Every finding on record at Caregivers of Pleasant Grove, Inc

Based on interviews, record review, review of facility incident report, review of facility policy titled, ACCIDENT/INCIDENT/UNUSUAL OCCURRENCE REPORT, and the State Agency's Intake Information, the facility failed to provide evidence that: 1. RI # 5's representative/responsible party was notified when RI #5 had an unwitnessed fall on the 11-7 shift on 02/21/2022. 2. Resident Identifier (RI) #1's representative/responsible party was notified when RI #1 developed a pressure ulcer on his/her bottom (identified at the hospital on 9/24/2021), and This deficient practice affected RI #1 and RI #5; two of three residents sampled for notifications. Findings include: 1. Review of a facility policy titled, ACCIDENT/INCIDENT/UNUSUAL OCCURRENCE REPORT, effective date 12/01/2006 and last revised 02/22, revealed the following: I. PURPOSE To facilitate appropriate reporting and resolution of accidents/incidents/unusual occurrences. III. PROCEDURE A. If an incident or accident or unusual occurrence occurs, use criteria listed to decide the first appropriate action to take. 7. Notify family or legal guardian and physician. RI #5 was admitted to the facility on [DATE] and readmitted [DATE]. Review of facility untitled document dated 2/21/2022 regarding RI #5 documented, . Incident Description Nursing Description: RESIDENT FOUND ON FLOOR IN (HIS/HER) ROOM NEXT TO (HIS/HER) BED, NON-WITNESSED FALL . Immediate Action Taken Description . HEAD TO TOE ASSESSMENT DONE FOR INJURY, SMALL SKIN TEAR NOTED TO RESIDENT'S OUTER LEFT FOOT PROXIMAL TO THE SMALL TOE. WILL NOTIFY RESPONSIBLE PARTY IN AM. NURSE PRACTITIONER ON CALL NOTIFIED. DON NOTIFIED. On 2/25/2022 at 11:07 AM, in a telephone interview, Employee Identifier (EI) #4, Licensed Practical Nurse (LPN), stated she attempted to call two family members of RI #5 regarding the incident but it was 2AM so she passed it on to dayshift. On 2/25/2022 at 02:01 PM, in a telephone interview, RI #5's Responsible Party stated he/she was not notified of RI #5's fall. On 2/25/2022 at 09:03 PM, EI #3, LPN, reported she was asked by EI #4 to call the resident's representative but, EI #4 was still at the facility at 9AM so, EI #3 thought EI #4 would call since she knew more about the incident. EI #3 stated she did not call the family and she did not know if EI #4 called the family and they did not answer. On 2/25/2022 at 07:41 PM, EI #2, DON, stated she talked to the family member on 2/24/2022 regarding the incident with RI #5. EI #2 stated the contact with the family should have been made early in the morning on 2/21/2022. EI #2 stated EI #3 or the next nurse should have notified the family. EI #2 stated she did not know if the notification was made. On 2/26/2022 at 03:57 PM in a follow-up interview, EI #2 stated the record did not reflect that the notification was done. 2. Review of the State Agency's Intake Information regarding RI #1, with a received date of 11/01/2021, revealed, . Caller alleges (RI #1) was admitted to the facility on [DATE] and the nurse at the facility assured (the caller that RI #1) had no wounds on (his/her) body. However, when discharged to the hospital on 09/25/2021, the called stated (he/she) found out that (RI #1) had developed a pressure ulcer on (his/her) bottom that the facility never notified (him/her) of. RI #1 was admitted to the facility on [DATE]. Review of RI #1's Progress Notes dated 9/21/2021 by EI #9, LPN, revealed, . Resident skin has open areas under both breast and under abdominal folds also has redden area on her sacrum. Nurse attempts to call Residents (representative) and the contact number is busy X3 times. Nurse will attempt at a later date. Review of RI #1's UAB (University of Alabama at Birmingham) Medicine Discharge Summary with an admitted [DATE], revealed, . Integ (Integunentary): Buttock Pressure Ulcer . Present on presentation . WOCN (Wound, Ostomy and Continence Nurse) Consult Wound care by nursing . Continue to monitor . On 2/24/2022 at 10:34 AM, in a telephone interview, RI #1's Responsible party stated he/she was not notified that RI #1 had a wound while at the facility. On 2/25/2022 at 07:41 PM, EI #2, Director of Nursing (DON), stated according to the record, RI #1 had open [CONDITION(S)] under breasts, stasis and dermitis. On 2/26/2022 at 03:57 PM, in a follow-up interview, EI #2 stated the record for RI #1 did not indicate the resident's representative was notified about RI #1 change of condition (skin). On 2/26/2022 at 04:25 PM, in an interview, EI #1, Administrator, stated there was no documentation that the family representative for RI #1 was called regarding a change of condition (skin). This deficiency was cited as a result of AL 617.

Based on interviews, record reviews, a review of Potter and Perry, Fundamentals of Nursing, a review of NINTH EDITION, and Alabama Board of Nursing Administrative Code Documentation Standardsthe facility failed to ensure that Employee Identifier (EI) #5, Licensed Practical Nurse (LPN) document treatment as administered on the Treatment Administration Record (TAR) and administer treatment as ordered by the physican. EI #5 did not administer Zinc ointment to Resident Identifier (RI) #3 as ordered after each peri-care. This deficient practice affected RI #3, one of four residents sampled for wound care. Findings include: A review of Potter and Perry's Fundamentals of Nursing, NINTH EDITION, page 370, revealed the following: .Chapter 26 Documentation and Informatics .Informatics and Information Management In Health Care .A nurse's electronic or handwritten signature on an entry in a record designates accountability for the contents of that entry . A review of the Alabama Board of Nursing Administrative Code Documentation Standards, page 610-X-6, revealed the following: . (f) Administering of medications and treatments, when ordered by a legally authorized prescriber. RI #3 was admitted to the facility on [DATE]. RI #3's physician orders, Order Details on 2/7/2022 indicated clean area to left buttocks and inner thigh with wound cleanser. Apply zinc ointment to both areas after each incontinent episode. On 2/25/2022 at 8:25 AM, an interview was conducted with EI #5. EI #5 was asked, what care was ordered for the wounds on RI #3's bottom and thighs. EI #5 replied, Zinc with diaper changes. EI #5 was asked, who applied on the Zinc oxide. EI #5 replied, Certified Nursing Assistants (CNA)s. EI #5 was asked, how often was RI #3 getting that treatment. EI #5 replied, two or three times a shift. EI #5 was asked, how did she know the CNAs used the Zinc and how often. EI #5 replied, she put the Zinc oxide in the room at the beginning of the shift. EI #5 was asked, where did she put the Zinc oxide. EI #5 replied, in the top drawer in the resident's room. EI #5 was asked, how did she know the CNAs used it and how often. EI #5 replied, when she went into the room she saw there was white in between the resident's legs. EI #5 was asked, who documented it on the TAR. EI #5 replied, she did. EI #5 said the CNAs performed the treatment. On 2/25/2022 at 6:54 PM, an interview was conducted with EI #2 DON. EI #2 was asked, what staff members did treatments on wounds according to policy. EI #2 replied, nurses. EI #2 was asked, who should apply Zinc ointment on residents. EI #2 replied, nurses. EI #2 was asked, should the CNAs apply Zinc ointment on residents. EI #2 replied, no. EI #2 was asked, how should Zinc ointment be documented. EI #2 replied, on the TAR. EI #2 was asked, who documents on the TAR. EI #2 replied, the nurses. EI #2 was asked, should the CNAs put the Zinc ointment treatment on RI #3. EI #2 replied, no, the nurses should. EI #2 was asked, what was the risk of CNAs applying the Zinc ointment. EI #2 replied, it was a medication and you should be given accordingly. EI #2 was asked, how often should the nurses applied the Zinc to the resident. EI #2 replied, in according with the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . EI #2 replied, if staff did not do it, staff should not be charting, if the staff did not do the treatment. EI #2 was asked, why should staff not chart what the staff did not do. EI #2 replied, it was not being honest with the resident's care.

Based on observations, interviews, review of medical records, and a facility policy titled, Skin and Wound Care Protocol Skin Treatments, the facility failed to ensure: 1) Resident Identifier (RI) #1's reddened area to sacrum identified on admission was re-assessed and treatments were put in place to prevent the area from progressing to a pressure injury 2) Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . These deficient practices affected RI #1 and RI #3; two of four sampled residents reviewed for pressure ulcers. Findings include: Review of a facility policy titled, Skin and Wound Care Protocol Skin Treatments, with a revised dated of 9/2021, documented: .In collaboration with the attending physician, nursing will develop an individualized treatment regimen for each resident determined to have a skin or wound problem. Treatments are documented and a reassessment is completed weekly. Written reports are remitted to the Director of Nursing weekly . 1. RI # 1 was admitted to the facility on [DATE] and discharged on [DATE]. The review of RI #1's medical record revealed wounds were identified on the skin assessment at time of admission which revealed the resident had open lesion underneath both breasts under skin folds, bilateral left lower extremity had stasis and [CONDITION(S)], and resident had reddened area on the sacrum. There was no Treatment Administration Record (TAR). No orders for these wounds were obtained by the facility. No other assessments of the wounds were made by the facility during her stay. The review of the hospital medical record for RI #1 from the Certified Registered Nurse Practitioner (CRNP) note revealed there was a pressure ulcer present on admission on 9/24/21. A further review of RI #1's medical record from the UAB Hospital from the wound care consultant notes from 9/27/21 revealed, patient has a very large deep tissue injury to the buttocks and sacrum. Staging Deep tissue injury with measurement 10 centimeters (cm) by 12 cm. The color of the deep tissue injury was purple and red with a small amount of serous drainage. A further review of RI #1's medical record from UAB Hospital wound care consultant note from 10/5/2021 revealed, the deep tissue injury converted to a Stage Two on 10/5/2021. On 2/25/2022 at 6:45 PM, an interview was conducted with Employee Identifier (EI) #2, Registered Nurse (RN)/Director of Nursing (DON). EI #2 was asked, who had training on wound care. EI #2 replied, none of the staff are certified, the facility had a wound care doctor. EI #2 was asked, how often did the wound care doctor come in the building. EI #2 replied, weekly, unless the wound care doctor reschedules. EI #2 was asked how often should wound care be documented. EI #2 said weekly. EI #2 was asked to review RI #1's closed chart to determine if there were any orders for RI #1's wounds. EI #2 said no. EI #2 was asked why were there no orders for RI #1's wounds. EI #2 replied, she could not answer that. EI #2 was asked should there have been wound care orders ordered. EI #2 replied, under the resident's breasts yes, the other ones there was not enough information in the medical record for her to make that determination. EI #2 was asked, what was the risk of wounds not being cared for per standards of care for pressure injury. EI #2 replied, they could worsen. EI #2 was asked, based on the information you reviewed on that record, did the facility provide needed care and services. EI #2 replied, under the breasts they did not have a treatment as an order, for the rest she could not speak about. EI #2 was asked, did staff provide treatment consistent with the skin assessment completed on admission. EI #2 replied, no. 2. RI #3 was admitted to the facility on [DATE]. RI #3's order on 2/24/2022, documented, clean area to left buttocks and inner thigh with wound cleanser. Apply Zinc ointment to both areas after each incontinent episode. Every day shift. On 2/24/2022 at 3:36 PM the surveyor observed ten open areas to RI #3's skin. The surveyor observed there to be: three open areas to upper back of right thigh. The size of these areas was approximately 1.5 centimeter (cm) by (x) 0.5 cm, 2 cm x 0.5 cm, 3 cm by 0.5 cm; three open areas on upper back of left thigh approximately 3 cm x 0.5 cm, 2 cm x 0.5 cm, 1 cm x 0.5 cm; one open area on the back of middle of left thigh approximately 6 cm x 2 cm. All the open areas on the back of the thighs were pink in the center with white outer area around the wounds. two open areas on the right buttock approximately 1 cm x 1 cm. One area on the inner left thigh white color in center and pink around the edges of the wound approximately 4 cm x 2 cm. On 2/24/2022 at 3:46 PM, an observation was made with EI #6, CNA and EI #7, CNA performing perineal care on RI #3. EI #6 applied Periguard Skin Barrier Protectant on the open areas on the back of thighs, in between thighs, and on buttocks. On 2/24/2022 at 4:38 PM, an interview was conducted with EI #6, CNA. EI #6 was asked, how many times did you change RI #3 today. EI #6 replied, three. EI#6 was asked, what did you apply to the resident's open wounds. EI #6 replied, I put skin protectant on the resident's bottom, in between the thighs and on the open areas on her thighs. On 2/25/2022 at 8:25 AM, an interview was conducted with EI #5, Licensed Practical Nurse (LPN). EI #5 was asked, what care was ordered for the two wounds buttocks, three wounds on the back of the right thigh, four wounds on the back of the left thigh, and the wound on the inner right thigh. EI #5 replied, Zinc with diaper changes. EI #5 was asked, what did the policy instruct nursing staff to do about wounds. EI #5 replied, when staff first find one, the staff should have wrote standing order for wound care, until the wound care doctor determines what was needed on the wounds. EI #5 was asked, did she measure all the wounds. EI #5 replied, the doctor measures all wounds. EI #5 was asked, did she do a weekly report to the DON. EI #5 replied, she pulled up the TAR. EI #5 was asked, how long has RI #3 had wounds. EI #5 replied, since RI #3 came here; he/she came in here with them. EI #5 was asked, where are you documenting the changes. EI #5 replied, we do not document if they are getting better, only if they were getting worse. EI #5 was asked, who put on the Zinc oxide. EI #5 replied, Certified Nursing Assistants (CNAs). EI #5 was asked, how often was RI #3 getting that treatment. EI #5 replied, two or three times a shift. EI #5 was asked, how did you know the CNAs used the Zinc and how often. EI #5 replied, she had to put the Zinc oxide in the room at the beginning of the shift. EI #5 was asked, where did you put the Zinc oxide. EI #5 replied, in the top drawer in the resident's room. EI #5 was asked, how did she know the CNAs used it and how often. EI #5 replied, when she went into the room she saw there was white in between their legs. EI #5 was asked, who documented it on the TAR. EI #5 replied, she did. EI #5 was asked, who did the treatment. EI #5 replied, the CNAs. On 2/25/2022 at 6:15 PM, an interview was conducted with EI #8, CNA. EI #8 was asked, what care did you do for RI #3. EI #8 replied, change the resident, see if he/she needs anything, check on the resident. EI #8 was asked, what did she put on RI #3 thighs after incontinent care. EI #8 replied, this was what she used (EI #8 went into RI #3's room and picked up bottle that she used-Peri-guard skin protectant ingredients petroleum). EI #8 was asked if she applied Peri-guard Skin Protectant on the resident. EI #8 replied, yes. On 2/25/2022 at 6:54 PM, an interview was conducted with EI #2 DON. EI #2 was asked, who had training on wound care. EI #2 replied, none of the staff was certified; the facility had a wound care doctor. EI #2 was asked, how often did the nurse practioner come in the building. EI #2 replied, weekly, unless she rescheduled. EI #2 was asked, how often were body audits done on residents. EI #2 replied, they are done weekly and on admission. EI #2 was asked, who did the body audits. EI #2 replied, the nurses. EI #2 was asked, what wound care was done on the wounds for RI #3 from 2/7/2022 until 2/24/2022. EI #2 replied, there was an order but it was not on the TAR. EI #2 was asked, where was it documented that it was completed. EI #2 replied, it should be documented on the TAR so she did not know. EI #2 was asked, if it was not on the TAR, was the treatment done. EI #2 replied, she did not answer that. EI #2 was asked, what did policy say regarding documenting wound care. EI #2 replied, only pressure wounds and surgical wounds were documented, the basic stuff needs to be in the nurse's notes, when it g intense that was when we get the wound care doctor involved. EI #2 was asked, according to policy, how often should wound care be documented. EI #2 replied, weekly. EI #2 was asked, what staff members did treatments on wounds according to policy. EI #2 replied, nurses. EI #2 was asked, who should apply Zinc Oxide on residents. EI #2 replied, nurses. EI #2 was asked, should the CNAs apply Zinc Oxide on residents. EI #2 replied, no. EI #2 was asked, how should Zinc Oxide be documented. EI #2 replied, on the TAR. EI #2 was asked, who documents on the TAR. EI #2 replied, the nurses. EI #2 was asked, should the CNAs put on the Zinc Oxide treatment on RI #3. EI #2 replied, no, the nurses should. EI #2 was asked, what was the risk of CNAs applying the Zinc Oxide. EI #2 was asked, why would the nurse think the CNAs put on the zinc. EI #2 replied, I do not know. EI #2 replied, medications should be given according to the orders by the nurse. EI #2 was asked, how often should the nurses have applied the Zinc to the resident. EI #2 replied, according to what the order said. EI #2 was asked, what concerns did she have regarding the nurse saying she did not apply the Zinc to RI #3's wounds on the buttocks and thighs, but she charted that she did the treatment. EI #2 replied, if she did not do it, she should not be charting, if she did not do the treatment. EI #2 was asked, why should she not chart what she did not do. EI #2 replied, it was not being honest with the resident's care.

Based on interviews, review of Resident Identifier (RI) #1's medical record, RI #1's hospital medical record, the Witnessed Fall report, the facility's investigation file and a complaint received by the State Survey Agency, the facility failed to ensure the Hoyer lift (sling) pad, used to transfer RI #1 on 9/3/2021 was in good condition. During the morning of 9/3/2021, Employee Identifier (EI) #8 and EI #9, both Certified Nursing Assistants (CNAs) attempted to transfer the resident from the bed to a shower chair. While the resident was hoisted into the air, the sling pad on the Hoyer lift broke and RI #1 fell to the floor on his/her right side and hit his/her head on the metal portion of the Hoyer lift. Both CNAs stated once they hooked the sling (lift pad) underneath the resident, they noticed the sling (lift) pad was worn; however, they did not go and get another lift pad because, according to them, all the sling (lift) pads in the facility looked worn. RI #1 complained of pain on the right side and the back of the head. After assessment by the licensed nursing staff, RI #1 was transported to a local hospital with a chief complaint of fall and head laceration. The resident's final diagnoses were listed as: fall, head injury, a 1.5-centimeter (cm) scalp laceration that required three staples to close, a shoulder and hip contusion. This deficient practice placed RI #1; one of five sampled residents reviewed for accidents in immediate jeopardy, as the situation was likely to cause serious injury, harm, impairment, or death. On 9/17/2021 at 1:50 PM, the facility's Administrator and Director of Nursing (DON) were given a copy of the immediate jeopardy template and notified of the finding of substandard quality of care at the immediate jeopardy level in the area of Quality of Care / Free of Accident Hazards/Supervision/Devices, F689. Findings include: On 9/7/2021, the State Survey Agency received a complaint which alleged RI #1 fell from a Hoyer lift on Friday, 9/3/2021 while the resident was suspended in mid-air due to the straps on the Hoyer lift not being in good condition. The resident fell on his/her right side and hit the back of his/her head on the metal part of the Hoyer lift. RI #1 was admitted to the facility on [DATE] with a medical history to include a diagnosis of [CONDITION(S)]. RI #1's Quarterly Minimum Data Set with an assessment reference date of 7/1/2021, indicated the resident was cognitively intact with a Brief Interview for Mental Status (BIMS) of 15. The resident was assessed as being totally dependent on two+ staff for transfers. RI #1's care plan titled (RI #1) has an ADL (Activities of Daily Living) self-care performance deficit r/t (related to) weakness has an intervention that was initiated on 1/25/2021 that documented TRANSFER: (RI #1) requires Mechanical Lift with (2) staff assistance for transfers. The Witnessed Fall report for RI #1 dated 9/3/2021, documented . Incident Location: Resident's Room . Incident Description . Resident being transferred to the shower chair via Hoyer lift with assistance x3 (x2). In he (the) transfer process sling became unraveled causing the resident to bump (his/her) head. The resident assessed for injury and bleeding noted from the back of the head. Patient alert and oriented and pupils reactive to light and accommodating. Complaining of pain on (his/her) right side and still able to move all extremities . The resident c/o (complained of) pain on right side and the back of (his/her) head . Immediate Action Taken . CRNP (Certified Registered Nurse Practitioner) called with orders to send to ER (emergency room ) for eval (evaluation) . In an interview on 9/7/2021 at 4:15 PM, RI #1 stated when he/she fell , it was EI #8 and EI #9 that got him/her up in the Hoyer lift. Contained within the facility's investigation file was a STATEMENT FORM written by EI #9, a CNA dated 9/3/2021, which read I (EI #9) was in the room helping transfer (RI #1) to the shower chair when the lift pad broke and (he/she) fell on the floor. On 9/8/2021 at 8:10 AM, an interview was conducted with EI #9, the CNA who assisted in the transfer of RI #1 on 9/3/2021. EI #9 was asked about the incident that occurred with RI #1 on 9/3/2021. EI #9 replied, she and EI #8 were transferring RI #1 to the shower chair from the bed. They had the lift pad underneath RI #1 hooked to the lift. RI #1 was up in the air above the bed and as they turned the resident toward the shower chair, the lift pad broke. According to EI #9, EI #8 tried to break the fall by getting under RI #1, but she unable to do so and RI #1 went to the floor and landed on his/her right side flat on the ground. EI #9 stated they called the nurse who then called the paramedics. While RI #1 was lying on the floor, the resident kept saying that his/her head hurt. When the paramedics arrived, they took RI #1 to the hospital. When asked what the lift pad looked like, EI #9 replied, it was old, looked like it was worn and there was about an inch tear on the opposite side from where it broke. In a follow-up interview on 9/8/2021 at 10:00 AM, EI #9, a CNA, was asked why she did not get another lift pad if the one they had looked worn. EI #9 replied, all of them looked about the same. When asked should she have gotten another lift pad, EI #9 answered, yes, but all of them was the same. EI #9 was asked what the risk was of not getting another lift pad for the Hoyer lift. EI #9 replied, the facility needs new lift pads but the risk was falling. In another interview with EI #9, a CNA, on 9/9/2021 at 11:15 AM, she stated it was when RI #1 was up in the air that they (she and EI #8) noticed the lift pad had a tear in it. When asked if she should have looked (inspected) the lift pad before use, EI #9 said yes. When asked should the lift pad have been used on RI #1, EI #9 said no. When asked why not, EI #9 replied because it may cause a fall. Contained within the facility's investigation file was a STATEMENT FORM written by EI #8, a CNA, dated 9/3/2021, which read I (EI #8) was transferring (RI #1) to the shower chair from the bed and the lift pad broke. The resident fell from the lift to the floor. On 9/8/2021 at 1:14 PM, an interview was conducted with EI #8, the CNA assigned to care for RI #1 on 9/3/2021. EI #8 was asked about RI #1's incident on 9/3/2021. EI #8 explained that she had to give RI #1 a shower, so she went to the linen closet on the back hall to get a lift pad and there were none there. EI #8 then went to the laundry room and there were no lift pads in the laundry room. EI #8 found a lift pad in the Activity Room. According to EI #8, EI #9 assisted her in transferring RI #1. Once the lift pad was hooked to the Hoyer lift, the resident was lifted above the mattress. As the Hoyer lift was turned, the lift pad broke. EI #8 stated she tried to catch the resident, but it happened so fast. RI #1 fell on his/her right side and hit his/her head on the bottom of the Hoyer lift. EI #8 explained that once RI #1 was in the lift pad, they could see the lift pad was worn. In a follow-up interview on 9/9/2021 at 11:38 AM, EI #8, a CNA was asked if she should have used the lift pad. EI #8 replied, no but she probably would have used it anyway because that was the only one, she could find. When asked what the risk of using a worn lift pad, EI #8 replied, a fall, it could tear, and break and the resident could fall and injure themselves. In another interview on 9/13/2021 at 2:58 PM, EI #8, a CNA stated the incident occurred about 9:00 AM/10:00 AM. When asked if she checked the lift pad before placing RI #1 on it, EI #8 said no. In an interview on 9/14/2021 at 10:59 AM, EI #4, a Licensed Practical Nurse (LPN) was asked what she recalled about RI #1's incident on 9/3/2021. EI #4 stated she was called to RI #1's room by a staff member around 9:30 AM because RI #1 had fallen. EI #4 stated when she got to RI #1's room, EI #8 and EI #9 were in the room with the resident. RI #1 stated he/she was hurting on his/her right side and that he/she had bumped his/her head. According to EI #4, the resident didn't say what he/she hit his/her head on, but RI #1 was laying on his/her right side with his/her head on the base on the Hoyer lift, so she assumed the resident hit his/her head on that. EI #4 stated she asked another staff member to call 911. EI #4 stated she asked the CNAs what happened, and both CNAs stated the lift pad tore apart. EI #4 stated she didn't move the resident due to the head injury, so she made the resident comfortable and covered him/her with a sheet because the resident had only a gown on because he/she was going to the shower. EI #4 stated after she called the CRNP and received orders to send the resident to the hospital, she called the resident's representative to inform her of what had occurred. EI #4 was asked what she determined caused the fall. EI #4 replied, the sling unraveled which caused the resident to fall. When asked how she knew the sling unraveled, EI #4 stated the strap was hanging and it was disconnected from the lift pad. RI #1's Caregivers of Pleasant Grove, Inc Progress Notes written by EI #4, a LPN and dated 9/3/2021 9:00 AM, documented The CNA's called this Nurse to (RI #1's room), during transferring the resident to the shower chair, the sling unraveled and the resident hit (his/her) head. ROM (Range of Motion) done on all extremities, the resident c/o pain on right side and the back of (his/her) head. The sling pad noted unraveled on one side. (Name) CRNP called with orders to send to the ER. Sponsor (Name) called and made aware. Stated she will meet (RI #1) at the ER. Orders to send to (local hospital) ER . RI #1's physician order dated 9/3/2021 9:42 AM, documented Transfer to (local hospital) for eval r/t (related to) fall. RI #1's local hospital emergency room record with an admit and discharge date of [DATE], documented . Reason for Visit: FALL/HEAD LAC (laceration) . Chief Complaint: Pt (patient) was being moved today with a lift device at (his/her) nursing home, per ems (Emergency Medical Services) pt was dropped . presents to (local hospital) via EMS from Nursing Home for evaluation for laceration to the posterior head today. Per EMS, the pt was dropped while being transferred into the shower at her nursing home. Pt states fell out of (his/her) lift and fell on to floor during transfer this AM. Pt states (he/she) fell on to (his/her) right side, and (he/she) is now having right shoulder and right hip pain. Pt has a laceration to the back of (his/her) head. (He/She) denies LOC (loss of consciousness), nausea, vomiting, neck pain, back pain . Medical Decision Making . 1.5 cm (centimeter) linear superficial laceration to right posterior parietal region. Bleeding controlled . Swelling present that is consistent with hematoma . Patient has full but tender ROM of right shoulder . Patient has full but painful ROM to bilateral hips . Shoulder x-ray shows no evidence of acute fracture or dislocation. Hip x-ray shows no evidence of acute fracture or dislocation . CT (Computed Tomography) head shows right posterior parietal scalp laceration otherwise no acute intracranial abnormality . Discussed results with patient and daughter . Instructed patient and daughter to take Tylenol as needed for pain. Instructed patient and daughter to have staples removed in 10 days . Final Diagnosis Fall Head Injury Scalp laceration repair Shoulder contusion Hip contusion . During an interview on 9/9/2021 at 2:48 PM, EI #2, DON acknowledged that she was informed of RI #1's fall on 9/3/2021 from the Hoyer lift. EI #2 stated she assessed the resident by completing neuro-checks, placed ice on the resident's head and a pillow under his/her head. When asked who determined the root cause of the accident, EI #2 stated she did. When asked what the root cause of the accident was, EI #2 stated it was equipment failure and human error. EI #2 was asked who was responsible for checking to make sure the lift pads are not worn, torn, or frayed. EI #2 replied, the CNAs are supposed to check them before use, as well as laundry and the Restorative Nurse. EI #2 was asked what the condition of the lift pad used to transfer RI #1 was. EI #2 answered, it was a little worn. When asked should the staff have used the lift pad (sling), EI #2 replied no. When asked why it was used, EI #2 stated, they (EI #8 and EI #9) were lazy, cut corners and did not want to find a good one. When asked what the risk of using a worn lift pad was, EI #2 stated mild to severe injury up to death of a resident. In an interview on 9/15/2021 at 9:44, EI #3, the Staff Development Coordinator (SDC) acknowledged the lift pad used to transfer RI #1 on 9/3/2021 was brought to her by the facility's Administrator, EI #1. As EI #3 described the condition of the lift pad, she was asked should the staff have used this lift pad to transfer RI #1 on 9/3/2021. EI #3 answered, no. When asked why not, EI #3 replied because for one thing it was unraveled too much. EI #3 stated she would have tried to locate another lift pad before transferring RI #1 with this lift pad. EI #3 further stated she would have informed the Charge Nurse and she would have never considered using that lift pad. In a follow-up interview on 9/15/2021 at 10:05 AM, EI #2, the DON acknowledged she investigated the incident. When asked what her findings were, EI #2 replied, while getting RI #1 up the lift pad broke and the immediate intervention was to get a brand-new lift pad from the closet. EI #2 was asked what caused the accident and she replied, the lift pad broke. EI #2 was asked whose responsibility was it to check the lift pad prior to use. EI #2 answered, the CNAs are to assess the condition of the lift pad prior to use and report any issues to the Charge Nurse. The Charge Nurse would then instruct the staff not to use the lift pad and obtain another one. ************************* On 9/17/2021 at 9:49 PM, the facility submitted an acceptable Removal Plan which documented: F689 TRAINING [DATE] - The Staff Development Coordinator (SDC) inserviced the CNA's and the nurses in the building, both agency and direct employees, on the use of Hoyer lifts and pad inspection, including the proper technique to remove them from service. Those nurses were then designated as trainees. The SDC and those designees continued to inservice other nurses and CNA's, both agency and direct employees, as they entered the building before they began their shifts. This training included CNA's taking any sling they felt showed wear and tear or might be compromised to the DON, Administrator or the charge nurse if the Don and Admin are not available. The charge nurse would then place the sling in a bag and label it out of service and lock it in the med room until it can be delivered to the Don or Admin. One of them will dispose of the sling in the bag in the dumpster-out of the building. [DATE] - (Name), Administrator and (Name), Director Environmental Services inserviced the laundry staff to ensure they were checking slings as they laundered them. They were instructed to report any suspected issues the discovered to their supervisor, or if she is unavailable, to the charge nurse. If the sling is brought to the supervisor, she will take it to the charge nurse. The charge nurse will place the sling in a bag and label in out of service and lock it in the med room until it can be delivered to the DON or Admin. One of them will dispose of the sling in the bag in the dumpster-out of the building. [DATE] - The two CNA's involved in the incident were re-educated in hoyer sling inspection in a one-on-one session. Beginning [DATE], Staff Development Coordinator, or designated nurse, reiterated training to all nurses and CNA's regarding the proper protocol for removing slings from service and disposing of them (as outlined above and originally presented in the [DATE]rd training) INSPECTION [DATE]-Corporate Director of Clinical Services trained the DON, the Administrator and the RN (Registered Nurse) Supervisor on inspecting slings. [DATE] - (Name), AIT (Administrator in Training) inspected all slings in the building under the direction of the Administrator. One was replaced. Weekly inspections were implemented. [DATE] - All slings were inspected by our DME (durable medical equipment) provider/inspector and our Restorative department. All were found to be in acceptable condition. [DATE] - All slings were inspected under the supervision of the RN supervisor and found to be in acceptable condition. [DATE] - All slings were inspected under the supervision of the RN supervisor and found to be in acceptable condition. Slings have been now been numbered so they can be more easily tracked during the inspection process. Any sling that is found to be damaged, or in any way compromised, will be removed from service immediately by delivering it to the Administrator, the DON or the Charge Nurse. If the Administrator or the DON are not available to immediately dispose permanently of the sling (bag and deposit in the dumpster), the charge nurse will place it in a bag that is labeled out of service and lock it in the med room until it can be delivered to the DON or Administrator. ************************* After reviewing the facility's information provided in their Removal Plan and verifying the immediate corrective actions had been implemented, the scope/severity level of F689 was lowered to a D level on 9/17/2021, to allow the facility time to monitor and/or revise their corrective actions as necessary to achieve substantial compliance. The deficiency was cited as a result of the investigation of complaint/report number AL 524.

Based on interviews and review of the DIRECTOR OF NURSING JOB DESCRIPTION and the ADMINISTRATOR JOB DESCRIPTION, the facility's Director of Nursing (DON), who is responsible for the direction of the overall nursing department and the facility's Administrator, who directs the day-to-day functions of the facility, failed to have a system in place to check the Hoyer lift equipment to ensure it was in good working condition. During the morning of 9/3/2021, Employee Identifier (EI) #8 and EI #9, both Certified Nursing Assistants (CNAs) attempted to transfer the resident from the bed to a shower chair. While the resident was hoisted into the air, the sling pad on the Hoyer lift broke and RI #1 fell to the floor on his/her right side and hit his/her head on the metal portion of the Hoyer lift. Both CNAs stated once they hooked the sling (lift pad) underneath the resident, they noticed the sling (lift) pad was worn; however, they did not go and get another lift pad because, according to them, all the sling (lift) pads in the facility looked worn. The DON acknowledged she did designate someone to check the lift (sling) pads after the Restorative Nurse left the facility in August 2021. Further, the facility could not provide any documentation of any prior checks for of the lift (sling) pads that supposed to be completed by the Restorative Nurse. RI #1 complained of pain on the right side and the back of the head. After assessment by the licensed nursing staff, RI #1 was transported to a local hospital with a chief complaint of fall and head laceration. The resident's final diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . This deficient practice placed RI #1; one of five sampled residents reviewed for accidents in immediate jeopardy, as the situation was likely to cause serious injury, harm, impairment, or death. On 9/17/2021 at 1:50 PM, the facility's Administrator and Director of Nursing were given a copy of the immediate jeopardy template and notified of the finding of immediate jeopardy in the area of Administration, F835. Findings include: During the morning of 9/3/2021, EI #8 and EI #9, both CNAs attempted to transfer the resident from the bed to a shower chair. While the resident was hoisted into the air, the sling pad on the Hoyer lift broke and RI #1 fell to the floor on his/her right side and hit his/her head on the metal portion of the Hoyer lift. Both CNAs stated once they hooked the sling (lift pad) underneath the resident, they noticed the sling (lift) pad was worn; however, they did not go and get another lift pad because, according to them, all the sling (lift) pads in the facility looked worn. RI #1 complained of pain on the right side and the back of the head. After assessment by the licensed nursing staff, RI #1 was transported to a local hospital with a chief complaint of fall and head laceration. The resident's final diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Refer to F689 The DIRECTOR OF NURSING JOB DESCRIPTION dated 6/23/2021 and signed by EI #2, documented . General Purpose: To plan, organize, develop and direct the overall operation of the Nursing Department in accordance with current federal, state and local standards governing the facility, and as may be directed by the Administrator, to ensure that the highest degree of quality care is maintained at all times . During an interview on 9/9/2021 at 2:48 PM, EI #2, the DON acknowledged the facility had two Hoyer lifts in the facility, five lift pads (slings) and 15 residents that required the use of the Hoyer lift for transfers. When asked who determined the root cause of the accident, EI #2 stated she did. When asked what the root cause of the accident was, EI #2 stated it was equipment failure and human error. EI #2 was asked who was responsible for checking to make sure the lift pads are not worn, torn, or frayed. EI #2 replied, the CNAs are supposed to check them before use, as well as laundry and the Restorative Nurse. In a follow-up interview on 9/9/2021 at 6:37 PM, EI #2, the DON was asked, how often the Restorative Nurse was to check the slings (lift pads) for the Hoyer lifts. EI #2 replied, at least once a week. The facility's Restorative Nurse left the faciity on [DATE]. When asked did she designate anyone to check the lift pads after the Restorative Nurse ended her employment with the facility on 8/1/2021, EI #2 said, she did not designate anyone; she (EI #2) just took over. EI #2 was asked did she check the lift pads and she said no. When asked what could happen if someone was not given the responsibility of checking the lift pads, EI #2 answered, a worn sling/lift pad would be in rotation to be used; just what occurred with RI #1 (the resident fell from the Hoyer lift on 9/3/2021). In another interview on 9/15/2021 at 10:05 AM, EI #2, the DON acknowledged there was no documentation from the previous Restorative Nurse that indicated the Hoyer lift (sling) pads were routinely inspected. The ADMINISTRATOR JOB DESCRIPTION dated 7/6/2021 and signed by EI #1, documented . General Purpose: To direct the day-to-day functions of the facility in accordance with current federal, state and local standards governing long-term care facilities to ensure that the highest degree of quality care can be provided to the residents at all times . During an interview on 9/15/2021 at 2:12 PM, the Administrator, EI #1, was asked what her responsibility was to ensure slings (lift pads) were in good condition and good repair for resident use. EI #1 replied, ultimately it was everyone's responsibility to check the equipment before use. EI #1 explained the DON (EI #2) failed to assign someone to check the slings (lift pads) after the Restorative Nurse left. In a follow-up interview on 9/15/2021 at 2:40 PM, EI #1 stated ultimately everything in the building (nursing facility) was her responsibility, but that she was not a nurse and relied on the DON for her clinical expertise. ************************* On 9/17/2021 at 9:49 PM, the facility submitted an acceptable Removal Plan which documented: F835 TRAINING [DATE] - The Corporate Director of Clinical Services (DCS) educated and trained the DON and the Administrator to proper oversight and monitoring of staff regarding hoyer lift and sling procedures. This included evaluating slings for wear and tear and any potential compromise and the proper disposal of any compromised slings. They are to be removed from the floor immediately and disposed of in a bag in the dumpster. The oversight and monitoring by the DON and Admin will include reviewing the inservice sheet for employees and comparing to the work schedule of the nurses and CNA's, including agency, everyday for all three shifts to ensure training was completed prior to working a shift. They will also review all new hires of Nurses and CNA's for training on the hoyer lift, lift pad inspections and potential disposal of compromised lift pad procedures upon orientation. September 17.2021-The DCS conducted a one-on-one education with the DON INSPECTION The Corporate Director of Clinical Services will monitor the DON to ensure compliance with education provided in her inservice of September 17,2021. Education will be ongoing with monitoring weekly for four weeks, then monthly for 3 months. ********************************************* After reviewing the facility's information provided in their Removal Plan and verifying the immediate actions had been implemented, the scope/severity level of F835 was lowered to a D level on 9/17/2021, to allow the facility time to monitor and/or revise their corrective actions as necessary to achieve substantial compliance. The deficiency was cited as a result of the investigation of complaint/report number AL 524.

Based on observations, interviews and a review of the facility's documents titled, Resource: Taking Accurate Temperatures, Proper Handwashing Technique, and Receiving And Storing Foods, the facility failed to ensure on 3/8/21 and 3/9/21: 1. dietary staff did not sanitized the food thermometer in the red bucket sanitizing solution and ensure staff washed her hands after using the cloth from the red bucket solution; and 2. food in the deep freezer was labeled with an open and use by date. This had the potential to affect 41 of 41 residents who received meals from the kitchen. Findings Include: 1. A review of a policy titled, Resource: Taking Accurate Temperatures with a date of 2017 revealed .Taking Accurate Temperatures using metal stem thermometers 1. To take temperatures, a clean, rinsed, sanitized and air-dried thermometer that is the metal stem type, .Thermometers should be sanitized thermometers may be sanitized using a dish machine or three sink method. In between uses at one meal, an alcohol swab may be used to sanitize . A review of a facility document addressing proper handwashing technique revealed, .Objective The attendee will understand the importance of following proper handwashing techniques in order to prevent the spread of foodborne pathogens that are major cause of foodborne, illnesses. It is important to wash their hands when performing the following activities: . After using any cleaning, polishing or sanitizing solution . On 03/09/21 at 10:46 AM, the staff was observed using the cleaning cloth from the red sanitizing buckle to clean the side of the mash potatoes pot. Employee Identifier (EI) #7 (the cook) did not wash her hands after squeezing the cloth out. EI #7 was also observed cleaning off the top of grill with the cloth from the solution bucket. EI #7 did not wash her hand after cleaning the top of the grill. EI #7 cleaned the preparation table with the cloth from the sanitizer bucket and put the cloth back in the bucket. EI #7 did not wash her hands after using the cloth. Also, during this observation EI #7 was observed dipping a thermometer in the red bucket after taking it out of the mash potatoes. EI #7 put the thermometer holder back on the thermometer and put it in her apron pocket. At 10:56 AM, EI #7 used the thermometer from her pocket and placed it in the mash potatoes again. Afterward, she dipped the thermometer in the red bucket and placed the cap back on it and put it back in her apron pocket. EI #7 took the temperature of the collard greens and dipped the thermometer in the solution bucket and placed the thermometer back in her apron pocket. On 03/10/21 at 8:42 AM, an interview was conducted with EI #7, first shift cook. EI #7 was asked how should the thermometer be sanitized. EI #7 replied, the thermometers are placed in a solution from the third compartment sink in a cup. EI #7 was asked how did she sanitize the thermometer on 3/9/21. EI #7 replied, on yesterday, she did it incorrectly. EI #7 stated she used the sanitizing bucket. EI #7 stated, she dipped the thermometer in the sanitizer solution bucket used for the tables. EI #7 was asked why did she sanitize the thermometer by dipping it into the red bucket solution. EI #7 replied, she was trying to get the food on the line. EI #7 continued to say she was in a hurry. EI #7 was asked when the water was put in the red bucket. She replied she put it in there in the morning when she got there at 6am. When asked if the water was changed prior to the lunch meal, she replied she did not change it. EI #7 was asked what was in the red bucket. EI # 7 replied, a towel and solution. EI #7 was asked what kitchen equipment did she wipe down with the cloth from the red bucket. EI #7 replied, the counter top where she was cooking and the grill area. EI #7 was asked what did she do with the cloth after wiping down kitchen equipment. EI #7 replied, she put it back in the red bucket. EI #7 was asked what food temperatures did she take after dipping the thermometer in the red bucket. EI #7 replied, pork chop, mash potatoes, greens, and the hamburger patties. EI #7 replied, basically all of her food. EI #7 was asked when wiping down the preparation table, and the grill in the kitchen was the water solution in the red bucket clean. EI #7 replied, no ma'am. EI #7 was asked why was it important that the thermometer be sanitized properly before taking food temperatures. EI #7 replied, because of cross contamination. EI #7 continue to say if it was not clean you would contaminate the second food item that she was trying to take the temperature. EI #7 was asked what was the facility's policy on sanitizing thermometer. EI # 7 replied, put in a cup with the sanitizing solution. EI #7 was asked how had she been trained to sanitize the food thermometer. EI #7 replied, put it in the solution water. EI #7 was asked did she wash her hands after using the cloth from the red bucket solution. EI #7 replied, no ma'am. EI #7 was asked did she wash her hands each time she used the cloth from the sanitizer solution bucket. EI #7 replied, no ma'am. EI #7 was asked why did she not wash her hands after using the cloth from the red solution bucket. EI #7 replied, she forgot to. On 3/10/21 at 9:11 AM, an interview was conducted with EI #8, Dietary Manager. EI #8 was asked should staff wash their hands after using the cloth from the red bucket solution. EI #8 replied, yes. EI #8 was asked why should staff wash their hands after using the cloth from the red bucket solution. EI #8 replied, because the solution have chemical in it and it could contaminate the food. 2. A review of a facility document revealed, . Outline Proper receiving and storing procedures are essential to safe food handling and the first control point in the facility. Receiving . Label items with the date of delivery and the use by date. On 3/8/21 at 05:10 PM., a tour of the kitchen was conducted. The surveyor along with EI #8, observed chicken fingers in the chest freezer out of the original box with no used by date on it. There were about 30 chicken fingers in a bag. There was diced ham in a medium bag with no name of what it was and no use by date. On 3/10/21 at 9:11 AM, an interview was conducted with EI #8. EI #8 was asked what food items was in the freezer with no label on it. EI #8 replied, the chicken fingers and diced ham. EI #8 was asked, was the chicken fingers out of the original container. EI #8 replied, yes ma'am. EI #8 was asked, why was there no label on the food items. EI #8 replied, they (staff) intended to put the label on the food but probably got redirected. EI #8 was asked, who was responsible for labeling food items before placing them into the freezer. EI #8 replied, the cook. EI #8 was asked what did the facility policy say regarding labeling food items when placing them in the freezer. EI #8 replied, once the food comes in they need to be dated with a date and a use by date. EI #8 was asked why was it important to label food items before placing them in the freezer. EI #8 replied, so they can tell how long to keep the food and when to discard it.

Based on observations, interviews, and record review the facility failed to ensure Resident Identifier's (RI) #17, 34, and 29's, residents with urinary catheters, had a care plan specific enough to guide urinary catheter care, and RI #6 had a care plan for oxygen use. This affected three of three sampled residents with urinary catheters, and one of one sampled residents with oxygen. Finding Include: 1) RI #17 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. A review of RI #17's Active Orders As Of: 3/20/2021 revealed a prescriber written order . Change suprapubic catheter . (Q) month and as needed (PRN) .dated 10/30/2020. On 3/9/21 at 9:34 AM RI #17 was observed with an indwelling catheter. 2. RI #34 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. A review of RI #34's Active Orders As Of 3/11/2021 revealed an order . Change suprapubic catheter . monthly . and as needed (PRN) dated 10/30/2020. On 3/9/21 at 2:21 PM catheter bag was observed hanging at bedside. 3. RI #29 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #29's Active Orders As Of 3/10/2021 revealed an order . Change suprapubic catheter . each month . and as needed (PRN) dated 11/20/2020. On 3/9/21 at 2:46 PM RI #29's urinary catheter site was observed. On 3/10/21 at 12:11 PM an interview was conducted with EI #21, Certified Nursing Assistant (CNA), a staffing agency CNA. EI #21 was asked, how did she know which residents required catheter care during her shift. EI #21 replied, the nurse told her. On 3/10/21 at 3:48 PM an interview was conducted with EI #20, CNA. EI #20 was asked, how did she know which residents needed catheter care. EI #20 replied, she was familiar with the residents that needed catheter care. EI #20 was asked, when agency staff were there, how did they know which residents required catheter care and when it was to be performed. EI #20 replied, the agency staff were given verbal instructions. EI #20 was asked, did CNAs use care plans to guide care. EI #20 replied, yes, it was on the kiosk. EI #20 was asked, was catheter care on the kiosk. EI #20 replied, the kiosk did not indicate if the resident had a catheter. On 3/10/21 at 3:57 PM an interview was conducted with EI #4, Registered Nurse (RN), Director of Clinical Services, previous Minimum Data Set (MDS) Coordinator. EI #4 was asked, when was RI #17's suprapubic catheter inserted. EI #4 replied, he/she was admitted with it on 12/14/18. EI #4 was asked, who was responsible for ensuring residents' care plans were comprehensive to their needs. EI #4 replied, each department did their own; EI #6 did the nursing sections. EI #4 was asked, when should a resident with a catheter have a care plan addressing the urinary catheter. EI #4 replied, anytime the resident had a catheter. EI #4 was asked, what interventions would be included on a care plan for a urinary catheter. EI #4 replied, cleaning information, monitoring for infection, notification of physician if removed, and emptying every shift. On 3/10/21 at 4:29 PM during an interview with EI #6, EI #6 was asked, did RI #29 have a care plan for urinary catheter and urinary catheter care specific enough to guide the provision of care. EI #6 replied, no. EI #6 was asked, why not. E I#6 replied, it did not have frequency for catheter care. On 3/11/21 at 9:32 AM an interview was conducted with EI #6. EI #6 was asked, what was the purpose of care plans in the facility. EI #6 replied, to paint an adequate picture so staff can provide care to the resident. EI #6 was asked, when should a care plan be specific enough to guide the provision of catheter care. EI #6 replied, when the resident had a catheter. EI #6 was asked, did RI #34 have a suprapubic catheter. EI #6 replied, yes, he/she had it since she was hired in 11/2019. EI #6 was asked, did RI #34 have a care plan for urinary catheter care specific enough to guide the provision of care. EI #6 replied, no. EI #6 was asked, what did the care plan not include. EI #6 replied, how often to perform suprapubic catheter care. EI #6 was asked, when should the catheter care of cleaning the catheter be performed. EI #6 replied, every day. EI #6 was asked, as of 3/10/21, did RI #17, 29, or 34 have a care plan specific enough to guide the provision of catheter care. EI #6 replied, not until 3/10/21. EI #6 was asked, did RI #17, 29, or 34 have a care plan that included measurable objectives and timeframes to meet their need of catheter care, cleaning of the catheter. EI #6 replied, no. EI #6 was asked, when should a resident with an indwelling catheter not have a care plan or physician's orders [REDACTED]. EI #6 replied, they should not. On 3/11/21 3:08 PM an interview was conducted with EI #2, RN, Director of Nursing (DON). EI #2 was asked, what was the purpose of care plans in the facility. EI #2 replied, to document the care that was needed for residents. EI #2 was asked, when should a resident with an indwelling urinary catheter have a care plan for catheter. EI #2 replied, when it was placed, and the care plan should be re-assessed and changes made as necessary. EI #2 was asked, what interventions should the catheter care plan include. EI #2 replied, monitoring for redness and infection, and cleaning the catheter daily or as needed. EI #2 was asked, when should a care plan be specific enough to guide the provision of catheter care including cleaning the catheter. E I#2 replied, always. EI #2 was asked, why was important to have a care plan specific enough to guide the provision of catheter care that included cleaning the catheter. EI #2 replied, the care plan communicated with staff how to care for the catheter and prevent infection. EI #2 was asked, what was the potential harm to a resident with an indwelling urinary catheter and without a care plan that addressed cleaning the catheter. EI #2 replied, higher risk for infection. 4. RI #6 was admitted to the facility on [DATE] and had a [DIAGNOSES REDACTED]. A review of RI #6's Medication Administration Record [REDACTED]. Start date 2/8/2021. On 3/11/21 at 8:31 AM an observation was made of RI #6 with oxygen infusing through a nasal cannula. On 3/11/21 at 9:25 AM an interview was conducted with EI #6, LPN, MDS Coordinator. EI #6 was asked, did RI #6 receive oxygen. EI #6 replied, yes. EI #6 was asked, should a resident receiving oxygen continuously or as needed be care planned. EI #6 replied, yes. EI #6 was asked, to present the care plan for oxygen use. EI #6 replied, it was not there. EI #6 was asked, should RI #6 have a care plan. EI #6 replied, yes. EI #6 was asked, what was the purpose of a resident having a care plan. EI #6 replied, to paint a picture of the resident so staff can adequately take care of their needs. EI #6 was asked, who was responsible for ensuring he/she had a care plan. EI #6 replied, herself.

Based on observation, interview, and a review of a facility policy titled HIPPA (Health Insurance Portability and Accountability Act) PRIMARY RULES EMPLOYEE SECURITY AND CONFIDENTIALITY AGREEMENT, the facility failed to ensure a Registered Nurse (RN) Employee Identifier (EI) #9, did not leave the Electronic Medication Administration Record [REDACTED]. This deficient practice affected RI #17. One of five residents observed during the medication administration pass, and EI # 9 one of four nurses observed administering medication. Findings Include: Review of the facility's undated HIPPA PRIMARY RULES EMPLOYEE SECURITY AND CONFIDENTIALITY AGREEMENT revealed, . 2. I will treat all information received in the course of my employment with the provider, which relates to the residents of the provider, as confidential and privileged information. RI #17 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. On 3/09/2021 at 10:00 AM, the surveyor observed a MAR indicated [REDACTED]. EI #9 a Registered Nurse was observed walking out of RI #17's room to the unattended cart. The surveyor pointed at the screen and asked EI #9 what information was shown on the screen. EI #9 stated, patient information. The surveyor asked EI #9 why was the screen left open to view by anyone in the hall. EI #9 stated, she should have minimized her screen prior to leaving the medication cart. The surveyor asked EI # 9 why was it important to utilize the privacy screen when administering medication. EI #9 stated, anyone could walk by and view personal information and that was a HIPPA violation.

Based on interview, medical record review and a review of the CMS's (Center for Medicare Services) Long-Term Care Facility RAI (Resident Assessment Instrument) 3.0, User's Manual Version 1.17.1 October 2019, the facility failed to: 1) accurately code RI (Resident Identifier) #38 Admissions MDS's (Minimum Data Set) to reflect he/she was receiving [MEDICAL TREATMENT], 2) accurately code RI #17's Quarterly MDS as having an indwelling catheter. This deficient practice affected two of 21 sampled residents whose MDS's were reviewed. 1) A review of the CMS's, RIA 3. 0 User's Manual, Chapter 3, . MDS Items (O) documented: . O0100J, [MEDICAL TREATMENT] Code . renal dialyses which occurs . at another facility record treatment of [REDACTED]. RI #38 was admitted to the facility on [DATE] and readmitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. RI #38's March 2021 physician's orders [REDACTED]. one time a day every other day . Order date 11/01/2020. RI #38's Admission MDS 's dated 12/28/20 and 1/13/21 were not code for [MEDICAL TREATMENT]. On 3/10/21 at 3:34 PM, an interview was conducted with EI ( Employee Identifier) #6, LPN, (Licensed Practical Nurse), MDS Coordinator. EI #6 was asked if RI #38 was on [MEDICAL TREATMENT]. EI #6 said yes. EI #6 was asked if RI #38 was coded for [MEDICAL TREATMENT] on Section O of his/her Admission MDS dated [DATE]. EI #6 said no he/she was not. EI #6 was asked should RI #38 had been coded for [MEDICAL TREATMENT]. EI #6 said, yes he/she should have. EI #6 was asked if RI #38 was coded for [MEDICAL TREATMENT] on the Section O for his /her Admission MDS dated [DATE]. EI #6 said no he/she was not. EI #6 was asked should RI #38 had been coded for [MEDICAL TREATMENT]. EI #6 yes, she/he should have been. EI #6 was asked why RI #38 was not coded for [MEDICAL TREATMENT]. EI #6 said she did not know why. EI #6 was asked what was the importance of having an adequately coded MDS. EI #6 said to paint a picture of the resident and for payment. 2) RI #17 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. A review of RI #17's Active Orders As Of: 3/20/2021 revealed a prescriber written order . Change suprapubic catheter . (Q) month and as needed (PRN) . dated 10/30/2020. A review of RI #17's Quarterly MDS with a date of 12/1/2020 revealed the resident was coded for an indwelling urinary catheter in Section H. On 3/09/21 at 9:34 AM RI #17 was observed to have an indwelling urinary catheter. On 03/10/21 at 3:57 PM an interview was conducted with EI #4, Registered Nurse, Director of Clinical Services, former MDS coordinator. EI #4 was asked, when was RI #17's suprapubic catheter inserted. EI #4 replied, he/she was admitted with it on 12/14/18. EI #4 was asked, who was responsible for accurately completing the MDS. EI #4 replied, the MDS coordinator. EI #4 was asked, when was she the MDS coordinator. EI #4 replied, 2019 until November, 2020. EI #4 was asked, when different staff from different departments are completing sections of the MDS, who was ultimately responsible for accuracy of MDS. EI #4 replied, she was or whoever submitted it. EI #4 was asked, what was the date on the most recent MDS for RI #17. EI #4 replied, December 1, 2020. EI #4 was asked, what did that MDS indicate for section H.0100 question A. EI #4 replied, it said no, which indicated that he/she did not have an indwelling catheter. EI #4 was asked, did he/she have an indwelling catheter at that time. EI #4 replied, yes. EI #4 was asked, who completed the MDS dated [DATE]. EI #4 replied, the nursing department completed it and she locked and signed it. EI #6 was asked, what was the potential harm to a resident, with an indwelling urinary catheter or suprapubic urinary catheter, when the MDS indicated the resident did not have a urinary catheter. EI #4 replied, the data would have been entered by error or mistake and it would not give an accurate picture of the resident.

Based on record review, interviews, and review of a facility policy titled WEIGHT LOSS INTERVENTION, the facility failed to recognize and assess a ten pound weight loss over eight days for Resident Identifier (RI) #200. This affected one of four residents sampled for weight loss. This deficient practice was cited as the result of the investigation of complaint/ report number AL 289. Findings Include: A review of a facility policy titled, WEIGHT LOSS INTERVENTION POLICY & PROCEDURE with an effective date of 12/1/2010 revealed: Purpose: To intervene in unplanned weight loss process and prevent further decline in weight status and/or restore weight back to usual body weight . RI #200 was initially admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. A review of a facility form titled Weights and Vitals Summary revealed weights for RI #200 for the month of January 2021: 1/21/21 105 pounds and 1/29/21 95.4 pounds. This documentation revealed a ten pound weight loss in eight days. On 3/11/21 at 2:15 PM, an interview was conducted with Employee Identifier, (EI )#5, Dietary Consultant. EI #5 was asked, what was RI #200's admission weight. EI #5 replied, 119 pounds and 64 inches on 1/18/19. EI #5 was asked, what were RI #200's weight concerns. EI #5 replied, fluctuating weight which was addressed several times in November 2020, January and February of this year. EI #5 was asked, how often did she assess residents. EI #5 replied, monthly, with readmissions, and as needed. EI #5 was asked, what was RI #200's January 2021 weights. EI #5 replied, she assessed the resident's weight of 105 on 1/29/21, the staff gave her a weight of 105. EI #5 was asked, what about the weight of 95 pounds on 1/29/21. EI #5 replied, she was not aware of a weight of 95 pounds, the staff gave her a weight of 105, and she did her assessment based on that weight. EI #5 was asked, why was RI #200's weight of 95 pounds in January not addressed. EI #5 replied, she was not aware of a 95 pound weight. On 3/11/21 at 2:30 PM an interview was conducted with EI #1, Administrator and EI #2, Director of Nursing was present. EI #1 was asked, who did the weights. EI #1 replied, the Certified Nursing Assistants (CNA), there was inconsistencies with which CNAs did them. EI #1 was asked, what was the process for obtaining weights. EI #1 replied, the CNA gets the weight and gives it to the nurse or the dietary manager for them to record it in the resident record. EI #1 was asked, who entered RI #200's weight of 95 pounds on 1/29/21 in the record. EI #1 replied, EI #8, the Dietary Manager. EI #1 was asked, why was the ten pound weight loss not addressed. EI #1 replied, she did not know; it must have been an oversight; had they realized it, it would have been addressed. EI #1 was asked, when the weight was discovered at a ten pound loss, what should have been done. EI #1 replied, re-weigh the resident to determine if it was actual weight and assess the nutritional status. EI #1 was asked, what would the harm be in not recognizing a weight loss of ten pounds in a week. EI #1 replied, there could be continued weight loss and not identifying a change in the resident's nutritional needs. On 3/11/21 at 3:15 PM, an interview was conducted with EI #8, Dietary Manager. EI #8 was asked, who entered RI #200's weights to the record on 1/21/21 and 1/29/21. EI #8 replied, she did. EI #8 was asked, why was the weight of 95 pounds, a ten pound loss not identified. EI #8 replied, it was an oversight. When she entered the weight of 95 pounds only that weight was seen and not the previous ones. EI #8 was asked, what was the policy for addressing weight loss. EI #8 replied, assess the weights on admit and on readmit, then refer to the dietary consultant. EI #8 was asked, what was the harm in not recognizing a ten pound weight loss on a resident. EI #8 replied, it could result in malnutrition.

Based on observation, interviews and review of the (YEAR) Food Code, the facility failed to ensure there was an air gap between the 3 compartment sink and sewage drain. This has the potential for backflow from the sewage to the sink. This was observed on 1/14/20 and had the potential to affect 51 of 51 residents receiving meals from the kitchen. Findings Include: A review of the FDA (YEAR) Food Code revealed: . 5-402.11 Backflow Prevention. (A) . a direct connection may not exist between the SEWAGE system and a drain originating from EQUIPMENT in which FOOD, portable EQUIPMENT, or UTENSILS are placed. On 1/14/20 at 11:00 AM, the surveyor entered the kitchen to observe tray line. The surveyor observed a dietary staff at the 3 compartment sink washing pots and pans. There was no air gap noted under the sink. The drain extended from under the sink into the wall behind the sink. On 1/14/20 at 11:05 AM, an observation and interview was conducted with Employee Identifier (EI) #4, Dietary Manager. EI #4 was asked, was there a direct connection between the 3 compartment sink and the sewage drain. EI #4 replied, yes. EI #4 was asked if there was an air gap. EI #4 replied, no, but she would like for the maintenance man to check it. EI#4 was asked if she knew what an air gap was. EI #4 replied, yes it prevented backflow from sewage back to the sink. EI #4 was asked if there should be a direct connection from the sink to the sewage. EI #4 replied, no, because there could be back flow from the drain back to the sink. EI #4 was asked what was washed in the 3 compartment sink. EI #4 replied, pots and pans. EI #4 was asked how many residents received meals from the kitchen. EI #4 replied, 51. On 1/14/20 at 11:10AM, an observation and interview was conducted with EI #5, Maintenance Supervisor. EI #5 was asked, if there was a direct connection between the 3 compartment sink and the sewage drain. EI #5 replied, yes. EI #5 was asked what was the potential for harm with a direct connection. EI #5 replied, possibly back flow from the sewage to the 3 compartment sink. On 1/14/20 at 11:20 AM, the Administrator, EI #1, entered the kitchen and made an observation under the 3 compartment sink. An interview was conducted at that time. EI #1 was asked where was the air gap. EI #1 replied, he did not see it. EI #1 was asked what would the potential harm be in no air gap. EI #1 replied, he was not sure other than related to water draining from the sink to the sewage drain.

Based on observation, interviews and review a facility policy Clean and Used Linen Policy and Procedure, the facility failed to ensure laundry staff was not transporting clean linens to the main building of the facility from the outside laundry building uncovered. This was observed on 1/13/20 and had the potential to affect 57 residents residing in the facility. Findings Included: A review of a facility policy titled Clean and Used Linen Policy and Procedure with an effective date of (MONTH) 2019, revealed .From Pick-up Point to the Laundry: .Each linen storage cart must be carefully directed with the clean laundry on the cart covered. On 1/13/20 at 3:39 PM, the surveyor observed a laundry aide delivering linens to the hall on a 3 shelf rolling cart. On the very top of the cart was 2 stacks of brown and white blankets that were not covered. The middle shelves had towels, gowns, cloth pads, sheets and bath cloths, this section was covered with the blue cover over the cart. The laundry aide went to a linen closet, turned up the blue cover, placing it on top of the uncovered blankets and removed linens to place in the linen closet. On 1/13/20 at 3:44 PM, an interview was conducted with EI #6, Laundry Aide. EI #6 was asked what was on the cart. EI #6 replied, towels, sheets, pads, gowns and blankets. EI #6 was asked what was on the very top of the cart. EI #6 replied, blankets. EI #6 was asked if the blankets were covered. EI #6 replied, no. EI #6 was asked what was the policy on transporting linens and laundry. EI #6 replied, everything should be covered. EI #6 was asked where was the laundry department. EI #6 replied, out behind the facility. EI #6 was asked if she had to go out of the laundry room to outside then inside to the facility. EI #6 replied, yes. EI #6 was asked what was the harm in the linens not covered then transported from the outside laundry to the facility uncovered. EI #6 replied, germs could get on them. On 1/14/20 at 2:38 PM an interview was conducted with EI #5, Maintenance and Laundry Supervisor. EI #5 was asked how should linens be transported from the laundry department to the main building. EI #5 replied, on a cart and covered; everything being transported from or to the laundry should be covered. EI #5 was asked what would the harm be in linens being transported from the laundry department to the main building uncovered. EI #5 replied, there was a contamination risk.

Based on observation, interviews, review of the FACILITY ASSESSMENT, the policies titled CAREGIVERS OF PLEASANT GROVE, INC. -PPP 500 HEALTH AND SAFETY and ABUSE PREVENTION, the ADMINISTRATOR JOB DESCRIPTION, the facility's investigation file, a facility document titled CareGivers of Pleasant Grove, Inc. Employee Terminations, the State Agency's Online Incident Reporting System Report and the ALABAMA UNIFORM INCIDENT/OFFENSE REPORT, the facility failed to ensure the facility assessment addressed how the facility would maintain the safety of the physical environment for the residents and the staff. The facility's Administrator, responsible for the day to day functions of the facility, failed to ensure the physical environment of the facility was safe and secure for residents and staff. These failures contributed to residents' narcotic medication and petty cash being stolen from the facility during a robbery on 4/24/2019. During the 11:00 PM to 7:00 AM shift on 4/24/2019, two masked individuals armed with guns, entered the facility by way of the facility's back door, proceeded to each of the two facility's nurses' station and had the licensed staff to open up the narcotic boxes on each of the medication carts. The two masked armed individuals stole all of the residents' controlled medications and petty cash from both of the medication carts then exited the facility by way of the emergency door on Station 2. According to staff interviews, the back door could be entered by putting in the door code but the door should also have been locked with a key. The door code was only to alert staff. It was never a locking mechanism. Interviews with facility staff revealed they could not remember a key ever being used to lock/secure the back door. This deficient practice affected 34 of the 53 residents residing in the facility on 4/24/2019 who were prescribed narcotic medication, and placed all 53 residents in immediate jeopardy for serious injury, harm, impairment or death. Beginning on 5/18/2019 at 1:40 PM, the Interim Administrator/Director of Operations, Director of Nursing (DON) and the Administrator in Training were notified of the findings of immediate jeopardy and given a copy of the Immediate Jeopardy (IJ) template. Findings include: The FACILITY assessment dated [DATE] and reviewed by the facility's QAA/QAPI (Quality Assessment & Assurance/Quality Assessment Performance Improvement) committee on 10/26/2018, documented . Physical environment and building/plant List physical resources for the following categories. Review the resources in the example below and modify as needed. If applicable, describe your processes to ensure adequate supplies and to ensure equipment is maintained to protect and promote the health and safety or residents . Other physical plant needs . exit ways Nursing & Maintenance/Designee observation daily/PRN (as needed) . In a telephone interview on 5/17/2019 at 8:08 AM, Employee Identifier (EI) #9, the Corporate Director of Plant Operations was asked what was meant in the Facility Assessment about monitor exit ways daily and PRN (as needed). EI #9 replied, he wasn't exactly sure but assumed it meant checking the door daily when rounding. EI #9 commented there was not a form used to document the monitoring. In an interview on 5/17/2019 at 12:20 PM, EI #1, the Interim Administrator/Director of Operations was asked in the Facility Assessment what was meant by nursing and maintenance/designee will observe daily and PRN. EI #1 replied, It looks like there should be a door check of the exit ways according to what I am reading. When asked if that had been done, EI #1 stated that she had not seen any documentation where the exit doors were observed daily and PRN. EI #1 was asked should the facility have implemented the recommendations from the Facility Assessment. EI #1 replied, Yes ma'am. In a follow up interview on 5/18/2019 at 10:41 AM, EI #1 was asked when the Facility Assessment was completed, did the facility look at the environment to make sure there were interventions in place to keep the residents and employees safe. EI #1 looked through the Facility Assessment and replied no. EI #1 commented that is why the facility was going to adjust their assessment to the standards that were required. The facility's policy titled CAREGIVERS OF PLEASANT GROVE, INC. - PPP 500 HEALTH AND SAFETY effective 12/1/2006, documented I. PURPOSE To maintain a safe environment for the health and safety of residents and staff. II. POLICY It is the policy of CAREGIVERS OF PLEASANT GROVE, INC. to provide a safe environment for all employees, residents and visitors of the facility, through the development and maintenance of a sound health and safety program. Each facility will have a risk management Quality Circles Action Team . III. RESPONSIBILITY A. It is the responsibility of the Administrator to develop and maintain a health and safety program for the facility. B. It is the responsibility of the Administrator to see that possible hazards are identified, eliminated or controlled. D. It is the responsibility of the Administrator to establish a Safety Program within the facility. E. It was the responsibility of the Risk Management Team to identify hazards and make specific recommendations of corrective and/or preventive (preventative) measures, and to report such at the monthly safety meetings to the quarterly Quality Assessment and Assurance Committee. The facility's ADMINISTRATOR JOB DESCRIPTION documented . General Purpose: To direct the day-to-day functions of the facility in accordance with current federal, state and local standards governing long-term care facilities to ensure that the highest degree of quality care can be provided to the residents at all times . The facility's policy titled ABUSE PREVENTION revised 11/28/2016, documented I. PURPOSE . Misappropriation of resident property: deliberate misplacement, exploitation, or wrongful, temporary or permanent use of a resident's belongings or money without the resident's consent . II. POLICY . Each resident also has the right to be free from mistreatment, neglect, and misappropriation of personal property or exploitation . IV. RESPONSIBILITY . 2. Administrator is responsible to ensure that all aspects of this program are effectively implemented. According to the Online Incident Reporting System Report on 4/24/2019 at 7:00 AM, the facility submitted an allegation of Misappropriation of Resident Property to the Alabama State Survey Agency. The report indicated on 4/24/2019 at 2:42 AM, two men armed with guns entered the facility and robbed the charge nurses of all narcotics on the medication carts. During an observation on 5/14/2019 at 4:16 AM with EI #3, a Certified Nursing Assistant (CNA), the lock on the back gate was observed not to be locked. During an interview on 5/14/2019 at 4:31 AM, EI #3, a CNA acknowledged that she was working in the facility during the 11:00 PM to 7:00 AM shift on 4/24/2019. When asked why the back gate was not locked, EI #3 stated she didn't know. EI #3 explained the 11:00 PM to 7:00 AM shift goes out in the morning to put their trash in the dumpster, so someone from the 3:00 PM to 11:00 PM shift must have left the gate unlocked. EI #3 stated the two masked robbers stole all the residents' narcotic medication on both medication carts and then exited the building. When asked if she heard an alarm sound when the robbers entered the facility, EI #3 replied No. They must have had the code. They must have gotten it from somebody who use to work here. EI #3 was asked how the lock on the back gate should be. EI #3 replied, It should be locked at all times. In a telephone interview on 5/14/2019 at 1:17 PM, the Detective with the local police department stated physical security was a big point in the robbery at the nursing facility. He commented there were two places that should have been locked that were not at the time the robbers entered the facility. In an interview on 5/14/2019 at 5:23 AM, EI #4, a Registered Nurse (RN) acknowledged that she was working in the facility during the 11:00 PM to 7:00 AM shift on 4/24/2019. EI #4 explained that two masked robbers entered the facility and stole all the residents' narcotic medication on both medication carts and $22 of residents' petty cash that was located on the Station II medication cart. When asked if she heard an alarm sound when the robbers entered the facility, EI #4 said No, I said (EI #5) they must have put the code in because there was no alarm . EI #4 was asked what door the robbers entered. EI #4 answered, the back door by the smoking area. EI #4 commented At that time they came straight through the gate because at that time the lock was broke. When asked how long the lock had been broke, EI #4 replied she was not sure. EI #4 stated the lock on the back gate should be locked at all times. When asked who has the code to the back door, EI #4 stated Pretty much everyone who works in the facility to my understanding. It had not been changed for years . In an interview on 5/15/2019 at 1:32 PM, EI #12, a Licensed Practical Nurse (LPN) was asked who has access to the door codes. EI #12 replied, the staff. When asked about if the residents had access to the door codes, EI #12 answered They are not supposed to. EI #12 was asked how often the door codes are changed. EI #12 stated, up until the incident the door codes had not been changed. According to EI #12, since the robbery incident on 4/24/2019, the staff had been in-serviced not to give the door codes to residents, family or anyone that was not an employee of the facility. During a random observation on the smoking patio on 5/14/2019 at 9:53 AM, a resident informed the State Surveyor that if she wanted to go back into the facility, she had to put in the code. The resident gave the State Surveyor the code to re-enter the facility. The State Surveyor put the code into the keypad that was given by the resident and entered the facility. On 5/15/2019 at 2:48 PM, EI #5, a LPN acknowledged that she was working in the facility during the 11:00 PM to 7:00 AM shift on 4/24/2019. EI #5 explained that two masked robbers entered the facility and stole all the residents' narcotic medication on both medication carts and the residents' petty cash that was located on the Station II medication cart. When asked who has the code to the back door, EI #5 replied Everybody in the facility, the residents as well, possibly family. When asked if the code on the back door had ever been changed, EI #5 answered, No. During an interview on 5/15/2019 at 3:55 PM, EI #10, a CNA acknowledged that she was working in the facility during the 11:00 PM to 7:00 AM shift on 4/24/2019. EI #10 stated the two masked robbers armed with guns stole all the residents' narcotic medication and the residents' petty cash that was located on the medication carts. EI #10 was asked, which door the robbers entered. EI #10 answered, They had to have come in the back door. They (the robbers) knew the code because the alarm goes off if you open the door without putting the code in. When asked if the back door locks, EI #10 replied It does now. EI #10 acknowledged the back door did not lock prior to the robbery on 4/24/2019. EI #10 was asked who has the code to the back door. EI #10 answered, everyone that worked in the facility and the residents that go out of the facility to smoke. On 5/15/2019 at 4:59 PM, the surveyor conducted an interview with EI #7, the Maintenance Supervisor. EI #7, who has been employed at the facility for about a month stated the facility has four entrance/exit doors. When asked about the back door, EI #7 stated there was a key pad on the inside and outside but he could not answer whether the door locked. EI #7 explained that after the incident on 4/24/2019, the back door now locks at 7:00 PM to 6:00 AM. When asked how often the door codes are changed, EI #7 replied that he didn't know. EI #7 explained that at the facilities he had worked in prior, it was up to the facility when to change the door code access. EI #7 stated that he was notified by the Interim Administrator on 4/24/2019 that someone had robbed the facility. When asked if the lock on the gate in the back of the facility was locked at the time of the robbery, EI #7 replied he didn't know. EI #7 was asked, should the gate have been locked and he said It should have been. EI #7 was asked who had the access to the door codes. EI #7 replied, Everybody, all employees. I'm sure some residents now. When asked do residents' families and visitors have access to the door codes, EI #7 replied Probably, don't really know. When asked how does the facility secure the physical security of the building since the robbery on 4/24/2019, EI #7 said by having key locked doors and the gate should be locked at all times. When asked if the door codes are changed when an employee is terminated, EI #7 replied that would be a question for the Administrator. In a follow up interview on 5/15/2019 at 8:09 PM, EI #3, a CNA, who has been employed with the facility for [AGE] years was asked, has the code on the back door every been changed. EI #3 answered, she didn't think so. When asked has the back door ever locked since she has been employed at the facility, EI #3 stated, no ma'am. In a follow up interview on 5/16/2019 at 7:43 AM, EI #7, the Maintenance Supervisor was asked when he became aware that the back door was not being locked. EI #7 answered, That night of the incident I guess. When asked if the door was designed to be locked, EI #7 replied, it was designed to be locked. EI #7 was asked, if he knew why the door was not locked and he stated, no ma'am. EI #7 commented the previous Maintenance Supervisor no longer worked at the facility. According to a facility document titled CareGivers of Pleasant Grove, Inc. Employee Terminations, EI #6, the previous Maintenance Supervisor's employment was terminated on 3/20/2019. EI #6 had been employed by the facility since 3/17/2009. Multiple unsuccessful attempts were made on 5/16/2019 at 9:09 AM, on 5/16/2019 at 4:36 PM and 5/17/2019 at 10:15 AM, to contact EI #6 during the survey. On 5/16/2019 at 9:40 AM, EI #2, the DON was asked who had access to the facility's door codes. EI #2 answered I know everybody that works here does. But other than that I don't know. It's possible some residents have the code but we didn't give it to them. I don't know of an employee giving the residents the code. When asked how often the door codes are changed, EI #2 stated she didn't know. When asked if the door codes were changed after an employee was terminated, EI #2 said No ma'am they are not. EI #2 acknowledged that she was not sure if the back door locked prior to the robbery incident on 4/24/2019. EI #2 was asked if the stolen narcotics were considered misappropriation of resident property. EI #2 answered yes. During an interview on 5/16/2019 at 5:52 PM, EI #13, a LPN who works the 3:00 PM to 11:00 PM shift acknowledged prior to the robbery incident on 4/24/2019, the back door only had an alarm code on the back door. EI #13 stated the back door did not lock. On 5/16/2019 at 6:21 PM, EI #14, a 3:00 PM to 11:00 shift LPN was asked if the facility's back door was ever physically locked. EI #14 answered that she only knew of a door code and that she had never heard anyone say the back door locked. In a telephone interview on 5/17/2019 at 8:08 AM, EI #9, the Corporate Director of Plant Operations explained that after the robbery on 4/24/2019, he came to the facility. EI #9 stated from what he saw in the facility's video surveillance, it appeared the robbers came through the alley, punched in the code to the back door and entered the facility. EI #9 said it looked like the robbers knew the code. When asked who all has the code to the back door, EI #9 replied that it should only be the staff. EI #9 explained that since he had been with the facility, which was about [AGE] years, the door codes have never been changed; however, there was one incident where the code may have been changed because a resident entered the code and left the facility to go and smoke. In an interview on 5/17/2019 at 8:40 AM, EI #15, the Abuse Coordinator was asked who had access to the facility's door codes. EI #15 replied, Employees as far as I know. I don't know about residents. They (residents) shouldn't have it. In a follow up telephone interview with EI #5, a LPN, on 5/17/2019 at 9:20 AM, she was asked has there ever been a key to lock the back door that was kept at the nurse's station or on a key ring. EI #5 replied, Never heard of that. I have even asked if there was a key to the back door. I even tried my keys on the key ring for Station 1 and nothing fit . When asked if there was ever a system in place where the back door was locked after the last resident's smoke break, EI #5 answered no. On 5/17/2019 at 9:42 AM, the surveyor conducted an interview with EI #8, the Assistant Director of Nursing (ADON). EI #8 was asked if he ever knew the back door to be locked at night. EI #8 replied, no. EI #8 was asked if there was ever a key to lock the back door and he said no. In a telephone interview on 5/17/2019 at 11:29 AM, EI #16, the facility's Owner and prior Administrator was asked how did he expect the staff to ensure the physical environment was safe and secure for the residents and staff. EI #16 replied, that the facility was now locking the back door. In an interview on 5/16/2019 at 12:30 PM, EI #1, the Interim Administrator/Director of Operations stated she was notified on 4/24/2019 around 4:00 AM that the facility had been robbed. The robbers entered the back door by the smoking area, got all the (residents') medications and left out the side door. EI #1 said she was told who ever entered the facility keyed in the code and came in. The surveyor asked EI #1 was the back door designed to be locked. EI #1 said there was a key for staff to open and lock it. When asked if that was being done before the robbery. EI #1 said she had not heard anything to lead her to believe that was not being done. EI #1 said it was a concern when facility management got to looking further and saw where a key had not been used to get in the door. EI #1 said the masked individual just used the code to get in. EI #1 said the key would have been another measure to ensure the safety of the residents and staff. When asked if the back door was locked at the time of the robbery on 4/24/2019, EI #1 said it was not locked with a key. EI #1 was asked if the facility had a risk management Quality Circle Action team and she said no. EI #1 commented that the facility was going to develop a safety team and that it would be implemented during the next Quality Assurance meeting. Contained within the facility's investigation file was a typed statement which documented 4/26/19 RE: ROBBERY AT CAREGIVERS OF PLEASANT GROVE ON 4/24/19. ON 4/24/19 A FEMALE AND A MALE DID ENTER THE FACILITY AROUND 2:30 A.M. ARMED WITH GUNS. THEY DID TAKE THE NARCOTICS FROM THE FACILITY. NOTIFICATION WAS GIVEN TO STATE THE MORNING OF THE ROBBERY THAT A MISAPPROPRIATION OF RESIDENTS PROPERTY HAD [NAME]CURRED . AFTER THEY GOT ALL THE NARCOTICS THEY LEFT THE BUILDING THROUGH THE SIDE EXIT DOOR . INCLUDED IN THIS REPORT YOU WILL FIND: . 4. INVENTORY RECORD OF NARCOTICS THAT WERE TAKEN During an interview on 5/17/2019 at 9:42 AM, EI #8, the ADON acknowledged that he made the initial report to the State Agency regarding misappropriation of resident's property and he helped log the narcotics that had been stolen from the facility. According to the facility's inventory record, 34 residents' narcotic medication was stolen from the facility on 4/24/2019. Contained within the facility's investigation file was the ALABAMA UNIFORM INCIDENT/OFFENSE (police) REPORT dated 4/24/2019, which indicated the type of incident or offense was Robbery First Degree and Theft of Property First Degree (Greater than $2,500). The property description (items stolen) was listed as drugs/narcotics and cell phones. In a follow up interview on 5/17/2019 at 12:20 PM, EI #1, the Interim Administrator/Director of Operations was asked of if the risk management Quality Circle Action team should have already been in place. EI #1 answered, Yes. During an interview on 5/18/2019 at 10:41 AM, EI #1, the Interim Administrator/Director of Operations was asked when the armed robbers entered the facility on 4/24/2019, was the facility a safe environment for the residents and staff. EI #1 replied, No ma'am. When asked what should have been in place to ensure the safety of the facility's environment, EI #1 stated The back door should have been locked and the codes should have been changed periodically. In a follow up interview on 5/18/2019 at 11:39 AM, EI #9, the Corporate Director of Plant Operations acknowledged that the key the facility's back door had been found in the Maintenance Supervisor's office. When asked if the nurses had access to the key, EI #9 replied Evidently not. ************************* On 5/18/2019 at 11:30 PM, the facility submitted a Removal Plan which documented: Caregivers of Pleasant Grove Removal Plan On 4/24/2019 at 2:48 AM, two masked robbers entered the building by way of the back door using facility code for entrance and stole all of the controlled medication and petty cash that was on both med carts. On 4/24/2019 at 4:00 AM, the facility pharmacy was notified. On 4/24/19 at 12:06 PM, the facility received all controlled meds that had been stolen from the facility. From the time the meds were stolen until the time the pharmacy delivered the meds, 28 residents were not provided pain medications as ordered; however, the residents were assessed and those that verbalized complaints of pain, received pain medication from the STAT box /e-kit, as it was not stolen from the facility. On 4/24/2019, there were no verbalized complaints from residents receiving pain medication. The pharmacy billed the facility to replace the mediations. No other payment source was billed to replace the medications. The facility replaced petty cash. On 4/24/2019, the door codes were changed for resident and employee safety. On 4/24/2019, the door locks were rekeyed for resident and employee safety. On 4/24/2019 the door times were changed. The doors are locked at 7:00 PM and opened at 6:00 AM by nursing staff. On 4/24/2019, signs were posted at the nurses' station to remind staff of the locking and unlocking times of the doors. On 4/24/2019, staff was in-serviced about codes being changed at the back door, rekeying of both doors at facility, door lock times and safety procedures of the facility. All new hires will be inserviced upon hire by staff development/designee. Safety in-services will be ongoing until all staff have been inserviced. Staff development or designee will be responsible for training new hires on facility safety procedures. On 5/14/2019, the Interim Administrator/Director of Operations and Administrator in Training reviewed the facility assessment for needed revision concerning environmental safety. From the assessment it was revealed safety procedures needed to be added to the assessment on how exit doors are secure for safety of residents and staff. The new facility assessment, after changes are made will be reviewed by the QA committee to include the medical director. At this time changes for ensuring the safety of residents and staff have been made to include rekeying of the doors, changing the codes to the doors, changing the times the doors and gates are locked and opened. The door codes will be changed every 90 days. At the next QA meeting, all changes implemented will be discussed to see if new changes need to be made. On 5/17/2019, the monitoring sheets regarding locking doors and closing gates nightly were placed on Station 1. Monitoring of all shifts to include weekdays and weekends will be continued until substantial compliance is achieved. On 5/17/2019, staff in-serviced regarding the monitoring sheets. The nurse on Station 1 will be responsible for ensuring the doors are locked. Any staff found not to be following the facility new protocol for safety and security will receive re-education and/or disciplinary action. On 5/17/2019, the Administrator and/or designee began monitoring sheets to ensure compliance. Beginning on 5/18/2019, the facility system for changing the door codes will be every 90 days and always after staff termination. Social service will mail out a letter to all families and inform residents of the new hours of locking the doors, importance of not sharing the door codes, all doors have been rekeyed and the only way in is to ring the doorbell. On 5/18/2019, DON and Abuse Coordinator (responsible for reporting) were in serviced by the Interim Administrator on allegations of misappropriation of resident property and how an investigation should be conducted. The facility requests the immediacy be removed on 5/18/2019. The Administrator /designee is responsible for overseeing the implementation of the removal plan. ************************* After reviewing the facility's information provided in their removal plan and verifying the immediate actions had been implemented, the scope/severity level of F 584 was lowered to a D level on 5/19/2019, to allow the facility time to monitor and/or revise their corrective actions as necessary to achieve substantial compliance. This deficiency was written as the result of the investigation/report number AL 245.

Based on observation, interviews, and review of a facility policy titled, Laundry Policy & Procedures Handling Soiled & Clean Linen, the facility failed to ensure a Laundry Aide did not allow clean towels, sheets, wash cloths, and socks from the dryer to touch the staff's shirt on the their upper body area, and did not put one white sock and one white wash cloth in the large laundry container with other clothing after dropping them on the floor. This had the potential to affect one of three halls of residents (16 of 46 residents) in the facility. Findings Include: A review of a facility policy titled, Laundry Policy & Procedures Handling Soiled & Clean Linen with no date, revealed .a. Linen should not be allowed to touch the uniform or floor .to avoid contamination of air, surfaces, and persons . On 11/28/2018 at 12:10 p.m., the surveyor observed the laundry room in the facility. The surveyor observed Employee Identifier (EI) #2, a Laundry Aide, remove clean laundry from dryer one without an apron on over her clothes. EI #2 removed white towels, sheets, wash cloths, and socks from dryer one with the clean laundry items from the large laundry container touching the shirt on her upper body area. EI #2 dropped one white sock and one white wash cloth in the floor in front of the dryer, then put both of these items in the large laundry container with the other clothing that were removed from dryer one. EI #2 began folding the laundry that were mixed with the sock and wash cloth in the large laundry container. EI #2 stated when she finished folding these clothing items from the large container, she would take the items out to the residents on the back hall. On 11/28/2018 at 3:30 p.m., an interview was conducted with EI #2, Laundry Aide. EI #2 was asked if the clean clothing for the back hall touched her clothing without an apron on, when she removed the items from the dryer. EI #2 stated yes and that the clean clothes should not touch an employee's shirt. EI #2 was asked what is the concern with clean clothing touching an employee's shirt when taking clean clothing out of the dryer. EI #2 stated that the clothing could become contaminated and this could cause an infection for a resident. EI #2 was asked where she put the white sock and white wash cloth after taking both of these items out of the dryer. EI #2 stated she dropped the white sock and white wash cloth on the floor, then picked them up, and put the items in the large laundry container with the other clothes from dryer one. EI #2 was asked why did she put the white sock and white wash cloth in the large laundry container. EI #2 stated she thinks she did it by accident. EI #2 was asked what would be the concern with putting the white sock and white wash cloth that had fallen on the floor in the large laundry container with all the other laundry. EI #2 stated that the other clothing could become contaminated and could cause a resident to have an infection. EI #2 was asked if the facility has a policy on handling of clean laundry. EI #2 stated yes and it states the linen and clothing should not touch the uniform or floor. EI #2 was asked if the facility policy was followed when she put the laundry for the back hall from dryer one in the large container. EI #2 stated no. On 11/28/2018 at 4:30 p.m., an interview was conducted with EI #3, Director of Nursing/Infection Control Preventionist. EI #3 was asked what would be the concern with an employee taking the residents' laundry out of the dryer and touching the employee's shirt with the clean laundry, prior to putting the laundry in a large laundry container. EI #3 stated it could spread germs to other residents. EI #3 was asked what would be the concern with an employee taking a white sock and white wash cloth out of the dryer, dropping both on the floor, picking up both and putting in a large laundry container with other laundry from the dryer. EI #3 stated that this causes contamination to the clothing. EI #3 was asked if the facility had a policy on the handling of clean laundry. EI #3 stated yes and the policy stated that linen should not be allowed to touch the uniform or floor.

Based on observations and interview, the facility failed to ensure the facility's most recent survey results were accessible for residents and/or visitors to obtain at the facility. This had the potential to affect all residents, staff, and visitors in the facility. Findings Include: On 11/26/2018 at 1:35 p.m., the surveyor toured the building and observed a note on the bulletin board, in the hallway across from Nursing Station One, that stated, Resident and Family Members. You can find a copy of the most recent survey in the foyer of our facility. However, the Surveyor observed no recent survey results posted in the foyer of the facility. On 11/26/2018 at 4:25 p.m., the surveyor again toured the building and observed no recent survey results posted in the foyer. On 11/26/18 at 4:35 p.m., the surveyor toured the facility foyer with Employee Identifier (EI) #1, Director of Social Services, to determine if a copy of the most recent survey was available. No survey results were posted. On 11/27/2018 at 8:30 a.m., an interview was conducted with EI #1, Director of Social Services. EI#1 was asked were the facility's most recent surveys posted in the facility on 11/26/2018 when toured with the surveyor. EI #1 stated no. EI #1 was asked according to the sign posted on the bulletin board in front of Nursing Station One, where should the most recent survey results be posted. EI #1 stated in the foyer. EI #1 was asked why the facility's most recent survey results were not posted in the foyer of the facility. EI #1 stated that someone placed the most recent survey binder in a shelf inside Nursing Station One by mistake. EI #1 was asked why the facility's most recent survey should be posted in the foyer as stated on the bulletin board in front of the Nursing Station One. EI #1 stated it should be placed in the foyer so the residents and visitors can easily obtain the recent surveys of the facility and know how the facility was rated.

Based on observations, interviews, record review, a review of the facility's policy titled, SMOKING POLICY, and the facility's Resident Smoking Assessment, the facility failed to ensure Resident Identifier (RI) #3 and RI #8 were not smoking unsupervised. This affected two out twelve residents who smoke. Findings Include: A review of the facility's policy titled, Smoking Policy, with a revised date of 01/13/15 revealed: PURPOSE: To provide a safe smoking environment for our residents. POLICY: It is the policy of (Name of Facility) that residents are allowed to smoke ONLY under supervision. Residents MAY NOT keep lighters or matches, or any other smoking paraphernalia in their possession. Cigarettes and other items will be kept in a cabinet at station . Smoke breaks will be given at the following times: . 8:30 AM 3:45 PM 10:30 AM 6:00 PM 1:00 PM 8:00 PM . RI #3 was readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of RI #3's, Resident Smoking Assessment, dated 3/1/18, revealed RI #3 agreed to abide by the smoking policy noted by his/her signature. RI #8 was readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of RI #8's, Resident Smoking Assessment, dated 2/28/18, revealed RI #8 agreed to abide by the smoking policy noted by his/her signature. On 2/27/18 at 3:30 p.m., the surveyor, accompanied by Employee Identifier (EI) #1, the Speech Therapist, observed RI #3 and RI #8 smoking on the back patio with no supervision. EI #1 asked RI #3 and RI #8 who lit their cigarettes. RI #3 said he/she did not know and RI #8 said he/she did it. An interview was conducted on 3/1/18 at 2:40 p.m. with EI #2, the Administrator. EI #2 was asked if EI #1 had told him about RI #3 and RI #8 smoking without supervision on 2/27/18. EI #2 replied, She did. EI #2 was asked what was the harm in residents smoking unsupervised. EI #2 replied, Potential would be to burn themselves.

Based on observations, interviews and record review the facility failed to ensure wheelchair (w/c) and geri chair arm rest were free of cracked, torn or jagged areas in Room Locators (RL) #1, #2, #3, #4, #5 and #6. This affected two of three halls in the facility. Findings Include: The facility job description titled Director Of Maintenance Job Description, no date documented: General Purpose: To plan, organize and direct the overall operation of the Maintenance Department in accordance with current federal, state and local standards, ensuring that the facility is maintained in a safe, comfortable condition. Essential Job Functions: A. Maintenance Functions Duties: . assist in establishing and maintaining a preventive maintenance program; .C. Safety and Sanitation Functions Duties: . regularly inspect equipment . to ensure a safe and comfortable environment; promptly report . equipment damage to the Administrator . In the facility policy titled . Maintenance Inspections Policy, no date, documented: The resident wheelchair allows the resident to be mobile and active throughout the facility. The goal is to prevent breakdowns; it can be an inconvenience, a hardship and may even be a danger. The facility is responsible for keeping the resident wheelchair in operating order and well maintained. Taking care of issues or problems by following these steps. Wheelchairs/Gerichairs 6. Check arm rests: Check for sharp edges__Note upholstery for tears- repair immediately . On 03/08/16 at 2:00 PM, during the initial tour the following observations were made: RL #2 - the left arm rest on the gerichair was torn at the front. RL #3 - the right w/c arm rest was cracked and jagged to the touch. On 03/09/16 at 8:00 Am, the following observations were made: RL #1 - the right and left arm rests in the gerichair were torn and jagged RL #4 - the right w/c arm rest was cracked and jagged. RL #5 - the left arm rest was cracked, jagged and badly worn . RL #6 - the left w/c arm rest was cracked in the center. On 03/10/16 at 10:45 AM, EI # 10, Maintenance Director, was asked who was responsible to monitor and repair w/c arm rests for tears and cracked or jagged areas. EI #10 replied that would be him. EI #10 was asked how often was this done. EI #10 replied if he saw them or the residents told him, but there was no routine monitoring. EI #10 was asked when was the last time he checked w/c arm rest. EI #10 replied last month. EI #10 was asked then why there were several w/c arm rests on the hall that needed to be repaired. EI #10 replied he did not know why. EI #10 was asked what could be the potential harm to a resident with fragile skin with cracked or jagged arm rest. EI #10 replied They could get pinched or get a skin tear. EI #10 was asked what could be the potential harm to a resident that was on a blood thinner that had cracked or jagged arm rests. EI #10 replied they could bleed out.

Based interviews and record reviews, the facility failed to ensure to complete screenings for new employees prior to hire. This affected four of six personnel records reviewed. Findings Include: A review of the facility's policy and procedure titled, Abuse Prevention, page 1 of 5, with an effective date of 12/01/06, revealed the following: . III. Screening: 1. Prior to hire, each potential employee must give permission for checks of references in previous employment/s. (employments) criminal background, . 2. Each name and corresponding social security number will be submitted to abuse registries and appropriate licensure boards . On 03/10/16, a review of the facility's personnel files revealed the following: Employee Identifier (EI) #2 (Certified Nursing Assistant/CNA) hire date-11/17/15 one reference check was found without a date EI #3 (Licensed Practical Nurse/LPN) hire date-11/25/15 no documentation of reference checks EI #4 (CNA) hire date-11/17/15 no documention of reference checks EI #5 (CNA) hire date-02/10/16 no documention of reference checks On 03/10/16 at 9:10 AM, the surveyor interviewed EI #1 (Staff Development/Education Coordinator) and asked the following questions after personnel files were reviewed: When was EI #2 hired and when were the reference checks done. EI #1 replied hire date was 11/17/15 and only one reference check was done. EI #1 also stated there should be two reference checks; When was EI #3 hired and when were the reference checks done. EI #1 replied hire date was 11/25/15 and no reference checks were done. When was EI #4 hired and when were the reference checks done. EI #1 stated hire date was 11/17/15 and no reference checks were done; When was EI #5 hired and when were the reference checks done EI #1 replied hire date was 02/10/16 and no reference checks were done. The surveyor asked EI #1 was policy and procedure for Abuse Screening prior to hire for potential employees followed. EI #1 stated no. The surveyor asked who was responsible for obtaining information for employee screenings. EI #1 replied she was.

Based on interview and record review, the facility failed to accurately code a Minimum Data Set (MDS) assessment for Resident Identifier (RI) #5, for an Annual Assessment instead of a Significant Change Assessment, and for a pressure ulcer for RI #8 for the 12/10/15 Admission Assessment. This affected two of 14 sampled residents whose MDS's were reviewed. Findings Include: 1) RI #5 was re-admitted to the facility on [DATE]. During a review of RI #5's recent Significant Change assessment dated [DATE]. In review of the Quarterly assessment dated [DATE], prior to the 08/31/15 assessment, there were no declines or improvements documented in cognitive status, functional status (Activities of Daily Living), or incontinence. On 03/10/16 at 12:15 PM, Employee Identifier (EI) #12, MDS Coordinator, was asked what was the improvement or decline with RI #5 that warranted a Significant Change assessment. EI #12 replied RI #5 was more debilitated. EI #12 was asked to show where that was documented on the 08/13/15 assessment. EI #12 replied RI #5 had some weight loss and decline in functional status. EI #12 was asked again to show where that was reflected on the MDS. EI #12 commented it was in the nurses notes. EI #12 was asked again where it was reflected on the MDS, and EI #12 replied it was not. On 03/10/16 at 2:40 PM, EI #12 presented the surveyor with a corrected copy of RI #5's 08/31/15 assessment which was documented to be an Annual assessment. EI #12 commented she must have hit the wrong key. 2) RI #8 was re-admitted to the facility on [DATE]. A review of RI #8's Resident Assessment Data Collection Form, dated 11/30/15, documented: . R (right) heel SDTI (Suspected Deep Tissue Injury) . RI #8's admission Skin Condition Report, dated 11/30/15 documented: . R heel, SDTI (unstage) (unstageable) . During a review or RI #8's Admission MDS dated [DATE], in Section M Skin Conditions, the assessment was not coded to reflect RI #8 had the area on the right heel. On 03/10/16 at 12:30 PM, EI #12 was asked what was documented on RI #8's Resident Assessment Data Collection Form dated 11/30/15. EI #12 replied R heel DTI. EI #12 was asked what was documented on RI #8's Skin Condition Report dated 11/30/15. EI #12 replied resident has SDTI to rt heel. EI #12 was asked what was documented on RI #8's Admission MDS dated [DATE] for a pressure ulcer. EI #12 replied none and she (EI #12) should have put a DTI. EI #12 was asked was the 12/10/15 assessment coded inaccurately. EI #12 replied yes and it should have been modified. EI #12 was asked what could be the potential harm in an inaccurately coded assessment. EI #12 replied the care plan would not be developed. On 03/10/16 at 4:20 PM, EI #17, Treatment Nurse, was asked who was responsible to complete the Skin section on the MDS. EI #17 replied she was. EI #17 commented she did the assessment and EI #12 put the information related to the skin section into data entry. EI #17 was asked why RI #8 was not coded for the pressure ulcer on the right heel on the 12/10/15 MDS. EI #17 replied she did not know because she did give the information to EI #12. On 03/10/16 at 4:25 PM, EI #12 was asked why the information she was given was not entered. EI #12 replied she did not know because EI #17 gives her (EI #12) the information.

Based on interviews and record reviews, the facility failed to ensure care plans were developed for Resident Identifier (RI) #1, based on triggered CAA (Care Assessment Areas). This affected one of 12 sampled residents whose care plans were reviewed. Findings Include: A review of the facility's policy and procedure, CARE PLANS, with an effective date 12/01/16, revealed the following: . III. PROCEDURE 1. All disciplines involved in providing services to the resident will assess and identify the needs of the resident and attend the Care Planning Conference to coordinate and develop the resident Plan of Care. 5. The problems triggered from the MDS will be reviewed by the Care Plan Committee. 6. Care Plans are developed which will identify the resident's strengths and weaknesses . RI #1 was admitted to the facility with [DIAGNOSES REDACTED]. A review of RI #1's Annual Minimum (MDS) data set [DATE] revealed RI #1's Brief Interview for Mental Status score was a 12, indicating moderately impairment in cognition. A review of the MDS's CAA Summary dated 12/14/15 revealed the following triggered areas: Cognitive Loss/Dementia, ADL (Activities of Daily Living)/Rehabilitation Potential, Urinary Incontinence and Indwelling Catheter, Psychosocial Well-Being, Behavioral Symptoms, Falls, Nutritional Status, Pressure Ulcer and [MEDICAL CONDITION] Drug Use. On 03/09/16 at 11:00 AM, the surveyor asked Employee Identifier (EI) #12 (MDS Coordinator) who was responsible for care plans. EI #12 replied each discipline. EI #12 also stated care plans are developed based on the triggered areas from the Annual, Admission and Significant comprehensive assessments. EI #12 stated also the assessment of the resident and our care plan meeting discussion assist with care plan development. The surveyor asked what about [MEDICAL CONDITION] medications and [MEDICAL CONDITIONS]. EI #12 reviewed the CAA and stated it should have triggered for the antidepressant and for the left sided weakness. The surveyor asked where was the care plan for non-compliance with care and behaviors. EI #12 stated no care plan to indicate noncompliance. The surveyor asked what areas triggered. EI #12 reviewed the CAA and stated Cognition, ADLs, Incontinence, Behavior, Falls, At risk for Pressure areas and [MEDICAL CONDITION] medications. EI#12 reviewed RI #1's care plans and replied RI #1's care plans are for incontinence, pressure sores, behaviors with non compliance with care, activities, nutrition/therapeutic diet and ADLs. EI #12 also stated no care plans for falls, [MEDICAL CONDITION] medications and cognition. EI #12 further stated EI #13 (Certified Nursing Assistant/CNA) was responsible for the behavior and the cognition care plans and EI #14 (Licensed Practical Nurse/LPN/Restorative) was responsible for the falls care plan. The surveyor asked who was responsible for developing a care plan regardless of the discipline. EI #12 stated the nurse. On 03/09/16 at 2:20 PM, the surveyor asked EI #13 who was responsible for the care plan for cognition and [MEDICAL CONDITION] medications. EI #13 replied EI #12 was. The surveyor asked EI #13 was she a Registered Nurse/RN or an LPN. EI #13 replied she was a CNA. On 03/09/16 at 2:20 PM, the surveyor asked EI #15 (Education/Staffing Coordinator) who was responsible for care plans for triggered areas of the MDS. EI #15 replied the MDS Coordinator. On 03/09/16 at 2:20 PM, the surveyor asked EI #16 (Director of Nursing/DON), who should be completing the sections for the MDS and completing the care plans. EI #16 stated the nurse, because EI #13 (CNA) would not have the knowledge and the training. On 03/09/16 at 11:30 AM, the surveyor asked EI #14 (Restorative/LPN), where was the care plan for at risk for falls as it triggered on RI #1's MDS/CAA dated 12/14/15. EI #14 reviewed the care plans and stated she did not see the care plan. The surveyor asked what was the fall risk assessment score. EI #14 stated 7 and the resident should have a care plan for at risk for falls. EI #14 also stated she was responsible for the falls care plan. On 03/09/14 at 3:30 PM, the surveyor asked EI #7 (Assistant Director of Nursing/ADON) who signs off on the MDS what does the signature indicate. EI #7 replied he did and his signature indicated he reviewed it for accuracy. The surveyor asked what was EI #13 (CNA) discipline. EI #7 replied he was not sure. The surveyor asked was EI #13 a nurse, EI #7 stated no. The surveyor asked was EI #13 a social worker. EI #7 replied he did not know. The surveyor asked why would he sign his signature to an assessment without knowing the credentials or qualification of all involved individuals who completed the assessment. EI #7 replied he did not know individuals should have certain credentials. The surveyor asked with basic nursing who is responsible for developing care plans. EI #7 replied nurses. EI #7 further stated in order to have an effective and appropriate care plan staff must have knowledge of the problem through education.