Every finding on record at Bayley Place

Based on observation, staff interview and policy review, the facility failed to ensure Enhanced Barrier Precautions (EBP) were implemented for one (Resident #5) of three residents reviewed for EBP and failed to ensure catheter bag was not placed on the floor for one (Resident #5) of three residents reviewed for catheter bag placement. The facility census was 107. Findings include: Review of the medical record revealed Resident #5 was admitted to the facility on [DATE] with diagnoses of obstructive and reflux uropathy, indwelling Suprapubic catheter and methicillin-resistant staphylococcus aureus (MRSA). Review of the Minimum Data Set (MDS) Quarterly assessment dated [DATE] revealed Resident #5 had intact cognition and was occasionally incontinent of bowel and had an indwelling catheter for the bladder. The resident required set up assistance for eating and oral hygiene, maximal assistance for personal hygiene, bathing, dressing, bed mobility and transfers, and dependent for toileting. Observation on 07/22/26 at 9:49 A.M. revealed Resident #5 did not have EBP in place and was in a reclining chair with the catheter bag lying flat on the floor on the left side of the reclining chair, facing the room door to the corridor. There was no signage in place that indicated EBPs were implemented and no personal protective equipment (PPE) was available for staff use. Review of physician orders for Resident #5 revealed an order dated 04/28/26 for Enhanced Barrier Precautions (EBP) in place related to indwelling catheter and history of multi-drug resistant organisms (MDRO), every shift. Review of care plan for Resident #5 dated 04/26/26 revealed the need for EBP related to an indwelling catheter due to history of MDRO and MRSA with a goal to prevent the spread of infection and to reduce the spread of MDROs to residents. Interventions included to post signage on door or wall outside of resident room indicating the type of precaution and PPE required, high contact resident care activities such as dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs/assisting with toileting, device care (central line, urinary catheter, tube feed, trach/vent, etc.), wound care (any skin opening that required dressing) required gown and gloves when contact precautions do not otherwise apply. PPE must be changed before caring for another resident. Face protection was required if there was risk of splash or spray. During interview on 07/22/26 at 9:49 A.M. Licensed Practical Nurse #405 stated Resident #5 did not have EBP in place and should have EBP in place due to MRSA and MDRO and that the catheter bag was laying flat on the floor and should not touch the floor. Review of policy titled, Enhanced Barrier Precautions, reviewed 05/24/24, revealed Enhanced Barrier Precautions (EBPs) were utilized to prevent the spread of multi-drug resistant organisms (MDROs) to residents. EBPs remain in place for the duration of the resident's stay or until resolution of the would or discontinuation of the indwelling medical device that places them at increased risk. [NAME] signs are posted on the door or wall outside the resident room indicating the type of precautions and PPE required. PPE is available inside the resident rooms. Review of policy titled, Catheter Care, revised 09/07/25, revealed the purpose of this procedure was to prevent infection of the resident's urinary tract. The urinary drainage bag is to be kept below the level of the bladder and off the floor.

Based on observation, record review, staff interview, and policy review, the facility failed to provide dignified care for Resident #5 who had an indwelling Suprapubic catheter. This affected one (Resident #5) of four residents reviewed for dignity. The facility census was 107.Findings include: Review of the medical record revealed Resident #5 was admitted to the facility on [DATE] with diagnoses of obstructive and reflux uropathy, indwelling Suprapubic catheter and methicillin-resistant staphylococcus aureus (MRSA). Review of the Minimum Data Set (MDS) Quarterly assessment dated [DATE] revealed Resident #5 had intact cognition and was occasionally incontinent of bowel and had an indwelling Suprapubic catheter for the bladder. The resident required set up assistance for eating and oral hygiene, maximal assistance for personal hygiene, bathing, dressing, bed mobility and transfers, and dependent for toileting. Observation on 07/22/26 at 9:49 A.M. revealed Resident #5's was in a reclining chair with the catheter bag lying flat on the floor on the left side of the reclining chair, facing the room door to the corridor. The catheter bag did not have a dignity bag. The urine in the bag was visible to all individuals in the corridor. Interview on 07/22/26 at 9:49 A.M. with Licensed Practical Nurse #405 verified Resident #5's catheter bag did not have a dignity bag and should have had one. Review of policy titled, Promoting/Maintaining Resident Dignity, revised 05/07/25, revealed it is the practice of the facility to protect and promote resident rights and treat each resident with respect and dignity as well as care for each resident in a manner and in an environment, that maintains or enhances resident's quality of life by recognizing each resident's individuality. All staff members are involved in providing care to residents to promote and maintain resident dignity and respect resident rights.

Based on observation, staff interview, policy review, and review of the 2022 United States Food and Drug Administration Food Code, the facility failed to ensure dietary staff wore appropriate hair (beard) covers while in the food preparation area. This had the potential to affect 104 of 104 residents who received meals from the kitchen, excluding Resident #1. The facility census was 105. Findings included: Observation on 08/11/25 at 11:16 A.M., during the initial tour, [NAME] #9 was observed in the food preparation area with long, facial hair that was approximately an inch in length, uncovered. Food Service Supervisor (FSS) #8 was also observed walking around the food preparation areas and counters, with facial hair approximately an inch in length, uncovered.Interview on 08/11/25 at 11:16 A.M., with the Director of Dining Services (DDS) stated they did not use the beard restraints unless the beard was especially long and drawn out. He gave no precise measurements on what the threshold would be. He confirmed the staff had just completed the lunch service.Interview on 08/14/25 at 10:16 A.M., with [NAME] #9 stated he had taken the beard restraint off during the initial tour observation. He stated he wore the beard restrain every day in the kitchen.Interview on 08/14/25 at 10:18 A.M., with FSS #8 stated that he normally wore beard restraints, and the policy stated they were required to wear beard restraints if they had facial hair. He stated that the Director of Dining Services (DDS) did not usually wear a beard restraint. He stated the staff only wore a beard restraint if their beard were the length of his beard or longer. Observation on 08/13/25 at 11:27 A.M., the Assistant Director of Nutrition (ADON) was observed in the food preparation areas with no beard restraint. He had facial hair that was approximately an eighth of an inch in length. Interview on 08/14/25 at 10:33 A.M., the ADN stated he had seen FSS #8 and [NAME] #9 in the kitchen without beard restraints, but they were usually supervising rather than preparing food and stated he only wore a beard restraint if he was preparing food, not necessarily if he was just in the kitchen.During a follow-up interview on 08/15/25 at 9:28 A.M., the DDS stated if staff could grasp their facial hair, they wore a beard restraint. Per the DDS, beard restraints were only worn in situations where the hair could fall in the food. He stated that hair restraints should be worn whenever staff were in food preparation areas, regardless of whether there was the potential that hair could fall into food. The DDS was unable to explain why there was a distinction between his expectation for hair restraints and beard restraints. The DDS stated that he wanted staff to put on a hair restraint prior to entering the kitchen.Interview on 08/15/2025 at 9:58 AM, the Executive Director (ED) stated that the facility should follow regulations regarding beard restraints. The ED stated it was her understanding that beard restraints were not necessary if the staff were not handling food. She stated this applied to hair restraints too. Review of the untitled policy, revised August 2018, indicated, A. When entering the kitchen all employees must wear a hair restraint properly. Examples include hair restraints, hats, and beard nets that cover body hair as applicable. B. Hair restraints to be worn effectively to keep hair from contacting exposed food, equipment, utensils, and linens. C. Hair restraints must always be worn when working in kitchens, pantries, or food prep areas.Review of the 2022 Food Code U.S. [United States] Food and Drug Administration, 01/18/23 version, indicated, (A) Except as provided in (B) of this section, FOOD EMPLOYEES shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed FOOD; clean EQUIPMENT, UTENSILS, and LINENS; and unwrapped SINGLE-SERVICE and SINGLE-USE ARTICLES.

Based on staff interview, record review, and policy review, the facility failed to ensure a preadmission screening and resident review (PASARR) level 1 was updated and resubmitted following the onset of a new mental illness diagnosis. This affected one (#13) of one residents reviewed for PASARR. The facility census was 105.Findings included: Review of Resident #13's medical record revealed an admission date of [DATE]. Resident #13's medical diagnoses included psychotic disorder with delusions (onset date [DATE]), major depressive disorder (onset date [DATE]), and anxiety disorder (onset date [DATE]). Review of the quarterly Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of [DATE], revealed Resident #13 had a Brief Interview for Mental Status (BIMS) score of 4, which indicated the resident had severe cognitive impairment. The MDS indicated the resident had active diagnoses to include depression and psychotic disorder. Review of Resident #13's Care Plan Report included a problem statement dated [DATE] and revised [DATE], that indicated the resident used psychotropic medications due to depression, dementia with psychosis, psychotic disorder, sleep disorder, and anxiety.Review of Resident #13's record revealed no evidence to indicate a PASARR Level 1 was completed once the resident received a new mental illness diagnosis of psychotic disorder on [DATE], major depressive disorder on [DATE], or anxiety on [DATE].Interview on [DATE] at 2:35 P.M., with Resident Services Coordinator (RSC) #16 stated he was not sure if there were any residents with an identified change where a new PASARR was warranted. RSC #16 stated normally, he learned about new serious mental illnesses during interdisciplinary team meetings, or nursing staff communicated a resident's new serious mental illness diagnosis to him.Interview on [DATE] at 10:11 A.M., with the Director of Nursing (DON) stated that she did not have much of a handle on PASARRs, and deferred questions on the subject to other staff.Interview on [DATE] at 9:58 A.M., with the Executive Director (ED) stated that for PASARRs, the RSC handled new resident reviews if there was a change of condition. The ED stated she did not know why staff did not complete a new PASARR Level 1 for Resident #13 after their new serious mental illness diagnoses, stating it must have slipped through the cracks.Review of the policy titled, PASARR, revised on [DATE], indicated, 5. PASARR is triggered by significant changes, expired convalescent/respite stays, psychiatric readmission, or extension requests.

Based on record review, staff and physician interviews, and policy review, the facility failed to obtain laboratory test as ordered by the physician. This affected one (#13) of five residents reviewed for unnecessary medications. The facility census was 105. Findings included: Review of Resident #13's medical record revealed an admission date of 09/21/21. Resident #13's medical diagnoses included vascular dementia, psychotic disorder with delusions due to a known physiological condition, major depressive disorder, and anxiety disorder. Review of the quarterly Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 05/28/25, revealed Resident #13 had a Brief Interview for Mental Status (BIMS) score of 4, which indicated the resident had severe cognitive impairment.Review of Resident #13's Care Plan Report, included a problem statement revised 06/05/25, that indicated the resident was at nutritional risk with potential for dehydration related to dementia, hypertension, acute ischemic cerebrovascular accident with left-sided weakness, altered labs, and decreased appetite. Interventions directed staff to obtain and monitor lab/diagnostic work as ordered and report results to the medical doctor.Review of Resident #13's Order Recap [Recapitulation] Report, for the timeframe from 07/03/25 through 08/31/25, contained an order dated 07/03/25, for TSH [thyroid-stimulating hormone]**WAITING to be Sent**. The Order Recap Report contained another order, dated 08/12/25, for TSH **SENT Uncollected 08/12/25 at 1:40 PM ET**. Review of Resident #13's Progress Notes, revealed a note dated 07/03/25 at 5:22 P.M., that indicated a fax was received from Medical Director (MD) #6 with new orders for a complete blood count, comprehensive metabolic panel, TSH, and urinalysis with culture and sensitivity. A Progress Note dated 08/12/25 at 1:42 PM, revealed, TSH not completed on 7/3. Notified [MD#6] with new order for TSH next lab day 8/13/25.Review of Resident #13's Lab Results Report, dated 08/13/25, revealed Resident #13's TSH was 1.640 mciu/mL (micro-international units per milliliter), which was within the reference range of 0.400 - 4.500 mciu/mL. Interview on 08/12/25 at 2:19 P.M., with the Assistant Director of Nursing (ADON) and the Executive Director (ED)., the ADON stated the TSH level that was ordered on 07/03/25 was not completed and they did not realize it was missed until it was brought to their attention by the surveyor. The ADON stated the physician was notified and a new order was written. The ED stated that the facility should have identified ordered laboratory work that was not carried out within 24-48 hours. Interview via telephone on 08/12/2025 at 3:08 P.M., MD #6 stated the purpose of the TSH level for Resident #13 was just to follow up and make sure the TSH levels were where they needed to be. MD #6 stated she expected the nursing staff to follow physician orders as written. She said in this case, she was not worried about the delay in obtaining the lab because of the general clinical picture of the resident.Interview on 08/15/25 at 10:11 A.M., with the Director of Nursing (DON) stated that when a physician ordered a laboratory service, staff carried out the order by the date specified in that order. The DON stated that if there was no specified date, and it was a routine laboratory service, she expected a routine laboratory service to be carried out on the next day laboratory services were conducted. She stated that she did not know why Resident #13's TSH order was missed, but she suspected it was due to the laboratory service only recently integrating with the facility's electronic medical record (EMR). The DON stated that for whatever reason, there was miscommunication between the EMR and the laboratory service. The DON stated facility unit managers typically followed up on orders that were not completed. She stated that she was not sure why the unit managers missed it.Interview on 08/15/25 at 2:44 P.M., Nursing Supervisor (NS) #4 stated that it was the night shift unit managers who reviewed orders that might have been missed, and they did this on the night shift. She stated she was not sure why the TSH order for Resident #13 was missed. Interview on 08/15/25 at 9:58 A.M., the ED stated that physician orders should be carried out in a timely manner. The ED stated routine laboratory tests should be conducted within a day or two. The ED stated she believed the reason that Resident #13's TSH laboratory order was missed was because the order was entered into the EMR, but for whatever reason, it did not cross over to their laboratory service from the EMR. The ED stated there was no specific policy on following physician orders.Review of the policy titled, Laboratory Services, reviewed 05/09/25, indicated, Laboratory services shall be performed by licensed, CLIA [Clinical Laboratory Improvement Amendments]- certified laboratories and in accordance with the physician's orders, facility protocols, and applicable regulations.

Based on observation, staff interviews, record review, and policy review, the facility failed to ensure the medication error rate was less than 5 percent (%). The facility had 2 medication errors out of 26 opportunities, resulting in a 7.69% medication error rate. This affected one (#96) of 11 residents reviewed during the medication task. The facility census was 105. Findings included:Review of Resident #96's medical record revealed an admission date of 02/26/15. Resident #96's medical diagnoses included anxiety disorder, major depressive disorder, dementia, and gastro-esophageal reflux disease (GERD).Review of Resident #96's Order Summary Report, dated 08/13/25, contained a physician order dated 03/18/24 for simethicone (an anti-flatulent) 80 milligrams (mg) by mouth three times a day.Observation of medication pass on 08/12/25 at 3:58 P.M., Licensed Practical Nurse (LPN) #2 administered simethicone 125 mg by mouth to Resident #96.Interview on 08/15/25 at 1:20 P.M., with LPN #2 stated she did not realize the brand of simethicone had changed and was a different dose than what was provided previously. LPN #2 stated she assumed the medication was the correct dose, and it was not.Observation of medication pass on 08/13/25 at 3:23 P.M., LPN #3 administered simethicone 125 mg by mouth to Resident #96.Observation and interview on 08/13/25 at 3:51 P.M., LPN #3 reviewed Resident #96's medication administration record (MAR) and stated the correct dose for simethicone was 80 mg. LPN #3 then looked at the box of simethicone and stated the medication in the box that was administered to the resident was 125 mg. LPN #3 stated 125 mg was not the ordered dose. Interview on 08/14/25 at 2:21 P.M., with the Assistant Director of Nursing (ADON) stated nurses were expected to verify the right patient, right time, right dose, and follow the rights of medication administration. The ADON stated the medications should be double checked before being administered. The ADON stated the unit manager was responsible for monitoring medications being administered.Interview on 08/14/25 at 2:47 P.M., with Nursing Supervisor (NS) #4 stated that nurses were expected to check the medication order, the medication dosage, assess the resident, and document the medication. NS #4 stated the pharmacy sent the wrong dose of simethicone, and the nurse did not check the dosage. NS #4 stated the nurse should have checked the dosage on the medication. NS #4 stated the family, doctor, and pharmacy were notified of the medication error, and there was no harm to the resident. NS #4 stated medications should be monitored each time they were given.Interview on 08/14/25 at 3:03 P.M., with the Director of Nursing (DON) stated the staff member training the new nurses was responsible for monitoring the nurses administering medications while in training. The DON stated after training the unit manager monitored medication administration, and the expectation was that nurses followed the five rights of medication administration.Interview on 08/14/25 at 3:19 P.M., the Executive Director (ED) stated the expectation was for nurses to follow the policy and procedure for medication administration, complete a safe medication pass, and follow the five rights of medication administration. The ED stated the pharmacist checked medication carts and monitored medication passes during their monthly visit.Review of the policy titled, Medication Administration, revised July 2025, revealed, 4. Medications are administered in accordance with prescriber orders, including any required time frame. The policy continued, 8. The individual administering the medications also checks the label to verify the right resident, right medication, right dosage, right time, and right route before giving the medication. This deficiency represents non-compliance investigated under Complaint Number 137881.

Based on staff interview, record review, facility document and policy review, the facility failed to ensure a resident was provided a Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage (SNF ABN), Form CMS-10055. This affected one (#125) of three residents reviewed for beneficiary notices. The facility census was 105.Findings included:Based on interview, record review, facility document and policy review, the facility failed to ensure a resident was provided a Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage (SNF ABN), Form CMS-10055. This affected one (#125) of three residents reviewed for beneficiary notices. The facility census was 105.Findings included:Review of Resident #125's medical record revealed an admission date of 05/23/25. Resident #125's medical diagnoses included non-traumatic intracranial hemorrhage, abnormalities of gait and mobility, and unspecified convulsions.Review of the admission Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 05/30/25, revealed Resident #125 had a Brief Interview for Mental Status (BIMS) score of 12, which indicated the resident had moderate cognitive impairment. The MDS indicated that the resident required substantial/maximum assistance from staff with bathing and dressing and set-up or clean-up assistance from staff for personal hygiene.Review of the list of residents discharged from a Medicare covered Part A stay with benefit days remaining during the prior six months revealed Resident #125 was discharged from a Medicare covered Part A stay on 06/20/25.Review of Resident #125's SNF [Skilled Nursing Facility] Beneficiary Notification Review form, completed by the facility, revealed the facility initiated Resident #125's discharge from Medicare Part A services when the resident's benefit days were not exhausted. The form indicated the resident's last covered day (LCD) under the benefit was 06/16/25. The form indicated the facility issued a CMS-10123 NOMNC but not a CMS-10055 SNF ABN. There was no documented evidence in the resident's record to indicate the resident was informed of the SNF ABN.Interview on 08/14/25 at 9:58 A.M., with Resident Services Coordinator (RCS) #5 stated she started her current position in June 2025. RCS #5 indicated she was not familiar with the SNF ABN document and had not provided it to Resident #125 when the resident decided to stay at the facility for a few days following the LCD. RCS #5 stated a representative from the billing department had the resident sign documents if the resident decided to continue their stay at the facility as a private pay resident. Interview on 08/14/25 at 10:42 A.M., with Accounts Receivable (AR) [NAME] Supervisor #17 stated Resident #125 only stayed for a few days following the LCD, so a full residency agreement was not completed, but a form was signed that acknowledged the private pay rate and services that were and were not covered. Interview on 08/14/25 at 11:33 A.M., with the Medical Records Coordinator (MRC) stated they were responsible for the NOMNC and SNF ABN forms being signed prior to RCS #5 beginning her position in June 2025. The MRC stated the SNF ABN form was not a form she was aware of, so she reached out to her consultant to receive education on how to use the form. The MRC stated she also was not completing the SNF ABN forms because she was not aware of the form. Interview on 08/14/25 at 3:50 P.M., with the Director of Nursing (DON) stated it was her expectation that the facility staff followed the CMS regulations and that the SNF ABN form be used when a resident was transitioning from Medicare Part A to private pay.During an interview on 08/14/25 at 4:03 P.M., with the Executive Director (ED) stated she was aware of the concerns related to the SNF ABN documents. The ED stated it was her expectation for the facility to be in regulatory compliance with the ABN notification, and the team had already begun correcting their process. Review of the policy titled, Advanced Beneficiary Notice, revised March 2025, revealed, To establish guidelines for the appropriate use of the Advanced Beneficiary Notice of Non-coverage (ABN) in compliance with CMS [Centers for Medicare and Medicaid Services] requirements, enabling residents and their representatives to make informed decisions regarding services Medicare may not cover. The policy continued, Appropriate ABNs will be provided before the facility begins providing the service. Sufficient time will be provided for the resident or resident representative to consider options and ask questions.

Based on observation, staff interview, and policy review, the facility failed to ensure the survey results were posted in a location accessible to all residents, representatives, and visitors. This had the potential to affect all 105 of 105 residents who resided in the facility. Findings included:Observation on 08/12/25 at 3:30 P.M., of the facility revealed no evidence of a survey binder or signage indicating where the survey binder was located. Observation on 08/13/25 at 8:30 A.M., of the facility revealed no evidence of a survey binder or signage indicating where the survey binder was located. Observation and interview on 08/13/25 at 8:35 A.M., with the Executive Director (ED) revealed the survey binder was at the visitor sign-in kiosk located at the front entrance in a drawer. There were no signs observed indicating the survey binder was in the drawer at the kiosk or at the front desk. The ED stated they had just moved the binder from the Bistro to the new sign-in kiosk, and they did not have signs indicating the location of the survey binder, but people could ask where it was located.Interview on 08/13/25 at 9:22 A.M., with Receptionist #1 stated she had worked at the facility since 2019, and she was not aware of the survey results binder. She stated if someone asked her about the survey results binder, she would have to direct them to someone else who could help them locate the binder. Interview on 08/13/25 at 9:30 A.M., with Administrative Assistant (AA) #7 stated she did not know where the survey results binder was located prior to 08/13/25. AA #7 stated there was no signage that indicated the location of the survey results binder prior to her placing a sign that morning. Interview on 08/13/25 at 9:34 A.M., the Director of Nursing (DON) stated they had a survey result binder that was available for anyone who asked or requested to see it, and the binder contained their past survey results. The DON stated she was not aware of the current location of the survey results binder. She stated that typically it was accessible at the front desk upon request. She was not aware that the survey binder was to be readily available for anyone without having to ask for it. Interview on 08/13/25 at 9:41 A.M., the ED stated the survey result binder was available for residents, staff, visitors, or anyone. She stated anyone could ask a staff member or the receptionist where the survey binder was located and have access to it. The ED stated previously the binder was located on the counter in the Bistro, but since they had been renovating, they moved the survey results binder to the visitor kiosk located near the front entrance and did not have signs indicating the current location of the survey binder. Review of the policy titled, Access to Past Survey Results, revised March 2025, indicated, [Facility name] shall make available the most recent federal or state survey results in a public area that is accessible 24 x 7. Reports from the three preceding years, including deficiency statements and plans of correction, shall be made available for review upon request. A notice shall be displayed in public areas to inform residents, families, and visitors of this availability.

Based on observation, staff interview, policy review, review of personal files, and review of the Centers for Disease Control (CDC) guidance, the facility failed to ensure staff wore personal protective equipment (PPE) in a manner to prevent the potential spread of Covid-19. The facility identified six residents who had tested positive for COVID-19 in the past two weeks and four residents who were in isolation precautions for positive COVID-19 on the day of entrance. The facility failed to ensure newly hired employees had their first and second step [CONDITION(S)] skin test (PPD) as required. This affected two State tested Nursing Assistants (STNAs) #95 and #170 out of five newly hired staff reviewed. The facility also failed to ensure that individuals were safely removing their personal protective equipment (PPE) before leaving resident rooms where isolation precautions were in place to prevent the spread of infectious diseases. This affected three residents (#55, #200, and #247) of 32 residents reviewed for infectious diseases and had the potential to affect all residents residing in the facility. The facility census was 105. Findings include: 1. Observation on 08/01/22 at 11:41 A.M. revealed Food Service Specialist (FSS) #92 in the Hillside unit's dining area taking resident's lunch orders and delivering trays to residents. FSS #92 was observed wearing an N-95 mask with the upper strap secured around the head and the lower strap dangling in front of the mask. Random observations between 11:41 A.M. and 12:41 P.M. revealed FSS #92 continued serving residents wearing the N-95 mask incorrectly. Interview on 08/01/22 at 12:48 P.M. FSS #92 verified she was not wearing the lower strap of the N-95 mask. FSS #92 stated she was wearing it in that manner because she was hot. 2. Observation on 08/08/22 at 3:15 P.M. revealed State tested Nursing Assistant (STNA) #500 on the Hillside unit entering an unidentified resident's room and answer a call light. STNA #500 was observed wearing an N-95 mask with the upper strap secured around the head and the lower strap dangling in front of the mask. Observation and interview on 08/08/22 at 4:47 P.M., STNA #500 was seated at the table in the activity room and continued to have the lower strap of the N-95 mask dangling unsecured in front of the mask. STNA #500 verified she was not wearing the lower strap of the N-95 mask and stated her hair gets in the way of the lower strap. STNA #500 further stated she forgot to secure the lower strap when she came back from her last break. 3. Observation on 08/10/22 at 11:57 A.M. revealed Nursing Student (NS) #500 on the Hillside unit wearing glasses but no eye protection. Interview at the same time, NS #500 verified she was not wearing eye protection. NS #500 stated she had been working on the unit, assisting residents, since 7:00 A.M. and nobody had told her she needed to wear eye protection. 4. Observation on 08/10/22 at 11:57 A.M. revealed Licensed Practical Nurse (LPN) #501 on the Hillside unit not wearing any eye protection. Interview at the same time, LPN #501 verified she was not wearing eye protection. LPN #501 stated she was wearing her glasses up until a few minutes prior, however was not told she needed to wear eye protection upon starting her shift. 5. Observation on 08/10/22 at 11:58 A.M. revealed NS #503 on the Hillside unit not wearing any eye protection. Interview at the same time, NS #503 stated she had been working on the unit, assisting residents, since 7:00 A.M. and had not been told she needed to wear eye protection. 6. Observation on 08/10/21 at 11:59 A.M. revealed NS #504 on the Hillside unit not wearing any eye protection. NS #504 was observed entering Resident #76's room to answer the call light. Observation on 08/10/22 revealed NS #504 and NS #503 exit Resident #76's room. Neither were wearing eye protection. NS #504 affirmed she was not wearing eye protection. NS #504 stated she had been on the Hillside unit, assisting residents, since 7:00 A.M., and she had not been told she needed to wear eye protection. NS #504 further stated there was not any eye protection where the masks were located at the front entrance, where she checked in earlier that morning. Review of the facility policy titled, Coronavirus Infection Control Plan, dated 11/30/21, revealed staff and visitors will wear eye protection while in the facility based on county positivity and transmission rates. Review of the Centers for Disease Control (CDC) COVID-19 County Check (https://www.cdc.gov/coronavirus/2019-ncov/your-health/covid-by-county.html) revealed the facility was located in a county where the transmission level was high. Review of the CDC article, How to Use Your N-95 Respirator (chrome-extension://efaidnbmnnnibpcajpcglclefindmkaj/https://www.cdc.gov/coronavirus/2019-ncov/prevent-getting-sick/COVID-19_NIOSH_Freemasks_PRINT_F.pdf), dated 01/28/22, revealed the respirator straps should be placed over the crown of the head (top) and at the back of the neck below the ears (bottom strap). The N-95 must form a seal around the face to work properly. Gaps occur if the N-95 is not put on correctly. 7. Review of medical records for Resident #55 revealed an admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of physician order dated 07/25/22, Resident #55 was placed in quarantine due to positive Covid status. 8. Review of medical record for Resident #200 revealed an admitted [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of physician order dated 07/28/22, Resident #200 was placed in quarantine due to positive Covid status. Observation and interview on 08/02/22 at 12:50 P.M. revealed clean PPE containers and trash cans containing contaminated PPE. Infection Control Preventionist #38 verified the donning and doffing area for Residents #55 and #200 were in a public area and not inside the individual rooms or in a secured care area. 9. Review of the medical record of Resident #247 revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the Admit/Readmit note dated 07/29/22 revealed the resident was alert to person, place, and situation. The resident was noted to be forgetful and had difficulty with short-term memory at the time of admission. Review of an order dated 07/29/22, ending on 08/04/22 revealed the resident was to be in quarantine due to testing for positive for covid. Observation on 08/01/22 at approximately 3:30 P.M., revealed a trash can containing used gowns outside of Resident #247's door. The door to Resident #247's room contained a sign stating, See nurse before entering and there was a plastic drawer bin containing PPE and instructions for donning and doffing on top of the plastic bin. Interview at the same time, LPN #144 verified the trash can had used PPE should be contained inside the room, where PPE should be doffed prior to exiting the room. Review of policy Coronavirus Infection Control Plan, dated 11/30/21, revealed Removing and discarding the gown in a dedicated container for waste or linen before leaving the resident room or care area. 10. Record review of STNA #95 personnel file revealed the employee was hired on 06/22/22. STNA #95's 1st step [CONDITION(S)] skin test (PPD) was given on 06/23/22 that was not read. STNA #95's personnel file did not contain information regarding a second step PPD being completed. Record review of STNA #170 personnel file revealed the employee was hired on 07/13/22. STNA #170's 1st step PPD was given on 07/11/22 and read on 07/13/22. STNA #170's personnel file did not contain information regarding a second step PPD being completed. Email correspondence with the Administrator on 08/04/22 at 4:06 P.M. verified STNA #95's did not have her first step PPD read and STNA #95 and STNA #170 did not have second step PPDs. Review of the facility's [CONDITION(S)] testing and exposure management policy revised on 09/30/18 revealed newly hired employees will receive an initial TB test as part of the employee physical examination. This PPD will be read by the nursing supervisor. Newly hired employees may not begin work until the first step is read. Review of the facility's new employee orientation policy revised June 2014 revealed employees must complete the first step of the two step Mantoux TB test.

Based on record review, staff interview and policy review, the facility failed to ensure injuries of unknown origin were reported to the state agency for Resident #09, failed to ensure resident-to-resident altercations were reported to the state agency for Residents #18, #92, #26 and #146, and failed to ensure allegations of sexual abuse were reported to the state agency for Residents #18 and #65. This affected six Residents (#09, #18, #26, #65, #92, and #146) out of 32 reviewed for abuse. The facility census was 105. Findings included: 1. Review of the clinical record revealed Resident #26 was admitted to the facility on [DATE]. His diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the annual Minimum Data Set (MDS) assessment completed on 05/17/22 revealed he had severe cognitive impairment. He needed extensive assist of two staff for bed mobility, transfer, dressing, and toilet use. He did not walk. He needed extensive assist of one staff for locomotion and personal hygiene. He needed supervision and setup for eating. He was totally dependent on one staff for bathing. Review of the clinical record revealed behavior note dated 07/31/22 which indicated the resident was smacked in the face three times by another resident on 07/31/22 at 5:55 P.M. The resident had no injuries noted. 2. Record review of Resident #146's chart revealed she was admitted to the facility on [DATE]. Her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the admission MDS completed on 07/19/22 indicated she had severe cognitive impairment. She needed supervision of one staff for bed mobility, transfer, walking, and locomotion. She required limited assist of one staff for dressing and personal hygiene. She required extensive assist of one staff for eating. She needed supervision and setup help for toileting and was totally dependent on one staff for bathing. She exhibited physical and verbal behavioral symptoms directed towards others one to three days during the lookback period. She exhibited rejection of care one to three days during the lookback period and wandered four to six days during that timeframe. Review of care plan revealed she had impaired cognitive function/dementia or impaired thought processes related to Alzheimer's disease, dementia with behavioral disturbance, behaviors including resisting care (medications, meals, and activities of daily living care), hitting, swinging at staff during care, yelling at staff/others, and wandering. Review of the clinical record revealed a behavior note dated 07/31/22. It indicated the aide came at at 5:55 P.M. reporting Resident #146 was smacking another resident in the face three times. It stated the intervention was redirection and separated. It indicated the resident was a threat to herself and others and that she would be monitored. Further review revealed a health status note dated 08/01/22 which indicated regarding the incident on 07/31/22 at 5:55 P.M. where Resident #146 hit a male resident (Resident #26) in the face three times, staff intervened and Resident #146 was redirected back to her room. Due to the nature of this event, the interdisciplinary team (IDT) agreed to have the resident (Resident #146) evaluated at psychiatric hospital as the incident was unprovoked and aggressive behaviors continued towards the State tested Nursing Assistant (STNA) through out the night. It revealed she had been acclimating to a new unit over two weeks and continued with aggression. There was a Social Service note dated 08/01/22 which indicated they were made aware of Resident #146's increased agitation, behaviors hitting at staff and other residents. A resident to resident altercation was reported/noted occurring on 07/31/22. It indicated Resident #146 was with advancing dementia and was unaware to why, reasoning or recall of reported aggressive behaviors. She was approved to be sent for her current inpatient psychiatric needs. Self-reported incidents (SRIs) were reviewed on 08/09/22. There were no SRIs completed regarding this incident. An interview was conducted with the Administrator on 08/04/22 at 3:00 P.M. She indicated there was no SRI done due to it being witnessed by staff, there was no harm to either one, and both residents resided on the dementia unit. She indicated the families were notified, and the aggressor was sent out. An interview was conducted with Licensed Practical Nurse (LPN) #146 and Registered Nurse (RN) #60 on 08/04/22 at 3:46 P.M. They indicated Resident #146 was acclimating to the unit and was known to tap residents. She ended up chasing the STNA around and went out for a psychiatric evaluation in the morning. They indicated the STNA on the unit was a witness, but no statement was collected. They revealed they did not know the STNA's name. They indicated Resident #26 was taken in to his room and went to bed for the night. They revealed no other residents were assessed. 3. Review of the medical record of Resident #09 revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly MDS assessment dated [DATE] revealed the resident had severely impaired cognition. The resident required extensive assistance of one staff for eating, extensive assistance of two staff for bed mobility, and was dependent on two staff for transfers and toileting. The resident was assessed as having impaired range of motion to all four extremities. Review of a progress notes dated 07/07/22 revealed Resident #09 was found with a small, round, dime sized brown/purple bruise on the right side of her jaw/chin during the morning med pass. Resident #09 was unaware it was there or of how she obtained it. The family, Nurse Practitioner, and Nurse Manager were notified. Review of the facility's SRIs revealed the incident was not reported to the state agency. Interview on 08/04/22 at 3:04 P.M., Executive Director (ED) #110 verified there was not an SRI completed, regarding Resident #09's bruise. Interview on 08/04/22 at 3:43 P.M., LPN #146 stated she followed up on the incident, however she did not make a note about said follow-up. LPN #146 stated she talked with the staff who cared for Resident #09, however she did not have them write statements, nor did she talk to like residents, or check for additional skin issues on the unit. LPN #146 stated an SRI was not completed because there was no suspicion of abuse. Review of the facility policy titled, Injuries of Unknown Source-Bruises, Skin Tears, dated 08/20/09, revealed, regardless of how minor an injury (bruise, skin tear, injury of unknown source) may be, it must be reported and investigated as soon as it is discovered. 4. Review of the medical record of Resident #18 revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the comprehensive MDS assessment dated [DATE] revealed the resident had moderately impaired cognition. The resident was independent with bed mobility, transfers, eating, and toileting. Interview on 08/02/22 at 9:35 A.M., Resident #18 stated, approximately two weeks prior, another resident looked at him, told him they did not like him and hit him. Review of a progress note dated 07/25/22 revealed Resident #18 was witnessed being slapped repeatedly by another resident. Resident #18 told the other resident to stop touching him and the other resident was mocking him while slapping him. No injury was noted. 5. Review of the medical record of Resident #92 revealed an admitted [DATE]. The resident transferred to the hospital on 07/27/22. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly MDS assessment dated [DATE] revealed the resident had severely impaired cognition. The resident exhibited fluctuating inattention and 4-6 days of physical behavioral symptoms directed towards others and wandering during the assessment period. The resident required extensive assistance for bed mobility, transfers, locomotion on and off the unit, dressing, and toileting. The resident required supervision for eating. Review of a progress note dated 07/25/22 revealed Resident #92 was witnessed slapping another resident (Resident #18). Resident #18 stated several times for Resident #92 to stop touching him and Resident #92 was mocking what he was saying and continuously smacking him. Review of the facility's SRIs revealed the incident was not reported to the state agency. Interview on 08/04/22 at 10:11 A.M., ED #110 verified there was not an SRI completed for the incident on 07/25/22 because it was described as a light tapping. ED #110 verified the other resident was Resident #92, who was sent to the hospital a few days later. ED #110 further stated the incident was not investigated because it was witnessed. 6. Review of the medical record of Resident #65 revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly MDS assessment dated [DATE] revealed the resident had severely impaired cognitive status. The resident required extensive assistance of one staff for bed mobility, and was totally dependent on two staff for transfers and toileting. The resident required supervision for eating. Review of a progress note dated 07/24/22 revealed Resident #65 was touched inappropriately by another resident. Resident #65 voiced concerns to the staff. Review of the Daily Behavior Assessment for Resident #92 dated 06/24/22 revealed Resident #92 was wandering and touching residents inappropriately. Resident #65 stated Honey, she keeps rubbing my breast. I keep telling her to stop touching me, but she won't stop. Resident #92 was removed from the area and extensive one-on-one supervision was provided by the activity staff. Review of the facility's SRIs revealed neither of the incidents involving Resident #65 and #92 were reported to the state agency. Interview on 08/08/22 at 3:33 P.M., LPN #160 stated Resident #65 told her a few weeks ago that Resident #92 touched her breast and in the groin area and she was really upset about it. Interview on 08/08/22 at 4:36 P.M., STNA #17 stated she recently heard Resident #65 yell out that a resident had touched her breast. STNA #17 stated she did not physically see it occur, however Resident #92 was right next to her when it happened. STNA #17 further stated she heard Resident #92 had touched Resident #65 inappropriately a few times. Interview on 08/09/22 at 8:51 A.M., STNA #70 stated she had not seen Resident #92 touch Resident #65, however noticed Resident #65 telling everyone that Resident #92 had touched her breasts and private area for a few days following the incident. Interview on 08/09/22 at 4:24 P.M., the Director of Nursing (DON) verified there were no SRIs completed for either of the incidents between Resident #92 and #65. The DON stated an SRI was not completed because Resident #92 has dementia and was not touching the other resident with the intention of harm and the other resident did not seem to be in any distress. Review of the facility policy titled, Resident Abuse, dated 03/12/18, revealed abuse is defined as the willful infliction of injury, intimidation or punishment with resulting physical harm, pain, or mental anguish. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain, or mental anguis. Abuse includes verbal abuse, sexual abuse, physical abuse and mental abuse. Willful, as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. Sexual abuse is non-consensual sexual contact of any type with a resident. The investigation shall consist of interviews with any witnesses, interviews with staff members on all shifts having contact with the resident during the period of the alleged incident, interviews with the resident's family members and visitors, and interviews with other residents. The incident will be reported to the state agency within 24-hours of the reported abuse and completed within five working days.

Based on record review, staff interview and policy review, the facility failed to ensure injuries of unknown origin were investigated for Resident #09, failed to ensure resident-to-resident altercations were investigated for Residents #18, #92, #26, and #146, and failed to ensure allegations of sexual abuse were investigated for Resident #18 and #65. This affected six Residents (#09, #18, #26, #65, #92, and #146) out of 32 reviewed for abuse. The facility census was 105. Findings included: 1. Review of the clinical record revealed Resident #26 was admitted to the facility on [DATE]. His diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . He had an annual Minimum Data Set (MDS) assessment completed on 05/17/22. He had severe cognitive impairment. He needed extensive assist of two staff for bed mobility, transfer, dressing, and toilet use. He did not walk. He needed extensive assist of one staff for locomotion and personal hygiene. He needed supervision and setup for eating. He was totally dependent on one staff for bathing. Review of the clinical record revealed behavior note dated 07/31/22 which indicated the resident was smacked in the face three times by another resident on 07/31/22 at 5:55 P.M. The resident had no injuries noted. 2. Record review of Resident #146's chart revealed she was admitted to the facility on [DATE]. Her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . She had an admission MDS completed on 07/19/22 indicating she had severe cognitive impairment. She needed supervision of one staff for bed mobility, transfer, walking, and locomotion. She required limited assist of one staff for dressing and personal hygiene. She required extensive assist of one staff for eating. She needed supervision and setup help for toileting and was totally dependent on one staff for bathing. She exhibited physical and verbal behavioral symptoms directed towards others one to three days during the lookback period. She exhibited rejection of care one to three days during the lookback period and wandered four to six days during that timeframe. She had a care plan addressing her impaired cognitive function/dementia or impaired thought processes related to Alzheimer's disease, dementia with behavioral disturbance, behaviors including resisting care (medications, meals, and activities of daily living care), hitting, swinging at staff during care, yelling at staff/others, and wandering. Review of the clinical record revealed a behavior note dated 07/31/22. It indicated the aide came at at 5:55 P.M. reporting Resident #146 was smacking another resident in the face three times. It stated the intervention was redirection and separated. It indicated the resident was a threat to herself and others and that she would be monitored. Further review revealed a health status note dated 08/01/22 which indicated regarding the incident on 07/31 at 5:55 P.M. where Resident #146 hit a male resident (Resident #26) in the face three times, staff intervened and Resident #146 was redirected back to her room. Due to the nature of this event, the interdisciplinary team (IDT) agreed to have Resident #146 evaluated at psychiatric hospital as the incident was unprovoked and aggressive behaviors continued towards the State tested Nursing Assistant (STNA) through out the night. It revealed she had been acclimating to a new unit over two weeks and continued with aggression. There was a Social Service note dated 08/01/22 which indicated they were made aware of Resident #146's increased agitation, behaviors hitting at staff and other residents. A resident to resident altercation was reported/noted occurring on 07/31/22. It indicated Resident #146 was with advancing dementia and was unaware to why, reasoning or recall of reported aggressive behaviors. She was approved to be sent for her current inpatient psychiatric needs. Self-reported incidents (SRIs) were reviewed on 08/09/22. There were no SRIs completed regarding this incident. An interview was conducted with the Administrator on 08/04/22 at 3:00 P.M. She indicated there was no SRI or investigation done due to it being witnessed by staff, there was no harm to either one, and both residents resided on the dementia unit. She indicated the families were notified, and the aggressor was sent out. An interview was conducted with Licensed Practical Nurse (LPN) #146 and Registered Nurse (RN) #60 on 08/04/22 at 3:46 P.M. They indicated Resident #146 was acclimating to the unit and was known to tap residents. She ended up chasing the STNA around and went out for a psychiatric evaluation in the morning. They indicated the STNA on the unit was a witness, but no statement was collected. They revealed they did not know the STNA's name. They indicated Resident #26 was taken in to his room and went to bed for the night. They revealed no other residents were assessed. 3. Review of the medical record of Resident #09 revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly MDS assessment dated [DATE] revealed the resident had severely impaired cognition. The resident required extensive assistance of one staff for eating, extensive assistance of two staff for bed mobility, and was dependent on two staff for transfers and toileting. The resident was assessed as having impaired range of motion to all four extremities. Review of a progress notes dated 07/07/22 revealed Resident #09 was found with a small, round, dime sized brown/purple bruise on the right side of her jaw/chin during the morning med pass. Resident #09 was unaware it was there or of how she obtained it. The family, Nurse Practitioner, and Nurse Manager were notified. Review of the facility's SRIs revealed the incident was not reported to the state agency. Interview on 08/04/22 at 3:04 P.M., Executive Director (ED) #110 verified there was not an SRI completed, regarding Resident #09's bruise. Interview on 08/04/22 at 3:43 P.M., Licensed Practical Nurse (LPN) #146 stated she followed up on the incident, however she did not make a note about said follow-up. LPN #146 stated she talked with the staff who cared for Resident #09, however she did not have them write statements, nor did she talk to like residents, or check for additional skin issues on the unit. LPN #146 stated an SRI was not completed because there was no suspicion of abuse. Review of the facility policy titled, Injuries of Unknown Source-Bruises, Skin Tears, dated 08/20/09, revealed, regardless of how minor an injury (bruise, skin tear, injury of unknown source) may be, it must be reported and investigated as soon as it is discovered. 4. Review of the medical record of Resident #18 revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the comprehensive MDS assessment dated [DATE] revealed the resident had moderately impaired cognition. The resident was independent with bed mobility, transfers, eating, and toileting. Interview on 08/02/22 at 9:35 A.M., Resident #18 stated, approximately two weeks prior, another resident looked at him, told him they did not like him and hit him. Review of a progress note dated 07/25/22 revealed Resident #18 was witnessed being slapped repeatedly by another resident. Resident #18 told the other resident to stop touching him and the other resident was mocking him while slapping him. No injury was noted. 5. Review of the medical record of Resident #92 revealed an admitted [DATE]. The resident transferred to the hospital on 07/27/22. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly MDS assessment dated [DATE] revealed the resident had severely impaired cognition. The resident exhibited fluctuating inattention and 4-6 days of physical behavioral symptoms directed towards others and wandering during the assessment period. The resident required extensive assistance for bed mobility, transfers, locomotion on and off the unit, dressing, and toileting. The resident required supervision for eating. Review of a progress note dated 07/25/22 revealed Resident #92 was witnessed slapping another resident (Resident #18). Resident #18 stated several times for Resident #92 to stop touching him and Resident #92 was mocking what he was saying and continuously smacking him. Review of the facility's SRIs revealed the incident was not reported to the state agency. Interview on 08/04/22 at 10:11 A.M., ED #110 verified there was not an SRI completed for the incident on 07/25/22 because it was described as a light tapping. ED #110 verified the other resident was Resident #92, who was sent to the hospital a few days later. ED #110 further stated the incident was not investigated because it was witnessed. 6. Review of the medical record of Resident #65 revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly MDS assessment dated [DATE] revealed the resident had severely impaired cognitive status. The resident required extensive assistance of one staff for bed mobility, and was totally dependent on two staff for transfers and toileting. The resident required supervision for eating. Review of a progress note dated 07/24/22 revealed Resident #65 was touched inappropriately by another resident. Resident #65 voiced concerns to the staff. Review of the Daily Behavior Assessment for Resident #92 dated 06/24/22 revealed Resident #92 was wandering and touching residents inappropriately. Resident #65 stated Honey, she keeps rubbing my breast. I keep telling her to stop touching me, but she won't stop. Resident #92 was removed from the area and extensive one-on-one supervision was provided by the activity staff. Review of the facility's SRIs revealed neither of the incidents involving Resident #65 and #92 were reported to the state agency. Interview on 08/08/22 at 3:33 P.M., LPN #160 stated Resident #65 told her a few weeks ago that Resident #92 touched her breast and in the groin area and she was really upset about it. Interview on 08/08/22 at 4:36 P.M., STNA #17 stated she recently heard Resident #65 yell out that a resident had touched her breast. STNA #17 stated she did not physically see it occur, however Resident #92 was right next to her when it happened. STNA #17 further stated she heard Resident #92 had touched Resident #65 inappropriately a few times. Interview on 08/09/22 at 8:51 A.M., STNA #70 stated she had not seen Resident #92 touch Resident #65, however noticed Resident #65 telling everyone that Resident #92 had touched her breasts and private area for a few days following the incident. Interview on 08/09/22 at 4:24 P.M., the Director of Nursing (DON) verified investigations were nor completed for either of the incidents between Resident #92 and #65. The DON stated an investigation was not completed because Resident #92 has dementia and was not touching the other resident with the intention of harm and the other resident did not seem to be in any distress. Review of the facility policy titled, Resident Abuse, dated 03/12/18, revealed abuse is defined as the willful infliction of injury, intimidation or punishment with resulting physical harm, pain, or mental anguish. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain, or mental anguis. Abuse includes verbal abuse, sexual abuse, physical abuse and mental abuse. Willful, as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. Sexual abuse is non-consensual sexual contact of any type with a resident. The investigation shall consist of interviews with any witnesses, interviews with staff members on all shifts having contact with the resident during the period of the alleged incident, interviews with the resident's family members and visitors, and interviews with other residents. The incident will be reported to the state agency within 24-hours of the reported abuse and completed within five working days.

Based on record review, interviews, and observations, the facility failed to update a resident's care plan after the development of a pressure ulcer. This affected one (#91) of two residents reviewed for pressure ulcers. The facility census was 105. Findings include: Review of the medical record revealed Resident #91 was admitted to the facility on [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Significant Change Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #91 had severe cognitive impairment. Resident #91 was assessed to require one-person extensive assistance with transfers, dressing, and bathing, supervision with eating, and two-person extensive assistance with toileting. Review of the care plan dated 06/04/22 revealed Resident #91 had impairment to skin integrity related to immobility, weakness, and open area on sacrum. Interventions included encourage good nutrition and hydration in order to promote healthier skin. Staff to keep her clean, dry, and comfortable with bathing, linen, and gown changes as needed. Wound nurse to follow her. Staff to keep skin clean and dry and use lotion on dry skin. Staff to ensure pressure relieving mattress and wheelchair cushion. Staff to complete treatments as ordered. Review of the care plan revealed Resident #91's skin integrity care plan had not been accurately updated after the development of her pressure sore on 06/14/22. An intervention for Resident #91 to be followed by the wound nurse was added on 07/26/22. No other interventions were added after a deterioration in pressure ulcer. Review of the physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the progress note dated 06/14/22 at 1:47 P.M. revealed Resident #91 had an area noted on sacrum. Treatment was ordered and initiated. Call was placed to skin team for a follow-up, and a pressure relief cushion was placed to wheelchair and recliner. Review of the progress note dated 06/17/22 at 12:14 P.M. revealed Resident #91's coccyx was assessed, and an open area with slough was noted. Wound consult was obtained. Review of the wound progress note dated 06/20/22 revealed Resident #91 had a sacral wound that measured 1.7 centimeters (cm) length by 1.3 cm width and unable to determine in depth. Plan of care revealed to continue Aquaphor with [MEDICATION(S)] and gauze dressing every shift, and a pressure reduction mattress and cushion to bed and wheelchair. Review of the wound progress note dated 07/18/22 revealed Resident #91 had a sacral wound that measured 1.8 cm length by 1.2 cm width by 0.3 cm depth. Plan of care revealed to continue Aquaphor with [MEDICATION(S)] ad gauze dressing to sacrum every shift. Staff to continue to assist with activities of daily living and supplements. Review of the wound progress note dated 07/25/22 revealed Resident #91 had a sacral wound that measured 1.5 cm length by 0.8 cm width by 0.3 cm depth. Plan of care revealed to continue with Aquaphor with [MEDICATION(S)] and gauze dressing to sacrum every shift. Staff to encourage and assist Resident #91 to turn and reposition every two hours while in bed and to shift weight every hour while in chair. Review of the medical record revealed intervention to turn and reposition Resident #91 was not added to care plan or physician orders. Observation on 08/08/22 at 1:57 P.M. of wound Nurse Practitioner (NP) #300 and Licensed Practical Nurse (LPN) #146 completed a dressing change to Resident #91. The sacral wound measured 1.6 cm length by 0.6 cm width and 0.2 cm depth. The wound was cleaned with normal saline. [MEDICATION(S)] was applied to wound bed and covered with dry gauze. Interview on 08/08/22 at 2:03 P.M. with wound NP #300 revealed interventions including a pressure reduction mattress/cushion as well as turning and repositioning was part of the standard plan of care and should have been added accordingly.

Based on record review, staff and resident interviews, review of the facility shower schedules, and policy review, the facility failed to ensure residents received showers as scheduled. This affected two (#34 and #59) of three residents reviewed for activities of daily living (ADL) care. The facility census was 105. Findings include: 1. Review of the medical record revealed Resident #59 was admitted to the facility on [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #59 had intact cognition. Resident #59 was assessed to require one-person limited assistance with transfers, two-person extensive assistance with dressing, supervision with eating, and one-person extensive assistance with toileting and bathing. Review of the care plan dated 06/21/22 revealed Resident #59 had ADL functional rehabilitation potential related to history of L2 transverse fracture, seizures, weakness, and pain. Interventions included assess functional level and physical therapy and occupational therapy referrals as needed. Staff to assist with bathing and showering, able to wash upper torso but needs assistance cleaning groin area. Staff to encourage to use call light for assistance. Review of the physician order dated 04/24/22 revealed Resident #59 was ordered shower days on Wednesday and Saturday during the day. Review of the shower records for the last 30 days revealed Resident #59 was not given a shower on 07/23/22 and 07/30/22. Review of the facility's shower schedule revealed Resident #59 was scheduled on Wednesday and Saturday day shift for showers. Interview on 08/08/22 at 10:17 A.M. with State tested Nurse's Aide (STNA) #244 confirmed Resident #59 did not receive a shower on 07/23/22 and 07/30/22. STNA #244 reported Resident #59 does not refuse a shower, and the only reason why he would not get one would be due to staffing levels. 2. Review of the medical record of Resident #34 revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly MDS assessment dated [DATE] revealed the resident had intact cognition. The resident required extensive assistance of two staff for bed mobility, transfers, and toileting. The resident was dependent on two staff for bathing. Review of physician orders revealed an order dated 04/07/22 for the resident to receive showers three days per week, on Tuesday, Friday, and Sunday. Review of shower task charting revealed not applicable was checked on 07/31/22. Review of the facility shower schedule, last updated on 07/15/22, revealed Resident #34 was to receive showers on Sundays, Tuesdays, and Fridays on day shift. Interview on 08/01/22 at 12:52 P.M., Resident #34 stated he is supposed to receive showers on Tuesdays, Fridays, and Sundays and had not received a shower the day prior as scheduled. Resident #34 stated staff informed him they did not have enough people to provide his shower that day. Telephone interview on 08/09/22 at 12:45 P.M., STNA #165 verified she did not provide a shower to Resident #34 on 07/31/21 due to being short on staff. STNA #165 stated bathing Resident #34 requires two aides and there were four aides on the unit that day. STNA #165 stated Resident #34 is a very large individual and requires three showers per week to ensure appropriate care. Interview on 08/10/22 at 10:16 A.M., the Director of Nursing (DON) stated there was not a specific policy pertaining to showers, however the expectation is for residents to be showered per their schedule. Review of the facility policy titled, Bathing Choice, dated 03/19/12 revealed all residents will be offered a bath/shower as often as they would like. Resident choices will be posted in the resident's wardrobe readily available so they will know what choices they made.

Based on record review, observations, interviews, and policy review, the facility failed to ensure fall interventions were in place. This affected one (#19) out of nine residents reviewed for falls. The facility census was 105. Findings include: Review of the medical record revealed Resident #19 was admitted to the facility on [DATE]. Diagnoses included left femur fracture, acute kidney failure, type two diabetes mellitus, [CONDITION(S)], and acute respiratory failure with [CONDITION(S)]. Review of the Admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #19 had moderate cognitive impairment. Resident #19 was assessed to require two-person extensive assistance with transfers and toileting, and one-person extensive assistance with dressing, eating, and bathing. Review of the care plan dated 05/07/22 revealed Resident #19 was at risk for falls related to history of falls, hypertension, diabetes mellitus, [CONDITION(S)], and [CONDITION(S)]. Interventions included a beveled mat next to bed. A dual touch pad call light in place. Staff to ensure end slouch cushion to recliner. Staff to ensure urinal was always within reach. Staff to move nightstand away from bed. Staff to offer protective headgear as allows and as tolerated related to injury. Staff to have reminder sign in room to call for assistance. Review of the progress note dated 05/15/22 at 11:03 A.M. revealed staff found Resident #19 on the floor on his buttocks next to his bed. Resident #19 reported he attempted to get up without help and raised recliner too high and slid onto buttocks. Resident #19 was assisted back to bed with three staff members. No injuries noted. Educated Resident #19 on not getting out of bed unassisted, to use call light, and reminder sign placed in room. Review of the progress note dated 05/17/22 at 1:49 P.M. revealed fall and care plan reviewed during fall team meeting. End-slouch added to recliner in room. Restorative nurse to reevaluate recliner chair in room. Review of the progress note dated 05/18/22 at 10:30 P.M. revealed Resident #19 was found on the floor face down. Resident #19 had a large red abrasion with swelling to right forehead. Resident #19 reported he fell asleep watching golf. Resident #19 was assisted to bed about 45 minutes before incident. Physician gave orders to send to emergency room for evaluation related to fall, being on a blood thinner, and other medical issues throughout the day. Review of the progress note dated 05/19/22 at 1:30 P.M. revealed fall and care plan reviewed with interdisciplinary team. New interventions were a touch pad call light in room, knee-height bed, beveled mat next to bed, neurological checks. Resident #19 aware and educated on interventions. Review of the progress note dated 05/19/22 at 4:33 P.M. revealed Resident #19 found kneeling on floor by the sofa. Resident #19 was trying to reach for urinal and lost his balance. Resident #19 landed on knees and couldn't get up. Resident #19 had skin tear to the right knee. Review of the progress note dated 05/20/22 revealed new interventions for fall on 05/19/22 revealed staff should keep urinal and call light within reach at all times and place reminders signs in room to remind to call for help. Review of the progress note dated 05/23/22 at 2:24 P.M. revealed Resident #19 was found on his knees in front of bed. Intervention revealed to remind staff to place beveled mat on floor next to bed. Review of the fall investigation report dated 05/23/22 revealed Resident #19 did not have a beveled mat next to bed during the time of his fall. Observation on 08/04/22 at 10:24 A.M. revealed Resident #19 was lying in bed with eyes closed. No beveled fall mat in place next to bed. Observation on 08/08/22 at 10:33 A.M. revealed Resident #19 was lying in bed watching television without a beveled fall mat in place next to bed. Interview on 08/04/22 at 10:36 A.M. with Resident #19 revealed fall mat was not next to bed with previous falls and did not currently have a mat in his room. Interview on 08/04/22 at 11:03 A.M. with Registered Nurse (RN) #59 confirmed Resident #19 did not have a beveled mat next to his bed. Interview on 08/09/22 at 5:13 P.M. with RN #265 revealed the fall on 05/23/22 confirmed Resident #19 did not have a fall mat in place at the time of his fall. Review of the facility policy titled, Accident and Incident - Investigating and Reporting, dated 07/27/22 revealed the policy was to provide guidelines for assessing a resident after a fall and to assist staff in identifying causes of the fall. Staff were to implement appropriate interventions taken to prevent future falls.

Based on record review, interviews, and policy review, the facility failed to accurately document in the resident record regarding fall investigations. This affected two (#19 and #56) out of nine residents reviewed for falls. The facility census was 105. Findings include: 1. Review of the medical record revealed Resident #19 was admitted to the facility on [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #19 had moderate cognitive impairment. Resident #19 was assessed to require two-person extensive assistance with transfers and toileting, and one-person extensive assistance with dressing, eating, and bathing. Review of the care plan dated 05/07/22 revealed Resident #19 was at risk for falls related to history of falls, hypertension, diabetes mellitus, [CONDITION(S)], and [CONDITION(S)]. Interventions included a beveled mat next to bed, a dual touch pad call light in place, staff to ensure end slouch cushion to recliner, staff to ensure urinal was always within reach, staff to move nightstand away from bed, staff to offer protective headgear as allows and as tolerated related to injury, and staff to have reminder sign in room to call for assistance. Review of the progress note dated 05/15/22 at 11:03 A.M. revealed staff found Resident #19 on the floor on his buttocks next to his bed. Resident #19 reported he attempted to get up without help and raised recliner too high and slid onto buttocks. Resident #19 was assisted back to bed with three staff members. No injuries noted. Educated Resident #19 on not getting out of bed unassisted, to use call light, and reminder sign placed in room. Review of the progress note dated 05/17/22 at 1:49 P.M. revealed fall and care plan reviewed during fall team meeting with end-slouch added to recliner in room and restorative nurse to reevaluate recliner chair in room. Review of the progress note dated 05/18/22 at 10:30 P.M. revealed Resident #19 was found on the floor face down. Resident #19 had a large red abrasion with swelling to right forehead. Resident #19 reported he fell asleep watching golf. Resident #19 was assisted to bed about 45 minutes before incident. Physician gave orders to send to emergency room for evaluation related to fall, being on a blood thinner, and other medical issues throughout the day. Review of the progress note dated 05/19/22 at 1:30 P.M. revealed fall and care plan reviewed with interdisciplinary team. New interventions were a touch pad call light in room, knee-height bed, beveled mat next to bed, neurological checks. Resident #19 aware and educated on interventions. Review of the progress note dated 05/19/22 at 4:33 P.M. revealed Resident #19 found kneeling on floor by the sofa. Resident #19 was trying to reach for urinal and lost his balance. Resident #19 landed on knees and couldn't get up. Resident #19 had skin tear to the right knee. Review of the progress note dated 05/20/22 revealed new interventions for fall on 05/19/22 revealed staff should keep urinal and call light within reach at all times and place reminders signs in room to remind to call for help. Review of the incident charting dated 05/15/22 revealed Resident #19 was observed on the floor with no apparent injuries on 05/15/22. Review of the incident charting dated 05/19/22 revealed Resident #19 was observed on the floor with an apparent injury including the head on 05/15/22. Review of the incident charting dated 05/22/22 revealed Resident #19 was observed on the floor with an apparent injuring including the head on 05/22/22. Interview on 08/09/22 at 5:13 P.M. with Registered Nurse (RN) #265 revealed Resident #19 had a fall on 05/15/22 with no apparent injuries. On 05/18/22, Resident #19 had a fall with a head abrasion noted. On 05/19/22, Resident #19 had a fall where he obtained a skin tear to the right knee. On 05/23/22, Resident #19 had a fall where he obtained a skin tear to right great toe. RN #265 revealed documentation on incident charting was not accurate with injuries or dates of falls. 2. Review of the medical record revealed Resident #56 was admitted to the facility on [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly MDS assessment dated [DATE] revealed Resident #56 had moderate cognitive impairment. Resident #56 was assessed to require two-person extensive assistance with transfers, dressing, and toileting, independent with eating, and one-person total dependence with bathing. Review of the care plan dated 06/15/22 revealed Resident #56 was at risk for falls related to weakness, refused to wear head gear, refused physical therapy evaluation. Interventions included offered protective sleeves as allows. Staff to prompt toileting program initiated. Staff to place reminder sign in room to call for assistance with transfers. Staff to ensure standard house fall precautions per policy. Staff to use standard wheelchair with anti-tipping devices for transfers involving sit-stand lift. Review of the progress note dated 02/27/22 at 7:16 P.M. revealed Resident #56 had an unwitnessed fall in his room at approximately 4:00 P.M. Resident #56 said he hit his head and had an extensive skin tear to posterior right hand. Resident #56 was sent to the emergency room for evaluation. Review of the progress note dated 04/29/22 at 12:56 P.M. revealed Resident #56 was being assisted to the stand-up lift with two staff members when Resident #56 lifted foot to place onto lift and the transfer chair titled back. Resident #56 fell and hit his head. Resident #56 had a quarter size bump on back of his head. Review of the incident charting dated 02/28/22 revealed Resident #56 had a fall on 02/27/22 with a skin tear to right hand/wrist and a small arachnoid hemorrhage on computed tomography (CT) scan. Review of the incident charting dated 04/29/22 revealed Resident #56 had fall on 04/29/22 involving his head. Review of the incident charting dated 04/30/33 revealed Resident #56 had a fall on 04/29/22 involving his head with injuries including a skin tear to right hand/wrist and a small subarachnoid hemorrhage on CT scan. Incident charting for 05/01/22 and 05/02/22 show the same injuries, which were inaccurate. Interview on 08/09/22 at 5:13 P.M. with RN #265 revealed Resident #56 had a fall on 02/27/22 a fall, which included a skin tear to right hand/wrist and a small subarachnoid hemorrhage on CT scan. On 04/29/22, Resident #56 had a fall during a transfer with a quarter size bump on back of head. RN #265 revealed documentation on incident charting was not accurate with injuries or dates of falls. Review of the facility policy titled, Accident and Incident - Investigating and Reporting, dated 07/27/22 revealed the policy was to provide guidelines for assessing a resident after a fall and to assist staff in identifying causes of the fall. When a resident fall occurs, the date and time of the incident or when the resident was noted on the floor, assessment data including vital signs and injuries should be documented in the medical chart.

Based on record review and interviews, the facility failed to follow physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility census was 105. Findings include: Review of the medical record revealed Resident #19 was admitted to the facility on [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #19 had moderate cognitive impairment. Resident #19 was assessed to require two-person extensive assistance with transfers and toileting, and one-person extensive assistance with dressing, eating, and bathing. Review of the care plan dated 05/07/22 revealed Resident #19 was at risk for falls related to history of falls, hypertension, diabetes mellitus, [CONDITION(S)], and [CONDITION(S)]. Interventions included a beveled mat next to bed, a dual touch pad call light in place, staff to ensure end slouch cushion to recliner, staff to ensure urinal was always within reach, staff to move nightstand away from bed, staff to offer protective headgear as allows and as tolerated related to injury, and staff to have reminder sign in room to call for assistance. Review of the physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review orthostatic blood pressures and notify physician of abnormal results. Review of the physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review ortho blood pressures and notify physician of any abnormal results. Review of the progress note dated 07/17/22 at 7:13 P.M. revealed Resident #19 had a fall, and the intervention post-fall was to complete orthostatic blood pressures for three days. Review of the progress note dated 07/18/22 at 11:15 A.M. revealed plan of care was reviewed. Staff to check orthostatic blood pressures for three days. Review of the progress note dated 07/26/22 at 1:14 P.M. revealed plan of care reviewed. Orthostatic blood pressures were not completed and will restart orthostatic blood pressures for three days. Review of the treatment administration record (TAR) dated May 2022 revealed Resident #19's orthostatic blood pressures were not completed as ordered. Review of the TAR dated July 2022 revealed Resident #19's orthostatic blood pressures were not completed as ordered. Interview on 08/09/22 at 4:47 P.M. with Registered Nurse (RN) #265 revealed orthostatic blood pressures were not completed as ordered on 05/08/22 through 05/10/22, 07/17/22 through 07/19/22, and 07/26/22 through 07/28/22.

Based on medical record review, observation, staff interview, review of facility policy, and review of online resources per the Centers for Disease Control (CDC) and the Center for Medicare and Medicaid Services (CMS), the facility failed to implement proper infection control practices to potentially prevent the spread of Coronavirus Disease 2019 (COVID-19). The facility failed to ensure staff wore appropriate personal protective equipment (PPE) when providing care to a resident on transmission-based precautions which had the potential to affect one (#54) of four residents sampled. The facility failed to ensure soiled linen from the room of resident on transmission-based precautions was handled properly which had the potential to affect one (#61) of four residents sampled. The facility failed to ensure a private duty caregiver wore appropriate PPE when closer than six feet to a resident affecting one (#25) of four residents sampled. Facility census was 70. Findings include: 1. Review of the medical record for Resident #54 revealed an admission date of [DATE] with a [DIAGNOSES REDACTED]. Review of admission nursing note dated 01/22/21 revealed Resident #54 was admitted to the facility from the hospital on [DATE] Review of admission assessment for Resident #54 dated 01/22/21 revealed the resident was alert and oriented to person, place, and time with some periods of forgetfulness and required supervision with activities of daily living (ADL's). Review of the care plan for Resident #54 initiated 01/22/21 revealed resident was in 14-day isolation related to a recent hospitalization and was new to the facility. Interventions included staff should utilize appropriate PPE while giving care. Observation on 01/27/21 at 9:50 A.M. with the Director of Nursing (DON) revealed a sign had been placed on Resident #54's door which read Please check with nurse before entering. Further observation revealed there was an isolation cart outside Resident #54's door containing PPE including gowns, gloves, and surgical masks. Observation on 01/27/21 at 9:52 A.M. revealed State tested Nursing Assistant (STNA) #150 entered Resident #54's room carrying a water pitcher. STNA #150 was wearing an N-95 and eye protection prior to entering the resident's room. STNA #150 did not don any additional PPE prior to entering Resident #54's room. Interview on 01/27/21 at 9:55 A.M. with STNA #150 confirmed she had entered Resident #54's room and did not don any PPE in addition to an N-95 mask and eye protection prior to entering the room. STNA #54 confirmed she provided water to Resident #54 and conversed with resident while in the room. STNA #150 confirmed awareness of the sign outside Resident #54's room and the availability of additional PPE such as gloves, gowns, and surgical masks in the care outside Resident #54's door but further confirmed additional PPE was not necessary because the resident was not in the COVID-19 unit. Interview on 01/27/21 at 12:18 P.M. with the DON confirmed all newly admitted residents to the facility were to be placed in Quarantine Precautions for 14 days from admission. DON further confirmed staff should don a gown and gloves and a surgical mask over an N-95 mask prior to entering the resident's room. Review of current facility signage for Quarantine Precautions to be placed outside of resident rooms revealed mask, gloves, shield, and gown are to be worn at all times. Review of the facility policy titled Precautions: Standard, Contact and Droplet dated 10/23/20 revealed residents would remain in quarantine isolation for 14 times from the time of admission and staff would wear mask, gloves, shield, and gown at all times. Review of facility policy titled COVID-19 undated revealed the facility would follow CDC and CMS guidelines regarding management and prevention of the spread of COVID-19. Review of an online resource from the CDC at https://www.cdc.gov/coronavirus/2019-ncov/hcp/clinical-guidance-management-patients.html, revealed the incubation period for COVID-19 was thought to extend to 14 days and one study reported 97.5% of persons with COVID-19 who develop symptoms will do so within 11.5 days. 2. Review of the medical record for Resident #61 revealed an admission date of [DATE] with a [DIAGNOSES REDACTED]. Review of the MDS for Resident #61 dated 01/24/21 revealed resident was cognitively impaired and required extensive assistance of one staff with ADL's. Review of the care plan for Resident #61 initiated 01/18/21 revealed resident was to be placed in isolation for 14 days from admission on 01/18/21 due to recent hospitalization . Observation on 01/27/21 with the DON at 10:03 A.M. revealed had been placed on Resident #54's door which read Please check with nurse before entering. Further observation revealed there was an isolation cart outside Resident #54's door containing PPE and a large blue bag was laying on the floor of the resident's room at the foot of the bed. Interview on 01/27/21 at 10:03 A.M. with the DON confirmed Resident #54 was in quarantine precautions for 14 days due to her recent admission on 01/18/21. Interview on 01/27/21 at 10:09 A.M. with STNA #150 confirmed the large blue bag on the floor of Resident #54's room contained soiled linen. STNA #150 further confirmed she removed the soiled linen from Resident #54's bed, placed it in the bag, but had not taken it the linen to the appropriate place for soiled linen for residents on quarantine precautions. Review of the facility policy titled Precautions: Standard, Contact and Droplet dated 10/23/20 revealed the implementation of standard precautions applied to all residents regardless of suspected or confirmed infection status and safe infection practices should be maintained to minimize the risk of transmitting infections. 3. Review of the medical record for Resident #25 revealed an admission date of [DATE] with a [DIAGNOSES REDACTED]. Review of the MDS for Resident #25 dated 12/03/20 revealed resident was cognitively impaired and required supervision and one-person physical assistance with ADL's. Observation on 01/27/21 at 12:01 P.M. revealed Resident #54 was eating lunch in a private dining room seated closer than six feet to Private Duty Aide (PDA) #190. Further observation revealed PDA #190 was also eating lunch and had a soiled KN-95 mask sitting on the table next to her plate. PDA #190 was not wearing eye protection. Interview on 01/27/21 at 12:02 P.M. with PDA #190 confirmed she was employed by Resident #54's family as a private duty caregiver and she worked from 11:30 A.M. to 1:30 P.M. PDA #190 further confirmed the facility provided lunch to her and she was permitted to eat lunch in the resident dining area. PDA #190 confirmed the soiled KN-95 was hers and she thought the mask had been soiled with chocolate and she wore a mask she brought from home when caring for Resident #54 except when aide was dining with the resident. PDA #190 confirmed she was screened at the front desk for signs and symptoms of COVID-19 prior to entering the facility just like the regular staff did and she was also tested twice weekly for COVID-19 by the facility. Interview on 01/27/21 at 12:18 P.M. with the DON confirmed PDA #190 was a private duty caregiver employed by Resident #54's family. Interview on 01/27/21 at 3:00 P.M. with Registered Nurse (RN) #200, the facility's Infection Preventionist (IP) confirmed staff, vendors, and visitors or anyone who enters the facility must wear facemask's at all times in the resident care areas. RN #200 further confirmed staff are not currently permitted to dine with the residents due to COVID-19 concerns and staff have areas separate from residents where they may remove masks for eating and drinking. RN #200 further confirmed facemask's should be discarded and replaced when visibly soiled. Review of online resource per the CDC at https://www.cdc.gov/coronavirus/2019-ncov/hcp/long-term-care-strategies.html, revealed the following guidance regarding facemask's: ensure all healthcare care personnel (HCP) wear a facemask for source control while in the facility. Review of the CMS memo titled QSO-20-28-NH revealed the following: Residents are not forced to eat in their rooms. Residents may still eat in dining rooms, however, nursing homes should adhere to social distancing, such as being seated at separate tables at least six feet apart. We note that social distancing should be practiced at all times (not just while dining). Review of an online resource from CMS titled COVID-19 Nursing Home data at https://data.cms.gov/stories/s/COVID-19-Nursing-Home-Data-Test-Positivity-Rates/q5r5-gjyu/ revealed the county in which the facility was situated was experiencing a high spread of COVID-19 with a positivity rate of 15.6 percent (%) and was identified as red for the week ending 01/20/21. For the week ending 01/27/21, the county in which the facility was situation had a 13.5% or was identified as red regarding their COVID-19 positivity rate. This deficiency represents ongoing noncompliance from the survey dated 12/28/20.

Based on observation, staff interview, facility policy review and review of online resources from Centers for Medicare and Medicaid (CMS), and Centers for Disease Control (CDC) guidelines, the facility failed to ensure staff wore appropriate personal protective equipment (PPE) in the facility to prevent the spread of Coronavirus (COVID-19) This had the potential to affect all Residents (#1, #2, #3, #4, #5, #6, #8) being housed in the COVID-19 unit. Additionally, the facility failed to ensure non-COVID-19 staff did not enter and complete routine tasks inside the COVID-19 unit. This had potential to affect all 16 Residents (#7, #11, #12, #13, #14, #15, #16, #17, #18, #19, #20, #21, #22, #23, #24, and #26) who the facility identified as being housed on the Orchards hall and being cared for the staff member. Facility census was 88. Findings include: 1. During observation of the COVID-19 (orchards 70's) unit during the initial tour with Administrator #10 and Director of Nursing (DON) on 12/14/20 at 2:13 P.M. revealed Licensed Practical Nurse (LPN) #30, State tested Nurses Aide (STNA) #40 and Hospitality Aide (HA) #50 was assigned to the COVID-19 unit. Further observation of COVID-19 unit revealed LPN #30 was observed to have a surgical mask underneath her N95 mask and the bottom head strap of her N95 missing. Interview with LPN #30 at same time verified she had provided care to COVID-19 residents with the surgical mask underneath the N95 mask and bottom strap of her N95 missing. Further observation of the COVID-19 unit revealed STNA #40 was observed to have a surgical mask on under her N95 mask. Interview with STNA at same time verified she had provided care to COVID-19 residents with the surgical mask underneath the N95. Interview with DON at same time verified LPN #30 and STNA #40 had on surgical masks underneath their N95 masks and verified LPN #30 had on a N95 with the bottom head strap missing. Observation of PPE supplies on 12/14/20 at 3:00 P.M. revealed numerous boxes of N95 masks, gowns, and face shields. Interview with DON and Administrator #10 verified they were not in a crisis strategy related to PPE supplies. Observation of the COVID-19 unit on 12/14/20 at 4:00 P.M. revealed HA #50 working on the COVID-19 unit with a KN95 mask with ear loops and secured behind her ears and a surgical mask over top of KN95. Further observation at 4:05 P.M. revealed HA #50 exited the COVID-19 unit. Interview at same time, indicated she was assigned to the COVID-19 unit from 8:00 A.M. to 4:00 P.M. and she wore the same KN95 mask throughout the shift and also stated she had worn the same KN95 for the last week as she worked on the COVID-19 unit and she had worn the same two masks on and off the unit and as she traveled to and from work. Interview with Administrator #10 at same time, verified HA #50 had on a KN95 mask with ear loops that secured behind her ears as she worked the COVID-19 unit. 2. During subsequent observation of COVID-19 unit on 12/14/20 at 4:26 P.M. revealed STNA #42 was observed on the COVID-19 unit without a protective gown or face shield in place and standing directly next to a Resident #3 who was in a wheelchair and with no mask in place. Further observation at 4:33 P.M. revealed STNA #42 exited the COVID-19 unit into the main hallway where non-COVID-19 residents were being housed. Interview with STNA #42 at the same time indicated she was assigned to the non-COVID-19 adjacent Orchards hallway. STNA #42 stated she was tasked with delivering clean laundry to the COVID-19 unit and further stated she entered the COVID-19 unit to ask STNA #40 a question about a resident on her unit since STNA #40 was normally assigned to the Orchards hall. STNA #42 stated she was not aware the COVID-19 unit was a restricted unit and only dedicated staff should be on the unit. STNA #42 verified she was on the COVID-19 unit to complete routine tasks as she was assigned to the non-COVID-19 unit. Review of undated facility policy, titled COVID-19 revealed the facility will follow transmission based precautions which are the second tier of basic infection control and are to be used in addition to standard precautions for residents who are suspected or confirmed to have COVID-19. The facility will implement all three types of transmission-based precautions (contact, droplet and airborne) with residents who are suspect or confirmed to have COVID-19. Policy also revealed the faciliyt will protect resdients from unnecassary exposure to COVID-19. Review of online resources from CDC https://www.cdc.gov/niosh/npptl/usernotices/ counterfeitResp.html revealed the KN95 masks being worn on the COVID-19 unit were identified as being a counterfeit respirator listed on CDC website. Review of the CDC guidelines at https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html., revealed Health Care Professionals (HCP) working in facilities located in areas with moderate to substantial community transmission are more likely to encounter asymptomatic or pre-symptomatic patients with [DIAGNOSES REDACTED]-CoV-2 infection. Staff should also wear eye protection in addition to their facemask to ensure the eyes, nose, and mouth are all protected from exposure to respiratory secretions during patient care encounters and wear an N95 or equivalent or higher-level respirator, instead of a facemask. Guidelines revealed PPE for health care personnel (HCP) who enter the room of a patient with suspected or confirmed [DIAGNOSES REDACTED]-CoV-2 infection should adhere to standard precautions and use a (National Institute Occupational Safety and Health) (NIOSH) approved N95 or equivalent or higher-level respirator (or facemask if a respirator is not available), gown, gloves, and eye protection. Review of Centers for Medicare and Medicaid Services (CMS) memo titled Nursing Home Guidance, dated 04/02/20, revealed all nursing homes shall ensure they are complying with all CMS and CDC guidance related to infection control.

Based on medical record review, review of the hospital record, review of facility policy, and staff interview, the facility failed to report an injury of unknown origin to the state agency for one resident (#63) of five reveiwed for accidents. The facility census was 102. Findings include: Medical record review revealed Resident #63 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #63 had severely impaired cognition and required extensive assistance for activities of daily living. Review of the facility's Fall Investigation report dated 06/26/19, revealed Resident #63 fell from her wheel chair and was wearing hipsters at the time of the fall. The report revealed the resident sustained [REDACTED]. Review of Resident #63's progress note dated 07/08/19 at 12:42 P.M., revealed a late entry for 07/05/19 which documented the resident had no pain or discomfort. Review of Resident #63's progress note dated 07/06/19 at 8:50 P.M., revealed a State tested Nursing Assistant (STNA) had assisted the resident to bed and noticed the resident was having a lot of pain, was yelling out, and was grabbing at her left inner thigh and hip. The nurse was notified. The nurse's assessment revealed the resident's left foot to be rotated outward, the resident had extreme pain with range of motion, was grabbing at the left inner thigh, yelling out, and became tearful. The note further revealed the resident had a fall on 06/26/19 with no injuries noted. There was an old green bruise to left knee noted and thought to be from the fall on 06/26/19. The physician was notified and ordered x-rays of the left hip. The resident's family was notified and revealed they took the resident out of the facility on 07/04/19, transferring the resident in and out of the car, and the resident did not appear to be in pain. Review of the radiology report dated 07/06/19 at 11:14 P.M., revealed Resident #63 had an acute (sudden) transcervical versus basicervical left [MEDICAL CONDITION]. Review of the progress note dated 07/07/19 at 1:35 A.M., revealed the facility contacted Resident #63's physician with the hip x-ray results and the resident was sent to the hospital emergency room for evaluation. Review of the hospital history and physical dated 07/07/19 revealed Resident #63 presented to the acute care hospital with the chief complaint of hip pain. The note documented the resident had an x-ray of the left hip which revealed an acute left subcapital femoral neck fracture. Interview on 07/16/19 at 5:13 P.M., with the Director of Nursing (DON) and Nurse Supervisor (NS) #285 revealed Resident #63 had been out of the facility with family on 07/04/19, transferring in and out of a car multiple times. The DON reported the family was adamant the resident was not in any pain during the outing. The DON and NS #285 revealed the staff noted hip pain on 07/06/19, an x-ray revealed a [MEDICAL CONDITION], and an order was received to send the resident to the hospital for treatment. The DON and NS #285 denied the resident had any bruising to the hips prior to sending the resident to the hospital. Interview on 07/17/19 at 9:56 A.M., with the DON revealed Resident #63's [MEDICAL CONDITION] was not related to the fall on 06/26/19, and the facility thought something may have happened when the resident went out with the family 07/04/19. She was unsure if the facility investigated the injury of unknown origin. Interview on 07/17/19 at 10:47 A.M., with NS #285 revealed Resident #63 had a fall on 06/26/19 and had no signs of injury at the time. NS #285 confirmed the resident went out of the facility with the family on 07/04/19 and the family denied there was any injury or incident while transferring the resident in and out of the car. NS #285 revealed the facility then attributed the resident's [MEDICAL CONDITION] to the fall sustained on 06/26/19 (10 days prior). NS #285 verified the facility had no evidence a thorough written investigation was completed when the injury was discovered, including interviews/written statements with the STNA who assisted the resident to bed and reported the resident's sudden severe pain on 07/06/19 or other staff. Interview on 07/17/19 at 11:15 A.M., with the DON verified the facility did not have evidence of a written investigation of Resident #63's [MEDICAL CONDITION]. There were no injuries from staff who provided care up to the time of the noted injury. The DON verified the facility did not submit a Self-Reported Incident (SRI) to the state survey agency for the injury of unknown source. During an additional interview on 07/17/19 at 1:50 P.M., at the request of the DON, the DON revealed the facility had always thought Resident #63's [MEDICAL CONDITION] was related to her fall on 06/26/19, which was 10 days prior. NS #285 presented an unsigned, undated summary/timeline of the events surrounding the resident's fracture and stated she had just written it today (07/17/19). The summary noted the resident's daughter stated she would have noticed if the resident was having pain on 07/04/19, and there was no pain noted on 07/05/19. NS #285 also presented an undated written statement signed by the STNA who assisted the resident to bed when the resident initially complained of hip pain on 07/06/19. NS #285 verified the STNA had just written the statement today (07/17/19). Review of the facility policy titled, Resident Abuse revised 03/09/09, revealed an injury should be classified as an injury of unknown source when the source of the injury was not observed by any person, or the source of the injury could not be explained by the resident, and the injury is suspicious because of the extent of the injury or the location of the injury. The policy further revealed when a serious injury of an unknown source is reported, the DON or appointed designee and a member of social services would investigate the incident, the incident would be reported to the Ohio Department of Health within 24 hours and the investigation completed within five days.

Based on medical record review, review of the hospital record, review of facility policy, and staff interview, the facility failed to implement their abuse policy to report and investigate an injury of unknown origin for one resident (#63) of five reveiwed for accidents. The facility census was 102. Findings include: Medical record review revealed Resident #63 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #63 had severely impaired cognition and required extensive assistance for activities of daily living. Review of the facility's Fall Investigation report dated 06/26/19, revealed Resident #63 fell from her wheel chair and was wearing hipsters at the time of the fall. The report revealed the resident sustained [REDACTED]. Review of Resident #63's progress note dated 07/08/19 at 12:42 P.M., revealed a late entry for 07/05/19 which documented the resident had no pain or discomfort. Review of Resident #63's progress note dated 07/06/19 at 8:50 P.M., revealed a State tested Nursing Assistant (STNA) had assisted the resident to bed and noticed the resident was having a lot of pain, was yelling out, and was grabbing at her left inner thigh and hip. The nurse was notified. The nurse's assessment revealed the resident's left foot to be rotated outward, the resident had extreme pain with range of motion, was grabbing at the left inner thigh, yelling out, and became tearful. The note further revealed the resident had a fall on 06/26/19 with no injuries noted. There was an old green bruise to left knee noted and thought to be from the fall on 06/26/19. The physician was notified and ordered x-rays of the left hip. The resident's family was notified and revealed they took the resident out of the facility on 07/04/19, transferring the resident in and out of the car, and the resident did not appear to be in pain. Review of the radiology report dated 07/06/19 at 11:14 P.M., revealed Resident #63 had an acute (sudden) transcervical versus basicervical left [MEDICAL CONDITION]. Review of the progress note dated 07/07/19 at 1:35 A.M., revealed the facility contacted Resident #63's physician with the hip x-ray results and the resident was sent to the hospital emergency room for evaluation. Review of the hospital history and physical dated 07/07/19 revealed Resident #63 presented to the acute care hospital with the chief complaint of hip pain. The note documented the resident had an x-ray of the left hip which revealed an acute left subcapital femoral neck fracture. Interview on 07/16/19 at 5:13 P.M., with the Director of Nursing (DON) and Nurse Supervisor (NS) #285 revealed Resident #63 had been out of the facility with family on 07/04/19, transferring in and out of a car multiple times. The DON reported the family was adamant the resident was not in any pain during the outing. The DON and NS #285 revealed the staff noted hip pain on 07/06/19, an x-ray revealed a [MEDICAL CONDITION], and an order was received to send the resident to the hospital for treatment. The DON and NS #285 denied the resident had any bruising to the hips prior to sending the resident to the hospital. Interview on 07/17/19 at 9:56 A.M., with the DON revealed Resident #63's [MEDICAL CONDITION] was not related to the fall on 06/26/19, and the facility thought something may have happened when the resident went out with the family 07/04/19. She was unsure if the facility investigated the injury of unknown origin. Interview on 07/17/19 at 10:47 A.M., with NS #285 revealed Resident #63 had a fall on 06/26/19 and had no signs of injury at the time. NS #285 confirmed the resident went out of the facility with the family on 07/04/19 and the family denied there was any injury or incident while transferring the resident in and out of the car. NS #285 revealed the facility then attributed the resident's [MEDICAL CONDITION] to the fall sustained on 06/26/19 (10 days prior). NS #285 verified the facility had no evidence a thorough written investigation was completed when the injury was discovered, including interviews/written statements with the STNA who assisted the resident to bed and reported the resident's sudden severe pain on 07/06/19 or other staff. Interview on 07/17/19 at 11:15 A.M., with the DON verified the facility did not have evidence of a written investigation of Resident #63's [MEDICAL CONDITION]. There were no injuries from staff who provided care up to the time of the noted injury. The DON verified the facility did not submit a Self-Reported Incident (SRI) to the state survey agency for the injury of unknown source. During an additional interview on 07/17/19 at 1:50 P.M., at the request of the DON, the DON revealed the facility had always thought Resident #63's [MEDICAL CONDITION] was related to her fall on 06/26/19, which was 10 days prior. NS #285 presented an unsigned, undated summary/timeline of the events surrounding the resident's fracture and stated she had just written it today (07/17/19). The summary noted the resident's daughter stated she would have noticed if the resident was having pain on 07/04/19, and there was no pain noted on 07/05/19. NS #285 also presented an undated written statement signed by the STNA who assisted the resident to bed when the resident initially complained of hip pain on 07/06/19. NS #285 verified the STNA had just written the statement today (07/17/19). Review of the facility policy titled, Resident Abuse revised 03/09/09, revealed an injury should be classified as an injury of unknown source when the source of the injury was not observed by any person, or the source of the injury could not be explained by the resident, and the injury is suspicious because of the extent of the injury or the location of the injury. The policy further revealed when a serious injury of an unknown source is reported, the DON or appointed designee and a member of social services would investigate the incident, the incident would be reported to the Ohio Department of Health within 24 hours and the investigation completed within five days.

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on medical record review, staff interview and inservice records, the facility failed to ensure Resident #4 was transferred using a mechanical lift (Arjo Hoyer) with a cradle sling according to Resident #4's assessment and care plan to prevent injury. This resulted in Actual Harm when Resident #4 was transferred with a stand up lift and suffered a closed [MEDICAL CONDITION] femur and a closed [MEDICAL CONDITION] and tibia of the right leg. This affected one (#4) out of four Residents sampled for transfers. The facility census was 105. Findings included: Record review revealed Resident #4 was admitted to the facility originally on 04/09/13. She was most recently discharged to the hospital on [DATE] and readmitted on [DATE]. She passed away in the facility on 03/09/18. Her [DIAGNOSES REDACTED]. The record was updated on 03/02/18 with the [DIAGNOSES REDACTED]. She had a quarterly Minimum Data Set (MDS) assessment completed on 01/08/18. A Brief Interview for Mental Status (BIMS) score of six indicating the resident had severe cognitive impairment. She required extensive assist of two staff for bed mobility, transfer, dressing, toilet use and bathing. She did not walk. She required extensive assist of one staff for locomotion and personal hygiene. She required supervision of one staff for eating. She had a care plan initiated on 06/25/15 addressing her activities of daily living self-care performance deficit. One of the interventions put in place on 01/09/18 addressing her transfer revealed she required total assistance with one to two assist using a Hoyer style mechanical lift per therapy recommendation. A review of Resident #4's Physical Therapy Discharge Summary dated 01/08/18 revealed the Hoyer lift was the safest mode for transfers for Resident #4 due to the patient's inability to come to a complete stance and she actively resisted standing. Under discharge recommendations it stated the patient was to remain a Hoyer lift for transfers. A review of Resident #4's Kardex for care revealed the resident required total assistance with transfers with a two person assist using an Arjo Hoyer style mechanical lift with a cradle sling only. Review of Resident #4's progress note dated 02/28/18 at 10:13 P.M. revealed a state tested nursing assistant (STNA) notified the writer of bruising discovered after removing TED (support stockings) hose to the resident's legs. The left leg was noted to be shortened and turned out with a six by three centimeter bruise to the left shin and the right leg had bruising which was blue in color from the knee down on the anterior portion and inner lower leg. There was also bruising to the tops of the bilateral feet and toes also. The resident denied pain. The resident's vital signs were assessed and within normal limits. When the resident was asked what happened she stated she did not know. Review of Resident #4's progress note dated 02/28/18 at 11:39 P.M. revealed the resident was admitted to the hospital with [REDACTED]. She returned to the facility on [DATE] at 3:30 P.M. with bilateral immobilizers to her lower legs. An interview was conducted with the Director of Nursing (DON) on 03/19/18 at 1:43 P.M. She stated close to 11:30 P.M. on 02/28/18 she received a phone call from the nursing supervisor Licensed Practical Nurse (LPN) #15. She indicated earlier that evening around 8:40 P.M. Resident #4 was sent to the hospital for evaluation. She was informed the hospital called and reported the resident had fractures in both of her legs. The injuries sustained were fractures in the right leg below the knee in the tibia and fibula and the left leg was fractured above the knee on the femur. She revealed STNA #2 and STNA #4 transferred the resident into bed around 8:00 P.M. with a Hoyer lift. At that time she did not complain of any pain. STNA #2 was in the room as a support person for the transfer so when Resident #4 was positioned in bed she left the room and STNA #4 continued with care. When STNA #4 removed her pants and started to remove the TED hose she noticed bruising to the right leg and both legs appeared limp. LPN #17 was called into the room. She looked at the resident's legs and decided to call the doctor who had her sent out for evaluation. An investigation was started at 4:00 A.M. that morning by the DON. She spoke with STNA #5 and indicated she and STNA #3 had transferred Resident #4 in a stand up lift to toilet her that day, on 02/28/18, at around 3:00 P.M. to 4:00 P.M. when they were getting her ready for dinner. She indicated they were transferring Resident #4 to the toilet and it went fine. She told her that when she was transferred back to the wheelchair she slid to the right and one STNA braced her legs. STNA #5 told her she did not go below the level of the toilet, so they did not feel it would be considered a fall and it was not reported to the nurse. She indicated the resident was placed in her wheelchair and taken to dinner. The DON indicated it was not clear how she was braced. She stated Resident #4 had been in physical therapy and they concluded she was not safe for the stand up lift. When asked why the wrong transfer would have been used, she indicated the stand lift would enable Resident #4 to be placed on the toilet when that type of Hoyer lift would not work. The problem was that Resident #4 had to have enough upper body strength to assist with the transfer. She indicated it was believed the staff had good intentions but did not follow Resident #4's plan of care. STNA #3 and STNA #5 were both terminated. A call was made to State tested Nursing Assistant (STNA) #5 on 03/19/18 at 6:06 P.M. and a message was left. At 6:20 P.M. she returned the call. She stated she hadn't taken care of Resident #4 in quite a while due to floating on different units. She did not know what type of lift was required and had only come in to assist STNA #3. She indicated Resident #4 wanted to use the bathroom, so STNA #3 brought in a stand lift to transfer her to the toilet. She indicated the transfer lift was holding her up and she did attempt to assist with the transfer by holding on to the bars. She indicated she was not aware of any problems with the transfer and Resident #4 did not complain of any pain, so she went on to dinner. The education provided to staff during inservices on 10/18/17 and 03/01/18 was reviewed. The handout given to staff and the inservice agenda indicated all lifts MUST be evaluated by a Nurse, Supervisor, or Restorative staff member prior to use. It also indicated the staff could lose their job if they did not follow the care plan. Both STNA #3 and STNA #5 were in attendance of the inservice provided on 10/18/17. Review of the facility's corrective action revealed the following actions were implemented and the deficiency corrected as of 03/14/18: · On 02/28/18 at 8:00 P.M. an STNA reported to the charge nurse that Resident #4's lower leg had bruising. The charge nurse and supervisor assessed the resident, notified the physician, notified the family and sent the resident to the hospital for assessment and treatment. · The DON was notified of the incident on 02/28/18 at 11:30 P.M. and she notified the Administrator. · On 03/01/18 at 4:00 A.M. the DON interviewed the night shift nursing staff and initiated training to all direct care nursing staff on the protocols for the utilizing resident lifting equipment and following kardexes/care plans. · On 03/01/18 at 6:30 A.M. the DON began direct care interviews and discovered two (#3 and #5) STNA's did not transfer the resident according to the care plan. The staff were suspended while the remaining of the investigation was conducted. · On 03/02/18 random staff were observed using lifting equipment to collect data and determine root cause of the incident and evaluate further interventions needed. · On 03/06/17, STNA #3 was terminated. On 03/07/18, STNA #5 was terminated. · On 03/02/18 the DON continued staff inservices and Daily Rounding was added for the Supervisor to include daily tracking of random observed resident transfers. The inservice training and audits were completed on 03/14/18. · The facility reviewed the identified concern with the Quality Assurance Performance Improvement Committee. · During the survey on 03/19/18, three (#1, #2 and #3) residents were sampled for record review and observations. There were no further incidents involving the Hoyer lift. This deficiency substantiates Complaint Number OH 664.