**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to ensure residents had a right to participate in the development and implementation of their person-centered plan of care for one (#2) of one resident out of 37 sample residents. Specifically, the facility failed to invite Resident #2's representative to participate in the care conferences to review the resident's plan of care. Findings include: I. Facility policy The Care Planning - Interdisciplinary Team policy, revised March 2022, was provided by the nursing home administrator (NHA) on 6/5/24 at 12:00 p.m. It read in pertinent part, The interdisciplinary team is responsible for the development of resident care plans. The resident, the resident's family and/or the resident's legal representative or surrogate are encouraged to participate in the development of and revisions to the resident's care plan. If it is determined that participation of the resident or representative is not practicable for development of the care plan, an explanation is documented in the medical record. II. Resident #2 A. Resident status Resident #2, age [AGE], was admitted on [DATE]. According to the June 2024 computerized physician orders (CPO), diagnoses included Alzheimer's disease, severe dementia with mood disturbances, sleep apnea, hearing loss and insomnia (difficulty sleeping). The 5/10/24 minimum data set (MDS) assessment revealed the resident had severe cognitive impairment with a brief interview for mental status (BIMS) score of zero out of 15. He was dependent on staff for toileting, showering, personal hygiene, and dressing. He required supervision for eating and substantial assistance with oral hygiene. B. Resident representative interview The resident's representative was interviewed on 6/3/24 at 9:42 a.m. She said the facility did not invite her or the other resident's representatives to the care conferences. She said she was frustrated because the only time she was updated on the resident's care was when the facility wanted to change his risperdal (antipsychotic medication). She said the facility did not communicate with her and it took a long time to get the resident enrolled in hospice care. C. Record review The 1/23/24 multidisciplinary care conference note revealed the Resident #2's representative did not attend the care conference. The 4/30/24 multidisciplinary care conference note revealed the resident's representative did not attend the care conference. The 5/7/24 multidisciplinary care conference note revealed the residen'ts representative did not attend the care conference. The 5/16/24 multidisciplinary care conference note revealed the resident's representative did not attend the care conference. A review of the Resident #2's electronic medical record (EMR) on 6/5/24 at 9:00 a.m. revealed there was no documentation that the resident's representative was contacted to attend the care conferences on 1/23/24, 4/30/24, 5/7/24 and 5/16/24. III. Staff interviews The social services director (SSD) was interviewed on 6/5/24 at 10:40 a.m. The SSD said the MDS coordinator was responsible for coordinating care conferences. The SSD said care conferences were completed at least quarterly. The SSD said a care conference was held more frequently if the resident had a change in condition. The SSD said the social services department, the MDS coordinator, the dietary manager, the activities department and restorative services attended the care conferences. The SSD said the social services department was responsible for inviting the resident's representative. The SSD said a card was sent, by mail, 45 days before the care conference date. The SSD said the resident's representative called to confirm if they could or could not attend the conference. The SSD said if the representative did not call, social services was responsible for calling the representative the day before the care conference and when the care conference started. The SSD said the social services department documented in a progress note that a card was sent and if the resident's representative was contacted. The SSD said the social services department did not invite Resident #2's representative to any care conferences because she thought the representative did not want to be a part of the resident's care plan. The SSD said she should have called the representative to allow them to accept or decline. The SSD said she would contact the Resident #2's representative for future care conferences. The SSD said she would document in a progress note if the representative wanted to attend the care conferences. The director of nursing (DON) was interviewed on 6/5/24 at 11:11 a.m. The DON said Resident #2's representative should have been invited to the care conferences that took place. The DON said the social services department was responsible for inviting the resident or resident's representative to care planning conferences.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interviews, the facility failed to ensure the resident environment remained as free of accident hazards as possible for one (#87) of three residents reviewed for accidents/hazards out of 37 sample residents. Specifically, the facility failed to ensure Resident #87 had an order for a medication (Aleve) found at his bedside or a self medication assessment. Findings include: I. Resident status Resident #87, age [AGE], was admitted on [DATE]. According to the June 2024 computerized physician's order (CPO), diagnoses included difficulty walking, muscle weakness and abnormality of gait. The 5/15/24 minimum data set (MDS) assessment documented the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. II. Record review The care plan, initiated 5/7/24 and updated 5/14/24, identified the resident had activities of daily living (ADL) self care performance deficits. Interventions included supervising and assisting the resident with ADLs. A review of Resident #87's electronic medical record (EMR) did not reveal the resident had a physician's order for Aleve (pain medication). A review of Resident #87's EMR did not reveal a self medication assessment. III. Observations and interview There was a bottle of Aleve was on a television tray in Resident #87's room on 6/2/24 at 11:15 a.m. There was a bottle of Aleve was on a television tray in Resident #87's room on 6/3/24 at 2:05 p.m. There was a bottle of Aleve was on a television tray in Resident #87's room on 6/4/24 at 10:41 a.m. Licensed practical nurse (LPN) #2 retrieved the bottle of Aleve. She said Resident #87 did not have a physician's order for Aleve. Resident #87 said he only had it for when he had a headache. He said he did not need to tell a doctor about a headache. He said he had purchased the bottle while out of the facility. LPN #2 said she would let the provider know and ask for an as needed (PRN) medication for headaches. She removed the bottle from the resident's room. IV. Staff interview The director of nursing (DON) was interviewed on 6/4/24 at 11:30 a.m. The DON said the facility did not have any residents who were allowed to self administer medications. She said staff should have seen the bottle of Aleve and removed it from the resident's room She said if Resident #87 needed medication for headaches, the facility could ask the provider for a PRN medication order.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to ensure two (#18 and #19) of four residents investigated for abuse out of 37 sample residents were kept free from physical abuse. Specifically, the facility failed to: -Prevent a physical altercation between Resident #93 and Resident #19, and, -Prevent a physical altercation between Resident #71 and Resident #18. Findings include: I. Facility policy The Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating policy, reviewed September 2022, was provided by the nursing home administrator (NHA) on 6/2/24 at 3:36 p.m. The policy read in pertinent part, Findings of all investigations are documented and reported. Upon receiving any allegations of abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source, the administrator is responsible for determining what actions (if any) are needed for the protection of residents. All allegations are thoroughly investigated. The administrator initiates investigations. The administrator ensures that the resident and the person(s) reporting the suspected violation are protected from retaliation or reprisal by the alleged perpetrator, or by anyone associated with the facility. II. Altercation on 3/21/24 between Resident #93 and Resident #19 A. Facility investigation of the altercation on 3/21/24 The witness statement dated 3/21/24 by certified nurse aide (CNA) #7, noted she heard some yelling and saw Resident #19 on the floor being kicked by Resident #93. The victim statement dated 3/21/24 documented Resident #19 said he saw Resident #93 leaving his room with his belongings. Resident #19 told Resident #93 to give the items back. Resident #93 then slammed Resident #19 to the ground and started kicking Resident #19. Resident #19 stated he was afraid of Resident #93. A progress note dated 3/21/24 at 11:30 a.m. identified Resident #93 was in Resident #19's room. Resident #19 confronted Resident #93 for taking his belongings. Resident #93 pushed Resident #19 into the wall then threw Resident #19 to the floor and kicked Resident #19. Resident #93 admitted to pushing Resident #19. B. Resident #19 1. Resident status Resident #19, age [AGE], was admitted on [DATE], and readmitted on [DATE]. According to the June 2024 computerized physician's orders (CPO), diagnoses included paranoid schizophrenia (mental illness that affects a person's thoughts and behaviors), type II diabetes and chronic obstructive pulmonary disease (COPD). The 4/20/24 minimum data set (MDS) assessment documented the resident was moderately cognitively intact with a brief interview for mental status (BIMS) score of 11 out of 15. The MDS assessment did not identify behaviors during the assessment period. 2. Record review The care plan, initiated 6/29/23, identified Resident #19 had the inability to problem solve. Interventions included the staff were to remind Resident #19 to ask for help. The care plan, initiated 6/29/23, identified the diagnosis of schizophrenia to include paranoid ideation. Interventions included the target behaviors of paranoia and people persecuting him. Staff were to monitor for the behaviors. The progress note, dated 3/21/24 at 10:50 a.m. identified the following injuries to Resident #19 from the altercation with Resident #93: -A scalp contusion to the forehead, -An abrasion to the right arm measuring 0.5 centimeters (cm) by 0.3 cm; -An abrasion to the left hand measuring 0.1 cm by 0.5 cm; -An abrasion to the right arm measuring 1.2 cm by 0.5 cm; and, -A contusion to the right side of the forehead measuring 4.3 cm by 4 cm. The progress note dated 3/21/24 at 3:21 p.m. noted the resident had returned from the hospital with a contusion on the right side of the forehead that had been cleansed with normal saline (NS) and Bacitracin (topical antibiotic ointment) was applied. There were abrasions to his left and right arms also. C. Resident #93 1. Resident status Resident #93, age [AGE], was admitted on [DATE] and discharged to the hospital on 3/21/24. According to the March 2024 CPO, diagnoses included Alzheimer's disease, dementia and amnesia (memory loss). The 3/20/24 MDS assessment documented the resident had moderate cognitive impairments with a BIMS score of eight out of 15. The MDS assessment did not identify any behaviors during the look back period. 2. Record review The care plan, initiated 3/11/24, identified the resident had a diagnosis of dementia which made it hard for him to know time or place. Interventions included if he became upset, try to find out the cause and address it or resolve it. The care plan, initiated 3/13/24, identified Resident #93 was at risk for impaired psychiatric/mood status secondary to amnesia, dementia, anxiety, and Alzheimer's disease. Interventions included providing a calm and safe environment when the patient was emotional or frustrated and allowing time to voice his feelings. The multidisciplinary care conference form dated 3/19/24, identified Resident #93 would get confused regarding which room was his and he needed redirection to find his room. Interventions included potentially placing a sign on his door as a visual cue. -The facility failed to update Resident #93's care plan with the intervention discussed in the care conference on 3/19/24. The progress noted dated 3/21/24 at 11:30 a.m. identified the provider gave a verbal order to send Resident #93 to the hospital for an evaluation after the altercation. Resident #93 did not return to the facility following his discharge to the hospital. D. Staff interviews CNA #3 was interviewed on 6/4/23 at 1:55 p.m. CNA #3 said Resident #93 had a habit of wandering into other resident's rooms and saying items he found were his. She said when the altercation on 3/21/24 occurred, she saw Resident #19 on the floor getting kicked. She said she helped separate both the residents and called the administrative staff. She said Resident #19 had a scrape on his knees and a rug burn on his head. She said the other residents were afraid of Resident #93. The NHA was interviewed on 6/5/24 at 12:30 p.m. The NHA said the facility immediately separated the residents and each resident was placed on one on one staff monitoring until they were both sent to the hospital to see if they had suffered any injuries beyond the noted ones by the staff. She said the facility worked hard to prevent abuse in any form. III. Altercation on 5/28/24 between Resident #18 and Resident #71 A. Facility investigation Housekeeper (HSK) #1's statement, dated 5/28/24, indicated Resident #71 yelled at Resident #18, then got up and went over and slapped Resident #18 in the face. She said she could not hear what they were saying to each other. The investigation documented that during the investigation, Resident #71 continued to deny slapping Resident #18 even after showing him the video evidence. A progress note, dated 5/28/24 at 3:42 p.m., noted Resident #18 went outside to smoke and Resident #71 slapped him. Resident #18 was taken back inside the facility by staff. Resident #18 was noted to have a red mark on his left cheek. B. Resident #18 1. Resident status Resident #18, age [AGE], was admitted on [DATE] and readmitted on [DATE]. According to the June 2024 CPO, diagnoses included cerebral infarction (stroke), aphasia (difficulty talking) and left side weakness. The 3/20/24 MDS assessment documented the resident was cognitively intact with a BIMS score of 13 out of 15. The MDS assessment identified one episode of verbal behaviors during the assessment period. 2. Record review The care plan, revised 2/20/24, identified Resident #18 would display behaviors that included knocking people down. Interventions included allowing Resident #18 to express his feelings in appropriate ways, analyzing the behavior for a possible cause and effect relationship and explaining his behavior was not acceptable. C. Resident #71 1. Resident status Resident #71, age less than 65, was admitted on [DATE] and discharged home on 5/28/24. According to the May 2024 CPO, diagnoses included chronic obstructive pulmonary disease (COPD), heart disease and respiratory failure. The 3/20/24 MDS assessment documented the resident was cognitively intact with a BIMS score of 15 out of 15. The MDS assessment identified one episode of verbal behaviors during the assessment period. 2. Record review The care plan, initiated 10/16/23, identified Resident #71 had impaired psychiatric/mood status related to depression. Interventions included providing him with quality listening time and encouraging expressions of feelings. -The facility failed to identify and care plan that Resident #71 displayed verbal behaviors towards others (see MDS assessment above). The progress note, dated 5/28/24 at 3:21 p.m. documented Resident #71 began yelling at Resident #18. Resident #71 stood up and slapped Resident #18 on the left cheek. A nurse in the building heard a commotion, went outside to see what was going on. The nurse took Resident #18 into the facility. When Resident #71 was questioned, he denied he hit Resident #18. Resident #71 was shown the video of him hitting Resident #18 on the left cheek. Resident #71 was put on a one on one staff monitoring. IV. Staff interviews The social services assistant (SSA) was interviewed on 6/4/24 at 2:30 p.m. The SSA said Resident #71 was planning to leave the facility at the end of May 2024. She said he had not displayed any kind of aggressive behavior toward another resident before. She said he denied the assault even after he watched the video. She said Resident #18 had a reddened cheek after the incident. The NHA was interviewed on 6/5/24 at 12:30 p.m. The NHA said Resident #71 had not displayed aggressive behaviors previous to the altercation. She said after the one on one was started, Resident #71 signed out of the facility against medical advice (AMA) shortly after the altercation. She said everyone who lived at the facility had the right to be free from any form of abuse to include physical abuse.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interviews, the facility failed to ensure one (#80) of three residents with skin conditions of 37 sample residents received the highest practicable treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan. Specifically, the facility failed to identify, assess, monitor and care plan a large growth on Resident #80's face. Findings include: I. Resident status Resident #80, age over 65, was admitted on [DATE]. According to the June 2024 computerized physician's order (CPO), diagnoses included atrial fibrillation (irregular heart beat), dysphagia (difficulty swallowing) and chronic obstructive pulmonary disease (COPD). The 4/20/24 minimum data set (MDS) assessment documented the resident was cognitively intact with a brief interview for mental status (BIMS) score of 12 out of 15. II. Observation On 6/2/24 at 1:15 p.m. Resident #80 was observed to have a large growth that was approximately the size of a pear on the right side of his face in front of his right ear. III. Record review A 11/1/23 physician's note identified a mass on the right side of Resident #80's face by the mandible (jaw). A 12/20/23 physician's note identified the mass on the right side of the resident's face near the mandible. A 2/21/24 physician's note identified a large mass on the right side of the resident's face. A 4/16/24 physician's note identified a large growth on the right side of the resident's face by the mandible. -Resident #80's care plan did not address the growth on the right side of the resident's face. -The resident's admission assessment did not identify the resident had a growth on the right side of his face. -The facility did not have any assessments or monitoring of the growth on the right side of his face. IV. Interviews Certified nurse aide (CNA) #8 was interviewed on 6/4/24 at 10:10 a.m. CNA #8 said Resident #80 had always had the growth on his face. She said she did not think there were any special treatments for the growth. She said the family did not want any procedures done to the growth. She said if staff saw any changes to the growth she would report the changes to the nurse. Registered nurse (RN) #1 was interviewed on 6/5/24 at 9:00 a.m. RN #1 said the growth on Resident #80's face had always been there. She said she did not have an order to monitor the area. She said if she saw a change in the area she would have notified the director of nursing (DON). She said the family did not want any treatment to the area. The DON was interviewed on 6/5/24 at 11:15 a.m. The DON said the facility should have identified the growth upon initial assessment when the resident was admitted to the facility. She said she did not know why the growth was not being monitored by the facility staff. She said she did not know why there was not a care plan identifying the growth and indicating that the family wished to not remove the growth. She said the provider would see the resident later that day (6/5/24) and she would provide education to have the staff start monitoring the area. She said she would have a care plan started to identify the growth and the wishes of the family for non-treatment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and interviews the facility failed to use a person-centered approach when determining the use of bed rails for four (#27, #36, #40, and #70) of ten residents reviewed for bed rails out of 37 sample residents. Specifically, for Resident #27, #36, #40 and #70, the facility failed to: -Assess the resident for risk of entrapment prior to installing the bed rails; -Obtain consent, which included the risks versus benefits of bed rails, from the resident and/or the resident's representative prior to bed rail installation; and, -Conduct quarterly assessments of the bed rails to evaluate the safety and/or continued need for bed rails. Findings include: I. Professional reference The U.S. (United States) Food and Drug Administration (FDA) Recommendations for Health Care Providers Using Adult Portable Bed Rails (2/27/23), was retrieved on 6/8/24 from https://www.fda.gov/medical-devices/adult-portable-bed-rail-safety/recommendations-health- care-providers-using-adult-portable-bed-rails. It read in pertinent part, Avoid the routine use of adult bed rails without first conducting an individual patient or resident assessment. Evaluation is needed to assess the relative risk of using the bed rail compared with not using it for an individual patient. II. Facility policy and procedure The Bed Safety and Bed Rails policy and procedure, revised August 2022, was provided by the nursing home administration (NHA) on 6/8/24 at 12:00 p.m It read in pertinent part, Residents' beds meet the safety specifications established by the Hospital Bed Safety Workgroup. The use of bedrails are prohibited unless the criteria for use have been met. Consideration is given to the residents' safety, medical conditions, comfort and freedom of movement, as well as input from residents and resident families regarding previous sleeping habits and bed environment. Maintenance staff routinely inspects all beds and related equipment to identify risks and problems including potential entrapment risks. The maintenance department provides a copy of inspections to the administrator and reports results to the Quality Assurance and Performance Improvement (QAPI) committee for appropriate action. III. Resident #27 A. Resident status Resident #27, over the age of 65, was admitted on [DATE]. According to the June 2024 computerized physician orders (CPO), diagnoses included dementia, heart failure, chronic pain syndrome, and arthritis of the right shoulder. The 3/20/24 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. She required supervision with transfers, toileting, personal hygiene, eating, and bed mobility. -The assessment documented Resident #27 did not use bed rails. B. Observations On 6/3/24 at 9:40 a.m., Resident #27 was sitting in her wheelchair in her room with one metal half bed rail attached to the resident's bed. On 6/4/24 at 1:15 p.m., Resident #27 was lying in bed with one metal half bed rail attached to her bed. C. Resident interview Resident #27 was interviewed on 6/4/24 at 9:17 a.m. Resident #27 said the side rail helped her with transfers. She said the bed rail had been attached to the bed since she arrived in the room. D. Record review -The June 2024 CPO revealed Resident #27 had no physician's order for a bed rail on one side of the resident's bed to help with mobility. The comprehensive care plan, initiated and revised on 6/11/23, revealed Resident #27 had impaired mobility, poor range of motion and was at risk for falls. -The care plan failed to include an intervention for the use of a bed rail for Resident #27. -A comprehensive review of the resident's electronic medical record (EMR) failed to reveal a bed rail evaluation and consent prior to the initiation of the one bed rail as a positioning enabler. -The EMR failed to reveal quarterly assessments for the evaluation of the continued use and safety of the bed rail. -The maintenance department had no routine inspections for the resident's bed rail. IV. Resident #36 A. Resident status Resident #36, under the age of 65, was admitted on [DATE]. According to the June 2024 CPO, diagnoses included paraplegia, type 2 diabetes mellitus, bipolar disorder and difficulty in walking. The 5/6/24 MDS assessment revealed the resident was cognitively intact with a BIMS score of 15 out of 15. She required supervision assistance with toileting, showering, dressing, personal hygiene and mobility. -The assessment documented Resident #36 did not use bed rails. B. Observation On 6/3/24 at 9:50 a.m. and 6/4/24 at 3:02 p.m., one bed rail was observed on the left side of Resident #36's bed. On 6/5/24 at 9:05 a.m. Resident #36 was lying down in bed with a bed rail attached to her bed on the left side. C. Resident interview Resident #36 was interviewed on 6/5/24 at 9:06 a.m. Resident #36 said she was offered a new bed by the facility and the new bed arrived with one side rail. The resident said she used the side rail to assist her with transfers and positioning during incontinence care. She said the bed rail prevented her from falling out of bed. D. Record review The care plan, revised on 4/11/24, revealed Resident #36 was at risk for falls due to impaired mobility related to the diagnosis of paraplegia. Interventions included to assess the need for assistive/supportive devices. -The care plan failed to include an intervention for the use of a bed rail for Resident #36. -A review of Resident #36's June 2024 CPO revealed there was no physician's order for the resident's bed rail. -The resident's EMR revealed Resident #36 was not evaluated for the use of a bed rail, there was no consent for bed rails, and no documentation about the risks and benefits of using a bed rail. -The EMR failed to reveal quarterly assessments for the evaluation of the continued use and safety of the bed rail. -The maintenance department had no routine inspections for the resident's bed rail. V. Resident #40 A. Resident status Resident #40, over the age of 65, was admitted on [DATE]. According to the June 2024 CPO, diagnoses included muscle weakness, anemia, abnormality of gait and movement and pain. The 4/5/24 MDS assessment documented the resident was cognitively intact with a BIMS score of 15 out of 15. She required moderate assistance for mobility and maximum assistance with showers, personal hygiene, and toilet transfers. -The assessment documented Resident #40 did not use bed rails. B. Observation On 6/3/24 at 10:00 a.m. and 6/4/24 at 2:15 p.m., Resident #40 was sitting in her wheelchair in her room. A bed rail was observed attached to the right side of the resident's bed. C. Resident interview Resident #40 was interviewed on 6/3/24 at 11:04 a.m. Resident #36 said the bed rail was for her to hold on to to assist her with turning herself during incontinence care at night. D. Record review The resident's care plan, revised on 2/11/24, revealed Resident #40 had potential for skin integrity impairment due to immobility. The care plan documented the use of a right-sided grab bar (bed rail) attached to the resident's bed for assistance in repositioning. -A review of Resident #40's June 2024 CPO revealed there was no physician's order for the resident's bed with the bed rail. -The resident's EMR revealed Resident #40 was not evaluated to use a bed rail. There was no consent and no documentation about the risks and benefits of using a bed rail. -The EMR failed to reveal quarterly assessments for the evaluation of the continued use and safety of the bed rail. -The maintenance department had no routine inspections for the resident's bed rail. VI. Resident #70 A. Resident status Resident #70, age greater than 65, was admitted on [DATE]. According to the June 2024 computerized CPO, diagnoses included heart failure, type 2 diabetes mellitus, chronic obstructive pulmonary disease (COPD), muscle weakness, chronic pain and rheumatoid arthritis. The 4/30/24 MDS assessment documented the resident had severe cognitive impairment with a BIMS score of four out of 15. She required supervision assistance with showers, toileting and personal hygiene. -The assessment documented Resident #70 did not use bed rails. B. Observation On 6/3/24 at 10:30 a.m. and 6/4/24 at 1:57 p.m. bed rails were observed on both sides of Resident #70's bed. C. Record review The care plan, revised on 10/30/23, revealed Resident #70 was at risk for falls related to obesity, muscle weakness, pain and rheumatoid arthritis. -It indicated the use of a grab bar (bed rail) for assistance with bed mobility. -A review of Resident #70's June 2024 CPO revealed there was no physician's order for the resident's bed rails. -The resident's EMR revealed Resident #70 was not evaluated to use a bed rail, there was no consent and no documentation about the risks and benefits of using a bed rail. -The EMR failed to reveal quarterly assessments for the evaluation of the continued use and safety of the bed rails. -The maintenance department had no routine inspections for the resident's bed rails. VII. Staff interviews The physical therapy assistant (PTA) was interviewed on 6/5/24 at 11:00 a.m. The PTA said the bed rails were handles added to the sides of the bed to assist residents during transfers and repositioning. The PTA said. if used appropriately, bed rails could help residents become independent. She said she had noticed several resident's beds with the bed rails and would assume all of the residents had physician's orders and assessments completed for the bed rails. She said the maintenance department should be monitoring the functioning of the bed rails. The maintenance supervisor (MS) was interviewed on 6/5/24 at 11:15 a.m. The MS said he installed the bed rails of the residents' beds when he received a maintenance order from nursing staff. He said he thought, before an order was placed for a bed rail, the nursing staff would ensure the proper assessment for the bed rails had been completed. The MS said there was no ongoing monitoring of the bed rails once he initially installed them. The director of nursing (DON) was interviewed on 6/5/24 at 12:42 p.m. The DON said it was the policy of the facility to complete a bed rail assessment prior to attaching bed rails to a bed. She said the therapy department was responsible for completing bed rail assessments. She said once the decision was made to attach bed rails to a resident's bed frame, it was the responsibility of nursing staff to obtain informed consent from the resident or resident's representative. The DON said it was the responsibility of the nursing unit nurse manager to update a resident's care plan to identify the bed rail use as an intervention. The DON said when bed rails were attached to residents' bed frames there should be ongoing routine maintenance checks for functioning. The DON said routine maintenance checks were not being done and she would immediately ensure consent, assessment, and routine monitoring of all bed rails.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to ensure three (#2, #21, #54) of five residents reviewed for unnecessary medications out of 37 sample residents were free from unnecessary medications. Specifically, the facility failed to: -Ensure Resident #2, Resident #21 and Resident #54 had appropriate non-pharmacological interventions for behaviors initiated; and, -Ensure informed consent, which included the risks associated with taking a psychotropic medication, were obtained from the resident or resident's representative before the resident's use of a psychotropic medication for Resident #2, Resident #21 and Resident #54. Findings include: I. Facility policy The Psychotropic Medication Use policy, revised July 2022, was provided by the nursing home administrator (NHA) on 6/5/24 at 12:00 p.m. It read in pertinent part, Non-pharmacological approaches are used to minimize the need for medications, permit the lowest possible dose, and allow for the discontinuation of medications when possible. Residents, families and/or the representative are involved in the medication management process. Psychotropic medication management includes the indication for use, dose, duration, adequate monitoring for efficacy and adverse consequences and preventing, identifying and responding to adverse consequences. Residents and representatives have the right to decline treatment with psychotropic medications. The staff and physician will review with the resident and representative the risks related to not taking the medication as well as appropriate alternatives. II. Resident #2 A. Resident status Resident #2, [AGE] years old, was admitted on [DATE]. According to the June 2024 computerized physician orders (CPO), diagnoses included Alzheimer's disease, severe dementia with mood disturbances, sleep apnea, hearing loss and insomnia (difficulty sleeping). The 5/10/24 minimum data set (MDS) assessment revealed the resident had severe cognitive impairments with a brief interview for a mental status (BIMS) score of zero out of 15. He was dependent on staff for toileting, showering, personal hygiene, and dressing. He required supervision for eating and substantial assistance with oral hygiene. The resident exhibited verbal and other behavioral symptoms not directed towards others one to three days. The resident took antipsychotic, antidepressant and hypnotic medications on a routine basis. B. Resident representative interview The resident's representative was interviewed on 6/3/24 at 9:42 a.m. She said the resident had a terrible time when he was admitted to the facility. She said she was frustrated because the facility tried a couple of times to decrease his Risperdal (medication used to treat mood disorders). She said it was difficult for him with the constant changes in the strength of the Risperdal because his behaviors like spitting and kicking were managed. She said when the facility tried to lower the strength his behaviors were not managed. She said she wished they kept him at the dose where his behaviors were managed. She said she did not know if the facility tried non-pharmacological interventions in addition to the antipsychotic medications he was prescribed. C. Record review The dementia and Alzheimer's care plan, revised on 2/2/24, revealed the resident had impaired cognitive function related to dementia with delusions and Alzheimer's disease. Interventions included monitoring for side effects of medication and disease conditions that could affect his cognition and orientation, redirecting as needed and notifying hospice and the primary care physician of any significant changes in resident's baseline cognitive status. The psychiatric and mood status care plan, revised on 2/2/24, revealed the resident was at risk for impaired mood status related to dementia, Alzheimer's disease and depression. Interventions included monitoring and reporting to hospice of any signs or symptoms of acute psychosis or changes from resident's baseline and monitoring sleep pattern changes The psychotropic medication care plan, revised on 1/29/24, revealed the resident took psychotropic medications related to insomnia, dementia and depression. Interventions included monitoring for adverse effects of antidepressant medication and antipsychotic medication, monitoring for effectiveness and completing a quarterly review for gradual dose reduction if appropriate. -A review of the comprehensive care plan revealed there was not an intervention that identified person-centered non-pharmacological interventions. The June 2024 CPO revealed the following physician orders: Lexapro (medication used to treat depression) 5 milligrams (mg). Administer one tablet by mouth one time a day related to dementia with mood disturbance, ordered 5/2/24. Trazodone (antidepressant medication) 100 mg. Administer one tablet by mouth at bedtime for insomnia, ordered 4/18/24. Risperdal 1 mg. Administer one tablet by mouth two times a day for hospice related to dementia with severe mood disturbance, ordered 5/11/24. Lorazepam (anti-anxiety medication) 2mg/ml (milliliters). Administer 0.5 ml by mouth every four hours as needed for anxiety, agitation and for hospice, ordered 6/4/24. Offer non-pharmacological interventions prior to behavior medication administration. Non-pharmacological behavior interventions that are effective include a calm approach, positive reassurance, one on one, quiet environment, offering fluids or snacks, diversion activities, re-orientation and redirection. Document Y for interventions were attempted and N for no interventions were attempted, ordered 1/20/24. -The January 2024 MAR revealed non-pharmacological interventions were not offered on 24 of 31 days. -The February 2024 (2/1/24 to 2/29/24) MAR revealed non-pharmacological interventions were not offered on 18 of 28 days. -The March 2024 (3/1/24 to 3/31/24) MAR revealed non-pharmacological interventions were not offered on 30 of 31 days. -The April 2024 (4/1/24 to 4/30/24) MAR revealed non-pharmacological interventions were not offered on 30 of 30 days. -The May 2024 (5/1/24 to 5/31/24) MAR revealed non-pharmacological interventions were not offered on 30 of 31 days. -The June 2024 (6/1/24 to 6/5/24) MAR revealed non-pharmacological interventions were not offered on 5 of 5 days. -A review of the resident's electronic medical record (EMR) revealed there was no documentation to indicate person centered non-pharmacological behavioral interventions that were attempted to address the resident's behaviors and if the interventions were effective. The facility's psychotropic medication consent form contained a section that included two boxes. One box read Consent to use and one box read Refuse the use. The consent form included a line for the resident or the resident's representative to sign after they reviewed the form and marked the appropriate box for consent or no consent for the medication to be administered to the resident. -A review of the consent form for Resident #2's Lorazepam revealed the resident's representative had signed the form, however, neither of the boxes on the consent form was marked to indicate whether or not the representative gave consent to use or refused the use of the medication for Resident #2. III. Resident #21 A. Resident status Resident #21, [AGE] years old, was admitted on [DATE]. According to the June 2024 CPO, diagnoses included paranoid schizophrenia (psychosis that affects thoughts and behavior), extrapyramidal and movement disorder (a drug-induced disorder that causes uncontrollable movement), hallucinations, insomnia and anxiety. The 2/23/24 MDS assessment revealed the resident was cognitively intact with a BIMS score of 14 out of 15. He required partial assistance with oral hygiene, personal hygiene and showering. He required substantial assistance with toileting and dressing. B. Record review The anxiety care plan, revised on 7/16/23, revealed the resident had an anxiety disorder that caused continuous pacing. Interventions included eliminating or correcting underlying causes of problems, offering drink or food, sitting with him, and promoting relaxation exercises. The aggressive behavior care plan, revised on 7/16/23, revealed the resident had a history of aggressive behaviors towards staff and peers. Interventions included offering the resident to listen to classical music, providing deep breathing exercises, going on short walks, and providing him with his teddy bear. The antipsychotic medication care plan, revised on 7/16/23, revealed the resident was at risk for adverse side effects. Interventions included monitoring for target behaviors of pacing, yelling and hallucinating. The June 2024 CPO revealed the following physician orders: Clozapine (antipsychotic medication) 100 mg. Administer one tablet by mouth one time a day at 8:00 a.m. and administer three tablets by mouth one time a day at 8:00 p.m. for paranoid schizophrenia, ordered 2/1/23. Clonazepam 0.5 mg. Administer one tablet by mouth one time a day for anxiety, ordered 2/1/23. Trazodone 50 mg. Administer one tablet by mouth at bedtime for insomnia, ordered 2/1/23. Risperidone 1 mg. Administer one tablet by mouth two times a day for paranoid schizophrenia, ordered 2/1/23. Offer non-pharmacological interventions prior to behavior medication administration. Non-pharmacological behavior interventions that are effective include repositioning, pillows for support, cold compress and massage. Document Y for interventions were attempted and N for no interventions were attempted, ordered on 2/12/24. -The February 2024 (2/1/24 to 2/29/24) MAR revealed non-pharmacological interventions were not offered on 23 of 28 days. -The March 2024 (3/1/24 to 3/31/24) MAR revealed non-pharmacological interventions were not offered on 31 of 31 days. -The April 2024 (4/1/24 to 4/30/24) MAR revealed non-pharmacological interventions were not offered on 30 of 30 days. -The May 2024 (5/1/24 to 5/31/24) MAR revealed non-pharmacological interventions were not offered on 31 of 31 days. -The June 2024 (6/1/24 to 6/5/24) MAR revealed non-pharmacological interventions were not offered on 5 of 5 days. -A review of the resident's EMR revealed there was no documentation to indicate person centered non-pharmacological behavior interventions that were attempted to address the resident's behaviors and if the interventions were effective. The facility's psychotropic medication consent form contained a section that included two boxes. One box read Consent to use and one box read Refuse the use. The consent form included a line for the resident or the resident's representative to sign after they reviewed the form and marked the appropriate box for consent or no consent for the medication to be administered to the resident. -A review of the consent forms for Resident #21's clozapine, clonazepam, trazodone and risperidone revealed the resident's representative had signed the consent forms for each psychotropic medication, however, neither of the boxes on the consent forms was marked to indicate whether or not the representative gave consent to use or refused the use of the medications for Resident #21. IV. Resident #54 A. Resident status Resident #54, age greater than 65, was admitted on [DATE]. According to the June 2024 CPO, diagnoses included severe dementia with agitation, insomnia and muscle weakness. The 2/15/24 MDS assessment revealed the resident had severe cognitive impairments with a BIMS score of zero out of 15. She required partial assistance with oral hygiene, toileting, dressing and personal hygiene. She required substantial assistance with showering. B. Record review The antipsychotic drug use care plan, revised on 2/2/24, revealed the resident was at risk for side effects and falls. Interventions included assessing the resident for adverse side effects, completing quarterly psychotropic medication review and administering medications as ordered. The sleep care plan, revised on 6/23/23, revealed the resident had difficulty with insomnia. Interventions included monitoring sleep patterns, providing a pharmacy consultant review of medication and side effects. The June 2024 CPO revealed the following physician orders: Donepezil (medication used for Alzheimer's disease) 5 mg. Administer one tablet by mouth at bedtime for dementia with severe agitation, ordered 9/25/23. Risperdal 0.25 mg. Administer one tablet by mouth at bedtime for agitation for dementia with agitation, ordered 6/3/24. Trazodone 50 mg. Administer 1.5 tablets by mouth at bedtime for insomnia, ordered 5/18/24. Memantine 10 mg. Administer one tablet by mouth two times a day for severe dementia with agitation, ordered 3/19/24. Offer non-pharmacological interventions prior to behavior medication administration. Non-pharmacological behavior interventions that are effective include calm approach, positive reassurance, one on one, quiet environment, fluids/snacks, diversion activities, re-orientation and redirection. Document Y for interventions were attempted and N for no interventions were attempted, ordered 12/29/23. Offer non-pharmacological interventions prior to behavior medication administration. Non-pharmacological behavior interventions that are effective include repositioning, pillows for support, cold compress and massage. Document Y for interventions were attempted and N for no interventions were attempted, ordered 12/29/23. -The January 2024 (1/1/24 to 1/31/24) MAR revealed non-pharmacological interventions were not offered on 14 of 31 days. -The February 2024 (2/1/24 to 2/29/24) MAR revealed non-pharmacological interventions were not offered on 18 of 28 days. -The March 2024 (3/1/24 to 3/31/24) MAR revealed non-pharmacological interventions were not offered on 24 of 31 days. -The April 2024 (4/1/24 to 4/30/24) MAR revealed non-pharmacological interventions were not offered on 30 of 30 days. -The May 2024 (5/1/24 to 5/31/24) MAR revealed non-pharmacological interventions were not offered on 31 of 31 days. -The June 2024 (6/1/24 to 6/5/24) MAR revealed non-pharmacological interventions were not offered on 5 of 5 days. -A review of the resident's EMR revealed there was no documentation to indicate person centered non-pharmacological behavior interventions that were attempted to address the resident's behaviors and if the interventions were effective. The facility's psychotropic medication consent form contained a section that included two boxes. One box read Consent to use and one box read Refuse the use. The consent form included a line for the resident or the resident's representative to sign after they reviewed the form and marked the appropriate box for consent or no consent for the medication to be administered to the resident. -A review of the consent forms for Resident #54's Risperdal, trazodone, donepezil and memantine revealed the resident's representative had signed the consent forms for each psychotropic medication, however, neither of the boxes on the forms was marked to indicate whether or not the representative gave consent to use or refused the use of the medications for Resident #54. V. Staff Interviews Licensed practical nurse (LPN) #2 was interviewed on 6/5/24 at 9:46 a.m. LPN #2 said she tried non-pharmacological interventions when a resident was anxious or had facial grimacing. She said interventions included playing music, playing a video or porch time. She said she documented non-pharmacological interventions in progress notes as a behavior note. LPN #2 said said Resident #2's effective non-pharmacological interventions included repositioning, lying down in the recliner or in his bed, playing music and playing an action movie. LPN #2 said Resident #21's effective non-pharmacological interventions included offering him to read a book, complete a puzzle and word searches. LPN #2 said Resident #54's effective non-pharmacological interventions included to keep her near staff, provide one on one care, talk to the resident and read the newspaper. LPN #2 said consent for psychotropic medications was obtained at the time of admission by the admissions department. She said once a resident was admitted , social services was responsible for obtaining consent when a resident was prescribed a new psychotropic medication. She said she checked the resident's EMR to ensure a consent form was on file for each psychotropic medication. The social services director (SSD) was interviewed on 6/5/24 at 10:40 a.m. The SSD said the social services department and the nursing staff determined behaviors that needed to be monitored. The SSD said she completed a demographics form upon a resident's admission to the facility. She said she wrote any behaviors that needed to be monitored in the comment section. The SSD said she wrote non-pharmacological interventions in the same area. She said nursing staff were responsible to offer and to document the non-pharmacological interventions that were attempted. She said the nurse documented the behavior and interventions in a behavior progress note. The SSD said she was familiar with Resident #2, Resident #21 and Resident #54. The SSD said Resident #2 found Native American music was helpful when he had behaviors. The SSD said Resident #21 found if staff walked with him or talked to him about different topics was helpful when he had behaviors. The SSD said Resident #54 found reading flower and family magazines was helpful when she had behaviors. The SSD said informed consents should be signed before a psychotropic medication was administered. She said the admissions department was responsible for obtaining consent for any medications the resident took at the time of admission. She said the psychotropic medication consent form was part of the admissions paperwork the resident or representative reviewed and signed. She said the consent forms contained a section for each type of psychotropic medication, what side effects would be monitored and what the risks and benefits were for each type of psychotropic medication. The SSD said the resident or the resident's representative authorized the facility that psychotropic medications may or may not be administered by an initial next to the phrase Consent to use or the phrase Refuse the use on the consent form. The initials were to be obtained on the form in addition to a resident or resident representative's signature. The SSD said she was not sure what the nurses did when a resident was prescribed a new psychotropic medication. She said she thought the nurses called the resident's representative to review the medication, why it was prescribed, the side effects and the risks versus benefits of the medication. She said she thought the nurses obtained verbal consent and documented the conversation in a progress note. The SSD said she mailed a two page consent form to the resident's representative. She said once the consent was mailed back, she added the informed consent form to the resident's EMR. The SSD said she did not check the progress notes to see if the nurses documented their phone call to the resident's representative. She said she should start checking the nurses progress note. The SSD confirmed Resident #2, Resident #21 and Resident #54 were administered psychotropic medications without a signed informed consent. The director of nursing (DON) was interviewed on 6/5/24 at 11:11 a.m. The DON said the nurses did not consistently offer and did not document if non-pharmacological interventions were offered. She said non-pharmacological interventions should be documented in the resident's MAR. She said the type of non-pharmacological interventions offered and used should be documented in the resident's MAR. The DON said when an existing resident was prescribed a new psychotropic medication the nurse called to notify the resident's representative. The DON said the nurse only contacted the resident's representative to inform them the resident had started a new medication. The DON said the resident's representative did not review why it was prescribed, the side effects, and the risks versus benefits. She said informed consents should be obtained before the nurse administered a new psychotropic medication to a resident. The DON said she would change the process so nursing staff was responsible for obtaining informed consents on psychotropic medications. The DON confirmed Resident #2, Resident #21 and Resident #54 were administered psychotropic medications without a signed informed consent.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to ensure that the hospice services provided met professional standards and principles that applied to individuals providing services in the facility for one (#89) of five residents receiving hospice services out of 37 sample residents. Specifically, the facility failed to orient hospice aides to the facility, including the policies and procedures. Findings include: I. Facility policy The Hospice Program policy, revised July 2017, was provided by the nursing home administrator (NHA) on 6/5/24. It read in pertinent part, Ensuring that our facility staff provides orientation on the policies and procedures of the facility, including resident rights, appropriate forms, and record keeping requirements, to hospice staff furnishing care to the residents. II. Resident status Resident #89, age [AGE], was admitted on [DATE]. According to the June 2024 computerized physician's orders (CPO), diagnoses included neoplasm of the prostate, chronic kidney disease and malignant neoplasm of bone. The 5/5/24 minimum data set (MDS) assessment documented the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. The MDS assessment identified the resident received hospice services during the assessment period. III. Staff interviews Certified nurse aide (CNA) #1, who worked for a hospice agency, was interviewed on 6/3/24 at 4:25 p.m. He said he had been providing hospice services at the facility for about a year and a half. He said he was familiar with the facility, having worked there previously. He said he had not received an orientation to the facility to include the facility policy and procedures since providing care as a hospice aide. The director of nursing (DON) was interviewed on 6/4/24 at 12:30 p.m. The DON said she was not aware the facility needed to provide an orientation to the facility and the facility policy and procedures to the hospice aides. She said going forward she would provide orientation to the hospice aides prior to providing care in the facility.

Based on record review and interviews, the facility failed to complete a performance review of every nurse aide at least once every 12 months and provide regular in-service education based on the outcome of these reviews for four of four staff reviewed. Specifically, the facility had not completed annual performance reviews and/or provided regular in-service education based on the outcome of the reviews for certified nurse aide (CNA) #2, CNA #3, CNA #5 and CNA #6. Findings include: I. Record review CNA #2 (hired on 2/1/11), CNA #3 (hired on 7/26/11), CNA #5 (hired on 4/5/23) and CNA #6 (hired on 1/26/21) did not have an annual performance review completed. The CNAs did not have an in-service education plan based on the outcome of the review. II. Interview The director of nursing (DON) was interviewed on 6/4/24 at 12:30 p.m. The DON said she was not aware the performance reviews needed to include a regular in-service plan based on the outcome of the reviews. She said going forward she would ensure the performance reviews were completed annually to ensure the best care was being delivered to the residents.

Based on observations and interviews, the facility failed to store, prepare, distribute, and serve food in a sanitary manner in the facility's kitchen and dining room. Specifically, the facility failed to: -Ensure nourishment beverages in the main dining room and unit refrigerators were dated and labeled; -Ensure cooking utensils were dried appropriately; -Ensure food preparation area vents were free from hanging dust and lint; -Ensure the main dining room refrigerator maintained a safe operating temperature; and, -Ensure dented food cans were not used. Findings include: I. Ensure nourishment beverages in the main dining room and unit refrigerators were dated and labeled. A. Professional reference The Colorado Department of Public Health and Environment (3/16/24) The Colorado Retail Food Establishment Rules and Regulations, were retrieved on 6/13/24 from https://www.colorado.gov/pacific/sites/default/files/DEHS_RetailFd_RFE_Reg_6 CCR 1010-2_2024_EN.pdf. It read in pertinent part, Time/temperature control for safety food prepared and packaged by a food processing plant shall be clearly marked, at the time the original container is opened in a food establishment and if the food is held for more than 24 hours, to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded, based on the temperature and time combinations. A date marking system may include using a method approved by the regulatory authority for refrigerated, ready-to-eat time/temperature control for safety food that is frequently rewrapped, such as lunch meat or a roast, or for which date marking is impractical, such as soft serve mix or milk in a dispensing machine, 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 and/or 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. B. Observations On 6/2/24 at 2:15 p.m. the following was observed at the main dining room nourishment refrigerators during the initial kitchen tour: -In the dining room refrigerator, there were two opened gallons of milk. Both of the gallons of milk were not labeled with the date they were opened or the date they were to be used by. -Additionally, one of the gallons of milk did not have a lid on it. On 6/3/24 at 2:30 p.m. the south side unit refrigerator was observed to have a half-used bottle of mango juice which was not dated with the date it was opened or a use by date. C. Staff interviews Dietary aide (DA) #1 was interviewed on 6/4/24 at 2:40 p.m. DA #1 said opened beverages were to be dated and labeled to ensure every staff member knew when the beverage should be discarded. He said one of the gallons of milk in the dining room refrigerator had no lid and needed to be thrown away. He said residents could become sick from drinking milk products that had been left open without the lid or were past the date they should be discarded. II. Ensure cooking utensils were dried appropriately. A. Professional reference The Colorado Department of Public Health and Environment (3/16/24) The Colorado Retail Food Establishment Rules and Regulations, were retrieved on 6/13/24 from https://www.colorado.gov/pacific/sites/default/files/DEHS_RetailFd_RFE_Reg_6 CCR 1010-2_2024_EN.pdf. It read in pertinent part, Equipment and Utensils, Air-drying required. After cleaning and sanitizing, equipment and utensils shall be air-dried or used after adequate draining before contact with food and may not be cloth dried. B. Facility policy The nursing home administrator (NHA) provided the Dishwashing policy, with no revision date, on 6/11/24. The policy read in pertinent part, The dishwashing procedures and techniques are well developed, understood, and carried out in compliance with the state and local health codes to assure the safety of the residents. C. Observation On 6/4/24 at 3:30 p.m. a volunteer and an unidentified staff member were observed using paper towels to dry eating and cooking utensils, such as silverware, plates, pots and pans, before placing them on the dish rack. D. Staff interview The dietary manager (DM) was interviewed on 6/4/24 at 4:00 p.m. The DM said the staff used paper towels to dry clean dishes to hurry the drying process so they could use the utensils again. The DM said she was unsure if utensils should be dried with paper towels and said she would verify the process with her supervisor. III. Ensure food preparation area vents were free from hanging dust and lint. A. Professional reference According to The Food and Drug Administration (FDA) Food Code (2019) p. 441, retrieved on 6/8/24 from https://www.fda.gov/media/164194/download?attachment, Surface Characteristics: Floors, walls, and ceilings that are constructed of smooth and durable surface materials are more easily cleaned. Requirements and restrictions regarding floor coverings, utility lines, and floor/wall junctures are intended to ensure that regular and effective cleaning is possible. Heating and air conditioning system vents that are not properly designed and located may be difficult to clean and result in the contamination of food, food preparation surfaces, equipment, or utensils by dust or other accumulated soil from the exhaust vents. B. Facility policy and procedures The Sanitation policy, undated, was provided by the NHA on 6/11/24 at 12:01 p.m. It read in pertinent part, Sanitation conditions are maintained at all times in the dietary department. Effective procedures for cleaning all equipment are well developed and are followed consistently. C. Observations On 6/2/24 at 3:30 p.m., during the initial kitchen tour, two vents in the food preparation area were observed to have hanging dust and cobwebs. On 6/4/24 at 3:00 p.m. the two vents in the food preparation area continued to have lint and dust around them. The cook was observed preparing mechanical and pureed food directly underneath the area where the vents were located. D. Staff interviews The DM was interviewed on 6/4/24 at 4:00 p.m. The DM said there was a daily, weekly and monthly cleaning schedule for maintaining the kitchen in a sanitary condition. The DM said the hanging dust and cobwebs around the vents in the food preparation area was unsanitary.The DM said the maintenance department were responsible for cleaning the high sky ceiling vents. She said a work order had been submitted. The DM said the hanging dust would be cleaned after hours by the maintenance department once the kitchen had completed all food services for the day. The maintenance supervisor (MS) was interviewed on 6/5/24. The MS said he was a new employee and was still being trained. The MS said he had received a work request for the cleaning of the kitchen vents but had not cleaned them yet. IV. Ensure the main dining room refrigerator maintains a safe operating temperature A. Professional reference The Food and Drug Administration (FDA) Food Code (2022), reviewed 1/18/23, was retrieved on 6/8/24 from https://www.fda.gov/food/retail-food-protection/fda-food-code. It read in pertinent part, Bacterial growth and/or toxin production can occur if time/temperature control for safe food remains in the temperature 'danger zone' of 41 degrees Fahrenheit (F) to 135 degrees F for too long. B. Facility policy The Refrigerators and Freezers policy, undated, was provided by the NHA on 6/11/24 at 12:01 p.m. It read in pertinent part, All refrigerated foods are stored in such a manner to keep them safe and free from contamination. The temperature of each refrigerated unit will be maintained below 40 degrees Fahrenheit (F) C. Observations On 6/2/24 at 3:30 p.m. during the initial kitchen tour, the refrigerator in the main dining room, which contained beverages and snack foods, was observed with a temperature of 51 degrees F. On 6/4/24 at 4:00 p.m. the dining room refrigerator continued to have a temperature of 51 degrees F. D. Staff interview The DM was interviewed on 6/4/24 at 4:00 p.m. The DM said all nourishment refrigerators should maintain an operating temperature of 40 degrees F and below. She said it was unsafe for beverages and food items to remain too long in the food danger zone. The DM said all beverages and food items in the dining room refrigerator would be discarded and she would request maintenance to check the refrigerator. The DM was interviewed again on 6/5/24 at 11:30 am. The DM said the beverages and snack foods in the dining room refrigerator had been removed and the refrigerator would not be in use again until maintenance ensured that it was operating at a proper temperature. V. Ensure dented food cans were not used. A. Professional reference According to the United States Department of Agriculture (USDA), retrieved on 6/13/24 from https://ask.usda.gov/s/article/Is-food-in-damaged-cans-dangerous. It read in pertinent part, Never use food from cans that are leaking, bulging, or badly dented, cracked jars or jars with loose or bulging lids, canned food with a foul odor or any container that spurts liquid when opening. Such cans could contain clostridium botulinum. A deep dent is one that you can lay your finger into. Deep dents often have sharp points. A sharp dent on either the top or side seam can damage the seam and allow bacteria to enter the can. Discard any can with a deep dent on any seam. While extremely rare, a toxin produced by it is the worst danger in canned goods. Don't taste such foods. Even a minuscule amount of botulinum toxin can be deadly. Recommended storage times are as follows: two to five years for low-acid foods (such as meat, poultry, fish, and vegetables; 12-18 months for high-acid foods (such as juices, fruit, pickles, tomato soup, and sauerkraut). B. Observations On 6/2/24 at 3:30 p.m., during the initial kitchen tour, one dented can of crushed pineapple and two dented cans of fancy shredded sauerkraut were observed on the canned food rack in the pantry. On 6/4/24 at 4:20 p.m. there was one dented crushed orange can observed on the canned food rack in the pantry. C. Staff interview The DM was interviewed on 6/5/24 at 11:30 am. She said she had previously removed the dented food cans from the rack but they somehow got put back on the food rack. The DM said staff were educated and were aware not to place dented food cans on the rack to be used. The DM said she had removed the dented can and would offer education to the kitchen staff immediately to avoid staff using any dented food cans. VI. Additional interviews The regional registered dietitian (RRD) was interviewed on 6/5/24 at 11:35 a.m. The RRD said dented food cans could allow bacteria growth which could be detrimental to the health of the residents. The RRD said kitchen utensils should be air dried according to facility policy and staff should avoid the use of paper towels to dry plates and silverware. She said drying utensils with paper towels could cause cross contamination leading to illnesses. The RRD said all opened beverages should be dated and labeled when opened. The NHA was interviewed on 6/5/24 at 11:50 a.m. The NHA said she had initiated training for the DM to complete and would ensure that all kitchen staff were appropriately retrained immediately to maintain proper refrigerator temperatures, air dry eating and cooking utensils and to ensure all opened items in the unit's refrigerators were dated and labeled. She said all dented food cans would be separated and returned to the vendor for credit or replacement.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interviews and resident record review, the facility failed to designate a resident representative to advocate for the resident and ensure advance directives matched the resident's current needs and wishes for one (#83) of three residents reviewed out of 52 sample residents. Specifically, the resident was not provided an opportunity to have interested parties attend care plan conferences, and be involved in advanced directives as the resident's health and ability to participate had declined. Findings include: I. Facility policy and procedure The Surrogate Decision Making policy, undated, provided by the nursing home administrator (NHA) on [DATE], revealed in pertinent part: An appropriate surrogate is designated to make decisions on behalf of a resident who is incapable of making decisions for self. -Surrogate decision making because of resident mental incompetence to make personal health care decisions must be supported by court approval or by the observed fact that resident is unresponsible (sic) to any kind of communication. II. Resident #83 status Resident #83, admitted on [DATE], was most recently readmitted on [DATE]. According to the February 2020 medication administration record (MAR), diagnoses included unspecified dementia without behavioral disturbance, tuberculosis of other urinary organs, anorexia, and idiopathic orofacial dystonia. According to the resident's face sheet, he was his own responsible party. The [DATE] minimum data set (MDS) assessment revealed a brief interview for mental status (BIMS) score of zero out of 15, indicating severe cognitive impairment. Numerous attempts were made during the survey to interact and discuss advanced directive concerns with the resident. None were successful. III. Record review A social service note on [DATE] documented that the social service director (SSD) had asked the medical director if he would evaluate the resident and document the resident's ability, or lack thereof, to make decisions for himself. This would aid in the search to find someone who could act as a healthcare proxy. A [DATE] progress note from the medical director documented he was asked to see the resident regarding his need for a patient advocate. The resident appeared immobile for the most part with only minimal movement of his head. He opened his eyes and tried to speak but his speech was very quiet and unintelligible. He made some head movements, but did not give clear or consistent responses to simple questions. He was not able to effectively communicate or make his wishes known and needed a patient advocate to make healthcare decisions. On [DATE] at 4:05 p.m. the resident's paper medical record was observed in a binder, with a bright green full code sticker placed on the spine for easy viewing. In the first pages of the resident's hard chart, a purple paper in a plastic protector read, I am a code I, full code. a) Cardiopulmonary resuscitation (CPR); b) artificial life support such as intubation with mechanical ventilation, tube feedings; c) I understand that this facility does not do intubation with mechanical ventilation therefore, CPR will be initiated and performed, 911 will be called and I will be transported to the nearest hospital in the event that this is necessary. The Colorado medical orders for scope of treatment (MOST) additional review signature page was in the resident's hard chart. The original form initiated by patient or responsible party on date was blank. The form was documented as reviewed on [DATE] and [DATE] and signed off by the social service assistant (SSA). No change was checked. There was no first page of the MOST form, and no original green MOST form. There was no additional paperwork identifying a medical proxy or a doctor's signature. The paper read, Attach this form to the current MOST form. An advance directive form, dated [DATE], was signed by the resident, and documented code 1: full code. An [DATE] hospital note documented that the resident was not cognitively able to understand his medical conditions/complications/prognosis and was not capable of making his own medical decisions. This patient would benefit from a medical proxy decision maker. An annual history and physical completed on [DATE] documented the resident was not able to make appropriate decisions on his own behalf. He had no power of attorney (POA). The resident was not very verbal at this point and interventions were starting to be made to find a representative to assist with decisions on care. IV. Staff interviews Certified medication tech (CMA) #2 was interviewed on [DATE] at 4:15 p.m. He said Resident #83's condition had been steady. He said that sometimes you could get the resident to communicate with very small engagement, but it was not very often. CMA #2 said he did not feel that the resident was currently capable of managing his own care needs. He said that the resident did not have a POA or proxy to help with decision making, but had heard that it was something that had been discussed, without resolution that he was aware of. He did not know what advanced directives were appropriate for the resident, but stated that the resident was fragile. The medical director (MD) was interviewed on [DATE] at 10:25 a.m. The MD said that he was not the resident's primary physician, but was aware that the resident's physician had been discussing the resident's advance directives. The MD said that he did not believe the resident's primary physician could be the medical proxy and also his physician. The MD said he agreed that the resident needed to be followed up on to ensure that there was resolution for getting the resident representation. He said he did not know if they should get other agencies involved or not. The MD said he would also be willing to step up, to be the resident's proxy, so the resident could continue to have the same physician. The social service director (SSD) was interviewed on [DATE] at 10:33 a.m. She said that the minimum data set (MDS) coordinator sends out the invitations for care conferences to the interested parties. She said the MDS coordinator would invite the resident verbally. If the family comes to the meeting, they will bring the resident as well. They send out summaries to the interested parties, after the meeting is done. If the resident did not attend, the MDS coordinator would go and verbally discuss the outcome of the meeting to them. The MDS coordinator was interviewed on [DATE] at 2:30 p.m. She said that she sent out invitations for quarterly and change of condition care conferences. She said that anytime there was a power of attorney, medical proxy, interested party, or engaged family member, she sent them an invitation as well. She said she would also verbalize a reminder to the resident. She said she sent a letter to Resident #83 because he did not have anyone else to represent him. She said that the resident had been declining gradually. She said he did not attend his meetings. Instead, she said the care conference for Resident #83 was a staff meeting to go over his needs. She said she did not know if he was able to make care decisions for himself, and that he was difficult to communicate with. The social service assistant (SSA) was interviewed on [DATE] at 2:52 p.m. She said that you had to catch Resident #83 on a good day to review his advance directives with him. She said you could ask him yes or no questions. She said they had an advanced directive in his record that documented he had shaken his head yes to continue CPR. The SSA also provided an advanced directive form, which had been signed in 2011 by the resident, to provide CPR. This form was also signed by a physician that no longer treated the resident. The SSA said that she had signed the resident's more current MOST form, but the resident had not signed it. The most current MOST form also did not include advanced directive choices, a physician signature, or the signature of the resident or interested party. The SSA said that the resident's current physical state could possibly make CPR a questionable choice. She said the Ombudsman had never been invited to participate in the resident's care conferences. She said the resident's physician at the facility wanted to look into getting the resident a medical proxy, but did not know if that had been followed up on. The SSD was interviewed on [DATE] at 4:15 p.m. The SSD said that Resident #83 could communicate, that it was very difficult, was usually a yes or no response, and had to take place at the right time of day. The SSD said the last advanced directive the resident had signed was in 2011. She said the resident did not have a more current MOST form. The SSD said the facility had discussed getting the resident a healthcare proxy, and that the resident's physician was willing to step up and take on the responsibility for saying yes or no about his care, in regards to going to the hospital or not. The SSD said the physician was aware, and agreed with two other physicians at the facility that the resident was not able to make his own medical decisions, and a proxy was needed. When the SSD was asked where the facility was in regard to pursuing a proxy or guardian, the SSD said she still needed to figure out what paperwork was involved and needed to be completed. The SSD was unable to provide any documentation indicating the process had been implemented.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interviews, the facility failed to ensure one (#94) of one out of a total of 52 sampled residents who entered the facility with limited mobility and range of motion received appropriate services and assistance to maintain or improve mobility with the maximum practicable independence unless a reduction in mobility was demonstrated as unavoidable, out of 52 sample residents. Resident #94, who required supervision with ambulation in his room and on the corridor had a decline in his mobility which showed he no longer ambulated in the corridor and required limited assistance in his room. He had an avoidable decline in his walking ability after staff failed to assess for interventions. The staff failed to update the care plan with interventions and to initiate recommendations for walking with the resident. As a result of the facility's failures Resident #94 went from walking with supervision in the corridor to limited assistance and now to the activity not occuring. Findings include: I. Resident #94's status Resident #94, age [AGE], was admitted on [DATE]. According to the February 2020 computerized physician orders (CPO), the diagnoses included fall risk and mobility impairment. The 10/7/19 minimum data set (MDS) indicated that the residents functional status scores were higher than the scores taken on 1/6/2020. The 10/7/19 MDS scored walking in his room and in the corridor at a one which meant that the resident only required supervision and cuing for this task.The walking on the unit was limited assistance at a two. His gait was not steady but he could stabilize himself without assistance. He could also move from seated to standing without assistance. The 1/6/2020 MDS assessment revealed the resident was cognitively impaired with a brief interview for mental status score of 11 out of 15. He experienced delusions without behaviors and had a history of falls. The resident resided on the secured unit. The resident was able to walk in his room with one person physical assistance. The resident was not able to walk in the corridor of the unit. He was not able to go from a seated to a standing position without assistance with a score of two. The functional status scores were for walking in his room, the resident needed limited assistance and a score of two. The activity of walking in the corridor did not occur.The resident's walking on the unit required one person assistance with total dependence and a score of two. His gait was not steady and he was not able to stabilize himself without assistance. He was not able to go from a seated to a standing position without assistance with a score of two. A. Observations Observations throughout the survey showed the resident was not encouraged to ambulate, when he was restless the intervention to walk was not utilized. He was not provided any explanation as to the reason he had to sit back down in his wheelchair when he attempted to stand up. 1. On 1/28/2020 --At 2:24 p.m., Resident #94 stood up very fast from his wheelchair, tightened up his oxygen tubing and the medical records director (MRD) helped the resident sit down by placing her hand on his left shoulder. --At 2:34 p.m., Resident #94 stood up from his wheelchair and laid on the floor in front of his chair. He was assisted to the floor by the medical records director (MRD). She then put a pillow under his head. --At 3:00 p.m., the resident was still lying on the floor. --At 3:09 p.m., Resident # 94 was helped up from the floor by MRD and certified nurse aide CNA #2 and assisted him to sit back in his wheelchair. --At 4:15 p.m. the resident was sitting in his wheelchair in the living room. --At 4:17 p.m., the resident tried to stand up from his wheelchair. CNA#2 touched the resident on the arm and told him to sit back down. 2. On 1/29/2020 --At 8:31 a.m., Resident #94 was sitting in his wheelchair in the living room. --At 8:43 a.m., the resident tried to stand up from his wheelchair. The activity assistant (AA) touched the resident's left arm and told him to sit back down. --At 8:44 a.m., the resident was observed to stand up from his wheelchair and CNA#2 put her hand on the resident's shoulder and asked him to sit back down. --At 8:45 a.m., CNA#2 assisted the resident to his room. --At 8:57 a.m., the resident was observed lying in bed. --At 10:45 a.m., the resident was assisted out of bed. He was assisted to the common area of the unit. --At 10:46 a.m., the resident stood up from his wheelchair. The LPN called him by name and told him to sit down. --At 10:52 a.m., the resident told LPN#3 that he needed to go to the restroom and the LPN asked him if he could wait to which he replied no. The LPN assisted him to the restroom. --At 4:14 p.m., the resident attempted to stand while he was sitting in the wheelchair. The AA sat him back down by placing her hand on his right shoulder. --At 6:12 p.m. The resident was observed sitting behind the sofa in the living room after dinner with his feet tucked under the sofa and the brakes were engaged on his wheelchair. He was not able to move. B. Record review The care plan dated 1/10/2020 identified Resident #94 had mobility impairment. He was at risk for falls due to psychotropic medications and had a history of falls. A care plan goal was the resident would maintain ambulation and transfer skills. Interventions used to minimize falls were ambulation with set up and supervision. He would sometimes walk behind his wheelchair or self propel if he was weak or tired. The care plan directed staff to offer to walk him in the hallway with a restorative CNA when he was restless. The interdisciplinary team (IDT) notes dated 12/6/19 at 5:07 p.m. indicated that the resident received neuromuscular education from the occupational therapist for coordination, posture and balance related to sitting and standing. There were no notes listed for physical therapy during the month of December 2019 or for the month of January 2020. C. Change of condition The resident experienced a change of condition in his ambulation ability within the past 12 months. The MDS changes were as follows: 1/1/19 quarterly assessment documented the resident required supervision oversight with walking on the corridor, between locations in his room, and in his room. 4/2/19 quarterly assessment documented the resident required supervision oversight with walking in room. Although he declined to limited assistance with walking in the corridor on the unit. 7/2/19 change of condition documented the resident required supervision oversight with walking in room. He needed limited assistance with walking in the corridor on the unit. 7/8/19 change of condition documented the resident required supervision oversight with walking in room. He needed limited assistance with walking in the corridor on the unit. 10/7/19 quarterly assessment documented the resident required supervision oversight with walking on the corridor, between locations in his room, and in his room. 1/6/2020 quarterly assessment documented, the resident had a decline in walking in his room and was assessed at limited assistance required with the physical help of one person. The resident was coded as activity of walking in the corridor did not occur during the look back period. The resident did not have any impairment in range of motion for either upper or lower extremities. D. Failure to assess and promote interventions The complete list of residents who received restorative services as of 2/3/2020 was provided by the director of nurses (DON). The list contains all residents who had ambulation services, however, Resident #94 was not on the list. The medical records failed to show evidence the resident was on an ambulation program. The medical record also failed to show he was referred to physical therapy. E. Staff interviews LPN #3 was interviewed on 02/04/20 at 10:08 a.m. She said that resident #94 was basically blind and needed everything done for him. He was able to stand and walk but he was unsteady on his feet and needed assistance. He had no walker. She said that the resident could make his needs known and sometimes ended up on the floor. She said she had been working with him for two years and the resident had no mental changes. She said the resident had poor balance. She stated that the resident had been on hospice care for a year. The director of nursing (DON) was interviewed on 2/4/2020 at 11:20 a.m.She stated the resident could benefit from a restorative program and a walking program.She did not know if the resident was on a walking program at this time. Nurse aide (NA) #2 was interviewed on 2/4/2020 at 1:00 p.m. NA#2 said Resident # 94 required two person assistance with bathroom, showers and dressing.She said the resident could walk a short distance with the assistance of one. She said the resident was always trying to stand up from his wheelchair and staff had made him sit down to prevent falling.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews, and record review the facility failed to ensure residents were free from accidents for two of one residents (#61) out three out of 52 total sampled residents. Specifically the facility failed to ensure: -Resident #61 received appropriate assessments, interventions, and post-fall reviews to ensure further falls were prevented. (Cross-reference to F695). Findings include: I. Facility policy and procedure The Accident/Incident Report policy, undated, provided by the nursing home administrator (NHA) on 2/4/2020, revealed in pertinent part: An accident is defined as any happening, not consistent with the routine operation of the long-term care facility. -All residents who fall or are found on the floor must have their vital signs taken as soon as possible. -Update resident care plan. II. Resident #61 Resident #61 was admitted to the facility 3/9/11, and readmitted on [DATE]. According to the February 2020 medication administration record (MAR), diagnoses include schizoaffective disorder bipolar type, history of falling, chronic kidney disease stage 3, folate deficiency anemia, and low back pain. The 12/30/19 quarterly minimum data set (MDS) revealed a brief interview for mental status (BIMS) score of 9 out of 15, indicating moderate cognitive impairment. The resident had behavior present, fluctuating, of inattention and disorganized thinking. The resident had no falls during the last assessment period. The resident was not steady, but able to stabilize without human assistance when walking. A. Resident Observation and Interviews 1/27/2020 Resident #61 was observed in his bed on 1/27/2020 at 9:39 a.m., facing the wall. The resident's room oxygen concentrator was observed to be on, with the nasal cannula and tubing laying on the other side of the room. A staff member was asked to come and check on the resident. Certified nurse aide with medication authority (CNA-Med #2) came down to check on the resident. He stated that the resident was currently on neurological checks from a recent fall. He said the resident often took off his oxygen when he gets up to go to the bathroom, and forgets to put it back on. The CNA-Med #2 picked up the nasal cannula from the ground, and placed it onto the resident's nose. He went to get the oximeter, which the CNA-Med #2 stated the resident was due for. The CNA-Med #2 returned to the resident's room at 9:43 a.m., and put on the oximeter. The nasal cannula was still in place. The oximeter read 85%. CNA-Med #2 said he was going to go call the nurse. He said that the nurse was on the unit upstairs. At 9:48 a.m. the CNA-Med #2 returned from calling for the nurse, and said that the nurse told him to put the resident's oxygen on 3 liters per minute (LPM), and they were going to come and check on him. At 9:50 a.m. the resident's oxygen saturation was at 85-85%, on 3 LPM. Registered nurse (RN #1) entered the resident's room at 9:50 a.m. The RN asked about the resident's temperature, which was within normal limits. The resident responded to the RN and stated no concerns. The RN asked the CNA-Med #2 to check the oxygen concentrator to make sure it was functioning properly. The resident's oxygen saturation level rose to 90%. The RN said the concentrator could potentially be failing. The nursing staff stayed within the resident until he was stable at 92%. RN #1 provided an update at 10:49 a.m. that they had let the doctor know, and that they had changed out the resident's room oxygen concentrator. He said the resident was now in the mid-90's and stable. The CNA-Med #2 said that if there was no nurse on the unit, it is the responsibility of the next senior level staff member to monitor the neurological checks. He said that the resident had fallen without injury, and was still within his first 24 hour of checks, and was currently being monitored at 4 hour intervals. B. Resident Observations and Interviews on 1/29/2020 On 1/29/2020 at 2:45 p.m., the resident was observed on the secured unit sitting in his wheelchair. He had no shoes on, but did have black socks on. The resident was observed standing up 3 times to drink at the water fountain unsupervised. The resident's socks were not non-skid. The secured unit housekeeper (ENV) was asked by the nurse to see if the resident had any non-skid socks available. The ENV went to the resident's furniture closet, and opened the sock drawer. It was full, but contained no non-skid socks. She said she did not see any available. The ENV said that she regularly worked the secured unit, but unless facility staff has told her about a fall, she does not know. She said she was unaware the resident had fallen recently. She said she did not know about fall interventions unless the information was shared with her. She said the information would be helpful to know, since she spent a lot of time with the residents, too. C. Record review A care plan initiated on 6/28/19 without noted revision, documented the resident had mobility impairment. The resident was at risk for falls due to unsteady shuffling gait and walking too fast. Interventions included to give resident verbal reminders not to ambulate or transfer without assistance. Therapy to evaluate and treat. Also, to ensure that the resident had and wore properly-fitting non-skid soled shoes for ambulation. The last fall identified on the care plan was 4/10/19. A 7/27/19 physician order documented the resident to receive oxygen via nasal cannula at 2 LPM, to check O2 saturation levels of 90% or greater. The nurse may titrate oxygen by increasing at 1LPM to achieve/maintain saturation level of 90% and notify the physician. An occupational therapy (OT) progress note on 10/1/19 documented that the resident was a fall risk. Precautions included oxygen at 2 LPM via nasal cannula for saturation to remain above 90%. Contraindications include oxygen saturation lower than 90%. The assessed need for oxygen monitoring to prevent falls was not identified on the care plan, as an intervention. The precaution to prevent falls documented to maintain the resident's oxygen saturation level above 90%, however, the physician order states to keep the level at 90% or greater. A monthly 10/20/19 Fall Assessment was completed, with a score of 11. The assessment documented that a score above 10 the resident was deemed a high risk for falls, and the resident should be monitored closely for fall precautions. A physical therapy (PT) progress note on 11/7/19 also documented that the resident was a fall risk, and precautions included oxygen at 2 LPM via nasal cannula for saturation to remain above 90%. The assessed need for oxygen monitoring to prevent falls was not identified on the care plan, as an intervention. The precaution to prevent falls documented to maintain the resident's oxygen saturation level above 90%, however, the physician order states to keep the level at 90% or greater. A Morse Fall Risk Assessment on 1/20/2020 assessed the resident as a low fall risk, but noted the resident had a history of falling, had a weak gait, and was oriented to his own ability. The assessment documented to implement standard fall prevention interventions. The 1/26/2020 post-fall nurse note, documented at 8:19 a.m., said that the resident was observed attempting to climb into his chair (wheelchair) from the back in the hallway. The chair tipped and the resident landed on the floor and hit his head. The resident jumped back up on his own. By the time the RN and LPN arrived, the resident was in the dining room eating breakfast. Vitals were stable, and pupils were reactive to light. The resident denied pain. The physician and family were notified, and the neuros were started. Fall investigation on 1/26/2020 at 8:00 a.m. documented that staff saw the resident roll over the left side of his wheelchair, falling to the floor hitting his head. As staff ran to assist, the resident stood back up and was ambulating in the hallway. Staff assisted him to his wheelchair upon reaching him. Orders were received to send him to the hospital for evaluation and treatment. The resident would be screened for PT and OT upon return. The resident was noted often for standing up from his wheelchair, and being reminded to sit. The resident's room was moved closer to the dining room to enable a shorter distance to an area he frequented. Nurse note on 1/26/2020 at 12:16 p.m. stated that the hospital called to report that the resident's CT (computed tomography) was negative, and vital signs were all stable. On 1/27/2020 at 8:00 a.m., the resident's oxygen saturation level was noted as 90% on 2 LPM. The neurological observation record had no date on it, identifying which fall it was utilized for. The form stated to assess every 15 minutes for the first 4 hours, every 30 minutes for 2 hours, every hour for 6 hours, every 4 hours for 16 hours, and every shift for 4 shifts. The form was started at 8:45 p.m. (without the date). The resident's readmission time from the hospital was not noted. The form was signed by an RN and 2 licensed practical nurses (LPN). A 1/28/2020 therapy screening form documented that the resident's prior level of functioning was moderate independence, unsafe, and refuses help. Physical therapy (PT) and occupational therapy (OT) both noted no change of condition, and no evaluation indicated. A Morse Fall Risk Assessment on 2/4/2020 documented the resident as a high fall risk, noting a history of falls, and that the resident forgets his limitations. The assessment stated to implement high risk fall prevention interventions. No new interventions were noted in the care plan. D. Staff interviews Licensed practical nurse (LPN #3) was interviewed on 1/29/2020 at 3:10 p.m. LPN #3 said Resident #61 had fallen a few days ago. She said he liked to stand up, and a fall risk. She was informed that the ENV was unable to find non-skid socks for the resident. She said that perhaps the ENV was looking in the wrong location for his socks. She asked certified nursing aide (CNA #2) and nurse aide (NA #2) to see if they could find some. CNA #2 and NA #2 went and checked the resident's belongings, but were also not able to find any non-skid socks. The staff members said that the resident sometimes liked to take his shoes off, and they could go missing for multiple days. The staff said they would go find some appropriate socks for Resident #61. Neither the CNA nor the NA were aware of any specific fall precautions for the resident. LPN #3 was interviewed a second time on 1/29/2020 at 3:16 p.m. LPN #3 said that when a resident had a fall, there was a meeting to review interventions. The MDS coordinator would then update the resident's care plan. She said that the CNAs learned about the current interventions by reviewing the hard (medical) record for any updates to the care plans themselves. She said that there was no 24 hour report, or communication form, shared with floor staff regarding falls or interventions. The MDS coordinator was interviewed on 2/4/2020 at 10:35 a.m. She said that she and the restorative staff review the care plans for an activity of daily living (ADL) needs during the quarterly and yearly care conferences. She said that they also kept track of any change of conditions in ADL need, and update as needed. She said they update the care plans that were posted in the resident bathroom, and should always be up to date and accurate. A certified occupational therapy assistant (COTA) was interviewed on 2/4/2020 at 12:24 p.m. The COTA said that they had a request to do a screen for positioning and after falls. She said that the process was to do a screening after every incident. She said therapy received a copy of the incident report, or a certified nursing aide (CNA) communication form, which would be placed in the Therapy room. She said staff was pretty good about letting them know about falls, but a little slower on requesting positioning or screenings. She said after a fall incident report, they would do the screening immediately. Therapy tried to get the CNAs to walk them through what they do to help residents with transferring, safety, and positioning. She said if the resident did not need treatment, they would only do the screen. They keep trying to find new ideas for fall prevention. She said that some of the incident investigations that they are given, to use as a fall intervention guide, were very vague, and did not necessarily tell them in any specific details what had occurred. This often prevented therapy from offering more interventions that would cater to the individual need. She said that for the recent fall for Resident #61, the therapy department received the screening request and the incident report. They did not receive additional documentation about the incident. She said that occasionally a nurse would give them a little extra information, but usually not. She said Resident #61 was not picked up for therapy after his last fall due to non-compliance. She said residents were often kept in the common television area to be within eyesight. She said at a lot of facilities, all residents wore non-skid socks for fall prevention. She did not know how the facility was determining other interventions, or how they were ensuring floor staff was educated. CNA-Med #2 was interviewed on 2/4/2020 at 4:15 p.m. He said that after a resident has had a therapy screening, the information from therapy should go into the resident record. But it often did not. He said that information coming from therapy after a screening, was usually done verbally with staff. He said that staff would need to pass that information on to their colleagues. The director of nursing (DON) was interviewed on 2/5/2020 at 11:19 a.m. She said all of the staff know that Resident #61 takes his oxygen off. She said the staff is told to make sure his oxygen is in use properly, and if not, she expects the staff to put his oxygen back on. The DON said if the resident's oxygen saturation level is down, they must call the nurse. She said they have standing orders for below 90% to titrate up. She said all staff knows the resident's oxygen needs because they are on the physician order and care plans. The DON said after a resident fell, the staff who found the residnet on the floor notified the licensed nurse. She said that the nurse would then assess the resident. The DON said that if the nurse observed an injury, they would call for an ambulance, to send the resident to the hospital. The DON said if there was an RN, they would assess the resident on the ground, but if there was no RN in the building, the LPN would call an RN or the DON. The LPN would proceed to inform the RN over the phone, what was going on. The DON said that the RN would discuss the issue over the phone with the LPN, and determine if the resident could get up or not. The LPN would tell the RN what the resident looked like, as well as a breakdown of an assessment. The DON said that she would, as the RN on the call, ask the LPN to check the resident vitals, and what their current status was. She said that she had computer access at home, so she could check in on what charting was occurring in the resident's record. She said that if the resident said they had anything unusual going on, such as pain, or leg shortening, then she would tell the LPN to not pick them up, but call the ambulance and leave them there for the responders to move. The DON said falls were discussed in the daily meetings, and weekend falls were pulled from report to discuss on Monday morning. Weekend falls were not discussed over the weekend unless she was in the facility. She said the interdicipliary team reviewed the post-fall, and any other incidents. The DON said that they discuss interventions in the morning meeting, and then re-discuss the effectiveness of them a few days later. If they determine that the interventions were not working, they would look at other ideas. For the falls, they would put in a request for the resident to be screened by therapy, and put the form in therapy's in-box. The DON said the therapy director was in attendance for the morning meetings about 5 days a week. If they cannot come, sometimes another therapy staff member would try to come. If the therapy screen comes back with a recommendation to receive therapy, she would write an order. The DON said falls were tracked and trends evaluated. She said the resident record would indicate when new interventions were added. The DON said Resident #61 was in a wheelchair, and fell forward. She said they sent him to the hospital. They did a PT and OT screen. She said they reminded him to not be standing up from his wheelchair. They moved him next to the dining room because his issue in prior falls was because he was walking to the dining room, which was further away. Now he is closer to the dining room. They do have to redirect him away from his former room, which was where he fell. She said he did not require non-skid socks because he usually wore shoes. She said she tried to keep the same staff on the secured unit every day because they know the residents best.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure appropriate respiratory services were provided for one (#61) of five residents reviewed out of 52 sample residents. Specifically, the facility failed to ensure physician orders were followed and respiratory care was provided per professional standards for Resident #61. Cross-reference to F689, accident hazards Findings include: I. Resident #61 status Resident #61 was admitted on [DATE] and readmitted [DATE]. According to the February 2020 computerized physician orders (CPO), diagnoses included schizoaffective disorder bipolar type, history of falling, chronic kidney disease stage 3, folate deficiency anemia, and low back pain. The 12/30/19 quarterly minimum data set (MDS) assessment revealed the resident had moderate cognitive impairment with a brief interview for mental status (BIMS) score of nine out of 15. The resident had behaviors, present and fluctuating, of inattention and disorganized thinking. The resident was on oxygen. II. Resident observation and interviews 1/27/2020 Resident #61 was observed in his bed on 1/27/2020 at 9:39 a.m., facing the wall. The resident's room oxygen concentrator was on with the nasal cannula and tubing laying on the other side of the room. A certified nurse aide (CNA) was asked to come and check on the resident. Certified nurse aide with medication authority (CNA-Med #2) came down to check on the resident. He stated that the resident was currently on neurological checks from a recent fall. He said the resident often takes his oxygen off when he gets up to go to the bathroom, and forgets to put it back on. The CNA-Med #2 picked up the nasal cannula from the ground, and placed it onto the resident's face and back into his nose. He went to get the oximeter, which the CNA-Med #2 stated the resident was due for. The CNA-Med #2 returned to the resident's room at 9:43 a.m., and put on the oximeter. The nasal cannula was still in place. The oximeter read 85%. CMA #2 said he was going to go call the nurse, who was on the unit upstairs. At 9:48 a.m. the CNA-Med #2 returned from calling for the nurse, and said that the nurse told him to put the resident's oxygen on 3 liters per minute (LPM), and they were going to come and check on him. At 9:50 a.m. the resident's oxygen saturation was at 85% on 3 LPM. Registered nurse (RN #1) entered the resident's room at 9:50 a.m. The RN asked about the resident's temperature, which was within normal limits. The resident responded to the RN and stated no concerns. The RN asked the CMA to check the oxygen concentrator to make sure it was functioning properly. The resident's oxygen saturation level rose to 90%. The RN said the concentrator could potentially be failing. The nursing staff stayed within the resident until he was stable at 92%. RN #1 provided an update at 10:49 a.m. that they had let the doctor know, and that they had changed out the resident's room oxygen concentrator. He said the resident was now in the mid-90's and stable. III. Resident observations and interviews on 2/3/2020 On 2/3/2020 at 11:42 a.m. the resident was observed sitting at the dining table for lunch, without wearing his oxygen. Twelve staff members were observed present in the dining room, without speaking to the resident about his oxygen needs. On 2/3/2020 at 11:47 a.m. the resident's oxygen room concentrator was observed turned on in his room, and set at 2 LPM. The resident's portable oxygen concentrator was observed turned on in his room, and set at 2½ LPM. The resident was in the dining room, not in his room. The resident was interviewed on 2/3/2020 at 11:48 a.m. while not wearing his oxygen, as he walked independently back to his room. He said that he did not want to wear his oxygen, and felt he could get by without it. Staff from medical records (MR) was interviewed on 2/3/2020 at 11:50 a.m. She said she was also a CNA. She was informed of the above observations in Resident #61's room. She went into his room, picked up the nasal cannula from the room concentrator, and placed it on him as he lay in bed. He did not resist. She stated the resident was to be on 2 LPM. The CNA observed the room concentrator was set to 2 LPM and the portable concentrator was set at 2½ LPM. She said she was going to go and check to make sure the resident's physician order was posted correctly. She said all nursing staff can monitor oxygen. She said that generally the CNAs check residents' oxygen every two hours during their rounds. She said the orders are on the care plans, which are posted in the resident bathroom, for easy review. She said the restorative aide makes sure the care plans are up to date. The MR left, and quickly returned, and said that yes, the resident was supposed to be on 2 LPM. IV. Resident observations and interviews on 2/5/2020 On 2/5/2020 at 10:35 a.m. Resident #61 was wheeling himself to the dining area with his oxygen tubing and nasal cannula dragging on the floor behind him. At 10:40 a.m. a maintenance assistant (AMT) picked up his oxygen tubes and asked Resident #61 if he wanted his air back on. When Resident #61 told him no he hung the cannula on Resident #61's wheel chair handle. At 10:45 a.m. Resident # 61 went into another resident's room and lay down on her bed. Certified nurse assistant (CNA) #6 entered the resident's room and talked Resident #61 out of her bed, telling him it was not his bed, and got him into his chair. At 10:49 a.m. Resident #61 was wheeled out of the other resident's room by CNA #6 with his nasal cannula in his nose. The maintenance director (MTD) was interviewed on 2/5/2020 at 10:58 a.m. He said the maintenance staff assisted the secured unit in order to make sure there were no altercations. He said the procedure when residents' nasal cannulas and tubing were on the floor was to notify the nursing staff right away, because they could not go back into the resident's nose because they were dirty. The AMT was interviewed on 2/5/2020 at 11:05 a.m. He said his process when finding a resident's nasal cannula and tubing on the floor was to pick them up and ask the resident if they wanted them back into their nose. He said if the resident did not want them in their nose then he would place them on the wheelchair. The director of nursing (DON) was interviewed on 2/5/2020 at 1:55 p.m. She said the AMT should have told a nursing staff member or CNA to get Resident #61 a new air tube and nasal cannula. V. Record review A care plan initiated on 6/28/19, without noted revision, documented the resident has alteration in breathing pattern: hypoxemia. Interventions included, in pertinent part, to observe for pain, cyanosis, fatigue, signs and symptoms of infection, fever, cough, and abnormal lung sounds. To notify the physician as needed. Also, to assess pulse oximeter as needed for complaints of shortness of breath. To notify the physician as needed. To avoid agitation or situations that cause anxiety for the resident. There was no indication of resident non-compliance with the use of the oxygen. A 7/27/19 physician order documented the resident was to receive oxygen via nasal cannula at 2 LPM, to check O2 saturation levels of 90% or greater. The nurse may titrate oxygen by increasing at 1 LPM to achieve/maintain saturation level of 90% and notify the physician. Review of the December 2019 MAR revealed O2 saturation not documented on 17 of 62 shifts. Review of the February 2020 MAR revealed on 2/1/2020 at 8:00 p.m., the resident was on no oxygen. A nurse note, in pertinent part, on 1/27/2020 at 6:53 p.m., noted the resident observation above. The note documented the resident was found to be at 85% with O2 at two liters. The resident's O2 remained at 85% after being titrated to 3 LPM. The nurse noted that the resident denied pain, and stated he was ok. The nurse auscultated the resident's lungs, and they were clear. The nurse noted that he had the CMA switch the resident to the portable concentrator, and after he did that the O2 went to 93%. VI. Staff interviews The director of nursing (DON) was interviewed on 2/5/2020 at 11:19 a.m. She said all of the staff know Resident #61 takes his oxygen off. She said the staff were told to make sure his oxygen was in use properly, and if not, she expects the staff to put his oxygen back on. The DON said if the resident's oxygen saturation level was down, they must call the nurse. She said they have standing orders for below 90% to titrate up. She said if the resident needed to get a higher or lower LPM, they would call the doctor for the change in his order. She said she would expect the staff to monitor the resident for a while, because they would not want to permanently increase his oxygen LPM if not necessary. The DON said that she would consider monitoring his oxygen saturation levels throughout the shift, and would make the request to increase his oxygen LPM only if needed. She said all staff knew the resident's oxygen needs because they are on the physician order and care plans. The DON also said that if oxygen tubing was found on the floor, she would expect staff to replace it with new tubing. The DON was interviewed again on 2/5/2020 at 6:00 p.m. She said she wanted the CNAs to check the residents' oxygen. She said they should check to make sure the oxygen concentrators are full during their rounds, which are every two hours, and before and after meals. She said the CNAs should also check oxygen supply before a resident leaves the facility for a trip. She said that only the nurses can check the LPM levels and the oxygen saturation levels.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** II. Resident #248 A. Resident status Resident #248, age [AGE], was admitted on [DATE]. According to the February 2020 computerized physician orders (CPO), the diagnoses included dementia with behavioral disturbance and hypertension. The 1/8/2020 minimum data set (MDS) assessment revealed the resident was cognitively impaired with a brief interview for mental status score of 8 out of 15. She required limited assistance with activities of daily living. The resident was prescribed medications for behaviors beginning 1/24/2020. No antipsychotic medications were prescribed before that time. B. Observations Observations throughout the survey showed the resident was excessively sleeping. Observations were as follows: 1/27/2020 --At 10:09 a.m., Resident #248 was asleep on the sofa in the living room. --At 10:22 a.m., the resident was still asleep. --At 10:37 a.m., the activity assistant (AA) woke the resident up to give her some water. She drank the water and went back to sleep. 1/28/2020 --At 8:58 a.m., the resident was not in the living room, her room or the dining room. She was found in room # 13 by certified nurse aide #3 (CNA#3). She was asleep on the bed. The CNA helped the resident to her room #one, and helped her get into bed. 1/29/2020 --At 8:52 a.m., the resident was in her bed asleep. --At 9:49 a.m., the resident was in her bed asleep. --At 10:50 a.m., the resident was asleep in her bed. --At 11:30 a.m., the CNA got the resident up and assisted her to the dining room for lunch. --At 1:30p.m., the resident went to her room from the living room. --At 2:29 p.m.,the resident was asleep in her room.The CNA woke the resident up and assisted her to the living room. --At 2:43 p.m.,the resident fell asleep on the sofa. 1/30/2020 --At 9:17 a.m.,the resident was sitting at a table in the activity room by herself. --At 9:24 a.m.,the resident had put her head down on the table. --At 9:33 a.m.,the resident had fallen asleep at the table. --At 9:47 a.m.,the resident was asleep at the table. C. Record review The January 2020 CPO showed physician orders for Depakote sprinkles 125 mg twice daily with a start date of 1/23/2020 with the associated diagnosis of dementia with behavioral disturbances. The CPO also showed the resident was prescribed 25 mg of Seroquel twice daily with a start date of 1/23/2020 with the associated diagnosis of dementia with behavioral disturbances.The CPO indicated for the Seroquel to be crushed and mixed with applesauce or pudding. The February 2020 CPO indicated an increase in medications for Resident # 248. On 1/29/2020 the Depakote was increased from 125mg twice daily to 250 mg twice daily. Risperdal 1mg tablet twice daily was added on 1/29/2020. The resident continued the Seroquel 25 mg twice daily. Registered nurse #1 (RN#1) said the increase in Depakote was due to an incident in which the resident hit another resident on 1/28/2020. He called the physician and asked for the increase in dose. The medical record failed to show non-pharmacological interventions were tried prior to the start of the antipsychotic medications and also failure to track the hours of sleep. The care plan dated 1/24/2020 communicated the resident resided in the secure unit due to disruptive behaviors and the risk for elopement. She yelled and banged her walker against doors and wandered into other resident's rooms. The care plan goal was to give the resident a structured environment that would support her cognitive impairment. D. Interviews Licensed practical nurse #3 (LPN#3) was interviewed on 2/4/2020 at 12:45 p.m. The LPN said the resident was prescribed Depakote, Seroquel and Risperdal for aggressive behaviors. The LPN said the resident slept a lot in the common area, however, did not know the reason. Registered nurse #1 (RN#1)was interviewed on 2/4/2020 at 12:46 p.m. He said he worked the past weekend on 2/1/2020. He checked on Resident #248 because of the medication change and made sure the resident was not overmedicated. He said the Depakote, Seroquel and Risperdal were prescribed for the residents' aggressive behaviors. The RN contacted the resident's doctor after the incident with her hitting another resident on 1/28/2020. He asked the doctor for an increase in the dose of the Depakote from 250mg a day to 500 mg a day. This change was implemented on 1/29/2020. The Risperdal was added on 1/29/2020. The RN checked the resident on 2/1/2020 and said she was awake.The nurses on the floor said the resident did not look over medicated. The RN said that signs of overmedication included extensive sleeping, slurred speech or unsteady gait. He said that one non pharmacological method used for intervention for the resident was offering her food. He said the resident was awake and alert all day on the day she fell. The RN said that if he saw something with the resident that he reported it and he expected the staff to do the same thing. Based on observation, interview, and record review, the facility failed to ensure for two (#16 and #248) of six residents reviewed for the use of unnecessary medications out of 52 total residents were free from unnecessary drugs. Specifically, the facility failed to: -Ensure gradual dose reduction was attempted for Resident #16; and -Provide non pharmacological interventions for Resident #248 before administering antipsychotic medications. Findings include: I. Resident #16 A. Resident status Resident #16, under [AGE] years old, was admitted on [DATE]. According to the January 2020 computerized physician orders (CPO) diagnoses included mild intellectual disabilities, type 2 diabetes, hemiplegia from cerebral vascular disease. The 11/15/19 minimum data set (MDS) assessment revealed the resident had not cognitive impairment with a brief interview for mental status (BIMS) of 15 out of 15. The resident exhibited no behaviors, and showed no symptoms of depression. The resident was coded as received an antidepressant seven out of seven days. B. Resident interview The resident was interviewed on 2/5/2020 at approximately 11:00 a.m. The resident said she was not lonely and that she attended all the group activities which she chose. She said she enjoyed being around others and had a lot of friends. C. Observations The resident was observed throughout the survey from 1//27/2020 to 2/5/2020 to attend activities daily and was seldom in her room. The resident was pleasant and had a calm affect. D. Record review The January 2020 CPO revealed an order for Zoloft (anti-depressant) 100 mg tablet one time a day with a start date 3/23/18 with the associated diagnosis of major depressive disorder single episode. The January and February 2020 medication administration record (MAR) showed the resident continued to receive the Zoloft 100 mg tablet one time a day. The care plan dated, identified the resident displayed symptoms of depression and expressions of self isolates.The goal was to have the resident have fewer documented episodes of isolation. The goal was to get the resident out of her room and to be with others and Zoloft as ordered. The 11/7/19 activities note documented the resident enjoyed arts crafts reading, bingo, visiting with others, trivia, socials, going on outings, watching TV and music. The note further documented the resident was active in activities of choice. The conclusion of the note was that there were no concerns at this time. The psychoactive quarterly review 11/15/19 showed the resident was on Zoloft 100 mg every day with the associated diagnosis of major depressive disorder. The form showed the resident was on the medication due to self isolation. The note said a risk benefit was completed on 6/6/19 and no recommendations at this time. However, there were not indications that the resident was exhibiting any of the targeted behaviors to justify continuing use of the medication without an attempt to gradually reduce the medication. See interviews below. The risk benefit was completed on 3/23/19 and also on 1/2/2020. However, no record to show a reason for the continued use of the medication on the 1/2/2020. The psychoactive risk benefit statement documented the resident resided at the facility since 6/7/12. The resident had a history of depression and had recently been wanting to visit her son more often and crying while on the phone. Staff monitored adverse side effects and interactions monthly. Psychoactive committee met and reviewed the medication quarterly. Staff monitors adverse/side effects which included but were not limited to dizziness, nausea, diarrhea, anxiety. The risk benefit documented the resident ate in the main dining room and visited with other residents, she liked to attend activities. The note documented the benefit outweighs the risk. The January 2020 medication regimen review (MRR) was completed and it did not have any recommendations to complete a gradual dose reduction. The medical record failed to show evidence that the resident self isolated, or show signs and symptoms of depression. Furthermore, the record failed to show the psychoactive committee had tracked and trended the residents, mood and behavior tracking such as self isolation and signs and symptoms of depression. E. Interviews The social service director (SSD) was interviewed on 2/4/2020 at approximately 1:00 p.m. The SSD said the facility had a psychotropic medication meeting every month. She said the resident was reviewed monthly to discuss the use of the anti-depressant. She said the pharmacist and the director of nurses attends the meetings. She said that was when a risk benefit statement was completed. She said no physician attends the meeting. She reviewed the medical record and stated no gradual dose reduction for the Zoloft had been attempted since the resident was prescribed the medication. She said the resident was social and attended activities. She was unable to show evidence that the resident was self isolating. The activity assistant (AA) #3 was interviewed on 2/4/2020 at 10:12 a.m. The AA said the resident attended all activities which included (store name) outings. He said she was social with all the other residents and that she was pleasant and upbeat. He said she did not self isolate. The activity director (AD) was interviewed on 2/4/2020 at 10:40 a.m. The AD said the resident was very social and that she attended all activities. She said that she interacted with other residents and was involved with the activities. She said that she had not self isolated, and if she was in her room she would be reading. She said she has worked at the facility for three years and she had been active for the past three years. She added the resident was upbeat. The residents primary physician was interviewed on 2/8/2020 at 12:00 p.m. The physician said the facility had a psychotropic drug committee meeting monthly and that each resident was reviewed quarterly. He said he did not participate in the meeting, and he felt it was a good program. He said Resident #16 was on an antidepressant, he said she had not had a gradual dose reduction, however, could possibly benefit from one as he knew she was active in the facility.

Based on record review and staff interview, the facility failed to ensure for three (#25, #82, and #94) of six residents who receive Medicaid benefits were notified out of 52 total sample residents. Specifically, the facility failed to ensure: -Residents/legal representatives were notified when personal funds account reached $200.00 less than resource limit allowed for one person. Findings include: I. Record review The Trial Balance, dated 2/3/2020, revealed three sample Residents (#25, #82 and #94) had a personal needs account (PNA) balance within $200 of the State allowable limit of $2000.00. The medical records for Resident #25, #82 and #94 failed to show any evidence that the family had been contacted and notified of the PNA account was within $200 of the State allowable limit of $2000.00 A. Resident #25 Resident #25 PNA quarterly statements dated 11/1/19 through 1/13/2020 showed an opening balance of $1708.26 and an ending balance of $1963.88. The Resident's account had been within $200 of the State allowable resource limit of $2000.00 for the last two months. The PNA ledger dated 2/3/2020 showed his PNA account balance was $1963.88 on 2/3/2020. The PNA was within $200 of the State allowable limit of $2000.00 B. Resident #82 Resident #82 PNA quarterly statements dated 10/1/19 through 12/31/19 showed an opening balance of $1638.34 and an ending balance of $1854.81. The Resident's account had been within $200 of the State allowable resource limit of $2000.00 for the last month. The PNA ledger dated 2/3/2020 showed his PNA account balance was $1932.86 on 2/3/2020. The PNA was within $200 of the State allowable limit of $2000.00. C. Resident #94 Resident #94 PNA quarterly statements dated 11/1/19 through 1/31/2020 showed an opening balance of $1691.18 and an ending balance of $1949.38. The Resident's account had been within $200 of the State allowable resource limit of $2000.00 for the last two months. The PNA ledger dated 2/3/2020 showed his PNA account balance was $1944.38 on 2/3/2020. The PNA was within $200 of the State allowable limit of $2000.00. III. Interviews The social service director (SSD) was interviewed on 2/5/2020 at approximately 2:00 p.m. The SSD said she assisted families to spend the personal funds account money when it was higher than the $200.00 less than resource limit. However, she said she did not document when she was told and not her interventions. She said she had not been told recently that a resident was above the limit. The administrative assistant (AA) was interviewed on 2/5/2020 at approximately 4:00 p.m. The AA said she handled the PNA. She reviewed the open balance report sheet and confirmed Resident #25, #82 and #94 personal funds accounts reached $200.00 less than the resource limit allowed for one person. She said that she would notify social services and she would also inform the family/resident to spend down the money. Although, she could not show any documentation that social services or family were notified. The AA said she did not document. The nursing home administrator (NHA) was interviewed on 2/5/2020 at approximately 8:00 p.m. The NHA said there were emails with documentation that showed they were aware of the PNA's being above the $200. resource limit. The emails were not provided after the completion of the survey or by 2/14/2020.

Based on record review, staff interview, the facility failed to inform two of three sample residents (#18 and #96) of changes in services covered by Medicare, in a timely and appropriate manner. Specifically, the facility failed to demonstrate that residents who previously received skilled nursing facility services (SNF), funded through Medicare benefits, had received timely and appropriate written notice of discontinuation of benefits and notice of liability. Findings include: I. Resident #18 A. Notice of Medicare Provider Non-Coverage Resident #18 The Notice of Medicare Provider Non-Coverage (NOMPNC) for resident #18 was not delivered in a timely manner. According to the facility, the last covered day (LCD) was 10/3/19. However, the NOMPNC showed the notice was not given timely and was given on 10/7/19 which was six days late. B. Liability Notices According to the documentation provided by the facility on 2/5/2020, the Medicare Part A benefits were terminated for resident #18 on 10/3/19 and the resident continued to reside in the facility after the termination of benefits. The facility did not provide evidence that the resident received notice of her liability for non-covered as the liability which was attached to the NOMPNC was blank with no cost listed. The notice only contained a date and the resident's name. II.Resident #96 A. Notice of Medicare Provider Non-Coverage The Notice of Medicare Provider Non-Coverage (NOMPNC) for resident #96 was not delivered in a timely manner. According to the facility, the last covered day (LCD) was 1/17/2020. However, the NOMPNC showed the notice was not given timely and was given on 1/20/2020 which was five days late. B. Liability Notices According to the documentation provided by the facility on 2/5/2020, the Medicare Part A benefits were terminated for resident #96 on 1/17/2020 and the resident continued to reside in the facility after the termination of benefits. The facility did not provide evidence that the resident received notice of her liability for non-covered as the liability was not provided. III. Interviews The social services director (SSD) was interviewed on 2/5/2020 at 5:00 p.m. The SSD said when a resident's Medicare services for part A were ending, the social service department was responsible to notify two days prior to benefits ending in writing. She said if they can not notify in writing two days prior, then she would notify via phone. However, she would not document in the record that she had made a phone call. She said when the Medicare part A services were ending, then it was necessary to establish another pay source if the resident remained at the facility. The SSD could not explain why the liability forms for Resident #18 and #96 were not filled out.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure five (#1, #78, #26, #77 and #37) of 10 residents reviewed for activities of 20 sample residents had an ongoing activity program based on comprehensive assessments, care plans and resident preferences. Specifically, the facility failed to provide person centered, meaningful activities that met the interests and needs of Residents #1, #78, #26, #77 and #37. Findings include: I. Facility policy and procedure The Activities in Nursing Home policy, dated 6/9/16, was provided by the medical records director on 2/5/2020 at 11:15 a.m. It revealed in pertinent part, Because absence of meaningful and/or enjoyable activity can lead to mental and physical deterioration in residents, the Activities Department will work as a member of the interdisciplinary team to keep resident functioning at the highest level possible in all dimensions of life, physical, mental, social, emotional and spiritual, encourage independence and pre-institutional interest, a sense of community and self esteem . Activities will be offered daily and these activities will be suited to resident needs, abilities and interests . The Activity department will encourage and assist residents in independent activities in such a way as to encourage independence without jeopardizing residents' safety. II. Activity calendar The January 2020 activities calendar revealed on 1/28/2020 at 3:00 p.m. the group activities were beach volleyball bounce in one unit and ring toss in another unit. On 1/29/2020 at 9:30 a.m. there was sit-er-size in the activities room and at 10:30 a.m. was a trip to Walmart. III. Resident #1 Resident #1, age [AGE], was admitted on [DATE]. According to the January 2020 computerized physician orders (CPO), diagnoses included dementia with behavioral disturbance and altered mental status. The 1/17/2020 minimum data set (MDS) assessment revealed the resident was severely cognitively impaired with a brief interview for mental status (BIMS) score of five out of 15. The resident required extensive assistance with a one person physical assist with bed mobility, transfer, locomotion on and off of unit, and personal hygiene. She required limited assistance with a one person physical assist with locomotion on and off of the unit, and eating. She required total assistance with a one person physical assist with toilet use and bathing. A. Record review The care plan dated 1/18/2020 documented Resident #1 had a potential for alteration in activities due to her confusion and dementia. It read she enjoyed reading, cleaning, and being helpful. It read that she enjoyed slow soft music, bingo, and crafts. The goals were to maintain appropriate activity participation. The approaches were to offer verbal praise to reinforce positive social behavior in group activities, assist the resident in selecting appropriate activities, and supervise the resident in all activity areas. B. Observations Resident #1 was observed on 1/28/2020 from 2:20 p.m. until 4:20 p.m. -At 2:21 p.m. Resident #1 was sitting in her wheelchair in the corner of the unit common television area yelling help, help, help, help, then ha, ha, ha, ha. No one responded to her. -At 2:46 p.m. the activities assistant (AA) #2 went into the common television area announcing that a ring toss activity was being held in the chapel. She then approached a resident with little cognitive impairment and asked if she wanted to go. She did not ask anyone else, including Resident #1, if they wanted to go to the activity. -At 2:57 p.m. the social services director (SSD) took Resident #1 to the ring toss activity so she could sit and watch. -At 3:30 p.m. the residents who were in the ring toss activity went back to the common television area with the AA #2. The AA #2 then proceeded with the ring toss activity in the common television area. Resident #1 was not invited to attend. -At 3:36 p.m. Resident #1 was sitting in the corner of the common television area room next to the wall, unengaged with activities, staff or other residents. -At 3:53 p.m. Resident #1 was taken to the dining room, where she was unengaged with activities, staff or other residents, and was not served dinner until 4:20 p.m. Resident #1 was observed on 1/29/2020 from 8:20 a.m. to 12:20 p.m. -At 8:30 a.m. AA #2 was asking trivia questions to the residents who were not cognitively impaired. Resident #1 was not engaged or encouraged to participate in the activity. -At 8:48 a.m. Resident #1's family member brought her into the common television area. -At 8:55 a.m. Resident #1's family member left. -At 9:20 a.m. CNA #9 and registered nurse (RN) #3 assisted Resident #1 to her room to use the toilet. -At 9:31 a.m. RN #3 took Resident #1 back to the common television area and left her in front of the television. -At 9:32 a.m. RN #3 asked Resident #1 is she wanted a snack with no response from the resident, so she brought her a cup of water. -At 9:39 a.m. RN #3 took Resident #1 to her room to lie down for a nap. -At 10:32 a.m. nurse aide (NA) #1 brought Resident #1 out of her room in her wheelchair and took her to the dining room. -At 10:55 a.m. the director of nursing (DON) was assisting Resident #1 with eating. -At 11:18 a.m. NA #1 took Resident #1 out of the dining area and took her back to her unit and into bed for a nap. Resident #1 remained in bed napping until 12:20 p.m. During observations on 1/28/2020 and 1/29/2020 dates, the resident was observed spending most of her time in front of the TV unengaged with others, in bed or in the dining room for meals. The resident was not observed being invited to engage in her favorite activities of reading, cleaning, helping others, listening to slow soft music, bingo, and crafts. C. Staff interview The activities director was interviewed on 2/4/2020 at 4:30 p.m. She said Resident #1 would maintain appropriate activities, and she thought the resident was sufficiently engaged in activities. She said Resident #1 needed verbal praise and assistance with activities. She said Resident #1 needed help to select activities and she needed staff to sit with her during the activity. She said Resident #1 worked at the facility prior to becoming a resident. She said Resident #1 would become supervisory toward staff and residents. She said Resident #1 would scold residents she feels were messing around. She said Resident #1 liked to hold on to newspapers even though she could not read them. She said Resident #1 fed herself and liked hand held foods. IV. Resident #78 Resident #78, age [AGE], was admitted on [DATE]. The January 2020 CPO diagnoses included dementia without behavioral disturbance, cerebrovascular disease, polyosteoarthritis, muscle wasting and atrophy, and history of falling. The 1/12/2020 MDS assessment revealed the resident had severe cognitive impairment with a BIMS score of five out of 15. The resident required total dependence with two person physical assistance for bed mobility, transfer, dressing, toilet use, and bathing. She required total dependence with a one person physical assist with locomotion off the unit and personal hygiene. She required limited assistance with a one person physical assist with locomotion on the unit. She required extensive assistance with eating. A. Record Review The care plan dated 1/14/2020 read that Resident #78 needed verbal reminders of activities before commencement of the activity and to familiarize her with nursing home environment and activity programs on a regular basis. The resident's favorite activities were not listed in her care plan. B. Observations The following observations were made on 1/28/2020 from 2:20 p.m. to 4:20 p.m. -At 2:21 p.m. Resident #78 was sitting in her wheelchair in the common television room watching the television. -At 2:50 p.m. Resident #78 was given a half peeled banana as a snack from the snack cart. -At 3:02 p.m. Resident #78 was having trouble peeling the rest of her banana so she tore the rest of the peel off and dropped them on the ground, almost losing the banana. No staff offered to assist or her stopped to engage her in conversation. -At 3:15 p.m. the activities director (AD) asked Resident #78 if she wanted to go to the ring toss activity. Resident #78 nodded her head yes and the AD took her. -At 3:25 p.m. AA #2 brought Resident #78 back to the common television area and set her in front of the television, unengaged, instead of taking her to the ring toss activity -At 3:45 p.m. Resident #78 was watching television -At 3:51 p.m. Resident #78 was taken to the dining area. -The resident sat at the dining room table unengaged until she was served her meal at 4:20 p.m. The following observations were made on 1/29/2020 from 8:20 a.m. to 12:20 p.m. -At 8:24 a.m. Resident #78 was sitting in the corner of the common television area away from the gathered half circle that staff was using for staging after breakfast. -At 8:50 a.m. CNA #9 woke up Resident #78 which startled her, and asked if she wanted to go to bed. He then took her to her room and RN #3 went to help. -At 8:53 a.m. CNA #9 brought Resident #78 back to the common television area and set her in the hallway not facing the television, but looking at the group that was facing the television. She was far enough away from the group that she could not hear or have any engagement with the group. -At 9:00 a.m. Resident #78 pointed at another resident's snack so AA #2 brought a banana, peeled it half way and gave it to her. -At 9:02 a.m. Resident #78 took a bite of the banana and the top of it broke off and landed on the floor. She then struggled to peel the rest of the banana and was unsuccessful so she used the front of her teeth to scrape as much of the banana as she could. No staff offered to assist her or engage her in conversation. -At 9:03 a.m. AA #2 was walking around the unit asking residents if they wanted to go exercise. She did not ask Resident #78 if she wanted to go exercise -At 9:04 a.m. Resident #78 gave up struggling with the banana and folded the peeled portion over the top of the banana. -At 9:05 a.m. Resident #78 began to try to peel the banana again. She succeeded in peeling the banana, but lost control of it and dropped it on the ground. She then looked at the peel, then dropped it on the ground. No staff offered to assist or engage her. -At 9:11 a.m. Resident #78 began to fall asleep in her chair. -At 9:18 a.m. A housekeeping staff member picked the banana peel up off of the ground without saying a thing to the resident. -At 9:20 a.m. CNA #9 woke Resident #78 up, asked her if she wanted some water, then gave her a cup of water. -At 9:47 a.m. RN #3 woke up Resident #78 and took her to her room to use the toilet and lie down. NA #1 went in as well to assist. -At 9:54 a.m. NA #1 came out of Resident #78's room with her and left her in front of the television. -At 10:12 a.m. Resident #78 fell asleep in her wheelchair. -At 10:20 a.m. Resident #78 was taken to the dining room. -At 10:38 a.m. Resident #78 was brought back from the dining room and left in the common television room. -At 10:43 a.m. Resident #78 was taken back to the dining room. -At 10:55 a.m. The DON was assisting Resident #78 with eating. -At 11:15 a.m. DON took Resident #78 back to her unit and left her in front of the television in the common television area. -At 12:15 p.m. Resident #78 was in the same place the DON left her after lunch with no contact or communication from staff. During observations on 1/28/2020 and 1/29/2020 dates, the resident was observed spending most of her time in front of the TV unengaged with others, in bed or in the dining room for meals. The resident was not observed being invited to engage in her favorite activities, which were not identified in her care plan (above). C. Staff interview The activities director was interviewed on 2/4/2020 at 4:15 p.m. She said Resident #78 would always need assistance. She said Resident #78 liked her space and liked to make her own choices. She said Resident #78 would panic if staff did not talk to her prior to providing care. She said Resident #78 liked snacks. She said Resident #78 had her drinks in a cup with a lid and she needed assistance when eating. She said Resident #78 needed to be assisted to and from activities. She said Resident #78 liked large group activities because the activity was not centered around her. She said during floor activities Resident #78 was very passive and during activities centered around food she was very active. She said Resident #78 could hold her attention to activities for a short time, then took it back because she liked her time. She said the process was to ask Resident #78 if she wanted to go to an activity at the beginning of the day, then would give her reminders of the activity a few times before the activity began. She said when the activity was ready to begin staff should have asked Resident #78 if she wanted to go and she would make the decision on whether or not she wanted to go. The registered nurse (RN) #3 was interviewed on 2/4/2020 at 5:30 p.m. She said Resident #78 was sometimes up for activities and sometimes not. She said Resident #78 needed verbal cues if she was not participating in an activity. She said assistance should have been hand over hand and her participation was half yes and half no. She said Resident #78 needed assistance with dining. She said before staff provided care they needed to state what they were doing such as providing medication, activities of daily living, and so on all the while asking her if it was okay to perform the assistance. She said if Resident #78 did not want to go to an activity it could be because she was thirsty, hungary, or in pain. She said the staff was to ask how she was feeling. She said the nurses were to coordinate with the activities director to ensure activities were being done. V. Resident #26 Resident #26, age [AGE], was admitted on [DATE]. The January 2020 computerized physician order (CPO) diagnosis included lower back pain, chronic pain, generalized osteoarthritis, nutritional deficiency, macular degeneration, spinal stenosis, osteoporosis without pathological fracture. The 12/1/19 minimum data set (MDS) assessment revealed the resident had cognitive impairment with a brief interview for mental status (BIMS) score or 7 out of 15. She required supervision with oversight, encouragement or cueing for locomotion on and off unit and eating. She required limited assistance with one person physical assistance with bed mobility, transfer, and dressing. She required extensive assistance with one person physical assistance with toileting and personal hygiene. A. Record review The care plan dated 12/3/19 read that Resident #26's interests were intellectual groups, parties, special events, crafts, reading and visiting with others. It read that she was independent in activities of her choice and participation. It read to give Resident #26 verbal reminders prior to activities and to encourage and accommodate Resident #41's daily routine activities, including watching television news, listening to the news on the radio, reading newspapers and magazines. B. Observation The following observations were made on 1/28/2020 from 2:20 a.m. to 4:20 p.m. -At 2:56 p.m. Resident #26 was brought to the common television area, where she remained, unengaged with staff or other residents. -At 3:44 p.m. Resident #26 was taken to the dining room, where she remained unengaged until her meal was served at 4:20 p.m. The following observations were made on 1/29/2020 from 8:20 a.m. to 12:20 p.m. -At 8:20 a.m. Resident #26 was in the dining room finishing breakfast. -At 8:35 a.m. Resident #26 was wheeling herself up and down the main hallway. -At 8:39 a.m. Resident #26 wheeled herself to the common television area in her wheelchair behind Resident #78 and bumped her wheelchair wheels into the back wheelchair wheels of Resident #78, then looked around the room to see if any staff was watching. Staff were not observed to notice or respond. -At 8:45 a.m. Resident #26 moved Resident #78 forward using the front of her wheelchair wheels, pushing the back of Resident #78's wheels to settle where she wanted to be. Staff were not observed to notice or offer assistance. -At 8:50 a.m. Resident #26 fell asleep. -At 9:03 a.m. AA#2 woke up Resident #26 and asked if she wanted to go exercise. Resident #26 said no. -At 9:13 a.m. Resident #26 was asleep again in her chair. -At 9:19 a.m. CNA #9 woke up Resident #26 and gave her a cup of water. -At 9:27 a.m. Resident #26 pushed herself backward using her foot and hit the wall with the back of her wheelchair and startled herself. -At 9:33 a.m. CNA #9 took Resident #26 to her room to be toileted. -At 9:41 a.m. Resident #26 came out of her room in her wheelchair and was sitting by her door. -At 9:57 a.m. NA #1 took Resident #26 back to the common television area and left her in the same spot she was in prior to going to her room. -At 10:00 a.m. Resident #26 fell asleep. -At 10:04 a.m. RN #3 and CNA #9 took Resident #26 back to her room. -At 10:06 a.m. RN #3 brought Resident #26 back to the common television area. -At 10:35 a.m. Resident #26 was taken to the dining room for lunch. -At 11:15 a.m. Resident #26 was finished with lunch and wheeled herself back to the common television area. -At 11:22 a.m. Resident #26 was sitting in the same spot as she was in prior to lunch with her spill bib still on. -At 12:20 p.m. Resident #26 was sitting in the same spot in the common television area taking a nap. During observations on 1/28/2020 and 1/29/2020, the resident was observed spending most of her time in front of the TV unengaged with others, in bed or in the dining room for meals. She was not seen in intellectual groups, parties, special events, crafts, reading and visiting with others. C. Staff interview The AD was interviewed on 2/4/2020 at 4:45 p.m. She said Resident #26 was a little like Resident #78. She said Resident #26 had certain spots she liked to be in on the unit. She said Resident #26 would smile then refuse an activity. She said she posted an activities calendar in Resident #26's room . She said Resident #26 loved magazines. She said Resident #26 needed verbal reminders of activities and then should have been asked to attend. She said Resident #26 liked to watch the activities but does not want to participate and she does her own thing. She said Resident #26 loved to sit and observe people and would sometimes go through the activity to retrieve a snack. She said Resident #26 was passive in group activities and is active in individual activities. The RN #3 was interviewed on 2/4/2020 at 5:45 p.m. She said Resident #26 participated in activities about forty percent of the time. She said Resident #26 liked to sit and observe. She said Resident #26 needed verbal cues if she was interested in an activity. She said if a resident was in the spot she wanted to be in within the common television area, that Resident #26 would push the other resident out of her spot with her wheelchair. VI. Resident #77 Resident #77, age [AGE], was admitted on [DATE]. The January 2020 computerized physician orders (CPO) diagnosis included dementia with behavioral disturbance, major depressive disorder, and nutritional deficiencies. The 1/12/2020 minimal data set (MDS) assessment revealed the resident had severe cognitive impairment with a brief interview for mental status (BIMS) score as not ratable. She required total dependence with a one person physical assist with bed mobility, locomotion on and off unit, dressing, eating, toilet use, personal hygiene, and bathing. She required extensive assistance with one person physical assistance with transfer. A. Observations The following observations were made on 1/28/2020 from 2:20 a.m. to 4:20 p.m. Resident #77 stayed in bed during this observation until 3:50 p.m. when NA #1 assisted her into her wheelchair to be taken to the dining room for dinner. The following observations were made on 1/29/2020 from 8:20 a.m. to 4:20 p.m. -At 8:20 a.m. Resident #77 was in the dining room finishing lunch. -At 8:30 a.m. Resident #77 was taken from the dining room to the common television area. -At 8:36 a.m. CNA #9 took Resident #77 to her room to lay her down for a nap. -At 10:46 a.m. NA #1 took Resident #77 to the common television area, then to the dining room for lunch. -At 11:15 a.m. NA #1 took Resident #77 to her room to lay her down for a nap. -At 12:20 a.m. Resident #77 was in her room taking a nap. During observations on 1/28/2020 and 1/29/2020 dates, the resident was observed spending most of her time in front of the TV unengaged with others, in bed or in the dining room for meals. B. Staff interviews The NA was interviewed on 1/29/2020 at 10:48 a.m. He said he got Resident #77 out of bed and in her chair so she could go to the dining room for lunch. The AD was interviewed on 2/4/2020 at 5:00 p.m. She said Resident #77 was able to hold a conversation when she was in her room. She said Resident #77 came back to the facility from the hospital and did not want to participate in the facilities activities from that moment on. She said Resident #77 would participate but got overwhelmed in the large group activities and was encouraged to take rest breaks, but did well in smaller activities. She said Resident #77 showed frustration by the expressions on her face. She said Resident #77 attended floor activities on a regular basis. She said Resident #77 was very private and did not trust people so staff needed to not be pushy with her. The RN #3 interviewed on 2/4/2020 at 5:50 p.m. She said Resident #77 did not participate in activities very often because she did not want to. She said If Resident #77 would have participated then staff would have needed to assist her by giving her verbal cues and using hand over hand assistance. The AD was interviewed on 2/5/2020 at 11:00 a.m. She said she was not certified but she worked under the regional AD manager. She said she had been the activities director for the last three years. The DON was interviewed on 2/05/2020 at 12:45 p.m. The said staff members took dementia training two times a year. She said one of the training sessions was hand in hand videos. She said activities were part of the dementia training for all the straff. She said the nursing staff watched more videos. She said some of the other dementia training sessions were communication with the residents, different stages of dementia, and different types of lifestyles, anticipation of their needs, and being in their world. She said there was no written form for individualized resident care. She said she tried to keep staff in the same area so they know the residents. She said staff got cross trained in case someone called off. The AD was interviewed on 2/5/2020 at 3:45 p.m. She said her process was to come up with the activities calendar using a criteria cheat sheet. She said the criteria should have included exercising and stimulation. She said she got the residents input of what activities they wanted to participate in at the resident council meetings and whenever a resident came to her. She said she built the activities calendar and sent it to the regional AD manager for approval. She said if the regional AD manager did not approve the calendar that she would send it back to the AD with the date and time of what needed to be changed or fixed, then the two of them would discuss the changes. She said she could reach the regional AD manager through the phone or email at any time. The AD said she did not realize her assistants were not providing activities to certain residents. She said she was relying on them for help with activities. She said she was going to educate her assistants in providing activity participation to all of the residents. VII. Resident #37 Resident #37, age [AGE], was admitted on [DATE]. According to the January 2020 computerized physician orders (CPO), diagnoses included unspecified dementia with behavioral disturbance and anxiety disorder. The 12/4/19 MDS assessment revealed the resident had severe cognitive impairment with a brief interview of mental status (BIMS) score of zero out of 15. He required limited assistance with bed mobility and transfers. A. Observations On 1/29/2020 from 8:51 a.m. to 10:15 a.m., the resident was observed walking around on the unit, walked into another resident's room and walked out. On 1/29/20 at 2:06 p.m., the resident was observed walking around in the activity room. No staff was present and no activity was going on. However, according to the activity calendar, arts and crafts should have started at 2:00 p.m., but it was not happening as scheduled. On 1/30/2020 from 8:41a.m. to 10:00 a.m., the resident was walking up and down the halls on the unit. On 2/3/2020 at 3:00 p.m., the resident was walking in the common area and later walked up and down the hall. On 2/4/2020 from 10:25 a.m. to 11:00 a.m., the resident was observed walking up and down the halls. He was observed to stop and bend over to reach to the floor but then he continued walking. During these observations, Resident #37 was not offered or encouraged to participate in activities. B. Record review 1. Care plan The care plan, initiated on 8/18/19, identified the resident as a private man who preferred independent activities. The resident had a potential for alteration in activities due to his confusion and short attention span. It also identified the resident enjoyed visiting and reminiscing, going for walks indoors and outdoors, listening to the radio, and looking at books and magazines. It further identified the resident would observe and be passive during activities on Cokedale (the secure unit). It documented the resident needed encouragement and redirection. Some interventions included to remind the resident of activity before commencement of the activity, document resident response to interventions, post activity calendar in the resident's room, engage the resident in group activities and provide cues to assist the resident with improving his orientation. The care plan failed to include strategies to engage the resident in preferred individualized and group activities or encourage independent activities. 2. Activity assessment A significant change activity assessment was done on 9/4/19. It documented the assessment was completed by staff. The assessment documented snacks between meals. The activity note, written by the activity director (AD) on 9/5/19, documented the resident was up for a significant change review. It documented the resident enjoyed walking around for exercise, snacks and visits from family and staff. It documented the resident needed reminders of activities and times, and to be offered all activities and assistance. It documented there were no concerns at the time. 3. Activity participation record The activity participation record for January 2020 documented the resident participated in four different activities on the following days: 1/29/2020 and 1/30/2020. However during observations on those days, the resident was not invited or encouraged to participate in activities. The activity participation record for February 2020 documented the resident participated in four different activities on the following days: 2/3/2020 and 2/4/2020. However during observations on those days, the resident was not invited or encouraged to participate. 4. Activity calendars The activity calendar for 1/27/2020 to 1/30/2020 included: -1/27/2020-morning chat with current events, social and ring toss. -1/28/2020-morning chat with current events, coffee social, bingo and hi/low. -1/29/2020-morning chat with current events, Walmart, arts and crafts and picture bingo. -1/30/2020-morning chat with current events, sunroom time, and bingo and BV ball. The activity calendar for 2/3/2020 to 2/5/2020 included: -2/3/2020-music and movement, snack, social and BV ball. -2/4/2020-music and movement, Hi/low, bingo, picture bingo, reminisce. -2/5/2020-music and movement, Walmart, arts and crafts and basketball. C. Staff interviews Certified nurse aide (CNA) #2 and nurse aide (NA) #2 were interviewed on 1/30/2020 at 11:00 a.m. They said Resident #37's daily routine was to get up, get dressed, eat breakfast and walk around on the unit. They said when they saw him getting tired, then they would offer him to sit down. They said there was no specific program for him to follow. They said it was difficult to get the resident to participate in activities. Licensed practical nurse (LPN) #3 was interviewed on 1/30/2020 at 9:00 a.m. She said it was difficult to get the resident to sit down. She said he walked around all day on the unit. She said he had not participated in activities. She said when she noticed he was tired, she would offer him to sit down to prevent him from falling. She said she was not sure of any individualized program that was created for him. She said he just walked all day. The activity director was interviewed on 2/5/2020 at 1:23 p.m. She said she had worked in the activity department for two and a half years. She said her process was when a resident was admitted , she would introduce herself and interview the resident about what he or she would like to do while in the facility. She said if the resident could not make his or her own decision, then she would interview the resident's family or responsible party regarding activities. She said in regard to Resident #37, it was difficult at times to get him to sit down and participate in activities. She said he liked to walk around. She said she was not aware the resident was not invited and encouraged to attend activities. She said she would provide education to her assistant to invite and encourage the resident to participate in activities. She said it was important for him to participate in activities because it would help improve his cognitive status and also help minimize behaviors (such as resident-to-resident altercations). She acknowledged that having one activity person on the secure unit, it would be difficult to meet all residents' needs. She said she would ensure all residents' activity needs were met by making rounds on the unit more frequently.

Based on record review and interview, the facility failed to ensure five out of five nurses were able to demonstrate competencies in skills and techniques necessary to care for residents' needs, as identified through resident assessments, and described in the plan of care. Specifically, the facility failed to conduct comprehensive competencies in skills for nurses. Findings include: I. Facility demographics Cross-reference F838 due to the facility assessment failed to include the complete and through competencies for licensed nurses. The January 2020 Census and Condition form was provided by the director of nursing (DON) on 1/27/2020 at 11:00 a.m. It documented 44 residents were on respiratory treatments, two residents had indwelling or external catheters and one resident with colostomy. The Facility Assessment last updated January 2020, was provided by the nursing home administrator (NHA) on 1/27/2020 at 11:00 a.m. It identified nursing staff competencies to provide care needed for the residents were: hand hygiene, meal feeding skills, medication pass and needle skills. The facility assessment failed to include nurse competencies identified in the resident census and condition: catheter, colostomy and respiratory care. II. Competency records The competencies for five nurses were provided by the DON on 2/5/2020 at 1:00 p.m. The competencies included: needle skills, hand hygiene, medication pass, and meal feeding skills. It failed to include catheter, colostomy and respiratory care as identified in the Census and Condition form. III. Staff interview The director of nursing (DON) was interviewed on 2/5/2020 at 4:43 p.m. She said she created the competency checklist for nurses and CNAs. She said she created a competency skills checklist based on the current census and condition in the facility but not the Facility Assessment. She said she would set-up different stations and go around and observe nurses perform the skills. She said she was not sure why she did not include catheter, colostomy and respiratory care. She said she should have included them because there were residents currently residing at the facility with those special care needs. She said her plan was to recreate a new skills checklist that included every special care need identified in the Census and Conditions form.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interviews, the facility failed to ensure six (#14, #19, #29, #36, #37 and #66) of six residents reviewed out of 52 sample residents received the appropriate treatment and services to maintain their highest practicable physical, mental, and psychosocial well-being. The facility was aware that Resident #36 with a diagnosis of dementia with behavioral disturbance and had physical resident-to-resident altercations with four residents (#29, #36, #66 and #37) when she resided on the secured unit. The facility failed to comprehensively assess and effectively identify person-centered approaches for dementia care for Resident #36 by addressing repeated behavioral issues created an environment where the 16 other residents residing on the secured unit were at risk for harm. The facilities failures to implement appropriate interventions timely for Resident #36 who had documented history of resident-to-resident altercations towards multiple residents contributed to the resident-to-resident physical altercations. Cross-reference F600-facility failed to ensure residents remained free from resident-to-resident altercations. Findings include: I. Facility policy and procedure The undated 14-1.1 Alzheimer's Unit Standards and Philosophy policy was provided by the medical records director on 2/5/2020 at 11:15 a.m. It read in pertinent part The facility provides each resident with a safe and structured environment that meets physical, emotional, social and spiritual needs throughout the disease progression. Reduces feelings of anxiety and confusion through both environmental and communication support. Provides care to the resident in a holistic manner. The goal is to provide experiences and activities that add to the quality of their lives. Recognizes that residents are autonomous human beings who can expect their special needs and needs of their families to be met with sensitivity and appropriateness. II. Census and Conditions demographic The 1/27/2020 Census and Condition form documented that 98 total residents resided at the facility, 51 residents (over 50%) with dementia diagnosis and two residents with behavioral healthcare needs. The facility had a secured unit in which 17 residents resided. III. Resident-to-resident altercations with Resident #36 A. Resident #36's status Resident #36, age [AGE], was admitted [DATE]. According to the February 2020 computerized physician orders (CPO), diagnoses included dementia with behavioral disturbance and other specified depressive episodes. The 12/3/19 minimum data set (MDS) assessment revealed the resident had moderate cognitive impairment with a brief interview of mental status (BIMS) score of nine out of 15. She did not understand others. There were no physical and verbal behavior symptoms toward others documented. She had no rejection of care and received antipsychotic daily. She was supervised with bed mobility and transfers. IV. Failure to develop a comprehensive care plan with effective interventions to protect residents on the secured unit from resident-to-resident altercations. The care plan dated last updated 11/1/9, identified the resident had cognitive impairments. However, the care plan failed to identify aggressive behaviors (kicking, hitting, and slapping) with appropriate interventions to prevent further resident-to-resident altercation as identified in the interviews below. The incident follow up from 12/14/19 with Resident #66 showed the intervention was to keep Resident #36 in line of sight, however, this was not documented in Resident #36's care plan. Record review revealed no evidence of an interdisciplinary team meeting to discuss Resident #36's physically aggressive behaviors, no care plan to address the abusive behavior, and no plan to supervise the resident when she was around others on the secured unit. V. Observations On 1/29/2020 at 3:44 p.m., Resident #37 was observed standing in front of Resident #36. Resident #36 was sitting in a chair in the common area by the nurses station. Certified nurse aide (CNA) #2 and nurse aide (NA) #2 were present in the common area. Resident #36 said to Resident #37, Get away from here. Resident #37 did not move and Resident #36 proceeded to hit him in his stomach. Both staff present in the area said to Resident #36, Why did you hit him? Resident #36 said, because he was in front of me and was bothering me. CNA #2 removed Resident #37 from the area and Resident #36 remained sitting in the common area around other residents. Observations, revealed throughout the survey, Resident #36 was not in the line of sight of staff. The resident was left alone sitting in the common area alone with other residents including Resident #66. VI. Record review Review of Resident #36's medical record revealed at least five incidents of Resident #36 hitting, kicking and slapping other residents who resided on the secured unit. Cross reference to F600 because on 12/2/19 Resident #29 was walking in the hallway when Resident #36 slapped her on her right arm while not having close oversight. Cross reference to F600 because on 12/5/19 when Resident #36 grabbed and squeezed Resident #66's arm. Cross reference to F600 because on 12/14/19 because Resident #66 was sitting in the common area near Resident #36, when Resident #36 kicked Resident #66 on her left leg. It documented no bruising, swelling or redness noted. Cross reference to F600 because on 12/17/19 when Resident #36 hit Resident #37 in his chest. The interdisciplinary team (IDT) determined the intervention was to keep Resident #36 in line of sight. Cross reference to F600 because on 1/29/2020 Resident #37 was in the common area and was standing in front of Resident #36 when Resident #36 hit Resident #37 across his lower stomach and upper groin area. VII. Staff interviews Licensed practical nurse (LPN) #3 was interviewed on 1/29/2020 at 4:00 p.m. LPN #3 said Resident #36 displayed aggressive behaviors towards others. She said the resident liked to be alone. She said when anybody got close to her, she would get agitated and strike out at the person. She said they tried to keep other residents from being close to her but sometimes it was impossible to do so. Nurse aide (NA) #2 was interviewed on 1/29/2020 at 3:48 p.m. NA #2 said Resident #36 displayed aggressive behaviors towards other residents and staff members. She said she did not like to be around people. She said she would get agitated and aggressive when other residents came too close to her. The NA said the resident would say if anyone got close to her she would either hit, kick or slap that person. She said they tried to keep other residents from going around her, however they were unable to ensure she was not around other residents. She said she asked Resident #36 why she hit Resident #37 in his stomach. She said, Resident #36 said, he was in her face and was bothering her. The NA #2 said Resident #37 walked all day in the unit and would not sit down to participate in activities. The NHA and director of nursing (DON) were interviewed on 2/4/2020 at 12:21 p.m. The NHA did not recognize the resident-to-resident altercations as abusive behavior. She said an investigation was completed, in order to put interventions in place, or to know more of what happened. The DON confirmed there had been resident-to-resident altercations on the unit. She said the activity assistant (AA) was added to the secured unit in December 2019. The AA was primarily located on the secured unit. She said the AA could also assist with hydration and eating. She said the resident-to-resident altercations had decreased significantly in the last 30 days since the activity staff was on the unit. The DON was interviewed on 2/5/2020 at 12:45 p.m. The said staff members took dementia training two times a year. She said one of the training sessions was hand in hand videos. She said activities were part of the dementia training for all the straff. She said the nursing staff watched more videos. She said some of the other dementia training sessions were communication with the residents, different stages of dementia, and different types of lifestyles, anticipation of their needs, and being in their world. She said there was no written form for individualized resident care. She said she tried to keep staff in the same area so they know the residents. She said staff got cross trained in case someone called off.

Based on observation, record review and interviews, the facility failed to ensure it was free of a medication error rate of five percent or greater for two (#8 and #96) out of nine residents observed during medication administration. Specifically, the facility failed to: - Ensure the correct strength of Refresh eye drop was administered to Resident #96, - Ensure prescribed medications were administered at the scheduled time for Residents #8 and #96, - Ensure Resident #8's mouth was rinsed after the administration of his inhaler, - Prevent an error rate of 36.67%, resulting from eleven medication errors out of 30 opportunities. Findings include: I. Facility policy The Medication Administration policy dated February 2011, was provided by the director of nursing (DON) on 2/4/2020 at 11:00 a.m. It read in pertinent part, If there is any discrepancy between the medication administration record (MAR) and the label, check physician orders before administering the medication. If mediation is given at a time different from the scheduled time, give reason for change in time in the electronic medication administration record (EMAR). The undated Medication Aide Job Description was provided by the DON on 2/4/2020 at 11:00 a.m. It read in pertinent part, The certified medication aide (CMA) must possess knowledge of safe medication administration technique and demonstrate this knowledge with a medication error rate of five percent or below. Administers and accurately records the administration of medications for residents as prescribed by the physician in accordance with established policies and procedures of this facility. II. Failed to ensure the correct strength of lubricating eye drop was administered to Resident #96. CMA #3 was observed preparing medication for Resident #96 on 1/28/2020 at 3:37 p.m. The January 2020 computerized physician orders read Refresh Celluvisc 1% eye drops, instill two drops in each eye three times daily. The CMA administered Refresh Celluvisc lubricant eye drops 0.5% which was not the same dose as the physician orders indicated. III. Failed to ensure prescribed medications were administered at the scheduled time for Residents #8 and #96. CMA #2 was observed administering medications on 2/4/2020 at 11:30 a.m., three and a half hours after the medications scheduled times. The February 2020 MAR for Resident #8 read that the following medications were scheduled to be administered 8:00 a.m. with the exception of Maalox suspension 30 milliliters (ml) which was scheduled at 7:00 a.m. - Atenolol 50 milligrams (mg) , give one tablet by mouth daily for the associated diagnosis of hypertension. - Baclofen 10 mg, give one tablet by mouth everyday with associated diagnosis of disorder of muscle. -Breo-ellipta 100-25 microgram (mcg) inhale one puff daily. The CPO instructed to rinse mouth after each use for chronic obstructive bronchitis. - Lisinopril 10 milligram (mg), give one tablet by mouth daily - Cymbalta 30 mg one capsule by mouth daily for major depressive disorder. - Glucosamine & chondroitin capsule give one capsule by mouth daily for osteoarthritis. - Metformin 500 mg, give on tablet by mouth each morning for diabetes. - Docusate sodium 100 mg, give one tab by mouth daily for bowel management. IV. Failed to ensure Resident #8 ' s mouth was rinsed after the administration of his inhaler. CMA #2 was observed administering Breo-ellipta 100-25 (mcg) inhaler on 2/4/2020 at 11:30 a.m. CMA #2 did not follow prescribed instructions to rinse Resident #8's mouth after it was administered. Staff interviews CMA #3 was interviewed on 1/28/2020 at 3:30 p.m. CMA #3 said before she administered medication, she usually read the physician order and verified the medication with the label. However, CMA #3 said she did not realize the Refresh eye drops box label read 0.5 % instead of 1% as the physician ordered. She said she would follow up with the charge nurse and report the incident. CMA #2 was interviewed on 2/4/2020 at 11:35 a.m. He said the resident liked to sleep until noon. That was why he did not administer his medication at the scheduled time. He said he reported to his charge nurse that the medication was late and the charge nurse instructed him to administer the medications at that time. He said he should have instructed the resident to rinse his mouth after he administered his inhaler but it slipped his mind to do so. He said he was going back to the resident to instruct him to rinse his mouth, which was ten minutes after it was administered. Licensed practical nurse (LPN) #3, the charge nurse of CMA #2 was interviewed on 2/4/2020 at 11:40 a.m. She said she was not aware CMA #2 administered Resident #8 ' s medications outside of the prescribed time. She said he should have reported it to her and she would call the physician for further instructions. She said he should have followed the physician orders as written. She said he should have ensured that the resident rinsed his mouth after he administered the inhaler. She said not rinsing his mouth could result in the resident getting mouth sores. She said she would report the incident to her supervisor. The DON was interviewed on 2/5/2020 at 11:52 a.m. She said the normal practice was for the CMA to read the physician order and verify it with the label to ensure it was correct, then ensure it was the right resident and at the right time to administer the medication. She said medications could be administered one hour before and after the prescribed time. She said the CMA should have read the physician order and verified it with the label, and ensure it was correct before she administered it to the resident. She said CMA#2 should not have administered Resident #8's medications late. She said he should have reported it to the charge nurse. She said if the medication was administered late then it was a medication error. The DON said CMA #2 should have instructed and ensured the resident rinsed his mouth after his inhaler was administered to him. She said if the resident did not rinse his mouth it could possibly cause mouth sores. She said she would provide education to both CMA #2 and #3 including all nursing staff to read all physician orders accurately and ensure the order matches the label before administration.

Based on observations and interviews, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Specifically, the facility failed to provide assistance with hand hygiene to the residents before meals. Findings include Observations On 1/27/2020, 1/28/2020 and 1/29/2020, prior to the lunch and supper meals, as staff assisted residents into the downstairs dining room, the staff failed to offer and provide hand hygiene assistance before residents ate their meals. On 1/30/2020, prior to the lunch and supper meals, as staff assisted residents into the main dining room, the staff failed to offer and provide hand hygiene assistance before residents ate their meals. Staff interview The director of nursing (DON) was interviewed on 2/5/2020 at 6:06 p.m. She said she was the facility's infection control preventionist. She said all staff were trained on proper hand washing techniques.The process for the residents for hand hygiene was that a CNA took the resident to the bathroom and offered a clean wet washcloth to the resident to wash his/her hands and face. She said the staff would offer the sanitary wipes for their hands before they left their rooms. She said a CNA inspected the residents' hands before they ate. She said that the staff should have washed the residents' hands in their rooms. The DON explained that she would provide more education and training for staff to ensure the residents hands were washed before meals.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interviews, the facility failed to ensure freedom from abuse for six (#14, #19, #29, #36, #37 and #66) of six residents reviewed out of 52 sample residents. Specifically, the facility failed to protect Residents #29, #37 and #66 from physical abuse by Resident #36 who was physically aggressive toward others and protect Resident #14 from physical abuse by Resident #19. Cross reference F609 failure to report abuse allegations. Findings include: I. Facility policy and procedure The abuse policy entitled Resident safety dated 5/31/19 was sent via email by the nursing home administrator (NHA) on 2/12/2020. It read, in pertinent part; It is the policy of our facility to maintain a work and living environment that is professional and free from threat and/or occurrence of harassment, abuse (verbal, mental or sexual), neglect, corporal punishment, involuntary seclusion and misappropriation of property; -Our facility promotes an atmosphere of sharing with residents and staff without fear of retribution. Residents must not be subject to abuse by anyone, including, but not limited to, facility staff, other residents, consultants or volunteers, staff of other agencies serving the residents, family members or legal guardians, friends, or other individuals. Physical abuse includes but is not limited to hitting, slapping, pinching and kicking . II. Resident to resident abuse A. Resident #36, perpetrator 1. Resident status Resident #36, age [AGE], was admitted [DATE]. According to the February 2020 computerized physician orders (CPO), diagnoses included unspecified dementia with behavioral disturbance and other specified depressive episodes. The 12/3/19 minimum data set (MDS) assessment revealed the resident had moderate cognitive impairment with a brief interview of mental status( BIMs) score of nine out of 15. There were no physical and verbal behavior symptoms toward others documented. She had no rejection of care and received antipsychotic daily. She was supervision with bed mobility and transfers. Resident #36's care plan was reviewed. It failed to identify aggressive behaviors (e.g., kicking, hitting, and slapping) with appropriate interventions to prevent further resident to resident altercation as identified in the interviews below. B. Staff knowledge the Resident #36 had aggressive behaviors The nurse aide (NA) #2 was interviewed on 1/29/2020 at 3:48 p.m. NA #2 said Resident #36 displayed aggressive behaviors towards other residents and staff members. She said the resident did not like to be around people. She said the resident would get agitated and aggressive when other residents came too close to her. The NA said the resident would say if anyone got close to her she would either hit, kick or slap that person. NA #2 said the staff tried to keep other residents from going around the resident; however, the staff were unable to ensure Resident #36 was not around other residents. She said she asked Resident #36 why she hit Resident #37 in his stomach. She said, Resident #36 said, He was in her face and was bothering her. NA #2 said Resident #37 walked all day in the unit and would not sit down to participate in activities. Licensed practical nurse (LPN) #3 was interviewed on 1/29/2020 at 4:00 p.m. LPN #3 said Resident #36 displayed aggressive behaviors towards others. She said Resident #36 liked to be alone. She said when anybody got close to Resident #36, the resident would get agitated and strike out at the person. She said the staff tried to keep other residents from being close to Resident #36, but sometimes it was impossible to do so. Review of Resident #36's record revealed at least five incidents of Resident #36 hitting, kicking and slapping other residents in the secured unit. -A nursing note, dated 12/2/19 documented a CNA reported that while Resident #29 was walking in the hallway, Resident #36 slapped her on her right arm. It further documented when Resident #36 was asked why she slapped Resident #29, she said I slapped her because she is (a different race than Resident #36). -A nursing note, dated 12/5/19 documented the activity staff witnessed Resident #36 grab and squeeze Resident #66's arm. -A nursing note, dated 12/14/19 documented, Resident #66 was sitting in the common area near Resident #36. It documented Resident #36 kicked Resident #66 on the left leg. It documented no bruising, swelling or redness noted. The follow-up investigation documented Resident #36 was sitting in the common area and Resident #66 got close to Resident #36. It documented Resident #36 kicked Resident #66 on her left leg. It documented no injuries. It further documented Resident #36 denied kicking her. -A nursing note, dated 12/17/19 documented a kitchen staff witnessed Resident #36 hit Resident #37 in his chest. It documented no mark was noted on Resident #37's chest. Intervention was to keep Resident#36 in line of sight; however, this was not documented in Resident #36's care plan. -A nursing note, dated 1/29/2020 documented, Resident #37 was in the common area and was standing in front of Resident #36. It documented Resident #36 hit Resident #37 across his lower stomach and upper groin area. C. Failure to develop a comprehensive plan with effective interventions to protect Residents #37, #29, and #66 and the other 14 residents on the secured for abuse. 1. Observation Observations, revealed throughout the survey, Resident #36 was not in the line of sight of staff (see planned intervention above). Resident #36 was left alone sitting in the common area alone with other residents including Resident #66 (see incident above). On 1/29/2020 at 3:44 p.m., Resident #37 was observed standing in front of Resident #36. Resident #36 was sitting in a chair in the common area by the nurse station. Certified nurse aide (CNA) #2 and nurse aide (NA) #2 were present in the common area. Resident #36 said to Resident #37, get away from here. Resident #37 did not move and Resident #36 proceeded to hit him in his stomach. Both staff present in the area said to Resident #36, oh why did you hit him? Resident #36 said because he was in front of me and was bothering me. CNA #2 removed Resident #37 from the area and Resident #36 remained sitting in the common area around other residents. 2. Record review revealed no evidence of an interdisciplinary team meeting to discuss Resident #36's physically aggressive behaviors, no care plan to address the abusive behavior, and no plan to supervise the resident when she was around others in the secured unit. D. Residents abused by Resident #36 1. Resident #37 Resident status Resident #37, age [AGE], was admitted [DATE]. According to the January 2020 computerized physician orders (CPO), diagnoses included unspecified dementia with behavioral disturbance and anxiety disorder. The 12/4/19 (MDS) assessment revealed the resident had severe cognitive impairment with a BIMs score of zero out of 15. There were no physical and verbal behavior symptoms toward others documented. He had no rejection of care and received antipsychotic daily. He required limited assistance with bed mobility and transfers. The resident resided on the secured unit. Record review -A nursing note, dated 12/17/19 documented a kitchen staff witnessed Resident #36 hit Resident #37 in his chest. It documented no mark was noted on his chest. The follow up incident reported documented Resident #37 was leaning forward near Resident #36 and Resident #36 hit him in his chest. -A nursing note, dated 1/29/2020 documented, Resident #37 was in the common area and was standing in front of Resident #36. It documented Resident #36 hit Resident #37 across his lower stomach and upper groin area. It further documented Resident #36 stated get your stuff out of my face. Staff went to assist and removed Resident #37 out of the area. No bruising was noted. The record failed to show an intervention was put into place to prevent recurrence of similar incidents between Residents #37 and #36. Same as the staff did not put interventions in place to keep Resident #36 from abusing other residents. The follow-up investigation documented the resident was walking into the dining room and bent over when Resident #36 hit him with an open fist. It documented staff immediately separated both residents. It documented Resident #37 said he was not afraid of anyone. It further documented it was not a reportable incident. 2. Resident #29 Resident status Resident #29, age [AGE], was admitted [DATE]. According to the February 2020 CPO, diagnoses included schizoaffective disorder and unspecified psychosis. The 11/20/19 MDS assessment revealed the resident was cognitively intact with a BIMS score of 15 out of 15. There were no physical and verbal behavior symptoms toward others documented. She required limited assistance with bed mobility and supervision with transfer Record review Resident to resident altercation The 12/2/19 nurse's note documented a CNA reported that while Resident #29 was walking in the hallway, Resident #36 slapped her on her right arm. It further documented when Resident #36 was asked why she slapped Resident #29, she said I slapped her because she is (a different race than Resident #36). The follow-up investigation dated 12/3/19 documented staff and residents were interviewed. It documented the incident was witnessed by staff. Resident #36 had no recollection of what happened. The planned intervention was for staff to monitor Resident #36 where abouts. 3. Resident #66 Resident status Resident #66, age [AGE], was admitted [DATE]. According to the February 2020 CPO, diagnoses included dementia and anxiety disorder. The 12/31/19 MDS assessment revealed the resident had severe cognitive impairment with a BIMs score of zero out of 15. There were no physical and verbal behavior symptoms toward others documented. She required limited assistance with bed mobility and transfer. Record review -A 12/5/19 nursing note documented the activity staff witnessed Resident #36 grab and squeeze Resident #66's arm. It documented no bruising, redness and no swelling. It further documented charge nurse, director of nursing (DON) and NHA were notified. The investigation documented staff and Resident #36 were interviewed. It documented Resident #66 was in her wheelchair close by Resident #36 and Resident #36 grabbed Resident #66's arm. Staff separated both residents. Resident #36 denied she grabbed Resident #66's arm. It documented the social worker interviewed both residents and both were not afraid of each other. There was no intervention put in place to prevent further altercations. - A nursing note, dated 12/14/19 documented, Resident #66 was sitting in the common area near Resident #36. It documented Resident #36 kicked Resident #66 on the left leg. No bruising, swelling or redness was noted. III. Other resident to resident altercations on the secured unit. A. Resident #19 Resident Status Resident #19, age [AGE], was admitted [DATE]. According to the February 2020 CPO, diagnosis included dementia. The 11/11/19 MDS assessment revealed the resident had a BIMS of seven out of 15 which indicated severe cognitive impairment. There were no physical and verbal behavior symptoms toward others documented. He required supervision with bed mobility and transfer. Record review -A nurse's note, dated 12/4/19 documented Resident #14 was in her wheelchair in the hallway and Resident #19 came from behind and pushed her out of the way which resulted in Resident #14 hitting both knees against the wall. It further documented no bruising, or redness and no complaint of pain Staff were instructed to keep Residents #14 and #19 apart. Resident #19's care plan was reviewed. It failed to identify Resident #19 displayed aggressive behaviors (pushing) toward other residents and failed to identify appropriate interventions to prevent further resident-to-resident altercation. B. Resident #14 Resident #14, age above 90, was admitted on [DATE]. According to the February 2020 CPO, diagnoses included dementia with behavioral disturbance and obsessive-compulsive disorder. The 11/4/19 MDS assessment revealed the resident had severe cognitive impairments with a BIMs score of four out of 15. She had delusions and no behaviors documented. She required extensive assistance with bed mobility and total dependence with transfer. Record review A nurse's note, dated 12/4/19 documented Resident #14 was in her wheelchair in the hallway and Resident #19 came from behind and pushed her out of the way which resulted in Resident #14 hitting both of her knees against the wall. It further documented no bruising, or redness and no complaint of pain. It documented Resident #14's son was notified. Staff interview The NHA and the director of nursing (DON) were interviewed on 2/4/2020 at 12:21 p.m. The NHA said the above incidents were not abuse. She said because the residents did not have intent, it was not considered abuse. Additionally, because there were no injuries, and no fear it was not abuse, and therefore she did not report the incidents to the health department or other agencies. She said an investigation was completed, in order to put interventions in place, or to know more of what happened. The DON agreed the above incidents were not abuse allegations. The DON confirmed there had been resident-to-resident altercations on the unit and she said her intervention was an activity assistant (AA) who was primarily on the secured unit was added in December 2019. She said the AA could also assist with hydration and eating. She said the incidents had decreased significantly in the last 30 days since the activity staff was on the unit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews the facility failed to report to the state survey and certification agency, in accordance with state law, five of five incidents of physical abuse stemming from resident-to-resident altercations in the memory care unit. The facility failure to report alleged abuse involved six (#14, #19, #29, #36, #37 and #66) of six residents reviewed for abuse reporting out of 52 sample residents. Cross-reference F600 Free from Abuse Findings include: I. Facility policy and procedure The abuse policy entitled Resident safety dated 2/1/11 was sent via email by the nursing home administrator (NHA) on 2/12/12020 . It read, in pertinent part; any suspected, observed or reported violation of this resident safety policy will be reported to the supervisor on duty. The supervisor on duty shall report any suspected violations of this resident safety policy immediately to the administrator and to the director of nursing (DON) or their designee(s) as soon as practicable. The state Department of Health, Health facilities division will be notified by no later than the next business day. II. Failure to report resident to resident physical allegations of abuse A. Resident #36 Resident #36, age [AGE], was admitted [DATE]. According to the February 2020 computerized physician orders (CPO), diagnoses included unspecified dementia with behavioral disturbance and other specified depressive episodes. The 12/3/19 MDS assessment revealed the resident had moderate cognitive impairment with a BIMS score of nine out of 15. There were no physical and verbal behavior symptoms toward others documented. She had no rejection of care and received antipsychotic daily. She was supervision with bed mobility and transfers. B. Record review Review of Resident #36's record revealed multiple incidents of Resident #36 hitting, kicking and slapping other residents in the secured unit. -A nursing note, dated 12/2/19 documented a CNA reported that while Resident #29 was walking in the hallway, Resident #36 slapped her on her right arm. It further documented when Resident #36 was asked why she slapped Resident #29, she said I slapped her because she is (a different race than Resident #36). -A nursing note, dated 12/5/19 documented the activity staff witnessed Resident #36 grabbed and squeezed Resident #66's arm. -A nursing note, dated 12/14/19 documented, Resident #66 was sitting in the common area near Resident #36. It documented Resident #36 kicked her on her left leg. It documented no bruising, swelling or redness noted. The follow-up investigation documented Resident #36 was sitting in the common area and Resident #66 got close to her. It documented resident #36 kicked Resident #66 on her left leg. It documented no injuries. It further documented Resident #36 denied kicking her. -A nursing note, dated 12/17/19 documented a kitchen staff witnessed Resident #36 hit Resident #37 in his chest. It documented no mark was noted on his chest. B. Resident #19 Resident #19, age [AGE], was admitted [DATE]. According to the February 2020 CPO, diagnosis included dementia. The 11/11/19 MDS assessment revealed the resident had a BIMS of 7 out of 15 which indicated moderate cognitive impairment. He understood others.There were no physical and verbal behavior symptoms toward others documented. He required supervision with bed mobility and transfer. Record review -A nurse's note, dated 12/4/19 documented Resident #14 was in her wheelchair in the hallway and Resident #19 came from behind and pushed her out of the way which resulted in the resident hitting both knees against the wall. III. Failure to report allegations of abuse None of the above resident to resident altercations were reported as physical abuse to the state survey certification agency. The DON and the NHA were interviewed on 2/4/2020 at 12:21 p.m. The NHA confirmed the above allegations of abuse were not reported to the state survey certification agency. She said the resident to resident altercations were not abuse and therefore not reported. She said if there was bodily injury and intent, then she would report it. The DON and NHA said they felt all the altercations were not willful, intent and there were no bodily injuries. They said after the incidents the residents had no recollection of what had happened. The NHA said the residents had not reported that they had been abused. Later on that day, the NHA acknowledged the incidents should have been reported to the state. She said she read the regulations and she understood now.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to provide written notice of the bed hold policy before transfer to the hospital to the residents or their representatives in a sample of four ( #248, #63, #80 and #60) of four out of 52 total sample residents reviewed. Specifically the facility failed to ensure: Resident #248, #63, #80 and # 60 were informed,in writing of the bed hold policy, when they were transferred to the hospital from the facility. Findings include I. Policy The bed hold policy read, residents who were discharged or transferred from the facility to a hospital or other facility upon physician's orders or who leave the facility for any reason, medical or otherwise shall be offered a reservation on their bed at the facility under the following conditions. The policy shall be included in the admissions contract, and must additionally be furnished to the resident at the time of transfer or discharge. II. Resident #248 A. Resident #248, age [AGE], was admitted on [DATE]. According to the February 2020 computerized physician orders (CPO), the diagnoses included unspecified dementia with behavioral disturbance and hypertension. The 1/8/2020 minimum data set (MDS) assessment revealed the resident was cognitively impaired with a brief interview for mental status score of 8 out of 15. She required limited assistance and cuing with activities of daily living. B. Record review The hospital transfer form for resident # 248 documented the resident was transferred to the hospital on 2/2/2020. The medical record failed to show that a bed hold policy form was given to the resident or her representative. The facility provided a signed bed reserve policy form for Resident #248 upon admission to the facility on [DATE]. The policy must be additionally furnished to the resident at the time of transfer or discharge. This paperwork should accompany the resident upon admission to the hospital.The social service paperwork (policy No:3-5.2) about the bed hold policy includes residents that were discharged or transferred from the facility for any reason should be offered a reservation of their bed at the facility. III. Resident # 60 A. Resident #60, age [AGE], was admitted on [DATE]. According to the February 2020 CPO diagnoses included, lack of coordination, unsteady on feet, and essential tremor. The 12/28/19 MDS assessement revealed the resident was cognitivly intact with a brief interview for mental status (BIMS) of 15 out of 15. Record review The hospital transfer form for resident #60 documented the resident was transferred to the hospital on 7/8/19. The medical record failed to show that a bed hold policy form was given to the resident. Resident #60 was interviewed on 1/27/2020 at 1:27 p.m. The resident said he was transferred to the hospital in the past six months. He said he was not provided a written bed hold policy when he was transferred to the hospital. IV. Resident #80 A. Resident status Resident #80, age [AGE], was admitted on [DATE]. According to the January 2020 computerized physician orders (CPO) diagnoses included, Parkinson's disease, generalized arthritis, and unspecified lack of coordination. The 12/1/19 minimum data set (MDS) assessment documented the brief interview for mental status (BIMS) score of 15 out of 15. The resident required extensive assistance with transfers, and personal hygiene. She required limited assistance with activities of daily living and locomotion on unit. B. Record review The hospital transfer form for resident #60 documented the resident was transferred to the hospital on [DATE]. The medical record failed to show that a bed hold policy form was given to the resident C. Interviews The social service director (SSD) was interviewed on 2/4/19 at 10:20 a.m. The SSD said she was not aware that a bed hold policy should be provided to residents when they were transferred from the facility to the hospital. She stated that she would do so in the future. She did the bed hold policy when the residents were admitted to the facility. V. Resident #63 A. Resident #63, age [AGE], was admitted on [DATE]. According to the January 2020 computerized physician orders (CPO) diagnoses included urinary tract infection, Klebsiella pneumonia and muscle weakness. The 1/21/2020 minimum data assessments (MDS) did not document the cognitive status. It documented zero for daily decision making skills. She required extensive assistance with bed mobility and transfer. Record review The transfer form dated 1/21/2020 was reviewed. It documented the resident was sent to the emergency room for emesis (vomiting) positive for blood. There was no evidence that the resident returned to the facility from the hospital. The progress note written by activity staff on 1/25/2020(four days after the resident was sent to the emergency room) was reviewed. It documented the resident's granddaughter went to the facility to get the resident belongings while she was in the hospital. It further documented that the resident representative was called. It documented the resident's representative gave permission for granddaughter to take resident's belongings. A review of progress notes and the transfer paper work failed to reveal the resident/resident representative was given a bed hold notice when she was transferred to the hospital on 1/21/2020. Interview The nursing administrator (NHA) was interviewed on 2/03/2020 at 3:11p.m. She said when a resident was admitted , the bed hold policy was given to the resident in the admission packet. She said she was not sure whether bed hold notice was given to residents at the time of transfer. The social service director (SSD) was interviewed on 2/3/2020 at 4:40p.m. She said she gave the residents bed hold policy on admission. She said the bed hold policy was a part of the admission package paperwork. She said she gave Resident #63 the bed hold policy and she signed it at the time of admission however, the resident was not provided a bed hold notice at the time she was transferred to the hospital. She said she was not aware that a bed hold notice should be given to residents/residents representative at the time of transfer to the hospital. She said since she was aware now she would give bed hold notices to residents at the time of transfer from the facility to the hospital.

Based on observations and staff interviews, the facility failed to ensure the dietary department followed safe practices to prevent the potential contamination of food and spread of food-borne illness through proper kitchen sanitation procedures. Specifically, the facility failed to ensure: -Holding temperatures were at appropriate level; -Adequate hand washing occured; -Moisture was not between stacked pans; and, -Health shakes were appropriately dated. Findings include: I. Food temperatures of cold and hot food items were not held at the proper temperature to reduce the risk of food borne illness. A. Professional reference The Colorado Department of Public Health and Environment (2019) The Colorado Retail Food Establishment Rules and Regulations, https://www.colorado.gov/pacific/sites/default/files/DEHS_RetailFd_6CCR10102_RFFC_EffJan2019.pdf. It read in pertinent part; The food shall have an initial temperature of 41ºF or less when removed from cold holding temperature control or 135°F or greater when removed from hot holding temperature control. B. Main kitchen The evening meal began to be served at 3:30 on 1/29/2020. The tray line was observed beginning at 4:15 p.m. The dining room consistently had residents continue to come to the dining room to be served. During observations of the tray line the following food temperatures were obtained from the steam table with the staff member present: -The tuna salad was at 50 degrees F. The tuna was in a deep full size pan. Although the tuna salad was on ice, the ice did not encase the tuna salad to ensure it was kept at the appropriate holding temperature. -The garlic pasta was 130 degrees F after the server gave a good stir to the pasta. The pasta was in a large deep pan with the lid off. C. Secured unit The evening meal on the secured unit was observed at 4:30 p.m., on 1/29/2020. During observations of the tray line the following food temperatures were obtained from the steam table prior to serving with the dietary staff member present: -The pureed tuna was 50 degrees F. The tuna was in a smaller pan, and in ice, however it was not encased around the tuna salad. -The regular texture tuna was 58 degrees F. The tuna was in a large pan and the ice was not encased around the tuna salad. -The puree tortellini (pasta) was 124 degrees F. -The toss green salad was 50 degrees F. -The mechanical soft green salad was 50 degrees F. -The puree green salad was 50 degrees F. The dietary aide #1 was interviewed on 1/29/2020 at approx 4:45 p.m. The DA #1 said the holding temperatures for the cold foods should be about what they are or lower. She said the hot foods should be held at 170 degrees F. The DM was interviewed on 1/30/2020 12:26 p.m. The DM said the food temps needed to be held at below 40 degrees. He said the hot foods need to be held between 160 and165 degrees F. The DM said they are all trained on proper holding temperatures. The DM said the lids should be on the hot foods at the tray line II. Handwashing A. Policy The Colorado Department of Public Health and Environment (2019) The Colorado Retail Food Establishment Rules and Regulations, https://www.colorado.gov/pacific/sites/default/files/DEHS_RetailFd_6CCR10102_RFFC_EffJan2019.pdf. It read in pertinent part; Food employees shall clean their hands and exposed portions of their arms for at least 20 seconds and shall use the following cleaning procedure: Vigorous friction on the surfaces of the lathered fingers, finger tips, area between the fingers, hands and arms for at least 15 seconds, followed by; thorough rinsing under clean, running, warm water; and immediately follow the cleaning procedure with thorough drying of cleaned hands and arms .Food employees shall clean their hands and exposed portions of their arms immediately before engaging in food preparation including working with exposed food, clean equipment and utensils, and unwrapped single-service and single-use articles .after handling soiled equipment or utensils . B.Observations 1. Main kitchen Dietary aide (DA)#2 was observed to serve the evening meal on 1/29/2020 beginning at 4:15 p.m. The DA #2 had gloved hands. He touched the meal tickets, his shirt, and various other items, he then proceeded to reach into the hamburger bun bag, and retrieved a bun (ready-to-eat food) and placed tuna salad on the bun. He then used his other gloved hand to put the top bun onto the tuna salad. He did not use utensils when touching ready-to-eat foods. This process happened through several other meals. When he did change his gloves, he did not wash his hands prior to putting a new set of gloves on. 2. Secured unit Dietary aide #1 was observed to serve the evening meal on 1/29/2020 beginning at 4:30 p.m. The DA #2 was observed to have gloved hands. She was observed to use a pen while taking the food temperatures, touched the meal tickets, and the refrigerator handle. She then began to serve the meal, and touched the hamburger buns with the same gloved hands. She then placed the tuna salad onto the bun and used her other hand to place the top bun onto the tuna salad. She did not use utensils when touching ready to eat foods. This process happened throughout the meal service in the secured unit. The DM was interviewed on 2/5/2020 at approximately 5:00 p.m. The DM said ready to eat foods should not be touched by gloved hands. He said utensils should be used. The DM said he would provide additional training. The DM said hands should be washed in between tasks and also prior to putting on new gloves. III. Health shakes A. Directions The health shakes contained directions on the box which documented, the health shake needed to be used 14 days after being thawed. B. Observations On 1/27/2020 at 9:26 a.m. nine thawed 4 oz. (ounces)vanilla and strawberry health-shakes were observed in the north hall refrigerator without any thaw dates posted or written on the container. On 1/29/2020 at 5:00 p.m., the secured unit refrigerator had three 4 oz. health-shakes were without any thaw dates posted or written on the container. On 1/30/2020 at 12:00 p.m., the north hall refrigerator had approximately 20 health-shakes without any thaw dates posted or written on the container. The DM was interviewed on 1/30/2020 at 12:30 p.m. The DM was not aware the health shakes needed to be used within 14 days of being thawed. He said a lot of times the health shakes are delivered thawed. He said he would put dates on each individual health shake indicating a use by date. IV. Moisture in pans A. Policy The Colorado Department of Public Health and Environment (2019) The Colorado Retail Food Establishment Rules and Regulations, https://www.colorado.gov/pacific/sites/default/files/DEHS_RetailFd_6CCR10102_RFFC_EffJan2019.pdf. It read in pertinent part; . Unless used immediately after sanitization, all equipment and utensils shall be air-dried. B. Observations -During the initial tour of the kitchen on 1/27/2020 at approximately 9:45 a.m., there were two stacks of six pans each which were stacked and stored as ready to use. In between the pans were trapped moisture, as the pans were not completely dried before stacking or stacked in a way that would allow the pans to fully dry. -On 2/5/2020 at 4:30 p.m., with the DM, the stacked pans were observed. there were a stack of six high large pans, and four stacked half pans. The pans had moisture between them, same as the above observation. The DM was interviewed on 2/5/2020 at 4:30 p.m. The DM said the pans needed to be completely air dried prior to stacking. He said the staff had been trained, however, he would provide additional training.

Based on record review, and staff interviews, the facility failed to conduct and document a facility-wide assessment to determine and identify what resources are necessary to care for its residents appropriately during both day-to-day operations and emergencies. Specifically, the facility failed to develop a facility assessment which was specific to the residents of the facility. Findings include: The deficiency was cited previously during a recertification survey on 2/7/19. Although the facility corrected the deficiency, based on the findings below, the facility has not maintained compliance with the regulatory requirement. I. Record review The facility assessment was last reviewed on 1/10/2020 by the nursing home administrator (NHA). The facility assessment failed to include the following: -Include staff competencies that were necessary to provide the level and types of care needed for the resident population or include the staff training program to ensure any training needs were met for all new and existing staff; -Identify the certified medication technicians job duties -Identify the population which was served. The assessment did not include oxygen dependent residents, also use of the continuous positive airway pressure (CPAP) and Bilevel positive airway pressure (BIPAP) machines. -Identify how the facility evaluated what policies and procedures may be required in the provision of care, and how you ensure those meet current professional standards of practice; and, -Create a facility assessment that was accurate and unique to the facility. -Identify the secured unit and the population it served. II. Interviews The nursing home administrator (NHA) was interviewed on 2/5/2020 at approximately 12:00 p.m. The NHA said she reviewed the facility assessment earlier last month. She said the facility was cited on it at the last standard survey. She reviewed the facility assessment and agreed it did not contain information in regards to the secure unit oxygen, CPAP and BIPAP machines, staff competencies with licensed nurses, the job duties of the certified medication technicians, and also a facility assessment which was unique to the facility.

Based on staff, medical director interviews and record review, the facility failed to ensure all responsibilities of the medical director were effectively performed, which had the potential to affect all residents of the facility. Specifically the facility failed to ensure: -The medical director fulfilled his responsibility for the implementation of resident care policies or the coordination of medical care in the facility; and, -Participated in the Quality Assessment and Assurance (QAA) committee or assigned a designee to represent him/her. Findings include: I. Medical director agreement The medical director (MD) independent contract agreement was signed 2/2/11. The agreement documented the medical director shall participate in the development and annual review of written facility policies and procedures as they relate to resident medical and nursing. The MD will serve on the quality assurance committee, infection control committee, pharmacy committee. Review of incident and accident reports as may be requested by the facility nursing home administrator to identify health and safety hazards to residents and employees. II. Record review The QAA attendance logs for 9/25/19, 10/23/19, 11/13/19 and 1/8/2020 were reviewed. The attendance logs were not signed by the MD. The nursing home administrator (NHA) provided a list of the QAA committee on 1/27/2020. The MD was listed as a member of the QAA. III. Interviews The MD was interviewed on 2/5/2020 at 12:00 p.m. The MD said he was in the facility a few days a month. He said while he was in the facility seeing his patients, he would touch base with the director of nurses and nursing home administrator. The MD said he was not involved with writing policies or reviewing policies as the policies came from corporate. He said he would make suggestions if needed. The MD said he would review reports if they were provided to him. The MD said he did not attend the QAA meetings or the psychoactive medication pharmacy meetings which were held monthly. The MD said he had been informed on 2/4/2020 of the substandard care in abuse F600 and F609. He said that he was not aware there was a pattern and to his knowledge the abuse which occured on the secured unit was not severe, as there were no injuries. He said he was notified of the resident to-resident altercations for his residents in which he was the primary physician, however, if not his resident, then he did not hear about it. The director of nurses (DON) was interviewed on 2/5/2020 at approximately 2:00 p.m. The DON said the MD did not review or write the policies. She said recently the MD asked about the influenza policy, as the facility had an active case of the influenza. The DON said the MD did not attend the QAA or psychoactive medication pharmacy meetings. The social service director was interviewed on 2/5/2020 at approximately 2:00 p.m. The SSD said she attended the QAA meetings monthly, however the MD did not attend, nor did he attend the psychoactive medication pharmacy monthly meetings. The NHA and the DON were interviewed on 2/5/2020 at approximately 6:30 p.m. The NHA said the MD did not attend the QAA meetings. She said that she will review the fall report and also the infections report. The DON said the reports were verbal.

Based on record review and staff interview the facility failed to have in effect a written transfer agreement with one or more hospitals approved for participation under Medicare and Medicaid programs in order to reasonably ensure residents would be transferred from the facility to a hospital, and assured of timely admission to the hospital when transfer was medically appropriate. Findings include: Record review The facility was unable to provide a written agreement for the one area hospital. The facility provided a transfer agreement between the area hospital and the facilities prior ownership. The agreement was between the former owner and the area hospital which was dated 8/1/95. Interview The nursing home administrator was interviewed on 2/5/2020 at 8:00 a.m. The NHA said she did not have a written transfer agreement. She provided the version from 1995 and previous owners, as mentioned above. Follow-up The NHA was interviewed a second time on 2/5/2020 at approximately 1:00 p.m. The NHA said she contacted the hospital and an hospital transfer agreement was signed. The agreement was reviewed and was signed by both the NHA and the hospital representative on 2/5/2020.

Based on interviews and record review, the facility failed to ensure an effective quality assurance program to identify and address facility compliance concerns was implemented, in order to facilitate improvement in the lives of nursing home residents, through continuous attention to quality of care, quality of life, and resident safety. Specifically, the quality assurance performance improvement (QAPI) program committee failed to identify and address concerns related to, abuse prevention and reporting, kitchen sanitation, staff competencies, meaningful activities, medication administration, facility assessment, unnecessary medications. Findings include: I. Cross-reference citations Cross-reference F600: The facility failed to ensure freedom from abuse. The facility's failure to identify and address quality concerns of abuse resulted in the facility having substandard care. The facility's failure to report all alleged violations of potential abuse was cited at a F level and resulted in substandard care. Cross-reference F609: The facility failed to report alleged violations of potential abuse of resident to resident altercations to the state survey and certification agency in accordance with state law that involved. The facility's failure to report all alleged violations of potential abuse was cited at a F level and resulted in substandard care. Cross-reference F726: The facility failed to have staff with the appropriate competencies in skills and techniques necessary to care for residents' needs, as identified through resident assessments, and described in the plan of care. The facilty was cited at a F level widespread for more than minimal harm. Cross-reference F758: The facility failed to ensure residents were free from the use of unnecessary medications. The facility was cited at a D level potential for more than minimal harm. Cross-reference F759: The facility failed to have a medication error rate less than 5%. The facility was cited at an E level for a pattern for more than potential for minimal harm. Cross-reference F841: The facility failed to ensure all responsibilities of the medical director were effectively performed, which had the potential to affect all residents of the facility. The facilty was cited at a F level widespread for more than minimal harm. II. Repeat deficiencies F679: The facility failed to ensure an ongoing activity program based on comprehensive assessment and care plan and the preference for each resident. The facility was previously cited F679 at a D level on 2/7/19. The facility was currently cited at a E level for a pattern at potential for more than minimal harm. F812: The facility failed to ensure the dietary department followed safe practices to prevent the potential contamination of food and spread of food-borne illness through proper kitchen sanitation. The facility was previously cited at widespread potential for more than minimal harm on 2/7/19 at an F and currently cited at an F. F838: The facility failed to conduct and document a facility-wide assessment to determine and identify what resources are necessary to care for its residents appropriately during both day-to-day operations and emergencies. The facility was previously cited at an F widespread potential for more than minimal harm on 2/7/19 and was cited at an F for more than potential for minimal harm. Interview The medical director (MD) was interviewed on 2/5/2020 at 12:00 p.m. The MD said he was in the facility a few days a month. He said while he was in the facility seeing his patients, he would touch base with the director of nurses and nursing home administrator. The MD said he did not attend the QAA meetings or the psychoactive medication pharmacy meetings which were held monthly. The director of nurses (DON) was interviewed on 2/5/2020 at approximately 2:00 p.m. The DON said the MD did not attend the QAA or psychoactive medication pharmacy meetings. The social service director was interviewed on 2/5/2020 at approximately 2:00 p.m. The SSD said she attended the QAA meetings monthly, however the MD did not attend, nor did he attend the psychoactive medication pharmacy monthly meetings. The NHA and the DON were interviewed on 2/5/2020 at approximately 6:30 p.m. The NHA said the quality assurance meeting was held monthly. The entire interdisciplinary team attended the meeting. The NHA said the MD did not attend the QAA meetings. The meeting had an agenda which was followed. The NHA said some of the areas of concern come from the past citations, resident council, complaints and incidents. The NHA said abuse was not identified in the QAA. She said that incidents of resident-to-resident altercations were reviewed in the daily morning meetings. She said it was not reported to the State agency, as it was not considered abuse, however, now through the survey process, the facility was reviewing the abuse allegations differently. The NHA said when a problem was identified it was placed on the QAA for three months. The DON said she did have an issue with medication error rate, however, she said that it did get better. She said that medication pass and spot checks were observed periodically. She said the new staff members did not know the floors well and that could lead to errors. The NHA said the staff competencies were completed, however, agreed that the competencies did not include all of the areas which the licensed nurses were responsible for. The NHA said the activity director had brought a few areas to the QAA, however, it was not specific to the survey findings of the activity program based on the comprehensive assessments. The projects she brought were different arts and crafts. The NHA said the dietary manager had been completing random hand washing audits. The NHA said it may get to the point that discipline needs to happen with the staff when they were not compliant with handwashing. The NHA said ultimately she was responsible to ensure the facility showed improvement with the identified issues. The NHA said an action plan was determined and assigned to the appropriate member of the IDT team . The activity director (AD) was interviewed on 2/5/19 at approximately 7:00 p.m. The AD said her current QAA projects were the upcoming calendar, invite checklist, and one and one charting.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interview, the facility failed to ensure for one (#42) of 34 residents had a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility out of 34 sample residents. Specifically, the facility failed to allow Resident #42 a visit with a lawyer for a change of power of attorney (POA). I. Professional reference Shari D Caton, Esq. Colorado Bar association, Power of Attorney, http://www.cobar.org/portals/cobar/repository/SLH/chap23.pdf (2/12/19), .Does a power of attorney take away a principal's rights? A power of attorney does not take away a principal ' s right to make decisions. An agent simply has the power to act along with the principal in accordance with the authorization set forth in the document. Only a court, through a guardianship and/or conservatorship proceeding, can take away a principal ' s rights . Can a principal change his or her mind? A principal may change his or her mind and revoke a power of attorney at any time, so long as the principal has capacity. All a principal needs to do to revoke a power of attorney is send a letter to the agent notifying the agent that his or her appointment has been revoked. II. Findings include: A. Resident status Resident #42, age [AGE], was admitted on [DATE]. According to the February 2019 computerized physician order (CPO), diagnoses included dementia and muscle weakness. The 10/1/18 minimum data set (MDS) assessment revealed, the resident had moderate cognitive impairment with a brief interview for mental status (BIMS) score of nine out of 15. The MDS failed to complete a section under cognitive patterns-cognitive skills for daily decision making. B. Record review The residents record was reviewed from the date of admission, no documentation was found from the residents physician or any specialist documenting Resident #42 was incompetent to make her own decisions. The facility failed to complete a resident specific care plan to include the resident frequent requests for a change of POA. The face sheet identified the resident as her own responsible party. The resident had not been deemed incompetent. Record review revealed there was no documentation deeming Resident #34 incompetent or unable to make her own decisions. An investigation was started on 1/30/19 at 2:00 p.m. by the social services director. The investigation stated, At approximately 11:30 a.m. this morning, I was notified by the DON that a man and a woman were in the resident's room. I went and knocked on the resident's door and asked if I may come in. The resident stated Yes! I did recognize the gentleman as lawyer (LW), a local lawyer and his assistant. I did ask them what they were here for and if they had spoken to the resident's POA? LW had stated that is what we are here for is to revoke POA. I again asked, do you have permission of the POA to speak with the resident. He stated No, we do not. I then told him, I would have to ask you both to leave. His assistant had asked, Why can't we speak to her? I informed her if you haven't spoken with the POA and received permission to speak with her. I must ask you to leave. Does she have dementia, his assistant had questioned. I told her, you were a social worker and you know I can't divulge this information as it is a HIPPA violation. I asked them both to step out and we could call the POA, to inquire if it was permissible to speak with her. We went to the medical records office and I called, but the POA did not answer. I asked the LW for his number that way I could give it to the POA and she could call him. He did write down his number and they both left. -At 1:30 p.m. I received a phone call from the POA, who is the residents granddaughter and she asked me what was wrong. I assured her her grandmother was fine, but that LW and his assistant were here to talk with the resident. She asked for the number and stated she would be calling the LW as soon as she finished with me. She thanked us for our diligence in keeping her grandmother safe and stated she did not want them to speak with her grandmother. I thanked her for calling me back. The NHA investigation started on 2/1/19 stated, The resident is constantly asking random people to change her power of attorney. Her current POA was filled out prior to her coming to our facility. She has a dementia diagnosis and has had the limiting diagnosis since she admitted to our facility. Her friends sent a lawyer to help her change her POA. We stopped the lawyer on 1/30/19 due to her limiting diagnosis not allowing her to sign paperwork and contacted the actual POA. No medical information was given by the staff. The POA requested that lawyers information and for us not to allow her to talk to him. Certified occupational therapy assistant (COTA) was interviewers (sic) from out therapy staff due to the fact that the day before, 1/29/19, we stopped the lawyer talking to our maintenance director (MTD) said that guy was in the building the previous day asking for COTA. COTA stated that her friends were just trying to help her by hiring a lawyer and they asked COTA to make sure he gets to her room. Her supervisor interviewed her on 1/29/19. In the end, no harm occurred due to the fact that we intercepted before legal paperwork could be signed. POA thanked us for out help. The progress notes did not include the visit from the lawyer (LW) or the facility staff asking him to leave. C. Interviews The resident was interviewed on 2/4/19 at 1:43 p.m. She said she wanted to go home. She said she knew she would need assistance if allowed to go home. She stated she did not like her granddaughter because she would not let her go home. She said she had told the staff this. The LW was interviewed on 2/5/19 at 11:00 a.m. He said a friend of Resident #34 had contacted him because she wanted to change her POA. He said he went in for an initial visit with her on 1/29/19 to assess her POA status and needs. He said he returned on 1/30/19 with his administrative assistant (who was also a notary) to begin the paperwork for the change of POA. He said the facility asked him to leave before he could start. The social services director (SS) was interviewed on 2/6/19 at 11:29 a.m. She said the resident could have a visitor if the visitor was approved by the POA and the facility. She said if the resident was cognizant, they could change their POA at any time but Resident #42 could not because she had a diagnosis of dementia. She said when the LW returned with his administrative assistant and paperwork, the facility asked him to leave and notified the POA immediately. She said the resident had not been deemed incompetent through the courts. She said if a resident wanted to change their POA, the facility would have to investigate why the residents would want to change the POA to include input from the POA and the family. She said she did not know why there were no progress notes about the LW visit and asking him to leave. She said the facility was trying to protect the resident and keep her best interests and safety in mind. She said after reviewing the residents chart, she now understood it was the resident ' s right to choose her own POA. The nursing home administrator (NHA) was interviewed on 2/7/18 at 10:15 a.m. She said she did not know the investigation needed to be reported to the state agency. She said the facility was looking out for the safety of the resident to stop any exploitation from LW. She said she understood now that the frequent visitors asking about her safety should have prompted an investigation to ensure the facility was protecting the resident from and form of abuse.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interview, the facility failed to ensure a resident who is unable to carry out activities of daily living receives the necessary services and assistance during meals for one (#77) of four residents reviewed for meal assistance of 34 sample residents. Specifically, the facility failed to provide timely assistance during a meal for Resident #77. Findings include: A. Resident status Resident #77, age [AGE], was admitted on [DATE] and readmitted on [DATE]. According to the February 2019 computerized physician order (CPO), diagnoses included orofacial dystonia and anorexia. The 10/1/18 minimum data set (MDS) assessment revealed, the resident had severe cognitive impairment with a brief interview for mental status (BIMS) score of 00 out of 15. No mood or behavior symptoms were noted. No rejection of cares noted. He required total assist with eating. B. Record review The care plan, revised on 10/11/18, identified a nutritional risk with a diagnosis of anorexia. Interventions included to provide a nutritious meal prepared to diet order. The facility failed to identify a resident specific care plan to include the resident required total assistance from staff with meals. C. Observation The resident was observed pushed up to a table in the assisted dining room at 11:00 a.m. on 2/4/19. He had no fluids in front of him. At 11:35 a.m. a female resident joined the table and was immediately given fluids, he was not given any fluids. The aide asked if anyone needed anything from the two residents sitting at the table. Resident #77 motioned his hand toward himself (as to gesture for the staff to come to him) while looking directly at the staff. The aide smiled and walked away without assisting or seeing what Resident #77 wanted. At 11:33 a.m. registered nurse (RN) #2 sat at the table. She started to assist the female resident at the table. Resident #77 again motioned toward himself while looking at RN #2, who saw him but did not move from her position. -At 11:50 RN #2 was informed Resident #77 had not had anything to drink or eat. She said she was not familiar with the resident and was sure it was coming soon. An aide noticed the conversation and went immediately to the kitchen and returned with the residents meal. She said, it was the aide assigned to south to make sure everyone received their fluids in the dining room when they were being passed out. The resident received his fluids at 11:54 a.m. and his meal at 11:56 a.m. (This was more than 50 minutes after he was first observed in the dining room) D. Interviews Nurse aide (NA) #1 was interviewed on 2/6/19 at 9:40 a.m. She said Resident #77 did make motions if he needed something. She said he didn't talk much, but did move a little bit. Certified nurse aide (CNA) #7 was interviewed on 2/6/19 at 10:00 a.m. She said he can answer yes or no questions. She said he did make movements sometimes when he wants the staff's attention. Certified nurse aide with medication aide authority (CNA-MED) #3 was interviewed on 2/5/19 at 9:20 a.m. He said the resident can wave his arm to get the staffs your attention. The director of nurses (DON) was interviewed on 2/6/19 at 3:47 p.m. She said the resident can move his arm to get staff attention. She said with the resident being a dependent resident, he should have not had to wait that long for fluids or his meal. She said the resident was already a risk for weight loss and the staff should have addressed his fluid and food situation sooner.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and staff interviews, the facility failed to provide an ongoing program to support residents in their choice of activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident, encouraging both independence and interaction in the community for three (#84, #3 and 58) of eight residents reviewed for activities out of 34 sample residents. Specifically, the facility failed to: -Ensure Resident #84, #3 and #58 were invited and encouraged to attend activities of their preference. Findings include: I. Professional reference According to the University of Rochester Medical Center, Older Adults and the Importance of Social Interaction, 2015, https://www.urmc.rochester.edu/encyclopedia/content.aspx (March 2017), in pertinent part: .Specific health benefits of social interaction in older adults include: Potentially reduced risk for cardiovascular problems, some cancers, osteoporosis, and rheumatoid arthritis. Potentially reduced risk for Alzheimer's disease. Lower blood pressure. Reduced risk for mental health issues such as depression. Conversely, social isolation carries real risks. Some of these risks are feeling lonely and depressed. Being less physically active. Having a greater risk of death. Having high blood pressure. Social interaction helps keep your brain from getting rusty, but it's most effective when coupled with an overall healthy lifestyle, including a nutritious diet and physical activity . II. Resident #84 A. Resident status Resident #84, age [AGE], was admitted on [DATE] and readmitted on [DATE]. According to the February 2019 computerized physician order, (CPO), diagnoses included dementia with behaviors, Parkinson ' s, mental disorders due to known physiological condition, anorexia and anxiety. The 1/14/19 minimum data set (MDS) assessment revealed, the resident had severe cognitive impairment with a brief interview for mental status (BIMS) score of five out of 15. No mood or behavior symptoms were noted. The preference for customary routine and activities documented in part: it was very important to listen to music and enjoyed daily snacks. He required extensive assistance for bed mobility, transfers, grooming and toilet use The previous 10/2/18 MDS assessment revealed the resident preference for customary routine and activities documented in part: it was very important to listen to music, it was very important to keep up with the news, to do my favorite activity, go outside when the weather was good and enjoyed daily snacks. B. Record review The care plan initiated 6/26/12 and revised 1/15/19, identified the resident ' s passion was sports. He enjoys music, keeping up with news, visiting with staff and other residents ' . Resident ' s family visits often. Resident was independent in wheelchair. Interventions include invite and encourage residents to participate in activities of interest. Offer reading materials such as books, magazines and newspapers. Assist resident to and from activities. Activities calendar was reviewed for the dates of 2/4/19-2/5/19 -The activity calendar for 2/4/19 listed the following: - 9:00 a.m. today is - 10:30 a.m. reminisce - 1:30 p.m. movie - 3:30 p.m. ring toss. -The activity calendar for 2/5/19 listed the following: - 9:00 a.m. today is -10:30 a.m. hi/low - 2:00 p.m. bingo - 3:30 p.m. basketball. C. Observations Observations on 2/4/19 revealed the resident did not have any meaningful activity. The resident was lying in his bed sleeping at the following times: 9:07 a.m, 9:20 a.m., 10:01 a.m., 10:24 a.m., 11:18 a.m. -At 11:20 a.m., certified nurse aid medication aide (CNA-MED) # 3 and certified nurse aide (CNA) #6 provided perineal (PERI) care for Resident # 84. -At 11:35 a.m., Resident # 84 was placed in the dining room. The resident was sleeping from 3:00 p.m. - 4:00 p.m. During the observation, staff, other residents and/or volunteers did not interact with the resident. Additionally, the resident was not provided with sensory activities and was not invited to attend any of the scheduled activities. On 2/5/19 -At 8:55 a.m., the resident was lying in bed sleeping. -At 9:00 a.m., there were four residents in the common area watching television. The activity assistant (AA) #1 was reading today in history. -At 9:14 a.m., the AA #1 read the menu to the resident in the common area and stated to the residents, Have a good day. The AA turned the TV on then exited the secured area. -At 10:30 a.m., Resident #84 was lying in bed sleeping. -At 10:37 a.m., the AA #1 returned to the secured unit. The same four residents were in the common area watching TV. The AA #1 proceeded to start the card game of hi/low. The AA #1 did not attempt to invite any other residents ' from the secure unit. -At 10:52 a.m., the AA #1 ended the game of hi/low. The AA #1 said, I would like to thank my four participants today. -At 11:07 a.m., Resident #84 was lying in bed sleeping. -At 11:36 a.m., Resident #84 was escorted into the dining room by CNA #6 -At 1:09 p.m., Resident #84 was sleeping in his wheelchair (w/c) next to the dining room. -At 1:13 p.m., the resident was sliding down in his wheelchair. Social service director observed the resident and requested CNA #6 to help her reposition the resident in his w/c. -At 1:30 p.m., Resident #84 was placed next to his room in his w/c. The resident was sleeping in his w/c. -At 2:07 p.m., the AA #1 was recruiting resident to participate in bingo. The AA #1 walked right by Resident #84 and did not ask or encourage Resident #84 if he would like to participate in bingo. -At 2:10 p.m., the resident was lying in bed sleeping. -At 3:05 p.m., Resident #84 was sleeping in his w/c. -At 3:28 p.m., AA #1 started basketball activities in common area. He would walk around the common area having residents ' throwing a ball into a basket as he held the basket. -At 3:32 p.m., Resident #84 was lying in bed sleeping. -At 4:01 p.m., Resident #84 was lying in bed sleeping. During the observation, staff, other residents and/or volunteers did not interact with the resident. Additionally, the resident was not provided with sensory activities and was not invited to attend any of the scheduled activities. III. Resident #3 A. Resident status Resident #3, age [AGE], was admitted on [DATE]. According to the February 2019 CPO, diagnoses included paranoid schizophrenia, hallucinations, anxiety, insomnia other long-term drug therapy. The 1/27/19 minimum data set (MDS) assessment revealed, the resident had no cognitive impairment with a brief interview for mental status (BIMS) score of 15 out of 15. The resident had minimal depression with the resident scoring two of 27 on the patient health questionnaire (PHQ-9). The MDS revealed the resident hallucinated. The preference for customary routine and activities documented in part: it was very important to keep up with the news, to do my favorite activity, go outside when the weather was good. B. Record review The care plan, initiated 1/12/15 and revised 2/1/18, identified the resident enjoyed music, animals taking walks. The resident had a short attention span. The resident required assistance to and from activities. Praise and encourage resident to attend activities. Interventions include seat resident next to staff so resident can redirect resident when he starts to lose interest. Give resident verbal reminders of activity before commencement of activity. Engage resident in-group activities. Assist resident to and from activities. C. Observations Observations on 2/4/19 revealed the resident did not have any meaningful activity. The resident was lying in his bed sleeping at the following times: 9:10 a.m, 9:30 a.m., 10:10 a.m., 10:30 a.m., -At 11:19 a.m., the resident was walking into his restroom. CNA #6 walked into resident room to assist resident -At 11:35 a.m., Resident #3 was seated in the dining room. -At 11:42 a.m., Resident #3 was wandering to other tables in the dining room. Staff redirected Resident #3 to his table. The resident was in his room sleeping from 12:55 p.m. - 4:00 p.m. During the observation, staff, other residents and/or volunteers did not interact with the resident. Additionally, the resident was not provided with sensory activities and was not invited to attend any of the scheduled activities. Observations on 2/5/19 revealed the resident did not have any meaningful activity. The resident was lying in his bed sleeping at the following times: 8:55 a.m., 9:00 a.m., 10:35 a.m., 10:37 a.m., 10:52 a.m., 11:11 a.m. -At 11:40 a.m., Resident #3 was seated at his table in the dining room. -At 11:59 a.m., Resident # 3 stood up and exited the dining room. -At 1:10 p.m., - 4:05 p.m., Resident #3 was lying in bed sleeping. -At 2:10 p.m., the AA #1 had two resident who participated in bingo. -At 3:05 p.m., Resident #3 was lying in bed sleeping. -At 3:28 p.m., the resident was lying in bed sleeping -At 3:39 p.m., AA #1 walked into Resident #3 ' s room with the basket and ball. AA #1 exited the room immediately as Resident #3 was lying in bed sleeping. During the observation, staff, other residents and/or volunteers did not interact with the resident. Additionally, the resident was not provided with sensory activities and was not invited to attend any of the scheduled. III. Resident #58 A. Resident status Resident #58, age [AGE], was admitted on [DATE]. According to the February 2019 CPO, diagnoses included dementia with behaviors, insomnia and other symptoms and signs involving cognitive function. The 12/24/18 minimum data set (MDS) assessment, the resident had severe cognitive impairment with a brief interview for mental status (BIMS) score of six out of 15. No mood or behavior symptoms were noted. The preference for customary routine and activities documented in part: it was very important to keep up with the news, to do my favorite activity, go outside when the weather was good. B. Record review The care plan, initiated 12/28/17 and revised 12/12/18, identified the resident was independent in activities choice and participation. Post calendar in their room. periodically ask them if there was anything, they need for independent activity pursuits and provide if available. If residents are unable, ask family and friends to provide alternatives. Invite to community outings as appropriate. Offer opportunity for assisting at and activity with staff to promote feelings of usefulness. C. Observations Observations on 2/4/19 revealed the resident did not have any meaningful activity. The resident was walking up and down the halls. 2/4/19 -At 9:02 a.m., the resident was walking down the hall with a male resident. -At 9:30 a.m., the resident was observed standing by the elevator with same male resident. -At 10:15 a.m., the resident was observed walking into her room. -At 10:30 a.m., the resident observed walking throughout the secured unit. She would walk by the current scheduled activity of reminiscing. No staff was observed to encourage or invite resident to activity. -At 11:19 a.m., the resident was walking into another room with CNA-MED #3 redirecting Resident #58 out of the residents ' room. -At 11:35 a.m., Resident #58 walked toward the dining room and walked toward her room. -At 11:45 a.m., Resident #58 was wandering up and down the halls of the secured unit. -At 1:12 p.m., the resident was observed lying in bed sleeping. - At 2:23 p.m., the resident was walking in the halls asking staff if they had seen her bike. -At 2:32 p.m., CNA #6 had found the residents wheelchair, which she referred to as her bike. - At 3:28 p.m., Resident #58 was walking up and down the halls with her w/c. -At 3:42 p.m., the AA walked by the resident and did not ask if she wanted to participate or encourage her to play ring toss. During the observation, staff, other residents and/or volunteers did not interact with the resident. Additionally, the resident was not provided with sensory activities and was not invited to attend any of the scheduled activities. Observations on 2/5/19 revealed the resident did not have any meaningful activity. The resident was walking up and down the halls. 2/5/19 - At 9:00 a.m.-10:55 a.m., the resident was lying in bed sleeping. - At 12:01 p.m.-3:38 p.m., the resident was lying in bed sleeping. -At 3:41 p.m., the resident was observed leaving her room. CNA #6 escorted the resident back to her room and provided cares for Resident #58. - At 3:50 p.m., CNA #6 exited the resident room. -At 4:07 p.m., the resident was walking throughout the halls in the secured unit. During the observation, staff, other residents and/or volunteers did not interact with the resident. Additionally, the resident was not provided with sensory activities and was not invited to attend any of the scheduled activities. D. Interviews AA #2 was interviewed on 2/4/19 at 3:49 p.m. He said he was new to the position and he usually worked up stairs and was trying to get familiar with the residents. AA #1 was interviewed on 2/5/19 at 2:40 p.m. He said it was difficult to get participants for activities at times, especially for bingo. The activity director (AD) was interviewed on 2/7/19 at 8:55 a.m. The AD was informed of the observations above. She said she they have three activity staff but only two worked on Mondays, Wednesday and Fridays. She said activity staff are supposed to be in the secure unit through their entire shift. AD said AA #2 was recently hired and was adjusting to his new position. She said they do not provide a specific needs program for residents with dementia. She said all residents ' should be encouraged and invited to all activities. She said the negative outcome for residents ' not participating in activities could be boredom, isolation, negative behaviors and wandering.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident and family interviews and record review, the facility failed to ensure the resident received treatment and care in accordance with professional standards of practice, their comprehensive, person centered care plan and the residents choice for one (#55) of five residents reviewed for supplemental oxygen use out of 34 sample residents. Specifically, the facility failed to notify Resident #55s physician of low oxygen saturation levels (SATs); and did not educate or remind the resident when he was found without his oxygen on. Findings include: 1. Resdient status Resident #55, age [AGE], was admitted on [DATE] and readmitted on [DATE]. According to the February 2019 computerized physician order (CPO), diagnoses included congestive schizoaffective disorder, personality disorder, dementia with behaviors and dependence on supplemental oxygen. The 12/19/18 minimum data set (MDS) assessment revealed, the resident had no cognitive impairment with a brief interview for mental status (BIMS) score of 15 out of 15. No mood or behavior symptoms were noted. The MDS revealed the resident received oxygen therapy. 2. Observations On 2/4/19 at 9:38 a.m., the resident was observed sitting in his recliner in his room. The resident was observed not wearing his oxygen. The oxygen cannula/tubing was on the ground. On 2/5/19 at 11:39 p.m. The resident was observed sitting in the secure unit dining room. Resident #55 ' s oxygen tubing was wrapped tightly around his front wheeled walker (FWW). He stood up grabbed his FWW and walked out of the secured unit dining room. The resident did not have his oxygen cannula on as he exited the dining room. - At 12:13 p.m., the resident was in his room sitting in his recliner with his oxygen tubing lying on the ground. - At 1:15 p.m., the resident was in his room sleeping in his recliner his oxygen tubing was on the ground. - At 1:20 p.m., registered nurse (RN) #3 measured the resident's oxygen saturation. The levels varied from 82% to 84%. RN #3 asked the resident to take in several deep breaths, which elevated the resident ' s oxygen saturation to 92%. RN #3 replaced the oxygen tubing (without cleaning it, or exchanging it for a new one) and instructed the resident he needed to keep the oxygen on at all times. On 2/6/19 at 1:23 p.m., the resident was in his room sleeping in his recliner. His oxygen tubing was on the floor. - At 1:32 p.m., licensed practical nurse (LPN) #1 measured the resident's oxygen saturation. The levels varied from 83% to 85%. LPN #1 asked the resident to take in several deep breaths, which elevated the resident ' s oxygen saturation to 92%. LPN #1 replaced the oxygen tubing on the resident and told the resident, You need to keep your oxygen on. 3. Record review -No documentation was found for the two observations (?-2/6/19) documenting the resident was found without his oxygen on, that his oxygen level was checked, and the nurse re-checking his oxygen level to ensure his oxygen saturations stayed above 90 %. The February 2019 (CPO) showed a physician order for oxygen (O2) via nasal cannula at one liter per minute. Check O2 SATs daily to maintain SAT level of 90 % or greater. Nurse may titrate O2 by increasing at one liter per minute to achieve /maintain sat level 90 % and notify provider, start date 7/14/18. The care plan, initiated 7/5/18 and revised 12/20/18, identified the resident had an alteration in breathing related to (r/t) diagnosis of hypoxemia. Interventions include administer oxygen flow as ordered. Notify physician if any changes needed in increasing or decreasing oxygen flow r/t decrease O2 saturation. Observe resident for pain, cyanosis, fatigue, signs and symptoms (s/s) of infections, fever, cough and abnormal lung sounds. Notify physician as needed. Assess pulse oximeter as needed (PRN) complaints of shortness of breath. 4. Interviews The RN # 3 was interviewed on 2/5/19 at 1:20 p.m. RN #1 said Resident #55 should have had his oxygen on. She said Resident #55 does remove his oxygen regularly. She said a negative outcome for the resident not wearing his oxygen could affect mental status, cause shortness of breath, wheezing and cough. LPN #1 was interviewed on 2/6/19 at 1:32 p.m. She said the resident oxygen should have been on him. LPN #1 said Resident #55 will take his oxygen throughout the day or he forgets to put it back on after he washes up. She said the only time we would call the physician would be if the resident ' s oxygen level did not go above 90%. The director of nursing (DON) was interviewed on 2/6/19 at 4:00 p.m. She said the staff was supposed to check oxygen saturation levels when a resident was found without their oxygen. The DON said the staff were supposed to measure the oxygen saturation levels again when the oxygen had been on for a few minutes; the doctor was notified of the levels if they would not increase and ask what to do. She said an RN was able to adjust liter flow and then follow up with the medical provider. The DON said it was important for staff to ensure the resident ' s had supplemental oxygen as ordered to reduce the risk of altered mental status, dizziness, falls, and prevent a hypoxic event.

Based on observations and staff interviews, the facility failed to provide sufficient support personnel competent to carry out the functions of the dietary service for one of two dining rooms. Specifically, the facility failed to ensure an adequate system was in place to provide meal services in a timely fashion to residents seated in the secured dining room. Findings include: The food was prepared in the main kitchen and transported to the secure unit at all meal times. The meal carts were brought into the secure unit at 11:50 a.m. A. Posted mealtimes The posted meal times for the main dining room were breakfast was scheduled to begin breakfast at 6:30 a.m., lunch at 10:30 a.m. and dinner at 3:30 p.m. B. Lunch observations On 2/4/19 at 11:03 a.m., 14 residents were observed sitting in various locations in the Cokedale dining room. Residents were helped to their respective tables. -At 11:36 a.m., 19 residents were seated in the dining room. -At 11:42 a.m.-11:45 a.m., two certified nurse aide (CNA)'s started taking residents orders and serving drinks to the residents. -At 11:45 a.m., Resident #58 got up and proceeded to leave the dining area, staff did not encourage the resident to wait for his meal. -At 11:48 a.m., Resident #67 was taking others residents drinks at her assigned table and drank from them. -At 11:52 a.m., Resident #3 got up and proceeded to leave the dining room. He was redirected by CNA back to his table. -At 11:58 a.m., the first meal was served in the dining room. On 2/5/19,at 11:04 a.m., 17 residents were observed sitting in various locations in the dining room. Residents were helped to their respective tables, served beverages and offered clothing protectors. - At 11:14 a.m., Resident #45 attempted to leave the dining room with CNA #6 redirecting him back to his table. - At 11:19 a.m., Resident #84 was brought into the dining room and by 11:21 a.m. there were 19 residents seated in the dining room -At 11:27 a.m., Resident #67 was walking to other tables and attempting to grab other residents ' drinks. Certified nurse aide-medication aide (CNA-MD) #3 redirected the resident back to her table. -At 11:30 a.m., Resident #55 exited the dining room. - At 11:32 a.m., Resident #55 stood up and exited the dining room. He left his front wheeled walker at his table. -At 11:36 a.m , Resident #67 was self-propelling himself to other tables in the secured dining room. - At 11:37 a.m., Resident #55 returned to the dining room and sat at his table. - At 11:41 a.m., Resident #3 was wandering in the dining room. CNA #6 redirected him to his seat. - At 11:43 a.m., Resident #55 stood up and said, I am tired I don ' t want to eat. He grabbed his walker and exited the dining room. - At 11:44 a.m., medical records was assisting the residents ' in the dining room. She said, It takes too long to serve the residents ' we lose them. - At 11:56 a.m., the first meal was served in the dining room. C. Staff interview The dietarydirector (DD) was interviewed on 2/6/19 at 3:03 p.m. The DD said the dining room should be served within five to seven minutes when the food was delivered to each dining room. The DD was informed of the observations above. The DD said he was not aware of the wait time in the secured dining room. He said the negative outcome of this could be agitation, wandering, choking, boredom, loss of appetite and just losing the opportunity of the residents eating their meals. The nursing home administrator (NHA) was interviewed on 2/6/19 at 3:28 a.m. The NHA was told of the dining observation on 2/4/19 and 2/5/19. She said the longest residents should wait for their meals would be no more than 15 minutes. She said open dining allowed the residents to eat when they were ready. She said residents should not sit in the dining room for prolonged amounts of time. She said a negative outcome could be residents having increased in agitation and could have possible weight loss.

Based on record review and interview, the facility failed to have sufficient staff with the appropriate competencies in skills and techniques necessary to care for residents ' needs, as identified through resident assessments, and described in the plan of care. Cross reference F838-failed to have a completed comprehensive facility assessment Specifically, the facility failed to: -Provide a completed facility assessment and with the lack of skill competencies the facility could not make sure the cares provided were up to professional standards; and, -Document and ensure the above CNAs and CNA-MED had completed competencies in skills and techniques. Findings include: Record review No competencies for staff were found in the files for the CNAs. Interviews CNA #8 was interviewed on 2/7/19 at 9:20 a.m. He said he had not had to demonstrate his skills in order to prove his competency in providing care before providing care. CNA #7 was interviewed on 2/7/19 at 9:42 a.m. She said she had not had to demonstrate her skills in order to prove her competency in providing care before providing care. CNA #2 was interviewed on 2/7/19 at 10:02 a.m. She said she had not had to demonstrate her skills in order to prove her competency in providing care before providing care. The nursing home administrator was interviewed on 2/7/19 at 10:04 a.m. She said she was under the impression the staff trainings were also the same as the competencies. She said a negative outcome would be staff would not be providing skilled and quality care to all residents' .

Based on observations, record review and staff interviews, the facility failed to ensure food was stored, prepared, and served under sanitary conditions in one of one kitchens. Specifically, the facility failed to ensure: -Appropriate hand hygiene by food service staff. Findings include: I. Improper hand hygiene A. Professional references A. According to the Centers for Disease Control (CDC), Hand Hygiene in Healthcare Settings, March 2016, https://www.cdc.gov/handhygiene/providers/index.html (January 2018). It read in pertinent part, .When to Perform Hand Hygiene .After contact with inanimate object (including medical equipment) in the immediate vicinity of the patient . B. According to Aurora Health Care, Neutropenic Precautions, May 2016, https://ahc.aurorahealthcare.org/fywb/X31975.pdf (January 2018). It read in pertinent part, . Placing you on neutropenic precautions means that we are taking extra steps to protect you from germs, because you have a lowered ability to fight infections .Read and follow the instructions on the door. Family/visitors may be asked to wear a mask or gown and gloves, while in your room . B. Observations 1. Observation of meal preparation was conducted on 2/16/19 from 9:15 a.m. to 10:30 a.m. Observations in the primary production kitchen included: Cook #2 was observed preparing the pureed meals. [NAME] #2 walked over to the oven and retrieved a container of beef. [NAME] #2 placed the beef into the blender and then exited the kitchen and returned with a pitcher of hot water from the dining. He proceeded to puree the meal and added hot water. He lifted the lid with his hand wiped his hand on the side of his apron and replaced the lid. He grabbed a plastic spatula from a drawer and proceeded to empty the beef into a metal container. He then went over to the preparation table and grabbed a thermometer. He did not sanitize the thermometer prior to placing it in the meat. He placed the thermometer into the meat and documented the food temperature. He then grabbed an alcohol wipe and wiped the thermometer. He placed the dirty alcohol wipe into the trash can touching the inside of the trash can with his gloved hand. He then placed plastic wrap over the metal container. He then walked over and placed the pureed meat into the steam table with the same contaminated gloves. He returned to the food preparation area removed the container from the blender and went to the dirty side of the kitchen area to have the blender cleaned by the dishwash staff. He returned to the preparation area and wiped the area with a wet towel. He removed his gloves and threw his dirty gloves into the trashcan touching the side of the can. He put on another pair of gloves (without washing his hands) on and retrieved the blender from the dish area. He returned to the food preparation area. He proceeded to puree the mechanical soft food in the blender He grabbed a plastic spatula and proceeded to empty the beef into a metal container. He again went over to the preparation table and grabbed a thermometer. He did not sanitize the thermometer prior to placing it in the meat. He placed the thermometer into the meat and documented the food temperature. He then grabbed an alcohol wipe and wiped the thermometer. He placed the dirty alcohol wipe into the trash can touching the inside of the trash can with his gloved hand. He then placed plastic wrap over the metal container. He then walked over and placed the pureed meat into the steam table with the same contaminated gloves on. He returned to the food preparation area removed the container from the blender and went to the dirty kitchen area to have the blender cleaned. He returned to the food preparation area and cleaned the area with a wet towel. He put on a new pair of plastic gloves and threw the empty glove box in the trash. The trash was full so he forcefully pushed the box into the trash. He then proceeded to cut tomatoes on the cutting board. He did not wash or sanitize his hands during this process and touching ready-to-eat foods. Cook #2 was on the serving line preparing residents ' meals. He was making a sandwich for a special order. He put on a pair of plastic gloves and opened a bag of bread by touching the outside of the bag. He grabbed the bread with his gloved hands, removed four slices of bread, and placed them on a plate. He then wiped his hands on the side of his pants and tied the bag of bread closed. He walked over to the walk-in refrigerator grabbed the door with his right gloved hand and returned to the serving line with a small cup of yogurt. He then finished preparing the sandwich. He grabbed tomatoes and lettuce with his contaminated gloved hands and placed them on the sandwich and placed the other half of bread on the plate as well. He then cut the sandwich holding and touching it with his gloved hand. He grabbed the plate took it over to the serving line and placed it on a tray. He walked into the refrigerator grabbed a tray of cake and proceed to cut slices for the residents ' meals. Cook #2 was warming up tortillas for the meal. He grabbed six tortillas from the bag and placed the tortillas into the microwave. He did not place the tortillas onto a plate (barrier). He opened the door to the microwave with his gloved hands and grabbed all tortillas and walked over to the serving line and proceeded to make soft tacos. He placed a spoon full of ground beef onto the tortilla, one hand holding the handle of the spoon and the other had he used to keep the meat on the tortilla. He then walked over to the cart, which had the lettuce and tomatoes in it and he wiped his hand on the side of his pants while plating the food. He repeated this process several times. He did not wash or sanitize his hands during this process. He contaminated not only the food on the plate but also the left over portions of the ready-to-eat foods. Cook #1 was observed making a plate of beef taco salad. He opened a bag of tortilla chips reached inside the bag and retrieved a hand full of chips. He placed them on the plate, and wiped his hands on the side of his pants. He then placed a scoop of meat onto the tortilla chips and with his contaminated gloved hand he guided the meat onto the chips. He then placed tomatoes and lettuce onto the chips. He repeated this process several times. He then walked over to the refrigerator and retrieved a cup of yogurt, gave it to the dining staff and wiped his hands on the side of his pants again. He did not wash or sanitize his hands during this process. C. Staff interview The dietary director (DD) was interviewed on 2/6/19 at 3:03 p.m. He said all kitchen staff needed to wash their hands between every task. He said all staff must wash their hands before handling or serving food. Staff should also wash their hands when they left the kitchen area and upon returning. The DD was told of the staff observations (above) during meal service. The DM said staff should be washing their hands every time they change their gloves as well. The DD said it good hygiene was necessary to avoid cross contamination.

Based on record review and interview, the facility failed to conduct and document a facility-wide assessment to determine what resources are necessary to care for its residents competently during both day-to-day operations and emergencies. Specifically, the facility failed to have a comprehensive facility assessment. I. Findings include The facility assessment (FA) was reviewed and revealed it was not a comprehensive assessment of the facilities resources necessary to provide daily care to the resident population. The FA was developed on 12/29/17 and updated 1/2/19. The facility had a secured unit with 23 residents. The FA did not identify a secured unit. The facility failed to identify the care required by the resident population specifically the secured unit. The FA did not complete the ethnic, cultural, and religious factors to include languages, cultural preferences, and religions within the resident population. The FA did not include a staffing plan to include sufficient staff to meet the needs of the residents at any time. The FA did not identify staff training and competencies needed to provide care to the various residents residing in the facility. The FA identified it provided tracheostomy care. The FA did not identify the physical environment, equipment, services, and other physical plant considerations that are necessary to care for their population. The FA did not identify all buildings and/or other physical structures and vehicles. The FA did not identify the equipment used in the facility to provide care including both medical and non-medical. The FA failed to identify all personnel, including managers, staff (both employees and those who provide services under contract), and volunteers, as well as their education and/or training and any competencies related to resident care. The FA did not include the review of staff assignments. The FA failed to identify contracts, memorandums of understanding, or other agreements with third parties to provide services or equipment to the facility during both normal operations and emergencies. The FA failed to identify health information technology resources, such as systems for electronically managing patient records and electronically sharing information with other organizations. The FA and failed to identify evaluations of the infection prevention and control program to include effective systems for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement, that follow accepted national standards. II. Interview The nursing home administrator (NHA) was interviewed on 2/7/18 at 10:15 a.m. She said she was not aware the FA was not complete. She said it should cover all the facility resources to provide care for all the residents. The NHA said the facility did not provide tracheostomy care as documented on the assessment. She said she was not aware the secured unit was not included on the FA. She said she will review the FA and make the necessary changes to ensure all residents are receiving the care they require and it is reflected on the facility assessment.