Every finding on record at Denver North Care Center

Based on record review and interviews, the facility failed to report allegations of abuse to the State Survey and Certification Agency in accordance with state law for one of one allegations of abuse.Specifically, the facility failed to report an allegation of physical abuse between Resident #3 and Resident #4 on 7/11/26 timely.Findings include:Record review and interviews confirmed the facility corrected the deficient practice prior to the onsite investigation on 8/5/26, resulting in the deficiency being cited as past noncompliance with a correction date of 7/22/26. I. Facility plan of correctionThe corrective action plan the facility implemented in response to the physical abuse reporting incident involving Resident #3 and Resident #4 on 7/11/26 was received from the nursing home administrator (NHA) on 8/6/26 at 2:08 p.m. The plan of correction documentation revealed that upon notification of physical abuse allegations, the incident investigation was initiated and was reported immediately to the appropriate agencies. On 7/13/26, education was provided to the NHA by the regional director of operations regarding reportable time frames. Education was provided on 7/13/26 to the witness of the physical abuse incident on 7/11/26 regarding reporting allegations. All residents were identified to be potentially affected by the deficient practice. The plan for sustained compliance included the director of nursing (DON)/NHA/designee to complete a daily (Monday through Friday) review of progress notes to ensure that any potential abuse allegations are reported and investigated. Identified concerns to be addressed at morning meeting with the interdisciplinary team (IDT). All staff completed education on abuse, neglect and exploitation and the Elder Justice Act on 7/18/26 and 7/29/26. All allegations of abuse were to be reviewed by the quality assurance and performance improvement (QAPI) team monthly for the next three months in order to ensure reporting requirements were met. II. Facility policy and procedureThe Abuse policy, revised 5/3/23, was provided by the NHA on 8/5/26 at 3:48 p.m. It read in pertinent part, If a resident abuse, neglect, exploitation or misappropriation of resident property or injury of unknown source is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law. Reporting can be completed verbally or in writing. Immediately is defined as within two hours of an allegation involving abuse or that results in serious bodily injury or within 24 hours of an allegation that does not have abuse or results in a serious bodily injury. Notification is also made to the following persons and agencies within the time frames defined by regulation or statute for the state licensing/certification agency, the local/state ombudsman, the resident's representative, adult protective services, law enforcement officials, the resident's attending physician, the medical director (when necessary) and the board of nursing when nursing staff are involved.III. Record reviewThe facility investigation for a physical abuse allegation on 7/11/26 was provided by the NHA on 8/5/26 at 9:45 a.m. The investigations documented an allegation of abuse between Resident #3 and Resident #4 occurred on 7/11/26 at 10:30 p.m. -However, the facility reported the alleged abuse on 7/13/26 at 9:00 a.m., 34 hours after the incident occurred.IV. Staff interviewsThe NHA was interviewed on 8/5/26 at 1:26 p.m. She said that the allegation of physical abuse between Resident #3 and Resident #4 occurred on 7/11/26, which was a Saturday. The NHA said the staff in the building at the time of the allegations of physical abuse implemented interventions to keep residents safe, but did not communicate the allegation of physical abuse to the NHA. The NHA said when she got to the facility the following Monday morning (7/13/26), she reviewed the nursing reports from the prior weekend and saw the notes regarding the allegation of physical abuse. The NHA said she reported the allegation of physical abuse immediately to the appropriate agencies. The NHA said she provided education to the staff members regarding timely reporting of abuse to the NHA beginning on 7/13/26. Licensed practical nurse (LPN) #3 was interviewed on 8/5/26 at 2:45 p.m. LPN #3 said he was one of the nurses working at the time of the incident on 7/11/26 between Resident #3 and Resident #4. LPN #3 said he was Resident #4's (the assailant) nurse. LPN #3 said the incident happened during shift change and he thought there was miscommunication between himself and the oncoming nurse as to who was going to report the incident to the NHA. LPN #3 said he did not document that he reported the incident to the NHA.

Based on observations and interviews, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety in the main kitchen.Specifically, the facility failed to ensure:-Staff performed hand hygiene was conducted during dishwashing, and, -The food preparation area was clean and sanitary. Findings include: I. Failure to perform hand hygiene during dishwashingA. Professional referenceThe Colorado Department of Public Health and Environment Colorado Retail Food Establishment Rules and Regulations (revised 3/16/24), was retrieved on 12/22/25. It revealed in pertinent part, 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 and: after touching bare human body parts other than clean hands and clean, exposed portions of arms; after using the toilet room; after coughing, sneezing, using a handkerchief or disposable tissue; using tobacco products, eating, or drinking; after handling soiled equipment or utensils; during food preparation, as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks; before donning gloves to initiate a task that involves working with food; and after engaging in other activities that contaminate the hands. (2-301.15)B. ObservationsOn 12/17/25 at 12:49 p.m. dietary aide (DA) #3 was washing the dishes in the dish room utilizing the dishwasher. The clean dish area was full of clean dishes. DA #3 loaded a rack of dirty dishes (with his bare hands). He then went to the clean dish area and began to unload the clean dishes and put them away, without performing hand hygiene. DA #3 then went to the dirty dish side and proceeded to push the rack of dirty dishes into the dishwasher with his bare hands. He then went to the clean dish side and unloaded another rack of clean dishes and put them away without performing any kind of hand hygiene. C. Staff interviewsDA #3 was interviewed on 12/17/25 at 1:58 p.m. He said he would sanitize his hands when going from dirty to clean dishes or he would rinse his hands with the sprayer when going from dirty to clean dishes. The dietary manager (DM) and the nursing home administrator (NHA) were interviewed together on 12/18/25 at 12:35 p.m. The DS said her expectation was for her staff to clean their hands with soap and water before putting away clean dishes. II. Failure to ensure food preparation area was clean and sanitaryA. Professional referenceThe Colorado Department of Public Health and Environment Colorado Retail Food Establishment Rules and Regulations (revised 3/16/24), was retrieved on 12/22/25. It revealed in pertinent part, Materials that are used in the construction of utensils and food-contact surfaces of equipment may not allow the migration of deleterious substances or impart colors, odors, or tastes to food and under normal use conditions shall be: finished to have a smooth, easily cleanable surface. Multiuse food contact surfaces shall be: smooth, free of breaks, open seams, cracks, chips, inclusions, pits, and similar imperfections, free of sharp internal angles, corners and crevices, finished to have smooth welds and joints. Equipment, food-contact surfaces and utensils shall be clean to sight and touch. (Chapter 4)B. Facility policy and procedureThe Kitchen Sanitation policy and procedure, revised November 2022, was provided by the NHA on 12/18/25 at 6:11 p.m. It read in pertinent part, All utensils, counters, shelves and equipment are kept clean, maintained in good repair and are free from breaks, corrosions, open seams, cracks and chipped areas that may affect their use or proper cleaning. Seals, hinges and fasteners are kept in good repair. All equipment, food contact surfaces and utensils are cleaned and sanitized using heat or chemical sanitizing solutions.C. ObservationsOn 12/17/25 at approximately 2:00 p.m. there was a curved piece of metal that was approximately a foot by two and a half inches on the small food preparation table next to the main steam table and underneath the shelf that held the microwave. Where the metal piece was bent to curve into the depression, there were crumbs that were visible and on each end the metal did not lie flat causing there to be a gap between the metal piece and the table surface. On 12/17/25 at 2:12 p.m. DA #4 pried the piece of metal up with a knife. Once the metal piece was pried up and out of the hole, there were piles of crumbs sitting in the hole and a brown sticky substance was around the edge of the metal piece and the hole. There was also a foul odor coming from the hole. D. Staff interviewsDA #4 and CK #1 were interviewed together on 12/17/25 at 2:12 p.m. DA #4 asked cook (CK) #1 what the metal piece was for. CK #1 said the table used to hold a juice machine and that was where the liquids would drain from. CK #1 said that they switched from that juice machine to a new one years ago and they no longer needed the drainage area. CK #1 said she normally cleaned the area two to three times a day but she had just gotten back from vacation. The DM and the NHA were interviewed together on 12/18/25 at 12:35 p.m. The DM said she was currently working on coming up with a cleaning schedule and she would add cleaning that particular part of the table to the schedule. She said that she would be doing staff training and education regarding cleaning. The NHA said she was not aware of the sticky substance near the table. The registered dietitian (RD) and the DM were interviewed together on 12/18/25 at 1:45 p.m. The DM said the table was used for small types of meal preparation and they would use the table for getting ready to serve the meals. She said it was not used for food preparation. The RD said that they could work it into their budget to get a new preparation table for that area.

Based on observations and interviews, the facility failed to remove medications and biologicals that were stored and labeled properly according to professional standards in two of two medication rooms, two of four medication carts and two of four vaccination refrigerators.Specifically, the facility failed to ensure expired medications were removed from the medication room, medication carts, vaccination refrigerator and medication refrigerator. Findings include:I. Professional referencesThe United States Food and Drug Administration (USFDA) Don't Be Tempted to Use ExpiredMedicines (revised 10/31/24), was retrieved on 12/29/25 from https://www.fda.gov/drugs/special-features/dont-be-tempted-use-expired-medicines. It read in pertinent part, Expired medical products can be less effective or risky due to a change in chemical composition or a decrease in strength. Certain expired medications are at risk of bacterial growth, and sub-potent antibiotics can fail to treat infections, leading to more serious illnesses and antibiotic resistance. Once the expiration date has passed, there is no guarantee that the medicine will be safe and effective. If your medicine has expired, do not use it.II. Facility policy and procedureThe Storage of Medication policy was provided by the nursing home administrator (NHA) on 12/18/25 at 6:11 p.m. It read in pertinent part, The facility stores all drugs and biologicals in a safe, secure, and orderly manner. The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner. Drugs and biologicals used in the facility are stored in locked compartments under proper temperature, light, and humidity controls. Only persons authorized to prepare and administer medications have access to locked medications. Medications requiring refrigeration are stored in a refrigerator located in the drug room at the nurses' station or in another secure location. Medications are stored separately from food and are labeled accordingly.III. Observations On 12/16/25 at 12:00 p.m. The first-floor medication room was observed with licensed practical nurse (LPN) #2The medication refrigerator contained the following:-Six Acetaminophen (fever and pain reducer) 650 milligrams (mg) suppositories, which expired in October 2025; and, -Four vials of Prevnar 20 (pneumococcal vaccine) three which expired in January 2025 and the other expired in March 2025.The first floor medication cart B was observed on 12/16/25 at 12:30 p.m. with LPN #2. There were five loose pills observed within the drawers LPN #2 was able to identify.The pills included: -Two Busparone tablets used to treat anxiety disorders;-Two Atrovastin tablets used to lower cholesterol; and, -One Baclofen tablet, used as a muscle relaxant. The second floor medication cart A was observed on 12/16/25 at 1:00 p.m. with LPN #1. There were eight tablets of Mucus Relief DM (expectorant and cough suppressant) which expired in November 2025.There were six unidentified loose pills at the bottom of the drawer. LPN #1 was not able to identify the pills.The second-floor medication room was observed with LPN #1 on 12/16/25 at 11:45 a.m.The following was observed:-Two Hemacolt Developers, a liquid reagent solution used for the fecal occult blood test, expired in January 2025;-Eighty Hemacolt test cards (used for the fecal occult blood test), expired in October 2025;-Two COVID home tests, expired 11/1/24;-Three Assure control solutions (used to check that the meter and the test strips are working properly), expired October 2025, March 2025 and August 2025;-Two open bottles of Vitamin C 500 mg, 200 tablets expired November 2025;-Thirty soft gels of CoQ10 100 mg (an antioxidant), expired August 2025; -Two bottles of Ocular Vitamin, 60 tablets expired November 2025;-Two hundred and fifty tablets of folic acid 400 micrograms (mcg) expired September 2025;-Forty-five Tuberculin syringes with needle expired October 2025; and,-One bottle of eye itch relief expired November 2025.The second-floor medication refrigerator was observed on 12/16/25 at 11:40 a.m. with LPN #1 nurse. There were four Ativan suppositories (used to treat anxiety,) expired 12/14/25IV. Staff interviewsLPN #2 was interviewed on 12/16/25 at 12:25 p.m. LPN #2 said expired medications were to be cleaned out by the nurse manager and the director of nursing (DON). LPN #2 said she would take expired medications to the unit manager. LPN #2 said the medication cart was cleaned every shift as the nurses responsibility. LPN #1 was interviewed on 12/16/25 at 1:30 p.m. LPN #1 said that every nurse was responsible for checking the expiration of medications, before giving medications. LPN #1 said the unit manager also checked periodically. LPn #1 said every nurse on their shift was responsible for cleaning the medication cart.The DON and the NHA were interviewed on 12/17/25 at 1:45 p.m. The DON said the nurses and central supply staff were responsible for checking for expired medications. The DON said the risk of giving a medication that was expired was that it could be ineffective. The DON said each nurse on their shift was responsible for cleaning the medication cart.

Based on observations and interviews, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of diseases and infection on one of two units.Specifically, the facility failed to:-Ensure housekeeping staff cleaned resident rooms in a hygienic manner;-Ensure housekeeping staff disinfected high-touch areas (call lights, door handles and handrails) when cleaning residents' rooms;-Ensure dwell times were followed during room cleaning;-Ensure staff wore personal protective equipment (PPE) while providing wound care to residents;-Ensure hand sanitizer was not expired;-Ensure staff performed hand hygiene while providing wound care to residents;-Ensure a clean field was created for wound care supplies; and,-Ensure staff performed hand hygiene during meals. Findings include: I. Failure to clean resident rooms in a hygienic manner and disinfect high-touch areas. A. Professional reference Assadian O, Harbarth S, Vos M, et al. Practical Recommendations for Routine Cleaning and Disinfection Procedures in Healthcare Institutions: A Narrative Review. The Journal of Hospital Infection, (July 2021) 113:104-114, was retrieved on 12/22/25 from https://www.journalofhospitalinfection.com/article/S0195-6701(21)00105-5/fulltext. It revealed in pertinent part, High-touch surfaces, on the other hand, are usually close to the patient, are frequently touched by the patient or nursing staff, come into contact with the skin and, due to increased contact, pose a particularly high risk of transmitting pathogens (virus or microorganism that can cause disease) Healthcare-associated infections (HAIs) are the most common adverse outcomes due to delivery of medical care. HAIs increase morbidity and mortality, prolonged hospital stay, and are associated with additional healthcare costs. Contaminated surfaces, particularly those that are touched frequently, act as reservoirs for pathogens and contribute towards pathogen transmission. Therefore, healthcare hygiene requires a comprehensive approach. This approach includes hand hygiene in conjunction with environmental cleaning and disinfection of surfaces and clinical equipment. The Centers for Disease Control and Prevention (CDC) Environment Cleaning Procedures, (revised 3/19/24) was retrieved on 12/22/25 from https://www.cdc.gov/healthcare-associated-infections/hcp/cleaning-global/procedures.html. It read in pertinent part, High-Touch Surfaces: The identification of high-touch surfaces and items in each patient care area is a necessary prerequisite to the development of cleaning procedures, as these will often differ by room, ward and facility. Common high-touch surfaces include: bed rails, IV (intravenous) poles, sink handles, bedside tables, counters, edges of privacy curtains, patient monitoring equipment (keyboards, control panels), call bells and door knobs. Proceed from cleaner to dirtier areas to avoid spreading dirt and microorganisms. Examples include: during terminal cleaning, clean low-touch surfaces before high-touch surfaces, clean patient areas (patient zones) before patient toilets, within a specified patient room, terminal cleaning should start with shared equipment and common surfaces, then proceed to surfaces and items touched during patient care that are outside of the patient zone, and finally to surfaces and items directly touched by the patient inside the patient zone. In other words, high-touch surfaces outside the patient zone should be cleaned before the high-touch surfaces inside the patient zone and clean general patient areas not under transmission-based precautions before those areas under transmission-based precautions. Profect HP Hydrogen Peroxide Disinfectant (2025), was retrieved on 12/29/25 fro: https://www.spartanchemical.com/globalassets/sharepoint/product-literature--documentation---epidocuments/product-literature/l1008_profect_hp.pdf. It revealed in pertinent part One minute contact time ensures efficacy and compliance. Disinfects high touch surfaces in one minute. B. Facility policy and procedure The Cleaning and Disinfecting Resident Rooms policy. revised August 2013, was received from the nursing home administrator (NHA) on 12/18/25 at 6:11p.m. It revealed in pertinent part, the purpose of this procedure is to provide guidelines for cleaning and disinfecting resident rooms. Perform hand hygiene after changing gloves. Change cleaning cloth when they become soiled. Clean horizontal surfaces (bedside tables, overbed tables, and chairs) daily with a cloth moistened with disinfectant solution. Clean personal use items (lights, phones, call bells, bedrails, etc.) with disinfectant solution at least twice weekly. C. Observations On 12/17/25 at 10:14 a.m. housekeeper (HK) #1 was observed cleaning room [ROOM NUMBER], a double occupancy room. HK#1 performed hand hygiene using an alcohol based hand rub (ABHR) then applied clean gloves. HK #1 took a dry cloth and a spray bottle with hydrogen peroxide disinfectant. She sprayed the dry cloth three times and then began wiping down the door handles to the main door of the resident room. HK #1 then moved the vanity sprayed disinfectant to the cloth again she wiped the counter top then skin handles, then the sink bowel. With the same cloth she cleaned the sink bowl and the soap and paper towels dispensers. -HK #1 failed to use a clean cloth to clean surfaces after wiping down the sink bowl. HK#1 failed to ensure the disinfectant remained wet on the surface for one minute to ensure it was effective in disinfecting the surface. HK #1 returned to her cleaning cart just outside the entry way of the residents' room. HK #1 collected a new cloth, sprayed it with the disinfectant and went to bed B side of the room. She began to wipe down the dresser, night stand, and floor fan. HK #1 moved to bed A side of the room and used the same cloth to wipe down the night stand, dresser and bed side table. -HK #1 failed to change the cloth between bed A and bed B sides of the room. HK#1 returned to her cart, collected a new cloth and collected another spray, NABC Concentrate On The Go (broad range germicidal cleaner-disinfectant) and went to the residents' shared bathroom. HK #1 sprayed the NABC cleaner all over the toilet from top to bottom including the riser that was attached to the toilet seat. HK #1 then took a toilet bowl brush stored in the corner of the bathroom behind the toilet and scrubbed the toilet bowl, inner walls of the toilet riser and the bottom of the toilet seat that was propped up in the up position to be kept out of the way from the rise. -HK #1 failed to use only the toilet bowl brush in the bowl of the toilet and failed to clean in a clean to dirtiest manner. She then took the cloth and wiped the toilet from top to bottom. She ran the rag across the floor and the heating unit along the base of the wall in front of the toilet. -HK #1 used the rag she used to clean the toilet to wipe down other areas. HK #1 then returned to her cleaning cart and collected a mop pad from a bucket with multiple pads in it. She wrung the mop pad out allowing excess mop water to fall into the bucket. -HK #1 failed to change her soiled gloves after cleaning the toilet and contaminated her mop water when she reached into it for a mop pad. HK #1 then mopped the bathroom and returned to her cart and reached into the mop bucket a second time with the same gloves. She collected a new mop pad and mopped bed B side of the room. Then HK #1 went to bed A side of the room. HK #1 touched the bedside table with gloves and the fall mat in order to mop the floor on bed A side of the room. HK #1 touched the same items again to put them back in their place after mopping the floor. -HK #1 failed to change her gloves after cleaning the bathroom which then led to her touching surfaces with soiled gloves throughout the resident room. HK #1 contaminated the mop water a second time with soiled gloves touching the mop pads in the bucket. HK #1 returned to her cart and collected another spray bottle and sprayed the room with an odor neutralizer. -HK#1 touched the cart several times throughout observations without changing her gloves. HK #1 returned to her cart, removed her gloves and performed hand hygiene with ABHR. -HK #1 cleaned the entire room with the same gloves. She failed to disinfect the high touch areas in rooms like call lights, bed controls and light switches. D. Staff interviews HK #1 was interviewed on 12/17/25 at 10:21 a.m. HK #1 said areas such as the call light and bed controls were cleaned when a deep clean was done on the room and not on a daily basis. HK #1 said she was not aware she needed to change her gloves at certain times when cleaning a double occupancy room or after cleaning the bathroom. She said she did not know she contaminated her mop bucket when she reached in twice to retrieve a mop pad during observations. HK #1 said she was not sure how many cloths' she should have used for cleaning the double occupancy room and she said she did not know she needed to use one cloth for bed A and one for bed B. The environmental service director was interviewed on 12/18/25 at 9:23 a.m. The environmental services director said training for housekeepers was given in a language they understand and he had staff available when he needed something to be communicated to non English speaking staff. The environmental services director said all staff went through two weeks of training where they learned to clean the room in order to ensure they were cleaning high touch areas daily. The environmental services director said high touch areas were to be cleaned daily to prevent the spread of infection. He said high touch areas were call lights, bed controls, handles, bed side tables and light switches. The environmental services director said he did monthly audits of rooms to ensure they were cleaned however he had no documentation to show his audits being completed. The environmental services director said gloves should be changed throughout the cleaning process at certain intervals like moving from bed A to bed B side, after cleaning the bathroom and at any time gloves appear visibly soiled. The environmental service director said the Profect HP disinfectant was effective when the surface remained wet for one minute to ensure it had ample time to properly work. The infection preventionist (IP) was interviewed on 12/18/25 at 11:05 a.m. She said she was to monitor staff for hand hygiene practices and provide education every two weeks or when observed staff needing education. The IP said she worked with the environmental services director to ensure housekeepers were following infection prevention practices like hand hygiene. The IP said her goals were to ensure every one masters hand washing, PPE to help ensure they were informed and prevent infections. II. Enhanced barrier precautions failures A. Professional reference According to the Implementation of personal protective equipment used in nursing homes to prevent the spread of multidrug-resistant Organisms (MDROs) (dated April 2, 2024). Was retrieved on 12/22/25 from https://www.cdc.gov/long-term-care-facilities/hcp/prevent-mdro/ppe.html. It revealed in pertinent part, Enhanced barrier precautions expand the use of PPE and refer to the use of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing. MDROs may be indirectly transferred from resident-to-resident during these high-contact care activities. Nursing home residents with wounds and indwelling medical devices are at especially high risk of both acquisition of and colonization with MDROs. The use of gown and gloves for high-contact resident care activities is indicated, when Contact Precautions do not otherwise apply, for nursing home residents with wounds and/or indwelling medical devices regardless of MDRO colonization as well as for residents with MDRO infection or colonization. Dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, device care or use: central line, urinary catheter, feeding tube, tracheostomy/ventilator, wound care: any skin opening requiring a dressing. B. Facility policy and procedure The Enhanced Barrier Precautions policy, dated August 2022, was received from the NHA on 12/18/25 at 6:11 p.m. It revealed in pertinent part, Enhanced barrier precautions (EBPs) are utilized to prevent the spread of multi-drug resistant organisms (MDROs) to residents. EBPs employ targeted gown and glove use during high contact resident care activities when contact precautions do not otherwise apply. a. Gloves and gown are applied prior to performing the high contact resident care activity (as opposed to before entering the room).b. Personal protective equipment (PPE) is changed before caring for another resident. c. Face protection may be used if there is also a risk of splash or spray. Examples of high-contact resident care activities requiring the use of gown and gloves for EBPs include:a. Dressing; b. bathing/showering; c. transferring; d. providing hygiene; e. changing linens; f. changing briefs or assisting with toileting; g. device care or use (central line, urinary catheter, feeding tube, tracheostomy/ventilator, etc.); and h. wound care (any skin opening requiring a dressing). EBPs are indicated (when contact precautions do not otherwise apply) for residents with wounds and/or indwelling medical devices regardless of MDRO colonization. EBPs remain in place for the duration of the resident's stay or until resolution of the wound or discontinuation of the indwelling medical device that places them at increased risk. Staff are trained prior to caring for residents on EBPs. Signs are posted in the door or wall outside the resident room indicating the type of precautions and PPE required. PPE is available outside of the resident rooms. C. Observations On 12/17/25 at 9:35 a.m. wound care was observed for Resident #5. The wound care physician , an unidentified person who came to the facility with the wound care physician and licensed practical nurse (LPN) #4 entered Resident #5 rooms to complete weekly wound rounds. All three entered the resident room and completed the wound care. They completed the wound care without applying all PPE that was required for EBP. The staff applied clean gloves. There was no PPE outside the resident room or inside the resident's room. There was no sign on the resident's door indicating EBP were to be used for Resident #5. At 10:25 a.m. registered nurse (RN) #1 entered resident room [ROOM NUMBER] along with a nurse practitioner. The resident had a right shin wound and staff were observed to enter the room, apply gloves, remove the old dressing and change gloves The wound care supplies were placed directly on the resident's bed. They cleaned the wound, applied triple antibiotic ointment and covered it with a border dressing.is -The staff failed to wash hands before, during and after wound care. The staff failed to apply PPE while providing wound care and failed to have a clean working area. D. Staff interviews LPN #4 was interviewed on 12/18/25 at 11:05 a.m. she said they did not need to wear PPE when providing wound care as the wound was not draining and there was no risk of splash back. The IP was interviewed on 12/18/25 at 11:05 a.m. She said she was unaware PPE needed to be worn during dressing changes. The IP said staff were informed of EBP during huddles and through reports at shift change. III. Expired hand sanitizer A. Professional reference The Expired hand Sanitizer: Keep or Discard? (Undated) was retrieved on 12/30/25 from: https://ehs.usc.edu/2023/05/12/expired-hand-sanitizers-keep-or-discard/. It revealed in pertinent part, Hand sanitizers are regulated as over-the-counter drugs by the US Food and Drug Administration (FDA) and are required to have an expiration date. Hand sanitizer products past their expiration date are still viable for killing germs on hands; however, their alcohol content may be diminished over time due to evaporation, especially if the container is only partly full, or was stored in a warm place (the interior of a vehicle). B. Observations On 12/16/25 at 12:00 p.m. the first floor medication room was observed with LPN #2. There was one 12 ounce bottle of hand sanitizer that expired March 2023. At 12:30 p.m. the first floor medication cart B was observed with LPN #2. There were two four ounce bottles of hand sanitizer which expired April 2021 and one 18 ounce bottle of hand sanitizer which expired 2022 the month was rubbed off and not legible. C. Staff interviews The IP was interviewed on 12/18/25 at 11:05 a.m. She said ABHR should contain 60 percent (%) alcohol and staff should wash their hands with soap and water after three uses of ABHR. The IP said if ABHR were expired it was not as effective in killing microorganisms. IV. Failure to perform hand hygiene during meals A. Observations On 12/16/25 at 12:08 p.m. Resident #11 was eating with his hands while holding his basketball. Resident #11 was holding the basketball with his right hand while eating with his left hand. He was touching the basketball with his left hand prior to the meal starting and hand hygiene was not performed or offered. On 12/16/25 at 12:21 p.m. Resident #11 finished his meal and his drinks. Resident #11 handed his empty cup to an unidentified staff member who was assisting another resident. The staff member took the cup from Resident #11 by grabbing the cup with her thumb on the inside of the cup and the rest of her finger on the outside of the cup. Resident #11 then reached his hand out to her and she then shook his hand using the same hand that she took his used cup from, and shook his hand. She then went back to assisting the other resident with their meal, using the same hand she had used to take the cup and shake Resident #11's hand with, without performing hand hygiene. -The unidentified staff member failed to perform hand hygiene after touching multiple dirty surfaces. During a continuous observation on 12/16/25, beginning at 3:24 p.m. and ending at 5:40 p.m., the following was observed: At 3:24 p.m. Resident #11 was in bed and his basketball was on the floor by the sink in his room. At 4:44 p.m. certified nurse aide (CNA) #1 and CNA #3 went to his room to help get him up. At 4:54 p.m. CNA #3 picked the basketball up off the floor and handed it to Resident #11 without sanitizing the basketball. At 5:05 p.m. the DON sanitized Resident #11's hands and set his basketball on the dining room table. At 5:11 p.m. Resident #11 was holding his basketball again and tapping the ball with his fingers and hand. At 5:22 p.m. Resident #11 was holding an unidentified nurse's hand At 5:23 p.m. Resident #11 handed his basketball to the unidentified nurse and she took it from him, tapped the basketball with her fingers and handed it back to him. The unidentified nurse did not sanitize her hands. She then picked up a spare table setting of silverware from the table and let people know that if they needed another table setting there was one, and she then placed it where it could be used. She then put her hands in her pockets and then cleared some dirty dishes. She did not sanitize her hands. At 5:36 p.m. the unidentified nurse cut Resident #11's food into smaller pieces. She had not sanitized her hands. Resident #11 began eating with his hands and the staff did not sanitize his hands before he began eating. B. Staff interviews LPN #5 was interviewed on 12/18/25 at 1:00 p.m. She said hand hygiene was expected at the start and end of each meal for residents. She said the staff were expected to perform hand hygiene each time they delivered a meal and any time they touched a resident, dirty dishes and in between delivering meals. CNA #2 was interviewed on 12/18/25 at 1:58 p.m. She said hand hygiene should be performed before and after meals and any time their hands got soiled. CNA #2 said the staff should be performing hand hygiene all the time. CNA #2 said staff should be performing hand hygiene before touching a resident's meal. CNA #2 said staff could use hand sanitizer five to ten times before washing their hands with soap and water. She said if their hands were soiled then they should wash their hands with soap and water. CNA #2 said if the staff touched Resident #11's basketball they should sanitize their hands before touching any one else's meal. CNA #2 said staff should also sanitize Resident #11's hands and staff should try and sanitize his basketball as much as possible. CNA #3 was interviewed on 12/18/25 at 2:04 p.m. CNA #3 said hand hygiene should be performed after delivering a meal tray to the dishwashing area. CNA #3 said staff should sanitize their hands after touching a resident. CNA #3 said staff should sanitize their hands after touching Resident #11's basketball. CNA #3 said the day shift tried to sanitize Resident #11's basketball at the beginning and end of their shift. The DON was interviewed on 12/18/25 at 4:35 p.m. She said staff should be washing their hands prior to serving and they should hold the plates from the bottom and should not have their thumbs or fingers on the plate. The DON said they should sanitize their hands between plates, but every third plate they should be washing their hands with soap and water. The DON said it was not sanitary for staff to grab a resident's cub by the rim The DON said the staff needed to perform hand hygiene after touching Resident #11's basketball and between tasks.

Based on record review and interviews, the facility failed to provide response, action and rationale to residents involved in group grievances. Specifically, the facility failed to effectively address, resolve and demonstrate the facility's response to grievances identified during resident council. Findings include:I. Resident group interviewFour alert and oriented residents (#12, #20, #36 and #71) who regularly attended the resident council meetings were interviewed on 12/18/25 at 11:25 a.m. The residents were identified as alert and oriented through facility and assessment.The group of residents said resident council meetings were not productive and the facility did not follow up on grievances brought up in the resident council meetings or provide resolution.Resident #20 said the residents reported that the staff noise levels on the evening shift woke up residents, but nothing had been done to address it. He said there was a lack of communication from administration as to what is done to resolve the grievances brought up. Resident #12 said if the facility was addressing the grievances, the resolutions were not shared with the resident council or with the resident council president. Resident #12 said the residents on the second floor who did not come to the dining room were served their room trays between an hour and one and a half hours later than the other residents. He said he had reported the concern to staff.II. Record reviewA review of a resident council meeting minutes, dated 9/17/25, revealed group grievances concerning old business from August 2025 of staff coming in on the evening shift being too loud and meals being served late. New business included grievances concerning nurses not being available during meals, having a hard time finding nurses and staff barging into resident rooms without knocking. -There was no documentation that indicated in the meeting minutes that the grievances from August 2025 had been reviewed or resolved. A review of the resident council meeting minutes, dated 10/15/25, revealed group grievances concerning staff coming in on the evening shift were being too loud.-There was no documentation that indicated the resolutions for September 2025 grievances were shared with the resident council. A review of the resident council meeting minutes, dated November 2025, revealed group grievances concerning staff coming in on the evening shift were being too loud.-There was no documentation that indicated the resolutions for October 2025 grievances were shared with the resident council. A review of the grievance forms dated 8/1/25 through 12/1/25 revealed:A grievance form, dated 8/20/25, revealed a resident council concern regarding staff being too loud on the evening shift. The resolution on 9/3/25 was to provide staff education to give reports at shift change in a softer tone or in another area. The grievance had not been documented when resolution was provided or approved by the resident council.A grievance form, dated 9/17/25, revealed a resident council concern regarding that staff were barging into the rooms without knocking. The resolution on 10/6/25 was to provide staff education to knock before entering resident rooms. The grievance had not been documented when resolution was reviewed or provided to the resident council.A grievance form, dated 9/17/25, revealed a resident council concern regarding nursing being more available during medication pass. The resolution on 10/6/25 was to provide staff education to the nurses to assist in the dining room during the evening meals. The grievance had not been documented when resolution was provided to the resident council.-There were no grievance forms regarding late meals provided during the survey (see resident group interview above). III. Staff interviewsThe activities director (AD) was interviewed on 12/17/25 at 2:55 p.m. She said she had just started running the resident council the prior month. The AD said she went over old business and if there was a resolution. She said then the resident council went over any new business. She said when the residents brought up concerns in the resident council, she filled out a grievance form and she brought back a resolution the following month. The AD said that there should be a grievance form for every concern. The NHA was interviewed on 12/17/25 at approximately 3:30 p.m. She said the facility filled out grievance forms for individual grievances and also for group grievances. The NHA said resolutions were provided to the residents during resident council on the resolutions the following month. She said she was unable to provide any of the staff education provided that was mentioned on the grievance forms (see record review above). IV. Facility follow upThe NHA provided documentation on 12/17/25 at 4:55 p.m. The documentation indicated staff education regarding knocking on doors, being disruptive at evening shift change and nurses being more available during evening meals was conducted on 12/17/25 (during the survey).

Based on record review and interviews, the facility failed to inform two (#14 and #27) of four residents reviewed for beneficiary notices and appeal rights out of 38 sample residents of changes in their services covered by Medicare in a timely manner.Specifically, the facility failed to provide written notification of a Medicare Non-Coverage letter (NOMNOC) to the resident's representative that Medicare-covered services were ending for Resident #14 and Resident #27 in a timely manner. Findings include:I. Resident #14A. Resident statusResident #14, age [AGE], was admitted on [DATE]. According to the December 2025 computerized physician orders (CPO), diagnoses included hemiplegia and hemiparesis (weakness and paralysis on one side of the body) and limitation of activities due to disability.According to the 9/16/25 minimum data set (MDS) assessment, the resident had mild cognitive impairment with a brief interview for mental status (BIMS) score of 12 out of 15. The resident's speech therapy start date was 8/4/25 and did not have a documented end date.B. Record reviewA therapy note, dated 10/7/25, revealed the speech therapist discussed goals with Resident #14 prior to her discharge on [DATE], and the resident agreed with the therapist's goals.The Skilled Nursing facility (SNF) Beneficiary Protection Notification Review revealed the resident's last covered Medicare Part A skilled service was on 10/17/25. The NOMNC was signed by Resident #14 on 10/23/25, which was six days after the resident's Medicare Part A benefits ended. The resident continued to reside in the facility.-However, the facility provided the NOMNC to Resident #14 six days the resident's Medicare Part A services ended, which was not sufficient notification that the current skilled nursing services would likely not be paid for by the Medicare provider and/or health plan and that the resident might have to pay for any services after this date (10/17/25).-Additionally, the untimely issuance of the NOMNC did not provide Resident #14 sufficient time to request for an immediate appeal of the discontinuation of skilled services, which ended on 10/17/25.II. Resident #27A. Resident statusResident #14, age greater than 65, was admitted on [DATE]. According to the December 2025 CPO, diagnoses included chronic embolism and thrombosis (blood clots and blood vessel obstructions) of his right lower extremity and dementia.According to the 11/12/25 MDS assessment, the resident had severe cognitive impairment and was unable to complete a BIMS assessment. The assessment documented the resident was receiving physical therapy services.B. Record reviewA progress note, dated 11/13/25 at 2:34 p.m., revealed a therapy staff member called Resident #27's representative and informed her the resident had been discharged from therapy. The resident's representative gave verbal consent for the notice of noncoverage and did not have any questions at the time.The SNF Beneficiary Protection Notification Review revealed the resident's last covered Medicare Part A skilled service was on 11/13/25. The NOMNC was signed by Resident #27's representative on 11/13/25, which was the same day the resident's Medicare Part A benefits ended. The resident continued to reside in the facility.-However, the facility provided the NOMNC to Resident #27's representative the same day the resident's Medicare Part A services ended, which was not sufficient notification that the current skilled nursing services would likely not be paid for by the Medicare provider and/or health plan and that the resident might have to pay for any services after this date (11/23/25).-Additionally, the untimely issuance of the NOMNC did not provide Resident #27's representative sufficient time to request for an immediate appeal of the discontinuation of skilled services, which ended on 11/23/25.III. Staff interviewsThe health information manager (HIM) and director of rehabilitation (DOR) were interviewed together on 12/18/25 at 10:24 a.m. The HIM said when the therapy team told her a resident had reached their end of therapy and then the HIM or the therapy team filled out the resident's NOMNOC/ABN. The HIM said she checked to see if the resident has a responsible party, notified the responsible party and got their signature before uploading the NOMNOC into the resident's chart. The HIM said she issued the NOMNOC and ABN four days prior to their discharge from therapy.The HIM said Resident #27's therapy services ended 11/13/25.The DOR said Resident #27's discharge date from therapy was 11/13/25. The DOR said she missed the date for issuing Resident #27's NOMNOC. The DOR said the therapy team had talked to Resident #27's representative and she was aware of the resident's progress and that his time in therapy was winding down. The DOR said they had realized the therapy team had not done their non-coverage notice. The DOR said she had assumed the role of director earlier that month and was new to the position, and was not yet tracking non-coverage as part of her role.The HIM said Resident #14's NOMNOC was issued on 10/23/25. The DOR said they did not have a rehabilitation director at the time who tracked services/noncoverage, so the therapy team was trying to catch up on their notices. The DOR said the therapy team had talked with Resident #14 and she was aware her services were winding down. The DOR said Resident #14's therapy services ended on 10/17/25. The DOR said the therapy team had discussed Resident #14's goals and upcoming discharge on [DATE] during their session on 10/7/25.-However, the facility did not provide a written NOMNOC to Resident #14 until 10/25/25, six days after the resident's services were discontinuedThe nursing home administrator (NHA) was interviewed on 12/18/25 at 3:01 p.m. The NHA said the NOMNOC was issued three days prior to the resident's end of services and was sent to the resident or their responsible party to be signed. The NHA said the NOMNOC was sent out three days prior to the end of service date so the resident or their representative could appeal the decision if they did not want to lose services. The NHA said the HIM issued the NOMNOCs.The NHA said there were notes prior to Resident #14's discharge from services which documented the resident was aware she was being discharged from therapy, and the resident had not mentioned wanting to extend her services.The NHA said the former DOR had left the faciity on leave and later resigned from her position. The NHA said the current DOR worked at another facility during that time and came to the facility to help with staff coverage. The NHA said if there were any NOMNOCs that were issued late, it was due to the lapse in DOR position coverage. The NHA said she would do education for the staff and be more involved in the non-coverage process moving forward.-However, the facility did not provide a written NOMNOC to Resident #14 until 10/25/25, six days after the resident's services were discontinued.

Based on record review and interviews, the facility failed to ensure one (#24) of five residents were free from chemical restraints and were receiving the least restrictive approach for their needs out of 34 sample residents. Specifically, the facility failed to ensure evidence was present that indicated Resident #24 had an increase in behaviors that warranted an increase in antipsychotic medication increases. Findings include:I. Facility policy and procedureThe Psychopharmological policy, undated, was provided by the nursing home administrator (NHA) on 12/18/25 at 6:11 p.m. It revealed in pertinent part,The primary physician, psychiatrist (if applicable) and/or consultant pharmacist will monitor residents who are prescribed psychopharmacological drugs at least quarterly to assure these drugs are utilized according to State and Federal regulations and for the appropriate treatment of resident diagnosis.The interdisciplinary team which may consist of, but is not limited to, Nurse Managers, Social Services, dietary manager, activity professional, CNA (certified nurse aide), and mental health professional/case manager will review residents on psychopharmacological drugs at least quarterly. This meeting will include a review of the following: behavior tracking and psychiatrist (if applicable) /mental health clinician notes.II. Resident #24A. Resident statusResident #24 age [AGE], was admitted on [DATE]. According to the December 2025 computerized physician orders (CPO), diagnoses included anxiety, major depressive disorder and unspecified dementia. The 12/12/25 minimum data set (MDS) assessment revealed Resident #24 had severe cognitive impairments with a brief interview for mental status (BIMS) score of five out of 15. The MDS assessment indicated the resident had demonstrated behaviors of delusions, verbal aggression and wandering. B. Resident interviewResident #24 was interviewed on 12/16/25 at 2:17 p.m. Resident #24 was unable to determine the day of the week, the year or what type of facility he was living in. He said he was not taking any psychiatric medications and could not identify any of his medications. C. Record reviewThe antidepressant medication care plan, revised 7/29/25, revealed Resident #24 used antidepressant medications related to signs and symptoms of depression. Interventions included monitoring behaviors of wandering/exit seeking, verbal aggression, paranoia, disruptive/intrusive, and disorganized thinking (revised 3/24/25), providing education to the resident, family, and caregivers about risks, benefits and the side effects and/or toxic symptoms (revised 5/16/23) and monitoring for hallucinations/delusions, social isolation, suicidal thoughts, decline in activity of daily living abilities, and insomnia (initiated 7/22/2020). -The antidepressant medication care plan did not include the physician's indication for use (hypersexual behaviors).The antipsychotic medication care plan, revised 7/29/25, revealed Resident #24 used antipsychotic medications related to symptoms and behaviors related to dementia. Interventions included monitoring behaviors of hallucinations/expressing delusions, verbal/physical aggression, and hypersexualized comments (revised 3/24/25), reviewing behaviors/interventions and alternate therapies attempted and their effectiveness (initiated 7/22/2020) and utilizing non-pharmacological interventions such as cold therapy, range of motion therapy, massage, relaxation/breathing techniques, imagery and distraction techniques, aromatherapy, and therapeutic touch (initiated 7/22/2020). -The antipsychotic medication care plan did not include revisions related to the 8/18/25 or the 10/22/25 medication increases revealing an increase in behaviors or a worsening of the resident's condition. Review of Resident #24's December 2025 CPO revealed the following physician's orders:Sertraline (an antidepressant medication) 100 milligram (mg) one time a day for hypersexual behaviors, ordered on 5/21/25.Olanzapine (an antipsychotic medication) 5 mg. Give one time a day for dementia with agitation, ordered 5/21/25 and increased 8/18/25.Olanzapine 5 mg. Give two tablets (total of 10 mg) one time a day for dementia with agitation, ordered 8/18/25 and increased 10/22/25. Olanzapine 20 mg. Give one time a day for dementia, ordered 10/22/25.Monitor behaviors related to dementia: 1. Hallucinations/expressing delusions. 2. Verbal/physical aggression. 3. Hypersexualized comments. Non-pharmological interventions included: A. Redirection. B. One-on-one. C. Activity. D. Low stimulation environment. E. Offer toileting. F. Offer a snack. G. Offer fluids. H. Assess for pain. I. Other- document in progress notes, ordered on 8/17/25.-The dementia behavior monitoring order did not include revisions to reflect an increase in behaviors or a worsening of the resident's condition related to the increase of the resident's antipsychotic medication on 10/22/25. Monitor behaviors related to major depressive disorder: 1. Wandering/exit seeking. 2. Verbal aggression. 3. Paranoia 4. Disruptive/intrusive. 5. Disorganized thinking. Non-pharmological interventions included: A. Redirection. B. One-on-one. C. Diversional activity. D. Offer to call family or friend. E. Other-document in progress notes. F. Offer a walk, candy, soda, or snack of choice, ordered on 10/13/25.Review of Resident #24's EMR from 8/1/25 to 12/16/25 revealed the following:A guardianship referral, dated 3/24/24, revealed the facility had sent a referral to a guardianship agency for Resident #24 due to the resident being unable to make his own decisions related to diminished cognition. The pharmacist's monthly medication review, dated 6/14/25, revealed a recommendation to decrease Resident #24's olanzapine. The physician made a note at the bottom of the review that they neither agreed or disagreed but that there needed to be a review of history and behaviors with the nurse.A psychiatrist visit note, dated 7/7/25, revealed that the resident was assessed for safety and deemed his current risk to be low and was at his psychiatric baseline. The psychiatrist included their observation of the resident as calm and agreeable and during the interaction with the psychiatrist, Resident #24 was pleasant and cooperative. No hallucinations or delusions were reported or observed. The pharmacist's monthly medication review, dated 7/10/25, revealed a recommendation to decrease Resident #24's olanzapine. The physician made a note at the bottom of the review that they neither agreed or disagreed but that the physician deferred the decision to the psych team managing. A psychiatrist visit note, dated 7/21/25, revealed the resident was psychiatrically stable and at his baseline with no acute mood or behavioral concerns. The psychiatrist included their observation of the resident as calm and agreeable and during the interaction with the psychiatrist, with no new or ongoing symptoms of anxiety, depression, psychosis or other psychiatric disturbances. The resident also remained socially appropriate and cooperative during interactions with others. No hallucinations, paranoia or delusions were reported or observed. A psychiatrist visit note, dated 8/5/25, revealed the resident was assessed for safety and deemed his current risk to be low and was at his psychiatric baseline. The note indicated the resident was calm and agreeable. During the interaction with the psychiatrist, Resident #24 was pleasant and cooperative. No hallucinations or delusions were reported or observed. A psychiatrist visit note, dated 8/19/25, revealed the psychiatrist documented the staff had not reported any recent behavioral changes or psychiatric concerns. The note documented Resident #24 had been stable in mood, sleep and appetite patterns. The note documented the resident was calm, cooperative and in no acute distress. The resident engaged appropriately with the clinician and responded clearly to direct questions, with no signs of psychosis, mania, agitation or hallucinations.Review of the interdisciplinary team (IDT) psychotropic pharmacological meeting notes, dated 8/19/25, revealed there were no recommendations made to Resident #24's medication regimen and no explanation for the increase of the olanzapine on 8/18/25. A nursing note, dated 8/20/25, revealed the resident used derogatory racial slurs towards staff and the staff redirected the resident.A nursing note, dated 8/21/25, revealed the resident's physical condition had declined and the resident had to be sent out to the hospital. A psychiatrist visit note, dated 9/2/25, revealed the resident was assessed for safety and deemed his current risk to be low and was at his psychiatric baseline. The resident was calm and agreeable. During the interaction with the psychiatrist Resident #24 was pleasant and cooperative.A psychiatrist visit note, dated 9/16/25, revealed the resident was psychiatrically stable and at his baseline. The resident was calm and agreeable. Resident #24 was pleasant and cooperative. The concluded findings were the resident presented without mood or behavioral disturbances or safety concerns.-Psychiatrist visit notes dated 6/14/25 and 9/16/25 failed to reveal documentation the pharmacist was made aware of the rationale for not conducting a reduction. The visit notes from 7/7/25 to 9/16/25 also failed to mention increasing the resident's olanzapine and instead documented the resident was stable and had no psychiatric changes necessitating increases to his antipsychotic usage.-Review of the resident's EMR revealed there were no documented psychiatrist visits after 9/16/25. The pharmacist's monthly medication review, dated 10/4/25, revealed the following note from the pharmacist: CMS recommended max doses for dementia with behaviors diagnosis of olanzapine is 5mg. The resident is currently taking 10 mg daily. Consider a gradual dose reduction (GDR) for olanzapine with a target dose of 5 mg or adjust to an appropriate diagnosis. The physician made a note at the bottom that they declined the recommendation due to staff and nurse practitioners noting Resident #24's behaviors continue and pose a significant risk to others. A behavior note, dated 10/8/25, revealed the resident punched the wall with his hand and the staff redirected him. A behavior note, dated 10/22/25, revealed the resident was verbally aggressive towards another resident and the staff redirected him.The IDT psychotropic pharmacological meeting notes, dated 11/12/25, revealed there were no recommendations made to Resident #24's medication regime and no explanation for the increase of the olanzapine on 10/22/25.A review of the nurse behavior monitoring on the treatment administration records (TAR) from 8/1/25 to 12/16/25 revealed no documented behaviors.A review of certified nurse aide (CNA) behavior notes from 8/1/25 to 12/16/25 revealed the following: On 10/4/25 the resident displayed behaviors not directed at others of refusing care. Interventions attempted were redirection and offering snacks/fluids. The behavior note did not indicate which, if any, interventions were effective. On 10/11/25 the resident displayed behaviors not directed at others of refusing care and self neglect. Interventions attempted were redirection, offering snacks/fluids, and engaging in conversation. The behavior note did not indicate which, if any, interventions were effective. On 11/8/25 the resident displayed behaviors not directed at others of refusing care. Interventions attempted were redirection, ADL care, engaging in conversation and offering a calm environment. The behavior note did not indicate which, if any, interventions were effective. -CNA behavior notes did not reveal there was an increase in the resident's behaviors that warranted an increase of the antipsychotic medication Informed consent for psychoactive medication use, dated 8/18/25, listed an increase of olanzapine 5 mg once a day but did not document that the medication was being increased to twice a day to equal 10 mg a day.Informed consent for psychoactive medication use, dated 10/24/25, listed an increase of olanzapine to 20 mg a day. III. Staff interviewsCNA #4 was interviewed on 12/17/25 at 9:30 a.m. CNA #4 said Resident #24 had behaviors of yelling at people if someone came too close to him or to his belongings. She said the resident was generally very agreeable and kind towards staff and she could not recall the last time she had observed any aggressive behaviors with Resident #24. Registered nurse (RN) #1 was interviewed on 12/17/25 at 9:41 a.m. RN #1 said the nurses were to look at the resident's care plan for target behaviors and resident specific non-pharmological interventions. RN#1 said what typically happened is that the nurses would call social services to come and intervene when the resident was having a behavior. She said nurses were expected to document resident behaviors in a progress note and the MAR. RN #1 said Resident #24 had behaviors of yelling at people, becoming frustrated when he could not remember where his room was, and making racist statements. She said he did not have behaviors of physical aggression, hallucinations, or delusions. Licensed practical nurse (LPN) #7 was interviewed on 12/17/25 at 10:11 a.m. LPN #7 said the nurses looked at the behavior monitoring in the CPO for behaviors and interventions and documented them in the TAR. She said Resident #24 did not have any aggressive verbal or physical behaviors. The NHA and the social services director (SSD) were interviewed on 12/18/25 at approximately 12:30 p.m. The NHA said the facility's process for ensuring the efficacy of psychoactive medications was to consult through the behavioral health provider and the psychiatrist on appropriate behaviors and interventions. She said the director of nursing (DON) and the SSD worked together to manage the behavior monitoring through monthly review. The NHA said the SSD established the timeframes for when residents were to be reviewed in the psychotropic drug meeting. The NHA said during the psychotropic drug meeting, the IDT reviewed the behavior documentation completed by the CNAs and nurses. She said nurses documented behaviors in the TAR and made a behavior progress note by exception. The NHA said the CNAs documented in their own charting system. The NHA said the CNA charting did not allow for the CNAs to customize the behaviors or the interventions, it only provided a generic template that was the same for all the residents. She said the IDT reviewed the number of behaviors documented throughout the month but if there was a behavior displayed that was not on the generic template, the CNAs had to verbally tell the nurse. The NHA said the IDT utilized nurse and CNA behavior monitoring to track the effectiveness and necessity of the psychoactive mediations by showing increases, decreases or stability in behaviors. The SSD said after she received the visit notes from the psychiatric team, she reviewed the notes for any recommendations and relevant changes to the resident's condition. She said she was unable to say why the psychiatrist notes did not indicate antipsychotic medication increases for Resident #24. The NHA said psychotropic consents were obtained from the resident or responsible party before the medication was administered. She said Resident #24 was showing an increase in behaviors and verbal threats to others and the behavior increases were discussed and documented in the IDT psychotropic pharmacological meeting notes. She said she was unable to locate the notes for the behavior increases and discussion for the necessity of increasing the olanzapine. The NHA said she would locate the documentation of behaviors to justify the increases to the olanzapine for Resident #24. -However, documentation was not provided that provided a justification for the increases in medication. The NHA said she was unable to explain why Resident #24 was taking an antidepressant for hypersexual behaviors and said she would have to look into this. The NHA said regarding pharmacist's recommendations, the NHA satisfied her obligation to ensure the recommendations were given to the physician to review. She said that was her only responsibility, not to ensure there was documentation of the recommendations being acted upon. V. Facility follow-upAn email was received by the NHA on 12/18/25 at 4:20 p.m. It contained the following explanation for Resident #24's Sertraline diagnosis of hypersexual behaviors:It was identified upon review of documentation that we had the incorrect diagnosis of Sertraline, the provider came in and changed the order to hypersexualized behaviors, however the diagnosis should have remained depression.The NHA was interviewed again on 12/18/25 at approximately 5:00 p.m. The NHA said the facility had not noticed that the Sertraline diagnosis had been changed to hypersexual behaviors on 5/21/25 until brought to their attention during the survey. She said this had been reviewed by the IDT psychotropic pharmacological meeting team, the psychiatrist and the pharmacist nine times between 6/14/25 and 10/4/25. On 12/18/25 at 6:10 p.m. the NHA forwarded an email from the psychiatrist, dated 12/18/25 (during survey). The psychiatrist revealed in the email that the GDR recommendations made by the pharmacist on 6/14/25 and again on 7/10/25 for the olanzapine were discussed between her and the nurse practitioner (NP) for Resident #24. The psychiatrist said the two agreed that a GDR would be too soon after the last GDR in May 2025 from 7.5 mg to 5 mg. -However, review of Resident #24's EMR did not reveal documentation regarding the conversation between the psychiatrist and the NP. -The facility failed to provide documentation indicating the resident had increased behaviors from his baseline that warranted an increase in psychotropic medications.

Based on record review and interviews, the facility failed to incorporate recommendations from the preadmission screening and resident review (PASRR) Level II determination and evaluation from the State Mental Health Agency in the case of residents with serious mental illness or a related condition for one (#39) of two residents reviewed for PASRR out of 38 sample residents.Specifically, the facility failed to arrange and incorporate recommendations from the PASRR Level II notice of determination (NOD) for Resident #39. Findings include:I. Facility policy and procedureThe PASRR policy, dated 9/26/23, was provided by the nursing home administrator (NHA) on 12/18/25 at 6:11 p.m. It revealed in pertinent part,The social service staff are responsible for assuring that the specialized services needed or recommended by the PASRR- Level II are reviewed, implemented, and care planned within the facility within 14 days of admission. There should be a valid and detailed written explanation in cases when the PASRR -Level II recommendations cannot be implemented. If services recommended cannot be provided, then the facility is responsible for transferring/discharging the individual to a placement where such services are available.II. Resident #39A. Resident statusResident #39, age [AGE], was admitted on [DATE]. According to the December 2025 computerized physician orders (CPO), diagnoses included borderline personality disorder and major depressive disorder. The 11/5/25 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. The assessment indicated the resident had behaviors of delusions.The assessment did not identify that the resident had been identified as having a Level II PASRR. B. Record reviewResident #39's PASRR Level II, provided to the facility on 8/6/24, included the evaluation which revealed the resident had been evaluated for mental illness due to a qualifying diagnosis of major depressive disorder. The resident was to receive a neurocognitive evaluation (an assessment to determine how different parts of the brain function to understand the impact of neurological conditions and brain injuries).Resident #39's mood and behavior care plan, revised 3/4/24, revealed the resident had a Level II PASRR due to a diagnosis of major depressive disorder and borderline personality disorder. Interventions, initiated dated 8/7/23, included psychiatric care services, offering one-on-one conversation and reviewing her medications quarterly. -The care plan failed to include the PASRR Level II recommendation for Resident #40 to have a neurocognitive evaluation (see PASRR Level II above). Review of the December 2025 CPO failed to reveal any orders for a neurocognitive evaluation since the resident's NOD date of 8/6/24. Progress notes were reviewed from 8/1/25 through 12/16/25 and documentation was found regarding the Level II PASRR or recommendations for Resident #40. There were no PASRR progress notes revealing communication with the State Mental Health Agency regarding a delay or inability to follow Resident #40's PASRR Level II recommendations.III. Staff interviewsThe social services director (SSD) and the NHA were interviewed together on 12/18/25 at approximately 12:30 p.m. The SSD said the social services department was responsible for managing and reviewing the recommendations made by the State Mental Health Agency included in the PASRR Level II. The NHA said if the recommendations from the NOD were not followed, then a progress note would be made and it would also be included in the resident's care plan. The NHA said she would have to look into if a neurocognitive evaluation was ever scheduled for Resident #39. -However, documentation was not provided during the survey that indicated Resident #39 received a neurocognitive evaluation.

Based on record review and interviews, the facility failed to ensure one (#24) of five residents received medically related social services out of 38 sample residents. Specifically, the facility failed to:-Assist Resident #24 with obtaining a designated representative who could assist the resident with making choices; and,; -Ensure Resident #24 had the ability to give informed consent to psychoactive medications. Findings include:I. Resident #24A. Resident statusResident #24, age [AGE], was admitted on [DATE]. According to the December 2025 computerized physician orders (CPO), diagnoses included anxiety, major depressive disorder and unspecified dementia. The 12/12/25 minimum data set (MDS) assessment revealed Resident #24 had severe cognitive impairments with a brief interview for mental status (BIMS) score of five out of 15. The MDS assessment indicated the resident had a wander guard device but no other forms of restraints. B. Resident interviewResident #24 was interviewed on 12/16/25 at 2:17 p.m. Resident #24 was unable to determine the day of the week, the year, or what type of facility he was living in. He said he was not taking any psychiatric medications and could not identify any of his medications. Resident #24 said he had never consented to the transfer pole in his room and could not explain the risks of a transfer pole. C. Record reviewThe cognition care plan, revised 7/29/25, revealed Resident #24 used antipsychotic medications related to symptoms and behaviors of dementia with behaviors. Interventions included discussing with the medical director, power of attorney or family the ongoing need for medication and alternate therapies attempted (initiated 7/22/20). -The care plan failed to include documentation regarding the transfer pole or cognitive impairments requiring a guardian referral (see progress notes below). Review of Resident #24's December 2025 CPO revealed the following physician's orders:Olanzapine (an antipsychotic medication) 5 milligram (mg). Give one time a day for dementia with agitation, ordered 5/21/25 and increased 8/18/25.Sertraline (an antidepressant medication) 100 mg one time a day for hypersexual behaviors, ordered on 5/21/25.Olanzapine 5 mg. Give two tablets one time a day for dementia with agitation, ordered 8/18/25 and increased 10/22/25. Olanzapine 20 mg. Give one time a day for dementia, ordered 10/22/25.Review of Resident #24's electronic medical record (EMR) from 3/24/24 to 12/16/25 revealed the following:A guardianship referral, dated 3/24/24, revealed the facility had sent a referral to a guardianship agency for Resident #24 due to the resident being unable to make his own decision related to diminished cognition. -However, review of Resident #24's EMR did not reveal documentation indicating the referral had been followed up on.A nurse practitioner visit note, dated 4/22/24, revealed the nurse practitioner documented that Resident #24 had impairments to the quality of his speech and language, short term memory impairments, poor judgement, and poor insight. The IDT psychopharmacology meeting note, dated 11/12/25, revealed Resident #24 needed a guardian.A social services note, dated 12/16/25 (during survey), revealed the social services director (SSD) had sent an email to a guardianship agency. The psychiatrist visit notes dated 8/19/25 to 12/16/25 revealed the following;A visit note, dated 8/19/25, indicated Resident #24 was unable to participate in the assessment in a meaningful way due to cognitive deficits. The resident was oriented to self and disoriented to time and place. A visit note, dated 9/16/25, revealed the resident presented with severe cognitive deficits present in one or more areas of memory and thought production during the visit.Review of Resident #24's treatment consents from 1/1/25 to 12/16/25 revealed the following:Informed consent for physical restraint/assistive device for the transfer pole, dated 1/6/25, did not reveal the resident or any representative had given consent, or had been informed of the potential negative outcomes, the risks, and the benefits.Informed consent for physical restraint/assistive device for the transfer pole, dated 4/28/25, did not reveal the resident or any representative had given consent, or had been informed of the potential negative outcomes, the risks and the benefits.Informed consent for psychoactive medication use, dated 8/18/25, revealed the resident signed the consent himself and the consent listed an increase of Olanzapine 5 mg once a day but did not document that the medication was being increased to twice a day to equal 10 mg a day.Informed consent for psychoactive medication use, dated 10/24/25, revealed the resident signed the consent himself and the consent listed an increase of Olanzapine to 20 mg a day. -However, the resident was not aware he was on psychotropic medications and had severe cognitive impairments. -A review of Resident #24's EMR failed to reveal an appointed resident representative to assist on the resident's behalf in making care decisions. II. Staff interviewsCNA #4 was interviewed on 12/17/25 at 9:30 a.m. She said Resident #24 had behaviors of yelling at people if they came too close to him or his belongings related to his dementia and not understanding other's intentions. Registered nurse (RN) #1 was interviewed on 12/17/25 at 9:41 a.m. She said Resident #24 was only oriented to himself and some people. She said he was unable to make his own decisions or sign consents for himself and he had no friends or family members to make decisions on his behalf. She said the medical director (MD) made all the decisions for Resident #24 because the resident could not make his own decisions. Licensed practical nurse (LPN) #7 was interviewed on 12/17/25 at 10:11 a.m. She said Resident #24 could express his basic needs to the staff but did not know what medications he took. The social services director (SSD) was interviewed on 12/18/25 at 9:45 a.m. She said that it was the social services departments' job to initiate guardianship referrals and follow up on making sure a physician letter was obtained and sent to the guardianship agency. The SSD said she had only worked at the facility for three months but was not sure why no one else had followed up on the referral or why she did not follow up on the referral herself until the survey. The NHA was interviewed on 12/18/25 at approximately 12:30 p.m. The NHA said she was not sure why the guardian referral for Resident #24 was not followed up on. III. Facility follow upOn 12/18/25 at 6:21 p.m., the NHA forwarded an email from the guardianship agency dated 12/18/25.The email confirmed the agency would schedule an assessment within two weeks.

Based on observations, record review and interviews, the facility failed to ensure residents were provided adequate hydration for one (#11) of two residents reviewed for hydration out of 38 sample residents. Specifically, the facility failed to provide drinks during meal time and provide fluids throughout the day for Resident #11. Findings include: I. Facility policy and procedureThe Hydration policy, dated 2/29/24, was received from the nursing home administrator (NHA) on 12/18/25 at 6:11 p.m. It read in pertinent part, Residents are provided with sufficient fluid intake to maintain proper hydration and health. Residents identified at risk for fluid volume deficit will be assessed timely and provided appropriate interventions to promote adequate hydration. Address resident's individual needs with respect to fluid intake. Initiate appropriate strategies and interventions to prevent dehydration.II. Resident #11A. Resident statusResident #11, age [AGE], was admitted to the facility on [DATE]. According to the December 2025 computerized physician orders (CPO), diagnoses included epilepsy (seizure disorder), hypothyroidism, hyperlipidemia and unspecified intellectual disabilities. The 10/31/25 minimum data set (MDS) assessment revealed Resident #11 was rarely or never understood. Through staff assessment, it was revealed Resident #11had severe cognitive impairment. The MDS assessment further revealed Resident was dependent on staff for all of his activities of daily living (ADL). B. Resident representative interviewResident #11's resident representative was interviewed on 12/16/25 at 10:38 a.m. She said she never saw drinks in his room or at his bedside. C. ObservationsDuring a continuous observation on 12/16/25, beginning at 3:24 p.m. and ending at 6:04 p.m., the following was observed:At 3:24 p.m. Resident #11 was in his bed with his eyes closed. There was no water or other beverages in his room at his bedside. At 3:28 p.m. Resident #11 was sitting up in his bed leaning against the wall with his legs tucked underneath him. At 3:55 p.m. Resident #11 was sitting up in his bed. No staff members had entered his room to offer him a beverage. At 4:44 p.m. o certified nurse aide (CNA) #1 and and CNA #3 entered Resident #11's room to assist him up for dinner. At 5:05 p.m. Resident #11 was in the dining room sitting at his table. He did not have any drinks. At 5:36 p.m. Resident #11 received his dinner, but did not have any drinks. At 5:40 p.m. Resident #11 was eating his finger foods and staff did not offer him or provide any drinks. At 5:47 p.m. Resident #11 handed his plate to an unidentified nurse, she took his plate from him and did not offer him any drinks. Resident #11 was not provided with any drinks. At 6:04 p.m. CNA #1 assisted Resident #11 to his room. -He did not receive any drinks at dinner and there were no beverages in his room. D. Record reviewThe skin integrity care plan, revised 9/15/25, documented Resident #11 was at risk for skin integrity issues because he had soft, friable skin and was dependent on staff for personal care and mobility. Interventions included encouraging good nutrition and hydration in order to promote healthier skin. The malnutrition care plan, revised 7/29/25, documented Resident #11 was low to moderate risk for malnutrition due to poor intake. Interventions included encouraging Resident #11 to eat food and drink fluids. E. Staff interviewsCNA #1 was interviewed on 12/18/25 at 9:08 a.m. She said the staff usually gave Resident #11 orange juice to drink and they put milk in his cream of wheat. She said the resident was on a regular diet with thin liquids. She said most residents were able to walk around and get their own ice and drinks from the nurse's station or the coffee area in the dining room. She said the CNAs would fill residents' water jugs if they ask. She said they offered water at the dining room table during meals and the staff offered water to the residents every two hours. -However, Resident #11 was not offered drinks (see observations above)Licensed practical nurse (LPN) #6 was interviewed on 12/18/25 at 9:28 a.m. She said Resident #11 consumed fluids well at the dining room table. She said Resident #11 had drinks at his bedside. -However, Resident #11 did not have drinks at his bedside (see observations above).The registered dietician (RD) and the regional dietary consultant were interviewed together on 12/18/25 at 1:15 p.m. They said every resident should receive at least eight ounces of liquid at every meal. The regional dietary consultant said that some of the residents did not have the water jugs in their room as the had used them as a weapon. The regional dietary consultant said most of the residents received their fluids during meal time or activities. She said fluids should be offered frequently. They said residents should be given drinks with their meals. CNA #3 was interviewed on 12/18/25 at 2:04 p.m. He said he delivered drinks with room trays, and he offered drinks as the residents came in from smoke breaks. He said Resident #11 was up in his chair most of the day. CNA #3 said Resident #11 could not drink when he was in bed unless the staff sat him up. He said the staff tried to get him to drink when he was up in his chair. He said the staff offered him fluids when he was in bed and each time they checked on him for incontinence care -However, CNA #3 did not offer Resident #11 a drink when he checked on him (see observations above). The director of nursing (DON) and the NHA were interviewed together on 12/18/25 at 4:35 p.m. The NHA said any staff member could offer fluids to residents. The DON said staff should be offering fluids during meals and outside of meals. The DON said the risks for residents if they did not get enough fluids are urinary tract infections, dehydration, skin issues and elevated temperature. The DON said the staff needed to be better with rounding with fluids on dependent residents.

Based on observations, record review and interviews, the facility failed to ensure two (#6 and #9) of three residents reviewed for abuse out of 11 sample residents were kept free from abuse. Specifically, the facility failed to protect Resident #6 and Resident #9 from physical and verbal abuse from Resident #7. Findings include: I. Facility policy and procedure The Abuse policy, dated 5/3/23, was provided by the nursing home administrator (NHA) on 2/11/25 at 5:55 pm. It read in pertinent part, The facility does not condone resident abuse and shall take every precaution possible to prevent resident abuse by anyone, including other residents. Residents have the right to be free from abuse. Providing a safe environment for the resident is one of the most basic and essential duties of our facility. Identification of abuse shall be the responsibility of every employee. Residents at risk for abusive situations are identified and appropriate care plans are developed. If a resident experiences a behavior change resulting in aggression toward other residents, the community will implement interventions for protection of the alleged assailant and other residents. The resident's care plan is revised to include new approaches to reduce or eliminate any further chance of abuse. If abuse happens, separate the assailant from the victim, isolate the assailant to protect others, assess and treat the victim and notify the abuse coordinator. II. Incident of physical abuse between Resident #9 and Resident #7 on 10/1/24 A. Facility investigation The facility's investigation revealed there was a resident to resident altercation between Resident #7 and Resident #9 in the residents' shared room on 10/1/24. Resident #7 became upset when his roommate (Resident #9) called him crazy. Resident #7 punched Resident #9. Resident #9 punched Resident #7 back and they began to hit each other multiple times. Immediately, the residents were separated and Resident #7 was placed on one-to-one supervision with a staff member and a room change for Resident #7 was initiated. Resident #9 was assessed and found to have sustained an abrasion to his right arm and a headache from hitting his head on the door frame. Resident #9 was sent to the hospital for evaluation and further assessment to rule out a head injury. He was sent back to the facility from the hospital with negative results for a head injury. The local police department, the ombudsman, the residents` physicians and both residents` representatives were notified. B. Resident #7 (assailant) 1. Resident status Resident #7, age less than 65, was admitted on [DATE]. According to the February 2025 computerized physician orders (CPO), diagnoses included personal history of traumatic brain injury (TBI), post-traumatic stress disorder unspecified, schizoaffective disorder bipolar type, unspecified intellectual disabilities, nicotine dependence and anxiety disorder. The 1/21/25 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. He was able to ambulate independently and required supervised smoking assistance and minimal assistance with personal hygiene. The MDS assessment indicated the resident had hallucinations and delusions but did not exhibit physical or verbal symptoms. 2. Resident observations On 2/11/25 the following was observed: At 11:26 a.m. Resident #7 was sitting in the dining room rocking back and forth in his seat with his head in his hands being closely monitored by a staff member sitting beside him providing one-to-one supervision. At 11:35 a.m. Resident #7 let out a loud noise and stood up telling the staff member I can't be in here anymore and walked towards his room while being followed by the one-to-one supervision staff member. At 4:55 p.m. Resident #7 was pacing the hallway talking to himself and responding to internal stimuli (talking back to voices he was hearing in his head) and singing to himself. 3. Resident interview Resident #7 was interviewed on 2/11/25 at 4:57 p.m. Resident #7 was exhibiting paranoid behavior and was distracted by internal stimuli during questioning, but remained calm and pleasant. He said he made attempts to prevent altercations by being non-violent. He said staff were sometimes helpful in helping him control his urges. He said the interventions were sometimes helpful. Resident #7 said he was better now than when he had past altercations with other residents and said he tried to avoid the people who caused him problems. 4. Record review The behavior care plan, initiated 10/7/24 and revised 2/2/25, revealed Resident #7 had the potential to be physical toward other residents when he believed another resident had disrespected him and must defend himself. Pertinent interventions included one-on-one monitoring following an occurrence as needed (PRN), administering medications as ordered and documenting and monitoring side effects and effectiveness, reminding Resident #7 to seek out staff support to de-escalate the behavior, monitoring and documenting observed behaviors and attempted interventions PRN, monitoring, documenting and reporting PRN any signs or symptoms of the resident posing a danger to himself or others when Resident #7 became agitated, intervening before agitation escalated, guiding the resident away from the source of distress and engaging him calmly in conversation and if the resident responded aggressively, staff should calmly walk away and approach later. -The resident's behavior care plan was not initiated until 10/7/24, six days after the resident's altercation with Resident #9 (see investigation above). The psychotropic medication care plan, revised 10/3/24, revealed Resident #7 was prescribed antidepressant medication for trouble sleeping, an antihistamine and an anxiolytic medications for anxiety and antipsychotic medication for symptoms and behaviors associated with the diagnosis of schizoaffective disorder bipolar type. Pertinent interventions included monitoring, documenting and reporting changes in behavior, mood or cognition, hallucinations and delusions, monitoring and documenting side effects and efficacy of medications, administering medications as ordered and reviewing alternate therapies attempted and effectiveness. -The resident's psychotropic care plan was not updated with any new interventions after the resident's altercation with Resident #9 on 10/1/24. The auditory hallucinations and delusions care plan, initiated 12/31/24 and revised 2/2/25, revealed Resident #7 paced the halls most of the day, responded to internal stimuli and believed he was part African American and would say the N word as he believed he had a right to do so since it was socially acceptable for African Americans to say it to each other and staff had difficulty redirecting this delusion. Additional pertinent interventions included allowing Resident #7 to express how he felt and what he was talking about, offering psychiatric services and offering to take him out for a cigarette to assist in re-directing him. -The resident's auditory hallucinations and delusions care plan was not initiated until 12/31/24, almost three months after the resident's altercation with Resident #9 (see investigation above) and over a month after the resident's second altercation with Resident #6 (see investigation below). A progress note, dated 10/1/24 at 11:53 p.m., documented Resident #7 came out of his room and reported his roommate (Resident #9) was being mean to him and calling him names. Resident #9 then came out of the room and called Resident #7 crazy. Resident #7 told Resident #9 he was not crazy and started hitting Resident #9. The residents continued hitting each other and both residents fell to the floor. The residents were separated and assessed for injury and no injuries were noted. A nurse progress note, dated 10/3/24 at 10:16 p.m., documented Resident #7 continued to be monitored post physical altercation with another resident. The resident continued to be on one-to-one monitoring. -There was no further documentation related to the 10/1/24 incident with Resident #9 in Resident #7's electronic medical record (EMR). C. Resident #9 (victim) 1. Resident status Resident #9, age less than 65, was admitted on [DATE]. According to the February 2025 CPO, diagnoses included schizophrenia, hypertension, cognitive communication deficit and major depressive disorder, recurrent severe, without psychotic features. The 12/6/24 MDS assessment revealed the resident was cognitively intact with a BIMS score of 13 out of 15. The resident was independent for all activities of daily living (ADL). The MDS assessment indicated the resident was taking antipsychotic and antidepressant medications. The MDS assessment documented the resident did not have physical or verbal behaviors directed at others or other behavioral symptoms not directed toward others. 2. Resident interview Resident #9 was interviewed on 2/11/25 at 2:30 p.m. Resident #9 said he felt safe in the facility. He said he did not remember the altercation with Resident #7. 3. Record review The behavior care plan, initiated 10/7/24, revealed Resident #9 had the potential to become verbally and physically aggressive toward other residents and staff members at the facility. He presented anger problems, history of harm to others and poor impulse control. Resident #9 had the potential to become physically aggressive toward other residents when he was physically or verbally instigated by others. Pertinent interventions included administering medications as ordered, monitoring and documenting for side effects and effectiveness, providing physical and verbal cues to alleviate anxiety, giving positive feedback, assisting the resident's verbalization of the source of agitation, assisting the resident to set goals for more pleasant behavior, encouraging the resident to seek out staff members when agitated, offering the resident choices about his care and activities, providing psychiatric consultation, intervening before agitation escalated and guiding Resident #9 away from source of distress and engaging the resident calmly in conversation and walking away if the response was aggressive. A nursing progress note, dated 10/1/24 at 11:05 p.m, revealed a physical altercation occurred between Resident #9 and Resident #7 in the residents' room. The note documented Resident #7 became upset when his roommate (Resident #9) called him crazy and Resident #7 punched Resident #9. Resident #9 punched Resident #7 back and they began to hit each other multiple times. Immediately, the residents were separated and Resident #7 was placed on one-to-one supervision with a staff member and a room change was initiated for Resident #7. Resident #9 was assessed and found to have sustained an abrasion to his right arm and a headache from hitting his head on the door frame. Resident #9 was sent to the hospital for evaluation and assessment to rule out a head injury. He was sent back to the facility from the hospital with negative results for a head injury. Resident #9 felt safe in the facility and continued with his usual activities. He denied feeling fear. D. Staff interviews Certified nurse aide (CNA) #1 was interviewed on 2/11/25 at 1:30 p.m. CNA #1 said she had not witnessed Resident #7 acting aggressively toward other residents but knew he was capable when triggered. She said he would talk to himself frequently. She said the tone of his voice could sound aggressive and other residents might mistakenly believe Resident #7 was talking to them offensively. CNA #1 was interviewed a second time on 2/11/25 at 4:45p.m. She said she would de-escalate Resident #7 by talking to him in a calm voice. She said she would redirect him by talking to him about a different topic or offer other distractions. She said Resident #7 was able to tell staff if he was being triggered. She said he would ask the CNAs to remove him from the situation before being triggered. She said staff were required to take mandatory online and in-person training on de-escalation of residents. She said her last in-person training was in October 2024. She said she would make behavior notes in residents' EMR which the nurses could see. She said new orders and intervention changes for residents would be sent to staff via text message from management. CNA #2 was interviewed on 2/11/25 at 12:30 p.m. CNA #2 said Resident #7 had frequent mood swings and could show physical and verbal aggression toward others. She said he paced and appeared to be agitated often. She said he often talked to the personalities inside his head. CNA #2 was interviewed a second time on 2/11/25 at 4:45p.m. She said she would approach him in a calm manner during an altercation and would offer choices, such as going outside or going to another area in the facility. She said she would redirect by taking Residen #7 out of the altercation. She said she received mandatory ongoing de-escalation training with computer based training. She said CNAs would chart behavior notes in the residents' EMRs and report the behaviors to the nurse. CNA #2 said interventions or new orders would be communicated from the admission office upon admission and via mass text to staff. III. Incident of physical and verbal abuse of Resident #6 by Resident #7 on 11/20/24 A. Facility investigation The facility's investigation revealed that on 11/20/24 at 5:00 p.m., Resident #7 and Resident #6 were sitting in the dining room. Resident #7 was responding to internal stimuli. Resident #6 thought he was talking to him so he stood holding up a fist. Resident #7 then stood up, held up his fist, said okay and pushed Resident #6 against the wall. The immediate safety measures put into place to protect Resident #6 included separating the residents from one another, placing each resident on 15-minute checks for 72 hours and on a psychosocial follow up scheduled for one week following the incident. The investigation documented that the police, the residents' representatives, the ombudsman and the residents' physicians were notified. The investigation indicated that Resident #6 was assessed by the licensed practical nurse (LPN) on duty during the incident and he was found to have no pain or sign of injury. Resident #6 was interviewed during the investigation (date and time unknown). Resident #6 said Resident #7 was talking to no one about demons. When Resident #6 told Resident #7 to shut up, Resident #7 then told Resident #6 to shut up twice and asked Resident #6 if he wanted to fight. Resident #6 said Resident #7 got up and put two fists up so Resident #6 got up and put two fists up. Resident #6 said Resident #7 then pushed him and he tripped over his chair backwards and hit the wall. The investigation indicated that Resident #7 was interviewed by management during the investigation (date and time unknown). Resident #7 said Resident #6 said he (Resident #7) was talking to demons. Resident #7 said he told Resident #6 he was not talking to demons. Resident #7 said Resident #6 got up and put two fists up so Resident #7 got up and pushed him. Three resident witnesses of the occurrence were interviewed by management. Witness #1 said she looked up and saw Resident #7 push Resident #6. She said Resident #6 then fell against the wall. Witness #2 said Resident #7 stood up and then Resident #6 stood up. Witness #2 said both residents put two fists up and Resident #7 pushed Resident #6. Witness #3 said Resident #7 and Resident #6 had an argument and Resident #6 fell against the wall. Staff interviews conducted during the investigation revealed that no staff witnessed the occurrence. Record review revealed Resident #7 had a potential to be physical towards other residents when he felt he had been disrespected and had to defend himself. B. Resident #7 (assailant) 1. Record review Review of Resident #7's revealed there were no interventions updated on the resident's behavior, psychotropic medications or auditory hallucinations and delusions care plans following the resident to resident altercation with Resident #6 on 11/20/24 (see investigation above). A nursing progress note, dated 11/20/24 at 6:19 p.m., documented that the nurse was at the nursing station when a concierge ran up saying a nurse was needed in the dining room because Resident #6 and Resident #7 were fighting. The nurse ran to the dining room as the concierge said it was over now. The nurse asked Resident #7 what happened. Resident #7 said he was defending himself because Resident #6 started yelling at him and stood up with his fist in the air, so Resident #7 stood up to defend himself and pushed Resident #6. Staff removed Resident #7 for safety and placed him on 15-minute checks until further notice. Resident #7 was assessed for injury and the nurse found no bruising or signs of injury. The nurse educated Resident #7 on controlling his emotions and physical impulsions and instructed him on walking away and deep breathing exercises. Resident #7 said he understood, although he was just trying to defend himself. He denied feeling fearful towards Resident #6. The nurse notified the manager on call, the physician and the residents' representative. The November 2024 progress notes revealed that one nursing progress note and two alert notes, all dated 11/21/24, were charted in the 72-hour period following the incident with Resident #6. The alert notes documented that the nurse would have the social worker talk with Resident #7. -There were no behavior monitoring notes regarding the incident documented on 11/22/24 or 11/23/24. The November 2024 treatment administration record (TAR) revealed staff failed to document Resident #7's targeted behaviors of anxiety and psychosis on 11/20/24. -However, according to the facility investigation of the incident with Resident #6 on 11/20/24, Resident #7 was exhibiting symptoms of psychosis as evidenced by him responding to internal stimuli (see investigation above). The interdisciplinary team (IDT) risk management review note, dated 11/29/24 at 6:35 a.m., documented that the abuse allegation for the 11/20/24 physical aggression incident was found to be unsubstantiated. -However, abuse occurred because Resident #7 willfully pushed Resident #6 (see investigation above). The behavior note, dated 1/27/25 at 5:57 p.m., revealed Resident #7 had an incident with his roommate following a psychotic episode of loudly responding to stimuli and yelling and using racial slurs. When the roommate responded, Resident #7 began to yell derogatory words louder and more directly. Staff intervened by moving Resident #7 to a new room not far from Resident #6's room. -However, Resident #7 had already had an abuse incident with Resident #6 on 11/20/24 (see investigation above). The behavior note, dated 2/10/25, documented that Resident #7 had an episode of loud yelling and talking to himself, was very restless and refused to talk with the nurse. -The note failed to indicate whether interventions were attempted or if the physician or the social worker were notified. The 11/20/24 frequent check form revealed close monitoring of Resident #7 every 15 minutes was conducted between the hours of 5:00 p.m. (prior to the incident) and 12:00 a.m. -The 11/21/24 frequent check form revealed staff failed to closely monitor the resident between the hours of 6:15 a.m. to 9:45 p.m. -The 11/22/24 frequent check form revealed staff failed to closely monitor the resident between the hours of 6:15 a.m to 12:00 a.m. -The facility was unable to provide a frequent check form for 11/23/24. -The facility failed to perform frequent checks on Resident #7 during the 72-hour alert monitoring timeframe following the resident's incident with Resident #6 on 11/20/24. D. Resident #6 (victim) 1. Resident status Resident #6, age greater than 65, was admitted on [DATE]. According to the February 2025 CPO, diagnoses included psychoactive substance abuse with psychoactive substance-induced psychotic disorder unspecified, antisocial personality disorder, drug-induced subacute dyskinesia (movement disorder that develops over days or weeks after taking certain drugs or medications) and schizophrenia unspecified. The 12/10/24 MDS assessment revealed the resident was cognitively intact with a BIMS score of 13 out of 15. He was independent and required minimal assistance with showers and hygiene. 2. Resident interview Resident #6 was interviewed on 2/11/25 at 1:04 p.m. Resident #6 said that during the incident on 11/20/24 with Resident #7, Resident #7 was running his mouth so he told him to shut up and Resident #7 started calling people names so they got in a fight and he (Resident #6) fell out of his chair. Resident #6 said he felt staff did not handle the situation well because Resident #7 still had the same behaviors. He said Resident #7 was a menace. He said sometimes Resident #7 saw him and apologized and told him he loved him, however, Resident #6 said Resident #7 was dangerous. Resident #6 said it was harder for him to avoid Resident #7 recently because Resident #7 had a fight with his roommate and he now lived upstairs closer to his (Resident #6) room. Resident #6 said he would feel safer if staff managed Resident #7's, and other problematic residents', behaviors better. 3. Record review The nursing progress note, dated 11/20/24 at 10:25 p.m., revealed that the nurse was alerted that a fight broke out in the dining room where she rushed to find Resident #6 sitting at the dining room table with no visible injuries. At that time, Resident #6 said Resident #7 was yelling at him so he had to defend himself. The nurse manager and the physician were notified and both residents were placed on 15-minute checks until further notice. The November 2024 progress notes revealed one alert note, dated 11/21/24 at 9:15 a.m., was documented following the 11/20/24 incident. -The facility failed to ensure 72-hour follow-up monitoring was documented for Resident #6. E. Staff interviews LPN #1 was interviewed on 2/11/25 at 12:25 p.m. LPN #1 said Resident #7 had been talking to himself and pacing but had not been violent lately. She said if there was a resident-to-resident altercation, she would intervene by separating the residents for safety and notify the administrator, the supervisor and sometimes the police. LPN #1 said Resident #7's behaviors had not changed since he was admitted to the facility. She said when he first admitted to the facility he moved downstairs after an altercation with his roommate, then he was moved upstairs again after another altercation with another roommate. LPN #1 said the staff were offered crisis intervention training frequently in the form of meetings and in-services, but they were not mandatory. She said when management implemented new interventions for new behaviors, staff was notified via group messages. Registered nurse (RN) #1 was interviewed on 2/11/25 at 1:21 p.m. RN #1 said social services and management were highly involved in crisis intervention and prevention training. She said staff were provided mandatory online training that included informative videos on de-escalation and managing difficult resident behaviors. RN #1 said that new or unwanted resident behaviors were charted in the residents' EMR under the task documentation system for CNAs and in the residents' behavior progress notes for nurses. She said behaviors were also documented in a 24-hour nursing report. She said a mass text was sent out to nursing staff by management or social services for residents needing one-to-one supervision or frequent checks. She said behavior notes were mandatory for residents on 15-minute checks. LPN #2 was interviewed on 2/11/25 at 1:38 p.m. LPN #2 said that crisis intervention and prevention training was organized by the NHA. She said when Resident #7 had an altercation with his roommate, staff intervened by separating them, providing one-to-one supervision for him for 72 hours and placing the residents involved on frequent 15-minute checks for 72 hours. She said Resident #7 had had several resident to resident altercations and the same interventions were put into place. She said that Resident #7 was usually easily redirected and he liked snacks. She said he talked to himself and he paced a lot. LPN #2 said at one time, Resident #7 was attending a day program but had to stop going due to his behaviors and the facility was working on a new plan for him because he liked to socialize. The social services director (SSD) was interviewed on 2/11/25 at 3:42 p.m. The SSD said residents' behavior interventions were to be documented in care plans and progress notes and were updated based on whether staff had found new effective interventions or when there was an incident. The SSD said interventions implemented for verbally and physically aggressive behaviors included redirecting and relocating the resident, ensuring safety and communicating with the resident to find the root of the problem. She said following Resident #7's incident with Resident #6, the police were notified but the facility did not send him out to the hospital as he was not a threat to himself or others at the time. The SSD said to keep other residents safe when Resident #7 experienced an episode of aggression, staff coordinated a room change and provided one-to-one supervision, frequent checks and medication review. She emphasized that he was usually very sweet, he just had mental anguish and got very upset at times. She said Resident #7's behaviors were not a daily concern and they were not unprovoked. The NHA was interviewed on 2/11/25 at 3:42 p.m. The NHA said staff huddles at nursing stations were implemented in 2024 and were intended to highlight residents' targeted behaviors and other pertinent incidents and changes in condition. She said a binder on huddle discussions was available at the nursing station for staff to review. The NHA said interventions for targeted behaviors were put into place by the director of nursing (DON) and the nurses and they were to be documented in the treatment administration record (TAR). The NHA said in the event of physical or verbal aggression, staff would move the resident to a new room, if deemed necessary, and conduct frequent 15-minute checks and one-to-one supervision would be implemented. The NHA said she was working on getting crisis prevention intervention (CPI) training for all staff. She said staff had monthly meetings, including how to manage verbally and physically aggressive behaviors, and said she felt staff were sufficiently trained on the subject. She said the training was also provided at the annual skilled nursing facility (SNF) competency training, as well as in verbal and written education materials. The NHA said staff was last trained on TBI behavior management around November 2024. She said Resident #7 had auditory hallucinations and responded to internal stimuli frequently. She said he would often go into the bathroom to yell, wander the halls and talk to himself. She said he would let staff know if he felt troubled by his mental state and needed to go to the hospital. She said a very effective de-escalation intervention was to take Resident #7 on walks or to smoke a cigarette. The NHA said Resident #7 often used derogatory language when responding to internal stimuli and this had been ongoing since he was first admitted to the facility. She said the care plan reflected his belief that he was half African American and felt he had the right to use the N word. The NHA said the intervention for Resident #7, after the incident with Resident #6, was to speak with staff regarding his concerns and place both residents on frequent checks. She said she was under the impression that Resident #6 was the assailant and Resident #7 was the victim in the incident. The NHA said, after the most recent incident involving Resident #7 on 1/27/25, Resident #7 was placed on one-to-one supervision with a staff member for 24 hours and relocated to a room upstairs. She said she did not acknowledge Resident #6 as the victim in the 11/20/24 occurrence. The NHA said she did not have any concerns about Resident #6 or Resident #7's safety, even though their rooms were now in closer proximity. 52094

Based on record review and interviews, the facility failed to provide the necessary behavioral health care and services to attain and maintain the highest practicable physical, mental and psychosocial well-being for one (#1) of two residents reviewed out of 11 sample residents. Specifically, the facility failed to implement person centered interventions to address Resident #1's pattern of escalating behaviors. Findings include: I. Facility policy and procedure The Behavior Monitoring policy, dated 2/29/24, was provided by the nursing home administrator (NHA) on 2/11/25 at 4:23 p.m. It read in pertinent part, The purpose of behavior monitoring is to establish an accurate pattern of resident targeted behaviors as determined by the resident's history, evaluation, assessment. The goal is to determine appropriate behavior interventions such as counseling, behavior management plan including non-pharmacological interventions, and psychoactive medication management. When a resident displays targeted and/or inappropriate behavior, facility staff will implement behavioral interventions to assure the safety of the resident and/or other residents and staff/visitors. The behavior monitoring records of those residents under review will be discussed at the psychotropic drug committee for review and recommendations. IDT (interdisciplinary) members and/or designee will review behavior monitoring daily and as needed to follow up on any changes in behaviors. II. Resident #1 A. Resident status Resident #1, age less than 65, was admitted on [DATE]. According to the February 2025 computerized physician orders (CPO), the diagnoses included traumatic brain injury, mood disorder and mild cognitive impairment. The 12/20/24 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status score (BIMS) score of 15 out of 15. He required moderate to extensive assistance with dressing, bathing, transfers, and bed mobility. He used a wheelchair for ambulation. The assessment indicated the resident had behaviors of physical and verbal aggression directed towards others. The MDS assessment indicated the resident did not experience hallucinations or delusions. The MDS assessment indicated the resident participated in the discharge assessment and there was no active discharge plan for the resident. B. Resident interview and observations Resident #1 was interviewed on 2/11/25 at 2:30 p.m. He said he did not recall any physical altercations between himself and other residents. Resident #1 said he struggled with anxiety and anger. Resident #1 said he had been in the facility for close to a year but did not feel the facility tried to understand his brain injury. He said the facility did not do anything to work with him regarding his brain injury or provide any type of rehabilitation for him to become more cognitively independent. Resident #1 said he would like to go to a facility that specialized in the care of brain injuries but no one at the facility has talked to him about helping locate a different facility. He said he had a difficult time with the other residents who suffer from mental illness and it was hard for him to handle being around them. He said he expressed this frustration with anger. C. Record review The social services care plan, revised 9/3/24, revealed the resident exhibited behaviors of cursing and yelling at staff and peers, name calling, and poor money management with the potential to be reduced with the implementation of a positive reinforcement/incentive program. The care plan documented therapy, social services, and activities would work with the resident on implementation of a reinforcement/incentive program utilizing cigarettes and lottery tickets to reward positive behavior. Interventions included providing consistent reinforcement and incentives to maintain motivation (initiated 6/27/24), regularly assessing progress towards goals and the effectiveness of reinforcement strategies (initiated 6/27/24), adapting reinforcement strategies to accommodate individual preferences and learning styles (initiated 6/27/24), being open to adjusting the resident's goals and incentives based on progress (initiated 6/27/24) and breaking down larger goals into smaller more manageable milestones (initiated 6/27/24). The psychosocial care plan, revised 10/6/24, revealed the resident exhibited behaviors of verbal and physical aggression towards others, displayed as the use of racial slurs, verbal aggression, spitting and striking out physically at others. The care plan indicated the residents identified triggers included: feeling the staff were not moving fast enough, believing others had wronged him and when he or his wheelchair were accidentally touched. Interventions included allowing the resident to verbalize his frustration (initiated 7/7/24), educating the resident on what is appropriate behavior (initiated 7/7/24), completing a medication review requested by the pharmacist and the medical director (initiated 9/6/24), reminding the resident to verbalize his dislike of being moved without his permission to avoid physical aggression (initiated 10/6/24), setting clear and strict boundaries (initiated 7/7/24) and weekly follow ups from the NHA/IDT team following an occurrence (initiated 9/6/24). The behavior care plan, revised 2/5/25, revealed the resident had the potential to be verbally and physically aggression related to poor impulse control and a traumatic brain injury. The care plan indicated the resident would swing at other residents, use derogatory language and spit at the staff. Interventions included administering medications as ordered (initiated 6/27/24), analyzing key times, places, circumstances, triggers, and what de-escalated the resident's behavior and document this (initiated 6/27/24), assessing the resident's coping skills and support systems (initiated 6/27/24), assessing the resident's understanding of the situation (initiated 6/27/24), behavior monitoring (initiated 6/27/24), providing positive feedback for good behavior (initiated 6/27/24) and intervening before agitation escalates when the resident becomes agitated escalates (initiated 6/27/24). The discharge care plan, revised 6/27/24, revealed the resident would remain in the facility for long term care related to a history of a traumatic brain injury. Interventions included discussing the resident's current living arrangement and desire for discharge to the community with the power of attorney/family periodically or as needed (initiated 6/18/24). -The facility failed to update the care plan to include person centered interventions to address the residents escalated behavior after resident to resident altercations on 9/29/24, 10/14/24, 10/18/24, 11/2/24, 11/13/24 and 2/1/25 (see record review below). The February 2025 CPO revealed the following physician's orders: -Behavior monitoring for behaviors of hallucinations/expressing delusions, verbal/physical aggression, and hypersexualized comments, ordered on 8/16/24. A review of the monthly psychoactive pharmacological meeting notes from 9/15/24 to 1/27/25 did not reveal the resident's behaviors were reviewed or interventions were implemented to address the resident's aggressive behaviors. A review of the progress notes in resident's electronic medical record (EMR) from 9/29/24 to 2/10/25 revealed documented behaviors of verbal or physical aggression towards others occurred on 9/29/24, 10/1/24, 11/14/24, 11/17/24, 11/18/24, 11/19/24, 12/2/24, 12/23/24 and 1/26/25. -There were no descriptions of the non-pharmological interventions that had been tried to address the behaviors or if the interventions were effective in the resident's progress notes. The NHA provided the facility's investigations of the resident to resident altercations pertaining to Resident #1 on 2/11/25 at approximately 11:00 a.m. A review of the investigations revealed the following: The 9/29/24 incident revealed Resident #1 and Resident #11 were arguing. Resident #1 attempted to spit in Resident #11's face. Both residents were separated with no injuries reported. Interventions put into place to prevent a recurrence included providing education to Resident #11 to talk to staff if she was having problems with another resident. The 9/29/24 incident revealed Resident #2 tried to move Resident #1's wheelchair out of the walkway and Resident #1 hit him in the stomach. Resident #2 responded by hitting Resident #1 in the back. Both residents were separated with no injuries reported. Interventions put into place to prevent a recurrence included reminding Resident #1 to verbalize his dislike for being moved without his permission to avoid physical aggression. The 10/14/24 incident revealed Resident #1 believed Resident #4 was trying to cut in line to go into the social services office and Resident #1 attempted to hit Resident #4. When he was unable to hit him, Resident #1 kicked Resident #4's wheelchair. Both residents were separated with no injuries reported. Interventions put into place to prevent a recurrence included putting Resident #1 on frequent checks, reviewing his behaviors and medications in the monthly psychoactive pharmacological meeting and continuing to seek alternative placement for Resident #1 due to increasing behaviors. The 10/18/24 incident revealed Resident #3 accidentally cut in line in front of Resident #1. Resident #1 cursed at him and kicked him in the leg. Both residents were separated with no injuries reported. Interventions put into place to prevent a recurrence included putting Resident #1 on frequent checks, reviewing his behaviors and medications in the monthly psychoactive pharmacological meeting and to continue to seek alternative placement for Resident #1 due to increasing behaviors. -However, frequent checks and reviewing medications were existing implemented interventions. Upon record review, there was no evidence the facility made efforts to find alternative placement. The 11/2/24 incident revealed Resident #4 was passing Resident #1's wheelchair and Resident #1 became upset. Resident #1 began to hit Resident #4 in the arm and Resident #4 attempted to hit him in return. Both residents were separated with no injuries reported. Interventions put into place to prevent a recurrence included putting Resident #1 on frequent checks for 72 hours and for the psychoactive pharmacological team to review medications and behaviors during monthly meetings. -However, frequent checks and reviewing medications were existing implemented interventions. The 11/13/24 incident revealed Resident #1 hit Resident #5 in the face after cutting in front of Resident #5 in line and Resident #5 attempting to hit him. Both residents were separated with no injuries reported. Interventions put into place to prevent a recurrence included putting Resident #1 on 15 minute checks for 72 hours and for the psychoactive pharmacological team to review medications and behaviors during monthly meetings. However, frequent checks and reviewing medications were existing implemented interventions. The 2/1/25 incident revealed Resident #10 was trying to pass Resident #1 to exit the smoking area and accidentally hit his wheelchair with hers. Resident #1 hit Resident #10 in the left arm twice. Both residents were separated with no injuries reported. Interventions put into place to prevent a recurrence included putting both residents involved on 15-minute checks and escorting Resident #1 to and from the smoking area. -However, review of Resident #1's comprehensive care plan did not reveal the intervention of escorting Resident #1 to and from the smoking area (see care plan above). -Review of Resident #1's EMR did not reveal any psychological and psychiatric behavior health provider notes. -Review of the resident's medication administration records (MAR) and treatment administration records (TAR) from 9/1/24 to 2/10/25 did not reveal any behaviors had been documented. III. Additional resident interview Resident #10 was interviewed on 2/11/25 at 2:19 PM. Resident #10 said the incident between herself and Resident #1 happened so fast she did not even see it coming. She said it occurred outside of the facility in the designated smoking area. She said she had tried to go past Resident #1 to get back into the facility and he reached out and hit her in the arm. She said she now tried to avoid him and not go out to smoke when he was out there. She said she had not seen the staff do anything different with Resident #1 in regards to his escalating behaviors. IV. Staff interviews Licensed practical nurse (LPN) #1 was interviewed on 2/11/25 at 12:25 p.m. LPN #1 said if there was an incident between two residents, she would separate them, call the NHA, the SSD, her supervisor and the police. She said when a resident had behaviors, she would chart in the behavior progress notes. LPN #1 said if the IDT team put new interventions in place to address a resident's behaviors, the staff were notified in the twice weekly huddles. LPN #1 said Resident #1 displayed behaviors such as arguing with other residents, yelling at others who walked past him and demanding the staff's attention. LPN #1 said the staff redirected the resident when he had these behaviors. Certified nurse aide (CNA) #2 was interviewed on 2/1/25 at 1:00 p.m. CNA #2 said Resident #1 had behaviors of demanding staff attention and becoming impatient with the staff. CNA #2 said these behaviors could trigger physical and verbal aggression from the resident. She said the interventions the CNAs tried were to speak to him in a calm voice or offer him a soda. CNA #2 was interviewed on 2/1/25 at 1:15 p.m. She said Resident #1 was inpatient and was physically aggressive. She said the interventions she tried with the resident were to speak in a calm voice, remove him from the situation or redirect him to an activity. Registered nurse (RN) #1 was interviewed on 2/11/25 at 1:21 p.m. She said Resident #1 expressed behaviors when he did not get his way, such as being told he had to wait for staff assistance. She said this would trigger him to become verbally and physically aggressive. She said the resident would apologize sometimes and acknowledge his behavior was inappropriate. She said the staff attempted to redirect Resident #1 and would try to resolve the concern he had. RN #1 said the CNAs charted behaviors in the CNA electronic charting system and the nurses charted behaviors in the progress notes. She said if the IDT team put a new intervention into place, the nurses were notified via text message. LPN #2 was interviewed on 2/11/25 at 1:38 p.m. She said Resident #1 had behaviors of attention seeking and using his call light frequently for staff attention. She said he was verbally and physically abusive towards the staff, so the staff had to provide care in pairs (two people providing care at all times). -However, review of Resident #1's comprehensive care plan did not identify the intervention of cares in pairs. LPN #2 said the interventions for Resident #1's behavior included redirection. She said his behaviors were documented on the behavior tracking order in the TAR. She said when new interventions were implemented, the management team put an alert into the EMR to alert the nurses. RN #2 was interviewed on 2/11/25 at 2:46 p.m. She said Resident #1 had behaviors of lashing out at other residents and staff and becoming physically aggressive. She said Resident #1 was triggered when other residents or staff were in his personal space when he would prefer they not be. She said the non-pharmological interventions for his behaviors consisted of assisting him back and forth to the smoking area and providing care in pairs. However, review of Resident #1's comprehensive care plan did not identify the intervention of cares in pairs or escorting the resident back and forth to the smoking area. She said when the resident displayed behaviors, the nurse wrote a progress note, as well as documented the behavior on his behavior tracking order in the TAR. RN #2 said she was not sure why there was no documentation on the resident's behavior sheet on the TAR from 9/1/24 to 2/11/25. She said she had access to view the resident's care plans but she did not look at the care plan for target behaviors or non-pharmacological interventions. She said the nurses got their information regarding behaviors and interventions from the behavior tracking order and verbal instructions from the administration. RN #2 said the CNAs did not have access to view the resident's care plans. The social services director (SSD) and the NHA were interviewed together on 2/11/25 at 3:45 p.m. The SSD said she expected nursing staff to document the resident's behaviors in a progress note and to let social services know if there were behavior concerns. The SSD said the IDT team also conducted twice a week huddles at each nursing station to address any concerns the staff had with any of the departments. She said this meeting included discussing behavioral issues with residents. The SSD said there was a behavior tracking order on Resident #1's TAR. She said the behavior tracking order included the behaviors the nurses were to observe for and the non-pharmological interventions the nurses were to attempt. She said the nurses could either document behaviors on the TAR or in the progress notes. She said the CNA's documented behaviors on their task sheet in their own electronic system which was separate from the nurses. She said if there were specific interventions the SSD wanted the staff to try with the resident, she would tell the staff during a huddle or the IDT would send out a text message to the staff. She said all updated behaviors and interventions were included in the resident's care plan which the staff, including the CNAs, had access to review. The SSD said when a resident had a change in condition regarding behaviors or non-pharmological interventions, the staff provided feedback on interventions they had tried, or there was an occurrence involving a resident it would trigger an update to the resident's behavior tracking order and care plan. She said if a resident was having behaviors of physical or verbal aggression towards others some of the behavior interventions that would be tried would be redirection, changing the environment, determining the psychosocial trigger, frequent checks, and one-on-one supervision. The SSD said r Resident #1 displayed impulsive reactions when feeling strong emotions such as anger or frustration. She said the resident had a short temper and if another resident bumped into him or his wheelchair, he would respond immediately and could become verbally and physically aggressive. The SSD said the IDT reviewed the resident in the psychoactive pharmacology monthly meeting. She said during the meeting, the residents' behaviors and occurrences were discussed as well as reviewing medication changes and behavior interventions for efficacy. The SSD said she was not aware these meetings were not documented. The SSD said some of the interventions tried with Resident #1 included monitoring him when he went back and forth to the smoking area and moving his room to a calmer and quieter area of the building without the disruptions of other residents coming and going from the smoking area. She said additional interventions included locating a facility specializing in traumatic brain injuries for Resident #1. The SSD said she had sent out several referrals but had not had facilities show interest due to the aggressive behaviors. She said her efforts to find him placement were documented in the progress notes as well as on paper documentation within her office. She said when Resident #1 began displaying behaviors of verbal and physical aggression, the staff tried to redirect him from the environment and would try talking to him about his feelings. The SSD said Resident #1 could show insight into his behavior at times. She said the resident had told her he was not always the way he was currently, as far as his behaviors in relation to his traumatic brain injury. She said he currently saw the facility's psychological and psychiatric behavior health provider and that was documented in his progress notes. -However, review of Resident #1's EMR did not reveal documentation that the resident was seen by the behavior health provider (see record review above). The NHA said the facility kept other residents safe from Resident #1's behaviors by monitoring Resident #1 to ensure he did not get too physically close to other residents, initiating room changes if necessary, reviewing his medications and behaviors in the psychoactive pharmacological meeting and discussing new interventions with the care staff in the huddles. She said the expectation of the nursing staff was to either document the resident behaviors on the behavior tracking order on the TAR or to make a progress note in the chart. The NHA said the progress note included the same information found on the behavior tracking order such as non-pharmological interventions the staff were to use and whether the interventions were effective or not. The NHA said she was unsure why the behavior progress notes did not include the intervention attempted to address Resident #1's behaviors or the effectiveness of the non-pharmalogical intervention. The NHA said whenever the facility developed new interventions for Resident #1, the interventions were added to his care plan and the care plan was updated after every occurrence the resident was involved in. -However, review of Resident #1's comprehensive care plan did not reveal new person centered interventions to address the resident's aggressive behaviors after the 10/14/24, 10/18/24, 11/2/24, 11/13/24 and 2/1/25 resident to resident altercations (see record review above). The NHA said the behavior care plan was updated after the resident to resident altercations. -However the updates made were to the focus behaviors and there had been no updates to the interventions since initiated on 6/27/24. The NHA said she reviewed the resident to resident altercations involving Resident #1. She acknowledged the facility implemented the same interventions that were put into place to prevent a recurrence on several occasions and were not person centered. V. Facility follow up The NHA provided documentation of one psychological visit note for Resident #1 on 2/11/25 at approximately 4:45 p.m. The note was dated 9/18/24 and revealed the resident had been discharged from services on 9/11/24 due to verbally aggressive behaviors during the therapist. The NHA said the psychological provider said the facility could attempt to put him back on services, but from 9/11/24 to 2/11/25 (the time of the survey) the resident was not receiving psychological services. No additional psychiatric visit notes were provided. The NHA provided documentation on 2/11/25 at approximately 4:45 p.m. that indicated the SSD had sent out referrals to 22 other skilled nursing facilities on 9/7/24 with six denials and sixteen facilities not responded. There were no additional documented efforts to find alternative placement provided by the NHA or SSD. -However, review of Resident #1's EMR did not reveal any other evidence of efforts to find alternative placement or a specialized facility for Resident #1 was provided (see record review above).

Based on observations, record review and staff interviews, the facility failed to ensure food was stored, prepared and served under sanitary conditions in one kitchen. Specifically, the facility failed to ensure: -Cutting boards were free from deep scratches and stains; -Frozen food thawing process was followed; and, -Beard restraints were worn in kitchen areas while preparing food. Findings include: I. Cutting boards A. Professional reference According to the State Board of Health Colorado Retail Food Establishment Rules and Regulations (updated 1/1/19), page 132, retrieved 1/16/24 from https://cdphe.colorado.gov/environment/food-regulations, Cutting surfaces that are scratched and scored must be resurfaced so as to be easily cleaned, or be discarded when these surfaces can no longer be effectively cleaned and sanitized. B. Observation The initial kitchen tour conducted on 1/3/24 at 8:29 a.m. revealed five large cutting boards and the cutting board on the serving line. There was one green, one blue, one red, one large white, and one yellow cutting board. All cutting boards were heavily scored and stained. On 1/4/24 at 10:30 a.m., the cook was slicing the ham on the red cutting board that was heavily scored and stained (see above). On 1/8/24 at 8:36 a.m., the cook was cutting up vegetables on the green cutting board that was heavily scored and stained (see above). C. Staff interview The dietary manager (DM) was interviewed on 1/9/24 at 8:36 a.m. The DM was told of the observations of the cutting boards in the kitchen. He said the cutting boards were visibly stained and showed wear. He said he would replace them immediately. He said the deep scratches could be a potential for bacteria to grow. II. Frozen food thawing A. Professional reference According to the Colorado Retail Food Establishment Rules and Regulations (effective 1/1/19) pg.88-89, retrieved 1/16/24 from https://cdphe.colorado.gov/environment/food-regulations, Time/temperature control for food safety shall be thawed: Under refrigeration that maintains the food temperature at 41 degrees F or less; or completely submerged under running water: at a water temperature of 70 degrees F, with sufficient water velocity to agitate and float off loose particles in an overflow, and for a period of time that does not allow thawed portions of ready-to-eat food to rise above 41 degrees F, or for a period of time that does not allow thawed portions of a raw animal food requiring cooking as specified under 3-401.11or to be above (41 degrees F), for more than 4 hours including: the time the food was exposed to the running water and the time needed for preparation for cooking, ort he time it takes under refrigeration to lower the food temperature to 41 degrees F. B. Observations A tour of the kitchen was completed on 1/3/24 at 8:29 a.m. and revealed the following: The three compartment sink had approximately five large rolls of frozen hamburger thawing in the sink. The rolls of hamburger were in a metal container filled with water. The water was warm to the touch. A second observation of the kitchen was conducted on 1/9/24 at 8:25 a.m. There were four large frozen packages of chili con carne sitting in a metal pan with warm water. C. Staff interview The DM was interviewed on 1/9/24 at 8:32 a.m. The DM said when staff were thawing out any food item they needed to place it in the two compartment sink. The DM was told of the observations of the hamburger being thawed in a metal pan in the three compartment sink. The DM said the hamburger and chili con carne should have been thawing in the two compartment sink as the three compartment sink was for sanitizing. The DM said a negative outcome could be the buildup of harmful bacteria. III. Beard restraints A. Professional reference According to the Colorado Retail Food Establishment Rules and Regulations (updated 1/1/19) pg. 51, food employees shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed food; clean equipment, utensils, and linens; and unwrapped single service and single-use articles. B. Observations and interviews On 1/4/24 at 8:21 a.m. the DM had a beard that was approximately two inches in length. He was in the kitchen area without wearing a beard restraint. The DM was preparing individual entrees for the residents. The DM had a beard was approximately two inches in length On 1/8/24 at 10:15 a.m. the DM was in the kitchen area not wearing a beard restraint. The DM was preparing several cups of smoothies for the lunch meal. The DM was scooping the ice cream into several cups and then mixing other ingredients into the smoothie. The DM was interviewed on 1/9/24 at 8:36 a.m. The DM stated all kitchen staff were required to wear hair restraint and should have all hair covered. The DM said he had beard guards on order and had not yet received them. He said all male staff who had facial hair should be wearing proper beard restraints while in food preparation areas.

Based on observations and staff interviews, the facility failed to maintain a sanitary, orderly and comfortable environment for residents in 14 of 40 resident rooms in six hallways. Specifically, the facility failed to ensure walls, floors, baseboards, doors and ceilings were properly maintained and rooms were free of trash and floors deep cleaned. Findings include: I. Initial observations Observations of the resident living environment were conducted on 1/8/24 at 9:18 a.m. revealed: room [ROOM NUMBER]: The wall next to the resident's bed had sticker residue from four large picture adhesive tape on the wall. The wood chair molding was missing a section approximately seven inches long by four inches wide. The closet door was off the rails and leaning against the wall. The floors had trash and debris underneath the resident's bed. The edges of the whole room and under the baseboard heater had a large build of dirt. The transition strip at the entrance door was missing which had approximately a one-fourth inch lip. The ceiling outside of room [ROOM NUMBER] had a large water stain approximately four feet wide by three feet wide. room [ROOM NUMBER]: The wall next to the resident's headboard had chipped and peeling paint. There were nine pea sized holes above the toilet paper dispenser. The caulking around the sink had an area approximately 17 inches long that was missing and there was caulking on the other side of the sink that had black matter on it. The floors had trash and debris underneath the resident's bed. The edges of the whole room and under the baseboard heater had a large build of dirt. The transition strip at the entrance door was missing which had approximately a one-fourth inch lip. room [ROOM NUMBER]: The restroom had an area approximately four feet by four feet with water damaged tiles which were discolored and brown. The wall next to the restroom had scratched and chipped paint from the wheelchair hitting the wall. There were four large nails sticking out of the wall behind the resident's recliner. The floors had trash and debris underneath the resident's bed. The edges of the whole room and under the baseboard heater had a large build of dirt. The transition strip at the entrance door was missing which had approximately a one-fourth inch lip. room [ROOM NUMBER]: The wall next to the restroom had 16 pea sized holes. The room had a strong odor of urine. The floor in the restroom was sticky and had yellow stains. The baseboard cove next to the restroom was falling off the wall. The resident's oxygen concentrator was plugged into a non-medical grade power strip. The floors had trash and debris underneath the resident's bed. The edges of the whole room and under the baseboard heater had a large build of dirt. room [ROOM NUMBER]: The wall in the middle of the room had three dime sized holes. The door had deep chips and splintering wood approximately three feet high. The floors had trash and debris underneath the resident's bed. The edges of the whole room and under the baseboard heater had a large build of dirt. room [ROOM NUMBER]: The resident's wall had 17 metal picture clips on the wall. The door had deep chips and splintering wood approximately three feet high. The resident's oxygen concentrator was plugged into a non-medical grade power strip. The edges of the whole room and under the baseboard heater had a large build of dirt. The shower room on the 100 hundred hall had water damage with the sheetrock being soft and crumbly due to the absorption of water. The floor tile outside of the shower room had white water spots approximately 15 feet along the west wall and 10 feet toward the dining room. room [ROOM NUMBER]: The bathroom floor tiles had brown water stains from a water leak. The edges of the whole room and under the baseboard heater had a large build of dirt. room [ROOM NUMBER]. The resident's window blinds were broken. The laminate underneath the sink was chipped and missing a section approximately four inches long by two inches wide. The corner next to the sink had chipped and damaged sheet rock approximately 13 inches high by two inches wide from the wheelchair hitting the corner. The floor tiles were damaged and broken approximately 12 inches long by two inches thick. The floors had trash and debris underneath the resident's bed. The edges of the whole room and under the baseboard heater had a large build of dirt. The wall in the dining room had a corner wall approximately five feet high by five inches wide with bubbling and peeling paint. The wall underneath the table had an area approximately seven feet long by four feet high with chipped and peeling paint. The corner behind a cabinet had trash and debris and the edges of the whole dining room and under the baseboard heater had a large build of dirt. The elevator had a chipped and broken panel approximately seven inches high by five inches wide which was falling off. The elevator floor had yellow stains and the corners of the floor with built up dirt. The second floor common area floors were stained from various liquids which had been spilled. The edges of the whole common area, behind the furniture and under the baseboard heater had a large build of dirt. The wood edging was chipped and splintering. The ceiling had several tiles which were missing and another area of water damage on the ceiling tile had water stains approximately 12 inches wide by seven inches wide. room [ROOM NUMBER]: The wall next to the resident's bed had six pea sized holes. The wall next to the resident's sink had an area approximately three feet wide by two feet high which had chipped and peeling sheetrock. The corner next to the sink had chipped and peeling sheetrock approximately 14 inches high by three inches wide with the metal corner strip visible. The closet door behind the entrance door had a large hole from the door knob slamming into it. The floors had trash and debris underneath the resident's bed. The edges of the whole room and under the baseboard heater had a large build of dirt. The tile outside of the phone room had a white discolored paint stain approximately 12 inches by 12 inches. room [ROOM NUMBER]: The floors had trash and debris underneath the resident's bed. The edges of the whole room and under the baseboard heater had a large build of dirt. The entrance had a missing transition strip with a one-fourth inch lip. Room # 201: The floors were sticky and stained from unknown liquid. The floor tiles next to the 200 hall were damaged, chipped and had medium brown stains approximately 16 feet long by three feet inches wide with a one-fourth inch lip. The sheetrock outside of the shower room had water damage approximately four feet high by six feet long with the sheetrock soft and crumbly from the water damage. room [ROOM NUMBER]: The resident's restroom floor was sticky and had yellow stains on the floor. The floors had trash and debris underneath the resident's bed. The edges of the whole room and under the baseboard heater had a large build of dirt. room [ROOM NUMBER]: The wall next to the resident's bed had an area approximately four feet by five feet of peeling and chipped sheetrock. II. Environmental tour and staff interview The environmental tour was conducted with the maintenance supervisor (MS) and environmental regional director ([NAME]) on 1/9/24 at 9:44 a.m. The above detailed observations were reviewed. The MS documented the environmental concerns. The MS said staff had not been utilizing the work orders, had recently been educated on the work order process and how to fill out requisition requests for repairs in the facility, which were located at each nursing station. The MS said he did not have any repair requisition requests for the above-mentioned items. The MS said the above-mentioned damage should have been repaired and addressed in a timely manner.

Based on record review and interviews, the facility failed to ensure five (#56, #34, #3, #45 and #128) of six residents were free from unnecessary psychotropic medications out of 27 sample residents. Specifically, the facility failed to: -Implement effective individualized behavior monitoring in the medical record and follow physician orders to determine the efficacy of psychoactive medications for Residents #56, #34, #3 and #128; -Track behaviors of sexual aggression for Resident #128; and, -Update behavior tracking to reflect an increase in an antipsychotic medication for Resident #45. Findings include: I. Facility policy The Behavior Monitoring policy, dated 3/10/23, was provided by the nursing home administrator (NHA) on 1/8/24 at 8:42 a.m. It read in pertinent part: Specific behavior(s) documentation will be utilized to monitor residents and behaviors. Identify the potential cause of the behavior(s), Attempt to eliminate or decrease the behavior(s) through interventions, Document the specific and observable behaviors such as continuous pacing, biting, kicking, crying, grabbing, hitting, repetitive questions/concerns, hallucinations, paranoia or verbalizations of delusions. The Psychopharmacological policy, dated 3/10/23, was provided by the NHA on 1/8/24 at 8:42 a.m. It read in pertinent part: Licensed nurses and additional staff will monitor and document any targeted behaviors that occur. These behaviors will be documented on one or more of the following: Point of Care (POC), Progress Notes, or on a Risk Management Incident Report II. Resident #56 A. Resident status Resident #56, age under 65, was admitted on [DATE]. According to the January 2024 computerized physician order (CPO), diagnoses included paranoid schizophrenia. The 12/20/23 minimum data set (MDS) assessment documented the resident was cognitively intact with a brief interview of mental status (BIMS) score of 15 out of 15. The behavior section of the MDS assessment had not been completed. B. Record review The comprehensive care plan, initiated 6/8/21, revealed the resident experienced hallucinations, delusions and behaviors of self harm. The resident frequently heard voices and if he became overwhelmed by the voices, he would bang his head against the wall. The resident had a history of banging his head against the wall and causing a traumatic brain injury. Interventions included to redirect the resident to independent activities of interest such as video games or putting on Beatles music for him. Staff were to monitor behavior episodes and attempt to determine the underlying cause. The January 2024 CPO revealed the following physician orders: Clozapine (antipsychotic) 50 milligram (MG)- give one time a day for paranoid schizophrenia-ordered on 9/27/22. Clozapine 100 MG- give two times a day for paranoid schizophrenia-ordered on 9/27/22. Clozapine 200 MG- give two times a day for paranoid schizophrenia-ordered on 9/27/22. Document behaviors observed and interventions in progress notes-ordered on 9/13/22. A review of the resident's medication administration records (MAR) and treatment administration records (TAR) from 12/1/23 to 1/7/24 revealed: Behaviors indicated as occurring on 12/3/23, 12/9/23, 12/10/23, 12/16/23, 12/23/23, 12/25/23, 1/6/24 and 1/7/24. -There were no descriptions of the behaviors observed indicated in the resident's progress notes, the interventions tried to address the behaviors or if the interventions were effective. III. Resident #34 A. Resident status Resident #34, age 69, was admitted on [DATE]. According to the January 2024 CPO, diagnoses included dementia, depression and epilepsy. According to the 10/20/23 MDS assessment, the resident had severe cognitive impairment with a BIMS score of four out of 15. The resident had no behavioral symptoms. B. Record review The care plan, initiated 5/26/2020 and revised 11/10/23, identified the resident was receiving psychotropic medications for the symptoms of behaviors. The resident's current medication was Risperdal. The resident had a history of gradual dose reduction (GDR) with this Risperdal and had become physically aggressive towards peers during the GDR trials. Do not GDR this medication. Interventions include utilizing non-pharmacological interventions as possible. Medication reductions and or risk benefit assessments as indicated. Monitor for medication effectiveness, behaviors, administer medications per physician order, quarterly medication management review, labs per physician orders, abnormal involuntary movement (AIMS) quarterly or as needed, and assess for side effects as needed. Monitor for dermatologic reactions during lamotrigine therapy and monitor for symptoms of immune system reactions-fever, rash blood dyscrasias (blood disorder) any are noted-notify the prescriber for possible discontinue and initiation of alternative anticonvulsant therapy. The care plan, initiated 5/26/20 and revised 11/10/23, identified the resident had behaviors of agitation, physical and verbal aggression toward others and making false allegations. The resident can become physically aggressive (pushing, hitting others with his fists or objects) related to neurocognitive disorder with aggression, traumatic brain injury (TBI), paranoid and delusional disorder. Interventions include analyzing the times of day, places, circumstances, triggers and what de-escalates behaviors and documents. Medication monitoring; document paranoid statements every shift (Q shift), document verbal aggression q shift, was resident paranoid regarding money q shift and were paranoid statements regarding staff or peers made. The January 2024 CPO included: -Ativan 0.5 mg tab by mouth two times a day for anxiety related to dementia. Start date 9/26/23. -Risperidone 1 mg tab by mouth two times a day related to unspecified dementia, unspecified severity with other behavioral disturbance. Start date 8/15/23. -Please document behaviors observed and interventions in progress note every shift related to unspecified dementia with behavioral disturbance. Start date 9/13/22. -Behavior documentation for Ativan and Risperidone revealed there were no behaviors documented for November 2023 to 1/8/24. A written request was made for behavior tracking in the Foresight behavior tracking was requested on 1/8/24 at 1:29 p.m. -At time of exit on 1/9/24, no requested documentation was provided. IV. Resident #3 A. Resident status Resident #3, age 70, was admitted on [DATE]. According to the January 2024 CPO, diagnoses included schizoaffective disorder bipolar type and major depressive disorder recurrent. The 10/20/23 MDS assessment documented the resident was cognitively impaired with a BIMS score of eight out of 15. The assessment documented no behaviors. B. Record review The comprehensive care plan, revised 5/16/23, revealed the resident had a history of sexually inappropriate behaviors and a history of wandering. The resident had delusions and a potential for suicidal ideations or self harm. Interventions included to report inappropriate behaviors to nursing and track on behavior tracking log. Staff were to engage the resident in activities of interest, provide education on boundaries, and follow the facility self harm protocol. The January 2024 CPO revealed the following physician orders: Clozapine 200 MG- give two tablets one time a day for schizoaffective disorder bipolar type-ordered on 8/11/21. Clozapine 50 MG- give one time a day for schizoaffective disorder bipolar type-ordered on 9/8/21. Document behaviors observed and interventions in progress notes-ordered on 9/13/22. A review of the resident's MAR and TAR from 12/1/23 to 1/7/24 revealed: Behaviors indicated as occurring on 12/2/23, 12/3/23, 12/9/23, 12/10/23, 12/16/23, 12/23/23,12/24/23, 1/6/24 and 1/7/24. -There were no descriptions of the behaviors observed in the resident's progress notes, the interventions tried to address the behaviors or if the interventions were effective. V. Resident #128 A. Resident status Resident #128, age under 65, was admitted on [DATE]. According to the January 2024 CPO, the diagnoses included schizoaffective disorder bipolar type and paranoid personality disorder. The 10/9/23 MDS assessment revealed the resident had not been assessed for a BIMS. The behavior section of the MDS assessment had not been completed. B. Record review The comprehensive care plan, revised on 12/26/23, revealed the resident had sexually inappropriate behaviors such as making verbally explicit comments or suggestions, attempting to follow staff or other residents making others uncomfortable with a history of sexually assaulting women. The resident had shown no interest in alternative ways to satisfy his sexual needs and needed continual reminders of acceptable public behavior. Interventions included to redirect the resident's sexual feelings, expressions, and needs to appropriate outlets. The resident had behaviors of anger manifestations displayed as excessive or unrealistic anxiety. Interventions included assisting the resident in learning relaxation techniques as a coping skill. He exhibited behaviors of suicidal ideations or interpreted behaviors such as verbalizations, statements of means and calling 911. Interventions included reporting all suicidal or homicidal ideations to management and educating the resident on appropriate communication methods. The January 2024 CPO revealed the following physician orders: Clozapine 250 MG- give one time a day for schizoaffective disorder bipolar type-ordered on 11/10/23 and discontinued 12/12/23. Clozapine 200 MG- give two tablets one time a day for schizoaffective disorder bipolar type-ordered on 12/12/23. Depakote (mood stabilizer) 1000 MG-give one time a day for schizoaffective disorder bipolar type-ordered on 11/10/23 and discontinued 12/12/23. Fluphenazine (antipsychotic) injection 25 MG/milliliter (ML)-give 0.75 ML intramuscular (IM) injection one time a day every 21 days for schizoaffective disorder bipolar type-ordered on 12/12/23 and discontinued 12/14/23. Fluphenazine injection 25 MG/ML-give 0.75 ML IM injection one time a day every 21 days for schizoaffective disorder bipolar type-ordered on 12/14/23. Depakote 500 MG- give one tablet two times a day for schizophrenia- ordered on 12/12/23 and discontinued on 12/14/23. Depakote 125 MG- give one tablet two times a day for a total of 375 MG a day for schizoaffective disorder bipolar type-ordered on 12/14/23. -There was no physician order for behavior monitoring. The admission packet from the psychiatric inpatient unit dated 9/4/21 documented the resident had a history of self mutilation, biting himself and banging his head. He had a history of physical and verbal aggression along with unwanted touching of female staff members and exposing his penis. It was recommended by the hospital he be discharged to a secure locked all male unit. The level II preadmission screening and resident review (PASRR) evaluation dated 10/6/22 showed the resident had a long history of psychiatric inpatient stays for suicidal ideations and sexual aggression. At the time of the evaluation, staff had reported hypersexual behavior and verbal aggression toward female staff. The resident frequently displayed verbal aggression and threats of sexual violence towards female staff and residents. The resident had not acted on threats but had a history of incarceration due to perpetration in a sexual assault. The facility placed the resident on one-on-one supervision to ensure staff and resident safety. Psychiatric history and physical dated 11/27/23 documented the resident had readmitted to the facility on [DATE] after a mental health hold to a psychiatrist inpatient stay in the hospital post statements of suicidal ideations, threats to others, and public masturbation in front of peers and staff. A review of progress notes from 11/25/23 to 1/7/24 revealed: Nursing progress note dated 11/25/23 documented the resident was transported to the hospital after calling 911 and expressing suicidal ideations. Nursing progress note dated 12/12/23 documented the resident had returned from the hospital. Nursing progress note dated 12/17/23 documented the resident had refused to take his psychotropic medications. Nursing progress note dated 12/18/23 documented the resident was transferred to the hospital on 12/17/23 after calling 911 and expressing intent to kill himself. Nursing progress note dated 12/18/23 documented resident had returned from the hospital at 9:50 a.m. Nursing progress note dated 12/18/23 at 9:24 p.m. documented the resident had refused to take his psychotropic medications. Behavior note dated 12/19/23 documented the resident was showing signs of hallucinating and psychomotor agitation. Behavior note dated 12/21/23 at 11:28 a.m. documented the resident approached staff and stated he no longer wanted to be in the facility and wanted to go to a sex lodge. He explicitly explained he needed to have oral sex performed on him. The resident was offered visual stimulation videos and personal masturbation devices which he refused. He repeated he needed to go to a sex lodge. Behavior note dated 12/21/23 at 11:30 a.m. documented the resident went to the NHA and director of nursing (DON) and asked to go to a sex lodge. He again explicitly explained he needed to have oral sex performed on him. The resident was offered visual stimulation videos and personal masturbation devices which he refused. The social worker was informed and the resident was placed on 15 minute checks from staff. Social services quarterly evaluation dated 12/25/23 documented the resident occasionally expressed sexual ideations. Nursing progress note dated 12/31/23 documented the resident had refused to take his psychotropic medications. Nursing progress note dated 1/1/24 documented the resident was transported to the hospital after calling 911 and expressing suicidal ideations. Behavior note 1/2/24 documented the resident had been responding to internal stimuli (voices) and stated his head was getting louder. The resident refused his medications. He was pacing and attempted to elope from the facility but was redirected. Nursing progress note dated 1/4/24 documented the resident had called 911 and expressed homicidal and suicidal thoughts. The resident had a plan to hit his head or jump off of a table. The resident was handcuffed and taken to the hospital. VI. Resident #45 A. Resident status Resident #45, age 70, was admitted on [DATE]. According to the January 2024 CPO, the diagnoses included schizophrenia. The 10/9/23 MDS assessment revealed the resident was cognitively intact with a BIMS score of fifteen out of 15. The behavior section of the MDS assessment had not been completed. B. Record review The comprehensive care plan, revised on 8/10/23, revealed the resident took antipsychotic medications related to his diagnosis of schizophrenia. Interventions included to monitor behaviors related to antipsychotic medications. Review behaviors/interventions and alternative therapies attempted and effectiveness according to facility policy. The January 2024 CPO revealed the following physician orders: Perphenazine (antipsychotic) 2 MG- give 1 MG tablet one time a day for schizophrenia to take with 2 MG to equal 3 MG-ordered on 6/18/22 and discontinued on 12/11/23. Perphenazine 4 MG- give one time a day for schizophrenia -ordered on 12/11/23. Document behaviors observed and interventions in progress notes-ordered on 9/13/22. Progress notes dated 12/6/23 through 1/4/24 revealed in pertinent part, Nursing progress note dated 12/6/23 documented the resident had a trash can and a staff member attempted to take the trash can from him. The resident pulled the trash can from the staff and hit the staff member in the side of the face. No further details were documented. Medical provider long term care follow up note dated 12/10/23 documented the provider followed up due to increased behaviors. It was recommended the resident's antipsychotic medication be increased, perphenazine, due to worsening behaviors. Psychiatric follow up progress note dated 12/19/23 documented the resident appeared disheveled and guarded during the visit. He had been irritable and uncooperative with the provider. No reported or observed signs of homicidal ideations. The resident's pre-admission level II PASRR was reviewed. The level II evaluation dated 6/1/18 did not show the resident had a history of harming others. VI. Staff interviews Certified nurse aide (CNA) #2 was interviewed on 1/8/24 at 8:30 a.m. She said Resident #34 did not have any behaviors and the resident stayed in his room and sat in his recliner and watched television. She said if a resident had a behavior she would tell the nurse what was going on. Licensed practical nurse (LPN) #3 was interviewed on 1/8/24 at 8:54 a.m. LPN #3 said the nursing track behaviors on the resident's TAR. The specific behaviors and interventions were to be charted in the resident's progress note. He did not know where the certified nursing aides (CNA) documented residents' behaviors. If the social worker or the director of nursing (DON) wanted to communicate particular target behaviors or interventions, it would be put in the communication section of the resident's electronic medical record but only remained there for a few days. He did not know how this information was communicated to staff who had missed the notification in the electronic medical record. LPN #3 said he did not look in the resident's care plan for target behaviors or non-pharmacological interventions. He said Resident #56 did not have behaviors. He did not know what type of medication the resident's Clozaril was or why specifically it was being administered. Resident #128 had behaviors of calling 911, refusing medications, suicidal and homicidal ideations. LPN #3 was not aware of any sexually inappropriate history to monitor Resident #128 for. Resident #3 was cooperative with staff and had no behaviors. LPN #4 was interviewed on 1/8/24 at 9:09 a.m. She said Resident #45 had behaviors of tearing his clothes, sheets and blankets apart. LPN #4 said nursing track behaviors on the TAR and then progress note the specific behaviors and interventions. CNAs track behaviors in a separate tracking system called Foresight. It was a computer tracking program separate from the resident medical record. The nurse could track in Foresight as well, however LPN #4 said she could not recall her login information. CNA #5 was interviewed on 1/8/24 at 9:15 a.m. She said resident behaviors were in the resident kardex (abbreviated care plan) but the behaviors were generic and not individualized. If CNAs wanted to document resident specific behaviors, the CNAs used Foresight. CNA #5 attempted to login but could not recall her login information. CNA #6 was interviewed on 1/8/24 at 9:25 a.m. He said Resident #45 had behaviors of tearing up his clothes and his roommate's belongings. CNAs track resident behaviors in Foresight. LPN #2 was interviewed on 1/8/24 at 9:50 a.m. She said the nurses track behaviors on the TAR and in Foresight. -However, she was unable to locate the login website and could not recall her login information. LPN #2 said she documented on the resident's TAR only. CNA #1 was interviewed on 1/8/24 at 9:55 a.m. He said Foresight was only on the CNA computers on the first floor of the facility. He said CNAs tracked in Foresight only and not on the kardex. LPN #4 and CNA #6 were interviewed again on 1/8/24 at 10:00 a.m. CNA #6 did not have his login information to get into Foresight. LPN #4 said the facility had been using Foresight for five years to track behaviors but she used the resident's TAR. LPN #4 and CNA #6 did know how behaviors marked in Foresight were incorporated into the resident's electronic medical record. CNA #9 was interviewed on 1/8/24 at 10:05 a.m. She was able to login into Foresight. She said CNAs use the kardex for behaviors and if the behaviors were more serious, the CNAs would document in Foresight. The resident care director (RSC) was interviewed on 1/8/24 at 11:15 a.m. Resident #3 and Resident #56 did not have behaviors. Resident #128 had behaviors of expressing suicidal ideations in order to be sent out to the hospital. Resident #128 had not had any inappropriate sexual behaviors towards female staff or residents since RSC started working at the facility in June of 2023. The facility had not initiated behavior tracking for this behavior because it was not an active behavior of his and he had not exhibited any sexual ideations, despite documentation showing sexual ideations as recent as November and December 2023. Licensed practical nurse (LPN) #5 was interviewed on 1/8/24 at 1:07 p.m. She said Resident #34 spent the majority of his time in his room watching television. She said the resident was compliant with taking his medication and never really had any behaviors to speak of. She said the resident would yell things throughout the day but that was just typical of Resident #34. The director of nursing (DON) was interviewed on 1/8/24 at 1:09 p.m. The DON said the problem with documenting Resident #34's behavior was that staff would see his behaviors as typical baseline behaviors and his behaviors were not being tracked correctly. She said the facility needed to change how staff were documenting behaviors for all residents. The DON said a negative outcome for not correctly identifying behaviors for a resident could be isolation, paranoia, added depression and the use of unnecessary medications. The RSC, the NHA and the DON were interviewed on 1/8/24 at 1:34 p.m. The NHA said the facility used the tracking on the TAR in the electronic medical record and Foresight program. The staff were more accustomed to using Foresight but the goal was to integrate tracking to just the electronic medical record. The nurses made a progress note after marking a behavior on the TAR. The RSC and DON had just started putting the quarterly summaries from Foresight into the electronic medical record as a progress note. -However, these summaries were not in the progress notes for Residents #56, #35, #3, #45 or #128. The DON said the behavior tracking on the TAR were not personalized because the severity of the mental illness amongst the facility's residents on psychoactive medications would require too many behaviors listed on the tracker. The NHA and RSC were responsible for entering the behaviors into Foresight to be tracked. The NHA said the nurses should be checking the residents' care plan and reading the psychotropic drug committee notes to find target behaviors and non-pharmacological interventions. The nurses should be able to determine the behaviors to track based on the resident's diagnosis alone. She was not aware the staff were not utilizing Foresight and nurses were not making supplemental progress notes to explain behaviors indicated. CNA #6 was interviewed on 1/8/24 at 1:55 p.m. She said Resident #34 yelled all day and he was now trying to kiss female CNAs when he got a chance. She said the resident would yell out all day long. She said his yelling gets out of control at times but staff just go in and check to see if he needs anything. She said when a resident would have behaviors she would report them to the nurse on duty. She said she did not use foresight but would tell the nurse on duty of the resident's behaviors. V. Facility follow-up On 1/8/24 at 11:25 a.m. six months of behavior tracking were requested from the NHA for Resident #45, #56, #3 and #128. On 1/8/24 at 11:56 a.m. only behavior tracking from Foresight was provided by the NHA for Resident #45, #56, #3 and #128. Behavior tracking for 8/1/23 to 12/31/23 for Resident #45 was provided. -No tracking for January 2024 was provided to show tracking of physical aggression are behaviors related to antipsychotic usage. Behavior tracking for 8/1/23 to 12/31/23 for Resident #56 was provided. -There were no dates on the tracker to confirm what time frame it was from. Behavior tracking for 8/1/23 to 12/31/23 for Resident #3 was provided. -There were no dates on the tracker to confirm what time frame it was from. Behavior tracking for 8/1/23 to 12/31/23 for Resident #128 was provided and only had one behavior incident listed on 8/29/23 the resident had been staring at two other residents who reported he was making them uncomfortable. -The tracker failed to have targeted behaviors. 31821

Based on observation and staff interviews, the facility failed to provide a safe, functional and comfortable environment for residents, staff and the public. Specifically, the facility failed to ensure a backflow prevention device was installed on the hand held shower in the shower on the 100 hall, increasing the risk of contamination to the facility's main water supply. Findings include: I. Observation Observations of the resident living environment conducted on 1/8/24 at 9:18 a.m. revealed: The hand held shower head in the 100 hall shower room did not have a backflow prevention valve on it. The hand held shower was long enough to sit on the side on the floor next to the drain. There was visible standing water at the base of the shower pan. II. Staff interview The maintenance supervisor (MS) was interviewed on 1/9/24 at 9:44 a.m. He said he was familiar with the backflow valve protocol. The MS stated the hand held shower should have a backflow prevention valve on. He said he would install one immediately.

Based on observations, record review and interviews, the facility failed to provide appropriate treatment and services to maintain or improve the ability to perform activities of daily living (ADLs) for one (#3) of two residents reviewed for ADLs out of 27 residents. Specifically, the facility failed to provide supervision, oversight, encouragement and cueing with personal hygiene for Resident #3. Findings include: I. Resident status Resident #3, age 70, was admitted on [DATE]. According to the January 2024 computerized physician orders (CPO), diagnoses included schizoaffective disorder bipolar type and major depressive disorder recurrent. The 7/28/23 minimum data set (MDS) assessment documented the resident was cognitively impaired with a brief interview for mental status (BIMS) score of eight out of 15. The resident required supervision to one person assistance with personal hygiene and dressing. The assessment documented no behaviors of refusals of care. II. Observations and interview On 1/3/24 at 10:05 a.m. the resident was sitting in the common area. The resident's hair appeared to be greasy. The resident's shirt had what appeared to be stains from food or liquids on it. His teeth were discolored with debris. The resident was wearing shorts and a short sleeve shirt despite the weather ranging from 18 degree Fahrenheit (F) to 40 degree F. On 1/4/24 at 12:36 p.m. the resident was in his room. He was sitting on his bed. The resident's hair appeared to be greasy. The resident's shirt had what appeared to be stains from food or liquids on it. Holes could be seen in his shorts and his socks. The resident was wearing the same shorts from 1/3/24. The weather ranged from 25 degree F to 35 degree F on 1/4/24. On 1/8/24 at 9:38 a.m the resident was exiting the facility to the outside smoking section. He was wearing a jacket, a shirt and a pair of shorts. The temperature at the time was 22 degrees F. The resident passed licensed practical nurse (LPN) #3 who acknowledged the resident but did not say anything to him about his clothing. III. Record review The comprehensive care plan, revised 5/6/23, revealed the resident had impaired decision making abilities and required assistance to make safe, good decisions. The resident had poor safety awareness related to cognitive deficits and a traumatic brain injury. The resident had an ADL self care performance deficit related to cognitive impairments. Interventions included providing the resident with verbal cues and prompting. The resident had oral/dental health problems related to poor dentition. The resident required assistance with his ADLs and required staff to complete his oral care. Interventions included to assist with mouth care as per ADL self care personal hygiene. IV. Staff interview Certified nurse aide (CNA) #5 was interviewed on 1/8/24 at 8:30 a.m. She said Resident #3 did not refuse showers, changing his clothes or brushing his teeth. The CNAs provide cueing, prompting and stand by assistance for showers and dressing and one person assistance for brushing teeth. LPN #3 was interviewed on 1/8/24 at 8:54 a.m. He said Resident #3 was cooperative with care staff. The resident did not have a preference for shorts and was agreeable to receiving help from staff with changing clothes. The resident was independent physically in ADLs but had cognitive deficits requiring curing, prompting and stand-by assistance with showers, dressing and personal hygiene. The director of nursing (DON) and nursing home administrator were interviewed on 1/8/24 at 2:03 p.m. The DON said the resident required cueing up to one person assistance with personal hygiene tasks. She said the resident would refuse to change his clothes and choose clothing inappropriate for the weather. The DON was unaware the staff failed to document those behaviors. The staff interviews did not reveal the resident had these behaviors. The NHA said when she saw the resident wearing shorts, she would ask him if he would like to change into pants and he declined. -No further prompting or encouragement was provided per the NHA or risk-benefit education regarding wearing clothing not appropriate for the weather.

Based on interviews and record review, the facility failed to notify the state mental health agency promptly after a significant change in the mental condition of two (#45 and #128) of five residents out of 27 sample residents. Specifically, the facility failed to: -Notify the State Mental Health Agency of Resident #128 necessity for inpatient psychiatric hospitalization s; and, -Notify the State Mental Health Agency of Resident #45's suicide attempt and physical aggression towards others. Findings include: I. Facility policy and procedure The PASRR (Pre-Admission Screen and Resident Review) policy, dated 9/26/23, was provided by the nursing home administrator (NHA) on 1/8/24. It revealed in pertinent part, If a resident's psychiatric status changes after admission, the social services staff are responsible for contacting the State Mental Health Agency via completion and submission of a PASRR level I screen and indicate the reason for referral as a change in mental health status or psychiatric diagnosis. Status change level I screens should be submitted in the following circumstances: significant deterioration in mental health condition; significant increase in psychiatric symptoms or psychiatric hospitalization , regardless of whether there is a change in diagnosis or medications. II. Resident #45 A. Resident status Resident #45, age 70, was admitted on [DATE]. According to the January 2024 computerized physician orders (CPO), the diagnoses included schizophrenia. The 10/9/23 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. The MDS assessment section for identification of a level II PASRR for a serious mental illness had not been completed. The depression screen and behavior section of the MDS assessment were incomplete. B. Record review The comprehensive care plan, revised on 10/27/23, revealed the resident had a level II PASRR due to a diagnosis of schizophrenia. He exhibited behaviors of throwing away his personal belongings and accidently taking his roommates belongings. The resident had impaired vision and was not aware he was taking others belongings. He also would give personal belongings and money away. Interventions include monitoring the resident's room for unfamiliar belongings, providing positive interaction and reminding the resident to maintain his personal property. -The care plan did not reflect behaviors of harm to self or others. Progress notes dated 12/4/23 through 1/4/24 revealed in pertinent part, Psychiatric follow up progress note dated 12/6/23 at 10:00 a.m. documented the resident had a depression assessment and scored nine out of 27 indicating mild depression. No reported or observed signs of suicidal or homicidal ideations. Nursing progress note dated 12/6/23 at 3:58 p.m. documented the resident had a trash can and a staff member attempted to take the trash can from him. The resident pulled the trash can from the staff and hit the staff member in the side of the face. Medical provider long term care follow up note dated 12/7/23 documented the provider was following up with the resident due to the assault on 12/6/23. The resident had punched the staff member in the face. The staff had been instructed to monitor the resident. The resident appeared stable during the provider visit. Medical provider long term care follow up note dated 12/10/23 documented the provider was following up due to increased behaviors. It was recommended there would be an increase in the resident's antipsychotic medication, perphenazine, due to worsening behaviors. Psychiatric follow up progress note dated 12/19/23 documented the resident appeared disheveled, underweight and guarded during the visit. He was irritable, uncooperative and avoided eye contact. No reported or observed signs of suicidal or homicidal ideations. Order administration note dated 1/1/24 documented the resident was found by staff with a gait belt (transfer belt) around his neck. No injury was noted. Medical provider long term care follow up note dated 1/5/24 documented the provider was following up due to worsening behaviors. The staff had reported finding the resident with a gait belt around his neck and was put on one-on-one staff supervision for concern of suicidal intent. The resident told the provider he did not remember how the gait belt got around his neck. -No progress notes were found documenting the State Mental Health Agency had been updated on the new behaviors the resident had displayed; the physical assault and a suicide attempt. The resident's pre-admission level II PASRR was reviewed. The level II notice of determination dated 6/1/18 identified the resident as meeting the criteria for PASRR mental illness. -The level II evaluation dated 6/1/18 did not show the resident had a history of harming self or others. III. Resident #128 A. Resident status Resident #128, age under 65, was admitted on [DATE]. According to the January 2024 CPO, the diagnoses included schizoaffective disorder bipolar type and paranoid personality disorder. The 10/9/23 MDS assessment revealed the resident had not been assessed for a BIMS. The MDS assessment section for identification of a level II PASRR for a serious mental illness had not been completed. The depression screen and behavior section of the MDS assessment were incomplete. B. Record review The comprehensive care plan, revised on 12/26/23, revealed the resident had a level II PASRR due to a diagnosis of schizophrenia and paranoid personality disorder. He exhibited behaviors suicidal ideations or interpreted behaviors such as verbalizations, statements of means and calling 911. Interventions included reporting all suicidal or homicidal ideations to management and educating the resident on appropriate communication methods. According to the January 2024 CPO, the resident had orders dated 12/18/23 to transfer to the hospital for expressions of suicidal ideations. Progress notes dated 12/4/23 through 1/4/24 revealed in pertinent part, Nursing progress note dated 12/18/23 documented the resident was transferred to the hospital after calling 911 and expressing intent to kill himself. Behavior note dated 12/19/23 documented the resident was showing signs of hallucinating and psychomotor agitation. Social services quarterly assessment dated [DATE] documented the resident was cognitively intact with a history of suicidal and homicidal ideations. The resident PASRR level II and recommendations were reviewed during the assessment. Nursing progress note dated 1/1/24 documented the resident was transported to the hospital after calling 911 and expressing suicidal ideations. Nursing progress note dated 1/4/24 documented the resident had called 911 and expressed he wanted to kill himself. The resident had a plan to hit his head or jump off of a table. The resident was handcuffed and taken to the hospital. -No progress notes were found documenting the State Mental Health Agency had been updated on the resident's worsening symptoms and repeated expressions of suicidal ideations. Psychiatric history and physical dated 11/27/23 documented the resident had readmitted to the facility on [DATE] after a mental health hold to a psychiatrist inpatient stay in the hospital post statements of suicidal ideations, threats to others and public masturbation. The resident's pre-admission level II PASRR was reviewed. The level II notice of determination dated 10/6/22 identified the resident as meeting the criteria for PASRR mental illness. The level II evaluation dated 10/6/22 showed the resident had a long history of psychiatric inpatient stays for stabilization and an inpatient stay for suicidal ideations. IV. Staff interview The resident care director (RSC) was interviewed on 1/8/24 at 11:15 a.m. She said a status change was sent into the State Mental Health Agency if a resident had new or worsening symptoms. She said new or worsening symptoms could be a resident exhibiting suicidal attempts or ideations when this was not a baseline behavior. If a resident had an inpatient psychiatric hospitalization due to needing to be stabilized, a status change update would be completed. She did not know why an update had not been sent for Resident #45 or Resident #128 but said the updates should have been sent in.

Based on observation, record review and interviews, the facility failed to ensure one (#3) of six residents reviewed for medication administration received treatment and care in accordance with professional standards of practice out of of 27 sample residents. Specifically, the facility failed to ensure that Resident #3 was not administered an expired inhaler as identified by the manufacturer's directions. Findings include: I. Professional references According to the Centers for Disease Control (CDC) website, retrieved on [DATE] from https://www.cdc.gov/wtc/prescriptionsafety.html#:~:text=You%20should%20dispose%20of%20any,or%20misusing%20the%20medication%20intentionally. included the following recommendations, You should dispose of any unused or expired prescription medicine as soon as possible. Timely disposal of prescription medicine can reduce the risk of others taking the medication accidentally or misusing the medication intentionally. According to the Food and Drug Administration (FDA) website, retrieved on [DATE] from https://www.fda.gov/drugs/special-features/dont-be-tempted-use-expired-medicines#:~:text=Expired%20medicines%20can%20be%20risky&text=Once%20the%20expiration%20date%20has,expired%2C%20do%20not%20use%20it. included the following recommendations, Once the expiration date has passed there is no guarantee that the medicine will be safe and effective. If your medicine has expired, do not use it. II. Manufacturer recommendations According to the Severent Diskus inhaler manufacturer guidelines, revised ,d+[DATE], retrieved on [DATE] from https://gskpro.com/content/dam/global/hcpportal/en_US/Prescribing_Information/Serevent_Diskus/pdf/SEREVENT-DISKUS-PI-MG-IFU.PDF on [DATE] included the following recommendations, Storage and handling Severent Diskus should be stored inside the unopened moisture-protective foil pouch and only removed from the pouch immediately before initial use. Discard Severent Diskus six weeks after opening the foil pouch or when the counter reads ' 0 ' (after all blisters have been used), whichever comes first. The inhaler is not reusable. Do not attempt to take the inhaler apart. III. Observations and interviews On [DATE] at 9:25 a.m., licensed practical nurse (LPN) #3 reviewed the Severent Diskus inhaler for Resident #3 from the medication cart. The inhaler had a written open date of [DATE]. LPN #3 said the inhaler had expired. He said he had administered the inhaler for the morning dose. He said he would order a new one. On [DATE] at 9:20 a.m., LPN #3 identified the same inhaler from the previous day in the medication cart. He said he was going to order a new inhaler later that day and he had not removed the inhaler from when the inhaler was identified as expired. IV. Record review The computerized physician orders for Resident #3 identified he was ordered the Serevent Diskus inhaler twice a day, once in the morning and once in the evening. The [DATE] medication administration record (MAR) for Resident #3 had documentation that the resident had received the evening dose of the Serevent Diskus inhaler after the inhaler had been identified as expired. The evening nurse administered an expired inhaler after the medication had been identified as expired on [DATE] with LPN #3 (see above). The provider was not notified of the expired medication being administered twice on [DATE]. V. Staff interviews The director of nursing (DON) was interviewed on [DATE] at 9:50 a.m. She said when a medication was ordered it usually would arrive in the afternoon or evening. She said the nurses had been trained how to order a medication if needed. She said when the inhaler had been identified as expired, it should have been removed from the medication cart and re-ordered. She said she did not want an expired medication to be administered to a resident for the safety of the medication. She said she would remove the inhaler from the medication cart immediately to ensure the safety of the resident and provide education to the nurse on duty.

Based on interviews and record review, the facility failed to ensure each resident was being screened for a mental disorder prior to admission or that residents identified with a mental disorder were evaluated to receive care and services in the most integrated setting to meet their needs for one (#9) of four residents reviewed out of 27 sample residents. Specifically, the failed failed to: -Notify the State Mental Health Agency Resident #9 had exceeded the 60 day convalescent preadmission screening and resident review (PASRR) period; and, -Submit a new PASRR to the State Mental Health Agency for Resident #9 to determine if a level II evaluation was needed. Findings include: I. Facility policy and procedure The PASRR (Pre-Admission Screen and Resident Review) policy, dated [DATE], was provided by the nursing home administrator (NHA) on [DATE]. It revealed in pertinent part, Provisional Approval: Provisional approvals permit nursing facilities (NF) to accept a resident without a full level II evaluation (mental health evaluation) in certain circumstances that are time-limited or where the need for NF is clear. This determination is made by the State Mental Health Agency after review of the level I and other supporting documentation. These exemptions include: Convalescent Care: convalescent care is due to discharge from an acute care hospital. A physician determines that the resident will likely require fewer than 30 days of nursing services. A level I screen shall be submitted to the State Mental Health Agency if the resident remains at the facility past 30 days. II. Resident #9 A. Resident status Resident #9, age under 65, was admitted on [DATE]. According to the [DATE] computerized physician orders (CPO), the diagnoses included epilepsy and an intellectual disability. The [DATE] minimum data set (MDS) assessment revealed the resident was unable to participate in the brief interview for mental status (BIMS) due to being never or rarely understood. A staff assessment was never completed. The PASRR section on the assessment was blank. B. PASRR level II notice of determination for MI (mental illness) evaluation and facility failures The resident's pre-admission level I PASRR dated [DATE] revealed the resident was approved under a convalescent care admission. The PASRR included the end date of [DATE] for the convalescent care admission. It documented if the resident stayed past the end date, the facility would need to contact the State Mental Health Agency to have the resident evaluated for a level II. -There were no additional level I PASRR screens in the resident's chart to indicate the State Mental Health Agency was notified the resident had resided in the facility past the 60 day end date. This failure resulted in the resident not being screened for a level II PASRR and not being identified for any specialized services or needs. C. Record review The comprehensive care plan, revised on [DATE], revealed the resident had severe cognitive and communication deficits. He benefited from 24 hour nursing care and his guardians had no plans to move him. The resident was anticipated to remain for long term care. Progress notes reviewed from [DATE] to [DATE] revealed no social service notes were located documenting a new PASRR had been submitted. III. Staff interviews The resident care director (RSC) was interviewed on [DATE] at 11:15 a.m. The RSC said she completed the resident PASRR after admission, the hospital or sending facility completed the preadmission PASRR. If the preadmission PASRR indicated a time limit, the RSC would be responsible for sending in the update once the time limit had expired. She said residents who required a level II PASRR were residents with a major mental illness or a diagnosis of an intellectual or developmental disability. Resident #9 had a diagnosed intellectual disability and met the criteria for a level II PASRR. The importance of completing the level II PASRR was to receive a notice of determination from the State Mental Health Agency with instructions for specialized services and needs for the resident. She said she was not aware Resident #9 did not have a level II PASRR in his medical record. She said she would look for this, however she did not provide the PASRR. IV. Facility follow up On [DATE] at 2:42 p.m. a level II PASRR for Resident #9 was requested from the NHA. By time of survey exit on [DATE] at 2:00 p.m., no level II PASRR was provided by the facility for Resident #9.

Based on record review and interviews the facility failed to provide effective pain management services to one (#52) of three out of 24 sample residents. Resident #52, with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident stated his pain was typically seven to nine out of 10 on the pain scale. Non-pharmacological interventions for pain were not administered to help alleviate his pain. The resident pain assessment completed 6/22/21 documented he had a decrease in physical activity and socialization attributed to his pain. Due to the facility failures of not managing the resident's pain, he said he did not want to get out of bed and his pain was worse when up in his wheelchair. Findings include: I. Facility policy and procedure The Pain policy, revised on 10/11/19, was received from the nursing home administrator (NHA) on 6/23/21 at 9:00 a.m. It read in pertinent part: Pain is subjective and is what the resident says it is, existing when and where the resident says it does. The purpose of pain management is to accurately assess and achieve pain control. It does not mean the resident is pain free however an acceptable level of tolerable pain would be defined by the resident. All residents shall be evaluated for pain upon admission by using the pain evaluation tool in the residents medical record. This evaluation will be done upon admission, readmission, quarterly and with any significant changes in residents conditions. All pain evaluations will be documented in the residents medical record or in the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . It will include the residents' response to pain interventions. The pain scale will be zero (none) to ten(severe). The findings will be documented in the medical record or in Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Do not forget the non-pharmacological interventions for pain including repositioning, relaxation therapy, aromatherapy or massage therapy. These interventions should be documented in the progress notes and included on the residents care plan. II. Resident #52 Resident #52, under age 65, was admitted on [DATE]. According to the June 2021 computerized physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The 5/10/21 minimum data set (MDS) assessment revealed the resident was slightly cognitively impaired with a brief interview for a mental status score of 13 out of 15. He required extensive two person Hoyer (mechanical) assistance with dressing, toileting, bathing and transferring.The pain assessment indicated the resident had frequent pain over the past five days. The resident experienced trouble sleeping at night due to his pain. The resident indicated his pain was at level seven on the pain scale. II. Interview and observations Resident #52 was interviewed on 6/21/21 at 4:00 p.m. He said he had been at the facility for almost [AGE] years. He indicated that he had chronic pain in his lower back and legs on a daily basis. He said the pain had gone on for the last couple of months and it was never completely relieved. He said the Oxycodone 5 milligrams (mg) tab he received for pain management worked a little. He included his pain was usually between a seven and a nine on the pain scale (out of 10) and the medication would sometimes lower the pain to a five out of 10. He said he did not get out of bed very often because his back hurt worse when he was in his wheelchair. He indicated that he reported his pain to the nurse at least once per day.He said he never remembered to ask for the [MEDICATION(S)] gel. Resident # 52 was interviewed again on 6/22/21 at 10:15 a.m. He was observed to be sitting in his wheelchair in his room. He said that his pain was at level eight. He included that the staff did not use non-pharmacological pain interventions like heat and cold pack, massage or relaxation therapy. He indicated his back pain intensified when he sat in the wheelchair. Resident #52 was interviewed again on 6/23/21 at 8:19 a.m. He was observed to be sitting in his wheelchair in his room. He said he had been out of bed for about a half hour. He said his pain was in his middle back. He indicated that he had been given Oxycodone 5 mg tab at 6:00 a.m. and his pain was still an eight on the pain scale. He said he had already informed the nurse and she was going to call the physician. III. Record review The June 2021 CPO for pain control included the following: [MEDICATION(S)] 1% gel one pump transdermally as needed every eight hours for pain, started 6/8/17. Oxycodone 5 milligrams (mg) tab, 1 tab three times a day for pain, started 5/1/2020. Tylenol Extra Strength 500 mg tab, 2 tabs two times a day for pain, started 5/1/2020. The treatment administration record (TAR) for April 2021, May 2021, and June 2021 indicated [MEDICATION(S)] 1% gel one pump transdermally as needed every eight hours for pain. -The TAR was not signed for the Voltearen gel for April, May and June 2021 indicating the medication was not applied except for 6/22/21 (during survey). The June 2021 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . -It was documented that 16 out of 22 days for the month of June 2021 the resident experienced pain at a level of five or greater. The order to monitor the residents pain level every shift was discontinued on 6/22/21. The new order started 6/22/21 (during survey) indicated that an acceptable level of pain for the resident was between four and five on the pain scale (based on pain assessment completed 6/22/21, see below). The resident's pain care plan, dated 6/10/21, indicated Resident #52 had pain with [CONDITION(S)], lower extremity pain and back pain. It included the resident should be monitored for any side effects with pain medications. The care plan indicated the resident should be offered [MEDICATION(S)] medication and non pharmacological interventions for pain. The non-pharmacological interventions listed were massage, warm and cold packs, music therapy and aromatherapy. The 6/15/21 progress note from the nurse practitioner (NP) indicated Resident #52 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . The patient reported new pain in his right shoulder about a week ago. The NP said he reminded the patient to ask for the Volteran gel when he needed it. The 6/22/21 progress note at 3:07 p.m. indicated that Resident #52 complained of unresolved pain to his right shoulder and did not remember to request the [MEDICATION(S)] gel. The resident also complained of new back and leg pain. The note included the nurse had reported reports of pain to nurse practitioner (NP). Nurse practitioner indicated he would be at the facility on the next day (6/23/21) to see the resident. The most recent pain assessment dated [DATE] indicated the resident had a medical diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The assessment included the resident had experienced sharp pain in his sacrum area within the past five days. The resident said his numeric pain level was at an eight during the assessment (out of 10). He said his acceptable level of pain was between a four and a five (out of 10) on the pain scale. The assessment indicated that the resident had a decrease in physical activity and socialization attributed to his pain. It included that Resident# 52's pain was relieved by medication, relaxation therapy and repositioning. Some interventions listed on the assessment were: -Evaluate the effectiveness of pain interventions each shift. Document this on resident record. -Notify the physician if interventions were unsuccessful. -Offer non-pharmacological interventions for pain. The interventions were not indicated on the assessment. -Monitor for side effects of medications and document findings on the resident record. The side effects were nausea, vomiting, dizziness and falls. III Interviews Certified nurse aide (CNA) #1 was interviewed on 6/22/21 at 10:08 a.m. She said Resident #52 complained of intense pain when transferring and repositioning in the bed. She said the resident required a two person Hoyer (mechanical) lift when transferring out of bed. She indicated that this caused the resident serious back pain. Licensed practical nurse (LPN #1) was interviewed on 6/22/21 at 1:22 p.m. She said Resident #52 had scheduled pain medication and he was not due for any more medication until 3:00 p.m. She said she had not used any non-pharmacological interventions to help the resident with his pain. She said he did not like to get out of bed because sitting in the wheelchair made his back pain worse. She indicated that the resident could reposition himself in bed. She said she checked with the resident to ensure the pain medication was effective about 45 minutes after it was given. She indicated that Resident#52 did not have any as needed (PRN) medication for pain. -However, the resident had an PRN order for Volteran gel (see orders above). The NHA and director of nursing (DON) were interviewed on 6/22/21 at 2:31 p.m. The NHA said that Resident #52 had non-pharmacological interventions for pain indicated in his care plan. Those interventions were warm or cold compress, massage therapy, and relaxation therapy. The DON said the staff should be using the non-pharmacological interventions to help manage the resident's pain. The DON said she did not know where the staff should be documenting those interventions and that she would look more closely at this. She said she did not know if the staff had been offering these interventions to the resident. The DON indicated that there was an order on the TAR for [MEDICATION(S)] gel 1% for PRN pain relief. The order noted to apply one pump every eight hours as needed for pain to affected areas. She said this medication had not been signed out on the TAR from 6/1/21 to 6/23/21 so it had not been given. The DON was interviewed again on 6/23/21 at 8:57 a.m. She said there was no place to document the non-pharmacological interventions for Resident #52. She indicated that an order was added to the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . She said the staff should indicate what non-pharmacological intervention was tried on this documentation. She said the [MEDICATION(S)] gel was added to TAR as a scheduled medication because the resident never remembered to ask for it as of 6/22/21 (see facility follow-up below). The nurse practitioner (NP) was interviewed on 6/23/21 at 10:16 a.m. He said he had been treating Resident #52 for two years. He said he had a call from the DON yesterday indicating the resident was experiencing more pain than usual. He indicated that after seeing the resident today he decided to change the MEDICATION ORDERS FOR [MEDICAL RECORD OR PHYSICIAN ORDER] He said the nurses had to monitor the Oxycodone doses carefully due to the resident's addiction history. He said he would assess the resident in a week or two unless the nurses called him before then. He included that staying in bed caused more pain to the resident's back. He said that he recommended non-pharmacological interventions for pain such as massage, heat and cold packs to the area of pain, and repositioning. IV. Facility follow-up The order dated 6/22/21 read: [MEDICATION(S)] gel 1% apply one strip transdermally every eight hours as needed for around the shoulder and apply one strip transdermally two times a day for pain management. The progress notes dated 6/22/21 indicated the medication was applied by LPN #1 at 5:25 p.m. The note indicated that the medication was effective. The 6/22/21 order for Oxycodone 5mg tab three times per day was changed to Oxycodone 5 mg tab four times a day. -It was not added to the MAR until 6/23/21 at 10:08 a.m. The 6/22/21 order for Tylenol Extra Strength 500mg tab two tabs twice daily was changed to Tylenol extra strength 500 mg tag two tabs three times a day. -It had not been added to the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] The 6/23/21 order read Oxycodone 5 mg: give one tab STAT for breakthrough pain. The medication was given by LPN #1 at 8:35 a.m.

Based on record review and interviews, the facility failed to ensure one (#2) of three residents reviewed for accidents out of five sample residents remained as free from accident hazards as possible. Specifically, the facility failed to prevent Resident #2 from sustaining a fall with a fracture. The facility identified the resident's numerous fall risks (recent [DIAGNOSES REDACTED]. The resident had a fall on 9/14/2020, and sustained an inoperable [MEDICAL CONDITION] hip. Cross-reference to F657; failure to update Resident #2's care plan with new interventions after her functional status changed. Findings include: I. Facility policies and procedures The Fall Management policy, revised 9/10/19, was provided on 9/30/2020 by the nursing home administrator (NHA). The policy read Each resident will be reevaluated quarterly, annually and when a significant change occurs. Individualized care plan interventions will be implemented for those residents found to be at high risk for falls. Resident and resident representative will be invited to all care plan meetings. Please note interventions are to be re-evaluated when a resident falls. Document in PCC the resident's response to interventions and alter interventions if they are not successful. II. Family interview The resident's daughter was interviewed on 10/1/2020 at 9:33 a.m. She said after it became known that her mom had chronically dislocated hip there were no new interventions put in place by the facility, she was still using the same manual wheelchair that she always did. She said she was leaning forward all the time and they (staff) should have provided something to hold her in place. She said nothing was put in place such as a seat belt or any other options that would prevent her from falling forward out of her chair. She said her mom was able to communicate and say what she likes and dislikes. She said she wished the facility did something else to prevent this fall from happening, the fracture was inoperable. III. Resident #2 A. Resident status Resident #2, age 79, was admitted on [DATE]. According to the September 2020 computerized physician orders [REDACTED]. The 9/1/20 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score 15 out of 15. The resident required extensive two person physical assistance for bed mobility, transfers, dressing, toileting and personal hygiene. She was always incontinent of the bowel and bladder. The fall section revealed the resident did not have a fall in the last six months. The behavior section indicated the resident did not resist the care, she did not have hallucinations, delusions or other types of behaviors. 1. Resident's status prior to the fall on 9/14/2020 a. Change of condition on 6/10/2020, new [DIAGNOSES REDACTED]. The nurses progress notes between 6/8/2020 and 6/10/2020 reveal that the resident developed a pain in her left hip that did not respond to pain medications that resident had. The x-ray showed dislocation of the left hip. Resident was sent to the emergency room for evaluations. The discharge summary from the hospital on [DATE] revealed that Resident #2 was admitted to the emergency room due to pain and was diagnosed with [REDACTED]. Orthopedics attempted a closed reduction of the left hip which was unsuccessful. It was determined that dislocation was chronic. Resident was not a good candidate for open reduction surgery and was discharged back to the nursing facility. b. Record review The 5/20/2020 assessment she scored as high fall risk with a score of ten. Her fall risks were related to medications she was taken and three and more [DIAGNOSES REDACTED]. The care plan for falls was initiated on 5/24/2019, and revealed that the resident was at risk for falls. Interventions such as to anticipate resident's needs, make sure the call light is within the reach, educate the resident about safety reminders, and physical therapy evaluation and treatment as needed were added to the care plan on the same day as it was initiated, 5/24/2019. -No new interventions were added to the care plan after 6/10/2020 after the resident was diagnosed with [REDACTED]. -The intervention to offer the resident her repositioning pillow so she can lean over it was added on 9/30/2020 (the day of the survey exit). The care plan for behaviors, initiated on 5/24/2019 and revised on 9/30/2020 (the day of the survey exit) revealed the resident struggled with making safe choices in regards to care and declined care at times. Specifically, Resident #2 will decline transfers to and from wheelchair, Gerichair, shower chair, commode. Resident #2 screams at the staff when she does not want the care provided. Leave me alone. Help. Somebody help me. -Following interventions were added to resident's care on 9/27/2020: When Resident #2 declines care, yells, or refuses to speak; educate and encourage Resident #2 three times for any care that is needed. Approach Resident #2 every five minutes for three intervals, allow to decline care three times before other interventions are introduced. The third time Resident #2 is educated and encouraged to provide care, staff will intervene one of two ways: 1. Position Resident #2 safely and give her space by staff leaving her immediate area. 2. Staff will get a clinical member of IDT, NHA or nursing supervisor to explain to the resident that staff will provide the care that is needed. The nursing supervisor will assist in providing care and talk to Resident #2 through the care while the staff provides care so is informed of exactly what will occur. -There were no new interventions that were added on or after 6/10/2020 that were specific to the resident's new [DIAGNOSES REDACTED]. The 6/10/2020 assessment of the resident was marked as a high risk of falls with a score of fifteen. Her fall risks were identified as having one to two falls in the last 90 days, she was wheelchair bound and required assistance with elimination, her gait and orthostatic blood pressure were not evaluated because resident was not able to stand up, she was daily taken three or more medications that can increase confusion or lethargy, and had three or more [DIAGNOSES REDACTED]. The physical therapy (PT) discharge summary dated 9/5/2020, revealed the resident was discharged from PT on 9/5/2020 as she achieved maximum potential. The comments read: patient with severe fear of falling and often unwilling to attempt transfers, refusing assistance or to attempt transfer from wheelchair, however able to perform sit to stand transfer in parallel bars and did perform squat pivot transfer with sliding board from bed. Nursing staff report that patient will intermittently allow transfers as willing, however patient is allowed to refuse cases and was educated on the benefits of transfer training practice for strength and mobility. Patient will benefit from restorative nursing program to promote exposure to task and to reduce fear of movement. Restorative nursing program notes for Resident #2 were requested from DON on 9/30/2020, no notes were provided by the time of survey exit or one business day after. 2. Fall on 9/14/2020 a.Record review The incident report on 9/14/2020 reads: Resident #2 calling out for help from the room. Upon entering the room Resident #2 found on the floor sitting up against the wall. Resident #2 stated she fell out of the wheelchair on the floor. Immediate actions were listed as Resident #2 state she was reaching for something in front of her and fell . No injuries observed at the time of incident. Resident #2 was oriented to person, place and situation. Predisposing environmental factors listed as clutter, crowding, and furniture. Predisposing physiological factors listed as boredom. Under predisposing other factors read: Resident #2 was previously encouraged to go to bed at change of shift, but Resident #2 became upset and refused to let the care team put her to bed. This behavior was previously charted in a Foresight report by certified nurses aids (CNAs). The Foresight report by CNAs on 9/14/2020 demonstrated that the resident was approached at 12:27 a.m., when she refused to be changed or go to bed. No interventions were documented regarding what was done to keep the resident safe from falling. Next time the resident was approached at 1:35 a.m., she refused the care and refused to go to bed. Interventions were documented as positive reinforcement after which the resident appeared to be the same. There were no documented interventions regarding what was done to keep the resident safe from falling. At 4:49 a.m. was documented that the resident had a fall. The late entry progress note documented by the DON on 9/30/2020 (day of the survey exit), read that the resident was assessed by a registered nurse (RN) after the fall and was complaining of unresolved pain. The fall and pain were reported to the physician who ordered an x-ray. The nurses progress note on 9/14/2020 at 12:52 p.m. revealed that results of the x-ray showed right [MEDICAL CONDITION]. Physician was contacted and the resident was sent to the hospital for evaluation and treatment. The hospital's physician note on 9/17/2020 read: Resident#2 with [MEDICAL CONDITION] and [MEDICAL CONDITION] hypertension with prior admission for chronic left hip dislocation that was unable to be reduced presenting with right knee pain after fall out of bed. Patient with significant pain with any movement of the right leg. The scan revealed lower extremity with displaced distal femur fracture. Ortho came to evaluate the patient and unfortunately due to chronic severe comorbidities she is not a surgical candidate. She was admitted to medicine for pain control and further management. Patient has baseline dementia and is unable to say what happened today or understand that she has a broken leg. 4. Resident interview Resident was interviewed on 9/29/2020 at 1:31 p.m., she did not answer any questions about what happened to her leg. She was positioned on her back with both legs under the blanket. She said she did not have any pain, closed her eyes and fell asleep. 5. Staff interviews CNA #1 was interviewed on 9/30/20 at 12:10 p.m. She said she was also a restorative aide. She said prior to the recent fall Resident #2 was able to propel herself in a wheelchair independently but would ask for assistance often. She said the resident was alert and oriented to place and people and she preferred to call someone instead of using her call light. She said resident frequently would say Help me, help me to passing people. She said prior to the fall they did frequent checks on resident because she refused to be transferred from her wheelchair to bed. She said after the fall resident was no longer ambulatory and was transferred to geri chair by four people on the sheet. She said a restorative program was currently on hold due to the COVID 19 and she was working on the floor as a regular CNA. She did not recall if resident participated in a restorative program or had any other interventions (besides frequent checks) before the fall. Licensed practical nurse (LPN) #1 was interviewed on 9/29/2020 at 12:31p.m. She said she was a primary nurse for the resident and new resident well. She said the resident was alert and oriented, and at times confused. She said the resident was recently hospitalized and diagnosed with [REDACTED]. She said prior to the [DIAGNOSES REDACTED]. She said the resident was propelling herself in the regular wheelchair independently. She said the resident did complain of pain in all of her joints and received scheduled and PRN medications for that. She said the resident occasionally refused care but was very cooperative if staff would return in five minutes and remind her about what needs to be done. LPN #2 was interviewed on 9/30/2020 at 3:30 p.m. She said when one of the residents sustained the fall, nursing responsibility was to assess the resident for injury, notify family, physician and follow any received orders from the physician. She said nurses were expected to fill out an incident report and put in place immediate interventions to keep the resident safe and prevent any additional falls. She said care plans were updated by MDS nurse and other managers, she said floor nurses were able to update care plans too. She said she did not work with Resident #2. Physical therapist (PT) #1 was interviewed on 9/30/2020 at 4:00 p.m. over the phone. She said she was currently working with Resident #2 who was referred to the therapy after a fall with fracture several days ago. She said resident's cognitive status fluctuated daily and some days she was more oriented than others. She said the resident had severe fear of movement and refused transfers at times. She also had chronic pain in all her joints and therapy was not aware that she had a dislocated left hip prior to her [DIAGNOSES REDACTED]. She said the resident was discharged from therapy 9/5/2020 because she reached maximum potential and was referred to a restorative nursing program. Social services assistant (SSA) #1 was interviewed on 9/30/2020 at 4:30 p.m. over the phone. He said he was familiar with the resident. He said Resident #2 had memory issues, she would fall asleep frequently at times during the day, and she was ambulating with a wheelchair by propelling herself forward. He said the resident was dependent on staff with care and was very persistent in not using the call light. The DON was interviewed on 9/30/2020 at 4:30 p.m. She said facility staff were not aware that the resident had a chronic hip dislocation until it was diagnosed in June 2020. She said after the diagnosis, the resident was participating in physical and occupational therapy. She said the resident was very resistant to care and the nursing department tried different things to keep her safe. She said all interventions were documented under activities of daily living (ADLs) care plan and behavior care plan. She provided a copy and said the resident participated in a restorative nursing program and it was documented under a behavioral care plan. She said she was in charge of the restorative program but she did not know how often the resident participated, what exactly was done and where it was documented. Regarding safety interventions she said the resident was offered a pillow that she kept on her laps that was supposed to prevent her from leaning forward. She said oftentimes the resident refused the pillow. She said the resident frequently did not use her call light and preferred to call out for help. She said many interventions were attempted to keep the resident safe, but they are not documented. She said she was responsible for updating the care plans with new interventions but she has not had a chance to write down everything what was attempted. She said she believed nothing else could have been done to prevent the fall on 9/14/2020. 6. Facility follow-up after the survey exit On 10/2/2020 the facility submitted the following statement by an email: In regards to the fall on 9/14/2020, the resident had been restless prior to the fall, the staff had been reapproaching her as it was late and they wanted her to get some rest. The resident is alert and oriented and structures her days, she knows what she wants and values her independence, thus, the staff was reapproaching and trying at a later time. The fall could not have been prevented unless the resident was on a 1:1 and that would not have been an option for this resident. The staff was reapproaching frequently, attempting to anticipate her needs, and encouraging the resident to allow them to let them lay her down. However, the resident's choice was honored on how she wanted to conduct her evening. Upon readmission, a new intervention was implemented to attempt to prevent recurrence while the resident heals. Therapy will be monitoring the resident closely and as the resident starts having less pain and becoming more mobile, they will work with the resident to transition back to a different wheelchair. The resident was not having recurrent falls where the facility had failed to implement new interventions to prevent falls, over the past quarter, the resident had not had a fall. It was an isolated incident and not due to a failure of implementing interventions to attempt to prevent falls.