Every finding on record at Clapp's Convalescent Nursing Home Inc

Based on observations and staff interviews, the facility failed to dispose of expired foods and remove foods with signs of spoilage stored for use in 1of 1 dry goods storage room. The facility also failed to label, date and remove expired leftover foods stored for use in 1 of 1 walk-in cooler, and in 1 of 1 freezer. This deficient practice had the potential to affect food served to residents. The findings included: a. During an initial tour of the kitchen conducted with the Dietary Manager on 12/08/25 at 10:45 AM, the following problems were identified in the dry goods storage room: - Two opened seasoning products with the expiration date of 6/1/25.- One jar of pickles with the expiration date of 9/30/25. - Two lemon extract bottles with the expiration date of 9/15/25. - Two cans of baking soda with the expiration date of 11/1/2025.- Three bananas exhibited visible dark spotting, a strong foul odor, when gently pressed during observation, the bananas were soft and mushy in texture. The bananas were stored on top of fresh bananas. An interview was conducted with the Dietary Manager on 12/08/25 at 10:45AM in the dry goods storage room. The Dietary Manager stated that once food items were opened, the staff member who opened the item was responsible for labeling the opening date and expiration date. The Dietary Manager further stated that all kitchen staff were responsible for routinely checking food items for expiration. The Dietary Manger also indicated that the expired items identified were overlooked and should have been removed. b. During the observation of the walk-in cooler with the Dietary Manager on 12/08/25 at 11:00 AM, the following problems were identified: - Four opened packages of sliced cheese that were removed from their original packaging, placed in a resealable plastic bag without labeling. - Two gravy vegetable base packs with the expiration date of 05/13/25.- Five bags of diced potatoes that were removed from original packaging and stored in a resealable plastic bag labeled with the expiration date of 12/07/25. An interview conducted with the Dietary Manger on 12/08/25 at 11:00 AM in the walk-in cooler revealed the expired foods should have been used or discarded on or before the expiration date. The items were removed and put into the trash. The Dietary Manager stated it was the responsibility of all dietary staff to check expiration dates.c. During the observation of the freezer with the Dietary Manager on 12/8/25 at 11:25 PM the following problems were identified: - Five opened bags of hash browns that were removed from original package and stored without labeling. - Three opened bags of french fries that were removed from original package and stored without labeling; the french fries were noted to have ice crystals.- Three opened boxes of frozen pancakes that were removed from original package and stored without labeling.- Fifteen slices of pizza that were removed from original package and stored without labeling and noted to have ice crystals. - Two opened bags of mixed vegetables that were removed from original package, with ice crystals, and stored without labeling. - Three opened packages of labeled fatback with the expiration date of 12/03/24. An interview conducted with the Dietary Manager on 12/8/25 at 11:25AM revealed all dietary staff were responsible for checking expiration dates of food in the freezer. The Dietary Manager stated she last checked the freezer on 12/1/25 (the last time she received a food shipment). The Dietary Manager indicated that if the expiration date was not visible, it was every member of the dietary staff's responsibility to check and put the expiration date on the package. A follow-up interview with the Dietary Manager on 12/10/25 at 1:45PM revealed that once food was opened, staff were to label the item with the open date and expiration date before placing it in the refrigerator. The Dietary Manager reported there was no system in place to ensure food items were consistently labeled after being opened and if a label on a food item cannot be read, the item should be discarded. She stated that all kitchen staff shared responsibility for identifying expired or improperly labeled items. Any staff member could perform a weekly kitchen check of the dry storage and refrigerated areas. She acknowledged she did not check expiration dates on seasonings and some dry storage items as often as she should because these items were stored toward the back of the kitchen and not near the stove, where she spent most of her time. She further stated that any food removed from its original packaging should be placed into a clean container and labeled with both the product name and the date it was opened. Dietary Manger reported that the expired food items were overlooked and should have been discarded.An interview with the Administrator was conducted on 12/10/25 at 2:00 PM. He stated that kitchen staff were to follow the facility's food-storage policy and conduct frequent checks to ensure expired or unlabeled food items were not kept in the kitchen. He reported that kitchen staff were responsible for monitoring food storage areas on a routine basis to maintain compliance.

Based on observations and staff interviews, the facility failed to post cautionary and safety signage that indicated the storage of oxygen and the potential hazard on the outside of 3 of 4 oxygen storage locations (100-300 hall, 400-600 hall and 700 hall medication storage rooms). The findings included: Observations and an interview were conducted with the Director of Nursing (DON) on 12/10/2025 at 10:50 AM. An observation was conducted of the medication storage room on the 700 hall, the shared medication room for the 400-600 hall and the shared medication room for the 100-300 hall. Each room had a combination of full and empty oxygen tanks stored in these locations with no sign to identify the rooms as oxygen storage areas. An observation in the 100-300-hall, 400-600 hall, and 700 hall medication storage room revealed oxygen cylinders stored in separated storage racks. A sign posted on the wall in the 100-300 hall, 400-600 hall and 700 hall medication storage rooms showed the full oxygen tanks were stored on the left side of rack, and the empty tanks were stored on the right side of the rack. There was no signage on the outside of these medication storage rooms to show oxygen was stored in these areas. During the interview DON stated they did not have any signs for oxygen storage in the facility because they were a smoke free facility. An interview was conducted on 12/10/2025 at 8:55 AM with Nurse Aide (NA) #1. NA #1 stated that the oxygen tanks were in the locked medication room located on the 700- hall at the nurse's station. NA #1 stated she observed the oxygen stored while working the day shift (7:00 AM- 3:00 PM). NA #1 stated she did not recall seeing any oxygen signs where the oxygen was stored in the building. An interview was conducted with Nurse #1 on 12/10/2025 at 8:57 AM. He stated the oxygen tanks were stored in the medication room located on the 700- hall where he worked. Nurse #1 explained the nurses changed the empty tanks for full tanks when necessary. Nurse #1 stated there were no oxygen warning signs at the 700-hall medication storage room and he did not remember seeing oxygen warning signs where oxygen is stored. An interview was conducted on 12/10/25 at 9:30 AM with the Director of Operations. She stated they were a smoke free facility. There were signs posted at the main entrance to notify the public not to smoke and that oxygen was in use. Oxygen in use signs were also posted at the front and back entrance doors. She stated the facility was a smoke free facility and warning signs for oxygen were posted at the two entrances. An interview with the Administrator on 12/11/2025 at 1:50 PM. He indicated he was made aware that there were no cautionary signs for oxygen outside the medication storage rooms. He stated that he understood the concern and he would refer to the facilities oxygen policy.

Based on record review, staff, and resident interviews, the facility failed to protect the residents' right to be free from misappropriation of narcotic medications (oxycodone and hydromorphone) prescribed to treat pain for 6 of 6 residents (Residents #66, 282, 284, 281 and #280) reviewed for misappropriation of property. The findings included: 1a. Resident #66 was admitted on [DATE] with diagnoses that included fracture of the right hip. Resident #66's physician orders included an order dated 04/09/24 for oxycodone 5 milligrams (mg) one tablet by mouth every 6 hours as needed (PRN) for pain. Resident #66's Medication Administration Record (MAR) revealed that between 07/17/24 to 07/28/24, the PRN oxycodone was documented as administered 4 times by Nurse #1. The dates of administration were: 07/22/24, 07/24/24, 07/27/24 and 07/28/24. The pharmacy-controlled drug record sheet for Resident #66 revealed that PRN oxycodone was signed out 9 times by Nurse #1 between 07/17/24 to 07/28/24. The dates signed out were once on 07/22/24, twice on 07/23/24, three times on 07/27/24, and three times on 07/28/24. Review of quarterly Minimum Data Set (MDS) dated [DATE] revealed that Resident # 66's cognition was moderately impaired. During the interview of Resident #66 on 10/01/24 at 04:42 PM the resident denied she asked for pain medications from Nurse #1 and did not receive pain medications. Resident #66 denied having pain. 1b. Resident #283 was admitted to facility on 05/24/24 with diagnoses that included pain disorder and pain in right toe. Resident #283's physician's orders included an order dated 07/15/24 for oxycodone 5 mg by mouth, 1 tablet every 6 hours PRN for pain. The medical record indicated Resident #283 resided in the facility 7/17/24 through 7/28/24. Resident #283's MAR revealed that between 07/17/24 to 07/28/24 Nurse #1 documented administration of the PRN oxycodone two times. The dates of administration were 07/22/24 and 07/24/24. Resident #283's pharmacy-controlled drug record sheet revealed that PRN oxycodone was signed out 12 times by Nurse #1 between 07/17/24 to 07/28/24. The dates signed out were twice on 07/22/24, once on 07/23/24, three times on 07/24/24, three times on 07/27/24, and three times on 07/28/24. 1c. Resident #282 was admitted to the facility on [DATE] with diagnoses that included fracture of the neck of the right femur. Resident #282's physician's orders included an order dated 07/23/24 for hydromorphone 2 mg by mouth every 4 hours PRN for pain. The medical record indicated that the resident resided in the facility from [DATE] to 07/28/24. Resident #282's MAR revealed that between 07/23/24 to 07/28/24, hydromorphone was documented as administered once by Nurse #1 on 07/27/24. The pharmacy-controlled drug record sheet for Resident #282 revealed that hydromorphone was signed out 9 times by Nurse #1 between 07/23/24 to 07/28/24. The dates signed out were: one time on 07/24/24, four times on 07/27/24, and four times on 07/28/24. 1d. Resident #284 was admitted to the facility on [DATE] with diagnoses that include pain in right knee and right foot. Resident #284's physician's orders included an order dated 07/09/24 for oxycodone 5 mg by mouth, 1 tablet by mouth every 4 hours PRN for moderate to severe pain. The medical record indicated Resident #284 resided in the facility 7/17/24 through 7/28/24. Resident #284's MAR revealed that between 07/17/24 to 07/28/24, oxycodone 5 mg was documented as administered one time by Nurse #1 on 07/27/24. The pharmacy-controlled record for Resident #284 revealed that oxycodone was signed out 6 times between 07/17/24 to 07/28/24 by Nurse #1. The dates oxycodone was signed out were twice on 07/23/24, 07/24/24, twice on 07/27/24, and on 07/28/24. 1e. Resident #281 was admitted to the facility on [DATE] with diagnoses that included arthritis in right knee and pain in right and left knee. Resident #281's physician orders included an order dated 07/11/24 for oxycodone 5 mg one tablet by mouth every 6 hours PRN for moderate to severe pain. The medical record indicated Resident #281 resided in the facility 7/17/24 through 7/28/24. Resident 281's MAR revealed that oxycodone was documented as administered 2 times between 07/17/24 to 07/28/24 by Nurse #1. The dates of administration were 07/19/24 and 07/27/24. The pharmacy-controlled drug record revealed that oxycodone was signed out 5 times by Nurse #1 between 07/17/24 and 07/28/24. The dates oxycodone was signed out were 07/19/24, 07/22/24, 07/24/24, 07/27/24 and 07/28/24. 1f. Resident #280 was admitted to the facility on [DATE] with diagnoses that included fracture of left femur. Resident #280's physician order included an order dated 06/30/24 for oxycodone 5 mg by mouth every 4 hours PRN for pain. The medical record indicated Resident #280 resided in the facility 7/17/24 through 7/28/24. Resident #280's MAR revealed that from 07/17/24 to 07/28/24 oxycodone was documented as administered 2 times by Nurse #1. The dates of administration were 07/22/24 and 07/28/24. The pharmacy-controlled drug record for Resident #280 revealed that oxycodone was signed out 6 times by Nurse #1 between 07/17/24 and 07/28/24. The dates oxycodone was signed out were 07/22/24, 07/23/24, 07/24/24, twice on 07/27/24, and 07/28/24. On 10/02/24 at 10:34 AM, a telephone interview with Nurse #2 revealed on 07/28/24 she arrived and counted the narcotics in medication carts with Nurse #1. On the 700-hall cart, 4 cards of narcotics did not reconcile with the pharmacy-controlled drug record. Nurse #2 stated that she then counted the narcotics on the 600-hall cart with Nurse #1. This count revealed that the medications were reconciled, but there were medication cards that had tape on the back. She reported that she could tell that something was off. She called the Director of Nurses (DON) and then the Administrator. On 10/02/24 at 10:40 AM, a telephone interview with Nurse #1 was attempted and unsuccessful. On 10/02/24 at 9:13 AM, an interview was conducted with the DON who reported that on the night of 07/28/24, Nurse #2 reported that Nurse #1 was different and there was concern about medication discrepancy, the Administrator was called. The DON indicated the Administrator came in and was in the facility while Nurse #1 completed her documentation. Nurse #1 was sent home until further notice. The DON reported she called Nurse #1 to come in the next day. During the interview with the Administrator in the conference room, Nurse #1 admitted that she diverted the medications and that she had a problem. Law enforcement was called, and Nurse #1 was arrested. The Director of Operations reported that this Nurse #1 had no previous allegations with the Board of Nursing. On 10/02/24 at 10:02 AM, an interview was conducted with the Director of Operations and the Administrator. The Administrator reported that Nurse #1 had been in orientation for 9 days. The first night Nurse #1 had worked independently with access to the medication cart was 07/28/24. The Administrator reported that he got a call on 07/28/24 from Nurse #2 about medication discrepancy concerns. He stated he arrived at the facility at midnight and Nurse #1 was still on-site. He observed Nurse #1 had completed her documentation, and he informed Nurse #1 to go home until further notice. The Administrator and Director of Operations reported that they audited all the MARs and noted diversion in the medication carts for 600 and 700 halls only with Nurse #1. After the audit of the MAR monitoring of the MARs began. The facility provided the following action plan with a completion date of 07/29/24: 1.Corrective action for residents(s) affected by the alleged deficient practice: On 07/29/24, termination of Nurse #1, reporting the nurse to law enforcement, reporting the misappropriation to the state agency, reporting the nurse to the state board of nursing. On 07/29/24, Director of Operations and Administrator assessed if affected residents had any issues during their stay with receiving either the scheduled or PRN pain medications. 2.Corrective action for residents (s) with the potential to be affected by the alleged deficient practice: A full audit of all narcotic sheets of all residents was completed on 07/29/24 to ensure no other discrepancies or trends were noted with any other nurses signing out medications. 3.Measures/Systemic changes to prevent recurrence of deficient practice: On 07/29/2024 at approximately 04:30 PM, education to all nurses and med-aides was started by the DON related to abuse (specifically diversion of drugs/misappropriation), reporting of concerns/abuse, as well as the narcotic count process. All nurses on the 3rd shift (11:00 PM- 07:00 AM) of 07/29/24 were educated and no other nurse was allowed to work on going until being educated. On 7/29/24 a Quality Assurance and Performance Improvement (QAPI) committee meeting was held immediately after discovering the area of concern with appropriate QAPI members, to include Administrator, Director of Operations, Director of Nursing, and Nurse Managers. QAPI members discussed and approved the plan of correction as written. QAPI members agreed to monitor this plan in the monthly meeting. Should any areas of concern arise between meetings, the appropriate committee members will address timely and accordingly. 4.Monitoring procedure was started on 7/29/24 to ensure that the plan of correction is effective, and that specific deficiency cited remains corrected and sustained: To help ensure this plan of correction remains effective, the Director of Operations or designees will review 5 narcotic sheets per week X4 weeks to ensure the medication sign outs for the previous week match the MAR for the residents. Should the residents be alert and oriented, the Director of Operations or designee will also interview that resident and ensure they receive the medication as requested on the dates it was documented. Should substantial compliance continue to be found, this monitoring tool will be reduced to 5 sheets per month until the next recertification survey. This Plan of Correction will be followed and reviewed by the Quality Assurance and Performance Improvement (QAPI) committee 8/14/24 who will reassess the need for continuation of this monitoring tool. This Plan of Correction will be followed and reviewed by the QAPI committee and areas of concern will be addressed immediately by the appropriate members. Correction Date was 7/29/24.

Based on observations, record review, and staff interviews, the facility failed to post cautionary and safety signage outside of resident rooms that indicated the use of oxygen for 2 of 2 residents reviewed for respiratory care (Residents #15 and #34). This practice had the potential to affect other residents receiving supplemental oxygen. The findings included: a. Resident #15 was admitted to the facility on [DATE] with the diagnosis of Chronic Obstructive Pulmonary Disease (COPD). A review of Resident #15's physician orders dated 8/3/22 revealed an order for oxygen to be administered continuously via nasal cannula at 2 liters per minute (l/min). A review of the annual Minimum Data Set (MDS) dated [DATE] indicated Resident #15 was coded for receiving oxygen. Observations on 9/30/24 at 11:34 AM, 10/1/24 at 1:56 PM, and 10/2/24 at 8:17 AM revealed Resident #15 was sitting in her wheelchair in her room wearing a nasal cannula with oxygen being administered at 2 l/min. There was no cautionary or safety signage posted at Resident #15's room to indicate oxygen was in use during the observations. b. Resident #34 was admitted to the facility on [DATE] with a diagnosis of COPD exacerbation, acute with chronic respiratory failure with risk of decline, and pneumonia. Resident #34 had a physician's order dated 6/12/24 for oxygen administered at 2 liters per minute by nasal cannula. Review of Resident #34's quarterly MDS dated [DATE] revealed she was severely cognitively impaired with no mood or behavioral disturbances. Resident #34 was coded for receiving oxygen. Observations conducted on 10/1/24 at 9:12 AM, 10/2/24 at 8:17 AM, and 10/2/24 at 11:02 AM revealed there was no cautionary signage at Resident #34's room indicating oxygen was in use. Resident #34 was in her room using oxygen delivered by nasal cannula during the observation times. An interview was conducted with Nurse #1 on 10/02/24 at 11:02 AM. She stated she had not seen any oxygen in use signs posted in the facility, and she did not recall placing one in any resident's room. Nurse #1 stated that since the facility was smoke free, she didn't think they needed oxygen in use signage. She stated that the staff educated family members regarding no smoking around oxygen. On 10/2/24 at 1:55 PM an interview was conducted with the Director of Nursing (DON). She verbalized the facility had 11 total residents using oxygen. The DON stated the facility did not use oxygen signage. She further stated that since the building was smoke-free she didn't think the facility was required to use individual no smoking signs. An interview with the Administrator was conducted on 10/2/24 at 2:04 PM. He stated it was illegal for indoor smoking in North Carolina facilities. He stated since the facility was smoke-free it was unnecessary to post signs of no smoking in the residents' rooms. He stated he had posted no smoking signage at the facility's entrance.

Based on record review and staff interview, the facility failed to accurately complete the daily nurse staffing information posting for 14 of 30 days reviewed (October 1 - November 1, 2021). Findings included: The daily schedule and the daily nurse staffing information posting were reviewed from October 1, 2021 through November 1, 2021. The nurse staffing information posting did not match the daily schedule for the licensed nurses on the following dates: 10/1/21 (3rd shift) - the daily schedule has 1 Registered Nurse (RN) and 1 Licensed Practical Nurse (LPN) while the staff posting has 2 LPNs 10/2/21 (1st shift) - the daily schedule has no RN while the staff posting has 1 RN 10/5/21(1st shift) - the daily schedule has 2 RNs while the staff posting has 1 RN 10/8/21 (1st shift)) - the daily schedule has 1 RN and 5 LPNs while the staff posting has no RN and 4 LPNs 10/11/21 (1st shift) - the daily schedule has 5 LPNs while the staff posting has 4 LPNs 10/13/21 (1st shift) - the daily schedule has 4 LPNs while the staff posting has 3 LPNs 10/15/21 (1st shift) - the daily schedule has 3 LPNs while the staff posting has 2 LPNs 10/18/21 (1st shift) - the daily schedule has 4 LPNs while the staff posting has 3 LPNs 10/20/21 (1st shift) - the daily schedule has 4 LPNs while the staff posting has 3 LPNs 10/22/21 (1st shift) - the daily schedule has 5 LPNs while the staff posting has 4 LPNS 10/25/21 (1st shift) - the daily schedule has 5 LPNs while the staff posting has 4 LPNs 10/26/21 (1st shift) - the daily schedule has 2 RNs while the staff posting has 1 RN 10/27/21 (1st shift) - the daily schedule has 4 LPNs while the staff posting has 3 LPNs 10/29/21 (1st shift) - the daily schedule has 4 LPNs while the staff posting has 3 LPNs The Medical Records staff was interviewed on 11/3/21 at 10:37 AM. The Medical Records staff member stated that she was responsible for completing and for posting the daily nurse staffing information. She reviewed the daily schedule and the daily nurse staffing information and verified that she had completed the daily staff posting incorrectly on 10/1/21 (3rd shift), 10/2/21, 10/5/21, 10/8/21, 10/11/21, 10/13/21, 10/15/21, 10/18/21, 10/20/21, 10/22/21, 10/25/21, 10/26/21, 10/27/21 and 10/29/21 on 1st shift. She reported that the daily staffing form was confusing, and she would check if the form could be revised. The Director of Nursing (DON) was interviewed on 11/3/21 at 10:38 AM. The DON reviewed the daily schedule and the daily staff posting form and verified that it could be confusing. She reported that she would revise the form and ensure that the daily staff posting was completed accurately.

Based on record reviews, interviews of staff and police Detective, the facility failed to report an allegation of abuse to the State Agency within the required timeframe for 1 of 3 residents reviewed for abuse (Resident #1). The findings included: Resident #1 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #1's discharge Minimum Data Set (MDS) dated [DATE] indicated the resident had mild cognitive impairment and no behaviors. The resident was coded as having functional vision and hearing and required limited assistance with activities of daily living and hygiene. A record review revealed Resident #1 was discharged home with home health on 6/30/2021. According to facility records, it was a resident-initiated discharge. A phone interview was conducted with the detective on 7/19/2021 at 11:11am. She stated she went to the facility on Friday 7/9/2021 around 4:30pm. The facility administrator was not in the building, so she spoke with the Chief Operating Officer (COO). She first asked the COO if Resident #1 had resided in the facility. The COO confirmed the resident had resided in the facility up until her discharge home. The Detective stated she informed the COO Resident #1 had made an allegation of abuse that was sexual in nature and that the alleged abuse occurred during her time at the facility. The Detective stated she asked the COO about how many male employees were working in the facility, how many of them would have had access to Resident #1's room, and what kind of attire they would have been wearing. The Detective stated she did not give any further details regarding the alleged perpetrator. On 7/19/2021 at 3:30pm an interview was conducted with the COO. She stated the Detective did come to the facility on [DATE] around 4 or 4:30pm. The detective asked her about Resident #1 and the COO confirmed she had been a resident in the facility. The COO stated the Detective would not give her information other than the name of the Resident and that the allegation was sexual in nature. She stated the Detective did ask about male employees and what attire the facility employees wore. The COO stated she did notify the facility Administrator of the Detective's visit and what was reported. The COO stated she did not report to the State Agency or start an investigation at that time because she did not know what the allegation was other than it was sexual in nature and she did not feel like she had enough information to begin an investigation. An interview was conducted with the facility Administrator on 7/9/2021 at 3:30pm. He stated he was not in the facility at the time the Detective notified the COO of the allegation. He was notified by the COO of the Detective's visit and her statements. He stated he was not in the office on Monday 7/12/2021. When he returned to the office on Tuesday July 7/13/2021 he had a voice message from another skilled nursing facility informing him Resident #1 had made an allegation of abuse that occurred at Clapps Convalescent, and they had reported to the State Agency and began an investigation. The Administrator stated he spoke to the interim Administrator at that facility on Tuesday 7/13/2021 around 9:00am and obtained some additional details that allowed him to report to the state and start his own investigation. He stated he reported to the State Agency around 9:27am on Tuesday 7/13/2021. He stated he did not feel like he had enough information to report to State Agency and start an investigation prior to Tuesday 7/13/2021. When asked what information he would have needed to report to the State Agency and begin an investigation, he stated he needed the name of the resident and an actual allegation. He also stated he did not feel like the Detective stated clearly the alleged abuse occurred at Clapps. A second phone interview was conducted with the Detective on 7/21/2021 at 10:30am. When asked if she notified the facility the alleged abuse took place at Clapps Convalescent, she stated she made it clear to the COO the alleged abuse happened at the facility, then asked her about the number of male employees in the facility and their attire.

Based on observations and staff interviews, the facility failed to use standard infection precautions when placing ice into a resident ' s reusable water cup (Hall 300) for 1 of 4 halls. Two nursing assistants used the same ice scoop to retrieve ice from a universal cooler with ice and touched the ice scoop to the inside and lip after touching two resident ' s reusable water cups. These failures occurred during the COIVD 19 pandemic. Findings included: An observation occurred on 12/8/2020 at 10:40 am of Nursing Assistant #1 on Hall 300 who provided ice to the resident in room [ROOM NUMBER]A. The NA had a gloved hand and retrieved the resident ' s reusable water cup from her bedside table, removed the lid, took hold of the ice scoop from a clear container on a hall cart, scooped ice from a universal cooler, and placed the scoop into the reusable water cup to slide the ice. The scoop touched the lip and inside of the reusable water cup. The NA then placed the scoop back into the clear container and removed her gloves. At 10:42 am Nursing Assistant #2 on Hall 300 retrieved the reusable water cup on the bedside table from the resident in room [ROOM NUMBER]A. The NA had a gloved hand and removed the cover from the water cup, retrieved the same ice scoop used by NA #1 housed in the clear container on the hall cart, scooped ice from the same universal cooler, and placed the scoop into the cup to slide the ice. The scoop touched the lip and inside of the reusable water cup. The NA then placed the scoop back into the clear container on the hall cart and removed her gloves. The Facility Nurse Manager was standing nearby observing the hall (within 5 feet). On 12/8/2020 at 10:44 am an interview was conducted with NA #1, NA #2, and the Facility Nurse Manager (FNM). The FNM, after being informed of the NAs observed process for ice pass, agreed the ice scoop used for all residents on the hall should not touch the reusable water cup. The FNM stated a direction to both NAs to bring the ice scoop they were using to the kitchen and to obtain a clean ice scoop. (The ice was not discarded, and no mention of NA touched the outside of the individual resident ' s reusable water cup with a clean glove and then touched the ice scoop was mentioned.) An interview was conducted with the Nurse Unit Manager on 12/8/2020 at 11:05 am. She stated that each resident ' s water/ice cup was for reuse for 2 weeks and then replaced by the nursing assistant (initial orientation). The Dietary Manager commented during observation of the kitchen on 12/8/2020 at 12:05 pm that the facility was using all disposable dishware to prevent the spread of COVID-19. (Nursing is responsible for water/ice at the bedside.) On 12/8/2020 at 1:05 pm an interview was conducted with the Administrator, Director of Operations, and Director of Nurse (also infection preventionist). The Administrator was informed of the observation and interview with staff regarding the handling (touch) of the resident ' s reusable water/ice cup and process for providing ice with potential for [MEDICAL CONDITION] spread (COVID-19). The Administrator commented that this was addressed (corrected ice scoop touching the cup during pour) by the FNM today (12/8/2020). (There was no mention of facility-wide education).

Based on record review, observation, and staff interview, the facility failed to revise care plans related to wanderguards for 2 of 3 sampled residents (Residents #6 and #19). The findings included: 1. Resident #19 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A physician's order [REDACTED].#19. The annual Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #19 ' s cognition was severely impaired. She was noted to wander daily and a wander/elopement alarm was used daily. Resident #19 ' s care plan included the problem/need of the risk for increased behaviors due to wandering. This problem /need was initiated on 5/15/19 and included, in part, the intervention of monitoring the skin breakdown around the wanderguard and checking circulation. An observation was conducted on 7/22/19 at 12:30 PM of Resident #19. Resident #19 was self-propelling her wheelchair in a common area of her unit. Her wanderguard was attached to her wheelchair. Resident #19 had no wanderguard in place to her ankle or wrist. An observation was conducted on 7/24/19 at 11:45 AM of Resident #19. Resident #19 was self-propelling her wheelchair in the hallway of the facility that led to the main entrance/exit door. Her wanderguard was attached to her wheelchair. Resident #19 had no wanderguard in place to her ankle or wrist. An interview was conducted with Nurse #3 on 7/24/19 at 2:00 PM. She stated Resident #19 had a wanderguard and that it was in place on her wheelchair. Nurse #3 reported that Resident #19 had previously taken off her own wanderguard when it was on her ankle which was why it was on her wheelchair. She indicated that she was unable to recall when the wanderguard was initially placed on her wheelchair, but she thought it was at least 6 months ago. During an interview with the Director of Nursing (DON) on 7/25/19 at 8:47 AM she reported that she was unsure how long Resident #19 had her wanderguard on the wheelchair, but she indicated it had been several months at minimum. In an interview on 7/25/19 at 11:53 AM, the Minimum Data Set (MDS) Coordinator #2 stated she was not aware that Resident #19's wanderguard was not on her ankle or wrist but rather on her wheelchair. She stated the care plan should have been revised when the wanderguard was moved to the wheelchair. In a follow up interview on 7/25/19 at 11:53 AM, the DON stated it was her expectation that Resident #19's care plan was revised to reflect the wanderguard placement to her wheelchair rather than her person. 2. Resident #6 was admitted on [DATE] with a [DIAGNOSES REDACTED]. Review of Resident #6's (MONTH) 2019 Physician orders [REDACTED]. Resident #6's annual Minimum (MDS) data set [DATE] indicated he was cognitively intact and exhibited wandering behaviors. Resident #6's behavioral Care Area Assessment indicated he propelled around the facility in his wheelchair and had a wander guard in place. Resident #6's care plan last revised on 7/17/19 read he was at risk for injury related to wandering. Interventions included monitoring the skin for breakdown around the wander guard bracelet and checking circulation. In an observation on 7/24/19 at 9:40 AM, Resident #6 was observed propelling his wheelchair into the dining room. His wander guard was observed attached to the left armrest of his wheelchair. In an observation on 7/25/19 at 9:45 AM, Resident #6 was sitting in his wheelchair inside the staff lounge. His wander guard was attached to the left armrest of his wheelchair. In another observation on 7/25/19 at 10:00 AM, Resident #6 was in his room sitting in his wheelchair. His wander guard was attached to the left armrest of his wheelchair. He was noted to have bilateral lower extremity [MEDICAL CONDITION]. He was pleasant and stated he got a pack of crackers from the lounge. In an interview on 7/25/19 at 10:35 AM, the Director of Nursing (DON) stated his wander guard was moved from his lower extremity due to [MEDICAL CONDITION]. In an interview on 7/25/19 at 11:53 AM, the Minimum Data Set (MDS) Coordinator #2 stated she was not aware that Resident #6's wander guard was not on him but rather his wheelchair. She stated the care plan should have been revised on 7/17/19 to reflect that his wander guard was to be placed on his wheelchair due to [MEDICAL CONDITION]. In an interview on 7/25/19 at 11:53 AM, the DON stated it was her expectation that Resident #6's care plan was revised to reflect the wander guard placement to his wheelchair rather than his person due to [MEDICAL CONDITION].

Based on record review and staff interview, the facility failed to comprehensively assess Resident #72's for the Minimum Data Set, Section C in the area of cognition and mood for 1 of 19 sampled residents. Findings included: Resident #72 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Resident #72 ' s care plan dated 4/9/19 revealed a need to monitor for adverse reactions to [MEDICAL CONDITION] drug use (anti-anxiety and anti-depressant) and behavior. Medication was to be administered as ordered and to monitor mood, behavior and cognitive status. Resident #72 ' s annual comprehensive Minimum Data Set ((MDS) dated [DATE] revealed Section C Cognitive Patterns and mood was not assessed ' signed by MDS Coordinator #2 on 4/16/19. On 7/24/19 at 2:35 pm an interview was conducted with MDS Coordinator #2 who stated she completed Resident #72's annual MDS dated [DATE] and had not completed Section C cognitive patterns and mood because the Coordinator was out sick for the look-back period (7 days) and no other staff member completed the assessment. The assessment was not done. On 7/25/19 at 1 pm an interview was conducted with the Director of Nursing who stated she expected Resident #72 ' s annual MDS dated [DATE] to be completed and accurate.

Based on record reviews, observations, and resident and staff interviews, the facility ' s Quality Assessment and Assurance (QAA) Committee failed to maintain implemented procedures and monitor the interventions the committee put in place following the recertification/complaint survey of 5/24/18. This was for 1 deficiency originally cited 5/24/18 and was subsequently recited on the current recertification survey of 7/25/19. The recited deficiency was in the area of Minimum Data Set accuracy for diagnosis. The continued failure of the facility during two federal surveys of record shows a pattern of the facility's inability to sustain an effective QAA Program. The findings included: The tag is cross referenced to: 1. F-641 Based on record review, observation, and staff interview, the facility failed to code the Minimum Data Set (MDS) assessment accurately in the areas of physical restraints (Resident #25), behaviors (Resident #25), life expectancy (Resident #67), pressure ulcers (Resident #83), discharge status (Resident #89), and active diagnosis (Resident #82) for 5 of 22 sampled residents. During the recertification survey of 5/24/18 the facility was also cited at F641 for failing to code the MDS assessment accurately in the area of active diagnosis. On 7/25/19 at 11:40 am an interview was conducted with the Director of Operations who stated the root cause for the repeat tag was human error.

Based on record review, observation, and staff interview, the facility failed to provide a safe transfer with a mechanical lift for a dependent resident (Resident #25) to prevent the resident ' s toe from hitting the lift bar causing the resident to lose her toe nail for 1 of 9 residents sampled for accidents. The findings included: Resident #25 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The admission Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #25 ' s cognition was moderately impaired. She was assessed with [REDACTED]. Resident #25 was dependent on 2 or more staff for transfers and she had functional limitations with range of motion in both sides of her lower extremities. Resident #25 ' s care plan included the problem/need of the risk for unmet needs related to extensive to total staff assistance for all Activities of Daily Living (ADLs). This problem/need was initiated on 5/28/19 and included the intervention of transfers via a mechanical lift. An incident report dated 7/13/19 completed by Nurse #2 indicated Nursing Assistant (NA) #2 reported to her that she and another NA (NA #1) were transferring Resident #25 using the mechanical lift when the resident ' s left foot hit a bar on the mechanical lift resulting in her toenail of the 2nd digit to come off. Nurse #2 indicated that Resident #25 ' s toe was bleeding, and she cleaned the injury and applied a dressing. Resident #25 stated what happened and when she was informed her toenail came off she stated, I didn ' t even feel it. The physician are Responsible Party (RP) were notified of the incident. The immediate post incident action was noted to be NA re-education regarding monitoring resident ' s position while using the mechanical lift. On 7/13/19 Resident #25 ' s care plan related to the risk for impaired skin integrity was updated with the intervention of staff education on guarding extremities during mechanical lift transfers related to Resident #25 ' s toe nail falling off during a transfer. On 7/15/19 Resident #25 ' s care plan related to the risk for skin integrity was updated with the intervention of a podiatry referral with an appointment scheduled on 7/24/19. An observation was conducted of Resident #25 on 7/22/19 at 10:00 AM. Resident #25 was seated in her wheelchair in a common area of the facility. An interview was attempted, but she was unable to answer any open-ended questions. A phone interview was conducted with Nurse #2 on 7/23/19 at 11:48 AM. She confirmed that on 7/13/19 NA #2 came to her after she and NA #1 assisted Resident #25 out of bed using the mechanical lift. Nurse #2 reported that NA #1 and NA #2 told her Resident #25 ' s left foot hit a bar on the mechanical lift causing her toenail to come off. She stated that the toe was bleeding so she cleaned the injury and applied a dressing. She indicated that Resident #25 reported no pain from the injury. She reported that Resident #25 required no further medical treatment related to the injury, she had no bruising identified, and no residual pain following the injury. Nurse #2 stated that after the incident she re-educated NA #1 and NA #2 on the need to monitor where the resident ' s arms and legs were at throughout the use of the mechanical lift. She indicated she felt the injury was preventable if proper transfer technique of monitoring the resident ' s extremities throughout the transfer had been used. Nurse #2 reported that no other staff were re-educated on mechanical lift technique after this incident. A phone interview was conducted with NA #1 on 7/23/19 at 12:05 PM. She stated that on 7/13/19 she and NA #2 were transferring Resident #25 from her bed to wheelchair using the mechanical lift. She stated that during the transfer Resident #25 ' s left foot had hit one of the bars on the mechanical lift and her toenail fell off. She indicated that Resident #25 ' s toe was bleeding but that the resident reported no pain. NA #1 stated that Nurse #2 re-educated her and NA #2 after the incident on monitoring where the resident ' s arms and legs were at throughout the use of the mechanical lift. She explained that she and NA #2 had not been paying close enough attention to Resident #25 ' s lower extremities and had not realized the resident ' s left foot hit the bar on the mechanical lift until they noticed the bleeding from her left toe. NA #1 revealed she thought the incident could have been prevented by monitoring Resident #25 ' s limbs throughout the transfer. An interview was conducted with NA #2 on 7/23/19 at 3:30 PM. NA #2 confirmed NA #1 ' s statement that on 7/13/19 she and NA #1 were transferring Resident #25 from her bed to wheelchair using the mechanical lift and that during the transfer the resident ' s left foot had hit one of the bars on the mechanical lift causing her toenail to fall off. NA #2 stated that they had not noticed the injury until they saw blood on Resident #25 ' s left foot. She indicated that she got Nurse #2 to assess Resident #25 and that the resident said she had no pain from the injury. NA #2 stated that Nurse #2 re-educated her and NA #1 after the incident on monitoring where the resident ' s arms and legs were at throughout the use of the mechanical lift. She verified NA #1 ' s interview that that she and NA #1 had not been paying close enough attention to Resident #25 ' s lower extremities and had not realized the resident ' s left foot hit the bar on the mechanical lift until they noticed the bleeding from her left toe. NA #2 revealed she thought the incident could have been prevented by monitoring Resident #25 ' s limbs throughout the transfer. An interview was conducted with the Director of Nursing (DON) on 7/23/19 at 4:15 PM. The 7/13/19 incident report for Resident #25 in which she sustained a minor injury to her left foot during a transfer with a mechanical lift was reviewed with the DON. The DON stated that she expected residents to be transferred safely. She reported that after this incident NA #1 and NA #2 were re-educated by Nurse #2 on proper transfer technique with the mechanical lift. She indicated that proper transfer technique included monitoring the resident ' s extremities throughout the transfer. She reported that no other staff were included in this re-education. The DON stated that Resident #25 was also referred to podiatry with an appointment scheduled for 7/24/19. She explained that there were no after effects of the injury such as bruising or pain, but that they had wanted the podiatrist to assess the resident to ensure no further care or preventative treatments were required for Resident #25.

Based on record review, observation, and staff interview, the facility failed to code the Minimum Data Set (MDS) assessment accurately in the areas of physical restraints (Resident #25), behaviors (Resident #25), life expectancy (Resident #67), pressure ulcers (Resident #83), discharge status (Resident #89), and active diagnosis (Resident #82) for 5 of 22 sampled residents. The findings included: 1a. Resident #25 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The admission Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #25 ' s cognition was moderately impaired. She required the extensive assistance of 2 or more with bed mobility and was dependent on 2 or more staff for transfers. Resident #25 was coded with a physical restraint (any manual method or physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily which restricts freedom of movement or normal access to one's body) used in bed daily. MDS Coordinator #2 coded Resident #25 ' s 5/28/19 MDS in the area of physical restraints. The Care Area Assessment (CAA) related to physical restraints for Resident #25 ' s 5/28/19 MDS indicated she used side rails to the bed to aid in assistance with bed mobility. An observation was conducted of Resident #25 on 7/22/19 at 4:38 PM. Resident #25 was seated in her wheelchair in her room. Her bed was observed to have quarter length side rails in the down position. An interview was conducted with Nursing Assistant (NA) #1 on 7/22/19 at 4:39 PM. NA #1 reported that Resident #25 used the side rails to help her with bed mobility. She indicated that the rails had not prevented her from getting up nor had they restricted her movement. An interview was conducted with MDS Coordinator #2 on 7/23/19 at 9:54 AM. The physical restraints section of Resident #25 ' s 5/28/19 MDS was reviewed with MDS Coordinator #2. MDS Coordinator #2 revealed this was an error. She stated that Resident #25 ' s side rails were not a physical restraint and this section was coded inaccurately. An interview was conducted with the Director of Nursing (DON) on 7/25/19 at 12:05 PM. She indicated that she expected the MDS to be coded accurately. 1b. Resident #25 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A [MEDICAL CONDITION] medication documentation note indicated Resident #25 had verbal behaviors that shift, and she refused to eat dinner or a snack. The admission Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #25 ' s cognition was moderately impaired. She was coded with no behaviors and no rejection of care. The Social Worker (SW) coded Resident #25 ' s 5/28/19 MDS in the area of behaviors. An interview was conducted with the SW on 7/23/19 at 10:20 AM. The behavior section of Resident #25 ' s 5/28/19 MDS that indicated he had no behaviors and no rejection of care was reviewed with the SW. The [MEDICAL CONDITION] medication documentation note that indicated Resident #25 had behavioral symptoms on 5/28/19 was reviewed with the SW. The SW revealed that she reviewed nursing notes and medication administration notes to code the behavior section, but she had not reviewed the [MEDICAL CONDITION] medication documentation notes. She further revealed that this MDS was coded inaccurately in the area of behaviors. An interview was conducted with the Director of Nursing (DON) on 7/25/19 at 12:05 PM. She indicated that she expected the MDS to be coded accurately. 2. Resident #67 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review indicated Resident #67 was on hospice services since admission. The admission Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #67 ' s cognition was severely impaired. He was coded with hospice services but was not coded with a life expectancy of less than 6 months. MDS Coordinator #2 coded both the hospice section and the life expectancy section of Resident #67 ' s 7/1/19 MDS. An interview was conducted with MDS Coordinator #2 on 7/23/19 at 9:54 AM. The 7/1/19 MDS for Resident #67 that indicated he had hospice services but had no life expectancy of less than 6 months was reviewed with MDS Coordinator #2. The MDS Coordinator revealed this MDS was coded inaccurately for life expectancy. She stated that she had recently been to an MDS training where she learned that if hospice was coded that life expectancy needed to be coded as well. She reported she had not known this information prior to her training. An interview was conducted with the Director of Nursing (DON) on 7/25/19 at 12:05 PM. She indicated that she expected the MDS to be coded accurately. 3. Resident #83 was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED].#83 had moderate cognitive impairment and she had three (3) stage 3 pressure ulcers. Resident #83 had a doctor's order dated 4/30/19 to clean right heel wound with normal saline, pat dry, skin prep peri wound, place santyl (an ointment that removes dead tissue from the wound) in wound bed, cover with [MEDICATION NAME] blue (an antibacterial wound dressing) and cover with allevyn dressing (an absorbent foam dressing) and change once daily until healed. Review of the weekly pressure ulcer assessment dated [DATE] indicated that Resident #83 had one (1) stage 3 pressure ulcer on the right heel. On 7/24/19 at 9:26 AM, MDS Nurse #2 was interviewed. The MDS Nurse stated that Resident #83 had one pressure ulcer on her right heel. The MDS Nurse reviewed the annual MDS assessment dated [DATE] and stated that it was an error, it should have been coded 1 instead of 3 under stage 3 pressure ulcer. On 7/25/19 at 12:04 PM, the Director of Nursing (DON) was interviewed. The DON verified that Resident #83 had only 1 stage 3 pressure ulcer and it was on her right heel. She further indicated that she expected the MDS assessments to be coded accurately. 4. Resident #89 was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED].#89 had moderate cognitive impairment. The discharge MDS assessment dated [DATE] revealed that Resident #89 was discharged to the acute hospital on [DATE]. Resident #89's nurse's notes were reviewed. The note dated 6/18/19 at 6:09 PM revealed that discussion with the resident's family regarding end of life wishes and hospice services was conducted. The family voiced a desire to transfer Resident #89 to the hospice house. The attending physician was notified and gave an order for [REDACTED].#89 was transferred to the hospice house around 6:15 PM. On 7/24/19 at 9:26 AM, MDS Nurse #2 was interviewed. The MDS Nurse reviewed the nurse's notes and verified that Resident #89 was transferred to the hospice house instead of the acute hospital. The MDS Nurse reviewed the discharge MDS assessment dated [DATE] and stated that it was an error, the discharge status should have been coded hospice house instead of acute hospital. On 7/25/19 at 12:04 PM, the Director of Nursing (DON) was interviewed. The DON verified that Resident #89 was discharged to the hospice house. She further indicated that she expected the MDS assessments to be coded accurately. 5. Resident #82 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Resident #82 ' s 14-day Minimum Data Set ((MDS) dated [DATE] revealed entry from acute hospital. The resident had clear speech, understood and understands with a moderate cognitive deficit. Active [DIAGNOSES REDACTED]. Antipsychotic medications received section were coded antianxiety for 7 days and antidepressant for 7 days. Resident #82 ' s care plan onset dated 7/10/19 revealed [MEDICAL CONDITION] medication goal was effective with no side effects and intervention to monitor the resident ' s mood, behavior and cogitative status. On 7/24/19 at 2:00 pm an interview was conducted with MDS Coordinator #1 who stated that she missed checking the [DIAGNOSES REDACTED].#82's 14-day MDS dated [DATE] and it would be corrected. On 7/25/19 at 1:00 pm an interview was conducted with the Director of Nursing who stated she expected Resident #82 ' s 14-day MDS dated [DATE] to be completed and accurate.

Based on staff, resident, Physician and Pharmacist interviews and record review, the Consultant Pharmacist failed to identify and address the facility's failure to monitor targeted behavior and mood symptoms for the use of an antidepressant medication. This was for 1 (Resident #37) of 5 residents reviewed for unnecessary medications. The findings included: Resident #37 was admitted on [DATE] with a [DIAGNOSES REDACTED]. Resident #37's (MONTH) 2019 Physician orders [REDACTED]. Review of a Consultant Pharmacist Recommendation dated [DATE] read Resident #37 had been receiving [MEDICATION NAME] since (MONTH) (YEAR). There was no recommendation regarding the monitoring of mood or target behaviors. Review of a Consultant Pharmacist Recommendation dated [DATE] read Resident #37 had been receiving [MEDICATION NAME] since (MONTH) (YEAR). There was no recommendation regarding the monitoring of mood or target behaviors. Resident #37's quarterly Minimum (MDS) data set [DATE] indicated she was cognitively intact and exhibited no behaviors. Her mood was coded as feeling tired and problems concentrating. Resident #37 was coded as receiving an antidepressant 7 of 7 days of the look back period. Resident #37 care plan last revised on [DATE] read she was at risk for adverse effects due to the use of an antidepressant medication. Interventions included monitoring of mood, behaviors and cognitive status. In an interview on [DATE] at 9:40 AM, Resident #37 reported she was not feeling down or sad but reported a lack of energy. She appeared alert and pleasant. In an interview on [DATE] at 10:04 AM, the Physician stated it was his expectation that the Consultant Pharmacist identify any missing mood and behaviors monitoring for Resident #37 and notify the facility, so monitoring could be implemented. In a telephone interview on [DATE] at 2:30 PM, the Consultant Pharmacist stated it was her expectation that the facility monitored specific behaviors and mood for Resident #37. She stated she was unsure if she addressed with the facility the lack of behavior and mood monitoring for the use of Resident #37's [MEDICATION NAME]. The Consultant Pharmacist stated she started at the facility in (MONTH) (YEAR) and it could have been an oversight. In an interview on [DATE] at 8:30 AM, Nurse #3 stated Resident #37 lost a grandchild over a year ago and a roommate she was very close too died last year. Nurse #3 stated Resident #37 has not exhibited any evidence of sadness or crying. She stated Resident #37 participated in activities and has lots of visitors. In an interview on [DATE] at 11:53 AM, the Director of Nursing (DON) stated it was her expectation that the Consultant Pharmacist identify and address the facility's lack of mood and behaviors monitoring for the use of [MEDICATION NAME].

Based on record review and Physician and staff interview, the facility failed to try non pharmacological interventions prior to administering as needed (PRN) [MEDICAL CONDITION] medication and failed to have a specific behavior to indicate the use of the PRN [MEDICAL CONDITION] medication (Resident #77) and also failed to attempt a gradual dose reduction (GDR) as required for [MEDICAL CONDITION] medication (Resident #37) for 2 of 5 sampled residents reviewed for unnecessary medications. Findings included: 1. Resident #77 was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. The annual Minimum Data Set (MDS) assessment dated [DATE] indicated that Resident #77 had severe cognitive impairment and she had received an antianxiety medication for 6 days during the assessment period. Resident #77's care plan dated [DATE] included a problem of at risk for agitation and anxiety related to dementia and [MEDICAL CONDITION]. The goal was I will not have increased agitation and anxiety. The approaches included to provide diversional activities when behaviors became disruptive. Resident #77's doctor's orders included [MEDICATION NAME] (antianxiety medication) 0.25 milligrams (mgs) by mouth daily for anxiety. Resident #77 doctor's orders were reviewed. On [DATE], there was an order to give [MEDICATION NAME] 1 milligrams (mgs) intramuscular (IM) x (times) 1 dose now for anxiety/agitation, on [DATE] with 2 orders, (1)an order to give [MEDICATION NAME] 1 mgs IM x 1 dose now agitation/anxiety and (2) to give [MEDICATION NAME] 1 mgs IM now (no indication for use) and on [DATE], to give [MEDICATION NAME] 1 mgs IM x 1 dose now (no indication for use). Nurse #4 was the nurse who received the order for the PRN [MEDICATION NAME] and who administered the [MEDICATION NAME] on [DATE] at 4 PM and 10 PM and on [DATE] at 5:00 PM. Resident #77's Medication Administration Records (MARs) and the nurse's notes were reviewed. The (MONTH) 2019 MAR indicated [REDACTED]. The nurse's notes were reviewed and there was no entry for [DATE] of any nonpharmacological approaches that were tried prior to administering the PRN [MEDICATION NAME] IM and there was no entry of any specific behavior to indicate the use of the PRN [MEDICATION NAME]. The (MONTH) 2019 MAR indicated [REDACTED]. Review of the doctor's orders revealed that there was no order dated [DATE] for the [MEDICATION NAME] 1 mgs. The nurse's notes were reviewed and there was no entry for [DATE] of any nonpharmacological approaches that were tried prior to administering the PRN [MEDICATION NAME] IM and there was no entry of any specific behavior to indicate the use of the PRN [MEDICATION NAME]. The (MONTH) 2019 MAR indicated [REDACTED]. The nurse's notes were reviewed and there was no entry for [DATE] and [DATE] of any nonpharmacological approaches that were tried prior to administering the PRN [MEDICATION NAME] IM and there was no entry of any specific behavior to indicate the use of the PRN [MEDICATION NAME]. On [DATE] at 10:18 AM, the Physician was interviewed. The Physician stated that IM [MEDICATION NAME] was used for Resident #77 for quicker action. He indicated that Resident #77 had exhibited major behavioral issues. He reported that he expected the nursing staff to try diversional activities or redirections prior to administering any PRN [MEDICAL CONDITION] medications. The Physician also indicated that he expected the nursing staff to document the specific behavior exhibited by the resident and the approaches that were tried prior to administering the PRN [MEDICAL CONDITION] medication. On [DATE] at 3:24 PM, Nurse #4 was interviewed. She stated that when Resident #77 was exhibiting behaviors, she would redirect the resident by playing music, showing pictures or other activities and these normally would calm the resident down. The Nurse indicated that she would document these approaches in the nurse's notes. Nurse #4 also stated that when a PRN [MEDICAL CONDITION] medication was ordered, she would document the specific behavior exhibited by the resident in the nurse's notes. Nurse #4 reviewed the nurse's notes and she stated that she could not find any documentation of any diversional activities or specific behavior to indicate the use of the PRN [MEDICATION NAME] on [DATE] and [DATE]. On [DATE] at 3:55 PM, the Director of Nursing (DON) was interviewed. The DON stated that when a resident was agitated/combative, she expected the nurse to try to find the cause of the agitation/combativeness and to try to intervene prior to calling the doctor for PRN [MEDICAL CONDITION] medication and to document the interventions that were tried in the nurse's notes. The DON also indicated that her expectation was for the nurses to write on the order and in the nurse's notes the indication for the use of the PRN [MEDICAL CONDITION] medication. The DON further reported that she had reviewed the nursing notes and she did not find any documentation of any diversional activities tried and any specific behavior to indicate the use of the PRN [MEDICATION NAME] on [DATE], [DATE], [DATE] and [DATE]. On [DATE] at 1:30 PM, the Nurse Unit Manager #2 stated that she could not find any doctor's order for the PRN [MEDICATION NAME] that was administered on [DATE]. 2. Resident #37 was admitted on [DATE] with a [DIAGNOSES REDACTED]. Resident #37's (MONTH) 2019 Physician orders [REDACTED]. The (MONTH) 2019 Physician orders [REDACTED]. Review of a Consultant Pharmacist Recommendation dated [DATE] read Resident #37 had been receiving [MEDICATION NAME] 15 mg at bedtime since (MONTH) (YEAR) and [MEDICATION NAME] 0.25 mg at bedtime since (MONTH) (YEAR). The recommendation was marked by the Physician as he disagreed with an attempted gradual dose reduction (GDR) and dated [DATE]. There was no additional documentation noted. Review of a Consultant Pharmacist Recommendation dated [DATE] read Resident #37 had been receiving [MEDICATION NAME] 15 mg at bedtime since (MONTH) (YEAR) and [MEDICATION NAME] 0.25 mg at bedtime since (MONTH) (YEAR). The recommendation was marked by the Physician as he disagreed with an attempted GDR and dated [DATE]. There was also a handwritten note that read: Stable on current medication. Resident #37's quarterly Minimum (MDS) data set [DATE] indicated she was cognitively intact and exhibited no behaviors. Her mood was coded as feeling tired and problems concentrating. Resident #37 was coded as receiving an antidepressant and antianxiety 7 of 7 days of the look back period. Resident #37 care plan last revised on [DATE] read she was at risk for adverse effects due to the use of an antidepressant and antianxiety medication. Interventions included monitoring of mood, behaviors and cognitive status. Other interventions included psychoactive drug documentation and medications as ordered by the Physician. In an interview on [DATE] at 9:40 AM, Resident #37 reported she was not feeling down or sad but reported a lack of energy. She appeared alert and pleasant. In an interview on [DATE] at 10:04 AM, the Physician stated Resident #37 had several roommates last year and lost a relative about a year ago. He stated he ordered a GDR of her [MEDICATION NAME] on [DATE] but would not be ordering a GDR of her [MEDICATION NAME]. The Physician stated a GDR of Resident #37's [MEDICATION NAME] could potentially cause withdrawal since she had taken [MEDICATION NAME] for over [AGE] years. He confirmed he did not document in Resident #37's medical record the rationale for declining a GDR of [MEDICATION NAME] and [MEDICATION NAME] on [DATE] and on [DATE]. In a telephone interview on [DATE] at 2:30 PM, the Consultant Pharmacist stated she started at the facility in (MONTH) (YEAR) and had spoken to the Physician about the need for additional documentation regarding his repeat declining of attempted GDR or Resident #37's [MEDICATION NAME] and [MEDICATION NAME]. In an interview on [DATE] at 8:30 AM, Nurse #3 stated Resident #37 lost a grandchild over a year ago and a roommate she was very close too died last year. Nurse #3 stated Resident #37 has not exhibited any sadness or crying. She stated Resident #37 participated in activities and has lots of visitors. In an interview on [DATE] at 11:53 AM, the Director of Nursing (DON) stated it was her expectation that there be an attempted GDR of Resident #37's [MEDICATION NAME] and [MEDICATION NAME] unless it was contraindicated. She stated if a GDR was declined, it was her expectation that the Physician document the rationale in the medical record.

Based on record review and staff interviews, the facility failed to ensure the Posted Staffing and Census sheets reflected an accurate total number and total care hours worked for Registered Nurses (RNs) on 25 of 30 days reviewed. The findings included: A review of the facility ' s posted staffing and census sheets was conducted on 7/23/19 for the dates of (MONTH) 22 through (MONTH) 21, 2019. There were a total of 25 of 30 days (6/22, 6/23, 6/25-6/30, 7/2-7/7, 7/9-7/11, 7/13-7/15, and 7/17-7/21) that indicated 0 Registered Nurses (RNs) worked on all 3 shifts and 0 total care hours were worked by RNs on all 3 shifts. A review of the daily assignment sheets and staff time sheet hours was conducted from (MONTH) 22 through (MONTH) 21, 2019 and was compared to the posted staffing and census sheets and revealed the 25 days that indicated 0 total RNs and 0 RN care hours worked were inaccurate. An RN had worked on all 25 days for a minimum of 8 hours as required. An interview was conducted with the Director of Operations (DOO) on 7/23/19 at 10:50 AM. The posted staffing and census sheets for the 25 days that were found to be inaccurate in the area of total number and total care hours worked for RNs were reviewed with the DOO. He confirmed that the posted staffing and census sheets for these 25 days were inaccurate in the area of total number and total care hours worked for RNs. The DOO stated that Medical Records staff completed the posted staffing and census sheets and she had only accounted for nurses who were assigned on the floor and failed to include the RN Unit Managers (UMs). He reported that there were two RN UMs who worked Monday through Friday and they rotated on the weekends to ensure an RN was working a minimum of 8 hours per day as required. The DOO indicated he expected the posted staffing and census sheets to be accurate. An interview was conducted with Medical Records staff on 7/23/19 at 10:58 AM. She stated that she had spoken with the DOO and she confirmed his statement that she had only accounted for nurses who were assigned on the floor and she failed to include the RN UMs on the posted staffing and census sheets.

Based on record review, resident interview, and staff interview, the facility failed to prevent a resident who required the extensive assistance of 1 staff for toileting from falling in the bathroom and sustaining a subarachnoid hemorrhage (bleeding in the space between the brain and the tissue covering the brain) and a subdural hematoma (pool of blood between the brain and its outermost covering). Resident #28 was assisted to the bathroom by Nursing Assistant (NA) #1, NA #1 exited the bathroom to retrieve items from the resident ' s room, and Resident #28 fell as she attempted to transfer independently from the toilet to her wheelchair while unattended by staff. This was for 1 of 5 residents reviewed for accidents. The findings included: Resident #28 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. The admission Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #28 ' s cognition was fully intact. She had no behaviors and no rejection of care. Resident #28 required the extensive assistance of 2 or more staff with bed mobility and the extensive assistance of 1 staff for toileting, dressing, and personal hygiene. She required the limited assistance of 1 staff for transfers. Resident #28 was not steady on her feet, but she was able to stabilize without staff assistance. She utilized a wheelchair and walker and had no impairment with her range of motion. Resident #28 was frequently incontinent of bladder and bowel. The Care Area Assessment (CAA) related to Activities of Daily Living (ADLs) for Resident #28 ' s 1/12/18 MDS indicated she required limited to extensive assistance of 1 staff with ADLs related to a debilitated state, weakness, and balance problems. The CAA related to falls for Resident #28 ' s 1/12/18 MDS indicated she was at risk for falls with injury. Resident #28 ' s plan of care included the focus area of the potential for falls. This area was initiated on 11/28/17 and reviewed on 1/12/18. The interventions included, in part, Staff to monitor me during toileting task if assisted to bathroom .transfer back to chair/bed. Do not leave me alone in bathroom. A review was conducted of the NA documentation for Resident #28 ' s toileting task from 2/1/18 through 3/1/18. The NA documentation indicated Resident #28 ' s level of required assistance for toileting varied from the limited assistance of 1 staff to total dependence of 2 or more staff. An incident report dated 3/1/18 and written by Nurse #1 indicated Resident #28 had an unwitnessed fall with injury on 3/1/18 at 8:15 AM. Resident #28 ' s injuries were noted as, skin tear - superficial, bruise/redness, hematoma. Nurse #1 was called to Resident #28 ' s bathroom by staff. Resident #28 had fallen from the toilet onto the floor as she was attempting to transfer into her wheelchair. Resident #28 was noted to have two skin tears, one to the left elbow and one to the left knee. Both skin tears were cleaned and dressed. An ice pack was applied to Resident #28 ' s head. She was assisted back to her wheelchair by 2 staff. The physician and Responsible Party (RP) were contacted. The Fall Scene Investigation (FSI) Report related to Resident #28 ' s fall on 3/1/18 at 8:15 AM indicated NA #1 was the first staff present following Resident #28 ' s unwitnessed fall. Resident #28 was found on the floor in her bathroom after attempting to self-transfer. Resident #28 was assessed as alert and oriented prior to the fall. She stated she was trying to transfer to her wheelchair. The FSI Report provided a written statement from NA #1. NA #1 indicated Resident #28 pressed her call light on 3/1/18 around 7:50 AM. NA #1 answered the call light and proceeded to assist Resident #28 with her bathing and dressing. She then assisted Resident #28 to her bathroom (located inside of Resident #28 ' s bedroom). NA #1 reported that after she had transferred Resident #28 from her wheelchair to the toilet she had stepped out of the bathroom to pick-up the resident ' s nightgown and linens from the floor in her room. NA #1 indicated while she was outside of the bathroom she heard Resident #28 scream. She noted that Resident #28 had not called out verbally for her assistance and she had not rang the call bell. NA #1 indicated she reminded Resident #28 to use the call light for assistance in the bathroom. A nursing note dated 3/1/18 and written by Nurse #1 confirmed the information in the incident report dated 3/1/18. The note additionally indicated Resident #28 had bumped her head on the floor and neurological assessments were initiated. A physician's order [REDACTED].#28. A review was conducted of the neurological assessments dated 3/1/18 beginning at 8:30 AM. These assessments indicated no concerns with Resident #28 ' s condition through the assessment completed on 3/1/18 at 11:30 AM. A nursing note dated 3/1/18 at 12:02 PM indicated Nurse #1 was called to Resident #28 ' s room. Resident #28 had vomited and was shaking. She stated her head hurt and she didn ' t feel good. The physician was notified and an order was received to send Resident #28 to the emergency room (ER) for evaluation. The ER records indicated Resident #28 was seen in the Emergency Department on 3/1/18 and a neurology consultation was ordered. The neurology consultation indicated Resident #28 presented with a traumatic Subarachnoid Hemorrhage (SAH) on the right side. A head CT (computerized tomography) scan showed suspected Subdural Hematoma (SDH). She was admitted to the hospital for repeat CT head scans and monitoring. This consultation noted that it was discussed whether Resident #28 was more appropriate on neurology service or medicine service, but medicine service had not felt comfortable managing the size of Resident #28 ' s bleed. The hospital records indicated Resident #28 remained in the hospital from 3/1/18 through 3/5/18 when she was discharged back to the facility. Resident #28 ' s plan of care related to falls was updated on 3/5/18 with the handwritten intervention, Do not leave Resident alone in bathroom. This was a duplicate intervention as it was previously in place on the care plan. A physician ' s progress note dated 3/28/18 indicated Resident #28 was readmitted to the facility following a hospital stay for a fall resulting in closed head trauma, SAH, and SDH. Repeated head CTs at the hospital showed stability. A review of the medical record indicated Resident #28 has returned to her baseline health status. The NA Daily Care Guide, undated, for Resident #28 was reviewed on 5/22/18. The interventions for Resident #28 included, in part, Staff to monitor me during toileting task if assisted to bathroom .transfer back to chair/bed. Do not leave me alone in bathroom. An interview was conducted with the DON on 5/22/18 at 3:05 PM. The DON stated that the interventions on the care plan were linked to the NA Daily Care Guide interventions. She stated if the intervention was in place on the care plan, then it was also in place on the NA Daily Care Guide. The intervention for Resident #28 that indicated, Staff to monitor me during toileting task if assisted to bathroom .transfer back to chair/bed. Do not leave me alone in bathroom was reviewed with the DON. She confirmed this intervention was in place on the care plan and on the NA Daily Care Guide at the time of Resident #28 ' s 3/1/18 fall. An interview was conducted with NA #1 on 5/22/18 at 2:25 PM. She stated she had worked at the facility for about 3 years and she was familiar with Resident #28. She reported Resident #28 was a fall risk and she had several falls. She confirmed she was working with Resident #28 on 3/1/18 at the time of her 8:15 AM fall. She stated she had taken Resident #28 to the bathroom after she assisted her with bathing. NA #1 indicated she transferred Resident #28 to the toilet, she stayed in the bathroom during the task of toileting, and she changed Resident #28 ' s brief. She reported prior to transferring Resident #28 off of the toilet and back to her wheelchair, she left the bathroom to retrieve a roll of trash bags she had left in Resident #28 ' s room. She indicated she was out of the bathroom for about 5 seconds when she heard Resident #28 scream, she re-entered the bathroom, and she found her on the floor. NA #1 confirmed that Resident #28 had fallen while attempting to self-transfer without staff present. This interview with NA #1 continued. She was asked how she was made aware of fall risk interventions that were in place. She stated the NA kiosk, an electronic record of the NA Daily Care Guide, had a list of all of the interventions for each resident. The NA kiosk for Resident #28 was reviewed with NA #1. The kiosk included the intervention, Staff to monitor me during toileting task if assisted to bathroom .transfer back to chair/bed. Do not leave me alone in bathroom. NA #1 acknowledged she had assisted Resident #28 to the bathroom and left her alone while she retrieved items from the resident ' s room. She revealed she had not known this intervention was in place for Resident #28. She reported that she thought Resident #28 was able to toilet independently and that she only needed assistance changing her brief. An interview was conducted with Nurse #1 on 5/23/18 at 9:06 AM. She stated she had worked at the facility for over [AGE] years and she was familiar with Resident #28. She reported Resident #28 was a fall risk and she had several falls. She confirmed she was working with Resident #28 on 3/1/18 at the time of her 8:15 AM fall. She indicated Resident #28 had lost her balance and fell off of the toilet onto her bathroom floor. She stated Resident #28 had a couple of skin tears and redness noted to her head. Nurse #1 reported she assessed Resident #28 ' s neurological status and noted no concerns with her condition. She obtained an order for [REDACTED].#28 was then sent to the ER for evaluation and was admitted to the hospital. An interview was conducted with Resident #28 on 5/23/18 at 9:30 AM. She indicated she had fallen multiple times at the facility. She stated she needed help getting on and off the toilet and changing her briefs after toileting. The 3/1/18 fall at 8:15 AM was discussed with Resident #28. She stated she was in the bathroom, the NA (NA #1) left the bathroom, and she tried to get up on her own. She reported she lost her balance and fell and hit her head on the bathroom floor. A follow up interview was conducted with the DON on 5/24/18 at 10:10 AM. She stated the purpose of care plan interventions related to falls were to reduce the risk for falls and to avoid preventable falls. She indicated she expected staff to be aware of care plan interventions and to implement them at all times.

Based on record review, resident interview, and staff interview, the facility neglected to implement a care plan intervention related to falls that indicated Resident #28 was not to be left alone in the bathroom when she was assisted with toileting. Resident #28 was assisted to the bathroom by Nursing Assistant (NA) #1, NA #1 exited the bathroom to retrieve items from the resident ' s room, and Resident #28 fell as she attempted to transfer independently from the toilet to her wheelchair while unattended by staff. The fall resulted in Resident #28 sustaining a subarachnoid hemorrhage (bleeding in the space between the brain and the tissue covering the brain) and a subdural hematoma (pool of blood between the brain and its outermost covering). This was for 1 of 1 residents reviewed for neglect. The findings included: Resident #28 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. The admission Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #28 ' s cognition was fully intact. She had no behaviors and no rejection of care. Resident #28 required the extensive assistance of 2 or more staff with bed mobility and the extensive assistance of 1 staff for toileting, dressing, and personal hygiene. She required the limited assistance of 1 staff for transfers. Resident #28 was not steady on her feet, but she was able to stabilize without staff assistance. She utilized a wheelchair and walker and had no impairment with her range of motion. Resident #28 was frequently incontinent of bladder and bowel. The Care Area Assessment (CAA) related to Activities of Daily Living (ADLs) for Resident #28 ' s 1/12/18 MDS indicated she required limited to extensive assistance of 1 staff with ADLs related to a debilitated state, weakness, and balance problems. The CAA related to falls for Resident #28 ' s 1/12/18 MDS indicated she was at risk for falls with injury. Resident #28 ' s plan of care included the focus area of the potential for falls. This area was initiated on 11/28/17 and reviewed on 1/12/18. The interventions included, in part, Staff to monitor me during toileting task if assisted to bathroom .transfer back to chair/bed. Do not leave me alone in bathroom. A review was conducted of the NA documentation for Resident #28 ' s toileting task from 2/1/18 through 3/1/18. The NA documentation indicated Resident #28 ' s level of required assistance for toileting varied from the limited assistance of 1 staff to total dependence of 2 or more staff. An incident report dated 3/1/18 and written by Nurse #1 indicated Resident #28 had an unwitnessed fall with injury on 3/1/18 at 8:15 AM. Resident #28 ' s injuries were noted as, skin tear – superficial, bruise/redness, hematoma. Nurse #1 was called to Resident #28 ' s bathroom by staff. Resident #28 had fallen from the toilet onto the floor as she was attempting to transfer into her wheelchair. Resident #28 was noted to have two skin tears, one to the left elbow and one to the left knee. Both skin tears were cleaned and dressed. An ice pack was applied to Resident #28 ' s head. She was assisted back to her wheelchair by 2 staff. The physician and Responsible Party (RP) were contacted. The Fall Scene Investigation (FSI) Report related to Resident #28 ' s fall on 3/1/18 at 8:15 AM indicated NA #1 was the first staff present following Resident #28 ' s unwitnessed fall. Resident #28 was found on the floor in her bathroom after attempting to self-transfer. Resident #28 was assessed as alert and oriented prior to the fall. She stated she was trying to transfer to her wheelchair. The FSI Report provided a written statement from NA #1. NA #1 indicated Resident #28 pressed her call light on 3/1/18 around 7:50 AM. NA #1 answered the call light and proceeded to assist Resident #28 with her bathing and dressing. She then assisted Resident #28 to her bathroom (located inside of Resident #28 ' s bedroom). NA #1 reported that after she had transferred Resident #28 from her wheelchair to the toilet she had stepped out of the bathroom to pick-up the resident ' s nightgown and linens from the floor in her room. NA #1 indicated while she was outside of the bathroom she heard Resident #28 scream. She noted that Resident #28 had not called out verbally for her assistance and she had not rang the call bell. NA #1 indicated she reminded Resident #28 to use the call light for assistance in the bathroom. A nursing note dated 3/1/18 and written by Nurse #1 confirmed the information in the incident report dated 3/1/18. The note additionally indicated Resident #28 had bumped her head on the floor and neurological assessments were initiated. A physician's order [REDACTED].#28. A review was conducted of the neurological assessments dated 3/1/18 beginning at 8:30 AM. These assessments indicated no concerns with Resident #28 ' s condition through the assessment completed on 3/1/18 at 11:30 AM. A nursing note dated 3/1/18 at 12:02 PM indicated Nurse #1 was called to Resident #28 ' s room. Resident #28 had vomited and was shaking. She stated her head hurt and she didn ' t feel good. The physician was notified and an order was received to send Resident #28 to the emergency room (ER) for evaluation. The ER records indicated Resident #28 was seen in the Emergency Department on 3/1/18 and a neurology consultation was ordered. The neurology consultation indicated Resident #28 presented with a traumatic Subarachnoid Hemorrhage (SAH) on the right side. A head CT (computerized tomography) scan showed suspected Subdural Hematoma (SDH). She was admitted to the hospital for repeat CT head scans and monitoring. This consultation noted that it was discussed whether Resident #28 was more appropriate on neurology service or medicine service, but medicine service had not felt comfortable managing the size of Resident #28 ' s bleed. The hospital records indicated Resident #28 remained in the hospital from 3/1/18 through 3/5/18 when she was discharged back to the facility. Resident #28 ' s plan of care related to falls was updated on 3/5/18 with the handwritten intervention, Do not leave Resident alone in bathroom. This was a duplicate intervention as it was previously in place on the care plan. A physician ' s progress note dated 3/28/18 indicated Resident #28 was readmitted to the facility following a hospital stay for a fall resulting in closed head trauma, SAH, and SDH. Repeated head CTs at the hospital showed stability. A review of the medical record indicated Resident #28 has returned to her baseline health status. The NA Daily Care Guide, undated, for Resident #28 was reviewed on 5/22/18. The interventions for Resident #28 included, in part, Staff to monitor me during toileting task if assisted to bathroom .transfer back to chair/bed. Do not leave me alone in bathroom. An interview was conducted with the DON on 5/22/18 at 3:05 PM. The DON stated that the interventions on the care plan were linked to the NA Daily Care Guide interventions. She stated if the intervention was in place on the care plan, then it was also in place on the NA Daily Care Guide. The intervention for Resident #28 that indicated, Staff to monitor me during toileting task if assisted to bathroom .transfer back to chair/bed. Do not leave me alone in bathroom was reviewed with the DON. She confirmed this intervention was in place on the care plan and on the NA Daily Care Guide at the time of Resident #28 ' s 3/1/18 fall. An interview was conducted with NA #1 on 5/22/18 at 2:25 PM. She stated she had worked at the facility for about 3 years and she was familiar with Resident #28. She reported Resident #28 was a fall risk and she had several falls. She confirmed she was working with Resident #28 on 3/1/18 at the time of her 8:15 AM fall. She stated she had taken Resident #28 to the bathroom after she assisted her with bathing. NA #1 indicated she transferred Resident #28 to the toilet, she stayed in the bathroom during the task of toileting, and she changed Resident #28 ' s brief. She reported prior to transferring Resident #28 off of the toilet and back to her wheelchair, she left the bathroom to retrieve a roll of trash bags she had left in Resident #28 ' s room. She indicated she was out of the bathroom for about 5 seconds when she heard Resident #28 scream, she re-entered the bathroom, and she found her on the floor. NA #1 confirmed that Resident #28 had fallen while attempting to self-transfer without staff present. This interview with NA #1 continued. She was asked how she was made aware of fall risk interventions that were in place. She stated the NA kiosk, an electronic record of the NA Daily Care Guide, had a list of all of the interventions for each resident. The NA kiosk for Resident #28 was reviewed with NA #1. The kiosk included the intervention, Staff to monitor me during toileting task if assisted to bathroom .transfer back to chair/bed. Do not leave me alone in bathroom. NA #1 acknowledged she had assisted Resident #28 to the bathroom and left her alone while she retrieved items from the resident ' s room. She revealed she had not known this intervention was in place for Resident #28. She reported that she thought Resident #28 was able to toilet independently and that she only needed assistance changing her brief. An interview was conducted with Nurse #1 on 5/23/18 at 9:06 AM. She stated she had worked at the facility for over [AGE] years and she was familiar with Resident #28. She reported Resident #28 was a fall risk and she had several falls. She confirmed she was working with Resident #28 on 3/1/18 at the time of her 8:15 AM fall. She indicated Resident #28 had lost her balance and fell off of the toilet onto her bathroom floor. She stated Resident #28 had a couple of skin tears and redness noted to her head. Nurse #1 reported she assessed Resident #28 ' s neurological status and noted no concerns with her condition. She obtained an order for [REDACTED].#28 was then sent to the ER for evaluation and was admitted to the hospital. An interview was conducted with Resident #28 on 5/23/18 at 9:30 AM. She indicated she had fallen multiple times at the facility. She stated she needed help getting on and off the toilet and changing her brief after toileting. The 3/1/18 fall at 8:15 AM was discussed with Resident #28. She stated she was in the bathroom, the NA (NA #1) left the bathroom, and she tried to get up on her own. She reported she lost her balance and fell and hit her head on the bathroom floor. A follow up interview was conducted with the DON on 5/24/18 at 10:10 AM. She stated the purpose of care plan interventions related to falls were to reduce the risk for falls and to avoid preventable falls. She indicated she expected staff to be aware of care plan interventions and to implement them at all times.

Based on record review, resident interview, and staff interview, the facility failed to honor residents' choices by removing side rails for cognitively intact residents who expressed a desire to have side rails for 4 of 4 residents reviewed for choices (Residents #10, #12, #15, and #37). The findings included: 1. Resident #15 was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #15 ' s cognition was intact. She was assessed as requiring the limited assistance of 1 staff for bed mobility and transfers. She had no impairment with range of motion. The plan of care for Resident #15, dated 3/11/18, included a self-care deficit requiring the limited assistance of staff with bed mobility and with transfers at times. An interview was conducted with Resident #15 during the Resident Council Meeting held on 5/22/18 beginning at 2:00 PM. She indicated a concern about the removal of her side rails. She stated her side rails had been removed several months ago despite her expressed desire to have side rails on her bed to assist with positioning. Resident #15 indicated when her side rails were removed the staff had not addressed her desire to keep the side rails and they also had not discussed with her the risks and benefits of side rail usage. An interview was conducted with the Director of Nursing (DON) on 5/22/18 at 10:52 AM. The DON stated that at the beginning of (YEAR) most residents in the facility had side rails. She stated that the facility gradually began removing side rails to reduce their usage between (MONTH) (YEAR) and (MONTH) (YEAR). She reported that side rail assessments should have been completed prior to the removal of the side rails to determine the need for the side rails, to provide education on the risks and benefits of side rails, and to provide an alternative intervention if deemed necessary. The DON revealed side rail assessments had not been completed for all residents who had their side rails removed. She stated she reviewed Resident #15 ' s medical record and the most recent side rail assessment completed was dated 3/31/17. She reported this assessment indicated Resident #15 expressed a desire to have side rails raised while in bed. This assessment additionally indicated the recommendation was for bilateral side rails to serve as an enabler to promote independence. The DON confirmed the side rails for Resident #15 had been removed, no side rail assessment was completed prior to their removal, no education on the risks and benefits of side rail usage was provided to the resident, and no alternative intervention was implemented. An interview was conducted with the Administrator on 5/24/18 at 10:10 AM. The Administrator stated that side rail assessments should have been completed prior to the removal of the side rails. 2. Resident #10 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #10 ' s cognition was fully intact. He required the extensive assistance of 2 or more staff with bed mobility and transfers. He had no impairment with range of motion. The plan of care for Resident #10, dated 2/28/18, included a self-care deficit requiring the extensive assistance of 1-2 staff with bed mobility and transfers. An interview was conducted with Resident #10 during the Resident Council Meeting held on 5/22/18 beginning at 2:00 PM. He indicated a concern about the removal of his side rails. He stated his side rails had been removed several months ago despite his expressed desire to have side rails on his bed. Resident #10 indicated when his side rails were removed the staff had not addressed his desire to keep the side rails and they also had not discussed with him the risks and benefits of side rail usage. An interview was conducted with the Director of Nursing (DON) on 5/22/18 at 10:52 AM. The DON stated that at the beginning of (YEAR) most residents in the facility had side rails. She stated that the facility gradually began removing side rails to reduce their usage between (MONTH) (YEAR) and (MONTH) (YEAR). She reported that side rail assessments should have been completed prior to the removal of the side rails to determine the need for the side rails, to provide education on the risks and benefits of side rails, and to provide an alternative intervention if deemed necessary. She stated she reviewed Resident #10 ' s medical record and the most recent side rail assessment completed was dated 4/3/17. She reported this assessment indicated Resident #10 expressed a desire to have side rails raised while in bed. This assessment additionally indicated the recommendation was for side rails to serve as an enabler to promote independence. The DON confirmed the side rails for Resident #10 had been removed, no side rail assessment was completed prior to their removal, no education on the risks and benefits of side rail usage was provided to the resident, and no alternative intervention was implemented. An interview was conducted with the Administrator on 5/24/18 at 10:10 AM. The Administrator stated that side rail assessments should have been completed prior to the removal of the side rails. 3. Resident #12 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #12 ' s cognition was fully intact. She required the extensive assistance of 2 or more staff with bed mobility and 1 staff with transfers. She had no impairment with range of motion. The plan of care for Resident #12, dated 2/28/18, included a self-care deficit requiring the extensive assistance of staff with bed mobility and transfers. An interview was conducted with Resident #12 during the Resident Council Meeting held on 5/22/18 beginning at 2:00 PM. She indicated a concern about the removal of her side rails. She stated her side rails had been removed several months ago despite her expressed desire to have side rails on her bed. Resident #12 indicated when her side rails were removed the staff had not addressed her desire to keep the side rails and they also had not discussed with her the risks and benefits of side rail usage. An interview was conducted with the Director of Nursing (DON) on 5/22/18 at 10:52 AM. The DON stated that at the beginning of (YEAR) most residents in the facility had side rails. She stated that the facility gradually began removing side rails to reduce their usage between (MONTH) (YEAR) and (MONTH) (YEAR). She reported that side rail assessments should have been completed prior to the removal of the side rails to determine the need for the side rails, to provide education on the risks and benefits of side rails, and to provide an alternative intervention if deemed necessary. She stated she reviewed Resident #12 ' s medical record and the most recent side rail assessment completed was dated 3/31/17. She reported this assessment indicated Resident #12 expressed a desire to have side rails raised while in bed. The assessment additionally indicated the recommendation was for bilateral side rails to serve as an enabler to promote independence and to address the medical conditions/symptoms of [MEDICAL CONDITION] and weakness. The DON confirmed the side rails for Resident #12 had been removed, no side rail assessment was completed prior to their removal, no education on the risks and benefits of side rail usage was provided to the resident, and no alternative intervention was implemented. An interview was conducted with the Administrator on 5/24/18 at 10:10 AM. The Administrator stated that side rail assessments should have been completed prior to the removal of the side rails. 4. Resident #37 was admitted to the facility on [DATE] and most recently readmitted on [DATE] with [DIAGNOSES REDACTED]. The annual Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #37 ' s cognition was intact. He required the extensive assistance of 2 or more staff for bed mobility and was dependent on 2 or more staff for transfers. He had impairment on both sides of his upper and lower extremities. The plan of care for Resident #37, dated 4/3/18, included a self-care deficit requiring the extensive to total assistance of staff with personal care and mobility. An interview was conducted with Resident #37 during the Resident Council Meeting held on 5/22/18 beginning at 2:00 PM. He indicated a concern about the removal of his side rails. He stated his side rails had been removed several months ago despite his expressed desire to have side rails on his bed. Resident #37 indicated when his side rails were removed the staff had not addressed his desire to keep the side rails and they also had not discussed with him the risks and benefits of side rail usage. An interview was conducted with the Director of Nursing (DON) on 5/22/18 at 10:52 AM. The DON stated that at the beginning of (YEAR) most residents in the facility had side rails. She stated that the facility gradually began removing side rails to reduce their usage between (MONTH) (YEAR) and (MONTH) (YEAR). She reported that side rail assessments should have been completed prior to the removal of the side rails to determine the need for the side rails, to provide education on the risks and benefits of side rails, and to provide an alternative intervention if deemed necessary. She stated she reviewed Resident #37 ' s medical record and the most recent side rail assessment completed was dated 3/31/17. She reported this assessment indicated Resident #37 expressed a desire to have side rails raised while in bed. The assessment additionally indicated the recommendations were for bilateral side rails to serve as an enabler to promote independence and to address the medical conditions/symptoms of TBI. The DON confirmed the side rails for Resident #37 had been removed, no side rail assessment was completed prior to their removal, no education on the risks and benefits of side rail usage was provided to the resident, and no alternative intervention was implemented. An interview was conducted with the Administrator on 5/24/18 at 10:10 AM. The Administrator stated that side rail assessments should have been completed prior to the removal of the side rails.

Based on observations, staff interviews and record review, the facility failed to prepare and administrator resident's medications using Infection Control Practices for 6 (Resident #305, Resident #301, Resident #306, Resident #307, Resident #308 and Resident #15) of 6 residents observed during a medication pass with Nurse #1. The findings included: Review of the Facility policy dated 6/9/15 titled Preparation and General Guidelines, read the person administering medications should adhere to good hand hygiene which included washing hands thoroughly. Hand sanitization should be done between hand washings when returning to the medication cart or preparation area assuming the hands have not touched a resident or potentially contaminated surface. Hand sanitizer should be used at regular intervals during the medication pass such as after each room, assuming handwashing was not indicated. A medication pass was conducted on 7/18/18 beginning at 8:30 AM with Nurse #1 on 300 hall. Nurse #1 did not sanitize her hands prior to preparing medications for Resident #305. Nurse #1 prepared medications for Resident #305. Nurse #1 prepared three house stock medications utilizing proper technique by pouring the prescribed dose into the top of the bottle cap then pouring tablets into the medication cup. Next she prepared Resident #305's prescribed medications contained inside a pharmacy sealed dispensing card. Nurse #1 was observed popping two medications from the sealed dispensing card directly into her hand then from her hand to the medication cup. She next administered Resident #305's medications orally. She returned to the medication cart to prepare the next resident's medications without washing her hands or using any hand sanitizer. Nurse #1 prepared medications for Resident #301. Nurse #1 prepared one house stock medication utilizing proper technique by pouring the prescribed dose into the top of the bottle cap then pouring tablet into the medication cup. Next she prepared Resident #301's prescribed medications contained inside a pharmacy sealed dispensing card. Nurse #1 was observed popping three medications from the sealed dispensing card directly into her hand then from her hand to the medication cup. She administered Resident #301's medications orally using a plastic spoon so not to touch each tablet. She returned to the medication cart to prepare the next resident's medications without washing her hands or using any hand sanitizer. Nurse #1 reported that Resident #306 was feeling nauseous therefore she was going to administrator a medication prescribed for nausea. She prepared Resident #306's prescribed medication contained inside a pharmacy sealed dispensing card. Nurse #1 was observed popping one medication from the sealed dispensing card directly into her hand then from her hand to the medication cup. She administered Resident #306's medications orally. She returned to the medication cart to prepare the next resident's medications without washing her hands or using any hand sanitizer. Nurse #1 prepared medications for Resident #307. Nurse #1 prepared one house stock medication utilizing proper technique by pouring the prescribed dose into the top of the bottle cap then pouring tablet into the medication cup. Next she prepared Resident #307's prescribed medications contained inside a pharmacy sealed dispensing card. Nurse #1 was observed popping three medications from the sealed dispensing card directly into her hand then from her hand to the medication cup. She administered Resident #307's medications orally using a plastic spoon so not to touch each tablet. She was observed touching Resident #307's bedside table during the administration of Resident #307's medications. She returned to the medication cart to prepare the next resident's medications without washing her hands or using any hand sanitizer. Nurse #1 prepared medications for Resident #308. Nurse #1 prepared one house stock medication utilizing proper technique by pouring the prescribed dose into the top of the bottle cap then pouring tablet into the medication cup. Next she prepared Resident #308's prescribed medications contained inside a pharmacy sealed dispensing card. Nurse #1 was observed popping five medications from the sealed dispensing card directly into her hand. Three of the five prescribed medications went from her hand into the medication cup while one tablet requiring a pulse check and one capsule that was to be opened were placed on top of the medication cart while she crushed the already prepared medications. Nurse #1 then poured the crushed medications into the medication cup and then picked up the tablet lying on the medication cart and added to the medication cup after verifying Resident #308 pulse was above the prescribed parameter. Nurse #1 next picked up the capsule from off the top of the medication cart and opened the capsule with ungloved hands and poured the contents into the medication cup. She then added applesauce to the medications. She administered Resident #308's medications orally. She returned to the medication cart to prepare the next resident's medications without washing her hands or using any hand sanitizer. Nurse #1 prepared medications for Resident #15. She prepared one house stock medication utilizing proper technique by popping the tablet from the sealed packaging directly into the medication cup. Next she prepared Resident #15's prescribed medications contained inside a pharmacy sealed dispensing card. Nurse #1 was observed popping seven medications from the sealed dispensing card directly into her hand then from her hand to the medication cup. She administered Resident #15's medications orally using a plastic spoon so not to touch each tablet. She returned to the medication cart to prepare the next resident's medications without washing her hands or using any hand sanitizer. In an interview on 7/18/18 at 9:25 AM, Nurse #1 stated she always prepared her medications by popping them directly into her hand so not to drop the medications. She stated the stomach acid kills any bacteria on the medications. Nurse #1 stated she should have washed her hands or used hand sanitizer in between the preparation and administration of each resident's medications. In an interview on 7/18/18 at 10:53 AM, the Administrator stated it was her expectation that Nurse #1 should not have dispensed resident's medications directly into her hand, no unsealed medications should have been sat on top of the medication cart during preparation, gloves should have been worn to open the capsule and hand washing practices be followed in between residents.

Based on observations, staff interviews and record review, the facility failed to prepare and administrator resident's medications using Infection Control Practices for 6 (Resident #305, Resident #301, Resident #306, Resident #307, Resident #308 and Resident #15) of 6 residents observed during a medication pass with Nurse #1. The findings included: Review of the Facility policy dated 6/9/15 titled Preparation and General Guidelines, read the person administering medications should adhere to good hand hygiene which included washing hands thoroughly. Hand sanitization should be done between hand washings when returning to the medication cart or preparation area assuming the hands have not touched a resident or potentially contaminated surface. Hand sanitizer should be used at regular intervals during the medication pass such as after each room, assuming handwashing was not indicated. A medication pass was conducted on 7/18/18 beginning at 8:30 AM with Nurse #1 on 300 hall. Nurse #1 did not sanitize her hands prior to preparing medications for Resident #305. Nurse #1 prepared medications for Resident #305. Nurse #1 prepared three house stock medications utilizing proper technique by pouring the prescribed dose into the top of the bottle cap then pouring tablets into the medication cup. Next she prepared Resident #305's prescribed medications contained inside a pharmacy sealed dispensing card. Nurse #1 was observed popping two medications from the sealed dispensing card directly into her hand then from her hand to the medication cup. She next administered Resident #305's medications orally. She returned to the medication cart to prepare the next resident's medications without washing her hands or using any hand sanitizer. Nurse #1 prepared medications for Resident #301. Nurse #1 prepared one house stock medication utilizing proper technique by pouring the prescribed dose into the top of the bottle cap then pouring tablet into the medication cup. Next she prepared Resident #301's prescribed medications contained inside a pharmacy sealed dispensing card. Nurse #1 was observed popping three medications from the sealed dispensing card directly into her hand then from her hand to the medication cup. She administered Resident #301's medications orally using a plastic spoon so not to touch each tablet. She returned to the medication cart to prepare the next resident's medications without washing her hands or using any hand sanitizer. Nurse #1 reported that Resident #306 was feeling nauseous therefore she was going to administrator a medication prescribed for nausea. She prepared Resident #306's prescribed medication contained inside a pharmacy sealed dispensing card. Nurse #1 was observed popping one medication from the sealed dispensing card directly into her hand then from her hand to the medication cup. She administered Resident #306's medications orally. She returned to the medication cart to prepare the next resident's medications without washing her hands or using any hand sanitizer. Nurse #1 prepared medications for Resident #307. Nurse #1 prepared one house stock medication utilizing proper technique by pouring the prescribed dose into the top of the bottle cap then pouring tablet into the medication cup. Next she prepared Resident #307's prescribed medications contained inside a pharmacy sealed dispensing card. Nurse #1 was observed popping three medications from the sealed dispensing card directly into her hand then from her hand to the medication cup. She administered Resident #307's medications orally using a plastic spoon so not to touch each tablet. She was observed touching Resident #307's bedside table during the administration of Resident #307's medications. She returned to the medication cart to prepare the next resident's medications without washing her hands or using any hand sanitizer. Nurse #1 prepared medications for Resident #308. Nurse #1 prepared one house stock medication utilizing proper technique by pouring the prescribed dose into the top of the bottle cap then pouring tablet into the medication cup. Next she prepared Resident #308's prescribed medications contained inside a pharmacy sealed dispensing card. Nurse #1 was observed popping five medications from the sealed dispensing card directly into her hand. Three of the five prescribed medications went from her hand into the medication cup while one tablet requiring a pulse check and one capsule that was to be opened were placed on top of the medication cart while she crushed the already prepared medications. Nurse #1 then poured the crushed medications into the medication cup and then picked up the tablet lying on the medication cart and added to the medication cup after verifying Resident #308 pulse was above the prescribed parameter. Nurse #1 next picked up the capsule from off the top of the medication cart and opened the capsule with ungloved hands and poured the contents into the medication cup. She then added applesauce to the medications. She administered Resident #308's medications orally. She returned to the medication cart to prepare the next resident's medications without washing her hands or using any hand sanitizer. Nurse #1 prepared medications for Resident #15. She prepared one house stock medication utilizing proper technique by popping the tablet from the sealed packaging directly into the medication cup. Next she prepared Resident #15's prescribed medications contained inside a pharmacy sealed dispensing card. Nurse #1 was observed popping seven medications from the sealed dispensing card directly into her hand then from her hand to the medication cup. She administered Resident #15's medications orally using a plastic spoon so not to touch each tablet. She returned to the medication cart to prepare the next resident's medications without washing her hands or using any hand sanitizer. In an interview on 7/18/18 at 9:25 AM, Nurse #1 stated she always prepared her medications by popping them directly into her hand so not to drop the medications. She stated the stomach acid kills any bacteria on the medications. Nurse #1 stated she should have washed her hands or used hand sanitizer in between the preparation and administration of each resident's medications. In an interview on 7/18/18 at 10:53 AM, the Administrator stated it was her expectation that Nurse #1 should not have dispensed resident's medications directly into her hand, no unsealed medications should have been sat on top of the medication cart during preparation, gloves should have been worn to open the capsule and hand washing practices be followed in between residents.