Every finding on record at Forest Ridge Health and Rehab LLC

Based on observations, record review and interviews, the facility failed to ensure residents consistently received food prepared by methods that conserved nutritive value and was palatable in taste, texture and temperature.Specifically, the facility failed to ensure the residents' food was palatable in taste, texture and temperature.Findings include:I. Facility policy and procedureThe Standardized Menus policy, dated 10/1/25, was provided by the nursing home administrator (NHA) on 2/25/26 at 1:17 p.m. It revealed in pertinent part, It is the policy of this facility to provide nourishing, palatable meals to meet the nutritional needs of residents based on the Recommended Daily Allowances of the Food and Nutrition Board and that standardized cycle menus are planned in advance and utilized. The facility will make reasonable efforts to provide food that is appetizing and culturally appropriate for residents. Menus will be planned to meet basic nutritional needs by providing meals based on individual nutritional assessment and the individualized plan of care.-However, the policy did not include specific procedures or quality control measures to ensure food was served in an acceptable taste, texture and temperature, including prevention of overcooking, undercooking, dryness or burned food items to assess meal palatability prior to service.II. Resident representative interviewsResident #8's representative was interviewed on 2/23/26 at 11:38 a.m. The representative said food at the facility had been an ongoing issue. The representative said they discussed these concerns during resident group meetings and had tried to advocate for correction of the problem. The representative said the issue had improved recently, however the eggs continued to be served runny at times and the concerns had not been fully resolved. She said she would like the facility to fix the issues.Resident #33's representative was interviewed by phone on 2/23/26 at 3:45 p.m. The representative said the facility's food continued to be a major concern. The resident representative said the food was often cold and the ice cream was soupy. The resident representative said during the past few days, Resident #33 was not awakened for breakfast and when awakened at approximately 10:15 a.m. she was provided cereal with milk, which disrupted her normal meal pattern.Resident #33's representative was interviewed again in-person on 2/24/26 at 10:10 a.m. The representative said on several occasions, she observed potato soup that was too watery, broccoli that was mushy and a baked potato that was not cooked enough and was hard. The representative said the last time she observed these concerns was during the week of 1/17/26 at lunch. The representative said Resident #33 ate some of the baked potato but could not finish it. The representative said the french fries were cold and meats, such as beef, were tough to chew. The representative said Resident #33 preferred to eat at her daughter's home twice each week. The representative said she felt guilty for leaving Resident #33 in the facility and Resident #33 deserved to feel good about living at the facility.III. Resident group interviewA group interview was conducted on 2/24/26 at 1:00 p.m. with seven alert and oriented residents (#15, #19, #33, #46, #59, #62 and #71) who were deemed interviewable per the facility and assessment.The residents said the food was served cold. The residents said the pork was impossible to chew and other meats were tough. The residents said meal delivery took hours, even though they had reported their concerns to the leadership of the facility. IV. Additional resident interviewsResident #8 was interviewed on 2/23/26 at 11:35 a.m. Resident #8 said her eggs were served with excess moisture and were runny. She said after the transition to the new company that oversaw the facility in October 2025, she spoke with the dietary manager (DM) several times and the DM told her the food concerns would be fixed, but the concerns had not been fixed. Resident #33 was interviewed on 2/23/26 at 1:48 p.m. Resident #33 said the food did not have taste and was lukewarm. She said the meals were bland. She said she ordered a cheeseburger last week (week of 1/16/26) but received the wrong meal. She said the staff brought the correct meal approximately one hour later and she did not like it.Resident #33 said she usually woke up and ate breakfast; however, lately staff had not been waking her and they had left her breakfast in her room. She said the pork was not served in a solid piece and appeared in strings. She said the french fries were not crisp and were cold. She said she felt like the facility did not care about residents. Resident #67 was interviewed on 2/23/26 at 3:00 p.m. Resident #67 said the food did not taste good. She said she did not receive condiments with her meals and had to ask for them. She said sometimes condiments were unavailable. She said she did not receive butter with her rolls unless she asked and if it was available, staff would bring it. She said two days ago (2/21/26) she ordered a cheeseburger and did not receive onion with the burger as requested. She said the meals lacked flavor. She said she felt like the facility was not listening to her. Resident #65 was interviewed on 2/23/26 at 4:00 p.m. Resident #65 said the food was horrible and did not taste good. She said she informed the DM and the operations manager and they told her the food was as good as it was going to get. She said approximately five times per week, she obtained sliced meat and cheese from the store because she did not like the facility's food. She said the continued food concerns made her feel unheard.V. ObservationsOn 2/24/26 at 8:05 a.m. Resident #8 was observed in her room eating breakfast. She said she woke up at 4:00 a.m. on her own and staff did not have to wake her.Resident #8 was observed taking a bite of the toast on her breakfast tray. The toast was burned on both sides. She said the toast was very hard to chew. She said she was not wearing her dentures and it was hard on her gums. She said she received her dentures the previous day but it would take time to get used to them and she was not currently wearing them. Resident #8 took one bite and said she could not eat any more of the toast because it was burned and hard.Scrambled eggs were additionally observed on Resident #8's breakfast tray. The eggs had were very moist and slightly wet looking in texture. A napkin next to the eggs was observed to be very wet. Resident #8 said she used the napkin to absorb the excess moisture from the eggs because the eggs were very runny and she did not like them that way. She said she and her daughter had brought the concern regarding runny eggs to the DM several times, however the issue had not been fixed.Resident #65 was observed in her room on 2/24/26 at 8:45 a.m. eating oranges for breakfast. Resident #65 said she did not like the facility's scrambled eggs because they were fake. She said she liked to eat scrambled eggs at her daughter's house. She said she did not like the food the facility provided because it did not taste good and did not meet her expectations.VI. Test trayA test tray for a regular diet was evaluated by four surveyors immediately after the last resident was served their room tray for lunch on 2/25/26 at 12:23 p.m.The test tray consisted of shrimp [NAME] over pasta, a dinner roll and Caesar salad with two dressing packets. The following was observed:-The pasta was 106 degrees Fahrenheit (F) and tasted cool on the palate;-The pasta had a dry texture and was slightly firm; -The shrimp was 106.9 degrees F and tasted cold; and,-No butter was provided for the dinner roll.VII. Record reviewA review of the 12/17/25 resident council meeting minutes documented residents voiced concerns related to food service. The dietary section documented concerns regarding hot carts. The follow-up section documented that hot carts had been ordered but were on back order. The response section was signed and dated 12/20/25 as addressed.-During the survey, four hot carts were observed still in their delivery boxes outside the main entrance of the facility.A review of the 1/21/26 resident council grievance form documented concerns that food was cold. The staff response section documented residents were pleased with the resolution of meal carts and meal covers being ordered. The form was signed on 1/21/26 and documented an implementation date of 1/22/26.-However, hot carts were observed still in their delivery boxes outside the main entrance of the facility and had not been implemented yet (see observation above).A review of the 2/18/26 resident council grievance form documented dietary concerns related to food quality. The dietary section documented that two managers began completing test trays of food to offer feedback. The staff response section was signed and dated 2/18/26. VIII. Staff interviewsThe DM was interviewed on 2/25/26 at 1:45 p.m. The DM said the eggs should not have been runny and said she did not know why runny eggs had been served to residents.The DM said there had been complaints about overcooked food. The DM said residents complained that meats, such as turkey, were too chewy. The DM said she did not know what she could do to make the meat tender.The DM said when resident room trays were prepared, the cook checked the temperature of the food. The DM said when room trays were delivered to the floor, staff performed a final temperature check of the food. The DM said if a resident received a cold room tray, the certified nurse aide (CNA) could reheat the food or request a new plate for the resident. The DM said if a resident was not satisfied with their meal, the CNA would bring the tray back to the kitchen and the cook would prepare a fresh plate.The cook (CK) and the DM were interviewed on 2/26/26 at 10:20 a.m.The CK said her training in the facility began on 1/18/26. She said she had prior baking and restaurant experience, but had not previously cooked in a hospital or nursing home. She said the biggest challenge was meeting different dietary needs, including minced and moist and puree textures. She said breakfast was challenging because some residents could not have eggs and she had to pay close attention to that.The CK said she was shocked regarding the burned toast for Resident #8 and said she would not send burned toast because it did not taste good and was hard to chew. She said she cooked eggs thoroughly and did not know why eggs were served runny.The DM said eggs could have been runny if they were not cooked long enough and said it was important to maintain proper texture to preserve safety and taste.The director of nursing (DON) was interviewed on 2/26/26 at 11:00 a.m. The DON said staff monitored meal tickets to ensure meals served to residents were prepared to the appropriate texture and quality. She said the CK and the dietary staff were responsible for checking temperatures of the food before they left the kitchen and room trays went through multiple checks, with staff on the floor completing the final temperature check before serving the room trays to residents. She said when food was observed to be undercooked, overcooked or not palatable, staff were expected to return the food to the kitchen and obtain another plate for the residents.

Based on observations, interviews and record review, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of disease and infection. Specifically, the facility failed to:-Ensure housekeepers followed chemical dwell times and appropriately disinfected residents' rooms; and,-Ensure housekeepers performed appropriate hand hygiene when cleaning residents' rooms.Findings include:I. Professional reference According to the 730 Hydrogen peroxide (HP) Disinfectant Cleaner product specification sheet, retrieved on 3/4/26 from chromeextension://efaidnbmnnnibpcajpcglclefindmkaj/https://www.waxie.com/pdf/spec-sheets/170059-WAXIE-spec-sheet.pdf, 730 HP disinfectant cleaner is a one-step hospital-use germicidal disinfectant cleaner and deodorant designed for general cleaning, disinfecting, and controlling mold and mildew odors on hard, non-porous surfaces when used according to disinfection directions. The contact time ranges from one minute to 10 minutes, depending on the type of bacteria, virus or fungus. II. Facility policy and procedureThe Hand Hygiene policy and procedure, revised 10/1/25, was received from the clinical resource nurse on 2/25/26 at 3:21 p.m. It documented in pertinent part, All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. This applies to all staff working in all locations within the facility. Staff will perform hand hygiene when indicated, using proper technique consistent with accepted standards of practice. The use of gloves does not replace hand hygiene. If your task requires gloves, perform hand hygiene prior to donning gloves and immediately after removing gloves.The Routine Cleaning and Disinfection policy and procedure, revised 10/1/25, was received from the clinical resource nurse on 2/25/26 at 3:21 p.m. It documented in pertinent part, It is the policy of this facility to ensure the provision of routine cleaning and disinfection in order to provide a safe, sanitary environment and to prevent the development and transmission of infections to the extent possible. Routine surface cleaning and disinfection will be conducted with a detailed focus on visibly soiled surfaces and high touch areas to include, but not limited to: toilet flush handles, bed rails, tray tables, call buttons, TV (television) remotes, telephones, toilet seats, monitor control panels, touch screens and cables, resident chairs, IV (intravenous) poles, sinks and faucets, light switches and door knobs and levers. Follow manufacturer recommendations regarding appropriate contact time to ensure adequate disinfection.III. ObservationsDuring a continuous observation on 2/24/26, beginning at 12:00 p.m. and ending at 12:30 p.m., the following was observed:Housekeeper (HK) #2 was observed cleaning resident room [ROOM NUMBER]. -HK #2 donned (put on) clean gloves without performing hand hygiene. HK #2 rinsed the shower. HK #2 changed her gloves and donned a new pair of clean gloves.-HK #2 failed to perform hand hygiene after removing her gloves and putting on a new pair of gloves. HK #2 wiped the shower with a rag soaked in Waxie 730 HP disinfectant chemical. HK #2 immediately rinsed the shower with the shower head. HK #2 changed her gloves and donned a new pair of clean gloves.-HK #2 failed to allow the disinfectant to remain on the shower surface for the appropriate dwell time before rinsing the shower.-HK #2 failed to perform hand hygiene after removing her gloves and putting on a new pair of gloves. HK #2 mopped the bedroom. HK #2 changed her gloves and donned a new pair of clean gloves.-HK #2 failed to perform hand hygiene after removing her gloves and putting on a new pair of gloves. HK #2 mopped the bathroom and removed her gloves prior to exiting room [ROOM NUMBER].-HK #2 failed to perform hand hygiene after removing her gloves and exiting room [ROOM NUMBER]. HK #2 moved the cleaning cart to resident room [ROOM NUMBER]. -HK #2 donned clean gloves without performing hand hygiene. HK #2 dusted the bedroom furniture. HK #2 changed her gloves and donned a new pair of clean gloves.-HK #2 failed to perform hand hygiene after removing her gloves and putting on a new pair of gloves. HK #2 swept the bedroom floor. HK #2 changed her gloves and donned a new pair of clean gloves.-HK #2 failed to perform hand hygiene after removing her gloves and putting on a new pair of gloves. HK #2 sprayed Waxie 730 HP disinfectant chemical into the sink, around the toilet and the grab bar in the bathroom and immediately wiped it down. HK #2 changed her gloves and donned a new pair of clean gloves.-HK #2 failed to allow the disinfectant to remain on the sink, toilet and grab bar for the appropriate dwell time before rinsing the shower.-HK #2 failed to perform hand hygiene after removing her gloves and putting on a new pair of gloves. HK #2 cleaned the bathroom mirror. HK #2 changed her gloves and donned a new pair of clean gloves.-HK #2 failed to perform hand hygiene after removing her gloves and putting on a new pair of gloves. HK #2 wiped down the sink and counter with a rag soaked in Waxie 730 HP disinfectant chemical. HK #2 immediately dried the sink with paper towels.-HK #2 failed to allow the disinfectant cleaner to remain on the sink and counter for the appropriate dwell time before rinsing the shower. -HK #2 changed her gloves and failed to perform hand hygiene prior to donning clean gloves. HK #2 wiped down the wall next to the toilet with a rag soaked in Waxie 730 HP disinfectant chemical. HK #2 changed her gloves and donned a new pair of clean gloves.-HK #2 failed to perform hand hygiene after removing her gloves and putting on a new pair of gloves. HK #2 wiped down the toilet. HK #2 changed her gloves and donned a new pair of clean gloves.-HK #2 failed to perform hand hygiene after removing her gloves and putting on a new pair of gloves. HK #2 scrubbed the inside of the toilet. HK #2 changed her gloves and donned a new pair of clean gloves.-HK #2 failed to perform hand hygiene after removing her gloves and putting on a new pair of gloves. HK #2 mopped the bedroom and the bathroom. HK #2 removed her gloves prior to exiting room [ROOM NUMBER].-HK #2 failed to perform hand hygiene after removing her gloves and exiting room [ROOM NUMBER].-Additionally, HK #2 failed to disinfect the high touch surfaces in room [ROOM NUMBER] and room [ROOM NUMBER]. During a continuous observations on 2/25/26 beginning at 11:24 a.m. and ending at 11:50 a.m., the following was observed: HK #1 was observed cleaning resident room [ROOM NUMBER]. HK #1 swept the bedroom floor and then mopped the bedroom and bathroom floors. HK #1 removed his gloves prior to exiting room [ROOM NUMBER].-HK #1 failed to perform hand hygiene after removing his gloves and exiting room [ROOM NUMBER]. HK #1 moved the cleaning cart to resident room [ROOM NUMBER]. -HK #1 donned clean gloves without performing hand hygiene. HK #1 wiped down the high touch surfaces in the bedroom and then proceeded to wipe down the high touch surfaces in the bathroom. HK #1 scrubbed the toilet and then swept the bedroom and mopped the bedroom and bathroom without changing gloves. -HK #1 failed to remove his gloves and perform hand hygiene after cleaning the toilet and prior to sweeping and mopping the floors.HK #1 removed his soiled gloves, exited room [ROOM NUMBER] and moved the cleaning cart to resident room [ROOM NUMBER].-HK #1 failed to perform hand hygiene after removing his gloves and exiting room [ROOM NUMBER]. -HK #1 donned clean gloves without performing hand hygiene, prior to entering room [ROOM NUMBER]. HK #1 wiped down the high touch surfaces in the bedroom and then proceeded to wipe down the high touch surfaces in the bathroom. HK #1 scrubbed the toilet and then swept and mopped the bedroom and the bathroom without changing gloves. -HK #1 failed to remove his gloves and perform hand hygiene after cleaning the toilet and prior to sweeping and mopping the floors.HK #1 removed his soiled gloves and exited room [ROOM NUMBER].-HK #1 failed to perform hand hygiene after removing his gloves and exiting room [ROOM NUMBER].IV. Staff interviews The environmental services supervisor was interviewed on 2/25/26 at 3:35 p.m. The environmental services supervisor said the Waxie 730 HP disinfectant dwell time was three to four minutes. She said the importance of following the dwell times was so the surfaces were appropriately disinfected to help control the transmission of infection. She said high touch surfaces, such as door knobs, light switches, dresser knobs and bedside tables should be cleaned every day to prevent the transmission of infection. She said hand hygiene should be completed after removal of gloves. She said gloves should be changed with every new task, such as moving from the bedroom into the bathroom. The infection prevention (IP) and the assistant director of nursing (ADON) were interviewed together on 2/26/26 at 9:37 a.m. The IP said she conducted monthly audits of hand washing and did not have concerns with staff not performing hand hygiene. The IP said hand hygiene should be completed before going into residents' rooms, after coming out of rooms, before and after perineal care, when moving from dirty to clean tasks, after gloves removal and before and after medication pass. The IP said it was important to follow the dwell times for cleaning products so the chemical had time to appropriately disinfect the surface. The director of nursing (DON) was interviewed on 2/26/26 at 11:00 a.m. The DON said hand hygiene should be performed when going in and out of residents' rooms, when hands were visibly soiled, between resident cares, when moving from a dirty area to a clean area and after removal of gloves. She said hand hygiene was important for infection control. The DON said the importance of following chemical dwell times was so the product had time to kill germs on surfaces. She said the high touch surfaces, including door knobs, TV remotes, bed controls, bedside tables, toilet handles and other remotes should be cleaned daily.

Based on record review and interviews, the facility failed to ensure residents were free from sexual abuse for one (#54) of three residents reviewed for abuse out of 37 sample residents.Specifically, the facility failed to protect Resident #54 from sexual abuse by Resident #57.Findings include:I. Facility policy and procedureThe Abuse, Neglect and Exploitation policy, undated, as provided by the director of nursing (DON) on 2/23/26 at 3:15 p.m. It read in pertinent part, It is the policy of the facility to provide protection for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploiAbuse means the willful infliction, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish, which include staff to resident abuse and certain resident to resident altercations. It includes verbal abuse, sexual abuse, physical abuse and mental abuse.Sexual abuse is non-consensual sexual contact of any type with a resident.II. Sexual abuse allegation involving Resident #54 and Resident #57 on 12/25/25A. Facility investigationThe 12/26/25 facility investigation revealed that staff witnessed Resident #54 and Resident #57 walking toward each other in the hall when Resident #54 gave a hug to Resident #57. As Resident #54 was walking away, Resident #57 grabbed Resident`s #54 buttocks and slid his hand down to her crotch. After the incident, Resident #57 was placed with a one-to-one staff member. The facility substantiated the allegation of sexual abuse.B. Resident #54 (victim)1. Resident statusResident #54, age greater than 65, was admitted on [DATE] and readmitted on [DATE]. According to the February 2026 computerized physician orders (CPO), diagnoses included Pick`s disease (causes the atrophy of the brain's frontal and temporal lobes) dementia, and Alzheimer`s disease. The 2/10/26 minimum data set (MDS) assessment revealed the resident had severe cognitive impairment and a brief interview for mental status (BIMS) assessment was not conducted. She exhibited physical behavior problems toward others. The resident required maximal assistance with toileting and showering. She required set up assistance with eating, supervision, oral hygiene and moderate assistance with dressing. 2. Record reviewThe capacity to consent care plan, initiated 12/31/25 (after the incident with Resident #57), identified Resident #54 lacked the capacity to consent to sexual intimacy related to severe cognitive impairment, placing the resident at risk for misunderstanding interpersonal boundaries, exploitation, or emotional and physical harm. The goal was to allow Resident #54 to maintain psychosocial well-being and dignity while engaging in safe, appropriate, non-sexual, affectionate interactions. The interventions included not allowing sexual activity at that time due to lack of resident capacity to consent.-However, the care plan failed to include interventions to keep the resident safe from another recurrence due to her lack of capacity to consent.C. Resident #57 (assailant)1. Resident statusResident #57, age greater than 65, was admitted on [DATE]. According to the February 2026 CPO, diagnoses included severe vascular dementia (restricted blood flow to the brain), personal history of transient ischemic attack (mild stroke) and cerebral infarction without residual deficit, disorientation, and post-traumatic stress disorder. The 12/23/25 MDS assessment revealed the resident had severe cognitive impairment, and a BIMS assessment was not conducted. He required set up assistance with eating, supervision with oral hygiene and dressing, and moderate assistance with showering. The MDS assessment identified the resident did not have physical and verbal behavioral symptoms directed at others.2. Record reviewThe behavior care plan, revised 12/18/25, identified Resident #57 had a history of exhibiting affectionate behavior with female residents related to cognitive impairment. The goal was to prevent Resident #57 from engaging in inappropriate touching of others. Pertinent interventions included having two staff members to provide gentle redirection to the resident if consent could not be clearly established and if the resident's behavior escalated beyond kissing or one resident appeared uncomfortable (initiated 12/18/25) and providing one-to-one supervision with emphasis on ensuring the resident had no opportunity for physical contact with any other resident and not to seat him near female residents (initiated 12/26/25).A progress note, dated 12/11/25, revealed Resident #57 exhibited increased interest in female residents starting on 12/11/25. The staff documented approximately ten separate progress notes between 12/11/25 and 12/25/25 when he exhibited these behaviors. A progress note, dated 12/26/25 at 6:37 a.m., documented Resident #57 had been having issues with touching certain female residents. Resident #57 was in the hallway with a female resident (Resident #54) who he was not supposed to be touching. Both residents were hugging each other and rubbing each others' arms. Resident #57 was asked to please stop and continue to his room. When Resident #57 started to walk away from Resident #54, he smacked her on the bottom and then slid his hand from her bottom to her crouch. After sliding his hand on her crouch, went to his room. Resident #54 was not upset or agitated by the actions of Resident #57.D. Staff interviewsCertified nurse aide (CNA) #5 was interviewed on 2/25/26 at 1:06 p.m. CNA #5 said Resident #57 often exhibited flirtatious behaviors toward females in the memory care unit. He said Resident #57 seemed to pay more attention to female residents than male residents. CNA #5 said Resident #57 frequently initiated physical contact with females, including holding hands and kissing them on the cheek. He said it was difficult to determine whether the contact was consensual due to the female residents' cognitive impairment He said Resident #54 did not exhibit any behaviors that would suggest her dislike of Resident #57's attention. CNA #5 said he reported all incidents to the nurse. CNA #5 said that the staff agreed to increase monitoring for Resident #57 due to his behaviors. Registered nurse (RN) #3 was interviewed on 2/25/26 at 12:55 p.m. RN #3 said Resident #57's behavior slowly escalated over the weeks on the unit. She said Resident #57`s behavior started innocently, such as sitting by female residents and holding hands with them. RN #3 said Resident #57's behavior escalated and he was seen rubbing a female resident's knee and then he started going into female residents' rooms. RN #3 said the staff tried to intervene and redirect the residents involved. She said the staff was encouraged to monitor and redirect Resident #57. She said Resident #57 was placed on alert charting and the management was aware of his behavior. RN #3 said that the occurrence between Resident #57 and Resident #54 was a surprise to her, as she had never seen Resident #57 being interested in Resident #54 before. She said Resident #57 was placed on one-to-one observation after the occurrence with Resident #54 on 12/26/25.The DON was interviewed on 2/25/26 at 2.30 p.m. The DON said Resident #57 was redirected numerous times and the staff educated him on personal boundaries but Resident #57's behavior did not change. She said Resident #57 was placed on one-to-one observation after the incident between him and Resident #54 due to lack of available rooms off of the memory care unit. She said Resident #57's behavior with other female residents prior to the occurrence was not foretelling and the facility did not suspect that his behavior would escalate. She said that the facility had initiated a sexual capacity consent since the occurrence with Resident #54. She said a resident with dementia would consent to physical contact by their body language. She said if they were pulling away, walking away, showing any sign of fear or standing by the nurse, that would show disagreement. RN #1 was interviewed on 2/25/26 at 3:37 p.m. RN #1 said she witnessed Resident #57 initiate contact with several female residents on 12/26/25. She said Resident #57 kept inviting the females to kiss him on the cheek. She said the staff intervened and redirected him several times during that day and reminded him that the other residents did not want to be engaged physically. She said Resident #57 walked away but then initiated contact again later. She said it was hard to tell whether it was consensual contact or not. She said the residents did not verbally refuse or pull away. She said she did not believe that the female residents involved in these occurrences were able to understand the weight of their consent. She said it was possible that the female residents only agreed to the attention to avoid conflict.

Based on record review and interviews, the facility failed to ensure one (#9) of five residents were free from chemical restraints out of 37 sample residents.Specifically, the facility failed to monitor behaviors, side effects and effectiveness for Resident #9, who was prescribed a psychotropic medication.Findings include:I. Facility policy and procedureThe Unnecessary Drugs policy, revised 10/1/25, was provided by the regional clinical resource on 2/25/26 at 3:15 p.m. It read in pertinent part, It is the facility's policy that each resident's entire drug/medication regimen is managed and monitored to promote or maintain the resident's highest practicable mental, physical and psychosocial well-being free from unnecessary drugs. Each resident's drug regimen will be reviewed on an ongoing basis, taking into consideration the following elements: -Dose; -Duration;-Indications;-Adequate monitoring for efficacy and adverse consequences; and,-Preventing, identifying and responding to adverse consequences.II. Resident #9A. Resident statusResident #9, age greater than 65, was admitted on [DATE]. According to the February 2026 computerized physician orders (CPO), diagnoses included unspecified mood disorder, anxiety disorder, vascular dementia and depression. The 12/15/25 minimum data set (MDS) assessment revealed the brief interview for mental status (BIMS) assessment was not conducted as the resident was rarely understood. According to the staff assessment for mental status, the resident had short and long term memory problems. His cognitive skills for daily decision making were severely impaired. He required maximal assistance with most of his activities of daily living (ADL).B. Record reviewReview of Resident #9's February 2026 CPO revealed the resident had a physician's order for Sertraline (an antidepressant) 25 mg (milligrams) one time a day with a start date of 1/14/26.-Review of Resident #9's electronic medical record (EMR) revealed there was no documentation related to behavior monitoring, monitoring the resident for side effects related to the use of the medication or the effectiveness of the medication.-Review of Resident #9's there was no care plan for behavior monitoring or side effect monitoring related to the use of the antidepressant medication. III. Staff interviewsCertified nurse aide (CNA) #1 was interviewed on 2/25/26 at 2:01 p.m. CNA #1 said Resident #9 would yell out for help, move tables around in the dining room and hit staff. He said he did not know Resident #9 was started on an antidepressant. He said he did not know what behaviors or side effects staff should be monitoring for the effectiveness of the resident's antidepressant medication. Licensed practical nurse (LPN) #1 was interviewed on 2/25/26 at 2:06 p.m. LPN #1 said Resident #9 slept all the time and that was all he did. She said he would get angry when awoken and the facility started the antidepressant to help with his energy and happiness. She said when a resident was started on a psychotropic medication, the resident was added to the alert charting binder. -However, LPN #1 reviewed the alert charting binder and said Resident #9 was not added to the binder when he started the antidepressant medication. LPN #1 said Resident #9 should have had monitoring for side effects and behavior tracking for the effectiveness of the antidepressant medication. She said she was not sure if a care plan was required when a resident was started on a psychotropic medication. The director of nursing (DON) was interviewed on 2/25/26 at 2:40 a.m. The DON said when a resident was started on a new psychotropic medication, the resident should be added to the alert charting binder which alerted staff to the start of a new psychotropic medication. She said the residents' medications were discussed monthly in the psychotropic/pharmacological meeting. She said all psychotropic medications should have a care plan implemented which identified behaviors and what side effects of the medication to monitor for. She said the facility monitored the effectiveness of psychotropic medications through behavior charting.

Based on observations, record review and interviews, the facility failed to ensure proper storage of medications in two of four medication carts and one of four medication storage rooms. Specifically, the facility failed to: -Ensure medications were labeled with the date they were opened; and,-Ensure expired medications were removed and discarded from medication carts and medication storage rooms.Findings include: I. Professional referenceAccording to the Xalatan (latanoprost) package insert, retrieved on 3/2/26 from https://www.accessdata.fda.gov/drugsatfda_docs/label/2012/020597s044lbl.pdf, Once a bottle is opened for use, it may be stored at room temperature up to 25 degrees Celsius (77 degrees Fahrenheit) for 6 (six) weeks. According to the Symbicort (budesonide formoterol) package insert, retrieved on 3/3/26 from https://www.accessdata.fda.gov/spl/data/1f05ded1-7d31-4cfc-8537-0e75f99ad452/1f05ded1-7d31-4cfc-8537-0e75f99ad452.xml, The inhaler should be discarded when the labeled number of inhalations have been used or within 3 (three) months after removal from the foil pouch.II. Facility policy and procedure The Medication Storage policy, revised 10/1/25, was received from the clinical resource nurse on 2/25/26 at 3:20 p.m. It documented in pertinent part, It is the policy of this facility to ensure all medications housed on our premises will be stored in the pharmacy and/or medication rooms according to the manufacturer's recommendations and sufficient to ensure proper sanitation, temperature, light, ventilation, moisture control, segregation, and security. The medication carts and all medication rooms are routinely inspected by the consultant pharmacist (or designee) for discontinued, outdated, defective, or deteriorated medications with worn, illegible, or missing labels. These medications are destroyed in accordance with our Destruction of Unused Drugs Policy.III. Observations and staff interviews On 2/24/26 at 1:20 p.m., the Maple unit medication cart was observed with licensed practical nurse (LPN) #1. The following items were found: -A hospice emergency kit containing five different medications. All five medications in the kit had an expiration date of 12/24/25. -One bottle of Pro-Stat (concentrated liquid protein) had an expiration date of 5/21/25.On 2/24/26 at 1:40 p.m., the Pine medication cart and medication storage room were observed with LPN #2. The following items were found in the medication cart: -Latanoprost ophthalmic solution (eye drops used to treat pressure in the eye) 0.005% was not labeled with an open date. -Budesonide/formoterol (inhaler to treat chronic obstructive pulmonary disease) 160 micrograms (mcg)/4.5 mcg had an open date of 3/1/26, however the medication was already open. -A bottle of vitamin B12 1000 mcg had an expiration date of January 2026.The following item was found in the medication storage room: -A bottle of sunscreen had an expiration date of May 2021. LPN #2 said she would dispose of the expired medications. She said the night shift nurses were responsible for the disposal of expired medications. IV. Additional staff interview The director of nursing (DON) was interviewed on 2/25/26 at 2:35 p.m. The DON said the night shift nurses audited the medication carts on Sunday nights for expired medications. She said it was important to keep the medication storage areas free from expired medications and mislabeled medications so the residents were getting the correct strength of medication. She said it was additionally important so the nurses were aware of the expiration dates for medications with shortened expirations date, such as eye drops.

Based on record review and interviews, the facility failed to ensure three (#1, #2 and #3) of three residents reviewed for abuse out of four sample residents were free from abuse. Specifically, the facility failed to:-Protect Resident #1 and Resident #2 from physical abuse by each other on 8/9/25 and 8/16/25; and,-Protect Resident #3 from physical abuse by Resident #1 on 8/16/25. Findings include:I. Physical abuse between Resident #2 and Resident #1 on 8/9/25 A. Facility investigationThe 8/9/25 facility investigation documented Resident #1 was wandering the halls of the unit. Resident #1 stopped outside of Residents #2`s room. Resident #2 came to the doorway and began to yell at Resident #1 to get out of his room. The investigation documented Resident #2 continued to yell and Resident #1 took a fighting stance with his fists raised. Resident #2 stepped out of his doorway and hit Resident #1 in the chest. Resident #1 then hit Resident #2 in the chest. Resident #1 then grabbed the beard of Resident #2 and pulled him across the hallway. Both residents had a hold of each other. The residents were separated by staff and placed on 15-minutes checks for the next 72 hoursThe investigation documented the incident was witnessed by registered nurse (RN) #1.Both residents were assessed. Resident #2 had a sore chin. No other injuries were noted to either resident. The investigation documented both residents were interviewed and did not recall the incident. Resident #2 reported he became upset when other residents entered his room. The investigation documented the social services director (SSD) conducted interviews with other residents on the unit and no concerns were noted. Staff were interviewed and educated to encourage other residents not to enter Resident #2's room. A stop sign was placed on Resident #2's door. Additionally, Resident #2 was moved off the secured unit as a trial. The investigation concluded abuse occurred. B. Resident #2 (assailant and victim) 1. Resident statusResident #2, age [AGE], was admitted on [DATE]. According to the September 2025 computerized physician orders (CPO), diagnoses included dementia in other diseases classified elsewhere severe with agitation, dementia in other diseases classified elsewhere severe with psychotic disturbance, vascular dementia unspecified severity with other behavioral disturbance and major depressive disorder. The 8/6/25 minimum data set (MDS) assessment revealed the resident had mild cognitive impairment with a brief interview for mental status (BIMS) score of 10 out of 15. The assessment indicated the resident did not exhibit behavior disturbances during the assessment review look-back period. 3. Record reviewResident #2's behavior care plan, initiated 5/27/25, revealed Resident #2 had a behavior problem of being verbally abusive to staff and becoming agitated and angry. The care plan documented Resident #2`s triggers included he did not tolerate if others wandered into his room and lack of sleep. Pertinent interventions included placing a stop sign across his door and staff was to discourage other residents from wandering into the resident's room.The nursing progress note, dated 8/9/25, revealed a physical altercation occurred between Resident #1 and Resident #2. Resident #1 wandered in front of Resident #2`s room. The note documented the two residents exchanged chest punches then continued into the hallway while grabbing each other without falling. The residents were separated by staff without force. No injuries were noted. C. Resident #1 (assailant and victim) 1. Resident statusResident #1, age [AGE], was admitted on [DATE] and discharged to the hospital on 8/16/25. According to the September 2025 CPO, diagnoses included unspecified dementia, unspecified severity with other behavioral disturbance and dementia in other diseases classified elsewhere severe with anxiety. The 8/16/25 MDS assessment revealed the resident had severe cognitive impairments with a brief interview for mental status (BIMS) score of three out of 15. The assessment indicated he exhibited physical and verbal behaviors toward others and wandering behavior during the assessment review look-back period. 2. Record reviewResident #1's behavior care plan, initiated 8/14/25, revealed the resident had the potential to be physically aggressive. Pertinent interventions included monitoring and reporting symptoms of danger toward himself or others and to redirect the resident as needed. Review of Resident #1's electronic medical record (EMR) did not reveal documentation regarding the resident-to-resident altercation with Resident #2 on 8/9/25. II. Physical abuse between Resident #2 and Resident #1 on 8/16/25A. Facility investigationThe 8/16/25 facility investigation documented Resident #1 was in Resident #2's room. Resident #2 yelled at Resident #1 to get out of this room. The investigation documented the yelling continued for a couple of minutes. Resident #2 pushed Resident #1 out of his room. Resident #1 then pushed Resident #2 to the ground. Resident #1 then walked away. The investigation documented the incident was not witnessed. The nurse on duty notified the assistant director of nursing (ADON). The ADON reviewed video surveillance. The investigation documented the residents were separated and assessed. Resident #2 sustained an abrasion to his right knee, right elbow and left elbow.The SSD interviewed Resident #2 who said he wanted other residents to stay out of his room and leave him alone. The SSD interviewed other residents on the unit and no concerns were voiced. The investigation documented it was recommended after the last incident between Resident #1 and Resident #2 (on 8/9/25), that Resident #2 was going to be moved off the secured unit. However, a room had not become available yet. The investigation documented a room was opened, but needed to be cleaned prior to the resident moving. It documented the stop sign was in place, but was ineffective as Resident #1 went under the sign.The investigation concluded abuse occurred. B. Resident #2 (assailant and victim) 1. Record reviewThe nursing progress note, dated 8/17/25, revealed Resident #2 was angry about the altercation and that he did not feel safe on the unit. The note documented the facility placed Resident #2`s room under increased hallway checks. Resident #2 was educated to yell for help if another resident entered his room. The note documented the director of nursing (DON) and the ADON were consulted to see if a trial of a do not enter sign on Resident #2's door might be helpful as long as Resident #2 understood that he could enter his room at any time and the sign was meant for other residents.C. Resident #1 (assailant and victim) 1. Record reviewThe 8/17/25 nursing progress note documented Resident #1 had an altercation the day before (8/16/25) at 8:45 p.m. and 8:53 p.m. The altercation between Resident #1 and Resident #2 occurred on 8/16/25 at 8:45 p.m. The altercation between Resident #1 and Resident #3 occurred on 8/16/24 at 8:53 p.m. (see facility investigation below). The note documented that the previous interventions, such as the stop sign banner across the doors and calm redirection had failedIII. Physical abuse by Resident #3 towards Resident #1 on 8/16/25 A. Facility investigationThe facility investigation documented Resident #1 was in common area where could be seen by staff after the previous altercation with Resident #2. The staff took care of Resident #2 while Resident #1 started walking towards his own room. Resident #1 entered his neighbors room (Resident #3) instead of his own and shut the door. Staff heard yelling from the hallway and staff quickly responded. Staff attempted to enter the room but the residents (Resident #1 and Resident #3) were up against the door inside the room. The nurse told the residents to let each other go and seconds later the staff were able to open the door. Upon entering the room the staff witnessed Resident #1 with his hands on Resident #3's neck and Resident #3 had a hold of Resident #1`s shirt. The certified nurse aide (CNA) was able to separate residents.The investigation documented the incident was witnessed by RN #2 and CNA #3.Resident #1 was placed with a one-to-one caregiver until emergency medical services (EMS) arrived. Resident #3 was assessed and had red marks to his left forearm. The resident was interviewed by the SSD and said he wanted other residents to stay out of his room. Resident #1 was transported to the emergency room for a psychological evaluation and did not return to the facility. The investigation concluded abuse occurred. B. Resident #3 (victim) 1. Resident statusResident #3, age [AGE], was admitted on [DATE]. According to the September 2025 CPO, diagnoses included unspecified moderate dementia with agitation, unspecified severity of dementia without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety, recurrent depressive disorder and mild neurocognitive disorder due to known physiological condition with behavioral disturbance. The 5/29/25 MDS assessment revealed the resident had severe cognitive impairments with a brief interview for mental status (BIMS) score of two out of 15. 2. Record reviewReview of Resident #3's EMR did not reveal documentation regarding the physical abuse incident with Resident #1 on 8/16/25.C. Resident #1 (assailant)1. Record reviewReview of Resident #1's EMR did not reveal documentation regarding the physical abuse incident with Resident #3 on 8/16/25. V. Staff interviewsLicensed practical nurse (LPN) #1 was interviewed on 9/8/25 at 10:10 a.m. LPN #1 said she saw a positive impact when Resident #2 moved to the second floor. She said the second floor was a more relaxed environment. She said the residents on the second floor were more cognitively intact and understood that they were not to enter other residents' rooms. She said Resident #2 kept his door closed at all times, but he ate his meals in the dining room with other residents. She said Resident #2 started interacting with others and did not exhibit any behavioral problems. She said there were no incidents when other residents attempted to enter Resident #2's room since he had moved to the second floor. She said there were no residents with wandering behaviors on the second floor. She said she had never seen or heard about Resident #2 acting aggressively to staff or other residents. CNA #1 was interviewed on 9/8/25 at 10:30 a.m. CNA #1 said she had been working on the secured unit since June 2025. She said Resident #2 stayed in his room most of the time and kept his door closed. She said it was well known that Resident #2 was protective over his room. She said she did not work on the unit on the day of the incidents between Resident #1 and Resident #2. CNA #1 said she remembered Resident #1 often wandered. She said Resident #2 had a stop sign banner across his door but he kept it above head level. CNA #1 said Resident #1 usually disregarded the stop banners across doors and he ducked under them. She said the staff needed to keep an extra set of eyes on him during their shifts and redirect him often. She said they had two CNAs and one RN on each shift for both hallways. She said the CNAs and the RN would divide the unit up between themselves to monitor residents. She said the nurses' station had cameras and the nurse was able to see all of the residents' doors at the same time. CNA #2 was interviewed on 9/8/25 at 11:00 a.m. CNA #2 said a nurse informed her that Resident #1 often wandered.

Based on observations, record review and interviews, the facility failed to ensure one (#68) of four residents reviewed for nutrition received the care and services necessary to meet their nutritional needs and maintain their highest physical well-being level out of 33 sample residents. Resident #68 was admitted to the facility for long term care on 8/1/23 with diagnoses of dementia with agitation, abdominal pain, vascular disorder of the intestine (blocked blood vessels to the intestines) and cystic disease of the liver (a disease that causes growths in the liver). Upon admission, Resident #68 weighed 212.4 pounds (lbs). The resident was hospitalized from 10/13/23 to 10/19/23 for a large bowel ischemic (a condition that caused pain and difficulty for intestines to work properly) and necrosis of the colon (part of the colon dies). Resident #68's weight was stable between September 2023 to November 2023 after the hospitalization . On 12/4/23 Resident #68 sustained a 7% (13.8 lbs) weight loss from 11/7/23 to 12/24/24, which was considered severe. On 12/5/23 the registered dietitian (RD) recommended to provide the resident large portions at meals to provide additional calories and nutrition to combat the severe weight loss. Observations on 5/21/24 and 5/22/24 revealed the resident did not receive large portions and was not offered additional food when he consumed 100% of his meal. On 2/5/24 Resident #68 sustained an additional 6.9% (12.6 lbs) weight loss from 1/3/24 to 2/5/24, which was considered severe. The facility did not implement a person-centered nutritional intervention related to the resident's severe weight loss. Due to the facility's failures to provide timely and effective nutritional interventions and ensure staff followed implemented nutritional interventions, Resident #68 sustained a severe weight loss. Findings include: I. Facility policy and procedure The Nutritional Assessment policy, revised October 2017, was provided by the director of nursing (DON) on 5/23/24 at 11:47 a.m. It revealed in pertinent part, The dietitian, in conjunction with the nursing staff and healthcare practitioners, will conduct a nutritional assessment for each resident upon admission (within current baseline assessment timeframes) and as indicated by a change in condition that places the resident at risk for impaired nutrition. Once current conditions and risk factors for impaired nutrition are assessed and analyzed, individual care plans will be developed that address or minimize to the extent possible the resident's risks for nutritional complications. Such interventions will be developed within the context of the resident's prognosis and personal preferences. Individualized care plans shall address, to the extent possible, the identified causes of impaired nutrition, the resident's personal preferences, goals and benchmarks for improvement and timeframes and parameters for monitoring and reassessment II. Resident #68 A. Resident status Resident #68, age [AGE] years old, was admitted on [DATE] and readmitted on [DATE]. According to the May 2024 computerized physician orders (CPO), diagnoses included dementia with agitation, abdominal pain, vascular disorder of the intestine and cystic disease of the liver. The 2/13/24 minimum data set (MDS) assessment documented the resident had severe cognitive impairment with a brief interview for mental status (BIMS) score of two out of 15. The resident required partial assistance with oral hygiene and dressing. He required substantial assistance with showering and personal hygiene. He required supervision with toileting, The assessment documented the resident was 75 inches (six feet, three inches) tall and weighed 183 lbs. It indicated the resident had no weight loss or weight gain in the last six months. -However, Resident #68 had sustained a 6.9% (12.6 lbs) weight loss in one month from 1/3/24 to 2/5/24, which was considered severe. B. Observations On 5/21/24, lunch meal service was observed for the secured unit. Resident #68's meal ticket indicated the resident was on a regular diet. The serving size on his plate matched the regular diet serving on the meal ticket. During a continuous observation on 5/22/24, beginning at 12:09 p.m. and ending at 1:08 p.m., the following was observed in the secured unit dining room: At 12:25 p.m. Resident #68 was served his lunch. The meal ticket indicated the resident was on a regular diet. He consumed 100% of his lunch, dessert and the fluids that were provided to him. When his plate was empty, he picked up the plate and licked it until there was nothing left on his plate. From 12:44 p.m. until 12:51 p.m. Resident #68 picked up his empty cup and tried to drink out of it. He picked up his fork and attempted to eat off his empty plate. At 12:52 p.m. a certified nurse aide (CNA) #1 said to Resident #68 he must be hungry and asked if he wanted a snack. He said yes. CNA #1 gave the resident a fruit cup. At 12:59 p.m. Resident #68 finished eating the fruit cup. He drank the fruit juice that was in the bottom of the fruit cup. At 1:02 p.m. Resident #68 stood behind another resident who was sitting in the dining room eating her lunch, At 1:07 p.m. Resident #68 moved to stand behind another resident who was eating her lunch. CNA #1 redirected Resident #68 by telling him to let the two residents eat their lunch. He followed CNA #1 out of the dining room. C. Record review The nutrition care plan, revised 3/19/24, revealed the resident had potential for altered nutrition due to increased poor vision and sporadic intake. The care plan indicated on 2/13/24 the resident had a poor appetite and his diet was changed to finger foods to improve intake. The care plan indicated on 3/19/24 the resident had mild weight gain after he had lost weight and was eating most of his meals. Interventions included providing the resident finger foods, providing supplements and providing the diet as ordered. -However, a review of Resident #68's electronic medical record (EMR) did not reveal the resident was prescribed a nutritional supplement. Resident #68's weights were documented in the resident's medical record as follows: -On 8/9/23, the resident weighed 201.8 pounds; -On 9/4/23, the resident weighed 197.0 pounds; -On 10/3/23, the resident weighed 194.4 pounds; -On 11/7/23, the resident weighed 196.0 pounds; -On 12/4/23, the resident weighed 182.2 pounds; -On 1/3/24, the resident weighed 183.4 pounds; -On 2/5/24, the resident weighed 170.8 pounds; -On 3/19/24, the resident weighed 173.0 pounds; -On 4/9/24, the resident weighed 173.6 pounds; and, -On 5/5/24, the resident weighed 172.0 pounds. -The resident lost 13.8 lbs (7%) from 11/7/23 to 12/4/23 in one month, which was considered severe weight loss. -The resident lost 12.6 lbs (6.9%) from 1/3/24 to 2/5/24 in one month, which was considered severe weight loss. The 10/19/23 hospital discharge summary revealed the resident was hospitalized from 10/13/23 to 10/19/23 for large bowel ischemia and necrosis of the colon. The resident had dementia and surgery was determined not to be in the resident's best interest. The resident was treated conservatively with antibiotics, intravenous fluids and pain medication. The family understood that the resident's abdominal process could happen again. If the resident's status worsened, the family was ready for hospice services. The resident was discharged with a regular diet. The 10/20/23 nursing progress note revealed the resident returned from the hospital. He did not have any complaints of abdominal pain. He asked for food and he ate soup without any issues. The 10/21/23 nursing progress note revealed the resident ate his breakfast well. He had an Ensure liquid nutritional supplement. The resident gagged and produced mucus. The Ensure was discontinued. The 12/5/23 RD progress note revealed the resident was on a fortified regular diet. The note documented the resident walked around the unit a lot of the day. The RD documented the resident was prescribed Olanzapine (a medication used to treat mental disorders). There were no recent labs to review and the resident's skin was intact. The resident had significant weight loss in 30 days. The resident had increased nutritional needs related to his height. The resident was consuming more than 94% of his meals. The note documented the resident likely was not meeting his nutrition needs. The RD requested large portions with all meals. The note documented the RD would continue to monitor the resident. -A review of the resident's EMR did not reveal documentation that large portions was added to the resident's diet order. -A review of the resident's comprehensive care plan did not reveal the intervention to provide the resident large portions was added the care plan. The 12/15/23 nursing progress note documented at 2:53 a.m. revealed Resident #68 took food off other resident's plates. He also took a quesadilla out of the trash can. The resident ate three slices of pecan pie and four glasses of juice. He returned to his room and settled into bed. The 12/27/23 nursing progress note revealed the resident paced and walked around the unit. The note documented the resident's jeans were too big and were constantly falling down. He said he was hungry and he ate two fruit cups. He ate well. At 10:30 p.m. he went to bed. The 2/9/24 quarterly dietary assessment revealed the resident was on a regular diet with regular portions. He had a poor appetite with his average intake of meals ranging from 25 to 50%. He had good hearing and good eyesight. He used regular utensils and required partial assistance with meals. -However, the resident was not observed to be provided assistance with his meals during the survey (see observations above). -The 2/9/24 quarterly dietary assessment did not address the resident's significant weight loss of 6.9% (12.6 lbs) from 1/3/24 to 2/5/24 in one month. The 3/19/24 RD progress note revealed the resident was reviewed by the interdisciplinary team (IDT) in an at-risk meeting. He was on a regular diet and finger foods provided. He required supervision with meals. His meal intake was 76% or more for one to three meals a day. The resident was not receiving an oral supplement at this time. The resident had significant weight loss in the last six months.The resident had mild weight gain in the last 30 days after the significant weight loss. The note documented further weight gain was desirable and the RD would continue to monitor the resident's weight. -However, the facility did not implement a person-centered nutrition intervention after the RD determined further weight gain was desirable for the resident. The 4/12/24 physician progress note revealed the resident's abdominal pain was evaluated. The resident was acting as though he was in pain. The resident was doing better this week. The note documented the resident required restraints and one on one care. Diagnostic testing confirmed a large liver cyst. The assessment and plan revealed the resident had generalized abdominal pain. The abdominal pain was stable. The main therapy would be pain control. -The 4/12/24 physician progress note did not address the resident's severe weight loss. The 5/14/24 quarterly dietary assessment revealed the resident had a regular diet with regular portions. He had a poor appetite and was consuming 25 to 50% of his meals. He had good hearing and good eyesight. He used regular utensils and required partial assistance with his meals. -However, Resident #68 was supposed to receive large portions according to the interview with the RD (see interview below). III. Staff interviews Certified nurses aide (CNA) #3 was interviewed on 5/22/24 at 3:52 p.m CNA #3 said Resident #68 had lost weight in October 2023 since he was having intestinal issues.She said the resident was ill, but was doing better. She said the resident ate everything on his plate and drank his fluids at most meals. Licensed practical nurse (LPN) #3 was interviewed on 5/22/24 at 3:59 p.m. LPN #3 said Resident #68 had a history of weight loss She said the resident had been hospitalized in October 2023 for an ischemic bowel and was not doing well at the time. She said since then the resident had improved and was eating and drinking everything he was served. The assistant director of nursing (ADON) was interviewed on 5/23/24 at 12:30 p.m. The ADON said when weight loss was identified the facility typically implemented nutritional interventions, which included liquid nutritional supplements, a fortified diet, double portions and speech therapy study. The ADON said the minimum data set coordinator (MDSC) was responsible to update the care plan after the ADON met with the RD to discuss potential nutritional interventions. The ADON said Resident #68 went to the hospital in October 2023 for an ischemic bowel. The ADON said the family did not want the resident to have surgery. The ADON said the resident started antibiotics in the hospital and then returned to the facility. The ADON thought the hospital environment was not good for the resident because he had dementia. The ADON said the facility thought he was actively dying, because he was lethargic, in pain and was not able to eat food because of digestive system issues. She said the facility could adjust a diet if a resident was actively dying. The ADON said the facility switched electronic systems that managed all resident's diets. She said that was possibly one reason the resident did not receive large portions at lunch on 5/21/24 and 5/22/24. She said the facility could have put the resident on weekly weights to monitor the resident's weight status closer. She said the resident was not on weekly weights. The RD was interviewed on 5/23/24 at 11:48 a.m. The RD said dietary assessments were completed upon admission, quarterly and if there was a significant change in the residents condition. She said the dietary manager (DM) completed the quarterly assessments. She said when a resident was admitted to the facility they were weighed for three days, then weekly for three weeks and then monthly. She said when a resident had weight loss she reviewed the resident's meal intakes, acceptance of the liquid nutritional supplements and determined the root cause of the weight loss. She said the ADON was responsible for notifying the family and the physician regarding the weight loss. The RD said the resident was on a regular diet with finger foods. She said the resident's weight was stable since 2/5/24 with minor fluctuations. She said he lost weight initially because he had dementia. She said he needed more queuing and encouragement if he was not eating. She said the resident was not weighed weekly because his weight had been stable recently. She said it was not necessary to weigh him weekly. The RD said she last assessed the resident on 3/19/24. She said since admission, the resident had significant weight loss. The RD said the resident was supposed to receive fortified foods and large portions. She said the diet order was handled by the DM. The RD said she had told the DM to change the diet order on 12/9/23. She said there was a time when the facility did not have a DM, so the diet order could have been overlooked during that time. The director of nursing (DON) was interviewed on 5/23/24 at 10:23 a.m. The DON said the assistant director of nursing (ADON) and the RD were responsible for identifying severe weight loss and sending a formal recommendation of intervention to the IDT team. She said the ADON was responsible for notifying the RD when a resident had a significant weight loss. The DON said the physician was part of care planning on a weekly basis. The DON said typical interventions that were implemented after a significant weight loss were liquid nutritional supplements and a change in diet orders. The DON said Resident #68 used to eat everything that was left out on the kitchen counter and dining room table. She said the resident had a decrease in vision which could have contributed to his weight loss. She said the previous dietary manager (DM) no longer worked at the facility. She said the previous DM did not follow the portion sizes indicated on the meal extensions. She said she observed the previous DM underserve multiple residents on several occasions at meals. She said Resident #68 was supposed to have double portions and the resident's meal ticket needed to indicate he was to receive double portions at meals. The DON said Resident #68 had a history of pretending to eat when there was nothing left on his plate. The DON said this was a behavior he displayed when he was still hungry. She said it was hard to identify a resident's needs when they had dementia. The DON said Resident #68 had triggered significant weight loss. IV. Facility follow up The MDSC sent a performance improvement plan to improve tracking, follow up and prevention of weight loss on 5/28/24 at 7:23 a.m. It revealed that the facility had four action plans. The action steps included to review all resident's weight trends to determine weight loss and risk, review and update care plans based on weight review and educate nursing staff on what to document for weight loss and monitor resident meals. -The follow-up did not include dates when the action steps were completed.

Based on observations, interviews and record review, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of disease and infection in four of four units. Specifically, the facility failed to -Ensure clean technique was followed during wound care for Resident #56; and, -Ensure the facility had an active Legionella water management plan in place to prevent or reduce Legionella in the facility. Findings include: I. Clean technique during wound care A. Facility policy and procedure The Wound Care policy and procedure, revised October 2010, was provided by the director of nursing (DON) on 5/23/24 at 8:30 a.m. It read in pertinent part, Use disposable cloth to establish a clean field on the resident's overbed table. Place all items to be used during the procedure on the clean field. Put on exam gloves. Loosen tape and remove dressing. Pull gloves over the dressing and discard it into the appropriate receptacle. Wash and dry hands thoroughly. Be certain all clean items are on a clean field. B. Observations Licensed practical nurse (LPN) #1 was observed providing wound care, with the assistance of DON, to Resident #56's right foot wound on 5/22/24 at 10:00 a.m. LPN #1 placed a trash bag onto Resident #56's bed with the clean supplies on top of it. -LPN #1 did not establish a clean field separate from Resident #56's bed and placed clean supplies on a trash bag directly on the bed. LPN #1 removed the dressing and placed the old dressing onto the trash bag on the bed next to the clean supplies. -LPN #1 placed a dirty dressing next to clean dressing supplies on a non clean field. LPN #1 picked up the wound cleanser bottle, opened a gauze dressing lying on the trash bag and sprayed wound cleanser onto the wound and wiped it with a gauze dressing. -LPN #1 did not change gloves or perform hand hygiene after removing the old dressing and before touching clean supplies and cleaning the wound. LPN #1 opened up a betadine swab and swabbed around edges of the wound and disposed of the betadine swab onto the trash bag that was lying on the bed with the wound supplies on top of it. -LPN #1 opened the clean betadine swab that was lying on the trash bag next to the soiled dressings and disposed of the used swab back onto the trash bag that contained the soiled dressing and clean supplies. LPN #1 did not change gloves and perform hand hygiene before handling the betadine swab. LPN #1 picked up a skin prep package and opened it and swabbed around the edges of the wound. -LPN #1 did not change her gloves and perform hand hygiene before handling the clean skin prep pad. LPN #1 picked up a gauze dressing package from the trash bag and opened the package. She placed the open gauze package back on the trash bag. She then changed her gloves and performed hand hygiene -LPN #1 did not change her gloves or perform hand hygiene before touching the clean gauze dressing and placed the opened gauze package down onto the non clean field. LPN #1 picked up the open gauze package and placed the gauze onto the wound. -Throughout the wound observation, LPN #1 did not maintain a designated clean field that kept clean wound supplies separate from dirty dressings and supplies. She did not perform hand hygiene or change gloves after touching dirty dressings or supplies. C. Staff interviews The DON was interviewed on 5/22/24 at 10:15 a.m. The DON said when performing a clean technique, a clean field for clean supplies should be maintained and kept separate from dirty dressings and supplies. She said after a nurse removed a soiled dressing or touched soiled supplies, the nurse should change their gloves and perform hand hygiene. The DON said during Resident #56's wound care, LPN #1 should have set-up and maintained a clean field. She said the clean supplies should have been kept separate from the soiled dressings and supplies. She said the nurse should perform hand hygiene and put on clean gloves after touching a dirty dressing or wound supply item and before cleaning or applying a new dressing to a wound. The DON said changing gloves and performing hand hygiene frequently helped prevent cross contamination of organisms from soiled to clean. She said she would review clean technique with LPN #1. LPN #1 was interviewed on 5/22/24 at 10:20 a.m. LPN #1 said she did not set-up a clean field correctly for Resident #56's wound care. She said she should have had a separate clean field established. She said clean wound supplies should be kept on the clean field and dirty items should not be mixed with clean wound items. She said after removing a dirty dressing, touching soiled supplies or after cleaning a wound hand hygiene should be performed and gloves changed. II. Legionella water management A. Professional reference The Centers for Disease Control (CDC). (6/24/21). Developing a Water Management Program to Reduce Legionella Grown and Spread in Buildings. U.S. Department of Health and Human Services was provided by the minimum data set coordinator (MDSC) on 5/23/24 at 10:00 a.m. It read in pertinent part, Legionnaires disease is a serious type of pneumonia caused by bacteria, called Legionella, that lives in water. Legionella can make people sick when they inhale contaminated water from building water systems that are not adequately maintained. B. Facility policy and procedure The Legionella Water Management Program policy and procedure, revised September 2022, was provided by the minimum data set coordinator (MDSC) on 5/23/24 at 10:00 a.m. It read in pertinent part, As part of the infection prevention and control program, our facility has a water management program, which is overseen by the water management team. The water management team consists of at least the following personnel: infection preventionist, administrator, medical director (or designee), director of maintenance and director of environmental services. The purposes of the water management program are to identify areas in the water system where Legionella bacteria can grow and spread, and to reduce the risk of Legionnaires disease. C. Record review A request was made for the water management monitoring and testing on 5/23/24. -The facility was unable to provide documentation of water management monitoring or testing for the facility. D. Staff interviews The infection preventionist (IP) was interviewed on 5/23/24 at 8:45 a.m. The IP said she was not involved in the water management program for Legionella and she did not know if a water management program was in place. She said the environmental services director (ESD) would have the records of the water management program and testing. The ESD was interviewed on 5/23/24 at 9:30 a.m. The ESD said he was new to his role and was not aware of a water management program for Legionella for the facility. He said he received a report from the city regarding water quality outside of the facility but did not have documentation of water monitoring or testing for Legionella for the facility. He said he was not aware that a water management program needed to be in place to help reduce or prevent Legionella within the facility. The nursing home administrator (NHA) was interviewed on 5/23/24 at 9:40 a.m. The NHA said she had recently started working at the facility. She said it had been identified by the medical director at a recent quality assurance and performance improvement (QAPI) meeting that a Legionella water management program needed to be in place at the facility. She said the facility did not have an active water management program in place yet. She said they were using the CDC guidelines in implementing the Legionella water program. She said this program was necessary to help prevent Legionella in the facility.

Based on observations, record review and interviews, the facility failed to store, prepare, distribute and serve food in a sanitary manner in the main kitchen. Specifically, the facility failed to: -Ensure temperatures were taken of refrigerators in the main kitchen; and, -Have a system in place to monitor the internal temperature of the dishwasher to ensure the functioning of the dishwasher. Findings included: I. Professional reference According to the Food and Drug Administration Food Code (2022), retrieved on 5/28/24 from https://www.fda.gov/media/164194/download?attachment, Water temperature is critical to sanitization in ware washing operations. This is particularly true if the sanitizer being used is hot water. A temperature measuring device is essential to monitor manual ware washing and ensure sanitization. Effective mechanical hot water sanitization occurs when the surface temperatures of utensils passing through the ware washing machine meet or exceed the required 160 degrees F (Fahrenheit). Parameters such as water temperature, rinse pressure, and time determine whether the appropriate surface temperature is achieved. Although the Food Code requires integral temperature measuring devices and a pressure gauge for hot water mechanical ware washers, the measurements displayed by these devices may not always be sufficient to determine that the surface temperatures of utensils are reaching 160 degrees). The regular use of irreversible registering temperature indicators provides a simple method to verify that the hot water mechanical sanitizing operation is effective in achieving a utensil surface temperature of 160 degrees F. II. Facility policy and procedure The Refrigerator, Freezer and Dishwashing policy, revised in 2009, was provided by the nursing home administrator (NHA) on 5/22/24 at 11:00 a.m. It read in pertinent part, The facility will ensure safe refrigerators and freezers maintenance, temperatures, and sanitation, and will observe food expiration guidelines. Acceptable temperatures should be 35 degrees to 40 degrees Fahrenheit (F) for refrigerators and below zero degrees F for freezers. Monthly tracking sheets for all refrigerators and freezers will be posted to record temperatures. Monthly tracking sheets will include time, temperature, initials, and action taken. The Food Service Supervisor or designated employees will check and record refrigerator and freezer temperatures daily with the first opening and at closing in the evening. The dishwasher operator will check temperatures using the dishwasher gauge with each washing cycle, and will record the results in a facility approved log. The operator will monitor the gauge frequently during the dishwashing machine cycle. III. Observations and interviews On 5/20/24 at 8:43 a.m. dietary aide (DA) #2 put a load of dishes through the dishwasher. He said the dishwasher was high temperature and indicated that the external temperature gauge displayed 180 degrees F. He said there was not a temperature log to record the dishwasher temperatures (see record review below). DA #2 said he did not know how to check the internal temperature of the dishwasher to ensure the temperature on the outside display was correct. He said the facility did not keep a log of the temperature of the dishwasher. IV. Record review A request was made for the dishwasher temperature log on 5/20/24. DA #2 said the facility did not utilize temperature logs (see interview above). A review of the temperature log that was hung outside the main kitchen's walk-in refrigerator and freezer on 5/22/24 revealed the log was missing 21 of 46 opportunities to monitor the walk-in refrigerator and freezer temperatures on the May 2024 (from 5/1/24 to 5/22/24) walk-in refrigerator and walk-in freezer temperature log. V. Staff interviews DA #1 was interviewed on 5/22/24 at 1:16 p.m. DA #1 said the kitchen had recently gotten a new dishwashing machine. DA #1 said the former dietary manager (DM) explained to her verbally how to operate the dishwasher. DA #1 said she did not remember the appropriate recommendations for a high-temperature dishwasher. She said the facility used to have a log for the dishwasher but she said she did not know why they did not have it now. She said she had not seen the temperature log for the dishwasher for a while. The DM was interviewed on 5/22/24 at 1:35 p.m. The DM said the dining staff members needed to monitor the temperature of the dishwasher on a regular basis and put it on a log to ensure the dishwasher was functioning properly. The DM said it was necessary to monitor the temperature to ensure proper sanitation of the dishes to prevent bacterial growth. She said the temperature logs for the main kitchen walk-in refrigerator and the walk-in freezer were missing temperatures. She said the temperature of the refrigerator and freezer needed to be monitored on a regular basis to ensure they were maintaining the correct temperature. The DM said she would immediately initiate training for all of the kitchen staff on obtaining and documenting daily temperatures of the walk-in refrigerator and freezer. She said she would also provide education on how to monitor and log the temperatures of the dishwasher.

Based on observations and interviews, the facility failed to ensure all drugs and biologicals were properly stored and labeled in accordance with professional standards on two of four units. Specifically, the facility failed to: -Ensure Tuberculin purified protein derivative (PPD) was dated after opening; and, -Ensure refrigerated medications were stored in a sanitary manner, separately from refrigerated food items. Findings include: I. Professional reference According to the Sanofi Pasteur (2020) package insert for Tuberculin Purified Protein Derivative (Mantoux): Tubersol Food and Drug Administration (FDA), retrieved on 5/31/24 from https://www.fda.gov/media/74866/download, A vial of Tubersol (tuberculin purified protein derivative) which has been entered and in use for 30 days should be discarded. Do not use it after the expiration date. II. Facility policy and procedure The Storage of Medications policy and procedure, reviewed 2/17/23, was provided by the director of nursing (DON) on 5/23/24 at 10:00 a.m. It read in pertinent part, The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner. Refrigerated medications are stored separately from food and are labeled accordingly. III. Observations On 5/22/24 at 2:11 p.m. unit medication refrigerator #1 was observed with registered nurse (RN) #1. The following items were found: -A vial of Tubersol PPD was opened and undated. -A vial of Tubersol was dated as opened on 4/12/24. The vial should have been discarded on 5/12/24. -Several unopened nutritional supplement drinks and unopened soda drinks were in the medication refrigerator. On 5/22/24 at 2:15 p.m. unit medication refrigerator #2 was observed. The following items were found: -Multiple unopened yogurt and pudding cups. -One opened med pass shake was lying on its side at the bottom of the refrigerator. -Bisacodyl suppositories, eye drops and probiotic containers were stored on the top shelf of the refrigerator. IV. Staff interviews RN #1 was interviewed on 5/22/24 at 2:14 p.m. RN #1 said nutritional supplements, as long as they were not opened, could be stored in the same refrigerator with the medications. She said she was not sure if soda could be stored in the refrigerator with nutritional supplements. RN #1 said it was not good practice to store food items and beverages with medications. She said tuberculin should be dated after opening and was only good for 30 days after opening, per the manufacturer's directions. The assistant director of nursing (ADON) was interviewed on 5/22/25 at 2:18 p.m. The ADON said food items should not be stored with medications and tuberculin should be dated so it could be identified when it needed to be discarded. She said the manufacturer's recommendation was to discard it after 30 days. She said storing medications and food and beverage items together was not a sanitary practice. The nursing home administrator (NHA) was interviewed on 5/22/24 at 2:18 p.m. The NHA said storing medications and beverages and food items in the same refrigerator was not a sanitary practice and the facility would order additional refrigerators to keep medications and food items separate.

Based on observations, record review, and interviews, the facility failed to use a person-centered approach when determining the use of bed rails for eight (#1, #33, #36, #44, #18, #25, #41, and #53) of seventeen residents reviewed for bed rails out of 33 sample residents. Specifically, for Resident #1, #33, #36, #44, #18, #25, #41 and #53, the facility failed to: -Assess the resident for risk of entrapment prior to installing the bed rails; -Obtain consent, which included the risks versus benefits of bed rails, from the resident and/or the resident's representative prior to bed rail installation; -Obtain physician's orders for bed rails; and, -Conduct quarterly assessments of the bed rails to evaluate the continued need and safety of the bed rails. Findings include: I. Professional reference The U.S. Food and Drug Administration (FDA) Recommendations for Health Care Providers Using Adult Portable Bed Rails (2/27/23), was retrieved on 5/28/24 from https://www.fda.gov/medical-devices/adult-portable-bed-rail-safety/recommendations-health- care-providers-using-adult-portable-bed-rails. It read in pertinent part, Avoid the routine use of adult bed rails without first conducting an individual patient or resident assessment. Evaluation is needed to assess the relative risk of using the bed rail compared with not using it for an individual patient. II. Facility policy and procedure The Bed Safety and Bed Rails policy and procedure, revised August 2022, was provided by the nursing home administration (NHA) on 5/22/24 at 2:00 p.m. It read in pertinent part, Residents' beds meet the safety specifications established by the Hospital Bed Safety Workgroup. The use of bedrails are prohibited unless the criteria for use have been met. Consideration is given to the residents' safety, medical conditions, comfort and freedom of movement, as well as input from residents and resident families regarding previous sleeping habits and bed environment. Maintenance staff routinely inspects all beds and related equipment to identify risks and problems including potential entrapment risks. The maintenance department provides a copy of inspections to the administrator and reports results to the Quality Assurance and Performance Improvement (QAPI) committee for appropriate action. III. Resident #1 A. Resident status Resident #1, under age 65, was admitted on [DATE]. According to the May 2024 computerized physician orders (CPO), diagnoses included multiple sclerosis, dementia, contracture of muscle and chronic respiratory failure. The 2/28/24 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. He was dependent on staff assistance with transfers, toileting personal hygiene and mobility. -The assessment documented Resident #1 did not use bed rails. B. Observations On 5/20/24 at 9:40 a.m., Resident #1 was observed lying in bed with two metal half rails attached to the resident's bed. On 5/21/24 at 2:35 p.m. Resident #1 was observed to be lying in bed with the two metal half rails up on the bed. C. Resident interview Resident #1 was interviewed on 5/22/24 at 10:57 a.m. Resident #1 said the bed rails were used to help him roll left and right side when the staff changed his briefs. He said the bed rails had been in place for a long time. D. Record review The May 2024 CPO revealed Resident #1 had a physician's order for a set of half side rails on each side of the bed to help aid with mobility, ordered on 3/9/18. The comprehensive care plan, initiated on 3/7/18 and revised on 1/9/19, revealed Resident #1 used half side rails to his bed related to multiple sclerosis. Interventions included Resident #1 holding on to the bed rails to assist with turning and repositioning. -A comprehensive review of the resident's electronic medical record (EMR) failed to reveal a bed rail evaluation and consent prior to the initiation of the bed rails as a positioning enabler. -The EMR failed to reveal quarterly assessments for the evaluation of the continued use and safety of the half bed rails. -The maintenance department had no routine inspections for the resident's half bed rails. IV. Resident #33 A. Resident status Resident #33, over the age 65, was admitted on [DATE]. According to the May 2024 CPO, diagnoses included multiple sclerosis, dementia, major depressive disorder, lower back pain and chronic obstructive pulmonary disease (COPD). The 3/19/24 MDS assessment revealed the resident was cognitively intact with a BIMS score of 14 out of 15. She required set up assistance with toileting, showering, dressing, personal hygiene and mobility. -The assessment documented Resident #33 did not use bed rails. B. Observation On 5/20/24 at 10:36 a.m. and on 5/21/24 at 3:02 p.m., a bed rail was observed on the left side of Resident #33's bed. C. Resident interview Resident #33 was interviewed on 5/22/24 at 11:05 a.m. Resident #33 said the bed rail had been on her bed for a very long time. The resident said she does not know the reason the bed rail was attached to her bed because she does not use it. D. Record review The care plan, initiated on 4/19/24 and revised on 10/10/23, revealed Resident #33 was at risk for falls related to multiple sclerosis and abnormality of gait. Interventions included the use of a bedside rail for mobility. -Review of Resident #33's May 2024 CPO revealed there was no physician's order for the resident's bed rail. -The resident's EMR revealed Resident #33 was not evaluated for the use of a bed rail, there was no consent for bed rails and no documentation about the risks and benefits of using a bed rail. -The EMR failed to reveal quarterly assessments for the evaluation of the continued use and safety of the bed rail. -The maintenance department had no routine inspections for the resident's bed rail. V. Resident #36 A. Resident status Resident #36, over the age 65, was admitted on [DATE]. According to the May 2024 CPO, diagnoses included cerebral infarction (a condition that occurs when brain tissue is damaged), type 2 diabetes and depressive disorder. The 2/22/24 MDS assessment documented the resident was cognitively intact with a BIMS score of 14 out of 15. She required set up assistance for oral and personal hygiene, substantial to maximum assistance with showers, dressing, and was dependent on staff with toileting. -The assessment documented Resident #36 did not use bed rails. B. Observation On 5/20/24 at 9:14 a.m. and on 5/21/24 at 2:15 p.m. Resident #36 was lying in her bed. Bed rails were observed on both sides of the resident's bed. C. Resident interview Resident #36 was interviewed on 5/22/24 at 1:04 p.m. Resident #36 said the bed rails were for her to hold on to to assist her with turning herself during incontinent care. D. Record review The resident care plan, revised on 5/24/21, revealed Resident #36 had a mobility deficit related to stroke and cognitive impairment as evidenced by difficulty with bed mobility requiring the use of bed rails. -Review of Resident #36's May 2024 CPO revealed there was no physician's order for the resident's bed rails. -The resident's EMR revealed Resident #36 was not evaluated to use a bed rail, there was no consent and no documentation about the risks and benefits of using a bed rail. -The EMR failed to reveal quarterly assessments for the evaluation of the continued use and safety of the bed rails. -The maintenance department had no routine inspections for the resident's bed rails. VI. Resident #44 A. Resident status Resident #44, age greater than 65, was admitted on [DATE]. According to the May 2024 computerized CPO, diagnoses included Alzheimer's disease, myxedema coma (severe hypothyroidism leading to decreased mental status, hypothermia, and other symptoms related to slowing of function in multiple organs), insomnia and muscle weakness. The 4/30/24 MDS assessment documented the resident had severe cognitive impairment with a BIMS score of four out of 15. She required partial assistance with showering and supervision with toileting and personal hygiene. -The assessment documented Resident #44 did not use bed rails. B. Observation On 5/20/24 at 3:30 p.m., 5/21/24 at 8:57 a.m. and 5/22/24 at 10:30 a.m. bed rails were observed on both sides of Resident #44's bed. C. Record review The care plan, revised on 4/12/24, revealed Resident #44 had an activity of daily living (ADL) self care performance deficit related to Alzheimer's disease. -Bed rails were not included in the resident's care plan interventions. -Review of Resident #44's May 2024 CPO revealed there was no physician's order for the resident's bed rails. -The resident's EMR revealed Resident #44 was not evaluated to use a bed rail, there was no consent and no documentation about the risks and benefits of using a bed rail. -The EMR failed to reveal quarterly assessments for the evaluation of the continued use and safety of the bed rails. -The maintenance department had no routine inspections for the resident's bed rails. VII. Staff interviews Certified nurse aide (CNA) #5 was interviewed on 5/22/24 at 9:14 a.m. CNA #5 said the bed rails were handles added to the sides of the bed. She said bed rails helped a resident, if used appropriately, for bed mobility and when the resident got in and out of bed. CNA #5 said the resident held on to the bed rails during incontinence care. Licensed practical nurse (LPN) #4 was interviewed on 5/22/24 at 9:32 a.m. LPN #4 said the bed rails were used when residents were alert and oriented and could help themselves instead of waiting for a staff member to help them. She said a resident should be evaluated for safety before using the side rail. She said the evaluation was based on the residents' level of care based on their everyday needs. LPN #4 said consent should be obtained from the resident or resident's representative prior to use of the bed rails. The director of nursing (DON) was interviewed on 5/22/24 at 2:15 p.m. The DON said, before side rails could be used, a bed rail evaluation and consent needed to be completed. However, she said the facility did not consider the bed rails as a form of restraint, therefore the facility did not perform evaluations and did not obtain consent from the residents. The DON said the facility did not have a formal document to show maintenance staff routine inspections of all bed rails for a potential entrapment risk. The DON said the facility would immediately ensure consent and evaluations were completed. 47350 VIII. Resident #18 A. Resident status Resident #18, age over 65, was admitted on [DATE] and readmitted on [DATE]. According to the May 2024 CPO, diagnoses included chronic obstructive pulmonary disease (COPD), chronic kidney disease (CKD) and dementia. The 1/23/24 MDS assessment revealed the resident was cognitively intact with a BIMS of 13 out of 15. She required partial/moderate assistance with transfers and toileting, set up assistance with personal hygiene and was independent with eating and bed mobility. -The assessment indicated that restraints and bed rails were not used. B. Observations On 5/23/24 at 8:00 a.m. Resident #18 was observed with a bed rail on her bed. C. Record review The activities of daily living (ADL) care plan, initiated on 2/21/22 and revised 9/1/22, revealed Resident #18 used a halo assistive device (bed rail) on the door side of the bed to maximize independence with turning and repositioning in bed. -A comprehensive review of the resident's EMR failed to reveal a bed rail evaluation, physician's order or consent done prior to the initiation of the bed rail as a positioning enabler. -The EMR failed to reveal quarterly assessments for the evaluation of the continued use and safety of the bed rail. IX. Resident #25 A. Resident status Resident #25, age less than 65, was admitted on [DATE]. According to the May 2024 CPO, diagnoses included encephalopathy and protein malnutrition. The 2/22/24 MDS assessment revealed severe cognitive impairment with a BIMS score of zero out of 15. He was dependent with toileting and personal hygiene, required substantial/maximal assistance with bed mobility and transfers and required supervision with eating. -The assessment indicated that restraints and bed rails were not used. B. Observation On 5/23/24 at 8:02 a.m. Resident #25 was observed with bed rails on his bed. C. Record review The ADL care plan, initiated on 6/10/23 and revised on 2/27/24 revealed Resident #25 had a bed rail on his bed for assistance with positioning. The May 2024 CPO revealed a physician's order for bilateral bed rails to be used for positioning, ordered 2/22/23. -A comprehensive review of the resident's EMR failed to reveal a bed rail evaluation prior to the initiation of the bed rails. -The EMR failed to reveal quarterly assessments for the evaluation of the continued use and safety of the bed rail. X. Resident #41 A. Resident status Resident #41, age greater than 65, was admitted on [DATE]. According to the May 2024 CPO, diagnoses included CKD, chronic respiratory failure and vascular dementia. The 2/1/24 MDS assessment revealed the resident had severe cognitive impairment with a BIMS score of seven out of 15. She required substantial/maximal assistance with transfers, partial/moderate assistance with personal hygiene, bed mobility, toileting and was independent with eating. -The assessment indicated that restraints and bed rails were not used. B. Observations On 5/23/24 at 8:04 a.m. Resident #41 was observed with a bed rail on her bed. C. Record review The ADL care plan, initiated on 8/11/23 and revised on 3/6/24, revealed Resident #41 required partial/moderate assistance of one staff member for bed mobility. -The care plan failed to indicate the use of bed rails as an intervention as a positioning enabler. -A comprehensive review of the resident's EMR failed to reveal a bed rail evaluation, physician's order or consent done prior to the initiation of the bed cane/halo as a positioning enabler. -The EMR failed to reveal quarterly assessments for the evaluation of the continued use and safety of the bed rail. XI. Resident #53 A. Resident status Resident #53, age 80, was admitted on [DATE]. According to the May 2024 CPO, diagnoses included atrial fibrillation, pancreatic insufficiency and cognitive communication deficit. The 4/11/24 MDS assessment revealed the resident had severe cognitive impairment with a BIMS score of seven out of 15. She required partial/moderate assistance for toileting, supervision with bed mobility, transfers and was independent with eating, personal hygiene. -The assessment indicated that restraints and bed rails were not used. B. Observations On 5/23/24 at 8:06 a.m. Resident #53 was observed with a bed rail on her bed. C. Record review The ADL care plan, initiated on 5/12/23 and revised on 1/31/24, revealed Resident #53 was able to roll side to side in bed and go from sitting to lying and lying to sitting with the partial/moderate assistance of one staff member. -The care plan failed to indicate the use of bed rails as an intervention as a positioning enabler. -A comprehensive review of the resident's EMR failed to reveal a bed rail evaluation, physician's order or consent done prior to the initiation of the bed cane/halo as a positioning enabler. -The EMR failed to reveal quarterly assessments for the evaluation of the continued use and safety of the bed rail. XII. Staff interviews CNA #2 was interviewed on 5/23/24 at 8:30 a.m. CNA #2 said Residents #18. #25. #41 and #53 all used bed rails as bed mobility positioning or bed transferring devices. Licensed practical nurse (LPN) #2 was interviewed on 5/23/24 at 8:34 a.m. LPN #2 said residents with bed rails should all have an assessment by occupational or physical therapy for their use of the bed rails. She said the resident or the resident's representative should give consent for the bed rails prior to their use. She said an order should be placed before the bed rails were used. She said bed rails should have a regular assessment by maintenance to maintain the safety and functionality of their use. She said she was new to the facility and was unfamiliar with the facility's policies and procedures.

Based on observations, record review and interviews, the facility failed to ensure residents received adequate supervision to prevent accidents for two (#68 and #70) of five residents reviewed for falls out of 33 sample residents. Specifically, for Resident #68 and #70, the facility failed to: -Identify the root cause of falls and implement timely and effective interventions to prevent further falls; and, -Update and revise the residents' care plans with new interventions after each fall. Findings include: I. Facility policy. The Fall Clinical Protocol policy, revised March 208, was provided by the director of nursing (DON) on 5/16/24 at 1:44 p.m. It read in pertinent part, Staff will begin to try to identify possible causes within 24 hours of the fall. The staff will continue to collect and evaluate information until either the cause of the fall is identified or it is determined that the cause cannot be found or is not correctable. If underlying causes cannot be readily identified, staff will try various relevant interventions based on assessment until fall reduces or stops or until a reason is identified for its continuation. II. Resident #68 A. Resident status Resident #68, age [AGE] years old, was admitted on [DATE] and readmitted on [DATE]. According to the May 2024 computerized physician orders (CPO), diagnoses included dementia with agitation, abdominal pain, vascular (blood vessels) disorder of the intestine and cystic disease (condition that causes fluid filled sacs) of the liver. The 2/13/24 minimum data set (MDS) assessment documented the resident had severe cognitive impairment with a brief interview for mental status (BIMS) score of two out of 15. The resident required partial assistance with oral hygiene and dress. He required substantial assistance with showering and personal hygiene. He required supervision with toileting. B. Record review Resident #68's fall care plan, revised 1/4/24, revealed the resident was at risk for falls related to confusion and poor safety awareness. Interventions included ensuring the resident wore non-skid shoes when ambulating and anticipating the resident's needs. The vision care plan, revised 8/16/23, revealed the resident had impaired visual functions in both eyes. Interventions included reminding the resident to wear glasses and ensuring glasses were clean and free from scratches. A 4/13/24 fall nurse note revealed Resident #68 had an injury to the left side of his eye, brow and bridge of his nose. -A 4/14/24 nurse note revealed there was bruising noted over the bridge of his nose, left eye upper and lower eyelids and lateral aspect of the left eye. There was black and blue bruising of his bilateral hands. -An incident report was requested for the 4/13/24 fall but not provided. A 4/25/24 interdisciplinary team (IDT) progress note revealed a fall meeting was held. The fall from 4/13/24 was reviewed. The new intervention was for physical therapy to do an evaluation. -The intervention was not implemented until 12 days after the resident's 4/13/24 fall. -The interdisciplinary team (IDT) did not identify the root cause of the fall. -The new intervention for a physical therapy evaluation was not added to the Resident #68's fall care plan. A 5/16/24 fall incident report was reviewed. The resident was found on the floor in the secure unit dining room. The report documented the resident tried to maneuver around another resident's wheelchair and his foot was caught in the other resident's wheelchair's back wheel. He tried to hold onto the wheelchair's handles but lost his balance and fell on his right side. -The incident report did not identify any new fall interventions that were implemented at the time of the fall. A 5/17/24 nurse note revealed the resident continued to walk around the unit. He looked down at the floor while walking instead of looking ahead. A 5/19/24 nurse note revealed the resident walked around the unit with his head down at the floor or bent over to pick up items from the floor. Staff monitored the resident to give safety prompts as needed. -There was no IDT note documented to indicate the fall had been reviewed by the IDT and new interventions were implemented. -The fall care plan did not identify new interventions after the fall. -The IDT did not identify the root cause of the fall. The 5/22/24 fall risk assessment revealed that the resident fell before, did not use an assistive device, such as a wheelchair or walker to ambulate, had a weak gait and overestimated or forgot his limits. He scored a 65 which indicated he was a high risk to fall. D. Staff interviews Certified nurse aide (CNA) #6 was interviewed on 5/23/24 at 11:32 a.m. CNA #6 said she knew a resident was at a high fall risk if the resident used oxygen, if they were woozy or if the resident tried to stand without assistance when the resident required assistance. She said she kept an eye on residents to prevent a fall. She said she was familiar with Resident #68. She said he was a high fall risk. She said she kept an eye on the resident, encouraged the resident to sit down and kept food and water close to him to prevent him from falling. Registered nurse (RN) #2 was interviewed on 5/23/24 at 11:40 a.m. RN #2 said she knew a resident was at a high fall risk based on their gait, diagnoses and observation of the resident. She said she made sure the area was clear of spills to prevent a fall. She said she was familiar with Resident #68. She said he was a high fall risk. She said she asked him to sit and walked with him to prevent him from falling. The DON was interviewed on 5/23/24 at 10:13 a.m. The DON said staff knew a resident was a high fall risk based on a fall star placed on the door of residents who were a high fall risk. She said a nurse knew a resident was a fall risk based on the fall assessment. She said the nurses communicated to the staff verbally when a resident was a fall risk. She said if a resident fell , a RN completed an assessment and started a fall protocol that included neurological checks. The DON said the nurse should look at what happened to cause the fall and add a fall intervention to prevent further falls. She said the IDT met weekly and added further interventions if appropriate. She said she was familiar with Resident #68. She said he was a high fall risk. The DON said there was not a root cause analysis done for Resident #68's falls on 4/13/24 and 5/16/24. She said she was not aware Resident #68's eyesight was decreasing and his head was down frequently. She said if she knew she would include therapy and maintenance to develop interventions to prevent accidents and falls. The DON said interventions were not reviewed and a new intervention was not added for Resident #68's fall on 5/16/24. She said the nurse who completed the nurse assessment should identify the initial root cause of the fall and an intervention. V. Facility follow up On 5/28/24 at 7:23 a.m. the minimum data set coordinator (MDSC) sent a performance improvement plan which indicated the facility had created an action plan to review falls and interventions in a timely manner and to decrease the number of falls. It revealed the steps included reviewing falls, reviewing interventions, staff considerations, staff education and staff awareness of high fall risk residents. -The follow-up plan did not include dates when the action steps were completed. 31229 III. Resident #70 A. Resident status Resident #70, age 81, was admitted on [DATE]. According to the May 2024 CPO, diagnoses included malignant melanoma of skin, malignant neoplasm of prostate, malignant neoplasm of brain, nontraumatic intracerebral hemorrhage, and history of falling. The 2/29/24 MDS assessment revealed the resident's cognition was severely impaired with a BIMS score of six out of 15. He had no behaviors. He required partial moderate assistance with toileting, dressing, personal hygiene and transfers. B. Resident representative interview Resident's #70's representative was interviewed on 5/20/24 at 3:45 p.m. The representative said the resident was falling frequently at home and in the facility. She said the resident still thought he was strong and tried to do things he used to, such as getting up and walking. She said he was not able to use the call light to call for assistance with transfers. C. Record review The fall care plan, initiated 3/7/24, revealed the resident had a history of falls due to poor balance, poor communication/comprehension and unsteady gait. Interventions included placing a fall mat by the resident's bed while he was in bed (initiated 4/1/24), placing a wedge cushion in the resident's wheelchair (initiated 4/8/24), placing a silent bed sensor (bed alarm) on the resident's bed (initiated 4/23/24), staff to provide frequent checks on the resident (initiated 4/23/23) and providing a lipped mattress on the bed (initiated 5/16/24). -Despite the resident's history of frequent falls (see resident's diagnoses and resident representative interview above), the facility failed to initiate a fall care plan with interventions to prevent falls until 3/7/24, after Resident #70 sustained a fall on 3/6/24 (see below). -The care plan failed to specify how often frequent checks should be conducted for Resident #70. On 2/17/24, a nursing note revealed Resident #70 was admitted to the facility under hospice care. The note documented the resident was admitted to the facility following falls at home. The resident required extensive assistance of one staff member for transfers. 1. Fall on 3/6/24 On 3/6/24 at 5:45 a.m. a nurse documented Resident #70 sustained an unwitnessed fall. The resident was noted to be on the floor at the side of his bed, face down. The resident had been displaying increased restlessness and/or confusion during the night. The resident's call light had been in reach, but the resident did not always use it to call for assistance from staff. -The progress note failed to document a new intervention to prevent further falls. -There was no IDT follow up note for the fall which indicated the facility identified a root cause for the fall. 2. Fall on 3/26/24 On 3/26/24, a nurse documented Resident #70 was sitting in one of the regular chairs, watching TV (television) in the lounge area. The resident's wheelchair was locked/parked close to the chair. The nurse heard a noise and found the resident lying on his back on the floor in front of the chair he had been sitting in and the resident's wheelchair had been unlocked. The resident was placed in bed with the bed in low position and the call light in reach. The door to the resident's room was left open so he could be monitored by the staff. The nurse encouraged the resident to call for assistance when needing to transfer. The resident continued to display his usual episodes of forgetfulness/confusion and made some comments to the nurse that he could stand on his own. -The progress note failed to document a new intervention to prevent further falls. -There was no IDT follow up note for the fall which indicated the facility identified a root cause for the fall. -The resident's fall care plan was not updated until 4/1/24 (six days after the fall) when a floor mat was added as an intervention (see care plan above). 3. Fall on 4/4/24 On 4/4/24 at 10:30 p.m. a nurse documented Resident #70 was found sitting on the floor in front of his wheelchair in the hallway. Two staff members used a gait belt to stand the resident and get him in his wheelchair. The resident had been watching TV late in the TV room. -The progress note failed to document a new intervention to prevent further falls. -There was no IDT follow up note for the fall which indicated the facility identified a root cause for the fall. -The resident's fall care plan was not updated until 4/8/24 (four days after the fall) when a wedge cushion was added to the resident's wheelchair as an intervention (see care plan above). 4. Fall on 4/14/24 On 4/14/24 at1:14 a.m. a nurse documented Resident #70 was found sitting on the floor with his feet towards the wall, holding on to the bed halo (bed rail). The resident was unable to state what occurred but mentioned his wife and trying to meet with someone. The resident was reoriented to time. He required a two) person assistance back to bed. -The progress note failed to document a new intervention to prevent further falls. -There was no IDT follow up note for the fall which indicated the facility identified a root cause for the fall. -The resident's fall care plan was not updated until 4/23/24 (when the resident sustained another fall which was nine days after the 4/14/24 fall) when a bed alarm and frequent checks on the resident were added as interventions (see care plan above). 5. Fall on 4/23/24 On 4/23/24 at 7:11 a.m. a nurse documentedResident #70 had been in his wheelchair in the lounge area watching TV. The nurse was searching for him and found him on the floor beside his bed in his room. The resident had closed the door to his room. The floor mat was beside the bed and the resident had landed on the floor mat. The resident's call light was in reach, but the resident did not use it to call for staff assistance. -The progress note failed to document a new intervention to prevent further falls. -There was no IDT follow up note for the fall which indicated the facility identified a root cause for the fall. 6. Fall on 5/16/24 On 5/16/24 at 6:30 a.m. a nurse documented Resident #70 attempted to transfer himself out of bed and was found by CNA lying on the fall mat beside his bed. The 5/16/24 IDT fall review note documented the hospice services provider was to provide a lipped mattress. No further interventions were documented. D. Staff interviews CNA #7 was interviewed on 5/22/24 at 10:45 a.m. CNA #7 said Resident #70 was falling frequently during evening or nighttime looking for his wife or trying to get out of bed. She said the resident's room was across the nurses' desk and the staff was keeping an eye on him through the open door. RN #3 was interviewed on 5/22/24 at 10:55 a.m. RN #3 said most of Resident #70's falls happened at night. She said the resident was not able to understand or remember to use his call light. She said he did not have any of his falls on her shifts (during the day). CNA #8 was interviewed on 5/23/24 at 1:18 p.m. CNA #8 said she checked on Resident #70 frequently and took him to the toilet. She said the resident did not fall on her shifts. RN #4 was interviewed on 5/23/24 at 1:23 p.m. RN #4 said the resident had been falling usually in the late afternoon and at night. She said he had a short attention span. She said the resident would not participate in activities for longer than a couple of minutes before he started looking for his wife. RN #4 said when he was in the living room watching TV he would try to stand up and look for his wife. She said he did the same thing when he was in bed. She said as soon as he opened his eyes he would try to stand up and ask the staff about his wife. She said the best approach to prevent falls for the resident would be to have someone with the resident at all times. RN #4 said his wife lived very close to the facility and visited most of the weekdays in the afternoon. The DON was interviewed on 5/23/24 at 3:00 p.m. The DON said falls were reviewed in the facility during morning stand-up meetings and approaches to prevent falls were discussed. She said the IDT was meeting to review falls weekly and there was a new fall intervention added after each fall for Resident #70. -However, Resident #70's progress notes and care plan did not reflect that a new intervention was added timely after each of the resident's falls (see record review above).

Based on interviews and record review, the facility failed to ensure four (#7, #8, #9 and #10) out of 12 sample residents were kept free from abuse. Specifically, the facility: -Failed to prevent a resident-to-resident altercation between Residents #2 and #10; -Failed to prevent a resident-to-resident altercation between Residents #2 and #7; -Failed to prevent a resident-to-resident altercation between Residents #2 and #9; -Failed to prevent a resident-to-resident altercation between Residents #2 and #8; and, -Failed to prevent a second resident-to-resident altercation between Residents #2 and #7. Cross-reference F744: the facility failed to develop person centered individualized care plans for dementia and failed to train staff on individualized person centered interventions for dementia care. Findings include: I. Facility policies and procedures The Abuse Prevention Program policy, revised March 2017, was provided by the nursing home administrator (NHA) on 10/12/21 at 1:53 p.m. by email. The policy documented, Our residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse, and physical or chemical restraint not required to treat the resident's symptoms. As part of the resident abuse prevention, the administration will: Protect our residents from abuse by anyone including, but not necessarily limited to: facility staff, other residents, consultants, volunteers, staff from other agencies, family members, legal representatives, friends, visitors, or any other individual II. Altercation on 8/27/21 between Resident #2 and #10. A. Investigation Resident #10 was in her bed resting. Resident #2 laid in the bed with her. Resident #10 asked Resident #2 to please get out of her bed. Resident #2 got up and began slapping at Resident #10 on her leg. Staff redirected Resident #2 out of the room. The two residents were separated and assessed for injuries. The conclusion of the investigation substantiated physical abuse from Resident #2 to Resident #10. III. Altercation on 8/28/21 between Resident #2 and Resident #7. A. Investigation Resident #7 was in her room. A certified nurse aide (CNA) heard Resident #7 yell out. Resident #2 hit Resident #7 on her head and then walked out of Resident #7's room. Staff immediately redirected Resident #2 away from Resident #7. A skin assessment was completed for Resident #7 and no change in skin integrity was noted. The conclusion of the investigation substantiated physical abuse from Resident #2 to Resident #7. IV. Altercation on 8/28/21 between Resident #2 and Resident #9. A. Investigation Resident #9 was in the kitchen with staff and Resident #2 slapped her in the right upper arm. Resident #9 denied pain. The conclusion of the investigation substantiated physical abuse from Resident #2 to Resident #9. V. Altercation on 8/29/21 between Resident #2 and Resident #8. A. Investigation Resident #8 was found by the nurse in the sitting room on the unit. Resident #8 was getting pushed in her wheelchair by Resident #2. Resident #2 was repeatedly pushing Resident #8's wheelchair into another resident's wheelchair. The nurse asked Resident #2 to stop pushing residents in wheelchairs around in the unit.The nurse locked the brakes on Resident #8's wheelchair to get Resident #2 to stop pushing Resident #8's wheelchair into another resident's wheelchair. Resident #2 stopped pushing Resident #8, raised her hands in the air and took her left hand and slapped down on the top of Resident #8's head. Resident #8 began to cry and was soothed by this nurse. No injury to the area was noted. Resident #8 denied any pain following the incident.The conclusion of the investigation substantiated physical abuse from Resident #2 to Resident #8. VI. Altercation on 8/29/21 between Resident #2 and Resident #7. A. Investigation Resident #7 was sitting in her wheelchair in the dining room. Resident #7 was having several repeated nonsensical but loud verbalizations. This was Resident #7's baseline while awake most days. Resident #2 was walking through the dining room with her one-on-one sitter, the NHA. Resident #7 was having one of her verbal outbursts. This appeared to have upset Resident #2, and before the one-to-one caregiver could redirect Resident #2, she responded by turning around and slapping Resident #7 on her back. Resident #2 was redirected away from Resident #7. No injury was noted to Resident #2's skin. The conclusion of the investigation substantiated physical abuse from Resident #2 to Resident #7. VII. Resident #2 A. Resident status Resident #2, age 72, was admitted on [DATE]. According to the October 2021 computerized physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The 9/14/21 minimum data set (MDS) assessment revealed the resident was cognitively impaired with no brief interview for mental status (BIMS) assessed. The MDS identified the resident had physical behavioral symptoms directed towards others four to six days in the past seven, and verbal behavioral symptoms directed towards others one to three days in the past seven. The MDS identified the resident refused cares daily. B. Record review The care plan (date unknown) identified Resident #2 had the potential to be physically aggressive with staff during cares and other residents if they were first aggressive with her, related to Resident #2's dementia. Interventions included: -Ask alternate staff to provide cares as able. -Assess and address for contributing sensory deficits. -Assess and anticipate Resident #2's needs: food, thirst, toileting needs, comfort level, body positioning, pain, etc. -Wait 10 to 15 minutes to re-approach when she shows aggression. -When Resident #2 becomes agitated, intervene before the agitation escalates. Guide away from the source of the distress, engage calmly in conversation, and if her response is aggressive, have the staff walk calmly away, and approach later. The August 2021 treatment administration record (TAR) identified: -Monitor for the following target behavior(s): #1 crying, #2 isolation, #3 decreased appetite, #4 change in sleep patterns, #5 aggression/combative each shift. No behaviors observed type 0. -Behaviors observed: 1. Identify target behaviors (1-6), 2. Document non-pharmacological interventions used (0-11), 3. (see below) -Document behaviors outcome every shift. Non-pharmacological interventions: 0= N/A, 1=redirect, 2= validate feelings, 3= empathetic listening, 4=activity, 5=toileting, 6= food, 7=fluids, 8=repositioning, 9=offer alternative choices, 10= other -Start Date 8/20/2021 Behaviors noted aggression three times in the morning and four times in the evening in August 2021. The TAR did not identify who the aggression was toward. The September 2021 TAR identified: Behaviors noted aggression once in the morning, and once in the afternoon. The October 2021 TAR (from the first to the fifth) had no aggressive behaviors identified. The October 2021 CPO identified the following medication changes after the altercations: -[MEDICATION(S)] (anticonvulsant/antipsychotic) capsule delayed release sprinkles 125 mg, give two capsules by mouth twice a day related to obsessive-compulsive disorder. Start date 8/30/21, end date 9/1/21. -[MEDICATION(S)] capsule delayed release sprinkles 125 mg, give four capsules by mouth twice a day related to obsessive-compulsive disorder. Start date 9/1/21, end date 9/21/21. -[MEDICATION(S)] capsule delayed release sprinkles 125 mg, give three capsules by mouth twice a day related to obsessive-compulsive disorder. Start date 9/21/21, end date 10/1/21. VIII. Resident #10 status Resident #10, age 77, was admitted on [DATE]. According to the October 2021 CPO, diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The 9/21/21 MDS assessment revealed the resident was cognitively impaired with no BIMS assessed. The MDS identified the resident had physical behavioral symptoms directed towards others one to three days in the past seven, and no verbal behavioral symptoms directed towards others. The MDS identified the resident did not refuse cares. IX. Resident #7 status Resident #7, age 64, was admitted on [DATE]. According to the October 2021 CPO, diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The 9/21/21 MDS assessment revealed the resident was cognitively impaired with no BIMS assessed. The MDS identified the resident had physical behavioral symptoms directed towards others one to three days in the past seven, and verbal behavioral symptoms directed towards others one to three days in the past seven. The MDS identified the resident refused cares one to three days in the past seven. X. Resident #9 status Resident #9, age 84, was admitted on [DATE]. According to the October 2021 CPO, diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] The 7/13/21 MDS assessment revealed the resident had a severe cognitive deficit with a BIMS score of three out of 15. The MDS identified the resident had other behavioral symptoms not directed towards others one to three days in the past seven. The MDS identified the resident refused cares one to three days in the past seven. XI. Resident #8 status Resident #8, age 67, was admitted on [DATE]. According to the October 2021 CPO, diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] The 7/13/21 MDS assessment revealed the resident had a severe cognitive deficit with a BIMS score of three out of 15. The MDS identified the resident had verbal behavioral symptoms directed towards others one to three days in the past seven, and other behavioral symptoms not directed towards others one to three days in the past seven. The MDS identified the resident did not refuse cares. XII. Staff interviews CNA #1 was interviewed on 10/6/21 at 9:15 a.m. She said Resident #2 did not have any aggressive behaviors towards other residents on the secured unit. She said Resident #2 had a couple of bad days, but had some medication changes and had been doing better. CNA #2 was interviewed on 10/6/21 at 9:50 a.m. She said Resident #2 had aggressive behaviors toward other residents in the past, but had not displayed aggressive behaviors toward another resident recently. She said there were some medication changes and the medications helped her be less aggressive. Registered nurse (RN) #1 was interviewed on 10/6/21 at 10:15 a.m. She said Resident #2 was not aggressive toward other residents. She said she had heard Resident #2 had been aggressive toward other residents, but had not seen the behavior herself. The NHA was interviewed on 10/6/21 at 5:15 p.m. She said she had completed a full investigation after each incident and had reported the altercations to the required entities. She said Resident #2 had a bad couple of days. She said the IDT team and the primary physician met and adjusted her medications and she had been doing well since the altercations. She said Resident #2 had not had any further incidents since the medication changes. The NHA said she understood the residents had the right to live free from abuse and would work to ensure the safety of all the residents in the facility.

Based on observations, record review and interviews, the facility failed to ensure the resident environment remained as free of accident hazards as possible, and adequate supervision was provided to prevent accidents, for one (#1) of nine residents reviewed for elopment out of 12 sample residents. Specifically, the facility: -Failed to provide qualified supervision for an at risk adult resulting in an elopment, and -Failed to assess a resident upon returning to the facility after an elopement. Findings include: I. Facility policy The Elopements policy, undated, was provided by the nursing home administrator (NHA) on 10/6/21 at 2:09 p.m. The policy included, When the resident returns to the facility, the Director of Nursing Services (DON) or Charge Nurse shall . Examine the resident for injuries . II. Resident #1 A. Resident status Resident #1, age 69, was admitted on [DATE]. According to the October 2021 computerized physician orders (CPO), diagnoses included [CONDITION(S)] and [CONDITION(S)] following cerebral infarction affecting the right dominant side, ataxic gait, and cognitive communication deficit. The 8/19/21 minimum data set (MDS) assessment revealed the resident was moderately cognitively impaired with a brief interview for mental status (BIMS) score of eight out of 15. The MDS identified the resident had no physical behavioral symptoms directed towards others, no verbal behavioral symptoms directed towards others, and did not reject evaluations or care. B. Record review The care plan (date unknown) identified Resident #1 had a history of leaving the facility without telling staff or signing out. Resident #1 would be reminded by staff to sign out and tell staff that he would like to leave the facility. The care plan did not identify interventions for Resident #1 leaving the facility. The resident had an elopement evaluation completed on 5/7/2020. Resident #1 was not identified as an elopement risk. The progress note dated 6/7/21 at 8:43 p.m. documented, (Resident #1) left the building to go see his mom at the hospital next door. His sister brought him back around 8:30 (p.m.) upset and said she found him outside the hospital without his walker. She stated it should not be that easy to just walk out of here. He has been to his mom's room several times this evening and just sits. He is obviously distressed and concerned for his mom. (Resident #1) is on every Q (every) 15 minute checks. He stated his sister did not update him on his mom and how she was doing. We will get information for him tomorrow if possible. The progress note dated 6/20/21 at 9:09 p.m. documented, Late Entry: On 6/8/21 (Resident #1) had wandered over to the hospital (across the street) where his mother was to visit her. (Resident #1) did not have his walker and did not inform staff that he was leaving the facility. (Resident #1's) sister contacted this writer and said she feels he needs to go to the secure memory unit. (The NHA) explained that this is the only documented wandering episode that was documented and the criteria for admitting someone to the secure memory unit is more detailed than one episode. Resident #1 was placed on one to one (1:1) supervision upon returning by his sister. The facility failed to complete an elopement assessment with Resident #1 after he was returned to the facility by his sister. C. Staff interviews Certified nurse aide (CNA) #3 was interviewed on 10/6/21 at 10:45 a.m. He said Resident #1 had not tried or successfully eloped while he had been on duty. He said Resident #1 would wander around the unit. The assistant director of nursing (ADON) was interviewed on 10/6/21 at 10:50 a.m. She said Resident #1 would get to go for a walk outside with staff twice a week. She said the night in question he had left the building and his sister had found him in the parking lot for the hospital across the street. She said Resident #1 had not attempted to elope again. She said Resident #1's mother was in the hospital at the time and had since passed and he had not tried to leave since. She said he was on 15 minute checks. Registered nurse (RN) #2 was interviewed on 10/6/21 at 11:05 a.m. She said Resident #1 had not displayed any wandering behaviors. She said Resident #1 was a very pleasant resident. She said she had heard he left the building once, but he has not recently. She said he was on 15 minute checks. The DON was interviewed on 10/6/21 at 5:28 p.m. via telephone. She said the facility completes a midnight census to ensure all the residents are in the building. She said staff provide care at a minimum of every two hours, so each resident should have been seen at least every two hours. She said on 6/7/21 Resident #1 was very concerned about his mother's health and left the facility without letting staff know to check on her at the hospital across the street from the facility. She said his sister returned him at 8:30 p.m. She said he was immediately placed on 1:1 supervision. She said there was not an assessment completed upon return because he had no apparent injuries. She said since the elopement, the facility now offers him to go for a walk twice a week outside with staff. She said he enjoyed the walks. She said the facility reinforced education to Resident #1 on the correct process to leave the building to include using his walker, letting staff know, and asking for staff to go with him. The NHA was interviewed on 10/6/21 at 2:35 p.m. She said Resident #1 was considered an at risk adult. She said the elopement had only happened once, and it was related to his mother being in the hospital across the street from the facility. She said the resident remained on 15 minute checks. She said the resident was offered to go for walks outside with staff twice a week. She said she did not know why an assessment was not completed upon return to the facility.

Based on record review and interviews, the facility failed to ensure residents who were diagnosed with Alzheimer's/dementia received the appropriate treatment and services to attain or maintain their highest practicable physical, mental, and psychosocial well-being for three (#2, #3, and #5) out of four residents reviewed for mood and behavior out of 12 sample residents. Specifically, the facility: -Failed to develop a person centered individualized care plan for dementia for Residents #2, #3, and #5; and -Failed to train staff on individualized person centered interventions for dementia care for Residents #2, #3, and #5. Findings include: I. Resident #2 A. Resident status Resident #2, age 72, was admitted on [DATE]. According to the October 2021 computerized physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The 9/14/21 minimum data set (MDS) assessment revealed the resident was cognitively impaired with no brief interview for mental status (BIMS) assessed. The MDS identified the resident had physical behavioral symptoms directed towards others four to six days in the past seven, and verbal behavioral symptoms directed towards others one to three days in the past seven. The MDS identified the resident refused cares daily. B. Record review The care plan (date unknown) identified the behavior of Resident #2 getting into bed with other residents. Resident #2 was often resistant to redirection from staff. Resident #2 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . Interventions included: -Resident #2 seemed to be comforted when holding a lifelike baby doll as she held/cradled or carried the baby at times. She enjoyed folding baby clothes and towels and would do this over and over and seemed to enjoy the focus of attention the activity brought. -Resident #2's husband explained Resident #2 did not like to be told what to do. The staff were made aware to use words such as Will you go over here with me? vs You can't go in there. -Staff were to redirect Resident #2 to Resident #2's room after meals, after toileting etc. to assist Resident #2 in locating her room. The care plan (date unknown) identified Resident #2 had a behavior of wandering aimlessly in and out of other residents' rooms. Interventions included: -Staff were to attempt to guide Resident #2 to Resident #2's room after meals and guide Resident #2 to her bed to see if Resident #2 wanted to lie down. -Utilize signs with arrows to assist Resident #2 to locate her room. The care plan (date unknown) identified Resident #2 was at risk for communication deficits related to a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Interventions included: -Incorporate visual prompting, cues or gestures. -Provide clear, simple instructions. -Staff to anticipate needs such as toileting and guide her to complete tasks of daily living. The care plan (date unknown) identified Resident #2 had impaired cognitive function/dementia or impaired thought processes related to Alzheimer's and dementia. Interventions included: -Administer medications as ordered. Monitor/document for side effects and effectiveness. -Ask yes/no questions in order to determine the resident's needs. -Cue, reorient and supervise as needed. The care plan (date unknown) identified Resident #2 had the potential to be physically aggressive with staff during cares, and with other residents if they were first aggressive with her, related to Resident #2's dementia. Interventions included: -Ask alternate staff to provide care as required. -Assess and address for contributing sensory deficits. -Assess and anticipate Resident #2's needs: food, thirst, toileting needs, comfort level, body positioning, pain, etc. -Wait 10 to 15 minutes to re-approach when Resident #2 shows aggression. -When Resident #2 becomes agitated, intervene before the agitation escalates. Guide away from the source of the distress, engage calmly in conversation, and if Resident #2's response was aggressive, have the staff walk calmly away, and approach later. The progress note dated 8/28/21 at 6:46 p.m. included, Spoke to husband on 8-27-2021 regarding a negative interaction between (Resident #2) and another resident. Explained (to the husband) it (the altercation) would be reported. (The husband) said (Resident #2) had always been angry and that (Resident #2's) whole family was angry. (Resident #2's) behaviors of getting into bed with other residents was explained and he was asked if he would feel comfortable laying in the bed with (Resident #2). It was explained this may be an unmet need for physical touch. (The husband) said he would be glad to do this. (The husband) said he appreciated that staff were taking (an) interest in her and trying to assist (Resident #2). The progress note dated 8/30/21 at 2:21 p.m. included, The nursing home administrator (NHA), director of nursing (DON), social service director (SSD), and assistant director of nursing (ADON) met to speak about recent behaviors and possible interventions for (Resident #2). Pain was discussed due to (Resident #2) had mentioned to one staff member that she was hurting. Music was mentioned as a possible intervention. She also asked about her shoes. Plan would be to continue one to one monitoring. The progress note dated 8/30/21 at 2:32 p.m. included, Contacted (her) husband. Asked (her) husband if he had ever known any pain with (Resident #2). (The husband) said not that he recalled. He said (Resident #2's) disposition was to slap out if she was angry. (The husband) said it did not happen often but she came from a family that was angry and used physical behaviors in their family. (The husband) said she did not like being told what to do and it may (have been) a trigger. He said he laid in her bed with her yesterday and the mattress felt pretty good. He said she seemed more restless than last week. (The husband) said she used to enjoy listening to country music. (The husband) said she loved house cleaning and seemed to be obsessive about it. This information would be used to update her care plan and communication with (Resident #2). The GEM maintenance program (a program developed for care and treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . The form identified appropriate approaches and interventions: -Allow extra time for redirection. -Tempering your tone of voice. -Hand-under-hand. -Use Resident #2's name in conversations. -Mimicking actions. Strategy #1: Set up a laundry folding table. Strategy #2: Walk with Resident #2 inside or outside in facility garden. Strategy #3: Allow Resident #3 to make empty beds, breakdown and help set up bed making stations again. Strategy #4: Walk to her room after meals and set Resident #2 up for a nap. Strategy #5: Remember that you need to earn Resident #2's trust every time you interact with her. Move slow and tell her what you are doing. The care plans did not include the resident-specific interventions identified in the meeting held by the NHA, DON, ADON, and SSD and did not include interventions identified by the husband. C. Staff interviews Activities assistant (AA) #1 was interviewed on 10/5/21 at 12:30 p.m. She said she was not familiar if Resident #2 had any behaviors. She said she knew what room Resident #2 lived in, but did not know about behaviors. She said she had not received training on Resident #2's behaviors. She said if Resident #2 did display any behaviors she would redirect Resident #2 to her room and let the nurse know. Certified nurse aide (CNA) #1 was interviewed on 10/6/21 at 9:15 a.m. She said Resident #2 had not displayed behaviors recently. She said she had heard that Resident #2 had behaviors in the past, but had not in the past few weeks. She said redirection worked well for Resident #2. She said she would often redirect Resident #2 out of rooms. She said the training she had received was the GEM system, but the training had not been completed, it was ongoing. She said the GEM book had interventions. She said she did not know if the interventions from the GEM program were included in Resident #2's care plan. CNA #2 was interviewed on 10/6/21 at 9:50 a.m. She said Resident #2 used to be aggressive, but had not been recently. She said Resident #2 had some medication changes and she calmed down. She said she used the strategies identified in the GEMS program when she worked with Resident #2. She said she had received training on the GEM system, but the training had not been completed for anyone in the building. She said she did not know if the strategies were included in Resident #2's care plan. She said she would use redirection if Resident #2 displayed behaviors. Registered nurse (RN) #1 was interviewed on 10/6/21 at 10:15 a.m. She said Resident #2 liked to go into other rooms, either occupied or empty, and lie down on the beds. She said redirection worked well. She said she was receiving training on the GEM program which was a specialized program for dementia care. She said the training was not done. She said the facility had not completed the training as a whole. She said she would look at the GEM sheet if she did not know how to approach Resident #2. She said she did not look at the care plans. She said she did not know if the identified strategies in the GEM program were incorporated into the current care plan. II. Resident #5 A. Resident status Resident #5, age 75, was admitted on [DATE]. According to the October 2021 CPO, diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The 8/19/21 MDS assessment revealed the resident's cognitive status was severely impaired with a BIMS score of one out of 15. The MDS identified the resident had verbal behavioral symptoms directed towards others one to three days in the past seven. The MDS identified the resident refused cares one to three days in the past seven. B. Record review The care plan (date unknown) identified Resident #5 had behaviors of aggression toward other residents which were verbal as well as physical. The behavior seemed to be triggered by territorial behaviors related to when residents walked by her room or if a resident was sitting in a chair in the living room area. Noise may also be a trigger for these behaviors. She may make statements to others such as I'll teach you by holding up her fist and/or telling other residents to get out of here. Interventions included: -A white noise machine was placed in Resident #5's room to help create a calming atmosphere. -Re-direct to a quiet setting if able. -Re-direct other residents away from wandering into her room when able. The care plan (date unknown) identified Resident #5 had communication deficits related to being unable to form words when communicating and a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Interventions included to ask yes or no questions when able. The care plan (date unknown) identified Resident #5 had the potential for physical aggression related to a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Interventions included: -Assess and address for contributing sensory deficits. -Give the resident as many choices as possible about care and activities. -Resident #5 was on a one to one (1:1) monitoring and every (q) 15 minute checks to prevent any harm to self or others. -When the resident becomes agitated, intervene before her agitation escalates. Guide Resident #5 away from the source of the distress. Engage Resident #5 calmly in conversation. If her response was aggressive, staff are to walk calmly away, and approach later. The care plan (date unknown) identified Resident #5 had impaired cognitive function related to dementia. Interventions included: -Ask yes/no questions in order to determine Resident #5's needs. -Cue, reorient and supervise as needed. -Engage the resident in simple, structured activities that avoid overly demanding tasks. Resident #5 prefers walks, being outdoors, 1:1 caregivers, and watching television. -Present just one thought, idea, question or command at a time. The care plan note dated 8/24/21 at 7:52 p.m. included, The SSD, the guardian, the NHA, the ADON , and the AD were present . (Resident #5's) behaviors were reviewed. She continues to have territorial behaviors and becomes very aggressive if another resident wanders into her room. A full-time sitter was with her 24 hours-7 days a week to prevent negative interactions with other residents . The discharge plan was for (Resident #5) to move to a less restrictive environment. (Resident #5's) guardian inquired about moving her to a different unit, but it was explained that due to the behaviors such as going into the living room area and shouting for all the other residents to get out (which has occurred in the past few months) . AD spoke about her interests in walking and picking fresh flowers. She also really enjoys food socials. The GEM maintenance program form identified appropriate approaches and interventions of: Resident #5 responds best to the presence of a sitter 24 hours a day. Strategy #1: Engage in activities on and off the unit with the aid of a sitter. Strategy #2: Structure outside time with the sitter throughout the day. The care plan did not identify interventions discussed during the care plan meeting or the strategies found on the GEM form. C. Staff interviews AA #1 was interviewed on 10/5/21 at 12:30 p.m. She said Resident #5 could be physically aggressive. She said she had a one-to-one (1:1) staff person to be there to address any behaviors. She said she had not received any training on Resident #5's behaviors because, That's what the 1:1 was for. CNA #1 was interviewed on 1/6/21 at 9:15 a.m. She said Resident #5 had a 1:1 due to aggressive behaviors toward other residents. She said Resident #5 liked things to be a certain way. She said the resident had calmed down with the 1:1. She said Resident #5 liked to garden outside and was easy to redirect. She said the training she had received was the GEM system, but the training had not been completed, it was ongoing. She said the GEM book had interventions. She said she did not know if the interventions from the GEM program were included in Resident #5's care plan. CNA #2 was interviewed on 10/6/21 at 9:50 a.m. She said Resident #5 had a 1:1 because she does not like other people. She said Resident #5 had a specific chair she sat in and would become upset and potentially strike out if someone else was sitting in it. She said the 1:1 was there to work with Resident #5 and prevent behaviors. She said she used the strategies identified in the GEMS program when she worked with Resident #5. She said she had received training on the GEM system, but the training had not been completed for anyone in the building. She said she did not know if the strategies were included in Resident #5's care plan. RN#1 was interviewed on 10/6/21 at 10:15 a.m. She said Resident #5 can be aggressive, and would get angry if someone sat in her chair or if the chair was moved. She said the 1:1 was there to redirect Resident #5 and help prevent aggressive outbursts. She said she was receiving training on the GEM program which was a specialized program for dementia care. She said the training was not done. She said the facility had not completed the training as a whole. She said she would look at the GEM sheet if she did not know how to approach Resident #5. She said she did not look at the care plans. She said she did not know if the identified strategies in the GEM program were incorporated into the current care plan. III. Resident #3 A. Resident status Resident #3, age 77, was admitted on [DATE]. According to the October 2021 CPO, diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The 7/21/21 MDS assessment revealed the resident's cognitive status was severely impaired with a BIMS score of three out of 15. The MDS identified the resident had verbal behavioral symptoms directed towards others one to three days in the past seven and other behavioral symptoms not directed toward others one to three days in the past seven. The MDS identified the resident refused cares one to three days in the past seven. B. Record review The care plan (date unknown) identified Resident #3 required continual reminders of acceptable public behavior and resident's rights. Resident #3 may be unable to comprehend or remember appropriate behavior related to diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] -Staff would respond with re-direction and engaging with Resident #3 without judgement. -Educate staff about behavior approaches designed to effectively manage unacceptable sexual advances for example, avoid discussions that could have sexual implications. -Teach staff about Resident #3's sexual actions due to dementia. -Praise Resident #3 for accepting re-directions and maintaining physical boundaries. The care plan (date unknown) identified Resident #3 had behaviors of becoming verbally aggressive with staff, for example: she would call staff b----. This usually occurred when she was being redirected from inappropriate behaviors or staff was attempting to assist with cares. Interventions listed included to re-approach in 10-15 minutes when Resident #3 becomes aggressive. The care plan (date unknown) identified Resident #3 had behaviors of resisting care. Resident #3 would strike out, yell, scream, push, and grab. Resident #3 had abusive behavior and threatening behaviors mostly toward staff. There were no interventions identified. The GEMs maintenance program form identified the appropriate approaches and interventions for Resident #3 as walking with staff on errands, scheduling social interactions with staff and with other units. Strategy #1: Schedule regular daily walks with Resident #3. Bring Resident #3 on staff errands. Strategy #2: Include Resident #3 in all resident social activities in the unit and off the unit when appropriate. Strategy #3: Give Resident #3 tasks to complete such as placing supplies for activities, folding laundry, and making beds. The care plan did not integrate the identified strategies from the GEM form when a behavior presented itself. C. Staff interviews CNA #1 was interviewed on 10/6/21 at 9:15 a.m. She said Resident #3 would be irritable sometimes, but did not have overall behaviors. She said Resident #3 loved to color. She said if Resident #3 looked irritable, she would give her a coloring book and crayons and Resident #3 would color endlessly. She said she could suggest interventions to the nursing staff and they (nursing) would determine if the suggestion would make it into the GEM book or the care plan. She said the training she had received was the GEM system, but the training had not been completed, it was ongoing. She said the GEM book had interventions. She said she did not know if the interventions from the GEM program were included in Resident #3's care plan. CNA #2 was interviewed on 10/6/21 at 9:50 a.m. She said Resident #3 was sweet. She said Resident #3 had one incident when she first arrived at the facility, but had not displayed any behaviors in front of her. She said if Resident #3 displayed any behaviors, she would use the strategies identified in the GEMS program when she worked with Resident #3. She said she had received training on the GEM system, but the training had not been completed for anyone in the building. She said she did not know if the strategies were included in Resident #3's care plan. RN #1 was interviewed on 10/6/21 at 10:15 a.m. She said Resident #3 had some aggression when she had first arrived, but had not had any recently. She said she paced. She said she would attend activities on the other floor periodically. AA #2 was interviewed on 10/7/21 at 9:11 a.m. she said she had not received training for Residents #2, #3, and #5. She said the facility was learning the GEM program to help with residents with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] The AD was interviewed on 10/7/21 at 9:14 a.m. She said she worked occasionally on the unit where Residents #2, #3, and #5 resided. She said she had not received any training on resident specific behaviors for Residents #2, #3, and #5. She said she had never seen the identified residents display any behaviors. The SSD was interviewed on 10/6/21 at 4:06 p.m. She said she was new to her position and was the SSD for the entire building. She said Resident #2, #3, and #5 were all integrated into the GEM program. She said the GEM program was created by a specialist in dementia for the progression of the disease. She said the program would help staff direct person-centered care, and to help the staff do what was best for the residents. She said the staff development coordinator (SDC) was in charge of the program and the training. She said she did not know how the identified strategies were incorporated into the care plan. She said the GEM program had not been completely rolled out, and it was an ongoing training for the facility. She said she had not provided any training to staff on Resident #2, #3, and #5's behaviors and interventions. The SCD was interviewed on 10/6/21 at 4:23 p.m. She said the GEM program was developed by an authority on dementia care. She said resident specific interventions were a trial and error as the disease process of dementia was ever evolving. She said staff could make suggestions to her and she would take it to the team to help develop the strategies. She said the GEM program was still being taught, and that the facility had not completed the training on the program. She said it was the nurse's responsibility to integrate the strategies into the most current care plans. She said the floor nurse should be adding them to the care plan. The NHA was interviewed on 10/6/21 at 4:41 p.m. She said everyone was responsible for the GEM program. She said the program was not completely rolled out. She said the training was ongoing. She said the resident specific interventions discussed in the tem meetings and care plan meetings should have been incorporated into the care plans. She said all staff were able to make suggestions. She said the identified strategies in the GEM forms should have been in the care plans. She said each resident had a care plan meeting every three months where the interventions were discussed. She said the plan going forward would integrate the strategies: into the current care plans and to have more training for the staff on resident-specific interventions for individualized behaviors and needs. The NHA and DON (the DON via phone) were interviewed on 10/6/21 at 5:39 p.m. The NHA said the facility was working on updating all the care plans. She said all the managers were responsible for training all the staff on all the interventions.

Based on record review, resident interview and staff interviews, the facility failed to ensure one (#4) of three residents reviewed out of six sample residents was free from abuse. Specifically, the facility failed to ensure Resident #4 was free from verbal and physical abuse from registered nurse (RN) #1 (see CNA #1's response in the facility investigation) when identified by staff working with her as being agitated, angry and in a bad mood. Cross-reference F609 for reporting of alleged violations and F610 for reporting findings of an alleged violation. Findings include: I. Facility policy and procedure The Abuse policy, revised April 2012, was provided by the nursing home administrator (NHA) on 10/26/2020 at 10:30 a.m. It documented in pertinent part, our facility does not condone resident abuse by any one including staff members, physicians, consultants, volunteers, staff of other agencies serving the resident, family members, legal guardians, sponsors, other residents, friends, or other individuals.Verbal abuse is defined as any use of oral, written, or gestured language that willfully include disparaging and derogatory terms to residents or their families, or within their hearing distances, to describe residents, regardless of their age, ability to comprehend, or disability of the resident. II. Resident status Resident #4, age 77, was admitted [DATE]. According to the October 2020 computerized physician orders [REDACTED]. The 9/17/2020 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 13 out of 15 with no long term or short term memory impairment. She required extensive assistance from staff with bed mobility, transfers and toileting. III. Resident interview The resident was interviewed on 10/26/2020 at 10:50 a.m. She said she could not recall the date but registered nurse (RN) #1 was mean to her. She said it had been a couple of weeks since the incident happened. She said the nurse was not a nice person. She said she was always concerned about what would happen next when the nurse was working with her. She said that made her afraid of the nurse. She said the nurse was yelling at her in the presence of the certified nurse aide (CNA) on that day. She said the nurse told her not to get up from her chair or else she would fall. She said she told the nurse not to tell her what to do and she did not own the facility. She said the nurse told her that she owned the facility and she needed to do what she told her to do. She said the nurse scolded her like she was a child. She said the nurse was not a nice person and she was afraid that she did not know what to expect next. She said she was told by the NHA that the nurse was no longer working at the facility and she had not seen her since the incident. She said she felt safe and she was not afraid of any staff in the facility. IV. Facility investigation The 10/9/2020 investigation reported was provided by the NHA on 10/22/2020 at 1:00 p.m. It documented CNA #1 reported an interaction between RN #1 and Resident #4 during the night shift of 10/8/2020 via email. It documented CNA #1 was interviewed by the NHA on 10/9/2020 and was asked if she felt there was any verbal or physical abuse occurred during the interactions between RN #1 and Resident #4. CNA #1 said no but it was more of the way the nurse spoke to Resident #4 was very disrespectful including her tone. It documented several residents were interviewed on the unit, including Resident #4. Resident #4 was interviewed and was asked about any negative interaction between her and RN #1. She said about few weeks ago, RN#1 stopped her from getting up out of bed so she did not fall. It documented that the nurse had been instructed at that time that Resident #4 had the right to get up to go to the bathroom when she requested at night. It documented the resident was asked about what happened the night before on 10/8/2020. She said she fell and hit her head on the table. She said the nurses and CNAs came in and they were really loud. She was asked what happened after the nurses and cnas came into her room. She said RN #1 was a little huffy with her and said she owned the house. It further documented RN #1 was contacted by the director of nursing (DON) and was placed on suspension due to comments from Resident #4 on 10/9/2020. It documented CNA #2 was contacted on 10/9/2020 for interview regarding the interaction between RN #1 and Resident #4. CNA #2 said she felt the way the nurse talked to the resident was disrespectful. It documented an email was received from CNA #1 on 10/13/2020 which revealed there was no physical abuse; it was how the nurse talked to the resident and that her tone was disrespectful. It further documented that an additional email was received on 10/18/2020 from CNA #1 which included allegations of physical abuse and verbal abuse regarding the same incident on 10/8/2020. It documented RN #1 was interviewed on 10/9/2020 and was asked if she had made comments to Resident #4 in a disrespectful tone and she said no. It further documented that the verbal abuse allegation was substantiated and a physical abuse allegation was being investigated as a result of the facility's investigation. It documented that RN #1 was terminated on 10/19/2020. Resident #4 medical records were reviewed. There was no documentation that the resident was verbally or physically abused by staff. The resident had fallen on 10/8/2020 and assessment was done indicating she had fading bruises from fall and no documentation about any bruising to her arms. An email from CNA #2, sent 10/8/2020 was provided by the NHA on 10/22/2020 at 1:30 p.m. It documented RN #1 came in to work in a bad mood and started to micro-manage anything CNA #2 did. It further documented RN#1 sternly scold Resident #4 and said don't get up or you'll fall. An email from CNA#1, sent 10/18/2020 was provided by the NHA on 10/22/2020 at 1:30 p.m. The email documented RN #1 was frustrated about being asked to help out. It documented RN #1 asked CNA #1 to assist with Resident #4 because she was leaning over in her chair attempting to tie her shoes. It further documented CNA #1 approached the resident to assist her. At the same time, RN #1 approached the resident on the other side and aggressively grabbed Resident #4's arm and told her she needed to sit back that she was going to fall. The resident started swinging at the nurse. It documented the nurse and the resident got into a verbal fight and a physical confrontation as the nurse tried to pull her back into her chair. It further documented the resident was fighting and said that she could do what she wanted to do and that the nurse was not her boss and she did not own the place. It documented that the nurse told the resident that she did own the place and that the resident would do what she wanted her to do. V. Staff interviews CNA #2 was interviewed on 10/26/2020 at 4:35 p.m. She said RN #1 arrived at work with a bad attitude. She said the nurse yelled at her about not documenting 15 minutes checks. She said she made her rounds but was busy and unable to chart it. She said Resident #4 fell during the shift. She said the nurse was upset and in a bad mood and started to yell and scream at the resident. She said RN #1 said to the resident you see what you did to yourself, next time you won't try to get upand she made a face at the resident and walked away. She said she felt the nurse verbally abuse the resident. CNA #1 was interviewed on 10/27/2020 at 11:00 a.m. She said she worked on 10/8/2020 on the Aspen unit and was assigned to Resident #4. She said RN #1 was the nurse for the shift. RN #1 asked her to assist Resident #4 to tie her shoes because the resident was bending over attempting to tie her shoe lace. She said the nurse was observed to be agitated and angry and was in a bad mood. She said she walked over to the resident to assist her. She said at the same time the resident was trying to get up from her chair and the nurse aggressively grabbed her arm and pulled her back in the chair and told her to sit or else she would fall. She said the resident was angry and said to the nurse Don't tell me what to do, you do not own this place. She said the nurse got into a verbal argument with the resident and she said to the resident yes I own this place and you will do what I tell you to do. She said the resident was upset. She said after the argument, she assisted the resident with her shoes. She said the nurse verbally and physically abused the resident and she reported the incident to the DON via email. The NHA and the DON were interviewed on 10/26/2020 at 2:30 p.m. the NHA said she and the DON were responsible to investigate any alleged abuse allegations. She said she was responsible to report the allegation to the State Agency. The DON said when she received the email regarding the alleged abuse allegation she was on vacation and she forwarded the email to the NHA. The NHA said the initial email she received from CNA #2 on 10/8/2020 did not indicate verbal or physical abuse allegations. She said she investigated and interviewed CNA #2 on 10/9/2020. She said CNA #2 said she did not feel RN #1 verbally abused the resident but she yelled at the resident in a disrespectful way. She said she interviewed the resident and she did not feel it was an abuse. She felt that the nurse was disrespectful to her and that she was afraid of the nurse because she was not a nice person. She said the resident could not recall any physical contact between she and the nurse. She said the nurse was suspended pending investigation. The NHA said she received an email on 10/13/2020 from CNA #1, who also worked with the resident when the incident happened on 10/8/2020. She said CNA#1 documented she did not feel the nurse verbally abused the resident but the manner in which the nurse talked to the resident was disrespectful and degrading. She said on 10/18/2020, she received additional information regarding the 10/8/2020 incident via email from CNA #2 which documented RN #1 verbally and physically abuse Resident #4. She said RN#1 was already on suspension. She said it was not the practice of the facility for any resident to be abused by staff or anyone. She said she investigated and based on the additional information she received. She said it was determined that RN #1 verbally abused Resident #4. She said the nurse was terminated from her position on 10/19/2020. She said she had already started with training on 10/20/2020 on resident's rights and abuse to all staff to prevent further abuse from happening in the future.

Based on resident interview, record review and staff interviews, the facility failed to treat one (#4) of six sample residents in a respectful and dignified manner. Specifically, administrative staff entered and searched Resident #1's room without his permission and removed personal items from his room. Findings include: I. Facility policy The Resident Rights policy, no date, was provided by the nursing home administrator(NHA) on 10/26/2020 at 4:10 p.m. It read in pertinent part, the resident has a right to a dignified existence, self-determination and communication with and access to person and services inside and outside the facility. A facility must protect and promote the rights of each resident, including each of the following rights: privacy and confidentiality, retain and use personal possessions to the maximum extent that space and safety permit. II. Resident status Resident #1, under 50, was admitted on [DATE]. According to the October 2020 computerized physician orders [REDACTED]. The 9/9/2020 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) with a score 14 out of 15. He required supervision with activities of daily living (ADLS). III. Resident interview The resident was interviewed on 10/22/2020 at 1:30 p.m. He said the NHA and other administrative staff searched his room without his knowledge or permission. He said he was in the hospital when they searched his room. He said they went through his drawers and took his cigarettes, lighters, bio freeze and his aerosols spray. He said it was demeaning and made him angry because they went through all of his belongings. IV. Record review The resident's medical record was reviewed. There was no documentation that the resident's room had been searched or that the resident had provided consent to have his room searched. The NHA provided a list of items that were removed from the resident's room during the search on 10/22/2020 at 3:00 p.m. It documented the resident's room was searched on 9/4/2020. The following items were removed from the resident's room: three lighters, bottles of alcohol, cigarettes and aerosol sprays. V. Staff interviews The social service director (SSD) was interviewed on 10/26/20 at 12:45 p.m. She said she was asked by the NHA to assist in searching the resident's room. She said the resident was in the hospital during the search. She said the resident's room was searched to search for unsafe items in the room. She said she was not sure if the NHA obtained a consent or permission from the resident to search his room. She said the NHA said she had a physician order [REDACTED]. The NHA was interviewed on 10/26/2020 at 2:15 p.m. She confirmed the resident's room was searched on 9/4/2020 by herself, the SSD and the environmental director. She said they found cigarettes, lighters, bottles of alcohol and aerosols spray. She said she removed those items and locked them up in her office. She said she did not get consent from the resident, but she obtained a physician order [REDACTED]. She said the resident had been seen smoking outside on the facility grounds. She said the facility was a smoke free facility. She said she asked the resident if he had been smoking outside and he told her he was smoking along the highway not on the facility property. She acknowledged that she should have gotten consent from the resident before searching his room but she said the resident was in the hospital.

Based on record review and staff interviews, the facility failed to report an alleged violation of abuse to the State survey and certification agency in accordance with State law for one (#4) of three residents reviewed out of six sample residents. Specifically, the facility failed to report a verbal and physical abuse allegation by registered nurse (RN) #1 to the State Agency timely. Cross-reference F600 for freedom from abuse and F610 for reporting findings of an alleged violation. Findings include: I. Facility policy and procedure The Abuse policy, revised April 2012, was provided by the nursing home administrator (NHA) on 10/26/2020 at 10:30 a.m. It documented in pertinent part, our facility does not condone resident abuse by any one including staff members, physicians, consultants, volunteers, staff of other agencies serving the resident, family members, legal guardians, sponsors, other residents, friends, or other individuals. It is the responsibility of our employees, facility consultants, attending physicians, family members,visitors and ect, to promptly report any incident or suspected incident of neglect or resident abuse including injuries of unknown source, and theft or misappropriation of resident property to facility management. II. Resident status Resident #4, age 77, was admitted [DATE]. According to the October 2020 computerized physician orders [REDACTED]. The 9/17/2020 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 13 out of 15 with no long term or short term memory impairment. She required extensive assistance from staff with bed mobility, transfers and toileting. III. Facility investigation and documentation An email from certified nurse aide (CNA) #1, dated 10/18/2020, was provided by the NHA on 10/22/2020 at 1:30 p.m. The email documented registered nurse (RN) #1 was frustrated about being asked to help out. It documented RN #1 asked CNA #1 to assist with Resident #4 because she was leaning over in her chair attempting to tie her shoes. It further documented CNA #1 approached the resident to assist her. At the same time, RN #1 approached the resident on the other side and aggressively grabbed Resident #4's arm and told her she needed to sit back and that she was going to fall. The resident started swinging at the nurse. It documented the nurse and the resident got into a verbal fight and a physical confrontation as the nurse tried to pull her back into her chair. It further documented the resident was fighting and said that she could do what she wanted to do and that the nurse was not her boss and she did not own the place. It documented that the nurse told the resident that she did own the place and that the resident would do what she wanted her to do. The 10/19/2020 abuse investigation was provided by the nursing home administrator (NHA) on 10/27/2020 at 9:52 a.m. It documented an email was received from certified nurse aide (CNA) #1 on 10/18/2020 which included an allegation of verbal and physical abuse against Resident #4 by registered nurse (RN) #1. It documented Resident #4 was interviewed on 10/26/2020 and was asked if she could recall if RN #1 grabbed her arms. Resident #4 said no. It documented Resident #4 said she could not recall any physical aggression towards her from RN #1. It documented Resident #4 said RN #1 spoke to her in a disrespectful manner. It further documented, the allegation was reported to non-emergency police in the county on 10/19/2020. It documented, RN #1 was interviewed on 10/19/2020. She was asked to speak of any physical contact with Resident #4. She said she placed her hands under Resident #4's arms to assist with transfer from floor to bed and that was the only time she touched the resident. It documented CNA #1 was interviewed on 10/20/2020 and was asked if RN #1 intentionally meant to cause harm to Resident #4 and she said no. It documented CNA #1 changed her statements throughout the conversation and her answers were not consistent. It documented CNA #2 was interviewed on 10/26/2020 (eight days of the allegation) regarding any inappropriate physical contact between RN #1 and Resident #4 on 10/18/2020. She said no. It documented the director of nursing (DON) interviewed RN #2 on 10/26/2020 (eight days of the allegation) and asked her if she witnessed any inappropriate verbal or physical interactions between RN #1 and Resident #4. She said no. It documented the conclusion of the investigation was unsubstantiated. It documented the completed report of the investigation findings was done on 10/26/2020. The initial report to the state survey agency of the allegation was not made until 10/22/2020, which was during the survey after the facility was made aware. The report to the State Agency was made four days after the allegation was made by CNA #1 on 10/18/2020. IV. Staff interview The NHA was interviewed on 10/22/2020 at 2:15 p.m. She said she was responsible for reporting any allegation of abuse to the state agency. She said if an allegation of abuse was reported, she would immediately report it to the State Agency and investigate the allegation. She said she received an email on 10/19/2020 from CNA #1 reporting physical abuse (a day after the email was sent 10/18/2020). She said she was not sure if physical abuse occurred so she did not report it to the State Agency. She said all abuse allegations should be reported within two hours. She said she should have reported the allegation to the State Agency within two hours of the allegation. She said she would immediately report the allegation to the State Agency, which was four days after the allegation was reported.

Based on record review and staff interview, the facility failed to report investigative findings of an alleged violation of abuse within five working days of the allegation to the State survey and certification agency in accordance with State law, for one (#4) of three residents reviewed out of six sample residents. Specifically, the facility failed to report investigative findings of physical and verbal abuse allegation by registered nurse (RN) #1 within five working days of the allegation to the State Agency. Cross-reference F600 for freedom from abuse and cross-reference F609 for reporting of alleged violations. Findings include: I. Facility policy and procedure The Abuse policy, revised April 2012, was provided by the nursing home administrator (NHA) on 10/26/2020 at 10:30 a.m. It documented in pertinent part, The administrator will provide a written report of the results of all abuse investigations and appropriate action taken to the state survey and certification agency, the local police department, the ombudsman, and others as may be required by state or local laws, within five working days of the reported incident. II. Resident status Resident #4, age 77, was admitted [DATE]. According to the October 2020 computerized physician orders [REDACTED]. The 9/17/2020 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 13 out of 15 with no long term or short term memory impairment. She required extensive assistance from staff with bed mobility, transfers and toileting. III. Facility investigation and documentation An email from CNA#1, dated 10/18/2020 was provided by the NHA on 10/22/2020 at 1:30 p.m. The email documented RN #1 was frustrated about being asked to help out. It documented RN #1 asked CNA #1 to assist with Resident #4 because she was leaning over in her chair attempting to tie her shoes. It further documented CNA #1 approached the resident to assist her. At the same time, RN #1 approached the resident on the other side and aggressively grabbed Resident #4's arm and told her she needed to sit back and that she was going to fall. The resident started swinging at the nurse. It documented the nurse and the resident got into a verbal fight and a physical confrontation as the nurse tried to pull her back into her chair. It further documented the resident was fighting and said that she could do what she wanted to do and that the nurse was not her boss and she did not own the place. It documented that the nurse told the resident that she did own the place and that the resident would do what she wanted her to do. The 10/19/2020 abuse investigation was provided by the NHA on 10/27/2020 at 9:52 a.m. It documented an email was received from certified nurse aide (CNA) #1 which included an allegation of physical abuse against registered nurse (RN) #1 towards Resident #4. It documented Resident #4 was interviewed and was asked if she could recall if RN #1 grabbed her arms. Resident #4 said no. It also documented Resident #4 said she could not recall any physical aggression towards her from RN #1. It documented Resident #4 said RN #1 spoke to her in a disrespectful manner. It further documented, the allegation was reported to non-emergency police in the county on 10/19/2020. It documented, RN #1 was interviewed on 10/19/2020. She was asked to speak of any physical contact with Resident #4. She said she placed her hands under Resident #4's arms to assist with transfer from floor to bed and that was the only time she touched the resident. It documented CNA #1 was interviewed on 10/20/2020 and was asked if RN #1 intentionally meant to cause harm to Resident #4 and she said no. It documented CNA #1 changed her statements throughout the conversation and her answers were not consistent. It documented CNA #2 was interviewed on 10/26/2020 (eight days of the allegation) regarding any inappropriate physical contact between RN #1 and Resident #4 on 10/8/2020. She said no. It documented the director of nursing (DON) interviewed RN #2 on 10/26/2020 (eight days after the allegation) and asked her if she witnessed any inappropriate verbal or physical interactions between RN #1 and Resident #4. She said no. It documented the conclusion of the investigation was unsubstantiated. It documented the completed report of the investigation findings was done on 10/26/2020. The results of the investigative findings of the allegation that was originally reported on 10/18/2020, was reported to the State Agency on 10/26/2020, which was three days late; the findings of an abuse investigation were to be reported within five working days after an allegation was made. IV. Staff interview The NHA was interviewed on 10/26/2020 at 2:00 p.m. She said she was responsible for investigating all abuse allegations. She said all abuse investigations should be completed within five working days and the results should be reported to the State Agency. She said she was unable to complete the investigation timely because she was having a hard time getting staff for interviews. She said CNA #2 was from an agency and she worked on the night shift. She said she should have completed the investigation within five working days and reported the findings to the State Agency.

Based on observations, interviews and record review, the facility failed to establish and maintain an infection control program designed to provide a safe, sanitary environment and to help prevent the development and transmission of communicable diseases and infections such as Coronavirus disease (COVID-19). Specifically, the facility failed to: -Ensure staff properly disinfected reusable personal protective equipment (PPE); -Ensure dietary staff performed proper hand hygiene while serving meals; -Ensure staff performed hand hygiene in between serving residents their meals; -Ensure resident hand hygiene was performed prior to meals; -Ensure residents and staff followed guidelines for facial coverings to prevent the spread of infections; -Ensure staff had all updated training and information about COVID-19 prior to caring for residents; and -Ensure all staff and visitors, including vendors, were properly screened prior to entering the facility. Finding include: I. Professional references According to the Centers for Disease Control and Prevention (CDC website, Preparing for COVID-19: Long-term Care Facilities, Nursing Homes: https://www.cdc.gov/coronavirus/2019-ncov/hcp/long-term-care.html (Retrieved 6/2/2020), Cloth face coverings are not considered personal protective equipment (PPE) because their capability to protect healthcare personnel (HCP) is unknown. Implement Source Control Measures: Residents should wear a cloth face covering or facemask (if tolerated) whenever they leave their room, including for procedures outside the facility. Patients may remove their cloth face coverings when in their rooms but should put them back on when leaving their room or when others enter their room. HCP should perform hand hygiene before and after all patient contact, contact with potentially infectious materials and before putting on and after removing PPE, including gloves. Remove eye protection before leaving the patient room or care area. Reusable eye protection (e.g., goggles) must be cleaned and disinfected according to manufacturer's reprocessing instructions prior to re-use. Screen all HCP at the beginning of their shift for fever and symptoms of COVID-19. Actively take their temperature and document absence of shortness of breath, new or change in cough, sore throat, and muscle aches, nausea, vomiting, diarrhea, abdominal pain, headache, runny nose, fatigue. Provide HCP with job-or task-specific education and training on preventing transmission of infectious agents, including refresher training Ensure that HCP are educated, trained and have practiced the appropriate use of PPE prior to caring for a patient, including attention to correct use of PPE and prevention of contamination of clothing, skin and the environment during the process of removing such equipment. Educate them about new policies for source control while in the facility. According to the COVID-19 Preparation and Rapid Response: Checklist for Long-Term Care Facilities, 5/13/2020, All staff should be screened at the beginning of their shift for fever (take temperature) or symptoms (cough, shortness of breath, difficulty breathing, fever, chills, rigors, myalgia, headache, sore throat, new olfactory (smell) and taste disorder; consider also rhinorrhea, diarrhea, nausea or vomiting). When possible, all long-term care facility residents, whether they have COVID-19 symptoms or not, should cover their noses and mouths when staff are in their rooms. Residents can use tissues for this. They could also use cloth, non-medical masks when those are available. According to the COVID-19 Focused Survey for Nursing Homes, 3/20/2020, page 2, staff should assist residents to perform hand hygiene after toileting and before meals. According to the Centers for Disease Control and Prevention (CDC website, https://www.cdc.gov/coronavirus/2019-ncov/hcp/ppe-strategy/eye-protection.html, retrieved 6/2/2020, Reprocessed disposable face shields should be dedicated to one healthcare provider (HCP) and reprocessed whenever it is visibly soiled or removed prior to putting it back on. II. Disinfecting PPE A. Observations On 5/21/2020 at 1:45 p.m. room [ROOM NUMBER] had an over-the-bed table outside the door with isolation PPE sitting on top, including two paper bags, lined with plastic bags, with surgical masks inside of them and a container of Micro Kill disinfectant wipes. CNA #1 came out of the room pulling a weight chair. She removed her face shield and set it on the table then removed her N-95 mask and placed it in the paper bag lined with the plastic bag after removing the surgical mask. She applied the surgical mask and walked to the nurse's station to wash her hands at the sink. She did not disinfect the face shield. At 1:50 p.m. the admissions coordinator came out of room [ROOM NUMBER], removed her face shield and placed it on the table. She did not disinfect the face shield. B. Staff interviews CNA #1 was interviewed at 1:52 p.m. She said she had only been working on the unit with the isolation room for a couple of days. She said she did not know that her face shield needed to be disinfected. III. Proper hand hygiene A. Facility policy The Dietary Department policy and procedure was provided by the NHA via email on 5/22/2020, which included in pertinent part, All food purchased, stored and distributed is handled with appropriate food-handling practices. Do not store, prepare, handle and/or consume food in any area in which food may be contaminated, particularly around blood, body fluids or hazardous chemicals. Staff will wash their hands prior to handling or consuming food. Wear gloves when handling ready to eat food. Gloves should be changed when ever contaminated surfaces are touched Handle all food carefully to avoid contamination with potentially harmful debris such as glass. B. Observations The following observations were made on 5/21/2020 between 12:00 p.m. and 12:38 p.m. on the secure unit: -Dietary aide (DA) #1 was wearing gloves but touched multiple surfaces with the same gloves including reaching into the plastic bag to remove a hamburger bun. Occasionally he would change his gloves, but did not perform hand hygiene in between. -CNA #2 was wearing a glove on her left hand to hold the hamburger bun to cut it. She did not perform hand hygiene in between changing her gloves. -CNA #3 was observed serving the resident's plates of food and touching different items such as the table, the back of a chair or the resident's shoulder and did not perform hand hygiene prior to picking up another plate to serve. -None of the residents were provided hand hygiene prior to being served their meals. The following observations were made on 5/21/2020 between 12:00 p.m. and 12:30 p.m. on the Pine unit: -DA #2 removed hamburger buns from the bag, opened the bun and placed it on the plate with her bare hands. -DA #2 dispensed soap to her hands and rubbed them together without water for approximately 10 seconds then turned on the water and rinsed her hands. She dried her hands with a paper towel and placed the paper towel on the tray table approximately a half an inch from a stack of clean plates in a pile of other dirty paper towels. The DA continued to put her dirty paper towels on the table until it was approximately three to four inches high and six inches across. -DA #2 picked up a pen to mark off meals served multiple times without performing hand hygiene afterwards. C. Staff interviews The DON and NHA were interviewed on 5/21/2020 at 1:31 p.m. They said gloves should be worn whenever food is touch and hand hygiene should always occur between glove changes and after touching any unclean surface. They said used paper products should be disposed of in a trash can and not on the serving area. They said all residents should be provided hand hygiene prior to being served their meal. They said the staff usually tried to get the resident's to wash their hands in their rooms before coming to the dining room. D. Facility follow-up On 5/22/2020 an in-service was provided to management staff, including the NHA, DON, dietary manager (DM) and the SDC by the registered dietitian that included developing an updated audit tool for the kitchenettes and infection control. IV. Facial covering A. Observations Observations on 5/21/2020 from 11:15 a.m. until 2:33 p.m. revealed no residents were wearing facial coverings when they left their room or covered their mouths when staff entered their rooms to provide care. Staff were wearing cloth masks. B. Resident interview A male resident on the Pine unit was interviewed on 5/21/2020 at 12:30 p.m. He was eating his lunch. He stated he received a mask just before he received his lunch. C. Staff interviews The director of nursing (DON) and nursing home administrator (NHA) were interviewed on 5/21/2020 at 1:31 p.m. The DON said residents wore masks only when they wanted to and most of them did not want to. The NHA said staff who are not doing direct care for residents used cloth masks to conserve their limited supply of masks. She said all the residents had cloth masks in their room. She said if the resident was coughing or sneezing, they would encourage the resident to wear a mask, but most of the residents didn't want anything to do with covering their faces. V. Providing updated education A. Record review Review of the training records and sign-in sheets for the training on 5/28/2020 revealed the following: -The trainer was not listed on the training forms. -No documentation of the length of time the training was. -Training on cough/sneeze etiquette, dated 4/17/2020, was not signed off by 16 staff members. -Training on the signs and symptoms to monitor for, dated 4/17/2020, was not signed off by 19 staff members. B. Staff interviews The DON was interviewed on 5/21/2020 at 1:31 p.m. She said the CNA's, upon hire, go through a skills test. Nurses do a skills test annually with a medication pass. She said audits were done, clocking the staff for 20 seconds when washing their hands, looking for infection control concerns, and daily reminders to assist residents with handwashing. The DON was interviewed again on 5/28/2020 at 11:20 a.m. She said she thought all of the staff had completed all the required training but did not sign the sign-in sheet. VI. Screening A. Vendors 1. Observations Upon arrival to the facility on [DATE] 11:10 a.m. a delivery truck was parked diagonal between the front entrance and the side delivery entrance. The delivery person was not wearing a mask. He had loaded dollies and wheeled them onto the delivery door inside the facility. When he exited the facility he went into the back of the truck to get another load. 2. Interview The delivery person was interviewed on 5/21/2020 at 11:12 a.m. He said he did not know where to go to be screened. He said he was not screened prior to entering the facility but said he was screened at his work every morning anyway. 3. Staff interviews The NHA was interviewed on 5/21/2020 at 11:20 a.m. She said she was not aware the vendor was coming into the facility. She said the items being delivered were supposed to be left outside and facility staff would bring it in to isolate it for 72 hours. She said she was going to do education to all vendors immediately. 4. Facility follow-up The NHA developed a sign for the inside and outside of the side kitchen delivery door. The sign read, ALL DELIVERY PERSONNEL MUST BE SCREENED PRIOR TO ENTRY. PLEASE GO TO FRONT DOOR. MASK IS REQUIRED. A letter dated 5-21-2020 from the NHA revealed she provided education to vendors of the facility for proper screening. The letter included, Each vendor connected with our Dietary Department here at Forest Ridge was contacted via phone and education was provided on our Infection Control process regarding deliveries. It was explained that we prefer for them to ring the doorbell and when staff answer the door, let them know they are here to deliver an order and proceed to leave items at the back door of the kitchen. If they would need to enter the facility, they would have to wear a mask and follow the other guidelines implemented such as answering questions, having their temperature taken and washing their hands for a least twenty seconds. B. Visitors and staff 1. Record review On 5/28/2020, review of the staff and visitor logs from 4/1/2020 to 5/22/2020 revealed a lack of consistent documentation. Visitor Logs showed no visitor's temperatures were taken, there was missing documentation of dates, symptoms of COVID-19, and exposure to someone with COVID-19. The staff surveillance logs showed missing dates, missing last names, incorrect documentation coding even after a note was added to the form in May. One staff had a temperature above 100 degrees, staff had up to three symptoms and no documentation anyone questioned or reviewed the symptoms prior to the staff entering the facility to work. 2. Staff interviews CNA #1was interviewed on 5/21/2020 at 1:52 p.m. She said when she comes to work, she comes in through the front door, and if someone is at the desk, then they will screen her before she goes to her unit unless there is no one there, then they just go to their unit and have the nurse screen them. Registered nurse (RN) #1 was interviewed on 5/21/2020 at 2:33 p.m. He said when he comes to work at 6:00 a.m. there is no staff at the front desk so the staff go to their assigned units, complete the questionnaire and take their temperatures. Each staff screen themselves and the nurse monitors it.