**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to ensure the resident's legal representative was provided an opportunity to exercise a right on behalf of the resident for one (#30) of five residents reviewed for resident rights out of 38 sample residents. Specifically, the facility failed to: -Ensure Resident #30's Medical Orders for Scope of Treatment (MOST) form was signed by the resident's medical durable power of attorney (MDPOA) instead of a family member who was not the resident's legal representative. Findings include: I. Facility policy The Advanced Directive and Health Care Directive policy, revised [DATE], was provided by the social services director (SSD) on [DATE] at 7:15 p.m. It read in pertinent part, It is the policy of the facility to honor their residents'advanced directives. The facility will provide orientation and training programs to educate staff on advance directives. A health care power of attorney or medical durable power of attorney delegating authority for an agent to make health care decisions in the case the individual delegating that authority subsequently becomes incapacitated. The legal representative, agent, attorney in face, proxy, substitute decision-maker, or surrogate decision-maker is a person designated and authorized by an advanced directive or by State law to make a treatment decision for another person in the event the other person becomes unable to make necessary health care decisions. II. Resident status Resident #30, age [AGE], was admitted on [DATE]. According to the [DATE] computerized physician orders (CPO), diagnoses included Alzheimer's disease (a progressive brain disorder that slowly destroys memory and thinking skills) and dementia (impaired ability to remember, think and make decisions). The [DATE] minimum data set (MDS) assessment documented Resident #30 had a severe cognitive impairment with a brief interview for mental status (BIMS) score of three out of 15. III. Record review Resident #30's MDPOA document, signed and effective [DATE], was provided by the director of nursing (DON) on [DATE] at 3:25 p.m. It documented that the resident legally granted two of his family members the power to act in his place, for his benefit, to the same extent he could have acted for himself with regard to all medical matters. The document identified, by name, the two family members (first MDPOA and second MDPOA) the resident wished to have act on his behalf when he could not. The second MDPOA would act on his behalf if the first MDPOA was no longer able to fill that role. The document was signed by the resident and both MDPOAs on [DATE]. Resident #30's MOST form was reviewed on [DATE]. The MOST form documented that Resident #30 wished for no cardiopulmonary resuscitation (CPR), he wanted selective treatment without burdensome measures and no artificial nutrition by tube. The MOST form documented the discussion and the form was completed by one of Resident #30's family members. -However, the facility failed to ensure the family member who signed the MOST form was Resident #30's first MDPOA or the second MDPOA, who were legally appointed as the resident's representatives. IV. Staff interviews Registered nurse (RN) #1 was interviewed on [DATE] at 4:25 p.m. RN #1 said she completed MOST forms when residents were admitted to the short-term rehabilitation hall. She said she checked the electronic medical record (EMR) to find out who the MDPOA was for the resident. She said she was unsure how to confirm the MDPOA listed was actually the resident's MDPOA. The social services director (SSD) was interviewed on [DATE] at 7:10 p.m. The SSD said the nurse assigned to the hall the resident was admitted to was responsible for getting the resident's MOST form completed. She said she confirmed the MDPOA as she checked the paperwork received from the last placement of the resident. She said the rehabilitation residents MOST forms were reviewed during admission and at care conferences and the long-term care residents were reviewed quarterly. The SSD said if it was discovered a MOST form was signed by someone other than the resident or the MDPOA, the form was inaccurate and a new form needed to be completed. The SSD said the MOST forms were not reviewed by social services except during care conferences. The director of nursing (DON) was interviewed on [DATE] at 7:27 p.m. The DON said the floor nurses were responsible for completing the MOST forms during admission. She said she did not know how the nurses confirmed the MDPOA was accurate. She said there was not a process but the facility worked with the residents and their families to get a guardianship going if that was needed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to ensure residents were kept free from abuse for two (#66 and #6) of five residents reviewed for abuse out of 38 sample residents. Specifically, the facility failed to: -Prevent Resident #6 from physically abusing Resident #66; -Update Resident #66 and Resident #6's care plans with effective interventions to prevent abuse; and, -Identify patterns or causes of resident-to-resident abuse. Findings include: I. Facility policy The Resident or Client Protection Freedom from Abuse, Neglect and Misappropriation policy, revised 11/3/22, was provided by the director of nursing (DON) on 5/20/24 at 10:00 a.m. It read in pertinent part, It is the policy of this facility that all residents are free from abuse and neglect. Each individual has the right to be free from verbal, sexual, physical and mental abuse, including injuries of unknown source, misappropriation of resident property, corporal punishment, mistreatment, neglect and involuntary seclusion. Residents must not be subjected to abuse by anyone, including but not limited to, other residents. The objectives of this resident protection plan are to protect individuals cared for at our facility from maltreatment, to describe the policies and procedures adopted and implemented by our facility to protect the individuals, to comply with and exceed the protection required by law, facilitate the process of reporting suspected maltreatment and review the resident protection plan on an annual basis or more frequently if needed. II. Resident-to-resident incident between Resident #66 and Resident #6 on 5/6/24 The incident notes for the 5/6/24 physical abuse incident were provided by the DON on 5/22/24 at 5:53 p.m. The victim, Resident #6, was documented as being severely impaired cognitively and had a history of behaviors that included agitation, outbursts, crying, restlessness, sadness, throwing items, yelling, hallucinations and paranoia. The alleged assailant, Resident #66, was documented as being severely impaired cognitively and had a history of behaviors that included hallucinations, restlessness, wandering into other residents'rooms, exit-seeking, yelling out at people who were not there and believing people were stealing her money. On 5/6/24 Resident #66 was trying to enter a room to use the bathroom as Resident #6 was leaving the room. Resident #66 asked Resident #6 to excuse her because she needed to use the bathroom. Resident #6 grabbed Resident #66 by the arm and slapped her across the face. Resident #66 was upset and yelled that she was going to bash her head in and referred to Resident #6. Resident #6 did not hear what Resident #66 said. Resident #6 yelled, They (Resident #66) do not want me in their room. The residents were separated. The incident was witnessed by a housekeeping staff member. The residents were assessed for injuries the following day 5/7/24. The investigation began on 5/7/24 because the incident was not reported timely by the staff. Resident #66 had a bruise on the back of her right hand and it was documented as a bruise that was healing from the resident hitting her hand on the bathroom door. Resident #6 had no new injuries documented. -However, the facility failed to assess the residents immediately after the incident to ensure temporary injuries were not present and to confirm the source of Resident #66's injury. III. Resident #66 A. Resident status Resident #66, age [AGE], was admitted on [DATE]. According to the May 2024 computerized physician orders (CPO), diagnoses included dislocation of the right shoulder, dementia with other behavioral disturbances and adjustment disorder with depressed mood. The 4/3/24 minimum data set (MDS) assessment documented Resident #66 had severe cognitive impairment with a brief interview for mental status (BIMS) score of two out of 15. Resident #66 experienced hallucinations, physical behavioral symptoms, verbal behavioral symptoms and behavioral symptoms not directed toward other people, including wandering. Resident #66 put herself and other residents at significant risk for physical injury, her behaviors interfered with the resident's care, interfered with the resident's participation in activities or social interactions and potentially put Resident #66 at risk for wandering into a dangerous area or situation. B. Record review Resident #66's dementia care plan, initiated 3/7/24, documented the resident had dementia, unspecified severity of dementia with other behavioral disturbances. Interventions included keeping a daily routine consistent with the same repetition to promote memory cueing, keeping the resident's environment constant and items in reach, providing activities or recreation of the resident's choice and praising efforts when tasks were completed. Resident #66's behavioral care plan, initiated 3/11/24, documented the resident's target behaviors included agitation, angry outbursts, crying, restlessness, sadness, throwing items, yelling, hallucinations and paranoia. Interventions included providing one-on-one activities such as crafts, keeping the resident separated from Resident #6 as much as possible with direct staff supervision if they were in the common area together, offering coffee and soda to the resident as well as sweet snacks, redirecting the resident and reapproaching the resident after a few moments, removing the resident from a high-stress area or common area, taking the resident outside to calm her down, turning on sports on the television (TV) as she enjoyed golf and softball, approaching the resident in a calm manner, not arguing with the resident, documenting behaviors and the resident's response to interventions and talking with the resident in a calm voice when behavior was disruptive. Resident #66's vulnerability care plan, revised 4/18/23, documented the resident was on an individual abuse prevention plan because she had behaviors and low cognition. Interventions included if the resident was displaying persistent or inappropriate behaviors, staff was to remove the resident to an area away from others, observing and implementing interventions to minimize and prevent reoccurrence and providing a safe environment for the individual and others and ensuring the safety of others. -However, the facility failed to revise Resident #66's care plans with personalized effective interventions to prevent resident-to-resident abuse following the physical altercation with Resident #6 on 5/6/24 (see physical altercation above). Cross-reference F744: failure to provide treatment/services for dementia care. IV. Resident #6 A. Resident status Resident #6, age greater than 65, was admitted on [DATE]. According to the May 2024 CPO, diagnosis included mild dementia. The 3/6/24 MDS assessment documented Resident #6 had a severe cognitive impairment with a BIMS score of one out of 15. Resident #6 experienced hallucinations, delusions, physical behavioral symptoms and behavioral symptoms not directed at others, including wandering. B. Record review Resident #6's behavioral care plan, revised 8/22/23, documented the resident had a severe cognitive loss. Interventions included keeping the resident separated from Resident #66 as much as possible with direct staff supervision if they were in the common area together, offering crafts and one-on-one time, offering crafts and religious shows on TV, offering to go outside when she was agitated, offering her to read her bible and coloring, offering sweet treats, tea, juice, water and soda, approaching the resident in a calm manner and documenting behaviors and resident's response to interventions. Resident #6's mood care plan, revised 6/26/23, documented the resident experienced an alteration in feelings of well-being and hallucinations that altered her mood. Interventions included approaching the resident warmly and positively, identifying the resident's interests and involving the resident in meaningful activities. Resident #6's dementia care plan, revised 4/4/23, documented she had mild dementia without behavioral disturbances. Interventions included approaching the resident in a calm, slow manner and reapproaching at a later time as needed, keeping daily routines consistent with the same repetition to promote memory cueing, keeping the environment constant and items in reach and providing activities or recreation of resident's choice and praising efforts when tasks were completed. -However, the facility failed to update Resident #6's care plans with effective personalized interventions to prevent resident-to-resident abuse following the physical altercation with Resident #66 on 5/6/24 (see physical altercation above) -Resident #6's care plan failed to document a vulnerability care plan and an individual abuse prevention plan. Cross-reference F744: failure to provide treatment/services for dementia care. V. Staff interviews Certified nurse aide (CNA) #5 was interviewed on 5/22/24 at 4:25 p.m. CNA #5 said the memory care unit had a lot of resident-to-resident abuse because most of the residents had dementia. She said sometimes the staff were fast enough to prevent contact from being made and sometimes the staff were not fast enough. CNA #9 was interviewed on 5/22/24 at 4:30 p.m. CNA #9 said the resident-to-resident incidents occurred but it depended on the day and which residents had behaviors. She said sometimes there were a lot of incidents on the unit. Activity aide (AA) #1 was interviewed on 5/22/24 at 4:35 p.m. AA #1 said the residents sometimes got into arguments or fights with each other but it was because of their dementia. Registered nurse (RN) #2 was interviewed on 5/22/24 at 4:38 p.m. RN #2 said if the staff kept the residents separated it helped prevent resident-to-resident incidents. She said it was a memory care unit so the residents had incidents but she was unsure if she would call the interactions abuse. The memory care coordinator (MCC) was interviewed on 5/23/24 at 11:05 a.m. The MCC said patterns of resident-to-resident incidents had not been identified but she noticed the incidents occurred in the evenings or when she was not there. The MCC said she thought the incidents were because of sundowning (behaviors that occurred in people with Alzheimer's or dementia in the afternoon or evening). Cross-reference F744: failure to provide treatment/services for dementia care. The MCC said she wondered if staff provided the residents with activities in the evening and was worried the lack of activities caused the residents to become more restless and agitated. The MCC said she planned to change her hours to provide the evening shift with more supervision. She said the memory care unit needed an activity aide who worked well on the unit and helped with activities. The MCC said if activities occurred like the residents needed, then the unit would have decreased behaviors and resident-to-resident altercations. The DON was interviewed on 5/23/24 at 2:11 p.m. The DON said a handful of residents were admitted ded to the memory care unit very quickly and overwhelmed the unit. The DON said she was unaware staff failed to provide activities on the evening shift. She said the MCC needed to have her own AA for the unit because the current AAs rotated each week as to who worked the memory care unit. She said the AA who covered the unit was supposed to work more of an 11:00 a.m. to 7:00 p.m. or 12:00 p.m. to 8:00 p.m. shift. She said she was not aware the AA worked from 2:00 p.m. to 10:00 p.m. and was not consistently providing activities like the residents needed.

Based on observations, record review and interviews, the facility failed to ensure residents were free from physical restraints for one (#50) of three residents out of 38 sample residents Specifically, the facility failed to ensure staff used a gait belt appropriately for assistance and not to restrain a resident from getting out of her wheelchair. Findings include: I. Facility policy The Physical Devices and Bedrails policy, revised 3/15/23, was provided by the director of nursing (DON) on 5/22/24 at 6:51 p.m. It read in pertinent part, In accordance with Federal and State laws, this company has a very stringent policy regarding the use of physical devices on residents, as a restraint. Our philosophy of providing residents with the highest possible quality of care and life, is reflective of our belief that it is essential for our residents to maintain their dignity and independence by being permitted to take the normal risks of everyday life. Devices used in an attempt to remove these normal risks of living, violate the rights of residents, greatly reduce their quality of life and present significant physical and psychological risks. For these reasons, and in accordance with Federal and State laws, devices used in our facility will only be considered to treat a medical symptom or condition that endangers the physical safety of the resident or other residents, and under the following conditions: -To improve the resident's mobility and independent function; -To treat residents'medical symptoms; -To restrict movement to protect the resident during treatment and diagnostic procedures; -As a last resort measure, after less restrictive measures have been taken and proven unsuccessful; -To prevent the resident from injuring himself or others; -With a physician's order; -With the consent of the resident or responsible party; and, -When the benefits of the device outweigh the identified risks. II. Observations During a continuous observation on 5/22/24, beginning at 3:00 p.m. and ending at 5:28 p.m., the following was observed: At 3:00 p.m. Resident #50 was observed continuously standing up and sitting down. She walked a couple of steps and pulled her wheelchair behind her. Resident #50 had a gait belt on and the staff with her used it to provide the resident with assistance because she was unsteady on her feet. At 3:44 p.m. registered nurse (RN) #2 switched out with certified nurse aide (CNA) #5 and took over providing oversight of Resident #50. Resident #50 continued to stand up and sit down. Resident #50 continued to walk a few steps as she pulled her wheelchair behind her. At 3:47 p.m. Resident #50 attempted to stand up and RN #2 used the resident's gait belt to pull her back into the seat of her wheelchair. Resident #50 stood up and walked a couple of steps. RN #2 pulled Resident #50's gait belt backward and pushed the resident's wheelchair forward and Resident #50 sat back down. At 3:49 p.m. Resident #50 attempted to stand up and RN #2 pulled the resident's gait belt. RN #2 held the gait belt to the back of the wheelchair when the resident sat back down so the resident was unable to stand up. At 3:50 p.m. Resident #50 stood up and RN #2 pulled the gait belt as she used her right knee to push the wheelchair under the resident. At 3:52 p.m. Resident #50 was trying to stand up and walk with her wheelchair. The resident said please, please, please as RN #2 pulled the wheelchair backward and prevented the resident from moving forward. At 3:53 p.m. Resident #50 stood up and RN #2 used her right hand to grab the resident's right shoulder and pushed the resident back into her wheelchair. CNA #5 saw what happened and told RN #2 that Resident #50 was strong. At 3:55 p.m. Resident #50 stood up and RN #2 pulled the resident by her gait belt and made her sit back in her wheelchair. At 3:57 p.m. CNA #5 switched with RN #2 and began providing oversight of Resident #50. Resident #50 stood up and walked a few steps while she pulled her wheelchair behind her and then sat down in her wheelchair. CNA #5 walked with Resident #50 as she walked. CNA #5 assisted Resident #50 to her bedroom to use the bathroom. At 4:07 p.m. RN #2 switched out with CNA #5 again and began providing oversight of Resident #50. The activity director (AD) entered the memory care unit and RN #2 let Resident #50 walk without pulling the gait belt. When the AD left the unit RN #2 pulled Resident #50's gait belt and sat her back in her wheelchair. At 4:08 p.m. Resident #50 stood up and said give it to me. RN #2 said not right now and used both hands to pull the resident back into her wheelchair by her gait belt. At 4:09 p.m. Resident #50 stood up and pulled her wheelchair forward while RN #2 pulled the wheelchair backwards. The resident and the nurse pulled on the wheelchair so hard that the wheels stopped moving. RN #2 tried getting Resident #50 to sit in her wheelchair but the resident wanted to walk. Resident #50 made a sstt-sstt-sstt sound but when RN #2 prevented the resident from walking, the noise was more frequent. At 4:11 p.m. RN #2 let Resident #50 walk a little bit but she got too close to another resident and RN #2 pulled her gait belt and sat her back in her wheelchair. At 4:12 p.m. Resident #50 sat in her wheelchair and RN #2 pushed down on the gait belt so the resident was not able to stand. Resident #50 stood up and said hurry, come on, hurry, come on as she tried to walk. RN #2 pulled her gait belt backward and she sat back in her wheelchair. At 4:14 p.m. Resident #50 tried walking again and RN #2 pulled her back into her wheelchair with the resident's gait belt. Resident #50 said please, please, please and appeared upset. At 4:15 p.m. Resident #50 stood up and sat down numerous times. Each time Resident #50 stood up RN #2 pulled her back down with her gait belt. This occurred five times in a row. At 4:16 p.m. Resident #50 stood up and walked approximately five steps before RN #2 used her gait belt to pull her back into her wheelchair. When Resident #50 was sitting in the wheelchair, RN #2 pushed down on the gait belt which prevented the resident from standing. At 4:17 p.m. Resident #50 stood up and pulled her wheelchair for approximately 10 steps. RN #2 pulled the gait belt and the resident pulled her wheelchair. The wheelchair slid sideways and the nurse had to straighten the wheelchair out before she had the resident sit down. At 4:18 p.m. the AD entered the unit again and RN #2 let Resident #50 walk a few steps. When the AD looked at RN #2, the nurse pulled Resident #50's gait belt as she used her right knee to push the wheelchair under the resident and made her sit down. The AD saw the incident, however, the AD did not speak to RN #2 and left the unit. At 4:19 p.m. Resident #50 stood up and tried walking forward. As she pulled her wheelchair forward, RN #2 pulled the wheelchair backward which prevented the resident from walking. At 4:44 p.m. CNA #5 switched out with RN #2 and began providing oversight of Resident #50. Resident #50 walked around as she pulled her wheelchair behind her and stopped making the sstt-sstt-sstt noise as much as she was when she was prevented from walking by RN #2. III. Record review Resident #50's dementia care plan, initiated on 7/21/21, documented the resident had unspecified dementia without behavioral disturbances. Interventions included approaching the resident in a calm, slow manner and re-approaching at a later time as needed, keeping daily routines consistent with the same repetition to promote memory cueing and cueing and reorienting the resident as needed. Resident #50's fall care plan, revised 10/11/23, documented the resident was at high risk for falls with a Morse fall risk score of 55. Interventions included keeping the bed in the lowest position while the resident was in bed, placing a fall mat at bedside while the resident was in bed, providing stand-by assistance when the resident was ambulating, hourly rounding for the 4P's (personal items, pain, personal needs and positioning), being sure the call light was in place in room and bathroom and reminding the resident to use the call light when assistance was needed and keeping needed items in reach of the resident. -However, the facility failed to include interventions to address what to do when the resident was constantly up and down and interventions to address what to do when the resident pulled her wheelchair behind her as she walked. IV. Staff interviews CNA #5 was interviewed on 5/22/24 at 4:25 p.m. CNA #5 said she covered any unit the facility assigned her. She said Resident #50 paced and was constantly standing and sitting. CNA #5 said when Resident #50 was walking, the staff pulled the wheelchair behind the resident in case she needed to sit down. CNA #5 said Resident #50 started pulling her wheelchair behind her while she walked on 5/22/24. CNA #5 said the resident probably pulled her wheelchair the way therapy pulled it behind residents to prevent falls. CNA #5 said Resident #50 was a fall risk but she was unaware of what fall interventions were in place for the resident. CNA #5 said staff were supposed to hold the gait belt in a supportive way and did not really touch the gait belt. She said staff just kept their hand under the gait belt in case the resident sat down unexpectedly. CNA #5 said she had Resident #50 walk because she was determined to get up and there was no reason to stop her. CNA #5 said she had seen other staff pull on the resident's gait belt and try to keep the resident in her wheelchair but CNA #5 was uncomfortable with that practice and did not tell anyone or speak to the staff who pulled the gait belt. CNA #9 was interviewed on 5/22/24 at 4:30 p.m. CNA #9 said she worked the memory care unit a lot and Resident #50 paced every day. CNA #9 said she felt Resident #50 had been standing and sitting constantly and walking with her wheelchair for quite some time. CNA #9 said she kept her hand by Resident #50's gait belt to support the resident as she walked. CNA #9 said she saw other staff pull on Resident #50's gait belt to make her sit down but the facility never allowed for the staff to pull on gait belts. CNA #9 said she let Resident #50 walk around and pace and hoped it would help with her behaviors. CNA #9 said she was taught if a resident wanted to walk the staff needed to let them walk safely. CNA #9 said staff were not supposed to restrain residents. CNA #9 said Resident #50 was a fall risk but she was unaware of any fall interventions in place. CNA #9 said she had not told anyone that some staff were pulling on the resident's gait belt in order to keep the resident from standing up. Activity aide (AA) #1 was interviewed on 5/22/24 at 4:35 p.m. AA #1 said she was assigned to the unit for activities. AA #1 said Resident #50 was always up and down. AA #1 said Resident #50 was a fall risk but she was unaware of any fall interventions in place because she was not allowed to provide resident care. AA #1 said she observed some staff pull the resident's gait belt to make her sit back in her wheelchair. AA #1 said she knew the staff were not allowed to pull on the gait belt but had not told anyone it was occurring. RN #2 was interviewed on 5/22/24 at 4:38 p.m. RN #2 said she was the nurse assigned to the memory care unit and she worked the unit all the time. She said Resident #50 started wandering within the past few weeks. RN #2 said Resident #50 was a fall risk and her fall interventions were that she needed one-to-one supervision. RN #2 said staff were not allowed to pull on the gait belt but the staff held the gait belt if they felt she was going to fall. RN #2 said she sometimes let Resident #50 walk but it depended on how her balance was at that moment. RN #2 said she pulled on Resident #50's gait belt if the resident was too far forward. RN #2 said she felt she was not pulling on the gait belt and she was concerned the resident was going to fall. The director of nursing (DON) and the corporate consultant (CC) were interviewed on 5/22/24 at 7:08 p.m. The DON said a gait belt was used to transfer residents and it was not okay to be used as a restraint or to put a resident in their wheelchair. The CC said some residents received restorative therapy and the staff needed to keep their hand under the bottom of the gait belt, not on top of the gait belt to be pulled. The DON said she was opening an investigation and was investigating abuse and restraints. The CC said the investigation started as abuse for the night. The CC said the facility was a restraint-free facility. The DON said she knew RN #2 and felt the nurse was probably more concerned about Resident #50's safety than trying to restrain her to her wheelchair. The DON said RN #2 probably did not realize she was hurting Resident #50 or potentially causing injuries and probably did not know she was using the gait belt as a restraint. The memory care coordinator (MCC) was interviewed on 5/23/24 at 10:30 a.m. The MCC said Resident #50 recently started walking. The MCC said the resident had a change in her condition a while back which prevented her from walking and staff used a lift for transfers. The MCC said RN #2 was not supposed to pull on the gait belt or prevent Resident #50 from getting out of her wheelchair. The MCC said she requested Resident #50's hospice team to complete an assessment because the MCC worried the resident was experiencing end-of-life agitation and restlessness. The MCC said she provided education to the staff who worked the unit on 5/23/24 and the DON was helping with the education to the rest of the facility. The MCC said all staff were required to complete a six-hour dementia computer course by 6/1/24 and felt it would help. The MCC said if activities occurred the way the residents needed, it prevented a lot of incidents which included potential staff burnout. The MCC said it was unacceptable for RN #2 to pull on Resident #50's gait belt, push the wheelchair into the resident, or prevent the resident from walking. The DON was interviewed again on 5/23/24 at 2:11 p.m. The DON said RN #2 was suspended and the investigation was ongoing. The DON said every shift was provided education in-person on the proper use of a gait belt. The DON said the facility assigned all staff online training for gait belts and restraints. The DON said all staff were required to complete a six-hour dementia training by 6/1/24 and she monitored everyone's progress to ensure it was being completed. The DON said dementia capable care training was going to be completed by all staff by the end of July 2024. The DON said the facility wanted the MCC to have an AA who was managed by the MCC so the AA was consistent for the unit and was able to provide the residents with the activities they needed. The DON said it was important not to pull on a gait belt to prevent injuries and pain. The DON said a lot of residents were admitted to the memory care unit at the same time which overwhelmed the unit and increased the tension. The DON said RN #2 was probably burnt out from Resident #50 and providing one-on-one supervision alone. The DON said she walked with Resident #50 and saw it was difficult to provide assistance to the resident with just one staff member. The DON said Resident #50's interventions were updated and if the resident wanted to walk she needed two staff members to provide assistance. The rehabilitation therapy director (RTD) was interviewed on 5/23/24 at 4:52 p.m. The RTD said gait belts should be used for assistance and not used to restrain residents. RN #1 was interviewed on 5/23/24 at 4:49 p.m. RN #1 said she was the rehabilitation nurse and said the gait belts were used to assist residents with transfers and ambulation. RN #1 said gait belts were not to be used as restraints. CNA #6 was interviewed on 5/23/24 at 6:21 p.m. CNA #6 said gait belts were used to walk with residents who were a fall risk. CNA #6 said gait belts kept the residents safe and prevented falls. CNA #6 said she had not seen staff restrain residents with a gait belt. CNA #4 was interviewed on 5/23/24 at 6:23 p.m. CNA #4 said gait belts were used to safely walk with residents. CNA #4 said she did not think staff were allowed to pull on the gait belt. CNA #4 said gait belts should not be used to restrain residents at any time. RN #3 was interviewed on 5/23/24 at 6:31 p.m. RN #3 said gait belts were used to safely transfer residents. RN #3 said staff were not allowed to pull on the gait unless staff were preventing a fall. RN #3 said gait belts were not used to restrain residents. V. Facility follow-up The DON provided a follow-up report on 5/29/24 at 3:08 p.m. The DON said RN #2 was no longer assigned to the memory care unit. She said RN #2 was required to complete gait belt and restraint training. The DON said RN #2 was assigned to work under the direct supervision of the evening nurse supervisor and was assigned the same schedule as the supervisor. The DON said RN #2's supervision level would be re-evaluated in six months.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review, the facility failed to ensure residents received the appropriate treatment and services to maintain their highest practicable physical, mental and psychosocial well-being for two (#6 and #66) of six residents reviewed for dementia care out of 38 sample residents. Specifically, the facility failed to: -Effectively implement a meaningful activity program for Resident #6 and Resident #66 to prevent resident-to-resident abuse; and, -Implement person-centered interventions for Resident #6's and Resident #66's behaviors. Findings include: I. Facility policy The Guidelines for Memory Support Programs and Services, revised February 2015, was provided by the director or nursing (DON) on 5/22/24 at 5:53 p.m. It read in pertinent part, The facility's memory support program or services operates under a person-centered model, with emphasis on the whole person. This model recognizes that all persons have physical, social, emotional, intellectual, occupational and spiritual needs, regardless of their level of cognitive function. Activity-focused living recognizes that all aspects of the residents'- anything they do or are involved with - are their activity at that moment. Activities, either individual or in groups, create a purposeful use of time and are adapted from tasks the residents would be doing if they did not have dementia. Memory support programs engage residents in cognitive, physical and psychosocial activities that focus on abilities, not limitations. The Activities Programs policy, revised 8/2/23, was provided by the corporate consultant (CC) on 5/23/24 at 3:53 p.m. It read in pertinent part, Varied activities will be planned and routinely scheduled. Activities will focus on the following: -To stimulate socialization and encourage fellowship; -To help maintain muscle tone and coordination; -To encourage and provide opportunities for mental functioning; -To provide sensory stimulation; -To reduce isolation, build self-esteem and strengthen coping capabilities and identity; -To provide entertainment; and, -To strengthen existing spiritual tenets and to provide an opportunity to express individual beliefs. II. Observations On 5/20/24 at 10:00 a.m. an informational video about bees was being played in the common area of the memory care unit. There were five residents in the common area during the activity and Resident #66 was sitting hunched over the counter by the common area. -However, four of the residents were asleep in recliners during the activity and Resident #66 was asleep at the counter. A continuous observation was conducted on 5/22/24, beginning at 3:00 p.m. and ending at 5:28 p.m. The following observations were made: At 3:00 p.m. six residents were observed in recliners in the common area with a movie playing on the television (TV). Resident #6 and Resident #66 were sitting in the dining room without staff interaction. At 3:30 p.m. Resident #66 and Resident #6 were still not being interacted with by the staff. Activity aide (AA) #1 sat in the common area watching the movie. Resident #66 was hunched over the kitchen counter and Resident #6 was looking for her money. At 3:42 p.m. AA #1 offered to paint a female resident's fingernails. AA #1 did not interact with the other residents. A resident was having some difficulty and Resident #6 was becoming agitated and concerned for the other resident. -Certified nurse aide (CNA) #5 told Resident #6 the female resident was okay but no one offered Resident #6 an activity or redirection. At 4:00 p.m. the residents were being moved to the dining room for dinner. At 4:35 p.m. CNA #5 said dinner was usually late and the residents were restless by the time the meal arrived on the unit. At 4:48 p.m. the meal cart arrived at the unit. Two male residents had left the dining room and went to their bedrooms because dinner was taking too long to arrive. Resident #6 was becoming agitated while waiting for dinner and said someone stole my money. At 4:59 p.m. cook #3 started serving meals after returning from the main kitchen. The unit staff tried to keep the residents at the tables for dinner. On 5/23/24 at 10:30 a.m. Resident #66 was sitting in the dining room, four residents were asleep in the recliners in the common area and one resident was watching the movie playing on the TV. Staff interactions were not provided because there were only two staff members on the unit at the time. III. Resident #6 A. Resident status Resident #6, age greater than 65, was admitted on [DATE]. According to the May 2024 CPO, diagnoses included mild dementia. The 3/6/24 minimum date set (MDS) assessment documented Resident #6 had a severe cognitive impairment with a brief interview for mental status (BIMS) score of one out of 15. Resident #6 experienced hallucinations, delusions, physical behavioral symptoms and behavioral symptoms not directed at others including wandering. B. Record review Resident #6's behavioral care plan, revised 8/22/23, documented the resident had a severe cognitive loss. Interventions included keeping the resident separated from Resident #66 as much as possible with direct staff supervision if they were in the common area together, offering crafts and one-on-one time, offering crafts and religious shows on TV, offering to go outside when she was agitated, offering her to read her bible and coloring, offering sweet treats, tea, juice, water and soda, approaching the resident in a calm manner and documenting behaviors and resident's response to interventions. Resident #6's mood care plan, revised 6/26/23, documented the resident experienced an alteration in feelings of well-being and hallucinations that altered her mood. Interventions included approaching the resident warmly and positively, identifying the resident's interests and involving the resident in meaningful activities. Resident #6's dementia care plan, revised 4/4/23, documented she had mild dementia without behavioral disturbances. Interventions included approaching the resident in a calm, slow manner and reapproaching at a later time as needed, keeping daily routines consistent with the same repetition to promote memory cueing, keeping the environment constant and items in reach and providing activities or recreation of resident's choice and praising efforts when tasks were completed. Resident #6's activity and life enrichment care plan, revised 9/19/23, documented the resident had interests and preferences in activities that she wished to continue for as long as possible. Interventions included 7 Day Adventist, Bible study was important to the resident and, incorporating this into her plan providing the resident with her interests which included books and magazines, country music, movies, sitting in the day room, her own room and spending time outdoors, familiarizing the resident with the facility environment and activity programs regularly and providing the resident with independent activities of reading, writing and computer use, assisting only as needed. -However, the facility failed to update Resident #6's care plan with effective interventions to prevent resident-to-resident abuse and behaviors following a resident to resident altercation with Resident #66 on 5/6/24. (Cross-referenced F600: failure to prevent abuse) -Additionally, the facility failed to provide Resident #6 with meaningful activities as care planned (see observations above). IV. Resident #66 A. Resident status Resident #66, age [AGE], was admitted on [DATE]. According to the May 2024 CPO, diagnoses included dislocation of the right shoulder, dementia with other behavioral disturbances and adjustment disorder with depressed mood. The 4/3/24 MDS assessment documented Resident #66 had a servere cognitive impairment with a BIMS score of two out of 15. Resident #66 experienced hallucinations, physical behavioral symptoms, verbal behavioral symptoms and behavioral symptoms not directed toward other people including wandering. Resident #66 put herself and other residents at significant risk for physician injury, her behaviors interfered with the resident's care, interfered with the resident's participation in activities or social interactions and potentially put Resident #66 at risk for wandering into a dangerous area or situation. B. Record review Resident #66's dementia care plan, initiated 3/7/24, documented the resident had dementia, unspecified severity of dementia with other behavioral disturbances. Interventions included keeping a daily routine consistent with the same repetition to promote memory cueing, keeping the resident's environment constant and items in reach, providing activities or recreation of the resident's choice and praising efforts when tasks were completed. Resident #66's behavioral care plan, initiated 3/11/24, documented the resident's target behaviors included agitation, angry outbursts, crying, restlessness, sadness, throwing items, yelling, hallucinations and paranoia. Interventions included providing one-on-one activities such as crafts, keeping the resident separated from Resident #6 as much as possible with direct staff supervision if they were in the common area together, offering coffee and soda to the resident as well as sweet snacks, redirecting the resident and reapproaching the resident after a few moments, removing the resident from a high-stress area or common area, taking the resident outside to calm her down, turning on sports on the television (TV) as she enjoyed golf and softball, approaching the resident in a calm manner, not arguing with the resident, documenting behaviors and the resident's response to interventions and talking with the resident in a calm voice when behavior was disruptive. Resident #66's activity and life enrichment care plan, revised 3/12/24, documented the resident had interests and preferences in activities that she wished to continue for as long as possible. Resident #66 was prone to behaviors of hitting and being disruptive during the day. Interventions included during behaviors resident will be taken to a quiet area and redirected to decrease behaviors, giving the resident the opportunity to express opinions of activities attended, giving the resident verbal reminders of activity before the commencement of activity, posting personal activity schedules in the resident's room, providing the resident with group activities and transporting the resident to activities. -However, the facility failed to update Resident #66's care plan with effective interventions to prevent resident-to-resident abuse and behaviors following a resident-to-resident altercation with Resident #6 on 5/6/24. (Cross-reference F600: failure to prevent abuse) -Additionally, the facility failed to provide Resident #66 with meaningful activities as care planned (see observations above). (Cross-reference F600: failure to prevent abuse) V. Staff interviews CNA #5 was interviewed on 5/23/24 at 4:25 p.m. CNA #5 said the staff provided activities but some days were crazier than other days. CNA #5 said with a resident constantly up and down the staff relied on the activity aide (AA) scheduled on the unit. CNA #9 was interviewed on 5/23/24 at 4:30 p.m. CNA #9 said staff tried to provide activities but right before and after dinner it was hard to complete activities. AA #1 was interviewed on 5/23/24 at 4:35 p.m. AA #1 said she was assigned to the memory care unit as the unit's AA. She said most of the residents slept during the movie so she waited around until there was an activity to do and that was why she offered to paint a female resident's nails. AA #1 said after she painted the resident's nails she waited for dinner to be served. Registered nurse (RN) #2 was interviewed on 5/23/24 at 4:38 p.m. RN #2 said the AAs provided activities to the residents and it was the AAs responsibility. RN #2 said that was the reason an AA was assigned to the unit. The memory care coordinator (MCC) was interviewed on 5/23/24 at 11:05 a.m. The MCC said the nursing staff needed to provide activities to the residents, not just the AAs. The MCC said during the day when she worked on the unit the staff provided a lot of activities. The MCC said she wondered if the evening shift provided activities when she was not there. The MCC said she needed to provide more supervision to the evening shift because she noticed residents had more behaviors, falls and resident-to-resident interactions in the late afternoon to early evening. The MCC said a lack of activities for the residents with dementia led to more problematic behaviors because they had nothing to do. The MCC said she was planning on working with the activity director (AD) to get some tailored activities for the memory care unit. The AD was interviewed on 5/23/24 at 1:44 p.m. The AD said she planned the activities on the memory care unit but received input from the MCC. The AD said the AA assigned to the unit was supposed to provide activities all day long, whether it was one-on-one or group activities. The AD said she was unaware the residents were not offered activities and were just left to sleep in the recliners. The AD said not interacting with the residents was not okay and she was going to discuss it with AA #1. The DON was interviewed on 5/23/24 at 2:11 p.m. The DON said the facility's management team was trying to approve an AA position on the memory care unit that worked directly under the MCC. The DON said the AAs rotated who covered the memory care unit so they did not know the residents as well as an AA who was permanently assigned to the unit. The DON said the memory care unit and residents needed an AA who worked well on the unit and management was hoping to find someone.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** III. Resident #21 A. Resident Status Resident #21, over the age of 65, was admitted on [DATE]. According to the May 2024 CPO, diagnoses included dementia, cerebrovascular disease (disease affecting the blood vessels) and insomnia (difficulty sleeping). The 4/17/24 MD) assessment revealed the resident was severely cognitively impaired with a BIMS assessment score of three out of 15. She required substantial or maximal assistance with eating, oral hygiene, and personal hygiene.She was dependent on staff for bathing, dressing, and toileting. B. Record review A review of the CPO revealed the resident had a physician's order for Seroquel (antipsychotic medication) 400 milligrams (mg) orally at bedtime for agitation and give 100 mg orally every 12 hours as needed for agitation, ordered on 8/8/23 and was discontinued on 9/11/23. -The antipsychotic medication was prescribed for over 14 days on an as needed basis. A review of the resident's EMR did not reveal documentation from a physician indicating the medication needed to be prescribed as needed for over 14 days. Further review of the May 2024 CPO revealed a physician's order for Lorazepam oral tablet 1 mg every 6 hours for anxiety/agitation and give one tablet by mouth every four hours as needed for anxiety/agitation for 90 days, ordered on 8/16/23 and discontinued on 9/21/23. -The anti-anxiety medication was prescribed for over 14 days on an as needed basis. A review of the resident's electronic medical record (EMR) did not reveal documentation from a physician indicating the medication needed to be prescribed as needed for over 14 days. IV. Staff interviews The pharmacist (PH) was interviewed on 5/23/24 at 4:44 p.m. The PH said psychotropic medications can only be ordered for more than 14 days if there was a documented reason by the physician. The PH said she did not have a documented reason why Resident #21's PRN Lorazepam or Seroquel was ordered for more than 14 days. The director of nursing (DON), nursing home administrator (NHA) and the corporate consultant (CC) were interviewed together on 5/34/24 at 7:27 p.m. The DON said PRN psychotropic medications could only be ordered for more than 14 days if there was a documented reason by the physician, up to a maximum of 90 days. The DON and the CC said there was not a documented reason why Resident #21 was prescribed Lorazepam and Seroquel for more than 14 days. The CC said it was against the regulation to have PRN psychotropic medications ordered without a reason for more than 14 days. Based on interviews and record review, the facility failed to ensure residents were free from unnecessary psychotropic medications for two (#30 and #21) of five residents reviewed for medications out of 38 sample residents. Specifically, the facility failed to ensure as needed (PRN) psychotropic medications were discontinued after 14 days for Resident #30 and Resident #21. Findings include: I. Facility policy and procedure The Psychoactive medication use policy, revised 8/14/23, was provided by the nursing home administrator (NHA) on 5/23/24 at 7:34 p.m. It read in pertinent part, PRN orders for psychotropic medications are limited to 14 days, but orders may be extended beyond 14 days if the attending physician or prescribing practitioner believes it is appropriate to extend the order. II. Resident #30 A. Resident status Resident #30, age [AGE], was admitted on [DATE]. According to the May 2024 computerized physician order (CPO), diagnoses included Alzheimer's disease (a progressive brain disorder that slowly destroys memory and thinking skills) and dementia (impaired ability to remember, think and make decisions). The 4/26/24 minimum data set (MDS) assessment documented Resident #30 had a severe cognitive impairment with a brief interview for mental status (BIMS) score of three out of 15. B. Record review A review of the September 2023 CPO revealed the resident had a physician's order Lorazepam oral concentrate (anti-anxiety medication) 0.5 milliliter (ml) every four hours PRN for anxiety or agitation related to dementia for 90 days, ordered on 6/13/23 and discontinued on 9/11/23. -The anti-anxiety medication was prescribed for over 14 days on an as needed basis. A review of the resident's electronic medical record (EMR) did not reveal documentation from a physician indicating the medication needed to be prescribed as needed for over 14 days. A review of the January 2024 CPO revealed the resident had a physician's order w for Lorazepam oral concentrate 0.5 ml every four hours PRN for anxiety or agitation related to dementia for 90 days, ordered on 10/31/23 and discontinued on 1/29/24. -The anti-anxiety medication was prescribed for over 14 days on an as needed basis. A review of the resident's EMR did not reveal documentation from a physician indicating the medication needed to be prescribed as needed for over 14 days. A review of the May 2024 CPO revealed the resident had a physician's order for Lorazepam oral concentrate 0.5 ml every four hours PRN for anxiety or agitation related to dementia, ordered on 2/14/24 and discontinued on 5/14/24. -The anti-anxiety medication was prescribed for over 14 days on an as needed basis. A review of the resident's EMR did not reveal documentation from a physician indicating the medication needed to be prescribed as needed for over 14 days. A review of the May 2024 CPO revealed the resident had a physician's order for Lorazepam oral tablet 1 milligram (mg) every four hours PRN for anxiety or agitation related to dementia for 60 days, ordered on 5/16/24 and was scheduled to be discontinued on 7/15/24. -The anti-anxiety medication was prescribed for over 14 days on an as needed basis. A review of the resident's EMR did not reveal documentation from a physician indicating the medication needed to be prescribed as needed for over 14 days.

Based on interviews, record review and observations, the facility failed to ensure residents consistently receive food prepared by methods that conserved nutritive value, palatable in taste, texture, appearance and temperature. Specifically, the facility failed to ensure the residents'food was palatable in taste, texture, appearance and temperature. Findings included: I. Resident interviews Resident #23 was interviewed on 5/20/24 at 3:02 p.m. Resident #23 said some of the meals she had been served were cold. Resident #16 was interviewed on 5/20/24 at 4:54 p.m. She said the beef was often tough. Resident #54 was interviewed on 5/21/24 at 8:58 a.m. He said the facility was a lost cause when it comes to food and tried to eat as little of the food provided by the facility as possible. He said he bought most of his own food. He said the food was frequently served cold. Resident #46 was interviewed on 5/21/24 at 9:06 a.m. She said the food was served cold and had limited seasoning. Resident #45 was interviewed on 5/21/24 at 10:25 a.m. She said the vegetables were usually overcooked. Resident #4 was interviewed on 5/21/24 at 12:49 p.m. She said the food was often over cooked and the cooked vegetables squirted water out of them when she tried to eat them. She said the food was usually cold even though the plate it was served on was warm. Resident #53 was interviewed in the dining room on 5/22/24 at 12:55 p.m. after her meal. She said her meal was served cold. II. Observations During a continuous observation on 5/22/24 beginning at 3:40 p.m. and ending at 6:01 p.m. the following was observed during the dinner meal preparation and service in the main kitchen: At 4:25 p.m. cook #2 took the temperature of the cooked carrots and mixed vegetables. The cooked carrots and mixed vegetables sat in covered containers with water. The temperature of the first container of carrots was 200 degrees F. The second container of carrots were 185 degrees F. The last container of carrots was 179 degrees F. The mixed vegetables were 200 degrees F. -At 4:29 p.m. cook #2 tested how soft the carrots were with a fork and said some of the carrots had bounced back and some were easily mashed with a fork. -At 4:49 p.m. cook #2 placed the containers in the steam table. -At 4:54 p.m. cook #2 took the temperatures of the food that was in the steam table. The mashed potatoes were 125 degrees F. The pureed carrots were 136 degrees F. The hamburger patties were 122 degrees F. The DM said the hamburger patties needed to be above 135 holding temperature. She said she would reheat the hamburger patties to 165 degrees F. because the meat fell into the danger zone. -At 5:03 p.m. meal service began in the main dining room. -At 5:31 p.m. the dining room service was completed and cook #2 started plating the room trays to load onto a hot holding cart. Two test trays were evaluated immediately after the last resident had been served their room tray for dinner on 5/22/24 by three surveyors. The regular diet test tray consisted of salisbury steak with gravy, mashed potatoes and carrots. -The temperature of the salisbury steak covered in gravy was 120 degrees F. Portions of the steak that were not covered in gravy and were 111 degrees F. The steak was lukewarm. -The mashed potatoes and gravy were 136.8 degrees F. -The carrots were 100.5 degrees F. The carrots were lukewarm, watery in taste and over cooked texture. The pureed diet test tray consisted of salisbury steak with gravy and pureed carrots. -The salisbury steak was 111 degrees F. -The pureed carrots were 121 degrees F. III. Record review The January 2024 resident council minutes indicated concerns with the cooked vegetables identifying the vegetables tasted like wall paper paste. -The resident council minutes did not identify a plan to correct the vegetables after residents identified a concern (cross-reference F565 grievances of a group). The February 2024 resident council minutes read the vegetables were too watery. One resident said she felt the dietary staff did not love food. Another resident said she no longer loved food after living at the facility. The March 2024 resident council minutes read a resident said her vegetables were mushy. According to the minutes, the other residents agreed. The March 2024 food committee minutes read the pasta salad and the tuna salad needed to be less watery and the overcooked broccoli was gross. The May 2024 resident council minutes read the meat was too tough, the quality of the soup had declined and the broth and chicken tasted bad, the food had been cold and the vegetables were mushy. According to the minutes, the quality of the food was worse later in the week. The May 2024 food committee read the dietary department was working on ways to improve food temperatures. IV. Staff interview The dietary manager (DM) was interviewed on 5/23/24 at 1:17 p.m. The DM said she was aware there were resident concerns with food temperatures for the last couple of months. The DM said some of the cooks did not turn the steam table on prior to the meal services. She said she also had identified that the staff were plating the meals too early and the meals were sitting too long before the staff delivered the meals to the residents. She said she has retrained all of the staff on timing and on 5/20/24 she changed the order of delivery service. She said the dining room was now served first and the room trays were served last in hopes to improve the meal temperatures. The DM said the residents had expressed concerns with the taste of the food. She said some of the residents felt the food was too salty or too tough to chew. The DM said she observed the weekend cook and identified some food preparation concerns. She provided additional training to the weekend cook. The DM said other concerns that had been identified were the overcooking and taste of the vegetables. The DM said the steamer had ongoing concerns with not working correctly and had been reviewed by the facility maintenance department and the equipment service vendor. The DM said the steamer helped the dietary department maintain food temperatures and helped prevent the overcooking and undercooking of the vegetables. She said a new part was ordered on 5/15/23 for the steamer but it had not arrived at the facility yet. The DM said she identified concerns with the cooks preparing the meals. She said the cooks were leaving the vegetables in the streamer for too long. She said this caused the vegetables to get overcooked. She said the cooks were also not setting the steamer at the correct temperature. She said she started seeing concerns with overcooking since the beginning of the year. The DM said she felt it was a combination of the cooks error and a need for new equipment. The DM said the steamer not working correctly had been an ongoing concern over the last couple of years. She said the steamer has had parts replaced and fixed but still was not working correctly. She said she was currently waiting on invoices and then would present her concerns to the nursing home administrator (NHA). The DM said she has tried to train the cooks on different methods of cooking to improve palatability and make sure the vegetables were not mushy in taste and texture. She said she was at the facility for two and a half days a week to provide kitchen and cooking oversight. She said the charge cook was here five days a week for three meals a day. The DM said there was an overlap between her schedule and the charge cook which caused the kitchen to not have a supervisor for two days a week. She said the limited oversight of the food could have been part of the palatability concerns and not using proper cooking techniques. The DM said when she was not at the facility, the charge cook was the one to ensure cooks were cooking the food properly, however, the charge cook needed to be retained on proper cooking methods too. The DM said she had scheduled to retrain the charge cook on 5/28/24. The DM said she had provided training to the charge cook off and on since March 2024 but was still identifying concerns. She said one possible reason was a language barrier. She said she acquired training handouts in Spanish on 5/17/24 but had not handed the training material out yet to the staff who primarily spoke Spanish. The DM said she tried to communicate with the charge cook by using a translating hot line but there was still communication barriers. She said the charge cook was responsible for oversight of the other cooks for three of the cooks only spoke English which could also be a breakdown in communication. The SSD was interviewed on 5/23/24 at 5:57 p.m. She said she frequently received grievances on food concerns. The quality assurance nurse (QAN) was interviewed on 5/23/24 8:01 p.m. The QAN said resident food palatability had been discussed in the quality assurance and improvement (QAPI) meetings after residents had grievances about food temperatures being off or food being mushy. The QAN said the DM and registered dietitian (RD) were working on correcting the concerns. The QAN said the following resident council meeting there were no further concerns and the grievance was resolved. The QAN was informed of ongoing resident concerns and test tray observations. The QAN said the facility would look at opportunities for improvement and needed to get a better oversight on the issues.

Based on observations and interviews, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of disease and infection on two of two units. Specifically, the facility failed to wipe down a shared mechanical lift and slings between residents. Findings include: I. Facility policy The Infection Prevention and Control Program policy, revised on 2/25/19, was provided by the DON on 5/20/24 at 2:00 p.m. It read in pertinent part, The Infection Prevention and Control Program will utilize the policies and procedures within the Infection Control Manual. The program includes employee health, management of residents with infectious diseases, hand hygiene for staff, residents and visitors, cleaning and disinfection procedures including appropriate surfaces and equipment, food safety and linen handling. Staff education is provided at orientation, yearly, during outbreaks and as needed and includes cleaning and disinfecting of surfaces and equipment. The Infection Prevention and Control Manual, effective 12/2016, was provided by the DON on 5/23/24 at approximately 2:00 p.m. It read in pertinent part, All items, other than disposables, are cleaned and disinfected following federal, state and local guidelines and manufacturers'recommendations. The Transfer with a Mechanical Lift procedure, revised 5/20/24, was provided by the DON on 5/23/24 at approximately 2:00 p.m. It read in pertinent part, Inspect all equipment and supplies. Make sure that the accessory equipment (sling, straps and hooks) undergoes proper cleaning and disinfection before use to prevent microorganism transmission. Clean and disinfect the mechanical lift accessory equipment after use according to the manufacturer's instructions to prevent the spread of infection. II. Observations On 5/23/24 at 10:34 a.m. the memory care coordinator (MCC) and licensed practical nurse (LPN) #4 assisted a male resident to the bathroom. The unit had a mechanical lift, similar to a sit-to-stand mechanical lift, which used a partial sling. The resident used the small sling to be transferred. At 10:37 a.m. the MCC returned the mechanical lift to the common area of the unit. -The MCC did not wipe down the lift or the sling after using it with the male resident. At 10:39 a.m. a hospice services certified nurse aide (CNA) took the mechanical lift to provide another resident with a shower. -At 10:40 a.m. the MCC and LPN #4 asked the hospice services CNA for the mechanical lift first to move a female resident to her wheelchair. The resident was provided with the same small sling the first resident used. -At 10:47 a.m. the female resident was attached to the lift with the sling and her hands were placed on the handlebars which were not disinfected after the first resident. -At 10:48 a.m. the mechanical lift was given to the hospice services CNA without being disinfected. At 10:57 a.m. the hospice services CNA said the resident she was giving the shower to used the larger sling. III. Staff interviews LPN #4 was interviewed on 5/23/24 at 11:00 a.m. LPN #4 said the mechanical lifts were cleaned at the end of each shift, not after each resident used the lift. She said the sling touched the residents'clothes and not their skin, so the lift and sling did not need to be disinfected. The MCC was interviewed on 5/23/24 at 11:05 a.m. The MCC said the lift and sling needed to be disinfected after each use. She said after the first and second residents were assisted, she asked LPN #4 to disinfect the mechanical lift. The MCC said she did not watch to ensure LPN #4 disinfected the lift and sling. The DON was interviewed on 5/23/24 at 2:11 p.m. The DON said the slings did not need to be disinfected between each resident because they were applied over the residents'clothes. She said the mechanical lift needed to be disinfected after each use because the residents grabbed the handlebars to be transferred. The regional infection preventionist (RIP) was interviewed on 5/23/24 at 4:48 p.m. The RIP said the residents who used the full mechanical lift had their own slings. He said the sit-to-stand type mechanical lift on the memory care unit only had two slings that were shared between the residents. The RIP said the lift needed to be wiped down after each use and the staff needed to do their best to wipe down the shared slings, whether the sling touched the resident's skin or clothes. Registered nurse (RN) #1 was interviewed on 5/23/24 at 4:49 p.m. RN #1 said all items associated with the sit-to-stand mechanical lift needed to be cleaned between each use. RN #1 said it was important to disinfect the mechanical lifts for infection control and it was good practice to clean the mechanical lifts. CNA #6 was interviewed on 5/23/24 at 6:21 p.m. CNA #6 said all of the mechanical lifts and slings needed to be disinfected after each use. CNA #4 was interviewed on 5/23/24 at 6:23 p.m. CNA #4 said all of the mechanical lifts and slings needed to be disinfected after each use. RN #3 was interviewed on 5/23/24 at 6:31 p.m. RN #3 said the mechanical lift and the slings needed to be disinfected after each use.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident and staff interviews and record review, the facility failed to act promptly upon the grievances concerning issues of resident care and life in the facility that were important to the residents. Specifically, the facility failed to effectively address, resolve and maintain a systematic approach to ongoing resident concerns of staff treatment towards residents that were brought up during resident council. Findings include: I. Facility policy and procedure The following policies were provided by the director of nursing (DON) on [DATE] at 6:06 p.m. The Resident Council policy, revised [DATE], identified the facility must consider the views of the resident council and must respond promptly to the grievances and recommendations of the council. The policy directed to the facility to follow the grievance process. The Grievance/Concern policy, last revised [DATE], read in pertinent part, Grievances will be routed and tracked by the grievance officer/social service or designee. They (grievances) will be given to the appropriate department manager for follow-up, according to the nature of the grievance. Grievances will be responded to within 7 days for non-emergency concerns. The facility will notify the complainant to provide updates on resolution for the complaint. Additionally, complainants have the right to a written decision regarding the grievance. The manager responsible for investigating and resolving the grievance will complete the grievance/concern form including a plan for resolution. Grievance decisions will include: the date of the grievance was received, the summary of the resident's grievance, steps taken to investigate the grievance, summary of finding/conclusion regarding the grievance, statement is whether the grievance was confirmed or not confirmed, corrective action taken by the facility as a result of the grievance, and the date the written grievance was issued Tracking system will be used for quality assurance, identifying any trends, systematic problems, and Improvement efforts. II. Resident council minutes The resident council minutes and a sheet identified as resident council follow-up were provided by the DON on [DATE] at 5:05 p.m. The review of the resident council minutes identified residents indicated concerns with staff treatment during care. The minutes did not identify follow-up and/or a sustainable plan for resolution. The concerns were not resolved according to resident interviews (see below interviews). The [DATE] resident council minutes read a resident had problems with the certified nursing aides (CNAs) being rough with her and careless. Two other residents agreed and commented that the CNAs did a lot of jerking and pulling. According to the minutes, the concerns would be addressed by the DON and CNAs would be educated on bedside care. A [DATE] follow-up notation was attached to the minutes regarding the CNAs were rough. The notation read the resident who identified the staff was rough was followed up with after the council meeting. She said did not feel abused but felt the CNA's were rushing her when she needed assistance with her care and were always in a hurry to go to the next resident. The resident felt the CNAs needed to take their time when providing more care. The [DATE] through [DATE] grievance/concern tracking resolution log was provided by the corporate consultant (CC) at approximately 6:15 p.m. The [DATE] log did not identify residents expressed rough or rushed care. The February 2024 resident council minutes identified three residents still felt the CNAs rushed too much and were not taking their time with provided care. The minutes did not identify a plan to address the continued and unresolved concern of CNAs rushing during care. The February 2024 grievance/concern tracking resolution log did not identify residents in resident council and continued to express feelings of rushed care by CNAs. The [DATE] resident council minutes indicated reeducation to nursing would be completed related to staff rushing during care. The minutes did not identify when staff would be reeducated as identified in the [DATE] and February 2024 minutes. The minutes did not identify the residents felt their concerns with rushing were resolved. The [DATE] resident council minutes read a resident was concerned about CNAs and nurses stating they would be back or the staff would not return to the resident. Other residents indicated they also had that as a concern and wanted an explanation on why the CNAs were not attending to them. Another resident said she was not happy that the staff left her on the toilet for a while. The minutes identified residents felt staff were giving the residents attitudes and reprimanding them for asking for help. According to the minutes, the former NHA told the residents that everyone needed to go to the bathroom after meals so receiving assistance may take longer at that time. The minutes did not identify how the facility was going to address the concerns of staff not returning to the resident; staff attitudes; feelings of being reprimanded; and a resident concerned she was left on the toilet for a while. The minutes did not identify whether the residents felt their concerns with staff rushing with care were resolved from the [DATE] and February 2024 resident council meetings. The [DATE] grievance/concern resolution tracking log identified a resident not included in resident council meetings and not part of the below resident interviews, felt a CNA was rude. According to the log the identified CNA's contract expired as the resolution. The [DATE] log did not include residents from resident council who felt the staff had attitudes and felt they were reprimanded for asking for help. The [DATE] healthy workplace meeting minutes were provided by the CC on [DATE] at approximately 6:15 p.m. The workplace minutes identified the meeting was attended by seven members of the interdisciplinary team (IDT). The workplace minutes read the staff needed to be reminded at all staff meetings not to rush with residents and take their time as part of good customer service. A customer service sheet defining the traits of good customer service with a handwritten notation that read [DATE] all staff meeting was provided by the CC on [DATE] at approximately 6:15 p.m. The sheet did not identify who attended the all staff meeting and the sheet did not identify not rushing with care was addressed in the inservice as identified as a concern with residents in resident council. The sheet did not instruct staff to make sure the resident's needs were addressed before the staff left the room. According to the sheet, staff should maintain a positive attitude. The resident council follow up sheet, dated [DATE], read follow up items from resident council since [DATE]. The follow up form listed multiple concerns brought in resident council including water temperature, shower schedule, hearing aids, missing laundry, television on at night and staff rough/rushing. The follow-up sheet did not identify when the concerns were addressed other than on [DATE]. According to the follow up sheet, all the concerns were resolved or improved, other than Resident #24 still felt there was one CNA who still had issues with the rushing. However, this was contrary to resident interviews below, identifying other residents also identified concerns with rushing staff. The [DATE] follow up said the identified CNA would no longer provide care to the resident for the time being. The [DATE] resident council minutes did not identify if the residents felt their concerns of staff rushing, staff attitudes and staff reprimanding them when asking for help, left on the toilet, and staff telling residents they would be back and not return were resolved. The [DATE] grievance/concern resolution tracking log identified additional residents had concerns with staff treatment towards them. On [DATE] and again on [DATE], two different residents expressed concerns with rude staff. The [DATE] response was the nurse's contract expired. The [DATE] response was staff agreed to be careful. The residents were not part of the resident council meeting or resident interviews The [DATE] resident council follow up sheet did not identify the [DATE] resident council concern of staff attitudes and feelings of being reprimanded which was still identified as a concern during the [DATE] through [DATE] interviews (see below). An undated quality assurance and performance improvement (QAPI) discussion form was provided by the CC on [DATE] at approximately 6:15 p.m. According to the form there had been a decrease in concerns and grievances which was unusual. The form identified between [DATE] and [DATE] there were grievances logged without follow up. The form identified resident council minutes were reviewed for the past three months and there were alot of concerns but most of the concerns were from one resident. The form identified action was to start generating concerns/grievances from resident council and log the concerns and leadership should plan to attend the meeting. The interdisciplinary (IDT) morning meeting would review all grievances and discuss until resolution. -QAPI discussion form read most of the resident council concerns were from one resident however a review of the council minutes identified multiple residents expressed concerns with staff care. III. Resident interviews A. Resident individual interviews Resident #4 was interviewed on [DATE] at 4:10 p.m. Resident #4 said the staff had an attitude in the way they spoke to her when she answered her call light or if she took a while in the bathroom. Resident #31 was interviewed on [DATE] at 4:31 p.m. Resident #31 said his main concern was staff would come in to help him but they would be very quick in the process with whatever he needed and then leave before he was able to get all the assistance he wanted such as help put on his jacket. He said he would like the staff not to rush so much and take the time to make sure he did not need more assistance. He said some things were very hard for him to do on his own. Resident #16 was interviewed on [DATE] at 4:36 p.m. Resident #16 said some of the staff were rude and had an attitude during care and they spoke to her. She said she had to ask one staff member not to come into her room because she was very rude. Resident #45 was interviewed on [DATE] at 10:20 a.m. Resident #45 said when the CNAs answered her call light, they did not stay long enough in her room to finish helping her. She said sometimes she just needed something small like getting her earrings for her but the CNAs leave too fast to help with the request. B. Resident group interview Five residents (#4, #22, #45, #51 and #53), who were identified as interviewable by the facility and assessment, were interviewed on [DATE] at 10:30 a.m. Resident #45 said one problem that she and everyone had continued to have was that staff rushed in the room and did not take the time to listen to what the residents asked and needed from them. She said when the staff were rushed could cause miscommunication between staff and the residents. She said the staff leave and assume all the needs were met without asking the residents. Resident #4 agreed. Resident #4 said the staff dashed in and out of her room. Resident #4 said had reported her concerns repeatedly but staff continued to rush during care. Resident #4 said when the staff helped her dress the CNAs took her shirt off so fast it hurt her ears. Resident #4 and Resident #51 said when staff helped transfer them, they moved so fast it made them feel dizzy. Resident #51 said he has asked staff not to assist him anymore and he does most things by himself. Resident #51 said that when he told staff he had a problem or need, the staff did not pay attention. Resident #22 said there was a nurse that would do that to her. Resident #53 said staff would complete the first thing he asked them to do but would then leave the room without making sure she did not need anything else. She said she would then have to push the call light on again to have them come back. She said the CNAs seemed so happy to leave the room before the resident could ask for items such as her water and her chapstick. She said the staff had too many people to take care of at one time and told her they were short staffed. Resident #4 said she had the same concerns and had told the nurses and the social service director (SSD). The group said staff treated them with dignity but the CNAs had an attitude and rushed care because they were so busy. Resident #22 said the staff was pushy when they gave her instructions. Resident #53 said CNA's tell her she was confused and talk to each other and not her when she asked for something. Resident #51 said he would tell the nurses his concerns but they would just raise their eyes up and talk over the top of him to other staff which made him feel frustrated. Resident #45 said she was worried and felt she was a burden to staff so she tried to do as much as she could by herself. Resident #22 and Resident #53 agreed. Resident #53 said she would try to give the CNAs all of her requests at one time because their time was short with her but still would do only one of the tasks. Resident #51 staff just needed to pay more attention. Resident #4 said she has bumped the bathroom wall because the CNAs rushed to put her on the toilet. She said the CNA would leave her on the toilet and tell her they needed to help another resident and would come back later. She said they would leave her there for a while. She said it was not comfortable to have to remain on the toilet for extended times. She said she did not have a clock in the bathroom so she could not say how long she was left there. She said it made her feel annoyed when she was left there. Resident #22 said she had been left on the toilet for over 15 minutes. IV. Staff interviews The DON, the corporate consultant (CC) and the SSD was interviewed on [DATE] at 5:57 p.m. The SSD said the activity director used to be the one responsible for notifying staff of concerns addressed in resident council. The SSD said the resident council meetings were on Mondays every month but she did not work at the facility on Mondays. The SSD said she was present for the resident council in [DATE] and [DATE]. The DON said the SSD changed her schedule so she could help lead and be present for the meetings. The SSD said grievance cards also known as blue cards were created after resident council meetings if the residents expressed concerns. The SSD said every open/not resolved concern was reviewed in the morning meetings. The CC said during a [DATE] mock survey (survey preparation review) it was identified not all of the grievances were followed up on but there was a decrease in grievance cards generated. The CC said in [DATE] the facility started working on a process to address the grievances. She said the facility logged the grievances but the grievances cards for staff to follow-up on got lost in piles. The SSD said she was the one responsible for tracking unresolved or open concerns until the concern was addressed and resolved. She said on [DATE] she started writing down all the concerns in [DATE] and [DATE] because they needed to be addressed The SSD said she reviewed the recent resident concerns. She said Resident #4 had a concern with toileting in [DATE] regarding being left on a bed pan. She said no other resident had expressed concerns of being left too long on a toilet or a voiding device. The SSD said she checked in with Resident #4 and she did not say anything about being left too long on the toilet. The SSD reviewed the grievance tracking log and said nothing was reported in [DATE] and she was not aware of the concern. The SSD said she reviewed the [DATE] resident council minutes and said there was a concern regarding toileting care. She said she did not receive a grievance form and was not provided the [DATE] resident council minutes from the activity director. The CC said the resident council minutes should be reviewed in the quality assurance performance improvement (QAPI) meeting. The CC said starting next week the resident council minutes would be reviewed in QAPI. The SSD said regarding staff attitudes, a resident on [DATE] submitted a grievance that a nurse was rude to him. The SSD said the resident council said they would prefer to have a conversation with CNA's but the CNAs were too much in a hurry to talk to them. She said the staff sometimes were too fast in resident rooms and the residents felt the staff was rushing with the care and not communicating enough with the resident. The SSD said the follow-up of the concern should have been documented in council minutes and addressed on a grievance form. The SSD said the regarding staff rushing through resident care was not followed up using the grievance form process but she was made aware of the concern when the activity director told her about the concern after a meeting. The SSD said Resident #4 still felt there were concerns with an identified CNA and the CNA was removed for her care this week ([DATE]-[DATE]). The CC said the facility addressed customer service with staff during an [DATE] staff meeting. -However, the facility was unable to provide documentation which demonstrated that not rushing residents or asking residents if they needed anything else before the staff member left the room was included in the inservice. The CC said it was important for the residents to feel important and heard. The CC said there needed to be more oversight in the grievance process. The CC said they identified the concerns with lack of grievance follow-up in February 2024 but plans to improve the process did not start till the week on [DATE] (during the survey process). The CC said the activity director who was originally responsible for the grievance cards after resident council was educated in [DATE] but there were still identified concerns but lack of follow through. The DON said the former NHA was responsible for overseeing the process but he was no longer at the facility. The SSD said in the QAPI meeting they had identified a slow down in grievance cards but there was not a follow-up plan. The DON the quality assurance nurse (QAN) led QAPI. The CC said the facility reminded staff not to rush with care but the facility could evidence that they addressed the concern with staff. -However, the CC could not provide dates when reminders were provided to staff. The SSD said moving forward she would regularly attend the resident council meeting, document staff education and concerns on a grievance form. She said the facility would provide timely follow-up of the concerns within a week of the concern and follow up with the resident to make sure the resident felt the concern was addressed and resolved. The QAN, DON and the SSD were interviewed together on [DATE] at 8:01 p.m. The QAN said during QAPI each department gave an update on what the facility needed to address, if there was anything reportable, and if there was anything we needed to discuss as a team. The QAN said if there were concerns in the resident council the activity director addressed the concerns in QAPI and the QAPI members would then review each concern. The SSD said starting this week she was ultimately responsible for the grievance follow-up in the resident council. The DON said the facility was to go over the concerns they knew they already had and there were more concerns they did not know about. She said she would review the concerns with the QAN and create a performance action plan to make sure all concerns are put on the grievance forms. The DON said there was a gap when not all of the concerns were addressed in QAPI.

Based on observations, record review and interviews, the facility failed to store, prepare, distribute and serve food in a sanitary manner in two of three dining rooms and one of one kitchenette. Specifically, the facility failed to: -Ensure hand hygiene was offered and provided to residents during meal times; -Ensure staff plating ready-to-eat food used hand hygiene after touching potentially contaminated surfaces; and, -Ensure staff used hand hygiene before donning gloves to serve ready-to-eat food. Findings include: I. Facility policy The Infection Prevention and Control Program policy, revised 2/25/19, was provided by the director of nursing (DON) on 5/20/24 at 2:00 p.m. It read in pertinent part, The Infection Prevention and Control Program will utilize the policies and procedures within the Infection Control Manual. The program includes employee health, management of residents with infectious diseases, hand hygiene for staff, residents and visitors; cleaning and disinfection procedures including appropriate surfaces and equipment, food safety and linen handling. Staff education is provided at orientation, yearly, during outbreaks and as needed includes handwashing. -The Hand Washing policy, dated 2021, was provided by the corporate consultant (CC) on 5/23/24 at 3:53 p.m. The policy identified staff should perform hand hygiene when entering the kitchen, immediately before engaging in food preparation, before donning disposable gloves before and after working with food and after engaging in other activities that would contaminate the hands. According to the policy, staff should be educated and reminded of the importance of hand washing. -The Hand Hygiene policy and procedure, dated 8/21/23, was provided by the CC on 5/23/24 at 3:53 p.m. It read in pertinent part, The hands of the conduits for almost every transfer of potential pathogen from one patient to another, from a contaminated object to a patient, and from a staff member to a patient. Because of this, hand hygiene is the single most important procedure to prevent infection. To protect patients from healthcare associated infection, hand hygiene must be performed routinely and thoroughly. Clean and healthy hands with intact skin, short fingernails, and no rings minimize the risk of contamination. The Centers of Disease Control (CDC) recommends that patients perform hand hygiene with soap and water or alcohol-based hand sanitizer before and after eating food, before touching the eyes, nose, or mouth, after using the restroom, after blowing the nose, coughing, or sneezing and after touching any surfaces in healthcare facility, such as the bed rail or remote control, to decrease the spread of infection. The Bare Hand Contact with Food and Use of Plastic Gloves policy, dated 2021, was provided by the CC on 5/23/24 at 3:53 p.m. It read in pertinent part, Single-use gloves will be worn when handling food directly with hands to ensure that bacteria was not transferred from the food handlers hands to the food product being served. Bare hand contact with food is prohibited. Hands are to be washed when entering the kitchen and before putting on single-use gloves and after removing single-use gloves. Gloves are just like hands. They get soiled. Anytime a contaminated surface is touched the gloves must be changed, and the hands must be washed. II. Observations The main dining room was observed continuously on 5/20/24, beginning at 11:23 a.m. and ending at 12:55 p.m. Observations identified the following: -19 residents were not offered hand hygiene before they were served their meal of fish, rice and zucchini or a hamburger and chips or sandwich. -Three residents self propelled their wheelchairs into the dining room by using their hands on the wheels of the wheelchair. Staff did not offer or encourage the residents to use hand hygiene before they ate their meal in the dining room. -Hand hygiene supplies were not passed out in the dining room or provided on the dining room tables. The memory care unit dining room was observed during a continuous observation on 5/20/24, beginning at 11:00 a.m. and ending at 12:07 p.m. Observations identified the following: On 5/20/24 at 11:00 a.m. 10 residents were in the memory care dining room. -The residents were not offered hand hygiene. -A male resident and a female resident entered the dining room using their walkers, The residents were not not offered hand hygiene before lunch after touching the handles of their walkers. At 11:04 a.m. a male resident self-propelled his wheelchair by placing his hands on the wheels of his wheelchair into the dining room. -The male resident was not offered hand hygiene. Between 11:36 a.m. and 12:07 p.m. four residents were served hand held food which included a grilled cheese sandwich, an egg salad sandwich, a fried egg sandwich or a peanut butter and jelly sandwich. The remainder of the residents were serviced cod, chips, asparagus, and angel food cake. The memory care unit dining room was observed during a continuous observation on 5/22/24, beginning at 11:42 a.m. and ending at 12:36 p.m. Observations identified the following: On 5/22/24 at 11:42 a.m. six residents were in the dining room. -At 11:43 a.m., four residents were brought into the dining room and not offered hand hygiene. -At 11:45 a.m. another resident was brought into the dining room and was not offered hand hygiene. -At 11:46 a.m. three tables were observed with hand sanitizer placed on them while nine tables were without hand sanitizer. -At 11:47 a.m. a male resident walked into the dining room and a female resident entered the dining room with staff, neither of the residents were offered hand hygiene. -At 11:48 a.m. a female resident wrapped tissue around her finger and stuck her finger up her nostril to clean out her nose. The resident then grabbed a lemon, with the finger that was in her nose, and squeezed it on her fish. -At 11:52 a.m. two residents were brought into the dining room and were not offered hand hygiene. -At 11:57 a.m. a female resident was assisted to the dining room and was not offered hand hygiene. -At 11:58 a.m. a male resident was assisted to the dining room and was not offered hand hygiene. At 12:00 p.m. two residents at the assistance table were offered hand hygiene. -At 12:04 p.m. a male resident was brought into the dining room and not offered hand hygiene. -At 12:07 p.m. a female resident was brought to the dining room and was not offered hand hygiene but the staff completed hand hygiene after she placed the resident at the table. -At 12:13 p.m. two more residents at another assistance table were offered hand hygiene. -At 12:15 p.m. a female resident who was not offered hand hygiene, ate her fish and cake with her hands. At 12:24 p.m. a male resident struggled to put condiments on his hamburger. His tablemate took his hamburger and buns, applied condiments and sat them back on the table cloth. The resident took his burger back from his table mate and assembled his burger. The resident ate his hamburger. -Neither resident was offered hand hygiene. -At 12:28 p.m. a female resident was eating a cookie with her hands. She was not offered hand hygiene and licked chocolate off her fingers. -At 12:36 p.m. two female residents were wiping their nose with their hands and proceeded to eat the fish with their hands. The memory care unit dining room was observed during a continuous observation on 5/22/24, beginning at 4:00 p.m. and ending at 5:13 p.m. Observations identified the following: -At 4:00 p.m. residents were being brought into the dining room by staff for the dinner meal. Hand sanitizer or hand wipes were not readily available on the tables. -At 4:13 p.m. 11 residents were seated at the dining room tables and none of the residents were offered hand hygiene. -At 4:15 p.m. a male resident walked into the dining room using his walker, he was not offered hand hygiene. At 4:48 p.m. cook #3 arrived at the unit with the meal cart. He grabbed the door handle to enter into the memory care unit. -Cook #3 did not perform hand hygiene when he entered the kitchenette after touching the door. At 4:53 p.m. cook #3 exited the memory care unit kitchenette and went to the main kitchen. -At 4:57 p.m. cook #3 returned to the memory care unit. He grabbed the door handle to the memory care unit and failed to perform hand hygiene when he entered the kitchenette. [NAME] #3 added food to the steam table and retrieved clean dishes. He touched the center of the clean plates with his thumb. -At 4:59 p.m. cook #3 wiped his right hand on his right thigh then put a glove on his left hand. He failed to wash his hands before applying the glove and cutting the residents ' sandwiches. -At 5:02 p.m. cook #3 removed the glove. He failed to wash his hands and proceeded to plate the main entree. He touched serving utensils, meal tickets and the surface of clean dishes. -At 5:09 p.m. cook #3 put on one glove without performing hand hygiene to cut an uncrustable peanut butter and jelly sandwich in half. He removed the glove and did not wash his hands. At 5:13 p.m. cook #3 broke down the steam table and left the unit. -Cook #3 again failed to wash his hands. III. Record Review The following trainings were provided by the registered dietitian (RD) on 5/23/24 at 1:19 p.m.: A 1/16/24 memory care unit staff training identified hand hygiene during meals was reviewed with the certified nurse aides (CNA) and nurses who worked on the memory care unit. -The training did not identify dietary staff who served on the memory care unit received the hand hygiene training. -A 1/18/24 dietary meeting did not identify hand hygiene was reviewed with the two cooks and the dietary assistant who attended the meeting. Glove use was reviewed during the meeting. -A 3/27/24 dietary meeting identified hand hygiene and glove use was reviewed with four dietary assistants and two cooks. The signature sheet identified cook #3 attended the meeting. The undated online food handling training documented the goal of food safety was to prevent the hazards that cause foodborne illness. To prevent foodborne safety hazards from affecting food, staff must understand the relationship between their actions and potential risk of foodborne illness. According to the online training, the most important thing that anyone can do to prevent foodborne illness was to wash their hands. The training identified that, during food preparation, staff should perform hand hygiene as often as necessary to remove soil and contamination and prevent cross contamination when changing tasks. Hand hygiene should be performed before eating food. III. Staff interviews The RD) was interviewed on 5/23/24 at 9:49 a.m. The RD said staff was trained on hygiene during the facility ' s annual skills fair and online training. The RD said the dietary staff received additional hand hygiene and infection control training with the dietary manager (DM). The DM was interviewed on 5/23/24 at 1:17 p.m. The DM said she reviewed hand hygiene with her staff. She said she reviewed how often and how long staff should clean their hands and proper glove use. She said the nursing department was responsible for training the nurses and CNAs. The DM said staff serving meals to the residents should perform hand hygiene between passing each plate, between helping each resident with their meal, when donning and doffing gloves and after touching any high touch surface area such as a door. She said hand hygiene helped prevent the spread of germs and bacteria. Observations of the memory care unit during meal service were shared with the DM. She said staff should have performed hand hygiene every time they stepped away and returned to the service line. She said touching a door or any high touch surface and then plating resident meals without hand hygiene increased the risk of spreading germs to the residents ' food. The regional infection preventionist (RIP) was interviewed on 5/23/24 at 2:29 p.m. The RIP said staff should perform hand hygiene before and after resident cares and entering resident rooms and anytime after touching their face or high contact surfaces. He said residents should be offered hand hygiene after toileting, before food, and anytime as needed. He said staff should use alcohol based hand rub (ABHR) before handling anything resident food related and in between residents during meal service. He said residents should be offered hand hygiene just before they eat at the table so the resident would have clean hands while they ate and decrease the risks of consuming germs and/or bacteria. The RIP said if a resident was propelling themselves to the dining room table, staff should make sure to encourage residents to use ABHR near the entrance of the dining room. He said staff should offer hand wipes at the dining room tables before the residents received their meal. The RIP said residents should not touch another resident ' s food. He said staff should intervene and redirect the resident to their own food. He said if food contact occurred by another resident, staff should offer to replace the touched food to avoid potential cross contamination. The RIP said the facility had not set up a hand hygiene process before meals other than encouraging residents to use hand hygiene. He said the facility had not set up a process or procedure to make sure hand hygiene was offered to residents before meals. He said staff were educated on the importance of hand hygiene a couple of times a year. CNA #4 was interviewed on 5/23/24 at 7:44 p.m. CNA #4 said she offered hand hygiene before residents went to the dining room. She said the rehab dining room did not have hand wipes to clean the residents ' hands. CNA #2 was interviewed on 5/23/24 at 7:45 p.m. CNA #2 said she used hand hygiene before she entered and left each residents ' room. She said she washed with soap and water after three uses of hand sanitizer or using the restroom. She said she offered the residents hand hygiene before meals and after they used the bathroom. She said she offered and provided residents hand hygiene in their rooms because she typically took them to the restroom before meals then offered it again in the dining room. She said if residents refused, she would still offer hand hygiene at meals and sometimes she would place ABHR in her hands and ask the residents how they were while she would rub the ABHR into their hands. CNA #7 was interviewed on 5/23/24 at 7:48 a.m. CNA #7 said most residents washed their hands at the sink in their room or she offered hand wipes to them before they ate. The quality assurance nurse (QAN) was interviewed on 5/23/24 at 8:01 p.m. The QAN said, during a January 2024 and February 2024 quality and assurance performance improvement (QAPI) meeting, the interdisciplinary team (IDT) discussed the facility ' s dining room process. She said in January 2024 the facility identified the residents refused to wash their hands. She said staff needed to stay on top of hand hygiene in the dining room and in resident rooms. She said the staff needed to encourage the residents to perform hand hygiene before meals in the dining room and offer hand wipes when residents received meal room trays. She said the IDT discussed how they could have residents practice hand hygiene more often and how to make it more appealing for the residents. The QAN said the dietary staff was provided hand hygiene education and the DM encouraged her staff to use hand hygiene. She said the staff providing the meals had tried hand wipe sanitizer packets on the meal trays and helped residents use the wipes. She said if the residents did not like the wipes, staff should offer the residents ABHR. Observations were reviewed with the QAN. She said the facility would start conducting more hand hygiene education with staff and complete audits of hand hygiene practices.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to ensure residents were free of misappropriation of property for one (#26) of eight residents reviewed for misappropriation of property of 23 sample residents. Specifically, the facility failed to ensure a resident's credit card was not stolen and used by staff. Findings include: I. Facility policy and procedure The Resident/Client Protection policy, revised 11/3/22, provided by the director of nursing (DON) on 11/17/22 at 3:00 p.m. read in pertinent part, Each individual has the right to be free from verbal, sexual, physical, and mental abuse, including injuries of unknown source, misappropriation of resident/particpant property, corporal punishment, mistreatment, neglect, and involuntary seclusion. Resident/client/participants must not be subjected to abuse by anyone, including but not limited to, facility/service staff, other residents/clients/participants, consultants or volunteers, staff of other agencies service the resident/client/participant, or legal guardians, friends, or other individuals. II. Resident #26 A. Resident status Resident #26, age [AGE], was admitted [DATE]. According to the November 2022 computerized physician orders (CPO) diagnosis included major depressive disorder, generalized muscle weakness, and unspecified abnormalities of gait and mobility. According to the 10/25/22 minimum data set (MDS) assessment the resident scored a 14 out of 15 on the brief interview for mental status exam (BIMS) indicating the resident was cognitively intact. There was no evidence of an acute change in mental status from the resident ' s baseline. B. Resident interview Resident #26 was interviewed on 11/14/22 at 1:06 p.m. She said her credit card was taken from her bill fold in her room at the facility. She said fraudulent charges were made on the card in the last month in a neighboring town. She said the facility was aware and helped her cancel the cards, and was waiting for the new credit cards in the mail. She said it had to have been someone at the facility that took the credit card. III. Facility investigation A. Credit card fraud report An October 2022 credit card fraud detection notification statement sent to the resident showed: -Five charges at retailers and gas stations on 10/17/22 totaling $289.43. -Three additional attempted charges on 10/17-10/19/22 which were declined by the credit card company totaling $91.64 B. Facility interviews Resident #26 was interviewed by the facility on 10/21/22 at 12:40 p.m. The resident reported to the facility she was missing her credit card from her purse, which she kept in her room in her purse. She said she suspected it was someone working at the facility, and no staff had been acting differently around her nor did she have any suspicions of who specifically may have taken it. There were 21 staff members and five other residents who were interviewed during the course of the facility's investigation which began immediately on 10/21/22. The facility was not able to identify a suspect during the course of their investigation. IV. Interviews The DON was interviewed on 11/15/22 at 2:53 p.m. She said she was not able to determine which staff member took the credit cards during her internal investigation, but the police were in the building that day (11/15/22) with a photo of a suspect that was provided by one of the retailers of which the credit card was used. She said the police had asked staff members at the facility about the photo and staff were able to identity the person in the photo as certified nurse aide (CNA) #24. She said CNA #24 was arrested and removed from the facility by the police. She said she would be turning the staff member over to the Board of Nursing and the staff member who was working via a staffing agency would not be allowed back into the facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews, the facility failed to report allegations of abuse to the State Survey and Certification Agency in accordance with State law involving one (#14) of eight residents reviewed for abuse out of 23 sample residents. Specifically, the facility failed to report allegations of physical abuse for Residents #14. Findings include: I. Facility policies and procedures The Resident/Client Protection policy for Freedom from Abuse, Neglect, and Misappropriation, last revised 11/3/22, was provided by the director of nursing (DON) on 11/17/22 at 3:00 p.m. The policy read in pertinent part: It is the policy of (the facility) that all (residents) are free from abuse and neglect. According to the policy, it was the responsibility of everyone to prevent abuse by providing staff and residents with information on how and who to report abuse to. The policy identified the facility should have created an atmosphere of reporting without fear of retribution. The policy read staff should always report alleged abuse. The executive director or designated representative must be contacted immediately by a supervisor or the reporter of abuse regarding all allegations of abuse with documentation of the notification. The policy read if there was suspicion of abuse, it would be reported to the State Reporting Agency in accordance with the state law immediately, not later than two hours if the alleged violation involved abuse. II. Resident #14 status Resident #14, age [AGE], was admitted on [DATE] and readmitted on [DATE]. According to the November 2022 computerized physician orders (CPO), diagnoses included spinal stenosis, lumbar region without neurogenic claudication (narrowing of the spinal canal in the lower back), chronic pain, pain in the right hip, anxiety disorder and major depressive disorder, single episode, unspecified. According to the 10/13/22 minimum data set (MDS) assessment, the resident was cognitively intact with a brief interview for a mental status score of 14 out of 15. The MDS assessment identified the resident required extensive physical assistance of more than two staff with bed mobility, transfers, dressing and toileting. III. Resident interview Resident #14 was interviewed on 11/14/22 at 1:42 p.m. She said she had a lot of pain in her hip and back related to her sciatica. She said it hurt when staff changed her brief and had requested them to position/move her slowly during activity of daily living (ADL) care. Resident #14 said a few weeks ago, during ADLs, a licensed practical nurse (LPN) yanked her hip and grabbed her arm to yank her whole body to roll over to her side. She said she screamed out in pain because the rapid movement felt hard enough to cause bruising and aggravate her sciatic nerve. She said she was told to be quiet when she yelled because she was waking up the other residents. She said a certified nurse aide (CNA) was present when the LPN yanked her. The resident said the CNA who witnessed the incident was vindictive. She said the CNA told her, Who are you going to report today? Resident #14 said she reported the incident to another CNA or LPN after she felt yanked but reporting to staff did not do any good. The resident said she did not want to identify the LPN and CNA involved in the incident because she did not want to get them in trouble because she (the resident) would get in trouble. She said she did not want to be treated any worse than she already was. (Cross-reference F550, The right to be treated with dignity and respect.) IV. Resident record The 10/8/22 nurses note read the nurse and a CNA entered Resident #14 ' s room and proceeded to change the resident ' s brief and bedding when the resident began to yell and say you are being so rough. According to the note the LPN and CNA told the resident they were not trying to be rough and were just trying to change her. The resident said staff were trying to hurt her. The note read the resident began to yell again and the nurse asked the resident not to yell at her and the resident yelled back that she could yell at whoever she wanted to. During the ADL process, the resident said I don't want to be here anymore. The note read the nurse reported issues to the resident's cart nurse. The 10/18/22 nurses note read Resident #14 was checked and changed with Care in Pairs due to complaints of staff being too rough. According to the note, the resident fought against the roll and it was difficult to clean her. According to the note, the resident started talking about how she never said anything about staff being rough. -The note did not identify why the resident felt she needed to tell staff that she never said anything about staff being rough. The 10/20/22 interdisciplinary (IDT) note read the resident often describes pain as shooting pain from mid back down right leg with spasms. She is easily distracted from yelling out/screaming etc., with certain staff members and more triggered by other staff. V. Staff interviews The social service director (SSD) and the social service consultant (SSC) were interviewed on 11/17/22 at 2:04 p.m. The SSD said she reviewed grievances and reported incidents and investigations and did not identify any concerns or reports made about staff or Resident #14 regarding rough treatment and/or staff trying to hurt her. The SSD and SSC reviewed the above progress notes. She said she was not aware of staff providing Cares in Pairs because of the resident ' s complaints of rough treatment as identified in the 10/18/22 note. The SSD said she was not aware of reports of rough treatment from staff. The SSD and the SSC said the documented comments made by Resident #14 of rough treatment and feelings of staff trying to hurt her, should have been reported to the State Agency and the facility should have conducted an investigation. The SSD said the facility should have also identified why some staff triggered her as identified in the IDT note so they could be retrained and whether or not those particular staff should work with the resident. She said resident notes and staff communication was supposed to have been monitored to help identify potential concerns. The director of nursing (DON) reviewed the 10/8/22 note on 11/17/22 at 3:16 p.m. The DON said she was not made aware of the resident ' s comments in the 10/8/22 note and did not receive a report from staff that the resident felt staff was rough and trying to hurt her. Nurse manager (NM) #3 was interviewed on 11/17/22 at 3:29 p.m. She said she was not aware of comments identified in the 10/8/22 nurse note and the staff did not report concerns to her after it was reported to the resident ' s cart nurse as identified in the above 10/8/22 nurse note. She said she was part of the 10/20/22 IDT meeting which documented Resident #14 was triggered by certain staff. She said Resident #14 was triggered by some of the new agency staff that she was not familiar with and was more comfortable with routine staff. The NM said the resident had a particular way she liked to be positioned during cares to decrease her pain, which the routine staff were more accustomed to. She said the facility would have a seasoned staff member work with a new staff member during her ADLs. The NM said if she saw the comments in the 10/8/22 note or if staff reported to her that the resident was stating rough treatment and staff were trying to hurt her, she would have reported the concerns to the SSD and the DON immediately. She said staff should have notified the managers and documented the concerns on a grievance form. Staff could report concerns to management so the facility could report the allegation of potential abuse within two hours to the State Agency and start an investigation. The UM said the facility should have immediately put interventions in place and ensure the resident felt safe. The DON was interviewed on 11/17/22 at 4:34 p.m. She said residents should never worry about retaliation and the facility would provide education staff on abuse and reporting alleged abuse.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews, the facility failed to thoroughly investigate an allegation of sexual abuse involving one (#29) of eight residents reviewed for abuse out of 23 sample residents. Specifically, the facility failed to thoroughly investigate potential sexual abuse on 9/7/22 and failed to complete an investigation of potential abuse on 9/13/22 for Resident #29. Findings include: I. Facility policy The Resident/Client Protection policy for Freedom from Abuse, Neglect, and Misappropriation, last revised 11/3/22, was provided by the director of nursing (DON) on 11/17/22 at 3:00 p.m. The policy read in pertinent part: It is the policy of (the facility) that all (residents) are free from abuse and neglect. According to the policy, all staff must monitor the resident for possible signs of abuse which include suspicious bruising. The abuse policy identified an investigation as the immediate process to try to identify what happened. The investigation would include: -Who was involved; -Resident statements; -Staff and witness statements; -A description of the resident's behavior and environment; -Injuries present; and, -Observations of the resident behaviors during the investigation. The abuse policy under identification and reporting of suspected/alleged abuse read the resident would be assessed for physical appearance, skin injuries, trauma, changes in the resident's affect, mood, and behavior, occurrences, patterns, and trends. The facility would investigate alleged violations and put measures in place in order to prevent further potential abuse while the investigation is in process. The policy indicated the investigation, the follow up and the findings would be documented. II. Resident #29 status Resident #29, age [AGE], was admitted on [DATE]. According to the November 2022 computerized physician orders (CPO), diagnoses included Alzheimer's disease with late onset, dementia with psychotic disturbance, and delusional disorders (on 9/7/22), psychotic disorder with hallucinations due to known physiological conditions (on 9/8/22), disorientation, and mild cognitive impairment of uncertain or unknown etiology. According to the 9/8/22 minimum data set (MDS) assessment, the resident had severe cognitive impairment with a brief interview for a mental status score of three out of 15. The MDS assessment identified the resident as independent in most of her activities of daily living (ADLs). III. Allegation of potential sexual abuse on 9/7/22 A. Record review The 9/7/22 late entry post incident note read Resident #29 had an Other on 9/7/22 at 7:15 a.m. The incident note referred to the post incident review for additional information and details. The 9/7/22 investigation of the 9/7/22 incident was provided by the facility on 11/14/22. According to the investigation, Resident #29 told the nurse that a man entered her room and attempted to have oral sex with her. The resident also reported the man rubbed her abdomen/breast area. There were no witnesses to the allegation. There was not a male in the facility during the alleged time period that matched the description of the man Resident #29 described during the investigation. The resident said she was not afraid. Nurse manager (NM) #3 assessed the resident and found no injuries related to the allegation. The resident was transferred to the hospital for evaluation related to the allegation. The review of the hospital report did not identify trauma and the resident did not recall the incident at the time of her hospital evaluation. According to the report, the screening exam performed by the emergency department was for acute medical conditions only and did not eliminate the necessary monitoring and treatment while a resident was at the nursing facility. During the investigation, staff and residents were interviewed. According to the investigation, a male staff member who was working during the alleged time was interviewed. According to the male staff member, he entered the resident's room to check on her because her bedroom light was on. He did not provide cares and only touched her arm/shoulder. The resident asked the staff member if he was married. The staff member did not meet the physical description as described by the resident. Review of the staff interviews from the facility investigation identified the following: -A 9/7/22 interview with a certified nurse aide (CNA) said on 9/6/22 the resident told her she was a man who hugged and kissed her. The man left and a second man did the same thing. According to the CNA, she had not made the allegation before. -An interview with a licensed practical nurse (LPN) identified Resident #29 reported to her on 9/7/22 at 7:15 a.m., a man who worked at the facility tried to put his penis in her mouth last night (9/6/22 to 9/7/22.) The resident described the situation to the LPN as awful. -An interview with nurse manager (NM) #3 was conducted on 9/7/22 at 9:15 a.m. after she performed a skin audit on Resident #29. The resident told the NM, a man that she saw everyday came into her room and got too friendly and fondled her breasts. According to the interview, the resident described the resident to be in his 40's (years old) but could not really tell what he looked like. The facility's response according to the investigation read the resident was placed on 15 minute checks during the investigation and the staff was educated to have only female caregivers or have two person assistance with Resident #29 if a male caregiver was necessary. According to the investigation, the allegation was not substantiated. The 9/10/22 pharmacy consultant note read the resident's medication regimen contained no new irregularities. The behavior care plan, last revised on 9/12/22, read Resident #29 had behaviors that included rejection of care; refusing to have staff to change clothes or let staff wash her clothes; slamming her door and yelling when upset. According to the care plan, the resident had behaviors regarding men. The care plan read the resident could become jealous or seek attention from men. The behavior care plan read the resident would make false statements against others and would tell staff stories about intimate relations with men related to her confusion. The September 2022 treatment administration record (TAR) identified the resident did not have hallucinations on 9/7/22. B. Staff interviews The director of nursing (DON), the social service director (SSD) and the social service consultant (SSC) were interviewed on 11/15/22 at 4:12 p.m. The SSD said she was new to the facility and was in training to conduct abuse investigations. She said the DON and the nursing home administrator (NHA) were currently leading the investigations. The SSD and the DON said the former social service director (FSSD) was available for questions as needed. The SSC said for allegations of potential abuse, the facility needed to report and investigate the allegation. The SSC said the facility needed to ensure the resident felt safe and was protected during the investigation. She said the facility would make sure no other residents were reporting the same concerns through resident interviews. The SSC said the facility would interview staff for witnesses, look at schedules and collect descriptions/details pertaining to the allegation. According to the SSC, the investigation would include a five day follow up report. The DON reviewed the 9/7/22 allegation and said the facility initiated an investigation on 9/7/22 after the resident reported potential abuse. The resident did not identify she was afraid. She said when the resident was interviewed again she said she was sitting in her chair sleeping when she woke up and there was a man rubbing her breast and abdomen. The DON said every male staff member was interviewed and it was identified that there was one male nurse who was an agency staff member working the overnight shift. The male nurse was interviewed and said he chatted with her for a little bit and patted her shoulder or arm. The male nurse did not match the description provided by the resident. The DON said the former social service director was part of the investigation and currently worked PRN (as needed.) The DON said nurse manager (NM) #3 conducted the skin assessment after the 9/7/22 allegation and documented a skin tear to the resident's left arm, a bruise on her arm and bruises to her lower legs. The DON said they did not do an investigation for bruises of unknown origin at the time. She said the resident was sent to the emergency room as a precaution. The DON said the facility did not have all the results of the exam. She said she was told by the hospital, the collected specimens could take four to six weeks. The DON said she spoke to the family service supervisor at the facility and they did not indicate they had evidence of a concern at time of her ER (emergency room) visit. IV. Injuries identified on 9/7/22 after allegation of abuse. A. Record review The review of progress notes between July 2022 and 11/17/22 did not identify a recent historical pattern of Resident #29 bumps and bruises from her foot rests. The skin care plan, initiated on 9/6/18, identified the resident was at risk for friction and shearing. The care plan directed staff to inspect the resident's skin daily with cares and report concerns to the nurse. The care plan did not identify the resident was prone to hitting her legs on her foot rests, or was at risk of bumps and bruising related to her foot rests. The review of the 9/7/22 skin assessment read Resident #29 had a new skin injury. According to the assessment, the resident had a yeast-like rash to her groin, abdominal fold and under her left breast. The resident had an old, healing skin tear to her arm and multiple small bruises noted to anterior lower extremities & one small bruise to Lt (left) anterior forearm. Resident (#29) is independent with transfers and historically bumps lower extremities on leg rests. -The skin assessment did not identify the condition of the bruises other than they were small and there were multiple bruises. The assessment did not explain why the nurse felt these bruises were from the leg rests other than the history and the resident was independent in transfers. The review of the above care plan and progress notes did not identify a history of bumps and bruising to her legs from the leg rests. The assessment did not identify what was done to prevent future bruising if there was an identifiable cause. The assessment did not identify the possible causation of the bruises on her arm. The physician was faxed for orders to treat the rash on 9/7/22. The review of the skin checks or other documentation in the medical record, prior to 9/7/22, did not identify the rash, multiple bruises on the resident's legs, the skin tear, or the bruise on her forearm. The review of the provided investigations and the medical record of Resident #29 did not identify an investigation for bruises of unknown origin. B. Staff interviews NM #3 was interviewed on 11/16/22 at 4:41 p.m. with the DON and the FSSD. The NM said she was asked to conduct a skin assessment of Resident #29 without knowing why. The former social service director said she asked NM #3 to conduct the skin assessment without explaining the reason. The NM said she identified a skin tear to the resident's left arm that had scabbed over and was beginning to heal. She said the resident had small bruises to both of her anterior shins. She said some of the bruises were faded in color. The NM said the resident had other discoloration to her legs but the bruises were identifiable. The NM said the bruises and skin tear were not identified prior to 9/7/22. She said she just looked at the bruising from the medical side so she thought the bruising to legs could have been from her leg rests. NM #3 said if she knew why she was conducting the assessment, she would have asked the resident more questions and if someone tried to hurt her or if something hit against her. She said she did not question the bruise or skin tear on the resident's arm. The FSSD said she did not tell the NM why she was conducting the skin assessment. The DON said the facility should have looked more into bruises identified on 9/7/22. V. Allegation of potential sexual abuse on 9/13/22 A. Record review The 9/13/22 behaviors and mood note indicated Resident #29 identified another allegation of sexual advances towards her that were unwanted. The 9/13/22 behavior note read when staff was providing care for Resident #29, the resident said, Several men came into my room tonight and wanted to have sex with me. I told them to get lost. According to the note, the resident was matter of fact when stating the incident and she was not upset, afraid or anxious. The note indicated there was no male staff working on her unit on 9/13/22. The note identified the concern was reported to the house supervisor and social services. The note did not identify additional follow up. -The review of the facility investigations did not identify allegations made on 9/13/22. -The review of additional progress notes on 9/13/22, or in days following 9/13/22, did not identify additional follow up to the allegations other than a hallucination/paranoia care plan initiated on 9/13/22. The 9/13/22 hallucination care plan included interventions to direct staff to be alert to the resident's needs; provide simple, direct, and concise interactions; and provide the resident activities. The review of the progress notes identified an activity note on 9/17/22 which read Resident #29 did not want to leave her room for activities for the past few days (as of 9/17/22) because her family was coming to get her. The resident agreed to attend if she had her phone with her to the activity. The September 2022 TAR indicated the resident had hallucinations on 9/13/22. B. Staff interviews The SSD was interviewed on 11/15/22 at 4:05 p.m. She reviewed the facility investigations, grievances and progress notes and could not find follow up to Resident #29's allegation on 9/13/22. The SSD said she did not work at the facility at the time of the allegation. She said the former social service director would have been the one to conduct the investigation. The DON, the FSSD, the SSD and the SSC were interviewed on 11/16/22 at 4:00 p.m. The SSC said the facility would have needed to have more details to determine if a request for sex that was unwanted on 9/13/22 as reported by Resident #29 was a reportable incident. The SSC said an immediate investigation would have provided potentially details of the situation from interviews with the resident, staff and other female residents. She said an investigation would have also included a body audit, review changes in the resident's behavior, and if she had past trauma. The former social service director said she was contacted by the nurse supervisor on 9/13/22 after Resident #29 informed staff of the sexual advances made towards her. She said she asked the nurse supervisor to follow up with the resident to clarify if the 9/13/22 allegation was the same incident that was reported on 9/7/22. She said the nurse supervisor did not document any additional follow up regarding the allegations. The former SSD said she was under the understanding that the resident was perseverating on the 9/7/22 allegation but no additional investigation was conducted. The DON said an investigation should have occurred. She said the facility needed to do more staff education around investigating abuse, identifying what was involved, what was found, and follow up to findings. The DON said the staff needed to know how to do an investigation when the allegation was from a resident with dementia. She said Resident #29 has had multiple different stories.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to ensure a Preadmission Screening and Resident Review (PASARR) Level II was completed for one (#8) of two residents reviewed for PASARR out of 23 sample residents. Specifically, Resident #8's PASARR Level I assessment revealed a Level II was needed, but the facility failed to ensure it was completed, to ensure an appropriate plan of care was developed and care provided to meet the resident's needs. Findings include: I. Facility policy The Preadmission Screening and Resident Review (PASARR) for Individuals with Mental Retardation or Mental Illness policy, dated 10/24/22, was provided by the director of nursing (DON) on 11/17/22 at 3:00 p.m. The policy required in pertinent part: Prior to admission, all individuals seeking nursing facility admission must have pre-admission screening (PASSAR) for mental illness and mental retardation. A positive Level I screen necessitates an in-depth evaluation of the individual, by the state-designated authority known as Level II PASARR, which must be conducted prior to admission to the facility. A Level II PASARR is a comprehensive evaluation conducted by the appropriate state-designated authority that determines what, if any, specialized service and/or rehabilitative services the individual needs. II. Resident status Resident #8, under age [AGE], was admitted on [DATE]. According to the November 2022 computerized physician orders (CPO), pertinent diagnoses included paranoid schizophrenia, mild vascular dementia with mood disturbance, post-traumatic stress disorder, and dissociative and conversion disorder. The 9/14/22 minimum data set (MDS) assessment documented Resident #8 had moderate cognitive impairment with a brief interview for mental status (BIMS) score of 11 out of 15, with no behavioral symptoms or rejection of care. Her mood severity score was eight out of 27, indicating mild depression. III. Record review Review of Resident #8's medical record revealed a Level I PASARR dated 10/6/22, which documented a Level II was required, but none could be found. IV. Staff interviews The social services director (SSD) and social service consultant (SSC) were interviewed on 11/17/22 at 11:19 a.m. They looked for Resident #8's PASARR Level II and said they were unable to find one, but said they would investigate further. In a follow-up interview on 11/17/22 at 2:55 p.m., the SSC said Resident #8 had a trauma assessment upon admission, and a related care plan was developed, but her care plan would have been fleshed out more with recommendations from a Level II PASARR. She said they resubmitted the Level I per direction from Telligen (the company that accepts PASARR assessments). She said evidently Telligen received the PASARR Level I and emailed the former social worker but she did not receive the email because she had left, and the current SSD did not receive PASARR training until last week. She said the Level I and Level II should have been done before Resident #8 was admitted to the facility. She said the facility would make sure all the PASARRs were done now.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to ensure that a current copy of a resident's advance directives were in the resident's medical record for one (#69) of two residents reviewed for advance directives of 39 sample residents. Specifically, the facility failed to ensure Resident #69's updated advance directives were readily available to nursing staff to ensure the resident's wishes were honored in case of an emergency. Findings include: I. Facility policy and procedure The Advance Directive/Health Care Directive policy, revised December 2018, documented in pertinent part: Adult individuals, 18 and older, have the right to make decisions about their health care, choose the limit or extent of his/her own medical treatment and the right to execute an 'Advance Directive.' II. Resident status Resident #69, age [AGE], was admitted on [DATE]. According to the July 2021 computerized physician orders (CPO), diagnoses included metabolic encephalopathy, stage III pressure ulcer, dysphagia, respiratory failure, COVID-19, cognitive communication deficit, and failure to thrive. The 7/26/21 minimum data set (MDS) assessment revealed the resident had severely impaired cognition with a brief interview for mental status (BIMS) score of six out of 15. III. Record review The resident had a baseline care plan initiated 7/20/21 with an updated terminal care area initiated on 8/12/21 that read in pertinent part: Resident #69 had a terminal illness with a diagnosis of COVID-19 and coronary artery disease with a less than six month terminal prognosis. The resident received hospice services. The August 2021 CPO included an order dated 7/20/21 which documented Resident #69 was ordered to have full resuscitation attempts. Record review revealed no medical orders for scope of treatment (MOST) form scanned in the resident's chart as of 8/10/21 at 1:45 p.m. A long term care billing form, the medical record under miscellaneous forms, documented that Resident #69 was admitted to hospice on 8/5/21. Documentation provided by social services director (SSD) showed the following: -A MOST form dated 7/20/21 documented Resident #69 was to undergo full resuscitation attempts -A Best Wishes form provided to the facility by hospice dated 8/5/21 and signed by Resident #69's medical durable power of attorney (MDPOA) documented the resident was to be changed to a do not resuscitate (DNR) and do not intubate (DNI). -On 8/10/21, during the survey, the CPO was updated to reflect the resident's current DNR/DNI status -On 8/12/21 at 1:27 p.m. the SSD provided an updated MOST form dated 8/12/21 which reflected DNR/DNI status. The form was signed by Resident #69's MDPOA. V. Staff interviews During an interview on 8/11/21 at 10:14 a.m., the SSD stated that in case of an emergency, staff would look at the current orders (CPO) in the electronic medical record (EMR). On 8/11/21 at 4:52 p.m. the western regional nurse consultant (WRNC) was interviewed about the discrepancy in paper orders and CPOs. She stated that she would have expected to see a change in advance directive orders entered into the CPO immediately upon being changed. She stated that in an emergency situation they would refer to the code status in the EMR.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to coordinate assessments with the pre-admission screening and resident review (PASRR) for one (#56) of two residents reviewed for PASRR services of 39 sample residents. Specifically, the facility failed to perform a post admission level (PAL) assessment for Resident #56, as directed in the previously submitted PASRR. Findings include: I. Professional Reference Centers for Medicare and Medicaid services (2011), Preadmission Screening and Resident Review (PASRR) Technical Assistance for States, retrieved from https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/ActiveProjectReports/Active-Projects-Reports-Items/CMS1187516 (retrieved on 8/16/21) documented: Federal law mandates that Medicaid-certified nursing facilities (NF) may not admit an applicant with serious mental illness (MI), mental retardation (MR), or a related condition, unless the individual is properly screened, thoroughly evaluated, found to be appropriate for NF placement, and will receive all specialized services necessary to meet the individual's unique MI/MR needs. States are required to have a PASRR program in order to screen all NF applicants to Medicaid certified NFs (regardless of payer source) for possible MI/MR, and if necessary to further evaluate them according to certain minimum requirements. The state uses the evaluation to determine, prior to admission, whether NF placement is appropriate for the individual, and whether the individual requires specialized services for MI/MR. As a condition of the Centers for Medicare and Medicaid Services's (CMS's) approval of a Medicaid state plan, the state must operate a preadmission screening program that complies with federal regulations. Additionally, the PASRR regulation requires resident reviews when there is a significant change in a NF resident's physical or mental condition. All applicants to Medicaid certified NFs (regardless of payer source) receive a Level I PASRR screen to identify possible MI/MR. These screens generally consist of forms completed by hospital discharge planners, community health nurses, or others as defined by the state. Individuals who do or may have MI/MR are referred for a Level II PASRR evaluation. II. Facility policy and procedure The social services director (SSD) said in an interview on 8/12/21 at 5:42 p.m. the facility did not have a policy for PASRRs, however they followed the operational memo from the Colorado Department of Healthcare Policy and Financing dated 4/8/21which became effective on 4/22/21 and documented: The PASRR process requires all applicants to Medicaid-certified nursing facilities (NF) be given a preliminary assessment (Level I) to determine whether they might have a mental illness (MI) and/or an intellectual or developmental disability (IDD). Those individuals who test positive at Level I are then referred for a more in-depth evaluation (Level II). The result of the Level II evaluation provides a determination of need, most appropriate setting, and a set of recommendations for services to inform the individual ' s care plan. III. Resident status Resident #56, age [AGE], was admitted on [DATE]. According to the computerized physician orders (CPO) dated October 2020, diagnoses included panic disorder, post-traumatic stress disorder (PTSD), major depressive disorder, and anxiety disorder. The 8/12/21 minimum data set (MDS) assessment revealed the resident had no cognitive impairment with a brief interview for mental status (BIMS) score of 15 out of 15. IV. Record review The resident had a care plan initiated 2/4/21 and revised 6/3/21 that documented in pertinent part: Resident #56 was at risk for being vulnerable related to altered mood, and should be observed for mental anguish. The care plan documented that Resident #56 suffered from anxiety, depression, and PTSD, requiring the use of psychotropic medications. The care plan documented that the resident should be evaluated for changes in behavior, mood, or anxiety. A Colorado PASRR Resident Review/Status Change form dated 12/16/20 documented an outcome of approved with follow up next quarter and triggered Level I approved for a 30 days stay, if client remains at SNF (skilled nursing facility) as of 1/16/21, SNF is required to submit an updated PAL at that time as a Level II may be warranted. It also documented that Resident #56 had diagnoses of major depression, panic disorder, PTSD, and anxiety. Psychotropic medications were used for the resident on a regular basis and mental status descriptions included depressed mood, hopelessness, and anxiety. V. Staff interviews On 8/11/21 at 4:21 p.m. an updated PASRR that was to be performed on 1/16/21 was requested from the SSD. At 4:52 p.m. the SSD stated that she was not able to find an updated PASRR and that it had not been completed. The nursing home administrator (NHA), director of nursing (DON), SSD and quality coordinator (QC) were interviewed on 8/12/21 at 8:50 p.m. The SSD and QC stated they had instituted a performance improvement plan (PIP) for PASRR right before COVID-19, and stated that it was a continuing process.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and observation, the facility failed to provide necessary services to one (#17) of three residents out of a sample size of 39, who were dependent on staff to carry out activities of daily living (ADL). Specifically the facility failed to assist Resident #17 to the restroom in a timely manner, resulting in the resident experiencing urinary incontinence. Findings include: I. Facility policy and procedure The ADL policy, revised in 2006, was provided by the social services director (SSD) on 8/12/21 at 5:42 p.m. The policy documented in pertinent part: The facility was to assist the resident as necessary in achieving maximum functional ability with dignity and self-esteem. II. Resident status Resident #17, age [AGE], was admitted on [DATE]. According to the August 2021 computerized physician orders (CPO), diagnoses included fracture of left femur, osteoporosis (weakness and loss of bone mass), restless leg syndrome (RLS), and neuropathy (nerve damage). The 5/17/21 minimum data set (MDS) assessment revealed the resident had no cognitive impairment with a brief interview for mental status (BIMS) score of 15 out of 15. She required extensive assistance with bed mobility, transfers, locomotion, ADLs, and toileting. Resident #17 experienced urinary incontinence frequently and was always continent of bowels. She had not been determined to be on a toileting schedule. III. Resident interview Resident #17 was interviewed on 8/10/21 at 8:43 a.m. She stated that there was a long wait time for call lights to be answered, the longest she had waited before was an hour. She said once it was very serious because she had an urgent need to use the restroom. She experienced incontinence due to having to wait too long. She said that she felt terrible, the staff reassured her that it was fine that she had experienced incontinence, but she had to wipe up the feelings she was raised with. She said that event happened two days prior to the interview on 8/8/21, she was not sure of the time. She said she felt like the staff got annoyed with her when she used the call light too much. IV. Record review The care plan, initiated 5/11/21 and revised 7/8/21, documented in pertinent part: Resident #17 requires extensive assistance with bed mobility, transfers, locomotion, toileting, and ADLs. The resident required stand pivot transfers with one person and front wheeled walker (FWW). She required two person assistance for bathroom, toileting, and clothing management. Resident #17 had occasional stress incontinence and the goal that was documented was for the resident to have a decrease in the amount of incontinent episodes. A progress note dated 8/12/21 at 13:59 p.m. documented Resident #17 had been frequently incontinent of urine and bowel, and the nursing team would encourage her to use the restroom every two hours during the day. The bowel and bladder elimination record (based on documentation by certified nurse aides) was reviewed on 8/11/21 at 11:52 a.m. It was documented that Resident #17 was only taken to the restroom twice on 8/8/21 at 12:03p.m. and again at 9:48 p.m. V. Staff interviews Certified nurse aide (CNA) #4 was interviewed on 8/11/21 at 11:19 a.m. S/he stated that due to being short staffed the residents sometimes did not get their needs met, such as timely restroom assistance, which had resulted in incontinence for residents. CNA #4 said the staff charted in the electronic medical record (EMR) every time a resident was taken to the restroom. On 8/11/21 at 3:32 p.m. CNA #4 was observed coming out of a different resident ' s room. CNA #4 said that the resident had called to ask to go to the bathroom, however both CNAs working on that hall needed to assist other residents first. CNA #4 stated the resident had to wait about 5-10 minutes before receiving assistance and she had experienced urinary incontinence while waiting. The director of nursing (DON) was interviewed on 8/12/21 at 6:37 p.m. She stated that she did not buy (didn ' t believe) that Resident #17 had to wait an hour for assistance. She stated that she had taken care of Resident #17 in the past, and when the resident used her call light, after the nurse arrived, the resident's first response was what takes you so long? even after short wait times. The DON, nursing home administrator (NHA), social services director (SSD), and quality coordinator (QC) were interviewed on 8/12/21 at 8:50 p.m. The QC stated that they do discuss ADLs in quality assurance (QA) meetings.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to document and alleviate severe pain for one (#17) of two residents reviewed for pain management out of 39 sample residents. Specifically, the facility failed to effectively manage Resident #17's pain or report the resident's severe pain levels to the physician, and failed to follow the physician order to document a description of the pain characteristics, interventions, and outcome of interventions for any pain level above zero out of 10 (0/10). Findings include: I. Facility policy and procedure The Pain Evaluation and Management policy, revised 9/2017, provided by the social services director (SSD) on 8/12/21 at 5:42 p.m. documented: All residents have the right for appropriate pain assessment and pain management. All residents will be evaluated for indicators or a history of pain for the MDS (minimum data set) on admission, quarterly, with a significant change in status, and with the new onset of potential pain or discomfort. Data will be collected through resident interviews, staff interviews and observations. II. Resident status Resident #17, age [AGE], was admitted on [DATE]. According to the August 2021 computerized physician orders (CPO), diagnoses included fracture of left femur, osteoporosis (weakness and loss of bone mass), restless leg syndrome (RLS), and neuropathy (nerve damage). The 5/17/21 MDS assessment revealed the resident had no cognitive impairment with a brief interview for mental status (BIMS) score of 15 out of 15. She required extensive assistance with bed mobility, transfers, locomotion, ADLs, and toileting. Resident #17 experienced pain frequently that affected her sleep and limited her day-to-day activities. The numerical pain scale rated the resident's pain at a 6/10 level. The resident received opioid medications seven days per week. III. Resident interview Resident #17 was interviewed on 8/10/21 at 12:10 p.m. She stated she had worked out a pain medication schedule with her physician and felt it was not always followed by the staff. She stated it depended on the nurse that was working, however she rated her highest level of pain in the past week at a 9/10. She did not appear in distress at time of the interview and stated that she was not currently in pain while sitting in her chair. IV. Record review The care plan initiated 5/11/21 and not since revised, documented in pertinent part: Resident #17 had osteoporosis and would report any pain or discomfort to nursing. The resident was at risk for pain due to left femur fracture and RLS. The documented goal was for the resident to remain comfortable. Review of the August 2021 CPO revealed an order dated 5/11/21 regarding pain monitoring, which documented: If anything but a zero level, chart a progress note explaining pain more and your interventions used to treat, plus effect. Pain scale 0=No Pain; 1-2=Mild Pain; 3-4=Moderate Pain; 5-6=Severe Pain; 7-8=Very Severe; 9-10=Worst Possible. From 7/9/21-8/9/21 the pain scale assessment documented the resident had a pain level above zero 66 times with 30 occasions being severe pain (5/10 or higher). Her highest pain level was documented at 9/10 (worst possible pain). There was no documentation the physician was notified of her daily severe pain. According to the medication administration record (MAR) Resident #17 had the following medications ordered: - Gabapentin 100mg once daily at bedtime for neuropathy (ordered 5/11/21) - Ropinirole 1mg three times a day for RLS (ordered 5/21/21) - Acetaminophen 650mg every six hours as needed for arthritis pain and 325mg every four hours as needed for pain/fever (ordered 5/11/21) - Cyclobenzaprine 5mg every 8 hours as needed for muscle spasms (ordered 6/22/21) - Morphine sulfate 20mg/ml, 5mg every four hours as needed for pain (ordered 5/23/21) - Tramadol 50mg every four hours as needed (ordered 5/25/21) When the resident's pain level was above zero, pharmaceutical intervention was provided, and a follow up pain scale documented that pain was alleviated, however no progress notes were completed explaining pain, interventions, or effect. A progress note dated 8/12/21 at 1:59 p.m. from a Medicare meeting documented Resident #17 rated her pain as high as 8/10 during that week on one occasion, however she rated an average of 5/10 or less. In that week she was administered acetaminophen on seven occasions, flexeril on one occasion, and Tramadol on seven occasions. A progress note dated 8/4/21 at 12:36 p.m. from a Medicare meeting documented Resident #17 rated her pain as high as 9/10 during that week on one occasion, however she rated an average of 6/10 or less. In that week she was administered acetaminophen on four occasions, flexeril on three occasions, and tramadol on eight occasions. Physical therapy (PT) decreased ambulation with the resident to assist in improving pain. V. Staff interviews Registered nurse (RN) #2 was interviewed 8/9/21 at 8:17 p.m. The RN stated that Resident #17 had hip pain from a fracture and usually requested Tramadol once a shift which seemed to control her pain. The RN stated that the resident had not complained of pain during that shift. Certified nurse aide (CNA) #4 was interviewed on 8/11/21 at 3:22 p.m. The CNA stated that if pain was mentioned to him from any resident that his process was to inform the nurse on duty. He did not recall any specific incidents of Resident #17 having uncontrolled pain. The director of nursing (DON) was interviewed on 8/12/21 at 6:37 p.m. She said she was not aware of the order stating the progress note for pain above a zero level was physician ordered, however she would look into it.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to provide behavioral health services for one (#21) of five residents reviewed for behaviors out of 39 sample residents. Specifically, the facility failed to behavioral health services to Resident #21 to address his severe post-traumatic stress disorder (PTSD). Findings include: I. Facility policy and procedures The Trauma Informed Care: Understanding and Intervening for Potential Behavioral Challenges policy, provided by the health information manager (HIM) on 8/18/21 at 3:44 p.m., was undated. It documented it was the policy of the nursing facility to provide an environment as free of accident hazards as is practicable and to provide each resident adequate supervision and assistance devices to prevent accidents. It documented risk factors to consider included factors such as mental health diagnosis, isolation and life circumstances. It addressed how to intervene with resident's behaviors by detecting and connecting with the resident, considerations related to escalating behaviors, communication and addressing resident's emotional needs. It documented, Lack of awareness and understanding trauma increases the risk of doing additional harm. Individuals' trauma results from an event, series of events or set of circumstances that is experienced by an individual as physically or emotionally harmful or life threatening and that has lasting adverse effects on the individual's functioning and mental, physical, social, emotional or spiritual well-being. -The director of nursing (DON) stated via telephone on 8/18/21 at 3:57 p.m., the facility did not have an actual policy related to behavioral health because their facility was not classified as a behavioral health facility. II. Resident #21 A. Resident status Resident #21, age [AGE], was admitted on [DATE]. According to the August 2021 computerized physician's orders (CPO), the resident's primary diagnosis was unspecified dementia without behavioral disturbance. His secondary diagnosis was post-traumatic stress disorder (PTSD), chronic. Additional diagnoses included alcohol abuse, major depressive disorder, cannabis abuse, generalized anxiety disorder and legal blindness. The 6/2/21 minimum data set (MDS) assessment revealed the resident was moderately cognitively impaired with a brief interview for mental status (BIMS) score of nine out of 15. It documented the resident used a cane for ambulation and required supervision of one for his ambulating. The MDS documented Resident #21 displayed no physical or verbal behaviors towards others, as well as no behaviors not directed towards others. He displayed no rejection of cares and no wandering. B. Incident 7/13/21 Resident #21 was involved in an incident of resident to resident abuse the morning of 7/31/21. The facility's abuse investigation disclosed Resident #21 pushed a female resident (Resident #32) in the facility's secured memory care unit (MCU) the morning of 7/31/21. Resident #32 had pulled the Velcro stop sign off Resident #21's room and Resident #21 opened the door to his room and roughly shoved Resident #32 away (Cross-reference to F600 for abuse). C. Record review 1. Physician orders The August 2021 computerized physician's order (CPO) documented the resident was receiving Sertraline (an antidepressant) for his depression and Ativan (an anti-anxiety medication) for his generalized anxiety and PTSD. 2. Care plan As of 8/16/21 at 3:30 p.m., the facility did not provide a care plan for Resident #21 related to his post-traumatic stress disorder or the resident to resident abuse allegation. 3. Social service history data collection The social service history data collection form dated 3/17/21, completed 13 days after the resident was admitted , documented Resident #21 lived alone prior to placement in the facility. It documented the resident preferred being alone. It documented leaving him alone helped get him through difficult times. It documented drinking and smoking were calming and relaxing to the resident and he found those coping mechanisms helpful. This form was signed by the program director (PD) of the MCU unit on 3/30/21, or 26 days after the resident was admitted . D. Resident observations Resident #32 was initially observed on 8/9/21 at 7:09 p.m. He resided in the facility's MCU. He had opened his closed bedroom door, looked out into the common area and stood in place for a short time. There was a Velcro stop sign across his room. The resident had a straight cane in his hand and just walked out of his room by ducking down under the stop sign rather than removing the stop sign. He came out to the common area and calmly sat down in a brown recliner which was near his room and away from the main couch and other chairs in the MCU common area. The resident was soft spoken and did not have behaviors at this time. On 8/10/21 at 8:33 a.m. He was again seated in a brown recliner near his room and eating his breakfast off a television tray next to his chair. He said his breakfast was good and he got enough to eat. Shortly after this interaction, the resident went back into his room, replaced the stop sign and shut the door. -At 10:32 a.m., the resident remained in his room. -At 10:55 a.m., the program director (PD) of the MCU entered his room to speak to the resident and check on him. -At 12:31 p.m., Resident #32 was eating by himself at the lunch counter. He was quietly sitting alone and eating his meal, wiping his mouth with his cloth napkin. -At 2:46 p.m. the resident was observed sitting by himself in the common area recliner, drinking coffee. He was not observed interacting with anyone at this time. Resident #32 was observed on 8/11/21 at 8:17 a.m. He was seated by himself in his brown recliner in the common area. He had drinks in front of him on a rolling table and had just finished breakfast. He said he had eaten and slept well the night prior. He was calm and polite when speaking. -At 10:42 a.m., the resident was observed napping with his eyes closed in his recliner in the common area. He had his straight cane in his hand. -At 4:54 p.m., the resident was observed in his recliner, watching the balloon ball game and was still holding onto his cane. III. PASRR (pre-admission screen, resident review) findings The PASRR Level II dated 5/3/21 was provided by the social services director (SSD) on 8/11/21 at 12:10 p.m. It documented the resident was admitted on [DATE] for rehabilitation less than 60 days. It documented Resident #21 received psychotropic medication for PTSD, depression and anxiety. It documented the resident was prescribed Sertraline (an antidepressant), 25 mg QD (every day) and Ativan (an anti-anxiety), 0.5 mg Q (every) 6 hours prn (as needed). It documented the resident could be aggressive with other residents and yells and slams his doors at noises. During the Behavioral and Functional Impacts in Past 3-6 Months section, it documented Resident #21 was sent to the memory care locked unit when he first admitted to the facility. It documented other residents would wander in his room at times, and (Resident #21's name) would attack them, even tackling a resident on one occasion. It documented the facility moved him to a hallway with the social worker and few residents. It documented, at times, the noises in the facility could be loud and Resident #21 had no tolerance for this and would yell down the hallway and slam his door. It documented he could be verbally aggressive and tended to isolate in his room. Under the Behavioral Health and Support Services section, it documented the resident had an approximately two month psychiatric hospitalization in Miami, Florida in 1966. It documented no behavioral health and support services were being provided to Resident #21 at this time. The current behavioral symptoms of this Level II screen documented the following chronic behaviors: - Physical aggression on a monthly basis; -Verbal aggression on a daily basis; -Reclusiveness on a daily basis; and, -Hopelessness on a daily basis. The Level II screen documented all four above behavioral symptoms were severe under the severity level. Additional comments about the above behavioral symptoms documented, (Resident #21's name) has attacked other residents who wandered into his room. He is verbally abusive when there are loud noises. He tends to perseverate on being in the Navy constantly. He has a wish to die without a suicidal plan or intent at this time. He had more distinct suicidal ideation at admission, but this had improved. This Level II screen documented Resident #21's primary diagnosis was PTSD. The other two psychiatric diagnoses included unspecified neurocognitive disorder and major depression. It documented the Veterans Administration Medical Center had been supportive to the resident medically and years ago, with mental health, and the facility had made a referral for mental health services for Resident #21. The Stressor section documented that noise really bothered the resident and staff should work hard to minimize noise on his end of the hallway. It documented that people in his room bothered him and staff should move him away from other residents and from the memory care unit to minimize people wandering in his room. The Level II screen summary documented he continues to have a severe cognitive and functional decline with behavioral problems, including verbal and physical aggression and the facility had diagnosed him with dementia. It documented this was probably due to his presentation in this interview and a recent BIMS score of 1. He does have sadness and feels that he has been sad for the past five years, as his physical health and functional level have been declining. He demonstrates helplessness and hopelessness, anhedonia, sadness, isolation, anger, anxiety, and a wish to die, although suicidal ideation is denied at this time. Treatment for depression is recommended. It documented the resident was also struggling with constant memories of his (self-reported) four tours to Vietnam, spoke of this constantly and stated he saw horrible atrocities in combat. The resident said he had multiple hospitalizations after leaving the Navy, which he said was for mental health reasons. It documented the resident met the criteria for PTSD, which may be the cause of his noise sensitivity and violence to other residents who wander in his room. PTSD can be made worse by the onset of dementia, as the focus of cognition can shift to more remote memories. In addition, (Resident #21's name) is sober for the first time in many, many years, which also may be worsening his traumatic memories that he previously blocked out with drugs and alcohol. This Level II screen recommended the specialized service of individual therapy. -However, Resident #21 was not receiving any type of therapy as of 8/12/21. IV. Staff training documentation The MCU training, provided by the PD of that unit the afternoon of 8/11/21, documented that all memory care staff completed some validation training on 3/15/21. This documentation did not include the duration of the training, but the topics included always using open-ended questions with the residents, the importance of not arguing with residents and accepting residents the way they were and not trying to change them. She also provided documentation that 19 staff completed a two-hour training on trauma-informed care on 11/6/19. She provided documentation that facility staff completed computer based trauma-informed care sometime during 2020. The documentation did not include the duration of that training. V. Staff interviews The SSD was interviewed on 8/11/21 at 11:46 a.m. She said Resident #21's PASRR Level II was the first one the facility completed under the new PASRR system. She said some residents were no longer deemed appropriate for specialized services under the new PASRR system. -However, that Resident #21 was recommended for individual therapy under specialized services, refer to PASRR Level II dated 5/3/21 (above). She stated the primary diagnosis documented in the Level II screen dated 5/3/21 was severe PTSD. She stated the facility's primary diagnosis was dementia. The PD of the MCU and the SSD were interviewed together on 8/11/21 at 1:35 p.m. The PD said Resident #21's primary diagnosis was PTSD. The SSD said the dementia was also increasing this resident's fight or flight feelings due to his loss of impulse control. The PD said Resident #21 was not receiving any psychiatric services through the VA Medical Center (VAMC). She said they looked into services through the local VA clinic, but that clinician's caseload was too busy to accommodate the resident. The PD said they attempted one Zoom meeting with the VAMC located 60 miles away, but the resident refused to participate in that Zoom meeting. The date of this Zoom meeting was not specified. The PD said this was the one case that she and the SSD had really struggled with. The SSD said the lack of behavioral health services in their community, plus Resident #21 also having a diagnosis of dementia, limited the facility in acquiring behavioral/mental health services for this resident. The SSD said Resident #21 really did not fit in with the facility's secured memory care unit. The PD and SSD said they had reached out to the VAMC and to Resident #21's guardian, who was court appointed from a justice center in the larger town 60 miles away. They said they would be discussing alternative placement with the resident's guardian.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interviews, the facility failed to ensure two (#32, and #7) of five residents reviewed for dementia care of 39 sample residents, received the appropriate treatment and services to maintain their highest practicable physical, mental and psychosocial well-being. Specifically, the facility failed to: -Ensure Resident #32 received adequate supervision and dementia care services to prevent the resident from attempting to enter another resident's room without permission, resulting in a resident to resident altercation involving physical abuse with the potential for harm; (cross-reference F600) and, -Provide adequate staff monitoring and dementia care services to Resident #7 during a bingo activity, resulting in resident to resident verbal and physical abuse. Findings include: I. Facility policy and procedure The Guidelines for Memory Support Programs and Services, provided by the program director (PD) of the facility's secured memory care unit (MCU) on 8/12/21, was revised February 2016. It documented the facility operated under a person-centered model, with emphasis on the whole person. It documented that the model recognized that all persons have physical, social, emotional, intellectual, occupation and spiritual needs, regardless of their level of cognitive function. The memory support program and services would meet the needs of persons with dementia in a safe, nurturing environment in which the program is determined by the needs of the resident. It documented programming was flexible and responsive to meeting changing needs. The policy documented staff was instructed on the philosophy of care that shaped policies and practices. II. Resident #32 A. Resident status Resident #32, age [AGE], was admitted on [DATE]. According to the August 2021 computerized physician orders (CPO), diagnoses included unspecified dementia with behavioral disturbance, hallucinations, hypertension and diabetes mellitus. The 6/11/21 minimum data set (MDS) assessment revealed the resident was severely cognitively impaired with both short-term and long-term memory deficits. There was no brief interview for mental status (BIMS) score completed on this MDS. The resident required supervision of two or more staff for ambulation and the resident did not require an assistive device to ambulate. The MDS documented the resident displayed physical behaviors during four to six days of the seven day lookback period. She displayed verbal behaviors during one to three days. She displayed other behaviors not directed towards others during one to three days. It documented Resident #32's behaviors put the resident at significant risk for physical injury, significantly interfered with her care and significantly interfered with other resident's participation in activities or social interactions. The MDS documented Resident #32's behaviors put others at significant risk for physical injury, significantly intruded on the privacy or activities of others and significantly disrupted care or the resident's living environment. The MDS documented Resident #32 rejected cares during four to six days of the seven day lookback period, wandered during four to six days and this wandering significantly intruded on the privileges of other residents. B. Resident observations Resident #32 was observed on 8/9/21 at 8:13 a.m. She was lying in bed in a darkened room. She had a private room on the memory care unit (MCU) and her eyes were closed. She had been up earlier for breakfast, but was not engaged with anyone at this time. The resident was observed on 8/10/21 at 8:41 a.m. She was seated in the MCU common area on the couch, with her hand to her forehead. A few minutes later, her eyes were closed. There was a video about funny animals on the television in that area. She was not interacting with any other residents or any staff at this time. -At 10:29 a.m., the resident was seated by herself on a bench in the MCU hallway. She did not speak when spoken to and just turned her head away. She was not interacting with anyone at this time. -At 10:36 a.m., the resident was pacing around the unit without supervision or redirection. She was observed trying door handles of several residents rooms and tried to get into the nurse's office on the MCU. -At 10:43 a.m., after 14 minutes of trying to enter various rooms, a CNA began monitoring the resident and offered her some water at this time. -At 12:37 p.m., the resident was lying down on her bed after wandering and pacing the MCU most of the morning, per facility staff. The PD of the MCU said she would probably be up again in 30 to 60 minutes. -At 2:45 p.m., the resident was seated on her bed, taking off her shoes. Resident #32 was observed on 8/11/21 at 8:22 a.m. She was walking down the hall with certified nurse aide (CNA) #6. The resident was barefoot and her hair was disheveled. -At 10:39 a.m., the resident was seated by herself on a bench in the hallway of the memory care unit (MCU). Her hair remained disheveled and she was still barefoot. No staff were observing or monitoring the resident at this time. A few minutes later, the resident got up and began wandering down the hall. She was observed entering a few residents' rooms, but exited a short time later, as most of the other residents were involved in a balloon batting activity at this time. -At 10:51 a.m., the resident stood up and began looking for something on the lunch counter. The resident went to the nurse's office and tried to get into that area. CNA was able to redirect the resident away from the area and the resident took off down the hall with the CNA closely behind her. Resident #32 was wandering and agitated at this time. There were no observations of any staff encouraging this resident to put back on appropriate footwear the entire morning. -At 4:43 p.m., the resident was in her room while another balloon ball game was being conducted in the MCU common area. She was rummaging through the dresser drawers. C. Record review The care plan dated 6/7/21 related to cognitive loss documented Resident #32 displayed inappropriate motor responses, such as hitting and yelling; dementia; short-term and long-term memory deficits; inappropriate social interactions, impaired judgement and delusional and depressive features. Interventions included observing the resident for increased confusion and disorientation daily, as well as observing the resident for unsafe behaviors. The care plan dated 6/7/21 related to dementia documented interventions of approaching the resident in a calm, slow manner, giving medications as ordered and providing activities/recreation of the resident's choice. The care plan dated 6/7/21 related to behavior documented escalation of Resident #32's behaviors included: Rummaging in other things and space, exit seeking, intruding in other's space, rejection by others and disruption of groups and her roommate. Interventions included having this resident wander only within specified boundaries and observing this resident closely when she was awake. Additional interventions including offering sweet treats and drinks, taking the resident outside for a walk or redirecting this resident out of other's space (including the room of Resident #21). The facility did not have a dementia care plan that included 1:1 staffing when the resident was actively wandering. The August 2021 CPO documented Resident #32 was prescribed the following medications: -Seroquel (an anti-psychotic medication), 75 mg BID (twice a day) for hallucinations, dementia behaviors and psychosis. This medication was increased to this dosage on 7/12/21. -Ativan (an anti-anxiety medication), 0.25 mg Q 4 hours prn (as needed) and Ativan, 0.5 mg Q 4 hours prn for anxiety. This was ordered on 7/13/21. The July and August medication administration records (MARs) were reviewed. The July MAR documented the resident received 0.25 mg of Ativan on 7/13/21, 7/16/21 and 7/23/21. She received 0.5 mg twice on 7/15/21, 7/16/21, twice on 7/18/21, 7/19/21, 7/20/21, 7/21/21, 7/22/21, twice on 7/23/21, twice on 7/25/21, 7/29/21 and 7/30/21. The August MAR documented Resident #32 received 0.5 mg of Ativan on 8/1/21. The July and August 2021 treatment administration records (TARs) were reviewed. The facility was monitoring several behaviors this resident exhibited, which included continued pacing, space invading and danger to self and others. These TARs documented multiple behaviors exhibited on an almost daily basis. The facility's progress notes were reviewed from 7/5/21 through 8/2/21 and the following were examples of those progress notes: The progress notes dated 7/5/21, 7/6/21, 7/7/21, 7/12/21, 7/13/21, 7/14/21, 7/17/21, 7/18/21, 7/19/21, 7/20/21, 7/21/21, 7/26/21, 7/27/21, 7/31/21, 8/1/21, 8/2/21 and 8/4/21 all documented essentially the same thing, Resident wandering in other resident's rooms. Rummaging, trying to take food and drink from other resident's plates. Resistive and combative with cares, punching staff, yelling loudly, unable to redirect. There was an additional progress note dated 7/31/21 at 10:15 a.m. which documented, (Resident #21's name) was sitting in his room at the doorway with the door closed and the stop sign on. He heard the resident (Resident #32) pull off his stop sign off and he opened the door and pushed her. The activity person caught her before she fell. No complaints of pain or injury noted. There was nothing in this progress note documenting interventions the staff would put into place to redirect Resident #32 from continuing to enter other resident's rooms. At 1:00 p.m., the facility documented, (Resident #32) wandering in other resident's rooms, getting in their personal space, rummaging, trying to take food and drinks from other resident's plates, resistive, yelling loudly, unable to redirect. The QA (quality assurance) Medication Regimen/Gradual Dose Reduction (GDR) Committee Review dated 6/29/21 documented Resident #32 was prescribed Seroquel, 25 mg BID on 6/15/21. It documented this dose was increased on this date to 50 mg BID, per pharmacist recommendation. D. Staff interviews The certified nurse aide (CNA) #8 was interviewed on 8/11/21 at 8:22 a.m. She said Resident #21 was less combative now than when she was first admitted to the facility. She said the resident's medications had been increased a few months prior. Licensed practical nurse (LPN) #5 was interviewed on 8/11/21 at 10:58 a.m. She said she felt Resident #32 was doing well and explained the resident was care planned for close monitoring. She said the resident's diagnoses included paranoia, psychosis and dementia, which was pretty severe. She said staff have to keep an eye on her because she's in a different world. She said the resident would call out for her deceased family members and wants to go home. She said the resident conversed in word salad at times, but was able to make her wants and needs known. She said this resident often tried to go into other resident's rooms as she continuously wandered and was exit-seeking. She said this resident was too restless to participate in activities, but was not really invited to activities since COVID-19 because Resident #32 was not vaccinated. She said the resident would passively observe activity groups before COVID-19 hit and the new restrictions were in place. She said sometimes the resident would wear appropriate footwear and sometimes she would throw them across the room or hide them. The PD of the MCU and the social services director (SSD) were interviewed together on 8/11/21 at 1:35 p.m. The PD stated Resident #21 was the one resident she and the SSD had really tried to work with, but was not always successful. The SSD said the lack of behavioral health treatment centers in their community, along with the resident's diagnosis of severe dementia made this resident difficult to manage and redirect all the time. III. Resident #7 A. Resident status Resident #7, age [AGE], was admitted on [DATE]. According to the August 2021 CPO, diagnoses included Alzheimer's disease with late onset, dementia with behavioral disturbance and major depression. According to the 5/19//21 MDS assessment, she had severe cognitive impairment with a BIMS score of six of 15. She exhibited disorganized thinking; delusions; felt down, depressed and hopeless; and had behavioral symptoms not directed toward others. She required extensive assistance with most ADLs. B. Abuse incident on 7/3/21 Review of facility investigations revealed a witnessed incident on 7/3/21 during a group activity where Resident #7 and Resident #57 exchanged words. Resident #57 hit Resident #7 on the shoulder with the back of his hand. (Cross-reference F600, abuse.) C. Record review 1. Care plans Resident #7's care plan, initiated 1/4/19, identified vulnerability related to impaired cognition, behaviors, altered moods, using a wheel chair for mobility and needing assistance with cares. Interventions included: remove from potentially abusive situations, observe for and implement interventions to minimize and prevent re-occurrence; provide safe environment and ensure safety of others; if issues are noted, evaluate for possible causative factors; observe for potential pain, discomfort and mental anguish; incidents to be reviewed at IDT meeting; and refer to cognitive loss, behavioral, falls, and mood/psychosocial care plans. Resident #7's behavior care plan, initiated 10/7/19, identified being short tempered, yelling/screaming, abusive/racist language, physically aggressive towards staff and entering others rooms. The goal was respond positively to interventions. Interventions included Avoid seating resident near (Resident #57) to avoid altercation while in activities or in the dining room. -This intervention was not written until 8/12/21, during the survey. Other interventions included: approach in a calm manner, document behaviors and resident response, encourage resident to verbalize through one-on-one interaction, explain all procedures before starting and allow time to adjust to changes, if reasonable discuss behavior, explain why behavior is inappropriate and/or unacceptable, provide emotional support, and discuss resident's options for appropriate channeling of anger with resident. The cognitive loss care plan, initiated 8/26/2020, identified diagnoses of Alzheimer's disease and dementia, a fluctuating BIMS score from moderate to severe cognitive impairment and significant memory loss. Interventions included: communicate with resident at eye level when able, explain procedures prior to beginning, give one instruction at a time, give simple choices that will not be overwhelming, observe for and report changes in cognitive status, offer simple choices, provide verbal reminders, speak simply and repeat as needed, use unhurried speech, and validate feelings and issues where appropriate. The other care plan sections included similar information to the above. 2. Interdisciplinary team (IDT) notes Review of the resident's medical record for the past year revealed the resident exhibited behavioral symptoms that affected herself and others throughout the day and night, which had been ongoing since 9/13/2020. Specifically, IDT notes revealed the following in pertinent part: -9/13/2020 at 1:32 p.m., Res yelling out 'HELP,' when staff went to check on her she stated 'who is killing all the birds?' Staff asked follow up questions, reassured resident that no one was killing birds. -9/18/2020 at 3:43 a.m., calling every 5 min for 1.5 hrs in middle of night, yelling hey hey, come here, both while call light was on and before. Resident called multiple times to have head rolled up, head rolled down, pillow fluffed, window opened, window closed, pick tissue box off floor, and throw away, get new tissue box, hand her Chapstick, give her drink of water, adjust shades, etc. Verbalized it was the middle of the night and everyone was sleeping, and reminded resident that we would answer her call light as soon as possible, resident continued to push call light frequently for another 30 min before falling asleep. -9/22/2020 at 5:06 a.m., extremely rude to aides. Insulting to (staff name) for her ethnicity. Cussing at (staff name). She has been yelling up and down the hallways, right after she pushes her call light. -10/18/2020 at 2:11 a.m., ringing her call light constantly since getting up to the bathroom. Resident has been rude toward both CNAs while they were taking care of resident's roommate. -10/30/2020 at 10:25 p.m., verbally abusive to CNA calling her 'dumb'. On the call light 30+ times this shift at times stating 'I don't know what I want.' Try to appoint another CNA in room. -11/6/2020 at 2:08 a.m., yelling at CNA, telling staff to shut the hell up and don't treat me that way. -12/6/2020 at 4:02 p.m., banging cup on her table and yelling out. Call light is on and resident is yelling and yelling. Resident has pushed her call light 20 times in last 2 hours. Angry and cursing at staff. -12/11/2020 at 11:49 a.m., nurse answers call light and roommate had put it on for assist to her bed. (Resident #7) yelling and pounding her cup on the table, yelled at this nurse (expletives). (Resident #7) then yelled at the roommate that it is not time to lie down. Roommate is quiet and not saying anything back. (Resident #7) called her roommate a 'fat cow' and continued to yell about the lazy staff. Ask activities to speak with resident. -There was no documentation regarding how the staff protected the resident's roommate from Resident #7's verbal abuse. -12/15/2020 at 3:57 a.m., pushing her call light every 5 minutes or less. X3 this shift resident pushed call light within one minute of this nurse exiting room. The last three times resident has called was to request staff fluff pillow, increase HOB (head of bed), and move/adjust bedside table. All of these things resident is able to do for herself. If call light is not answered within one minute of resident turning it on, resident begins to scream and yell 'hello' and help.' Nurse told resident she was keeping other residents up with her constant yelling ,resident replied, 'I don't give a damn who I keep up I need help and I don't care.' Nurse to fax dr. r/t (related to) increased behaviors. -2/20/21 at 4:19 p.m., has been yelling every one to two minutes since start of shift except when in bingo. Resident has various needs, from moving flowers to adjusting blinds, to more Kleenex. If staff does not respond immediately, this resident asks roommate to go to door and yell. -2/21/21 at 1:45 p.m., yelling out constantly, agitated with staff, calling them names. -2/24/21 at 8:36 p.m., continues to yell throughout the shift, able to remember needs at times, other times states she can't remember what she wanted. Resident has physician appointment on Monday per scheduling. (Although physician progress notes were requested for the previous year, no progress notes were provided for this time period, and there was no evidence of new physician orders or consults.) -3/8/21 at 6:30 p.m., yelling at roommate stating she was unsafe and needed to listen to her. This writer asked resident to please lower her voice and that roommate heard her. Resident then began increasing yelling at staff. -3/8/21 at 7:00 p.m. resident's roommate was moved to another room. This resident came out of her room 'looking for her roommate and bringing her back.' Advised resident that it is not okay to go after the roommate. Roommate moved per her choice. Resident began yelling at this writer that I could not keep her from her roommate. Redirected resident to her room, spoke with her about the situation. Resident calmed and apologized. (There was no documentation to show why the facility waited so long to relocate Resident #7's roommate despite the yelling and verbal abuse directed toward the roommate and staff, which the roommate had endured for several months.) -3/27/21 at 9:46 p.m., became agitated this evening when she put on her call light, expected immediate response. Came out of her room down the hall and attempted to enter another resident's room where the CNAs were doing a 2 person assist transfer. This nurse assisted resident back to her room and toileted her. When the CNA went to answer her call light a little while later, she hit the CNA for no known reason, then denied it and stated the aide was lying. -4/5/21 at 3:24 a.m., yelling loudly 'help me, help me' at (3:00 a.m.). Another resident began repeating this resident. CNA entered resident room and resident yelled at CNA for forgetting to charge cordless phone, causing it to beep. -Similar behaviors were documented on the following dates and times: 4/13/21 at 7:36 p.m., 4/13/21 at 8:42 p.m., 4/17/21 at 9:23 p.m., 4/19/21 at 1:51 p.m., 4/19/21 at 9:23 p.m., 5/5/21 at 10:32 p.m., 5/10/21 at 3:42 p.m., 5/10/21 at 10:45 p.m., 5/17/21 at 10:26 p.m., 5/18/21 at 4:23 p.m., 5/29/21 at 9:24 p.m., 6/2/21 at 2:32 p.m., 6/6/21 at 2:02 p.m., 6/7/21 at 10:03 p.m., 6/21/21 at 10:49 p.m., and 7/4/21 at 9:50 a.m. -On 7/4/21 at 9:50 a.m. Resident #7 was yelling in the dining room, wheeling herself in wheelchair yelling at another resident in front to 'hurry the hell up.' Resident is pushing the other w/c with hers. She calls the other resident ' you son of a bitch.' Resident is instigating the others in the activity room by yelling and making rude comments. She gets angry and verbally aggressive when asked to stop. Resident pushed at the activity aide and shoved her hands when trying to place the bingo pieces on the table. Resident separated from other residents. -On 7/10/21 at 10:51 a.m., resident yelled at another resident 'Can't you move' when the other resident replied he could not (Resident #7) stated 'you are too goddamn fat that's why.' Removed resident to another area for a visit. -The resident's yelling behaviors at staff, which were undoubtedly disturbing to other residents, were further documented on 7/17/21 at 9:30 p.m., cursing/name calling staff on 7/20/21 at 8:47 p.m., yelling on 7/26/21 at 9:29 p.m., 8/5/21 at 9:39 p.m. yelling at staff and resumes yelling after call light answered; and 8/7/21 at 9:42 p.m. yelling and banging remote on bedside table. Resdient #7's roommate was Resident #47 The facility did not document the continuous interventions attempted after the resident's behaviors. There were no documented attempts at resolutions each time the resident exhibited behavioral symptoms that affected others. 3. Physician progress notes On 7/13/21 the physician documented in pertinent part: -Stop Abilify (antidepressant) tablet, 2 mg, 1 tablet at bedtime, orally, once a day. -Start Seroquel (antipsychotic) tablet, 25 mg, 1 tablet, orally, twice a day, 30 days, 60 tablet, refills 11. Patient does demonstrate behavioral disturbance that is a threat to self or others. She agrees that her filter is gone. Her nature is to be outspoken. However, in her current medical state the outspokenness has led to altercations that pose a danger to herself. She is agreeable to modifying her current Abilify regimen to use an antipsychotic that may be more beneficial to lower her anxiety levels and improving inhibition. We will follow up in 2-3 weeks to ensure a safe transition. We will monitor for worsening mood and oversedation. I have asked that the family stay closely involved as they are a good window into the behavioral concerns. Of note, I have received no behavioral notes from (the facility). 4. Current physician orders and medication administration Review of the August 2021 medication administration record (MAR) revealed the following pertinent medications: -Clonazepam (anticonvulsant) tablet 0.5 mg in the evening related to restless legs syndrome, ordered 3/5/21 -Desveniafaxine Succinate ER tablet Extended Release 24 hour (antidepressant) 50 mg, one tablet daily related to major depressive disorder, ordered 12/5/18 -Trazodone HCI tablet (antidepressant and sedative) 50 mg, give 75 mg by mouth at bedtime for insomnia, ordered 3/1/21 -Seroquel tablet (antipsychotic) 25 mg, give 25 mg twice daily for dementia with behavioral disturbance, ordered 7/13/21, discontinued 7/20/21 -Seroquel tablet 25 mg twice daily for dementia with behavioral disturbance, notify of side effects or worsening behaviors, ordered 7/20/21, discontinued 8/3/21 5. Dementia care training Although the facility provided evidence of general dementia care training for staff, there was no documentation of physician notification when the resident's behavioral symptoms were not addressed and affected the well-being of Resident #7 and other residents in the facility. Further, there was no evidence of dementia care training specifically related to Resident #7's ongoing behavioral symptoms, which led her to abuse her roommate (Resident #47) and other residents on numerous occasions, and be victimized by abuse herself during an activity on 7/3/21. The resident's behaviors were not documented as improved by the above listed medications. D. Staff interview The NHA and DON were interviewed on 8/12/21 at 8:15 p.m. They said it was impossible to predict what residents were going to do or say. They said they wanted to help residents but it put the facility at risk to be cited when a resident unpredictably abused another resident. They acknowledged residents had the right to be free from abuse.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review, the facility failed to ensure five (#21, #32, #57, #7, and #47) of five residents reviewed for abuse out of 39 residents were kept free from abuse. Specifically, the facility failed to: -Provide adequate staff monitoring and dementia care services to Resident #32 to ensure she did not wander and attempt to enter Resident #21's room uninvited; -Address Resident #21's behavioral health needs to prevent this resident from pushing Resident #32 when she tried to enter his room, resulting in resident to resident physical abuse with potential for harm; -Provide adequate staff monitoring and dementia care services to Residents #57 and #7 during a bingo activity, resulting in resident to resident verbal and physical abuse; and, -Resident #7 verbal abuse to her roommate (Resident #47) Cross-reference F740, behavioral health services; F744, treatment and services for dementia; and F725, sufficient nursing staff. Findings include: I. Facility policy and procedure The Resident/Client/Participant Protection/Freedom from Abuse, Neglect and Misappropriation policy and procedure, revised January 2021, was provided by the western regional nurse consultant (WRNC) the afternoon of 8/10/21. It documented the policy was created to establish and enforce written policies and procedures related to suspected or alleged maltreatment. It documented, in the event of suspected maltreatment, the needs of the resident would be immediately assessed and the safety of the resident would be ensured. It documented physical abuse included hitting, slapping, kicking, pinching, biting or corporal punishment of a vulnerable adult. II. Resident #32 and 21 A. Resident #32 1.Resdient status Resident #32, age [AGE], was admitted on [DATE]. According to the August 2021 computerized physician orders (CPO), diagnoses included unspecified dementia with behavioral disturbance, hallucinations, hypertension and diabetes mellitus. The 6/11/21 minimum data set (MDS) assessment revealed the resident was severely cognitively impaired with both short-term and long-term memory deficits. There was no brief interview for mental status (BIMS) score completed on this MDS. The resident required supervision of two or more staff for ambulation and the resident did not require an assistive device to ambulate. The MDS documented the resident displayed physical behaviors during four to six days of the seven day lookback period. She displayed verbal behaviors during one to three days. She displayed other behaviors not directed towards others during one to three days. It documented Resident #32's behaviors put the resident at significant risk for physical injury, significantly interfered with her care and significantly interfered with other resident's participation in activities or social interactions. The MDS documented Resident #32's behaviors put others at significant risk for physical injury, significantly intruded on the privacy or activities of others and significantly disrupted care or the resident's living environment. The MDS documented Resident #32 rejected cares during four to six days of the seven day lookback period, wandered during four to six days and this wandering significantly intruded on the privileges of other residents. 2. Record review The care plan dated 6/7/21 related to cognitive loss documented Resident #32 displayed inappropriate motor responses, such as hitting and yelling; dementia; short-term and long-term memory deficits; inappropriate social interactions, impaired judgement and delusional and depressive features. Interventions included observing the resident for increased confusion and disorientation daily, as well as observing the resident for unsafe behaviors. The care plan dated 6/7/21 related to dementia documented interventions of approaching the resident in a calm, slow manner, giving medications as ordered and providing activities and recreation of the Resident #32's choice. The care plan dated 6/7/21 related to behavior documented escalation of Resident #32's behaviors included: Rummaging in other things and space, exit seeking, intruding in other's space, rejection by others and disruption of groups and her roommate. Interventions included having this resident wander only within specified boundaries and observing this resident closely when she was awake. Additional interventions including offering sweet treats and drinks, taking the resident outside for a walk or redirecting this resident out of other's space (including the room of Resident #21). The August 2021 CPO documented Resident #32 was prescribed the following medications: -Seroquel (an anti-psychotic medication), 75 mg BID (twice a day) for hallucinations, dementia behaviors and psychosis. This medication was increased to this dosage on 7/12/21. -Ativan (an anti-anxiety medication), 0.25 mg Q 4 hours prn (as needed) and Ativan, 0.5 mg Q (every) 4 hours prn for anxiety. This was ordered on 7/13/21. B. Resident #21 1. Resident status Resident #21, age [AGE], was admitted on [DATE]. According to the August 2021 CPO, the resident's primary diagnosis was unspecified dementia without behavioral disturbance. His secondary diagnosis was post-traumatic stress disorder (PTSD), chronic. Additional diagnoses included alcohol abuse, major depressive disorder, cannabis abuse, generalized anxiety disorder and legal blindness. The 6/2/21 MDS revealed the resident was moderately cognitively impaired with a BIMS score of nine out of 15. It documented the resident used a cane for ambulation and required supervision of one for his ambulating. The MDS documented Resident #21 displayed no physical or verbal behaviors towards others, as well as no behaviors not directed towards others. He displayed no rejection of cares and no wandering. 2. Record review The August 2021 CPO documented the resident was receiving sertraline (an anti-depressant) for his depression and ativan (an anti-anxiety medication) for his generalized anxiety and PTSD. As of 8/16/21 at 3:30 p.m., the facility did not provide a care plan for Resident #21 related to his post-traumatic stress disorder or the resident to resident abuse allegation. C. Initial facility investigation The facility's initial abuse investigation related to the resident to resident abuse between Resident #32 and Resident #21 was provided by the WRNC the morning of 8/11/21. The investigation documented a physical abuse investigation was filed on the state portal related to a resident to resident abuse between Resident #32 and Resident #21. This incident was reported to the State Agency on 7/31/21 at 11:18 a.m. by the social services director (SSD). This physical abuse occurred in the facility's secured memory care unit (MCU) on 7/31/21 at 10:15 a.m. The facility's abuse investigation documented Resident #32 wandered to the bedroom door of Resident #21. Resident #32 removed the mesh stop sign that was across the closed bedroom door of Resident #21. Resident #21, who was seated in a chair immediately inside his bedroom door, heard the Velcro of the stop sign being removed. He immediately opened his door, while simultaneously yelling at Resident #32 to get away and pushing Resident #32 away from his room. The facility documented both residents were interviewed, Resident #32 was assessed for injury and witness statements from four staff members were obtained. The facility investigation documented that staff immediately separated both residents. It documented the mesh stop sign was replaced on Resident #21's door and increased monitoring was conducted for Resident #32. It documented neither resident was injured during this resident-to-resident physical abuse. It documented both residents were assessed for causative factors and interventions were put into place for both residents. The investigation documented Resident #32's care plan was updated to include increased monitoring while the resident was up and around. It documented Resident #21's care plan was updated with the following interventions: Continue with stop sign on door, highly encourage resident to come to all meals and highly encourage resident to come to therapeutic recreation and observe in the library, highly encourage resident to not block or barricade the door and resident's computer chair was removed from the resident's room. It documented the victim, Resident #32, was unable to recall the incident and reported no pain. It documented Resident #32 did not sustain any bruising or markings from the altercation and no treatment was needed. It documented no behavioral or mood changes with Resident #32. It documented the assailant, Resident #21, expressed no fear nor intent to harm Resident #32. The investigation documented Resident #32 was reactive, thinking someone was going to come into his space. The investigation documented one on one validation was provided to Resident #21 by staff until this resident had calmed down. The investigation documented, The results of the documentation is that while the altercation did happen, per guidelines, physical abuse is not substantiated. No fear or harm occurred. The initial facility investigation documented there were two staff members interviewed as part of this investigation: the activity assistant (AA) and a housekeeper (HSKP) who directly witnessed this abuse allegation. The AA was interviewed at an undocumented time on 7/31/21. She said she was standing at the activities cabinet when she heard the commotion. She stated Resident #32 had taken off the stop sign barrier at Resident #21's door. She said Resident #21 opened his door, took the barrier from Resident #32 and proceeded to push Resident #32 with a great amount of force while saying,Get the hell out of here. The AA said she stepped in between the two residents to catch (Resident #32's name), who was pushed backwards and started falling sideways. She said Resident #32 responded by whining and asking, Why would you do that? as she walked away. The AA said she stood in front of Resident #21 at his door and validated his feelings of someone invading his space. The AA said she responded by saying, I'm sorry (Resident #21's name), I apologize for invading your space as she comforted him with gentle physical contact, rubbing his arm and back. The AA said she told Resident #21 that it was okay and she would stand guard at his door while he relaxed and got comfortable again. She said, at that time, Resident #21 turned around while she shut his door and placed the mesh stop sign back on his door. The HSKP who witnessed this resident to resident abuse was interviewed on 7/31/21 at an unspecified time. The HSKP stated she saw Resident #32 take off the Velcro stop sign on Resident #21's room. She stated Resident #21 opened his door and yelled at Resident #32 to get the hell out of there. She stated Resident #21 pushed Resident #32 at the same time he was yelling at her and the activity lady hurried over to catch (Resident #32's name) falling. Everything happened so fast. -However, when the initial facility investigation was provided, the staff training forms dated 8/3/21 as part of this investigation were incomplete. The undated checklist for physical abuse, which was in the investigation folder, was also incomplete. The facility reported the police report #21-019379 was filed, but the investigation did not document when this occurred. D. Staffing training The program director (PD) of the MCU provided documentation on 8/12/21 that staff had completed the course Preventing, Recognizing and Reporting Abuse between the dates of 1/1/21 through 8/12/21. -The documentation did not note the length of this training. E. Staff interviews Licensed practical nurse (LPN) #5 was interviewed on 8/11/21 at 11:04 a.m. She said the Velcro stop signs were being used on their memory care unit to prevent residents who wander from entering other resident's rooms who did not wish for their rooms to be entered, like Resident #21, who had severe PTSD. She said she was at lunch when the altercation between Resident #32 and Resident #21 occurred on 7/31/21. She said she was told Resident #21 was sitting on his chair directly inside his room's doorway with the door shut. She said Resident #21 heard Resident #32 pull the stop sign down. She said the AA witnessed the altercation and the AA said Resident #21 opened the door and pushed Resident #32. She said Resident #32 did not fall nor was she injured. She said the AA immediately separated both residents following the altercation. She said, since the incident on 7/31/21, Resident #21 had some interventions put into place. He no longer has a chair right inside his bedroom door to barricade his room and this resident has been encouraged to come out of his room more often. She said, for Resident #32, the intervention is for staff to observe her more frequently for behaviors. She also said Resident #32's Seroquel (an anti-psychotic medication) had been increased prior to the incident of resident to resident abuse. She said, in general, the medication increase of the resident's anti-psychotic medication has helped. She said Resident #32's dementia was very severe. She said Resident #32 also had a diagnosis of hallucinations. She said Resident #32 was not as combative as prior, was easier to redirect, was increasingly pleasant and would now tell the staff she loved them. She said Resident #32 was now kind of settling in. The PD of the MCU and the SSD were interviewed together on 8/11/21 at 1:51 p.m. The PD said LPN #5 initiated the abuse investigation because the PD's phone was not working. She said LPN #5 reported the abuse allegation to the SSD on 7/31/21 and the SSD reported the allegation to the State Agency on 7/31/21. The PD said she completed the abuse investigation herself. She said the two residents were immediately separated following the incident. She said additional oversight of Resident #32 was added as an intervention and was care-planned. She said statements were taken from LPN #5, certified nurse aide (CNA) #7, the AA and the HSKP. She said the AA was right there to intervene by catching Resident #32 to prevent her falling. She said time was spent with Resident #21 for his de-escalation following the incident. She said Resident #21 was now sitting by himself in his designated space in the common area of the secured unit because he still does not like anyone in his space. She said the LPN and the AA were not actually witnesses to the resident-to-resident physical alleged abuse, but she conducted interviews with them also. The NHA, DON and quality coordinator (QC) were interviewed on 8/12/21 at 8:15 p.m. They said the incident on the memory care unit between Residents #21 and #32 was unsubstantiated. They said there was no harm to the resident, no intent, and no behavior changes on the part of the victim. F. Facility follow-up Two additional staff interviews were provided by the PD of the memory care unit the morning of 8/12/21: LPN #5 was interviewed at an unspecified time on 7/31/21. She stated she was in the office having her lunch when the resident to resident alleged physical abuse occurred. It was reported to her that Resident #21 was sitting in his room in his chair behind the door with the door to the room shut and the Velcro stop sign up. Resident #32 pulled the stop sign off the door. (Refer to LPN #5's interview above for details). This interview documented LPN #5 immediately notified the PD of the MCU, the SSD, and the director of nursing (DON) of the resident-to-resident incident. CNA #7 was interviewed at an unspecified time on 7/31/21. She said she was performing close observation with (Resident #32's name) when she noticed another high fall risk resident attempting to ambulate on her own. She assisted this other resident to her walker in her room nearby. She said she was assisting this other resident when she heard Resident #21 yell and she rushed out to see the AA preventing Resident #32 from falling. The CNA said she went over and ensured both Resident #32 and Resident #21 were separated and not in any pain. She said she then alerted the LPN on duty about the resident to resident altercation. III. III. Abuse incident involving Residents #7 and #57 A. Residents' status 1. Resident #7, age [AGE], was admitted on [DATE]. According to the August 2021 CPO, diagnoses included Alzheimer's disease with late onset, dementia with behavioral disturbance and major depression. According to the 5/19/21 MDS assessment, she had severe cognitive impairment with a BIMS score of six of 15. She exhibited disorganized thinking; delusions; felt down, depressed and hopeless; and had behavioral symptoms not directed toward others. She required extensive assistance with most ADLs. 2. Resident #57, age [AGE], was admitted on [DATE]. According to the 5/5/21 MDS assessment, diagnoses included medically complex conditions, anemia and hyperlipidemia. According to the 5/5/21 MDS assessment, he was cognitively intact with a BIMS score of 15 of 15, and had no mood or behavioral symptoms. He needed supervision for most ADLs. B. Abuse incident on 7/3/21 Review of facility investigative reports revealed Resident #57 hit Resident #7 on the left shoulder with the back of his hand. The incident occurred during a group activity and was witnessed by activities assistant (AA) #2, who wrote the following statement on 7/3/21 at 2:30 p.m.: I started bingo and (Resident #57) came in late so he replied 'I haven't gotten my cards out yet' and (Resident #7) said 'that's your fault' in a loud stern voice but not yelling. He replied something and then she said 'you should get out of here' and he said 'you should get out of here' and smacked her left shoulder with the back of his hand (not hard) and I got up and said okay (Resident #57) that's not appropriate and I told (Resident #7) to stop arguing to get the argument to stop. That's when I called (CNA #1) over the walkie (walkie talkie). She came out quickly and I told her what happened so she spoke to (Resident #57) while (Resident #7) yelled at them to get him out and he shouldn't be in here with women. Both residents were interviewed on 7/3/21. Resident #7 said she was not afraid, that she felt a tap on her back as Resident #57 went by and she thought he may have accidentally tapped me as he went by. Resident #57 acknowledged he hit Resident #7 because he wanted to get her attention. I didn't mean to hurt her. He acknowledged that hitting or touching others was unacceptable, and said, Yeah, I know, I was just upset. I won't do that anymore. The incident was reported to the appropriate parties including the local police department and State Agency. There was no documentation in the investigative report of actions to prevent recurrence, other than speaking with both residents, such as providing additional resident assistance from staff during group activities to ensure residents could fully participate without becoming frustrated. C. Interdisciplinary team (IDT) progress notes and care plans 1. Resident #57 Review of Resident #57's medical record revealed a 7/12/21 IDT final post review follow-up note documented by the DON as follows: The (IDT) team reviewed the individual to individual altercation incident and determined the effectiveness of the interventions put into place are effective, no further incidents. -The interventions put into place, however, were not documented in the progress note. Moreover, the IDT note was not written until nine days after the abuse incident. Resident #57's care plan identified risk for behaviors with a goal to comply with care routine. Interventions included, Avoid seating resident near (Resident #7) to prevent altercation while in activities or dining room. -This intervention was not documented until 8/12/21, during the survey. 2. Resident #7 Review of the medical record revealed no documentation in IDT progress notes about the 7/3/21 abuse incident. Resident #7's care plan, initiated 10/7/19, identified risk for behaviors including being short tempered, yelling/screaming, abusive/racist language, physically aggressive towards staff and entering others rooms. The goal was respond positively to interventions. Interventions included Avoid seating resident near (Resident #57) to avoid altercation while in activities or in the dining room. -This intervention, like Resident #57's (see above) was not written until 8/12/21, during the survey. D. Resident #7 interviews Resident #7 was interviewed on 8/11/21 at 3:46 p.m. She said staff treated her with dignity and respect and she probably had been abused but she did not think the person meant to do it, and she had probably done things like that herself, such as name calling. Resident #7 was interviewed a second time on 8/12/21 at 1:30 p.m. She said she was not afraid of anyone, and as far as the incident with another resident, she said she saw the resident around once in a while but I just ignore her. It was physical abuse. It hurt a little but didn't leave a bruise. I'm not afraid of her. I'm not really afraid of anybody except maybe a man who is bigger than I am. They moved her someplace else. Resident #7 said when the incident happened she felt like she was being picked on. She said she felt safe in the facility, and she felt that moving the other resident to a different part of the building was a good resolution. -The resident seemed to be talking about two different incidents. -Further review of her IDT notes revealed Resident #7's roommate (Resident #47) had moved out on 3/8/21. Progress notes also revealed Resident #7 had behavioral symptoms of yelling out, banging on her bedside table, and verbally/physically abusing staff. However, there was no documentation about any physical altercations with her roommate. However, there were numerous documented incidents of Resident #7 verbally abusing her former roommate and other unnamed facility residents as follows: -12/11/2020 at 11:49 a.m., nurse answers call light and roommate had put it on for assist to her bed. (Resident #7) yelling and pounding her cup on the table, yelled at this nurse (expletives). (Resident #7) then yelled at the roommate that it is not time to lie down. Roommate is quiet and not saying anything back. (Resident #7) called her roommate a 'fat cow' and continued to yell about the lazy staff. Ask activities to speak with resident. -There was no documentation regarding how the staff protected the resident's roommate from Resident #7's verbal abuse. -12/15/2020 at 3:57 a.m., pushing her call light every 5 minutes or less. X3 (three times) this shift resident pushed call light within one minute of this nurse exiting room. The last three times resident has called was to request staff fluff pillow, increase HOB (head of bed), and move/adjust bedside table. All of these things resident is able to do for herself. If call light is not answered within one minute of resident turning it on, resident begins to scream and yell 'hello' and ' help.' Nurse told resident she was keeping other residents up with her constant yelling, resident replied, 'I don't give a damn who I keep up I need help and I don't care.' Nurse to fax dr. r/t (related to) increased behaviors. -2/20/21 at 4:19 p.m., has been yelling every one to two minutes since start of shift except when in bingo. Resident has various needs, from moving flowers to adjusting blinds, to more Kleenex. If staff does not respond immediately, this resident asks roommate to go to door and yell. -3/8/21 at 6:30 p.m., yelling at roommate stating she was unsafe and needed to listen to her. This writer asked resident to please lower her voice and that roommate heard her. Resident then began increasing yelling at staff. -3/8/21 at 7:00 p.m. resident's roommate was moved to another room. This resident came out of her room 'looking for her roommate and bringing her back.' Advised resident that it is not okay to go after the roommate. Roommate moved per her choice. Resident began yelling at this writer that I could not keep her from her roommate. Redirected resident to her room, spoke with her about the situation. Resident calmed and apologized. -There was no documentation to show why the facility waited so long to relocate Resident #7's roommate despite the yelling and verbal abuse directed toward the roommate and staff, which the roommate had endured for several months. After her roommate moved out, Resident #7 directed verbal abuse toward other residents: -On 7/4/21 at 9:50 a.m. Resident #7 was yelling in the dining room, wheeling herself in wheelchair yelling at another resident in front to 'hurry the hell up.' Resident is pushing the other w/c (wheelchair) with hers. She calls the other resident 'you (expletive).' Resident is instigating the others in the activity room by yelling and making rude comments. She gets angry and verbally aggressive when asked to stop. Resident pushed at the activity aide and shoved her hands when trying to place the bingo pieces on the table. Resident separated from other residents. -On 7/10/21 at 10:51 a.m., resident yelled at another resident 'Can't you move' when the other resident replied he could not (Resident #7) stated 'you are too goddamn fat that's why.' Removed resident to another area for a visit. -The resident's yelling behaviors at staff, which were undoubtedly disturbing to other residents, were further documented on 7/17/21 at 9:30 p.m., cursing/name calling staff on 7/20/21 at 8:47 p.m., yelling on 7/26/21 at 9:29 p.m., 8/5/21 at 9:39 p.m. yelling at staff and resumes yelling after call light answered; and 8/7/21 at 9:42 p.m. yelling and banging remote on bedside table. E. Staff interviews LPN #6, who provided care for Resident #7, was interviewed on 8/12/21 at 11:07 a.m. She said Resident #7 had a verbal altercation, nothing physical, with her former roommate but she knew of no other resident-to-resident altercations involving Resident #7. She said Resident #7's former roommate lives on a different hall now. The NHA, DON and quality coordinator (QC) were interviewed on 8/12/21 at 8:15 p.m. They said they reviewed abuse incidents and investigations during their monthly quality assurance meetings, and had an active action plan for incident review. They said they had not yet reviewed the incidents above, and they would in their next meeting later in August 2021. The DON said she, the NHA and the SSD determined how incidents were investigated and what could be done differently, whether the incidents were substantiated or unsubstantiated. If substantiated, there would be education, re-education, or specific follow-up for identified concerns. They said the incident involving Residents #7 and #57 was not substantiated either because there was no harm or bodily injury. Resident #7 was not fearful, had no change of behavior, and was not scared or frightened. The assailant said yes he did hit her but did not intend to hurt her, so it was not substantiated. They said it was impossible to predict what residents were going to do or say. They said they wanted to help residents but it put the facility at risk to be cited when a resident unpredictably abused another resident. They acknowledged residents had the right to be free from abuse.

Based on record review, observation and interviews, the facility failed to provide sufficient nurse staffing to ensure resident care needs were met. The failure to provide and deploy sufficient nurse staffing contributed to residents experiencing incontinence and not having needs met. Cross reference F677, activities of daily living (ADLs). The facility failed to respond in a timely manner to Resident #17's request for assistance to the bathroom, resulting in incontinence accidents. Resident #17 stated she felt terrible, the staff reassured her that it was fine that she had experienced incontinence, but she had to reconcile her hurt feelings. She said she felt like the staff got annoyed with her when she used the call light. Findings include: I. Facility policy and procedure The Staffing policy, dated March 2020, was provided by the social services director (SSD) on 8/12/21 at 5:42 p.m. It documented in pertinent part: It is the policy to plan in advance for efficient operations. Resident needs may change and the facility reserves the right to change staffing patterns to best meet those needs. II. Resident census and status The resident census and staff schedule, provided by the director of nursing (DON) on 8/12/21 at 5:01 p.m., revealed 73 residents lived in the facility. According to the Resident Census and Conditions of Residents report, signed on 8/10/21 by the minimum data set (MDS) coordinator, the facility census was 72. The census and conditions report revealed the following: 18 residents were dependent for bathing and 51 required assistance of one or two staff; One resident was dependent for dressing and 54 required assistance; Four residents were dependent for transferring and 43 required assistance; One resident was dependent for toilet use and 53 required assistance; One resident was dependent for eating and six required assistance; Five residents had indwelling catheters; 50 residents were incontinent of bladder and 38 were incontinent of bowel occasionally or frequently; 41 residents were on urinary toileting programs and 33 residents were on bowel toileting programs; Four residents were bedfast all or most of the time; 18 residents needed assistance with ambulation; 33 residents had contractures, 27 since admission; 19 residents had psychiatric diagnoses; 33 residents had dementia diagnoses; Three residents had pressure ulcers, two since before admission; 22 residents had behavioral healthcare needs; 11 residents received hospice care; 31 residents received respiratory treatment; -Two residents received tube feedings; 13 residents received antipsychotic medications; Eight residents had unplanned significant weight loss. The facility was divided into four halls with the following resident to staff ratio: -Garden Hall: 24 residents, eight of which required two person assistance with transfers, ADLs, or toileting. One registered nurse (RN), one licensed practical nurse (LPN), four certified nurse aides (CNAs), and one bath aide were scheduled to provide care for Garden Hall. -Sunshine Hall and Short Hall: 25 residents, nine of which required two person assistance with transfers, ADLs, or toileting. One LPN, four CNAs, and one bath aide were scheduled to provide care to Sunshine and Short Hall. -Memory Care: 15 residents. One LPN and two CNAs were scheduled to provide care to Memory Care. -Rehab Hall: Five residents, one of which required two person assistance with transfers, ADLs, or toileting. The staffing schedule was requested, however was not provided for this hall. -During night shift one nurse and one CNA were scheduled for each hall. III. Resident interviews Interviews with residents who, per facility assessment, were cognitively independent and interviewable, revealed the following: Resident #41 was interviewed on 8/9/21 at 6:37 p.m. She said there were not enough staff, and they were rushed all the time. She said she needed assistance with transfers, and sometimes had to wait for a long time. She said lately meal service had been slower. Resident #59 was interviewed on 8/9/21 at 7:59 p.m. The resident stated that he wanted to get out of the facility. He stated when he required help it felt like the staff would just try to get done with him and then shove him away. He denied any abuse, however stated that he felt like a prisoner on his deathbed. Resident #17 was interviewed on 8/10/21 at 8:43 a.m. She stated that there was a long wait time for call lights to be answered, the longest she had waited before was an hour. She said once it was very serious because she had an urgent need to use the restroom. She experienced incontinence due to having to wait too long. She said that she felt terrible, the staff reassured her that it was fine that she had experienced incontinence, but she had to reconcile her hurt feelings. She said she felt like the staff got annoyed with her when she used the call light. Resident #25 was interviewed on 8/10/21 9:19 a.m. She said the facility did not have enough staff and she had to wait too long for assistance to the bathroom. Resident #5 was interviewed on 8/10/21 at 11:21 a.m. She said that one of her main concerns was that there was not enough staff to help her when she needed assistance to get ready for bed or go to the bathroom. She said this happened at any time of the day. Resident #64 was interviewed on 8/10/21 at 1:35 p.m. He said they did not have enough staff to assist him out of bed and into his power wheelchair in the mornings. He said once he was in his wheelchair he was independent, but he had to rely on staff to get him out of bed. He said he liked to have breakfast in his room at 7:30 or 8:00 a.m. and get on the commode at about 8:30 a.m., but it's usually 9:00 or 9:30 a.m., like today, before they got me on the commode, and then he missed exercises which he likes to attend in the morning. They've been having trouble with their help. Meals are often late too. Now breakfast is served closer to 9:00 a.m. Resident #61 was interviewed on 8/10/21 at 2:04 p.m. She said that when she called for assistance to go to the bathroom it took a long time to get help. She said that because of this she had two episodes of wetting her pants and it made her feel embarrassed. She said she did not feel they were adequately staffed. IV. Observations On 8/11/21 at 3:32 p.m. CNA #4 was observed coming out of Resident #34's room. CNA #4 stated that the resident had an episode of incontinence. S/he stated that Resident #34's call light was answered and the resident stated she needed to use the restroom, however both CNAs on the hall needed to help other residents first and by the time they got back to Resident #34 she had urinary incontinence. During intermittent observation of staffing from 8:00 a.m. to 6:00 p.m. on 8/12/21, only one LPN and two CNAs were observed on the Garden Hall. V. Staff interviews CNA #4 was interviewed on 8/11/21 at 11:19 a.m. S/he stated that staffing was horrible and was getting worse. S/he stated that they often only had one nurse and one CNA for each hall and that staffing was only increased because state was present in the facility. CNA #4 stated that residents do have to go without having needs met, such as timely assistance to the restroom. CNA #11 was interviewed on 8/11/21 at approximately 2:00 p.m. She said they did not have enough staff to meet resident needs when there were call-offs. She said they had a call-off that morning and were unable to get to one of the residents on time. She said a continent resident had incontinence that morning because she could not wait long enough for them to help her. CNA #11 said she could not recall who the resident was. CNA #3 was interviewed on 8/12/21 at 11:05 a.m. CNA #3 stated that most of the time the facility had enough staff. CNA #3 stated that s/he usually worked in the rehab unit which usually had a ratio of seven to eight residents per CNA. LPN #6 was interviewed on 8/12/21 at 11:07 a.m. She said they should have four CNAs on her hall but they had only two. She said as a result of short staffing, things that sometimes went undone were oral care, lotioning, and spending time with residents. She said the CNAs were really good at trying to get the needs met, but they were rushed. She said residents complained about waiting too long to have their call lights answered. CNA #4 and CNA #3 were interviewed together on 8/12/21 at around 5:20 p.m. They verified that just one LPN and two CNAs were working the Garden Hall floor. They said that there was a bath aide for each hall, however the bath aide did not go out to the floor to assist with other resident care. The DON was interviewed on 8/12/21 at 6:37 p.m. She said that she felt like the facility was normally staffed appropriately. She said that the bath aides could come out and help the floor CNAs if need be. She also said that the facility sometimes had a float CNA that could go around to each hall and help where needed. She said at night the nurses could help CNAs with residents that required two person assistance. DON said that she had to work the floor and help cover for other staff occasionally. She said she had not heard of any residents experiencing incontinence due to having to wait too long. She reported the facility had not done a call light audit in quite a while. She did not have a response to the facility only having one LPN and two CNAs on Garden Hall on 8/12/21 when one RN, one LPN, four CNAs, and one bath aide were documented on the staffing list that was provided.

Based on observations, record review and staff interviews, the facility failed to ensure food was prepared, distributed, and served under sanitary conditions in one out of one kitchen and one out of one food service area. Specifically, the facility failed to ensure: -Proper hand hygiene and gloving was occurring; -Food was prepared and served in a sanitary manner; and, -Proper personal protective equipment (PPE) was worn when serving and preparing food in the kitchen. Findings include: I. Professional reference The Colorado Department of Public Health and Environment (2019) The Colorado Retail Food Establishment Rules and Regulations, retrieved on 8/16/21 from: https://drive.google.com/file/d/18-uo0wlxj9xvOoT6Ai4x6ZMYIiuu2v1G/view on 8/16/21. It read in pertinent part; -Ready-to-eat is considered a food without further washing, cooking, or additional preparation and that is reasonably expected to be consumed in that form. -Employees prevent bare hand contact with ready-to-eat food by properly using suitable utensils such as deli tissue, spatulas, tongs, single-use gloves, or dispensing equipment. -Single-use gloves shall be used for only one task, such as working with ready-to-eat food, or with raw animal food. Single-use gloves shall be used for no other purpose, and discarded when damaged, when interruptions occur in the operation, or when the task is completed. II. Facility policy and procedures A Bare Hand Contact with Food and Use of Plastic Gloves policy, with no date when initiated, was provided by the dietary manager (DM) on 8/12/21 at 9:53 a.m. The policy documented in pertinent part, Single-use gloves will be worn when handling food directly with hands to assure that bacteria are not transferred from the food handlers hands to the food product being served. Bare hand contact with food is prohibited; -Staff will use clean barriers such as single-use gloves, tongs, deli paper and spatulas when handling food; -Gloved hands are considered a food contact surface that can become contaminated or soiled. If used, single use gloves shall be used for only one task (such as working with ready-to-eat food or with raw animal food), used for no other purpose, and discarded when damaged or soiled, or when interruptions occur in the operation; -Hands are to be washed before putting on single-use gloves and after removing single use gloves; -Gloves are just like hands. They get soiled. Anytime a contaminated surface is touched, the gloves must be changed, and hands must be washed. A Hand Washing policy, with no date when initiated, was provided by the DM on 8/12/21 at 9:53 a.m. The policy documented in pertinent part, Employees will wash hands as frequently as needed throughout the day using proper hand washing procedures. Hands and exposed portions of arms should be washed immediately before engaging in food preparation. When to wash hands: -When entering the kitchen at the start of a shift; -After handling soiled equipment or utensils; -During food preparation as often as necessary to remove soil or contamination and to prevent cross contamination when changing tasks; -When switching between working with raw food and working with ready to eat food; -Before donning disposable gloves for working with food and after gloves are removed; and, -After engaging in other activities that contaminate the hands. How to wash hands: -Turn on the faucet using a paper towel to avoid contamination of the faucet; -Wet hands and forearms with warm water and apply an antibacterial soap; -Scrub well with soap and additional water as needed, scrubbing all areas thoroughly. Pay close attention to the fingernails using a brush as needed. Scrub for a minimum of 10 to 15 seconds within the 20-second hand washing procedure. Apply vigorous friction between the fingers and fingertips. Rinse with clean, running warm water; -Rinse thoroughly; -Dry hands with paper towel or use a hand blow-dryer; and, -Use the paper towel to turn the faucet off and open the door if needed, and then discard towel. III. Observations A. On 8/10/21 beginning at 10:15 a.m. puree food preparation was observed in the kitchen. At 10:30 a.m. cook #1 began to prepare the puree bread. He did not wash his hands or change gloves after preparing the puree fish. He took a small kitchen pan which he used to prepare the puree bread in to the wash sink, set it on the edge of the sink, and added some water to it. He then added the powdered bread mix into the pan of water and began to mix it together with a whisk. The mixture was still too thick and he then took the pan with the mixture to the wash sink and again set it on the edge of the sink, turned on the water and with a measuring spoon added more water until it was the correct consistency. At 10:43 a.m., with the same gloves on he went to the oven, and touched the handle of the oven door and removed a sheet pan with baked fish fillets and then temped the fish. He then doffed his gloves and went to the wash sink and turned on the hot water, placed soap in his hands and quickly rubbed his hands together under the running water for five seconds. He then turned off the faucet handle with his bare hand and then dried his hands. He then donned a new pair of gloves and went to the oven to remove another sheet of the baked fish. He then took a large kitchen pan and placed the fish into the pan, covered it and returned it to the oven. He then took the puree bread pan and placed it into the steamer. He then doffed his gloves, went to the wash sink and turned on the hot water, placed soap in his hands and rubbed his hands together under the water for five seconds. He then turned off the faucet handle with his bare hand and then dried his hands. At 11:05 a.m. cook #2 entered the prep area, went to the wash sink, turned on the cold water faucet, took a small amount of soap and quickly rubbed his hands under the running water for five seconds. He then turned the faucet off with his bare hand and then dried his hands and donned a pair of gloves. B. On 8/12/21, a continuous meal service observation was observed beginning at 4:20 p.m. and ending at 5:30 p.m. Upon entering the front service line portion of the kitchen, cook #2 was observed preparing for the dinner meal service. The cook had a pair of gloves on, a blue procedure mask that did not completely cover his nose. He was not wearing eye protection and the facility was currently in outbreak status. He was observed placing serving utensils, scoops and ladles into each of the kitchen pans that were already on the steam table. He then opened the standing refrigerator handle with his gloved hand. He said he was the only one in the kitchen and did not have a cook assist to help prepare special orders. The cook continued to pull his mask up and over his nose with his gloved hand. At 4:27 p.m. the cook began to take the temperatures of the food on the steam table and was still wearing the same gloves. After taking the temperatures, he went to the back prep area and checked to make sure his grill was turned on and opened and closed the lid. At 4:35 p.m. the cook began the meal service. He did not change gloves or wash his hands. He began by preparing the room trays and picked up each of the clean plates by touching the inside of the plate with his gloved thumb and placing them on a heated pellet. As he scooped up the sweet and sour pork with stir fry vegetables and then the rice with his right hand, he would touch the food and shape it with his left gloved hand to ensure the food was not spread out and had a neat presentation. After plating four plates, he stopped to prepare a special ordered hamburger. He left the steam table area and went to the back prep area and removed a package of hamburger buns off the shelf. He then reached into the bag and grabbed a hamburger bun with his gloved hand (the same gloves from the start of the observation). He took it back to the steam table and placed the bun on a plate. He then removed a hamburger patty from the kitchen pan with tongs and placed it on the bottom bun. He then touched the patty with his gloved hand to center it on the bun. He then said he needed to get cheese from the back kitchen refrigerator. He left the front service area, went to the kitchen, got a small kitchen pan and then went to the walk-in refrigerator. He opened the door with his gloved hand, picked up the package of sliced cheese, opened it and with his gloved hand and removed a handful of cheese slices and placed them in the kitchen pan. He came back to the tray line, took a slice of cheese out of the pan with his gloved hand and placed it on the hamburger patty. He then went to the back prep area and removed a piece of lettuce and slice of tomato from the small kitchen pan with his gloved hands and placed them on the plate with the cheeseburger. He then continued to plate more food for the room trays. He continued to touch the plates in the same manner as above and to touch the food in the same manner once he scooped it onto the plate; with his gloved hand. He then stopped to prepare two more cheese burgers. He did not change gloves or wash his hands and then removed two buns from the package with his gloved hands and placed them on plates. He then placed a hamburger patty on each bottom bun and then placed a slice of cheese on each of the patties with his gloved hand. He then got lettuce and tomato garnish and placed it on each of the plates and served them out. He then went to the microwave, opened the door of the microwave and placed a magic cup frozen supplement inside to defrost it for 20 seconds. He then walked over to the rolling cart where the sheet pan containing the pre-served pieces of cake were and placed it on the service window. He then prepared a plate with mechanical meat and then stopped. He then went and retrieved a scooped plate off the shelf to his left, placed it next to the regular plate and then with his gloved hand scraped the mechanical meat onto the scoop plate (using the same gloves he had on at the beginning of service). He then continued to plate food and began serving out to the main dining room. He then left the service line to go to the back kitchen to retrieve a special ice cream for a lactose intolerant resident. He opened the door of the walk-in freezer using his gloved hand and removed a carton of ice cream. He then went and retrieved a clean plastic dessert bowl and ice cream scoop and portioned out a serving. He then placed the ice cream back into the freezer, shut the door and returned to the tray line. He received a special order for a ham and cheese sandwich. He went to the standing refrigerator and removed a pre-made sandwich, removed it from the package and placed it on a plate and then holding the sandwich on one side with his gloved hand sliced it in half. He then took some lettuce and a slice of tomato and placed it on the same plate. He did not stop to change gloves or wash his hands. At 5:08 p.m. the cook noticed he was out of hamburger patties. He said he needed to go to the back kitchen and prepare more. He left the tray line, went to the back kitchen and removed a large baking sheet from the rack and placed it on the prep table. He then went to the walk-in freezer, opened the door with the same gloved hands he had at the beginning of service. He then removed a package of uncooked frozen patties, opened and reached in with his gloved hands and placed twelve patties on the sheet. He then doffed his gloves, took a bottle of seasoning off the shelf and seasoned the patties. He then opened the oven door and placed the pan into the oven. He then donned a clean pair of gloves and did not wash his hands. He then went to the walk-in freezer, opened the door with his newly gloved hand and placed the frozen patties into the freezer. He returned to the tray line and continued to serve the main dining room. He continued to touch the clean plates (with gloved thumb touching inside of plate) and the food with his gloved hand to ensure it was not spread out and shaped in its own pile. He continued to go in and out of the standing refrigerator for additional items. His mask continued to slide down his nose and he had to repeatedly pull it back up over his nose as he continued to plate food. At 5:15 p.m. he received a special order for a grilled cheese sandwich. He stopped serving at the tray line, went and took two slices of bread out of the package with his gloved hands, went into the standing refrigerator and removed a slice of cheese, placed it on the bread, placed the sandwich on a plate, and sliced it in half. He then took half a sandwich to the grill, lifted the handle and placed the sandwich inside to toast it. After a few minutes, he removed the sandwich and placed it on a plate and served it out. At 5:20 p.m. he left the tray line to go to the walk-in freezer. He opened the freezer door with his gloved hand and retrieved a box of gluten free doughnuts for a resident. He then returned to the front service area, said he was going to warm up the doughnut. He then reached inside the box, retrieved one doughnut, placed it on a plate and opened the microwave door and placed the doughnut inside for 10 seconds. He then opened the door, removed the plate and placed it on the tray and continued to plate food. At 5:25 p.m., the DM opened the door to the service area and told the cook that his hamburger patties were done. He then stopped serving, took the empty kitchen pan where the patties were stored from the steam table and went to the kitchen. He then removed the sheet of cooked hamburger patties and placed six patties into the pan. He then returned to the front tray line, placed the pan of patties on the steam table and continued to plate food. The cook did not wash hands or change gloves in-between going from one task to the next and continued to touch potentially contaminated surfaces by going from one area to the other (service area, kitchen, walk-in freezer, and refrigerator, etc.). IV. Interviews Cook #2 was interviewed on 8/11/21 at 5:30 p.m. He said he worked alone at night and did not have a cooking assistant which made it hard especially when there were special orders and when the certified nurse aides asked for different things. He said he was always running from one area to the next and it was very frustrating. He said he got behind at times and that meant that meal service was late. The registered dietician (RD) and DM were interviewed together on 08/12/21 at 5:14 p.m. The DM said she just went into the managerial position a week ago and had previously been one of the cooks and a dietary aide over the past year. She said that her two cooks were new as well and that she had been learning her new position along with training them. She said that their training so far was hands-on. She said she checked in with the new staff to see how they were doing and if she saw they were struggling, she would ask them if they needed any help. The RD said that cook #2 received two days of training from the DM. The DM said she tried to provide oversight to the new kitchen staff and was not aware that they were not following proper practices. She said that she trained the cooks about being prepared and having their food items prepared ahead of time and to prepare enough food like hamburgers. She said if cook #2 was running around, it was due to him not being properly prepared. The RD said that the kitchen was currently staffed with one cook and one cook assist for days and two dietary aides. She said for the evening shift it was one cook and two dietary aides. She said there was not a cook assist in the evening because it was only one meal. The RD said that the new staff had received their training regarding processes and procedures. She said that hands should be washed and gloves should be changed between changing tasks. She said hand washing should occur for twenty seconds under warm water to ensure all bacteria was removed and that the faucet should be turned off with a paper towel. She said that kitchen staff should be wearing eye protection/goggles according to their company policy. She said they serve a high-risk population and they must follow preparatory, sanitary and infection control practices to avoid food borne illness.