**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop and implement an effective discharge planning process for one (#13) out of 17 sample residents. Specifically, the facility failed to ensure the discharge planning process focused on Resident #13's discharge goals. Findings include: I. Resident #13 A. Resident status Resident #13, age [AGE], was admitted on [DATE]. According to the February 2024 computerized physician orders (CPO), diagnoses included chronic obstructive pulmonary disease (COPD) and developmental disorder of scholastic skills (learning disability). The 1/11/24 minimum data set (MDS) assessment revealed the resident had no cognitive impairment with a brief interview for mental status (BIMS) score of 12 out of 15. She used a wheelchair for mobility and required substantial staff assistance with transfers, toileting, showering, and dressing. The section about discharge planning and goals revealed the resident had not been interviewed but had been interviewable. The legal representative was interviewed and there were no plans for discharge. B. Resident interview The resident was interviewed on 2/5/24 at 10:46 a.m. She said the facility would not let her leave and she did not know why. No one had explained to her why she was unable to leave and she did not want to live in the facility anymore. The resident became emotional and could not further articulate where she wanted to be discharged . C. Record review The resident had a medical durable power of attorney for assistance with medical decisions dated 11/16/02. -There were no documents in the resident's medical record showing the resident was unable to make decisions. The comprehensive care plan, revised 1/11/21, revealed the resident required extensive assistance with bathing and toileting. The resident required limited to set up assistance with mobility, dressing and personal hygiene. The resident or family expressed a preference to remain in long term care at the facility. The resident at times made statements of wanting to return to the community. Interventions included to assess the resident on comprehensive assessments for discharge planning. A review of progress notes dated 10/1/23 to 2/6/24 failed to reveal concerns regarding discharge planning. Certified nurse aide (CNA) tasks (abbreviated care plan) revealed a task for discharge planning initiated on 4/24/23. It indicated if the resident made statements regarding wanting to return to the community, staff were to listen and validate the resident's concerns. Staff were to explain to the resident a discharge plan home was unrealistic and it was imperative she remain in 24 hour care. II. Staff interviews The social services consultant (SSC) was interviewed on 2/7/24 at 2:00 p.m. The SSC said the facility had hired a social services director who started a few days before the survey. The SSC was filling in as the director from September 2023 until January 2024. The social worker was responsible for assisting residents with discharge planning. If a resident consistently brought up wanting to discharge and there were efforts made to assist the resident with discharge planning, the care plan should be updated to reflect. The SSC said the resident's family wanted her to remain in long term care but Resident #13 was able to make her own decisions. The resident had told the SSC she had a friend who she could live with but did not have contact information. The SSC said if the resident provided him with contact information, he would have followed up with her friends to discuss if a discharge plan was feasible. He could not recall exactly when he had these conversations with the resident. The SSC said he would look for documentation of the discharge planning conversations. The SSC was interviewed on 2/8/24 at 9:45 a.m. He said he just checked in with the resident this morning regarding discharge planning. He said the resident would let him know when she was ready to discharge but currently did not have a formulated plan. He was not able to find documentation of prior conversations. The NHA was interviewed on 2/8/24 at 9:46 a.m. She said there had not been conversations with the resident regarding discharge planning. The resident would become anxious and conversations regarding discharge would have done the resident more harm than good. The conversations consisted of redirecting the resident to another topic or an activity. The NHA said she would look to see if there were any care conference notes regarding discharge conversations with the resident. -There was no additional documentation provided by the time of exit on 2/8/24.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interviews, the facility failed to ensure residents received appropriate services and assistance to maintain or improve mobility with the maximum practicable independence unless a reduction in mobility was demonstrated as unavoidable for one (#23) of two residents reviewed for mobility out of 17 sample residents. Specifically, the facility failed to ensure a carrot contracture prevention device was placed according to physician orders for Resident #23. Findings include: I. Resident #23 A. Resident status Resident #23, age over 65, was admitted on [DATE] and readmitted on [DATE]. According to the January 2024 computerized physician orders (CPO), diagnoses included muscle weakness and Parkinson's disease. The 11/15/23 minimum data set (MDS) assessment revealed the resident's mental status was severely impaired. The assessment did not identify functional limitations in the upper extremities. B. Observations Resident #23 was in her room on 2/5/23 at 9:53 a.m. with no carrot splint in her hand. Resident #23 was in her room on 2/6/23 at 9:30 a.m. with no carrot splint in her hand. C. Record review The care plan, initiated 2/23/23 and revised on 1/15/24, identified the resident was at risk for skin tears and bruises. Interventions included an orange carrot palm protector to the left hand, on in the morning and off at noon. Check skin before and after application. -The resident did not have a care plan focus that addressed the contracture of the resident's left hand. Review of the February 2024 CPO revealed the following physician order: Place orange carrot in left hand in morning upon awakening and remove at midday. Check for red areas or skin breakdown two times a day for contracture. The occupational therapy (OT) note dated 12/10/23 documented Resident #23 was tolerating wearing the left hand carrot splint. The OT discharge summary note dated 12/14/23 documented Resident #23 was wearing the left hand carrot splint in the palm to reduce the risk of skin breakdown. -There was no documentation in the resident's electronic medical record (EMR) to indicate Resident #23 was refusing to wear the carrot splint. D. Interviews Certified nurse aide (CNA) #2 was interviewed on 2/6/24 at 9:50 a.m. CNA #2 said Resident #23 often pulled the carrot out of her hand. She said she would report it to the nurse who would attempt to replace the carrot three times. After the third time, the carrot would be put away. She said the nurse was the person responsible for placing the carrot. She said the resident only wore the device in the mornings. Licensed practical nurse (LPN) #1 was interviewed on 2/6/24 at 10:00 a.m. LPN #1 said the carrot would be placed in Resident #23's left hand in the morning and taken out at 12:00 p.m. She said the resident did not like the carrot and would pull it out. She said after three attempts she would stop trying to replace the carrot in the resident's hand and put it away. She said if the resident refused to let her put the carrot in her hand she would not force her to wear it. The director of nursing (DON) was interviewed on 2/7/24 at 10:01 a.m. The DON said the nurses were to put the carrot in Resident #23's left hand in the morning and remove it at lunch. She said when the carrot was applied the nurses were to assess her skin for any breakdown. She said the resident did remove the carrot by herself. She said if an aide found the carrot they were to give it to the nurse for her to reapply the carrot. She said if the resident removed it repeatedly or refused to wear it, there should be a nurse note documented so the team would know the resident was refusing to wear the device. She said the resident was not getting the benefits of contracture prevention when the carrot was not put in her left hand consistently She said she would talk to the staff about documenting the resident's refusals of the carrot and report the refusals to the provider and the therapist.

Based on record review and interviews, the facility failed to complete a performance review of every nurse aide at least once every 12 months and provide regular in-service education based on the outcome of these reviews for three of four 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) #3, CNA #4 and CNA #5. Findings include: I. Record review CNA #3 (hired on 10/20/15), CNA #4 (hired on 6/16/93) and CNA #5 (hired on 10/1/21) 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. Interview The director of nursing (DON) was interviewed on 2/7/24 at 10:30 a.m. She said she could not locate the performance reviews for CNA #3, CNA #4 and CNA #5. She said she was not aware the performance reviews needed to include a regular in-service plan based on the outcome of these reviews. She said going forward she would ensure the performance reviews were completed annually to ensure best care was being delivered to the residents.

Based on observations, interviews and record review, the facility failed to ensure drugs and biologicals were labeled and stored in accordance with accepted professional standards, in one of one medication rooms. Specifically, the facility failed to date a multi use vial of tuberculin when opened. Findings include: I. Professional reference According to the Tubersol package insert, retrieved 2/12/24 from: https://www.fda.gov/media/74866/download, A vial of Tubersol which has been entered and in use for 30 days should be discarded. II. Observation and interview The medication room was reviewed on 2/6/24 at 1:15 p.m. An opened multi use vial of Tubersol was in the refrigerator. -There was no date on the vial to indicate when the medication was opened. Licensed practical nurse (LPN) #1 said she did not know when the vial was opened. She said it should have been dated when opened for the safety of the residents. III. Additional interview The director of nursing (DON) was interviewed on 2/6/24 at 3:30 p.m. She said Tubersol was good for 30 days after opening. She said the vial should have been dated when opened to make sure the medication was safe for residents.

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 staff, laundry and housekeeping. Findings include: I. Facility policy and procedure The Grievance policy, which was undated, was provided by the nursing home administrator (NHA) on 2/7/24 at 11:05 a.m. 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 interviews Resident #13 was interviewed on 2/5/24 at 10:46 a.m. She said the facility did not follow up on grievances brought up in the resident council meetings. She said she had brought up grievances regarding call lights and staffing but the facility had not followed up with a resolution. The resident council president, Resident #3, was interviewed on 2/6/24 at 3:13 p.m. She said the resident council had brought up grievances regarding call lights, staffing shortages and rooms not getting cleaned enough. Resident #3 said when a grievance came up in the resident council meeting the department head tried to address it during the meeting. If it was an individual grievance the department head would follow up with the individual resident. If it was a group grievance a resolution was not brought back to the next resident council meeting by the facility. III. Record review A review of the resident council meeting minutes dated 11/8/23 revealed group grievances concerning beds not being made, not enough staff in the facility, one CNA's attitude and residents getting other residents' clothes returned from the laundry department. A review of the resident council meeting minutes dated 12/13/23 revealed group grievances concerning resident rooms not getting cleaned. A review of the resident council meeting minutes dated 1/10/24 revealed group grievances regarding the facility needing more certified nurse aides (CNA). -There was no documentation in any of the resident council minutes to indicate resolutions were discussed with the resident council members for the grievances brought up at the 11/8/23, 12/13/3 or 1/10/24 resident council meetings. Resident council generated grievances for November 2023, December 2023 and January2024 were requested from the NHA on 2/7/24 at 2:51 p.m. Individual grievances for Resident #13 and Resident #3 were also requested at that time. -The NHA responded via email on 2/7/24 at 3:35 p.m. that there were no grievances for Resident #13 or Resident #3 or the concerns from the resident council meetings. IV. Staff interviews The social services consultant (SSC) was interviewed on 2/7/24 at 2:00 p.m. The SSC said the facility had hired a social services director (SSD) who started a few days before the survey. The SSC was filling in as the director from September 2023 until January 2024. He said resident council grievances should be handled the same as individual grievances. A grievance form should be completed and a resolution should be brought back to the council by the next meeting. He said he would look for resident council grievances. The NHA was interviewed on 2/8/24 at 9:46 a.m. The NHA said the social services department handled resident council grievances and the SSD was the grievance official. A grievance needed to be filled out on a grievance form and then the form was given to the department responsible for the resolution. A resolution should be brought back to the next resident council meeting for the group grievances. If it was an individual grievance, a follow up should be completed within 24-48 hours. -There were no grievances from the resident council meetings provided by the end of the survey on 2/8/24.

Based on observations and staff interviews, the facility failed to maintain a sanitary, orderly and comfortable environment for six of 22 resident rooms in two hallways. Specifically, the facility failed to ensure blinds were intact in six resident rooms. Findings include: I. Environmental tour and interview The environmental tour was completed with the nursing home administrator (NHA) and the maintenance director (MTCE) on 2/8/24 at 9:03 a.m. The following items were found: Resident rooms #2, #4, #31, #33, #35 and #37 had broken blinds covering the windows. The NHA said prior to the ongoing change of ownership the facility was only ordering a few items at a time. She said the blinds may have been ordered previously and the facility was waiting for the delivery. She said it was important for the residents' privacy to have intact blinds. II. Record review The December 2023 resident council meeting minutes documented the facility had informed the residents they were going to get estimates to replace the blinds. III. Facility follow up The NHA provided an order receipt for the blinds dated 2/6/24, during the survey.

Based on record review and interviews, the facility failed to have a registered nurse (RN) scheduled eight hours consecutively a day for seven days a week. Specifically, the facility failed to have a RN on duty for eight consecutive hours on a consistent basis from 11/1/23 to 2/5/24. Findings include: I. Record review Review of the nursing schedule from 11/1/23 to 2/5/24 revealed the following: -In November 2023, the facility did not have a RN on duty for eight consecutive hours on seven days during the month; -In December 2023, the facility did not have a RN on duty for eight consecutive hours on seven days during the month; -In January 2024, the facility did not have a RN on duty for eight consecutive hours on four days during the month; and, -In February 2024, from 2/1/24 to 2/5/24, the facility did not have a RN on duty for eight consecutive hours for one day. II. Staff interview The director of nursing (DON) was interviewed on 2/7/24 at 10:26 a.m. She said she was not aware of the federal requirement regarding the need for a RN for eight consecutive hours seven days a week. She said going forward she would do her best to meet the federal requirement for the safety of the residents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to develop and implement policies and procedures related to pneumococcal immunizations for four (#13, #3, #16 and #20) of five residents reviewed for vaccinations of 17 sample residents. Specifically, the facility failed to ensure Residents #13, #3, #16 and #20 were offered and/or received pneumococcal immunization. Findings include: Findings include: I. Professional reference The Centers for Disease Control and Prevention (CDC), Pneumococcal Vaccine Recommendations website, revised 9/21/23, retrieved on 2/13/24 from https://www.cdc.gov/vaccines/vpd/pneumo/hcp/recommendations.html read in pertinent part, CDC recommends routine administration of pneumococcal conjugate vaccine (PCV15 or PCV20) for all adults 65 years or older who have never received any pneumococcal conjugate vaccine or whose previous vaccination history is unknown: If PCV15 is used, this should be followed by a dose of PPSV23 one year later. The minimum interval is 8 weeks and can be considered in adults with an immunocompromising condition, cochlear implant, or cerebrospinal fluid leak. According to the CDC Recommended Immunization Schedule for Adults Aged 19 Years or Older, United States, 2023, retrieved on 3/27/23 from https://www.cdc.gov/vaccines/schedules/downloads/adult/adult-combined-schedule.pdf. It read, in pertinent part, The pneumococcal vaccine was to be administered to immunocompetent adults aged 65 years or older one dose of 13-valent pneumococcal conjugate vaccine (PCV13), if not previously administered, followed by one dose of 23-valent pneumococcal polysaccharide vaccine (PPSV23) at least one year after PCV13; if PPSV23 was previously administered but not PCV13, administer PCV13 at least one year after PPSV 23. For special situations (see-www.cdc.gov/mmwr/preview/mmwrhtml/mm6140a4. htm): individuals aged 19-64 years with chronic medical conditions (chronic heart excluding hypertension, lung, or liver disease, diabetes), alcoholism, or cigarette smoking: give 1 dose PPSV23. II. Resident #13 Resident #13, age [AGE], was admitted on [DATE]. The medical record revealed the resident declined the influenza vaccination on 12/6/23 and her pneumococcal vaccination was not up-to-date. The minimum data set (MDS) assessment dated [DATE] indicated the resident had refused the influenza vaccine and the pneumococcal vaccine. -The facility did not have evidence of an offer or refusal of the pneumococcal vaccine. III. Resident #3 Resident #3, age [AGE], was admitted on [DATE]. The medical record revealed the resident received the influenza vaccination on 11/30/23 and her pneumococcal vaccination was not up-to-date. The MDS assessment dated [DATE] indicated the resident had received the influenza vaccine and had not been offered the pneumococcal vaccine. -The facility did not have evidence of an offer or refusal of the pneumococcal vaccine. IV. Resident #16 Resident #16, age [AGE], was admitted on [DATE]. The medical record revealed the resident declined the influenza vaccination on 11/30/23 and her pneumococcal vaccination was not up-to-date. The MDS assessment dated [DATE] revealed the section pertaining to vaccines had not been completed. -The facility did not have evidence of an offer or refusal of the pneumococcal vaccine. V. Resident #20 Resident #20, age [AGE], was admitted on [DATE]. The medical record revealed the resident received the influenza vaccination on 10/30/23 and her pneumococcal vaccination was not up-to-date. The MDS assessment dated [DATE] indicated the resident had received the influenza vaccine and had declined the pneumococcal vaccine. -The facility did not have evidence of an offer or refusal of the pneumococcal vaccine. V. Staff interviews The nursing home administrator (NHA) was interviewed on 2/8/24 at 9:46 a.m. She said she did not know if the facility had documentation of pneumococcal vaccines being offered to the residents. The NHA would have to look for the records. The infection preventionist (IP) was responsible for the tracking but was not available for interview during the survey. The nurse practitioner (NP) was interviewed on 2/8/24 at 11:00 a.m. She said the residents should be offered the pneumococcal vaccine when they enter the facility if there was no record of the vaccine being given. Proof of the vaccine being offered or refused with education should be in the resident's medical record at the facility. -There was no pneumococcal vaccine documentation provided by the exit on 2/8/24.

Based on record review and staff interview, the facility failed to inform one (#135) of three residents reviewed for liability notices and beneficiary appeal rights of 18 sample residents, both orally and in writing in a language that the resident understood, of their rights. Specifically, the facility failed to provide Resident #135 or their representative a notice of discharge from Medicare services, ensuring acknowledgement of their rights to appeal the discharge. Findings include: I. Notice of non-coverage regulatory reference The Notice of Medicare Provider Non-Coverage (form CMS-10123) letters, also called Non-Coverage letters, Expedited Appeal Notice (ABN), or a Generic Notice, are provided to residents receiving skilled nursing facility (SNF) services funded through Medicare benefits. Non-Coverage letters document that residents and/or their legal representatives have received written notification that discontinuation of Medicare coverage is imminent. II. Record review On 10/8/19 at 10:21 a.m., the social services director (SSD) provided requested copies of the liability notices for two of three sample residents. Review of the liability notices revealed one of the three liability notices, for Resident #135, was missing. III. Staff interview The SSD was interviewed on 10/10/19 at 9:36 a.m. She said could not locate the notice for Resident #135. The SSD said the resident and power of attorney (POA) should have been provided a copy of a liability notice and appeal rights.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to refer one (#4) of one resident reviewed of 18 sample residents to the appropriate state-designated authority for level II preadmission screening and resident review (PASARR) evaluation and determination for services. Specifically, the facility failed to update a PASARR level II for the use of lamotrigine (a mood stabilizer) and for a patient health questionnaire (PHQ-9) score of 12 out of 27. Findings include: I. Resident status Resident #4, age [AGE], was admitted on [DATE]. According to the October 2019 computerized physician orders (CPO), diagnoses included unspecified mood affective disorder and major depression. According to the 10/7/19 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 moderate depression, scoring 12 of 27 on the PHQ-9. The resident had no behavioral symptoms. The resident had little interest or pleasure in doing things; felt down, depressed, or hopeless; felt tired or had little energy; had poor appetite or overeating; felt bad about himself; and trouble concentrating. The symptom frequency was two to six days per week. II. Record review A. Care plan The care plan, initiated 12/21/18 and revised 9/29/19, identified the resident had a behavior problem related to (r/t) diagnoses (DX) of unspecified mood affective disorder, post-traumatic stress disorder (PTSD), and major depression. At times the resident refused to participate in activities of daily living (ADLS), transfers, and meals. The resident refused care when upset with staff and when they discussed his inappropriate behaviors such as inappropriate sexual talk and touch and manipulative behaviors. Interventions included: -Assisting the resident in developing more appropriate methods of coping and interacting with staff. -Encouraging the resident to express feelings appropriately. -Explaining all procedures to the resident before starting and allowing the resident a few minutes to adjust to changes. -Intervening as necessary to protect the rights and safety of others. -Approaching and speaking in a calm manner; diverting attention. -Removing from problematic situations and taking the resident to an alternate location as needed. -Encouraging the resident to participate in care. -Educating on the benefits of increased independence. B. Physician orders The October 2019 CPO included an order for lamotrigine, 200 mg tab by mouth daily related PTSD and major depression, order date 9/24/19. III. Staff interview The social services director (SSD) was interviewed on 10/10/19 at 9:36 a.m. She said a Level II PASRR should be initiated when a resident had a change of medication, a change in behavior, a new diagnosis, a new medication and/or a PHQ-9 score above nine. The SSD said she was not aware of the resident's lamotrigine medication. She said the resident's PASARR should have been updated with a PHQ-9 of 12 and the medication lamotrigine. The SSD stated she would update the resident's PASARR immediately.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review, the facility failed to ensure the resident received treatment and care in accordance with professional standards of practice, their comprehensive, person-centered care plan and the resident's choice for one (#133) of one resident reviewed for quality of care of 18 sample residents. Specifically, the facility failed to ensure donning of Geri sleeves per physician's orders. Findings include: I. Resident status Resident #133, age [AGE], was admitted on [DATE]. According to the October 2019 computerized physician orders (CPO), diagnoses included atherosclerotic heart disease, macular degeneration, dementia and diabetes mellitus. According to the 9/25/19 minimum data set (MDS) assessment, the resident was not administered the brief interview for mental status (BIMS). The MDS documented the resident's cognitive skills for daily decision making were severely impaired. She required extensive assistance for bed mobility, transfers, grooming and toilet use. II. Record Review The October 2019 CPO showed a physician order to apply Geri sleeves to bilateral arms, to be worn throughout the day and removed at night, two times a day for prevention, start date 9/19/19. The care plan, initiated 10/7/19, identified the resident required assistance to meet basic activity of daily living (ADL) self-care and performance of bed mobility, bathing, dressing, personal hygiene, toilet use and transfers. Interventions included: -Assist the resident with dressing daily. -Give the resident a choice of two outfits to choose from. -Provide showers at least twice weekly to promote good hygiene. -Resident will be assisted by staff to meet her daily ADL needs. The resident had no care plan identifying Geri sleeves placement. III. Observations On 10/7/19 at 1:02 p.m., the resident was observed sitting in her wheelchair in her room. The resident was not wearing her Geri sleeves. On 10/8/19 at 1:34 p.m., the resident was observed sitting in her wheelchair in the common area with no Geri sleeves on. On 10/9/19 at 9:23 a.m., the resident was sitting in her wheelchair in her room. The resident was not wearing her Geri sleeves. -At 9:34 a.m., CNA #4 was observed searching the resident's closet and dresser. IV. Interviews Licensed practical nurse (LPN) #3 was interviewed on 10/9/19 at 9:32 a.m. She said the certified nurse aides (CNAs) would place Geri sleeves on the resident in the mornings and take them off in the evenings, then nurses would sign them off. She said, I did not sign them off today. LPN #3 asked CNA #4 to locate and place Resident #133's Geri sleeves. CNA #4 was interviewed on 10/9/19 at 9:36 a.m. CNA #4 said, I checked the resident's closet and dresser drawers and she does not have any Geri sleeves. LPN #3 was interviewed a second time on 10/9/19 at 9:42 a.m. She said, I instructed (CNA #4) to locate some new Geri sleeves and put them on (Resident #133) immediately. LPN #3 said the resident should have had Geri sleeves on per physician order. The director of nursing (DON) was interviewed on 10/9/19 at 1:30 p.m. The DON was told of the observations above. The DON said the CNAs were to apply the Geri sleeves. The licensed nurse should verify placement of the Geri sleeves on all residents and they were applied and taken off according to the physician's orders. She said Resident #133 refused to wear her Geri sleeves at times. She said the nurse should document refusal and if the resident refused on a regular basis, they should contact the physician to discontinue the order if appropriate. She said negative outcomes for not wearing Geri sleeves could be bruising, skin tears or other skin issues.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** II. Resident #4 A. Resident status Resident #4, age [AGE], was admitted on [DATE]. According to the October 2019 CPO, diagnoses included paroxysmal atrial fibrillation and chronic respiratory failure with hypoxia. According to the 10/7/19 MDS assessment, the resident had no cognitive impairment with a BIMS score of 15 out of 15. He required extensive assistance for bed mobility, transfers, grooming and toilet use. The resident had shortness of breath or trouble breathing with exertion and while lying flat. The resident was receiving oxygen therapy. B. Record review The care plan, initiated 12/21/18 and revised 9/29/19, identified the resident was being treated for chronic obstructive pulmonary disease (COPD). Interventions included: -Give aerosol or bronchodilators as ordered. Monitor and document side effects and effectiveness. -Give oxygen therapy as ordered by the physician. -Head of bed to be elevated (semi-Fowler's to Fowler's) or out of bed upright in a chair during episodes of difficulty breathing (dyspnea). -Identify and eliminate sources of respiratory irritation such as cigarette smoke, pollen, perfumes, etc. -Monitor for difficult breathing (dyspnea) on exertion. -Remind resident not to push beyond endurance. -Monitor, document and report to medical doctor as needed (PRN) any signs or symptoms of respiratory infection: fever, chills, increase in sputum (document the amount, color and consistency), chest pain, increased difficulty breathing (dyspnea), increased coughing and wheezing. The October 2019 CPO showed no physician orders for oxygen. C. Observations The resident was sitting in his wheelchair next to his bed on 10/7/19 at 10:52 a.m. He was wearing his oxygen that was connected to the portable oxygen concentrator. His oxygen concentrator was set at three liters per minute (3LPM). He was receiving oxygen via nasal cannula (NC). The resident was sitting in her wheelchair next to his bed on 10/8/19 at 9:51 a.m. His portable oxygen concentrator was set at 4 LPM. He was receiving the oxygen via NC. D. Interviews Licensed practical nurse (LPN) #1 was interviewed on 10/8/19 at 10:09 a.m. She said she did not know off hand what Resident #4's oxygen order was. LPN #1 reviewed the physician orders and said she did not see a physician's order for the use of oxygen for Resident #4. She said she would check to see what the issue was with the physician's order. The director of nursing (DON) was interviewed on 10/8/19 at 10:16 a.m. The DON was informed of the observations and interview above. The DON reviewed the medical record to verify the physician's order. She said the resident was sent to the hospital for a procedure and the physician order for oxygen was not inputted upon the resident's return to the facility. She said oxygen was a medication, should be administered as the provider ordered it, and there should have been a physician order for the oxygen. She said she would contact the physician immediately and relay this to nursing staff. The DON said a negative outcome of not having ordered oxygen could be altered mental status, dizziness, falls, hypoxic event, and could have put the resident in respiratory distress. Based on observations, record review and interviews, the facility failed to ensure residents who needed respiratory care were provided such care, consistent with the comprehensive person-centered care plan and the residents' goals and preferences for two (#26 and #4) of three residents reviewed for oxygen therapy out of 18 sample residents. Specifically, the facility: -Failed to ensure oxygen was delivered at the ordered liter flow for Resident #26; and -Failed to ensure Resident #4 had a physician's order for the use of oxygen. Findings include: I. Resident #26 A. Resident status Resident #26, age [AGE], was admitted on [DATE] and readmitted on [DATE]. According to the October 2019 computerized physician orders (CPO), diagnoses included hypoxemia, shortness of breath, and chronic obstructive pulmonary disease (COPD). The 8/16/19 minimum data set (MDS) assessment revealed the resident had moderate cognitive impairment with a brief interview for mental status (BIMS) score of eight out of 15. The resident received supplemental oxygen therapy. B. Record review The care plan, initiated 8/8/16 and revised on 8/14/18, identified oxygen therapy related to COPD. Interventions included oxygen settings to be eight liters per minute (8LPM) to keep oxygen saturation above 88%. The October 2019 CPO included: -Portable oxygen tank during the day to deliver oxygen continuously at 8LPM to maintain peripheral oxygen saturations above 88%. The order was started on 4/2/19. C. Observations The resident was in his room on 10/7/19 at 10:16 a.m. The concentrator he used was set at 4LPM. The resident was in his room on 10/8/19 at 8:43 a.m. The concentrator he used was set at 5LPM. He was sitting in his room at 9:14 a.m. with the portable concentrator set at 4LPM. D. Interviews Certified nurse aide (CNA) #2 was interviewed on 10/8/19 at 9:38 a.m. CNA #2 was returning the resident to his room after a smoke break. He reset the portable tank to 4LPM. He said the resident's portable tank and room concentrator were set between 4-6 LPM. He said it had always been that way. Licensed practical nurse (LPN) #4 was interviewed on 10/8/19 at 9:40 a.m. She said the resident had a titration order for 4-6 LPM. She could not locate the order in the CPO. She found the order for 8LPM. She said that was an old order. She checked the oxygen saturation for Resident #26. His oxygen level was 92% with the 4LPM. She could not locate a different order for the oxygen liter flow. She said the physician would be notified and a new oxygen liter flow would be requested. The director of nursing (DON) was interviewed on 10/8/19 at 9:44 a.m. She said the physician order should be followed. She said the ordered liter flow was high for a resident with a diagnosis of COPD. She said if the resident's oxygen levels were above 88% on 4LPM, she would request an order from the provider for 4LPM. She said if a resident with COPD received too much oxygen it would not be beneficial for the resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record review, the facility failed to monitor and document behaviors to prevent behavioral difficulties for three (#4, #132, and #24) of five residents reviewed for behaviors of 18 sample residents. Specifically, the facility failed to: -Monitor and document behaviors and outbursts for Resident #4; -Monitor and document wandering/elopement behaviors for Resident #132; and -The facility failed to effectively track and care plan individualized interventions for Resident #24 who had a diagnosis of dementia. Findings include: I. Resident #4 A. Resident status Resident #4, age [AGE], was admitted on [DATE]. According to the October 2019 computerized physician orders (CPO), diagnoses included muscle weakness, paroxysmal atrial fibrillation, chronic viral hepatitis, unspecified intracranial injury with loss of consciousness, chronic respiratory failure with hypoxia, and major depression. According to the 10/7/19 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 moderate depression with the resident scoring 12 of 27 on the patient health questionnaire (PHQ-9). The resident had no behavioral symptoms. B. Record review The care plan, initiated 12/21/18 and revised 9/29/19, identified the resident had a behavior problem related to (r/t) diagnoses (DX) of unspecified mood affective disorder, post-traumatic stress disorder (PTSD), and major depression. At times the resident refused to participate in activities of daily living (ADLS), transfers, and meals. The resident refused care when upset with staff and when they discussed his inappropriate behaviors such as inappropriate sexual talk and touch and manipulative behaviors. Interventions included: -Assisting the resident in developing more appropriate methods of coping and interacting with staff. -Encouraging the resident to express feelings appropriately. -Explaining all procedures to the resident before starting and allowing the resident a few minutes to adjust to changes. -Intervening as necessary to protect the rights and safety of others. -Approaching and speaking in a calm manner; diverting attention. -Removing from problematic situations and taking the resident to an alternate location as needed. -Encouraging the resident to participate in care. -Educating on the benefits of increased independence. The September 2019 medication administration record (MAR) behavior tracking revealed two behaviors, on 9/29/19 and 9/30/19. The August 2019 MAR behavior tracking revealed zero behaviors. Nursing log notes revealed behaviors on 8/11, 8/12, 8/13, and 8/14. The July 2019 MAR behavior tracking revealed zero behaviors. Nursing log notes revealed behaviors on 7/11, 7/14, 7/15, and 7/23. The June 2019 MAR behavior tracking revealed zero behaviors. Nursing log notes revealed behaviors on 6/2, 6/11, 6/15, 6/18, and 6/28/19. C. Observations On 10/7/19 at 3:53 p.m., the resident was observed sitting in his room. Certified nurse aide (CNA) #4 entered Resident #4's room. The resident could be heard stating, Leave me alone; I don't know why you all are always bothering me. CNA #4 exited the room. On 10/8/19 at 2:24 p.m. the resident was in his room with his door closed. CNA #6 knocked on the resident's door to check on him. CNA #6 entered and Resident #4 could be heard yelling at CNA #6. She exited the resident's room. On 10/9/19 at 4:24 p.m. The resident was sitting in his wheelchair in his room. CNA #1 knocked on the resident's door and asked if he wanted some fresh water. The resident was heard yelling but conversation was unclear to the content. D. Staff interviews Certified nurse aide (CNA) #4 was interviewed on 10/8/19 at 8:42 am. She stated she often worked with Resident #4. She said Resident #4 would yell or refuse care on a daily basis. She said Resident #4 had a history of being sexually inappropriate with female staff. She said she had to be aware of her surroundings and redirect Resident #4 when he said anything inappropriate. She said she reported all behaviors to the nurses. CNA #6 was interviewed on 10/8/19 at 2:23 a.m. She said Resident #4 yelled out on a regular basis. She said Resident #4 refused to go to the bathroom and would urinate or defecate wherever he wanted. She said they were always having to change his bedding because he refused to let staff help him. He even will make a mess in his wheelchair. She said he had behaviors on a daily basis and made sexually inappropriate comments regularly. She said, I will report it to nursing because we don't have any place to document behaviors. CNA #3 was interviewed on 10/9/19 at 2:22 p.m. She said Resident #4 had a lot of behaviors on a daily basis. She said the resident was easily agitated and would just start yelling at staff. She said he liked the attention his behaviors would get him. She said he would urinate wherever he wanted to in his room and refused daily care. She said Resident #4 was sexually inappropriate with female staff. She said, I report all behaviors to the nursing staff. CNA #1 was interviewed on 10/10/19 at 8:43 a.m. She said Resident #4 had behaviors every time I provide care. She said he refused care on a daily basis and was sexually inappropriate with female staff. She said he smacked a CNA on her butt while she was giving him a shower. She said Resident #4 would purposely fall on the floor and then call the fire department to help get him off the floor. She said he constantly refused ADL care and isolated himself in his room. She said she reported all behaviors to nursing. Licensed practical nurse (LPN) #1 was interviewed on 10/10/19 at 9:24 a.m. She said the resident would yell at staff occasionally, but other than an occasional outburst he did not have too many behaviors. The social service director (SSD) was interviewed on 10/10/19 at 9:36 a.m. The SSD was told of the observations, record review and interviews. She said, We are currently working on behavior tracking because we are not getting a true record of residents' behaviors because the CNA staff have no place to document residents' behaviors. Ever since we went paperless we have lost a lot of behavior tracking due to the breakdown of communication between nursing and CNAs. We have discussed where we could have CNAs document behaviors. She said, It would be my expectation that the resident behaviors would be documented correctly, especially if they are happening on a daily basis. The director of nursing (DON) was interviewed on 10/10/19 at 10:18 a.m. The DON was told of the observations, record review and interviews. She said all documentation should clearly identify the resident's behaviors and should be matching to ensure the resident's behaviors were being correctly identified by all staff. She said a negative outcome would be all staff not documenting behaviors because they saw it as a daily behavior. II. Resident #132 A. Resident status Resident #132, age [AGE] was admitted on [DATE]. According to the October 2019 CPO, diagnoses included major depression. No minimum data set was available. B. Record Review 1. Care plan The care plan, initiated 10/7/19, identified the resident was at risk for elopement related to wandering and dementia diagnoses. Interventions included: -Educate staff to watch for the resident when exiting a door. -Encourage family to bring in personal possessions. -Evaluate the effect of cognitive impairment upon resident's ability to understand changes in surroundings. -Introduce patient to other patients in the facility. 2. Nursing notes A nursing log note dated 10/1/19 at 11:14 p.m. documented: Resident on alert charting for new admission to facility. Resident up ambulating throughout facility. Pleasantly confused. Going in and out of other resident's rooms, was easily redirected. Follows staff at times up and down the halls. In bed at this time resting for long intervals. Breathing even and unlabored. Checked often by staff for safety. Call light within reach. Will monitor. Nursing log notes further documented as follows: -On 10/2/19 at 5:10 p.m. Alert charting for new admit to facility. Resident wandering in halls, very pleasant. Participated in all activities and eats in dining room for all meals. Resident was able to be redirected. -On 10/3/19 at 1:37 a.m. Resident wandered up and down halls during evening hours. In and out of other resident rooms but was easily redirected, no signs or symptoms (s/s) of pain or discomfort. No attempts to leave facility. Remained in bed with no complaints. -On 10/3/19 at 4:14 p.m. Resident continues on alert charting for new admission to facility. Resident ambulates throughout facility throughout the day. Resident pleasantly confused and was noted to go in and out of other residents rooms; resident easily redirected and follows staff at times up and down the halls. Checked often by staff for safety. Call light within reach. Will continue to monitor. -On 10/3/19 at 7:10 p.m. Resident adjusting well to the facility, staff, and other residents. Resident had pleasant affect and able to make needs known. Will continue to monitor. -On 10/4/19 at 2:38 p.m. Walks throughout the facility during the day. Friendly but confused. -On 10/6/19 at 10:17 a.m. Resident followed another resident out the front door. She was in between the two doors when spotted by myself and activity assistant. Activity assistant went to the door, which did not alarm when she went out to get resident, brought resident back into the facility. Resident obviously followed another resident out the door. Alarm was reset on the door and tested, and it worked just fine. Resident was placed on every 15 minute checks for her protection. Son notified. -On 10/6/19 at 3:26 p.m. Spoke with (other) resident and told him to please be sure no other resident is following him out the door. He verbalized understanding. -On 10/8/19 at 6:37 p.m. No further elopement attempts identified. -On 10/9/19 at 2:17 a.m. Resident on alert charting for elopement attempt. No further attempts reported. Resident in bed at this time. Resident up three times this shift. Will monitor. Resident #132 did not have a behavior monitoring form identifying wandering and elopement attempts/exit seeking. C. Observations On 10/7/19 at 5:15 p.m., the resident was observed standing next to the exit in the front of the facility. The resident watched the front door and waited to see who was leaving the facility. Observations on 10/08/19 revealed the resident was wandering throughout the facility halls, at 8:21 a.m., 9:16 a.m., 10:00 a.m., 10:45 a.m., and 11:16 a.m. -At 11:20 a.m., CNA #1 escorted the resident out of room [ROOM NUMBER]. Resident #132 held CNA #1's arm and walked with CNA #1 for a while. The resident wandered the facility from 1:10 p.m. to 2:32 p.m. No staff were observed to monitor Resident #132's whereabouts. -At 3:38 p.m., the resident was observed to push against the door at the end of the hall. During the observation, staff did not redirect the resident or offer any other interventions or activities for Resident #132. On 10/9/19 at 3:32 p.m. Resident #132 entered the social service director's office, which surveyors were using as a conference room. The resident stayed in the office for approximately 10 minutes. Resident #132 stood up and was visibly unsteady on her feet. This surveyor immediately searched for a staff member and was able to locate LPN #1. LPN #1 was informed of the concerns with Resident #132. The resident was escorted to her room by LPN #1 for further evaluation. D. Interviews Certified nurse aide (CNA) #4 was interviewed on 10/8/19 at 8:42 am. She stated she often worked with Resident #132. She said Resident #132 did not have any behaviors. She said she did not know Resident #132 had attempted to elope. CNA #6 was interviewed on 10/8/19 at 2:23 a.m. She said Resident #132 wandered around the facility all the time. She said, I never heard that she had attempted to elope. CNA #3 was interviewed on 10/9/1 at 2:22 p.m. She said Resident #132 had no behaviors that she was aware of other than she wandered the facility a lot. She said, I did not hear she tried to elope. CNA #1 was interviewed on 10/10/19 at 8:43 a.m. She said Resident #132 liked to wander around to different places in the facility. She said the only problem they had with Resident #132 was she latched onto staff and grabbed their arms and followed them into other residents' rooms when they were providing care. She gets agitated when we tell her she cannot come into the rooms with us. CNA #1 said she was not aware Resident #132 had attempted to elope. The social service director was interviewed on 10/10/19 at 9:36 a.m. The SSD was told of the observations, record review, and interviews above. She said the resident had severe cognitive impairment. She said she tried to get some history about the resident from the family but they had not been supportive with Resident #132's care. She said they had 24 hour report where they discussed residents' issues. She said, I was not informed of the elopements. Yes, wandering is a behavior and Resident#132's wandering and attempted elopements should have been documented and tracked, especially with staff not being aware of her elopement attempts. III. Resident #24 A. Resident status Resident #24, age [AGE], was admitted on [DATE] and readmitted on [DATE]. According to the October 2019 computerized physician orders (CPO), diagnoses included schizophrenia, depressive disorder, and developmental disorder of scholastic skills. The 9/7/19 minimum data set (MDS) assessment revealed the resident did not have a brief interview for mental status (BIMS) completed due to the resident was rarely/never understood. No behaviors were noted, and no rejections of cares were identified. B. Record review 1. Care plans The care plan, initiated 3/1/18 and revised on 9/17/19, identified the resident would hit herself with her hair brush and the remote to the TV and or magazine. Interventions included: -Redirect her actions to a non-violent action and sit with her for a while to ensure her behavior did not occur. -Social services would contact mental health for a psych visit. The care plan did not include tracking and monitoring the resident's behavior of hitting herself. The care plan, initiated 11/27/19 and revised on 9/17/19, identified the resident was being treated for schizophrenia with the medications Seroquel and Abilify. Interventions included: -Nursing to assess for any change in mood or anxiety that could trigger a schizophrenic episode. -Nursing to interview the family/resident if appropriate to find out possible triggers or concerns related to her schizophrenia. -Provide consistent staff, and a calm quiet atmosphere. The care plan did not include tracking and monitoring any specific behaviors identified with the diagnosis of schizophrenia and the identified medications Seroquel and Abilify. The care plan identified one intervention. The care plan, initiated on 11/27/17 and revised 9/17/19, identified the use of the antidepressant medication Citalopram. Interventions included: -Monitor/document/report to medical doctor (MD) as needed (PRN) ongoing signs and symptoms of depression unaltered by antidepressant medications; sad, irritable, anger, never satisfied, crying, shame, worthlessness, guilt, suicidal ideations, negative mood/negative comments, slowed movement, agitation, disrupted sleep, fatigue, lethargy, does not enjoy usual activities, changes in cognition, changes in weight/appetite, fear of being alone or with others, unrealistic fears, attention seeking, concern with body functions, anxiety, and constant reassurance. The care plan did not identify individualized person-centered interventions if the identified behaviors presented themselves. The care plan, initiated on 11/27/17 and revised on 9/17/19, identified the use of Seroquel and Abilify for schizophrenia. Interventions included: -Monitor/record/report to MD PRN side effects and adverse reactions of psychoactive medications. 2. Behavior monitoring The August 2019 behavior monitoring flow sheet (BMF) for schizophrenia identified the medication Abilify. The target behaviors identified to track were yelling/crying, fear, and hitting self/pinching. The resident had one episode of yelling/crying documented. The August 2019 BMF for schizophrenia identified the medication Seroquel. The target behaviors identified to track were agitation, visual hallucinations, and anger. The resident had five episodes of agitation documented. The August 2019 BMF for depression identified the medication Citalopram. The target behaviors identified to track were unexplained crying and self isolation. The resident had one episode of unexplained crying documented. The September 2019 BMF for schizophrenia identified the medication Abilify. The target behaviors identified to track were yelling/crying, fear, and hitting self/pinching. The resident had three episodes of yelling/crying documented. The September 2019 BMF for schizophrenia identified the medication Seroquel. The target behaviors identified to track were agitation, visual hallucinations, and anger. The resident had no episodes of the identified target behaviors documented. The September 2019 BMF for depression identified the medication Citalopram. The target behaviors identified to track were unexplained crying and self isolation. The resident had one episode of unexplained crying documented. The October 2019 (from the first to the eighth) BMF for schizophrenia identified the medication Abilify. The target behaviors identified to track were yelling/crying, fear, and hitting self/pinching. The resident had no episodes of the identified target behaviors documented. The October 2019 (from the first to the eighth) BMF for schizophrenia identified the medication Seroquel. The target behaviors identified to track were agitation, visual hallucinations, and anger. The resident had no episodes of the identified target behaviors documented. The October 2019 (from the first to the eighth) BMF for depression identified the medication Citalopram. The target behaviors identified to track were unexplained crying and self isolation. The resident had no episodes of the identified target behaviors documented. The interventions identified on the form were not person centered or individualized to the resident. The target behavior of visual hallucinations was not identified on the care plan. C. Interviews Certified nurse aide (CNA) #2 and CNA #5 were interviewed on 10/9/19 at 1:01 p.m. They said the resident cried almost every day. They said she was very particular with who provided care to her. They said she could become angry when the cares provided were by someone she did not like. They agreed the best intervention was to remind her that her friend would come by and visit her after he got off work. On the weekends the aides would remind her he would come by to visit and stated he sometimes would come by twice a day to visit with her. They said it worked almost all the time. They said they would report the crying to the nurse assigned to the hall. Licensed practical nurse (LPN) #2 was interviewed on 10/9/19 at 1:10 p.m. He said the resident cried often. He said the best approach was to remind her of her friend's visits in the evening. He said she would calm down with the reminder. He said when the CNAs would report crying to him or if he saw the behavior, he would write a progress note and document on the BMF. The social services director (SSD) was interviewed on 10/10/19 at 10:39 a.m. She said she was familiar with the resident having crying episodes. She said the care plan needed to have person-centered, individualized interventions for the resident's specific identified behaviors. She said she had started having the CNAs write down behaviors and turn the documented behaviors for any resident in to the hall nurses. She said the floor nurses needed to document the behaviors. She said the facility was going to change the documentation system and adapt the kiosk to allow the CNAs to document behaviors as well. She said the staff should get the credit for the effective interventions of the resident's identified behavior. The director of nursing (DON) was interviewed on 10/10/19 at 11:05 a.m. She said it was important to effectively track behaviors and provide appropriate person-centered interventions to the resident to have a better understanding of medication management, and to possibly alleviate the symptoms to improve the quality of the resident's stay.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interviews, the facility failed to provide person-centered dementia care services to two (#26 and #21) of five residents reviewed of 18 sample residents. Specifically, the facility failed to develop and implement person-centered interventions so Residents #26 and #21 could reach their highest practicable quality of life. Findings include: I. Resident #26 A. Resident status Resident #26, age [AGE], was admitted on [DATE] and readmitted on [DATE]. According to the October 2019 computerized physician orders (CPO), diagnoses included dementia with behavioral disturbance and anxiety disorder. The 8/16/19 minimum data set (MDS) assessment revealed the resident had moderate cognitive impairment with a brief interview for mental status (BIMS) score of eight out of 15. The resident was identified as having verbal outbursts in the previous one to three days from the date of the evaluation. The verbal outbursts disrupted care, affected the living environment, and put others at risk for physical injury. No refusals of care were identified. B. Record review 1. Care plans The care plan, initiated 8/8/16 and revised 10/7/19, identified the use of psychoactive medications related to the diagnosis of dementia. Interventions included staff to monitor behaviors related to psychoactive medications. The care plan, initiated 10/4/16 and revised on 10/7/19, identified the resident would yell for a coke, yell for cigarettes, yell that he was in pain, yell for help and was not easily redirected. Interventions included: -He becomes even more agitated when he feels like he is being ignored. -Try carrying on a conversation with him. Find out about him, what he used to do, etc. -Address his concerns even if he is repeating himself. -Staff have been educated to let the resident know that he was just out for a cigarette and tell him when his next cigarette is due. -Stick to the smoking schedule and reminisce. -When the resident is yelling for pain medication, remind him when he received his last dose and when he can get another pain pill. -When the resident is yelling in front of other residents, nicely explain to him that that behavior is inappropriate and offer to take him to his room, offer coffee, and attempt to redirect him. -When unable to redirect, take him to the dining room and sit and have a conversation and spend some time talking with him. The care plan, initiated 8/14/18 and revised 10/7/19, identified anti-anxiety medication related to anxiety and shortness of breath. Interventions included: -Monitor/record occurrence for the target behavior symptoms of inappropriate response to verbal communication, violence/aggression towards staff/others and document per facility protocol. The care plan, initiated 8/21/18 and revised 10/7/19, identified the resident exhibiting difficulty with behavioral issues as evidenced by repetitive yelling and refusing care. Interventions included: -Invite/encourage to attend activities. -Monitor every shift for episodes described behavior and record on medication sheet. -Staff will encourage resident to express his feelings. -Staff will redirect maladaptive behaviors with verbal interventions, snacks, or beverages. 2. Behavior monitoring The August 2019 behavior monitoring flow sheet (BMF) for the diagnosis of depression identified the medication Prozac. The target behaviors identified to track were decreased appetite, self isolation, and insomnia. The resident had no episodes of the identified target behaviors documented. The August 2019 BMF for the medication Lorazepam and Prozac did not include diagnoses. The target behaviors identified to track were yelling/screaming, inappropriate language, and aggressive actions. The resident had 21 episodes of yelling/screaming and 15 episodes of inappropriate language documented. The September 2019 BMF for the diagnosis of depression identified the medication Prozac. The target behaviors identified to track were decreased appetite, self isolation, and insomnia. The resident had no episodes of the identified target behaviors documented. The September 2019 BMF for the medication Lorazepam and Prozac did not include diagnoses. The target behaviors identified to track were yelling/screaming, inappropriate language, and aggressive actions. The resident had eight episodes of yelling/screaming and one episode of inappropriate language documented. The October 2019 BMF (from 10/1 to 10/8/19) for the diagnosis of depression identified the medication Prozac. The target behaviors identified to track were decreased appetite, self isolation, and insomnia. The resident had no episodes of the identified target behaviors documented. The October 2019 BMF (from 10/1 to 10/8/19) for the diagnosis of anxiety identified the medication Lorazepam. The target behaviors identified to track were yelling/screaming, inappropriate language, and aggressive actions. The resident had one episode of yelling/screaming and one episode of inappropriate language documented. The BMFs did not include or document effective and identified person-centered individualized interventions that were identified in the care plans. C. Interviews Certified nurse aide (CNA) #2 and CNA #5 were interviewed on 10/9/19 at 1:01 p.m. They stated the resident yelled out most of the time, at least once a day. They said he would complain about pain even after receiving pain medication. They said he would demand coffee right after the aides would fill his cup with fresh coffee. They said he gets bossy frequently. They said the most effective intervention was to accommodate him and his requests. The aides said they would report the behaviors to the nurse for documentation. Licensed practical nurse (LPN) #2 was interviewed on 10/9/19 at 1:10 p.m. He said the resident had more behaviors/outbursts when returning from smoking. He said the resident would yell out daily, sometimes frequently on one shift. He said the resident would sit in the hall and yell for his pain medication, yell for another cigarette, and yell for coffee. When he exhibited the behaviors, the nurse stated he would talk to the resident and try to calm him down. He said they would be firm with the resident, but not mean. He said he would make a progress note and mark the behavior on the BMF. The social services director (SSD) was interviewed on 10/10/19 at 10:39 a.m. She said she was familiar with the resident yelling out, being demanding for pain medications and cigarettes, and using inappropriate language. She said the care plan needed to have person-centered individualized interventions for the resident's specific identified behaviors. She said the identified interventions needed to be applied by all staff from the aides to the nurses. She said she had started having the CNAs write down behaviors and turn in the documented behaviors for any resident to the hall nurses. She said the floor nurses needed to document the behaviors. She said the facility was going to change the documentation system and adapt the kiosk to allow the CNAs to document behaviors as well. She said the staff should get the credit for the effective interventions of the resident's identified behavior. The director of nursing (DON) was interviewed on 10/10/19 at 11:05 a.m. She said it was important to effectively track behaviors and provide appropriate person-centered interventions to the resident, to have a better understanding on medication management and to possibly alleviate the symptoms to improve the quality of the resident's stay. She said the identified effective person-centered interventions should be used when the identified behaviors occurred, to be consistent with the resident. II. Resident #21 A. Resident status Resident #21, age [AGE], was admitted on [DATE]. According to the October 2019 CPO, diagnoses included dementia with behavioral disturbance and depression with psychosis. The 8/16/19 MDS assessment revealed the resident had severe cognitive impairment with a BIMS score of four out of 15. No behaviors were identified. No refusals of care were identified. B. Record review 1. Care plans The care plan, initiated 2/8/19 and revised 8/21/19, identified the potential for a behavior problem related to a diagnosis of dementia with behaviors. Interventions included: -Assist the resident in developing more appropriate methods of coping and interacting. -Encourage him to express his feelings appropriately. -Explain all procedures to the resident before starting and allowing the resident time to adjust to changes. -Intervene as necessary to protect the rights of others. The care plan, initiated 3/7/19 and revised on 8/21/19, identified impaired cognitive function or impaired thought process related to dementia. Interventions included: -Identify yourself at each interaction. Face the resident, when speaking to and make eye contact. Reduce any distractions if need to. Use simple directive sentences. -Provide consistent care by staff and maintain a routine to minimize confusion. The care plan, initiated 8/14/19 and revised on 8/21/19, identified the potential for drug related complications associated with the use of psychotropic medications. Interventions included the BMF. The care plan, initiated 9/10/19, identified PASRR level II for a diagnosis of major depressive disorder with psychosis. Interventions included to monitor behaviors and side effects of medications for possible gradual dose reductions (GDR) or elimination of medications. 2. Behavior monitoring The August 2019 BMF identified the diagnosis of dementia with behaviors and the medication Risperidone. The target behaviors identified to track were agitation and aggression. The resident had one episode of agitation. The September 2019 BMF identified the diagnosis of dementia with behaviors and the medication Risperidone. The target behaviors identified to track were agitation and aggression. The resident had no episodes of the identified target behaviors documented. The October 2019 BMF (from the first to the eighth) identified the diagnosis of dementia with behaviors and the medication Risperidone. The target behaviors identified to track were agitation and aggression. The resident had no episodes of the identified target behaviors documented. 3. Interdisciplinary team review The interdisciplinary team (IDT) review, dated 8/16/19, included the recommendation, discontinue Risperidone and try an antidepressant Zoloft 25 mg every day (QD). IDT recommendations faxed to the medical doctor (MD). The identified team members were the SSD, the nursing home administrator (NHA), the DON, the pharmacy consultant, and the medical director. The pharmacy consultation review, signed and dated 8/16/19, reiterated the recommendation to discontinue Risperidone and starting Zoloft. The consultation report was not signed. C. Interviews CNA #2 and CNA #5 were interviewed on 10/9/19 at 1:01 p.m. They said they were not aware the resident had any behaviors. CNA #6 was interviewed on 10/9/19 at 2:33 p.m. She said the resident would yell, but it did not happen very often. She said when the resident did have a behavior, she would try to calm him down. LPN #3 was interviewed on 10/9/19 at 2:33 p.m. She said the resident did not have behaviors very often since his medication was increased. She identified the transfer lift was a source of stress for the resident. She said now that the staff use a walker to assist with transfers, his behaviors have decreased. She said she did not remember if she documented his behavior around the transfer lift. The social services director (SSD) was interviewed on 10/10/19 at 10:39 a.m. She said she was not familiar with the anxiety associated with the transfer lift. She said the identified interventions in the care plan should be carried through to the BMF as individualized person centered effective interventions. She said the IDT team pharmacy review recommendations were faxed over to the MD, however since the shift in management, she was not sure if the recommendations were faxed to the MD. She said the care plans needed work and the staff would receive more training for behavior management. The director of nursing (DON) was interviewed on 10/10/19 at 11:05 a.m. She said since the shift in administration and ownership, she was not sure if the IDT recommendations were sent to the MD. She said it was the responsibility of the pharmacist to fax over the IDT recommendations. She said the MD had been in the facility after the team meeting, and she was not sure if the recommendations were relayed to the MD. She said the resident had been stable and the behaviors had decreased. She said it was important to effectively track behaviors and provided appropriate person-centered interventions to the resident, to have a better understanding on medication management and to possibly alleviate the symptoms to improve the quality of the resident's stay. She said the identified effective person-centered interventions should be used when the identified behaviors occurred, to be consistent with the resident.

Based on observations, record review and interviews, the facility failed to store and prepare food under sanitary conditions. Specifically, the facility failed to ensure: -Cutting boards were free from deep scratches and stains; and -Food was stored properly, off the floor. Findings include: I. Cutting boards A. Professional Standard 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 10/7/19 at 10:00 a.m. revealed four cutting boards that were heavily scored and stained. On 10/8/19 at 10:00 a.m., kitchen staff were observed using cutting boards to cut vegetables, bread and fruit. C. Staff Interview The dietary manager (DM) was interviewed on 10/09/19 at 12:50 p.m. The DM looked at the stains on all the cutting boards and said, I could see the deep scratches being a possible bacteria issue if not cleaned correctly. She observed the green and red cutting boards which were discolored in the middle approximately eight inches in circumference. She said, I will replace the cutting boards; they do need replacing. II. Food storage A. Professional reference According to the Colorado Retail Food Establishment Rules and Regulation, page 76, Food shall be protected from contamination by storing the food: (1) In a clean, dry location; (2) Where it is not exposed to splash, dust, or other contamination; and (3) At least 15 cm (6 inches) above the floor. B. Observations and interview On 10/7/19 at 10:00 a.m. the freezer had two boxes of frozen bread and one box of whipped topping on the floor in the back of the freezer. The dry storage had a box of potato chips and a case of canned tomatoes on the floor. On 10/8/19 at 8:00 a.m. the freezer had two boxes of frozen bread and one box of whipped topping on the floor in the back of the freezer. The dry storage had a box of potato chips and a case of canned tomatoes on the floor. The dietary manager was interviewed on 10/8/19 at 8:22 a.m. She said the food should not be stored on the floor of the freezer and in the dry storage. She said the food should have been stored on a milk crate and not on the floor.

Based on record review and interviews, the facility failed to ensure certified nurse aides (CNAs) were able to demonstrate competencies in skills and techniques necessary to care for residents' needs, as identified through resident assessments, and described in the plan of care. Specifically, the facility failed to complete staff competencies for all CNAs. Findings include: I. Competency records The facility did not have competency records for CNA skills. II. Interviews CNA #2 was interviewed on 10/8/19 at 1:45 p.m. He said he was trained on the correct way to turn on oxygen for a resident on either a concentrator or a portable tank about five years ago. (Cross-reference F695, respiratory care.) The director of nursing (DON) was interviewed on 10/9/19 at 2:30 p.m. She said the facility could not locate the competencies of the CNAs providing care in the facility. She said the facility was going to schedule a skills fair in December.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to establish an infection control program for antibiotic stewardship to include an antibiotic stewardship program for one (#1) of five residents reviewed of 18 sample residents. Specifically, the facility: -Failed to track antibiotic usage in the facility, and -Failed to assess for the appropriate use of an antibiotic for Resident #1. Findings include: I. Professional standard The Centers for Disease Control and Prevention (CDC), antibiotic prescribing and usage in hospitals and long-term care, dated 2019, retrieved from https://www.cdc.gov/antibiotic-use/core-elements/hospital.html on 10/17/19, included the following recommendations: Implement policies that apply in all situations to support antibiotic prescribing to include specifying the dose, duration and indication for all courses of antibiotics so that they are readily identifiable. Implement facility specific treatment recommendations, based upon the national guidelines and local susceptibilities and formulary options that optimizes antibiotic selections, duration, and common indications for the usage of community acquired pneumonia, urinary tract infections, skin and soft tissue infections. Implement broad interventions, antibiotic time out prompts reassessment of the continuing need and choice of antibiotics when the clinical picture is clearer and more diagnostic information is available. Clinicians should perform a review of antibiotics within 48 hours of antibiotic initiation to include key questions: Does this patient have an infection that will respond to antibiotics and how long should the patient receive the antibiotics. Many patients who get antibiotics for urinary tract infections actually have asymptomatic bacteriuria and not infections. Interventions for urinary tract infections focus on avoiding unnecessary urine cultures and treatment of patients who are asymptomatic and ensuring that patients receive appropriate therapy based on local susceptibility and for the recommended duration. The potential misuse of antibiotics has contributed to the growing problem of antibiotic resistance. Accountability and drug expertise may include identifying a single leader responsible for antibiotic stewardship program outcomes and a pharmacy leader who will co-lead the program. II. Antibiotic tracking system The facility infection control program was reviewed on 10/9/19 at 1:35 p.m. with the NHA and director of nursing (DON). The facility did not have an antibiotic tracking system. The DON explained there had recently been a change in leadership in both the ownership of the facility and administration. She said there were different expectations from the new owners. She said the facility currently had not tracked all antibiotic usage, however the facility did document new ordered antibiotics on the Infection Tracking form. Review of the form revealed it did not have a current or ongoing antibiotic usage, only new ordered antibiotics or suspected infections ruled out by not meeting the assigned criteria. III. Resident #1 A. Resident status Resident #1, age [AGE], was admitted on [DATE]. According to the October 2019 computerized physician orders (CPO), diagnoses included urinary tract infection (UTI) and rhabdomyolysis. The 9/24/19 minimum data sets (MDS) assessment revealed the resident had moderate cognitive impairment with a brief interview for mental status (BIMS) score of eight out of 15. She required extensive assistance with bed mobility, transfer, and toilet use. B. Record review The resident did not have a care plan to address the long-term use of an antibiotic. The resident did not have a risk vs. benefit statement for the long term use of an antibiotic. 1. CPOs The April 2019 CPO included: -Keflex 250 mg, give one capsule by mouth in the morning for UTI prophylaxis (original order date of 2/24/19). - Keflex 250 mg, give one capsule by mouth in the morning for UTI prophylaxis on hold from 4/9/19 to 4/16/19. -Keflex 500 mg, give one capsule by mouth twice a day for UTI starting 4/9/19 and ending 4/16/19. The May 2019 CPO included: -Keflex 250 mg, give one capsule by mouth in the morning for UTI prophylaxis. -Keflex 250 mg, give one capsule by mouth in the morning for UTI prophylaxis on hold from 5/3/19 to 5/10/19. -Ceftriaxone sodium solution reconstituted one gram (GM). Inject one GM intramuscularly (IM) in the morning for UTI for seven days (5/3/19 to 5/10/19). The September 2019 CPO included: -Keflex 250 mg, give one capsule by mouth in the morning for UTI prophylaxis. -Keflex 250 mg, give one capsule by mouth in the morning for UTI prophylaxis on hold from 9/15/19 to 9/22/19. -Cipro 250 mg give one tablet by mouth in the morning for UTI until 9/22/19. 2. Progress notes The progress note (PN) dated 4/16/19 at 10:15 a.m. included, Resident completed her antibiotic treatment with Keflex 500 mg twice daily. Keflex 250 mg once daily is continued this morning for UTI prophylactic treatment of UTI . The PN dated 5/2/19 at 10:03 a.m. included, Received call from medical doctor (MD), urine culture results reviewed and new orders given. Ceftriaxone one gram daily IM daily for seven days (starting 5/3/19), hold Keflez until ceftriaxone is completed . The PN dated 9/15/19 at 11:22 a.m. included, Received order to start (the resident ) on Cipro 250 mg daily for seven days related to a UTI. Hold Keflex while taking Cipro . 3. Pharmacy recommendations The pharmacy consultation report, dated 8/30/19, read in part, Resident has orders for Keflex 250 mg daily for UTI prophylaxis, she has taken the Keflex since 2/24/19, and if therapy is continued it is recommended that the prescriber document an assessment of risk versus benefits indicating the Keflex to be a valid therapeutic intervention for the resident. The pharmacy consultation report, dated 9/30/19, read in part, Resident has orders for Keflex 250 mg daily for UTI prophylaxis, she has taken the Keflex since 2/24/19, and if therapy is continued it is recommended that the prescriber document an assessment of risk versus benefits indicating the Keflex to be a valid therapeutic intervention for the resident. Antibiotic prophylaxis increases the risk of resistance and incidence of Clostridium difficile infection. C. Staff interview The director of nursing was interviewed on 10/9/19 at 1:35 p.m. She said a fax was provided to the physician for the pharmacy recommendations. She said due to the change of administration/ownership she was not sure if the physician had received the fax. She said it was the pharmacy's responsibility to notify the physician of pertinent recommendations.

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 2/15/17, pp. 94-95: -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. C. According to the Armed Forces Pest Management Board, Technical Guide No. 20, Pest Management Operations in Medical Treatment Facilities, December 2016, pp. 7-9: -Pests, especially cockroaches, flies and rodents, may contaminate or damage food and equipment and are therefore considered of significant health importance. -Pest infestations often cause anxiety and may interfere with comfort and recovery. -Pest infestations are often seen as an indicator of inadequate sanitary conditions, thereby adversely affecting a person's perception of their quality of care. -The primary goal in preventing or reducing pest infestations should be to use non-chemical control techniques, such as basic sanitation, routine food and premises surveillance procedures and mechanical exclusion and control procedures. II. Main kitchen observations and interviews On 10/7/19 at 10:00 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. On 10/9/19 from 9:45 a.m. to 11:40 a.m., continuous observation during meal preparation and meal service revealed several staff members were working in the kitchen preparing food, while swatting flies away from the tables, food and themselves. Dietary aide #4 was observed swatting flies away with her hand. She said, These flies are terrible. III. Main dining room observations and interview Observation of the lunch meal service on 10/7/19 at 11:30 a.m. revealed flies were around the tables on residents, walkers, wheelchairs and lunch plates. Multiple residents were observed swatting the flies from their eating area. Observation of the lunch meal service on 10/8/19 at 11:32 a.m. revealed flies were around the tables on residents, walkers, wheelchairs and lunch plates. Multiple residents were observed swatting the flies from their eating area. The dietary manager was interviewed on 10/9/19 at 12:50 p.m. She said the problem with flies in the kitchen was due to the screen door being left open and the weather was getting colder, which brings the flies into the facility. She said a negative outcome with the flies was the flies could be carriers of bacteria and just a plain nuisance. IV. Resident environment observations and interviews On 10/7/19, 10/8/19, 10/9/19 and 10/10/19, flies were observed throughout the facility. On 10/7/19 at 1:23 p.m., flies were observed throughout the [NAME] hall, flying into this surveyor's face. On 10/10/19 at 10:23 a.m., during the environmental tour, Resident #26 was observed swatting flies away from his face. He said the flies were terrible in his room. -At 1:54 p.m., Resident #4 said the flies are terrible in this area. He said they were always flying around his face and landing on his bedside table. He said they are bad in the dining room as well. The maintenance director (MTCE) was interviewed on 10/10/19 at 11:05 a.m. during the environmental tour. The above detailed observations were reviewed. The MTCE said the flies were a seasonal problem and he had been trying to get a handle on the problem. The MTCE said he had contacted the facilities exterminator but they really didn't have a solution as they couldn't spray. He said, I have been looking for alternatives and I am contacting a company and inquired about blue light to use. The MTCE said the negative outcome from the flies would be passing germs.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interview, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs for two (#8, and #22 ) of 15 residents reviewed for comprehensive care plans of 15 sample residents. Specifically, the facility: -failed to develop a care plan for Resident #8's increased risk and history of falling; and, -failed to develop a care plan for the potential for pressure injuries for Resident #22. 1. Resident #8 A. Resident status Resident #8, age [AGE], was admitted on [DATE]. According to the August 2018 CPO, diagnoses included urinary retention, cardiac pacemaker, history of falling, congestive heart failure, artherosclerotic heart disease, tremor, hypoxemia, chronic obstructive pulmonary disease with acute exacerbation, pain in left and right knees and pain in left and right hips. The 5/30/18 MDS assessment revealed the resident had moderate cognitive impairment with a BIMS score of nine out of 15. The resident did not display behaviors of concern, including rejection of care, during the seven-day assessment period. The resident was independent with bed mobility but needed supervision and oversight for transfers. Balance during transfers and while walking was described as unsteady but the resident was able to stabilize without human assistance. Mobility devices used by the resident included a walker and a wheelchair. The resident experienced two or more falls without injury since the previous assessment completed on 2/27/18. He was not seen by therapy during the assessment period but did receive active range of motion exercises. The care area assessment (CAA), completed with the admission MDS assessment on 11/27/17, triggered falls as an area for care plan development. B. Record review The August 2018 CPO included orders to have the resident participate in restorative therapy daily for strengthening. A 4/24/18 social services note revealed the resident had multiple falls in his bathroom due to what he described as urgent toileting needs. The circumstances of these falls prompted the facility to refer the resident for mental health services. Staff noted the resident was capable of using a front wheeled walker in the community with family and friends but insisted on using a wheelchair in the facility. The physician and therapy continued working to determine if there was a root cause for the resident's falls. Progress notes revealed additional falls occurred on 5/8/18, 5/10/18, 5/14/18 and 7/23/18. A review of the comprehensive care plan failed to reveal a care plan to address the resident's recent falls was developed. Additionally, the care plan for behaviors was not revised to address the potential that many of the resident's falls were behavioral. C. Staff interviews CNA #1 and #10 were interviewed on 8/16/18 at 2:10 p.m. CNA#1 said she usually worked the weekend shift and was not aware of any falls by the resident. She said she did not know what fall precautions were in place for the resident. CNA #10 said the resident did a lot on his own and would call if he needed something. The CNAs were not aware of his history of falling as a behavior. The staff responsible for care plan development, who was also the MDS coordinator, and the nursing home administrator (NHA) were interviewed on 8/16/18 at 3:42 p.m. The NHA said the resident experienced a number of unwitnessed falls that were reported by his roommate as intentional. The NHA said the resident was independent with most ADLs but did use assistive devices including a walker and a wheelchair. The NHA said the resident was referred for a mental health screen and, since then, has had fewer falls. The MDS coordinator said the resident used to have a care plan for falls but it was discontinued when he no longer was falling. The MDS coordinator said she recognized the resident's increased potential for falling and the possibility he might return to his previous behaviors. The MDS coordinator and the NHA said the facility should maintain a care plan for falls for this resident. 2. Resident #22 A. Resident status Resident #22, age [AGE], was admitted on [DATE] and readmitted on [DATE]. According to the August 2018 CPO, diagnoses included arthropathy, dermatitis personal history of diseases of the skin and subcutaneous tissue, unspecified protein-calorie malnutrition, unspecified intellectual disabilities, pruritus and dementia. According to the 6/30/18 MDS assessment, the resident's cognitive skills for daily decision making were severely impaired and she never/rarely made decisions. She experienced delirium described as continuous inattention. She did not exhibit behaviors of concern, including rejection of care, during the seven day assessment period. The resident was totally dependent on staff for bed mobility, transferring, locomotion, dressing, eating, toilet use and hygiene. She did not experience any functional limitation in range of motion but was unable to stabilize without assistance from others when moving from surface to surface. The resident was always incontinent of bladder and occasionally incontinent of bowel. She was four feet eleven inches tall and weighed 89 pounds. According to the assessment, the resident was at risk of pressure ulcers and required pressure reducing devices for her bed and her chair. B. Record review The care plan, initiated on 12/31/12 and revised 4/18/18, identified the resident had very fragile, dry skin and a tendency to pick at her skin until the skin tears. Approaches included resident refuses lotion at times, try another time; diet as ordered, supplements as ordered to promote healthy skin; dressing change to wound care when needed per physician order; and, keep nails trimmed and apply lotion as allowed. The care plan, initiated 12/26/13 and revised 4/18/18, identified the potential for skin irritation and open skin related to chronic neurodermatitis. Approaches included keep fingernails trimmed, medication per orders, monitor if resident picks skin, monitor for exacerbation of condition and nutritional supplements to support healthy skin. The care plan, initiated 3/27/14 and revised 4/18/18, identified frequent bladder and bowel incontinence. Approaches included check and change as required and provide incontinence care but did not address the resident's skin or establish a frequency for checking her for incontinence. The care plan, initiated 11/27/12 and revised 4/18/18, identified the resident had an activity of daily living (ADL) self care deficit. Approaches included dependent on staff for bed mobility and transferring. Approaches did not address repositioning needs when seated in wheelchair or lying in bed. The care plan, initiated 1/8/13 and revised 4/18/18, identified the resident had limited physical mobility. Approaches included monitor and report to physician any signs and symptoms of immobility, contractures, thrombus formation, skin breakdown and falls. Approaches did not address repositioning needs or preventative skin care related to immobility. The August 2018 CPO included orders to -check resident's skin daily and notify physician of changes; and -monitor skin weekly every Thursday morning. The 3/20/18 care area assessment (CAA) triggered pressure ulcers for care plan development. A review of the comprehensive care plan failed to reveal the resident's risk for the potential to develop a pressure injury was care planned. C. Staff interviews CNA #1 and CNA #4 were interviewed on 8/16/18 at 2:15 p.m. CNA #1 said staff try to reposition the resident ever two hours and check on her regularly when lying in bed. She said the resident spent a small amount of time each day seated in her wheelchair, mostly before and after meals. CNA #4 said the resident was unable to shift her weight, in bed or in her chair, and needed assistance to reposition her weight. CNA #1 said the resident used to help with toileting but slept most of the time and was totally incontinent of bladder and bowel. CNA #1 and #4 said they were not aware of a care plan for potential skin impairment for the resident and did not know if interventions were included on the [NAME]. The MDS coordinator and the NHA were interviewed on 8/16/18 at 3:45 p.m. The NHA said the resident's condition was slowly declining and she was not able to do much for herself. The NHA said the resident could not reposition herself in bed or in her chair and needed assistance from staff for positioning, mobility and toileting needs. The MDS coordinator said the resident did not have a pressure wound so her care plan did not reflect the need for treatment. The MDS coordinator said she recognized the need for including preventative measures in the care plan for residents with increased risk based on condition or diagnosis. The MDS coordinator and the NHA acknowledged the resident should have a care plan for the potential to develop pressure wounds related to her immobility, incontinence and weight loss and would reassess the resident and include preventative measures for pressure wounds in her care plan.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to ensure care plans were revised and appropriate for one (#26) of 15 residents reviewed for comprehensive care plans out of 15 sample residents. Specifically, the facility failed to revise Resident #26's care plan to include interventions to prevent pressure injuries in a variety of locations. Resident #26 had a significant history of serious pressure injuries in multiple locations; however, care plan interventions were only specific to an existing injury. Findings include: A. Resident status Resident #26, age , was admitted on [DATE]. According to the August 2018 computerized physician orders (CPO), diagnoses included peripheral vascular disease, unstageable pressure ulcer of the right ankle, polyneuropathy, disorder of kidney and ureter, type 2 diabetes, schizoaffective disorder and dementia. The 7/8/18 minimum data set (MDS) assessment revealed, the resident had severe cognitive impairment with a brief interview for mental status (BIMS) score of six out of 15. The resident engaged in verbal, physical and other behaviors daily and rejected care during four to six days of the seven day assessment period. She required total assistance from two or more staff for bed mobility, transferring and toileting. The resident was not steady and only able to stabilize with assistance from others when moving from one surface to another. The resident used a wheelchair for mobility. The resident used a catheter (which was removed prior to the most recent care plan) and was always incontinent of bladder and bowel. She had a current unhealed unstageable pressure ulcer with eschar. The resident had previous pressure ulcers and was at risk of developing other pressure ulcers. Skin and ulcer treatments included pressure reducing devices for bed and chair, turning and repositioning program, nutrition/hydration intervention to manage skin problems, pressure ulcer care, administration of non-surgical dressings and application of ointments/medications. B. Record review The August 2018 CPO included orders for: -air mattress to bed for decubitus ulcer; -monitor skin weekly, every Thursday morning; -turn every two hours while in bed for decubitus ulcer; The [NAME] report (staff instructions for care) documented the resident refused to use geri sleeves, an air mattress and heel protectors. The [NAME] also noted the resident was completely dependent on staff for bed mobility and was incontinent of bowel and bladder. A review of progress notes completed between 4/1/18 and 8/14/18 revealed the resident had a stage 4 pressure wound (resolved June 2018) to her coccyx upon admission. The care plan, initiated 4/1/18 and revised 8/7/18, identified the resident had an unstageable pressure ulcer to the left ankle. Interventions included (Resident) has metal from an ankle repair under open area. Healing may not occur as resident has severe PVD (peripheral vascular disease) .and debridement could cause wound to just be larger and more chance for infection, dressing changes per physician order, assess for healing and report any adverse side effects to physician; and, resident refused heel protectors and air mattress. The care plan failed to include interventions to address the potential for pressure injuries in a variety of locations and did not include approaches such as chair cushions, offloading, repositioning according to physician's orders and the MDS assessment. C. Staff interviews The nursing home administrator (NHA) and the staff responsible for care plan development and revisions, who was also the MDS coordinator, were interviewed on 8/16/18 at 3:45 p.m. The NHA said the resident was admitted to the facility with pressure wounds so significant they believed her health was endangered. The NHA said the facility successfully healed a wound on the resident's coccyx and reduced the wound on her ankle significantly. The NHA said, based on the resident's condition and her history, she would always be at risk of having skin breakdown and staff needed to diligently follow care instructions such as timely incontinence care, repositioning and using assistive devices to avoid future issues. The MDS coordinator said the resident had a care plan for pressure wounds but, upon reviewing the interventions, acknowledged the care plan focused narrowly on the resident's ankle wound. The MDS coordinator and the NHA said the care plan should be revised to include overall preventative skin interventions to address the resident's increased risk for developing other wounds.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interviews, the facility failed to ensure the resident environment remained as free from accident hazards as possible for one (#22) of one resident reviewed for accident hazards out of 15 sample residents. Specifically, the facility failed to ensure a homemade/modified call light cord could be used safely by Resident #22 to prevent a possible accident hazard. Findings include: A. Resident status Resident #22, age [AGE], was admitted on [DATE] and readmitted on [DATE]. According to the August 2018 computerized physician orders (CPO), diagnoses included arthropathy, hypoxemia, unspecified intellectual disabilities, dysphagia, abnormal posture and unspecified dementia without behavioral disturbance. According to the 6/30/18 minimum data set (MDS) assessment, the resident's cognitive skills for daily decision making were severely impaired and she never/rarely made decisions. She experienced delirium described as continuous inattention. She did not exhibit behaviors of concern, including rejection of care, during the seven day assessment period. The resident was totally dependent on staff for bed mobility, transferring, locomotion, dressing, eating, toilet use and hygiene. She did not experience any functional limitation in range of motion but was unable to stabilize without assistance from others when moving from surface to surface. B. Observations The resident was observed in her room on 8/13/18 at 3:40 p.m. She was reclined on her right side and covered with a blanket as she laid on her bed. A call light cord was draped across her body, on the opposite side, between her elbow and shoulder. The call light cord was made of a pliable, nylon rope, approximately four and a half feet long and 5/8 of an inch in diameter. The rope was connected to the call box by the thin plastic cord provided by the manufacturer. The thin plastic cord was cut to a shorter length and the ends of the rope and the cord were tied together in a knot. The rope formed to the resident's body, across her chest, around the outside of her upper arm and back as she laid sleeping in the bed. The resident was observed in her room on 8/14/18 at 10:22 a.m. She was reclined on her left side as she laid in her bed. The call light was positioned behind her on the wall and the nylon rope was draped across her right upper arm. The resident was observed in her room on 8/15/18 at 2:30 p.m. She was positioned on her right side and was covered with a blanket that had been moved from her shoulders toward her waist and was twisted near her legs. The nylon rope was draped across her shoulder on the opposite side and her back. Staff were summoned to address the resident's position. C. Record review The care plan, initiated 11/27/12 and revised 7/5/18, identified the resident experienced deficits in activities of daily living (ADLs). Interventions included encourage resident to use bell to call for assistance, limited assist with bed mobility (revised 10/20/15) to include dependence on one staff for bed mobility at night and dependent on staff for all transfers. The care plan, initiated 1/18/13 and revised 4/18/18, identified the resident had limited physical mobility. Interventions included providing supportive care and assistance as needed. The [NAME] report (staff instructions for care) included approaches to keep resident's call light within reach and encourage resident to use it for assistance as needed. Progress notes documented the resident experienced seizures while in the bathroom on 11/8/17 and 4/7/18. A review of care plans, nurses' notes, therapy notes and assessments completed between 4/1/18 and 8/12/18 failed to reveal the facility assessed the appropriate and safe use, by the resident, of the modified call light cord or that the resident required such an adaptation to summon assistance. D. Staff interviews CNA #1 and CNA #4 were interviewed on 8/16/18 at 2:15 p.m. CNA #1 said staff try to reposition the resident ever two hours. She said the resident was not able to move in bed by herself. CNA #4 said the resident was not capable of using the call light cord to call for staff. She said staff must anticipate the resident's needs and check on her more frequently. CNA #1 said staff were instructed to place the call light cord within the resident's reach and were careful to place it safely near the resident's hand The nursing home administrator (NHA) and director of nursing (DON) were interviewed on 8/15/18 at 2:35 p.m. The DON said the resident was unable to perform transfers or bed mobility without assistance from others. The NHA said the resident could not activate the resident call system by using the rope but believed it was a requirement for her to have one. The NHA said staff thought using the rope might help the resident (and five or six others) to use the call system because it was easier to pull than the thin cords and could be seen better by residents with limited vision. The NHA said using the rope was makeshift and not based upon an industry standard or accepted model. She added the therapy department did not assess the resident for the use of a modified call light cord, and did not consider using a pad or other activation device. The NHA said the therapy department did not assess the homemade system for its safe use by this and other residents. Upon viewing the resident in her bed, the NHA said it was not likely but could be possible for the resident to become entangled in the rope.

Based on record review and interviews, the facility failed to ensure 10 out of 10 certified nurse aides (CNA) receive the required in-service training. Specifically, the facility failed to: -Consistently provide annually 12 hours of in-service training for nine out of 10 CNAs; and -Ensure the training included dementia management training and resident abuse prevention Findings include: 1. Failure to have the required (12) hours of inservice and to include abuse and dementia Review of 10 CNAs files, revealed the following: -CNA #9 had received 15 hours of training these hours did not include abuse and dementia. -CNA #8 had received 9.75 hours of training did not include abuse and dementia. -CNA #6 had received 8.75 hours of training did not include abuse. -CNA #4 had received two hours of training did not include abuse. -CNA #5 had received three hours of training did not include abuse. CNA #5 was hired on 3/2018. -CNA #3 had received 4.75 hours of training did not include abuse and dementia. -CNA #10 had received 5.75 hours of training did not include abuse and dementia. -CNA #7 had received 6.25 hours of training did not include abuse. -CNA #12 had received 9 hours of training did not include abuse and dementia. -CNA #1 had received two hours of training did not include abuse and dementia. 2. Interviews CNA #9 was interviewed on 8/15/18 at 10:45 a.m. She said the facility provides in-services once a month. She said she attended the in-services if she is already in the building, but had not attended any training when she was scheduled to be off and out of the building. CNA #1 was interviewed on 8/15/18 at 2:15 p.m. She said the aides received training during the monthly meetings. She said she had not attended any recently. The interim director of nursing (DON) was interviewed on 8/15/18 at 2:45 p.m. She said training was ongoing and completed at the monthly meetings. She said all aides (with the exception of the new hire on 3/2018) had completed 12 hours of training. The DON reviewed the data, and said the facility will make sure in the future all aides had completed the mandatory 12 hours to include dementia and abuse training for the benefit of all the residents, to ensure, well educated and trained staff would be providing cares as outlined in each resident's care plan.