**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, record review, and facility policy review, the facility failed to ensure allegations of abuse were reported per the federal regulations to the Colorado Department of Public Health and Environment (CDPHE) within two hours of the facility being made aware of the abuse allegations for three of three residents (Residents (R) 61, R237, and R387) reviewed for allegations of abuse out of a total sample of 31. Findings include: Review of the facility's policy titled, Abuse: Prevention of and Prevention Against, revision date of 10/2022, revealed, . Allegations of abuse, neglect, misappropriation of resident property, or exploitation will be reported outside the facility and to appropriate State or Federal agencies in the applicable timeframes . and applicable regulations . 1. Review of R61's undated Face Sheet, located in the electronic medical record (EMR) under the Profile tab, indicated R61 was admitted to the facility on [DATE] with diagnoses including major depressive disorder, anxiety disorder, and dementia without behavioral disturbance. Review of R61's quarterly Minimum Data Set (MDS), located in the EMR under the MDS tab and with an Assessment Reference Date (ADR) of 08/22/24, revealed R61 had a Brief Interview of Mental Status (BIMS) score of 15 out of 15, indicating the resident was cognitively intact. Further review of the MDS indicated the resident did not exhibit any behaviors. Review of R61's Care Plan, dated 12/05/22, revealed R61. utilizes [medication name] for diagnoses of depression. She has times where she can have extreme mood fluctuations that can cause increased angry and tearfulness . Interventions included, . assist with a program of activities that is meaningful and of interest . assist to identify strengths, positive coping skills, and reinforce these . R61 had not been cared planned for behaviors, including making false accusations. During this surveyor's Resident Council meeting, conducted on 09/25/24 at 1:53 PM, R61 requested to speak with this surveyor privately when questioned if any of the staff make you feel uncomfortable. Upon the conclusion of the meeting, this surveyor met with R61 in private, on 09/25/24 at 3:08 PM. R61 stated that she had seen Certified Nurse Aide (CNA) 3 and CNA4 come out of her room, and when she went into her room, there was water all over the sink and floor. R61 stated she went back out to the hallway and yelled at CNA3 and CNA4 to please clean up their mess next time. R61 stated CNA3 yelled at her, Would you like for me to pee all over your sink, and you can clean that up? When questioned if R61 had reported this to the administration, she replied Yes. R61 was visibly upset and crying over the incident. R61 stated that she had reported this to Registered Nurse (RN) 4, who asked her what she wanted to be done and suggested they file a grievance. When asked if she recalled how long ago this happened, R61 stated she thought it had been a year or two ago. Review of R61's Grievance Report, provided by the facility, indicated the report was made on 08/26/23 at 1:00 PM. The detail description of concern documented, Resident stated she asked [CNA3] to clean up the water around the sink in her room after they used it and he turned around while she was in the bathroom and said, 'should I just pee all over your sink and floor, would you like that?' Resident said she was upset and asked him to leave. During an interview on 09/25/24 at 5:15 PM, the Administrator stated the incident had not been reported to the State agency. The Administrator was asked to review the initial report of the alleged incident. The Administrator stated, Just looking at the initial comments on the grievance report, it does appear to be an allegation of verbal abuse and should have been reported to the state. The facility reported the incident on 09/25/24 at 7:00 PM. 2. Review of R237's Profile tab of the EMR reviewed R237 was admitted to the facility on [DATE] and discharged on 07/2624. Review of R237's admission MDS, with an ARD of 04/15/24, revealed R237 had a BIMS score of 15 out of 15, which indicated the resident was cognitively intact. Review of the facility's investigative documentation revealed that on 07/20/24 between 12:00 AM to 2:00 AM, R237 did not recall the exact time, R237 stated that she thought she heard LPN3 down the hallway near the nurses' station state, Get out of my face or I will hit you. At 8:00 AM-8:30 AM, R237 informed the weekend supervisor, Registered Nurse (RN) 4 about the allegation of verbal abuse regarding the night nurse, LPN3. The Administrator reviewed the Colorado (CO) State Agency's (SA) website which indicated that the facility's Social Service Director (SSD) notified the CO SA on 07/20/24 at 11:35 AM and the Occurrence number was 24020432015. Interview on 09/26/24 at 01:43 PM, the SSD confirmed by looking at the CO SSA website that the allegation of verbal abuse was reported to the SA on 07/20/24 at 11:30 AM, which was three hours after R237 reported to staff the allegation of verbal abuse. 3. Review of R387's undated Face Sheet, located in the EMR under the Profile tab, indicated R387 was initially admitted to the facility on [DATE], with a readmission on diagnoses including vascular dementia without behavioral disturbance, cognitive communication deficit, and aphasia. Review of R387's admission MDS, located in the EMR under the MDS tab and with an ARD of 01/07/24, revealed R387's BIMS score was 00 out of 15, indicating the resident was severely cognitively impaired. Further review of the MDS indicated R387 was assessed as not exhibiting any behaviors. Review of R387's Care Plan, dated 11/09/23, indicated R387 was . at risk for worsening/impaired cognitive function/dementia or impaired thought processes r/t [related to] new environment and diagnoses of vascular dementia. [Resident name] at time will become agitated with staff's redirection for safety concerns. He can yell and cuss at staff . Review of the Facility Reportable Incident (FRI), dated 01/09/24 and provided by the facility, documented, . [CNA2] was coming down hallway and witnessed nurse shut her med cart and turned to resident stating 'stop spitting on the floor that's f**king nasty.' Upon further investigation other staff report that resident was going behind nurse station and [name withheld] was redirecting him. Resident became verbally aggressive with her and was calling her names such as 'bitch'. Further review of the FRI indicated the incident occurred on 01/08/24 at 8:00 PM and was submitted on 01/09/24 at 5:12 PM to the CDPHE. During an interview on 09/26/24 at 12:53PM, RN1 stated that she had not been in the facility at the time of the incident since it happened on night shift, but the incident had been reported to her on 01/09/24, the next day, at change of shift. RN1 stated CNA3 reported that Licensed Practical Nurse (LPN) 3 got into the face of R387 and yelled at him. RN1 stated she did feel this was an allegation of verbal abuse, so she immediately told LPN4, North Unit Manager. During an interview on 09/26/24 at 1:06 PM, LPN4, the North Unit Manager, was asked what she did when she was informed about R387's incident. LPN4 stated that she turned the grievance over to the Director of Nursing (DON) at that time, who was no longer employed at the facility. During an interview on 09/26/24 at 5:30 PM, the Administrator was asked if he was aware of the incident with R387. The Administrator stated he did not recall the incident but confirmed that the allegation of verbal abuse should have been reported immediately.

Based on record review and interview, the facility failed to ensure two of two residents and their representatives (R) 86 and R109) reviewed for facility initiated emergent hospital transfer from a total sample of 31 residents were provided with written transfer/discharge notices that contained the required information. This failure had the potential to affect the residents and their Resident Representative (RR) by not having the knowledge of how to appeal the transfer, if desired, and how to notify the State Long-Term Care (LTC) Ombudsman's office. Findings include: 1. Review of R86's electronic medical record (EMR) Progress Notes in the Progress Notes tab revealed, . 03/11/24 at 3:48 AM, Resident . reported that he wasn't feeling well . BP [blood pressure] was 123/72, HR [heart rate] 132 Temp [temperature] 101.3 O2 [oxygen] 75% on 5L [5 liters] resp [respirations] 28 . orders to send to ER [emergency room] . Paramedics took resident to [hospital] . Review of R86's EMR Progress Notes in the Progress Notes tab indicated, . 03/13/24 at 11:32 PM, res [resident] back from the hospital . 2. Review of R109's EMR Progress Notes in the Progress Notes tab indicated, . 08/03/24 at 5:27 PM, Suprapubic catheter continues to leak . paramedics contacted to transfer patient to ER for replacement . EMT [Emergency Medical Technician] here at approximately 6:30PM to take patient to ER . Interview on 09/25/24 at 2:01 PM, the Director of Nursing (DON) stated that when residents are discharged to the ER, the nurses send the Medical Orders for Scope of Treatment (MOST), Power of Attorney (POA) document, and face sheet with the resident, and if staff have time, they would print the transfer form, labs pertinent to the situation, and progress notes. Interview on 09/25/24 at 3:10 PM, the Social Service Director (SSD) provided the list of transfers that were sent to the State LTC Ombudsman's office. The SSD confirmed that neither R86 nor R109's hospital transfers were included on the list. The SSD stated that only transfers to home or death were sent to the State LTC Ombudsman's office. Interview on 09/25/24 at 5:00 PM, the DON provided a copy of R86 and R109's Transfer Form that was sent with the residents at the time of their transfer to the hospital. The DON reviewed the document and confirmed that neither transfer document included the resident's appeal rights nor the information regarding the State LTC Ombudsman office. The DON confirmed that the facility did not have a policy regarding facility initiated transfers and notification of the State LTC Ombudsman's office.

Based on interview and record review, the facility failed to complete a significant change in status Minimum Data Set (MDS) for one of one resident (Resident (R) 121) reviewed for hospice in a total sample of 31 residents. This had the potential to cause unmet care needs for R121. Findings include: A review of R121's admission Record, located in the electronic medical record (EMR) under the Profile tab, revealed an admission date of 09/27/23 with medical diagnoses including stage IV sacral pressure ulcer and osteomyelitis of the vertebra, sacral and sacrococcygeal area. A review of R121's Order Summary Report, located in the resident's EMR under the Orders tab, revealed the following order, dated 04/07/24: admitted to [Hospice Name Withheld] with diagnosis of Osteomyelitis of Vertebra, Sacral and Sacrococcygeal Region. A review of R121's EMR revealed a quarterly MDS, with an Assessment Reference Date of 06/18/24 and located in the MDS tab of the EMR, which documented the resident was receiving hospice services. A significant change in status MDS was not completed until 07/03/24. During an interview on 09/26/24 at 11:39 AM, the MDS Coordinator (MDSC) confirmed that since R121 was placed on hospice in April, a significant change assessment should have been completed at least two weeks later. The MDSC stated that she was on vacation during that period, and it was overlooked; however, the significant change MDS was completed in July.

Based on observation, interview, record review, and review of facility policy, the facility failed to secure one of two medication carts on the East Wing when out of the site of the nursing staff. This failure could permit individual unauthorized access to residents' medications. Findings include: A review of a facility document titled, Medication Access and Storage, E kit access, with a revision date of 04/2024 read in part, Only licensed nurses, the consultant pharmacist and those lawfully authorized to administer medications (e.g., medication aides) are allowed access to medications. Medication rooms, carts, and medication supplies are locked or attended by persons with authorized access. Observation on 09/25/24 at 4:47 PM revealed the medication cart on the East wing was left unlocked at the nurses' station. There were no staff members present at the nurses' station. Residents (R) 8 and R22 were around the unlocked medication cart. R8 sat in a wheelchair across from the cart, and R22 propelled herself up next to the cart. Registered Nurse (RN) 3 returned to the unit and went to the bathroom. RN3 returned to the nurses' station and started talking to another staff member. R22 remained close to the unlocked medication cart. RN3 obtained a drinking cup from the cart and went into the medication room. The medication cart remained unlocked. RN3 returned carrying a drinking cup with clear liquid and gave it to R22. RN3 then briefly returned to the nurses' station without locking the medication cart. RN3 then got up pulled the medication drawer open and started to set up evening medications. The medication cart was unlocked for seven and one-half minutes. A review of R8's admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 07/23/24 and located in the resident's electronic medical record (EMR) under the MDS tab, revealed R8 had severely impaired cognition. A review of R22's quarterly MDS, with an ARD of 07/09/24 and located in the resident's EMR under the MDS tab, revealed the resident's cognition was intact and was able to make decisions. An interview on 09/25/24 at 5:10 PM with RN3 revealed that she did not realize that she had left the medication cart unlocked. RN3 stated that she had left the unit to escort a resident to the dining room. RN stated that R22 was alert and oriented and was waiting for her evening drink. RN3 acknowledged that R8 was cognitively impaired and did not think that the resident could propel herself over to the medication cart. An interview was conducted on 9/25/24 at 5:30 PM with the Unit Care Coordinator Licensed Practical Nurse (LPN)1. LPN1 stated it was an expectation that the medication would always be kept locked when not in use. LPN1 stated it did not matter whether a cognitively intact or cognitively impaired resident was in the area; an unlocked cart would be a safety issue.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, record reviews, and review of facility policy, the facility failed to 1.) follow current standards of practice related to the use of personal protective equipment (PPE) with transmission-based precautions and/or implement their policy and procedures related to enhanced barrier precautions (EBP) for two of two residents (Resident (R) 107 and R389) reviewed for transmission-based precautions out of a total sample of 31, and 2.) sanitize glucometers in a manner that prevented cross-contamination for one of three residents (R76) observed receiving fingerstick blood glucose tests (FSBG). These failures had the potential to lead to the spread of infection throughout the facility. Findings include: Review of the facility's policy titled, IPCP Standard and Transmission-Based Precautions, revised 03/2024, revealed, Droplet Precautions (TBP) are used for patients known or suspected to be infected with pathogens transmitted by respiratory droplets that are generated by a patient who is coughing, sneezing, or talking (e.9. influenza). Implement source control by placing a mask on the patient. Ensure appropriate patient placement in a single room if possible. In long-term care and other residential settings, make decisions regarding patient placement on a case-by-case basis considering infection risks to other patients in the room and available alternatives. Use personal protective equipment (PPE) appropriately. [NAME] mask (and eye protection if indicated) upon entry into the patient room or patient space. Limit transport and movement of patients outside of the room for medically necessary purposes. If transport or movement outside of the room is necessary, instruct patient to wear a mask and follow Respiratory Hygiene/Cough Etiquette. Implementation: a. The facility will implement a system to alert staff, residents, and visitors that a resident is on Transmission Based Precautions (TBP). Post clear signage on the door or wall outside of the resident room indicating the type of Precautions and required PPE (e.g., gown and gloves) ii. For Enhanced Barrier Precautions, signage should also clearly indicate the high-contact resident care activities that require the use of gown and gloves b. Make PPE, including gowns and gloves, available immediately outside of the resident room, or for EBP gown and gloves can be available inside the room to promote dignity and quality of life. c. Ensure access to alcohol-based hand rub d. Position a trash can inside the resident room and near the exit for discarding PPE after removal, prior to exit of the room or before providing care for another resident in the same room e. Provide education to residents and visitors as needed. A review of the undated facility's document titled, Glucometer Disinfection, reads in part . create a clean . perform hand hygiene . disinfect the glucometer for with Micro kill disinfectant wipes for one minute . actively wipe the machine for one minute and let the glucometer air dry on a clean surface . 1. Review of R389's undated Face Sheet, located in the electronic medical record (EMR) under the Profile tab, indicated the resident was admitted to the facility from the hospital on [DATE] with diagnoses including malignant neoplasm of main bronchus, chronic obstructive pulmonary disease, and irritable bowel syndrome with diarrhea. Review of R389's hospital's undated Discharge Notes, located in the EMR under the Miscellaneous tab, revealed the resident had tested positive for COVID-19 on 09/12/24. During the facility's initial tour conducted on 09/23/24 at 11:56AM, an observation was made of R389's room. There was a sign on R389's door, indicating the resident was on droplet precautions; instructing staff and visitors to wear N95 mask, gloves, gowns, and googles or face shield; and to keep door closed. During an observation made on 09/23/24 at 11:56 AM, R389's door was left open. During observations conducted on 09/23/24 at 12:25 PM, and 12:30 PM, Certified Nurse Aide (CNA) 1 was observed going into and out of R389's room without the appropriate PPE, except for a surgical mask. During an interview conducted with CNA1 on 09/23/24 at 12:31PM, CNA1 was asked what she was supposed to wear to go into R389's room. CNA1 responded, I normally just wear a mask. CNA1 was asked why R387 was on droplet precautions. CNA1 stated, I was told it was for COVID; guess I should have been wearing goggles and gown. During an interview conducted with the Administrator on 09/23/24 at 12:50 PM, the Administrator stated he would expect whoever enters an isolation room to follow the precaution signs. During an interview conducted with the Director of Nursing (DON) on 09/23/24 at 1:51 PM, the DON was asked what her expectations were of staff and isolation residents. The DON responded, Staff should be aware of who is on isolation and what PPE is supposed to be worn. During observations conducted on 09/24/24 at 9:52 AM, 11:04 AM, and 3:39 PM revealed R389's room was no longer on isolation. R389 was observed to have an indwelling urinary catheter. There was no PPE available, and there was no signage to indicate the resident was on EBP, as per the facility's policy. During an interview with LPN2 on 09/24/24 at 4:28 PM, LPN2 confirmed R389 was supposed to be on EBP, and that there was no PPE or sign on the door. During an interview with the Infection Preventionist (IP) on 09/24/24 at 5:00PM, the IP was asked if R389 was supposed to be on EBP. The IP confirmed that there was not an EBP sign or PPE on 389's door. The IP stated that it was her fault, that she forgot to hang the sign and PPE on the door. 2. Review of R107's Face Sheet, located in the EMR under the Profile tab, revealed that R107 was originally admitted to the facility on [DATE] with the diagnoses that included chronic respiratory failure with hypoxia, anoxic brain damage, and muscle wasting. Review of R107's Physicians Order, located in the EMR under the Orders tab and dated 05/27/24, revealed, . on Enhanced Barrier Precautions . related to having a tracheostomy and gastrostomy tube. Review of the EBP sign located on R107's door revealed, . wear gloves and gown for the following high care areas dressing, bathing showering . Observation on 09/23/24 at 11:29 AM revealed CNA1 was already in the room providing incontinent care. CNA1 wore gloves but did not wear a gown as per facility policy related to EBP precautions. During an interview on 09/23/24 at 11:37 AM, CNA1 confirmed she was not wearing a gown while providing incontinent care to R107. CNA1 stated she did not don a gown because she was in a hurry. She stated she had received infection control training, and that the purpose of EBP is to prevent the spread of infections. 3. An observation on 09/25/24 at 5:00 PM revealed RN3 preparing to perform a FSBG test on R76. RN3 did not disinfect the glucometer before using it on R76. Once RN3 obtained the blood glucose test, she returned to the medication cart, created a clean field, obtained a Micro Kill Germicidal wipe, and wiped the glucometer for ten seconds. She then started putting the glucometer back in the medication cart drawer, stopped and wiped the glucometer for a few more seconds, wrapped the glucometer in the Micro Kill Wipe, and placed the wrapped glucometer inside the medication cart drawer. An interview was conducted on 09/25/24 at 5:33 PM with RN3. RN3 stated that she disinfected the glucometer that morning after testing the resident's blood glucose, and the glucometer had not been used since that time. RN3 stated she did not see the need to disinfect the machine before the evening fingerstick blood glucose check. RN3 stated that she was unsure of how long the glucometer should be wiped down with the germicidal wipe. An interview with Unit Care Coordinator Licensed Practical Nurse (LPN) 1 was conducted on 09/25/24 at 5:53 PM. LPN1 stated it was an expectation that glucometers be disinfected before and after each resident use. LPN1 stated the nurse is expected to perform hand hygiene, create a clean field, and use the Micro Kill One Germicidal Wipe, wiping the machine down for a full minute, and then leaving the machine to air dry.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, interview, and policy review, the facility failed to 1.) maintain a comfortable temperature for residents in their rooms and hallway for two of three units (West unit and the East unit), and 2.) maintain the residents' wheelchairs in a condition that was in good repair. Specifically, the wheelchair arms for seven of 78 residents' wheelchairs (Resident (R) 64, R239, R8, R240, R1, R118, and R117) were cracked and missing vinyl exposing the white material underneath. This failure prevented the cleaning and sanitizing of the wheelchair arm rests. Findings include: 1. a. Interview on 09/23/24 at 12:03 PM, R24 stated that her room gets hot and that she needs to use her fan. She stated that the room is not air conditioned (AC) and that the AC was in the hallway. Review of R24's electronic medical record (EMR) Care Plan tab revealed R24's annual Minimum Data Set (MDS), with an assessment referent date of 06/20/24, indicated a Brief Interview of Mental Status (BIMS) score of 14 out of 15, indicating the resident's cognition was intact. b. Interview on 09/23/24 at 12:11 PM, R1 stated that her room was hot, and she has to use her fan. Review of R1's EMR Care Plan tab revealed a quarterly MDS, with an ARD of 08/22/24, which indicated a BIMS score of 15 out of 15, indicating the resident's cognition was intact. c. Interview on 09/23/24 at 1:30 PM, R40 stated that it was very hot in her room last night. Review of R40's EMR Care Plan tab revealed a quarterly MDS, with an ARD of 07/25/25, which indicated a BIMS score of 15 out of 15, indicating the resident's cognition was intact. d. Review of R94's admission MDS, with an ARD of 07/23/24 and located in the resident's EMR section titled MDS, documented that the resident was cognitively intact and able to make decisions for herself. Observation on 09/23/24 at 11:15 AM revealed R94's room was stifling hot. There was no air coming from the air conditioning vents. During an interview with R94 on 09/23/24 at 1:30 PM, the resident stated that her room was hot as hell. R94 noted that she had complained several times to the staff and the Administrator, but nothing was ever done. Interview with the Director of Nursing (DON) on 09/23/24 at 1:42 PM, the DON stated the rooms do not have AC in them and that the hallways have the AC. Interview with the Maintenance Director on 09/23/24 at 2:43 PM, he confirmed that the residents' room do not have AC and that the AC was in the hallways. The Maintenance Director stated that when he checks the residents' hot water temperature in their bathrooms, he notices if the rooms are hot. He stated that he does not have any documentation of checking the residents' ambient room temperatures. During an interview on 9/24/24 at 11:10 AM, Certified Nursing Aide (CNA) 5 revealed the night shift usually turned the heat on at night because it was too cold, and the day shift must turn the heat off in the morning. During the tour of the residents' rooms throughout the facility and the thermostats on each hallway at 09/25/24 at 4:30 PM, the following observations were made of the thermostats. Observation on the [NAME] unit of the thermostat near room [ROOM NUMBER]B, revealed it was turned off. The Maintenance Director stated when the thermostat is turned off, there is no AC in that hallway and that causes the rooms on that hallway to feel warm. When the Maintenance Director turned on the thermostat and the AC came on, the hallway was 79.0 degrees Fahrenheit (F). Observation on the [NAME] unit of the thermostat in the hallway outside of the beauty shop, revealed it was turned off. When the Maintenance Director turned on the thermostat and there was AC, the temperature in the hallways was 77 degrees F. Observation of the East unit nurses' station revealed the thermostat was turned off, and when the Maintenance Director turned on the thermostat and there was AC, the temperature was 75.0 degrees F. Review of the facility's policy titled, Safe and Homelike Environment, dated 2024 and provided by the Administrator indicated, . 7. The facility will maintain comfortable and safe temperature levels. a. The facility should strive to keep the temperature in common resident areas between 71 and 81 degrees F . 2. During the tour of the facility on 09/25/24 at 4:30 PM, the following observations were made of the residents' wheelchair arm rests: R64, R239, R8, R240, R1, R118 and R117's wheelchair arm rests were cracked, exposing the white material below. Interview with the Maintenance Director on 09/25/24 at 4:53 PM, he stated that the Rehabilitation department or restorative nursing was responsible for the replacement of the damaged wheelchair arm rests. Review of the facility's policy titled, Wheelchair Management, dated 03/2024 and provided by the Administrator, indicated, . 5. The facility will maintain the wheelchair by providing maintenance as needed .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to develop and implement a baseline care plan that included the instructions needed to provide effective and person-centered care of the resident that met professional standards of quality care for one (#117) of three residents out of 47 sample residents. Specifically, the facility failed to: -Develop and revise a person-centered acute/baseline care plan within 48 hours of admission for Resident #117 that included pertinent healthcare information related to the resident's psychosocial needs, anxiety with depression, and history of trauma for staff to use to prevent potential further anxiety and retraumatization; and, -Review the baseline care plan with the resident or the resident's representative for input into choices and approaches. Findings include: I. Facility Policy The Baseline Care Plan policy and procedure, undated, was provided by the nursing home administrator (NHA) on 3/27/23 at 4:30 p.m. It documented in pertinent part, The facility will develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care. The admitting nurse, or supervising nurse on duty, shall gather information from the admission physical assessment, hospital transfer information, physician orders, and discussion with the resident and resident representative, if applicable. Once gathered, initial goals shall be established that reflect the resident's stated goals and objectives. Interventions shall be initiated that address the resident's current needs including any identified needs for supervision, behavioral interventions, and assistance with activities of daily living. II. Resident status Resident #117, age [AGE], was admitted on [DATE]. According to the March 2023 computerized physician orders (CPO) diagnoses included traumatic brain injury, chronic pain syndrome and anxiety with depression. The 2/7/23 minimum data set (MDS) assessment indicated the resident had a moderate cognitive impaired with a brief interview of mental status (BIMS) score of nine out of 15. He required supervision of one staff member for bed mobility, transfers, dressing, and personal hygiene. He required limited one person assistance with toileting. According to the MDS assessment, Resident #117 had verbal behaviors directed towards others, rejection of care and symptoms of depression. He was on an antidepressant daily. III. Record review The 2/3/23 nursing admission assessment documented the resident was anxious and withdrawn at times. The baseline care plan, initiated 2/3/23, was reviewed. The care plan did not include the resident's depression, or any specific interventions related to Resident #117. -It did not include information from the resident's admitting nursing assessment on 2/3/23 (see above) about being anxious and withdrawn at times. There were no revisions to the baseline care plan during the resident's stay. There was no evidence the baseline care plan was reviewed with the resident or the resident's representative for input into what interventions would be helpful for the resident. The baseline care plan included that the resident was at risk for impaired cognitive function. The goal was that the resident would remain oriented to person, place, situation, time through the review date. A preprinted box of interventions was listed. The box next to communication was checked and documented, Identify yourself at each interaction. Face when speaking and make eye contact. Reduce any distractions- turn off TV, radio, close door etc. (etcetera) Use simple, directive sentences. Provide with necessary cues- stop and return if agitated. -However, there were no specific person centered interventions for Resident #117 with his diagnosis of depression, or feelings of anxiety documented on his admission. The comprehensive care plan, initiated 2/3/23, documented the above cognitive function risk and the same interventions. It further documented Resident #117 was on an antidepressant and at risk for adverse effects. The goal was that he would be free of adverse reactions. The only intervention listed was to monitor for signs and symptoms of the side effects. -There were no further interventions to address his anxiety with depression. On 2/4/23 at 5:12 p.m. the nursing progress notes documented, Resident frequently refused CNA's (certified nurse aides) assistance throughout shift. Verbally aggressive towards staff. On 2/5/23 at 1:59 p.m. the nursing progress notes documented, new admit charting resident verbally aggressive with CNA's cussing and hollering at them, kicking CNA's out of the room. On 2/6/23 at 9:37 a.m. the skilled nursing notes documented the resident had refused therapy. On 2/6/23 the history and physical documented in pertinent part, Has significant mood disorder in addition to memory deficits. Since admission to SNF (skilled nursing facility) setting he has been highly resistant to cares and interventions including routine vital sign monitoring, routine therapy, is verbally aggressive at times. On 2/6/23 at 10:14 a.m. the nursing progress notes documented, Resident refused to have VS (vital signs) taken. Stated to CNA, 'Get . out of my room. 'When the provider entered, the patient refused to talk to him. Refusing care, refusing to be weighed. On 2/6/23 at 5:52 p.m. the nursing progress notes documented complaint of left sided neck muscle spasm and pain. Patient verbally aggressive and yelling at this nurse when offered Tylenol. On 2/7/23 at 11:46 a.m., the social service assessment documented, Currently he utilizes Venlafaxine (antidepressant) for diagnosis of anxiety/depression. Resident #117 reported feeling down depressed/hopeless, having trouble falling asleep, feeling tired, feeling bad about himself and moving/speaking so slowly that others may have noticed. Resident #117 reported 'experiencing trauma when in he was physically attacked by a (person of color) man at a store in Alaska in 2013.' He reported that seeing (person of color) people is a trigger for him. Resident #117 was verbally aggressive toward staff and refused care. On 2/7/23 at 3:54 p.m. the nursing notes documented, Nursing entered patient room and he yelled at her, stating, 'Get out of my room before I call 911.' On 2/8/23 at 9:15 a.m., the nursing notes documented, Resident refused to have VS (vital signs) taken, while yelling obscenities at and making derogatory remarks to CNA #3. On 2/8/23 at 1:44 p.m., the skilled nursing note documented, Resident intermittently agitated, anxious, verbally abusive to staff, decreased participation, depressed feelings or statements, anger issues, verbal behavior directed to others, rejection of care Resident expresses frustration with facility, staff, overwhelmed by number of different people caring for him. On 2/8/23 at 3:19 p.m., the social service note documented, Writer spoke with the resident's representative later about Resident #117's reports that staff were 'getting in his face and yelling at him' The note further documented that the resident and the resident's representative had been offered mental health services on 2/6/23 and had declined. The care plan and progress notes were reviewed from 2/3/23 to 2/8/23. There was no documentation that the care plan had been reviewed with the resident or resident's representative within 48 hours of admission. IV. Interviews CNA #3 was interviewed on 3/29/23 at 11:50 a.m. She said she remembered Resident #117 and had cared for him. She said Resident #117 was outspoken and cussed sometimes or called the staff names. She said when Resident #117 did cuss or call her names; she had no specific interventions for his behavior. She said she was not aware he had a history of being physically assaulted, his anxiety or depression. CNA #3 said she had never been told about any specific approaches, interventions or triggers for Resident #117. CNA #3 went to the nurse's desk and pulled up Resident #117's care plan on the computer. She said there was no care plan with interventions for his behavior or depression. CNA #5 was interviewed on 3/30/23 at 8:40 a.m. She said she did not know if behaviors with specific approaches were part of the resident's care plan. CNA #6 was interviewed on 3/30/23 at 8:47 a.m. She said she had behavior training in the past for residents with aggressive behavior, but she did not know how the staff would know what specific approaches to use with a resident who had behavior issues and or a history of trauma. The social service director (SSD) and social service assistant (SSA) were interviewed on 3/30/23 at 10:30 a.m. The SSD said that residents should have a care plan with specific interventions for behavior, including a history of trauma and triggers for behavior. She said she thought his trauma could be part of his agitation, but she did not know. She reviewed the care plan on her laptop and said there was no care plan related to his behavior, interventions for depression, or trauma. She said he should have had a care plan, and that the care plan would link to a [NAME] (abbreviated plan of care) for the CNAs to use. She said the baseline care plan is done within 48 hours of admission. She did not know if there was documentation that the baseline care plan had been reviewed with the resident or family, but she said the SSA talked to the resident's representative frequently. -The baseline care plan failed to include anxiety with depression, the resident's behavior, and possible triggers such as pain or history of trauma. It was not revised during his stay despite multiple documented entries in the electronic medical record (EMR) beginning on admission of feeling anxious, and throughout his stay, refusing care, and verbal aggression and distress. There was no evidence the baseline care plan was reviewed with the resident or the resident representative for input into choices or approaches that would be helpful for the resident within 48 hours or anytime thereafter. V. Facility follow-up On 3/31/23, after the survey exit, the facility sent a document in an email, undated, unsigned which documented, Review of 62 pages of hospital records there was no indication that Resident #117 experienced trauma in his history. There was mention that Resident #117 had a diagnosis of altered mental status with recent ETOH (alcohol) abuse and potential dementia diagnoses. Charting did also indicate potential paranoid delusions with unknown causes. Hospital documentation clearly stated no emotional abuse, physical abuse or sexual abuse had occurred. This was stated several times in the hospital documentation. There was no prior knowledge or documentation that Resident #117 had experienced trauma. He was diagnosed with depression and prescribed Venlafaxine to treat. There was no diagnoses of post traumatic stress disorder in any of the documentation. There was no indication to initiate a baseline care plan for trauma within the initial 48 hour period. The resident had exhibited behavioral disturbances and angry outbursts with staff soon after admission, so on 2/6/23 staff offered the option of mental health services to (resident name) and his family member, but these services were declined. Social service staff followed policy and procedure and conducted the initial social service assessment on 2/7/23 and during this assessment Resident #117 reported a past traumatic event. On 2/8/23 Resident #117 decided that he wanted to discharge back to the community against medical advice. -However, the baseline care plan did not include the resident's history of anxiety with depression or any of the behaviors documented in the progress notes that occurred almost daily. The admitting nurse documented on day one the residents anxiety, and feeling withdrawn at times. The resident's verbal aggression began soon after admission. The facility never developed a baseline care plan for the behavior. The staff were unaware of approaches to take with the resident. On 2/7/23, the social service assessment documented trauma related to a physical assault. Her assessment did not include any interventions or preferences from Resident #117. The trauma was not included on the baseline care plan either.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interviews, and observations the facility failed to develop a comprehensive care plan for two (#75 and #4) out of eight residents out of 47 sample residents for services to attain or maintain the residence highest practical physical, mental, and psychosocial well-being. Specifically, the facility failed to: -Ensure the care plan for Resident #75 reflected activity preferences; and, -Ensure the care plan for Resident #4 reflected dental needs. Findings include: I. Facility policy and procedure: The Care Plan policy, revised November of 2022, was received by the nursing home administrator (NHA) on 4/4/23 at 2:09 p.m. It revealed in pertinent part, It is the policy of this facility that the interdisciplinary team (IDT) shall develop a comprehensive care plan for each resident. The care plan is developed by the IDT which includes, but is not limited to the following professions: attending physician, registered nurse responsible for the resident, dietary supervisor/dietitian, social services staff member responsible for the resident, rehabilitation specialist physical, occupational, and or speech therapist as indicated, consultants (as appropriate), director of nursing services (as applicable), nursing assistance responsible for care, others as necessary or indicated. II. Resident #75 A. Resident status Resident #75, age [AGE], was admitted on [DATE]. According to the March 2023 computerized physician orders (CPO), the diagnoses included dementia, emphysema (shortness of breath), depression and anxiety. The 1/17/23 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status score of 13 out of 15. He required extensive assistance of two staff members for transfers, and extensive assistance of one staff member for dressing and mobility assistance. B. Record review The care plan with a date of 12/2/22 did not reveal a section for activity preferences for Resident #75. The MDS quarterly review dated 1/17/23 revealed an assessment had not been completed. The 1/18/23, quarterly activity review, progress note revealed Resident #75 enjoyed being in his room watching television programs that involved news, sports, or watching movies. It revealed Resident #75 would occasionally attend group activities involving music or being outside. It revealed Resident #75 would accept monthly visits from a Chaplain. It revealed Resident #75 would accept social visits from staff two or three times a week to provide updates and inquire if needs were being met. It revealed a care plan was in place that reflected interests, needs, strengths, and abilities of Resident #75. C. Staff interviews Activities director (AD) # 1 was interviewed on 3/30/23 at 11:00 a.m. She said she was unable to locate an activities care plan for Resident #75. She said that the facility transitioned to a new charting system recently. She said Resident #75 did not have a care plan for activities. Certified nurse aide (CNA) #1 was interviewed on 3/30/23 at 11:30 a.m. He said that Resident #75 enjoyed watching television and went to the dining room for lunch occasionally. CNA #1 said he was not aware of other activities the resident enjoyed. Registered nurse (RN) # 2 was interviewed on 3/30/23 at 4:00 p.m. She said Resident #75 enjoyed watching television, specifically investigation series. She said Resident #75 would go to the dining room for lunch occasionally. She said she was not aware of any other activities the resident enjoyed. CNA #8 was interviewed on 3/30/23 at 6:30 p.m. She said Resident #75 enjoyed watching television. She said she was not aware of any other activities the resident enjoyed. III. Resident #4 A. Resident status Resident #4, age [AGE], was admitted on [DATE]. According to the March 2023 computerized physician orders (CPO) diagnoses included dysphagia (swallowing difficulty) and hypertension. The 2/8/23 minimum data set (MDS) assessment coded the resident with a brief interview for mental status of 13 out of 15. The resident required extensive assistance with personal hygiene. The MDS dated [DATE] was coded incorrectly and documented the resident had no natural teeth. -However, the resident did have natural teeth. B. Record review The care plan with a review date 1/3/23 of did not reveal a section for dental care needs for Resident #4. The 1/20/23 dental note documented an oral evaluation and the chief complaint was pain to the both upper and lower posterior teeth. (#30 tooth) and (#2 tooth). The note documented an offer would be developed and possible extractions. C. Staff interview The MDS coordinator (MDSC) was interviewed on 3/30/23 at approximately 4:00 p.m. The MDSC said the dental care plan would be developed if the resident had an acute issue. He was not aware of the dental issues the resident was experiencing.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** II. Resident #87 A. Resident Status Resident #87, age [AGE] was admitted on [DATE]. According to the March 2023 CPO diagnoses included schizoaffective disorder, post-traumatic stress disorder (PTSD), and urge incontinence. The most recent MDS dated [DATE] showed the resident had no cognitive impairments with a brief interview for mental status (BIMS) score of 15 out of 15. The resident required extensive assistance from one person with activities of daily living. The resident was coded as frequently incontinent of urine. B. Observations and interview On 3/27/23 at 10:25 a.m., the resident was observed and interviewed while she sat in her wheelchair. She was dressed for the day and smelled of urine. Resident #87 said she needed assistance to go to the bathroom. Although, when she rang her call light, it was not not answered timely, and she had been told by certified nurse aide (CNA) to urinate in her brief. At 3:00 p.m. Resident #87's room smelled strongly of urine. On 3/28/23 at 2:30 p.m. Resident #87's room smelled strongly of urine and when entering the room there was a strong odor of urine. On 3/29/23 at 4:00 p.m. Resident #87's room smelled strongly of urine. C. Record review The care plan last updated on 1/3/23 identified Resident #87 was incontinent of urine. Pertinent interventions included, offer toileting upon awakening, before meals, and after meals, in the afternoon and prior to going to bed. The resident required extensive assistance with toileting. D. Staff interview CNA #2 was interviewed on 3/27/23 at 10:50 a.m. CNA #2 said residents use the call lights when they need assistance going to the bathroom. She said sometimes she needed to remind the residents that CNAs could only come to help with toileting every two hours. She said sometimes the residents needed to wait so the CNAs could help the other residents. Based on observations, record review and interviews the facility failed to ensure that activities of daily living (ADL) for dependent residents were provided for two (#57 and #87) out of 47 sample residents. Specifically, the facility failed to: -Ensure Resident #57 was provided repositioning and personal hygiene assistance in a timely and consistent manner; and, -Ensure Resident #87 was provided timely incontience care. Findings include: I. Resident #57 A. Resident status Resident #57, under age [AGE], was admitted on [DATE]. According to the March 2023 computerized physician orders (CPO), the diagnoses included acute respiratory failure with hypoxia (low oxygen levels), depression, chronic pain, anoxic brain damage (complete lack of oxygen to the brain), dependence on supplemental oxygen, and anxiety. The 1/20/2023 minimum data set (MDS) assessment revealed the resident was in a persistent vegetative state with no discernible consciousness (coma). She was dependent on extensive assistance of two staff members with positioning in bed, transfers, dressing, eating, toilet use, and personal hygiene tasks. B. Observations A continuous observation was conducted on 3/28/23 beginning at 10:27 a.m. and concluded at 1:43 p.m. Resident #57 was observed to be lying in bed positioned on her back with the head of the bed elevated approximately 30 degrees. Resident #57 was observed to be unkempt as evidenced by facial hair grown out on her chin, her nails were approximately an inch in length from the cuticle, unfiled, with beige nail polish grown out appropriately a quarter of an inch from the cuticle. No staff were observed entering room of Resident #57 during the continuous observation. At 2:30 p.m. Resident # 57 was observed to be lying in bed positioned on her back. A continuous observation was conducted on 3/29/23 beginning at 8:30 a.m. and concluded at 10:55 a.m. Resident #57 was observed to be lying in bed positioned on her back with the head of the bed elevated approximately 30 degrees. No staff were observed entering room of Resident #57 during the continuous observation. Facial hair was observed on the chin area and fingernails continued to be outgrown and unfiled. On 3/29/23 at 11:00 a.m. Resident #57 was observed to be lying in bed positioned on her back with the head of the bed elevated approximately 30 degrees. Facial hair was observed on the chin area and fingernails continued to be outgrown and unfiled. A continuous observation was conducted on 3/29/23 beginning at 2:35 p.m. and concluded at 3:44 p.m. Resident #57 was observed to be lying in bed positioned on her back with the head of the bed elevated approximately 30 degrees. One staff member was observed entering the room of Resident #57 for a 10 minute duration of time. Upon exit of staff member, Resident #57 was observed to be lying in bed positioned on her back with the head of the bed elevated approximately 30 degrees. Facial hair was observed on the chin area and fingernails continued to be outgrown and unfiled. On 3/29/23 at 4:30 p.m. Resident #57 was observed to be lying in bed positioned on her back with the head of the bed elevated approximately 30 degrees. Facial hair was observed on the chin area and fingernails continued to be outgrown and unfiled. On 3/30/23 at 2:25 p.m. Resident #57 was observed to have the lower portion of the bed adjusted to bend knees, head of the bed elevated approximately 30 degrees; hospital gown presented as a different color and pillows were observed under the left side of her lower and middle back area. Resident #57 was observed to be unkempt as evidenced by facial hair grown out on her chin, her nails were approximately an inch in length from the cuticle, unfiled, with beige nail polish grown out appropriately a quarter of an inch from the cuticle. At 5:15 p.m. Resident #57 was observed to be lying on her back, lower portion of the bed adjusted to bend knees, head of the bed elevated approximately 30 degrees. Facial hair was observed on the chin area and fingernails continued to be outgrown and unfiled. C. Record review The care plan, dated 1/12/23, revealed Resident #57 had an activity of daily living (ADL) self care performance deficit (unable to perform independently) related to acute respiratory failure with hypoxia (low oxygen levels), anoxic brain damage (complete lack of oxygen to the brain); additionally she had arthritis, anxiety, chronic pain, and depression. The care plan revealed Resident #57 required total assistance from staff for toilet use, bed mobility, bathing, personal hygiene, dressing, eating, and transfers. The care plan, dated 1/12/23, retrieved from facility electronic health record on 3/28/23 at 4:51 p.m. did not indicate repositioning as an intervention for the (ADL) self care performance deficit (unable to perform independently). The care plan, dated 1/12/23, was provided by the nursing home administrator (NHA) on 4/4/23 at 2:09 p.m. It revealed a revision date or 3/30/23 for a bed mobility intervention to include turning and repositioning Resident #57 frequently for comfort and integumentary optimization (optimal skin integrity). The nursing progress note, dated 3/27/23 revealed Resident #57 was on check, change, and reposition scheduled every two hours; another dated 3/28/23, revealed Resident #57 was on a check and change schedule. Multiple nursing progress notes for the month of March 2023 revealed Resident #57 was to be checked, changed, and repositioned every two hours for comfort and skin integrity. The point of care (POC) response history, with a 30 day look back period, was retrieved from facility electronic health record on 3/29/23 at 3:21 p.m. It revealed nail care was not provided. D. Staff interviews CNA #10 was interviewed on 3/30/23 at 11:30 a.m. She said Resident #57 was on a check and change schedule. She said it entailed repositioning and checking for bowel or bladder incontinence. She said the check and change was to occur every two to three hours. She said repositioning was documented once a shift. She said it entailed alternating the use of pillows under the left or right side of a resident back. She said the foot of the bed was adjusted for repositioning. She said she had not provided nail care or facial hair removal care for Resident #57. CNA #9 was interviewed on 3/30/23 at 11:45 a.m. She said Resident #57 was to be repositioned every two to three hours. She said this was because of the vegetative state of the resident. She said repositioning was documented once a shift. She said the staff were to alternate pillows and adjust the foot of the bed as a method for repositioning. She said she has not provided nail care or facial hair removal care for Resident #57. Registered nurse (RN) #3 was interviewed on 3/30/23 at 12:20 p.m. She said bed bound residents should be repositioned, and checked for incontinence every two to three hours or as needed. The director of nursing (DON) was interviewed on 3/30/23 at 2:40 p.m. She said residents who were bed bound or in a persistent vegetative state were on a check and change schedule. She said it entailed a resident being repositioned and checked for incontinence every two hours. The minimum data set (MDS) coordinator was interviewed on 3/30/23 at 6:00 p.m. He said residents who were bedbound or in a persistent vegetative state should be on a repositioning schedule. He said this information should be included in the care plan.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and staff interviews, the facility failed to provide an ongoing program to support residents in their choice activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident, encouraging both independence and interaction in the community for two (#57 and #107) out of four residents reviewed for activity programming out of 47 sample residents. Specifically, the facility failed to offer and provide personalized activity programs for Resident #57 and #107 as documented in their care plan. Findings include: I. Facility policy and procedure The Activity Programs policy statement, revised January 2022, was provided by the activities director on 3/30/23 at 4:50 p.m. It revealed in pertinent part, It is the policy of this facility to ensure that activities are available to meet resident needs and interests that support the physical, mental, and psychosocial well-being of the resident. Activities may be facility-sponsored groups or independent. Activities: any endeavor, other than routine ADLs (activities of daily living), in which a resident participates that is intended to enhance her/his well being and to promote or enhance Physical, cognitive, and emotional health. These include, but are not limited to, activities that promote self-esteem, pleasure, Comfort, education, creativity, success, and Independence. II. Resident #57 A. Resident status Resident #57, age under 65, was admitted on [DATE]. According to the March 2023 computerized physician orders (CPO), the diagnoses included acute respiratory failure with hypoxia (low oxygen levels), depression, chronic pain, anoxic brain damage (complete lack of oxygen to the brain), dependence on supplemental oxygen, and anxiety. The 1/20/2023 minimum data set (MDS) assessment revealed the resident was in a persistent vegetative state with no discernible consciousness (coma). She was dependent on assistance of two staff members with positioning in bed, transfers, dressing, eating, toilet use, and personal hygiene tasks. B. Observations A continuous observation was conducted on 3/28/23 beginning at 10:27 a.m. and concluded at 12:23 p.m. Resident #57 was observed to be lying in bed positioned on back. The television was observed to be on the [NAME] channel (often plays reality shows). According to the resident's care plan (see below) preferred to watch religious services on television. The room was observed to have a small radio and an audio book player machine on top of the dresser. No meaningful activities were observed to be provided to Resident #57. At 2:30 p.m. Resident #57 was observed to be lying in bed positioned on her back. The television was observed to be on the same channel. No meaningful activities were observed to be provided to Resident #57. A continuous observation was conducted on 3/29/23 beginning at 8:30 a.m. and concluded at 10:55 a.m. Resident #57 was observed to be lying in bed positioned on her back. The television was observed to be on the same channel as was 3/28/23. No meaningful activities were observed to be provided to Resident #57. No staff were observed entering room of Resident #57 during the continuous observation. A continuous observation was conducted beginning at 2:35 p.m. and concluded at 3:44 p.m. Resident #57 was observed to be lying in bed positioned on her back. The television was observed to be on the same channel as earlier. One staff member was observed entering the room of Resident #57 for a 10 minute duration of time. Upon exit of the staff member, Resident #57 was observed to be lying in bed positioned on her back. The television was observed to be on the same specific station prior to staff member's entry and no meaningful activities were observed to be provided to Resident #57. On 3/30/23 at 2:25 p.m. the television was observed to be on the same station as the previous two days. The room was observed to have a small radio and an audio book player machine on top of the dresser. No meaningful activities were observed to be provided to Resident #57. At 5:15 p.m. Resident #57 was observed to be lying in bed positioned on her back. The television was observed to be on the same channel as was earlier on this day. No meaningful activities were observed to be provided to Resident #57. No staff were observed entering room of Resident #57. The television in room of Resident #57 had been on the same channel on 3/28/23, 3/29/23, and 3/30/23. No meaningful activities were observed to be provided to Resident #57 during the three days of observation. C. Resident records The activity admission evaluation, dated 1/18/23, revealed that Resident #57 had minimal difficulty hearing and her vision was moderately impaired. The activity evaluation revealed Resident #57 had an interest in music, singing, and listening to the radio. The activity evaluation revealed spiritual/religious interests that included religious services on television and visits from the facility Chaplain. The activity evaluation revealed Resident #57 enjoyed being outside in warm weather, and group activities involving manicures. The care plan, dated 1/12/23, revealed Resident #57 was interested in music, family, and spiritual interventions; she was to be provided three one-to-one therapeutic visits weekly for socialization and stimulation. The care plan revealed Resident #57 needed one-to-one visits if she was unable to attend out of room events; staff was to converse while providing care; she was to be provided with materials for individual activities such as radio or talking books; she needed to be escorted by staff to activity functions. The care plan revealed the preferred interests of Resident #57 were music, gentle touch, spiritual visits, and family visits. The one-to-one activity log for Resident #57 for the month of March 2023 revealed four times of her being read too, two times of music, one time of talking book, one Chaplain visit, and four times auditory stimulation. D. Calendar of events The March 2023 activity calendar documented the following activities on 3/28/23, 2/29/23, and 3/30/23. On 3/28/23: 10:30 a.m. Rhythmic drumming 2:00 p.m. Walmart outing On 3/29/23: 10:30 a.m. Manicures 2:30 p.m. Women's history Q&A (question and answer) 6:00 p.m. Game night On 3/30/23: 10:30 a.m. Bingo 2:30 p.m. Travel video 5:00 p.m. Grizzly [NAME] outing -Manicures were observed to be listed on the March 2023 activity calendar every Wednesday and listed as a preferred group activity of Resident #57. The resident was not provided nail activity on 3/29/23. E. Staff interviews The activities director (AD) was interviewed on 3/30/23 at 11:00 a.m. She said Resident #57 had passive stimulation during the day. She said passive stimulation included having the television on. She said music and books on tapes were considered passive and should be alternated from television. She said Resident #57 received one-on-one visits during the week. She said these visits included a tactile component (involving touch). She said this is primarily a hand massage. She said the certified nurse aides (CNA) assisted with activities when activities staff were unable. CNA #10 was interviewed on 3/30/23 at 11:30 a.m. She said the television was mainly on for Resident #57. She said activities staff read to Resident #57. She said she occasionally turned on the radio. She said she conversated with Resident #57 while providing care. CNA #9 was interviewed on 3/30/23 at 11:45 a.m. She said the televisions was mainly on for Resident #57. She said she was unaware of what activities staff did for Resident #57. She said she did not switch out television for radio or books on tape. CNA #11 was interviewed on 3/30/23 at 12:00 p.m. She said she was not familiar with what the resident liked or disliked. II. Resident #107 A. Resident status Resident #107, age [AGE], was admitted on [DATE]. According to the March 2023 computerized physician orders (CPO) diagnoses included dementia, mood disturbance, and anxiety. The 1/5/23 MDS assessment showed the resident had severe cognitive impairment with a score of one out of 15 on the brief interview for mental status. The resident required extensive assistance with activities of daily living. The preferences showed it was very important for the resident to have animals around her and to participate in religious services, and somewhat important to listen to music, to do things with groups of people, to do her favorite activities, and to be outside when the weather was good. B. Observations 3/27/23 -At 9:00 a.m., the resident was in the lounge chair in the common area. The resident was awake, the TV was on however, the volume was not loud. The resident had no meaningful activity. -At 10:30 a.m., the resident was sitting in her recliner in the common area. She was awake, the TV was on however, the volume was not loud. The resident had no meaningful activity. -At 2:06 p.m., the resident was in the lounge chair. She was asleep in the recliner On 3/28/23 -At 12:22 p.m., the resident was in the lounge chair in the common area. She was sleeping. -At 3:30 p.m., the resident was sitting in the lounge chair. She had no meaningful activity. The TV was on but the volume was low. 3/29/23 -At 10:53 a.m., the resident was sleeping in the lounge chair. Music was playing, however it could hardly be heard. -At 11:50 a.m., the resident was in the dining room. She had nothing to do while she waited for her meal. She did not have a magazine to look at as the care plan directed (see record review). -At 12:22 p.m., the resident was in the dining room awaiting her meal. However, she had nothing to do. The meal began to serve at 12:30 p.m. -At 12:37 p.m., the resident received her meal. -At 12:39 p.m., a certified nurse aide (CNA) sat with the resident to assist with eating, however, she did not talk with the resident. -At 1:28 p.m., the resident was assisted out of the dining room back to the recliner in the common area. The resident was not offered any activity when the CNA left the resident. -At 2:41 p.m., the resident was sitting in the recliner. Nothing was happening. The music was on in the lounge, however, it could hardly be heard. 3/30/23 -At 7:50 a.m., the resident was in the dining room at the table. She was awaiting her meal. She had nothing to do as she sat there. The dining room had no music on -At 8:11 a.m., the resident continued to wait in the dining room for her meal. She had no meaningful activity while she waited. The music was turned on in the dining room. -At 8:30 a.m.,the resident continued to sit in the dining room awaiting her meal. She had no magazine to look at, as the care plan directed. -At 3:22 p.m., the resident was awake in the lounge chair, however, nothing was going on. -At 7:50 p.m., the resident continued to sit in the recliner in the common area awake. She had no meaningful. C. Record review The care plan last revised on 1/5/23 identified the resident had interest in family visits,music, sensory based programs and Catholic visits. The care plan documented she needed two to three social visits weekly for invites and reminders and assistance. Pertinent approaches included, staff to converse during care, invite to scheduled activities, preferred activities were music, television, sensory based programs, Catholic visits, outdoors in nice warm weather. The 1/5/23 activities progress note documented, the resident was receiving hospice services. She was able to make her needs known with invites to recreational activities. She needed assistance to and from locations in her wheelchair. She enjoyed being in the social area, people watching and viewing the fish aquarium, television and listening to music. In the dining area she occasionally looked through magazines. She was offered Catholic visits weekly. She accepted two to three activities a week. Participation records from 3/5/23 to 3/26/23 showed she participated in one religious activity, she was not available for one activity and one activity she refused. The participation records from 3/1/23 to 3/30/23 showed out of 18 opportunities the resident only participated in two activities. The records documented, she was not available for the 16 times. D. Staff interview The activity director (AD) and the activity assistant (AA) were interviewed on 3/30/23 at approximately 4:30 p.m. The AD said the resident had a supportive family and visited on a regular basis. She said the resident had a history of falls. The AD said she agreed the resident did sit around more this week. She said the resident was able to voice if she wanted to go to an activity when asked. However, at times the CNA would not get the resident to the group activity. She said that the not available could also be that the resident was sleeping. She said dogs were new to coming to the building. The resident was not on a one-on-one program. She said a tactile blanket had not been tried, but the resident would benefit from touch stimulation. The AD said there were activity packets which included puzzles which were available for the dining room.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interviews, the facility failed to ensure one (#87) of three residents out of 47 sample residents with limited mobility reviewed for range of motion (ROM) received appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion. Specifically, the facility failed to establish a consistent restorative nursing program for Resident #87. Findings include: I. Facility policy The Restorative Nursing Manual, revised July 2017, provided by the nursing home administrator (NHA) on 3/29/23 at 4:00 p.m. read in pertinent part: Any member of the interdisciplinary team (licensed nurses, therapists, certified nursing aides, dietary, social services or activities), may refer a resident to the Restorative Nursing program. A nurse manager and/or therapist will make the determination as to the specific program plan. The interdisciplinary care plan will reflect the plan of care for meeting the restorative needs of each resident including problems/needs, measurable goals and individualized approaches. All disciplines will make recommendations for the plan of care. Nursing and rehab are responsible for documentation of the restorative nursing program plan of care. II. Resident #87 A. Resident status Resident #87, age [AGE], was admitted on [DATE]. According to the March 2023 computerzied physician orders (CPO) diagnoses included schizoaffective disorder, post-traumatic stress disorder (PTSD) and urge incontinence. The minimum data set (MDS) assessment dated [DATE] showed the resident had a brief interview for mental status (BIMS) score of 15 out of 15. The resident required extensive assistance from one person with activities of daily living. There were no therapy or restorative minutes coded. B. Observation and interview Resident #87 was observed on 3/27/22 at 10:25 a.m. Resident #87 was observed sitting in her wheelchair with her right arm on the armrest and her right hand was curled inward towards her body. She did not have any type of splint on her right. The resident was interviewed on 3/28/23 at 10:31 a.m. She said she would like to receive therapy. C. Record review The care plan initiated on 12/6/22 identified the resident with limited physical mobility related to muscle weakness and documented the resident was on a restorative program for walking. Pertinent interventions included ambulate with stand by assistance and front wheel walker in hall up to 150 feet up to seven times per week, standing with front wheel walker marches, hip abduction, heel raises, sit to stand, wall slide, push ups and seated chair dips up to seven times weekly. -The resident did not have a care plan for the restorative program or range of motion exercises for upper extremities. The care plan failed to include the limited range of motion (ROM) for upper extremities. The progress note for 1/20/23 documented range of motion (ROM) within normal limits (WNL) for lower extremities and had limited ROM of upper extremities. III. Staff interview The restorative nurse aid (RNA) was interviewed on 3/29/23 at 1:37 p.m. The RNA said Resident #87 was discharged from physical therapy and to a restorative program. She said at times she was pulled to work the floor as a certified nurse aide (CNA), so the ROM or restorative exercises did not occur.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to manage pain in a manner consistent with professional standards of practice for one (#61) out of three residents out of 47 sample residents. Specifically the facility failed to: -Complete a thorough pain assessment for Resident #61 when she experienced an increase in pain; -Ensure the as needed (PRN) pain medication was available for Resident #61; and, -Follow-up on recommendations for Resident #61 from the pain clinic. Findings include: I. Facility policy and procedure The Pain Management policy, not dated, read in pertinent part, The facility must ensure that pain management is provided to residents who require such services consistent with professional standards of practice, the comprehensive person-centered care plan and the resident's goals and preferences. II. Resident #61 A. Resident status Resident #61, age [AGE], was admitted on [DATE]. According to the March 2023 computerized physician orders (CPO) diagnoses included diabetes mellitus with diabetic neuropathy, major depressive disorder and chronic pain. The minimum data set (MDS) assessment coded the resident as having no cognitive impairment with a score of 15 out of 15 on the brief interview for mental status (BIMS). The MDS assessment coded the resident as having a scheduled pain regimen and receiving an as needed pain regimen. B. Resident interview Resident #61 was interviewed on 3/28/23 at 11:40 a.m. The resident said she had pain in her in her legs and the pain was worst in her knees. She said she was told that she could not have an as needed pain medication, if she received scheduled pain medication. She said the pain medications were scheduled three times a day, however she had pain between the scheduled medications. She said there were no non-pharmalogical interventions for her pain. Resident #61 was interviewed a second time on 3/30/23 at approximately 5:00 p.m. The resident said when she had the breakthrough pain it was extremely uncomfortable and that she lost sleep. She said that it hurt and kept her awake. She said when she told the nurses and she was told that she could not get any pain medication until later. C. Pain management plan The March 2023 CPO showed an order for the resident's pain level to be checked every shift using a 0-10 pain scale. 0=no pain, 1-3=mild pain, 4-5=moderate pain, 6-9=severe pain and 10=excruciating pain. The March 2023 CPO and recent physician telephone orders revealed current orders for pain control include: -Gabapentin 300 milligrams (mg) two capsules by mouth three times a day for diabetic neuropathic pain with a start date of 1/18/23; and, -Roxicodone 5 mg one tablet by mouth three times a day for pain management with a start date of 12/1/22. D. Pain assessment and care plan The care plan last reviewed on 12/5/22 identified the resident had chronic pain. Interventions included to monitor characteristics of pain, and any non verbal signs of pain and notify the physician if interventions were unsuccessful. -No non-pharmological interventions were indicated on the care plan, the location of the resident's pain, her tolerable pain level and recommendations from the pain clinic (see below). The pain assessment dated [DATE] documented the resident had pain daily or several times a day. The pain was in her back and joint pain. The assessment showed the pain was worst in the early morning and it was an [NAME], burning, dull, and tingling sensation. She had an acceptable pain level of three. The March 2023 medication administration record (MAR) showed the resident was experiencing pain from 3/1/23 to 3/30/23 with a score of more than 3, her acceptable pain level: -Pain level of 8 (severe pain) during the night pain assessment seven times from 3/1/23 to 3/29/23. -Pain level of 7 during the night pain assessment four times from 3/1/23 to 3/29/23. -Pain level of 4-5 (moderate pain) during the day pain assessment 23 times from 3/1/23 to 3/30/23. -Pain level of 6-9 (severe pain) during the day pain assessment three times from 3/1/23 to 3/30/23. E. Failure to follow up on pain clinic recommendations The 1/13/23 pain clinic documented the pain can range from 4-9/10. She describes the pain as constant deep, aching, throbbing, sharp, stabbing, burning. Alleviating factors include changing positions often sitting, laying, down, heat, ice, rest, elevation, limited weight bearing. Exacerbated with prolonged sitting standing, walking lifting, carrying twisting weather changes, changing clothes, going from sitting to standing, sneezing, flexation, extension. She denies recent spinal imaging. Patient presents with a pain score of 8/10 with medication. She complains of pain located in her knees, back and left foot. She describes this pain (sic) as constant, but her pain fluctuates, throughout the day because her muscles spasm randomly. She said the pain worsens with walking and too much movement and it is better with hot showers and propping her feet up. The plan from the pain clinic was to continue with prescribed pain medications; Prescribe P 3X (joint and muscle cream) topical to affected areas 1-2 times a daily as needed; and, Prescribe CBD (pain cream) topical to affected areas 1-2 times a daily as needed to affected area. -The pain clinic orders were signed off by the facility staff on 2/13/23 (over a month later). The medical record failed to show the topical medications were ordered. In addition, non-pharmological interventions indicated by the pain clinic were not incorporated into her pain regimen. III. Interview Registered nurse (RN) #2 was interviewed on 3/30/23 at 4:07 p.m. The RN reviewed the medical record and physician orders. RN #2 confirmed the resident did not have any as needed (PRN) medications. She confirmed the resident frequently had pain at an eight (severe pain) when she administered the scheduled pain medication. She said those medications were effective, but never brought her pain to a zero. The RN reviewed the pain clinic notes dated 1/13/23. She said the pain clinic had given orders for two PRN creams, she said the orders should have been noted and written. She said she was going to text the primary care physician (PCP) and inquire about the topical creams the pain clinic ordered on 1/13/23 and whether a breakthrough PRN medication could be ordered. IV. Facility follow-up The PCP provided the following orders on 3/30/23 at 4:33 p.m. The physician ordered: -Voltaren External Gel 1 % (Diclofenac Sodium) topical, Apply to affected areas topically every 6 hours as needed for pain apply 2 grams to knees, shoulders and other affected joints; and, -PRN oxycodone order.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** III. Resident #87 A. Resident status Resident #87, age [AGE], was admitted on [DATE]. According to the March 2023 computerized physician orders (CPO), the diagnoses included schizoaffective disorder, post-traumatic stress disorder (PTSD), major depressive disorder, and anxiety disorder. The minimum data set (MDS) dated [DATE] showed the resident had a brief interview for mental status (BIMS) score of 15 out of 15 and was cognitively intact. She had no behaviors and did not reject care. She had a diagnosis of PTSD and received an antidepressant and antianxiety medication daily. B. Resident interview Resident #87 was interviewed on 3/28/23 at 10:19 a.m. She said the facility did not address her PTSD. She said she had a male certified nurse aide (CNA) come in to provide care on more than one occasion which included personal care. She said that it made her uncomfortable due to her history of rape. C. Record review The facility was unable to provide a care plan related to Resident #87's post-traumatic stress disorder to include person-centered individualized interventions, personalized triggers, or personalized signs and symptoms. The psychological services progress note dated 3/9/23 identified Resident #87 with PTSD and listed a goal to identify a list of triggers associated with trauma (s). The social services assessment/evaluation dated 1/17/23 did not address Rresident #87's PTSD. V. Staff interviews Licensed practical nurse (LPN) #4 was interviewed on 3/29/23 at 11:35 a.m. She said the facility tracked resident's behaviors on the medication administration record (MAR). She said she was unsure how the staff would have known if the resident had a history of trauma. LPN #4 said she thought it would be helpful to know this history if the resident had disclosed it. She said it would have helped the staff with how to approach a resident with a trauma history The unit manager (UM) was interviewed on 3/29/23 at 11:59 a.m. She said the staff would not have known if the resident had a history of trauma unless they had disclosed it to the provider and it was documented in the history and physical. CNA #5 was interviewed on 3/30/23 at 8:40 a.m. She said she did not know how the staff would have known if the resident had a history of trauma or if that contributed to any behavior seen with residents. CNA #5 said she did not know if specific resident centered approaches were part of the residents care plan for their behavior and/or history of trauma. She said it would be helpful to have specifics about resident's lives if they chose to disclose this information so the staff knew how to approach them. CNA #6 was interviewed on 3/30/23 at 8:47 a.m. She said she had behavior training in the past for aggressive behavior, but she did not know how the staff would have known what specific approaches to use for a resident who had behavior issues and or a history of trauma. LPN #5 was interviewed on 3/30/23 at 8:50 a.m. She said if a resident had a history of trauma, it should have been care planned with specific interventions on how to care for them. Based on record review and interviews, the facility failed to ensure that a resident who was a trauma survivor received culturally competent, trauma-informed care in accordance with professional standards of practice and accounting for residents' experiences and preferences in order to eliminate or mitigate triggers that may cause re-traumatization of the resident for two (#87 and #117) of four residents reviewed out of 47 sample residents. Specifically, the facility failed to identify Resident #87 and #117 post traumatic stress disorder (PTSD) and identify triggers which may retraumatize them. Findings include: I. Facility Policy The Trauma Informed Care policy and procedure, revised November 2019, was provided by the social service director (SSD) on 3/30/23 at 12:00 p.m. It read in pertinent part: It was the policy of the facility to ensure residents who were trauma survivors received culturally competent, trauma-informed care in accordance with professional standards. The facility will account for residents' experiences, preferences, and cultural differences in order to eliminate or mitigate triggers that may cause re-traumatization of the resident. Potential causes of re-traumatization by staff may include, but are not limited to: -Being unaware of the residents' traumatic history; -Failing to screen resident for trauma history prior to treatment planning; -Challenging or discounting reports of traumatic events; -Endorsing a confrontational approach to counseling; -Failing to provide adequate safety; -Minimizing, discrediting or ignoring resident responses. II. Resident #117 A. Resident status Resident #117, age [AGE], was admitted on [DATE]. According to the March 2023 computerized physician orders (CPO) diagnoses included traumatic brain injury (TBI), chronic pain syndrome anxiety with depression. The 2/7/23 minimum data set (MDS) assessment indicated the resident was moderately cognitively impaired with a brief interview of mental status (BIMS) score of nine out of 15. He required supervision of one staff member for bed mobility, transfers, dressing, and personal hygiene. He required limited one person assistance with toileting. According to the MDS assessment, Resident #117 had verbal behaviors directed towards others, rejection of care and symptoms of depression. He was on an antidepressant daily. B. Record review The 2/1/23 hospital notes, prior to admission to the facility and located in the resident's electronic medical record, documented in pertinent part, that the resident had anxiety with depression, a traumatic brain injury and was in a motor vehicle accident resulting in multiple surgeries to his left lower extremity and causing him to be disabled. Additionally, the hospital notes documented possible dementia with generally feeling unwell, malaise (general feeling of discomfort) and ETOH (alcohol abuse). On 2/7/23 at 11:46 a.m., the social service assessment documented, Currently he utilizes Venlafaxine (antidepressant) for diagnosis of anxiety/depression. Resident #117 reported feeling down depressed/hopeless, having trouble falling asleep, feeling tired, feeling bad about himself and moving/speaking so slowly that others may have noticed. Resident #117 reported 'experiencing trauma when in he was physically attacked by a (person of color) at a store in Alaska in 2013.' He reported that seeing (person of color) is a trigger for him. Resident #117 was verbally aggressive toward staff and refused care. -However, there was no further discussion documented with the resident about his needs or preferences related to the history of trauma. On 2/7/23 at 3:54 p.m. the nursing notes documented, Nursing entered patient room and he yelled at her, stating, 'Get out of my room before I call 911. ' On 2/8/23 at 1:44 p.m., the skilled nursing note documented, Resident intermittently agitated, anxious, verbally abusive to staff, decreased participation, depressed feelings or statements, anger issues, verbal behavior directed to others, rejection of care resident expresses frustration with facility, staff, overwhelmed by number of different people caring for him. On 2/8/23 at 3:19 pm, the social service note documented by the social service assistant (SSA), documented in part, Writer spoke with the resident's representative later about Resident #117's reports that staff were 'getting in his face and yelling at him.' Writer informed the North Unit Manager and together attempted to speak with Resident #117 to get more details in an attempt to address his concerns. Resident #117 became very hard to understand but kept on pointing at the writer stating that writer needed 'to listen to him as he was the patient, that the writer is supposed to do whatever he needs, and that he wanted to have some peace and quiet so he can rest.' The writer determined that he may need his furniture to be arranged differently due to the placement of his bed and the call light, where it may appear that staff is 'in his face' since his call light is located by the head of his bed. In addition, the note documented the writer placed a sign for Resident #117's door to remain closed as much as possible per his preference since he was complaining that staff were loud in the morning and that his door was opened. Furthermore, the social service note documented the SSA had spoken to the resident's insurance about a complaint the resident had filed regarding his care at the facility. It further documented Resident #117 and the resident's representative had requested the resident transfer to another facility. The note further documented Resident #117 and the resident's representative had been offered mental health services on 2/6/23, and had declined. -There was no documentation that the SSA spoke to Resident #117 about rearranging his room, or whether he was in agreement with that plan. There was no documentation about when he had complained about the staff being loud in the morning or when he had requested to have his door remain closed per his preference. The baseline care plan, initiated 2/3/23, was reviewed. -The care plan did not include the resident's anxiety with depression, trauma, or any specific interventions related to Resident #117. It did not include information from the resident's admitting nursing assessment on 2/3/23, about being anxious and withdrawn at times. There were no resident centered interventions based on the resident's choices or preferences. The care plan did not address the resident's behavior. There were no revisions to the baseline care plan after the 2/7/23 social service assessment documenting the trauma related to being assaulted. There were no interventions related to noise and keeping the residents door closed. There was no documentation the baseline care plan was reviewed with the resident or the resident's representative for input into what interventions would be helpful for the resident. Cross-reference F655 baseline care plans. C. Staff interviews CNA #3 was interviewed on 3/29/23 at 11:50 a.m. She said she remembered Resident #117 and had cared for him. She said Resident #117 was outspoken and cussed sometimes or called the staff names. She said when Resident #117 did cuss or call her names; she had no specific interventions for his behavior. She said she was not aware he had a history of being physically assaulted, his anxiety or depression. CNA #3 said she had never been told about any specific approaches, interventions or triggers for Resident #117. CNA #3 went to the nurse's desk and pulled up Resident #117's care plan on the computer. She said there was no care plan with interventions for his behavior, trauma or depression. The social service director (SSD) and social service assistant (SSA) were interviewed on 3/30/23 at 10:30 a.m. The SSD said residents should have a care plan with specific interventions for behavior, including a history of trauma and triggers for behavior. She said she thought Resident #117's trauma could be part of his agitation, but she did not know. She reviewed the care plan on her laptop and said there was no care plan related to his behavior, interventions for depression, or trauma. She said Resident #117 should have had a care plan for those areas especially if some of his triggers were known and the care plan would link to a [NAME] (abbreviated plan of care) for the CNAs to use. The SSD said he had a care plan for cognition, but she said that did not address his specific needs related to trauma.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure one (#96) resident out of 47 sample residents received the appropriate treatment and services to maintain their highest practicable physical, mental, and psychosocial well-being. Specifically, the facility failed to effectively identify person-centered approaches for dementia care for Resident #96. Findings include: I. Facility policy The Dementia Care policy, last revised March 2016, was provided by the nursing home administrator (NHA) on 4/4/23 at 2:09 p.m. it read in pertinent part: It is the policy of this Facility to provide residents with dementia with an environment designed to attain or maintain the highest level of functioning and well-being possible, taking into consideration the resident's medical condition and functional status. When providing care and services for a resident with dementia, the Facility will have a program designed to meet the identified needs of the residents; develop and implement program policies and procedures; and train all staff, who have resident contact, in the special needs and care approaches applicable to residents with dementia. A nursing home that has a locked or secured dementia unit must: Always have staff present in the unit, available to meet the needs of the residents and to protect them in the event of an emergency; Have staff available to assist residents, as needed, in accessing outdoor areas; Have admission, transfer, and discharge criteria which ensures that: the process of informed consent is followed before admission to or transfer/discharge from the unit; The resident is provided with unit specific admission or transfer/discharge criteria, prior to admission to the unit; The resident's need for admission to the unit from another part of the nursing home, or transfer/discharge from the unit, is based on the comprehensive assessment and plan of care;through an evaluation prior to admission, a resident admitted directly from outside the nursing home meets the cognitive and functional criteria of the unit; and in the case of an individual admitted directly to the unit from outside the nursing home, as specified above, the nursing home may complete the comprehensive assessment after the individual's admission to the unit, provided that the nursing home complies with required time frames for completion of the resident assessment. II. Resident status Resident #96, age [AGE], was admitted on [DATE]. According to the March 2023 computerized physician orders (CPO), diagnoses included restlessness and agitation, dementia and chronic obstructive pulmonary disease. The 3/9/23 minimum data set (MDS) assessment documented the resident had severe cognitive impairment. The brief interview for mental status (BIMS) was not completed because the resident was not understood. The MDS assessment coded the resident had long and short term memory problems.The MDS assessment coded the resident required extensive assistance of one person for toileting, dressing, bed mobility, transfers and personal hygiene. The MDS assessment coded the resident required total dependence of one person for locomotion on and off unit, eating and bathing. The resident was incontinent of bowel and bladder and used a wheelchair for mobility. The resident was coded for not having any behaviors. The MDS assessment coded the resident as Spanish speaking only. The MDS assessment for preferences for customary routine and activities was incomplete and did not document the resident ' s preferences. III. Observations On 3/27/23 Resident #96 was observed from 8:30 a.m. to 11:30 a.m. sitting on the edge of a recliner in the living room watching television (TV). Staff did not interact with the resident, although the resident would extend her arms out, look at staff and utter sounds. She was not offered a one-to-one activity visit or offered participation in other activities. The resident did not have any activities or stimulation during that time period. On 3/28/23 Resident #96 was observed from 8:30 a.m. to 6:00 p.m. sitting on the edge of a recliner in the living room watching TV. Staff did not interact with the resident, although the resident would extend her arms out, look at staff and utter sounds. She was not offered a one-to-one activity visit or offered participation in other activities. The resident did not have any activities or stimulation during that time period. The TV was on in the common area, however, it was not loud, and it was an English speaking TV show. On 3/29/23 at 10:30 a.m., the resident was sitting in the common area, she did not have any meaningful activity. She would reach her hand out as staff passed by, however, no staff would stop to visit, or to assess her needs. At 3:57 p.m. Resident #96 was assisted to the common area. The certified nurse aide (CNA) sat the resident into the recliner, however, she did not speak to the resident and did not provide her with any activity. On 3/30/23 at 8:00 a.m., the resident was assisted to the common area. She remained in her wheelchair. The CNA did not talk to the resident prior to leaving, or provide any activity. At 8:20 a.m.,the resident received her breakfast meal. The resident was assisted by an unidentified registered nurse (RN). The RN assisted the resident, however, there was no communication, no interaction as she took each spoonful of food and gave it to the resident. The resident would attempt to touch the plate, the RN would brush her hand away from the food plate. IV. Record review The activity focused care plan, last updated on 3/17/23, identified the resident was dependent on staff for activities, cognitive stimulation, social interaction related to dementia. She had interests in sensory bases programming, busy items, music and gentle touch. She required 1:1 (one-to-one) therapeutic visits and to be provided with spiritual support. Her identified goals were to engage in three one-to-one therapeutic visits weekly for sensory stimulation and social interaction by being awake, moving around, holding hands and fidgeting with items. Review of the 2/27/23 to 3/27/23 activity participation records, including one-to-one visits revealed Resident #96 participated in independent activities in the living room [ROOM NUMBER] percent of the time to include watching tv. She participated in walking and wheeling activities 11 percent of the time that included visiting with staff, folding and or rummaging with clothes simultaneously during the time she watched tv. -The records failed to show any touch stimulation or Spanish speaking activities. V. Staff interviews CNA #7 was interviewed on 3/28/23 at 10:01 a.m. She said Resident #96 preferred to get up at 8:00 a.m. and required total assistance to get the resident dressed, showered, personal hygiene and incontinence care. CNA #7 provided activities to the resident such as painting nails, turning on the radio, playing with blocks and turning on the television. CNA #7 said the resident spoke Spanish as her primary language and hard of hearing. The CNA said Resident #96 never said anything but made noises and could not make her needs known, and the facility did not use an interpreter although she was Spanish speaking only. The CNA said phrases in Spanish were used, but she still used English even though she could not understand, and she kind of guessed what she wanted. She said there were Spanish speaking employees and they attempted to understand what she was saying. CNA #7 said Resident #96 spent her day watching tv in English and playing with blocks. The resident hung out all day in the living room and did not participate in activities. The activity director (AD) was interviewed on 3/30/23 at 4:19 p.m. She said Resident #96 was on three one-on-one specialized visits each week, which usually lasted 15 minutes a session. The AD said that 45 minutes per week was enough for Resident #96 to maintain activity and socialization needs. Resident #96 ' s visits were gauged towards sensory hand massages, TV and movies. The resident had a sensory basket to use, but she started chewing the items so we removed it. The resident engaged in chaplain and religious services. Other interventions activities staff provided include reading to her in English, companionship and light massage. The resident spent her day resting in the recliner watching tv and listening to music in English. Activities staff communicated with the resident in English and it was hard to know if she understood staff due to her dementia. The resident did not understand English, and did not necessarily follow directions and she was not sure if it was due to the language barrier. The facility had Spanish speaking volunteers but activity staff have never used the service. The facility had done general dementia care training but activity staff had not provided individualized dementia care training to nursing staff based on the resident ' s needs. -Although the AD said during the interview the resident was busy doing independent activity, and staff initiated activity, during the observations (see above) showed this did not occur.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident and staff interviews and record review the facility failed to assist a resident to obtain routine or emergency dental services, as needed, for one (#4) out of 47 sample residents. Specifically, the facility failed to provide dental services for Resident #4. Findings include: I. Resident #4 A. Resident status Resident #4, age [AGE], was admitted on [DATE]. According to the March 2023 computerized physician orders (CPO) diagnoses included dysphagia (swallowing difficulty) and hypertension. The 2/8/23 minimum data set (MDS) assessment coded the resident with a brief interview for mental status of 13 out of 15. The resident required extensive assistance with personal hygiene. The MDS assessment dated [DATE] was coded incorrectly and documented the resident had no natural teeth. -However, the resident did have natural teeth. B. Resident interview The resident was interviewed on 3/28/23 at 10:51 a.m. The resident said he needed to see a dentist. The resident was interviewed a second time on 3/29/23 at 2:03 p.m. The resident said he needed to see a dentist, as he was having pain when he ate certain foods on his lower teeth. C. Record review The 1/20/23 dental note documented an oral evaluation and the chief complaint was pain to the both upper and lower posterior teeth. (#30 tooth) and (#2 tooth). The note documented an offer would be developed and possible extractions. The 2/15/23 dental note documented the resident was out of the facility and was not seen. He would be seen next visit. -The resident's medical record failed to show any further followup on the possible extractions. II. Interviews The director of nurses (DON) was interviewed on 3/30/23 at 2:24 p.m. The DON said the social service department handled all of the dental services. The social service director (SSD) was interviewed on 3/30/23 at 3:32 p.m. The SSD said she had a dentist who came into the facility monthly and when needed. She said she knew the resident needed to see a dentist, but did not know he was having pain when he ate certain foods. She said he missed the last dental visit in February 2023, as he was out of the building. The SSD said she had not contacted the dentist to reschedule. She said that she had developed a performance improvement plan to ensure dental visits were timely, however, she had not started any audits.

Based on observations and interviews, the facility failed to ensure residents received notices orally and in writing which included a written description of their legal rights. Specifically, the facility failed to post a list of names, addresses and telephone numbers of the State Agency in the facility. Findings include: I. Resident group interview The resident group interview was conducted on 3/30/23 at 3:00 p.m. The group consisted of five alert and oriented residents selected by the facility. All five residents (#61, #45, #72, #85 and #56) said they did not know where the facility posted information in regardS to State Agency contact information, nor did they know how to contact the States Agency. II. Observations Observations, on 3/30/23, throughout the building revealed there was no posting which informed resident's how to contact the State Agency.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to ensure residents were provided prompt efforts by the facility to follow up on grievances. Specifically, the facility failed to file and follow up on resient grievances related to: -Missing clothes and items; and, -Call light times. Findings include: I. Facility policy and procedure The Grievances policy and procedure, last revised in November 2022, was provided by the social services director (SSD) on 3/29/23 at 2:47 p.m. It read in pertinent part, It is the policy of this facility to establish a grievance process to: address resident concerns without fear of discrimination or reprisal. Such grievances include those with respect to care and treatment which has been furnished as well as that which has not been furnished (examples may include the behavior of staff and of other residents; and other concerns regarding their facility stay; Make prompt efforts to resolve grievances the resident may have. Ensure information regarding how to file a grievance is made available to the resident, either individually or through postings in prominent areas throughout the facility, and includes the name and contact information of who to file a grievance and policy. Resident and/or Resident Representatives have the right to file a grievance orally or in writing, the right to file grievances anonymously, and obtain a written decision regarding his or her grievance as requested. Copies of the Grievance Resolution Forms are available from the Social Services Designee or Grievance official and at designated locations throughout the facility. These forms are to be initiated when grievances are reported. The Grievance official or designee responds to the individual expressing the concern within (3) working days of the initial concern to acknowledge receipt and describe steps taken toward resolution. II. Grievances for missing clothes and items A. Resident interviews Resident #44 was interviewed on 3/27/23 at 11:43 a.m. Resident #44 said she was missing an item of clothing. The item was a blue hoodie (sweatshirt). Resident #34 was interviewed on 3/27/23 at 2:05 p.m. She said she had been missing a tall coffee mug since Christmas. She reported the missing item to staff but nothing got done about the situation. She said staff get into her drawers and move things around. Resident #97 was interviewed on 3/27/23 at 3:36 p.m. He said he was missing three items of clothing and he reported it to staff a week ago but they did not do anything about it. Resident #102 was interviewed on 3/27/23 at 3:36 p.m. he said he was missing a N95 mask and three pairs of socks. He said he wore shoes without socks because all of his socks were missing. He said he was missing fingernail clippers with traction on the handle. He said he reported it to staff and had not heard back. Resident #37 was interviewed on 3/28/23 at 9:42 a.m. She said she filed a complaint to staff about two Broncos jerseys that went missing. The facility gave them to another resident and never took them back from the other resident. She said the facility replaced them with new ones. She said she did not want new ones and wanted the old ones back. Resident #87 was interviewed on 3/28/23 at 10:22 a.m. She said she was missing catalogs, soda and perfume. Resident #29 was interviewed on 3/28/23 at 10:33 a.m. She said $60 or $70 dollars went missing the first night in the facility along with several other small items and she told people running the place but they did not do anything about it. Resident #4 was interviewed on 3/28/23 at 10:48 a.m. She said he was missing blankets and clothes. Resident #61 was interviewed on 3/28/23 at 11:34 a.m. She said she was missing clothes after they were sent to be laundered by the facility and never returned back. She reported it to staff and had not heard back. Resident #14 was interviewed on 3/28/23 at 1:05 p.m. She said she was missing clothes and little odds and ends. She said before Christmas, she took some of her property out of the facility due to it going missing and only had clothes at the facility she did not care about losing. C. Staff interviews The laundry service staff member/housekeeper (HSKP) #2 was interviewed on 3/28/23 at 11:20 a.m. HSKP #2 said it was the laundry services department to tag the property with the resident's name. If a clothing item came with no name, it was placed to the furthest left of the rack. At the time of the interview, HSKP #2 said there were seven unlabeled and unaccounted items of clothing on the rack that was just delivered. There have been times when a resident had lost their property because it was unlabeled, when that happens, the certified nurse aide (CNA) or resident complained verbally. Then the laundry staff let the resident describe the item to them and then they looked for it and if the item matched the description they gave the resident the item. The housekeeping and laundry manager (HLM) was interviewed on 3/28/23 at 11:34 a.m. The HLM said CNAs dropped off dirty laundry everyday and the laundry staff delivered clean laundry everyday, and at times laundry staff delivered two times a day. The CNAs brought the laundry to the dirty side, which typically were two barrels for each wing. The CNA tagged the laundry before it came down. When property came to the laundry department unlabeled, they asked the CNA staff if they recognized the item. If the CNA could not identify any of the unlabeled items laundry staff would then hold them for a week or two then if they were still unaccounted for, the clothes would go to the donation pile or the social services department. The HLM said sometimes they were told of missing clothes complaints verbally or the social services department provided a note. Typically they received three complaints a week for missing property. When a resident had lost clothing, a description of the clothes was requested. The HLM said the donation pile and unlabeled rack was checked to see if the clothing item was found. Lastly, if laundry staff find the item that matched the description, laundry staff would give the clothing item to the resident. If the clothing item was not found, laundry staff would allow the resident to pick something else out and or replace it for them. At the time of the interview, the HLM said the entire donation pile was developed from unaccounted and or unlabeled property, which had 75 items of missing clothing and the residents never seem to come look for their items. The social services director (SSD) was interviewed on 3/28/23 at 11:55 a.m. The SSD said when someone reports missing property anyone that was scheduled to work should fill out a concern form at the time it was reported and look for the item. If staff find the item they fill out the form and turn it in and give the resident the missing item. However, if staff could not find the missing item, they would turn in the grievance form to the SSD, in order for the facility to start an investigation. When a grievance was filed, the facility had five business days to respond to the resident but the facility preferred an immediate response. If there was no resolution within five days we go to the resident and verbally talk to them and give the residents updates on the progress; weekly or anytime they want an update. If the items were not found by the facility, the facility would offer to replace the item. -The statement made by the SSD related to the resident response timeline of five business days to respond to the resident was in contrast with the facility's grievance policy which read to provide a response within three working days (see grievance policy above). D. Record review The 3/26/23 nursing progress note documented that Resident #29 had reported hearing aides were missing. The nurse told the resident she would let the social service director know on 3/27/23. -It did not provide any further documentation if an investigation had been completed or the steps taken to resolve the resident's concern. The grievance forms and investigations were requested on 3/28/23, during the survey process. The facility was unable to provide grievances and or documentation that an investigation had been conducted to resolve Residents' (#37, #61, #34, #29, #102, #44, #4, #14 and #87) concerns for missing items. The facility provided two grievance forms and investigation documents for Resident #97. -The grievance filed on 3/27/23 at 1:00 p.m. read the resident was missing clothing items. The facility failed to provide a resolution related to the missing items. -The grievance filed on 3/29/23 at 12:20 p.m. read the resident was missing two pairs of black socks, one beige short sleeve shirt, black sweat pants and two pairs of gray briefs. The facility located one pair of black socks and postponed further resolution of inventorying clothing items in a black bag found at the time the grievance was filed. -The grievances provided by the SSD were filed approximately a week after Resident #97 voiced concerns to the facility as indicated in the resident's interview. The timeline of filing the grievances were in contrast with the facility's timeline of initiating a grievance at the time the resident first reported the concern as noted in the facility's grievance policy. -The grievance form was incomplete and did not provide a resident response to acknowledge receipt and or satisfaction of the resolution. III. Grievances related to call lights A. Resident interviews Resident #29 was interviewed on 3/27/23 at 10:24 a.m. She said that she activated her call light but had to wait a long time. Resident #44 was interviewed on 3/27/23 at 11:45 a.m. She said the staff did not answer the call light. The other residents or a roommate would go and get the staff to help her. She said sometimes it takes quite a while for the facility to respond, everyday the response time was typically 30 minutes. Resident #34 was interviewed on 3/27/23 at 2:07 p.m. She said when another resident showered, residents were told by staff that they were not allowed to push the call button because staff were busy and if the residents pushed the call light, they would make residents wait for a long period of time. Resident #114 was interviewed on 3/27/23 at 4:01 p.m. Resident #114 said there were long waiting times with call lights. Resident #27 was interviewed on 3/27/23 at 4:20 p.m. Resident #27 said there were long call light times. Resident #82 was interviewed on 3/28/23 at 8:50 a.m. Resident #82 said the facility had long wait times on call lights. Resident #37 was interviewed on 3/28/23 at 9:42 a.m. She said call lights sometimes took two hours to respond and she was always up at the nursing station yelling at the staff and giving them a hard time because either there was no one at the desk or they were at the desk ignoring us. Resident #87 was interviewed on 3/28/23 at 10:22 a.m. Resident #87 said it takes the staff awhile for staff to respond to call lights. Resident #4 was interviewed on 3/28/23 at 10:49 a.m. Resident #4 said it depends on who was working to answer call lights but sometimes he had waited 45-60 minutes for help. Resident #45 was interviewed on 3/28/23 at 11:04 a.m. Resident #45 said it took 30 minutes at night for staff to respond to call lights, especially between 2:30 p.m. to 10:30 p.m. Resident #85 was interviewed on 3/28/23 at 11:32 a.m. Resident #85 said call lights take too long for them to show up. Resident #61 was interviewed on 3/28/23 at 11:34 a.m. She said there were not enough staff, a year and a half ago it was different. The good staff were no longer at the facility. She had a few accidents because of a delayed response by staff when she had to use the bathroom a few times. C. Record review The call light record revealed the following: For room [ROOM NUMBER]: -3/26/23- 44 minutes. For room [ROOM NUMBER]: - 3/20/23 - 41 minutes; and, - 3/25/23 - 35 minutes. For room [ROOM NUMBER]: -3/21/23 - 42 minutes; and, -3/24/23 - 37 minutes. For room [ROOM NUMBER]: -3/19/23 - more than 30 minutes; -3/20/23 - more than 30 minutes; and -3/24/23 - more than 30 minutes. For room [ROOM NUMBER]: -3/21/23 - 95 minutes (one hour and 35 minutes). D. Staff interview The director of nursing (DON) was interviewed on 3/30/23 at 3:20 p.m. She said that the call light system was only available on a desktop computer located in her office. She said the call light logs were not regularly reviewed.

Based on observations and interviews the facility failed to ensure two out of three medication refrigerators stored and secured drugs and biologicals in accordance with accepted professional principles. Specifically, the facility failed to: -Ensure controlled medications were in a locked storage area that was secured to the refrigerator; -Ensure medication room door was locked; -Ensure medication cart was locked when nurse not at the cart; -Ensure alcohol for drinking was not stored with used culture vials; -Ensure batteries and medications were not stored together; and, -Ensure controlled medications for disposal were kept in a double locked area until disposal. Findings include: I. Facility policy and procedure The Storage of Medications policy and procedure, dated January 2021, was provided by the director of nursing (DON) on 3/29/23 at 4:35 p.m. It read in pertinent part, Controlled medications requiring refrigeration are stored within a locked, permanently affixed box within the refrigerator. In order to limit access to prescription medications, only licensed nurses, pharmacy staff, and those lawfully authorized to administer medications (such as medication aides) are allowed access to medication carts. Medication rooms, cabinets and medication supplies should remain locked when not in use or attended by persons with authorized access. Potentially harmful substances (such as urine test reagent tablets, household poisons, cleaning supplies, disinfectants) are clearly identified and stored in an area separate from medications. III. Observations and interviews On 3/27/23 at 8:33 a.m., a medication cart on the north 900 hall was observed to be unlocked and the nurse was not within direct line of sight with the cart for several minutes. When the nurse returned, she was notified that she left the medication cart unlocked and she said I know, I just went to get some ice. The ice machine was located around the corner down a separate hall. At 8:52 a.m. the medication room on the north unit was not locked, there were not any nurses nearby, the box storing the refrigerated controlled medications was not permanently affixed inside the refrigerator, and the refrigerator was not locked. At 1:30 p.m. the medication room on the north unit was still unlocked. At 5:00 p.m. the medication room on the north unit remained unlocked. On 3/28/23 at 8:30 a.m. the medication room on the north unit was unlocked. At 1:00 p.m. the medication room on the north unit was unlocked. At 6:00 p.m. the medication room on the north unit remained unlocked. On 3/30/23 at 1:14 p.m. the west medication room was observed. A COVID swab vial, marked with date collected and residents name, was in the refrigerator used to store resident alcohol, batteries were stored in the medication refrigerator and the controlled medication box was not permanently affixed to the refrigerator. On 3/27/23, 3/28/23, 3/29/23 and 3/30/23 observations of the director of nursing (DON) office revealed she was often out of her office and her office door remained open, leaving the controlled medications only in the single locked metal filing cabinet. IV. Administrative interviews The director of nursing (DON) was interviewed on 3/30/23 at 11:00 a.m. She said she took the controlled medications from the medication carts and medication rooms when they were no longer in use. She put them in a locked filing cabinet in her office and her office door locked. The DON acknowledged none of the medication refrigerators were locked.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interviews, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of diseases and infection. Specifically, the facility failed to: -Ensure housekeeping staff were following the proper cleaning techniques for cleaning resident rooms and disinfecting high frequency touched areas; -Ensure staff used proper hand hygiene; -Ensure residents were provided with an opportunity to participate in hand hygiene prior to meals; and, -Ensure residents' personal property were labeled and stored appropriately. Finding include: I. Ensure housekeeping staff were following the proper cleaning techniques for cleaning resident rooms and disinfecting high frequency touched areas A. Professional reference Assadian O, Harbarth S, Vos M, et al. Practical recommendations for routine cleaning and disinfection procedures in healthcare institutions: a narrative review. The Journal of Hospital Infection. 2021 Jul;113:104-114 was retrieved on 2/21/23 revealed, in pertinent part: High-touch surfaces, on the other hand, are usually close to the patient, are frequently touched by the patient or nursing staff, come into contact with the skin and, due to increased contact, pose a particularly high risk of transmitting pathogens (virus or microorganism that can cause disease) Healthcare-associated infections (HAIs) are the most common adverse outcomes due to delivery of medical care. HAIs increase morbidity and mortality, prolonged hospital stay, and are associated with additional healthcare costs. Contaminated surfaces, particularly those that are touched frequently, act as reservoirs for pathogens and contribute towards pathogen transmission. Therefore, healthcare hygiene requires a comprehensive approach. This approach includes hand hygiene in conjunction with environmental cleaning and disinfection of surfaces and clinical equipment. The Centers for Disease Control (CDC) Environment Cleaning Procedures https://www.cdc.gov/hai/prevent/resource-limited/cleaning-procedures.html# retrieved on 4/10/23 read in pertinent part, High-Touch Surfaces: The identification of high-touch surfaces and items in each patient care area is a necessary prerequisite to the development of cleaning procedures, as these will often differ by room, ward and facility. Common high-touch surfaces include: -bedrails -IV (intravenous) poles -sink handles -bedside tables -counters -edges of privacy curtains -patient monitoring equipment (keyboards, control panels) -call bells -door knobs Proceed From Cleaner To Dirtier Proceed from cleaner to dirtier areas to avoid spreading dirt and microorganisms. Examples include: -During terminal cleaning, clean low-touch surfaces before high-touch surfaces. -Clean patient areas ( patient zones) before patient toilets. -Within a specified patient room, terminal cleaning should start with shared equipment and common surfaces, then proceed to surfaces and items touched during patient care that are outside of the patient zone, and finally to surfaces and items directly touched by the patient inside the patient zone. In other words, high-touch surfaces outside the patient zone should be cleaned before the high-touch surfaces inside the patient zone. -Clean general patient areas not under transmission-based precautions before those areas under transmission-based precautions. B. Facility policy and procedure The Housekeeping Services Infection Control policy and procedure, last revised in January 2009, was provided by the nursing home administrator (NHA) on 4/4/23 at 2:09 p.m. It read in pertinent part, It is the policy of this facility to require effective environmental sanitation to lessen the hazards of exposure to contaminated air, dust, furnishings, equipment and other fomites. Frequent cleaning of the facility's interior will aid in physically removing and reducing microorganisms' potential contribution to the incidence of health-associated infections (HAI); The housekeeping supervisor will work closely with the infection control team to establish and maintain consistent practices and high standards of cleanliness; Periodic inspection of the facility will be made by the housekeeping supervisor or as a joint exercise with the infection control team; Cleaning shall be performed in a manner to minimize the spread of pathogenic organisms;dust high places before dusting lower areas light fixtures, tops of closets, tops of door casings, window coverings, TV's (televisions), pictures and other wall hangings tables, beds, medical apparatus, window sills; straighten displayed resident personal belongings (no gloves on); Wipe down with disinfectant soaked rag all touched surfaces in room, allow to air dry; door knobs, TV remotes, bed controllers, phones, bed-side tables, light switches,closet doors/dresser drawers medical apparatus like oxygen concentrators, clean heavily soiled restroom fixtures and porcelain surfaces using disinfectant and a rag or brush clean restroom walls with disinfectant; clean mirror with glass cleaner; Wipe down with disinfectant soaked rag all touched surfaces in room, allow to air dry; remove trash and re-line the receptacle, clean the receptacle as needed using disinfectant to disinfect sweep entire room including under beds;mop floors with dispensed solution of floor cleaner. C. Manufacturer recommendations The disinfectants in the facility were identified as: Comet Disinfectant-Sanitizing Bathroom Cleaner The product label was reviewed which read in pertinent part, Clean surfaces prior to disinfecting heavily soiled areas. For highly heavily soiled areas, clean before disinfecting following disinfecting directions. Thoroughly wet hard, non-porous surfaces with disinfecting solution for 10 minutes, then rinse or wipe clean. Spray the product on the surface and let stand for 10 minutes before wiping. Spic N Span -Disinfectin All-purpose Spray & Glass Cleaner Concentrated The product label was reviewed which read in pertinent part, to disinfect visibly soiled areas a preliminary cleaning is recommended. Spray 6-8 inches from hard, non-porous surfaces. Treated surfaces must remain visibly wet as indicated below.Wipe with a paper towel. Effective in 2 minutes against: SARS related coronavirus 2, Influenza A, H5N1, Respiratory Syncytial Virus, Human Coronavirus, Hepatitis B, Hepatitis C, HIV Type 1, Vaccinia Virus. Effective in 3 minutes against: Staphylococcus Aureus, Salmonella Enterica, Pseudomonas aeruginosa, MRSA, Norovirus, Rotavirus, E. Coli, Listeria Monocytogenes, Feline Calicivirus. Effective in 10 minutes against: Klebsiella Pneumoniae, NDM1, Acinetobacter baumannii, Enterobacter Cloacaen, Shigella Flexneri, Proteus Mirabilis, Candida Albicans and Candida Glabrata. D. Observations On 3/30/23 housekeeper (HSKP) #3 was continuously observed from 10:06 a.m. to 10:45 a.m. The observations showed the surface disinfectant time of the disinfectant was not ten minutes as indicated (see above). room [ROOM NUMBER] -At 10:06 a.m., HSKP #3 engaged in hand hygiene with sanitizer then wore gloves. -At 10:12 a.m., HSKP #3 wiped the sink and faucet with a disinfectant soaked wet wiping cloth for 39 seconds, the surface disinfectant time was not adhered to. -At 10:14 a.m., HSKP #3 did not disinfect high frequency touch areas (door handles, light switches and call lights). -At 10:20 a.m., HSKP #3 wiped a desk and a drawer for 11 seconds with a spic and span disinfectant soaked wiping cloth. -At 10:23 a.m., HSKP #3 wiped the bathroom rails with a different disinfectant soaked wiping cloth for five seconds. HSKP #3 wiped half the call light string in the bathroom. The call lights in the room by the bed were not disinfected. room [ROOM NUMBER] -At 10:25 a.m., HSKP #3 engaged in hand hygiene with hand sanitizer then wore gloves. -At 10:27 a.m., HSKP #3 sprayed disinfectant (comet) in the toilet and changed out all trash can liners. -At 10:28 a.m., HSKP #3 changed gloves and engaged in hand hygiene between switching from the wiping cloth to the broom. HSKP #3 swept the room and bathroom. -At 10:31 a.m., HSKP #3 wiped the sink for 23 seconds with a disinfectant soaked wiping cloth. The surface disinfectant time was not adhered to. -At 10:32 a.m., HSKP #3 wiped the desk for six seconds with a disinfectant soaked wiping cloth. The surface disinfectant l time was not adhered to. -At 10:35 a.m., HSKP #3 wiped the dresser for 13 seconds with a disinfectant soaked wiping cloth. The surface disinfectant time was not adhered to. HSKP #3 replaced her gloves and engaged in hand hygiene with sanitizer. -At 10:36 a.m., HSKP #3 wiped the bathroom rails first then the toilet. The surface disinfectant time was not adhered to. The total time elapsed from initial comet disinfectant spray was nine minutes.HSKP #3 scrubbed the toilet with a brush. The surface disinfectant time was not adhered to. -At 10:37 a.m., HSKP #3 wiped the toilet rim and water tank with a disinfectant soaked rag. The base of the toilet was not cleaned. HSKP #3 changed gloves after she cleaned the toilet and proceeded to grab a mop. -At 10:42 a.m., HSKP #3 mopped the floor with a disinfectant soaked wet pad. -At 10:45 a.m., HSP #3 completed the cleaning of the room. High frequency touch areas were not disinfected. HSKP #4 was continuously observed from 10:52 am to 11:05 am. room [ROOM NUMBER] -At 10:52 a.m., HSKP #4 changed her gloves and engaged in hand hygiene with sanitizer for eight seconds. -At 10:54 a.m., HSKP #4 sprayed the sink bowl with spic n span. -At 10:55 a.m., HSKP #4 sprayed the toilet bowl with comet. -At 10:56 a.m., HSKP #4 replaced the trash can liners in the room. -At 10:58 a.m., HSKP #4 changed her gloves and engaged in hand hygiene with sanitizer. HSKP #4 wiped the desk and drawer for 19 seconds with a disinfectant soaked wet wiping cloth. HSKP #4 replaced the disinfectant soaked wet wiping cloth with a new wiping cloth to begin cleaning the other side of the room. A desk and dresser were wiped for 10 seconds. The surface disinfectant time was not adhered to. -At 10:59 a.m., HSKP #4 wiped sink bowl within four minutes from the initial spray of spic n span. The faucets and countertop were wiped with a disinfectant soaked wiping cloth for 18 seconds. The surface disinfectant time was not adhered to. -At 11:01 a.m., HSKP #4 wiped the toilet with a disinfectant soaked wet rag within six minutes from the initial spray of comet and used a brush to clean the toilet bowl. The surface disinfectant time was not adhered to. -At 11:04 a.m, HSKP #4 wiped the bathroom hand rails for 17 seconds.The bathroom call light was not cleaned. The surface disinfectant time was not adhered to. -At 11:05 a.m., HSKP #4 did not disinfect high frequency touch areas (door handles, light switches and call lights). E. Interviews HSKP #3 was interviewed on 3/30/23 at 10:46 a.m. HSKP #3 said she used comet which had a 10 minute surface disinfectant time to clean the toilets and spic and span with a three to five minute surface disinfectant time, but was uncertain, for the sink and other areas. HSKP #3 said surface disinfectant time meant to use a soaked wiping cloth and just wipe the area and was unsure what high frequency touch areas were. She said she did not keep track of time for surface disinfectant times but she just did her cleaning process and enough time should pass for the surface disinfectant time after she completed other housekeeping tasks in the room. HSKP #4 was interviewed on 3/30/23 at 11:06 a.m. HSKP #4 said she used comet first and had to wait 10 minutes for it before she wiped it and then she used spic and span on all other surfaces by spraying the surface first then wiping it off shortly after with the rag. HSKP #4 said surface disinfectant times mean to spray the surface once and just wait 10 minutes for the comet but the spic and span could be sprayed and wiped after she was done brooming the room. HSKP #4 was unable to identify high touch areas. She said she did not keep track of time for the surface disinfectant times to ensure enough time has passed before she wipes the surfaces. The housekeeping and laundry manager (HLM) was interviewed on 3/30/23 at 1:48 p.m. The HLM said housekeeping staff should clean all the resident rooms daily. The process to clean the room was to start by emptying the trash and then use four rags per room. First, they start on the right and do light dusting (window sills, blinds, dresser, desk). Second, they should ring the rag and wipe surfaces, once done they change the rag and then go to the next side and wipe the mirror, counters, sink, paper towel and soap dispenser. Third, they check if there are paper towels and soap in there. Fourth, they go to the bathroom and wipe all the rails, toilet and inside the bowl with the brush. Lastly, they swept the floors in the room and bathroom then mopped after it and then wiped the window ledge. All high touch areas were not cleaned by the housekeepers and were cleaned by her and HSKP #2 which they try to get to every other day, however, housekeeping staff were expected to clean call lights,blinds, light switches, door knobs, closet doors and use a duster for the blinds. The HLM acknowledged cleaning methods observed were not correct with the facility's procedure and the surface disinfectant times were not followed. The infection preventionist (IP) was interviewed on 3/30/23 at 4:43 p.m. The IP said she was not involved yet with the housekeeping department in regards to infection control. The IP was unsure of the cleaning products used at the facility without observing a list of the cleaning products which had to be obtained from the HLM. The IP was unaware of the surface disinfectant times of the cleaning products used without asking the HLM. However, the IP said surface disinfectant times meant the surface must stay wet for the disinfectant time listed on the label of the disinfecting product; if the product did not stay wet for the time listed then the disinfectant would be ineffective. The IP identified high touch areas in the resident room as: over the bed table and everything on it, call lights, sink area, faucets, toilet area, everything the resident touched, grab bars, door knobs and light switches. II. Medication pass obervations Medication pass was observed on two units and infection control protocols were not followed. On 3/28/23 at 4:00 p.m. licensed practical nurse (LPN) #1 was observed for medication pass. One controlled medication was dropped onto the surface of the medication cart and it was not disposed of. Instead she picked up the medication and put it in the medication cup and proceeded to give it to the resident. At 4:02 p.m. LPN #1 was observed for medication pass. The LPN did not use hand sanitizer or wash her hands prior to donning gloves to administer eye drops. At 5:15 p.m. registered nurse (RN) #1 punctured the fingertip of a resident, she did not discard the first drop of blood and used that first drip as the collection amount to obtain the blood sugar reading. She used the same alcohol swab that was used to clean the residents fingertip to cover the bleeding after the collection was complete. On 3/29/23 at 12:20 p.m. RN #2 was observed for medication pass. She did not use hand sanitizer or don gloves after knocking on the residents door and opening the door to ask about the residents pain level. The RN went back to the medication cart to collect medications for the resident, placed them into the medication cup, picked up the cup and carried it back to the residents room and gave the medications to the resident without performing any hand hygiene. Prior to the nurse opening the residents door housekeeping did not sanitize any high touch surfaces such as door handles (see observations above). On 3/30/23 at 8:14 a.m. RN #2 was observed for medication pass. She used hand sanitizer but then pulled her sleeves down. III. Failed to ensure residents were provided with an opportunity to participate in hand hygiene prior to meals A. Professional reference The Centers for Disease Control (CDC) Hand Hygiene updated 2/7/23, retrieved on 4/11/23 from: https://www.cdc.gov/coronavirus/2019-ncov/hcp/hand-hygiene.html, revealed in part, Hand hygiene is an important part of the U.S. response to the international emergence of COVID-19. Practicing hand hygiene, which includes the use of alcohol-based hand rub (ABHR) or handwashing, is a simple yet effective way to prevent the spread of pathogens and infections in healthcare settings. CDC recommendations reflect this important role. The exact contribution of hand hygiene to the reduction of direct and indirect spread of coronaviruses between people is currently unknown. However, hand washing mechanically removes pathogens, and laboratory data demonstrate that ABHR formulations in the range of alcohol concentrations recommended by CDC, inactivate SARS-CoV-2. ABHR effectively reduces the number of pathogens that may be present on the hands of healthcare providers after brief interactions with patients or the care environment. The CDC recommends using ABHR with greater than 60% ethanol or 70% isopropanol in healthcare settings. Unless hands are visibly soiled, an alcohol-based hand rub is preferred over soap and water in most clinical situations due to evidence of better compliance compared to soap and water. Hand rubs are generally less irritating to hands and are effective in the absence of a sink. B. Facility policy and procedure The Hand Hygiene Infection Control policy and procedure, last revised in October 2022, was provided by the NHA on 4/4/23 at 2:09 p.m. It read in pertinent part, Hand hygiene is one of the most effective measures to prevent the spread of infection. Studies show that effective hand decontamination can significantly reduce the rate of healthcare associated infection. Residents, family members and/or visitors will be encouraged to practice hand hygiene through the use of fact sheets, pamphlets and/or other written materials provided at the time of admission and/or posted throughout the facility. Hand hygiene should occur before and after eating or handling food. C. Observation The resident room meal trays were delivered on 3/29/23 at 5:45 p.m. to the [NAME] unit and residents were not offered or encouraged hand hygiene prior to eating their meal. -At 5:45 p.m., a certified nurse aide (CNA) delivered a room tray to room [ROOM NUMBER]B and did not offer hand hygiene to the resident. -At 5:47 p.m., a CNA delivered a room tray to a resident in room [ROOM NUMBER]A. She failed to offer hand hygiene to the resident. -At 5:50 p.m., a CNA delivered a room tray to a resident in room [ROOM NUMBER]A. No hand hygiene was offered to the resident. On 3/29/23 the dining room was observed continuously from 5:30 p.m. to 7:00 p.m. -At 5:45 p.m. meal trays were provided to residents, no hand hygiene was offered by staff. Hand hygiene products were not available on any trays. -At 6:25 p.m. all meal trays were provided to residents, no hand hygiene was offered by staff. Hand hygiene products were not available on any trays. -At 6:02 p.m. an unidentified kitchen staff member served one resident in the dining room. Hand hygiene was not offered to the resident. -At 6:26 p.m. residents in the dining room were being served dinner. Hand hygiene was not offered to residents in the dining room. -At 6:47 p.m. the last meal tray was provided to a resident. Hand hygiene was not offered to all residents in the dining room. C. Interview RN #5 was interviewed on 3/27/23 at 8:35 a.m. RN #5 said prior to eating, the resident should be provided hand hygiene. IV. Failure to label and store personal items properly A. Facility policy and procedure The Resident Personal Belonging policy and procedure, undated, was provided by the NHA on 4/4/23 at 2:09 p.m. It read in pertinent part, It is the policy of this facility to protect the resident's right to possess personal belongings such as clothing and furnishings for their use while in the facility and assure the personal belongings and/or possessions are rightfully returned to the resident. All resident possessions, regardless of their apparent value to others, will be treated with respect. The facility will support the resident's right to retain and use personal possessions to promote a homelike environment and maintain their independence. All resident personal items will be inventoried at the time of admission by the social services designer, or another designated staff member and documentation shall be retained in the medical record. The facility will ensure resident belongings are kept in a neat and orderly fashion and maintained in each resident's room. The facility will exercise reasonable care for the protection of the resident's property from loss or theft. B. Observations On 3/27/23 room at approximately 11:00 a.m., room [ROOM NUMBER] a shared room had a toothbrush and unmarked hair brush at the sink. On 3/28/23 at 9:52 a.m. room [ROOM NUMBER] had unmarked toothbrush and hairbrush in a shared room. At 12:44 p.m. an unmarked hairbrush and toothbrush were on the counter of room [ROOM NUMBER]. At 1:00 p.m. an unmarked toothbrush was at the sink. 3/30/23 -At 8:00 a.m. room [ROOM NUMBER] in a shared room had a hair brush and toothbrush was unmarked. -At 8:02 a.m. room [ROOM NUMBER] had a toothbrush laying directly on the counter. -At 8:15 a.m. room [ROOM NUMBER], had a toothbrush on the sink and was not marked in a shared room. C. Interviews The staff development coordinator (SDC) was interviewed on 3/30/23 at 3:40 a.m. The SDC said it was the CNA's responsibility to use a sharpie marker to label any resident's personal property including personal hygiene products and to put it in a plastic bag to store it.

Based on observations and staff interviews, the facility failed to ensure the dietary department followed safe practices to prevent the potential contamination of food and spread of food-borne illness. Specifically the facility failed to: -Ensure holding temperatures were at appropriate temperatures; -Ensure proper food handling practices; -Ensure health shakes were dated when thawed; -Ensure artificial nails with polish were not worn by food worker; and, -Ensure meat was thawed correctly. Findings include: I. Food temperatures of cold and hot food items were not held at the proper temperature to reduce the risk of food-borne illness. A. Professional reference The Colorado Department of Public Health and Environment (2019) The Colorado Retail Food Establishment Rules and Regulations, https://www.colorado.gov/pacific/sites/default/files/DEHS_RetailFd_6CCR10102_RFFC_EffJan2019.pdf. It read in pertinent part, The food shall have an initial temperature of 41ºF (fahrenheit) or less when removed from cold holding temperature control or 135°F or greater when removed from hot holding temperature control. B. Ensuring holding temperatures 1. 3/28/23 Dinner meal On 3/28/23 at 4:43 p.m. the temperature for the pureed dessert was 52.5 degrees F. The pudding was in individual monkey dishes and were on a large tray. There was no mechanism to keep it cold. The dessert consisted of vanilla pudding, pie crust and milk. -At 6:49 p.m., the temperatures were taken after the last resident was served. The temperature were as follow: -Coleslaw that was in individual serving bowls was 44 degrees F. There was no mechanism to keep it cold. -Coleslaw which was in a clear measured container next to the serving line was 59 degrees F. The container had no mechanism to keep it below 41 degrees F. 2. Health shakes The health shakes documented to store frozen and to discard after 14 days when thawed. During the initial walk-through of the kitchen on 3/27/23 at approximately 7:50 a.m., the walk in refrigerator had a pan with approximately 12 thawed health shakes with no dates of when they were thawed. 3/30/23 -At 8:00 a.m., the refrigerator at the East nurse ' s station had 14 thawed shakes that did not have an expiration date written on any shakes. -At 10:21 a.m., the refrigerator at the East nurse ' s station had 14 thawed health shakes that did not have an expiration date written on any shakes. 3. Medication carts On 3/27/23 at 8:00 a.m., a medication cart was observed near the dining room. A yogurt was opened and did not have any mechanism to keep it cold. On 3/30/23 at 9:57 a.m., the container holding yogurt and health shakes on the nurse ' s medication cart for the East wing was observed. The container had an ice block on the bottom. The ice block was not solid. The temperature for the yogurt and shake was as follows: -The health shake was 60.6 degrees F; and, -The yogurt was 57.3 degrees F. A second nurse ' s medication cart for the East wing was observed. The yogurt was in a quarter pan, with no mechanism to keep it cold. There were two health shakes which were thawed and no date as to when it was thawed. The temperature for the yogurt and shake was as follows: -The health shake was 46.2 degrees F; and, -The yogurt was 66.3 degrees F. The nurse ' s medication cart for the [NAME] wing was observed. The yogurt and health shake was in a metal container. The temperature for the yogurt and health shake was as follows: -The health shake was 43.8 degrees F; and, -The yogurt was 50.3 degrees F. 4. Interviews Licensed practical nurse (LPN) #2 was interviewed on 3/30/23 at 9:57 a.m. The LPN said she did not know what the temperature of the health shake and yogurt located on the medication cart should be. She did not have a thermometer on the cart or with her to check the temperature. She said that the expiration date for the shake was the printed expiration date on the cartons, not the handwritten date. She did not know that the shake was good for 14 days after the shake was removed from the freezer to the refrigerator or medication cart. Registered nurse (RN) #2 was interviewed on 3/30/23 at 10:10 a.m. The RN said she did not know what the temperature of the health shake and yogurt located on the medication cart should be. She did not have a thermometer on the cart or with her to check the temperature. She said that the expiration date for the shake was 72 hours after the shake was placed in the refrigerator. She did not know that the shake was good for 14 days after the shake was removed from the freezer to the refrigerator or medication cart. LPN #5 was interviewed on 3/30/23 at 10:20 a.m. The LPN stated she did not know what the temperature of the shake and yogurt located on the medication cart should be. She did not have a thermometer on the cart or with her to check the temperature. She did not know that the shake was good for 14 days after the shake was removed from the freezer to the refrigerator or medication cart. The registered dietitian (RD) was interviewed on 3/30/23 at 5:42 p.m. The RD said there should be a cooling mechanism for the health shake and yogurt located on the medication carts. The RD said food should be held at 135 degrees F and above for hot food, and 41 degrees F below for the cold foods. II. Ensure proper food handling A. Professional reference The Colorado Department of Public Health and Environment (2019) The Colorado Retail Food Establishment Rules and Regulations, https://www.colorado.gov/pacific/sites/default/files/DEHS_RetailFd_6CCR10102_RFFC_EffJan2019.pdf. It read in pertinent part, Food employees shall clean their hands and exposed portions of their arms for at least 20 seconds and shall use the following cleaning procedure: Vigorous friction on the surfaces of the lathered fingers, finger tips, area between the fingers, hands and arms for at least 15 seconds, followed by; thorough rinsing under clean, running, warm water; and immediately follow the cleaning procedure with thorough drying of cleaned hands and arms.Food employees shall clean their hands and exposed portions of their arms immediately before engaging in food preparation including working with exposed food, clean equipment and utensils, and unwrapped single-service and single-use articles after handling soiled equipment or utensils. B. Observations On 3/28/23 at 5:03 p.m., the dietary manager (DM) corrected the dietary aide (DA) #1 on how to handle the resident ' s plates when placing their meals on a meal tray. At 5:59 p.m. DA #1 continued to handle the resident ' s plate incorrectly by placing her fingers on the eating surface of the plate DA #1 had long artificial nails. At 6:04 p.m., DA #2 made several grilled cheese sandwiches. When the DA #2 sliced the sandwich, she placed her gloved hand over the cooked sandwich to cut it. She did not have clean gloves on as she had touched the stove handles, a cart and various other items in the kitchen. C. Interview The registered dietitian (RD) was interviewed on 3/30/23 at 5:42 p.m. The RD said ready to eat foods should be handled with a utensil, or clean gloves. III. Fingernails A. Professional reference The Colorado Department of Public Health and Environment (2019) The Colorado Retail Food Establishment Rules and Regulations, https://www.colorado.gov/pacific/sites/default/files/DEHS_RetailFd_6CCR10102_RFFC_EffJan2019.pdf. It read in pertinent part, Unless wearing intact gloves in good repair,a food employee may not wear fingernail polish or artificial fingernails when working with exposed food. B. Observations On 3/30/23 at 4:30 p.m., DA #1 was observed to preparing tartar sauce into small individual containers. She had false nails which were approximately a half an inch over the nail bed with nail polish. DA #1 was not wearing gloves. She then proceeded to work the tray line with the resident meal plates and desserts. C. Interview The registered dietitian (RD) was interviewed on 3/30/23 at 5:42 p.m. The RD said staff that handled food should have well-groomed nails to be consistent with Colorado retail food establishment regulations. He said if staff had artificial nails with nail polish then they needed to wear gloves. IV. Thawing meat A. Professional reference The Colorado Department of Public Health and Environment (2019) The Colorado Retail Food Establishment Rules and Regulations, https://www.colorado.gov/pacific/sites/default/files/DEHS_RetailFd_6CCR10102_RFFC_EffJan2019.pdf read in pertinent part, potentially hazardous foods (time/temperature control for safety foods) shall be thawed: A. Under refrigeration that maintain the food temperature at 41°F (5°C) or less; or B. Completely submerged and with packaging removed under running water: 1. At a water temperature of 70°F (21°C) or below, 2. With sufficient water velocity to agitate and float off loose particles in an overflow. B. Observation On 3/30/23 at approximately 6:45 p.m., there were four hamburger rolls that were five pounds each. They were sitting in a pan of water and only a small stream of water was running on the edge of the pan and not directly on the meat. C. Interview The registered dietitian (RD) was interviewed on 3/30/23 at 6:45 p.m. The RD said the meat was not being thawed correctly, and that it needed to be under running water. He asked the cook to put the thawed meat into the refrigerator.

Based on interviews and record review, the facility failed to ensure an effective quality assurance program to identify and address facility compliance concerns was implemented, in order to facilitate improvement in the lives of nursing home residents, through continuous attention to quality of care, quality of life, and resident safety. Specifically, the quality assurance performance improvement (QAPI) program committee failed to identify and address concerns related to resident safety. Findings include: I. Cross-reference citations Cross-reference F689: The facility failed to keep residents free from accident hazards for unsafe hot water temperatures. Cross-reference F880: The facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of communicable diseases and infections for medication pass, housekeeping, and hand hygiene before meals. II. Facility policy The Quality Assurance and Performance Improvement policy, revised January 2022, was provided by the nursing home administrator (NHA) on 3/30/23 at 7:00 p.m. It read in pertinent part: The purpose of the QAPI plan and process was to continually assess the facility's performance in all service areas, so that systems and processes achieve the delivery of person-centered care, and which maximizes the individual's highest practicable, physical, mental, and social well-being. QAPI committee members include, the director of nursing services (DNS), the medical director, the NHA, the infection preventionist, and at least two staff members. The committee meets at least monthly or more often as the facility deems necessary. III. Repeat deficiencies Review of the facility's regulatory record revealed it failed to operate a QA program in a manner to prevent the repeat deficiency of F689 accident hazards cited previously on 3/24/22 at a G scope and severity, and F880 infection control cited previously on 7/28/21 at an L scope and severity, immediate jeopardy. During the recertification survey on 3/30/23, accident hazards were cited at an K scope and severity, at immediate jeopardy and infection control was cited at an E scope and severity. IV. Staff interview The NHA was interviewed on 3/30/23 at 8:48 p.m. He said the QAPI committee met once a month. He said the medical director, the pharmacist, and himself were always in the meeting. He said each department had their own target areas to address, and put a performance improvement plan (PIP) in place in areas that needed attention. He said the facility did not identify hot water temperatures and the maintenance director (MTD) did not bring it to their attention and the committee was unaware of the high temperatures. The NHA said the facility educated staff on the importance of hand washing and housekeeping roll in infection prevention. He said resident hand hygiene was very important. He said the staff had training in January 2023 after the new company took over. He said the facility used the cleaning supplies given to them from the vendor. He said the facility needed to be better at identifying failures.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews the facility failed to provide sufficient nursing staff to ensure the residents received the care and services they required to achieve their highest practicable physical, mental, and psychosocial well-being. Specifically, the facility failed to provide assistance and respond to resident call lights in a timely manner. I. Facility policy and procedure The Answering the Call Light policy, revised October 2010, was provided by the nursing home administrator (NHA) on 11/12/19. It read, in pertinent part, Answer the resident's call as soon as possible. If you have promised the resident you will return with an item or information, do so promptly. If assistance is needed when you enter the room, summon help by using the call signal. A. Resident Interviews A group interview was held on 11/7/19 at 3:30 p.m. with six (#120, #41, #125, #46, #48, and #35) alert and oriented residents selected by the facility for participation. The residents said they had to wait a long time, up to an hour, for staff to respond to their call lights. They said mornings and meal times were the most difficult times to get assistance from staff. Resident #15, a cognitively intact resident, was interviewed on 11/7/19 at 2:58 a.m. She said staff encouraged her to ask for help to get out of bed safely due to a risk of falls. She said she called for help after an incontinence episode in the middle of the night and had to wait 45 minutes to get her brief changed. She said another morning she pressed her call light to get out of bed in the morning to go to physical therapy, however it took 45 minutes to get the staff assistance to transfer her out of bed. She said she could hear staff in the hall talking but nobody checked to see what she needed. She said an acceptable wait time would be two to five minutes, but she would wait longer if staff acknowledged her and tell her they would be back. Resident #49 was interviewed on 11/6/19 at 9:26 a.m. He said he had to wait a long time to get out of bed because he required two people to assist him with the transfer. He said sometimes he didn't get out of bed because there was not enough staff to use a hoyer lift to help him timely. He said he has had to wait an hour to get out of bed. He said he would be okay to wait ten minutes for his call light to be answered if he did not need urgent assistance. Resident #70 was interviewed on 11/6/19 at 3:09 pm. He said staff took 20 minutes to an hour to answer his call light and it took longer at meal times to get assistance. He said if he needed urgent assistance he had to yell out for help. Resident #47 was interviewed on 11/6/19 at 2:04 p.m. He said staff frequently took 40 minutes to an hour to answer his call light. He said staff told him they were busy then never came back to assist him. Resident #65 was interviewed on 11/12/19 at 10:31 a.m. He said he frequently had to wait a long time to get his call light answered. He said he can see and hear staff in the hallway and they did not go in his room to ask what he needed. He said his preferred wait time was no longer than five minutes, but he would wait longer if staff acknowledged him and went back to help him. B. Record review Review of the call light log revealed the following pertinent wait times on 11/4/19: - 20 minutes 59 seconds room [ROOM NUMBER] - 57 minutes 3 seconds room [ROOM NUMBER] - 17 minutes 12 seconds room [ROOM NUMBER] - 18 minutes 54 seconds room [ROOM NUMBER] - 12 minutes 32 seconds room [ROOM NUMBER] - 11 minutes 9 seconds room [ROOM NUMBER] - 14 minutes 6 seconds room [ROOM NUMBER] - 12 minutes 46 seconds room [ROOM NUMBER] Review of the call light log revealed the following pertinent wait times on 11/5/19: - 22 minutes 3 seconds room [ROOM NUMBER] - 23 minutes 46 seconds room [ROOM NUMBER] - 15 minutes 46 seconds room [ROOM NUMBER] - 30 minutes 31 seconds room [ROOM NUMBER] - 11 minutes 54 seconds room [ROOM NUMBER] - 12 minutes 23 seconds room [ROOM NUMBER] - 18 minutes 6 seconds room [ROOM NUMBER] - 15 minutes 16 seconds room [ROOM NUMBER] - 13 minutes 18 seconds room [ROOM NUMBER] - 13 minutes 24 seconds room [ROOM NUMBER] - 26 minutes 16 seconds room [ROOM NUMBER] - 11 minutes 58 seconds room [ROOM NUMBER] Review of the call light log revealed the following pertinent wait times on 11/6/19: - 15 minutes 14 seconds room [ROOM NUMBER] - 20 minutes 50 seconds room [ROOM NUMBER] - 17 minutes 4 seconds room [ROOM NUMBER] - 16 minutes 28 seconds room [ROOM NUMBER] - 33 minutes 33 seconds room [ROOM NUMBER] - 24 minutes 56 seconds room [ROOM NUMBER] - 27 minutes 49 seconds room [ROOM NUMBER] - 33 minutes 21 seconds room [ROOM NUMBER] - 51 minutes 57 seconds room [ROOM NUMBER] Review of the call light log revealed the following pertinent wait times on 11/7/19: - 18 minutes 43 seconds room [ROOM NUMBER] - 36 minutes 17 seconds room [ROOM NUMBER] - 39 minutes 46 seconds room [ROOM NUMBER] - 41 minutes 26 seconds room [ROOM NUMBER] Review of the call light log revealed the following pertinent wait times on 11/8/19: - 26 minutes 56 seconds room [ROOM NUMBER] - 46 minutes 30 seconds room [ROOM NUMBER] - 38 minutes 50 seconds room [ROOM NUMBER] - 23 minutes 23 seconds room [ROOM NUMBER] - 20 minutes 20 seconds room [ROOM NUMBER] - 28 minutes 3 seconds room [ROOM NUMBER] - 14 minutes 30 seconds room [ROOM NUMBER] - 16 minutes 39 seconds room [ROOM NUMBER] - 10 minutes 20 seconds room [ROOM NUMBER] Review of the call light log revealed the following pertinent wait times on 11/9/19: - 24 minutes 4 seconds room [ROOM NUMBER] - 23 minutes 32 seconds room [ROOM NUMBER] - 10 minutes 46 seconds room [ROOM NUMBER] - 19 minutes 58 seconds room [ROOM NUMBER] - 15 minutes 8 seconds room [ROOM NUMBER] - 13 minutes 1 second room [ROOM NUMBER] - 18 minutes 52 seconds room [ROOM NUMBER] Review of the call light log revealed the following pertinent wait times on 11/10/19: - 1 hour 18 seconds room [ROOM NUMBER] - 24 minutes 46 seconds room [ROOM NUMBER] - 25 minutes 7 seconds room [ROOM NUMBER] - 20 minutes 33 seconds room [ROOM NUMBER] Review of the call light log revealed the following pertinent wait times on 11/11/19: - 25 minutes 44 seconds room [ROOM NUMBER] - 10 minutes 25 seconds room [ROOM NUMBER] - 12 minutes 53 seconds room [ROOM NUMBER] C. Staff interviews Registered nurse (RN) #3 was interviewed on 11/12/19 at 12:37 p.m. She said she only audited call lights on her unit if a resident complained about their wait times. She said she did not regularly check call light times. The director of nursing (DON) was interviewed on 11/12/19 at 1:22 p.m. She said if someone filed a grievance about call light times she would audit wait times for that person then educate staff if the wait was too long. She said she expected call lights to be answered as soon as possible, but did not have a specific time for nursing staff to answer. She said over 20 minutes was too long, and one hour was not an acceptable wait time for resident call light times. She said they did not have a process to identify long call light times if there was not a grievance for the times and she did not complete audits regularly. II. Resident #112's status Resident #112, age [AGE], was initially admitted on [DATE] and readmitted on [DATE]. According to the November 2019 computerized physician orders (CPO), diagnoses included muscles weakness. The 10/24/19 minimum data set (MDS) assessment revealed the resident had moderate cognitive impairment with a brief interview for mental status (BIMs) score of 12 out of 15. He required extensive assistance with bed mobility, dressing, toilet, personal hygiene and totaly dependent on staff with eating. A. Resident interview Resident #112 was interviewed on 11/6/19 at 11:15 a.m. He said he had to wait frequently a long time for his call light to be answered. He said he called for help after an incontinence episode in the middle of the night and had to wait for two hours to get his brief changed. B. Record review The alert notification report (call light response time log) was provided by the director of nursing (DON) on 11/11/19 at 4:45 p.m. It documented the following: - On 11/4/2019 at 4:02 a.m., the resident activated his call light. The call light was answered at 4:48 a.m. which revealed the resident had to wait for 45 minutes before his call light was answered. - On 11/4/19 the resident activated his call light at 4:37 p.m. and it was answered at 5:58 p.m. which revealed the resident had to wait for one hour and 21 minutes before his call light was answer. - On 11/5/19 the resident activated his call light at 5:34 p.m. and it was answered at 6:47 p.m. which revealed the resident had to wait for one hour and 13 minutes before his call light was answered.

Based on observations and interviews, the facility failed to properly store medications in six of six medication carts. Specifically, the facility failed to - Ensure multi-dose medications were labeled with the date of opening or the proper resident identifier or both; and, - Discard of expired medication from the medication cart. - Discard of discontinued medication from the medication cart. Findings include: I. Facility policies and procedures The policy for Storage and Labeling of Medication Containers was provided by the director of nursing (DON) on 11/16/19 at 11:35 a.m. The policy, revised April 2007, read in part, All medications maintained in the facility shall be properly labeled in accordance with the current state and federal regulations . medication labels must be legible at all times . and shall include all necessary information, such as the resident's name, the date that the medication was initially dispensed. The policy for Medication with Special Expiration Date Requirements was provided by the director of nursing (DON) on 11/16/19 at 11:35 a.m. The policy, revised December 2010, read in part, The beyond use date after initially entering or opening multiple-dose vials is 28 days unless otherwise specified by the manufacturer. The policy for Storage and Labeling of Medication Containers was provided by the director of nursing (DON) on 11/16/19 at 11:35 a.m. The policy, revised October 2007, read in part, When medications are discontinued by prescriber order . the medications are marked as discontinued and destroyed or returned to the pharmacy, if applicable per state regulations. If a prescriber discontinues a medication, the medication container is removed from the medication cart immediately. II. Observations On 11/6/19 at 9:00 a.m., the East 12-Hour unit medication cart was inspected with registered nurse (RN) #4. The following were found inside the medication cart: - Lantus vial with initial opened date 0f 10/4/19 was in the cart as of 11/6/19. - Symbicort Inhaler which was discontinued for a resident as of 6/23/18 was in the cart. On 11/6/19 at 9:14 a.m., the [NAME] 8-Hour unit medication cart was inspected with registered nurse (RN) #5. The following were found inside the medication cart: - Advair Diskus Aerosol powder breath activated 250-50 MCG/DOSE was not labeled with the resident's identifier or dated with the initial date of use. - Spiriva Inhaler Dispenser was not labeled with the resident's identifier or dated with the initial date of use. On 11/6/19 at 9:23 a.m., the North 12-Hour unit medication cart was inspected with registered nurse (RN) #6. The following were found inside the medication cart: - Levemir FlexTouch Solution Pen-injector 100 UNIT/ML (Insulin Detemir) was not dated with the initial date of use. - Anoro Ellipta Inhaler was not labeled with the resident's identifier or dated with the initial date of use. - Wixela Inhaler was not labeled with the resident's identifier or dated with the initial date of use. On 11/6/19 at 9:38 a.m., the East 8-Hour unit medication cart was inspected with registered nurse (RN) #7. Advair inhaler was not labeled with the resident's identifier or dated with the initial date of use. On 11/6/19 at 10:12 a.m., the North 700 unit medication cart was inspected with RN #5. The following were found inside the medication cart: - Flovent Inhaler was not labeled with the resident's identifier or dated with the initial date of use. - Flovent Diskus inhaler was not labeled with the resident's identifier or dated with the initial date of use. On 11/6/19 at 10:21 a.m., the [NAME] 12-Hour unit medication cart was inspected with a licensed practical nurse (LPN) #1. The following were found inside the medication cart: - Wixela Inhub inhaler was not labeled with the resident's identifier or dated with the initial date of use. - Breo Ellipta Inhaler was not labeled with the resident's identifier or dated with the initial date of use. IV. Staff interview RN #4 was interviewed on 11/6/19 at 9:10 a.m. She said the expectation was to always label every new medication when opened, check for discontinued medications, and remove expired medications from the cart. The DON was interviewed on 11/7/19 at 11:41 a.m. She said it was the facility's expectation for staff to label all multi-vial medications and inhalers upon opening with the resident's name and the initial date of opening. She said all nurses will be re-educated on the facility's policy and procedure for medication storage. The DON said all discharged /expired residents' medication should be discarded in accordance with the facility's policy and procedures.