alerted nursing she was feeling anxious and wanted to lie down. -Nursing progress notes dated 7/9/23 at 12:29 p.m. revealed the resident continued to show confusion with pacing back and forth in her wheelchair. -Nursing progress notes dated 7/10/23 at 7:43 p.m. revealed the resident continued to show confusion and attempted to leave the dining room during meals repeatedly. The resident stated she did not know why she was there, she was confused, and did not know where she was. She expressed her confusion and forgetfulness was making her feel anxious. The resident had also begun to not recall when to use her call light for assistance and would instead yell for staff. -Order administration notes dated 7/11/23 at 2:37 p.m. revealed the resident expressed frustration related to her onset of confusion and desired to isolate in her room. -Nursing progress notes dated 7/11/23 at 3:27 p.m. revealed the resident continued to show confusion and attempted to leave the dining room during meals repeatedly. Nursing documented the resident had become less talkative and presented as sad. -Order administration notes dated 7/12/23 at 7:26 a.m. revealed the resident had increased anxiety. -Nursing progress notes dated 7/12/23 at 2:37 p.m. revealed the resident continued to tell nursing staff she felt anxious and nervous. The resident would exit her room after being taken there by staff to roam the hallways. -Nursing progress notes dated 7/12/23 at 8:52 p.m. revealed the resident continued to show confusion. She would request to use the bathroom when she did not need to. After being laid down in bed, the resident would attempt to get out of bed unassisted. -Nursing progress notes dated 7/13/23 at 3:36 p.m. revealed the resident continued to show increased anxiety and restlessness. -Nursing progress notes dated 7/13/23 at 7:08 p.m. revealed the resident asked to be laid down and then frequently asked staff to get her up and lay her down again. -Nursing progress notes dated 7/14/23 at 6:59 a.m. revealed the resident had been restless throughout the night, requesting the staff not leave her alone. She frequently asked the staff to get her up and lay her down again stating she could not sleep. The note documented the behavior had been occurring for the last several nights. -Nursing progress notes dated 7/14/23 at 3:09 p.m. revealed nursing contacted the nurse practitioner regarding the resident's increased restlessness, anxiety, and fears of being left alone by the staff. The resident was refusing to lie down or stay in her room. Nursing requested the addition of Ativan from the nurse practitioner. -Order administration notes dated 7/15/23 at 12:29 p.m. revealed the resident displayed restlessness, anxiety, and self isolating in her room. -Nursing progress notes dated 7/15/23 at 12:31 p.m. revealed the resident was given an Ativan for restlessness and anxiety. The medication was ineffective. The resident continued to ask to get up and lay down frequently. The resident continued to pace the hallways seeking staff and requested to stay with them. She expressed wanting the staff to sit with her and hold her hand. -Nursing progress notes dated 7/15/23 at 9:10 p.m. revealed the resident continued to display restlessness, anxiety, pacing, and requests to be put to bed and then gotten out of bed. -Nursing progress notes dated 7/16/23 at 3:24 p.m. revealed the resident continued to display restlessness and requested the staff to sit with her. Ativan was ineffective. -Order administration notes dated 7/17/23 at 1:34 a.m. revealed the resident displayed anxiety. -Order administration notes dated 7/17/23 at 7:43 p.m. revealed the resident stated she was feeling anxiety. -Order administration notes dated 7/18/23 at 1:48 a.m. revealed the resident displayed anxiety. -Nursing progress notes dated 7/18/23 at 4:16 p.m revealed the provider was contacted and the Ativan was increased for continued anxiety. -Behavior notes dated 7/22/23 at 8:04 p.m. revealed after agreeing to take a shower, the resident refused once inside the shower. -Nursing progress notes dated 7/24/23 at 11:28 a.m. revealed the resident continued to display anxiety and agitation. Calling for staff when they walked past her room and showing forgetfulness. -Nursing progress notes dated 7/25/23 at 10:39 a.m. revealed the resident continued to display confusion. -Nursing progress notes dated 7/25/23 at 10:47 a.m. revealed the resident had a telehealth appointment with the mental health provider by request of her nephrologist (kidney doctor) to determine if lithium could be discontinued. The resident became agitated by the questions and refused to continue with the appointment. -Social services notes dated 7/25/23 at 11:02 a.m. revealed the SSD was advised by the mental health provider of the outcome of the appointment. -Nursing progress notes dated 7/25/23 at 12:50 p.m. revealed the resident continued to display irritability. -Nursing progress notes dated 7/26/23 at 2:50 p.m. revealed the resident continued to display anxiety. -Nursing progress notes dated 7/27/23 at 4:50 p.m. revealed nursing contacted the nurse practitioner regarding increasing the resident's Ativan again as the current dose was not effective. The nurse practitioner declined as the provider had recently increased it. The provider was questioning if hospice/comfort care needed to be considered. -Nursing progress notes dated 7/29/23 at 2:29 p.m. revealed nursing contacted the daughter to discuss possible hospice/comfort care. The daughter declined. -Nursing progress notes dated 8/4/23 at 9:52 p.m. revealed the resident continued with anxiety and restlessness. -Nursing progress notes dated 8/6/23 at 2:44 p.m. revealed the resident continued to attempt to self transfer. The resident had refused her shower the prior day and wanted to reschedule it for 8/6/23. While staff came to take the resident for her shower, she refused three times and called the staff inappropriate names. From 6/20/23 to 8/24/23, twenty six progress notes were documented concerning anxiety, distress, and confusion. From 7/6/23 to 8/6/23, the resident also displayed behaviors consistent with her care plan as indicators of bipolar episodes: decreased sleeping, inappropriate comments, wandering, and resistance to care. According to the resident's medical record, from 12/31/22 until 7/6/23, the resident's behaviors had been stable. There was only one social service progress note in the time frame and it did not reflect the SSD addressed with the resident her behaviors or increased anxiety. III. Resident #9 A. Resident status Resident #9, age [AGE], was admitted on [DATE]. According to the August 2023 CPO, the diagnoses included recurrent depressive disorder and insomnia. The 7/5/23 MDS assessment revealed the resident was cognitively intact with a BIMS score of 15 out of 15. No behaviors were indicated. B. Resident interview The resident was interviewed on 8/22/23 at 2:01 p.m. The resident stated she had requested information from the facility to contact the state health department regarding flies in the facility but was never given the information. She said she had episodes of depression since coming to the facility but no one had asked her if she would like to see a psychologist for depression or adjustment issues. When she was upset, the nurses would come and talk to her sometimes. C. Record review The comprehensive care plan revised on 6/29/23 revealed the resident had anxiety and adjustment issues related to nursing home placement. Interventions included encouraging the resident to participate in activities, providing her with choices, providing consistency of care, praising good behavior, and if possible schedule times for ADL care with the resident. The resident was taking an antidepressant medication related to depression manifesting as tearfulness, lashing out at staff, and being argumentative. Interventions were to monitor the resident's behaviors. The August 2023 CPO revealed the following physician orders: -Prozac (antidepressant) 10 MG- give three capsules by mouth one time a day for recurrent depressive disorder- ordered on 6/12/23. Progress notes reviewed from 6/13/23 to 8/24/23 revealed: -Order administration notes dated 6/13/23 at 9:27 p.m. revealed the resident expressed to nursing staff distress with her roommate for not turning off her television or lights when she went to bed. The resident stated she had been unable to sleep for two nights as a result. -Order administration notes dated 6/14/23 at 1:12 a.m. revealed the resident expressed frustration to the nurses regarding her roommate. The resident was yelling and touching her roommate's television, complaining about the roommate's light being on. -Nursing progress notes dated 6/14/23 at 4:09 a.m. revealed the resident expressed to nursing staff she could not sleep because there was a light on in her room. The resident came out of her room several times to complain to staff about the light. The resident was arguing with her roommate and attempting to turn her roommate's television off. The resident was yelling at staff stating she could not take this anymore and wanted to leave. -Nursing progress notes dated 6/14/23 at 2:20 p.m. revealed the resident expressed to the nurses being unhappy with her roommate. Nursing advised the social services director of the situation. -Social service progress notes dated 6/14/23 at 3:12 p.m. revealed the behavior committee reviewed the resident's chart and no changes were recommended due to the resident being a new admission. The note did not indicate the SSD followed up with the resident on her distress or concerns. -Order administration notes dated 6/14/23 at 8:04 p.m. revealed the resident displayed behaviors of frequently calling the staff into her room to address superficial needs in order to have someone in the room with her. -Order administration notes dated 6/19/23 at 1:34 p.m. revealed the resident had been tearful when nursing was communicating with her due to feeling frustration. The staff brought her coffee in a facility cup and not in her personal coffee cup as per her preference. -Order administration notes dated 6/20/23 at 8:03 p.m. revealed the resident displayed behaviors of anger and distress regarding the dinner served. She expressed dinner being disgusting and then expressed anxiety regarding a potential new roommate she was going to get. She was concerned the roommate would also leave a light on. -Behavior notes dated 6/21/23 at 8:07 p.m. revealed the resident expressed anger and distress to nursing regarding her new roommate and the door being cracked open in the evening so the nurses could check on the roommate. The resident was upset about the light coming into her room and disrupting her sleep. -Order administration notes dated 6/23/23 at 8:49 p.m. revealed the resident expressed tearfulness and frustration to nursing staff but no further details were provided in the note. -Nursing progress notes dated 6/23/23 at 9:46 p.m. revealed the resident expressed distress and frustration to the nursing staff stating the situation with the roommate had been handled poorly. The resident demanded to speak to someone in upper management. Nursing advised her the director of nursing would be notified. -Nursing progress notes dated 6/24/23 at 3:41 p.m. revealed the resident expressed distress to nursing regarding needing her room to be rearranged and needing an extension cord in order to use her stereo. -Social service notes dated 6/26/23 at 10:29 a.m. revealed the SSD had a conversation with the resident's daughter. The conversation pertained to items the resident was missing from her previous facility. The SSD was aware of the resident's behaviors and informed the daughter of the behaviors. However, progress notes did not indicate the SSD had met with the resident to discuss her behaviors, distress, challenges adjusting, or desire to express grievances. -Social service notes dated 6/26/23 at 4:44 p.m. revealed the SSD completed the resident's MDS and was aware the resident was unhappy with her roommates. -Order administration notes dated 6/26/23 at 8:36 p.m. revealed the resident did not receive her dinner in her room as she requested and was upset she had been forgotten. -Order administration notes dated 6/28/23 at 3:08 p.m. revealed the resident expressed tearfulness and frustration to nursing staff regarding her iced tea not being strong enough. She lashed out at staff accusing them of not knowing what they were doing and not being able to do anything right for her. -Order administration notes dated 7/3/23 at 12:42 p.m. revealed the resident had been tearful every time the staff went into her room but could not explain what she was tearful about. -Order administration notes dated 7/3/23 at 8:54 p.m. revealed the resident had been calling staff frequently to her room for superficial requests like moving a table or closing her blinds. -Order administration notes dated 7/4/23 at 1:31 p.m. revealed the resident had been tearful. The resident denied physical discomfort and attempted to express her emotional distress to the staff regarding feeling her previous facility had been better. -Social service progress notes dated 7/6/23 at 11:44 a.m. revealed the resident had come to the SSD's office to request discharge back to her prior facility. The resident felt the current facility was charging her for her incontinence supplies. The SSD called the prior facility and left a message. No further conversation was documented reflecting the SSD addressed the resident's grievance. -Nursing progress notes dated 7/7/23 at 11:48 a.m. revealed the resident had an appointment in the morning and had been upset about leaving the facility for the appointment. She had been upset about her incontinent pads and oxygen tubing. -Order administration notes dated 7/8/23 3:10 p.m. revealed the resident expressed frustration and was argumentative with nu

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interviews, the facility failed to ensure each resident's drug regimen was free from unnecessary drugs for one (#39) of five residents reviewed for unnecessary medications. Specifically, the facility failed to ensure the ordered antibiotic was effective to treat the resident. Findings include: I. Resident status Resident #39, age [AGE], was admitted on [DATE] and readmitted [DATE]. According to the August 2023 computerized physician orders (CPO), diagnoses included chronic obstructive pulmonary disease (COPD) and urinary tract infections. The 5/8/23 minimum data set (MDS) assessment revealed the resident was unable to conduct a brief interview for mental status (BIMS) due to severe cognitive decline. During the look back period, she had received an antibiotic seven out of seven days. II. Record review The August 2023 CPO included an order for Keflex 250 mg (cephalexin). Give one capsule by mouth at bedtime for recurrent urinary tract infections (UTIs). The order started 8/23/21. The hospital discharge paperwork dated 7/14/23 included: -Page four listed the discharge medications to include cephalexin 250 mg, take one capsule by mouth nightly at bedtime. -Page seven noted, antibiotic resistance to cephalosporins. III. Interviews The director of nursing (DON) was interviewed on 8/23/23 at 2:00 p.m. She said she was not aware the resident had developed a resistance to Keflex. She said the facility went by the discharge orders and did not see the notation of resistance. She said going forward she would review the discharge instructions more closely and would contact the primary to discontinue the Keflex.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to ensure three (#24, #12, and #9) of five residents reviewed were free from unnecessary psychotropic medications out of 24 sample residents. Specifically, the facility failed to monitor targeted behaviors and provide non-pharmacological interventions for psychotropic medications for Residents #24, #12 and #9. Findings include: I. Resident #24 A. Resident status Resident #24, age [AGE], was admitted on [DATE]. According to the August 2023 computerized physician orders (CPO), the diagnoses included post traumatic stress disorder, alcohol induced dementia, and depression. The 7/12/23 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 13 out of 15. The resident's depression screen revealed a score of 14 out of 27 indicating moderate depression. No behaviors were indicated. B. Resident interview Resident #24 was interviewed on 8/22/23 at 9:52 a.m. The resident stated he suffered from post traumatic stress disorder (PTSD), flashbacks, and hallucinations. The flashbacks and hallucinations were disturbing to him at times, and consisted of things he saw and did when in Vietnam. He said he was still trying to process those feelings. Some of his triggers were when people came up behind him and not having a safe place to go to process. He said interventions that worked for him were listening to his music, playing on his phone, smoking cigarettes, and one-to-one visits with staff. D. Record review The comprehensive care plan, initiated on 5/10/23, revealed the resident had PTSD with nightmares related to military service. The resident had the potential to be verbally aggressive related to mental and emotional illness. The resident took antidepressant medications related to depression and PTSD. The resident took antipsychotics related to PTSD, nightmares, and flashbacks. Interventions included administering medications as ordered, monitor for adverse reactions, and educate the resident on risks/benefits and side effects of medications. Interventions for the resident's psychotropic medications did not include non-pharmacological approaches. The August 2023 CPO revealed the following physician orders: -Monitor for signs and symptoms of depression: withdrawn, tearful, resistive with care. If behaviors observed document the behavior episode, interventions used and effectiveness of interventions- ordered on 4/20/23. No specific medication was indicated. -Monitor for signs and symptoms of mood swings: withdrawal, depression, anxiety, flashbacks, irritability. If behaviors observed document the behavior episode, interventions used and effectiveness of interventions- ordered on 4/20/23. No specific medication was indicated. -Abilify (Aripiprazole, antipsychotic) 10 milligrams (MG)- give one tablet by mouth one time a day for PTSD- ordered on 6/7/23. -Trazodone (antidepressant) 100 MG- give one tablet by mouth for depression- ordered on 4/20/23. -Venlafaxine (Effexor, antidepressant) 75 MG- give three capsules by mouth two times a day for PTSD- ordered on 4/27/23. Behavior monitoring dated 5/1/23 to 8/23/23 revealed: -May 2023 monitoring documented behaviors of mood swings on 5/2/23-5/4/23, 5/10/23, 5/11/23, 5/20/23, 5/22/23, 5/27/23, 5/29/23, and 5/30/23. -May 2023 monitoring documented behaviors of depression on 5/3/23, 5/4/23, 5/6/23, 5/10/23, 5/11/23, 5/17/23, 5/20/23, and 5/27/23. -June 2023 monitoring documented behaviors of mood swings on 6/2/23 and 6/25/23. -June 2023 monitoring documented behaviors of depression on 6/2/23. -July 2023 monitoring documented behaviors of mood swings on 7/24/23 and 7/29/23. -July 2023 monitoring documented no behaviors of depression. -August 2023 monitoring documented no behaviors of mood swings. -August 2023 monitoring documented behaviors of depression on 8/14/23. Progress notes reviewed from 5/1/23 to 8/24/23 revealed: -Incident notes on 5/3/23 at 3:20 a.m. revealed the resident had crawled out of bed and pulled out his catheter. He refused to allow staff to reinsert it. He was experiencing hallucinations of men in his room yelling at him. No non-pharmacological interventions were documented. -Order administration notes dated 5/3/23 at 3:29 p.m. revealed the resident was experiencing delusions he had his sister's car at the facility and needed to return it to her. No non-pharmacological interventions were documented. -Order administration notes dated 5/4/23 at 12:57 p.m. documented a behavior was observed: yes. No other information included in the note. -Order administration notes dated 5/6/23 at 11:56 a.m. documented a behavior was observed: yes. No other information included in the note. -Order administration notes dated 5/10/23 at 2:31 p.m. revealed the resident was experiencing confusion and agitation with increased anxiety. No non-pharmacological interventions were documented. -Order administration notes dated 5/11/23 at 12:07 p.m. documented a behavior was observed: yes. No other information included in the note. -Order administration notes dated 5/17/23 at 8:23 p.m. revealed the resident refused his shower. This progress note was marked as a behavior associated with depression. No non-pharmacological interventions were documented. -Order administration notes dated 5/21/23 at 2:03 a.m. revealed the resident had experienced delusions and hallucinations. He said there were sheriffs outside his window and he had been talking to a sergeant. No non-pharmacological interventions were documented. The behavior episode had not been documented on the behavior tracker. -Order administration notes dated 5/23/23 at 5:48 a.m. documented a behavior was observed: yes. No other information included in the note. The behavior episode had not been documented on the behavior tracker. -Order administration notes dated 5/28/23 at 1:28 a.m. documented a behavior was observed: yes. No other information included in the note. The behavior episode had not been documented on the behavior tracker. -Behavior notes dated 6/9/23 at 8:26 p.m. revealed the resident had been found in his room yelling and swinging suspenders around the room. The resident was experiencing delusions and hallucinations where someone else was in the room. The behavior episode had not been documented on the behavior tracker. -Order administration notes dated 6/25/23 at 7:34 p.m. documented a behavior was observed: yes. No other information included in the note. -Social services progress notes dated 7/14/23 at 10:41 a.m. revealed while the SSD was conducting a depression screen with the resident he stated he had lost interest in activities he enjoyed, had been feeling down, had trouble sleeping due to nightmares, felt bad about himself and had thoughts he would be better off dead. He denied a plan to harm himself. Those indicators of depression were not documented on his behavior tracker and the depression behavior tracker was not modified to include suicidal ideations. No non-pharmacological interventions were documented. -Order administration notes dated 7/25/23 at 2:23 a.m. revealed the resident had expressed depression related to the situation with his son. No non-pharmacological interventions were documented. The behavior episode had not been documented on the behavior tracker. -Order administration notes dated 7/29/23 at 5:54 p.m. revealed the resident had behaviors of yelling, using obscene language, anxiety, and irritability. No non-pharmacological interventions were documented. -Order administration notes dated 8/15/23 at 1:57 a.m. documented a behavior was observed: yes. No other information included in the note. The behavior episode had not been documented on the behavior tracker. No progress note was located for the behavior documented on the August 2023 tracker for 8/14/23. II. Resident #12 A. Resident status Resident #12, age [AGE], was admitted on [DATE]. According to the August 2023 CPO, the diagnoses included bipolar, depression, and anxiety. The 7/5/23 MDS assessment revealed the resident was cognitively intact with a BIMS score of 12 out of 15. No behaviors were indicated. B. Resident interview Several attempts were made to interview the resident between 8/21/23 and 8/24/23. The resident was sleeping each time. C. Record review The comprehensive care plan, revised on 7/11/21, revealed the resident had bipolar disorder with anxiety. The resident took Lithium (a psychiatric mood stabilizer) and Cymbalta (an antidepressant) for depression. Interventions included monitoring for behaviors and adverse reactions. Provide activities of choice and provide a safe environment. The resident took Risperdal (an antipsychotic) for bipolar as evident by inappropriate verbal comments and resistance to care. Interventions included monitoring for behaviors and adverse reactions. When manic, the resident would display excessive talking, seeking out men, wandering, expressing a desire to smoke, and decreased sleeping. Non-pharmacological interventions included; snacks from nurses station, call daughter, puzzles, Bingo, personal comfort food (Mexican food), and games. The August 2023 CPO revealed the following physician orders: -Monitor for signs and symptoms of depression: sad expression, irritability or frustration, isolating self in room. If behaviors observed document the behavior episode, interventions used and effectiveness of interventions for use of Cymbalta- ordered on 5/5/2020. -Lithium carbonate (mood stabilizer) 150 MG- give one by mouth once a day for bipolar- ordered on 5/7/21. -Monitor for signs and symptoms of mood swings: inappropriate verbal comments to staff and elders (residents) and resistance to care. If behaviors observed document the behavior episode, interventions used and effectiveness of interventions for use of Risperdal- ordered on 9/30/21. -Cymbalta (antidepressant) 30 MG- give one by mouth once a day for bipolar- ordered on 4/8/21 (original start date 11/15/2020). -Risperdal (antipsychotic) 1 MG- give one by mouth once a day for dementia with behaviors- ordered on 12/21/22 (original start date 1/29/2020). -Lorazepam (Ativan, anti-anxiety) 0.5 MG- give one tablet by mouth at bedtime for other specified anxiety disorders- ordered on 7/18/23. -Lorazepam 0/25 MG- give one tablet two times a day for anxiety- ordered on 7/19/23. No behavior trackers for Lithium or Lorazepam were located in physician orders. Behavior monitoring dated 5/1/23 to 8/23/23 revealed: -May 2023 monitoring documented no behaviors of mood swings. -May 2023 monitoring documented behaviors of depression on 5/15/23 and 5/29/23. -June 2023 monitoring documented no behaviors of mood swings. -June 2023 monitoring documented no behaviors of depression. -July 2023 monitoring documented no behaviors of mood swings. -July 2023 monitoring documented behaviors of depression on 7/11/23, 7/13/23, 7/15/23, 7/17/23, 7/21/23, 7/25/23, and 7/27/23. -August 2023 monitoring documented no behaviors of mood swings. -August 2023 monitoring documented no behaviors of depression. Progress notes reviewed from 5/1/23 to 8/24/23 revealed: -Order administration notes dated 5/29/23 at 1:20 p.m. documented the resident had a sad expression. No other information included in the note. -Nursing progress notes dated 7/6/23 at 3:49 p.m. revealed the resident stated to the nurse the prior day's storm had made her feel nervous and voiced increased anxiety before and after the storm. Twice during the shift, the resident had attempted to transfer and ambulate herself, needing to be reminded to call for assistance. No non-pharmacological interventions were documented. The behavior episode had not been documented on the behavior tracker. -Nursing progress notes dated 7/8/23 at 2:04 p.m. revealed the resident alerted nursing she was feeling anxious and wanted to lie down. The behavior episode had not been documented on the behavior tracker. -Nursing progress notes dated 7/9/23 at 12:29 p.m. revealed the resident continued to show confusion with pacing back and forth in her wheelchair. No non-pharmacological interventions were documented. The behavior episode had not been documented on the behavior tracker. -Nursing progress notes dated 7/10/23 at 7:43 p.m. revealed the resident continued to show confusion and attempted to leave the dining room during meals repeatedly. The resident stated she did not know why she was there, she was confused, and did not know where she was. She expressed her confusion and forgetfulness was making her feel anxious. The resident had also begun to not recall when to use her call light for assistance and would instead yell for staff. No non-pharmacological interventions were documented. The behavior episode had not been documented on the behavior tracker. -Order administration notes dated 7/11/23 at 2:37 p.m. revealed the resident expressed frustration related to her onset of confusion and desired to isolate in her room. No non-pharmacological interventions were documented. -Nursing progress notes dated 7/11/23 at 3:27 p.m. revealed the resident continued to show confusion and attempted to leave the dining room during meals repeatedly. Nursing documents the resident had become less talkative and presented as sad. No non-pharmacological interventions were documented. -Order administration notes dated 7/12/23 at 7:26 a.m. revealed the resident had increased anxiety. No other information included in the note. The behavior episode had not been documented on the behavior tracker. -Nursing progress notes dated 7/12/23 at 2:37 p.m. revealed the resident continued to tell nursing staff she felt anxious and nervous. The resident would exit her room after being taken there by staff to roam the hallways. No non-pharmacological interventions were documented. The behavior episode had not been documented on the behavior tracker. -Nursing progress notes dated 7/12/23 at 8:52 p.m. revealed the resident continued to show confusion. She would request to use the bathroom when she did not need to. After being laid down in bed, the resident would attempt to get out of bed unassisted. No non-pharmacological interventions were documented. The behavior episode had not been documented on the behavior tracker. -Nursing progress notes dated 7/13/23 at 3:36 p.m. revealed the resident continued to show increased anxiety and restlessness. No non-pharmacological interventions were documented. -Nursing progress notes dated 7/14/23 at 6:59 a.m. revealed the resident had been restless throughout the night, requesting the staff not leave her alone. She frequently asked the staff to get her up and lay her down again stating she could not sleep. The note documented the behavior had been occurring for the last several nights. No non-pharmacological interventions were documented. The behavior episode had not been documented on the behavior tracker. -Nursing progress notes dated 7/14/23 at 3:09 p.m. revealed nursing contacted the nurse practitioner regarding the resident's increased restlessness, anxiety, and fears of being left alone by the staff. The resident was refusing to lie down or stay in her room. Nursing requested the addition of Ativan from the nurse practitioner. -Order administration notes dated 7/15/23 at 12:29 p.m. revealed the resident displayed restlessness, anxiety, and self isolating in her room. No non-pharmacological interventions were documented. -Nursing progress notes dated 7/15/23 at 9:10 p.m. revealed the resident continued to display restlessness, anxiety, pacing, and requests to be put to bed and then gotten out of bed. No non-pharmacological interventions were documented. -Nursing progress notes dated 7/16/23 at 3:24 p.m. revealed the resident continued to display restlessness and requested the staff to sit with her. Ativan was ineffective. The behavior episode had not been documented on the behavior tracker. -Order administration notes dated 7/17/23 at 1:34 a.m. revealed the resident displayed anxiety. No other information included in the note. -Order administration notes dated 7/17/23 at 7:43 p.m. revealed the resident stated she was feeling anxiety. No other information included in the note. -Order administration notes dated 7/18/23 at 1:48 a.m. revealed the resident displayed anxiety. No other information included in the note. The behavior episode had not been documented on the behavior tracker. -Behavior notes dated 7/22/23 at 8:04 p.m. revealed after agreeing to take a shower, the resident refused once inside the shower. The behavior episode had not been documented on the behavior tracker. -Order administration notes dated 7/24/23 at 3:04 a.m. revealed the resident had an unwitnessed fall and was sent out to the hospital. The progress note was marked as a behavior associated with mood swings. -Nursing progress notes dated 7/25/23 at 12:50 p.m. revealed the resident continued to display irritability. No other information included in the note. -Nursing progress notes dated 7/26/23 at 2:50 p.m. revealed the resident continued to display anxiety and staff contacted the provider per the resident's request. The behavior episode had not been documented on the behavior tracker. -Nursing progress notes dated 8/4/23 at 9:52 p.m. revealed the resident continued with anxiety and restlessness. No non-pharmacological interventions were documented. The behavior episode had not been documented on the behavior tracker. -Nursing progress notes dated 8/6/23 at 2:44 p.m. revealed the resident continued to attempt to self transfer. The resident had refused her shower the prior day and wanted to reschedule it for 8/6/23. While staff came to take the resident for her shower, she refused three times and called the staff inappropriate names. No non-pharmacological interventions were documented. The behavior episode had not been documented on the behavior tracker. No progress note was located for the behavior documented on the May 2023 tracker for 5/15/23. III. Resident #9 A. Resident status Resident #9, age [AGE], was admitted on [DATE]. According to the August 2023 CPO, the diagnoses included recurrent depressive disorder and insomnia. The 7/5/23 MDS assessment revealed the resident was cognitively intact with a BIMS score of 15 out of 15. No behaviors were indicated. B. Resident interview The resident was interviewed on 8/22/23 at 2:01 p.m. She said she had episodes of depression since coming to the facility but no one had asked her if she would like to see a psychologist for depression or adjustment issues. When she was upset, the nurses would come and talk to her sometimes. C. Record review The comprehensive care plan, revised on 6/29/23 revealed the resident had anxiety and adjustment issues related to nursing home placement. The resident was taking an antidepressant medication related to depression manifesting as tearfulness, lashing out at staff, and being argumentative. Interventions were to monitor the resident's behaviors. Interventions for the resident's psychotropic medication did not include non-pharmacological approaches. The August 2023 CPO revealed the following physician orders: -Prozac (antidepressant) 10 MG- give three capsules by mouth one time a day for recurrent depressive disorder- ordered on 6/12/23. -Monitor for signs and symptoms of depression: tearful, frustrated, statements of feeling sad, argumentative, lashing out at staff. If behaviors observed document the behavior episode, interventions used and effectiveness. No specific medication indicated- ordered on 6/26/23. Behavior monitoring dated 6/12/23 to 8/23/23 revealed: -June 2023 monitoring documented behaviors of depression on 6/26/23 and 6/27/23. -July 2023 monitoring documented behaviors of depression on 7/3/23-7/6/23, 7/8/23, 7/9/23, 7/11/23-7/13/23, 7/17/23- 7/20/23, 7/24/23- 7/27/23, and 7/31/23. -August 2023 monitoring documented behaviors of depression on 8/3/23, 8/6/23-8/17/23, 8/19/23, 8/22/23-8/24/23, 8/27/23, and 8/28/23. Progress notes from 6/26/23 to 8/24/23 revealed: -Order administration notes dated 6/28/23 at 3:08 p.m. revealed the resident expressed tearfulness and frustration to nursing staff regarding her iced tea not being strong enough. She lashed out at staff accusing them of not knowing what they were doing and not being able to do anything right for her. The behavior episode had not been documented on the behavior tracker. -Order administration notes dated 7/3/23 at 12:42 p.m. revealed the resident had been tearful every time the staff went into her room but could not explain what she was tearful about. No non-pharmacological interventions were documented. -Order administration notes dated 7/3/23 at 8:54 p.m. revealed the resident had been calling staff frequently to her room for superficial requests like moving a table or closing her blinds. This progress note was marked as a behavior associated with depression. No non-pharmacological interventions were documented. -Order administration notes dated 7/4/23 at 1:31 p.m. revealed the resident had been tearful. The resident denied physical discomfort and attempted to express her emotional distress to the staff regarding feeling her previous facility had been better. This progress note was marked as a behavior associated with depression. No non-pharmacological interventions were documented. -Order administration notes dated 7/5/23 at 10:42 p.m. documented a behavior was observed: yes. No other information included in the note. -Order administration notes dated 7/6/23 at 2:03 p.m. documented a behavior was observed: yes. No other information included in the note. -Order administration notes dated 7/6/23 at 9:53 p.m. documented a behavior was observed: yes. No other information included in the note. -Order administration notes dated 7/8/23 3:10 p.m. revealed the resident expressed frustration, was argumentative with nursing staff and threatened to start throwing things. No non-pharmacological interventions were documented. -Order administration notes dated 7/9/23 at 11:32 a.m. revealed the resident expressed frustration, complaints, and was argumentative with nursing staff but no further details were provided in the note. -Order administration notes dated 7/11/23 at 1:36 p.m. documented a behavior was observed: yes. No other information included in the note. -Order administration notes dated 7/12/23 at 1:02 p.m. documented a behavior was observed: yes. No other information included in the note. -Order administration notes dated 7/13/23 at 12:33 p.m. documented a behavior was observed: yes. No other information included in the note. -Order administration notes dated 7/17/23 at 7:41 p.m. documented a behavior was observed: yes. No other information included in the note. -Order administration notes dated 7/19/23 at 1:50 p.m. documented a behavior was observed: yes. No other information included in the note. -Order administration notes dated 7/20/23 at 1:28 p.m. revealed the resident expressed tearfulness towards nursing staff stating she could not do this anymore, was frustrated, and felt exhausted. No non-pharmacological interventions were documented. -Order administration notes dated 7/24/23 at 2:21 p.m. revealed the resident expressed frustration and was screaming because she could not get her oxygen on her face correctly. This progress note was marked as a behavior associated with depression. No non-pharmacological interventions were documented. -Order administration notes dated 7/25/23 at 12:49 p.m. revealed the resident expressed frustration to nursing but no further details were provided in the note. -Order administration notes dated 7/26/23 at 1:24 p.m. documented a behavior was observed: yes. No other information included in the note. -Order administration notes dated 7/31/23 at 12:50 p.m. revealed the resident expressed tearfulness and frustration to nursing staff but no further details were provided in the note. -Order administration notes dated 8/3/23 at 12:38 p.m. documented a behavior was observed: yes. No other information included in the note. -Order administration notes dated 8/6/23 at 5:21 p.m. revealed the resident expressed frustration to nursing staff but no further details were provided in the note. -Order administration notes dated 8/7/23 at 1:12 p.m. revealed the resident expressed frustration, was argumentative, and lashing out at staff but no further details were provided in the note. -Order administration notes dated 8/8/23 at 1:34 p.m. revealed the resident expressed frustration, was argumentative, and lashing out at staff but no further details were provided in the note. -Order administration notes dated 8/9/23 at 2:15 a.m. documented a behavior was observed: yes. No other information included in the note. -Order administration notes dated 8/9/23 at 3:03 p.m. documented a behavior was observed: yes. No other information included in the note. -Order administration notes dated 8/10/23 at 12:47 p.m. documented a behavior was observed: yes. No other information included in the note. -Order administration notes dated 8/10/23 at 8:14 p.m. revealed the resident expressed she was upset the staff had promised her sheets on the bed would be changed to her own personal sheets she had brought per her preference but it had not been done. This progress note was marked as a behavior associated with depression. No non-pharmacological interventions were documented. -Order administration notes dated 8/11/23 at 10:28 a.m. documented a behavior was observed: yes. No other information included in the note. -Order administration notes dated 8/12/23 at 4:56 p.m. documented a behavior was observed: yes. No other information included in the note. -Order administration notes dated 8/13/23 at 11:32 a.m. revealed the resident expressed frustration, lashing out at staff, and was argumentative but no further details were provided in the note. -Order administration notes dated 8/14/23 at 10:43 a.m. revealed the resident expressed frustration and was argumentative but no further details were provided in the note. -Order administration notes dated 8/15/23 at 11:11 a.m. revealed the resident expressed frustration and was argumentative but no further details were provided in the note. -Order administration notes dated 8/16/23 at 9:05 p.m. documented a behavior was observed: yes. No other information included in the note. -Order administration notes dated 8/17/23 at 1:17 p.m. documented a behavior was observed: yes. No other information included in the note. -Order administration notes dated 8/19/23 at 1:43 p.m. documented a behavior was observed: yes. No other information included in the note. -Order administration notes dated 8/22/23 at 1:46 revealed the resident expressed frustration and was argumentative but no further details were provided in the note. -Order administration notes dated 8/23/23 at 2:26 a.m. documented a behavior was observed: yes. No other information included in the note. -Order administration notes dated 8/23/23 at 2:34 p.m. revealed the resident expressed frustration and was argumentative but no further details were provided in the note. III. Staff interviews Certified nurse aide (CNA) #8 was interviewed on 8/22/23 at 2:30 p.m. She stated Resident #9 had forgetfulness but no other behaviors. Resident #24 had forgetfulness. She had not been told he had PTSD or what his triggers were. Resident #12 had no behaviors, just slept a lot. CNA #8 said the SSD and DON did not let them know resident specific behaviors; the staff had to read the care plan. The target behaviors and interventions were in the care plans. The CNAs reported behaviors to the nurses and the nurses documented in the resident's chart. Registered nurse (RN) #1 was interviewed on 8/23/23 at 9:59 a.m. She stated Resident #24 did not have behaviors anymore; he used to self-isolate. He had PTSD, nightmares, and sometimes he heard voices. RN #1 was not aware of specific triggers or interventions for Resident #24. Resident #12 currently had behaviors of flat affect, isolating, resisting care and refusing therapies. She had been getting paranoid and had decreased sleep for the last few months. Resident #9 had quite a few behaviors. She got easily frustrated when things did not happen the way she expected. She got angry and tearful; the adjustment to placement had been hard for her. Doing her art and listening to her stereo were really important to her. If a resident was having behaviors, the nurse would visit with the resident and make a progress note. The behavior would also be marked on the resident's behavior tracker. The behavior tracker popped up like the MAR and prompted the nurse to make a progress note after a behavior was indicated. The progress note should include the behavior, the intervention tried, and whether or not the behavior intervention was effective. The SSD was interviewed on 8/23/23 at 11:53 a.m. She said Resident #24 initially refused care when he first arrived. She did not know what his PTSD triggers were or effective interventions; she said she could go and ask him. Resident #12 did not have behaviors. The SSD did not know if the resident had changes in behavior or mental cognition since her fall on /20/23; the SSD would have to look into it. Resident #9 did have behaviors, the resident could be demanding and attention seeking. Behavior tracking was entered as an order. Nursing entered those orders and did not include her in the conversation regarding the content. During the psychotropic drug review meeting, the physician would review the resident's behavior in the chart to decide if medication was still needed. The SSD did not know every element required in the behavior note. When a resident was having behavioral issues, nursing staff did not contact the SSD. Behaviors were reviewed in the morning management meeting the SSD attended. The NHA was interviewed on 8/23/23 at 12:38 p.m. The NHA said the MDS manager reviewed the resident's history to find target behaviors to include in the behavior tracking order. The NHA did not know where in the resident's chart the MDS manager found the target behaviors. The MDS manager did not work in the building; it was a remote position. The director of nursing (DON) and NHA were interviewed on 8/24/23 at 11:00 a.m. The DON stated when behavior trackers were established, part of the process included looking at the medication the resident was taking and the signs and symptoms of the diagnosis associated with the medication. When a behavior occurred, the nurses documented the behavior, the interventions tried, and if the interventions were effective or ineffective. When the nurse made a behavior tracking progress note, it should not say yes for a behavior indicated with no further information. The behavior tracking was used to provide the physician with information on whether a medication was effective or ineffective. The physician would use the information to decide on discontinuing medication, increasing medication, or starting a dose reduction. Monitoring was important to determine the overall safety of the resident. The SSD tracked the resident behaviors and was able to run a report in the medical records system. In the morning management meeting, behaviors were discussed from the prior twenty four hours and the SSD was expected to follow up with the residents.

Based on observations and interviews, the facility failed to ensure menus met the needs of residents and were followed. Specifically, the facility failed to ensure menu items were not omitted from the lunch menu service for all residents. Findings include: I. Lunch meal menu on 8/23/23 The menu called for 3 ounces of chicken tarragon, one cup of roasted potatoes, one cup of herbed green beans, wheat roll and pudding parfait. Pureed diet: The menu called for 3 ounces of chicken tarragon, one cup of mashed potatoes, one cup of herbed green beans, wheat roll and pudding parfait. II. Lunch meal observation on 8/23/23 The menu had a main entree of chicken tarragon, one cup of roasted potatoes, one cup of herbed green beans, and pudding parfait. B. Observations During observations of the tray line service in the main dining room during the noon meal on 8/23/23 wheat rolls were not observed to be served for the residents who had pureed texture and regular meals. Pureed bread was not observed on the tray line. The bread was omitted from all of the meals. C. Staff Interviews The dietary aide (DA) #3 was interviewed on 8/23/23 at 12:17 a.m. He confirmed bread was not served with the noon meal. The dietary manager (DM) was interviewed on 8/23/23 at 2:00 p.m. The DM was told of the meal observations on 8/23/23. She said the dietary aide (DA) #1 did not read the menu correctly and she did not prepare any of the wheat rolls for the afternoon meal. She confirmed staff served all of the meals with no bread. She said staff needed to ensure all menu items were served to all diet orders and that included bread.

Based on record review and interviews, the facility failed to provide response, action, and rationale to residents involved in group grievances. Specifically, the facility failed to effectively address, resolve and demonstrate the facility's response to grievances concerning resident care and dignity. Findings include: I. Facility policy and procedure The Grievance policy, undated, was provided by the nursing home administrator (NHA) on 8/23/23. It read it pertinent part, All grievances, complaints, or recommendations stemming from resident or family groups concerning issues of resident care in the facility will be considered. Actions on such issues will be responded to in writing, including a rationale for the response. Upon receipt of a grievance or complaint, the grievance officer will review and investigate the allegations and submit a written report of such findings to the administrator within five working days of receiving the grievance. The resident, or person filing the grievance on behalf of the resident, will be informed (verbally and in writing) of the findings of the investigation and any actions that will be taken to correct any identified problems. II. Resident interview The resident council president, Resident #8, was interviewed on 8/22/23 at 3:32 p.m. He stated the social services director (SSD) was supposed to handle the grievances brought up in the council meeting. Resident #8 said the grievance system was like a brain bleed. The council did not get a resolution brought back after a grievance was aired the system did not function well. Because of this, residents had stopped bringing up grievances. III. Record review A review of the resident council meeting minutes dated 7/7/23 revealed group grievances concerning certified nurse aides (CNA) having conversations with each other in the dining room pertaining to patient care and using the resident's names. The CNAs were using personal cell phones in the dining room while assisting residents. And once residents in the dining room received the meal tray, the CNAs did not follow up with the residents to inquire if anything else was needed. A review of the resident council meeting minutes dated 8/1/23 revealed the same group grievances from the previous meeting concerning CNAs having conversations with each other in the dining room pertaining to patient care and using the resident's names. The CNAs were using personal cell phones in the dining room while assisting residents. And once residents in the dining room received the meal tray, the CNAs did not follow up with the residents to inquire if anything else was needed. The meeting minutes did not reveal a resolution had been brought back to the resident council. A review of a resident council response form dated 7/7/23 revealed the director of nursing (DON) had a meeting with the CNAs to address the resident council grievance on 7/7/23. The form included the agendia but no staff roster of attendance. There was no follow up with the resident council documented on the response form. A review of a resident council response form dated 8/7/23 revealed the DON had a meeting with the CNAs to address the resident council grievance on 8/10/23. The form included the agendia and a staff roster of attendance. There was no follow up with the resident council documented on the response form. IV. Staff interviews The SSD was interviewed on 8/23/23 at 2:07 p.m. She said she handled individual grievances and not the resident council grievances. The activities director (AD) ran the resident council meeting and the other managers only went if the council invited the manager. The AD filled out the grievance form and gave it to the responsible department manager to resolve. The SSD did not know where the grievance form went after it was resolved or who was responsible for following up with the residents. The AD was interviewed on 8/24/23 at 8:55 a.m. She said she facilitated the resident council meeting with the residents. When a grievance was brought up, she filled out the grievance form and gave it to the department manager who needed to follow up. The department manager took it to the NHA once it had been resolved for approval. Then the NHA would return it to the AD to file. The AD would provide the resident council with the resolution. The director of nursing (DON) and NHA were interviewed on 8/24/23 at 11:00 a.m. The NHA stated after a resident council grievance had been addressed, a resolution was taken back to the resident council meeting. The SSD was the grievance official and the NHA did not know why the resident council grievances were not addressed by the SSD like the individual grievances were. The DON could not explain why the CNAs received the same in-service training two months in a row for the same grievance or why the problem continued after the first in-service training.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and staff interviews, the facility failed to maintain a sanitary, orderly, and comfortable environment for residents in 13 of 32 resident rooms in three hallways. Specifically, the facility failed to ensure walls, baseboards and doors were properly maintained. Findings include: I. Initial observations Observations of the resident living environment were conducted on 8/23/23 at 2:24 p.m. revealed: room [ROOM NUMBER]: The wall next to the window had three dime sized holes. The baseboard cove next to room [ROOM NUMBER] was missing a section approximately five inches long by four inches high. room [ROOM NUMBER]: The wall next to the sink had a plastic corner piece which was broken with a sharp edge approximately three inches long. The wall in the bathroom had deep scratches from the wheelchair hitting the wall. room [ROOM NUMBER]: The wall next to the resident's bed had deep scratches from the bed being lifted and lowered. The wall in the bathroom had an area approximately six inches wide by 14 inches long which had rough and unfinished plaster, and the wall next to the toilet had an unfinished painted area approximately eight inches in circumference. The wood edge next to the television in the common area had a missing piece approximately five inches long by three inches wide and had exposed sharp corners. The wall in the biohazard room had an area at the bottom of the sink which had water damage approximately eight inches wide by 13 inches long. room [ROOM NUMBER]: had a plastic cover missing approximately four inches wide by four inches long which had sharp edges. The wall next to the resident's bed had approximately 14 areas of painted patch work which had not been completed. room [ROOM NUMBER]: The wall next to the resident's bed had four dime sized holes. The wall had approximately 10 areas of painted patch work which had not been completed. room [ROOM NUMBER]: The window next to the resident's bed had two missing curtain brackets approximately three inches by three inches. The wall above the resident's bed had two large white unpainted areas. room [ROOM NUMBER]: The wooden door had an area approximately two feet long by nine inches wide with peeling and splintering edges. room [ROOM NUMBER]: The wall next to the resident's bed had an area approximately six inches in circumference of painted patch work which had not been completed. The wall next to the television in the south hall had chipped and peeling paint approximately five inches wide by seven inches long. The shower room on the south hall had the outline of a soap dispenser which had been removed with five dime sized holes. room [ROOM NUMBER]: The wood railing was falling off the wall next to the window with damaged sheetrock approximately six inches wide by five inches long. room [ROOM NUMBER]: The wall behind the recliner had two damaged areas from the recliner hitting the wall. The damage was approximately six inches long by three inches wide and seven inches long by two inches wide. II. Environmental tour and staff interview The environmental tour was conducted with the maintenance director (MTCE) on 8/24/23 at 9:30 a.m. The above detailed observations were reviewed. The MTCE documented the environmental concerns. The MTCE said the facility utilized work orders as well as a computer system to identify environmental issues. The MTCE said he did not have work orders for the damage identified during the environmental tour. The MTCE said the above-mentioned damage should have been repaired and addressed in a timely manner.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interview, the facility failed to ensure that the resident environment remained as free of accident hazards as possible. Specifically, the facility failed to ensure safe water temperatures. Findings include: I. Water temperature observations 8/21/23: -At 9:02 a.m., the temperature of the tap water was obtained in room [ROOM NUMBER]. The water was found to be 139 degrees Fahrenheit (F); -room [ROOM NUMBER]'s water temperature was 139.4 degrees F; -room [ROOM NUMBER]'s water temperature was 139.4 degrees F; -room [ROOM NUMBER]'s water temperature was 139.4 degrees F; The [NAME] shower room [ROOM NUMBER].4 degrees F; -room [ROOM NUMBER]'s water temperature was 139.4 degrees F; -room [ROOM NUMBER]'s water temperature was 139.4 degrees F. -At 10:09 a.m., certified nurse aide (CNA) #1 observed the temperature of the resident's water in room [ROOM NUMBER]. The temperature was 139.4 degrees F. CNA #1 said the thermometer reading was 139.4 degrees F. CNA #1 was unsure what the water temperature was supposed to be kept at. -At 10:13 a.m., the maintenance director (MTCE) observed the water temperature in room [ROOM NUMBER]. The temperature was 139.4 degrees F. II. Staff interviews The maintenance supervisor MTCE was interviewed on 8/21/23 at 10:33 p.m. He stated the facility immediately purged all the hot water from the lines. The MTCE said the boiler had recently been replaced. The MTCE said the water had been holding at 116 degrees F. The MTCE said the water mixing valve may have been the issue and he was currently checking to see if it was functioning correctly. The MTCE said the facility monitored the water temperatures weekly and would provide the temperature logs. The nursing home administrator (NHA) was interviewed on 8/21/23 at 10:45 a.m. The NHA was informed of the observations above. The NHA said there had not been any residents burned by the water. She said the water temperature should be at or around 117 degrees F. Certified nurse aide (CNA) #8 was interviewed on 8/21/23 at 11:00 a.m. CNA #8 provided showers to the residents. She said she checked the water temperature on her wrist to ensure the water temperature was not too hot. She said if the resident was cognitively alert she would ask the resident to tell her as well but would constantly check the water temperature.

Based on record review and interviews, the facility failed to ensure licensed nurses were able to demonstrate competencies in skills and techniques necessary to care for residents' needs, as identified through resident assessments, facility assessments, and described in the plan of care for four of five certified nurse aides (CNAs), one of one licensed practical nurses (LPNs) and four of four registered nurses (RNs). Specifically, the facility: -Failed to complete competencies as identified in the facility assessment for CNAs #1, #2, #4, and #5; -Failed to complete competencies as identified in the facility assessment for LPN #1; and -Failed to complete competencies as identified in the facility assessment for RNs #1, #3, #4, and #5. Findings include: I. Facility assessment The facility assessment, reviewed 6/7/23, identified the staff training topics provided by the facility to meet the needs of the residents, which read in pertinent part: Facility training topics are conducted at hire, annually, and as needed. -Be sufficient to ensure the continuing competence of nurse aides, but must be no less than 12 hours per year. -Address areas of weakness as determined in nurse aides' performance reviews and facility assessment and may address the special needs of elders as determined by the facility staff. -Identification of elder changes in condition, including how to identify medical issues appropriately, how to determine if symptoms represent problems in need of intervention, how to identify when medical interventions are causing rather than helping relieve suffering and improve quality of life. II. Census and conditions The census and condition form, provided by the nursing home administrator on 8/23/23, identified: 45 residents needed the assistance of one or two staff for bathing; -40 residents needed the assistance of one or two staff for dressing; -47 residents needed the assistance of one to two staff with transferring; -38 residents needed the assistance of one to two staff with toilet use; and -48 residents needed the assistance of one to two staff with eating. III. Training records The training records were requested on 8/23/23 at 10:01 a.m. The facility was not able to provide competencies for CNAs #1, #2, #4, and #5; LPN #1; and RNs #1, #3, #4, and #5 as identified in the facility assessment. IV. Interviews The staff development coordinator (SDC) was interviewed on 8/23/23 at 1:10 p.m. She said she was responsible for nurse aide training, and the director of nursing (DON) was responsible for the nursing staff training/competencies. She said there had not been annual training completed for the nurse aides, that the only time competencies were completed were on hire. She said annually there were specific topics identified that the facility would conduct competencies on. She said it would be important to ensure the aides were providing cares safely and correctly. The director of nursing (DON) was interviewed on 8/24/23 at 10:23 a m. She said the facility had not completed competencies as outlined in the facility assessment. She said she would be responsible for the nurses and the SDC would be responsible for the aides. She said competencies would ensure the correct cares for the overall best practices for the elders in the facility. She said it would help support the staff and reinforce best practices.

Based on record review and interviews, the facility failed to complete a performance review of every nurse aide at least once every 12 months, and provide regular in-service education based on the outcome of these reviews for four of five staff reviewed. Specifically, the facility had not completed annual performance reviews and/or provided regular in-service education based on the outcome of the reviews for certified nurse aide (CNA) #1, CNA #2, CNA #4 and CNA #5. Findings include: I. Record review CNAs #1, #2, #4, and #5 did not have an annual performance review completed. The CNAs did not have an in-service education plan based on the outcome of the review. II. Interviews The staff development coordinator (SDC) was interviewed on 8/23/23 at 1:10 p.m. She said she was not aware nurse aide performance reviews were required annually. She said going forward there would be performance reviews completed. The director of nursing (DON) was interviewed on 8/24/23 at 10:23 a m. She said the facility had not completed any annual performance reviews. She said it would help support the aides and reinforce best practices.

Based on observations, record review and staff interviews, the facility failed to ensure food was stored, prepared, and served under sanitary conditions in one kitchen. Specifically, the facility failed to ensure: -Foods of modified consistency were reheated to safe temperatures following the use of a multi-step preparation process; -Cutting boards were free from deep scratches and stains; and, -Food was stored and labeled properly. Findings include: I. Food temperatures A. Professional reference According to the United States Public Health Service Food and Drug Administration (FDA) 2022 Food Code 3-403.11 (A) pg. 36, Time/Temperature Control for Safety Food (TCS) that is cooked, cooled, and reheated for hot holding shall be reheated so that all parts of the food reach a temperature of at least 74 degrees C (165 degrees F) for 15 seconds. B. Observations and staff interview On 8/23/23 at 9:55 a.m., dietary aide (DA) #1 had just completed preparing minced moist mechanical soft meals of chicken tarragon. DA #1 placed the minced moist mechanical soft chicken into a metal pan and proceeded to wrap it with aluminum foil. DA #1 was asked what the temperature of the mechanical altered chicken tarragon was. DA #1 stated the temperature of the chicken tarragon was 114 degrees F. She then wrapped the metal container and placed it into the warming oven. DA #1 proceeded to complete the same process for pureed chicken tarragon. She then placed seven large pieces of chicken into the blender and proceeded to puree the chicken. After getting it to the correct consistency she grabbed another metal pan and poured the pureed chicken into the pan. She placed it on the counter and took the temperature, which was 113 degrees F. She wrapped it with aluminum foil and placed it into the oven. -At 10:12 a.m., the DA #1 was asked if she checked the temperature of the minced moist foods and pureed food after pureeing them. The DA #1 said, No, I do not, but I would take the temperatures before serving them and they should be at 160 degrees F. -At 11:40 a.m., DA #1 again took the temperature of all items listed above. The chicken tarragon minced meat mechanical soft was at 162 degrees F and the pureed tarragon chicken was at 164 degrees F. C. Additional interview The DM was interviewed on 8/23/23 at 2:00 p.m. She said she was aware that the temperatures of the modified food dropped at times. She said, It's my expectation that the food was ok as long as it reached 165 degrees F before serving. She said dietary staff would be educated immediately to ensure the modified consistency of food reached proper temperatures and time frames. II. Cutting Boards A. Professional reference According to the State Board of Health Colorado Retail Food Establishment Rules and Regulations (updated 1/1/19), page 132, and Cutting surfaces that are scratched and scored must be resurfaced so as to be easily cleaned, or be discarded when these surfaces can no longer be effectively cleaned and sanitized. B. Observation The initial kitchen tour conducted on 8/21/23 at 8:40 a.m. revealed three large cutting boards. There were green, blue, and brown cutting boards. All cutting boards were heavily scored and stained. On 8/21/23 at 8:47 a.m., DA#1 was cutting toast on the green cutting board. On 8/23/23 at 1:54 p.m. during kitchen observations DA #3 was cutting raw pork on a brown cutting board. C. Staff Interview The DM was interviewed on 8/23/23 2:00 p.m. The DM was told of the observations of the cutting boards in the kitchen. She acknowledged the cutting boards were visibly stained and showed wear. She said he would replace them immediately. She said the deep scratches could be a potential for bacteria to grow. III. Labeling food A. Professional reference According to the State Board of Health Colorado Retail Food Establishment Rules and Regulations (effective 1/1/19) 3-701, 4 a-d. pg. 104, 4 a-d. It read in part, A date marking system that meets the criteria using a method approved by the Department for refrigerated, ready-to-eat, potentially hazardous food (time/temperature control for safety food) that is frequently re-wrapped, such as lunch meat or a roast. Marking the date or day of preparation with a procedure to discard the food on or before the last date or day by which the food must be consumed on the premises. Marking the date or day the original container is opened in a food establishment with a procedure to discard the food on or before the last date or day by which the food must be consumed on the premises. Using calendar dates, days of the week, color coded marks or other effective marking methods. B. Observations and interviews On 8/21/23 at 7:40 a.m. during the initial tour of the kitchen items stored in the walk-in freezer that were not labeled included: a chocolate cream pie, pastry pie shells, peach bites, mixed vegetables, corn on the cob, hamburger patties, corn dogs, country steak, and chicken nuggets. The mixed vegetables, corn on the cob, hamburger patties, country steak, and corn dogs were not sealed in the bag. On 8/23/23 at 1:45 p.m., during the kitchen tour the unlabeled bags listed above had not been dated or labeled when they were opened. The dietary manager was shown the items mentioned. C. Staff interview The dietary manager (DM) was interviewed on 8/23/23 at 2:00 p.m. She said all food should have been labeled to include the item and date. She said by doing so, it identified the product, so staff knew what they were grabbing and it was the correct product. She said it was important to date the items so the staff knew when to discard them. She said the potential risk of not labeling or sealing the bags was serving an incorrect food item and serving food which had freezer burn due to it being left open. She said a negative outcome would be serving residents food which had lost its flavor or nutrient value due to not having a date of when it was opened.

Based on observations, interviews and record review, the facility failed to ensure an effective program of pest management. Specifically, the facility failed to ensure the main kitchen, dining room, resident rooms and hallways were free from flies. Findings include: I. Professional references A. According to the State Board of Health Colorado Retail Food Establishment Rules and Regulations (last amended 1/1/19) page 186, The premises shall be maintained free of insects, rodents, and other pests. The presence of insects, rodents, and other pests shall be controlled to eliminate their presence on the premises by: -Routinely inspecting incoming shipments of food and supplies -Routinely inspecting the premises for evidence of pests -Using methods, if pests are found, such as trapping devices or other means of pest control as specified under; and -Eliminating harborage conditions. B. According to the Center for Disease Control's (CDC) Guidelines for Environmental Infection Control in Health-Care Facilities, last updated July 2019, pp. 95-96: -Insects 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 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: -Excluding pests from entering the indoor environment and -Applying pesticides as needed. II. Main kitchen observations and interviews On 8/21/23 at 8:56 a.m., during the initial tour of the main kitchen, two staff members were observed working in the kitchen preparing food, and were observed swatting away flies. Flies were observed in all food preparation areas. Two staff members were observed utilizing their hands to clear flies from the area. Several flies were observed on walls, clean dishes, scoops and tongs, and the dishwashing machine. Dietary aide (DA) #2 was interviewed on 8/22/23 at 8:58 a.m. DA #2 said the flies had been especially bad recently and they were everywhere. On 8/23/23 at 8:45 a.m., during the morning kitchen tour one staff member was making toast with the flies flying and landing on the bread. On 8/23/23 at 10:09 a.m., flies were observed on chicken which was being prepared for the afternoon meal. The dietary manager was interviewed on 8/23/23 2:00 p.m. She said the flies in the kitchen had been getting worse and she really did not know what to use to get rid of the flies. She said, I know I cannot use sticky fly traps but I have to do something about the flies. She said a negative outcome with the flies was the flies could be carriers of bacteria and just a plain nuisance. III. Resident interviews Resident #9 was interviewed on 8/22/23 at 2:30 p.m. She said the flies were so bad that she did not eat in the dining room, and she said they were just as bad in her room. She said, Isn't there anything that can be done? Resident #6 was interviewed on 8/22/23 at 2:46 p.m. She said the flies were so bad in herroom. The resident had a fly swatter on her bed. She said, I have to cover my food with a napkin when I am eating in the dining room. Resident #36 was interviewed on 8/22/23 at 3:14 p.m. She said that the flies were terrible this year. She said they were just a bother. Resident #20 was interviewed on 8/23/23 at 9:19 a.m. She said, These flies are crazy because they are everywhere. They seem to follow you everywhere you go, especially in the dining room. I can't eat in the dining room. Resident #19 was interviewed on 8/23/23 at 1:12 p.m. He said the flies were not too bad in his room but were worse in the dining room. IV. Staff interviews The maintenance supervisor (MTCE) was interviewed on 8/23/23 at 9:30 a.m. The MTCE was told of the observations and resident interviews. The MTCE said he had not heard of any problems with flies in the kitchen, dining room or in residents' rooms. The MTCE said they had a contract with a local pest control company who came in monthly or as needed. He said he would contact him immediately to see what the facility's alternatives were. The nursing home administrator (NHA) was interviewed on 8/24/23 at 10:35 a.m. The NHA was told of the observations above. The NHA said she had just heard about the problem with flies with the residents this past Tuesday. She said we had one complaint from one particular resident and the facility got her a fly swatter.

Based on observation and staff interviews, the facility failed to provide a safe, functional and comfortable environment for residents, staff and the public. Specifically, the facility failed to ensure backflow prevention devices were installed on a hose in the biohazard room sink, west shower room and the south shower room, increasing the risk of contamination to the facility's main water supply. Findings include: I. Observation Observations of the resident living environment conducted on 8/23/23 at 2:24 p.m. revealed backflow prevention devices were not installed on the hose in the biohazard room, west shower and south shower room hand held shower. The hose in the biohazard room was utilized to rinse soiled items. The hose was sitting inside the rinse sink which had standing water on the bottom of the sink. The hand held showers in the west and south shower rooms were long enough for the nozzle end to be submerged beneath the level of the drain threshold. II. Staff Interview The maintenance supervisor (MTCE) was interviewed on 8/24/23 at 9:30 a.m. He said the hose in the biohazard room was used to rinse soiled clothing and other facility items, and it did not have a backflow prevention valve installed. He said the west and south shower room did not have a functioning backflow preventer valve on the hand held shower head. He said he would place the backflow valves on them immediately.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure immediate physician notification for one (#15) of five residents reviewed out of 25 sample residents. Specifically, the facility failed to notify the physician of Resident #15's high blood sugars/glucose levels that were out of physician ordered parameters. Findings include: I. Resident status Resident #15, age [AGE], was admitted on [DATE] and readmitted on [DATE]. According to June 2022 computerized physician orders (CPO), diagnoses included type two diabetes mellitus, bacteremia, anxiety and depression. The 3/14/22 minimum data set (MDS) assessment revealed the resident had intact cognition with a brief interview for mental status (BIMS) score 15 out of 15. She required extensive assistance of two staff with bed mobility, transfers, dressing, toilet use and personal hygiene, and supervision with eating. Medications included daily insulin injections, antidepressant, anticoagulant, antibiotic and diuretic. II. Record review Review of the resident's comprehensive care plan revealed: -I have DM (diabetes mellitus) type two with skin complication, diabetic chronic kidney disease, and diabetic autonomic (poly) neuropathy (dated 5/14/21). Interventions included: I have DM (diabetes mellitus) and I am not compliant with my care. I have been educated many times on proper diet, medication, and care I need to take with my skin. I am eating what I want to, snacking many times a day, and will not call to be cleaned up after voiding putting my skin at risk. I have signed a risk vs. benefit concerning my diet and how much I eat. I am putting my body in danger d/t (due to) high BG (blood glucose). I frequently state that I want to lose weight and have set goals in the past for weight loss, I often times do not follow recommendations from my PCP (primary care provider/physician) and the IDT (interdisciplinary team) to achieve my weight loss goals. Diabetes medication as ordered by doctor. Monitor/document for side effects and effectiveness. Discuss meal times, portion sizes, dietary restrictions, snacks allowed in daily nutritional plan, compliance with nutritional regimen. Educate elder/family/caregiver: diabetes is a chronic disease and that compliance is essential to prevent complications of the disease. Review complications and prevention with the elder/family/caregiver. Elicit a verbal understanding from the elder/family/caregiver that nails should always be cut straight across, never cut corners. File rough edges with emery board. Review of the May 2022 CPO revealed the following orders -Levemir FlexTouch Solution Pen-injector 100 unit/ml, (insulin Detemir), inject 74 units subcutaneously every 12 hours for DM 2 (type two diabetes mellitus), hold if BG <120 (blood glucose below 120), start date 3/7/22. --NovoLOG Solution 100 unit/ml, (insulin Aspart), inject 12 units subcutaneously before meals related to type two diabetes mellitus with diabetic chronic kidney disease, may hold Novolog if ill and not wanting to eat a meal, start date 1/2/22. -Blood sugar check Q 0600 (at 6:00 a.m.) and HS (hours of sleep). Notify MD (physician) for levels <80 and >400 (below 80 and above 400) two times a day for DM (diabetes mellitus), start date 3/8/22. Review of the May 2022 medication administration record (MAR) and treatment administration record (TAR) revealed the following: -On 5/4/22 blood glucose reading was 405; -On 5/21/22 blood glucose reading was 522; -On 5/27/22 blood glucose reading was 426; and, -On 5/28/22 blood glucose reading was 405; Review of the nursing notes in Resident #15's medical record revealed one note corresponded to the above blood glucose reading. On 5/21/22 a nurse documented: BS (blood sugar) 522. (Physician clinic and name) contacted re: BS (blood sugar). Ordered 10 additional units Humalog insulin and usual dose of Levemir. Elder admitted to eating a lot of peanut brittle this afternoon. -There was no other documentation in the resident's records indicating the physician was notified of blood glucose levels above 400 as ordered. III. Staff interview The director of nursing (DON) was interviewed on 6/9/22 at 1:10 p.m. She said she reviewed Resident #15's MAR and nursing notes and did not find any documentation the physician was notified of the above parameters blood sugar. She said the nurse who checked the resident's blood sugar, and it was above 400, should immediately call the resident's physician. She said she will provide additional education to all nurses.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** III. Resident #32 A. Resident status Resident #32, above the age of 70, was admitted on [DATE]. According to the June 2022 computerized physician orders (CPO), diagnoses included Alzheimer's disease, hypertension (HTN), and dementia. The 4/6/22 minimum data set (MDS) assessment revealed the resident was cognitively impaired with a brief interview for mental status (BIMS) score of three out of 15. He had no behaviors or rejections of care. He was identified wandering one to three days of the past seven. -The MDS did not identify the use of a wanderguard. B. Record review The care plan, initiated on 11/21/21 and revised on 6/9/22, identified the resident had a wanderguard for his safety. Interventions included: -Provide him with a wanderguard linked to alarms and door locks providing a safe environment for elder. Check wanderguard every night shift and as needed (PRN) for proper functioning. C. Staff interview The MDSC was interviewed on 6/9/22 at 1:57 p.m. The MDSC said she was not aware the wanderguard had not been identified on the MDS until the facility was made aware. The MDSC said the use of the wanderguard should have been coded on the MDS assessment. She said she had made a modification earlier that day. She said any use of any wanderguard should be identified in the MDS for a complete assessment on a resident. Based on record review and interviews, the facility failed to ensure the minimum data set assessment (MDS) accurately reflected residents' status for three (#20, #26 and #32) of 16 out of 25 sample residents. Specifically, the facility failed to appropriately assess, according to the Resident Assessment Instrument (RAI): -Behavior-Psychosis for Resident #20; -Medications for Resident #26; and, -Restraints-Alarms for Resident #32. Findings include: I. Resident #20 A. Resident status Resident #20, age [AGE], was admitted to the facility on [DATE]. According to the June 2022 computerized physician orders (CPO), diagnoses included Parkinson's disease, anxiety disorder, repeated falls, dementia with behavioral disturbance, and hallucinations. The 3/29/22 minimum data set (MDS) assessment revealed intact cognition with a brief interview for mental status (BIMS) score 14 out of 15. Section E (Behavior) documented verbal behavioral symptoms directed toward others occurred one to three days. No hallucinations or delusions were documented. B. Record Review Review of the resident's comprehensive care plan revealed: The resident has a behavior problem r/t (related to) my Parkinson's disease (hallucinations, delusions, and paranoia). Date initiated: 4/20/22. Interventions included: I want you to tell me when I am hallucinating. I frequently think my mirror is a window and someone is watching me through the mirror and will throw things into my room through the mirror, I believe I hear people talking negatively all the time in the hallway. Date initiated: 5/3/22. Review of nursing notes revealed: -On 3/23/22 a nurse documented: Resident with increased paranoia about medications and staff. Family at bedside, resident trying to leave facility. Updated administration, waiting on wander-guard. Pt (patient) is a high fall risk due to quick movements, and instability. Pt is verbally aggressive. Instructed CNAs (certified nurse aide) to check on pt (patient) q 30 mins (every 30 minutes) for safety reasons. -On 3/25/22 a nurse noted: Spoke with Dr. (physician's name) neurology office about pts (patient ' s) increasing paranoia, and manic episodes. Telehealth visit scheduled for March 29th @ 3:00 p.m. Called and left a message with Dr. (physician's name) as well, and pts (patient ' s) daughter to make her aware, no voicemail available. -On 3/26/22 a nurse documented: Elder (resident) stated at 10:30 this morning, she is upset because people are talking about her saying ' they are all so mad at me out there, they said I have a knife and a gun and I am going to shoot up the place. I have no gun, or knife I have never shot a gun either. ' She is crying. ' I am not supposed to be here. I need to go home. I don't want therapy anymore. I just want to leave. -On 3/27/22 a nurse documented: Elder is making statements that the staff is talking about her and her family and that she heard them say her daughter was arrested for trying to kill her boyfriend . -On 3/28/22 a nurse noted: Elder has been up in the hallway several times this evening and without her walker. She is very unsteady and a high fall risk. She states she is looking for her mother who lives down the hallway. She has been redirected several times back to her room, she stays for approximately 30 minutes. Will continue to monitor. The above notes of resident's episodes of hallucinations and delusions were documented within the seven days look-back period of the assessment. The facility failed to accurately reflect Resident #20s status in section E. Further notes revealed the following: -On 4/3/22 a nurse noted: Elder spent from 1700 (5:00 p.m.) to end of shift (10:00 p.m.) exit seeking, attempting to walk into other elder's rooms, and being verbally aggressive toward staff. Elder had multiple episodes of delusions throughout this shift. Elder stated to this nurse, ' Why would you allow little children in a place like this? That boy just came in here and stole my candy then hid behind his mother! ' , and also asked multiple times where the nursery was so she could see the babies. When staff informed Elder that there is no nursery, Elder started screaming at staff stating, ' You're a bunch of liars! You're just trying to keep me away from the babies and my sister! ' Staff was unable to redirect Elder despite efforts made. Elder has attempted to run over staff with her wheeled walker and repeatedly cursing at staff and stating, ' You're just trying to keep me as a (expletive) hostage! -On 4/6/22 a nurse documented: Insisted that she received a phone call and was told Memorial school was burning and was trying to find an exit so she could see for herself. Another oncoming nurse assured it was not burning as she just drove past it on the way to work. Elder settled. Later asked another elder if she was spending the night (at the facility) because she had been there since early in the morning and wanted to go home . C. Interviews The social service director (SSD) was interviewed on 6/9/22 at 1:45 p.m. She said she was responsible for completion of sections B, C, D and E on MDS assessments. She said she did not know the resident very well as she was new to the facility. She said she was not aware Resident #20 experienced and exhibited psychotic episodes including hallucinations and delusions. The director of nursing (DON) and the MDS coordinator (MDSC) were interviewed on 6/9/22 at 2:00 p.m. The MDSC said she was new to the facility and her role as the MDS coordinator. She said the SSD was responsible for completion of residents ' assessments in section E. She said she was not aware of Resident #20's episodes of hallucinations and delusions. The DON said the MDS assessment will be corrected and resubmitted. II. Resident #26 A. Professional reference According to the [NAME] Nursing Drug Handbook, 2020, read in part: Tramadol, classification-centrally acting synthetic opioid, analgesic. B. Resident status Resident #26, age [AGE], was admitted on [DATE]. According to the June 2022 CPO, diagnoses included cerebral infarction, acute osteomyelitis of left ankle and foot, end stage renal disease, dementia with behavioral disturbance, and type two diabetes mellitus. The 3/19/22 MDS assessment revealed severely impaired cognition with BIMS score six out of 15. She required supervision with bed mobility and eating, limited assistance of two staff with transfers and toilet use, and limited assistance of one person with walking, dressing and personal hygiene. Section J (Health Conditions) revealed the pain management included scheduled and as needed medications. Section N (Medications) revealed Resident #26 received an anticoagulant and diuretic medications daily. Opioid was marked 0 not administered. C. Record review Review of the resident's comprehensive care plan revealed: The resident is on pain medication therapy Tramadol r/t (related to) disease process (dated 3/21/22). Interventions included: Administer analgesic medications as ordered by physician. Monitor/document side effects and effectiveness. Monitor for increased risk for falls. Monitor/document/report PRN (as needed) adverse reactions to analgesic therapy: altered mental status, anxiety, constipation, depression, dizziness, lack of appetite, nausea, vomiting, pruritus, respiratory distress/decreased respirations, sedation, urinary retention. Review of the computerized physician orders (CPO) and medication administration record (MAR) for March 2022 revealed the resident was prescribed pain medication, opioid, Tramadol on 11/16/21. The order read: -Tramadol HCl tablet 50 mg, give one tablet by mouth two times a day for pain According to the March 2021 MAR, the opioid was administered as prescribed. On 3/17/22 the March 2021 CPO revealed a new order: -Tramadol HCl, tablet 50 mg, give one tablet by mouth three times a day for pain The opioid medication was administered as prescribed. -The facility failed to ensure Resident #26's medications assessment reflected an accurate opioid administration during the observation period of the MDS. D. Staff interview The MDSC was interviewed on 6/9/22 at 2:04 p.m. She said she did not realize Tramadol was an opioid medication. During the interview, the DON made a phone call to the facility's pharmacist and was informed Tramadol was a synthetic opioid and should be marked as such in section N. The MDSC said the assessment did not accurately reflect Resident #26's medications.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observations and interviews the facility failed to develop and implement a comprehensive, resident centered care plan that included measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychosocial needs for one (#26) of 16 out of 25 sample residents. Specifically, the facility did not ensure Resident #26's comprehensive care plans were developed and included appropriate preventative interventions and treatments for wounds on her buttocks. Findings include: I. Resident status Resident #26, age [AGE], was admitted on [DATE]. According to the June 2022 CPO, diagnoses included cerebral infarction, acute osteomyelitis of left ankle and foot, end stage renal disease, dementia with behavioral disturbance, and type two diabetes mellitus. The 3/19/22 MDS assessment revealed severely impaired cognition with BIMS score six out of 15. She required supervision with bed mobility and eating, limited assistance of two staff with transfers and toilet use, and limited assistance of one person with walking, dressing and personal hygiene. The resident was at risk of pressure ulcers and had a stage two pressure ulcer present upon admission. The moisture associated skin damage (MASD) was not marked. II. Record review Review of the resident's comprehensive care plan revealed: -The resident has potential/actual impairment to skin integrity of the right heel, left second toe (amputation site), top of 3rd toe, side of left great toe r/t (related to) abrasion, fragile skin, PVD (peripheral vascular disease), decreased PO (oral) intake, comorbidities. Interventions included: (name) wound consults as indicated (dated 6/7/22). Educate resident/family/caregivers of causative factors and measures to prevent skin injury. Encourage good nutrition and hydration in order to promote healthier skin. Follow facility protocols for treatment of injury. Identify/document potential causative factors and eliminate/resolve where possible. Monitor/document location, size and treatment of skin injury. Report abnormalities, failure to heal, s/sx (signs/symptoms) of infection, maceration etc. to MD (physician). Pressure relieving boots when doing non-weight bearing activities. Use caution during transfers and bed mobility to prevent striking arms, legs, and hands against any sharp or hard surface. Weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue and exudate and any other notable changes or observations. (dated 3/21/22). ProStat, Multi Vitamin, and labs as appropriate. Cushion for chair (dated 3/29/22). Obtain and monitor lab/diagnostic work as ordered. Report results to MD and follow up as indicated. Provide and serve supplements as ordered. (dated 4/6/22). Review of the medication administration record (MAR) and treatment administration record (TAR) revealed the following: -Wound to left lower buttocks-cleanse with NS (normal saline) wash, dry, skin prep peri wound, apply slightly moist collagen powder (mostly dry) to wound bed, then apply superabsorbent adhesive dressing to site, change QD (daily) and PRN (as needed) until healed every day shift for wound care . Start Date 5/16/2022 -Evening and night nurse to check and make sure wound dressings are in place to right heel, and left lower buttocks, and re-do wound care if necessary every evening and night shift Start Date 2/6/2022 Review of the interdisciplinary notes revealed the following: -On 1/16/22 a nurse documented: Wound to coccyx found with just sure site on it. Two open wounds measuring 1.3 x 0.3 x 0 cm. Wound bed 100% pink granulation tissue. Peri wound appears white and macerated. Current treatment orders: Cleanse with NS (normal saline), dry, apply collagen powder to wound bed, cover with foam and secure with silicone tape. During wound change, open area noted to elder's left buttocks measuring 1.1 x 1 x 0 cm. Nursing notes state this wound was noted 1/16/22 on day shift. Wound bed pale pink granulation tissue. Periwound pink in color. Cleansed wound with NS, dried, applied collagen to wound bed, applied oil emulsion and covered with sure site. TAR updated. POA (power of attorney), (name), notified of new open area found. -On 5/9/22 a nurse documented, in parts: Wound to left lower buttocks r/t (related to) weight loss and moisture, skin breakdown, MASD (moisture associated skin damage). Wound bed 100% red and pink granulation tissue. Small serosanguinous drainage noted. Peri wound is slightly macerated, white, edges intact. Measurement: 1.1 x 1.0 x 0.2 cm. Treatment: clean with NS (normal saline) wash, dry, skin prep peri wound, apply mixture of hydrogel with collagen powder to wound bed, then apply superabsorbent adhesive dressing, change QD (daily) and PRN (as needed) to area. -On 5/15/22 a nurse documented, in parts: Wound to left lower buttocks r/t (related to) weight loss and moisture, skin breakdown, MASD (moisture associated skin damage). Wound bed 100% red and pink granulation tissue. Small serosanguinous drainage noted. Peri wound is slightly macerated, white, edges intact. Measurement: 1.1 x 1.0 x 0.2 cm. Treatment changed due to continued lack of improvement: clean with NS (normal saline) wash, dry, skin prep peri wound, apply slightly moist (mostly dry) collagen powder to wound bed, then apply superabsorbent adhesive dressing, change QD (daily) and PRN (as needed) to area. -On 5/18/22 a nurse documented, in parts: Wound to left lower buttocks. Wound bed 100% red and pink granulation tissue. Small drainage noted. Peri wound is slightly macerated, white, edges intact. Cleansed with NS wash, dry, skin prep peri wound, apply slightly moist collagen powder to wound bed, then apply superabsorbent adhesive dressing. -On 5/23/22 a nurse documented, in parts: Wound to left lower buttocks r/t (related to) weight loss and moisture, skin breakdown, MASD (moisture associated skin damage). Wound bed 100% red and pink granulation tissue. Small serosanguinous drainage noted. Peri wound is slightly macerated, white, edges intact. Measurement: 1.0 x 0.5 x 0.2 cm. Treatment: clean with NS (normal saline) wash, dry, skin prep peri wound, apply slightly moist (mostly dry) collagen powder to wound bed, then apply superabsorbent adhesive dressing, change QD (daily) and PRN (as needed) to area .Elder has MVI (multivitamin) and ProStat ordered as well as cushion for chairs. Elder is to wear pressure prevention boots on both feet most of the time except with transfers and weight bearing activities. Elder continues to have inconsistent PO (oral) intake, and overall has poor skin integrity and limited healing with wounds, due to comorbidities and overall status. Continues to have limited wound healing. Elder showing no s/sx nor vocalized any pain during wound care. -On 5/31/22 a registered dietitian documented, in parts: (Resident) L (left) lower buttock that measures 1.1 X 1.0 X 0.2 cm. 100% pink and red granulation, slight maceration of wound edges, intact. No tunneling, odor, or pain at this time. Intake: 60% of meals. Supplements: Glucerna TID (three times daily) 100% most offerings. Needs: 50 kg 1238-1387 25-28 cal/kg BW) 60- 70 gm protein (1.2 -1.4 gm/kg BW) 1238 mL fluids (25 mL/kg BW) Recommendations: 1. Provide supplementation in between meals at 10 (10:00 a.m.), 2 (2:00 p.m.), and 7 (7:00 p.m.) for best acceptance. 1. Continue Prostat 30 mL BID (two times daily) supplementation for wound healing. 3. Promote SF (sugar free) snacks as available r/t (related to) diabetic. RD (registered dietitian) will follow prn (as needed). -On 6/7/22 a nurse documented, in parts: Wound to left lower buttocks r/t (related to) weight loss and moisture, skin breakdown, MASD (moisture associated skin damage). Wound bed 100% pink epithelial tissue. No drainage noted. Peri wound is slightly macerated, white, edges intact. Measurement: 0.3 x 0.3 x 0.2 cm. Treatment: clean with NS (normal saline) wash, dry, skin prep peri wound, apply collagen powder to wound bed, then apply superabsorbent adhesive dressing, change QD (daily) and PRN (as needed) to area .Elder has MVI (multivitamin) and ProStat ordered as well as cushion for chairs. Elder is to wear pressure prevention boots on both feet most of the time except with transfers and weight bearing activities. Elder continues to have inconsistent PO (oral) intake, and overall has poor skin integrity and limited healing with wounds, due to comorbidities and overall status. Elder showing no s/sx nor vocalized any pain during wound care. III. Staff interviews Registered nurse (RN) #4 was interviewed on 6/9/22 at 11:10 a.m. He said the resident had a wound on her left buttock that was not a pressure injury. He said he changed the wound dressing during his shift. He said he was not aware the resident's care plan did not address this wound. The director of nursing (DON) was interviewed on 6/9/22 at 2:07 p.m. She said there was no specific person assigned in the facility to write care plans. She said the unit manager or the wound nurse should update residents' care plans with new problems and interventions. She said she was aware of the moisture associated wound on Resident #26's buttock. She said there was no care plan related to the wound on the resident's buttock.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to ensure the resident environment remained as free of accident hazards as possible for one (#20) of three residents reviewed for falls out of 25 sample residents. Specifically, the facility failed to comprehensively review, implement effective interventions and update the resident's care plans after multiple falls for Resident #20. Findings include: A. Resident status Resident #20, age [AGE], was admitted to the facility on [DATE]. According to the June 2022 computerized physician orders (CPO), diagnoses included Parkinson's disease, anxiety disorder, repeated falls, dementia with behavioral disturbance, and hallucinations. The 3/29/22 minimum data set (MDS) assessment revealed intact cognition with a brief interview for mental status (BIMS) score 14 out of 15. Section J (Health Conditions-Fall History) indicated the resident had falls prior to admission to the facility. Section G (Functional Status) revealed bed mobility, transfers, walking, dressing, toilet use and personal hygiene occurred only once or twice and the resident required one person physical assist. B. Resident interview Resident #20 was interviewed on 6/6/22 at 3:42 p.m. She was sitting in her reclining chair in her room. She said she has poor balance, was very unsteady on her feet and had been falling frequently. She said she had to call her daughter on two occasions to come to the facility and pick her up from the floor. She said after her daughter called the facility a staff came to her room and helped her get up. C. Record review Review of the resident's comprehensive care plan revealed: -I have an ADL (activities of daily living) self-care performance deficit r/t (related to) confusion, disease process (Parkinson's), impaired balance (Date Initiated 3/24/22) Interventions included: I require SBA (stand by assist) for mobility using my 4WW (four wheeled walker). I can be unsteady at times. I require SBA (stand by assist) for all transfers using my 4WW (four wheeled walker). I am a fall risk, anticipate my needs and encourage me to use my call light. -I am an elopement risk and wanderer r/t (related to) impaired safety awareness and my Parkinson's disease. I have a wander guard in place for my safety. (Date initiated 3/24/22) Interventions included: Assess for fall risk. -I am a high risk for falls r/t (related to) gait/balance problems r/t (related to) Parkinson's disease Date initiated 3/23/22 Interventions included: Anticipate and meet the resident's needs. Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance. Educate the resident/family/caregivers about safety reminders and what to do if a fall occurs. Review information on past falls and attempt to determine cause of falls. Record possible root causes. Alter, remove any potential causes if possible. Educate resident/family/caregivers/IDT (interdisciplinary team) as to causes, ensure that the resident is wearing appropriate footwear, tennis shoes when ambulating. Ensure that the resident is wearing appropriate footwear, tennis shoes when ambulating. Skid strips next to bed. I often crawl on the floor from bed/chair as a means of mobility and when I am looking for something or someone during my periods of hallucinations/delusions. (Date initiated 5/4/22). I require SBA (stand by assist) for mobility and transfers using my 4WW (four wheeled walker), I can be unsteady at times. If you see me without my walker, please remind me to grab to walk with it. (Date initiated 5/3/22). Review of the interdisciplinary notes revealed the following: -On 3/23/22 a nurse documented: Resident with increased paranoia about medications and staff. Family at bedside, resident trying to leave facility. Updated administration, waiting on wander-guard. Pt (patient) is a high fall risk due to quick movements, and instability. Pt (patient) is verbally aggressive. Instructed CNAs (certified nurse aides) to check on pt q (every) 30 minutes for safety reasons. -On 3/27/22 a nurse documented, in parts: She was walking around her room without a walker and almost fell twice and was assisted to her chair. She states, ' I don't need anyone to tell me I need to use a walker, it is none of their business. ' Just now the elder was found walking in the hallway with no walker and stumbling when the CNAs (certified nurse aides) ran to keep her from falling. -On 3/28/22 a nurse documented: Elder has been up in the hallway several times this evening and without her walker. She is very unsteady and a high fall risk. -On 3/30/22 director of nursing documented: (Name) was passing by elder's room when she witnessed her fall. (Name) calling this nurse to room. Elder stating she had dropped her earrings and fell over attempting to pick them up. Denies pain, has an old bruise on her left hip/buttock area from previous fall. Elder has a light red area to lateral side of left elbow, will monitor for bruising. POA (power of attorney) and PCP (physician) notified. -On 3/31/22 a nurse documented: This nurse was called into the elder's room d/t (due to) elder sitting on the floor blocking them from entering her room. Spoke with elder and she stated she fell in the bathroom and crawled to the door. This nurse talked elder into moving away from the door so we could get into help and evaluate her. Elder moved away from the room with no issues. Elder was assessed from head to toe and there was a half dollar sized bruise staring on the center of elder's forehead . Provider called and requested us to perform neuro checks and if there is any change, to contact her again to send elder out. This nurse educated elder to push the call light if she is going to get out of bed or her chair d/t (due to) her unstable walking. DON (director of nursing) aware at 1946 (7:46 p.m.). POA (power of attorney) (name) aware at 2000 (8:00 p.m.). -On 4/2/22 a nurse documented: Elder was found on the floor in front of her bathroom in her room. Elder states she slipped when she closed the door. Elder did not have on non-skid socks that she has in her drawer, only her regular socks. (Name) RN (registered nurse) came to assess elder prior to elder getting up off the floor, neuro checks re-started, abrasion noted to right knee & left wrist area. Notified (physician) via fax and call to (name) elder's daughter. -On 5/2/22 a nurse documented: Elder was found in her room on the floor in from of her recliner. She stated, ' I was trying to pull the recliner away from the wall so I could lay the top down more. Then I fell backwards. ' This nurse educated elder on the importance of use her call light and coming to ask for help. She stated, ' Oh, yeah I know, but there's no need to call for help when I can just do it myself. ' Completed head-to-toe assessment and started 72 hour neuros (neurological checks). No injury to hips, she did hit her back between the shoulder blades on one of the wheels on her walker, she had a 3 (three) cm red mark, the red mark was gone within an hour. This nurse called POA (power of attorney) daughter (name) and faxed (physician). Will continue to monitor. -On 5/13/22 at 8:05 p.m. a nurse noted: Came out of room at a rapid rate of speed and slipped on floor landing on left hip and left elbow. No initial injury. Was a witnessed fall. This nurse was standing at a med (medication) cart but unable to get to her in time to prevent or cushion fall. -On 5/13/22 at 9:09 p.m. a nurse documented: Follow-up on fall. Left elbow showing evidence of bruising. Left hip sore but no evidence of bruising. Lrg (large) hematoma on inner aspect of left lower leg. Applied ice but doesn't think it will work. -On 5/14/22 at 9:47 p.m. a nurse documented: Daughter called nurse's station to state pt (patient) was on her floor and needed help getting up. Pt (patient) had crawled from chair to floor and was sitting on pillow. No s/s (signs/symptoms) of pain or injury noted, full range of motion to extremities . Helped pt (patient) back to bed, call light within reach, encouraged pt (patient) to call for help, and to use walker when ambulating. Pt (patient) stated, ' white bugs crawling all over room, and now in sink. ' No bugs noted in room. -On 5/17/22 at 1:00 p.m. a nurse documented: Elder was found on the floor in the hallway. Once this nurse arrived she was up in the recliner in the junction. Elders hips, good ROM (range of motion), shoulders and knees. L (left) elbow pain. Old bruise present, past skin tear covered with sure site . -On 5/17/22 at 9:46 p.m. a nurse documented: Pt (patient) slid from chair to floor in bedroom, no noted wounds that are new. Pt (patient) complaint L (left) hip pain, no bruising or redness noted to the area. Pt (patient) continues on neuro check from previous fall . Gave 500 mg of Tylenol for complaint of pain. Pt (patient) with normal rom (range of motion), WNL (within normal limits) gait for pt (patient). -On 5/19/22 a nurse noted: Pt (patient) sitting in floor, scooting across the floor on a pillow. Pt (patient) care planned for activity. Pt (patient) complaint of hip pain related to previous fall, pt (patient) has full range of motion, and is ambulating WNL (within normal limits) for pt (patient). Pt (patient) continues to be unsteady with gait, and mobility. Helped pt (patient) to bed, and placed call light on bedside. Encouraged pt (patient) to use light if she needed help with anything. Gave pt (patient) 2 (two) Tylenol po (orally) for hip pain. -On 5/28/22 a nurse documented: Heard someone holler and found elder on floor beside bed. Examined and assisted back to bed. No new injuries found but has multiple bruises about back, legs and arms from previous falls .Medicated for neck pain from previous falls. Elder states she has had h/a (headache) for about 1 (one) week. -On 5/29/22 a nurse documented: This nurse was called into elder's room by another elder stating, ' (name) is screaming on the floor ' . Upon investigation, elder was lying on her right side on the floor. When asked what happened elder stated, ' I don't know. I moved my walker and landed on the floor. I think I hit my head. ' Assessed elder's head and discovered a very small (< (less than) 0.5 cm) LAC (laceration) to the back, upper portion of her head with a small amount of blood in elder's hair at the injury site. Elder's VS (vital signs) were obtained Neuros assessed and WNL (within normal limits), ROM (range of motion) assessed and WNL (within normal limits), and assisted off the floor onto her chair. Elder denied any dizziness or LOC (loss of consciousness) at this time. (Name), RN (registered nurse) into the room to assess elder and voiced no concerns. This nurse attempted to call PCP (physician) at 1725 (5:25 p.m.) but was placed on hold for 20+ mins (longer than 20 minutes). DON (director of nursing) aware at 1724 (5:24 p.m.). POA (power of attorney) aware at 1840 (6:40 p.m.). Fax attempted to PCP (physician) at 1806 (6:06 p.m.) but fax failed d/t (due to) ' busy/no response ' . Another fax to PCP (physician) attempted at 2234 (10:34 p.m.) but that fax also failed. -On 6/1/22 a nurse noted: Pt (patient) found in room in front of sink, on the floor. Pt (patient) holding head, stating, 'I hit my head, I was trying to wash my dishes in the sink. 'Assessed pts (patient's) head and neck before moving, pt (patient) to the recliner in her room . ROM (range of motion) in all extremities is intact with no new skin wounds noted. Small golf ball size knot on middle of left top of head noted, no bleeding at site, pt (patient) co (complain) pain when pressing. There is no bruising or redness noted. Placed ice pack on affected area and sat with pt (patient) while doing the first 30 minutes of neuro checks. All neuro checks are WNL (within normal limits). Notified PCP (physician) (name), no new orders given at this time. Notified POA (power of attorney) (name). Pt resting and drinking juice with no complaint of pain. -On 6/3/22 a nurse documented: Elder had an unwitnessed fall in room. This nurse alerted by staff that elder was laying on the floor and chair was tipped over. This nurse assessing situation and for injuries. Elder stating she hit her head. Redness is noted to left ear. No swelling or redness noted around head. Neuros and VS (vital signs) are WNL (within normal limits). No other injuries noted at this time. Bruising continues to be noted around body and healing in various stages. Elder has no changes in gait and transfers. PRN APAP (as needed acetaminophen) given for discomfort. No changes noted elder's condition. No behaviors at this time. Will monitor. -Resident #20 had 14 falls in 35 days. -Further record review revealed the facility failed to address resident's frequent falls in interdisciplinary notes. -The facility failed to timely and appropriately revise Resident #20's care plan and implement interventions including required staff physical assistance with all activities of daily living and ambulation as documented in her 3/29/22 minimum data set (MDS) assessment. The facility failed to provide staff education and increase resident's supervision to prevent falls when she did not initiate staff assistance by using her call light. The facility failed to monitor the effectiveness of Resident #20's care planned interventions and modify the interventions to prevent her from falling. -After the last modification to Resident #20's care plan on 5/4/22, the resident fell 10 times. D. Staff interviews Certified nurse aide (CNA) #4 was interviewed on 6/9/22 at 12:46 p.m. She said the resident was independent in her room and she was falling very often. She said the resident should be checked by staff more frequently, like every 15 minutes, but this intervention was not in the care plan. She said there was no education provided to staff on how to prevent the resident's falls. CNA #5 was interviewed on 6/9/22 at 12:50 p.m. She said she knew the resident was falling very often. She said she was not aware of any interventions for fall preventions for Resident #20. She said there is not much we can do for her. The director of nursing (DON) was interviewed on 6/9/22 at 2:11 p.m. She said she was aware of the resident's frequent falls. She said frequent checks, closer staff supervision were not implemented. She said the resident fall prevention education was not provided to the facility staff for Resident #20. E. Facility follow-up The facility submitted a revision to the Resident #20's care plan on 6/13/22 with an additional intervention for falls prevention that included: Frequent checks. (Date initiated 6/9/22). -The intervention did not specify how frequent checks were implemented or where they should be documented.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interviews, the facility failed to ensure residents who needed respiratory care were provided such care, consistent with professional standards of practice for one (#41) of three residents reviewed for oxygen therapy out of 25 sample residents. Specifically, the facility failed to ensure oxygen was administered according to physician orders for Residents #41. Findings include: I. Professional reference According to [NAME]/[NAME], Fundamentals of Nursing, ninth edition, Elsevier, Canada, 2017, p 900, Oxygen is a therapeutic gas and must be prescribed and adjusted only with a health care provider's order. II. Resident #41 A. Resident status Resident #41, above the age of 90, was admitted on [DATE] and readmitted on [DATE]. According to the June 2022 computerized physician orders (CPO), diagnoses included chronic obstructive pulmonary disease (COPD), heart failure and cardiac pacemaker. The 5/1/22 minimum data set (MDS) assessment revealed the resident was cognitively moderately impaired with a brief interview for mental status (BIMS) score of 12 out of 15. She had no behaviors or rejections of care. She was independent with bed mobility, transfers, locomotion on and off the unit and personal care. The MDS identified the resident utilized oxygen. B. Record review The care plan, initiated on 5/3/22, identified the resident had a self-care performance deficit related to COPD. Interventions included: -Vision: Severe Problem; My vision is impaired and I do not wear glasses. I can see shapes, please guide me in the right direction. -Safety: Oxygen 3L/m (liters per minute) NC (nasal cannula); Direction; help me know if objects are in my way, I am a fall risk; I am unsteady on my feet please, assist me when I try to get up on my own. Clip call bell to me when in my room. The June 2022 CPO included: -Oxygen via nasal cannula 2-3 liters per minute (LPM), ordered on 5/3/22. C. Observations and interviews The resident was in her room with her concentrator set to 4 liters (L) on 6/6/22 at 4:19 p.m. The resident was in her room with her concentrator set to 4 liters (L) on 6/7/22 at 8:43 a.m. The resident was in her room with her concentrator set to 4 liters (L) on 6/7/22 at 10:00 a.m. Registered nurse (RN) #1 was interviewed on 6/7/22 at 10:00 a.m. She said oxygen was considered a medication. She said Resident #41's order was for 2 to 3L. She observed the concentrator set at 4L. She said the setting was not correct and turned the concentrator to the correct setting of 3L. She said only nursing staff should be setting the concentrator. She said the resident did have some vision impairment. The director of nursing (DON) was interviewed on 6/9/22 at 11:40 a.m. She said oxygen was a medication that needed a provider order to administer to any resident. She said only a nurse can change the concentrator settings. She said the concentrator for Resident #41 should have been set at the ordered level. She said Resident #41 did have some vision impairment. She said too much oxygen would have been bad with a diagnosis of COPD.