Every finding on record at Browns Valley Health Center

Based on observation, interview, and document review, the facility failed to ensure dignity was maintained for 2 fo 2 residents (R2, R6 ) who were reviewed for activity of daily living (ADLs).R2's quarterly minimal data set (MDS) dated [DATE], identified moderate cognitive impairment, and had a diagnosis that included heart failure, hypertension, and diabetes. R2 was dependent on staff for activities of daily living (ADLs) such as dressing, toileting, and personal hygiene, including shaving and combing hair. R2's care plan revised on 12/17/25, identified R2 required assistance from staff with personal hygiene. R2 had impaired cognitive function. R2's care sheet dated 4/21/26, identified R2 required assistance from staff with personal hygiene. During an observation on 4/20/26 at 6:31 p.m., R2 had facial hair approximately 1 millimeter (mm) on chin. R2 was unable to verbalize whether the facial hair bothered her. During an observation on 4/21/26 at 8:39 a.m., R2 had facial hair approximately 1 mm on chin. During an interview on 4/20/26 at 7:05 p.m., with family member (FM)-B indicated having facial hair would bother R2 and would expect staff to keep R2 shaved. During an interview/observation on 4/21/26 at 9:42 a.m., nursing assistant (NA)-B verified R2 needed assistance with ADLs. NA-B verified R2 had approximately 1 mm of facial hair, and R2 should be shaved per her preference. During an interview/observation on 4/21/26 at 10:14 a.m., licensed practical nurse (LPN)-A verified R2 needed assistance with activities of daily living, such as shaving. LPN's expectation would be for staff to shave residents per their preference. LPN-A verified R2 had approximately 1 mm of facial hair on her chin and should have been shaved. During an interview on 4/21/26 at 10:22 a.m., director of nursing (DON) expectation would have been for staff to shave residents per their preference. DON indicated this was important related to dignity. R6's quarterly Minimum Data Set (MDS) dated [DATE], identified R6 had severe cognitive impairment and had diagnoses which included: dementia, hypertension and arthritis. R6 was dependent on staff for personal hygiene and dressing. R6's MDS also identified R6 had no rejection of care exhibited. R6's comprehensive care plan revised 1/16/26, identified R6 had self-care performance deficit related to aggressive behavior and dementia. R6 was totally dependent on staff for personal hygiene. Review of R6's progress notes from 3/21/26 to 4/21/26, lacked documentation of refusal of facial hair removal. During observation on 4/20/26 at 6:57 p.m., R6 was in wheelchair in common area participating in an activity. R6 had a large amount of white facial hair across her chin and above her lip approximately six to seven millimeters (mm) long. During observation on 4/21/26 at 8:54 a.m., R6 was dressed in street clothes in wheelchair in dining room finishing breakfast. R6 continued to have white facial hair across her chin and above her lip approximately six to seven mm long. During phone interview on 4/21/26 at 9:24 a.m., family member (FM)-A stated it would bother R6 if she knew she had facial hair visible. FM-A indicated she had recently purchased a new razor for R6 and would expect staff to remove R6's facial hair if present. During interview on 4/21/26 at 9:34 a.m., nursing assistant (NA)-A stated R6 was dependent on staff for cares and did not think R6 refused cares. NA-A stated she had not assisted R6 with morning cares that day, but if seen R6 had facial hair would have shaved R6 with her razor. NA-A indicated if R6 refused she would let the nurse know. NA-A viewed R6 and verified R6 had facial hair present. During interview on 4/21/26 at 9:42 a.m., trained medication aide (TMA)-A verified R6 had facial hair visible on her face. TMA-A stated R6 had her own razor in her room. TMA-A stated generally residents were shaven on bath days, but she would do it more often if present. TMA-A stated usually R6 would allow staff to shave her facial hair, but if R6 refused she would try again later or have a different person try. During interview on 4/21/26 at 10:17 a.m., licensed practical nurse (LPN)-A stated residents should be shaven every morning before they left their rooms. LPN-A indicated TMA-A had just shaven R6 after we spoke. LPN-A indicated it was important to remove resident's facial hair for their dignity. If a resident refused, she would expect staff to reapproach or have someone else do it. During interview on 4/21/26 at 10:25 a.m. director of nursing (DON) stated facial hair removal was based on resident preference. If a resident preferred to have facial hair present, she would expect it to be written on their care plan, if not, she would expect the resident to be free of facial hair. DON indicated shaving should be done with morning cares and was important for their dignity. Review of facility policy titled Dignity revised on 4/17/23, identified residents shall be groomed as they wish to be groomed (e.g. hair styles, nails, facial hair.) Review of the facility policy titled Activities of Daily Living (ADL) dated 9/23/25, identified activities of daily living (ADLs) include, but are not limited to: Personal hygiene and grooming- bathing, oral care, hair care, shaving, and nail care. Nursing and direct care staff will provide ADL assistance in accordance with the individualized care plan. Staff will encourage residents to actively participate in their own care to the degree they are able. All ADL care will be delivered respectfully, maintaining privacy, dignity, and honoring resident choice.

Based on interview and document review the facility failed to protect 1 of 1 resident (R1) from abuse when nurse aid (NA)-B physically and verbally abused R1 during cares. This resulted in serious psychosocial harm for R1 who became withdrawn, had a decreased appetite, and increased crying following the incident. The IJ began on 2/21/26 at 7:45 p.m., when NA-B was witnessed to make derogatory statements, used foul and aggressive language, and slapped R1 on the backside. NA-B was not removed from shift and continued to work with R1 and other vulnerable residents despite an internal report being made. The administrator and director of nursing (DON) were notified of the IJ on 3/4/25 at 1:00 p.m. The facility implemented corrective action by 2/25/25 prior to the start of the survey and therefore is issued as past non-compliance. Findings include: Facility incident report submitted 2/22/26 at 4:22 p.m., identified on 2/22/26 at 2:00 p.m., staff reported R1 was more tearful today with a decreased appetite. on-call nurse received a call from charge nurse and inquired if anything had been reported regarding concern from the previous evening shift. Director of nursing (DON) and administrator were notified, and an investigation was started. It was explained that on 2/21/26 at 7:45 p.m., two staff were caring for R1, the trained medication assistant (TMA)-A was outside R1's door and heard NA-B speaking loudly and demandingly to R1. Following, TMA-A asked NA-A who was in the room with her, what happened and stated NA-B was assisting R1 with peri cares, R1 swung her arms at staff and NA-B started raising her voice at R1 and used an open hand to slap R1's bottom, stating, if you want to act like a child, you will be treated like a child. R1's quarterly Minimum Data Set (MDS) dated [DATE], identified she had unclear speech, with limited verbal and non-verbal skills, would respond adequately to simple, direct communication only, had disorganized thinking, and moderately impaired cognition with long-term and short-term memory loss. R1 was dependent upon staff for personal and toileting hygiene, all transfers, bathing, and lower body dressing. She was always incontinent of bladder and frequently incontinent of bowel. R1's medical diagnoses included: non-Alzheimer's dementia, depression, and a psychotic disorder. Medications taken during look back period: antipsychotic, antianxiety, and antidepressant. R1's care plan dated 11/18/25, identified activities of daily living (ADL) self-care performance deficit related to dementia. Staff were directed to aid of one for bathing and hygiene and assistance of two for toilet use, ambulation, transfers, bed mobility, and dressing. R1 had impaired cognitive function/dementia or intellectual disability and can act out with attention seeking behaviors towards others in line with estimated age of an 8-year-old per family. Staff were directed to face her when speaking, making eye contact, and reduce distractions. She understood simple, directive sentences. Provide R1 with necessary cues, stop and return if agitated. R1 used anti-anxiety mediations (Ativan) related to anxiety disorder. Her target behaviors included: peri area scratching, refusal to talk, slamming doors, and throwing objects. Staff were directed to use non-pharm interventions: leave her and return later to complete an activity to allow her time to calm self-down, do not ask me what is wrong, use quiet voice, allow freedom to refuse as she is safe to do so. Observe R1 for changes in mood and update provider with concerns. R1's progress notes from 2/21/26 through 2/25/26, identified: -No documentation in progress notes for 2/21/26. -On 2/22/26 at 11:56 a.m., R1 was sitting in the coliseum in her wheelchair and started crying. When approached by writer, tried to talk to her and continued to cry. She was asked if she wanted to lay down and she shook her head yes. R1 was taken to her room and laid down. -On 2/22/26 at 12:11 p.m., R1 refused to get up for dinner and was assisted to the side of the bed. She placed her feet back in the bed and rested quietly at this time. -On 2/23/26 at 10:04 a.m., R1 was very vocal with staff this morning with cares when they tried to get her up. R1 calmed down after she got in her wheelchair. -On 2/23/26 at 2:03 p.m., Yelling at staff. God Damn [sic] it when they are toileting her. Staff redirected her to task at hand. -On 2/25/26 at 9:18 a.m., Yelling, hitting, and scratching staff when they were doing her morning cares. Tried to calm her. R1 was ok and went to breakfast after cares being done. -On 3/2/26 at 2:20 p.m., Late Entry: After initial report was filed. DON contacted provider via telephone and spoke to her about the incident. DON called guardian to discuss vulnerable adult (VA) was filed on R1 and she was safe and did not suffer any physical harm. Guardian was very thankful for the update. -On 3/2/26 Late Entry: On 2/22/26 at 9:30 a.m., R1 was taken to her room and laid down, a full body assessment was done and no bruises were noted. R1 did not verbalize any pain or discomfort. R1's Nursing Assistant (NA) Behavior Monitoring and Interventions Report from 2/16/26 through 2/26/26:- 2/16/26 at 7:32 p.m., screaming at others. Intervention: moved to calm environment. Behavior better/improved. -On 2/22/26 at 7:22 p.m., Sad, tearful, withdrawn, and isolating. Intervention: Provide calm environment. Behaviors: better/improved. -On 2/23/26 at 10:03 a.m., Expressed frustration/anger at others and agitated. Intervention: Toilet. Behaviors: worsened. -On 2/23/26 at 1:59 p.m., Screaming at others. No interventions identified. -On 2/24/26 at 9:53 a.m., Cursing at others, express frustration/anger at others, and agitated. Intervention: reapproach. Behaviors: improved. -On 2/25/26 at 1:59 p.m., Hitting and scratching others and physically aggressive towards others. Intervention: Provide calm environment and toilet. Behaviors worsened. -On 2/25/26 at 7:22 p.m., Hitting, scratching, physically aggressive to others, and screaming at others. Intervention: Provide calm environment and toilet. Behaviors worsened. -On 2/26/26 at 1:59 p.m., Hitting, scratching, physically aggressive to others, cursing and screaming at others. Intervention: Provide calm environment and toilet. Behaviors worsened. Review of NA Behavior Monitoring from 2/8/26 through 2/21/26, identified no behaviors were observed/documented from 2/8/26 through 2/15/26 and 2/17/26 through 2/21/26 (13 days). R1's nurse behavioral documentation from 2/1/26 through 2/28/26, my target behaviors (choices to choose from): hitting, kicking, yelling, animal-like noises, seeing/hearing things, tantrums, feeling down/having little energy, irritable, sad affect & refusing to talk. Peri-area-scratching causes self-harm, slamming doors, throwing objects. Non pharm: turn on country music, leave me and return later to complete an activity to allow me time to calm myself, do not ask me what is wrong use calm quiet voice, allow her freedom to refuse as she is safe to do so. Every day (day and night shift) check marks (indicated no behaviors) were entered except on two-day shifts 2/20/26 and 2/28/26 were left blank. NA-B's timecard identified on 2/21/26, scheduled to work from 6:30 p.m. to 7:00 a.m. Time clocked in 6:28 p.m. and time clocked out 7:01 a.m. Worked 12 hours. NA-B scheduled to work 2/22/26 at 6:30 p.m. to 7:00 a.m. no time entered. NA-A was not scheduled for any other shifts or dates. Employee Concern document dated 2/21/26, at 7:04 p.m. The purpose of this form is to document what performance or action is a concern based on facility core values. This form is routed to the department supervisor for further investigation and follow-up. Staff person completing report and witness to the incident: NA-A. Performance issue or concern (be specific): While putting R1 to bed at 7:04 p.m. during the washing and toileting, R1 was hollering while trying to wipe her. NA-B proceeded to be vocally aggressive, and likewise R1 has a hard time getting off the toilet and hollered. NA-B then smacked R1's butt and said you wanna [sic] act like a child you can get treated like one, etc. NA-B termination document dated 2/27/26, identified discharged . Supervisor comments: employee did not respond regarding training, coming in, or texts. During an interview on 3/2/26 at 12:25 p.m., registered nurse (RN)-A stated R1 functioned at the level of an 8 to [AGE] year-old, occasionally swore, hit, kicked, slapped during cares, and rarely spoke in sentences. On 2/21/26, at approximately 6:00 p.m. she brought R1 to supper in the wheelchair and no behaviors were noted. On 2/22/26, she came back to work at 6:00 a.m. NA-B had worked the night shift (12 hours) and was still there when she arrived. She received report from licensed practical nurse (LPN)-A and there had been no mention about an incident with R1. RN-A completed treatment rounds when a NA approached her and asked, if she had heard what happened, adding, R1 and NA-B were yelling at each other yesterday. Additionally, a TMA-A informed her that she stood outside R1's closed door, heard her screaming and probably should have gone into the room. But then NA-A came out of the room with a funny look on her face (eyes wide open and bewildered look) and informed TMA-A, NA-B had told R1 to quit being a baby, grab the bar, fucking get up, go to the bathroom, because you are not a baby, and swatted R1 on her bottom. RN-A stated she was shocked and knew it was possible physical and verbal abuse. TMA-A informed her she reported the incident to the charge nurse LPN-A right away that evening right away. RN-A waited a couple more hours, most likely shouldn't have, but thought it had been reported to the on-call nurse. She called the on-call nurse and realized it had not been reported. Within 15 minutes of the call to the DON, she came to the facility. At 9:30 a.m. RN-A completed a skin assessment and no skin concerns noted. The skin assessment was not documented and should have been. RN-A verified NA-B had worked at the facility for approximately one month and she did not work directly with her. R1 rarely cried on the night shift, was unable to verbalize what was bothering her, would usually say ugh ugh and point at things, staff were expected to document her behaviors every shift in the electronic medical record. Follow-up interview on 3/3/26 at 5:15 p.m., RN-A stated on 2/22/26, R1 was out of bed and sat in her wheelchair for breakfast but refused to eat and started crying in the coliseum. RN-A stated she was unaware of the incident when she approached R1, tried to talk to her, but she kept crying. RN-A stated after she saw R1 crying, withdrawn, and refusing to eat, she knew something was wrong. She had known her for three years and had only seen her like this one other time. RN-A stated R1 does not cry for no reason, something was wrong. On 2/22/26, RN-A offered R1 snacks, meals and liquids and she refused all of them. This type of behavior for R1 was not considered normal, it was obvious something had happened. RN-A stated R1 functioned like a child, comparable to children, she would get really quiet and that's how she reacted on 2/22/26, like the incident made her feel sad. During an interview on 3/2/26 at 2:39 p.m., TMA-A stated on 2/21/26 at 6:45 p.m., she stood outside R1's closed door preparing medications and heard R1 and NA-B both yelling. NA-B stated hurry up and grab the fucking bar, you know how to fucking walk, so walk to the bed. The tone of NA-B 's voice was rude and aggressive. TMA-A remained at the medication cart until NA-A and NA-B exited R1's room. She was unaware NA-A was in the room and asked her what happened. NA-A informed TMA-A, NA-B had swatted R1 on the butt. At 7:15 p.m. she completed a medication count with the charge nurse LPN-A and informed her about the incident with R1. TMA-A stated she told LPN-A what she had heard and about the smack on the butt by NA-B. TMA-A stated because she considered this verbal and physical abuse and was not appropriate way for a resident to be treated under no circumstances, she assumed LPN-A would have called the nurse on call. NA-B continued to work with residents until at least 7:30 p.m. when TMA-A left for the day. TMA-A was surprised NA-B was not pulled off work and sent home so that something similar did not happen to another resident and no one would be around to see what happened. During an interview on 3/2/26 at 3:37 p.m., social service designee (SSD) stated R1's cognition was severely impaired with dementia, she was able to answer simple yes or no questions and chose not to speak at all at times. Staff were expected to respond to R1's behaviors by allowing her time and/or another staff to reapproach her. Staff would have been expected to monitor any residents unable to be interviewed after incident, during cares and report it to the nurse on duty. SSD stated she visited with R1 daily and had not seen any changes in behaviors. R1 had yelled at SSD this morning no but would not say anything more. During an interview on 3/2/26 at 7:51 p.m., NA-A stated on 2/21/26, she worked from 2:30 p.m. to 9:30 p.m. with NA-B. She did not have concerns about NA-B prior to the incident that night, other than NA-B's tone of voice threw her off because she could be loud and intimidating. At approximately 6:30 p.m., NA-A and NA-B assisted R1 in the bathroom. NA-A cleaned her bottom when charge nurse LPN-A entered the room and told NA-B, R1 could walk to the bed with the walker and left the room. While R1's brief was being placed she became combative, started yelling and grunting loudly, at that time NA-B stated, stand up and R1 responded oh shut up. NA-B stated out loud, if you want to act like a child then you will be treated like one and with an open hand smacked her on the right buttock (skin to skin and sounded like a loud smack). NA-B grabbed R1's walker and said OK, now let's walk to bed. R1 was whining and whimpering like she was in pain, laid down on bed, pillows positioned under her legs, covered up with a blanket, and remote placed. NA-A stated NA-B was verbally and physically abusive, made her very uncomfortable, and cannot imagine how R1 felt. NA-A stated she felt uncomfortable in the bathroom with NA-B because of her stature, her tone of voice, which was loud and aggressive, her use of foul language and R1 was most likely feeling the same way. R1 was making grunting sounds like she was nervous. NA-A stated once she left R1's room she talked to TMA outside R1's door and was asked if NA-B had been aggressive and she told her yes but was afraid of retaliation from NA-B. Five minutes later she located the charge nurse LPN-A and reported the incident of abuse. NA-A was provided with a complaint form with not a lot of room to write, so she placed as much information in the small area as she could and placed it in the DON's box. NA-A felt like nothing was done to protect the residents. The incident should have been reported within two hours and found out the next day it was not reported until later the next day. NA-A stated NA-B was allowed to work after incident, assisted NA-A with another resident transfer and toileting. At 9:30 p.m. left the facility and NA-B remained working with residents. During an interview on 3/3/26 at 1:15 p.m., clinical coordinator LPN-C stated she was notified about the allegation of abuse incident on 2/22/26 at 2:00 p.m., by charge nurse RN-A instructed her to have TMA-A write out what she heard and when. She was on call the entire weekend and would have expected LPN-A to notify her on 2/21/26 immediately so that an investigation could start and reported according to the guidelines. LPN-C stated she was not notified on 2/21/26, for concerns of physical and verbal abuse. NA-B was allowed to finish working her shift on 2/21/26, but if she had been notified and known about the allegations, she would have removed her from the facility and the schedule until the investigation was completed. LPN-C stated she notified DON right away and came to facility immediately, arrived just after 2:00 p.m. and started to investigate with staff and resident interviews. The incident happened on 2/21/26 and there were concerns brought to our attention on 2/22/26 about physical and verbal abuse. During an interview on 3/3/26 at 2:40 a.m., LPN-A stated on 2/21/26 just after 7:00 p.m., TMA-A informed her she had stood outside R1's closed door preparing medications and heard raised voices. R1 cried out while staff completed cares. NA-A and NA-B came out of R1's room and NA-A and informed TMA-A she wanted to write a complaint about the other staff NA-B but did not want her to know about it. LPN-A provided NA-A with the complaint form to fill out. NA-A asked LPN-A what to do with the completed form. NA-A showed the form to LPN-A, asked if it looked right. LPN-A did not read the document and probably should have, and informed NA-A the form was to be submitted to the DON. LPN-A stated she received a phone call from DON the following day on 2/22/26 and asked if she was aware of the incident with R1. She told DON the staff involved had not offered any information about abuse or anything. LPN-A stated she had no idea until the next day NA-B had been aggressive towards R1. She was aware staff were swearing at R1 and that was concerning. She did not ask any specific questions and should have and should have made a report sooner. LPN-A stated she thought the staff would have told her NA-B hit R1, more attention would have been brought to it if they had. Knowing what she knew now, NA-B slapped R1's butt, roughed her up, swore at her and this was considered abuse. LPN-A stated she thought it was just another staff complaining about a staff due to age difference. LPN-A stated NA-B continued to work the remainder of the shift and answered call lights and cared for residents without supervision until at least 7:00 a.m. LPN-A assisted NA-B with part of her rounds on a few residents (check and changes and toileting) and did not see any concerns. NA-B's tone of voice was gruffer, not sweet at all, loud when she spoke, but appeared to be good with the residents. LPN-A stated she was unsure if NA-B had contact with R1 after the incident. LPN-A stated she was unaware of many things that night, should have asked more questions, sent NA-B home to protect the residents so that there would not have been any chances of her abusing other residents. During an interview on 3/3/26 at 2:53 p.m., DON stated that on 2/22/26 at approximately 1:45 p.m., she had received a call from on-call nurse LPN-A and asked her if she had received a call from the facility. The day charge nurse RN-A had called LPN-A and asked why NA-B remained on the schedule because staff had told her how NA-B had swatted R1. DON informed LPN-A she was not aware of this incident, immediately came to the facility, and hit the floor running. DON stated she opened her office door and found a written statement dated 2/22/26 from TMA-A and in the locked box dated 2/21/26 from NA-A. TMA-A was pulled into the DON's office to give oral statement and interview. NA-A informed DON she heard swearing and NA-B stated grab the fucking bar. DON asked TMA-A why she did not enter R1's room when she heard NA-B speak to R1 like that. TMA-A informed DON she did not want to leave R1's narcotics on the medication cart. DON stated she would have expected TMA-A to open R1's door and check to see what was going on, for the protection of the residents. DON stated TMA-A could have used her radio to contact the charge nurse LPN-A and asked her to come to R1's room immediately if she had concerns. On 2/22/26, NA-A was called in for an interview/statement. NA-A demonstrated on DON what she witnessed on 2/21/26. NA-A stated NA-B wiped R1's bottom and stated in a loud tone, if you want to act like a child, you can get treated like one and swatted her on the bottom with an open hand. NA-A did not indicate NA-B swore at R1. NA-A demonstrated physically on DON per her request, how she witnessed the incident when NA-B swatted R1's bottom. DON stated the swat did not feel like she was abused but felt it was not ok to do to a resident, and no staff should swat the bottom of any resident. At 7:00 p.m. on 2/21/26, TMA -A talked to LPN-B during a medication count and informed her she heard swearing and R1 was crying. Additionally, NA-A informed LPN-B after incident on 2/21/26, she had a concern about NA-B and requested a concern form. Form was given to NA-A, completed, and placed in DON's box. DON stated she would have expected the charge nurse LPN-A to have read what NA-A wrote, immediately assess R1's skin and bottom, and contact the on-call nurse LPN-B right away. We had only two hours to report abuse. DON would have wanted to make sure all the residents were safe, and the staff (NA-B) was suspended and no longer in the building so that residents would not suffer any other harm. R1 did not suffer any harm but there was potential for harm, and all residents have the potential for harm. DON stated she believed R1 experienced verbal abuse during this incident. NA-B continued to work on 2/21/26 after the incident until the following morning at 7:01 a.m. On 2/22/26. NA-B completed an interview over the phone; no notes were taken. DON requested and received NA-B's written statement that included the same information discussed on the phone on 2/22/26 and was suspended from work. The facility policy was not followed by the charge nurse LPN-A, regarding communicating the incident with the on-call nurse and if she had been notified in a timely manner, things would have been taken care of on Saturday night and NA-B suspended from work. Maltreatment was verified by the witnesses: TMA-A verified verbal abuse and NA-A verified verbal and physical abuse by NA-B. During an interview on 3/4/26 at 10:21 a.m. NA-E stated R1's cognition was comparable to autism spectrum, struggled with verbalizing how she felt and knew more than she was able to verbalize. NA-E stated she was familiar with R1 and worked with her for over five years. R1 was a friendly and interactive person, loved activities, animals especially dogs, and children. R1 experienced a mental decline which seemed to have started approximately three years ago. R1 can get quite aggressive and overwhelmed at times, interventions used to help avoid and/or deescalate behaviors were distraction with music/pop/popcorn/stuffed animals, reapproach, remain calm, talk to her in a quiet voice in few simple words, and avoid using a loud voice to tell her what you are about to do. NA-E stated on 2/22/26, she entered R1's room in the morning and she was dry, laid in a wet bed, got her up and had taken her to breakfast. R1 sat in her wheelchair and was very quiet, not aggressive, refused to eat or drink, started crying, and laid her down in bed per RN-A's request. R1 refused to respond verbally when asked what was bothering her. At 11:30 a.m. R1 placed her call light on, was incontinent of urine, care provided, again she was not making any noises, withdrawn and not aggressive like she usually was with cares, she was different than normal. At 1:00 p.m. NA-E noted R1 was not up for lunch, went to her room, informed her it was time for lunch and assisted her up to the side of the bed. R1 started to grunt, unable to keep herself from sitting up, NA-E supported her upper body with a hand, and R1 started to cry and said no. NA-E asked R1, don't you want to get up, and she stated no and laid back down. NA-E stated this behavior was not normal for R1 and reported to RN-A and on-call nurse LPN-B was called. R1 stayed in bed all day, did not eat, drink or attend activities. NA-E offered R1 pop with a straw in it (usually drank at least two to three pops a day) and not one drink accepted, which was odd for her. NA-E stated during the incident on 2/21/26, R1 most likely felt helpless and scared. She appeared impacted when she did not want to get out of bed, was exhausted, withdrawn, refused food and pop and just wanted to sleep the next day. Unable to interview NA-B, call placed on 3/2/26 at 3:15 p.m. unable to leave message, phone disconnected. Unable to interview family/guardian on 3/2/26 at 4:23 p.m. and 3/3/25 at 5:13 p.m. messages left, no return call received. Facility policy Maltreatment Reporting Guidelines dated 11/26/24, identified care center will report any allegations of maltreatment of a vulnerable adult (VA) resident in our care center to the appropriate authorities as required by abuse reporting for Federal Regulations and maltreatment reporting for the Minnesota State Statues. Immediate notification to the administrator of any suspected maltreatment is necessary to fully assess the situation and proceed with reporting to officials according to regulation. Care center must report to the State Agency Minnesota Department of Health (MDH) any suspected maltreatment (alleged violations involving abuse neglect, financial exploitation or maltreatment, including injuries of unknown source and misappropriation of resident property) immediately but not later than 2 hours after the allegation was made. If alleged maltreatment occurs: Staff shall immediately report to their supervisor any suspected maltreatment, ensure the resident is safe, complete an initial assessment to determine if there is potential abuse, neglect or other type of maltreatment. The immediate supervisor or person responsible for implementing actions of Maltreatment Prohibition Policy shall: immediately suspend staff person(s) involved in the alleged maltreatment pending the outcome of the investigation. Begin investigating the alleged maltreatment, which may include resident and staff interviews, observations and medical record review and complete as much as possible within five working days as possible. Facility policy Maltreatment Prohibition Definitions dated 11/26/24, identified physical abuse was defined as: occurs when an individual is injured (hit, slapped, pinched, kicked, scratched, bitten, pushed, burned, controlling behavior through corporal punishment, assaulted or threatened with a weapon or inappropriately restrained). Verbal abuse was defined as: the use of oral, written, or gestured language that willfully includes derogatory terms to VA's or their families within hearing distance, regardless of their age, ability to comprehend, or disability. Psychological, emotional or mental abuse was defined as when a VA experiences trauma after exposure acts or coercive tactics. Examples include but are not limited to threats of punishment or deprivation, and harassment. The past noncompliance immediate jeopardy began on 2/21/26. The immediate jeopardy was removed and the deficient practice corrected by 2/25/26, after the facility implemented a systemic plan that included the following actions: -Reported Abuse to State Agency (SA). -Investigated the circumstances around allegations of physical and verbal abuse and implemented immediate resident protection. -Re-educated the staff on Abuse/Neglect, reporting, abuse prevention and resident rights, dementia, and vulnerable adult. -Education verified through interview and training records. The facility implemented corrective actions prior to the start of survey on 2/25/25 and therefore this is issued in past noncompliance.

Based on interview and documents review, the facility failed to report an allegation of abuse to the State Agency (SA) within two hours for 1 of 1 resident (R1) who was witnessed being verbally and physically abused by NA-B. Finding include:Facility incident report submitted 2/22/26 at 4:22 p.m., identified on 2/22/26 at 2:00 p.m. Staff reported R1 was more tearful today with a decreased appetite. on-call nurse received a call from charge nurse and inquired if anything had been reported regarding concern from the previous evening shift. DON and administrator were notified, and investigation started. It was explained that on 2/21/26 at 7:45 p.m., two staff were caring for R1, the trained medication assistant (TMA)-A was outside R1's door and heard NA-B speaking loudly and demandingly to R1. Following, TMA-A asked NA-A who was in the room with her, what happened and stated NA-B was assisting R1 with perineal cares, R1 swung her arms twice at staff during the care and NA-B started raising her voice at R1 and used an open hand to slap R1's bottom, stating, if you want to act like a child, you will be treated like a child. R1's quarterly Minimum Data Set (MDS) dated [DATE], identified she had unclear speech, with limited verbal and non-verbal skills, would respond adequately to simple, direct communication only, had disorganized thinking, and moderately impaired cognition with long- and short-term memory loss. R1 was dependent upon staff for personal and toileting hygiene, all transfers, bathing, and lower body dressing. She was always incontinent of bladder and frequently incontinent of bowel. R1's medical diagnoses included: non-Alzheimer's dementia, depression, and a psychotic disorder. Medications taken during look back period: antipsychotic, antianxiety, and antidepressant. During an interview on 3/2/26 at 2:39 p.m., TMA-A stated on 2/21/26 at 6:45 p.m., she stood outside R1's closed door preparing medications and heard R1 and NA-B both yelling. NA-B stated hurry up and grab the fucking bar you know how to fucking walk so walk to the bed. The tone of NA-B 's voice was rude and aggressive. TMA remained at the medication cart until NA-A and NA-B exited R1's room. She was unaware NA-A was in the room and asked her what happened. NA-A informed TMA, NA-B had swatted R1 on the butt. At 7:15 p.m. she completed a medication count with the charge nurse LPN-A and informed her about the incident with R1. TMA stated she told LPN-A what she had heard and about the smack on the butt by NA-B. TMA stated because she considered this verbal and physical abuse and was not appropriate way for a resident to be treated under no circumstances, she assumed LPN-A would have called the nurse on call, LPN-B. NA-B continued to work with residents until at least 7:30 p.m. when TMA left for the day. TMA was surprised NA-B was not pulled off work and sent home so that something similar did not happen to another resident and no one would be around to see what happened. TMA stated she had trained NA-B the first day she worked at the facility and had no concerns prior to 2/21/26, it was a real surprise when she heard her yelling at R1. During an interview on 3/2/26 at 7:51 p.m. NA-A stated on 2/21/26, NA-A worked from 2:30 p.m. to 9:30 p.m. with NA-B. While assisting R1 in the bathroom, she became combative, started yelling and grunting loudly when NA-B stated, stand up and R1 responded oh shut up. NA-B stated out loud, if you want to act like a child then you will be treated like one and with an open hand smacked her on the right buttock (skin to skin and sounded like a loud smack). NA-B grabbed R1's walker and said OK, now let's walk to bed. R1 was whining and whimpering like she was in pain, laid down on bed, pillows positioned under her legs, covered up with a blanket, and remote placed. NA-A stated NA-B was verbally and physically abusive, made her very uncomfortable, and cannot imagine how R1 felt. NA-A stated she felt uncomfortable in the bathroom with NA-B because of her stature, her tone of voice, which was loud and aggressive, her use of foul language and R1 was most likely feeling the same way. R1 was making grunting sounds like she was nervous. NA-A stated once she left R1's room she talked to TMA-A, they reported the abuse to the charge nurse LPN-A and was provided with a complaint form to complete and placed it in the DON's box. NA-A felt like nothing was done to protect the residents. The incident should have been reported within two hours and found out the next day it was not reported until later the next day. NA-A stated NA-B was allowed to work after incident, assisted NA-A with another resident transfer and toileting. At 9:30 p.m. left the facility and NA-B remained working with residents. During an interview on 3/3/26 at 2:40 a.m., LPN-A stated that on 2/21/26 just after 7:00 p.m., TMA-A informed her she had stood outside R1's closed door preparing medications and heard raised voices. R1 cried out while staff completed cares. NA-A and NA-B came out of R1's room and NA-A and informed TMA-A she wanted to write a complaint about the other staff NA-B but did not want her to know about it. LPN-A provided NA-A with the complaint form to fill out. NA-A asked LPN-A what to do with the completed form. NA-A showed the form to LPN-A, asked if it looked right. LPN-A did not read the document and probably should have, and informed NA-A the form was to be submitted to DON. LPN-A stated she received a phone call from DON the following day on 2/22/26 and asked if she was aware of the incident with R1. She told DON the staff involved had not offered any information about abuse or anything. LPN-A stated she had no idea until the next day NA-B had been aggressive towards R1. She was aware staff were swearing at R1 and that was concerning. She did not ask any specific questions and should have and should have made a report sooner. LPN-A stated she thought the staff would have told her NA-B hit R1, more attention would have been brought to it if they had. Knowing what she knew now, NA-B slapped R1's butt, roughed her up, swore at her and this was considered abuse. LPN-A stated she thought it was just another staff complaining about a staff due to age difference. LPN-A stated NA-B continued to work the remainder of the shift and answered call lights and cared for residents without supervision until at least 7:00 a.m. LPN-A assisted NA-B with part of her rounds on a few residents (check and changes and toileting) and did not see any concerns. NA-B's tone of voice was gruffer, not sweet at all, loud when she spoke, but appeared to be good with the residents. LPN-A stated she was unsure if NA-B had contact with R1 after the incident. LPN-A stated she was unaware of many things that night, should have asked more questions, sent NA-B home to protect the residents so that there would not have been any chances of her abusing other residents. During an interview on 3/3/26 at 2:53 p.m., DON stated she would have expected LPN-A to have read what NA-A wrote, immediately assess R1's skin and bottom, and contact the on-call nurse LPN-B right away. We had only two hours to report abuse. DON would have wanted to make sure all the residents were safe, and the staff (NA-B) was suspended and no longer in the building so that residents would not suffer any other harm. R1 did not suffer any harm but there was potential for harm, and all residents have the potential for harm. DON stated she believed R1 experienced verbal abuse during this incident. NA-B continued to work on 2/21/26, after the incident until the following morning at 7:01 a.m. LPN-A employee records did indicate she was retrained related to abuse and neglect reporting on 2/23/26. According to the facility schedule, LPN-A was allowed to work on 2/22/26, prior to this training. Additionally, the facility had yet to retrain all employees on abuse and neglect reporting policies prior to survey entrance. Facility policy Maltreatment Reporting Guidelines dated 11/26/24, identified immediate notification to the administrator of any suspected maltreatment is necessary in order to fully assess the situation and proceed with reporting to officials according to regulation. Care center must report to the State Agency (Minnesota Department of Heath) (MDH) any suspected maltreatment (all alleged violations involving abuse, neglect, financial exploitation or maltreatment, including injuries of unknown source and misappropriation of property) immediately, but not later than 2 hours after the allegation is made.

Based on interview and document review, the facility failed to provide sufficient resident protections and assessment following an allegation of abuse for 1 of 1 resident (R1) following a staff to resident abuse allegation. Additionally, the facility failed to complete a thorough investigation following a staff to resident abuse allegation for 1 of 1 resident (R1) when only verbally responsive residents were interviewed for concerns of abuse.Findings include: Facility incident report submitted 2/22/26 at 4:22 p.m., identified on 2/22/26 at 2:00 p.m. Staff reported R1 was more tearful today with a decreased appetite. on-call nurse received a call from charge nurse and inquired if anything had been reported regarding concern from the previous evening shift. DON and administrator were notified, and investigation started. It was explained that on 2/21/26 at 7:45 p.m., two staff were caring for R1, the trained medication assistant (TMA)-A was outside R1's door and heard NA-B speaking loudly and demandingly to R1. Following, TMA-A asked NA-A who was in the room with her, what happened and stated NA-B was assisting R1 with perineal cares, R1 swung her arms twice at staff during the care and NA-B started raising her voice at R1 and used an open hand to slap R1's bottom, stating, if you want to act like a child, you will be treated like a child. R1's quarterly Minimum Data Set (MDS) dated [DATE], identified she was admitted to the facility on [DATE]. She had unclear speech, responded adequately to simple, direct communication only, disorganized thinking, moderately impaired cognition with long and short term memory loss. R1 was dependent upon staff for all cares and transfers. R1's medical diagnoses included: non-Alzheimer's dementia, depression, and a psychotic disorder. During an interview on 3/2/26 at 12:25 p.m., registered nurse (RN)-A stated on 2/21/26, at approximately 6:00 p.m. she brought R1 to supper in the wheelchair and no behaviors were noted. On 2/22/26, she came back to work at 6:00 a.m. NA-B had worked the night shift (12 hours) and was still there when she arrived. She received report from LPN-A and there had been no mention about an incident with R1. TMA-A informed her she reported the incident to the charge nurse LPN-A right away that evening right. RN-A waited a couple more hours, most likely shouldn't have, but thought it had been reported to the on-call nurse. She called the on-call nurse after lunch and realized it had not been reported. Within 15 minutes of the call to the DON, she came to the facility. At 9:30 a.m. RN-A completed a skin assessment and no skin concerns noted. The skin assessment was not documented and should have been. RN-A verified NA-B had worked at facility for approximately one month and she did not work directly with her. R1 rarely cried on the night shift, was unable to verbalize what was bothering her, would usually say ugh ugh and point at things, staff were expected to document her behaviors every shift in the electronic medical record. R1's medical records lacked evidence of a skin check completed on R1 following initial report of allegation of abuse or the following day.During an interview on 3/2/26 at 2:39 p.m., TMA-A stated on 2/21/26 at 6:45 p.m., she stood outside R1's closed door preparing medications and heard R1 and NA-B both yelling. NA-B stated hurry up and grab the fucking bar you know how to fucking walk so walk to the bed. The tone of NA-B 's voice was rude and aggressive. TMA-A remained at the medication cart until NA-A and NA-B exited R1's room. She was unaware NA-A was in the room and asked her what happened. NA-A informed TMA-A, NA-B had swatted R1 on the butt. At 7:15 p.m. she completed a medication count with the charge nurse LPN-A and informed her about the incident with R1. TMA-A stated she told LPN-A what she had heard and about the smack on the butt by NA-B. TMA-A stated because she considered this verbal and physical abuse and was not appropriate way for a resident to be treated under no circumstances, she assumed LPN-A would have called the nurse on call, LPN-B. NA-B continued to work with residents until at least 7:30 p.m. when TMA left for the day. TMA was surprised NA-B was not pulled off work and sent home so that something similar did not happen to another resident and no one would be around to see what happened. During an interview on 3/2/26 at 3:37 p.m., social service designee (SSD) stated staff would have been expected to monitor any residents unable to be interviewed after incident, during cares and report it to the nurse on duty. SSD stated she visited with R1 daily and had not seen any changes in behaviors. R1 had yelled at SSD this morning no but would not say anything more. During an interview on 3/2/26 at 7:51 p.m. NA-A stated she worked from 2:30 p.m. to 9:30 p.m. with NA-B on 2/21/26 and at approximately 6:30 p.m. NA-B was verbally and physically abusive during R1's evening cares. While R1's brief was being placed she became combative and NA-B stated, stand up and R1 responded oh shut up. NA-B stated out loud, if you want to act like a child then you will be treated like one and with an open hand smacked her on the right buttock (skin to skin and sounded like a loud smack). NA-B grabbed R1's walker and said OK, now let's walk to bed. R1 was whining and whimpering like she was in pain, this made NA-A very uncomfortable, and she cannot imagine how R1 felt. NA-A stated she felt uncomfortable in the bathroom with NA-B, she was taller, her tone of voice was loud and aggressive, and she used inappropriate language. R1 was most likely feeling the same way but unable to verbalize how she was feeling and made grunting sounds like she was nervous. NA-A stated once she left R1's room she talked to TMA -A outside R1's door and was asked if NA-B had been aggressive and she told her yes and was afraid of retaliation from NA-B and moved down the hallway with TMA to discuss. Five minutes later she located the charge nurse LPN-A and informed her NA-B had been verbally aggressive and smacked her on her right buttock. LPN-A shook her head and said oh my. NA-A was provided with the complaint form with not a lot of room to write so placed as much information in the small area as she could and placed it in the DON's box. NA-A felt like nothing was done to protect the residents. The incident should have been reported within two hours and found out the next day it was not reported until later the next day. NA-A stated NA-B was allowed to work after incident, assisted NA-A with another resident transfer and toileting. At 9:30 p.m. left the facility and NA-B remained in facility working with residents. During an interview on 3/3/26 at 1:15 p.m. clinical coordinator LPN-C stated she was notified about R1's incident on 2/22/26 at 2:00 p.m. by charge nurse RN-A. NA-B was allowed to finish working her shift on 2/21/26, but if she had been notified and known about the allegations, she would have removed her from the facility and schedule until the investigation was completed. If the allegations were accurate or correct, we would not want it to continue happening and for the safety of the residents. LPN-C stated she notified DON right away and came to facility immediately, arrived just after 2:00 p.m. and started to investigate with staff and resident interviews. The incident happened on 2/21/26 and there were concerns brought to our attention on 2/22/26 about physical and verbal abuse. LPN-C stated she worked her way down each resident hallway randomly interviewed those residents located in their room for a total of 11. LPN-C was unable to verify how or if resident skin checks or behavior chart checks were completed after the incident and recommended checking with DON. LPN-C verified during interview no documentation located in R1's electronic medical record on 2/21/26 regarding the incident and seemed unusual. DON requested RN-A complete R1's assessment on 2/22/26 and would have expected her to document her findings when done. During an interview on 3/3/26 at 2:53 p.m., DON stated she would have expected the charge nurse LPN-A to have read what NA-A wrote, immediately assess R1's skin and bottom, and contact the on-call nurse LPN-B right away. The staff nurses check R1's skin when they complete her treatments every shift and the NAs are always monitoring R1's skin and report unusual skin issues. We should have probably monitored R1's skin at least each shift for three days to ensure no bruise came or was identified to make sure R1 did not have any injuries as a result of the allegations. We would have wanted to make sure all the residents were safe, and the staff (NA-B) was suspended and no longer in the building so that residents would not suffer any other harm. R1 did not suffer any harm but there was potential for harm, and all residents have the potential for harm. DON stated she believed R1 experienced verbal abuse during this incident. NA-B continued to work on 2/21/26 after the incident until the following morning at 7:01 a.m. On 2/22/26, NA-B completed an interview on the phone, no notes were taken. DON requested and received NA-B's written statement that included the same information discussed on the phone on 2/22/26 and was suspended from work. Additional staff involved in the allegation were interviewed and no other staff interviews were completed. DON stated the night staff should have been interviewed that worked with NA-B, especially the NA working the night shift with NA-B that night. The policy was followed, indicated staff interviews. There were no skin checks completed on all residents after the incident. DON stated she would have expected herself to review resident behavior charting to make sure something was not missed and important to see if there was anything unusual out of the norm to help protect the residents. The facility policy was not followed by the charge nurse LPN-A, regarding communicating the incident with the on-call nurse and if she had been notified in a timely manner, things would have been taken care of on Saturday night and NA-B suspended from work. Facility policy Maltreatment Reporting Guidelines dated 11/26/24, identified staff shall immediately report to their supervisor any suspected maltreatment. The supervisor shall first ensure the resident is safe and complete and initial assessment in order to determine if there is potential abuse, neglect or other type of maltreatment. The immediate supervisor or person responsible for the implementing actions of the Maltreatment Prohibition Policy shall: 1. Immediately suspend staff person(s) involved in the alleged maltreatment pending the outcome of the investigation. 2. Begin conducting an investigation of the alleged maltreatment, which may include resident and staff interviews, observations, and medical record review. The investigation shall be completed as much as able within five working days, at which time the investigation findings will be updated on the MDH/OHFC website.

Based on observation, interview, and document review, the facility failed to ensure staff wore hair restraints in the kitchen. Further, the facility failed to ensure food and beverages stored in the refrigerators, were labeled, dated and discarded properly. This deficient practice had the potential to affect all 28 residents who received food and beverages from the refrigerators and the kitchen. Findings include: Hair nets: On 3/10/25 at 12:02 p.m., dietary manager (DM) was standing at the dishwasher pulling clean dishes out of the dishwasher. DM hair was approximately 1/4 inch in length and was not wearing any type of a hair restraint. On 3/10/25 at 12:05 p.m., during the kitchen tour with the (DM), the following concerns were identified: Kitchen refrigerator: -Several slices of ham on a plate wrapped in saran wrap with a date of 2/28/25. Freezer -10 hamburger patty's in a bag without notation of an open date. Resident refrigerator and freezer on the unit: Fridge: -one slice of apple pie covered with saran wrap on a plate without notation of a date. -3/4 jar of salsa with a black crusty substance around the lid without notation of an open date. -1/4 container of mayonnaise without notation of an open date and an expiration date of 6/27/24. -1/2 jar of Queso cheese without notation of an open date. -3/4 bottle of Italian dressing without notation of an open date. -one ham sandwich on a plate covered with saran wrap without notation of a date. -one bowl of chili without notation of a date. -1/4 container of peppermint mocha creamer without notation of a date. Freezer: -half bag of pizza rolls without notation of an open date. -half bag of French fries without notation of an open date. -half bag of chicken nuggets without notation of an open date. During an interview on 3/10/25 at 12:35 p.m., DM verified the above findings during the kitchen tour. DM stated his expectation was that all opened food should have been dated and thrown away after the shelf life or the expiration date. DM stated since his hair was not very long he was not aware he needed to wear a hair restraint in the kitchen. During an interview on 3/11/25 at 9:23 a.m., dietician stated her expectation was that all food items would have been dated once opened and thrown away after the shelf life or the expiration date to prevent a food borne-illness. Dietician further stated her expectation was that all all staff would have worn a hair restraint while in the kitchen. A facility policy titled Perishable Food Management reviewed 8/29/22, identified perishable foods were those likely to spoil, decay or become unsafe to consume if not refrigerated. Further, identified all food once opened should have been labeled, and dated when opened and include a use-by date or discard date. A facility policy titled Hair covering and restraints dated 1/31/2012, identified dietary staff must wear hair restraints (hairnet or bonnet) to prevent hair from contacting exposed food or clean dishes. Identified all of the hair needs to be covered.

Based on observation and interview, the facility failed to disinfect a multi-use glucometer( a machine that is used for blood glucose monitoring) after use for 2 of 2 residents (R11, R6) reviewed for blood glucose monitoring. This deficient practice had the ability to affect all 9 residents who required blood glucose monitoring. Findings include: The Centers for disease Control and Prevention (CDC) Infection Prevention for Blood Glucose Monitoring and Insulin Administration dated 2/6/2013, identified due to the risk of transmitting infectious diseases during assisted blood glucose (blood sugar) monitoring whenever possible, blood glucose meters should not be shared. If they must be shared, the device should be cleaned and disinfected after every use, per manufacturer's instructions. R11 R11's significant change Minimum Data Set (MDS) dated [DATE], identified R11 had severe cognitive impairment and diagnoses which included, arthritis, dementia, and diabetes mellitus DM). Identified R11 required staff assistance with activities of daily living (ADL's). R11's current physicians orders signed 2/25/25, identified R11 required blood glucose monitoring checks three times daily. During an observation on 3/10/25 at 4:38 pm., registered nurse (RN)-A sanitized hands, applied gloves and removed a glucometer, strip and a lancet (small device with a needle used to get blood for blood glucose monitoring) from the top drawer of the medication cart. RN-A used the lancet to poke R11's finger and obtained a small drop of blood onto the glucometer strip. RN-A removed gloves and placed glucometer back into the medication cart without disinfecting the glucometer. RN-A proceeded to sanitize her hands and documented R11's blood glucose result on the computer. During an interview on 3/10/25 at 4:45 p.m., RN-A verified the glucometer was used for multiple residents. RN-A stated she should have disinfected the glucometer per manufacturer's guidelines prior to placing it into the drawer of the medication cart to prevent the spread of blood-borne infections. R6 R6's significant change MDS dated [DATE], identified R6 had moderate cognitive impairment and diagnoses which included dementia, renal insufficiency and DM. Identified R6 required staff assistance with ADL's. R6's current physicians orders signed 2/25/25, identified R6 required blood glucose monitoring checks three time daily on Monday, Wednesday, and Friday and as needed. During an observation on 3/10/25 at 6:47 p.m., licensed practical nurse (LPN)-A had done a blood glucose check using a glucometer on R6 in the common area on the unit. LPN-A walked to the cart and placed the glucometer in the top drawer. LPN-A was not seen disinfecting the glucometer. During an interview on 3/10/25 at 6:50 p.m., LPN-A verified the glucometer was used for multiple residents. LPN-A stated she had wiped the front of the glucometer with an alcohol wipe after doing R6's blood glucose monitoring. LPN-A stated she thought it was ok to use an alcohol wipe to disinfect the glucometer between residents. LPN-A stated she was unsure what the manufacturer's suggested to use to disinfect the glucometers between resident use. During a joint interview on 3/11/25 at 1:25 p.m., infections preventionist (IP) and director of nursing (DON) verified the glucometer in the top drawer of the medication cart was used for several residents and DON stated using an alcohol wipe was not appropriate to disinfect the glucometer between resident use. IP and DON stated their expectation was that the glucometer would have been disinfected between residents using a Sani-wipe or per manufacturer's guidelines to prevent blood- borne infections. Review of Manufacturers guideline for Assure Platinum glucometer undated, identified disinfecting the glucometer was to be completed using a commercially available EPA-registered disinfectant detergent or germicide wipe, or one milliliter (ML) of household bleach to 9 (ML) of water to achieve a 1:10 dilution, or bleach wipes. Review of a facility policy titled Cleaning/ Disinfecting Resident Care Equipment reviewed 1/25/22, identified reusable resident equipment including glucometer was to be decontaminated between residents following manufactures instructions.

Based on observation, interview and document review, the facility failed to ensure professional standards of practice were followed during medication set-up and administration of insulin with a Humalog insulin pen ( rapid-acting insulin, used to improve blood sugar control in people with diabetes mellitus) for 1 of 1 residents (R11) who received insulin without the pen primed according to manufacturer's recommendations. Findings include: R11's significant change Minimum Data Set (MDS) dated [DATE], identified R11 had severe cognitive impairment and diagnoses which included arthritis, dementia, and diabetes mellitus (DM) and received injections of insulin. R11's care plan dated 10/7/24, identified R11 had DM and staff were to administer diabetic medications as ordered. R11's Order Summary Report signed 2/28/25, identified Humalog Kwik Pen 100 units per milliliter (ml) subcutaneous (an injection into the fatty tissue) per sliding scale ( a scale that identifies how much insulin to administer per blood glucose readings) three times daily. Review of R11's treatment administration record (TAR) from 3/1/25 to 3/10/25, identified R11's blood glucose ranged from 177 to 347. Identified R11 received 2 to 8 units of Humalog insulin during this time period. During an observation on 3/10/25 at 4:38 p.m., registered nurse (RN)-A prepared R11's Humalog insulin RN-A removed the Humalog insulin pen from the medication cart, removed the tip, attached a needle to the end of the pen, dialed up 8 units of insulin picked up an alcohol wipe, went to R11's room and administered the 8 units of insulin to R11. RN-A then removed the needle from the end of the pen, placed it in the sharps container and sanitized her hands. RN-A did not prime the pen (waste 2 units of insulin to remove the air bubbles) per manufacturer's instructions prior to drawing up the 8 units of insulin. During an interview on 3/109/25 at 4:44 p.m., RN-A verified she had not primed the insulin pen prior to dialing up the 8 units of Humalog for R11 per manufacturer's recommendations. RN-A stated she did not need to prime the pen because she had administered R11's insulin earlier in the day. During an interview on 3/11/25 at 9:30 a.m., consultant pharmacist (CP) stated it was important to always prime an insulin pen prior to drawing up the dosage to ensure the residents received the correct dosage of insulin. During an interview on 3/11/25 at 1:35 p.m., director of nursing (DON) stated her expectation was that the insulin pen would have been primed prior to dialing up the insulin dose for R12 to ensure the proper dose of insulin was administered. Review of Humalog insulin manufactures package insert dated 7/23, identified the need to prime the pen before drawing up the insulin. Identified priming the pen means removing the air from the needle and cartridge. Identified if you do not prime the pen before each injection, you may get too much or too little insulin. Review of a facility policy titled Medication Administration revised 8/7/23, identified the facility would ensure all medications were administered safely according to current standards of practice and regulatory requirements.

Based on interview and document review, the facility failed to submit complete and accurate direct care staffing information, including information for licensed practical nursing staff, based on payroll and other verifiable and auditable data, during 1 of 1 quarters reviewed (Quarter 1), to the Centers for Medicare and Medicaid Services (CMS) according to specifications established by CMS. This deficient practice had the potential to affect all 27 residents residing in the facility. Findings include: Review of the Payroll Based Journal Report (PBJ) [NAME] Report 1705 D identified the following dates triggered for review: 10/01/23, 10/03/23, 10/07/23, 10/08/23,1 0/10/23, 10/12/23, 10/14/23, 10/15/23, 10/17/23, 10/21/23, 10/22/23, 10/23/23, 10/26/23, 10/28/23, 10/29/23, 10/31/23, 11/04/23, 11/05/23, 11/10/23, 11/11/23, 11/12/23, 11/14/23, 11/17/23, 11/18/23, 11/19/23, 11/21/23, 12/02/23, 12/03/23, 12/09/23, 12/10/23, 12/12/23, 12/19/23, 12/23/23, 12/24/23, 12/29/23, 12/30/23, and 12/31/23, for failure to have licensed nurse coverage 24 hours per day. Review of staffing schedules from 10/1/23 thorough 12/31/23, identified the facility had ten staff identified to have worked: registered nurse (RN)-A, RN-B, RN-C, Licensed Practical Nurse (LPN)-A, LPN-B, LPN-C, LPN-D, LPN-E, director of nursing (DON) and assistant director of nursing (ADON) on each of the above dates listed. In addition, review of staff's time cards from 10/1/23 through 12/31/23, on the above-mentioned dates identified licensed nursing staff had worked. Review of the facility's staffing schedules and time cards identified a discrepancy with the PBJ report. During an interview on 4/15/24 at 6:20 p.m., administrator confirmed the above findings and stated licensed staff had worked on the dates mentioned above. In addition, administrator indicated the PBJ report was inaccurate and was aware of the issues. Administrator stated the LPN staff and trained medication aides (TMAs) were not coded correctly, and the facility knew how to fix the issues going forward. Review of the facility policy titled Payroll Based Journal (PBJ) dated 4/1/19, identified PBJ was CMS's mandatory electronic submission for long-term care of each care center's staffing information based on payroll data. The facility would use PBJ data to assure the delivery of quality of care to assure compliance with regulatory requirements. The policy identified the facility would gather complete and accurate direct care staffing information and the facility's Employment System Department (ESD) would review all PBJ data for accuracy and submit prior to the CMS mandated deadline.

Based on observation, interview and document review, the facility failed to ensure proper wheelchair positioning was implemented for 1 of 1 residents (R4) observed to have concerns with positioning. In addition, the facility failed to comprehensively assess and implement interventions for 1 of 1 residents (R16) observed with edema (excess of watery fluid collection in tissues of body). Findings include: POSITIONING R4's annual Minimum Data Set (MDS) dated [DATE], identified R4 had severe cognitive impairment with diagnoses which included: dementia, arthritis, and low back pain. Indicated R4 used a wheelchair with substantial/maximal assistance to wheel 50 feet, and was dependent to wheel 150 feet. R4's care plan dated 4/17/24, identified R4 required a Hoyer (mechanical) lift to transfer, a manual wheelchair with interventions that included: needed assistance with wheelchair, clear obstacles from pathway, and staff to propel from one destination to another. During an observation on 4/15/24 at 4:31 p.m., R4 was dressed in street clothes and seated in manual wheelchair in the Coliseum sitting area. R4 wore slipper socks and R4's feet dangled from the wheelchair seat, approximately five to six inches off the floor with her toes pointed down. R4's wheelchair had no foot pedals and R4's feet could not reach the floor. At 6:01 p.m., R4 was observed in her wheelchair in the Coliseum sitting area. R4's feet continued to dangle from the wheelchair seat, approximately two inches from the floor, while her toes pointed down towards the floor. At 7:46 p.m., R4 was observed in her wheelchair in the Coliseum sitting area, while her feet continued to dangle above the floor approximately two inches. During an observation on 4/16/24 at 11:52 a.m., R4 was dressed in street clothes seated in a manual wheelchair in the Coliseum sitting area. R4's stocking covered toes were observed to touch the floor by the tips of the toes, while the rest of R4's feet dangled off the floor. At 1:21 p.m., R4 was observed in the wheelchair in the Coliseum sitting area. R4's stocking covered feet were observed to dangle from the floor one to two inches above the floor. R4 began to propel herself slowly around the area in her wheelchair, using her hands on the wheels. During an interview on 4/16/24 at 2:40 p.m., nursing assistant (NA)-A stated R4 used her hands to propel her wheelchair however it went slowly. NA-A indicated R4 had never used wheelchair pedals and felt R4's feet would not sit flat on the floor. NA-A indicated she was not aware if R4 had ever been assessed for wheelchair positioning. During an interview on 4/16/24 at 3:56 p.m., licensed practical nurse (LPN)-C stated R4 required a Hoyer for transferring and used a wheelchair for mobility. LPN-C confirmed R4's feet dangled from the wheelchair above the floor, and indicated R4 used the tips of her toes while propelling the wheelchair and did not use foot pedals on her wheelchair. LPN was unsure if R4 had been assessed for wheelchair positioning by therapy and stated R4 had not had a therapy evaluation recently. LPN-C stated it was important for R4's feet to be supported in her wheelchair for good positioning. During an observation on 4/17/24 at 7:14 a.m., R4 was dressed in street clothes seated in her wheelchair, R4's right foot dangled above the floor, while R4's left toes were touching the floor. At 12:47 p.m., R4 was in wheelchair at table in the dining room. R4's left toes were touching the floor by the tips, while R4's right toes rested on the bottom of the table stand. During an interview on 4/17/24 at 1:03 p.m., certified occupational therapist assistant (COTA)-A confirmed COTA-A had worked with R4 previously related to her shoulder however it had been over a year ago. COTA-A stated for wheelchair assessments, they looked for proper fit, sitting balance, posture, safety and mobility. COTA-A stated R4 did not use foot pedals due to contractions in both knees and ankles and confirmed R4's feet barely touched the floor. COTA-A indicated when a resident's feet dangled above the floor, staff just needed to ensure the resident was safe and it did not cause pressure on their legs. COTA-A indicated improper positioning could cause discomfort for the resident. COTA-A stated COTA-A had never observed R4 propel herself in her wheelchair using her feet, just her arms. COTA-A stated they could do an assessment for a different wheelchair for R4, as R4's wheelchair could not be lowered. EDEMA R16 R16's significant change MDS dated [DATE], identified R16 was cognitively intact and had diagnoses which included: heart failure, hypertension, chronic kidney disease and diabetes mellitus. Identified R16 was dependent on staff assistance for dressing and putting on/taking off footwear. R16's care plan dated 4/17/24, identified R16 was at risk for shortness of breath, edema or chest pain related to congestive heart failure. Interventions included to monitor for signs and symptoms of heart failure, which included edema. Indicated R16 required assistance with dressing, with interventions which included assist of one with putting on knee high socks in morning (AM) and removing at bed time (HS). To do while in bed or recliner. R16's Weekly General Observation Results assessments reviewed form 1/18/24 to 4/12/24, identified the following: -1/18/24-pedal edema (swelling from fluid gathered in feet and lower legs) present -yes, right lower extremity, edema-2+ (numbered pitting edema scale which identified indentation and depth, with rebound time, scale of 1-4), left lower extremity edema-2+. -1/24/24-pedal edema present-yes, right lower extremity edema-2+, left lower extremity edema-2+. -2/7/24, area blank related to edema, not assessed. -2/14/24-pedal edema present-yes, bilateral extremities-3+. -2/21/24-area blank related to edema, not assessed. -3/14/24-pedal edema present-yes, bilateral extremities-3+. -3/20/24-area blank related to edema, not assessed. -3/29/24- pedal edema present-yes, right lower extremity edema-2+, left lower extremity edema-2+. -4/12/24-pedal edema present-yes, right lower extremity edema-1+, left lower extremity edema-1+. R16's progress notes reviewed from 1/23/24 to 4/17/24, identified on 2/25/24, R16 was admitted to hospital related to decline in health condition with CHF and renal failure. R16's primary care physician (PCP)-A's progress note dated 4/9/24, identified R16 had recovered from the serious illness he had. Progress note identified extremities had no clubbing (enlargement of ends) or cyanosis (bluish discoloration). R16's progress note lacked information if R16 had edema present or there was treatment for R16's edema. During an interview on 4/15/24 at 2:06 p.m., R16 stated he did have edema and swelling. R16 indicated the staff did not want to apply his stockings any more as they were tight and too small. R16 stated he liked to wear them, however was unable to get to town to purchase new ones. R16 was wearing regular black socks, and no compression stockings during observation, and his feet and ankles appeared slightly swollen. During an observation and interview on 4/16/24 at 11:18 a.m., R16 was in the common area seated in his wheelchair participating in exercise activity. R16 wore sandals with regular black socks. At 1:29 p.m., R16 was in his room in his wheelchair reading. R16 stated he did have some swelling of his feet and ankles today. R16's feet appeared to have some indentation where the sandal straps were across the tops of his feet. R16 stated he did not wear his shoes since they were too tight and they were stored on a small shelf on a table next to his chair. During an interview on 4/16/24 at 2:53 p.m., NA-A stated night staff assisted him with dressing in the morning since he usually woke up around 4 a.m. NA-A stated R16 did not ask for his knee high socks any more and was not certain why. During an interview on 4/16/24 at 4:19 p.m., LPN-C stated R16 wore compression stockings and the night shift usually applied them. LPN-C indicated the stockings were important to help with edema and circulation. LPN-C stated it would have been identified on R16's care guide (care plan) for the nursing assistants or the treatment administration record (TAR) if the nurses were to apply the compression stockings. LPN-C stated it might have been on the night shifts TAR. At 4:32 p.m., LPN-C confirmed R16 did not have compression stockings on and confirmed R16 had 3+ edema of his feet and ankles. During an interview on 4/17/24 at 1:14 p.m., director of nursing (DON) confirmed residents feet should not dangle above the floor while in wheelchairs. DON indicated she became aware of the concern with R4's wheelchair positioning yesterday and stated they noticed R4 had a different wheelchair cushion in her wheelchair. They placed R4's old cushion back in her wheelchair yesterday and thought that was helpful. DON indicated the facility's usual process was to have therapy assess residents for proper fitting wheelchairs. DON stated it was important to have proper fitting wheelchairs to prevent injury. DON confirmed R4's feet dangled off the floor and indicated it could cause R4 pain and R4 did not have any where to rest her feet. During an interview on 4/16/24 at 4:52 p.m., director of nursing (DON) confirmed R16 had never had an order for compression stockings. DON confirmed R16 had 2-3+ edema now. DON indicated it would have been helpful for R16 to wear compression stockings to decrease swelling. DON stated she had assisted to apply R16's knee high stockings on, however it was not easy to apply them. DON stated she would have to discuss with PCP-A to obtain an order for them. DON stated R16 had a type of compression knee high stockings in his drawer. At 5:27 p.m., DON stated she contacted PCP-A, and indicated PCP-A was not aware R16 wore compression stockings, and wanted R16 measured for Job stockings by therapy. DON stated she would have expected the nurses to notify PCP-A that R16 had edema and was wearing compression stockings. DON stated it was important to obtain R16's measurements for correct fit for R16's edema. DON indicated she was not sure if any nursing staff were aware R16's knee high stockings were actually compression stockings. On 4/17/23 at 10:31 a.m., DON indicated she had contacted R16's family member and was informed R16 purchased those stockings over the counter himself. On 4/17/24 at 11:53 a.m., a phone call and message was left to PCP-A for interview. No return call was received. The facility policy titled Adaptive And Positioning Equipment dated 11/2023, identified the facility would provide equipment that allowed residents to achieve their highest most practicable level of function. The policy procedure identified nursing would make referral to occupational therapy (OT) or physical therapy (PT) for wheelchair positioning, seating assessment or other adaptive equipment recommendation. OT/PT staff would conduct the assessment and make a recommendation for wheelchair modification and/or equipment. Nurse manager documented equipment use in care plan. Nursing and/or OT department (dept.) observed appropriateness of continued use of equipment. The facility policy titled Application & Removal Of Compression Stockings/Support Hose dated 1/2014, identified application and removal of compression stockings/support hose was done in accordance with the physician's plan of care. Continuous assessment/monitoring of the lower extremities should always accompany the changing of compression stockings/support hose. This included swelling, color changes, temperature changes, presence of pain, areas of constriction, or skin abrasions. The policy procedure included to check the care plan for any specific client instructions.

Based on observation, interview and document review, the facility failed to maintain dignity for 1 of 1 resident (R13) who utilized an incontinent pad in her wheelchair. Findings Include: R13's significant change Minimum Data Set (MDS) dated [DATE], identified R13 had moderate cognitive impairment and diagnoses which included: depression, dementia and arthritis. Indicated R13 was continent of bowel and bladder and required extensive assistance with dressing, toilet use, and transfers. R13's care plan revised 3/28/23, identified R13 required assistance with bed mobility, bathing, transfers, and elimination. R13's care plan indicated she was at risk of bladder incontinence due to needing assistance with toileting. On 3/28/23, at 12:13 p.m. R13 was in the dining room with other residents and staff. R13's wheelchair had a green incontinence pad draped over the wheelchair cushion visible from all sides which hung down the front of R13's wheelchair four to six inches. On 3/28/23, at 12:38 p.m. R13 was lying in her bed, her wheelchair was next to the bed and the green incontinence pad continued to draped over the wheelchair cushion. R13's door was open and R13's bed and wheelchair were visible from the doorway to other residents and visitors. During an interview on 3/28/23, at 4:51 p.m. nursing assistant (NA)-A stated R13 was continent of bowel and bladder. NA-A indicated she was not certain why R13 had an incontinent pad in her wheelchair or how long the pad had been used in R13's wheelchair. On 3/28/23, at 5:28 p.m. a green incontinence pad was positioned on the center of R13's bed, on top of the linen visible from the doorway. At 5:30 p.m. R13 was in the dining room seated in her wheelchair. A green incontinence pad was draped over the cushion, visible from all sides of the wheelchair and hung down in front of the wheelchair four to six inches. During a telephone interview on 3/29/23, at 8:06 a.m. family member (FM)-A indicated she was not aware R13 had an incontinence pad in her wheelchair and stated it was unusual since R13 was continent of bowel or bladder. FM-A stated it was not dignified for R13 to have the incontinence pad used in her wheelchair since R13 was continent. On 3/29/23, at 8:48 a.m. R13 was seated in her wheelchair in the dining room. A green incontinence pad was draped over the wheelchair cushion visible to other residents, staff and visitors from all sides of the wheelchair. During an interview on 3/29/23, at 10:31 a.m. NA-B confirmed an incontinence pad was present in R13's wheelchair when they assisted R13 with morning cares and transferred R13 to the wheelchair that morning. NA-B stated R13 was continent. NA-B indicated it was not dignified for R13 to have the incontinence pad placed in her wheelchair. During an interview on 3/29/23, at 10:51 a.m. licensed practical nurse (LPN)-A indicated R13 was continent and confirmed R13's wheelchair had a green incontinence pad positioned on the wheelchair cushion. LPN-A stated it should not have been there and indicated it was a dignity issue. During an interview on 3/29/23, at 11:29 a.m. director of nursing (DON) confirmed she had observed R13 in the dining room in her wheelchair with the green incontinence pad draped over the wheelchair cushion. DON confirmed R13 should not have had an incontinence pad in her wheelchair as she was continent. DON stated the facility should not place incontinence pads in their wheelchairs as it was not dignified. In addition, DON indicated the incontinence pads should not have been visible on resident beds. Review of the facility policy titled Dignity, revised 10/23/17, identified the facility would treat each individual residing in their facility with respect and dignity. Indicated staff would provide care that could help avoid situations that could be demeaning to the residents. The policy lacked direction for the use of incontinence products, including incontinence pads.

Based on observation, interview and document review, the facility failed to ensure staff were following fall risk interventions implemented for 1 of 2 (R1) residents identified at risk for falls to prevent further falls. Findings include: R1's quarterly Minimum Data Set (MDS) dated [DATE], identified R1 had moderate impaired cognition and had diagnoses which included diabetes mellitus, non-Alzheimer's dementia, and depression. The MDS indicated R1 required extensive assistance from staff with toileting, transfers, and personal hygiene. R1's fall assessment dated [DATE], identified R1was at risk for falls due to impaired cognition, impaired vision and previous falls. R1's fall assessment indicated R1 was occasionally incontinent of bladder and required staff assistance with transfers. R1's fall investigation report dated 10/7/22, identified R1 had an unwitnessed fall at 5:00 a.m. The report indicated R1 was found sitting on her fall mat next to the bed, had no footwear on and R1's wheelchair was across the room. The report indicated R1 was sent to the emergency room (ER) for left hip pain. The report identified R1 received an Xray of her left hip which was inconclusive and a cat scan (CT) scan had been completed which indicated a fracture of the left hip. CT scan dated 10/7/22, indicated R1 sustained a left hip fracture. R1's care plan dated 10/8/22, identified R1 was at risk for falls and required assistance from staff with mobility and transfers. R1's care plan indicated the call light should have been within reach. The care plan identified R1 was to wear gripper socks at all times, a bed sensor and arial silent floor sensor were to be in place and R1's wheelchair was to be placed next to the bed. During an observation on 10/17/22, at 10:36 a.m. R1 was lying in her bed, fall mat was placed on the floor next to the bed and R1's wheelchair was noted to be across the room near the bathroom door. During an observation on 10/17/22, at 11:10 a.m. nursing assistant (NA)-A was observed exiting R1's room. R1 was observed lying in bed on her left side and wheelchair was noted to be across the room near the entrance of the room. During an observation on 10/17/22, at 1:18 p.m. NA-A placed a transfer belt on R1 and used the non mechanical lift to transfer R1 to the bathroom. R1 wiped herself after completing her toileting tasks and NA-A pulled up R1's pants. NA-A proceeded to assist R1 into bed using the non-mechanical lift to transfer her. NA-A washed her hands and placed R1's wheelchair across the room near the entrance of the room. During an interview on 10/17/22, at 1:36 p.m. NA-A stated R1 required moderate assistance with her activities of daily living (ADL's). NA-A stated R1 had fallen twice. NA-A indicated she was aware of the fall interventions prior to R1's last fall however was not aware of any new interventions being implemented after R1's last fall on 10/7/22. NA-A confirmed she had placed the wheelchair near the entrance of the room.instead of next to R1's bed. NA-A stated she was unaware the wheelchair should have been placed next to R1's bed. During an interview on 10/17/22, at 1:48 p.m. NA-B indicated R1 required moderate assistance from staff with transfers and toileting. NA-B stated R1 had fallen twice recently and had fractured her left hip during the last fall. NA-B stated the new fall interventions for R1 after the last fall was a toileting plan and to ensure R1 was wearing gripper socks. NA-B stated she was unaware R1's wheelchair should have been placed next to R1's bed. During an interview on 10/17/22, at 2:55 p.m. licensed practical nurse (LPN)-A indicated R1 was at risk for falls and required extensive assistance with transferring and toileting. LPN-A stated R1 recently had two falls and had fractured her left hip during the last fall. LPN-A indicated after R1's last fall, a toileting plan had been implemented. LPN-A verified R1's care plan identified R1's wheelchair should have been placed next to R1's bed when R1 was in bed. LPN-A confirmed R1's wheelchair had been placed across the room near the entrance to her room and was not near R1's bed. During an interview on 10/17/22, at 3:30 p.m. LPN-B stated she had been working the night when R1 fell and fractured her left hip. LPN-B stated on 10/7/22, at 5:00 a.m. R1 had been found sitting on her fall mat next to her bed and R1's wheelchair had been placed across the room near the entrance. LPN-B stated R1 had been attempting to use the bathroom when she fell . LPN-B indicated she assessed R1 at the time of the fall and R1 appeared to not have had any injuries. LPN-B stated R1complained of left hip later that same day and had been sent to the ER where she was diagnosed with a fractured left hip. LPN-B confirmed she implemented an immediate intervention of placing R1's wheelchair next to the bed when R1 was in bed. Additionally, LPN-B stated a trial toileting plan had been started for R1. LPN confirmed the new interventions had been placed in R1's care plan. During an interview on 10/17/22, at 3:39 p.m. director of nursing (DON) verified R1 had fallen out of bed on 10/7/22, and sustained a left hip fracture. DON verified the immediate care planned interventions were to initiate a toileting plan, to decrease fluids after 9:00 p.m. and to ensure R1's wheelchair had been placed next to the bed when R1 was in bed. DON stated it was her expectation staff would have followed care planned interventions. Review of a facility policy title Fall Prevention and Management revised 3/7/22, indicated a post fall assessment would have been done when the resident was residing in the care center. Policy indicated an immediate intervention would have been put into place and all interventions identified through the assessment would have been documented in the resident's care plan using person centered language.

Based on observation, interview, and document review, the facility failed to provide range of motion (ROM) treatment/services and assistance to improve and maintain mobility as recommended by therapy for 1 of 2 residents (R1) reviewed for mobility. Findings include: R1's quarterly Minimum Data Set (MDS) dated [DATE], identified R1 had moderate cognition impairment and diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS also indicated R1 required extensive assist of 1 staff for bed mobility, transfers, ambulation, dressing, personal hygiene, and toilet use. R1 had no impairments in functional range of motion for upper or lower extremities. The MDS further indicted R1 had not received physical therapy (PT), occupational therapy (OT) or restorative nursing programs. R1's current face sheet identified diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's current care plan dated 7/30/22, identified R1 was at risk for decline in mobility (r/t) related to diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The care plan indicated R1 was to receive a functional maintenance program (FMP) a minimum of 3 times a week and up to 5 times a week. Additionally, R1 had decreased mobility r/t fracture of right hip on 3/21/22. The care plan directed staff to ambulate R1 with assist of 1 to 2 with walker 3 times a day, every day. R1's Fall Risk assessment dated [DATE], identified unsteady gait and only able to stabilize with human assistance, weak, and high risk for falls. R1's physical therapy discharge summary dated 5/20/22, identified following R1's hip fracture and surgical repair significant progress had been made from full assist for mobility and using lift to independent with bed mobility, walking with FWW 20 to 40 feet. Staff educated on FMP and walking with R1. Discharge recommendations: continue walking with FMP and strength exercises. R1 was to receive a program of ambulation and lower extremity (LE) exercises 3 to 5 times weekly, dated 5/4/22. The program included: -Ambulation with front wheeled walker (FWW) assist of 1 with wheelchair follow and gait belt 15 to 30 feet two times, slow gait. -Nustep (lower extremity machine) level two 5 to 10 minutes, slow movements. -Walk to and from chair with FWW five times and if she cannot walk perform pivots. R1's FMP assessments completed by Therapy Manager (TM) identified the following: -On 4/1/22, resident had recent fall with major injury and was working with active therapies. FMP will be placed on hold until active therapies has been discontinued. -On 5/28/22, FMP 3 to 5 times a week. Resident recently discharged from active therapies. Changes made to FMP. -On 8/24/22, frequency of program: active range of motion 3 to 5 times a week. Goal: Resident will participate with Functional Maintenance (FMP) a minimum of 3 times a week. Evaluation: Staff continue to encourage resident participation in in FMP. Resident frequently declines. Staff may bring equipment to room if needed. No changes. The FMP assessments lacked any documentation related R1's ambulation status including her ability to complete the ordered therapy/exercises. R1's FMP daily flow sheets completed when specified therapy/exercises were completed and documented identified the following: -May 2022, on 5/11/22, and 5/31/22, 15 minutes of therapy/exercises. R1 refused on 5/30/22 (only receiving the FMP twice the entire month of May). -June 2022, on 6/7/22, 6/9/22, and 6/14/22, 20 minutes of therapy/exercises and 6/15/22, 15 minutes of therapy/exercises (only receiving the FMP 4 days). -July 2022, on 7/5/22, refused, 7/10/22, 15 minutes of therapy/exercises, and 7/20/22, out of building (only receiving the FMP 1 day). -August 2022, on 8/18/22, 8/21/22, 15 minutes of therapy/exercises, 8/20/22, and 8/22/22, 16 minutes of therapy/exercises, and 8/24/22, 20 minutes of therapy/exercises (only receiving the FMP 5 days). -[DATE], on 9/4/22, 16 minutes of therapy/exercises, 9/6/22, 9/20/22, and 9/27/22, 15 minutes of therapy/exercises (only receiving the FMP 4 days). There was no further information documented on the sheets. Review of R1's nursing assistant (NA) activities of daily living (ADL) flow sheets for the months of May, June, July, August, September 2022, identified the following additional ambulation: -May, on 5/29/22 and 5/31/22 walked in room (2 days) -June, on 6/3/22, 6/11/22, 6/13/22, 6/16/22, 6/18/22, 6/19/22, 6/20/22, 6/21/22, 6/22/22, 6/24/22, 6/25/22, 6/27/22, 6/30/22, walked in room (13 days) -July, on 7/4/22, 7/6/22, 7/8/22, 7/9/22, 7/10/22, 7/16/22, 7/25/22, 7/26/22, 7/28/22, walked in room (9 days) -August, on 8/10/22, 8/16/22, 8/23/22, and 8/24/22 (4 days) -September, on 9/13/22, walked in corridor (1 day) The ADL flow sheets lacked documentation of R1's ambulation duration status including her ability to complete the ordered therapy/exercises. Review of R1's progress notes dated 8/24/22, at 11:00 a.m. care conference identified PT/OT completed see therapy detail for plan of care (POC) goals. R1's progress notes lacked any documentation related to R1's ambulation status including her ability to complete the ordered therapy/exercises. On 9/27/22 at 12:00 p.m. nursing assistant (NA)-C pushed R1 out of her room in wheelchair down to the dining room. -At 1:12 p.m. NA-C pushed R1 in wheelchair from the dining room back to her room. NA-C removed oxygen tubing from her face, applied gait belt, assisted R1 to standing, pivoted, and lowered her down onto the bed. R1 laid on her left side. NA-C replaced the oxygen tubing to her face, lowered the bed, covered her up, and shut off the lights. -At 1:30 p.m. 2:00 p.m., 2:30 p.m., 3:00 p.m., 4:00 p.m., and 4:30 p.m. R1 laid in her low bed on left side, covered up with blankets, fall mat and sensor on floor next to the bed. No staff were observed to offer or encourage R1 to ambulate to in the room, hallway, or to and from the dining room. During an observation/interview on 9/28/22, at 1:44 p.m. NA-E pushed R1 in wheelchair into her room from the dining room. NA-E entered the bathroom while R1 remained in the wheelchair. NA-E applied a gait belt and gave R1 cues while she grabbed the bar on the wall and stood up. NA-E instructed R1 to pivot onto toilet. R1 sat down onto toilet with difficulty. NA-E held onto gait belt, gave R1 cues to stand up, and pivoted into wheelchair. R1 washed her hands at the sink and NA-E pushed her over to the bed. R1 took a hold of the short bed railing and slowly pulled herself up to standing, pivoted and lower herself onto the bed. NA-E replaced oxygen nasal cannula on R1's face, lifted her legs/feet onto the bed, placed a pillow under her knees, lowed bed, adjusted fall and sensor mats, and exited room. NA-E stated it had been quite a while since she had walked R1. NA-E indicated R1 had been on a walking and exercise program and thought therapy staff completed that. During an interview on 9/27/22, at 1:30 p.m. nursing assistant (NA)-A stated R1 transfers stand by assist of 1 and pivots, she really did not walk. NA-A indicated after R1 fell and broke her hip she received therapy and when discharged from there she went to the FMP program and worked on exercises and walking. NA-A identified R1 only goes to FMP when she felt up to it and was unsure of how often. During an interview on 9/27/22, at 2:00 p.m. exercise therapy aide (ET)-A stated R1 had not done much therapy. ET-A also stated R1 should have completed at least 15 minutes of the program at least 3 times a week. ET-A indicated R1 could no longer complete the bike exercise and needed to be reassessed. ET-A stated R1's POC had not been updated since May 2022. ET-A identified R1 refused therapy a lot, had less strength, and her mobility was slower since she fell and fractured her hip March 2022. During an interview on 9/27/22, at 2:15 p.m. ET-B stated R1 had become weaker especially this past month. ET-B indicted R1 had been unable and no longer completed the bike exercise. ET-B also stated she had been aware therapy had not been completed as ordered and sometimes it just did not get done due to a shortage of staff. During an interview on 9/27/22, at 3:20 p.m. NA-C stated R1 required assistance with all cares and a very high risk for falls. NA-C indicated R1's strength had gotten worse and had been able to walk to her meals all the way to the dining room about 250 feet before she fractured her hip. NA-C identified R1 had seemed withdrawn and had observed her complete therapy only a couple of times during the past two months. During an interview on 9/27/22, at 4:11 p.m. family member (FM) stated she had been worried R1 had gotten weaker and may fall again. FM indicated R1 did refuse some of the therapy at times and had not been walking or taken part in therapy recently. FM also stated R1 verbalized she wanted to be able to walk again and not fall. During an interview on 9/28/22, at 9:15 a.m. NA-D stated she had transferred R1 from her bed to the wheelchair to take her to the bathroom. NA-D indicated R1 usually did not walk and understood staff were expected to transfer with the wheelchair only. During an interview on 9/28/22, at 9:45 a.m. R1 stated she had refused therapy at times. R1 indicated she wanted to get stronger but needed more encouragement from staff. R1 stated she felt weaker and struggled to get out of bed. R1 also stated she needed therapy but did not like it. R1 indicated she had therapy until the end of May 2022, after it ended, she felt like she had been dropped from therapy. During an interview on 9/28/22, at 10:31 a.m. Director of Nursing (DON) stated staff were expected to have reported the FMP had not been done with R1 as ordered. DON also stated a new evaluation should be completed and a referral made to physical therapy agency. During an interview on 9/28/22, at 12:34 p.m. licensed practical nurse (LPN)-A stated staff were expected to walk R1 in the hallway only. LPN-A indicated she had been informed by the physical therapist staff R1 would have been encouraged to walk in her room by herself and that would not have been safe. During an interview on 9/28/22, at 1:15 p.m. physical therapy assistant (PTA) stated R1 expected staff to continue with the FMP designed by the physical therapist 3 to 5 times a week. PTA stated R1 required upper and lower body strength to to safely transfer. PTA verified she had written in the staff communication book on 4/25/22, R1 can use FWW and assist of 1 to do stand pivot transfers from wheelchair to bed or recliner. PTA also stated R1 needed to continue with the ordered therapy program to maintain the strength she had in her hips, ROM, and to self propel herself in the wheelchair. PTA also stated the facility had not notified her of any changes needed. During an interview on 9/28/22, at 2:30 p.m. with trained medication assistant (TMA)-A stated she transferred R1 to and from the bathroom via wheelchair and unaware of the last time she saw R1 ambulating. TMA-A indicated R1 was mostly likely transported in the wheelchair to make it easier because of the oxygen tubing could have been an issue. TMA-A also stated, I have not encouraged her to walk but planned on starting today. During an interview on 9/28/22, at 3:00 p.m. NA-B stated R1 needed assistance with transfers. NA-B also stated she had not walked R1, lacked information, and had not seen her walk since she started work there over 8 months ago. NA-B indicated R1 had some falls and R1 told her she really wanted to walk but needed help to get stronger. During an interview on 9/28/22, at 3:15 p.m. registered nurse (RN) stated the NA ADL flow sheets provided additional information however lacked documentation of the distance the resident walked. The FMP should be evaluated by a nurse periodically to ensure it is being followed and there was no decline in ability. If refusals or decline, the resident should be referred back to therapy. During an interview on 9/28/22, at 3:40 p.m. therapy manager (TM) stated staff are expected to educate R1 on the how beneficial the therapy would have been, and it was her right to refuse. TM also stated staff are expected to have provided encouragement rather than taking away her therapy and do nothing. TM indicted R1 had never been a high participant in therapy and expected staff to communicate to her when a resident's plan needed to be changed and if they continued to refuse. TM indicated R1's therapy program should have met her needs, provided a program she would have liked and participated in, and helped keep and maintain her current level of function and ability to participate in her ADLS. During a telephone interview on 9/29/22, at 9:05 a.m. physical therapist (PT) stated R1 had been discharged from physical May 2022. PT also stated recommendations had been given to facility to continue ambulation and exercises 3 to 5 times a week and at least a minimum of 3 times a week. PT indicated the therapy/exercise program was intended for R1 to have maintained function as best as she could, keep her independent as possible and strong to lessen the chance of falling. PT stated she expected the facility to contact her or her assistant if R1 refused to take part in the therapy/exercise. Facility policy titled Restorative Nursing Program Classifications undated, identified the Functional Maintenance Program was a therapy/exercise to be offered by the restorative nursing staff. The ambulation and range of motion (ROM) programs were provided to show maintenance of skill with or without adaptive devices. The daily flow sheet was to be completed when ambulation and/or ROM was completed.

Based on observation, interview and document review, food was not served in a sanitary and clean manner for 33 residents who resided in the facility, observed during dining observation. In addition, the facility failed to maintain the ice machine in a sanitary manner to prevent potential contamination for 33 residents who currently received ice from the ice machine. Findings include: Food Service On 6/7/21, at 5:33 p.m. dietary cook (DC)-A was observed applying gloves to his left hand or both hands during each time he plated a residents meal on the plates for service. At 5:35 p.m. DC-A removed his glove from his left hand, placed the used glove on top of the glass cover over the steam table, wiped off his hands with a sanitary wipe from a container kept on top of the glass cover, placed the used wipe on top of the glass cover, then applied new gloves. At 5:35 p.m. during plate set up, DC-A was observed touching the paper slips with residents' dietary information on them, with his gloved hand, then would reach into the metal bin with the same gloved hand to get a sandwich, then placed the sandwich on the plate. Dietary manager (DM)-A came to assist DC-A with meal service, wearing gloves to place potato chips onto residents' plates using tongs. DC-A continued multiple times to touch the residents' paper dietary slips with his gloved hand prior to picking up the sandwiches with his same gloved hand. DC-A then proceeded to remove gloves after each plate setting, throwing gloves onto bottom shelf of the food cart which had dishes of desserts and salads on the top and the middle shelf. DM-A assisted DC-A with food service, standing next to DC-A while he was touching the paper slips with his gloved hand, and throwing used sanitary wipes on top of the glass cover and used gloves onto the bottom shelf of the food cart. At 5:55 p.m. used gloves were hanging off the bottom shelf of a food cart, 3 used gloves were noted on the floor and one used glove was stuck to the bottom of DC-A's shoe. One used glove was hanging off the edge of the glass top onto the glass sneeze tray above the serving area. Multiple used sanitary wipes were piled on top of the glass cover over the steam table. On 6/7/21, at 6:04 p.m. the facility ice machine stored in the clean utility room had thick flaky heavy hard water lime scale build up on the outside of the machine along the entire right side seam between the top and bottom of the unit about 1/2 inch thick. Inside the ice machine bin on the top, there was also an area of approximately 4 inches by 8 inches long of hard water lime scale build up near the right side back, and a few inches of area of thick hard water lime scale buildup on the left front top of the ice machine bin, which was full of ice. On 6/10/21, at 8:42 a.m. DM-A confirmed DC-A had thrown used gloves on the cart, on top of the glass cover over the steam table, and threw his used sanitary wipes on top of the glass cover as well. DM-A confirmed DC-A also was touching the residents' sandwiches with his gloved hand after touching their paper dietary slips. DM-A confirmed the paper slips were obviously dirty, they were printed, touched by many, stored in many areas and could have caused cross contamination. DM-A indicated it was her expectation for staff to not touch the paper slips with a gloved hand prior to touching the sandwiches. DM-A stated her expectation was to place all soiled sanitary wipes and used gloves in a garbage can. DM-A indicated the facility's usual practice was to have a small metal garbage can in the serving area that could be opened by the server's foot. DM-A stated it was important for sanitary reasons and safety to place the used gloves and sanitary wipes in the garbage can after use. DM-A indicated the presence of the used gloves on the floor, on the bottom shelf of the cart, on the top of the glass cover over the steam table and the used sanitary wipes laying on top of the glass cover of the steam table made for an unsanitary appearance. DM-A stated she had instructed DC-A to grab the garbage can and he did not. DM-A confirmed she had not corrected DC-A of this practice when they had served the food. DM-A indicated she expected DC-A to change his gloves when his gloved hands became contaminated or soiled. On 6/10/21, at 8:36 a.m. DM-A observed the ice machine with surveyor and confirmed there was hard water lime scale build up on both the outside and inside of the ice machine. DM-A stated she was not aware of who was responsible to clean the ice machine, but indicated the machine needed to be cleaned, because the lime scale build up could get into the ice and be ingested by the residents. At 8:37 a.m. DM-A and environmental service (ES)-A observed the ice machine with surveyor. ES-A confirmed there was hard water lime scale buildup on the outside and inside of the ice machine. ES-A confirmed he was responsible to clean the ice machine and the usual facility practice was to clean the ice machine once every 2 months. ES-A stated it was probably due to be cleaned. ES-A indicated the ice machine should have been cleaned because every body liked clean ice. DM-A indicated she began work in the middle of March and confirmed the ice machine had not been cleaned since she began working at the facility. DM-A confirmed the facility used the ice to keep their juices cold. The facility Ice Machine Cleaning Logs reviewed from 7/17/19, to 6/10/21, included a column for date, notes, and cleaned by, which was initialed by who cleaned it. The log reviewed included the following dates, which indicated it had been cleaned on 7/17/19, 9/12/19, 11/13/19, 1/15/20, 4/7/20, 6/18/20, 8/19/20, 10/21/20, 12/16/20, 2/17/21, and 4/14/21. The facility policy titled Sanitize Ice Scoop & Holder Daily Per Dietary dated 2/29/12, identified the ice scoop and holder must be washed and sanitized at least once daily by dietary. The policy did not identify when the ice machine would be cleaned. The facility policy titled No Bare Hand Contact reviewed 1/31/20, instructed staff to have a barrier between their hands and ready to eat foods or when serving the food. The policy instructed staff to use tongs, scoops, etc, to place the food on the plate and tray. The policy also advised using a clean hand that was gloved. The policy further identified hands must be washed between any contaminations, that meant touching anything that could be contaminated; face, hair, resident, wheelchairs, pencils, tray tickets, etc. When contaminated, gloves must be removed, hands need to be rewashed and gloves applied.

Based on observation, interview, and document review, the facility failed to ensure 5 of 6 residents' (R1, R5, R6, R7, R12 ) insulin pen rubber stoppers were cleansed with an alcohol wipe prior to applying the needle and had the potential to affect all 9 residents currently using insulin pens. Findings include: R1's medication set-up was observed on 6/7/21, at 4:45 p.m. licensed practice nurse (LPN)-A removed a NovoLog insulin [MEDICATION(S)] from the medication cart. LPN-A took off the cover and did not cleanse the rubber stopper with alcohol prior to when she applied the needle. LPN-A primed the insulin pen with 2 units of insulin then dialed up 7 units. R12's medication set-up was observed on 6/7/21, at 4:50 p.m. LPN-A removed a NovoLog insulin [MEDICATION(S)] from the medication cart. LPN-A took off the cover and did not cleanse the rubber stopper with alcohol prior to when she applied the needle. LPN-A primed the insulin pen with 2 units and then dialed up 14 units. R5's medication set-up was observed on 6/7/21, at 5:00 p.m. LPN-A removed a NovoLog insulin [MEDICATION(S)] from the medication cart. LPN-A took off the cover and did not cleanse the rubber stopper with alcohol prior to when she applied the needle. LPN-A primed the insulin pen with 2 units and then dialed up 20 units. R6's medication set-up was observed on 6/7/21, at 5:05 p.m. LPN-A removed a NovoLog insulin [MEDICATION(S)] from the medication cart. LPN-A took off the cover and did cleanse the rubber stopper with alcohol prior to when she applied the needle. LPN-A primed the insulin pen with 2 units and then dialed up 12 units. R7's medication set-up was observed on 6/7/21, at 5:30 p.m. LPN-A removed a NovoLog insulin [MEDICATION(S)] from the medication cart. LPN-A took off the cover and did not cleanse the rubber stopper with alcohol prior to when she applied the needle. LPN-A primed the insulin pen with 2 unites and then dialed up 20 units. During an interview on 6/9/21, at 7:40 a.m. LPN-B stated the insulin pen was like a vial, the end of the pen should have been cleaned off prior to placing the needle on it. LPN-B indicated it was important to clean it off to help prevent infection and it was the facility expectation and usual standard of practice. During an interview on 6/9/21, at 12:50 p.m. LPN-A stated they were not required to clean off the rubber end of the insulin pen with alcohol prior to application of the safety needle. LPN-A indicated it was necessary to clean off the top of a vial with alcohol, however and it was important for infection control reasons. During an interview on 6/10/21, at 11:55 a.m. facility pharmacist stated the insulin rubber end should have been wiped down with an alcohol swab prior to placement of the safety needle to help prevent infection and was the best standard of practice. During an interview on 6/10/21, at 1:30 p.m. director of nursing (DON) stated staff were not expected to clean off the rubber stopper on the insulin pen with alcohol prior to application of the safety needle. DON indicated staff were expected to follow the manufacturers recommendations and guidelines. DON stated the staff needed to be re-educated and the policy required revision to help prevent the spread of infection. Review of the facility policy titled Medication Administration last revised 5/20/19, indicated St. [NAME] Health Services (SFHS) care centers will ensure all medications will be administered safely according to current standard of practice and regulatory requirements. PURPOSE: To provide guidance to nursing staff on administering medications. The facility policy failed to identify guidance to nursing staff regarding the administration of insulin via insulin pens according to current standards and manufacturers recommendations. Review of NovoLog manufacturer recommendations dated 2019, identified preparation of the NovoLog flex pen included removal of the the pen cap and then wipe the rubber stopper with an alcohol swab. Remove the protective tab from the disposable needle and screw in tightly onto your [MEDICATION(S)].

Based on observation, interview, and document review, the facility failed to ensure the resident council concerns related to cold food and late meals were resolved in a timely manner. This practice affected 6 of 11 resident council members (R12, R13, R17, R23, R30 ,R31) and had the potential to affect all 33 residents who received meals from the main kitchen. Findings include: During a resident council meeting conducted on 6/8/31, at 12:52 p.m. R31 stated the resident council had consistent concerns related to cold foods and late meals. R17, R30, and R31 verified the resident council had not received a resolution of the cold food by the facility therefore the problem continued. R12, R13, R17, R23, R30, and R31 all verified the food was cold and the facility had not fixed the problem. The residents present stated the cooks do not put the steam table on before they place the food in there and the food was not hot and was served late. The residents present stated these issues had been brought up in previous resident council meetings and had not been addressed. Review of the Resident Council Agendas from 1/29/21, to 4/30/21, revealed the following information: - 1/29/21, coffee was not always hot. - 2/25/21, if coffee was not always hot, residents were told to ask for a new cup. - 3/10/21, coffee was not always hot. If the food was not warm enough residents were asked to just talk to dietary department and your plate could be warmed up. - 4/30/21, no concerns related to cold coffee or late food. During an interview on 6/10/21, at 8:58 a.m. cook (C)-B stated during a taste test of a food tray and indicated the oatmeal, sausage, and eggs were hot, the bacon was warm, and the toast was cold. C-B also stated the food was tested daily and he had received more complaints of the food being cold in the evening. C-B indicated he felt the complaints were due to the timeliness of the food being served. C-B stated he had received complaints from residents in passing and confirmed meals had been served up to one and a half hours late at times. During an interview on 6/10/21, at 9:00 a.m. dietary manager (DM) stated she was aware of the complaints regarding cold food mostly in the evenings that dated back prior to when she stated work at this facility on 4/1/21. During a taste test of a breakfast tray with food items of oatmeal, sausage, eggs, bacon, and toast the DM confirmed the food was flavorful, however the toast was cold. The DM indicated the food prep needed to be completed prior to bringing the food out to allow the temperature of the food to maintain a high enough temperature to keep it hot. DM also verified it has taken the evening cook a long time to serve meals in the past and meals had been served too late. During an interview on 6/10/21, at 9:50 a.m. activity director (AD) stated she coordinated and worked with all resident council meetings and concerns. AD stated she was aware of the concerns related to cold coffee and late food and had passed the concerns onto the DM. AD indicated one dietary cook struggled with time management and usually served meals up to 30 minutes late in the evening. AD stated the evening cook would start serving the meal, then had to run back into the kitchen and make gravy or something else and then come back out to finish serving. AD stated unfortunately, the council continued to express concerns related to cold coffee and late food without a resolution.

Based on interview and document review, the facility failed to ensure the attending physician acted upon the pharmacist recommendations for 1 of 5 residents (R19) reviewed for unnecessary medications. Findings include: R19's significant change Minimum Data Set (MDS) dated [DATE], identified R19 had diagnoses which included gastro-[CONDITION(S)] reflux disease, arthritis, dementia and was cognitively intact. The MDS identified R10 required extensive assistance from staff for bed mobility, transfers, dressing, toileting, and personal hygiene. The MDS further indicated R19 had pain present frequently. Review of R19's Physician Order sheet dated 5/27/21, indicated R19 had an order for Tums 200 milligrams (mg) one tablet by mouth as needed for gastro-[CONDITION(S)] reflux and muscle rub as needed for areas with muscle aches/arthritis/pain. Review of R6's Medication Administration Record (MAR) dated 6/1/21, to 6/10/21, revealed R19 was to have the Tums and muscle rub at bedside. There was not documentation of how often or how many times a day R19 was receiving these medications. Review of R19's Pharmacy Review Progress Notes from 3/18/21, to 6/10/21, revealed the following: - 3/18/21, medication review completed, no pharmacy recommendations at this visit. Gradual dose reduction (GDR) evaluation of [MEDICATION(S)] and [MEDICATION(S)] was prompted by nursing staff on 3/2021. - 4/16/21, please update transcription of as needed Muscle rub, Alka-[NAME], and Tums to include frequency. - 5/10/21, Medication review completed, no pharmacy recommendations at this visit, as needed Alka- [NAME] was discontinued secondary to non use. Awaiting nursing response to 4/2021 pharmacy recommendations to clarify frequency of as needed Muscle rub and Tums and update MAR accordingly. R19's medical record lacked documentation that R19's primary physician was updated on the CP recommendations. On 6/10/21, at 10:27 a.m. the director of nursing (DON) confirmed the above findings and indicated the pharmacy reviews were done on a monthly basis. The DON indicated she would expect staff to follow up on pharmacy recommendations and to follow the facility policy. The DON stated this should have been addressed on doctors rounds and completed as directed. On 6/10/21, at 11:49 a.m. consulting pharmacist (CP) confirmed the above findings and indicated she would expect the recommendations be followed up on in a timely manner. The CP indicated she would have expected the recommendations to be followed up on by the next pharmacy review visit and they should have been following the facility policy. Review of facility policy titled, Drug Regimen Review revised on 10/8/18, indicated the facility would have formal arrangements with a licensed pharmacist to review the drug regimen for each individual receiving services at the time of admission, at least once a month. A potential or actual issue that in the clinicians professional judgement, warrants physician communication and completion of prescribed/recommended action by midnight of the next calendar day at the latest.

Based on observation, interview and document review the facility failed to provide shaving assistance for 1 of 2 residents (R27) who required assistance from staff to complete personal cares. Findings include: R27's quarterly Minimum Data Set (MDS) dated [DATE], indicated R27 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS indicated R27 was independent with bed mobility, transfers, toileting, eating and required staff assistance with dressing, bathing and personal hygiene. R27's care plan revised on 5/21/21, indicated R27 required limited assistance with grooming and personal hygiene and staff were to assist with completion of tasks as needed. The care plan also indicated R27 would be neatly groomed daily. R27's Nursing Aid sheet dated 6/8/21, indicated R27 required staff assistance with dressing and lacked any direction for staff to assist R27 with grooming. During observations on 6/7/21, at 3:09 p.m. R27 was walking independently with his four wheeled walker down the hallway and was noted to have dark black and white, thick, facial hairs on the left and right side of his neck area, below his upper and lower lip, chin area, under his nose area that were approximately 1/4 centimeters (cm) to 1/2 cm or longer. - at 6:32 p.m. R27's facial hair remained. During observations on 6/8/21, at 8:44 a.m. R27 was seated in the dining room eating breakfast independently and was noted to have dark black and white, thick, facial hairs on the left and right side of his neck area, below his upper and lower lip, chin area, under his nose area that were approximately 1/4 cm to 1/2 cm or longer. - at 1:03 p.m. R27's facial hair remained. During observations on 6/9/21, at 8:17 a.m. R27 came out of his room with his four wheeled walker and walked independently to the dining room for breakfast. R27 was noted to have dark black and white, thick, facial hairs on the left and right side of his neck area, below his upper and lower lip, chin area, under his nose area that were approximately 1/4 cm to 1/2 cm or longer. During observations on 6/10/21, at 11:13 a.m. R27 was seated in his chair in his room and was noted to have dark black and white, thick, facial hairs on the left and right side of his neck area, below his upper and lower lip, chin area, under his nose area that were approximately 1/4 cm to 1/2 cm or longer. On 6/8/21, at 9:25 a.m. R27 indicated he likes to be shaved clean and did not like hair on his face. R27 indicated staff did not assist him and he tried to do it himself. On 6/10/21, at 11:13 a.m. nursing assistant (NA)-A confirmed R27 needed staff assistance with activities of daily living (ADL's) personal hygiene, grooming and shaving. NA-A indicated she had not asked or offered R27 assistance with shaving and indicated he had a bath today. NA-A verified R27 needed to be shaved and staff had forgot to ask him. On 6/10/21, at 11:22 a.m. licensed practical nurse (LPN)-A confirmed R27 needed staff assistance and verbal cues at times with personal hygiene and shaving. LPN-A indicated she would have expected staff to follow the care plan and assist R27 with personal cares and shaving when he needed more assistance. On 6/10/21, at 11:35 a.m. the director of nursing (DON) confirmed R27 required staff assistance with personal hygiene and shaving. The DON indicated her expectation of staff was to follow the care plan and to ask R27 about shaving. The DON stated she expected staff to provide assistance when he needed to be shaved. Review of facility policy titled, AM (morning) and HS (bedtime) Resident Cares undated, indicated procedure was to provide shaving of facial hair assistance as needed.

Based on observation, interview and document review, the facility failed to implement safe smoking interventions for 1 of 1 residents (R27) who required staff to manage smoking materials. In addition, the facility failed to implement safe use of portable oxygen cylinders for 1 of 1 residents (R30) who required continuous use of oxygen. In addition, the facility failed to ensure interventions were implemented to prevent falls and/or injury for 1 of 3 residents (R19) reviewed for falls. Findings include: Smoking: R27's quarterly Minimum Data Set (MDS) dated [DATE], indicated R27 had diagnoses of dementia, [CONDITION(S)], [CONDITION(S)] or [CONDITION(S)] and was moderately cognitively impaired. The MDS indicated R27 was independent with bed mobility, transfers, toileting, eating and required staff assistance with dressing, bathing and personal hygiene. R27's care plan revised on 5/21/21, indicated R27 had a potential for smoking related incidents and required staff assistance with smoking. The care plan listed various interventions which included: R27 would have access to a wireless pendant to call for assistance when needed, R27 would utilize a smoking apron, smoking materials would be kept in a cling drawer on the nurses cart and staff were to observe for burn holes in clothing and for [CONDITION(S)] to skin after smoking. R27's Nursing Aid sheet dated 6/8/21, indicated the nursing assistant (NA) was to escort R27 outside, set up smoking materials, put smoking apron on, provide R27 with a pendant and then R27 was independent. R27's Smoking Risk assessment dated [DATE], indicated R27 was slightly impaired, had vision impairment, full hand dexterity, had safe smoking practices and was moderately independent with safety awareness for decision making and problem solving. The assessment indicated R27 was a low smoking risk. During observations on 6/7/21, at 3:13 p.m. R27 asked license practical nurse (LPN)-B for a cigarette. LPN-B went over to the medication cart and obtained a cigarette from the drawer. R 27 walked independently with his four wheeled walker (FWW) with LPN-B down the hallways to the back door of the nursing home. R27 sat down on a bench outside of the nursing home independently, LPN-B placed R27's smoking apron on him, gave R27 his cigarette, got a lighter out of the seat of R27's walker, lit his cigarette for him, put R27's light back in the seat of his walker and immediately came back into the nursing home. R27 began to smoke independently. - at 3:20 p.m. R27 was done smoking and independently took his smoking apron off, folded it and hung it on the side of his walker. R27 proceeded to walk independently with walker back into the facility and went directly to his room. R27 was not observed to have his call light pendant with him and staff were not observed to check R27 when he came back in from smoking for burn holes to his clothing or [CONDITION(S)] to his skin. R27 continued to have his lighter in his walker and did not take it the nurses station to be stored in the medication cart. On 6/8/21, at 1:07 p.m. R27 walked independently to the nurses station and asked registered nurse (RN)-A for a cigarette. RN-A proceeded to get a cigarette out of the top drawer of the medication cart, handed the cigarette to R27 and he put it inside of the seat of his walker. R27 and RN-A walked down the hallway together to the back door and RN-A told R27 she would put his apron on when he got there. RN-A assisted R27 out the back door, he sat down on the bench outside of the back door, RN-A placed his smoking apron on him and immediately went back into the building. R27 got his cigarette out of his walker seat, lit it independently, put his lighter back in the seat of his walker and began to smoke. R27 had his call light pendant attached to his left wrist. R27 indicated he was suppose to wear his call light pendant at all times, could not find it, had to go to his room to look for it and found it in his drawer. - at 1:18 p.m. R27 was done smoking, put cigarette in receptacle on the wall, got up independently with walker, walked into the facility with his smoking apron hanging from his neck and began to walk back to his room. R27 was standing outside of his room with the smoking apron hanging around his neck, when NA-A walked by, said how are you doing and continued to walk towards the dining room area. R27 entered his room and shut the door. Staff were not observed to check R27 when he came back in from smoking for burn holes to his clothing or [CONDITION(S)] to his skin. R27 continued to have his lighter in his walker and did not take it the nurses station to be stored in the medication cart. - at 2:31 p.m. R27 was laying in bed resting and indicated he always had his lighter on him and kept it in his walker. R27 indicated he received his cigarettes from the nurses at the nurses station and he had to have this thing on his wrist to call (call light pendant). R27 indicated he did not wear his call light pendant all the time and wore it periodically. - at 2:42 p.m. R27 was noted to be outside smoking independently and continued to have his lighter stored in the seat of his walker. On 6/12/21, at 11:13 a.m. NA-A confirmed R27 routinely smoked, his smoking materials were to be locked up and R27 would ask for a cigarette when he wanted to smoke. NA-A indicated staff assisted R27 with his smoking apron and he was independent with smoking after that. NA-A indicated R27 kept his lighter in his walker at all times and staff assisted R27 with filling his lighter with lighter fluid. NA-A indicated R27 usually went back to his room after he was done smoking and indicated they did not check on R27 after he smoked. NA-A confirmed R27's care plan and indicated they should have been following it. NA-A indicated R27 should have been wearing his call light pendant when he went outside to smoke and stated they could not find it. On 6/10/21, at 11:22 a.m. LPN- A confirmed R27 smoked and verified R27 was to have his cigarettes and lighter locked in the medication cart at all times. LPN-A indicated she would expect staff to follow R27's care plan and to make sure he was safe. On 6/10/21, at 11:35 a.m. the director of nursing (DON) confirmed R27 routinely smoked and was grandfathered in when they went to a smoke free building. The DON indicated R27 went to the nurses station to get his cigarette and lighter from facility staff. The DON stated staff assisted R27 with his smoking apron, made sure he had his call light pendant and was able to smoke independently after that. The DON indicated staff should have been following R27's care plan when he went out to smoke. Review of facility policy titled, Resident Smoking revised on 10/23/17, indicated St. [NAME] Health Services of [NAME] would provide a safe and healthy environment for residents. Smoking was forbidden anywhere on property grounds, with exception of grandfathered in residents and the residents smoking would be care planned. Oxygen use: R30's quarterly MDS dated [DATE], indicated R30 had diagnoses of diabetes, anxiety disorder, [CONDITION(S)] ([CONDITION(S)]) and was cognitively intact. The MDS indicated R30 was independent with bed mobility, transfers, toileting, eating, dressing, bathing and personal hygiene. The MDS further identified R30 required oxygen therapy. R30's care plan revised on 11/19/20, indicated R30 had shortness of breath (SOB) related to [CONDITION(S)], allergies, trouble breathing or SOB when lying flat. The care plan listed various interventions and instructed staff to administer oxygen as ordered and to monitor for and be present to render support to prevent anxiety if episodes of SOB occur. R30's General Nurses Observation dated 5/10/21, identified R30 continued to experience SOB related to [CONDITION(S)], allergies and trouble breathing. The assessment indicated R30 required continuous oxygen use of three liters via nasal cannula, used a concentrator in her room and had a portable oxygen tank on her walker. During observations on 6/7/21, at 2:34 p.m. R30 was seated in a chair in her room, had oxygen vial nasal cannula and had her FWW across from her with her portable oxygen cylinder seated in her FWW. The oxygen cylinder was not safely secured to her FWW. -at 5:22 p.m. R30 was seated at the dining room table, had her oxygen on via nasal cannula and was visiting with other residents after lunch. R30 was noted to have her FWW at her side. R30's FWW had the lid of the seat open and contained a small cylinder of oxygen covered by a black carrying case. The oxygen cylinder was not safely secured to her walker. - at 7:21 p.m. R30 was seated in a chair in her room, had oxygen on vial nasal cannula and had her FWW across from her with her portable oxygen cylinder seated in her FWW. The oxygen cylinder was not safely secured to her FWW. During observations on 6/8/21, R30 was seated in a chair in her room, had oxygen on vial nasal cannula and had her FWW across from her with her portable oxygen cylinder seated in her FWW. The oxygen cylinder was not safely secured to her FWW. - at 12:54 p.m. R30 was seated at the dining room table, had her oxygen on via nasal cannula and was visiting with other residents after lunch. R30 was noted to have her FWW at her side. R30's FWW had the lid of the seat open and contained a small cylinder of oxygen covered by a black carrying case. The oxygen cylinder was not safely secured to her FWW. - at 12:55 p.m. R30 got up from the dining room table independently and began to walk down the hall independently with her FWW. R30 proceeded to walk the entire length of two long hallways back to her room, switched out her oxygen from the portable oxygen cylinder seated in the seat of her walker to the concentrator in her room and sat down on the chair in her room. R30's portable oxygen tank was not secured to her walker. - at 1:22 p.m. R30 was seated in her chair in her room with her eyes closed and her portable oxygen cylinder continued to be unsecured in the seat of her FWW. - at 1:52 p.m. R30 was walking down the hallway independently with her FWW towards the main entrance of the building and had her oxygen on via nasal cannula and sat down in a chair . R30 was noted to have her portable oxygen cylinder seated in the seat of her FWW and was unsecured. - at 2:25 p.m. R30 continued to be seated in a chair out by the main entrance and listened to bible study with several other residents. - at 2:37 p.m. R30 walked back to her room independently after bible study was over and continued to have her oxygen on via nasal cannula. R30's portable oxygen cylinder continued to be in the seat of her FWW and was not safely secured to her walker. During observations on 6/9/21, at 7:38 a.m. R30 was seated at the dining room table, had her oxygen on via nasal cannula and was visiting with other residents during breakfast. R30 was noted to have her FWW at her side. R30's FWW had the lid of the seat open and contained a small cylinder of oxygen covered by a black carrying case. The oxygen cylinder was not safely secured to her walker. - at 8:07 a.m. R30 got up from the dining room table independently and began to walk down the hall independently with her FWW. R30 proceeded to walk the entire length of two long hallways back to her room, switched out her oxygen from the portable oxygen cylinder seated in the seat of her walker to the concentrator in her room and sat down on the chair in her room. R30's portable oxygen tank was not safely secured to her walker. - at 12:16 p.m. R30 was seated at the dining room table with other residents eating lunch and R30 continued to have her oxygen on via nasal cannula and was noted to have her FWW at her side. R30's portable oxygen cylinder was not safely secured in her FWW. On 6/9/21, at 8:15 a.m. R30 confirmed she used oxygen continuously and indicated she took care of the oxygen herself. R30 indicated staff would check her oxygen cylinder and get her a new one when it was empty. R30 indicated she has always had her portable oxygen cylinder in the seat of her walker. On 6/10/21, at 9:17 a.m. NA-A confirmed R30 used oxygen via nasal cannula continuously and indicated they would assist R30 with her portable oxygen tank when it needed to be replaced. NA-A indicated R30 was independent with switching her oxygen from her portable cylinder in her walker to her concentrator in her room. NA-A indicated R30 always had her portable oxygen cylinder in the seat of her FWW and stated it was convenient for R30. NA-A indicated this was not a safe practice and stated the oxygen cylinder should have been secured to her FWW. NA-A indicated if R30 had a fall the oxygen cylinder could have exploded. On 6/10/21, at 9:25 a.m. the DON confirmed the above finding and indicated the portable oxygen cylinder needed to be secured to R30's FWW. The DON indicated her expectations would be for staff to make sure the oxygen cylinder was secured, so it would not fall out of her walker. The DON indicated it could have potentially exploded and indicted she would have expected staff to follow the facility policy regarding portable oxygen use. Review of facility policy titled, Accident/Incident reviewed on 1/18/18, indicated the facility would establish guidelines and procedures that adequately identified, assessed, treated, and prevented accidents and incidents that placed the resident at risk for injury. Review of facility policy titled, Oxygen reviewed on 5/14/18, indicated the facility stored and distributed oxygen in a safe manner. The facility staff were provided with direction on proper storage and distribution of oxygen to ensure resident safety. Falls: R19's significant change Minimum Data Set (MDS) dated [DATE], identified R19 had diagnoses which included gastro-esophegeal reflux disease, arthritis, dementia and was cognitively intact. The MDS identified R10 required extensive assistance from staff for bed mobility, transfers, ambulation, dressing, toileting, and personal hygiene. The MDS further identified R19 was not steady with moving from a seated to a standing position, walking, turning around facing opposite direction while walking, moving on and off the toilet, surface to surface transfers and needed staff assistance to stabilize. The MDS further identified R19 utilized a wheelchair, a walker and had no falls from prior assessment. R19's Fall Risk assessment dated [DATE], indicated R19 was at risk for falls. R19's care plan revised 3/11/21, indicated R19 was at risk for falls or injury related to cognitive and physical deficits. The care plan indicated R19 required staff assistance as needed for mobility and transfers. The care plan listed various interventions which included non- skid strips on floor in front of recliner and gripper socks or shoes at all times when up. R19's Nursing Aid Care Sheet dated 6/8/21, indicated R19 required staff assistance as needed using a FWW for ambulation. The care sheet further indicated staff were to encourage R19 to wear gripper socks, attach her call light to a blanket or grab bar and have a night light on at night. R19's Fall Scene Investigation Report dated 4/2/21, indicated R19 removed her shoes, walked to the door to shut it and slid onto the floor. Immediate intervention was to place grip strips in the room around door area. Care plan was followed. During observations on 6/8/21, at 1:20 p.m. R19 was laying in bed on her right side covered up with a blanket and sleeping. R19's floor did not have non- skid strips on floor in front of recliner/door. During observations on 6/9/21, at 7:24 a.m. R19 was laying in bed on her right side covered up with a blanket and sleeping. - at 11:00 a.m. R19 was seated on the edge of her bed and was drinking a malt. R19 was observed not to have her grippy socks on her feet and R19 indicated she put them on when she was up. - at 11:27 a.m. R19 was dressed, had no grippy socks on her feet, was laying in bed and talking to her daughter on the phone. R19 was not observed to have grippy socks on nor was R19's floor observed to have non- skid strips on floor in front of recliner/door. During observations on 6/10/21, at 8:46 a.m. R19 was laying in bed on her right side covered up with a blanket and sleeping. R19's floor did not have non- skid strips on floor in front of recliner/door. On 6/10/21, at 10:13 a.m. NA-B verified R19 required staff assistance with activities of daily living (ADL's) and ambulation. NA-A indicated R19 would at times self transfer herself and was a fall risk and had fallen in the past. NA-B indicated R19 was to wear grippy socks, have a night light on at night and her call light within reach. NA-B was not aware of the care planned intervention of the non-skid strips next to R19's recliner/door. On 6/10/21, at 10:19 a.m. LPN-A indicated R19 required stand by assist with transfers and ambulation. LPN-A indicated R19 would self transfer herself at times and was a fall risk. LPN-A verified R19 did not have non- skid strips on the floor by her recliner/door and indicated her expectations were for staff to follow R19's care plan and for it to be corrected immediately. On 6/10/21, at 10:27 a.m. DON confirmed R19 was a fall risk and needed staff assistance with ADL's, transfers and ambulation. The DON indicated R19 would self transfer at times and did not always use her call light. The DON confirmed R19 did not have non-skid strips next to her recliner/door. There DON verified R19's care plan and indicated she would expect staff to follow the care plan, put the intervention in place to prevent further falls and to follow the facility policy. Review of facility policy titled, Fall Prevention and Management revised on 10/12/17, indicated the facility would assess each resident for their fall risk and would identify interventions to help prevent falls, and/or to prevent injuries from falls.

Based on observation, interview, and document review the facility failed to implement appropriate hand hygiene for 1 of 1 staff (housekeeper (H)-A) and failed to identify appropriate signage for transmission based precautions (TBP) on 2 of 2 residents rooms (R2, R3) who were on isolation precautions and required assistance with activities of daily living, in accordance with Centers for Disease Control (CDC) and Centers for Medicare and Medicaid Services (CMS) guidelines for COVID-19. Findings include: HAND HYGIENE Observation on 12/19/20 at 11:56 a.m., of housekeeper (H)-A identified after cleaning the toilet in the community tub room, H-A her removed gloves and placed them in the garbage container. Without sanitizing her hands, she walked down the hall to resident R1's room. H-A entered R1's room. R1 sat in wheel chair positioned by the window. H-A stood next to R1's wheel chair, adjusted the window blinds, opened the window, touched R1's hand, and repositioned R1's wheelchair and bedside table. H-A exited room and did not sanitize her hands. Without sanitizing her hands, H-A walked down hallway to the housekeeping cart, applied new gloves, and re-entered the residents' community tub bathroom and mopped the floor. Interview on 12/19/20 at 12:15 p.m., H-A identified she had cleaned the toilet and removed her gloves. She agreed she had failed to sanitize her hands prior to entering R-A's room, provide personal assistance for R, and sanitize her hands before returning to her duties. H-A confirmed she usually wore gloves when she entered a resident's room. The facility policy required staff to sanitize their hands prior to entering and exiting resident rooms. Interview on 12/19/20 at 1:00 p.m., with licensed practical nurse (LPN)-A verified all staff were expected to wash or sanitize their hands prior to entering and exiting a resident's, and after removal of gloves. Interview on 12/19/20 at 1:16 p.m., with nursing assistant (NA)-A confirmed all staff were expected to wash or sanitize their hands prior to entering and exiting a resident's room, after removal of gloves, and in between cares for each resident. Interview on 12/19/20 at 1:50 p.m. with the director of nursing (DON) identified she expected all staff to perform hand hygiene with an alcohol based product to sanitize their hands prior to entering and leaving a resident's room, and after the removal of gloves. Review of the 5/18/17, Hand Hygiene policy identified it directed staff to sanitize hands with an alcohol based hand sanitizer before and after assisting a resident when not in contact with bodily fluids, before and after contact with environmental surfaces or equipment in the immediate vicinity of the resident, between glove charges, and before leaving the resident's room. There was no documentation to support the policy was reviewed annually required by federal regulation. SIGNAGE FOR TBP Review of R2's and R3's current, nursing assistant care sheets identified R2 and R3 required full personal protective equipment (PPE) during cares and were on isolation for 14 days and started on 12/15/20 and ends 12/28/20 Observation on 12/18/20 at 10:15 a.m. of R2's door identified a sign in sheet was posted on the outside of the door for staff to sign into his room. R2 had a night stand outside of his room which contained PPE (gloves, gowns, masks). During this time two staff members donned their PPE, indicated R2 was in quarantine due to coming in contact with worker that had tested positive for COVID and proceeded to enter R2's room. R2's room was not observed to have any signs posted outside of his room indicating what type of isolation precautions he was on and what type of PPE staff were required to use when entering his room. Observation on 12/18/20 at 10:46 a.m., of R3's door identified a sign in sheet posted on the outside of the door for staff to sign into her room. R3 had a night stand outside the right hand side of her room which contained PPE (gloves, gowns, masks). R3's room was not observed to have any signs posted outside of her room indicating what type of isolation precautions she was on or what type of PPE staff were required to use when entering her room. Interview on 12/18/20 at 12:10 p.m. with nurse aide (NA)-B identified R3 and R2 were currently in isolation after being exposed to a staff member that tested positive for COVID. Neither resident had signage posted outside of her room indicating what type of isolation precautions they were on or what type of PPE staff were required to use when entering their rooms. Interview on 12/18/20 at 12:56 p.m., with trained medication aid (TMA)-A confirmed R2 and R3 were currently in isolation precautions due to another staff member coming in contact with them that tested positive for COVID. The TMA-A verified the doors had no signs posted outside of their rooms indicating what type of isolation precautions they were on and what kind of PPE was to be used by staff when entering their rooms. The TMA-A indicated a sign should be posted outside the room to notify staff and others of what kind of precautions the residents are currently on. Interview on 12/18/20 at 1:24 p.m. the director of nursing (DON) confirmed the above finding and indicated R2 and R3 are on full droplet precautions due to being exposed to a staff member that tested positive for COVID. The DON indicated when a resident goes into isolation she would expect staff to post the stop sign on the outside of the residents door to alert people they are on isolation precautions and to make sure the proper precautions are taken. Review of the 6/7/17, Transmission Based Precautions policy indicated staff were to post the appropriate notice on the room entrance door and in the resident chart so that all personnel would be aware of precautions, or be aware they must first see the nurse to obtain additional information about the situation before entering the room.

Based on observation, interview, and document review, the facility failed to ensure insulin pens were properly labeled accurately to include directions for administration for 5 of 5 residents (R10, R15, R16, R20, R24) who received insulin injections. Findings include: R10's Physician order [REDACTED]. The order sheet included an order for [REDACTED]. R15's Physician order [REDACTED]. R15's order sheet included orders: - [MEDICATION NAME] (insulin [MEDICATION NAME]) 100 units/milliliters (ml) (3ml) insulin pen: insulin subcutaneous two times per day at 8:00 a.m. and 8:00 p.m. inject 66 units. - [MEDICATION NAME] (insulin [MEDICATION NAME]) 100 units/ml insulin pen: Insulin subcutaneous three times per day at 8:00 a.m., 12:00 p.m. and 5:00 p.m. inject 44 units. R16's Physician order [REDACTED]. R16's order sheet included order: -[MEDICATION NAME] (insulin [MEDICATION NAME]) 100 units/milliliters (ml) (3ml) insulin pen: one time per day at 7:30 a.m. inject 70 units subcutaneous every morning. - [MEDICATION NAME] (insulin [MEDICATION NAME]) 100 units/ml insulin pen: inject 34 units before meals three times a day at 7:30 a.m., 11:30 a.m. and 4:30 p.m. R20's Physician order [REDACTED]. R20's order sheet included orders: - [MEDICATION NAME] (insulin [MEDICATION NAME]) 100 units/milliliters (ml) (3ml) insulin pen: one time per day at 8:00 p.m. inject 60 units subcutaneous. - Humolog Kwikpen U-100 (insulin [MEDICATION NAME]) 100 units/ml insulin pen: inject 15 units three times a day at 7:30 a.m., 11:30 a.m. and 4:30 p.m. R24's Physician order [REDACTED]. R24's order sheet included an order for [REDACTED]. On 6/3/19 at 4:55 p.m. during observation of the treatment/insulin cart with licensed practical nurse (LPN)-B present. The insulin pens for R10, R15, R16, R20 and R24's had a label that contained the prescription number, the residents name, what kind of insulin it was, the physicians name and the name of the pharmacy was on the insulin pens. LPN-B confirmed the insulin pens lacked a proper pharmacy label with instructions for use and indicated pharmacy did not label the pens with instructions. LPN-B indicated the pharmacy only labeled the boxes the insulin pens come in which are kept in the fridge in the medication room. LPN-B indicated she felt the pharmacy should know the insulin pens needed to be labeled properly. On 6/3/19 at 5:01 p.m. registered nurse (RN)-A confirmed findings and indicated the insulin pens should have been properly labeled and the pharmacy knows they need to be labeled properly. On 6/3/19 at 5:42 p.m. chief pharmacist (CP) confirmed the insulin pens only contained the following information on the label such as: prescription number, the resident's name, what kind of insulin it was, the physicians name and the name of the pharmacy. The CP indicated the pharmacy would be labeling the insulin pens individually from now on. On 6/6/19 at 3:24 p.m. the director of nursing (DON) verified the above finding and confirmed R10, R15, R16, R20 and R24's insulin pens were not properly labeled. The DON indicated she would expect staff to make sure every insulin pen was properly labeled with instructions for use and to flag with direction sticker if the prescription had changed. Review of facility policy titled, Medication Administration Policy and Procedures reviewed on 2/2011, indicated no medications can be administered without a proper label.

Based on observation, interview and record review, the facility failed to conduct a comprehensive falls assessment to determine effective interventions for 1 of 1 resident (R29) who had a history of [REDACTED]. This deficient practice resulted in immediate jeopardy for R29. The immediate jeopardy began on 6/12/17, when R29 had not been comprehensively assessed for the root cause of repeated attempts of self transfer and appropriate interventions implemented and was identified on 9/21/17. The administrator and director of nursing (DON) were notified of the immediate jeopardy at 11:09 a.m. on 9/21/17. The immediate jeopardy was removed at 3:39 p.m. on 9/22/17, but noncompliance remained at the lower G scope and severity level, which indicated actual harm that is not immediate jeopardy. Findings include; Review of R29's signed Physician order [REDACTED]. R29's quarterly Minimum Data Set ((MDS) dated [DATE], identified R29 had [DIAGNOSES REDACTED]. The MDS listed R29 had severe cognitive impairment, and required extensive assistance with dressing, hygiene, toileting, transfers and locomotion. Further, the MDS identified R29 had a fall since the prior assessment. R29's significant change MDS dated [DATE], identified R29 had severe cognitive impairment, required extensive assistance with dressing, hygiene, eating and locomotion, total assistance with transfers, toileting and did not walk. The MDS identified they were unable to determine if R29 had a fall or fracture since the prior assessment. The MDS also identified R29 had no falls since the prior assessment. However, R29 had sustained a fall with major injury noted on 6/12/17, a fall with no injury on 7/8/17 and a fall with major injury on 8/20/17. R29's Fall Risk Care Area Assessment (CAA) dated 9/7/17, indicated R29 was at risk for falls. The CAA indicated R29 had a history of [REDACTED]. The CAA further indicated R29 had sustained a left hip fracture from the fall. The CAA indicated R29 had recent return from hospital, therapy department was working with R29 and safety precautions remained in place. Staff were alert to R29's risk factors for fall potential. R29's Fall Risk assessment dated [DATE], identified R29 had a score of 24. The assessment indicated a resident whose score was over 9 was at risk for falls. No further Fall Risk Assessments were provided by facility. Review of R29's current care plan printed on 9/20/17, at 3:04 p.m., last updated 8/21/17, at 3:23 p.m., identified R29 had dementia, and was at risk for falls due to cognitive deficits. R29's care plan listed various interventions which included: use of a low bed, perimeter mattress, resident did not remember that she needed assistance with transfer or ambulate and directed to anticipate needs, inspect shoes/footwear for proper fit, reduced slip shoes, keep call light in easy reach, no skid strips in front of toilet, alarm on bathroom door to alert entering, gripper socks in bed, and safety bed/chair alarms and floor mat alarms for resident at all times. Review of the facility form titled NAR (nursing assistant registered) Care Sheet, dated 9/20/17, directed staff to use 2 staff for transfers, and safety devices included alarm BR (bathroom) door TABS and wanderguard. No further fall interventions were listed on the care sheet. On 9/19/17, at 11: 33 a.m. R29 was observed lying in her bed on her right side. Her bed was in a low position, and observed to have bilateral grab bars in place and a concave mattress. She had a colored mat located on the floor on the right side of her bed and a black pressure floor mat was present on the left side of her bed. She had a white rectangular box (TABS alarm unit) attached to the left grab bar on her bed, with a string running from the box to her shirt on her mid upper back. On 9/20/17, at 2:17 p.m. R29 was observed lying in bed with the head of bed slightly elevated. The bed was in low position. Grab bars were observed in place and a concave mattress was on the bed. She had a TABS alarm unit attached to the left grab bar. The string from the unit was attached to her shirt with a metal clip on the front of her left shoulder. A black pressure floor mat alarm was in place on the left side of her bed, and a colored padded mat was on the floor on the right side of her bed. On 9/21/17, at 5:28 a.m. R29 was observed lying on her back with eyes closed in her bed. The bed was in low position and had a concave mattress. There was a black pressure floor alarm on the floor near the left side of her bed and a colored padded mat on the floor on the right side of her bed. The TABS alarm unit was attached to the left grab bar with a red cord leading from the tab unit to under her back. Review of R29's Incident Details/Fall Scene Investigation Reports from 11/29/16 to 9/18/17, revealed the following: -11/29/16, at 1:20 a.m. found on floor next to her bed, alert. The wheelchair was in front of her, brakes not on, and stockings were on her feet. The report identified R29 had socks on feet and slipped while attempting self transfer. The report indicated gripper socks were to be applied at bedtime, no alarms were utilized at the time of the fall, and no injury noted. An IDT (interdisciplinary team) meeting note dated 12/5/16, identified the root cause of fall was R29 self transferring and improper footwear. Gripper socks were applied to feet and maintenance was notified to place gripper strips next to the bed. -11/29/16, at 10:20 p.m. found on the floor next to her bed. R29 was disorientated, incontinent of loose stool, stated she had been reaching for a stool, although she pointed to her nightstand. The report listed R29 had gripper socks on, and wore shoes on her feet. Staff were unaware when R29 had last toileted. An IDT meeting note dated 12/5/16, identified the root cause of fall was R29 self transferring and loose stools. Nurse to monitor BM pattern, move night stand closer to bed so resident able to reach from bed, TABS alarms applied. -12/4/16, at 2:07 p.m. staff heard a loud sound and found sitting on the floor in front of her nightstand. R29 was disorientated, stated my wrist and rubbed her wrist, no injury noted. Staff looked under her bed and retrieved a bracelet on the floor under the bed. The bracelet was placed on R29's wrist. An IDT meeting note dated 12/5/16, identified the root cause of the fall was R29 resident appeared to attempt to get bracelet that fell under her bed when lost balance and fell off of bed. Evaluation sent to therapy in regards to number of falls. -1/24/17, at 6:50 p.m. staff had been assisting roommate and noticed R29 on the floor in her room outside her bathroom. R29 was disorientated, appeared to attempt self transfer, wheelchair alarm had been unhooked from resident and not sounding. No injuries were noted and a pad alarm placed in her wheelchair. An IDT meeting note dated 1/30/17, identified the root cause of fall was R29 slipped out of wheelchair while attempting self transfer. R29 had removed TABS alarm from self. Pad alarm was placed in chair as R29 disabled the TABS alarm. - 2/6/17, at 6:30 p.m. found sitting on the floor near the conference room, with her back leaning against a geri-chair. R29 was disorientated, wheelchair next to her, with brakes on. TABS alarm had been attached to resident, resident removed clip, alarm not sounding. No injury noted. The report identified R29 had self transferred to a geri-chair which was stored in front of the conference room. The geri-chair was removed from the common area and properly stored in the conference room with doors shut. No IDT meeting notes were found. -2/12/17, at 7:20 p.m. found on floor with her back against the wall, in her bathroom. R29's mental status was normal for her, and had fall while self transferring. She had removed the wheelchair alarm, which had been hooked on the back of her shirt. The report listed a secondary alarm on the bathroom floor, had not been activated by staff. R29 expressed some discomfort across her upper torso and chest area, and a chest x-ray completed on 2/13/17, revealed no acute findings. Staff educated on the use of the secondary alarm, toileting plan. An IDT meeting note dated 2/13/17, identified R29 had taken self to toilet and fell . TABS alarm was placed on bathroom door to alert staff of taking self to toilet. An addendum dated 9/20/17, (during survey) identified the care plan was not followed as bathroom door alarm had already been in place. The notes did not address how to deal with R29 removing alarms. -3/28/17, at 7:45 p.m. found on the floor in her room near her bed. R29 was disorientated, and indicated she was going to bed. No injury noted. No alarm was observed on her wheelchair at that time. Wheelchair alarm applied at that time. An IDT meeting note dated 4/3/17, identified R29 had been attempting to transfer self into bed and fell . The note indicated R29's care plan had been followed, the immediate intervention put in place was the use of a TABS alarm on the wheelchair to alert staff of any self transfer. However, R29's clinical record indicated the alarm on her wheelchair had been in place during R29's 1/24/17, 2/6/17, and 2/12/17 falls and a pad alarm had been placed on R29's wheelchair after R29's 1/24/17 fall. The note lacked any further documentation of analysis of R29's fall. -6/12/17, at 8:00 a.m. during a.m. cares R29 was disorientated, and complained of discomfort in her right shoulder with movement. A bruise on the top of her right clavicle region was noted, with swelling around the site. A scrape below her right knee was also noted. R29 winced with discomfort with movement of the area. The report indicated R29 reported, I fell and denied any assistance after the fall. The report listed staff were to use 2 for all transfers with a gait belt until after the portable x-ray was completed. The report indicated a portable x-ray done identified a fracture of her distal right clavicle. The record included written statements from staff dated which noted R29 had been assisted to bed at approximately 6:30 p.m. on 6/11/17 and had no visible bruises and no complaints of pain at that time. The staff statement indicated 5:00 a.m. rounds had been completed on 6/12/17 and she was sleeping at that time and no complaints of pain. A staff written statement, dated 6/13/17 indicated the staff member had assisted R29 with morning cares on 6/12/17. The statement indicated during cares, R29 had indicated her arm hurt and staff found bruises on her shoulder and front of her right leg. The record also included written statements from 6/13/17, which indicated R29's bed had been unable to be put in low position a week prior and maintenance personnel had been notified of the broken bed. Maintenance had determined new parts for the bed needed to be ordered, and adjusted the bed to the lowest position, and would remain in that position until the new part installed. The written statement from maintenance personnel dated 6/13/17 indicated he had set the bed in approximately 3 inches higher than the lowest position possible, ordered the needed parts for the bed and installed the parts on 6/13/17. An IDT meeting note dated 6/13/17, indicated R29 had been noted to have bruising and complaints of pain in her right shoulder during morning cares. The note indicated staff had asked R29 what happened and she had stated she fell and nobody had helped her get up. R29's care plan was revised to include 2 assist for transfers at that time. No documentation of further investigation of the cause of R29's injury was noted, no further analysis of the effectiveness/use or function of the safety devices in place had been completed. - 7/8/17, at 8:55 a.m. R29 was found lying on her side on the floor, in the doorway of another resident's bathroom. The report listed R29 had unhooked her alarm, gotten up without assistance, removed her shoes and TABS alarm and was in stocking feet. No injuries noted. A TABS alarm pressure pad was placed in her wheelchair to alert staff to her needs. An IDT meeting note dated 7/10/17, indicated R29 was found crawling on the floor outside of another resident's bathroom. The note indicated R29 had no injury, and care plan had been followed. The immediate intervention was for implementation of a pressure pad in her wheelchair to alert staff to self transfers. No further analysis of the fall was documented. However, R29's clinical record indicated a pad alarm had been placed on R29's wheelchair after the 1/24/17 fall. Despite the facility having knowledge R29 repeatedly removed/unhooked alarms previously, analysis of R29's fall interventions and use of alarms had not been completed. -8/20/17, at 12:45 a.m. staff heard a noise and found R29 on the floor outside her room, with her walker in her room. R29 was disorientated and indicated she was going to close the door and buff the floor. The report identified R29 had been observed earlier in the shift taking alarms off herself. R29 denied discomfort at that time. The report indicated staff were to place bed alarm out of resident sight and reach, so she would not take off the alarm or turn the alarm off. On 8/21/17, R29 indicated she had discomfort in her left leg and hip area, guarding of the area and was unwilling to transfer. A x-ray completed at that time, identified an acute intertrochanteric fracture of the left femur associated with 90 degrees varus angulation of the femoral shaft fragment. An IDT meeting note dated 8/22/17, identified staff noted that R29 had removed her TABS alarm earlier in the shift and was talking delusional and was unsettled earlier in the shift. The note indicated the immediate intervention was to reapply the TABS alarm and place where she could not remove it herself. The note indicated on 8/21/17, R29 had complained of left leg and hip pain, guarded leg and was unwilling to transfer. Further, the note indicated R29 had been transferred to the hospital for evaluation of a left hip fracture. The note indicated R29's care plan had been followed. No further analysis of R29's fall was documented. However, despite R29's repeated removal/unhook of alarms, no other interventions had been implemented prior to R29's fall on 8/20/17. Review of R29's progress notes from 11/29/16 to 9/20/17, revealed the following: -11/29/16, at 1:30 a.m. R29 was found on floor, sitting next to bed, wheelchair in front of her, brakes not locked. Denied pain. Was in stocking feet, gripper socks applied. Maintenance notified to put down grippy strips next to her bed. Hourly checks tonight for safety. -11/29/16, at 10:29 p.m. R29 was found sitting on floor next to her bed. Was wearing gripper socks and shoes. Her wheelchair was behind her. Denied pain. R29 indicated she was reaching for stool, but pointed towards nightstand. Put back into bed, TABS alarm in place. -12/4/16, at 2:25 p.m. staff heard loud sound, found R29 on the floor in front of her nightstand. R29 indicated her wrist and rubbed it. Looked under bed and found bracelet, retrieved and placed bracelet on R29's wrist. No injury noted. -12/6/16, at 7:39 a.m. R29 identified as fall risk with safety interventions in place. Has had falls this quarter. Last fall 12/4/16. Grab bars and perimeter mattress used. -12/12/16, at 1:30 p.m. Therapy evaluation completed. R29 was appropriate for activity therapy services. Review of R29 identified she had multiple falls and review of safety interventions in place completed. -1/16/17, Discontinued from active therapy. Restorative AROM(active range of motion)/Toileting program to continue. -1/24/17, at 11: 58 p.m. R29 was found on the floor outside the bathroom at 6:50 p.m. No injury noted. Placed a pad alarm on chair. Cause of fall identified alarm was on chair and unhooked. -2/6/17, at 7:23 p.m. R29 was found at 6:30 p.m. sitting on floor with back leaning against Geri-chair with wheelchair next to resident with brakes on. R29 had removed the clip from the alarm and it was not sounding. No injury noted. Geri-chair removed from common area and properly stored in conference room with doors shut. -2/12/17, at 10:56 a.m. R29 was found sitting on floor of bathroom. R29 had self transferred. R29 complained of chest pain and mid area sharp. Message left for primary physician. -3/13/17, at 1:35 p.m. R29 had falls in last quarter. Last fall was 2/12/17. Note indicated R29 had severe cognitive impairment with a BIMS score of 5. R29 has rolled out of bed in the last 3 months and a perimeter mattress is used. R29 has history of chest pain from previous fall. The follow up x-ray indicated no fracture. -3/20/17, at 4:31 p.m. note indicated R29 recognized objects and people, but did not recognize place, time or situation -5/21/17, at 1:49 p.m. note indicated a review of R29's safety devices was completed. Falls risk assessment indicated she was at risk for falls. Does wander in wheelchair. Is inconsistent in asking for help and does attempt independent transfer in and out of bed and chair. Currently using an alarm on bathroom door and alarms used in bed, wheelchair and lift chair. Toileting program remains in place. Will continue usage of alarms in plan of care. -6/8/17, at 2:14 p.m. At risk for falls, R29 had had falls this quarter, last fall 3/28/17, and safety interventions in place. R29 has severe cognitive impairment and disorientated to time and place. Last noted fall from bed was 3/28/17, and R29 had a perimeter mattress in place. No changes to bowel and bladder assessment or interventions. No changes or updates to plan of care. -6/12/17, at 8:15 a.m. R29 grabbed and squeezed right shoulder winced and complained of pain. R29 had a bruise on top of her right clavicle region, swelling was noted around the site. A scrape was noted also below R29's right knee. R29 stated she fell when asked, and when asked if anyone helped her she shook her head no. R29's primary physician was notified and orders were received for a PPX (portable x-ray). Two staff assistance for R29 with all transfers and transfer belt until PPX completed. -6/12/17, at 7:59 p.m. results of x-ray indicated fracture of distal right clavicle. R29's primary physician was notified. -6/13/17, at 5:29 p.m. R29 had increased difficulty with transfers since incident. R29's primary physician was called and new orders received for clavicle strap to use as needed for comfort and physical therapy may evaluate and treat to direct safe transfers. -6/14/17, at 1:52 p.m. A care conference was held and 90 day assessments were completed. Assessment indicated falls, wanderguard, bed/chair/floor alarms, bed low, anti-roll backs. No further documentation related fall assessment documented. -6/30/17, at 10:11 p.m. R29 was very anxious and attempting to get out the doors of the facility. Staff explained this was her home. -7/5/17, at 2:27 a.m. R29 was up in her wheelchair from 12:10 a.m. to 2:00 a.m. R29 had wheeled herself to the north and south doors and both times the alarm went off. -7/5/17, at 3:16 p.m. new order from primary physician to discontinue the clavicle strap, to do a follow up clavicle x-ray and for physical and occupational therapy to evaluate and treat for post clavicle fracture. -7/8/17, at 5:53 p.m. R29 was in another resident's bathroom doorway lying on her right side. R29 had removed her shoes and removed her TABS alarm. No injury noted. A TABS pressure alarm was placed in her wheelchair seat. Further, the note included Remember, alarms do not prevent falls, they just alert staff to resident whereabouts, so if not alarming, is not included as care plan not being followed, therefore is not reportable. -7/12/17, at 11:55 a.m. R29 had declined in activity tolerance, strength, and transfers were more difficulty. R29 was unable to walk since recent fracture. Orders received for therapy to evaluate and treat. -7/26/17, at 10;14 a.m. Chest of drawers was secured to wall. Care plan was followed. -7/26/17, at 10:36 a.m. active therapy services discontinued and restorative program remained in place. -8/16/17, at 5:38 a.m. R29 was in her wheelchair from 1:00 a.m. to 3:30 a.m. The note indicated R29 told the writer that the girl needs cough syrup, but she did not. R29 ambulated out to the lobby and watched TV for awhile. -8/19/17, at 7:15 p.m. R29 was attempting to get outside and her wanderguard alarm was going off. One to one visit completed and resident toileted. -8/20/17, at 12:00 a.m. R29 was setting off alarm on her bed. R29 was assisted to the bathroom then back to bed and alarms were activated. -8/20/17, at 12:30 a.m. R29's bed alarm was ringing and R29 informed staff that she had woodticks. Staff checked R29 and found no woodticks. Bed alarm and floor mat were activated. Call light was within reach. -8/20/17, at 12:45 a.m. staff heard a noise coming from R29's room. She was on the floor outside of her room and her walker was inside her room. R29 stated she was going to shut the door and buff the floor. R29 sustained a 2 centimeter bump on her head and denied discomfort. Ice was applied. R29 was assisted back to bed with assistance of 2 staff and gait belt. R29 was observed to unhook alarm at this time. Informed she needed to keep the alarm on and R29 continued to play with alarm buttons. Alarm moved out of reach of R29. -8/20/17, at 4:37 a.m. R29's bed and floor pad were on and not within reach. Denied any discomfort. -8/21/17, at 8:30 a.m. R29 complained of left hip pain when she was sitting in her wheelchair. R29 was guarding her left leg. R29's primary physician was notified, and orders for x-ray were received. -8/21/17, at 1:00 p.m. R29 was repositioned every 2 hours and was rolled to support her left leg. Ice was applied for comfort. R29 showed signs of pain with repositioning and guarded her left leg and hip area. -8/21/17, at 9:00 p.m. x-ray of pelvis and left hip. -8/21/17, at 10:00 p.m. x-ray results indicated fracture of left hip. R29's primary physician was notified. Orders for foley indwelling urinary catheter, to keep resident on bed rest, NPO (no oral intake) after midnight and to transfer for surgery in the morning. -8/25/17, at 4:15 p.m. R29 returned from hospital for left femur fracture and left hip fracture. New orders received, including PT (physical therapy) and OT (occupational therapy) to evaluate and treat. -8/26/17, at 6:11 a.m. R29 had left hip pinned on 8/23/17, PT evaluation 8/25/17. Hoyer lift for all transfers. -8/29/17, at 3:59 a.m. R29 exercised poor judgement and did not use call lights. Low bed, bed alarm, floor pad in place and activated. Call light was within reach. -8/30/17, at 9:00 a.m. care conference was completed and 90 day assessments were reviewed including R29's comprehensive report. Safety indicated falls, wanderguard, bed/chair/floor alarms,bed low, anti-rollbacks. No further documentation of a comprehensive assessment of R29's falls was documented. -9/1/17, at 3:30 p.m. R29 had severe cognitive impairment. R29's health status had changed with recent hip fracture and pinning. R29 had experienced lethargy and poor appetite. -9/5/17, at 11:41 a.m. review of progress notes. On 9/5/17, at 8:50 a.m. has had falls this quarter, last fall 8/20/17, fall risk noted, safety interventions in place. Hoyer used for R29's transfers and she was unable to walk. R29 identified as at risk for falls. Staff noted fall risk potential as recent. -9/6/17, at 1:35 p.m. care conference held and 90 day assessments reviewed including Resident Comprehensive Report. Fall, wanderguard, bed/chair/floor alarms, bed low, anti-rollbacks. No further documentation of R29's fall assessment was documented. -9/8/17, at 3:15 p.m. PT evaluation completed and R29 appropriate for active therapy services. -9/13/17, at 9:00 p.m. comment added by registered nurse (RN)-A 9/20/17, at 2:12 p.m. on 9/13/17 (during survey) a review of R29's safety devices was completed during weekly PPS-modifications made as directed. -9/19/17, at 4:04 a.m. R29 was restless and trying to climb out of bed. R29 was assisted up to the wheelchair with extensive assistance of 2 staff. R29 refused to go to the bathroom at that time. Acetaminophen 325 mg X 2 tablets were given to the resident for right hip and leg pain. R29 was unable to rate pain, and her incision site was dry and intact. R29 was given pudding for a snack. -9/20/17, at 4:36 p.m.(during survey) R29's safety devices currently in place were reviewed by IDT. Note indicated to continue to problem solve to meet her safety needs. Staff interview indicated R29 was not actively pulling at alarm strings/devices. R29's plan of care was modified to meet her needs. R29 was being seen by active therapy services. Screen was to be sent to therapy to review current safety device/interventions in place and aide with problem solving to meet R29's needs. During interview on 9/20/17, at 1:39 p.m. NA-A indicated the last time she was aware R29 attempted to take the alarm off was several weeks ago, maybe a month or two ago. On 9/20/17, at 2:02 p.m. NA-D indicated staff utilized a TAB alarm in her bed and wheelchair for R29 and she also had an alarm on her bathroom door. She stated R29 did not use her call light. She indicated R29 was at risk of falls. She indicated R29 had removed her alarms in the past, but was not aware of her doing it lately. On 9/20/17, at 2:19 p.m. NA-E indicated R29 utilized a TAB alarm connected to her bed or wheelchair which staff clipped to the back of her shirt. She indicated R29 had not tried to remove her alarm in awhile. She indicated the facility had added a pressure floor mat alarm after her fracture. R29 utilized a cushioned pad on the floor on the side near the window, but she had never seen her get out of bed on that side. On 9/20/17, at 2:38 p.m. NA-C indicated staff watched R29 for falls. He indicated R29 utilized a TAB alarm and indicated he was aware R29 self transferred. He indicated R29 attempted to self transfer at least once a day, and the most recent time he was aware of R29's self transfer was the last evening at approximately 7:00 p.m., when he heard the floor alarm pad sound. NA-C indicated he did not feel R29 could remove the TAB alarm herself. On 9/20/17, at 2:49 p.m. during group interview with RN-A and licensed practical nurse (LPN)-A, RN-A indicated LPN-A completed fall assessments for the facility. RN-A indicated her last fall risk assessment had been completed on 9/7/17, and she scored 24, and a score of anything over 9 indicated the resident was at risk of falls. RN-A stated R29 had fallen in June and broke her clavicle and fractured her hip with her most recent fall. She indicated the facility had made many changes to R29's care plan because staff needed to provide much more assistance to R29. RN-A indicated the facility reviewed falls routinely in a weekly therapy meeting which she identified as a interdisciplinary meeting. At that time, interventions were reviewed and changes were made as needed. RN-A indicated the facility documented the meeting in a IDT note in each resident's chart. However, the fall scene investigation forms and IDT meetings failed to comprehensively assess R29's risk for falls to include but not limited to trends/patterns to falls, factors that may be causing the falls, and effectiveness of interventions. On 9/20/17, at 3:04 p.m. LPN-A indicated after R29's clavicle fracture the facility had increased staff to 2 assist with ADLs (activities of daily living) and the floor pressure alarm had been added after her hip fracture. RN-A confirmed R29 had severe cognitive impairment, history of hallucinations and indicated she felt R29 was a reliable historian related to the incident when R29's clavicle fracture was found. RN-A indicated she felt R29 was right on and sometimes she was not and felt her cognitive status was intermittent. RN-A indicated she felt R29 could still communicate effectively. LPN-A indicated she was aware R29 had a history of [REDACTED]. RN-A indicated she felt R29 would not be candidate for 1 hour checks, and she had no consistency with toileting patterns in the past. RN-A stated staff were in R29's room a lot, because of her roommates condition, but the facility had never put in a formal program for R29 safety checks. On 9/20/17, at 4:16 p.m. director of nursing (DON) confirmed R29's current care plan and indicated her care plan should of been updated to include applying the TABS alarm in a place where she could not remove it when this was discussed on 8/22/17. The DON confirmed it also should have been updated on the NAR care sheet. During review of R29's electronic health record with surveyor, the DON stated there were inconsistencies with the computer data related to the placement of the clip for the alarms and was unable to explain the inconsistencies. At 4:29 p.m. DON stated she had been made aware of revisions to the care plan made at that time, and felt that was the reason for the inconsistencies. She indicated she assumed the intervention related to placement of the clip for alarm was removed because it was no longer effective. During follow up interview at 4:39 p.m. DON indicated licensed staff had talked with staff and found out R29 had no longer tried to remove her alarm, so she felt that intervention was no longer needed. She confirmed R29 was restless, but indicated she felt she had not tried to remove her alarm or self transfer. DON stated she was not aware of the self transfer attempt documented in R29's medical record on 9/19/17. On 9/21/17, at 5:31 a.m. RN-B stated R29 was sometimes restless at night and indicated R29 had slept very well at present. RN-B felt R29 had slept better last night because her roommate was out of the room during the night. RN-B indicated the roommate would make noise and wake up R29. RN-B indicated she had not witnessed R29 try to self transfer since her fractured hip, but she indicated she was aware other staff had reported R29 continued to attempt self transfers since her fractured hip. She indicated she had witnessed R29 attempt to self transfer approximately one week prior, when she assisted R29 to put her legs back into bed. She stated R29 had dementia and indicated R29 at times would understand what staff say to her and at other times not. RN-B indicated the last time she was aware R29 attempted self transfer was earlier that night when a nursing staff informed her of the self transfer. RN-B indicated R29 utilized a floor alarm, TABS alarm and she indicated the facility staff checked her frequently. RN-B stated the facility had implemented hourly checks last night and stated R29's floor alarm had been in place for a few months, but was unsure exactly how long it had been utilized. RN-B indicated she was aware R29 knew how to take her TABS alarm off and that she had shut off the pressure floor alarm. She indicated R29 took the TABS alarm off herself every other day or every third day. RN-B indicated R29 was confused at times, was difficult to know if she understood and indicated that was her normal state. On 9/21/17, at 5:54 a.m. trained medication aide (TMA)-A indicated R29 utilized a TABS alarm and indicated R29 always took it off. She indicated R29 had been able to remove the clip of the TABS alarm, from wherever it was placed. TMA-A indicated R29 also had a pressure floor alarm and stated the alarms had been in place a long time, and the floor pressure alarm on the floor had been used for R29 6 months or more. TMA-A indicated she also had a door alarm on her bathroom to alert staff also. TMA-A indicated R29 had confusion and communicated in only a few words. TMA-A stated R29 sometimes tried to get up on her own, and she could get herself onto t