Every finding on record at Paonia Care and Rehabilitation Center

Based on record review and interviews, the facility failed to ensure that residents were free from significant medication errors for one (#4) of three residents reviewed for medication errors out of 11 sample residents.Resident #4, who had a diagnosis of seizures, was admitted to the facility from home on 4/27/26 for a five-day respite stay. The resident had physician's orders for levetiracetam (a medication used to treat seizures) to be administered two times per day related to her seizures.The resident was scheduled to receive the levetiracetam medication between 3:00 p.m. and 6:00 p.m., per her home medication regimen. However, the medication orders were not obtained until 4:00 p.m. (over five hours after the resident was admitted to the facility). When the medication orders were put into the resident's electronic medical record (EMR), the timeframe for the first medication dose to be administered was entered as being due the next day (4/28/26). As a result, Resident #4 missed her scheduled dose of levetiracetam on the evening of 4/27/26, between the hours of 3:00 p.m. and 6:00 p.m. Resident #4 experienced two seizures on the morning of 4/28/26.Specifically, the facility failed to ensure Resident #4 was administered her levetiracetam medication per physician's orders, which likely contributed to the resident suffering a seizure.Findings include:Record review and interviews confirmed the facility corrected the deficient practice prior to the onsite investigation on 7/13/26 to 7/14/26, resulting in the deficiency being cited as past noncompliance with a correction date of 4/30/26.I. Situation of [NAME] 4/27/26 Resident #4 did not receive her evening scheduled dose of anticonvulsant medication, levetiracetam. Due to the missed administration of the medication, Resident #4 experienced two seizures on the morning of 4/28/26, which likely resulted from the missed medication administration the evening prior.II. Facility plan of correctionThe corrective action plan the facility put in place in response to the incident with Resident #4 on 4/27/26 was provided by the nursing home administrator (NHA) on 7/14/26 at 12:25 p.m. The plan read as follows: The facility failed to ensure that medications ordered upon admission from the facility were entered and verified appropriately within the EMR system prior to the scheduled medication administration time. This resulted in the resident's evening anticonvulsive medication potentially contributing to seizure activity experienced by the resident on 4/28/26.A. Corrective action Corrective action was initiated immediately on 4/28/26 upon discovery of the missed medication administration. Resident #4 was immediately assessed following the seizure activity.Nursing staff initiated emergency response procedures, including seizure precautions, oxygen administration, neurological monitoring, and administration of ordered emergency medication.The director of nursing (DON) and the physician were immediately notified.The resident's responsible party was notified of the event and interventions performed.Medication orders were reviewed and corrected in the EMR to ensure all medications populated appropriately on the active electronic medication administration record (eMAR). Resident #4 resumed prescribed medication regimen immediately following stabilization.The resident remained under direct nursing observation through the postictal recovery phase (recovery period immediately following a seizure).The date completed was 4/28/26.B. Identification of other residentsBeginning 4/29/26, the DON and nurse managers completed an audit of all current admissions and readmissions within the previous 30 days, all newly entered medication orders, all high risk medications, including anticonvulsants, anticoagulants, insulin, narcotics, and cardiac medications and the medication administration record (MAR) verification processes related to EMR order entry timing. The audit specifically reviewed whether medications entered during active medication administration windows appropriately populated on the eMAR and whether first-dose administration was completed timely. Any discrepancies identified were corrected immediately. No other discrepancies were identified. The date completed was 4/30/26.C. Systematic changes Effective 4/29/26, the facility implemented the following systemic changes:A revised admission and readmission protocol was implemented requiring:-Verification that all physician medication orders were received prior to completion of admission whenever possible;-If verbal orders were accepted pending written documentation, nursing leadership must verify reconciliation against physician facility documentation before medication pass;-All medications entered into the EMR during an active administration window must undergo a secondary nurse verification to ensure medications populate appropriately on the eMAR; and, -First-dose verification documentation would be completed for all newly admitted residents. D. Monitoring The DON, staff development coordinator, or designee will conduct the following audits: Review of all admissions and readmissions for medication reconciliation accuracy, verification that medications populate correctly on the eMAR, verification of first-dose administration completion, and review of high- risk medication admissions. Audit five admissions and readmissions and add all admissions and readmissions to the morning meeting report and audit findings will be reviewed through the facility Quality Assurance and Performance improvement (QAPI) committee. Any identified concerns will result in immediate corrective action and additional staff education as necessary. E. EducationBeginning 4/29/26, all licensed nursing staff received education regarding: EMR medication order entry timing, eMAR verification procedures, admission and readmission medication reconciliation, high risk medication monitoring, escalation procedures for delayed physician orders and admission requirements.The facility's admission from the Community policy was reviewed and reinforced with nursing staff.The date implemented was 4/29/26.III. Professional referenceAccording to [NAME], P.A., [NAME], A.G et.al, Fundamentals of Nursing, 10th ed., (2023). Elsevier, St. Louis, Missouri, pp. 606-607, Take appropriate actions to ensure the patient receives medication as prescribed. To prevent medication errors, follow the seven rights of medication administration consistently every time you administer medications:1. The right medication;2. The right dose;3. The right patient;4. The right route;5. The right time;6. The right documentation; and,7. The right indication.IV. Facility policy and procedure The Adverse Consequences and Medication Errors policy, revised June 2025, was provided by the NHA on 7/14/26 at 12:10 p.m. It read in pertinent part, The interdisciplinary team (IDT) monitors medication usage to prevent and detect medication-related problems such as adverse drug reactions and side effects. A significant medication related-error is defined as: requiring hospitalization, or extending a hospitalization, resulting in disability; requiring treatment with a prescription medication; resulting in cognitive deterioration or impairment; life threatening; and or resulting in death. Review the residents medication regimen for efficacy and actual or potential medication-related problems on an ongoing basis. Evaluate the resident for possible medication-related adverse consequences when the resident has clinically significant change in condition or status, including: unexplained decline in function, cognition, or behavior: and or worsening of an existing problem or condition. In the event of a significant medication-related error, take action, as necessary, to protect the residents safety and welfare. Promptly notify the provider of any significant error.V. Resident #4A. Resident statusResident #4, age less than 65, was admitted on [DATE] and discharged on 4/28/26. According to the April 2026 computerized physician orders (CPO), diagnoses included cerebral palsy, neuralgia and neuritis (general nerve pain and nerve inflammation), unspecified and other seizures.The 4/28/26 minimum data set (MDS) assessment documented Resident #4 was moderately cognitively intact with a brief interview for mental status (BIMS) score of 11 out of 15. The MDS assessment indicated the resident received anticonvulsant medications. B. Record reviewReview of Resident #4's April 2026 CPO revealed the following physician's orders:Levetiracetam 500 milligrams (mg), administer three tablets by mouth two times a day related to other seizures, ordered 4/27/26. Nayzilam nasal solution (a prescription nasal spray used to treat acute repetitive seizures) 5 mg/0.1 milliliters (ml), administer one spray to alternating nostrils one time a day as needed related to other seizures, ordered 4/27/26. The nurse progress note, dated 4/28/26 at 9:25 a.m. and written by the assistant director of nursing (ADON), revealed Resident #4 was admitted to the facility on [DATE] at approximately mid-morning. The resident's medication orders were not obtained until 4:00 p.m., and when the medication orders were put into the EMR system, the the timeframe for the first medication dose to be administered was entered as being due the next day (4/28/26). Resident #4 missed her scheduled dose of levetiracetam on the evening of 4/27/26, between the hours of 3:00 p.m. and 6:00 p.m. Resident #4 experienced two seizures on the morning of 4/28/26. The resident was now up in the wheelchair and doing well.The nurse progress note, dated 4/28/26 at 9:36 a.m. and written by registered nurse (RN) #3 revealed Resident #4 appeared to start having a seizure in the dining room. Another nurse was present and took the resident out of the dining room and into the resident's room, transferred her to the bed and turned her onto her side. The resident's first seizure was presumed to have started around 7:48 a.m. and lasted until 7:52 a.m. The resident's second seizure started at 7:54 a.m. Nayzilam nasal spray medication was administered by another nurse at 7:55 a.m. and the seizure stopped at 7:58 a.m. Resident #4's vital signs were obtained at the end of the seizure and oxygen was initiated. The progress note further revealed the postictal phase started at 8:03 a.m., and more vital signs were obtained every 15 minutes. The oxygen was removed with the resident's oxygen saturation level at room air (above 90 percent). The resident's lung sounds were clear throughout and the resident was resting comfortably at the time of the assessment. Staff remained with the resident until 8:49 a.m. Resident #4's representative was called at 8:50 a.m. Staff reported to the resident's representative when the first and second seizure began and ended and when the postictal phase started. The resident's representative stated, What do you mean she had a seizure, she only has seizures under certain circumstances. According to the note, Resident #4 awoke around 9:00 a.m. and said she wanted to get up. Staff promptly helped the resident up and levetiracetam medication was administered right away.Review of Resident #4's EMR revealed the resident's levetiracetam medication order was entered into the EMR at 4:42 p.m. on 4/27/26 and scheduled be administered two times a day, once in the morning, between 6:00 a.m and 10:00 a.m, and once in the evening, between 3:00 p.m. and 6:00 p.m. -However, review of Resident #4's April 2026 medication administration record (MAR) revealed no levetiracetam medication doses were administered to the resident on 4/27/26 between 3:00 p.m. and 6:00 p.m., and one dose of the levetiracetam medication was administered on 4/28/26 at 9:14 a.m., which was after the resident's seizures had already occurred. The nurse progress note, dated 4/28/26 at 10:36 a.m. and written by the ADON, revealed Resident #4 missed the evening dose of levetiracetam medication (on 4/27/26) and possibly could have assisted in the result of the resident sustaining a seizure on 4/28/26. The progress note documented Resident #4 presented with shaking, stiffening, limpness and possible seizure activity, which may have been the result of a missed medication. Neurological checks (focused assessment to evaluate brain function) were initiated and the resident's representative and the medical director were notified. VI. Staff interviewsRN #1 was interviewed on 7/13/26 at 4:40 p.m. RN #1 said medications were administered per the physician's orders. He said when needed, certain medications, such as antibiotics, controlled medications or seizure medication were taken out of the facility's locked emergency medication dispensing system so the resident did not miss a dose of the medication. He said evening medication administration times were between the hours of 3:00 p.m. to 6:00 p.m. and the day nurse was responsible for administering the medications in that timeframe. RN #2 was interviewed on 7/14/26 at 10:16 a.m. RN #2 said physician's admission orders were entered into the EMR system and two nurses verified them, once the paper copy arrived with the resident. The medication orders are administered from those orders. She said evening medication times were from 3:00 p.m to 6:00 p.m. and morning medication times were 6:00 a.m. to 10:00 a.m. She said evening administration of medications was usually completed by 4:00 p.m.The ADON was interviewed on 7/14/26 at 10:30 a.m. The ADON said she assessed Resident #4, who appeared to have had two seizures (on 4/28/26). The ADON said the resident was laid down in the bed and anticonvulsant nasal spray medication was administered. She said once the seizure was over, the resident woke up and wanted to attend activities. She said the medication orders were entered into the EMR system after 4:00 p.m. on 4/27/26 and defaulted to the next scheduled dose on 4/28/26 instead of the current evening dose (on 4/27/26). The ADON said the resident did have the medication in the facility, as Resident #4's representative delivered the medications to the facility when the resident arrived (mid-morning on 4/27/26). She said the resident did not receive the evening dose of levetiracetam medication on 4/27/26, which could be the reason the resident had a seizure on 4/28/26. She said the IDT recognized the importance of a missed seizure medication and the team started a plan of correction on 4/28/26. The DON was interviewed on 7/14/26 at 10:40 a.m. The DON said seizure medications and any prescribed medications were important to administer per physician's orders. She said Resident #4 did not receive the scheduled medication levetiracetam on 4/27/26. She said a POC was started and completed on 4/28/26. The medical director was interviewed on 7/14/26 at 11:30 a.m. The medical director said he was notified when Resident #4 had the seizure. He said a missed dose of the medication levetiracetam was not that detrimental and may or may not cause a seizure. He said unfortunately, Resident #4 did have a seizure after missing the dose of medication. He said the resident's last seizure was approximately two years ago. He said taking medication as prescribed was important and it was important to not miss any doses. He said Resident #4 was doing fine afterwards. The pharmacist was interviewed on 7/14/26 at 11:45 a.m. The pharmacist said levetiracetam medication was used for seizures, mood disorders and post cerebral vascular accidents (stroke). He said one missed dose of the medication usually did not cause a seizure, but the missed higher dose of levetiracetam, at 1500 mg, for Resident #4 could have triggered a seizure.

Based on record review and interviews, the facility failed to revise and implement an effective discharge plan for one (#4) of one resident reviewed for discharge planning out of 11 sample residents. Specifically, the facility failed to complete a discharge summary for Resident #4.Findings include:I. Facility policy and procedureThe Discharge Summary and Plan policy, revised March 2025, was provided by the nursing home administrator (NHA) on 7/14/26 at 12:10 p.m. It read in pertinent part, When a resident's discharge is anticipated, a discharge summary is created, and the discharge plan is finalized to assist the resident with plans for care after the discharge.The medical record contains a copy of the discharge summary with the identity of the recipient of the summary. A discharge summary includes: a recapitulation of the resident's stay at the facility, a final summary of the resident's status at the time of the discharge and a reconciliation of all pre-discharge medications with the resident's post discharge medications. II. Resident #4A. Resident statusResident #4, age less than 65, was admitted on [DATE] and discharged on 4/28/26. According to the April 2026 computerized physician orders (CPO), diagnoses included cerebral palsy, neuralgia and neuritis (general nerve pain and nerve inflammation) unspecified and other seizures.The 4/28/26 minimum data set (MDS) assessment documented Resident #4 was cognitively intact with a brief interview for mental status (BIMS) score of 11 out of 15. The MDS assessment indicated the resident received anticonvulsant medications.B. Record Review The progress note, dated 4/27/26 and written by registered nurse (RN) #3, revealed Resident #4 admitted to the facility at 10:20 a.m. in a wheelchair, with transportation provided by the resident's representative. The representative said she would be back to pick up the resident next Monday (6/1/26) after lunch sometime. The resident was admitted to the facility for a five-day respite stay. Review of Resident #4's electronic medical record (EMR) revealed no discharge progress note or discharge summary for the resident. III. Staff interviews The assistant director of nursing (ADON) was interviewed on 7/14/26 at 10:30 a.m. The ADON said Resident #4 was admitted to the facility for a five-day respite stay. She said the resident had been a prior resident several times. The ADON said on the morning of 4/28/26 Resident #4 appeared to be having a seizure and was laid down in the bed.Cross reference F760 for failure to ensure residents were free from significant medication errors. The ADON said a nasal spray medication was administered to stop the seizure and staff monitored the resident. She said once the seizure was over, the resident woke up and wanted to attend activities. The ADON said the resident's representative was notified and within an hour, the representative arrived at the facility to discharge Resident #4 from the facility. The ADON said the discharge summary was not completed for Resident #4 because the discharge happened so quickly. The director of nursing (DON) was interviewed on 7/14/26 at 10:40 a.m. The DON said a discharge summary was important to complete for every resident. The DON said the discharge summary provided information for the disposition of the residents and to finalize the records from the resident's admission to the facility. She said a discharge summary was not completed for Resident #4. The NHA was interviewed on 7/14/26 at 12:15 p.m. The NHA said the discharge summary was completed by nursing staff and uploaded to the residents' EMRs to show the disposition of the residents. He said Resident #4 discharged from the facility one day after admission and the discharge summary was overlooked. He said he would complete the discharge summary for Resident #4.-However, no discharge summary was provided by the facility prior to the survey exit date on 7/14/26.

Based on observations, record review and interviews, the facility failed to ensure that one (#42) of 10 residents reviewed for freedom from involuntary seclusion out of 27 sample residents was provided the least restrictive environment and was not placed on a secured locked unit without an evaluation, assessment, justification, or documentation.Resident #42 was cognitively intact and had no history of wandering. On 7/13/25, following an incident in which she attempted to leave the facility to walk to a nearby store, staff redirected Resident #42 to a room on the secured locked memory care unit. Facility documentation revealed no physician's order, no completed assessment justifying locked secured unit placement, no evidence the secured placement was the least restrictive alternative and no interdisciplinary team (IDT) review before or immediately after the move.Although initial notes reflected Resident #42's temporary agreement to remain on the secured unit for the night, progress notes and interviews revealed that the secured unit placement continued beyond that evening, with the resident not knowing the door code and requiring staff assistance to exit. The resident reported feeling awful about being in a place where the door would not open, said she could not communicate with peers on the secured unit and expressed fear of certain male residents who knocked on her door at night.Resident #42's representative said there was no written consent, no assessment and no evaluation of the resident's emotional reaction to secured unit placement. The representative reported the resident was more agitated since the move and was struggling mentally.Specifically, the facility failed to ensure Resident #42 was removed from the secured unit after she agreed to stay overnight on the unit, which led to fear for the resident.Findings include:I. Facility policy and procedureThe Restraint Management policy, dated March 2023, was provided by the nursing home administrator (NHA) on 8/6/25 at 1:49 p.m. It revealed in pertinent part, Restraints are implemented in accordance with State and Federal regulations. If indicated, the least restrictive restraint is used for the least amount of time. Restraints are not used as a disciplinary action or for the convenience of the facility to control behavior. In cases where restraints are implemented based on the resident's assessment, the facility will make reasonable efforts to systematically and gradually reduce their use.II. Resident #42A. Resident statusResident #42, age [AGE], was admitted on [DATE]. According to the August 2025 computerized physician orders (CPO), diagnoses included Alzheimer's disease and delusional disorder (false beliefs).The 6/5/25 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. She had behaviors of verbal aggression towards others. She did not have behaviors of physical aggression towards others. She did not have behaviors of wandering. She required setup and cleanup assistance with bathing. B. Resident representative interviewResident #42's representative was interviewed on 8/7/25 at 10:25 a.m. The representative said Resident #42 was doing well from a health perspective but she had been frustrated and struggling from a mental perspective at being in the facility. The representative said the resident had told her there was a situation where she left the facility and an employee led her back inside. She said Resident #42 was upset when redirected by the certified nurse aide (CNA) and she was frustrated because she could not go to the grocery store. The representative said the resident had told her that staff had been overly aggressive and she did not want to return to her normal room because the CNA was in that section of the facility. She said that ever since then, the resident did not want to leave the secured unit. The representative said staff had been trying to get her back to her room in the non-secured section of the building, but she refused. The representative said it was supposed to be a temporary placement in the memory care unit due to a transition to another state.The representative said no assessment or evaluation had been completed for the memory care unit placement and there was no written consent, only verbal. The representative said that since the secured unit placement, the resident had been fussier and more agitated. The representative said Resident #42 continued calling her to pick her up and get her out of the facility. C. Resident interview Resident #42 was interviewed on 8/5/25 at 11:47 a.m. Resident #42 said her daughter had brought her to the facility three years earlier and had told her to take a look inside and see if she liked it, but then had left her there and dumped her. She said she did not come to the facility out of her own free will and had felt people in the facility had hurt her emotionally. She said she had come to the secured unit after an incident when she wanted to be taken to the store before it closed at 7:00 p.m. to get hairspray. She said staff at the front desk had said someone would take her, but as it was getting closer to 7:00 p.m., she had become worried. She said she realized the staff had no intention of taking her to the store and perceived they were laughing at her. She said she decided to walk to the store herself. She said she was not sure how it happened, but then several staff members tried to stop her and she became fearful. She said she had been told she was free to leave the facility whenever she wanted and then they would not let her. She said as a result of being fearful of staff, she asked to stay the night in an empty room and had been brought to the locked unit. Resident #42 said she felt awful about being in a place where the door would not open and she had been very unhappy in the unit. She said she had also been fearful of moving back to the other side of the building because she believed she had been physically attacked by staff when trying to go to the store. She said she was scared of some of the men on the secured unit and that they would knock on her door at night. She said there was a man who pushed on the exit door and set the alarm off all of the time. She said she could not talk to the other residents in the secured unit because they did not understand what she was saying. She said she had asked for the code to the door and had reiterated she was supposed to be able to leave whenever she wanted, but she did not know the code to the locked door.D. Record reviewThe behavioral care plan, initiated 12/20/22 and revised 3/28/24, documented Resident #42 had delirium related to unspecified dementia with behavioral disturbances and delusional disorders. Pertinent interventions included monitoring signs of delirium, providing gentle reorientation, maintaining consistent routines and caregivers, monitoring cognitive changes, providing activities suited to abilities, administering medications with monitoring and communicating with the resident and family.The elopement care plan, initiated 2/13/25 and revised 5/20/25, documented Resident #42 was alert and oriented and not at risk for elopement but had a history of leaving the facility without alerting staff. It documented the resident declined a wanderguard. It indicated due to barricading behavior and refusal of the wanderguard, the facility provided a lock on the room door for safety with nursing retaining emergency access. Pertinent interventions included distracting the resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, books, educating the staff to alert them before the resident would leave the building and ask for a ride when needed, identifying the pattern of wandering to determine if it was purposeful, aimless, or escapist, assessing whether the resident was looking for something and evaluating if wandering indicated a need for more exercise.The social services care plan, revised 7/14/25, revealed Resident #42 chose to admit to the memory care unit with guardian consent. Pertinent interventions included completing daily wellness checks and allowing the resident to leave the unit as requested, educating staff to allow the resident to leave the secured when she requested and allowing the resident to return to her room on the 200 hall as requested.Review of Resident #42's August 2025 CPO did not reveal a physician's order for the resident's placement on the secured unit.An elopement evaluation, dated 6/3/25, revealed Resident #42 ambulated independently. It indicated the resident had no history of elopement at home or the facility, had not expressed a desire to leave or pack belongings, was not recently admitted and did not wander.An elopement evaluation dated 6/21/25 revealed Resident #42 ambulated independently and had a history of elopement at home and the facility. It documented the resident did not express a desire to leave, pack belongings, or stay near exits. It indicated the resident was not recently admitted and did not wander.The facility's census of admissions and room moves was reviewed. It documented Resident #42 was admitted to the secured memory care unit on 12/7/22. It indicated the resident was moved to another room within the secured memory care unit on 12/12/22 where she remained until 8/6/23. It revealed on 8/7/23 the resident was moved to a non-secured unit. It identified the resident was then moved back to the secured memory care unit on 7/14/25.Resident #42's progress notes were reviewed from 6/21/25 to 8/5/25 and revealed the following:A nursing progress note, dated 6/21/25, revealed Resident #42 wanted to go to the store to get food. The note documented the staff had told her that they would get her something she liked from the kitchen and that someone might take her to the store on Monday. When the staff returned from the kitchen, the resident was no longer there. The therapy manager had taken her to the store and brought the resident from the store and returned her safely to the facility. Resident #42 was agitated upon returning from the store and a CNA was assigned to provide one-on-one supervision with 15-minute checks due to safety concerns. Resident #42 declined a skin assessment.A nursing progress note, dated 7/13/25, documented that around 5:45 p.m., Resident #42 escalated after staff informed her no one was available to immediately take her to the local grocery store (less than 0.5 miles away). Staff told her the delay was due to unsafe environmental conditions from the high heat index and poor air quality. Staff redirected Resident #42 to an area near her preferred nurse and provided education about the dangers of walking to the store, which she refused to accept. It revealed that the resident called emergency services and the police responded. The note documented the officer told the resident it was not safe to walk to the store and suggested she wait for a safer time. The staff attempted to redirect the resident to her assigned room, which she refused, stating she would not sleep there because she did not know who had been in there. The director of nursing (DON) offered to inspect her assigned room and offered to go to the store or accompany her, which she refused. The resident demanded to see another room and the DON showed her an available room on the secured unit, which had been prepared for admission. The resident agreed to use the secured unit room for the night if staff moved some of her comfort items. The staff told the resident the move was for the evening only and that she could access her original room at any time. It revealed the resident responded with verbal aggression and the DON left the interaction. A message was left for the representative after the move occurred.A social services progress note, dated 7/14/25, documented that the memory care coordinator met with Resident #42 and reminded her she could leave the secured and access the rest of the facility with staff assistance. It revealed the resident understood this information. The NHA and the social services director (SSD) met with her to review the weekend events and room options. Resident #42 said she preferred to remain in the secured unit. Resident #42 was educated she could not have a lock on her personal door on the secured unit and she would need staff assistance to exit the secured unit. It revealed that both the resident and her representative later consented to her staying in the secured unit.An administration progress note, dated 7/16/25, revealed Resident #42 reported an allegation of rough treatment by staff during the move to the secured unit but she had no injuries. It documented she was initially fearful of the staff member, but after reassurance, elected to remain in the secured unit. The resident and her representative consented to the permanent move. The staff documented increased resident engagement with peers and activities and the resident's acknowledgment that she may leave the secured unit at any time upon request.An administration progress note, dated 7/23/25, revealed Resident #42 appeared to be adjusting well to the secured unit and the staff observed increased door-blocking behavior but noted the resident allowed staff access to her room. The resident had been approved for flight to another state with discharge anticipated.An activities progress note, dated 7/30/25, documented staff observed Resident #42 standing at the front door attempting to leave the facility. Staff engaged the resident, who said she wanted to leave the facility and go to a different city. Staff assisted the resident in calling the police and the police officers reassured the resident and she was returned to her room and became calm. The DON, the SSD and the NHA were notified.III. Staff interviews The NHA was interviewed on 8/5/25 at 12:03 p.m. The NHA said Resident #42 suffered a lot of trauma from World War 2 where her family had to flee and hide. She said she had behaviors related to that trauma (barricading herself in her room, paranoia) and her representative had told the facility the resident had always been this way.CNA #5 was interviewed on 8/5/25 at 1:27 p.m. CNA #5 said Resident #42 previously lived in the 200 hall and would not allow staff into her room in the morning, displayed paranoia and barricaded her door. CNA #5 said she did not know of any interventions that worked with the resident. CNA #5 said she was unsure of the exact reason Resident #42 was currently on the secured unit.CNA #6 was interviewed on 8/6/25 at 11:44 a.m. CNA #6 said Resident #42 preferred to be alone in her room and became triggered when staff repeatedly asked her questions or knocked on her door. He said the staff attempted interventions for the resident that included allowing her to lock her room, providing choices, not touching her personal items without permission and knocking before entering. He said when the resident was on the unsecured unit, she interacted with other residents and had favorite residents and staff she would speak with regularly. He said that since being on the secured unit, he had not seen the resident talking with other residents, though she did have favorite staff she talked to, especially female staff. He said Resident #42 expressed a neutral view about being on the secured unit and did not describe it as better or worse.The memory care director and the SSD were interviewed on 8/6/25 at 2:03 p.m. The memory care director said that secured unit placement depended on the resident's individual situation. The memory care director said if the resident came from an external source, the interdisciplinary team (IDT) reviewed the case, considered recommendations from a third-party reviewer, then obtained approval before discussing placement with the family. She said the review included wandering risk, elopement risk, communication ability, decision-making capacity and the BIMS assessment. The memory care director said the facility conducted a secured unit evaluation prior to admission, with follow-up evaluations at 30 days, quarterly, with any changes and annually. She said if a resident already lived at the facility, the memory care director requested documentation and recommendations from a third-party reviewer to determine if the resident was a good fit for the secured unit. The memory care director said the difference between the secured and the unsecured units was that residents in the unsecured units generally had higher cognition, made better decisions and often participated in activities without staff assistance. She said the secured unit had controlled access with doors that locked to prevent wandering outside. The memory care director said evaluations occurred before admission to the secured unit. She said when residents came from the community, it was implied they would be placed on the secured unit, with conversations held with their representatives and documentation completed in care conferences and social services progress notes after admission. The memory care director said Resident #42 had been living in the secured unit due to exit seeking behaviors and by personal choice due to being scared of staff on the unsecured unit. The memory care director said there had been no evaluation or assessment for appropriateness of secured unit placement, and according to the assessment, Resident #42 would not qualify because her placement was voluntary. The memory care director said she had offered to move Resident #42 back to the other side of the building, but the resident appeared to feel more supported on the secured unit and had not expressed fear since. The memory care director said she had not offered to give Resident #42 the exit code for the secured door because she did not know which residents on the unit were allowed to come and go freely.The SSD said the residents in the secured unit often could not sit still and required one-to-one assistance with activities and more supervision to stay focused, while residents in the unsecured unit engaged more independently. The SSD said Resident #42 was social for the first two weeks after moving to the secured unit but was now hyper-focused on discharging to another state. The SSD said that about three weeks ago, Resident #42 had an incident with a staff member after expressing she wanted to leave the facility to walk to the store. The SSD said a staff member guided her back into the building, but two or three additional staff members were also present, and being around a crowd was triggering for her.The social services consultant was interviewed on 8/6/25 at 4:09 p.m. The social services consultant said that all staff working with a resident needed to be aware of their trauma triggers to prevent retraumatizing the resident. She said if staff were not aware of triggers, it would put the resident at higher risk of being traumatized repeatedly. The social services consultant said if a resident was living on the secured memory care unit in a voluntary capacity, there should be a plan on how the facility was working to reintegrate the resident to the unsecured side of the facility. She said part of this process would be to trial the resident with the door code so they could come and go off the unit independently. She said if this was not feasible, the staff on the secured unit would need to drop everything they were doing every time the resident wanted to leave the secured unit in order to prevent the resident from being restricted to the secured unit. The NHA and the DON were interviewed together on 8/7/25 at 12:49 p.m. The NHA said the difference between the secured and unsecured units was that residents on the unsecured unit were more autonomous and engaged in activities more independently, while the secured unit was more structured with additional staff trained for dementia and behavior management. The NHA said residents who could not verbalize their needs were better supported on the secured unit to prevent escalation and allow for redirection and calming. The NHA said staff education was important to maintain safety, both emotionally and physically, and improve quality of life. The NHA said for new admissions, the IDT reviewed information, discussed needs and goals with the resident's representative and collaboratively determined placement. The NHA said factors considered included elopement risk and exit-seeking behavior. The NHA said the primary care provider (PCP) was contacted for orders and input on placement appropriateness. The NHA said for current residents, placement decisions involved reviewing documentation and observations, IDT collaboration, input from a third party reviewer and conversations with family. The NHA said the facility informed families if they recommended a move to enhance quality of life. The NHA said least restrictive measures were used first, such as wanderguards and redirection, and if these were unsuccessful then placement on the secured unit was considered and documented in the care plan. The NHA said they tried offering Resident #42 the option to move back to the unsecured unit, but she continued to decline the move. The NHA said Resident #42's discharge to another state was pending, with a recent court order and physician clearance and travel arrangements were up to the daughter. The NHA said conversations continued about the resident's wishes to leave the secured unit, and staff were educated that she was free to leave. The NHA said behavior monitoring included regular check-ins but no specific monitoring was documented on the medication administration record (MAR). The NHA said that Resident #42's stay on the secured unit was completely voluntary. The NHA said their consultant recommended documenting the voluntary nature of the placement.The DON said staff were assigned to the secured unit who better understood and could manage residents' specific needs. The DON said the IDT considered whether the resident was at risk of danger to self.

Based on record review and interviews, the facility failed to ensure five (#40, #28, #45, #5 and #43) of seven residents reviewed for abuse out of 27 sample residents were kept free from abuse. Specially, the facility failed to:-Protect Resident #40 from physical abuse by Resident #45;-Protect Resident #28 from physical abuse by Resident #45; -Protect Resident #28 and Resident #45 from physical abuse by each other;-Protect Resident #5 from physical abuse by Resident #28; and, -Protect Resident #43 from physical abuse by Resident #32.Findings include: I. Incident of physical abuse of Resident #40 by Resident #45 on 6/3/25A. Facility investigation The 6/3/25 facility investigation documented a nurse witnessed Resident #40 back his motorized wheelchair into the hallway. Resident #45 was ambulating down the hallway and came upon Resident #40 and hit him on the back of the head (near the base of the skull/top of neck) with the back of her open hand. The staff redirected Resident #45 away from the Resident #40. Resident #40 continued moving his wheelchair and did not acknowledge that anything had occurred.The two residents were separated by staff and assessed for injuries and no injuries were noted. When interviewed by staff, neither resident could recall the events due to their cognitive impairments. The residents resided on the same secured unit of the facility. Resident #45 was assigned one-on-one observation by staff and new interventions were added to offer a milkshake for distraction, redirect others from Resident #45 or step between her and other residents at times of increased agitation. The physician was notified and an increase of Resident #45's antipsychotic medication was requested. The facility substantiated the incident, but did not substantiate abuse as there was no injury and no fear.-However, abuse occurred due to Resident #45 being observed slapping Resident #40 in the head. B. Resident #45 (assailant)1. Resident statusResident #45, age [AGE], was admitted on [DATE]. According to the August 2025 computerized physician orders (CPO), diagnoses included unspecified dementia and a traumatic brain injury (TBI). The 7/2/25 minimum data set (MDS) assessment revealed the resident had severe cognitive impairments and was unable to participate in the brief interview for mental status (BIMS) assessment. A staff assessment for mental status revealed the resident had short and long term memory impairments and had severe impairments to her daily decision-making skills. The MDS assessment indicated the resident had behaviors not directed at others (physical symptoms such as scratching self, pacing, smearing bodily fluids or food, disrobing, public sexual acts, screaming or disruptive sounds), physical and verbal aggression, rejecting care, and wandering. The resident experienced delusions. 2. Record reviewResident #45's behavior care plan, revised 6/13/25, revealed the resident had behaviors of verbal aggression with other residents related to dementia and a history of TBI. The resident would pace and wander to the point of exhaustion and did not have awareness of others' space and would enter others' rooms. The resident could be paranoid and did not not get along with another female resident on the unit and would have altercations with her if in close proximity. The resident would strike others unprovoked and could become verbally aggressive if feeling threatened. Interventions, initiated 4/14/25, included redirecting the resident from others' space and to her room or common areas, allowing the resident to sit in chairs in the hallway, engaging with the resident when passing her in the hallway with smiles and greetings, if the resident felt she was being followed, offering reminders of where the other resident's rooms were and offering to walk away from them with her, offering sweet treats, assisting with turning on the resident's television in her room during times of frustration, allowing the resident independent visits with her male friend in the unit, offering the resident compliments on her appearance, and offering to paint her nails. Interventions, initiated 6/4/25, included offering the resident a milkshake when agitated, and staff were to create a space between her and others or stand between them if unable to redirect the resident away from others. Interventions, initiated 6/7/25, included providing one-on-one staff at times of increased agitation and with busy waking hours.Interventions, initiated 6/9/25, included encouraging a calm bedtime environment and relaxation to promote sleep, offering the resident a back rub, smoothing of the resident's hair, providing soft or calming music and encouraging the resident to take walks outside with staff daily to reduce [NAME] up energy and reduce the risk of agitation .Interventions, initiated 6/13/25, included for the facility to purchase an identical pillow for the resident as another resident had as Resident #45 frequently took the other resident's pillow, which caused conflict, redirecting the resident away from the female resident she did not get along with and redirecting her from going into others' rooms or taking their belongings. Interventions, initiated 6/30/25, included reducing one-on-one observation to afternoon hours or with times of agitation. A nursing progress note, dated 6/3/25, revealed that Resident #45 had been upset, anxious, and agitated while pacing and cursing throughout the unit. As Resident #45 was pacing the hallway, Resident #40 was wheeling backwards down the unit and Resident #45 used her flat hand and smacked Resident #40 in the back of the head. Staff separated the residents. Further review of Resident #45's electronic medical record (EMR), from 2/24/25 to 8/5/25, revealed the resident had a history of wandering into other residents' rooms, and verbally antagonizing other residents, resulting in altercations with other residents.-The facility failed to address Resident #45's behaviors of wandering into other residents' rooms in the care plan until 4/14/25 and failed to address the resident's behaviors of verbally antagonizing other residents.C. Resident #40 (victim)1. Resident statusResident #40, age less than 75, was admitted on [DATE]. According to the August 2025 CPO, diagnoses included anxiety and intracranial injury (TBI). The 5/22/25 MDS assessment revealed the resident had moderate cognitive impairments with a BIMS score of seven out of 15. The MDS assessment indicated the resident experienced delusions. 2. Record reviewResident #40's behavior care plan, revised 6/3/25, revealed the resident took an antipsychotic medication related to an anxiety disorder with target behaviors of verbal outbursts/aggression. Interventions, revised 6/14/24, included offering one-on-one, redirection, offering food/fluids, toileting, removing from the situation, offering an activity, assessing for pain or offering massage/back rub. -Resident #40's care plan failed to address the incident with Resident #45 on 6/3/25.II. Incident of physical abuse of Resident #28 by Resident #45 on 6/4/25 A. Facility investigationThe 6/4/25 incident investigation documented a dietary aide witnessed an altercation between Resident #45 and Resident #28 in the dining area of the secured unit that both of the residents resided on. Resident #45 had been assigned one-on-one observation by staff after the incident between Resident #45 and Resident #40 on 6/3/25 (see 6/3/25 incident above). However the dietary staff member who reported the incident between Resident #45 and Resident #28 to the nursing staff was the only staff member present at the time of the incident. Nursing staff were not present or observing Resident #45 at the time of the incident. Resident #28 had been sitting at the dining room table for lunch. Resident #45 entered the dining room to take her seat for lunch, but approached Resident #28 unprovoked and hit her in the head with a pillow four to five times and then walked away. Resident #28 yelled out and said no to Resident #45. The two residents were separated by staff and assessed for injuries and no injuries were noted. Resident #45 had been assigned one-on-one observation by staff and was assisted with an activity off the unit with staff.When interviewed by staff, neither resident could recall the events due to cognitive impairments. The residents resided on the same secured unit of the facility. Resident #45 was assigned one-on-one observation by staff and a medication review was requested. The facility substantiated the incident, but did not substantiate abuse due to no injury. -However, abuse occurred due to Resident #45 being observed hitting Resident #28 with a pillow. B. Resident #45 (assailant)1. Record reviewA nursing progress note, dated 6/4/25, revealed that a dietary staff member informed the nurse that Resident #45 hit Resident #28 in the face in the dining room. The nurse separated the residents and assessed for injury and there were no injuries. The NHA and the director of nursing (DON) were contacted. C. Resident #28 (victim)1. Resident statusResident #28, age [AGE], was admitted on [DATE]. According to the August 2025 CPO, diagnoses included Alzheimer's disease, dementia with mood disturbance and major depressive disorder.The 6/18/25 MDS assessment revealed the resident had severe cognitive impairments with a BIMS score of two out of 15. The MDS assessment indicated the resident had behaviors not directed at others (physical symptoms such as scratching self, pacing, smearing bodily fluids or food, disrobing, public sexual acts, screaming or disruptive sounds), wandering, delusions and physical aggression. B. Record reviewResident #28's behavior care plan, revised 6/13/25, revealed the resident would strike out at other residents if she felt threatened or if they were in her personal space. The resident did not get along with another female resident on the unit and was at high risk for having altercations with that other resident.Interventions, initiated 6/13/25, included redirecting all residents from Resident #28's space/room and her personal belongings, redirecting Resident #28 away from the female resident on the unit that she did not get along with, providing space between the two residents when passing in common areas and creating a barrier if possible by standing between them or ambulating on the passing side of the resident.Interventions, initiated 7/23/25, included providing as needed one-on-one observation related to periods of agitation/frustration that was not easily redirectable with person-centered interventions.-Resident #28's care plan did not reveal that the resident's care plan was reviewed to determine if the current interventions were effective or if new interventions were needed to prevent further abuse incidents. -Additionally, Resident #28's care plan did not reveal that the resident's care plan was reviewed to determine if the current interventions were effective or if new interventions were needed to prevent further abuse incidents following the incidents with Resident #45 on 6/8/25 and 6/12/25 or following the incident with Resident #5 on 7/5/25 (see 6/8/25, 6/12/25 and 7/5/25 incidents below).A nursing progress note, dated 6/4/25, revealed that a dietary staff member informed the nurse that Resident #45 hit Resident #28 in the face in the dining room. The nurse separated the residents and assessed for injury, no injuries. The NHA and the DON were contacted.III. Incident of physical abuse of Resident #45 and Resident #28 by each other on 6/8/25A. Facility investigationThe 6/8/25 incident investigation documented a nurse witnessed an altercation between Resident #45 and Resident #28 in the hallway of the secure unit that both residents resided on. Resident #45 was pacing down the hallway and teasing and laughing at Resident #28. Resident #45 than passed Resident #28 on the opposite side of the hallway. Resident #45 raised her fist and made punching motions in the air. When Resident #28 walked down the hallway on the side of the hallway were Resident #45 was, Resident #45 then tapped Resident #28's arm with a closed fist and Resident #28 tapped Resident #45 in the upper arm with a closed fist in return. The two residents were separated by staff and assessed for injuries, no injuries noted. Resident #45 was assigned one-on-one observation by staff and assisted with an activity off the unit with staff.When interviewed by staff, neither resident could recall the events due to cognitive impairments. The residents resided on the same secured unit of the facility. Resident #45 was assigned one-on-one observation by staff and a medication review was requested. -However, Resident #45 had been assigned one-on-one observation by staff after the incident with Resident #28 on 6/4/25 and that intervention failed to mitigate the altercation on 6/8/25. The facility unsubstantiated the incident due to cognitive impairments. -However, abuse occurred due to Resident #45 being observed hitting Resident #28 with a closed fist.B. Resident #45 (assailant and victim)1. Record reviewA nursing note, dated 6/8/25, revealed that Resident #45 was witnessed walking up and down the hallway laughing and teasing Resident #28. Resident #45 continued pacing despite being redirected many times, and got closer to Resident #28. As Resident #45 got closer, Resident #45 raised her fist and punched the air while looking at Resident #28. Resident #28 walked down the hallway but came too close to Resident #45, resulting in Resident #45 using her fist to tap Resident #28 in the left arm. Resident #28 responded by using her fist to tap Resident #45 in the right arm. Resident #45 was redirected to go outside for a walk and Resident #28's arm was assessed with no injury. C. Resident #28 (victim and assailant) 1. Record reviewA nursing note, dated 6/8/25, revealed that Resident #45 was witnessed walking up and down the hallway laughing and teasing Resident #28. Resident #45 continued pacing despite being redirected many times, and got closer to Resident #28. As Resident #45 got closer, Resident #45 raised her fist and punched the air while looking at Resident #28. Resident #28 walked down the hallway but came too close to Resident #45, resulting in Resident #45 using her fist to tap Resident #28 in the left arm. Resident #28 responded by using her fist to tap Resident #45 in the right arm. Resident #45 was redirected to go outside for a walk and Resident #28's arm was assessed with no injury. IV. Incident of physical abuse of Resident #45 and Resident #28 by each other on 6/12/25A. Facility investigationThe 6/12/25 incident investigation documented a nurse observed Resident #45 go into Resident #28's room and took her pillow from the room. Resident #28 had been in the hallway and became upset when Resident #45 walked past her with Resident #28's pillow. Resident #28 then hit Resident #45 in the head with an open hand and Resident #45 hit Resident #28 in the shoulder with an open hand in return. Resident #28 hit Resident #45 again in the head twice with an open hand before staff intervened. The two residents were separated by staff and assessed for injuries and no injuries noted. Resident #45 was assigned one-on-one observation by staff and assisted with an activity off the unit with staff.When interviewed by staff, neither resident could recall the events due to cognitive impairments. The residents resided on the same secured unit of the facility. Resident #45 and Resident #28's care plans were updated to instruct staff to keep the two residents away from each other and staff received training to keep the residents away from each other. Resident #45 was assigned one-on-one observation by staff. -However, Resident #45 had been assigned one-on-one observation by staff after the incidents on 6/4/25 and 6/8/25 and that intervention had failed to mitigate the altercation on 6/12/25.The facility unsubstantiated the incident due to no injury.-However, abuse occurred due to Resident #45 and Resident #28 were observed hitting each other. B. Resident #28 (assailant and victim) 1. Record reviewA nursing note, dated 6/12/25, revealed Resident #45 took Resident #28's pillow from her bedroom, which made Resident #28 upset, resulting in Resident #28 hitting (open handed) Resident #45 on the head. Resident #45 then hit Resident #28 back in the left shoulder, causing Resident #28 to hit Resident #45 in the head two times open handed. Both residents were separated, redirected and assessed. Both residents did not recall the situation and denied pain. C. Resident #45 (victim and assailant) 1. Record reviewA nursing note, dated 6/12/25, revealed Resident #45 took Resident #28's pillow from her bedroom, which made Resident #28 upset, resulting in Resident #28 hitting (open handed) Resident #45 on the head. Resident #45 then hit Resident #28 back in the left shoulder, causing Resident #28 to hit Resident #45 in the head two times open handed. Both residents were separated, redirected and assessed. Both residents did not recall the situation and denied pain. V. Incident of physical abuse of Resident #5 by Resident #28 on 7/5/25A. Facility investigation The 7/5/25 incident investigation documented activities assistant (AA) #1 witnessed an altercation between Resident #28 and Resident #5 in the outside secure unit courtyard during an activity. Resident #28 walked up to Resident #5 and pushed Resident #5 in the arm and was redirected by staff. However, Resident #28 returned to Resident #5 and pushed her in the arm a second time. The two residents were separated by staff and offered snacks, both residents were taken inside and assessed for injuries. No injuries were noted. Resident #28 was assigned one-on-one observation by staff on 7/8/25, three days after the incident. -Review of Resident #28's EMR and care plan revealed one-on-one observations were not initiated until 7/8/25 (three days after the incident), despite Resident #28 being involved in other incidents of physical abuse towards other residents on 6/8/25 and 6/12/25 (see 6/8/25 and 6/12/25 incidents above).When interviewed by staff, neither resident could recall the events due to cognitive impairments. The residents resided on the same secured unit of the facility. Resident #28 was assigned one-on-one observation by staff on 7/8/25 (three days after the incident) and the physician was notified.The facility unsubstantiated the incident due to no injury. -However, abuse occurred due to Resident #28 being observed pushing Resident #5 twice, despite being redirected. B. Resident #28 (assailant) 1. Record reviewReview of Resident #28's progress notes revealed there was no progress note related to the incident.C. Resident #5 (victim)1. Resident statusResident #5, age [AGE], was admitted on [DATE]. According to the August 2025 CPO, diagnoses included vascular dementia, anxiety and insomnia. The 6/19/25 MDS assessment revealed the resident had severe cognitive impairments with a BIMS score of six of 15. The MDS assessment indicated the resident had behaviors of wandering and experienced delusions. 2. Record reviewResident #5's behavior care plan, revised 6/9/25, revealed the resident was an elopement risk related to disorientation to place, impaired safety awareness, and wandering aimlessly which significantly intruded on the privacy of activities. The resident wandered daily and had a lack of awareness of other's personal space/boundaries and would benefit from a smaller, more structured environment of the secure unit. Interventions, initiated 6/9/25, included distracting the resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, or a book, and providing structured activities such as toileting, walking inside and outside, reorientation strategies including signs, pictures and memory boxes. Interventions, initiated 7/7/25, included redirecting the resident away from others' personal space as needed.-Resident #5's care plan failed to address the incident with Resident #28 on 7/5/25.Review of Resident #5's progress notes revealed there was no progress note related to the incident. VI. Incident of physical abuse of Residents #43 by Resident #32 on 8/4/25A. ObservationOn 8/4/25 at 1:11 p.m. Resident #32 was observed in the doorway of the room he shared with Resident #43. During the observation, Resident #32 had his right arm around Resident #43's neck with his left hand positioned to lock the hold by grabbing his right hand. Resident #43 was standing with his hands down to his sides and was not engaging physically with Resident #32. Certified nurse aide (CNA) #5 ran over to the two residents to intervene. B. Facility investigation The 8/4/25 incident investigation documented the CNA #5 witnessed an altercation between Resident #32 and Resident #43 as they exited their room together. Resident #32 had his hand on the neck of Resident #43 and Resident #43 was pushing Resident #32 in the neck with his open hands. The two residents were separated by staff and assessed for injuries, no injuries noted. Resident #32 and Resident #43 were assigned one-on-one observation by staff. When interviewed by staff, Resident #32 said he was cleaning his side of the room and looked over at his roommate's side of the room and told his roommate, Resident #43, to clean his side of the room. Resident #43 responded by telling Resident #32 to get out of his room and an argument started. When interviewed by staff, Resident #43 could not describe the events but said he wanted Resident #32 out of his room. The residents resided on the same secured unit of the facility and shared a room. Resident #43 and Resident #32 were both assigned one-on-one observation by staff on 8/4/25 and the physician was notified.The facility unsubstantiated the incident due to no injury. -However, abuse occurred due to Resident #32 being observed with his hand around Resident #43's neck (see observation above). -Additionally, the facility's description of the incident did not match the observation of the incident (see incident above).C. Resident #32 (assailant)1. Resident statusResident #32, age under 70, was admitted on [DATE]. According to the August 2025 CPO, diagnoses included anxiety and Wernicke's encephalopathy (alcohol-induced encephalopathy). The 6/25/25 MDS assessment revealed the resident had severe cognitive impairments and was unable to participate in the BIMS assessment. A staff interview for mental status revealed the resident had short and long term memory impairments and had severe impairments related to his daily decision making skills. The MDS assessment indicated the resident had behaviors of hallucinations, delusions, rejecting care, and wandering. 2. Record reviewResident #32's mood care plan, revised 8/4/25, revealed the resident could become verbally aggressive when frustrated or throw items. The resident had an episode of physical aggression toward his roommate. The resident could become frustrated if his roommate's side of the room was dirty/cluttered. Interventions, initiated 8/4/25, included reminding others to respect the resident's personal space and offering to assist with tidying of his room as the resident allowed.Resident #32's behavior sheet, undated, was kept at the nurses station and was reviewed on 8/5/25. The behavior sheet revealed that Resident #32 had behaviors of becoming aggressive, throwing things, and could become triggered if his roommate's side of the room was cluttered. Resident #32 had an aversion to being around other men and could become fearful and aggressive. Interventions included assisting him to a quiet area, redirecting him from other residents, offering chocolate ice cream or chocolate milk, allowing him to read a book of choice, assisting him in calling his sister, encouraging the resident to stay in his room and reorganizing if desired, encouraging the resident to keep a distance from other men, allowing him to sit alone in the dining room or encouraging female peers to sit with him, allowing him to watch the television in the dayroom and offering to assist the resident in tidying his personal space. -However, Resident #32's care plan and behavior monitoring orders failed to identify potential challenges with Resident #32 being around other males (see care plan above). A psychoactive medication evaluation meeting minute note, dated 6/20/25, revealed a physician note written during the meeting indicated Resident #32 had recently moved to the secure unit and he would be getting a roommate, which had historically increased Resident #32's behaviors, anxiety, and distress. The facility was to monitor and assess Resident #32's adjustment. A room change form revealed Resident #32 moved to his room in the secure unit on 5/21/25. -Resident #32's EMR failed to reveal staff provided psychosocial checks on Resident #32 once Resident #43 moved into his room on 6/30/25. -Resident #32's care plan, behavior monitoring orders, and behavior sheet failed to identify potential challenges with Resident #32 once he received a roommate. A nursing note, dated 8/4/25, revealed Resident #32 had an altercation with his roommate. Both residents came out of their room holding each other's necks. No injuries were noted. D. Resident #43 (victim) 1. Resident statusResident #43, age [AGE], was admitted on [DATE]. According to the August 2025 CPO, diagnoses included unspecified dementia with behavioral disturbances, post traumatic stress disorder (PTSD), major depressive disorder and anxiety. The 6/30/25 MDS assessment documented Resident #43 had severe cognitive impairments with a BIMS score of three out of 15. The MDS assessment indicated Resident #43 had behaviors of being verbally abusive, experiencing delusions and wandering.2. Resident interviewResident #43 was interviewed on 8/4/25 at approximately 3:30 p.m. However, he became agitated when his roommate was mentioned, although he was unable to say why.3. Record review Resident #43's behavior care plan, initiated 6/30/25, revealed the resident had a history of aggressive behaviors at his previous facility towards female caregivers and other residents. The resident would become frustrated when he felt that others were in his personal space andcould become physical to show where his boundaries were. He had exhibited physical aggression toward others with times of frustration (pushing and hitting), revised 8/4/25, during the survey. Interventions, initiated 6/30/25, included approaching the resident from the side when attempting to engage in conversation with a slow and calm demeanor while using open body language andspeaking in a low, soft tone. Avoiding making prolonged eye contact with the resident as this frustrated him and made him feel uneasy and if the resident became physically aggressive, ensure he was in a safe space and give him a few minutes alone to calm down. If possible, staff were to sit next to the resident and face forward rather than turning towards the resident during conversation. Interventions, initiated 8/4/25, during the survey, included engaging the resident in talking about the town where he was from and farming, assisting the resident with praying, offering snacks (sweets and hot chocolate) and offering time outside. -Resident #43's care plan failed to address the incident on 8/4/25. A nursing note, dated 8/4/25, revealed Resident #43 had an altercation with his roommate. Both residents came out of their room holding each other's necks. No injuries were noted. Resident #43 was yelling He needs to get out of my room.Resident #43's behavior sheet, undated, was kept at the nurses station and was reviewed on 8/5/25. The behavior sheet revealed that Resident #43 had behaviors of becoming verbally aggressive or physically aggressive (hitting and pushing). Interventions included engaging the resident in talking about where he was from or farming, approaching the resident from the side when attempting to engage in conversation with a slow and calm demeanor while using open body language and speaking in a low, soft tone, avoiding making prolonged eye contact with the resident as this frustrated him and made him feel uneasy and if the resident became physically aggressive, ensure he was in a safe space and give him a few minutes alone to calm down. If possible, staff were to sit next to the resident and face forward rather than turning towards the resident during conversation -A review of Resident #43's care plan and behavior monitoring orders failed to identify Resident #43's specific triggers (body language, body positioning and eye contact) that were identified on his behavior sheet. Review of Resident #43's EMR, from 6/30/25 to 8/5/25, revealed the resident had behaviors of believing he was being held against his will/in prison twice, refusing care due to agitation five times, exit seeking three times, demanding to go home twice, paranoid of others twice and attempting to hit staff three times. -Review of Resident #43's EMR failed to reveal resident specific behavior monitoring for the behaviors displayed since admission, nor did it reveal staff had assisted Resident #43 to unpack or organize his room, despite his roommate having identified triggers related to clutter (see Resident #32's behavior sheet above) and Resident #43 having triggers of others being in his personal space (see care plan above). -Review of Resident #43's EMR failed to reveal staff provided psychosocial checks on Resident #43 and his roommate, Resident #32, during the period Resident #43 was having disruptive behaviors (see above). VII. Staff interviewsCNA #5 was interviewed on 8/5/25 at 1:27 p.m. She said she came around the hall when she heard a commotion and found Resident #32's hand on Resident #43's neck. CNA #5 said she had not witnessed the two residents initially leaving their room and was not certain exactly where everyone's hands were with all the commotion. She said Resident #43 had been struggling to adjust to placement and she was unaware that Resident #32 had issues with males. She said the staff were currently providing both residents with one-on-one observation and this consisted of staff ensuring the residents were never in the room together. She said management was working on a room move for Resident #32. -During the interview, Resident #43 sat at the table with CNA #5 and became increasingly agitated and paranoid there was a plan to harm him.CNA #5 said Resident #45 would instigate altercations with Resident #28, but she was unclear on why Resident #28 triggered Resident #45. She said management had staff keep the two residents separated as much as possible as a new intervention after the altercations. The dietary aide (DA), who witnessed the incident on 6/4/25, was interviewed on 8/6/25 at 12:52 p.m. The DA said she saw Resident #45 walking past Resident #28 in the dining room as Resident #28 was sitting in her seat waiting for lunch. The DA said she did not see anything happen between the two residents leading up to the incident. She said Resident #45 approached Resident #28 and hit her in the head with a pillow four to five times and she said she physically got in between the two residents until a CNA arrived shortly after. The memory care director was interviewed on 8/6/25 at 11:53 a.m. The memory care director said physical aggression was a new behavior for Resident #28 and Resident #45 had been the original aggressor. She said that Resident #45 had a history of being kicked out of her previous facilities due to behaviors, but once Resident #28 admitted to the facility, Resident #45 started going after her. The memory care director said she believed that it was due to Resident #28 having a flat affect and sometimes making sounds that were not directed at Resident #45, however, seemed to trigger Resident #45. She said her root cause analysis of the repeated incidents between the two residents, was that Resident #45 was getting one-on-one staff supervision and Resident #28 perceived she was getting less attention, and began acting out as well. The memory care director said that both women had strong personalities and the staff tried to redirect them away from each other. She said that Resident #45 would have increased pacing, made negative statements towards others, and become more fidgety when she was beginning to ramp up her aggression. The memory care director said that Resident #28 would also have increased pacing and make more nonverbal noises with a more negative tone of voice. She said that Resident #28 would keep her mouth closed and not smile, while holding he

Based on record review and interviews, the facility failed to ensure that a resident who was a trauma survivor received culturally competent, trauma-informed care in accordance with professional standards of practice and accounting for residents' experiences and preferences in order to eliminate or mitigate triggers that may cause re-traumatization of the resident for one (#42) of five residents with a documented history of trauma out of 27 sample residents.Specifically, the facility failed to identify and create a person-centered individualized care plan that addressed Resident #42's past history of trauma, and/or triggers which may cause re-traumatization and train staff on the residents trauma and triggers.Findings include:I. Resident #42A. Resident statusResident #42, age [AGE], was admitted on [DATE]. According to the August 2025 computerized physician orders (CPO), diagnoses included Alzheimer's disease and delusional disorder (false beliefs).The 6/5/25 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. The resident's health questionnaire (PHQ-9) assessment for depression scored zero out of 27 which indicated no depression. B. Resident representative interviewResident #42's representative was interviewed on 8/7/25 at 10:25 a.m. The representative said that Resident #42 became increasingly agitated and distressed due to staff interventions and the lack of trauma-informed care. The representative said that no assessment, evaluation or written consent had been completed to guide staff in supporting the resident's trauma history. She said that the resident refused to return to her previous room in the unsecured unit and was frustrated and upset with staff interactions. C. Resident interviewResident #42 was interviewed on 8/5/25 at 11:47 a.m. Resident #42 said her daughter had brought her to the facility three years earlier and had told her to take a look inside and see if she liked it, but then had left her there and dumped her. She said she did not come to the facility out of her own free will and had felt people in the facility had hurt her emotionally. She said she had come to the secured unit after an incident when she wanted to be taken to the store before it closed at 7:00 p.m. to get hairspray. She said staff at the front desk had said someone would take her, but as it was getting closer to 7:00 p.m., she had become worried. She said she realized the staff had no intention of taking her to the store and perceived they were laughing at her. She said she decided to walk to the store herself. She said she was not sure how it happened, but then several staff members tried to stop her and she became fearful. She said she had been told she was free to leave the facility whenever she wanted and then they would not let her. She said as a result of being fearful of staff, she asked to stay the night in an empty room and had been brought to the locked unit. Resident #42 said she felt awful about being in a place where the door would not open and she had been very unhappy in the unit. She said she had also been fearful of moving back to the other side of the building because she believed she had been physically attacked by staff when trying to go to the store. She said she was scared of some of the men on the secured unit and that they would knock on her door at night. She said there was a man who pushed on the exit door and set the alarm off all of the time. She said she could not talk to the other residents in the secured unit because they did not understand what she was saying. She said she had asked for the code to the door and had reiterated she was supposed to be able to leave whenever she wanted, but she did not know the code to the locked door.Cross reference F603 for failure to keep residents free from involuntary seclusion. D. Record reviewThe Colorado preadmission screening and resident review (PASRR) Level II notice of determination for mental illness, dated 2/1/23, documented that Resident #42 had a PASRR condition of delusional disorder. The PASRR Level II evaluation indicated the resident had a known or suspected diagnosis of a major mental illness. The PASRR Level II identified that the resident had a history of trauma and recommended individual therapy as a specialized service. -However, Resident #42 did not have a care plan that addressed the trauma identified in the PASRR Level II, the triggers or person-centered individualized interventions to prevent re-traumatization.The social services director (SSD) updated Resident #42's care plan, during the survey on 8/5/25, and addressed the resident's preferences, triggers, and need for individualized trauma-informed approaches. New interventions included avoiding speaking with Resident #42 about her daughter unless Resident #42 brought her up, monitoring and reviewing with the resident regularly and obtaining the resident's and her representative's consent for the resident to remain in the secured memory unit as it made Resident #42 feel safe. -However, the care plan was not updated to include person-centered individualized interventions, personalized triggers or personalized signs and symptoms to prevent re-traumatization of Resident #42. The behavioral care plan, initiated 12/20/22 and revised 3/28/24, documented that Resident #42 had delirium related to unspecified dementia with behavioral disturbances and delusional disorder. Pertinent interventions included monitoring intake and output, observing environmental factors and signs of delirium, providing gentle reorientation, maintaining consistent routines and caregivers, monitoring cognitive changes, providing activities suited to abilities, administering medications with monitoring and communicating with the resident and family.-However, the care plan did not address the trauma identified in the PASRR Level II (see above) and it did not include person-centered individualized interventions, specific triggers or personalized signs and symptoms to prevent re-traumatization of Resident #42.The trauma life event screening questionnaire, dated 7/31/25, revealed that Resident #42 had experienced significant and repeated traumatic events throughout her life. The screening documented the following traumatic events:-Physical assault, such as being attacked, hit, slapped, kicked, or beaten up;-Assault with a weapon, such as being shot, stabbed, or threatened with a knife, gun or bomb;-Combat or exposure to a war zone, either in the military or as a civilian;-Captivity, such as being kidnapped, abducted, held hostage, or being a prisoner of war;-Severe human suffering;-Loss of home or property, such as through homelessness or divorce;-Witness to a sudden violent death;-Upsetting thoughts or memories about the above-mentioned events that came into her mind against her will;-Feeling as though the above-mentioned events were happening again;-Feeling upset by reminders of the above-mentioned events;-Talking about the above-mentioned events induced bodily reactions, such as a fast heartbeat or stomach churning;-Experiencing irritability or outbursts of anger;-Feeling jumpy or startled by something unexpected; and,-Heightened awareness of potential dangers to herself and others.II. Staff interviewsThe nursing home administrator (NHA) was interviewed on 8/5/25 at 12:03 p.m. The NHA said Resident #42 suffered a lot of trauma from World War 2 where her family had to flee and hide. She said she had behaviors related to that trauma (barricading herself in her room, paranoia) and her daughter had told the facility the resident had always been this way.Certified nurse aide (CNA) #5 was interviewed on 8/5/25 at 1:27 p.m. CNA #5 said Resident #42 previously lived in the 200 hall and would not allow staff into her room in the morning, displayed paranoia and barricaded her door. CNA #5 said she did not know of any interventions that worked with the resident.CNA #6 was interviewed on 8/6/25 at 11:44 a.m. CNA #6 said Resident #42 preferred to be alone in her room and became triggered when staff repeatedly asked her questions or knocked on her door. He said the staff attempted interventions for the resident that included allowing her to lock her room, providing choices, not touching her personal items without permission and knocking before entering.The social services director (SSD) and the memory care director were interviewed together on 8/6/25 at 2:03 p.m. The SSD said that when a new resident was admitted , if staff discovered any signs of trauma, the facility added it to the care plan and offered the resident a visit to the facility's clinic. The SSD said that after trauma was identified, a trauma evaluation was completed to identify triggers, such as past caregiver incidents. The SSD said psychological services were offered, and the facility was working with a company to provide that service consistently. The SSD said interventions listed in the care plan would trigger updates to the Kardex (a tool utilized by staff to provide consistent resident care) and staff were educated on how to approach residents with trauma. The SSD said Resident #42's triggers were documented in her care plan. The SSD said the behavior binder the facility kept at the nurses' station for staff reference could be a little more specific for a better trauma-informed approach. The SSD said moving forward, resident's trauma-related triggers would be taken to the interdisciplinary team (IDT) and Resident #42 would be offered the option to return to the unsecured unit while maintaining the same interventions. The SSD said the resident had refused occupational therapy (OT) and physical therapy (PT) had been offered multiple times, but the resident had refused every attempt.The memory care director said that when a resident had identified trauma, she considered potential triggers, spoke with the resident and the resident's family about the trauma and triggers, and created a plan of care. The memory care director said a trauma assessment was completed with Resident #42 two to three weeks ago. The memory care director said the resident was open about her past life and reported being held captive in Russia for 10 years, that her family could not survive and that her family was shot in front of her. The memory care director said the resident's triggers included family-related triggers. The memory care director said the resident had thought people were coming from the television and believed it was her daughter, which had been a recurring issue. The memory care director said she had not provided staff with any information regarding Resident #42's trauma history because she was concerned the resident might overhear staff discussing it or that staff would be unable to act surprised if they already knew. The memory care director said the facility did not list specific triggers in the behavior binder because talking about them could have created more anxiety for the resident. The memory care director said she was concerned that staff knowing specific details of the resident's trauma history could worsen the issue. The memory care director said she understood that providing staff with Resident #42's triggers and interventions related to her trauma would help prevent incidents of re-traumatization. The social services consultant was interviewed on 8/6/25 at 4:09 p.m. The social services consultant said that all staff working with a resident needed to be aware of their trauma triggers to prevent re-traumatizing the resident. She said if staff were not aware of triggers, it would put the resident at higher risk of being traumatized repeatedly. The NHA and the director of nursing (DON) were interviewed together on 8/7/25 at 12:49 p.m. The NHA said it was important for staff to know a resident's trauma history in order to prevent future behaviors, to maintain emotional and physical safety and to improve quality of life. She said the facility did a lot of education with the staff prior to taking care of a new resident with trauma; however, this education was not documented and was primarily verbal. She said Resident #42 went to the secure unit as a trauma response after she was triggered by a CNA trying to redirect her back into the building when she wanted to leave.

Based on observations, record review and interviews, the facility failed to ensure that one (#28) of ten residents out of 27 sample residents were free from chemical restraint and were receiving the least restrictive approach for their needs. Specifically, for Resident #28, the facility failed to provide adequate documentation to justify the addition of new psychotropic medications, the increase in dosage of psychotropic medications and/or the continued use of psychotropic medications. Findings include:I. Facility policy and procedureThe Behavior Assessment, Intervention, and Monitoring policy, undated, was provided by the nursing home administrator (NHA) on 8/6/25 at 2:01 p.m. It read in pertinent part,Interventions are individualized and part of an overall care environment that supports physical, functional, and psychosocial needs and strives to understand, prevent or relieve the residents distress or loss of abilities.Non pharmacologic approaches are used to the extent possible to avoid or reduce the use of psychotropic medications to manage behavioral symptoms. Psychotropic medications are prescribed for behavioral symptoms and documentation includes rationale for use, potential underlying causes of the behavior, non-pharmacological approaches and interventions tried prior to the use of the psychotropic medication, specific target behaviors and expected outcomes, monitoring for efficacy and adverse consequences, and plans (if applicable) for gradual dose reductions. II. Resident #28A. Resident statusResident #28, age [AGE], was admitted on [DATE]. According to the August 2025 computerized physician orders (CPO), diagnoses included Alzheimer's disease, dementia with mood disturbance and major depressive disorder.The 6/18/25 minimum data set (MDS) assessment revealed the resident had severe cognitive impairments with a brief interview for mental status (BIMS) score of two out of 15. The MDS assessment indicated the resident had behaviors not directed at others (physical symptoms such as scratching self, pacing, smearing bodily fluids or food, disrobing, public sexual acts, screaming or disruptive sounds), wandering, delusions and physical aggression. B. Record reviewResident #28's depression care plan, revised 7/10/25, revealed the resident took Sertraline (an antidepressant) related to depression with target behaviors of isolation and loss of interest in things she enjoyed. She additionally took Trazodone (an antidepressant) for insomnia. Interventions, revised 7/10/25, included to redirect, provide a quiet environment, take on a walk, reposition, offer music, offer activity of interest or provide snacks or beverages.Review of Resident #28's August 2025 CPO revealed the following physician's orders:Trazodone 50 milligrams (mg) tablet. Give one tablet in the evening for insomnia, ordered 4/15/25. Sertraline 50 mg tablet. Give one tablet a day for depression, ordered 6/16/25.Monitor for behaviors related to antidepressant medication Sertraline. 1-Isolation 2-Loss of interest in activities the resident is known to enjoy. Use non-pharmological interventions 1. Redirect. 2. Reposition. 3. Offer snacks. 4. Offer fluids. 5. Adjust room temperature. 6. Distraction/offer activity. 7. See nurses note for additional information, ordered 7/10/25.Review of Resident #28's electronic medical record (EMR), from 5/1/25 to 8/4/25, revealed the following progress notes:Between 5/1/25 to 5/30/25, there was no documentation to indicate Resident #28 exhibited any episodes of isolating or decreased interest in activities she was known to enjoy.Between 6/1/25 to 6/31/25, there was no documentation to indicate Resident #28 exhibited any episodes of isolating or decreased interest in activities she was known to enjoy. A system order note, dated 6/8/25, revealed Resident #28 was standing in her doorway when another resident walked past her and teased and laughed at her. The other resident then raised her fist at Resident #28, walked away, and then returned. At that time, the other resident hit Resident #28 in the arm and Resident #28 hit her back in the arm. Both residents were separated and redirected.Cross reference F600 for failure to protect residents from physical abuse. A depression screen evaluation note, dated 6/10/25, revealed Resident #28 participated in a depression screen and did not show any signs or symptoms of depression, with a score of zero out of nine.A system order note, dated 6/12/25, revealed another resident (same resident from 6/8/25) took a pillow out of Resident #28's room, upsetting Resident #28. Resident #28 then hit the other resident in the head and the other resident hit Resident #28 in the arm. Both residents were separated and redirected. A system order note, dated 6/16/25, revealed Resident #28 had been started on Sertraline for depression.-However, review of Resident #28's EMR failed to reveal documentation to justify the addition of the antidepressant medication or a physician's rationale for the medication.An at-risk review note, dated 6/18/25, revealed after the initiation of Sertraline, there were no noted change in behaviors. The staff were to continue to offer person-centered interventions and redirect Resident #28 from the resident she frequently had altercations with. An at-risk review note, dated 6/25/25, revealed Resident #28 had been without behaviors toward others and no aggression was reported or observed.Between 7/1/25 to 7/31/25, there was no documentation to indicate Resident #28 exhibited any episodes of isolating or decreased interest in activities she was known to enjoy. A nursing note, dated 7/5/25, revealed Resident #28 went outside with supervision and pushed another resident in the arm and was easily redirected. -Between 5/1/25 to 8/5/25, there was no documentation to indicate Resident #28 exhibited any episodes of isolating or decreased interest in activities she was known to enjoy with a zero depression score on 6/10/25. However, Sertraline was ordered on 6/16/25 for depression (see physician's orders above). A review of Resident #28's behavior monitoring documented on the May 2025 through August 2025 medication administration records (MAR), from 5/1/25 to 8/4/25, revealed Resident #28 had one behavior on 7/2/25 of a loss of interest in activities she was known to enjoy. A review of progress notes failed to indicate the specific behavior on 7/2/25.-A psychoactive medication evaluation meeting minute note, dated 6/20/25, failed to reveal the rationale for the addition of Sertraline on 6/16/25. A pharmacist consultant report, dated 5/6/25, revealed the pharmacist documented a request for review of Resident #28's Trazodone due to the hours of sleep not being charted for all shifts (only morning charting was completed).A pharmacist consultant report, dated 6/9/25, revealed the pharmacist documented this was the second request for review of Resident #28's Trazodone due to the hours of sleep not being charted for all shifts (only morning charting was completed).A pharmacist report to the physician, dated 7/8/25, revealed the pharmacist recommended a dose reduction of Resident #28's Trazodone from 50 mg to 25 mg due to Resident #28 sleeping eight to 12 hours a day and the use of a hypnotic at that dose could not be supported. -Review of Resident #28's August 2025 CPO failed to reveal a dose reduction had occurred (see physician's order above).-Review of Resident #28's EMR failed to reveal documentation to justify the rationale for not decreasing the resident's Trazodone.Review of Resident #28's behavior sheet, undated, which was kept at the nurses' station, was reviewed on 8/5/25and revealed that Resident #28 had behaviors of becoming physically aggressive with staff and other residents and would have altercations with Resident #45. Interventions focused on ways to redirect the resident related to physically aggressive behaviors. -There was no behavior sheet located which indicated Resident #28 had behaviors related to depression or insomnia.III. Staff interviewsCertified nurse aide (CNA) #5 was interviewed on 8/5/25 at 1:27 p.m. CNA #5 said Resident #28 had behaviors of refusing care in the afternoons and becoming agitated if overstimulated. She said when Resident #28 first came to the facility in March 2025, she used to communicate more but in the last two months, CNA #5 said she had noticed Resident #28 makes more noises instead of talking. She said non-pharmacological interventions that worked for Resident #28 were to sing to her and show her family pictures. CNA #5 said the staff found resident behaviors and interventions in the behavior book at the nurses station, however CNA #5 said she doesn't use the behavior book because she knows the residents. CNA #5 said the CNAs documented behaviors on the CNA behavior monitoring task but the behaviors and interventions indicated on the task were generic and the same for all the residents. CNA #2 was interviewed on 8/5/25 at 3:05 p.m. CNA #2 said that Resident #28 had behaviors of becoming agitated and she liked to color when upset. She said the CNA's found the behaviors and interventions in the CNA behavior monitoring task but the behaviors and interventions indicated on the task were generic and the same for all the residents. Registered nurse (RN) #3 was interviewed on 8/5/25 at 3:15 p.m. RN #3 said Resident #28 did not really have behaviors. She said the nurses documented the residents' behaviors and interventions on the MARs and made progress notes. CNA #6 was interviewed on 8/6/25 at 11:44 a.m. CNA #6 said he had been at the facility for six months. CNA #6 said he had to retrieve the behavior binder because he could not recall the person-centered interventions or resident specific behaviors for Resident #28. He read the behaviors and interventions from the binder. CNA #6 said the CNAs did not document behaviors but told the nurse who then would document any behaviors in the progress notes. The NHA and the director of nursing (DON) were interviewed together on 8/7/25 at 12:50 p.m. The DON said that the facility determined the efficacy of psychoactive medications being administered by using behavior monitoring physician's orders within the MAR, with resident specific behaviors listed. She said her expectation was that the nurses documented behaviors on the MAR and also put in a behavior progress note to include the non-pharmological interventions attempted. The DON said that there should be non-pharmacological interventions on the behavior monitoring order for the nurses. She said that non-pharmacological interventions were important because the facility did not want to use psychotropic medications as a first resort and instead wanted to use non-pharmacological interventions first because it was more humane and ethical for the care of the resident. The DON said that the behavior monitoring physician's orders provided data that was used during the psychotropic drug meeting to decide on increasing medications or considering gradual dose reductions. She said that she continuously trained her staff on where to find the non-pharmacological interventions and what they were, as well as providing education on triggers. The DON was unaware that the CNAs and nursing staff on the secure unit were not consistent in knowing where to find behaviors and interventions for residents.The NHA said that if the staff were not consistently or accurately documenting resident behaviors, it would be difficult to determine the effectiveness of the medications and this prevented the monitoring from demonstrating a clear picture of behaviors.

Based on observations, record review and interviews, the facility failed to provide residents who were unable to carry out activities of daily living (ADLs) the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for one (#1) of three residents reviewed out of 27 sample residents. Specifically the facility failed to -Offer repositioning to Resident #1, and;-Provide assistance with toileting for Resident #1. Findings include: I. Resident #1A. Resident status Resident #1, age [AGE], was admitted on [DATE] and readmitted [DATE]. According to the August 2025 computerized physician's orders (CPO), diagnoses included acute respiratory failure, irritable bowel syndrome, osteoarthritis and history of pneumonia. The 5/19/25 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for a mental status (BIMS) score of 14 out of 15. She required substantial/maximal staff assistance with chair/bed to chair transfer with and substantial/maximal staff assistance with toileting transfers. B. Resident interview.Resident #1 was interviewed on 8/4/25 at 3:32 p.m. The resident said she was supposed to be checked every two hours because she needed help going to the bathroom. She said the nursing staff did not check on her. Resident #1 said she had to make sure she did not drink too much water so she did not go to the bathroom. C. Observations During a continuous observation on 8/5/25, beginning at 12:30 p.m. and ending at 4:12 p.m., the following was observed: At 12:33 p.m. Resident #1 was in bed eating her lunch and watching television. At 12:45 p.m. an unidentified staff member went into Resident #1's room. The staff member asked the resident if she was done with her meal and removed her lunch tray.At 12:55 p.m. Resident #1 was in bed lying on her back watching television.At 1:30 p.m. Resident #1 remained in bed lying on her back looking at a book with her television on.At 1:50 p.m. Resident #1 was in bed lying on her back watching televisionAt 2:15 p.m. the nursing home administrator (NHA) brought a vase of flowers into the resident's room. -However, the NHA did not ask the resident if she needed to be repositioned or use the restroom.At 3:30 p.m. Resident #1 was in her bed watching television.At 4:06 p.m. Resident #1 initiated her call light for assistance.At 4:12 p.m. certified nurse's aide (CNA) #1 and registered nurse (RN) #2 went into Resident #1's room to answer her call light. CNA #1 and RN #2 changed the resident's brief. The resident's brief was saturated with urine. There was a blue line on the outside of the brief that indicated the brief was wet.-The resident was not provided incontinence care from 12:30 p.m to 4:12 p.m. D. Record review The ADL care plan, initiated on 3/27/24 and revised on 5/28/25, revealed Resident #1 had a self-care performance deficit. Pertinent interventions included the resident required staff assistance for repositioning-However, observations revealed staff failed to offer or provide Resident #1 with repositioning for four hours (see observations above).E. Staff interviewsCNA #1 was interviewed on 8/5/25 at 4:21 p.m. CNA #1 said the staff needed to check on Resident #1 every two hours. CNA #1 said he was busy and was unable to check on the resident. CNA #1 said it was important to check the residents every two hours because they may need assistance changing out of the wet brief. He said if a resident stayed in a wet brief for more than two hours, it can lead to urinary infections or skin breakdown. RN #2 was interviewed on 8/6/25 at 10:18 a.m. RN #2 said Resident #1 required staff assistance for toileting. RN #2 said it was the responsibility of the nursing staff to check on the resident every two hours to make sure she was not sitting for prolonged periods in a wet brief. The director of nursing (DON) and the NHA were interviewed together on 8/7/25 at 2:35 p.m. The DON said the nursing staff should be checking on residents who were dependent on staff for toiling assistance at a minimum of every two hours. The DON said if the staff did not stick with the two hour time frame for providing incontinence care, it could expose the resident to developing skin breakdown or urinary infections. The NHA said she would provide education to the nursing staff regarding providing the residents with according to their care plan. The NHA said adhering to the resident's care plan in regards to incontinent care to maintain skin integrity was important.

Based on record review, observations, and interviews, the facility failed to identify and address the behavioral health care needs of two (#45 and #32) of 10 residents out of 27 sample residents. Specifically, the facility failed to:-Develop individualized interventions related to psychotropic medications for Resident #45 and Resident #32; and,-Consistently document the non-pharmacological interventions that were attempted and/or effective for Resident #45 and Resident #32's behaviors.Findings include:I. Facility policy and procedureThe Behavior Assessment, Intervention, and Monitoring policy, undated, was provided by the nursing home administrator (NHA) on 8/6/25 at 2:01 p.m. It read in pertinent part,Interventions are individualized and part of an overall care environment that supports physical, functional, and psychosocial needs and strives to understand, prevent or relieve the residents distress or loss of abilities.Non-pharmacological approaches are used to the extent possible to avoid or reduce the use of psychotropic medications to manage behavioral symptoms. Psychotropic medications are prescribed for behavioral symptoms and documentation includes; rationale for use, potential underlying causes of the behavior, non- pharmacological approaches and interventions tried prior to the use of the psychotropic medication, specific target behaviors and expected outcomes, monitoring for efficacy and adverse consequences, and plans (if applicable) for gradual dose reductions.II. Resident #45A. Resident statusResident #45, age [AGE], was admitted on [DATE]. According to the August 2025 computerized physician orders (CPO), diagnoses included unspecified dementia and a traumatic brain injury (TBI). The 7/2/25 minimum data set (MDS) assessment revealed the resident had severe cognitive impairments and was unable to participate in the brief interview for mental status (BIMS) assessment. A staff interview for mental status revealed the resident had short and long term memory impairments and had severe impairments to her daily decision-making skills. The MDS assessment indicated the resident had behaviors not directed at others (physical symptoms such as scratching self, pacing, smearing bodily fluids or food, disrobing, public sexual acts, screaming or disruptive sounds), physical and verbal aggression, rejecting care and wandering. The resident additionally experienced delusions. B. Resident observationDuring a continuous observation of Resident #45 on 8/5/25, beginning at 11:04 a.m. and ending at 1:24 p.m., the resident was observed pacing back and forth across the secure unit. No staff members attempted to offer any interventions to the resident to redirect her from her continuous pacing or engage with her while she paced. C. Record reviewResident #45's behavior care plan, revised 6/13/25, revealed the resident had behaviors of verbal aggression with other residents related to dementia and a history of TBI. The resident paced and wandered to the point of exhaustion, lacked awareness of others' space and would enter others' rooms, experienced paranoia, struck out at others unprovoked due to agitation, and did not get along with another female resident on the unit and would altercate with her if in close proximity. Interventions included redirecting the resident from others' space, allowing the resident to sit in chairs in the hallway, offering finger foods while pacing, engaging with the resident when passing her in the hallway, offering her sweet treats, offering the resident compliments on her appearance and offering to paint the resident's nails. Resident #45's mood care plan, revised 7/9/25, revealed the resident had a mood problem related to the disease process of dementia with behavioral disturbances. Interventions included observing for signs and symptoms of mania or hypomania, racing thoughts or euphoria, increased irritability, frequent mood changes, pressured speech, flight of ideas, marked change in need for sleep and agitation or hyperactivity. Resident #45's psychosocial care plan, revised 7/22/25, revealed the resident took antipsychotic medications for agitation related to dementia with a target behavior of striking out at others. Interventions included consulting with the pharmacist and the physician to consider dosage reductions when clinically appropriate at least quarterly (initiated 1/16/25), monitoring and documenting occurrence of target behaviors symptoms and updating target behavior documentation as needed (initiated 1/16/25) and trying non-pharmacological interventions, such as one-on-one, redirect, offer food/fluids, toilet, remove from situation, activity, assess for pain, or massage/back rub (initiated 5/27/25). Review of Resident #45's August 2025 CPO revealed the following physician's orders:Rexulti (an antipsychotic medication) 1 milligram (mg) tablet. Give one 1 mg tablet one time a day for dementia with agitation, ordered 1/2/25 and increased 6/7/25.Rexulti 3 mg tablet. Give 0.5 tablet (1.5 mg) by mouth twice a day for Alzheimer's disease, ordered 6/7/25. Trazodone (antidepressant medication) 50 mg tablet. Give 75 mg at bedtime for insomnia, ordered 3/21/25. Monitor for behaviors of agitation due to dementia for Rexulti. Use non-pharmacological interventions 1. Refused. 2. One-on-one. 3. Redirect. 4. Offer snacks/fluids. 5. Toilet. 6. Remove from the situation. 7. Offer activity. 8. Assess for pain. 9. Massage/back rub. 9. See nurses note for additional information, ordered 5/1/25 and discontinued 7/14/25. Lamotrigine (mood stabilizer) 100 mg. Give one tablet twice a day for hypomania, ordered 5/12/25.Monitor for behaviors of 1. Restlessness. 2. Pacing to the point of exhaustion. 3. Irritability associated with Lamotrigine. Use non-pharmacological interventions 1. Redirect. 2. Reposition. 3. Offer snacks. 4. Offer fluids. 5. Adjust room temperature. 6. Distraction/offer activity. 7. See nurses note for additional information, ordered 7/14/25.Monitor for behaviors of inability to sleep associated with Trazodone. Use non-pharmacological interventions 1. Redirect. 2. Reposition. 3. Offer snacks. 4. Offer fluids. 5. Adjust room temperature. 6. Distraction/offer activity. 7. See nurses note for additional information, ordered 7/14/25.Trazodone 50 mg tablet. Give one tablet in the morning for insomnia and depression, ordered 7/22/25.Monitor for behaviors of striking others unprovoked associated with Rexulit. Use non-pharmacological interventions 1. Redirect. 2. Reposition. 3. Offer snacks. 4. Offer fluids. 5. Adjust room temperature. 6. Distraction/offer activity. 7. See nurses note for additional information, ordered 7/22/25.Hydroxyzine (antihistamine used for anxiety) 25 mg. Give one tablet every six hours as needed for anxiety/agitation related to unspecified dementia, ordered 6/7/25 and discontinued 6/20/25.-The non-pharmacological interventions documented for all three of Resident #45's active behavior monitoring physician's orders indicated the same identical, non person-centered non-pharmacological interventions were to be used for every behavior, regardless of the behavior. Review of Resident #45's progress notes, from 6/4/25 to 8/4/25, revealed the following:Resident #45 had 13 episodes of verbal and physical aggression towards others (on 6/4/25, 6/8/25, 6/16/25, 6/17/25, twice on 6/18/25, twice on 6/19/25, twice on 6/20/25, 6/23/25, 6/24/25, and 6/25/25) without identified non-pharmacological interventions attempted. -Of the 13 episodes of verbal and physical aggression towards others, eight times an as needed (PRN) medication was given to the resident for anxiety and agitation. However, there was no documentation to indicate what non-pharmacological interventions were attempted prior to the administration of the medication.-Review of Resident #45's behavior monitoring for June 2025 failed to reveal monitoring had been ordered for the PRN Hydroxyzine. -The electronic medical record (EMR) failed to reveal which identified non-pharmacological interventions had been attempted and if the interventions were effective or not prior to increases in Resident #45's Rexulti or Trazodone. A psychoactive medication evaluation meeting minute note, dated 6/20/25, revealed Resident #45 had an addition of Hydroxyzine for aggressive behaviors, an increase in Rexulti with continued behaviors. Hydroxyzine was discontinued and Trazodone 50 mg was added. A pharmacist consultant report, dated 7/8/25, revealed the pharmacist documented the diagnosis of hypomania for the Lamotrigine needed to be changed to dementia with behaviors with specific behaviors indicated to the Lamotrigine use. -A review of Resident #45's EMR failed to reveal the diagnosis for the Lamotrigine had been corrected or the behaviors of hypomania clarified and monitored. The resident's behavior sheet, undated, which was kept at the nurses' station, was reviewed on 8/5/25. The behavior sheet revealed that Resident #45 had behaviors of being verbally aggressive with others, paranoid about others following her causing verbal aggression, pacing to the point of exhaustion, physical aggression, especially towards Resident #28, and striking out at others unprovoked. Interventions included allowing the resident to rest in chairs placed in the hallway, offering finger foods while walking, smiling and greeting the resident, offering to walk with her if she became paranoid someone was following her, offering her chocolate, allowing her independent visits with her male friend, complimenting her on her appearance, offering to paint her nails when she was pacing or frustrated, offering a milkshake, offering to take her outside for a walk, offering her simple tasks (watering plants, folding napkins, wiping tables), creating space between the resident and others, promoting relaxation (offer back rub, smoothing hair, or soft music), providing one-one-one when agitated, redirecting the resident from taking items from others' rooms and redirecting her when within arm's reach of Resident #28. -Resident #45's behavior monitoring in the August 2025CPO and the behaviors in the care plan failed to include the resident specific and person-centered interventions included on her behavior sheet (see physician's orders and care plan above).III. Resident #32A. Resident statusResident #32, age less than 70, was admitted on [DATE]. According to the August 2025 CPO, diagnoses included anxiety and Wernicke's encephalopathy (alcohol induced encephalopathy). The 6/25/25 MDS assessment revealed the resident had severe cognitive impairments and was unable to participate in the BIMS assessment. A staff interview for mental status revealed the resident had short and long term memory impairments and severe impairments to his daily decision-making making skills. The MDS assessment indicated the resident had behaviors of hallucinations, delusions, rejecting care and wandering. B. Record reviewResident #32's mood care plan, revised 1/1/24, revealed the resident took antianxiety medication related to anxiety with target behaviors of increased pacing, finger wringing, and clenching fists. Interventions, initiated 8/27/23, included redirecting, offering food or fluid, toileting, removing from the situation, offering activities, assessing for pain and offering massage/back rub. Resident #32's depression care plan, revised 10/7/24, revealed the resident took antidepressant medication related to Wernicke's anxiety disorder with target behaviors of negative statements. Interventions, initiated 2/26/24, included monitoring/documenting for side effects of anti-depressant therapy, change in behavior/mood/cognition, hallucinations/delusions, social isolation, suicidal thoughts or withdrawal. Resident #32's psychosocial care plan, revised 3/24/25, revealed the resident took an antipsychotic medication related to Wernicke's encephalopathy with target behaviors of verbal outbursts/threats. Interventions, initiated 8/27/23, included redirecting, offering food or fluid, toileting, removing from the situation, offering activities, assessing for pain and offering massage/back rub.Review of Resident #32's August 2025 CPO revealed the following physician's orders:Lorazepam (an antianxiety medication) 0.5 mg. Give two times a day for anxiety, ordered 2/28/24. Seroquel (an antipsychotic medication) 300 mg. Give one tablet two times a day for Wernicke's encephalopathy, ordered 5/17/24. Sertraline (antidepressant medication) 100 mg tablet. Give one tablet a day for anxiety, ordered 5/17/24.Monitor for behaviors related to antianxiety medication Lorazepam. 1-increased pacing; 2-finger wringing; 3-clenched fists. Use non-pharmological interventions 1. Redirect. 2. Reposition. 3. Offer snacks. 4. Offer fluids. 5. Adjust room temperature. 6. Distraction/offer activity. 7. See nurses note for additional information, ordered 7/11/25.Monitor for behaviors related to antidepressant medication Sertraline. 1-negative statements. Use non-pharmacological interventions 1. Redirect. 2. Reposition. 3. Offer snacks. 4. Offer fluids. 5. Adjust room temperature. 6. Distraction/offer activity. 7. See nurses note for additional information, ordered 7/11/25.Monitor for behaviors related to antipsychotic medication Seroquel. 1-verbal outbursts. 2. Threats. Use non-pharmacological interventions 1. Redirect. 2. Reposition. 3. Offer snacks. 4. Offer fluids. 5. Adjust room temperature. 6. Distraction/offer activity. 7. See nurses note for additional information, ordered 7/11/25.-The non-pharmacological interventions documented for all three of Resident #32's behavior monitoring physician's orders indicated the same identical, non person-centered non-pharmacological interventions were to be used for every behavior, regardless of the behavior. -Review of Resident #32's EMR from 6/1/25 to 8/4/25, revealed no documentation to indicate Resident #32 had displayed any behaviors related to the usage of Lorazepam, Sertraline or Seroquel. A psychoactive medication evaluation meeting minute note, dated 6/20/25, revealed there had been no dose reductions of Resident #32's Seroquel, Sertraline or Lorazepam. The physician note during the meeting indicated Resident #32 was recently moved to the secure unit and he would be getting a roommate, which had historically increased Resident #32's behaviors, anxiety, and distress. The facility was to monitor and assess Resident #32's adjustment. The resident's behavior sheet, undated, which was kept at the nurses' station, was reviewed on 8/5/25. The behavior sheet revealed that Resident #32 had behaviors of becoming aggressive, throwing things, and could become triggered if his roommate's side of the room were cluttered. Resident #32 had an aversion to being around other men and could become fearful and aggressive. Interventions included assisting him to a quiet area, redirecting him from other residents, offering chocolate ice cream or chocolate milk, allowing him to read a book of choice, assisting him in calling his sister, encouraging the resident to stay in his room and reorganize if desired, encouraging the resident to keep a distance from other men, allowing him to sit alone in the dining room or encouraging female peers to sit with him, allowing him to watch the television in the dayroom and offering to assist the resident in tidying his personal space. -Resident #32's behavior monitoring from the August 2025 CPO and the behaviors in the care plan failed to include the resident specific and person-centered interventions included on his behavior sheet (see physician's orders and care plan above).IV. Staff interviewsCertified nurse aide (CNA) #5 was interviewed on 8/5/25 at 1:27 p.m. She said Resident #45 had behaviors of walking continuously throughout the day and becoming agitated around too many residents and overstimulated. CNA #5 was unaware of non-pharmacological interventions that helped for Resident #45. CNA #5 said Resident #32 had behaviors of becoming agitated and throwing things. CNA #5 said Resident #32 could become depressed, tearful and focused on going home. CNA #5 said interventions that worked for Resident #32 were to offer him a less stimulating environment, offer to take him outside for a walk or talk to him about the Bible. CNA #5 was unaware Resident #32 had behavioral triggers related to being around other males. CNA #5 said the staff found resident behaviors and interventions in the behavior book at the nurses' station, however CNA #5 said she did not use the behavior book because she knew the residents. CNA #5 said the CNAs documented behaviors on the CNA behavior monitoring task but the behaviors and interventions indicated on the task were generic and the same for all the residents. CNA #2 was interviewed on 8/5/25 at 3:05 p.m. CNA #2 said Resident #45 had behaviors of pacing and an intervention that worked for her was to take her outside for a walk. CNA #2 said Resident #32 had behaviors of becoming agitated and staff had to redirect him to his room.Registered nurse (RN) #3 was interviewed on 8/5/25 at 3:15 p.m. RN #3 said Resident #45 had behaviors of pacing and the interventions that worked for her were to offer her chocolate milk and space. RN #3 said Resident #32 did not really have behaviors and he liked to read, have soda and sit alone in the dining room.CNA #6 was interviewed on 8/6/25 at 11:44 a.m. CNA #6 said he had been at the facility for six months. CNA #6 needed to retrieve the behavior binder because he could not recall the person-centered interventions or resident specific behaviors for Resident #45 and Resident #32. He read the behaviors and interventions from the binder. CNA #6 said the CNAs did not document behaviors but told the nurse, who then would document it in the progress notes.The memory care director and the social services director (SSD) were interviewed together on 8/6/25 at 2:00 p.m. The SSD said that he was fairly involved with the psychoactive medication reviews and that he reviewed the activity assessments and social service assessments when preparing for the psychotropic medication meeting. The SSD said the behavior monitoring orders on the list in the physician's orders documented specific behaviors for the resident's psychoactive medications along with specific non-pharmacological interventions that should also match the interventions in the resident's care plan.-However, the non-pharmacological interventions listed for each of Resident #45 and Resident #32's psychotropic medications were identical for each medication, despite what behavior might be exhibited (see record review above).The NHA and the director of nursing (DON) were interviewed together on 8/7/25 at 12:50 p.m. The DON said that the facility determined the efficacy of psychoactive medications being administered by using behavior monitoring physician's orders within the MAR with resident specific behaviors listed. She said her expectation was that the nurses documented behaviors on the MAR and also put in a behavior progress note to include the non-pharmological interventions attempted. The DON said that there should be non-pharmacological interventions on the behavior monitoring order for the nurses. She said that non-pharmacological interventions were important because the facility did not want to use psychotropic medications as a first resort and instead wanted to use non-pharmacological interventions first because it was more humane and ethical for the care of the resident. The DON said that the behavior monitoring physician's orders provided data that was used during the psychotropic drug meeting to decide on increasing medications or considering gradual dose reductions. She said that she continuously trained her staff on where to find the non-pharmacological interventions and what they were, as well as providing education on triggers. The DON was unaware that the CNAs and nursing staff on the secure unit were not consistent in knowing where to find behaviors and interventions for residents.The NHA said that if the staff were not consistently or accurately documenting resident behaviors, it would be difficult to determine the effectiveness of the medications and this prevented the monitoring from demonstrating a clear picture of behaviors.

Based on observations and interviews, the facility failed to ensure infection prevention and control programs (IPCP) were maintained and followed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections on two of three units. Specifically, the facility failed to: -Ensure staff performed hand hygiene prior to providing wound care for Resident #19;-Ensure staff followed appropriate infection control guidelines for handling of wound care supplies for Resident #19; and,-Ensure staff wore the appropriate personal protective equipment (PPE) when providing incontinence care for Resident #6, who was on enhanced barrier precautions (EBP) for having an indwelling urinary catheter.Findings include:I. Failed to ensure staff performed hand hygiene prior to providing wound care and handled wound care supplies appropriately for Resident #19 A. Observations On 8/4/25 at 2:39 p.m. Resident #19's right foot was observed to be wrapped with wound dressings.On 8/6/25 at 10:26 a.m. registered nurse (RN) #4 entered Resident #19's room to complete wound care for the resident. RN #4 donned gloves and a gown prior to entering the room. -However, RN #4 failed to complete hand hygiene prior to donning the gown and gloves and before proceeding to perform the resident's wound care.On 8/6/25 at 10:27 a.m., after completing wound care for Resident #19, RN #4 dropped a partially opened package of medical gauze that was used for the resident's wound care bandages on the floor. The opened package of gauze landed upside down on the floor, with the exposed gauze touching the floor. RN #4 picked up the package of gauze and proceeded to place the package of gauze into a clean medical supply basket designated for Resident #19. -RN #4 placed contaminated medical wound dressing supplies into a clean basket of medical supplies.II. Failed to ensure staff wore the appropriate PPE when providing incontinence care for Resident #6, who was on EBP for having an indwelling urinary catheterA. Professional referenceAccording to the Centers for Disease Control and Prevention's (CDC) Implementation of Personal Protective Equipment (PPE) Use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDROs), retrieved on 8/10/25 from https://www.cdc.gov/long-term-care-facilities/hcp/prevent-mdro/PPE.html, It read in pertinent parts,Enhanced barrier precautions (EBP) are an infection control intervention designed to reduce transmission of resistant organisms that employ targeted gown and glove use during high contact resident care activities. Nursing home residents with wounds and indwelling medical devices are at especially high risk of both acquisition of and colonization with MDROs. The use of gown and gloves for high-contact resident care activities is indicated, when contact precautions do not otherwise apply, for nursing home residents with wounds and/or indwelling medical devices regardless of MDRO colonization, as well as for residents with MDRO infection or colonization. Examples of high-contact resident care activities requiring gown and glove use for enhanced barrier precautions include dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, device care or use (central line, urinary catheter, feeding tube, tracheostomy/ventilator) and wound care, any skin opening requiring a dressing.B. Facility policy and procedureThe Enhanced Barrier Precautions policy, undated, was received from the nursing home administrator (NHA) on 8/6/25 at 1:49 p.m. The policy read in pertinent part, Enhanced barrier precautions (EBP) are utilized to prevent the spread of multi-drug resistant organisms (MDRO) to residents. Enhanced barrier precautions refer to infection prevention and control interventions designed to reduce the transmission of multi drug resistant organisms during high contact resident care activities. EBP apply when a resident is not known to be infected or colonized with any MDRO, has a wound or indwelling medical device, and does not have secretions or excretions that are unable to be covered or contained. Examples of high contact resident care activities requiring the use of gown and gloves for EBPs include dressing, bathing or showering, providing hygiene or grooming, changing briefs or assisting with toileting, transferring, providing bed mobility, changing linens, prolonged, high contact with items in the residence room, with residents equipment, or with residents clothing or skin, device care or use including central lines urinary catheters feeding tubes tracheostomies or ventilators, and wound care. C. Observations On 8/4/25 at 2:25 p.m. there was a sign on Resident #6's door that indicated the resident was on EBP. The sign on the resident's door indicated gloves and a gown must be worn for resident care activities, including dressing, bathing/showering, transferring, linen changes, providing hygiene, changing briefs or assisting with toileting and device care or use, such as central lines, urinary catheters, feeding tubes, tracheostomies and wound care. On 8/4/25 at 2:39 p.m. Resident #6 was sitting on his bed. He had an indwelling urinary catheter draining yellow urine attached to his bed. On 8/7/25 at 11:12 a.m. certified nurse aid (CNA) #3 was providing incontinence care to Resident #6. -However, CNA #3 failed to put on a protective gown prior to providing incontinence care to Resident #6, who was on EBP.D. Resident interviewOn 8/4/25 at 3:50 p.m. Resident #6 said he only needed help with using the bathroom and staff would assist him with that task. He said the staff did not wear a gown when they were assisting him with toileting.III. Staff interviewsRN #1 was interviewed on 8/5/25 at 12:05 p.m. RN #1 said Resident #6 was on enhanced barrier precautions because he had a Foley catheter. She said staff were supposed to wear a gown and gloves when emptying his Foley catheter and assisting him to the bathroom. She said nursing staff were supposed to wash or sanitize their hands before entering and exiting the room when providing direct care to residents on EBP.RN #4 was interviewed on 8/6/25 at 10:30 a.m. RN #4 said staff were supposed to wash their hands before entering a resident's room to provide wound care in order to prevent the spread of germs and potential infections. RN #4 said if medical supplies were dropped on the floor, they should be discarded because they were considered contaminated. RN #4 said she was moving too quickly after providing wound care for Resident #19 and did not realize she dropped the clean bandages on the floor before placing them back into the clean supply bin. CNA #3 was interviewed on 8/7/25 at 11:30 a.m. CNA #3 said she thought she only needed to wear a gown for Resident #6 if she emptied his indwelling Foley catheter. CNA #3 said she was agency staff and was not provided with any education on enhanced barrier precautions before working in the facility. CNA #4 was interviewed on 8/7/25 at 11:59 a.m. CNA #4 said she did not receive any specific education from the facility regarding EBP. However, she said she knew to wear a gown and gloves whenever she came in close contact with any resident that had a wound or a Foley catheter. CNA #4 said she understood the importance of the need to maintain EBP to prevent the spread of infections. The infection preventionist (IP) and the director of nursing (DON) were interviewed together on 8/6/25 2:00 p.m. The IP said she conducted audits for hand washing in addition to educating staff on infection protocol and policy. The IP said the staff should wash or disinfect their hands before entering a resident's room and after the staff exited the room. She said it was important to maintain EBP precautions to prevent the spread of infectious organisms throughout the facility. The IP said Resident #6 was currently being treated for a urinary tract infection and Resident #19 had wounds on his foot. The IP said both of these residents had portals of entry for infections which lead them to be highly susceptible to acquiring an infection.The DON said all nursing staff were provided education regarding EBP and she said staff would be re-educated accordingly. She said it was important that the staff understood the proper policies and procedures to protect the health of the facility's residents. The DON and the NHA were interviewed together on 8/7/25 at 2:35 p.m. DON said if medical supplies were dropped on the floor, they needed to be thrown into the trash and not placed back into an area designated for clean, uncontaminated items because they were considered dirty at that time. The NHA said nursing staff were to follow the policies and procedures in place for enhanced barrier precautions.

Based on observations, record review and interviews, the facility failed to develop an antibiotic stewardship program that promotes the appropriate use of antibiotics and includes a system of monitoring to improve resident outcomes and reduce antibiotic resistance for one (#6) of two residents out of 27 sample residents. Specifically, the facility failed to ensure clinical signs and symptoms of an infection were identified and/or culture results were obtained prior to the administration of antibiotics for Resident #6.Findings include:I. Professional referenceThe Centers for Disease Control and Prevention's (CDC) Antibiotic Prescribing and Usage in Hospitals and Long-term Care, dated 2019, was retrieved on 8/10/25 from https://www.cdc.gov/antibiotic-use/hcp/core-elements/hospital.html. It read in pertinent part,Implement policies that apply in all situations to support antibiotic prescribing to include specifying the dose, duration and indication for all courses of antibiotics so that they are readily identifiable. Implement facility specific treatment recommendations, based upon the national guidelines and local susceptibilities and formulary options that optimizes antibiotic selections, duration, and common indications for the usage of community acquired pneumonia, urinary tract infections, skin and soft tissue infections.II. Resident #6 A. Resident statusResident #6, age [AGE], was admitted on [DATE]. According to the August 2025 computerized physician orders (CPO), diagnoses included congestive heart failure, anemia, hypertension (high blood pressure), benign prostate hyperplasia (BPH - an enlargement of the prostate), obstructive uropathy (a condition where urine flow is blocked, causing a backup of urine into the kidneys) and asthma. According to the 6/9/25 minimum data set (MDS) assessment, Resident #6 was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. He required minimal assistance for showering/bathing, dressing and transferring. The MDS assessment revealed the resident was receiving an antibiotic medication.B. Resident interview Resident #6 was interviewed on 8/4/25 at 2:55 p.m. Resident #6 said he had a catheter because he retained urine. Resident#6 did not think he had any infections.C. Record review Review of Resident #6's August 2025 CPO revealed the following physician's order:Cefdinir (antibiotic) oral tablet 300 milligrams (mg). Give one tablet by mouth two times a day for urinary tract infection (UTI) for five days, ordered 8/1/25.The 7/30/25 nursing progress notes documented Resident #6 was admitted to the hospital for a urinary tract infection and discharged back to the facility the same day. Review of Resident #6's electronic medical record (EMR) revealed a urinalysis was completed during his hospital stay on 7/30/25 with results positive for a UTI and an indication for a culture and sensitivity (a two-part diagnostic procedure used to identify the cause of an infection and determine the most effective treatment). -There was no documentation in the resident's EMR to indicate the culture and sensitivity was completed, prior to the start of the resident's antibiotics.III. Staff interviews Registered nurse (RN) #1 was interviewed on 8/5/25 12:05 p.m. RN #1 said there was no specific monitoring or documentation that needed to be done for residents on antibiotics. RN #1 said the physician would order the antibiotic for a resident if the resident had an infection. RN #1 said the facility would send out a urine test to confirm the presence of a UTI in a resident.The director of nursing (DON) and the infection preventionist (IP) were interviewed together on 8/6/25 at 2:00 p.m. The IP said she started in her role at the facility on 7/14/25. She said her role as IP involved monitoring infections and antibiotic use with mapping and monitoring trends. The IP said she used the McGreer's criteria when assessing a resident who may need an antibiotic. She said the McGreers's Criteria consisted of symptoms, such as burning with urination and cloudy urine, which would require a urinalysis and a culture and sensitivity to be completed before initiating antibiotic treatment.The IP said Resident #6 was the only resident who was being treated for a UTI. She said the resident was sent to the hospital and diagnosed with a UTI and started on antibiotics. The IP said the UTI was confirmed via urinalysis with a culture and sensitivity pending. The IP said she never followed up with the hospital for the culture results. The IP said because the facility did not have the culture results for Resident #6, it was possible the facility did not treat his UTI effectively.The DON said Resident #6 was started on an antibiotic in the hospital after the hospital conducted a urinalysis on the resident. The DON said the facility did not receive any documentation from the hospital regarding the results of a culture and sensitivity that was indicated. The DON said the facility should have followed up on the culture and sensitivity because the culture and sensitivity results would identify what antibiotic would most effectively treat the UTI.

Based on record review and interviews, the facility failed to implement policies and procedures related to pneumococcal immunizations for two (#19 and #7) of five residents reviewed for immunizations out of 27 sample residents.Specifically, the facility failed to offer the pneumonia vaccine to Resident #19 and Resident #7.Findings include:I. Professional referenceAccording to the Centers for Disease Control and Prevention (CDC), updated 2025, Recommended Immunization Schedule for Adults Aged 19 years or Older, retrieved on 8/11/25 from https://www.cdc.gov/vaccines/hcp/imz-schedules/downloads/adult/adult-combined-schedule.pdf,Pneumococcal vaccination-Routine vaccination-Age 50 years or older who have not previously received a dose of PCV13 (pneumococcal conjugate vaccine), PCV15, PC20, OR PCV21 or whose previous vaccination history is unknown: one dose PCV15 or PCV20 or one dose PCV21. If PCV15 is used, administer one dose PPSV23 at least one year after the PCV15 dose (may use a minimum interval of eight weeks for adults with an immunocompromising condition, cochlear implant, or cerebrospinal fluid leak). Previously received only PCV7: follow the recommendation above.Previously received only PCV13: one dose PCV20 or one dose PCV21 at least one year after the last PCV13 dose.Previously received only PPSV23: one dose PCV15 or one dose PCV20 or one dose PCV21, at least one year after the last PPSV23 dose. If PCV15 is used, no additional PPSV23 doses are recommended.Previously received both PCV13 and PPSV23 but no PPSV23 was received at age [AGE] years or older; one dose PCV20 or one dose PCV21 at least five years after the last pneumococcal vaccine dose.Previously received both PCV13 and PPSV23, and PPSV23 was received at age [AGE] years or older: Based on shared clinical decision making, one dose of PCV20 or one dose of PCV21 at least five years after the last pneumococcal vaccine dose.II. Facility policy and procedureThe Pneumococcal Vaccine policy, revised March 2022, was provided by the nursing home administrator (NHA) on 8/6/25 at 2:48 p.m. It read in pertinent part,All residents will be offered pneumococcal vaccines to aid in preventing pneumonia or pneumococcal infections. Prior to or upon admission, residents are assessed for eligibility to receive the pneumococcal vaccine series, and when indicated, are offered the vaccine series unless medically contraindicated or the resident has completed the current recommended vaccine series. Before receiving a pneumococcal vaccine the resident or legal Representatives receive information and education regarding the benefits and potential side effects of the pneumococcal vaccine. Residents have the right to refuse vaccination. If refused, appropriate information is documented in the residence medical record indicating the date of the refusal of the pneumococcal vaccination. For each resident who receives a vaccine, the date of the vaccination, Lot number, expiration date, person administering and site of the vaccinations are documented in the resident's medical record.III. Resident #19 A. Resident statusResident #19, age [AGE], was admitted on [DATE]. According to the August 2025 computerized physician's orders (CPO), diagnoses included atrial fibrillation (irregular heartbeat), lymphedema (swelling), hypertension (high blood pressure), dermatitis and open wound of the left lower leg. The 2/27/25 minimum data set (MDS) assessment revealed the resident had mild cognitive impairments with a brief interview for mental status (BIMS) score of 12 out of 15. He required substantial/maximal assistance with toileting, personal hygiene. He required partial/moderate assistance with bed mobility and was independent with eating.The assessment did not indicate the resident was offered the pneumonia vaccine. B. Resident interviewResident #19 was interviewed on 8/4/25 at 4:07 p.m. Resident #19 said he received some vaccines years ago while living at home, but was not offered any vaccinations while living at the facility.C. Record reviewReview of Resident #19's electronic medical record (EMR) on 8/6/25 did not reveal documentation that the pneumonia vaccine was offered to the resident. The August 2025 CPO revealed a physician's orders for the pneumonia vaccine, ordered on 2/20/25. -However, review of the EMR failed to reveal documentation in the resident's EMR that the pneumonia vaccine was administered.IV. Resident #7A. Resident statusResident #7, age less than 65, was admitted on [DATE]. According to the August 2025 CPO, diagnoses included chronic osteomyelitis (infection) in the right ankle, diabetes type 2, cirrhosis of the liver, anxiety and depression. The 7/17/25 MDS assessment revealed the resident had mild cognitive impairments with a BIMS score of 10 out of 15. He was independent with toileting or personal hygiene. He required partial/moderate assistance with wound care and was independent with eating.The assessment did not indicate the resident had not been offered the pneumonia vaccine. B. Resident interviewResident #7 was interviewed on 8/4/25 at 4:18p.m. Resident #7 said he had not received, nor was he offered any vaccines while living at the facility. C. Record reviewA review of the EMR on 8/6/25 did not reveal documentation that the pneumonia vaccine was offered to the resident. The August 2025 CPO revealed a physician's order for the pneumonia vaccine, ordered on 7/11/25. -However, a review of the EMR on 8/6/25 failed to reveal documentation in the resident's EMR that the pneumonia vaccine was administered.D. Staff interviewsThe director of nursing (DON) and the NHA were interviewed together on 8/7/25 at 2:35 p.m. The DON said it was the responsibility of the admitting nurse to offer, obtain consents and administer vaccinations to newly admitted residents to the facility. The DON said the facility utilized the immunization tab in the resident's EMR to documented relevant historic vaccination information, such as refusals or administration of vaccinations. The DON said she remembered Resident #19 declined to receive any vaccine after it was offered to him from the facility. The DON said she would look for additional information regarding Resident #7 vaccination status. -However, the facility did not provide any additional information regarding Resident #7's vaccination status.D. Facility follow-up-The facility provided vaccine declination (influenza, pneumonia and COVID-19) documentation for Resident #19 with a signature date of 8/7/25 at 6:25 p.m. (after the survey exit).

Based on record review and interviews, the facility failed to implement policies and procedures related to COVID-19 immunizations for two (#19 and #7) of five residents reviewed for immunizations out of 27 sample residents.Specifically, the facility failed to offer the COVID-19 vaccine was offered to Resident #19 and Resident #7. Findings include:I. Professional referenceAccording to the Centers for Disease Control and Prevention (CDC), COVID-19 guidelines (revised 1/7/25), retrieved on 8/10/25 from https://www.cdc.gov/covid/vaccines/stay-up-to-date.html. Everyone ages six months and older should get a 2024-2025 COVID-19 vaccine. The COVID-19 vaccine helps protect you from severe illness, hospitalization, and death. It is especially important to get your 2024-2025 COVID-19 vaccine if you are age [AGE] and older, are at risk for severe COVID-19, or have never received a COVID-19 vaccine. Vaccine protection decreases over time, so it is important to get your 2024-2025 COVID-19 vaccine.II. Facility policy and procedureThe COVID vaccine policy, revised March 2022, was provided by the nursing home administrator (NHA) on 8/6/25 at 2:48 p.m. It read in pertinent part,All residents will be offered COVID vaccines to aid in preventing COVID infections. Prior to or upon admission, residents are assessed for eligibility to receive the COVID vaccine series, and when indicated, are offered the vaccine series unless medically contraindicated or the resident has completed the current recommended vaccine series. Before receiving a COVID vaccine the resident or legal Representatives receive information and education regarding the benefits and potential side effects of the COVID vaccine. Residents have the right to refuse vaccination. If refused, appropriate information is documented in the residence medical record indicating the date of the refusal of the COVID vaccination. For each resident who receives a vaccine, the date of the vaccination, Lot number, expiration date, person administering and site of the vaccinations are documented in the resident's medical record.III. Resident #19 A. Resident statusResident #19, age [AGE], was admitted on [DATE]. According to the August 2025 computerized physician's orders (CPO), diagnoses included atrial fibrillation (irregular heartbeat), lymphedema (swelling), hypertension (high blood pressure), dermatitis and open wound of the left lower leg. The 2/27/25 minimum data set (MDS) assessment revealed the resident had mild cognitive impairments with a brief interview for mental status (BIMS) score of 12 out of 15. He required substantial/maximal assistance with toileting, personal hygiene. He required partial/moderate assistance with bed mobility and was independent with eating.The assessment did not indicate that the resident was ever offered the covid vaccine. B. Resident interviewResident #19 was interviewed on 8/4/25 at 4:07 p.m. Resident #19 said he received some vaccines years ago while living at home, but was not offered any vaccinations while living at the facility.C. Record reviewReview of Resident #19's electronic medical record (EMR) on 8/6/25 did not reveal documentation that the COVID-19 vaccine was offered or administered to the resident. IV. Resident #7A. Resident statusResident #7, age less than 65, was admitted on [DATE]. According to the August 2025 CPO, diagnoses included chronic osteomyelitis (infection) in the right ankle, diabetes type 2, cirrhosis of the liver, anxiety and depression. The 7/17/25 MDS assessment revealed the resident had mild cognitive impairments with a BIMS score of 10 out of 15. He was independent for toileting or personal hygiene. He required partial/moderate assistance with wound care and was independent with eating.The assessment did not indicate that the resident was offered the COVID-19 vaccine. B. Resident interviewResident #7 was interviewed on 8/4/25 at 4:18 p.m. Resident #7 said he did not receive, nor was he offered any vaccines while living at the facility. C. Record reviewReview of Resident #7's EMR on 8/6/25 did not reveal documentation that the COVID-19 vaccine was offered or administered to the resident. D. Staff interviewsThe director of nursing (DON) and the NHA were interviewed together on 8/7/25 at 2:35 p.m. The DON said it was the responsibility of the admitting nurse to offer, obtain consents and administer vaccinations to newly admitted residents to the facility. The DON said the facility utilized the immunization tab in the resident's EMR to document relevant historic vaccination information, such as refusals or administration of vaccinations. The DON said she remembered Resident #19 declined to receive any vaccine after it was offered to him from the facility.-However, documentation indicating Resident #19 declined the COVID-19 vaccination was not provided. The DON said she would look for additional information regarding Resident #7 vaccination status. -However, the facility did not provide additional information regarding Resident 37's vaccination status.

Based on record review and interviews, the facility failed to ensure one (#8) of two residents reviewed for respiratory care out of 27 sample residents were provided respiratory care consistent with professional standards of practice.Specifically, the facility failed to ensure cleaning and proper care of Resident #8's CPAP (continuous positive airway pressure) machine according to manufacturer's instructions and per physician's orders.Findings include:I. Facility policy and procedureThe CPAP/BiPAP (bilevel positive airway pressure) Support and Cleaning, Respiratory and Pulmonary Conditions policy and procedure, revised March 2015, was provided by the nursing home administrator (NHA) on 8/7/25 at 4:37 p.m. It read in pertinent part, Purpose: To provide the spontaneously breathing resident with continuous positive airway pressure with or without supplemental oxygen; To improve arterial oxygenation (Pa02) in residents with respiratory insufficiency, obstructive sleep apnea, or restrictive/obstructive lung disease; To promote resident comfort and safety. General Guidelines for Cleaning: These are general guidelines for cleaning. Specific cleaning instructions are obtained from the manufacturer/supplier of the PAP device. These guidelines are for single-resident use cleaning. Machines must be preprocessed for use between residents by the supplier of the device. Machine cleaning: Wipe machine with warm, soapy water and rinse at least once a week and as needed. Humidifier (if used): Use clean, distilled water only in the humidifier chamber. Clean humidifier weekly and air dry. To disinfect, place vinegar-water solution (one to three ratio) in a clean humidifier. Soak for 30 minutes and rinse thoroughly. Filter cleaning: Rinse washable filter under running water once a week to remove dust and debris. Replace this filter at least once a year. Replace disposable filters monthly. Masks, nasal pillows and tubing: Clean daily by placing in warm, soapy water and soaking/agitating for five minutes. Mild dish detergent is recommended. Rinse with warm water and allow it to air dry between uses. Headgear (strap): Wash with warm water and mild detergent as needed. Allow to air dry. Document the following in the resident's medical record: general assessment (including vital signs, oxygen saturation, respiratory, circulatory and gastrointestinal status) prior to procedure; time CPAP was started and duration of the therapy; mode and settings for the CPAP; oxygen concentration and flow, if used; how the resident tolerated the procedure; and oxygen saturation during therapy.II. Manufacturer's instructionsThe [NAME] Respironics CPAP Machine cleaning instructions were provided by the NHA on 8/6/25 at 5:35 p.m. It read in pertinent part, - Daily Cleaning: Items to clean: Mask cushion, tubing (optional), and humidifier chamber (if used); Unplug the CPAP machine; Disassemble the mask - separate the cushion from the frame and headgear; Wash the mask cushion in warm water with mild, non-antibacterial soap. Rinse thoroughly. If desired, rinse the tubing with warm water (not necessary daily unless visibly soiled). Empty the humidifier chamber (if applicable), rinse with warm water, and let air dry. Air dry all parts on a clean towel - do not expose to direct sunlight. Wipe the CPAP unit exterior with a dry cloth - do not submerge or spray with water. Weekly Cleaning: Items to clean: Tubing, mask frame, headgear, humidifier chamber. Soak the tubing, mask frame, headgear, and humidifier chamber in warm, soapy water for 15-30 minutes. Rinse all items thoroughly to remove all soap residue. Hang tubing to air dry - make sure it dries completely before reconnecting. Wipe the outside of the CPAP device with a soft, damp cloth. Monthly Cleaning: Items to check/replace/clean: Air filter. Inspect the reusable pollen filter (gray foam) for dust or discoloration.Wash gently with water if reusable. Let dry completely before reinserting. If using a disposable fine filter (white), replace it monthly or as needed (do not wash). Check for signs of wear and tear on the mask, tubing, and chamber. Do Not Use: Bleach, alcohol, antibacterial soap, or harsh cleaners. Dishwasher (unless your model specifically states parts are dishwasher-safe). Direct sunlight to dry. Machine parts while wet. Replacement Schedule (General Guidelines): Mask cushion/pillows are replaced every two to four weeks; Tubing replaced every three months; Humidifier chamber replaced every six months; Filter (disposable) replace monthly; Filter (reusable foam) replace after six months (wash monthly). Full mask/headgear replaced every six months.III. Resident #8A. Resident statusResident #8, age greater than 65, was admitted on [DATE] and readmitted on [DATE]. According to the August 2025 computerized physician orders (CPO), diagnoses included hemiplegia (paralysis on the right side), traumatic brain injury, cognitive communication deficit, status post fracture of right pubis (pelvis) and sleep apnea. The 5/29/25 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 13 out of 15. She was dependent with bed to chair transfers, toilet transfers and shower transfers. She required substantial/maximal assistance with bed mobility, showering, and lower body dressing. She required partial/moderate assistance for personal hygiene and was independent with eating.The assessment indicated the resident had functional limitation in range of motion with impairment on one side in the upper and lower extremities. B. Resident interview and observationResident #8 was interviewed on 8/4/25 at 2:42 p.m. Resident #8 said she used a CPAP machine but it did not have distilled water in it because the facility ran out of water last week. The CPAP machine sat on a small shelf next to the bed, the large tubing was touching the floor. The CPAP mask was sitting on top of the machine under the shelf. Resident #8 said she cleaned the CPAP mask herself by giving the mask a quick rinse with water in the sink in the morning. Resident #8 mimicked with her left arm running the mask under the facet. Resident #8 said she never used soap to clean the CPAP mask or machine, only water. Resident #8 said the staff never cleaned her machine so she just did it.C. Record reviewReview of Resident #8's CPAP care plan, initiated 11/11/18 and revised 12/11/22, revealed the resident was at risk for altered breathing patterns/altered gas exchange/ineffective air exchange related to asthma as evidenced by wheezing, need for aerosol/inhaler medications and CPAP at resting hours. Pertinent interventions included monitoring the use of the CPAP machine every night shift, initiated 11/16/23. -The care plan failed to include cleaning frequency for the CPAP or cleaning instructions.Review of Resident #8's August 2025 CPO revealed the following physician's orders related to the resident's CPAP machine: CPAP at night time only. Every night shift clean equipment per manufacturer recommendations daily. Resident to perform daily cleaning, ordered 11/28/18.-However there was no documentation on the medication administration record/treatment administration record (MAR/TAR) that this was being completed.Monitor proper use of CPAP every night shift, ordered 10/24/23.Resident requires the use of CPAP supplies related to sleep apnea, ordered 2/21/24.IV. Staff interviewsThe NHA and the director of nursing (DON) were interviewed together on 8/7/25 at 12:49 p.m. The NHA said she had no documentation that Resident #8 was instructed how to clean her CPAP machine and that the facility should be doing that. The DON said she added a new physician's order (during the survey) for the nurses to be cleaning Resident #8's CPAP machine. She said Resident #8 should not be cleaning her own equipment, especially since she had a disabled arm. The NHA and the DON said Resident #8's CPAP machine was not being cleaned per the manufacturer's recommendations but it should be for best practice and hygiene.

Based on observations, record review and interviews, the facility failed to ensure two (#2 and #3) out of 10 residents reviewed for abuse were free from sexual abuse out of 13 sample residents. Specifically, the facility failed to protect Resident #2 and Resident #3 from sexual abuse by Resident #1. Findings include: I. Facility policy and procedure The Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating policy, dated September 2022, was provided by the nursing home administrator (NHA) on 3/24/25 at approximately 1:30 p.m. The policy read in pertinent part, All reports of resident abuse, neglect, exploitation, or theft/misappropriation of resident property are reported to local, state and federal agencies and thoroughly investigated by facility management. All findings of all investigations are documented and reported. II. Incident of sexual abuse of Resident #2 by Resident #1 on 12/20/24 A. Facility investigation The 12/20/24 investigation file of the incident involving Resident #2 and Resident #1 was provided by the corporate consultant (CC) on 3/20/25 at 5:33 p.m. The investigation included an investigation report under sexual abuse, an interview note with two staff witnesses, interviews with other staff members and residents and notification of the incident to the appropriate parties. The investigation report documented dietary aide (DA) #1 observed Resident #1 in the activity room with his hand inside the shirt of Resident #2. DA #1, alerted certified nurse aide (CNA) #1 about Resident #1's behavior. The behavior was immediately stopped and the assistant director of nursing (ADON) was alerted. The residents were separated and Resident #1 was placed on a one-to-one observation/supervision with an employee. Resident #2 was assessed and no injuries or signs of distress/discomfort were identified. The investigation report documented Resident #2 was non-verbal, had no signs of emotional/mental distress and was behaving and reacting at her baseline. The investigation report identified Resident #1 was interviewed and had no memory of the incident. The investigation report documented the facility concluded physical contact was made between Resident #1 and Resident # 2. Immediate action was taken to protect Resident #2 and all other residents. The investigation report indicated the facility placed Resident #1 on one-to-one supervision after the 12/20/24 incident to help prevent a recurrence. According to the report, Resident #2 did not have a change in her regimen or care plan following the incident, but she was assessed for signs of emotional/mental distress. A handwritten and undated witness interview note documented DA #1 said Resident #1 was sitting next to Resident #2 in the activity room. Resident #1 had his hand inside Resident #2's shirt for an undetermined amount of time. According to the interview of DA #1, she said Resident #2 did not appear in distress and CNA #1 immediately removed Resident #1. The witness interview note indicated CNA #1 said Resident #1 was witnessed reaching over to Resident #2 and placing his hand under her shirt and over her breast. The investigation identified four other residents and four staff members who were interviewed on 12/20/24 did not have concerns regarding abuse. B. Resident #2 (victim) 1. Resident status Resident #2, age greater than 65, was admitted on [DATE]. According to the March 2025 computerized physician orders (CPO), diagnoses included unspecified dementia unspecified severity, without behavioral disturbances, psychotic disturbance, mood disturbance, and anxiety, generalized muscle weakness, lack in coordination, psychomotor deficit and Alzheimer's disease. The 1/22/25 minimum data set (MDS) assessment identified Resident #2 had severe cognitive impairment, per a staff assessment for mental status. Resident #2 had short and long term deficits. She was dependent on staff for all of her activities of daily living (ADL) care and used a wheelchair for mobility. The MDS assessment indicated she had inattention, disorganized thinking and altered level of consciousness. 2. Record review Review of the March 2025 care plan for Resident #2 identified the resident had a communication and memory problem related to dementia, decreased vision, decreased mobility and difficulty expressing needs and wants. -The care plan did not identify Resident #2 was at risk for abuse. -The care plan did not identify new interventions were put in place for Resident #2 to prevent her from sustaining future occurrences of potential sexual abuse following the 12/20/24 incident with Resident #1. Review of Resident #2's progress notes between 12/20/24 and 3/24/25, did not reveal documentation of the 12/20/24 incident between Resident #1 and Resident #2 or what interventions for Resident #2 were put in place to prevent potential sexual abuse from reoccurring. -Review of the progress notes did not identify Resident #2 was monitored for changes in her behavior after the 12/20/24 incident with Resident #1. C. Resident #1 (assailant) 1. Resident status Resident #1, age greater than 65, was admitted on [DATE]. According to the March 2025 CPO, diagnoses included unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, unsteadiness on feet, generalized muscle weakness, lack of coordination, Alzheimer's disease and cognitive communication deficit. The 2/6/25 MDS assessment identified Resident #1 had severe cognitive impairments with a brief interview for mental status (BIMS) score of four out of 15. He used a wheelchair for mobility and needed partial to moderate assistance with most of his ADLs. According the MDS assessment, Resident #1 did not have physical, verbal or other behavioral symptoms directed towards others. 2. Observations On 3/20/25 at 12:25 p.m. Resident #1 was in the secured unit dining room eating his lunch at the dining room table with female residents. A CNA sat between him and one of the female residents. The other female resident sat across the table from Resident #1. CNA #2 stood in the dining room facing Resident #1. On 3/20/25 at 2:05 p.m. Resident #1 was sleeping in bed in his room in the secured unit. CNA #2 sat in the hallway near the room of Resident #1. On 3/24/25 at 11:38 a.m. Resident #1 was asleep in his room while a staff member sat inside the room near the doorway. 3. Record review Review of Resident #1's behavior care plan, revised 2/27/25, revealed the resident had inappropriate social/sexual behaviors (verbal/physical) related to dementia and he exhibited poor safety awareness and had a lack of spatial awareness and awareness of others' personal space. Interventions initiated on 8/4/23, included allowing Resident #1 to express anger within social parameters, approaching the resident in a calm but firm manner, assisting the resident to a quieter calmer area of the living environment, if reasonable, discussing with Resident #1 the behaviors identified and explaining/reinforcing why the behavior is inappropriate and/or unacceptable to the resident, notifying the family and physician of increased behavioral concerns, redirecting and assisting Resident #1 away from confrontational situations. The intervention initiated on 2/26/24 directed staff to notify hospice of any changes in the resident's behaviors. The behavior care plan interventions, initiated 2/27/25, directed staff to offer Resident #1 activity of choice, sensory activities, food/fluid or one-to-one engagement, redirecting from other residents' personal space and providing line of sight supervision when Resident #1 was in common areas. According to the 2/27/25 interventions, Resident #1 would benefit from the smaller, structured environment of the secure unit. -The facility failed to initiate new care plan interventions following the 12/20/24 incident where Resident #1 placed his hand inside the shirt of Resident #2. -The facility failed to implement new interventions for Resident #1's sexually inappropriate behaviors until 2/26/25, over two months later, after the resident was involved in a second sexual abuse incident with Resident #3 (see incident involving Resident #3 below). -The behavior care plan did not identify Resident #1 was on one-to-one supervision or line of sight supervision after the 12/20/24 incident with Resident #2, as had been identified in the 12/20/24 investigation report (see investigation report above). Review of Resident #1's March 2025 CPO revealed the following physician's orders: Frequent checks/monitoring for inappropriate sexual behaviors, ordered 10/26/23 and discontinued 3/24/25, during the survey. -The physician's order indicated Resident #1 should have been frequently monitored for inappropriate sexual behaviors between 10/26/23 and 3/24/25. Non-pharmacological behavior monitoring interventions for inappropriate sexual behaviors to include one-to-one's, ordered 10/26/23. -The physician's order did not specify whether the one-to-one's were visits made by staff members or if the resident was to be on consistent one-to-one supervision. Line of sight when out of room order, ordered 2/25/25. -Review of Resident #1's physician's order history failed to reveal a physician's order for the resident to be on one-to-one supervision or line of sight monitoring from 12/20/24 through 2/25/25, following the sexual abuse incident with Resident #2 (see investigation above). Review of Resident #1's progress notes from 7/26/24 through 2/6/25 revealed the following progress notes: A 7/26/24 interdisciplinary team (IDT) psychotropic committee note identified Resident #1 had a physician's order for finasteride for support in management of inappropriate sexual behaviors. An 8/8/24 IDT note identified Resident #1 had an increase in sexual behaviors towards a hospice staff member. A 10/11/24 nursing note identified Resident #1 was observed kissing another resident in the dining room. The 10/15/24 nursing note identified Resident #1 was found licking another resident's hair. A 10/18/24 IDT psychotropic committee note indicated occupational therapy (OT) monitored/observed Resident #1 due to his increase in sexual behaviors. According to the note, OT felt the resident would benefit from a sensory related program based on his oral fixations to help decrease these types of behaviors. The note identified the IDT agreed to the sensory programming with OT. -There was no progress note documented on 12/20/24 regarding the incident with Resident #2 where Resident #1 was found by staff with his hand on Resident #2's breast inside her shirt (see investigation above). A 1/2/25 IDT (which was documented as a late entry note with the effective date of 12/20/24) indicated Resident #1 was placed on one-on-one supervision due to recent sexual behaviors. The note identified the physician and all reporting parties were notified on 12/20/24. Both residents involved (Resident #1 and Resident #2) were safe and neither resident recalled the incident. According to the note, staff education completed by the director of nursing (DON) regarding safety and emotional monitoring, was completed. -However, review of Resident #1's physician orders history revealed there was no physician's order for the resident to be on one-to-one supervision following the 12/20/24 incident (see physician's orders above). The 1/16/25 at risk review note documented Resident #1 was without behaviors for several weeks and it recommended to discontinue the of line of sight physician's order and move to frequent roundings and checks and redirection for inappropriate behaviors. -However, review of Resident #1's physician orders history revealed there was no physician's order for the resident to be on line of sight monitoring following the 12/20/24 incident (see physician's orders above). The 2/6/25 at risk note for quarterly review documented Resident #1's behavior monitoring was still in place for inappropriate sexual behaviors and there had been no significant changes at the time. -However, review of Resident #1's behavior tracking records revealed staff were not consistently documenting the resident's one-to-one supervision or line of sight monitoring (see below). The December 2024 behavior tracking record for monitoring inappropriate sexual behaviors did not identify Resident #1 had behaviors on 12/20/24. The behavior tracking record identified the resident was provided redirection and one-to-one supervision on 12/1/24, 12/2/24, 12/3/24, 12/15/24, 12/16/24, 12/17/24 and 12/28/24. -The December 2024 behavior tracking record for monitoring inappropriate sexual behaviors did not identify Resident #1 was provided consistent one-to-one or line of sight supervision after he placed his hand in the shirt of a female resident on 12/20/24. The resident was only documented as receiving one-to-one supervision on 12/28/24. The January 2025 behavior tracking record for monitoring inappropriate sexual behaviors did not identify Resident #1 was provided one-to-one or line of sight supervision. The February 2025 behavior tracking record for monitoring inappropriate sexual behaviors identified Resident #1 had one incident of inappropriate sexual behaviors and was provided one-to-one supervision on 2/25/25 (see incident with Resident #3 below). -The behavior tracking record for inappropriate sexual behavior did not identify the resident was on a one-to-one supervision for any of the rest of the days in February 2025. III. Incident of sexual abuse of Resident #3 by Resident #1 on 2/25/25 A. Facility investigation The 2/25/25 investigation file was provided by the CC on 3/20/25 at 5:29 p.m. The investigation file included the suspected abuse initial investigation record, Resident #1's care plan for behaviors, an investigation report under sexual abuse, the abuse allegation incident report and resident and staff member interviews. The suspected abuse initial investigation record identified Resident #1 approached Resident #3, touched her on her knee and told her she had nice legs. The staff removed Resident #1 from the area and staff redirected him to an alternate space. According to the investigation, there were interventions identified to potentially reduce the risk of the incident prior to the event. -However, the facility failed to implement effective interventions prior to the event with Resident #3 (see incident with Resident #2 above). The investigation referred to Resident #1's care plan. The investigation record noted that new interventions were added to his care plan. The investigation record identified Resident #1 had a new 2/25/25 intervention of a line of sight observation when the resident was not in his room and a 2/26/25 intervention to move the resident to the secured unit. Resident #1's behavior care plan, initiated 8/4/23, that was included in the the facility's investigation file, identified Resident #1 displayed inappropriate social/sexual behaviors, both physical and verbal. The interventions documented in the care plan included staff to discuss with the resident the identified behaviors and explaining/reinforcing why the behavior was inappropriate, initiated 8/4/23; redirecting and assisting the resident away from confrontational situations, initiated 8/4/23; assisting the resident to calmer areas of the living environment, initiated 8/4/23; staff to observe and redirect the resident in public areas as needed and offering reminders to not touch others as appropriate, revised 1/16/25. The 2/25/25 investigation report under sexual abuse, documented Resident #1's behaviors were wandering, inappropriate social/sexual behaviors, lack of spatial awareness and he was not aware of others' personal space. The report identified the resident was involved in another sexual allegation on 12/20/24 (see incident above). The investigation report indicated Resident #1 was placed on a one-to-one line of sight observation when he was out of his room. The report identified the incident made Resident #3 uncomfortable. She was not injured or in pain. She denied Resident #1 touched her leg in a rough manner. She denied she was touched anywhere else on her body. The investigation report identified the incident was witnessed by an activity assistant (AA). According to the investigation report, Resident #3 did not have behavioral changes but said she felt uneasy around Resident #1 since the incident. The investigation report documented Resident #1 had a history of behaviors with a recent increase in wandering in the facility and entering others' personal space. The investigation report concluded the facility was able to substantiate the incident occurred, but was not able to determine motives or intent of the alleged assailant (Resident #1) due to his cognitive deficit. The abuse allegation incident report documented there were no injuries to either Resident #1 or Resident #3 identified after Resident #1 touched Resident #3's leg and made an inappropriate comment. The report documented Resident #3 did not like Resident #1 touching her leg and did not want to be around him. The staff member and resident interviews identified one staff member, Resident #1, Resident #3, and six other residents were interviewed after the 2/25/25 incident. The staff member interviewed was the AA who said she witnessed the incident. According to the AA's interview, she heard Resident #1 tell Resident #3 she had nice legs and witnessed him touch her. The interview did not identify where he touched her. The provided interviews identified Resident #3 was interviewed three times on 2/25/25. The social services director (SSD) interview documented Resident #3 told the SSD another resident (Resident #1) wheeled his wheelchair over to her and said she had nice legs and then he felt them with his hands. Resident #3 motioned that Resident #1 touched her down the front of her thigh. The interview indicated Resident #3 denied feeling scared, felt safe, but looked visibly upset. The DON interview documented Resident #3 did not like when Resident #1 touched her and did not want to be around him. She said she felt safe and did not think he could get to her now. Resident #3 requested for the DON to keep Resident #1 away from her. Resident #3 was interviewed again, later on the evening of 2/25/25. Resident #3 said she was okay but did not want Resident #1 to touch her again. When the resident was asked if she felt scared, Resident #3 said she knew he could not get her now because he was in bed. She said she just did not want to be around him anymore. The interview documented Resident #3 was more relaxed once in her own space and was assured that the staff were actively monitoring his behaviors and the location to keep her safe. The 2/25/25 interview with Resident #1, conducted by the DON, identified when questioned about the 2/25/25 incident with Resident #3, he was not able to recall the incident or indicate he understood the questions asked. The review of the six other residents' interviews did not identify the interviewed residents felt upset, uncomfortable, fearful, or were physically harmed by another resident. According to the interviews, the residents felt they were treated with respect and dignity from other residents at the facility. B. Resident #3 - victim 1. Resident status Resident #3, age greater than 65, was admitted on [DATE] and readmitted on [DATE]. According to the March 2025 CPO, diagnoses included Huntington's disease, major depressive disorder, recurrent and partial remission, unsteadiness on feet, generalized muscle weakness and lack of coordination. The MDS assessment identified Resident #3 was cognitively intact with a BIMS score of 15 out of 15. The resident did not have inattention or disorganized thinking behaviors. According the the MDS assessment, Resident #3 was independent in her mobility and ADL care. 2. Resident interview Resident #3 was interviewed on 3/20/25 at 3:35 p.m. Resident #3 said Resident #1 touched her leg during an activity. She said she told him not to touch her and she reported the incident to staff. Resident #3 said she felt scared and worried because she thought Resident #1 might touch her again. She said Resident #1 was moved into the secured unit and she had not had any more concerns. 3. Record review The trauma care plan, initiated 2/27/25, identified Resident #3 was a victim of a traumatic experience and experienced anxiety and feelings of being scared and upset. The 2/27/25 goal for the resident was to feel safe and less anxious throughout the period of post trauma. The 2/27/25 interventions directed staff to complete wellness checks as needed and offer one-to-one activities when Resident #3 felt overwhelmed. The 2/25/25 system note documented Resident #3 was touched on the back of the leg below her knee by another resident (Resident #1) who told her she had nice legs. The note identified the registered nurse (RN) did not witness the encounter but spoke to the resident. According to the note, Resident #3 said she was okay but she wanted to stay away from him (Resident #1). The 2/25/25 social services note documented Resident #3 notified the SSD that she was touched on the leg by another resident. The note indicated Resident #3 appeared uncomfortable but said she was not scared and felt safe. According to the note, the SSD immediately notified the DON, the charge nurse and the NHA to let them know the aggressor (Resident #1) needed to be on line of sight monitoring. The 2/25/25 nursing note identified a nurse had a wellness visit with Resident #3. The note documented the resident was not scared but did not like (Resident #1) touching her and did not want to be around him. The 2/26/25 IDT note documented Resident #3 was a victim in the 2/25/25 event that made her feel uncomfortable. According to the note, all immediate safety/wellness checks were completed on 2/25/25, 72-hour wellness checks were put in place and interventions were initiated for Resident #1 to keep the two residents separated. C. Resident #1 - assailant The 2/25/25 behavior note documented the DON visited with Resident #1 after he had inappropriate behaviors with another resident (Resident #3). According to the note, the resident was in good spirits and was happy to be at the dinner table. There was no emotional/physical distress noted/reported and Resident #1 reported no recollection of the events earlier in the evening. The 2/26/25 at risk review note documented Resident #1 had behaviors affecting others. Resident #1 had increased wandering and poor safety awareness/awareness of other residents' personal space. He was unable to retain information/education related to his actions but was easily redirectable with identification of behaviors. The intervention identified in the at risk note was to transfer Resident #1 to a secure unit for safety due to increased wandering and for increased staff observation. The note indicated Resident #1 would be maintained on a line-of-sight observation while in common areas or with wandering. The 2/27/25 at risk review note documented the summary of the IDT discussion included Resident #1's inappropriate touching of a female resident's leg (Resident #3) and commenting on her legs. The intervention was to immediately separate Resident #1 from Resident #3, implement a line of sight order and conduct wellness checks for both residents involved. According to the at risk note, Resident #1 had been evaluated as appropriate for the dementia unit, as the increased structure provided would help with redirection and sensory needs and the physician and the resident's responsible party were made aware. A physician's order, revised 2/26/25, identified Resident #1 was admitted to the secured unit due to the risk of wandering away from the facility and placing himself at risk of harm due to inability to find a way back to the facility and a history of behavioral disturbances that seriously disrupted the rights of others. According to the physician's order, a less restrictive alternative would be unsuccessful and a smaller focused environment would be beneficial. Review of the February 2025 behavior tracking record for monitoring inappropriate sexual behaviors identified Resident #1 had one incident of inappropriate sexual behaviors on 2/25/25. The behavior marked the resident was provided one-to-one supervision on 2/25/25. -The behavior tracking for inappropriate sexual behavior did not identify the resident was on one-to-one supervision or line of sight monitoring following the incident with Resident #3 on 2/25/25. IV. Staff education A 12/10/24 all staff in-service (conducted 10 days prior to the incident between Resident #1 and Resident #2) was provided by the facility on 3/24/25. The provided training materials identified abuse was reviewed with the staff. According to the abuse training materials, anything that caused fear in a resident's home was considered abuse and it was the facility's responsibility to provide a safe place for the residents to live. The 12/10/24 all staff in-service training materials identified the difference between and the purpose of a line of sight observation and a one-to-one observation. According to the training material, line of sight observation meant a staff member could see the resident at all times. The purpose of a line of sight observation was to ensure the resident's safety and prevent potential harm or incidents. A specific staff member was assigned to maintain a line of site observation, and this was done in person, and not through video monitoring. The staff should document and assess the resident's condition at regular intervals, such as every 15 minutes. The 12/10/24 all staff in-service training materials identified a one-to-one observation meant a staff member was consistently with the resident within arm's reach. The purpose of a one-to-one observation was to provide the highest level of observation and immediate intervention if needed. The staff member remained with the resident at all times and the resident never left the staff member's immediate presence. Staff should document the resident's condition and any interventions at regular intervals, such as every 15 minutes. The 12/10/24 all staff in-service participation sheet documented 17 staff members attended the training, however, only two staff members were nursing staff members. The 1/10/25 staff inservice staff for one-to-one observation due to inappropriate behavior education was provided by the DON on 3/20/25 at 5:27 p.m. The education documented one-to-one supervision of a resident was set in place for the safety of their respective environment, including but not limited to themselves, other residents, staff, guests, or any other person in the facility. According to the education, when the resident was not alone in their room, the resident must be in line of sight, at arm's length at all times. The DON, the hall nurse, or the NHA would assign the one-on-one attendee. One-to-one staff members must always follow one-to-one guidelines, no exceptions. For breaks, shift change or any other need, one-to-one staff members must wait for another staff member to take their one-to-one position with the resident. The education indicated any actions from a resident that was placed on a one-to-one that put others at risk must be immediately reported to the NHA and the DON. -The 1/10/25 education was provided three weeks after the 12/20/24 incident between Resident #1 and Resident #2. A 3/10/25 staff in-service was provided by the CC on 3/20/25 at 5:33 p.m. The in-service identified abuse prevention was reviewed with 22 staff members, including some nursing staff. V. Staff interviews CNA #2 was interviewed on 3/20/25 at 2:05 p.m. CNA #2 said he had been watching Resident #1 for falls and behaviors the past two to three months, four days a week from 5:30 a.m. to 6:30 p.m. He said other available staff would be responsible for watching the resident the rest of the time. He said he needed to make sure Resident #1 was in line of sight, kept away from female residents and exhibited appropriate behaviors. CNA #2 said since Resident #1 had been in the secured unit, there was also a sensor by the door that identified when the resident was out of bed. He said he was not aware of Resident #1's behaviors toward female residents other than touching people's hands, but nothing more serious. He said Resident #1 was easy to redirect. Licensed practical nurse (LPN) #1 was interviewed on 3/20/25 at 2:10 p.m. LPN #1 identified herself as the nurse for the secured unit. She said precautions to watch for for Resident #1 was inappropriate sexual behaviors. She said Resident #1 needed to be kept in the line of sight of staff. She said that she had not observed any inappropriate sexual behaviors since the resident had been on the secured unit. Registered nurse (RN) #1 was interviewed on 3/20/25 at 3:44 p.m. RN #1 said she had worked on the non-secured hall since January 2025, before Resident #1 was on the secured unit. She said she never saw Resident #1 with inappropriate behaviors. She said she was not aware of extra monitoring or supervision for Resident #1. She said the staff were responsible for keeping an eye on all of the residents. The DON and the CC were interviewed together on 3/20/25 at 3:49 p.m. The DON said Resident #1 was discontinued from one-to-one staff supervision on 2/26/25 and then placed on line of sight supervision on 2/26/25. The DON said Resident #1 was placed on one-to-one supervision after Resident #1 had inappropriate sexual behaviors towards Resident #2 on 12/20/24. -However, there was no documentation or a physician's order in Resident #1's EMR to indicate he had been placed on one-to-one supervision following the 12/20/24 incident (see record review above). The CC said other interventions for Resident #1 included the timing of the medication finasteride and since the change of the medication's administration timing from day to night, staff had seen improvement in his behaviors. She said after the incident with Resident #3 on 2/25/25, Resident #1 was moved to the secured unit for more line of sight monitoring and engagement. The SSD was interviewed on 3/20/25 at 4:05 p.m. The SSD said Resident #1 was kept in line of sight supervision since 12/20/24, after the incident with Resident #2. -However, according to the facility's investigation of the 12/20/24 incident, Resident #1 was supposed to be on one-to-one supervision (see above). The SSD said other interventions for Resident #1 were to offer individual activities that required his hands to help prevent him from touching other residents. He said Resident #1 loved activities. He said there were evening activities but not activities later at night. The SSD said one-to-one supervision was when an assigned staff member would stay with and make sure the supervised resident was not within an arm's length of another resident. He said staff received an education in December 2024 regarding one-to-one supervision (see education above). The CC was interviewed again on 3/20/25 at 4:46 p.m. The CC said Resident #1's one-to-one supervision should have been documented in the behavior tracking record. The CC reviewed the December 2024 behavior tracking record and said the behavior tracking for Resident #1 after the 12/20/24 incident was inconsistent. The CC reviewed the behavior care plan for Resident #1. She said no new interventions were identified on the care plan after the 12/20/24 incident. The NHA was interviewed on 3/24/25 at 11:40 a.m. She said the staff education completed on 12/10/24 (prior to the 12/20/24 incident) was not conducted for a specific resident, but had been part of an all-staf[TRUNCATED]

Based on record review, and observations, the facility failed to ensure seven (#6, #15, #14, #18, #33, #8, and #26) of nine residents with a dysphasia diagnosis out of 35 sample residents received food and fluids prepared in a form designed to meet their needs per physician orders and the residents' care plans. Observations of the tray line and dining room service on 2/28 and 2/29/24 revealed the facility failed to follow the residents' therapeutic diet orders. Seven out of seven residents, all with a dysphagia diagnosis, failed to receive a mechanically altered diet that required a change in texture (mechanical soft) as ordered and care planned. One of the seven residents failed to receive thickened liquid. Interviews with the dietary supervisor and cook revealed they lacked the necessary training to ensure the seven residents were served a mechanical soft diet and/or thickened liquids as ordered. The speech-language pathologist (SLP) indicated that obstruction of the airway might occur if a dysphagia resident who cannot chew failed to receive a mechanical soft diet. The SLP further stated aspiration might occur if a dysphagia resident ordered to receive thickened liquids failed to receive thickened liquids. The dietary manager from a sister facility said if a resident was served the incorrect diet texture, the resident could choke. The facility's failure to implement the residents' therapeutic diet orders for mechanical soft textures and/or thickened liquids created an immediate jeopardy situation that placed the residents at risk for serious harm if the failure was not immediately corrected. Cross-reference F801 for qualified dietary staff and F803 for menus to meet residents' needs. Findings include: I. Immediate jeopardy A. Findings of immediate jeopardy Observations of the tray line and dining room service on 2/28 and 2/29/24 revealed the facility failed to follow the residents' therapeutic diet orders. Seven out of seven residents, all with a dysphagia diagnosis, failed to receive a mechanically altered diet that required a change in texture (mechanical soft) as ordered and care planned. One of the seven residents failed to receive thickened liquid. Interviews with the dietary supervisor and cook revealed they lacked the necessary training to ensure the seven residents were served a mechanical soft diet and/or thickened liquids as ordered. The speech-language pathologist (SLP) indicated that obstruction of the airway might occur if a dysphagia resident who cannot chew failed to receive a mechanical soft diet. The SLP further stated aspiration might occur if a dysphagia resident ordered to receive thickened liquids failed to receive thickened liquids. The dietary manager from a sister facility said if a resident was served the incorrect diet texture, the resident could choke. On 2/29/24 at 9:13 p.m., the nursing home administrator (NHA) and director of nursing (DON) were informed that the facility's failure to implement the residents' therapeutic diet orders for mechanical soft textures and thickened liquids created an immediate jeopardy situation that placed the residents at risk for serious harm if the failure was not immediately corrected. B. Interim plan to ensure resident safety On 2/29/24 at 10:30 p.m., the facility provided a document that showed no snacks were to be served to any resident unless the charge nurse approved. C. Facility plan to remove immediate jeopardy On 3/1/24 at 12:05 p.m. the facility submitted its final plan to remove immediate jeopardy. The plan read: The identified residents were provided dinner following the Incorrect physician-ordered diet texture. The dietary staff working the evening and night shift of 02/29/24, and the dietary staff that is scheduled for breakfast on 03/01/24 were educated by an external Certified Dietary Manager on the importance of following the physician's order for an altered textured diet, following all menus and substitutions requirements associated with an altered textured diet, as well as education on the use and following of Dietary Meal Tickets. The list of identified residents was placed at both nurses' stations to alert the night shift staff of all residents [who] may request a snack during the night of 3/1/24. This list has been provided. The night shift nurses and CNAs (certified nurse aides) were educated that the identified residents on the list required an altered therapeutic diet and what that diet was. The CNAs were educated that they were not to give any snacks to any of the identified residents without prior approval from the charge nurse that the snack was appropriate for the resident. This was educated by two RNs in person. A list of approved altered diet textured snacks was also left at each nurse's station and all staff trained on that list. Training on 3/1/2024 started when AM staff entered their shift. NOC (night) shift was trained before the IDT (interdisciplinary) team left the building last night. All dietary and nursing staff will be trained on 3/1/24. Staff [who] are not available to be trained on 3/l/24 will be trained prior to their next shift. to include varying shifts. The training included snacks appropriate for each diet per the list and confirmation that all snacks must be cleared with [the] Charge nurse before giving them to a resident on an altered diet texture. Identification of others The Director of Nursing completed an audit to identify all residents [who] had physician orders for an altered therapeutic diet and correct meal tickets. System Changes An externally qualified dietary manager will be in place to provide full-time oversight of all kitchen operations to include following the menus related to altered textured diets until the internal dietary manager becomes certified. Education was provided to dietary staff by the external certified dietary manager regarding applicable diet textures to include mechanical soft and puree consistency, as well as proper usage of meal tickets. The dietary staff were also educated to maintain compliance with resident specific dietary interventions, and food preparation consistent with each resident's dietary orders. To follow all menus, menu extensions, and recipes for all applicable diets, and to follow all menu substitutions as needed. The Certified Dietary Manager has reviewed all menus and recipes through 3/4/2024 to validate they meet all applicable diet texture standards prior to preparing and serving the meal. Education was provided to nursing staff by the same certified dietary manager as above on how to read the resident's tray card, and how to properly identify correct altered textured diets, such as mechanical soft, puree, honey and nectar thick liquids following physician orders. All training was completed by 03/01/24 for staff on shift. Education [is] to continue through the weekend to ensure all staff are sufficiently trained. All new staff hired post 03/01/24 will be given the same training prior to working in the kitchen and or serving any residents their food, snack, or beverage. The list of residents with altered textured diets will be kept in the kitchen and nurses' station to identify residents [who] require an altered textured meal, snack, or beverage. The qualified dietary manager has provided an approved list of available snacks and beverages for residents requiring altered textured diets and will continue to update them if any new diets are added. The DON reviewed all identified residents with altered diet textures care plan and updated it accordingly to reflect each resident's specific dietary interventions and needs. Monitoring The Dietary Manager/ designee will audit all new admissions for three months on [the] day of admission to ensure the dietary orders/recommendations/documentation are accurate in the medical record and match the dietary department's tray card information for that resident. The Dietary Manager/designee will audit each meal daily for 1 month then daily for a week [then] once a week indefinitely or per the [facility] QAPI identification to validate that each meal has been prepared and is in compliance with the resident's specific altered texture requirements prior to being served. The Registered Dietician will complete an audit of at least 2 meals each time the RD is in the center to validate that the meals are being prepared and served according to the residents' specific dietary requirements. The DON/designee will audit the snacks daily to validate that the snacks set out and provided for the residents with altered textured diets meet the residents' specific dietary requirements. All results of each audit will be provided to the [facility's] administrator who will review in QAPI monthly for 3 months and adjust as the center identifies necessary. The IJ removal plan was signed and dated by the nursing home administrator. D. Removal of immediate jeopardy On 3/1/24 at 4:00 p.m., the NHA and DON were notified that the facility's plan to remove immediate jeopardy was accepted based on the facility's plan to implement the measures above. However, the deficient practice remained at E level, a pattern with the potential for more than minimal harm. II. Expectations for compliance with mechanical soft texture diets A. Professional references 1. According to the National Dysphagia Diet (NDD): Level three for advanced dysphagia This level consists of food of nearly regular textures with the exception of very hard, sticky or crunchy foods. Foods still need to be moist and should be in bite-sized pieces at the oral phase of the swallow. This diet is a transition to a regular diet. Adequate dentition and mastication are required. The textures of this diet are appropriate for individuals with mild oral or pharyngeal phase dysphagia. This texture needs to avoid: -Tough, dry, crusty breads; -Coarse or dry cereals; -Dry cakes, cookies that are chewy or very dry and anything with nuts, seeds, dry fruits, coconut and pineapple; -Difficult-to-eat fruit due to skins, raspberries, stringy, high-pulp fruits, fresh fruits with difficult-to-chew peels, uncooked dried fruits and fruit leather or fruit snacks; -Tough, dry meats and poultry, dry fish or fish with bones, chunky peanut butter and yogurt with nuts or coconut; -Tough crisp-fried potatoes, potato skins and dry bread dressing; -Soups with tough meats, corn or clam chowder and soups that have large chunks of meat or vegetables greater than one inch; -All raw vegetables except shredded lettuce, cooked corn and non-tender or rubbery cooked vegetables; and -Nuts, seeds, coconut, chewy caramel or toffee-type candies and candies with nuts, seeds or coconut. https://swallowstudy.com/wp-content/uploads/National-Dysphagia-Diet-FULL-DETAILS.pdf 2. According to the International Dysphagia Diet Standardisation Initiative (IDDSI): Level 6 soft and bite-size Characteristics of this level are foods that can be eaten with a fork, spoon or chopsticks, can be mashed or broken down with pressure from a fork, spoon or chopsticks, a knife is not required to cut this food but may be used to help load a fork or spoon, soft, tender and moist throughout but with no separate thin liquid, chewing is required before swallowing and bite-sized pieces as appropriate for size and oral processing skills. Adults' bite-sized food pieces should be no larger than half an inch but half an inch. Foods allowed on this diet include: -Cooked, tender meat no bigger than half an inch by half an inch; -Soft enough cooked fish to break into small pieces with a fork no bigger than half an inch by half an inch without bones or tough skins; -Casseroles, stew, or curry the liquid portion (sauce) must be thick, and can contain meat, fish or vegetables if the final cooked pieces are soft and tender and no bigger than half an inch by half an inch and should not have large lumps; -Fruit should be served minced or mashed if it cannot be cut into soft and bite-sized pieces, fibrous parts of the fruit are not suitable, drain the excess juice and assess the individual's ability to manage fruit with a high water content where the juice separates from a solid in the mouth during chewing; -Steamed or boiled vegetables with the final cooked size no bigger than half an inch by half an inch. Stir-fried vegetables may be too firm and are not soft or tender, check softness with the fork or spoon pressure test; -Cereal should be smooth with soft tender lumps no bigger than half an inch by half an inch, the texture should be fully softened and any excess milk or liquid must be drained or thickened to the thickness level recommended by the clinician; -No regular dry bread, sandwiches or toast of any kind, use IDDSI level 5 minced and moist sandwich recipe video to prepare bread and add to fillings that meet the soft and bite-sized requirements, pre-gelled (soaked) breads that are very moist and gelled through the entire thickness; and -Rice, couscous and quinoa (and similar food textures) should not be particulate, grainy, sticky or glutinous. When testing foods with the fork or spoon pressure test, the preparer's thumbnail should blanch (turn) white when pressing on the food and the food squashes and does not return to its original shape when the pressure is released. https://www.iddsi.org/IDDSI/media/images/Complete_IDDSI_Framework_Final_31July2019.pdf B. Facility policy The Therapeutic Diets policy, unrevised, was provided by the nursing home administrator (NHA) on 2/26/24. It read in pertinent: When necessary, the facility will provide a therapeutic diet that is individualized to meet the clinical needs and desires of a resident to achieve outcomes or goals of care. Available therapeutic diets should coincide with the therapeutic diets on the facility's menu extensions. The registered dietitian nutritionist will approve all therapeutic diet menu extensions; A list of approved or standard diets will be available for the nursing staff, who will notify physicians of the diets available in the facility; Diets will be offered as ordered by the physician; The resident's medical record and diet on file in the food and nutrition service office's system must be reviewed on a regular basis; and A diet and nutrition manual will be available in the food and nutrition services department for staff use. Support staff work under the supervision of the registered dietitian. Support staff includes the nutrition and dietetics technicians, certified dietary manager, director of food and nutrition services, etc. C. Interviews with the dietary supervisor (DS), a sister facility's dietary manager (DM), the speech-language pathologist (SLP), and the corporate registered dietitian (CRD) revealed expectations for compliance with mechanically soft textured diets and thickened liquids. The NHA was interviewed on 2/29/24 at 9:02 p.m. and said all seven residents had dysphagia and were ordered to receive a mechanical soft level 3 diet. The DS was interviewed on 2/29/24 at 11:12 a.m. She said staff use the NDD dysphagia diet for mechanical soft while the facility is transitioning to the IDDSI dysphagia diet. The DM was interviewed on 3/1/24 at 9:11 a.m. She said when making food mechanically soft, everything needed to be soft, half-inch, bite-sized pieces. She said all meats needed to be ground and served with gravy or a source mixed throughout the meat. She said if a resident was on thickened liquids, then broth needed to be thickened. The SLP was interviewed on 3/1/24 at 11:48 a.m. She said on a mechanical soft diet, the resident can have chopped meat and soft vegetables, soft canned fruits, and soft bread if allowed for a soft mechanical diet level 3. The CRD was interviewed on 3/1/24 at 10:30 a.m. She said mechanical soft diets should have no pieces [of food] larger than half an inch. Gravy on. Bread with crust removed. III. Residents diagnosed with dysphagia and ordered and/or care planned to receive a mechanical soft diet. A. Resident #6 Resident #6, age over 65, was admitted on [DATE]. According to the February 2024 computerized physician orders (CPO), the resident had a diagnosis of oral phase dysphagia. According to the 1/9/24 minimum data set (MDS) assessment, Resident #6 had a brief interview for mental status (BIMS) score of 99 because she was unable to complete the interview. The staff interview documented Resident #6 had a moderately impaired cognition level, fluctuating inattention, and fluctuating disorganized thinking. The MDS read Resident #6 was on a mechanically altered diet that required a change in the texture of foods or liquids. Physician orders revealed Resident #6 had an order for a mechanical soft diet with ground meats and nectar thick liquids. Resident #6's care plan, revised 2/23/24, documented the resident had a nutritional problem or she had the potential for a nutritional problem. Interventions were documented as: -Monitor, document and report as needed any signs or symptoms of dysphagia- pocketing, choking, coughing, drooling, holding food in her mouth, several attempts at swallowing, refusing to eat or appearing concerned during meals; -Resident #6's diet is mechanical soft with ground meats and nectar thick liquids; and -Provide and serve diet as ordered. Monitor intake and record every meal. ' B Resident #15 Resident #15, age 72, was admitted on [DATE]. According to the February 2024 CPO, the resident had a diagnosis of unspecified dysphagia. According to the 2/1/24 MDS assessment, Resident #15 had a severe cognitive impairment with a BIMS score of 6 out of 15. The MDS read Resident #15 was on a mechanically altered diet that required a change in the texture of foods or liquids. Physician orders revealed Resident #6 had an order for a mechanical soft diet with ground meats and regular or thin liquids. Resident #15's care plan, revised 5/17/22, documented the resident had a potential for weight loss that referred to adult failure to thrive and he refused meals. Interventions were documented as: -Resident #15 is on a regular diet that is mechanical soft with ground meat texture and regular or thin liquids; and -Provide and serve diet as ordered. Monitor intake and record every meal. C. Resident #33 Resident #33, age 80, was admitted on [DATE]. According to the February 2024 CPO, the resident had a diagnosis of unspecified dysphagia. According to the 1/16/24 MDS assessment, Resident #33 had severe cognitive impairment with a BIMS score of 6 out of 15. The MDS read Resident #33 was on a mechanically altered diet that required a change in the texture of foods or liquids. Physician orders revealed an order for a regular diet that is mechanical soft with ground meat texture and regular or thin liquids. Resident #33's care plan, revised 1/23/24, documented he had impaired cognitive function or impaired thought processes which referred to his disease process. Interventions were documented as: -Provide and serve diet as ordered. Monitor intake and record every meal; and -Resident #33 is on a regular diet with mechanical soft with ground meat texture and regular or thin liquids. D. Resident #26 Resident #26, age 85, was admitted on [DATE]. According to the February 2024 CPO, the resident had a diagnosis of unspecified dysphagia. According to the 2/7/24 MDS assessment, Resident #26 had a BIMS score of 99 because he was unable to complete the interview. The staff interview documented Resident #26 had a moderately impaired cognition level, fluctuating inattention, and fluctuating disorganized thinking. The MDS read Resident #26 was on a mechanically altered diet that required a change in the texture of foods or liquids. Physician orders revealed an order for a regular diet with a mechanical soft diet with ground meat texture and a recommendation for pureed vegetables and regular or thin liquids. Resident #26's care plan, revised 11/12/22, documented Resident #26 had a swallowing problem which referred to a diagnosis of unspecified dysphagia. Interventions were documented as: -All staff to be informed of the resident's special dietary and safety needs; -Alternate small bites and sips. Use a teaspoon for eating. Do not use straws; -Check mouth after meals for pocketed food and debris. Report to nurse. Provide oral care to remove debris; -Diet to be followed as prescribed; -Instruct resident to eat in an upright position, to eat slowly and to chew each bite thoroughly; -Keep head of bed elevated to 45-degrees during meals and thirty minutes afterwards; -Monitor for shortness of breath, choking, labored respirations and lunch congestion; and -Monitor, document and report as needed any signs or symptoms of dysphagia like pocketing, choking, coughing, drooling, holding food in mouth, [several] attempts at swallowing, refusing to eat or appears to be concerned during meals. E. Resident #8 Resident #8, age 82, was admitted on [DATE]. According to the February 2024 CPO, the resident had a diagnosis of unspecified dysphagia. According to the 1/1/24 MDS assessment, Resident #8 had a BIMS score of 99 because he was unable to complete the interview. The staff interview documented Resident #8 had a moderately impaired cognition level, fluctuating inattention, and fluctuating disorganized thinking. Resident #8 was on a mechanically altered diet that required a change in the texture of foods or liquids. Physician orders revealed an order for a mechanical soft diet with ground meat texture and regular or thin consistency. Resident #8's care plan, revised 7/15/19, documented the resident was at risk for weight fluctuation which referred to his mood, behavior, decreased appetite, and cognition level. Interventions were documented as: -Allow ample time at each meal and encourage to eat as much as possible to ensure adequate intake; -Current diet is mechanical soft with ground meat texture and regular or thin consistency; and -Provide and serve diet as ordered, monitor intake, and record every meal. F. Resident #14 Resident #14, age 77, was admitted on [DATE]. According to the February 2024 CPO, the resident had a diagnosis of oropharyngeal phase dysphagia. According to the 1/1/24 MDS assessment, Resident #14 had a BIMS score of 99 because he was unable to complete the interview. The staff interview documented Resident #14 had a moderately impaired cognition level, fluctuating inattention, and fluctuating disorganized thinking. The MDS read Resident #14 was on a mechanically altered diet that required a change in the texture of foods or liquids. Physician orders revealed an order for a mechanical soft diet with ground meat texture and regular or thin consistency. Resident #14's care plan, revised 10/11/23, documented the resident had a potential for weight loss which referred to dementia, chronic obstructive pulmonary disease (COPD), and bipolar disorder. The resident needed mechanical soft diet textures. Interventions were documented as: -Current diet is regular with mechanical soft foods and regular or thin liquids; -Allow ample time to eat each meal and encourage the resident to eat as much as possible to ensure adequate intake; -Monitor, document and report as needed any signs or symptoms of dysphagia like pocketing, choking, coughing, drooling, holding food in mouth, several attempts at swallowing, refusing to eat or appearing concerned during meals; and -Provide and serve diet as ordered. Monitor intake and record every meal. G. Resident #18 Resident #18, age over 65, was admitted on [DATE]. According to the February 2024 CPO, the resident had a diagnosis of unspecified dysphagia. According to the 1/1/24 MDS assessment, Resident #18 had moderate cognitive impairment with a BIMS score of seven out of 15. Resident #18 was on a mechanically altered diet that required a change in the texture of foods or liquids. Physician orders revealed an order for a mechanical soft diet with ground meat texture and regular or thin consistency. Resident #18's care plan, revised 8/3/18, documented the resident had actual weight loss which referred to a history of poor nutrition secondary to vascular dementia. Interventions were documented as: -Allow resident ample time to eat each meal and encourage the resident to eat as much as possible to ensure adequate intake; -Resident #18 is on a regular diet, mechanical soft texture and regular or thin liquids; -The resident requires set up and supervision for eating; and -Provide and serve diet as ordered. Monitor intake and record every meal. IV. Facility failure to implement the residents' therapeutic diet orders for mechanical soft textures and/or thickened liquids. Staff interviews and observations of the tray line and dining room service on 2/28 and 2/29/24 revealed the facility failed to follow the residents' therapeutic diet orders. Seven out of seven residents failed to receive a mechanically altered diet that required a change in texture (mechanical soft) as ordered and care planned. One of the seven residents failed to receive thickened liquids. A. Observations and interview - Lunch and snack on 2/27/24 At 12:38 p.m. certified nurse aide (CNA) #2 cleared some plates from the secured unit dining room. She said the breadsticks that had been served with the lunch meal were as hard as wood and asked the residents who were still eating not to eat the breadsticks because she was worried the residents would break their teeth. At 3:38 p.m. Resident #8 was eating crackers from a snack bag that were not mechanical soft, according to his therapeutic diet order. B. Observations and interview - Snack and dinner on 2/28/24 1. Snack -At 9:43 a.m. the activities director (AD) offered donuts to residents. Resident #8 was served a whole chocolate donut with sprinkles. Resident #8 ate the donut which was not mechanical soft in texture and therefore inconsistent with their therapeutic diet order. -At 12:15 p.m. Resident #8 was served a whole piece of caramel cake, roast beef that was not ground, a whole bread roll that was not bite-sized, and mashed potatoes. The cake, roast beef, and roll were not mechanical soft in texture and therefore inconsistent with their therapeutic diet order. 2. Dinner At 4:35 p.m. cook (CK) #1 prepared a bacon, egg, and cheese quiche for residents on a regular textured diet and an egg and cheese quiche for residents on a mechanical soft textured diet. CK#1 also prepared oven-fried potatoes that were bigger than a half-inch by half-inch and peaches for the sides. -Resident #6 was served food inconsistent with their order for a mechanical soft texture. Resident #6 was served an egg and cheese quiche; however, the crust was still attached. Further, the quiche was a whole slice, not bite-sized. -Resident #15 was served food inconsistent with their order for a mechanical soft texture. Resident #15 was served an egg and cheese quiche; however, the crust was still attached. Further, the quiche was a whole slice, not bite-sized. -Resident #8 was served food inconsistent with their order for a mechanical soft texture. Resident #8 was served an egg and cheese quiche; however, the crust was still attached. Further, the quiche was a whole slice, not bite-sized. -Resident #14 was served food inconsistent with their order for a mechanical soft texture. Resident #14 was served an egg and cheese quiche; however, the crust was still attached. Further, the quiche was a whole slice, not bite-sized. -Resident #33 was served food inconsistent with their order for a mechanical soft texture. Resident #33 was served an egg and cheese quiche; however, the crust was still attached. Further, the quiche was a whole slice, not bite-sized. -Resident #18 was served food inconsistent with their order for a mechanical soft texture. Resident #18 was served an egg and cheese quiche; however, the crust was still attached. Further, the quiche was a whole slice, not bite-sized. -Resident #26 was served food inconsistent with their order for a mechanical soft texture. Resident #26 was served an egg and cheese quiche; however, the crust was still attached. Further, the quiche was a whole slice, not bite-sized. 2. Staff interviews CK #1 was interviewed at 4:45 p.m. CK #1 said she did not have to cut the quiche into bite-sized pieces because the filling was already mechanically soft. The DS was interviewed on 2/29/24 at 11:12 a.m. She said she provided training to new hires but relied on her cook to train cooks and her dietary aide (DA) to train DAs. She said the staff used the national dysphagia diet for mechanical soft while the facility transitioned to using IDDSI. She said food served for mechanical soft diets needed to be ground up but did not share any other criteria on how to accurately serve mechanical soft textured foods. The DS said she had not observed the dinner served on 2/28/24 to see if the textures were correct and apologized for not having CK #1 fix the textures before the meal was served. She said the food needed to be the correct texture to prevent residents from choking. The DS said she was going to talk with the kitchen staff to ensure the correct textures were served to the residents. D. Observations and interviews - Snack and dinner on 2/29/24 Contrary to the DS interview above, that she was going to talk with the kitchen staff to ensure the correct textures were served to the residents, on 2/29/24 a snack was provided and meals were plated for the residents with foods that were not mechanical soft. 1. Snack On 2/29/24 at 8:11 a.m. Resident #8 was observed eating a whole muffin that was not mechanical soft in texture and therefore inconsistent with their therapeutic diet order. 2. Dinner from 4:40 p.m. to 5:00 p.m. At 4:40 p.m. CK #1 prepared a vegetable stew and chicken salad sandwich with an oatmeal cookie. -Resident #6 was plated food that was not consistent with their orders for a mechanically soft texture and thickened liquids. Specifically, Resident #6 was plated a bowl of vegetable stew that contained large pieces of vegetables that were not cut bite-sized. The soup broth for Resident #6 was not nectar-thick. The sandwich was not moistened with a sauce and the crust had not been removed from the bread. The bread was dry and cut into half slices but not bite-sized pieces. The oatmeal cookie was plated as a whole cookie. -Resident #26 was plated food that was not consistent with their orders for a mechanically soft texture. The resident was plated a bowl of vegetable stew containing large pieces of vegetables that were not bite-sized. The sandwich was not moistened with a sauce and the crust had not been removed from the bread. The bread was dry and cut into half slices, not bite-sized pieces. The oatmeal cookie was plated as a whole cookie. -Resident #15 was plated food that was not consistent with their orders for a mechanical soft texture. The resident was plated a bowl of vegetable stew containing large pieces of vegetables not bite-sized. Resident #15 disliked bread because it was hard for him to swallow and was only served the sandwich filling. The oatmeal cookie was plated as a whole cookie. -Resident #8 was plated food that was not consistent with their orders for a mechanical soft texture. The resident was plated a bowl of vegetable stew containing large pieces of vegetables that were not cut bite-sized. The sandwich was not moistened with a sauce and the crust had not been removed. The bread was dry and cut into half slices but not cut bite-sized. The oatmeal cookie was plated as a whole cookie. -Resident #33 was plated food that was not consistent with their orders for a mechanical soft texture. The resident was plated a bowl of vegetable stew containing large pieces of vegetables [TRUNCATED]

Based on observation, record review and interviews, the facility failed to ensure one (#29) of three residents reviewed for nutrition received the care and services necessary to meet their nutritional needs and maintain their highest physical well-being level out of 35 sample residents. Resident #29 was at nutritional risk with a diagnosis of dementia. Interventions were implemented by the registered dietitian due to the resident's nutritional risk and history of weight loss, however, these interventions were not consistently evaluated for effectiveness. Observations during the survey revealed the resident's intake of nutritional supplements were not accurately documented. When the resident sustained a significant weight loss from 1/2/24 to 2/2/24, the intervention of offering fortified foods was not added until 20 days later. Due to the facility's failure to implement timely nutritional interventions and evaluate the effectiveness of nutritional interventions in place, the resident sustained a 16.3 pound (lbs) weight loss from 1/2/24 to 2/2/24, 10.7% which was considered significant. Findings include: I. Resident status Resident #29, over the age of 65, was admitted on [DATE]. According to the February 2024 computerized physician order (CPO), diagnoses included dementia, abdominal aortic aneurysm (an enlarged area in the lower portion of the aorta, the body's main artery) and high blood pressure (hypertension). According to the 12/6/23 minimum data set (MDS) assessment, Resident #29 had significant cognitive impairment and was unable to complete the brief interview for mental status (BIMS). The assessment documented Resident #29 required set-up or cleaning assistance with meals and maximal assistance with bathing, toileting and dressing. The resident was able to eat independently after set-up assistance was completed. The assessment did not identify weight loss. II. Observation On 2/28/24 at 9:46 a.m., Resident #29 was administered 237 milliliters (ml) of a nutritional supplement. Licensed practical nurse (LPN) #1 documented 237 ml of nutritional supplement consumed while the resident was actively drinking the supplement at 9:46 a.m. When the resident stopped drinking the nutritional supplement at 9:54 a.m., the MDS coordinator (MDSC) cleared Resident #29's tray, including the nutritional supplement. -The MDSC failed to observe or measure for any remaining nutritional supplement and did not communicate the amount of nutritional supplement consumed by Resident #29 to LPN #1. It was unknown how much nutritional supplement was consumed by Resident #29. At 4:16 p.m., LPN #1 discarded a nutritional supplement bottle in which medications were added for medication administration. Some remaining nutritional supplement and pill fragments were in the bottle. LPN #1 documented Resident #29 consumed 237 milliliters of nutritional supplement. III. Record review Review of Resident #29's electronic medical record (EMR) revealed the following documented weights: -On 8/16/23, the resident weighed 157.6 lbs; -On 9/8/23, the resident weighed 154.4 lbs; -On 10/25/23, the resident weighed 147.8 lbs; -On 12/2/23, the resident weighed 150.0 lbs; -On 1/2/24, the resident weighed 152.3 lbs; -On 2/2/24, the resident weighed 136.0 lbs; -On 2/15/24, the resident weighed 137.1 lbs; and, -On 2/23/24, the resident weighed 137.0 lbs. Resident #29's weight record showed the resident lost 16.3 pounds between 1/2/24 and 2/2/24. This was considered significant weight loss of 10.7% of the resident's body weight in one month. The care plan, dated 12/14/23, identified that Resident #29 was at risk for nutritional concerns and he required set-up assistance and a high back chair for all meals. Pertinent interventions included monitoring for decreased oral intake with meals and snacks, set up and supervision while eating, additional time to complete the meal, cueing to remain focused on eating and snacks throughout the day. The dietary quarterly assessment dated [DATE] documented a significant weight loss of 10.7%. -The dietary quarterly assessment failed to identify or implement additional nutritional interventions. The Dietary Nutritional assessment, dated 2/22/24, documented Resident #29 had a height of 73 inches and a weight of 137.1 pounds. It documented a significant weight loss of 10.7% in a month and 13.7% weight loss since 8/16/23. The nutritional assessment documented interventions including nutritional supplements three times a day, fortified food and allowing him extra time to finish meals. The nutritional assessment documented the resident did not refuse the nutritional supplements and consumed 100% of nutritional supplements three times a day. -The intervention to offer finger foods to the resident was added 2/22/24, however, this was 20 days after the significant weight loss was identified. The January 2024 and February 2024 medication administration record (MAR) documented nutritional supplements ordered 6/8/23 to be administered three times per day. There were 174 nutritional supplement administration opportunities between 1/1/24 and 2/27/24, of which 30 administrations were not given because the resident was sleeping. There was no documentation to indicate the nutritional supplement was re-offered to the resident when he was awake. The remaining 144 nutritional supplement administrations documented Resident #29 consumed 237 milliliters (ml) or 100% of the nutritional supplement. -However, observations revealed the resident did not consistently consume 100% of the supplement (see observations above). IV. Staff interviews LPN #1 was interviewed on 2/28/24 at 4:19 p.m. LPN #1 said nutritional supplements should be observed, measured and then appropriately charted. LPN #1 said the resident's MAR should accurately document how many milliliters of nutritional supplements were consumed. LPN #1 said the nutritional supplements were ordered to prevent weight loss for Resident #29. The corporate registered dietitian (CRD) was interviewed on 2/29/24 at 10:30 a.m. The CRD said she had not witnessed Resident #29 consume a nutritional supplement. The CRD said she relied on the milliliters documented to know how much of the nutritional supplement residents' consumed. The CRD said staff should roughly estimate how much of the nutritional supplement had been consumed by a resident. The CRD said she was not aware of Resident #29 not receiving nutritional supplements because he was asleep. The CRD said she was not aware of nursing staff charting nutritional supplement totals before the resident finished consuming them. The director of nursing (DON) was interviewed on 3/1/24 at 12:55 p.m. The DON said if a resident was sleeping staff should re-offer nutritional supplements later in the day and document this. The DON said nutritional supplements should be measured after residents finished consuming them to accurately document the volume consumed. The DON said nursing staff, the CRD and the DON were all responsible for identifying if residents needed additional interventions for weight loss.

Based on interviews and record review, the facility failed to ensure an effective quality assurance program to identify and address facility compliance concerns was implemented, in order to facilitate improvement in the lives of nursing home residents, through continuous attention to quality of care, food and nutrition services and resident safety. Specifically, the quality assurance performance improvement (QAPI) program committee failed to identify and address concerns related to food and nutrition services, quality of care, resident safety and infection control. Findings include: I. Facility policy The Quality Assurance and Performance Improvement (QAPI) Program-Analysis and Action was received from the nursing home administrator (NHA) on 2/26/24. The policy read in pertinent part, Quality deficiencies that are identified through feedback and data and will undergo appropriate corrective action. Corrective actins are monitored against established goals and benchmarks by the QAPI committee. The QAPI program overseen by the QAPI committee is designed to identify and address quality deficiencies through the analysis of the underlying cause and actions targeted at correcting systems at a comprehensive scope and severity. II. Review of the facility's regulatory record revealed it failed to operate a QA program in a manner to prevent repeat deficiencies and initiate a plan to correct F689 Accident hazards During the recertification survey on 7/29/21 F689 was cited at a D scope and severity, a potential for more than minimal harm, isolated. During the abbreviated survey on 11/3/22 F689 was cited at a D scope and severity, a potential for more than minimal harm, isolated. During the recertification survey on 3/1/24 F689 was cited at an E scope and severity, a potential for more than minimal harm, pattern. F692 Nutrition parameters During the abbreviated survey on 11/3/22 F692 was cited at a G scope and severity, actual harm. During the recertification survey on 3/1/24 F692 was cited at a G scope and severity, actual harm. F867 Quality assurance program During an abbreviated survey on 6/15/22 F867 was cited at an F scope and severity, a potential for more than minimal harm, facility wide. During the abbreviated survey on 11/3/22 F867 was cited at an F scope and severity, a potential for more than minimal harm, facility wide. During the recertification survey on 3/1/24 F867 was cited at an F scope and severity, a potential for more than minimal harm, facility wide. F880 Infection control During an abbreviated survey on 3/9/22 F880 was cited at an E scope and severity, a potential for more than minimal harm, pattern. During the recertification survey on 3/1/24 F880 was cited at an F scope and severity, a potential for more than minimal harm, facility wide. III. Cross-reference citations Cross-reference F805 food in form to meet resident needs: The facility failed to implement the residents' therapeutic diet orders for mechanical soft textures and/or thickened liquids. Cross-reference F692 nutrition parameters: The facility failed to implement timely nutritional interventions and evaluate the effectiveness of nutritional interventions in place. IV. Staff interviews The nursing home administrator (NHA) and the director of nurses (DON) were interviewed on 3/1/24 at 3:23 p.m. The NHA said the QAPI committee met monthly with the interdisciplinary team (IDT) and the medical director in attendance. The NHA said the meeting had an agenda. She said the agenda changed monthly. The NHA said the IDT met daily to discuss any issues from the previous night and answered the Five Whys in order to determine the root cause (an interative interrogative technique used to explore the cause-and-effect relationships underlying a particular problem. The primary goal of the technique is to determine the root cause of a defect or problem by repeating the question Why? five times). The QAPI committee looked for trends and then root causes and then put a performance improvement plan in place. \ The NHA said the dietary manager (DM) attended the QAPI meetings as part of the IDT. She said prior to the survey, the DM was in school and needed to receive training. She said they did have a performance improvement plan for food temperatures and the dish machine not registering correctly, however, that was resolved. She said the kitchen has had turnover of two cooks and has had an issue on retaining staff. She said the the menu had been switched and there was lack of training and education provided to the kitchen staff on how to read and understand the menus. The DON said the nursing staff were trained to use proper transfer techniques. However, staff turnover and consistent solid staff were attributed to the deficient practice. The DON said the QAPI committee did discuss weights for both weight loss and gain at each meeting. She said they had identified that once weight loss was identified then the resident was placed on weekly weights and would be followed which included watching meal intakes and who required eating assistance. She said she was aware resident's weight loss continued to be addressed. She said multiple interventions were attempted with Resident #29. The DON said infection control was something they were always working on. She said the infection preventionist was performing hand hygiene audits and trainings. The NHA said since her employment from November 2023, she did recognize there were a lot of areas that needed changes. She said she was involving the IDT with recognizing and putting solutions in place.

Based on observations, record review and interviews, the facility failed to ensure menus met the needs of residents and were followed. Specifically, small portions were served to all residents and menu items were omitted without substitutions being made. Findings include: I. Observations A. Dinner on 2/28/24 At 4:35 p.m. cook (CK) #1 prepared a bacon, egg and cheese quiche for residents on a regular textured diet and an egg and cheese quiche for residents on a mechanical soft textured diet. The menu called for a bacon and cheddar quiche with oven-browned potatoes and parslied cauliflower and a tropical fruit parfait, however, CK #1 served peaches and omitted the cauliflower and said the residents did not like vegetables with dinner. -Resident #31 was served half of a portion of the mechanical soft quiche, although she did not have a physician's order for small portions. The vegetables were omitted. -Resident #15 was served half of a portion of the mechanical soft quiche, although he had a physician's order for extra portions. The vegetables were omitted. -Resident #8 was served half of a portion of the mechanical soft quiche, although he did not have a physician's order for small portions. The vegetables were omitted. -Resident #16 was served half of a portion of the regular bacon and cheese quiche, although he did not have a physician's order for small portions. The vegetables were omitted. -Resident #14 was served half of a portion of the mechanical soft quiche, although he did not have a physician's order for small portions. The vegetables were omitted. -Resident #30 was served half of a portion of the regular bacon and cheese quiche, although he did not have a physician's order for small portions. The vegetables were omitted. -Resident #33 was served half of a portion of the regular bacon and cheese quiche, although he did not have a physician's order for small portions. The vegetables were omitted. -Resident #23 was served half of a portion of the regular bacon and cheese quiche, although he did not have a physician's order for small portions. The vegetables were omitted. -Resident #22 was served half of a portion of the regular bacon and cheese quiche, although he did not have a physician's order for small portions. The vegetables were omitted. -Resident #21 was served half of a portion of the regular bacon and cheese quiche, although he did not have a physician's order for small portions. The vegetables were omitted. -Resident #3 was served the alternative meal of fruit (peaches) and cottage cheese. She was not served vegetables or a carbohydrate. -Resident #4 was served the alternative meal of fruit (peaches) and cottage cheese. She was not served vegetables or a carbohydrate. -Resident #25 was served the alternative meal of fruit (peaches) and cottage cheese. She was not served vegetables or a carbohydrate. She had a severe cognitive impairment and was unable to order her meal. CK #1 said fruit and cottage cheese were easier to puree than the main meal. -Resident #1 was served the alternative meal of fruit (peaches) and cottage cheese. She was not served vegetables or a carbohydrate. She had a severe cognitive impairment and was unable to order her meal. CK #1 said fruit and cottage cheese were easier to puree than the main meal. II. Staff interviews CK #1 was interviewed on 2/28/24 at 4:35 p.m. CK #1 said Resident #3 and Resident #4 were the only residents who ordered the alternative meal of fruit and cottage cheese. She said she served fruit and cottage cheese to Resident #1 and Resident #25 because it was easier to puree and the residents could not order their meals due to their cognitive levels. CK #1 said she served half or small portions to the residents who did not eat much because she did not want food to be wasted. The corporate registered dietitian (CRD) was interviewed on 2/29/24 at 10:30 a.m. The CRD said meals needed to be served based on the physician's orders, therapeutic diets, residents' care plans and meal tickets. She said residents were to receive the full portion unless they had a physician's order documented for small portions. The CRD said the kitchen needed to serve the residents a full portion even if they wasted the food. The dietary supervisor (DS) was interviewed on 2/29/24 at 11:12 a.m. The DS said the cook needed to serve the meals based on the menu and recipes. She said residents had the right to waste food and CK #1 was not supposed to omit items or serve small portions to prevent food waste. She said if the meal ticket did not say small portion the resident needed to be served the full portion. The DS said the menu called for the quiche to be made in a pie pan and a regular portion needed to be one-sixth of the quiche and a small portion was one-eighth of the quiche. She said the facility only had one or two residents who had physician's orders for small portions. The DS said she needed to talk to CK #1 to tell her not to omit items from the menu without replacing the items with something of similar nutritional value. 50314

Based on observations, record review and interviews the facility failed to store, prepare, distribute, and serve food in a sanitary manner. Specifically, the facility failed to ensure: -Cold food items were held at the proper temperature to reduce the potential risk of foodborne illness; -Expired dry goods were disposed of; -Proper hand hygiene was performed during meal service; -Kitchen refrigerators were held at the appropriate temperature; and, -Food items were labeled with use-by dates. Findings include I. Food storage A. Professional reference The Colorado Department of Public Health and Environment (2019) The Colorado Retail Food Establishment Rules and Regulations, retrieved on [DATE] from: https://drive.google.com/file/d/18-uo0wlxj9xvOoT6Ai4x6ZMYIiuu2v1G/view, revealed in pertinent part, A date marking system that meets the criteria stated in (2) of this section may include: Marking the date or day of preparation, with a procedure to discard the food on or before the last date or day by which the food must be consumed on the premises, sold, or discarded; Marking the date or day the original container is opened in a food establishment, with a procedure to discard the food on or before the last date or day by which the food must be consumed on the premises, sold, or discarded; or Using calendar dates, days of the week, color-coded marks, or other effective marking methods, provided that the marking system is disclosed to the Department upon request. B. Initial kitchen tour observations on [DATE] At 8:40 a.m. the initial tour of the kitchen was conducted. The following items were found: -A case of cranberry juice was stored on the same shelf with bottles of two different kinds of cleaning solutions and bottles of bleach in the pantry. -A bucket of chocolate chips was dated to be used by [DATE] and had a lid that was only partially on the bucket, exposing the chocolate chips. -A bucket of red velvet cake mix was dated to be used by [DATE] and had a lid that was only partially on the bucket, exposing the cake mix. -A bucket of thickener powder was dated to be used by [DATE] and had a lid that was only partially on the bucket, exposing the thickener powder. -A refrigerator/freezer appliance in the refrigerated cold storage room had significant amounts of spilled grime on the seals and the doors. -Two reusable grocery bags were sitting on the floor by the refrigerator/freezer appliance. The bags contained lettuce, cheese, queso, mixed vegetables and smoked salmon. -The food items in the bags were not dated or labeled and the bag of lettuce, cheese and mixed vegetables had condensation present inside the bag. -A large white refrigerator contained a bucket of pickle slices that were dated to be used by [DATE]. -Six dozen eggs in the refrigerator were unlabeled. -The refrigerator labeled Fridge #2 had an internal thermometer that read 38 degrees Fahrenheit and the spare thermometer in the refrigerator read 42 degrees Fahrenheit. The refrigerator felt warm and contained dairy items. -A bucket of whipped margarine was dated to be used by [DATE]. -An opened box of cream of wheat was dated to be used by [DATE]. -An opened box of corn muffin mix was dated to be used by [DATE]. -An opened box of biscuit mix was dated to be used by [DATE]. C. Staff interviews Cook (CK) #1 was interviewed on [DATE] at 8:40 a.m. CK #1 said she had just put the six dozen eggs in the refrigerator and had not had time to date and label them when she put them in the refrigerator. -However, 13 eggs out of the six dozen eggs had been used and served to the residents. The dietary supervisor (DS) was interviewed on [DATE] at 11:12 a.m. The DS said the food needed to have a date labeled on each item to indicate when the items were received and when the items needed to be used by. She said the cooks were responsible for going through the leftover cooked meals and checking the dates. She said she was responsible for the rest of the food inventory. The DS said she was unaware there were chemicals in the pantry with food items. The DS said she did not know what use by date she needed to put on different food types because the list she used was outdated. The DS said she tried not to use buckets to store foods, however, she said she was aware they were in the pantries and that the lids did not always fit. II. Food temperatures A. Professional reference The Colorado Department of Public Health and Environment (2019) The Colorado Retail Food Establishment Rules and Regulations, retrieved on [DATE] from: https://drive.google.com/file/d/18-uo0wlxj9xvOoT6Ai4x6ZMYIiuu2v1G/view revealed in pertinent part, Except during preparation, cooking or cooling, food shall be maintained at 135 degrees Fahrenheit or above for ready-to-eat hot foods and 41 degrees Fahrenheit or below for ready-to-eat cold foods. B. Dinner observations on [DATE] At 4:35 p.m. CK #1 prepared dinner. CK #1 took the temperature of the meal before she plated it for the residents. -The temperature of the pureed peaches was 42 degrees Fahrenheit (F) and the temperature of the pureed cottage cheese was 41.8 degrees F. -Both food items were above the recommended safe serving temperature of 41 degrees for ready to eat cold foods. -Despite the peaches and cottage cheese having temperatures above the safe zone, CK #1 proceeded to serve the five residents peaches and cottage cheese. C. Staff interviews CK #1 was interviewed on [DATE] at 4:35 p.m. CK #1 said when she took the temperature of the peaches and the cottage cheese they both registered at 41 degrees F. She said the cold foods needed to be 41 degrees F or lower when she served them. -However, the thermometer had indicated the temperature of the peaches was 42 degrees F and the cottage cheese temperature was 41.8 degrees F (see observations above). The DS was interviewed on [DATE] at 11:12 a.m. The DS said the kitchen staff needed more education regarding safe food serving temperatures. The DS said cold foods needed to be 34 to 46 degrees F and hot foods needed to be anything above 65 degrees Fahrenheit. -However, cold foods needed to be served at temperatures below 41 degrees F or below and hot foods needed to be served at 135 degrees F or higher (see professional reference above). III. Hand hygiene in the kitchen A. Professional reference The Colorado Department of Public Health and Environment (2019) The Colorado Retail Food Establishment Rules and Regulations, retrieved on [DATE] from: https://drive.google.com/file/d/18-uo0wlxj9xvOoT6Ai4x6ZMYIiuu2v1G/view, revealed in pertinent part, Food employees shall clean their hands and exposed portions of their arms, including surrogate prosthetic devices for hands or arms for at least 20 seconds, using a cleaning compound in a handwashing sink. B. Dinner observations on [DATE] At 4:35 p.m., CK #1 prepared plates for the residents for dinner. At 4:44 p.m., CK #1 used hand sanitizer and grabbed plates for the residents' dinner. At 4:47 p.m., CK #1 prepared five residents' plates and used hand sanitizer. At 4:50 p.m CK #1 prepared two residents' plates and used hand sanitizer. At 4:54 p.m., CK #1 prepared two residents' plates and used hand sanitizer. At 4:56 p.m., CK #1 put a meal tray in the meal cart, closed the meal cart door and used hand sanitizer. At 4:57 p.m., CK #1 prepared four residents' plates and used hand sanitizer. At 4:58 p.m., CK #1 prepared one resident's plate and used hand sanitizer. At 4:59 p.m., CK #1 touched the meal cart and used hand sanitizer. At 5:02 p.m., CK #1 prepared one resident's plate and used hand sanitizer. At 5:06 p.m., CK #1 prepared three residents' plates and used hand sanitizer. At 5:10 p.m., CK #1 washed her hands with soap and water after she picked something up from the floor. At 5:15 p.m., CK #1 prepared five residents' plates and used hand sanitizer. At 5:16 p.m., CK #1 used hand sanitizer. At 5:20 p.m., CK #1 prepared seven residents' plates and used hand sanitizer. At 5:22 p.m., CK #1 used hand sanitizer after putting plate covers on two residents' plates. -During the dinner service observation, CK #1 performed hand hygiene with soap and water instead of hand sanitizer only one time between 4:35 p.m. and 5:22 p.m. C. Lunch observations on [DATE] The DS assisted CK #1 with preparing a chocolate cake with frosting for residents on a mechanical soft diet. At 11:47 a.m., the DS cut up a piece of cake and stirred the frosting throughout the chunks of cake. -The DS licked her fingers and prepared another piece of cake for another resident. At 12:05 p.m., the DS cut up a couple more pieces of cake and stirred the frosting throughout the chunks of cake. -The DS licked her fingers again and prepared more cake for the residents. D. Staff interviews CK #1 was interviewed on [DATE] at 4:35 p.m. CK #1 said the facility installed hand sanitizer dispensers in the kitchen and she was unaware soap and water needed to be used instead of hand sanitizer in the kitchen. The DS was interviewed on [DATE] at 11:12 a.m. The DS said she was unaware the kitchen staff could not use hand sanitizer in the kitchen. She said the facility installed the hand sanitizer dispensers and was confused as to why the facility would do that if staff needed to use soap and water instead of hand sanitizer for hand hygiene in the kitchen.

Based on record review and interviews, the facility failed to employ dietary staff with the appropriate competencies and skill sets to carry out the functions of the food and nutrition service for 38 census residents. Specifically, the facility failed to: -Provide dietary competencies and skill tests to ensure staff could carry out the functions of the food and nutrition service according to professional standards of practice; and -Ensure the dietary supervisor was trained and certified as a dietary manager. Cross-reference F803 for dietary menus to meet residents' needs. Cross-reference F804 for food palatability and proper temperature. Cross-reference F805 for food prepared in a form to meet residents' needs. Cross-reference F806 for food prepared to accommodate residents' allergies. Cross-reference F812 for failure to prepare and serve food in a sanitary manner. Findings include: I. Record review -The dietary supervisor (DS) was unable to provide documentation that indicated she was a certified dietary manager. -The dietary supervisor (DS) was unable to provide copies of training and competencies completed for the dietary staff, including herself. II. Staff interviews Cook (CK) #1 was interviewed on 2/28/24 at 4:35 p.m. CK #1 said she served smaller portions to certain residents because some residents did not eat as much and she wanted to limit food waste. She said the residents who were on a pureed diet got fruit and cottage cheese instead of the main meal because the foods were easier to blend. CK #1 said she was unaware foods served on a mechanical soft diet needed to be either one-inch by one-inch pieces or half-inch by half-inch sized pieces. She said she was educated that mechanical soft foods only needed to be soft. She said she had not completed additional training but had been a cook at long-term care facilities for over [AGE] years. CK #1 said she substituted items on the menu if they were not thawed in time or if the items were not in the kitchen. She said she omitted vegetables at dinner every day because the residents did not like vegetables with dinner. CK #1 said she did not replace the omitted items with food of similar nutritional value or calories. The DS was interviewed on 2/29/24 at 11:12 a.m. The DS said the dietary staff, including herself, completed annual training. She said when new dietary staff were hired she relied on a cook to train the new cooks and a dietary aide to train the new dietary aides. The DS said the dietary staff needed more training, especially for texturizing food for residents on altered diets. The DS said she was previously a cook for [AGE] years in long-term care facilities and had been at the current facility for two years as the dietary supervisor. The DS said she had completed school and was expected to take her test on 3/5/24 to become a certified dietary manager. The DS said she was unaware of bread alterations required for mechanical soft textured diets. The DS said she did not know hand sanitizer was not allowed to be used in the kitchen and that staff needed to wash their hands with soap and water only while they were in the kitchen. The DS said the menus used at the facility were confusing and the cooks needed to follow what was on the menu for meals. The DS said she believed cold foods were to be held at a temperature of 34 to 46 degrees Fahrenheit (F) and hot foods needed to be held at a temperature over 65 degrees F. She said she tried to complete food temperature training every year. The DS said she provided menus to the kitchen staff with the dates blacked out and had mixed up the menus for February 2024. The DS said she was informed CK #1 did not serve vegetables at dinner time but was unaware it happened every night. She said she thought the cook omitted items occasionally. The DS said she was unaware the cook served half or small portions of food servings to the residents without a physician's order. She said if the resident wasted the food it was their right and CK #1 needed to serve the portions according to the menu and recipes. The DS said the kitchen staff needed more training and guidance. She said she did not observe meals as much as she needed to because she was tied up in meetings every day. She said she felt the kitchen had enough staff but lacked adequate education. The DS said she called her registered dietitian (RD) if she had questions or needed help, however, she said she needed more support. The nursing home administrator (NHA) was interviewed on 2/29/24 at 9:02 p.m. The NHA said the facility was in the process of switching from the National Dysphagia Diet to the International Dysphagia Diet Standardization Initiative. She said all residents who were on a mechanical soft diet were on a level three mechanical soft diet. She said the DS was in charge of the kitchen and all dietary staff. -The facility failed to provide any follow-up documentation that included training completed by the dietary staff and the DS by the end of the survey on 3/1/24.

Based on observations, record review and interviews, the facility failed to provide adequate supervision and assistance to prevent accidents for two (#186 and #13) of five residents reviewed out of 19 sample residents. Specifically, Resident #186 had three falls within one week of her admission. However, the facility failed to assess and implement safe and effective approaches to prevent falls other than seatbelts and alarms, creating further accident potential when a gait belt was applied to tie her to her chair for two days. (Cross-reference F604, Restraints.) Resident #13, who frequently rejected care, suffered two skin tears during a shower after she became combative with staff. Findings include: I. Facility policy The Fall Management policy, dated June 2022, provided via email by the nursing home administrator (NHA) on 11/7/22 at 6:09 p.m., revealed in pertinent part: The center assists each resident in attaining/maintaining his or her 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 risk. A care plan is developed and implemented, based on this evaluation, with ongoing review. Newly admitted residents will be considered at risk for falls until they are reviewed by the IDT. Upon admission, the admitting nurse will complete the Fall Risk User Defined Assessment, the nursing initial plan of care, address risk factors related to the resident in the plan of care and implement appropriate interventions as identified. II. Resident #186 A. Resident status Resident #186, age 77, was admitted on [DATE]. Admission records revealed Resident #186 had severe cognitive impairment and diagnoses included Alzheimer's disease, unspecified atrial fibrillation (irregular heart rate), essential primary hypertension and depression. The minimum data set (MDS) assessment had not been completed as of survey date due to resident's new admission to the facility. B. Record review Resident #186's progress notes revealed that she fell on [DATE] at 12:07 a.m. and at 8:23 p.m., respectively, and on 10/28/22 at 6:00 p.m. A nursing note on 10/24/22 at 8:23 p.m. documented that the nurse received approval to place a tab alarm on the wheelchair and a pressure alarm in the bed for resident safety. -No documentation was found to show from whom the nurse received approval for the alarms. The facility's fall investigations were provided by the staff development coordinator (SDC) on 11/2/22 in the afternoon. The facility performed a fall investigation on 10/24/22 at 8:30 p.m. and 10/28/22 at 3:56 p.m. -No fall investigation documentation was found for the fall that occurred on 10/24/22 at 12:07 a.m. -According to documentation from the fall investigation on 10/28/22, it was performed at 3:56 p.m., for the fall that occurred on 10/28/22 at 6:00 p.m., more than two hours later. It was unclear if the documented time of the resident's fall was accurate. The fall risk assessment, post fall, for the fall on 10/24/22 at 12:07 a.m. revealed a history of falls, three or more falls in the past three months. Also, the resident had balance problems with standing/walking, decreased muscular strength and required the use of an assistive device. -No fall risk assessment, post fall, documentation for the falls on 10/24/22 at 8:23 p.m. and 10/28/22 at 6:00 p.m. were found in the resident's medical records. Resident #186's care plan, initiated on 10/24/22, identified fall risk and revealed: -After the resident's fall on 10/24/22, a goal was added to the care plan that the resident would not experience adverse effects from falls, which included an intervention of identifying contributing factors if possible. -No interventions were noted under fall prevention measures. -No specific interventions were included regarding attempts to decrease injuries from falls. C. Observations On 11/1/22 at 1:58 p.m., Resident #186 was in the activity room, with bruises on her right hand and the right side of her forehead. A seat belt restraint was attached to her wheelchair. Resident #186 was in the activity room on 11/1/22 at 4:07 p.m. She was sitting in her wheelchair with the seat belt restraint in place. She was awake and not talking. Resident #186 was in the television (TV) room on 11/2/22 at 9:56 a.m., sitting in her wheelchair with the seat belt restraint in place. She appeared drowsy, and was not participating in any activity. D. Interviews Licensed practical nurse (LPN) #1 was interviewed on 11/3/22 at 10:47 a.m. He stated that if a fall prevention plan was implemented that he would anticipate interventions such as keeping the resident in line of sight and providing proper toileting and positioning. He also stated that the resident would not need restraints if the facility had more staff. He stated that they had been without rehabilitative therapy services for a couple of months. The nursing home administrator (NHA) and the staff development coordinator (SDC) were interviewed on 11/2/22 at 4:29 p.m. The NHA stated that after a resident falls, the facility performs a fall investigation. And, that the fall investigation is reviewed by the interdisciplinary team (IDT) the following morning. The NHA stated the resident fell twice, then the facility placed a tab alarm and bed alarm, and before the two alarms were placed the only less restrictive measures taken were monitoring the resident. The NHA was interviewed on 11/3/22 at 2:59 p.m. She stated that the facility did not have rehabilitative therapy services available to conduct a fall or restraint evaluation of the resident. The NHA and the director of nurses (DON) were interviewed on 11/3/22 at 4:40 p.m. The NHA stated that the rehabilitation therapy staff screened the residents for falls. The NHA stated that the occupational therapist was at the facility the previous week to perform an evaluation, but the resident refused. She reported that the occupational therapist was going to try again next week with his visit. The NHA stated that walking would be a goal for the resident. And the resident should have activities that she likes with input from the resident's husband. The NHA stated that the resident should have been in a high/low bed and a fall mat implemented next to the bed. The DON stated that the resident was in a high/low bed. -None of the above interventions were found in the care plan. -No occupational therapy documentation was found regarding resident's refusal of therapy. -No IDT notes regarding falls were found in the resident's medical record. 12905 III. Resident #13 A. Resident status Resident #13, age 88, was admitted on [DATE]. According to the November 2022 computerized physician orders (CPO), diagnoses included dementia with behavioral disturbance. The 9/15/22 MDS assessment documented she was unable to complete the BIMS, had short-term and long-term memory problems and was moderately impaired for decision making. She had delirium symptoms of inattention and disorganized thinking. She had problems sleeping, was tired with little energy, had trouble concentrating, and was short tempered and easily annoyed. Resident #13 exhibited behavioral symptoms not directed toward others, such as hitting or scratching herself, pacing, rummaging, and making disruptive sounds. Rejection of care was not exhibited. Wandering occurred daily but there was no documentation if it placed her at risk or intruded on others' privacy. She needed supervision/oversight/setup for transfers and walking, limited assistance with dressing, and extensive assistance with toilet use and personal hygiene. She needed physical assistance with part of her bathing activity. B. Record review The care plan, initiated on 6/9/21 and not revised with additional approaches, identified she needed assistance with activities of daily living (ADLs) including bathing, and was resistive to cares. Pertinent interventions included providing praise for successes with self-care, and task segmentation to assist with completion of ADLs. -There were no specific approaches regarding how to assist the resident with bathing to ensure she was comfortable and safe. Her preferences for baths or showers, time of day, and how many times per week, were not documented in her care plan. It was also not documented that she became combative at times during showers, what triggered that response, and how staff should respond if it occurred. A nurse's note on 10/29/22 at 2:05 p.m. documented, Resident became combative during shower, sustaining ST (skin tear) to L (left) hand and RUE (right upper extremity). STs irrigated with wound cleanser, skin approximated, steri-strips applied, clear site dsg (dressing) to protect. DON (director of nursing) and POA (power of attorney) notified. -There were no follow-up nursing notes regarding follow-up monitoring and measurements of the skin tears or the resident's condition after she was injured in the shower. Her care plan was not updated after this incident with injury. The incident report dated 10/29/22 at 8:49 a.m. documented in part, Resident became combative during shower and sustained ST to L hand 4cm x 1cm and to RUE 5cm x 2cm. CNAs trying to shower resident, she was okay until they turned on the water, (resident) then started trying to bite (CNA #3 initials), the CNA tried to defend from being bit and hit, and during the time to calm down she sustained injuries. The resident's mental status was described as alert, oriented to person, combative, confused. A written statement by CNA #4 accompanied the incident report, dated 10/29 with no date, an illegible signature, signed below by the NHA with no date or time. The statement documented that Resident #13 was getting in the bath house when (CNA #3) turned on the shower water, she became combative trying to bite (CNA #3) when we went to make sure the sprinkles weren't hitting her feet any more she went to bite again so (CNA #3) grabbed her one side while I tried the other side so she wouldn't hurt herself and the bottom of (CNA #3's) hand tore her skin. We then got the nurse (who) patched her up. She was mad at (CNA #3) so she left the room while me & (LPN #1) finished her up. -Although it was documented that the CNAs grabbed the resident from both sides, there was no written statement or evidence of an interview with CNA #4 (cross-reference F610, failure to investigate potential abuse), or follow-up staff training. C. Staff interviews CNA #4 was interviewed on 11/2/22 at 11:58 a.m. about the 10/29/22 incident. She said she was the shower aide and worked regularly with Resident #13. She said CNA #3 took Resident #13 into the bath house and put on the call light so she went in and Resident #13 was starting to get combative. They figured it was because a little cold water was splattering on her feet which made her combative and she started hitting and biting at both CNAs. CNA #3 went to block it with her hand and the bottom of her palm got Resident #13's hand. Resident #13 got a skin tear and CNA #4 left to get the nurse. The resident was really mad at CNA #4 so they got her out of there and once we got her out we calmed (Resident #13) down. CNA #4 said Resident #13 was combative with staff at least once a day probably but a lot of times we can re-route her. She said they did not receive follow-up training after the shower incident on 10/29/22, but they were currently in CPI (crisis prevention) training which helps you block them without hurting them or yourself. She said Resident #13 would sometimes be great with her showers, depending on her mood, but on other days she would become combative halfway through her shower. She did not like baths. Sometimes if you give her full control she will bathe herself independently. CNA #1 was interviewed on 11/3/22 at 9:52 a.m. She said she regularly provided care for Resident #13. She said she was aware of the skin tear Resident #13 received over the weekend during a shower. She said it was looking better, was about two inches in diameter, and Resident #13 had not complained about pain or discomfort. CNA #1 said Resident #13 had gotten combative during showers with CNA #4. She said, Letting her do her own thing sometimes works with her. If she's combative I step away for a minute, take a breather, ask her if she's okay and try to talk her down from it. It sometimes works and sometimes I get hit. She said she had not been hurt by Resident #13. She could get combative right in the middle of the shower and she was not sure what triggered it. When she's done we get her out of there. I get her dressed quickly and get her out of the shower room after telling her that's the plan. She said Resident #13 should be a two-person assist in the shower. She said she had never held onto her. I've asked her if she'd hold my hands and she's done that, but when she held my hands I let her hold my hands (instead of taking her hands against her will). Some days she absolutely doesn't want her hair done. Licensed practical nurse (LPN) #1 was interviewed on 11/3/22 at 10:47 a.m. He said he was called into the shower room on 10/29/22 to treat Resident #13's skin tears. She had a skin tear to the top of her hand and upper arm by the time he got there. He had no idea what had happened before or what initiated the fight. He said he had never seen a problem with CNA #3, that she was amazing with the residents, and had sent CNA #4 out to get him. Once he realized Resident #13 was adamant about CNA #3 not touching her, he sent her out. He said generally Resident #13 did not need two-person assistance with showers, it depended on the day, and he had never had a big issue with her. He said he guessed that early in her life Resident #13 was sarcastic which now came across to some people as aggressive. She tends to become resistive. LPN #1 described the injuries to Resident #13 as two skin tears. The back of her left hand was approximately 4cm long x 1-1/2cm wide, a crescent moon shape. Her upper arm skin tear was approximately 5cm x 1-1/2cm. He said his guess would be she hit the bath chair but he had no way of saying for sure. He said for preventing recurrence, it could depend on making sure her shower was given at the right time of day; she may not have had breakfast before her shower. He said he had not known her to be injured or super aggressive in the shower at any other time. The social services director (SSD) was interviewed on 11/3/22 at 11:40 a.m. She said mornings were preferable to Resident #13 for showers. She can get combative in the shower. She said she had not personally done any staff training related to that. The NHA was interviewed on 11/3/22 at 5:05 p.m. The director of nursing (DON) was not in the facility during the first three days of the survey. The NHA said that until recently Resident #13 did not want a bath and they had been trying to coax her and had not had any issues. She said to her knowledge what happened on 10/29/22, after talking with CNAs #3 and #4, was that Resident #13 was fine when they were starting her shower. When CNA #3 turned on the water Resident #13 was naked, got startled, she was not sure if the water was cold, the resident backed up, started punching, hitting, scratching, hit her hand on the tile and got the skin tears. The NHA said she discussed with CNAs #3 and #4 about using warm blankets or towels after undressing her, ensuring the water was nice and warm when they took the resident into the shower, and it was okay for them to leave a towel on her when she was showering. We talked about that, the girls were good about it. And she didn't want her hair wet; that was another thing. Sometimes she'll have a shower and won't wash her hair. The NHA said she had trained staff not to put up their hands and not to say calm down. She said she talked to both CNAs on the phone after the incident and asked them to tell her what happened. It was over the weekend and on the phone. She said she interviewed both CNAs but did not interview any other residents about their experiences in the bath house (cross-reference F610). The facility failed to ensure Resident #13 was safe and free from accidents during showers. Person-centered approaches that staff had learned from caring for Resident #13 were not added to the care plan or to all-nursing-staff training.

Based on observations, record review and staff interviews, the facility failed to ensure one (#1) of two residents reviewed for nutrition/hydration maintained acceptable parameters of nutritional status to avoid unintended weight loss out of 19 sample residents. Specifically, the facility failed to prevent significant weight loss and implement physician's orders related to Resident #1's weight decline. Resident #1 was identified to have a potential nutritional deficit and had actual significant weight loss. New interventions were not put in place after the identified weight loss and current interventions were not offered as ordered to help prevent the potential additional weight loss. Resident #1 had a diagnosis of dementia and relied on staff to meet her nutritional needs. Resident #1 lost more than 14% of her weight in six months. Between May 2022 and June 2022, the resident lost 19 pounds, a significant weight loss in one month. The facility chose not to implement new interventions after the resident lost 19 pounds according to a July 2022 nutritional at risk note. Resident #1's 10/22/22 most recent weight of 105 pounds revealed she was unable to gain the weight back. Resident #1's physician orders, October 2022 dietary assessment and nutrition care plan identified she should have received fortified foods three times a day for weight decline; however the resident was not receiving the fortification of her food. Review of additional diet supplementation identified Resident #1 was scheduled to receive Ensure twice a day, however the supplement was scheduled when the resident was often sleeping and would frequently not receive it. Findings include: I. Professional reference The World Health Organization (WHO) at https://www.who.int/health-topics/food-fortification#tab=tab_1, retrieved on 11/13/22, documented in pertinent part: Fortification is the practice of deliberately increasing the content of one or more micronutrients in a food or condiment to improve the nutritional quality of the food supply. II. Facility policy and procedure The Nutrition and Hydration policy, undated, was provided by the staff development coordinator (SDC) on 11/3/22 at 4:22 p.m. The policy read in pertinent part: The nutrition and hydration status of each resident is maintained as close to optimal level as possible. According to the policy, a physician order is obtained for all regular and therapeutic diets, including those with modified textures. A diet communication is sent to the Food and Nutrition services department for all orders written by the physician. III. Resident Status Resident #1, age 92, was admitted on [DATE]. According to the November 2022 computerized physician orders (CPO), diagnoses included dementia without behavioral disturbances, generalized osteoarthritis and chronic pain. The 7/28/22 minimum data set (MDS) assessment revealed the resident had short term and long term memory problems. The MDS indicated the resident was severely impaired in decision making regarding tasks of daily life. According to the MDS assessment, Resident #1 exhibited inattention and disorganized thinking. The MDS identified Resident #1 required extensive to total assistance for activities of daily (ADLs), including with eating. IV. Record view A. Significant weight loss within six months. The 2/19/22 dietary assessment read Resident #1's admission weight was 190 pounds (4/30/14). The dietary assessment identified her weight as of time assessed (2/19/22) was 141.9 pounds (lbs) and her usual body weight was between 140 lbs and 145 lbs. According to the February 2022 dietary assessment, the resident's nutritional goal was to maintain her weight without a significant change. The assessment identified intervention was to continue with the current plan of care and routine monitoring and offer Ensure twice a day (BID) between meals. The weight record identified the resident had a weight loss between 4/13/22 and 10/22/22 (most recent weight). The weight record identified the resident weighed 123 lbs on 4/10/22 and was down to 105 lbs on 10/22/22, a significant weight loss in six months at 14.63%. The weight record identified the resident had a significant loss of 19 lbs in one month between May 2022 and June 2022. The record identified on 5/18/22 the resident weighed 123 lbs, and on 6/22/22 the resident weighed 104 lbs. The 5/8/22 dietary assessment did not identify weight loss concerns. The 5/12/22 late entry interdisciplinary (IDT) nutrition at risk note documented there were no nutritional or skin concerns at this time, as Resident #1 weighed 123 lbs. on 4/13/22 and maintained her 123 lb weight on 5/18/22. Between 5/12/22 and 7/13/22, the resident's progress notes did not identify nutritional weight concerns. However, according to the resident's weight record, Resident #1 was down to 104 lbs on 6/22/22 (see above.) The 7/14/22 IDT nutrition at risk note read Resident #1 was reviewed for recent weight loss. The note identified the resident weighed 104 lbs on 7/13/22, with a weight loss of 19 lbs in 3 months. According to the nutrition at risk note, there were no new recommendations. The note read the resident had a rollercoaster weight fluctuation in her history every four to six months of increases and decreases. The note read the resident previously had weight gain approximately three months ago (April 2022) although was still below her weight from 6 months ago (January 2022.) The note indicated meal intakes were stable and the resident appeared comfortable. The resident would continue supplements as ordered and monitor for additional needs. -The nutrition at risk note identified no new interventions were added even though the resident lost 19 lbs in a month between 5/18/22 and 6/22/22 and did not gain any weight back by the time IDT reviewed the weight loss concern on 7/14/22, almost a month after the onset of the identified 19 lb weight loss. The 10/19/22 dietary assessment read Resident #1 was dependent on staff for all food and fluids. According to the 10/19/22 dietary assessment, Resident #1 had a significant weight loss of 12.5% in 180 days. The assessment indicated the resident had a body mass index (BMI) of 19.2% which was low for the age group. The 10/27/22 interdisciplinary (IDT) nutrition at risk note read: -The resident weighed 120 lbs on 4/20/22; -The resident weight on 7/23/22 was 105 lbs; -The resident weight on 9/25/22 was 106.1 lbs (loss of 1.1 lbs in a month); and, -The resident weight on 10/22/22 was 105 pounds (lbs). According to the nutrition at risk note, the resident was stable for the past 30 days and had a loss of 15 lbs in six months. According to the assessment the resident received Ensure BID and there were no acute concerns identified during the quarterly review. B. High calorie, high protein interventions The 12/4/17 CPO for Resident #1 identified the resident had dietary orders for a pureed texture, and fortified foods at every meal. According to the CPO, the resident required fortified foods related to weight decline. The nutrition care plan, revised 3/24/22, read Resident #1 had a potential nutritional/hydration deficit related to dementia and dysphagia. The care plan directed staff to provide Resident #1: -Fortified foods at every meal; -Ensure Plus 237 milliliters (ml), twice a day (BID) for increased caloric intake; and, -Provide, serve diet as ordered. According the care plan, the registered dietitian (RD) was to evaluate and make diet change recommendations as needed, and the dietary supervisor was to reinforce the importance of maintaining Resident #1's diet as ordered. The 10/19/22 dietary assessment identified interventions included Ensure twice a day (BID), fortified meals in place and continue with the current plan of care through the next review. The October 2022 and November 2022 medication administration records (MAR) read, Ensure two times a day for increased calorie intake. Give 1 carton two times a day. The October 2022 and November 2022 medication administration record (MAR) identified Resident #1 did not receive the Ensure supplement 29 out of 67 ordered attempts to provide Ensure between 10/1/22 and the morning on 11/3/22. The review of the MAR indicated the resident did not receive the Ensure almost half of the time it was scheduled. A supplement list, undated, was provided by the dietary manager (DM) on 11/3/22 at 1:44 p.m. The list read seven residents received additional supplementation to their diets. The seven residents listed received items such as protein powder, ice cream, magic cup (high calorie and protein dessert), Ensure or Boost supplements. Resident #1 was not identified on the supplement list. V. Observations Preparation and service of the noon meal was observed on 11/2/22 at 11:06 a.m. to 12:10 p.m. During the preparation and service of the meal, protein powder was not identified to be added to the meal. The cook said none of the items had additional fortified protein powder added to the meal including the pureed meal. The cook said Resident #1 was the only resident on a pureed meal. On 11/3/22 at 10:05 a.m. the dietary card and preparation process for Resident #1's pureed diet was observed. The observation of the preparation and plating of Resident #1's pureed meal did not reveal the resident's pureed meal had additional fortification added to the meal; such as a protein powder. VI. Staff interviews The dietary manager (DM) was interviewed on 11/2/22 at 3:02 p.m. The DM reviewed her list of residents on fortified diets. Resident #1 was not identified on the list of residents who received fortified meals. The DM said residents who had fortified diets received protein powder in the meal. The cook was interviewed on 11/3/22 at 1:10 p.m. The cook said she did not add protein powder to any resident meals. The cook said the dietary aide (DA) added the protein powder to residents' drinks if the resident was ordered to be on a fortified diet. The DA was interviewed on 11/3/22 1:11 p.m. The DA said she followed a posted list identified as a supplemental list. The DA reviewed the list which identified residents who received a certain types of calorie/nutrition enhancing food and beverages, including protein powder. Resident #1 was not identified on the list. The DM was interviewed again on 11/3/22 at 1:15 p.m. The DM said the registered dietitian was at the facility one to two times a month. The RD informs the DM on how to assist residents with weight loss. The DM said she also participated in the nutrition at risk committee meetings. The DM said there were only a couple of residents reviewed by the committee for potential weight concerns. The DM did not identify Resident #1. The DM said Resident #1's weight or weight interventions had not been identified as a concern or change. The DM said Resident #1 was not identified as needing or receiving fortified meals. The DM said the RD completed the dietary assessment. The DM reviewed both Resident #1's care plan and 10/19/22 dietary assessment then confirmed both the assessment and the care plan listed Resident #1 should have fortified meals. The DM said the diet type list she received and was directed to follow did identity Resident #1 should have received fortified food. The DM said she would request the RD to inform her when there were changes to the resident's diets. The DM confirmed fortified foods were identified on Resident #1's care plan since 3/24/22 as an intervention to weight loss. Licensed practical nurse (LPN) #1 was interviewed at approximately 1:30 p.m. LPN #1 said Resident #1 had an order for Ensure twice a day but was often sleeping or very tired and would not accept the supplement, so the resident often did not receive the supplement twice a day as ordered. The RD was interviewed on 11/3/22 at 1:59 p.m. The RD said Resident #1 was reviewed in the nutrition risk meeting because she triggered a significant weight loss in a six month comparison. The RD confirmed Resident #1 lost a significant amount of weight between May 2022 and June 2022. The RD said there were no new interventions or changes in interventions because the resident had a pattern of fluctuating weight gains and losses. The RD said Resident #1's past weight loss and current interventions were reviewed without change. The RD said she did not know when fortified foods were initiated. She said the nursing home administrator (NHA) was the one who ordered it. The RD said she included the intervention of fortified foods on her 10/19/22 dietary assessment because it was on the CPO. The RD said the DM might have been the one to take her off fortified foods. The RD reviewed the interdisciplinary notes and could not identify when the resident was placed on fortified foods and when or if she was taken off fortified foods. The RD said she thought the resident was receiving the fortified foods, as ordered. The RD said the resident was receiving Ensure as a high calorie supplement as a weight loss intervention. The RD was informed of the interview with LPN #1 (see above). The RD said she was not informed the resident was not regularly receiving Ensure because the resident was frequently sleeping when it was scheduled. The RD said Resident #1 had been stable but acknowledged she had an ongoing pattern of weight loss over the last year and since admission. The RD said additional weight loss would be concerning and that was why nutritional interventions were added. The NHA was interviewed on 11/3/22 at 6:38 p.m., with the director of nursing (DON). The NHA said interventions such as fortified foods and supplements were in place to maintain Resident #1's weight and help prevent additional weight loss. The DON said they needed to improve how they provided information to the DM so she knew when residents had dietary orders. The DON said she was not aware Resident #1 was not receiving fortified foods and/or supplements. The DON said she would educate nursing staff to inform management when a resident did not routinely take their supplements. The NHA acknowledged Resident #1 was not always receiving her Ensure supplement because the resident was sleeping and would change the schedule of when the supplement was provided to improve the probability that Resident #1 would consume the supplement.

Based on record review and interviews, the facility failed to create an environment that protected 10 (#2, #4, #5, #8, #9, #10, #11, #12, #13 and #19) of 10 out of 23 sample residents from mental, physical and potential sexual abuse, contributing to residents experiencing repeated incidents of resident to resident abuse, three with injury (#2, #10 and #12), and two residents fearful of violence (#9 and #19). Other facility residents experienced repeated incidents of verbal abuse by Resident #8. Abusive incidents in April 2022 were followed by additional abusive incidents in May 2022, subjecting residents to physical abuse, mental abuse, verbal abuse and potential sexual abuse; and in June 2022, subjecting residents to physical abuse. Record review and interviews revealed systemic failures in the facility's response to the incidents of resident to resident abuse. Investigation of abusive incidents failed to trigger re-evaluation of interventions to keep residents safe, failed to trigger the development of resident-centered care plans to address known behaviors, and failed to trigger review of the facility's process in communicating abusive behaviors to management to ensure they were acted upon. Finally, there was no evidence that the repeat incidents of resident to resident abuse were reviewed in the facility's quality assurance and performance improvement (QAPI) program to ensure that abusive incidents would be reviewed and analyzed and changes implemented to prevent future incidents of abuse. The facility's failures created a situation of immediate jeopardy for serious harm at a pattern. Failure to protect residents from abuse was cited previously during a recertification survey on 7/29/21. Although the facility corrected the deficiency, based on the findings below, the facility has not maintained compliance with this regulatory requirement. Cross-reference F740 failure to provide behavioral/mental health services, and F744 failure to provide dementia care services resulting in psychosocial harm. Findings include: I. Immediate jeopardy A. Findings of immediate jeopardy Record review and interviews revealed the facility failed to create an environment that protected 10 residents (#2, #4, #5, #8, #9, #10, #11, #12, #13 and #19) from ongoing resident to resident mental, physical and potential sexual abuse. These repeated incidents of abuse have resulted in physical injuries, and feelings of fear and distrust that staff can keep residents safe from abuse, particularly abuse by Resident #8. Record review and interviews revealed systemic failures in the facility's response to incidents of resident to resident abuse. Facility investigations of abusive incidents failed to trigger re-evaluation of interventions to keep residents safe, failed to trigger the development of resident-centered care plans to address known behaviors, and failed to trigger review of the facility's process in communicating abusive behaviors to management to ensure they were acted upon. There was no evidence that the repeat incidents and potential incidents of resident to resident abuse were reviewed in the facility's quality assurance and performance improvement (QAPI) program to ensure the incidents would be reviewed and analyzed and changes implemented to prevent future abuse that is likely to result in serious outcomes. A second onsite visit was initiated on 6/14/22 at 10:37 a.m. The nursing home administrator (NHA) said there was an additional abusive incident where Resident #8 hit Resident #19 over the head Saturday night, 6/11/22. No injuries were identified; however, the investigation was not yet completed. Resident #8 was in the TV room and under line of sight supervision because he was out of his room. Staff had looked away, then heard commotion. Resident #19 was interviewed on 6/14/22 at 11:19 a.m., and said, over the weekend, Resident #8 hit her on the side of the head near her eye, causing more than transient pain and numbness. She said Resident #8 tried to hit her again but was stopped by staff. She said she was fearful of Resident #8 and was afraid she would not hear him if he tried to come into her room at night and now has an alarm on her room door. She did not believe there were enough staff to respond quickly to keep residents safe. She said Resident #8 continues to do these things because he can, and the staff cannot do anything. She said other residents' quality of life and mental health is affected by Resident #8's behavior. Abusive incidents in April 2022 were followed by additional incidents in May 2022 and June 2022, subjecting residents to continued physical abuse, mental abuse, verbal abuse and possible sexual abuse. This prolonged and unmitigated exposure to abuse for several months has caused the residents to feel fearful, anxious, and unsafe. Residents repeatedly stated that residents with aggressive behaviors negatively affect their well-being and quality of life, and make them feel afraid of physical retaliation. Facility interventions have failed to protect residents from abuse, particularly abuse from Resident #8, creating a situation of immediate jeopardy for serious harm if corrective action was not taken. On 6/14/22 at 3:00 p.m., the NHA was notified due to the facility's failure to protect other residents from Resident #8 created a situation of immediate jeopardy. B. Interim plan to ensure resident safety On 6/14/22 at 3:00 p.m. the NHA implemented an interim plan to ensure the safety of all residents until a formal, final plan could be submitted on 6/15/22. Resident #8 was in the hospital as of the morning of 6/14/22 and would not be returning to the facility. C. Facility plan to remove immediate jeopardy On 6/15/22 at 3:15 p.m., the facility submitted its final plan to remove immediate jeopardy. The plan read: 1. Resident #8 no longer resides in the facility and return is not anticipated. The immediate danger associated with resident #8 is removed with his/her discharge. Facility IDT (interdisciplinary team) will review the care plans of other residents with behaviors to ensure approaches are appropriate/effective in order to prevent future incidents of abuse between residents who are not (Resident #8) by 6/15/22. 2. Residents #2, #4, #5, #9, #10, #11, #12 and #13 were assessed to ensure they did not have any ongoing fear, anxiety or concerns associated with resident #8 or other residents that had not been addressed. There were no further concerns, fears or anxiety identified or voiced since resident #8 has been discharged . The social services director will assess the identified residents except for resident #8 each day for the next 3 days for any signs or symptoms of fear, anxiety or any behavior changes and will be documented in the residents' medical record. Residents #2, #4, #5, #9, #10, #11, #12 and #13 have not been involved in any other incidents since 6/2/22. 3. Management staff immediately began and completed interviewing the interviewable residents on 6/14/22 regarding whether they felt safe in the facility and/or had any concerns related to abuse, any new concerns will be addressed immediately. Families/responsible parties of non-interviewable residents were also called and interviewed to identify if they had any concerns with abuse or neglect, and no concerns were identified. This was completed by 6:30 p.m. 4. The residents were notified that resident #8 is no longer in the facility and will not be coming back to relieve their fears and anxiety related to him/her. Emotional support was provided as needed. Ongoing support will be provided as needed by the social services director and/or designee, as well as facility contracted licensed professional counselor. Facility will start a resident support group on 6/22/22 with the contracted licensed professional counselor. Facility will identify vulnerable and at risk residents with a history of traumatic life events and invite them to participate in the resident support group. 5. Staff members currently working have been educated on all aspects of abuse and neglect by the SDC (staff development coordinator) and BOM/CNA (business office manager/certified nurse aide). The SDC and BOM/CNA were educated by the DON (director of nursing) and NHA (nursing home administrator) after they received education from the corporate chief nursing officer. They were educated on types of abuse; who the facility's abuse and neglect coordinator is, when to report, who to report to, how to report, and to report any and all evidence of and potential evidence of abuse immediately. All staff that are not currently working will be educated prior to beginning their next shift at the facility. Staff in all departments' education will be completed by 6/15/22 or prior to their next shift. This education will be conducted by the NHA, DON, and/or management designee. 6. NHA and DON received verbal education on abuse reporting, abuse identification, abuse prevention, abuse policy and procedure by corporate chief nursing officer on 6/14/22 at 4:00 p.m. This education in addition to all education regarding abuse and neglect included direction to the facility to notify the corporate clinical resource team immediately upon any abuse and neglect type event involving resident or staff. This will allow for further review of each event, validate a thorough investigation and an evaluation of interventions and potential new interventions for any repeat event and any additional oversight needed. 7. Cell phone numbers for the NHA, DON, and the SSD are provided with the educational materials, so they have the contacts handy at all times. Contact information will be posted throughout the facility for staff, residents, families, and visitors. Contact information will also be handed out directly to the residents in the facility. 8. The facility will assess and evaluate all potential new admissions for aggressive and abusive behaviors, and will not be admitting high risk residents. D. Removal of immediate jeopardy On 6/15/22 at 3:25 p.m., the NHA and DON were notified that the facility's plan to remove immediate jeopardy was accepted based on the facility's plan to implement the measures above. However, deficient practice remained at H scope, a pattern of actual harm. II. Facility policy and procedures The Abuse Prevention Program policy and procedure, dated December 2016, was provided by the nursing home administrator (NHA) on 6/6/22 at 3:53 p.m. In part: It documented the facility's residents had the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This included, but was not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse. It documented that, as part of the resident abuse prevention, administration would protect all residents from abuse by anyone, including facility staff and other residents. It documented the facility would implement measures to address factors that may lead to abusive situations. It documented the facility should establish and implement a QAPI review and analysis of abuse incidents and implement changes to prevent future occurrences of abuse. It documented the facility should involve the resident council in monitoring and evaluating the facility's abuse prevention program. It documented employees must ensure that all instances of abuse or suspected abuse are reported immediately to the administrator in accordance with state law. II. Failure to protect Resident #9 and #4 from verbal, mental and potential sexual abuse by Resident #8 A. Resident #8 and #9 - mental and potential sexual abuse Resident #8, age 68, was admitted on [DATE] and readmitted on [DATE]. According to the June 2022 computerized physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . This resident did not have a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The 5/12/22 MDS assessment revealed Resident #8's cognition was moderately impaired with a brief interview for mental status (BIMS) score of nine out of 15. 1. Resident #8 was observed on 5/31, 6/1 and 6/2/22 -On 5/31/22 at 4:00 p.m., the resident was lying in bed, awake, with the door to his room open. He had several cardboard boxes scattered throughout the room and seemed to be packing up things. Resident #8 resided in a private room. -On 6/1/22 at 11:30 a.m., the resident's room revealed things torn up and trash all over the floor. Resident #8 had ripped the cover off the meal served in a Styrofoam container and was eating his lunch with plastic utensils. (Staff reported the resident was not served with real plates and silverware for safety reasons.) He had some bags packed and said he was moving, but stated he was not happy about it. At 1:05 p.m., Resident #8 was in his room with the door shut. -On 6/2/22 at 10:06 a.m., Resident #8 was sitting in the doorway of the activity area, refusing to move for anyone. He was in direct line of sight of licensed practical nurse (LPN) #3. At 11:15 a.m., Resident #8 was sitting in his wheelchair in the doorway of his room, within line of sight of the staff. 2. Record review - known behaviors that put residents at risk of injury, intruded on the privacy of others and significantly disrupted care and the facility's living environment a. The 5/12/22 MDS documented: -The resident was short-tempered and easily annoyed on 12-14 days of the lookback period; the resident was delusional, with misconceptions or beliefs that were firmly held, contrary to reality; the resident displayed physical behavioral symptoms towards others, such as scratching, biting and having the potential to abuse others sexually on one to three days of the seven day lookback period; the resident displayed verbal behaviors towards others on one to three days and behavioral symptoms not directed towards others, such as coming out of his room with his pants down on one to three days. -These behaviors put Resident #8 at significant risk for injury, that his behaviors significantly interfered with his care, and his participation in social interactions or activities, that his behaviors put others at significant risk of physical injury, and intruded on the privacy of others and significantly disrupted care and the facility's living environment. -The resident rejected care during one to three days of the seven-day lookback period. -The resident's current behavior status was worsening. b. The resident's care plan revealed: The resident was care planned for verbal aggression, behavior problem and inappropriate social behaviors -The verbal aggression care plan, revised 4/30/22, documented Resident #8 had the potential to be verbally aggressive related to not liking his current living and health situation and not getting his needs met immediately, as sometimes his needs were unrealistic and exaggerated. It documented, FOLLOW BEHAVIOR MANAGEMENT PLAN WHEN HE BECOMES AGITATED OR BELLIGERENT. Interventions included that when the resident became agitated to intervene before his agitation escalated. It documented the staff should guide the resident away from the source of distress and engage him calmly in conversation. If his response was aggressive, staff were instructed to walk away calmly and approach him later. -The behavior problem care plan, revised 4/30/22, documented Resident #8's behavior problems included manipulation of staff, delusions, poor historian and exaggeration related to a history of such behaviors, cursing at staff and residents, demanding to staff, threatening staff with abuse reports, statements of holding him hostage, exaggerating the truth to get what he wants, refusal of care (medication and treatments) and hygiene, then stating no one offered the care, being socially inappropriate, etc. It documented, FOLLOW BEHAVIOR MANAGEMENT PLAN WHEN HE BECOMES AGITATED OR BELLIGERENT. Interventions included assisting the resident to develop more appropriate methods of coping and interacting with staff and encouraging the resident that the facility was providing him a place to stay and were attempting to find another placement, per his wishes. A final intervention was to set boundaries with the resident when verbally aggressive behaviors and threats were being displayed. -The inappropriate social behaviors care plan, revised 4/30/22, documented Resident #8 expressed inappropriate social behaviors (verbal/physical) as evidenced by resident to resident and resident to staff interactions. Interventions included redirecting and assisting the resident away from confrontational situations and reassuring other residents in the area that the situation will be handled. The Behavior Management Plan referenced in the above care plans was initiated on 8/8/21 and not revised, and was included in the resident's care plan as follows: FOLLOW BEHAVIOR MANAGEMENT PLAN WHEN HE BECOMES AGITATED OR BELLIGERENT: -Triggers: says call light not being answered, being around the wanderers, not getting his way, calling vitamins medications, staff arguing, calling him SIR, racist, sexist, imperfection of daily routines, emptying of urinal. -Interventions: calling (friend's name), getting different staff members to intervene, always have two people, be firm, pay close attention to small details, anticipating needs, offer walking outside, private van rides. 2. Resident #9 Resident #9, age 69, was admitted on [DATE] and readmitted on [DATE]. According to the June CPO, diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . a. The 3/16/22 MDS revealed the resident's cognition was moderately impaired with a BIMS score of ten out of 15. The MDS documented the resident showed no physical or verbal aggression towards others nor did she wander. b. The resident was care planned for: Impaired cognition r/t (related to) chronic mental illness care plan, initiated 3/23/22 included in part to: -Administer medications as ordered (antipsychotics and mood stabilizers) -Ask yes/no questions to determine resident needs -Cue, reorient and supervise as needed -Keep the resident's routine consistent and try to provide consistent caregivers as much as possible in order to decrease confusion. -Present just one thought, idea, question or command at a time -Auditory door alarm, initiated on 5/24/22 and revised on 5/31/22. It documented Resident #9 required use of an auditory door alarm related to her preference for safety concerns and comfort. Interventions included monitoring the resident for safety needs, needed changes and implementing as indicated. It documented staff would intervene when the alarm sounded to ensure the resident was aware and approved of the person trying to enter her room. 3. Incidents 4/8 and 5/7/22 involving Resident #8 and Resident #9 Review of Resident #8's behavior/mood tracking forms and a concern report revealed two incidents between the residents. -A behavior/mood tracking form dated 4/8/22 read: Staff reported Resident #9 came to speak to the social services director (SSD) about being fearful of Resident #8. She said that people had told her that Resident #8 had been going into girls'rooms. The intervention documented by the SSD was that Resident #9 was told that Resident #8 was being monitored whenever he was out of his room. She also said that Resident #8 had an alarm on his door so staff knew when he left his room. The SSD said those interventions made Resident #9 feel better about Resident #8. - A concern report created by licensed practical nurse (LPN) #3 on behalf of Resident #9's daughter, dated 5/7/22 (untimed), read: The resident disclosed to her daughter that Resident #8 had been stalking her as recently as 5/7/22. She told her daughter that he fondled her privates and has attempted to kiss her. The daughter reported these behaviors had been occurring for at least two weeks. It documented Resident #9 was afraid of Resident #8 becoming violent due to her rejecting his advances. The daughter reported she personally saw Resident #8 following her mother and waiting for her when she visited her mother on this date. 4. Failure of the facility to consistently implement safety measures and re-evaluate interventions to protect Resident #9 from mental abuse and potential sexual abuse. a. Although the 4/8/22 monitoring form read that Resident #8 was being monitored whenever he was out of his room and that he had an alarm on his door so staff when he left his room, record review and staff interview revealed these interventions were neither consistently implemented nor effective. The DON, in an interview of 5/31/22 at 3:05 p.m., stated Resident #8 was on locator checks every 15 minutes and that all facility staff was documenting where this resident was and what he was doing. However, review of the locator logs for Resident #8 provided by the DON in the morning on 6/1/22 revealed otherwise. Specifically, the locator logs which began on 4/8/22 at 2:45 p.m. revealed there was no documentation in the logs for 4/16/22, 4/21/22, 4/23/22, 4/24/22 and 4/27/22. Further, the facility failed to provide any locator logs for May or June, 2022. Further, the social service director (SSD), in an interview on 6/1/22 at 4:32 p.m., said the facility had tried a chirper alarm on Resident #8's door so staff would know when he left his room, but Resident #8 pulled the alarm off the door and destroyed it. While the concern on 5/7/22 was reported to the state, investigated by the facility and determined unsubstantiated, there was no documentation of Resident #9's interview regarding the incident or the daughter's interview regarding her observation of Resident #8 following her mother. Further record review revealed no evidence either resident's care plan was re-evaluated and updated with new interventions to address Resident #8's reported behavior. In addition, contrary to the facility's Abuse Prevention Policy, there was no evidence of a QAPI review and analysis of the incidents involving Resident #8 and #9 and the implementation of changes to prevent future incidents of abuse. c. Staff interviews The director of nursing (DON) was interviewed on 5/31/22 at 11:30 a.m. -The DON said Resident #9 did express concerns that Resident #8 sexually abused her, but after the facility investigation and reviewing the facility cameras that only showed the two residents passing each other in the hall, they determined the sexual abuse was unsubstantiated. The DON said the cameras never caught either resident entering into the other resident's room. The DON said the facility filed a police report and the police, too, were unable to substantiate the claim. - The DON said Resident #9 had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . However, record review revealed no reference to the resident's perseveration. The SSD was interviewed on 6/1/22 at 4:32 p.m. She said she was aware that Resident #9 was very bothered by Resident #8 because he always stared at her and made her uncomfortable. -She said Resident #9 also was upset because she felt the facility was not believing her and taking her concerns seriously. She said Resident #9 was clearly fearful of Resident #8, so the facility placed a chirper alarm on her door. -She said Resident #9 told her that the evening of 5/31/22, she was watching a movie in the television room and Resident #8 came into the room and just stared at her. The SSD said she touches base with Resident #9 often to process her feelings of being uncomfortable around Resident #8. The director of therapy (DT) was interviewed on 6/2/22 at 10:17 a.m. She said she felt Resident #8 needed to be in direct line of sight by staff for safety reasons. She said Resident #9 was still expressing fear of Resident #8 to her during their therapy sessions. She said because of this level of fear, she would ensure that she or someone else from therapy would escort Resident #9 back to her room to make sure she got there safely and to help minimize her contact with Resident #8. She said redirection did not work with Resident #8 at all. d. Resident interview Resident #9 was interviewed briefly on 6/1/22 at 4:00 p.m. She stated she remained fearful of Resident #8. 5. Facility follow up The current NHA, interviewed on 6/2/22 at 1:07 p.m. said that Resident #9 saw a local psychiatrist and she had an appointment with him. She said the facility also would ask their contracted psychologist who visited the facility to touch base with Resident #9 as needed. B. Resident #8 and #4 - potential sexual abuse 1. Resident #8 See above; Resident #8 was known and care planned for behaviors that put residents at risk of injury, intruded on the privacy of others and significantly disrupted care and the facility's living environment 2. Resident #4 Resident #4, age 75, was admitted [DATE]. According to the June 2022 CPO, diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The 4/5/22 MDS revealed the resident's cognition was moderately impaired with a BIMS score of nine out of 15. The MDS documented the resident showed no physical or verbal aggression towards others nor did she wander. The impaired cognition care plan, revised 1/25/22, documented Resident #4 had impaired cognitive functioning or impaired thought processes related to dementia. Interventions included cueing, reorienting and supervising Resident #4 as needed. It also documented staff should redirect Resident #4 when she expressed inappropriate gestures to male residents by letting her know that was not her significant other. It documented the resident needed supervision and assistance with all decision making. 3. Incidents 3/26, 4/3, and 4/4/22 involving Resident #8 and Resident #4 a. Review of Resident #8's behavior/mood tracking forms revealed: -3/26/22 at 4:05 p.m.: Staff reported Resident #8 was witnessed in Resident #4's room when Resident #4 was not present. Resident #8 was witnessed going through Resident #4's belongings. Resident #8 was told by staff to not go into other resident's rooms. The intervention documented by the director of nursing (DON) was that Resident #8 was counseled and stated he was not doing anything wrong. The document read the DON alerted staff again about him going into other rooms. -4/3/22 at 7:30 p.m. Staff reported Resident #8 was sitting in the hallway outside Resident #4's room, visiting with her. The nurse noticed Resident #4 wheeling herself across the hall to Resident #8's room. The nurse asked Resident #4 to please not enter Resident #8's room and Resident #4 agreed to that request. The nurse overheard Resident #4 telling Resident #8 that she couldn't come in. Resident #8 asked why and Resident #4 told him, That woman down there said to stay out. The nurse heard Resident #8 tell Resident #4, I invited you in. Resident #4 sat in the hallway visiting with Resident #8. After the change of shift reporting, the nurse found Resident #4 in Resident #8's room with the door closed. Resident #4 was removed from the room and was taken to her own room. It was explained to Resident #4 that she should not be in Resident #8's room and they should conduct their visits in the hallway or in the television lounge in front of the building. This report further documented that a certified nurse aide (CNA) found Resident #8 in Resident #4's room when she was in her recliner that she sleeps in, ready for bed (see behavior report); however, no additional behavior report was provided on this date during the complaint survey. Following this observation, staff followed up with Resident #4 to ensure that she was okay. Resident #4 stated, We weren't doing anything inappropriate I don't think. It was reiterated to Resident #4 that Resident #8 should not be in her room at any time and Resident #4 said okay. The nurse wrote she spoke with the DON by telephone and discussed monitoring Resident #8's whereabouts at all times and to place the medication cart in front of Resident #4's room for the night as a deterrent. The intervention documented by the DON was Resident managed by staff. The other resident made safe by nursing interventions. -4/4/22: Staff reported Resident #8 was sitting in Resident #4's doorway and the staff told Resident #8 he was not supposed to be there. Resident #8 proceeded to tell the staff to f*** themselves. The intervention documented by the DON was that Resident #8 was moved per nursing management and intervention per behavior care plan. b. Staff interviews regarding the above incidents involving Resident #4 and #8 -A staff member who wished to remain anonymous was interviewed on 5/31/22 at 2:14 p.m. He said staff have found Resident #8 in Resident #4's room with his hands down her pants. -CNA #3 was interviewed on 6/1/22 at 2:59 p.m. She said Resident #4 had to be moved to the 100 hall because of Resident #8's behaviors. She said Resident #8 was trying to get handsy with Resident #4. She said, in the evenings, the two residents would talk together a lot. She said one evening, Resident #4 was in her nightgown, but was not ready to get into her recliner that she slept in. She said Resident #8 lifted up Resident #4's nightgown and when confronted, said he was trying to fix her nightgown. She said after Resident #4 did go and lie in her recliner, Resident #8 was observed in Resident #4's room again, trying to lift her nightgown up again. She said Resident #4's incontinence brief appeared to have been slightly moved in the front, but she did not observe Resident #8's hands down Resident #4's pants. -LPN #1 was interviewed on 6/1/22 at 3:24 p.m. She said she recalled one evening when she was speaking to Resident #4 while passing medications, she observed Resident #8 talking to Resident #4. She said when she got further down the hall, she saw Resident #4 heading to Resident #8's room. She said she intervened and Resident #8 got upset with her, calling her names and threatening to report her. She said she moved Resident #4 back into her room, where she sat in her doorway. She said Resident #8 sat in his doorway and the two continued to talk to each other. She said shortly that same evening, a CNA came to her and said she did not see if anything happened, but she was concerned that something did not look right and asked the LPN to take a look. She said she saw Resident #8 sitting in front of Resident #4, that Resident #4's gown had been moved and her Attends had been pulled down and adjusted almost to the pubic area. She said she reminded both residents that they needed to be in their own rooms. She denied seeing Resident #8 with his hands down Resident #4's pants. 3. Resident interview Resident #4 was interviewed on 6/1/22 at 8:45 a.m. She said a man had been bothering her and she thought it was just a crush. She said the man was persistent, but he did nothing inappropriate. He said she had no fear of him and that she could take care of herself. She said she would have told staff if anything happened she didn't like. 4. Failures in facility response a. Failure to assess Resident #4's ability to consent and to develop interventions to protect her from sexual abuse A staff member who wished to remain anonymous was interviewed on 5/31/22 at 2:14 p.m. He said Resident #4 was not cognitively intact enough to give consent for sexual relations. Further, he said he did not recall the facility discussing sexual abuse or inappropriate behavior between resident unable to consent. The SSD was interviewed on 6/1/22 at 4:32 p.m. She said Resident #8 had tried to start a relationship with Resident #4, who was very se[TRUNCATED]

Based on record review and interviews, the facility failed to ensure six (#2, #5, #10, #11, #12 and #13) of 20 residents reviewed for dementia care out of 23 sample residents, received the appropriate treatment and services in dementia care to maintain their highest practicable physical, mental and psychosocial well-being and their freedom from repeated resident to resident abuse that included pushing, kicking and hitting and contributed to abrasions, skin tears, swelling and pain. Findings include: I. Professional standard The Gerontologist (February 2018), retrieved from: https://academic.oup.com/gerontologist/article/58/suppl_1/S1/ 59?login=true The Alzheimer's Association Dementia Care Practice Recommendations included the following foundations for person-centered care: 1. Know the person living with dementia. It is important to know the unique and complete person, including his/her values, beliefs, interests, abilities, likes, and dislikes-both past and present. This information should inform every interaction and experience. 2. Recognize and accept the person's reality. It is important to see the world from the perspective of the individual living with dementia. Doing so recognizes behavior as a form of communication, thereby promoting effective and empathetic communication that validates feelings and connects with the individual in their reality. 3. Identify and support ongoing opportunities for meaningful engagement. Engagement should be meaningful to, and purposeful for, the individual living with dementia. It should support interests and preferences, allow for choice and success, and recognize that even when the dementia is most severe, the person can experience joy, comfort, and meaning in life. 4. Build and nurture authentic, caring relationships. Persons living with dementia should be part of relationships that treat them with respect and dignity, and where their individuality is always supported. This type of caring relationship is about being present and concentrating on the interaction, rather than on the task. It is about doing with rather than doing for as part of a supportive and mutually beneficial relationship. 5. Create and maintain a supportive community for individuals, families and staff. This allows for comfort and creates opportunities for success. 6. Evaluate care practices regularly and make appropriate changes. II. Facility policy and procedure The Dementia Care policy and procedure, dated 1/20/21, was provided by the staff development coordinator (SDC) on 6/14/22 at 1:55 p.m. It documented in part: The general approach was to recognize that every interaction a resident had with the environment and staff members offers an opportunity to promote a sense of purpose, pleasure, success and a feeling of being normal. The staff would provide care that was focused on what each resident needed to maintain dignity and a positive sense of self, and tailor person care approaches to the individual by paying close attention to past life history, as well as current functional and cognitive levels. Staff should provide stimulation to decrease boredom activities including one on one from direct caregivers, and respond to any behavior of distress/emotion as an unmet need versus attention to preventing escalation of distress. III. Resident Census and Conditions of Residents The Resident Census and Conditions of Residents form was provided by the director of nurses (DON) on 5/31/22, and documented a total census of 38 residents. Of those, 20 of them (52%) had dementia or Alzheimer's disease, 15 of them (39%) had behavioral healthcare needs, and 11 of them (28%) had documented psychiatric diagnoses. IV. Repeated failure by the facility to provide appropriate treatment and services for residents with dementia in order to promote and maintain the residents' highest practical level of well-being and their freedom from resident to resident abuse with injury. A. Resident #5 and Resident #2 Review of Resident #5 and Resident #2's records revealed the facility failed to provide the residents, both of whom had dementia diagnoses, with person-centered treatment and services necessary to promote their highest practicable level of well-being and freedom from abusive incidents. (Cross-reference F600, Free from Abuse and Neglect) 1. Incident of resident to resident abuse with injury 5/3/22 Review of a progress note in Resident #2's record, dated 5/3/22 at 1:30 p.m., documented the director of nursing (DON) was called to assist with an incident between Resident #5 and #2 in the hallway. Resident #2 was in the hallway in front of Resident #5's room and he wanted her to leave the area. Resident #5 pushed at Resident #2, she pushed back, and then Resident #5 kicked Resident #2 in her left lower extremity causing three skin tears. Both residents were in wheelchairs. Housekeeping staff were in the hallway, witnessed the event, and called for help from a certified nurse aide (CNA) in the hallway. The CNA intervened and separated the two residents, called for nursing assistance, and took Resident #2 to her room for treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . A registered nurse assessed Resident #2 and determined she had three large skin tears to her left lower extremity. 2. Record review revealed the facility failed to provide Resident #5 person-centered care, tailored to the resident through knowledge of the resident's past life history, interests, beliefs, values, abilities, likes and dislikes and functional and cognitive levels, by individualizing care plan interventions to address and minimize behaviors, by evaluating and revising interventions, and by promoting his engagement in activities meaningful to him. a. Resident status Resident #5, age 72, was admitted on [DATE] and readmitted on [DATE]. According to the June 2022 computerized physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The 3/17/22 minimum data set (MDS) assessment documented the resident's cognition was intact with a brief interview for mental status (BIMS) score of 15 out of 15. [CONDITION(S)] signs and symptoms included inattention and disorganized thinking. b. Although Resident #5's 3/17/22 MDS documented it was very important to the resident to keep up with the news, do things with groups of people, do his favorite activities, and go outside and get fresh air when the weather was good, none of these interests and likes and dislikes were found in the resident's care plans designed to address his inappropriate behaviors. Specifically: (1) The resident's care plan, revised 3/30/22, documented the resident had a behavior problem (verbal, physical) related to dementia and borderline personality disorder. An intervention was to intervene as necessary to protect the rights and safety of others. -However, this care plan lacked any specificity regarding the characteristics of resident's behaviors and failed to identify which situations the resident should avoid and which situations should be promoted based on his interests and likes and dislikes. (2) The resident care plan, initiated 12/10/17 and revised 3/30/22, identified the resident had the potential to be physically aggressive related to vascular dementia and borderline personality disorder. The approaches included analyzing times of day, places, circumstances, triggers and what de-escalates this resident's behavior and document it, modify the environment and monitor/document/report any signs and symptoms of posing danger to himself or others. If the resident was agitated, staff should intervene, guide the resident away from the source of distress and engage him calmly in conversation. -However, the care plan was not individualized to address Resident #5's behaviors; it did not identify the circumstances, triggers, times of day and places that caused the resident to be physically aggressive, and did not explain how to effectively modify his environment. Further, the 5/3/22 resident to resident altercation failed to prompt a re-evaluation of the above interventions and failed to reference the circumstances of the event that triggered the resident to resident abuse on 5/3/22. (3) The care plan, initiated 12/10/17 and revised 3/30/22, identified the resident expressed inappropriate social behaviors (sexual/verbal/physical). The approaches included assisting the resident to a quieter, calmer area of the living environment, provide reassurance to other residents in the area that the situation would be handled, redirect and assist the resident away from confrontational situations and remind him that his behavior was socially unacceptable. -However, the care plan was not individualized to address Resident #5's behaviors; it did not identify what the resident's inappropriate social behaviors were, identify confrontational situations, or instruct staff how to redirect the resident away from such situations with person-centered interventions and approaches. c. Although the resident's 3/17/22 MDS documented it was very important to the resident to keep up with the news, do things with groups of people, do his favorite activities, and go outside and get fresh air when the weather was good, review of the resident's activity participation records revealed a lack of ongoing opportunities for the resident to engage in activities known to be important to him as well as a lack of his engagement in any activities regularly. (1) The most current activities assessment was requested from the facility on 6/15/22 and was provided by the staff development coordinator (SDC) at 10:29 a.m. The Activities Participation Review form was dated 6/13/22 and was void of documentation on the resident's favorite activities which per his MDS were very important to him. (2) The activities participation log for Resident #5 was reviewed from 3/30/22 through 6/14/22 (76 days). It revealed: -No offer or participation in sensory activities -No offer or participation in creative activities -No offer or participation in physical activities, although the resident liked to go outside -One group outing (shopping) on 5/25/22 offered. -Participation in independent and leisure activities almost daily, documented as watching television. 3. Record review revealed the facility failed to provide Resident #2 person-centered care, tailored to the resident through knowledge of the resident's past life history, interests, beliefs, values, abilities, likes and dislikes and functional and cognitive levels, by individualizing care plan interventions to address and minimize behaviors, and by evaluating and revising interventions, and by promoting her engagement in activities meaningful to her. a. Resident #2 status Resident #2, age 95, was admitted on [DATE]. According to the June 2022 CPO, diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The 5/17/22 MDS assessment documented the resident's cognition was severely impaired with a BIMS score of zero out of 15. b. Review of Resident #2's care plans revealed the plan was not person-centered and updated with new interventions designed to meet her needs and keep her free from resident to resident abuse. Specifically: The care plan, initiated on 1/7/19 and revised 4/20/22, documented the resident had difficulty expressing needs and wants related to vascular dementia. It documented that when the resident became frustrated or uncomfortable, she could become restless and if the source of discomfort was not removed, the resident would handle the situation with aggression secondary to decreased understanding of the environment. Interventions included attempting to keep the resident from becoming overstimulated by moving her to a quiet area, observing for general restlessness, providing an activity or offering food and fluids to the resident. -However, the care plan did not identify what the resident's signs of restlessness were, describe what her aggression looked like, what type of person-centered activity would be meaningful for her and should be offered, or what types of food or fluids the resident preferred. Further, it failed to identify frustrating and overstimulating situations that the residents should avoid. Likewise, the care plan did not include interventions to protect her safety, given her severe cognitive impairment. Finally, the care plan was not updated with person-centered, effective interventions after a physical altercation incident occurred between Resident #5 and Resident #2 on 5/3/22, in order to prevent a repeat incident. B. Resident #10 and Resident #11 Review of Resident #10 and Resident #11's records revealed the facility failed to provide the residents, both of whom had dementia diagnoses, with person-centered treatment and services necessary to promote their highest practicable level of well-being and freedom from abusive incidents. (Cross-reference F600, Free from Abuse and Neglect) 1. Incident of resident to resident abuse 5/17/22 with injury Review of Resident #10's record revealed a progress note, dated 5/17/22, that documented Resident #11 ambulated down the hallway and came up next to Resident #10 and began interacting. Resident #11 touched Resident #10 on his shoulder in a non-aggressive way. Resident #10 began to lift and swing his walker at the other resident, hit him with the walker, and began to lose his balance. Once Resident #10 hit Resident #11 with the walker, Resident #11 swung and hit him, pushed him, and he fell on to his left side causing a skin tear to his left forearm. Resident #10 reported pain in his left shoulder and was sent to the local emergency room for X-rays. The event was not witnessed but was verified on video camera footage. 2. Record review revealed the facility failed to provide Resident #10 person-centered care, tailored to the resident through knowledge of the resident's past life history, interests, beliefs, values, abilities, likes and dislikes and functional and cognitive levels, by individualizing care plan interventions to address and minimize behaviors, by evaluating and revising interventions, and by promoting his engagement in activities meaningful to him. a. Resident status Resident #10, age 80, was admitted on [DATE]. According to the June 2022 CPO, diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The 4/12/22 MDS assessment revealed the resident's cognition was severely impaired with a BIMS score of four out of 15. He had no physical or verbal behaviors directed towards others and no rejection of care. b. Although Resident #10's 4/12/22 MDS documented he had no physical or verbal behaviors directed towards, his care plans indicated otherwise. Review of his care plans revealed they lacked individualized, person-centered and updated approaches that recognized his needs and abilities. (1) The care plan, initiated 6/6/19 and revised 4/26/22, identified the resident had a behavior problem related to dementia. The approaches included explaining to the resident that being physical with others was inappropriate and intervene as necessary to protect the rights and safety of others, anticipate and meet his need, and assist him to develop more appropriate methods of coping and interacting, -However, the care plan did not include interventions that recognized the effect of his severe cognitive impairment, did not identify what his specific inappropriate physical behaviors were, what needs should the staff anticipate. In addition, it did not define how to assist him to develop appropriate methods of coping and interacting with person-centered interventions and approaches. Further, the care plan was not regularly updated with person-centered, effective interventions, including after the physical altercation incident occurred between Resident #10 and Resident #11 on 5/17/22, in order to prevent a repeat incident. (2) The care plan, initiated 6/6/19 and revised 4/26/22, documented the resident had the potential to be physically aggressive. The goals were he would verbalize understanding of the need to control the aggressive behavior, would not harm himself or others, and would have fewer episodes of physically aggressive behavior. The approaches included analyzing times of day, places, circumstances, triggers and what de-escalates behavior and document; give him as many choices as possible about care and activities, and monitor/document/report signs of the resident posing danger to himself or others. -However, the care plan did not include information for staff on the analysis of the resident's aggressive behaviors, including what time of day, places, or circumstances might trigger his aggressive behavior or what types of physical behaviors to watch for that he might demonstrate and that were unique to him. Further, the care plan was not updated with person-centered, effective interventions after a physical altercation incident that occurred between Resident #10 and Resident #11 on 5/17/22, in order to prevent a repeat incident. In an interview on 5/31/22 at 3:05 p.m., with the cirector of nurses (DON), assistant director of nurses (ADON) and SDC, the DON said Resident #10 was very territorial about his walker. This was not noted on his care plan. c. Review of the resident's activities assessment and activities participation log revealed the facility failed to promote the resident's involvement in activities identified as of interest and of importance to him. The resident's annual Activities Assessment, dated 4/6/22, documented the resident enjoyed watching TV/movies, visiting with staff and family, and walking around and watching the birds. It was very important to him to listen to music he liked, keep up with the news, and go outside and get fresh air when the weather was good. He needed reminders and encouragement for activities. Yet, the resident's activity participation records revealed a lack of ongoing opportunities for the resident to engage in activities known to be important to him as well as a lack of his engagement in any activities regularly. The activities participation log for Resident #10 were reviewed from 3/30/22 through 6/14/22 (76 days) and documented the following participation: -No offer or participation in cognitive activities. -No offer or participation in creative activities. -No offer or participation in group outings. -He participated in one sensory activity (aromatherapy) on 4/4/22. There was no documentation to show he was offered participation in any other sensory activities offered. -He participated in independent and leisure activities almost daily, which was documented as watching television. 3. Record review revealed the facility failed to provide Resident #11 person-centered care, tailored to the resident through knowledge of the resident's past life history, interests, beliefs, values, abilities, likes and dislikes and functional and cognitive levels, by individualizing care plan interventions to address and minimize behaviors, and by evaluating and revising interventions. a. Resident status Resident #11, age 74, was admitted on [DATE]. According to the June 2022 CPO, diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The 5/26/22 MDS assessment revealed the resident's cognition was severely impaired with a BIMS score of five out of 15. [CONDITION(S)] signs and symptoms included inattention and disorganized thinking, and he wandered daily. He had minimal difficulty hearing in some environments and difficulty communicating some words or finishing thoughts but was able if prompted or given time. b. Review of the resident's care plans revealed they lacked individualized, person-centered and updated approaches that recognized his needs and abilities. The resident's care plan, initiated 3/3/22 and revised on 3/23/33, identified the resident had a communication problem related to dementia. The goal was he would be able to make basic needs known. The approaches included anticipate and meet his needs, be conscious of the resident's position when in groups, activities or the dining room to promote proper communication with others, as well as monitoring and documenting for physical/nonverbal indicators of discomfort or distress and follow up as needed. Also, provide a program of activities that accommodated his communication abilities. -While the care plan identified the resident's communication needs, the care plan did not identify what person-centered needs to anticipate, specify what his unique physical and nonverbal indicators of distress were, or how to follow up. Further, the care plan was not updated with person-centered, effective interventions after a physical altercation incident that occurred between Resident #10 and Resident #11 on 5/17/22 to prevent a repeat incident. Specifically, in an interview on 5/31/22 at 3:05 p.m., the DON said Resident #11 was new and patted everyone on the back. Resident #11's care plan did not document his behavior of patting everyone on the back to alert staff that this could put the resident at risk for abuse. C. Resident #12 and Resident #13 Review of Resident #12 and Resident #13's records revealed the facility failed to provide the residents, both of whom had dementia diagnoses, with person-centered treatment and services necessary to promote their highest practicable level of well-being and freedom from abusive incidents. (Cross-reference F600, Free from Abuse and Neglect) 1. Incident of resident to resident abuse on 5/18/22 with injury The facility conducted an investigation of an episode of physical abuse that occurred on 5/18/22 at 4:05 a.m. between Resident #12 and Resident #13. The investigation revealed Resident #13 hit Resident #12 in the face with a hairbrush. The event was not witnessed, but it was captured on the facility's camera. Resident #12 was crying and sustained swelling to her right cheek and experienced pain. The facility substantiated resident-to-resident physical abuse had occurred. Resident #12's progress notes were reviewed from 3/18/22 through 3/23/22, and there was no documentation that the above resident-to-resident physical abuse had occurred. 2. Record review revealed the facility failed to provide Resident #12 person-centered care, tailored to the resident through knowledge of the resident's past life history, interests, beliefs, values, abilities, likes and dislikes and functional and cognitive levels, by individualizing care plan interventions to address and minimize behaviors, by evaluating and revising interventions, and by promoting her engagement in activities meaningful to her. a. Resident #12 status Resident #12, age 81, was admitted on [DATE]. According to the June 2022 CPO, diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The 4/12/22 MDS assessment documented the resident's cognition was severely impaired with a BIMS score of zero out of 15. She had trouble concentrating on things such as reading the newspaper or watching television and had wandering behaviors present. She required supervision and limited assistance with activities of daily living (ADL) and had no physical or verbal symptoms directed towards others. b. Review of Resident #12's record revealed the resident's care plans lacked individualized, person-centered and updated approaches that recognized her unique needs and abilities. The care plan, initiated 1/18/22 and revised 1/23/22, identified Resident #12 was at risk for wandering related to dementia as evidenced by entering multiple rooms in the hallway. Approaches included reorienting the resident to their surroundings, encouraging her to voice feelings of concern about her admission to the facility, and documented she liked to fold clothes, drink caffeinated beverages, wash tables, and sweep. Staff were to offer toileting frequently, personalize her room with familiar objects to increase her comfort, take her outside for a walk, and reorient her to her surroundings, the reason for admission, activities and other residents. -However, the care plan did not identify how to monitor her known wandering behavior that put her at risk for abuse. Further, the care plan was not reviewed and updated with person-centered or effective interventions to address the resident's wandering after a physical altercation that occurred between Resident #12 and Resident #13 on 5/18/22, in order to prevent a repeat incident. c. Review of the resident's activities assessment and activities participation log revealed the facility failed to promote the resident's involvement in activities identified as of interest and of importance to her. A readmission Activity Assessment, dated 1/18/22, documented it was very important to Resident #12 to do things with groups of people, go outside to get fresh air when the weather was good and to be outdoors as much as possible, be around animals such as pets, and have books, newspapers, and magazines to read. It was very important for her to do her favorite activities, which included attending anything that had to do with church, like Bible study, church music, and church services, gardening, visiting and loved to clean. The assessment documented she liked to play cards/games, creative expression, exercise/sports, intellectual discussion groups, and conversing with family, friends, staff or peers. The assessment documented Resident #12 enjoys watching movies in (her) room. She needed to be invited and reminded to do activities due to her cognition, and the resident's responsible party provided the information for her unique preferences. Notwithstanding the above information on the resident's interests and activities important to her, the activities participation logs for Resident #12, reviewed from 3/30/22 through 6/14/22 (76 days), revealed a lack of her participation in the activities set forth in the assessment. The logs revealed: -No offer or participation in sensory activities. -No offer or participation in cognitive activities. -No offer or participation in spontaneous activities. -Participation in one group outing on 5/9/22. There was no documentation to show she was offered participation in any other group outings activities. 3. Record review revealed the facility failed to provide Resident #13 person-centered care, tailored to the resident through knowledge of the resident's past life history, interests, beliefs, values, abilities, likes and dislikes and functional and cognitive levels, by individualizing care plan interventions to address and minimize behaviors, by evaluating and revising interventions, and by promoting her engagement in activities meaningful to her. a. Resident status Resident #13, age 74, was admitted on [DATE]. According to the June 2022 CPO, diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The 3/1/22 MDS assessment revealed the resident's cognition was severely impaired with a BIMS score of zero out of 15. She had highly impaired vision and sometimes had the ability to understand others and express her ideas and wants adequately. [CONDITION(S)] signs and symptoms included inattention and disorganized thinking, and she had physical and behavioral symptoms directed towards others. b. Review of Resident #13's care plans revealed they lacked individualized, person-centered and updated approaches that recognized her needs and abilities. (1) The care plan, initiated 8/2/16 and revised 10/9/21, identified the resident had a behavior problem related to dementia and anxiety. The approaches included assisting the resident to develop more appropriate methods of coping and interacting, encouraging her to express feelings appropriately and intervene as necessary to protect the rights and safety of others. Remove from the situation and take to an alternate location as needed. -However, the care plan was not individualized to instruct staff on what approaches in coping would be appropriate for the resident, and what situations might trigger an inappropriate response. (2) The care plan, revised 1/25/21, identified the resident had a potential to be physically aggressive related to decreased awareness of surroundings and decreased understanding of actions of others around her, possessive of personal items and space. The approaches included that when the resident became agitated, intervene before agitation escalated. Guide away from source of distress. -However, the care plan failed to include that based on knowledge of the resident, what action to take to promote the resident's understanding of the actions of others and minimize an aggressive response. Further, the care plans were not updated following the incident with Resident #12 on 5/18/22. Further, the care plans did not reference actual abuse, or how to protect other residents that might enter her room. c. Review of the resident's activities assessment revealed the facility was aware of the resident's activity interests and meaningful activities and had participated in group and independent activities; however, no participation logs were provided to see if the participation promoted the resident's involvement in activities identified as of interest and of importance to her. The resident's Activities Quarterly Participation Review, dated 5/31/22 (during survey), was provided by the SDC on 6/14/22, and documented the resident participated in 5+ group and 5+ independent activities a week, she was active and partially active in her participation. Resident needs an invite, some cuing and redirection related to (her) cognition. She enjoyed visiting, Bingo, TV, painting, coloring, music, playing ball, aromatherapy, socials, and church and Bible studies. The resident's goals were met and the interventions/approaches had been partially effective in attaining goals. As of 6/22/22, however, no individual or group activity participation logs had been provided. V. Staff interviews The DON, SDC, and nursing home administrator (NHA) were interviewed on 6/15/22 at 5:22 p.m. They said the facility did not currently have any action plans in place for behavior management or dementia care, but they would be creating one. They explained these issues were discussed internally back in March, but the facility did not follow through on a quality assurance performance improvement plan at that time.

Based on record review and interviews, the facility failed to provide an environment which was conducive to the residents' highest practicable physical, mental and psychosocial well-being for one (#8) of 10 residents reviewed for behaviors out of 23 sample residents. Specifically, the facility failed to adequately address ongoing incidents of aggressive behaviors exhibited by Resident #8, provide the resident with appropriate behavioral health services to address his ongoing aggressive behavior, and continued physical abuse, mental abuse, verbal abuse, and possible sexual abuse against other residents. Aggressive behavioral incidents were directed toward multiple other residents by Resident #8 in April 2022, followed by additional abusive incidents in May 2022, subjecting other residents to physical abuse, mental abuse, verbal abuse and potential sexual abuse; and in June 2022, subjecting residents to physical abuse. Cross-reference F600-Free from Abuse and Neglect Findings include: I. Facility policy and procedure The Behavioral Assessment, Interventions and Monitoring policy and procedure, undated, was provided by the staff development coordinator (SDC) on 6/14/22 at 2:46 p.m. It documented the following in pertinent part: Behavioral symptoms will be identified using behavioral screening tools and the comprehensive assessment. Behaviors are regulated by the brain and are influenced by experiences, personality traits, environment, and interactions with other people. Behavior can be a way for an individual in distress to communicate unmet needs, indicate discomfort, or express thoughts that cannot be articulated. Appropriate assessment and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . The interdisciplinary team will evaluate behavioral symptoms in residents to determine the degree of severity, distress and potential safety risk to the resident, and develop a plan of care accordingly. Safety strategies will be implemented immediately if necessary to protect the resident and others from harm. Atypical behavior would be differentiated from behavior that was dangerous or problematic for the residents or staff, or behavior that signaled underlying distress. The care plan would incorporate findings from the comprehensive assessment and be consistent with current standards of practice. The interventions would be individualized and part of an overall care environment that supported physical, functional and psychosocial needs, and strived to understand, prevent or relieve the residents' distress or loss of abilities. The director of nursing (DON), or designee, would evaluate whether the staffing needs had changed based on acuity of the residents and their plans of care. Additional staff and/or staff training would be provided if it was determined that the needs of the residents could not be met with the current level of staff or staff training. The interventions would be adjusted based on the impact on behavior and other symptoms, including any adverse consequences related to treatment. II. Resident Census and Conditions The Resident Census and Conditions of Residents form was provided by the director of nurses (DON) on 5/31/22. It documented the facility had 15 (39%) of 38 residents who had behavioral healthcare needs. III. Resident #8 A. Resident status Resident #8, age 68, was admitted on [DATE] and readmitted [DATE]. According to the June 2022 computerized physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . -The resident did not have a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The 5/12/22 minimum data set (MDS) assessment revealed Resident #8's cognition was moderately impaired with a brief interview for mental status (BIMS) score of nine out of 15. His mood was documented as being short tempered and easily annoyed nearly every day. He had physical and verbal behavioral symptoms directed toward others that put him and other residents at risk for physical injury and interfered with his care. His behavioral symptoms significantly interfered with his participation in activities or social interactions, had an impact on others, and put them at significant risk of physical injury. He would intrude on the privacy of others and disrupted the care/living environment significantly. He was independent with activities of daily living and had rejection of care. In addition, the MDS documented his interview for daily and activity preferences should be conducted, but could not be completed by the resident or family/significant other and documented, No response or non-responsive to preferences when asked. A staff assessment of his daily and activity preferences revealed he preferred reading books, newspapers, or magazines, listening to music, keeping up with the news, doing things with groups of people, participating in his favorite activities, spending time away from the nursing home, and spending time outdoors. B. Record review 1. Activities and behavioral care plans The care plan, initiated 8/8/21 and revised 6/7/22, identified the resident was at risk for social isolation related to his inability to participate in his usual routine. His activity interests included studying law, fishing, work, animals, music, and religious activities and he needed independent activities in his room. The goal was the resident would have the opportunity to practice and gain social and communication skills through interacting with others on a daily basis and that he would be able to participate in an acceptable daily routine. The approaches included to ask him about his activity preferences and help him plan them, assist with mail and phone calls as needed, help him visit with family and friends in a private location, invite and encourage him to attend group activities, outdoors, socials, resident council, music and pet visits, provide with a monthly calendar of scheduled activities, and remind him when activities were scheduled. He enjoyed outdoor activities like fishing and getting fresh air, and he enjoyed spending most of his day in his room doing independent activities such as studying things. He also enjoyed socializing with staff and friends from the community. -However, the care plan did not provide specific, person-centered interventions on how to provide him with materials to study law or other unique interests, did not clarify the types of music he enjoyed or how that could be provided for him. The care plan did not define specific topics of conversation he would enjoy that would promote engagement and positive, meaningful relationships among other residents and staff, and did not establish routinely scheduled walks or activities outdoors that he preferred. -Further, the care plan was contradictory as evidenced by he liked group activities, the outdoors and getting fresh air but spent most of his day in his room. The care plan was not adequately individualized to address his customary routines, enhance his well-being and maximize his socialization. The verbal aggression care plan, revised 4/30/22, documented resident #8 had the potential to be verbally aggressive related to not liking his current living and health situation and not getting his needs met immediately, as sometimes his needs were unrealistic and exaggerated. It documented, FOLLOW BEHAVIOR MANAGEMENT PLAN WHEN HE BECOMES AGITATED OR BELLIGERENT. Interventions included that when the resident became agitated to intervene before his agitation escalated. It documented the staff should guide the resident away from the source of distress and engage him calmly in conversation. If his response was aggressive, staff were instructed to walk away calmly and approach him later. The behavior problem care plan, revised 4/30/22, documented Resident #8's behavior problems included manipulation of staff, delusions, poor historian and exaggeration related to a history of such behaviors, cursing at staff and residents, demanding to staff, threatening staff with abuse reports, statements of holding him hostage, exaggerating the truth to get what he wants, refusal of care (medication and treatments) and hygiene, then stating no one offered the care, being socially inappropriate, etc. It documented, FOLLOW BEHAVIOR MANAGEMENT PLAN WHEN HE BECOMES AGITATED OR BELLIGERENT. Interventions included assisting the resident to develop more appropriate methods of coping and interacting with staff and encouraging the resident that the facility was providing him a place to stay and were attempting to find another placement, per his wishes. A final intervention was to set boundaries with the resident when verbally aggressive behaviors and threats were being displayed. The inappropriate social behaviors care plan, revised 4/30/22, documented Resident #8 expressed inappropriate social behaviors (verbal/physical) as evidenced by resident-to-resident and resident to staff interactions. Interventions included redirecting and assisting the resident away from confrontation situations and reassuring other residents in the area that the situation would be handled. The Behavior Management Plan referenced in the above care plans was initiated on 8/8/21 and not revised, and was included in the resident's care plan as follows: FOLLOW BEHAVIOR MANAGEMENT PLAN WHEN HE BECOMES AGITATED OR BELLIGERENT: -Triggers: says call light not being answered, being around the wanderers, not getting his way, calling vitamins medications, staff arguing, calling him SIR, racist, sexist, imperfection of daily routines, emptying of urinal. -Interventions: calling (friend's name), getting different staff members to intervene, always have two people, be firm, pay close attention to small details, anticipate needs, offer walking outside, private van rides. 2. Activities assessment and participation The most recent activities assessment was requested from the facility on 6/15/22, but was not provided. -However, a quarterly Activities Participation Review, dated 5/8/22, was provided by the facility on 6/15/22 and documented the resident needed invitations to group activities, but because he was not vaccinated for COVID-19, he had not been participating in group activities unless he was social distancing. The review documented that his activity goals were not met, but resident progress was achieved towards them. (The review did not include what his activity goals were). The activity participation logs for Resident #8 were reviewed from 3/30/22 through 6/14/22 (76 days) and documented the following participation: -No offer or participation in creative activities -No offer or participation in sensory activities -No offer or participation in spontaneous activities -He participated in one group outing (shopping) on 5/25/22. There was no documentation to show he was offered to participate in any other group outings. -He participated in three outdoors activities (4/22/22, 5/2/22 and 5/3/22). There was no documentation to show he was offered to participate in any other outdoor activities offered. -He participated in three spiritual activities (church) on 4/19/22, 5/8/22, 5/10/22. There was no documentation to show he was offered to participate in any other spiritual activities offered. -He participated in reminiscing with staff four times (4/18/22, 5/16/22, 5/17/22 & 5/25/22). There was no documentation to show he was offered to participate in other opportunities to reminisce with staff. -He participated in Independent and Leisure activities almost daily, which was documented as watching television. -There were no resident refusals documented for any of the activities offered during the 76 days. -The facility did not provide Resident #8 with meaningful, person-centered activities that were unique to his preferences to promote appropriate engagement with other residents and staff that would enhance his well-being. C. Observations Observations throughout the facility over a two-day onsite period (6/14/22 from 10:37 a.m. to 5:30 p.m. and 6/15/22 from 9:45 a.m. to 5:30 p.m.) revealed no evidence of activities being conducted other than television (TV) in the TV lounge. No residents were observed outside. Residents were spending time in their rooms, in the hallways, in the front lobby or in the TV lounge, unengaged with any activities. There were no organized group activities or one-to-one interactions observed. IV. Staff interviews The director of nurses (DON), staff development coordinator (SDC), and nursing home administrator (NHA) were interviewed on 6/15/22 at 5:22 p.m. They said the facility did not currently have any action plans in place for behavior management or dementia care (cross-reference F744 for dementia care and services), but they would be creating one. They explained these issues were discussed internally back in March 2022, but did not follow through on a quality assurance performance improvement plan at that time.

Based on observations, record review and interviews, the facility failed to provide a safe environment and protect residents from resident-to-resident abuse, involving six residents of seven reviewed (#16, #23, #29, #34, #44 and #199) out of 34 sample residents. Record review revealed a pattern of potentially sexually abusive behavior by Resident #199 towards Resident #44 on 6/29/21 and toward Resident #23 on 7/1/21. On 6/29/21, Resident #199 was found in Resident #44's bed and straddling her. The interaction alerted Resident #44's roommate and she called out for help. The roommate reported Resident #44 was scared to death and for a while, wanted someone to hold her hand until she fell to sleep. Two days later, Resident #199 climbed into Resident #23's bed and attempted to cuddle with her. Resident #23 said she feared Resident #199. Both incidents were unsolicited by the female residents. Interviews and observation also revealed Resident #199 kissed Resident #16 on her forehead and on 7/25/21, attempted to take her to his room. Observations on 7/25/21 revealed Resident #44 in her room in her wheelchair with her shirt pulled over her head and her breasts exposed, minutes after Resident #199 was found alone and unsupervised in her hallway. On 7/26/21 video footage from 7/25/21 showed Resident #199 entering Resident #44's room and remaining there for four minutes. Record review revealed Resident #199, #44, #23 and #16 were all cognitively impaired. Interviews revealed administration and facility staff failed to identify Resident #199's pattern of behavior toward Residents #44, #23, and #16 as potentially sexually abusive, and failed to respond to protect them from further abuse. The failures placed these residents, as well as other residents in the facility, at risk for serious harm if the failures were not immediately corrected. Cross-reference F609, failure to report alleged abuse; and F610, failure to thoroughly investigate allegations of abuse and protect residents from further abuse, F744, dementia care and F725, insufficient staffing to meet the needs of residents. Findings include: I. Immediate jeopardy A. Findings of immediate jeopardy Record review revealed a pattern of potentially sexually abusive behavior by Resident #199 toward Resident #44 on 6/29/21, and Resident #23 on 7/1/21. On 6/29/21, Resident #199 was found in Resident #44's bed and straddling her. The interaction alerted Resident #44's roommate and she called out for help. The roommate reported Resident #44 was scared to death, and for a while, wanted someone to hold her hand until she fell to sleep. Two days later, Resident #199 climbed into Resident #23's bed and attempted to cuddle with her. Resident #23 said she feared Resident #199. Both incidents were unsolicited by the female residents. Interviews and observation also revealed Resident #199 kissed Resident #16 on her forehead and on 7/25/21, attempted to take her to his room. Observations on 7/25/21 revealed Resident #44 in her room in her wheelchair with her shirt pulled over her head and her breasts exposed, minutes after Resident #199 was found alone and unsupervised in her hallway. On 7/26/21, video footage from 7/25/21 showed Resident #199 entering Resident #44's room and remaining there for four minutes. Interviews revealed administration and facility staff failed to identify Resident #199's pattern of behavior toward Residents #44, #23, and #16 as potentially sexually abusive, and failed to respond to protect them from further abuse. The facility failures placed these residents, as well as other residents in the facility, at risk for serious harm if the failures were not immediately corrected. On 7/26/21 at 5:41 p.m. the nursing home administrator (NHA) and director of nursing (DON) were informed the facility failures created an immediate jeopardy situation that placed these residents, as well as other residents in the facility, at risk for serious harm if the failures were not immediately corrected. B. Interim plan to ensure resident safety On 7/26/21 at 6:47 p.m. the NHA provided an interim plan to ensure the safety of all residents overnight until a formal, final plan could be submitted on 7/27/21. The interim plan included in part the following: A safety plan was put into place on 7/25/21 at 9:20 p.m. An individual would be put into place as a one-to-one monitor 24 hours, seven days a week for the alleged assailant. The assigned monitor will check with the nurse on duty when they need to use the restroom or take a break to ensure the resident was under constant surveillance; The resident would be on continuous one-to-one monitoring until planned discharge home with son on August 2, 2021. Staff will be re-educated on preventing, recognizing, and reporting abuse prior to the start of their next shift. Staff on duty at the time of this written plan will be educated immediately. Facility to complete house-wide audits and identify any residents with a BIMS (brief interview of mental status) of eight or less due to increased risk of abuse. Staff to be interviewed to identify resident needs, interventions, or redirection techniques to decrease risk of abuse. C. Facility plan to remove immediate jeopardy On 7/28/21 at 1:00 p.m. the facility submitted its final plan to remove immediate jeopardy. The plan read as follows: 1.Resident #199 was provided a one-on-one staff member on 7/2/21 at 9:30 p.m. The one-on-one staff member to continue throughout the remainder of his planned stay. discharge date scheduled for 8/2/21. Resident is to be discharged home with his son and wife. a. Medical Director reviewed the resident's chart on 7/27/21 and agreed with following physician's recommendations for labs and continued 1 on 1. Items reviewed included H&P (history and physical), hospital records and medication list. b. Labs ordered: CBC (complete blood count), CMP (complete metabolic panel), [MEDICATION(S)] level, TSH (thyroid) and UA (urinalysis) on 7/27/21. c. Medication regimen reviewed 7/27/21. d. Family updated on resident status with discharge planning in place e. Family goal to get home, agreeable to sending referrals for male locked unit if unable to take home. f. Resident specific intervention identified and include: 1. 1 to 1 until discharge 24 hours, 7 days a week; a. 1 to 1 sitters will be educated on abuse identification, prevention and interventions. Alzheimer's Disease and related disorders: behavior and ADL (activities of daily living) management. Ten tips for Crisis Prevention. 2. Low stimulus breaks when demonstrating increased agitation. 3. Resident specific interventions for behaviors including: taking for a walk, tv/movie, low stimulus environment, provide snack (prefers sandwich). 4. Care plan updated. 5. Facility identified previous resident-specific interventions were not in place or identified. 2. Interviewable residents were interviewed by the IDT (interdisciplinary team) on 7/27/21 regarding whether they felt safe in the facility and/or had any concerns related to abuse. Licensed nurses who care for residents who were not interviewable were interviewed for any noted changes in those residents' behavior related to their well-being. The residents will be monitored for the next three days. Any psychosocial issues or concerns identified will be addressed. 3. NHA and DON received verbal education on abuse reporting, abuse identification, abuse prevention, abuse policy and procedure by Regional Clinical Resource (director of clinical operations) on 7/27/21 at 21 at 6:00 p.m. 4. Staff education began on 7/26/21 at 6:15 p.m. on how to prevent, identify, report and investigate any abuse allegations. Re-initiated abuse education on 7/27/21 on how to prevent, identify, report, and investigate any abuse allegations, including sexual and emotional abuse. Ten tips for crisis prevention and Alzheimer's disease and related disorders. Behavioral and ADL activity of daily living) management. a.Target end date for initial abuse education 7/29/21. b. Any staff member who is not present will be educated verbally via phone. All education will also be sent to all staff via DocuSign. Physical signature to be completed on first shift to work. c. All staff will be interviewed about abuse with target completion 7/29/21. 5. All identified occurrences will be investigated and reported to (State Agency): a. Occurrence [case number] involving Resident #16; b. Occurrence [case number] involving Resident #44; c. Occurrence [case number] involving Resident #23; d. Occurrence [case number] involving Resident #47; e. Occurrence [case number] involving Resident #44 (second identified incident). 6. Police notification completed 7/27/21 at 4:40 p.m. on occurrence c, d and e (occurrence a and b completed previously). Ombudsman notification completed 7/27/21 at 4:53 p.m. 7. Family notification completed 7/27/21 for Resident#199 and #44; Resident #47 on 7/28/21; Resident #23 on 7/27/21 and Resident #16 on 7/26/21. 8. Systemic changes: all staff educated on abuse identification, prevention, and reporting with a completion goal for initial education 7/29/21. a. All staff will be educated on CPI (non-violent crisis intervention), behavior management in dementia/Alzheimer's as well as preventing, recognizing, reporting and investigating abuse via verbal education, written education and relias (computer training) with a target completion date of 8/10/21. b. All residents will be interviewed and/or monitored weekly x3 months regarding abuse, safety, emotional support and will be on-going as indicated. c. DON/designee will review all progress notes 7 days a week to identify potential abuse, resident behaviors or any needed interventions. Electronic morning meeting form will be utilized to track progress note review and any identified issues on a daily basis x90 days. d. IDT will review any high-risk residents upon admission and monthly to identify potential triggers to prevent any abuse. 1. Resident specific interventions for wanderers. 2. Appropriate monitoring with effective training and intervention management based on behavior being demonstrated. 3. Staffing will be reviewed daily by the DON/ADON to ensure sufficient staffing and frequent rounding and supervision of resident care is provided. Systemic changes to be reviewed through daily, weekly and monthly QAPI to identify any trends, risk and on-going compliance. D. Removal of immediate jeopardy On 7/28/21 at 2:30 p.m. the NHA and DON were notified the facility's plan to remove immediate jeopardy was accepted. However, deficient practice remained at a G level, actual harm that is isolated. II. Facility policy and procedures on Abuse Prevention The Abuse prevention program policy, initiated 11/1/17, was provided by the NHA on 7/21/21 at 5:53 p.m. The policy documented in part, Our residents have the right to be free from abuse, neglect, misappropriation or resident property, corporal punishment and involuntary seclusion. Comprehensive policies and procedures have been developed to aid our facility in preventing abuse, neglect, or mistreatment of [MEDICAL RECORD OR PHYSICIAN ORDER] -Mandated staff training/orientation programs that include such topics as abuse prevention, identification and reporting of abuse; -Identification of occurrences and patterns of potential mistreatment/abuse; -The protection of residents during abuse investigations; -Timely and thorough investigations of all reports and allegations of abuse; -An ongoing review and analysis of abuse incidents; and, -The implementation of changes to prevent future occurrences of abuse. The Preventing Resident Abuse policy, initiated 11/1/17, was provided by the NHA on 7/21/21 at 5:53 p.m. The policy documented in part, Our facility will not condone any form of resident abuse and will continually monitor our facility's policies, procedures, training programs, systems, etc., to assist in preventing resident abuse. The facility's goal is to achieve and maintain an abuse-free environment. Our abuse prevention/intervention program includes, but is not necessarily limited to: -Assessing, care planning, and monitoring residents with needs and behaviors that may lead to conflict or neglect; -Conduct background investigations to avoid hiring persons or admitting new residents who have been found guilty (by a court of law) of abusing, neglecting, or mistreating individuals or those who have had a finding of such action entered into the state nurse registry or state sex offender registry; -Striving to maintain adequate staffing on all shifts to ensure that the needs of each resident are met; -Encouraging all personnel, residents, family members, visitors, etc., to report any signs or suspected incidents of abuse to facility management immediately. III. Resident-to-resident potential sexual abuse The facility failed to identify and respond to an on-going pattern of potential sexual abuse by Resident #199 involving Residents #44, #23 and #16. A. Residents #199, #44, #23 and #16 1. Resident #199, age 84, was admitted on [DATE]. According to the computerized physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The admission minimum data set (MDS) revealed he was moderately cognitively impaired (incomplete brief interview of mental status/BIMS), had delusions, behaviors that interfere/ intrude/ disrupt, and required one person assist for locomotion. His 6/28/21 care plan read he expressed inappropriate verbal and physical behaviors related to dementia. 2. Resident #44, age 96, was admitted on [DATE]. According to the CPO, diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . According to the 6/15/21 MDS assessment, the resident's cognition was severely impaired; she had short and long term memory (loss), disoriented thinking and inattention to focus. She also presented with unclear speech and difficulty hearing. She required extensive physical assistance of one person for bed mobility, dressing, locomotion, and personal hygiene. Her care plan, initiated 3/22/21 and revised 4/30/21, read she had difficulty expressing her needs and wants related to dementia. 3. Resident #23, age 84, was admitted on [DATE]. According to the CPO, diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . According to the 4/14/21 MDS assessment, the resident was moderately cognitively impaired (brief interview for mental status/BIMS 9/15). She did not have delusional or disorganized thinking or inattention. She required extensive physical assistance for activities of daily living. Her care plan read she had depression and staff should monitor her changes in behavior, mood, cognition as well as for signs of hallucinations, delusions, social isolation, suicidal thoughts and withdrawal. 4. Resident #16, age 92, was admitted on [DATE]. According to the July 2021 CPO, diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . According to the 5/6/21 MDS assessment, the resident had moderate cognitive impairment with memory loss (BIMS not completed). She did not have disorganized thinking or inattention. Resident #16 required extensive physical assistance with activities of daily living. Her care plan, revised 4/30/21, read Resident #16 had difficulty expressing her needs and wants related to dementia. B. Record review and interview revealed Resident #199 exhibited a pattern of sexually abusive and/or potentially sexually abusive behavior toward female Residents #44, Resident #23 and Resident #16, and the facility failed to take necessary steps to protect these residents from further abuse. 1. First incident a. Incident of potential sexual abuse on 6/29/21 involving Residents #199 and #44 A nursing note in Resident #199's record, dated 6/29/21, read Resident #199 entered a female resident's room (Resident #44). He climbed onto the bed straddling her, attempting to lay on top of her. The certified nurse aides (CNAs) immediately ran to the room and removed the resident with the help of the registered nurse (RN). Resident #199 was documented as combative, belligerent and threatening towards the staff involved. A 6/29/21 nursing note in Resident #44's record read Resident #44 was awakened by a male resident climbing on the bed and straddling her. CNAs were outside of the room and immediately intervened. They removed the male resident off the bed and into his room. The noted read Resident #47 (Resident #44's roommate) was excited after the incident. The nurse's note indicated the on-call manager was notified via text. Resident #44 was not able to be interviewed based on her cognitive impairment, memory loss, impaired hearing and speech. However, Resident #47, Resident #44's roommate, was interviewed on 7/26/21 at 12:31 p.m. Resident #47 said a male resident wearing only his underwear and who matched the description of Resident #199, came into their room and got on top of Resident #44. Resident #47 said Resident #44 started to scream out and waved her arms to try to get him off of her. Resident #47 said she yelled out for help and two CNAs took the male resident out of the room. Resident #47 said Resident #44 was non-verbal, but she could tell the resident was scared to death from her tone in voice and her facial expressions after the incident. Resident #47 said now she shuts the door when she leaves the room if Resident #44 is alone in room to try to protect her roommate from Resident #199. She said for a while, Resident #44 wanted to have someone hold her hand before she could fall asleep. CNA #4 was interviewed on 7/26/21 at 6:36 p.m. She said she worked overnights from 5:30 p.m. to 6:00 p.m. She witnessed Resident #199 attempting to get into bed with Resident #44 on 6/29/21. She said she saw him place his knee on the bed while pulling down the covers from Resident #44. She said they held his arm and showed him the name on the door and helped him to bed. She said Resident #199 usually enters resident rooms, stands there and then turns around. She said he goes into some rooms multiple times and they have to redirect him. She did not know what his fixation was about certain rooms. Registered Nurse (RN) #3 was interviewed on 7/29/21 at 4:15 p.m. She said on 6/29/21, staff were alerted by yells from the room of Resident #44. She said she observed Resident #199 over the top of Resident #44. She said Resident #44 faced the wall as he straddled over her legs. She said Resident #199 was confused and started yelling that it was his bed. She said he believed he was getting in bed with his wife. She said staff had to pick him up to remove him from the bed. The RN said the resident thought a lot of small women in wheelchairs were his wife and attempted to push their wheelchairs. He told those female residents he loved them. She said he tended to be overly affectionate. RN #3 said she did not believe the incident was sexually motivated at the time, but now could see how the female resident could think that it was intentional. She said the staff had been concerned enough about his behavior to monitor his actions, although, see below, there were no directions to staff on the level of supervision he required. b. Facility response Notwithstanding Resident #44's reported response to the incident (see above), record review revealed no evidence the facility identified the incident as potential sexual abuse, investigated the incident (cross-reference F610, reported the incident (F609) or took steps necessary to protect Resident #44, as well as other residents, from further potential abuse by Resident #199. Specifically: -A nursing note in Resident #199's record on 6/30/21 read Resident #199 thought he had a wife at the facility, believed one female resident was his wife and another female resident was his sister. The note indicated he was monitored for behavioral concerns. The note further read that it was difficult to redirect him from these ideas and would become aggressive with attempts to redirect. However, the note did not identify the resident's behavioral concerns or reference the incident on 6/29/21 involving Resident #44. Further, there was no instruction for staff on how the monitoring was to be done; specifically, what level of supervision should be provided. -A review of nursing notes for Resident #44's record revealed a note, dated 6/30/21 at 4:45 that read, no issue or verbal expressions of issues related to incident with another resident. However, there no further notes about the incident on 6/29/21, no reference to an investigation of the incident, no report of the incident to the families, physicians' police, or the state, and no reference to the steps taken to protect the resident from further abuse. -A review of the residents' care plans revealed neither resident's care plan was revised to include revised or new interventions following the incident. Resident #44's care plan did not include a reference to the incident, her new need for support as reported by her roommate or interventions to ensure her safety. Resident #199's care plan did not instruct staff on the level of supervision he required. -Finally, there was no documentation, confirmed during interviews with the nursing home administrator (NHA) and director of nursing (DON) (see final administrative interviews below), that the incident was thoroughly investigated by the facility until 7/27/21 (during survey) (Cross-reference F610) and reported to the state, the residents' physicians, or families until 7/27/21 (Cross-reference F609) Interviews with the NHA and DON on 7/26/21 revealed the DON was aware of the 6/29/21 incident, but did not think it was abusive. She said Resident #199 was not in distress; he was tired and just wanted to go to bed. See full interview below. 2. Second incident a. Incident of potential sexual abuse on 7/1/21 involving Resident #199 and Resident #23 A review of Resident #199's record revealed a 7/1/21 at 2:46 a.m. behavior note that read Resident #199 had been up and down throughout the night. Staff toileted him, offered snacks and walked with him. The resident returned to his room. According to the note, he had been in bed for several hours before staff heard a female resident yelling out at approximately 2:30 a.m. The note read Resident #199 entered Resident #23's room which was directly across from his room. He tried to lay beside the female resident and insisted to staff he was in his bed. The note indicated Resident #199 was resistant but returned to his room. However, a second note read he attempted to enter another resident's room at approximately 4:30 a.m. but was redirected by staff. A review of Resident #23's record revealed a 7/1/2021 nursing note that read Resident #23 was startled on 7/1/21 at 2:30 a.m. when Resident #199 wandered into her room and had attempted to get into bed with her. Resident #23 called out for help to get him out of her room. According to the note, the resident said Resident #199 tried to get in bed with her and Resident #23 called him a dirty old man. Resident #23 was interviewed on 7/26/21 at 3:50 p.m. She said a few weeks prior to the interview, a male resident (describing Resident #199) entered her room and got in bed with her when she was sleeping. Resident #23 said the male resident was only in his underwear and pulled the covers and scooted next to her. She said she screamed loudly and the staff got him out of her bed. She said it happened twice. She said the second time he started to get in bed with her, she yelled out, scaring him away. Resident #23 said she did not want to think of him anymore. She said she was upset he still lived in the facility and feared him. Licensed practical nurse (LPN) #2 was interviewed on 7/26/21 at 6:10 p.m. She said she had been told a male aide had to physically lift Resident #199 out Resident #23's bed because he would not get out of her bed. LPN #3 was interviewed on 7/28/21 at 4:28 p.m. She said Resident #199 frequently wandered in other resident rooms and he attempted to crawl in bed with Resident #23. She said she had heard Resident #199 had gotten in bed with another resident before. She said he liked females that looked like his wife and would refer to them as his wife. She said staff heard Resident #23 yelling and entered Resident #23's room; it was in the middle of the night, so she did not alert upper management. The LPN said she wrote a note, charted the behavior. She requested a door alarm be put in his room and she had seen it in place the following night. b. Facility response Notwithstanding this was a second incident, two days after the first incident of Resident #199 entering a female resident's bed, interview and record review revealed no evidence the facility identified the incident as potential sexual abuse, investigated the incident (cross-reference F610, reported the incident (F609) or took steps necessary to protect Resident #23, as well as other residents, from further abuse by Resident #199. Specifically: Review of the facility's July 2021 grievance log revealed documentation that read, on 7/1/21 a man entered Resident #23's room and she and the roommate were upset about it. The log read Staff intervened, no sexual issues, male resident precautions enacted and staff were educated. However, there was no documentation on how staff determined there were no sexual issues, no explanation of male resident precautions, and what education staff received. Moreover, the action plan associated with the grievance was not presented by the facility. Resident #23, during her interview on 7/26/21 at 3:50 p.m. said she said she was not asked by staff what happened or how she felt about Resident #199. LPN #2, in an interview on 7/26/21 at 6:10 p.m., said after the incident on 7/21, she got a report that staff needed to watch Resident #199, know where he was at all times and a door alarm was added to his room at that time. However, review of the residents' nursing notes revealed no further documentation of the 7/1/21 incident. Likewise, a review of the residents' care plans revealed neither resident's care plan was revised after the 7/1/21 incident to include revised or new interventions following the incident. Specifically, Resident #199's care plan was not revised to ensure staff consistently increased his level of supervision. Further, there was no documentation, confirmed during interviews with the nursing home administrator (NHA) and director of nursing (DON) (see final administrative interviews below), that the incident was thoroughly investigated by the facility until 7/27/21 (during survey) (Cross-reference F610) and reported to the state, the residents' physicians, or families until 7/27/21 (Cross-reference F609) 3. Undocumented incidents a. Staff reported a number of potentially sexually abusive incidents involving Resident #199 and #16. On 7/26/21 at 12:49 p.m. LPN #1 said Resident #199 sought out Resident #16. He said Resident #199 believed Resident #16 was his wife. He said he was informed by another nurse that Resident #199 openly kissed her, referring to Resident #16. Asked to clarify, he could not recall who informed him. The NHA and the DON were interviewed on 7/26/21 at 9:44 a.m. The DON said she learned from staff during the initial investigation of the most recent incident involving Resident #199 on 7/25/21 (see below) that Resident #199 had tried to kiss Resident #16. Nurse aide (NA) #1 was interviewed on 7/26/21 at 12:59 p.m. NA #1 said he often saw Resident #199 wandering in and out of other resident rooms. He said Resident #199 thought Resident #16 and Resident #44 were both his wife. The NA said he had seen Resident #199 bent down to talk to them, holding their hand in a flirtatious and cheerful manner. He said he would usually separate the residents when he saw the flirtatious behavior. He said he had not been asked by management to separate the residents; he said he did it because he did not want the behavior to escalate. CNA #4 was interviewed on 7/26/21 at 6:36 p.m. She said she worked overnights from 5:30 p.m. to 6:00 p.m. She said Resident #199 goes into Resident #16's room but could be redirected. CNA #4 said Resident #16 does not like Resident #199's attention towards her. LPN #2 was interviewed on 7/26/21 at 6:10 p.m. The LPN said Resident #199 tended to push Resident #16's wheelchair because he thought she was his wife. She said he holds her hands and rubs her back. The LPN said they encourage and try to redirect Resident #199 from pushing Resident #16's wheelchair because he would push it too fast. b. Facility response Review of both Resident #199 and #16's records revealed no documentation of the incidents reported by staff. Neither residents' nursing notes or care plans referenced Resident #199's behavior toward Resident #16, including the need to keep them separated as reported by staff. Resident #199's care plan was updated 7/20/21 to read he was at risk of injury due to wandering/exit seeking episodes, to place STOP signs across doorways of residents who agree to deter wandering resident from entering uninvited, and to assign the resident a room in a location of increased staffing where resident whereabouts are easily monitored. However, although CNA #4 (interviewed 7/26/21 at 6:36 p.m.) said, prior to 7/25/21, staff was told to keep an extra eye on Resident #199 and conduct 15 minute checks because he entered other residents' rooms, as noted above, his care plan was not revised to include these instructions to ensure staff consistently provided this increased level of supervision. Finally, there was no documentation, confirmed during interviews with the nursing home administrator (NHA) and director of nursing (DON) (see final administrative interviews below), that Resident #199's inappropriate behaviors toward Resident #16, which staff knew Resident #16 disliked, were thoroughly investigated by the facility until 7/26/21 (during survey) (Cross-reference F610) and reported to the state, the residents' physicians, or families until 7/26/21 (Cross-reference F609). At this time, and after the 7/25/21 incident (see below), Resident #199 was placed on one on one monitoring 24 hours a day, seven days per week until he was discharged home with family. C. Current incidents involving Resident #199 and Residents #44 and #16 1. Observations 7/25/21 revealed Resident #199 unattended on Resident #44's hallway and Resident #44 in her room, exposed. Observations also revealed Resident #199 pushing Resident #16 in her wheelchair, unsupervised. After being informed of the observations, staff initiated interventions. -At 8:04 p.m. Resident #199 was observed walking down the 200 hall (where Resident #44 resided) toward the nursing station. He was alone in the hallway. Staff were not observed in the 200 hall. -At 8:05 p.m. Resident #44 was observed in her room facing her bed. The bottom of her shirt was pulled up over her head and behind her neck. Her breasts were exposed, her shoulder and back remained covered. -At 8:06 p.m. RN #4 was informed of Resident #44's exposure and at 8:07 p.m. she entered the resident's room and dressed the resident in a hospital gown. -At 8:35 p.m., Resident #199 was observed standing over Resident #16, facing her with his hands on each wheelchair armrest. He attempted to move her wheelchair. CNA #2 quickly called out to CNA #4 and said the residents needed to be separated. After separation, CNA #2 said Resident #199 could be very sexual and believed Resident #16 was his wife so they tried not to leave them alone together. -[TRUNCATED]

Based on observations, interviews and record review, the facility failed to provide sufficient, competent nursing staff to ensure residents received the care and services they required in a timely manner in two of two resident hallways and one of one dining room. Specifically, the facility failed to: -Provide sufficient staff supervision to prevent residents who tended to wander, contributing to potential resident-to resident sexual and physical abuse in the facility; -Provide sufficient staff to assist residents with activity of daily living (ADL) tasks, to avoid untimely toileting assistance, contributing to residents experiencing incontinence, poor personal hygiene, and anger and frustration from lying in soiled linens. -Provide sufficient staffing to ensure residents who required assistance with eating received timely and consistent assistance at mealtime; -Provide sufficient staff to address repeated resident council concerns and residents' reported concerns about staffing; and -Develop quality index measures to ensure the residents' needs were being addressed in a timely manner. Cross-reference F585, grievances; F600, freedom from abuse; F677, ADL care provided for dependent residents; and F744, dementia treatment and services. Findings include: I. Facility policy and procedure The Staffing policy, provided by the social services director (SSD) on 7/29/21 at 11:17 a.m., read the facility provided sufficient number of staff with the skills and competency necessary to provide care and services for all residents in accordance with resident care plans and the facility assessment. It read licensed nurses and certified nursing assistants were available 24 hours a day to provide direct resident care services. It further read that staffing numbers were determined by the needs of the residents based on each resident's plan of care. II. The facility failed to provide a sufficient number of staff with the skills and competency necessary to ensure care and services for all residents in accordance with the residents' needs for care and services. A. Resident census and conditions The census and conditions form dated 7/21/21 read currently 51 residents lived in the facility and identified the residents' needs for the following care and services: -Sixteen to 39 residents needed the assistance of one or two staff for their ADL care; -Two to 17 residents were totally dependent on staff for the ADL care; -Fourty-five residents were frequently incontinent of bladder; -Thirty-three residents were frequently incontinent of bowel; -Thirty-seven residents were in their wheelchairs all or most of the time; -Thirty-four residents had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] -One resident had a current pressure injury and 51 residents received preventative skin care; -Five residents received hospice services; -Nine residents received respiratory treatment; -One resident received ostomy care; -Four residents had contractures; and, -Thirty-seven residents were on a pain management program. B. Observations revealed an insufficient number of staff to timely respond to residents' call lights, to ensure residents known to wander received adequate supervision, and to assist residents at mealtime. 1. Insufficient number of staff to timely respond to residents' call lights Call light observations were conducted on 7/21/21 at 4:31 p.m. -At this time, call lights were going off simultaneously in both rooms [ROOM NUMBERS], the last two rooms on the right side of the 200 hall. The resident in room [ROOM NUMBER] stated his call light had been going off for 10 minutes. The resident said staffing was his biggest concern and that staffing was worse on weekends; therefore, it was worse than was presently being observed. Staff were observed answering other resident call lights before making it down to the end of the hall. Other residents were being assisted to the dining room at this time. -At 4:42 p.m. the resident in room [ROOM NUMBER] approached the surveyor, stating he wanted his fan turned on. He said he had his call light on for 10 minutes, but no one had answered it. At this time, the maintenance director was observed painting the outside of room [ROOM NUMBER]'s door and did not answer either 216 or 214's call light. Both call lights had been going off for 15 minutes at this time. -At 4:45 p.m., nurse aide (NA) #1 answered the call light of room [ROOM NUMBER]. The NA asked the surveyor how long the resident's call light had been sounding. -At 4:46 p.m., the NA answered the call light for the resident in room [ROOM NUMBER]. The resident's needs were met and the call light was turned off at 4:48 p.m. 2. Insufficient number of staff to supervise residents known to wander Interviews with administration revealed the facility had opened up the memory care unit that had been secured so all residents, including those that wandered, resided among the general population. The facility was now entirely open. a. On Sunday, 7/25/21 at 7:15 p.m., surveyors entered the facility. Resident #34, who, per her care plan, was at risk for elopement and wandering and who was encouraged to remain in areas with increased supervision, was observed seated at the COVID-19 screening desk in the lobby, immediately upon entrance. She was by herself, playing with several surgical masks, and staff were not readily visible to either observe, redirect or engage with the resident. -At 7:20 p.m., the licensed practical nurse (LPN) on duty said there were two nurses and three certified nurse aides (CNAs) in the building at this time. She said the facility should have four CNAs working this shift. -The halls were continuously observed on 7/25/21 from 7:15 p.m. through 8:00 p.m. Resident #199, who, per his minimum data set assessment (6/15/21), intruded on the privacy or activity of others and significantly disrupted the living environment, was observed pacing the halls with staff attempting to redirect him from wandering. -At 9:19 p.m., Resident #34 was observed again. She was picking something off the cleared top of a medication cart and putting it into her mouth. Two male residents (Resident #199 and one other) were in the common area near the nursing station, speaking with the assistant director of nursing (ADON). b. On Sunday, 7/25/21 at 8:04 p.m. and again at 9:15 p.m., Resident #199 was observed in both of the facility hallways, No staff was present or observed anywhere in the area. Resident #199 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . 3. Insufficient number of staff to assist residents at mealtime. a. General observations On 7/21/21, lunch was observed in the main dining room between 11:44 p.m. and 1:25 p.m. Observations revealed many of the residents required extensive meal assistance, cueing, encouragement and/or supervision. There were three certified nurse aides (CNAs) available for the 14 residents in the dining room. During the observation, management was not observed assisting the three staff members in the dining room. Observations of the 14 residents in the dining room identified five were able to eat independently and four of the residents were provided consistent, total meal assistance. Three residents were provided total meal assistance intermittently. One resident needed occasional total meal assistance and/or cueing. Two other residents in the dining room required assistance but they did not receive assistance with their meal until over an hour after they were served their food. CNA #8 and CNA #11 each sat next to two residents requiring total meal assistance. The third CNA, CNA #12, was responsible for assisting four residents at three different tables. The lack of staff in the dining room resulted in several residents experiencing a delay in eating, eating cold food, and/or not eating all the food they could have eaten, if they had received consistent meal assistance. b. Observations of residents at four different tables 7/21 and 7/25/21 (1) Resident #36 - observations 7/21/21: Resident #36's record revealed she was cognitively impaired. Her minimum data set (MDS) assessment dated [DATE] revealed she required extensive assistance of one with her meals. -At 12:03 p.m. Resident #36 was served lunch at the far right corner table. The resident was served a meal consisting of meatloaf with tomato sauce, soft broccoli cubes and mashed potatoes. The resident was not offered finger foods. -At 12:08 p.m. She was observed looking at her plate of food. She did not have staff sitting next to her, providing meal assistance and encouragement. -At 12:16 p.m. Resident #36 tried to eat her meal. Her finger and thumb were placed together and she pinched at the mashed potatoes, licking the potatoes off her fingers and then biting her fingers. Her plate was half off the table. -At 12:21 p.m. Resident #36 attempted to feed herself a second time. Her full plate of food fell to the floor. CNA #12 cleaned up the spill from the floor. -At 12:23 p.m. CNA #12 served the resident a new plate of food and pushed the resident up to the table. The CNA did not stay with the resident to provide meal assistance. Resident #36 proceeded to attempt to eat the meatloaf, broccoli and mashed potatoes with her fingers. The resident continued to bite her fingers when she placed them in her mouth. -Between 12:23 p.m. and 1:14 p.m., Resident #36 continued to attempt to eat her meal with her fingers. Most of the food fell to the floor underneath her. At times, she attempted to pinch empty spots on her plate, searching for the food. She did not receive meal assistance from staff. She did not attempt to drink from her second cup on the table. She was not encouraged or offered assistance with her drink. -At 12:57 p.m., 10 percent of the meal remained on her plate and 50% to 75 % was on the floor around her. CNA #8 said Resident #36 was almost done with her food. The CNA did not offer to assist Resident #36 with the remainder of the food and drink. The CNA did not notice or acknowledge that most of the resident ' s food was on the floor. -At 1:16 p.m. CNA #11 offered and assisted Resident #36 with three sips of her drink and the rest of the food on her plate. CNA #12 was heard telling CNA #11 that the resident ate well after she was offered a second plate. CNA #12, too, did not notice or acknowledge most of the resident's food was on the floor. -At 1:18 p.m. Resident #36 was taken out of the dining room. Observations above revealed Resident #36 was not offered meal assistance for over an hour after she was served, resulting in a spilled plate of food and low meal intake. Throughout the meal she ate only with her fingers; however, no finger foods were offered, even after staff interacted with her. (2) Resident #2 - observations 7/25/21: Record review revealed Resident #2 was totally dependent on staff with eating. On 7/25/21 at 12:04 p.m. Resident #2 and another resident requiring total meal assistance were served their lunch at the back table. -At 12:05 p.m. CNA #12 assisted the Resident #2 with his thickened drinks. -At 12:06 p.m. the CNA left the back table to provide meal assistance to a resident at the center table and a resident at the table in the back far left corner. -At 12:13 p.m. Resident #2 was offered a bite of his food before CNA #12 left again to assist a resident at another table. -At 12:20 p.m. CNA #12 provided total meal assistance to the second resident at the back table who continued to attempt to kick her in a non-aggressive manner. -At 12:23 p.m. CNA #12 returned to Resident #2. She started to assist him when she was pulled away to clean up a spill from across the room. -At 12:30 p.m. CNA #12 returned to the back table to assist the second resident. -At 12:32 p.m. the second resident completed his meal. -At 12:32 p.m. CNA #12 proceeded to help Resident #2 eat. She offered him one bite before assisting another resident at another table. -At 12:38 p.m. CNA #12 returned to the back table and offered Resident #2 four more bites of his lunch before leaving the table to assist another resident. -At 12:53 p.m. CNA #12 offered Resident #2 a spoonful of his thickened juice and a bite of his dessert. -At 12:54 p.m. CNA #12 left the table to assist another resident out of the dining room. -At 1:11 p.m. CNA #11 sat next to Resident #2 and offered the resident two more bites of food and a spoonful of drink. -At 1:14 p.m. CNA #11 assisted Resident #2 out of the dining room. Observation above revealed Resident #2 was offered 25% of his pureed meal, 25% of his dessert and 25% of his drinks during an hour ' s time. The meal was never observed to be warmed throughout the hour. The resident never refused to eat or drink during the observation. Low meal intake was a result of inconsistent meal assistance to the dependent diner. The low meal intake was not based on resident choice. (3) Resident #18 and Resident #33 - observations 7/21/21: Record review revealed the following: The MDS dated [DATE] documented Resident #33 required limited assistance of one for his meals. The MDS dated [DATE] documented Resident #33 required extensive assistance from one for his meals. On 7/21/21 at 12:06 p.m. Resident #18 and #33 were observed at the center table. Resident #18 ' s meal assistance needs fluctuated between independent eating with cueing, and total meal assistance. At times, Resident #18 was observed putting an empty spoon in his mouth. The second resident at the table, Resident #33, was observed to require total meal assistance. -At 12:11 p.m. CNA #12 provided meal assistance to Resident #18 at the center table. The resident finished his first offered plate of lunch. Resident #33 slept as his meal sat in front of him. He was not aroused to wake and eat. -At 12:33 p.m. CNA #11 provided a second plate to Resident #18 and provided meal assistance. -At 12:36 p.m. Resident #33 remained asleep with his meal in front of him. There were no attempts to wake him. -At 12:50 p.m. Resident #33 was awakened by CNA #11. She sat next to him and offered him a sip of his drink before assisting another resident. -At 1:02 p.m. Resident #33 was offered his first bite of food. The food had sat in front of him for over an hour before staff attempted to wake and provide meal assistance. The food was never warmed before he was offered the bites. (4) Unidentified Resident - observations 7/21/21: On 7/21/21 at 12:13 p.m., CNA #12 was observed providing total meal assistance to a lone resident in the left back corner before leaving to assist another resident. -At 12:16 p.m. CNA #12 returned to the resident in the corner and offered five more bites of food. Between 12:40 p.m. and 12:50 p.m. CNA #12 returned to the corner table and continued to offer the resident food and drink. -At 1:03 p.m. the resident was observed alone at the corner table. Her meal intake was observed. The resident ate 25% of her meal, 25% of her dessert, 25% of her chocolate milk and 75% of her juice. Her glass of water remained full. Observations revealed the resident was not offered consistent meal assistance until 12:40 p.m., 35 minutes after she was served. c. Continuous dining observations on 7/26/21, from 11:38 a.m. through 12:30 p.m. -At 11:38 a.m., licensed practical nurse (LPN) #1 was in the dining room with his medication cart, passing medications. One unidentified CNA was passing drinks out to the residents. Resident #41: Resident #41 was dependent on staff for meal assistance. She required frequent cuing and up to extensive assistance for meals, which was care planned. The MDS dated [DATE] documented that the resident required extensive assistance of one for her meals. -At 11:50 a.m., Resident #41, who was observed in a high-backed wheelchair, was seated at a table by herself without any staff interacting with her. The resident held her head in her hands with her meal in front of her. -At 12:02 p.m., CNA #6 assisted Resident #41 with her meal for two minutes before leaving to assist another table. -At 12:10 p.m., Resident #41 spilled her meal and the dietary manager (DM) brought her another plate of food. -At 12:11 p.m., CNA #6 returned to assist Resident #41 with her second delivered meal. Again, CNA #6 assisted Resident #41 for a minute or two, then left to assist other residents. -At 12:27 p.m., Resident #41 began clapping her hands at the table and CNA #6 returned to assist her. Resident #18: Resident #18 had his meal delivered by the DM at 11:58 a.m. -At 12:07 p.m., no one had encouraged the resident to start eating or physically assisted the resident with his meal. -At 12:21 p.m., CNA #6 was observed going over to Resident #18 to encourage him to eat and was overheard commenting that he had not eaten very much. Resident #18 immediately started eating his meal with staff encouragement. Additional observations during the lunch meal on 7/26/21: -LPN #1 was observed sitting with Resident #199 for one on one observations, but the LPN was not observed assisting either Resident #199 or any other resident with their meal. At 12:24 p.m., LPN #1 and another unidentified staff were overheard conversing with each other and not interacting with the residents in the dining room. -CNA #6 was observed assisting four different residents at two separate tables. She was observed leaving the dining room at 12:23 p.m. while 15 residents were still eating in the dining room. She returned to the dining room at 12:26 p.m. No staff was observed taking CNA #6's place in her absence. C. Record review revealed on-going concerns related to a lack of a sufficient number of staff to ensure care and services for all residents, gaps in the number of staff assigned to all shifts, and lack of quality index measures, such as call light audits to determine if residents' needs were being addressed in a timely manner. 1. Resident council minutes The resident council minutes were reviewed from 2/18/21 through 7/15/21. Residents brought the following issues to the facility's attention related to staffing: -2/18/21: Call lights taking a long time to get answered, (Resident's name) stated it took 30 minutes to answer her roommate's call (2/17/21 from 4:30 to 5:00). (2nd Resident's name) said it takes them a long time to help her to the bathroom as well. Two residents stated they were only receiving one bath a week and wanted to be bathed twice a week. Another resident wanted to remind staff she needed more help than she did in the past. Yet another resident said she would like her bedding changed more often. -3/18/21: Call lights are getting better, but they still need some work. Residents expressed worry over how long their roommates and friends call lights were taken to get answered. Residents stated staffing was a problem in the afternoons. It was documented that the NHA would be speaking to the residents about a call light audit the facility had been wanting to conduct to assist with call light response time. Residents stated they were still not getting their bed linens changed as often as they would like or getting their dirty laundry picked up often enough. -4/14/21: Call light had improved after our last Resident Council Meeting, but they are back to taking a long time again. (Resident's name) stated she had to wait from 3:00 to 6:00 to use the restroom. It was documented the DON spoke to the residents about changes being made, such as new CNA schedules, that would assist with sufficient opportunities to bathe and with call light response times. -5/12/21: Call lights have improved but still needs more work. -6/23/21: One resident expressed concern she did not receive her medications from a night nurse. -7/15/21: Residents expressed concerns that wandering residents were still coming into their room, uninvited and unwanted. Residents feel it is taking a long time to get their call lights answered. They feel we need more staff. One resident expressed fear for his roommate, as his roommate moved quickly and staff did not always get to their room timely before his roommate would transfer himself to bed or toilet himself when he was unable to do so safely. 2. Resident grievance forms A resident grievance form, dated 7/15/21 and signed by the NHA on 7/19/21, documented that a resident complained about the facility not having enough staff to respond to call lights or to meet the needs of residents. The facility's response was ongoing hiring probes. It documented ads would be placed on Indeed, Facebook, a local newspaper and on local message boards. 3. Daily nursing staffing schedules The daily staff schedules, provided by the DON on 7/21/21, were reviewed from 6/20/21 through 7/24/21. There were gaps in all nursing positions and shifts during this timeframe, especially on the night shifts. New daily staff schedules were provided by the DON on 7/26/21. The nurse's schedule had been updated on 7/23/21 and the CNA schedule had been updated on 7/25/21. A greater number of both nurses and CNAs were included on the new schedules created by the DON. D. Call light audits The NHA was interviewed on 7/29/21 at approximately 3:00 p.m. He said, to his knowledge, the facility had not conducted any call light audits that he had documentation on. Although call lights had been an on-going issue for a number of months (see Resident Council minutes above), no call light audit documentation was provided during this survey. III. Resident interviews confirmed the facility failed to ensure sufficient, competent staff to meet the residents' needs, contributing to residents experiencing incontinence, poor personal hygiene, and anger and frustration from lying in soiled linens. A. Group interview The group interview was conducted with residents deemed by the facility as alert and oriented. According to the group, the facility continued to be short staffed, impacting resident care needs and contributing to long call light waits. The residents said there were also not enough staff on the weekends to help everyone. They said the CNAs did everything they could but there were not enough of them. They said they have complained in Resident Council but nothing has changed. B. Interviews with residents determined by the facility to be interviewable: Resident #11 was interviewed on 7/21/21 at 11:31 a.m. and said the facility had a sufficient number of nursing staff scheduled, but the residents' needs were still not always being met in a timely manner. She said staff were often outside smoking when the residents needed them, rather than working on the floor. Resident #25 was interviewed on 7/21/21 at 11:43 a.m. and said the facility did not have enough staff and it impacted the amount of desired showers the residents received in a week. She said she would ask why the residents were not receiving their showers as scheduled and never received any good excuse from the staff. Resident #10 was interviewed on 7/21/21 at 12:06 p.m. and said the facility was way understaffed on a daily basis. He said the staffing shortage was mainly CNAs and the shortage occurred on all shifts. He said the shortage affected him by delays in assistance to the toilet and in assistance with shaving. He said an average call light response time was five to ten minutes, but he has often waited 18 to 20 minutes for his call light to be answered. He said staffing was also worse on the weekends. Resident #47 was interviewed on 7/21/21 at 3:36 p.m. She said the facility did not have enough nursing staff working the floor and, sometimes, especially at night, it could take up to an hour for her call light to be answered due to insufficient staffing. She said this delay was very frustrating for her. Resident #24 was interviewed on 7/21/21 at 3:49 p.m. He said the facility did not have enough staff, especially on weekends. He said he had experienced some urinary incontinence due to delayed call light response times. He said five minutes was an average call light response time, but he had experienced several wait times of ten to 15 minutes. Resident #13 was interviewed on 7/21/21 at 4:06 p.m. and said she did not feel the facility had enough nursing staff, especially during the night shift when the facility only had CNAs and one nurse. She said sometimes it took a long time for staff to answer her call light and for her to receive toileting help. She said she had wet her pants while waiting for assistance and she had to sit and wait until staff got to her. She said it made her feel angry and helpless. Resident #46 was interviewed on 7/21/21 at 4:34 p.m. and said the facility did not have enough staff working, as evidenced by poor call light response time. He said staffing was worse on weekends. Resident #3 was interviewed on 7/21/21 at 4:55 p.m. and said she wanted to have a shower twice a week, but the facility was short staffed and she only received a shower once a week. It was noted there was an odor of urine surrounding the resident during this interview. Resident #40 was interviewed on 7/22/21 at 10:59 a.m. and said she had to wait a long time for staff to answer her call light and help get her up. She said by the time they came to assist her in the morning, both she and her bed were soaked with urine. She also said she did not routinely receive a shower on her scheduled days because someone did not show up for work, and observations revealed the resident's hair was oily. Resident #100 was interviewed on 7/26/21 at 1:21 p.m. and said she did not feel the residents were receiving quality care at the facility because of staffing. She said, I think, for one, a lot of staff don ' t want to be here. They don't listen to the residents and don't follow through with what they say they will do. She said if all staff actually did their assigned jobs, there would be enough help. She said some staff just come to work for a social hour and visit with each other and not the residents. She said an average call light response time depended on which staff were scheduled to work. She said during the past weekend, on 7/24/21, she had to wait 20 minutes for her call light to be answered on the day shift. She also said her roommate had to wait forever for assistance to the toilet and sometimes she had to wait so long, she could not get to the toilet in time and had an incontinent accident. Resident #42 was interviewed on 7/26/21 at 6:30 p.m. She said the facility did not have enough staff to monitor the roamers (wanderers). She said, It's not that kind of a facility. She did not elaborate on that statement. VII. Staff interviews A. Direct care staff interviews revealed staff found it difficult to keep all residents safe, to complete care and to provide residents quality attention. CNA #4 was interviewed on 7/25/21 at 7:35 p.m. She said the facility had been working short-staffed ever since she started working in the facility several months ago. -She said it was very difficult to keep eyes on certain residents who wandered while performing their other duties. She said it was hard to keep all residents safe when residents wandered around unsupervised because some of the wanderers could become violent when redirected away from somewhere they wanted to go. She also said residents whose rooms were entered by the residents who wandered could become physical in trying to get the confused residents out of their room, as they were unwanted visitors. -She said it was hard to monitor and keep residents safe when they were trying to assist other residents to bed. She said the third CNA assigned to the evening shift today went off duty at 10:00 p.m., leaving only two CNAs on the floor for 50 plus residents. She said two CNAs could not assist with one on one care and give the quality attention to the residents that they want and deserve. She said it was hard to assist residents with their desired number of baths and take out all the residents who wanted to smoke. -She said she thought an average call light response time was about five minutes and the longest was maybe eight minutes. She said it was sometimes difficult to find the second person to assist with mechanical or two-person transfers. She said one resident required a Hoyer lift, six residents required a sit-to-stand mechanical lift and seven residents needed two-person transfers. CNA #3 was interviewed on 7/25/21 at 7:44 p.m. She said staffing had been inadequate and stressful recently, as the facility was short two CNAs who were out with COVID-19. She said the facility was short this evening shift. She said the facility should have four CNAs working the night shift. Two of the CNAs should be scheduled for the 2:00 p.m. to 10:00 p.m. shift to assist the others with getting the residents to bed. -She said lack of staffing was stressful for both residents and staff. She said, I get burned out, residents get upset and are running around, feeling ignored. She said the resident care eventually got done, but care was performed slowly. She said she felt opening the doors to the memory care unit was both a good and bad thing. She said the CNAs were able to work together more, but the residents were wandering more and causing more issues with staffing. She said this required a lot more redirection on the staff's part and they could not always redirect all residents. She said residents were getting more annoyed with each other and kept bickering. -She said the facility just needed more employees, specifically more CNAs to cover every shift. She said it could be difficult to find a second person to assist with transfers and it usually took her 15-20 minutes to find someone and transfer a resident. She said the worst case scenario recently when the facility was short-handed was waiting 30-45 minutes to find assistance to complete a safe transfer of a resident. She said sometimes the residents are going without cares, like getting their second requested shower per week. She said Resident #10 told her he felt so dirty if he did not get a second shower weekly. LPN #2 was interviewed on 7/25/21 at 7:31 p.m. and again at 8:04 p.m. She said the night staffing consisted of an LPN, a RN, and three CNAs in until 10:00 p.m. LPN #2 said at 10:00 p.m. there were two CNAs and two nurses. She said she helped the aides with care needs at that time. -She said the facility's staffing was strained, but she felt that was the case everywhere due to COVID-19. She said it was not due to the facility's lack of trying and the facility was advertising for help in local papers and on social media. -She said she had noticed more residents wandering around aimlessly since the memory care unit doors were opened. She said residents get upset when confused residents wander into their rooms, but are understanding. She said residents would attempt to verbally redirect other residents out of their rooms and, on occasion, physically redirect, but staff knew which residents wandered and tried to redirect those residents away from others' rooms before anything happens. The assistant director of nursing (ADON) was interviewed on 7/25/21 at 8:01 p.m. She said she was not routinely at the facility at night but came in as needed. She said she felt the facility was well staffed for care needs at night. The ADON said there were many staff that preferred to work at night and management was only five minutes away if there was a concern. CNA #2 was interviewed on 7/25/21 at 8:18 p.m. CNA #2 said the nights could be very busy and difficult. She said there were multiple residents with a lot of care needs requiring two people, especially in the 200 hall. She said the facility could use more staff to meet everyone's needs. CNA #7 was interviewed on 7/28/21 at 9:29 a.m. She said staff had to keep redirectin [TRUNCATED]

Based on observations, record review, and interviews, the facility failed to ensure a resident diagnosed with dementia, received the appropriate treatment and services to attain or maintain his or her highest practicable physical, mental, and psychosocial well-being for three (#29, #34 and #199) of seven residents reviewed for mood and behavior out of 34 sample residents. Resident #199 had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Due to the facility failures of not identifying approaches to address his behaviors, Resident #199 was involved in incidents of abuse involving female residents (cross-reference F600 for abuse). Additonally, the facility failed to address Resident #34 dementia care needs with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Observations and record review revealed the resident had behaviors of wandering into other resident rooms. Due to the facility failures, the resident was involved in a resident-to-resident altercation that involved her wandering to another resident's room (cross-reference F600). Furthermore, the facility failed to address Resident #29 dementia care needs with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Lastly, the facility no longer had a secured dementia care unit and those residents were placed into the general population placing them and others at risk which closed around May 2021 (see director of nursing interview). The facility failed to prevent actual and potential resident-to-resident abuse involving wandering, behavioral and predatory residents to meet their highest practicable physical, mental and psychosocial well-being (cross-reference F600). Findings include: I. Professional reference The Alzheimer's Association (last updated 3/30/2020) Tips for Dementia Caregivers in Long-Term or Community-Based Settings, retrieved on 8/4/21 from: https://www.alz.org/professionals/professional-providers/coronavirus-covid-19-tips-for-dementia-caregivers?_ga=2XXX 437XXX XXX - XXX &_gac=1XXX 9244XXX .eaiaiqobchmiqfd6qvlr6wivqdbach2thgoceaayasaaegl_8pd_bwe. It read in pertinent part, Nonverbal dementia-related behaviors may be an option or response for a person living with dementia to communicate a feeling, unmet need or intention. These behaviors are triggered by the interaction between the individual and his or her social and physical environment. A response may include striking out, screaming, or becoming very agitated or emotional. The dementia care provider's role is to observe and attempt to understand what the person living with dementia is trying to communicate. Root causes of dementia-related behaviors may include: -Pain. -Hunger. -Fear, depression, frustration. -Loneliness, helplessness, boredom. -Hallucinations and/or overstimulation. -Changes in environment or routine. -Difficulty understanding or misinterpreting the environment. -Difficulty expressing thoughts or feelings. -Unfamiliarity with personal protective equipment or clothing, such as gowns or masks. Strategies to observe and respond to dementia-related behaviors include: -Rule out pain, thirst, hunger or the need to use the bathroom as a source of agitation. -Speak in a calm low-pitched voice. -Try to reduce excess stimulation. -Ask others what works for them. -Validate the individual's emotions. Focus on the feelings, not necessarily the content of what the person is saying. Sometimes the emotions are more important than what is said. -Understand that the individual may be expressing thoughts and feelings from their own reality, which may differ from generally acknowledged reality. Offer reassurance and understanding, without challenging their words, can be effective. -Through behavioral observation and attempted interventions, try to determine what helps meet the person's needs and include the information in the individualized plan of care. -Be aware of past traumas (veterans, abuse survivors, survivors of large-scale disasters). Never physically force the person to do something. Proactive strategies for addressing dementia-related behaviors It can be difficult to anticipate and respond to dementia-related behaviors in a changing environment-especially in emergency situations. However, applying some of the following strategies may help: -Provide a consistent routine. -Use person-centered care approaches for all individuals living with dementia during activities of daily living-every interaction or task is an opportunity for engagement. -Promote sharing of person-centered information across the care team. -Encourage all staff to treat individuals living with dementia with dignity and respect. -Put the person before the task. II. Facility policy and procedure The Dementia care policy and procedure, revised 7/20/21, was provided by the nursing home administrator (NHA) on 8/4/21 at 4:48 p.m. The policy documented in part, General approach: -Involve the resident or family/representative in discussions about the potential use of any specific approaches to his/her care; -Recognize that every interaction a resident has with the environment and staff members offers us an opportunity to promote a sense of purpose, pleasure, success and a feeling of being normal; -Providing care that is focused on what each resident needs to maintain dignity and a posibit sense of self; -Tailoring personal care approaches, meal service and activities to the individual by paying close attention to past life history, as well as current functional and cognitive levels. Basic dementia care approaches: -Re-direct whenever possible away from high stress environment such as loud noises or activity; -Provide stimulation to decrease boredom activities including one on one from direct care givers. Physical environment: -Respond to any behavior of distress/emotional as an unmet need versus attention to preventing escalation of distress; -Assess the environment regularly for too much or too little noise, light, and stimulation. III. Resident census and conditions The 7/21/21 resident census and condition form documented 51 total residents with 34 residents (76%) with dementia and 26 residents with behavioral healthcare needs (51%). The facility used to have a secured memory unit, however; this was disbanded and the residents that required a secured unit now resided in one unit with other residents. IV. Resident #199 A. Resident status Resident #199, age 84, was admitted on [DATE]. According to the computerized physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . According to the 7/27/21 minimum data set (MDS) assessment for a significant change, a brief interview for mental status (BIMS) could not be completed. According to the MDS, the resident's cognition was moderately impaired. The MDS assessment identified that Resident #199 had impaired short and long term memory. He had disoriented thinking and inattention to focus, fluctuating in severity. The resident had delusions. The MDS indicated the resident had multiple behaviors which had worsened since admission on 6/15/21. He wandered daily. He significantly intruded on the privacy or activity of others and significantly disrupted the care or living environment. He had physical and verbal behaviors directed towards others, including short-tempered and easily annoyed. The MDS also identified the resident had behavioral symptoms not directed towards others. B. Observations On 7/25/21 at 8:04 p.m. Resident #199 was observed walking down the 200 hall towards the nursing station. He was alone in the hallway. Resident #44, a female resident with severe cognitive impairment, was found in her room with her breast exposed a minute after Resident #199 was observed alone in the hall. At 8:35 p.m. Resident #199 was observed standing over Resident #16 with his hands on each of her wheelchair armrests, facing her. He attempted to move her wheelchair. CNA #2 quickly called out to certified nurse aide (CNA) #4 and said the residents needed to be separated. After separation, CNA #2 said Resident #199 could be very sexual and believed Resident #16 was his wife so they tried not to leave them alone together. At 9:15 p.m. Resident #199 was observed in 100 hallway talking to Resident #16. Staff were not present or observed anywhere in the area. He started to push her wheelchair down the hall towards the 200 hall. Resident #199 was heard to say to Resident #16 I'm going to take you with me to my room. At 9:17 p.m. the assistant director of nursing (ADON) was informed of the observation. She separated the residents, and asked a CNA to take him to the lounge and offer him a snack. The resident went with the CNA. On 7/26/21 at 11:35 a.m. the 7/25/21 video recording was reviewed with the nursing home administrator (NHA) and the director of nursing (DON). The recording revealed on 7/25/21 between 7:58 p.m. and 8:02 p.m. Resident #199 was alone with Resident #44 for four minutes before exiting her room. Cross-reference F600 for abuse, the facility failed to protect residents form Resident #199 who had behaviors of sexual inappropriateness and wandered into other resident rooms. C. Record review 1. Care plan The behavior care plan, initiated on 6/28/21, identified Resident #199 expressed inappropriate verbal and physical behaviors related to dementia. The care plan was revised on 7/28/21 (during the survey) to include inappropriate sexual behaviors. According to the care plan, the resident has had resident to resident altercations and resident to staff altercations. The care plan read the Resident #199 had abused other residents. New interventions included low stimulating breaks, with one-to-one staff supervision outside of his room, when agitated. Utilize behavioral interventions for resident specific care. According to the 7/28/21 revised care plan, Resident #199 was on strict one-to-one staff supervision at all times, and would not be out of sight. -Resident #199 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . His care plan did not include sexual behavior risk until 7/28/21. The mood stabilizer care plan, initiated 6/28/21 read Resident #199 utilized [MEDICATION(S)] for behaviors related to dementia to include verbal outbursts, exit seeking, sudden mood changes, delusions, and resisting care. Interventions included monitoring and record occurrences of target behaviors, monitor increase in behavior problems and report concerns to charge the nurse/IDT(interdisciplinary team)/physician for further evaluation and need for interventions The wandering care plan, initiated on 7/20/21, revised on 7/27/21, identified Resident #199 was at risk for injury related to wandering and exit seeking. According to the care plan, the resident was at risk for abuse from wandering into other resident rooms. Interventions identified in the care plan included staff to orient Resident #199 to others' privacy and where it was appropriate to visit. Assign Resident #199 a room in a location of increased staffing where Resident #199 would be easily monitored and place stop signs across doorways of residents who agree; to deter wandering the resident from entering uninvited. 2. Progress notes Record review identified Resident #199 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . The 6/16/21 nursing note read Resident #199 had difficulty understanding staff when they attempted to assist him to the restroom. According to the note he was verbally agitated. The 6/17/21 nursing note indicated Resident#199 was resistant to care and uncomfortable in environments. According to note, Resident #199 yelled at the staff they did not know what they were doing and he wanted to walk out there, implying his room. The 6/18/21 [CONDITION(S)] committee note read the medical director, physician, pharmacist, social services director (SSD), DON, NHA reviewed Resident #199's medications and behaviors. According to the note, the physician would see the resident and make recommendations and determine if medication or adjustments were needed. If needed. The note indicated the facility would continue to monitor for behaviors and adverse effects. The 6/20/21 physician note read Resident #199 was seen by the physician on 6/18/21. According to the note, Resident #199 was cooperative with care. Physician recommended to continue the current order of [MEDICATION(S)] with oversight. The 6/25/21 nursing note read that the resident did not understand simple directions and it was difficult to toilet. The note identified the resident in a constant delusional state and went through his roommates belongings, upsetting his roommate. The 6/28/21 social service note identified Resident #199 was monitored for behaviors and was administered [MEDICATION(S)] for dementia with behavioral disturbance. According the note, documented behaviors include of persistent anger on 6/21/21, repetitive verbalizations on 6/21/21, resistive to care on 6/15/21, 6/16/21, 6/21/21 and 6/23/21, and socially inappropriate on 6/16/21, 6/21/21, and 6/23/21. First incident of potential sexual abuse was identified on 6/29/21. According to the 6/29/2021 nursing note Resident #199 climbed on the bed of a female resident, (Resident #44). The note read he was straddling her and attempted to lay on top of her. When staff intervened Resident #199 was combative, belligerent and threatening towards the staff involved (Cross-reference F600). The 6/30/21 nursing note identified Resident #199 believed a female resident was wife, and another one his sister. According to the note, the resident was aggressive when staff tried to redirect him from these ideals. The note did not indicate how staff attempted to redirect or what actions he demonstrated towards the female resident where they felt they had to redirect. The 7/1/21 behavior note read staff heard a female resident yelling to get out of her room. According to the note, Resident #199 attempted to lay in bed beside the female resident (Resident #23). (Cross-reference F600). The 7/1/21 behavior note read the resident entered a second resident's room on 7/1/21 at 4:30 a.m. According to the note, the resident was resistant and uncooperative with them as they assisted him back into his room. The 7/5/21 behavior note read a CNA attempted to redirect Resident #199 from the facility exit. According to the note, the resident hit the CNA in the head and hit another CNA in the kidney. The nurse was informed and the resident observed sitting calmly in the lounge. -The note did not indicate the physician was notified of the physically aggressive behavior. The 7/6/21 behavior note read Resident #199 wandered towards the nurses station with his pants down. He was soiled with urine. He tried to move the nurse medication cart and refused to return to his room to be cleaned. After multiple approaches and at times the resident refused to enter his restroom. He told the staff they were going to kill him if he went in there. After multiple approaches, staff were able to clean and change the resident. The 7/14/21 behavior note read Resident #199 set off a door alarm at the back of a hallway at approximately 2:00 a.m. The nurse attempted to redirect him from the area and was told by the resident that he was going to cut their neck and hit her. According to the note, the resident stated to the nurse and CNA why don't you just kill me and your going to kill me aren't you. The note indicated the resident was reassured of his safety and assisted to bed. The 7/16/21 physician note identified Resident #199 was seen for his monthly evaluation. The physician indicated the resident had some incidents over the last month required redirection. A 7/29/21 nurse note written at 12:48 a.m. read Resident #199 had one sexually motivated request with staff. -The note did not clarify the request. The June 2021 and July 2021 individual targeted behavior monitoring log for Resident #199 identified verbal outbursts, exit seeking, sudden mood changes and delusions, and resists care, were recorded on the behavior tracking tool. -Sexually related behaviors and physical aggression were not on the individual targeted behavior monitoring log for June or July 2021. -The facility failed to implement individualized interventions to prevent Resident #199 from wandering into other resident rooms, especially female residents (see observations above) with his history of sexual inappropriate behaviors to prevent resident-to-resident abuse. V. Resident #34 A. Resident #34 status Resident #34, age 83, was admitted to the facility on [DATE]. According to the July 2021 computerized physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . According to the 6/3/21 minimum data set (MDS) assessment, the resident had severe cognitive impairment with short and long-term memory loss. She had moods that included trouble concentrating on things, such as reading the newspaper or watching television, being short-tempered and easily annoyed. She had delusions, physical and verbal symptoms directed towards others and other behavioral symptoms such as hitting, scratching and rummaging. She rejected care and wandered. B. Observations On 7/25/21 at 7:10 p.m., upon arriving at the facility, the front doorbell was rung. Resident #34 was observed sitting at the screening table by the front entrance. She was rummaging through papers and binders. She was also touching and taking surgical masks out of a box. There was no staff observed in the area and a male resident (Resident #100) had come to the door to try and open it. At 8:07 p.m. Resident #34 opened the door to room [ROOM NUMBER] and began to walk into the room. The resident in the room attempted to direct the resident out of the room and a staff member in the area went and removed her from the room. The resident in the room called after the certified nurse aide (CNA) and told her to get her out of here! At 8:54 p.m. the resident was observed wandering up and down the 100 hallway. Licensed practical nurse (LPN) #2 was walking beside her and was not making any attempt to redirect her or offer her a snack or an activity. At 9:20 p.m. Resident #34 was observed at the treatment cart and moving two white baskets around that were on top of the cart. The baskets were empty. Staff were passing by and in the area and did not make any attempt to redirect her. On 7/26/21 at 9:26 a.m. the resident was sitting in the open secure unit dining room at the end of 100 hallway. There were no staff in the area and no other residents. The resident had a half empty glass of water in front of her. At 6:10 p.m. Resident #34 was attempting to enter another resident's room. A nurse was standing just inside the other resident's room at the time. The resident was overheard saying not to let the resident into her room. The nurse guided Resident #34 away from the door. C. Record review A physician's progress note dated 7/2/21 documented in part that the resident's chart showed she had an episode of going into another resident's room and was having difficulty being redirected. The note did not document any recommendations from the physician on how to address her wandering behaviors. The July 2021 CPO documented to monitor for behaviors of wandering due to the need for meaningful activity/relationships. Assist to recliner in room, assist to watch the birds, snacks or juice and provide dry rag/towel every shift for wandering. Order date 7/29/21. A care plan initiated 7/22/16 and last revised on 8/24/2020, identified the resident at risk for elopement and wandering due to dementia, alteration in cognition and history of wandering. Interventions included distracting from wandering by offering pleasant diversions, structured activities, food, and conversation. Encouragement to remain in areas with increased supervision. Identify patterns of wandering. -The care plan did not address strategies to keep the resident from entering into other resident rooms. Behavior tracking logs for June and July 2021 documented the following behaviors being monitored: Slamming doors, increased agitated behaviors, short tempered, hitting/pinching, extreme physical outbursts, pushing and shoving others related to territorial behaviors. In June 2021 she had three episodes of hitting/pinching and three episodes of pushing/shoving. One to one attention and redirection was effective. In July 2021 she had one episode of pushing/shoving. One-to-one staff attention and redirection was effective. The documented episodes occurred during the night shift. -The behavior logs did not identify/document the resident's behaviors of wandering, specifically into other resident rooms (see other resident interviews below). C. Resident-to-resident altercations Resident #34 was involved in a resident-to-resident altercation on 6/26/21 which involved her wandering into another resident's room (Resident #29). Cross-reference F600 for abuse. -The facility failed to implement individualized interventions to prevent Resident #34 from wandering into other resident rooms (see observations above) to prevent resident-to-resident altercations. VI. Resident #29 A. Resident status Resident #29, age 73, admitted to the facility 4/24/16. According to the July 2021 CPO, diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . According to the 6/1/21 MDS assessment, the resident had severe cognitive impairment with short and long term memory loss. She had moods that included trouble concentrating on things, such as reading the newspaper or watching television, being short tempered and easily annoyed. She had delusions, physical behaviors directed towards others and rejection of care. -Wandering behavior was not coded. B. Record review A care plan initiated 8/2/16 and revised on 10/8/2020 identified the resident with a behavior problem related to dementia and anxiety. Interventions included anticipate and meet resident needs, assist the resident to develop more appropriate methods of coping and interacting and intervene as necessary to protect the rights and safety of others. Approach/speak in a calm manner, divert attention and remove from the situation and take to an alternate location as needed. C. Observations On 7/22/21 at 9:36 a.m. the resident was with the activity assistant getting a manicure. At 3:48 p.m. Resident #29 was getting up from a table at the end of 100 hallway and started walking down the hallway towards her room. A staff member was walking after her to give her her walker. On 7/26/21 at 11:37 a.m. Resident #29 was walking down the 100 hallway accompanied by the activity assistant. On 7/28/21 at 2:40 p.m. Resident #29 was walking alone back and forth down the 100 hallway. Throughout the survey beginning on 7/21/21 through 7/29/21, Resident #29 was observed in and out of her room. When she was out of her room she paced back and forth from one area to the other as if she did not know where she was going. She was usually being followed by a staff member. She was observed once opening the door to another resident's room. Staff saw her and redirected her to her room. D. Record review Behavior tracking logs for June and July 2021 documented the following behaviors being monitored: Irritability/temper tantrums, aggression/threats, hitting, kicking/biting, scratching, weepy/crying, episodes of negative/vindictive statements, upset about being in a nursing home, increased agitation over smoking requests (wants immediate gratification), sudden mood changes, physically/verbally attacking staff, delusional ideations (re: personal space, family relations and other residents). In June 2021 she had two episodes of irritability, three episodes of aggression/threatening, one episode of hitting/kicking, eight episodes of negative statements, twelve episodes of physical/verbal aggression, six episodes of being delusional and eight episodes of sudden mood changes. Overall, one to one attention, redirection, decreased stimuli, toileting and repositioning were all effective approaches. In July 2021 she had seven episodes of irritability, two episodes of aggression/threatening, eight episodes of negative statements,one episode of increased agitation, nine episodes of sudden mood change, three episodes of physical/verbal aggression, one episode of being delusional. Overall, one to one and redirection were applied and effective approaches. The resident did have a dose reduction of her antipsychotic medication on 6/21/21. The physician was notified of the failed dose reduction and her previous order for [MEDICATION(S)] was reinstated. Resident #29 was involved in a resident-to-resident altercation on 6/26/21 which involved Resident #34 when she wandered into Resident #29's room. Cross-reference F600. -The facility failed to implement individualized interventions to prevent Resident #29 from wandering into other resident rooms (see observations above) to prevent resident-to-resident altercations. VII. Resident interviews Residents were identified by facility and assessment as interviewable. Resident #25 was interviewed on 7/21/21 at 11:32 a.m. She said that there was a female resident that regularly came into her room; usually at night and she rummaged through her things and tried to take things. She said it was Resident #34. She said she had verbally told her to get out of her room and she did not listen. She said she had to physically escort her out of her room. She said she resented the resident coming into her room and that they (the facility) knew about it. Resident #42 was interviewed on 7/21/21 at 1:15 p.m. She said that there were roamers that go into resident rooms and that they have come into her room even when the door was closed. She said the roamers go through her dresser drawers and have even taken drinks out of her personal drinking cups. She said there was one that was really mean and cussed her out when she came into her room. She said it was Resident #34. She said there was also another female resident that had come into her room and swung her walker around hitting her furniture. She said it was Resident #29 and she did not know if the resident thought it was her room. She said she called on her call light each time for help from staff to get these people out of her room. She said one time a male resident wandered into her room and tried to urinate in the corner of her room. She said she was scared of Resident #29 swinging her walker around and also scared of Resident #34. She said the (the facility staff) knew about it and no one has come up with any solutions. She said she should not have to worry about her safety here. Resident #100 was interviewed on 7/25/21 at 8:08 p.m. She said that every night there were residents out in the hallway wandering around and there was never any staff around to monitor them. She said Resident #34 was constantly getting into things at the nurses station and staff just let her do that. She said Resident #199 was always trying to get out through the doors and he was verbally aggressive towards staff when they tried to redirect him. Resident #47 was interviewed on 7/26/21 at 12:31 p.m. She said a male resident came to her room and got on top of her roommate (Resident #44), wearing only underwear. Resident #47 described the physical characteristics matching Resident #199. Resident #47 said Resident #44 started to scream out and waved her arms to try to get him off of her. She said she yelled out for help and two CNAs took him out of the room. Resident #47 said Resident #44 was non-verbal but she could tell the resident was scared to death from her tone in voice and her facial expressions after the incident. Resident #47 said she shuts the door when she leaves the room if Resident #44 was alone in room to try to protect her roommate from Resident #199. She said for a while Resident #44 wanted to have someone hold her hand before she could fall asleep. Resident #23 was interviewed on 7/26/21 at 3:50 p.m. She said a few weeks prior to the interview, a male resident (describing Resident #199's physical description) entered her room and got in bed with her when she was sleeping. Resident #23 said the male resident was only in his underwear and pulled the covers and scooted next to her. She said she screamed loudly and the staff got him out of her bed. She said it happened twice. She said the second time he started to get in bed with her and she yelled out, scaring him away. Resident said she did not want to think of him anymore. She said she was upset he still lived in the facility and had feared him. She said she was not asked by staff what happened or how she felt about Resident #199. On 7/27/21 at 12:40 p.m. Resident #47 was interviewed again. The resident said she was happy the facility put the stop sign banner across their door. She said it could be a good line of protection for Resident #44 in deterring Resident #199 from entering their room when she was not there to keep a watch. Resident #47 said she wanted Resident #44 to be safe. VII. Group interview The group interview was conducted with residents deemed by the facility as alert and oriented. According to the group, the several residents continue to wander into their rooms including Resident #199. The group said they were very concerned about the wandering residents in their room for privacy and safety. The facility has put up stop signs on the doors and plastic covers on the door handles but nothing has helped (cross-reference F565 for grievances). IX. Resident council minutes The June 2021 and July 2021 minutes revealed for the past two months, the resident council addressed the concern of wandering residents. According to the minutes, confused residents wandered into their rooms. They said the facility had put stop signs on their doors and plastic covers over their door knobs but nothing has resolved their concern. They said they still had the wandering residents in their room, including at night. One resident said she has to remove the residents herself because using the call light for staff assistance would take too long. The residents said some of the residents were physically aggressive towards staff. X. Grievance log The June 2021 grievance log identified all the residents in the resident council complained about wandering residents. The facility indicated a new locking system for resident doors would be considered. The July 2021 grievance log identified on 7/1/21 a man entered a room of two female residents and they were upset about it. The log read Staff intervened, no sexual issues, male resident precautions enacted and staff were educated. According to the grievance log, the facility was informed of the residents' concern on 7/1/21 (Cross-reference F600). The July 2021 grievance log identified on 7/15/21 all residents wanted a secure way to lock their doors in response to the wandering residents. XI. Staff interviews Registered nurse (RN) #4 was interviewed on 7/25/21 at 7:18 p.m. She said that Resident #34 was a wanderer and that she did go into resident rooms and needed constant redirection. She said the resident usually was redirected easily and that she will offer her food, fluids and Tylenol to calm her down. She said if she wandered into the wrong resident room, the resident in the room may yell at her to get out. She said that upon her hire she received training and e [TRUNCATED]

Based on interviews and record review, the facility failed to recognize and implement action plans to prevent quality deficiencies, prevent repeat deficiencies and correct quality concerns that affected resident care and quality of life. Specifically, the facility failed to implement quality assurance and performance improvement (QAPI) action plans to address facility failures identified during the recertification survey. Findings include: I. Facility policy and procedure The Quality Assurance and Performance Improvement Program, with no revision date, was provided by the nursing home administrator (NHA) on 7/21/21 at 3:00 p.m. The policy documented in pertinent part, This facility shall develop, implement and maintain an ongoing facility wide Quality Assurance and Performance Improvement (QAPI) program that builds on the Quality Assessment and Assurance Program to actively pursue quality of care and quality of life goals. The QAPI program has been developed with five strategic elements in mind: Design and scope, Governance and leadership, feedback, data systems, monitoring, performance improvement projects (PIPS) and systematic analysis and systematic action. The following steps are employed or will be employed to support and enhance the facility QAPI program: -Recognizing patterns in systems of care that can be associated with quality problems; -Prioritizing identified quality issues based on risk of harm and frequency of occurrence and determining which will become the focus of PIPS; -Planning, conducting and documenting PIPS; -Conducting root-cause analysis to identify the underlying issues that contribute to recognized problems; and, -Taking systematic action targeted at the root causes of identified problems. This encompasses the utilization of corrective actions that provide significant and meaningful steps to improve processes and do not depend on staff to simply do the right thing. II. Record review During a recertification survey conducted 7/21, 7/22, 7/25, 7/26, 7/27, 7/28 and 7/29/21, 12 deficiencies were cited based on observations, interviews and record review including deficiencies cited in abuse at immediate jeopardy (IJ) level. Quality deficiencies included: F565E, failure to timely respond to grievances of the resident council, cited at potential for more than minimal harm at a pattern level. F582E, failure to ensure non-coverage letters were provided to residents/responsible parties, cited at potential for more than minimal harm. F600K, failure to ensure residents were free from sexual and physical abuse, cited at immediate jeopardy to resident health or safety. F609E, failure to report alleged violations of resident abuse, cited at potential for more than minimal harm at a pattern level. F610E, failure to investigate alleged violations of resident abuse, cited at potential for more than minimal harm at a pattern level. F658D, failure to ensure professional standards of quality, cited at potential for more than minimal harm. F677D, failure to provide assistance with meals when needed, cited at potential for more than minimal harm. F689D, failure to ensure adequate supervision was provided to prevent falls, cited at potential for more than minimal harm. F725G, failure to ensure adequate staffing to meet resident needs, cited at actual harm that was not immediate jeopardy. F744G, failure to provide appropriate treatment and services to attain or maintain his or her highest practicable physical, mental, and psychosocial well-being, cited at harm that was not immediate jeopardy. F867G, failure to ensure QAPI program addressed quality concerns, cited at actual harm that was not immediate jeopardy. F880D, failure to follow proper isolation precautions, cited at potential for more than minimal harm. III. Staff interview The quality assurance/performance improvement (QAPI) interview was conducted with the nursing home administrator (NHA) and director of nursing (DON) on 7/29/21 at 4:30 p.m. The NHA said they looked at different sources of information to bring to QA such as grievance logs and resident council meetings. He said that they monitor [NAME] reports for quality indicators and monitor survey data and risk factors. He said that some concerns come from their daily morning meetings when reviewing any concerns from the previous day. He said the next step was to create a PIP for whatever issues they identified and complete a root-cause analysis to see where they are falling short, who was affected and they make goals and review for effectiveness. Regarding beneficiary notices (F582) he said they had recognized they had concerns in this area and had an action plan for that and were still monitoring them, however; they had not sustained compliance in this area. Regarding abuse prevention, investigating and reporting (F600, F609 and F610) he said that abuse was not identified as a concern and was not discussed at QAPI. He said the only thing they discussed was the issue of getting reports into the occurrence portal in a timely manner. Both the NHA and the DON said they were not aware that abuse was a concern in their facility and did not recognize that physical and sexual behaviors could lead to a more serious outcome. Regarding staffing (F725), a repeat deficiency, he said it was an ongoing concern and that it was discussed at QAPI. He said that although they had looked at the root-cause analysis, they did not have a plan in place to address staffing concerns. The NHA said that QAPI was an ongoing process and that for the remaining areas of concern found on the survey, they had not been previously identified or brought to QAPI. The DON said the concerns need to be identified in order to follow a plan and to get to the root cause to make sure the standards stay in place rather than why it kept happening. She said they need to look closer at what they are missing and why.