**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to ensure two (#2 and #3) of three residents reviewed for abuse out of three sample residents were kept free from abuse.Specifically, the facility failed to protect Resident #2 and Resident #3 from physical abuse by Resident #1. Findings include:I. Facility policy and procedureThe Abuse policy, revised 2/29/24, was provided by the nursing home administrator (NHA) on 8/14/25 at 10:29 a.m. It read in pertinent part, Residents have the right to be free from abuse. This includes but is not limited to freedom from physical abuse. Providing a safe environment for the residents is one of the most basic and essential duties of our facility. Employees have a unique position of trust with vulnerable residents. This facility promotes an atmosphere of sharing with residents and staff without fear of retribution. Residents must not be subjected to abuse by anyone, including but not limited to other residents. Identification of abuse shall be the responsibility of every employee.II. Physical abuse by Resident #1 towards Resident #3 on 5/28/25A. Facility investigationThe 5/28/25 facility abuse investigation documented that at 10:00 a.m. two female residents (Resident #1 and Resident #3) were in the hallway in the secured dementia unit. The nursing staff were providing medications and care to other residents when the staff heard someone yell, Hey! The staff immediately checked and saw that one female resident (Resident #1) was reaching toward and hitting another female resident (Resident #3) in the chest. The staff immediately separated both residents. The investigation documented Resident #3 had two superficial abrasions on her chest with slight redness. Resident #3 was unable to recall the incident. The investigation documented Resident #1 said Resident #3 was after her. Both residents were placed on increased supervision and were in line of sight when they left their rooms. The investigation documented a summary of the staff interviews revealed Resident #3 was agitated prior to the incident and she was unhappy she had to wait for the nurse as the nurse was passing medications. The staff were uncertain if Resident #1 was standing in her doorway or if she was exiting her room, but the incident occurred in the doorway to Resident #1's bedroom. Both residents indicated the other resident attacked them, however, Resident #3 was the only resident with injuries. After the incident Resident #1 calmed down and Resident #3 required one-on-one supervision to calm down. Resident #1 was placed on 15-minute checks for 72 hours. An intervention of line of sight supervision was put into place to prevent a recurrence of the situation.-The facility investigation documented the abuse was substantiated.III. Physical abuse by Resident #1 towards Resident #2 on 6/13/25A. Facility investigationThe 6/13/25 facility investigation documented a female resident (Resident #1) was sitting in the dining room chair watching television. Another female resident (Resident #2) was standing behind her chair next to a certified nurse aide (CNA). Resident #2 put her hand on the back of Resident #1's chair. Resident #1 reached up and said Do not touch me! Resident #1 then grabbed Resident #2's arm using her fingernails, which resulted in three red areas and one superficial open area on Resident #2's right forearm. The investigation documented the CNA stepped between the residents in order to separate them. Resident #1 attempted to hit Resident #2, but the staff prevented the resident from making contact. Resident #1 was asked to go to her room until she was able to calm down, which she agreed to do. The investigation documented a summary of the staff interviews revealed Resident #1 was seated at a table in the main dining room and a CNA was on the right side of Resident #2 as she guided her through the dining room. Resident #2 reached for the back of the chair Resident #1 was sitting in. Resident #2 made contact with the back of Resident #1's chair. Resident #1 did not like being touched and perceived the contact as being hit, as she stated She hit me. Resident #1 reacted with a retaliatory behavior by grabbing Resident #2's forearm, resulting in skin tears and redness. The investigation documented Resident #2 walked independently but needed staff guidance. The investigation indicated the dining room was a little congested with other residents sitting and walkers and chairs. The congestion made Resident #2 navigate around obstacles which resulted in Resident #2 needing to use a chair for either comfort or to steady herself while ambulating. Both residents were placed on 15-minute checks for 72 hours. -The interventions to prevent a recurrence of the situation section of the investigation was not filled out.-The facility investigation documented the abuse was substantiated.IV. Resident #1 (assailant) A. Resident statusResident #1, age greater than 65, was admitted on [DATE] and passed away on 6/20/25. According to the June 2025 computerized physician order (CPO), diagnoses included Alzheimer's disease, paranoid schizophrenia (mental illness) and dementia with psychotic disturbances.According to the 5/1/25 minimum data set (MDS) assessment Resident #1 had severe cognitive impairment with a brief interview for mental status (BIMS) score of four out of 15. The MDS assessment documented the resident rejected care at times. B. Record reviewResident #1's behavior care plan, revised on 6/30/25, documented the resident had physical aggression, paranoid delusions, dementia and poor impulse control. Pertinent interventions included performing 15-minute checks for 72 hours (initiated 8/29/24), removing or redirecting Resident #1 away from other residents when she was agitated (initiated 9/10/24), conducting medication administration as ordered (initiated 8/6/24) assessing and anticipating the resident's needs (initiated 8/6/24), providing physical and verbal cues to alleviate Resident #1's frustrations (initiated 8/26/24), encouraging Resident #1 to sit with her male friends for meals because she preferred male companionship while eating (initiated 8/30/24), monitoring for any signs of Resident #1 posing danger to herself and others (initiated 8/6/24) and intervening before Resident #1 became agitated and guiding the resident away from sources of distress (initiated 8/6/24).-Review of the resident's care plan did not reveal new interventions were implemented after the resident was involved in two physical abuse altercations.-Review of Resident #1's electronic medical record (EMR) did not include documentation regarding the physical abuse incidents on 5/28/25 or 6/13/25.V. Resident #3 (victim)A. Resident statusResident #3, age greater than 65, was admitted on [DATE]. According to the August 2025 CPO, Resident #3 had a diagnosis of dementia with severe anxiety.The 7/17/25 MDS assessment revealed Resident #3 had severe cognitive impairment per staff interview. The assessment indicated Resident #3 had physical behavioral symptoms directed towards others and verbal behavioral symptoms directed towards others.B. Record review-Review of Resident #3's comprehensive care plan did not reveal documentation indicating the resident received received physical aggression from Resident #1. -Review of Resident #3's EMR did not reveal documentation regarding the physical abuse incident on 5/28/25.VI. Resident #2 (victim)A. Resident statusResident #2, age greater than 65, was admitted on [DATE]. According to the August 2025 CPO, diagnoses included Alzheimer's disease with late onset and dementia.According to the 5/29/25 MDS assessment Resident #2 had a severe cognitive impairment per staff assessment. The assessment documented Resident #2 did not have any behaviors.B. Record reviewResident #2's comprehensive care plan, revised 6/2/25, documented she received physical aggression from another resident. Interventions included assessing and addressing for contributing sensory deficits (initiated 6/2/25), assessing and addressing for contributing sensory deficits (initiated 6/2/25), sitting with the resident and taking her for a walk outside as needed (initiated 6/2/25) and monitoring for any signs of other residents posing danger to the resident (initiated 6/2/25).A progress note, dated 6/13/25, documented a resident (Resident #1) was sitting in the dining room chair as she watched television. Resident #2 stood behind the resident's chair and next to a CNA. Resident #2 placed her hand on the back of the resident's chair. The resident (Resident #1) reached up and said Do not touch me! Resident #1 grabbed Resident #2 by the arm with her fingernails, which resulted in three red areas and one superficial open area on Resident #2's right forearm. The CNA stepped between the residents and separated them. The resident attempted to hit Resident #2 again, but the staff prevented her from making contact. Resident #1 was asked to go to her room until she was calm.VII. Staff interviewsThe memory care director was interviewed on 8/13/25 at 11:20 a.m. The memory care director said the staff on the dementia unit prevented resident-to-resident altercations and behaviors with snacks and a lot of redirection. The memory care director said all staff received dementia training once a year. She said Resident #1 was sometimes volatile but had recently calmed down. She said Resident #1 was good at leaving the area if she was anxious, but often tried hitting others who invaded her personal space. The NHA was interviewed on 8/13/25 at 11:35 a.m. The NHA said it was important to update care plans with new interventions because whatever was previously in place obviously did not work. She said it was important to prevent resident-to-resident abuse to prevent fear or injuries. The NHA said she felt Resident #1 did not instigate the altercations for either incident. The NHA said the root cause of the incident on 6/13/25 appeared to be the dining room was cluttered and Resident #2 got in Resident #1's personal space. The NHA said Resident #3 was the one who was agitated and near Resident #1's doorway on 5/28/25. She said both incidents of abuse were substantiated.

Based on observations, record review and interviews, the facility failed to maintain an effective pest control program so the environment was free of pests. Specifically, the facility failed to prevent and take adequate measures to eliminate mice within the facility. Findings include: I. Professional references According to the State Board of Health Colorado Retail Food Establishment Rules and Regulations (revised 3/16/24) retrieved on 5/1/25, read in pertinent part, The premises shall be maintained free of insects, rodents, and other pests. The presence of insects, rodents, and other pests shall be controlled to eliminate their presence on the premises by: -Routinely inspecting incoming shipments of food and supplies -Routinely inspecting the premises for evidence of pests -Using methods, if pests are found, such as trapping devices or other means of pest control as specified under; and -Eliminating harborage conditions. (Chapter 6) II. Facility policy and procedure The Pest Control policy and procedure, revised May 2008, was provided by the corporate consultant (CC) on 4/29/25 at 10:12 a.m. The policy read in pertinent part, This facility maintains an on-going pest control program to ensure that the building is kept free of insects and rodents. The Pest Control policy and procedure for dietary services, revised October 2022, was provided by the director of nursing (DON) 4/29/25 at 12:45 p.m. The policy read in pertinent part, A program will be established for the control of insects and rodents for the dining services department. The dining service director coordinates with the director of maintenance to arrange pest control services on a monthly basis, or as needed. All food preparation, service, and storage areas will be monitored regularly for any signs of pest/vermin. The (facility) staff will be notified immediately of any concerns. When applicable, bulk foods will be removed from their original packaging and stored in containers with tight fitted lids. III. Observations On 4/28/25 at 3:31 p.m. two closed container mouse traps were identified on the floor in the kitchen. One trap was located under the dish washing station and the other trap was in the dry storage room under a dry food storage shelf. The floor of the kitchen and dry storage room had visible food remnants and other indistinguishable surface debris throughout the kitchen floor egress, under storage shelves, under the food prep station, under the stove and behind the waste bin. At 4:29 p.m. the kitchen floor was observed by the dietary consultant (DC) who identified mouse feces on the floor in the dry food storage room. IV. Resident interviews Resident #6 and Resident #7 were interviewed together on 4/28/25 at 4:55 p.m. The residents shared the same room. Resident #6 said she saw a mouse in their room last night (4/27/25). Resident #7 said mouse droppings/feces were found under her bed by her family member on 4/28/25. Resident #7 said there was mouse droppings in her dresser drawer a few days ago. She said she notified staff and they cleaned the dresser drawer. Resident #7 said she kept her snacks in her dresser drawer. Resident #6 said it bothered her to see mice in her room because she did not like mice. Resident #8 was interviewed on 4/28/25 at 5:03 p.m. She said a few weeks ago she had a mouse run out from under her reclining chair as she sat in it. She said it really startled her. Resident #9 was interviewed on 4/28/25 at 5:11 p.m. He said two mice jumped out of his desk drawer and ran across his bedroom floor a month ago. He said he kept candy bars in his desk drawer. V. Record review The March 2025 resident council minutes, dated 3/25/25, were provided by the DON on 4/28/25 at 3:45 p.m. The minutes identified the facility had a plan of correction related to mice and their pest control vendor had come out to the facility three times in March 2025. According to the minutes, food had been a big issue so the facility was spring cleaning to help with mice entering the facility. A pest control plan of correction binder was provided by the maintenance director (MTD) on 4/28/25 at 3:50 p.m. The plan of correction contained a summary timeline and monitoring goals, photos of interventions such as potential mouse entry holes filled with mouse foam sealant, new door sweeps, contract pest control service invoices and recommendations, identification of findings and audits of room cleanliness. The plan of correction summary of action documented on 2/25/25, the nursing home administrator (NHA) and the MTD were notified of mice sightings in the facility and contacted a pest control vendor. The pest control vendor sprayed a chemical pest control barrier around the outside of the facility. The plan of correction indicated the pest control vendor returned to the facility on 3/10/25, after additional mouse sightings and dropping were reported on 3/10/25. The pest control vendor removed three mice from the facility, placed glue boards in the mouse traps and recommended the facility complete exclusion work (fix potential mouse entry ports) in several locations around the kitchen. According to the plan of correction, more mice sightings were reported to the NHA on 3/11/25. The MTD sealed all possible entrances with a mouse shield foam spray patched damaged wall surfaces. The plan of correction indicated the NHA conducted education on 3/12/25 with staff regarding facility cleanliness to prevent the drawing in of mice into the facility. The plan of correction identified all residents had the potential to be affected by pests/mice in the facility and monitoring was put in place. The plan of correction documented the MTD would interview staff five days a week on each hallway to determine if there were new mouse sightings or dropping found and notify the NHA if there were concerns. The housekeeping director (HKD) or designee would complete visual checks five days a week of cleanliness of all resident rooms. The dietary director (DM) would complete an inspection of the kitchen area for cleanliness, mice and mice droppings, notify the NHA if concerns were identified and maintain a kitchen deep cleaning log. A maintenance audit identified maintenance conducted floor observations and questionnaires for mice sightings in resident areas between 3/10/25 and 4/27/25. A housekeeping audit identified a daily floor visual cleanliness assessment was conducted on 3/10/25 through 4/21/25. The 3/10/25 pest control vendor service report identified the mice were breeding in the walls and entering near the exposures of plumbing pipes that required exclusion work. The service report documented the mice breeding inside the walls, indicating the mice were finding adequate amounts of food, water and shelter resources to reproduce. The service report recommended the facility reduce the mice resources to reduce the number of mice. The 4/14/25 pest control vendor service report identified a large quantity of drain flies were found in the kitchen and six mice in the kitchen mouse traps. The service report recommended the facility to leave the traps in place and not to bait the mice with human food. The report also recommended two holes under the sink in the kitchen, a hole in the wall in the memory care unit, and broken/damaged/clogged drains be repaired. -The plan of correction did not include the identification and prevention of food sources such as the back door of the kitchen routinely left open on warm weather days and residents'snacks in resident room drawers (see interviews below). -The plan of correction did not identify how long the plan of correction audits should be maintained/conducted. A kitchen audit was provided by the DC on 4/28/25 at 4:25 p.m. The kitchen indicated a daily visual cleanliness and storage check for mice and mice droppings audit was conducted on 3/15/25 through 4/8/25. According to the audit, the floors and counters were clean, all food was sealed and there were no mice or mice droppings found. -The review of the kitchen audit documented the review of kitchen cleanliness for mouse prevention and observation was completed for three weeks, even though the facility continued to have reports of mice (see staff and resident interviews). VI. Staff interviews Dietary aide (DA) #1 was interviewed on 4/28/25 at 3:40 p.m. DA #1 said he had seen mice and mice droppings in the kitchen but the sightings had been less in the last few weeks. He said the pest control vendor installed mouse traps in the kitchen. The MTD was interviewed on 4/28/25 at 3:50 p.m. The MTD said the facility had a contract with a pest control vendor beginning in 2024. He said the pest control vendor routinely came every month to the facility. The MTD said recently, the facility had to use their services more often. He said the pest control vendor used a barrier spray around the facility and placed mouse traps in various areas around the building. He said over the couple of months, there had been quite a few mouse sightings in the facility. He said mice had been found in five known resident rooms and in the kitchen. He said the most recent incident was on 4/27/25. He said a mouse was found in a resident's dresser drawer. The drawer contained food and candy. He said he was conducting mice sighting audits in resident rooms and the kitchen staff were conducting their own audits. Cook (#1) was interviewed on 4/28/25 at 4:25 p.m. [NAME] #1 identified himself as the acting supervisor while the DM was on leave. He said he had not seen any mice or evidence of mice in the kitchen in the last two to three weeks. [NAME] #1 said seven mouse traps were outside the back door of the kitchen so they could be checked for mice. He said after every meal, the staff should sweep and mop the floors and after every shift they should do a deep cleaning of the kitchen. [NAME] #1 said he reviewed the kitchen audit for mouse prevention and said he did not know why the audit was not conducted after 4/8/25. He said the DM was responsible for the audit. [NAME] #1 said he just made sure the staff were keeping things clean. [NAME] #1 said the DM did not delegate the continuation of the audit to him while the DM was gone. [NAME] #1 did not know if the audits were delegated to someone else and did not know if the audits should have been continued past 4/8/25. The DC was interviewed on 4/28/25 at 4:29 p.m. after the above observations in the kitchen. She said she would ensure the kitchen cleanliness would be addressed and corrected on the evening of 4/28/25. Certified nurse aide (CNA) #1 was interviewed on 4/29/25 at 11:49 a.m. CNA #1 said she had not seen any mice or had been instructed on how to help prevent mice in the facility. CNA #2 was interviewed on 4/29/25 at 11:57 a.m. CNA #2 said she heard mouse traps were set up in the facility but she has not seen any mice or evidence of mice or other mouse prevention. She said residents kept snacks in their room. CNA #2 said there was no set location on where the snacks were stored in the residents' room. She said the location of the snacks in a resident's room was the resident's choice. The DC was interviewed on 4/29/25 at 12:05 p.m. She said on 4/28/25 (during the survey), the dietary staff pulled all the equipment from the walls and center console and cleaned the floors underneath. The DC said the dietary staff pulled everything off the shelves and inspected all the boxes for damage and feces. She said the only thing they found was an open container of pudding. She said the refrigerators were cleaned and all surfaces in the kitchen were wiped down. The DC said the dietary staff needed to make sure every crumb on the floor was addressed quickly. She said the facility was prone for pests. She said the kitchen staff have been told to move everything when they sweep and mop and make sure any mess they made was cleaned up right away to prevent mice. The DC said removing food debris on the floor was a preventative measure in pest control so mice do not consume the food and breed. The DC said she contacted the DM and he said the NHA told him he no longer had to continue the kitchen audit logs for cleanliness and mouse prevention. She said the kitchen had other cleaning logs but they were more directed at basic cleaning. The DC said she would do an education with the dietary staff scheduled today (4/29/25) on sanitation and continue the education for the remainder of the dietary staff. The DON was interviewed on 4/29/25 at 12:47 p.m. She said there were mouse sightings at the facility and pest control was contacted. She said audits were conducted and the staff was educated to remind residents not to keep food in their room. She said she was not aware of any new reports of mice. The MTD was interviewed on 4/29/25 at 1:27 p.m. The MTD said the pest control vendor came out the morning of 4/29/25 and found a couple more holes in the kitchen's dish room that needed a foam seal. The MTD said the mice could come into the facility through the kitchen's back door. He said the dietary staff leave the kitchen back door open even though he has put up signs to remind the staff to keep the door closed so mice do not enter. He said he has also had to remind the staff to not remove the traps from the kitchen. A staff member who wished to remain anonymous was interviewed on 4/29/25 at 1:35 p.m. The staff member said mouse droppings have been seen in the kitchen and the mouse traps were not routinely cleaned causing an odor. The staff member said the mouse traps were not helping get rid of the problem. The staff member said the dietary staff left the back door of the kitchen open to help with the warm temperatures in the kitchen. The staff member said the staff had not been told to put food away and where it belonged to help prevent the mice. The staff member said the mice infestation was really bad in March 2025 and they had not seen much of an improvement in April 2025. The HKD was interviewed on 4/29/25 at 2:55 p.m. He said he has seen mouse urine or droppings in a few resident rooms but not in the last couple of weeks until today (4/29/25). He said a resident room was reported to have a mouse sighting. He said the room was cluttered per the resident's choice. He said the room was deep cleaned and a trap was placed in the room. The HKD said residents with food in their rooms had been the common pattern of evidence of mice in a resident's room and almost always found in dresser drawers. He said on the back side of most of the residents' dressers with predrilled holes. He said the holes make it easy for the mice to get into the dressers and assess resident's stored snacks. The HKD said he was still auditing the rooms after 4/21/25 but did not have the audit logs at the facility (see audits above). The DON was interviewed on 4/29/25 at 3:05 p.m. The DON said the facility would start a full facility cleaning of all rooms and look at food storage. She said the dietary staff would be educated on keeping the kitchen back door closed and the facility will look at ways to reduce the heat in the kitchen without the reliance of an open door for air flow. The DON said she would implement more monitoring in the kitchen for mouse prevention interventions such as closing the back door. VI. Facility follow up A 4/29/25 dietary department education was provided by the DON on 4/29/25 at 12:45 p.m. The education reviewed the dietary pest control policy and cleaning and sanitizing procedures with three dietary staff. The education included an accompanied quiz that highlighted the education materials. According to the cleaning and sanitizing procedures, resident safety in a health care environment was a top priority. Cleaning and sanitizing properly was one of the most important things staff for staff to continually do in a kitchen to prevent harm.

Based on record review and interviews, the facility failed to ensure the money from personal funds accounts was managed adequately for two (#7 and #13) of five residents reviewed for personal funds out of 41 sample residents. Specifically, the facility failed to notify Resident #7 and Resident #13, who were Medicaid funded, or their legal representative, when the resident's personal funds account reached $200.00 less than the eligibility resource limit for one person. Findings include: I. Facility policy and procedure The Management of Residents' Personal Funds policy, revised March 2021, was provided by the nursing home administrator (NHA) on 7/23/24 at 5:15 p.m. It documented in pertinent part, The facility manages the residents' funds, the facility acts as a fiduciary of the resident funds and holds, safeguards, manages and accounts for the personal funds of the resident. No service charge is levied against the resident for the management of personal funds. II. Record Review A. Resident #7 A review of the facility's current trust account balance on 7/18/24 revealed Resident #7 had $2,083.69 in her account, which was $83.69 over the allotted $2000.00 eligibility limit for Medicaid funded residents. -There was no documentation to indicate the facility had notified Resident #7 or her legal representative when her personal funds account reached $200 less than the eligibility resource limit. B. Resident #13 A review of the facility's current trust account on 7/18/24 revealed Resident #13 had $1,876.24 in her account. -There was no documentation to indicate the facility had notified Resident #13 or her legal representative when her personal funds account reached $200 less than the eligibility resource limit. III. Staff interviews The business office manager (BOM) was interviewed on 7/22/24 at 3:04 p.m. The BOM said she had not provided letters to Resident #7 and Resident #13 stating they were within $200 of the Medicaid spending limit. The BOM said she was trained by the regional personnel at the same time as a few other BOM's at other health care facilities. She said she was concerned that some business office education may have been lost in the training process. The nursing home administrator (NHA) and the director of nursing (DON) were interviewed together on 7/23/24 at 4:53 p.m. The NHA said she was not aware that Medicaid letters had not been sent when residents were within $200 of the spending limit. The DON said Medicaid spending limit letters should be provided to residents.

Based on observations and interviews, the facility failed to ensure residents' personal privacy for two (#18 and #49) of three residents reviewed for privacy out of 41 sample residents. Specifically, the facility failed to ensure residents had privacy during personal phone calls. Findings include: I. Facility policy and procedure The Promoting/Maintaining Resident Dignity policy, dated 1/1/23, was provided by the nursing home administrator (NHA) on 7/23/24 at 5:15 p.m. It documented in pertinent part, All staff members are involved in providing care to residents to promote and maintain resident dignity and respect resident rights. Maintain resident privacy. II. Observations On 7/17/24 at 10:05 a.m., an unidentified resident was observed using the landline telephone at the nurse's station. Two staff members were sitting close by in the nurses station within a few feet of the resident. -No privacy was provided to the unidentified resident. On 7/19/24 at 1:41 p.m., Resident #18 was observed at the nurse's station. The resident was talking on the landline telephone. During the telephone conversation, the resident had to repeat herself in a louder voice so she could be heard on the telephone. Multiple nursing staff and residents were present within the immediate area of the telephone conversation which was easily overheard. -No privacy was provided to the resident. On 7/23/24 at 9:11 a.m., Resident #18 was observed at the nurse's station. The resident was talking on the landline telephone. The resident used her hands to attempt to block sound from the room going into the mouthpiece of the landline telephone. Multiple nursing staff and residents were present within the immediate area of the telephone conversation, which was easily overheard. -No privacy was provided to the resident. III. Resident interviews Resident #49, who was cognitively intact, was interviewed on 7/18/24 at 10:33 a.m. Resident #49 said he was not able to make private phone calls in the facility if his personal cell phone stopped working. Resident #49 said his personal cell phone ran out of battery power a month ago (June 2024) and he was unable to have private phone conversations with his wife on the facility phone. Resident #49 said he had to use the phone at the nurse's station to speak to his wife which made him uncomfortable because there were multiple staff members and residents within a few feet of him listening to the conversation. Resident #49 said since the incident when his phone ran out of battery power he ensured his phone was fully charged every day so he did not have to use the community phone at the nurse's station. Resident #18, who was cognitively intact, was interviewed on 7/22/24 at 3:12 p.m. Resident #18 said she could not make a private phone call in the facility. Resident #18 said her only option to make any phone call was to use the landline phone at the nurse's station. Resident #18 said she did not like to use the landline phone at the nurse's station because she knew staff and other residents listened to her telephone conversations. Resident #18 said she had heard nursing staff make comments about her telephone conversations while she was talking on the landline phone, which made her feel uncomfortable. Resident #49 was interviewed again on 7/23/24 at 10:58 a.m. Resident #49 said he did not know there were cell phones for resident use. Resident #49 said the staff in the facility had not informed him that cell phones for resident use were available. Resident #49 said he wished he had known about the option when he needed to make private phone calls and his personal cell phone was not available to him. Resident #18 was interviewed again on 7/23/24 at 12:56 p.m. Resident #18 said she was not aware the facility had cell phones for residents to use. Resident #18 said she was never informed by staff that cell phones were available for resident use. Resident #18 said she would like to use the cell phones for private phone calls in her room if that was available to her. III. Resident group interview Four residents (#16, #49, #59 and #65), who were identified as interviewable by the facility and assessment, were interviewed on 7/22/24 at 9:30 a.m. The following comments were made regarding privacy when making or receiving phone calls: -Residents said there was a shared phone available at the nurse's station on the south unit or residents could use the phone at the front desk. -The facility had cell phones but the residents had been told the cell phones were lost. -A resident said when she had to make a phone call at the nurse's station, she did not have privacy because there were staff and other residents all around her. -Another resident said if she wanted to have a private phone call she would have to ask staff to borrow one of their personal phones. IV. Staff interviews Licensed practical nurse (LPN) #2 was interviewed on 7/23/24 at 10:11 a.m. LPN #2 said the facility had two cell phones that the residents could use but she did not know where they were located. LPN #2 said the cell phones for resident use should be kept at the nurse's station. LPN #2 said she did not know when the cell phones were last requested for personal use. LPN #2 was interviewed again on 7/23/24 at 10:24 a.m. LPN #2 said the cell phones for resident use were now being kept at the front desk. LPN #2 said she did not know when this change occurred. LPN #2 said the residents should know that cell phones were available to them. LPN #2 said she did not know when the cell phones first became available for the residents. Certified nurse aide (CNA) #7 was interviewed on 7/23/24 at 10:41 a.m. CNA #7 said she did not know if there were personal cell phones for the residents to use. CNA #7 said she had not been asked for a cell phone to make a private phone call in the facility. The director of nursing (DON) was interviewed on 7/23/24 at 4:53 p.m. The DON said the residents should have privacy during phone calls to respect the residents ' dignity and privacy. The DON said the facility should do more to inform the residents that cell phones were available for their personal use. The DON said she would type up a newsletter to distribute to the residents to ensure they were aware that the cell phones were available to them. The NHA was interviewed on 7/23/24 at 7:33 p.m. The NHA said she had not identified resident phone call privacy as an issue in the QAPI committee.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to ensure residents were kept free from abuse for one (#29) of four residents reviewed for abuse out of 41 sample residents. Specifically, the facility failed to protect Resident #29 from physical abuse by Resident #44. Findings include: I. Facility policy and procedure The Abuse policy, revised 2/29/24, was provided by the nursing home administrator (NHA) on 7/22/24 at approximately 12:00 p.m. It read in pertinent: Residents have the right to be free from abuse.This includes but is not limited to verbal and physical abuse. The resident's care plan is revised to include new approaches to reduce or eliminate any further chance of abuse. Recommendations for appropriate intervention can then be implemented. When another resident jeopardizes the safety of one resident, alternative placement may be considered for that resident. II. Incident of physical abuse between Resident #44 and Resident #29 on 7/2/24 A. Facility investigation of the altercation on 7/2/24 The initial report, completed 7/2/24, documented two female residents in the secured dementia unit had a verbal and physical altercation. Resident #44 and Resident #29 shared a bedroom, where this incident occurred. Resident #44 told Resident #29 to shut up. Resident #29 responded with I do not have to, you are not my boss. Resident #44 pushed Resident #29 which resulted in Resident #29 falling to the ground. The staff immediately separated the residents for the night and Resident #29 was placed on 15-minute checks. The nurse assessed the residents and Resident #29 had a bruise to her left elbow. Certified nurse aide (CNA) #6 was interviewed and said she heard a commotion and checked in the resident's room. CNA #6 separated the residents for the night because they shared a room. A summary of the investigation revealed Resident #44 did push Resident #29 to the ground which resulted in a bruise. The allegation of the resident to resident altercation was substantiated by the facility. III. Resident #44 (assailant) A. Resident status Resident #44, age [AGE], was admitted on [DATE]. According to the July 2024 computerized physician orders (CPO), diagnoses included Wernicke's encephalopathy (life-threatening illness caused by thiamine deficiency) and dementia. The 6/27/24 minimum data set (MDS) assessment revealed Resident #44 had a severe cognitive impairment with a brief interview for mental status (BIMS) score of zero out of 15. The MDS assessment indicated Resident #44 did not have behaviors. B. Record review A change of condition was completed for Resident #44 on 7/2/24. Resident #44 was documented as having had behavioral symptoms. Resident #44 exchanged aggressive words with her roommate, Resident #29, and shoved Resident #29 which caused her to fall. Resident #29 and Resident #44 were separated and Resident #29 was in another room for the night. A progress note dated 7/2/24 documented Resident #44 was unable to recall an incident that occurred with her roommate (Resident #29). Resident #44 and Resident #29 were separated and 15-minute checks were initiated. The nursing home administrator (NHA), the on-call nurse and the physician were notified. Resident #44's care plan, revised 7/3/24, documented the resident had the potential to become verbally or physically aggressive toward other residents. Interventions included ensuring the resident had a routine, providing redirection if the resident had escalating behavior, redirecting the resident when she approached other residents and redirecting other residents from Resident #44's bedroom. An interdisciplinary team (IDT) risk management note dated 7/3/24 documented the root cause of the incident was because Resident #44 was territorial and she was adjusting to a new roommate. The interventions that were put into place after the altercation were 15-minute checks and the residents were to be monitored for adjustment of becoming roommates. IV. Resident #29 (victim) A. Resident status Resident #29, age greater than 65, was admitted on [DATE]. According to the July 2024 CPO, diagnoses included anxiety disorder, insomnia, dementia that was moderate with anxiety and Alzheimer's disease. The 4/30/24 MDS assessment revealed Resident #29 had severe cognitive impairment with a BIMS score of zero out of 15. The MDS assessment did not indicate Resident #29 had any behaviors. B. Record review A change of condition was completed for Resident #29 on 7/2/24. Documentation revealed she had a fall. Resident #29 was observed on the floor next to her bed on her hands and knees. Resident #29 said Resident #44 pushed her after the residents exchanged words. Resident #29 had minor pain in her left elbow. Resident #29's left elbow had an area that was two inches in diameter that was slightly discolored. The residents were separated and 15-minute checks were started. A progress note dated 7/2/24 documented in Resident #29's EMR verbalized Resident #44 shoved her and she fell. A blue bruise about two diameters in size was noted on her left elbow. An IDT note was entered in Resident #29's EMR on 7/3/24. It documented the resident received physical aggression. The root cause was identified as the residents were adjusting to a room change. The residents were separated, 15-minute checks were started and Resident #29's bruise was monitored. V. Staff interviews Certified nurse aide (CNA) #1 was interviewed on 7/17/24 at 12:42 p.m. CNA #1 said the staff attempted to keep the residents separated if residents appeared upset. She said separation did not always work because the residents on the unit had dementia. CNA #5 was interviewed on 7/17/24 at 12:45 p.m. CNA #5 said staff kept a close eye on all of the residents in the dementia unit. CNA #5 said she had not witnessed a lot of resident to resident altercations on the unit. CNA #5 said the residents mainly yelled at each other. CNA #5 said the activity staff were supposed to help entertain the residents while nursing staff provided the residents' care. Licensed practical nurse (LPN) #4 was interviewed on 7/23/24 at 3:57 p.m. LPN #4 said the residents who had dementia were in an altered mental state but that was to be expected because that's how the residents were. The memory care director (MCD) was interviewed on 7/23/24 at 4:06 p.m. The MCD said the staff watched the residents who had a diagnosis of dementia very closely. She said the staff kept the resident's doors open and had staff who walked the hallways to keep an eye on the residents. She said staff offered snacks, cookies and popcorn throughout the day. The MCD said the staff were vigilant and kept an eye on the residents to prevent resident to resident altercations. She said some of the shared resident rooms were in close quarters to each other. The MCD if staff noticed any type of escalation, yelling, cussing or facial expressions the staff redirected the resident. The MCD said when the weather was cooler the staff brought the residents outside to entertain the residents. The nursing home administrator (NHA) was interviewed on 7/23/24 at 6:21 p.m. The NHA said she was not at the facility when the resident to resident altercation between Resident #44 and Resident #29 occurred. The NHA said Resident #44 and Resident #29 were roommates. The NHA said on the night of the incident (7/2/24) the residents did not remember they were roommates which started a verbal altercation. She said the staff separated the residents and there were no further incidents between the residents. The NHA said Resident #44's care plan was updated but Resident #29's care plan was not because she was the victim and staff did not think to update it.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interviews, the facility failed to provide treatment and services to maintain hearing in a timely manner for one (#3) of one resident reviewed out of 41 sample residents. Specifically, the facility failed to ensure recommendations for Resident #3 were followed after an audiologist appointment. Findings include: I. Facility policy and procedure The Ancillary Services policy, dated 11/4/13, was provided by the nursing home administrator (NHA) on 7/23/24 at 5:15 p.m. The policy read in pertinent part, Any resident needing or requesting ancillary services, such as dental, vision, audiology and podiatry will have their needs met timely. The facility will keep available a provider for ancillary services and/or assist the resident with utilizing the provider of their choice. II. Resident status Resident #3, age greater than 65, was admitted on [DATE]. According to the July 2024 computerized physician orders (CPO), diagnoses included unspecified intracranial injury with loss of consciousness (head injury), anxiety, major depressive disorder post-traumatic stress disorder and unspecified perpetrator of maltreatment and neglect. The 4/29/24 minimum data set (MDS) assessment indicated Resident #3 had moderate cognitive impairments with a brief interview for mental status (BIMS) score of 10 out of 15. He did not have inattention or disoriented thinking. No behavioral symptoms or care rejection were documented. The resident required limited one-person physical assistance with most activities of daily living (ADL). According to the MDS assessment, the resident's hearing was adequate and he did not use hearing aids. III. Resident interview Resident #3 was interviewed on 7/17/24 at 1:52 p.m. Resident #3 said he had not gone to bingo lately because he had not been able to hear well enough to play. He said he had difficulty hearing and had been asking to go to the physician to get his ears tested. He said he was supposed to have his ears tested a while ago but he never heard anything more about it. Resident #3 was interviewed again on 7/23/24 at 4:28 p.m. Resident #3 said he was very happy because he was told the nurse was going to put drops in his ears so he could have his ears tested. He said he had been waiting to have his hearing checked for a long time (see record review and interviews below). IV. Record review The 2/13/23 patient appointment visit information form identified Resident #3 had a physician's order to schedule an appointment with the physician/nurse for ear wax removal. According to the physician's orders, the resident had too much wax to test (Resident #3's hearing). The information form requested the facility to look in the resident's ears before scheduling an appointment and if there was a lot of earwax, remove the wax prior to the appointment. The 7/28/23 weekly nursing note read Resident #3 had difficulty hearing in some environments. A speaker may be needed to increase the volume or speak distinctly. -Review of Resident #3's physician's orders did not identify that the resident had orders to remove the earwax after the failed attempt to test his hearing with the specialist. -Review of Resident #3's progress notes did not identify the resident's earwax was removed and another appointment was made to test his hearing. -Review of the resident's comprehensive care plan revealed he did not have a care plan regarding hearing, difficulty hearing, or interventions to help with his difficulties in hearing. V. Staff interviews The social services director (SSD) and the NHA were interviewed together on 7/22/24 at 4:16 p.m. The SSD said when a resident returned to the facility after an appointment, the nurse would enter the new orders, recommendations and/or referrals in the resident's electronic medical record (EMR). The SSD said an appointment would be scheduled for follow up as needed. The SSD said she was not aware of the concerns with Resident #3's hearing. The NHA and the SSD said they reviewed the resident's EMR. The NHA said the resident last went to the audiologist on 2/13/23. She said the audiologist requested for Resident #3's excess earwax to be removed so his hearing could be tested. The NHA said she did not see an order to remove the excess earwax. She said she did not see documentation that the audiologist's orders were followed. The NHA and the SSD said neither of them were in their current positions in February 2023 and they were not sure why the recommendations were not followed up with at the time of the audiology appointment. The SSD said she would notify the director of nursing (DON) and the nurse practitioner of the orders and schedule a follow up appointment with the audiologist to test Resident #3's hearing. The SSD said she would create a grievance form to make sure the needed steps to correct the concern were taken, tracked and reviewed in the interdisciplinary team's (IDT) meeting. The DON was interviewed on 7/23/24 at 3:14 p.m. The DON said when a resident went to a specialist, the resident's nurse would review the visit summary, put the recommendations in the EMR as verbal orders and notify the nurse practitioner. She said she was informed on 7/22/24 (during the survey) Resident #3 was having a harder time hearing. The DON said she discussed the concern with the physician and the resident had a new physician's order for ear drops to help with his earwax removal. The DON said an appointment would be made when Resident #3's earwax buildup was clear. She said she did not know how the orders were missed, but the facility had implemented a new double check process to make sure all physician's orders were put into the EMR after recommendations were made from a specialist, following the appointment. The activity director (AD) was interviewed on 7/23/24 at 6:29 p.m. The AD said Resident #3 had not been going to bingo as much as he used to and, over the last couple of months, he stopped going completely. She said she was not aware Resident #3 was having a hard time hearing. She said she could have offered to have him sit by her during bingo so he could hear the numbers called out.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interviews, the facility failed to provide an effective pain management regimen in a manner consistent with professional standards of practice, the comprehensive person-centered care plan and the resident's goals for one (#49) of two residents reviewed for pain out of 41 sample residents. Specifically, the facility failed to: -Consistently and accurately assess Resident #49's pain to ensure the resident's pain was at or below the resident's stated tolerable pain level; -Ensure Resident #49's care plan included person-centered non-pharmacological interventions for pain; and, -Ensure the physician's order for routine pain medication for Resident #49 was administered as ordered. Findings include: I. Facility policy and procedure The Pain Management policy, dated 5/3/23, was provided by the nursing home administrator (NHA) on 7/23/24 at 5:15 p.m. It revealed in pertinent part, Acceptable (tolerable) pain control is defined by the resident. All residents will be evaluated for pain by utilizing a pain evaluation tool in the electronic medical record (EMR) system. The pain evaluation will be completed upon admission, readmission, quarterly, and with any significant change in condition. The pain evaluation includes the following: location(s), quality, intensity, associated symptoms, precipitating, aggravating, and relieving factors, chronology, pattern (frequency, onset and duration of pain), medication regimen and other treatment modalities used for pain management and their degree of effectiveness. II. Resident #49 A. Resident status Resident #49, age less than 65, was admitted on [DATE]. According to the July 2024 computerized physician orders (CPO), diagnoses included chronic obstructive pulmonary disease (COPD), right leg amputation below the knee, aortic heart valve disorder, peripheral vascular disease (narrowed blood vessels), chronic kidney disease, type two diabetes, diabetic neuropathy (nerve damage caused by diabetes) and generalized muscle weakness. The 7/8/24 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview mental status (BIMS) score of 15 out of 15. The assessment documented Resident #49 had a limb prosthesis and used both a walker and a wheelchair. The assessment documented Resident #49 was on a scheduled pain regimen and did not receive as-needed pain medications or non-medication interventions for pain in the last five days during the assessment period. The assessment documented the resident occasionally had pain, but the pain did not interfere with the resident's sleep or participation with therapy. The resident's pain rarely interfered with his day to day activities. The resident's occasional pain was mild in intensity. B. Observations On 7/22/24 at 4:23 p.m., medication pass was observed with licensed practical nurse (LPN) #5. After preparing other medications for Resident #49, LPN #5 prepared pain medication. LPN #5 opened the narcotic medication lockbox, removed one oxycodone-acetaminophen 5-325 milligram (mg) tablet and placed the tablet into a medication cup. LPN #5 closed the narcotic medication box and locked the medication cart. LPN #5 turned away from the medication cart with the intention to deliver the medications to Resident #49. Upon prompting, LPN #5 reread Resident #49's physician's order for oxycodone-acetaminophen. LPN #5 said she did not know if she could give the medication to the resident at 5:00 p.m. because the physician's order was confusing on when to administer the medication. LPN #5 asked for help from LPN #2 and the director of nursing (DON). The DON clarified and updated the physician's order in the July 2024 CPO on 7/22/24. (see interview below) B. Resident interviews Resident #49 was interviewed on 7/18/24 at 10:33 a.m. Resident #49 said he had pain throughout all hours of the day and it often felt severe for him. Resident #49 said he recently received a prosthetic leg, but it caused him pain wearing it, so he did not wear the prosthetic as much as he would like. Resident #49 said he felt his pain limited his ability to perform activities of daily living (ADL) and limited his sleep. Resident #49 said he normally only slept a few hours each night and it was usually in the early morning when sleep occurred. Resident #49 said he felt constant phantom pain (a painful sensation that is perceived in a body part that is no longer present due to surgical or traumatic removal) in his right leg from the amputation and he had some occasional pains in his hands that felt like lightning to him. Resident #49 said he had tried several nerve pain medications, such as gabapentin and Lyrica, but they did not help his pain. He said the medications he was receiving did not bring his pain to a tolerable level. Resident #49 said that his pain level was a 7 or 8 out of 10 throughout the day, and his acceptable level of pain was a 3 out of 10. Resident #49 said he used lotion for his hands to relieve pain between pain medication doses, but that only reduced his pain a little and did not relieve his pain. Resident #49 said sometimes the nursing staff did not ask him what his pain level was and would just give him his pain pills when he could have them. Resident #49 said his pain medicine was last changed when he had a wound on his left leg in May 2024, but he said the wound was completely healed now. Resident #49 said he had complained of pain so much that he felt he was annoying the nursing staff. Resident #49 and his partner were interviewed together on 7/19/24 at 9:49 a.m. Resident #49 said he barely slept last night (7/18/24) because his phantom pain was shooting down his leg which kept him awake. Resident #49's partner said she felt Resident #49's pain had never been controlled by the facility despite several inquiries regarding his pain. Resident #49 and his partner said they were concerned the facility was not doing enough to manage Resident #49's pain. Resident #49 was interviewed again on 7/22/24 at 10:02 a.m. Resident #49 said he slept for a few hours between 6:00 a.m. and 8:00 a.m. this morning (7/22/24). Resident #49 said the pain in his right leg and hands prevented him from sleeping more the previous night. Resident #49 said he received his pain medication as scheduled but it did not relieve his pain. Resident #49 said his pain was constant. Resident #49 was interviewed again on 7/23/24 at 2:48 p.m. Resident #49 said he tried walking with his prosthetic leg today (7/23/24) but it caused so much pain in his leg he had to stop. Resident #49 said he was disappointed he could not walk or work to achieve his goals of walking more because of his pain today. He said he did not receive additional pain medication or non-pharmacological interventions to help him with the pain and he chose to stop walking instead. C. Record review The pain care plan, created and revised on 10/18/23, documented the resident had pain related to his right leg amputation below the knee. Interventions included administering analgesia (pain medication) as ordered, evaluating the effectiveness of the pain interventions, monitoring and documenting the cause of each pain episode, monitoring and documenting the side effects of pain medication, monitoring, recording and reporting to the nurse complaints of pain or requests for pain medication and offering non-pharmacological interventions for pain prior to administering medications. -The care plan did not identify Resident #49's pain in his hands (see pain assessment documentation below). -The care plan failed to include specific person-centered non-pharmacological interventions. The 10/17/23 pain assessment documented the resident had a hot or burning pain in the right knee, phantom pain in the right foot and pain in the sacrum. The assessment documented Resident #49 stated his pain caused him to be withdrawn from his relationships, made him withdrawn from activities, caused a decrease in physical activity, caused a loss of appetite and caused an inability to perform ADL's. Resident #49 stated that his pain prevented him from doing anything during the assessment. The assessment documented the resident's acceptable level of pain was a 2 out of 10. The 11/20/23 pain assessment documented the resident had a sharp, stabbing, and throbbing pain in the front of the right knee. The assessment documented the resident's acceptable level of pain was a 2 out of 10. -The pain assessment documented Resident #49's acceptable level of pain was a 2 out of 10, however, the physician's order to check the resident's pain level every shift documented the resident's acceptable level of pain was a 7 out of 10 (see physician's orders below). The 2/20/24 pain evaluation documented Resident #49 had a constant aching, throbbing, and tingling pain in the right knee, the left lower leg, the sacrum, and generalized aches and pains. The assessment documented the pain was worse in the evening and at night. The assessment documented the resident's acceptable level of pain was a 4 out of 10. The assessment documented that Resident #49's pain caused a decrease in physical activity, caused an inability to perform ADL's, affected Resident #49's ability to focus, and caused changes in Resident #49's mood and emotions. -The pain assessment documented Resident #49's acceptable level of pain was a 4 out of 10, however, the physician's order to check the resident's pain level every shift documented the resident's acceptable level of pain was a 7 out of 10 (see physician's orders below). The 5/20/24 pain evaluation documented Resident #49 had an aching and sharp phantom pain in his right knee, and generalized aches and pains. The evaluation documented the resident's acceptable level of pain was a 4 out of 10 on a numerical pain scale. The assessment documented that Resident #49's pain caused a decrease in physical activity, caused an inability to perform ADL's, affected Resident #49's ability to focus, and caused changes in Resident #49's mood and emotions. The assessment summary documented that pain was present and a management plan was needed, and to see the care plan for specifics. -However, the pain care plan was not updated after 10/18/23 (see care plan above). -The pain assessment documented Resident #49's acceptable level of pain was a 4 out of 10, however, the physician's order to check the resident's pain level every shift documented the resident's acceptable level of pain was a 7 out of 10 (see physician's orders below). The July 2024 CPO revealed the following physician's orders for pain management: Pain check every shift using PAINAD (pain assessment in advanced dementia) scale. Resident's acceptable level of pain is a 7, ordered on 11/20/23. -However, the pain assessments on 10/17/23, 11/20/23, 2/20/24 and 5/20/24 documented Resident #49's acceptable level of pain was a 2 or a 4 out of 10 (see pain assessments above). -The physician's order recommended using a pain evaluation for cognitively impaired residents, which was based on staff assessment. However, Resident #49 was cognitively intact and was able to state his pain level when asked. Oxycodone-acetaminophen oral tablet 5-325 milligrams (mg). Give one tablet by mouth three times a day for 8:00 a.m., 12:00 p.m., 8:00 p.m. and two tablets at 12:00 a.m., ordered on 5/30/24. A review of the medication administration record (MAR) from May 2024 to July 2024 revealed Resident #49 was documented to have received an oxycodone-acetaminophen oral tablet on 52 consecutive days at 5:00 p.m. between 5/31/24 and 7/21/24. -However, the physician's order specified the resident was to receive the medication at 8:00 p.m., not 5:00 p.m. -The MAR from May 2024, June 2024, and July 2024 failed to document non-pharmacological interventions used to address Resident #49's pain. A review of pain assessment documentation on the MAR revealed that Resident #49's pain was assessed using the PAINAD scale a total of 105 times between 5/30/24 and 7/21/24. Of those 105 assessments, Resident #49 was documented to be experiencing pain above a 4 out of 10 on 71 of those pain assessments. -A review of Resident #49's EMR revealed there was no documentation to indicate the physician was notified or the facility addressed the resident's pain when his pain level was above his stated tolerable level of pain. IV. Staff interviews LPN #5 was interviewed on 7/22/24 at 4:48 p.m. LPN #5 said she had not assessed Resident #49's pain before obtaining his pain medication from the medication cart. LPN #5 said the physician's order for oxycodone-acetaminophen 5-325 mg for Resident #49 was confusing. LPN #5 said when a physician's orders appeared confusing, nursing staff should clarify the order to ensure the medication was administered correctly. LPN #5 said she had not clarified Resident #49's pain medication order before 7/22/24 (during the survey). LPN #2 was interviewed on 7/22/24 at 4:49 p.m. LPN #2 said she had always given Resident #49 his pain medication at 5:00 p.m. because the MAR had pain medicine scheduled for 5:00 p.m. LPN #2 said she re-read the order and was unsure if the pain medication could be given at 5:00 p.m. LPN #2 said confusing physician's orders should be clarified with the provider. LPN #2 was interviewed again on 7/23/24 at 9:11 a.m. LPN #2 said Resident #49 always had pain whenever she assessed him for pain. LPN #2 said she did not know what Resident #49's acceptable pain level was. LPN #2 said Resident #49's pain medication was last reviewed and updated in May 2024. Certified nurse aide (CNA) #7 was interviewed on 7/23/24 at 9:17 a.m. CNA #7 said Resident #49 frequently complained of pain in his leg or his hands. CNA #7 said the facility managed Resident #49's pain with pain medications. CNA #8 was interviewed on 7/23/24 at 9:26 a.m. CNA #8 said Resident #49 complained of pain every day. CNA #8 said the nursing staff had known about Resident #49's pain for a long time. CNA #8 said the facility used pain medications to help Resident #49's pain, but she was unsure how well the pain medications were working for the resident's pain. The DON was interviewed on 7/22/24 at 4:51 p.m. The DON said the physician's order for oxycodone-acetaminophen 5-325 mg for Resident #49 was confusing. The DON said the ordering provider had clicked a scheduling button to schedule a dose at 5:00 p.m. when the provider entered the order into the facility's electronic medical record system. She said this prompted the order to be scheduled at 5:00 p.m. on the MAR instead of at 8:00 p.m. as was documented in the physician's order. The DON said the order was correct but should be clarified with the provider. The DON said she would call the ordering provider and change the medication order to be more easily understood by the nursing staff. -However, the nursing staff was administering Resident #49's pain medication at 5:00 p.m. instead of 8:00 p.m. which was the time specified in the physician's order (see record review above). The DON and corporate consultant (CC) #2 were interviewed together on 7/23/24 at 4:53 p.m. The DON said it was normal for the facility to assess pain on admission, quarterly and whenever a resident experienced a change in condition. The DON said she was not aware Resident #49 was having uncontrolled pain. The DON said she was not concerned about documented discrepancies regarding Resident #49's acceptable pain level because Resident #49 had not alerted staff that he was having uncontrolled pain. CC #2 said the ordering provider had entered Resident #49's pain order incorrectly but the order had been corrected to reflect the appropriately scheduled time of administration in the July 2024 CPO.

Based on record review and interviews, the facility failed to complete a performance review of every nurse aide at least once every 12 months and provide regular in-service education based on the outcome of these reviews for four out of five staff reviewed. Specifically, the facility did not complete annual performance reviews and/or provided regular in-service education based on the outcome of the reviews for certified nurse aide (CNA) #2. Findings include: I. Record review CNA #2 (hired on 6/23/22) did not have an annual performance review completed. CNA #2 did not have an in-service education plan based on the outcome of the review. II. Staff interviews The director of staff development (DSD) was interviewed on 7/22/24 at 2:18 p.m. The DSD said she completed an audit of the system when she accepted her position in the beginning of 2024. She said she discovered there was an issue with staff completing their training as required. She said she worked on a spreadsheet to help track the training staff needed to complete. She said the staff completed a performance every year and if it was a good performance review, the staff received a raise. She said CNA #2 received a raise but she was unable to find their performance reviews. The nursing home administrator (NHA) was interviewed on 7/23/24 at 7:19 p.m. The NHA said if a CNA received an annual raise then an annual performance review was completed. -However, the facility was unable to provide documentation indicating CNA #2 had received an annual performance review. III. Facility follow-up On 7/26/24 at 12:44 p.m. the NHA said CNA #2 received a raise for the 2024 year but she was unable to find her performance review.

Based on record review and interviews, the facility failed to ensure the facility's binding arbitration agreement was thoroughly and accurately explained to the residents and or resident representatives before signing the agreement for two (#176 and #40) of three residents out of 41 sample residents. Specifically, the facility failed to: -Thoroughly explain the binding arbitration agreement in a form and in a manner to ensure Resident #176 and Resident #40 and/or their representatives understood the agreement before signing the arbitration agreement; and, -Ensure staff reviewing the arbitration agreement with Resident #176 and Resident #40 and/or their representatives understood the components of the agreement. Findings include: I. The Arbitration Agreement The Arbitration Introduction form, undated, was provided by the nursing home administrator (NHA) on 7/22/24 at 2:51 p.m. The Arbitration Introduction read in pertinent part, Arbitration is a cost effective, private and time saving alternative means of resolving disputes outside of the courts. In arbitration, disputes are heard and decided by a private individual called an arbitrator. the disputes will not be heard or decided by a judge or jury under any circumstances. The decision of the arbitrator is binding on both parties and any judgment on an award can be enforced by court if necessary. there is no appeal of an arbitrator's decision, so disputes can be resolved efficiently and timely. The Arbitration Agreement form, dated 2019, was provided by the NHA on 7/22/24 at 2:51 p.m. The agreement read in part: The parties agree that any legal dispute, controversy, demand or claim shall be resolved exclusively by binding arbitration administered by (an entity that assists with arbitration, mediation and other alternative dispute resolutions with facilities throughout the United States; contact information by a single neutral arbitrator agreed upon the parties and not by a lawsuit or resort to court processes, except to the extent that's applicable by state and federal law providing judicial review of arbitration proceedings or judicial enforcement of arbitration agreements and awards. This agreement and the claim or claims to which it applies includes, but is not limited to, those that arise out of or relate to the admissions agreement, any service or health care provided by us to you, violations of any right granted to you by law or by the admission is agreement that would constitute a cause of action in court of law and include, but not limited to, breach of contract or warranty, express or implied, fraud or misrepresentation, wrongful death, survival action, negligence, gross negligence, malpractice, any claim based on any departure from accepted standards of care for medical or other health care related services, healthcare or safety. This includes all claims whether sounding in tort, in contract or based on any claim of violation of any federal, state, local or other government law, statute, regulation, ordinance, or common law and including any consumer protection act. This agreement shall not limit your right to file a grievance or complaint, formal or informal, with us or any appropriate state or federal agency. It is the intention of the parties to this agreement that it shall inure to the benefit of and bind the parties, their successors and assigns, including our agents, employees, managers or owners, and all persons who claim is derived through, as a result of or on behalf of you including that of any parent, spouse, sibling, child, guardian, executor, personal representative, administrator, conservator, legal representative or heir. Both parties to this agreement, by entering into it, have agreed the use of binding arbitration in lieu of having any dispute decided in a court of law before a jury. By signing this agreement you are agreeing to have any issue of medical malpractice decided by neutral binding arbitration rather than a jury or court trial. you have the right to seek legal counsel and you have the right to rescind this agreement within 90 days from the date of signature by both parties unless this agreement was signed in contemplation of hospitalization in which case you have 90 days after discharge or release from the hospital to resend the agreement. II. Resident representative interview Resident #176's representative was interviewed on 7/22/24 at 3:45 p.m. The representative said she signed the arbitration agreement for Resident #176 but questioned the admissions coordinator (AC) about the court process. She said she told the AC, by signing the arbitration agreement, it looked like she could not sue the facility if there was ever any problem. She said she was told by the AC that a mediator would be used if there was a concern, but if mediation did not work to resolve the concern, she could still go to court. The representative said she declined a paper copy of the agreement but received it electronically. She said she had not reviewed it since she signed the agreement. III. Resident interview Resident #40 was interviewed on 7/22/24 at 5:58 p.m. Resident #40 said she signed everything the facility asked her to sign when she was admitted to the facility. She said she was not sure what she signed because could not see well enough to read it. She said she had a basic understanding of what arbitration was, and believed it was binding, but she was not told that she could not go to court if she wanted to after signing the agreement. Resident #40 said she had to rely on someone to tell her what all her paperwork read because of her impaired vision. IV. Record review Arbitration Agreement and Arbitration Introduction forms for Resident #40 and Resident #176 were provided by the NHA on 7/22/24 at 2:51 p.m. Resident #40 signed her own Arbitration Agreement and Arbitration Introduction forms. The Arbitration Agreement and Arbitration Introduction were signed by the AC as the staff representative. Resident #40's Arbitration Agreement and Arbitration Introduction forms were signed by Resident #40 on 7/2/24 at 4:37 p.m. The Arbitration Agreement and Arbitration Introduction forms were signed by the AC on 7/2/23. Resident #176's Arbitration Agreement and Arbitration Introduction forms were signed by Resident #176's representative on 5/22/24. -Resident #176's Arbitration Agreement and Arbitration Introduction forms were signed by the AC but the signature was not dated. V. Staff interviews The AC was interviewed on 7/18/24 at 5:06 p.m. The AC said she had been responsible for the facility's admissions paperwork since May 2024. She said the Arbitration Agreement and Arbitration Introduction forms were part of the admission packet. She said she would review the Arbitration Agreement and Arbitration Introduction forms with the resident if they were signing forms. She said if the resident's representative signed the Arbitration Agreement and Arbitration Introduction forms, she would review the forms with them in person or send the forms to them electronically to sign and return it to her. The AC said she explained to the resident and/or their representative that they had the right to have their disputes reviewed and decided by a third party. The AC said she would usually read the Arbitration Agreement and Arbitration Introduction forms to the resident or resident's representative if they signed in person. She said if the resident's representative was not able to come into the facility to sign the Arbitration Agreement and Arbitration Introduction forms with her in person, she would email the forms to them and have them sign the forms electronically. The AC said she was not sure if the arbitration agreement was binding. She said she would have to find out. She said she was not sure if or when the resident/representative could revoke the arbitration agreement. The AC said she did not receive training on the arbitration agreement or arbitration process. She said if she or families had questions, she could contact the corporate consultant (CC #2) or someone else. She said CC #2 used to be the facility's admissions coordinator. The NHA was interviewed on 7/22/24 at 3:56 p.m. The NHA said the AC reviewed all of the admissions paperwork with the resident/resident's representative, including the Arbitration Agreement and Arbitration Introduction forms. The NHA said the resident/resident representative had the option not to sign the forms. She said the AC should explain what an arbitration agreement was. She said the resident/representative could review the Arbitration Agreement and Arbitration Introduction forms with a lawyer. The NHA said from her understanding, the arbitration agreement was not binding and the resident/representative could still go to court. The NHA said she was not sure how long the resident/repersentive had to rescind the arbitration agreement after signing it. CC #2 was interviewed on 7/23/24 at 10:24 a.m. CC #2 said she had been the facility's admissions coordinator off and on between October 2022 and March 2024. She said prior to the current AC, she would review the Arbitration Agreement and Arbitration Introduction forms with the resident/resident's representative if they signed the forms in person or she would email them the forms to them to sign and return to her. CC #2 said she would ask the resident/resident representative if they were familiar with what an arbitration agreement was and then touch on a few components of the agreement. She said she would tell them arbitration was the last step in the grievance/concern process. She said she would emphasize that the arbitration agreement could be canceled anytime within 30 days with written notice, and not signing the agreement would not affect the care and services provided at the facility. She said it was the resident/resident representative's choice to sign or not. CC #2 said the arbitration agreement was binding after 30 days. She said she did not reiterate if the resident/representative could still go to court after the 30 days. She said no one usually asked about it so she did not go over it. CC #2 said she would tell the resident/representative, arbitration was prior to other legal processes. CC #2 said she was not sure what the legal processes were after arbitration. CC #2 said most residents who signed the Arbitration Agreement and Arbitration Introduction forms did not want a copy, however, she said they were informed the Arbitration Agreement and Arbitration Introduction forms were available to them in their medical record. CC #2 said she reviewed and trained the current AC on the Arbitration Agreement and Arbitration Introduction forms but had since learned there were things the AC did not know regarding the arbitration agreement process. CC #2 said she was a facility resource and occasionally the AC would contact her with admissions questions. CC #1 was interviewed on 7/23/24 at 12:23 p.m. CC #1 said the arbitration agreement was not binding until the resident entered into the arbitration agreement and it could be revoked. She said she did not work much with arbitration and would need to get clarification from CC #2. CC #3 was interviewed on 7/23/24 at 1:25 p.m. CC #3 said the arbitration agreement needed to be in plain legal language and the resident/resident representative needed to acknowledge they understood the Arbitration Agreement and Arbitration Introduction forms. She said the arbitration agreement had to state the arbitration agreement could be revoked within 30 days but the facility's agreement would allow the resident/representative to revoke the arbitration agreement by 90 days. She said the arbitration agreement was binding after 90 days from the signing of the arbitration agreement. She said the whole point of the arbitration agreement was not to go to court if there was a dispute between the resident and the facility. CC #3 said, by signing the arbitration agreement, the resident/resident representative gave up the right to go to court. She said she hoped the facility was going over the arbitration process with the residents/representatives. The NHA was interviewed again on 7/23/24 at 1:36 p.m. The NHA said the facility would conduct an education with any staff involved or had the potential to be involved in the admissions process. She said the education would go over the components of the arbitration process. She said she would clarify the arbitration process with all residents and resident representatives who had signed the Arbitration Agreement and Arbitration Introduction forms since May 2024. She said she would contact the residents and their representatives before the 90 day deadline of signing the arbitration agreement.

Based on observations, record review and interviews, the facility failed to consistently serve food that was palatable, attractive and at the appropriate temperature. Specifically, the facility failed to ensure food was palatable and attractive when delivered to residents. Findings include: I. Resident interviews Resident #65 was interviewed on 7/17/24 at 11:54 a.m. Resident #65 said when he received his breakfast in his room it was always served cold and under seasoned. Resident #49 was interviewed on 7/18/24 at 8:40 a.m. Resident #49 said the food was bland and had no taste. He said he received cold food. Resident #13 was interviewed on 7/18/24 at 10:34 a.m. Resident #13 said breakfast was always served cold. She said she was the last resident to get her tray. Resident #28 was interviewed on 7/18/24 at 11:56 a.m. Resident #28 said the food tasted awful and the meals were frequently served cold. Resident #28 said he had received undercooked chicken so he ordered something different if chicken was being served. II. Resident group interview Four residents (#65, #16, #59 and #49), who were identified as interviewable by the facility and assessment, were interviewed on 7/22/24 at 9:30 a.m. Residents made the following comments: -The vegetables were soggy or uncooked; -The meals were served cold; -Food items were switched out (received chips instead of french fries); -Food items were served burnt; and, -The meat was undercooked. III. Test tray A test tray was evaluated by three surveyors on 7/22/24 at 12:29 p.m. The test tray consisted of cheesy ham and macaroni casserole, sauteed garlic and spinach, pineapple tidbits and a dinner roll. -The cheesy ham and macaroni casserole was dry, bland and did not have a cheese sauce mixed through it. - The spinach tasted plain and did not have garlic seasoning. IV. Food committee notes The food committee notes were provided by the nursing home administrator (NHA) on 7/22/24 at 4:00 p.m. The food committee notes from 5/7/24 revealed the kitchen was still working on proper food temperatures and appealing plating. The food committee notes from 6/4/24 revealed the kitchen was still working on proper food temperatures and appealing plating. The food committee notes from 7/16/24 revealed the kitchen was working on ensuring food was properly cooked before it was served and getting the meals out on time and promptly. V. Staff interviews The cook (CK) was interviewed on 7/22/24 at 11:30 a.m. The CK said he seasoned the meals based on what the recipe indicated. The dietary manager (DM) and the dietary consultant (DC) were interviewed together on 7/23/24 at 10:15 a.m. The DM said she and the DC were worried about the pineapple not being on ice during the meal service and had placed the last tray of pineapple in the refrigerator to try to cool it down before the last half of the residents were served. The DC said the CK was supposed to put poultry gravy over the top of the casserole for all residents who were on a dysphagia altered diet. The DC said the cheesy ham casserole was dry and bland because the CK was adding poultry gravy to the casserole for the residents but failed to add it to the test tray. She said the CK was worried about how the gravy tasted on top of macaroni and cheese and omitted it from the test tray. The DC said she was going to review the recipes. She said she would let the kitchen staff know if the recipe indicated to provide a sauce, it needed to match the menu item and not just a form of gravy. She said the CK should have provided a cheese sauce to the residents on a dysphagia diet and the test tray, instead of gravy, since it was a macaroni and cheese type of casserole. The DM said she tried to follow-up on the residents' concerns in food committee meetings but she had a budget she had to stay under and she tried her best to please the residents while not going over the budget. The DC said the DM needed to make sure the residents were happy and not focus on the budget as much. The DC said she was going to work with the DM to fix the concerns in the kitchen.

Based on observations, record review and interviews, the facility failed to store, prepare, distribute and serve food in a sanitary manner in the main kitchen and two of two kitchenettes. Specifically, the facility failed to: -Ensure residents were offered and provided hand hygiene before meals; -Ensure the kitchen staff appropriately cleaned thermometers before temperatures were obtained from ready-to-eat foods; and, -Ensure cold foods were held at 41 degrees Fahrenheit (F) or below before serving residents. Findings include: I. Resident hand hygiene A. Facility policy and procedure The Handwashing and Hand Hygiene policy, revised August 2019, was provided by the nursing home administrator (NHA) on 7/23/24 at 5:15 p.m. It documented in pertinent part, All personnel shall be trained and regularly in-serviced on the importance of hand hygiene in preventing the transmission of healthcare-associated infections. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors. Wash hands with soap and water when hands are visibly soiled. Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap and water for the following situations: before and after direct contact with residents, and before and after eating or handling food. B. Observations On 7/17/24 during a continuous observation, beginning at 11:49 a.m. and ending at 12:58 p.m., the following was observed in the main dining room: At 11:55 a.m. Resident #5 was observed self-propelling herself in the dining room. The resident shook the hands of Resident #27 and Resident #70. After shaking hands, Resident #5 then self-propelled herself to a dining table. At 12:08 p.m., Resident #5 was served her lunch plate by staff, which included peas, a dinner roll, meatloaf, mashed potatoes and an ice cream cup. -The resident was not offered hand hygiene by staff members. At 12:10 p.m., Resident #5 began eating her lunch plate. Resident #5 used her fingers to scoop the ice cream out of the ice cream cup and then eat the ice cream. The resident frequently licked her fingers between bites of the ice cream she was scooping out with her fingers. After finishing her ice cream with her hands, she began picking up pieces of meatloaf, peas and mashed potatoes with her hands. The resident continued to lick her fingers between small scooping bites which she ate with her fingers. The resident had been provided with tableware but did not attempt to use it. At 12:15 p.m., Resident #70 began eating his dinner roll with his hands. -Resident #70 had not been offered hand hygiene after he shook hands with Resident #5. At 12:19 p.m., Resident #27 began eating his dinner roll with his hands. -Resident #27 had not been offered hand hygiene after he shook hands with Resident #5. At 12:36, Resident #5 finished eating. After licking her fingers, she self propelled herself in her wheelchair and shook hands with Resident #27. After shaking hands with Resident #27, Resident #5 self-propelled herself out of the dining room. -The facility failed to offer hand hygiene to Resident #5 before or after meals. -The facility failed to offer hand hygiene to Resident #27 or Resident #70 when their hands became contaminated. C. Resident interviews Resident #16 was interviewed on 7/18/24 at 10:31 a.m. Resident #16 said the facility did not offer hand hygiene before or after meals in the main dining room. Resident #16 said the facility used to have hand sanitizer on dining room tables but one resident ate the hand sanitizer and there had not been hand sanitizer available in the dining room for residents since that incident. Resident #27 was interviewed on 7/18/24 at 11:13 a.m. Resident #27 said the facility sometimes offered hand hygiene before meals but it was not done consistently. Resident #27 said he would like to be able to clean his own hands when he wanted to during meals but he said he would have to either leave his table or bother the busy staff to do so. D. Staff interviews The dietary manager (DM) was interviewed on 7/23/24 at 10:15 a.m. The DM said it was the nursing staff's responsibility to provide the residents with hand hygiene at meals. The infection preventionist (IP) and the director of nursing (DON) were interviewed together on 7/23/24 at 1:58 p.m. The IP said all residents should be offered hand hygiene before and after all meals. The IP said the dining room staff should offer hand hygiene to residents that were eating with their hands. The DON said she was not aware of any concerns with hand hygiene of residents in the dining room. II. Improper cleaning of food thermometer A. Professional reference The Colorado Department of Public Health and Environment (2024) The Colorado Retail Food Establishment Rules and Regulations, retrieved on 7/28/24 from https://drive.google.com/file/d/1kEtv4f6YciFXXzLEu6amUc9Anu9uWGYn/view, revealed in pertinent part, Equipment food-contact surfaces and utensils shall be clean to sight and touch. Utensils shall be cleaned before using or storing food temperature measuring devices. B. Lunch observations on 7/22/24 at 11:30 a.m. The cook (CK) grabbed five thermometers to obtain the temperatures of lunch before service began. The CK uncovered one thermometer and immediately placed it in the pureed spinach. The CK uncovered the second thermometer and immediately placed it in the pureed cheesy ham and macaroni casserole. The CK uncovered the third thermometer and immediately placed it in the dinner rolls. The CK uncovered the fourth thermometer and immediately placed it in the vegetable soup. The CK uncovered the fifth thermometer and immediately placed it in the mashed potatoes. -The CK did not sanitize any of the thermometers prior to putting them into the food to obtain the temperatures. C. Staff interviews The CK was interviewed on 7/22/24 at 11:45 a.m. CK said he assumed the thermometers were disinfected from the last time the thermometers were used. The CK said the thermometers appeared clean. The DM and the dietary consultant (DC) were interviewed together on 7/23/24 at 10:15 a.m. The DM said the staff were to gather the thermometers, temperature recording log and alcohol wipes. She said the staff needed to use an alcohol wipe to clean the thermometer when the cover was removed because staff should not assume the thermometers were clean. The DM said she disinfected the thermometers after the CK took the initial temperatures but failed to see he did not disinfect the thermometers prior to use. The DC said the CK should have sanitized each thermometer before he placed the thermometers in the food and it was unacceptable to assume the thermometers were already sanitized. III. Correct cold food holding temperatures A. Professional reference The Colorado Department of Public Health and Environment (2024) The Colorado Retail Food Establishment Rules and Regulations, retrieved on 7/28/24 from https://drive.google.com/file/d/1kEtv4f6YciFXXzLEu6amUc9Anu9uWGYn/views, read in pertinent part, Except during preparation, cooking, or cooling, or when time is used as the public health control time and temperature control for safety food shall be maintained at 41 degrees Fahrenheit (F) or less. The FDA (Food and Drug Administration) food code (3/27/23) was retrieved on 7/28/24 from https://www.fda.gov/food/fda-food-code/food-code-2022. It read in pertinent part, Bacterial growth and/or toxin production can occur if time/temperature control for safety food remains in the temperature danger zone (41 degrees to 135 degrees F) too long. B. Observations On 7/22/24 at 11:30 a.m., the CK obtained the temperature of the two trays of individually portioned pineapple sitting on the counter near the serving line. He said one tray was 45 degrees F and the other tray was 42 degrees F. C. Test tray A test tray was evaluated by three surveyors on 7/22/24 at 12:29 p.m. The test tray consisted of cheesy ham and macaroni casserole, sauteed garlic and spinach, pineapple tidbits and a dinner roll. -The temperature of the pineapple was 47.5 degrees F. D. Staff interviews The CK was interviewed on 7/22/24 at 11:30 a.m. The CK said he preferred the temperature of cold items to be below 39 degrees F but the pineapple was okay to be served at the temperatures he got. The DM and the DC were interviewed together on 7/23/24 at 10:15 a.m. The DM said she was concerned about the pineapple not being on ice while lunch was served. The DC said she moved the last tray of pineapple to the refrigerator until it was needed for lunch. The DC said she hoped it would keep the pineapple cold and at the proper temperature. The DC said the trays the pineapple was on should have had ice under them to keep the pineapple at the correct temperature.

**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 possible development and transmission of infectious diseases. Specifically, the facility failed to: -Implement an effective water management plan; and, -Ensure housekeeping staff properly sanitized resident rooms. Findings include: I. Failure to have an effective water management plan A. Professional reference According to The Center for Disease Control (CDC) Legionella (Legionnaires Disease and Pontiac fever) (3/25/21), retrieved on 7/10/24 from https://www.cdc.gov/legionella/wmp/toolkit/index.html?CDC_AA_refVal=https%3A%2F%2Fwww.cdc.gov%2Flegionella%2Fmaintenance%2Fwmp-toolkit.html and https://www.cdc.gov/legionella/wmp/overview.html, Many buildings need a water management program to reduce the risk for Legionella growing and spreading within their water system and devices. Legionella bacteria are typically found naturally in [NAME] environments, but can become a health concern when they grow and spread in human-made water systems. Legionella can cause a serious type of pneumonia (lung infection) known as Legionnaires disease. Some water systems in buildings have a higher risk for Legionella growth and spread than others. Legionella water management programs are now an industry standard for many buildings in the United States. Legionella bacteria can cause a serious type of pneumonia (lung infection) called Legionnaires disease. Legionella bacteria can also cause a less serious illness called Pontiac fever. The key to preventing Legionnaires disease is to reduce the risk of Legionella growth and spread. Building owners and managers can do this by maintaining building water systems and implementing controls for Legionella. Water management programs identify hazardous conditions and take steps to minimize the growth and transmission of Legionella and other waterborne pathogens in building water systems. Developing and maintaining a water management program is a multi-step process that requires continuous review. Seven key elements of a Legionella water management program are to: -Establish a water management program team -Describe the building water systems using text and flow diagrams -Identify areas where Legionella could grow and spread -Decide where control measures should be applied and how to monitor them -Establish ways to intervene when control limits are not met -Make sure the program is running as designed (verification) and is effective (validation) -Document and communicate all the activities. Principles: In general, the principles of effective water management include:maintaining water temperatures outside the ideal range for Legionella growth; preventing water stagnation;ensuring adequate disinfection; and,maintaining devices to prevent sediment, scale, corrosion, and biofilm, all of which provide a habitat and nutrients for Legionella. Once established, water management programs require regular monitoring of key areas for potentially hazardous conditions and the use of predetermined responses to respond when control measures are not met. A consultant with Legionella-specific environmental expertise may sometimes be helpful in implementing and operating water management programs. According to the CDC's Controlling Legionella in Potable Water Systems, (2/3/21), retrieved on 7/10/24 from https://www.cdc.gov/control-legionella/media/pdfs/Control-Toolkit-Potable-Water.pdf, Store hot water at temperatures above 140 degrees fahrenheit (F) and ensure hot water in circulation does not fall below 120 degrees F. Recirculate hot water continuously, if possible. Store and circulate cold water at temperatures below the favorable range for Legionella (77 degrees F to 113 degrees F). Legionella may grow at temperatures as low as 68 degrees F. B. Facility policy and procedure The Legionella Water Management Program policy, revised September 2022, was obtained from the nursing home administrator (NHA) on 7/23/24 at 5:15 p.m. It documented in pertinent part, Our facility is committed to the prevention, detection and control of water-borne contaminants, including Legionella. As part of the infection prevention and control program, our facility has a water management program, which is overseen by the water management team. The water management team consists of at least the following personnel: the infection preventionist, the administrator, the medical director, the director of maintenance, and the director of environmental services. The water management program used by our facility is based on the Centers for Disease Control and Prevention and ASHRAE (The American Society of Heating, Refrigeration, and Air Conditioning Engineers) recommendations for developing a Legionella water management program. The water management program includes the following elements: -An interdisciplinary water management team, a detailed description and diagram of the water system in the facility, the identification of areas in the water system that could encourage the growth and spread of Legionella or other waterborne bacteria, the identification of situations that can lead to Legionella growth and specific measures used to control the introduction and/or spread of Legionella. B. Record review The facility's water management plan was provided by the director of maintenance services (DMS) on 7/23/24 at 11:01 a.m. The documentation included a copy of the CDC's recommendations for developing a Legionella water management program and a diagram of the building, without identifying water systems. -The facility failed to describe the building water systems using text and flow diagrams. -The facility failed to document when the water management program was initiated. -The facility failed to identify areas where Legionella could grow and spread. -The facility failed to decide where control measures should be applied and how to monitor them. -The facility failed to establish ways to intervene when control limits were not met. -The facility failed to make sure the program was running as designed and was effective. -The facility failed to document and communicate all the activities of the water management program. C. Staff interviews The DMS was interviewed on 7/23/24 at 1:24 p.m. The DMS said he checked some of the water systems regularly in the building but did not keep documentation of water system maintenance. He said he was not sure if he knew where all the water lines in the building were. The DMS said he was unsure if the facility had a diagram of all of the water lines in the building. He said he did not know if the facility had identified a method for ensuring the water management program was effective. The DMS said he had not read the water management program documentation that he had provided during the survey on 7/23/24 at 11:01 a.m. The NHA and the DON were interviewed together on 7/23/24 at 4:53 p.m. The NHA and the DON said they were unaware the facility did not have a water management program. The NHA was interviewed again on 7/23/24 at 7:33 p.m. The NHA said she was not familiar with the details of what needed to be done concerning Legionella and Legionella prevention. II. Housekeeping failures A. Professional reference The CDC Environment Cleaning Procedures, (3/19/24) was retrieved on 7/25/24 from https://www.cdc.gov/healthcare-associated-infections/hcp/cleaning-global/appendix-c.html. It read in pertinent part, High-Touch Surfaces: The identification of high-touch surfaces and items in each patient care area is a necessary prerequisite to the development of cleaning procedures, as these will often differ by room, ward and facility. Common high-touch surfaces include: bed rails, IV (intravenous) poles, sink handles, bedside tables, counters, edges of privacy curtains, patient monitoring equipment (keyboards, control panels), call bells and door knobs. Proceed from cleaner to dirtier areas to avoid spreading dirt and microorganisms. Examples include: during terminal cleaning, clean low-touch surfaces before high-touch surfaces, clean patient areas (patient zones) before patient toilets, within a specified patient room, terminal cleaning should start with shared equipment and common surfaces, then proceed to surfaces and items touched during patient care that are outside of the patient zone, and finally to surfaces and items directly touched by the patient inside the patient zone. In other words, high-touch surfaces outside the patient zone should be cleaned before the high-touch surfaces inside the patient zone and clean general patient areas not under transmission-based precautions before those areas under transmission-based precautions. B. Observations On 7/22/24 at 1:04 p.m. housekeeper (HSKP) #1 was observed cleaning room [ROOM NUMBER]. -The call light cords in the resident's room and the resident's bathroom were not cleaned by HSKP #1 during the room cleaning process. On 7/23/24 at 10:36 a.m. HSKP #2 was observed cleaning room [ROOM NUMBER]. -The call light cords in the resident's room and the resident's bathroom were not cleaned by HSKP #1 during the room cleaning process. C. Record review Housekeeping in-service documentation, not dated, was obtained from corporate consultant (CC) #4 on 7/23/24 at 5:15 p.m. It documented the five step daily patient room cleaning procedure included emptying trash, disinfecting horizontal surfaces, spot cleaning walls, dust mopping the floor, and damp mopping the floor. It documented the seven-step washroom cleaning process included checking supplies, emptying trash, dust mopping the floor, cleaning and sanitizing the sink and tub, cleaning and sanitizing the toilet, spot cleaning walls and/or partitions, and damp mopping the floor. -The in-service documentation did not indicate who attended the training or when the training was held. -The documentation failed to identify when housekeepers should clean resident call light cords. D. Staff interviews HSKP #1 was interviewed on 7/22/24 at 1:29 p.m. HSKP #1 said she did not clean the resident call lights when she cleaned room [ROOM NUMBER]. HSKP #1 said resident call light cords should be cleaned but did not have to be cleaned every day. HSKP #2 was interviewed on 7/23/24 at 10:56 a.m. HSKP #2 said she did not clean the resident call lights in room [ROOM NUMBER]. HSKP #2 said that housekeepers did clean resident call lights but not every day. The infection preventionist (IP) and the director of nursing (DON) were interviewed together on 7/23/24 at 1:58 p.m. The IP said the resident call lights should be cleaned because they were considered high touch surfaces that could transmit infections. The IP said resident call light cords should be cleaned every day. The IP said she had not provided the housekeeping staff with room cleaning education. The DON said the housekeeping staff were contracted outside of the facility.

Deficiency Text Not Available

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to ensure one (#3) of three residents reviewed for dementia care received the appropriate treatment and services to maintain their highest practicable physical, mental and psychosocial well-being out of 19 sample residents. Specifically, the facility failed to: -Prevent Resident #3 from eloping the facility; -Have a procedure in place for the nurses to know which residents needed supervision when leaving the facility and which residents were able to independently leave the facility; and, -Ensure Resident #3 was assessed appropriately for his elopement risk. Findings include: I. Facility policy The Elopement and Wandering policy, revised March 2023, was provided by the nursing home administrator (NHA) on 11/7/23 at 3:24 p.m. read in pertinent: The purpose is to ensure the safety and well-being of all residents with potential elopement risk. A wander/elopement assessment will be completed on all residents upon admission to the facility. The outcome is shared with the IDT (interdisciplinary team) during the initial care conference, or earlier if the elopement risk is of immediate concern. The elopement risk is assessed quarterly or as needed with a change of condition. Nursing staff will address initial elopement risk concerns in the baseline care plan. If the resident is identified as an elopement risk, the following will be maintained: The elopement resident identification form, including the current color photo, physical description of the resident, as well as approaches for an individualized plan of care will be in the elopement binder. Implementing and care planning interventions to address safety and decrease risk of elopement. II. Resident status Resident #3, age [AGE], was admitted on [DATE]. According to the November 2023 computerized physician orders (CPO) diagnoses included unspecified intracranial injury (traumatic brain injury) with loss of consciousness of unspecified time, unspecified convulsions (seizures), bilateral pinguecula (noncancerous tumor in both eyes), age-related cataract (cloudy area in the lens of the eyes), anxiety, post-traumatic stress disorder (PTSD), unspecified psychosis not due to a substance or known physiological condition, and severe major depressive disorder with psychotic features. -A diagnosis of alcohol dependence with alcohol-induced persisting dementia was listed on Resident #3's care plan, however, it was not on his CPO. According to the 3/22/23 minimum data set (MDS) a brief interview for mental status (BIMS) assessment was completed with a score of nine out of 15. Resident #3 needed supervision or touch assistance while he used his walker to ambulate for all distances. Resident #3 was documented as not having any type of behavior. III. Resident interview Resident #3 was interviewed on 11/6/23 at 5:41 p.m. He said on 10/1/23 he went for a walk and wanted to see some old friends at his former facility. Resident #3 said he asked the staff if he could go into the community and the staff walked away so the female staff at the front desk used the button to let him out the front door since it was locked and he did not have the code. He said he was safe while he walked to see his friends about a mile away. Resident #3 said he looked both ways as he crossed the street and used the crosswalk lights to let cars know he was crossing. He said he asked a community member if the park was up ahead and the community member said yes. Resident #3 said the park was close to where he used to live so he knew he was going the right way. He said he was gone less than an hour and a half. When he arrived to his former living place his friends were not there so he lit a cigarette and turned around to return to the facility. He said a vehicle pulled up to him and he did not recognize the female at first but she asked if he was Resident #3 and he said yes. She told him you are in big trouble buddy and he said that was when he recognized it was a staff member. He said the lady helped him back to the facility. Resident #3 said he had memory problems and he forgot to tell the facility he was leaving the facility. He said he had to have a staff member with him now whenever he left the facility which he thought was unfair. He said he used to walk eight miles a day by himself and this was only a one-mile walk and he was not injured. He said he was not scared and had a great time by himself walking through the town. IV. Record review The facility missing person report was completed on 10/1/23 and documented Resident #3 had asked staff if he could go into the community. Staff verified with nurse management that the resident needed a staff member to go with him due to cognitive impairment. While the staff reached out to nursing management the resident took himself into the community. Staff noted about 10 minutes had lapsed since the last time they had eyes on Resident #3. A staff member went to the community to look for the resident while other staff completed a facility sweep. Once the staff verified the resident was not on the property the staff notified the police, the NHA, the resident's family and his physician. The NHA recommended checking the former facility Resident #3 lived at which was about one mile away. Resident #3 was found at his former facility. The NHA, police, physician and his family were notified when the resident was found. The incident lasted about 45 minutes from when the resident was last seen to when the resident was found. A staff from the nursing team assessed the resident when he returned to the facility. Resident #3 was placed on 15-minute checks for 72 hours. The resident was educated on safety about leaving the building without a staff or family member and staff were educated on safety concerns related to cognitive impairment and residents with an increased risk of elopement. Resident #3's care plan was updated on 10/1/23. It documented Resident #3 had impaired cognitive function/dementia or impaired thought processes which referred to a diagnosis of dementia (initiated and revised on 10/1/23). Interventions were documented as: Communicate with the resident/family/caregivers regarding Resident #3's capabilities and needs (initiated 10/1/23), Review his medications and record possible causes of cognitive deficit: new medications or dosage increases, anticholinergics (medications that blocked actions of neurotransmitters), opioids (narcotic medications), benzodiazepines (medications with symptoms of sleepiness), recent discontinuation, omission or decrease in dose of benzodiazepines, drug interactions, errors or adverse drug reactions, or drug toxicity (initiated 10/1/23); and Resident #3 had one elopement into the community. Provide reminders of safety risks of leaving the facility on his own and provide a staff member to go into the community with Resident #3 to meet his needs (initiated 10/1/23). His care plan was updated again on 10/11/23 which documented Resident #3 was an elopement risk/wanderer which referred to his cognitive deficit (initiated 10/11/23). The interventions were documented as: Identify patterns of wandering: is the wandering purposeful, aimless, or escapist? Is the resident looking for something? Does it indicate the need for more exercise? Intervene as appropriate (initiated 10/11/23, Distract the resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, or books. The resident prefers conversations (initiated 10/11/23). A wandering/elopement risk assessment was completed on 12/22/22 and documented the resident was at low risk for wandering or elopement with a score of three out of 12. He was documented to not have a diagnosis of dementia or cognitive impairment and had no history of wandering or elopement. A wandering/elopement risk assessment was completed on 3/22/23 and documented the resident was at risk of wandering or elopement and documented him having diagnosis of dementia or cognitive impairment. -However, a score was not documented so the assessment did not show if the resident was a low, moderate, or high risk for wandering or elopement. A wander/elopement risk assessment was completed on 10/11/23 by the assistant director of nursing (ADON) that documented the resident ambulated independently, routinely wandered or paced and wandered in a manner that placed his safety at risk. The resident was documented to have a diagnosis of dementia, a diagnosis or medical condition that impacted decision-making, he verbalized wanting to leave the facility, he had previous attempts to elope before placement at the facility and had previous attempts to elope at the current facility. The summary documented the resident was an elopement risk and was educated on the facility's rules and regulations. The resident verbalized his understanding. The outcome documented the impaired cognitive status of the resident put him at increased risk of wandering outside the facility or exit seeking but this was well-managed during supervised outings or with other specific guidelines established by the IDT. Another wandering/elopement risk assessment was completed on 10/11/23 and documented the resident was at low risk for wandering or elopement with a score of three out of 12. He had no history of wandering or elopement. -However, the question of if he had a diagnosis of dementia or cognitive impairment was left blank. -The additional assessment contradicted the assessment complemented by the ADON (see above) that documented the resident was an elopement risk. V. Staff interviews On 11/7/23 at 11:22 a.m. a resident covered the front desk for the receptionist. He said if a resident asked to go outside he told them he could not let them out. He said if the resident did not know the code to the front door they could not go to the community unsupervised. The activities director (AD) was interviewed on 11/7/23 at 11:30 a.m. She said she did not think the resident who covered the front desk knew which residents needed staff supervision in the community. She said there was a sign-in and sign-out sheet at the front desk and the staff just needed to know which residents needed supervision. The AD said the nurses usually knew who could leave alone and who could not. She said the resident covered the front desk while the receptionist (RESP) completed mail runs or minor errands for activity programming. The AD said she set up the program but the RESP trained him. The RESP was interviewed on 11/7/23 at 12:05 p.m. She said very few residents could leave the facility alone and the NHA informed the staff of who could. She said she trained the resident at the front desk to ask the nurses if he needed to but if the residents knew the code to the front door they were safe to leave alone and if the resident knew to sign-in or sign-out that indicated they could leave alone. The RESP said the manager on duty (MOD) covered the front desk on the weekends. Licensed practical nurse (LPN) #2 was interviewed on 11/7/23 at 12:40 p.m. He said the RESP was aware who could leave alone and the resident who covered the front desk asked the nurses. LPN #2 said the nurses determine a resident could leave the facility unsupervised based on their BIMS. He said he could not provide a BIMS score range to know if a resident could leave however there was a scale that had it broken down but he could not locate it. He said he looked to see if they were competent in the community alone and if he did not feel comfortable he verified with the NHA or the director of nursing (DON). LPN #1 was interviewed on 11/7/23 at 12:51 p.m. She said the nurses needed to know the residents and the front desk staff knew which residents could leave unsupervised or who needed supervision in the community. She said it depended on their cognitive level and she completed her own test on the residents but the facility used BIMS scores and she looked at that too. LPN #1 said the front door was always locked unless you had the code to open it. She said she relied on the front desk staff to know because residents were alert and oriented to person, place, time and situation but could be a flight risk or had no safety awareness. The social services director (SSD), NHA, and regional operations manager (ROM) were interviewed on 11/7/23 at 12:57 p.m. The SSD said she completed the residents' BIMS score and talked with their families about if a resident was able to go into the community alone or supervised. The SSD made sure the staff were aware of what was approved by the IDT for each resident. The ROM said the resident who covered the front desk was pretty good about asking staff to accompany residents who needed supervision in the community. She said the facility's policy was the residents needed to have an order that said they could go on pass alone and there was an elopement binder at each nurses' station. The ROM said the elopement binder was essentially a cheat sheet for the nurses to know who needed supervision in the community and the nurses knew what the binder was and what it was used for. Certified nurse aide (CNA) #1 was interviewed on 11/7/23 at 1:13 p.m. She said she did not know how to find which residents needed supervision versus the residents who were independent in the community. She said she asked the nurses if a resident asked to go into the community. She said she liked to make sure they could go out by themselves or needed help. She said a nurse was always available or at leave a regular staff was available at all times so someone would know. Registered nurse (RN) #1 was interviewed on 11/7/23 at 1:17 p.m. She said she looked at the resident's profile and checked their preferences or the family's preferences. She said she checked to see if the resident was alert and oriented to person, place, time, and situation, and if the resident was a flight risk it was documented on their charts. RN #2 was interviewed on 11/7/23 at 1:23 p.m. She said the nurses got to know the residents and wanted to know if the residents had behaviors in the community. She said she assessed the residents, similar to other assessments, to see if they were safe alone in the community. She said if she covered a different hall she checked with other nurses or checked the resident's BIMS score. RN #2 said if the resident had a BIMS score of 13-15 (no cognitive impairment) she believed they could be unsupervised in the community but also checked the resident's history with traffic and safety situations. The social services specialist (SSS) was interviewed on 11/7/23 at 1:43 p.m. She said she checked the resident's care plan to see if the resident was supervised or unsupervised in the community. She said she usually worked a certain part of the building and was unaware of Resident #3's supervision status in the community. The activities assistant (AA) #2 was interviewed on 11/7/23 at 2:48 p.m. She said she did not know if Resident #3 was allowed to go to the community by himself because he would exit seek. She said the activities director (AD) was good at informing the AAs if residents were exit seekers and which residents needed supervision. She said she asked the nurses or the RESP if a resident needed supervision outside of the facility. The AD was interviewed on 11/7/23 at 3:01 p.m. She said she was not aware Resident #3 eloped to go see friends where he used to live. She said the activities staff provided group outings and provided a resident aide (RA) if they wanted to go on an individual outing. She said she wished he told her that was what he wanted to do before he left but she would make arrangements for visits if it helped prevent future elopements and was important to Resident #3. She said she knew he had an onset of dementia when he was admitted to the facility but he hid it very well. The SSD and NHA were interviewed on 11/7/23 at 3:18 p.m. The SSD said she looked at the resident's BIMS score and completed a wandering or elopement assessment then constructed a care plan for the resident. She said the facility documented their preferences, likes, dislikes, and triggers if they were known. The NHA said if there was a behavior witnessed at the facility they documented it in the care plan otherwise they updated the care plan after the behavior occurred. LPN #2 was interviewed on 11/7/23 at 3:57 p.m. He said the elopement binder was kept at the nurses' station but he was unable to locate it and said it was probably being updated. He said if he passed report to an agency nurse he informed them of the elopement binder and where it was kept so the next nurse was aware. The NHA and ROM were interviewed on 11/7/23 at 4:13 p.m. with the elopement binder. The NHA said the binder contained all of the residents' information for the entire facility in case they eloped, not a binder that showed which residents were at risk of eloping. The binder contained all the residents' information and included their diagnoses, their pictures, emergency contacts, and physician's contact information. The NHA said, basically every resident is at risk for elopement and that was how the staff should treat each resident. She said the nurses checked the resident's care plan for specific residents. She said the RESP should let the nurses know if she was not aware of a particular resident. She said the MOD covered the front desk on the weekends and was there at all times except during meal times. The NHA said the MOD was aware of the residents who were flight risks from the management meetings since the MOD was a part of the IDT. She said before COVID-19 the facility had wander guards for residents at flight risk but after COVID-19 the doors remained locked and if the residents did not remember the code they needed supervision in the community. The ROM said she thought the facility had a binder for residents who were flight risks specifically. -However, the staff did not have a consistent way to check if a resident was supervised or unsupervised in the community which led to Resident #3 elopement from the facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interviews, the facility failed to ensure three (#12, #13 and #18) of eight residents reviewed out of 19 sample residents were provided personal privacy during care. Specifically, nursing staff failed to: -Ensure privacy during medication administration and treatment for Resident #13; -Ensure staff pulled the privacy curtain and/or closed the door while Resident #18 was getting dressed; and, -Ensure privacy during nail care for Resident #12. Findings include: I. Facility policy The Statement of Resident Rights and Responsibilities, undated, was provided by the regional operations manager (ROM) on 11/7/23 via email. According to the policy statement, the residents had the right to personal privacy. The Medication Administration policy, revised 11/1/22, was provided by the nursing home administrator (NHA) on 11/7/23 at 1:40 p.m. the policy directed staff to provide privacy during medication administration. II. Resident #13 A. Resident status Resident #13, age [AGE], was admitted on [DATE]. According to the November 2023 computerized physician orders, diagnoses included type II diabetic mellitus with other specified complications. The 11/1/23 minimum data set (MDS) assessment indicated the resident had severe cognitive impairment with a brief interview for mental status (BIMS) score of two out of 15. The assessment identified the resident received insulin injections. B. Observation Registered nurse (RN) #1 was observed passing medication to residents in the dining room during the noon meal on 11/6/23. -At 12:06 p.m. RN #1 tested Resident #13's blood sugar levels tested by use of glucometer in the dining room. The resident was at his dining room table near other residents. The resident was not offered privacy for his diabetic management. C. Record review The medication administration record (MAR) read the resident received Lispro Injection Solution insulin subcutaneously with meals for diabetic (management). According the MAR under the order for his insulin injection, Resident #13's blood sugar levels were checked on 11/6/23 by RN #1 during the noon administration. III. Resident #18 A. Resident status Resident #18, age [AGE], was admitted on [DATE]. According to the November 2023 computerized physician orders, diagnoses included dementia in other diseases classified elsewhere, unspecified severity, with behavioral disturbance and need for personal assistance. The 8/31/23 minimum data set assessment indicated the resident had moderated cognitive impairment with a brief interview for mental status (BIMS) score of nine out of 15. B. Observation On 11/7/23 at 9:34 a.m. Resident #18 was observed in her room with certified nurse aide (CNA) #1 and resident aide (RA) #2. The resident was dressing. The resident was exposed to the hallway. The resident's privacy curtain was not pulled shut. The resident's room door was not shut to provide the resident privacy as she dressed. -At 9:38 a.m. licensed practical nurse (LPN) #1 entered Resident #18's room and shut the door. 3. Resident interview Resident #18 was interviewed on 11/7/23 at 9:50 a.m. The resident said when she was dressing for the day, she did not want her privacy curtain pulled closed but she wanted the staff to shut the door for privacy. C. Record review Resident #18's activity of daily living (ADL) care plan, initiated on 8/26/23, identified Resident #18 had an ADL self-care performance deficit. According to the care plan, required assistance with dressing. IV. Resident #12 On 11/7/23 at 9:12 a.m. registered nurse (RN) #2 was observed clipping a resident's toenails in the common area. There were six other residents in the common area but no residents sat directly next to the resident who received care. The resident said he did not want to go to his room to have his nails clipped. V. Staff interviews RN #1 was interviewed on 11/6/23 at 5:47 p.m. The RN said Resident #13 got insulin shots four times a day and blood sugar levels were checked at meals and at night. She said medication administration and treatments were allowed in common areas and the dining room around other residents including wound care as long as the resident's bikini/brief area on their body was not exposed. She said treatments that could expose the resident should be conducted in the resident's room with the privacy curtain and or door should be closed. The social service director (SSD), the nursing home administrator (NHA) and the director of nursing (DON) were interviewed on 11/7/23 at 1:10 p.m. The SSD said residents' right to privacy was reviewed with staff during new hire orientation. RN #2 was interviewed on 11/7/23 at 1:23 p.m. She said resident care could not be provided in the common areas if it was considered invasive care like eye drops, checking blood sugar, administering insulin, wound care or applying creams. RN #2 said she was informed by management that she could administer medications in the common areas to residents. She said she did not usually cut toenails in the common area however Resident #12 refused to go into his room so she clipped his nails in the common area on the morning of 11/7/23. She said the chairs on the side of him were empty and the certified nurse aide (CNA) helped her clean up as soon as she was finished. The NHA said during a recent facility inservice, she reminded staff to pull privacy curtains to ensure residents' privacy during toileting, bedpan use and incontinent care. She said they did not review privacy during clothing changes or clinical treatments. The DON said staff should perform clinical treatments related to infection control and privacy. The DON said staff should only assist residents to eat in the dining room, all other care should be done in the resident's room including medication administration and clinical treatment. The DON said the nursing staff should know where they could and could not do resident care. The DON was interviewed on 11/7/23 at 1:25 p.m. The observations diabetic management in the dining room with Resident #13 and the open door exposing Resident #18 to the hallway as she dressed was reviewed with the DON. She said the RN violated Resident #13's privacy in the dining room. She said clinical care should not have been done in a common area and in front of other residents. The DON said staff should have shut the door as Resident #18 was dressing. The staff could have been in a rush and task focused, forgetting to provide the resident privacy. She said the staff involved would reeducated on privacy. LPN #1 was interviewed on 11/7/23 at 3:10 p.m. The LPN said Resident #13 received Lispro insulin before meals. The LPN said a glucometer was used to determine the resident's blood sugar levels based on a sliding scale. The regional operations manager (ROM) was interviewed on 11/7/23 at 4:13 p.m. She said RN #2 should have approached the resident later to provide care in private since he refused to go into his room initially. The ROM said medications may be administered in the common areas if medications were not being explained but all other care should be completed in the resident's room or in an area that offered privacy. The ROM and the NHA were interviewed again on 11/7/23 at 4:45 p.m. The ROM said during the CNA education class, the incoming CNAs were taught the importance of privacy as part of their training before they became an employee at the facility and then it was reviewed in orientation. Observations of residents not provided privacy were shared. The ROM and the NHA said RN #1 would have a one-on-one education completed to review resident privacy regarding medication administration and treatments. The ROM said blinds and doors should be closed during resident ADL care. A former staff member for the facility was interviewed on 11/7/23 at 5:42 p.m. She said she was not trained on privacy when she attended the new hire orientation. She said the orientation primary was videos and signing off on policies and procedures. The former staff member staff she frequently observed staff not closing doors when the staff was providing resident care and observed RN #1 providing wound treatment in the dining room during a breakfast meal. VI. Record review The new hire resident rights training for orientation was provided by the NHA on 11/7/23 at 1:45 p.m. The training involved the purpose of resident rights, the main categories of resident rights, ways to support and promote resident rights and the facility's responsibilities. According to the training, the facility was required to treat each resident with respect and dignity and provide care for each resident in an environment that promotes and protects their rights including privacy. The training identified that during orientation staff were trained that the residents have the right to privacy during treatment, care of personal needs and privacy in all personal, financial and medical affairs.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and observations, the facility failed to consistently ensure a phone was available for resident use for two (#13 and #3) out of 16 sample residents. Specifically, the facility failed to consistently provide operational phones for residents to use from their rooms or other private areas. Resident #3 was told by staff that there was no facility phone available for resident use. Resident #13 said it was hard to access a private phone at the facility if her cell phone did not work. Findings include: I. Resident/family interviews Resident #13 was interviewed on [DATE] at 11:25 a.m. She said it was hard to access a private phone conversation. My cell phone doesn't always have service because Wi-Fi's often down. The Wi-Fi here is terrible; it's down most of the time. She said she could always make a call at the nurses' desk but it was not private. Resident #3's son was interviewed on [DATE] at 11:04 a.m. He said Resident #3 was in the facility from [DATE] through [DATE] (Friday through Monday) and was bed bound in severe pain (cross-reference F697). Her son said she had her cell phone but there was a problem with it. She could not find her charger and when her battery died she asked for a phone to call him. They said they didn't have an outside line for patients so she couldn't call to ask me to bring her anything or anything else. He said this occurred on Saturday or Sunday, and he had no idea which staff told her that. Her roommate's son came to visit and called me and said Mom couldn't get an outside line. II. Observations and staff interviews Observations throughout the day from 8/22 through [DATE] revealed residents often used the phone at the nurse's desk on south hall. The phone was not in a private or quiet location and residents could not make calls there without their conversations being overheard. The nurse's desk was adjacent to a busy hallway intersection, the therapy gym, a medication cart, staff offices, and a staff restroom. Licensed practical nurse (LPN) #4 was interviewed on [DATE] at 8:14 a.m. She said they had a resident cell phone which was usually charged but she opened a drawer at the nurse's desk, checked the cell phone inside the drawer and found that it was dead. She said she did not know where the charger was; it was usually attached to the phone. She said they had a second one, which she found sitting out on the nurse's desk labeled for resident use, which she checked and said it was charged and ready to go. She said they should also have a cordless phone for residents who had difficulty using a cell phone, but she did not know where it was at the time. The social services director (SSD) was interviewed on [DATE] at 8:52 a.m. She said the residents had cell phones and cordless phones available to them for private conversations. She was not aware of any concerns with them not being provided to residents or not functioning properly. The nursing home administrator (NHA), director of nursing (DON) and regional director of operations (RDO) were interviewed on [DATE] at 3:48 p.m. The NHA said she had heard of a problem with cell service and facility phones. She said they ordered a new facility phone system, installed 11 new office phones, went through the entire building and did summary wiring which took two or three days, two weeks ago. She said the phones should not be a problem except when the power goes out. She said they were looking at different options to boost the facility Wi-Fi. The NHA, DON and RDO said they did not know why staff would tell residents there was no private facility phone for them to use. The RDO said they would ensure staff were educated that phones were available for private resident use and should be provided upon resident request.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to ensure the medical durable power of attorney (MDPOA) and the physician were notified of changes in condition for one (#2) out of 15 sample residents. Specifically the facility failed to: -Add the resident's MDPOA to the charting system with contact information; -Notify the MDPOA and physician of the resident's high blood glucose (BG); -Notify the MDPOA when the nurse observed black coffee ground-like stool; and -Notify the MDPOA of Resident #2's death in a timely manner. Cross-reference F684, quality of care regarding diabetic and anticoagulant management and monitoring. Findings include: I. Resident status Resident #2, age [AGE], was admitted on [DATE] and passed away on 3/14/23 at 10:13 p.m. in the facility. According to the March 2023 computerized physician orders (CPO), diagnoses included acute embolism and thrombosis of the right internal jugular vein (what happens when a blood clot blocks a vein in your neck), acute kidney failure, chronic kidney disease stage 3B, other specified symptoms and signs involving the circulatory and respiratory system, disorder of arteries and arterioles (small branches from arteries), pulmonary hypertension (a condition that affects the blood vessels in the lungs), nonrheumatic tricuspid (valve) insufficiency (one or more abnormal structures that can be in any one of the four heart chambers), hyperkalemia (increased potassium in the blood), anemia (low amount of healthy red blood cells), encephalopathy (decreased blood flow or oxygen to the brain), and type two diabetes mellitus (DM) without complications. The 3/21/23 minimum data set (MDS) showed the resident had cognitive impairment with a brief interview for mental status (BIMS) score of five out of 15. II. Record review Resident #2's care plan was implemented on 3/14/23 however only his wishes to be a full code (receive full treatment) were documented in the care plan. -The facility failed to enter any diabetic management or anticoagulant therapy into the care plan. The MDPOA was never listed in Resident #2's medical chart by the facility. The resident was admitted with orders for insulin administration which noted to call the doctor if blood glucose was greater than 300 for more than two checks in a row, check at least every one to four hours, drink water, and call the doctor for an adjustment. Resident #2's blood glucose was entered into the facility's charting system as follows: 3/10/23 at 8:45 p.m. BG levels were 222 3/11/23 at 9:46 a.m. BG levels were 553 3/11/23 at 9:51 a.m. BG levels were 553 3/11/23 at 1:26 p.m. BG levels were 599 3/11/23 at 5:55 p.m. BG levels were 594 3/11/23 at 7:35 p.m. BG levels were 462 3/12/23 at 6:50 a.m. BG levels were 406 3/12/23 at 1:00 p.m. BG levels were 599 3/12/23 at 4:13 p.m. BG levels were 588 3/12/23 at 7:26 p.m. BG levels were 490 3/13/23 at 9:37 a.m. BG levels were 599 3/13/23 at 9:58 a.m. BG levels were 599 3/13/23 at 2:20 p.m. BG levels were 599 3/13/23 at 5:48 p.m. BG levels were 599 3/14/23 at 7:03 a.m. BG levels were 467 3/14/23 at 7:09 a.m. BG levels were 467 3/14/23 at 7:16 a.m. BG levels were 467 3/14/23 at 11:28 a.m. BG levels were 442 3/14/23 at 4:57 p.m. BG levels were 499 3/14/23 at 5:02 a.m. BG levels were 499 -There was no evidence the resident's physician or MDPOA were notified of his high blood sugar levels until 3/13/23 at 8:40 p.m. The medical record review revealed a verbal order was received from the resident's doctor on 3/13/23 at 6:59 p.m. for sliding scale insulin administration based on his blood sugar readings. If his blood glucose read over 500 the nursing staff needed to notify the doctor. This was entered into the facility's charting system. The sliding scale was documented as follows: Insulin Aspart with Niacinamide 100 unit/milliliter: Inject as per sliding scale: If BG levels were 71-149=0 units, If BG levels were 150-199=3 units, If BG levels were 200-249=5 units, If BG levels were 250-299=7 units, If BG levels were 300-349=10 units, If BG levels were 350-399=12 units, If BG levels were 400-499=14 units, Subcutaneously three times a day for diabetes type 2.If BG levels were less than 70 call provider, if above 500 call provider. -However the nursing staff never documented they notified the doctor of blood glucose levels greater than 300 (previous order upon admission) or greater than 500 (once the new order was received) except on 3/13/23 (see nurse's note below) when the facility received the new order for blood glucose levels over 500. The nursing staff entered progress notes for Resident #2 in the facility's charting system as follows: Progress note dated 3/13/23 at 8:40 p.m. Called doctor office today in regards to resident's high blood sugar. His blood sugar all day and other days too, have been over 599 the meter just reads 'HI.' We received his aspart insulin that should be given on a sliding scale but did not receive the sliding scale. The doctor gave a verbal order for the aspart sliding scale which was put in as a new order. Progress note dated 3/14/23 at 6:57 p.m. This licensed practical nurse (LPN) was asked by a certified nurse aide (CNA) to come and observe the resident stool that was in the toilet and some was dried to the toilet seat. Upon entering there was an odor and the stool was black in color and may have had possible coffee ground appearance. Fax sent to his doctor. Resident reports that it has been like this for a while. Progress note dated 3/15/23 at 9:48 a.m. Emergency contact returned a phone call. Nurse on shift informed her of the resident's status (death) and provided the coroner's information. Daughter called the facility, as no paperwork is on file with the facility at this time stating daughter is power of attorney information was not released. Daughter stated she will send over power of attorney paperwork. -However, the facility did not release the resident's status to his MDPOA for over 12 hours. V. Staff interviews The director of nursing (DON), nursing home administrator (NHA) and regional director of operations (RDO) were interviewed on 8/23/23 at 6:41 p.m. The RDO said Resident #2 was not at the facility long enough after admission to be seen by the doctor. The nursing staff completed a phone call with the doctor for his insulin order on 3/13/23. Resident #2 was also on Lantus (a type of log acting insulin) and Lispro (a type of fast acting insulin) 4 units with each meal. He was admitted with high blood sugar. The NHA said the facility received MDPOA documentation upon admission and the admissions coordinator would upload it to the resident's charting system. If documentation for the MDPOA was not provided at admission then medical records worked to get it and upload it in their chart. She said Resident #2 was listed as his own responsible party and his spouse was listed as his emergency contact. If he was not able to make decisions he would not have been listed as the responsible party and the staff entering the information in his chart would have listed whoever it actually was. The DON, NHA and RDO were interviewed again on 8/24/23 at 3:42 p.m. The RDO said the nurses should have notified the doctor soon for Resident #2's high blood sugar and every time they obtained a high blood sugar from him. Resident #2 had stool that looked like black coffee grounds on 3/13/23. The progress notes entered in the facility's charting system said a fax was sent to the doctor's office and although the doctor usually received the faxes fairly quickly the nurses should have called the doctor and informed him over the phone. The NHA said the MDPOA was located in the discharge paperwork provided for Resident #2 from the hospital. She said she was not the NHA at the time but someone from admissions should have seen it and requested a copy of the paperwork for the facility. The NHA said an audit was started on 8/24/23 to ensure all MDPOAs were documented appropriately in the chart for each resident in the facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews the facility failed to assess, report, and treat high blood sugar and potential side effects of anticoagulants (blood thinner) for one (#2) of 15 sample residents. Specifically the facility failed to: -Get clarifying orders for an sliding scale insulin and transcribe admission order for insulin upon admission for Resident #2; -Notify the physician and medical durable power of attorney (MDPOA) in a timely manner about Resident #2's extremely high blood glucose levels -Call rather than fax the physician and call the MDPOA to report that the resident bowel movements were tarry black stools and resembling coffee grounds; -Update Resident #2's care plan for diabetes and anticoagulant management; and -Have a physician examine and assess the resident upon admission due to his complicated diagnoses and condition changes. Cross-reference F580, for failure to notify the resident physician and MDPOA of the resident change of condition. Findings include: I. Facility policies The Diabetic Management Policy, revised 7/28/23, was provided by the nursing home administrator (NHA) on 8/23/23 and read in pertinent part: Upon admission the interdisciplinary team (IDT) evaluates the diabetic resident and implements a plan of care: -To ensure orders are received and are accurately related to blood glucose monitoring and anti-diabetic agents. Blood glucose orders should include parameters to follow in communicating with the physician. Procedure: 9. If a resident has high blood sugar, follow physician-ordered parameters. If the blood glucose (BG) is above 'high' parameter, the physician must be contacted for further interventions. The Anticoagulation Policy, revised 4/14/23, was provided by the NHA on 8/23/23 and read in pertinent part: The facility recognizes that some medications, including anticoagulants, are associated with greater risks of adverse consequences than other medications. This policy addresses the facility's collaborative, systematic approach to managing anticoagulant therapy for efficacy and safety. Procedure 5. A care plan will be developed for anticoagulants to promote safe use of the medications; 6. Monitoring for adverse effects and interventions for prevention, documentation will be completed by exception. -However, the NHA said the facility did not have these policies in place in March 2023 due to their corporation change. The NHA did not have access to the former corporate policies that were in effect at the time of Resident #2's stay at the facility. II. Professional standards According to the Centers for Medicare and Medicaid Services (CMS) Local Coverage Determination (LCD) ID L34834 blood glucose monitoring in a skilled nursing facility, https://www.cms.gov/medicare-coverage-database/view/lcd.aspx?LCDId=34834, last revised 11/7/19, accessed 8/29/23, in pertinent part: When blood glucose (blood sugar) values are below 60 (low) or over 300 (high), the physician must be notified of the results immediately .When reporting an abnormal blood glucose value to the physician, the previous two or more, as appropriate, should also be provided for trending purposes. According to the Eliquis (anticoagulant) medication information resource, https://packageinserts.bms.com/medguide/medguide_eliquis.pdf, last revised September 2021, in pertinent part: Call your doctor or get medical help right away if you have any of these signs or symptoms of bleeding when taking Eliquis: Unexpected bleeding or bleeding that lasts a long time from the gums, nosebleeds that happen often, bleeding that is severe or you cannot control; red, pink, or brown urine, red or black stool, coughing up blood, vomiting blood, unexpected pain or joint pain, headaches, feeling dizzy, or feeling weak. According to Gastrointestinal (GI) Bleed: Nursing Diagnoses, Care Plans, Assessment & Interventions, Nurse Together website, https://www.nursetogether.com/gastrointestinal-bleed-nursing-diagnosis-care-plan/#physical-assessment, updated 7/30/23, accessed 8/30/23, in pertinent part: Assess for GI bleeding. Note the following GI bleeding symptoms: -CNS (central nervous system): decreased mentation, decreased level of consciousness, lightheadedness, fainting (syncope), dizziness -HEENT: pale eyes, mucosa, and lips -Respiratory: decreased oxygen saturation, shortness of breath -Cardiovascular: chest pain, tachycardia, hypotension -Gastrointestinal: abdominal pain, abdominal cramping, presence of anal fissures, hemorrhoids, masses, bright red or coffee-ground blood in the vomitus (hematemesis), black, tarry stools (melena) -Hematologic: anemia -Integumentary: skin pallor. III. Resident status Resident #2, age [AGE], was admitted on [DATE] and passed away on 3/14/23 at 10:13 p.m. in the facility. According to the March 2023 computerized physician orders (CPO), diagnoses included acute embolism and thrombosis ( a blood clot blocks a vein in your neck) of the right internal jugular vein , acute kidney failure, chronic kidney disease stage 3, other specified symptoms and signs involving the circulatory and respiratory system, disorder of arteries and arterioles (small branches from arteries), pulmonary hypertension (a condition that affects the blood vessels in the lungs), nonrheumatic tricuspid (heart valve) insufficiency (one or more abnormal structures that can be in any one of the four heart chambers), hyperkalemia (increased potassium in the blood), anemia (low amount of healthy red blood cells), encephalopathy (decreased blood flow or oxygen to the brain), and type two diabetes mellitus (DM) without complications. The 3/21/23 minimum data set (MDS) revealed the resident had cognitive impairment with a brief interview for mental status (BIMS) score of five out of 15. IV. Record review A. Care plan Resident #2's care plan was initiated on 3/14/23, however only his wishes to be a full code (full treatment) were documented in the care plan. -The facility failed to enter any diabetic management or anticoagulant therapy into the care plan. B. Hospital discharge facility admission orders A guideline for insulin dosing was provided upon resident #2s' admission to the facility. The orders were not transcribed into the resident's CPO or on the medication administration record MAR) for nurses to assess when administering the resident medications. admission orders documents that the resident was prescribed two types of insulin; the orders were documented as follows: Xultophy (long acting insulin), inject 15 units daily at the same time every morning. Fiasp (generic name aspart) (fast acting insulin), administer insulin before each meal, up to four times a day according to the following fast acting administration scale per blood glucose (BG) assessment results: If BG is less than 70: treat with 15-20 grams of quick-acting sugar, If BG is 70-150 inject 2 units of Fiasp, If BG is 151-200 inject 3 units of Fiasp If BG is 201-250 inject 4 units of Fiasp, If BG is 251-300 inject 5 units of Fiasp, If BG is 300-350 inject 6 units of Fiasp, If BG is 351-400 inject 7 units of Fiasp, If BG is 401 or great inject 8 units of Fiasp, If BG is greater than 300 for more than two checks in a row, start checking BG levels at least every one to four hours, (have the patient) drink water, and call the doctor for an adjustment (treatment recommendations) . C. Physician orders from 3/10/23 through 3/15/23 Review of the March 2023 MAR revealed the following pertinent orders included: Lantus solostar (long acting insulin) subcutaneous (SQ) solution pen-injector 100 unit/ML, inject 4 unit SQ one time a day for DM 2, ordered 3/10/23 and discontinued 3/12/23; Lantus solostar SQ solution pen-injector 100 unit/ML, inject 4 unit SQ one time a day for DM2, ordered 3/12/23 at 12:52 a.m. and discontinued on 3/15/23 at 9:33 a.m. -No parameters were documented for when to notify the physician for high or low blood sugar levels; and the resident's insulin orders for fast acting insulin were not documented into the CPO or MAR records. D. Blood sugar levels Resident #2's blood sugars entered into the MAR read as follows: 3/10/23 at 8:45 p.m. BG was 222 3/11/23 at 9:46 a.m. BG was 553 3/11/23 at 9:51 a.m. BG was 553 3/11/23 at 1:26 p.m. BG was 599 3/11/23 at 5:55 p.m. BG was594 3/11/23 at 7:35 p.m. BG was462 3/12/23 at 6:50 a.m. BG was 406 3/12/23 at 1:00 p.m. BG was599 3/12/23 at 4:13 p.m. BG was588 3/12/23 at 7:26 p.m. BG was 490 3/13/23 at 9:37 a.m. BG was 599 3/13/23 at 9:58 a.m. BG was 599 3/13/23 at 2:20 p.m. BG was 599 3/13/23 at 5:48 p.m. BG was 599 3/14/23 at 7:03 a.m. BG was 467 3/14/23 at 7:09 a.m. BG was 467 3/14/23 at 7:16 a.m. BG was 467 3/14/23 at 11:28 a.m. BG was 442 3/14/23 at 11:32 a.m. BG was 442 3/14/23 at 4:57 p.m. BG was 499 3/14/23 at 5:02 a.m. BG was 499 -There was no evidence the resident's physician or MDPOA were notified of his high blood sugar levels until 3/13/23 at 8:40 p.m. Following notification to the physician of the resident elevated BG levels, the medical record review revealed a verbal order was received from the resident's doctor on 3/13/23 at 6:59 p.m. for a sliding scale for insulin administration based on the resident BG readings. The order was not transcribed to the resident's MAR and the medication until 3/14/23 (see nursing note below). -The order read: if the resident's BG assessment was over 500 notify the doctor. The MAR documented the following new orders. Insulin Aspart with Niacinamide (fast acting insulin) 100 unit/milliliter: Inject as per sliding scale: If If BG is 71-149=inject 0 units, If BG is 150-199=inject 3 units, If BG is 200-249=inject 5 units, If BG is 250-299=inject 7 units, If BG is 300-349=inject 10 units, If BG is 350-399=inject 12 units, If BG is 400-499=inject 14 units, Subcutaneously three times a day for diabetes type 2. Call the prescribing physician for BG results less than 70 or if above 500. -However the nursing staff never documented they notified the doctor of blood sugar levels greater than 500 (once the new order was received) (see nurse's note below) when the facility received the new order for blood sugar levels over 500. E. Nursing progress notes Progress note dated 3/13/23 at 8:40 p.m., read: Called doctor office today in regards to resident's high blood sugar. His blood sugar all day and other days too, have been over 599, the meter just reads 'HI.' We received his aspart insulin that should be given on a sliding scale but did not receive the sliding scale. The doctor gave a verbal order for the aspart sliding scale which was put in as a new order. Progress note dated 3/14/23 at 6:57 p.m., read: This licensed practical nurse (LPN) was asked by a certified nurse aide (CNA) to come and observe the resident stool that was in the toilet and some was dried to the toilet seat. Upon entering there was an odor and the stool was black in color and may have had possible coffee ground appearance. Fax sent to his doctor. Resident reports that it has been like this for a while. F. Anticoagulant orders Review of the resident's March 2023 MAR revealed he was taking Aspirin 81 milligrams (mg) once per day and Apixaban (Eliquis an anticoagulant blood thinning medication) 20 mg - two 5 mg tablets twice per day. V. Staff interviews The director of nursing (DON), nursing home administrator (NHA) and regional director of operations (RDO) were interviewed on 8/23/23 at 6:41 p.m. The RDO said Resident #2 was not at the facility long enough after admission to be seen by the doctor. The nursing staff completed a phone call with the doctor for his insulin order on 3/13/23. Resident #2 was also on Lantus (a type of insulin) and Lispro (a type of insulin) 4 units with each meal. He was admitted with high blood sugar. The DON, NHA and RDO were interviewed again on 8/24/23 at 3:42 p.m. The RDO said the nurses should have notified the doctor soon for Resident #2's high blood sugar and every time they obtained a high blood sugar from him. Resident #2 had stool that looked like black coffee grounds on 3/13/23. The progress notes entered in the facility's charting system said a fax was sent to the doctor's office and although the doctor usually received the faxes fairly quickly the nurses should have called the doctor and informed him over the phone. The RDO acknowledged that diabetic management and anticoagulant use and monitoring should have been included in Resident #2's care plan.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to ensure resident rights to be treated with respect and dignity in keeping with their individuality for five (#3, #12, #13, #14 and #16) out of 16 sample residents. Specifically, the facility failed to: -Provide dignified assistance when Resident #3 requested a bedpan instead of instructing her to use her brief and be changed at a later time; -Provide timely and dignified call light response when Resident #3 needed assistance with pain medications and care; and -Provide timely and dignified call light response when Residents #12, #13, #14 and #16 needed assistance with care when they were choking, incontinent or needed colostomy care or assistance to the bathroom. Findings include: I. Facility policy The Dignity policy, revised February 2021, provided by the regional director of operations (RDO) on [DATE], included in pertinent part: Each resident shall be cared for in a manner that promotes and enhances their sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem. Residents are treated with dignity and respect at all times. The facility culture supports dignity and respect for residents by honoring resident goals, choices, preferences, values and beliefs. This begins with the initial admission and continues throughout the resident's facility stay. Individual needs and preferences of the resident are identified through the assessment process. Demeaning practices and standards of care that compromise dignity are prohibited. Staff are expected to promote dignity and assist residents, for example: promptly responding to a resident's request for toileting assistance. II. Resident #3 A. Resident status Resident #3, age [AGE], was admitted on [DATE] with diagnoses including malignant neoplasm (cancerous tumor) of vulva and breasts; secondary malignant neoplasm of bone; right lower quadrant and abdominal pain; pain, unspecified; intra-abdominal and pelvic swelling, mass and lump and Crohn's (inflammatory bowel) disease. A minimum data set (MDS) assessment was not completed due to Resident #3's recent admission. According to the [DATE] nursing admission assessment, Resident #3 was alert and oriented to person, place, time and situation. She needed extensive assistance for transfers, bed mobility, eating and drinking; was totally dependent for dressing and incontinence care, had generalized weakness and used a wheelchair for ambulation. She had generalized, severe pain at 9 out of 10 on a scale of 1 to 10. Resident #3 was admitted to the facility on [DATE] and discharged to the hospital on [DATE]. B. Family interview Resident #3's son was interviewed by phone on [DATE] at 11:04 a.m. He said Resident #3 was admitted to the facility in severe intractable pain from bone cancer, which was not alleviated during her entire stay in the facility (cross-reference F697, pain management). He said when she rang her call light it took them 30 to 45 minutes to come to her room to even get her her pain medicine. When he went to the nurse's desk to ask for a bedpan per Resident #3's request, the nurse on duty told him, She's wearing a diaper; it's okay, she doesn't need one. He said, When I heard that I just got angry and walked away; I didn't know what to do. My mom's in agony, my blood's boiling. 'How can I help my Mom?' was the only thing going through my mind. They didn't bring the bedpan and didn't come in to check on her. I was used to the hospital where you push a button and the nurse comes. When we tried to get people in there it took forever for them to come and see what she needed. He said after waiting too long for call light response for his mother he would usually just holler for the nurse or I'd just go get one. And then we'd wait and wait and wait and wait and wait. He said during those times Resident #3 needed something to drink, incontinence care or pain medication. C. Record review Resident #3's care plan dated [DATE] identified bladder incontinence. Interventions included: the resident uses disposable briefs, clean peri-area with each incontinence episode, encourage fluids during the day to promote prompted voiding responses, check frequently and as required for incontinence, clean and dry perineum, and change clothing as needed after incontinent episodes. The activities of daily living (ADL) self-care performance deficit care plan dated [DATE] documented the resident required assistance for toileting and needed extensive assistance by two staff to move between surfaces. Encourage the resident to use bell to call for assistance. -Frequent checks for incontinence were not defined in the care plan. The potential for bowel incontinence and offering a bedpan per resident needs and requests was not included in the care plan, although the resident requested and was denied access to a bedpan. Although the resident was encouraged per the care plan to use the bell to call for assistance, timely staff response was not care planned or provided per family interview. Review of Resident #3's activities of daily living (ADL) toilet use documentation revealed the resident was assisted with toileting/incontinence care only five times during her stay in the facility: on [DATE] at 2:30 a.m., [DATE] at 12:19 p.m., [DATE] at 11:59 p.m., [DATE] at 5:59 p.m., and [DATE] at 1:01 p.m. III. Resident interviews Interviews with residents who were cognitively intact and interviewable revealed facility failures to provide dignified care and timely call light response. Specifically: Resident #12 was interviewed on [DATE] at 944 a.m. She said she waited 20 minutes for call light response during lunch on [DATE], and she was choking. Somebody could have died. There's no sense in that. She said a staff person walked up and was playing with the air conditioner in the hall and left for a few minutes, and my light's going off. She should've come in and just checked. She said call light response was a problem for everyone. I've heard people going down the hall screaming for help and it went on for a long time. When I hear it I'll push my button and say 'can't you guys hear that? Please help this person.' The halls echo so much I can hear all the way down to the end of the hall when someone is in distress. Resident #13 was interviewed on [DATE] at 11:25 a.m. She said call light response time during lunch was slow. Yesterday it took 20 minutes; I needed help changing my depends. She said it felt bad especially when she had been sitting in the same one all day. She said it happened about once a day, at mealtimes and other times during the day. I need to get changed right away otherwise my privates start burning. She said sometimes the staff just could not keep up with the call lights. They have RAs (resident assistants) who come and answer the light but they can't do anything and half the time they forget to tell the CNAs that I need help. Resident #16 was interviewed on [DATE] at 3:32 p.m. She said she had waited an hour for call light response when she needed her pants changed after incontinence. IV. Staff interviews Licensed practical nurse (LPN) #4 was interviewed on [DATE] at 8:14 a.m. She said residents had complained to her about slow call light response and lack of incontinence care. She said it had also been reported to her that staff had told a resident to use their brief instead of providing bathroom assistance or a bedpan. She could not recall further details and said it had been several months ago. Certified nurse aide (CNA) # 2 was interviewed on [DATE] at 10:43 a.m. She said some of the residents complained about slow call light response. She said some of the staff, even nurses, would say about residents they're on hospice or they're dying indicating they did not need anything, or that hospice staff would take care of their needs, not facility nursing staff. The staffing coordinator (SC) was interviewed on [DATE] at 3:30 p.m. She said a long-term former CNA was fired two weeks ago for resident care, dignity and neglect issues, and treating other staff poorly. She said an RA had reported to her that the former CNA (#4) had told Resident #13 to use her brief and she would change her later. She heard another report that CNA #4 had refused to provide assistance to Resident #14 after her colostomy exploded because she was not her resident, and left her in that condition for 10 minutes. The SC said she had reported these concerns to the nursing home administrator (NHA), she thought, and CNA #4 was fired for these and multiple other reasons. CNA #3 was interviewed on [DATE] at 3:30 p.m. She said with current staffing on south hall it was hard to answer call lights timely and residents do complain. The director of nursing (DON), nursing home administrator (NHA) and regional director of operations (RDO) were interviewed on [DATE] at 3:48 p.m. The DON and NHA said they were not aware of the concerns documented above. The NHA said they would investigate and provide staff education. They said their expectation for call light response was five minutes or less and residents should be treated with dignity and respect.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review, the facility failed to provide a clean, comfortable, homelike environment for residents. Specifically, the facility failed to ensure: -Residents were not subjected to uncomfortable noise levels in their rooms; -Resident room doors opened properly and safely; -Resident rooms were clean, comfortable, free of urine and cigarette smoke odors and in good repair; -Common areas were homelike and well-maintained; and -Bed linens were in good condition. Findings include: I. Facility policy The Homelike Environment policy, revised February 2021, provided by the regional director of operations (RDO) on 8/24/23, included in pertinent part: Staff provides person-centered care that emphasizes the residents' comfort, independence and personal needs and preferences. The facility staff and management maximizes to the extent possible the characteristics of the facility that reflect a personalized, homelike setting to include: -clean, sanitary and orderly environment; -clean bed and bath linens that are in good condition; -pleasant, neutral scents; -comfortable sound levels. II. Resident/family interviews Resident #13 was interviewed on 8/22/23 at 11:25 a.m. She said it was too loud in the facility at night and it kept her awake. They (staff) walk up and down the halls and talk. And my roommate snores really bad. We have to leave the room door open, otherwise it's too hot in here. Resident #13 said she loved her roommate and did not want to move but she wanted an eye mask to block out the light at night. Upon trying to exit the resident's room at 12:07 p.m., the door stuck and would not open. Resident #13 said that happened all the time and she rang her call light. A staff person arrived and tried to push open the door from the outside but was unsuccessful. A certified nurse aide was able to shove the door open by pushing her body against it at 12:09 p.m. Staff said the doors stuck sometimes due to humidity. Resident #4 was interviewed on 8/22/23 at 2:56 p.m. She said it was too noisy at night. It's mostly staff standing right outside your door talking and having a good time. The kitchen door bothers me the most. I've requested many times that they fix it because at night when it slams the whole place shakes. She said it had gotten better after they posted a sign on the kitchen door saying please close the door gently. She said staff were hoarding wheelchairs and medical equipment in the therapy gym, on the back porch and in the shower room, which bothered her and was not homelike. She said the flower beds at the front were not cared for by staff. She said they were full of weeds and residents and family members had to water and maintain them. She said she saw a resident struggling to sweep up the mulch that had migrated onto the sidewalk. Resident #6 was interviewed on 8/22/23 at 3:32 p.m. The surface of her bedside table was damaged and uncleanable and unsightly. The formica top had peeled off in a six-inch diameter area on the outer corner. Good luck getting that fixed, she said. It's an old building with lots of challenges. Resident #3's son was interviewed by phone on 9/6/23 at 11:04 a.m. His mother was in the facility from the afternoon of 8/4/23 (Friday) through the morning of 8/7/23 (Monday), suffering intractable severe pain (cross-reference F697). He said, Mom got no sleep or rest there at all. It was loud, noisy. He said staff were often standing on a deck right outside her window, talking. Her roommate was great but couldn't hear so the TV was blaring and people talking right outside the window, so it was horrible. He said they would ask for the TV to be turned down but the volume would slowly turn back up to uncomfortable levels. He said the linens on her bed were dirty from the get-go. She had a [NAME] blanket that looked like something from a homeless shelter: dirty, stained. On Sunday afternoon he observed the same stains as the evening she arrived, and said, These are dirty sheets. He said they got changed on the third day. III. Observations and staff interviews A. Urine odors and disrepair in resident rooms Observations throughout the day on 8/22/23 during resident interviews revealed multiple rooms smelled of urine. Observations on 8/22/23 and 8/24/23 of resident rooms #31 and #29 respectively revealed the pervasive smell of urine, unsightly damage to walls and flooring, sticky surfaces on bedside tables and dressers, damaged chests of drawers, water damaged dividers between a small closet intended for two residents to use, worn and pilled bedspreads, privacy curtains that did not completely close at the room entry, and a brown smear that looked like feces on the footboard of the bed by the window in room [ROOM NUMBER]. The housekeeping director, interviewed on the afternoon of 8/22/23 and 8/24/23, said the rooms had been deep cleaned and were ready for residents to move in. She was unable to smell urine but acknowledged the other conditions in the room and said she would ask a housekeeper to deep clean the room again. She said it was an old building and the urine odor may have seeped into the walls and flooring. The nursing home administrator (NHA) was interviewed on the afternoon of 8/24/23 and said she was unable to smell urine. She said she smelled wet wood. She said she did not know what the brown smear on the footboard of the bed but she would ensure the room was cleaned. She acknowledged the other conditions in the resident rooms and said it was an old building and they did not have a maintenance manager. A corporate maintenance person had been assisting them with repairing the cooling and plumbing system. B. Institutional resident activity room and unkempt flower beds at building entrance Observations from 8/22 through 8/24/23 revealed the resident activity/television (TV) room was not homelike. There were only two upholstered chairs, positioned against the wall and to the side where the TV could not be easily viewed. The rest of the room furnishings consisted of office furniture, a conference table, and a work desk in the corner that staff were sometimes observed using as office space. The flower beds at the front of the building were overgrown with weeds that were encroaching onto the sidewalk. IV. Record review The most recent resident council meeting minutes dated 7/31/27 were provided by the NHA on 8/22/23. Twelve residents were present during the meeting and concerns were documented in pertinent part as follows: Old business: Group concerns were not completely addressed. (The activity director) will make sure that the group concerns go out to make sure we can come up with a solution. Maintenance: Televisions are too loud in hallways, between the hours of 10 pm and 4 am. V. Additional staff interviews Licensed practical nurse (LPN) #4 was interviewed on 8/24/23 at 8:14 a.m. She said she had heard concerns from residents about loud roommate TVs and Resident #14 had complained about cigarette smoke coming in her window. The nursing home administrator (NHA), director of nursing (DON) and regional director of operations (RDO) were interviewed on 8/24/23 at 3:48 p.m. The observations and resident/family concerns above were discussed. They agreed with the resident comment that the building was old and had lots of challenges. They said they were without a maintenance director and the corporate maintenance person was addressing repair issues in the meantime. They said they would address the maintenance, housekeeping and homelike environment concerns.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interviews and observation, the facility failed to assess and ensure nutritional and hydration parameters were met and food and drink preferences provided for four (#3, #12, #13 and #4) out of 16 sample residents, and failed to provide dietary preferences for multiple additional facility residents as voiced by resident council members. Specifically, Resident #3 was admitted to the facility on [DATE] and discharged to the hospital on 8/7/23 with severe intractable pain from metastatic cancer with the goal for strengthening so she could move home with her family. Her nutritional and hydration needs were not assessed, care planned or provided. Current facility residents including Residents #12, #13 and #4 likewise said during individual interviews and in resident council their food preferences were not honored and/or available and the facility was not responsive to their stated concerns. Findings include: I. Resident #3 A. Resident status Resident #3, age [AGE], was admitted on [DATE] with diagnoses including malignant neoplasm (cancerous tumor) of vulva and breasts; secondary malignant neoplasm of bone; right lower quadrant and abdominal pain; pain, unspecified; intra-abdominal and pelvic swelling, mass and lump and Crohn's (inflammatory bowel) disease. A minimum data set (MDS) assessment was not completed due to Resident #3's recent admission. According to the 8/4/23 nursing admission assessment, Resident #3 was alert and oriented to person, place, time and situation. She needed extensive assistance for transfers, bed mobility, eating and drinking; was totally dependent for dressing and incontinence care, had generalized weakness and used a wheelchair for ambulation. She had generalized, severe pain at 9 out of 10 on a scale of 1 to 10. Resident #3 was admitted to the facility on [DATE] and discharged to the hospital on 8/7/23. B. Family interview Resident #3's son was interviewed by phone on 9/6/23 at 11:04 a.m. He said the facility did not honor his mother's food and drink choices. He said she had asked for cranberry juice at 7:00 a.m. on 8/5/23 and at 9:00 a.m., nothinghappened. He said he went to the kitchen and got it for her. He said they finally brought her cranberry juice with her lunch at 1:00 p.m. He said by then he had gotten her several drinks upon her request. I just sat with her most of the day so she could get what she needed. He said the nurse on duty was getting annoyed with him and treating him like he was a nuisance. Resident #3's son said Resident #3 told him they had never asked her what she wanted for breakfast but they asked her roommate. She said they just brought her oatmeal. I've never seen Mom eat oatmeal. She wanted 2 scrambled eggs, cream of wheat and cranberry juice, so he went to the kitchen and asked them to give her that same thing every morning. She wasn't happy that her roommate got a real breakfast while she got a bowl of oatmeal. He said, She wasn't able to eat more than a taste or two of this or that anyway, just enough to keep a mouse alive but that's not the point. He said he never saw the staff offer his mother protein drinks, shakes, supplements or snacks. C. Record review Resident #3's care plan, initiated 8/4/23, did not include approaches regarding nutrition or hydration. The activities of daily living (ADL) care plan did not include approaches regarding dining. The bladder incontinence care plan included an intervention to encourage fluids. Physician orders dated 8/4/23 documented a regular diet, regular texture with thin consistency fluids. There was no documentation in Resident #3's medical record of food and drink preferences, likes and dislikes. There was no evidence of an assessment of the resident's nutritional and hydration needs. According to Resident #3's ADL and meal documentation report, she needed supervision, oversight, encouragement or cueing for meals. Her meal intakes were: -On 8/423: Zero (refused) dinner and 120 ml (milliliters) of fluid; -On 8/5/23: 51-75% for breakfast with 240 ml of fluid, zero for lunch with 75 ml of fluid, and 26-50% for dinner with 240 ml of fluid; -On 8/6/23: Zero for breakfast and 480 ml of fluid, zero for lunch and 200 ml of fluid, and 26-50% for dinner with 240 ml of fluid; -On 8/7/23: Nothing was documented for food or fluid intake. -Resident #3 was not documented to consume sufficient food or fluids. Average daily intake recommended for older adults is a minimum of 1500 ml. There was no documentation her physician was notified of her poor intake, and no evidence she was offered her favorite foods or even nutritional supplements to assist in meeting her nutritional needs. II. Observation Observation on 8/22, 8/23 and 8/24/23 revealed a sign posted on the kitchen door that read as follows: Kitchen hours were 0630-1830 (6:30 a.m. to 6:30 p.m.). If you need something before or after the open and closed times please ask your nursing station. III. Resident interviews Resident #12 was interviewed on 8/22/23 at 9:44 a.m. She said she had not been feeling well the previous evening, and at about 6:20 p.m. she asked what she could eat that would be easy on her throat that night. The kitchen was closed and I couldn't get anything but snacks and I think that should change. Finally one of my favorite CNAs (certified nurse aides) came in and said she'd bring me some blueberry yogurt and that I could handle. She said it would be nice if they would serve macaroni and cheese more often because she liked it and it was easy to swallow. Resident #13 was interviewed on 8/22/23 at 11:25 a.m. She said, Sometimes you knock on the kitchen door and nobody will answer, even during daytime hours. She said she knocked on the kitchen door when she needed coffee. They don't get here till 6:30 a.m. and they close the kitchen at 6:30 pm. I could have used some coffee last night when I couldn't sleep. Resident #4, the resident council president, was interviewed on 8/22/23 at 2:56 p.m. She said they very seldom were served the food that was on the menu and the staff always had an excuse. She said food ran out all the time, including basics like condiments, coffee, peanut butter and sugar. She said when the residents voiced their concerns in resident council, the facility response was always the same: we're working on it. IV. Record review Twelve residents attended the most recent resident council meeting on 7/31/23, according to resident council minutes provided by the nursing home administrator (NHA) on 8/22/23. Resident council meeting minutes documented the following in pertinent part: Old business: Group concerns were not completely addressed. (The activity director) will make sure that the group concerns go out to make sure we can come up with a solution. Dietary: Condiments concern did not get taken care of, still not enough supply. Not enough fresh fruit, running out of supplies, French fries are too hard or too cold, still same issue with the menu not matching what they are getting, too much rice and carrots, too many flies in the dining room, toast is soggy, the kitchen running out of ice. Activities: Would like popsicles for snacks. V. Staff interviews The dietary manager was interviewed on the morning of 8/24/23. She said residents could access whatever they needed from the kitchen during the day, and from nursing staff before and after posted kitchen hours. She said nursing staff could always access juices, coffee, hot chocolate, soups, sandwiches, macaroni and cheese, yogurt, ice cream, whatever residents requested. The director of nursing (DON), nursing home administrator (NHA) and regional director of operations (RDO) were interviewed on 8/24/23 at 3:48 p.m. They acknowledged the nutritional concerns and poor food and fluid intake documented for Resident #3. The nurses should never tell residents they could not access food or drinks from the kitchen, but should find out what residents wanted and get it for them. They said they were in the process of completing an investigation, audit and plan of correction regarding dietary and nutritional concerns.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and resident and staff interviews, the facility failed to ensure the building was kept at comfortable and safe temperatures. Specifically, the facility failed to maintain comfortable and safe temperatures in the resident rooms and hallways for three of four units. Findings include: I. Professional reference An article posted on the Centers of Disease Control and Prevention (CDC) website, titled Tracking in Action: Extreme Heat, reviewed 5/30/23, was retrieved on 8/2/23 at https://www.cdc.gov/nceh/features/trackingheat/. The article read in pertinent part: Extreme heat events, or heat waves, are one of the leading causes of weather-related deaths in the United States. When temperatures rise in the summer, extremely hot weather can cause sickness or even death. Heat stress is heat-related illness caused by your body's inability to cool down properly. The body normally cools itself by sweating. But under some conditions, sweating just isn't enough. In such cases, a person's body temperature rises rapidly. Very high body temperatures may damage the brain or other vital organs. II. Facility policy and procedure The Loss of Air Conditioning/High Heat procedure guide, undated, was provided by the nursing home administrator (NHA) on 7/27/23. The procedure guide provided general actions to implement in a high temperature/heat situation. According the the guide, the facility may implement the following: -Use fans and portable air conditioning units, if available. -Keep blinds, curtains, drapes, closed in areas of the building that received direct sunlight. -Open doors and windows, as necessary to take advantage of available breezes. -Avoid activities that may excite residents or require physical exertion. -Keep residents out of direct sunlight. -Turn off lights as well as other heat-producing appliances whenever possible. -Had plenty of liquids for residents and staff. -Monitor vital signs of residents and staff. III. Resident council minutes The June 2023 resident council minutes identified the residents in the 6/27/23 council meeting expressed concerns with the inside temperature of the facility. According to the minutes, the residents said the facility had uncomfortably high temperatures. The minutes read the interim nursing home administrator (INHA) told the residents the swamp coolers were all turned on the weekend of 6/24/23. The INHA said there were two portable units in use at the nurses stations and fans in the dining room. A frequent facility visitor said she had received complaints of the high temperatures in the facility. The INHA said part of the problem was related to staff training. The INHA said staff were using the vent setting on the coolers instead of the cool setting. The frequent visitor said in the past, the facility was going to install new swamp coolers. The minutes read staff said the delay might be partially due to new management and ownership. -There were no additional actions identified on the minutes or associated resident council action plan/grievance follow up for resolution after the 6/27/23 resident council concern. IV. Resident interviews and observations On 7/26/23 and 7/27/23 temperatures in the facility were measured on the four facility hallways, multiple resident rooms, and common areas. The below observations identified multiple temperatures over 81 degrees F and/or residents expressing discomfort with temperatures in the facility on other three facility halls. During the survey on 7/26/23 and 7/27/23, additional evaporative coolers were found and/or purchased and positioned throughout the facility. A. The westside south hall On 7/26/23, the westside of the facility had two hallways with a nursing station between the south hallway and the secured memory care unit, located north of the nursing station. -At 12:19 p.m. a large portable cooler was positioned in front of the nursing station portable cooler. There was not a portal cooler positioned down the south hallway where the resident rooms were located. There were ceiling vents blowing air in the hallway. The outside temperature was 90 degrees F. -At 12:23 p.m. the hallway temperature in front of room [ROOM NUMBER] was 82.2 degrees Fahrenheit (F). -At 12:25 p.m. the temperature in room [ROOM NUMBER] was 82.2 F. The resident said the room was hotter than hell. The window was observed open. The resident said staff opened it the night before but has not closed in yet. She said the facility provided her with a small fan that had helped a little. The resident said she had not complained about the heat in her room. She said they already knew it was hotter than the dickens in the facility. The resident said the dining room was one of the few comfortable rooms in the facility. She said staff kept her water container filled and recently started offering popsicles. The resident said she tried to do as little as possible when it was so hot. -At 12:33 p.m. the hallway outside of room [ROOM NUMBER] was 83.1 degrees F. -At 12:41 p.m. the temperature in room [ROOM NUMBER] was 84 degrees F. There were two fans in the room and the window was closed. The resident said she was fine with the temperature but the roommate had told her that she felt the room was overheated. -At 4:52 p.m. the hallway outside of room [ROOM NUMBER] was 82.5 degrees F. The temperature in room [ROOM NUMBER] was 81.3 degrees F. The temperature outside was 98 degrees F. -At 5:10 p.m. the hallway outside of room [ROOM NUMBER] was 83.1 degrees F. The temperature in room [ROOM NUMBER] was 82.7 degrees F. -At 5:13 p.m. room [ROOM NUMBER] was 83.3 degrees F. -At 5:20 p.m. the temperature in room [ROOM NUMBER] was taken a second time. The room temperature rose to 85.5 degrees F. The resident said she felt hot. -At 5:26 p.m. the hallway outside of room [ROOM NUMBER] was 86.5 degrees F. -At 5:32 p.m. the temperature in room [ROOM NUMBER] was 85.7 degrees F. The resident said that her room had been hot lately, but today (7/26/23) was the first day it felt a little better. She said she thought it was because the temperatures outside were starting to cool down. The temperature outside was 97 degrees with some cloud cover. -At 8:19 p.m. the temperature in room [ROOM NUMBER] was 84.5. -At 8:23 p.m. an evaporative cooler in the hall near room [ROOM NUMBER] was not on. On 7/27/23 at 1:28 p.m. the temperature in room [ROOM NUMBER] was 81.6. Two residents were in the room. Both residents said the temperature in the room was better than it was the night before. One of the residents said she was anticipating the room to get warmer later that day. She said the room was usually boiling by late afternoon. -At 1:35 p.m. the temperature in room [ROOM NUMBER] was 81.6. The hallway outside the room was 82.7 degrees F . B. Eastside north hall On 7/26/23 at 2:50 p.m. a resident was observed outside of room [ROOM NUMBER], under a vent. The ceiling vent was blowing cold air. The resident said her room was too warm and she was trying to cool off. The window was open and the fan was off and positioned facing her roommates bed. The resident said the fan was the roommates and she could not touch it. She said she would like to have a fan for her side of the room. -At 2:58 p.m. the temperature in room [ROOM NUMBER] was 81.1. The window was open and the fan was not on. The temperature outside was 96 degrees F. The hallway temperature in front of room [ROOM NUMBER] was 81.3 degrees F. -At 5:53 p.m. the temperature in room [ROOM NUMBER] was taken a second time. The temperature rose to 82.7 degrees F. The hallway temperature outside of his room was 81.5 degrees F. -At 6:01 p.m. the temperature in room [ROOM NUMBER] was 82 degrees F. -At 6:05 p.m. the temperature in room [ROOM NUMBER] was 81 degrees F. The resident said she was hot and the fan did not help. -At 8:43 p.m. a resident said he would like his room to be cooler but his room was cooler at night then during the day. -At 8:50 p.m. a resident was observed in the hallway under a ceiling vent for a second time. She said the hallway was cooler than her room. The one fan in the room was blowing directly towards her roommate's side of the room. On 7/27/23 at 12:38 p.m. the resident was in bed. The window was open directly by his head and the fan was not on. The resident said he felt pretty warm and it was usually pretty warm in the building. C. Eastside south hall On 7/26/23, the hallway temperature and four sample resident room temperatures were taken on 7/26/23 between 1:15 p.m. and 6:10 p.m. -At 1:26 p.m. the temperature in room [ROOM NUMBER] was 80.2 degrees F. The resident said she was comfortable at the moment but in the evenings, her room was very warm which affected her sleep. -At 6:10 p.m. the temperature in room [ROOM NUMBER] was 82 degrees F. Two residents resided in the room. Both residents were wearing hospital gowns and said their choice in clothing was to help keep cool. The residents said they were hot but they have had times in their room where they felt hotter. One of the residents said the staff offered her a popsicle earlier. She said she wanted a popsicle but the staff member offered it at the same time her meal was served so she could not take the popsicle. -At 8:28 p.m. the temperature in room [ROOM NUMBER] was 79.7. He said he was comfortable because there was an evaporative cooler just outside of his room. -At 8:39 p.m. the temperature in room [ROOM NUMBER] was 83.6 degrees F. The resident was asleep without cover and in just a brief. He had two fans in his room and an evaporative cooler. -At 8:57 p.m. the temperature in room [ROOM NUMBER] was 82 degrees F. The resident was sleeping. She wore only under garments with no covers.There were two evaporative coolers blowing cool air in the hallway. On 7/27/23 at 1:50 p.m. the temperature in room [ROOM NUMBER] was 82 degrees F. The resident said he was hot and his room was always hot so he only wore a brief to try to stay cool. He said he had two fans and used his own evaporative cooler. The resident said the facility added a tower fan in his room today (7/27/23). He said they only just added the hallway evaporative coolers in the last couple of days. He said his room was still hot. IV. Resident group interview Five residents (#1, #2, #3, #4 and #5) were interviewed on 7/26/23 at 3:10 p.m. The following comments were made in the group interview regarding the temperature of the facility and the facility response. -Resident #2 said the maintenance department had been working on the swamp coolers on the roof but her room was always hot. Resident #1 said she and her roommate each had a fan but the room was still hot. She said she told the NHA. She said a thermostat was placed in her room to measure how hot the room was. She said she recorded the temperatures in the room for four to five days and reported them to the NHA but it did not change anything. She said she did not get an evaporative cooler in her room until this week, after her family member complained to the NHA. The resident said the evaporative cooler helped lower the temperature in her room but her room remained between 80 degrees F and 82 degrees F during the day. She said her room was still 80 degrees F at night. She said the facility needed something for the other residents in the facility. Resident #1 said she was worried about the other residents. She said the residents could get sick from the heat. She said residents go to the dining room at night because it was cooler there than the rooms. Resident #2 said she went to the dining room at night to watch television but other residents have told her they were in the dining room because their room was hot and they could not sleep. Resident #3 said the temperature in the facility has been hot since the beginning of summer. She said she had three fans in her room but it was still too hot to sleep. Resident #1 said the resident's concerns with the high temperature in the facility were brought up by the resident council last month. She said residents did not usually bring up individual concerns on concern forms because nothing happens to change the concern. She said residents were told that the facility was looking into it or it would take time to fix. She said in June 2023 the facility started putting some of the evaporative coolers in some of the hallways but the facility was still hot. Resident #1 said the coolers needed to be filled with water but staff did not always have time to do it. She said the high heat zapped everyone's energy. Resident #1 said between noon and 6:00 p.m. was the hottest time of day. She said the residents need to keep hydrated. She said the facility passed out popsicles yesterday and was going to make snow cones today. Resident #1 said staff had passed out popsicles only once before when it was hot. Resident #2 said the facility used to pass water from a cart three times a day but had stopped after COVID. Staff would tell her it was not their job. Resident #3 said the facility had a hydration time in the dining room as an activity but she was concerned about the residents who did not come to the dining room. V. Family interviews A frequent facility visitor was interviewed on 7/26/23 at 4:00 p.m. The visitor said she had been at the facility four times in the last month. She said she was at the facility on 7/21/23. She said the temperature outside was 104 degrees in the late afternoon. The visitor said there were two large evaporative coolers at the nursing stations but not by the resident rooms. She said a room on the westside of the building in the south hall was 86 degrees F. The resident was sweaty. The ceiling vents in the hallway were just blowing warm air. She said the hallway on the eastside of the facility was 84 degrees F. The room had only one little fan for two residents. The visitor said the temperature in room [ROOM NUMBER] was 82 degrees F. The room did not cool down until the family started to complain. She said that was when the facility placed an evaporative cooler in room [ROOM NUMBER] on 7/25/23. The visitor said she returned to the facility on 7/25/23 and the corporate consultant (CC) was passing out popsicles. She said the maintenance director had been working all week on the roof making repairs to the air conditioning system. A family member for a resident in room [ROOM NUMBER] was interviewed on 7/27/23 at 9:27 a.m. She said the room temperature was between 82 degrees to 85 degrees. She said a fan did not help bring down the temperature in the room. The family member said she complained to the NHA on 7/20/23 but was told by the NHA that there was nothing that could be done about the facility temperature until the CC was at the facility on 7/24/23. The family member said she requested a thermostat to be placed in room [ROOM NUMBER] and an evaporative cooler placed in the room. The family member said an evaporative cooler was not placed in room [ROOM NUMBER] until 7/25/23. Another family member for the resident who also resided in room [ROOM NUMBER] was interviewed on 7/27/23 at 12:14 p.m. She said she had a major problem with the temperature since the temperature of the room reached 85 degrees F. She said she had to contact the NHA on 7/24/23. She said the evaporative cooler was not in place until after her 7/24/23 call to the NHA. VI. Staff Interviews The CC was interviewed on 7/26/23 at 5:25 p.m. She said she had been monitoring the temperatures. The CC took the temperature in room [ROOM NUMBER] and said it was 86 degrees F. The CC said there were concerns of high temperatures in the facility last week. She said the facility ordered evaporative coolers online but the coolers were on backorder. She said they had purchased some evaporative coolers for rooms and halls on 7/25/23 from a physical store. Certified nurse aide (CNA) #1 was interviewed at 5:30 p.m. She said the facility had been very warm in the building for several weeks. She said she just checked on a resident in his room and his back was very sweaty. She said it was hard to work in the high heat and residents have been complaining about high heat. The CC was interviewed on 7/26/23 at 5:51 p.m. The CC said she would send someone tonight (7/26/23) to the store to get the store's last evaporative cooler. The CC was interviewed again on 7/26/23 at 6:15 p.m. She said she just found a few more evaporative coolers in the facility storage shed and placed the coolers around the facility. The CC said the nurses all had timers and would fill the coolers every two hours. CNA #2 was interviewed on 7/26/23 at 9:03 p.m. as she cooled off in front of the evaporative cooler in front of the nursing station. She said the facility was warm but some residents liked it. Registered nurse (RN) #1 was interviewed on 7/26/23 at 9:08 p.m. He said if a resident was sweaty and hot, staff would have them sit in the common area near the cooler. He said at night, the residents would have less clothes on to sleep. The housekeeping supervisor was interviewed on 7/27/23 at 10:05 a.m. She said she did not mind the temperature in the facility during the day but she noticed the facility started to warm up after 4:00 p.m. The maintenance service director (MSD) was interviewed on 7/27/23 at 10:20 a.m. The MSD said the facility had 14 swamp coolers and two refrigerated coolers. He said both of the refrigerated coolers and one of the swamp coolers were not working. He said he had been trying to repair the coolers and needed repair parts. He said the facility cooling system was not working at full capacity, causing the warm temperatures in the facility. He said temperatures in the facility needed to be between 72 degrees and 81 degrees. He said he was monitoring temperatures. He said the temperatures averaged between 79 degrees and 81 degrees, which were within appropriate range but he said he felt it was still too warm for comfort. He said he did not log the specific temperatures, only checked if the temperatures were when the appropriate range (81 degrees or less). The NHA was on 7/27/23 at 10:50 a.m. She said the facility did not have a staff member in the maintenance department for four months. She said the current MSD was hired in June 2023 and started making repairs to the roof swamp coolers. She said on 7/13/23, the MSD located a vendor who could supply the needed parts. The NHA said funding for the parts was approved on 7/26/23. She said she was hoping the repairs would be completed next week. She said the facility, for the last couple of weeks, had been placing evaporative coolers around the facility. The NHA said fans have been placed in resident rooms and a hydration cart went up and down the halls. The NHA said the residents had not complained of the temperature in the facility until last week. The June 2023 resident council concern regarding uncomfortably high temperatures was shared with the NHA. She said she was not present for the resident for the council meeting and was not aware the residents expressed the temperature concern in June 2023. The NHA said staff had a verbal education on 7/21/23 and a formal education today (7/27/23) regarding facility temperature maintenance (see below). The NHA said the MSD monitored the temperatures a couple times a day. The activity director was interviewed on 7/27/23 at 12:50 p.m. She said the residents had been complaining about the heat. She said when she returned from vacation on 7/24/23, she noticed the heat so she started doing extra hydration carts. She said popsicles were offered the other day and today (7/27/23) she would serve watermelon. The NHA was interviewed again on 7/27/23 at 3:10 p.m. She said she just received purchasing authorization for the repair work needed for the facility cooling system. VII. Record review An employee education form was provided by the NHA on 7/27/23. The education form identified on 7/27/23 twelve staff members were directed to perform the following tasks to aid in the building temperature management: -Monitor all resident windows. Closed the windows to one to two inches wide to encourage appropriate air flow and/or prevent too much air flow. Educate the residents of the risks and benefits of the open windows to prevent increased warmth in the room. -Keep all resident doors open as they allow. Educate residents of risks/benefits to prevent increased warmth in the room. -Pull down all blinds as the resident allows. Provide education of risks/benefits to prevent increased warmth in the room. -Pass ice water and other cold beverages before, after and in between meals to promote hydration. Encourage the residents to increase intake. -Check all portable coolers to ensure the coolers were filled with water to maintain function and cooler air. The coolers should be running at all times. The facility temperature management timeline was provided by the NHA on 7/27/23. The timeline included: -A box of 10 arctic air water coolers and eight stand up oscillating fans were delivered to the facility on 5/30/23. -The MSD was hired on 6/26/23. -A work order was submitted to the MSD on 7/3/23 for temperatures on the eastside south hall. The work order was completed on 7/7/23. -An evaporative cooler was purchased on 7/4/23. -A credit application was sent to the corporate office for a local vendor parts purchase. -Swamp cooler belts were purchased by the MSD on 7/13/23 and again on 7/14/23. -An evaporative cooler was purchased for the therapy gym on 7/15/23. -Additional swamp cooler repairs parts were purchased on 7/19/23. -A discussion with the regional maintenance consultant was conducted on 7/21/23 to implement a plan of purchase based on the identified repair needs. -The MSD purchased four more evaporative coolers. The MSD placed two of the coolers in the facility and held the other two evaporative to determine the best locations within the facility. -Additional evaporative coolers were placed in the facility on 7/26/23.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to document resuscitation choices accurately in the medical record for one (#4) out of five residents reviewed for advanced directives out of 41 sample residents. Specifically, the facility failed to ensure a facility nurse assigned to Resident #4 knew where to locate Resident #4's advance directives to ensure the directives would be carried out in case of emergency. Findings inclue: I. Facility policy The Communication of Code Status policy, revised [DATE], was provided by the facility on [DATE] at 6:47 p.m. The policy read: It is the policy of this facility to adhere to the residents' rights to formulate advanced directives. In accordance to these rights, the facility will Implement procedures to communicate a resident's code status to those individuals who need to know this information. According to the policy, the designated sections in the medical record to find the resident's code status was the physician orders under code status, and the miscellaneous tab in the electronic medical record for the MOST form. II. Resident status Resident #4, age [AGE], was admitted on [DATE]. According to the [DATE] computerized physician orders (CPO), the diagnoses included major depression disorder, unspecified injury of the head, unspecified intracranial (within the skull) injury with loss of consciousness of unspecific duration, aneurysm (the ballooning or weakening area of an artery) of unspecific site, and unspecific convulsions (sudden, violent, irregular movement of the body.) The [DATE] minimum data set (MDS) assessment revealed the resident had severe cognitive impairment with a brief interview for mental status (BIMS) with a score of seven out of 15. He required supervision with all activities of daily living (ADLs). III. Observation and staff interview Licensed practical nurse (LPN) #2 was interviewed on [DATE] at 4:48 p.m. The LPN #2 said residents' advanced directives were scanned and placed in the electronic medical record for reference. LPN #2 looked in the electronic medical record for Resident's #4's medical orders for scope of treatment (MOST) form. The LPN said the MOST form had not been uploaded yet. LPN #2 said the hard copy of the MOST form would be located at the nursing station in a binder. The LPN reviewed the binder and could not find the MOST form. The nurse said if Resident #4 had a medical emergency and needed to identify the resident's advanced directives to determine his code status, and the MOST form was not available, he said the first thing he would do was call 911, then he would check with the medical record director (MRD) for the resident's advanced directives. He said if the medical emergency took place when the MRD was not available, he would attempt to contact the resident's family. The LPN was asked if the resident was coding, how would he immediately know if he needed to perform CPR (cardiopulmonary resuscitation) and could not find the resident's MOST form. LPN #2 said he would refer to his nurse report which identified all his residents'code status.' The LPN did not refer to the resident's CPO or care plan to identify the resident's advance directive. The LPN showed the list of residents from his nursing cart and identified Resident's #4's code status was typed next to the resident's name. The code status next to the resident's name read DNR (do not resuscitate.) -The review of the resident's MOST form (later provided by the facility) and the resident's CPO, identified the Resident #4 wanted CPR and full treatment. The MRD was interviewed on [DATE] 5:56 p.m. The MRD said she had Resident #4's MOST form had not been placed in the binder at the nursing station or uploaded yet because she was still waiting for it to be signed by the physician. She said the MOST form was currenting in her office and the physician should be at the facility in a few days. The MRD said she was new to the facility as identified the facility needed a new process with documents the physician needed to sign. She said while the MOST form was waiting to be signed, there should have still been a copy of it in the binder at the nurses' station for quick reference. She said normally she would have identified the concern in an audit but she had only been at the facility for the past two weeks and had not had an opportunity to audit everything. The MRD said the nurse could also referred to the resident's CPO. The MRD pulled up the CPO for Resident #4 and confirmed his advanced direct orders were in place and identified the resident was full code. The MRD said the LPN should have known to refer to the CPO for the resident's correct code status. She said she would in-service the LPN. IV. Record review The CPO, dated [DATE], read: CPR; full treatment; artificial nutrition. The care plan, initiated [DATE], read I choose to have CPR. I will have all of my wishes and advanced directives honored until I request otherwise, or until the next review period. Please provide CPR. The MOST form was provided by the interim nursing home administrator/director of operations (INHA/DO) on [DATE] at approximately 5:30 p.m. The MOST form identifying Resident #4 wanted full treatment medical interventions and wanted CPR in the event of a cardiopulmonary arrest. The MOST form was signed and dated by the resident's power of attorney (POA) on [DATE]. The MOST form was not signed by the physician. V. Facility follow-up A blank copy of the nurse report was provided by the night nurse after the change of shift on [DATE] at 7:06 p.m. The nurse report identified the DNR status next the name of Resident #4 was scratched out and FULL was hand written above the scratched out DNR. A [DATE] employee education form was provided by the facility on [DATE]. The education reviewed the communication of code status policy. The education was signed off by the facility nurses, including LPN #2. The education included an added on to the policy. Under designated sections on where to find the residents' code status, now included MOST form binder at nurses station.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interviews, the facility failed to ensure one (#25) of 12 residents reviewed out of 41 sample residents was provided personal privacy during care. Specifically, nursing staff failed to ensure they pulled the privacy curtain and keep the door closed while providing incontinence care for Resident #25. Findings include: I. Resident #25 status Resident #25, age [AGE], was admitted on [DATE]. According to the January 2023 computerized physician orders, diagnoses included Alzheimer's disease, reduced mobility, and need for assistance with personal care. The 11/17/22 minimum data set assessment documented severe cognitive impairment, physical behavior directed toward others, and no care rejection. She needed extensive assistance with activities of daily living. II. Observation On 1/19/23 at 5:00 p.m., certified nurse aide (CNA) #3 was observed leaving Resident #25's room pushing a Hoyer (mechanical) lift ahead of her and parking it in the hallway. She had left the door open and the privacy curtain was not pulled. CNA #11 was providing peri care for Resident #25 who was naked and exposed from the waist down. The resident's roommate was in the room; she and anyone walking down the hallway could have observed Resident #25. CNA #11 told CNA #3 to close the door. III. Record review Resident #25's care plan, initiated on 11/23/21, identified, I am incontinent of bowel and bladder. I have Alzheimer's and am not always able to use the bathroom or know when I need to void. The interventions included check and change to maintain dignity. IV. Staff interviews CNA #6 was interviewed on 1/25/23 at 4:14 p.m. regarding the observation above. She acknowledged she should have pulled the curtain and closed the door, but said she was in a hurry because they don't have enough staff. (Cross-reference F725, sufficient nursing staffing.) The interim nursing home administrator/director of operations (INHA/DO) and director of nursing mentor were interviewed on 1/25/23 at 5:18 p.m. regarding the observation above. The INHA/DO said the failure to pull the privacy curtain and close the door while providing resident care was not in keeping with their corporate policy. They said they would provide additional staff training regarding resident rights, dignity and respect.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and staff interviews, the facility failed to ensure the resident environment remained as free of accident hazards as possible for two (#32 and #56) of eight residents reviewed for accident hazards out of 41 sample residents. Specifically, the facility failed to: -Ensure appropriate and effective measures were in place to prevent Resident #32 from repeated falls, often related to the need to use the restroom. The resident fell eight times between 12/1/22 and 1/23/23. The repeat falls resulting in increased pain for Resident #32; -Ensure fall prevention interventions were put in place after the Resident #56 had an increase in medications that increased the residents risk for falls.; and, -Ensure Resident #56 had walking/locomotion assistance as identified on the resident's minimum data set assessment. Findings include: I. Facility policy and procedure The Fall Management policy, revised December 2022, the policy read and pertinent part: The facility assists each resident in attaining/maintaining his or her highest practical level of function by providing the resident adequate supervision, assistive devices and/or functional programs, as appropriate, to minimize the risk of falls. The interdisciplinary team (IDT) evaluates each resident's fall risk. A care plan is developed and implemented, based on this evaluation with ongoing review. According to the practical guidelines of the fall management policy, the nurse should communicate the resident fall to the interdisciplinary team and initiate interventions to reduce the potential of additional falls. The IDT team reviews all resident falls within 24 to 72 hours to evaluate circumstances and probable cause for the fall. The care plan will be reviewed and or revised as indicated. II. Resident #32 A. Resident status Resident #32, age [AGE], was readmitted on [DATE]. He resided in the secured/memory care unit. According to the January 2023 computerized physician orders (CPO), diagnoses included delirium due to known physiological condition, and unspecified dementia with unspecified severity without behavioral disturbance, history of falling and repeated falls, muscle weakness, unsteadiness on his feet, history of transient ischemic attack and cerebral infarction without residual deficits (stoke). The 12/13/22 minimum data set (MDS) assessment revealed the resident had severe cognitive impairment with a brief interview for mental status (BIMS) score of zero out of 15. The resident exhibited inattention, disorganized thinking and an altered level of consciousness. The resident required limited physical assistance of one person for toileting, personal hygiene and dressing. He needed staff supervision with walking in the corridor, locomotion of and off the unit, bed mobility and transferring. The MDS assessment did not identify the resident had rejections of care. B. Resident observation Resident #32 was observed on 1/19/23 at 11:20 a.m. pacing the hall. The resident was walking with his walker back and forth down the hall following the wall angles. A certified nursing assistant (CNA) on the memory care unit said the resident had set a pattern to only turn when he gets to a corner. On 1/24/23 at 9:53 a.m. Resident #32 was in the dining room in a dining chair. He wore a gait belt around his waist. The resident attempted to start to stand when the activity assistant (AA) #1 asked the resident to wait for her to find out how he was transferring. On 1/25/23 at 12:10 p.m. Resident #32 was observed sleeping in the reclining chair with the foot of the recliner extended. The resident slid partly down in the chair. His feet were halfway off the side of the chair. AA #1 was walking with another resident when she observed Resident #32's position. She requested for CNA assistance to help him but they were all in resident rooms. The AA told the resident she was walking with that she (AA) could not leave the dining room until someone helped Resident #32. The AA continued to walk with her resident while trying to keep an eye on Resident #32. The CNAs and the nurse were available to assist Resident #32 after a few minutes. C. Record review The review of Resident #32's medical record identified the resident fell eight times in less than two months. The 12/1/23 Morse fall scale identified Resident #32 was at high risk for falls. The fall care plan, last revised on 1/20/23, read Resident #32 was at high risk for falls related to Alzheimer's disease with late onset. His gait was imbalanced and he required a walker. According to the care plan, the resident had an actual fall, poor safety awareness and declining health. The care plan identified the resident as at the end of life. The review of the fall care plan identified: -New interventions were not added to the care plan after each fall; -Repeated need for reminders to staff to assist the resident with his ADLs, including meeting his toileting needs. The review of the January 2023 comprehensive care plan identified the resident was incontinent of bladder. The care plan did not identify the type of toileting assistance the resident required. The review of the resident's medical record did not identify documented staff monitoring, or the resident was on a scheduled toileting plan. Fall #1 The 11/30/22 Administration note read the resident was placing his mattress and bedding on the floor. The 12/1/22 incident report identified the resident fell on [DATE] at 4:15 a.m. The fall was unwitnessed. A CNA found the resident on the floor of his room. The resident stated he was attempting to put his shoes on when he fell. According to the report, the resident did not exhibit pain or an injury as a result of the fall. The 12/1/22 progress note read the resident complained of left rib pain. The care planned fall intervention initiated on 12/1/22, informed staff that the resident liked to get up during the night and use the restroom and was tall and needed his bed at a safe anatomical height. The care plan instructed staff to assist the resident with non-slip socks in the evenings. Fall #2 The12/14/22 incident report identified the resident had an unwitnessed fall on 12/14/22 at 12:00 a.m. The report read a CNA heard the resident moaning and entered the resident room. The CNA found the resident on the floor beside his bed with his walker on top of him. According to the report the resident said he had gone to the restroom and when he came back to bed, he slipped and fell on the floor. The resident complained of pain to his upper posterior shoulder/scapular region. There was no noted redness or injury identified. The resident presented guarded pain when asked to demonstrate range of motion. The resident was assisted back to bed. The incident report plan was to increase resident monitoring due to his declining health and continue current interventions. The report identified the resident would be evaluated for palliative care. The review of the progress notes identified the resident had x-rays done on the 12/14/22. The x-ray results did not identify a fracture however the resident continued to guard his left shoulder and express pain to his shoulder region. The 12/14/22 post fall assessment identified it was unknown what footwear the resident was wearing at time of the fall. According to the assessment, the resident was taking both laxatives and diuretics at the time of the fall. The care planned fall interventions initiated on 12/14/22 included reminders to staff to check on the resident frequently at night related to declining health and being evaluated for hospice; physical therapy evaluate and treat as orders or as needed; follow facility fall protocol, and provide activities that minimize the potential for falls while providing diversion and distraction; review information on past falls and attempt to determine the cause of falls; record possible root causes; remove any potential causes if possible; educate resident family/caregivers/interdisciplinary team as to causes. The care plan interventions did not identify reviewing his scheduled timing of laxatives and diuretics or how that may impact his timing and frequency for toileting needs. Fall #3 The 12/29/22 incident report read the resident was found on the floor in his bedroom next to his bed at 4:30 p.m. The fall was not witnessed. According to the resident, he twisted his legs when turning as he was getting up from the bed. The incident report notes dated 1/3/23, identified a root cause analysis of the timeline of falls would be conducted, medications would be reviewed to look for any trends, and there would be more frequent checks due to his cognitive decline. The 12/29/22 post fall assessment identified the resident was assessed and there was no injury as a result of the fall, but complained of a sore arm from the previous fall (12/14/22.) The post fall assessment identified getting up to go to the bathroom was a trend of Resident #32. According to the assessment, the resident could not demonstrate that he could use the call light in his room or in the bathroom. The 12/29/22 Morse fall scale identified the resident was forgetful of his own safety limits. The review of the care plan did not identify new interventions after the 12/29/22 fall or interventions based on the identified trend. Fall #4 The 12/30/22 fall incident report identified the resident had another unwitnessed fall. According to the report the resident fell on [DATE] at 10:30 p.m. He was found on the floor by his bedroom door. The resident said he was going to the bathroom and he tripped and fell. The report identified the resident hit his head by his left ear and was also complaining of continued pain in his left shoulder. The resident exhibited occasional labored breathing, and occasional moaning. The resident was described to have distressed or tense body language and sad, frightened or a frown in his facial expression. The incident report notes dated 1/3/23, a root cause analysis of the timeline of falls would be conducted, medications would be reviewed to look for any trends, and there would be more frequent checks due to his cognitive decline. identified the same interventions at the 12/29/22 but suggested considering a toileting schedule. The review of the care plan did not identify the intervention of a toileting schedule after the 12/30/22 fall. The care plan did not identify any new interventions immediately following the 12/30/22 fall. The 12/30/22 progress note read the resident was observed by the CNA via camera monitor. According to the note, by the time the CNA arrived at the resident's room, the resident was on the floor by his door. The resident then proceeded to scoot himself across the floor and placed himself back into bed before he was assessed by nursing staff. Fall #5 The 1/2/23 at 3:52 a.m. behavior note read the resident was more restless. The resident was monitored by a video camera and had been attempting to get out of bed multiple times without assistance. According to the CNA has gone to assist the resident multiple times. The resident had to use the restroom a couple of times upon checks. The resident was expressing difficulty communicating related to increased pain medication administered. The fall incident report read the fall on 1/2/23 at 10:45 p.m. was not unwitnessed. According to the report the camera monitor was not connected so when the CNA went to check on the resident the resident was found sleeping on the floor beside his bed.An assessment was conducted and no injuries or pain noted. The incident report identified the resident had been more confused lately. The resident was fidgeting in bed, taking off his clothes and bedding, seeing things around in his room and being confused about time of day. The incident report notes dated 1/3/23, identified a root cause analysis of the timeline of falls would be conducted, medications would be reviewed to look for any trends, and there would be more frequent checks due to his cognitive decline. The interventions were the same as described after the falls on 12/29/22 and 12/30/22, however the notes for 1/2/23 did not suggest a toileting plan or provide follow up the use of a toileting plan. The 1/3/23 interdisciplinary (IDT) progress note read a fall timeline was reviewed to aid in root cause analysis due to the resident's sudden increase in falls. The review of the timeline determined three out of five falls occurred between 10:30 pm and midnight, all next to bed with documentation indicating the resident was attempting to toilet himself each time. There were no significant changes with his vitals and no other anomalies noted. The care planned fall interventions, initiated on 1/3/23, were added to the care plan after the resident had three falls between 12/29/22 and 1/2/23. The interventions read to inform staff that he was more confused; increase his checks for the restroom and activities of daily living (ADLs) related to weakness and cognitive decline; and, remind the resident (He had a BIMS score of zero out of 15) to call for help when he was getting up to use the restroom. -The intervention to increase checks of the restroom and ADL need was not a new intervention. -The intervention to encourage/remind the resident to use the call light was not a new intervention. The intervention was implemented on 4/7/21. The 1/4/23 at 1:27 p.m. nursing note read the IDT reviewed the resident's risk for falls. The resident had three falls in the past week. The root cause was determined to be using the bathroom at night and increased pain to his left upper extremity (LUE), causing difficulty with use of his walker. A second X-ray was completed (1/3/23) to LUE, shoulder,and scapula. There were no acute abnormalities noted per the reports. According to the note, interventions to increase assisted toileting at night and pain review for the need of PRN (as needed) Tylenol at NOC (night.) The 1/4/23 at 5:42 p.m. read Resident #32 had been sliding out of his chair in the dining room and had to be sat back up today (1/4/23.) No other interventions were identified to assist the resident with sliding. Fall #6 The fall incident report identified the resident had a fall on 1/12/23 at 10:00 a.m. The fall was witnessed by a nurse. According to the report the resident was sitting in a recliner watching television (TV) in the main activity dining room. The report read that somehow the resident or someone else had the recliner legs pulled forward to a full extension. The resident was attempting to scooch out of the recliner when it tipped forward and the resident fell face first hitting his left cheek and left upper extremity. The resident identified pain to his left cheek and left upper extremity from previous falls. Ice was applied to the resident's cheek bone. The report read due to the resident's continued decline staff will need to monitor the resident closely and anticipate his needs more quickly. No other interventions were identified. The care planned fall intervention, initiated on 1/13/23, reminded staff that the resident was declining cognitively and they needed to anticipate his needs more frequently. The care planned fall intervention, initiated on 1/18/23, staff education to increase assistance with ADLs. Fall #7 The 1/23/22 at 4:30 a.m. nursing note read the resident woke up moaning in pain. The resident continued to moan loudly and was provided Tylenol 650 milligrams (mg). The fall incident report read Resident #32 fell on 1/23/23 at 7:00 a.m. The resident was found on his bedroom floor with his walker in front of him. The bed was at a safe anatomical height, the light was on in the bathroom, and monitoring was on and in place. Resident was assessed for injuries, none were identified and he was then assisted to the bathroom. The resident requested to lay down a while before going to breakfast. The report recommended staff to increase monitoring due to his increased restlessness. The 1/23/23 at 7:00 a.m. post fall assessment read the resident was in bed prior to his fall and ambulated out of bed unassisted with use of his walker. The identified intervention was a medication review by hospice. Fall #8 The fall incident report identified the resident had a second fall on 1/23/23 at 9:00 a.m. The fall was not witnessed. There were no injuries identified. According to the report the resident was found on his bathroom floor. He was toileted prior to the fall 15 minutes earlier. No injuries were identified. The resident was obsessed and placed into a wheelchair. The resident was brought out to the common area where he could be monitored by a few staff. Notes documented on the fall report on 1/24/23 read the resident had been assisted to the bathroom then assisted bed the resident got up and wandered into the bathroom he was found on the floor monitoring was in place. The staff witnessed that the resident was out of bed and went in to assist. The resident was found on the floor. The resident has had some increased restlessness and hospice has been made aware. A medication review was pending. The resident was assisted to the wheelchair and brought to a common area for increased supervision and to engage in activities. The plan of care was updated to ensure gait belt was in place when the resident is up so staff can assist when attempting transfers and ambulation. The 1/23/23 at 9:00 a.m. post fall assessment read the resident self-ambulated to the bathroom from his bed and fell.The resident was then brought to the common area to participate in activities. No additional interventions were identified on the post fall assessment. Fall #9 The fall incident report identified the resident fell a third time on 1/23/23 at 12:00 p.m. The fall was witnessed. According to the report the resident was in the activity/dining room and was attempting to get up out of the wheelchair. He started to slide to the floor. The resident was assisted to the floor by staff. There were no injuries identified resulting from the fall. The resident was helped into the recliner and one-on-one monitoring was implemented for the day of 1/23/23 due to increased weaknesses with attempts to get up without assistance. The hospice nurse visited the resident at bedside in the afternoon for an assessment and review. The hospice ordered medication changes. The situation, background, assessment and recommendation (SBAR) communication form read Resident #32 had increased confusion and new or worsening behavior symptoms. According to the SBAR, the treatment since the last episode was to monitor, have a video camera at the nursing station to monitor while in bed. According to the SBAR, the resident's confusion and agitation worsened the condition (fall risk), and quiet rest and one to one monitoring made the condition/risk better. The SBAR identified the resident had just started a medication to help him sleep because he had been up at night. The resident has had a history of hallucinating but the hallucinations had recently been increasing. The 1/23/23 nursing note read Resident #32 had three falls on the morning on 1/23/22. Two of the falls unwitnessed and one fall was from the resident sliding out of a chair. Hospice changed his Seroquel to Risperidone (antipsychotic medications). According to the note, there was no physical injury but the resident was holding his head. The note indicated the resident was provided a one to one staff member to stay with the resident for the duration of the day. The care plan fall interventions, initiated on 1/23/23, identified staff was educated to remove the fall mat when Resident #32 was not in bed; contact hospice services for a medication review; and, keep a gait belt on the resident when he was up to assist staff to help him ambulate and transfer due to poor safety awareness. The care plan fall intervention, initiated on 1/23/23, read staff was educated to remove the fall when the resident was out of bed and contact hospice for a medication review. The care plan fall intervention, initiated on 1/24/23, read a video monitoring device was at bedside, however, review of prior falls identified the camera was in place since at least the end of December 2022. The care plan did not identify a change in the resident's transfer and ambulating need, such as use of gait belt when ambulating, how much transfer assistance the resident needed or the use of a wheelchair as identified in the above 1/24/23 observation. V. Resident #56 A. Resident status Resident #56, age [AGE], was admitted on [DATE]. He resided in the secured/memory care unit. According to the January 2023 CPO, diagnoses included Alzheimer's disease, major depression, and unspecified dementia with unspecified severity without behavioral disturbance. The 11/10/22 MDS assessment revealed the resident had severe cognitive impairment with a brief interview for mental status (BIMS) score of one out of 15. The resident exhibited disorganized thinking. The resident required extensive physical assistance of one person for transferring, dressing, and toileting. The MDS assessment revealed the resident required limited physical assistance of one person for bed mobility, walking in his room, walking in corridor, locomotion on and off the unit. The MDS assessment did not identify the resident had rejections of care. B. Observation On 1/19/23 at 11:45 a.m. Resident #56 was observed in the dining/activity room. The resident had an abrasion to the left side of his forehead. Resident #56 was observed to walk throughout the memory care/secured unit during the duration of the survey period without staff assistance contrary to the resident's identified need of limited physical assistance needed from one person as identified by the MDS assessment. C. Record Review The review of Resident #56's medical record identified Resident #56 had a resident to resident altercation with another resident on 12/18/22 and continued to exhibit intimidating behaviors towards that resident in the days following. The altercation was prompted when Resident #56 was walking without assistance in his room and tripped on his roommate's (Resident #32) walker. The 12/20/22 nursing note read hospice added scheduled ativan (antianxiety medication) and seroquel at night due to increased agitation. The 12/22/22 nursing note the CNA reported to the nurse that Resident #56 did not eat breakfast, had some lunch, but slept through dinner. The note read hospice recently ordered the resident lorazepam (ativan) 0.25 ml (milliliters) tid (three times a day.) According to the note, the resident appeared to be lethargic, and slept most of the day. The 12/27/22 nursing note read the nurse spoke with hospice regarding the resident's falls and drowsiness/lethargy from recent medication changes. The January 2023 CPO directed staff to observe for side effects of disorientation/confusion, lethargy and drooling related to anti-psychotics (seroquel) and for side effects of drowsiness, slurred speech, and dizziness, restlessness and agitation related to the anti anxiety medications (ativan). The fall care plan, initiated on 11/1/22, read Resident #56 was a high risk for falls. The care plan directed staff to anticipate and meet his needs. The review of the fall care plan did not identify the increase in the resident's fall risk due to his change in medications with potential fall risk side effects. The increase in fall risk due to his medications was not identified till 12/27/22, after the resident fell three times on 12/26/22. The fall care plan intervention, initiated on 12/27/22 (after the below identified falls), directed staff to help Resident #56 ambulate related to his medications and continue physical therapy. No additional interventions were implemented for falls till after the resident fell on 1/17/23. The review of the care plan did not identify the resident needed limited physical assistance of one person for ambulation since 11/10/22 when it was last identified in the MDS assessment. 1. Resident falls on 12/26/22 The 12/25/22 at 9:16 p.m. nursing note read Resident #56 had been getting out of bed and ambulating into the main living space for a few minutes then walked back to his room. The staff would assist him back to bed only for him to get back up again. According to the note, the in and out of bed behavior occurred three times in an hour and the resident remained restless. Fall #1 The 12/26/22 at 6:30 a.m. progress note read the resident was found on his bedroom floor and had slipped on a puddle of urine. The note indicated the resident had open lacerations to both elbows and there was blood on both the resident and the floor. The 12/26/22 at 6:32 a.m. incident report identified the fall was not witnessed. According to the incident report the immediate action taken was to assess the resident and assist him to the shower to clean up prior to dressing both elbows. Injuries were identified. The resident had a laceration to his right elbow and a skin tear to his left elbow. The predisposing factors to the fall included a wet floor, the resident was incontinent, and the resident had recent change in medications and a recent room change. A note dated 12/27/23 was included in the incident report. According to the note, a hospice medication review was suggested because the resident had recent medication changes that may have resulted in the resident being too sedative. The resident was placed on 72-hour alert charting for a fall and staff monitored skin tears until healed. The report indicated physical therapy would continue services. The 12/26/22 Morse fall scale late entry note identified the resident was at high risk for falling. According the note, Resident #56 had a history of falls. The morse scale note read the resident did not use ambulatory aids, he had normal gait and was forgetful of own safety limits. Fall #2 The 12/26/22 at 6:10 p.m. progress note read Resident #56 had a second fall on 12/26/22. The fall was witnessed in the dining/activity room with multiple staff and residents present. According to the note, the resident bent over to pick up something that fell on the floor, lost his balance and continued forward onto the floor. The resident was not injured in the fall. The note identified the resident was able to ambulate to his room for full assessment without difficulty. The note revealed the resident is noted to be drooling from mouth but no oral injuries noted. The resident's vital signs were stable and staff continued to monitor. The 12/26/22 at 6:10 p.m. fall incident report did not identify immediate actions taken after the fall. According to the incident report predisposing physiological factors included drowsiness, weakness and sedation. The resident was ambulating without assistance. The interventions as identified on 12/27/22 were identified as physical therapy to continue to treat and occupational therapy to evaluate; request medication review with hospice; and, continue all other current interventions. The 12/26/22 at 6:10 p.m. post fall assessment identified the resident was wearing shoes at the time he fell and was witnessed by staff to fall when he attempted to pick up an object off the floor. The object was not identified in the assessment. According to the post fall review assessment the resident was recommended to need assistance with ambulation due to his new medications. Fall #3 The 12/26/22 at 10:50 p.m. nursing note identified Resident #56 had a third fall on 12/26/22. The fall was unwitnessed. Resident #56 was found on the floor beside his bed. Resident laying on his left side beside bed. The resident responded to verbal stimuli and answered questions appropriately but slowly and needed time to respond. The resident's vital signs were stable and there were no injuries identified. According to the note the resident attempted to get out of bed without assistance and fell. The note read the resident has had recent increase in anxiety and antipsychotic medications, causing resident to have decreased reaction times, increased sedated symptoms,and balance concerns. The fall incident report identified no new injuries as a result of the 12/26/22 at 10:45 fall. Predisposing factors included poor lighting; the resident was drowsy, the resident had imbalanced gait, The resident was ambulating without assistance and had recent medication changes. The instant report read the resident has had a recent increase in anxiety and antipsychotic medications which are causing the resident to have a decreased reaction time; increased sedation symptoms and balance concerns. According to the fall report, current interventions were to continue; request a medication review; occupational therapy to evaluate and treat; and continue with physical therapy. According to the incident report, staff needed to assist the resident with ambulation due to the new medications, and frequent checks on the resident while in his room. The 12/26/22 post fall review read the resident had an increase in his medications, there was poor lighting, and the resident was not wearing footwear including socks at the time of the fall. The post fall review identified the resident could not demonstrate he could use the call light in the room or in the bathroom. The room was dark except for the light for the television. 2. Fall on 1/17/23 The 1/17/23 at 1:54 a.m. nursing note read Resident #56 had been restless the past evening. According to the note, the rest was fidgeting with covers all night. He was getting up and down out of bed, and was confused. Staff provided multiple and frequent attempts to redirect and help the resident be comfortable in bed, but the behaviors did not stop. The resident was given a PRN (as needed) dose of lorazepam on 1/17/23 at 1:05 p.m. The note indicated his behaviors continued at time of note and would continue to monitor. The 1/17/23 at 4:17 a.m. nursing note read the resident's restlessness continued so he was brought into the common area. The resident continued to be restless in the common area for a while till fell asleep in a chair. The resident was then escorted back to his room where he had ongoing restlessness but fewer episodes. The 1/17/23 nursing note read Resident #56 had an unwitnessed fall in his resident room on 1/17/23 at 10:30 p.m. According to the note the staff heard a noise, entered the resident's room and found the resident on the floor near his bed, laying on his left side near a wooden chair. The note identified the resident's brief was off and next to him on the floor. The resident sustained injuries as a result of the fall. Resident #56 was noted to have bleeding noted from his head and right hand. An assessment was conducted and the resident was identified to have a laceration to his forehead above left eye 1.0 centimeters (cm) long x 0.5 cm wide; right first metatarsal knuckle 0.5cm wide and his anterior right wrist 0.5cm wide. The 1/18/23 nursing note read the physician visited the resident on 1/18/23 after the resident hit his head and cut his right wrist/hand. The physician discontinued the resident's ativan due to the resident sleepier in the mornings. The note revealed the staff was seeing the resident's behaviors more after 2:00 p.m. than in the morning. According to the note the resident presents sundowning behaviors and he gets more active after 2:00 p.m. and stays up late. The post fall assessment identified the resident's unsteady gait, history of falls, change in medications, cognitive deficits and an infection may have contributed to the resident's fall. The assessment identified the resident was not wearing footwear, including socks, at the time of the fall. The assessment indicated there was poor lighting in the room at the time of the fall and a fall mat was beside the bed. According to the post fall assessment the interdisciplinary team recommended interventions [TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and interviews, the facility failed to ensure one (#42) out of one resident who required dialysis care, out of 41 sample residents received dialysis services consistent with professional standards of practice. Specifically, the facility: -Failed to blood pressure (BP) measurements were not checked on the right arm where the dialysis fistula/shunt was located; and, -Failed to ensure communication between the dialysis center and the facility. Findings include: I. Facility policy and procedure The Hemodialysis policy and procedure, dated 2022, was provided by the interim nursing home administrator/corporate director of operations (INHA/DO) on 1/26/23 at 12:35 p.m., and included the following: The facility will assure that each resident receives care and services for the provision of hemodialysis consistent with professional standards of practices. This will include ongoing communication and collaboration with the dialysis facility regarding dialysis care and services. The facility will coordinate and collaborate with the dialysis facility to assure that the resident's needs related to dialysis treatments are met and there is ongoing communication and collaboration for the development and implementation of the dialysis care plan by nursing home and dialysis staff. The resident will not receive blood pressures or laboratory sticks on the arm where the dialysis access device was located. II. Resident #42 status Resident #42, age younger than 60, was admitted on [DATE], and then readmitted on [DATE]. According to the January 2023 computerized physician orders, diagnoses included diabetes, end stage renal disease, dependence on renal dialysis, and vascular dementia. The minimum data set (MDS) assessment, dated 10/3/22, revealed the resident was severely cognitively impaired with a brief interview for mental status (BIMS) score of six out of 15. He required extensive assistance with most activities of daily living (ADL), had inattention behavior continuously present, and no psychosis or behavioral symptoms. The current MDS failed to identify the resident received the special treatment and program of dialysis while he was a resident. A. Record review The care plan, initiated 1/16/2020 and revised on 1/11/23, identified the resident needed hemodialysis related to end stage renal disease on Tuesdays, Thursdays and Saturdays at a local dialysis center. The approaches included checking and changing the dressing daily at the access site, the Dialysis Communication Record was sent to the dialysis center with each appointment, and return of the form was ensured after the appointment was completed, and do not draw blood or take blood pressure in arm with graft. In addition, the resident would often not let staff remove the dressing after dialysis, and the dialysis wanted a more forceful approach to remove the dressing, but it was explained to the dialysis staff that the resident had the right to refuse. The electronic medical record revealed a section titled, Tasks, that included resident specific interventions and included ADL care requirements and vital signs information that certified nurse aides (CNA) and nursing staff could refer to for planned care. The documentation did not include specific instructions to not check BPs on his right arm. 1. Current orders The CPO revealed the following orders: -Consistent carbohydrate renal diet, no concentrated sweets. The order was started 1/5/23. -1500 milliliter (ml) fluid restriction every 24 hours and document amount consumed every 12 hours. The order was started 1/25/23. -Auscultate and palpate arteriovenous (AV) fistula shunt, check for bruit and thrill x2 in eight hours post-return from dialysis in the evenings every Tuesday, Thursday, and Saturday. The order was started 2/4/21. -Dialysis three times a week at (name of dialysis center) on Tuesday, Thursday and Saturday mornings at 9:00 a.m. Monitor vital signs, weights, nutritional and fluid needs or other restriction, lab results. The order was started 2/1/2020. However, there were no orders with instructions not to check blood pressures on his right arm where the AV fistula was. 2. Dialysis clinic communication The Dialysis Communication Forms and dialysis clinic notes were reviewed from 11/1/22 through 1/24/23, and revealed the following: The dialysis clinic notes, dated 11/1/22, documented Patient came into treatment with soiled briefs that appeared to be old/dried/caked. This has been an ongoing problem. There was no communication form for 11/8/22, 11/10/22 or 11/12/22. The dialysis clinic notes, dated 11/12/22, documented Patient arrived to treatment on 11/12 with soiled dressing still on access from 11/10. There was no communication form for 11/26/22. There was no communication form for 12/1/22 or 12/3/22. There was no communication form for 12/10/22, 12/17/22 or 12/24/22. On 1/7/23, the dialysis center reported the resident requested to be taken off dialysis early that day. There was no communication form for 1/10/23. In total, there were 10 dialysis appointments during the 85-day period that did not include communication between the facility and the dialysis center. 3. Blood pressure checked on right arm The Blood Pressure Vital Signs Summary was reviewed from 9/17/22 through 1/26/23 and revealed the following: On 9/17/22, the BP was checked on the right arm twice, at 7:58 a.m. and 3:24 p.m. On 9/24/22, the BP was checked on the right arm. On 11/29/22, the BP was checked on the right arm twice, at 8:24 a.m. and 4:06 p.m. On 11/30/22, the BP was checked on the right arm. On 12/1/22, the BP was checked on the right arm twice, at 8:30 a.m. and 4:16 p.m. On 12/6/22, the BP was checked on the right arm. On 12/17/22, the BP was checked on the right arm. On 1/5/23, the BP was checked on the right arm. On 1/10/23, the BP was checked on the right arm. B. Resident observations On 1/24/23 at 2:22 p.m., the resident's room was observed and did not include any posted instructions or guidance to not check BPs on his right arm. On 1/25/23 at 5:00 p.m., Resident #42 was sitting in his wheelchair in the hallway near the nurses' station, wearing a short-sleeved shirt that revealed his AV shunt in his upper right arm. It was open to air and appeared clean and dry. On 1/26/23 at 10:16 a.m., Resident #42 was pushed in his wheelchair to the reception area of the facility by registered nurse (RN) #1 to wait for transportation to the dialysis clinic. The Dialysis Communication Form was crumpled up and sticking up out of a bag that was draped over the back of his wheelchair handles. At 10:36 a.m., he left the facility with the transportation service to go to dialysis. III.Staff interviews Licensed practical nurse (LPN) #2 was interviewed on 1/26/23 at 1:50 p.m., and he said CNAs would refer to the electronic medical records Tasks section for specific interventions and guidance for each resident for vital signs. He said if there was anything unique to the resident, that was where the information would be located. CNA #6 was interviewed on 1/26/23 at 1:58 p.m., and she said she routinely worked with Resident #42. She said there was not any documentation or [NAME] type form for CNAs to follow about resident specific information. She said they verbally told each other during shift report that a BP could not be checked on Resident #42's right arm because of his dialysis catheter. She said if there was something more formal and written down with specific information, she did not know what that was or where she would look. RN #4 was interviewed on 1/26/23 at 6:06 p.m., and she said she had worked at the facility for over 15 years. She said both nursing and CNA staff took vital signs in the facility, and it was not assigned or designated to be completed by either CNAs or nurses. She said she preferred to check the vital signs herself on the residents she cared for. LPN #4 was interviewed on 1/26/23 at 7:54 p.m., and she said she routinely worked with Resident #42. She said both CNAs and nurses check vital signs in the facility, and she showed each of her CNAs his fistula and instructed them not to take the BP on his right arm. CNA #10 was interviewed on 1/26/23 at 7:55 p.m., and she said she knew Resident #42 well. She said residents who had a dialysis catheter should have their BP checked on the opposite arm that the shunt was in, so for Resident #42, it should be checked on his left arm. The DON was interviewed on 1/26/23 at 6:12 p.m. and she said she had worked at the facility for approximately one week. She said she thought communication between the facility and the dialysis clinic was facilitated by a communication sheet that was sent with the resident from the facility, and then returned with them from the dialysis clinic. It should include information such as the resident's blood glucose, vital signs, amount of fluid taken off at dialysis, how the resident tolerated it, and anything significant that happened should be included in the communication. The DON was not yet aware of how effective or ineffective the communication was with the dialysis clinic, and was not aware of any concerns the facility had received regarding Resident #42. She was not aware of the 10 dialysis appointments that did not have communication forms, and said the forms were important and should be looked at by the nursing staff because there should be orders on those. If there were orders, the orders needed to be implemented. If there were no orders included, the nurse needed to note that they reviewed the form, and then it was sent to medical records to be scanned into the resident's electronic chart. The DON said if a resident had an AV fistula in their arm, the blood pressure should be checked in the opposite arm because there was a risk of damaging the dialysis catheter access site. She said she was not aware Resident #42 had numerous BPs checked on his right arm that had his fistula, and said the facility should provide education for the CNAs and nurses on when not to check a blood pressure on a limb, and gave the example for residents who had a dialysis catheter, or perhaps had a mastectomy (removal of breast) and was at risk for lymphedema (swelling due to fluid).

Based on observations, record review and staff interviews, the facility failed to ensure one (#42) of 10 residents reviewed for medication administration of 41 sample residents were free from a significant medication error that involved insulin. Specifically, the insulin pen was not primed prior to injection for Resident #42. Findings include: A. Facility policy and procedure The Medication Administration and General Guidelines policy and procedure, dated November 2022, was provided by the interim nursing home administrator/corporate director of operations (INHA/DO) on 1/26/23 at 6:53 p.m. It included medications were administered as prescribed, in accordance with State regulations using good nursing principles and practices. The proper steps in the administration of medications included adherence to the six rights of medication administration including: 1) Right dose 2) Right route 3) Right resident 4) Right Medication 5) Right time 6) Right documentation B. Medication error 1. Observation Licensed practical nurse (LPN) #3 was observed preparing and administering medications to Resident #42 on 1/25/23 at 5:13 p.m. The resident's order was for insulin Lispro solution 100 units/milliliter; inject seven units subcutaneously three times a day. Call the doctor if BG (blood glucose) is less than 80 or consistently above 450. Hold if BG is less than 120. The order was started 1/5/23. According to the manufacturer's specifications, provided by the INHA/DO on 1/26/23 at 6:53 p.m., the following steps should be taken prior to administering the medication: Prime before each injection. Priming your pen means removing the air from the needle and cartridge that may collect during normal use and ensure that the pen is working correctly. If you do not prime before each injection, you may get too much or too little insulin. To prime your pen, turn the dose knob to select two units. Hold your pen with the needle pointing up. Tap the cartridge holder gently to collect air bubbles at the top. Continue holding your pen with needle pointing up. Push the dose knob in until it stops, and ' 0 ' is seen in the dose window. Hold the dose knob in and count to five slowly. You should see insulin at the tip of the needle. If you do not see insulin, repeat priming steps. At 5:22 p.m., the LPN dialed seven units into the dose knob on the pen and administered the insulin to the resident. She did not prime the pen prior to injection. 2. LPN #3 interview LPN #3 was interviewed on 1/25/23 at 5:24 p.m. She said she did not routinely prime insulin pens prior to dialing in the amount of insulin that was ordered to be administered and stated, Only when the pens are brand new. She said she had not been taught to prime insulin pens prior to administering the insulin, and was not aware that they needed to be primed. C. Director of nurses (DON) interview The DON was interviewed on 1/26/23 at 6:12 p.m., and she said she had been working at the facility as the DON for approximately one week. She said new nurses to the facility needed at least two to three days of orientation with the medication cart in order to become familiar with the residents, their medications, and the electronic medication administration record. The DON said insulin pens were supposed to be primed with two units of insulin prior to injecting the ordered amount of insulin in order to ensure air was purged from the syringe and that the correct amount of medication was administered. The DON said the LPN made a mediation error by not priming the insulin pen and should write an incident report about the error, document what happened, notify the physician, the family, the DON and write a progress note about it.

Based on interviews and record review, the facility failed to take action to resolve grievances of the resident council group, affecting 10 (#34, #24, #22, #23, #35, #60, #62, #54, #7 and #68) of 41 sample residents, and potentially affecting all the residents who lived in the facility. Specifically, the facility failed to follow-up with concerns that were brought up by the group of residents during the resident council meetings. Findings include: I. Resident group interview A resident group interview was conducted on 1/23/23 at 10:30 a.m. with 10 residents who were resident council officers, regularly attended resident council meetings, and were identified by the facility as interviewable. Residents said the facility did not have enough staff. They have good staff, just not enough of them. As a result, It takes longer to respond to a call light. One resident said his roommate was in bad shape and he had to keep an eye on him because he was unable to call staff for assistance. One thing we lack is a bath aide, because baths are a problem. I have a bath scheduled today but don't know if I'll get it. Residents said baths had been a problem for about two months. Residents said they had baths scheduled but did not get them. They hope to get their baths. Residents said sometimes the traveler/agency staff were less than respectful. One resident said a certified nurse aide (CNA) who gave her a shower spoke to her in an undignified manner. The residents said the food was sometimes horrendous. There was not enough fresh food, too much processed food, even the fruit is canned. Residents said some people needed help to cut their meat and there were no staff assigned to that, and there you go again without enough help. If they forget something (in the dining room) you have to wait and raise your hand for something as simple as ketchup. The food was sometimes burned. We don't get anything made from scratch. Even the mashed potatoes and scrambled eggs are powdered. They run out of food sometimes. So they will substitute something, and residents get grouchy, irritable, and nasty with cooking staff. The highlight of our days is eating and it's not as pleasant as it should be. The residents said they did not know what the next meal would be. They have these awful menus they get from some company but they have to follow the silly menu, and there was too much repetition. Residents gave examples of chicken fingers served three times a week, fish twice a week, the same vegetable for a month, then they would switch to a different vegetable. One resident said he had to buy his own food. Residents said snacks were not offered, other than a tray on the nurses' station and then certain people will come along and take them all and there's not enough left for others and that's not good. They don't go around and offer snacks to everyone. They don't replenish the supply. Residents said they were not served snacks they liked, such as candy bars, Goldfish, Fig Newtons, and fresh fruit. They said the staff said they had to get fresh fruit donated in order to serve it. They sometimes had bananas, but they were overripe and black when they came from the supplier. One resident said she used to eat blueberries every day when she lived at home. Another resident said it would be nice to have bananas, raspberries, strawberries and fruit smoothies. These issues have been reported. One resident said he had submitted multiple complaint forms but nothing gets done from the kitchen. (Cross-reference F804, palatable foods.) Residents said their rooms and bathrooms were not clean enough, and they did not have enough clean towels and washcloths. Residents said there were not enough places to meet with family or in private indoors when the weather is cold. The facility rooms were very small, they had roommates, and had no private place to talk on the phone or visit with family and friends. The conference room was a resident activity room, but it was taken from resident access without asking. Residents said they were promised by management yesterday (1/23/23) that the conference room would be returned to the residents for their private use. Residents said staff had taken over the common areas for offices and/or storage. You can't even get into the activities offices. Staff need to get rid of old puzzles missing pieces and get a couple of new ones. Too much crap, that's what's wrong with the staff offices. They said the South hall phone did not work. Residents said there were not enough activities staff. On Sundays we don't have any activities, only manicures. Residents said they would like more checkers, cards and chess games, and a reading club. These activities were suggested and never seemed to be offered, only kindergarten (juvenile) crafts and many residents were not interested. Some residents said they would like more bingo with better prizes, and other residents said they would like more other things besides bingo. The residents reiterated that these issues had been shared with staff at one point or another. Residents said the facility did not take action on the grievances and suggestions of the resident group. II. Resident council meeting minutes The resident council minutes reviewed for the past six months revealed the following: A. 7/1/22 - residents were told by the former dietary manager they could only get fresh fruits and veggies from Costco, that activities would be getting Palisade peaches and make a peaches and cream dessert out of them. Residents were happy with that. They were working on a contract with another farm. No other resident concerns were documented. There was no discussion of old business. B. 8/15/22 - residents said dietary staff never served what they said was going to be on the menu. Residents said they would like to have peaches bought, even with the donation. Residents asked maintenance staff about adding the different channels they had voted on to meet their interests. The maintenance manager said he was waiting to hear back from the company. C. 9/22/22 - residents said nursing staff need more help at night. They were not getting their baths on schedule. Dietary staff were serving too much pasta, there were still no fresh fruits or vegetables, wait time was 25 minutes for meals, residents sometimes did not know what they were having for meals, and meals were not posted. Residents requested more volunteer workers for activities. D. 10/20/22 - dietary staff did not post menus, salads were great, meals were late, residents requested hand wipes, the new dietary manager said he would take care of those concerns and he would be getting fresh fruit in. E. 11/17/22 - regarding the dietary department, the new DM introduced himself, residents said they were not receiving tickets from certified nurse aides (CNAs), the Thanksgiving dinner menu was discussed, the DM suggested if residents wanted to eat quickly they could eat in the dining room. Regarding housekeeping, residents said corners were not getting cleaned very well, the corridor was dirty, they had seen spiders, and dusting needed to be done. F. 12/22/22 - residents requested more green salad, the holiday meal menu was discussed, the vents needed to be cleaned, and the residents would like to get a pool table. G. 1/19/23 - regarding the nursing department, residents expressed a concern about bathing. Regarding the dietary department, the DM said the oven was out of order, he was training staff not to burn rolls, serve less processed food, no sauces or gravy to go with pork or other meats, reviewed the weekend idea of take-out Saturday, having a suggestion box for meals. The residents had several ideas and suggestions about activities. III. Facility follow-up On 1/25/23 at 10:20 a.m., the interim NHA provided the one concern form generated from the resident council. She said she had checked the grievance log for the last six months and this was all she found, from their most recent meeting. She said in the future they would be following up with action plans. The Concern Form, dated 1/24/23, read, Residents not receiving baths. Residents stated had burnt rolls. The name was resident council and the best way to contact the individual was in the resident council president's room. The concern form action/resolution read, In resident council (INHA/DO) explained that they have a plan set in place to better bath schedule. (The dietary manager) has been working on training staff better. The form was signed on 1/24/23 by the interim NHA. There was a check-mark next to the question Is the individual who raised the concern satisfied with the resolution? -There was no evidence of detailed plans to address these two, or any other, resident concerns. There was no resident signature or evidence of a discussion with the resident council president or follow-up with the resident group. The INHA/DO and interim NHA were interviewed about the findings above on 1/26/23 at 4:30 p.m. They said they would follow up and address the resident concerns from the group interview. The interim NHA said the conference room would be turned back into the residents' space, with a sitting area, private phone, and library. One of the residents was interested in being the librarian and starting a reading club. They said resident grievances had not been investigated and resolved previously because of the lack of leadership from the former administration. They planned to provide education for the leadership team, and a grievance logging and tracking system to ensure timely response time and proper follow-up.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and interviews, the facility failed to consistently ensure a safe, clean, comfortable, homelike environment in resident rooms, shower/tub rooms and common areas in four of four neighborhoods. Specifically, the facility failed to ensure: -Resident rooms and bathrooms were properly cleaned and maintained; -Wash cloths and towels were available in residents' bathrooms; and -Shower/tub rooms were functional, safe and properly cleaned. Cross-reference F565, grievances of the resident group. Findings include: I. Observations during the initial facility tour on 1/19/23 at 9:30 a.m., and throughout the survey on 1/22, 1/23, 1/24, 1/25 and 1/26/23, revealed resident rooms and bathrooms were not thoroughly cleaned and needed repairs, and clean towels and wash cloths were not readily available for residents. Specifically, dust build-up and debris were not swept from under beds and furniture, toilets were soiled or stained and not properly cleaned, privacy curtains were soiled and/or stained, bedside and over-bed tables were sticky with dried fluids and food, window blinds did not open and close properly, fall mats were sticky and covered with hair and debris, some windows did not properly open and close, and there were frequently insufficient wash cloths or hand towels in residents' bathrooms. Walls, doors and heat registers were damaged and needed repair. The linen closets were not stocked with wash cloths or sufficient towels for residents' use. Nursing staff were observed looking for wash cloths they were unable to find. The Hoyer and [NAME] mechanical lifts stored in the North and South hallways were soiled with white matter and other debris on the surfaces residents would hold or put their feet, with white matter and debris, and needed to be cleaned. The windows in the dining area of the [NAME] secure neighborhood were opaque and unsightly due to lime deposits, and needed to be cleaned. II. The environmental tour was conducted with the maintenance manager (MM) on 1/26/23 at 12:05 p.m. A. In the South hall shower room: -Black mold/mildew was observed along the entire bottom edge of the shower area; -The safety belt in the lift chair for the tub lift was worn and rough, creating a skin tear hazard; -The toilet had black mold/mildew around the water line and under the rim, readily visible from across the room; -The toilet seat was stained, damaged, unsightly, and needed to be replaced; -There was no toilet paper or toilet paper holder near the toilet; -The ceiling plaster was damaged and unsightly. The MM got a roll of toilet paper and placed it on the back of the toilet. He wiped the shower grout with a tissue revealing a brown substance, and said he would notify housekeeping that the shower needed to be cleaned. He said he would replace the toilet seat, add a toilet paper holder, repair the ceiling, and notify housekeeping to clean the toilet. He said he would start pressure-washing the shower tiles quarterly and as needed. B. In the North shower room: -The tub was not working; -The ceiling light above the tub was not working, flashed on and off when the switch was turned on, and there was standing water inside the light fixture cover; -Orange mildew was observed around the bottom back edge and right corner of the shower. The MM said the tub was not working and parts would be ordered. He was not sure when the tub would be functional. He said a light replacement was on order, with no confirmed date of receipt, but hopefully 2/3/23. The MM said the roof and ceiling had been leaking, and he had repaired the roof but was waiting to see if the repairs he had done would stop the leaking. He could not repair the ceiling, light or tub until the roof repairs were confirmed, either next time it rained, or when he got up on the roof with a hose to test it. He said in the meantime residents and staff were still using the shower portion of the shower/tub room, because the light still worked in the shower. He was unable to speak to whether or not this was safe, or when the repairs would be done, but he would discuss with the nursing home administrator (NHA). C. A tour of accessible resident rooms revealed examples of the concerns in most rooms in the facility. In room [ROOM NUMBER]: -The window latch in the bathroom did not work; -The picture window did not open and close properly; -The fall mat was rolled up, covered with debris, and needed to be wiped down and the floor swept underneath; -The heat register and walls were damaged and needed touch-up paint; -The bathroom was full of wheelchairs and medical equipment. The sink was inaccessible to the residents, and difficult for caregivers to access. The toilet bowl had a ring around the water line and dark spots inside that looked like black mold; -The privacy curtains were stained and soiled. The MM said he would repair the items and notify housekeeping. He said he was not sure on the cleaning schedule for privacy curtains but he would find out. In room [ROOM NUMBER]: The privacy curtain on the window side did not pull closed, and the privacy curtain on the door side was soiled and stained. The MM said he would pull them down and replace them. In room [ROOM NUMBER]: There was no privacy curtain or track for the bed by the window. The MM said it had probably been taken down when the room was repainted, and he did not realize it had not been replaced. He said he would replace the track and the curtain immediately. In room [ROOM NUMBER]: -There were no wash cloths in the residents' bathroom; -The over-bed table for the resident by the window had a damaged surface with half the plastic cover pulled off, and was uncleanable. The maintenance manager documented the above concerns, said he would follow up with the housekeeping supervisor and the NHA, and would repair what he could as soon as possible.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to ensure level I and level II preadmission screening and resident review (PASRR) were completed for four (#4, #5, #37 and #57) out of five residents reviewed for PASRR to gain and maintain their highest practical medical, emotional, and psychosocial well-being out of 41 sample residents. Specifically, the facility failed to: -Ensure Resident #37, with a known psychological disorder, was properly assessed with a PASRR level I or level II assessment; -Ensure Resident #5 and #57 had a level I PASRR screening completed timely; and, -Have the training and knowledge to follow up with PASRR screening identified concerns for Resident #4. Findings include: I. Resident #57 A. Resident status Resident #57, age [AGE], was admitted on [DATE]. She resided in the secured/memory care unit. According to the January 2023 CPO, diagnoses included Wernicke's encephalopathy (a brain disorder causing confusion), anxiety disorder, and delusional disorders. The 12/19/22 MDS assessment revealed the resident had moderate cognitive impairment with a brief interview for mental status (BIMS) score of nine out of 15. The resident exhibited disorganized thinking and inattention. B. Record review The review on the Resident #57 medical records on 1/23/23, did not reveal evidence that a level I PASRR preliminary assessment was completed since the resident's 9/7/22 admission, to determine if the resident qualified for additional services. C. Staff interview The social services director (SSD) was interviewed on 1/25/23 at 10:25 a.m. The SSD confirmed Resident #57 did not have a level I PASRR completed. The SSD said she did not know she was responsible for all the facility residents' PASRRs. She said she was only completing the PASRRs for residents not residing on the memory care/secured unit. She said the life enrichment coordinator LEC was assigned to do the PASRRs for the memory care unit but she has not had access to the program to submit the PASRR. The SSD said the LEC had been requesting access for months. The SSD said she just found out from management that she should have been completing all the PASRRs till the LEC had access. The SSD was interviewed again on 1/25/23 at 4:35 p.m. She said the LEC now had access to complete the PASRRs for the residents on the memory care unit and as of 1/25/23 she submitted all needed PASRRs. D. Facility follow up The authorization request summary and level I PASRR screening for Resident #57 was provided by the interim nursing home administrator/director of operations (INHA/DO) on 1/24/23 at 5:15 p.m. The authorization request identified the level one screening was submitted on 1/24/23 at 4:56 p.m. -The screening was done four months after the resident was admitted to the facility. A PASRR submission list, dated 1/25/23, was provided by the SSD on 1/25/23 at 6:23 p.m. The list identified six other residents that required level I screening. The level I screenings were submitted on 1/25/22. II. Resident #4 A. Resident status Resident #4, age [AGE], was admitted on [DATE]. According to the January 2023 computerized physician orders (CPO), the diagnoses included major depression disorder, post-traumatic stress disorder (PTSD), unspecified psychosis not due to a substance or known physiological condition, anxiety disorder and other specified mental disorders due to known physiological condition. The 12/30/22 MDS assessment revealed the resident had severe cognitive impairment with a BIMS with a score of seven out of 15. He required supervision with all activities of daily living (ADLs). B. Record review The review on the Resident #4's medical records on 1/23/23, did not reveal evidence that a level I PASRR preliminary assessment was completed. The resident was admitted to the facility on [DATE]. The authorization request summary and level I PASRR screening for Resident #4 was provided by the interim nursing home administrator/director of operations (INHA/DO) on 1/24/23 at 5:15 p.m. The authorization request identified the level I screening was submitted by the SSD on 1/4/23 but the review of the outcome read Technical Denial however the PASRR screening indicated the resident had major mental illness and used antipsychotic, mood stabilizer, or antidepressant. C. Staff interview The SSD was interviewed on 1/25/23 at 10:25 a.m. The SSD said she did not know why the resident denied or what the technical denial meant. She said she received notice of the technical denial on either 1/9/23 or 1/10/23 but she did not know the phone number on who to contact in relation to PASRR. The SSD said he should have qualified for a PASRR level II and a telehealth appointment set up because of his diagnosis. The SSD said she had only been at the facility for four months and would have to ask her corporate consultant on how to proceed. The SSD was interviewed again on 1/25/23 at 4:35 p.m. She said today (1/25/23) her consultant provided her with a phone to follow up with PASRR concern for Resident #4 found out why his authorization form read there was a technical denial. The SSD said she forgot to upload the resident's history and physical from the physician. The SSD said the concern had now been corrected and they will use the 1/4/23 level one date. She said if she had not corrected the concern, the resident would have been at risk for not receiving services. The SSD said her corporate consultant would provide her with a PASRR training in the next couple of days. III. Resident #37 A. Record review Resident #37 was admitted on [DATE] with a diagnosis of bipolar disorder, according to the 12/9/22 MDS assessment. She was cognitively intact with a BIMS score of 14 out of 15, and had no behavior or mood symptoms. She took antipsychotic medication daily. However, MDS section N450 documented no antipsychotics were received and no gradual dose reduction or medication review was needed. No PASRR level I or II could be found in the resident's medical record. B. Staff interview The SSD was interviewed on 1/25/23 at 9:45 a.m. She confirmed that Resident #37 had a bipolar diagnosis, and would probably need a level II, but she checked and found that no level I was done. She said it was her understanding the level I was due within 30 days of the resident's move-in and they did not think Resident #37 would stay beyond 30 days. The SSD said, It's my fault; I'll do it right now. This is important so residents can be evaluated for psychiatric reasons. C. Facility follow-up The SSD provided a copy of the level I authorization request summary she had submitted for Resident #37 on the afternoon of 1/25/23. It documented Resident #37 had a diagnosis of bipolar disorder, indications of a major mental illness related to bipolar disorder of her history, and was taking Seroquel and Valproic Acid Solution. The SSD also provided a copy of the response from the utilization review and management contractor, dated 1/25/23, which documented, A decision cannot be made at this time because we were unable to obtain the necessary information. To process the review, the following information was needed within five business days: The most recent history and physical, or any medical documentation with a review of systems and vitals (actual vital data/vital #'s are required), from within the last 6 months. The SSD said she had not read the letter and was not aware additional information was needed from the utilization review and management contractor. She acknowledged this might be the reason other PASRR level II requests had been delayed. She said she would send the follow-up information to the contractor. IV. Resident #5 A. Record review Resident #5 was admitted on [DATE] with diagnoses including unspecified dementia without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety; delusional disorders; dissociative and conversion disorders; bipolar disorder, current episode depressed moderate; and mood (affective) disorder. The 11/18/22 MDS assessment documented no level II PASRR and no major mental illness. She was cognitively intact with a BIMS score of 14 out of 15. She felt tired with little energy, had problems with sleeping and overeating, and sometimes felt down, depressed or hopeless. She had behavioral symptoms not directed toward others. She had dementia and psychotic disorder. She took antidepressants daily. There was no evidence of a PASRR level I or level II in the resident's medical record. On 11/16/22, Resident #5's medical record documented she was threatening suicide and hitting her head on the wall, saying she would go crazy if she had to stay in the facility. She was referred to the local mental health center, who could not admit her, and was then sent to the emergency room on [DATE]. She returned from the hospital the same day, after it was determined she was not at risk for harming herself or others. The resident's care plan, initiated 11/30/22 and revised 1/3/23, identified mental health diagnoses, delusions, threats of self-harm, and a history of trauma. The resident was referred to the local mental health center for counseling. Review of physician orders revealed she was started on Propranolol for anxiety on 12/5/22; and Seroquel, an antipsychotic, on 1/21/23 for bipolar disorder with behaviors and exhibited auditory and visual hallucinations. Nursing and social services notes in the resident's medical record revealed she was considering a transfer to a local assisted living facility. B. Staff interview The SSD was interviewed on 1/25/23 at 10:05 a.m. She checked and found that a PASRR level I authorization request was entered on 11/25/22, but there was no response from the contractor. She said the facility did not have a policy and procedure for follow-up with the contractor when they did not receive a timely response. They often won't respond until they have a provider for the resident to use. She said she was not even sure how to contact the contractor to see if the request was misplaced or still under review. She said she would have to check with her social services mentor. On the afternoon of 1/25/23, the SSD provided a copy of Resident #5's authorization request summary dated 11/25/22. The resident's last name was misspelled, the review outcome was technical denial, and under insurance no coverage was found (although the resident's medical record documented she was Medicaid pending and had insurance). It was documented the resident had a major mental illness although all her mental health diagnoses (see above) were not listed. She was taking Sertraline, an antidepressant medication. The SSD acknowledged she might have sent incomplete information to the contractor, and would have to contact them to find out what further information was needed in order to proceed with the request for a PASRR level II. -No further information was provided. The facility failed to ensure complete and accurate information was submitted and that PASRR level I and II assessments were completed for residents in a timely manner, in order to assess and provide mental health services.

Based on observations, interviews and record review, the facility failed to provide and deploy sufficient nursing staffing to meet the needs of residents in keeping with their comprehensive care plans, and ensure their highest practicable quality of care. Specifically, the facility failed to provide sufficient staffing to provide a dignified and respectful resident environment, keep residents free from abuse, prevent falls and accidents, provide adequate nutrition and hydration, and provide dementia care and services. Findings include: Cross-reference F565, grievances of the resident group involving care and services issues; F600, freedom from abuse; F689, falls and accidents; F692, nutrition and hydration; and F744, dementia care. I. Resident status According to the 1/25/23 Resident Census and Conditions report, 75 residents lived in the facility. For bathing, 37 residents needed assistance of one or two staff and 13 were dependent. For dressing, 69 residents needed assistance. For transfers, 60 residents needed assistance and five were dependent. For toilet use, 63 residents needed assistance and five were dependent. For eating, 71 residents needed assistance. Fifty residents had incontinence, but there were no bowel and bladder programs. Thirty-five residents had dementia and 15 had behavioral health needs. Forty-six residents received psychoactive medications, and 25 residents (one-third of the population) received antipsychotic medications. Two residents had pressure ulcers and six residents had significant unplanned weight loss. II. Resident/family interviews Resident #53 was interviewed on 1/23/23 at 11:28 a.m. and said call light response could take up to an hour, and frequently took 30 to 40 minutes. Staff had lots of turnovers, so it was hard to get to know staff, three days a week, always different. The resident said it could be uncomfortable with personal care and they felt embarrassed. Resident #37 was interviewed on 1/19/23 at 10:37 a.m. and said sometimes there was only one certified nurse aide (CNA) to cover the whole south hall. She did not remember when but she talked to the former nursing home administrator (NHA) about last incident, but she could not recall the last time she had spoken with management. She said the former NHA said they were trying everything to hire CNAs. She said the longest time she had to wait after using the call light was 45 minutes to an hour. Resident #225 was interviewed on 1/19/23 at 11:11 a.m. She said it sometimes took staff a while to answer her call light, because they're too busy. She said she had experienced incontinence as a result. Resident #18 was interviewed on 1/19/23 at 11:38 a.m. She said sometimes staff were short-handed and slow getting to her. She said she did not receive baths often enough. Resident #43's wife was interviewed on 1/24/23 at 4:30 p.m. She said she visited almost every day and assisted her husband with lunch or dinner. She said staff had told her they had 35 patients on the South hall and could not just cater to Resident #43 all day. She said they did not have enough staff to assist her husband to eat and drink. Resident #28's wife was interviewed on 1/26/23 at 1:00 p.m. She said she visited daily and assisted her husband with at least one meal. She said they did not have enough staff to assist her husband. It's hard because the CNAs are running themselves ragged. CNAs can only do so much. III. Staff interviews Registered nurse (RN) #5, who worked in the [NAME] secure neighborhood on the weekend, was interviewed on 1/22/23 at 12:45 p.m. She was working with one certified nurse aide (CNA) who was passing out lunch trays to residents. She said there were not enough staff and residents were doing without attention and residents experienced falls as a result. She said there were no activities staff on [NAME] on Friday, Saturday or Sunday, and to her, staffing levels were not safe due to resident care needs, fall risks and behavioral issues. She said they could not call on North hall staff to help because they were short-staffed too. She said things were good until the former administration took over, then it became a nightmare. She said some of their good veteran staff had left and gone to work at other facilities. She said the former interim director of nursing (DON) had been helpful, and the new DON had been back to [NAME] several times to check the lay of the land, but normally the managers on duty never stepped foot in the [NAME] neighborhood. RN #5 said that on Willow, There should always be two CNAs, but there are not. I know the night nurse has complained too. She said they did not have a good system for alerting staff that they needed assistance, with their antiquated phone system. She said it was impossible for staff to leave for lunch because they would be putting their residents and team members at risk. She said one resident on [NAME] got agitated and aggressive, so they had to watch him closely. CNA #6 was interviewed on 1/25/23 at 3:40 p.m. She said there were only two CNAs on the south hall and she felt at least three CNAs and an RA (resident assistant) would help out because there are lots of residents here. There are four residents who need two-person assist on the south short hall. It's hard to manage. Showers get put to the side sometimes. Sometimes I'll have eight showers to do in a day. I've talked to them about getting more CNAs on this hall and they've talked about it. With not as many CNAs it's hard; having the CNA class here has been very helpful. RN #2 was interviewed on 1/22/23 at 2:20 p.m. She said she and CNA #2 were typically the only staff on North hall on the weekends. She said they worked well together and had a system to get residents' needs met, but they had to prioritize care. She said residents were just not getting showers on the weekends because there were not enough staff. CNA #8 was interviewed on 1/24/23 at 9:30 a.m. She said with a full census and two CNAs on North hall, they would have difficulty getting showers done again today (Monday). She said she needed to assist four residents with their meals, who ate in their rooms and had not yet been assisted. She acknowledged their coffee and food could be cold by now. CNAs #8 and #9 and the RA were interviewed on 1/25/23 at 4:30 p.m. They worked on the North hall and said ideal staffing was at least two CNAs. They said they provided resident showers after rounds, refilled water pitchers twice per shift, morning and afternoon. CNA #8 said they tried to do rounds together so they had two people to assist with transfers when needed. They said they thought the night shift team could use another CNA. She could use someone else and weekends are tough. They said having a bath aide for each side of the building (one each for North & South) would be nice. Weekends really need more staff. LPN #3 was interviewed on 1/25/23 at 4:45 p.m. She said they usually had two nurses and two CNAs, but needed one extra person on the South hall, That would be wonderful. CNA #3 was interviewed on 1/25/23 at 4:14 p.m. She said she was often in a hurry because they did not have enough staff. She said she sometimes had to transfer residents with mechanical lifts by herself because there were not have enough staff, not from bed to chair but from chair to bed, because the surface was larger and it was safer. She said it was the same with rolling a resident in bed who needed two-person assistance, that she had had to do this alone because she sometimes could not find another staff person to help her. She acknowledged it was an accident risk but they did not have enough staff to do otherwise and meet residents' needs. She said if someone was going to get hurt, she would ensure it was her, not the resident. She said they had only one CNA at night on each hall, and with that level of staffing residents were neglected. She said they needed three CNAs and an RA on each hall (North and South). LPN #2 was interviewed on 1/25/23 at 5:04 p.m. He said on Thursdays, staffing could be kind of sketchy because there's only one CNA (on North hall) and that's not enough. He said getting CNAs hired and trained was difficult. Weekends and nights are a lot worse. One CNA isn't enough. Night shift and weekends it's not enough and residents don't get baths. We need a bath aide for each side (North and South). I've made it very clear to my CNAs, absolutely come grab me and I'll be right there. LPN #1 was interviewed on 1/26/23 at 10:26 a.m. She said they did not have enough staff on South hall, and needed three CNAs and two nurses. The South long hall was the skilled hall and almost everyone is a two-person transfer. She said, Anything can happen, especially with the residents on the skilled side being fresh out of the hospital, care would go easier and smoother if there were three CNAs and two nurses. I think three CNAs should be good, but if we had four we could have one doing showers all day. She said, Staffing could go smoother. She said there had been some call-offs and it was happening more frequently, and sometimes coverage to replace staff call-offs was limited. She added, When there's only one CNA (on South hall), there's only so much that person can do. Nurses help out, but we've still got to make sure we handle the medical portion. IV. Leadership interview The interim nursing home administrator/director of operations (INHA/DO), director of nursing mentor, and current interim NHA were interviewed on 1/26/23 at 7:15 p.m. The INHA/DO said ideal facility staffing with current census was: -Three CNAs on South hall with two nurses; -Two CNAs on North hall with one nurse; -Two CNAs on [NAME] secure unit with one nurse. They said nursing management was frequently in the facility on weekends, and it was up to facility leadership on how to structure staff in the building. They said they did not realize that four residents on North hall needed total assistance with eating until after the fact. They said they were assessing resident preferences for bathing for residents who were missing baths, to ensure they were offering at a time when residents preferred. They said their goal was to have all the residents' preferences assessed week, but they could not do so because of the survey, but hoped to have it done and updated next week. She said they reviewed with nursing staff how many staff were needed, would acquire more agency staff if needed, they were doing Indeed resume searches to look for resumes updated within the last two weeks, and were reaching out to get an RA to go through the next CNA class. Staff had been educated. They continually educated staff and reminded them to ask management for help. The INHA/DO said census and acuity were not being considered by the prior NHA. We're still determining if we have sufficient staff and it's a constant work in progress. We are increasing hourly pay, and looking at doing sign-on bonuses, which we are not opposed to. V. Record review The staffing daily sheets were reviewed from 12/1/22 to 1/26/23. The schedule called for an RA assigned to each of the three halls per shift (three total RAs). Those positions were never filled. The ideal staffing discussed by the INHA/DO for CNAs was never documented as provided. Actual CNA staffing was two for all of South hall, one for North, and one for Willow. The facility failed to provide sufficient nursing staffing to meet the residents' needs.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and interviews, the facility failed to ensure a resident diagnosed with dementia, received the appropriate treatment and services to attain or maintain his or her highest practicable physical, mental, and psychosocial well-being for six (#32, #40, #56, #57, #71 and #226) of nine residents reviewed for mood and behavior out of 41 sample residents. Specifically, the facility failed to effectively identify and implement person-centered approaches for dementia care to prevent resident-to-resident altercations. Cross-reference: F600 failure to prevent resident abuse. Specifically, to create an environment to: -Provide consistent and engaging group activities when routine activity was not available; and, -Ensure the activity environment was appropriate for all residents in the memory care unit based on the resident ' s comprehensive care plan. Findings include: I. Professional reference The Alzheimer's Association Tips for Dementia Caregivers in Long-Term or Community-Based Settings, retrieved on 2/5/23 from: https://www.alz.org/professionals/professional-providers/coronavirus-covid-19-tips-for-dementia-caregivers?_ga=2.60771437.1764019204.1600198071-1912608917.1600198071&_gac=1.254029244.1600198071.eaiaiqobchmiqfd6qvlr6wivqdbach2thgoceaayasaaegl_8pd_bwe. It read in pertinent part, Nonverbal dementia-related behaviors may be an option or response for a person living with dementia to communicate a feeling, unmet need or intention. These behaviors are triggered by the interaction between the individual and his or her social and physical environment. A response may include striking out, screaming, or becoming very agitated or emotional. The dementia care provider's role is to observe and attempt to understand what the person living with dementia is trying to communicate. Root causes of dementia-related behaviors may include: -Pain. -Hunger. -Fear, depression, frustration. -Loneliness, helplessness, boredom. -Hallucinations and/or overstimulation. -Changes in environment or routine. -Difficulty understanding or misinterpreting the environment. -Difficulty expressing thoughts or feelings. -Unfamiliarity with personal protective equipment or clothing, such as gowns or masks. Strategies to observe and respond to dementia-related behaviors include: -Rule out pain, thirst, hunger or the need to use the bathroom as a source of agitation. -Speak in a calm low-pitched voice. -Try to reduce excess stimulation. -Ask others what works for them. -Validate the individual's emotions. Focus on the feelings, not necessarily the content of what the person is saying. Sometimes the emotions are more important than what is said. -Understand that the individual may be expressing thoughts and feelings from their own reality, which may differ from generally acknowledged reality. Offer reassurance and understanding, without challenging their words, can be effective. -Through behavioral observation and attempted interventions, try to determine what helps meet the person's needs and include the information in the individualized plan of care. -Be aware of past traumas (veterans, abuse survivors, survivors of large-scale disasters). Never physically force the person to do something. Proactive strategies for addressing dementia-related behaviors It can be difficult to anticipate and respond to dementia-related behaviors in a changing environment-especially in emergency situations. However, applying some of the following strategies may help: -Provide a consistent routine. -Use person-centered care approaches for all individuals living with dementia during activities of daily living-every interaction or task is an opportunity for engagement. -Promote sharing of person-centered information across the care team. -Encourage all staff to treat individuals living with dementia with dignity and respect. -Put the person before the task. II. Facility policy and procedure The Dementia care policy and procedure, revised January 2023, was provided by the facility on 1/26/23. The policy read in pertinent part: Is the policy of the facility to provide the appropriate treatment and services to every resident who displays signs of or is diagnosed with dementia to meet his or her highest practical, physical, mental and psychological well-being. According to the policy the facility would access, develop and implement care plans through the interdisciplinary team approach that included the residents, their family, and/or resident representative to the extent possible. The care plan goal would be achievable and the facility would provide resources necessary for the residents to be successful in their goals. Care and services would be person-centered and reflect each residents individual goals while maximizing the residents ' dignity, autonomy, privacy, socialization, independence, choice, and safety. III. Resident to resident altercation on 12/18/22 between Resident #56 and Resident #32 A. Resident status 1. Resident #56 Resident #56, age [AGE], was admitted on [DATE]. He resided in the secured/memory care unit. According to the January 2023 CPO, diagnoses included Alzheimer's disease, major depression, and unspecified dementia with unspecified severity without behavioral disturbance. The 11/10/22 MDS assessment revealed the resident had severe cognitive impairment with a brief interview for mental status (BIMS) score of one out of 15. The resident exhibited disorganized thinking. The resident required extensive physical assistance of one person for transferring, dressing, and toileting. The MDS assessment revealed the resident required limited physical assistance of one person for bed mobility, walking in his room, walking in corridor, locomotion on and off the unit. 2. Resident #32 Resident #32, age [AGE], was readmitted on [DATE]. He resided in the secured/memory care unit. According to the January 2023 computerized physician orders (CPO), diagnoses included delirium due to known physiological condition, and unspecified dementia with unspecified severity without behavioral disturbance. The 12/13/22 minimum data set (MDS) assessment revealed the resident had severe cognitive impairment with a brief interview for mental status (BIMs) score of zero out of 15. The resident exhibited inattention, disorganized thinking and an altered level of consciousness. The resident did not exhibit behaviors of concern during the seven day assessment period. B. Record review The 10/31/22 Morse fall scale for Resident #56 identified the resident was a high fall risk. According the scale, Resident #56 has a history of falls, did not use ambulatory aids, exhibited weak gait and was forgetful of his own safety limits. The fall care plan, initiated on 11/1/22, read Resident #56 was a high risk for falls. The care plan directed staff to anticipate and meet his needs. Additional fall interventions were not implemented until after 12/27/22. -The review of the resident ' s fall care plan and comprehensive care plan did not identify the resident needed limited physical assistance of one person for ambulation including in his room as it was last identified in the 11/10/22 MDS assessment. An investigation of alleged physical abuse was initiated on 12/18/22. According to the investigative record, Resident #32 was in bed when his roommate (Resident #56) was documented to trip over Resident #32 ' s walker and hit Resident #32 in the face on 12/18/22 at 6:30 p.m. The investigation identified Resident #32 had injuries to his face as a result of Resident #56 tripping on his roommate's walker and then hitting him in the face. The 12/18/22 change of condition/situation-background-assessment-recommendations form (SBAR) for Resident #56 read Resident #56 started talking fast and oddly, stating Everyone wants to kill me. According to the note, Resident #56 standing over Resident #32, punching Resident #32 in the face. The 12/20/22 administration note for Resident #56, read Resident #56 was pacing and staring down another resident. The resident was placed on one-to-one monitoring and implemented a medication change to help with his agitation. The behavior care plan for Resident #56 , initiated 1/21/23, identified Resident #56 had the potential to be physically aggressive towards others related to his dementia. -The care plan did not identify the resident had an actual resident to resident altercation. The physical aggression care plan was initiated over one month after the 12/18/22 physical altercation. The 12/24/22 nursing note for Resident #32 read Resident #32 did not want to remain at the facility. According to the note, Resident #32 was afraid and not sleeping well after being hit. The 12/27/22 nursing note read Resident #32 still spoke about feeling fearful after being punched. The review of the January 2023 care plan did not identify the resident was at risk for abuse, the resident had an actual resident to resident altercation, or how to support the resident after the physical altercation. IV. Resident to resident altercation between Resident #40 and Resident #71 A. Resident status 1. Resident #40, age [AGE], was admitted on [DATE]. He resided in the secured/memory care unit. According to the January 2023 CPO, diagnoses included neurocognitive disorder with [NAME] bodies and anxiety disorder. The 11/10/22 MDS assessment revealed the resident had severe cognitive impairment with a BIMS score of one out of 15. The resident did not exhibit inattention or disorganized thinking. The resident did not exhibit behaviors of concern during the seven day assessment period. 2. Resident #71, age [AGE], was admitted on [DATE]. She resided in the secured/memory care unit. According to the January 2023 CPO, diagnoses included unspecified dementia with unspecified severity without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety. The 12/30/22 minimum data set (MDS) assessment revealed the resident had severe cognitive impairment with a BIMS) score of two out of 15. The resident exhibited inattention and disorganized thinking. The resident did not exhibit behaviors of concern during the seven day assessment period. B. Record review The review of the progress notes for Resident #40 between 12/15/22 and 1/10/23 read he had several incidents of verbal and physical aggression towards residents and staff lead up the a physical altercation between Resident #40 and Resident #71. The resident continued to have behaviors after the altercation. The December 2022 and January 2023 progress notes also identified the resident was experiencing gentital discomfort from a chronic condition and had an appointment/ procedure addressing the condition pending, potentially escalating his behaviors. An investigation of alleged physical abuse was initiated on 1/10/23. According to the investigative record, Resident #40 was witnessed to be agitated and pacing the halls when he saw Resident #71 and struck her on the back on 1/10/23 at 6:15 p.m. The physical aggression care plan, initiated 1/21/23, read Resident #40 had the potential to exhibit physical aggression towards staff and other residents. According to the care plan the resident had the potential to yell and cuss at others The care plan read the resident would quickly pace when agitated and could be difficult to be redirect. The care plan directed staff to take the resident for a walk if the resident was overstimulating. Observe the resident for any potential triggers that may increase the resident ' s agitation such as noise level, overstimulation, other residents entering his space. Offer the resident his own place to sit in the dining room/activity room, as sage distance from other residents. -The care plan was not initiated until survey and after the resident had ongoing behaviors of physical and verbal aggression towards residents and staff leading up to the altercation. -The care plan did not identify the resident had an actual physical altercation with another resident. The review of the comprehensive care plan for Resident #40 identified the resident ' s gentital discomfort (as identified in progress notes) was not included in the resident ' s care plan until 1/20/23, during the survey. The intervention, initiated on 1/24/23, read his testicle enlargement could cause the resident agitation. The physical aggression care plan for Resident #71, initiated 1/20/23, read Resident #71 received physical aggression from another resident. The care plan directed staff to provide reassurance, monitor, redirect, and offer meaningful activities. V. Incident #2 and #3 with Resident #57 and Resident #226 A. Resident status 1. Resident #57, age [AGE], was admitted on [DATE]. She resided in the secured/memory care unit. According to the January 2023 CPO, diagnoses included [NAME] ' s encephalopathy (a brain disorder causing confusion), anxiety disorder and delusional disorders. The 12/19/22 MDS assessment revealed the resident had moderate cognitive impairment with a BIMS score of nine out of 15. The resident exhibited disorganized thinking and inattention. According to MDS assessment, the resident exhibited physical and verbal behaviors directed towards others. 2. Resident #226, age [AGE], was admitted on [DATE]. She resided in the secured/memory care unit. According to the January 2023 CPO, diagnoses included Alzheimer's disease, early onset, bipolar disorder, and unspecified dementia with unspecified severity with agitation. The 12/22/22 MDS assessment revealed the resident had severe cognitive impairment with a BIMS score of zero out of 15. The resident exhibited disorganized thinking and inattention. The resident exhibited physical and verbal behaviors directed towards others, impacting their care and social interactions. According to the MDS assessment, Resident #226 put others at significant risk for injury. B. Record review 1. Incident on 12/11/22 between Resident #226 and Resident #57 The 12/11/22 at 4:00 p.m. behavior note documented in the medical record of Resident #226 read Resident #226 was very anxious, and briskly pacing in and out of rooms, and up and down the hall. According to the note, a resident (Resident #57) started to yell at her. Resident #226 proceeded to throw juice at Resident #57. The 12/11/22 at 4:02 p.m behavior note documented in the medical record of Resident #57 read Resident #57 felt frustrated regarding the juice altercation and needed to be cleaned up. The 12/11/22 investigation of a resident to resident altercation read the facility was to create a non-pharmacological plan to assist with the behaviors of Resident #226. The 12/12/22 at 4:57 a.m. behavior note for Resident #57 identified the resident had an increase in behaviors following the incident. The behavior note read Resident #57 got out of bed several times throughout the shift, wandering the hallway and exit seeking. According to the note, the resident would be verbally abrasive and shoot the finger several times when the staff guided her back to her room. The 12/24/22 change of condition/SBAR note documented in the medical chart of Resident #226 indicated the behaviors between Resident #226 and Resident #57 escalated. The note read Resident #226 was leaving an activity when another resident (Resident #57) said a few grumpy things to Resident #227. Resident #226 lightly slapped Resident #57 ' s face and walked away. The behavior care plan, initiated on 12/27/22, read the resident had potential for physical and verbal outbursts related to her dementia, bipolar disorder, and poor impulse control. The care plan was not initiated until the resident had two resident to resident altercations. The behavior care plan, initiated on 1/24/23, read the resident had the potential to become verbally or physically aggressive towards other residents. Her care plan goal was to not harm or be harmed by others. The care plan did not identify the resident had actual physical altercation. The care plan read to encourage the resident to participate in activities throughout the day redirected the resident to painting (see observation below), coloring, walks or one to one visits. -The behavior/aggression care plan was not initiated until 1/24/23 during the survey. The activity care plan, initiated on 9/18/22, read the resident preferred to go to activities such as arts and crafts, color art, balloon toss or other group activities. According to the care plan the resident needed activities that were appropriate for her ability level and needed assistance to attend the activities. VI. Resident #57 activity observation and interview On 1/23/23 at 3:50 p.m. Five residents were observed in the activity room/dining room. One of the residents was watching television and another played with puzzle blocks. The two residents looked around the room with purposeful direction and one resident slept. -At 4:05 p.m. Resident #57 and two residents entered the memory care unit with the AD. The AD said the residents were at a music program off of the unit. -At 4:09 p.m. the activity director informed the resident in the lounge they were going to have a painting/coloring group. The AD assisted residents to tables in the activity/dining room. The group included three residents. -At 4:12 p.m. Resident #57 said she wanted to paint and sat down at the table. The AD provided her with a piece of paper. -4:17 p.m. Resident #57 requested a bigger paint brush. The AD told her she would have to get one off the unit. Resident #57 said she wanted to go with the AD. The AD escorted her and two hall residents of the unit. The painting group disbursed. One resident walked around the activity room holding her blank sheet of paper. -At 4:23 p.m. the AD returned with the three residents and left the unit. -At 4:25 p.m. Resident #57 asked the certified nurse aide (CNA) where the AD went because she (the resident) could paint. The CNA said the AD went to get something. -At 4:27 p.m. Resident #57 told her tablemate All I said to her (AD) was ' I want to paint. ' I had to ask for a brush. I have no idea what they wanted, she just told me to paint. Resident #57 held up her blank piece of paper and said to her tablemate, See this pretty picture I painted, wait, where did it go? -At 4:32 p.m. the AD returned with ice cream and went to the nurses station to prepare it for another resident. -At 4:39 p.m. Resident #57 asked CNA #9 for help with painting set up and was having difficulty with her paper. The CNA informed the AD. The AD told Resident #57 that she would find her watercolor paints. -At 4:40 p.m. the AD left the unit. Residents who wanted to paint were walking around the unit without engagement. -At 5:02 p.m. The AD returned to the unit. Most of the residents who wanted to paint were walking around the activity room and hall. A resident asked the AD for coffee when she returned to the unit. The AD proceeded to get coffee for the resident. The AD did not set up Resident #57 with watercolor painting. -At 5:15 the AD sat down at the computer to chart and socialized with the staff at the nurse ' s station. Several residents walked around the unit waiting for dinner and asking for snacks and water. Resident #57 was interviewed on 1/24/23 at 5:07 p.m. She said she liked to stay busy and liked to paint. She said everything kept changing. The resident did not elaborate on what kept changing. VII. Staff interview Activity assistant (AA) #1 was interviewed on 1/25/23 at 8:47 a.m. The AA #1 said she normally worked Monday through Thursday but was on vacation so she was not available on 1/23/23. She said it was important for residents in the memory care unit to stay in engaged. She said staff needed to be prepared for the activities so residents could be engaged. The interim nursing home administrator/director of nursing (INHA/DO) was interviewed on 1/26/23 at 6:54 p.m. The INHA/DO said the facility was always looking at how to improve dementia care and would be focusing on dementia care interventions. She they were trying to focus on person centered interventions, staff education, meeting staffing needs. She said the facility identified the need for increased behaviors in the afternoon. She said they always try to have two CNA ' s on the unit and during that they have an activity aide and or the life enrichment coordinator. She said they were also working on utilizing a resident assistant as extra one-to-one supervision. She said the facility identified an increase in incidents of resident to resident altercations and falls on the dementia unit so AA #1 was scheduled in the memory care unit because of her strong ability to engage them. The INHA/DO said activities on the unit were important because the residents need to stay engaged. She said meaningful engagement reduced the risk of negative resident interactions and behaviors. She said activities promote the best quality of life and were included as intervention to help reduce resident to resident altercations. The observations on the AD on the memory care unit was reviewed with the INHA/DO. The INHA/DO said the AD did not spend a lot of time on the memory care unit. She said the former NHA did not help the department heads such as the AD, so they could identify and correct concerns. The INHA/DO said the facility was looking on during dementia specific training and CPI (crisis prevention institute) training for facility staff. The activity director was interviewed on 1/26/23 at 9:19 a.m. The AD said her job was to provide mental, social, and physical well-being to the residents and provide quality of life and happiness. She said residents ' who have cognitive difficulties need to have activities structured to their individual needs and abilities. She said some residents could be just set up with an activity and walk away, other residents needed to have more help. She said the main thing was to make sure there was a good setup for the activity. The AD said the majority of residents in the memory care center could not self initiate their own activities and had short attention spans. She said many of the residents needed someone to guide them in the activity. The AD said she has had dementia training. The AD said she learned activities could help with behavior by calming the residents, offering them walks and redirecting the behavior. She said a behavior is just an unmet need and the staff needed to find out what the need was. The AD said activities could also help resident altercations and fall prevention by providing extra supervision, making sure the residents were comfortable and had lots of attention. The AD said the residents on the memory care unit would benefit from an ongoing activity program but sometimes she and her staff are having to run back and forth between the memory and the main unit. She said the situation had recently improved but for a while they were pulled in multiple places such as helping residents with smoke breaks, personal shopping, and banking. She said she had also recently hired new staff. The AD said when they did not have enough activity staff coverage they tried to to bring some of them to some of the activities of the unit but it was hard to try to meet all the residents' needs for residents that reside in memory care unit and residents not in the unit so sometimes the activity staff would just try to check on them. She said when someone was on vacation or when someone was ill, she tried to cover the activities as much as possible.

Based on observations, record review, and interviews, the facility failed to ensure it was free of a medication error rate of five percent (%) or greater. Specifically, the medication administration observation error rate was 16%, or four errors out of 25 opportunities for error. Findings include: I. Facility policy and procedure The Medication Administration and General Guidelines policy and procedure, dated November 2022, was provided by the interim nursing home administrator/corporate director of operations (INHA/DO) on 1/26/23 at 6:53 p.m. It included medications were administered as prescribed, in accordance with State regulations using good nursing principles and practices. The proper steps in the administration of medications included adherence to the six rights of medication administration including: 1) Right dose 2) Right route 3) Right resident 4) Right Medication 5) Right time 6) Right documentation II. Medication error observations and interviews A. Licensed practical nurse (LPN) #3 was observed preparing and administering medications to Resident #42 on 1/25/23 at 5:13 p.m. The resident's order was for insulin Lispro solution 100 units/milliliter; inject seven units subcutaneously three times a day. Call doctor if BG (blood glucose) is less than 80 or consistently above 450. Hold if BG is less than 120. The order was started 1/5/23. According to the manufacturer's specifications, provided by the INHA/DO on 1/26/23 at 6:53 p.m., the following steps should be taken prior to administering the medication: Prime before each injection. Priming your pen means removing the air from the needle and cartridge that may collect during normal use and ensure that the pen is working correctly. If you do not prime before each injection, you may get too much or too little insulin. To prime your pen, turn the dose knob to select two units. Hold your pen with the needle pointing up. Tap the cartridge holder gently to collect air bubbles at the top. Continue holding your pen with needle pointing up. Push the dose knob in until it stops, and '0' is seen in the dose window. Hold the dose knob in and count to five slowly. You should see insulin at the tip of the needle. If you do not see insulin, repeat priming steps. At 5:22 p.m., the LPN dialed seven units into the dose knob on the pen and administered the insulin to the resident. She did not prime the pen prior to injection. LPN #3 was interviewed on 1/25/23 at 5:24 p.m. She said she did not routinely prime insulin pens prior to dialing in the amount of insulin that was ordered to be administered and stated, Only when the pens are brand new. She said she had not been taught to prime insulin pens prior to administering the insulin, and was not aware that they needed to primed. B. Registered nurse (RN) #1 was observed preparing and administering medications to Resident #18 on 1/26/23 at 9:18 a.m. The resident's order was for Aspirin tablet 325 milligrams (mg) by mouth one time a day for maintenance. The order was started on 1/6/23. The RN poured out one aspirin tablet into a soufflé cup from an over-the-counter bottle with a label that read, 81 mg chewable aspirin and administered it to the resident at 9:21 a.m. She did not give the ordered dose of the medication. RN #1 was interviewed at 9:52 a.m. and said, I made a med error. She searched through the medication cart and found an over-the-counter bottle of aspirin tablets, 325 mg that should have been given to the resident instead of the 81 mg tablet. She said when a medication error was made, she would need to fill out an SBAR (Situation, Background, Assessment, Recommendation) form, contact the doctor, and inform the resident and the family of the error. RN #1 said she was a new nurse at the facility and had been working there for a short time. She said she had worked on all of the neighborhoods so far, but had not been there long enough to have any type of routine and that was difficult for her. She said her training and orientation to the facility was brief, and had never worked on her current hall before. C. RN #1 was observed preparing and administering medications to Resident #18 on 1/26/23 at 9:18 a.m. The resident's order was for Metamucil Fiber Packet (psyllium, bulk-forming laxative); Give 3.4 grams by mouth one time a day for constipation. The order was started on 1/6/23. The RN said the facility did not have Metamucil Fiber Packets in stock, so she picked up a bottle of Clear Lax (polyethylene glycol powder, an osmotic-type laxative), measured out 17 grams and diluted it in approximately six ounces of water. The RN administered the Clear Lax to the resident at 9:20 a.m., and did not give the ordered dose of the medication. RN #1 was interviewed at 9:52 a.m., and said the Clear Lax did not contain the ordered 3.4 grams of fiber that was ordered and a traveling agency nurse who oriented her had instructed her that Clear Lax was what they were supposed to use instead. She said the two medications were not the same or interchangeable, and said she had made another medication error. She said she would fill out an SBAR form, contact the doctor, and inform the resident and the family of the error. D. RN #1 was observed preparing and administering medications to Resident #18 on 1/26/23 at 9:18 a.m. The resident's order was for Vitamin D3 tablet, give 1,000 units by mouth one time a day for a supplement. The order was started on 1/6/23. The RN searched the cart for the medication but was unable to locate it. She looked in the medication cart on the neighboring hall and in the medication storage room, but was unable to find the Vitamin D3 tablets in the 1,000 unit dose. The RN said she would have to search for the correct dose and the medication was not administered to the resident. At 6:33 p.m., the minimum data set coordinator (MDSC) was asked if the medication had been located and given to the resident that day and she said it had not been. She said if medications were not available to be administered to residents, a progress note should be written by the nurse, and that was not completed either. III. Director of nurses (DON) interview The DON was interviewed on 1/26/23 at 6:12 p.m., and she said she was new to the facility and had been working as the DON for approximately one week. She said new nurses to the facility needed at least two to three days of orientation with the medication cart in order to become familiar with the residents, their medications, and the electronic medication administration record. The DON said insulin pens were supposed to be primed with two units of insulin prior to injecting the ordered amount of insulin in order to ensure air was purged from the syringe and that the correct amount of medication was administered. The DON said the LPN made a mediation error by not priming the insulin pen and should write an incident report about the error, document what happened, notify the physician, the family, the DON and write a progress note about it. The DON said she was not yet familiar with how the facility ensured medications were available for nurses to administer to the residents at their scheduled times, and said they received daily deliveries from the pharmacy every evening. She said if an over-the-counter medication was running low, they could send someone to the store to buy it. Otherwise, there was a piece of paper located in the medication storage room where nurses were supposed to write down over-the-counter medications when they were getting low on the supply, and then a staff member would purchase them. The DON said RN #1 had made a medication error when she administered 81 mg of aspirin instead of the ordered 325 mg, and had not been informed of the error by the nurse. The DON said Metamucil fiber packets and Clear Lax were not the same medication and were not interchangeable. She said she was not aware of an instruction for nurses to give the Clear Lax as a substitute for the Metamucil, and considered it a medication error. The DON said the Vitamin D3 1,000 unit dosage was not currently in stock in the facility, but should be available for nurses to give, since it was an ordered medication. She had been made aware of the omitted medication approximately one hour prior and considered it a medication error because the medication had not been given.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, record review and observations, the facility failed to ensure residents consistently receive food prepared by methods that conserved nutritive value, palatable in taste, texture, appearance and temperature. Specifically, the facility failed to ensure: -Resident food was palatable in taste, texture, appearance and temperature; and, -Meals were served at a palatable temperature. Findings include: I. Facility policy The Quality and Palatability policy, revised September 2007, was provided by the corporate dietary manager (CDM) on 1/25/23 at 2:44 p.m. The policy read in pertinent part: Food will be prepared by methods that conserve nutritive value, flavor and appearance. Food will be palatable, attractive and served at a safe and appetizing temperature. Food and liquids are prepared and served in a manner, form, and texture to meet residents' needs. The policy defined food attractiveness as the appearance of the food when served to residents. The policy defined food palatable as the taste and/or flavor of the food. The policy defined proper (safe and appetizing) temperature as food at the appropriate temperature as determined by the type of food to ensure resident satisfaction and minimize the risk for scalding and burns. II. Resident interviews Resident #53 was interviewed on 1/19/23 at 10:25 a.m. He said the food was garbage till the last couple months. He said the dietary department now had a new crew and the food was better than before but still could use a lot of improvements. Resident #53 said the food was often cold. He said in general he did not like most of the meal options available so he would usually just order a cheeseburger. He said the meals frequently change from what was advertised on the menus. The resident said the menus note the meals were subject to change without notice but then he did not know what would be served that day. Resident #4 was interviewed on 1/19/23 at 10:25 a.m. He said the food often had no flavor, bland. Resident #37 was interviewed on 1/19/23 at 10:53 a.m. She said the food was served hot in the dining room, but for room trays lunch and dinner are sometimes cold because there are not enough staff to serve residents in their rooms. They need more people working in the kitchen. Resident #225 was interviewed on 1/19/23 at 11:11 a.m. Her oatmeal from breakfast was still on her bedside table, and looked cold and hardened. She took a very small bite and said she would have to give it up. She said the food was not good. She had a large box of snacks at her bedside which contained homemade cookies and candy. Resident #18 was interviewed on 1/19/23 at 11:38 a.m. She said the food was slopped in the plate and doesn't look appetizing or they give you way too much and you don't want to eat it. It doesn't taste like my cooking. I always used a little garlic and a little bit of different stuff and it gave it a little bit better flavor. She said she preferred smaller portions but did not receive them. Resident #125 was interviewed on 1/19/23 at 11:44 a.m. She said the alternate meals every day were hot dog, grilled cheese, or a hamburger, no other alternates were offered for meals. She said today's lunch was cheese pizza, garlic bread, salad, canned fruit, and no alternative was given. Last night nurses brought her apple slices and peanut butter. She said yesterday's lunch (1/18/23) was only two chicken fingers; they did not offer an alternative meal. Last night (1/18/23) they brought shredded pork, no bun on the menu. Instead they brought ground pork with a dollop of mayo on top of a slice of white bread, canned fruit cocktail, and cooked cabbage. They said they were offering pulled pork. She said they brought snacks when she requested them. She asked for soda, but a CNA told her they did not have soda. Resident #27 was interviewed on 1/19/23 at 1:58 p.m. She said she needed larger portions of food. She did not get enough to eat and had to provide food on her own. She was eating a large portion of what looked like beans and rice or thick gumbo, and said this was leftover food that dietary staff gave to her. Resident #28's wife was interviewed on 1/22/23 at 1:41 p.m. She said, Food service here is terrible; sometimes lunch is served at 2:00 p.m. She said she came in and assisted her husband with his lunch every day, and she could see they don't have enough dietary staff. Resident #34 was interviewed on 1/22/23 at 2:00 p.m. He said, The food here is [NAME]. I've been trying to get them to change dietary companies for years. They buy the cheapest stuff they can, no fresh fruits and vegetables. He said he had to buy his own food at the store. By the time you get bananas (in the facility) they're usually black because Sysco (food vendor) stores them next to the freezer. The food's getting worse and worse. They say they'll change the menus but they just change the names. All the meals are getting later and later, most of the time they're just reheating stuff. Resident #53 was interviewed again on 1/24/23 at 9:27 a.m. He said he was just finishing his breakfast and it was served late but usually was. He said the breakfast was better today but his coffee was cold. Resident #19 was interviewed on 1/24/23 at 9:36 a.m. She said her breakfast this morning was ice cold, but she was able to eat a little bit. Resident #52 was interviewed on 1/24/23 at 1:30 p.m. She said the facility had a new cook and for a short time, the food tasted better. However, she said now she was not able to eat some of the food provided because it was not seasoned at all and was bland. She said the French fries were always cold. She said if her food was not hot when it was served, she was not going to eat it. She explained that she could ask the staff to reheat it, but then it was a matter of waiting 10 minutes or more before she could eat. She said the ice cream had to be eaten right away because it was already like soup when it was served to her with her meals. She said powdered eggs were served for breakfast every morning and she did not like those; she preferred to eat a muffin, coffee cake or a donut instead, and would like to have those options. The resident explained white rice was served multiple times each week and it would be nice to have a variety of brown or fried rice to choose from. III. Record review A. Meal times The dietary manager (DM) provided the posted daily meal times on 1/23/23. Meal posting read: -Breakfast served at 7:45 a.m. -Lunch is served at 11:45 a.m. -Dinner served at 4:45 p.m. B. Menu The lunch menu was provided by the dietary manager on 1/23/22. The 1/24/23 lunch menu indicated in the meal preparation and service observation: -Chicken salad sandwich; -Potato chips; -Hearty vegetable soup; and, -Broccoli salad (The broccoli salad was not served, see below) III. Observations A. Meal delivery The dining meal times of actual service was observed on the memory care unit and on the North hall. Observations identified the meals were served after the posted times (identified above.) In the memory care unit, the residents frequently had to wait to be served after the meals arrived as staff became available. On 1/19/23 at 12:21 p.m. the dietary manager dropped off the covered food cart on the memory care unit. -At 12:23 p.m. the CNA #9 started encouraged and assisted residents to the to the dining tables -At 12:32 p.m. CNA #12 began passing meal trays to residents in the memory care unit dining room. On 1/23/23 at 5:30 p.m. residents in the memory care unit are observed walking around the dining room. Residents began asking for snacks and water. -At 5:33 p.m. the diner meal cart arrived in the memory care unit. The residents were assisted to their table. -At 5:36 p.m. the activity director (AD) begins passing out one tray to a resident in the memory care unit. -At 5:38 p.m. the AD passed the second tray out to another resident. No other staff member was available to assist passing the trays. -At 5:43 p.m. the AD passed the third tray. The CNAs were then available to help pass the rest of trays after assisting a resident in a resident room. On 1/24/23 at 8:48 a.m. on the memory care unit the meal cart arrived. The activity assist (AA) identified not all needed food items were on the cart. The AA left the unit to go to the kitchen. At 8:55 a.m. the AA returned to the unit and the first meal tray was served. Additional meal trays followed. On 1/24/23 at 8:58 a.m the breakfast cart arrived in the North hall for room delivery. Most residents in the main dining room were already done with their breakfast. B. 1/24/23 meal preparation and test tray Observations of the meal lunch preparation and plating was conducted on 1/24/23 between 11:15 a.m. and 1:04 p.m. The observation identified the dietary staff had difficulty bringing the temperature down of their cold meals items, specifically the salads. The dietary staff could not bring the temperature down of the planned broccoli cold salad, identified from the menu, so they quickly prepped a garden salad to replace the broccoli and requested the registered dietitian (RD) sign off on the change. The dietary staff also struggled to get the temperature down of the chicken salad sandwiches so they placed the sandwiches back in the refrigerator and would retrieve a couple at a time when plating. The difficulty with cold item temperatures slowed the meal service down and also impacted the temperature of the meals served to residents and the type of salad offered to the residents. A test tray was requested on 1/24/23 in response to residents' concerns of poor taste and temperature of the food. The test tray was the lunch meal of hearty vegetable soup, a garden salad and a chicken salad sandwich. On 1/24/23 at 1:04 p.m. the dietary manager plated and covered the test tray. -At 1:05 p.m. the test tray arrived in the North hall to be picked up as the last resident room tray. -At 1:15 the last resident room served at the test tray was picked up. -At 1:17 p.m. test tray temperatures were conducted. The garden salad, identified as a cold item was 56.8 degrees Fahrenheit (F); The chicken salad, identified as a cold item, was 60.6 degrees F. The vegetable soup, identified as a hot item, was 93.4 degrees F. -The cold items were above palatable temperatures for cold items and the soup was below palatable temperature for hot items. The appearance and taste of the food items were also reviewed. The vegetable soup was not appetizing in temperature, taste and appearance. The soup was lukewarm in temperature. The broth was watery and all the vegetables rested at the bottom of the bowl. The vegetables were bland in color and difficult to distinguish what type of vegetables they were but most of the vegetables had the appearance of canned green beans. Most of the vegetables tasted like each other and bland. The broth of the soup was salty. C. Room trays During lunch in the main dining room on 1/19/23 at 12:42 p.m., the meal was pizza, tater tots, salad, ice cream and canned fruit cocktail. A few residents had cheeseburgers. Resident #23 said they were served too much processed food and not enough fresh. She said it was not the kitchen staff's fault, because they worked very hard, but because of corporate, the kitchen is limited in what they can buy and provide. Resident #18 said the tater tots were greasy and she could not eat them. 1. Lunch observations of room tray service on 1/24/23 revealed: The first lunch tray was served in the dining room at 12:03 p.m. and the drink cart was being passed throughout the dining room. At 12:06 p.m., lunch trays were brought out one at a time with multiple staff serving the residents. At 12:16 p.m., Resident #23 said, See why we need more help in here? She was getting items for another resident and said, We need somebody to cut open salad dressing packets. She added, This chef is the best thing that's happened to us and he comes from (a city an hour and a half away). The residents love him. He'd get them anything they want, make them something special. A staff person walked by and told Resident #23 she needed a walkie-talkie. Resident #23 returned to the table and told a resident the dietary staff were making her something special. At 12:26 p.m., most of the residents in the dining room had been served and were eating. -A tray cart was delivered to the [NAME] secure neighborhood at 12:42 p.m. The second meal cart went to the South hall at 12:49 p.m. At 12:51 p.m., two CNAs were passing trays to resident rooms on South hall. -At 1:02 p.m. the third meal cart was delivered to the North neighborhood. -At 1:08 p.m. Resident #28's wife was starting to assist him with a pureed meal of mashed potatoes with gravy and pale brown meat. The meal was brown and there were no vegetables. She tasted the meat and said she could not tell what it was. She said the milk was still cold, but the ice cream was melted on the bottom and soft when she opened it. She said she might have to do like yesterday and go get a frozen one. Resident #28's roommate, Resident #64, had his meal on his over-bed table but he was sound asleep. He was dependent for eating. 2. Breakfast room tray service observations on 1/26/23 revealed: -At 9:08 a.m., the room tray cart was observed on South hall. The oatmeal was uncovered. Three CNAs were passing out trays to residents. -At 9:15 a.m. Resident #43's breakfast tray was in front of him on his over-bed table and he had eaten most of it. He said he had enough to eat and requested another orange juice. His CNA said she could go to the kitchen to get some and would do so after passing the tray she was holding. She returned at 9:24 a.m. with a glass of juice for Resident #43. At 9:32 a.m. he was resting with his eyes closed; his over-bed table was pushed away from him against the privacy curtain. -At 9:34 a.m. Resident #64, who was dependent for eating, was sleeping. His untouched breakfast was on his bedside table. -At 9:35 a.m. breakfast trays were being passed on the North neighborhood by CNA #3 and CNA #13, who told CNA #3 there were no drinks on the meal cart. CNA #3 said she would have to go back to the kitchen, That's what they do (send out meal trays without drinks). One resident said he needed a second milk and she said she was going to get it. CNA #13 asked if she was going to get drinks for everyone or if she was just going for one person. CNA #13 said it was her first day here and she had been a CNA for a long time but it's just the disorganization. CNA #13 continued to pass trays to residents' rooms. At 9:41 a.m. CNA #3 returned with six drinks including one milk and five juices. Only the one milk was covered. The life engagement coordinator (LEC/CNA) approached CNA #3 and said everything should be covered. She handed CNAs #3 and #13 a stack of lids for the drinks and oatmeal. CNA #3 said the oatmeal was always sent out uncovered; That's how the kitchen does it. -At 9:49 a.m., the LEC/CNA began to assist with passing out breakfast trays. She asked CNA #3 to go assist Resident #2 who needed to be assisted with their meal. At 9:51 a.m., CNA #13 had just begun assisting Resident #64, who was dependent for eating. CNA #3 was observed going back to the kitchen, saying Resident #2 asked for a cup of coffee. -At 9:54 a.m., the LEC/CNA was taking a tray out of the meal cart with an uncovered cup of coffee. She said all the residents who requested coffee should have had it on their trays. She said coffee should be covered and she hoped it was hot. If not, she said she would warm it up for the residents. D. Staff interview Registered nurse (RN) #5 was interviewed on 1/22/23 at 12:45 p.m. She said she worked on the [NAME] secure unit on the weekends. She said, I've been complaining about meals forever because food portions are too small, unattractive and ice cold. She said she had filled out concern forms weekly for about a year. She said the kitchen staff did not show up until 8:20 a.m. that morning (Sunday), breakfast was at 10:00 a.m. and lunch was served at noon. She said meals were sometimes served an hour and a half late, which meant residents went without food for 16 to 17 hours. She said for snacks, they had nothing but graham crackers. She opened the refrigerator and demonstrated there were two half sandwiches packaged and dated 1/19/23 and individual packets of vanilla ice cream in the freezer. The other items were residents' personal foods provided by their families. She said they were provided no pudding or yogurt, and she would sometimes bring it in herself. CNA #9 was interviewed on 1/23/23 at 5:21 p.m. She said lately the memory care unit was not receiving the dinner cart until almost 6:00 p.m. CNA #8 was interviewed on 1/24/23 at 9:32 a.m. She said she needed to go assist four residents who were dependent with their meals and had not yet been assisted They eat in their rooms. The residents say meals here aren't good and are frequently late. She acknowledged the residents' food would be cold by now, due to the delay. The CDM was interviewed on 1/25/23 at 2:55 p.m. She said after the observation of the 1/24/23 lunch services, she did an inservice with the dietary staff on food temperatures and food preparation. She said the staff did not realize the planned meal was a multiple cold salad day and they did not give themselves enough preparation time to ensure the cold items were both ready at the time of service and at the appropriate temperature. The CDM was asked about the preparation of the 1/24/23 vegetable soup. She said the dietary staff did follow the recipe but should have also provided an adaptation to the recipe to add both color and flavor, improving the overall taste. She said the cook should have added more of a tomato base to help the taste of the soup for the residents not on a renal diet. The dietary manager (DM) and the CDM were interviewed on 1/26/23 at 2:48 p.m. The CDM said they needed to look into a better system to maintain the temperatures of both the cold and hot items once they were sent out to the halls for room delivery and the memory care unit. The CDM said dietary services used to have a separate beverage cart but the former administrator asked them not to use it and to put all items in one cart to make it easier on the nursing staff when meals were delivered. The DM said now was had to constantly come in the kitchen to request additional beverages, slowly down the service and delivery of resident meals. The DM said all food and drink items should be properly covered to maintain proper temperature and avoid exposure. The DM said the timing of the delivery was something they were trying to work on and has been getting better the last few days. He said dietary staff were working on consistency and had new cooks understand the importance of meal timing. He said he wanted to see each meal to only take about 13 seconds to plate for service. The CDM said they needed to work with nursing on the meal delivery process once the meals leave the kitchen. This would help maintain meal temperatures. The DM said he had not heard a lot of food concerns from residents. He said in November 2022 resident council, the residents did express concerns on the taste and temperature of food. He said there was no action plan generated but after hearing of the concerns, he focused on food flavor and temperature when training the cooks. He said they also encourage residents to give suggestions for special monthly and weekly meals. He said a few months ago, dietary services also purchased a new plate warmer and [NAME] to maintain the heat. The DM said residents in the past did not want a separate dining committee but he would approach the idea with residents so dietary could continue to get their food input and improve overall service.

Based on observations and interviews the facility failed to prepare and serve food in a safe and sanitary manner to prevent cross-contamination and potential food borne illnesses, in one of one kitchen during meal services, and one of two dining rooms. Specifically, the facility failed to: -Ensure staff followed accepted hand hygiene practices during the meal service to prevent potential cross-contamination; and, -Ensure resident food was served at the appropriate temperature. Findings include: I. Professional standards The Centers for Disease Control and Prevention (CDC), reviewed 8/5/22, retrieved on 2/4/23 from: https://www.cdc.gov/foodsafety/keep-food-safe.html, under Four Steps to Food Safety read to Wash your hands for at least 20 seconds with soap and warm or cold water before, during, and after preparing food and before eating. According to the CDC, food should be chilled promptly because bacteria could multiply rapidly if left at room temperature or in the ' Danger Zone ' between 40 degrees F (Fahrenheit) and 140 degrees F. II. Facility policy The Food Preparation policy, revised September 2007, was provided by the corporate dietary manager (CDM) on 1/26/23 at 2:44 p.m. The policy read in pertinent part: -All foods Are prepared in accordance with the FDA (Food and Drug Administration) Food Code; -All staff will practice proper hand washing techniques and glove use; -Dining service staff will be responsible for food preparation procedures that avoid contamination by potentially harmful physical, biological, and chemical contamination; -The dining service director/cook(s) Will be responsible for food preparation techniques which minimize the amount of time that food items are exposed to temperatures greater than 41 degrees F. (Fahrenheit) and/or less than 135° F. per state regulation. -All foods will be held at appropriate temperatures, greater than 135 degrees F. for a hot holding, and less than 41 degrees F. for cold food holding. III. Observations A. Above safe temperatures for resident consumption Observations of lunch preparation and plating were conducted on 1/24/23 between 11:15 a.m. and 1:04 p.m. The observation identified the dietary staff had difficulty bringing the temperature down of their cold meals items to safe temperatures. -At 11:49 a.m. the cold items of chicken salad sandwiches and broccoli salad were placed on the prep counters. The temperature of a chicken salad sandwich was taken. The thermometer read 55 degrees F. The DM tempted the sandwich again and it read 54.1 degrees F. The DM said the temperatures did not make sense because the sandwiches just came out of the freezer. -At 11:52 a.m. a second pan of chicken salad sandwiches were pulled out and the temperature was obtained. The sandwiches read 39.1 degrees F. The DM said he would serve the chicken salad sandwiches directly out of the refrigerator. -At 11:58 a.m. the temperature of the broccoli salad was taken. The broccoli salad temperature was at 54.3 degrees F. The corporate dietary manager (CDM) said they would serve the broccoli salad and change the salad option to a garden salad and inform the registered dietitian (RD). A small bin of the garden salad was placed in ice. -At 12:02 p.m. the plating of resident meals began. The DM manager pulled two chicken sandwiches out a time to place them on plates from both pans (the first pan of sandwiches were not held at the appropriate temperature). The DM opened and closed the refrigerator door each time he retrieved the sandwiches. -At 12:08 p.m. the dietary aide prepared additional garden salads. -At 12:12 p.m. the CDM placed the larger portion of garden salad with ice. -At 12:16 p.m the salad was added to the plates. -At 12:20 p.m. the CDM tempted the garden salad again and it read 49.1 degrees F. She said the salad was two degrees below palatable but it was not going to stay that way. She said temperatures of cold items would rise once the items were in the halls on room trays. The CDM said cold food items like the salad should be below 52 degrees F. She said if the salad was mayo based (such as the chicken salad), she would like the salad to be close to 40 degrees F. -At 12:24 p.m. the CDM placed the garden salad in a metal bin surrounded by ice and partially covered it with a metal lid. At 12:45 p.m. the DM said he needed to have a cold bin near the steamline, after having to walk back and forth to the refrigerator to retrieve the individual chicken salad sandwiches. B. Hand hygiene Continuous observations on the memory care unit were conducted on 1/19/23 between 11:20 a.m and 12:50 p.m. Between 11:20 a.m. and 12:20 p.m. residents hand hygiene was not performed in preparation of the upcoming meal service. -At 12:21 p.m. the meal cart arrived in the memory care unit. -At 12:23 p.m. the residents were assisted to the dining tables. They were not offered hand hygiene. -At 12:32 p.m. the residents' meals were passed. Residents were not offered hand hygiene before their meals were served. -At 12:36 p.m. CNA #9 sat down next to a resident and wiped his hands with a sanitizer wipe before she proceeded to assist him in eating. The other residents were identified to eat independently in the dining room. They were not assisted in wiping their hands with sanitizer wipes, alcohol based hand rub (ABHR) or soap and water before they ate their meal. -At 12:48 p.m. CNA #12 had a handful of packets of condiments in her hand that she was passing out. She dropped a packet on to the floor when she was attempting to open one of the packets up. She picked the packet off the floor and placed it in the other hand. She did not use hand hygiene after picking the packet off the floor. The CNA proceeded to open and pass the packets out, using both hands. Continuous observations on the memory care unit were conducted on the memory care unit on 1/23/23 between 3:50 p.m and 5:45 p.m. Between 3:50 p.m. to 5:33 p.m. residents hand hygiene was not performed in preparation of the upcoming meal service of pork stir fry rice with vegetables and a dinner roll. -At 5:33 p.m. the meal cart arrived in the memory care unit. Residents were not provided hand hygiene. Between 5:38 p.m. and 5:45 p.m. the passing of meals began. The residents proceeded to eat following the delivery of each meal. No resident hand hygiene was provided. C. Uncovered food and drink Observations on the South hall on 1/26/23 during the breakfast identified inconsistent coverage of the drinks and oatmeal. During the meal delivery, bowls of oatmeal on the meal trays were identified to be uncovered and exposed to the open air and potential contaminants. -At 9:35 p.m. staff identified there were limited beverages sent with the meal cart. CNA #3 went to the kitchen. -At 9:41 a.m. CNA #3 returned with individual cups of milk and juice. The one glass of milk was the only beverage covered. The five glasses were uncovered. The life engagement coordinator (LEC/CNA) informed CNA #3 that everything should be covered. She handed CNAs #3 and #13 a stack of lids for the drinks and oatmeal. CNA #3 said the oatmeal was always sent out uncovered; That's how the kitchen does it. IV. Staff interview The corporate dietary manager (CDM) was interviewed on 1/25/23 at 2:55 p.m. She said after the observation of the 1/24/23 lunch services, she did an inservice with the dietary staff on food temperatures and food preparation. She said the staff did not realize the planned meal was a multiple cold salad day and they did not give themselves enough preparation time to ensure the cold items were both ready at the time of service and at the appropriate temperature. The dietary manager (DM) and the CDM were interviewed on 1/26/23 at 2:48 p.m. The CDM said they needed to look into a better system to maintain the temperatures of both the cold and hot items once they are sent out to the halls for room delivery and the memory care unit. The DM said all food and drink items should be properly covered to maintain proper temperature and avoid exposure. The DM said the timing of the delivery was something they were trying to work on. The CDM said dietary staff needed to work with nursing staff on the meal delivery process once the meals left the kitchen. This would help maintain meal temperatures. The CDM said she would need to work with nursing to improve hand hygiene of residents and potential cross-contamination concerns. V. Facility follow-up The CDM provided dietary staff inservice forms on 1/25/23 at 2:44 p.m. The in-services forms indicated the dietary staff received education on 1/25/23 regarding food quality, palatability and food preparation following the above 1/24/23 meal observation.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review, the facility failed to manage and alleviate pain for one (#37) of five residents reviewed for pain out of 33 sample residents. Resident #37 experienced daily, unrelieved, severe pain described at level 10 on a scale of zero to 10, with 10 being the worst possible pain. Facility assessment on 12/4/21 documented her pain was constant and severe at 8-10 in her back and joints. The pain interfered with her sleep, daily activities and quality of life. The pain evaluation further documented the resident was not satisfied with her pain regime with her pain described as stabbing, aching and shooting spasms. Furthermore, the facility failed to notify the physician of the resident's frequent breakthrough pain, or schedule a pain clinic consultation to find ways to alleviate the resident's pain. Findings include: I. Facility policy The undated Pain Management policy, provided by the corporate nurse consultant on the afternoon of 12/20/21, documented in pertinent part that pain management was provided to residents consistent with the comprehensive care plan and resident goals and preferences. The policy further provided: -Recognize when the resident is experiencing pain and identify circumstances when the pain can be anticipated. -Evaluate the resident for pain during ongoing scheduled assessments and when a significant change in condition or status occurs, such as after a fall, new pain or an exacerbation of pain. -Manage or prevent pain consistent with the resident's goals. Facility staff will observe for nonverbal indicators which may indicate the presence of pain including but not limited to: -Fidgeting, increased or recurring restlessness -Facial expressions such as grimacing, frowning, fright or clenching of the jaw -Behavior such as resisting care, distressed pacing, irritability, depressed mood, or decreased participation in usual physical and/or social activities -Difficulty eating or loss of appetite -Weight loss -Difficulty sleeping -Negative vocalizations such as groaning, crying, whimpering, or screaming Be aware of verbal descriptors a resident may use to report or describe their pain including: heaviness or pressure, stabbing, throbbing, hurting or aching, gnawing, cramping, burning, numbness, tingling, shooting or radiating, spasms. Use a pain assessment tool appropriate for the resident's cognitive status to assist in consistent assessment of pain. An assessment of pain by the appropriate members (nurses, practitioner, pharmacists, and anyone else with direct contact with the resident) of the interdisciplinary team may necessitate gathering the following information, as applicable to the resident: -History of pain and its treatment. -Asking the resident to rate the intensity of the pain using a numerical scale, a verbal or visual descriptor that is appropriate and preferred by the resident. -Reviewing the resident's current medical conditions, identifying key characteristics of the pain: duration, frequency, location, timing, pattern (constant or intermittent), radiation of pain. -Obtaining descriptors of the pain (stabbing, aching, pressure, spasms). -Identifying activities, resident care or treatment that precipitate or exacerbate pain and those that reduce or eliminate pain. -Impact of pain on quality of life. -Current prescribed pain medications, dosage and frequency. -The resident's goals for pain management and his/her satisfaction with the current level of pain control. -Physical and psychosocial issues that might be causing or exacerbating the pain. -Additional symptoms associated with pain (such as nausea, anxiety). Based on the evaluation, the facility in collaboration with the physician and other health care professionals and the resident and/or representative will develop, implement, monitor and revise as necessary interventions to prevent or manage each individual resident's pain beginning at admission. The interventions for pain management will be incorporated into the components of the comprehensive care plan, addressing conditions or situations that may be associated with pain or may be included as a specific pain management need or goal. The interdisciplinary team and the resident and/or representative will collaborate to arrive at pertinent, realistic and measurable goals for treatment. Pharmacological interventions will follow a systemic approach for selecting medications and doses to treat pain. The interdisciplinary team is responsible for developing a pain management regime that is specific to each resident who has pain. The following are general principles the facility will utilize for prescribing analgesics: -Consider administering medication around the clock instead of PRN or combining longer acting medications with PRN medications for breakthrough pain. -Use lower doses of medication initially and titrate slowly upward until comfort is achieved. -Reassess and adjust the medication dose to optimize the resident's pain relief while monitoring the effectiveness of the medication and work to minimize or manage side effects. -Review clinical conditions which may require several analgesics and/or adjuvant medications; documentation will clarify the rationale for a treatment regimen and acknowledge associated risks. -Opioids will be prescribed and dosed in accordance with current professional standards of practice and manufacturers' guidelines to optimize their effectiveness and minimize their adverse consequences. -Facility staff will notify the practitioner, if the resident's pain is not controlled by the current treatment regimen. -Referral to a pain management clinic for other interventions that need to be administered under the close supervision of pain management specialists will be considered for residents with more advanced, complex or poorly controlled pain. Facility staff will reassess resident's pain management for effectiveness and/or adverse consequences at established intervals. -If reassessment findings indicate pain is not adequately controlled, the pain management regimen and plan of care will be revised as indicated. -If pain has resolved or there is no longer an indication for pain medication, the interdisciplinary team will work to discontinue or taper (as needed to prevent withdrawal symptoms) analgesics. II. Resident status Resident #37, age [AGE], was admitted on [DATE] and most recently readmitted on [DATE] following a hospitalization. According to the December 2021 computerized physician orders (CPO), pertinent diagnoses included arthropathy (joint disease), chronic pain, osteoporosis (bone density loss), scoliosis of the thoracolumbar region (spinal curve to the right which causes compression of spinal nerves and pain), and dementia without behavioral disturbance. According to the 11/1/21 minimum data set (MDS) assessment, the resident was unable to complete the brief interview for mental status (BIMS). Her memory status was not documented through staff assessment. The sections on delirium, mood and behavioral symptoms were left blank. Resident #37 required supervision and set-up assistance for bed mobility, transfers, locomotion with a wheelchair, dressing, eating, and toilet use. She had a scheduled pain medication regimen, as-needed (PRN) pain medications, and pain was present almost constantly. Her pain did not make it hard to sleep or limit her day-to-day activities. Her pain intensity was eight out of 10, but no verbal descriptor was documented. There was no staff assessment for pain. There was no end-of-life prognosis. III. Observations and interviews Resident #37 was observed and interviewed periodically throughout the days of survey, conducted on 12/14, 12/15, 12/16 and 12/20/21. She spent most of her time during the day in her room, in bed, and going to and from the smoking area outside. Whenever she was approached, greeted and asked how she was, she said she was experiencing pain. She was often grimacing or frowning and rubbing the area that hurt her, including her hip and/or lower back. On 12/14/21 at 10:28 a.m., she was resting in bed, grimacing, and said she was in pain. She said the nurse gave her a pain pill, nothing else helps. She said her pain medications helped her sometimes but not always. When asked her pain level, she said it was 10 out of 10. The resident's nurse was notified and a pain medication was given (see record review below). On 12/14/21 at 12:05 p.m., the resident was ambulating down the hall in her wheelchair, grimacing. She said she did not know what hurt worse, her back or her toe. She said the podiatrist was supposed to come and trim her nails, and she hoped they would come today. Her nurse was notified. -The resident's pain medication was given at 10:28 a.m. which was ineffective. There were no nurses' notes to indicate the physician was notified. On 12/15/21 at 8:45 a.m., the resident was sitting up in her bed, frowning and grimacing. She said she was in terrible pain in her back and her foot, she felt like her toe was coming off and she did not know what was wrong with it. She used her call light to summon the nurse, and a certified nurse aide (CNA) responded and said she would tell the nurse the resident was having pain. -Record review revealed no corresponding nurses' note regarding non-pharmacological interventions, medication provided, or a call made to the physician. On 12/16/21 at 8:45 a.m. the resident was lying in bed with her eyes closed. According to her orders and medication administration record (MAR), she received scheduled morphine at 8:00 a.m. and 8:00 p.m. On 12/16/21 at 9:15 a.m., the resident had just come into the dining room after a smoke break outside. She was frowning and grimacing, said she was in terrible pain, and said she would inform the nurse. -Record review (below) revealed pain medication was given at 9:15 a.m. IV. Family interview The resident's family member was interviewed on 12/21/21 at 9:24 a.m. She said the resident was in a lot of pain, and had been for years. She said the resident had scoliosis of the spine, and had been to a pain clinic and received shots and epidurals but they did not really last. She said the resident's pain could be worse now that they took away some of her pain meds (medications). I always know she's in pain because she calls me a lot more. When she calls she sounds like she's in pain, it's really bad, groaning, moaning, crying. She'll call me and the first thing she says is 'Can you take me to the doctor?' I tell her we need an appointment and she just hangs up on me. I wish she could be free from pain, even for an afternoon. V. Record review The care plan, initiated 3/16/18 and revised on 10/25/21, identified actual pain related to scoliosis with abnormal posture and chronic low back pain. The goal was for pain to be alleviated with both pharmacological and non-pharmacological interventions with evidence of pain relief through both verbal and non-verbal indicators, such as grimacing, groaning, and crying, through next review. Interventions, all dated 3/16/18 and revised 10/1/21, were: -Observe for signs/symptoms of verbal and non-verbal indicators of pain at each medication pass, and periodically. -Notify MD (physician) of unrelieved pain. Consults may be scheduled to pain and/or spine specialists. -Provide diversion activities, such as positioning, smoking, music, television and a cup of coffee with conversation. The most recent physician progress notes by a nurse practitioner, dated 11/17/21, documented in pertinent part that the resident had a telemedicine visit for readmission after hospitalization from 11/13 through 11/15/21 for treatment of acute encephalopathy (alteration in mental status) and renal insufficiency. Her chief complaint was fatigue. They felt that her clinical picture was more consistent with an acute encephalopathy and respiratory depression from polypharmacy with pain medications and decreased renal clearance/accumulation of metabolites. The treatment plan was to continue to decrease polypharmacy to help decrease minimizing CNS (central nervous system) -active medications. For chronic pain: -Continue Morphine Sulfate ER, 15 mg, 1 tablet twice daily Changed dose from TID (three times daily) to BID (twice daily) -Continue Oxycodone HCI tablet, 5 mg, 1 tablet as needed pain, orally, every 6 hours -Continue Acetaminophen capsule, 325 mg, 2 tablets as needed every 4 hours -Stop Effexor (antidepressant/nerve pain) XR capsule extended release 24 hour, 75 mg, 3 capsules with food, once a day in AM (morning) -Stop Tizanidine (muscle relaxant) HCI tablet, 2 mg, 1 tablet as needed muscle spasm, every 8 hours -Stop Lyrica capsule (nerve pain), 100 mg, 1 capsule 3 times a day Notes: Continue to encourage pain relief with other conservative ways including moist heat to areas of tenderness, light massage, relaxation music. Will need to continue medications as prescribed from ER visit. Schedule patient with physician for GDR (gradual dose reduction) next visit. Follow up 1 week for GDR. -There was no documentation of the follow-up physician appointment, other than a 12/3/21 care conference note documented by a registered nurse regarding an IDT (interdisciplinary team) Psych/Pharm meeting with the Medical Director, which included that several medications were discontinued with no apparent changes to pain level, mood appears to be more stable. MD recommends to continue treatment. The December 2021 physician orders revealed the following pertinent medications and instructions: -Morphine Sulfate ER tablet extended release 15 mg every 12 hours related to chronic pain, started 11/15/21. -Oxycodone HCI tablet 5 mg every 6 hours as needed for pain, started 6/17/21. -Tylenol tablet 325 mg, give 2 every 4 hours as needed for fever, ordered 4/26/17. -Nonpharmacological interventions for pain: go outside and smoke a cigarette, sit and talk with me when I am awake, lie down and rest in a dark and quiet environment, back massage every day shift, ordered 2/17/2020. -Observation: Pain - Observe every shift. If pain present, treat trying non-pharmacological interventions prior to medicating if appropriate. Interventions: 1 = positioning/support, 2 = relaxation, 3 = are needs met? (toileting, food, drink), 4 - music if pain persists, give PRN medication as ordered, document in the PNs every day shift for pain assessment, ordered 6/28/2020. -The non-pharmacological interventions were not documented as provided, either on the MAR or in nursing notes (see below). The resident's most recent pain evaluation, dated 12/4/21 and conducted after a fall, documented she had severe 8-10 level pain constantly to her back and joints, described as continuous sharp and aching pains and muscle spasms and a history of chronic back pain. The pain interfered with her sleep, appetite, physical activity and behavior/mood. Terminal or end stage disease was checked off as an underlying factor, although per the recent MDS assessment (above) the resident did not have a terminal diagnosis. The resident verbalized her pain as 8/10 very severe, and said the worst it got was 10/10 worst possible pain. The best it got was 2/10 mild pain. The resident's goal was no hurt/no pain. The resident was not satisfied with her current pain regime. What relieved her pain/hurting was rest, positioning, and medications. She further described the quality of her pain as stabbing, aching and shooting spasm. Interventions were routine and PRN narcotic pain medications, there were no side effects or adverse consequences experienced. The pain management plan was to continue current orders. Review of the December 2021 MAR, nursing notes and narcotic sheets through 12/20/21 at 4:00 p.m., revealed the resident was assessed for pain twice daily with her Morphine administration scheduled for 8:00 a.m. and 8:00 p.m. Her pain was seven (out of 10) twice, eight on 11 occasions, and 10 on 19 occasions. The resident had breakthrough pain for which PRN Oxycodone was documented as given 20 out of 20 days as follows: -On 12/1/21 at 12:23 a.m. for 10/10 pain, 12:15 p.m. for 8/10 pain and 10:21 p.m. for 10/10 pain; -On 12/2/21 at 1:39 p.m. for 10/10 pain; -On 12/3/21 at 10:58 a.m. for 9/10 pain, and 11:39 p.m. for 8/10 pain; -Licensed practical nurse (LPN) #2 documented at 3:30 a.m. that an Oxycodone tablet was pulled but it was not documented on the MAR as given. (Cross-reference F755 for pharmacy services) -On 12/4/21 Oxycodone was given at 11:19 a.m. for 10/10 and 6:13 p.m. for 10/10 pain; -LPN #2 documented at 5:30 a.m. that an Oxycodone tablet was pulled but it was not documented on the MAR as given. (Cross-reference F755) -On 12/5/21 Oxycodone was given at 2:00 a.m. for 10/10, 12:25 p.m. for 10/10 and 6:46 p.m. for 10/10 pain; -On 12/6/21 at 11:30 a.m. for 10/10 and 11:27 p.m. for 10/10 pain; -LPN #2 documented at 2:00 a.m. that an Oxycodone tablet was pulled but it was not documented on the MAR as given. (Cross-reference F755) -On 12/7/21 Oxycodone was given at 9:40 a.m. for 7/10, 3:40 p.m. for 8/10, and 9:52 p.m. for 10/10 pain; -On 12/8/21 Oxycodone was given at 9:11 p.m. for 10/10 pain; -LPN #1 documented at 12:20 p.m. that an Oxycodone tablet was pulled but it was not documented on the MAR as given. (Cross-reference F755) -On 12/9/21 Oxycodone was given at 4:57 a.m. for 10/10, 11:49 a.m. for 7/10, and 6:09 p.m. for 8/10 pain; -On 12/10/21 at 3:10 p.m. for 10/10 pain; -LPN #2 documented at 12:05 a.m. and 6:00 a.m. that Oxycodone tablets were pulled but were not documented on the MAR as given. (Cross-reference F755) -On 12/11/21 Oxycodone was given at 12:00 a.m. for 8/10 and 1:33 p.m. for 10/10 pain; -At 2:59 a.m. LPN #2 documented the resident was at desk asking for another pain pill, explained that it was not time, offered apap per prn order, this denied, resident states that the pain pills have had no effect on her pain. -The nurse did not document notifying the physician that the pain medication was ineffective. -LPN #2 documented at 6:00 a.m. that an Oxycodone tablet was pulled but was not documented on the MAR as given. (Cross-reference F755) -On 12/12/21 Oxycodone was given at 12:19 a.m. for 8/10, 5:55 a.m. for 8/10, 2:08 p.m. for 10/10, and 10:26 p.m. for 8/10 pain; -On 12/13/21 at 4:27 a.m. for 8/10, 11:34 a.m. for 10/10 and 9:02 p.m. for 10/10 pain; -On 12/14/21 at 3:31 a.m. for 10/10, 10:30 a.m. for 7/10 and 6:28 p.m. for 10/10 pain; -On 12/15/21 at 12:30 a.m. for 10/10, 9:45 a.m. for 8/10, and 6:24 p.m. for 10/10 pain; -On 12/16/21 at 12:32 a.m. for 10/10, 9:15 a.m. for 8/10 and 3:15 p.m. for 7/10 pain; -On 12/17/21 at 2:45 a.m. for 8/10, 12:56 p.m. for 10/10 and 11:07 p.m. for 8/10 pain; -On 12/18/21 at 5:30 a.m. for 8/10 and 1:10 p.m. for 10/10 pain; -At 3:10 a.m. a nurse documented resident approached desk requesting pain med. Informed resident that she had one at 11p.m. and could get another at 5 am. Resident offered apap per prn order, resident declined and stated she hoped the doctor would someday hurt like her. -The MAR (see above) did not document the resident received a pain medication at 11:00 p.m. as the nurse told her, or that the nurse contacted the physician about the resident's pain. -On 12/19/21 Oxycodone was given at 12:14 a.m. for 8/10, 11:06 a.m. for 10/10 and 10:29 p.m. for 8/10 pain; -At 1:12 a.m. a nurse documented the resident approached the desk for a pain pill. This nurse reminded resident she had one an hour ago, resident states 'I know but it's not helping.' Offered resident her PRN tylenol, resident declines this offer and returned to her room. -At 4:50 a.m. the nurse documented resident up to desk at 3 and 4 am to request next pain pill, refuses tylenol stating it doesn't do anything. -However, the nurse did not document that she told the resident she could have another Oxycodone at 4:30 a.m. (which was avaliable for administration), nor that she notified the physician of the resident's pain. -On 12/20/21 Oxycodone was given at 5:12 a.m. for 8/10 and 1:47 p.m. for 8/10 pain. The Oxycodone administrations were documented as effective on all but five occasions: 12/3, 12/11, 12/13, 12/18 and 12/19/21. Effectiveness was not documented on 12/20/21 after the 1:47 p.m. administration. -Non-pharmacological pain interventions were not documented in nursing notes or the MAR, other than as checkmarks with nurse initials for each shift daily at 7:00 a.m. and 7:00 p.m. The type of interventions used and their effectiveness were not documented. VI. Staff interviews Registered nurse (RN) #2 was interviewed on 12/16/21 at 9:42 a.m. She said the resident's physician was aware of her pain. She said the resident liked to lie down with her legs out of bed so she tried to reposition her to make her more comfortable. When she's up I look at her hip, rub it a little, see if that helps at all, maybe it's just a cramp. She was recently hospitalized and her kidneys weren't working so well. She said they discontinued the resident's Lyrica, and changed her Morphine from TID to BID. Her pain has been about the same. She said the resident had not been to a pain clinic since last year, and a new appointment had not been scheduled. She said when the resident's foot was hurting, she changed her socks, put on a looser pair, and that seemed to help her. She said her pain was usually in her back. She'll refuse non-pharm measures and just go back to her room. She said she did not think the resident's physician was aware that the resident refused non-pharmacological measures for pain management, but he was aware of her pain. The social services director on 12/20/21 at 12:08 p.m. She said she had made an appointment today (after being identifed during survey) for the resident to visit the pain clinic on 1/19/21. The director of nursing (DON) was interviewed on 12/20/21 at 12:18 p.m. She said the resident had been going to a pain clinic before and was getting shots. She said there had not been a palliative care evaluation that she was aware of. She said the resident refused non-pharmacological interventions. She said the resident's pain levels were the same before her medications were adjusted after her hospitalization. She said she thought the resident's pain might be partly behavioral because she asked for more pain medications before her current ones could take effect. The therapy director was interviewed on 12/20/21 at 2:53 p.m. She said they had tried the following interventions: pain clinic, dry needling, massage, heat, changing her wheelchair, cushioning, bed, bed positioning, and nothing consistently helped her pain. She said aside from the scoliosis curvature, her cognition and inability to retain or understand exacerbated the situation. She said they had changed the back of the resident's wheelchair several times. She believed they had tried TENS (electrical nerve stimulation) treatments, hot packs, and it might be great one day but the next day it hurt. She said the resident was resistant to therapy. She said when she assessed the resident and really narrowed down her pain levels, she usually got between 3/10 and 7/10. She said it had been about three months since the resident received therapy services for pain management. -Documentation was requested during the survey from the facility regarding scheduling pain consultations for the resident and communication to the resident's physician about her breakthrough pain; however, no documentation was provided by 12/21/21.

Based on interviews and record review, the facility failed to establish a system of record of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation for nine residents (#37, #42, #305, #15, #34, #6, #18, #47 and #14) out of 24 residents reviewed for narcotic administration out of 33 sample residents. Specifically, the facility failed to ensure narcotic removal documentation in the narcotic log matched the dates of narcotic administration in the resident's electronic medical record (EMR) for Residents #37, #42, #305, #15, #34, #6, #18, #47 and #14. Findings include: I. Facility policy and procedure A Controlled Substance Administration and Accountability policy, undated, was provided by the nursing home administrator (NHA) on 12/20/21 at 12:39 p.m. that read: It is the policy of this facility to promote safe, high quality patient care, complaint with state and federal regulations regarding monitoring the use of controlled substances. The facility will have safeguards in place in order to prevent loss, diversion or accidental exposure. II. Record review The director of nursing (DON) provided narcotic administration sheets for all residents receiving narcotic medications on 12/16/21 at an unknown time. The following dates and times documented that a narcotic medication was removed from the medication cart, however was not documented as being given to the resident in the electronic medical record (EMR) for the month of December 2021: On the following dates Oxycodone was recorded as being removed from the narcotic supply, however was not recorded as being given in the MAR: Resident #37, Computerized physician order (CPO): Oxycodone 5mg tablet; give one tablet by mouth every six hours as needed for pain. -12/3/21 at 3:30 a.m. by licensed practical nurse (LPN) #2 -12/4/21 at 5:30 a.m. by LPN #2 -12/6/21 at 2:00 a.m. by LPN #2 -12/8/21 at 12:20 p.m. by LPN #2 -12/10/21 at 12:05 a.m. by LPN #2 -12/10/21 at 6:00 a.m. by LPN #2 -12/11/21 at 6:00 a.m. by LPN #2 Resident #42, CPO: Oxycodone 5mg tablet; give 5mg by mouth twice daily as needed for pain. -12/4/21 at 10:00 a.m. by LPN #1 -12/6/21 at 6:00 a.m. by unknown staff member -12/10/21 at 10:00 a.m. by LPN #1 Resident #305, CPO: Oxycodone 5mg tablet; take one or two tablets by mouth every six hours as needed for pain. -12/12/21 at 5:15 p.m. by LPN #3 On the following dates hydrocodone/acetaminophen was recorded as being removed from the narcotic supply, however was not recorded as being given in the MAR: Resident #15, CPO: Hydrocodone/acetaminophen 5-325mg; give one tablet by mouth every six hours as needed for pain. -12/11/21 at 12:50 p.m. by LPN #1 -12/11/21 at 5:00 p.m. by LPN #1 -12/12/21 at 9:00 a.m. by LPN #1 -12/12/21 at 1:30 p.m. by LPN #1 -12/12/21 at 5:30 p.m. by LPN #1 Resident #34, CPO: Hydrocodone/acetaminophen 5-325mg; give one tablet by mouth every six hours as needed for pain. -12/10/21 at 8:00 a.m. by LPN #3 -12/11/21 at 8:00 a.m. by LPN #3 -12/12/21 at 8:00 a.m. by LPN #3 Resident #6, CPO: Hydrocodone/acetaminophen 5-325mg; give one tablet by mouth every six hours as needed for pain. -12/2/21 at 8:00 p.m. by LPN #2 -12/10/21 at 8:50 a.m. by LPN #3 On the following dates Oxycodone/acetaminophen was recorded as being removed from the narcotic supply, however was not recorded as being given in the MAR: Resident #18, CPO: Oxycodone/acetaminophen; give one tablet by mouth as needed for pain four times a day. -12/10/21 at 2:00 p.m. by LPN #3 -12/11/21 at 5:00 p.m. by LPN #3 On the following dates Morphine was recorded as being removed from the narcotic supply, however was not recorded as being given in the MAR: Resident #47, CPO: Morphine 100/5ml solution; give 0.25ml by mouth every four hours as needed for air hunger. -12/10/21 at 10:30 a.m. by LPN #3 -12/11/21 at 12:00 p.m. by LPN #3 -12/12/21 at 11:30 a.m. by LPN #3 On the following dates Tramadol was recorded as being removed from the narcotic supply, however was not recorded as being given in the MAR: Resident #14, CPO: Tramadol 50mg; give one tablet by mouth every 12 hours as needed for pain. -12/5/21 at 8:00 p.m. by LPN #2 -12/10/21 at 8:00 a.m. by LPN #3 -12/12/21 at 8:00 a.m. by LPN #3 The NHA provided a medication administration nurse competency check for LPN #2 dated 9/19/2020 which included: Medication administration process and documentation, controlled substance count validation process, and medication cart use and security. A Medication Pass Observation form dated 11/15/21 was provided by the NHA on 12/20/21 at 1:03 p.m. There were six staff members that were listed as being observed, however none of the employees who administered medications (see above) were listed as being observed during a medication pass. IV. Staff interviews The DON was interviewed on 12/16/21 at 4:46 p.m. She said if a narcotic medication was pulled from the medication cart and not given for any reason that it should be documented as being wasted (disposed of) by two nurses. She said that she did not believe that they had a diversion issue and she believed the nurses were just forgetting to document in the resident's MAR that the medications were administered. She said that she would discuss with and provide one-to-one training for LPNs #1, #2, and #3, and would provide education to all nurses on narcotic medication administration process. The DON was interviewed again on 12/20/21 at 10:30 a.m. She said that she had started providing training for staff on narcotic medication administration and documentation. She performed one-to-one training with LPN #2. She said that LPN #2 said she thought maybe in the middle of the night when a resident would request pain medication she was pulling the medication from the cart and administering it to the resident and then was forgetting to document in the resident's MAR. The DON was interviewed on 12/20/21 at 12:18 p.m. She said that she would be writing up (taking corrective action) LPNs #1, #2, and #3. LPN #3 was interviewed on 12/20/21 at 1:47 p.m. She said that her process of administering narcotics was to ask the resident their pain level, pull up the resident's MAR to see what medication was available for pain relief, she would log the removal of the medication in the narcotic log, and then would document it as administered in the resident's MAR. She acknowledged that there were several incidences where it appeared that a narcotic medication was removed, but not documented as being given in the resident's MAR. She said that she was always giving the medication to the residents and that she thought that maybe in the mornings she was trying to hurry and get to the residents in pain and would forget to mark the medication as administered in the resident's MAR. She said she was a new nurse and was still trying to find a routine that worked for her. She said she did receive training on narcotic medication administration upon being hired and did know the process of proper documentation.