**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interviews, the facility failed to ensure that one (#28) of ten residents out of 27 sample residents were free from chemical restraint and were receiving the least restrictive approach for their needs. Specifically, for Resident #28, the facility failed to provide adequate documentation to justify the addition of new psychotropic medications, the increase in dosage of psychotropic medications and/or the continued use of psychotropic medications. Findings include:I. Facility policy and procedureThe Behavior Assessment, Intervention, and Monitoring policy, undated, was provided by the nursing home administrator (NHA) on 8/6/25 at 2:01 p.m. It read in pertinent part,Interventions are individualized and part of an overall care environment that supports physical, functional, and psychosocial needs and strives to understand, prevent or relieve the residents distress or loss of abilities.Non pharmacologic approaches are used to the extent possible to avoid or reduce the use of psychotropic medications to manage behavioral symptoms. Psychotropic medications are prescribed for behavioral symptoms and documentation includes rationale for use, potential underlying causes of the behavior, non-pharmacological approaches and interventions tried prior to the use of the psychotropic medication, specific target behaviors and expected outcomes, monitoring for efficacy and adverse consequences, and plans (if applicable) for gradual dose reductions. II. Resident #28A. Resident statusResident #28, age [AGE], was admitted on [DATE]. According to the August 2025 computerized physician orders (CPO), diagnoses included Alzheimer's disease, dementia with mood disturbance and major depressive disorder.The 6/18/25 minimum data set (MDS) assessment revealed the resident had severe cognitive impairments with a brief interview for mental status (BIMS) score of two out of 15. The MDS assessment indicated the resident had behaviors not directed at others (physical symptoms such as scratching self, pacing, smearing bodily fluids or food, disrobing, public sexual acts, screaming or disruptive sounds), wandering, delusions and physical aggression. B. Record reviewResident #28's depression care plan, revised 7/10/25, revealed the resident took Sertraline (an antidepressant) related to depression with target behaviors of isolation and loss of interest in things she enjoyed. She additionally took Trazodone (an antidepressant) for insomnia. Interventions, revised 7/10/25, included to redirect, provide a quiet environment, take on a walk, reposition, offer music, offer activity of interest or provide snacks or beverages.Review of Resident #28's August 2025 CPO revealed the following physician's orders:Trazodone 50 milligrams (mg) tablet. Give one tablet in the evening for insomnia, ordered 4/15/25. Sertraline 50 mg tablet. Give one tablet a day for depression, ordered 6/16/25.Monitor for behaviors related to antidepressant medication Sertraline. 1-Isolation 2-Loss of interest in activities the resident is known to enjoy. Use non-pharmological interventions 1. Redirect. 2. Reposition. 3. Offer snacks. 4. Offer fluids. 5. Adjust room temperature. 6. Distraction/offer activity. 7. See nurses note for additional information, ordered 7/10/25.Review of Resident #28's electronic medical record (EMR), from 5/1/25 to 8/4/25, revealed the following progress notes:Between 5/1/25 to 5/30/25, there was no documentation to indicate Resident #28 exhibited any episodes of isolating or decreased interest in activities she was known to enjoy.Between 6/1/25 to 6/31/25, there was no documentation to indicate Resident #28 exhibited any episodes of isolating or decreased interest in activities she was known to enjoy. A system order note, dated 6/8/25, revealed Resident #28 was standing in her doorway when another resident walked past her and teased and laughed at her. The other resident then raised her fist at Resident #28, walked away, and then returned. At that time, the other resident hit Resident #28 in the arm and Resident #28 hit her back in the arm. Both residents were separated and redirected.Cross reference F600 for failure to protect residents from physical abuse. A depression screen evaluation note, dated 6/10/25, revealed Resident #28 participated in a depression screen and did not show any signs or symptoms of depression, with a score of zero out of nine.A system order note, dated 6/12/25, revealed another resident (same resident from 6/8/25) took a pillow out of Resident #28's room, upsetting Resident #28. Resident #28 then hit the other resident in the head and the other resident hit Resident #28 in the arm. Both residents were separated and redirected. A system order note, dated 6/16/25, revealed Resident #28 had been started on Sertraline for depression.-However, review of Resident #28's EMR failed to reveal documentation to justify the addition of the antidepressant medication or a physician's rationale for the medication.An at-risk review note, dated 6/18/25, revealed after the initiation of Sertraline, there were no noted change in behaviors. The staff were to continue to offer person-centered interventions and redirect Resident #28 from the resident she frequently had altercations with. An at-risk review note, dated 6/25/25, revealed Resident #28 had been without behaviors toward others and no aggression was reported or observed.Between 7/1/25 to 7/31/25, there was no documentation to indicate Resident #28 exhibited any episodes of isolating or decreased interest in activities she was known to enjoy. A nursing note, dated 7/5/25, revealed Resident #28 went outside with supervision and pushed another resident in the arm and was easily redirected. -Between 5/1/25 to 8/5/25, there was no documentation to indicate Resident #28 exhibited any episodes of isolating or decreased interest in activities she was known to enjoy with a zero depression score on 6/10/25. However, Sertraline was ordered on 6/16/25 for depression (see physician's orders above). A review of Resident #28's behavior monitoring documented on the May 2025 through August 2025 medication administration records (MAR), from 5/1/25 to 8/4/25, revealed Resident #28 had one behavior on 7/2/25 of a loss of interest in activities she was known to enjoy. A review of progress notes failed to indicate the specific behavior on 7/2/25.-A psychoactive medication evaluation meeting minute note, dated 6/20/25, failed to reveal the rationale for the addition of Sertraline on 6/16/25. A pharmacist consultant report, dated 5/6/25, revealed the pharmacist documented a request for review of Resident #28's Trazodone due to the hours of sleep not being charted for all shifts (only morning charting was completed).A pharmacist consultant report, dated 6/9/25, revealed the pharmacist documented this was the second request for review of Resident #28's Trazodone due to the hours of sleep not being charted for all shifts (only morning charting was completed).A pharmacist report to the physician, dated 7/8/25, revealed the pharmacist recommended a dose reduction of Resident #28's Trazodone from 50 mg to 25 mg due to Resident #28 sleeping eight to 12 hours a day and the use of a hypnotic at that dose could not be supported. -Review of Resident #28's August 2025 CPO failed to reveal a dose reduction had occurred (see physician's order above).-Review of Resident #28's EMR failed to reveal documentation to justify the rationale for not decreasing the resident's Trazodone.Review of Resident #28's behavior sheet, undated, which was kept at the nurses' station, was reviewed on 8/5/25and revealed that Resident #28 had behaviors of becoming physically aggressive with staff and other residents and would have altercations with Resident #45. Interventions focused on ways to redirect the resident related to physically aggressive behaviors. -There was no behavior sheet located which indicated Resident #28 had behaviors related to depression or insomnia.III. Staff interviewsCertified nurse aide (CNA) #5 was interviewed on 8/5/25 at 1:27 p.m. CNA #5 said Resident #28 had behaviors of refusing care in the afternoons and becoming agitated if overstimulated. She said when Resident #28 first came to the facility in March 2025, she used to communicate more but in the last two months, CNA #5 said she had noticed Resident #28 makes more noises instead of talking. She said non-pharmacological interventions that worked for Resident #28 were to sing to her and show her family pictures. CNA #5 said the staff found resident behaviors and interventions in the behavior book at the nurses station, however CNA #5 said she doesn't use the behavior book because she knows the residents. CNA #5 said the CNAs documented behaviors on the CNA behavior monitoring task but the behaviors and interventions indicated on the task were generic and the same for all the residents. CNA #2 was interviewed on 8/5/25 at 3:05 p.m. CNA #2 said that Resident #28 had behaviors of becoming agitated and she liked to color when upset. She said the CNA's found the behaviors and interventions in the CNA behavior monitoring task but the behaviors and interventions indicated on the task were generic and the same for all the residents. Registered nurse (RN) #3 was interviewed on 8/5/25 at 3:15 p.m. RN #3 said Resident #28 did not really have behaviors. She said the nurses documented the residents' behaviors and interventions on the MARs and made progress notes. CNA #6 was interviewed on 8/6/25 at 11:44 a.m. CNA #6 said he had been at the facility for six months. CNA #6 said he had to retrieve the behavior binder because he could not recall the person-centered interventions or resident specific behaviors for Resident #28. He read the behaviors and interventions from the binder. CNA #6 said the CNAs did not document behaviors but told the nurse who then would document any behaviors in the progress notes. The NHA and the director of nursing (DON) were interviewed together on 8/7/25 at 12:50 p.m. The DON said that the facility determined the efficacy of psychoactive medications being administered by using behavior monitoring physician's orders within the MAR, with resident specific behaviors listed. She said her expectation was that the nurses documented behaviors on the MAR and also put in a behavior progress note to include the non-pharmological interventions attempted. The DON said that there should be non-pharmacological interventions on the behavior monitoring order for the nurses. She said that non-pharmacological interventions were important because the facility did not want to use psychotropic medications as a first resort and instead wanted to use non-pharmacological interventions first because it was more humane and ethical for the care of the resident. The DON said that the behavior monitoring physician's orders provided data that was used during the psychotropic drug meeting to decide on increasing medications or considering gradual dose reductions. She said that she continuously trained her staff on where to find the non-pharmacological interventions and what they were, as well as providing education on triggers. The DON was unaware that the CNAs and nursing staff on the secure unit were not consistent in knowing where to find behaviors and interventions for residents.The NHA said that if the staff were not consistently or accurately documenting resident behaviors, it would be difficult to determine the effectiveness of the medications and this prevented the monitoring from demonstrating a clear picture of behaviors.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interviews, the facility failed to provide residents who were unable to carry out activities of daily living (ADLs) the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for one (#1) of three residents reviewed out of 27 sample residents. Specifically the facility failed to -Offer repositioning to Resident #1, and;-Provide assistance with toileting for Resident #1. Findings include: I. Resident #1A. Resident status Resident #1, age [AGE], was admitted on [DATE] and readmitted [DATE]. According to the August 2025 computerized physician's orders (CPO), diagnoses included acute respiratory failure, irritable bowel syndrome, osteoarthritis and history of pneumonia. The 5/19/25 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for a mental status (BIMS) score of 14 out of 15. She required substantial/maximal staff assistance with chair/bed to chair transfer with and substantial/maximal staff assistance with toileting transfers. B. Resident interview.Resident #1 was interviewed on 8/4/25 at 3:32 p.m. The resident said she was supposed to be checked every two hours because she needed help going to the bathroom. She said the nursing staff did not check on her. Resident #1 said she had to make sure she did not drink too much water so she did not go to the bathroom. C. Observations During a continuous observation on 8/5/25, beginning at 12:30 p.m. and ending at 4:12 p.m., the following was observed: At 12:33 p.m. Resident #1 was in bed eating her lunch and watching television. At 12:45 p.m. an unidentified staff member went into Resident #1's room. The staff member asked the resident if she was done with her meal and removed her lunch tray.At 12:55 p.m. Resident #1 was in bed lying on her back watching television.At 1:30 p.m. Resident #1 remained in bed lying on her back looking at a book with her television on.At 1:50 p.m. Resident #1 was in bed lying on her back watching televisionAt 2:15 p.m. the nursing home administrator (NHA) brought a vase of flowers into the resident's room. -However, the NHA did not ask the resident if she needed to be repositioned or use the restroom.At 3:30 p.m. Resident #1 was in her bed watching television.At 4:06 p.m. Resident #1 initiated her call light for assistance.At 4:12 p.m. certified nurse's aide (CNA) #1 and registered nurse (RN) #2 went into Resident #1's room to answer her call light. CNA #1 and RN #2 changed the resident's brief. The resident's brief was saturated with urine. There was a blue line on the outside of the brief that indicated the brief was wet.-The resident was not provided incontinence care from 12:30 p.m to 4:12 p.m. D. Record review The ADL care plan, initiated on 3/27/24 and revised on 5/28/25, revealed Resident #1 had a self-care performance deficit. Pertinent interventions included the resident required staff assistance for repositioning-However, observations revealed staff failed to offer or provide Resident #1 with repositioning for four hours (see observations above).E. Staff interviewsCNA #1 was interviewed on 8/5/25 at 4:21 p.m. CNA #1 said the staff needed to check on Resident #1 every two hours. CNA #1 said he was busy and was unable to check on the resident. CNA #1 said it was important to check the residents every two hours because they may need assistance changing out of the wet brief. He said if a resident stayed in a wet brief for more than two hours, it can lead to urinary infections or skin breakdown. RN #2 was interviewed on 8/6/25 at 10:18 a.m. RN #2 said Resident #1 required staff assistance for toileting. RN #2 said it was the responsibility of the nursing staff to check on the resident every two hours to make sure she was not sitting for prolonged periods in a wet brief. The director of nursing (DON) and the NHA were interviewed together on 8/7/25 at 2:35 p.m. The DON said the nursing staff should be checking on residents who were dependent on staff for toiling assistance at a minimum of every two hours. The DON said if the staff did not stick with the two hour time frame for providing incontinence care, it could expose the resident to developing skin breakdown or urinary infections. The NHA said she would provide education to the nursing staff regarding providing the residents with according to their care plan. The NHA said adhering to the resident's care plan in regards to incontinent care to maintain skin integrity was important.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to ensure one (#8) of two residents reviewed for respiratory care out of 27 sample residents were provided respiratory care consistent with professional standards of practice.Specifically, the facility failed to ensure cleaning and proper care of Resident #8's CPAP (continuous positive airway pressure) machine according to manufacturer's instructions and per physician's orders.Findings include:I. Facility policy and procedureThe CPAP/BiPAP (bilevel positive airway pressure) Support and Cleaning, Respiratory and Pulmonary Conditions policy and procedure, revised March 2015, was provided by the nursing home administrator (NHA) on 8/7/25 at 4:37 p.m. It read in pertinent part, Purpose: To provide the spontaneously breathing resident with continuous positive airway pressure with or without supplemental oxygen; To improve arterial oxygenation (Pa02) in residents with respiratory insufficiency, obstructive sleep apnea, or restrictive/obstructive lung disease; To promote resident comfort and safety. General Guidelines for Cleaning: These are general guidelines for cleaning. Specific cleaning instructions are obtained from the manufacturer/supplier of the PAP device. These guidelines are for single-resident use cleaning. Machines must be preprocessed for use between residents by the supplier of the device. Machine cleaning: Wipe machine with warm, soapy water and rinse at least once a week and as needed. Humidifier (if used): Use clean, distilled water only in the humidifier chamber. Clean humidifier weekly and air dry. To disinfect, place vinegar-water solution (one to three ratio) in a clean humidifier. Soak for 30 minutes and rinse thoroughly. Filter cleaning: Rinse washable filter under running water once a week to remove dust and debris. Replace this filter at least once a year. Replace disposable filters monthly. Masks, nasal pillows and tubing: Clean daily by placing in warm, soapy water and soaking/agitating for five minutes. Mild dish detergent is recommended. Rinse with warm water and allow it to air dry between uses. Headgear (strap): Wash with warm water and mild detergent as needed. Allow to air dry. Document the following in the resident's medical record: general assessment (including vital signs, oxygen saturation, respiratory, circulatory and gastrointestinal status) prior to procedure; time CPAP was started and duration of the therapy; mode and settings for the CPAP; oxygen concentration and flow, if used; how the resident tolerated the procedure; and oxygen saturation during therapy.II. Manufacturer's instructionsThe [NAME] Respironics CPAP Machine cleaning instructions were provided by the NHA on 8/6/25 at 5:35 p.m. It read in pertinent part, - Daily Cleaning: Items to clean: Mask cushion, tubing (optional), and humidifier chamber (if used); Unplug the CPAP machine; Disassemble the mask - separate the cushion from the frame and headgear; Wash the mask cushion in warm water with mild, non-antibacterial soap. Rinse thoroughly. If desired, rinse the tubing with warm water (not necessary daily unless visibly soiled). Empty the humidifier chamber (if applicable), rinse with warm water, and let air dry. Air dry all parts on a clean towel - do not expose to direct sunlight. Wipe the CPAP unit exterior with a dry cloth - do not submerge or spray with water. Weekly Cleaning: Items to clean: Tubing, mask frame, headgear, humidifier chamber. Soak the tubing, mask frame, headgear, and humidifier chamber in warm, soapy water for 15-30 minutes. Rinse all items thoroughly to remove all soap residue. Hang tubing to air dry - make sure it dries completely before reconnecting. Wipe the outside of the CPAP device with a soft, damp cloth. Monthly Cleaning: Items to check/replace/clean: Air filter. Inspect the reusable pollen filter (gray foam) for dust or discoloration.Wash gently with water if reusable. Let dry completely before reinserting. If using a disposable fine filter (white), replace it monthly or as needed (do not wash). Check for signs of wear and tear on the mask, tubing, and chamber. Do Not Use: Bleach, alcohol, antibacterial soap, or harsh cleaners. Dishwasher (unless your model specifically states parts are dishwasher-safe). Direct sunlight to dry. Machine parts while wet. Replacement Schedule (General Guidelines): Mask cushion/pillows are replaced every two to four weeks; Tubing replaced every three months; Humidifier chamber replaced every six months; Filter (disposable) replace monthly; Filter (reusable foam) replace after six months (wash monthly). Full mask/headgear replaced every six months.III. Resident #8A. Resident statusResident #8, age greater than 65, was admitted on [DATE] and readmitted on [DATE]. According to the August 2025 computerized physician orders (CPO), diagnoses included hemiplegia (paralysis on the right side), traumatic brain injury, cognitive communication deficit, status post fracture of right pubis (pelvis) and sleep apnea. The 5/29/25 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 13 out of 15. She was dependent with bed to chair transfers, toilet transfers and shower transfers. She required substantial/maximal assistance with bed mobility, showering, and lower body dressing. She required partial/moderate assistance for personal hygiene and was independent with eating.The assessment indicated the resident had functional limitation in range of motion with impairment on one side in the upper and lower extremities. B. Resident interview and observationResident #8 was interviewed on 8/4/25 at 2:42 p.m. Resident #8 said she used a CPAP machine but it did not have distilled water in it because the facility ran out of water last week. The CPAP machine sat on a small shelf next to the bed, the large tubing was touching the floor. The CPAP mask was sitting on top of the machine under the shelf. Resident #8 said she cleaned the CPAP mask herself by giving the mask a quick rinse with water in the sink in the morning. Resident #8 mimicked with her left arm running the mask under the facet. Resident #8 said she never used soap to clean the CPAP mask or machine, only water. Resident #8 said the staff never cleaned her machine so she just did it.C. Record reviewReview of Resident #8's CPAP care plan, initiated 11/11/18 and revised 12/11/22, revealed the resident was at risk for altered breathing patterns/altered gas exchange/ineffective air exchange related to asthma as evidenced by wheezing, need for aerosol/inhaler medications and CPAP at resting hours. Pertinent interventions included monitoring the use of the CPAP machine every night shift, initiated 11/16/23. -The care plan failed to include cleaning frequency for the CPAP or cleaning instructions.Review of Resident #8's August 2025 CPO revealed the following physician's orders related to the resident's CPAP machine: CPAP at night time only. Every night shift clean equipment per manufacturer recommendations daily. Resident to perform daily cleaning, ordered 11/28/18.-However there was no documentation on the medication administration record/treatment administration record (MAR/TAR) that this was being completed.Monitor proper use of CPAP every night shift, ordered 10/24/23.Resident requires the use of CPAP supplies related to sleep apnea, ordered 2/21/24.IV. Staff interviewsThe NHA and the director of nursing (DON) were interviewed together on 8/7/25 at 12:49 p.m. The NHA said she had no documentation that Resident #8 was instructed how to clean her CPAP machine and that the facility should be doing that. The DON said she added a new physician's order (during the survey) for the nurses to be cleaning Resident #8's CPAP machine. She said Resident #8 should not be cleaning her own equipment, especially since she had a disabled arm. The NHA and the DON said Resident #8's CPAP machine was not being cleaned per the manufacturer's recommendations but it should be for best practice and hygiene.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to ensure that a resident who was a trauma survivor received culturally competent, trauma-informed care in accordance with professional standards of practice and accounting for residents' experiences and preferences in order to eliminate or mitigate triggers that may cause re-traumatization of the resident for one (#42) of five residents with a documented history of trauma out of 27 sample residents.Specifically, the facility failed to identify and create a person-centered individualized care plan that addressed Resident #42's past history of trauma, and/or triggers which may cause re-traumatization and train staff on the residents trauma and triggers.Findings include:I. Resident #42A. Resident statusResident #42, age [AGE], was admitted on [DATE]. According to the August 2025 computerized physician orders (CPO), diagnoses included Alzheimer's disease and delusional disorder (false beliefs).The 6/5/25 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. The resident's health questionnaire (PHQ-9) assessment for depression scored zero out of 27 which indicated no depression. B. Resident representative interviewResident #42's representative was interviewed on 8/7/25 at 10:25 a.m. The representative said that Resident #42 became increasingly agitated and distressed due to staff interventions and the lack of trauma-informed care. The representative said that no assessment, evaluation or written consent had been completed to guide staff in supporting the resident's trauma history. She said that the resident refused to return to her previous room in the unsecured unit and was frustrated and upset with staff interactions. C. Resident interviewResident #42 was interviewed on 8/5/25 at 11:47 a.m. Resident #42 said her daughter had brought her to the facility three years earlier and had told her to take a look inside and see if she liked it, but then had left her there and dumped her. She said she did not come to the facility out of her own free will and had felt people in the facility had hurt her emotionally. She said she had come to the secured unit after an incident when she wanted to be taken to the store before it closed at 7:00 p.m. to get hairspray. She said staff at the front desk had said someone would take her, but as it was getting closer to 7:00 p.m., she had become worried. She said she realized the staff had no intention of taking her to the store and perceived they were laughing at her. She said she decided to walk to the store herself. She said she was not sure how it happened, but then several staff members tried to stop her and she became fearful. She said she had been told she was free to leave the facility whenever she wanted and then they would not let her. She said as a result of being fearful of staff, she asked to stay the night in an empty room and had been brought to the locked unit. Resident #42 said she felt awful about being in a place where the door would not open and she had been very unhappy in the unit. She said she had also been fearful of moving back to the other side of the building because she believed she had been physically attacked by staff when trying to go to the store. She said she was scared of some of the men on the secured unit and that they would knock on her door at night. She said there was a man who pushed on the exit door and set the alarm off all of the time. She said she could not talk to the other residents in the secured unit because they did not understand what she was saying. She said she had asked for the code to the door and had reiterated she was supposed to be able to leave whenever she wanted, but she did not know the code to the locked door.Cross reference F603 for failure to keep residents free from involuntary seclusion. D. Record reviewThe Colorado preadmission screening and resident review (PASRR) Level II notice of determination for mental illness, dated 2/1/23, documented that Resident #42 had a PASRR condition of delusional disorder. The PASRR Level II evaluation indicated the resident had a known or suspected diagnosis of a major mental illness. The PASRR Level II identified that the resident had a history of trauma and recommended individual therapy as a specialized service. -However, Resident #42 did not have a care plan that addressed the trauma identified in the PASRR Level II, the triggers or person-centered individualized interventions to prevent re-traumatization.The social services director (SSD) updated Resident #42's care plan, during the survey on 8/5/25, and addressed the resident's preferences, triggers, and need for individualized trauma-informed approaches. New interventions included avoiding speaking with Resident #42 about her daughter unless Resident #42 brought her up, monitoring and reviewing with the resident regularly and obtaining the resident's and her representative's consent for the resident to remain in the secured memory unit as it made Resident #42 feel safe. -However, the care plan was not updated to include person-centered individualized interventions, personalized triggers or personalized signs and symptoms to prevent re-traumatization of Resident #42. The behavioral care plan, initiated 12/20/22 and revised 3/28/24, documented that Resident #42 had delirium related to unspecified dementia with behavioral disturbances and delusional disorder. Pertinent interventions included monitoring intake and output, observing environmental factors and signs of delirium, providing gentle reorientation, maintaining consistent routines and caregivers, monitoring cognitive changes, providing activities suited to abilities, administering medications with monitoring and communicating with the resident and family.-However, the care plan did not address the trauma identified in the PASRR Level II (see above) and it did not include person-centered individualized interventions, specific triggers or personalized signs and symptoms to prevent re-traumatization of Resident #42.The trauma life event screening questionnaire, dated 7/31/25, revealed that Resident #42 had experienced significant and repeated traumatic events throughout her life. The screening documented the following traumatic events:-Physical assault, such as being attacked, hit, slapped, kicked, or beaten up;-Assault with a weapon, such as being shot, stabbed, or threatened with a knife, gun or bomb;-Combat or exposure to a war zone, either in the military or as a civilian;-Captivity, such as being kidnapped, abducted, held hostage, or being a prisoner of war;-Severe human suffering;-Loss of home or property, such as through homelessness or divorce;-Witness to a sudden violent death;-Upsetting thoughts or memories about the above-mentioned events that came into her mind against her will;-Feeling as though the above-mentioned events were happening again;-Feeling upset by reminders of the above-mentioned events;-Talking about the above-mentioned events induced bodily reactions, such as a fast heartbeat or stomach churning;-Experiencing irritability or outbursts of anger;-Feeling jumpy or startled by something unexpected; and,-Heightened awareness of potential dangers to herself and others.II. Staff interviewsThe nursing home administrator (NHA) was interviewed on 8/5/25 at 12:03 p.m. The NHA said Resident #42 suffered a lot of trauma from World War 2 where her family had to flee and hide. She said she had behaviors related to that trauma (barricading herself in her room, paranoia) and her daughter had told the facility the resident had always been this way.Certified nurse aide (CNA) #5 was interviewed on 8/5/25 at 1:27 p.m. CNA #5 said Resident #42 previously lived in the 200 hall and would not allow staff into her room in the morning, displayed paranoia and barricaded her door. CNA #5 said she did not know of any interventions that worked with the resident.CNA #6 was interviewed on 8/6/25 at 11:44 a.m. CNA #6 said Resident #42 preferred to be alone in her room and became triggered when staff repeatedly asked her questions or knocked on her door. He said the staff attempted interventions for the resident that included allowing her to lock her room, providing choices, not touching her personal items without permission and knocking before entering.The social services director (SSD) and the memory care director were interviewed together on 8/6/25 at 2:03 p.m. The SSD said that when a new resident was admitted , if staff discovered any signs of trauma, the facility added it to the care plan and offered the resident a visit to the facility's clinic. The SSD said that after trauma was identified, a trauma evaluation was completed to identify triggers, such as past caregiver incidents. The SSD said psychological services were offered, and the facility was working with a company to provide that service consistently. The SSD said interventions listed in the care plan would trigger updates to the Kardex (a tool utilized by staff to provide consistent resident care) and staff were educated on how to approach residents with trauma. The SSD said Resident #42's triggers were documented in her care plan. The SSD said the behavior binder the facility kept at the nurses' station for staff reference could be a little more specific for a better trauma-informed approach. The SSD said moving forward, resident's trauma-related triggers would be taken to the interdisciplinary team (IDT) and Resident #42 would be offered the option to return to the unsecured unit while maintaining the same interventions. The SSD said the resident had refused occupational therapy (OT) and physical therapy (PT) had been offered multiple times, but the resident had refused every attempt.The memory care director said that when a resident had identified trauma, she considered potential triggers, spoke with the resident and the resident's family about the trauma and triggers, and created a plan of care. The memory care director said a trauma assessment was completed with Resident #42 two to three weeks ago. The memory care director said the resident was open about her past life and reported being held captive in Russia for 10 years, that her family could not survive and that her family was shot in front of her. The memory care director said the resident's triggers included family-related triggers. The memory care director said the resident had thought people were coming from the television and believed it was her daughter, which had been a recurring issue. The memory care director said she had not provided staff with any information regarding Resident #42's trauma history because she was concerned the resident might overhear staff discussing it or that staff would be unable to act surprised if they already knew. The memory care director said the facility did not list specific triggers in the behavior binder because talking about them could have created more anxiety for the resident. The memory care director said she was concerned that staff knowing specific details of the resident's trauma history could worsen the issue. The memory care director said she understood that providing staff with Resident #42's triggers and interventions related to her trauma would help prevent incidents of re-traumatization. The social services consultant was interviewed on 8/6/25 at 4:09 p.m. The social services consultant said that all staff working with a resident needed to be aware of their trauma triggers to prevent re-traumatizing the resident. She said if staff were not aware of triggers, it would put the resident at higher risk of being traumatized repeatedly. The NHA and the director of nursing (DON) were interviewed together on 8/7/25 at 12:49 p.m. The NHA said it was important for staff to know a resident's trauma history in order to prevent future behaviors, to maintain emotional and physical safety and to improve quality of life. She said the facility did a lot of education with the staff prior to taking care of a new resident with trauma; however, this education was not documented and was primarily verbal. She said Resident #42 went to the secure unit as a trauma response after she was triggered by a CNA trying to redirect her back into the building when she wanted to leave.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observations, and interviews, the facility failed to identify and address the behavioral health care needs of two (#45 and #32) of 10 residents out of 27 sample residents. Specifically, the facility failed to:-Develop individualized interventions related to psychotropic medications for Resident #45 and Resident #32; and,-Consistently document the non-pharmacological interventions that were attempted and/or effective for Resident #45 and Resident #32's behaviors.Findings include:I. Facility policy and procedureThe Behavior Assessment, Intervention, and Monitoring policy, undated, was provided by the nursing home administrator (NHA) on 8/6/25 at 2:01 p.m. It read in pertinent part,Interventions are individualized and part of an overall care environment that supports physical, functional, and psychosocial needs and strives to understand, prevent or relieve the residents distress or loss of abilities.Non-pharmacological approaches are used to the extent possible to avoid or reduce the use of psychotropic medications to manage behavioral symptoms. Psychotropic medications are prescribed for behavioral symptoms and documentation includes; rationale for use, potential underlying causes of the behavior, non- pharmacological approaches and interventions tried prior to the use of the psychotropic medication, specific target behaviors and expected outcomes, monitoring for efficacy and adverse consequences, and plans (if applicable) for gradual dose reductions.II. Resident #45A. Resident statusResident #45, age [AGE], was admitted on [DATE]. According to the August 2025 computerized physician orders (CPO), diagnoses included unspecified dementia and a traumatic brain injury (TBI). The 7/2/25 minimum data set (MDS) assessment revealed the resident had severe cognitive impairments and was unable to participate in the brief interview for mental status (BIMS) assessment. A staff interview for mental status revealed the resident had short and long term memory impairments and had severe impairments to her daily decision-making skills. The MDS assessment indicated the resident had behaviors not directed at others (physical symptoms such as scratching self, pacing, smearing bodily fluids or food, disrobing, public sexual acts, screaming or disruptive sounds), physical and verbal aggression, rejecting care and wandering. The resident additionally experienced delusions. B. Resident observationDuring a continuous observation of Resident #45 on 8/5/25, beginning at 11:04 a.m. and ending at 1:24 p.m., the resident was observed pacing back and forth across the secure unit. No staff members attempted to offer any interventions to the resident to redirect her from her continuous pacing or engage with her while she paced. C. Record reviewResident #45's behavior care plan, revised 6/13/25, revealed the resident had behaviors of verbal aggression with other residents related to dementia and a history of TBI. The resident paced and wandered to the point of exhaustion, lacked awareness of others' space and would enter others' rooms, experienced paranoia, struck out at others unprovoked due to agitation, and did not get along with another female resident on the unit and would altercate with her if in close proximity. Interventions included redirecting the resident from others' space, allowing the resident to sit in chairs in the hallway, offering finger foods while pacing, engaging with the resident when passing her in the hallway, offering her sweet treats, offering the resident compliments on her appearance and offering to paint the resident's nails. Resident #45's mood care plan, revised 7/9/25, revealed the resident had a mood problem related to the disease process of dementia with behavioral disturbances. Interventions included observing for signs and symptoms of mania or hypomania, racing thoughts or euphoria, increased irritability, frequent mood changes, pressured speech, flight of ideas, marked change in need for sleep and agitation or hyperactivity. Resident #45's psychosocial care plan, revised 7/22/25, revealed the resident took antipsychotic medications for agitation related to dementia with a target behavior of striking out at others. Interventions included consulting with the pharmacist and the physician to consider dosage reductions when clinically appropriate at least quarterly (initiated 1/16/25), monitoring and documenting occurrence of target behaviors symptoms and updating target behavior documentation as needed (initiated 1/16/25) and trying non-pharmacological interventions, such as one-on-one, redirect, offer food/fluids, toilet, remove from situation, activity, assess for pain, or massage/back rub (initiated 5/27/25). Review of Resident #45's August 2025 CPO revealed the following physician's orders:Rexulti (an antipsychotic medication) 1 milligram (mg) tablet. Give one 1 mg tablet one time a day for dementia with agitation, ordered 1/2/25 and increased 6/7/25.Rexulti 3 mg tablet. Give 0.5 tablet (1.5 mg) by mouth twice a day for Alzheimer's disease, ordered 6/7/25. Trazodone (antidepressant medication) 50 mg tablet. Give 75 mg at bedtime for insomnia, ordered 3/21/25. Monitor for behaviors of agitation due to dementia for Rexulti. Use non-pharmacological interventions 1. Refused. 2. One-on-one. 3. Redirect. 4. Offer snacks/fluids. 5. Toilet. 6. Remove from the situation. 7. Offer activity. 8. Assess for pain. 9. Massage/back rub. 9. See nurses note for additional information, ordered 5/1/25 and discontinued 7/14/25. Lamotrigine (mood stabilizer) 100 mg. Give one tablet twice a day for hypomania, ordered 5/12/25.Monitor for behaviors of 1. Restlessness. 2. Pacing to the point of exhaustion. 3. Irritability associated with Lamotrigine. Use non-pharmacological interventions 1. Redirect. 2. Reposition. 3. Offer snacks. 4. Offer fluids. 5. Adjust room temperature. 6. Distraction/offer activity. 7. See nurses note for additional information, ordered 7/14/25.Monitor for behaviors of inability to sleep associated with Trazodone. Use non-pharmacological interventions 1. Redirect. 2. Reposition. 3. Offer snacks. 4. Offer fluids. 5. Adjust room temperature. 6. Distraction/offer activity. 7. See nurses note for additional information, ordered 7/14/25.Trazodone 50 mg tablet. Give one tablet in the morning for insomnia and depression, ordered 7/22/25.Monitor for behaviors of striking others unprovoked associated with Rexulit. Use non-pharmacological interventions 1. Redirect. 2. Reposition. 3. Offer snacks. 4. Offer fluids. 5. Adjust room temperature. 6. Distraction/offer activity. 7. See nurses note for additional information, ordered 7/22/25.Hydroxyzine (antihistamine used for anxiety) 25 mg. Give one tablet every six hours as needed for anxiety/agitation related to unspecified dementia, ordered 6/7/25 and discontinued 6/20/25.-The non-pharmacological interventions documented for all three of Resident #45's active behavior monitoring physician's orders indicated the same identical, non person-centered non-pharmacological interventions were to be used for every behavior, regardless of the behavior. Review of Resident #45's progress notes, from 6/4/25 to 8/4/25, revealed the following:Resident #45 had 13 episodes of verbal and physical aggression towards others (on 6/4/25, 6/8/25, 6/16/25, 6/17/25, twice on 6/18/25, twice on 6/19/25, twice on 6/20/25, 6/23/25, 6/24/25, and 6/25/25) without identified non-pharmacological interventions attempted. -Of the 13 episodes of verbal and physical aggression towards others, eight times an as needed (PRN) medication was given to the resident for anxiety and agitation. However, there was no documentation to indicate what non-pharmacological interventions were attempted prior to the administration of the medication.-Review of Resident #45's behavior monitoring for June 2025 failed to reveal monitoring had been ordered for the PRN Hydroxyzine. -The electronic medical record (EMR) failed to reveal which identified non-pharmacological interventions had been attempted and if the interventions were effective or not prior to increases in Resident #45's Rexulti or Trazodone. A psychoactive medication evaluation meeting minute note, dated 6/20/25, revealed Resident #45 had an addition of Hydroxyzine for aggressive behaviors, an increase in Rexulti with continued behaviors. Hydroxyzine was discontinued and Trazodone 50 mg was added. A pharmacist consultant report, dated 7/8/25, revealed the pharmacist documented the diagnosis of hypomania for the Lamotrigine needed to be changed to dementia with behaviors with specific behaviors indicated to the Lamotrigine use. -A review of Resident #45's EMR failed to reveal the diagnosis for the Lamotrigine had been corrected or the behaviors of hypomania clarified and monitored. The resident's behavior sheet, undated, which was kept at the nurses' station, was reviewed on 8/5/25. The behavior sheet revealed that Resident #45 had behaviors of being verbally aggressive with others, paranoid about others following her causing verbal aggression, pacing to the point of exhaustion, physical aggression, especially towards Resident #28, and striking out at others unprovoked. Interventions included allowing the resident to rest in chairs placed in the hallway, offering finger foods while walking, smiling and greeting the resident, offering to walk with her if she became paranoid someone was following her, offering her chocolate, allowing her independent visits with her male friend, complimenting her on her appearance, offering to paint her nails when she was pacing or frustrated, offering a milkshake, offering to take her outside for a walk, offering her simple tasks (watering plants, folding napkins, wiping tables), creating space between the resident and others, promoting relaxation (offer back rub, smoothing hair, or soft music), providing one-one-one when agitated, redirecting the resident from taking items from others' rooms and redirecting her when within arm's reach of Resident #28. -Resident #45's behavior monitoring in the August 2025CPO and the behaviors in the care plan failed to include the resident specific and person-centered interventions included on her behavior sheet (see physician's orders and care plan above).III. Resident #32A. Resident statusResident #32, age less than 70, was admitted on [DATE]. According to the August 2025 CPO, diagnoses included anxiety and Wernicke's encephalopathy (alcohol induced encephalopathy). The 6/25/25 MDS assessment revealed the resident had severe cognitive impairments and was unable to participate in the BIMS assessment. A staff interview for mental status revealed the resident had short and long term memory impairments and severe impairments to his daily decision-making making skills. The MDS assessment indicated the resident had behaviors of hallucinations, delusions, rejecting care and wandering. B. Record reviewResident #32's mood care plan, revised 1/1/24, revealed the resident took antianxiety medication related to anxiety with target behaviors of increased pacing, finger wringing, and clenching fists. Interventions, initiated 8/27/23, included redirecting, offering food or fluid, toileting, removing from the situation, offering activities, assessing for pain and offering massage/back rub. Resident #32's depression care plan, revised 10/7/24, revealed the resident took antidepressant medication related to Wernicke's anxiety disorder with target behaviors of negative statements. Interventions, initiated 2/26/24, included monitoring/documenting for side effects of anti-depressant therapy, change in behavior/mood/cognition, hallucinations/delusions, social isolation, suicidal thoughts or withdrawal. Resident #32's psychosocial care plan, revised 3/24/25, revealed the resident took an antipsychotic medication related to Wernicke's encephalopathy with target behaviors of verbal outbursts/threats. Interventions, initiated 8/27/23, included redirecting, offering food or fluid, toileting, removing from the situation, offering activities, assessing for pain and offering massage/back rub.Review of Resident #32's August 2025 CPO revealed the following physician's orders:Lorazepam (an antianxiety medication) 0.5 mg. Give two times a day for anxiety, ordered 2/28/24. Seroquel (an antipsychotic medication) 300 mg. Give one tablet two times a day for Wernicke's encephalopathy, ordered 5/17/24. Sertraline (antidepressant medication) 100 mg tablet. Give one tablet a day for anxiety, ordered 5/17/24.Monitor for behaviors related to antianxiety medication Lorazepam. 1-increased pacing; 2-finger wringing; 3-clenched fists. Use non-pharmological interventions 1. Redirect. 2. Reposition. 3. Offer snacks. 4. Offer fluids. 5. Adjust room temperature. 6. Distraction/offer activity. 7. See nurses note for additional information, ordered 7/11/25.Monitor for behaviors related to antidepressant medication Sertraline. 1-negative statements. Use non-pharmacological interventions 1. Redirect. 2. Reposition. 3. Offer snacks. 4. Offer fluids. 5. Adjust room temperature. 6. Distraction/offer activity. 7. See nurses note for additional information, ordered 7/11/25.Monitor for behaviors related to antipsychotic medication Seroquel. 1-verbal outbursts. 2. Threats. Use non-pharmacological interventions 1. Redirect. 2. Reposition. 3. Offer snacks. 4. Offer fluids. 5. Adjust room temperature. 6. Distraction/offer activity. 7. See nurses note for additional information, ordered 7/11/25.-The non-pharmacological interventions documented for all three of Resident #32's behavior monitoring physician's orders indicated the same identical, non person-centered non-pharmacological interventions were to be used for every behavior, regardless of the behavior. -Review of Resident #32's EMR from 6/1/25 to 8/4/25, revealed no documentation to indicate Resident #32 had displayed any behaviors related to the usage of Lorazepam, Sertraline or Seroquel. A psychoactive medication evaluation meeting minute note, dated 6/20/25, revealed there had been no dose reductions of Resident #32's Seroquel, Sertraline or Lorazepam. The physician note during the meeting indicated Resident #32 was recently moved to the secure unit and he would be getting a roommate, which had historically increased Resident #32's behaviors, anxiety, and distress. The facility was to monitor and assess Resident #32's adjustment. The resident's behavior sheet, undated, which was kept at the nurses' station, was reviewed on 8/5/25. The behavior sheet revealed that Resident #32 had behaviors of becoming aggressive, throwing things, and could become triggered if his roommate's side of the room were cluttered. Resident #32 had an aversion to being around other men and could become fearful and aggressive. Interventions included assisting him to a quiet area, redirecting him from other residents, offering chocolate ice cream or chocolate milk, allowing him to read a book of choice, assisting him in calling his sister, encouraging the resident to stay in his room and reorganize if desired, encouraging the resident to keep a distance from other men, allowing him to sit alone in the dining room or encouraging female peers to sit with him, allowing him to watch the television in the dayroom and offering to assist the resident in tidying his personal space. -Resident #32's behavior monitoring from the August 2025 CPO and the behaviors in the care plan failed to include the resident specific and person-centered interventions included on his behavior sheet (see physician's orders and care plan above).IV. Staff interviewsCertified nurse aide (CNA) #5 was interviewed on 8/5/25 at 1:27 p.m. She said Resident #45 had behaviors of walking continuously throughout the day and becoming agitated around too many residents and overstimulated. CNA #5 was unaware of non-pharmacological interventions that helped for Resident #45. CNA #5 said Resident #32 had behaviors of becoming agitated and throwing things. CNA #5 said Resident #32 could become depressed, tearful and focused on going home. CNA #5 said interventions that worked for Resident #32 were to offer him a less stimulating environment, offer to take him outside for a walk or talk to him about the Bible. CNA #5 was unaware Resident #32 had behavioral triggers related to being around other males. CNA #5 said the staff found resident behaviors and interventions in the behavior book at the nurses' station, however CNA #5 said she did not use the behavior book because she knew the residents. CNA #5 said the CNAs documented behaviors on the CNA behavior monitoring task but the behaviors and interventions indicated on the task were generic and the same for all the residents. CNA #2 was interviewed on 8/5/25 at 3:05 p.m. CNA #2 said Resident #45 had behaviors of pacing and an intervention that worked for her was to take her outside for a walk. CNA #2 said Resident #32 had behaviors of becoming agitated and staff had to redirect him to his room.Registered nurse (RN) #3 was interviewed on 8/5/25 at 3:15 p.m. RN #3 said Resident #45 had behaviors of pacing and the interventions that worked for her were to offer her chocolate milk and space. RN #3 said Resident #32 did not really have behaviors and he liked to read, have soda and sit alone in the dining room.CNA #6 was interviewed on 8/6/25 at 11:44 a.m. CNA #6 said he had been at the facility for six months. CNA #6 needed to retrieve the behavior binder because he could not recall the person-centered interventions or resident specific behaviors for Resident #45 and Resident #32. He read the behaviors and interventions from the binder. CNA #6 said the CNAs did not document behaviors but told the nurse, who then would document it in the progress notes.The memory care director and the social services director (SSD) were interviewed together on 8/6/25 at 2:00 p.m. The SSD said that he was fairly involved with the psychoactive medication reviews and that he reviewed the activity assessments and social service assessments when preparing for the psychotropic medication meeting. The SSD said the behavior monitoring orders on the list in the physician's orders documented specific behaviors for the resident's psychoactive medications along with specific non-pharmacological interventions that should also match the interventions in the resident's care plan.-However, the non-pharmacological interventions listed for each of Resident #45 and Resident #32's psychotropic medications were identical for each medication, despite what behavior might be exhibited (see record review above).The NHA and the director of nursing (DON) were interviewed together on 8/7/25 at 12:50 p.m. The DON said that the facility determined the efficacy of psychoactive medications being administered by using behavior monitoring physician's orders within the MAR with resident specific behaviors listed. She said her expectation was that the nurses documented behaviors on the MAR and also put in a behavior progress note to include the non-pharmological interventions attempted. The DON said that there should be non-pharmacological interventions on the behavior monitoring order for the nurses. She said that non-pharmacological interventions were important because the facility did not want to use psychotropic medications as a first resort and instead wanted to use non-pharmacological interventions first because it was more humane and ethical for the care of the resident. The DON said that the behavior monitoring physician's orders provided data that was used during the psychotropic drug meeting to decide on increasing medications or considering gradual dose reductions. She said that she continuously trained her staff on where to find the non-pharmacological interventions and what they were, as well as providing education on triggers. The DON was unaware that the CNAs and nursing staff on the secure unit were not consistent in knowing where to find behaviors and interventions for residents.The NHA said that if the staff were not consistently or accurately documenting resident behaviors, it would be difficult to determine the effectiveness of the medications and this prevented the monitoring from demonstrating a clear picture of behaviors.

Based on observations and interviews, the facility failed to ensure infection prevention and control programs (IPCP) were maintained and followed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections on two of three units. Specifically, the facility failed to: -Ensure staff performed hand hygiene prior to providing wound care for Resident #19;-Ensure staff followed appropriate infection control guidelines for handling of wound care supplies for Resident #19; and,-Ensure staff wore the appropriate personal protective equipment (PPE) when providing incontinence care for Resident #6, who was on enhanced barrier precautions (EBP) for having an indwelling urinary catheter.Findings include:I. Failed to ensure staff performed hand hygiene prior to providing wound care and handled wound care supplies appropriately for Resident #19 A. Observations On 8/4/25 at 2:39 p.m. Resident #19's right foot was observed to be wrapped with wound dressings.On 8/6/25 at 10:26 a.m. registered nurse (RN) #4 entered Resident #19's room to complete wound care for the resident. RN #4 donned gloves and a gown prior to entering the room. -However, RN #4 failed to complete hand hygiene prior to donning the gown and gloves and before proceeding to perform the resident's wound care.On 8/6/25 at 10:27 a.m., after completing wound care for Resident #19, RN #4 dropped a partially opened package of medical gauze that was used for the resident's wound care bandages on the floor. The opened package of gauze landed upside down on the floor, with the exposed gauze touching the floor. RN #4 picked up the package of gauze and proceeded to place the package of gauze into a clean medical supply basket designated for Resident #19. -RN #4 placed contaminated medical wound dressing supplies into a clean basket of medical supplies.II. Failed to ensure staff wore the appropriate PPE when providing incontinence care for Resident #6, who was on EBP for having an indwelling urinary catheterA. Professional referenceAccording to the Centers for Disease Control and Prevention's (CDC) Implementation of Personal Protective Equipment (PPE) Use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDROs), retrieved on 8/10/25 from https://www.cdc.gov/long-term-care-facilities/hcp/prevent-mdro/PPE.html, It read in pertinent parts,Enhanced barrier precautions (EBP) are an infection control intervention designed to reduce transmission of resistant organisms that employ targeted gown and glove use during high contact resident care activities. Nursing home residents with wounds and indwelling medical devices are at especially high risk of both acquisition of and colonization with MDROs. The use of gown and gloves for high-contact resident care activities is indicated, when contact precautions do not otherwise apply, for nursing home residents with wounds and/or indwelling medical devices regardless of MDRO colonization, as well as for residents with MDRO infection or colonization. Examples of high-contact resident care activities requiring gown and glove use for enhanced barrier precautions include dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, device care or use (central line, urinary catheter, feeding tube, tracheostomy/ventilator) and wound care, any skin opening requiring a dressing.B. Facility policy and procedureThe Enhanced Barrier Precautions policy, undated, was received from the nursing home administrator (NHA) on 8/6/25 at 1:49 p.m. The policy read in pertinent part, Enhanced barrier precautions (EBP) are utilized to prevent the spread of multi-drug resistant organisms (MDRO) to residents. Enhanced barrier precautions refer to infection prevention and control interventions designed to reduce the transmission of multi drug resistant organisms during high contact resident care activities. EBP apply when a resident is not known to be infected or colonized with any MDRO, has a wound or indwelling medical device, and does not have secretions or excretions that are unable to be covered or contained. Examples of high contact resident care activities requiring the use of gown and gloves for EBPs include dressing, bathing or showering, providing hygiene or grooming, changing briefs or assisting with toileting, transferring, providing bed mobility, changing linens, prolonged, high contact with items in the residence room, with residents equipment, or with residents clothing or skin, device care or use including central lines urinary catheters feeding tubes tracheostomies or ventilators, and wound care. C. Observations On 8/4/25 at 2:25 p.m. there was a sign on Resident #6's door that indicated the resident was on EBP. The sign on the resident's door indicated gloves and a gown must be worn for resident care activities, including dressing, bathing/showering, transferring, linen changes, providing hygiene, changing briefs or assisting with toileting and device care or use, such as central lines, urinary catheters, feeding tubes, tracheostomies and wound care. On 8/4/25 at 2:39 p.m. Resident #6 was sitting on his bed. He had an indwelling urinary catheter draining yellow urine attached to his bed. On 8/7/25 at 11:12 a.m. certified nurse aid (CNA) #3 was providing incontinence care to Resident #6. -However, CNA #3 failed to put on a protective gown prior to providing incontinence care to Resident #6, who was on EBP.D. Resident interviewOn 8/4/25 at 3:50 p.m. Resident #6 said he only needed help with using the bathroom and staff would assist him with that task. He said the staff did not wear a gown when they were assisting him with toileting.III. Staff interviewsRN #1 was interviewed on 8/5/25 at 12:05 p.m. RN #1 said Resident #6 was on enhanced barrier precautions because he had a Foley catheter. She said staff were supposed to wear a gown and gloves when emptying his Foley catheter and assisting him to the bathroom. She said nursing staff were supposed to wash or sanitize their hands before entering and exiting the room when providing direct care to residents on EBP.RN #4 was interviewed on 8/6/25 at 10:30 a.m. RN #4 said staff were supposed to wash their hands before entering a resident's room to provide wound care in order to prevent the spread of germs and potential infections. RN #4 said if medical supplies were dropped on the floor, they should be discarded because they were considered contaminated. RN #4 said she was moving too quickly after providing wound care for Resident #19 and did not realize she dropped the clean bandages on the floor before placing them back into the clean supply bin. CNA #3 was interviewed on 8/7/25 at 11:30 a.m. CNA #3 said she thought she only needed to wear a gown for Resident #6 if she emptied his indwelling Foley catheter. CNA #3 said she was agency staff and was not provided with any education on enhanced barrier precautions before working in the facility. CNA #4 was interviewed on 8/7/25 at 11:59 a.m. CNA #4 said she did not receive any specific education from the facility regarding EBP. However, she said she knew to wear a gown and gloves whenever she came in close contact with any resident that had a wound or a Foley catheter. CNA #4 said she understood the importance of the need to maintain EBP to prevent the spread of infections. The infection preventionist (IP) and the director of nursing (DON) were interviewed together on 8/6/25 2:00 p.m. The IP said she conducted audits for hand washing in addition to educating staff on infection protocol and policy. The IP said the staff should wash or disinfect their hands before entering a resident's room and after the staff exited the room. She said it was important to maintain EBP precautions to prevent the spread of infectious organisms throughout the facility. The IP said Resident #6 was currently being treated for a urinary tract infection and Resident #19 had wounds on his foot. The IP said both of these residents had portals of entry for infections which lead them to be highly susceptible to acquiring an infection.The DON said all nursing staff were provided education regarding EBP and she said staff would be re-educated accordingly. She said it was important that the staff understood the proper policies and procedures to protect the health of the facility's residents. The DON and the NHA were interviewed together on 8/7/25 at 2:35 p.m. DON said if medical supplies were dropped on the floor, they needed to be thrown into the trash and not placed back into an area designated for clean, uncontaminated items because they were considered dirty at that time. The NHA said nursing staff were to follow the policies and procedures in place for enhanced barrier precautions.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interviews, the facility failed to develop an antibiotic stewardship program that promotes the appropriate use of antibiotics and includes a system of monitoring to improve resident outcomes and reduce antibiotic resistance for one (#6) of two residents out of 27 sample residents. Specifically, the facility failed to ensure clinical signs and symptoms of an infection were identified and/or culture results were obtained prior to the administration of antibiotics for Resident #6.Findings include:I. Professional referenceThe Centers for Disease Control and Prevention's (CDC) Antibiotic Prescribing and Usage in Hospitals and Long-term Care, dated 2019, was retrieved on 8/10/25 from https://www.cdc.gov/antibiotic-use/hcp/core-elements/hospital.html. It read in pertinent part,Implement policies that apply in all situations to support antibiotic prescribing to include specifying the dose, duration and indication for all courses of antibiotics so that they are readily identifiable. Implement facility specific treatment recommendations, based upon the national guidelines and local susceptibilities and formulary options that optimizes antibiotic selections, duration, and common indications for the usage of community acquired pneumonia, urinary tract infections, skin and soft tissue infections.II. Resident #6 A. Resident statusResident #6, age [AGE], was admitted on [DATE]. According to the August 2025 computerized physician orders (CPO), diagnoses included congestive heart failure, anemia, hypertension (high blood pressure), benign prostate hyperplasia (BPH - an enlargement of the prostate), obstructive uropathy (a condition where urine flow is blocked, causing a backup of urine into the kidneys) and asthma. According to the 6/9/25 minimum data set (MDS) assessment, Resident #6 was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. He required minimal assistance for showering/bathing, dressing and transferring. The MDS assessment revealed the resident was receiving an antibiotic medication.B. Resident interview Resident #6 was interviewed on 8/4/25 at 2:55 p.m. Resident #6 said he had a catheter because he retained urine. Resident#6 did not think he had any infections.C. Record review Review of Resident #6's August 2025 CPO revealed the following physician's order:Cefdinir (antibiotic) oral tablet 300 milligrams (mg). Give one tablet by mouth two times a day for urinary tract infection (UTI) for five days, ordered 8/1/25.The 7/30/25 nursing progress notes documented Resident #6 was admitted to the hospital for a urinary tract infection and discharged back to the facility the same day. Review of Resident #6's electronic medical record (EMR) revealed a urinalysis was completed during his hospital stay on 7/30/25 with results positive for a UTI and an indication for a culture and sensitivity (a two-part diagnostic procedure used to identify the cause of an infection and determine the most effective treatment). -There was no documentation in the resident's EMR to indicate the culture and sensitivity was completed, prior to the start of the resident's antibiotics.III. Staff interviews Registered nurse (RN) #1 was interviewed on 8/5/25 12:05 p.m. RN #1 said there was no specific monitoring or documentation that needed to be done for residents on antibiotics. RN #1 said the physician would order the antibiotic for a resident if the resident had an infection. RN #1 said the facility would send out a urine test to confirm the presence of a UTI in a resident.The director of nursing (DON) and the infection preventionist (IP) were interviewed together on 8/6/25 at 2:00 p.m. The IP said she started in her role at the facility on 7/14/25. She said her role as IP involved monitoring infections and antibiotic use with mapping and monitoring trends. The IP said she used the McGreer's criteria when assessing a resident who may need an antibiotic. She said the McGreers's Criteria consisted of symptoms, such as burning with urination and cloudy urine, which would require a urinalysis and a culture and sensitivity to be completed before initiating antibiotic treatment.The IP said Resident #6 was the only resident who was being treated for a UTI. She said the resident was sent to the hospital and diagnosed with a UTI and started on antibiotics. The IP said the UTI was confirmed via urinalysis with a culture and sensitivity pending. The IP said she never followed up with the hospital for the culture results. The IP said because the facility did not have the culture results for Resident #6, it was possible the facility did not treat his UTI effectively.The DON said Resident #6 was started on an antibiotic in the hospital after the hospital conducted a urinalysis on the resident. The DON said the facility did not receive any documentation from the hospital regarding the results of a culture and sensitivity that was indicated. The DON said the facility should have followed up on the culture and sensitivity because the culture and sensitivity results would identify what antibiotic would most effectively treat the UTI.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to implement policies and procedures related to pneumococcal immunizations for two (#19 and #7) of five residents reviewed for immunizations out of 27 sample residents.Specifically, the facility failed to offer the pneumonia vaccine to Resident #19 and Resident #7.Findings include:I. Professional referenceAccording to the Centers for Disease Control and Prevention (CDC), updated 2025, Recommended Immunization Schedule for Adults Aged 19 years or Older, retrieved on 8/11/25 from https://www.cdc.gov/vaccines/hcp/imz-schedules/downloads/adult/adult-combined-schedule.pdf,Pneumococcal vaccination-Routine vaccination-Age 50 years or older who have not previously received a dose of PCV13 (pneumococcal conjugate vaccine), PCV15, PC20, OR PCV21 or whose previous vaccination history is unknown: one dose PCV15 or PCV20 or one dose PCV21. If PCV15 is used, administer one dose PPSV23 at least one year after the PCV15 dose (may use a minimum interval of eight weeks for adults with an immunocompromising condition, cochlear implant, or cerebrospinal fluid leak). Previously received only PCV7: follow the recommendation above.Previously received only PCV13: one dose PCV20 or one dose PCV21 at least one year after the last PCV13 dose.Previously received only PPSV23: one dose PCV15 or one dose PCV20 or one dose PCV21, at least one year after the last PPSV23 dose. If PCV15 is used, no additional PPSV23 doses are recommended.Previously received both PCV13 and PPSV23 but no PPSV23 was received at age [AGE] years or older; one dose PCV20 or one dose PCV21 at least five years after the last pneumococcal vaccine dose.Previously received both PCV13 and PPSV23, and PPSV23 was received at age [AGE] years or older: Based on shared clinical decision making, one dose of PCV20 or one dose of PCV21 at least five years after the last pneumococcal vaccine dose.II. Facility policy and procedureThe Pneumococcal Vaccine policy, revised March 2022, was provided by the nursing home administrator (NHA) on 8/6/25 at 2:48 p.m. It read in pertinent part,All residents will be offered pneumococcal vaccines to aid in preventing pneumonia or pneumococcal infections. Prior to or upon admission, residents are assessed for eligibility to receive the pneumococcal vaccine series, and when indicated, are offered the vaccine series unless medically contraindicated or the resident has completed the current recommended vaccine series. Before receiving a pneumococcal vaccine the resident or legal Representatives receive information and education regarding the benefits and potential side effects of the pneumococcal vaccine. Residents have the right to refuse vaccination. If refused, appropriate information is documented in the residence medical record indicating the date of the refusal of the pneumococcal vaccination. For each resident who receives a vaccine, the date of the vaccination, Lot number, expiration date, person administering and site of the vaccinations are documented in the resident's medical record.III. Resident #19 A. Resident statusResident #19, age [AGE], was admitted on [DATE]. According to the August 2025 computerized physician's orders (CPO), diagnoses included atrial fibrillation (irregular heartbeat), lymphedema (swelling), hypertension (high blood pressure), dermatitis and open wound of the left lower leg. The 2/27/25 minimum data set (MDS) assessment revealed the resident had mild cognitive impairments with a brief interview for mental status (BIMS) score of 12 out of 15. He required substantial/maximal assistance with toileting, personal hygiene. He required partial/moderate assistance with bed mobility and was independent with eating.The assessment did not indicate the resident was offered the pneumonia vaccine. B. Resident interviewResident #19 was interviewed on 8/4/25 at 4:07 p.m. Resident #19 said he received some vaccines years ago while living at home, but was not offered any vaccinations while living at the facility.C. Record reviewReview of Resident #19's electronic medical record (EMR) on 8/6/25 did not reveal documentation that the pneumonia vaccine was offered to the resident. The August 2025 CPO revealed a physician's orders for the pneumonia vaccine, ordered on 2/20/25. -However, review of the EMR failed to reveal documentation in the resident's EMR that the pneumonia vaccine was administered.IV. Resident #7A. Resident statusResident #7, age less than 65, was admitted on [DATE]. According to the August 2025 CPO, diagnoses included chronic osteomyelitis (infection) in the right ankle, diabetes type 2, cirrhosis of the liver, anxiety and depression. The 7/17/25 MDS assessment revealed the resident had mild cognitive impairments with a BIMS score of 10 out of 15. He was independent with toileting or personal hygiene. He required partial/moderate assistance with wound care and was independent with eating.The assessment did not indicate the resident had not been offered the pneumonia vaccine. B. Resident interviewResident #7 was interviewed on 8/4/25 at 4:18p.m. Resident #7 said he had not received, nor was he offered any vaccines while living at the facility. C. Record reviewA review of the EMR on 8/6/25 did not reveal documentation that the pneumonia vaccine was offered to the resident. The August 2025 CPO revealed a physician's order for the pneumonia vaccine, ordered on 7/11/25. -However, a review of the EMR on 8/6/25 failed to reveal documentation in the resident's EMR that the pneumonia vaccine was administered.D. Staff interviewsThe director of nursing (DON) and the NHA were interviewed together on 8/7/25 at 2:35 p.m. The DON said it was the responsibility of the admitting nurse to offer, obtain consents and administer vaccinations to newly admitted residents to the facility. The DON said the facility utilized the immunization tab in the resident's EMR to documented relevant historic vaccination information, such as refusals or administration of vaccinations. The DON said she remembered Resident #19 declined to receive any vaccine after it was offered to him from the facility. The DON said she would look for additional information regarding Resident #7 vaccination status. -However, the facility did not provide any additional information regarding Resident #7's vaccination status.D. Facility follow-up-The facility provided vaccine declination (influenza, pneumonia and COVID-19) documentation for Resident #19 with a signature date of 8/7/25 at 6:25 p.m. (after the survey exit).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to implement policies and procedures related to COVID-19 immunizations for two (#19 and #7) of five residents reviewed for immunizations out of 27 sample residents.Specifically, the facility failed to offer the COVID-19 vaccine was offered to Resident #19 and Resident #7. Findings include:I. Professional referenceAccording to the Centers for Disease Control and Prevention (CDC), COVID-19 guidelines (revised 1/7/25), retrieved on 8/10/25 from https://www.cdc.gov/covid/vaccines/stay-up-to-date.html. Everyone ages six months and older should get a 2024-2025 COVID-19 vaccine. The COVID-19 vaccine helps protect you from severe illness, hospitalization, and death. It is especially important to get your 2024-2025 COVID-19 vaccine if you are age [AGE] and older, are at risk for severe COVID-19, or have never received a COVID-19 vaccine. Vaccine protection decreases over time, so it is important to get your 2024-2025 COVID-19 vaccine.II. Facility policy and procedureThe COVID vaccine policy, revised March 2022, was provided by the nursing home administrator (NHA) on 8/6/25 at 2:48 p.m. It read in pertinent part,All residents will be offered COVID vaccines to aid in preventing COVID infections. Prior to or upon admission, residents are assessed for eligibility to receive the COVID vaccine series, and when indicated, are offered the vaccine series unless medically contraindicated or the resident has completed the current recommended vaccine series. Before receiving a COVID vaccine the resident or legal Representatives receive information and education regarding the benefits and potential side effects of the COVID vaccine. Residents have the right to refuse vaccination. If refused, appropriate information is documented in the residence medical record indicating the date of the refusal of the COVID vaccination. For each resident who receives a vaccine, the date of the vaccination, Lot number, expiration date, person administering and site of the vaccinations are documented in the resident's medical record.III. Resident #19 A. Resident statusResident #19, age [AGE], was admitted on [DATE]. According to the August 2025 computerized physician's orders (CPO), diagnoses included atrial fibrillation (irregular heartbeat), lymphedema (swelling), hypertension (high blood pressure), dermatitis and open wound of the left lower leg. The 2/27/25 minimum data set (MDS) assessment revealed the resident had mild cognitive impairments with a brief interview for mental status (BIMS) score of 12 out of 15. He required substantial/maximal assistance with toileting, personal hygiene. He required partial/moderate assistance with bed mobility and was independent with eating.The assessment did not indicate that the resident was ever offered the covid vaccine. B. Resident interviewResident #19 was interviewed on 8/4/25 at 4:07 p.m. Resident #19 said he received some vaccines years ago while living at home, but was not offered any vaccinations while living at the facility.C. Record reviewReview of Resident #19's electronic medical record (EMR) on 8/6/25 did not reveal documentation that the COVID-19 vaccine was offered or administered to the resident. IV. Resident #7A. Resident statusResident #7, age less than 65, was admitted on [DATE]. According to the August 2025 CPO, diagnoses included chronic osteomyelitis (infection) in the right ankle, diabetes type 2, cirrhosis of the liver, anxiety and depression. The 7/17/25 MDS assessment revealed the resident had mild cognitive impairments with a BIMS score of 10 out of 15. He was independent for toileting or personal hygiene. He required partial/moderate assistance with wound care and was independent with eating.The assessment did not indicate that the resident was offered the COVID-19 vaccine. B. Resident interviewResident #7 was interviewed on 8/4/25 at 4:18 p.m. Resident #7 said he did not receive, nor was he offered any vaccines while living at the facility. C. Record reviewReview of Resident #7's EMR on 8/6/25 did not reveal documentation that the COVID-19 vaccine was offered or administered to the resident. D. Staff interviewsThe director of nursing (DON) and the NHA were interviewed together on 8/7/25 at 2:35 p.m. The DON said it was the responsibility of the admitting nurse to offer, obtain consents and administer vaccinations to newly admitted residents to the facility. The DON said the facility utilized the immunization tab in the resident's EMR to document relevant historic vaccination information, such as refusals or administration of vaccinations. The DON said she remembered Resident #19 declined to receive any vaccine after it was offered to him from the facility.-However, documentation indicating Resident #19 declined the COVID-19 vaccination was not provided. The DON said she would look for additional information regarding Resident #7 vaccination status. -However, the facility did not provide additional information regarding Resident 37's vaccination status.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to ensure five (#40, #28, #45, #5 and #43) of seven residents reviewed for abuse out of 27 sample residents were kept free from abuse. Specially, the facility failed to:-Protect Resident #40 from physical abuse by Resident #45;-Protect Resident #28 from physical abuse by Resident #45; -Protect Resident #28 and Resident #45 from physical abuse by each other;-Protect Resident #5 from physical abuse by Resident #28; and, -Protect Resident #43 from physical abuse by Resident #32.Findings include: I. Incident of physical abuse of Resident #40 by Resident #45 on 6/3/25A. Facility investigation The 6/3/25 facility investigation documented a nurse witnessed Resident #40 back his motorized wheelchair into the hallway. Resident #45 was ambulating down the hallway and came upon Resident #40 and hit him on the back of the head (near the base of the skull/top of neck) with the back of her open hand. The staff redirected Resident #45 away from the Resident #40. Resident #40 continued moving his wheelchair and did not acknowledge that anything had occurred.The two residents were separated by staff and assessed for injuries and no injuries were noted. When interviewed by staff, neither resident could recall the events due to their cognitive impairments. The residents resided on the same secured unit of the facility. Resident #45 was assigned one-on-one observation by staff and new interventions were added to offer a milkshake for distraction, redirect others from Resident #45 or step between her and other residents at times of increased agitation. The physician was notified and an increase of Resident #45's antipsychotic medication was requested. The facility substantiated the incident, but did not substantiate abuse as there was no injury and no fear.-However, abuse occurred due to Resident #45 being observed slapping Resident #40 in the head. B. Resident #45 (assailant)1. Resident statusResident #45, age [AGE], was admitted on [DATE]. According to the August 2025 computerized physician orders (CPO), diagnoses included unspecified dementia and a traumatic brain injury (TBI). The 7/2/25 minimum data set (MDS) assessment revealed the resident had severe cognitive impairments and was unable to participate in the brief interview for mental status (BIMS) assessment. A staff assessment for mental status revealed the resident had short and long term memory impairments and had severe impairments to her daily decision-making skills. The MDS assessment indicated the resident had behaviors not directed at others (physical symptoms such as scratching self, pacing, smearing bodily fluids or food, disrobing, public sexual acts, screaming or disruptive sounds), physical and verbal aggression, rejecting care, and wandering. The resident experienced delusions. 2. Record reviewResident #45's behavior care plan, revised 6/13/25, revealed the resident had behaviors of verbal aggression with other residents related to dementia and a history of TBI. The resident would pace and wander to the point of exhaustion and did not have awareness of others' space and would enter others' rooms. The resident could be paranoid and did not not get along with another female resident on the unit and would have altercations with her if in close proximity. The resident would strike others unprovoked and could become verbally aggressive if feeling threatened. Interventions, initiated 4/14/25, included redirecting the resident from others' space and to her room or common areas, allowing the resident to sit in chairs in the hallway, engaging with the resident when passing her in the hallway with smiles and greetings, if the resident felt she was being followed, offering reminders of where the other resident's rooms were and offering to walk away from them with her, offering sweet treats, assisting with turning on the resident's television in her room during times of frustration, allowing the resident independent visits with her male friend in the unit, offering the resident compliments on her appearance, and offering to paint her nails. Interventions, initiated 6/4/25, included offering the resident a milkshake when agitated, and staff were to create a space between her and others or stand between them if unable to redirect the resident away from others. Interventions, initiated 6/7/25, included providing one-on-one staff at times of increased agitation and with busy waking hours.Interventions, initiated 6/9/25, included encouraging a calm bedtime environment and relaxation to promote sleep, offering the resident a back rub, smoothing of the resident's hair, providing soft or calming music and encouraging the resident to take walks outside with staff daily to reduce [NAME] up energy and reduce the risk of agitation .Interventions, initiated 6/13/25, included for the facility to purchase an identical pillow for the resident as another resident had as Resident #45 frequently took the other resident's pillow, which caused conflict, redirecting the resident away from the female resident she did not get along with and redirecting her from going into others' rooms or taking their belongings. Interventions, initiated 6/30/25, included reducing one-on-one observation to afternoon hours or with times of agitation. A nursing progress note, dated 6/3/25, revealed that Resident #45 had been upset, anxious, and agitated while pacing and cursing throughout the unit. As Resident #45 was pacing the hallway, Resident #40 was wheeling backwards down the unit and Resident #45 used her flat hand and smacked Resident #40 in the back of the head. Staff separated the residents. Further review of Resident #45's electronic medical record (EMR), from 2/24/25 to 8/5/25, revealed the resident had a history of wandering into other residents' rooms, and verbally antagonizing other residents, resulting in altercations with other residents.-The facility failed to address Resident #45's behaviors of wandering into other residents' rooms in the care plan until 4/14/25 and failed to address the resident's behaviors of verbally antagonizing other residents.C. Resident #40 (victim)1. Resident statusResident #40, age less than 75, was admitted on [DATE]. According to the August 2025 CPO, diagnoses included anxiety and intracranial injury (TBI). The 5/22/25 MDS assessment revealed the resident had moderate cognitive impairments with a BIMS score of seven out of 15. The MDS assessment indicated the resident experienced delusions. 2. Record reviewResident #40's behavior care plan, revised 6/3/25, revealed the resident took an antipsychotic medication related to an anxiety disorder with target behaviors of verbal outbursts/aggression. Interventions, revised 6/14/24, included offering one-on-one, redirection, offering food/fluids, toileting, removing from the situation, offering an activity, assessing for pain or offering massage/back rub. -Resident #40's care plan failed to address the incident with Resident #45 on 6/3/25.II. Incident of physical abuse of Resident #28 by Resident #45 on 6/4/25 A. Facility investigationThe 6/4/25 incident investigation documented a dietary aide witnessed an altercation between Resident #45 and Resident #28 in the dining area of the secured unit that both of the residents resided on. Resident #45 had been assigned one-on-one observation by staff after the incident between Resident #45 and Resident #40 on 6/3/25 (see 6/3/25 incident above). However the dietary staff member who reported the incident between Resident #45 and Resident #28 to the nursing staff was the only staff member present at the time of the incident. Nursing staff were not present or observing Resident #45 at the time of the incident. Resident #28 had been sitting at the dining room table for lunch. Resident #45 entered the dining room to take her seat for lunch, but approached Resident #28 unprovoked and hit her in the head with a pillow four to five times and then walked away. Resident #28 yelled out and said no to Resident #45. The two residents were separated by staff and assessed for injuries and no injuries were noted. Resident #45 had been assigned one-on-one observation by staff and was assisted with an activity off the unit with staff.When interviewed by staff, neither resident could recall the events due to cognitive impairments. The residents resided on the same secured unit of the facility. Resident #45 was assigned one-on-one observation by staff and a medication review was requested. The facility substantiated the incident, but did not substantiate abuse due to no injury. -However, abuse occurred due to Resident #45 being observed hitting Resident #28 with a pillow. B. Resident #45 (assailant)1. Record reviewA nursing progress note, dated 6/4/25, revealed that a dietary staff member informed the nurse that Resident #45 hit Resident #28 in the face in the dining room. The nurse separated the residents and assessed for injury and there were no injuries. The NHA and the director of nursing (DON) were contacted. C. Resident #28 (victim)1. Resident statusResident #28, age [AGE], was admitted on [DATE]. According to the August 2025 CPO, diagnoses included Alzheimer's disease, dementia with mood disturbance and major depressive disorder.The 6/18/25 MDS assessment revealed the resident had severe cognitive impairments with a BIMS score of two out of 15. The MDS assessment indicated the resident had behaviors not directed at others (physical symptoms such as scratching self, pacing, smearing bodily fluids or food, disrobing, public sexual acts, screaming or disruptive sounds), wandering, delusions and physical aggression. B. Record reviewResident #28's behavior care plan, revised 6/13/25, revealed the resident would strike out at other residents if she felt threatened or if they were in her personal space. The resident did not get along with another female resident on the unit and was at high risk for having altercations with that other resident.Interventions, initiated 6/13/25, included redirecting all residents from Resident #28's space/room and her personal belongings, redirecting Resident #28 away from the female resident on the unit that she did not get along with, providing space between the two residents when passing in common areas and creating a barrier if possible by standing between them or ambulating on the passing side of the resident.Interventions, initiated 7/23/25, included providing as needed one-on-one observation related to periods of agitation/frustration that was not easily redirectable with person-centered interventions.-Resident #28's care plan did not reveal that the resident's care plan was reviewed to determine if the current interventions were effective or if new interventions were needed to prevent further abuse incidents. -Additionally, Resident #28's care plan did not reveal that the resident's care plan was reviewed to determine if the current interventions were effective or if new interventions were needed to prevent further abuse incidents following the incidents with Resident #45 on 6/8/25 and 6/12/25 or following the incident with Resident #5 on 7/5/25 (see 6/8/25, 6/12/25 and 7/5/25 incidents below).A nursing progress note, dated 6/4/25, revealed that a dietary staff member informed the nurse that Resident #45 hit Resident #28 in the face in the dining room. The nurse separated the residents and assessed for injury, no injuries. The NHA and the DON were contacted.III. Incident of physical abuse of Resident #45 and Resident #28 by each other on 6/8/25A. Facility investigationThe 6/8/25 incident investigation documented a nurse witnessed an altercation between Resident #45 and Resident #28 in the hallway of the secure unit that both residents resided on. Resident #45 was pacing down the hallway and teasing and laughing at Resident #28. Resident #45 than passed Resident #28 on the opposite side of the hallway. Resident #45 raised her fist and made punching motions in the air. When Resident #28 walked down the hallway on the side of the hallway were Resident #45 was, Resident #45 then tapped Resident #28's arm with a closed fist and Resident #28 tapped Resident #45 in the upper arm with a closed fist in return. The two residents were separated by staff and assessed for injuries, no injuries noted. Resident #45 was assigned one-on-one observation by staff and assisted with an activity off the unit with staff.When interviewed by staff, neither resident could recall the events due to cognitive impairments. The residents resided on the same secured unit of the facility. Resident #45 was assigned one-on-one observation by staff and a medication review was requested. -However, Resident #45 had been assigned one-on-one observation by staff after the incident with Resident #28 on 6/4/25 and that intervention failed to mitigate the altercation on 6/8/25. The facility unsubstantiated the incident due to cognitive impairments. -However, abuse occurred due to Resident #45 being observed hitting Resident #28 with a closed fist.B. Resident #45 (assailant and victim)1. Record reviewA nursing note, dated 6/8/25, revealed that Resident #45 was witnessed walking up and down the hallway laughing and teasing Resident #28. Resident #45 continued pacing despite being redirected many times, and got closer to Resident #28. As Resident #45 got closer, Resident #45 raised her fist and punched the air while looking at Resident #28. Resident #28 walked down the hallway but came too close to Resident #45, resulting in Resident #45 using her fist to tap Resident #28 in the left arm. Resident #28 responded by using her fist to tap Resident #45 in the right arm. Resident #45 was redirected to go outside for a walk and Resident #28's arm was assessed with no injury. C. Resident #28 (victim and assailant) 1. Record reviewA nursing note, dated 6/8/25, revealed that Resident #45 was witnessed walking up and down the hallway laughing and teasing Resident #28. Resident #45 continued pacing despite being redirected many times, and got closer to Resident #28. As Resident #45 got closer, Resident #45 raised her fist and punched the air while looking at Resident #28. Resident #28 walked down the hallway but came too close to Resident #45, resulting in Resident #45 using her fist to tap Resident #28 in the left arm. Resident #28 responded by using her fist to tap Resident #45 in the right arm. Resident #45 was redirected to go outside for a walk and Resident #28's arm was assessed with no injury. IV. Incident of physical abuse of Resident #45 and Resident #28 by each other on 6/12/25A. Facility investigationThe 6/12/25 incident investigation documented a nurse observed Resident #45 go into Resident #28's room and took her pillow from the room. Resident #28 had been in the hallway and became upset when Resident #45 walked past her with Resident #28's pillow. Resident #28 then hit Resident #45 in the head with an open hand and Resident #45 hit Resident #28 in the shoulder with an open hand in return. Resident #28 hit Resident #45 again in the head twice with an open hand before staff intervened. The two residents were separated by staff and assessed for injuries and no injuries noted. Resident #45 was assigned one-on-one observation by staff and assisted with an activity off the unit with staff.When interviewed by staff, neither resident could recall the events due to cognitive impairments. The residents resided on the same secured unit of the facility. Resident #45 and Resident #28's care plans were updated to instruct staff to keep the two residents away from each other and staff received training to keep the residents away from each other. Resident #45 was assigned one-on-one observation by staff. -However, Resident #45 had been assigned one-on-one observation by staff after the incidents on 6/4/25 and 6/8/25 and that intervention had failed to mitigate the altercation on 6/12/25.The facility unsubstantiated the incident due to no injury.-However, abuse occurred due to Resident #45 and Resident #28 were observed hitting each other. B. Resident #28 (assailant and victim) 1. Record reviewA nursing note, dated 6/12/25, revealed Resident #45 took Resident #28's pillow from her bedroom, which made Resident #28 upset, resulting in Resident #28 hitting (open handed) Resident #45 on the head. Resident #45 then hit Resident #28 back in the left shoulder, causing Resident #28 to hit Resident #45 in the head two times open handed. Both residents were separated, redirected and assessed. Both residents did not recall the situation and denied pain. C. Resident #45 (victim and assailant) 1. Record reviewA nursing note, dated 6/12/25, revealed Resident #45 took Resident #28's pillow from her bedroom, which made Resident #28 upset, resulting in Resident #28 hitting (open handed) Resident #45 on the head. Resident #45 then hit Resident #28 back in the left shoulder, causing Resident #28 to hit Resident #45 in the head two times open handed. Both residents were separated, redirected and assessed. Both residents did not recall the situation and denied pain. V. Incident of physical abuse of Resident #5 by Resident #28 on 7/5/25A. Facility investigation The 7/5/25 incident investigation documented activities assistant (AA) #1 witnessed an altercation between Resident #28 and Resident #5 in the outside secure unit courtyard during an activity. Resident #28 walked up to Resident #5 and pushed Resident #5 in the arm and was redirected by staff. However, Resident #28 returned to Resident #5 and pushed her in the arm a second time. The two residents were separated by staff and offered snacks, both residents were taken inside and assessed for injuries. No injuries were noted. Resident #28 was assigned one-on-one observation by staff on 7/8/25, three days after the incident. -Review of Resident #28's EMR and care plan revealed one-on-one observations were not initiated until 7/8/25 (three days after the incident), despite Resident #28 being involved in other incidents of physical abuse towards other residents on 6/8/25 and 6/12/25 (see 6/8/25 and 6/12/25 incidents above).When interviewed by staff, neither resident could recall the events due to cognitive impairments. The residents resided on the same secured unit of the facility. Resident #28 was assigned one-on-one observation by staff on 7/8/25 (three days after the incident) and the physician was notified.The facility unsubstantiated the incident due to no injury. -However, abuse occurred due to Resident #28 being observed pushing Resident #5 twice, despite being redirected. B. Resident #28 (assailant) 1. Record reviewReview of Resident #28's progress notes revealed there was no progress note related to the incident.C. Resident #5 (victim)1. Resident statusResident #5, age [AGE], was admitted on [DATE]. According to the August 2025 CPO, diagnoses included vascular dementia, anxiety and insomnia. The 6/19/25 MDS assessment revealed the resident had severe cognitive impairments with a BIMS score of six of 15. The MDS assessment indicated the resident had behaviors of wandering and experienced delusions. 2. Record reviewResident #5's behavior care plan, revised 6/9/25, revealed the resident was an elopement risk related to disorientation to place, impaired safety awareness, and wandering aimlessly which significantly intruded on the privacy of activities. The resident wandered daily and had a lack of awareness of other's personal space/boundaries and would benefit from a smaller, more structured environment of the secure unit. Interventions, initiated 6/9/25, included distracting the resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, or a book, and providing structured activities such as toileting, walking inside and outside, reorientation strategies including signs, pictures and memory boxes. Interventions, initiated 7/7/25, included redirecting the resident away from others' personal space as needed.-Resident #5's care plan failed to address the incident with Resident #28 on 7/5/25.Review of Resident #5's progress notes revealed there was no progress note related to the incident. VI. Incident of physical abuse of Residents #43 by Resident #32 on 8/4/25A. ObservationOn 8/4/25 at 1:11 p.m. Resident #32 was observed in the doorway of the room he shared with Resident #43. During the observation, Resident #32 had his right arm around Resident #43's neck with his left hand positioned to lock the hold by grabbing his right hand. Resident #43 was standing with his hands down to his sides and was not engaging physically with Resident #32. Certified nurse aide (CNA) #5 ran over to the two residents to intervene. B. Facility investigation The 8/4/25 incident investigation documented the CNA #5 witnessed an altercation between Resident #32 and Resident #43 as they exited their room together. Resident #32 had his hand on the neck of Resident #43 and Resident #43 was pushing Resident #32 in the neck with his open hands. The two residents were separated by staff and assessed for injuries, no injuries noted. Resident #32 and Resident #43 were assigned one-on-one observation by staff. When interviewed by staff, Resident #32 said he was cleaning his side of the room and looked over at his roommate's side of the room and told his roommate, Resident #43, to clean his side of the room. Resident #43 responded by telling Resident #32 to get out of his room and an argument started. When interviewed by staff, Resident #43 could not describe the events but said he wanted Resident #32 out of his room. The residents resided on the same secured unit of the facility and shared a room. Resident #43 and Resident #32 were both assigned one-on-one observation by staff on 8/4/25 and the physician was notified.The facility unsubstantiated the incident due to no injury. -However, abuse occurred due to Resident #32 being observed with his hand around Resident #43's neck (see observation above). -Additionally, the facility's description of the incident did not match the observation of the incident (see incident above).C. Resident #32 (assailant)1. Resident statusResident #32, age under 70, was admitted on [DATE]. According to the August 2025 CPO, diagnoses included anxiety and Wernicke's encephalopathy (alcohol-induced encephalopathy). The 6/25/25 MDS assessment revealed the resident had severe cognitive impairments and was unable to participate in the BIMS assessment. A staff interview for mental status revealed the resident had short and long term memory impairments and had severe impairments related to his daily decision making skills. The MDS assessment indicated the resident had behaviors of hallucinations, delusions, rejecting care, and wandering. 2. Record reviewResident #32's mood care plan, revised 8/4/25, revealed the resident could become verbally aggressive when frustrated or throw items. The resident had an episode of physical aggression toward his roommate. The resident could become frustrated if his roommate's side of the room was dirty/cluttered. Interventions, initiated 8/4/25, included reminding others to respect the resident's personal space and offering to assist with tidying of his room as the resident allowed.Resident #32's behavior sheet, undated, was kept at the nurses station and was reviewed on 8/5/25. The behavior sheet revealed that Resident #32 had behaviors of becoming aggressive, throwing things, and could become triggered if his roommate's side of the room was cluttered. Resident #32 had an aversion to being around other men and could become fearful and aggressive. Interventions included assisting him to a quiet area, redirecting him from other residents, offering chocolate ice cream or chocolate milk, allowing him to read a book of choice, assisting him in calling his sister, encouraging the resident to stay in his room and reorganizing if desired, encouraging the resident to keep a distance from other men, allowing him to sit alone in the dining room or encouraging female peers to sit with him, allowing him to watch the television in the dayroom and offering to assist the resident in tidying his personal space. -However, Resident #32's care plan and behavior monitoring orders failed to identify potential challenges with Resident #32 being around other males (see care plan above). A psychoactive medication evaluation meeting minute note, dated 6/20/25, revealed a physician note written during the meeting indicated Resident #32 had recently moved to the secure unit and he would be getting a roommate, which had historically increased Resident #32's behaviors, anxiety, and distress. The facility was to monitor and assess Resident #32's adjustment. A room change form revealed Resident #32 moved to his room in the secure unit on 5/21/25. -Resident #32's EMR failed to reveal staff provided psychosocial checks on Resident #32 once Resident #43 moved into his room on 6/30/25. -Resident #32's care plan, behavior monitoring orders, and behavior sheet failed to identify potential challenges with Resident #32 once he received a roommate. A nursing note, dated 8/4/25, revealed Resident #32 had an altercation with his roommate. Both residents came out of their room holding each other's necks. No injuries were noted. D. Resident #43 (victim) 1. Resident statusResident #43, age [AGE], was admitted on [DATE]. According to the August 2025 CPO, diagnoses included unspecified dementia with behavioral disturbances, post traumatic stress disorder (PTSD), major depressive disorder and anxiety. The 6/30/25 MDS assessment documented Resident #43 had severe cognitive impairments with a BIMS score of three out of 15. The MDS assessment indicated Resident #43 had behaviors of being verbally abusive, experiencing delusions and wandering.2. Resident interviewResident #43 was interviewed on 8/4/25 at approximately 3:30 p.m. However, he became agitated when his roommate was mentioned, although he was unable to say why.3. Record review Resident #43's behavior care plan, initiated 6/30/25, revealed the resident had a history of aggressive behaviors at his previous facility towards female caregivers and other residents. The resident would become frustrated when he felt that others were in his personal space andcould become physical to show where his boundaries were. He had exhibited physical aggression toward others with times of frustration (pushing and hitting), revised 8/4/25, during the survey. Interventions, initiated 6/30/25, included approaching the resident from the side when attempting to engage in conversation with a slow and calm demeanor while using open body language andspeaking in a low, soft tone. Avoiding making prolonged eye contact with the resident as this frustrated him and made him feel uneasy and if the resident became physically aggressive, ensure he was in a safe space and give him a few minutes alone to calm down. If possible, staff were to sit next to the resident and face forward rather than turning towards the resident during conversation. Interventions, initiated 8/4/25, during the survey, included engaging the resident in talking about the town where he was from and farming, assisting the resident with praying, offering snacks (sweets and hot chocolate) and offering time outside. -Resident #43's care plan failed to address the incident on 8/4/25. A nursing note, dated 8/4/25, revealed Resident #43 had an altercation with his roommate. Both residents came out of their room holding each other's necks. No injuries were noted. Resident #43 was yelling He needs to get out of my room.Resident #43's behavior sheet, undated, was kept at the nurses station and was reviewed on 8/5/25. The behavior sheet revealed that Resident #43 had behaviors of becoming verbally aggressive or physically aggressive (hitting and pushing). Interventions included engaging the resident in talking about where he was from or farming, approaching the resident from the side when attempting to engage in conversation with a slow and calm demeanor while using open body language and speaking in a low, soft tone, avoiding making prolonged eye contact with the resident as this frustrated him and made him feel uneasy and if the resident became physically aggressive, ensure he was in a safe space and give him a few minutes alone to calm down. If possible, staff were to sit next to the resident and face forward rather than turning towards the resident during conversation -A review of Resident #43's care plan and behavior monitoring orders failed to identify Resident #43's specific triggers (body language, body positioning and eye contact) that were identified on his behavior sheet. Review of Resident #43's EMR, from 6/30/25 to 8/5/25, revealed the resident had behaviors of believing he was being held against his will/in prison twice, refusing care due to agitation five times, exit seeking three times, demanding to go home twice, paranoid of others twice and attempting to hit staff three times. -Review of Resident #43's EMR failed to reveal resident specific behavior monitoring for the behaviors displayed since admission, nor did it reveal staff had assisted Resident #43 to unpack or organize his room, despite his roommate having identified triggers related to clutter (see Resident #32's behavior sheet above) and Resident #43 having triggers of others being in his personal space (see care plan above). -Review of Resident #43's EMR failed to reveal staff provided psychosocial checks on Resident #43 and his roommate, Resident #32, during the period Resident #43 was having disruptive behaviors (see above). VII. Staff interviewsCNA #5 was interviewed on 8/5/25 at 1:27 p.m. She said she came around the hall when she heard a commotion and found Resident #32's hand on Resident #43's neck. CNA #5 said she had not witnessed the two residents initially leaving their room and was not certain exactly where everyone's hands were with all the commotion. She said Resident #43 had been struggling to adjust to placement and she was unaware that Resident #32 had issues with males. She said the staff were currently providing both residents with one-on-one observation and this consisted of staff ensuring the residents were never in the room together. She said management was working on a room move for Resident #32. -During the interview, Resident #43 sat at the table with CNA #5 and became increasingly agitated and paranoid there was a plan to harm him.CNA #5 said Resident #45 would instigate altercations with Resident #28, but she was unclear on why Resident #28 triggered Resident #45. She said management had staff keep the two residents separated as much as possible as a new intervention after the altercations. The dietary aide (DA), who witnessed the incident on 6/4/25, was interviewed on 8/6/25 at 12:52 p.m. The DA said she saw Resident #45 walking past Resident #28 in the dining room as Resident #28 was sitting in her seat waiting for lunch. The DA said she did not see anything happen between the two residents leading up to the incident. She said Resident #45 approached Resident #28 and hit her in the head with a pillow four to five times and she said she physically got in between the two residents until a CNA arrived shortly after. The memory care director was interviewed on 8/6/25 at 11:53 a.m. The memory care director said physical aggression was a new behavior for Resident #28 and Resident #45 had been the original aggressor. She said that Resident #45 had a history of being kicked out of her previous facilities due to behaviors, but once Resident #28 admitted to the facility, Resident #45 started going after her. The memory care director said she believed that it was due to Resident #28 having a flat affect and sometimes making sounds that were not directed at Resident #45, however, seemed to trigger Resident #45. She said her root cause analysis of the repeated incidents between the two residents, was that Resident #45 was getting one-on-one staff supervision and Resident #28 perceived she was getting less attention, and began acting out as well. The memory care director said that both women had strong personalities and the staff tried to redirect them away from each other. She said that Resident #45 would have increased pacing, made negative statements towards others, and become more fidgety when she was beginning to ramp up her aggression. The memory care director said that Resident #28 would also have increased pacing and make more nonverbal noises with a more negative tone of voice. She said that Resident #28 would keep her mouth closed and not smile, while holding he

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interviews, the facility failed to ensure two (#2 and #3) out of 10 residents reviewed for abuse were free from sexual abuse out of 13 sample residents. Specifically, the facility failed to protect Resident #2 and Resident #3 from sexual abuse by Resident #1. Findings include: I. Facility policy and procedure The Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating policy, dated September 2022, was provided by the nursing home administrator (NHA) on 3/24/25 at approximately 1:30 p.m. The policy read in pertinent part, All reports of resident abuse, neglect, exploitation, or theft/misappropriation of resident property are reported to local, state and federal agencies and thoroughly investigated by facility management. All findings of all investigations are documented and reported. II. Incident of sexual abuse of Resident #2 by Resident #1 on 12/20/24 A. Facility investigation The 12/20/24 investigation file of the incident involving Resident #2 and Resident #1 was provided by the corporate consultant (CC) on 3/20/25 at 5:33 p.m. The investigation included an investigation report under sexual abuse, an interview note with two staff witnesses, interviews with other staff members and residents and notification of the incident to the appropriate parties. The investigation report documented dietary aide (DA) #1 observed Resident #1 in the activity room with his hand inside the shirt of Resident #2. DA #1, alerted certified nurse aide (CNA) #1 about Resident #1's behavior. The behavior was immediately stopped and the assistant director of nursing (ADON) was alerted. The residents were separated and Resident #1 was placed on a one-to-one observation/supervision with an employee. Resident #2 was assessed and no injuries or signs of distress/discomfort were identified. The investigation report documented Resident #2 was non-verbal, had no signs of emotional/mental distress and was behaving and reacting at her baseline. The investigation report identified Resident #1 was interviewed and had no memory of the incident. The investigation report documented the facility concluded physical contact was made between Resident #1 and Resident # 2. Immediate action was taken to protect Resident #2 and all other residents. The investigation report indicated the facility placed Resident #1 on one-to-one supervision after the 12/20/24 incident to help prevent a recurrence. According to the report, Resident #2 did not have a change in her regimen or care plan following the incident, but she was assessed for signs of emotional/mental distress. A handwritten and undated witness interview note documented DA #1 said Resident #1 was sitting next to Resident #2 in the activity room. Resident #1 had his hand inside Resident #2's shirt for an undetermined amount of time. According to the interview of DA #1, she said Resident #2 did not appear in distress and CNA #1 immediately removed Resident #1. The witness interview note indicated CNA #1 said Resident #1 was witnessed reaching over to Resident #2 and placing his hand under her shirt and over her breast. The investigation identified four other residents and four staff members who were interviewed on 12/20/24 did not have concerns regarding abuse. B. Resident #2 (victim) 1. Resident status Resident #2, age greater than 65, was admitted on [DATE]. According to the March 2025 computerized physician orders (CPO), diagnoses included unspecified dementia unspecified severity, without behavioral disturbances, psychotic disturbance, mood disturbance, and anxiety, generalized muscle weakness, lack in coordination, psychomotor deficit and Alzheimer's disease. The 1/22/25 minimum data set (MDS) assessment identified Resident #2 had severe cognitive impairment, per a staff assessment for mental status. Resident #2 had short and long term deficits. She was dependent on staff for all of her activities of daily living (ADL) care and used a wheelchair for mobility. The MDS assessment indicated she had inattention, disorganized thinking and altered level of consciousness. 2. Record review Review of the March 2025 care plan for Resident #2 identified the resident had a communication and memory problem related to dementia, decreased vision, decreased mobility and difficulty expressing needs and wants. -The care plan did not identify Resident #2 was at risk for abuse. -The care plan did not identify new interventions were put in place for Resident #2 to prevent her from sustaining future occurrences of potential sexual abuse following the 12/20/24 incident with Resident #1. Review of Resident #2's progress notes between 12/20/24 and 3/24/25, did not reveal documentation of the 12/20/24 incident between Resident #1 and Resident #2 or what interventions for Resident #2 were put in place to prevent potential sexual abuse from reoccurring. -Review of the progress notes did not identify Resident #2 was monitored for changes in her behavior after the 12/20/24 incident with Resident #1. C. Resident #1 (assailant) 1. Resident status Resident #1, age greater than 65, was admitted on [DATE]. According to the March 2025 CPO, diagnoses included unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, unsteadiness on feet, generalized muscle weakness, lack of coordination, Alzheimer's disease and cognitive communication deficit. The 2/6/25 MDS assessment identified Resident #1 had severe cognitive impairments with a brief interview for mental status (BIMS) score of four out of 15. He used a wheelchair for mobility and needed partial to moderate assistance with most of his ADLs. According the MDS assessment, Resident #1 did not have physical, verbal or other behavioral symptoms directed towards others. 2. Observations On 3/20/25 at 12:25 p.m. Resident #1 was in the secured unit dining room eating his lunch at the dining room table with female residents. A CNA sat between him and one of the female residents. The other female resident sat across the table from Resident #1. CNA #2 stood in the dining room facing Resident #1. On 3/20/25 at 2:05 p.m. Resident #1 was sleeping in bed in his room in the secured unit. CNA #2 sat in the hallway near the room of Resident #1. On 3/24/25 at 11:38 a.m. Resident #1 was asleep in his room while a staff member sat inside the room near the doorway. 3. Record review Review of Resident #1's behavior care plan, revised 2/27/25, revealed the resident had inappropriate social/sexual behaviors (verbal/physical) related to dementia and he exhibited poor safety awareness and had a lack of spatial awareness and awareness of others' personal space. Interventions initiated on 8/4/23, included allowing Resident #1 to express anger within social parameters, approaching the resident in a calm but firm manner, assisting the resident to a quieter calmer area of the living environment, if reasonable, discussing with Resident #1 the behaviors identified and explaining/reinforcing why the behavior is inappropriate and/or unacceptable to the resident, notifying the family and physician of increased behavioral concerns, redirecting and assisting Resident #1 away from confrontational situations. The intervention initiated on 2/26/24 directed staff to notify hospice of any changes in the resident's behaviors. The behavior care plan interventions, initiated 2/27/25, directed staff to offer Resident #1 activity of choice, sensory activities, food/fluid or one-to-one engagement, redirecting from other residents' personal space and providing line of sight supervision when Resident #1 was in common areas. According to the 2/27/25 interventions, Resident #1 would benefit from the smaller, structured environment of the secure unit. -The facility failed to initiate new care plan interventions following the 12/20/24 incident where Resident #1 placed his hand inside the shirt of Resident #2. -The facility failed to implement new interventions for Resident #1's sexually inappropriate behaviors until 2/26/25, over two months later, after the resident was involved in a second sexual abuse incident with Resident #3 (see incident involving Resident #3 below). -The behavior care plan did not identify Resident #1 was on one-to-one supervision or line of sight supervision after the 12/20/24 incident with Resident #2, as had been identified in the 12/20/24 investigation report (see investigation report above). Review of Resident #1's March 2025 CPO revealed the following physician's orders: Frequent checks/monitoring for inappropriate sexual behaviors, ordered 10/26/23 and discontinued 3/24/25, during the survey. -The physician's order indicated Resident #1 should have been frequently monitored for inappropriate sexual behaviors between 10/26/23 and 3/24/25. Non-pharmacological behavior monitoring interventions for inappropriate sexual behaviors to include one-to-one's, ordered 10/26/23. -The physician's order did not specify whether the one-to-one's were visits made by staff members or if the resident was to be on consistent one-to-one supervision. Line of sight when out of room order, ordered 2/25/25. -Review of Resident #1's physician's order history failed to reveal a physician's order for the resident to be on one-to-one supervision or line of sight monitoring from 12/20/24 through 2/25/25, following the sexual abuse incident with Resident #2 (see investigation above). Review of Resident #1's progress notes from 7/26/24 through 2/6/25 revealed the following progress notes: A 7/26/24 interdisciplinary team (IDT) psychotropic committee note identified Resident #1 had a physician's order for finasteride for support in management of inappropriate sexual behaviors. An 8/8/24 IDT note identified Resident #1 had an increase in sexual behaviors towards a hospice staff member. A 10/11/24 nursing note identified Resident #1 was observed kissing another resident in the dining room. The 10/15/24 nursing note identified Resident #1 was found licking another resident's hair. A 10/18/24 IDT psychotropic committee note indicated occupational therapy (OT) monitored/observed Resident #1 due to his increase in sexual behaviors. According to the note, OT felt the resident would benefit from a sensory related program based on his oral fixations to help decrease these types of behaviors. The note identified the IDT agreed to the sensory programming with OT. -There was no progress note documented on 12/20/24 regarding the incident with Resident #2 where Resident #1 was found by staff with his hand on Resident #2's breast inside her shirt (see investigation above). A 1/2/25 IDT (which was documented as a late entry note with the effective date of 12/20/24) indicated Resident #1 was placed on one-on-one supervision due to recent sexual behaviors. The note identified the physician and all reporting parties were notified on 12/20/24. Both residents involved (Resident #1 and Resident #2) were safe and neither resident recalled the incident. According to the note, staff education completed by the director of nursing (DON) regarding safety and emotional monitoring, was completed. -However, review of Resident #1's physician orders history revealed there was no physician's order for the resident to be on one-to-one supervision following the 12/20/24 incident (see physician's orders above). The 1/16/25 at risk review note documented Resident #1 was without behaviors for several weeks and it recommended to discontinue the of line of sight physician's order and move to frequent roundings and checks and redirection for inappropriate behaviors. -However, review of Resident #1's physician orders history revealed there was no physician's order for the resident to be on line of sight monitoring following the 12/20/24 incident (see physician's orders above). The 2/6/25 at risk note for quarterly review documented Resident #1's behavior monitoring was still in place for inappropriate sexual behaviors and there had been no significant changes at the time. -However, review of Resident #1's behavior tracking records revealed staff were not consistently documenting the resident's one-to-one supervision or line of sight monitoring (see below). The December 2024 behavior tracking record for monitoring inappropriate sexual behaviors did not identify Resident #1 had behaviors on 12/20/24. The behavior tracking record identified the resident was provided redirection and one-to-one supervision on 12/1/24, 12/2/24, 12/3/24, 12/15/24, 12/16/24, 12/17/24 and 12/28/24. -The December 2024 behavior tracking record for monitoring inappropriate sexual behaviors did not identify Resident #1 was provided consistent one-to-one or line of sight supervision after he placed his hand in the shirt of a female resident on 12/20/24. The resident was only documented as receiving one-to-one supervision on 12/28/24. The January 2025 behavior tracking record for monitoring inappropriate sexual behaviors did not identify Resident #1 was provided one-to-one or line of sight supervision. The February 2025 behavior tracking record for monitoring inappropriate sexual behaviors identified Resident #1 had one incident of inappropriate sexual behaviors and was provided one-to-one supervision on 2/25/25 (see incident with Resident #3 below). -The behavior tracking record for inappropriate sexual behavior did not identify the resident was on a one-to-one supervision for any of the rest of the days in February 2025. III. Incident of sexual abuse of Resident #3 by Resident #1 on 2/25/25 A. Facility investigation The 2/25/25 investigation file was provided by the CC on 3/20/25 at 5:29 p.m. The investigation file included the suspected abuse initial investigation record, Resident #1's care plan for behaviors, an investigation report under sexual abuse, the abuse allegation incident report and resident and staff member interviews. The suspected abuse initial investigation record identified Resident #1 approached Resident #3, touched her on her knee and told her she had nice legs. The staff removed Resident #1 from the area and staff redirected him to an alternate space. According to the investigation, there were interventions identified to potentially reduce the risk of the incident prior to the event. -However, the facility failed to implement effective interventions prior to the event with Resident #3 (see incident with Resident #2 above). The investigation referred to Resident #1's care plan. The investigation record noted that new interventions were added to his care plan. The investigation record identified Resident #1 had a new 2/25/25 intervention of a line of sight observation when the resident was not in his room and a 2/26/25 intervention to move the resident to the secured unit. Resident #1's behavior care plan, initiated 8/4/23, that was included in the the facility's investigation file, identified Resident #1 displayed inappropriate social/sexual behaviors, both physical and verbal. The interventions documented in the care plan included staff to discuss with the resident the identified behaviors and explaining/reinforcing why the behavior was inappropriate, initiated 8/4/23; redirecting and assisting the resident away from confrontational situations, initiated 8/4/23; assisting the resident to calmer areas of the living environment, initiated 8/4/23; staff to observe and redirect the resident in public areas as needed and offering reminders to not touch others as appropriate, revised 1/16/25. The 2/25/25 investigation report under sexual abuse, documented Resident #1's behaviors were wandering, inappropriate social/sexual behaviors, lack of spatial awareness and he was not aware of others' personal space. The report identified the resident was involved in another sexual allegation on 12/20/24 (see incident above). The investigation report indicated Resident #1 was placed on a one-to-one line of sight observation when he was out of his room. The report identified the incident made Resident #3 uncomfortable. She was not injured or in pain. She denied Resident #1 touched her leg in a rough manner. She denied she was touched anywhere else on her body. The investigation report identified the incident was witnessed by an activity assistant (AA). According to the investigation report, Resident #3 did not have behavioral changes but said she felt uneasy around Resident #1 since the incident. The investigation report documented Resident #1 had a history of behaviors with a recent increase in wandering in the facility and entering others' personal space. The investigation report concluded the facility was able to substantiate the incident occurred, but was not able to determine motives or intent of the alleged assailant (Resident #1) due to his cognitive deficit. The abuse allegation incident report documented there were no injuries to either Resident #1 or Resident #3 identified after Resident #1 touched Resident #3's leg and made an inappropriate comment. The report documented Resident #3 did not like Resident #1 touching her leg and did not want to be around him. The staff member and resident interviews identified one staff member, Resident #1, Resident #3, and six other residents were interviewed after the 2/25/25 incident. The staff member interviewed was the AA who said she witnessed the incident. According to the AA's interview, she heard Resident #1 tell Resident #3 she had nice legs and witnessed him touch her. The interview did not identify where he touched her. The provided interviews identified Resident #3 was interviewed three times on 2/25/25. The social services director (SSD) interview documented Resident #3 told the SSD another resident (Resident #1) wheeled his wheelchair over to her and said she had nice legs and then he felt them with his hands. Resident #3 motioned that Resident #1 touched her down the front of her thigh. The interview indicated Resident #3 denied feeling scared, felt safe, but looked visibly upset. The DON interview documented Resident #3 did not like when Resident #1 touched her and did not want to be around him. She said she felt safe and did not think he could get to her now. Resident #3 requested for the DON to keep Resident #1 away from her. Resident #3 was interviewed again, later on the evening of 2/25/25. Resident #3 said she was okay but did not want Resident #1 to touch her again. When the resident was asked if she felt scared, Resident #3 said she knew he could not get her now because he was in bed. She said she just did not want to be around him anymore. The interview documented Resident #3 was more relaxed once in her own space and was assured that the staff were actively monitoring his behaviors and the location to keep her safe. The 2/25/25 interview with Resident #1, conducted by the DON, identified when questioned about the 2/25/25 incident with Resident #3, he was not able to recall the incident or indicate he understood the questions asked. The review of the six other residents' interviews did not identify the interviewed residents felt upset, uncomfortable, fearful, or were physically harmed by another resident. According to the interviews, the residents felt they were treated with respect and dignity from other residents at the facility. B. Resident #3 - victim 1. Resident status Resident #3, age greater than 65, was admitted on [DATE] and readmitted on [DATE]. According to the March 2025 CPO, diagnoses included Huntington's disease, major depressive disorder, recurrent and partial remission, unsteadiness on feet, generalized muscle weakness and lack of coordination. The MDS assessment identified Resident #3 was cognitively intact with a BIMS score of 15 out of 15. The resident did not have inattention or disorganized thinking behaviors. According the the MDS assessment, Resident #3 was independent in her mobility and ADL care. 2. Resident interview Resident #3 was interviewed on 3/20/25 at 3:35 p.m. Resident #3 said Resident #1 touched her leg during an activity. She said she told him not to touch her and she reported the incident to staff. Resident #3 said she felt scared and worried because she thought Resident #1 might touch her again. She said Resident #1 was moved into the secured unit and she had not had any more concerns. 3. Record review The trauma care plan, initiated 2/27/25, identified Resident #3 was a victim of a traumatic experience and experienced anxiety and feelings of being scared and upset. The 2/27/25 goal for the resident was to feel safe and less anxious throughout the period of post trauma. The 2/27/25 interventions directed staff to complete wellness checks as needed and offer one-to-one activities when Resident #3 felt overwhelmed. The 2/25/25 system note documented Resident #3 was touched on the back of the leg below her knee by another resident (Resident #1) who told her she had nice legs. The note identified the registered nurse (RN) did not witness the encounter but spoke to the resident. According to the note, Resident #3 said she was okay but she wanted to stay away from him (Resident #1). The 2/25/25 social services note documented Resident #3 notified the SSD that she was touched on the leg by another resident. The note indicated Resident #3 appeared uncomfortable but said she was not scared and felt safe. According to the note, the SSD immediately notified the DON, the charge nurse and the NHA to let them know the aggressor (Resident #1) needed to be on line of sight monitoring. The 2/25/25 nursing note identified a nurse had a wellness visit with Resident #3. The note documented the resident was not scared but did not like (Resident #1) touching her and did not want to be around him. The 2/26/25 IDT note documented Resident #3 was a victim in the 2/25/25 event that made her feel uncomfortable. According to the note, all immediate safety/wellness checks were completed on 2/25/25, 72-hour wellness checks were put in place and interventions were initiated for Resident #1 to keep the two residents separated. C. Resident #1 - assailant The 2/25/25 behavior note documented the DON visited with Resident #1 after he had inappropriate behaviors with another resident (Resident #3). According to the note, the resident was in good spirits and was happy to be at the dinner table. There was no emotional/physical distress noted/reported and Resident #1 reported no recollection of the events earlier in the evening. The 2/26/25 at risk review note documented Resident #1 had behaviors affecting others. Resident #1 had increased wandering and poor safety awareness/awareness of other residents' personal space. He was unable to retain information/education related to his actions but was easily redirectable with identification of behaviors. The intervention identified in the at risk note was to transfer Resident #1 to a secure unit for safety due to increased wandering and for increased staff observation. The note indicated Resident #1 would be maintained on a line-of-sight observation while in common areas or with wandering. The 2/27/25 at risk review note documented the summary of the IDT discussion included Resident #1's inappropriate touching of a female resident's leg (Resident #3) and commenting on her legs. The intervention was to immediately separate Resident #1 from Resident #3, implement a line of sight order and conduct wellness checks for both residents involved. According to the at risk note, Resident #1 had been evaluated as appropriate for the dementia unit, as the increased structure provided would help with redirection and sensory needs and the physician and the resident's responsible party were made aware. A physician's order, revised 2/26/25, identified Resident #1 was admitted to the secured unit due to the risk of wandering away from the facility and placing himself at risk of harm due to inability to find a way back to the facility and a history of behavioral disturbances that seriously disrupted the rights of others. According to the physician's order, a less restrictive alternative would be unsuccessful and a smaller focused environment would be beneficial. Review of the February 2025 behavior tracking record for monitoring inappropriate sexual behaviors identified Resident #1 had one incident of inappropriate sexual behaviors on 2/25/25. The behavior marked the resident was provided one-to-one supervision on 2/25/25. -The behavior tracking for inappropriate sexual behavior did not identify the resident was on one-to-one supervision or line of sight monitoring following the incident with Resident #3 on 2/25/25. IV. Staff education A 12/10/24 all staff in-service (conducted 10 days prior to the incident between Resident #1 and Resident #2) was provided by the facility on 3/24/25. The provided training materials identified abuse was reviewed with the staff. According to the abuse training materials, anything that caused fear in a resident's home was considered abuse and it was the facility's responsibility to provide a safe place for the residents to live. The 12/10/24 all staff in-service training materials identified the difference between and the purpose of a line of sight observation and a one-to-one observation. According to the training material, line of sight observation meant a staff member could see the resident at all times. The purpose of a line of sight observation was to ensure the resident's safety and prevent potential harm or incidents. A specific staff member was assigned to maintain a line of site observation, and this was done in person, and not through video monitoring. The staff should document and assess the resident's condition at regular intervals, such as every 15 minutes. The 12/10/24 all staff in-service training materials identified a one-to-one observation meant a staff member was consistently with the resident within arm's reach. The purpose of a one-to-one observation was to provide the highest level of observation and immediate intervention if needed. The staff member remained with the resident at all times and the resident never left the staff member's immediate presence. Staff should document the resident's condition and any interventions at regular intervals, such as every 15 minutes. The 12/10/24 all staff in-service participation sheet documented 17 staff members attended the training, however, only two staff members were nursing staff members. The 1/10/25 staff inservice staff for one-to-one observation due to inappropriate behavior education was provided by the DON on 3/20/25 at 5:27 p.m. The education documented one-to-one supervision of a resident was set in place for the safety of their respective environment, including but not limited to themselves, other residents, staff, guests, or any other person in the facility. According to the education, when the resident was not alone in their room, the resident must be in line of sight, at arm's length at all times. The DON, the hall nurse, or the NHA would assign the one-on-one attendee. One-to-one staff members must always follow one-to-one guidelines, no exceptions. For breaks, shift change or any other need, one-to-one staff members must wait for another staff member to take their one-to-one position with the resident. The education indicated any actions from a resident that was placed on a one-to-one that put others at risk must be immediately reported to the NHA and the DON. -The 1/10/25 education was provided three weeks after the 12/20/24 incident between Resident #1 and Resident #2. A 3/10/25 staff in-service was provided by the CC on 3/20/25 at 5:33 p.m. The in-service identified abuse prevention was reviewed with 22 staff members, including some nursing staff. V. Staff interviews CNA #2 was interviewed on 3/20/25 at 2:05 p.m. CNA #2 said he had been watching Resident #1 for falls and behaviors the past two to three months, four days a week from 5:30 a.m. to 6:30 p.m. He said other available staff would be responsible for watching the resident the rest of the time. He said he needed to make sure Resident #1 was in line of sight, kept away from female residents and exhibited appropriate behaviors. CNA #2 said since Resident #1 had been in the secured unit, there was also a sensor by the door that identified when the resident was out of bed. He said he was not aware of Resident #1's behaviors toward female residents other than touching people's hands, but nothing more serious. He said Resident #1 was easy to redirect. Licensed practical nurse (LPN) #1 was interviewed on 3/20/25 at 2:10 p.m. LPN #1 identified herself as the nurse for the secured unit. She said precautions to watch for for Resident #1 was inappropriate sexual behaviors. She said Resident #1 needed to be kept in the line of sight of staff. She said that she had not observed any inappropriate sexual behaviors since the resident had been on the secured unit. Registered nurse (RN) #1 was interviewed on 3/20/25 at 3:44 p.m. RN #1 said she had worked on the non-secured hall since January 2025, before Resident #1 was on the secured unit. She said she never saw Resident #1 with inappropriate behaviors. She said she was not aware of extra monitoring or supervision for Resident #1. She said the staff were responsible for keeping an eye on all of the residents. The DON and the CC were interviewed together on 3/20/25 at 3:49 p.m. The DON said Resident #1 was discontinued from one-to-one staff supervision on 2/26/25 and then placed on line of sight supervision on 2/26/25. The DON said Resident #1 was placed on one-to-one supervision after Resident #1 had inappropriate sexual behaviors towards Resident #2 on 12/20/24. -However, there was no documentation or a physician's order in Resident #1's EMR to indicate he had been placed on one-to-one supervision following the 12/20/24 incident (see record review above). The CC said other interventions for Resident #1 included the timing of the medication finasteride and since the change of the medication's administration timing from day to night, staff had seen improvement in his behaviors. She said after the incident with Resident #3 on 2/25/25, Resident #1 was moved to the secured unit for more line of sight monitoring and engagement. The SSD was interviewed on 3/20/25 at 4:05 p.m. The SSD said Resident #1 was kept in line of sight supervision since 12/20/24, after the incident with Resident #2. -However, according to the facility's investigation of the 12/20/24 incident, Resident #1 was supposed to be on one-to-one supervision (see above). The SSD said other interventions for Resident #1 were to offer individual activities that required his hands to help prevent him from touching other residents. He said Resident #1 loved activities. He said there were evening activities but not activities later at night. The SSD said one-to-one supervision was when an assigned staff member would stay with and make sure the supervised resident was not within an arm's length of another resident. He said staff received an education in December 2024 regarding one-to-one supervision (see education above). The CC was interviewed again on 3/20/25 at 4:46 p.m. The CC said Resident #1's one-to-one supervision should have been documented in the behavior tracking record. The CC reviewed the December 2024 behavior tracking record and said the behavior tracking for Resident #1 after the 12/20/24 incident was inconsistent. The CC reviewed the behavior care plan for Resident #1. She said no new interventions were identified on the care plan after the 12/20/24 incident. The NHA was interviewed on 3/24/25 at 11:40 a.m. She said the staff education completed on 12/10/24 (prior to the 12/20/24 incident) was not conducted for a specific resident, but had been part of an all-staff e[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to ensure residents can communicate in their native language for one (#10) resident reviewed for language services out of 35 sample residents. Specifically, the facility failed to provide a system for Resident #10 to receive medical information in his native language. Findings include: I. Facility policy The Resident Rights policy, not dated, was obtained from the nursing home administrator (NHA) on 2/28/24 at 5:46 p.m. failed to document the resident's right to receive information in their primary language. II. Resident status Resident #10, over the age of 65, was admitted on [DATE]. According to the February 2024 computerized physician order (CPO), diagnoses included Alzheimer's dementia, anxiety, diabetes and high blood pressure (hypertension). According to the 1/23/24 minimum data set (MDS) assessment Resident #10 had significant cognitive impairment and was unable to complete the brief interview for mental status (BIMS) score. The assessment documented the resident's preferred language was Spanish. III. Record review The comprehensive care plan dated 4/25/23 documented Resident #10 spoke Spanish as a first language. IV. Staff interviews The laundry aide (LA) was interviewed on 2/28/24 at approximately 11:30 a.m. The LA said she spoke Spanish as her native language. She said she was not used as an interpreter. She said she was willing but had not been asked for quite some time. Certified nurse aide (CNA) #4 was interviewed on 2/29/24 at 3:42 p.m. CNA #4 said one other CNA on staff and a housekeeper spoke Spanish, and staff utilized them to communicate with Resident #10. CNA #4 said she only asked Resident #10 simple questions about what he needed because Resident #10 had limited English understanding. RN #1 was interviewed on 2/29/24 at 3:42 p.m. RN #1 said nursing staff used a housekeeper as a primary translator. RN #1 did not know how nursing staff would communicate with Resident #10 should housekeeping staff be unavailable to translate. RN #1 did not know how the nursing staff would provide medical information to Resident #10 in his primary language. The activities director (AD) was interviewed on 2/29/24 at 6:21 p.m. The AD said she communicated with Resident #10 by looking up words on her phone or using simple phrases. The AD said that Resident #10 should be able to regularly talk in his native language. The director of nursing (DON) was interviewed on 3/1/24 at 12:55 p.m. The DON said residents should be able to receive information in their primary language.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews the facility failed to permit a resident to return to the facility after going to the hospital for one (#137) of two residents reviewed for discharge out of 35 sample residents. Specifically, the facility failed to allow Resident #137 to return to the facility once he was medically cleared by the hospital to return. Findings include: I. Facility policy The Discharge Summary and Plan policy, revised October 2022, was received from the nursing home administrator (NHA) on 2/29/24 at 2:39 p.m. It read in pertinent part: The discharge summary includes a recapitulation of the resident's stay at the facility and a final summary of the resident's status at the time of discharge in accordance with established regulations governing the release of the resident information and as permitted by the resident. A member of the (interdisciplinary team) reviews the final post-discharge plan with the resident and family at least twenty-four hours before the discharge is to take place. II. admission packet The termination, transfer or discharge agreement was in the admission packet Resident #137 signed on 10/23/23 and read in pertinent: The facility may terminate this agreement and the resident's stay and transfer or discharge the resident if: -The transfer or discharge is necessary for the resident's welfare and the resident's needs cannot be met in the facility; -The resident's health improved sufficiently so the resident no longer needs the services provided by the facility; -The resident has failed, after reasonable and appropriate notice to pay for (or have paid or treated as paid under the Medical or Medicaid Programs) charges for the resident's care and stay at the facility; or -The facility ceases to operate. III. Resident status Resident #137, age over 65, was admitted on [DATE] and discharged to the hospital on [DATE]. According to the November 2023 computerized physician orders (CPO), diagnoses included unspecified bipolar disorder and unspecified anxiety disorder. The 11/13/23 minimum data set (MDS) agreement revealed the resident was unable to complete a brief interview for mental status (BIMS). A staff assessment for mental status revealed the resident had a memory problem, severe cognitive impairment, delirium, fluctuating inattention and fluctuating disorganized thinking. The assessment revealed the resident had delusions, physical behaviors directed toward others, verbal behaviors directed toward others, behaviors not directed toward others (pacing, rummaging) and rejection of care. IV. Record review A progress note, written on 10/26/23 at 2:13 a.m., documented Resident #137 arrived at the facility on 10/25/23 at 7:00 p.m. Resident #137 ambulated independently. Resident #137 was offered dinner and ate approximately 50 percent (%) without any difficulties. The resident was in and out of his room for most of the night and asked questions about how the facility worked. The resident settled down to sleep at approximately 1:00 a.m. and told the nurse he was more of a night person. A progress note, written on 10/26/23 at 5:29 p.m., documented Resident #137 was adjusting moderately to his new surroundings. The resident asked about getting out of the facility. The resident was polite and followed directions and redirection. A progress note, written on 10/27/23 at 4:59 p.m., documented Resident #137 adjusted well to his room and roommate. The resident was independent with ambulation and participated in activities. He had increased confusion in the evening. An order administration note, written on 10/29/23 at 11:53 p.m., documented Resident #137 received a dose of Quetiapine (an antipsychotic medication) because the resident sat on the floor in the hallway and laid down outside the doorway of another resident's room while the other resident slept. All attempts for redirection failed. An order administration note, written on 10/30/23 at 5:50 p.m., documented Resident #137 received a dose of Quetiapine because the resident was very confused about his role at the facility and he did not know if he was being admitted or discharged . Resident #137 was restless and paced up and down the hallways. A behavioral note, written on 11/3/23 at 2:13 a.m., documented Resident #137 was restless during the shift and was crawling around on the floor on his hands and knees in his room and in the activity room. Resident #137 kept his roommate awake and his roommate was very frustrated with the resident. An order administration note, written on 11/3/23 at 12:35 p.m., documented Resident #137 received a dose of Quetiapine because he wandered around the unit most of the morning as he looked for his wallet. He was frustrated and agitated but easily redirected by staff. A behavioral note, written on 11/6/23 at 9:29 a.m., documented that at 8:50 p.m. (on 11/5/23) Resident #137 grabbed another resident from behind and attempted to drag the resident down the hallway which caused both residents to fall on the ground. No injuries were noted on either resident. Resident #137 ran around the facility with no shoes and resisted assistance from the nursing staff. The resident accused staff of stealing his things, hit staff multiple times and yelled at another resident while he was three feet away from the resident. Resident #137 was placed on one-to-one supervision but the resident kept running away from the nursing staff. The resident accused the staff of working with Satan. The resident requested to speak to the police and the nurse called for the police to come to the facility. When the police arrived, Resident #137 had slurred speech and raised both his arms when he swung his fists at staff. An ambulance was called and he was verbally aggressive toward the paramedics and the police officer. The nurse and paramedics decided to send the resident to the emergency room for further evaluation. Resident #137 was sedated by the paramedics and transported to the emergency room. A progress note, written on 11/6/23 at 6:36 p.m., documented Resident #137 returned from the emergency room mid-morning and appeared calm and cooperative. In the afternoon the resident exhibited strange behavior and tried to lay on the floor in an empty room. The resident grabbed the food delivery cart and would not let go of it as he used the cart like a walker. The staff asked Resident #137 to let go of the meal cart and he was aggressive and swung at staff. He had a strong desire to go outside. After he spent a considerable amount of time outside he said he was tired and returned inside to go to bed. A discharge planning summary was completed on 11/6/23. The social services director documented Resident #137 was at the facility for long-term care and there was no plan for the resident to be discharged . A progress note, written on 11/8/23 at 11:11 p.m., documented Resident #137 was aggressive and agitated. The resident was on the floor in the hallway. Staff removed other residents from the area for safety reasons. The nurse noticed Resident #137 had blood on his hands but he refused first aid from staff. The resident was experiencing delusions and screamed at staff and residents as he tried going into other residents' rooms. He was throwing items, banged his fists on surfaces and attempted to leave the facility through locked doors. The resident refused all attempts of redirection from staff. The resident lunged at the nurse and missed. He ran through the hallways of the facility. He attempted to jump over the half door into the memory care unit office. The nurse called non-emergency dispatch and requested assistance with a resident who was a danger to himself and others. Resident #137 attempted to punch another resident and no contact was made. The police attempted to de-escalate the resident and failed. Paramedics arrived and sedated the resident as two officers restrained him for safety. The resident was transported to the emergency room. A discharge summary, completed on 11/8/23, documented Resident #137 was at the facility for long-term services. The resident became very agitated and was a harm to himself and potentially other residents. He was transferred to the hospital after being sedated for his safety and others. The resident had a previous transfer for a similar situation on 11/5/23 and returned within 24 hours. The resident was awaiting placement from the emergency room with a geriatric psychiatric unit. The discharge summary documented the resident was discharged to the hospital and referrals were not needed for new placement. -There was no documentation to indicate the facility had reassessed Resident #137 when the hospital notified them the resident was medically cleared to return. -There was no documentation from the resident's physician to indicate the specific needs of the resident which could not be met by the facility, what efforts the facility took to attempt to meet the resident's specific needs or the specific services provided by the accepting facility which could not be provided by the current facility. V. Staff interviews The director of nursing (DON) was interviewed on 3/1/24 at 1:05 p.m. The DON said Resident #137 handled his admission well at first, however, she said he experienced delusions and had a lot of physical aggression and the police and paramedics were called for assistance on 11/5/23. She said the paramedics sedated Resident #137 and took him to the emergency room. The DON said Resident #137 was returned to the facility on [DATE]. She said there were no changes made to any of his medications by the hospital. She said the facility worked with the resident's physician to adjust his medications. The DON said Resident #137's second incident on 11/8/23 was similar to the first incident but with increased delusions and physical aggression. She said the police and paramedics responded again and transported the resident to the emergency room. She said she spoke with the staff at the emergency room and requested they hold the resident until the emergency room adjusted his medications so he would be safe to return. She said the hospital refused to keep Resident #137. The DON said while the resident was at the hospital the second time, he was diagnosed with dementia which made it harder to get him admitted to a geriatric psychiatric facility because those types of facilities usually refused residents with a diagnosis of dementia. The DON said she worked with a sister facility who had more experience with behaviors. The DON said she did not reassess Resident #137 immediately on 11/8/23 when the hospital said he was ready for discharge because she wanted him to be kept longer than 24 hours. She said he stayed at the hospital for about a week and was transferred to the sister facility. The DON said she was unaware she needed a physician's order to document the specific needs the facility could not meet, the facility's effort to meet those needs and the specific services the receiving facility was providing to meet the needs of the resident which could not be met at the current facility. The DON said she felt like the facility did everything right for Resident #137 except having the physician's documentation for the facility-initiated discharge. -Despite the DON saying she spoke with the hospital and worked with a sister facility to have the resident transferred there, there was no documentation found in Resident #137's electronic medical record to indicate her attempts (see record review above).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** IV. Resident #6 A. Resident status Resident #6, over the age of 65, was admitted on [DATE]. According to the February 2024 CPO, diagnoses included vascular dementia, obsessive-compulsive disorder and depression. According to the 1/30/24 MDS assessment Resident #6 had significant cognitive impairment and was unable to complete the BIMS assessment. B. Record review The speech therapy evaluation dated 7/22/23 documented the need for Resident #6 to sit up at 90 degrees for all meals. Cross-reference F689 for accident hazards. According to the care plan dated 2/23/24, Resident #6 required assistance with transferring, toileting, walking and incontinence care. -The care plan did not include the speech therapy evaluation intervention which documented the need for Resident #6 to sit up at 90 degrees for all meals. D. Staff interviews CNA #1 was interviewed on 2/29/24 at 5:46 p.m. CNA #1 said Resident #6 needed to be at 75-90 degrees to eat The speech and language pathologist (SLP) was interviewed on 3/1/24 at 11:48 a.m. The SLP said Resident #6 needed to sit up at 90 degrees for all meals. The SLP said the swallow study evaluation recommendations to be followed by the facility and it should be reflected in the plan of care. V. Resident #5 A. Resident status Resident #5, over the age of 65, was admitted on [DATE]. According to the February 2024 CPO, diagnoses included acute respiratory failure, pneumonia, fibromyalgia and generalized muscle weakness. According to the 1/5/24 MDS assessment Resident #5 had no significant cognitive impairment with a brief interview for mental status (BIMS) score of 15 out of 15. Resident #5 required set up or cleaning up assistance with oral hygiene. B. Record review -The comprehensive care plan dated 1/3/24 failed to document Resident #5's oral care assistance needs. C. Staff interviews Licensed practical nurse (LPN) #2 was interviewed on 2/29/24 at 8:19 a.m. LPN #2 said that Resident #5 required set up and take down assistance for oral care. The director of nursing (DON) was interviewed on 2/29/24 at 1:38 p.m. The DON said that oral care should be performed twice a day for residents. The DON said oral care should be documented in the electronic health record. The DON said oral care should have been provided to Resident #5 twice a day every single day. Based on record review and interviews, the facility failed to develop a comprehensive care plan for services that were to be provided in order to attain or maintain the resident's highest practicable physical, mental and psychosocial well-being for four (#3, #4, #5 and #6) residents of four residents reviewed for care planning out of 35 sample residents. Specifically, the facility failed to: -Develop a bathing care plan focus for Resident #4; -Develop a nutrition care plan focus for Resident #3; -Develop a care plan to include speech therapy interventions at meals for Resident #6; and, -Develop an oral hygiene assistance care plan focus for Resident #5. Findings include: I. Facility policy The Care Planning policy, not dated, was received from the nursing home administrator on 3/6/24 at 12:34 p.m. It read in pertinent part: Comprehensive, person-centered care plans are based on resident assessments and developed by an interdisciplinary team (IDT). -The policy did not include any guidelines or timeframes for creating person-based care plans for residents. II. Resident #4 A. Resident status Resident #4, age younger than 65, was admitted to the facility on [DATE]. According to the February 2024 computerized physician orders (CPO), diagnoses included schizophrenia, anxiety and blindness. The 11/28/23 minimum data assessment (MDS) assessment revealed the resident was moderately cognitively impaired. The resident was mostly independent and needed partial or moderate assistance with bathing. B. Record review The 7/30/17 care plan for activities of daily living, revised 2/25/24, revealed Resident #4 had a performance deficit with bathing and personal hygiene due to decreased vision and mood/behavior concerns. Pertinent interventions and information included the resident needed assistance with bathing and preferred to have a shower in the mornings. The 3/19/17 care plan for activities of daily living, revised 12/7/23, listed Resident #4's personal preferences with care. Pertinent information included that the resident preferred to shower once per week in the afternoon or evening. Pertinent interventions included having staff only ask Resident #4 if he wanted a shower once per week, as asking multiple times created agitation. The Bath Logs from 1/1/24 to 2/29/24 revealed the resident had been offered a shower on four days during this time period and refused each time. C. Staff interviews Registered nurse (RN) #1 was interviewed on 2/28/24 at 3:59 p.m. RN #1 said some residents preferred alternative techniques of bathing, such as sink baths or bed baths and these preferences were noted in the facility's bath sheets. RN #1 said if a resident was offered a bath three times and refused each time they should find another staff member to ask. The social services director (SSD) was interviewed on 2/29/24 at 2:44 p.m. The SSD said that if a resident was repeatedly refusing care, the SSD would educate facility staff on how to use different approaches for the resident and would try to find different ways to navigate the care area. The SSD said that Resident #4 preferred to take a shower every three months,and one of the staff members had some success with getting the resident to agree to bathing. The SSD said the facility staff had tried a variety of bathing methods to see if they would make Resident #4 more comfortable with bathing but could not find any record of these attempts. The director of nursing (DON) was interviewed on 2/29/24 at 4:40 p.m. The DON said Resident #4's bathing preferences should have been documented in the care plan, bathing task and the facility staff's [NAME], an abbreviated care plan for care The DON said Resident #4's bathing task was not popping up on their software to alert the nursing staff, which was something they had recently discovered. The DON said Resident #4 did not like water and she thought this was due to some trauma from his past. The DON said the SSD used a trauma screening for residents in her evaluations so that they could create a care plan appropriately. The DON said Resident #4 tried to clean himself up in the sink. III. Resident #3 A. Resident status Resident #3, age [AGE], was admitted to the facility on [DATE]. According to the February 2024 CPO, diagnoses included atherosclerotic heart disease, diverticulosis and gastro-esophageal reflux. The 11/14/23 MDS assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. The resident was mostly dependant and required moderate to substantial assistance to perform most activities of daily living. B. Observations On 2/28/24 at 4:35 p.m. the resident was eating cottage cheese and fruit that appeared to be peaches. On 2/29/24 at 4:40 p.m. the resident was eating cottage cheese and fruit that appeared to be peaches. On 3/1/24 at 11:45 a.m. the resident was eating cottage cheese and fruit that appeared to be peaches. C. Resident interview Resident #3 was interviewed on 2/26/24 at 11:43 a.m. Resident #3 stated the food she received from the facility was very fattening and she chose to eat cottage cheese and fruit for each meal to prevent weight gain. Resident #3 was interviewed again on 2/27/24 at 12:54 p.m. Resident #3 said she worked with the kitchen staff members on her meals and they switched the fruits she received each meal if she ever got tired of them. Resident #3 said the dietary staff did not try to give her other options with meals and she had to lead this change herself. D. Record review The 12/15/22 care plan, revised 1/3/23, revealed Resident #3 had a potential for weight loss due to her disease processes. Pertinent interventions for this included asking Resident #3 and her family for past food preferences, offering alternate meals as needed if the resident ate less than 50% of her meals and providing and serving her diet as ordered. The 12/15/22 care plan, revised 1/3/23, revealed Resident #3 had gastroesophageal reflux disease. Pertinent interventions for this included encouraging the resident to consume a bland diet and providing the resident with small frequent meals. A medical progress note from 2/8/24 from an interdisciplinary team (IDT) meeting revealed Resident #3 was trying to eat healthy and was eating cottage cheese and fruit for most meals. The dietary quarterly assessment for Resident #3 was completed on 2/12/24. The assessment revealed that Resident #3 was tolerating her diet, was on a regular diet and the resident preferred to eat in her room. -There was no mention of Resident #3's dietary preferences. E. Staff interview Cook (CK) #1 was interviewed on 2/28/24 at 4:35 p.m. CK #1 said Resident #3 ordered cottage cheese and fruit for lunch and dinner every day. CK #1 said Resident #3 would not eat anything else from the menu.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to develop and implement an effective discharge plan that focused on each resident's goals and involved the resident in the development of the discharge plan for one (#36) of two residents reviewed for discharge planning out of 35 sample residents. Specifically, the facility failed to: -Ensure Resident #6's discharge planning needs were identified and documented in order to develop an appropriate discharge plan; and, -Involve the interdisciplinary team in the ongoing discharge process. Findings include: I. Facility policy The Discharge Summary and Plan policy, revised October 2022, was received from the nursing home administrator (NHA) on 2/29/24 at 2:39 p.m. It read in pertinent part: The discharge summary includes a recapitulation of the resident's stay at the facility and a final summary of the resident's status at the time of discharge in accordance with established regulations governing the release of the resident information and as permitted by the resident. A member of the (interdisciplinary team) reviews the final post-discharge plan with the resident and family at least twenty-four hours before the discharge is to take place. II. Resident #36 A. Resident status Resident #36, age over 65, was admitted on [DATE] and discharged to another facility on 1/5/24. According to the January 2024 computerized physician order (CPO), diagnoses included Alzheimer's disease, dementia with agitation and unspecified diastolic (congestive) heart failure. According to the 1/5/24 minimum data set (MDS) assessment Resident #36 had a severe cognitive impairment. The staff interview documented Resident #36 had a memory problem, moderate cognitive impairment, fluctuating inattention and fluctuating disorganized thinking. The 11/6/23 MDS assessment prior to Resident #36 discharging documented the resident was not actively planning to discharge and the resident's clinical record documented only to ask questions about discharge planning on comprehensive assessments. B. Representative interview Resident #36's representative was interviewed on 2/29/24 at 10:43 a.m. He said he was unaware who initiated the transfer of the resident to another facility but he assumed it was the Veteran's Affairs (VA) hospital. He said Resident #36 had VA benefits and wanted to use them but could not at the facility where he was originally staying. The resident and his family were not involved in the discharge planning. C. Record review Resident #36's discharge care plan, initiated on 11/7/23, documented the resident planned to remain in a long-term care facility. The intervention documented was for social services will initiate discharge planning and facilitate a return to the community if applicable and desired by the resident. A progress note, written on 7/24/23, which documented Resident #36 was admitted around 8:45 a.m. Resident #36 was transported by his family and was at the facility for a respite stay. An interdisciplinary team (IDT) note was written on 8/10/23 and documented Resident #36's family decided the resident would stay in long-term care instead of their initial plan for a respite stay. A social service note, written on 8/28/23, documented the social service director (SSD) talked to the resident's family about Resident #36's room change to the memory care unit. The family was documented as happy with the new room. A social service note, written on 10/13/23, documented the SSD sent a referral to another long-term care facility as requested by hospice and Resident #36's family. -There was no further follow up documentation regarding the referral or any indication the resident was planning to discharge to another facility. A progress note written on 1/5/24 by the NHA revealed Resident #36 had been discharged to another facility. -No other progress notes were written in Resident #36's chart from 10/13/23 to 1/5/24, when the resident was discharged from the facility. A discharge summary, completed on 1/5/24, revealed Resident #36 was admitted to the facility as respite care and transitioned to long-term care with hospice. The discharge summary included information on Resident #36's activities, mental and physical status and level of assistance needed, among other pertinent information. -The facility failed to document why the transfer was initiated. III. Staff interview The director of nursing (DON) was interviewed on 3/1/24 at 1:05 p.m. The DON said Resident #36 was admitted to the facility because the VA hospital was not accepting residents at the time. The DON said Resident #36's representative was hoping to arrange coverage through the VA while keeping the resident at the facility but was unable to. The DON said Resident #36's family spoke with her and the staff at the VA to arrange the resident's discharge and said discharges were usually discussed during the facility's morning meeting with their interdisciplinary team. The DON said discharge summaries should document why a resident was being discharged or transferred. The DON said Resident #36's discharge planning was not documented and the summary did not contain information regarding why he was discharged .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interviews, the facility failed to provide assistance with activities of daily living (ADL) for two (#5 and #10) of two residents reviewed for ADLs out of 35 sample residents. Specifically, the facility failed to: Provide set-up teeth brushing assistance for Resident #5; and, Provide set-up bathing assistance for Resident #10. Findings include: I. Facility policy The Activities of Daily Living (ADLs) policy, dated March 2018, was received from the nursing home administrator (NHA) on 2/28/24 at 5:46 p.m. It documented that residents who are unable to complete activities of daily living will receive appropriate care and services, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with mobility (transfer and ambulation, including walking). II. Resident #5 A. Resident status Resident #5, over the age of 65, was admitted on [DATE]. According to the February 2024 computerized physician order (CPO), diagnoses included acute respiratory failure, pneumonia, fibromyalgia and generalized muscle weakness. According to the 1/5/24 minimum data set (MDS) assessment Resident #5 had no significant cognitive impairment with a brief interview for mental status (BIMS) score of 15 out of 15. The MDS assessment documented Resident #5 required set up or cleaning up assistance with oral hygiene. B. Resident interview Resident #5 was interviewed on 2/26/24 at 3:37 p.m. Resident #5 said she required assistance with setting up teeth brushing since she had surgery on both arms. Resident #5 said she had not brushed her teeth in six days. Resident #5 said she preferred to brush her teeth twice a day. C. Record review -Review of the comprehensive care plan dated 1/3/24 failed to document Resident #5's oral care assistance needs. Oral hygiene documented in the resident's electronic health record (EHR) documented 24 events out of an estimated 58 events where nursing staff offered set-up assistance with oral care in 29 days between 1/29/24 and 2/27/24. D. Staff interviews Licensed practical nurse (LPN) #2 was interviewed on 2/29/24 at 8:19 a.m. LPN #2 said Resident #5 required set up and take down assistance for oral care. The director of nursing (DON) was interviewed on 2/29/24 at 1:38 p.m. The DON said oral care should be performed twice a day for residents. The DON said oral care should be documented in the resident's electronic health record. The DON said oral care should have been provided to Resident #5 twice a day every single day. III. Resident #10 A. Resident status Resident #10, over the age of 65, was admitted on [DATE]. According to the February 2024 CPO, diagnoses included Alzheimer's dementia, anxiety, diabetes and high blood pressure (hypertension). According to the 1/23/24 MDS assessment Resident #10 had significant cognitive impairment and was unable to complete the brief interview for mental status (BIMS) assessment. Resident #10 required set up or touch assistance with tub or shower transfers. B. Observations On 2/28/24 at 10:02 a.m. Resident #10 was sitting in the recliner chair in his room. The resident room smelled strongly of urine. On 2/29/24 at 10:06 a.m. Resident #10's room smelled strongly of urine while Resident #10 was sitting in his recliner chair. B. Record review The care plan dated 1/25/23 documented Resident #10 preferred morning showers twice a week. The care plan documented Resident #10's bathing assistance needs which included set-up assistance, supervision of bathing and occasional one person assistance with bathing. The bathing records documented one event of offering set-up bathing assistance to Resident #10 in the month of January 2024. C. Staff interview The director of nursing (DON) was interviewed on 2/29/24 at 1:38 p.m. The DON said all residents should be bathed twice per week while accommodating resident preferences.

Based on observation and interviews, the facility failed to ensure residents were free from significant medication errors for one (#19) of 11 residents reviewed for medication errors out of 35 sample residents. Specifically, the facility failed to ensure Resident #19 was administered insulin according to the manufacturer's guidelines. Findings include: I. Manufacturer's guidelines The How to Use your Lantus Solostar Pen manufacturer's procedure guide, dated 2022, was received from the nursing home administrator (NHA) on 2/28/24 at 5:30 p.m. It documented in pertinent part: -Dial a test dose of two units. -Hold pen with the needle pointing up and lightly tap the insulin reservoir so the air bubbles rise to the top of the needs. This will help you get the most accurate dose. -Press the injection button all the way in and check to see that insulin comes out of the needle. The dial will automatically go back to zero after you perform the test. -If no insulin comes out, repeat the test two more times. If there's still no insulin coming out, use a new needle and do the safety test again. -Always perform the safety test before each injection -Never use the pen if no insulin comes out after using a second needle. II. Observation Resident #19 was observed on 2/28/24 at 4:59 p.m. receiving insulin medication being administered by registered nurse ( RN) #1. RN #1 was took the resident's blood sugar. According to the sliding scale physician order, the resident was to receive six units of Lispro insulin. RN #1 obtained the six units of Lispro insulin from the medication cart. RN #1 administered the Lispro insulin to Resident #19, however, the insulin pen safety check was not completed including priming with two units of insulin prior to administering the insulin. III. Staff interviews Registered nurse (RN) #1 was interviewed on 2/28/24 at 5:12 p.m. RN #1 said she did not know insulin pens had to be primed as part of their safety check before administration. RN #1 did not know where the manufacturer's guidelines for administering insulin were located in the facility. The NHA was interviewed on 2/28/24 at 5:14 p.m. The NHA did not know where the manufacturer's guidelines were kept for insulin pens in the facility. The NHA said she would have to contact the pharmacist to have that information available for bedside nursing staff. The director of nursing (DON) was interviewed on 2/28/24 at 6:13 p.m. The DON said she was not aware insulin pens needed a safety check performed including priming the pen needle. The DON said medication orders by the physician should always be followed. The DON said training on insulin pens was performed in initial orientation only and continuing education on multi-dose insulin pens had not been provided to nursing staff. The pharmacist (PH) was interviewed on 2/29/24 at 3:46 p.m. The PH said Resident #19 had two different kinds of multi-dose insulin pens and the safety check process for administering the two kinds of insulin was the same for the bedside nurse. The PH said every insulin pen sent to the facility should be primed with two units of insulin before administering the medication to the resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interviews, the facility failed to provide food that accommodated resident allergies, intolerances, and preferences for one (#20) of three residents reviewed for dietary preferences out of 35 sample residents. Specifically, the facility failed to provide meals and snacks according to Resident #20's lactose and gluten allergy. Findings include I. Resident status Resident #20, age over 65, was admitted on [DATE]. According to the February 2024 computerized physician order (CPO), diagnoses included unspecified anxiety disorder, other unspecified depressive disorder and underweight. According to the 11/28/23 minimum data set (MDS) assessment, Resident #20 had no cognitive impairment with a brief interview for mental status (BIMS) score of 14 out of 15. II. Resident interview Resident #20 was interviewed on 2/26/24 at 9:28 a.m. Resident #20 said one cook at the facility was good at accommodating her lactose and gluten allergies. She said she needed to gain weight because she was under 100 pounds. She said when her food contained lactose or gluten it gave her horrible diarrhea and made her not want to eat. Resident #20 said she received items she could not eat mainly at dinner time. III. Observations A. Dinner on 2/28/24 At 4:35 p.m. cook (CK) #1 prepared a bacon, egg and cheese quiche. CK #1 served Resident #20 a piece of the quiche without the side crust. -The bottom crust was left on the quiche. -The quiche contained regular cheese. -CK #1 did not prepare a quiche without gluten or dairy. III. Record review Resident #20's care plan, revised 11/9/23, documented the resident had a gluten and lactose-free diet. Interventions were documented as: -Every Saturday night Resident #20 gets a special gluten-free pizza made for her; -Offer Resident #20 regular menu foods, if she declines that food offer her foods off of the specialized menu; -Assist Resident #20 with meal intake as needed; -Provide the necessary level of assistance for meal participation and to maximize intake; -Offer and encourage snacks between meals and as needed upon request; -Provide ordered diet; -Serve meals in individual bowls due to poor eyesight; -Resident #20 prefers to eat small portions at meals; and -Resident #20 likes egg salad stuffed tomatoes and gluten-free biscuits. The care plan further documented Resident #20 had an alteration in gastro-intestinal status which referred to gastroesophageal reflux disorder and diarrhea associated with gluten sensitivity. The intervention was documented as: The resident is sensitive to food products with gluten. Monitor intake of non-gluten products and associated increase in diarrhea concerns. Report to the dietary manager if increased concerns arise and encourage decreased intake of gluten foods when exacerbation of diarrhea arises. IV. Staff interviews CK #1 was interviewed on 2/28/24 at 4:35 p.m. CK #1 said Resident #20 wanted to try the quiche but she did not make a separate quiche without gluten or lactose. She said she removed the side crust to remove the gluten but did not think about the cheese that was in the quiche. The dietary supervisor (DS) was interviewed on 2/29/24 at 11:12 a.m. The DS said the cooks needed to prepare a separate dish for residents with allergies at each meal. She said CK #1 should not have served the regular quiche to Resident #20 even if the side crust was removed because the bottom crust was not gluten-free and the cheese in the quiche was not dairy-free.

Based on record review and interviews the facility failed to ensure that personal funds accounts were managed adequately for six (#19, #20, #1, #4, #10 and #138) of six residents out of 35 sample residents. Specifically, the facility failed to -Have signed written authorizations to manage the personal funds accounts for Residents #1, #4, #20, #138 and #19; and, -Have personal funds withdrawal sheets signed to ensure the residents' permission was obtained to withdraw funds from their personal needs accounts for Residents #1, #10, #4 and #138. Findings include: I. Lack of written authorizations -The facility was unable to provide written authorizations to manage the personal funds account for Residents #1, #4, #20, #138 and #19. The current balance in the personal needs account for Resident #1 was $105.56 as of 3/1/24. The current balance in the personal needs account for Resident #4 was $2,253.24 as of 3/1/24. The current balance in the personal needs account for Resident #20 was $7,180.40 as of 3/1/24. The current balance in the personal needs account for Resident #138 was $3,971.40 as of 3/1/24. The current balance in the personal needs account for Resident #19 was $409.77 as of 3/1/24. II. Personal Funds Withdrawal A. The Personal Funds Withdrawal sheet was reviewed for Resident #1. The resident was found to have two withdrawals from her account with no signed authorization. The withdrawals were as follows: On 8/18/23 a withdrawal for $376.65. On 4/6/23 a withdrawal for $95.70. -The facility provided receipts, however, the facility failed to have the resident or two staff members sign the resident funds request forms. B. The Personal Funds Withdrawal sheet was reviewed for Resident #10. The resident was found to have one withdrawal from his account with no signed authorization. The withdrawal was as follows: On 4/28/23 a withdrawal for $92.37. -The facility provided a receipt and a resident funds request, however, the facility failed to have the resident or a second staff member sign the resident funds request form. C. The Personal Funds Withdrawal sheet was reviewed for Resident #4. The resident was found to have two withdrawals from his account with no signed authorization. The withdrawals were as follows: On 5/10/23 a withdrawal for $6.88. On 7/21/23 a withdrawal for $4.00. -The facility provided receipts and a resident funds request, however, the facility failed to have the resident or a second staff member sign the resident funds request form. D. The Personal Funds Withdrawal sheet was reviewed for Resident #138. The resident was found to have one withdrawal from his account with no signed authorization. The withdrawal was as follows: On 4/3/23 a withdrawal for $235.40. -The facility provided receipts, however, the facility failed to have a resident funds request signed by the resident or by two staff members. III. Staff interviews The business office manager (BOM) and nursing home administrator (NHA) were interviewed on 3/1/24 at 4:20 p.m. The BOM said all residents with trust fund accounts in the facility needed to have a signed written authorization for the facility to manage the residents' funds. The BOM said Resident #19 no longer had a financial power of attorney (POA) and when the BOM realized the resident did not have a signed authorization form she had him sign one on 2/29/24 (during the survey). The BOM said the former BOMs did not handle the residents' funds accounts accurately and she planned on fixing the problems. The BOM said all resident funds requests needed to be signed by the resident. She said if the resident was unable to sign the request two staff members were required to sign the form. She said she was unsure why some purchases had receipts and signed resident fund requests and some purchases did not, however, she said now that she was aware of the issue she would fix it. The NHA said the BOM identified a handful of problems when she looked into the residents' accounts. She said the resident trust fund accounts would be included in the facility's quality assurance and performance improvement (QAPI) program.

Based on record review and interviews, the facility failed to ensure money from personal funds accounts was managed accurately for two (#138 and #4) out of seven residents reviewed for personal funds accounts out of 35 sample residents. Specifically, the facility failed to: -Were dispersed within 30 days after discharge for Resident #138; and, -Notify Resident #4, who was Medicaid funded, or his legal representative when the resident's personal funds account reached $200.00 less than the eligibility resource limit. Findings include: I. Record review A. Resident #138 A review of the current trust account balance provided by the facility revealed Resident #138, who had been discharged over 30 days before, had a remaining balance of $3,971.40 in his personal funds accounts. -There was no documentation the facility had attempted to disperse the funds to the resident. B. Resident #4 A review of the current trust account balance revealed Resident #4 had $2,253.24 in his account which was $253.24 over the allotted limit for Medicaid funded residents. -There was no documentation the facility had notified Resident #4 or his legal representative when his personal funds account reached $200 less than the eligibility resource limit. II. Staff interviews The business office manager (BOM) and nursing home administrator (NHA) were interviewed together on 3/1/24 at 4:20 p.m. The BOM said if the resident passed away the remainder of their funds would go to the family or towards burial costs. She said their funds would be returned to the state if the resident received Medicaid. She said all funds should be dispersed within 30 days. The BOM said previous BOMs did not close out Resident #138's account and disperse the funds timely. The BOM said she was not aware Resident #4 was over the allotted limit for Medicaid eligibility. She said she would work with the resident's family to complete a spend down of the excess funds so he would not lose his benefits. The NHA said the facility was unable to locate the resident's family and they were not sure what to do with the funds or how long the facility needed to attempt to locate the resident's family. She said the resident trust fund accounts were being included in the facility's quality assurance and performance improvement (QAPI) program. The BOM said she would reach out to a state agency for guidance on Resident #138's account and find out where she needed to send the $3,971.40. She said she was completing a full audit of all resident trust fund accounts to see if there were concerns for other resident accounts as well.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and interviews, the facility failed to provide a functional, sanitary and comfortable environment for residents on two of two units. Specifically, the facility failed to: -Provide linens to residents; and, -Mitigate unpleasant odors throughout the facility; and, -Ensure ceiling fans in resident areas were working. Findings include: I. Observations On 2/26/24 at 9:15 a.m. there was a urine smell on the 200 wing of the building. At 9:20 a.m. in room [ROOM NUMBER] there were no hand towels or washcloths. At 11:39 a.m. there was a strong body odor near the exit door of the 200 wing of the building, specifically coming from room [ROOM NUMBER]. At 2:24 p.m. in room [ROOM NUMBER] there were no hand towels or washcloths and the paper towel dispenser did not function when tested. On 2/27/24 at 8:41 a.m. there was a strong odor of urine throughout the 200 wing of the building. At 9:47 a.m. room [ROOM NUMBER] smelled strongly of urine. There were no hand towels or washcloths in the room and no soap in the soap dispenser. At 9:51 a.m. in room [ROOM NUMBER] there were no hand towels or washcloths. At 9:55 a.m. in room [ROOM NUMBER] there were no hand towels or washcloths. Beginning at approximately 11:00 a.m., the following observations were made: -room [ROOM NUMBER] had no hand towels or washcloths; -room [ROOM NUMBER] had no hand towels or washcloths; -room [ROOM NUMBER] had no hand towels or washcloths; -room [ROOM NUMBER] had no hand towels or washcloths; -room [ROOM NUMBER] had no hand towels or washcloths; -room [ROOM NUMBER] had no hand towels or washcloths; -room [ROOM NUMBER] had no hand towels or washcloths; and, -room [ROOM NUMBER] had no hand towels or washcloths. On 2/28/24 at approximately 9:30 a.m., the following observations were made: -room [ROOM NUMBER] had no hand towels or washcloths; -room [ROOM NUMBER] had no hand towels or washcloths; -room [ROOM NUMBER] had no hand towels or washcloths; -room [ROOM NUMBER] had no hand towels or washcloths; -room [ROOM NUMBER] had no hand towels or washcloths; -room [ROOM NUMBER] had no hand towels or washcloths; -room [ROOM NUMBER] had no hand towels or washcloths; -room [ROOM NUMBER] had no hand towels or washcloths; -room [ROOM NUMBER] had no hand towels or washcloths; -room [ROOM NUMBER] had no hand towels or washcloths; -room [ROOM NUMBER] had no hand towels or washcloths; and, -room [ROOM NUMBER] had no hand towels or washcloths. The towel rack in this room was observed to be broken. At 9:41 a.m. there was a strong urine odor in the hallway of the secured unit. On 2/29/24 at 9:05 a.m. there was a strong odor of urine in the 200 wing of the building. At 11:55 a.m., the shower room on 200 wing had an odor. The maintenance director (MTD) said the fan was on, however, when he put a toilet paper square to the fan, it did not suck the paper up which indicated it was not pulling air. The MTD observed room [ROOM NUMBER], #104 and #212 and found that the fans were not working in the rooms. The MTD said that the fans not working could contribute to the odors in the building. II. Resident council interview Residents who frequently attend monthly resident council meetings and the resident council president were interviewed on 2/28/24 at 10:38 a.m. The six residents (#9, #19, #21, #22, #24 and #32) attending the meeting said they did not receive cloth towels and had to use paper towels instead. Two residents said they wanted to use cloth towels. The resident council president said she usually had to get her own towels. During this meeting, the residents said there were unpleasant odors in the building and it was terrible sometimes. The residents said when they have previously tried to complain, the facility staff just told them they were trying but there have not been any improvements. The resident council president, whose room was down the hallway from the smoking area, said she could smell the smoke in the hallway during smoking times. She said she could not handle the smell of smoke. III. Staff Interviews The director of nursing was interviewed on 2/28/24 at 5:21 p.m. The DON said the towels were to be supplied by the certified nurse aides. She said that the residents could request also. The housekeeper (HSK) #1 was interviewed on 2/29/24 at 12:00 p.m. HSK #1 was observed earlier to spray the hallways with air freshener. HSK #1 said she sprayed the air freshener to make the building smell better. She said there was an odor in the hallways. However, she said she did not know why it was persistent. HSK #1 said she did not have any direct involvement with providing towels. The MTD was interviewed on 2/29/24 at 12:30 p.m. The MTD said the building had an odor. He said he tested the air vents quarterly. He said that individual air vents were on one duct with one exit. He said the system was old and it was not doing the job properly.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** III. Resident #10 A. Resident status Resident #10, over the age of 65, was admitted on [DATE]. According to the February 2024 CPO, diagnoses included Alzheimer's dementia, anxiety, diabetes and high blood pressure (hypertension). According to the 1/23/24 MDS assessment, Resident #10 had significant cognitive impairment and was unable to complete the BIMS. According to the 4/4/23 MDS assessment, it was very important for Resident #10 to listen to music and be able to do his favorite activities. B. Observations On 2/26/24 at 12:00 p.m., Resident #10, who spoke primarily Spanish, was sitting in the television (TV) lounge. -The TV was on, however, it was in the English language. On 2/27/24 at 2:55 p.m., Resident #10 was sleeping in bed in his room during a scheduled group activity in the main activities room. On 2/28/24 at 10:02 a.m., Resident #10 was watching TV in his room. A donut with chocolate frosting and sprinkles and a Glucerna shake were on his bedside table. Several residents were socializing in the main activities room. On 2/28/24 at 1:51 p.m., Resident #10 was watching TV in his room during a scheduled group activity. C. Record review Review of the care plan, revised 1/18/24 documented that Resident #10 was at risk for social isolation and decreased group interaction and spoke Spanish as a primary language. The resident enjoyed activities including television, animals, the outdoors, and visiting with other residents and staff. The resident needed to be invited to activities. D. Staff Interviews CNA #4 was interviewed on 2/29/24 at 3:42 p.m. CNA #4 said nursing staff used a housekeeper who spoke Spanish if they could not understand Resident #10. CNA #4 said she was not aware of interpreter services being available. CNA #4 was not aware of any activities in the Spanish language being provided to Resident #10. RN #1 was interviewed on 2/29/24 at 3:42 p.m. RN #1 said that she was not aware of any activities planned in the Spanish language for Resident #10. RN #1 said that she would ask housekeepers that spoke Spanish for help if she could not understand Resident #10. RN #1 was not sure how she would speak with Resident #10 if bilingual housekeeping staff were not present. The activities director (AD) was interviewed on 2/29/24 at 6:21 p.m. The AD said she communicated with Resident #10 by looking up words in Spanish on her phone. The AD said she had provided Resident #10 with Spanish crossword puzzle books and Spanish word finding books, however, she said she had not planned any other activities for Resident #10 in the Spanish language. The AD said residents should have the opportunity to participate in activities in their primary language. IV. Resident #29 A. Resident status Resident #29, over the age of 65, was admitted on [DATE]. According to the February 2024 CPO, diagnoses included dementia, abdominal aortic aneurysm (AAA) (an enlarged area in the lower part of the aorta, the body's main artery) and high blood pressure (hypertension). According to the 12/6/23 MDS assessment, Resident #29 had significant cognitive impairment and was unable to complete the BIMS. The 1/6/23 MDS assessment documented it was very important for the Resident #29 to be able to do his favorite activities. B. Observations On 02/26/24 at 9:55 a.m., Resident #29 was sitting in the common dining area eating breakfast. A moving and grooving activity, scheduled for 9:00 a.m., was going on, however, Resident #29 was unable to participate because he was still eating. -Nursing staff did not invite Resident #29 to participate in activities after he finished breakfast. On 02/27/24 at 2:56 p.m., a hot cocoa and snacks activity was scheduled to start at 2:30 p.m. for the afternoon activity. Music was playing in the dining room, and some residents were gathered for the activity. -Resident #29 was in his room for the duration of the activity, and was not observed to be invited to participate in the activity. On 02/28/24 at 10:06 a.m., a 9:00 a.m. moving and grooving activity was scheduled. Music was playing while Resident #29 continued to eat his breakfast throughout the scheduled morning activity time. -Resident #29 was not offered activities after finishing his breakfast. C. Record Review Resident #29's activity care plan, initiated 1/12/24, documented Resident #29 was at risk for social isolation, required one on one assistance with all activities, should be asked about his interests so he could plan his day and that he could not focus on activities for long periods of time. His documented interests included western music and television, animals, the outdoors, and sorting papers. Based on observations, record review, and interviews, the facility failed to provide person-centered, individualized activities to meet the psychosocial needs of five (#1, #28, #20, #29 and #10) out of eight residents reviewed for activities out of 35 sample residents. Specifically, the facility failed to: -Create a program of Spanish-language activities for Resident #10 in order to support his physical, cognitive, social and emotional health; -Provide person-centered activities to accommodate Resident #28's preferences; -Create a program of activities that were accessible for Resident #20 with visual impairment; and, -Provide meaningful, engaging activities for Resident #1 and Resident #29. Findings include: I. Facility policy The Activity Programs policy, no date of creation or revision, was received from the nursing home administrator (NHA) on 3/6/24 at 12:34 p.m. It read in pertinent part: Activity programs are designed to meet the interests of and support the physical, mental and psychosocial well-being of each resident. Activities offered are based on the comprehensive resident-centered assessment and the preferences of each resident. Individualized and group activities are provided reflect the cultural and religious interests, hobbies, life experiences and personal preferences of the residents. II. Resident #1 A. Resident status Resident #1, age [AGE], was admitted to the facility on [DATE]. According to the February 2024 computerized physician orders (CPO), diagnoses included dementia, osteoarthritis and intervertebral disk disorder. The 1/16/24 minimum data assessment (MDS) assessment revealed the resident was severely cognitively impaired The resident was dependent and required supervision and assistance with all activities of daily living (ADL). B. Resident representative interview The resident's representative was interviewed on 2/27/24 at 8:57 a.m. The representative said Resident #1 may be able to participate in activities but she was not sure how much she could process due to her dementia. The representative said Resident #1 sat in group activities but tone-on-one interactions with staff were more important to her. C. Observations On 2/26/24 at 8:35 a.m. Resident #1 sat in a recliner in the activities room. Resident #1 was not involved in any meaningful activities. At 11:00 a.m. Resident #1 was transferred from the recliner in the activities room to her wheelchair. Resident #1 had not moved or been engaged in any meaningful activities since 8:35 a.m. At 4:04 p.m. the activities director (AD) was talking to Resident #1 in her room. On 2/27/24 at 8:43 a.m. Resident #1 was in the activity room sitting hunched over in her wheelchair. No meaningful activities were taking place. At 2:55 p.m. Resident #1 was sitting in her wheelchair in the activities room. Resident #1 was holding stuffed animal and was not engaged in any meaningful activities. At 3:35 p.m. Resident #1 was sitting in her wheelchair in a different location of the activities room. Resident #1 had dropped her stuffed animal and was chewing and sucking on her fingers. At 3:45 p.m. Resident #1 was sitting in her wheelchair in the same location and position. Resident #1 was petting the stuffed animal that was on the floor and was not engaged in any meaningful activity. At 3:47 p.m. Resident #1 was assisted to her room by the nursing home administrator (NHA). The NHA then applied lotion to Resident #1's hands. At 3:51 p.m. Resident #1 was assisted to the activities room. At 4:41 p.m. Resident #1 was sitting in her wheelchair in the activities room. Resident #1 was hunched over looking at her hands and her stuffed animal was on the ground next to her wheelchair. Resident #1 was not engaged in any meaningful activities. On 2/28/24 at 9:28 a.m. Resident #1 was sitting in her reclining chair with her legs up. At 9:29 a.m. the AD went around to each room on the hall and offered residents a donut and juice. At 9:47 a.m. the AD finished providing conducting the activity involving donuts. The AD did not engage with Resident #1 during this activity due to her being on a pureed diet (see orders and interview below). At 10:45 a.m. Resident #1 was still in her reclining chair. At 10:50 a.m. an unidentified certified nurse aide (CNA) checked on Resident #1. The CNA helped Resident #1 with her drink before leaving the room. At 11:00 a.m. Resident #1 was still in her reclining chair. At 11:03 a.m. registered nurse (RN) #1 went into Resident #1's room to provide medications and walked out of the room after administering the medications. Resident #1 was still in her reclining chair in the same position. At 11:15 a.m. Resident #1 was still in her reclining chair. At 11:22 a.m. the AD went into Resident #1's room to invite her roommate to join an activity but did not invite Resident #1. At 11:30 a.m. Resident #1 was still in her reclining chair. At 5:42 p.m. Resident #1 was alone in her room. Resident #1 was sitting in her wheelchair and rubbing her hands. On 2/29/24 at 9:14 a.m. Resident #1 was sitting in her wheelchair in the activities room. Resident #1 was holding her stuffed animal and had her eyes closed. Resident #1 was not engaged in any meaningful activities. At 9:32 a.m. Resident #1 was assisted away from activities by an unidentified CNA and left in the hallway outside of her room. Resident #1 remained in the hallway alone until 9:40 a.m., at which time the CNA assisted Resident #1 into her room and provided care. D. Record review Resident #1 had physician orders for a pureed texture diet and significant assistance with each meal. The 9/26/16 care plan, revised on 12/10/22, revealed that Resident #1 was at risk of decreased group interaction without encouragement and assistance due to her cognitive impairment. Pertinent interventions noted that Resident #1 enjoyed having a baby doll or stuffed animal to take care of, that the resident enjoyed music and going outdoors and that the resident needed one-to-one assistance for any activities due to her cognitive impairment. Group activity logs from 1/31/24 to 2/29/24 revealed Resident #1 had joined seven group activities during that time. One-on-one activity logs from 1/31/24 to 2/29/24 revealed Resident #1 had listened to music once and had one-on-one interactions with staff nine times during that time. Resident #1 had connected with family via phone or video communication four times during that period. E. Interviews The AD was interviewed on 2/29/24 at 4:48 p.m. The AD said for residents with disabilities, she asked them what they would like to do. When the AD did activities that involved food, she had a printout of the residents' dietary needs on her cart. The AD said when she was doing activities that involved foods like donuts, she offered pudding to residents on pureed diets. CNA #4 was interviewed on 3/1/24 at 3:36 p.m. The CNA said Resident #1 liked to take naps after meals and loved to hold stuffed animals. The CNA said Resident #1 liked to sit in the activities room. Since Resident #1 sat in the activities room for long periods of time, the CNA said it was best for Resident #1 to be assisted into one of the reclining chairs in the room. V. Resident #20 A. Resident status Resident #20, age [AGE], was admitted on [DATE]. According to the February 2024 CPO, diagnoses included visual loss in both eyes, unspecified anxiety disorder, generalized muscle weakness, lack of coordination and other unspecified depressive disorders. The MDS assessment revealed Resident #20 was cognitively intact with a BIMS score of 14 out of 15. Resident #20 required partial or moderate staff assistance for toileting, bathing, personal hygiene and dressing. She required extensive assistance with all surface transfers. He required setup and clean-up assistance with eating and oral hygiene. B. Resident interview Resident #20 was interviewed on 2/26/24 at 9:28 a.m. Resident #20 said the facility offered too many group social activities which she did not like to participate in. She said she enjoyed talking with staff, listening to music, football being outside and animals. She said it was too cold to go outside but when it warmed up she looked forward to going outside even if she just sat there. She said she felt forgotten by the staff because she did not participate in group activities. She said the facility failed to offer enough independent activities, especially for her, because she was legally blind. She said she wished she could do animal therapy and maybe animal therapy would help with her anxiety and depression. Resident #20 said she felt alone at the facility. C. Observations On 2/28/24, during a continuous observation beginning at 8:16 a.m. and ending at 11:30 a.m., the following observations were made: At 8:16 a.m., Resident #20 was in her room with her door closed. At 9:29 a.m., the activity director (AD) went to the residents' rooms and offered a donut and a drink. The AD did not stop at Resident #20's room. Resident #20 was not offered a donut or drink, or a substitution due to her gluten and lactose allergy. At 9:37 a.m., an unidentified certified nurse aide (CNA) checked on Resident #20 and asked if she wanted a snack. Resident #20 declined. At 11:22 a.m., the AD invited a handful of residents to a group activity but did not invite Resident #20. D. Record review Resident #20's care plan, revised 6/19/23, documented the resident was at risk for social isolation due to her preference not to participate in group activities. The care plan documented Resident #20 liked music, animals, the outdoors and her favorite sport was Nascar and she enjoyed watching the races. Interventions included: -Ask the resident about her activity preferences and help her plan; -Assist Resident #20 with mail and phone calls as needed; -Help Resident #20 visit with family and friends in a private location; -Provide Resident #20 with a monthly calendar of scheduled activities; -Respect Resident #20's right to refuse, privacy and spiritual choices; -Resident #20 does not see well enough to watch television (TV) but she enjoys listening to the TV; -Resident #20 enjoys spending most of her day in her room listening to [NAME] (blue tooth speaker); -Resident #20 enjoys country music; -Resident #20 gets upset with invites to group activities; -Resident #20 has an [NAME] that she uses almost daily; -Resident #20 has a low tolerance for activities; -Resident #20 has poor vision, assist her as needed; -Resident #20 is able to vote. Assist the resident with voting needs as needed; -Resident #20 is unable to have gluten and is lactose intolerant, offer her foods that fit her diet; -Resident #20 prefers not to participate in group activities; and -Resident #20 states she enjoys the outdoors but declines invites to go outdoors. -The care plan did not include animal therapy as an activity intervention for Resident #20. A review of the activity progress notes revealed Resident #20 had multiple one-on-one activity visits between 8/1/23 and 11/24/23. -However, there were no one-on-one activity progress notes documented from 11/24/23 through 2/22/24. -There were no one-on-one activity progress notes documented from 2/25/23 through 3/1/24. D. Staff interviews Registered nurse (RN) #1 was interviewed on 2/29/24 at 11:50 a.m. RN #1 said Resident #20 could not see very well which caused her not to participate in activities outside of her room. RN #1 said the resident enjoyed watching football with staff and another resident, but when football season ended she stayed in her room listening to music on her [NAME] speaker. Certified nurse aide (CNA) #4 was interviewed on 2/29/24 at 12:45 p.m. CNA #4 said Resident #20 was visually impaired but could see objects that were close to her. She said the resident recognized staff by their voices. She said Resident #20 enjoyed spending time with animals. CNA #4 said she brought her bearded dragon to work and Resident #20 loved spending time with it. The social services director (SSD) was interviewed on 2/29/24 at 5:41 p.m. The SSD said she was previously the AD before she switched departments. She said Resident #20 was legally blind but she could see shapes. The SSD said Resident #20 preferred to visit with male staff. She said the facility provided a talking book to the resident and she did not really like using it but the SSD said she could offer it again. The SSD said Resident #20 talked to her [NAME] speaker. The SSD said she provided guidance to the AD and would provide more as needed. The AD was interviewed on 2/29/24 at 6:05 p.m. The AD said the activity staff, including herself, invited and encouraged Resident #20 to attend activity groups. She attended one-on-one activities in her room. She said when the weather was nice Resident #20 sat outside and enjoyed a glass of wine. She said Resident #20 had a friend who visited with an animal and Resident #20 loved animals. The AD said animal therapy was not offered to Resident #20 because the AD had not thought of that as an activity. She agreed the resident would benefit from animal therapy or animal visits. 2 The AD said she did not offer Resident #20 a donut on 2/28/24 because the resident could not have it and often declined a substitution snack because it was different from what the other residents received. The AD said she should have offered a gluten and lactose-free donut to the resident so she was not left out of the activity. She said she bought Resident #20 gluten-free snacks but the resident refused to eat them because she believed the items still had gluten in them. The AD said the facility used to provide homemade gluten-free snacks to Resident #20 but stopped because she got burnt out on the items but she was willing to start making the gluten-free snacks again. VI. Resident #28 A. Resident status Resident #28, age [AGE], was admitted on [DATE]. According to the February 2024 CPO, diagnoses included unspecified dementia with other behavioral disturbances, delusional disorders and generalized muscle weakness. The 12/13/23 MDS assessment revealed Resident #28 was cognitively intact with a BIMS score of 15 out of 15. B. Observations On 2/26/24 at 12:59 p.m. Resident #28 had a chair blocking her bedroom door from being opened and said she was busy. Her room was dark and quiet. Resident #28 allowed certain staff into her bedroom. On 2/28/24, during a continuous observation beginning at 8:16 a.m. and ending at 11:30 a.m., the following observations were made: At 8:16 a.m., Resident #28 had her bedroom door closed. At 9:29 a.m., the AD offered Resident #28 a donut and asked if she wanted something to drink. At 9:38 a.m., the NHA brought Resident #28 a cup of coffee. At 9:51 a.m., the NHA left Resident #28's room. At 11:22 a.m., the AD invited residents to a group activity but did not invite Resident #28. C. Record review Resident #28's care plan, revised 12/27/22, documented the resident was at risk for isolation without invites or encouragement to activities. Resident #28 enjoyed reading, walking around, socializing, card games, TV and movies and arts and crafts. Interventions were documented as: -Assist Resident #28 with mail and phone calls as needed; -Help the resident visit with family and friends in a private location; -Resident #28 enjoys doing her makeup and hair; -Resident #28 enjoys having phone calls with family and friends; -Resident #28 enjoys outdoor activities like going for walks when the weather is nice; -Resident #28 enjoys independent activities like watching TV or movies, visiting with staff and other residents and reading books or magazines; -Resident #28 enjoys inviting people to come help her in her room and to carry her stuff around if she needs the help; -Resident #28 enjoys shopping trips; -Resident #28 enjoys socializing with staff and other residents; -Resident #28 likes to walk around the halls while pushing her wheelchair to help carry stuff; -Resident #28 watches TV and movies in her room and occasionally comes out to the activity room to watch movies with other residents; -Provide Resident #28 with a monthly calendar of scheduled activities; -Remind and encourage Resident #28 to do group activities daily and offer assistance while in group activities; -Remind Resident #28 when activities are scheduled; -The resident enjoys spending most of her day in her room watching TV and movies, cleaning and sometimes wandering around the halls of the facility; -Respect Resident #28's right to refuse, privacy and spiritual choices; and -Resident #28's most important activities are reading books or magazines, visiting with staff and residents and making phone calls to her family. On 4/30/23, an activity progress note documented the resident talked about the History Channel and true crime while the activity aide painted the resident's nails for 20 minutes. On 5/20/23, an activity progress note documented the resident talked about her problems and asked for help from the activity aide for 15 minutes. On 11/17/23, a nursing progress note documented Resident #28 was at Walmart with activity staff. -There were no activity progress notes documented from 11/17/23 to 3/1/24. D. Staff interviews RN #1 was interviewed on 2/29/24 at 11:50 a.m. RN #1 said Resident #28 was afraid of germs and often stayed in her room. She said Resident #28 did not participate in activities outside of her room. RN #1 said the resident enjoyed doing her hair and makeup and cleaning her room. RN #1 said the resident did not participate in activities in her room except for flipping through magazines. The AD was interviewed on 2/29/24 at 6:05 p.m. The AD said ADLs counted as an activity for Resident #28. She said the facility offered a rise and shine program where the nursing staff assisted residents with getting ready for the day and making their beds. The AD said Resident #28 preferred a particular activity staff member, however the staff member was on leave. She said Resident #28 had had a decline in activity participation since her preferred activity staff member went on leave. The AD said she offered the resident magazines, newspapers, word searches and other supplies for independent activities but the resident refused the items. The AD said she had not tried other activities for Resident #28 that assisted with her fears and delusions.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to ensure the activities program was directed by a qualified professional. Specifically, the facility failed to employ a qualified activities director in order to provide a program of activities for residents requiring activity and recreational support. Findings include: I. Professional reference According to the National Certification Council of Activity Professionals (NCCAP) (2023), retrieved on [DATE] from www.nccap.org, An activity director must meet specific qualifications in education, certification and/or experience. The activities program must be directed by a qualified professional who is a qualified therapeutic recreation specialist; or an activities professional who is licensed or registered, if applicable, by the State in which practicing; and, -Eligible for certification as a therapeutic recreation specialist or as an activities professional by a recognized accrediting body; or -Has two (2) years of experience in a social or recreational program within the last 5 years, one of which was full-time in a therapeutic activities program; or -Is a qualified occupational therapist or occupational therapy assistant; or -Has completed a training course approved by the State. An activity director is responsible for directing the development, implementation, supervision and ongoing evaluation of the activities program. This includes completion of the activities component of the comprehensive assessment; contribution to the comprehensive care plan goals and approaches that are individualized to match the skills, abilities, and interests/preferences of each resident. II. Record review Review of the staff list revealed an activity director (AD). According to the nursing home administrator (NHA), the activity director was currently in charge of activities (see interviews below). III. Staff interviews The AD was interviewed on [DATE] at approximately 11:00 a.m. The AD said she was the current director of activities. She said she planned the activities for the facility. She said she was not certified as an activity director. She said the social services director (SSD) was her mentor as she had previously worked as the AD. The SSD was interviewed on [DATE] at 5:41 p.m. The SSD said she used to be the activity director however, she changed positions and she no longer was the AD. The SSD said the facility's AD was not certified and she provided support to the AD. The SSD said she was no longer certified as an AD because she let her certification expire. The NHA was interviewed on [DATE] at 3:30 p.m. The NHA said she was not aware the SSD's activity certification had expired.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** III. Resident #27 A. Resident status Resident #27, over the age of 65, was admitted on [DATE]. According to the February 2024 CPO, diagnoses included metabolic encephalopathy (temporary or permanent brain damage resulting from a blood chemical imbalance), kidney failure, dementia, atrial fibrillation and high blood pressure (hypertension). According to the 1/30/24 MDS assessment Resident #27 had significant cognitive impairment and was unable to complete the brief interview for mental status (BIMS) score evaluation. According to the MDS assessment dated [DATE], Resident #27 required assistance with transferring, toileting, walking and incontinence care. B. Observations On 2/26/24 at 10:27 a.m. general nurse aide (GNA) #1 and certified nurse aide (CNA) #2 were transferring Resident #27 from the wheelchair to the recliner without the use of a transfer device. Resident #27 pushed away from the staff while being lifted by her upper arms and shoulders. C. Record review -A review of the comprehensive care plan failed to document the transfer assistance needs of the resident. C. Staff interviews CNA #2 was interviewed on 2/27/24 at 10:02 a.m. CNA #2 said that gait belts should be used to transfer residents from a wheelchair to a recliner chair. The director of nursing (DON) was interviewed on 3/1/24 at 12:55 p.m. The DON said Resident #27 required one to two person assistance and transferring Resident #27 without a gait belt was inappropriate. IV. Resident #6 A. Resident status Resident #6, over the age of 65, was admitted on [DATE]. According to the February 2024 CPO, diagnoses included vascular dementia, obsessive-compulsive disorder and depression. According to the 1/30/24 MDS assessment Resident #6 had significant cognitive impairment and was unable to complete the BIMS assessment. B. Observation On 2/29/24 at 5:36 p.m. Resident #6's bed was approximately at a 45 degree incline after set-up meal assistance was completed by certified nurse aide (CNA) #1. The resident began coughing after eating one bite of food. CNA #1 and licensed practical nurse (LPN) #2 entered the room and assisted the resident to sit up at 90 degrees. Resident #6 stopped coughing following this intervention. C. Record review The speech therapy evaluation dated 7/22/23 documented the need for Resident #6 to sit up at 90 degrees for all meals. According to the care plan dated 2/23/24, Resident #6 required assistance with transferring, toileting, walking and incontinence care. -The care plan did not include the speech therapy evaluation intervention which documented the need for Resident #6 to sit up at 90 degrees for all meals. Cross-reference F656 for care planning. D. Staff interviews CNA #1 was interviewed on 2/29/24 at 5:46 p.m. CNA #1 said that Resident #6 needed to be at 75-90 degrees to eat. CNA #1 stated the resident was not sitting at the correct angle when she began coughing. The speech and language pathologist (SLP) was interviewed on 3/1/24 at 11:48 a.m. The SLP said Resident #6 needed to sit up at 90 degrees for all meals. The SLP said the swallow study evaluation recommendations to be followed by the facility and it should be reflected in the plan of care. Based on record review, observations and interviews, the facility failed to ensure an environment free from risk of accidents and hazardous situations for four (#1, #27, #25 and #6) of four residents reviewed for accident hazards out of 35 sample residents. Specifically, the facility failed to: -Implement appropriate safety devices when assisting Resident #1 and Resident #25 in their wheelchairs; -Safely transfer Resident #27 and Resident #1 using an appropriate transfer device; and, -Ensure speech therapy recommendations were implemented for Resident #6. Findings include: I. Resident #1 A. Resident status Resident #1, age [AGE], was admitted to the facility on [DATE]. According to the February 2024 computerized physician orders (CPO), diagnoses included dementia, osteoarthritis and intervertebral disk disorder. The 1/16/24 minimum data assessment (MDS) assessment revealed the resident was severely cognitively impaired. The resident was dependent and required supervision and assistance with all activities of daily living. B. Observations On 2/26/24 at 11:10 a.m. Resident #1 was assisted to her room in her wheelchair by an unidentified staff member. Resident #1's wheelchair did not have foot pedals nor a footboard in place and her feet dragged along the ground as they moved. At 11:18 a.m. Resident #1 was assisted in her wheelchair back to the activities room. Resident #1's wheelchair did not have foot pedals nor a footboard in place and her feet dragged along the ground as they moved. On 2/28/24 at 9:00 a.m. certified nurse aide (CNA) #5 and #3 assisted the resident to her room. CNA #5 placed the gait belt around the resident's waist. The two CNAs lifted the resident, with one arm under each of the resident's arms and they held onto her pants while they lifted the resident. The resident did not stand on her own. The transfer was a total lift, and the gait belt was not utilized. At 4:38 p.m. the resident was assisted by the activity director (AD) to the television area. No pedals were used, as the resident's feet dragged on the floor. On 2/29/24 at 9:32 a.m. Resident #1 was assisted in her wheelchair by an unidentified certified nurse aide (CNA) from the activities room to the hallway outside of her room. Resident #1's wheelchair did not have foot pedals nor a footboard in place and her feet dragged along the ground as they moved. At 9:40 a.m. Resident #1 was assisted in her wheelchair from the hallway to her room. Resident #1's wheelchair did not have foot pedals nor a footboard in place, and her feet dragged along the ground as they moved. C. Record review The 1/31/2020 care plan, revised on 1/15/24, revealed that Resident #1 was at risk of skin breakdown due to her decreased mobility and fragile skin. Pertinent interventions included having foot pedals and a foot board on her wheelchair to protect her feet. The 1/31/2020 care plan, revised on 1/15/24, revealed that Resident #1 required up to extensive assist of (1-2) staff. However, the care plan failed to direct the staff to use a gait belt. A fall risk evaluation, performed on 1/14/24, revealed that Resident #1 was a low fall risk. The evaluation indicated that Resident #1 was chair-bound and was disoriented at all times. -The resident's medical record failed to show that the resident was assessed for the proper technique to be used for the resident's transfers. D. Staff interviews CNA #5 was interviewed on 2/28/24 at 9:15 a.m. The CNA said that Resident #1 was transferred daily in the same manner (see above). She said some days she stood better than she did during observation. The CNA said a mechanical lift was not utilized with this resident. The director of nurses (DON) was interviewed on 2/28/24 at 5:21 p.m. The DON said a gait belt should always be used when transferring a resident. She said that therapy did a screen on the resident to determine the transfer method. She said that when Resident #1 was transferred the gait belt should be held and under the arms was just support. She said she would get therapy to screen the resident. The DON said pedals should be used on resident wheel chairs so their feet did not drag when being propelled. However, if a resident self propelled the pedals could cause some problems so therefore the chairs did not have pedals. The DON said the pedals could be removed if the resident was being transported. She said injury could occur when a resident was being pushed by a staff member without foot pedals. II. Resident #25 A. Resident status Resident #25, age [AGE], was admitted to the facility on [DATE]. According to the February 2024 CPO, diagnoses included mild cognitive impairment, mild hypoxic ischemic encephalopathy (a form of brain damage caused by lack of oxygen to the brain during or just after birth), muscle weakness and repeated falls. The 12/26/23 MDS assessment revealed the resident was moderately cognitively impaired. The resident required assistance with all activities of daily living. B. Observations On 2/27/24 at approximately 9:00 a.m. Resident #25 was assisted to her room in her wheelchair by an unidentified staff member. Resident #25's wheelchair did not have foot pedals. The resident was told to lift her legs while she was pushed in the wheelchair. On 2/28/24 at 4:46 p.m. CNA #6 assisted the resident from her room to the dining room. The CNA asked the resident to pick up her feet as he pushed the resident. C. Record review The 10/5/22 care plan, revised on 12/18/23, revealed that Resident #25 had deficits in her ability to perform activities of daily living due to her impaired balance. Pertinent interventions included Resident #25 using a wheelchair with staff assistance in order to move around the facility and one staff member for all transfers between surfaces. A fall risk evaluation, performed on 12/23/23, revealed that Resident #25 was a high fall risk. This evaluation indicated that Resident #25 was chair-bound and intermittently confused. D. Staff interview CNA #6 was interviewed on 2/28/24 at 4:50 p.m. The CNA said he asked the resident to pick up her feet when he pushed her in the wheelchair. He said he did not know if she had foot pedals. He said therapy would know if the resident was to have foot pedals on the wheelchair.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interviews, the facility failed to ensure the medication error rate was less than five percent. Specifically, the facility had a medication error rate of 17.86%, which was five errors out of 28 opportunities for error. Findings include: I. Professional reference According to [NAME], P.A., [NAME], A.G., et.al., Fundamentals of Nursing, 10 ed. (2020), E.[NAME], St. Louis Missouri, pp. 606-607, retrieved on 3/8/24, Take appropriate actions to ensure the patient receives medication as prescribed and within the times prescribed and in the appropriate environment. Professional Standards such as nursing scope and standards of practice apply to the activity of medication administration. To prevent medication errors, follow the seven rights of medication administration consistently every time you administer medications. Many medication errors can be linked in some way to an inconsistency in adhering to these seven rights: the right medication, the right dose, the right patient, the right route, the right time, the right documentation and the right indication. II. Facility policy and procedure The Pharmacy Services Overview policy, undated, was received from the nursing home administrator (NHA) on 2/28/24 at 5:46 p.m. It documented in pertinent part: Medications are received, labeled, stored, administered and disposed of according to all applicable state and federal laws and consistent with standards of practice. Manufacturer's instructions or user manuals related to any medication administration devices are kept with the devices or at the nurses station. III. Manufacturer's guidelines The How to Use your Lantus Solostar Pen manufacturer's procedure guide, dated 2022, was received from the NHA on 2/28/24 at 5:46 p.m. It documented in pertinent part: -Dial a test dose of two units. -Hold pen with the needle pointing up and lightly tap the insulin reservoir so the air bubbles rise to the top of the needs. This will help you get the most accurate dose. -Press the injection button all the way in and check to see that insulin comes out of the needle. The dial will automatically go back to zero after you perform the test. -If no insulin comes out, repeat the test two more times. If there's still no insulin coming out, use a new needle and do the safety test again. -Always perform the safety test before each injection -Never use the pen if no insulin comes out after using a second needle. IV. Observations On 2/28/24 at 12:47 p.m. licensed practical nurse (LPN) #1 administered medication to Resident #31. LPN #1 reviewed the physician order and obtained Tylenol from the medication cart. LPN #1 added a small amount of the meal Resident #31 was currently eating and administered the medication. After administering the medication, LPN #1 asked Resident #31 if she had any pain or discomfort. -LPN #1 failed to assess Resident #31's pain before administering the physician ordered as-needed pain medication. According to the medication administration record (MAR), Resident #31 had a physician order for Tylenol every eight hours as needed for her pain. On 2/28/24 at 4:16 p.m. LPN #1 administered medications to Resident #29. Three ordered medications were crushed together and placed into a nutritional supplement. After Resident #29 consumed the nutritional supplement, the nursing staff emptied the remaining volume into the sink which contained several pill fragments. It was not known what dose of each medication Resident #10 received. -LPN #1 failed to ensure Resident #29 received the physician ordered dose of these three medications. The MAR documented that Resident #29 was to receive Trazodone 50 milligrams (mg) twice daily by mouth (an antidepressant), Tylenol 500mg twice daily by mouth and Seroquel 50mg twice daily by mouth (an antipsychotic). The physician orders documented the medications may be crushed and placed in an appropriate vehicle for medication administration for Resident #29. Resident #19 was observed on 2/28/24 at 4:59 p.m. receiving insulin medication administered by registered nurse (RN) #1. RN #1 took the resident's blood sugar. According to the sliding scale physician order, the resident was to receive six units of Lispro insulin. RN #1 obtained the six units of Lispro insulin from the medication cart. RN #1 administered the Lispro insulin to Resident #19. -RN #1 failed to complete the insulin pen safety check including priming with two units of insulin prior to administering the insulin. The MAR documented Resident #19 had ordered Lispro insulin to be administered subcutaneously per a sliding scale dose that varied depending on Resident #19's blood glucose reading. V. Staff interviews LPN #1 was interviewed on 2/28/24 at 12:49 p.m. LPN #1 said he should have asked Resident #31 about her pain before obtaining the pain medication from the medication cart. LPN #1 was interviewed on 2/28/24 at 4:16 p.m. LPN #1 said he had an order to place crushed medications in an appropriate vehicle. LPN #1 said that the nutritional supplement was not an appropriate vehicle for the medications because pill fragments remained in the supplement after medication administration. LPN #1 said he should have used pudding or applesauce as an appropriate vehicle for medication administration. The director of nursing (DON) was interviewed on 2/28/24 at 6:13 p.m. The DON said she was not aware insulin pens needed a safety check performed including priming the pen needle. The DON said medication orders by the physician should always be followed. The DON said applesauce or pudding was considered an appropriate vehicle for medication administration. The pharmacist was interviewed on 2/29/24 at 3:46 p.m. The pharmacist said Resident #19 had two different kinds of multi-dose insulin pens and the safety check process for administering the two kinds of insulin was the same for the bedside nurse. The pharmacist said every insulin pen should be primed with two units of insulin before medication administration.

Based on observations, interviews and record review, 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; and, -Ensure food was served at the appropriate temperature. Findings include: I. Resident interviews Resident #5 was interviewed on 2/26/24 at 3:50 p.m. Resident #5 said the kitchen mainly prepared eggs, chicken and pork. She said she rarely received beef. Resident #5 said she did not like the eggs the kitchen prepared and the eggs were served as the main source of protein. She said she told the kitchen not to serve her eggs because she disliked them. Resident #5 said the facility served french fries, potatoes and corn a lot. She said she was not provided with salt and pepper and the meals were often served not seasoned. The resident said her food was ice cold when she received it. Resident #8 was interviewed on 2/26/23 at 2:11 p.m. Resident #8 said the food was often served cold and the staff did not warm it up for the residents. Resident #20 was interviewed on 2/26/24 at 9:46 a.m. Resident #20 said the facility served a lot of canned or frozen vegetables. She said she wanted more fresh fruits and vegetables. She said she would eat a plain piece of lettuce if it was fresh. II. Resident group interview Residents who frequently attend monthly resident council meetings and the resident council president were interviewed on 2/28/24 at 10:38 a.m. One resident said the food was mediocre. Another resident who typically ate in her room said the food was sometimes cold. III. Test tray A test tray was evaluated by four surveyors on 2/28/24 at 5:30 p.m. The test tray consisted of an egg and cheese mechanical soft texture quiche and oven-fried potatoes. -The fruit that had been served to the residents was not sampled because the kitchen ran out of the fruit. -The egg and cheese quiche was 129.9 degrees Fahrenheit and the potatoes were 110.8 degrees Fahrenheit. -The crust on the bottom of the quiche was soggy and under-baked. -The quiche was cold, rubbery and flavorless. -The oven-fried potatoes tasted like frozen potatoes. The food on the test tray lacked seasoning. IV. Staff interviews Cook (CK) #1 was interviewed on 2/28/24 at 4:35 p.m. CK #1 said she seasoned the meals based on what she knew the residents liked and disliked. She said she did not completely follow the recipes because she knew her residents. She said the residents disliked vegetables with dinner and she always omitted the vegetables and did not replace them with something of similar nutritional value. The dietary supervisor (DS) was interviewed on 2/29/24 at 11:12 a.m. The DS said the cooks needed to follow the menus and the recipes. She said the meals needed to be seasoned based on the recipe, not based on how well CK #1 knew the residents. The dietary manager (DM) from a sister facility was interviewed on 3/1/24 at 10:15 a.m. The DM said the cooks needed to follow the recipes and season the meals. She said items from the menu needed to be served and if they were omitted they needed to be replaced with something of similar nutritional value. She said residents each liked or disliked items and their meal tickets needed to be updated to reflect their likes/dislikes. The DM said the cooks should not season meals the same for everyone because a handful of the residents disliked seasonings.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and interviews, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of diseases and infection on two of two units. Specifically, the facility failed to: -Ensure staff followed proper hand hygiene procedures when moving from task to task; -Ensure frequently touched surfaces were cleaned; and, -Ensure surface disinfectant times were adhered to for disinfecting products by all staff. Findings include: I. Failed to ensure staff performed hand hygiene and residents were offered hand hygiene prior to meals. A. Professional reference The Centers for Disease Control and Prevention (CDC) Hand Hygiene in Healthcare Settings (1/30/2020), retrieved on 3/12/24 from https://www.cdc.gov/handhygiene/providers/guideline.html, included the following recommendations, in pertinent part for hand hygiene, Use an alcohol-based hand sanitizer immediately before touching a patient, before performing an aseptic task or handling invasive medical devices, before moving from work on a soiled body site to a clean body site on the same patient, after touching a patient or the patient's immediate environment, after contact with blood, body fluids or contaminated surfaces, and immediately after glove removal. B. Facility policy The Handwashing/Hand Hygiene policy, revised October 2023, was received from infection preventionist (IP) #1 on 2/29/24 at 5:15 p.m. The policy read in pertinent part, This facility considers hand hygiene the primary means to prevent the spread of healthcare-associated infections. All personnel are trained and regularly in-services on the importance of hand hygiene in preventing the transmission of healthcare-associated infections. Hand hygiene products and supplies are readily accessible and convenient for staff use to encourage compliance with hand hygiene policies. Alcohol-based hand rub (ABHR) dispensers are placed in areas of high visibility and consistent with workflow throughout the facility. C. Observations On 2/26/24 at 12:30 p.m., general nurse aide (GNA) #1 was assisting Resident #31 during lunch. Resident #31 had dropped silverware into the middle of her plate and was eating food without utensils. GNA #1 picked up the serving utensils and redirected the resident to use them. -GNA #1 did not perform hand hygiene prior to picking up Resident #31's utensils from the middle of her plate On 2/26/24 at 12:37 p.m., licensed practical nurse (LPN) #1 was clearing resident plates and discarding refuse from the lunch meal. After clearing the plates, LPN #1 proceeded to enter and exit a resident's room. -LPN #1 did not perform hand hygiene prior to entering the resident's room. On 2/28/24 at 9:00 a.m., certified nurse aide (CNA) #5 and CNA #3 assisted Resident #1 to her room. CNA #5 performed incontinence care for the resident. -CNA #5 failed to change her gloves after performing the care and proceeded to touch items in the resident's room, such as the door knob and personal items of the resident's. On 2/28/24 at 10:00 a.m., the activity director (AD) gave a hug to a resident. -The AD proceeded to touch the hands of another resident without performing hand hygiene. On 2/28/24 at 4:46 p.m., CNA #6 assisted a resident to the dining room. -CNA #6 failed to perform hand hygiene when he left the dining room and began to assist another resident to the dining room. On 2/29/24 at approximately 12:00 p.m., housekeeper (HSK) #2 was cleaning a shared room. -HSK #2 failed to perform hand hygiene after changing gloves between cleaning the toilet and cleaning the remainder of the room. D. Record review A 1/16/24 in-service education sheet documented staff were educated on proper handwashing. E. Staff interview IP #1 and IP #2 were interviewed on 2/29/24 at 3:52 p.m. IP #2 said hand hygiene needed to be performed between tasks, after leaving a resident's room and when hands were visibly soiled. She said residents needed to be offered hand hygiene prior to consuming their meals. She said she performed hand hygiene audits and training on a regular basis. II. Failure to ensure housekeeping staff were following the proper cleaning techniques for cleaning resident rooms and disinfecting high frequency touched areas A. Professional reference Assadian O, Harbarth S, Vos M, et al. Practical Recommendations for Routine Cleaning and Disinfection Procedures in Healthcare Institutions: A Narrative Review. The Journal of Hospital Infection, (2021) Jul;113:104-114,retrieved on 3/12/24 revealed in pertinent part: High-touch surfaces, on the other hand, are usually close to the patient, are frequently touched by the patient or nursing staff, come into contact with the skin and, due to increased contact, pose a particularly high risk of transmitting pathogens (virus or microorganism that can cause disease) Healthcare-associated infections (HAIs) are the most common adverse outcomes due to delivery of medical care. HAIs increase morbidity and mortality, prolong hospital stays, and are associated with additional healthcare costs. Contaminated surfaces, particularly those that are touched frequently, act as reservoirs for pathogens and contribute towards pathogen transmission. Therefore, healthcare hygiene requires a comprehensive approach. This approach includes hand hygiene in conjunction with environmental cleaning and disinfection of surfaces and clinical equipment. The CDC Environment Cleaning Procedures (5/4/23), retrieved on 3/12/24 from https://www.cdc.gov/hai/prevent/resource-limited/cleaning-procedures.html#, read in pertinent part, High-Touch Surfaces: The identification of high-touch surfaces and items in each patient care area is a necessary prerequisite to the development of cleaning procedures, as these will often differ by room, ward and facility. Common high-touch surfaces include: -bedrails -IV (intravenous) poles -sink handles -bedside tables -counters -edges of privacy curtains -patient monitoring equipment (keyboards, control panels) -call bells -door knobs. B. Observations On 2/29/24 at approximately 12:00 p.m., HSK #2 cleaned room [ROOM NUMBER]. THSK #2 failed to clean the door knobs, pull cords and light switches in the room. C. Staff interview P#1 and IP #2 were interviewed on 2/29/24 at 3:52 p.m. IP #2 said the high touch areas included door knobs, light switches and pull cords. She said that it was important to ensure they were cleaned properly as it could pose a risk for infections to spread if they were not. III. Ensure surface disinfectant times were adhered to for disinfecting products by all staff A. Manufacturer recommendations The disinfectant in the facility was identified as HP202. The manufacturer's recommendations read in pertinent part, This product contains hydrogen peroxide and is a one step hospital use germicidal cleaner and deodorant designed for general cleaning, disinfection and controlling mold and mildew odors on hard, non-porous surfaces. Effective against in one minute on hard, non-pourous surfaces. For use as a one-step cleaner/disinfectant: All surfaces must remain visibly wet for 10 minutes. For use as a *virucide: All surfaces must remain visibly wet for 5 (five) minutes. A one minute contact time is required for *HIV-1 (AIDS virus), *Influenza Virus Type A (H1N1), *SARS-Related Coronavirus 2 (SARS CoV-2) (the virus that causes COVID-19). B. Observations On 2/29/24 at approximately 12:00 p.m., HSK #2 cleaned room [ROOM NUMBER]. HSK #2 sprayed the toilet with the cleaner/disinfectant HP202. He also sprayed the sink. -HSK #2 left cleaner/disinfectant on the toilet and sink for less than three minutes. C. Interviews HSK #2 was interviewed on 2/29/24 at 12:15 p.m. HSK #2 said he used HP 202 to clean and disinfect surfaces in residents' rooms. He said for COVID-19 disinfection the product had a dwell time of three minutes. He said for all other organisms, the dwell time was 10 minutes. CNA #4 was interviewed on 2/29/24 at approximately 10:00 a.m. CNA #4 said when she cleaned the shower chair between residents she would spray the chair with the HP202. She said she would imminently spray the chair off with water. IP#1 and IP #2 were interviewed on 2/29/24 at 3:52 p.m. Both IP #1 and IP #2 said they were not involved with the chemicals the housekeeping department used and were not sure what the dwell times for the chemicals were.

Based on record review and interviews, the facility failed to employ dietary staff with the appropriate competencies and skill sets to carry out the functions of the food and nutrition service for 38 census residents. Specifically, the facility failed to: -Provide dietary competencies and skill tests to ensure staff could carry out the functions of the food and nutrition service according to professional standards of practice; and -Ensure the dietary supervisor was trained and certified as a dietary manager. Cross-reference F803 for dietary menus to meet residents' needs. Cross-reference F804 for food palatability and proper temperature. Cross-reference F805 for food prepared in a form to meet residents' needs. Cross-reference F806 for food prepared to accommodate residents' allergies. Cross-reference F812 for failure to prepare and serve food in a sanitary manner. Findings include: I. Record review -The dietary supervisor (DS) was unable to provide documentation that indicated she was a certified dietary manager. -The dietary supervisor (DS) was unable to provide copies of training and competencies completed for the dietary staff, including herself. II. Staff interviews Cook (CK) #1 was interviewed on 2/28/24 at 4:35 p.m. CK #1 said she served smaller portions to certain residents because some residents did not eat as much and she wanted to limit food waste. She said the residents who were on a pureed diet got fruit and cottage cheese instead of the main meal because the foods were easier to blend. CK #1 said she was unaware foods served on a mechanical soft diet needed to be either one-inch by one-inch pieces or half-inch by half-inch sized pieces. She said she was educated that mechanical soft foods only needed to be soft. She said she had not completed additional training but had been a cook at long-term care facilities for over 20 years. CK #1 said she substituted items on the menu if they were not thawed in time or if the items were not in the kitchen. She said she omitted vegetables at dinner every day because the residents did not like vegetables with dinner. CK #1 said she did not replace the omitted items with food of similar nutritional value or calories. The DS was interviewed on 2/29/24 at 11:12 a.m. The DS said the dietary staff, including herself, completed annual training. She said when new dietary staff were hired she relied on a cook to train the new cooks and a dietary aide to train the new dietary aides. The DS said the dietary staff needed more training, especially for texturizing food for residents on altered diets. The DS said she was previously a cook for 20 years in long-term care facilities and had been at the current facility for two years as the dietary supervisor. The DS said she had completed school and was expected to take her test on 3/5/24 to become a certified dietary manager. The DS said she was unaware of bread alterations required for mechanical soft textured diets. The DS said she did not know hand sanitizer was not allowed to be used in the kitchen and that staff needed to wash their hands with soap and water only while they were in the kitchen. The DS said the menus used at the facility were confusing and the cooks needed to follow what was on the menu for meals. The DS said she believed cold foods were to be held at a temperature of 34 to 46 degrees Fahrenheit (F) and hot foods needed to be held at a temperature over 65 degrees F. She said she tried to complete food temperature training every year. The DS said she provided menus to the kitchen staff with the dates blacked out and had mixed up the menus for February 2024. The DS said she was informed CK #1 did not serve vegetables at dinner time but was unaware it happened every night. She said she thought the cook omitted items occasionally. The DS said she was unaware the cook served half or small portions of food servings to the residents without a physician's order. She said if the resident wasted the food it was their right and CK #1 needed to serve the portions according to the menu and recipes. The DS said the kitchen staff needed more training and guidance. She said she did not observe meals as much as she needed to because she was tied up in meetings every day. She said she felt the kitchen had enough staff but lacked adequate education. The DS said she called her registered dietitian (RD) if she had questions or needed help, however, she said she needed more support. The nursing home administrator (NHA) was interviewed on 2/29/24 at 9:02 p.m. The NHA said the facility was in the process of switching from the National Dysphagia Diet to the International Dysphagia Diet Standardization Initiative. She said all residents who were on a mechanical soft diet were on a level three mechanical soft diet. She said the DS was in charge of the kitchen and all dietary staff. -The facility failed to provide any follow-up documentation that included training completed by the dietary staff and the DS by the end of the survey on 3/1/24.

Based on observations, record review and interviews, the facility failed to ensure menus met the needs of residents and were followed. Specifically, small portions were served to all residents and menu items were omitted without substitutions being made. Findings include: I. Observations A. Dinner on 2/28/24 At 4:35 p.m. cook (CK) #1 prepared a bacon, egg and cheese quiche for residents on a regular textured diet and an egg and cheese quiche for residents on a mechanical soft textured diet. The menu called for a bacon and cheddar quiche with oven-browned potatoes and parslied cauliflower and a tropical fruit parfait, however, CK #1 served peaches and omitted the cauliflower and said the residents did not like vegetables with dinner. -Resident #31 was served half of a portion of the mechanical soft quiche, although she did not have a physician's order for small portions. The vegetables were omitted. -Resident #15 was served half of a portion of the mechanical soft quiche, although he had a physician's order for extra portions. The vegetables were omitted. -Resident #8 was served half of a portion of the mechanical soft quiche, although he did not have a physician's order for small portions. The vegetables were omitted. -Resident #16 was served half of a portion of the regular bacon and cheese quiche, although he did not have a physician's order for small portions. The vegetables were omitted. -Resident #14 was served half of a portion of the mechanical soft quiche, although he did not have a physician's order for small portions. The vegetables were omitted. -Resident #30 was served half of a portion of the regular bacon and cheese quiche, although he did not have a physician's order for small portions. The vegetables were omitted. -Resident #33 was served half of a portion of the regular bacon and cheese quiche, although he did not have a physician's order for small portions. The vegetables were omitted. -Resident #23 was served half of a portion of the regular bacon and cheese quiche, although he did not have a physician's order for small portions. The vegetables were omitted. -Resident #22 was served half of a portion of the regular bacon and cheese quiche, although he did not have a physician's order for small portions. The vegetables were omitted. -Resident #21 was served half of a portion of the regular bacon and cheese quiche, although he did not have a physician's order for small portions. The vegetables were omitted. -Resident #3 was served the alternative meal of fruit (peaches) and cottage cheese. She was not served vegetables or a carbohydrate. -Resident #4 was served the alternative meal of fruit (peaches) and cottage cheese. She was not served vegetables or a carbohydrate. -Resident #25 was served the alternative meal of fruit (peaches) and cottage cheese. She was not served vegetables or a carbohydrate. She had a severe cognitive impairment and was unable to order her meal. CK #1 said fruit and cottage cheese were easier to puree than the main meal. -Resident #1 was served the alternative meal of fruit (peaches) and cottage cheese. She was not served vegetables or a carbohydrate. She had a severe cognitive impairment and was unable to order her meal. CK #1 said fruit and cottage cheese were easier to puree than the main meal. II. Staff interviews CK #1 was interviewed on 2/28/24 at 4:35 p.m. CK #1 said Resident #3 and Resident #4 were the only residents who ordered the alternative meal of fruit and cottage cheese. She said she served fruit and cottage cheese to Resident #1 and Resident #25 because it was easier to puree and the residents could not order their meals due to their cognitive levels. CK #1 said she served half or small portions to the residents who did not eat much because she did not want food to be wasted. The corporate registered dietitian (CRD) was interviewed on 2/29/24 at 10:30 a.m. The CRD said meals needed to be served based on the physician's orders, therapeutic diets, residents' care plans and meal tickets. She said residents were to receive the full portion unless they had a physician's order documented for small portions. The CRD said the kitchen needed to serve the residents a full portion even if they wasted the food. The dietary supervisor (DS) was interviewed on 2/29/24 at 11:12 a.m. The DS said the cook needed to serve the meals based on the menu and recipes. She said residents had the right to waste food and CK #1 was not supposed to omit items or serve small portions to prevent food waste. She said if the meal ticket did not say small portion the resident needed to be served the full portion. The DS said the menu called for the quiche to be made in a pie pan and a regular portion needed to be one-sixth of the quiche and a small portion was one-eighth of the quiche. She said the facility only had one or two residents who had physician's orders for small portions. The DS said she needed to talk to CK #1 to tell her not to omit items from the menu without replacing the items with something of similar nutritional value.

Based on observations, record review and interviews the facility failed to store, prepare, distribute, and serve food in a sanitary manner. Specifically, the facility failed to ensure: -Cold food items were held at the proper temperature to reduce the potential risk of foodborne illness; -Expired dry goods were disposed of; -Proper hand hygiene was performed during meal service; -Kitchen refrigerators were held at the appropriate temperature; and, -Food items were labeled with use-by dates. Findings include I. Food storage A. Professional reference The Colorado Department of Public Health and Environment (2019) The Colorado Retail Food Establishment Rules and Regulations, retrieved on 3/9/24 from: https://drive.google.com/file/d/18-uo0wlxj9xvOoT6Ai4x6ZMYIiuu2v1G/view, revealed in pertinent part, A date marking system that meets the criteria stated in (2) of this section may include: Marking the date or day of preparation, with a procedure to discard the food on or before the last date or day by which the food must be consumed on the premises, sold, or discarded; Marking the date or day the original container is opened in a food establishment, with a procedure to discard the food on or before the last date or day by which the food must be consumed on the premises, sold, or discarded; or Using calendar dates, days of the week, color-coded marks, or other effective marking methods, provided that the marking system is disclosed to the Department upon request. B. Initial kitchen tour observations on 2/26/24 At 8:40 a.m. the initial tour of the kitchen was conducted. The following items were found: -A case of cranberry juice was stored on the same shelf with bottles of two different kinds of cleaning solutions and bottles of bleach in the pantry. -A bucket of chocolate chips was dated to be used by 3/16/21 and had a lid that was only partially on the bucket, exposing the chocolate chips. -A bucket of red velvet cake mix was dated to be used by 7/17/23 and had a lid that was only partially on the bucket, exposing the cake mix. -A bucket of thickener powder was dated to be used by 10/13/23 and had a lid that was only partially on the bucket, exposing the thickener powder. -A refrigerator/freezer appliance in the refrigerated cold storage room had significant amounts of spilled grime on the seals and the doors. -Two reusable grocery bags were sitting on the floor by the refrigerator/freezer appliance. The bags contained lettuce, cheese, queso, mixed vegetables and smoked salmon. -The food items in the bags were not dated or labeled and the bag of lettuce, cheese and mixed vegetables had condensation present inside the bag. -A large white refrigerator contained a bucket of pickle slices that were dated to be used by 8/1/23. -Six dozen eggs in the refrigerator were unlabeled. -The refrigerator labeled Fridge #2 had an internal thermometer that read 38 degrees Fahrenheit and the spare thermometer in the refrigerator read 42 degrees Fahrenheit. The refrigerator felt warm and contained dairy items. -A bucket of whipped margarine was dated to be used by 2/8/24. -An opened box of cream of wheat was dated to be used by 12/29/23. -An opened box of corn muffin mix was dated to be used by 12/22/23. -An opened box of biscuit mix was dated to be used by 2/22/24. C. Staff interviews Cook (CK) #1 was interviewed on 2/26/24 at 8:40 a.m. CK #1 said she had just put the six dozen eggs in the refrigerator and had not had time to date and label them when she put them in the refrigerator. -However, 13 eggs out of the six dozen eggs had been used and served to the residents. The dietary supervisor (DS) was interviewed on 2/29/24 at 11:12 a.m. The DS said the food needed to have a date labeled on each item to indicate when the items were received and when the items needed to be used by. She said the cooks were responsible for going through the leftover cooked meals and checking the dates. She said she was responsible for the rest of the food inventory. The DS said she was unaware there were chemicals in the pantry with food items. The DS said she did not know what use by date she needed to put on different food types because the list she used was outdated. The DS said she tried not to use buckets to store foods, however, she said she was aware they were in the pantries and that the lids did not always fit. II. Food temperatures A. Professional reference The Colorado Department of Public Health and Environment (2019) The Colorado Retail Food Establishment Rules and Regulations, retrieved on 3/9/24 from: https://drive.google.com/file/d/18-uo0wlxj9xvOoT6Ai4x6ZMYIiuu2v1G/view revealed in pertinent part, Except during preparation, cooking or cooling, food shall be maintained at 135 degrees Fahrenheit or above for ready-to-eat hot foods and 41 degrees Fahrenheit or below for ready-to-eat cold foods. B. Dinner observations on 2/28/24 At 4:35 p.m. CK #1 prepared dinner. CK #1 took the temperature of the meal before she plated it for the residents. -The temperature of the pureed peaches was 42 degrees Fahrenheit (F) and the temperature of the pureed cottage cheese was 41.8 degrees F. -Both food items were above the recommended safe serving temperature of 41 degrees for ready to eat cold foods. -Despite the peaches and cottage cheese having temperatures above the safe zone, CK #1 proceeded to serve the five residents peaches and cottage cheese. C. Staff interviews CK #1 was interviewed on 2/28/24 at 4:35 p.m. CK #1 said when she took the temperature of the peaches and the cottage cheese they both registered at 41 degrees F. She said the cold foods needed to be 41 degrees F or lower when she served them. -However, the thermometer had indicated the temperature of the peaches was 42 degrees F and the cottage cheese temperature was 41.8 degrees F (see observations above). The DS was interviewed on 2/29/24 at 11:12 a.m. The DS said the kitchen staff needed more education regarding safe food serving temperatures. The DS said cold foods needed to be 34 to 46 degrees F and hot foods needed to be anything above 65 degrees Fahrenheit. -However, cold foods needed to be served at temperatures below 41 degrees F or below and hot foods needed to be served at 135 degrees F or higher (see professional reference above). III. Hand hygiene in the kitchen A. Professional reference The Colorado Department of Public Health and Environment (2019) The Colorado Retail Food Establishment Rules and Regulations, retrieved on 3/9/24 from: https://drive.google.com/file/d/18-uo0wlxj9xvOoT6Ai4x6ZMYIiuu2v1G/view, revealed in pertinent part, Food employees shall clean their hands and exposed portions of their arms, including surrogate prosthetic devices for hands or arms for at least 20 seconds, using a cleaning compound in a handwashing sink. B. Dinner observations on 2/28/24 At 4:35 p.m., CK #1 prepared plates for the residents for dinner. At 4:44 p.m., CK #1 used hand sanitizer and grabbed plates for the residents' dinner. At 4:47 p.m., CK #1 prepared five residents' plates and used hand sanitizer. At 4:50 p.m CK #1 prepared two residents' plates and used hand sanitizer. At 4:54 p.m., CK #1 prepared two residents' plates and used hand sanitizer. At 4:56 p.m., CK #1 put a meal tray in the meal cart, closed the meal cart door and used hand sanitizer. At 4:57 p.m., CK #1 prepared four residents' plates and used hand sanitizer. At 4:58 p.m., CK #1 prepared one resident's plate and used hand sanitizer. At 4:59 p.m., CK #1 touched the meal cart and used hand sanitizer. At 5:02 p.m., CK #1 prepared one resident's plate and used hand sanitizer. At 5:06 p.m., CK #1 prepared three residents' plates and used hand sanitizer. At 5:10 p.m., CK #1 washed her hands with soap and water after she picked something up from the floor. At 5:15 p.m., CK #1 prepared five residents' plates and used hand sanitizer. At 5:16 p.m., CK #1 used hand sanitizer. At 5:20 p.m., CK #1 prepared seven residents' plates and used hand sanitizer. At 5:22 p.m., CK #1 used hand sanitizer after putting plate covers on two residents' plates. -During the dinner service observation, CK #1 performed hand hygiene with soap and water instead of hand sanitizer only one time between 4:35 p.m. and 5:22 p.m. C. Lunch observations on 3/1/24 The DS assisted CK #1 with preparing a chocolate cake with frosting for residents on a mechanical soft diet. At 11:47 a.m., the DS cut up a piece of cake and stirred the frosting throughout the chunks of cake. -The DS licked her fingers and prepared another piece of cake for another resident. At 12:05 p.m., the DS cut up a couple more pieces of cake and stirred the frosting throughout the chunks of cake. -The DS licked her fingers again and prepared more cake for the residents. D. Staff interviews CK #1 was interviewed on 2/28/24 at 4:35 p.m. CK #1 said the facility installed hand sanitizer dispensers in the kitchen and she was unaware soap and water needed to be used instead of hand sanitizer in the kitchen. The DS was interviewed on 2/29/24 at 11:12 a.m. The DS said she was unaware the kitchen staff could not use hand sanitizer in the kitchen. She said the facility installed the hand sanitizer dispensers and was confused as to why the facility would do that if staff needed to use soap and water instead of hand sanitizer for hand hygiene in the kitchen.

Based on interviews and record review, the facility failed to ensure an effective quality assurance program to identify and address facility compliance concerns was implemented, in order to facilitate improvement in the lives of nursing home residents, through continuous attention to quality of care, food and nutrition services and resident safety. Specifically, the quality assurance performance improvement (QAPI) program committee failed to identify and address concerns related to food and nutrition services, quality of care, resident safety and infection control. Findings include: I. Facility policy The Quality Assurance and Performance Improvement (QAPI) Program-Analysis and Action was received from the nursing home administrator (NHA) on 2/26/24. The policy read in pertinent part, Quality deficiencies that are identified through feedback and data and will undergo appropriate corrective action. Corrective actins are monitored against established goals and benchmarks by the QAPI committee. The QAPI program overseen by the QAPI committee is designed to identify and address quality deficiencies through the analysis of the underlying cause and actions targeted at correcting systems at a comprehensive scope and severity. II. Review of the facility's regulatory record revealed it failed to operate a QA program in a manner to prevent repeat deficiencies and initiate a plan to correct F689 Accident hazards During the recertification survey on 7/29/21 F689 was cited at a D scope and severity, a potential for more than minimal harm, isolated. During the abbreviated survey on 11/3/22 F689 was cited at a D scope and severity, a potential for more than minimal harm, isolated. During the recertification survey on 3/1/24 F689 was cited at an E scope and severity, a potential for more than minimal harm, pattern. F692 Nutrition parameters During the abbreviated survey on 11/3/22 F692 was cited at a G scope and severity, actual harm. During the recertification survey on 3/1/24 F692 was cited at a G scope and severity, actual harm. F867 Quality assurance program During an abbreviated survey on 6/15/22 F867 was cited at an F scope and severity, a potential for more than minimal harm, facility wide. During the abbreviated survey on 11/3/22 F867 was cited at an F scope and severity, a potential for more than minimal harm, facility wide. During the recertification survey on 3/1/24 F867 was cited at an F scope and severity, a potential for more than minimal harm, facility wide. F880 Infection control During an abbreviated survey on 3/9/22 F880 was cited at an E scope and severity, a potential for more than minimal harm, pattern. During the recertification survey on 3/1/24 F880 was cited at an F scope and severity, a potential for more than minimal harm, facility wide. III. Cross-reference citations Cross-reference F805 food in form to meet resident needs: The facility failed to implement the residents' therapeutic diet orders for mechanical soft textures and/or thickened liquids. Cross-reference F692 nutrition parameters: The facility failed to implement timely nutritional interventions and evaluate the effectiveness of nutritional interventions in place. IV. Staff interviews The nursing home administrator (NHA) and the director of nurses (DON) were interviewed on 3/1/24 at 3:23 p.m. The NHA said the QAPI committee met monthly with the interdisciplinary team (IDT) and the medical director in attendance. The NHA said the meeting had an agenda. She said the agenda changed monthly. The NHA said the IDT met daily to discuss any issues from the previous night and answered the Five Whys in order to determine the root cause (an interative interrogative technique used to explore the cause-and-effect relationships underlying a particular problem. The primary goal of the technique is to determine the root cause of a defect or problem by repeating the question Why? five times). The QAPI committee looked for trends and then root causes and then put a performance improvement plan in place. \ The NHA said the dietary manager (DM) attended the QAPI meetings as part of the IDT. She said prior to the survey, the DM was in school and needed to receive training. She said they did have a performance improvement plan for food temperatures and the dish machine not registering correctly, however, that was resolved. She said the kitchen has had turnover of two cooks and has had an issue on retaining staff. She said the the menu had been switched and there was lack of training and education provided to the kitchen staff on how to read and understand the menus. The DON said the nursing staff were trained to use proper transfer techniques. However, staff turnover and consistent solid staff were attributed to the deficient practice. The DON said the QAPI committee did discuss weights for both weight loss and gain at each meeting. She said they had identified that once weight loss was identified then the resident was placed on weekly weights and would be followed which included watching meal intakes and who required eating assistance. She said she was aware resident's weight loss continued to be addressed. She said multiple interventions were attempted with Resident #29. The DON said infection control was something they were always working on. She said the infection preventionist was performing hand hygiene audits and trainings. The NHA said since her employment from November 2023, she did recognize there were a lot of areas that needed changes. She said she was involving the IDT with recognizing and putting solutions in place.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews and record review, the facility failed to ensure residents were free from unnecessary restraints for one (#186) of three residents out of 19 sample residents. Specifically, the facility failed to use a position change alarm restraint appropriately, to use an appropriately approved type of restraint, attempt to use the least restrictive alternative restraint, and to follow the physician orders for appropriate use of a restraint, for Resident #186. Since the resident's admission on [DATE], the facility had implemented personal alarms to the resident's wheelchair and bed, a gait belt that was inappropriately used to restrain Resident #816 to her wheelchair, and an alarming seat belt to her wheelchair. Cross-reference F689, failure to prevent accidents and/or hazardous conditions. Findings include: I. Facility policy The Use of Restraints policy, dated 11/1/17, provided by the nursing home administrator (NHA) on 11/7/22 at 11:10 a.m., revealed in pertinent part: Restraints shall only be used for the safety and well-being of the resident and only after other alternatives have been tried unsuccessfully. Restraints shall only be used to treat the resident's medical symptom(s) and never for discipline or staff convenience, or for the prevention of falls. II. Resident status Resident #186, age [AGE], was admitted on [DATE]. admission records revealed Resident #186 had severe cognitive impairment and diagnoses included Alzheimer's disease, unspecified atrial fibrillation (irregular heart rate), essential primary hypertension and depression. The minimum data set (MDS) assessment had not been completed as of the survey due to the resident's new admission to the facility. III. Record review Resident #186's care plan, initiated on 10/24/22 and not revised, identified the resident was at risk for falls and revealed: After the resident's fall on 10/24/22, a goal was added to the care plan that the resident would not experience adverse effects from falls, which included an intervention of identifying contributing factors, if possible. -No interventions were documented under fall prevention measures. -No specific interventions were included regarding attempts to decrease injuries from falls. -Use of restraints was not mentioned in the care plan. -There was no documentation of a gait belt being used as a restraint, instead of a removable seat belt restraint. Review of nursing notes and assessments revealed the following: On 10/24/22 at 8:23 p.m., Received approval to place tab alarm on wheelchair and pressure alarm in bed for resident safety. Review of the resident's physical restraint assessments initiated on 10/24/22 and 10/29/22 but not completed until 11/2/22 (during the survey) revealed the resident had an unsteady gait; forgot to use recommended ambulation device; had frequent falls, slid out of the wheelchair; attempted to self-transfer; had acute confusion contributing to unsafe transfers; and was in a weak and poor cognition impacting safety. The assessment noted that a family companion and one-to-one activities were attempted prior to application of a restraint. -The type of restraint approved for useby the physician was a seat belt restraint. There was no documentation of the facility attempting to use an alternative interventions other than position alarms and a gait belt physical restraint on some occasions per staff interviews (see below). There was no documentation of the resident's responsible party/ family receiving education regarding the risks of the implemented physical restraints. Although the family was documented as being notified, there was no documentation of the responsible party/family giving consent for the physical restraints. There was no documentation of assessments for appropriateness of personal alarms being applied to the resident's chair and bed. A late entry nursing note, dated 10/29/22 at 12:09 p.m., documented a registered nurse (RN) received orders to place a seat belt in the resident's wheelchair, and an alarm in the resident's bed to decrease and prevent injury. A late entry nursing note, dated 10/29/22 at 4:15 p.m., documented an RN order placed for a seat belt in the wheelchair and alarm in bed related to unsafe transfer with poor cognition. Review of the October 2022 CPO revealed that a physician order was received on 10/31/22 to place a seat belt on the resident for poor cognition, unsafe transfers and to prevent falling. It was to be released during meals, and during care times. The resident was to be checked every 15 minutes and to have the resident sit in the recliner as often as she would allow. -The physician order was acquired two days after restraints were placed. -No documentation was found in the resident's medical record that staff were checking the resident every 15 minutes while the restraint was in place, per physician orders. IV. Observations The resident was observed throughout the day on 11/1/22, 11/2/22 and 11/3/22 wearing an alarming seat belt restraint, unless she was at the assistance table in the dining room. -However, interviews revealed the facility had used a gait belt to restrain the resident over the previous weekend (see below). V. Interviews Certified nurse aide (CNA) #1 was interviewed on 11/3/22 at 10:10 a.m. She stated that the tab alarm that was placed in the seat of the resident's wheelchair did not work; the resident would slide down and try to stand up. The CNA stated that the resident could remove the seat belt restraint with assistance from staff but not on her own. The CNA said she would check on the resident every two hours like the other residents. Licensed practical nurse (LPN) #1 was interviewed on 11/3/22 at 10:47 a.m., 2:16 p.m., and 3:37 p.m. LPN #1 said that the nursing home administrator (NHA), who was also an RN, told him over the phone on 10/29/22 to use a gait belt for a restraint instead of a seat belt restraint, because there were no seat belt restraints available, and that she would put an RN order in the resident's chart for a seat belt restraint. The LPN said the gait belt was applied on Saturday10/29/22 at approximately 4:15 p.m., and that he forgot to put a nursing note in the resident's medical record. The LPN said that the resident was not able to remove the gait belt because it was affixed in back of the resident's wheelchair with the buckle placed near the resident's back, and it was not a quick release gait belt. The LPN acknowledged the gait belt was technically a restraint. The LPN said he placed the gait belt on the resident because he was told to do it by his direct supervisor, and it was for the resident's safety. The LPN was unsure of when the gait belt was removed and replaced with the seat belt restraint. The LPN said that restraints would have not been needed if they had more staff. The NHA was interviewed on 11/3/22 at 2:59 p.m. The NHA said that she was unaware of staff using a gait belt for a restraint until it was brought to her attention on 11/3/22 during the survey. The NHA said that she gave an RN order on 10/29/22 for a seat belt restraint, not for a gait belt to be used as a restraint, and the following morning the seat belt restraint was implemented on the resident in place of the gait belt. The NHA said she did not go to the facility over the weekend and did not know how long the gait belt was in place, but that she would investigate. -No documentation was found in the resident's medical record that a gait belt was applied. The NHA and director of nurses (DON) were interviewed on 11/3/22 at 4:40 p.m. The NHA said that the gait belt was not to be used as a restraint, as it was not considered an acceptable restraint. The NHA said the resident could remove the seat belt restraint but not on command. The NHA reported that she had trained the nursing staff that gait belts are not to be used as restraints, as they are not considered an approved restraint. The NHA said if the facility had sufficient staff they would not need restraints or alarms. VI. Facility follow-up An email sent from the NHA on 11/4/22 at 11:58 a.m. documented: ALL restraints and alarms have been discontinued today. Education will be presented to staff about dementia care management. An email sent from the NHA on 11/5/22 at 1:11 p.m., outlined the timeline that the gait belt was used on Resident #186 as a restraint. The email documented, in summary: The gait belt was applied Saturday 10/29/22 at approximately 4:15 p.m. through Monday 10/31/22 after the breakfast meal. The gait belt was released and or removed while the resident was eating, during resident care, and at the resident's bedtime.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to ensure allegations of abuse were investigated for three (#25, #13, and #35) of nine residents reviewed for abuse allegations of 19 sample residents. Specifically, the facility failed to: -Conduct a comprehensive investigation into allegations of abuse for Residents #25 and #13; and, -Conduct a comprehensive investigation into Resident #35's skin tears obtained during bathing. Findings include: I. Facility policy and procedure The Abuse Investigations policy, no date of inception or revision, provided by the nursing home administrator (NHA) on 10/31/22 at 4:00 p.m. read in pertinent part, all reports of resident abuse, neglect, and injuries of unknown source shall be promptly and thoroughly investigated by facility management. Should an incident or suspected incident of resident abuse, mistreatment, neglect or injury of unknown source be reported, the administrator, or his/her designee, will appoint a member of management to investigate the alleged incident. II. Resident #25 A. Resident status Resident #25, age [AGE], was admitted on [DATE]. According to the November 2022 computerized physician orders (CPO), diagnosis included myalgia, history of urinary tract infections, and underweight status. According to the 9/13/22 minimum data set (MDS) assessment the resident scored a 12 out of 15 on the brief interview for mental status (BIMS) examination indicating the resident's cognition was moderately impaired. The resident required extensive one-person physical assistance with bed mobility and transfers. Walking in room or corridor activity did not occur. B. Resident interview Resident #25 was interviewed on 11/1/22 at 8:46 a.m. She said there was a certified nurse aide (CNA) at the facility who likes to talk on her phone and talk out loud about her sex life. She said this CNA then blamed her for the information getting around the facility and came into her room and jammed a COVID swab down her nose on purpose hurting her while telling her not to talk about her sex life. She said she felt it was abusive the way she jammed the COVID swab down her nose. She said she felt this was a few weeks ago, and she had reported this information to licensed practical nurse (LPN) #1. She said since the incident staff now come into her room in pairs and she feels like she has been punished since reporting it. She identified the staff member in the allegation as CNA #2. C. Staff interviews The NHA, the abuse coordinator for the facility, was notified of the abuse allegation on 11/1/22 at 3:18 p.m. She said she was unaware of this situation and it was not brought to her attention. LPN #1 was interviewed on 11/2/22 at 10:38 a.m. He said Resident #25 had reported to her that CNA #2 was pretty rough with her with a COVID swab purposefully. He said this allegation was about three or four weeks ago, and he immediately reported this information to his supervisor, the director of nursing (DON). He said CNA #2 has had historically a bad attitude at work and worse of late, and has had a mouth and been snarky with Resident #25 in an attempt to start trouble with the resident just cause she did not want to work with the resident. He said the process at the facility was to immediately report allegations from residents to management for them to investigate. He said the day the resident reported the allegation to him the NHA and DON were in the facility and he felt more comfortable going to the DON, so that was who he reported it to. The NHA and DON were interviewed on 11/3/22 at 4:42 p.m. The DON said the incident with the COVID swab was brought to her attention prior to survey. She was told by a staff member that CNA #2 shoved a COVID swab up Resident #25's nose. She said she was under the impression the allegation had been made over the weekend and she was told about it the following Monday on 10/24/22. She said she had gone and talked to CNA #2 about the incident, who denied it, and they decided the staff would need to enter Resident #25's room in pairs to provide care. She said she spoke with Resident #25 about the incident but she was snarky and did not want to speak to her about it. The DON said there was no investigation done that was written down on paper. She said staff were trained to report allegations of abuse and rough was a trigger word for staff to be aware of to report. She said an investigation should have been put down on paper. The NHA, and abuse coordinator for the facility, said she was not made aware of this incident with the COVID swab. She said the process at the facility was for investigations to begin immediately. She said she should have been notified of this allegation as that was the process at the facility, and it should have been investigated. D. Facility follow-up An investigation was initiated by the facility and ongoing during the time of survey. The facility was not able to provide any staff or resident interviews nor documentation related to the allegation from Resident #25, which happened approximately four weeks prior according to the resident and LPN #1. CNA #2 was noted to have been suspended pending the results of the facility's investigation. III. Resident #13 A. Resident status Resident #13, age [AGE], was admitted on [DATE]. According to the November 2022 CPO, diagnoses included dementia with behavioral disturbance. The 9/15/22 MDS assessment documented she was unable to complete the BIMS, had short-term and long-term memory problems and was moderately impaired for decision making. She had delirium symptoms of inattention and disorganized thinking. She had problems sleeping, was tired with little energy, had trouble concentrating, and was short tempered and easily annoyed. Resident #13 exhibited behavioral symptoms not directed toward others, such as hitting or scratching herself, pacing, rummaging, and making disruptive sounds. Rejection of care was not exhibited. Wandering occurred daily but there was no documentation if it placed her at risk or intruded on others' privacy. She needed supervision/oversight/setup for transfers and walking, limited assistance with dressing, and extensive assistance with toilet use and personal hygiene. She needed physical assistance with part of her bathing activity. B. Record review Cross-reference F689, Accidents, regarding failure to keep Resident #13 safe from injuries during a shower. A nurse's note on 10/29/22 at 2:05 p.m. documented, Resident became combative during shower, sustaining ST (skin tear) to L (left) hand and RUE (right upper extremity). STs irrigated with wound cleanser, skin approximated, steri-strips applied, clear site dsg (dressing) to protect. DON (director of nursing) and POA (power of attorney) notified. The incident report dated 10/29/22 at 8:49 a.m. documented in part, Resident became combative during shower and sustained ST to L hand 4cm x 1cm and to RUE 5cm x 2cm. CNAs trying to shower resident, she was okay until they turned on the water, (resident) then started trying to bite (CNA #3 initials), the CNA tried to defend from being bit and hit, and during the time to calm down she sustained injuries. The resident's mental status was described as alert, oriented to person, combative, confused. A written statement by CNA #4 accompanied the incident report, dated 10/29 with no date, an illegible signature, signed below by the NHA with no date or time. The statement documented that Resident #13 was getting in the bath house when (CNA #3) turned on the shower water, she became combative trying to bite (CNA #3) when we went to make sure the sprinkles weren't hitting her feet any more she went to bite again so (CNA #3) grabbed her one side while I tried the other side so she wouldn't hurt herself and the bottom of (CNA #3's) hand tore her skin. We then got the nurse (who) patched her up. She was mad at (CNA #3) so she left the room while me & (LPN #1) finished her up. Although it was documented that the CNAs grabbed the resident from both sides, there was no written statement or evidence of an interview with CNA #4, who performed the shower. There was no evidence that Resident #13 or other residents were interviewed regarding their experiences with showers. No other staff interviews were conducted regarding resident complaints or observations of staff being rough with residents during showers, to determine if there had been abuse. C. Staff interviews The NHA was interviewed on 11/3/22 at 5:05 p.m. The director of nursing (DON) was not in the facility during the first three days of the survey. She said to her knowledge what happened on 10/29/22, after talking with CNAs #3 and #4, was that Resident #13 was fine when they were starting her shower. When CNA #3 turned on the water Resident #13 was naked, got startled, she was not sure if the water was cold, the resident backed up, started punching, hitting, scratching, hit her hand on the tile and got the skin tears. The NHA said she discussed with CNAs #3 and #4 about using warm blankets or towels after undressing her, ensuring the water was nice and warm when they took the resident into the shower, and it was okay for them to leave a towel on her when she was showering. We talked about that, the girls were good about it. And she didn't want her hair wet; that was another thing. Sometimes she'll have a shower and won't wash her hair. The NHA said she had trained staff not to put up their hands and not to say calm down. She said she talked to both CNAs on the phone after the incident and asked them to tell her what happened. It was over the weekend and on the phone. She said she interviewed both CNAs but did not interview any other residents about their experiences in the bath house. She did investigate the incident for potential abuse. IV. Resident #35 A. Resident status Resident #35, age [AGE], was admitted on [DATE]. According to the November 2022 CPO, diagnoses included dementia with behavioral disturbance, mood disorder with depressive features, post-traumatic stress disorder, and kidney and bone cancer (malignant neoplasm). The MDS assessment was not readily available due to the resident's discharge from the facility on 10/6/22 by his family after Resident #35 alleged physical abuse. B. Record review Review of the facility's physical abuse investigative report regarding an incident involving Resident #35 on 10/5/22 revealed on 10/5/22 at approximately 8:20 p.m., Resident #35 returned from an outing with family and did not want to stay in the facility. Staff were unable to calm him because he was upset so they called his family who returned to the facility and took him home, choosing to discharge him that night. A staff witness statement included in the investigative report, dated 10/5/22, documented Resident #35's wife called, and while on the phone Resident #35 told her we hit him. Other staff witness statements documented Resident #35 had tried to hit staff with a stapler and a decorative painted rock. The NHA documented a behavior note on 10/5/22 at 10:44 p.m., This RN was called this evening to assist with (Resident #35's) outbursts of agitation and aggressiveness with staff. In questioning staff, no distraction or dementia technique was working to get him to calm down. Staff reported he had a painted rock and was brandishing it towards staff. He threw a stapler at a staff member. Physician notified of behaviors, new orders received, and we were to ship to the ER (emergency room) if we couldn't get him to take his medication. At this point I notified family and requested that the granddaughter come in to help and see if she could help de-escalate her grandpa. She came up to the facility to help. (Resident #35) did calm down with her with him. I received a call from the daughter and she stated she was coming up with the police since her dad told her that he was being hurt. I let (the daughter) know that this is fine, however, we can't meet his needs when he reacts this way. (Daughter) stated that she wants to take him home. I instructed the staff to help pack his things. I also instructed staff to give their statements to the police regarding the incident events. The police are here now, and everything is calming down. Staff removed other residents from the area when this event occurred and he has remained on a one to one monitor until the granddaughter got here. -Although the facility investigated Resident #35's aggression toward staff and possibly other residents, there was no evidence of a facility investigation into Resident #35's report that staff had hit him and that he was being hurt. Upon request, the NHA provided the local police department investigation narrative, which read: On 10-5-2022 at about 2104 hours (9:04 p.m.), I (officer name) was dispatched to (facility address) for a reported elder abuse. Upon arrival I made contact with the reported victim (Resident #35) and his granddaughter (name, who) stated her mom (name) was on her way to get (Resident #35). I tried to speak with (Resident #35) about what was going on and he was unable to put together a sentence without being coached along. He also seemed to forget he was speaking or forget where he was through the entire altercation. The only thing he could tell me was 'It was the big (man).' (Granddaughter) stated (Resident #35 had told his family he had been assaulted however he had dementia and she was unsure of his legitimacy. She also informed me he was a war vet and had PTSD and was known to go off to the smallest thing. I reviewed the four working cameras footage and was unable to find a point where the staff touched (Resident #35). The video shows the head nurse (name) attempt to hand (Resident #35) what appears to be medication. After which (Resident #35) refuses to take the medication and starts pacing. He walks to the front door where he begins to kick it and after some time comes back and goes behind the nurses station. Shortly after (Resident #35) comes back out talking on a wireless phone. He goes out of view of the camera after this point. All staff avoided (Resident #35) during the incident as far as I could see. I went back to (Resident #35's) room where (Resident #35's daughter and wife) had arrived. (Daughter) was very upset saying the facility had abused (Resident #35) before this night showing me old pictures of (Resident #35) with multiple nicks and cuts on his hands as well as a picture where his left butt and thigh were heavily bruised. I asked her to email copies of the pictures which she never did. (Daughter) then told me she used to work at (the facility) and had left for how the facility abused their clients. The family finished packing (Resident #35's) belongings and left without incident. (Resident #35 was unable to show me where he had been hit or any marks from this incident. Due to his known mental issues and lack of evidence no charges were filed at this time. I was supplied a list of nurse who worked on this night by (the head nurse). -Although Resident #35 reported to the facility and police that he had been hurt or hit by staff, and a family member showed pictures of injuries to Resident #35's body from alleged prior abuse, the facility did not investigate the root cause of the resident's statements and behavior. C. Interviews The NHA was interviewed on 11/3/22 at 5:12 p.m. She reiterated her knowledge of what occurred with Resident #35 on 10/5/22. She acknowledged they did not conduct a further investigation into Resident #35's allegations that someone had been hurting him, and let the police do it instead because her presence just escalated the resident's daughter. Resident #35's family member was interviewed on 11/7/22 at 9:10 a.m. She said she took Resident #35 home after he got so upset that night and reported that staff were hitting him, hurting him, and swinging at him. She said Resident #35 had reported physical and verbal abuse concerns to her before and she had heard the head nurse who was working the night of 10/5/22 screaming at him to go to his room after he had talked to her on the phone, not knowing he had not hung up the phone. She said Resident #35 had within the last few months suffered extensive bruising to his hip and upper leg, and an injury that looked like a bite mark to his hand (see police report above), and she suspected abuse directed towards Resident #35 and other facility residents. She said the NHA was never there (in the facility) when she wanted to talk to her about her concerns regarding Resident #35's treatment. The family member said Resident #35 currently resided in another nursing facility. D. Follow-up record review Review of Resident #35's progress notes from 8/1/22 until his discharge revealed the following nurses' notes regarding two injuries that were similar to those described by the resident's family: On 8/27/22 at 9:10 a.m., Resident found with 22cm x 8cm bruise to L (left) hip and thigh during incontinence care this shift. Resident stated no pain except upon palpation of the bruise. Event was unwitnessed, staff advised to keep a closer watch with resident to ensure safety. -A 9/20/22 nurse's note documented the bruising was resolved with scattered yellow patches only. However, there was no evidence of an investigation into the cause of the bruising. An incident in nurses' notes on 9/23/22 at 12:41 a.m. was described as follows: Resident very agitated since beginning of shift with frequent calls to wife. Began pushing and threatening staff raising arm as if to hit. Unable to redirect resident. Yelling and wanting to call the police. (Staff development coordinator) on call admin notified. (Physician) notified and order received for a one time dose of Trazadone 100mg. This did eventually calm resident down and as (of 3:00 a.m.) resident went to room and is resting at this time. Two days later, on 9/25/22 at 1:45 p.m., a nursing note documented, L hand S/T (skin tear) scabbed and OTA (open to air). -There was no prior documentation of the skin tear, how it was acquired, or an investigation into whether it occurred during the 9/23/22 incident or at another time. The facility failed to investigate Resident #35's allegation that he was being hit or hurt, and failed to investigate injuries of unknown origin to determine if abuse had occurred.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** III. Resident #186 A. Resident status Resident #186, age [AGE], was admitted on [DATE]. admission records revealed Resident #186 had severe cognitive impairment and diagnoses included Alzheimer's disease, unspecified atrial fibrillation (irregular heart rate), essential primary hypertension and depression. The minimum data set (MDS) assessment had not been completed as of survey date due to resident's new admission to the facility. B. Record review The physician orders revealed that on 10/21/22 at 2:51 p.m., orders for occupational and physical therapy to evaluate and treat the resident. The fall risk assessment, post fall, for the fall on 10/24/22 at 12:07 a.m. revealed a history of falls, three or more falls in the past three months. Also, it recognized that the resident had balance problems with standing/walking, decreased muscular strength and required the use of an assistive device. Resident #186's care plan, initiated on 10/24/22, identified fall risk and revealed: After the resident's fall on 10/24/22, a goal was added to the care plan that the resident would not experience adverse effects from falls, which included an intervention of identifying contributing factors if possible. -No interventions regarding rehabilitation therapy were added to the care plan. C. Observations On 11/1/22 at 1:58 p.m., Resident #186 was in the activity room, with bruises on her right hand and the right side of her forehead. A seat belt restraint was attached to her wheelchair. Resident #186 was in the activity room on 11/1/22 at 4:07 p.m. She was sitting in her wheelchair with the seat belt restraint in place. She was awake and not talking. Resident #186 was in the television (TV) room on 11/2/22 at 9:56 a.m., sitting in her wheelchair with the seat belt restraint in place. She appeared drowsy, and was not participating in any activity. D. Interviews Licensed practical nurse (LPN) #1 was interviewed on 11/3/22 at 10:47 a.m. He stated that if a fall prevention plan was implemented that he would anticipate interventions such as keeping the resident in line of sight and providing proper toileting and positioning. He stated that they had been without rehabilitative therapy services for a couple of months. The NHA was interviewed on 11/3/22 at 2:59 p.m. She stated that the facility did not have rehabilitative therapy services available to conduct a fall or restraint evaluation of the resident. The NHA and the director of nurses (DON) were interviewed on 11/3/22 at 4:40 p.m. The NHA stated that the rehabilitation therapy staff screened the residents for falls. The NHA stated that the occupational therapist was at the facility the previous week to perform an evaluation, but the resident refused. She reported that the occupational therapist was going to try again next week with his visit. The NHA stated that walking would be a goal for the resident. -None of the above interventions nor goals were found in the care plan. -No occupational therapy documentation was found. IV. Resident #7 A. Resident status Resident #7, age [AGE], was admitted on [DATE]. Medical diagnosis in her medical records revealed diagnoses included type 2 diabetes mellitus without complications, major depressive disorder, pigmentary retinal dystrophy, transient cerebral ischemic attack, and dementia with other behavioral disturbance. The minimum data set assessment completed on 10/6/22, revealed a brief interview for mental status (BIMS) score of seven out of 15, indicating severe cognitive impairment. B. Record Review The occupational evaluation and plan of treatment notes revealed an evaluation on 10/14/22 to assess resident adaptations and compensatory strategies to promote safety for her and others during tasks secondary to low vision. The treatment plan included: therapeutic exercises, self care management training and wheelchair management training. The treatments were to be done daily for four weeks. -The facility did not have a daily occupational therapist on staff and there was no documentation of occupational therapy service provision for Resident #7. C. Observations The resident was observed in her room, sitting in a reclining chair on 11/1/22 at 8:56 a.m. She was observed throughout the survey, conducted 10/31/22, 11/1/22, 11/2/22 and 11/3/22 spending most of her time sitting in the recliner in her room with her feet elevated, when not in the dining room for meals or activities. D. Interview The NHA was interviewed on 11/3/22 at 4:40 p.m. She stated that the facility currently does not have rehabilitation therapy services, and has been without the services for a couple of months. Based on interviews and record review, the facility failed to ensure therapy and restorative services to maintain highest practicable level of functioning for three (#25, #186, #7) of three residents reviewed for rehab and restorative services of 19 sample residents. Specifically, the facility failed to ensure services to maintain residents' highest practicable levels of functioning. Findings include: I. Facility policy and procedure The Restorative Nursing Services policy, revised July 2017, provided by the staff development coordinator (SDC) on 11/3/22 at 4:00 p.m. read in pertinent part, residents will receive restorative nursing care as needed to help promote optimal safety and independence. Policy interpretation and implementation included: -Restorative nursing care consisted of nursing interventions that may or may not be accompanied by formalized rehabilitative services (e.g., physical, occupation, or speech therapies); -Residents may be started on a restorative nursing program upon admission, during the course of stay or when discharged from rehabilitative care; -Restorative goals and objectives were individualized and resident-centered, and are outlined in the resident's plan of care; -The resident or representative would be included in determining goals and the plan of care; and Restorative goals may include, but are not limited to supporting and assisting the resident in: -Adjusting or adapting to changing abilities; -Developing, maintaining or strengthening his/her physiological and psychological resources; -Maintaining his/her dignity, independence and self-esteem; and -Participating in the development and implementation of his/her plan of care. II. Resident #25 A. Resident status Resident #25, age [AGE], was admitted on [DATE]. According to the November 2022 computerized physician orders (CPO), diagnosis included myalgia, history of urinary tract infections, and underweight status. According to the 9/13/22 minimum data set (MDS) assessment the resident scored a 12 out of 15 on the brief interview for mental status (BIMS) examination indicating the resident's cognition was moderately impaired. The resident required extensive one-person physical assistance with bed mobility and transfers. Walking in room or corridor activity did not occur. B. Resident interview Resident #25 was interviewed on 11/1/22 at 8:46 a.m. She said she had been working with therapy and had been up walking with them getting stronger. She said the facility had lost their therapy department about two months previous, and she had not been up walking since. She said she wants to walk, but had lost all the strength she built up working with therapy and can no longer walk. C. Record review Physical therapy (PT) documentation showed the resident was on therapy services for 8 weeks from 5/20/22-7/18/22 with a plan of service for therapeutic exercises, gait training therapy, PT evaluation, and therapeutic exercise with a frequency of 1-2 times per week. Objective goals showed the resident was showing progress with the current treatment plan and interventions. It commented in the notes the Resident #25 was progressing, participating consistently, and improving in strength and endurance. It was noted the resident was able to ambulate 150 ft to the therapy room from her room prior to reaching fatigue. The last documentation for therapy service was on 7/13/22, prior to the end of the therapy certification period. There was no discharge summary or discharge/restorative recommendations provided by the facility. The residents care plan interventions, revised 12/28/21, listed: -Montor need for referral/screening to therapy services: occupational therapy, PT, speech therapy,, Mental Health, Med-pysch social needs, and Restorative nursing. Resident # 25's CPO showed a completed order for PT services that ended on 7/27/22. There was no order for restorative services. D. Interviews Licensed practical nurse (LPN) #3 was interviewed on 11/02/22 04:41 p.m. She said she had been working at the facility for just a few months. She said she had never seen Resident #25 walk in the time she had been at the facility. She said therapy and restorative services were not at the facility during her time their either, and without out therapy to tell her she had no idea if Resident #25 could walk. Nursing assistant (NA) #2 was interviewed on 11/3/22 at 9:12 a.m. She said Resident #25 had been offered to walk with staff but she would refuse. She said she was working with therapy and was walking using the therapy bars at one time, but she would refuse therapy sometimes when they were in the building. NA #1 was interviewed on 11/03/22 01:24 p.m. She said Resident #25 used to walk when therapy was in the building, but it has been months since they had therapy and she had not seen her walk since. She said the facility was in the process of getting the restorative program up and running again but she was unsure if it was currently. LPN # 1 was interviewed on 11/3/22 at 2:05 p.m. He said Resident #25 could not walk on her own and needs staff assistance. He said she was up walking with therapy but there had not been a therapist in the building for a few months and she did not walk now. He said there were some restorative staff in title, but there was no real restorative program in the building he knew about. The staff development coordinator (SCD) was interviewed on 11/3/22 at 3:58 p.m. She said she had a restorative aide in training who was working with a few residents. She said normally therapy would screen residents and make restorative recommendations, but they were not in the building currently. She said the regional corporate staff were working on getting those therapy services back in the building. She said Resident #25 had refused restorative services. The nursing home administrator (NHA), a registered nurse, was interviewed on 11/3/22 at 4:42 p.m. She said she was working on getting some contracted therapy staff in the building hopefully soon in the next two weeks. They were having a hard time finding some therapy staff and were in negotiations with some travel therapy staff who were possibly going to sign a 13 week contract. She said they had been searching for therapy staff since the end of July when they left. She said Resident #25 would refuse therapy sometimes and had refused restorative services. -There was no documentation Resident #25 was ordered or offered restorative services, nor documentation of the resident refusing these services. There was no therapist, PT or OT, in the building during time of survey.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to ensure residents were free from abuse for six (#18, #10, #33, #7, #1, #22) of nine residents reviewed for abuse out of 19 sample residents. Specifically, the facility failed to ensure residents were free from resident-to-resident abuse. Findings include: I. Facility policy and procedure The Abuse Prevention Program policy, no date of inception or revision, provided by the nursing home administrator (NHA) on 10/31/22 at 4:00 p.m. read in pertinent part, Our residents have the right to be free from abuse, neglect, misappropriation of resident property, corporal punishment, and involuntary seclusion. Our facility is committed to protecting our residents from abuse by anyone including, but not necessarily limited to: facility staff, other residents, consultants, volunteers, staff from other agencies providing services to our residents, family members, legal guardians, surrogates, sponsors, friends, visitors, or any other individual. II. Physical abuse on 7/19/22 between Resident #10 and Resident #22 A. Resident #22 1. Resident status Resident #22, age [AGE], was admitted on [DATE]. According to the November 2022 computerized physician orders (CPO), diagnoses included Wernicke's encephalopathy (degenerative brain disorder). According to the 10/6/22 minimum data set (MDS) assessment, a brief interview for mental status (BIMs) was conducted with the resident. The resident was identified to have a BIMs score of seven out of 15, indicating severe cognitive impairment. The MDS did not identify the resident had behaviors towards others. The MDS assessment indicated Resident #22 was independent in most of his ADLs, including locomotion. 2. Record review The dementia care plan, last revised on 10/12/22, read Resident #22 had difficulty expressing his needs and wants related to dementia. According to the care plan, the resident could become frustrated, uncomfortable, resulting in restlessness. The care plan identified if the source of the discomfort was not removed the resident could become aggressive. The behavior care plan, last revised on 10/12/22 identified Resident #22 had physical and aggressive behaviors related to his dementia. According to the care plan, staff should encourage the resident to report concerns and needs to staff prior to attempting to deal with a situation himself. B. Resident #10 1. Resident status Resident #10, age [AGE], was admitted on [DATE]. According to the computerized physician orders (CPO), diagnoses included Alzheimers's disease, dementia with behavioral disturbances, and anxiety disorder. The 10/6/22 minimum data set (MDS) assessment revealed the resident had short term and long term memory problems. The MDS indicated the resident was moderately impaired in decision making regarding tasks of daily life, indicating the resident required supervision and cues. According to the MDS assessment, Resident #10 exhibited inattention and disorganized thinking. The resident was independent in most of his ADLs including walking and locomotion on and off the unit. The MDS assessment identified the resident had behaviors of rejecting care, was short-tempered, and easily annoyed. 2. Record review The 7/19/22 progress note identified Resident #10 had a physical altercation with another resident in the activity room resulting in Resident #10 being knocked off balance and falling. C. Review of physical altercation report on 7/19/22 between Resident #10 and Resident #22 The 7/19/22 facility investigation of the physical altercation was provided by the facility on 10/31/22. The investigation identified Resident #1 physical altercation between Resident #10 and Resident #22 on 7/19/22. The facility reported the incident to the State Agency, however not within the required timeframe (cross-reference F609, timely reporting of alleged abuse). According to the investigation packet, Resident #22 was sitting in a chair in the main activity room when Resident #10 walked by Resident #22. Resident #22 moved a empty chair that was next to Resident #22 away from him. Resident #10 came towards Resident #22 in a threatening manner. Resident #22 to put his leg up to keep distance between the two of them and Resident #10 continued to proceed towards him. Resident #22 pushed out his leg and Resident #10 fell to the floor. Resident #10 was not injured in the altercation. According to the investigation packet, the facility substantiated physical abuse. D. Staff interview The NHA was interviewed on 11/3/22 at 4:40 p.m. with the director of nursing (DON) and the corporate consultant. The NHA said Resident #10 took offense with Resident #22 move the chair away. She said the facility has trained staff to have Resident #10 and Resident #22 spend time in different areas of each other. According to the NHA, the incident occurred in the activity room. (Cross-reference F744 dementia care.) III. Physical abuse on 8/28/22 between Resident #18 and Resident #1 A. Resident #1 1. Resident status Resident #1, age [AGE], was admitted on [DATE]. According to the computerized physician orders (CPO), diagnoses included dementia without behavioral disturbances, and generalized arthritis. The 7/28/22 minimum data set (MDS) assessment revealed the resident had short term and long term memory problems. The MDS indicated the resident was severely impaired in decision making regarding tasks of daily life. According to the MDS assessment, Resident #1 exhibited inattention and disorganized thinking. The MDS identified Resident #1 required extensive to total assistance for activities of daily (ADLs). The MDS assessment identified the resident did not have behaviors or rejecting care. 2. Record review The behavior care plan, last revised on 7/7/22, directed staff to provide reassurance and ensure Resident #1's safety. The 8/28/22 nursing note read Resident #1 was sitting in front of another resident when the resident to the rear pulled Resident #1's hair and scratched her right posterior shoulder. Resident #1 sustained a wound measuring 2.5 centimeters (cm) x 0.4 cm and was surrounded by superficial scratches. The wound required cleansing and dressing. The skin integrity care plan, initiated on 8/28/22, read Resident #1 had an alteration in skin integrity related to scratches to her right shoulder. According to the care plan, staff were to review for causative factors; implement intervention as needed for prevention The review of the Resident #1's care plan did not identify Resident #1 had an physical altercation of 8/28/22, was at risk for abuse or how to prevent future resident to resident abuse/physical altercations. C. Review of physical altercation report on 8/29/22 between Resident #10 and Resident #35. The 10/13/22 facility investigation of the physical altercation was provided by the facility on 10/31/22. The investigation identified Resident #1 physical altercation between Resident #1 and Resident #18 on 8/28/22. The facility reported the incident to the State Agency, however not within the required timeframe (cross-reference F609). D. Staff interview The NHA was interviewed 11/3/22 at 5:25 p.m. The NHA confirmed Resident #1 was injured on 8/28/22 during the 8/28/22 physical altercation with Resident #18. The NHA said the facility substantiated physical abuse. The NHA said to prevent recurrence of abuse, she should not sit alone in the common area without staff supervision or placed near Resident #18. IV. Physical abuse on 8/29/22 between Resident #10 and Resident #35 A. Resident #10 1. Resident Status Resident #10, age [AGE], was admitted on [DATE]. According to the computerized physician orders (CPO), diagnoses included Alzheimers's disease, dementia with behavioral disturbances, and anxiety disorder. The 10/6/22 minimum data set (MDS) assessment revealed the resident had short term and long term memory problems. The MDS indicated the resident was moderately impaired in decision making regarding tasks of daily life, indicating the resident required supervision and cues. According to the MDS assessment, Resident #10 exhibited inattention and disorganized thinking. The resident was independent in most of his ADLs including walking and locomotion on and off the unit. The MDS assessment identified the resident had behaviors of rejecting care, was short-tempered, and easily annoyed. 2. Record review The 8/29/22 nursing note read the nurse heard yelling and found Resident #10 on the floor on his left side with his walker tipped over and another resident leaning over him. According to the note the resident complained of left shoulder pain with no obvious trauma and had a skin tear to the back of his right hand. The note read the resident was assisted to safety. The 8/31/22 nursing note read staff would continue to monitor both Residents (Resident #10 and Resident #35 and make sure they are distanced apart. The 9/1/22 behavior note read Resident #10 involved in a physical altercation with another male resident. According to the Resident #10 was very territorial. Staff was educated to keep these particular residents apart. According to the note, the other resident (Resident #35) was to be relocated to another hallway. An alarm was placed on the doorway to Resident #10's room to alert staff when the resident was out of room for possible redirection to appropriate location. The behavior care plan, initiated on 6/17/18, identified the resident was easily annoyed by others and would instigate other resident behaviors. The care plan read the resident did not want others in his space and an alarm was placed on his room door. The care plan did not identify when the alarm was initiated or other reasons the alarm was initiated other than he was territorial to his room/close proximity. The care plan did not identify the alarm was placed on the door as an intervention to prevent the recurrence of resident to resident altercations. The review of the behavior care plan did not identify new interventions after the 8/29/22 physical altercation. The dementia care plan, last revised on 8/2/22, identified the resident had difficulty expressing his needs. He would become restless when he was frustrated and uncomfortable. According to the care plan, if his source of discord was not removed, he would become aggressive. The care plan identified the resident would physically and verbally taunt others. The review of the dementia care plan did not identify new interventions after the 8/29/22 physical altercation. The potential for physical aggression care plan, last revised on 8/2/22, did not identify did not identify new interventions after the 8/29/22 physical altercation. The review of the Resident #10's care plan did not include an intervention to keep Resident #10 and Resident #35 apart or identified the resident had an physical altercation on 8/29/22. The care plan did not identify new interventions after the 8/29/22 physical altercation. B. Resident #35 1. Resident status Resident #35, age [AGE], was admitted on [DATE]. According to the November 2022 CPO, diagnoses included dementia with behavioral disturbance, mood disorder with depressive features, post-traumatic stress disorder, and kidney and bone cancer (malignant neoplasm). The MDS assessment was not readily available due to the resident's discharge from the facility on 10/6/22 by his family after Resident #35 alleged physical abuse. 2. Record review The 6/1/22 at risk for abuse and injury care plan was last revised on 9/7/22. According to the care plan, the resident was at risk for abuse and injury related, wandering and dementia. The risk for abuse care plan did not identify new interventions after the 8/29/22 physical altercation with Resident #10. The 6/1/22 psychological well-being care plan was last revised on 9/7/22. According to the care plan, Resident #35 had psychological well-being related to facility discord and an abuse event. The care plan did not identify new interventions after the 8/29/22 physical altercation with Resident #10. The 3/9/22 behavior care plan was last revised on 9/7/22. According to the care plan, Resident #35 had periods of agitation and increased confusion related to his anxiety. The care plan identified Resident #35 sundowned between 1:30 p.m. and 4:00 p.m. Interventions included contacting his wife, offering snacks, providing an activity or offering the outdoors. According to the care plan staff offered one to one visits. The review of the care plan did not include to keep Resident #10 and Resident #35 apart as identified in the resident's progress notes. C. Review of physical altercation investigation on 8/29/22 between Resident #10 and Resident #35. The facility investigation of the physical altercation was provided by the facility on 10/31/22. An alleged physical abuse altercation between Resident #10 and Resident #35 occurred on 8/29/22 at 4:50 p.m. The allegation of abuse was reported to the State Agency on 8/30/22 (cross-reference F609). Reports included in the investigation packet described Resident #35 was very agitated after the physical altercation and Resident #10 was trembling. According to the investigation packet, the facility identified Resident #10 and #35 had prior incidents between them and cursed at each other. The investigation packet indicated the facility plan was to keep Resident #10 and Resident #35 separated. The investigation read the residents were passing each (on 8/29/22). Resident #10 punched at Resident #35, who in response, hit Resident #10, causing Resident #10 to fall. Resident #35 was moved to another hall and a door alarm was placed on Resident #10's door. D. Staff interview The NHA was interviewed on 11/03/22 at 4:41 p.m. with the corporate resource consultant and the DON. The NHA said Resident #10 came out of his room when Resident #35 touched Resident #10's shoulder. Resident #10 pulled back with the walker, which startled Resident #35. Resident #35 grabbed Resident #10 and his walker. The NHA said staff needed to know when Resident #10 was out of his room so they added an alarm to his door. She said to prevent recurrence of resident to resident altercations with Resident #10, staff needed to be on alert and pay attention to where Resident #10 is located and how his attitude was (Cross-reference F744) The NHA said the facility substantiated physical abuse. V. Physical abuse on 10/13/22 between Resident #7 and Resident #33. A. Resident #33 1. Resident status Resident #33, age [AGE], was admitted on [DATE]. According to the November 2022 computerized physician orders (CPO), diagnoses included mild cognitive impairment of uncertain or unknown etiology, mood disorder due to known physiological condition with depressive features, and other conduct disorders. The 10/6/22 minimum data set (MDS) assessment revealed the resident had short term and long term memory problems. The MDS indicated the resident was moderately impaired in decision making regarding tasks of daily life, indicating the resident required supervision and cues. According to the MDS assessment, Resident #33 exhibited inattention and disorganized thinking. The resident required one person's physical assistance with most of her activities of daily living, including walking and locomotion on and off the unit. The MDS did not identify behaviors or rejections of care. 2. Record review The 10/13/22 at 9:22 a.m. nursing note revealed Resident #33 was involved in an altercation with another resident on 10/13/22. According to the note the incident was unwitnessed but a review of a facility video recording camera identified Resident #33 shoved her walker towards another resident, initiating aggression. Residents immediately separated and inspected for injury. The note did not indicated Resident #33 was not injured in the altercation. The note read staff would continue to monitor. The behavior care plan, initiated on 10/5/22, identified the resident had a behavior problem related to a conduct disorder with outbursts. According to the behavior care plan, staff would minimize the resident's risk for harm to self or others. The review of Resident #33's care plan identified her care plan was not updated after the resident to resident altercation. The care plan did not include new interventions to prevent the recurrence of resident to resident altercations. 3. Observations Resident #33 was brought into the activity room by a staff member on 11/22/22 at 9:29 a.m. She was placed in a chair in the center of the room with her back away for the activity group. The resident proceeded to interact with her baby doll. B. Resident #7 Resident #7, age [AGE], was admitted on [DATE]. According to the November 2022 computerized physician orders (CPO), diagnoses included unspecified dementia with other behavioral disturbance, anxiety disorder, major depression,transient cerebral ischemic attack, and legal blindness. According to the 10/6/22 minimum data set (MDS) assessment, a brief interview for mental status (BIMS) identified Resident #7 had BIMS score of eight out of 15, indicating the resident was moderately cognitively impaired. The MDS assessment identified the resident displayed disorganized thinking and experienced delusions. According to the MDS, the resident had verbal behavioral symptoms directed towards others. The MDS did not identify the resident had changes in her behaviors. The MDS assessment indicated Resident #7 required extensive physical assistance of one person for walking in her room and locomotion on and off the unit. 2. Record review The 10/13/22 at 9:30 a.m. nursing note revealed Resident #7 was involved in an altercation with another resident on 10/13/22. According to the note, the altercation was related to a personal space violation and resident confusion. The altercation resulted in a skin tear to Resident #7's left hand from a walker pushed into her hand. The 10/13/22 at 5:06 p.m. nurse note indicated staff was educated to supervise the resident when in common areas for redirection of behaviors. According to the note, when the resident was not in a supervised activity or a meal, she needed to be resting in her room in her recliner. The review of Resident #7's care plan identified her care plan was not updated after the resident to resident altercation. The care plan did not include Resident #7 needed staff supervision in common areas or needed to spend time resting in her room. The care plan did not identify how to prevent the recurrence of physical altercations after 10/13/22. C. Review of physical altercation investigation on 10/18/19 between Resident #7 and Resident #33. The 10/13/22 facility investigation of the physical altercation was provided by the facility on 10/31/22. According to the investigation packet, the charge nurse heard arguing from the activity room. The charge nurse reported to observe Resident #7 and Resident #33 engaged in a tug of war with a resident walker with Resident #33 shoving the walker towards Resident #7 in an attempt to drive her away. Resident #7 then shoved the walker back towards Resident #33. The residents were separated when staff arrived. Resident #7 sustained a skin tear to her hand, and was confused at the time of the incident. D. Staff interview Certified nurse aide (CNA) #1 was interviewed on 11/03/22 at 10:36 a.m. The CNA said Resident #7 was quick to become upset. She required redirection and did not like to be touched. The CNA said the resident enjoyed spending time in her recliner and watching television in her room and needed to be kept pre-occupied. The CNA said on some days, Resident #7 was upset all day long. The CNA said staff tried to keep her away from noise as much as possible, and have conversations with her alone. She said the resident often would calm down with coffee and big blankets. The NHA was interviewed on 11/03/22 at 4:41 p.m. with the director of nursing (DON) and the corporate consultant. According to the NHA, Resident #33 had a developmental delay and a low BIMS score. She said on the morning on 10/13/22, Resident #33 was sitting in chair by the door and Resident #7 came up behind her.The NHA said Resident #7 had poor vision and tended to get up close to others, requiring Resident #7 to need supervision. The NHA said the unwitnessed event was captured of the video camera which identified Resident #7 invaded Resident #33's person space and moved her walker, prompting Resident #33's baby doll to fall. She said the baby doll falling escalated the situation, resulting in the physical altercation between the two residents. The NHA said the intervention for Resident #33 was not to place her in a seat where there was high traffic in a common area and where she could be easily bumped. She said she was sick at the time of the 10/13/22 altercation, and did not look at other interventions such as helping offer securement of the baby doll with the resident's walker. The NHA confirmed Resident #7's care plan was not updated with her new interventions but the social service director would be working on that. During the interview, the NHA was informed Resident #33 was placed in the center of the activity room. The DON said the resident should have been placed in such a high traffic seat, in order to prevent potential resident to resident alterations.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews, the facility failed to report allegations of abuse to the State Survey and Certification Agency in accordance with State law involving seven (#1, #7 #10, #18, #22, #33, and #35) of nine residents reviewed for abuse out of 19 sample residents. Specifically, the facility failed to timely report allegations of: -Resident to resident physical abuse for Residents #1, #7, #10, #18, #22, #33 and #35; and, -Staff to resident physical abuse for Resident #35. Cross-reference F600, failure to protect residents' rights to be free from abuse. Findings include: I. Facility policies and procedures The Reporting Abuse to State Agencies and Other Entities/Individuals policy, initiated 11/1/17, was provided by the nursing home administrator (NHA) on 10/31/22. The policy read in pertinent part: All suspected violations and all substantiated incidents of abuse will be immediately reported to appropriate state agencies and other entities or individuals as may be required by law. Should a suspected violation or substantiated incident of mistreatment, neglect, injuries of an unknown source, or abuse (including resident to resident abuse) be reported, the facility Administrator, or his/her designee, will promptly notify the following persons or agencies (verbally and written) of such incident: The State licensing/certification agency responsible for surveying/licensing the facility. The Protection of Residents During Investigations policy, initiated 11/1/17, was provided by the NHA on 10/31/22. The policy documented in pertinent part, Within five working days of the alleged incident, the facility will give the resident, the resident's representative, the ombudsman, the state survey and certifications agencies, accused individuals, a written report of the findings of the investigations and a summary of the corrective actions taken to prevent such incidents from recurring. The facility will report within two to 24 hours or according to the state occurrence reporting guidelines. II. Allegations of resident to resident abuse not reported timely to the State Agency The facility provided the below abuse investigations on 10/31/22. (Cross-reference F600 for failure to prevent abuse.) A. Incident on 10/13/22 An alleged physical abuse incident between Resident #7 and Resident #33 occurred and the facility was notified of the altercation on 10/13/22 at 6:45 a.m. The facility did report the incident to the State Agency until 10/13/22 at 5:03 p.m., approximately 10 hours after the facility became aware of the incident. B. Incident on 8/29/22 An alleged physical abuse altercation between Resident #10 and Resident #35 occurred on 8/29/22 at 4:50 p.m. The facility was notified of the altercation on 8/29/22 at 6:00 p.m. The facility did report the incident to the State Agency until the following day, on 8/30/22 at 3:05 p.m. The incident was not reported to the State Agency for approximately 23 hours after the facility became aware of the incident. C. Incident on 8/28/22 An alleged physical abuse altercation between Resident #1 and Resident #18 occurred on 8/28/22 at 7:00 a.m. The facility was notified of the altercation on 8/28/22 at 9:00 a.m. The facility did report the incident to the State Agency until 8/28/22 at 3:12 p.m., approximately six hours after the facility became aware of the incident. D. Incident on 7/19/22 An alleged physical abuse altercation between Resident #10 and Resident #22 occurred and the facility was notified of the altercation on 7/19/22 at 8:52 a.m. The facility did report the incident to the State Agency until 7/19/22 at 6:15 p.m., approximately nine hours after the facility became aware of the incident. III. Allegation of staff to resident abuse on 10/5/22 not reported timely to the State Agency An alleged physical abuse incident between Resident #35 and a staff member was reported to the facility on [DATE] at 8:20 p.m. The facility did report the incident to the State Agency until 10/6/22 at 9:58 a.m., over 13 hours after the facility became aware of the allegation. IV. Staff interviews The NHA was interviewed on 11/3/22 at 5:34 p.m. According to the NHA, all allegations should be submitted to the State Agency within 24 hours of becoming aware of the abuse allegation. The NHA said only allegations of abuse that involved significant bodily injury needed to be reported to the State Agency before two hours after the facility became aware of the abuse allegation. The NHA reviewed the regulation for reported abuse and confirmed all allegations of abuse should have been reported within two hours of facility notification. She said she was not aware of the reporting timeline and would start reporting all allegations of abuse within the first two hours of known abuse allegations.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** VII. Resident #18 A. Resident status Resident #18, age [AGE], was admitted [DATE]. According to the November 2022 computerized physician orders (CPO), diagnoses included unspecified dementia, anxiety disorder, and bipolar disorder with psychotic features. According to the 8/30/22 minimum date set (MDS), the resident was unable to complete the brief interview for mental status exam (BIMS). The resident had memory problems with both short and long term memory. B. Record review A behavior progress note dated 8/18/22 showed a monthly review of psychotropic medications related to the resident. Target behaviors being monitored were delusional ideations, agitation with not receiving immediate gratification, sudden mood changes, temper tantrums, screaming uncontrollably, aggressive behaviors towards others, physical acts of aggression, negative statements, and weeping/crying. The resident had improved during the end of June and through July, but the resident in the last few weeks appeared to have more outbursts of crying/weeping and emotional distraught episodes. An interdisciplinary psychotropic committee progress note dated 8/19/22 showed the resident continued on depakote with target behaviors of delusional ideations, agitation with not receiving immediate gratification and sudden mood changes. The resident was on seroquel with target behaviors of temper tantrums/screaming uncontrollably, aggressive behavior towards others and physical acts of aggression. Citalopram with target behaviors of negative statements and weeping/crying. A social services note dated 8/26/22 showed the social services director interviewed nursing, CNAs, and activity staff over last couple of days regarding this residents psycho-social and emotional well being, tearfulness, increased anxiety, agitation, non verbal signs of fear, pain or of any changes noted for this residents baseline. The Resident appeared comfortable and no distress was noted, and she would follow up as needed. A nurses note on 8/28/22 at 9:44 a.m. showed Resident #18 was found in the common area pulling another residents hair (Resident #1). Resident #1 had scratches to her neck in several places with the most significant measuring 2.5 cm x 0.4 cm. The director of nursing (DON) and primary care provider (PCP) were notified. There were no injuries noted to Resident #18. (Cross-reference F600 Abuse.) The resident's care plan related to dementia was revised on 7/18/22 and identified resident triggers as: -Invading her space; -Touching her things and/or taking her things; -Needing to use the toilet or being wet; -Sundowning in the late afternoon; -wandering behaviors more after 2:30 p.m.;and, -someone talking to her about abuse upsets her and triggers past experiences. The care plan interventions were updated 9/6/22 (nine days after the resident-to-resident interaction with Resident #1). It showed an intervention to keep Resident #18 away from others when a staff member is not sitting next to her. Lay her down between meals so she can rest when she will. Offer the recliner in the activity room as often as possible to get her out of the wheelchair. -Progress notes showed Resident #18 was having an increase in behaviors and aggression; however, there were no updates to the residents care plan until 9/6/22. The resident behaviors staff resource book (not dated) included: Triggers: -Invading her space; -Touching her things and or taking her things; -Need to use the toilet or being wet; -Sundowning in the late afternoon; -Wandering behaviors more after 2:30 p.m.; and, -Someone talking to her about abuse upsets her and triggers past experiences. Interventions: -Personal grooming; -Relates well to male cnas; -Toileting and or changing her; -Offer food/fluids; -Finding her a calm quiet area; -Rubbing lotion on her hands and arms; -15 min checks; -Activities of folding and sorting; -Music: loves elvis and rock'n roll; -Coloring; -Reading children's stories; -Catholic mass/bible studies; -Fingernails painted; -Sitting outdoors; -Reminiscing about the past; -Personalized activity box; -Coffee and 1:1 visit with staff; -Sitting and watching the birds; and -Watching old westerns, football,and game shows. -The resident behaviors staff resource book did not identity an intervention to keep Resident #18 distanced from other residents. C. Interviews CNA #1 was interviewed on 11/3/22 at 8:18 a.m. She said Resident #18 would sometimes just start screaming for help and cry out of nowhere. She said sometimes she would do this if she needed to use the restroom and other times she would calm down after a snack. She said she was aggressive towards staff and other residents, but has not been for a long time. She said the incident with Resident #18 and Resident #1 was a one time thing between those two residents and they both forgot about it and don't remember it. Nursing assistant (NA) #2 was interviewed on 11/3/22 at 9:12 a.m. She said Resident #18 would have outbursts and get agitated. She said the resident would go from zero to sixty and be fine one moment and mad the next with agitation and yelling. She said this was going on for a long time but she had been better lately. She said the resident loved cheetos and that would help calm her down. She said they have had dementia care training at the facility which included how to identify signs and situations to look out for and protocols to use when residents are having outbursts. She said things like leading them out of situations before escalation were some of those things. She said there was a behavior book at the nursing station that would help staff identify triggers and de-escalation techniques for residents. -CNA #1 and NA #2 did not identify Resident #18 needed to be kept distanced from other residents. NA #1 was interviewed on 11/3/22 at 1:19 p.m. She there were times when Resident #18 would have mood swings of yelling or crying for no apparent reason, and she could be difficult. She said she was unaware of any specific triggers for her, but when she would act out they would give her a snack or toileting. She said she can become aggressive, and staff would have to give her a minute to calm down then come back to her. She said she has had issues with residents in the past, and the staff try to keep her distanced from others. She said she was not told to keep her separated from any specific residents. -NA #1 was unaware of resident specific triggers. LPN #1 was interviewed on 11/3/22 at 3:17 p.m. He said Resident #18 has specific cries for her needs. She has a soft cry when she is getting hungry, and more of a crabby cry when she needs toileting. He said the trick with her is to act timely to these needs to prevent her from escalating. He said there was an issue with getting her to take her meds, but since they began cruising them and she has been taking them she has improved to the point she barely has outbursts now. He said keeping her distanced from people was important because invasions of her personal space by other residents and staff could trigger aggression from her, but she was doing better with this now. He said he thought there was an incident with Resident #1 awhile back but he could not remember what the details were or when that happened. The NHA, a licensed nurse, was interviewed on 11/3/22 at 4:42 p.m. She said Resident #18 was their pepper jack because one minute she could be loving you and the next punching at you. She said it was very important that staff be with her when she is out and about in the facility because she has outburst quickly. She said the incident between Resident #18 and Resident #1 had no escalation or triggering event prior to it. She said Resident #18 just went up behind Resident #1 and grabbed her hair and scratched her neck. She said some of Resident #18's triggers included personal space issues and toileting needs. She said she was in the process of reimplementing a memory care unit and instilling a life care process there. She said they were working on doing more activities with residents that were more culture sensitive to dementia care. She said she was reaching out to the Alzheimer's Association to come out and do some dementia care training with her staff as well. V. Resident #20 A. Resident status Resident #20, age [AGE], was admitted on [DATE]. According to the November 2022 CPO, diagnoses included dementia without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety. According to the 8/25/22 MDS assessment, a brief interview for mental status (BIMS) identified Resident #20 had a score of eight out of 15, indicating the resident was moderately cognitively impaired. He displayed disorganized thinking and inattention. The MDS indicated Resident #20 had verbal behavioral symptoms directed towards others. The MDS assessment identified Resident #20 required supervision for locomotion on and off the unit. B. Resident interviews Resident #20 was interviewed on 11/1/22 at 8:47 a.m. He said he wanted the roommate (Resident #6) out of his room. He said he did not like the way the roommate talked to him. The resident did not clarify how Resident #6 spoke to him. Resident #20 said he had told the staff but they laughed it off. He said, If he comes after me, I will run over him. The resident said Resident #6 had not threatened him and he was not afraid of him. Resident #20 was interviewed again on 11/2/22 at 9:45 a.m. Resident #20 said Resident #6 frequently told him to shut the door and shut up and leave me alone. He said it could be difficult always being in the room with Resident #6 and he would like a change in scenery. The resident said if the roommate tried to hit him he would kill him. Resident #20 said Resident #6 had not threatened him and he was not afraid of him. He said if anyone tried to hit him, that was what he would do. Resident #6 was interviewed on 11/2/22 at 1:40 p.m. Resident #6 said he was going to talk to someone about getting another room. He said he did not feel comfortable with his new roommate because he just ignored him. C. Record review The long term care (LTC) care plan, revised 9/8/22, directed staff to encourage Resident #10 to discuss feelings and concerns with the choice to remain in LTC. According to the care plan, staff should monitor for and address episodes of anxiety, fear, distress related to LTC. The person centered triggers and intervention sheet for Resident #20, undated, was provided by the social services director (SSD) on 11/3/22 at 9:39 a.m. The triggers and interventions sheet identified under triggers Resident #10 did not like people in his personal space. According to the sheet, his boundaries should be respected and ask for invitations to enter his personal space. The 7/8/22 person centered care plan and triggers and interventions for abuse and dementia staff in-service training attendance log was provided by the facility on 11/3/22. The attendance log identified multiple members of nursing staff had attended the training. The 7/8/22 through 7/14/22 person centered resident information and care plans in-service training attendance log was provided by the facility on 11/3/22 at 10:10 a.m. The log identified the social service director (SSD) had attended the training. The 10/29/22 nursing note indicated Resident #20 introduced himself to Resident #6 and smiled at him when the resident became his roommate. According to the note, staff would continue to monitor. The review of the progress notes did not identify additional notes related to monitoring Resident #20 with his new roommate of additional behaviors directed towards or regarding the roommate or the roommate's personal belongings. The behavior/side effect monitoring record for October 2022 and November 2022 identified staff should track Resident #10's behaviors of verbal threats, aggressive, negative or derogatory statements towards others. According to the tracking record, staff should offer 1:1 visits, redirection, food/fluid, toileting, removing from the situation, activity, assessment for pain, massage/back rub, and/or other interventions identified in progress notes. The record indicated between 10/1/22 and 11/2/22, the resident did not have behaviors of verbal threats, aggressive, negative or derogatory statements towards others after the resident received a new roommate on 10/29/22. The room change notification form, for Resident #6 effective 10/31/22, was provided by the SSD on 11/3/22. The two part form identified a notification and agreement section and a 72 hour room change satisfaction and follow up section. Both sections were signed by the SSD and dated on 11/2/22, five days after Resident #6 moved into the room of Resident #20. The form identified Resident #20 and Resident #6 were notified of the room move. The satisfaction and follow section for Resident #6, identified the resident had concerns with his new room. According to the form, Resident #6 said he did not want to stay in his new room. According to the form, the resident was offered another and Resident decided he did not want to change rooms. The form indicated the SSD would follow up with Resident #6 as needed about his new room. D. Staff interviews CNA #1 was interviewed on 11/2/22 at 3:18 p.m. She said Resident #20 would get agitated. She said Resident #20 was recently going through his new roommate's closet. She said Resident #20 became upset and started yelling at staff when they told him the belongings in the roommate's closet were not his (Resident #20's.) The SSD was interviewed on 11/3/22 at 8:58 a.m. with the SSD's corporate consultant. The SSD said she was newer to her position as an SSD but was very familiar with the facility residents. The SSD said as the facility SSD, she monitors resident behaviors and their psychosocial wellness needs including how the residents felt about resident pertaining situations. She said before deciding on moving a resident in a room with another resident, the CNAs were asked to give their input on the possible roommate compatibility. The SSD said the roommates would then be introduced if they were not already familiar with each other. She said she would complete a notification of the room change. The SSD said after the room move, she would frequently follow up with the residents to ensure everything was going well in the room. The SSD said Resident #6 moved in to Resident #20's room over the past weekend (10/29/22). She said she met with both residents together on 10/31/22 and Resident #20 said Resident #20 said he really liked Resident #6. The SSD said she had been checking in with Resident #6 each day to see how the room move was working. She said his response had been wishy-washy. The SSD said on 10/31/22 he was not happy in his new room, then later on 10/31/22 and then again on 11/1/22 and 11/2/22, Resident #6 said the room was okay, fine, and really like the room. The SSD said she did not continue to check in with Resident #20 to ensure he was adjusting to and happy with having the new roommate. She said she did not document her check-ins/ visits with Residents #20 and #6. The SSD confirmed both residents had dementia and moods and behaviors could frequently fluctuate. The SSD said a CNA reported to her on 11/2/22 that Resident #20 went through the closet of Resident #6 and took his clothes. The SSD said Resident #20 has had a history of having problems with roommates in the past. She said Resident #20 also had a history of verbal threats and aggressive statements. The SSD was informed of statements made by Resident #20 when interviewed. The SSD said she should have followed up more with Resident #20 to see how he continued to feel about the new roommate and she should have asked him when his roommate was not present. The SSD and the CC said more monitoring and psychosocial check-ins were needed in new roommate situations and especially with residents with dementia. The CC said CNAs also needed more on the spot education to help identify concerns. The SSD said she would check with the residents and see if one of them would like to move to a different room. She said she did not want them to feel uncomfortable. She said Resident #20 may do best to not have a roommate for the time being. The SSD was interviewed again on 11/3/22 at 10:38 a.m. She said she met with Resident #20 and Resident #6. She said Resident #20 said he did not like that Resident #6 did not talk. Resident #20 said he did not like having a roommate. Resident #6 agreed to move to another room and was offered a couple different options. She said Resident #20's behavior triggers and interventions were not care planned but the care plan would be updated. The SSD said when she interviewed the residents, they may have been more reserved with her because they were interviewed together. The NHA was interviewed with the director of nursing and the corporate regional consultant on 11/3/22 at 5:46 p.m. The NHA said dementia care was the most vital key to preventing resident to resident abuse/altercations. She said staff needed to be where the resident was and make sure there was no unmet need. The NHA said if staff were able to identify the residents' needs there was less of a potential to have resident escalations. The NHA confirmed ongoing monitoring of new roommates with dementia would be an appropriate intervention in both dementia care and resident to resident altercation prevention. The NHA said monitoring would occur when there were new more changes to touch base with both residents to see how they were getting along. She said staff watched how the residents were reacting to the change. She said staff were usually good at monitoring the situation. She said the facility has trained all staff to be involved in the residents' care and report when they identify a concern. The NHA said staff thought Resident #6 and Resident #20 would be good roommates but Resident #20 upset Resident #6 when he went through Resident #6's clothes. She said that was when the shared room became an issue. VI. Resident #10 A. Resident status Resident #10, age [AGE], was admitted on [DATE]. According to the computerized physician orders (CPO), diagnoses included Alzheimers's disease and dementia with behavioral disturbances, and anxiety disorder. The 10/6/22 minimum data set (MDS) assessment revealed the resident had short term and long term memory problems. The MDS indicated the resident was moderately impaired in decision making regarding tasks of daily life, indicating the resident required supervision and cues. According to the MDS assessment, Resident #33 exhibited inattention and disorganized thinking. The resident was independent in most of his ADL's including walking and locomotion on and off the unit. The MDS assessment identified the resident had behaviors of rejecting care, was short-tempered, and easily annoyed. B. Observations Observations identified Resident #10 remained a risk for potential resident to resident altercations. Resident #10 was observed in the activity room [ROOM NUMBER]/2/22 8:40 a.m. and 9:25 a.m. The resident was sitting in a chair against the wall of the activity room. The television was on and the resident would occasionally look up at it. Across the room was an activity of residents playing board games with the activity assistant (AA). -9:00 a.m. started speaking in Spanish with repetitive phrases which did not seem directed at anyone as he looked around the room. Between 9:09 a.m. and 9:18 a.m., his verbalization became louder and more directed to the group activity. -At 9:18 a.m. a television western show briefly caught his attention. -At 9:21 a.m. Resident #10 directed his attention back to the group activity across the room. He spoke to the group in Spanish in a raised tone. An alert male resident participating in the group, looked at Resident #10. In a mocking manner, the male resident loudly spoke back to Resident #10 in an incomprehensible manner. The AA shushed the male resident and he apologized to her. Resident #10 continued to speak to the group in Spanish. The activity group proceeded, not focusing their attention on him. On 11/2/2 at 3:31 p.m. Resident #10 and Resident #22 were observed in the activity room watching a movie. Staff was not observed in the activity room with residents. (Cross-reference F600 resident to resident physical abuse.) Throughout the day on 11/3/22, Resident #10 and Resident #22 were observed in the activity room at the same time. There were no observations of staff attempting to redirect one of the residents to another location. C. Record review Review of progress notes on between 7/19/22 and 9/1/22 identified Resident #10 was involved in two physical altercations between two different male residents. The physical altercations occurred on 7/19/22 and 8/29/22 (cross-reference F600 abuse). According the notes, both incidents resulted in Resident #10 falling on the floor. A progress note on 8/29/22 identified Resident #10 sustained a skin tear to his hand and left shoulder pain. The 9/1/22 behavior note read an alarm was placed on the doorway to Resident #10's room to alert staff when the resident was out of room for possible redirection to appropriate location. However, a behavior care plan, initiated on 6/17/18, read the resident did not want others in his space and an alarm was placed on his room door. The care plan did not identify when the alarm was initiated or other reasons the alarm was initiated other than he was territorial to his room/close proximity. The care plan did not identify the alarm was placed on the door as an intervention to prevent the recurrence of resident to resident altercations. The review of the Resident #10's care plan did not include an intervention to keep Resident #10 and Resident #35 apart or identified the resident had an physical altercation on 8/29/22. The care plan did not identify new interventions after the 8/29/22 physical altercation. A dementia care plan, last revised on 8/2/22, identified the resident had difficulty expressing his needs. He would become restless when he was frustrated and uncomfortable. According to the care plan, if his source of discord was not removed, he would become aggressive. The care plan identified the resident would physically and verbally taunt others. The care plan identified staff should observe for general restlessness and make efforts to keep Resident #10 from becoming overstimulated by offering him a quiet area such as his recliner in his room or offer a nap. According to the care plan, staff should have offered the resident one on one attention. The behavior care plan related to dementia, revised 8/2/22, identified interventions to decrease behaviors. According to the care plan, staff should provide Resident #10 opportunities for positive interaction, attention. The intervention directed staff to stop and talk with residents as they passed him by. Additional interventions included: -Encourage the resident to express feelings appropriately; -Intervene as necessary to protect the rights and safety of others. -Staff should approach/speak to the resident in a calm manner, divert attention, remove from the situation and take to alternate location as needed; and, -Minimize potential for the Residents disruptive behaviors by offering tasks which divert attention, and provided safe activities of choice. D. Staff interview The NHA was interviewed on 11/3/22 at 4:40 p.m. with the DON and the corporate consultant. She said the facility had trained staff to have Resident #10 and Resident #22 spend time in different areas of each other. The NHA was informed of the observations. The NHA said she reminded the staff that Resident #10 and Resident #22 should be in separate locations. She said there should have been supervision in the activity room. The NHA said Resident #10 had a door alarm to alert staff when he was out of his room. She said staff pay attention to him, his whereabouts and his attitude. She said he needed to come out of his room for activities but also spent a lot of time in his room. The NHA was informed of the observation of Resident #10 increasing his volume when he was speaking in the activity room and staff did not address him and when another male resident mocked his language. The NHA said the activity assistant was new but should have redirected Resident #10 in the activity room and offered an intervention. Based on observations, record review and interviews, the facility failed to provide dementia care and services for six (#29, #13, #7, #18, #10 and #20) of eight residents reviewed out of 19 sample residents. Specifically, the facility failed to provide dementia care and services to enhance resident engagement and quality of life for: -Resident #29 regarding language and communication; -Resident #13 regarding care resistance to avoid injuries during bathing, and to address wandering behavior that affected other residents; -Resident #7 and Resident #10 regarding resident-to-resident interactions; -Resident #18 regarding inadequate supervision; and, -Resident #20 regarding failure to routinely monitor his comfort level after he received a new roommate. Findings include: I. Facility policy The Dementia Care Policy and Procedure, dated 1/20/21, provided by the nursing home administrator (NHA) in the afternoon of 11/3/22, included the following: General approach: -Involve the resident or family/representative to the extent possible and in accordance with the resident's wishes, in discussions about the potential use of any specific approaches to their care. -Recognize that every interaction a resident has with the environment and staff members offers an opportunity to promote a sense of purpose, pleasure, success and a feeling of being normal for residents, family and team members. -Providing care that is focused on what each resident needs to maintain dignity and a positive sense of self. -Tailoring personal care approaches, meal service and activities to the individual by paying close attention to past life history, as well as current functional and cognitive levels. Basic dementia care approaches: -Encourage maximal independence (have the resident perform activities/care routines they can perform if given adequate time and task segmentation cues). -Break up tasks when dressing or other activities to decrease confusion/anxiety. -Providing stimulation to decrease boredom, and activities including one-on-one from direct caregivers. Physical environment: -Use language that promotes dignity. -Residents are re-approached in a calm manner if refusing grooming assistance. -Response to any behavior of distress/emotional as an unmet need to prevent escalation of distress. II. Resident #29 A. Resident status Resident #29, age [AGE], was admitted on [DATE]. According to the November 2022 computerized physician orders (CPO), diagnoses included dementia with behavioral disturbance and mood disorder with depressive features. The 10/11/22 minimum data set (MDS) assessment documented no brief interview for mental status (BIMS) was done as Resident #29 was rarely or never understood. She had short term and long term memory problems, and moderate cognitive impairment. She had delirium symptoms including inattention and disorganized thinking, and no behavioral symptoms or rejection of care. She needed extensive assistance with transfers, dressing, toilet use, personal hygiene and ambulation in her wheelchair. Spanish was her preferred language, and she needed or wanted an interpreter to communicate with health care staff. B. Record review The care plan, initiated on 1/17/22 and not revised, identified Resident #29's primary language was Spanish, placing her at risk for communication problems. Interventions were to allow the resident adequate response time; identify disease/conditions that may be related to communication problems: dementia, primary language Spanish; make referrals to appropriate health care professional if needed; speak directly in front of resident in order to increase chances of understanding. -No dignified, effective, person-centered approaches to language interpretation and effective communication were documented in the resident's care plan. Review of nursing progress notes revealed no documentation that staff used an interpreter to communicate with Resident #29 when providing care, conducting assessments, or when she was in distress. C. Observations Resident #29 was observed throughout the survey, on 10/31/22, 11/1/22, 11/2/22 and 11/3/22, spending most of her time sitting in the common areas unengaged with other residents or staff, and sometimes attempting to communicate with passersby. On 11/1/22 at 3:40 p.m. Resident #29 was sitting at the 100 hall activity table with a small group of residents who were using crayons to color on pictures provided by activities staff. She was speaking Spanish and pointing to the crayons and pictures that other residents were working on, but had none in front of her. The activities assistant said she did not know what Resident #29 was saying, and she did not usually like to color. She did not offer colors to the resident, and did not attempt to respond to her. She said she thought certified nurse aide (CNA) #2 was the only bilingual person working in the facility that day, and she indicated she did not know how to communicate with Resident #29. The nurse on duty said CNA #2 was not working that day but they had a phone translation line, which neither she or the activity assistant offered to use to communicate with Resident #29. The nurse on duty said she knew basic Spanish words like dolor for pain. On 11/1/22 at 4:30 p.m. Resident #29 was in the 100 hall activity area by herself, with only CNA #5 nearby. When Resident #29 spoke in Spanish to CNA #5, she was unable to communicate with her or understand her. CNA #5 said they had a language phone line that she had tried to use to communicate with Resident #29, but she was unable to understand the resident's responses. D. Staff interviews Nursing assistant (NA) #1 and NA #2 were interviewed on 11/2/22 at 9:39 a.m. They said communication with Resident #29 was difficult, that they knew a few basic Spanish words for bathroom and water, but as far as whole sentences, no. They said one CNA, a housekeeper and one nurse spoke Spanish, and that Resident #29 sometimes spoke English. They said they had a phone translation service but we rarely need to do that. The activities director (AD) was interviewed on 11/2/22 at 9:52 a.m. She said Resident #29 enjoyed board games and anything that involved the Bible or church. She said she had ordered some Spanish Bibles. She said Resident #29's family had said she also enjoyed cleaning, organizing and doing dishes which could keep her engaged for hours. The AD said they had Spanish magazines and television and had thought about getting books but were having difficulty finding them. She said they had an account where they could order videos, and she could check with the library for Spanish language books that Resident #29 and other residents might enjoy. CNA #4 was interviewed on 11/2/22 at 12:18 p.m. She said CNA #5 or licensed practical nurse (LPN) #1 could translate if she needed to go beyond basic Spanish words she knew. During showers and baths she asked housekeeper (HK) #1 to come in and talk with Resident #29 if she was feeling uncomfortable or talkative and HK #1 would help her with Resident #29's shower. That makes her more comfortable. The social services director (SSD) was interviewed on 11/3/22 at 11:28 a.m. She said Re[TRUNCATED]

Based on interviews and record review, the facility failed to ensure an effective quality assurance program to identify and address facility compliance concerns were implemented, in order to facilitate improvement in the lives of nursing home residents, through continuous attention to quality of care, quality of life, and resident safety. Specifically, the quality assurance performance improvement (QAPI) program committee failed to identify and implement an effective system to identify facility concerns or address need for quality improvement in their QAPI program. Findings include: I. Review of the facility's regulatory record revealed the facility failed to operate a quality assurance (QA) program in a manner to prevent repeat deficiencies. Repeat deficiencies included: A. F600 Free from Abuse and Neglect During the recertification survey on 7/29/21, failure to prevent abuse was cited at an K scope, immediate jeopardy at a pattern. The 6/15/22 compliant survey identified deficient practices abuse prevention and again cited abuse at a K scope, immediate jeopardy at a pattern. During the recertification survey on 11/3/22, the facility was cited at a E scope, potential for more than minimal harm, pattern. B. F609 Reporting of Alleged Violations During the recertification survey on 7/29/21, failure to report abuse was cited at an E scope, potential for more than minimal harm, pattern. During the recertification survey on 11/3/22, the facility was cited again at a E scope. C. F610 Investigate alleged violations During the September recertification survey, failure to thoroughly investigate abuse was cited at an D scope, potential for more than minimal harm, isolated. During the recertification survey on 7/29/21, the deficiency was cited at an E scope, potential for more than minimal harm, pattern. During the recertification survey on 11/3/22, the facility was cited for failure to investigate abuse at a D scope. D. F689 Free from Accident Hazards During the September 2019 recertification survey, accident hazards was cited at an E scope, pattern. During the recertification survey on 7/29/21, the deficiency was cited at an D level. During the recertification survey on 11/3/22, the facility cited accident hazards again at a D scope. E. F744 Treatment/Services for Dementia Care During the recertification survey on 7/29/21, dementia care was cited at an G scope, at harm isolated. The 6/15/22 compliant survey identified deficient practices in dementia care and cited F744 at a H scope, harm at a pattern. The recertification survey on 11/3/22, the facility was cited at an E scope. F. F867 QAPI Program/Plan During the September 2019 recertification survey, QAPI was cited at an E scope. The 6/15/22 compliant survey identified deficient practices in QAPI and cited F867 at a F widespread. During the survey on 7/29/21, QAPI was cited at an G scope. During the recertification survey on 11/3/22, the facility was cited at a F at widespread scope. II. Cross-referenced citations affecting quality of care identified during the facility's recertification on 11/3/22. A. F604 Right to Be Free from Restraints was cited at an D scope, potential for more than minimal harm, isolated. B. F692 Nutrition Services cited at a G scope of severity, actual harm, isolated. C. F825 Rehabilitation and Restorative services was cited at an D scope, potential for more than minimal harm, isolated. III. The facility failed to self identify effective systems or need for quality improvement in their QAPI program. The NHA was interviewed on 11/3/22 at 7:26 p.m. She said the QAPI committee met monthly to continuously improve processes. The NHA identified all of the deficient practices cited on 11/3/22, during the recertification survey, were all reviewed in QAPI and often in the facility's morning quality assurance (QA) meeting. She said when concerns were identified, the facility tried to identify the root cause. The NHA said the management team would sit down with staff and try to problem solve. The facility would initiate a performance improvement plan, when needed, and give the plan six weeks to determine if the plan was effective in improving the concern. The NHA said the improvement plan would include audits, monitoring, and re-education of staff. The NHA said the QAPI process had grown and they have been working on identifying concerns, conducting audits, and acquiring more education resources and training but the facility still had issues to work on. The NHA said abuse prevention was reviewed in QAPI. The NHA said the facility had been working with their corporate abuse coordination and chief nursing officer to assist with the facility's abuse prevention practices. The NHA said restraints were reviewed in QAPI because the facility had recently added a lot of new restraints because of lack of available therapy services (cross-reference F825 rehab and restorative services) and the facility had some newly admitted high fall risk residents. The NHA said reporting abuse was reviewed in QAPI but not the need to report allegations of abuse within two hours because she was not aware of the two hour timeline. The NHA said investigating abuse was reviewed in QAPI. She said the facility had identified it as a concern and had been an ongoing learning process. The NHA said falls were reviewed in QAPI. The NHA said individual falls and interventions were reviewed as part of the quality assurance process. The NHA said nutrition services were reviewed at the nutrition at risk meetings and weight loss and weight loss prevention was part of their improvement process in QAPI. The NHA said dementia care had been reviewed in QAPI and the facility had been working on training for dementia since it was last identified as a concern in June 2022 during the complaint survey. The NHA said therapy services/restorative services were reviewed in QAPI because the facility had not been able to find qualified staff available for the open positions. The NHA said QAPI processes were reviewed in QAPI after it was identified as a concern in the June 2022 complaint. She said the facility created a new agenda for QAPI. The NHA said the facility was still having difficulty completing the improvement plan. The NHA said the facility had not always been successful in the improvement processes and would continue work on ways to grow.