Every finding on record at Evergreen Nursing Home

Based on record review and interviews, the facility failed to ensure residents were kept free from physical abuse for five (#5, #7, #4, #2 and #3) of ten residents reviewed for abuse out of 12 sample residents.Resident #5 was admitted on [DATE] with diagnoses of Alzheimer's disease with behavioral disturbances. Resident #6 had a history of wandering and physical aggression. Resident #6 was admitted on [DATE] with diagnoses of dementia. Resident #5 had a history of physical aggression.On [DATE], Resident #6 and Resident #5 had a physical altercation, where the nurse observed Resident #6 push Resident #5. Resident #5 lost his balanced and fell and hit his head on a chair before he landed on the floor. The nurse observed Resident #5 bleeding from his head. The nurse progress note revealed Resident #5 was transferred to the emergency department for evaluation and treatment.Specifically, the facility failed to: -Protect Resident #5 from physical abuse by Resident #6;-Protect Resident #7 from physical abuse by Resident #8;-Protect Resident #2 and Resident #4 from physical abuse by each other; and, -Protect Resident #2 and Resident #3 from physical abuse by each other. Findings include:I. Facility policy and procedureThe Abuse prevention policy and procedure, reviewed [DATE], was provided by the nursing home administrator (NHA) on [DATE] at 9:06 a.m. It read in pertinent part: It is the policy of this facility to prevent and prohibit all types of abuse. Identify, correct, and intervene in situations in which abuse is more likely to occur to include trained and qualified staff on each shift in sufficient numbers to meet the needs of the residents and ensure the staff assigned have knowledge of resident care needs and behavioral symptoms. Assure residents are free from neglect by having the structures and processes to provide needed care and services to all residents which included provisions of the facility assessment to determine what resources are necessary to care for its residents competently. Identify, assess, care plan for appropriate interventions, and monitor residents with needs and behaviors which might lead to conflict or neglect; such as,-Verbally aggressive behavior;-Physically aggressive behavior;-Wandering into other's rooms/space;-Residents with communication disorders or who speak a different language; and,-Residents that require extensive nursing care and/or are totally dependent on staff for the provision of care.II. Incident of physical abuse by Resident #6 towards Resident #5 on [DATE]A. Facility investigationThe [DATE] facility investigation revealed an altercation occurred between Resident #6 and Resident #5 on the Cottage unit. The investigation revealed Resident #6 struck Resident #5 on the chest, that caused Resident #5 to fall. Resident #5 hit his head on a chair and sustained a laceration to the back of his head. The investigation revealed a registered nurse (RN) assessed both residents and determined Resident #6 had a four centimeter laceration on the back of his head and Resident #5 had no injuries. Resident #6 was transported to the emergency department and received eight staples to close the head laceration and then returned to the facility. The investigation revealed staff monitored both residents per facility policy and neither resident had a fear of each other and the victim did not recall the altercation. The investigation revealed a resident on the Cottage unit was interviewed and reported she had observed Resident #5 agitated throughout the day on [DATE]. The resident reported, Resident #5 was seen exit seeking and trying to get into other residents' rooms. The resident reported to the facility investigator that Resident #5 had been hitting, kicking and trying to open doors. The investigation revealed that a staff member attempted to intervene and stop the altercation between Resident #6 and Resident #5, however Resident #6 escalated his aggression towards Resident #5.The investigation documented the facility substantiated the incident of physical abuse. B. Resident 5 (victim)1. Resident statusResident #5, age greater than 65, was admitted on [DATE], discharged to the hospital on [DATE], was readmitted to the facility on [DATE], and expired on [DATE]. According to the [DATE] computerized physician's orders (CPO), diagnoses included Alzheimer's disease, dementia without behavioral disturbance, irritability and anger, mood disturbance, anxiety, abnormality of walking gait and mobility, muscle weakness, gout,and osteoarthritis.The [DATE] minimum data set (MDS) assessment revealed the resident was unable to complete a brief interview for mental status (BIMS). Resident #5 had short and long term memory problems and was severely impaired with making decisions that regarded his daily life. The assessment documented Resident #5 had continuous disorganized or incoherent thinking, with physical behaviors directed towards others for one of three days, verbal behaviors directed at others for one of three days, and other behavior symptoms not directed at others daily, and wandered daily.Resident #5 required set up assistance/touching assistance for personal hygiene, toilet transfers, eating, sitting up in bed, and standing. He required partial to moderate assistance for dressing and putting on/removing footwear. The assessment identified Resident #5 required supervision/touching assistance for transfers from chair to chair,was independent with ambulation and used a cane or crutch.2. Record reviewThe behavioral care plan, initiated [DATE], revealed Resident #5 had wandering and disruptive behaviors. Pertinent interventions included redirecting from potentially dangerous situations when wandering and removing from situations when he was disruptive. The dementia care plan, initiated [DATE], revealed Resident #5 entered other residents' rooms and was verbally/physically aggressive and had thrown objects. Pertinent interventions included administering medications as ordered, anticipating and meeting resident needs, intervening as necessary to protect the rights and safety of others, approaching in a calm manner, and redirecting the resident to an alternate location as needed. The [DATE] nurse progress note revealed Resident #6 and Resident #5 had physical altercation and the nurse observed Resident #6 push Resident #5. Resident #5 lost his balance, fell and hit his head on a chair before he landed on the floor. The nurse observed Resident #5 bleeding from his head. The nurse progress note revealed Resident #5 was transferred to the emergency department for evaluation and treatment. He sustained a four centimeter (cm) laceration to the back of his head. Resident #5, was sent to the hospital, where he received staples to the laceration.The [DATE] progress note documented Resident #5 had behaviors that included sitting on beds of other residents on the unit, swinging at staff while they tried to redirect him, and yelling at others residents on the Cottage unit. The progress note read that attempts to redirect Resident #5 were ineffective. The [DATE] social services director (SSD) progress note revealed Resident #5 had aggressive behaviors and wandered into other residents' rooms. New interventions were recommended to supervise and redirect Resident #5 and to help set up farming videos to redirect Resident #5. The [DATE] the physician increased medication buspirone to 10 milligrams twice daily for increased behaviors, agitation, physical and verbal aggression and exit seeking. C. Resident #6 (assailant)1. Resident statusResident #6, age greater than 65, was admitted on [DATE]. According to the February 2026 CPO, diagnoses included insomnia, dementia with other behavioral disturbances, history of falling, and Alzheimer's disease.The [DATE] MDS assessment revealed the resident had short and long-term memory problems and had a severe impairment to cognitive skills for decision making per staff assessment. Resident #6 had verbal behaviors directed at others for one to three days and other behavioral symptoms not directed at others for four to six days and had wandering behaviors.The assessment documented Resident #6 required supervision or touching assistance for showers and personal hygiene, and was independent with eating, dressing, putting on/off footwear, bed mobility, transfers, and walking.2. Record reviewThe dementia care plan, initiated [DATE], revealed Resident #6 had behavioral disturbances. Resident #6 wandered in the Cottage unit and believed another female resident was his mother. When agitated,/bored Resident #6 had disruptive behaviors of singing or talking loudly, hitting/clapping his hands together, stomping his feet, and laughing and pointing at other residents on the Cottage unit. Pertinent interventions included administering medications as ordered, discussing behavior with resident and explaining why his behavior was unacceptable, intervening as necessary to protect the rights and safety of others, approaching in a calm manner, and removing from a situation to redirect to an alternate location as needed ([DATE]), monitoring, redirecting, removing from the area if needed ([DATE]), and deescalating triggers by redirecting, offering a job/task to assist staff on the Cottage unit, and one-to-one conversation ([DATE]).The physical aggression care plan, initiated [DATE], revealed Resident #6 exhibited behavior of treating/fighting with other residents on the Cottage unit by putting his hands out, nodding, and commenting. Pertinent interventions included administering medications as ordered, analyzing times of day for triggers and circumstances to deescalate triggers of aggression, documenting behaviors and attempted interventions, and redirecting and walking away from sources of distress. The [DATE] nurse progress note revealed the nurse was called to the Cottage unit after the altercation between Resident #6 and Resident #5. Resident #6 was observed striking Resident #5, which caused Resident #5 to fall. Resident #5 fell and hit his head on a chair before landing on the floor. Resident #5 sustained a four cm laceration that was treated at the hospital.The [DATE] behavioral health physicians progress note revealed a concern for Resident #6's safety and the safety of staff and others on the Cottage unit due to repeated complaints of wandering at night and agitation and violence towards another resident. The progress note revealed previous efforts to redirect Resident #6 on the Cottage unit had not been successful.III. Incident of physical abuse by Resident #4 towards Resident #2 on [DATE]A. Facility investigationThe [DATE] facility investigation revealed a staff member entered the Cottage unit and heard raised voices. The staff member observed Resident #4 yelling at another resident while Resident #2 stood between Resident #4 and the other resident. During the verbal altercation, a staff member redirected and escorted the other resident from the altercation. One staff member remained with Resident #2 and Resident #4. As the staff member redirected Resident #2, Resident #4 reached out and grabbed Resident #2 by her shoulders and pulled her backwards quickly. Resident #2 responded with what appeared to the staff member as a defensive responsive and Resident #2 hit Resident #4 in the abdominal area with the back of her hand. The investigation revealed Resident #2 and Resident #4 were separated immediately and an assessment revealed neither resident was injured. The facility investigation revealed Resident #2 had a history of physical and verbal aggression and wandering. The investigation documented the facility substantiated the incident of physical abuse. B. Resident #2 (victim and assailant) 1.Resident statusResident #2, age greater than 65, was admitted on [DATE]. According to the February 2026 CPO, diagnoses included Alzheimer's disease, dementia with other behavioral disturbances, anxiety, cognitive communication disorder, arthritis, osteoporosis, low back pain and had a surgical history of lumbar spine fusion.The [DATE] MDS assessment revealed Resident #2 was rarely understood and had a short and long term memory problem. Resident #2 could normally find the location of her room, and had severely impaired skills for decision making. The assessment revealed Resident #2 had physical behavioral symptoms directed towards others that put others at significant risk for physical injury. The assessment revealed Resident #2 wandered on the unit for four to six days during the assessment period. The assessment revealed Resident #2 was independent for eating, completing toilet hygiene, dressing, bed mobility, transfers, and ambulation. Resident #2 required set up assistance from staff for oral hygiene and bathing. 2. Record reviewThe behavior care plan, initiated [DATE], revealed Resident #2 had behavior problems of wandering and sleeping in other residents' beds because of her dementia. Resident #3 had a history of physical aggression towards staff and other residents whether provoked or unprovoked. Pertinent interventions included administering medications as ordered ([DATE]), anticipating and meeting the resident's personal needs ([DATE]), monitoring all residents that wander and rummage, intervene as necessary to protect the rights and safety of others, diverting attention and removing from a situation to an alternative location as needed, and approaching and speaking in a calm manner ([DATE]), observing for behavior episodes and determining underlying causes, considering location and time of day ([DATE]), observing for wandering and preventing escalation of physical aggression by monitoring for escalation ([DATE]), monitoring behavior and observing for wandering with verbal or physical aggression ([DATE]), and educating staff on residents that exhibit aggressive behaviors are not to be left alone and or unattended ([DATE]).The physical aggression care plan, initiated [DATE], revealed Resident #2 had potential to be physically aggressive with others because of her dementia Pertinent interventions included administering medications as ordered ([DATE]), intervening before agitation escalates (12/2123), ensuring Resident #2 went into the correct room when showing signs of feeling upset, confused, or wandering, placing a large imprinted sign with her name outside of her room, and redirecting or escorting Resident #2 to her room as needed ([DATE]).The [DATE] nurse progress note revealed the nurse observed a staff member attempting to redirect Resident #4 and Resident #2. The nurse progress note revealed the nurse observed Resident #4 grab Resident #2 by the shoulder and pulled her backwards. The nurse progress note note read that Resident #2 appeared startled and in a defensive response, made contact with Resident #3's abdomen with the back of her hand. The nurse progress note read both residents were assessed and both appeared uninjured,The [DATE] SSD progress note revealed Resident #2 had no changes in her behavior or mood after the altercation with Resident #4 and participated in activities without fear of other residents. C. Resident #4 (victim and assailant) 1. Resident statusResident #4, age greater than 65, was admitted on [DATE]. According to the February 2026 CPO diagnoses included shortness of Alzheimer's disease, epilepsy, anxiety, depression, bipolar disorder, and unspecified brain injury.The [DATE] MDS assessment revealed Resident #4 was unable to complete the BIMS. The assessment document Resident #4 had short and long term memory problems.The assessment documented Resident #4 had no behavioral symptoms directed at others and had physical and verbal behavior symptoms directed at others for one to three days during the assessment period.Resident #5 required partial to moderate assistance from staff for showering, set up assistance for hygiene, and was independent for eating, dressing, putting on/off footwear, bed mobility, transfers and walking.2. Record reviewThe [DATE] SSD progress note revealed Resident #4 had no changes in her behavior or mood after the altercation with Resident #2 and participated in activities without fear of other residents. IV. Incident of physical abuse by Resident #2 towards Resident #3 on [DATE]A. Facility investigation The [DATE] facility investigation revealed a staff member assisted Resident #2 to her bed and returned to the nurses desk at 9:25 p.m. The staff member documented minutes later she heard Resident #3 scream and then she ran to Resident #3's room. When the staff member entered Resident #3's room, she observed Resident #2 laying in Resident #3's bed. The staff member documented Resident #2 complained about a scratch on her face from Resident #3 and Resident #3 complained that Resident #2 was laying in her bed and tried to steal her bed. The investigation revealed staff separated the residents and the nurse completed a skin assessment. The skin assessment completed by the nurse after the altercation revealed Resident #2 had a scratch on her face and Resident #3 had a scratch on her right forearm. The investigation documented the facility substantiated the incident of physical abuse. B. Resident # 3 (victim and assailant) 1. Resident statusResident #3, age greater than 65, was admitted on [DATE] and discharged to the hospital [DATE]. According to the [DATE] CPO, diagnoses included dementia with other behavioral disturbances, symptoms involving cognitive functions and awareness, depression and anxiety.The [DATE] MDS assessment revealed the resident had moderate cognitive impairments with a BIMS score nine out of 15.The assessment documented Resident #3 had behavioral symptoms not directed toward others and wandered in the four to six days during the assessment period.Resident #3 required set-up assistance from staff for eating and toileting, and partial assistance from staff for hygiene, and dressing. Resident #3 was independent with bed mobility, transfers, and ambulation.2. Record reviewThe cognitive deficit care plan, initiated [DATE], revealed Resident #3 wandered. Interventions included conversing with Resident #3 while providing care, encouraging family involvement, establishing level of involvement and interest and providing assistance to activity functions ([DATE]).The physical aggression care plan, initiated [DATE], revealed Resident #3 had the potential to be physically aggressive if other residents exhibited aggression towards her. Interventions included modifying the environment, placing her bed further from the door and removing triggers for aggression by removing other residents from her room ([DATE]).The [DATE] nurse progress note revealed the CNA called out to the nurse after the CNA found Resident #2 in Resident #3's bed. The nurse and CNA separated Resident #2 and Resident #3. The nurse completed an assessment and documented that Resident #3 had a new scratch on her right forearm.C. Resident #2 (assailant and victim) The [DATE] nurse progress note revealed the CNA heard Resident #2 and Resident #3 yelling. The nurse progress note revealed the CNA found Resident #2 lying the Resident #3's bed and the nurse progress note documented Resident #2 and Resident #3 each had a new scratch. The [DATE] risk management report revealed Resident #2 was observed in Resident #3's bed and Resident #3 told a staff member Resident #2 tried to steal her bed. The risk management report revealed each resident had a scratch and staff separated the residents immediately and placed a large name sign outside Resident #3's room to assist Resident #3 with locating the correct room.The [DATE] SSD progress note revealed Resident #2 exhibited no fear of Resident #3 and had no changes in her mood or behavior. The [DATE] nurse progress note revealed Resident #2 was monitored for the altercation with Resident #3. The nurse progress note revealed Resident #2 had a scratch on her face from the altercation. There was no corresponding nurse assessment for the care or assessment of the scratch. V. Incident of physical abuse by Resident #8 towards Resident #7 on [DATE] A. Facility investigation The [DATE] facility investigation revealed a staff member observed Resident #8 attempting to enter Resident #7's room at 9:35 p.m The investigation revealed a staff member attempted to redirect Resident #8 but he had increased aggression toward Resident #7. The facility investigation revealed a staff member observed Resident #8 swing his rolling walker toward Resident #7 and struck Resident #7 on the face with his hand. The staff member called for assistance from another staff member on the Cottage unit to desescalate the altercation. The investigation revealed staff intervened, separated, and redirected Resident #7 and Resident #8 from each other. The nurse completed a skin assessment and noted Resident #7 had a red mark on her left cheek. Resident #7 reported pain at level was a 4 out of 10 and was administered Tylenol. The investigation revealed after the altercation staff separated the residents and redirected each resident to an activity of their choice. The facility investigation included interviews with five residents on the Cottage unit and no residents reported they had a fear of other residents on the Cottage unit. The investigation revealed Resident #8 had a trigger for aggression when he was unable to find his wife. The investigation documented a follow up assessment completed by the SSD revealed both residents had no changes to their mood or behavior and did not exhibit fear of residents on the Cottage unit. The investigation documented the facility substantiated the incident of physical abuse. B. Resident #7 (victim) 1.Resident status Resident #7, over the age of 65, was admitted on [DATE]. According to the February 2026 CPO, diagnoses included Alzheimer's disease, unspecified dementia without behavioral disturbance, mood disturbance, anxiety, and epilepsy. The [DATE] MDS assessment revealed the resident had severe cognitive impairment with a BIMS score of five out of 15. Resident #7 had continuous behavior of inattention and disorganized thinking and had wandering behavioral symptoms not directed toward others for one to three days of the assessment period.Resident #7 independent with eating, bed mobility, transfers, and walking, and required substantial to maximum assistance for dressing and showers.2. Record reviewThe physical aggression care plan, initiated [DATE], revealed Resident #7 had a history of anger and hitting staff. Pertinent interventions included documenting observed behavior and attempted interventions in behavior log each shift, and identifying triggers for physical aggression to descalate.The [DATE] nurse progress note revealed a CNA observed Resident #8 swinging his walker and then hit Resident #7 on the face with his hand. The nurse progress note revealed Resident #7 had a small red mark on her left cheek. The nurse progress note documented Resident #7 told the nurse that she was fine. C. Resident #8 (assailant)1. Resident statusResident #8, age greater than 65, was admitted on [DATE]. According to the [DATE] CPO, diagnoses included Alzheimer's disease and dementia with behavioral disturbance.The [DATE] MDS assessment revealed the resident had moderate cognitive impairments with a BIMS score one out of 15.The assessment documented Resident #8 had physical and verbal behaviors directed toward others and other behavioral symptoms of wandering that put others at significant risk of physical injury for one to three days of the assessment period.Resident #8 required set up assistance for eating, partial to moderate assistance for dressing, supervision or touching assistance for transfers and walking and was independent with bed mobility.2. Record reviewThe physical aggression care plan, initiated [DATE], revealed Resident #8 had poor impulse control with behavior triggered when he was unable to find his wife. Pertinent interventions included identifying behavior triggers, documenting observed behaviors and attempted interventions on the behavior log, intervening before the resident was agitated.The limited physical mobility care plan, initiated [DATE], revealed Resident #8 used a front wheel walker for walking and required supervision/touching assistance from staff. The [DATE] 10:00 p.m. nurse progress note revealed Resident #8 was agitated and not easily redirected. A CNA notified the nurse that as she sat at the nurses' station, she heard a door open and observed Resident #8 enter Resident #7's room. The progress note documented when the CNA responded she observed Resident #8 swinging his walker at Resident #7. Resident #8 struck Resident #7 in the face with his hand or a closed fist. The nurse documented the CNA called her to the Cottage unit to assist Resident #8 from Resident #7's doorway. The nurse progress note documented the residents were separated and the physician was contacted. The [DATE] 8:30 a.m. nurse progress note revealed Resident #8 was confused and had aggression in the evening and nights and had violent behaviors towards staff and other residents. The progress note revealed Resident #8 required constant supervision to redirect him from rooms of female residents. VI. Staff interviewsCNA #3 was interviewed on [DATE] at 11:30 a.m. CNA #3 said she regularly worked on the Cottage unit. CNA #3 said all of the residents on the Cottage unit required close supervision. CNA #3 said some residents required redirection away from each other because of their behaviors. CNA #3 said Resident #2 wandered around the Cottage unit and was agitated easily when routines changed. CNA #3 said Resident #2 could be redirected to activities she enjoyed. CNA #5 was interviewed on [DATE] at 11:36 a.m. CNA #5 said residents on the Cottage unit required continuous monitoring to redirect residents from each other to avoid altercations. CNA #5 said she was concerned about the safety of residents on the Cottage unit when staff were unable to monitor residents behavior such as when staff were on breaks or in rooms with residents. CNA #5 said at times the CNAs and the nurses were occupied, which left no designated staff to monitor residents. RN #1 was interviewed on [DATE] at 11:20 a.m. RN #1 said she was a new employee at the facility and had received her orientation and education on caring for residents with dementia by online courses and from the facility staff development coordinator. RN #1 said the behavioral care plans were stored in a binder at the nurses desk for staff to review. RN #1 said the care plans included resident specific interventions for staff to implement when residents' behaviors escalated. RN #1 said after altercations, the residents involved were separated and the nurse was notified to complete assessments. The SSD and NHA were interviewed together on [DATE] at 2:21 p.m. The NHA said after residents on the Cottage unit were involved in an altercation, the staff separated the residents. The NHA said the staff then reacted to the situation based on what occurred. The SSD said residents were monitored for seventy two hours after an altercation. The SSD said sometimes the residents were placed on one-to-one monitoring or 15-minute checks. The NHA said when one-to-one monitoring was implemented, a staff member was assigned to stay with the resident. The NHA said sometimes the staff member was a housekeeper, or activities coordinators if the clinical staff was already on a staffing assignment. The NHA said the Cottage unit had staffing levels set so that there was always staff available to provide care as required. The NHA said the staff on the Cottage unit observed and responded to residents who had increased agitation. The NHA said the altercation between Resident #5 and Resident #6 occurred during the night shift. The NHA said the investigations did not reveal concerns for staffing. The SSD said she was aware the resident's behaviors may be increased at night and that interventions did not include alternatives for night redirection when activities staff were not available and after 10:00 p.m. when fewer staff were assigned to work on the Cottage unit. The NHA said Resident #2 had less agitation after her pain medications were adjusted and wandered less after a large room assignment sign was placed on Resident #2's doorway to prevent wandering into other rooms.The SSD said Resident #6 had increased agitation when other residents entered his room. The SSD said staff redirected residents from his room and staff monitored Resident #6 for changes in his agitation. The NHA said the altercation between Resident #5 and Resident #6 was possibly escalated when Resident #5 wore a piece of clothing that resembled a clothing article Resident #6 owned.The SSD said Resident #8 had positive outcomes after his dementia medications were adjusted. The SSD said staff monitor and document his behaviors.

Based on record review and interviews, the facility failed to ensure that one (#5) of the three residents reviewed for accidents out of 12 sample residents remained free from accidents.Specifically, the facility failed to timely implement person centered fall interventions for Resident #5, who had multiple falls with major injury. Resident #5 was admitted on [DATE] with diagnoses of Alzheimer's disease and dementia. Resident #5 sustained a fall on [DATE] and on [DATE]. On [DATE] Resident #5 had a physical therapy evaluation that determined Resident #5 required supervision or touching assistance for ambulation. The change in level of assistance for ambulation was not communicated to nursing staff until [DATE]. During that time, Resident #5 sustained two more falls on [DATE] at [DATE]. After the fall on [DATE], Resident #5 was diagnosed with a subdural hematoma with a five millimeter midline shift (when brain tissue has sifted due to bleeding or swelling). On [DATE] Resident #5 sustained an additional fall. He was transferred to the hospital for evaluation and was diagnosed with a left hip fracture, fractures of the spine and multiple rib fractures. The resident returned to the facility on comfort care. Findings include:I. Facility policy and procedureThe Fall Management policy, revised [DATE], was provided by the nursing home administrator (NHA) on [DATE] at 9:00 a.m. It revealed in pertinent part, The facility will assess the resident upon admission/readmission, with a change in condition and with any fall event for any fall risks and will identify appropriate interventions to minimize the risk of injury related to falls. During the assessment, a care plan will be developed and initiated by the admitting nurse on any residents assessed to be at risk for falls. The interdisciplinary team (IDT) will review and revise the care plan if indicated upon a fall event. The interventions to reduce the risk of falls should be individualized based on the resident risk factors and fall history.II. Resident #5A. Resident statusResident #5, age greater than 65, was admitted on [DATE], discharged to the hospital on [DATE], was readmitted to the facility on [DATE], and expired on [DATE]. According to the [DATE] computerized physician's orders (CPO), diagnoses included subdural hematoma with midline shift, right hip fracture, head laceration, thoracic spine fracture, right rib fracture, Alzheimer's disease, dementia without behavioral disturbance, irritability and anger, mood disturbance, anxiety, abnormality of walking gait and mobility, muscle weakness, gout and osteoarthritis.The [DATE] minimum data set (MDS) assessment revealed the resident had short and long-term memory problems and had severe impairment in decision making skills per staff assessment. Resident #5 had continuous disorganized or incoherent thinking. He displayed behaviors directed at others. Resident #5 wandered daily.Resident #5 required set up assistance/touching assistance eating and transfers, supervision or touching for bed mobility, partial to moderate assistance for dressing, and Resident #5 was independent with ambulation.B. Record review1. Care plans and assessments The fall prevention care plan, initiated [DATE], revealed Resident #5 had a risk of falling. Pertinent interventions included orienting resident to his room ([DATE]), providing activities that minimize the potential for falls while providing diversion and distraction ([DATE]), referring for physical therapy as ordered, wearing a soft helmet at all times as tolerated ([DATE]), and proving adaptive equipment or devices as needed ([DATE]).\-However, the care plan did not reveal what adaptive equipment or device the resident needed.The [DATE] physical therapy evaluation and plan of treatment identified that resident #5. The evaluation identified that Resident #5 required set up assistance for walking ten feet, supervision or touching assistance for walking 50 feet and 150 feet. The fall prevention care plan was not updated to reflect the level of supervision Resident #5 required for ambulation. The evaluation on [DATE] was a change in condition from the Resident #5 previous level of function, when he could ambulate independently.2. Fall on [DATE] - witnessed The [DATE] nurse progress note revealed Resident #5 tripped on his feet while two staff members were assisting him to the restroom. The note documented Resident #5 displayed behaviors of agitation. Resident #5 fell to his knees and sustained a 2 centimeter (cm) by 2 cm and a 0.5 cm abrasion on his left knee. The nurse provided first aid to the resident and and Resident #5 had no complaints of pain. The [DATE] behavior huddle progress note recommended behavior interventions for supervision and redirecting.-However, the note did not include a post fall review or recommendations for fall prevention interventions.3. Fall on [DATE] - witnessedThe [DATE] nurse progress note revealed Resident #5 was struck by another resident and fell, hit his head on a chair, and landed on the floor. The nurse completed and assessment and found a 4 cm laceration on the back of Resident #5's head. Resident #5 was evaluated at the emergency department and the head laceration was closed with eight staples. The emergency department determined there were no additional injuries and Resident #5 returned to the facility on [DATE].There was no documentation the IDT reviewed the [DATE] fall and no fall prevention -interventions were recommended.Cross reference: F600 failure to protect residents from abuse.4. Fall on [DATE] - unwitnessedThe [DATE] 3:25 a.m. nurse progress note revealed Resident #5 was found by a staff member on the floor in his room. The progress not revealed Resident #5 either fell out of bed, or had been wandering in his room and fell. The completed an assessment and found a hematoma on the back of Resident #5's head on the right side. The nurse progress note read that Resident #5 wore big and bulky shoes when he fell. The progress note revealed the physician was notified and gave an order to monitor Resident #5. -There was no documentation the IDT reviewed the [DATE] fall and no fall prevention interventions were recommended.5. Fall on [DATE] - witnessedThe [DATE] 10:12 p.m. nurse progress note revealed Resident #5 had a fall in the hallway. The [DATE] fall investigation revealed Resident #5 had increased behaviors and the nurse attempted to redirect Resident #5 from a distance to sit on a chair. Resident #5 missed the chair and fell to the floor. The nurse completed an assessment and found a right forearm scratch and right elbow skin injury. The progress note revealed the physician was contacted and gave no orders. There was no documentation the IDT reviewed the [DATE] fall and no fall prevention interventions were recommended.The [DATE] 10:48 a.m. nurse progress note revealed Resident #5 had been combative and aggressive after the [DATE] fall. The physician was contacted and gave an order for a head computerized tomography scan to be completed at the hospital for head trauma. The progress note read the nurse arranged for the facility driver to transport Resident #5 to the hospital for the outpatient head computerized tomography scan. The [DATE] 7:42 p.m. nurse progress note revealed Resident #5 had a subdural hematoma found on the computerized tomography scan. The nurse progress note revealed staff would monitor Resident #5 and notify the physician if his condition worsened. The [DATE] nurse progress note revealed Resident #5 was provided a four wheel walker to assist with ambulation. The nurse progress note revealed Resident #5 did not do well with the walker and responded with aggression towards staff when they reminded him to use the walker. The progress note revealed the nurse thought the walker was a tripping hazard for Resident #5 due to his unwillingness to use the walker correctly. The [DATE] IDT post fall progress note revealed nursing made a request to the physician to add sleep medication for Resident #5 due to increased agitation at night. The physician declined the nursing request. -The IDT progress note had no additional fall prevention recommendations.6. Fall on [DATE] - unwitnessedThe [DATE] 1:50 p.m. nurse progress note revealed the nurse heard commotion from the hallway, went around the corner (from the nurses desk) and observed Resident #5 on the floor, on his back with his legs bent. The progress note revealed Resident #5 was in the hallway outside of his room. The nurse documented she heard Resident #5 as he yelled out in pain and observed him grabbing his left hip and leg. The nurse notified the physician and the physician gave an order to for Resident #5 to be transferred to the emergency department for evaluation.The [DATE] hospital discharge summary revealed Resient #5 sustained a left hip fracture, multiple rib fractures, fractures of the 11 and 12 vertebrae of the thoracic spine, and was admitted to the hospital and treated for pain and anxiety from his recent fall that caused a subdural hematoma. The progress note revealed the hospital physician reviewed the fractures, severe dementia, and falls with Resident #5's family and the family agreed to complete comfort care. The [DATE] nurse progress note revealed Resident #5 returned to the facility. -There was no documentation the IDT reviewed the [DATE] fall and no fall prevention interventions were recommended.IV. Staff interviewsCertified nurse assistant (CNA) #3 was interviewed on [DATE] at 11:30 a.m. CNA #3 said she provided care and monitored residents behavior based on the CNA task assignments. CNA #3 said she checked on all residents during her shift. CNA #3 said she remembered helping Resident #5 with his helmet and that he had nonslip tape on the floor next to his bed. CNA #3 said Resident #5 did not remember to use his walker and did not seem to understand why to use the walker. CNA #3 said she did not know of any alternatives available for safe walking. She said Resident #5 walked around the Cottage unit by himself. CNA #3 said she tried to supervise every resident when they were out of their room but she frequently was off the hallway when she provided care to other residents.CNA #5 was interviewed on [DATE] at 11:36 a.m. She said she worked full time on the Cottage unit and provided care to residents. CNA #5 said after residents had fallen, the unit manager or nurse updated the CNA on the resident's status and changes in care needs. CNA #5 said she was not sure what interventions could be effective to prevent falls on the Cottage unit except for continuous monitoring of residents with high risk. CNA #5 said close and continuous monitoring was hard to provide due to the CNAs other tasks. CNA #5 said when she left the Cottage unit for her breaks, there was no one to step in and monitor or care for her assigned residents.The NHA and the social services director (SSD) were interviewed together on [DATE] at 2:21 p.m. The NHA said Resident #5 fell on [DATE] after an altercation where he was pushed by another resident. The SSD said Resident #5 sustained a laceration to his head and was treated at the hospital. The SSD said staff monitored Resident #5 after he returned from the hospital and he did not require changes to his fall prevention plan of care.The NHA said Resident #5 had a fall with a head strike on [DATE] after he missed sitting on a chair. The NHA said Resident #5 sustained a new hematoma on the back of his head and the physician recommended monitoring. The NHA said a root cause for the fall was completed and determined Resident #5 had poor safety awareness. The NHA said the resident fell while a staff member was verbally guiding him to sit on a chair. The NHA said staff Resident #5 was supervised by staff for his ambulation The SSD said Resident #5 had no changes to his behavior or assessment and a new intervention was made to involve Resident #5 with activities closer to his interest to divert him from wandering or agitation. The NHA said on [DATE] the staff assisted Resident #5 to his bed for rest after lunch and was later found on the floor by staff. The NHA said Resident #5 was left unattended and attempted to ambulate without assistance from staff.The director of nursing (DON) and the NHA were interviewed on [DATE] at approximately 2:00 p.m. She said the IDT reviewed falls in the facility. The DON said if the IDT recommended changes to a resident's care plan, it was updated by the unit manager or the MDS coordinator. The DON said care plan changes were communicated to nursing staff by holding huddle meetings in the unit to discuss new interventions or changes to resident care. The DON said after physical therapy evaluated Resident #5 and determined he required supervision or hands on assistance for ambulation, there was a breakdown or delay in communicating the changes with nursing staff. The DON said the changes were recommended on [DATE] and the change was not made until [DATE]. The DON said the therapy staff posted a sign near each resident's bed to inform staff what level of assistance is needed for ambulation. The NHA said the facility initiated a performance improvement plan on [DATE] to reduce the number of falls with injury, improve communication between nursing and therapists, and to ensure safety and care interventions are implemented immediately after a resident falls.

Based on observations and interviews, the facility failed to provide a functional, comfortable and homelike environment for residents on two of two units. Specifically, the facility failed to: -Ensure the residents residing in room [ROOM NUMBER], room [ROOM NUMBER] and room [ROOM NUMBER] were provided with appropriate hot water in the bathroom sinks; and, -Ensure high back dining room chairs in the secure unit dining room and the main dining room were free from cracks and tears. Findings include: I. Facility policy and procedure The Resident Rights policy and procedure, revised 9/25/23, was provided by the director of nursing (DON) on 8/29/24 at 9:32 a.m. It read in pertinent part, At the time of admission and periodically throughout their stay, the facility will inform each resident, orally and in writing of their rights. A facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. The resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility. The resident has a right to a safe, clean, comfortable and homelike environment, including but not limited to, receiving treatment and support for daily living safely. II. Observations and interviews On 8/26/24 at 12:43 p.m. the hot water in the bathroom sink of room [ROOM NUMBER] was observed to be cool to the touch. The resident who resided in room [ROOM NUMBER] said the hot water had always been cold and not hot. On 8/26/24 at 2:40 p.m. the hot water in the bathroom sink of room [ROOM NUMBER] was observed to be cool to the touch. The resident who resided in room [ROOM NUMBER] said the water had never been hot and was always cool. On 8/28/24 at 12:58 p.m. the hot water temperature in the bathroom sink of room [ROOM NUMBER] was taken with a traceable thermometer held under the running water for three minutes and 58 seconds. The temperature of the water was 102.1 degrees Fahrenheit (F). On 8/28/24 at 1:30 p.m. the hot water temperature in the bathroom sink of room [ROOM NUMBER] was taken with a thermometer held under the running water for three minutes. The temperature of the water was 94.8 degrees F. On 8/28/24 at 2:03 p.m. the hot water temperature in the bathroom sink of room [ROOM NUMBER] was taken with a thermometer held under the running water for one minute. The temperature of the water was 109.7 degrees F. On 8/29/24 at 9:16 a.m. four high back dining room chairs in the secure unit dining room were observed to have several cracks and tears on the seats of the chairs. On 8/29/24 at 10:37 a.m. three high back dining room chairs in the main dining room were observed to have several cracks and tears on the seats of the chairs. An environmental tour was conducted on 8/29/24 at 12:19 p.m. with the maintenance director (MTD) and the above concerns were observed. The MTD said he needed to replace the circulation pump on the water heater. He said the facility had had the circulation pump for a year and he had not replaced it. He said he would be working on getting it replaced. The MTD was shown the dining room chairs in the main dining room and the secure unit dining room. He said he did an audit a year ago (2023) on all the chairs that needed to be replaced. He said he had been trying to get them replaced. He said he had not heard back from corporate management about getting them replaced. The MTD said he did a walk through of the facility every morning. He said he looked at the exit light signs, lights and fire extinguishers. He said there was a maintenance request book at each of the nurse's stations. He said when staff saw something that needed to be repaired or fixed they wrote it down in the maintenance request book. He said he looked at the maintenance request book every day. He said the facility's system that was supposed to communicate staff requests for facility repairs into maintenance repair tickets was not up and running and he was the only one who had been trained on the system. He said if the facility had the system up and running it would make things easier for him to see what repairs needed to be done. The MTD said if he had any issues with the repairs he would notify the NHA. He said the NHA did not do rounds with him. He said she did her own rounds. He said if the NHA had any questions for him regarding items needing repair she would notify him. He said if he had to get a part from the local hardware store, the NHA had to approve it. He said anything that cost above $500.00 to repair had to be approved by the NHA. He said if he had a question about a room or bigger projects that needed fixed or repaired, he would bring the NHA to see the concern. He said he communicated with the NHA all the time regarding repairs around the facility. III. Additional staff interviews The housekeeping and laundry manager (HLM) was interviewed on 8/29/24 at 9:20 a.m. The HLM said the dining room chairs on the secure unit and main dining room were cleaned as needed and weekly. She said the facility was working on getting the torn chairs replaced. The nursing home administrator (NHA) was interviewed on 8/29/24 at 9:25 a.m. The NHA said she was not aware that the dining room chairs in the main dining room and secure unit had cracks and tears on the seats of the chairs. -However, according to the MTD, he communicated with the NHA all the time about items in the facility that needed repair (see MTD interview above).

Based on record review and interviews, the facility failed to ensure one (#18) of three residents out of 26 sample residents reviewed for assistance with activities of daily living (ADL) received appropriate treatment and services to maintain or improve his or her abilities. Specifically, for Resident #18, the facility failed to: -Ensure a wheelchair positioning device was care planned; and, -Ensure the wheelchair positioning device was positioned appropriately and consistently to keep the resident from leaning in her wheelchair. Findings include: I. Resident #18 A. Resident status Resident #18, age greater than 65, was admitted on [DATE]. According to the August 2024 computerized physician orders (CPO), diagnoses included Alzheimer's disease (abnormal memory), kyphosis (outward curve in the spine), dysphagia (difficulty swallowing) and hypertension (high blood pressure). The 6/26/24 minimum data set (MDS) assessment revealed the resident had short and long term memory issues. She was dependent on staff for toileting, personal hygiene, transfers, dressing and required supervision with eating. She was dependent on staff for mobility with a manual wheelchair. B. Observations On 8/26/24 at 1:41 p.m. Resident #18 was observed sitting in her wheelchair with a specialized positioning device on the left side of the wheelchair. Resident #18 was leaning to her left with her arm tucked in to her side. The resident's arm was not positioned on top of the positioning device. On 8/27/24 at 2:34 pm Resident #18 was sitting in her wheelchair participating in an activity in the dining room. Resident #18 was leaning to the left but there was no positioning device on the left side of the wheelchair. On 8/28/24 at 11:36 a.m. Resident #18 was in the dining room for lunch and was seated in her wheelchair with the positioning device positioned on the left side of the wheelchair. Resident #18 was leaning to her left side with her arm tucked into her side and not on top of the positioning device. The director of nursing (DON) entered the dining room and observed that Resident #18 did not have her left arm positioned on top of the positioning device. The DON proceeded to place Resident #18's left arm on top of the wheelchair positioning device. The DON said the resident's left arm should be resting on top of the positioning device to aid in positioning her appropriately because the resident leaned to her left. C. Record review The August 2024 CPO revealed a physician's order for an arm wedge under the resident's left arm while in the wheelchair to assist with positioning, ordered 8/28/24 (during the survey). The 5/9/22 comprehensive care plan failed to document Resident #18's use of the wheelchair positioning device. Review of occupational therapy (OT) notes for Resident #18 revealed the following: Resident #18 was working with OT services beginning 6/11/24 and the OT recommended further wheelchair positioning due to staff reporting the resident was leaning in her wheelchair at times. Resident #18 was to receive wheelchair management training two times a week for 12 weeks starting 8/7/24. On 8/7/24 staff reported an increase in Resident #18's left sided leaning in her wheelchair at times and wheelchair positioning devices were recommended by the OT. On 8/20/24 OT notes revealed Resident #18 had a significant forward flexion (forward bend) when sitting in the wheelchair but positioned midline (more upright in the middle) with a new left side support. -However Resident #18 was observed leaning to the left due to the positioning device not being positioned appropriately in the wheelchair (see observations above and DON interview below). -There was no documentation to indicate staff were educated on the appropriate way to position Resident #18's positioning device to ensure she did not lean to her left while she was in her wheelchair. III. Staff interviews The DON was interviewed on 8/28/24 at 11:36 a.m. The DON said Resident #18 had a wheelchair cushion on the left side of her wheelchair to aid in positioning the resident since she had a tendency to lean to the left. The DON said because the device was used for positioning, the resident's arm should be placed on top of the positioning device (see record review above). The DON said the wheelchair positioning device should be careplanned for use to ensure all staff were aware of Resident #18's need for the positioning device. The restorative nurse aide (RNA) #1 was interviewed on 8/28/24 at 12:45 p.m. RNA #1 said Resident #18 had been using the wheelchair positioning device for a while. RNA #1 said the device was used to assist Resident #18 to sit up straight in her wheelchair due to her tendency to lean to the left. RNA#1 said Resident #18 should have her left arm at her side because she did not have great range of motion in her shoulder. RNA #1 said he did to know if it made a difference in the resident's positioning whether the resident kept her arm next to her or on top of the cushion. -However, according to the DON's interview (see above) the resident's arm should be positioned on top of the positioning device to ensure proper positioning in the wheelchair. Licensed practical nurse (LPN) #1 was interviewed on 8/28/24 at 12:49 p.m. LPN #1 said Resident #18 had had the wheelchair positioning cushion for a while. LPN #1 said Resident #18 leaned towards her left side but she was not sure why she leaned to that side. LPN #1 said she did not know if the resident had to have her arm on the cushion or if at her side was acceptable positioning. Certified nurse aide (CNA) #2 was interviewed on 8/29/24 at 12:33 p.m. CNA #2 said Resident #18's wheelchair positioning device was to be used when she was sitting in her wheelchair because she leaned to her left in the wheelchair. -Staff were aware Resident #18 used a positioning device on the left side of her wheelchair, however, staff were unable to verbalize how the resident's arm should be positioned on the positioning device to ensure the resident was sitting upright in her wheelchair.

Based on observations, record review and interviews, the facility failed to ensure one (#4) of two residents reviewed for pain out of 26 sample residents had an effective pain management regimen in a manner consistent with professional standards of practice, resident-centered care plans and resident preferences. Specifically, the facility failed to ensure Resident #4 was offered effective pain management to include non-pharmacological interventions and as needed (PRN) pain medications for breakthrough pain. Findings include: I. Facility policy The Pain Assessment and Management policy, revised 9/12/23, was received from the director of nursing (DON) on 8/28/24 at 12:31 p.m. It read in pertinent part, Pain management procedure: Based on the assessment, the facility, in collaboration with the attending physician/prescriber, other health care professionals, and the resident and/or his/her representative, develops, implements, monitors and revises as necessary interventions to prevent or manage each individual resident's pain, beginning at admission. These interventions may be integrated into components of the comprehensive care plan, addressing conditions or situations that may be associated with pain, or may be included as a specific pain management need or goal. The facility will address/treat the underlying causes of the pain, to the extent possible. Developing and implementing both non-pharmacological and pharmacological interventions/approaches to pain management, depending on factors such as whether the pain is episodic, continuous, or both. Identifying and using specific strategies for preventing or minimizing different levels or sources of pain or pain-related symptoms based on the resident-specific assessment, preferences and choices, a pertinent clinical rationale, and the resident's goals. Identifying target signs and symptoms (including verbal reports and non-verbal indicators from the resident) and using standardized assessment tools can help the interdisciplinary team evaluate the resident's pain and responses to interventions and determine whether the care plan should be revised. Monitoring appropriately for effectiveness and/or adverse consequences (constipation, sedation) including defining how and when to monitor the resident's symptoms and degree of pain relief. Modifying the approaches, as necessary. II. Resident #4 A. Resident status Resident #4, age greater than 65, was admitted on [DATE] and readmitted [DATE]. According to the August 2024 computerized physician orders (CPO), diagnoses included type 2 diabetes, primary osteoarthritis, muscle wasting and atrophy, anemia, polyosteoarthritis (involves five or more joints at one time), difficulty in walking and muscle spasms. The 7/25/24 minimum data set (MDS) assessment revealed, the resident was cognitively intact with a brief interview for mental status (BIMS) of 15 out of 15. The resident had verbal behavior directed towards others and other behavioral symptoms not directed at others on one to three days of the seven day look back period. She required moderate assistance with bathing and supervision with transfers. The MDS assessment indicated the resident received scheduled pain medications. The resident did not receive as needed pain medications or non-pharmacological interventions for pain. She had frequent pain, which occasionally interfered with day to day activities. The resident reported a pain level of 8 on a pain scale of 1-10. B. Resident interviews and observations Resident #4 was interviewed on 8/26/24 at 11:45 a.m. Resident #4 was sitting in her wheelchair at her bedside table. The resident said she had chronic pain and the scheduled medications helped her a little bit but did not relieve her pain. She said her pain was an 8 out of 10 at the time of the interview. Resident #4 was interviewed a second time on 8/27/24 at 9:46 a.m. sitting in her wheelchair at her bedside. She said she was in alot of pain. She said currently her pain was an 8 out of 10. She said the pain was in her back, knees, legs and hands. She said she loved to play bingo when her hands were not hurting too bad. Resident #4 was interviewed a third time on 8/27/24 at 9:53 a.m. She said when she told the nurse she was in pain, the nurse would respond that she already had her scheduled pain medication and it was not time for another pain pill. She said she had never been offered any non-pharmacological interventions but thought they may help. She said after the nurse assessed her pain, she did not feel the facility provided adequate interventions to address her pain level. She said she felt like the staff did not take her pain seriously. C. Record review A review of the resident's August 2024 medication administration record (MAR) revealed Resident #4 reported her pain as a 10 out of 10 one time, a 9 out of 10 one time, an 8 out of 10 10 times, a 7 out of 10 four times, a 6 out of 10 two times and a 5 out of 10 eight times. It revealed her acceptable pain level was a 3 out of ten. A review of the resident's electronic medical record (EMR) revealed Resident #4 did not receive non-pharmacological pain interventions. A physician's order, dated 1/24/24, revealed the resident was to receive tramadol 50 milligrams (mg) two times a day for generalized pain. A physician's order, dated 7/8/24, revealed the resident was to receive acetaminophen 325 mg two times a day for pain. -The August 2024 CPO did not reveal any physician's orders for PRN pain medications. The pain management care plan, revised 4/24/23, revealed the resident was on pain medication therapy. The goal was to be free of any discomfort or adverse side effects from the pain medication. The interventions included administering analgesic medication as ordered by the physician and observing for side effects and effectiveness. The arthritis care plan, revised 4/23/23, revealed the resident expressed pain all over related to arthritis. The goal was for the resident to express pain relief through the review date. The resident's pain was aggravated by increased activity. The resident's pain was alleviated/relieved by rest, repositioning and medication. The interventions included anticipating the resident's need for pain relief and respond immediately to any complaint of pain, evaluating the effectiveness of pain interventions, notifying the physician if interventions were unsuccessful, observing and reporting changes in usual routine, sleep patterns, decrease in functional abilities, decreased range of motion, withdrawl or resistance to care, observing and reporting to the nurse any signs and symptoms of non-verbal pain, such as yelling out, silence, more irritable, restless and aggressive behavior, observing and reporting to the nurse any resident complaints of pain or request for pain treatment and reporting to the nurse any change in usual activity attendance patterns or refusal to attend activities. A health status note dated 7/12/24 at 12:53 a.m. revealed the resident was frustrated when she asked for her pain medication but was told she had to wait for the scheduled administration time. She asked twice through the night before the pain medications were allowed to be administered. It was not helpful for her behaviors or pain. -The progress note failed to identify if any non-pharmacological interventions were attempted with the resident. -The progress noted failed to identify if the physician was notified about the resident's increased pain and the potential need for PRN pain medications for breakthrough pain. A behavior note dated 7/13/24 at 5:50 p.m. revealed Resident #4 had an increase in behaviors that shift. The resident repeatedly asked for her pain medications after they were already administered. She was on her call light the entire shift. When staff tried to redirect her she would tell the staff to go to hell. The resident repeatedly asked for the same thing over and over all shift. -The progress note failed to identify if any non-pharmacological interventions were attempted with the resident. -The progress noted failed to identify if the physician was notified about the resident's increased pain and the potential need for PRN pain medications for breakthrough pain. A health status note dated 7/17/24 at 4:17 a.m. revealed the resident was up early and loudly yelling about how much she hurt and her pain was severe. At one point she yelled out to the Virgin [NAME] to help her with her pain. Tylenol was given but the resident continued to sit in the hallway yelling at the pain to go away. A behavior note dated 7/24/24 at 1:58 a.m. revealed the resident got herself out of bed and came into the hallway. She was sitting in her wheelchair moaning, talking to herself loudly, making disruptive sounds and crying about how she was hurting. Tylenol was given, but the resident continued to moan loudly. -The progress note failed to identify if any non-pharmacological interventions were attempted with the resident. -The progress noted failed to identify if the physician was notified about the resident's increased pain and the potential need for PRN pain medications for breakthrough pain. A behavior note dated 7/25/24 at 9:24 a.m. revealed a huddle was held due to Resident #4 reporting pain, asking for tylenol and making sounds. The resident reported that she was in pain however, the nurse documented the resident had a behavioral health disorder, and diagnosis of anemia. The possible precipitating factors included her medical condition, reported pain, and behavioral health disorder. The interventions were to administer tylenol and assess the resident's needs. -The facility failed to identify that the resident's behavior could have been the result of her pain being out of control and failed to implement non-pharmacological interventions. -The progress noted failed to identify if the physician was notified about the resident's increased pain. III. Staff interviews Certified nurse aide (CNA) #1 was interviewed on 8/28/24 at 9:40 a.m. CNA #1 said if a resident complained of pain, the CNA would report it to the nurse and the nurse would look in the MAR to see what pain medication was available. She said Resident #4 complained of pain daily. CNA #2 was interviewed on 8/28/24 at 9:45 a.m. CNA #2 said Resident #4 complained of pain daily but she was not sure if it was really pain or just her behavior. CNA #2 said she could tell by the way Resident #4 moaned whether she was in true pain. She said she did not know if the resident's pain was causing her behaviors. Licensed practical nurse (LPN) #3 was interviewed on 8/27/24 at 9:50 a.m. LPN #3 said Resident #4 had physician's orders for scheduled Tylenol twice a day and Tramadol twice a day. She said the resident did not have any physician's orders for PRN pain medications for breakthrough pain. She said she was not aware of a pain clinic in their town. She said if the physician ordered pain medication was not effective, she would call the physician and see if a stronger medication or topical medication could be prescribed. LPN #3 reviewed Resident #4's August 2024 MAR and said no non-pharmacological interventions had been tried to help alleviate the resident's pain. She said it was important to control a resident's pain because the resident had the right to be comfortable. She said pain was not normal and could cause behavioral issues. The DON was interviewed on 8/28/24 at 11:09 a.m. The DON said if a resident's pain regimen was not effective, the facility would review the medications and call the physician. She said it was the facility's goal to always keep residents comfortable and free of pain. She said the facility could do a better job at re-educating the nurses to look at the physician order and to always offer non-pharmacological interventions when the pain medication was not effective. She said the nurse needed to focus on making the resident comfortable and meet their needs. She said the nurse should be addressing Resident #4's behavior to see if pain was the cause of her behaviors. The DON said it was important to manage a resident's pain so they were comfortable in their own home. She said when a resident was in pain it could lead to a decline in the quality of their life. She said the facility did not want to deprive the residents from living their best life.

Based on observations and interviews, the facility failed to ensure medications and biologicals were stored and labeled properly according to professional standards in one of one medication storage rooms. Specifically the facility failed to: -Ensure expired medications were removed from the medication refrigerator; and, -Ensure medications were labeled with open dates. Findings include: I. Professional Reference According to the Aplisol (Tuberculin Purified Protein Derivative used to test for tuberculosis) package insert, was retrieved on 9/3/24 from https://www.fda.gov/files/vaccines%2C%20blood%20%26%20biologics/published/Package-Insert---Aplisol.pdf, Aplisol vials should be inspected visually for both particulate matter and discoloration prior to administration and discarded if either is seen. Vials in use for more than 30 days should be discarded. II. Facility policy and procedure The Storage and Expiration Dating of Medications, Biologicals policy, revised 8/7/23, was received from the director of nursing (DON) on 8/28/24 at 12:21 p.m. It revealed in pertinent part, Once any medications or biological package is open, the facility should follow manufacturer/supplier guidelines with respect to expiration dates for opened medications. Facility staff should record the date opened on the primary medication container (vial, bottle or inhaler) when the medication has a shortened expiration date once opened. Medications with a manufacturer's expiration date expressed in month and year will expire on the last day of the month. If a multi-dose vial of an injectable medication has been opened or accessed (needle-punctured), the vial should be dated and discarded within 28 days unless the manufacturer specifies a different date for that opened vial. III. Observations and staff interview On 8/27/24 at 11:42 a.m. the [NAME] medication room was observed with the infection preventionist (IP). The following was observed in the medication refrigerator: -There was one vial of Aplisol that was opened and did not have an opened date on the vial or box; and, -There was one pre-filled syringe of FluZone High Dose Quadrivalent flu season 2023-2024 vaccine with an expiration date of June 2024. The IP said the vial of Aplisol should have had a date on it to indicate when it was opened because the medication was only good for 28 days after it was opened. The IP said the vial needed to be removed for destruction so no one could accidently administer it. The IP said the medication would not be as effective if it was used after the recommended use by date. The IP said the vaccine should have been removed from the refrigerator once it had expired to ensure it did not get used after the expiration date. The IP said if the vaccine was administered after it had expired it would not be as effective in preventing someone from getting influenza. IV. Additional staff interview The DON was interviewed on 8/28/24 at 11:15 a.m. The DON said it was the responsibility of the management team to perform weekly audits of the medication carts and monthly audits in the medication room to look for expired medications and medications that were not dated when opened. The DON said it was the responsibility of the nurses to label medications when they opened them. The DON said medications or vaccines may not be as effective if administered past the expiration date.

Based on observations, record review and interviews, the facility failed to establish a sanitary environment to help prevent the transmission of communicable diseases and infections. Specifically, the facility failed to ensure Resident #33's catheter drainage bag was not touching the floor. Findings include: I. Facility policy and procedure The Indwelling Urinary Catheter (Foley) Management policy, revised June 2023, was provided by the director of nursing (DON) on 8/28/24 at 12:31 p.m. It read in pertinent part, Based on comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan and the resident's choices. The facility must ensure those who were incontinent of bladder received appropriate treatment and services to prevent urinary tract infections. Keep the collecting bag below the level of the bladder at all times. Do not rest the bag on the floor. II. Resident status Resident #33, age greater than 65, was admitted on [DATE]. According to the August 2024 computerized physician orders (CPO), diagnoses included inflammatory disorders of the scrotum, muscle weakness, bladder neck obstruction, difficulty in walking, obstructive and reflux uropathy (urine flow was obstructed) and down syndrome. The 8/7/24 minimum data set (MDS) assessment revealed, the resident was unable to complete a brief interview for mental status score (BIMS). He had short and long term memory problems. His cognitive skills for daily living were severely impaired. He was dependent on staff for all of his activities of daily living (ADL). He had an indwelling catheter and was always incontinent of bowel. III. Observations On 8/26/24 at 10:52 a.m., the resident was lying in bed. The bed was in a low position and his catheter drainage bag was hanging from the bed frame and touching the floor. On 8/27/24, the following observations were made: At 11:05 a.m. the resident was lying in bed. The bed was in a low position and his catheter drainage bag was hanging from the bed frame and touching the floor. At 2:34 p.m. the resident was lying in bed. The bed was in a low position and his catheter drainage bag was hanging from the bed frame and touching the floor. On 8/28/24 at 10:36 a.m. the resident was observed lying in bed.The catheter had been placed in a privacy cover attached to the bed frame and was no longer touching the floor. IV. Record review The nursing admission form, dated 11/21/22, revealed Resident #33 was admitted with a urinary catheter related to obstructive uropathy. The indwelling suprapubic catheter care plan, revised 5/23/24, revealed the resident had an indwelling catheter related to obstructive uropathy. The interventions included catheter care every shift, positioning the catheter drainage bag and tubing below the level of the bladder and documenting urine output every shift. -The care plan failed to document that the resident's catheter drainage bag should be positioned off the floor. V. Staff interviews Certified nurse aide (CNA) #3 was interviewed on 8/28/24 at 10:31 a.m. CNA #3 said a catheter drainage bag should not be touching the floor and should be in a privacy bag for dignity and for infection control. CNA #3 said she realized Resident #33's catheter drainage bag was touching the floor and placed the catheter drainage bag into a privacy bag (on 8/28/24). Licensed practical nurse (LPN) #1 was interviewed on 8/28/24 at 10:35 a.m. LPN #1 said a resident's catheter drainage bag should be hanging on the bed frame but not touching the floor to avoid bacteria from entering the bladder and causing an infection. The infection preventionist (IP) was interviewed on 8/28/24 at 10:49 a.m. The IP said a catheter drainage bag should not be touching the floor because the floor could be dirty and the staff needed to keep the catheter system as clean as possible to avoid contamination which could cause a urinary tract infection. The DON was interviewed on 8/28/24 at 11:07 a.m. The DON said a catheter drainage bag should not be touching the ground because it could lead to an infection. She said the catheter drainage bag should be in a privacy bag for dignity and infection control. The DON said the catheter drainage bag should be hung on the bed frame, lower than the bladder, but not touching the ground or anything that could introduce bacteria into the urinary system and cause an infection.

Based on record review and interviews, the facility failed to implement policies and procedures related to pneumococcal immunizations for two (#33 and #346) of five residents reviewed for immunizations out of 26 sample residents. Specifically, the facility failed to offer Resident #33 and Resident #346 additional recommended doses of the pneumococcal vaccination. Findings include: I. Professional reference According to the Centers for Disease Control and Prevention (CDC) Recommended Immunization Schedule for Adults Aged [AGE] years or Older, United States (2023), retrieved on 9/4/24 from https://www.cdc.gov/vaccines/hcp/imz-schedules/downloads/adult/adult-combined-schedule.pdf, Routine vaccination-pneumococcal: routine vaccination for those age [AGE] years or older who have previously received only the PPSV23 (pneumococcal polysaccharide vaccine): one dose of PCV15 (pneumococcal conjugate vaccine) or one dose of PCV20. Administer either PCV15 or PCV20 at least 1 year after the last PPSV23 dose. II. Facility policy and procedure The Vaccination of Older Adults policy and procedure, revised 7/2/24, was received from the director of nursing (DON) on 8/29/24 at 12:21 p.m. It revealed in pertinent part, The facility, in conjunction with the public health authorities and CDC guidelines, will provide immunization to older adults that are recommended and ordered by a physician once determined to be eligible and without contraindications. Pneumococcal conjugate vaccine (PCV 15, PCV20, which protects against serious pneumococcal disease and pneumonia (recommended for all adults with a condition that weakens the immune system, cerebrospinal fluid leak or cochlear implant). Residents will be offered the vaccines, unless immunization is medically contraindicated, or the resident has already been immunized. If based on the nurse's assessment, contraindications are not noted, the vaccine may be administered per the physician's orders. Education, assessment findings, administration. Refusal or did not receive due to medical contraindications, and monitoring are documented in the resident's medical record. Update immunization record in the electronic health record. III. Resident #33 A. Resident status Resident #33, age greater than 65, was admitted on [DATE]. According to the August 2024 computerized physician orders (CPO), diagnoses included inflammatory disorders of the scrotum, muscle weakness, bladder neck obstruction, difficulty in walking, obstructive and reflux uropathy (urine flow was obstructed) and down syndrome. The 8/7/24 minimum data set (MDS) assessment revealed, the resident was unable to complete a brief interview for mental status score (BIMS). He had short and long term memory problems. His cognitive skills for daily living were severely impaired. He was dependent on staff for all of his activities of daily living (ADL). He had an indwelling catheter and was always incontinent of bowel. The assessment revealed the resident was not up to date on his pneumococcal vaccinations. -It failed to document if the vaccine was offered, declined or if the resident was not eligible. B. Record review According to the electronic medical record (EMR) Resident #33 received the following vaccines: Pneumovax dose one on 12/21/22. -The record failed to identify which specific pneumococcal vaccine Resident #33 received. Resident #33 received the pneumococcal conjugate vaccine (PCV20) on 8/28/24 (during the survey). C. Staff interview The infection preventionist (IP) was interviewed on 8/28/24 at 11:00 a.m. The IP said Resident #33 had received PPSV 23 on 12/21/22. The IP said Resident #33 should have received a second dose of pneumococcal vaccine a year later, either the PCV15 or the PCV20, to ensure he was up-to-date on his pneumococcal vaccinations.The IP was not aware if the second pneumococcal vaccination had been offered to the resident. IV. Resident # 346 A. Resident status Resient #346, age younger than 65, was admitted on [DATE] According to the August 2024 CPO, diagnoses included Parkinson's disease (a brain disorder affecting the nervous system), hemiplegia (unable to move one side of the body) and hypertension (high blood pressure). The 8/12/24 MDS assessment revealed the resident was cognitively intact with a BIMS score of 14 out of 15. The assessment revealed the resident was not up to date on pneumococcal vaccines. It documented the resident was offered and declined. -However, the resident had consented to the pneumococcal vaccine upon his admission to the facility three days earlier (see record review below). B. Record review According to the EMR, Resident #346 signed a consent for the pneumococcal vaccine on 2/2/23, during a previous admission to the facility. -The EMR failed to document if Resident #346 received a pneumococcal vaccination in February 2023. According to the EMR, Resident #346 signed a second consent on 8/9/24, upon his admission to the facility, to receive the pneumococcal vaccine. The EMR immunization record revealed Pneumovax dose one consent was required. -However, Resident #346 had already signed consents (on 2/2/23 and 8/9/24) to receive the pneumococcal vaccine and the consents were located in the EMR. The EMR immunization record revealed Resident #346 received te pneumococcal conjugate vaccine (PCV20) on 8/28/24 (during the survey). C. Staff interview The IP was interviewed on 8/28/24 at 11:00 a.m. The IP said, according to the the immunization record for Resident #346, he was administered PPSV 23 on 2/7/23 and the resident was eligible to receive a dose of the updated pneumococcal vaccine, either PCV15 or PCV20. V. Additional staff interviews The IP was interviewed again on 8/29/24 at 9:49 a.m. The IP said Resident #33 was due to receive his pneumococcal vaccine in February of 2023. The IP did not know why he had not received his second vaccine. The IP said Resident #33's responsible party was contacted (during the survey) for consent to receive the vaccine. The IP said resident #346 had given consent in February 2023 to receive a pneumococcal vaccine and it was not administered to the resident at that time. The IP said because the resident did not previously receive the vaccine, the facility obtained a verbal consent from the resident on 8/28/24, to go along with the consent Resident #346 signed upon his admission on 8/9/24. The IP said Resident #346 received the pneumococcal vaccination on 8/28/24 (during the survey). The IP was unable to say why Resident #346 had not received the pneumococcal vaccine prior to the survey. The IP said it was important to ensure all residents were vaccinated if they choose to be. The IP said vaccinations decreased the risk of residents becoming sick. The DON was interviewed on 8/29/24 at 10:07 a.m. The DON said vaccines were offered to residents upon admission to the facility. She was not aware there were issues with vaccinations not being administered until the survey. The DON said because the concern had been brought to her attention, the facility was completing an in-house audit to see who else may not have received their updated pneumococcal vaccinations and the facility had identified three other residents. The DON said the IP was new to the facility and would be receiving more training to ensure residents were vaccinated per the vaccination guidelines. The DON said residents who were not properly vaccinated were at an increased risk for developing infections, especially if they had underlying medical conditions that weakened their immune systems.

Based on record review and interviews, the facility failed to ensure licensed nurses and certified nurse aides (CNA) were able to demonstrate competencies in skills and techniques necessary to care for residents' needs, as identified through resident assessments, and described in the plan of care. Specifically, the facility failed to ensure nursing staff had completed competencies in the past 12 months prior to providing skilled services as described in the plan of care for three out of three registered nurses (RN), two out of two licensed practical nurses (LPN) and five out of five CNAs reviewed for competencies. Findings include: I. Resident census and condtitions According to the Resident Census and Conditions, the facility had: -41 residents dependent with bathing. -Eight residents dependent with dressing. -Five residents dependent with transferring, -Five residents dependent with toilet use. -Two residents with a catheter. -One resident with a tube feeding. II. Competency records Review of the past 12 months, facility did not evidence of skill competencies for five CNAs (#1, #2, #3, #4 and #5), two LPNs (#1 and #2), and three RNs (#1, #2 and #3). III. Interviews The director of nursing (DON) was interviewed on 1/31/23 at 1:41 p.m. She said there had been several different administrative changes recently, and the facility had not completed competencies for staff. She said competencies were important to ensure staff provided cares safely and correctly. The nursing home administrator (NHA) was interviewed on 1/31/23 at 3:30 p.m. She said she could not locate any current skill competencies for the identified staff. She said it was important to ensure staff had the correct competencies to provide the best care to the residents. The staff development coordinator (SDC) was interviewed on 2/2/23 at 11:45 a.m. She said the facility had started tube feeding competencies the previous night, however had not completed all the staff. She said the facility and another facility within the corporation were going to develop a skills fair to ensure the staff both licensed nurses and CNAs, had safe skills to provide care as outlined in the plan of care.

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: -Appropriate hand hygiene by food service staff; -Cutting boards were free from deep scratches and stains; -Beard restraints were worn in kitchen areas while serving food; and, -To ensure the food was stored and labeled properly. Findings include: I. Improper hand hygiene A. Professional references According to the Colorado Retail Food Establishment Rules and Regulations (effective 1/1/19) pg.46-47, 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 items and: -Before handling or putting on single use gloves for working with food, and between removing soiled gloves and putting on clean gloves. Food employees shall clean their hands and exposed portions of their arms including surrogate prosthetic devices for hands or arms with soap and water for at least 20 seconds and shall use the following cleaning procedure: 1. Vigorous friction on the surfaces of the lathered fingers, fingertips, areas between the fingers, hands and arms for at least 15 seconds, followed by; 2. Thorough rinsing under clean, running warm water; and 3. Immediately follow the cleaning procedure with thorough drying of cleaned hands and arms with disposable or single use towels or a mechanical hand-drying device. B. Observations Observation of meal service was conducted on 2/1/23 at 10:30 a.m. Cook (CK) #1 was preparing pureed noodles for the lunch meal. The CK #1 poured broth into the pureed noodles to get the right consistency. He again poured the broth into the food processor and placed the plastic container on the counter. He wiped his right hand on his pants. He proceeded to stir the pureed noodles until the right consistency was reached. He took the lid off of the food processor and poured the pureed noodles into a small metal container. CK #1 placed the pureed noodles onto the food cart while placing his thumb on the inside of the metal container. CK #1 then took the food processor to the dishwashing area and sent it through a washing cycle. CK #1 returned to the food preparation area. CK #1 then proceeded to grab a food thermometer with his right hand. He placed the end of the thermometer into the mechanical altered food and took the temperature. He placed the thermometer on the counter and placed a metal lid on the pureed noodles and opened the steam oven door with his right hand. He placed the container into the steam oven and closed the door with his right hand. CK #1 then proceeded to go into the dish room and retrieved the food processor and placed it on the food processor base. CK #1 completed the same process for pureed broccoli, beef tips and mushrooms. CK #1 did not perform hand hygiene during this process. Cook in training (CKT) #1 was being trained on the meal process. CKT #1 had his arms crossed while listening to CK #1 explain the meal ticket process. CKT #1 would clasp his hands together, place his hands on his hips and would touch his face. CKT #1 grabbed a plate with his hand and proceeded to plate the food. He continued to clasp his hands together while reviewing the meal ticket and then he would scoop the food onto the plate. CKT #1 did not perform hand hygiene during this process. Dietary aide (DA) #1 was observed preparing the trays for the secured unit. DA #1 placed several meal trays in the food preparation area. DA #1 walked out of the kitchen into the dining room. He opened the door with his right hand and exited the kitchen preparation area. DA #1 returned from the dining room with a pitcher of water. DA #1 proceeded to grab a stack of small plastic cups. The DA #1 grabbed a gallon of milk and juice from the refrigerator and proceeded to fill the glasses with water, milk, and juice. He placed all three cups onto the trays and waited for the meals to be served. During this time, DA #1 entered the walk-in refrigerator several times and walked into the freezer grabbing the door handles with his bare hand. DA #1 exited the kitchen area and returned with the metal room cart and placed it at the doorway. DA #1 started to receive meal plates from CKT #1. DA #1 would place the plastic lid covers for the meals for transportation. DA #1 placed several trays into the meal cart. He did not perform hand hygiene during this process. C. Staff Interview The dietary manager (DM) was interviewed on 2/2/23 at 10:30 a.m. She said all kitchen staff needed to wash their hands when their hands become contaminated. She said all staff must wash their hands before handling or serving food. Staff should also wash their hands when they leave the kitchen and dining area. The DM said it was her expectation all dietary staff would have been washing their hands between tasks to avoid cross contamination. II. 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, and 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 1/30/22 at 7:15 a.m. revealed four large cutting boards. There were blue, red, white and yellow cutting boards; all cutting boards were heavily scored and stained. On 1/31/23 at 8:22 a.m., DA #1 was cutting toast on the blue cutting board. On 2/3/23 at 10:40 a.m. during kitchen observations CK #1 was observed cutting chicken on the red cutting board. C. Staff Interview The DM was interviewed on 2/2/23 at 10:30 a.m. The DM was told of the observations of the cutting boards in the kitchen. She confirmed the cutting boards were visibly stained and showed wear. She said she thought she had some new cutting boards but stated they were from another facility within the corporation, as she works at both facilities. She said she would replace them immediately. She said the deep scratches could be a potential for bacteria to grow. 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 1/31/23 at 8:22 a.m., CKT #1 was observed in the kitchen area without wearing a beard restraint. CKT #1 beard was approximately an half inch long. CKT #1 was observed hand washing cooking pans in the three compartment sink. On 2/1/23 at 11:45 a.m., CKT #1 was observed in the kitchen area not wearing a beard restraint. CKT #1 was observed preparing and serving lunch meals. The DM was interviewed on 2/3/23 at 10:30 a.m. She stated all kitchen staff are required to wear hair restraint and should have all hair covered. The DM said staff who have facial hair should be wearing a mask or a beard guard while preparing or serving meals. She said all male staff who had facial hair should be wearing proper beard restraints while in food preparation areas to ensure hair from falling into any food. IV. Labeling food A. Professional reference According to the State Board of Health Colorado Retail Food Establishment Rules and Regulations (effective 1/1/19) 3-701, 4 a-d. pg. 104, 4 a-d. It read in part, A date marking system that meets the criteria using a method approved by the Department for refrigerated, ready-to-eat, potentially hazardous food (time/temperature control for safety food) that is frequently re-wrapped, such as lunch meat or a roast. Marking the date or day of preparation with a procedure to discard the food on or before the last date or day by which the food must be consumed on the premises. Marking the date or day the original container is opened in a food establishment with a procedure to discard the food on or before the last date or day by which the food must be consumed on the premises. Using calendar dates, days of the week, color coded marks or other effective marking methods. B. Observations and interviews On 1/30/23 at 7:15 a.m. during the initial tour of the kitchen items stored in the walk-in freezer that were not labeled included: half bag of French fries, half bag of sweet potatoes fries, half bag of potato cakes, half bag of tamales, half bag of taquitos, half bag of waffles, half bag of pancakes, half bag of pizza crust, and a half bag of frozen fish, which clearly had ice buildup in the bag. On 1/31/23 at 8:22 a.m. during the morning kitchen tour the bag of French fries, sweet potato fries, frozen fish, and potato cakes had been labeled with date 1/31/23. The items which were not labeled or dated were the bag of tamales, taquitos, half bag of pizza crusts, half bag of waffles and half bag of pancakes. On 2/2/23 at 10:25 a.m., during the morning kitchen tour the unlabeled bags listed above had not been dated or labeled when they were opened. The dietary manager was shown the items mentioned. C. Staff interview The dietary manager (DM) was interviewed on 2/2/23 at 10:30 a.m. She said all food should have been labeled to include the item and date. She said by doing so, it identified the product, so staff knew what they were grabbing and it was the correct product. She said it was important to date the items so the staff knew when to discard them. She said the potential risk of not labeling was serving an incorrect food item and serving food which had freezer burn due to it being left open. She said a negative outcome would be serving residents food which had lost its flavor or nutrient value due to not having a date of when it was opened.

Based on record review and interviews, the facility failed to ensure two (#40 and #10) of four residents reviewed for abuse out of 18 sample residents. Specially, the facility failed to prevent a resident to resident altercation between Resident #10 and Resident #40. Findings include: I. Facility policy and procedure The Abuse policy, dated 10/4/22, was received from the nursing home administrator (NHA) on 1/31/23. It read in pertinent part: The facility will ensure all residents are protected from physical and psychosocial harm during and after an investigation. Monitor the alleged victim and other residents at risk, such as conducting unannounced management visits at different times and shifts. II. Resident to resident physical altercation between Resident #10 and #40 A. Facility investigation Incident 1/24/23 The incident occurred in Resident #10's room on the secure unit, where both residents resided. The staff saw both residents in Resident #10's room and then heard arguing and slapping at approximately 8:00 p.m. When staff arrived, the residents were slapping each other than Resident #10 put her hands around Resident #40's neck. Resident #40 sustained two small abrasions to her neck. One-on-one (staff supervision) was put in place for both residents for three to five days. Resident #10 was moved off of the secure dementia unit on 1/25/23 and placed in the long term care side of the facility. The facility unsubstantiated the abuse investigation based on both residents' cognition. -However, the abuse should have been substantiated due to both residents slapping each other and Resident #10 putting her hands around Resident #40's neck. B. Resident #40 (victim) 1. Resident status Resident #40, age 76, was admitted on [DATE]. According to the January 2023 computerized physician orders (CPO), diagnoses included Alzheimer's, unspecified dementia, and anxiety. According to the 1/5/23 minimum data set (MDS) assessment, the resident had severe cognitive impairments and a brief interview for mental status (BIMS) interview was unable to be conducted. The resident was only oriented to self. The resident had behaviors of disorientation and disorganized thinking. She required supervision for transfers, walking and eating. She required extensive assistance with personal hygiene, toileting, and dressing. 2. Record review The care plan, initiated 12/28/22, identified the resident had behavioral problems consisting of agitation, physical/verbal aggression, wandering and exit seeking related to dementia. Interventions included to observe for behavior episodes, determine underlying causes, divert attention, and remove from situation. Certified nurse assistant (CNA) tasks for behavior monitoring were reviewed on 2/2/23 for the dates 1/20/23 through 1/25/23. It revealed the resident wandered into others rooms and personal space daily. The resident also pushed and grabbed others on 1/20/23, 1/21/23, 1/22/23, and 1/23/23. Progress notes dated 1/2/23 through 1/31/23 revealed, -Behavior note dated 1/3/23 revealed the interdisciplinary team (IDT) had a behavior huddle to discuss the resident's behaviors of verbal/physical aggression, agitation, wandering and exit seeking. Recommendations were to take the resident on walks outside and administer medication as ordered. -Behavior note dated 1/9/23 revealed that the resident was outside in the secure patio area. She had been trying to open the gate and use a chair to climb the fence. -Behavior note dated 1/10/23 revealed IDT had a behavior huddle to discuss the behavior in the patio area. Recommendations were to provide one-on-one supervision when the resident was in the patio area, remove the chairs and ensure the gate was locked. -Behavior note dated 1/16/23 revealed a CNA had reported to nursing that the resident was combative in the evening with behaviors of kicking, hitting, and biting. -Physician encounter note dated 1/17/23 revealed the staff had reported to the physician that the resident had increased agitation, exit seeking, and uncooperative behaviors in the evening. The physician prescribed Lorazepam (Ativan) 0.5MG (milligrams) twice a day as needed for anxiety. -Behavior note dated 1/17/23 revealed IDT had a behavior huddle to discuss behaviors of verbal/physical aggression and more combative behaviors than usual. Recommendations were to redirect, assess needs, ensure safety, and notify physician. -Nurse health status note dated 1/18/23 revealed the resident had been agitated due to noises other residents were making. Staff intervention was to redirect resident. -Behavior note dated 1/21/23 revealed the resident had been having behaviors of agitation. She had been pulling pictures off the walls and pushing and grabbing others. Staff intervention was to take turns following the resident around the unit. -Behavior note dated 1/23/23 revealed IDT had a behavior huddle to discuss behaviors of physical/verbal aggression and agitation. Recommendations were to continue with current interventions. -Behavior note dated 1/24/23 revealed an incident of physical aggression between Resident #10 and Resident #40 (see incident above). C. Resident #10 (assailant) 1. Resident status Resident #10, age 80, was admitted on [DATE]. According to the January 2023 CPO, diagnosis included Alzheimer's, dementia with behavioral disturbances, and anxiety. According to the 12/5/22 minimum data set (MDS) assessment, the resident had severe cognitive impairment with a brief interview for mental status (BIMS) score of two out of 15. The resident had no behaviors indicated except for wandering. She required extensive assistance for eating, dressing, personal hygiene, transfers, and toilet use. 2. Record review The care plan, initiated 12/8/22, identified the resident had behavioral problems consisting of physical aggression when provoked, wandering and exit seeking related to dementia. Interventions included to observe for behavior episodes, determine underlying causes, divert attention, and remove from situation. Certified nursing assistant (CNA) task behavior monitoring reviewed on 2/2/23 for the dates 12/8/22 through 1/25/23, failed to show any behavior monitoring had been initiated. Progress notes dated 12/8/22 through 2/2/23 revealed, -Behavior note dated 1/24/23 revealed an incident of physical aggression between Resident #10 and Resident #40 (see incident above). -Nursing health note dated 1/28/23 revealed the resident was being monitored for the move off of the secure unit. Resident gets confused and needs to be redirected at times. -Behavior note dated 2/1/23 revealed the resident had been wandering in and out of other resident's rooms, displaying verbal aggression and using profanity at other residents. III. Staff interview CNA #10 on the secure unit was interviewed on 1/31/23 at 9:27 a.m. She said Resident #40 had behaviors of wandering into other resident's rooms and attempting to get into their beds during the evening. This behavior was disruptive to the other residents and the staff had to redirect her constantly. If they took her outside for a walk on the secure patio, it would reduce her agitation but staff were not always available to do that. She stated that Resident #10 had behaviors of being territorial of her room and her space and could be verbally aggressive towards other residents. Licensed practical nurse (LPN) #3 on the secure unit was interviewed on 1/31/23 at 9:48 a.m. She stated that Resident #40 was very active and kept the staff busy with her behaviors of wandering in other resident's rooms, and out of rooms and her attempts to climb the fence in the patio. She can become agitated and difficult to redirect due to her cognition. LPN #3 stated that Resident #10 could become easily agitated and staff had to redirect her when she became agitated at other residents. The NHA was interviewed on 2/1/23 at 10:26 a.m. She said that Resident #40 had wandered into Resident #10's room and this resulted in a physical altercation. Staff separated the residents, reported to her and the director of nursing. Resident #40 was put on one-on-one supervision for three days afterwards and Resident #10 was trialed off of the secure unit. Resident #10 had been on one-on-one supervision for five days after the 1/24/23 altercation and behaviors were documented on a one-on-one sheet kept by the CNA. It was unclear who initiated the altercation, but since Resident #40 was the one who sustained injuries, it was determined that she was the victim. The NHA said he would provide the one-to-one sheet kept by the CNAs. NHA stated the facility had come to a conclusion unsubstantiated regarding the physical abuse because they did not believe Resident #10 had intent to harm the other resident. She did not believe that Resident #10 had the foresight to make the decision to hurt the other resident due to her dementia. NHA was unaware of the regulations language regarding willful and intent. -The NHA did not provide the one-to-one supervision sheet by the time of exit on 2/2/23. CNA #12 was observed on 2/2/23 at 9:27 a.m. sitting in a chair outside of Resident #40's room. She stated she had been with Resident #10 but was told by the nurse to come over to the secure unit and provide one-on-one supervision for Resident #40 instead. She said she was not told why. She also did not know why she had been providing one-on-one supervision to Resident #10. The social services director (SSD) was interviewed on 2/2/23 at 11:20 a.m. She stated Resident #40 was nonverbal and difficult to redirect. The resident had behaviors of sundowning, where she became more agitated in the later afternoon and evening. She would go into other resident's rooms, urinate in hallways, and climb furniture. Resident #10 had behaviors of walking around confused and disorientated without a purpose at times. She became aggressive if she felt she had been provoked, like if someone were to yell at her. The facility started behavior tracking for residents on psychotropic medications, residents who exhibited disruptive behaviors, or residents transitioning off of the secure unit. Disruptive behaviors could consist of verbal/physical aggression or exit seeking. According to SSD, after the incident, the facility started one-on-one staff supervision for both residents for three days. The SSD said there had been no behavior monitoring for Resident #10 before or after the incident. She stated that Resident #10 moved off of the secure unit after the incident on a trial basis. She had not had any exit seeking behaviors or behaviors that were disruptive to other residents since moving off the secure unit. Regarding the behavior note from 2/1/23, the SSD stated another resident became disoriented and wandered into Resident #10's room. The IDT had not had a behavior huddle yet to discuss recommendations. IV. Facility follow-up Abuse and neglect staff training was conducted on 1/24/23 at 6:00 p.m. and documentation was provided by the NHA on 1/31/23, with 17 staff members attending. Abuse training was conducted on 11/16/22 and documentation was provided by the NHA on 1/31/23. Of the 61 staff members listed to attend, 46 attended.

Based on record review and interviews, the facility failed to ensure a resident who displayed or was diagnosed with dementia, received the appropriate treatment and services to attain or maintain his or her highest practicable physical, mental, and psychosocial well-being for one (#10) of 10 residents reviewed for dementia care out of 18 sample residents. Specifically, the facility failed to -Develop and implement effective dementia management focused interventions to prevent Resident #10 form unsafe wandering and engaging in physically abusive resident to resident altercations; -Consistently document and assess Resident #10's wandering and physically aggressive behavior in order to determine the cause of behavior and ensure intervention effectiveness; and, -Reassess the effectiveness of care-plan intervention and adjust intervention approaches based on behavior tracking, for Resident #10. Cross-reference F600 for resident to resident physical abuse. Findings include: I. Facility policy and procedure The Behavior Management policy and procedure, revised 11/23/22, was provided by the nursing home administrator (NHA) on 1/31/23. It revealed in pertinent part, Monitoring the residents closely for expressions or indicators of distress. -Accurately document changes, including frequency of occurrence and potential triggers in the resident's records. -Ensuring that the necessary care and services are person centered. -Ensuring that pharmacological (medication) interventions are only used when non-pharmacological interventions are ineffective. The Dementia Care policy was requested from the NHA on 2/2/23 at 12:00 p.m. At the time of the survey exit on 2/2/23, the facility had not provided the dementia care policy. II. Resident #10 A. Resident status Resident #10, age 80, was admitted on [DATE]. According to the January 2023 computerized physician order (CPO), diagnosis included Alzheimer's, dementia with behavioral disturbances, and anxiety. According to the 12/5/22 minimum data set (MDS) assessment, the resident had severe cognitive impairments with a brief interview for mental status (BIMS) score of two out of 15. The resident had no behaviors indicated except for wandering. She required extensive assistance for eating, dressing, personal hygiene, transfers, and toilet use. B. Resident observations The resident was observed on 1/31/23 at 9:30 a.m. and on 2/2/23 at 9:30 a.m. During both times, the resident was observed walking around the hallway. The resident was not engaged during the time and there was nothing seen to keep the resident from wandering into other resident rooms. C. Record review The care plan, initiated 12/8/22, identified the resident had behavioral problems consisting of physical aggression when provoked, wandering and exit seeking related to dementia. Interventions include; observe for behavior episodes and attempt to determine underlying causes, divert attention, remove the resident from the situation, and document behaviors and attempted interventions. -There were no revisions to the resident's care plan to address the 1/26/23 incident or to identify person centered interventions to prevent a recurrence. Progress notes dated 12/8/22 through 2/2/23 revealed: -Behavior note dated 1/25/23 revealed a physical altercation between Resident #10 and another resident. Resident #10 had been found slapping the other resident and putting her hands around the other resident's neck. Staff found Resident #10 in the other resident's room and Resident #10 had to be redirected back to her room. Cross-reference F600. -Nursing health note dated 1/28/23 revealed the resident was being monitored for her move off of the secure unit. Behaviors identified were that the resident gets confused and needs to be redirected at times. -Behavior note dated 2/1/23 revealed the resident had been wandering in and out of other resident's rooms, displaying verbal aggression and using profanity at other residents. III. Staff interviews Licensed practical nurse (LPN) #1 was interviewed on 2/2/23 at 9:42 a.m. She said Resident #10 had recently moved over to the unit on the long term care side. She stated the resident frequently wandered into other residents' rooms, got lost, and had anxiety. Certified nurse aide (CNA) #3 was interviewed on 2/2/23 at 9:45 a.m. CNA #3 said Resident #10 recently moved over to the unit on the long term care side. She was not aware of the resident having any behaviors. The social services director (SSD) was interviewed on 2/2/23 at 11:20 a.m. She stated the facility would start behavior tracking for residents on psychotropic medications, residents exhibiting disruptive behaviors, or residents transitioning off of the secure unit. Disruptive behaviors could consist of verbal/physical aggression or exit seeking. The SSD ran a report, called the behavior monitoring and intervention report, in the computer to determine what behaviors had been documented and provided the report to the interdisciplinary team (IDT). The behavior monitoring and intervention report pulled documentation from the system. The nurses make behavior progress notes and the IDT reviewed each entry in morning management meetings. The IDT consisting of the director of nursing (DON), SSD and a floor nurse. The IDT members identified target behaviors and desired interventions but the results were not communicated directly to the floor nurse or CNAs. The SSD expected the CNAs and nurses to look in the resident's care plan to learn of the resident identified behaviors and interventions. -However, the resident's care plan was not personalized with interventions since she had an altercation with another resident after she wandered into their room. The SSD said when a resident moved off of the secure unit to transition to the long term side of the building, the nursing staff were to conduct behavior monitoring for three to five days. If there were no behaviors, the move became permanent and the family or responsible party were notified the move was considered permanent. The SSD ran the behavior monitoring and intervention report for Resident #10 for the date range of 1/1/23 through 2/2/23 at 11:25 a.m. There were no results on the report despite there was a documented resident to resident altercation involving Resident #10 on 1/25/23 and a recent behavior of aggression documented on 2/1/23. According to the SSD, when the staff failed to document behaviors, the negative outcome was that the IDT would not be able to determine how a resident was doing with medication changes or adjustments to environmental changes. The facility would not be effectively able to determine if a dose reduction or discontinuation of medication were successful. The nursing home administrator (NHA) was interviewed with the director of nursing (DON) on 2/2/23 at 12:00 p.m. According to the NHA, the facility provided dementia training to staff during an annual in person all staff training and through quarterly online courses. Resident #10 had been on one-on-one supervision for five days after the 1/25/23 altercation and behaviors were documented on a one-on-one sheet kept by the CNA. The NHA stated she provide one-on-one supervision sheet for Resident #10, the facility's dementia care policy, and staff online training for dementia. The DON confirmed that IDT reviewed the behavior monitoring and intervention report during the morning management meeting. The report pulled the information from the point of care charting. If there are no behavior monitoring tasks established for a resident then nothing would appear on that report. -However, the resident had behaviors documented in the progress notes (see above). IV. Facility follow-up On 1/31/23, the NHA provided documentation showing the facility conducted in person dementia care training on 3/14/22 Of the 63 staff members assigned to attend, only 29 attended. The facility did not have a makeup training schedule for the remaining 34 staff members not in attendance. At the time of the survey exit, 2/2/23, the facility had not provided the one-on-one supervision sheet for Resident #10, or staff online training for dementia documentation that was requested.

Based on record review and interviews the facility failed to ensure for one (#38) of one resident who required [CONDITION(S)] received such services, consistent with professional standards of practice out of 19 sample residents. Specifically, the facility failed to for Resident #38: -Obtain a physician's order for hemodialysis (HD); -Obtain a physician's order to monitor the HD port; -Obtain a physician's order for dressing changes on the port; -Update the [CONDITION(S)] care plan with the HD port; and, -Identify the resident was receiving [CONDITION(S)] services on the minimum data set (MDS). Findings include: I. Facility policy and procedure The [CONDITION(S)] policy, revised November 2016, was provided by the nursing home administrator (NHA) 10/18/21 at 9:16 a.m. and read in pertinent part: Procedure -The [CONDITION(S)] patient shall receive consistent care pre and post-[CONDITION(S)]. -The shunt site shall be checked daily on a daily basis with physician notification for any known or suspected problem. Pre-[CONDITION(S)] -The facility shall ensure the patient receives his [CONDITION(S)] treatment by assuring the necessary transportation. -Physicians shall have established an order and the amount of time required for the patient to be on [CONDITION(S)]. Post-[CONDITION(S)] -Internal vascular access (port) dressing should be reinforced with tape as needed to assure that the catheter is kept clean and dry. If the dressing becomes wet/soiled or if the patient removes it, please use the sterile technique to replace it. General guidelines -Monitor for any complaints or observations at vascular access site. -Notify physician of any change in mental or physical status. -Document in the clinical nursing record: [CONDITION(S)] treatment completed, order changes, condition of access site, complaints from patient, and whether physician was notified. II. Resident #38 Resident #38, age 83, was admitted on [DATE] and readmitted on [DATE]. According to the October 2021 computerized physician orders (CPO), the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The 9/29/21 MDS assessment revealed, the resident had moderate cognitive impairment with a brief interview for mental status score (BIMS) of 10 out of 15. She required extensive assistance with most activities of daily living (ADLs). -The MDS failed to identify that Resident #38 utilized [CONDITION(S)] services. III. Record review The 8/17/21 hospital discharge summary included Resident #38 was receiving [CONDITION(S)] on Monday, Wednesday, and Friday. The [CONDITION(S)] care plan, initiated 8/17/21 and revised 8/27/21, identified the resident received [CONDITION(S)] services related to [CONDITION(S)]. Interventions included: -[CONDITION(S)] treatments as ordered. -Do not take blood pressure on arm with shunt. -Dry weights obtained from the [CONDITION(S)] center. -Observe for bleeding at [CONDITION(S)] site, -Observe/report PRN (as needed) any S/S (signs and symptoms) of infection to access site: Redness, swelling or warmth. -The care plan was not updated to show the resident had a HD port. -The resident's electronic medical records (EMR) were reviewed on 10/18/21 at 11:44 a.m. There were no physician orders for the resident to receive [CONDITION(S)] services. There were no physician orders to monitor the HD access site for signs and symptoms of infection. There were no physician orders for dressing changes to the HD access site. -The August 2021 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] -The September 2021 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] -The October 2021 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] IV. Staff interviews Registered nurse (RN) #1 was interviewed on 10/20/21 at 9:47 a.m. She verified that Resident #38 was receiving [CONDITION(S)] services. She said all residents receiving [CONDITION(S)] should have a physician's order. She clarified that the resident did not have a shunt, but had a perma cath in her chest. She said there were no physician orders for [CONDITION(S)] services, for monitoring the access site or for dressing changes to the site. She said the [CONDITION(S)] center changed the dressing when she received [CONDITION(S)]. She said the [CONDITION(S)] center used paper tape which did not always stay on. She said she did not have specific orders to change the dressing, but would just try and replicate what the [CONDITION(S)] center had in place. She said in order to monitor the access site, she would have to remove the dressing. The director of nursing (DON) was interviewed on 10/20/21 at 11:38 a.m. He said all residents receiving [CONDITION(S)] services should have a physician order for [MEDICAL RECORD OR PHYSICIAN ORDER] . He said if the dressing was not staying in place, the nurse should have called the physician to get an order for [MEDICAL RECORD OR PHYSICIAN ORDER] The regional director of clinical services (RDCS) was interviewed on 10/20/21 at 11:40 a.m. She said the resident should have an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . She said it was very important to monitor the access site and have dressing orders in place to protect the resident from infection. She clarified that there were no physician orders in place.

Based on observations, record review, and interviews, the facility failed to properly maintain an infection control program designed to prevent the spread of COVID-19 in two of three neighborhoods for two of three sample residents. Specifically, the facility: -Failed to ensure hand hygiene was completed appropriately; -Failed to ensure social distancing for residents in social areas; -Failed to ensure residents had face covering while staff were assisting them in their rooms; and -Failed to ensure employees were screened appropriately Findings include: I. Hand washing A. Professional reference According to the Centers for Disease and Prevention (CDC) Hand Hygiene in Healthcare Settings, last up updated 1/31/2020, retrieved from https://www.cdc.gov/handhygiene/providers/index.html, included the following recommendations: Multiple opportunities for hand hygiene may occur during a single care episode. Following are the clinical indications for hand hygiene: Use an alcohol-based hand sanitizer immediately before touching a patient, before performing an aseptic task (e.g., placing an indwelling device) or handling invasive medical devices, before moving from work on a soiled body site to a clean body site on the same patient, after touching a patient or the patient's immediate environment, after contact with blood, body fluids or contaminated surfaces, and immediately after glove removal. Wash with soap and water when hands are visibly soiled, after caring for a person with known or suspected infectious diarrhea, and after known or suspected exposure to spores. When using alcohol-based hand sanitizer, put the product on hands and rub hands together. Cover all surfaces until hands feel dry. This should take around 20 seconds. When cleaning hands with soap and water, wet hands first with water, apply the amount of product recommended by the manufacturer to your hands, and rub together vigorously for at least 15 seconds, covering all surfaces of the hands and fingers. Rinse your hands with water and use disposable towels to dry. Use a towel to turn off the faucet. Avoid using hot water, to prevent drying of skin. Other entities have recommended that cleaning your hands with soap and water should take around 20 seconds. Either time is acceptable. The focus should be on cleaning your hands at the right times. B. Observations On 4/27/2020 at 3:59 p.m., certified nurse aide (CNA) #1 was observed to come back inside from the outside with a resident. She was observed to go to the handwashing sink on the secured unit, and she washed her hands, however, she did not wash her hands for 20 seconds. On 4/27/2020 at 4:27 p.m., CNA #1 was observed a second time to use the handwashing sink. She washed her hands under water, for six seconds. C. Interviews The NHA, director of nursing (DON) and the infection control preventionist (ICP) 9:30 a.m. The ICP said that handwashing should occur before any task, between residents, when they go to the common areas and when become soiled. He said the handwashing should be done with soap and water for 20 seconds. The NHA said the ABHR dries within 10 seconds and therefore can not be rubbed for 20 seconds. The DON said she used the ABHR the night before and she rubbed her hands vigorously, however it dried up prior to the 20 seconds. II. Face masks for residents A. CDC recommended guidelines The Center for Disease Control (CDC), Interim Infection Prevention and Control Recommendations for Patients with Suspected or Confirmed Coronavirus Disease 2019 (COVID-19) in Healthcare Settings (4/30/2020), https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html#minimize, (Update April 13, 2020) Patients may remove their cloth face covering when in their rooms but should put them back on when leaving their room or when others (e.g., HCP, visitors) enter the room. Screening for symptoms and appropriate triage, evaluation, and isolation of individuals who report symptoms should still occur. B. Facility policy The Personal Protective Equipment (PPE) for Residents and Visitors Policy with a revision dated o 3/25/2020 read in pertinent parts, PPE is utilized as needed for the protection of residents, staff and visitors. The types of personal protective equipment available to residents and visitors includes: face mask, gloves, impermeable gowns. Education is provided to residents and responsible parties regarding infection control per the Resident and Family education for Infection Control and Infectious Diseases policy. Staff will supply and assist residents with face masks as needed. C. Observations On 4/27/2020 at 4:18 p.m., CNA #2 was observed to enter the room of Resident #1. The resident was coughing. The CNA #2 was observed to bend down to get eye level with the resident to ask if she wanted some water. The CNA was approximately 12 inches from the resident at eye level. The resident continued to cough, while the CNA continued to be within 12 inches. The resident did not have a mask on, and the CNA failed to request the resident place a tissue in front of mouth or a mask on. The CNA proceeded to assist the resident to bed. On 4/27/2020 at approximately 4:45 p.m., CNA #2 entered Resident #3 ' s room. She spoke to the resident, however she did not ask the resident to cover her mouth with a tissue or to place a mask on. On 4/27/2020 at approximately 4:45 p.m., CNA #3 was observed to enter Resident #4 ' s room. She spoke with the resident and did not ask the resident to cover her mouth with a tissue or a face mask. On 4/27/2020 at approximately 5:00 p.m., the nursing home administro (NHA) was observed to serve the dinner meal to Resident #2. The NHA spoke with the resident and assisted the resident to fill the spoon. She did not ask the resident to place a tissue or wear a mask, when she was within 12 inches of the resident. On 4/27/2020 at 5:05 p.m., CNA #4 served dinner to Resident #5 her dinner meal. The CNA #4 failed to ask the resident to place a tissue over her face, while he was serving her meal within 12 inches of the resident. D. Interviews The CNA #1 was interviewed on 4/27/2020 at approximately 4:30 p.m. The CNA #1 said resident did not like to wear the mask. She confirmed that she did not remind the resident to place a tissue over her mouth. She said she had been trained to ask the resident to cover her mouth. The NHA, director of nursing (DON) and the infection control preventionist (ICP) 9:30 a.m. The DON said the staff had been trained to ask the resident to cover their mouth when the staff were working with the residents. She said the secured unit, the residents were not able to keep the masks on. She said the facility had enough cloth masks for the resident use. III. Social distancing on secured unit A. Professional Reference The Center for Disease Control (CDC), Key Strategies to Prepare for COVID-19 in Long-termCare Facilities (LTCFs) (4/30/2020), https://www.cdc.gov/coronavirus/2019-ncov/hcp/long-term-care-strategies.html, Prevent spread of COVID-19: Actions to take now: -Cancel all group activities and communal dining. -Enforce social distancing among residents. -Ensure all residents wear a cloth face covering for source control whenever they leave their room or are around others, including whenever they leave the facility for essential medical appointments. B. Observations On 4/27/2020 at approximately 3:50 p.m., the secured unit had residents sitting at tables not six feet apart. On 4/27/2020 at 4:00 p.m., an unidentified CNA assisted a resident to the dining room table. She sat him next to another resident at a square table. The residents were not social distancing and sitting approximately three feet from each other, with no mask. On 4/27/2020 at 4:05 p.m., Resident #7 was assisted to a table in the dining room. The table had another resident sitting at it. They were approximately three feet from each other. On 4/27/2020 at approximately 4:45 p.m., during the dinner meal, the Resident #6 was observed sitting with another resident which they were approximately three feet away from each other. The CNA #5 was sitting with the two residents and assisting. The dining room had two other tables which had two residents sitting at the tables. They were approximately three feet apart. Interviews The NHA was interviewed on 4/27/2020 at approximately 5:30 p.m. The NHA said the secured unit was difficult to keep social distancing, because the residents move themselves near others. The NHA said the staff had been trained on social distancing. The NHA, director of nursing (DON) and the infection control preventionist (ICP) 9:30 a.m. The NHA said the secured unit had five tables, and it was not possible to ensure that the residents kept six feet apart because of the configuration of the secured unit. She said she continued to encourage staff to keep the residents six feet apart. IV. Failure to screen staff properly A. Interviews CNA #5 was interviewed on 4/27/2020 at approximately 5:30 p.m. The CNA #5 said she screened herself including taking her own temperature when she arrived at work each day. The assistant business office manager was interviewed on 4/27/2020 at 5:30 p.m. The ABOM said he would screen visitors and vendors before entry to the facility. He said he took the temperature, asked the screening questions which included, signs and symptoms of COVID 19. He said he screened some staff, however, staff screened themselves for the most part when they came in to work The dietary aide (DA) was interviewed on 4/27/2020 at approximately 5:30 p.m. The DA said she screened herself when she came to work each day. The NHA, director of nursing (DON) and the infection control preventionist (ICP) 9:30 a.m. The NHA said that when staff come in groups it was difficult to have one person screen all of the staff. She said the staff then screen themselves because they were health care workers and understand temperatures and symptoms for COVID 19. She said the thermometer was audible so the temperatures could be heard. The NHA said it seemed to be safe and reasonable.

Based on observations and staff interview, the facility failed to maintain a sanitary, orderly, and comfortable environment for its residents in one of two resident shower rooms. Specifically, the facility failed to ensure shower stall tiles were repaired and properly maintained. Findings include: I. Initial observations Observations of the occupied resident living environment conducted on 6/3/19 at 8:43 a.m. revealed: The shower room on west hall had broken and missing tile. The shower stall had an area approximately seven feet long by four feet high of missing ceramic tiles. The walls had water damage and the walls were stained. There were broken and missing tiles along the base of the shower. II. Environmental tour and staff interview The environmental tour was conducted with the maintenance supervisor (MS) on 6/4/19 at 11:00 a.m. The above observations were reviewed. The MS documented the environmental concerns. The MS said the shower room was scheduled for remodel last year but there had been one person submit a bid and the remodel never happened. The MS said the missing tile and water damage could cause mold build up if not corrected. The MS said the above-mentioned damage should have been repaired and addressed in a timely manner. The nursing home administrator (NHA) was interviewed on 6/4/19 at 11:29 a.m. She was told of the observation in the west shower room and potential for mold. She said they had been trying to get contractors to place bids since last year but they had only received one, which was too high, and they never really followed up with the shower room remodel after that.

Based on observations, record review and interviews, the facility failed to ensure residents were free from physical restraints imposed for purposes of convenience and the least restrictive alternatives were used for four (#7, #39, #37, and #32) of five residents reviewed for assistive devices out of 23 sample residents. Specifically, the facility: -Failed to obtain a physician's orders [REDACTED]. -Failed to obtain consent prior to the use of a personal restraint; -Failed to re-evaluate the ongoing use of a personal restraint; and -Failed to care plan the use of a personal restraint. Findings include: I. Facility policy and procedure The Restraint and Position Change Alarm Use Policy, revised (MONTH) (YEAR), provided by the regional clinical consultant (RCC) on 6/3/19 at 3:13 p.m., included: Physical restraint - any manual method or physical or mechanical device, equipment, or material that meets all of the following criteria: -Is attached or adjacent to the resident's body, -Cannot be removed easily by the resident, and -Restricts the resident's freedom of movement or normal access to his/her body. Policy: The intent is for each resident to attain and maintain his/her highest practicable well-being in an environment that prohibits the use of physical restraints for discipline or convenience .When a physical restraint is used, the facility must use the least restrictive restraint for the least amount of time and provide ongoing re-evaluation of the need for the physical restraint. physician's orders [REDACTED]. The order should include the specific type of restraint, the condition and or medical symptom that warrants restraint use, where and how the restraint is to be applied and used, and the time and frequency the restraint should be used. The physician's orders [REDACTED]. Informed consent: The resident and/or resident representative must sign the Physical Restraint Informed Consent prior to restraint use. Care plan: The resident and/or resident representatives are involved in the development of the person-centered care plan and restraint use is reviewed at the time of the initial interdisciplinary resident care review (or when the restraint is initiated), quarterly and when a change is instituted. The use of the restraint must be based upon the resident's condition and medical symptoms must be treated. The care plan must include:the specific type of restraint, the length of time the restraint is anticipated to be used to treat the medical symptoms, identification of who may apply and release the restraint, where and how the restraint is to be applied and used, time and frequency the restraint should be released, type of specific direct monitoring and supervision provided during the use of the restraint, measures to reduce the risk of negative outcomes related to restraint use including but not limited to skin breakdown, loss of mobility or range of motion, loss of dignity, confusion, fear, agitation, anxiety, or irritation in response to restraint use. Re-evaluation: The need for the restraint is assessed quarterly and as indicated. Documentation in clinical notes may include, but not limited to; type of restraint, date and time of use, reason for use, resident tolerance, and the effectiveness of the restraint in treating the medical symptoms. II. Resident #37 A. Resident status Resident #37, age 83, was admitted on [DATE] and re-admitted on [DATE]. According to the (MONTH) 2019 computerized physician orders [REDACTED]. The resident resided on the secure unit. The 4/30/19 minimum data set (MDS) assessment revealed the resident had severe cognitive impairment with a brief interview for mental status (BIMS) score of three out of 15. He did not exhibit any behaviors. He required supervision to extensive assistance of one staff member with bed mobility, transfers, locomotion on and off the unit, dressing, toilet use, and personal hygiene. He did not walk during the seven-day look back. The MDS did not identify the use a restraint or a personal alarm. B. Record review According to the CPO, a bed alarm on while in bed, and to check every shift was ordered 2/17/19. The resident did not have an order for [REDACTED].>The care plan, initiated 4/30/19, identified Resident #37 was at high risk for falls. Interventions included a bed and chair alarm initiated on 4/30/19. The certified nurse aide (CNA) kardex included a bed and chair alarm and to sit resident at the table with support in front of him so he cannot fall forward under his safety needs. The Physical Restraint Informed Consent form was signed by the director of nursing (DON) and dated 5/30/19. The form identified the type of restraining device as bed and chair alarm. According to the form, the family member gave verbal consent on 5/29/19 for a physical restraint. The facility failed to obtain a signed consent before using the chair alarm, a physician's orders [REDACTED]. to reduce the risk of negative outcomes related to restraint use including but not limited to skin breakdown, loss of mobility or range of motion, loss of dignity, confusion, fear, agitation, anxiety, or irritation in response to restraint use. C. Observations The resident was observed on 5/29/19 at 8:41 a.m. in the activity area of the secure unit in front of the television. He had a chair alarm clipped to the back of his shirt and hooked on the back of his wheelchair. At 9:25 a.m. he stood up causing the alarm to alert. Activities aide (AA) #2 assisted him to sit back down. He stood up again at 10:24 a.m. and CNA #11 sat him back down at the table and offered him fluids. He was not allowed to stand and was not asked what he wanted or needed. The unit had five staff (CNA #1, CNA #2, CNA #7, CNA #11, and AA #2) at that time. The resident was observed on 6/3/19 at 9:30 a.m. at the activity table on the secure unit. He was sitting in his chair and tried to stand. When the chair alarm alerted, CNA #1 sat him back down, without asking him what he wanted or needed. The resident was observed on 6/4/19 at 12:04 p.m. at the table in the secured unit. He was sitting in a regular chair pushed up to the table with the chair alarm attached to the back of his shirt and hooked to the back of the chair he was sitting in. There were three staff (CNA #1, CNA #11, and CNA #7) assisting the residents for the lunchtime meal. III. Resident #39 A. Resident status Resident #39, age 86, was admitted on [DATE] and readmitted on [DATE]. According to the (MONTH) 2019 CPO, [DIAGNOSES REDACTED]. The resident resided on the secure unit. The 4/30/19 MDS assessment revealed the resident had severe cognitive impairment with a BIMS score of zero out of 15. He had mood symptoms and wandering. He needed extensive assistance by two people with bed mobility, transfers, locomotion on and off the unit, dressing, toilet use, and personal hygiene. The MDS did not identify the use a restraint or a personal alarm. B. Record review According to the CPO, the resident did not have a physician's orders [REDACTED]. The care plan, initiated 2/11/19 and revised on 5/19/19, identified the resident was at high risk for falls related to confusion. Interventions included a clip alarm when in his wheelchair initiated on 9/29/19. The CNA kardex included a chair alarm dated 9/29/18. The Physical Restraint Informed Consent form was signed by the DON and dated 5/28/19. The form identified the type of restraining device as a chair alarm. According to the form, the family member gave verbal consent on 5/29/19 for a physical restraint alarm. The facility failed to obtain a signed consent before using the chair alarm, a physician's orders [REDACTED]. to reduce the risk of negative outcomes related to restraint use including but not limited to skin breakdown, loss of mobility or range of motion, loss of dignity, confusion, fear, agitation, anxiety, or irritation in response to restraint use. C. Observations The resident was observed in the activity area of the secured unit on 5/29/19 at 10:37 a.m. He had a chair alarm hooked to the back of his wheelchair and clipped to the back of his shirt. The unit had five staff (CNA #1, CNA #2, CNA #7, CNA #11, and AA #2) at that time. The resident was observed on 6/3/19 at 9:30 a.m. He had a chair alarm clipped to the back of his shirt and hooked on the back of his wheelchair. In the immediate vicinity was AA #2 and CNA #1. The resident was observed on 6/4/19 at 12:04 p.m. at the table in the secured unit. He was in his wheelchair pushed up to the table, eating his lunch with prompting from the staff (CNA #1, CNA #11, and CNA #7) sitting at the table with all the residents during the lunch meal. IV. Resident #7 A. Resident status Resident #7, age 92, was admitted on [DATE]. According to the (MONTH) 2019 CPO, [DIAGNOSES REDACTED]. The resident resided on the secure unit. The 2/26/19 MDS assessment revealed the resident had severe cognitive impairment with a BIMS score of zero out of 15. He was positive for mood and behavior symptoms. He required extensive assistance of two people with bed mobility, transfers, dressing, toilet use, and personal hygiene. The MDS did not identify the use a restraint or a personal alarm. B. Record review According to the CPO, a bed alarm on while in bed, and to check every shift was ordered 4/9/19. The resident did not have an order for [REDACTED].>The care plan initiated on 3/11/19 identified the resident was a high fall risk due to daily confusion. Interventions included a chair alarm (3/11/19). The certified nurse aide (CNA) kardex included a chair alarm. The Physical Restraint Informed Consent form was signed by the director of nursing (DON) and dated 5/21/19. The form identified the type of restraining device as bed and chair alarm. According to the form, the family member gave verbal consent on 5/21/19 for a physical restraint alarm. The facility failed to obtain a signed consent before using the chair alarm, a physician's orders [REDACTED]. to reduce the risk of negative outcomes related to restraint use including but not limited to skin breakdown, loss of mobility or range of motion, loss of dignity, confusion, fear, agitation, anxiety, or irritation in response to restraint use. C. Observations The resident was observed in the activity area of the secured unit on 5/29/19 at 10:37 a.m. He had a chair alarm hooked to the back of his wheelchair and clipped to the back of his shirt. He was sitting at the table in the secured unit dining area with five staff in the immediate area The unit had five staff (CNA #1, CNA #2, CNA #7, CNA #11, and AA #2) at that time. The resident was observed on 6/3/19 at 9:30 a.m. in the secure unit at the dining area/activity area table. He had a chair alarm clipped to the back of his shirt and hooked on the back of his wheelchair. In the immediate area was AA #2 and CNA #1. The resident was observed on 6/4/19 at 12:04 p.m. at the table in the secured unit. He was in his wheelchair pushed up to the table, eating his lunch with prompting from the staff (CNA #1, CNA #11, and CNA #7) sitting at the table with all the residents during the lunch meal. V. Interviews CNA #1 was interviewed on 5/30/19 at 10:45 a.m. She said the chair alarms let the staff know when a resident was trying to stand up. She said if a resident was trying to stand up or move out of their wheelchair the aides would reposition them and help the residents back to the wheelchair. She said the alarm lets the CNAs know if someone is moving around when the aides are not in the area. She said the alarms were a big help when the aides were in a room or another area of the secured unit. She was interviewed a second time on 6/3/19 at 9:37 a.m. She said Resident #37 often would try to stand up with staff nearby. She said the alarm would remind staff to sit him back down so he won't fall. She said Resident #39 would lean over in his chair and had in the past fallen over out of the wheelchair. She said Resident #7 had the chair alarm because he could fall out of his chair. CNA #2 was interviewed on 5/30/19 at 10:53 a.m. She said the chair alarms alerted the CNAs to respond to a resident when they were trying to stand or fall over in their wheelchairs. She said when she responded to an alarm she would sit the resident back down in the wheelchair to prevent the resident from falling and getting hurt. Licensed practical nurse (LPN) #1 was interviewed on 6/3/19 at 9:53 a.m. She said the chair alarms were ordered by the physician after a fall. When she searched the CPO, she could not locate an order. She said on the secure unit there were only three residents who used chair alarms: Residents #7, #39, and #37. She said a signed consent was not needed, just a notification to the family of the alarm placement. The DON was interviewed on 6/4/19 at 10:20 a.m. She said the alarms helped staff know when a resident was trying to get out of their wheelchair. She said the alarms were put in place after a resident fell . She said the facility had reduced the number of chair alarms from 27 to six. She said Resident #37 was so fast that he had fallen from standing when a staff member was sitting next to him. She said if staff did not sit him down he would take off and walk briskly down the hall and possibly fall. She said the alarms were necessary to notify staff when a resident was leaning over too far in their chair which could lead to a fall. She said even with the increased ratio of staff to residents on the secure unit, the chair alarms let staff know when a potential fall could be happening. She said it was a nursing judgement to initiate the chair alarm. She said she did not have interdisciplinary team (IDT) notes discussing the use of alarms. VI. Facility follow-up The restraint evaluations for residents #7, #39, and #37 were requested on 6/3/19 at 2:30 p.m. The RCC said the residents did not have a restraint evaluation. The facility provided the following additional information on 6/5/19: -A spreadsheet of Resident #37's falls to include interventions after each fall. According to the form provided, the chair alarm was initiated on 10/12/18 at 8:45 a.m. The resident had six additional falls after the chair alarm was started. The facility provided a restraint (initial evaluation) form identifying the resident received an order from the physician for the chair alarm on 4/16/18. The form had the signature of the DON, but did not include a date it was signed. -A spreadsheet with dates for Resident #39. The sheet did not identify what the dates represented. The sheet did not include falls, but did identify the clip alarm was initiated on 9/29/18. The facility provided a restraint (initial evaluation) form identifying the resident received an order from the physician for the chair alarm on 9/29/18. The form had the signature of the DON, but did not include a date it was signed. -A spreadsheet with dates for Resident #7. The sheet did not identify what the dates represented. The sheet did not include falls, but did identify the clip alarm was initiated on 4/7/18. The facility provided a restraint (initial evaluation) form identifying the resident received an order from the physician for the chair alarm on 4/7/18. The form had the signature of the DON, but did not include a date it was signed. -A letter dated 5/28/19 from a local county adult protective services case manager identifying herself as the newly appointed guardian of Resident #32. The facility provided a restraint (initial evaluation) form identifying the resident received an order from the physician for the chair alarm on 1/18/19. The form had the signature of the DON, but did not include a date it was signed. The performance improvement plan (PIP) provided on 6/5/19 identified the date (MONTH) 2019, and identification of bed alarms, chair alarms, tab alarms etc. The PIP documented residents with active alarms needed to be reviewed for: -current consents -physician order -care plan updates -kardex updates -initial assessment -quarterly assessments -IDT to meet monthly -staff education and policy -family education -family notification -IDT ro review fall risk assessments for each resident -IDT to review fall interventions -IDT care plan reviews for fall interventions -pharmacy and MD to review medications -attempt to removal The PIP did not document a completion date. The PIP was assigned to the DON. VII. Resident #32 A. Resident Status Resident #32, age 72, was admitted on [DATE]. According to the (MONTH) 2019 CPO, [DIAGNOSES REDACTED]. The 4/19/19 MDS assessment revealed the resident had severe cognitive impairment with a BIMS score of six out of 15. No mood or behavior symptoms were noted. She required extensive two-person assistance for bed mobility, transfers, grooming and toilet use. The MDS documented no bed or chair alarms. B. Observations The resident was observed spending most of her time sitting in her wheelchair with a clip-on chair alarm. She did not sit in the chair in an unsafe manner, she did not attempt to stand up or move while sitting. The resident did not display unsafe behaviors during the following observations. On 5/29/19 at 11:46 p.m., the resident was sitting in her wheelchair with the alarm attached to the back of her blouse and chair. She was in the dining room in front of the fireplace. The staff development coordinator (SDC) was in the dining room. On 5/30/19 8:38 a.m., the resident was in her wheelchair in her room. The chair alarm was clipped to the back of her blouse. -At 11:35 a.m., the resident was taken into the hallway next to the DON's office. She was facing toward the dining room with her hands on her lap. She was not attempting to stand up. The alarm was attached to the back of her shirt. A CNA assisted her to her dining table. On 6/3/19 at 8:03 a.m., the resident was in her wheelchair in the dining room for breakfast. The chair alarm was clipped to the back of her shirt. A CNA assisted her with her drinks. The resident was not moving independently. She did not attempt to move or stand up from the wheelchair, bed during the above observations. The resident remained sitting in her wheelchair. C. Record review The care plan, initiated 2/14/19 and revised 4/19/19, identified the resident was at risk for falls due to gait/balance problems, poor communication/comprehension, and psychoactive drug use. Interventions included anticipate and meet the resident's needs. Assist with activities of daily living (ADLs) as needed (PRN). Bed and chair alarms, bed against wall, bed in low position and call light within reach. Remind resident and reinforce safety awareness. Educate/remind resident to request assistance prior to ambulation and have appropriate footwear. Staff to ensure resident was wearing proper footwear such as non-skid socks. The care plan did not include directives to staff when to check the alarm, when to release the alarm or when to complete assessments. The resident's initial evaluation, undated, documented she had a physical restraint due to aggressive behaviors, forgets ambulation device i.e. walker, cane, and attempts transfers and climbs out of bed . does not use call light when she attempts to transfer self. The DON documented the resident's guardian consented to the chair restraint verbally by phone on an undocumented date. The CPO revealed the resident's physician ordered a bed and chair alarm every shift for recurrent falls, on 6/3/19. A local county guardian communication letter, dated 5/28/19 at 11:13 a.m., documented, I am the new guardian of (Resident #32). I took over case as previous guardian moved out of state. I am trying to get everything caught up and in order. The 5/30/19 physical restraint informed consent documented the type of restraining device was a chair alarm for dementia, [MEDICAL CONDITION], muscle weakness, [MEDICAL CONDITION] disorder, and [MEDICAL CONDITION] with severe psychotic features. The guardian gave verbal consent for use of the physical restraint on 5/30/19. The CPO included bed and chair alarm every shift for recurrent falls, start date 6/3/19. There was no evidence of any attempts to use less restrictive alternative measures. D. Staff interviews CNA #9 was interviewed on 6/3/19 at 11:31 p.m. She said the alarms were used to ensure the residents were safe from falling. She said the alarm sounded when the residents moved, tried to stand up or roll out of bed. She said the clip detached from the back of the resident's blouse when a resident stood up and the alarm sounded. She said the alarm alerted staff when they were not in the area and staff would get to the resident as quickly as possible to try to have resident sit down in her wheelchair. CNA #3 was interviewed at 4:08 p.m. on (what date?)She said the DON determined when a resident needed an alarm. She said the CNAs told the charge nurse if they noticed a resident was confused or disoriented and attempting to stand up or transfer without help or if the resident had risks for falling. She said she thought the charge nurse documented in a progress note and reported the information to the DON. She said, When the alarm goes off we run to make sure she sits down right away. CNA #5 was interviewed on 6/4/19 at 8:09 a.m. She said she did not know how often the residents were assessed to ensure the alarms were needed. She said the alarms were used to let staff know when the resident was standing up so we could sit her in her wheelchair and not allow a resident to stand up. LPN #3 was interviewed on 6/3/19 at 11:04 a.m. She said the chair alarms and bed alarms were used to alert staff if a resident was trying to get out of bed or wheelchair. She said the alarm sounded when the residents stretched or reached too far. The LPN #3 said the alarms were placed after a resident had a fall or when the staff noticed the residents were trying to get out of bed or reaching for something. She said the alarms were used to prevent a resident from falling and notifying the staff when a resident was not in the bed or standing up. She said the staff attended to the resident when the alarm sounded and it was a prevention for the resident not to fall.

Based on observations, record review and interview, the facility failed to ensure that the resident environment remained as free of accident hazards as possible for two of 26 rooms with improperly used medical equipment. Specifically, the facility failed to ensure: -Medical equipment (oxygen concentrators) were plugged into a wall outlet instead of a non-medical grade power strip that came with the device; -Extension cords were not utilized to take the place of adequate wiring in the facility; and -The kitchen oven was working properly. Findings include: I. Oxygen concentrators plugged into power strips A. Initial observations Observations of the resident living environment conducted on 5/15/19 at 3:57 p.m. revealed: -In room [ROOM NUMBER], the oxygen concentrator was plugged into a power strip. -In room [ROOM NUMBER], the oxygen concentrator was plugged into a power strip. B. Environmental tour and staff interview The environmental tour was conducted with the maintenance supervisor (MS) on 6/4/19 at 11:00 a.m. The above observations were reviewed. The MS documented the concerns and said no medical equipment should be plugged into a power strip. The MS said that if the power strip was kicked off, the oxygen concentrator would not turn back on, leaving the resident with no oxygen. II. Extension cords used in outside patio area A. Initial observations On 6/3/19 at approximately 1:23 p.m., four residents and a family member were observed on the patio visiting. The patio had two large drains with two large sump pumps partially sitting in the drains. Each pump had an extension cord plugged into the end of the sump pump. The sump pump on the north end of the patio had a blue extension cord connected to the end of the pump. The extension cord was hanging off the end of the rain gutter with the end close to the outside outlet. The pump and cord were in the middle of the patio, and both were potential tripping hazards. The second pump was located on the north end of the patio. The pump was located underneath the gazebo, which too was a tripping hazard for the residents who were utilizing the patio. The orange extension cord was rolled up and hanging on the side of the wall. B. Staff interview The MS was interviewed on 6/4/19 at 11:24 a.m. The MS said he had placed the two sumps in the patio area, as it would flood during daily rainstorms. He said the pumps should be removed from the drain holes and the metal grates should be covering the drain holes when the weather was clear. He said the extension cords should not be used in the facility and the pumps should have been plugged into a wall outlet. He said the extensions could also be a tripping hazard for residents utilizing the patio area. He said he would remove them immediately. III. Kitchen oven not working properly A. Observation The kitchen tour conducted on 5/30/19 at 10:50 a.m. revealed the gas burners on the oven were not working correctly. Cook #1 was observed blowing on the pilot light trying to light the gas burner. Cook #1 attempted to light the front burner. A strong odor of gas was observed as cook #1 tried to light the gas burner. Cook #1 could not get the burner lit and proceeded to light the burner manually with a large green lighter. The burner lit with a large blast of flame from the excess gas. Cook #1 repeated the same process two times with the strong odor of gas present prior to manually lighting the gas burner. B. Staff interviews The dietary manager (DM) was interviewed on 5/30/19 at 1:20 p.m. She was told of the observation of cook #1 trying to light the gas burners. She said that sometimes the pilot light would light the burners but other times, No. She said the oven was the same way and they had to manually light the pilot light. She said they had been having this issue for approximately two to three weeks. She said she would contact maintenance immediately. The nursing home administration and regional clinical consultant (RCC) #2 were interviewed on 5/30/19 at 1:25 p.m. The NHA was told of the observation of the problem with the gas stove. The RCC #2 said he was immediately taking the oven out of service. He stood up and exited the NHA office. The NHA said a negative outcome of the gas burners not lighting could be disastrous, as staff could get burned or the facility could have an explosion. At 1:45 p.m., RCC #2 said all kitchen staff had been provided an in-service of what to do in case the burner went out. He said if the staff smelled gas to turn off burners and alert the DM and maintenance immediately. He said they were currently contacting a vendor to come in and check the stove. He said they had also contacted the maintenance supervisor who was off today, and he said he thought he knew what was going on with the burners. The MS was interviewed on 6/4/19 at 11:24 a.m. He said he had cleaned the burners a while back. He said, I have not been doing it on a regular basis. He said they would be placing the cleaning schedule into the facility computer system to remind them to clean it on a regular basis. He said he did not know if a repair vendor had been in the facility to fix the problem. He said a negative outcome could be a staff member could be burned or there could be a gas explosion. No repair invoice or work order was provided at the time of exit.

Based on record review and interview, the facility failed to conduct and document a facility-wide assessment to determine what resources were necessary to care for its residents competently during both day-to-day operations and emergencies. Specifically, the facility failed to have a comprehensive facility assessment. Findings include: I. Facility assessment review The facility assessment (FA) was reviewed and revealed it was not a comprehensive assessment of the facility's resources necessary to provide daily care to the resident population. The FA was reviewed by the quality assurance (QAA) committee on 5/14/19 and updated 5/15/19. The FA failed to identify the facility had a secured unit and the use of chair alarms. II. Interview The nursing home administrator (NHA) was interviewed on 6/4/19 at 12:45 p.m. She said she did not think the secured unit needed to be identified. She said the facility had overlooked the chair alarms. She said she understood why the secure unit and chair alarms should have been identified in the FA.

Based on observations, record review and interviews, the facility failed to meet professional standards of quality for two (#30 and #11) of four residents reviewed of 23 sample residents. Specifically, the facility failed to ensure physician oxygen administration orders were followed for Residents #30 and #11. Findings include: I. Professional reference According to Lippincott,[NAME] & Wilkins (2014) Lippincott Manual of Nursing Practice, p. 16, in pertinent part: The practice of professional nursing has standards of practice setting minimum levels of acceptable performance for which its practitioners are accountable . Common departures from the standards of nursing care (include) failure to assess the patient properly or in a timely fashion, follow physician orders. II. Resident #30 Resident #30, age 88, was admitted on [DATE]. According to the (MONTH) 2019 computerized physician orders [REDACTED]. The 4/17/19 minimum data set (MDS) assessment revealed the resident was not administered the brief interview for mental status (BIMS). The resident's cognitive skills for daily decision-making were severely impaired. The resident received oxygen therapy. Observations On 5/29/19 at 1:50 p.m., the resident was lying in bed sleeping. Her oxygen concentrator was set at two liters per minute (2 LPM). On 6/3/19 at 9:12 a.m., the resident was lying in bed. Her oxygen concentrator was set at 2 LPM. Record Review The care plan, initiated 2/27/19 and revised 5/20/19, identified the resident required oxygen therapy. Interventions included medications as ordered by physician; observe for signs and symptoms of respiratory distress and report to medical doctor (MD) as needed (PRN); oxygen (O2) setting: O2 1 LPM via nasal cannula. The (MONTH) 2019 CPO included oxygen at 1 LPM via nasal cannula, start date 2/19/19. III. Resident #11 Resident #11, age 89, was admitted on [DATE]. According to the (MONTH) 2019 CPO, [DIAGNOSES REDACTED]. The 3/4/19 MDS assessment revealed the resident had severe cognitive impairment with a BIMS score of zero out of 15. She required extensive assistance for most activities of daily living. She received oxygen therapy. Observation On 5/29/19 at 1:50 p.m., the resident was sitting in her wheelchair in her room. Her oxygen concentrator was set at 2 LPM. On 6/3/19 at 9:12 a.m., the resident was sitting in a wheelchair in her room. Her oxygen concentrator was set at 2 LPM. Record review The care plan, initiated 3/4/19 and revised 5/28/19, identified the resident required oxygen therapy related to [DIAGNOSES REDACTED]. The (MONTH) 2019 CPO included oxygen at 1 LPM continuously via nasal cannula, start date 4/8/19. IV. Staff interview The director of nursing (DON) was interviewed on 6/3/19 at 9:24 a.m. The DON observed both of the residents' concentrators and said, Oh, they are both on 2 LPM. The DON then reduced both concentrators to 1 LPM. She said it would be her expectation the residents' oxygen concentrators would be at 1 LPM per physician's orders [REDACTED].

Based on observations, record review and interviews, the facility failed to provide person-centered dementia care services to three (#7, #4, #34) of four residents reviewed of 23 sample residents. Specifically, the facility failed to develop and implement person-centered interventions so Residents #7, #4, and #34 could reach their highest practicable quality of life. Findings include: I. Facility policy and procedure The Behavioral Health Management policy, dated 5/16/19, provided by the regional clinical consultant (RCC) on 6/3/19 at 3:13 p.m., included: Procedure: Complete the nursing assessment and social services assessment upon admission/readmission, quarterly, and as needed with change in condition. The facility must monitor the resident closely for expressions or indications of distress, assess and plan for concerns identified in the resident assessment, accurately document the changes, including the frequency of occurrence and potential triggers in the resident's record, share concerns with the interdisciplinary team (IDT) to determine underlying causes, including differential diagnoses, ensure appropriate follow-up assessment, if needed, and discuss potential modifications to the care plan. II. Resident #7 A. Resident status Resident #7, age 92, was admitted on [DATE]. According to the (MONTH) 2019 CPO, [DIAGNOSES REDACTED]. The 2/26/19 minimum data set (MDS) assessment revealed the resident had severe cognitive impairment with a brief interview for mental status (BIMS) score of zero out of 15. He had trouble concentrating and moving or speaking slowly. B. Record review The care plan, initiated 2/13/19, identified the resident had the potential to be verbally aggressive related to dementia. Interventions included: -Analyze key times, places, circumstances, triggers, and what de-escalates behavior and document. -Provide positive feedback for good behavior. Emphasize the positive aspects of compliance. The behavior monitoring form (BMF) did not identify any resident specific behaviors to monitor. During (MONTH) 2019, the resident had 33 documented episodes of verbal aggression. He had 35 documented episodes of disruptive behavior. He had 18 documented episodes of physical aggression. He had 21 documented episodes of restlessness. Interventions of active listening, snack or drink, positive distraction, reassure of safety, address comfort, assess physical needs, validation, assist with a task, and assist to a quiet area were documented 36 times. The resident had no change in behavior after interventions, documented 41 times. The care plan did not identify resident specific behaviors or interventions specific to the resident to utilize when the resident was displaying a behavior. C. Observation The resident was in the dining/activity room in the secure unit on 5/30/19 at 8:15 a.m. He was verbally aggressive and disruptive for about 10 minutes. Certified nurse aide (CNA) #1 offered him a snack and he refused. When she walked away, he slowly calmed down. CNA #1 said that walking away did not work every time. D. Interviews CNAs #1 and #11 were interviewed on 6/4/19 at 9:29 a.m. They said the resident could become very mean and would say mean things to the staff. They said successful interventions were to distract him with other activities to do. They said there wasn't just one thing that would work with him; different days would require different approaches. They said they would sometimes write in the behavior book if his behavior was bad that day, but that his outbursts were normal for him. Licensed practical nurse (LPN) #1 was interviewed on 6/4/19 at 9:45 a.m. She said the resident would become fixed on his wife and his car keys. She said she would reassure him and remind him that his wife had passed. The social services director (SSD) was interviewed on 6/4/19 at 9:52. She said the resident's behavior was verbal aggression. She said when he displayed a behavior, she wanted the staff to talk to him in a low tone, sit and talk slowly to him and offer him reassurance. She said she did not know why his specific behaviors or the interventions were not care planned. She said the behaviors and interventions needed to be in the care plan. The director of nursing (DON) was interviewed on 6/4/19 at 10:11 a.m. She said when the resident decides he wanted to go home, he would become aggressive and combative with staff and would curse at the staff. She said the staff should back off and let him calm down. She said the resident specific behaviors should be in the care plan along with individualized interventions. She said all displayed behaviors should be documented. III. Resident #4 A. Resident status Resident #4, age 69, was admitted on [DATE]. According to the (MONTH) 2019 CPO, [DIAGNOSES REDACTED]. The 2/19/19 MDS assessment revealed the resident had severe cognitive impairment with no BIMS conducted. He had trouble concentrating, fidgeting, being short tempered, annoyed, and physical and verbal behaviors. B. Record review The care plan, initiated 2/12/19, identified behaviors of rummaging in other residents' areas and exit seeking/wandering. Interventions included: -Address wandering behavior by walking with the resident, redirect from inappropriate areas, engage in activities. -Anticipate care needs and provide them before the resident becomes overly stressed. -Encourage the resident to a quiet area with one on one attention when he was showing signs of aggressive behavior. The behavior monitoring form (BMF) did not identify any resident specific behaviors to monitor. In (MONTH) 2019, the resident had 13 documented episodes of verbal aggression. He had 18 documented episodes of disruptive behavior. He had 10 documented episodes of physical aggression. Interventions of active listening, snack or drink, positive distraction, reassure of safety, address comfort, assess physical needs, validation, assist with a task, and assist to a quiet area were documented 16 times. The resident had no change in behavior after interventions 12 times. The interventions were not individualized or resident-centered, and were the same interventions as for Resident #7 (above). C. Observations The resident was observed on 5/29/19 at 8:41 a.m. pacing in the hall. At 9:23 a.m. he pushed on the door leading to the outdoor patio and set off the door alarm. Staff responded and the resident walked away down the hall. The resident was observed on 5/30/19 at 9:36 a.m. He set off the door alarm on the door leading to the outdoor patio. He said he was trying to leave. Staff redirected him to activities, and did not let him go outside. D. Interviews CNAs #1 and #11 were interviewed on 6/4/19 at 9:29 a.m. They said the resident would get really mad and want to go home. They said putting him in his room with his TV on worked most of the time. They said when he became violent they had to leave him alone and try to keep him away from the other residents. They said they would sometimes write in the behavior book if his behavior was bad that day, but that his exit seeking and becoming angry was normal for him. LPN #1 was interviewed on 6/4/19 at 9:45 a.m. She said the resident would become angry and target other residents, accusing them of stealing his belongings. She said the look on his face would alert her to a bad mood/behavior. She said when he became accusatory, the staff would reassure him that his belongings were safe and in his room. The SSD was interviewed on 6/4/19 at 9:52 a.m. She said the resident would become violent and the police had to be called on a few occasions. She said he had hit other people before. She said to calm him down staff would ask him to go to his room to calm down or if he became violent staff would provide a one on one intervention. She said she did not know why his violent behaviors were not care planned or the interventions. She said the behaviors and interventions needed to be in the care plan. The DON was interviewed on 6/4/19 at 10:11 a.m. She said the resident could get aggressive, confrontational, could become loud, and had torn signs off doors. She said when he displayed those behaviors, staff needed to talk calmly and quietly. She said different staff had different approaches. She said the resident specific behaviors should be in the care plan along with individualized interventions. She said all displayed behaviors should be documented. IV. Resident #34 A. Resident status Resident #34, age 77, was admitted on [DATE]. According to the (MONTH) 2019 CPO, [DIAGNOSES REDACTED]. The 2/19/19 MDS assessment revealed the resident had severe cognitive impairment with no BIMS conducted. He did not have mood or behavioral problems identified. B. Record review The care plan, dated 5/19/19, identified a dementia [DIAGNOSES REDACTED]. -Explain all procedures to the resident before starting and allow the resident time to adjust to the changes. -Praise any indication of the resident's progress/improvement in behavior. The BMF did not identify any resident specific behaviors to monitor. In (MONTH) 2019, the resident had 20 documented episodes of verbal aggression. He had 33 documented episodes of wandering. He had 34 documented episodes of disruptive behavior. Interventions of active listening, snack or drink, positive distraction, reassure of safety, address comfort, assess physical needs, validation, assist with a task, and assist to a quiet area were documented 30 times. The resident had no change in behavior after interventions documented 26 times. The listed interventions were not person-centered or specific to Resident #34. C. Observations The resident was observed on 5/30/19 at 9:30 a.m. He was at the nurses' station asking where he was and why he was there. Staff told him he was at the facility for his safety. Staff redirected him to activities. The resident was observed on 6/3/18 at 10:45 a.m. at the nurses' station with a clipboard. He brought the clipboard to LPN #1 and asked her what the clipboard was for. LPN #1 said the papers had math problems on them and asked him if he could complete them. He sat down on a chair in the hallway across from the nurses' station, completed one problem and came back to the nurses' station. He asked again what the clipboard was for. Again LPN #1 explained the paper had math problems on it, and asked him if he could do the problems. This went on for the next half an hour. At 12:45 p.m. he asked LPN #1 if he could go out the doors where the lunch trays had exited just moments earlier. She redirected him to the activity area. D. Interviews CNAs #1 and #11 were interviewed on 6/4/19 at 9:29 a.m. They said the resident would get really upset at night, and want to go home. They said Mountain Dew (soda) worked really well with him. They said they would sometimes write in the behavior book if his behavior was bad that day, but that his exit seeking was normal for him. LPN #1 was interviewed on 6/4/19 at 9:45 a.m. She said the resident wanted to go home constantly and asked why he was there. She said she would remind him he was there by doctor's orders and provide a lot of reassurance. The SSD was interviewed on 6/4/19 at 9:52. She said the resident could get confused, and become angry and aggressive. She said he had really bad sundowner's. She said she wanted staff to calm him down and keep him safe. She said her and the activities director had developed an individualized schedule. She said the behaviors and interventions needed to be in the care plan. The DON was interviewed on 6/4/19 at 10:11 a.m. She said the resident could get aggressive and yell. She said when he displayed those behaviors, staff needed to do one-on-one intervention, get him to an activity, and answer his questions. She said different staff had different approaches. She said the resident specific behaviors should be in the care plan along with individualized interventions. She said all displayed behaviors should be documented.