Every finding on record at Lakewood Villa

Based on record review and interviews, the facility failed to ensure two (#1 and #2) of eight residents reviewed for abuse out of eight sample residents were free from abuse. Specifically, the facility failed to ensure Resident #1 and Resident #2 were free from abuse by each other. Findings include: I. Facility policy and procedure The Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating policy, revised September 2022, was provided by the nursing home administrator (NHA) on 7/7/25 at 11:00 a.m. It read in pertinent part, All reports of resident abuse (including injuries of unknown origin), neglect, exploitation, or theft/misappropriation of resident property are reported to local, state and federal agencies (as required by current regulations) and thoroughly investigated by facility management. Findings of all investigations are documented and reported. If resident abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source is suspected, the suspicion must be reported immediately to the administrator or to other officials according to state law. The individual conducting the investigation as a minimum reviews the documentation and evidence, reviews the resident's medical record to determine the resident's physical and cognitive status at the time of the incident and since the incident, reviews all events leading up to the alleged incident and documents the investigation completely and thoroughly. The follow up investigation report will provide sufficient information to describe the results of the investigation, and indicate any corrective actions taken if the allegation was verified. II. Physical abuse between Resident #1 and Resident #2 on 5/12/25. A. Facility investigation The facility investigation was provided by the NHA on 7/7/25 at 12:30 p.m. The investigation documented the NHA responded to a commotion from staff that occurred in the entrance of the front dining room. When the NHA arrived, the registered nurse (RN) on duty was standing by Resident #2 at the dining room entrance holding his glasses. At this time, Resident #1 was sitting at the table nearest to the dining room entrance. The NHA asked what happened. The staff present, including one certified nurse aide (CNA), one dietary aide and a RN , said that they did not witness the event but there was an event that occurred between Resident #1 and Resident #2. The NHA interviewed both residents following the event. Resident #1 said that he was walking to the dining room for dinner and Resident #2 kicked his shin when he walked by, then grabbed at his shirt and hit his chest. The NHA asked what happened next and Resident #1 said that he acted in self defense and hit Resident #2 to stop Resident #2 from grabbing his shirt. The NHA asked Resident #1 if he remembered if he hit Resident #2 with an open or closed hand. Resident #1 said he did not remember that detail. Resident #2 said he did not fully remember what happened and that Resident #1 came at him. The investigation documented the event was not caught on the facility's camera. The RN present said Resident #1 told her the same things that he communicated to the NHA but he told the RN he slapped Resident #2. B. Resident #1 1. Resident status Resident #1, age less than 65, was admitted on [DATE]. According to the July 2025 computerized physician orders (CPO), diagnoses included dementia, obesity, hypertension (high blood pressure), restlessness and agitation. The 2/22/25 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 14 out of 15. He was independent with mobility and for meals and needed moderate assistance with hygiene and set up assistance with other activities of daily living (ADL). 2. Record review Resident #1's dementia care plan, initiated 8/7/24, documented he had impaired cognitive function and dementia or impaired thought processes. Pertinent interventions, initiated 8/7/24, included to monitor, document and report to the physician any changes in cognitive function, specifically decision making ability, memory, recall and general awareness, difficulty expressing self, difficulty understanding others and mental status. Resident #1's psychotropic medication care plan, revised 12/16/24, documented he received psychotropic medications due to dementia with behaviors. Pertinent interventions, revised 5/20/25, included to monitor for agitation as evidenced by verbal and physical outbursts and monitor and record occurrences of target behavior symptoms (specify: pacing, wandering, disrobing, inappropriate response to verbal communication, violence/aggression towards staff/others) and document per facility protocol; administer medications as ordered; and monitor and document for side effects and effectiveness. Resident #1's antidepressant medication care plan, revised 12/20/24, documented he received antidepressant medication for dementia with behaviors and insomnia. Pertinent interventions, revised 12/20/24, included to monitor, document and report to the physician as needed ongoing signs and symptoms of depression: sadness, irritation, anger, crying, negative mood and/or comments, not enjoying usual activities, changes in cognition, unrealistic fears, attention seeking, and constant reassurance. A 5/13/25 alert note documented that on 5/12/25 at approximately 5:00 p.m., Resident #2 was in the dining room doorway when Resident #1 entered the dining room and as he was passing by, Resident #2 kicked Resident #1 on his shin, grabbed him and hit him on his chest. Resident #1 hit Resident #2 back in self defense on the left side of the head. A nurse was at the nurses'station and heard the slap and something fall to the ground. The nurse went to check on the commotion and found Resident #2's glasses on the floor and the left arm of the glasses was broken. Resident #2 was assessed. Resident #2 said Resident #1 hit him and broke his glasses. Resident #1 said he hit Resident #2 back in self defense so that Resident #2 would leave him alone. Resident #1 said he hit Resident #2 with a slap on the left side of his face and head. The NHA was notified. C. Resident #2 1. Resident status Resident #2, age greater than 65, was admitted on [DATE]. According to the July 2025 CPO, diagnoses included chronic respiratory failure, type 2 diabetes mellitus, Parkinson's disease (disease that causes unwanted movements), cognitive communication deficit and dementia. The 4/11/25 MDS assessment revealed the resident had moderate cognitive impairment with a BIMS score of nine out of 15. He needed set up assistance for meals and was dependent on staff assistance for his ADLs. 2. Record review Resident #2's behavior care plan, revised 2/4/25, documented he frequently made uninvited sexual advances toward female staff and explicit sexual comments towards female staff. Pertinent interventions included to administer medications as ordered and monitor and document for side effects and effectiveness (initiated 5/28/24) and staff were to assist Resident #2 to an appropriate table in the dining room to prevent collision with other residents (initiated 5/13/25). Resident #2's antipsychotic medication care plan, revised 2/4/25, documented he was on prescribed antipsychotic medications for dementia with behavioral disturbance and to monitor for: uninvited sexual advances towards others; hallucinations; and verbal outbursts Pertinent interventions, revised 9/3/24, included observing for behavior associated with anti-psychotic medications including delusions, paranoia and hallucinations. Resident #2's Kardex (care plan summary), as of 7/7/25, documented to monitor behavior episodes and attempt to determine the underlying cause, and consider the location, time of day, persons involved and solutions and document the resident's behavior and potential causes. -However, the Kardex failed to list a care planned intervention for staff to assist Resident #2 to an appropriate table in the dining room to prevent collision with other residents (see above). A 5/13/25 nursing note documented that at 5:20 a.m. a CNA reported a bruise above Resident #2's left eye. During the assessment Resident #2 said he got the bruise from the previous day's incident where he was in a fight with another resident. The nurse assessed the site, which was a minor bruise to the left eyelid, and the resident denied having pain. The previous day shift nurse reported Resident #2 was engaged in a physical fight with another resident which broke the left side of Resident #2's eyeglasses. III. Staff interviews CNA #1 was interviewed on 7/7/25 at 2:45 p.m. CNA #1 said she was aware of an incident between Resident #1 and Resident #2, but did not witness the incident. CNA #1 said all residents were monitored for behaviors in the building and she said residents had different interventions based on their behavior. CNA #1 said she could not could not recall any issues between Resident #2 and other residents prior to 5/12/25 and he was easily redirectable. CNA #1 said she could document a resident's behavior in the electronic medical record (EMR) multiple times a day if behaviors occurred. CNA #1 said if a resident had behaviors, she reported them to the nurse and also reported them to the CNA during the shift change so the other staff were aware. CNA #1 said she could find a resident's behaviors in the Kardex and could look up Resident #2's interventions in the Kardex, but she was not sure of Resident #2's exact interventions for his behavior. -However, a review of Resident #2's Kardex on 7/7/25 revealed the 5/13/25 care planned intervention for staff to assist Resident #2 to an appropriate table in the dining room to prevent collision with other residents was not on the resident's Kardex. Licensed practical nurse (LPN) #1 was interviewed on 7/7/25 at 2:52 p.m. LPN #1 said behavior monitoring was generally the same for all residents but if there was a different behavior than the resident's baseline, he would document that in a progress note. The NHA and the assistant director of nursing (ADON) were interviewed together on 7/7/25 at 4:20 p.m. The NHA said on 5/12/25, the nurse was at the nurses'station and heard something fall on the floor and determined it was Resident #2's glasses. The NHA said the nurse heard what she thought was an open handed slap. The NHA said Resident #1 consistently reported that Resident #2 reached out and kicked him. The NHA said Resident #2 was able to kick and self propel in his wheelchair if motivated. The NHA said Resident #2 reported that he was unable to remember what he did and he said Resident #1 attacked him. The NHA said after the incident, she let staff know that Resident #2 preferred to eat in his room at breakfast but if Resident #1 and Resident #2 were going to be in the dining room, the residents should be separated and not eat at the same table and Resident #2 should be assisted to the dining room because he was wheelchair ambulatory. The NHA said Resident #2's assistance to the dining room was added to his care plan and Kardex so the staff could see it. -However, a review of Resident #2's Kardex revealed the 5/13/25 care planned intervention for staff to assist Resident #2 to an appropriate table in the dining room to prevent collision with other residents was not on the resident's Kardex. The ADON said the CNAs were not able to see a resident's care plan but did use the Kardex. The ADON said Resident #2's Kardex had not been updated with the intervention for staff to assist Resident #2 to an appropriate table in the dining room to prevent collision with other residents. The ADON said she added the intervention to Resident #2's Kardex during the survey.

Based on record review and interviews, the facility failed to ensure four (#2, #3, #6 and #9) of nine residents reviewed for abuse out of 13 sample residents were kept free from abuse. Specifically, the facility failed to: -Protect Resident #2 from physical abuse by Resident #3; -Protect Resident #6 and Resident #3 from physical abuse from each other; and, -Protect Resident #9 from physical abuse by Resident #3. Findings include: I. Facility policy and procedure The Abuse, Neglect, Exploitation and Misappropriation policy and procedure, revised April 2021, was provided by the nursing home administrator (NHA) on 3/24/25 at 2:00 p.m. The policy read in pertinent part, Residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. The resident abuse program consists of a facility-wide commitment and resource allocation to support protecting residents from abuse by: -Developing and implementing policies and protocols to prevent and identify abuse, neglect and exploitation, ensure adequate staffing and oversight to prevent burnout, stressful working situations and high turnover rates; -Conduct employee background checks; -Establishing and maintaining a culture of compassion and caring for all residents; -Providing staff education and training on abuse; -Implementing measures to address factors that lead to abuse; -Identifying and investigating all possible incidents of abuse; -Protecting residents from further harm during investigations; -Reviewing allegations of abuse during monthly quality assurance and performance improvement (QAPI) meetings; and, -Involving the resident council in monitoring and evaluating the facility's abuse prevention program. II. Facility investigations of abuse incidents A. Incident of physical abuse by Resident #3 towards Resident #2 on 2/13/25 The 2/13/25 abuse investigation report was provided by the clinical resource nurse (CRN) on 3/24/25 at 9:50 a.m. It documented there was a witnessed, physical altercation between two residents (Resident #2 and Resident #3). The residents were separated, assessed, placed on frequent checks and their care plans were updated with new interventions. The staff assisted Resident #2 to the Red Rocks unit for an activity. The staff took turns watching Resident #3 on the Columbine (co-ed) unit. Resident #2 sustained an abrasion and bruise to her left eyebrow but declined care. Resident #3 was interviewed by the NHA on 2/13/25 at 2:28 p.m. Resident #3 was unable to answer the NHA's questions appropriately. Resident #2 was interviewed by the NHA on 2/13/25 at 2:47 p.m. Resident #2 made a punching motion and pointed to her face when asked if any of her fell ow residents had ever physically harmed her. Resident #2 was unable to appropriately answer the NHA's other questions. Eight additional residents were interviewed and did not have additional information. Housekeeper (HK) #1, who witnessed the altercation, said she was sweeping the dining room and Resident #2 was in a dining room chair. Resident #3 was sitting on a pink sofa chair. Resident #3 stood up and walked over to Resident #2. With a closed fist, Resident #3 hit Resident #2 three times on the eye. HK #1 separated the two residents and Resident #3 tried to hit her. A therapist and certified nurse aide (CNA) responded and the situation was de-escalated. The business office manager (BOM) took Resident #2 up front to the Valentine's Day party and Resident #3 grabbed the broom and started sweeping the hallway. The facility substantiated the incident. B. Incident of physical abuse between Resident #3 and Resident #6 on 2/16/25 The 2/16/25 abuse investigation was provided by the CRN on 3/24/25 at 9:50 a.m. It documented there was a witnessed physical altercation between Resident #3 and Resident #6. The residents were separated and assessed. Resident #6 was assisted to his room and Resident #3 stayed with a CNA in the dining room until he went to bed. The residents's care plans were updated with new interventions. Resident #3 had a new, small abrasion on his elbow upon assessment. Resident #3 was interviewed by the BOM on 2/17/25 at 11:08 a.m. Resident #3 was unable to answer the BOM's questions appropriately. Resident #6 was interviewed by the BOM on 2/17/25 at 11:37 a.m. He answered no when asked if he had recently been upset by an interaction with a fell ow resident at the facility, had felt uncomfortable, threatened or fearful by any fell ow residents or had been harmed by any fell ow residents. He had nothing additional to say. Eight residents were interviewed and had no additional information. CNA #5 made a witness statement on 2/16/25 at 10:56 p.m. CNA #5's witness statement documented that she was in the dining room. She said Resident #3 got up from his nap and came to the dining room. She said she was standing by a table. She said Resident #6 was sitting at another table but got up and began wandering. She said Resident #3 wandered over in the direction of where Resident #6 was wandering. The residents ran into each other and began arguing and yelling. Resident #3 pushed Resident #6 away. Resident #6 then grabbed at Resident #3 and pushed him hard. She said this caused Resident #3 to fall to the floor on his buttocks and tailbone. The nurse and another CNA helped the witness separate the two residents. The assisting CNA helped Resident #6 to his room where he remained for the rest of the night. The witness (CNA #5) stayed with Resident #3 until the nurse assessed him and got him up from the ground. Resident #3 did not hit his head but scraped his elbow on the wall. The facility substantiated the incident. C. Incident of physical abuse by Resident #3 towards Resident #9 on 3/24/25 On 3/24/25 at 9:55 a.m. (during the survey), Resident #3 was walking around while pushing a dining room chair in the Columbine unit. Resident #9 walked in front of the chair and sat down in the chair. Resident #3 tried pushing the chair forward and was not able to. Resident #3, with an open palm, slapped Resident #9 on the right side of the head. This incident was reported to licensed practical nurse (LPN) #1 on 3/24/25 at 9:57 a.m. and reported to the NHA on 3/24/25 at 10:02 a.m. LPN #1 separated the two residents and assessed each resident. The NHA said she would start an internal abuse investigation. III. Resident #3 - assailant and victim A. Resident status Resident #3, age 74, was admitted on [DATE]. According to the March 2025 computerized physician's orders (CPO), diagnoses included unspecified dementia with agitation, chronic obstructive pulmonary disease, low back pain and weakness. According to the 12/11/24 minimum data set (MDS) assessment the resident had short term and long term memory problems and his cognitive skills for daily decision making were severely impaired through staff assessment. He was dependent on staff for toileting and dressing. He was independent with ambulation. The MDS assessment documented Resident #3 had physical behavior symptoms directed towards others, verbal behavioral symptoms directed toward others and other behavioral symptoms not directed at others every one to three days. B. Record review Resident #3's cognitive impairment care plan, initiated 12/18/24, revealed he had impaired cognitive function related to dementia with behaviors. Interventions included monitoring and reporting changes in cognitive function to his physicians, reviewing medications and using task segmentation to support short term memory deficits. Resident #3's behavior care plan, initiated 12/23/24 and revised 3/21/25, revealed he had the potential to be verbally and physically aggressive related to dementia. Interventions added after the 2/13/25 incident included for staff to provide Resident #3 with meaningful activities, including sweeping with supervision and reading the menus that were posted. Interventions added after the 2/16/25 incident included encouraging Resident #3 to participate in goal oriented tasks, offering snacks and drinks throughout the day and referring Resident #3 to therapy for sensory integration. The skin assessment completed on 2/16/25 documented Resident #3 had a new bruise on his left elbow. The 2/13/25 nursing note documented the nurse was notified that Resident #3 was aggressive towards another resident (Resident #2). Resident #3 was unable to explain what happened. The residents were separated and frequent checks were initiated. Resident #3's representative was notified of the incident. The 2/16/25 nursing note documented that a CNA notified the nurse that Resident #3 and another resident were yelling in each other's faces. Resident #3 pushed the other resident so that resident (Resident #6) retaliated and pushed Resident #3 to the floor. Resident #3 hit his left elbow on the ground. The CNA called the nurse and they separated both residents and the nurse assessed both residents. Resident #3 denied pain and the nurse assisted him to lift himself from the floor. Resident #3 sustained light bruising to his left elbow and a dry dressing was applied on it. The nurse notified the physician, the director of nursing (DON) and the NHA. IV. Resident #2 - victim A. Resident status Resident #2, age 85, was admitted on [DATE]. According to the March 2025 CPO, diagnoses included unspecified dementia with behavioral disturbances, chronic kidney disease, mood disorder and chronic pain. The 2/5/25 MDS assessment revealed the resident had short and long term memory impairment and her cognitive skills for daily decision making were moderately impaired, per staff assessment. Resident #2 was independent with ambulation and required supervision with transfers, hygiene, dressing and toileting. The MDS assessment documented Resident #2 had physical behavior symptoms directed towards others, verbal behavioral symptoms directed toward others and other behavioral symptoms not directed at others every one to three days. B. Record review Resident #2's behavior care plan, initiated 2/14/25, revealed the resident had verbal aggression. The interventions included administering medications as ordered, letting Resident #2 clean-up after meals, allowing the resident choices regarding her care, analyzing key times and triggers and what de-escalated her, assessing and anticipating the resident's needs, assessing coping skills and support systems, offering evening activities, providing sensory integration from occupational therapy, redirecting the resident away from high-stimulus areas, completing sleep tracking, speech therapy to work on communication and intervening when resident became agitated. The skin assessment completed on 2/13/25 documented Resident #2 had a new bruise and abrasion to her left eyebrow. The 2/13/25 nursing progress note documented that the nurse was notified that Resident #2 was the non-aggressor in a resident-to-resident altercation. Resident #2 was unable to describe what happened. The residents were separated for safety. Resident #2's representative, the DON, the physician and the NHA were notified. Frequent checks were initiated. V. Resident #6 - assailant and victim A. Resident status Resident #6, age less than 65, was admitted on [DATE] and passed away on 3/12/25. According to the March 2025 CPO, diagnoses included cerebral infarction (disrupted blood flow to the brain), unspecified dementia with psychotic disturbance, muscle weakness and type 2 diabetes. The 2/14/25 MDS assessment revealed the resident was not assessed for a brief interview for mental status or cognitive skills for daily decision making. He was dependent on staff for eating, hygiene, toileting and dressing. He could ambulate independently. The MDS assessment indicated Resident #6 did not have any physical or verbal behaviors. B. Record review Resident #6's behavior care plan, initiated 2/17/25, revealed Resident #6 had the potential to be physically aggressive related to dementia and poor impulse control. He had vision deficits which contributed to his wandering and spatial awareness. Interventions included administering medications as ordered, analyzing times of the day and triggers that contributed to his behaviors, assessing for the residents needs, assessing the resident for sensory deficits, providing occupational therapy for communication and sensory integration, providing physical therapy, providing speech therapy, giving the resident choices and activities, modifying the environment to make Resident #6 comfortable and reducing agitation and intervening when Resident #6 got agitated before the behavior escalated. The 2/16/25 nursing note documented that a CNA noticed Resident #6 and another resident yelling in each other's faces. Resident #3 pushed Resident #6. Resident #6 retaliated and pushed Resident #3 on the floor. Resident #3 hit his left elbow on the ground. The CNA called the nurse and they separated both residents. The physician, the DON and the NHA were notified. VI. Resident #9 - victim A. Resident status Resident #9, age less than 65, was admitted on [DATE]. According to the March 2025 CPO, diagnoses included paranoid schizophrenia, osteoarthritis and dementia with behavioral disturbances. The 1/16/25 MDS assessment revealed the resident's cognitive skills for daily decision making were moderately impaired and he had short term and long term memory problems, through staff assessment. He was dependent on staff for hygiene, toileting, showering and dressing. He could ambulate independently. The MDS assessment indicated Resident #9 did not have any physical and verbal behaviors. B. Record review Resident #9's behavior care plan, initiated 6/16/23 and revised 8/28/23, documented Resident #9 had the potential for behavior problems related to his dementia. He had a history of physical aggression and redirection could be difficult at times. Interventions included a chart review from the pharmacist as needed, providing distraction with pleasant activities, encouraging Resident #9 to wear his eyeglasses, completing frequent rounding, providing individual activities, such as watching movies and providing a resident-specific activity box. VII. Staff interviews CNA #4 was interviewed on 3/24/25 at 1:40 p.m. CNA #4 said Resident #3 was very aggressive when he was first admitted to the facility. She said medication adjustments seemed to have started to calm his behaviors down. She said he still acted aggressive often and he was physically aggressive towards the residents that got in his personal space. She said that Resident #3 hit everybody and he did not target certain residents. CNA #4 said he sundowned (behavior changes caused by dementia) around 3:00 p.m. and that was usually when his behaviors got worse. The DON, the CRN and the NHA were interviewed together on 3/24/25 at 3:30 p.m. The NHA said she verbally educated staff on Resident #3's behavior interventions each time he got new interventions added. She said he was reviewed at monthly psychology pharmaceutical (psych pharm) meetings, weekly at-risk meetings and at the monthly QAPI meetings with the interdisciplinary (IDT) team. She said the facility identified that one of Resident #3's triggers was when he was woken up in the morning. She said the facility implemented interventions to let him sleep as long as he wanted and to wake on his own. The DON said the facility was working with the pharmacist and Resident #3's physician to adjust his medications and get him on the right medication regimen to ensure he maintained his quality of life while keeping his behaviors stable. The NHA said she had sent a referral for Resident #3 to work with a psychiatrist and that Resident #3 had been unable to participate. Resident #3's physician (PHY) was interviewed on 3/25/25 at 11:25 a.m. The PHY said he thought Resident #3's diagnosis was frontal lobe vascular dementia which was consistent with his behaviors and he would update the resident's diagnosis. He said he had been working with Resident #3 to get him on the right medication regimen since he was admitted . He said Resident #3 was gradually getting better with his behaviors. He said the staff that worked with him full-time knew him well and were able to redirect him. The PHY said he received calls from the agency staff regarding Resident #3's behaviors because they did not know him as well. The medical director (MD) was interviewed on 3/25/25 at 11:45 a.m. He said Resident #3 had dementia and would never be cured of his disease. He said just like other diseases, he had exacerbations with his behaviors. He said the staff were working with him to get him on the right medication regimen and the right interventions that worked for him. The MD said the goal was to minimize Resident #3's behaviors without sedating him to the point he had no behaviors. CNA #2 was interviewed on 3/25/25 at 8:35 a.m. CNA #2 said Resident #3 was not having any behaviors so far that morning (3/25/25). She said he refused his shower and they let him refuse because he could get aggressive. She said he got aggressive when other people got in his way or took his food off his plate. She said Resident #9 took food from other resident's plates in the dining room, so they had to keep Resident #3 and Resident #9 separated in the dining room. She said the two residents (Resident #9 and Resident #3) did not get along. CNA #2 said the staff redirected Resident #3 when he got aggressive with snacks, books and reading menus. The DON was interviewed a second time on 3/25/25 at 1:43 p.m. The DON said she felt like the facility was progressing with Resident #3 in the right direction. She said it had been a process to figure out Resident #3's triggers and what he responded well too. She said the facility had been working on getting information from staff and educating the staff regarding Resident #3. She said the staff kept other residents free from harm while residing with Resident #3 by knowing when Resident #3 was up and active, keeping an eye on him, redirecting him with reading material or activities when he was aimlessly wandering, being aware of his stimuli and keeping a close eye on him when he was in the dining room. She said she had not noticed any of the victims of Resident #3's incidents having any changes in their behaviors or mood. The DON said she educated the agency staff about Resident #3's patterns and triggers and also had them review a binder prior to their shift with the facility's policies.

Based on observations, record review and interviews, the facility failed to ensure food items were stored, prepared, distributed and served under sanitary conditions in the main kitchen. Specifically, the facility failed to have a system in place to monitor the internal water temperature and concentration (parts per million-ppm) of hypochlorite of the dish machine in the main kitchen to ensure tableware, drinkware and cookware were effectively sanitized. Findings include: I. Professional reference The Colorado Retail Food Establishment Rules and Regulations, revised March 2024, retrieved on 12/26/24, read in pertinent part: A test kit or other device that accurately measures the concentration in MG/L (milligrams per liter) of sanitizing solutions shall be provided. (page 125) A chemical sanitizer used in a sanitizing solution for a manual or mechanical operation at contact times shall meet the criteria specified in accordance with the EPA- registered label use instructions . A chlorine solution shall have a minimum temperature based on the concentration and PH of the solution as listed in the following chart: The concentration range minimum temperature chart indicated if the MG/L was 25 to 49 and the PH (potential of hydrogen) was 10 or less or the PH was eight or less the temperature of the water needed to be 120F. If the MG/L was 50 to 99 and the PH was 10 or less or eight or less the water needed to be 100F. If the MG/L was 100 and the PH was 10 or less or eight or less the water needed to be 55F. The temperature of the wash solution in spray-type warewashers that use chemicals to sanitize may not be less than 120 F. (page 129 to 130) II. Facility policy and procedure The Dishwashing Machine Use policy and procedure, revised March 2010, was received from the nursing home administrator (NHA) on 12/19/24 at 1:29 p.m. It revealed in pertinent part, Food Service staff required to operate the dishwashing machine will be trained in all steps of dishwashing machine use by the supervisor or a designee proficient in all aspects of proper use and sanitation . Dishwashing machine chemical sanitizer concentrations and contact times will be as follows: If the solution is chlorine the minimum concentration is 50 to 100 ppm with a contact time of 10 seconds. If the solution is iodine the minimum concentration is 12.5 ppm with a contact time of 30 seconds. If the solution is quaternary ammonium the minimum concentration is 150 to 200 ppm and the contact time is per the manufacturer's instructions. A supervisor will check the dishwashing machine for proper concentrations of sanitizer solution (measured as parts-per-million [PPM] or mL/L) after filling the dishwashing machine and once a week thereafter. Concentrations will be recorded in a facility approved log. Corrective action will be taken immediately if sanitizer concentrations are too low. The operator will check temperatures using the machine gauge with each dishwashing machine cycle, and will record the results in a facility approved log. The operator will monitor the gauge frequently during the dishwashing machine cycle. Inadequate temperatures will be reported to the supervisor and corrected immediately. The supervisor will check the calibration of the gauge weekly by running a secondary thermometer through the machine to compare temperatures; or using commercial temperature test strips following manufacturer's instructions. If hot water temperatures or chemical sanitation concentrations do not meet requirements, cease use of dishwashing machines immediately until temperatures or ppm are adjusted. III. Observations and staff interviews On 12/16/24 at 9:08 a.m. the kitchen dish machine was in use after the breakfast meal. The dietary manager (DM) said the dish machine used chemicals for sanitization. There were no test strips available to test the chemical solution. The DM said they ran out of test strips two or three days prior. The DM said the staff were using the temperature on the machine for monitoring the effectiveness of disinfecting until the test strips were delivered. The dish machine was 130F. On 12/18/24 at 1:25 p.m. the dishwasher was in use. The DM said he still had not received test strips to check the dishwashing machines chemical use. The dish washer temperature was 130F. Dietary aide (DA) #1 was interviewed on 12/18/24 at 1:30 p.m. She said she checked the temperature on the dish machine once per meal. DA #1 said she recorded the temperature on the log sheet. The November 2024 (11/1/24 to 11/30/24) and December 2024 (12/1/24 to 12/19/24) machine log sheets were reviewed with DA #1 and she confirmed there were days that were missing temperature monitoring of the dish machine. DA #1 said she did not know what was an acceptable temperature. DA #1 said she had never tested the dishwasher chemicals. IV. Record review The dishwasher temperature log from 11/28/24 to 12/19/24 was reviewed on 12/19/24 at 1:58 p.m. it documented the following: -On 11/28/24 there was not a temperature logged for the dinner service; -From 11/30/24 to 12/5/24 there were no temperatures logged; -On 12/7/27 there were no temperatures logged for the lunch or dinner service; -On 12/8/24 the temperature was 115F for breakfast service with no corrective action documented; -From 12/9/24 to 12/12/24 there were no temperatures logged; -On 12/13/24 there were no temperatures logged for the lunch or dinner service; -On 12/14/24 the temperature was 110F for breakfast and 100F for lunch. There was no temperature logged for dinner services. -On 12/15/24 the temperature was 100F for breakfast service. -On 12/16/24 the temperature was 110F for breakfast and there was no temperature logged for dinner service. -On 12/17/24 there was no temperature logged for dinner service. -The dishwasher machine log had no place to document the ppm was being monitored. The dishwasher log failed to consistently document the temperature of the dishwasher, along with no testing of the ppm for chemical sanitization. The log documented several days with temperatures out of range (see professional reference above). V. Additional staff interviews DA #2 was interviewed on 12/18/24 at 1:51 p.m. He said from time to time he would assist with washing dishes. DA #2 said the temperature on the dishwashing machine should be between 35 and 45 degrees fahrenheit. DA #2 said they were to use the dip sticks in the dishwasher to ensure the proper amount of chemical was being used for disinfecting purposes. DA #2 said the dip stick should be a green to dark green color to be in the correct range. DA #2 said he did not know the ppm levels the dishwasher should read during testing. The infection preventionist (IP) was interviewed on 12/19/24 at 10:27 a.m. The IP said the dishwasher chemicals were dispensed from a machine. The IP said she did not know what the chemical concentration needed to be to ensure proper sanitization. The IP said the dish machine was a low temperature dishwasher that used chemicals to sanitize the dishes. The IP said she needed to check with the DM for the correct intervals the dishwasher should be checked, but she believed it was every four hours. The IP said it was important for the dish machine to be functioning appropriately to ensure proper sanitization of dishes to prevent spread of infection. The DM was interviewed on 12/19/24 at 1:16 p.m. He said he had been educated to ensure the dishwasher temperature was at least 120F and the ppm should be between 50 and 100 for chlorine. The DM said he would call the chemical servicing company if they discovered the chemical dispensing was inaccurate based on testing strips. The DM said if the dishwasher was not working the dietary staff would washing dishes manually in the sink and the ppm would be checked of the sanitizer in the sink to ensure it was effectively sanitizing. The DM said he had testing strips the whole time during the survey. The DM said he did not know he could use the same testing strips he used on his sanitization buckets. The DM said the staff were responsible for documenting the ppm and the temperatures for all areas that chemicals were used in the kitchen. The DM said the manager on duty was responsible for checking the logs on the weekends or when he was not in the facility to ensure they were filled out daily. The DM said he was not sure why the logs were not being completed or how the log sheet did not have a section for ppm to be recorded. The DM said he would be completing education to the staff. He said he would change the log sheets immediately to ensure the temperatures and ppm could be recorded appropriately. The DM said he tested the ppm on the dishmachine once he learned he could use the same strips and it was above 50 ppm.

Based on observations and interviews, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of diseases and infection. Specifically, the facility failed to: -Ensure housekeeping staff followed proper cleaning techniques for cleaning and disinfecting resident rooms and high frequency touched areas (call lights, door handles and handrails); -Ensure housekeeping staff used the correct surface disinfectant products; -Ensure enhanced barrier precautions (EBP) were in place for a resident with a stage IV pressure injury prior to wound care; and, -Ensure washing machine temperatures were checked daily and lint traps were emptied timely. Findings include: I. Housekeeping A. Professional reference Assadian O, Harbarth S, Vos M, et al. Practical Recommendations for Routine Cleaning and Disinfection Procedures in Healthcare Institutions: A Narrative Review. The Journal of Hospital Infection, (July 2021) 113:104-114, was retrieved on 12/21/24 from https.//pubmed.ncbi.nlm.nih.gov. It revealed in pertinent part, High-touch surfaces, on the other hand, are usually close to the patient, are frequently touched by the patient or nursing staff, come into contact with the skin and, due to increased contact, pose a particularly high risk of transmitting pathogens (virus or microorganism that can cause disease). Healthcare-associated infections (HAIs) are the most common adverse outcomes due to delivery of medical care. HAIs increase morbidity and mortality, prolonged hospital stays, and are associated with additional healthcare costs. Contaminated surfaces, particularly those that are touched frequently, act as reservoirs for pathogens and contribute towards pathogen transmission. Therefore, healthcare hygiene requires a comprehensive approach. This approach includes hand hygiene in conjunction with environmental cleaning and disinfection of surfaces and clinical equipment. The Centers for Disease Control and Prevention (CDC) Environment Cleaning Procedures, (revised 3/19/24) was retrieved on 12/21/24 from https://www.cdc.gov/healthcare-associated- infections/hcp/cleaning-global/procedures.html?CDC_AAref_Val=https://www.cdc.gov/hai/pre ent/resource-limited/cleaning-procedures.html#cdc_generic_section_2-4-1-general-environmental-cleaning-techniques. It read in pertinent part, High-Touch Surfaces: The identification of high-touch surfaces and items in each patient care area is a necessary prerequisite to the development of cleaning procedures, as these will often differ by room, ward and facility. Common high-touch surfaces include: bed rails, IV (intravenous) poles, sink handles, bedside tables, counters, edges of privacy curtains, patient monitoring equipment (keyboards, control panels), call bells and door knobs. Proceed from cleaner to dirtier areas to avoid spreading dirt and microorganisms. Examples include: during terminal cleaning, clean low-touch surfaces before high-touch surfaces, clean patient areas (patient zones) before patient toilets, within a specified patient room, terminal cleaning should start with shared equipment and common surfaces, then proceed to surfaces and items touched during patient care that are outside of the patient zone, and finally to surfaces and items directly touched by the patient inside the patient zone. In other words, high-touch surfaces outside the patient zone should be cleaned before the high-touch surfaces inside the patient zone and clean general patient areas not under transmission-based precautions before those areas under transmission-based precautions. B. Facility policy and procedure The Daily Room Cleaning policy, undated, was provided by the nursing home administrator (NHA) on 12/19/24 at 1:19 p.m. It read in pertinent part, Throughout the cleaning process, you must be thorough as germs are everywhere. In corners, small openings, grooves, and the underside of objects. Dip the cleaning cloth into the disinfectant and hand wring. Wipe the headboard, the bed controls and the foot board. Disinfect the night stand top, the sides, the front, the back and the legs. Wipe the telephone paying close attention to the receiver. Clean the over bed table and clean it thoroughly, working from the upper surfaces to the lower surfaces. Wipe clean the pedestal, base and the casters. Disinfect the toilet bowls, flush before cleaning. Apply toilet bowl cleaner and disinfectant to the inside of the toilet. Clean the rim, spray the outside and bottom surfaces with disinfectant solution and wipe and spray the toilet seat with the disinfectant. Spray a small amount of cleaner in the sink and rub the cleaner around the top and inside of the sink. Wipe the sink and the top dry. Dampen a cloth in disinfectant and wipe the counter top, being careful to clean under personal items left by the resident. Clean under the personal items left by the resident. Clean under the items and place them back in a neat arrangement. Clean the counter front, inside sink doors, the piping, and all exposed surfaces of the entire unit. Use pre-measured disinfectant floor cleaning chemicals for mopping. Before leaving the room, inspect the room according to the checklist and to make sure all required cleaning tasks were performed. C. Observations During a continuous observation on 12/18/24 at 10:06 a.m. housekeeper (HSK) #1 was observed cleaning room [ROOM NUMBER], room [ROOM NUMBER] and room [ROOM NUMBER]. HSK #1 pushed the cleaning cart to the door way of room [ROOM NUMBER]. She donned (put on ) gloves and removed a disinfectant spray bottle and the toilet brush from the cart. She entered room [ROOM NUMBER]'s bathroom. She sprayed the inside of the toilet bowl and scrubbed it with the toilet brush. She placed the toilet brush back into the cart and removed her gloves. She used hand sanitizer and put on clean gloves. She removed a small container of a soap solution and a scrubbing pad. She washed the inside of the sink. She placed the container with the scrub pad back into the cart. She removed the broom and swept the room. She placed the broom and dust pan back onto the cart and removed a green rag. She placed the green rag on the sink and splashed water onto the mirror. She used a paper towel from the dispenser to wash the mirror. She turned on the sink and wet the green rag. She wiped out the inside of the sink, the top of the sink and the faucet. -HSK #1 did not use a disinfectant while cleaning the sink. HSK #1 washed her hands and donned clean gloves and removed the disinfectant spray bottle and a green rag from the cart. She sprayed the toilet. She used the green rag to wipe the seat of the toilet, the rim, the toilet seat a second time, the back of the seat, the side of the toilet, the front of the toilet tank and the top of the tank. She sprayed the two grab bars, on each side of the toilet, with the disinfectant spray and used the same rag to clean the grab bars. She placed the spray bottle and rag back onto the cart. She removed her gloves, used hand sanitizer, and donned clean gloves. She removed a mop pad from the water bucket and sprayed it with a cleaner. She dropped the mop pad on the floor and placed the mop handle on top. She mopped the room first and then the bathroom. She pushed the cleaning cart to room [ROOM NUMBER]. -HSK #1 failed to use the correct cleaning techniques to clean the toilet and the grab bars. -HSK #1 said there was no disinfectant in the mop pad bucket and it only contained plain water. -HSK #1 did not disinfect high touch areas such as the door knobs, light switches, call light and bed controller. HSK #1 used hand sanitizer and donned gloves and entered room [ROOM NUMBER]. She removed the container of a soap solution and a scrubbing pad and washed the inside of the sink. She returned the container to the cart and removed the disinfectant spray. She sprayed the leather recliner and used a green rag to wipe it down. She placed the soiled rag on the cart. She removed a clean green rag from the cart and walked to the sink. She used her gloved hand to splash water onto the mirror. She wiped it dry with a paper towel. She sprayed disinfectant onto the rag and wiped the top of both of the night stands. She placed the soiled rag on the cart and removed the broom. She then swept the room. She placed the broom back on the cart and removed a mop pad from the water bucket. She sprayed the mop pad with cleaner and mopped the bedroom floor. The bathroom was shared with room [ROOM NUMBER]. She pushed the cleaning cart to room [ROOM NUMBER]. -HSK #1 said there was no disinfectant in the mop pad bucket and it only contained plain water. -HSK #1 did not disinfect high touch areas such as the door knobs, light switches, call light and bed controller. HSK #1 used hand sanitizer, donned gloves and entered room [ROOM NUMBER]. She removed the toilet brush from the cart and proceeded to the bathroom. The toilet seat had feces on it and there was feces in the toilet bowl. She did not flush the toilet. She used the toilet brush to clean the inside of the toilet bowl and then used the brush to clean the feces off the seat. She placed the toilet brush back onto the cart and removed her gloves. She used hand sanitizer and donned clean gloves. She removed the broom from the cart and began sweeping the room. She moved the night stand and swept behind it. A comb and tube of toothpaste was in the debris. She picked up the items and shook them off. She placed both items back onto the night stand. There was still debris in the comb. She swept the rest of the debris to the doorway and picked it up with the dust pan. She removed the disinfectant and a green rag from the cart. She wet the rag at the sink and proceeded to the bathroom. She sprayed the toilet with disinfectant and used the rag to wipe it. She first wiped the tank, the seat, under the seat, the rim, the side of the toilet and the sides. She sprayed the window sill and used a clean rag to wipe it. She returned the spray bottle and the soiled rags to the cart. She removed her gloves, used hand sanitizer and donned clean gloves. She removed a mop pad from the water bucket and sprayed it with a cleaner. She dropped the mop pad on the floor and placed the mop handle on top. She mopped the room and emptied the trash. She removed the soiled mop pad and replaced it with a clean mop pad from the water bucket. She did not spray the second mop pad with a cleaner. She then mopped the bathroom floor. She placed the mop pad and handle back onto the cart. She removed a small container of a soap solution and a scrubbing pad. She washed the inside of the sink. She again splashed water onto the sink top and mirror and wiped them dry with a paper towel. She placed a wet floor sign at the door entrance and exited the room. -HSK #1 failed to use the toilet brush only on the inside of the toilet and use a disinfectant on the toilet. She failed to discard the comb and tooth paste into the trash and placed them back on the night stand to be used. She failed to use a disinfectant when mopping the bathroom floor and failed to use a disinfectant while cleaning the sink. She failed to clean horizontal surfaces and high touch surfaces. D. Staff interviews HSK #1 was interviewed on 12/18/24 at 10:37 a.m. HSK #1 said she used the container of dish soap and water, with the scrub pad, to clean the sink in all the resident's rooms. She said she changed the scrub pad once a week and used the dish soap because she felt it was the best product to disinfect with. She said the toilet brush should only be used for the inside of the toilet bowl, but since there was dried feces on the seat she had to use the toilet brush to clean the seat. She said the toilet should have been cleaned from top to bottom. She said she used the toilet brush to clean the seat, because she did not have another rag. She said high touch areas, such as door knobs, grab bars, sink handles and call lights should be cleaned daily. She said there was only water in the mop bucket, but she sprayed the mop with a cleaner to rid the room of odors. The housekeeping and laundry manager (HLM) was interviewed on 12/18/24 at 11:09 a.m. The HLM said a multipurpose cleaner should have been used for the cleaning of the floors. He said there was a chemical dispensing system in the janitor closet. He said when the HSK filled the mop bucket they should have pushed the button on the dispenser to add the cleaner to the water. He said the cleaner spray was only used to give the room a clean smell and did not disinfect. He said the toilet brush should never be used outside of the toilet bowl. He said the toilet should be cleaned with a disinfectant and wiped with a clean rag from top to bottom. He said high touch surfaces should be disinfected daily as well as the sink and any frequently touched surfaces. He said HSK #1 should not have cleaned the grab bars after the toilet with the same rag. He said the toilet should always be cleaned last. He said HSK #1 should have thrown the comb and tooth paste in the trash so it could not be used. He said he would reeducate HSK #1 on the room cleaning process and procedures. The infection preventionist (IP) was interviewed on 12/19/24 at 10:47 a.m. The IP said a resident's room should be cleaned from top to bottom and cleanest to dirtiest. She said the bathroom should always be cleaned last. She said the grab bars should have been cleaned prior to the toilet. She said the toilet should be cleaned from top to bottom and the toilet bowl last. She said the toilet brush should only be used inside the toilet. She said a disinfectant should have been used to clean the sink, high touch surfaces and when mopping the floor. She said if items were on the floor, they should have been thrown away. She said she would immediately reeducate the housekeeping staff on the correct room cleaning process and the use of the correct cleaning chemicals. II. Enhanced barrier precautions A. Facility policy and procedure The Enhanced Barrier Precautions policy, revised March 2024, was provided by the NHA on 12/19/24 at 1:19 p.m. It read in pertinent part, Enhanced barrier precautions were utilized to reduce the transmission of multi-drug resistant organisms (MRDOs) to residents. Gown and glove use in addition to standard precautions should be used during high contact resident care activities when contact precautions do not apply. High-contact resident care activities requiring the use of gown and gloves for EBPs include dressing, bathing, transferring, changing linen, changing brief or toileting, device care and wound care. EBPs are indicated for residents with wounds and/or indwelling medical devices regardless of MRDO colonization. Wounds generally include chronic wounds such as pressure ulcers, diabetic foot ulcers, venous stasis ulcers and unhealed surgical wounds. EBPs remain in place for the duration of the resident's stay or until resolution of the wound or discontinuation of the indwelling medical device that places them at increased risk. Staff are trained prior to caring for residents on EBPs. Signs are posted in the door or wall outside the resident room indicating the type of precautions and PPE required. PPE is available outside of the resident rooms. Residents, families and visitors are notified of the implementation of EBPs throughout the facility. B. Observations On 12/18/24 at 12:19 p.m. Resident #35 was laying in bed waiting for the wound physician to perform wound care. The wound care physician and registered nurse (RN) #1 used hand sanitizer and donned gloves. They entered Resident #35's room and began her wound care. -The facility failed to identify the need for Resident #35 to be placed on EBPs for her chronic stage IV pressure injury. C. Staff interviews RN #1 was interviewed on 12/18/24 at 1:43 p.m. RN #1 said he was not sure what enhanced barrier precautions were or when they should be put into place. The director of nursing (DON) was interviewed on 12/18/24 at 1:44 p.m. The DON said there were no residents in the facility, at the time of the survey, that required EBPs. She said she would check to see if any residents needed to be on EBP. When she returned, she said Resident #35 should have been placed on EBPs and was not sure why she was not. She said she would immediately get a physician's order and place Resident #35 on EBPs. She said when a resident was on EBP the staff needed to wear a gown, gloves and mask prior to completing wound care. III. Laundry A. Facility policy and procedure The Soiled Laundry and Bedding policy, revised September 2022, was provided by the nursing home administrator (NHA) on 12/19/24 at 1:19 p.m. It read in pertinent part: Laundry equipment (washing machines and dryers) are used and maintained according to the manufacturer's instructions for use to prevent microbial contamination of the system. Laundry processed in hot water temperatures is 160 degrees F (fahrenheit) for 25 minutes. Laundry that is not hot water compatible, low temperature washing at 71 degrees to 77 degrees F (22-25 degrees celcius) plus chlorine or oxygen-activated bleach can reduce microbial contamination. The Cleaning Lint in Laundry policy, undated, was provided by the NHA on 12/19/24 at 1:19 p.m. It read in pertinent part: The policy statement was to maintain a safe, efficient, and sanitary laundry environment, lint must be regularly cleaned from laundry machines, lint traps, and surrounding areas. THis reduces the risk of fire, ensures proper machine function and maintains hygiene standards in the facility. The purpose was to establish a consistent procedure for cleaning lint in laundry facilities to promote safety, improve equipment performance and ensure compliance with applicable regulations. Remove the lint trap from the machine carefully after every load of laundry. Use a lint brush or hand to remove accumulated lint. Place the lint into a designated trash receptacle. Inspect the lint trap for tears or damage. Report any issues to the supervisor immediately. Maintain a log of daily, weekly, and monthly lint cleaning activities. Note any issues, repairs, or maintenance required in the log. B. Observations The laundry room was observed on 12/18/24 at 2:34 p.m. There were two washing machines. C. Record review A request was made for the temperature log for the washing machines. The facility was unable to provide a temperature log for the two washing machines. D. Staff interviews The HLM was interviewed on 12/18/24 at 2:34 p.m. He said he did not know he needed to check the temperature on the washing machines. The regional director of plant operations (RDPO) was interviewed on 12/18/24 at 10:47 a.m. He said the washing machine temperatures should reach 160F and tested daily with a thermometer to disinfect the laundry properly. The IP was interviewed on 12/19/24 at 10:47 a.m. The IP said she did not know how often the washing machine temperatures should be checked or what the temperature should be at.

Based on interviews and record review, the facility failed to protect and keep residents safe from physical abuse for one (#37) of three residents reviewed for physical abuse out of 29 sample residents. Specifically, the facility failed to protect Resident #37 from physical abuse by a staff member. Findings include: I. Facility policy and procedure The Abuse, Neglect, Exploitation or Misappropriation Reporting and Investigating policy and procedure, revised September 2022, was received from the nursing home administrator (NHA) on 12/23/24 at 11:00 a.m. It revealed in pertinent part, If resident abuse, neglect, exploitation, misappropriation or resident property or injury of unknown source is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law. Upon receiving any allegation of abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source, the administrator is responsible for determining what actions (if any) were needed for the protection of the residents. Any employee who has been accused of resident abuse is placed on leave with no resident contact until the investigation is complete. If the investigation reveals that the allegations of abuse were found, the employee(s) is terminated. II. Incident of physical abuse The facility investigation of the incident involving Resident #37 revealed the following: On 11/16/24, an agency certified nurse aide (CNA) called the director of nursing (DON) and informed her she did not like how staff were treating residents and she would not be returning to the facility. The DON called the agency registered nurse (RN), who was working the night of 11/16/24 to get more information on the situation. The agency RN told the DON that the agency CNA was making negative remarks about the facility and the CNA was afraid Resident #37 would harm her. The agency RN told the DON Resident #37 had an increase in behaviors, along with exit seeking, during the evening and was placed on a one-to-one with a staff member. There were no further concerns reported to the DON regarding staff treating residents poorly. On 11/18/24 the nursing home administrator (NHA) and the DON reviewed security footage of the facility, per the usual routine, and identified an incident, on video surveillance, that occurred between Resident #37 and the agency RN. Video surveillance revealed the agency RN swinging her arm and knocking the resident's cup of water out of his hand and then she continued to push Resident #37, causing him to stumble backwards and lose his footing. The DON conducted an assessment on 11/18/24 of Resident #37 which concluded no injuries were noted to the resident. Resident #37 was interviewed but due to his level of cognition, he was unable to recall the event or provide information on what occurred. The facility identified Resident #37 was at his baseline for behaviors and exit seeking. The alleged assailant (agency RN) was interviewed on 11/18/24 by the DON and the NHA. The agency RN was shocked to hear she had pushed and hit Resident #37. The RN said the incident had only been a reaction and was not intentional. The facility investigation concluded that abuse did occur between the agency RN and Resident #37. The agency RN was not allowed to return to the facility and she was reported to the state board of nursing. The facility notified Resident #37's physician, the resident's representative and the local police department of the abuse. The incident was reported to the state occurrence website. An all staff meeting was conducted on 11/19/24 where the NHA reviewed appropriate interactions with residents and how they should be treated with dignity and respect. The NHA also reviewed the proper way to provide touch assistance. The NHA reviewed with all staff that it was never appropriate to put hands on a resident and if someone was experiencing behaviors that could not be redirected, it was best to give the resident some space and clear the area where the resident could de-escalate away from staff and other residents. III. Resident #37 A. Resident status Resident #37, age greater than 65, was admitted [DATE]. According to the December 2024 computerized physician orders (CPO), diagnoses included dementia with behavioral disturbances, chronic obstructive pulmonary disease (COPD - an abnormal exchange of oxygen in the lungs) and depression. The 9/20/24 minimum data set (MDS) assessment revealed the resident was severely cognitively impaired with a brief interview for mental status (BIMS) score of six out of 15. He required partial assistance from staff for dressing. He required set up assistance for eating and personal hygiene. He was independent with transfers and ambulation. The assessment documented the resident did not reject care assistance and was not physically aggressive towards others. B. Resident representative interview Resident #37's representative was interviewed on 12/16/24 at 2:28 p.m. The representative said the facility had contacted her in November 2024 about an incident where Resident #37 and a staff member were pushing each other. She said the staff member had been terminated by the facility and Resident #37 had no injuries from the incident. C. Record review The comprehensive care plan, initiated 9/18/24, documented Resident #37 had a behavior problem. He could be verbal with staff and other residents when sundowning. He could become agitated and physical with staff. He had a history of calling staff racial slurs during care or when they were attempting to redirect him. Interventions included allowing the resident to de-escalate in a calm area, providing activities of interest to the resident, explaining all care to the resident prior to initiating care to allow the resident to adjust to changes, offering snack preferences of chips and 7-Up, taking the resident for walks in the afternoon hours and monitoring the resident's hours of sleep. A behavior progress note, dated 11/16/24 at 6:06 a.m., documented Resident #37 was agitated and attempted to throw heavy objects at the nurse, along with exit-seeking and setting off the alarms on exit doors. A behavior note, dated 11/16/24 at 2:30 p.m., documented Resident #37 was exit-seeking. The resident was redirectable and given a task to complete. A behavior note, dated 11/16/24 at 10:10 p.m., documented Resident #37 had been exit-seeking with multiple attempts to redirect him. The resident was agitated and wanted to exit the alarmed doors. Resident #37 was mumbling as he approached the nurse who was at her medication cart preparing medications and the resident attempted to pour water on the nurse's head. The nurse put up her arm to stop the resident's advancement and the water from being poured. Resident #37 walked into the nurse's arm and stumbled off balance. The nurse documented the resident said he was sick of being told what to do. A CNA assisted the resident to his room in an attempt to calm him down with fewer people around to decrease the risk of negative interactions with other residents. Another resident was yelling at Resident #37 to not hit women. Resident #37 told the other resident to shut up. A CNA attempted to sit in Resident #37's room with him for safety but Resident #37 continued to exit-seek and became agitated. The CNA and the nurse attempted to change Resident #37's clothing due to it being soiled but he refused. Resident #37 became combative and attempted to trip and kick the nurse. A behavior note dated 11/17/24 at 12:00 a.m., documented direct care assignment of Resident #37 was directed to another licensed nurse with on- to-one CNA monitoring for safety and wellness. A behavior note, dated 11/17/24 a 5:32 p.m., documented Resident #37 had been on one-to-one supervision at all times to maintain safety and prevent exit-seeking actions. Resident #37 was provided with various chores and tasks to keep him occupied and reduce agitation. A behavior note, dated 11/18/24 at 3:52 a.m., documented there was no physical aggression against staff noted. Resident #37 continued to exit-seek with increased agitation due to his inability to successfully and independently exit the facility. Resident #37 randomly sat and slept for short periods of time and then woke up to start pacing/exit seeking. IV. Staff interviews The DON was interviewed on 12/19/24 at 10:20a.m. She said abuse allegations were to be reported to the NHA immediately for further investigation. The DON said she received a call from an agency CNA on the night of 11/16/24. She said the agency CNA said she wanted to be removed from the schedule because she did not want to work in a place where the residents were not treated right. The DON said the agency CNA hung up on her before giving her any details regarding what she was referring to. The DON said she made several attempts to get in touch with the agency CNA after she hung up on her but the CNA did not answer her calls. The DON said once she was able to finally get ahold of the agency CNA again, she said the CNA told her she did not like how a resident was taken to their room by two staff members and then she stopped answering questions. The DON said the agency CNA would not give her any details about why she had concerns. The DON said after she talked to the agency CNA the second time, she called the facility and spoke with the RN assigned to the front unit to try to figure out why the CNA said she did not want to work at the facility. The DON said the agency RN informed her she was unable to find the agency CNA in the building and she was not aware of any concerns involving residents and staff. The DON said she interviewed all staff in the building via telephone on 11/16/24 and did not find any concerns with staff not treating residents correctly. She said she called the NHA to inform her of the concern and her findings on the night of the incident. The NHA was interviewed on 12/19/24 at 11:53 a.m. The NHA said she was the abuse coordinator for the facility and any reports of abuse were to be called to her attention 24-hours a day/seven days a week. She said the facility educated staff on what abuse was on hire and at all staff meetings. The NHA said she directed staff to report anything they might suspect was abuse. She said even if staff had doubts about whether abuse actually occurred, they should report it. The NHA said she was notified by the DON on 11/16/24 about an agency staff CNA who called and said she would not be returning to the facility due to how a resident was treated. The NHA said the DON interviewed all staff members, via telephone, who were working in the facility on 11/16/24 about concerns voiced by the agency CNA. The NHA said none of the staff members reported any concerns to the DON on the night of 11/16/24. The NHA said the agency RN completed her scheduled shifts on 11/16/24 and 11/17/24 because the initial interviews conducted by the DON on 11/16/24 did not lead the facility to believe abuse had occurred, as none of the staff interviewed voiced any concerns The NHA said when she came into the facility on the following Monday (11/18/24), she reviewed the video surveillance of the facility from the weekend, as was her usual practice. The NHA said when she was going through the surveillance footage from the weekend, she saw an incident between Resident #37 and the agency RN the DON had spoken to on the night of 11/16/24. The NHA said the video footage revealed that Resident #37 walked up to the agency RN from behind with a cup of water and when the RN turned around, she swatted the cup out of the resident's hand. The NHA said the footage further revealed the agency RN pushed the resident backwards with one hand. The NHA said the video had voice recording and the agency RN was heard yelling stop, I didn't do anything to you. The NHA said Resident #37 was observed stumbling backwards and losing his balance but the NHA said the resident did not fall. The NHA said, after viewing the video footage and seeing what occurred between Resident #37 and the agency RN, she began an investigation into the incident. She said the facility attempted to interview Resident #37 about the incident, but she said based on his cognitive status, he was unable to recall the incident. She said the DON conducted a skin assessment on the resident and no injuries were noted. The NHA said she substantiated that abuse had occurred based on the video footage. The NHA said the physician, responsible party and the police were all notified of the occurrence on 11/18/24. The NHA said she reported the incident to the State Agency and the agency RN was reported to the agency company she worked for and to the state board of nursing. The NHA said the agency RN had been offered a position in the facility full-time prior to the incident, but the offer had been rescinded due to the abuse observed in the video surveillance. The NHA said the facility verified that all agency staff received education for abuse and dementia training from their respective agencies prior to working in the facility.

Based on observations, record review and interviews, the facility failed to ensure that its medication error rate was less than five percent (%). Specifically, the facility had a medication error rate of 6.45%, which was two errors out of 31 opportunities for error. Findings include: I. Professional reference According to [NAME], P.A., [NAME], A.G., et.al., Fundamentals of Nursing, 10 ed., E.[NAME], St. Louis Missouri, pp. 606-607. Take appropriate actions to ensure the patient receives medication as prescribed and within the times prescribed and in the appropriate environment. Professional Standards such as nursing scope and standards of practice apply to the activity of medication administration. To prevent medication errors, follow the seven rights of medication administration consistently every time you administer medications. Many medication errors can be linked in some way to an inconsistency in adhering to these seven rights: 1. The right medication 2. The right dose 3. The right patient 4. The right route 5. The right time 6. The right documentation 7. The right indication. According to the Instructions for use Humalin R KwikPen, retrieved on 11/23/24 from: https://pi.lilly.com/ca/humulin-n-r-ca-ifu-kp.pdf It revealed in pertinent Priming your pen. Prime before injections. Priming your Pen means removing the air from the needle and cartridge that may collect during normal use and ensure the pen is working correctly. If you do not prime the pen before injections, you may get too much or too little insulin. According to the How to Use Voltaren Gel instructions, retrieved on 12/23/24 from: https://www.voltarengel.com/arthritis-pain-gel/ It reveled in pertinent part Dosage: using the dosing care, apply the following amounts: Upper body areas (hand, wrist, elbow: 2.25 inches. Lower body areas (foot ankle, knee): 4.5 inches II. Facility policy and procedure The Administering Medications policy and procedure, revised April 2019, was received from the nursing home administrator (NHA) on 12/19/24 at 1:29 p.m. It revealed in pertinent part, Medications are administered in a safe and timely manner, and as prescribed. The individual administering medications checks the label three times to verify the right resident, right medication, right dose, right time, and right method (route) of administration before giving the medications. III. Observations On 12/17/24 at 11:40 a.m. registered nurse (RN) #1 was administering medications for Resident #3. The medication ordered was Humalin R U-500 Kwik pen 500 units/milliliter (ml) inject 125 units subcutaneously before meals for diabetes. RN #1 collected the Humalin R pen from the medication cart, applied a new needle to the tip and dialed the insulin pen to 125 units. RN #1 then identified Resident #3, applied gloves, cleansed the site with an alcohol swab and administered the injection via pen into the resident's right lower abdomen. -RN #1 failed to prime the insulin pen for the correct dose of medications ( see professional reference above). On 12/19/24 at 8:27 a.m. RN #1 was administering medications for Resident #10. The medication ordered was Volataren arthritis pain external gel one percent, apply to the right hip topically three times a day for osteoarthritis. RN #1 obtained a tube of Voltaren gel one percent from the treatment cart. He opened the tube and poured out about a quarter in diameter gel directly into a medication cup. RN #1 then identified Resident #10 applied gloves and applied the gel to the resident's right hip. -RN #1 failed to identify the medication order did not have a dose indicated (see professional reference above) in order to administer the correct dose to the resident. IV. Staff interviews RN #1 was interviewed on 12/17/24 at 12:41 p.m. RN #1 said insulin vials needed to be cleansed with an alcohol swab prior to inserting a needle to draw up the insulin. RN #1 was not aware he needed to cleanse the top of the insulin pen prior to applying the needle. RN #1 said he was did not know he needed to prime an insulin pen before dialing to the ordered dose. RN #1 said priming would waste the insulin. RN #1 said he would need to find out what the facility protocol on insulin pens was. Licensed practical nurse (LPN) #1 was interviewed on 11/17/24 at 12:56 p.m. LPN #1 said insulin pens did not need to be primed after applying a new needle. The director of nursing (DON) was interviewed on 12/18/24 at 3:09 p.m. The DON said insulin pens should be cleaned prior to applying the needle and the pen should be primed prior to dialing up the dose. The DON said priming was important to ensure the correct dose was administered, not priming could lead to too much or too little insulin being administered. RN #1 was interviewed again on 12/19/24 at 9:40 a.m. RN #1 said he administered the Voltaren gel as ordered for Resident #10. He said after reviewing the Voltaren gel order he was able to identify the order was missing a dose. He said he was not aware he needed to use the dosing card inside the Voltaren gel box. RN #1 said he would call the physician immediately to get the dose added to the order. The DON was interviewed again on 12/19/24 at 10:20 a.m. The DON said an order should include the right person, medication, dose, frequency and route. The DON said if the order was missing one of the five rights it was to be corrected immediately to prevent medication error. The DON said her charting system did not allow for the dose to be put in and she would have to figure out how it can be added. The DON said Voltaren gel had a dosing card that should be used to ensure the correct dose is being administered.

Based on observations, record review and interviews the facility failed to ensure residents were kept free of significant medication errors for one resident (#3) out of 29 sample residents. Specifically the facility failed to ensure insulin pens were primed prior to medication administration for Residents #3. Cross-reference F759 failure to ensure the medication error rate was less than five percent (%). Findings include: I. Professional reference According to the Instructions for use Humalin R KwikPen, retrieved 12/26/24 from: https://pi.lilly.com/ca/humulin-n-r-ca-ifu-kp.pdf It revealed in pertinent Priming your pen. Prime before injections. Priming your Pen means removing the air from the needle and cartridge that may collect during normal use and ensure the pen is working correctly. If you do not prime the pen before injections, you may get too much or too little insulin. II. Facility policy and procedure The Administering medications policy and procedure, revised April 2019, was received from the nursing home administrator (NHA) on 12/19/24 at 1:29 p.m. It revealed in pertinent part, Medications were administered in a safe and timely manner, and as prescribed. The individual administering medications checks the label three times to verify the right resident, right medication, right dose, right time, and right method (route) of administration before giving the medications. III. Resident #3 A. Resident status Resident #3, age greater than 65, admitted on [DATE]. According to the December 2024 computerized physician orders (CPO) diagnoses included type one diabetes (abnormal glucose control), obesity and paranoid schizophrenia (abnormal thinking process). The 11/22/24 minimum data set (MDS) assessment revealed the resident had severe cognitive impairments with a brief interview for mental status (BIMS) score of three out of 15. He required set up assistance with personal hygiene. He was independent for eating, dressing, toileting and transfers. The MDS assessment revealed the resident received insulin injections for the past seven days. B. Physician's orders The December 2024 CPO documented a physician's order for Resident #3. The order read: Humalin R U-500 kwikPen, Inject 125 units subcutaneously before meals for diabetes. C. Observations On 12/17/24 at 11:40 a.m. registered nurse (RN) #1 was administering medications for Resident #3. The medication ordered was Humalin R U-500 Kwik pen 500 units/milliliter (ml) inject 125 units subcutaneously before meals for diabetes. RN #1 collected the Humalin R pen from the medication cart, applied a new needle to the tip and dialed the insulin pen to 125 units. RN #1 then identified Resident #3, applied gloves, cleansed the site with an alcohol swab and administered the injection via pen into the resident's right lower abdomen. -RN #1 failed to prime the insulin pen for the correct dose of medications (see professional reference above). III. Staff interviews RN #1 was interviewed on 12/17/24 at 12:41 p.m. RN #1 said insulin vials needed to be cleansed with an alcohol swab prior to inserting a needle to draw up the insulin. RN #1 said he was not aware he needed to cleanse the top of the insulin pen prior to applying the needle. RN #1 said he did not know he needed to prime an insulin pen before dialing to the ordered dose. RN #1 said priming would waste the insulin. RN #1 said he would need to find out what the facility protocol on insulin pens was. Licensed practical nurse (LPN) #1 was interviewed on 11/17/24 at 12:56 p.m. LPN #1 said insulin pens did not need to be primed after applying a new needle. The director of nursing (DON) was interviewed on 12/18/24 at 3:09 p.m. The DON said insulin pens should be cleaned prior to applying the needle and the pen should be primed prior to dialing up the dose. The DON said priming was important to ensure the correct dose was administered, not priming could lead to too much or too little insulin being administered.

Based on observations, interviews, and record review, the facility failed to ensure two (#1 and #2) out of five sample residents at risk for elopement, received adequate supervision and facility assistive devices to prevent elopement. Specifically, the facility failed to provide Resident #1 and Resident #2 the supervision necessary to prevent elopements. These facility failures created a situation with serious harm and a situation with the likelihood of serious harm to residents' health and safety if not immediately corrected. Resident #1, diagnosed with schizoaffective disorder (a mental health disorder that is marked by a combination of schizophrenia symptoms, such as hallucinations or delusions, and mood disorder symptoms, such as depression or mania), unsteadiness on feet, restlessness and agitation and need for supervision, eloped from the facility on 12/24/23 at approximately 10:11 p.m. when he exited the facility through an alarmed dining room door and an outside gate which was unlocked. Facility staff were unaware Resident #1 was missing until agency certified nurse aide (ACNA) #1 returned to the facility from break at approximately 10:44 p.m. (33 minutes later) and observed the resident seated on the ground in the snow and stuck in an orange construction site fence (a safety barrier, lightweight fence) that separated the facility property from nearby construction. Resident #1 was brought back into the facility by staff and assessed by registered nurse (RN) #1. RN #1 encountered difficulties with obtaining the resident's vital signs and the resident was transported to the hospital for further evaluation shortly thereafter where the resident was diagnosed with right lower extremity frostbite. Resident #1 did not return to the facility per family request. The facility began investigating the incident on 12/27/24 (three days after the resident eloped) and determined Resident #1 eloped from the facility due to the staff's failure to respond to the sound of the dining room door alarm. The facility responded by providing education to the facility staff, beginning on 12/27/24, on resident elopement and what to do in the event a door alarm went off. The facility created a binder for all agency staff to read before their shift to learn what to do in the event a door alarm went off. The facility began monitoring the elopement interventions in the quality assurance and performance improvement (QAPI) meetings beginning on 1/11/24 and planned to monitor the process for three months or longer as needed. The education regarding elopement interventions and responding to door alarms proved to be ineffective as another resident elopement occurred on 2/2/24. Resident #2, diagnosed with paranoid schizophrenia (a mental disorder characterized by recurrent episodes of psychosis that are correlated with a general misperception of reality) and dementia, eloped from the facility on 2/2/24 at 9:48 p.m. when he exited the facility through the same alarmed dining room door and unlocked outside gate. At 10:20 p.m. (32 minutes later) the local police department called the facility to ask if the facility was missing a resident. Facility staff did a search of all residents and discovered Resident #2 was missing from the facility. At 10:30 p.m. the facility nurse called the police back and informed them Resident #2 was missing. The police informed the facility Resident #2 was found at a busy intersection approximately one tenth of a mile from the facility and had been taken to a local hospital for an evaluation. Resident #2 returned to the facility from the hospital on 2/3/24 at 1:25 a.m. with no noted injuries. Findings include: Observations, interviews, and record review confirmed the facility corrected the deficient practice prior to the onsite investigation on 4/25/24 to 5/1/24, resulting in the deficiency being cited as past noncompliance with a correction date of 2/7/24. I. Situation of serious harm The facility failed to ensure facility staff were aware of the proper procedures to respond timely to door alarms and how to reset the alarm for a door once an alarm had been triggered. This resulted in Resident #1 eloping from the facility on 12/24/23 and sustaining frostbite to his right lower extremity. Following the elopement incident with Resident #1 on 12/24/23, the facility failed to put effective interventions and systems into place to ensure further resident elopements did not occur. This resulted in Resident #2 eloping from the facility on 2/2/24 and being found by the local police department at a busy intersection approximately one tenth of a mile from the facility and taken to a local hospital for an evaluation. II. Facility plan of correction The corrective action plan the facility implemented in response to Resident #2's elopement incident on 2/2/24 was provided by the nursing home administrator (NHA) on 4/25/24 at 2:00 p.m. A. Immediate action Resident #2's care plan was updated on 2/5/24 to include the following interventions: -Provide activities to attempt giving the resident meaningful activities; -Facility to add a chirping alarm to dining room doors; and, -Nursing to conduct frequent checks for resident's whereabouts. B. Identification of others affected The facility determined, due to the facility's population of residents with dementia, every resident was at risk for eloping from the facility. C. Systemic changes -On 2/3/24 the facility ordered new door alarms. The new alarm system had no automatic shut off and the alarm continued to sound until it was turned off by the facility staff and rearmed with a key. -On 2/3/24 the facility ordered items to rebuild the entire egress area (where the outside gate was opened). The ordered items included black aluminum fence panels, fast setting concrete mix, a new gate door, door hardware for installation, and a battery operated powered door mounted weatherized exit alarm. -On 2/3/24 facility staff were educated on how to turn the current alarms off until the new door alarms were installed. -On 2/3/24 the staffing agency was notified via text of the elopement binder with directions of how to turn the current alarms off which was to be read by all agency staff before each person worked in the facility. -On 2/5/24 visual aide note cards were added to the doors about how the keys were to turn to reset the alarms on the doors. -On 2/7/24 the new door alarms were installed and staff education of how to work the alarms began. -On 2/7/24, weekly documentation of safety checks on the door alarms was started by the plant operations director (POD). -On 2/29/24, the outside gate improvement project was completed. Weekly checks of the outside gate area were started. -On 2/7/24 the new door alarm system was installed which removed the immediacy of the deficient practice. The outdoor gate improvement project, which was completed on 12/29/24, was an additional security measure put in place by the facility, however, it was not the main security issue, therefore the correction date for the deficient practice was 2/7/24. D. Monitoring The facility would monitor the elopement situation and the weekly safety check documentation in the monthly QAPI meetings. Observations, interviews and record review during the complaint investigation from 4/25/24 to 5/1/24 revealed corrective actions to identify the resident and other residents who had the potential to be affected by the deficient practice, systematic changes to prevent its recurrence, and monitoring to ensure sustained corrections were in place. III. Facility Policy and procedures The Elopement Management System policy, March 2023, was provided by the NHA on 4/25/24 at 2:50 p.m. It revealed in pertinent part, Each resident is assisted in attaining/maintaining his or her highest practicable level of function by providing the resident with adequate supervision, activity/functional programs as appropriate and safety interventions to minimize elopement risk. Signaling devices may be used, if available, and determined to be an appropriate intervention. The Interdisciplinary Team (IDT) evaluates each resident to identify elopement risk. A Care Plan is developed and implemented based on this evaluation, with ongoing review. The Administrator and Director of Nursing are responsible for coordination of an interdisciplinary approach to managing the process for prediction, risk assessment, treatment, evaluation, and monitoring of exit-seeking behavior. Unsafe Wandering or Elopement According to the Centers for Medicare & Medicaid Services,Wandering is random or repetitive locomotion. This movement may be goal-directed (the person appears to be searching for something such as an exit) or may be non-goal-directed or aimless. Non-goal-directed wandering requires a response in a manner that addresses both safety issues and an evaluation to identify root causes to the degree possible. Moving about the center aimlessly may indicate that the resident is frustrated, anxious, bored, hungry, or depressed. Unsafe wandering and elopement may be associated with falls and related injuries. Unsafe wandering may occur when the resident at risk enters an area that is physically hazardous or that contains potential safety hazards (chemicals, tools and equipment). While alarms can help to monitor a resident's activities, staff must be vigilant in order to respond to them in a timely manner. Alarms do not replace necessary supervision. The Maintenance Director or designee will complete preventive maintenance for door monitor testing, door range testing, function tester maintenance and elopement drills. Care Plan interventions are individualized to the resident and are based on the assessed risk of elopement. IV. Resident #1 A. Resident status Resident #1, age over 75, was admitted on [DATE] and readmitted on [DATE]. According to the October 2023 computerized physician orders (CPO), diagnoses included schizoaffective disorder, cerebral infarction (stroke), unsteadiness on feet, adult failure to thrive, vascular dementia, hypertension (high blood pressure), need for continuous supervision and restlessness and agitation. The 10/17/23 minimum data set (MDS) assessment revealed the resident had severely impaired cognitive skills for daily decision-making and had disorganized thinking. He required maximum assistance with toileting, showering, upper and lower body dressing, and putting on and off footwear. He was always incontinent of bowel and bladder. He used a wheelchair. He needed supervision or touch assistance to walk 150 ft. (feet). B. Record review The comprehensive care plan initiated, on 10/16/23 and revised on 11/3/23, revealed Resident #1 was at a high risk for falls related to confusion, gait and balance problems, poor communication and comprehension. The resident was unaware of safety needs and wandered. Pertinent interventions included anticipating and meeting the resident's needs, ensuring the resident's call light was within reach and encouraging the resident to use it for assistance as needed and responding promptly to all of the resident's requests for assistance. The elopement evaluation, dated 12/25/23 revealed the resident ambulated with or without the use of an assistive device or wheelchair. The resident had a history of elopement or attempted elopement while at home. The resident had a history of elopement or attempted to leave the facility without informing staff. The resident had expressed a desire to go home, packed belongings to go home or stayed near an exit door. The resident wandered and his wandering was likely to affect the safety of himself or others. The nursing progress note related to the elopement incident on 12/24/23, documented on 12/25/23 by RN #1 revealed RN #1 piled blankets on Resident #1 when he was brought back into the facility and RN #1 called 911. Resident #1 was shaking vehemently and RN #1 was unable to get a temperature or pulse oximeter (to read the oxygen levels in the body) for the resident. The resident's feet and hands had deep erythema (reddening of the skin) to his fingers and toes with a waxy appearance. A hospital progress note, dated 12/24/23 revealed the diagnoses of hypothermia and an altered mental status. On 12/25/23 the hospital documented Resident #1 complained of pain to his toes as they rewarmed. Emergency medical services (EMS) noted the resident was cold with a temperature of 88 degrees Fahrenheit. A nursing progress note dated 12/27/23 revealed a nurse from the facility called the hospital where Resident #1 was staying. The hospital told the facility's nurse Resident #1 was in stable condition and had right lower extremity frostbite. C. Review of the 12/24/23 incident On 4/25/24 at 2:00 p.m. the NHA provided the investigation of Resident #1's elopement on 12/24/23. The investigation revealed the following: Resident #1 was seen on the facility's video recording on 12/24/23 at 10:04 p.m. walking around the dining room. At 10:11 p.m. Resident #1 was observed on camera standing in front of the dining room door that led to the outside. The video camera did not record for approximately 1-2 minutes due to connection issues. When the camera turned back on the view was of a closed door, however, Resident #1 was no longer observed on the video. The facility documented Resident #1 went out the dining room door during the video outage and then out the unsecured gate where there was no video coverage. At 10:44 p.m. the camera revealed RN #1 at the front door of the facility talking to a staff member. The agency certified nurse aide (ACNA) #1 said he drove his car to a convenience store nearby and returned from his lunch break around 10:44 p.m. ACNA #1 said he saw a person seated on the ground in the snow who was stuck in an orange construction site fence, a barrier, safety, lightweight fence that separated the facility property from nearby construction. ACNA #1 walked up to the person who was seated on the ground but was unsure if it was one of the residents or a homeless person. ACNA #1 said the area had frequently spotted homeless individuals in the area. ACNA #1 went in the facility to get RN #1 and ACNA #2. RN #1 verified it was one of the facility residents and the two ACNA's used a wheelchair to bring the resident back into the facility. RN #1 documented difficulty obtaining vitals on Resident #1 and RN #1 called for an ambulance to take Resident #1 to the hospital. Resident #1 went to the hospital and did not return to the facility per the family's request. On 12/27/24 (three days after the incident) the facility began investigating the incident. The facility was unable to determine whether the outside gate, which had a code, was left open by the facility staff or was damaged by the homeless individuals who were often seen in the nearby field. The facility investigation determined the agency staff in the building did not recognize the chirping sounds from the alarm to be a warning sound of a door opening. The alarm sound was determined to stop sounding after 90 seconds. Following the 90 seconds, the door did not reset the alarm unless a key was manually used to reset it. On 12/27/24 education was provided to the facility staff and the facility made a binder for all agency staff to read before their shifts to learn what to do in the event a door alarm went off. The facility began monitoring the occurrence in the QAPI meetings on 1/11/24 and planned to monitor for three months or longer as needed. D. Staff interviews The NHA was interviewed on 4/25/24 at 2:15 p.m. The NHA said, on 12/27/23, she began training all facility staff on alarming the doors and locking the gate. She said on 12/27/23 she began an elopement book of procedures that she required all agency staff to read before they began a shift in the facility. She said she began monitoring the situation through the QAPI meeting process.The NHA said RN #1 no longer worked at the facility. ACNA #1 was interviewed on 4/29/24 at 4:35 p.m. ACNA #1 said, on 12/24/23, he was the one who found Resident #1 in the field. ACNA #1 said he drove his car to get something to eat around 10:10 p.m. and when he returned around 10:40 p.m. he saw someone in the field next to the facility. He said he approached the man to check if it was a resident or one of the homeless people in the area. He said the man was seated in the snow on his posterior and his legs and hands were stuck in the construction fence. He said he thought it was a resident so he went inside and got the nurse to come outside with him to evaluate the situation. ACNA #1 said RN #1 and ACNA #2 came outside with a wheelchair. He said he and ACNA #2 put Resident #1 in a wheelchair and brought the resident back inside the facility. He said Resident #1 was too cold to get vital signs so RN #1 called 911. He said EMS came shortly after the call and took Resident #1 to the hospital. ACNA #1 said after Resident #1 was safely back inside, he and ACNA #2 checked the alarms on the doors. ACNA #1 said the alarm on the door the resident seemed to have gone out did not sound and the gate outside was opened. He said he reset the alarm when it was discovered it was not on. He said he did not know how long the alarm had been off. ACNA #2 was interviewed on 4/29/24 at 4:56 p.m. ACNA #2 said, on 12/24/23 around 10:40 p.m., he received a text from ACNA #1 to come outside and give him help. He said he brought a wheelchair outside and he and ACNA #1 put Resident #1 in the wheelchair and brought him back into the facility. He said he did not hear an alarm go off that night. He said he and ACNA #1 tried to figure out how Resident #1 got outside of the building. He said ACNA #1 reset the alarms on the door after Resident #1 went to the hospital. -RN #1 was contacted for an interview on 4/29/24 at 5:14 p.m, however, an interview was unable to be conducted. V. Resident #2 A. Resident status Resident #2, age under 75, was admitted on [DATE]. According to the April 2024 CPO, diagnoses included paranoid schizophrenia, unsteadiness on his feet, hypertension (high blood pressure), dementia with behavioral disturbances, history of falls and shortness of breath. The 11/16/23 MDS assessment revealed the resident had short and long term memory problems, continued inattention and disorganized thinking. He had behavioral symptoms occasionally directed at others, kicking, biting, hitting, pushing, scratching or grabbing. He had impaired vision. B. Record review The comprehensive care plan, initiated on 11/21/22 and revised on 12/1/23, revealed Resident #2 was an elopement risk/wanderer with a history of attempts to leave a previous facility he lived in. Due to the resident's progressing dementia, Resident #2 had been determined to be in need of a secured unit facility. Resident #2 had aggressive behaviors related to exit seeking and was not redirectable. Pertinent interventions included identifying the resident's patterns of wandering, nursing to conduct frequent checks for the resident's whereabouts and de-escalating the resident's behaviors through redirection. The comprehensive care plan further revealed the resident had a history of pressing on doors to set off the alarm on them. Interventions included distracting the resident from wandering by offering pleasant diversions, structured activities, food, conversation, television and books. The elopement evaluation, dated 6/20/23, revealed the resident was able to ambulate without the use of assistive devices or a wheelchair. He had a history of elopement. He had a history of trying to leave the facility without informing the staff. He verbally expressed the desire to go home, packed belongings to go home or stayed near an exit door. The resident wandered and it was likely to affect his safety or the safety of others. A hospital progress note, dated after the elopement on 2/2/24, revealed the resident was found wandering in the middle of an intersection by the police and brought to the emergency room . The hospital found the resident to be safe and able to return to the nursing home. A nursing progress note related to the 2/2/24 elopement, documented on 2/3/24, revealed the police called the facility at 10:20 p.m. on 2/2/24 and said Resident #2 was found wandering alone on the street. At 10:30 p.m. the nurse called the police back and answered their questions. On 2/3/24 at 1:25 a.m. Resident #2 returned to the facility on a stretcher from the hospital. C. Review of the 2/2/24 incident On 4/25/24 at 2:00 p.m. the NHA provided the investigation of Resident #2's elopement on 2/2/24. The investigation revealed the following: On 2/2/24 at 9:48 p.m. Resident #2 was seen leaving out the same dining room door that Resident #1 went out at 9:48 p.m. on 12/24/23. At 10:20 p.m. the local police department called the facility to ask if the facility was missing a resident. Facility staff were not sure if any residents were missing and said they would look and call the police back. Facility staff did a search of all residents and discovered Resident #2 was missing from the facility. At 10:30 p.m. the facility nurse called the police back and informed them Resident #2 was missing. The police informed the facility Resident #2 was found at a busy intersection approximately one tenth of a mile from the facility and had been taken to a local hospital for an evaluation. Resident #2 returned to the facility from the hospital on 2/3/24 at 1:25 a.m. with no noted injuries. Resident #2 was unable to be interviewed due to cognitive impairment. Resident #2 had a legal representative who was notified of the incident. On 2/3/24 the NHA's investigation revealed the dining room door to the outside had an alarm that did not go off and sound. Staff said they were not in the area of the dining room and did not hear the alarm sound. Again the outside gate was unlocked and it was not determined if a staff person did not lock the gate or a homeless person from the nearby areas opened the gate. D. Staff interviews The NHA was interviewed on 4/25/24 at 2:15 p.m. The NHA said after Resident #2 was the second resident to elope from the facility, she determined the alarm system needed to be replaced and more education needed to be provided to the facility staff as well as any agency staff that worked in the building. She said the building had ongoing agency staff working in the building. She said she called the agency where the staff came from and informed them that all agency staff who came to work at the facility had to read the policy of elopement and what the process was to keep the door alarms on. The regional director of plant operations (RDPO) was interviewed on 4/25/24 at 2:53 p.m. over the phone. The RDPO said he came in a day or two after the 12/25/23 elopement incident to evaluate what had happened with the alarm system and the outside gate lock. The RDPO said after the first elopement investigation, it seemed possible that a staff person did not reset the alarm prior to Resident #1 leaving the facility. He said the alarm shut off in 90 seconds and needed a key to turn the alarm back on. He said it seemed, through education of the staff, the situation would be fixed. The RDPO said the second time there was an elopement, on 2/2/24, he came in the next day. He said he determined, along with the NHA, that a new alarm system needed to be installed. He said the outside gate also needed to have something new installed. He said new alarms were installed on the dining room door where the residents eloped from. The RDPO said it was determined that a security camera needed to be installed in the back gate area. He said he contacted (name of approving agency) to get approval to redesign and install a new egress area between the dining room door and the gate. He said the parts for the door alarm were ordered and put up around 2/7/24. The RDPO said as soon as he had approval, the egress area parts were ordered, and the installation took a few days. He said the egress was completed sometime at the end of February 2024. The RDPO said he and the NHA looked at everything after the first elopement and they thought education to the staff was the solution but it was not good enough. He said after the second elopement, he designed an entirely new solution. The RDPO said the second solution worked because no residents had eloped since the new system was put in place. CNA #3 was interviewed on 4/30/24 at 10:01 a.m. CNA #3 said she was working in the front part of the facility on the night Resident #2 eloped. She said the nurse on duty told her the police called to ask if the facility was missing a resident. CNA #3 said the staff began a head count of the residents and discovered Resident #2 was not in the facility. CNA #3 said staff checked the dining room door and the alarm was disarmed and the gate door was opened in the egress section. CNA #3 said she did not know who disarmed the alarm or when it happened. She said the staff did not know Resident #2 was gone out of the facility until the police called to tell them. Agency registered nurse (ARN) #1 was interviewed on 4/30/24 at 10:45 a.m. ARN #1 said he was told by his staffing agency to read the binder in the facility before he worked and then sign that he acknowledged what he read. He said the binder contained instructions on how to respond when the alarms sounded. He said he could hear the alarms clearly in the halls and resident rooms. He said the alarms took a key to shut off the alarm and reset the alarm. CNA #2 and CNA #3 were interviewed on 4/30/24 at 11:20 a.m. Both CNAs said they never entered for work through the gate where the residents eloped. Both CNAs said when a resident pushed on a door, an alarm sounded that was loud enough for them to hear wherever they were working in the building. Both CNAs said the alarm continued to sound until someone came with the key to turn the alarm off and reset the alarm. The NHA was interviewed again on 5/1/24 at 10:00 a.m. The NHA provided documentation of the QAPI process. She said all facility management, the pharmacist, and the medical director attended the QAPI meeting. The NHA said after the incident on 12/24/23 a review at QAPI began immediately in January 2024. She said the QAPI committee met one time per month. The NHA said she had hoped the review would be completed within three months after the 12/24/23 incident but it was not done in three months because of the 2/2/24 elopement. The NHA said the elopement situation would be reviewed in QAPI for at least three months, through May 2024 or longer if the situation needed more review. The NHA said the alarms and gates would be monitored weekly indefinitely.

Based on observations, record review and interviews, the facility failed to provide an effective pest control program to ensure the facility was free of pests. Specifically, the facility failed to: -Take the appropriate measures to control a mice problem in the facility including failing to eliminate or minimize food sources; and, -Attempt to eliminate the mice from entering the facility through door gaps and holes. Findings include: I. Professional reference According to the Center for Disease Control (CDC) revised July 2019 Guidelines for Environmental Infection Control in Health-Care Facilities, retrieved from:https://www.cdc.gov/infectioncontrol/guidelines/environmental/index.html Mice are among the typical pest populations found in health-care facilities. Insects and rodents can serve as agents for the mechanical transmission of microorganisms, or as active participants in the disease transmission process by passing pathogens from one source to another. Insects and rodents should be kept out of all areas of a health-care facility. From a public health and hygiene perspective, pests should be eradicated from all indoor environments. Approaches to institutional pest management should focus on: -Eliminating food sources, indoor habitats, and other conditions that attract pests; -Excluding pests from entering the indoor environments; and -Applying pesticides as needed. Rodents can transmit viruses such as Lymphocytic choriomeningitis, bacteria such as Campylobacteriosis, Leptospirosis, Plague, Salmonellosis, Tularemia, Yersiniosis, and fungi such as Dermatophytosis. II. Facility policy and procedure The facility's policy on pest control was requested from the nursing home administrator (NHA) on 1/25/23 at 12:00 p.m. -The policy was not provided by the end of the survey. II. Observations and interviews Conference room On 1/25/24 at 10:30 a.m., the conference room was observed. The conference room had a chair with two large pizza boxes. The boxes had half eaten, dried pizza. The pizza was left over from a staff meeting the previous day, almost 24 hours prior (see NHA interview below). Front Lobby On 1/25/24 at 10:32 a.m., the floors of the front lobby were dirty in the corners with grime, food crumbs and layers of debris. On 1/25/24 at 10:33 a.m., a door leading to a courtyard was observed off the lobby of the Red Rocks unit. The door had a large gap on the left side and toward the bottom. Sunlight was visible through the large gap. Red Rocks unit dining room On 1/25/23 at 10:40 a.m., the Red Rocks unit dining room was observed. The dining room had caked food which was orange and brown on the walls. Along the floors, under the heat register and in the corners of the dining room, the floors were blackened or brown with layers of debris including numerous crumbs, cheese, crackers, a ground meat substance which had dried, hair and mouse droppings. In a cabinet with the table cloths, on the bottom shelf, were crumbs, hair and mouse droppings. In the white activity closet in the dining room, there were mouse droppings and dried fluids trailing back behind the supplies. Food and debris were observed under the ice machine. Kitchen on Red Rocks unit On 1/25/23 at 10:46 a.m., the kitchen was observed. The kitchen floor around the trash cans and hallway had pieces of dried meat, hair and other dried unrecognizable food crumbs. Mouse droppings were observed within the debris. The top of the dishwasher was covered in crumbs, dust, and mouse droppings. Dietary aide (DA) #1 was interviewed on 1/25/24 at 10:48 a.m. DA #1 said he had seen packages torn open in the kitchen but he had not seen the mice himself. Red Rocks unit hallways On 1/25/24 at 11:02 a.m., the hallways were observed. The edges and corners of the hallway floors were darkened and caked with layers of debris, food, crumbs, dust, hair and mouse droppings. Certified nurse aide (CNA) #1 was interviewed on 1/25/23 at 12:26 p.m. CNA #1 said mice would run across the dining room under the ice machine, past the door that went outside and to the far wall under the heat registers. She said she had also seen mice entering through the gap in the door leading to the courtyard. CNA #1 pointed to the hole in the door to the courtyard with the sunlight coming through the gap. She said she had also seen mice run across the hall between resident rooms #10 and #11 at the end of the hall Resident room [ROOM NUMBER], at the end of the hallway on the right side, had crumbs, hair, and mouse droppings in the room on the floor to the right of the entry. Resident #1 was present in the room and said he had seen at least one mouse in his room. Columbine unit dining room and hallways On 1/25/24 at 11:15 a.m., The dining room and hallways were observed. The edges and corners of the dining room and hallway floors were darkened and caked with layers of debris, food, crumbs and chunks, dust, hair and mouse droppings. Licensed practical nurse (LPN) #1 was interviewed on 1/25/24 at 11:16 a.m. LPN #1 said she had heard about the concerns with mice from the other staff. She said the night nurse told her the night shift staff could hear the mice running around in the ceiling at night. III. Observation and interview with the NHA On 1/25/24 at 11:50 a.m., the front lobby, Red Rocks unit dining room and hallways were observed with the NHA. The NHA looked at the mouse droppings on the floors and in the cabinets of the dining room. She said the housekeeping staff should clean the dining room and wipe food off the walls. She said there was no schedule or plan for cleaning the common areas and hallways. The NHA said the facility had been without a maintenance director for several weeks. She said the housekeeping staff reported to the maintenance director. The NHA said the housekeeping staff did not speak any English and therefore she thought maybe there was a communication issue about cleaning the common areas. The NHA said she had not looked at points of entry or considered the amount of food available on the floors in relation to the facility's issue with mice. The NHA looked at the gap in the doorway leading to the courtyard and said the facility had not considered these areas as potential entries for the mice (see below). -However, the pest control company advised the facility multiple times to replace and repair door sweeps and patch holes (see below). The NHA said the regional maintenance person had been trying to come to the facility weekly since the facility maintenance director left. The NHA said she had reports of mice from the night shift who heard them in the ceiling and had the pest control company come out. She said the pest control company did not come to the facility unless the facility called them. She said she did not recall when she called them but they had come to the facility on [DATE]. The NHA said the pizza in the conference room was from a staff meeting the previous day at 1:00 p.m. The regional maintenance director (RMD) was interviewed via telephone on 1/25/24 at 12:44 p.m. He said he was out of the state this week and would not be able to come to the facility. He said he tried to come to the facility weekly since the facility lost their maintenance director over weeks ago. He said he thought the cleaning issues in the facility were due to a lack of supervision. He said he was aware of the rodent issue in the facility and an outside pest company had come monthly. The RDM said he had not investigated or inspected the facility for areas where the mice may be entering. He said he would have the pest company start coming out every two weeks. The RDM said he did not check any of the mouse traps due to the poison in them. He said that had to be done by a pest control company. IV. Record review A report from the outside pest control agency, dated 1/17/24, was received from the NHA on 1/25/24 at 11:24 a.m. The report documented the cafeteria, dining area, and front area of the facility needed to have the door sweeps replaced or repaired. The report documented the recommendations were previously made on 12/27/24. It further documented there was evidence of mice feeding at the exterior rat station. -However, the facility had not addressed the access points including door sweeps according to the NHA and RDM (see interviews above). V. Facility follow up On 1/25/24 at 5:25 p.m., after the survey, additional reports from the outside pest control company were received from the NHA. The additional reports revealed the following: -On 11/15/23 the pest control company documented there was evidence of mice feeding in the cafeteria and exterior rat stations. -On 11/18/23 the pest control company report documented the facility's exterior condition included branches and vegetation touching walls or roof allowing pests easy access. The report documented the facility condition with cracks around windows, doors, air conditioning lines and hose faucets which may permit entry and should be sealed. Items in the laundry room should be lifted off the floor. The 11/18/23 report documented the recommendations for these conditions was created on 9/29/23. The 11/18/23 report further documented, in the cafeteria area, cracks in the floor could allow water and debris to accumulate. The manager was notified of the recommendation to repair the area. The report further documented holes in the walls of the cafeteria would provide access for rodents and other pests. The facility manager was notified to seal the cracks and holes in the wall.The report documented to address these contributing conditions to the exterior, cafeteria and laundry room. -On 12/27/23 the pest control company documented there was evidence of mice in the cafeteria and exterior. Door sweeps were again mentioned in the report as needing repair or replacement. The report documented the facility management was made aware. The pest control report further documented on 12/27/23 there was evidence of mice feeding in the cafeteria and a dead mouse in a trap in the cafeteria. The exterior traps had evidence of mice eating. Door sweep repair or replacement was recommended again for the interior of the facility and cafeteria. -The 1/17/24 pest control report again documented the need for door sweep repair or replacement (see above). -On 1/25/24, after the survey, a new pest control company report documented again that door sweeps in the cafeteria, dining area and front area needed to be repaired or replaced to prevent pest entry. The recommendation was documented as made on 12/27/23 to the facility manager. It further documented wall damage and holes should also be repaired to prevent entry. The report documented several rooms were checked for mice and no activity was seen. The technician documented he did not think the facility was infested but documented concerns with holes in walls and around pipes. Additionally, the report documented doors to the outside had door sweep issues. -The facility had a pest control company place traps and poison for mice but failed to eliminate food sources and ports of entry to maintain a pest free environment as recommended by the pest control company.

Based on observations and interviews, the facility failed to ensure residents resided in a sanitary and comfortable environment for two of two units observed for cleanliness. Specifically the facility failed to: - Ensure resident rooms, dining rooms, hallways, kitchen floors and furniture were free from debris, food and mice droppings (cross reference F 925 pest control); -Ensure resident furniture and hand rails in common areas were in good repair; and, -Ensure the resident's courtyard was free of hundreds of cigarettes extinguished and disposed of on the ground. Findings include: I. Facility policy and procedures The Common Area Cleaning policy, undated, was received from the nursing home administrator (NHA) via email on 1/25/24 at 12:02 p.m. It read in pertinent part, The lobby and hallways. Damp wipe and disinfect the furniture by damp-wiping the top, inside the drawers, the pulls, the sides, the front and back, and the legs. Clean wall splash marks. Clean walls with your cloth dampened in disinfectant cleaner. Clean only the wall areas that need to be cleaned. If the wall needs thorough cleaning, clean the whole wall. Spot clean walls. Remove spots on the wall with your cloth dipped and wrung in your disinfectant-detergent solution as you move around the room. For a stubborn spot, wet your cloth with the disinfectant-detergent solution and then rub the spot with the saturated part of your cloth. Before you dust mop, check the floor for obstructions like gum stuck to the floor. Use your scraper to remove the gum before you begin dust mopping. Wet mop floor. Remember, it is important that the entire floor surface be mopped, including corners and behind fixtures, being careful not to splash or rub against the baseboards. II. Observations Conference room On 1/25/24 at 10:30 a.m., the conference room was observed. The conference room had a chair with two large pizza boxes. The boxes contained half eaten dried out pizza. The pizza was left over from a staff meeting the previous day, almost 24 hours prior (see below). Front lobby On 1/25/24 at 10:32 a.m., six black, vinyl chairs faced the front door entrance to the building. Five of the six chairs were missing pieces of upholstery on the arm rests. The missing upholstery pieces were several inches in diameter. Under the missing sections of upholstery was a white fabric which had become brown in many of the areas. Residents were observed sitting in the chairs with their arms on the torn upholstery. The floors of the lobby were dirty in the corners with visible grime, crumbs and layers of debris. On 1/25/24 at 10:33 a.m., a door leading to a courtyard was observed off the lobby. The door had a large gap at the left side and toward the bottom with sunlight coming through. Red Rocks dining room On 1/25/23 at 10:40 a.m., the Red Rocks unit dining room was observed. The dining room had caked orange, brown and white food splatters and chunks on the walls. Along the floors, under the heat register and in the corners of the dining room, the floors were blackened or brown with layers of debris including numerous crumbs, cheese, crackers, a ground meat substance which had dried, hair and mouse droppings. In a cabinet with the table cloths, on the bottom shelf, were crumbs, hair and mouse droppings. In the white activity closet in the dining room there were mouse droppings and dried fluids trailing back behind the supplies. Food and debris were observed under the ice machine. Kitchen On 1/25/23 at 10:46 a.m., the kitchen was observed. The kitchen floor, around the trash cans and hallway, had pieces of dried meat, hair and other dried unrecognizable food debris. Mice droppings were observed within the debris. The top of the dishwasher was covered in crumbs, dust, and mouse droppings. Red Rocks unit hallways On 1/25/24 at 11:02 a.m. the Red Rocks unit hallways were observed. The handrails were painted white and the paint was peeling on the handrails throughout the unit.The handrails were taped together with large strips of silver tape which was peeling at the corner of the two hallways. An isolation cart on the hallway was missing a wheel and leaning. The cart had a brown discolored dried substance along the entire right side and bottom of the cart. The brown substance had dust and debris dried in it. Resident room [ROOM NUMBER], at the end of the hallway on the right, had crumbs, hair, and mouse droppings in the room on the floor to the right of the entry. The edges and corners of the hallway floors were darkened and caked with layers of debris, food, crumbs, dust, hair and mouse droppings. Columbine unit dining room and hallways On 1/25/24 at 11:15 a.m., the dining room and hallways on the Columbine unit were observed. The edges and corners of the dining room and hallway floors were darkened and caked with layers of debris, food, crumbs and chunks, dust, hair and mouse droppings. Courtyard On 1/25/24 at 11:28 a.m., the courtyard off the front lobby of Red Rocks unit had grass with a sidewalk through the grass and sitting areas. The grass had hundreds of cigarette butts littering the ground. Some cigarette butts were new and sitting on top of the grass, and some were faded and shredded and embedded in the grass. The cigarette butts ran along the sidewalk edge in the grass and some were out further in the center of the grass.The concrete sitting areas and sidewalks contained approximately 100 cigarette butts. Some of the cigarette butts were new with black soot still sitting under them where they had been extinguished. Some of the cigarette butts were older and fading. III. Observation and interview with NHA On 1/25/24 at 11:50 a.m., the front lobby, Red Rocks unit dining room and hallways were observed with the NHA. The NHA looked at the torn furniture in the front lobby. She said she would like to replace it but did not have the money for it. She said she had no plan to replace the furniture. The Red Rocks unit dining room was observed. The NHA looked at the floors, mouse droppings on the floors and in the cabinets. She said the housekeeping staff should clean the dining room and wipe food off the walls. She said there was no schedule or plan for cleaning the common areas and halls. The NHA said the facility had been without a maintenance director for several weeks. She said the housekeeping staff reported to the maintenance director. The NHA said the housekeeping staff did not speak any English and therefore she thought maybe there was a communication issue about cleaning the common areas. The NHA did not comment on the dirty floors in the halls, or chipped and taped handrails. The NHA said the regional maintenance person had been trying to come to the facility weekly since the facility maintenance director left. The NHA said she had seen the cigarette butts in the courtyard and she had picked some up when she had time but she said she could not do it everyday. The NHA said she had reports of mice from the night shift who heard them in the ceiling and had the pest control company come out. The NHA said the pizza in the conference room was from a staff meeting the previous day at 1:00 p.m. IV. Additional interviews Resident #1 was interviewed on 1/25/25 at 11:31 a.m. He lived in room [ROOM NUMBER]. He said he had seen at least one mouse in his room. The director of nursing (DON) was interviewed on 1/25/24 at 12:39 p.m. She said she did not know who was responsible for ensuring the isolation carts were cleaned and in good working order. She said she did have additional isolation carts but did not feel the isolation cart on the Red Rocks unit with the missing wheel and dried brown substance and debris (see above) needed to be changed because it was already stocked with supplies. The regional maintenance director (RMD) was interviewed via telephone on 1/25/24 at 12:44 p.m. He said he was out of the state this week and would not be able to come to the facility. He said he tried to come to the facility weekly since the facility lost their maintenance director several weeks ago. He said he thought the cleaning issues in the facility were due to a lack of supervision. The RDM said he would create a common area cleaning schedule for the facility. He said he was aware of the rodent issue in the facility and an outside pest company had come monthly.

Based on observations, record review and interviews the facility failed to ensure three (#29, #18 and #25) of seven residents reviewed for accidents out of 27 sample residents received adequate supervision to prevent accidents. Resident #29, who was at fall risk, sustained 14 falls over six months. The facility failed to determine the root cause of the falls and failed to implement effective fall interventions. Resident #29 had an unwitnessed fall on 2/17/23 and had a clavicle (collarbone) fracture confirmed three days later from the fall. She was sent to the hospital for evaluation and treatment and returned to the facility on [DATE]. Resident #29 sustained nine additional falls after the fall with fracture. The facility failed to develop and implement a person-centered care plan that identified Resident #18's fall risk and put effective interventions into place to reduce falls and prevent an injury. Resident #18 was admitted to the facility on [DATE] with a diagnosis of vascular dementia moderate with other behavioral disturbance, other lack of coordination, wandering in disease classified elsewhere, suicidal ideations and macular degeneration (deterioration of the eye). On 11/10/22 and 11/13/22 Resident #18 sustained falls. The facility failed to put effective interventions into place and the resident had another fall on 11/25/22 for which he sustained a mildly displaced left rib (rib fracture). After the resident sustained rib fractures on 11/25/22, the resident sustained an additional four falls on 4/5/23, 4/25/23, 5/1/23 and 5/1723. The facility failed to determine the root cause of the resident's continued falls and put effective, person-centered interventions into place. Additionally, the facility failed to: -Ensure a registered nurse (RN) assessment was completed and documented following sustained falls by Resident #18 and Resident #25; -Ensure neurological checks were completed per standards of practice for Resident #18, Resident #25 and Resident #29; and, -Ensure post fall documentation was completed timely for Resident #25. Findings include: I. Facility policy and procedure The Fall Management policy, dated June 2022, was provided by the director of nursing (DON) on 7/13/23 at 8:53 a.m. It revealed in pertinent part, The center assists each resident in attaining/maintaining his or highest practicable level of function by providing the resident adequate supervision, assistive devices and/or functional programs, as appropriate, to minimize the risk for falls. The Interdisciplinary Team (IDT) evaluates each resident's fall risks. A Care Plan is developed and implemented, based on this evaluation, with ongoing review. Fall Event: When a fall occurs, the resident is assessed for injury by the nurse. The nurse will: enter the event (sic) information into the Risk Management portal of (electronic medical record); complete a detailed nursing progress note to include the nursing assessment and communication to the Physician, Family, resident and/or resident's representative; add the fall event to the 24-Hour Report; and, initiate the Interdisciplinary Post Fall Review UDA (user defined assessment). The nurse will discuss recommended interventions to reduce the potential for additional falls with the resident and/or resident's representative and document in the Care Plan and Progress note. The IDT reviews all resident falls within 24-72 hours at the IDT meeting to evaluate circumstances and probable cause for the fall. The IDT will complete the Interdisciplinary Post Fall UDA. The IDT designee will discuss recommended significant changes to the Care Plan to minimize repeat falls with the resident and/or resident's representative. The Care Plan will be reviewed and.or revised as indicated. The Care Kardex (staff directive) will be updated as appropriate. Fall trending and analysis information is reported to the Quality Assurance and Performance Improvement (QAPI) Committee. In the event a resident has a fall, and it has been determined they hit their head (the fall was witnessed, it is obvious there is a head injury, or the patient can verbalize they hit their head), or it cannot be determined if they hit their head (the fall was witnessed or the patient cannot verbalize if they hit their head), the nurse initiates the following actions: all items listed under Fall Event above are completed; and, Neurological checks are completed and documented per instructions. II. Resident #29 A. Resident status Resident #29, [AGE] years old, was admitted to the facility on [DATE] and readmitted on [DATE]. According to the July 2023 computerized physicians orders (CPO) diagnoses included dementia, history of falling, poor safety awareness, gait imbalance, impaired memory and ambulating without assistance. The 6/22/23 minimum data set (MDS) indicated the resident was severely cognitively impaired with a brief interview of mental status score of four out of 15. She required total dependence on staff with activities of daily living (ADLs). She utilized a wheelchair for mobility. The resident had two or more falls since admission with no injury. -However, the resident had multiple falls with minor and major injuries that were not identified on the assessment. B. Record review The fall care plan, initiated 4/7/2020 and revised 3/27/23, documented the resident was at risk for falls related to poor safety awareness. The resident prefers to be on the mattress on the floor next to the bed. The resident rolls off the mattress while on it on the floor. The resident was forgetful in using a walker, wheelchair or asking for assistance related to her dementia. The resident had a fall with a right shoulder fracture on 2/20/23. The interventions included: -Administer medication per orders; initiated on 3/8/23 -The resident likes to sleep on the floor on the fall mat at times per her preference. Encourage the resident to sleep on bed or recliner; initiated 1/19/23. -Encourage the resident to wear appropriate non-skid footwear during transfers or ambulation, she chooses to wear non-slip socks instead of shoes at times; initiated 4/7/2020. -Encourage the resident to use a wheelchair for safety; initiated 3/8/23. -Encourage the resident to ask for assistance and to use the walker when seen without these items remind/assist her to take them with her for ambulation safety; initiated 2/27/23. -Ensure the call light was within reach and give the resident encouragement to use when assist was needed; initiated 4/7/2020. -Frequent checks related to impulsiveness; initiated 7/13/23. -Keep environment clutter free; initiated 4/7/2020. -New recliner in her room per her preference; initiated 3/8/23. -Place bed in lowest position and place fall mat on floor when in bed; initiated 4/7/2020. -Provide appropriate lighting; initiated 4/7/2020. -Provide the resident and/or responsible party education on safety awareness and safety needs; initiated 4/7/2020. 1. Fall on 1/2/23-witnessed The 1/2/23 progress note documented the resident had witnessed a fall in the hall. She appeared lethargic, had an unsteady gait, lost her balance and fell down on her back. She hit her head slightly on the floor. The resident was walking with her eyes half closed. The nurse tried to take her to bed many times and the resident was up walking again. The resident needs frequent redirection. No visible injuries, no change in mentation, neurological checks and vital signs within normal limits. Neurological checks initiated per facility protocol. The physician, director of nursing (DON) and power of attorney (POA) were notified. The resident was up and walking again after the fall. -There were no interventions immediately after the fall and the care plan was not updated. The 1/2/23 change of condition progress note documented the resident had Ativan (antianxiety) increased to one milligram (mg) in the past week. The resident was drowsy/lethargic, did not want to stay in bed or sit in a chair. She was up walking many times despite attempts to redirect and help her lie in bed. The recommendation was a voicemail was left with the provider to look at her medications. The 1/4/23 IDT note documented the resident's medications were reviewed and her Ativan and Risperidone (antipsychotic) medications were adjusted due to lethargy. 2. Fall on 1/11/23-witnessed The 1/11/23 incident note documented Resident #29 fell and hit the back of her head. Resident #29 did not lose consciousness and neurological checks were initiated. The nursing progress note documented the nurse practitioner ordered the resident to be sent to the emergency room for evaluation and a CAT scan (x-ray). The 1/11/23 nursing progress note documented Resident #29 returned from the emergency room and the CAT scan was negative. The progress note documented Resident #29 had behaviors by punching the nurse and slapping the attendants. Upon returning to the facility Resident #29 slapped and pushed the paramedic. Resident #29 received her medications. -There were no interventions immediately after the fall and the care plan was not updated. 3. Fall on 1/16/23-unwitnessed The 1/16/23 alert note documented the RN was at the medication cart administering medications when a loud noise was heard in the dining room. Upon the RN arriving in the dining room Resident #29 was lying on her back on the floor. Approximately 10 minutes prior to the fall the resident was walking around in the dining room and the nurse encouraged Resident #29 to sit down. Resident #29 sat down for five minutes and then got up and began walking around again. The progress note documented Resident #29 apparently was attempting to sit down and fell to the floor. Resident #29 said she missed the chair when trying to sit down. Resident #29 had no pain and said she bumped her head on the wall. Resident #29 sustained a four centimeter by three centimeter skin tear to her right wrist. No other injuries were noted. Resident #29 was alert and able to answer questions. Resident #29 was assisted off the ground by two staff, toileted and assisted to bed. The skin tear was cleansed with normal saline, patted dry, approximated and steri strips were applied. Neurological checks were initiated. The DON, physician and POA were notified of the fall. -There were no interventions immediately after the fall and the care plan was not updated. 4. Fall on 2/16/23-witnessed The 2/16/23 alert note documented Resident #29 was attempting to swing at another resident and lost her balance. Resident #29 sustained a bump to her hairline and an abrasion to her forehead that was on top of an old bump. Resident #29 did not lose consciousness. The family and physician were notified. Neurological checks were initiated. A skin and a pain assessment were completed. -There were no interventions immediately after the fall and the care plan was not updated. 5. Fall on 2/17/23-unwitnessed The 2/17/23 alert note documented Resident #29 was found face down on the floor in the hallway. Resident #29 sustained a small blue bruise to her left eyebrow. Resident #29 said she hit her head when falling. Neurological checks were initiated. The progress note documented Resident #29's vital signs were assessed and stable. The DON, physician and family were notified. -There were no interventions immediately after the fall and the care plan was not updated. The 2/19/23 progress note documented when care was being performed by staff the resident had latent injuries to left eyebrow, right shoulder and coccyx area. Left eye brow showed slight discoloration less than one centimeter (cm). Right shoulder bruise was egg shaped dark blue seven cm by six cm with no changes in her range of motion (ROM). The coccyx bruise was two cm by two cm. The physician and family were notified. The 2/20/23 progress note documented the resident was complaining of right shoulder pain when moving post fall. An x-ray of the right shoulder was ordered. The 2/20/23 change of condition note documented the resident fell a few days ago and just complained of right shoulder pain. The x-ray was positive for a right clavicle fracture and the resident was sent to the emergency department. The 2/21/23 progress note documented the resident returned from the hospital with a diagnosis of fracture of the shaft of the right clavicle. The resident was wearing an arm sling and given Tylenol for comfort. -The resident sustaining a clavicle fracture was indicated on her care plan, however, there were no interventions implemented after the fall or when the resident returned from the hospital. 6. Fall on 4/16/23-witnessed The 4/16/23 change of condition note documented the resident bent over per the nurse to pick up something that was not there and toppled over. The resident had a bruise to her forehead. No complaints of pain. Recommendations: none. -There were no interventions immediately after the fall and the care plan was not updated. 7. Fall on 4/29/23-unwitnessed The 4/29/23 progress note documented the resident was lying flat on her back. She had a ping pong sized hematoma (bruise) on the back of her head with no bleeding. The resident complained of a headache, 10 out of 10 on a pain scale. The resident was given an ice pack for the affected area and scheduled Tylenol. The physician and family were notified. The physician stated to continue neurological checks and call if any changes. -There were no interventions immediately after the fall and the care plan was not updated. 8. Fall on 4/30/23-witnessed The 4/30/23 progress note documented the resident was on the floor lying on her side. Witnesses attested she was sitting on a chair and slowly slid down until she laid on the floor and turned on her side. The physician and family were notified. The 5/1/23 IDT note documented the resident had two falls from the weekend (4/29/23 and 4/30/23). Interventions included obtaining labs, medication review and neurological checks in place. The 5/2/23 IDT note documented the Risperidone (antipsychotic) medication was decreased due to recent falls. 9. Fall on 5/24/23-unwitnessed The 5/24/23 note documented the resident was found on the floor of the hallway lying down. Unsure if the resident fell or laid down there. No injury noted. -There were no interventions immediately after the fall and the care plan was not updated. 10. Fall on 6/14/23-witnessed The 6/14/23 progress note documented the resident was in the dining area and scooted to the edge of the chair very quickly and sat on the floor. No pain or injury noted. The 6/16/23 IDT note documented for therapy to evaluate. 11. Fall on 6/18/23-witnessed The 6/18/23 note documented the certified nurse aide (CNA) who witnessed the fall said the resident leaned back assuming she was in her chair and fell back. There were no injuries. The 6/19/23 IDT note documented therapy would observe safety and self transfers. -However, therapy was supposed to evaluate the resident after the 6/16/23 fall. 12. Fall on 6/23/23 The 6/23/23 change of condition note documented the social worker informed the nurse the resident was on the floor. The CNA stated the resident was sitting on the side of the bed and began to slide to the floor. No apparent injuries. The 6/26/23 IDT note documented the resident was non-compliant with using durable medical equipment. She needs cueing and redirection. She prefers to sleep in her recliner and when she sits on the edge of the bed she slides down. Her gait was not steady. She was seen by therapy. Will continue to monitor the resident. -There were no interventions immediately after the fall and the care plan was not updated. 13. Fall on 7/2/23-unwitnessed The 7/2/23 progress note documented the CNA called the nurse to the room. The resident was sitting on the floor, on the fall mat, facing the bed. The resident had a three cm skin tear to the right forehead and a two cm laceration to the right forehead. Blood was observed on the floor outside of the floor mat as if she fell forward while on the mat or getting out of bed. The physician, family and DON notified. Neurological checks and vital signs for 72 hours. The 7/3/23 progress note documented a decrease in Depakote (mood stabilizer) medication due to falls and labs were ordered. 14. Fall on 7/8/23-witnessed The 7/8/23 progress note documented the resident was in the hallway by the dining room trying to stand up and then slid down. The resident fell out of the wheelchair in the middle of the hallway and fell backwards on her bottom and back. The 7/11/23 progress note documented the resident was declining related to dementia. The resident was admitted to hospice care and the family agreed to discontinue therapy. The 7/12/23 IDT note documented on 7/10/23 the physician decreased the Depakote medication and increased the Risperdone (antipsychotic) medication due to her falls. -The documentation of the neurological checks for the falls (see above) could not be located (see DON interview). C. Staff interviews The director of nursing (DON) was interviewed on 7/10/23 at 10:00 a.m. She said no documentation of neurological checks could be found for Resident #29 for the past six months. CNA #2 was interviewed on 7/10/23 at 10:30 a.m. She said Resident #29 was impulsive and she stood up from her wheelchair by herself causing her to fall backwards onto the floor. CNA #2 said frequent checks on the resident have been implemented to the care plan due to impulsiveness. CNA#2 said the resident did not like sleeping in her bed. CNA #2 said the family bought a recliner for the resident that she seemed to like since she did not like sleeping in her bed. CNA #2 said the staff should encourage the resident to use her wheelchair for safety. CNA #2 said the resident's call light should be within reach to the resident. Licensed practical nurse (LPN) #1 was interviewed on 7/11/23 at 11:00 a.m. She said Resident #29 was just moved to the room across from the nurses station so the staff could keep a close eye on her. LPN #1 said the resident had several falls since admission. She said Resident #29 refused her walker and did not use her wheelchair although the staff were to encourage her to do so. LPN #1 said the resident should be encouraged to ask for assistance when ambulating to help prevent falls. The DON was interviewed on 7/14/23 at 2:00 p.m. She said Resident #29 had poor safety awareness and was unsteady on her feet. She stated that the resident would not use her walker and tried to walk without any other assistive device. She said the staff should encourage the resident to use her wheelchair when she wanted to get out of her recliner. The DON said the resident should wear non-skid socks or shoes when out of bed. 46022 III. Resident #18 A. Resident status Resident #18, age 72, was admitted on [DATE] and readmitted on [DATE]. According to the July 2023 computerized physician orders (CPO), the diagnoses included vascular dementia moderate with other behavioral disturbance, other lack of coordination, wandering in disease classified elsewhere, suicidal ideations and macular degeneration (deterioration of the eye). The 6/1/23 minimum data set (MDS) assessment revealed the resident had severe cognitive impairment with a brief interview for mental status (BIMS) with a score of seven out of 15. He required limited assistance of one person for bed mobility, transfers and walking in his room. He required extensive assistance of one person for walking in the corridor, locomotion on and off the unit and dressing. He required extensive assistance of two people for eating. He was totally dependent on two people for toileting and totally dependent of one person for personal hygiene. The resident had one fall within the review period. B. Resident observation During a continuous observation on 7/11/23 beginning at 12:20 p.m. and ended at 12:56 p.m. the following was observed: -At 12:20 p.m. Resident #18's door was closed. -At 12:36 p.m. an unidentified certified nurse aide (CNA) entered Resident #18's room and left his room at 12:37 p.m. -At 12:59 p.m. Resident #18's door remained closed. On 7/11/23 the following was observed: -At 2:06 p.m. Resident #18 was lying in bed with no fall mat next to his bed. -At 3:48 p.m. Resident #18 was walking around his room. On 7/12/23 at 9:35 a.m. Resident #18's door was closed. C. Record review The 10/3/19 admission fall risk assessment identified the resident at high fall risk for falls. The fall risk care plan, initiated on 10/14/19 and revised on 10/16/19, revealed Resident #18 was at risk for falls related to the diagnosis of dementia with behaviors and macular degeneration, antidepressant and antipsychotic use and poor safety awareness. The interventions included: completing a fall assessment upon admission (10/14/19), encouraging the use of hipsters while awake (9/11/2020), encouraging and assisting the resident to wear appropriate non-skid footwear during ambulation (he chooses to wear non slip socks instead of shoes at times) (9/17/22), providing appropriate lighting (10/14/19) and therapy to screen and evaluate (7/6/21). A review of Resident #18's kardex (staff directive) was completed on 7/12/23 at 11:00 a.m. documented the following fall interventions: encouraging the use of hipsters and encouraging use of nonskid footwear. 1. Fall incident on 11/10/22-witnessed The 11/10/22 fall risk assessment documented the resident was at a high risk for falls. The 11/10/23 nursing progress note documented the director of nursing (DON) was called to assess Resident #18 after a fall. Resident #18 was observed lying in the hallway next to the nurses station on his right side with a large pool of red flank blood. The note documented Resident #18 had sustained a cut on the bridge of his nose and had an open area to his right eyebrow. The note documented pressure was held to the bridge of the nose to stop the bleeding. The resident was on blood thinners. The bleeding stopped and the area was cleaned, triple antibiotics and three small [NAME] strips were applied. The resident was confused and at his baseline and did not want to stay still. The progress note documented neurological checks were started, Resident #18 was assisted to bed and a fall mat was at the bedside. -However, the facility did not have documentation that the neurological checks were completed after the resident sustained a fall with two lacerations to his head (see DON interview below). The 11/10/23 interact change in condition evaluation documented the resident had a fall, trauma (fall related or other), edema and bleeding. The resident was at the facility for long term care and had a diagnosis of congestive heart failure (CHF) and dementia. The resident had a cut to the bridge of his nose and had swelling to the right orbital (eye) area. The resident was alert, but confused related to dementia. The assessment documented the resident had a fall without an injury or minor injury. The resident's blood pressure was not documented in the assessment. The resident had a laceration to the bridge of his nose not requiring sutures. The resident had pain to the bridge of his nose and above his right eye. The assessment documented ice was placed to the right eye and a dry dressing was placed to his nose. The resident was in pain after the fall, but went to bed 35 minutes after the fall. The physician and the resident's family were notified of the fall. -A review of the resident's electronic medical record (EMR) on 7/12/23 at 9:30 a.m. did not reveal documentation of an interdisciplinary team review of the unwitnessed fall or a root cause analysis completed to determine the nature of the unwitnessed fall and implementation of an effective intervention post-fall. 2. Fall incident on 11/13/22-unwitnessed The 11/13/22 fall risk assessment documented the resident was at a high risk for falls. The 11/13/22 nursing progress note documented a resident notified the licensed nurse that a resident was lying on the floor. Resident #18 was lying on the floor on his left side in the fetal position in front of the laundry room. The progress note documented the resident was not crying or yelling out in pain, but blood was coming from his forehead. Resident #18 sustained a two to three centimeter long laceration on the top left side of his forehead and a large lump was forming. Resident #18 was able to move all four extremities without major discomfort and the resident did not express any signs of pain. The progress note documented the resident was not displaying any signs of pain such as grimacing. The resident's vital signs were taken. The DON and on call nurse practitioner were notified. The nurse practitioner ordered to hold Resident #18's blood thinner for 48 hours. The resident's power of attorney (POA) was notified and requested for the resident to stay at the facility to be treated. Resident #18 was in a wheelchair being monitored by the nurse and CNA. The 11/13/22 interact change in condition assessment documented Resident #18 sustained a fall. The assessment documented Resident #18 sustained a laceration with redness, bruising and a lump forming to the top left side of his forehead. The assessment documented neurological checks were initiated and the resident was monitored. -However, the facility did not have documentation that the neurological checks were completed after the resident sustained a fall with a laceration to his head (see DON interview below). The 11/14/22 alert note documented a medication review was completed for Resident #18 and it was recommended to decrease the prescribed Haldol (antipsychotic) medication as a fall intervention. 3. Fall incident on 11/25/22-witnessed and sustained a major injury The 11/25/22 change in condition assessment documented by licensed practical nurse (LPN) #4 revealed Resident #18 sustained a fall. The resident frequently wandered and had gait imbalance. The assessment documented to continue to do frequent checks for the resident's safety. The resident's representative was notified of the fall. The 11/26/23 fall risk assessment documented the resident was at a high risk for falls. The 11/27/22 order note documented an x-ray to the left rib cage was ordered after Resident #18 was having localized pain to his ribs after he sustained a fall on 11/25/22. The resident's ribs were tender to the touch, but did not have any bruising. The 11/27/22 incident note documented by LPN #4 revealed Resident #18 had a fall on 11/25/22. Resident #18 was having localized tenderness to the touch on his left rib cage. Resident #18 vocalized he had pain to the area. The on-call physician was called and ordered Tylenol, a topical pain medication and an immediate x-ray to the area. The 11/28/22 alert note documented the x-ray results showed a mildly displaced rib on the left side (rib fracture) and infiltrate (abnormality) was noted. The nurse practitioner ordered for the resident to start on an antibiotic. -There was not a registered nurse (RN) assessment documented in the resident's medical record. -A review of the resident's EMR (electronic medical record) on 7/12/23 at 9:30 a.m. did not reveal documentation of an interdisciplinary team review of the unwitnessed fall or a root cause analysis completed to determine the nature of the unwitnessed fall and implementation of an effective intervention post-fall. 4. Fall incident on 4/5/23-witnessed The 4/5/23 fall risk assessment documented the resident was at risk for falls. The 4/5/23 nursing progress note documented a CNA yelled out that Resident #18 had fallen. Resident #18 returned to pacing the hall. The note documented the resident did not have any injuries. The DON and POA were notified. Resident #18 did not sustain an injury from the fall. The 4/5/23 interact change in condition assessment documented Resident #18 sustained a fall while trying to step on the scale with the CNA. The assessment documented the nurse witnessed the CNA helping Resident #18 back to his feet. -A person-centered fall intervention was not implemented after Resident #18 sustained a fall on 4/5/23. 5. Fall incident on 4/25/23-witnessed fall The 4/25/23 fall risk assessment documented the resident was at risk for falls. The 4/25/23 incident note documented a CNA and a housekeeper notified the RN that Resident #18 slipped out of bed. Resident #18 did not hit his head. The RN completed an assessment and there were no injuries noted. Resident #18 had two non-blanchable regions to his right shoulder that were 10 centimeters by four centimeters and four centimeters by four centimeters. The physician, DON and POA were notified. Resident t#18 was unable to describe what happened, but did not appear to be in pain or distress. The note documented the RN would continue to monitor and notify the oncoming shift. The 4/25/23 change in condition assessment documented Resident #18 sustained a fall. The physician was notified and recommended to monitor the resident for any changes. The resident's POA was notified. -A review of the resident's EMR on 7/12/23 at 9:30 a.m. did not reveal documentation of an interdisciplinary team review of the unwitnessed fall or a root cause analysis completed to determine the nature of the unwitnessed fall and implementation of an effective intervention post-fall. 6. Fall incident on 5/1/23-unwitnessed fall The 5/1/23 incident note documented Resident #18 was found on the mattress next to his bed on the floor. Resident #18 did not have any injuries and his vital signs were stable. Resident #18 was able to move all extremities without difficulty. Resident #18 was non verbal and unable to explain how he fell . The 5/1/23 change in condition assessment documented Resident #18 sustained a fall. The physician was notified and recommended to monitor the resident for any changes. The resident's POA was notified. The 5/4/23 fall risk assessment documented the resident was at a high risk for falls. -The facility did not have documentation that the neurological checks were completed after the resident sustained an unwitnessed fall (see DON interview below). 7. Fall incident on 5/17/23-unwitnessed The 5/17/23 fall risk assessment documented the resident was at a high risk for falls. The 5/17/23 nursing progress note documented Resident #18 was found on the mattress next to his bed on the floor. Resident #18 did not have any apparent injury and his vital signs were stable. Resident #18 was able to move all extremities without difficulty. The progress note documented Resident #18 was non-verbal and was unable to explain what happened. -However, according to the skin progress note, Resident #18 sustained a skin tear to his left eyebrow. The 5/17/23 skin progress note documented Resident #18 was seen by the wound team during weekly rounds, because he had a new skin tear to his left eyebrow after a fall he had sustained that morning. The note documented there were no signs or symptoms of infection and there was minimal drainage. The wound physician evaluated and provided new orders for wound care to be performed every other day and as needed. The physician and POA were notified. The 5/17/23 change in condition assessment documented Resident #17 sustained a fall with a laceration to the left eyebrow. The assessment documented a bandaid was placed to the laceration and the resident had no pain. -A review of the resident's EMR on 7/12/23 at 9:30 a.m. did not reveal documentation of an interdisciplinary team review of the unwitnessed fall or a root cause analysis completed to determine the nature of the unwitnessed fall and implementation of an effective intervention post-fa[TRUNCATED]

Based on record review and interviews, the facility failed to ensure residents maintained acceptable parameters of nutritional status, such as usual body weight or desirable body weight range, unless the resident's clinical condition demonstrated that this was not possible or resident preferences indicated otherwise for two (#25 and #27) of five residents out of 27 sample residents. Resident #25, who was known to be at risk for weight loss due to hemiplegia (paralysis of one side of the body), dementia and dysphagia (difficulty with swallowing), experienced a choking episode on 3/27/23. The facility downgraded the resident to a pureed diet (a diet of foods that do not need to be chewed) and the resident was evaluated by a speech therapist and placed on the speech therapy caseload due to swallowing difficulties for one month. On 3/6/23, three weeks prior to the choking episode, Resident #25 weighed 175.8 pounds (lbs). On 4/5/23, nine days after the choking episode, the resident weighed 165.6 lbs, which was a significant weight loss of 10.2 lbs or 5.8% in one month. Prior to the choking episode, the resident received snacks two times per day, as did all the residents in the facility. He was not on any nutritional interventions. On 4/12/23, seven days after the significant weight loss was documented, the registered dietitian (RD) increased his snacks to three times per day, however, no other nutritional interventions were put into place. The facility reviewed the resident weekly at the nutrition at risk (NAR) meeting during the time he was on the speech therapy caseload, however, the facility did not closely monitor his weight to see if the implemented interventions worked. The resident's diet was upgraded to a mechanical soft texture (ground or chopped foods that are easier to swallow) by the speech therapist on 4/27/23. Resident #25's weight stabilized, however, the facility did not implement any nutritional interventions to assist the resident to gain back the weight that had been lost. Due to the facility's failures to implement effective nutritional interventions, Resident #25 sustained a significant weight loss of 5.8% in one month and he was unable to gain the weight back. Resident #27, who was known to be at risk for weight loss due to dementia, weighed 165.8 lbs on 4/5/23. On 5/1/23 the resident weighed 158.4 lbs, a loss of 7.4 lbs or 4.5% in one month, which was not a significant weight loss. Despite the weight loss, the resident's weight was not obtained more frequently when the resident was reviewed during the NAR meeting. On 5/11/23, 10 days after the weight loss was documented, the RD started the resident on Boost (a liquid nutritional supplement) one time a day. The facility did not document the amount of supplement the resident was consuming when it was offered to him. The facility did not increase the frequency of weight monitoring. On 5/26/23, the RD ordered double portions to be served to the resident at all meals. On 6/1/23, Resident #27 weighed 150.8 lbs. This was an additional loss of 7.6 lbs in one month. Between 4/5/23 and 6/1/23, the resident lost a total of 15 lbs or 9% in just under two months which was a significant weight loss. The facility added the resident to the NAR meetings for weekly review of his nutritional status on 6/7/23, however, no further nutritional supplements were added until 6/14/23 (two weeks after the additional weight loss was documented) when the RD increased his Boost supplement to two times a day. The facility did not increase Resident #27's frequency of weights or document the amount of the supplement the resident was consuming. Resident #27's weight stabilized, however, the facility did not implement any further nutritional interventions to assist the resident to gain back the weight that had been lost. Due to the facility's failures to implement timely and effective nutritional interventions, Resident #27 sustained a significant weight loss of 9% in just under two months and he was unable to gain the weight back. Resident #27 was placed on hospice services on 6/19/23. Findings include: I. Facility policy and procedures The Weight Management policy, revised June 2022, was provided by the director of nursing (DON) on 7/13/23 at 8:54 a.m. It read in pertinent part, Resident's nutritional status will be monitored on a regular basis to aid in the maintenance of acceptable parameters, such as body weight and protein levels, unless the resident's clinical condition demonstrates that this is not possible. Significant unintended changes in weight (loss or gain) or insidious weight loss may indicate a nutritional problem. Significant weight variance is defined as: 5% in one month (30 days), 7.5% in three months (90 days) and 10% in six months (180 days). Weekly At-Risk Review meetings will be conducted on each resident with weight loss until the interdisciplinary team (IDT) determines the weight has stabilized and can discontinue from weekly review. All scheduled weights will be obtained prior to the meeting, including any re-weights. Meal intake records, supplement/nourishment/snack/fortified food list with intake information and diet order list will be made available by the food service manager and/or registered dietitian (RD) during the meeting, as needed. II. Resident #25 A. Resident status Resident #25, age 89, was admitted on [DATE]. According to the July 2023 computerized physician orders (CPO), diagnoses included hemiplegia (paralysis of one side of the body) and hemiparesis (muscle weakness or partial paralysis on one side of the body) following cerebral infarction (stroke) affecting the left non-dominant side, ulcerative colitis (an inflammatory bowel disease that causes chronic inflammation and ulcers in the outermost lining of the large intestine), and dementia. The 6/22/23 minimum data set (MDS) assessment revealed that the brief interview for mental status (BIMS) was not assessed because the resident was rarely understood. The staff assessment for mental status revealed the resident had a problem with short and long term memory and his cognitive skills for daily decision making were severely impaired. He required one-person extensive assistance with bed mobility and transfers. He required two-person extensive assistance with dressing, toilet use and personal hygiene. He required setup help and supervision with eating. According to the MDS assessment, he did not have any swallowing difficulties and he did not have, or it was unknown if he had, a weight loss of 5% or more in the last month or a loss of 10% or more in the last six months. B. Record review Review of Resident #25's recorded weights from 2/1/23 to 7/3/23 revealed the following: -2/1/23: 175 lbs; -3/6/23: 175.8 lbs; -4/5/23: 165.6 lbs; -5/1/23: 167 lbs; -6/1/23: 165 lbs; and, -7/3/23: 164.6 lbs. -Despite the 10.2 lbs (5.8%) weight loss demonstrated in one month between 3/6/23 and 4/5/23, the facility did not add any nutritional interventions and the resident's number of snacks per day was not increased to three snacks per day until seven days after the significant weight loss was documented. Review of Resident #25's nutrition care plan, initiated 4/19/21 and revised 6/21/23, revealed that the resident had a potential for weight loss due to hemiplegia, dementia, chronic kidney disease stage 3 and dysphagia. Pertinent interventions included eliciting the resident and family for past food preferences, encouraging the resident to return and finish meals if he tended to leave the dining room prior to finishing meal, monitoring weights per facility schedule and reporting significant changes to the charge nurse for further evaluation, offering alternate meals as needed if less than 50% of meal intake was noted and offering snacks throughout the shift if the resident continued to refuse meals, providing diet as ordered, providing the resident ample time to eat each meal and encouraging the resident to eat as much as possible to ensure adequate oral intake. -The care plan did not document the resident's past food preferences. -The care plan did not document how many times per day the resident was to receive snacks (see physician orders below). Review of Resident #25's July 2023 CPO revealed the following physician orders: Snacks two times a day. Please give resident snacks two times per day. The order had a start date of 12/14/22. The order was discontinued on 4/12/23 when the resident's snacks were increased to three times per day. Snacks three times a day. Offer mechanical soft snacks (such as yogurt, applesauce) for weight stabilization. The order had a start date of 4/12/23. -There were no physician orders for nutritional supplements or fortified foods (foods which have extra nutrients added to them) to assist the resident to gain back the weight that had been lost. Review of Resident #25's medication administration records (MAR) from 4/1/23 through 7/12/23 revealed the resident was being offered snacks as ordered. -The MARs did not document how much of each snack was consumed. Review of Resident #25's electronic medical record (EMR) revealed a progress note dated 3/27/23. The progress note documented in pertinent part, This resident was in the dining area eating lunch. He started to choke on corn kernels and turn blue. The nurse tried the Heimlich maneuver (abdominal thrusts administered to lift the diaphragm and expel air from a person's lungs in an effort to dislodge an object, such as food that is blocking the person's airway when choking). The nurse could not reach around the resident so the certified nurse aide (CNA) did the Heimlich maneuver and out came corn. The resident's color immediately returned. Resident was observed after this incident to take a bite of cake and put it in his mouth and it took him over five minutes for it to be chewed and finally swallowed. Resident to be referred to therapy for a speech swallow evaluation and his food will be downgraded for now to a pureed diet. Review of the speech therapist's documentation revealed Resident #25 was on the speech therapy caseload for dysphagia (difficulties swallowing) from 3/28/23 through 4/27/23. The speech therapist upgraded the resident's diet from pureed diet to mechanical soft diet on 4/27/23. Review of Resident #25's EMR revealed the following interdisciplinary team (IDT) progress notes documented in pertinent part: 3/30/23: This resident uses his wheelchair for locomotion on the unit. He has left sided weakness. He has been downgraded to a pureed diet and is being followed by speech therapy. Family is aware of his swallowing issues. Will continue to monitor with the dietician. -The progress note did not discuss adding nutritional interventions to prevent weight loss or increase the frequency of weights to more closely monitor the resident for weight loss. 4/5/23: Remains on a pureed diet followed by speech therapy. Family is aware of diet changes. He was COVID-19 positive (3/22/23) and with the COVID-19, less appetite and pureed food he has lost a few pounds. Will continue to monitor with the dietician. -The progress note did not discuss adding nutritional interventions to prevent weight loss or increase the frequency of weights to more closely monitor the resident for weight loss. 4/14/23: Remains being followed by speech therapy for swallowing issues and is on a pureed diet. Will continue to monitor. -The progress note did not discuss adding nutritional interventions to prevent weight loss or increase the frequency of weights to more closely monitor the resident for weight loss. 4/19/23: This resident continues on a pureed diet related to swallowing concerns and is seen by speech therapy. Will continue to monitor this resident with the team. -The progress note did not discuss adding nutritional interventions to prevent weight loss or increase the frequency of weights to more closely monitor the resident for weight loss. 4/27/23: This resident was seen today by speech therapy via telehealth for swallowing concerns. He was advanced to a mechanical soft diet with thin liquids. He is a supervised meal resident. Will continue to monitor the dietician and team. -The progress note did not discuss adding nutritional interventions to prevent weight loss or increase the frequency of weights to more closely monitor the resident for weight loss. 5/3/23: This resident is seen by speech therapy. He is now on a mechanical soft diet and eating better. Will continue to monitor the dietician and team. -The progress note did not discuss adding nutritional interventions to prevent weight loss or increase the frequency of weights to more closely monitor the resident for weight loss. -The progress documented that the resident was being seen by speech therapy, however the resident had been discharged from the speech therapy caseload on 4/27/23. 5/17/23: This resident is on a mechanical soft ground meat diet and seen by speech therapy. He eats well and likes snacks. Will continue to monitor with the team. -The progress note did not discuss adding nutritional interventions to help the resident gain back the weight that had been lost. -The progress documented that the resident was being seen by speech therapy, however the resident had been discharged from the speech therapy caseload on 4/27/23. Resident #25's Dietary Quarterly assessment dated [DATE] documented in pertinent part, Intake of food 76-100%. Resident admitting diagnoses of hemiplegia and hemiparesis. Continues on a regular diet with mechanical soft textures and thin liquids. Snacks three times daily being offered and accepted at this time. No significant weight changes at this time. Continue with nutritional plan of care. Registered dietitian (RD) to remain available as needed. -The RD documented the weight change section of the assessment was not applicable, despite the resident having lost 5.8% in one month from 3/6/23 to 4/5/23. -The RD did not recommend any further nutritional interventions to assist Resident #25 in gaining back the weight he had lost. -There was no dietary assessment completed by the RD in April 2023 when the significant weight loss of 5.8% in one month was identified. Review of Resident #25's EMR revealed the following Nutrition At Risk (NAR) meeting progress notes documented in pertinent part: 4/12/23: Risk area being reviewed: weight loss Summary of IDT discussion: Current weight: 165.6 Previous weight: 175.8 Amount lost/gained: -5.8% Intakes: BMI (body mass index): 25.2 Resident had a choking episode and was immediately downgraded to a pureed/nectar diet. Diet downgrade is a possible reason for weight loss due to being restrictive. Will enter snacks three times per day (pureed consistency) and speak to the IDT team about diet being upgraded to a more appealing diet. Intervention(s): snacks three times per day. -No meal intakes were documented in the progress note. 4/19/23: Risk area being reviewed: weight loss Summary of IDT discussion: Current weight: 165.6 Previous weight: 175.8 Amount lost/gained: -5.8% Intakes: BMI (body mass index): 25.2 Resident had a choking episode and was immediately downgraded to a pureed/nectar diet. Diet downgrade is a possible reason for weight loss due to being restrictive. Will enter snacks three times per day (pureed consistency) and speak to the IDT team about diet being upgraded to a more appealing diet. Intervention(s): snacks three times per day. -The progress note was the exact same progress note that had been documented on 4/12/23. -No meal intakes were documented in the progress note. 4/26/23: Risk area being reviewed: weight loss Summary of IDT discussion: Current weight: 165.6 Previous weight: 175.8 Amount lost/gained: -5.8% Intakes: BMI (body mass index): 25.2 Resident had a choking episode and was immediately downgraded to a pureed/nectar diet. Diet downgrade is a possible reason for weight loss due to being restrictive. Will enter snacks three times per day (pureed consistency) and speak to the IDT team about diet being upgraded to a more appealing diet. Intervention(s): snacks three times per day. -The progress note was the exact same progress note that had been documented on 4/12/23 and 4/19/23. -No meal intakes were documented in the progress note. 5/3/23: Risk area being reviewed: weight loss Summary of IDT discussion: Current weight: 167 Previous weight: 179 Amount lost/gained: stable Intakes: 50-75% BMI (body mass index): 25.4 Resident had a choking episode and was immediately downgraded to a pureed/nectar diet. Diet downgrade is a possible reason for weight loss due to being restrictive. Resident was upgraded to mechanical soft textures, intakes and weight likely to increase as restrictive diet is no longer active. Removing from NAR as weight is stable at this time. Continue to offer snacks. Intervention(s): snacks three times per day. -The previous weight documented in the progress note was documented incorrectly, as the resident's previous weight was 165.6 lbs, not 179 lbs. -The progress note did not discuss adding further nutritional interventions to help the resident gain back the weight he had lost. -The progress note did not discuss increasing the frequency of weights to ensure his weight was consistently stable and the resident again lost weight in June 2023 (165 lbs) and July 2023 (164.6 lbs). Review of Resident #25's EMR revealed the following physician visit progress notes documented by the nurse practitioner in pertinent part: 4/6/23: Resident is seen today for follow up. Resident had an episode of choking in the dining room on 3/27/23 that required someone to do the Heimlich maneuver. His airway was cleared and he was fine. He has a swallow evaluation ordered and in the meantime has been switched to a pureed diet. Will continue to monitor. -The note did not address the resident's 5.8% significant weight loss in one month. 5/4/23: Resident is seen today for follow up. Resident had an episode of choking in the dining room on 3/27/23. He had a swallow evaluation and he is now on a mechanical soft diet and doing well. Will continue to monitor. -The note did not address the resident's 5.8% significant weight loss in one month. C. Interviews Activities associate (AA) #1 was interviewed on 7/12/23 at 10:20 a.m. while she was passing snacks to residents from a wheeled snack cart. AA #1 said she passed snacks to all residents in the facility two times per day at 10:00 a.m. and 2:00 p.m. Certified nurse aide (CNA) #3 was interviewed on 7/12/23 at 1:10 p.m. CNA #3 said Resident #25 had a period of weight loss in April 2023 after he had a choking episode and was changed to a pureed diet. She said he did not really like the pureed diet. She said he worked with speech therapy and was currently on a mechanical soft diet. CNA #3 said Resident #25 ate better on the mechanical soft diet. She said she thought the resident received two snacks per day just as the other residents did. She said the activities department gave the residents their snacks but she did not know if anyone documented how much of the snack the residents ate. Licensed practical nurse (LPN) #3 was interviewed on 7/12/23 at 1:35 p.m. LPN #3 said Resident #3 received two snacks per day like all of the other residents. He said any resident could have more snacks if they wanted them, but Resident #25 did not have an order for an extra snack. He said he did not know who documented how much of the snack offered was eaten by the resident. The registered dietitian (RD) was interviewed on 7/12/23 at 2:36 p.m. The RD said the facility obtained monthly weights on all residents. She said the facility did not usually increase frequency of weights for residents with weight loss. She said she ran a monthly weight report after all of the weights had been obtained each month. She said the report documented if any residents had sustained a significant weight loss. The RD said if a resident triggered for a significant weight loss of greater than 5% in one month, greater than 7.5 % in three months, or greater than 10% in six months the resident would be brought to the weekly Nutrition At Risk (NAR) meetings to determine what interventions were needed to prevent further weight loss. She said the IDT team would review each resident weekly until the resident's weight had stabilized. She said if a resident had not yet triggered for significant weight loss but was noted to be losing weight she would talk to the resident and the staff to determine what the reason might be for the weight loss. The RD said she would add a nutritional intervention immediately and add the resident to the NAR list for review even if the resident had not triggered for significant weight loss in an attempt to prevent further weight loss. The RD said interventions implemented were often a Boost nutritional supplement, however, she said sometimes she would just increase a resident's number of snacks per day or add extra protein to their snacks or meals. The RD said Resident #25 had a choking episode and was downgraded to a pureed diet which decreased his meal intakes. She said once the speech therapist upgraded him to a mechanical soft diet he started eating better and his weight stabilized. She said he did not gain back the weight he lost. The RD said she did not put him on a nutritional supplement for his weight loss because his weight stabilized once his diet was upgraded by speech therapy. She said she did increase his snacks to three times per day. She said she did not feel that the amount of snack consumed needed to be documented. The RD said she asked for the physician's order to ensure the resident was getting mechanically altered snacks to match his diet order. AA #1 was interviewed again on 7/17/23 at 10:17 a.m. AA #1 said she only passed snacks to Resident #25 two times per day when she passed snacks to all the other residents. She said she did not give the resident a third snack during the day. She said she was not sure who was responsible for passing extra snacks to residents. AA #1 said Resident #25 would usually accept an oatmeal cookie that he liked to dip in his coffee before he ate it or he would also eat pudding. She said he would always accept the snack that was offered and most of the time she thought he ate the whole snack. She said the activities staff did not generally go back to see if residents ate their snacks, however she said she did check on some residents to see if they ate the snack. AA #1 said she did not document how much of the snack was consumed by the residents. III. Resident #27 A. Resident status Resident #27, age 71, was admitted on [DATE]. According to the July 2023 CPO, diagnoses included dementia, muscle weakness, epilepsy and diabetes mellitus. The 6/16/23 MDS assessment revealed that the BIMS was not assessed because the resident was rarely understood. The staff assessment for mental status revealed the resident had a problem with short and long term memory and his cognitive skills for daily decision making were severely impaired. He required two-person extensive assistance for bed mobility, transfers, dressing, toilet use and personal hygiene. He required one-person extensive assistance with eating. According to the MDS assessment, he did not have any swallowing difficulties and he did not have, or it was unknown if he had, a weight loss of 5% or more in the last month or a loss of 10% or more in the last six months. B. Observation On 7/12/23 at 12:52 p.m. the dietary supervisor (DS) was observed preparing Resident #27's lunch tray. The DS served the resident a double portion of honey roasted pork loin, however, the resident was served only regular portions of monte [NAME] vegetables, cheddar grits and the apple crisp (see physician orders and RD interview below). C. Record review Review of Resident #27's recorded weights from 4/5/23 to 7/3/23 revealed the following: -4/5/23: 165.8 lbs; -5/1/23: 158.4 lbs; -6/1/23: 150.8 lbs; and, -7/3/23: 150.8 lbs. -Despite the 7.4 lbs (4.5%) weight loss, which did not trigger for a significant weight loss, demonstrated in one month between 4/5/23 and 5/1/23, the facility did not add any nutritional interventions until 5/11/23 (10 days after the weight loss was documented) when Boost (a liquid nutritional supplement) was added one time per day to the resident's plan of care. The facility added double portions of meals served to the resident's plan of care on 5/26/23 (25 days after the weight loss was documented (see physician's orders below). -The resident's weights were not increased to more closely monitor the resident's weights despite the 7.4 lb weight loss in one month and despite the care plan documenting the resident was to be weighed weekly (see care plan below). The resident continued to lose weight and on 6/1/23 the resident's weight was documented as 150.8 lbs, an additional weight loss of 7.6 lbs. This was a total weight loss of 15 pounds, or 9% in just under two months, which was a significant weight loss. -The facility did not add the resident to the weekly Nutrition At Risk (NAR) meetings despite the resident's loss of 7.4 lbs in one month (see NAR progress notes below). -Despite the significant weight loss of 15 pounds (9%) between 4/5/23 and 6/1/23, the facility did not increase the frequency of Resident #27's weights and no further supplements were added until 6/14/23 (13 days after the weight loss was documented) when the Boost nutritional supplement was increased to two times per day (see physician orders below). Review of Resident #27's nutrition care plan, initiated 2/8/23 and revised 6/21/23, revealed that the resident had a potential for weight loss due to dementia, diabetes, depression and epilepsy. Pertinent interventions included explaining and reinforcing to the resident the importance of maintaining an ordered diet, encouraging the resident to comply with the ordered diet and explaining consequences of refusals monitoring weight weekly and as needed, offering alternative meals as needed if 50% of meal intake was noted and offering snacks throughout the shift if the resident continued to refuse meals, providing diet as ordered and double portions for weight maintenance and providing supplements as ordered. -Despite the care plan documenting the resident's weights were to be obtained weekly, the facility failed to weigh the resident weekly (see weights above). -The intervention for supplements was not initiated on the care plan until 6/14/23 despite the initial order for Boost daily having been ordered on 5/10/23 (see physician orders below). -The care plan did not document what nutritional supplement the resident was to receive and how many times per day he was to receive it. Review of Resident #27's July 2023 CPO revealed the following physician orders: Boost supplement one time a day. Please give Boost daily at bedtime. The order had a start date of 5/10/23. The order was discontinued on 6/14/23 when the supplement was increased to two times per day. Boost Supplement two times a day. Please give Boost two times daily. The order had a start date of 6/14/23. Review of Resident #27's MARs from 5/11/23 through 7/12/23 revealed the resident was being offered the nutritional supplement as ordered. -The MARs did not document how much of each supplement was consumed by the resident. Review of Resident #27's EMR revealed the following IDT progress notes documented in pertinent part: 5/24/23: This resident needs a large amount of cueing for all activities of daily living (ADLs). He takes a supplement and is supervised dining for meals. Encourage fluids. Will continue to monitor this resident with the dietician as he has lost weight. -The progress note did not discuss adding further nutritional interventions to prevent weight loss or ensuring the resident was weighed more frequent to closely monitor the resident for weight loss. 5/26/23: Resident appears to want more food and diet increased to double portions. -The progress note did not discuss ensuring the resident was weighted more frequently to closely monitor the resident for weight loss. 6/1/23: This resident discussed with nutrition about weight loss. double portions ordered for all meals. boost supplement. Resident needs encouragement with supervision. Resident likes fluids and snacks. Will continue to monitor this resident with the team. -The progress note did not discuss ensuring the resident was weighed more frequently to monitor the resident for weight loss. 6/9/23: This resident needs total care for all ADLs. He needs constant cueing. He eats in the dining area with supervision and he now has double portions for all meals. Supplements, fluids and snacks in place. -The progress note did not discuss ensuring the resident was weighed more frequently to closely monitor the resident for weight loss. 6/16/23: This resident had been on intravenous (IV) fluids and has since declined in his mentation. His labs were done and normal. He does not want to get up. His physician and wife were notified and his wife decided on a do not resuscitate (DNR) status and hospice evaluation. Resident not eating well and not taking meds regularly since he is not feeling well. Awaiting hospice to come. Will continue to monitor. 6/19/23: Resident admitted to hospice services today. 6/25/23: This resident is on hospice services and remains with general weakness. He is eating well in the dining area with double portions. He is eating snacks and taking fluids. 7/4/23: This resident was sick and required IV fluids. He has a decline in all ADLs. He is now hospice. He is eating 50-75% of meals. He eats in the dining area with supervision. He has lost 15 lbs since March (2023) and has stabilized the last two months. Will continue to monitor. -The progress note documented the resident had lost 15 lbs since March (2023), however, the resident's weight loss had been since April 2023. Review of Resident #27's Dietary Quarterly assessment dated [DATE], prior to any weight loss, documented in pertinent part, Resident admitting diagnosis is dementia. Continues on a regular diet with thin liquids, accepting at a 50% average. Although intakes are low, weight is stable. Will add a supplement if weight decreases. No skin issues noted at this time. Registered dietitian (RD) to remain available as needed. -However, the resident was not meeting his meal intake with his average intake 50% and intakes described as low. The facility obtained weights once a month, which did not proactively address his nutritional and weight loss risk. Review of a Dietary Quarterly assessment dated [DATE] documented the resident had sustained a significant weight loss of 9% in 90 days. The dietitian documented in pertinent part, Resident admitting diagnosis is dementia. Continues on a regular diet with thin liquids, accepting at a 50% average. Intakes low, significant weight loss. Resident is being charted on weekly at NAR meetings. No skin issues noted at this time. RD to remain available as needed. -The assessment further documented the resident was receiving Boost two times per day and double portions at meals, however there was no documentation regarding how much of the nutritional supplement the resident was consuming. -The assessment did not discuss ensuring the resident was being weighed more frequently to more closely monitor the resident's weight. -There was no dietary assessment completed by the RD in May 2023 when the non-significant weight loss of 4.5 lbs in one month was identified. -There was no dietary assessment completed by the RD in June 2023 when the significant weight loss of 15 pounds (9%) in just under two months was identified. Review of Resident #27's EMR revealed the following Nutrition At Risk (NAR) meeting[TRUNCATED]

Based on observations, interviews and record review the facility failed to store, prepare, distribute and serve food in a sanitary manner in the main kitchen and one out of two nourishment rooms. Specifically, the facility failed to: -Ensure one unit nourishment room was clean and sanitary; -Ensure the kitchen ceiling was free from debris and dust; -Ensure appropriate hand washing occurred in the main kitchen; and, -Ensure dishes were dried appropriately. Findings include: I. Ensure the unit nourishment room was clean and sanitary A. Professional reference The Colorado Department of Public Health and Environment (2019) The Colorado Retail Food Establishment Rules and Regulations, https://www.colorado.gov/pacific/sites/default/files/DEHS_RetailFd_6CCR10102_RFFC_EffJan2019.pdf. It read in pertinent part; -Time/temperature control for safety of food prepared and held in a food establishment for more than 24 hours shall be clearly marked to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded when held at a temperature of 41 (degrees) F (Farenheit) or less for a maximum of 7 days. The day of preparation shall be counted as Day 1. The day or date marked by the food establishment may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on food safety. Food shall be protected from contamination by storing the food, in a clean dry location, where it is not exposed to splash, dust or other contamination and at least 15 centimeters (6 inches) above the floor. (Retrieved [DATE]). B. Facility policy and procedure The Food Receiving and Storage policy, revised [DATE], was provided by the regional director of rehabilitation (RDR) on [DATE] at 3:24 p.m. It revealed in pertinent part, Food in designated dry storage areas are kept at least six (6) inches off the floor (unless packaged for handling, for example, dollies, pallets, racks and skids) and clear of sprinkler heads, sewage/waste disposal pipes and vents. Foods and Snacks Kept on Nursing Units: All food items to be kept at or below 41 F (degrees fahrenheit) are place in the refrigerator located at the nurses' station and labeled with a 'use by' date; all food belonging to residents are labeled with the resident's name, the item and the 'use by' date; Refrigerators must have working thermometers and are monitored for temperature according to state-specific guidelines; beverages are dated when opened and discarded after twenty-four (24) hours; other opened containers are dated and sealed or covered during storage; partially eaten food is not kept in the refrigerator; and, medications, blood or blood products are not stored in the same refrigerator with food. C. Observations On [DATE] at 4:34 p.m. the following was observed in the back unit nourishment room: -In the refrigerator there was an opened matcha drink with no name or expiration date, an opened container of creamer that expired on [DATE], a container of pudding with no label or date, a half gallon of chocolate milk that expired on [DATE], two individual yogurts that expired on [DATE], one individual yogurt that expired on [DATE] and a bag of four rolls that did not have a use by label and the rolls were hard. -The refrigerator had smears of chocolate pudding and food debris at the bottom of the refrigerator. -In the freezer there was a frozen pizza that expired on [DATE], a frozen salisbury steak meal that expired on [DATE] and a container of lactose free ice cream with no open or use-by date. -The freezer had built-up ice and had built-up food brown food debris on the bottom shelf. -Next to the refrigerator were boxes of Boost (nutritional supplement) stored directly on the ground. On [DATE] at 11:05 a.m. the following was observed in the back unit nourishment room with the dietary supervisor (DS): -In the refrigerator there was an opened matcha drink with no name or expiration date. The DS said the drink might have been a nurse's drink and left it in the refrigerator. He said he was not sure how long the opened drink had been in the refrigerator. -A container of pudding with no label or date, a half gallon of chocolate milk that expired on [DATE], two individual yogurts that expired on [DATE], one individual yogurt that expired on [DATE]. The DS said these items needed to be disposed of and threw them out. -A bag of four rolls that did not have a use by label and the rolls were hard. The DS said the rolls belonged to a resident and he was unsure of how long they had been in the refrigerator. The DS left the bag of rolls in the refrigerator. -In the freezer there was a frozen pizza that expired on [DATE], a frozen salisbury steak meal that expired on [DATE]. The DS said these items likely belonged to residents and he said they needed to be disposed of and threw them away. -In the freezer there was a container of lactose free ice cream with no open or use-by date. The DS said the lactose free ice cream belonged to a resident and he was unsure of how long it had been in the freezer. -The DS said the refrigerator and the freezer had food debris built-up and were dirty. The DS said he would have a dietary staff member clean the refrigerator and freezer on [DATE]. -The DS said there was Boost stored directly on the floor in the nourishment room and said food items needed to be stored off of the ground. D. Staff interviews The DS was interviewed on [DATE] at 11:05 a.m. He said the nourishment room refrigerator and freezer should be clean and free from debris. The DS said foods should be labeled and dated. The DS said foods should be thrown away if they were past the expiration date. The DS said he was not sure who was responsible for cleaning the nourishment refrigerators, but he would have a dietary staff member clean the refrigerator on [DATE]. The DS said foods such as Boost should not be stored on the ground. The infection preventionist (IP) was interviewed on [DATE] at 11:34 a.m. She said all foods should be discarded on their expiration date. The IP said food should not be stored on the ground for pest control. II. Ensure the kitchen ceiling was free from debris and dust A. Professional reference The Colorado Department of Public Health and Environment (2019) The Colorado Retail Food Establishment Rules and Regulations, https://www.colorado.gov/pacific/sites/default/files/DEHS_RetailFd_6CCR10102_RFFC_EffJan2019.pdf. It revealed, in pertinent part, Equipment food-contact surfaces and utensils shall be clean to sight and touch. The food-contact surfaces of cooking equipment and pans shall be kept free of encrusted grease deposits and other soil accumulations. Non food contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris. Non food-contact surfaces of equipment shall be cleaned at a frequency necessary to preclude accumulation of soil residues. (Retrieved [DATE]) B. Facility policy and procedure The Sanitization policy, revised [DATE], was provided by the director of nursing (DON) on [DATE] at 4:07 p.m. It revealed in pertinent part, All kitchens, kitchen areas and dining areas are kept clean, free from garbage and debris, and protected from rodents and insects. C. Observations During the initial kitchen tour on [DATE] at 9:34 a.m. the following was observed: -The ceiling above the preparation table, two compartment sink and oven had built-up gray dust. The dust was hanging from the ceiling and the two vents that were in the area. During a continuous observation on [DATE] beginning at 11:26 a.m. and ended at 1:35 p.m. the following was observed: -The ceiling above the preparation table, two compartment sink and oven had built-up gray dust. The dust was hanging from the ceiling and the two vents that were in the area. -DA #1 portioned cooked apple crisp under the dust and the DS prepared the mechanically altered foods under the dust. D. Staff interviews The registered dietitian (RD) was interviewed on [DATE] at 10:59 a.m. She acknowledged the ceiling was dirty and needed to be cleaned. The DS was interviewed on [DATE] at 11:05 a.m. The DS said the kitchen ceiling should be cleaned. The DS said he was unsure of who was responsible for cleaning the ceiling. He said he would speak with the maintenance director and get the ceiling cleaned. The IP was interviewed on [DATE] at 11:34 a.m. She acknowledged the dust on the ceiling could become a contaminant in foods. III. Ensure appropriate hand washing occurred in the main kitchen A. Professional reference The Colorado Department of Public Health and Environment (2019) The Colorado Retail Food Establishment Rules and Regulations, https://www.colorado.gov/pacific/sites/default/files/DEHS_RetailFd_6CCR10102_RFFC_EffJan2019.pdf. Food employees shall clean their hands and exposed portions of their arms immediately before engaging in food preparation including working with exposed food, clean equipment and utensils, and unwrapped singled service and single-use articles and: after touching bare human body parts other than clean hands and clean, exposed portions of arms; after using the toilet room; after caring for or handing service animals or aquatic animals, after coughing, sneezing, using a handkerchief or disposable tissue, using tobacco, eating or drinking; after handling soiled equipment or utensils; during food preparation, as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks; when switching between working with raw food and working with ready-to-eat food; before dining gloves to initiate a task that involves working with food; and, after engaging in other activities that contaminate the hands. Food employees shall clean their hands in a handwashing sink or approved automatic handwashing facility and may not clean their hands in a sink used for food preparation or warwashing or in a service sink or a curbed cleaning facility used for the disposal of mop water and similar liquid waste. (Retrieved [DATE]). B. Facility policy and procedure The Handwashing/Hand Hygiene policy, dated [DATE], was provided by the RDR on [DATE] at 3:24 p.m. It revealed in pertinent part, The facility considers hand hygiene the primary means to prevent the spread of infections. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors. The Preventing Foodborne Illness - Employee Hygiene and Sanitary Practices policy, dated [DATE], was provided by the RDR on [DATE] at 3:24 p.m. It revealed in pertinent part, Food and nutrition services employees follow appropriate hygiene and sanitary procedures to prevent the spread of foodborne illness. Employees must wash their hands: after personal body functions; after using tobacco, eating or drinking; whenever entering or reentering the kitchen, before coming in contact with any food surfaces; after handling raw meat, poultry or fish and when switching between working with raw food and working with ready-to-eat food; after handling soiled equipment or utensils; during food preparation, as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks; and/or, after engaging in other activities that contaminate the hands. C. Observations During a continuous observation on [DATE] beginning at 11:26 a.m. and ended at 1:35 p.m. the following was observed: -At 12:06 p.m. dietary aide (DA) #1 loaded a rack of dirty dishes into the dish machine. DA #1 touched his phone, grabbed a towel and began drying clean dishes with the towel. -At 1:12 p.m. DA #1 was putting away clean dishes. DA #1 picked up dirty dishes, loaded them into a dish rack and sprayed the dishes off. He loaded the rack of dirty dishes into the dishwasher. He then used the dish sprayer to spray one hand then used the dish sprayer to spray the other hand. DA #1 went to the other side of the dish room where the clean dishes came out of the dishwasher and began putting away clean dishes. DA #1 put away two metal pans that were visibly wet. -DA #1 used his hands to adjust his hair net. DA #1 got his tablet and a speaker and went to the dishwasher. He opened the dish machine and pulled the clean dishes out. DA #1 went to the dirty side of the dishroom and began loading dirty dishes. He loaded the rack of dishes into the dishmachine and started it. DA #1 turned music on his speakers. DA #1 began putting away clean dishes without washing his hands. DA #1 used the same dish towel that had been in the dish room to dry off the food processor. DA #1 put the food processor away. DA #1 used the same towel to dry utensils and plates. He left the dish room and put away some clean utensils. -DA #1 went back into the dish room without washing his hands and put plates on a rack to dry. -DA #1 went back to the dirty side of the dish room and began loading dishes onto a rack and spraying them off. DA #1 opened the dishmachine and pulled clean dishes out. DA #1 loaded the dirty dishes into the dish machine. DA #1 used the dirty dish sprayer to spray off both of his hands. DA #1 began putting away clean dishes without washing his hands. DA #1 left the dish room and put clean dishes away. DA #1 entered the dining room and began picking up dirty dishes from the lunch meal. -DA #1 came back into the kitchen and without washing his hands he pulled out a rack of clean dishes from the dish machine. -DA #1 began rinsing and racking dirty dishes. DA #1 pushed a rack of dirty dishes into the dish machine. DA #1 touched his smart watch and then began putting away clean dishes without washing his hands. D. Staff interviews Nursing home administrator (NHA) #2 and the DS were interviewed on [DATE] at 1:52 p.m. The DS said there was not a hand washing sink in the dish room. The DS said staff needed to leave the dishroom and come to the main part of the kitchen to wash their hands appropriately. The DS said staff should wash their hands after handling dirty dishes and before handling clean dishes. The DS said staff should run three racks of dishes through the dish machine, then wash their hands, then begin putting away clean dishes. The infection preventionist (IP) was interviewed on [DATE] at 11:34 p.m. The IP said it was important to conduct proper hand hygiene after handling dirty dishes to prevent the spread of bacteria. IV. Ensure dishes were dried appropriately A. Professional reference The Colorado Department of Public Health and Environment (2019) The Colorado Retail Food Establishment Rules and Regulations, https://www.colorado.gov/pacific/sites/default/files/DEHS_RetailFd_6CCR10102_RFFC_EffJan2019.pdf. It read in pertinent part, Unless used immediately after sanitization, all equipment and utensils shall be air-dried. (Retrieved [DATE]). B. Facility policy and procedure The Sanitization policy, revised [DATE], was provided by the DON on [DATE] at 4:07 p.m. It revealed in pertinent part, Drying food preparation equipment and utensils with a towel or cloth may increase risks for cross contamination. C. Observations During a continuous observation on [DATE] beginning at 11:26 a.m. and ended at 1:35 p.m. the following was observed: -At 11:59 p.m. DA #1 was using a towel to dry off the food processor pieces. -At 12:06 p.m. DA #1 loaded a rack of dirty dishes into the dish machine. DA #1 touched his phone, grabbed a towel and began drying clean dishes with the towel. -At 1:12 p.m. DA #1 put away two metal pans that were visibly wet. -At 1:15 p.m. DA #1 used the same dish towel that had been in the dish room to dry off the food processor. DA #1 put the food processor away. DA #1 used the same towel to dry utensils and plates. -DA #1 began rinsing and racking dirty dishes. DA #1 moved to the clean side of the dishroom and used the same towel to dry dishes. D. Staff interviews DA #1 was interviewed on [DATE] at 1:32 p.m. He said he used a towel to dry dishes to speed up the process. NHA #2 and the DS were interviewed on [DATE] at 1:52 p.m. The DS said the dietary staff used a clean towel for drying pots and pans. The DS said those items were used more frequently and they needed them to be cleaned and dried quickly. The DS said it was important for dishes to be dried appropriately, so bacteria did not start growing. The RD was interviewed on [DATE] at 10:59 a.m. She said dishes should not be dried with a towel. The RD said drying dishes with a towel could introduce bacteria.

Based on observations and staff interviews the facility failed to ensure all drugs and biologicals were properly stored, secured, and labeled in accordance with accepted professional standards for one of two medication carts and one of one medication storage rooms. Specifically the facility failed to: -Remove expired medications from medication carts and medication storage rooms to prevent the use of expired medications; -Date insulins, eye drops and inhalers when opened; and, -Ensure the medication storage refrigerator temperature was within acceptable parameters. Findings include: I. Professional references The United States Food and Drug Administration (USFDA) (2/8/21) Don't Be Tempted to Use Expired Medicines, retrieved on 7/25/23 from https://www.fda.gov/drugs/special-features/dont-be-tempted-use-expired-medicines, read in pertinent part, Expired medical products can be less effective or risky due to a change in chemical composition or a decrease in strength. Certain expired medications are at risk of bacterial growth and sub-potent antibiotics can fail to treat infections, leading to more serious illnesses and antibiotic resistance. Once the expiration date has passed there is no guarantee that the medicine will be safe and effective. If your medicine has expired, do not use it. II. Facility policy and procedures The Storage of Medications policy, not dated, was provided by the director of nursing (DON) on 7/11/23 at 4:16 p.m. It read in pertinent part, The facility stores all drugs and biologicals in a safe, secure, and orderly manner. Drugs and biologicals used in the facility are stored in locked compartments under controlled temperature, light and humidity controls. Discontinued, outdated or or deteriorated drugs and biologicals are returned to the dispensary pharmacy or destroyed. Medications requiring refrigeration are stored in a refrigerator located in the drug room at the nurses station or another secured location. -The policy did not address labeling or dating of medications when opened. III. Observations, interviews and record review A. Back unit medication cart On 7/11/23 at 12:19 p.m., the back unit medication cart was observed with licensed practical nurse (LPN) #2 and the assistant director of nursing (ADON). The following items were found: A bottle of Simbrinza 1%-0.2% eye drops was open, however, the bottle was not labeled with the date it was opened. The ADON said the bottle should have been labeled at the time it was opened as there was not a way to know when it was opened and when it should be disposed of. The ADON removed the medication from the cart and said it would need to be disposed of and reordered for the resident. -According to the package insert instructions for Simbrinza 1%-0.2% eye drops, the medication should not be used for more than 125 days after opening the bottle. A bottle of Timolol Maleate ophthalmic solution 0.5% eye drops was open, however, the bottle was not labeled with the date it was opened. The ADON said the bottle should have been labeled at the time it was opened as there was not a way to know when it was opened and when it should be disposed of. The ADON removed the medication from the cart and said it would need to be disposed of and reordered for the resident. -According to the package insert instructions for Timolol Maleate ophthalmic solution 0.5% eye drops, the medication should be discarded four weeks after opening. A Lantus Solostar insulin pen 100 units/milliliter (ml) had been used by a resident, however the pen was not labeled with the date that the pen was first removed from the refrigerator. The ADON said the insulin pen would need to be disposed of because the insulin was only good for 28 days once the pen had been removed from the refrigerator. She said there was no way to tell when the insulin pen should be disposed of because the pen had not been labeled when it was removed from the refrigerator. The ADON removed the insulin pen from the medication cart and said she would dispose of it. -According to the package insert instructions for Lantus Solostar insulin pen 100 units/ml, the medication should be discarded 28 days after removing it from the refrigerator. A Serevent Diskus 50 mcg inhaler was open, however, the inhaler was not labeled with the date it was opened. The counter on the inhaler read there were nine doses remaining out of 60 doses. The ADON said the inhaler was good for six weeks after it was opened. She said there was no way to tell when the inhaler should be disposed of because it had not been labeled when it was removed from the package. The ADON removed the inhaler from the medication cart and said she would dispose of it. -According to the package insert instructions for Serevent Diskus 50 mcg inhaler, the medication should be discarded six weeks after removal from the moisture-protective foil overwrap pouch or after all the medication blisters have been used (when the dose indicator reads 0), whichever comes first. A tube of Lidocaine cream 5% was open and had been used, however the tube was not labeled with an individual resident's name. The ADON said the tube of cream should only be used for one resident. She said the cream should have been labeled with a specific resident's name to ensure staff did not use the same tube of cream for more than one resident. She removed the tube of cream from the cart and said she would dispose of it. A stock bottle of 1000 milligram (mg) fish oil capsules had an expiration date of March 2023. The ADON said the medication should have been removed from the cart when it expired. She removed the bottle of medication from the cart and said she would dispose of it. B. Medication storage room On 7/11/23 at 12:45 p.m., the medication storage room was observed with LPN #2 and the ADON. The following items were found: On initial observation of the medication storage refrigerator no thermometer was visible in the refrigerator. The ADON moved a plastic box which contained medications that were available for emergency use. The medications in the box required refrigeration. The label on the box documented the emergency medications should have been replaced by the pharmacy in May 2023 (see emergency medication box contents and ADON interview below). The ADON located the refrigerator thermometer behind the plastic box of emergency medications and removed it from the refrigerator. The thermometer had a light film of frost on it. The temperature on the thermometer read 22 degrees fahrenheit. LPN #2 and the ADON confirmed the temperature on the thermometer. The plastic box containing the emergency medications had a label which documented the medications should have been replaced by the pharmacy in May 2023. The box contained the following: -One Lantus Solostar 100 units/ml insulin pen; -One 3 ml 100 units/ml vial of Humulin 70/30 insulin; -One 3 ml 100 units/ml vial of Humulin N insulin; -One 3 ml 100 units/ml vial of Humulin R insulin; and, -Two 1 ml 2 mg/ml vials of Lorazepam. The ADON said nursing staff should have called the pharmacy in May 2023 to have the medications replaced. She said expired medications should not be used for residents. -According to the package insert instructions for Lantus Solostar insulin pen 100 units/ml, the medication could be kept at 36 degrees fahrenheit to 46 degrees fahrenheit until first use. The medication should not be allowed to freeze. -According to the package insert instructions for Humulin 70/30 insulin, the medication should not be frozen and should not be used after it had been frozen. -According to the package insert instructions for Humulin N insulin, the medication should not be frozen and should not be used after it had been frozen. -According to the package insert instructions for Humulin R insulin, the medication should not be frozen and should not be used after it had been frozen. -According to the package insert instructions for Lorazepam, the medication should be stored in a refrigerator (not a freezer). The ADON said the medication refrigerator temperature should be between 36 degrees fahrenheit and 46 degrees fahrenheit. She said there was no way to determine how long the refrigerator temperature was below the acceptable temperature ranges. She said the night shift nurses monitored the temperature of the medication refrigerator daily. She said the medications would need to be disposed of because the efficacy (ability to produce a desired or intended result) of the medications was potentially compromised due to the medications being stored below the acceptable temperature ranges. The ADON removed all of the medications from the refrigerator in order to dispose of them. The ADON provided the medication refrigerator logs for the months of May, June and July 2023. The medication refrigerator logs were documented daily, however, the temperature had been recorded each day as a consistent 39 degrees since 5/1/23. The ADON said the temperatures had not been monitored appropriately because the thermometer was found behind the plastic box of emergency medications which should have been replaced in May 2023. In addition to the above emergency medications, the refrigerator also contained the following unopened medications: -Two vials of Flucelvax quadrivalent influenza vaccine which expired 6/30/22; -Nine Lantus Solostar 100 units/ml insulin pens; -Two Humulin R 500 units/ml insulin kwikpens; -Three Trulicity 1.5 mg/0.5 ml insulin pens; -One 3 ml 100 units/ml vial of novolog insulin; -Five 3 ml 100 units/ml vials of Lantus insulin; and, -One bottle of Latanoprost ophthalmic solution .0005%. -According to the package insert instructions for Flucelvax quadrivalent influenza vaccine, the medication should be kept at 36 degrees fahrenheit to 46 degrees fahrenheit. The medication should be discarded if frozen. -According to the package insert instructions for Lantus Solostar insulin pen 100 units/ml, the medication could be kept at 36 degrees fahrenheit to 46 degrees fahrenheit until first use. The medication should not be allowed to freeze. -According to the package insert instructions for Humulin R 500 units/ml insulin kwikpens, the medication should not be frozen and should not be used after it had been frozen. -According to the package insert instructions for Trulicity 1.5 mg/0.5 ml insulin pens, the medication should be kept at 36 degrees fahrenheit to 46 degrees fahrenheit. The medication should not be frozen and should not be used after it had been frozen. -According to the package insert instructions for the Novolog insulin 3 ml 100 units/ml vial, the medication should be kept at 36 degrees fahrenheit to 46 degrees fahrenheit. The medication should not be frozen and should not be used after it had been frozen. -According to the package insert instructions for the Lantus insulin 3 ml 100 units/ml vial, the medication should not be frozen and should not be used after it had been frozen. -According to the package insert instructions for Latanoprost ophthalmic solution .0005%, the medication should be kept at 36 degrees fahrenheit to 46 degrees fahrenheit. IV. The director of nursing (DON) interview The DON was interviewed on 7/12/23 at 9:42 a.m. The DON said all medications, such as insulin, eye drops and inhalers which expired a certain amount of time after opening, should be labeled with the date the medication was opened. She said medications should not be used past the expiration date as the medication may not be as effective. She said expired medications should be removed from the medication cart or medication storage room and disposed of appropriately. The DON said multiple use items such as creams and ointments should be used by an individual resident only and should be labeled with the resident's name when opened. The DON said the medication storage refrigerator temperature was supposed to be checked daily and the temperature recorded accurately. She said medications that had been frozen should be discarded as the freezing temperature could have affected the efficacy of the medications. V. Facility follow-up On 7/12/23 at 11:25 a.m. the DON provided a copy of the medication refrigerator and expired medications performance improvement plan (PIP). The PIP was dated 7/12/23. The PIP read in pertinent part: Problem: Refrigerator temperatures not being done daily. Root Cause Analysis: Daily temperature log not being filled out correctly, staff not understanding the importance of this task. Interventions: Education needing to be done to nursing staff on daily temperature logs. The nurse managers need to verify the temperatures two times per week. Problem: Expired medications in refrigerator. Root Cause Analysis: Medications not being checked for expiration dates. Interventions: Medications in the refrigerator need to be checked weekly for expired medications, nurse managers to double check. -The PIP did not address the expired medications in the medication carts. Problem: Refrigerator not being defrosted. Root Cause Analysis: Nurses not knowing the policy for defrosting the medication refrigerator monthly. Interventions: Monthly cleaning/defrosting schedule.

Based on interviews and record review, the facility failed to ensure residents had a right to participate in the development and implementation of their person-centered plan of care for two (#9 and #23) of two out of 27 sample residents. Specifically, the facility failed to invite and conduct regular care conferences to review the resident's plan of care with Resident #9 and Resident #23. Findings include: I. Resident #9 A. Resident status Resident #9, age 68, was admitted on [DATE] and readmitted on [DATE]. According to the July 2023 computerized physician orders (CPO) the diagnoses included type two diabetes mellitus, anxiety and schizoaffective disorder. The 6/19/23 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) with a score of 15 out of 15. She required supervision of two people for bed mobility and locomotion on the unit. She required supervision of one person for transfers and walking in her room. She required supervision with set-up assistance for walking in the corridor, locomotion off the unit, dressing, eating and toileting. She required limited assistance of two people for personal hygiene. B. Resident interview Resident #9 was interviewed on 7/10/23 at 11:22 a.m. She said the facility did not schedule care conferences on a regular basis to review her plan of care. Resident #9 said she was not sure the last time she had a care conference. C. Record review -A review of the resident's medical record on 7/11/22 at 12:00 p.m. revealed no documentation in the progress notes that a care conference has occurred with the resident since his admission to the facility on [DATE]. The 7/11/23 social services progress note documented a care conference was completed today with Resident #9 and staff (during the survey process). II. Resident #23 A. Resident status Resident #23, age 82, was admitted on [DATE]. According to the July 2023 CPO the diagnoses included dementia, anxiety disorder and post-traumatic stress disorder (PTSD). The 4/5/23 MDS assessment revealed the resident had moderate cognitive impairment with a BIMS with a score of nine out of 15. He required supervision of one person for bed mobility, transfers, walking in his room and in the corridor and locomotion on the unit. He required limited assistance of one person for dressing and eating. He required extensive assistance of one person for toileting and personal hygiene. B. Resident interview Resident #23 was interviewed on 7/10/23 at 12:20 p.m. Resident #23 said the facility used to hold care conferences, but he had not had one in a long time to discuss his care goals. C. Record review -A review of the resident's medical record on 7/11/23 at 12:30 p.m. did not reveal documentation any additional care conferences had been conducted or the resident and/or responsible party had been invited since the resident's care conference on 2/28/23. The 7/12/23 social services progress note documented a care conference was scheduled with Resident #23's guardian for 7/26/23 at 11:30 a.m. (scheduled during the survey process). III. Staff interviews The social services director (SSD) was interviewed on 7/11/23 at 2:07 p.m. She said care conferences followed the MDS schedule and were held monthly. The SSD said residents and resident representatives were invited to the care conferences. The SSD was interviewed again on 7/13/23 at 10:04 a.m. The SSD said Resident #9 was wanting to move to Maine to be closer to her son. The SSD said Resident #9 signed the admission paperwork to a secured unit herself. The SSD was interviewed again on 7/13/23 at 10:04 a.m. She said she took over scheduling care conferences at the end of 2022. The SSD acknowledged that Resident #9 and Resident #11 had not had a care conference in approximately six months. The SSD said care conferences should be held every three months. Nursing home administrator (NHA) #1 said Resident #9 was planning her own discharge to Maine and did not want any assistance. NHA #1 acknowledged that Resident #9 and Resident #23 had not received quarterly care conferences.

Based on interviews, observations, and record review, the facility failed to take steps to protect three (#27, #47 and #40) of seven residents reviewed for abuse out of 27 sample residents. Specifically, the facility failed to ensure: -Resident #47 was free from physical abuse from Resident #40; -Resident #40 was free from physical abuse from Resident #47; and, -Resident #27 was free from physical abuse from Resident #12. Findings include: I. Incident of physical abuse between Resident #47 and Resident #40 The 6/23/23 abuse investigation documented it was reported to the DON and the NHA that alleged abuse had occurred on the back unit. Resident #47's state appointed guardian said that the alleged assailant (Resident #40) pinched Resident #47. This led Resident #47 to punch Resident #40 and then Resident #40 pulled Resident #47's hair. A facility housekeeper was present at the time and said Resident #47 got angry and took a fast swing towards Resident #40, which lead Resident #40 to pull Resident #40's hair. Both residents were placed on 15 minute checks until a room move was arranged. The NHA spoke with floor staff and found an appropriate room to move Resident #47 to. -However, documentation of the 15 minute safety checks was requested on 7/13/23 and the NHA #1 said she was unable to locate the documentation. Resident #47's guardian reported Resident #40 was standing in the doorway as Resident #47 and herself were entering the room. Resident #40 pinched Resident #47, which led Resident #47 to punch Resident #40, then Resident #47 pulled Resident #40's hair. The housekeeper that witnessed the altercation was interviewed and said Resident #47 grabbed Resident #47's arm. The housekeeper said Resident #40 looked upset and took a fast swing and hit Resident #47 in the face. Resident #47 reacted by pulling Resident #40's hair. After the investigation was conducted, the facility determined the altercation was substantiated due to being witnessed by a visitor and housekeeping staff, however due to diagnoses of dementia for both residents abuse was unsubstantiated. -However, physical abuse occurred because Resident #40 pinched and pulled Resident #47's hair and Resident #47 punched Resident #40. II. Resident #47 A. Resident status Resident #47, age 79, was admitted on [DATE]. According to the July 2023 computerized physician orders (CPO) the diagnoses included major depressive disorder and vascular dementia with behavioral disturbance. The 5/9/23 minimum data set (MDS) assessment revealed the resident had short-term and long-term memory impairment. The resident was severely impaired making decisions regarding tasks of daily life. She required supervision of one person for bed mobility, transfers, walking in her room and in the corridor and for locomotion on and off the unit.She required extensive assistance of one person for dressing, toileting and personal hygiene. She required limited assistance of one person for eating. It indicated the resident did not have any behaviors. B. Record review The behavior care plan, initiated on 8/10/22 and revised on 5/24/23, revealed Resident #47 had potential behavior problems. Resident #47 had a history of being physically aggressive related to her diagnosis of dementia. Resident #47 had a history of sexual behaviors towards other females and males. Resident #47 responded to redirection from Spanish speaking staff. The interventions included: analyzing the times of day, places, circumstances, triggers, and what de-escalated behavior and document, providing physical and verbal cues to alleviate anxiety, giving positive feedback, assisting verbalization of source of agitation, assisting to set goals for more pleasant behavior, encouraging seeking out of staff member when agitated, giving the resident as many choices as possible about care and activities, monitoring and documenting any signs or symptoms of resident posing danger to self and other and intervening before agitation escalates by guiding the resident away from the source of distress and engaging in calm conversation, III. Resident #40 A. Resident status Resident #40, age 70, was admitted on [DATE]. According to the July 2023 CPO the diagnoses included Alzheimer's disease, vascular dementia with behavioral disturbance and post-traumatic stress disorder (PTSD). The 7/11/23 MDS assessment revealed the resident had severe cognitive impairment with a brief interview for mental status (BIMS) with a score of seven out of 15. She required supervision of one person for bed mobility and locomotion off the unit. She required limited assistance of one person for transfers. She required supervision of two people for walking in her room and walking in the corridor. She required supervision with set-up assistance for locomotion on the unit and eating. She required extensive assistance of one person for dressing and personal hygiene. She was totally dependent on two staff for toileting. The MDS assessment documented the resident had physical and verbal behaviors directed towards others one to three days in the review period. She did not have physical or behavior symptoms not directed at others. B. Record review The cognitive impairment care plan, initiated on 7/20/21 revealed Resident #40 had impaired thought processes related to dementia. Resident #40 was often confused and forgetful. The interventions included: administering medications as ordered, asking yes or no questions in order to determine the resident's needs, communicating with the resident and family regarding the residents capabilities and needs, using the residents preferred name, identifying yourself during each interaction, reducing any interactions, cueing and reorienting the resident as needed, supervising the resident as needed, presenting one thought, idea, questions or command at a time, providing a program of activities that accommodates the resident's abilities and usingtask segmentation to support short term memory deficits. The behavior care plan, initiated on 8/23/21 and revised on 7/11/23 (during the survey process) revealed Resident #40 had behavior concerns related to her diagnosis of dementia with behaviors. Resident #40 had a history of being verbally aggressive towards others when they were in her room or around her baby dolls. Resident #40 had a history of refusing cares. Resident #40 preferred to wash her feet in the sink per her cultural preferences. Resident #40 had a history of refusing to eat unless her food was presented in plastic bags. Resident #40 had a history of becoming easily agitated over her own personal space in the common areas and could escalate to physical aggression. Resident #40 had a history of sitting and lying on the fall mat next to her bed per her choice. Resident #40 had a history of refusing housekeeping services. The interventions included: administering medications as ordered, allowing the resident to make decisions about treatment to provide her sense of control, anticipating and meeting the residents needs, providing the opportunity for positive interactions, encouraging participation by the resident during cares, explaining all procedures to the resident before starting, intervening as necessary to protect the rights and safety of others, providing a program of activities that were of interest and accommodated the resident's status, offering music to the resident, providing redirection during times of agitation and offering the same spot in the dining room for all meals. IV. Staff interviews Licensed practical nurse (LPN) #1 was interviewed on 7/12/23 at 3:40 p.m. LPN #1 said Resident #47 often wandered around the unit and took other residents' personal belongings. LPN #1 said Resident #40 did not like other residents near or touching her belongings. LPN #1 said she knew Resident #47 and Resident #40 had an altercation and she attempted to keep the two residents separated. The SSD was interviewed on 713/23 at 10:04 a.m. The SSD said she was not a witness to the resident to resident altercation on 6/23/23. The SSD said she helped move Resident #40 to a different room. The SSD said Resident #40 and Resident #47 both had a history of physical aggression towards others, but had not had physical aggression directed at each other previously. The activities director (AD) was interviewed on 7/13/23 at 11:43 a.m. The AD said she spent a lot of time with Resident #47. The AD said she was not aware that Resident #40 and Resident #47 had a resident to resident altercation. The clinical resource nurse (RCR) and NHA #1 were interviewed on 7/13/23 at 12:46 p.m. NHA #1 said Resident #47 grabbed Resident #40's arm. NHA #1 said Resident #40 then punched Resident #47 and Resident #47 pulled Resident #40's hair. NHA #1 said a housekeeper and Resident #47's guardian witnessed the altercation. NHA #1 said Resident #40 and Resident #47 were placed on 15 minute safety checks. NHA #1 said they were unable to find documentation that the 15 minute safety checks had been completed. NHA #1 said she would begin educating all staff on documenting 15 minute checks when they were implemented. The RCR said skin assessments were completed. The RCR said Resident #40 and Resident #47 did not sustain injuries from the altercations. NHA #1 said the facility substantiated that the altercation occurred. NHA #1 said the facility was unable to prove willfulness due to the residents' diagnoses of dementia, therefore abuse was unsubstantiated. 19262 VI. Incident of physical abuse between Resident #27 and #12 A. Incident report The facility incident report dated 7/10/23 at 8:26 p.m., identified Resident #27 was walking by Resident #12. Resident #12 thought that Resident #27 was going to step on his foot. Resident #12 stood up and pushed Resident #27 down. Resident #27 received a hematoma to his right forehead and had a small amount of blood from his nose. Resident #27 did not lose consciousness and picked himself up from the floor. Resident #27 was not able to describe the incident. The resident was not in any pain and did not realize what had happened. The resident was confused, had impaired memory and dementia. The facility received physician orders to send him to the hospital emergency department for evaluation with a computerized tomography (CT) scan. The families of both residents were notified. The investigation reported to the state reporting portal revealed the incident occurred on 7/10/23 at 9:00 p.m. The incident was witnessed by two staff members. Resident #27 was anxiously walking down the front hallways of the unit at 9:00 p.m. He was pacing to each door down the hallways. Resident #12 sat in a chair in the common area by the front nurse's station, when Resident #27 accidently stepped on Resident #12's toes. Resident #12 cried out that this hurt, stood up and pushed Resident #27. This caused Resident #27 to fall to the floor. Resident #27 stood up and started to interact with staff. The charge registered nurse (RN) observed a cut to Resident #27's upper right forehead, just above the eyebrow and edema to the right eye. The resident's vital signs were taken and within normal limits. The resident appeared to be at his baseline (normal) status. Resident #27 was moved away from Resident #12 by the floor staff and emergency services. The floor staff de-escalated Resident #12 by talking to him. Resident #12 sat back down in a chair and no aggressive behaviors were observed. There were no other residents in the common area at this time, due to lateness of the hour. Resident #27 was taken to the hospital by the paramedics. Resident #12 was interviewed immediately after the event and was unable to recall any events. He asked if he could help Resident #27 get up from the floor. He did not verbalize any injuries, pain and he felt safe. Resident #12 was placed on 15-minute checks and per his preference, he remained in his room. The resident was offered activities, snacks and beverages on a regular basis. The police were notified and a case number was assigned. The conclusion of the investigation revealed, this event was substantiated and injuries were observed. When it occurred to the willful actions of Resident #12, there needed to be an understanding of the resident's current significant change in his medical condition. In June 2023 the resident had a newly developed squamous cell carcinoma protruding from his left cheek. The staff observed that the resident had become increasingly guarded in his behaviors to his immediate surroundings. The resident has been admitted to hospice services due to his rapid decline. The facility's medical director (MD) felt that this event was more of a medical issue rather than an outward behavior issue. B. Resident interviews by staff The charge registered nurse (RN) interviewed Resident #12 on 7/10/23 at 9:45 p.m. The resident was unable to recall what had happened and asked if he could help Resident #27 from off the floor. He said he had no pain or injuries. He said he felt safe in the facility. NHA #1 interviewed Resident #27 on 7/11/23 at 7:00 a.m. The resident was unable to tell the NHA what had happened. He said he was not injured and he had a little bit of pain in his chest area. He said he always felt safe in the facility. C. Charge RN typed phone statement Typed charge RN statement to the NHA #1 dated 7/10/23 at 9:08 p.m., during a phone conversation, the RN said Resident #27 was walking back and forth due to being more anxious and he stepped on Resident #12's foot. Resident #12 yelled out that this hurt, stood up form a chair and shoved Resident #27. Resident #27 fell to the ground, his head and then got up from off the floor. Resident #27 had a cut on his right frontal area and his vital signs were within normal limits. This RN and a certified nurse aide (CNA) de-escalated Resident #12 and he sat back down in a chair. The residents were a good distance from each other at this time. An ambulance was notified immediately related to the hematoma to Resident #27's head. Resident #27 was neurologically intact. The DON, NHA, physician, police and emergency services were notified and a police case number was assigned to this event. D. Abuse Investigation Statements Abuse Investigation Statements (AIS) dated and signed on 7/10/23 at 10:30 p.m., by a RN, revealed she witnessed the event. The RN last provided cares to Resident #27 at 8:30 p.m. during medication administration. The RN overheard Resident #12 say ouch that hurt my foot to Resident #27, who had accidently stepped on Resident #12's foot. Resident #12 impulsively pushed Resident #27 which caused him to fall and hit his head. This resulted in a right forehead hematoma, ecchymosis, and periorbital edema to the right eye. She saw Resident #12 push Resident #27 which caused him to fall and hit his head. Resident #27's vital signs were taken and a neurological assessment was started. Emergency services was called to take Resident #27 to the hospital for evaluation. She wrote that both residents had advanced dementia with behaviors. Abuse Investigation Statement (AIS) dated and signed on 7/10/23 at 10:30 p.m., by a CNA, revealed she witnessed the event. The last time she provided care to Resident #27 was at 6:30 p.m., while taking vital signs. The CNA heard Resident #12 yelling at Resident #27 for stepping on his toes. Resident #12 proceeded to stand up from a chair and push Resident #27 to the ground. She witnessed Resident #27 fell and hit his head causing a hematoma on the right side followed by a light nose bleed. The residents were separated and vital signs were taken on Resident #27. VII. Resident #12 A. Resident status Resident #12, age 92, was admitted to the facility on [DATE] and readmitted on [DATE]. According to the July 2023 CPO, the diagnoses included dementia and unspecified severity with other behavioral disturbances, squamous cell carcinoma (cancer) of the face and exophthalmos (protrusion of the eye). The 5/15/23 MDS assessment revealed the resident had severe cognitive impairment with a BIMS score of six out of 15. The resident had disorganized thinking. The resident's thinking was disorganized or incoherent (rambling or irrelevant conversation, unclear or illogical flow of ideas, or unpredictable switching from subject to subject). This behavior was present and fluctuated (came and went, changed in severity). The resident had hallucinations (perceptual experiences in the absence of real external sensory stimuli). The resident had delusions (misconceptions or beliefs that are firmly held, contrary to reality). The resident had physical behavioral symptoms directed towards others (hitting, kicking, pushing, scratching, grabbing, abusing others sexually). This behavior occurred one to three days during the seven-day assessment. The resident had verbal behavioral symptoms directed towards others (threatening others, screaming at others, cursing at others). This behavior occurred one to three days during the seven-day assessment. The resident wandered. This behavior occurred one to three days during the seven-day assessment. The staff provided limited assistance for dressing, toileting, and personal hygiene. The staff provided supervision for bed mobility, transfers, and eating. The resident received antipsychotic medications on a routine basis, for seven consecutive days during the assessment period. B. Resident observation Resident #12 was observed seated on his bed on 7/13/23 at 1:20 p.m. He had a bed over table in front of him and his lunch was on the table. He wore white socks on both feet and his shoes were to the left of the bed, on the floor. He said the food was good and he was having a good day. The door to the room was partially open and he was the only person in the room. C. Record review Physician order dated 12/15/22 at 1:24 p.m., revealed that the resident was to reside at the facility (secure unit) due to a history of wandering and would not be able to find his way back. A least restrictive alternative would be unsuccessful in preventing wandering. The resident could have behaviors that might be disruptive to himself and others. He would benefit with a more structured environment. The resident had a diagnosis of dementia. Care plan for impaired thought processes related to dementia was initiated on 9/10/21 and revised on 7/11/23 (during the survey), revealed the resident was often confused and forgetful. The resident did not like others to walk in front of him or beside him. The resident thought that others might step on and/or roll over his toes. The pertinent interventions included to administered medications as physic ordered (9/10/21), keep the resident's routine consistent and try to provide consistent care givers as much as possible in order to decrease confusion (9/10/21) and encourage the resident to sit out of the way of wheelchairs (7/11/23). Care plan for concerns regarding dementia was initiated on 9/10/21 and revised on 5/21/23. The resident had a history of physical aggression toward others and staff were to redirect him to a [NAME] space was helpful at times. The resident had a history of delusions and hallucinations of being back in the Navy. Facility staff were to redirect him to a less stimulated location, which might be helpful. He had a history of unpredictable outbursts that were not triggered at times. The pertinent interventions dated 9/10/21 revealed to administer medications as physician ordered, allow the resident to make decisions about treatment regime to provide a sense of control, anticipate and meet the resident's needs, intervene as necessary to protect the rights and safety of others, approach and speak in a calm manner, remove the resident from a situation and take to an alternate location as needed. Nurse note dated 7/9/23 at 10:25 a.m., by the director of nursing (DON) revealed the on call for (manage care provider) was contacted by a facility nurse voicing a concern that the morning dose of Seroquel (antipsychotic medication) was not helping the resident with his new aggressive behaviors towards others. The resident had an appointment with (the managed care provider) on 6/27/23 regarding the cancer that was reoccurring on his left check that had become quite large. With the resident's dementia, it was hard to tell if he was in pain and creating new anxieties. The on call was not listening to the nurse and ordered more Seroquel that made him lethargic. A message was sent to another physician in relation to this concern. The resident's family was aware of the cancer and wanted the resident to be comfortable. The resident had new behaviors of being aggressive to residents in the halls with fists up and telling them to get to work or to not walk here. The resident was not redirectable, which was new for him. Incident note dated 7/10/23 at 10:57 p.m., by the DON revealed this resident was seated in the hallway, when another resident walked by. The resident's perception was that the other resident was going to step on his foot. Resident #12 pushed Resident #27 and Resident #27 fell on his forehead. Resident #12 did not recall what happened due to his dementia. The resident's family was notified, as well as his physician. Resident #12 had frequent outbursts and did have Ativan available. Resident #12 has a new cancer growth on the left side of his face. Resident #12 was ambulatory, but has been more confused lately. Nurse note dated 7/10/23 at 11:12 p.m., by the DON revealed that 15 minute checks were in progress for Resident #12 and both of the residents were separated in different halls. Resident #12's was started on 7/10/23 at 8:30 p.m., and continued during the survey. VIII. Resident #27 A. Resident status Resident #27, age 70, was admitted to the facility on [DATE]. According to the July 2023 CPO, the diagnoses included dementia and unspecified severity with other behavioral disturbances, depression, epilepsy and muscle weakness. The 6/16/23 MDS assessment revealed the resident had both short and long term memory problems. The resident was severely impaired with cognitive skills for daily decision making. The resident had an acute onset mental status change as evidenced by an acute change in mental status from the resident's baseline. The resident had inattention with difficulty focusing his attention; for example, being easily distractible or having difficulty keeping track of what was said. This behavior was continuously present, and did not fluctuate. The resident had disorganized thinking or incoherent (rambling or irrelevant conversation, unclear or illogical flow of ideas, or unpredictable switching from subject to subject). This behavior was continuously present, and did not fluctuate. The resident required extensive staff assistance for bed mobility, transfers, dressing, toileting and personal hygiene. B. Record review Care Plan for impaired cognition function with dementia or impaired through process related to dementia was initiated on 2/15/23 and revised on 6/22/23. The interventions included to administer medications as physician ordered, monitor for mediation side effects/effectiveness, ask yes or no questions to determine resident needs, and cue/reorient/supervise as needed. Care plan for exhibiting behavior problems due to a history of wandering into others' rooms and responding with physical aggression when asked to leave related to a diagnosis of dementia was initiated on 2/15/23 and revised on 5/4/23. The resident was a security guard for his career and would check all doors daily to ensure all were safe and secure. Staff intervention, redirection or distraction might be helpful. Staff were to offer the resident a binder with papers to look through, activities, and items to sort; this might help. The pertinent interventions were to administer medications as physician ordered, monitor for mediation side effects/effectiveness, create an activity binder for him, because he liked to look at binders related to his old job, provide an afternoon sitter for the resident's high anxiety and wandering when other residents were out in the hallways, if the resident became agitated the staff were to intervene before he agitation escalated, guide the resident away for the source of distress, staff were to calmly engage the resident in conversation and if his response was aggressive; the staff were to walk away calmly and approach later, staff were to divert his attention, staff were to remove the resident from the situation and take him to an alternate location as needed and intervene as necessary to protect the rights/safety of others. eINTERACT situation background, assessment recommendation (SBAR) note dated 7/10/23 at 10:14 p.m., by the DON revealed the change of condition was due to a fall. Resident #27 walked by Resident #12 who thought the resident was going to step on his foot. Resident #12 stood up and pushed Resident #27 down. Resident #27 received a hematoma to his right forehead and a small amount of blood came from his nose. Resident #27 did not lose consciousness and picked himself off the floor. Physician orders were received to send Resident #27 to the emergency room for evaluation with a CT scan. Families of both residents were notified. Incident note by the DON dated 7/10/23 at 10:33 p.m., revealed Resident #27 was walking by Resident #12 and Resident #12 through Resident #27 was going to step on his foot. Resident #12 stood up and pushed Resident #27 down. Resident #27 received a hematoma to his right forehead and a small amount of blood came from his nose. Resident #27 did not lose consciousness and picked himself off the floor. Physician orders were received to send Resident #27 to the emergency room for evaluation with a CT scan. Families of both residents were notified. Fall risk assessment dated [DATE] at 10:33 p.m., revealed a score of score of 11 or high risk. Pain assessment dated [DATE] at 10:40 p.m., revealed no indicators of pain were observed. Head to toe skin assessment dated [DATE] at 10:41 p.m., revealed a right forehead hematoma. Nurse note dated 7/10/23 at 11:10 p.m., by the DON revealed Resident #27 returned from the emergency room by stretcher and the paramedics stated the CT scan was negative. The resident had a hematoma to the left (should be right) forehead and eye black. The resident was alert and his baseline dementia. The resident did not present with pain and was smiling. The hospital CT scan dated 7/10/23 revealed the reason for the scan was facial trauma with a right frontal scalp hematoma. There was no acute intracranial abnormality or fracture. The resident's right frontal encephalomalacia (softening of the brain's tissue) was stable. Nurse note dated 7/10/23 at 11:12 p.m., by the DON revealed neurological assessments were in place upon the resident's return to the facility. Physician order dated 7/10/23 at 2:13 a.m., may transfer to the emergency room for CT scan and evaluation. Social services note dated 7/11/23 at 3:54 p.m., by the social services director (SSD) revealed Resident #27 was interviewed today and did not recall the event. He said he felt safe and had no nonverbal signs/symptoms of fear at this time. Staff would continue to monitor. Nurse note by the DON dated 7/11/23 at 6:41 p.m., revealed the resident had a hematoma to right forehead and right eye black. There was no further swelling observed and the resident was ambulating well. Nurse note dated 7/12/23 at 4:47 a.m., by an RN revealed the resident was awake for the majority of the night. He was ambulating back and forth nonstop. He had a right forehead hematoma that remained unchanged. He had ecchymosis (discoloration of skin usually due to bleeding) to the right eye. The resident denied pain. The resident was cooperative and redirectable throughout the shift. IX. Staff interviews The DON and the assistant director of nursing (ADON) were interviewed on 7/12/23 at 3:07 p.m. The DON said Resident #12 had depth perception issues. She said when you passed him, he thought you were right on top of him and he became very anxious and started yelling. She said this was the reason the facility placed a plant in the corner of the hall (by the chairs) to try to get residents to go around him a little further distance, so he would perceive they were not going to step on him. The DON said she was in her office at the time of the altercation. She said Resident #12 was seated in a chair (third chair from the door) in the common area by the nurse's station. She was unable to see this area because she was in her office. She said she heard the yelling Ow, get away from me and heard Resident #27's head hit the floor. The DON said herself, the RN and CNA both heard him yelling out and quickly went to see what was going on. She said Resident #27 was on his right side on the floor and his right eye was starting to swell. Resident #12 was standing over Resident #27 and was not exhibiting any threatening behaviors. Resident #27 was trying to get up, and we kept him on the floor during the assessment. The CNA took Resident #12 back to his room. The RN called 911, Resident #27's physician and family. The decision was made to send the resident to the hospital based on the swelling on his head. He was at his usual baseline and did not lose consciousness. Resident #27 got up from off the floor and was assessed by the paramedics. The resident was taken to the emergency room at the hospital for evaluation of a possible head injury related to the swelling on his head was getting bigger. The CT scan from the hospital was negative for fractures. The DON said Resident #12 had a lot of misperception and anticipated that people were going to step on his feet when they got too close, reacted accordingly, became very anxious about it and yelled out. She said the resident was pretty calm during the day and became more anxious in the evening. The DON said Resident #27's care plan intervention to an afternoon sitter was initiated at admission related to some behavioral issues and the adjustment of his medications. He did not have a sitter at this time and this should have been discontinued. She said Resident #27 was a lot calmer at this time. The SSD was interviewed on 7/13/23 at 10:36 a.m. She said Resident #12 had cancer on his face and did not like people in his space. She said his vision and depth perception were diminished. The resident saw objects closer than they were. She said when people walked near him, he feared that they were too close and would step on his toes or bump into him. She said he thought people were disrespecting him by being too close to him and he could be territorial. NHA #1, CRN and regional director of rehabilitation (RDR) were interviewed on 7/17/23 at 9:30 a.m. They said Resident #27 received a right frontal scalp hematoma for the altercation with Resident #12. NHA #1 said Resident #27 and Resident #12 have not expressed or demonstrated any fears regarding any residents or staff. NHA #1 said Resident #27 was unable to recall the event. NHA #1 said Resident #12 did not know he had pushed a resident down and did offer to help pick Resident #27 from off the floor. NHA #1 reviewed Resident #27's care plan intervention that was initiated on 4/4/23, which revealed that an afternoon sitter was to be provided for the resident's high anxiety and wandering at times when other residents are out and about. NHA #1 said afternoon was interpreted as 2:00 p.m., to 6:00 p.m. NHA #1 said the incident occurred around 8:00 p.m. NHA #1 said this intervention needed to be discontinued. NHA #1 said to her knowledge, there had not been any other incidents between these two residents. NHA #1 and the CRN were interviewed on 7/13/23 at 2:36 p.m. NHA #1 said this was a witnessed event on 7/10/23 at approximately 8:00 p.m., by the charge RN on the night shift and a CNA. Resident #27 was pacing and was anxious that night and was making his rounds down the hallways. He was a night security guard as part of his work history. Resident #12 was seated in a chair in the fro[TRUNCATED]

Based on observations, record review and interviews, the facility failed to ensure residents were as free from unnecessary psychotropic drugs as possible for one (#14) of five residents reviewed out of 27 sample residents. Specifically, the facility failed to: -Consistently track behaviors to justify the use of an antipsychotic medication for a resident with dementia for Resident #14; and, -Attempt an annual gradual dose reduction (GDR) of an antipsychotic medication for a resident with dementia, as is required unless it is clinically contraindicated, for Resident #14. Findings include: I. Facility policy and procedures The Psychotropic Medication Use policy, revised July 2022, was provided by the director of nursing (DON) on 7/13/23 at 3:30 p.m. It read in pertinent part, Residents will not receive medications that are not clinically indicated to treat a specific condition. A psychotropic medication is any medication that affects brain activity associated with mental processes and behavior. An antipsychotic medication is considered a psychotropic medication and is subject to prescribing, monitoring, and review requirements specific to psychotropic medications. Psychotropic medication management includes indications for use, dose, duration, adequate monitoring for efficacy and adverse consequences and prevention, identifying and responding to adverse consequences. Consideration of the use of any psychotropic medication is based on comprehensive review of the resident. This includes evaluation of the resident's signs and symptoms in order to identify underlying causes. Residents on psychotropic medications receive gradual dose reductions unless clinically contraindicated, in an effort to discontinue these medications. II. Resident #14 Resident #14, age younger than 65, was admitted on [DATE] and readmitted on [DATE]. According to the July 2023 computerized physician orders, diagnoses included alcohol-induced dementia and dementia with behavioral disturbance. The 6/20/23 minimum data set (MDS) assessment revealed that the brief interview for mental status (BIMS) was not assessed because the resident was rarely understood. The staff assessment for mental status revealed the resident had a problem with short and long term memory and his cognitive skills for daily decision making were severely impaired. He required supervision with bed mobility. He required one-person extensive assistance for transfers. He was totally dependent on one staff member for dressing, toilet use and personal hygiene. Resident #14 did not exhibit any potential indicators of psychosis such as delusions or hallucinations. He did not exhibit any physical or verbal behaviors, rejection of cares during the seven day MDS assessment look-back period. He exhibited wandering behaviors daily during the seven day MDS assessment look-back period. He received an antipsychotic medication daily. III. Observations On 7/10/23 at 11:48 a.m., Resident #14 was sitting in the dining room at a table. There was a female resident sitting at the table next to him. He had a bag of chips in his hand. He was busy crushing some chips in his hand. He appeared to be content and was not exhibiting any aggression or behaviors other than crushing the potato chips. On 7/11/23 at 12:07 p.m., Resident #14 was wandering in the halls of the secure unit. He was not exhibiting any behaviors or aggression toward other residents or staff members. On 7/12/23 at 2:23 p.m., Resident #14 was again wandering in the halls of the secure unit. He was calm and was not exhibiting any behaviors or aggression toward other residents or staff members. C. Record review Review of Resident #14's July 2023 CPO revealed a physician's order for Risperdal (an antipsychotic medication) tablet 1 milligram (mg). Give 1.5 tablets by mouth one time a day for alcohol related dementia with behaviors. The order had a start date of 4/18/22. Review of Resident #14's history of physician orders for Risperdal revealed the resident was initially started on Risperdal 1 mg on 12/3/19. The medication was increased to 1.5 mg on 3/10/21. The facility attempted a gradual dose reduction (GDR) of the medication by reducing the medication to 1.5 mg on Monday, Tuesday, Wednesday, Thursday, Friday and Saturday and 1 mg on Sundays on 2/3/22. The facility documented the GDR failed and the resident was restarted on 1.5 mg of the medication daily on 4/18/22. -There had been no other GDRs for the medication, as is required annually unless it is clinically contraindicated, since 4/18/22. Review of Resident #14's antipsychotic medication use care plan, initiated 2/23/21 and revised on 11/4/22, revealed the resident received antipsychotic medications for alcohol related dementia with behavioral disturbance. Pertinent interventions included consulting with pharmacy and physician to consider dosage reduction when clinically appropriate at least quarterly, monitoring for behavior associated with antipsychotic medication due to dementia with behaviors such as unprovoked physical aggression, verbal aggression toward others and repetitive speech and using non-pharmacological interventions such as redirection, repositioning, offering snacks, offering fluids, adjusting room temperatures and distraction/offering activities. Resident #14's medication administration records (MAR) were reviewed for 1/1/23 through 7/12/23. The MARs revealed the following: -January 2023: There were no behaviors documented for the entire month; -February 2023: There were no behaviors documented for the entire month; -March 2023: There were no behaviors documented for the entire month; -April 2023: There were no behaviors documented for the entire month; -May 2023: There were no behaviors documented for the entire month; -June 2023: There were no behaviors documented for the entire month; and, -July 2023: There were no behaviors documented for the entire month. -The facility did not attempt a GDR despite the MARs documenting the resident did not have any behaviors documented from 1/1/23 through 7/12/23. -Review of the certified nurse aide (CNA) behavior documentation from 6/14/23 through 7/13/23 revealed there was no behavior documentation completed by the CNAs for Resident #14. Review of Resident #14's electronic medical record (EMR) revealed a behavior note dated 3/21/23. The progress note read in pertinent part, Resident was observed urinating in the hallway next to the nurses station. Staff was able to redirect and get the resident to his room and changed. -There were no other progress notes regarding behaviors documented from 1/1/23 through 7/12/23. The quarterly IDT Psychotropic Medication Review assessment dated [DATE] documented Resident #14 was on the antipsychotic medication Risperdal and had a failed GDR on 4/18/22. The behavior review documented in pertinent part, (Resident #14) has a history of interacting with hallucinations. Staff continues to monitor and follow up as needed. -The review did not document that the resident was continuing to experience hallucinations or exhibit aggressive behaviors. A Psychotropic Medication Review Risk versus Benefit form dated 3/9/23 documented the following in pertinent part as a rationale for not conducting a GDR of Resident #14's Risperdal, Improved quality of life and history of hallucinations. -The form was not signed by the physician. -There was not a clinically contraindicated rationale for why any attempted dose reduction at that time would be likely to impair the resident's function or exacerbate an underlying medical or psychiatric disorder. Review of Resident #14's EMR revealed the following provider visit notes documented by the nurse practitioner (NP) in pertinent part: 3/9/23 Resident is seen today for follow up. Resident has a diagnosis of dementia with behaviors. Discussed resident in psychotropic/pharmacy meeting and recommendations. No changes in current Risperdal dose because he has failed a previous GDR. Will continue to monitor. -The NP did not document a clinically contraindicated rationale for why any attempted dose reduction at that time would be likely to impair the resident's function or exacerbate an underlying medical or psychiatric disorder. 5/4/23: Resident is seen today for follow up. Resident has a diagnosis of dementia with behaviors. Stable mood and no behaviors reported on current medications. Continue current medications at current dose and schedule. Will continue to monitor. -The NP did not document a clinically contraindicated rationale for why any attempted dose reduction at that time would be likely to impair the resident's function or exacerbate an underlying medical or psychiatric disorder. 6/8/23: Resident is doing well and has a stable mood with no behaviors on his current medications. His quality of life is improved on his current dose of Risperdal and the benefits outweigh the risks with him taking the medication. -The NP did not document a clinically contraindicated rationale for why any attempted dose reduction at that time would be likely to impair the resident's function or exacerbate an underlying medical or psychiatric disorder. Review of Resident #14's EMR revealed a provider visit note dated 6/19/23 documented by the physician. It read in pertinent part: Resident is doing well and has a stable mood with no behaviors on his current medications. His quality of life is improved on his current dose of Risperdal and the benefits outweigh the risks with him taking the medication. -The physician did not document a clinical rationale for why any attempted dose reduction at that time would be likely to impair the resident's function or exacerbate an underlying medical or psychiatric disorder. C. Interviews Licensed practical nurse (LPN) #2 was interviewed on 7/11/23 at 1:25 p.m. LPN #2 said she had never seen Resident #14 exhibit any behaviors. She said he was not aggressive with other residents and did not become agitated when staff provided him with cares. LPN #2 said the resident was easily redirectable when he was near the exit doors and did not become aggressive. LPN #1 was interviewed on 7/12/23 at 11:13 a.m. LPN #1 said Resident #14 did not have any behaviors. She said he would wander in the hallways, however, she said she had never seen him become aggressive with staff or other residents. The DON and the assistant director of nursing (ADON) were interviewed together on 7/12/23 at 3:30 p.m. The ADON said Resident #14 did not exhibit any aggressive behaviors. She said she had not seen him have any hallucinations or delusions. She said the resident wandered but was easy to redirect if the need to redirect him arose. The DON said GDRs should be attempted for all psychotropic medications. She said if a resident exhibited behaviors, staff should be documenting those behaviors on the MAR and in the progress notes. She said if there were no behaviors documented for the resident there was no justification to keep him on the same dose of antipsychotic medication. She said a GDR should have been attempted again for Resident #14. The DON said she would discuss the need for a GDR for the resident's Risperdal with the physician and the interdisciplinary team (IDT) at the next psychotropic medication review meeting which was scheduled for 7/13/23. Certified nurse aide (CNA) #1 was interviewed on 7/13/23 at 1:42 p.m. CNA #1 said Resident #14 did not have behaviors. She said he would wander on the unit and constantly pace, however, she said she had never seen him display any aggression toward other residents. CNA #1 said the resident occasionally resisted cares, however, she said if he was left alone for a few minutes staff could come back and he would allow them to finish his cares. She said he was very redirectable and easy to take care of.

Based on observation, record review, and interviews, the facility failed to ensure residents were free from resident-to-resident abuse for four residents (#1, #2, #3 and #4) of six residents reviewed out of eight sample residents. Specifically, the facility failed to prevent: -Resident #1 from physical abuse from Resident #2. Resident #2 had documented aggressive behaviors prior to the incident with Resident #1 on 2/19/23; and, -Resident #3 from physical abuse from Resident #4. Resident #4 had documented aggressive behaviors prior to the incident with Resident #3 on 2/28/23. Findings include: I. Resident census and conditions demographic The Resident Census and Condition was provided by the nursing home administrator (NHA) on 3/20/23 at 9:00 a.m. It revealed in pertinent part that 50 residents resided in the facility,44 of the 50 residents had dementia; 28 of the 50 residents had behavioral healthcare needs. The facility had two secured units. The secured units were called the front unit which had all male residents. The other unit was called the back unit which had men and women residents. II. Professional reference According to the Centers for Disease Control (CDC) website, Preventing Elder Abuse https://www.cdc.gov/violenceprevention/elderabuse/fastfact.html 6/2/21, (Retrieved 3/27/23), Elder abuse is an intentional act or failure to act that causes or creates a risk of harm to an older adult. Common types of elder abuse include: physical abuse, sexual abuse, emotional or psychological abuse, neglect and financial abuse. Physical abuse is when an elder experiences illness, pain, injury, functional impairment, distress, or death as a result of the intentional use of physical force and includes acts such as hitting, kicking, pushing, slapping, and burning. III. Facility policy and procedure The Abuse, Neglect, Exploitation, and Misappropriation Prevention Program policy and procedures, not dated, was provided by the nursing home administrator (NHA) via email on 3/23/23 at 8:27 a.m. It revealed in pertinent part, Residents have the right to be free from abuse, this includes but is not limited to physical abuse. The resident abuse, neglect and exploitation prevention program consists of a facility wide commitment and resource allocation to support the following objectives: Protect residents from abuse, neglect, exploitation or misappropriation of property by anyone including, but not necessarily limited to: other residents. IV. Physical abuse between Resident #1 and Resident #2 The 2/19/23 facility incident report which involved Resident #1 and Resident #2 was provided by the NHA on 3/20/22 at 11:00 a.m. It revealed in pertinent part, On 2/19/23 Resident #1 was seated in the facility dining room. The staff observed Resident #2 push Resident #1 from his chair. (The NHA interview below said Resident #2 stood over Resident #1 and pushed him down into his chair while he tried to stand up). The report read Resident #1 and #2 were unable to provide interviews because of their diagnosis of dementia. The report documented that staff were interviewed about the incident and educated. The facility was unable to provide any staff interviews or any type of education provided to the staff after the incident. The facility documented that because both Resident #1 and Resident #2 had a diagnosis of dementia, and because of their inability to understand the outcomes, the facility was unable to find the allegation of abuse substantiated. -However, the physical abuse should have been substantiated due to the willful action of Resident #2 push Resident #1. Interventions after the physical abuse: Resident #1 had no changes/interventions implemented after the altercation. Resident #2 would be provided with continued education (although facility documented due to dementia he could not recall the incident) and he would be provided with alternate places to sit in the dining room. -Staff were to be educated on redirecting residents and their dining room seats, but the NHA said the facility was unable to provide proof of staff being educated after the incident. -The facility incident report left blank the section for remarks of any predisposing environmental factors, psychosocial factors, or situation factors about the incident. V. Resident #1 A. Resident status (victim) Resident #1, age 69, was admitted on [DATE]. According to the March 2023 computerized physician orders (CPO), the diagnoses included Alzheimer's disease, dementia with other behavioral disturbances, epilepsy and depression. The 3/7/23 minimum data set (MDS) assessment revealed the resident had severe cognitive impairment with a brief interview for mental status score of one out of 15. He required extensive assistance with toilet use, and personal hygiene. He was independent with bed mobility, transfers, walking in his room and corridors. He had inattention, was easily distractible, had unclear or illogical flow of ideas, and was unpredictable. He switched from subject to subject, had an altered level of consciousness, and startled easily to any sound or touch. The resident had delusions, misconceptions of beliefs that were firmly held contrary to reality. The resident did not reject care provided by staff. B. Record review The 6/17/22 and revised 1/10/23 comprehensive care plan revealed, Goal: Resident #1 had communication problems with his diagnosis of dementia. He needed staff to help anticipate some of his needs. He had a potential mood problem with a history of dementia with behaviors. He had a lack of situational safety awareness and personal space of others. He had invasive behaviors. Interventions: Staff were to be conscious of where Resident #1 sat when (he was) in groups, activities, and the dining room, to promote proper communication with others. He was to be spoken to on an adult level, spoken to clearly and slower than normal. Staff were to anticipate and meet his needs. -Staff were to intervene as necessary to protect the rights and safety of others. He was to be approached/spoken to in a calm manner. Divert attention (as needed). Remove him from (a) situation (s) and take to an alternate location as needed. - Attempt non-pharmacological interventions: 1. Redirect to (a) calm environment.2. Respond calmly. 3. Distract and redirect. 4. Use consistent direction to make calm changes gradually. (5. Was not listed) 6. Distract with calm conversation. 7. Offer simple explanations. 8. Modification of (the) environment. 9. Walking. 10 Responded well to positive statements. The certified nurse aide (CNA) communication/organization sheets to be used for resident care as of 3/21/23 (during survey) was provided by the corporate resource person (CRP) on 3/21/23 at 11:30 a.m. It revealed in pertinent part, -Ask yes/no questions in order to determine the resident's needs. -Communication: Allow adequate time to respond, repeat as necessary, do not rush, request clarification from the resident to ensure understanding. Use simple, brief, consistent words/cues. Use alternative communication tools as needed. -Cue, reorient, and supervise as needed. -Encourage him to continue stating thoughts even if he had difficulty. Focus on a word or phrase that makes sense, or responds to the feeling he was trying to express. -Use task segmentation to support short term memory deficits. Break tasks into one step at a time. VI. Resident #2 A. Resident status (perpetrator) Resident #2, age under 70, admitted [DATE], and readmitted [DATE]. According to the March 2023 computerized physician orders (CPO), the diagnoses included dysarthria (difficulty speaking following cerebrovascular disease), dementia with behavioral disturbances, cognitive communication deficit, restlessness and agitation. The 1/25/23 annual minimum data set (MDS) revealed the resident was cognitively intact with a brief interview for mental status score of 15 out of 15. The resident had delusions, misconceptions or beliefs that were firmly held, contrary to reality. He did not reject care provided by the staff. He was independent with bed mobility, transfers, walking in his room and corridors, eating, toilet use, and personal hygiene. B. Resident interview Resident #2 was interviewed on 3/20/23 at 12:00 p.m. He said he had never had an altercation with anyone in the facility. He said he was homeless and in prison and he got along with everybody. C. Record review The 6/17/22 and revised on 1/10/23 comprehensive care plan revealed, -The resident had a history of physical aggression. He wandered into others' personal spaces and/or room. Redirection was often helpful and effective. Interventions: (Staff were to) intervene as necessary to protect the rights and safety of others. Approach/speak (to) in a calm manner. Divert (his) attention. Remove (him) from situation and take to alternate location as needed. The 4/3/22 behavioral progress note revealed, Resident #2 became physically aggressive with a staff member during a supervised cigarette smoking session. He was told by a nurse that he could not hit staff or anyone else. The staff member reported the resident hit her glasses off her face and then Resident #2 attempted to step on the glasses while the glasses were on the floor, and then (he) began to flip the outside tables. The 4/26/22 physician note revealed the resident was seen by the physician because the resident had physical aggression. The resident had triggered episodes where he had flipped tables. The 12/2/22 physician note revealed the resident was seen by the physician because the resident was the aggressor and had an altercation with another resident. The 2/19/23 progress note documented by the director of nursing (DON), Thinks that chair is his and has done this in the past. Each time we explained to him and he is unable to comprehend. He has aggression issues. Staff saw him pick up the back of (Resident #1's) chair and tried to stop him but could not. Immediate action taken was to explain to the resident that there was not assigned seating, and everyone can sit where they want. He had done this same behavior in the past. The 2/20/23 progress note revealed, Resident #2 was observed to tip a chair over that another patient was sitting in. This behavior was unprovoked by (a) fell ow patient. The 2/20/23 DON progress note documented Resident #2 did not want someone to sit in his chair that he usually sat in. Resident #2 picked up the back of the chair (that Resident #1 was seated in) and slid the resident out of his chair. -The facility incident report documented Resident #1 was pushed from his chair by Resident #2. The DON documented Resident #2 picked up the back of Resident #1's chair and slid him out of it. The NHA said in an interview that Resident #2 pushed Resident #1's shoulders so that he would sit down in his chair and that he did not come out of his chair. The CNA communication/organization sheets to be used for resident care as of 3/21/23 (during survey) was provided by the CRP on 3/21/23 at 11:30 a.m. It revealed in pertinent part, -Monitor behavior episodes and attempt to determine underlying cause. Consider location, time of day, persons involved, and situations. Document behavior and potential causes. -If reasonable, discuss the resident's behavior. Explain/reinforce why behavior is inappropriate and/or unacceptable to the resident. -Intervene as necessary to protect the rights and safety of others. Approach/speak to in a calm manner. Divert attention. Remove from (the) situation and take to (an) alternate location as needed. VII. Staff interviews The director of nursing (DON) was interviewed on 3/20/23 at 9:00 a.m. She said the front unit area was where Resident #1 and Resident #2 lived and had only male residents. She said most of the men on the unit had some sort of domestic violence in their past. She said Resident #2 wanted Resident #1's chair in the dining room. She said the incident was witnessed by the staff. She said both residents in the incident had a diagnosis of dementia. She said the incident was witnessed by staff. She said she thought maybe the resident to resident physical abuse that happened was reported as unsubstantiated because if it was reported as substantiated it would go on an administrator's professional license. VIII. Physical abuse between Resident #3 and Resident #4 The 2/28/23 facility incident report which involved Resident #3 and Resident #4 was provided by the NHA on 3/20/23 at 11:00 a.m. It revealed in pertinent part, Resident #3 was seated in the dining room and Resident #4 slapped Resident #3 in the face. Due to both residents with a diagnosis of dementia and both were unable to recall the event, the facility was unable to find the allegation of abuse substantiated. The facility documented it was unable to identify abuse or intent to harm. (see CNA #2 interview below about the incident) -However, physical abuse should have been substantiated due to Resident #4 slapping Resident #3 in the face. -Agency registered nurse (ARN) #1 documented immediately after the incident that Resident #4 showed impulsive and aggressive behavior slapping Resident #3. ARN #1 did not document (left blank on the incident report) any predisposing environmental, physiological, physiological, and situation factors. IX. Resident #3 A. Resident status (victim) Resident #3, age over 90, was admitted on [DATE]. According to the March 2023 computerized physician orders (CPO), the diagnoses included Alzheimer's Disease, history of falling, and other specified depressive episodes. The 2/7/23 minimum data set (MDS) assessment revealed the resident was not assessed for a mental status score (BIMS). The resident had delusions, misconceptions or beliefs that were firmly held, contrary to reality. She had verbal behavioral symptoms directed towards others, threatening others, screaming at others, or cursing at others. She required extensive assistance with transfers, dressing, toilet use, and personal hygiene. The resident utilized a wheelchair. B. Record review The 11/2/22 and revised 11/22/22 comprehensive care plan revealed, -The resident received psychotropic medications for behavior management and depression. The 2/17/23 behavioral progress note revealed the resident was very agitated since lunch, yelling, and screaming in the hallway. It took multiple attempts to stabilize her mood by redirection and offering snacks. X. Resident #4 A. Resident status (perpetrator) Resident #4, age 70, was admitted on [DATE]. According to the March 2023 computerized physician orders (CPO), the diagnoses included dementia with behavioral disturbances, other specified depressive episodes, and epilepsy. The 2/8/23 minimum data set (MDS) assessment revealed the resident was not assessed for a brief interview for mental status score (BIMS). The resident had short and long term memory problems. He had severe impairment for cognitive skills for daily decision making. The resident had delusions, misconceptions or beliefs that were firmly held, contrary to reality. The resident had continual inattention, and disorganized thinking. He was independent with bed mobility, transfers, and walking in his room and corridors. He required extensive assistance with dressing, toilet use, and personal hygiene. Resident #4 was admitted to the facility on [DATE] to the front all male secured unit. On 2/24/23 Resident #4 was moved to the back secured unit where males and females resided. (See DON interview) After the incident on 2/28/23 the resident was moved again back to the all male front unit on 3/1/22. B. Record review On 2/2/23 the secured unit placement evaluation revealed that the resident was a serious danger to himself and others. He had significant behavior problems that seriously disrupted the rights of others. He had a history of wandering, physical and verbal aggression, and was exit seeking. The 2/15/23 and updated 3/6/23 comprehensive care plan revealed, -The resident had a history of physical aggression. Interventions: Intervene before agitation escalates. Intervene as necessary to protect the rights and safety of others. The 2/16/23 nurse practitioner (NP) progress note revealed the resident had a history of aggressive behaviors with violence towards other residents and staff. The CNA communication/organization sheets to be used for resident care as of 3/21/23 (during survey) was provided by the CRP on 3/21/23 at 11:30 a.m. It revealed in pertinent part, If the resident became agitated to intervene before agitation escalated, guide away from the source of distress, and engage calmly in conversation. Intervene as necessary to protect the rights and safety of others. Divert his attention. XI. Staff interviews The DON was interviewed on 3/20/23 at 1:30 p.m. She said Resident #4 had been at another facility in the area and had perpetrated physical abuse while he was there. She said Resident #4 went to the hospital from that local facility and then the facility refused to take him back. She said she made the decision to admit him because she believed with some medication management he could do well in the facility. She said he was admitted to the front all male secured unit due to his physically aggressive behavior. She said she made the decision to put him into the male/female secured unit because of the need for his bed with a new admission. She said that was the only reason she moved him. She said she thought because he wandered the hallway the back unit residents were more accustomed to that behavior. She said after he hit Resident #3 she then moved him back to the all male secured unit. She said the physical abuse situation was observed by CNA #2. ARN #1 was interviewed on 3/21/23 at 10:10 a.m. She said she was the charge nurse on duty on the back secured unit when the the incident happened between Resident #3 and Resident #4. She said she did not see anything and could not give any insight into the physical abuse that happened. She said she did fill out the report that day after the incident. She said CNA #2 saw it all and CNA #2 separated the two residents. She said she could not discuss the physical abuse that occurred because she did not see or hear anything. CNA #2 was interviewed on 3/21/23 at 2:27 p.m. She said she was the only who witnessed the physical abuse with Resident #3 and Resident #4. She said she was walking down the back secured unit hallway with Resident #4 who was pushing Resident #3 while she was in her wheelchair. She said she was overseeing Resident #4 as he pushed Resident #3's wheelchair. She said the three of them walked from the dining room and up a hallway which led to the nurse's station next to the secured doors. She said she began talking to another resident in the area and looked away from Resident #3 and Resident #4. She said when she looked back she saw Resident #4 slap Resident #3 across her face which knocked Resident #3's glasses to the ground. CNA #2 said she had surgery on her arm and was unable to separate the residents due to her limitations. She said the facility was aware of her physical limitations. She said the agency nurse (ARN #1) who was seated at the nurse's station in front of her, got up and separated the two residents. CNA #2 said she had only met Resident #4 one other time and did not know a lot about him. CNA #2 said she was unaware of his behaviors so that she could have prevented the situation. She said sometimes a resident would get a certain look in their face or eyes and that was how she knew if something was going to happen negatively. She said they were not in the middle of the dining room when this situation occurred. She said her dementia training was primarily online training with videos not hands on return demonstration training. She said she did the best she could to redirect residents after something went wrong. She said she did not receive training about Resident #3 and #4 after the incident. XII. Administrative interviews The CRP was interviewed on 3/21/23 at 11:00 a.m. She said she was aware that many years ago a resident's intent to do physical harm was considered but that was not the way the regulations read any longer. She said resident-to-resident physical abuse was witnessed by staff for both incidents with Resident #1 and Resident #2, and Resident #3 and Resident #4. Activity assistant (#2) was interviewed on 3/21/23 at 2:00 p.m. She said if she wanted to know how to work with any of the dementia residents she could ask other staff members. She said she took the required online video training that the company made all employees take. She said she had watched the required staff videos of dementia training to learn how to work with dementia residents. She said with some residents she could see their mood changes by the look in their eyes. She said the resident may look wild and that was how she knew they might get aggressive. She said Resident #4 sometimes had a cranky mood and if he did she kept her body at a distance from him. She said Resident #4 hit the plant supervisor (PS) after Resident #4 moved back to the all male unit about two weeks ago. The (PS) was interviewed on 3/21/23 at 2:50 p.m. He said about two weeks ago he was at the front door getting ready to go outside and do snow removal when Resident #4 came up to him. He said he told Resident #4 that he could not go outside because of the bad weather. He said, I didn't see it coming, Resident #4 used a closed fist and upper cut me under my chin. Bam, it was hard and it hurt. He said he did not anticipate that aggressive behavior with Resident #4. He said where he had previously worked the staff had hands-on training to learn how to handle people with dementia. He said at the facility they were only required to watch videos about dementia. He said he had never received any specific education about how to handle Resident #4. The NHA was interviewed on 3/21/23 at 4:00 p.m. She said she was the abuse coordinator for the facility. She said the incident report between Resident #1 and Resident #2 meant that Resident #2 used his hands and pushed on the shoulders of Resident #1 and made him sit down in his chair when he tried to stand up. She said Resident #1 was not pushed out of his chair. She said Resident #4 did slap Resident #3 on the back secured unit. She said both incidents involved physical aggression. She said she documented both incidents and reported them to the State Agency. She said both incidents which involved all four residents, were reported as unsubstantiated even though there were eyewitnesses to the resident-to-resident physical abuse. She said all four of the residents had dementia therefore they could not recall the physical abuse after the incidents occurred. She said even though the altercations did occur, all four residents had dementia, so she did not document that the two incidents were substantiated. She said she did not have documentation proof that any staff were educated after the two different incidents. She said she had no documented proof that the incidents were even discussed in a group huddle type education environment.

Based on record review and interviews, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice for one (#14) out of 15 total sample residents. Specifically, the facility failed to provide interventions timely and notify a physician when Resident #14 experienced a change of condition. Findings include: I. Facility policy and procedures The Emergency and/or Alternative Physician Care policy, last revised April 2013, was provided by the director of nursing (DON) on 10/29/2020 at approximately 6:38 p.m. It read in pertinent part: All residents shall be provided with emergency and/or alternative physician care. Should an emergency arise, and the resident ' s attending physician is not available, the emergency on-call physician must be contacted. The staff will follow designated protocols for evaluating and triaging medical symptoms and changes in condition and for gathering and reporting information to attending physicians and covering practitioners. The facility did not provide a policy specific to resident changes in condition. II. Resident #14 A. Resident status Resident #14, under the age of 80, was admitted [DATE] and readmitted on [DATE]. According to the October 2020 computerized physician orders [REDACTED]. The 9/10/2020 minimum data set (MDS) assessment documented the resident was cognitively intact with the brief interview for mental status score (BIMS) of 15 out of 15. He was independent with activities of daily living (ADLs). B. Record review The care plan dated 10/16/2014 and revised on 6/18/2020 documented the resident received oxygen therapy related to respiratory illness. Interventions included monitoring for signs and symptoms of respiratory distress and reporting to the physician as needed, and oxygen 1-4 liters via nasal cannula as needed for saturation less than 90%. According to the October 2020 CPO, the resident had the following physician's orders [REDACTED].>Oxygen at 2 liters per nasal cannula for oxygen saturation below 90%. The start date for the order was 7/15/2020; Change over from the nasal cannula to a mask at this time for decreased oxygen saturations, titrate oxygen to maintain saturation of 90% or better. The start date for the order was 10/25/2020. -This order came two days after the first documentation which indicated the resident was having difficulty breathing, see progress notes below. Review of the resident ' s progress notes revealed the following: 10/23/2020 at 11:23 p.m: The resident was noted to be lethargic, had an increased need for help with ADLs, his oxygen saturations were in the 80s, the nurse advised the resident to reposition, with his head elevated but he was non-compliant. -The facility failed to notify the physician to report change in condition for this resident, delaying care and interventions. There was no further documentation until 10/24/2020 at 11:27 p.m. when the following note was entered into the medical record: The resident was noted to be lethargic, he had an increased need for assistance with ADLs, his oxygen saturations was 86% on 4 liters of oxygen. -The facility failed to notify the physician to report change in condition for this resident, delaying care and interventions. There were no documented interventions or notifications to a physician related to the resident ' s change in condition or low oxygen saturations until the following progress note was entered on 10/25/2020 at 11:10 a.m: Called and spoke to the nurse practitioner (NP) related to decreased oxygen saturation of 88% on nasal cannula, weakness and the resident was unresponsive. Orders received for a cbc (complete blood count), a cmp (comprehensive metabolic panel), a chest x-ray, start an IV (intravenous) fluids at a 100cc (cubic centimeters) per hour times 2 liters, [MEDICATION NAME] inhaler every 6 hours as needed. Call back in a few hours for a follow up update. 10/25/2020 at 12:42 p.m: Oxygen saturation is 89% on 5 liters on the mask. The resident is slow to respond to verbal commands, head of bed elevated 45%, attempted to start I.V. three times and unable to maintain a vain. Resident ' s respiratory sounds were very gurgled. Resident is a full core, spoke with the DON and she said to send the resident to hospital due to his rapid change in condition (COC) and his respiratory status and the potential for continued rapid decline. 10/25/2020 at 2:36 p.m: admitted to the hospital for bilateral pneumonia. III. Staff interviews The DON was interviewed on 10/29/2020 at 5:20 p.m. She said she would expect the nurses to provide interventions for low oxygen saturations and document the interventions in the progress notes. She said she would expect the nurses to notify the physician regarding a resident ' s COC and low oxygen saturations. She said she would expect every shift to monitor the resident with the changes he was experiencing.

Based on observations, record review and interviews, the facility failed to follow an effective infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of disease and infection such as COVID-19. Specifically, the facility failed to: -Ensure residents were offered hand hygiene before meals; -Ensure housekeeping performed hand hygiene between rooms, after removing gloves while cleaning a resident's room; -Ensure housekeeping followed labeled cleaning instructions on the disinfectant used to clean resident rooms; and, -Ensure housekeeping followed the proper procedural steps when cleaning a resident's room. Findings include: I. Professional standards According to the Centers for Disease and Prevention (CDC) Hand Hygiene in Healthcare Settings, last up updated 1/31/2020, retrieved from https://www.cdc.gov/handhygiene/providers/index.html, included the following recommendations: Multiple opportunities for hand hygiene may occur during a single care episode. Following are the clinical indications for hand hygiene: Use an alcohol-based hand sanitizer immediately before touching a patient, before performing an aseptic task (e.g., placing an indwelling device) or handling invasive medical devices, before moving from work on a soiled body site to a clean body site on the same patient, after touching a patient or the patient's immediate environment, after contact with blood, body fluids or contaminated surfaces, and immediately after glove removal. Wash with soap and water when hands are visibly soiled, after caring for a person with known or suspected infectious diarrhea, and after known or suspected exposure to spores. When using alcohol-based hand sanitizer, put the product on hands and rub hands together. Cover all surfaces until hands feel dry. This should take around 20 seconds. When cleaning hands with soap and water, wet hands first with water, apply the amount of product recommended by the manufacturer to your hands, and rub together vigorously for at least 15 seconds, covering all surfaces of the hands and fingers. Rinse your hands with water and use disposable towels to dry. Use a towel to turn off the faucet. Avoid using hot water, to prevent drying of skin. Other entities have recommended that cleaning your hands with soap and water should take around 20 seconds. Either time is acceptable. The focus should be on cleaning your hands at the right times. II. Facility policies and procedures A. The coronavirus/COVID-19 policy, dated 4/13/2020, was provided on 5/4/2020 by the infection control specialist (ICS). The policy read in pertinent part: To provide guidance to long term care providers on how to prepare for COVID-19, emerging infectious disease (EID), whose incidence in humans has increased or threats to increase in the near future and that has the potential to pose a significant public health threat and danger of infection to the residents, families and staff of the skilled nursing center Goal: To protect our residents, families, and staff from harm resulting from exposure to emerging infectious disease while in the facility Staff will be educated on the exposure risks, symptoms, and infection prevention and control, use of PPE, transmission based precautions, and hand hygiene Environmental cleaning: the facility will follow CDC guidelines for environmental cleaning in addition to routine cleaning for the duration of the threat. B. The COVID-19 ongoing education, dated 4/15/2020, read in pertinent part: Staff will encourage resident hand hygiene upon arising, after toileting, before and after meals, and at bedtime Resident handwashing: Clothes are to be retrieved from laundry prior to meals and placed in a plastic bin. Cover with hot water, distributed for hand washing with tongs and retrieved from residents prior to meals. Dirty cloths are to be returned to laundry after meals. III. Secured unit A. Observations The all men's secured neighborhood was observed on 5/4/2020 between 10:15 a.m. and 12:15 p.m. At 10:21 a.m. four residents sat in the dining room, including Resident #1 and Resident #2. Both residents wore cloth masks covering over their nose and mouth. The residents sat at individual tables. Resident #3 sat in the front lobby. Resident #4 walked up and down halls and in and out the outside smoking area talking on a cell phone. No observations of hand hygiene offered in the dining or common areas. Between 10:21 a.m. and beginning of the lunch meal service, Resident #1 and Resident #2 touched their masks multiple times. Resident #2 touched the wheels of his wheelchair. Resident #1 used his mask he had removed to wipe his nose. There were no observations of hand hygiene offered to either resident. -At 11:38 a.m., certified nursing aide, (C.NA) #1 recorded the temperatures of four residents sitting in the lobby, as well as and the temperatures of Resident #1 and Resident #2 in the dining room. Hand hygiene was not offered. -At 11:42 a.m., licensed vocational nurse (LVN) #2 walked Resident #3 from the lobby, held his hand and guided him to his table. She did not offer hand hygiene when he was in the lobby, when entering the dining room, or after holding his hand. The LVN remained in the dining room during the duration of the lunch service, serving the plated meals. -At 11:45 p.m. Resident #3 was first to be served his meal. He was not offered hand hygiene. -At 11:47 Resident #2 continued to touch the outside of the mask, then he removed his mask. He was served his meal without hand hygiene. Five other residents sat in the dining room. They were not offered hand hygiene before meals. -At 11:50 a.m., C.NA #1 assisted Resident #5 to a table, and sanitized his hands with alcohol based hand rub (ABHR). -At 11:55 a.m., Resident #6 observed eating his meal using hands, and placing his fingers in his mouth. LVN 2 observed him placing his fingers in his mouth and encouraged him to use a spoon. There were no observations of the resident hand hygiene prior to him serving his meal or after placing his fingers in his mouth. Resident #4 exited the smoking area, still talking on his cell phone. He sat at a table in the dining room and served his meal. He was not offered hand hygiene Two other residents were served their meal in the lobby, and hand hygiene was not offered. -At 12:01 p.m., Resident #7 self-propelled his wheelchair with his hands. -At 12:02 p.m., Resident #7 was served his lunch. He did not offer hand hygiene before he was served his meal. Eight out nine residents were served in the dining room during the observation period. They were not offered hand hygiene before they were served their meal, increasing the risk of transmission based infections and [MEDICAL CONDITION] to spread to the residents. B. Staff interviews The director of nursing (DON) was interviewed on 5/4/2020 at 9:45 a.m. She indicated the facility did not have active cases of transmission based infections or viruses. She identified the facility was a secured Alzheimer's/dementia facility. The DON said it was very important for her staff to use appropriate infection control practices to prevent the entry of, and spread of transmission based infections [MEDICAL CONDITION], including COVID-19. According to the DON, most residents eat in their rooms. She said some residents eat in the dining room or lobby with tables spaced six feet apart because of the wandering nature of the population and their need for routine. LVN #1, who identified herself as the infection control specialist (ICS) was interviewed on 5/4/2020 at 12:33 p.m. She said resident hand hygiene decreases the potential spread of transmission based infections [MEDICAL CONDITION]. Resident hand hygiene occurs on rise, before going to bed at night, after cares, before meals and throughout the day. Hand hygiene could be done at the resident sink, with alcohol based hand rub (ABHR) or by using the facility's portable hand washing process to include a plastic bin, warm water and soap and fresh towels. The ICS said residents should receive hand hygiene just before they eat because of the high risk that they touched potentially contaminated surfaces. LVN #2 was interviewed on 5/4/2020 at 12:39 p.m. She said resident hand hygiene should be offered upon waking, after toileting and before meals. Hand hygiene for lunch occurred between 10:00 a.m. and 11:00 a.m. daily. She said if a resident was observed touching contaminated surfaces in the dining room, she would assist him out of the dining room and hand wash his hands with soap and water in his room. She said hand sanitizer should not be used on residents for hand hygiene. According to the LVN she said she did not provide hand hygiene to Resident #3 after guiding him by the hand to his table because she felt her hands were clean. The LVN said staff have a portable hand washing process for residents in common areas. She said tongs were used so staff does not have to directly touch the clean surface of the towels offered to the resident. She said the portable hand washing in a plastic bin would not be conducted in the dining room because hand washing would be done outside the dining area. CNA #1 was interviewed on 5/4/2020 at 1:20 p.m. According to the CNA, hand washing with soap and water before meals should occur in resident's rooms if they are eating in their rooms. She said hand hygiene should occur before the resident was served in the dining room. She said residents should be offered hand hygiene in the dining room with either the ABHR or through the portable hand washing process. She said it was important to provide hand hygiene just as they are served their meal because staff may not know all the potentially contaminated surfaces the resident might have touched since their hands were last washed in their rooms. The nursing home administrator (NHA) was interviewed on 5/4/2020 at 4:33 p.m. He said staff education on appropriate infection control practices was ongoing. Education on practices included resident hand hygiene. Resident hygiene in an Alzheimer's/dementia facility had been difficult, however staff needed to continue to make every effort to ensure residents' hands stayed clean. According to the NHA, staff should attempt to provide hand hygiene throughout the day, after care and before every meal. The NHA stated hand hygiene should occur in the dining room, common areas, and resident rooms. The resident hand hygiene observations were reviewed with the NHA. He said it was normal practice of the facility to provide hand hygiene in the dining just before meal service to prevent or decrease the potential spread of infections from contaminated surfaces. He said he regretted that it did not occur during the observation period or according to an interviewed staff member. He said the facility would address the concern and correct it. IV. Improper room cleaning A. Facility policy The Isolation plan for coronavirus disease 2019(COVID-19), dated 4/20/2020, was provided by the director of nursing(DON) on 5/4/2020 at 10:00 a.m. It documented in pertinent parts, cleaning handout for Center housekeeping staff. Help keep residents safe: preventing and stopping the coronavirus is our top priority. How we clean the center is an important part of this starting now: hand washing stations or alcohol-based hand rubs available at all entry ways, frequent cleaning of surfaces like door knobs, countertops, handrails. Follow routine procedures for laundry, food service utensils and medical waste. Supervisors should observe to ensure cleaning is being done correctly. B. Observation On 5/4/2020 at 10:35 a.m., housekeeper (HK) #1 was observed. She exited room [ROOM NUMBER] after cleaning and removed her gloves at her cleaning cart. She donned clean gloves and did not perform hand hygiene. She pushed her cart in front of room [ROOM NUMBER]. She removed her disinfectant (Fuzion) from her cart and proceeded to room [ROOM NUMBER] which was shared with three residents. She started with the bathroom first. She sprayed the disinfectant in the toilet, around the toilet, the grab bars and wall in the bathroom. She went to her cart and returned to the bathroom in approximately one minute and started to clean the toilet using the commode brush (She did not allow the disinfectant to stay on the surface for two minutes. She wiped down the toilet, grabbed bars and the walls with a rag. She mopped the floor and exited the bathroom. She went to her cart and removed her gloves. She donned a clean pair of gloves and did not perform hand hygiene. She sprayed the sink with the disinfectant and immediately wiped it down (again she did not allow the disinfectant to remain on the surface for two minutes), removed another white cloth and went to the sink. She sprayed the disinfectant in and around the sink. She sprayed the disinfectant on a piece of paper towel and wiped down one of the resident bedside tables. She mopped the floor and left the room. She did not clean the other two resident care areas. C. Record review The instruction label on the disinfectant bottle documented: to disinfect, spray six to eight inches from surface until surface is thoroughly wet. Allow this product to remain wet for two minutes. Then wiped. An in-service entitled Preventing Cross contamination after resident care was provided by the ADON on 5/4/2020 at 1:00 p.m. It documented 4/30/2020, we disinfect using Fuzion (a type of disinfectant) we leave it on for two minutes and wipe it down. D. Interviews On 5/4/2020 at 11:15 a.m., HK #1 was interviewed. She said she received training on COVID-19. She said she was provided training to perform hand hygiene between rooms and also to perform hand hygiene every time she removed gloves. She said she had a bottle of hand sanitizer in her cleaning cart but forgot to perform hand hygiene. She said she was not aware how long the disinfectant would remain on the surface before cleaning. She said her normal process when cleaning was to start cleaning the bathroom first. She said she was trained to clean the bathroom first. The ADON who was also the infection control preventionist was interviewed on 5/4/2020 at 11:20 a.m. She said the staff were trained on hand hygiene. She said the training included: hand hygiene before entering and after leaving the resident's room and after removing gloves. She said HK #1 should have performed hand hygiene between rooms and after she removed gloves. She said HK #1 should have cleaned the resident's bedroom before cleaning the toilet. She said the normal process would be to clean the bedroom before cleaning the bathroom. She said she would immediately provide training to HK #1 to prevent the process from reoccurring into the next room. The plant manager (PM) was interviewed on 5/4/2020 at 11:32 a.m. He said he was responsible for housekeeping. He said the house keepers were trained on COVID-19 and how to clean and disinfect the resident's room. He said the process was to start from the resident's bedroom, then move to the bathroom.(clean to dirty) He said hand hygiene should be done between rooms and when gloves were removed. He said they should follow the instruction label on the disinfectant when cleaning. He said the house keepers were provided training on the dwell time of the disinfectant. He said HK #1 should have performed hand hygiene before entering the next room to clean and whenever she removed her gloves. He said HK #1 should have sprayed the disinfectant and allowed it to stay on the surface for two minutes as instructed on the label. He said if the instruction on the label was not followed, the surface would not be properly disinfected and could post a risk of spreading infection. He said he would re-educate HK #1. E. Facility follow-up On 5/4/2020 at 1:00 p.m., an in-service form was provided by the PM. It documented HK #1 was re-educated on the following: Sanitize hands before entering room, after each glove change and upon leaving room and clean from clean to dirty, top to bottom.

Based on record review and staff interviews, the facility failed to ensure one (#12) of five residents reviewed out of 29 sample residents remained free from resident-to-resident altercations. The facility failed to implement person-centered interventions and evaluate the effectiveness of the interventions for Resident #12 to protect other residents involved in altercations, and provide person centered care to prevent persistent abuse by Resident #12. Based on the facility's failure to protect Resident #12 and the other residents involved with the altercations, the resident was involved in eight resident-to-resident altercations from 11/26/18 to 10/22/19 which contributed to the harm caused to Resident #31 and Resident #5 on two different occasions. Conversely, Resident #12 was harmed in an altercation with with Resident #1. Findings include: I. Facility policy and procedure The Preventing Resident Abuse policy, dated 11/1/17, was provided by the nursing home administrator (NHA) on 10/30/19 at 5:26 p.m. It read, in pertinent part; -Our abuse prevention/intervention program includes, but is not necessarily limited to the following; -Assessing, care planning, and monitoring residents with needs and behaviors that may lead to conflict and neglect; -Assessing residents with signs and symptoms of behavior problems and developing and implementing care plans to address behavioral issues; -Involving Attending Physicians and the Medical Director when findings of abuse have been determined; -Involving qualified psychiatrist and other mental health professionals to help the staff manage difficult or aggressive residents; -Identifying areas within the facility that may make abuse and/or neglect more likely to occur and monitoring these areas regularly; and -Strive to maintain adequate staffing on all shifts to ensure that the needs of each resident our met. II. Resident census and conditions The 10/28/19 resident census and conditions documented that 45 residents had a [DIAGNOSES REDACTED]. Cross-reference F744 treatment and services for dementia care. III. Resident #12 [NAME] Resident #12 status Resident #12, age 80, was admitted [DATE]. According to the (MONTH) 2019 computerized physician orders [REDACTED]. The 8/17/19 minimum data set (MDS) assessment revealed the resident was cognitively imparied according to the brief interview for mental status (BIMS) score of eight out of 15. She had physical behavior symptoms toward others, verbal behavior symptoms towards others and other behavioral symptoms not directed toward others. She rejected care, wandered daily, administered an antipsychotic daily and required limited to extensive assistance from staff for most activities of daily living. IV. Resident-to-resident altercations involving Resident #12 [NAME] 11/26/18 1. Resident status Resident #31, age 88, was admitted on [DATE] with readmission 1/22/19. According to the (MONTH) 2019 CPO, [DIAGNOSES REDACTED]. The 9/22/19 MDS assessment revealed the resident had severe cognitive impairment according to the BIMS score of one out of 15. She had delusions, behaviors that were not directed towards others and did not wander or reject cares. She required extensive assistance from staff for ADLs. 2. Resident altercation The 11/26/18 nurse progress note documented the certified nurse aide (CNA) observed Resident #12 strike Resident #31on her bilateral cheeks as Resident #31 was yelling out. Resident #12 had a history of [REDACTED].#12 was removed from the area for decreased external stimulation for a cool down period. Resident #31 did not have injury to her face, however, the progress note documented, I ' m getting beat up. -There was no interdisciplinary team (IDT) review of the incident documented in Resident #12 ' s electronic medical record (EMR). The 11/27/18 nurse progress note documented Resident #12 was on follow up charting for the altercation with the other resident. The resident ' s antipsychotic medication) was raised to 2 mg (milligrams). -The 11/27/18 physician order [REDACTED]. B. 2/5/19 1. Resident status Resident #147, age 73, was admitted on [DATE] and discharged [DATE]. According to the (MONTH) 2019 CPO, [DIAGNOSES REDACTED]. The 2/18/19 MDS assessment revealed the resident had severe cognitive impairment according to the BIMS score of zero out of 15. He had physical behavior symptoms toward others, verbal behavior symptoms towards others, other behavioral symptoms not directed toward others and wandered. 2. Resident altercation The 2/5/19 nurse progress note documented Resident #12 was in a chair sitting next to room [ROOM NUMBER] for about 30 minutes. From the nursing station the registered nurse (RN) could see Resident #12 with hands and one foot up defending herself from Resident #147. Resident #12 sustained a strike to the throat but no injuries upon assessment. The 2/6/19 IDT progress note documented Resident #12 was sitting in a chair outside room [ROOM NUMBER] when Resident #147 came up and punched her in the throat. The RN was sitting close to this and jumped in between the residents and took Resident #147 to his room. Resident #12 was assessed for injuries and no redness or bruising no complaint of pain. Nursing will monitor for latent injuries. -There were no interventions put in place to prevent recurrence implemented by the IDT. C. 2/16/19 1. Resident status Resident #1, age 71, was admitted on [DATE]. According to the (MONTH) 2019 CPO, [DIAGNOSES REDACTED]. The 10/19/19 MDS assessment revealed the resident had severe cognitive impairment according to the BIMS score of three out of 15. She had no behaviors exhibited and required limited to extensive assistance from staff for most ADLs. 2. Resident altercation The 2/16/19 nurse progress note documented the RN heard load arguing and saw Resident #12 with both hands pulling Resident #1 ' s hair. ' She pulled my hair first, ' was what Resident #12 stated when questioned by the nurse. Resident #12 had been hit in the chest with no red marks or abrasions notes. Both residents immediately separated and fire doors were closed between two hallways to keep them apart. The 2/19/19 IDT progress note documented that upon reviewing the cameras it was noted that Resident #1 had stopped Resident #12 and starting talking with her. Then Resident #1 took steps in front of Resident #12 and again said something to the resident. Then Resident #1 came back and struck Resident #12 in the chest. Immediately Resident #12 grabbed the hair of Resident #1. Staff immediately separated the two residents. Doors between the two units were closed. -There were no interventions put in place to prevent recurrence implemented by the IDT. D. 7/6/19 1. Resident status Resident #1, age 71, was admitted on [DATE]. According to the (MONTH) 2019 CPO, [DIAGNOSES REDACTED]. The 10/19/19 MDS assessment revealed the resident had severe cognitive impairment according to the BIMS score of three out of 15. She had no behaviors exhibited and required limited to extensive assistance from staff for most ADLs. 2. Resident altercation The 7/6/19 nurse progress note documented a certified nurse aide (CNA) informed the nurse that there had been an incident in the dining room between Resident #12 and Resident #1. After the nurse reviewed the cameras, Resident #12 had been sitting quietly at the table waiting for breakfast and Resident #1 approached the table with a blanket and laid it on the table. Resident #12 and Resident #1 were talking then Resident #12 started to fold the blanket when Resident #1 grabbed the blanket from her. Resident #12 slapped Resident #1 on the right side of the face, then Resident #1 slapped her back. Resident #12 grabbed Resident #1 ' s hair and pulled her head on the table. The CNA separated the residents. The nurse described a small bruise on the Resident #12 ' s right wrist. The nurse documented that Resident #1 would eat in a different dining room than Resident #12 to prevent reoccurance. The 7/8/19 IDT progress note documented the events above, but indicated there were no injuries. -The intervention that IDT implemented were that the nurse was going to have her medication cart outside of the dining room to supervise Resident #12 in the dining room. E. 8/15/19 1. Resident status Resident #5, age 76, was admitted on [DATE]. According to the (MONTH) 2019 CPO, [DIAGNOSES REDACTED]. The 8/7/19 MDS assessment revealed the resident had short term and long term memory with severe impairment with daily decision making. She had physical behaviors towards others and other behavioral symptoms not directed towards others. She wandered and significantly intruded on the privacy of others. She required limited assistance from staff for most ADLs. 2. Resident altercation The 8/15/19 nurse progress note documented that staff heard a scream coming from the front area of the lobby. A physician was at the nurses station when she looked up and saw Resident #12 pulling the right ear of Resident #5 when a CNA separated the residents. The nurse assessed Resident #5 for injury and her right ear was red. The 8/16/19 IDT progress note documented that Resident #12 had pulled Resident #5 ' s right ear. Resident #5 right ear was red and painful at first and she was given Tylenol for pain. -There were no interventions put in place to prevent recurrence implemented by the IDT. F. 9/23/19 1. Resident status Resident #20, age 85, was admitted on [DATE]. According to the (MONTH) 2019 CPO, [DIAGNOSES REDACTED]. The 8/30/19 MDS assessment revealed the resident had cognitive impairment according to the BIMS score of seven out of 15. She had verbal behavioral symptoms directed towards others, rejected cares and wandered. She required limited assistance from staff for most ADLs. 2. Resident altercation Review of the Resident #12 ' s nurse progress notes revealed a progress note on 9/23/19 that documented, Neither resident had any recall of the incident 10 minutes later. DON informed Corporate authorities. Lakewood police arrived. -There was no documentation of what happened during the incident or what interventions put in place. In addition, the IDT review of the incident was not present. Review of the 9/23/19 abuse investigation form documented the dietary manager heard residents arguing when she saw Resident #12 pulling Resident #20 ' s hair and then put her hand around her neck. The residents were separated and wandered down the hall and with no injuries. [NAME] 10/7/19 1. Resident status Resident #24, age 76, was admitted on [DATE] with readmission 7/28/18. According to the (MONTH) 2019 CPO, [DIAGNOSES REDACTED]. The 9/5/19 MDS assessment revealed the resident had severe impairment with daily decision making and rejected cares. She required limited assistance from staff for most ADLs. 2. Resident altercation The 10/7/19 nurse progress note documented the nurse had a conversation with DON and after reviewing tape Resident #24 was sitting in her merry walker and had come to a standing position. Resident #24 went a few steps backwards coming into contact with Resident #12. In reaction Resident #12 placed her hands around Resident #24 ' s neck. A CNA was in proximity, she heard a commotion and stepped towards the two residents providing instruction for Resident #12 to let go of Resident #24 and she did moments later. Neither resident had an injury or pain and headed off in opposite directions as if nothing happened. The residents were monitored for the remainder of the evening with no further issue. The 10/10/19 IDT progress note documented that Neither resident showed any signs of distress or pain and were frequently checked on. Resident #12 was going to have her medications reviewed in the next [MEDICAL CONDITION] meeting on 10/10/19. -The [MEDICAL CONDITION] committee meeting was not held on 10/10/19 (see interviews below), therefore the resident's medications were not reviewed until 10/24/19 after an additional resident- to-resident altercation on 10/22/19. H. 10/22/19 1. Resident status Resident #5, age 76, was admitted on [DATE]. According to the (MONTH) 2019 CPO, [DIAGNOSES REDACTED]. The 8/7/19 MDS assessment revealed the resident had short term and long term memory with severe impairment with daily decision making. She had physical behaviors towards others and other behavioral symptoms not directed towards others. She wandered and significantly intruded on the privacy of others. She required limited assistance from staff for most ADLs. 2. Resident altercation The 10/22/19 nurse progress note documented that Resident #12 had been sitting in a chair in the hall, got up out of the chair and went on a walk down the hall. Resident #5 had sat in the chair and when Resident #12 returned she placed her hand on the neck of Resident #5 leaving a bright red ring around her neck with three finger nail marks on the right side of her neck and four finger nail marks on the left side of her neck. Implemented 30 minute checks for three days for Resident #12. The 10/25/19 IDT progress note documented the residents were separated and Resident #5 had red ring around her neck and fingernail marks. The residents were placed in their rooms. Resident #12 and Resident #5 had medication adjustments. Resident #12 was placed on 30 minutes checks until she went to sleep. -The 10/24/19 physician order [REDACTED]. V. Staff interviews Certified nurse aide (CNA) #1 was interviewed on 10/20/19 at 1:10 p.m. She said she had worked at the facility for many years and worked the day shift from 6:00 a.m. to 2:00 p.m. She said the facility provided training on a regular basis on dementia care and how to deal with behaviors. She said the CNA staff documented resident behaviors in their point of care charting if it was indicated in a task for them to chart. She said Resident #12 had been involved with some resident-to-resident altercations with the most recent one a few weeks ago. She said after that incident Resident #12 was on check every 15 minutes. She said Resident #12 sat in the dining room during meals with two to three residents. She said the staff often checked on the residents in the dining room since it was a common area where the residents attended activity programs as well. She said the staff were not sure what triggered Resident #12 ' s behaviors but if residents or staff were in her personal space she may grab them. CNA #2 was interviewed on 10/30/19 at 1:20 p.m. She said Resident #12 had aggressive behaviors towards other residents and staff when they were too close to her. She said if she is in the dining room or a congested area it helped to remove her from the situation, talk to her, or provide her food or drink. She said Resident #12 was involved with at least two resident-to-resident altercations in the past few months. She said she was not provided one-to-one activities or restorative programs which may be beneficial for her since she did not do well in group settings. The restorative certified nurse aide (RCNA) was interviewed on 10/30/19 at 1:30 p.m. She said she did not work with Resident #12 with a restorative program but was often around for the group activities held in the dining room where Resident #12 wandered in and out. She said Resident #12 did not like when residents or staff invaded her private space. She said Resident #12 can strike at resident at staff at anytime. She said the staff try to keep her active by walking her around the facility which seems to help with her aggression at times. RN #1 was interviewed on 10/30/19 at 1:40 p.m. She said she worked day shift 6:00 a.m. to 2:00 p.m. during the week. She said Resident #12 sometimes became aggressive with other residents that were in her space. She said that Resident #12 sometimes verbalized to the other resident to leave her alone. She said if residents continued to be in her space that she can become physically aggressive by hitting the other resident. She said her [MEDICATION NAME] medication was recently changed to 3 mg on 10/24/19 due to her most recent altercation on 10/22/19. She said the resident had previously been on a higher dose of [MEDICATION NAME] but was lethargic and not able to eat so the dose was lowered. She said she had not seen the symptoms of being lethargic since her [MEDICATION NAME] medication was increased. She said her nurses cart was often parked by the dining room during meals but she could not supervise the residents at al times since she had to pass medications. She said due to her behaviors being unpredictable the staff could not anticipate when she may be physically aggressive. She said most of the resident-to-resident altercation that had occurred over the past year that most of them were provoked by another resident in which Resident #12 reacted in a violent manner. The director of nursing (DON) was interviewed on 10/30/19 at 2:08 p.m. She said when a resident-to-resident altercation occurred then the staff were to intervene and assess the resident for any injury. The residents were charted on for three days after the incident to assess for latent injuries or psychosocial changes and the police were called. She said the facility conducted an abuse investigation by interviewing any pertinent staff involved or other residents, if interviewer able since it was a secured unit. She said the cameras could often be viewed after the incident to confirm what the events of the incident. She said upon conclusion of the internal abuse investigation the resident-to-resident altercation, the nursing home administrator reported it to the health department. She said for Resident #12 she had violent outbursts towards other residents, she was not provoked so it could happen at anytime and she liked to be left alone. She said one incident she was walking and initiated a violent attack on a resident and her most recent one she grabbed a resident around her neck leaving marks. She said in another instance she jammed a resident ' s head into a door jam that caused injury but she had not had that violent of an attack recently. She said due to the other residents initiating the attack by being in her personal space, her attacks were reationary to what the resident was doing to her like clapping in her face. She said the IDT had implemented different interventions like 30 minute checks and medication reviews by her physician. She said her husband was aware of her behavior and told the staff she was a mean person and violent at home prior to her being admitted to a secured unit. She said overall the facility staff know Resident #12 and her aggressive behaviors. She said the physician and staff did not want to increase her [MEDICATION NAME] due to her past of being lethargic and did not eat. She said since it had been almost a year since her previous increase in the [MEDICATION NAME] medication that the physician assistant felt it was appropriate to increase it on 10/24/19 since he recognized the resident had an increase in aggressive behaviors. She said the activity department was lacking previously and due to the added activities that reisden-to-resident altercations had subsided due to having additional group activities. She said Resident #12 ' s activity program did not change but she saw a difference with other residents. She said due to her favorable response to the increase in her [MEDICATION NAME] medication that she had not had a recurrence of aggressive behavior since 10/24/19 so the IDT thought that was the most effective approach to aide in controlling her behaviors to keep other residents safe. The NHA was interviewed on 10/30/19 at 4:15 p.m. He said he had worked at the facility for two weeks so he was not present for the incidents involving Resident #12 until the 10/22/19 altercation. He said the facility took the safety of the residents as a top priority and implement one-to-one staff with her until the facility could devise a short term and long term plan to ensure she did not hurt others and had a quality of life due to medication not being the answer. The nurse practitioner (NP) was interviewed 10/31/19 at 11:13 a.m. He said he had been following Resident #12 for years and saw her routinely alongside of the physician assistant and physician. He said Resident #12 had a history of [REDACTED]. He said she had been on [MEDICATION NAME] (antipsychotic medication) about two years ago but was discontinued due to her having a significant uptick in her aggression and per the [MEDICAL CONDITION] committee they switched her to [MEDICATION NAME]. He said when her [MEDICATION NAME] was at a higher dose past 2 mg, she was having trouble eating so they had to lower her dose to 1.5 mg. He said he did increase her [MEDICATION NAME] to 2 mg after the resident-to-resident altercation in (MONTH) 2019. He said after the increase of the [MEDICATION NAME] to 2mg each day her behavior had stabilized based on the reports he received from the nursing staff when he went to see her. He said he started seeing increased episodes of aggression in (MONTH) 2019 but since it was sporadic and she did not do well with an increase in the [MEDICATION NAME] medication they continued to monitor her. He said he had informed the floor nurse of behavioral approaches to curb her aggressive episodes like providing her with less stimulation, offering her to lay down when she had increased aggression, walking her around the facility or outside to keep her busy and removing her from the situations that may provoke her. He said due to the behavioral strategies that failed and the increase in resident-to-resident altercations, he increased her [MEDICATION NAME] to 3mg on 10/24/19. He said he did not think this would be a long term intervention due to her previous history of not doing well with the increased dose of [MEDICATION NAME]. He said the staff would continue to monitor for aggressive behaviors and side effects from the increased [MEDICATION NAME] dose. The medical director (MD) was interviewed on 10/31/19 at 11:55 am. He said that he attended the meeting as the facility monthly that included psychopharm and the quality assurance. He said residents were reviewed in psychopharm meeting at the very minimum quarterly but if a resident had increased behaviors or required an additional review then the facility would review more often. He said if there were identified issues or concerns in the facility then it was reviewed in their monthly quality assurance meeting. He said he could not recall that Resident #12 had been reviewed in any recent psychopharm meeting and that her resident-to-resident altercations being reviewed. He said since the facility was secured that they did their best to keep the residents safe but unfortunately there were many residents with behaviors. He said after being brought to the facility's attention and his attention the facility would review her at the next psychopharm and quality assurance meeting to be held in (MONTH) 2019. He said based on his professional opinion, antipsychotic medication does not always control an underlying behavior. He said the psychopharm committee required to discuss the trends of her behaviors like time of day and patterns of her behavior then analyze what behavioral interventions were working in addition to [MEDICAL CONDITION] medications.

Based on record review and interview, the facility failed to ensure one (#12) of five residents reviewed for dementia care of 29 sample residents, received the appropriate treatment and services to maintain their highest practicable physical, mental, and psychosocial well-being. The facility failed to comprehensively assess and effectively identify person-centered approaches for dementia care for Resident #12 to prevent resident-to-resident altercations, provide an activity program that was personalized to avoid group activities since she desired low stimulation, and address repeated behavioral issues created an environment where abuse persisted. Based on the facility's failure to protect Resident #12 and the residents involved with the altercations, it caused harm to Resident #31 and Resident #5 on two different occasions. The altercation that Resident #12 had harm caused to her was with Resident #1 . The resident was involved in eight resident-to-resident altercations from 11/26/18 to 10/22/19. Cross-reference F600-free from resident-to-resident altercations Findings include: I. Facility policy and procedure The Dementia Clinical Protocol policy, revised 10/31/19, was provided by the director of nursing (DON) on 10/31/19 at 4:04 p.m. It documented in pertinent part; -For individuals with confirmed dementia, the staff and physician will identify a plan to maximize remaining function and quality of life. -The physician will order appropriate medications and other interventions to manage behavioral and psychiatric symptoms related to dementia based on pertinent clinical guidelines and regulatory expectations. -The staff will monitor the individual with dementia for changes in condition and decline in function and will report these findings to the physician. -The physician and staff adjust interventions and the overall plan depending on the individual's responses to those interventions, progression of dementia, development of new acute medical conditions or complications and changes in resident or family wishes. -The physician and staff will review the effectiveness and complications of the long term use of medications used to enhance cognition and of psychoactive medications used to manage behavioral and psychiatric symptoms related to dementia and will adjust, stop or change such medications appropriately. II. Resident census and conditions The 10/28/19 resident census and conditions documented that 45 residents had a [DIAGNOSES REDACTED]. III. Resident #12 Resident #12 status Resident #12, age 80, was admitted [DATE]. According to the (MONTH) 2019 computerized physician orders [REDACTED]. The 8/17/19 minimum data set (MDS) assessment revealed the resident was cognitively imparied according to the brief interview for mental status (BIMS) score of eight out of 15. She had physical behavior symptoms toward others, verbal behavior symptoms towards others and other behavioral symptoms not directed toward others. She rejected care, wandered daily, administered an antipsychotic daily and required limited to extensive assistance from staff for most activities of daily living (ADLs). IV. Resident-to-resident altercations involving Resident #12 [NAME] 11/26/18 1. Resident status Resident #31, age 88, was admitted on [DATE] with readmission 1/22/19. According to the (MONTH) 2019 CPO, [DIAGNOSES REDACTED]. The 9/22/19 MDS assessment revealed the resident had severe cognitive impairment according to the BIMS score of one out of 15. She had delusions, behaviors that were not directed towards others and did not wander or reject cares. She required extensive assistance from staff for ADLs. 2. Resident altercation The 11/26/18 nurse progress note documented the certified nurse aide (CNA) observed Resident #12 strike Resident #31on her bilateral cheeks as Resident #31 was yelling out. Resident #12 had a history of [REDACTED].#12 was removed from the area for decreased external stimulation for a cool down period. Resident #31 did not have injury to her face, however, the progress note documented, I ' m getting beat up. -There was no interdisciplinary team (IDT) review of the incident documented in Resident #12 ' s electronic medical record (EMR). The 11/27/18 nurse progress note documented Resident #12 was on follow up charting for the altercation with the other resident. The resident ' s antipsychotic medication) was raised to 2 mg (milligrams). -The 11/27/18 physician order [REDACTED]. B. 2/5/19 1. Resident status Resident #147, age 73, was admitted on [DATE] and discharged [DATE]. According to the (MONTH) 2019 CPO, [DIAGNOSES REDACTED]. The 2/18/19 MDS assessment revealed the resident had severe cognitive impairment according to the BIMS score of zero out of 15. He had physical behavior symptoms toward others, verbal behavior symptoms towards others, other behavioral symptoms not directed toward others and wandered. 2. Resident altercation The 2/5/19 nurse progress note documented Resident #12 was in a chair sitting next to room [ROOM NUMBER] for about 30 minutes. From the nursing station the registered nurse (RN) could see Resident #12 with hands and one foot up defending herself from Resident #147. Resident #12 sustained a strike to the throat but no injuries upon assessment. The 2/6/19 IDT progress note documented Resident #12 was sitting in a chair outside room [ROOM NUMBER] when Resident #147 came up and punched her in the throat. The RN was sitting close to this and jumped in between the residents and took Resident #147 to his room. Resident #12 was assessed for injuries and no redness or bruising no complaint of pain. Nursing will monitor for latent injuries. -There were no interventions put in place to prevent recurrence implemented by the IDT. C. 2/16/19 1. Resident status Resident #1, age 71, was admitted on [DATE]. According to the (MONTH) 2019 CPO, [DIAGNOSES REDACTED]. The 10/19/19 MDS assessment revealed the resident had severe cognitive impairment according to the BIMS score of three out of 15. She had no behaviors exhibited and required limited to extensive assistance from staff for most ADLs. 2. Resident altercation The 2/16/19 nurse progress note documented the RN heard load arguing and saw Resident #12 with both hands pulling Resident #1 ' s hair. ' She pulled my hair first, ' was what Resident #12 stated when questioned by the nurse. Resident #12 had been hit in the chest with no red marks or abrasions notes. Both residents immediately separated and fire doors were closed between two hallways to keep them apart. The 2/19/19 IDT progress note documented that upon reviewing the cameras it was noted that Resident #1 had stopped Resident #12 and starting talking with her. Then Resident #1 took steps in front of Resident #12 and again said something to the resident. Then Resident #1 came back and struck Resident #12 in the chest. Immediately Resident #12 grabbed the hair of Resident #1. Staff immediately separated the two residents. Doors between the two units were closed. -There were no interventions put in place to prevent recurrence implemented by the IDT. D. 7/6/19 1. Resident status Resident #1, age 71, was admitted on [DATE]. According to the (MONTH) 2019 CPO, [DIAGNOSES REDACTED]. The 10/19/19 MDS assessment revealed the resident had severe cognitive impairment according to the BIMS score of three out of 15. She had no behaviors exhibited and required limited to extensive assistance from staff for most ADLs. 2. Resident altercation The 7/6/19 nurse progress note documented a certified nurse aide (CNA) informed the nurse that there had been an incident in the dining room between Resident #12 and Resident #1. After the nurse reviewed the cameras, Resident #12 had been sitting quietly at the table waiting for breakfast and Resident #1 approached the table with a blanket and laid it on the table. Resident #12 and Resident #1 were talking then Resident #12 started to fold the blanket when Resident #1 grabbed the blanket from her. Resident #12 slapped Resident #1 on the right side of the face, then Resident #1 slapped her back. Resident #12 grabbed Resident #1 ' s hair and pulled her head on the table. The CNA separated the residents. The nurse described a small bruise on the Resident #12 ' s right wrist. The nurse documented that Resident #1 would eat in a different dining room than Resident #12 to prevent reoccurance. The 7/8/19 IDT progress note documented the events above, but indicated there were no injuries. -The intervention that IDT implemented were that the nurse was going to have her medication cart outside of the dining room to supervise Resident #12 in the dining room. E. 8/15/19 1. Resident status Resident #5, age 76, was admitted on [DATE]. According to the (MONTH) 2019 CPO, [DIAGNOSES REDACTED]. The 8/7/19 MDS assessment revealed the resident had short term and long term memory with severe impairment with daily decision making. She had physical behaviors towards others and other behavioral symptoms not directed towards others. She wandered and significantly intruded on the privacy of others. She required limited assistance from staff for most ADLs. 2. Resident altercation The 8/15/19 nurse progress note documented that staff heard a scream coming from the front area of the lobby. A physician was at the nurses station when she looked up and saw Resident #12 pulling the right ear of Resident #5 when a CNA separated the residents. The nurse assessed Resident #5 for injury and her right ear was red. The 8/16/19 IDT progress note documented that Resident #12 had pulled Resident #5 ' s right ear. Resident #5 right ear was red and painful at first and she was given Tylenol for pain. -There were no interventions put in place to prevent recurrence implemented by the IDT. F. 9/23/19 1. Resident status Resident #20, age 85, was admitted on [DATE]. According to the (MONTH) 2019 CPO, [DIAGNOSES REDACTED]. The 8/30/19 MDS assessment revealed the resident had cognitive impairment according to the BIMS score of seven out of 15. She had verbal behavioral symptoms directed towards others, rejected cares and wandered. She required limited assistance from staff for most ADLs. 2. Resident altercation Review of the Resident #12 ' s nurse progress notes revealed a progress note on 9/23/19 that documented, Neither resident had any recall of the incident 10 minutes later. DON informed Corporate authorities. Lakewood police arrived. -There was no documentation of what happened during the incident or what interventions put in place. In addition, the IDT review of the incident was not present. Review of the 9/23/19 abuse investigation form documented the dietary manager heard residents arguing when she saw Resident #12 pulling Resident #20 ' s hair and then put her hand around her neck. The residents were separated and wandered down the hall and with no injuries. [NAME] 10/7/19 1. Resident status Resident #24, age 76, was admitted on [DATE] with readmission 7/28/18. According to the (MONTH) 2019 CPO, [DIAGNOSES REDACTED]. The 9/5/19 MDS assessment revealed the resident had severe impairment with daily decision making and rejected cares. She required limited assistance from staff for most ADLs. 2. Resident altercation The 10/7/19 nurse progress note documented the nurse had a conversation with DON and after reviewing tape Resident #24 was sitting in her merry walker and had come to a standing position. Resident #24 went a few steps backwards coming into contact with Resident #12. In reaction Resident #12 placed her hands around Resident #24 ' s neck. A CNA was in proximity, she heard a commotion and stepped towards the two residents providing instruction for Resident #12 to let go of Resident #24 and she did moments later. Neither resident had an injury or pain and headed off in opposite directions as if nothing happened. The residents were monitored for the remainder of the evening with no further issue. The 10/10/19 IDT progress note documented that Neither resident showed any signs of distress or pain and were frequently checked on. Resident #12 was going to have her medications reviewed in the next [MEDICAL CONDITION] meeting on 10/10/19. -The [MEDICAL CONDITION] committee meeting was not held on 10/10/19 (see interviews below), therefore the resident's medications were not reviewed until 10/24/19 after an additional resident- to-resident altercation on 10/22/19. H. 10/22/19 1. Resident status Resident #5, age 76, was admitted on [DATE]. According to the (MONTH) 2019 CPO, [DIAGNOSES REDACTED]. The 8/7/19 MDS assessment revealed the resident had short term and long term memory with severe impairment with daily decision making. She had physical behaviors towards others and other behavioral symptoms not directed towards others. She wandered and significantly intruded on the privacy of others. She required limited assistance from staff for most ADLs. 2. Resident altercation The 10/22/19 nurse progress note documented that Resident #12 had been sitting in a chair in the hall, got up out of the chair and went on a walk down the hall. Resident #5 had sat in the chair and when Resident #12 returned she placed her hand on the neck of Resident #5 leaving a bright red ring around her neck with three finger nail marks on the right side of her neck and four finger nail marks on the left side of her neck. Implemented 30 minute checks for three days for Resident #12. The 10/25/19 IDT progress note documented the residents were separated and Resident #5 had red ring around her neck and fingernail marks. The residents were placed in their rooms. Resident #12 and Resident #5 had medication adjustments. Resident #12 was placed on 30 minutes checks until she went to sleep. -The 10/24/19 physician order [REDACTED]. V. Record review 1. Care plan The 3/6/19 wandering care plan documented the resident wandered into other resident rooms at night while residents were in bed. Interventions documented were monitor Resident #12 while awake at night and redirect her from other resident rooms. The 5/6/19 dementia care plan documented the resident was physically aggressive. Interventions documented were administer antipsychotic medication as ordered, analyze for day and time the behaviors and what de-escalates the behavior, anticipate her needs, offer resident a nap when she becomes agitated, nurse will supervise the dining area during the morning medication pass, refer to physician for medication evaluation and when she becomes agitated intervene before her agitation escalates. 2. Physician documentation The 12/1318 physician assistant progress note documented the resident had behavioral issues that have improved since she was ordered [MEDICATION NAME] 2 mg and that she failed a gradual dose reduction of [MEDICATION NAME]. The residents [MEDICATION NAME] was increased after she began having unprovoked aggressive behaviors and the resident had no aggressive behavior since the increase. The 1/15/19 physician progress notes [REDACTED].#12 ' s behavioral issues have improved since increasing her [MEDICATION NAME] from 1.5 mg to 2 mg. It documented, has a history of severe violence banging another residents head between a door and a wall. The 8/1/19 nurse practitioner progress note documented that staff reported the resident had recently pinned a nurse to the wall by the neck. The resident ' s unprovoked aggressive behavior was baseline per the staff and that she remained on [MEDICATION NAME]. The 9/19/19 physician progress notes [REDACTED]. It documented, not long ago she grabbed another female resident by the ears, screaming, ' How do you like it? ' She was reviewed in psychopharm meeting in (MONTH) and no changes in her medications was recommended. The 10/24/19 nurse practitioner note documented the resident had increased unprovoked aggression towards other residents. Staff report she had sudden, violent behavior directed toward other residents and staff were unable to anticipate these outbursts. It documented to increase her [MEDICATION NAME] from 2mg to 3mg due to the increase in her behaviors. It documented, Note she has previously been on higher doses than this to manage these behaviors which place resident and others at risk of harm. 3. Behavior documentation a. [MEDICAL CONDITION] review The 4/17/19 [MEDICAL CONDITION] review documented did not review the residents altercations subsequent to the review and recommended no changes to her [MEDICATION NAME] medication at 2 mg. -There were no addition [MEDICAL CONDITION] review of her medication. The 9/11/19 [MEDICAL CONDITION] review was not completely filled out until 10/27/19 with no recommendations made. b. Behavior tracking Review of behavior tracking from the Medication Administration Record [REDACTED] The (MONTH) 2019 MAR indicated [REDACTED]. The (MONTH) 2019 MAR indicated [REDACTED]. The (MONTH) CNA behavior tracking documented the resident had two episodes of yelling/screaming, one episode of threatening behavior and one episode of abusive language. The (MONTH) 2019 CNA behavior tracking documented the resident had one episode of pinching/scratching/spitting. 4. Activities documentation The 12/12/18 and 8/19/19 activity participation review documented that Resident #12 engaged in group activities and sitting in the common area/dining room talking with other residents. Review of activity progress note from (MONTH) 2019 to (MONTH) 2019 revealed the resident often did not participate in the group activities. She watched the activity personal conduct the activity, sit in the room where the activity was being held and she liked to watch television alone. The 10/21/19 activities care plan documented that Resident #12 engaged in group activities such as crafts, bingo, intergenerational, happy hour, manicures, and special events. She enjoyed independent leisure activities such as sitting in common and dining area talking to other residents. Her goal was to attend three group activities per month. Pertinent interventions were if she was anxious to invite her to calmer and quieter area, invite and remind her of programs of interest and to review her activity interests with the resident and family. -Resident #12 ' s activity interests did not align with her behavioral interventions for decreased stimulation due to her agitation since she had aggression towards other residents in the dining room where most of the group activities took place (see interviews below). VI. Staff interviews CNA #1 was interviewed on 10/20/19 at 1:10 p.m. She said she had worked at the facility for many years and worked the day shift from 6:00 a.m. to 2:00 p.m. She said the facility provided training on a regular basis on dementia care and how to deal with behaviors. She said the CNA staff documented resident behaviors in their point of care charting if it was indicated in a task for them to chart. She said Resident #12 had been involved with some resident-to-resident altercations with the most recent one a few weeks ago. She said after that incident Resident #12 was on check every 15 minutes. She said Resident #12 sat in the dining room during meals with two to three residents. She said the staff often checked on the residents in the dining room since it was a common area where the residents attended activity programs as well. She said the staff were not sure what triggered Resident #12 ' s behaviors but if residents or staff were in her personal space she may grab them. CNA #2 was interviewed on 10/30/19 at 1:20 p.m. She said Resident #12 had aggressive behaviors towards other residents and staff when they were too close to her. She said if she was in the dining room or a congested area it helped to remove her from the situation, talk to her, or provide her food or drink. She said Resident #12 was involved with at least two resident-to-resident altercations in the past few months. She said she was not provided one-to-one activities or restorative programs which may be beneficial for her since she did not do well in group settings. The restorative certified nurse aide (RCNA) was interviewed on 10/30/19 at 1:30 p.m. She said she did not work with Resident #12 with a restorative program but was often around for the group activities held in the dining room where Resident #12 wandered in and out. She said Resident #12 did not like when residents or staff invaded her private space. She said Resident #12 can strike at resident ot staff at anytime. She said the staff try to keep her active by walking her around the facility which seems to help with her aggression at times. RN #1 was interviewed on 10/30/19 at 1:40 p.m. She said she worked day shift 6:00 a.m. to 2:00 p.m. during the week. She said Resident #12 sometimes became aggressive with other residents that were in her space. She said that Resident #12 sometimes verbalized to the other resident to leave her alone. She said if residents continued to be in her space that she can become physically aggressive by hitting the other resident. She said her [MEDICATION NAME] medication was recently changed to 3 mg on 10/24/19 due to her most recent altercation on 10/22/19. She said the resident had previously been on a higher dose of [MEDICATION NAME] but was lethargic and not able to eat so the dose was lowered. She said she had not seen the symptoms of being lethargic since her [MEDICATION NAME] medication was increased. She said her nurses cart was often parked by the dining room during meals but she could not supervise the residents at al times since she had to pass medications. She said due to her behaviors being unpredictable the staff could not anticipate when she may be physically aggressive. She said most of the resident-to-resident altercation that had occurred over the past year that most of them were provoked by another resident in which Resident #12 reacted in a violent manner. The director of nursing (DON) was interviewed on 10/30/19 at 2:08 p.m. She said when a resident-to-resident altercation occurred then the staff were to intervene and assess the resident for any injury. The residents were charted on for three days after the incident to assess for latent injuries or psychosocial changes and the police were called. She said the facility conducted an abuse investigation by interviewing any pertinent staff involved or other residents, if interviewer able since it was a secured unit. She said the cameras could often be viewed after the incident to confirm what the events of the incident. She said upon conclusion of the internal abuse investigation the resident-to-resident altercation, the nursing home administrator reported it to the health department. She said for Resident #12 she had violent outbursts towards other residents, she was not provoked so it could happen at anytime and she liked to be left alone. She said one incident she was walking and initiated a violent attack on a resident and her most recent one she grabbed a resident around her neck leaving marks. She said in another instance she jammed a resident ' s head into a door jam that caused injury but she had not had that violent of an attack recently. She said due to the other residents initiating the attack by being in her personal space, her attacks were reationary to what the resident was doing to her like clapping in her face. She said the IDT had implemented different interventions like 30 minute checks and medication reviews by her physician. She said her husband was aware of her behavior and told the staff she was a mean person and violent at home prior to her being admitted to a secured unit. She said in reviewing the timeline of the incidents starting in (MONTH) 2019 since those were most of the incident when she was the assailant that the IDT could not have implemented any additional changes due to her behavior being unprovoked and reactionary. She said in (MONTH) 2019 when she had the incident with Resident #1 in the dining room, Resident #1 had her meals in a different dining room to ensure that the incident would not happen again the dining room. She said the residents had regular contact with each other outside of meals since most of the activities were held in the dining room area and Resident #1 and Resident #12 were often in the dining room together. She said the incident in (MONTH) 2019 when she pulled Resident #5 ' s right ear that caused her pain was in the front lobby area of the building. She said her physician was at the nurses station and saw Resident #12 pulling her ear. She said the residents were redirected since Resident #5 was getting into Resident #12 ' s personal space and being invasive. She said the intervention implemented was reviewing Resident #12 ' s blood pressure medication being discontinued that month and if that caused the resident to be less tired which caused her to be more active. She said the (MONTH) 2019 altercation another resident was making too much noise and snapping her fingers in front of Resident #12 ' s face so she reached out and grabbed Resident #20 ' s neck. She said the dietary manager was present and was able to separate the residents right away. She said due to Resident #12 grabbing Resident #5 ' s neck was a reaction to her snapping in her face so there was not an intervention that could be implemented. She said Resident #12 had two resident altercations in (MONTH) 2019. She said on 10/7/19, Resident #24 back her merry walker into her so Resident #12 grabbed her neck. She said the Resident #12 ' s medication were to be reviewed by the [MEDICAL CONDITION] committee on 10/10/19 but due to a snowstorm the committee had to reschedule the meeting so there were not any additional measures put in place. She said the additional altercation was on 10/22/19 where Resident #5 had sat in the chair that Resident #12 had been previously sitting when she wandered back to the chair. Resident #12 grabbed Resident #5 ' s neck and left a red mark and scratches on her neck. She said the physician assistant saw her two days later on 10/24/19 and increased her [MEDICATION NAME] from 2mg to 3 mg due to the most recent incident. She said in the meantime the resident was on 30 minute checks for three days to ensure she did not have another altercation with another resident. She said overall the facility staff know Resident #12 and her aggressive behaviors. She said the physician and staff did not want to increase her [MEDICATION NAME] due to her past of being lethargic and did not eat. She said since it had been almost a year since her previous increase in the [MEDICATION NAME] medication that the physician assistant felt it was appropriate to increase it on 10/24/19 since he recognized the resident had an increase in aggressive behaviors. She said the activity department was lacking previously and due to the added activities that reisden-to-resident altercations had subsided due to having additional group activities. She said Resident #12 ' s activity program did not change but she saw a difference with other residents. She said due to her favorable response to the increase in her [MEDICATION NAME] medication that she had not had a recurrence of aggressive behavior since 10/24/19 so the IDT thought that was the most effective approach to aide in controlling her behaviors to keep other residents safe. The nursing home administrator (NHA) was interviewed on 10/30/19 at 4:15 p.m. He said he had worked at the facility for two weeks so he was not present for the incidents involving Resident #12 until the 10/22/19 altercation. He said the facility took the safety of the residents as a top priority and implement one-to-one staff with her until the facility could devise a short term and long term plan to ensure she did not hurt others and had a quality of life due to medication not being the answer. The activity supervisor (AS) was interviewed on 10/31/19 at 10:56 a.m. She said she had recently started at the facility in (MONTH) 2019. She said she geared her activities towards residents with dementia since the facility was a secured unit. She said she had a variety of sensory activities, entertainment, parties and religious programs. She said the activities were provided seven days a week and she had evening programs. She said for Resident #12 she had one-on-one visits that started recently that were 15 to 20 minutes two times per week. She said she was changed to more one-to-one activity programming due to her not being engaged in group programming. She said she invited her to group programming still and her goal was to attend group activities four times per month. She said she liked the musical entertainment sometimes but most of the time she wandered out of the group activities. She said she was not involved with the IDT team when the team reviewed Resident #12 and the resident altercations she had with the other residents. She said based on the information she was given from the NHA that she was going to change her activity programming due to her doing well with low stimulation and solo activities. She said she would provide the resident with more one-on-one visits, offer her to listen to music since she enjoyed it and walking around the building or outside if the weather was nice since those activities seemed to lessen her agitation. The nurse practitioner (NP) was interviewed 10/31/19 at 11:13 a.m. He said he had been following Resident #12 for years and saw her routinely alongside of the physician assistant and physician. He said Resident #12 had a history of [REDACTED]. He said she had been on [MEDICATION NAME] (antipsychotic medication) about two years ago but was discontinued due to her having a significant uptick in her aggression and per the [MEDICAL CONDITION] committee they switched her to [MEDICATION NAME]. He said when her [MEDICATION NAME] was at a higher dose past 2 mg, she was having trouble eating so they had to lower her dose to 1.5 mg. He said he did increase her [MEDICATION NAME] to 2 mg after the resident-to-resident altercation in (MONTH) (YEAR). He said after the increase of the [MEDICATION NAME] to 2mg each day her behavior had stabilized based on the reports he received from the nursing staff when he went to see her. He said he started seeing increased episodes of aggression in (MONTH) 2019 but since it was sporadic and she did not do well with an increase in the [MEDICATION NAME] medication they continued to monitor her. He said he had informed the floor nurse of behavioral approaches to curb her aggressive episodes like providing her with less stimulation, offering her to lay down when she had increased aggression, walking her around the facility or outside to keep her busy

Based on observations, record review and staff interviews, the facility failed to have written, accessible plans and procedures to meet all potential emergencies and disasters, affecting the safety of all 54 facility residents. Specifically, the facility failed to have detailed, written plans and procedures that directed staff how to respond in emergencies involving evacuation, fire and other disasters. On 4/17/17, the courtyard gate, identified on the facility map as an emergency exit, was observed locked with a chain and a combination lock. Based on interviews with staff, the code to the combination lock was not known to staff and was not documented in the facility's Emergency Preparedness Manual. Further review of the Emergency Preparedness Manual revealed the emergency and disaster plan was not detailed or tailored to the geographic location or type of residents the facility served. These failures created a situation of immediate jeopardy with widespread potential for serious harm. The findings include: I. Immediate Jeopardy a. Imposition of Immediate Jeopardy On 4/18/17 at 1:40 p.m., the nursing home administrator (NHA) was informed the locked courtyard gate and staff's lack of knowledge of the codes to unlock the gate, as well as the facility's failure to have detailed written emergency and disaster plans directing staff how to respond in emergencies, created a situation of immediate jeopardy for with widespread potential for serious harm. b. Facility Response to Immediate Jeopardy On 4/19/17 at 8:56 a.m., the following plan (draft #3) was submitted by the facility to the Colorado Department of Public Health and Environment (CDPHE) to remove the immediate jeopardy situation. The plan read: Abatement Plan 4/18/17 1:40 p.m. Immediate Jeopardy called On 4/18/17 at 2:20 p.m. the padlock was removed from courtyard gate by maintenance director (MTD). An alarm was placed on the courtyard gate to notify staff when the courtyard emergency gate is opened, in addition to the current alarm that sounds in the nursing station on 4/18/17 at 3:03 p.m. by MTD. The alarm will be checked daily for functionality by Maintenance staff. Any changes to a door code will be posted in both emergency manuals at the nursing stations, the employee break room, and both communication books by MTD. Emergency door codes were posted at each emergency exit, in the disaster manuals, and the staff breakroom on 4/18/17 at 3:00 p.m. by MTD. The facility maps with emergency exit routes were updated on 4/18/17 at 2:20 p.m. to include emergency exits by NHA. The Disaster Manual was updated to include specific staff roles during an evacuation, who can initiate an evacuation, in what order to remove residents, and other clarifying procedures on 4/18/17 at 4:30 p.m. by interdisciplinary team. Emergency Exit Only signs were posted at the courtyard gate on 4/18/17 at 3:05 p.m. by MTD. Education: No staff will be allowed to work until they have been educated on the updated evacuation policy and emergency exit codes by their direct supervisor or designee. Education will be completed with the next scheduled day of work or no later than April 30, 2017. Staff education was initiated on 4/18/17 at 2:35 p.m. and completed by 3:15 p.m. to all staff currently in the facility regarding the courtyard gate being used as an emergency exit only, and educating the staff on the codes to evacuate through the gate by NHA. Maintenance Director was educated to never lock an exit door without prior approval from Life Safety and CMS Personnel on 4/18/17 at 4:40 p.m. by NHA. Telephonic educat(ion) was initiated on emergency exit door codes for staff not present at the facility on 4/18/17 at 2:55 p.m. by NHA and DON. Staff will continue to be educated upon hire, monthly at all staff meetings for three months and then quarterly regarding the courtyard safety and emergency evacuation/disaster plan by (name of maintenance director) MTD or designee. Return demonstration education will be completed on every shift by means of fire drill by Friday, April 2017 by (name of maintenance director), MTD. The facility provided CDPHE the following updated policies and procedures, all of which were approved by CDPHE: - Disaster Plan - Duties of Disaster Control Committee - Fire Plan - Fire Alarm Stations - Inoperative Fire Alarm - Evacuation Center Receiving Plan - Facility Floor Plan c. Removal of the Immediate Jeopardy: On 4/19/17 at 10:15 a.m. the NHA was notified the immediate jeopardy had been removed based on staff interview and review of the facility's abatement plan. However, deficient practice remained at F level (potential for more than minimal harm that is widespread) based on facility's systemic failures in emergency preparedness identified during survey 4/11/17 - 4/20/17, including the lack of floor plans that mapped residents' evacuation and the lack of staff training on evacuation as well as on staff response to other emergency situations. II. Failure to have detailed, written plans and procedures that directed staff how to respond in emergencies involving evacuation, fire and other disasters. A. Observations On 4/18/17 at 11:45 a.m., the red notebooks labeled Emergency Preparedness Manual and containing emergency preparedness information were observed at each of the facility's two nurses' stations. The notebooks lacked a table of contents or index separators for quick access to various potential emergency situations, given the facility's geographic location and the type of residents the facility served. On 4/18/17 at 11:45 a.m. observations revealed the outdoor courtyard was approximately 30 feet by 30 feet in size with one exit through a gate. The gate was secured with a magnetic keypad lock and a chain held together with a combination lock. On 4/18//17 at approximately 12:00 p.m., observation of the facility floor plan posted down the hall from the Monarch dining room revealed it failed to identify an evacuation route and exit in case of an emergency, except to the courtyard. B. Record Review Review of the Emergency Preparedness Manual notebooks revealed: --No facility floor plan with an emergency evacuation route and exit identified; --No information on the location of the offsite evacuation site; --No information on how to evacuate residents and in what order; --No information on transportation of residents to the offsite evacuation location; --No information on the code to unlock the magnetic keypad lock or to the four digit combination lock securing the courtyard gate. --No severe winter weather policy or procedures. --No information on emergency water. C. Interview The Maintenance Director (MTD) was interviewed on 4/18/17 at approximately 1:00 p.m. The MTD said that he had only been employed at the facility for the past three months. He said he had not reviewed the Emergency Preparedness Manuals to ensure the information in the manuals was complete and accurate. He said he had recently updated all the facility employee contact information, but had not reviewed or amended the any other content in the manuals. The MTD confirmed the floor plans posted throughout the facility and in the Emergency Preparedness Manuals did not identify an emergency evacuation route and exit from the facility. He said he was in the process of getting a bid from the fire alarm company to print out a floor plan with an evacuation route. He said he did not know the location of the facility's offsite evacuation site. III. Facility follow-up during survey Review of the Emergency Preparedness Manuals revealed the manuals were updated on 4/18/17 at approximately 4:30 p.m. to include a floor plan with evacuation routes and exit, the codes to unlock the magnetic keypad lock and the combination lock on the outside courtyard gate, and the location of the offsite evacuation site. The manuals also had been updated to include specific staff roles during an evacuation, including who can initiate an evacuation, in what order to remove residents, and other relevant procedures in conducting a resident evacuation. The MTD was interviewed again on 4/20/17 at approximately 1:00 p.m. about the facility's supply of emergency water. The MTD said the hot water tanks held about 170 gallons of water and bottled water was maintained in the facility. He said he would update the Emergency Preparedness Manual to include information on where the bottled water was stored. The MTD also said he would re-work the manuals for quick access to potential emergencies based on the facility's geographic location and resident population.

Based on observations, interviews and record review, the facility failed to ensure all staff were trained in procedures to emergently evacuate residents from the facility's secured outdoor courtyard, affecting the safety of all 54 facility residents. Specifically: Review of the facility floor plan revealed two exits into the outdoor courtyard; each exit had an EXIT sign that pointed toward the courtyard doors. Observation of the outdoor courtyard revealed it was approximately 30 feet by 30 feet in size with one exit through a gate. The gate was secured with a magnetic keypad lock and a chain held together with a four digit combination lock. Staff reported they were unaware of the codes to release one or both of these locks on the gate. The facility's failure to ensure staff was trained in the codes to release the locks securing the outdoor courtyard created a situation of immediate jeopardy with widespread potential for serious harm. The findings included: I. Immediate Jeopardy a. Imposition of Immediate Jeopardy On 4/18/17 at 1:40 p.m., the nursing home administrator (NHA) was informed the locked courtyard gate and staff's lack of knowledge on how to unlock the gate to safely evacuate residents created a situation of immediate jeopardy with widespread potential for serious harm. b. Facility Response On 4/19/17 at 8:56 a.m., the following plan (draft #3) was submitted by the facility to the Colorado Department of Public Health and Environment (CDPHE) to remove the immediate jeopardy situation. The plan read: Abatement Plan 4/18/17 1:40 p.m. Immediate Jeopardy called On 4/18/17 at 2:20 p.m. the padlock was removed from courtyard gate by maintenance director (MTD). An alarm was placed on the courtyard gate to notify staff when the courtyard emergency gate is opened, in addition to the current alarm that sounds in the nursing station on 4/18/17 at 3:03 p.m. by MTD. The alarm will be checked daily for functionality by Maintenance staff. Any changes to a door code will be posted in both emergency manuals at the nursing stations, the employee break room, and both communication books by MTD. Emergency door codes were posted at each emergency exit, in the disaster manuals, and the staff breakroom on 4/18/17 at 3:00 p.m. by MTD. The facility maps with emergency exit routes were updated on 4/18/17 at 2:20 p.m. to include emergency exits by NHA. The Disaster Manual was updated to include specific staff roles during an evacuation, who can initiate an evacuation, in what order to remove residents, and other clarifying procedures on 4/18/17 at 4:30 p.m. by interdisciplinary team. Emergency Exit Only signs were posted at the courtyard gate on 4/18/17 at 3:05 p.m. by MTD. Education: No staff will be allowed to work until they have been educated on the updated evacuation policy and emergency exit codes by their direct supervisor or designee. Education will be completed with the next scheduled day of work or no later than April 30, 2017. Staff education was initiated on 4/18/17 at 2:35 p.m. and completed by 3:15 p.m. to all staff currently in the facility regarding the courtyard gate being used as an emergency exit only, and educating the staff on the codes to evacuate through the gate by NHA. Maintenance Director was educated to never lock an exit door without prior approval from Life Safety and CMS Personnel on 4/18/17 at 4:40 p.m. by NHA. Telephonic educat(ion) was initiated on emergency exit door codes for staff not present at the facility on 4/18/17 at 2:55 p.m. by NHA and DON. Staff will continue to be educated upon hire, monthly at all staff meetings for three months and then quarterly regarding the courtyard safety and emergency evacuation/disaster plan by (name of maintenance director) MTD or designee. Return demonstration education will be completed on every shift by means of fire drill by Friday, April 2017 by (name of maintenance director), MTD. The facility provided CDPHE the following updated policies and procedures, all of which were approved by CDPHE: - Disaster Plan - Duties of Disaster Control Committee - Fire Plan - Fire Alarm Stations - Inoperative Fire Alarm - Evacuation Center Receiving Plan - Facility Floor Plan c. Removal of the Immediate Jeopardy: On 4/19/17 at 10:15 a.m. the NHA was notified the immediate jeopardy had been removed based on staff interview and review of the facility's abatement plan. However, deficient practice remained at F level (potential for more than minimal harm that is widespread) based on facility's failure to train staff to release the locks securing the outdoor courtyard gate in order to evacuate residents off facility premises, if necessary. II. Failure to ensure all staff were trained in how to release the locks securing the gate in the outdoor courtyard. A. Observations and Resident Representative Interview Observations of 4/18/17 at 11:45 a.m. of the floor plan located down the hall from the Monarch dining room did not identify an evacuation route but showed two exits into the courtyard. Both of the exits had an EXIT sign that pointed toward the courtyard doors. Observations on 4/17/17 at 7:14 p.m. revealed the courtyard gate was secured with a magnetic keypad lock and a chain held together with a four digit combination lock. Resident #28's representative, interviewed on 4/17/17 beginning at 7:14 p.m., confirmed the gate in the courtyard was locked with a combination lock and magnetic keypad lock. She said she found out about the chain and combination lock on the gate approximately two to four weeks ago. B. Interviews Interviews with the NHA and the Maintenance Director indicated the locks were placed on the courtyard gate to prevent resident elopements, but without adequate training of staff as evidenced by staff stating they were unfamiliar with the codes to release one or both of the two locks securing the courtyard gate. 1. Maintenance Director (MTD) and NHA The MTD was interviewed in the courtyard on 4/18/17 at 12:03 p.m. and again at 1:00 p.m. He said he put the chain and lock on the gate about three weeks ago. He said vendors were coming in and out, people were going in and out, and he said residents had eloped through the courtyard gate. He said he put the chain and lock on because the facility did not want anyone going in or out through the gate. He also said the fire marshal approved securing the gate with a chain and combination lock and the NHA would have documentation of that approval in her computer. The NHA was interviewed regarding the courtyard gate on 4/18/17 at 12:12 p.m. Although she was unable to provide any documentation from the fire marshal, the NHA confirmed she called the fire marshal to look at the chain and combination lock because the gate presented such an elopement risk. She said the fire marshal said the courtyard was not considered an emergency exit but rather an area of refuge. She stated the fire marshal told her she could board up the gate and not have an exit from the courtyard at all. When asked how residents and staff would evacuate from the courtyard, she stated they could use the doors inside the facility as emergency exits which she acknowledged would require staff and residents to re-enter the building in an emergency. 2. Staff interviews A licensed practical nurse (LPN) was interviewed on 4/17/17 at approximately 12:15 p.m. The LPN said that in an event of a fire, she would evacuate the residents to the courtyard. She knew the code to the magnetic keypad on the courtyard gate, but she did not know the code to the combination lock securing the chain on the gate. Certified nurse aide #1 (CNA) was interviewed on 4/17/17 beginning at 7:30 p.m. She stated the magnetic keypad froze during the winter, so it did not always lock properly when it was cold. During the interview, the CNA unlocked the magnetic keypad lock but she was unable to unlock the combination lock because she did not know the code. She stated she was told staff could no longer enter or exit the courtyard gate. The social service director (SSD) and restorative certified nurse aide (RCNA) were interviewed in the courtyard on 4/18/17 at 11:45 a.m. Both staff stated they did not know the code to the combination lock securing the courtyard gate. Both staff stated they were not trained to on how to release the combination lock. A registered nurse (RN #1) was interviewed on 4/18/17 at approximately 12:15 p.m. The RN said that in event of an evacuation, she would use the courtyard. She did not know the code to release the combination lock securing the chain on the gate. Housekeeper #2 (HSK) was interviewed on 4/18/17 at 1:10 p.m. HSK #2 said there were two exits to the courtyard; she said she would follow the signs to exit out one of the courtyard exits. She said she did not know the codes to unlock the two locks on courtyard gate. HSK #2 said she does not use the locks and did not know if they were the same code. She stated a CNA would know and would use the code if there was an emergency. HSK #1 was interviewed on 4/18/17 at 1:10 p.m. She said if an evacuation was required, she would take the residents to the courtyard. She did not know the code to the lock that secured the chain on the courtyard gate. CNA #5 was interviewed on 4/18/17 at 1:15 p.m. She said if all the residents needed to be evacuated, she would take them to the courtyard. She did not know the code to the lock that secured the chain on the courtyard gate. The RCNA was interviewed on 4/18/17 at approximately 1:15 p.m. The RCNA said that if there were a fire, she would take residents out to the courtyard. She did not know code to the lock that secured the chain on the courtyard gate.

Based on observations, record review and interviews, the facility failed to ensure that the resident's environment remained as free of accident hazards as possible; and each resident received adequate supervision and assistance devices to prevent accidents for three residents (#4, #2 and #1) out of five sampled residents. Specifically, the facility failed to: - Monitor resident #4's location and subsequently the resident was found outside and exposed to heat and sun. Once the resident was located the resident was taken to the emergency room and evaluated for heat exposure. Additionally, the facility failed to: -Provide adequate supervision and secure the maintenance area to prevent resident #4 from wandering into the unsecured and unattended area which contained potentially dangerous materials; - Ensure resident #4 and #2 wandering risk assessment and scales were completed quarterly and annually in order to promote individualized resident care and prevent accidents; - Ensure resident #1 wandering risk assessment and scale was completed upon admission in order to promote individualized resident care and prevent accidents; and - Create an elopement and wandering care plan for resident #1. The findings included: 1. Professional References According to the Mayo Clinic, Fever: First aid, http://www.mayoclinic.org/first-aid/first-aid-fever/basics/art- 685, 2016 (7/16), in pertinent part: The average body temperature is 98.6 F (Fahrenheit) .normal body temperature can range between 97 (F) and 99 (F) or more. Your body temperature can vary depending on how active you are or the time of day. Generally, older people have lower body temperatures than younger people . The following thermometer readings generally indicate a fever: Rectal, ear or temporal artery temperature of 100.4 (F) .or higher .Oral temperature of 100 F or higher .Armpit temperature of 99 F or higher . According to the Mayo Clinic, Heat exhaustion, http://www.mayoclinic.org/diseases-conditions/heat-exhaustion/basics/definition/con- 366, 2016 (7/16), in pertinent part: Heat exhaustion is a condition whose symptoms may include heavy sweating and a rapid pulse, a result of your body overheating. It's one of three heat-related syndromes, with heat cramps being the mildest and heatstroke being the most severe . Causes of heat exhaustion include exposure to high temperatures, particularly when combined with high humidity, and strenuous physical activity. Without prompt treatment, heat exhaustion can lead to heatstroke, a life-threatening condition. Fortunately, heat exhaustion is preventable . 2. Facility policy and procedure The Missing Resident policy was provided on 7/25/16 at 3:00 p.m. by the nursing home administrator (NHA). The document included, the facility was .to ensure that the facility provides a safe and secure atmosphere for all residents in the facility . 3. Interested Party Interview An interested party was interviewed on 7/19/16. He said on 7/10/16 resident #4 went missing from staff supervision for three to four hours. The resident was found unconscious outside in the direct sunlight which was above 95 degrees F and inside of the maintenance area. She had sunburns on her head, face, arms, and hands. Her skin was hot, flushed and dry and she had a temperature of 111 degrees F. 4. Resident #4 Resident #4, age 79, was admitted on [DATE]. According to the face sheet, [DIAGNOSES REDACTED]. According to the 3/7/16 minimum data set (MDS) assessment, the resident was severely cognitively impaired with a brief interview for mental status (BIMS) score of three out of 15. She required limited to extensive assistance with activities of daily living (ADLs). She wandered daily, and was at significant risk of getting into a potentially dangerous place or intruding on the privacy or activities of others. The care plan, initiated on 9/25/14 and updated on 7/11/16, identified the potential for elopement and wandering related to dementia. She had impaired safety awareness, disorientation, and a history of attempting to leave the facility unattended. Interventions included: - Sent the resident to emergency room for evaluation after 7/10/16 incident; - Replaced the lock to the maintenance area after 7/10/16 incident; - Only the maintenance man and supervisor will have key to maintenance area after 7/10/16 incident; - Resident seen by nurse practitioner (NP) and monitored for seven days through skilled charting after 7/10/16 incident; - Assess appropriateness of the locked setting annually and as needed; - Assess for fall risk; - Distract resident from wandering by offering pleasant diversions; - Monitor fatigue and weight loss; - Provide structured activities; - The resident often opens doors to walk in the locked areas; and - Walk the resident away from the exits while making conversation and distract. A. Observations The courtyard and maintenance area was observed with the plant supervisor (PS) on 7/25/16 at 1:03 p.m. behind the gated and locked maintenance area of the courtyard several potentially dangerous items were present. There were over 20 different types of gardening tools including, rakes and shoves, four large containers of chemicals used for pest control, a lawn mower, broken electronics, a water heater, and more. B. Record review The 7/16 physician orders [REDACTED]. The 11/14/13 Wandering Risk Scale was the most recent risk assessment completed. The document revealed she scored a 12 (high risk to wander). The 1/21/16 Continued Stay Review revealed she wandered around the facility consistently. She was invasive and intrusive, which had put her at risk for harm. She would not be able to find her way back if she left (the) facility. The 7/10/16 incident progress note revealed the following pertinent information: - At 4:30 p.m. the staff was unable to locate resident #4 and a facility search was started; - The staff looked though all the rooms, bathrooms, closets, under beds, in locked rooms, and could not locate the resident; - A search of the courtyard revealed the maintenance gate did not have a lock on it; - During an inspection she was found behind the shed; - She was found semi-responsive and sunburned at approximately 1830 (6:30 p.m.); - She was moved inside and staff attempted to cool her off. Her temperature was 111 degrees F; - Physician order [REDACTED]. - She left the facility at approximately 1815 (6:15 p.m.); - The resident's family was notified; and - A lock was placed on the gate for future safety. The 7/11/16 interdisciplinary team (IDT) progress note revealed the following pertinent information: - The note was completed by the assistant director of nursing (ADON); - She was found unresponsive outside in the maintenance area; - The door was unlocked to the maintenance; - The outside area was checked after the inside of the building was checked; - She was lying on the floor unresponsive and extremely hot; - Her temperature was 105 degrees F when found; - Her temperature was lowered to 99 degrees F once resident became responsive; and - Lock was replaced and resident will be monitored for seven days with skill charting. The 7/11/16 nursing note revealed the resident continued close monitoring after a recent emergency room visit related to sunburn and decreased consciousness. The 7/13/16 IDT progress note revealed the following pertinent information: - The note was completed by the director of nursing (DON); - The note was a clarification note regarding the 7/10/16 incident; - The resident was last seen in the courtyard for the 3:30 p.m.-4:00 p.m. smoke break with other residents and staff members; - At dinner which was around 4:30 p.m. the staff was unable to locate her and a facility search started; - Staff looked though all the rooms, bathrooms, closets, under beds, and could not locate the resident; - The courtyard was observed and the lock that had been placed on the gate to keep residents from entering into the gated area was not there; - She was found and the staff members revealed that she was very tired in appearance and assisted into a wheelchair; - Cold washcloths and ice were placed on her skin to cool her off; - Her body temperature ranged from 103.9-105.9 degrees F per the staff; - A physician order [REDACTED]. - The staff was instructed to find the missing lock that was required to be on the gate; - The next day follow up meeting interventions were discussed; - Only maintenance, the NHA, the DON, and charge nurses will have the new combination for the shed area-lock; - The resident was placed on 15 minute checks and the gait lock was placed on hourly checks; and - All residents that were sitting outside will be offered water, sunscreen, hats, and sunglasses. The 7/18/16 nursing progress note revealed the resident continued on skilled charting after being found in the courtyard with a [DIAGNOSES REDACTED]. C. Hospital records The Hospital Patient Records were provided by the hospital on [DATE] at 8:15 a.m. The documents revealed the following pertinent information: - On 7/10/16 at 6:32 p.m. she arrived to the hospital via ambulance; - The chief complaint upon arrival was heat exposure; - The history revealed she had severe dementia and escaped from her memory care unit. She was found several hours later lying down in the 99 degree F heat and exposed to the sun; - Staff called 911 and stated she went missing around 2 or 3 and then we found her lying outside on the ground, in the sun, and unconscious. Staff reported that they carried her inside and began cooling her with cold water and ice packs. Staff reported an initial temperature of 111 degrees F and now had her down to 99 degrees F . Staff described the skin as extremely red and her color has now returned to normal . - Her body temperature was 99.7 degrees F; - She was treated with intravenous (IV) fluids; - The final [DIAGNOSES REDACTED]. - On 7/10/16 at 11:38 p.m. she discharged from the hospital and back into the facility. D. Facility investigation The facility's completed investigation for the 7/10/16 incident was observed on 7/25/16 at 4:36 p.m. Statement #1 (undated and no time), documented by the registered nurse (RN) #1, revealed the following pertinent information: - The staff reported they were looking for resident #4 at 4:30 p.m.; - All staff searched the rooms, closets, under the beds, bathrooms, and locked rooms with no luck; - The courtyard was searched and the maintenance gate was observed without a lock; - The staff found her behind the shed; - She was semi-responsive and sunburned at approximately 6:30 p.m.; - She was moved inside immediately and staff attempted to cool her off; - Her body temperature was recorded at 111 degrees F; - She was transported to the hospital; and - A lock was placed on the gate for future safety. Statement #2, dated 7/11/16 (no time), documented by the licensed practical nurse (LPN) #1, revealed the following pertinent information: - A staff member reported to the statement writer at 4:30 p.m. that they were unable to locate resident #4; - An immediate search of the building began; - The building was swept multiple times by staff looking in closets, under beds, bathrooms, showers, and linen closets; - The courtyard was searched and the maintenance gate was observed without a lock; - The maintenance area was a locked area; - She was found at the northwest corner and between the two sheds at 5:30 p.m.; - She was in the direct sunlight, semiconscious, face red, and unable to speak; - She was lifted into her wheelchair and brought inside; - Her clothes were removed and towels and wash clothes were used to cool her down; - Physician called and orders obtained to send her to the hospital for evaluation and treatment; and - She was sent to the hospital at 6:10 p.m. via ambulance. Statement #3, dated 7/11/16 at 11:06 a.m., documented by the DON, revealed the following pertinent information: - The facility was searched for unlocked doors and the shed was observed without a lock; and - The statement writer found resident #4 lying on the ground in the sun, bright red, and unresponsive. The 15 minute check documents revealed the following pertinent information: - The documents dated, 7/12/16-7/16/16, and 7/23/16 was completed; - The incident had occurred on 7/10/16; - The documents dated, 7/17/16-7/22/16, and 7/24/16 were not completed. The staff education/in-service documents, skilled charting documents, and skin assessments were not observed in the folder with the progress notes and staff statements. 5. Resident #1 Resident #1, age 77, was admitted on [DATE]. According to the face sheet, [DIAGNOSES REDACTED]. According to the 6/13/16 MDS assessment, the resident was cognitively intact with a BIMS score of 13 out of 15. He required supervision for ADLs, and did not utilize the assistance of any devices for mobility. He was not observed to wander or have behavior symptoms since admission to the facility. The care plan, dated 6/7/16, identified the resident was independent and dependant on staff for emotional, intellectual, physical, and social needs related to dementia with aggressive behaviors. Interventions included: - Speak to resident while providing cares; - Encouragement of family involvement; - Establish and record the resident's prior level of activity involvement and interest; - Introduce the resident to resident with similar backgrounds, interests, and encourage and facilitate interaction; and - Invite the resident to scheduled activities and provide a program of activities. Resident #1's paper and online charts were reviewed on 7/25/16 at 1:30 p.m. The review revealed there was only one care plan completed since the resident's admission to the facility. Resident #1's care plan was provided by the ADON on 7/25/16 at 1:50 p.m. She confirmed all the care plans were provided. A. Record review The 6/16 Secured Special Care Unit Acknowledgement revealed the secured unit criteria: 1. The resident is a serious danger to self or others, or 2. The resident habitually wanders or would wander out of the building (s) and is unable to find the way back, or 3. The resident has a significant behavior problem that seriously disrupts the rights of other residents; and in all cases 4. Less restrictive alternatives have been unsuccessful in preventing harm to self or others; and 5. Legal authority for such restrictive authority has been established . The wandering risk assessment and scale was not completed. The ADON was interviewed on 7/25/16 at 1:50 p.m. She said resident #1's Wandering Risk Assessment was not completed, and the facility did not utilize the assessments on elopement risk and mobility for any resident. 6. Resident #2 Resident #2, age 74, was admitted on [DATE]. According to the face sheet, [DIAGNOSES REDACTED]. According to the 5/23/16 MDS assessments, the resident was moderately cognitively impaired with a BIMS score of 10 out of 15. He required supervision to limited assistance with ADLs, and required the use of a wheel chair and walker for mobility. He was not observed to wander or have behavior symptoms. The care plan, dated 9/15/14, identified the potential for elopement and wandering related to dementia. He had impaired safety awareness and a history of attempting to leave the facility unattended. Interventions included: - Assess for falls; - Distract resident from wandering by offering pleasant diversions; - Identify pattern of wandering; - Monitor for fatigue and weight loss; and - Provide structured activities. A. Record review The 11/22/14 Wandering Risk Assessment was the most recent assessment completed. The document revealed he scored a 12 (high risk to wander). 7. Staff interviews The social worker (SW) was interviewed on 7/25/16 at 12:45 p.m. She said resident #4 was at-risk for wandering and had recently wandered into an unsecured maintenance area located outside and in the resident courtyard. The resident had low mental capacity and was unable to get out of the unlocked area on her own. She was found outside in between two sheds after a search of the facility was conducted. After the incident the gate was locked and the resident sent to the hospital for an evaluation. She revealed the intervention put into place was not customized for the resident, but intended to keep out unwanted staff and residents from the area for the future. She said the elopement and mobility assessments were not used by the facility, and the wandering assessments were not required to be completed. She revealed she had been working with the facility for approximately nine months and she had not completed a formal wandering assessment or scale for any resident. The approaches and interventions for all the residents were the same, because all of the residents resided in a locked facility; therefore, there was not a need for individualized wandering or elopement assessment. She revealed she was responsible for completing the MDS assessments, which were the same as the wandering assessments. The NHA was interviewed on 7/25/16 at 4:05 p.m. She said the interventions for resident #4 after the 7/10/16 incident included 15 minute checks and offering water. All residents that were sitting outside will be offered water, sunscreen, hats, and sunglasses in response to the incident. She said staff was educated on the new interventions via an in-service. A copy of the in-service was requested but not provided. She said she was unable to locate the in-service. She reported she was not present on the day of the incident, but believed the resident was not missing as long as the notes revealed. She said she knew she had not been missing for long because she had not been sunburned at all. She said the resident had a history of [REDACTED]. The checks were documented by the CNAs. She said wandering and elopement assessments, and care plans were required to be completed upon admission, quarterly, change of condition, and annually with the MDS assessments by the nursing staff or SW. She said wandering was part of the criteria for residents to reside in the secured facility, and their individualized care was based on the care planned interventions. The DON was interviewed on 7/25/16 at 12:08 p.m. She said after an incident occurred in the facility it was the responsibility of the charge nurse to document the incident and put an immediate intervention into place. The following day the IDT met and discussed secondary interventions and updates the care plans. She said the entire facility was locked and all of the residents residing in the facility were at risk of elopement and wandering. The elopement and wandering assessments were completed by the social worker (SW). The DON was interviewed on 7/25/16 at 4:28 p.m. She said the resident frequently wandered around the building and outside into the courtyard. She was not present on the day the resident went missing, but said she believed she went missing somewhere between 3:30 p.m. and 3:45 p.m. The resident was not in sight of staff for about an hour and a half before they began searching for her. She said after she was found the report said she was 111 degrees F, which was inaccurate. She said the resident was not unresponsive and the documentation was an error in reporting. The resident was on 15 minute checks prior to the incident because of her past history with wandering into men's bedrooms. Supporting documentation was requested and not received. The PS was interviewed on 7/25/16 at 1:05 p.m. He said he did not know who had left the gate opened or unattended. A new lock had been placed on the gate, and controlled access and monitoring was put into place after the incident. Certified nurse aide (CNA) #3 was interviewed on 7/25/16 at 1:15 p.m. She said the resident wandered the facility on a regular basis. She would walk into other resident's rooms, and had the ability to open doors and go through drawers and open bottles. Prior to the 7/10/16 incident she was not receiving 15 minute checks, but would have benefited from the monitoring. She revealed she did not receive an in-service on offering water, sunscreen, hats, and sunglasses to residents outside. CNA #5 was interviewed on 7/25/16 at 1:22 p.m. She said resident #4 had a history of [REDACTED]. She said she did not receive an in-service on offering water, sunscreen, hats, and sunglasses to residents outside or 15 minute checks for resident #4. Registered nurse #2 was interviewed on 7/25/16 at 1:35 p.m. She said resident #4 was at-risk of elopement due to her wandering. She revealed she could open doors and at times trapped herself in other resident's rooms. She said elopement and wandering assessments were completed upon admission, quarterly, change of condition, and annually by the nursing staff.

Based on record review and interviews, the facility failed to ensure one (#2) of three sample residents received the care and services necessary to maintain acceptable parameters of nutritional status. Specifically, the facility failed to adequately address weight loss in resident #2, who was assessed at high nutritional risk, to provide timely assessments and interventions of the continued weight loss, and assess the resident's oral status (lost dentures). As a result the resident had a 17.1 lb. weight loss from 2/ 5/14 through 8/15/14. The findings include: A. Facility policy The facilities weight assessment and intervention policy with a revision date of April 2012 read in pertinent part: - Any weight change of five percent (%) or three pounds (lbs.) more or less since the last weight assessment will be retaken the next day for confirmation. If the weight is verified, nursing will immediately notify the dietician in writing. Verbal notification must be confirmed in writing. - The dietitian will review the unit weight record by the 15th of the month to follow individual weight trends over time; negative trends will be evaluated by the treatment team whether or not the criteria for " significant " weight change has been met. - The threshold for significant unplanned and undesired weight loss will be based on the following criteria (where percentage of body weight loss = (usual weight - actual weight) / (usual weight) x 100): 1. One month - 5 % percent weight loss is significant; greater than five % is severe. 2. Three months - 7.5 % weight loss is significant; greater than 7.5 % is severe. 3. Six months - 10% weight loss is significant; greater than 10% is severe. 1. Resident Status upon admission Resident #2, age 97, was admitted to the facility on [DATE]. His/her pertinent admission [DIAGNOSES REDACTED]. According to the admission minimum data set (MDS) assessment dated [DATE], the resident had severe cognitive (memory) deficits. S/he had unclear speech, sometimes understood others, and was sometimes able to make his/her needs known. His/her height was 56 inches tall, weighed 107 lbs, and had not had any significant weight loss over the past one to six months. According to the physician's history and physical dated 2/5/14, the resident was admitted to the facility for increased assistance due to debility related to dementia with behaviors including wandering. The resident reported that s/he was doing well, except for some back and head pain due to a fall a few days ago. His/her past medical history revealed Alzheimer's, [MEDICAL CONDITION] with delusions, dysphagia, urinary incontinence, chronic pain, and [MEDICAL CONDITION]. The resident was on comfort measures and the physician's pertinent plan for the dysphagia indicated that there were no current issues and would follow. 2. Identification of nutritional risks and plans to address risks A nutritional assessment was completed by the registered dietician (RD) on 2/6/14. The nutritional assessment revealed the resident had a height of 56 inches and had a current weight of 106.4 lbs. His/her usual body weight was not identified and his/her body mass index (BMI) was 23.8. The assessment further revealed that the resident had some weight loss at a prior facility of 11 lbs in six months (not reflected in the admission MDS). The resident's weight goal was to maintain a healthier BMI. S/he required set up assistance at times for meals and could also wander at times. S/he was noted to have upper dentures. - The resident's intake evaluation revealed s/he ate 75-100% of supper and all other meals were left blank. His/her physical appearance was described as being nourished and hydrated. -His/her estimated nutritional needs were based on a weight of 106.4 lbs and required 1104 calories, based on 48 kilograms (kg) x 25 kilocalories (Kcal)/kilogram (kg), 53 protein, gram (gm) based on 1.1 gm/kg, 1440 fluid, milliliters (ml) based on 30 ml /kg -The resident had a [DIAGNOSES REDACTED]. - The nutrition plan/diet order included; regular diet, regular texture, and regular liquids. -The nutrition intervention included 90 ml of med pass (dietary supplement) three times a day (TID). - The nutrition intervention/prescription/recommendations included encourage good intake at meals, offer snacks or alternates as needed, assist as needed with meals, and continue to monitor weight trends and intake. - The resident currently had a healthy BMI and good intake at only couple of meals since admission. Staff would continue med pass until intake and weight history was established. Care Plans A dietary care plan initiated on 2/6/14, documented the resident had a nutritional problem or potential nutritional problem related to dementia, admitted with a possible significant weight loss prior to her admission to the facility, and was admitted with a dietary supplement. -The goal was to maintain adequate nutritional status as evidenced by maintain weight within a healthy BMI range and no signs and symptoms of malnutrition through next review. -The interventions included to provide and serve supplements as ordered: 90 ml med pass TID between meals, magic cup at night daily, provide and serve diet as ordered (regular diet, regular texture, thin liquids), monitor intake and record as needed, offer alternates or snacks as needed, and assist as needed. Registered dietician (RD) was to evaluate and make diet changes recommendations as needed, weight at same time of day and record: monthly or as needed weekly times four weeks upon admission. On 8/14/14 (after being brought to the facility's attention during a complaint survey) the resident's care plan was updated to reflect an unplanned/unexpected weight loss related to refusals of meals and poor oral intake and had to have partials replaced. -The goal was to consume 25% of two of three meals per day. -The interventions included: give the resident supplements as ordered and alert nurse/dietician if not consuming on a routine basis. Supplements included a 206 cookie once a day, magic cup once a day and med pass 90 ml three times a day. If weight decline persists, contact physician and dietician immediately, do labs as ordered and report results to the physician and ensure dietician is aware. Monitor and evaluate any weight loss, determine percentage lost and follow facility protocol for weight loss, monitor and record food intake at each meal. The resident needs encouragement, assistance, and support to maintain as much independence and control as possible. Offer substitutes as requested or indicated. Offer alternates if resident refuses meals offered. 3. Weight loss and facility response a. Resident Weights ? 2/5/14: 106.4 lbs. (admission weight) ? 2/9/14: 106.5 lbs. ? 2/26/14: 103.0 lbs. (-3%, -3.4 lbs. over 21 days) ? 3/2/14: 99.9 lbs. (- 6%, -16.5 lbs. over 28 days) re-weigh completed 3 days later. ? 3/5/14: 102.9 lbs.(+3 lbs. in three days) and no re-weigh done to confirm weight gain (-3.29% weight loss in 30 days) ? 3/9/14: 100.0 (-6.1 %, - 6.5 lbs within 30 days (comparison weight 2/9/14, 106.5 lbs)) ? 3/24/14: 97.1 lbs. (-2.9 %, - 2.9lbs. over 15 days, - 8.7 %, -9.3 lbs. over 30 days (comparison weight 2/9/14, 106.5)) ? 3/31/13: 99.2 lbs. (2.8 lbs. weight gain in seven days, -6.7%, -6.2lbs since admission) ? 4/1/14: 99.2 lbs. ? 5/6/14: 92.1 lbs. (-7% or 7.1 lbs. over 30 days (comparison weight 4/1/14 99.2 lbs.), -13% or 7.4 lbs. within 90 days or since admission (comparison weight 2/5/14, 106.4lbs.)) ? 5/7/14: 93.1 lbs. ? 5/12/14: 96.5 lbs. ? 5/13/14: 95.0 lbs. ? 5/17/14: 94.0 lbs. ? 5/25/14: 94.6 lbs. ? 6/1/14: 91. 5 lbs. (- 8% or 8.2 lbs. over 60 days (comparison weight 4/1/14, 99.2) -14.0% or - 14.9 lbs. since admission (comparison weight 2/5/14, 106.4 lbs, -14.0%, -14.9 lbs) ? 6/2/14: 92.3 lbs. ? 6/8/14: 93.6 lbs. ? 6/15/14: 93.2 lbs. ? 6/26/14: 92.5 lbs. ? 6/29/14: 92.6 lbs. ? 7/7/14: 95.8 lbs. (last recorded weight) ? 8/11/14: at approximately 5:00 p.m. no further weights were available in the record and the resident was weighed and his/her weight was 89.3 lbs. (- 7% or -6.6 lbs. (comparison weight 7/7/14, 95.8 lbs.), - 5% or 4.3 lbs. (comparison weight 6/8/14, 93.6 lbs.) and - 16% or 17.1 lbs. since admission (comparison weight 2/5/14 106.4 lbs.) b. Facility response According to a 2/20/14 weight change note, the resident's weight was 93.5 lbs on 2/18/14 for a 13 lbs or 12% weight loss since 2/9/14. His/her BMI was 21. His/her oral (PO) intakes could vary at times and s/he ate meals in the assisted dining room with supervision/cues. S/he was sleepy today and did not want to get up for the meal. An order was written for 90 ml of med pass PO three times a day (TID) upon admit given his/her weight loss history. On 2/18/14 a telephone order was written for 90 ml of med pass in coffee BID between meals and a magic cup (dietary supplement) at night (NOC) as snack. An order to discontinue the 90 ml in coffee BID, which was given previously TID was written (may be added to coffee as needed) and continue the magic cup. A re-weigh was needed and to have the staff notify the physician (MD), registered dietician (RD), and family if the weight loss was confirmed. According to a 2/21/14 order note, the resident was to be re-weighed and staff was to alert the physician if a 13 lbs. or 12% weight loss had been confirmed. On 2/26/14 (six days after the order to re-weigh the resident was written), the resident was re-weighed and revealed a weight of 103 lbs for a weight loss of 3% or 3.4 lbs since admission (2/5/14). According to a 2/27/14 interdisciplinary team (IDT) note the resident triggered for a weight loss within a month, as well as a new admission. His/her admission weight was 106 lbs. with a current weight of 103 lbs. His/her current meal intake was 25% - 50% for breakfast and lunch and that s/he commonly refused dinner. His/her average daily fluid intake was 1200 cc per day, above his/her daily needs. Supplements included 60 ml of PO med pass BID in coffee. The physician and son were aware of the resident's initial weight loss and stabilization of weight thereafter. No new interventions. According to a 3/6/14 health status note, the resident was noted to have non-[MEDICAL CONDITION] to his/her bilateral lower legs and the MD was notified (T.E.D. hose were ordered for [MEDICAL CONDITION]). According to a 3/6/14 weight change note, the resident triggered for a one month weight loss. His/her current weight was 99 lbs. This was a weight loss of 7.4 lbs. or 7% in one month. On 3/5/14 the resident ' s weight was 102.9 lbs. and his/her BMI was 23.1. The resident received supervision/assist at meals. S/he had varied PO intake. S/he received a magic cup at NOC and 90 ml of med pass TID (may add to coffee as needed). His/her labs included an [MEDICATION NAME] of 4.0 (normal). S/he had some [MEDICAL CONDITION] lately and may be related to the weight fluctuations. S/he would refuse meals or snacks/supplements at times even after much encouragement from staff. Staff will continue to encourage good oral (PO) intake at meals and snack/supplements as accepted. S/he will continue on weekly weights, and if s/he continued to lose weight, staff would consider adding pudding, milk, or other foods at meals. The resident was weighed on 3/9/14 (100.0 lbs.), refused to be weighed on 3/23/14, and weighed on 3/24/14 (97.1 lbs). Note: the resident was supposed to be weighed weekly (missing a weight the week of 3/16/14 through 3/22/14). According to a 3/25/14 health status note, the resident's son voiced concerns that the resident did not have his/her upper denture in place. The resident's partials were found in the nurses' cart. The nurse noted that s/he would write a note on the Medication Administration Record [REDACTED] According to a 3/26/14 IDT note, the resident triggered for a one and three month weight loss, his/her meal intake was 25%-50% with multiple refusals. The resident was on a no concentrated sweets (NCS), puree textured, with thin liquids diet (Incorrect diet). S/he received 90 ml of med pass BID (should be TID) and required assistance at meals ... no new nutritional labs since the last review. [MEDICATION NAME] (an, ACE inhibitor) was started last month (resident was never started on this medication). The resident's estimated needs were; calories 1250 kcal, protein: 50 grams, fluids 1500 ml. staff was to continue to offer the resident assistance as needed, s/he walked frequently, staff was to continue to monitor the resident and the MD and son had been updated. According to a 4/7/14 nursing note, staff talked with the resident's son about the resident's eating habits and that staff was concerned about his/her intake and possible weight loss. The son reported that in their family, "they never ate breakfast, would eat a small lunch and then a light dinner. This is how we were raised". The son was not surprised that the resident had not been eating much. Staff would notify the dietary manager and continue to monitor the resident. According to a 4/19/14 order note, the resident's family was concerned about not having his/her dentures in place and s/he was having difficulty chewing food ... the resident was noted to have been eating well on a regular diet; however the family requested that s/he have a softer diet. Staff would continue to search for the resident's dentures and would upgrade his/her diet once his/her dentures were acquired ... According to a 4/21/14 nursing note, staff was monitoring the resident for a diet change and no issues were noted. The resident had a reduced appetite and PO intake since his/her admission to the facility. The nurse discussed an appetite stimulant with the social worker and resident's son as a possibility, if the resident continued to lose weight. The nurse noted that the resident's dentures were found (note: dentures were not found and resident was scheduled to see the dentist on 4/25/14 for an upper partial). According to a 4/28/14 social services note, the dentist took impressions for the resident's upper partial denture. Delivery would take 7-10 days. The son was notified and the resident's diet was modified as the resident was eating well. According to a 5/7/14 weight change note, the resident triggered for a weight loss. The resident's weight was 93.1 lbs as of 5/7/14, and his/her BMI was 20.9. The resident had varied meal intake of 25% - 50% with multiple refusals, especially during breakfast. The resident's fluid intake average was [PHONE NUMBER] cc, again varied. S/he continued with a magic cup at night and 90 ml of med pass TID (may add to coffee as needed). The resident's meal intake continued to vary and s/he continued to refuse meals often. Staff would offer meals in small separate bowls to see if the resident would be more willing to eat when s/he saw his/her food in smaller containers. Staff would continue to monitor him/her weekly and as needed. According to a 5/14/14 nutrition/dietary note, the resident's weight was 95.0 lbs. as of 5/13/14 and a current BMI of 21.3. His/her fluid 1200cc/day, his/her PO intake was 25 - 75%, small portions were offered since s/he would get overwhelmed by the amount of food on his/her dinner plate. The resident also had an order for [REDACTED]. The resident wandered the building at times looking for his/her son. Sometimes s/he would be re-directable so s/he would eat at meals. No other concerns were noted at this time. Staff would continue to monitor his/her weights, labs, and PO intakes as needed. According to a 5/14/14 weight change note, the resident triggered for weight loss. His/her weight was 95 lbs and BMI was 21.3 as of 5/12/14. His/her PO intake varied 25% - 75% with multiple refusals, especially during breakfast. His/her fluid intake averaged [PHONE NUMBER] cc, again varied. S/he received a magic cup at NOC and 90 ml of med pass TID (may add to coffee as needed). The resident's meal intake continued to vary and s/he continued to refuse meals often. Small portions were trialed and s/he seemed to respond well. Staff would continue to monitor him/her weekly and as needed. According to a 5/21/14 weight change note, the resident triggered for weight loss. His/her weight was 94 lbs and BMI was 21.1 as of 5/17/14. His/her PO meal intakes varied 25-75% with multiple refusals, especially during breakfast and a few during lunch. His/her fluid intake averaged [PHONE NUMBER] cc, again varied. S/he received a magic cup at NOC and 90 ml of med pass TID (may add to coffee as needed). The resident's meal intake continued to vary and s/he continued to refuse meals often. Small portions were trialed and s/he seemed to respond well. Staff would continue to monitor him/her weekly and as needed. According to a 5/28/14 weight change note, the resident triggered for a weight loss. His/her weight was 94.6 lbs and BMI was 21.2 as of 5/25/14. His/her PO intake varied 25% - 75% with multiple refusals, especially during breakfast and a few refusals at lunch. His/her fluid intake averaged [PHONE NUMBER] cc, again varied. S/he received a magic cup at NOC and 90 ml of Med pass TID (may add to coffee as needed).His/her meal intakes continued to vary and s/he continued to refuse meals often. Staff would continue to monitor weekly and as needed. According to a 6/4/14 weight change note, the resident triggered for a weight loss. His/her weight was 92.3 lbs and BMI was 20.6 as of 6/2/14. His/her weight was 94.6 lbs and BMI was 21.2 as of 5/25/14. His/her PO intake varied 25% - 75% with multiple refusals, especially during breakfast and a few refusals at lunch. His/her fluid intake averaged [PHONE NUMBER] cc, again varied. S/he received a magic cup at NOC and 90 ml of Med pass TID (may add to coffee as needed). His/her meal intakes continued to vary and s/he continued to refuse meals often. Will add a 206 cookie to the resident's supplements and continue to monitor weekly and as needed. According to a 6/11/14 weight change note, the resident triggered for a weight loss. His/her weight was 93.6 lbs and BMI was 21.0 as of 6/8/14. His/her PO intake varied 25% - 75% with multiple refusals, especially during breakfast and a few refusals at lunch. His/her fluid intake averaged [PHONE NUMBER] cc, again varied. S/he received a magic cup at NOC and 90 ml of Med pass TID (may add to coffee as needed). His/her meal intakes continued to vary and s/he continued to refuse meals often. Will add a 206 cookie to the resident's supplements. According to a 6/18/14 weight change note, the resident triggered for a weight loss. His/her weight was 93.2 lbs and BMI was 21.9 as of 6/15/14. His/her PO intakes varied 25% - 75% with multiple refusals, especially during breakfast and a few refusals at lunch. His/her fluid intake averaged [PHONE NUMBER] cc, again varied. S/he received a magic cup at NOC and 90 ml of Med pass TID (may add to coffee as needed). His/her meal intakes continued to vary and s/he continued to refuse meals often. His/her weight slight decrease this month. Staff would continue to monitor the resident weekly and as needed. No changes at this time. Will add a 206 cookie to the resident's supplements. According to a 6/27/14 weight change note, the resident triggered for a weight loss. His/her current weight was 92.5 lbs and BMI was 20.7 as of 6/26/14. His/her PO intakes varied 25% - 75% with multiple refusals, especially during breakfast and a few during lunch. Fluid intakes averaged [PHONE NUMBER] cc, again varied. S/he received a magic cup at NOC and 90 ml of med pass TID (may add to coffee as needed). His/her meal intake continued to vary and she continued to refuse meals often. His/her weight slightly decreased this week, but his/her weight was close to his/her weight from the beginning of the month. Staff would continue to monitor him/her weekly and as needed. No changes at this time and staff would reassess the resident next week. Will add a 206 cookie to the resident's supplements. According to a 7/6/14 weight change note, the resident triggered for a weight loss. His/her current weight was 92.6 lbs. and BMI was 20.8 as of 6/29/14. His/her PO intake varied 25% - 75% with multiple refusals, especially during breakfast and a few during lunch. Fluid intakes averaged [PHONE NUMBER] cc, again varied. S/he received a magic cup at NOC and 90 ml of med pass TID (may add to coffee as needed). His/her meal intake continued to vary and she continued to refuse meals often. His/her weight slightly decreased this week, but his/her weight was close to his/her weight from the beginning of the month. Staff would continue to monitor him/her weekly and as needed. No changes at this time and staff would reassess the resident next week. Will add a 206 cookie to the resident's supplements. There were no further weight change notes or weekly weights since 7/6/14. On 8/11/14 at approximately 5:00 p.m. the staff was asked to obtain a weight. With the resident's permission s/he was weighed and was noted to weigh 89.3 lbs. for a total weight loss of 17.1 lbs or 16% weight loss since his/her admission on 2/5/14. 4. Facility Failures a. Failure to monitor weekly weights According to the dietary notes, weight change notes, health status notes, and nursing notes (see above) dated 2/27/14 through 8/11/14 revealed the following: 2/6/14: weekly weights x four weeks upon admission. There were no weights recorded the week of 2/16/14 through 2/22/14. 2/20/14: re-weigh was needed to confirm a recorded 13 lbs. weight loss. The re-weigh was not obtained until six days later. 3/6/14: staff was to continue weekly weights and if the resident continued to lose weight, consider adding pudding, milk, or other foods at meals. There were no weights recorded for the week of 3/16/14 through 3/22/14. On 3/24/14 the resident was weighed (97.1 lbs) and continued to lose weight, and no further interventions were initiated. 3/26/14: staff was to continue to monitor the resident and no further interventions were initiated. There were no weekly weights from 4/6/14 through 5/3/14. 5/6/14: the resident continued to lose weight and had a recorded weight of 92.1 lbs. 5/7/14: resident's weight noted to be 93.1 lbs ... s/he continued on magic cup and 90 ml of med pass TID. Staff was to offer meals in small separate bowls to see if s/he would be willing to eat when s/he saw food in smaller containers. Staff was to continue to monitor weekly and as needed. 5/14/14: continue to monitor weights, labs, and intakes. There were no weights for the week of 5/18/14 through 5/24/14. 5/21/14: resident's weight was noted to be 94 lbs. and s/he continued on magic cup, med pass, and small portions were trialed and resident seemed to respond well. Staff would continue to monitor the resident weekly. No further interventions were initiated. 6/2/14: resident noted to continue to lose weight (92.3 lbs). Staff added a 206 cookie (supplement) and staff were to continue to monitor the resident weekly and as needed. 7/6/14: resident's weight was noted to be stable (92.6 lbs). Staff was to continue monitoring the resident weekly and as needed. On 7/8/14 the resident's recorded weight was 95.8 lbs. for an increase of 3.2 lbs. in two days. The resident was not re-weighed to confirm the weight gain. Furthermore there were no additional weights noted in the resident's clinical record since 7/8/14. On 8/11/14 at 5:00 p.m. staff was asked to get a current weight on the resident and was noted to be 89.3 lbs. for an additional 6.5 lbs. weight loss (comparison weight 7/8/14), -16% or 17.1lbs since admission (comparison weight 2/5/14, 106.4 lbs.) b. Failure to update nutritional care plan The nutritional care plan initiated on 2/6/14 identified the resident as having a nutritional problem or potential nutritional problem related to dementia. S/he was admitted with possible significant weight loss prior to admission and was admitted with a supplement. The care plan failed to show that the facility had updated the resident's nutritional care plan to address the continued weight loss until after being brought to the facility's attention during a complaint survey on 8/14/14. c. Oral/Dental status: According to the health status note dated 3/25/14 (see above), the resident's son voiced concerns about the resident not being able to chew tough food thoroughly and whether or not s/he had his/her upper partial denture in. The facility was going to add this to the treatment records so that staff would provide the resident with his/her dentures in the morning, remove clean and keep in the nurses cart at night. On 4/19/14 again the family voiced concern that the resident did not have his/her dentures in. Review of the March/April 2014 TAR failed to reveal this action had been completed until 4/21/14, and then was immediately discontinued. According to the dental consults dated 4/24/14 through 5/28/14, the resident had been fitted for a new upper partial denture on 4/25/14. On 5/28/14 fittings continued and the resident's dentures were to be delivered on the next visit; however as of 8/15/14 the resident had not received his/her upper partial dentures. The staff was not able to say where the dentures were and why the resident had not received them. e. Failure to provide dietary interventions as ordered According to a 5/7/14 weight change note and diet order communication form dated 5/8/14, staff was to offer the resident food in separate bowls at meals. Observations were conducted on 8/11/14 at 11:43 a.m., 8/15/14 at 8:00 a.m. & 12:00 p.m. (12:00 p.m. observations was in the presence of the director of nurses) revealed staff was providing the resident meals on dinner plates and not in separate bowls as per the 5/7/14 weight change note, and diet communication form dated 5/8/14. On 8/15/14 at 12:00 p.m. the DON removed the resident's meal tray from the food cart and sent it back to the kitchen to be placed in small bowls. 5. Interviews The Director of Nurses (DON) was interviewed on 8/11/14 at 4:33 p.m. She stated that s/he was not sure why it would have taken six days to get a re-weigh on the resident. However; when the resident was re-weighed s/he did not have a 13 lb. weight loss as originally thought. The DON stated that if a resident had a weight gain or loss of three lbs. from the previous weeks' or months' weights she would expect staff to re-weigh the resident the next day to confirm the weight loss and to notify the physician and RD. The DON acknowledged that the resident was to be weighed weekly and reviewed the facility weight book and dietary managers weight books and was unable to find missing weights (see above). The DON reviewed the weight change note dated 3/26/14, and acknowledged that the information regarding the resident's diet order was incorrect and that the resident had never started on [MEDICATION NAME] the previous month. The DON stated that there were issues with the resident's dentures being lost and the resident was being seen by the dentist to have them replaced, and the resident's diet was changed to a mechanical soft diet per the family ' s request. The DON reviewed the resident's clinical record and acknowledged that as of 8/11/14 the resident still had not received his/her upper partial denture as of 8/11/14. The DON stated that on 5/7/14 the team discussed presenting the resident with smaller portions, because s/he became overwhelmed with the amount of food on his/her plate and on 5/8/14 a diet communication form was completed (see above) to provide small bowls to the resident with meals. The DON reviewed the resident's clinical records and was not sure why there were no weights since 7/7/14. The DON stated that the resident was on weekly weights, which should have continued. The DON reviewed the weekly weight forms for 7/2014 and 8/2014 and stated that the resident was not listed on the weekly weights and somehow must have fallen off the weekly weight list in error.