Every finding on record at Harlan Health and Rehabilitation Center

Based on observation, interview, record review, and facility policy review, the facility failed to develop a comprehensive care plan to address the residents' use of smokeless tobacco for 3 (Residents 33, 70, and 76) of 5 residents reviewed for tobacco use.Findings included: The facility policy titled, Care Plan Policy & Protocol, revised in September 2024, indicated, 2. The facility shall develop a comprehensive care plan for each resident that includes measurable objectives and timetables to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment.1. An admission Record indicated the facility admitted Resident (R) 33 on 01/10/2023. According to the admission Record, the resident had a medical history that included diagnoses of epilepsy, cognitive communication deficit, and spasmodic torticollis (chronic neurological disorder causing involuntary neck muscle contractures).An annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/22/2025, revealed R33 had a Brief Interview for Mental Status (BIMS) score of 11, which indicated the resident had moderate cognitive impairment. The MDS indicated the resident used tobacco, had no difficulties swallowing, and was not on a mechanically altered diet.Resident 33's Smoking/Vaping/Tobacco Safety Evaluation dated 12/22/2025 revealed the resident used smokeless tobacco.An observation of R33 on 03/23/2026 at 11:59 AM revealed the resident was asleep in bed. A can of Longhorn smokeless tobacco was seen next to a sealed spit bottle on their bedside table in front of them.An observation of R33 on 03/25/2026 at 11:27 AM revealed the resident was awake in bed. Three cans of Longhorn smokeless tobacco were seen next to a sealed spit bottle on their bedside table in front of them.R33's Care Plan Report, last reviewed on 01/08/2026, did not include a focus area, goals, interventions, or safety risks related to the resident's smokeless tobacco use.During an interview on 03/26/2026 at 1:53 PM, Minimum Data Set Coordinator (MDS) 1 stated there was no care plan for smokeless tobacco use. She stated smokeless tobacco use should be included in the resident care plans due to the associated risk factors, including oral pain, risk of aspiration, and tooth decay. She stated care plan interventions could include monitoring dental visits, performing oral assessments, ensuring the resident was sitting upright, and observing for signs and symptoms of aspiration.During an interview on 03/26/2026 at 3:34 PM, the Director of Nursing (DON) stated the facility did not create care plans for smokeless tobacco use. She stated there were risks associated with smokeless tobacco use that included aspiration, pneumonia, and gastrointestinal issues. She stated that smokeless tobacco should be included in resident care plans and would include swallowing status, potential concerns, and if they could perform the act safely and independently.During an interview on 03/26/2026 at 4:57 PM, the Administrator stated that a care plan for residents who used smokeless tobacco was important to monitor residents' safety. She stated the facility had not included smokeless tobacco use in resident care plans but should have.

Based on observation, interview, record review, and review of the facility's policy, it was determined the facility failed to develop and/or implement a comprehensive person-centered care plan related to dental needs to ensure that medical, nursing, mental and psychosocial needs related to weight loss were met for one (Resident (R) 99) of seven residents reviewed for nutrition out of a sample of 49 residents. R99 sustained pain and a severe weight loss of 20% in the six months between 09/17/2024 and 03/10/2025. The findings include: Review of the facility's policy Care Plan Policy and Protocol, revision 09/2024, revealed the care plan would be updated as indicated with changes in condition, physician orders, fall interventions, etc. Review of R99's clinical record revealed the facility admitted R99 on 07/05/2023, with diagnoses which included Huntington's disease and cognitive communication deficit. Review of R99's Admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 07/14/2023, revealed the resident had obvious cavities or broken teeth. 1. Review of R99's Comprehensive Care Plan (CCP), initiated on 07/16/2023 with a target date of 03/25/2025, revealed the facility assessed the resident to have broken or carious (decayed) teeth. Further review revealed R99's teeth were discolored and missing, as well as broken. Interventions included R99 would have consults with the dentist as indicated. a. Review of R99's CCP revealed no evidence that the facility care planned the resident to receive the facility's in-house 360 Care Dental Program (which provides routine care.) b. In addition, review of R99's clinical record revealed that on 05/29/2024, the resident saw an external dentist to have three teeth extracted. Review of R99's dental note, dated 05/29/2024, revealed that the dentist could not do the extractions and noted the need to refer to an oral surgeon for extraction of all of his remaining teeth. Review of a Progress Note, dated 06/11/2024, revealed the dental office sent R88's information to the referred dentist/oral surgeon, and the facility was informed that if they had not received a call back by 06/14/2024, they were to call the dental office. Further record review revealed there was no evidence in R99's record that the facility's staff contacted the dental office or the oral surgery regarding the referral, from the time of the 06/11/2024 note through 03/17/2025. Review of a Word Document provided by a regional corporate representative on 03/19/2025 at approximately 9:00 AM, revealed the facility documented they had left messages. However, the facility did not actually talk with staff at the oral surgery clinic about R99's referral for needed dental care, per the care plan, until 03/19/2025, after surveyor intervention. (Refer to F790.) Review of R99's clinical record revealed the Annual MDS, dated [DATE], documented that the resident continued to have obvious cavities/broken teeth. There was no evidence that the facility identified that they had failed to include the need for the routine Dental Care program on the care plan or that they had implemented successful actions to ensure the resident received the dental services he needed, per the care plan. Observation, of R99's mouth, on 03/21/2025 at 2:04 PM with Registered Nurse 6 (RN6) revealed the resident had missing multiple teeth in both the front and the back of his mouth, as well as on both the top and bottom. In addition, the resident had multiple discolored teeth, with some that were partially black in appearance. An interview conducted by RN6 revealed R99's teeth were hurting him at a level of 10/10 on a pain scale of 10. (Refer to F790) Review of MDS assessments dated 06/21/2024, 09/17/2024, and 12/10/2024 and a weight record dated 03/10/2025, and observation on 03/20/2025 at 5:47 PM, revealed R99 sustained a weight loss of 20% (32 pounds) in the six months between 09/17/2024 -03/10/2025. Further review revealed a weight loss of 42 pounds (24.4%) between 06/21/024- 03/20/2025, both of which constituted a severe (more extreme than significant) weight loss. (Refer to F692) However, the facility failed to implement a person centered plan to address the resident's dental care needs and his weight loss. 2. Review of R99's CCP, initiated on 07/16/2023 with a current target date of 03/25/2025, revealed the facility also identified the resident with the potential for alteration in nutrition/hydration status based on factors including poor dental status. Per the care plan, interventions included for staff to obtain speech therapy/occupational therapy (OT/ST) as indicated. Although the care plan called for ST/OT as indicated, an order for Speech Therapy was not obtained until 03/19/2025, after surveyor intervention. During an interview with the Speech-Language Pathologist (SLP) 1 on 03/19/2025 at 2:24 PM, SLP1 stated until 03/19/2025, R99 had not been assessed by speech therapy. SLP1 stated that upon assessment, R99's teeth were bad, they're terrible, and that could be the reason R99 had lost weight. During an interview with the Minimum Data Set Coordinator (MDSC) 1 on 03/20/2025 at 12:05 PM, MDSC1 stated CCP's should be followed to ensure the residents were safe, the residents received the care they needed, and that each CCP was individualized to meet each resident's care needs. MDSC1 stated All Supervisors just pop in randomly and check [for implementation of care plans]. Clinical Coordinators do, too. MDSC1 indicated that if staff were not following the care plan, Nursing staff should go with them to the Kardex (care plan system used by direct care staff), and ask What happened for you to not follow it? MDSC1 indicated that the failure should then be investigated with staff education in response. During an interview with the Administrator and Director of Nursing (DON) on 03/21/2025 at 11:23 AM, the Administrator stated that R99 should have been in the facility's 360 Dental Program, and this failure was an oversight on the facility's part.

Based on observation, interview, record review, and review of the facility's policy, the facility failed to maintain acceptable parameters of nutritional status such as body weight for one (Resident (R) 99) of seven residents reviewed for nutrition, out of a total sample of 49 residents. R99, who had significant dental breakdown, experienced pain and sustained a severe/significant unplanned weight loss that continued for at least six months after the facility was notified that the resident needed dental care. In addition, the facility failed to timely address the consistency of the resident's food and the need for dental care. The findings include: Review of the facility's Nutrition Policy, dated 08/2024, revealed the facility was to implement interventions to prevent unintentional weight loss. Per the policy, the facility will include the IDT [interdisciplinary team], provider, resident and/or representative, as well as the registered dietician in determining appropriate interventions/strategies to maximize nutritional status. The policy noted that interventions that may be considered included assessing for the potential need for food consistency change, as well as assessing for methods of increasing nutritional intake, such as nutritional supplements, and supplemental med pass. Review of the policy revealed it did not address weights, including who was responsible for obtaining weights, the time frames/how often in which a resident was to be weighed, who was to review the weights, and what action was to be taken in response to various parameters. Review of R99's medical record revealed the facility admitted the resident on 07/05/2023, with diagnoses which included Huntington's disease and cognitive communication deficit. Further review of the resident's record revealed the resident was not currently on hospice (end of life care) and had not been given an end-stage diagnosis. Review of the Admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 07/14/2023, revealed R99 weighed 153 pounds and was 63 inches tall (5 feet, 3 inches). Further review revealed R99 was not on a physician-prescribed weight loss diet. Per the MDS, R99 had obvious cavities or broken natural teeth, and no nutritional approaches (including but not limited to a mechanically altered diet) were provided. Both areas Nutrition and Dental Needs were triggered for Care Area Assessments, based on the MDS data. Review of a Progress Note dated 06/11/2024, revealed the facility received a phone call from a dental office regarding a referral to an oral surgeon because the resident needed to have multiple teeth extracted. The referring dental office informed the facility that R99's information was sent over and if the facility had not received a call by 06/14/2024, they were to call the referring dental office. Further record review revealed there was no evidence in R99's record that the facility's staff had actually contacted the dental office or the oral surgery regarding the referral, from the time of the 06/11/2024 note until 03/19/2025. Although the facility documented they had left messages, the facility did not speak with staff at the oral surgery clinic about R99's referral until 03/19/2025, after surveyor intervention. (Refer to F790.) Review of the Annual MDS, with an ARD of 06/21/2024, revealed R99 weighed 172 pounds, The resident continued to have obvious broken teeth or cavities with no nutritional approaches, such as a mechanically altered diet. R99 was not on a prescribed weight loss diet. Per the MDS, the resident was moderately cognitively impaired, based on a Brief Interview for Mental Status (BIMS) score of 12/15. R99 had unclear speech, with slurred or mumbled words, no refusal of care, and required set up assistance with eating. Review of a Nutrition/Dietary Note, dated 08/01/2024, revealed R99 had a 1% weight loss in one month and 6% in six months. At this time, the resident was consuming 77% of meals. Per the note, resident has high energy needs and will need to observe intakes and weights for decline. Review of the Quarterly MDS assessment with an ARD of 09/17/2024, revealed R99 now weighed 160 pounds, and had a weight loss of 5% or more in the last month or 10% or more in the last six months and was not on a prescribed weight loss diet. Per the MDS, the resident continued to not have nutritional approaches in place, needed set up assistance, and had unclear speech. The section of the assessment regarding the resident's dental status was not completed. Review of R99's 09/17/2024 Dietary Profile, completed by the Dietary Manager (DM), revealed the resident was now averaging 67% of his meals, which was down 20% since the previous review. However, the Dietary Profile did not address the resident's weight loss, which was noted on the MDS documented the same day. In addition, the Dietary Profile failed to address the resident's continued dental issues, and R99's regular consistency diet, which had the ability to impact the resident's food consumption/intake. Review of R99's 12/09/2024 Dietary Profile, also completed by the DM, revealed the resident now had lost 10% in six months and 8% in one month. Again, the Dietary Profile failed to address the resident's dental issues and/or the regular-consistency diet orders. Review of R99's Quarterly MDS, with an ARD of 12/10/2024, revealed the facility assessed the resident to have moderately impaired cognition, based on a BIMS of 8/15. The MDS documented the resident had a weight loss of 5% or more in the last month or 10% or more in the last six months. Per the MDS, the resident, who was not on a prescribed weight-loss diet, now weighed 139 pounds. This weight reflected a 33-pound weight loss of 19.18% since the 06/21/2024 MDS, and a 21-pound weight loss of 13.12% since the 09/17/2024 MDS. During an interview with Registered Dietician (RD)1, on 03/20/2025 at 3:04 PM, she stated R99 received large portions. However, review of the Quarterly MDS dated [DATE], revealed the facility failed to address R99's dental issues. The section of the assessment regarding the resident's dental status was not completed. Review of the weight records after the 12/10/2024 MDS revealed the resident's weight on 03/10/2025 was 128.4 lbs. Review of the 03/10/2025 Dietary Profile, completed by the DM, revealed R99's intake was now down to an average of 56% of his meals and snacks throughout the day. The Profile again noted the resident had more than a 10% weight loss in six months (severe weight loss.) The Dietary Profile again failed to address the resident's dental issues and/or regular-consistency diet, which had the ability to affect the resident's consumption/intake. Review of R99's Comprehensive Care Plan (CCP), initiated on 07/16/2023, with a current target date of 03/25/2025, revealed the facility identified the resident with the potential for alteration in nutrition/hydration status due to a regular diet and poor dental status. Review of the care plan revealed no evidence that it was revised with approaches to address the resident's dental issues when the weight loss was identified on both the 09/2024 and 12/2024 MDS assessments, Per the care plan, interventions included for staff to administer medications and supplements as ordered, observe for any difficulties in chewing food and notify the physician. Review of the R99's current dietary profile dated 03/10/2025, revealed that as of the initiation of the recertification survey on 03/17/2024, the resident remained on a regular, no mechanically altered consistency diet. Observation of the dinner meal on 03/17/2025 at 4:46 PM, revealed R99 sitting at a table in the dining room. Staff assisted R99 with opening his milk, silverware, and straw. Further observation revealed while feeding himself, R99 had involuntary spastic movements, indicative of Huntington's disease. However, staff did not assist R99 with eating. Observation on 03/17/2025 at 5:17 PM, revealed staff wheeled R99 to his room from the dining room in his wheelchair. R99's shirt and pants were wet with spilled liquid and pieces of food down the front of them. Observation of R99 on 03/20/2025 at 8:46 AM revealed the resident was in the bed. R99 was neat, clean, and dressed. The resident appeared thin, and his jeans were loose around his waist and in the legs. An interview was conducted with R99 during this observation. Because of his communication deficits, the State Survey Agency (SSA) team asked R9 single questions at a time, to which he would respond by answering 'yes' or 'no' and moving his head. During the interview, R99 indicated his teeth hurt all the time, and had been hurting about a year, nodding his head up-and-down and stating, yep to both of these questions. R99 indicated that the tooth pain made it difficult to eat at times, again nodding his head up-and-down and stating, yep. R99 indicated that there were times that he was hungry due to his inability to eat because of the tooth pain, as he nodded his head up-and-down stating, yep. Observation, on 03/20/2025 at 5:47 PM, revealed Certified Nursing Assistant (CNA) 10 weigh the resident in his wheelchair. The scale indicated a weight of 185.2 lbs. CNA10 then subtracted the wheelchair weight of 55.2 pounds, verifying the resident's current weight was 130 pounds. This weight indicated the resident had lost over 40 pounds since the 172-pound weight recorded on his annual MDS dated [DATE]. Observation on 03/21/2025 at 2:04 PM with Registered Nurse (RN) 6 of R99's mouth revealed the resident was missing multiple teeth in both the front and the back of his mouth, as well as on both the top and bottom. In addition, the resident had multiple discolored teeth, with some that were partially black in appearance. An interview conducted by RN6 revealed R99's teeth were hurting him at a level of 10/10 on a pain scale. (Refer to F790) During an interview with CNA8 on 03/20/2025 at 9:34 AM, CNA8 stated that during R99's oral care, R99 would wince in pain, like someone touching a nerve. CNA8 stated he thought that was why R99 had a hard time eating. CNA8 stated that he had previously informed nursing staff about the resident's dental pain but could not remember the specifics of when or who he told. Interview with CNA7 on 03/20/2025 at 9:20 AM, revealed she was one of the staff who did routine weights for the residents on the hall where R99 resided. CNA7 stated that the aides were not aware of weight loss as they did not see the previous weight when they recorded the current weight in the CNA book to give to the Care Coordinator. Although the care plan called for ST/OT (Speech Therapy/Occupational Therapy) to evaluate as indicated, an order for Speech Therapy was not obtained until 03/19/2025, after surveyor intervention. During an interview with the Speech-Language Pathologist 1 (SLP1) on 03/19/2025 at 2:24 PM, SLP1 stated until 03/19/2025, R99 had not been assessed by speech therapy. SLP1 stated that upon assessment, R99's teeth were bad, they're terrible, and that could be the reason R99 had lost weight. SLP1 stated that after assessing R99 on 03/19/2025, she changed R99's diet from regular with large portions, to mechanical soft meats and feeding assistance. Further interview with SLP1 on 03/20/2025 at 3:02 PM, revealed that once the resident's diet consistency was changed, R99 consumed 90 percent of his meal. Interview with Registered Dietician (RD) 1 on 03/20/2025 at 3:04 PM, revealed that she was a corporate regional dietitian and was answering questions for the facility's RD, who was out of the country and unavailable for interview. She stated that assessments were completed annually, on change in condition, or upon request. RD1 stated R99's last RD Assessment was in 06/2024, and at that time, R99 weighed 171.6 pounds. Per RD1, the facility's RD documented that at that time, the resident's usual weight was 165, with a Body Mass Index (BMI) of 30.4 (mild obesity.) Continued interview with RD1 revealed that as of 03/10/2025, R99 now weighed 128.4 pounds, adding, Wow, what happened? RD1 verified that the resident's average intake had declined. Although RD1 indicated that the facility's RD had made interventions such as an appetite supplement, a dietary supplement, and large servings. However, no information was provided to indicate that R99's ongoing issues with multiple missing/painful teeth and a regular diet, had either been considered as a possible cause of the resident's continued weight loss nor addressed the issue. During a joint interview with the Administrator and Director of Nursing (DON) on 03/21/2025 at 11:23 AM, the DON stated that the supervisor recorded the weights that the direct care staff obtained into the system, which then triggers it in the 24-hour report. Per the DON, this report was then reviewed in morning meeting. However, no evidence was provided by the DON prior to the exit from the survey to verify that this occurred each time R99's weight loss was identified. The DON stated that the RD came to the facility weekly, and the Quality Assurance and Performance Improvement Committee (QAPI) met quarterly to discuss the findings of the 24-hour reports, and sometimes more frequently. During the interview with the Administrator, she stated that R99's teeth were in the same condition as upon admission and she did not believe that this was the cause of the resident's weight loss. She stated that the resident should have been in the facility's 360 Dental Program (which provides routine dental care), and that was an oversight on their part. The Administrator stated R99 used to attend activities quite frequently with 75% of the activities involving food, and he would eat like a horse; however, he's not been going to activities much. The Administrator and DON expressed the opinion that R99's weight loss was due to the resident's diagnosis of Huntington's disease, with the Administrator describing it as end-stage. However, there was no documented evidence of this in the R99's clinical record. The Administrator stated R99 had stayed within a 10-pound range since 12/02/2024, adding that, I consider that stable. However, R99 had a 12-pound (7.9%) pound weight loss between the 12/10/2024 MDS and 03/10/2025 assessments, which occurred while the resident was not on a physician-ordered weight loss program. This weight loss constituted a severe (more extreme than significant) weight loss. In addition, the weight loss of 20% (32 pounds) in the six months between 09/17/2024 and 03/10/2025, and weight loss of 42 pounds (24.4%) between 06/21/024 and 03/20/2025 also both constituted a severe weight loss.

Based on observation, interview, record review, and review of the facility's policy, it was determined the facility failed to provide/obtain needed dental care for one of 49 sampled residents (Resident (R) 99) who was reviewed for dental services. The facility failed to obtain needed dental services over a nine-month period for the resident who had multiple broken teeth which needed extraction. During this time, the resident sustained pain, as well as, a severe weight loss over a six and nine-month period. The findings include: Review of the facility's policy titled, Protocol for Oral Status Assessment, revision date 08/2017, revealed An assessment of the oral cavity of each resident will be completed annually by a nurse. This assessment will be documented on the Comprehensive MDS [Minimum Data Set] in Section L, as well as in the CAAs [Care Area Assessments]. Each resident will have an Oral Status Care Plan which will be reviewed and updated quarterly with each MDS and prn [as needed]. The documentation of the assessment in the CAA should address the resident's gums, edentulous/dentures (upper/lower), partial, broken or carious teeth, pain, difficulty chewing, etc. The CAA should also address any consults or referrals that have occurred since last comprehensive assessment and if the resident/family decline consult or further referral. The Oral Status Care Plan will be updated annually and prn with any changes in condition. The resident will have consult with Dentist on annual basis as indicated, unless the resident or resident representative declines dental consults. It will be documented in the medical record if the consult is not obtained. The undated Protocol for Oral Hygiene policy revealed that, Staff will notify nurse of any changes noted in oral cavity during oral care, residents' ability to chew, teeth, etc. Review of R99's record revealed the facility admitted R99 on 07/05/2023, with diagnoses which included Huntington's Disease and cognitive communication deficit. Further review of the resident's record revealed that the resident was not currently on hospice and had not been given an end-stage diagnosis. The Admission MDS, with an Assessment Reference Date (ARD) of 07/14/2023, revealed the resident had obvious cavities or broken natural teeth. Per the MDS, the resident weighed 153 pounds and was 63 inches tall (5 feet, 3 inches), was not on a physician-prescribed weight loss plan, and had no nutritional approaches (such as mechanically altered diet). In response, the Dental Needs were triggered for CAA review, based on the MDS data. Review of the Comprehensive Care Plan (CCP), initiated on 07/16/2023 for R99 and still current as of 03/17/2025 (the date the Recertification survey was initiated), revealed the resident was care planned for alteration in nutrition/hydration status, in part due to poor dental status. Approaches included obtaining speech therapy/occupational therapy (OT/ST) as indicated. Further review of the care plan revealed that R99's teeth were discolored, missing, and broken, and interventions included that R99 would have consults with the dentist as needed. a. Review of the clinical record revealed R99 had a tooth extracted in 08/2023. The resident then went back to the external dental office on 05/29/2024, to have three more teeth extracted. Record review of R99's dental note dated 05/29/2024, revealed Patient [Resident] was very difficult to work on. He had trouble keeping his mouth open and he shakes. He tried really hard, but he was very uncomfortable, and he was very difficult to work on. He kept biting me. Will need to talk to his nurse at the nursing home and refer to an oral surgeon for extraction of all of his remaining teeth. Review of a Progress Note, dated 06/11/2024, revealed the facility received a phone call from the dental office regarding their referral to another provider for the extraction of the remaining teeth. The referring primary dental office informed the facility that R99's information was sent over and if the facility had not received a call back by 06/14/2024, they were to call the dental office. Further review of R99's clinical record revealed no evidence that the facility contacted either the dentist/oral surgeon to whom the referral was made or with the primary referring dentist between the 06/11/2024 note and the initiation of the Recertification survey on 03/17/2025. Further review of R99's medical record revealed no evidence that any other dentist saw R99 for the needed extractions. Review of the annual MDS, with an ARD of 06/21/2024, revealed the resident continued to have obvious broken teeth or cavities. Per the MDS, the resident was moderately cognitively impaired, based on a Brief Interview for Mental Status (BIMS) score of 12/15, and had unclear speech, with slurred or mumbled words, and no refusal of care. Review of the next two MDS, a quarterly assessment with an ARD of 09/17/2024 and a quarterly MDS with an ARD of 12/10/2024 revealed the section of the assessment regarding the resident's dental status was not completed. b. Record review revealed that, in addition to the outside dentist that R99 saw on 05/29/2024, the facility had an agreement with a dental provider who came to the facility for routine care. Review of the facility's agreement with 360 Care (the mobile dental provider), effective 11/01/2018, revealed 360 Care offered dental services to the facility that included dental examination and oral cancer screening, diagnostic x-ray examination, prophylaxis and denture cleaning, tooth surface restorations, simple extractions, and removable prosthetic fabrication, relines and repairs. Record review of 360 Care's visits to the facility revealed 360 Care had been to the facility on [DATE], 05/09/2024, 07/02/2024, 08/13/2024, 09/11/2024, 10/03/2024, 10/22/2024, and 01/02/2025. Review of R99's medical record revealed no evidence that R99 was seen or treated by this dental service during any of these visits. Review of facility records and observation revealed that, during the time that R99 failed to receive needed dental care, the resident (who was not on a physician-ordered weight loss plan) sustained unplanned weight loss. Review of MDS assessments dated 06/21/2024, 09/17/2024, and 12/10/2024, a weight record dated 03/10/2025, and observation on 03/20/2025 at 5:47 PM, revealed R99 sustained a weight loss of 20% (32 pounds) in the six months between 09/17/2024 - 03/10/2025, and weight loss of 42 pounds (24.4%) between 06/21/2024 - 03/20/2025, both of which constituted a severe (more extreme than significant) weight loss. (Refer to F692.) Although the care plan, date initiated 07/16/2023, called for ST/OT to evaluate as indicated, an order for Speech Therapy was not obtained until 03/19/2025, after surveyor intervention. During an interview with the Speech-Language Pathologist (SLP) 1 on 03/19/2025 at 2:24 PM, she stated R99 had not been assessed by speech therapy until 03/19/2025. SLP1 stated that upon assessment, R99's teeth were bad, they're terrible, and that could be the reason R99 had lost weight. An interview was conducted with R99 on 03/20/2025 at 8:46 AM. The resident was observed to have communication deficits, and as a result, the State Survey Agency (SSA) team asked R99 single questions at a time, to which he would respond by answering 'yes' or 'no' and moving his head. During the interview, R99 indicated his teeth hurt all the time, and had been hurting for about one year, nodding his head up-and-down and stating, yep to both of these questions (which were asked separately). R99 also indicated that teeth pain made it difficult to eat at times, again nodding his head up-and-down and stating, yep. R99 also indicated that there were times that he was hungry due to inability to eat because of the tooth pain, as he nodded his head up-and-down stating, yep. Observation on 03/21/2025 at 2:04 PM revealed Registered Nurse (RN)6 assessed R99, who was in bed, for pain. RN6 asked R99 if he could sit up and the resident followed the instruction, sitting on the side of the bed. RN6 asked R99 if he was having any pain and R99 nodded his head up-and-down stating yep, teeth. RN6 then asked R99 Your teeth are hurting right now? R99 nodded his head up-and-down, stating yep. RN6 asked R99 Scale of 1-10, how bad? R99 replied yep, and proceeded to hold his hand up. When RN6 asked R99 if his pain was a '5', R99 motioned his left thumb up. RN6 then asked Is it a 10? to which R99 stated yep. Observation at this time revealed RN6 examined R99's mouth which revealed that the resident was missing multiple teeth in both the front and the back of the mouth, as well as, on both the top and bottom. In addition, the resident had multiple discolored teeth, with some that were partially black in appearance. Interview with Certified Nursing Assistant (CNA) 8, on 03/20/2025 at 9:34 AM, revealed that during R99's oral care, the resident would wince in pain, like someone touching a nerve. CNA8 added that he thought that was why R99 had a hard time eating. CNA8 added that he had previously informed nursing staff about the resident's dental pain, but was informed the facility was waiting on a dentist. Further interview revealed CNA8 could not remember the specifics of when or who he told about R99's dental pain. During an interview with Licensed Practical Nurse (LPN)8 on 03/20/2025 at 3:05 PM, LPN 8 stated R99's teeth looked bad, noting that some teeth were missing. LPN8 stated there was no assigned staff responsible for dealing with referrals and making appointments, saying, No one handles the appointments specifically; we do our best to make sure they're followed up on. Further interview with LPN8 revealed when a resident complains of tooth/oral pain, nursing staff were required to notify the physician and document in the Health Status Note/Progress Note. Review of R99's chart for 2025 revealed no documentation regarding teeth/oral pain or notification to the physician about such an issue. On 03/19/2025 at approximately 9:00 AM, a Regional Corporate representative brought in a typed Word Document, which she stated was a list of the times that the facility had attempted to contact the oral surgeon to whom R99 was referred. Review of this compiled document revealed it listed attempts on 07/09/2024, 08/06/2024, 09/02/2024 (Labor Day), 10/07/2024, 11/11/2024, 12/09/2024, 12/10/20/24, 12/16/2024, 01/06/2024 [sic], and 02/03/02025. For each of these 10 attempts, there was a note that the facility had called and left a message and was awaiting a call back. There were no further attempts to contact the dental provider after 02/03/2025 until 03/19/2025, after initiation of the Recertification survey. Review of the Word document revealed that during the 03/19/2025 call (which was made after surveyor intervention regarding R99's dental needs}, the facility was able to make actual contact with the provider and speak with them for the first time since the referral was made nine months earlier. Further review of the Word Document provided by the Regional Corporate representative revealed that on 11/11/2024 and 11/12/2024, the facility contacted three additional dental office (two dentists and one oral surgeon). However, the dentist declined because they were not an oral surgeon, and the oral surgeon declined to see R99, as they preferred not to take Nursing Home or residents with the resident's payor source. Review of this Word Document revealed no further attempts after 11/12/2024 to locate an any other available oral surgeons to remove R99's teeth as needed. Interview with Unit Manager (UM)1 on 03/20/2025 at 11:15 AM, revealed she took charge of the dental referral for R99. Further interview with UM1 on 03/21/2025 at 11:58 AM, confirmed that there was nothing in R99's medical record about the follow up for needed dental care. Instead, UM1 stated, she kept a spiral notebook with the calls made to the dental office at her desk because It was easier to work on in a notebook. UM1 stated she had made calls to the oral surgeon's office; however, they were not returned. She added that she had also tried outside providers, but they declined to take the resident because of his nursing home and/or payor source. Interview with R99's physician, on 03/20/2025 at 3:22 PM, revealed he had not been notified of R99 having any dental pain. The physician stated the facility had told him that they had been trying to contact a dentist but were awaiting a call back. During a joint interview with the Director of Nursing (DON) and Administrator on 03/21/2025 at 11:23 AM, the Administrator stated R99 should have been in the facility's 360 Dental Program, and that was an oversight on their part. The Administrator stated it was her expectation that staff document dental pain or oral care in the progress notes or on the Medication Administration Record (MAR) to ensure it was on the 24-hour change in condition report. The DON also stated she expected to see pain documented in the progress notes or on the Medication Administration Review (MAR). Both the Administrator and DON indicated that the resident should have been seen for the broken teeth, saying that the facility had tried, but it was difficult to find someone who would take Nursing Home residents

Based on observation, interview, and record review, the facility failed to ensure it had safe drinking water available when there was a loss of normal water supply for all residents. This had the ability to affect all 132 residents. The findings include: In an interview with the Administrator, on [DATE] at 11:10 AM, she stated the facility did not have a policy to address the availability of water when there was a loss of normal water supply. Further, she stated it was her expectation that the facility would have drinkable water available each day for a period of three days, for the residents consumption. Review of the facility's Water Utility Agreement, dated [DATE], revealed the city's Municipal Water Works assisted the facility with emergency water access. Review of the facility's Emergency Preparedness Plan document, dated [DATE], from the Food Service Vendor, revealed the industry standard was to have 1.5 gallons of water per person, per day, available in the event of an emergency. Observation on [DATE] at 2:15 PM revealed the facility had a total of 1,368 gallons of water stored in a temperature-controlled building. Further observation revealed 1,248 gallons of the water had expired with expiration dates ranging from ,d+[DATE]. This left a total of 120 gallons of drinkable water reserved for the residents in the event of an emergency. Review of the facility's Emergency Preparedness Plan, however, revealed the industry standard was to have 1.5 gallons of water, per person, per day, which left the facility short of available water to support the residents for three days should the facility have a loss of normal water supply. In an interview with the Maintenance Director, on [DATE] at 2:27 PM, he stated he did not check the expiration dates on the potable (drinkable) water. Per interview, the Maintenance Director stated he thought it was the responsibility of the Dietary Manager to check the expiration dates of the water. Further, he stated it never occurred to him to check the dates of the water. In an interview the Dietary Manager, on [DATE] at 3:42 PM, she stated that she did not check the expiration dates and thought it was the responsibility of the Maintenance Director. The Dietary Manager stated that she was responsible for ordering the potable water but the Maintenance Director was responsible for storing the water and should have checked the dates. In an interview with the Corporate Registered Dietician, on [DATE] at 11:06 AM, she stated that the Registered Dietician (RD) had advised the Dietary Manager to check the potable water every August. The Corporate Registered Dietician stated that she had monthly phone meetings with the Dietary Managers and reminded them all to check their expiration dates. She stated that it was her expectation that the facility had enough potable water to provide to the residents, in the event of an emergency. In an interview with the Administrator, on [DATE] at 11:10 AM, she stated the facility did not have a policy for potable water but stated her expectation was to have one gallon of water a day for three days for each resident, to ensure the facility could safely care for the residents, if there was a shortage of water. Additionally, the Administrator stated that it was the responsibility of the Dietary Manager to check the dates of the potable water supply.

Based on observation, interview, record review, and review of the facility's policy, the facility failed to provide Notice of Medicare Non-Coverage (NOMNC) to residents before their coverage ended. Two of 10 residents reviewed (Residents (R) 282 and 279) revealed the NOMNC's were issued after the residents' benefits ended. The findings include: Review of the facility's policy titled, Notice Instructions for the Notice of Medicare Non-Coverage (NOMNC) CMS [Centers for Medicare and Medicaid Services]-10123, undated, revealed The NOMNC must be delivered to all Medicare beneficiaries at least two calendar days before Medicare covered services ended or the second to last day of service if care was not being provided daily. 1. Review of R282's NOMNC revealed the resident's Medicare coverage ended on 12/07/2024. Further review revealed Family Member (FM) 10 signed the NOMNC on 12/09/2024 which was two days after the resident's coverage ended. During an interview with the Business Office Manager 1 (BOM1) on 03/21/2025 at 9:19 AM, she stated she called FM10 and informed her of R282's coverage ending the week before. BOM1 stated she had also mailed a copy of the NOMNC out, but FM10 came into the office and signed it that day. The State Survey Agency (SSA) requested documentation that FM10 had been contacted regarding the Medicare coverage ending, and BOM1 stated she did not have any documentation. During an interview with FM10 on 03/21/2025 at 9:27 AM, she stated she did not know anything about R282's Medicare coverage ending and she did not remember receiving the NOMNC in the mail. 2. Review of R279's NOMNC revealed Medicare coverage would end on 03/07/2025. Further review revealed R279's NOMNC was unsigned by the resident or the resident's representative as of 03/21/2025. During an interview, on 03/21/2025 at 12:15 PM, BOM1 stated the NOMNC was mailed to R279's representative on 03/04/2025. She further stated she had verbally informed R279's representative she was mailing the NOMNC on 03/04/2025 and he should sign it and bring it back to the facility when he next visited R279. During an interview, on 03/21/2025 at 12:51 PM, R279's representative stated he was not notified prior to R279's Medicare coverage ending and was not informed of the right to appeal for Medicare coverage to continue. He stated he did receive paperwork in the mail several days after 03/07/2025 but was unsure which box to check and how to fill it out. He stated no one from the facility had informed him how to complete the form and had only told him he would need to check one of the boxes.

Based on observation, interview, record review, and review of the facility's policy, the facility failed to ensure each resident received food and drinks which were palatable, attractive, and at a safe and appetizing temperature for five of 35 sampled residents reviewed for food temperatures (Residents (R)19, R67, R86, R98, and R111). During resident council, residents expressed concerns of their food being served cold when the aides passed their trays. Observation of the breakfast meal, on 03/19/2025, revealed the sausage, eggs, biscuits, oatmeal, milk, and cranberry juice were not at an appetizing and acceptable temperature. Observation of the breakfast meal, on 03/20/2025, revealed the sausage, eggs, oatmeal, and grape juice were not at an appetizing and acceptable temperature. The findings include: Review of the facility's policy titled, Dietary Infection Control, undated, revealed temperatures must be maintained at 41 degrees (41 ) Fahrenheit (F) or below for cold or refrigerated food. Further review revealed temperatures must be maintained at the following Fahrenheit settings: all potentially hazardous food must be kept below 41 F and above 140 F during transportation. Continued review revealed temperatures must be maintained at 150 degrees F for pork (sausage). Observation of a test tray on 03/19/2025 at 8:55 AM, with Dietary Manager (DM) 1 and DM2 the following food temperatures were recorded: sausage: 114.0 F, scrambled eggs: 116.5 F, biscuit: 84.3 F, oatmeal, 136 F, milk: 43.0 F, and cranberry juice: 44.0 F. Observation of a second test tray on 03/20/2025 at 8:20 AM, with DM 2 and DM 3, revealed the following temperatures: sausage: 111.0 F; scrambled eggs: 111.0 F; oatmeal:138 F; and grape juice: 46 F. During the Resident Group meeting, held on 03/18/2025 at 2:00 PM, with 13 residents in attendance, three residents complained about cold food. R98 stated food often sat in the hallway and the kitchen sends it out on the carts and it sometimes sits there 20 minutes before the aides serve the food. R86 and R111 agreed the food was often cold. During an interview, on 03/17/2025 at 3:20 PM, R67 stated food was only warm about one-half the time and the food was no good. During an interview, on 03/17/2025 at 3:50 PM, R19 stated meals were not warm several times a week. During an interview, on 03/17/2025 at 6:00 PM, R98 stated food was often not warm and the food was not always pleasant tasting. During interview, on 03/19/2025 at 9:05 AM, DM1 stated the tray line was on schedule and that food service did not exceed expected preparation or delivery timeframes. DM1 stated that food temperature compliance was critical both for resident safety and palatability. DM1 stated that staff were expected to monitor food temperatures regularly during service. During an interview, on 03/19/2025 at 11:40 AM, R67 stated the food was so salty you can't eat it. R67 further stated the facility would not give any eggs that were not scrambled and the texture of the eggs was rubbery. During an interview, on 03/19/2025 at 2:45 PM, the Administrator stated the plate warmer was not working correctly and was not warming the middle row of plates. Additionally, the Administrator stated that serving foods within the safe handling zone was important to prevent foodborne illnesses. During interview on 03/20/2025 at 8:27 AM, DM2 stated the trays had been delivered without delay and that the service was consistent with internal protocols. DM 2 emphasized that delivering food at safe temperatures was essential not only for infection control but also for maintaining resident satisfaction and ensuring meals were served in a palatable state. 51157

Based on observation, interview, and review of the facility's policy, the facility failed to serve food in accordance with professional standards for food service safety. The census was 132. The findings include: Review of the facility's policy titled, Tray Line and Meal Delivery Service, undated, revealed staff were to not touch the food surface areas of plates, bowls, cups, or saucers. Staff were to pick the items up by the outer rim only. Continued review revealed staff were to use tongs, spoons, scoops, etc. to serve all food including bread. Additionally, staff should wash their hands and change gloves between each task. Review of the facility's policy titled, Hand Washing, undated, revealed staff were to wash their hands after handling soiled equipment or utensils and during food preparation, as often as necessary to remove soil or contamination and to prevent cross contamination when changing tasks. Observation on 03/17/2025 at 4:15 PM revealed Cook1 touched the surface area of plates as she removed them from the plate warmer. Further observation revealed she rested her gloved hands on the surface of the plates once they were sat on the tray line. Observation revealed Cook1 used her gloved hand to move the pot roast on the plate to make it look better. Cook1 then the proceeded to use the same gloved hand to place a roll on the plate. Continued observation of the tray line revealed Dietary Aide (DA)1 answered the telephone and did not wash her hands or change gloves. DA1 continued to work the tray line touching the bowl (inside) of the spoons and the fork prongs. During an interview, on 03/17/2025 at 6:35 PM, Cook1 stated that touching the surface area of plates could lead to the contamination of food and make the residents sick. During an interview, on 03/17/2025 at 6:45 PM, DA1 stated that touching the bowl of a spoon or the prongs of a fork could pass germs to the residents, and they could get sick. DA1 stated that she was unsure of the last time training on proper hand hygiene was conducted. During an interview, on 03/17/2025 at 6:52 PM, the Corporate Registered Dietician stated that touching the surface area of plates and silverware was not good practice and food safety was the utmost concern. Continued interview with the Corporate Registered Dietician revealed that not following proper hand hygiene could lead to cross contamination of foods and make residents sick. The Corporate Registered Dietician stated that it was her expectation that all staff follow proper hand hygiene policies. During an interview, on 03/17/2025 at 7:08 PM, the Dietary Manager (DM) stated that the [NAME] should not have touched the pot roast, roll, or the surface area of plates. She stated the DA should not have touched the surface area of silverware and not changed their gloves after answering the telephone. Continued interview with the DM revealed that touching the surface area of the plates and silverware, and not following proper hand hygiene could cause residents to get sick. Additionally, the DM stated that it was her expectation for all staff to follow all policies and procedures to prevent illness.

Based on interview, record review, and facility policy, it was determined the facility failed to develop and implement a comprehensive person-centered care plan (CCP) for one (1) of eleven (11) sampled residents (Resident #8). On [DATE] Resident #8 was rolled out of the bed, onto the floor, by State Registered Nursing Assistant (SRNA) #1, while providing care unassisted by another staff member. Resident #8 was care planned to be a two person staff assist for Activities of Daily Living (ADL's). The findings include: Review of the facility's policy, titled Care Plan Policy and Protocol, revised ,d+[DATE], revealed the facility would develop a comprehensive care plan for each resident that included measurable objectives and timetables to meet a resident's medical, nursing, and mental/psychosocial needs that are identified in the comprehensive assessment. Further review of the policy revealed the Kardex would be utilized as a guide for nurse aides in providing care on a daily basis. Continued review of the policy revealed the Kardex would be a working tool and revisions would be made when indicated and would reflect person-centered care preferences. Review of Facility's Investigation dated [DATE], revealed SRNA #1 completed care unassisted for Resident #8 who required two person staff assistance with care. Continued review revealed staff assisted Resident #8 back to bed and the nurse completed an assessment. Review of Resident #8's Admission Face Sheet, revealed the facility admitted Resident #8 on [DATE] with diagnosis to include but not limited to unspecified dementia, unspecified anxiety disorder, nontoxic goiter, and type 2 diabetes mellitus. Resident #8 expired in the facility on [DATE] while receiving palliative care. Review of Resident #8's Quarterly Minimum Data Set (MDS) dated [DATE], revealed the facility assessed Resident #8 with a Brief Interview for Mental Status (BIMS) score of three (3) out of fifteen (15), indicating the resident was severely cognitively impaired. Review of Resident #8's Comprehensive Care Plan (CCP) initiated on [DATE], revealed Resident #8 was at risk for fall due to impaired cognition with a goal to include the resident would be free from falls through the next review date. Interventions included keep call light within reach and encourage resident to utilize it when needing staff assistance, notify the MD and RP of any falls that occur, provide a safe environment including a well-lit, clutter-free room, keep personal belongings within reach, and physical therapy/occupational therapy consults as indicated. New interventions initiated on [DATE], included vital signs per order and as needed, if falls occur, consult with Interdisciplinary Team (IDT), encourage resident to wear non-skid shoes, socks when out of bed and reinforce importance as needed, every one hour checks for twenty four hours, ice pack to resident's head for three days, pain medication as needed for any complaints of pain, and turn bedside table so not in the path of fall mats. Review of Resident #8's Kardex, not dated, revealed Resident #8 was a two person staff assist for bed mobility and toileting and was checked as extensive assist for both. Review of Resident #8's Progress Note dated [DATE], entered by Licensed Practical Nurse (LPN) #1, revealed Resident #8 was accidentally rolled onto the floor while being rolled in bed by staff. Continued review revealed Resident #8 was alert with no serious injuries and the family was notified. However, review of Resident #8's Skin assessment dated [DATE], revealed Resident #8 had a bruise and small knot to the right side of the forehead and ecchymosis (bruising) to the bilateral upper extremities, bilateral lower extremities, and face. During an interview with State Registered Nursing Assistant (SRNA) #1 on [DATE] at 1:20 PM, she stated Resident #8 was a two person assist for care. SRNA #1 stated another aide (she couldn't remember her name) was in the room initially, but left the room, to go assist another resident. SRNA #1 stated she then proceeded to provide incontinence care to Resident #8 unassisted. SRNA #1 stated when she rolled Resident #8 onto his/her side while providing incontinence care, Resident #8 rolled out of bed onto the floor. SRNA #1 stated she hollered for a nurse to come and help her get Resident #8 back in the bed. SRNA #1 stated Resident #8 did not make any noise when he/she rolled out of the bed onto the floor but upon assessment did have a little place on his/her head after the incident. During a continued interview with SRNA #1, she stated she should have waited for the other aide to come back into the room to assist with incontinence care to prevent the resident from rolling onto the floor. SRNA #1 stated she had been trained by the Staff Development Coordinator (SDC) on what the Kardex was and how to use the Kardex. During an interview with SRNA #2 on [DATE] at 10:00 AM, she stated Resident #8 was a two person and she was in Resident #8's room assisting SRNA #1 with incontinence care when she was called away to assist the nurse with a new admission. SRNA #2 stated she was made aware of the incident involving Resident #8 after the fact, and Resident #8 had sustained a scratch and knot on his/her left side after the incident occurred. SRNA #2 stated it was important to follow the Kardex because it lets staff know what type of care the resident should receive. SRNA #2 stated if a staff member did not follow the Kardex, the resident could roll out of the bed, could choke, or if staff didn't turn the resident, a resident could get a sore place on their skin. SRNA #2 stated, looking back, if she had stayed to assist SRNA #1 with incontinence care instead of leaving to assist the nurse, Resident #8's fall could have been prevented. SRNA #2 stated she had been trained by the SDC on what the Kardex was and how to use the Kardex. During an interview with Licensed Practical Nurse (LPN) #1 on [DATE] at 11:15 AM, she stated she was the charge nurse on duty during the incident involving SRNA #1 and Resident #8. LPN #1 stated she was called to the room by SRNA #1 and when she entered the room, Resident #8 was on the floor. LPN #1 stated upon entering the room, Resident #8 was laying on the floor by the bed and the resident had a small knot with bruising on his/her right side of the head. LPN #1 stated Resident #8 denied pain and she assisted SRNA #1 with placing Resident #8 back into the bed. LPN #1 stated she notified Resident #8's family, the resident's primary provider, and the Clinical Coordinator (CC) on call. LPN #1 stated SRNA #1 did not follow the care plan for two person assist for bed mobility when providing incontinence care to Resident #8, and as a result, the resident rolled out of bed and onto the floor. LPN #1 stated the incident could have been prevented if SRNA #1 had waited for assistance to provide incontinence care to Resident #8. During an interview with Clinical Coordinator (CC) #2 on [DATE] at 1:24 PM, she stated she was aware of the incident involving SRNA #1 and Resident #8. CC #2 stated it was not appropriate for SRNA #1 to use a one person staff assist for Resident #8, who required a two person staff assist for bed mobility and incontinence care. CC #2 stated if staff did not follow the Kardex, the resident could be rolled out of bed and break a hip. She continued to state one person was not able to do provide care to Resident #8. CC #2 stated the SRNA's were responsible for reading the Kardex at the beginning of the shift in order to know what type of care each resident should receive. CC #2 stated staff should follow the facility policy, the care plan, and the Kardex when providing care to the residents. CC #2 stated the incident involving SRNA #1 and Resident #8 could have been prevented if SRNA #1 had waited for help to complete incontinence care. During an interview with Staff Development Coordinator/Infection Prevention Nurse (SDC/IP) on [DATE] at 2:37 PM, she stated she was responsible for training all new hires on following the care plan and Kardex when providing care to residents. She further stated staff were given a posttest to ensure understanding of the training provided upon hire. She stated the nurses and aides were trained on care plans, showed staff what the Kardex looked like, how to read the Kardex, and how to follow the care plan. The SDC/IP stated she had been made aware of the incident involving SRNA #1 and Resident #8 after the incident occurred. She continued to state staff did not follow the care plan resulting in Resident #8 being rolled out of the bed while care was being provided. She further stated had staff followed the Kardex and care plan when providing care to Resident #8, he/she would not have rolled off the bed onto the floor. The SDC stated Resident #8 was a two person assist and it was clear on the Kardex. The SDC/IP further stated the incident could have been prevented if the employee had used another person to assist with care. During an interview with Director of Nursing (DON) on [DATE] at 2:55 PM, she stated was made aware of the incident involving SRNA #1 and Resident #8 by the nursing staff who called her to report the incident on [DATE]. The DON stated SRNA #1 was providing assistance to Resident #8 by herself and should have had another staff member assisting with bed mobility and incontinence care. She continued to state as a result, Resident #8 was rolled out of bed, and onto the floor, causing Resident #8 to sustain a knot on the head and bruising to the extremities and face. The DON further stated, the incident could have been prevented by using two staff members when providing care for Resident #8. The DON stated she expected staff follow the care plan and Kardex when providing care to the residents. The DON stated failure to do so could potentially lead to further harm to the resident. The DON stated Resident #8 had been care planned for a two person staff assist for bed mobility and incontinence care, and the aides should have followed the Kardex which has all the resident information on it. The DON stated the SRNA's received report by the Charge Nurse or Clinical Coordinator from the Kardex at the beginning of each shift. The DON stated it was her expectation for staff to follow the Care Plan Policy to prevent injury to the residents. The State Survey Agency (SSA) was unable to conduct an interview with the Administrator during this survey period due to the Administrator was out on medical leave.

Based on interview, record review, and facility policy, it was determined the facility failed to ensure residents received appropriate supervision for one (1) of eleven (11) sampled residents (Resident #8). On [DATE] Resident #8 was rolled out of the bed, onto the floor, by State Registered Nursing Assistant (SRNA) #1, while providing care unassisted by another staff member. The findings include: Review of the facility's policy, titled Falls Management/Prevention, revised ,d+[DATE], revealed it was the policy of the facility to screen all residents to identify possible risk factors that may place a resident at risk for falls, to evaluate those risks, implement interventions to reduce those risks and observe those interventions and modify when necessary. Further review of the policy revealed it was the policy of the facility to investigate any resident fall to determine root cause and appropriate interventions to put in place to minimize the risk of recurrence and the risk of injury related to a fall. Review of Facility's Investigation dated [DATE], revealed SRNA #1 completed care unassisted for Resident #8 who required two person staff assistance with care. Review of Resident #8's facility Admission Face Sheet, revealed the facility admitted Resident #8 on [DATE] with diagnosis to include but not limited to unspecified dementia, unspecified anxiety disorder, nontoxic goiter, debility, and type 2 diabetes mellitus. Resident #8 expired in the facility on [DATE] while receiving palliative care. Review of Resident #8's Quarterly Minimum Data Set (MDS) dated [DATE], revealed the facility assessed Resident #8 with a Brief Interview for Mental Status (BIMS) score of three (3) out of fifteen (15), indicating the resident was severely cognitively impaired. Review of Resident #8's Comprehensive Care Plan (CCP) initiated on [DATE], revealed Resident #8 was at risk for fall due to impaired cognition with a goal to include the resident would be free from falls through the next review date. Interventions included keep call light within reach and encourage resident to utilize it when needing staff assistance, notify the MD and RP of any falls that occur, provide a safe environment including a well-lit, clutter-free room, keep personal belongings within reach, and physical therapy/occupational therapy consults as indicated. New interventions initiated on [DATE], included vital signs per order and as needed, if falls occur, consult with Interdisciplinary Team (IDT), encourage resident to wear non-skid shoes, socks when out of bed and reinforce importance as needed, every one hour checks for twenty four hours, ice pack to resident's head for three days, pain medication as needed for any complaints of pain, and turn bedside table so not in the path of fall mats. Review of Resident #8's Kardex, not dated, revealed Resident #8 was a two person staff assist for bed mobility and toileting and was checked as extensive assist for both. Review of Resident #8's Progress Note dated [DATE], entered by Licensed Practical Nurse (LPN) #1, revealed Resident #8 was accidentally rolled onto the floor while being rolled in bed by staff. Continued review revealed Resident #8 was alert with no serious injuries and the family was notified. However, review of Resident #8's Skin assessment dated [DATE], revealed Resident #8 had a bruise and small knot to the right side of the forehead and ecchymosis (bruising) to the bilateral upper extremities, bilateral lower extremities, and face. During an interview with State Registered Nursing Assistant (SRNA) #1 on [DATE] at 1:20 PM, she stated Resident #8 was a two person assist for care. SRNA #1 stated SRNA #2 was in the room initially, but left the room, to go assist the nurse with a new admission. SRNA #1 stated she then proceeded to provide incontinence care to Resident #8 unassisted. SRNA #1 stated when she rolled Resident #8 onto his/her side while providing incontinence care, Resident #8 rolled out of bed onto the floor. SRNA #1 stated she hollered for a nurse to come and help her get Resident #8 back in the bed. SRNA #1 stated Resident #8 did not make any noise when he/she rolled out of the bed onto the floor but upon assessment did have a little place on his/her head after the incident. During a continued interview with SRNA #1, she stated she should have waited for the other aide to come back into the room to assist with incontinence care to prevent the resident from rolling onto the floor. SRNA #1 stated she had been trained by the Staff Development Coordinator (SDC) on what the Kardex was and how to use the Kardex. During an interview with SRNA #2 on [DATE] at 10:00 AM, she stated Resident #8 was a two person and she was in Resident #8's room assisting SRNA #1 with incontinence care when she was called away to assist the nurse with a new admission. SRNA #2 stated she was made aware of the incident involving Resident #8 after the fact, and Resident #8 had sustained a scratch and knot on his/her left side after the incident occurred. SRNA #2 stated it was important to follow the Kardex because it lets staff know what type of care the resident should receive. SRNA #2 stated if a staff member did not follow the Kardex, the resident could roll out of the bed, could choke, or if staff didn't turn the resident, a resident could get a sore place on their skin. SRNA #2 stated, looking back, if she had stayed to assist SRNA #1 with incontinence care instead of leaving to assist the nurse, Resident #8's fall could have been prevented. SRNA #2 stated she had been trained by the SDC on what the Kardex was and how to use the Kardex. During an interview with Licensed Practical Nurse (LPN) #1 on [DATE] at 11:15 AM, she stated she was the charge nurse on duty during the incident involving SRNA #1 and Resident #8. LPN #1 stated she was called to the room by SRNA #1 and when she entered the room, Resident #8 was on the floor. LPN #1 stated upon entering the room, Resident #8 was laying on the floor by the bed and the resident had a small knot with bruising on his/her right side of the head. LPN #1 stated Resident #8 denied pain and she assisted SRNA #1 with placing Resident #8 back into the bed. LPN #1 stated she notified Resident #8's family, the resident's primary provider, and the Clinical Coordinator (CC) on call. LPN #1 stated SRNA #1 did not follow the care plan for two person assist for bed mobility when providing incontinence care to Resident #8, and as a result, the resident rolled out of bed and onto the floor. LPN #1 stated the incident could have been prevented if SRNA #1 had waited for assistance to provide incontinence care to Resident #8. During an interview with Clinical Coordinator (CC) #2 on [DATE] at 1:24 PM, she stated she was aware of the incident involving SRNA #1 and Resident #8. CC #2 stated it was not appropriate for SRNA #1 to use a one person staff assist for Resident #8, who required a two person staff assist for bed mobility and incontinence care. CC #2 stated if staff did not follow the Kardex, the resident could be rolled out of bed and break a hip. She continued to state one person was not able to do provide care to Resident #8. CC #2 stated the SRNA's were responsible for reading the Kardex at the beginning of the shift in order to know what type of care each resident should receive. CC #2 stated staff should follow the facility' Fall Prevention Policy and the Kardex when providing care to the residents. CC #2 stated the incident involving SRNA #1 and Resident #8 could have been prevented if SRNA #1 had waited for help to complete incontinence care. During an interview with Staff Development Coordinator/Infection Prevention Nurse (SDC/IP) on [DATE] at 2:37 PM, she stated she was responsible for training all new hires on following the care plan and Kardex when providing care to residents. She further stated staff were given a posttest to ensure understanding of the training provided upon hire. She stated the nurses and aides were trained on care plans, showed staff what the Kardex looked like, how to read the Kardex, and how to follow the care plan. The SDC/IP stated she had been made aware of the incident involving SRNA #1 and Resident #8 after the incident occurred. She continued to state staff did not follow the care plan resulting in Resident #8 being rolled out of the bed while care was being provided. She further stated had staff followed the Kardex and care plan when providing care to Resident #8, he/she would not have rolled off the bed onto the floor. The SDC stated Resident #8 was a two person assist and it was clear on the Kardex. The SDC/IP further stated the incident could have been prevented if the employee had used another person to assist with care. During an interview with Director of Nursing (DON) on [DATE] at 2:55 PM, she stated was made aware of the incident involving SRNA #1 and Resident #8 by the nursing staff who called her to report the incident on [DATE]. The DON stated SRNA #1 was providing assistance to Resident #8 by herself and should have had another staff member assisting with bed mobility and incontinence care. She continued to state as a result, Resident #8 was rolled out of bed, and onto the floor, causing Resident #8 to sustain a knot on the head and bruising to the extremities and face. The DON further stated, the incident could have been prevented by using two staff members when providing care for Resident #8. The DON stated she expected staff follow the care plan and Kardex when providing care to the residents. The DON stated failure to do so could potentially lead to further harm to the resident. The DON stated Resident #8 had been care planned for a two person staff assist for bed mobility and incontinence care, and the aides should have followed the Kardex which has all the resident information on it. The DON stated it was her expectation for staff to have adequate help when assisting residents and follow the facility's Fall Prevention Policy to prevent injury to the residents. The State Survey Agency (SSA) was unable to conduct an interview with the Administrator during this survey period due to the Administrator was out on medical leave.

Based on observation, interview, and facility policy review, it was determined the facility failed to label and store biologicals with currently accepted professional principles for one (1) of five (5) medication carts observed. Four (4) multi-dose vials of Insulin which were not dated when opened were observed on one (1) medication cart on the west wing. In addition, one of the vials of insulin did not have a pharmacy label which included the resident's name, medication name, dose, route, etc. The findings include: Review of the facility's policy titled, Protocol for Multi-Dose Vials, undated, revealed multi dose vials should be initialed and dated when opened and stored per manufacturers recommendations. Further review of the policy and review of the manufacturers recommendations revealed multi-dose vials of insulin will be discarded after twenty eight (28) days. Observation on 04/15/2021 at 3:59 PM of the west wing medication cart (for the 900 hallway) revealed two (2) ten (10) milliliter (ml) multi dose bottles of Novolog 70/30 Insulin, one (1) ten (10) ml multi dose bottle of [MEDICATION(S)] Insulin, one (1) ten (10) ml bottle of [MEDICATION(S)] R Insulin had been opened for use but were not dated when opened. Further observation revealed that the one (1) of the [MEDICATION(S)] R vial did not have pharmacy labeling. Interview with Licensed Practical Nurse (LPN) #1 on 04/15/2021 at 3:59 PM revealed she was assigned to the medication cart on the west wing for the 900 hall. LPN #1 further stated that insulin vials should have pharmacy labels and should be labeled with the date the bottle was opened. LPN #1 also revealed that she was responsible for checking for the presence of pharmacy labels and open dates on insulin vials. LPN #1 also stated she had been educated on the facility policy for labeling insulin vials. Interview with Director of Nursing (DON) on 4/15/2021 at 4:59 PM, revealed that when multi dose insulin vials were opened that the vial should be dated and bottles should have a pharmacy label. The Director of Nursing further stated that the nurse was responsible to check insulin vials at the start of the shift to ensure an open date and pharmacy labels are present. Per the DON, audits are completed two (2) times yearly and past audits have revealed no concerns with opened multi dose bottles not being labeled or dated.

Based on observation, interview, record review, review of Centers for Disease Control and Prevention (CDC) guidelines, and review of the facility's policy, it was determined the facility failed to properly prevent and/or contain COVID-19 for one (1) of five (5) sampled residents (Resident #1). Resident #1 was recently admitted to the facility after being hospitalized and was residing on the facility's COVID-19 Unit. Observation on 06/03/2020 at 9:15 AM, revealed Resident #1 was observed on an ambulance stretcher being transferred from the facility's COVID-19 care unit to the [MEDICAL TREATMENT] clinic. The ambulance crew parked the stretcher with Resident #1 at the Rosewood Place nursing station to talk to the nursing staff. Resident #1 was not observed to have on a face mask. Prior to the ambulance service leaving from the nurses' station Registered Nurse (RN) #1 placed a face mask on the resident. The findings include: Review of the facility's policy titled, Protocol: COVID-19, with a revision date of 04/01/2020, revealed all residents would be monitored daily for symptoms of COVID-19. Monitoring would include daily oxygen saturation and lung sounds. The policy also revealed that the CDC guidelines for identifying, monitoring, and treating residents with COVID-19 would be followed. The facility's Infection Preventionist would check the CDC's website on a daily basis for any updates regarding COVID-19. Review of the CDC's COVID-19 guidelines for new admissions titled, Responding To Coronavirus (COVID-19) in Nursing Homes, dated 2019, revealed if the resident must leave his/her room, they must reinforce adherence to universal source control policies and social distancing such as have the resident wear a cloth face covering or face mask and remain at least six (6) feet away from others when outside their room. The guidelines state new residents should be monitored for evidence of COVID-19 for fourteen (14) days after admission and cared for using all recommended COVID-19 personal protective equipment (PPE). Observation of Resident #1 on 06/03/2020 at 9:15 AM, revealed the resident was observed on the ambulance stretcher being transferred from the facility's COVID-19 care unit to the [MEDICAL TREATMENT] clinic. The ambulance crew parked the stretcher with Resident #1 at the Rosewood Place nursing station to talk to the nursing staff. Resident #1 was not observed to have on a face mask. Prior to the ambulance service leaving from the nurses' station Registered Nurse (RN) #1 was observed to place a face mask on the resident. Review of Resident #1's medical record revealed the facility admitted the resident on 05/29/2020, with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessments had not yet been completed. Review of Resident #1's baseline care plan dated 05/29/2020, revealed care plan interventions had been developed for infection related to COVID-19, for contact/droplet precautions for fourteen (14) days. Review of the baseline care plan revealed the care plan developed interventions that required staff to wear PPE (mask, gloves, and gown); however, the care plan did not address the resident coming out of his/her room. Review of physician's orders [REDACTED]. Interview conducted with Registered Nurse (RN) #1 on 06/03/2020 at 9:25 AM, revealed all residents coming out of their rooms on the COVID-19 Unit were required to don a face mask prior to leaving their room. The RN stated any resident going out of the facility was required to wear a face mask. RN #1 stated Resident #1 should have been wearing a face mask before he/she left his/her room. Interview with State Registered Nursing Assistant (SRNA) #1 on 06/03/2020 at 9:33 AM, revealed she assisted SRNA #2 with transferring Resident #1 from his/her bed over to the ambulance stretcher. The SRNA stated the resident had asked them to wait a minute prior to placing the mask on the resident. The SRNA stated she then went to assist another resident. The SRNA stated she should have either waited and placed the mask on Resident #1 or reported it to the nurse. The SRNA stated she had been trained to ensure a mask was placed on residents prior to them leaving the facility. Interview conducted with SRNA #2 on 06/03/2020 at 10:04 AM, revealed she had attempted to place a face mask on Resident #1 and the resident had asked her to wait. The SRNA stated she was required to notify the nurse and should have notified the nurse that the resident did not want to wear the face mask. The SRNA stated she then went with SRNA #1 to assist another resident. Interview conducted with the Infection Preventionist on 06/03/2020 at 10:30 AM, revealed residents on the COVID-19 Unit are encouraged to stay in their room and to don a face mask when out of their room. The Infection Preventionist stated all residents going to out of the facility for appointments or [MEDICAL TREATMENT] were required to don a face mask prior to coming out of their room. The Infection Preventionist stated she monitored daily to ensure staff and residents were donning appropriate PPE and had not identified any concerns. The Infection Preventionist stated Resident #1 should have been wearing a face mask prior to leaving his/her room. Interview conducted with the Director of Nursing (DON) on 06/03/2020 at 11:25 AM, revealed any resident coming out of their room on the COVID-19 Unit was required to don/wear a face mask. If a resident refused to wear a face mask, the SRNA was required to immediately notify the nurse. The DON stated Resident #1 should not have been taken out of his/her room without wearing a face mask. The DON stated the facility utilized CDC guidelines for isolation.

Based on observation, interview, record review, and facility policy review it was determined the facility failed to develop and implement person-centered comprehensive care plans for one (1) of two (2) residents (Resident #41) related to hospice care and one (1) of four (4) residents (Resident #43) related to oxygen therapy. The findings include: Review of the facility policy titled, Care Plan Policy and Protocol, revised (MONTH) (YEAR), revealed the facility would develop a comprehensive care plan for each resident which would include measurable objectives and timetables to meet a resident's medical, nursing, mental, and psychosocial needs that were identified in the resident's comprehensive assessment. 1. Review of Resident #41's medical record revealed the facility admitted the resident on 04/14/16 with [DIAGNOSES REDACTED]. Review of Resident #41's Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was unable to complete the Brief Interview for Mental Status (BIMS) and the facility assessed the resident to have moderately impaired decision-making ability. Review of Resident #41's physician orders dated (MONTH) (YEAR) revealed an order for [REDACTED].>Review of Resident #41's comprehensive plan of care dated 07/23/18 revealed the resident was receiving hospice care. However, the plan did not include the name of the hospice provider, what discipline was providing hospice care to Resident #41, how to contact hospice personnel twenty-four (24) hours a day, and had no interventions listed which included evidence of coordination between the hospice provider and the facility. Interview with the MDS Coordinator on 03/14/19 at 6:42 PM revealed she was not aware that there was specific criteria required to be included in the care plan for a resident receiving hospice services. 2. Review of Resident #43's medical record revealed the facility admitted the resident on 02/18/14 with [DIAGNOSES REDACTED]. Review of Resident #43's Minimum Data Set (MDS) assessment dated [DATE] revealed the facility assessed the resident to have a BIMS score of three (3), indicating the resident was cognitively impaired. Review of Resident #43's physician orders revealed an order for [REDACTED]. Review of Resident #43's comprehensive plan of care dated 01/08/19 revealed an intervention to provide the resident with oxygen therapy via nasal cannula as ordered and to monitor the resident's oxygen saturations every shift and as needed. However, further review of the care plan revealed the facility failed to develop a person-centered individualized care plan, which was individualized for the resident. The plan of care failed to include interventions that reflected when to administer oxygen to the resident such as continuous or intermittently, the equipment settings for the prescribed flow rates, monitoring for complications such as skin integrity issues related to use of a nasal cannula, or interventions to utilize if the resident was noncompliant with oxygen administration. Observation of Resident #43 on 03/12/19 at 10:50 AM revealed the resident was lying in bed with eyes closed. The resident had an oxygen concentrator in the room, which was running and set to deliver two (2) liters of oxygen per minute; however, the nasal cannula was not in the resident's nose. Interviews on 03/13/19 at 3:27 PM with SRNA #3 and 3:30 PM with SRNA #4, and on 03/14/19 at 9:34 AM with SRNA #2, revealed all the staff interviewed stated Resident #43 was noncompliant with wearing oxygen at times. Interview with Registered Nurse (RN) #1 on 03/14/19 at 3:35 PM revealed Resident #43 was not compliant with wearing oxygen at times. Further interview revealed RN #1 was not sure if she had notified the MDS Coordinator of Resident #43's noncompliance. Interview with RN #3 on 03/14/19 at 10:25 AM revealed she was aware that Resident #43 was noncompliant at times with oxygen administration. Further interview revealed she had made the MDS Coordinator aware of the resident's noncompliance with oxygen, but could not recall specific dates. Interview with the MDS Coordinator on 03/14/19 at 6:41 PM revealed she was responsible for developing and implementing resident care plans. The MDS Coordinator stated she had developed Resident #43's plan of care, and considered it to be resident-specific.

Based on observation, interview, medical record review, and review of the facility's policy, it was determined the facility failed to ensure two (2) of four (4) sampled residents (Resident #43 and Resident #123) who had physician orders [REDACTED]. Review of physician orders [REDACTED].#123 on 03/12/19 revealed the resident's nasal cannula was observed to be on the floor. 1. Review of Resident #43's medical record revealed the facility admitted the resident on 02/18/14 with [DIAGNOSES REDACTED]. Review of Resident #43's Minimum Data Set (MDS) assessment dated [DATE] revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of three (3), indicating the resident was not cognitively intact. Review of Resident #43's physician orders [REDACTED]. Review of Resident #43's comprehensive plan of care dated 01/08/19 revealed an intervention to administer the resident oxygen therapy via nasal cannula as ordered. Observations of Resident #43 on 03/12/19 at 10:50 AM and on 03/13/19 at 8:37 AM revealed the resident was lying in bed with his/her eyes closed and the oxygen concentrator was set to deliver oxygen at two (2) LPM; however, the resident's nasal cannula was not in place. Interviews on 03/13/19 with State Registered Nurse Aide (SRNA) #3 at 3:27 PM and SRNA #4 at 3:30 PM, and on 03/14/19 with SRNA #2 at 9:34 AM, revealed all the staff stated Resident #43 was noncompliant with wearing the oxygen at times. Continued interviews revealed when the staff observed Resident #43 not wearing the oxygen they would reapply the oxygen and report it to the nurse. Interview with Registered Nurse (RN) #1 on 03/14/19 at 3:35 PM revealed Resident #43 was not compliant with wearing oxygen at times. Further interview revealed when she observed the resident not to be wearing the oxygen, she would reapply it, document the resident's noncompliance, and notify the physician. 2. A review of Resident #123's medical record revealed the facility admitted the resident on 08/01/12, with [DIAGNOSES REDACTED]. Review of Resident #123's Minimum Data Set (MDS) assessment dated [DATE], revealed the facility had been unable to complete the assessment, but had determined the resident had moderately impaired decision-making ability. Review of Resident #123's physician's orders [REDACTED]. Review of the comprehensive care plan for Resident #123 dated 06/18/18, revealed the facility was to provide oxygen to the resident as ordered by the physician. Observations of Resident #123 on 03/12/19 at 10:45 AM, 12:58 PM, and 4:03 PM revealed the resident's oxygen concentrator was set to deliver three (3) liters of oxygen per minute; however, the resident's oxygen nasal cannula was observed to be on the floor during each observation. Interview conducted with SRNA #1 on 03/13/19 at 2:30 PM, revealed when she observed a resident's oxygen cannula to be on the floor, she was required to notify the nurse, who would replace the cannula. The SRNA stated she did not know why the resident's oxygen had been on the floor for most of the day, because she had reported to LPN #1 earlier in the morning that Resident #123's oxygen tubing was on the floor. Interview conducted with LPN #1 on 03/14/19 at 4:37 PM, revealed she was required to make rounds every two (2) hours, and had not identified that Resident #123's oxygen had been on the floor. The LPN stated she should have identified the issue but had not. The LPN further stated she could not recall if SRNA #1 had notified her of Resident #123's oxygen being on the floor. Interview conducted with RN #1 who was acting as Clinical Coordinator on 03/14/19 at 5:54 PM, revealed she made rounds every two (2) hours and as needed. RN #1 stated the nurse should have replaced Resident #123's oxygen tubing and ensured it was on the resident and functioning. The RN stated she had not identified that Resident #123's oxygen tubing was on the floor and stated, I just missed it. Interview conducted with the Director of Nursing (DON) on 03/14/19 at 7:05 PM, revealed she made rounds throughout the facility one time per week, and had not identified any concern with residents not receiving oxygen as ordered.

Based on observation, interview, record review, and facility policy review, it was determined the facility failed to implement the comprehensive plan of care for one (1) of thirty-two (32) sampled residents (Resident #21). On 01/03/18, the facility determined that the facility cat had scratched Resident #21 and developed care plan interventions to have the cat declawed and to remove the cat from the resident's room as needed. However, the cat was not declawed and observation revealed the cat was in the resident's room on 01/10/18. The findings include: Review of the facility's Care Plan Policy and Protocol, not dated, revealed the facility should develop a comprehensive care plan that included measurable objectives and timetables to meet a resident's medical, nursing, and mental and psychosocial needs. Review of Resident #21's medical record revealed the facility admitted the resident on 11/04/15, with [DIAGNOSES REDACTED]., History of Falling, and [MEDICAL CONDITION]. Review of Resident #21's annual Minimum Data Set (MDS) assessment dated [DATE] revealed the facility was unable to complete the resident's Brief Interview for Mental Status screening. Further review of the assessment revealed the resident was totally dependent on staff for bed mobility, transfer, dressing, toileting, personal hygiene, and bathing. Review of a comprehensive care plan for Resident #21 dated 01/03/18 revealed the facility cat scratched the resident and the facility developed interventions to have the cat declawed on 01/08/18, and to remove the cat from Resident #21's room as needed. Observation on 01/10/18 at 3:50 PM revealed a cat was in Resident #21's room on the vanity. No staff were observed to remove the cat from the room. Interview with Registered Nurse (RN) #1 on 01/11/18 at 5:59 PM revealed she developed the care plan for Resident #21 and expected staff to remove the cat from the resident's room if the cat was on the resident's bed or looked like it was going to jump onto the resident's bed. However, interview with State Registered Nurse Aide (SRNA) #4 on 01/11/18 at 1:23 PM revealed she was not aware the cat should be removed from or kept out of Resident #21's room. Interviews with SRNA #1 on 01/11/18 at 1:15 PM, and SRNA #2 on 01/11/18 at 1:23 PM, revealed they were not aware Resident #21 had been scratched by the cat. SRNA #2 stated she had never been instructed to keep cats out of any resident's room. Interview with the Administrator on 01/10/18 at 10:14 AM, and on 01/11/18 at 3:10 PM, revealed the facility took the cat to the veterinarian on 01/08/18, but was unable to have the cat declawed because the veterinarian could not be sure that the cat had not had anything to eat/drink before the surgery. The Administrator stated the cat continued to roam freely throughout the facility. The Administrator stated that due to the resident's inability to trigger the call light or kick/push the cat off the bed, the resident was vulnerable.

Based on observation, interview, record review, and facility policy review, it was determined the facility failed to ensure the environment was free from accident hazards for one (1) of thirty-two (32) sampled residents (Resident #21). On 01/03/18, the facility determined that the facility cat scratched Resident #21's right foot and calf multiple times. Interviews with staff revealed Resident #21 was not capable of alerting staff when the cat was in the room and record review revealed the resident was dependent on staff for all activities of daily living. The facility developed a care plan with an intervention to have the cat declawed and to remove the cat from the resident's room as needed; however, the facility failed to have the cat declawed and the cat was observed in the resident's room on 01/10/18. The findings include: Review of the facility's policy titled Incident Investigation Policy, undated, revealed it was the policy of the facility to complete a Resident Incident Report for any incident to track, trend, and determine the possible cause of the incident and to develop an intervention to prevent reoccurrence. Observation of Resident #21 on 01/09/18 at 1:56 PM and 4:52 PM revealed the resident was in a geri-chair dressed in street clothing. The resident was not oriented to time or place, but did respond to his/her name and spoke only in one-word replies. Observation of Resident #21's feet and legs on 01/10/18 at 9:56 AM revealed multiple broken and scabbed areas to the top of the right foot. Observation on 01/10/18 at 3:50 PM revealed a cat was in Resident #21's room on the vanity. No staff were observed to remove the cat from the room. Review of Resident #21's medical record revealed the facility admitted the resident on 11/04/15, with [DIAGNOSES REDACTED]., History of Falling, and [MEDICAL CONDITION]. Review of Resident #21's annual Minimum Data Set (MDS) assessment completed by the facility on 10/20/17 revealed the facility was not able to complete the interview to assess the resident's mental status. The assessment further revealed the resident was totally dependent for Activities of Daily Life (ADL), which included bed mobility, transfer, dressing, toileting, personal hygiene, and bathing. Review of an Incident Report, dated 01/03/18 at 2:20 AM, revealed a State Registered Nurse Aide (SRNA) entered Resident #21's room and discovered blood on the sheets at the foot of the bed. Scratches were observed on the resident's right foot and right calf. According to the incident report, the facility cat was under Resident #21's bed. The documentation revealed the cat was on the resident's bed forty-five (45) minutes earlier and was removed from the bed, but the cat would not leave the room. The facility determined the root cause of the scratches were related to the cat playing with the sheets while the resident's foot was under the sheet. The resident's physician was notified and orders were received to monitor the wounds for seven (7) days, and clean the wounds with normal saline. The physician also ordered [MEDICATION NAME] (an antibiotic) 300 milligrams for five (5) days by mouth. Review of the nurse's notes for Resident #21, dated 01/03/18 at 2:20 AM, revealed the cat frequented the resident's room and had a history of [REDACTED]. Interview with SRNA #3 on 01/11/18 at 2:57 PM revealed she was working the night of the incident and discovered blood on Resident #21's sheets when she entered the room and had observed the cat in the room prior to discovering the injuries. Interview with Licensed Practical Nurse (LPN) #1 on 01/11/18 at 9:05 AM revealed SRNA #3 reported to her on 01/03/18, that the cat had been in Resident #21's room and that the resident was bleeding. LPN #1 stated she assessed the resident's foot and found the right foot to have multiple scratches. She further revealed that when she entered the resident's room, the resident was moving his/her foot back and forth and she believed the cat may have been playing with the resident's foot resulting in the scratches. Review of Resident #21's comprehensive care plan dated 01/03/18 revealed the facility revised the resident's care plan to include the cat scratches and developed interventions to have the cat declawed on 01/08/18, and to remove the cat from Resident #21's room as needed. However, interview with State Registered Nurse Aide (SRNA) #4 on 01/11/18 at 1:23 PM revealed she was not aware the cat should be removed from or kept out of Resident #21's room. Interviews with SRNA #1 on 01/11/18 at 1:15 PM, and SRNA #2 on 01/11/18 at 1:23 PM, revealed they were not aware Resident #21 had been scratched by the cat. SRNA #2 stated she had never been instructed to keep cats out of any resident's room. Interview with the Administrator on 01/11/18 at 3:10 PM revealed she became aware of the incident on the morning of 01/03/18. She stated the incident was investigated and it was deduced that the cat caused the scratches. The Administrator stated the facility did not implement interventions to protect the resident from further scratches.

Based on observation, interview, and facility policy review, it was determined the facility failed to have an effective infection control program for one (1) unsampled resident (Resident #29). Observation of the evening meal on 01/09/18 revealed staff picked up a napkin from the floor in the dining room and placed the napkin on the table, and without washing her hands she placed Resident #29's plate of food on the napkin. The findings include: Review of the facility policy titled Infection Prevention and Control Program, undated, revealed the policy did not address placing dirty items near or on meal trays. Interview conducted with the Director of Nursing (DON) on 01/11/18 at 2:18 PM revealed staff were required to dispose of any item picked up from the floor and replace it with a clean item. The DON also stated staff were required to wash/sanitize their hands after touching any inanimate object that had been on the floor. Observation of the evening meal in the main dining room on 01/09/18 at 5:48 PM revealed State Registered Nursing Assistant (SRNA) #1 picked up a napkin from the floor with her bare hands and placed the napkin on the dining room table. SRNA #1 did not wash her hands after retrieving the item from the floor. SRNA #1 was then observed to take Resident #29's meal tray from the tray cart and place the tray on the table with the napkin. SRNA #1 then placed the napkin from the floor under Resident #29's plate. Continued observation revealed SRNA #1 proceeded to feed Resident #29 with the dirty napkin under the resident's plate. Interview with SRNA #1 on 01/11/18 at 1:36 PM revealed she was aware she had picked up a napkin from the floor, placed it on the table, and then placed it under Resident #29's plate. SRNA #1 stated she should have disposed of the napkin in the trash and washed her hands. Interview with the Infection Preventionist (IP) and the DON on 01/11/18 at 2:18 PM revealed all dirty items on the floor were required to be discarded in the trash and replaced with clean items. The DON stated picking up a napkin from the floor and placing it on a resident's table was a break in the infection control program. The DON stated she had not identified any concerns with staff placing dirty items under or near residents' meal trays.

Based on interview, record review, and facility policy review, the facility failed to ensure all alleged violations involving abuse were reported immediately to the Administrator of the facility and to other officials (including the state survey agency and Adult Protective Services). On 06/14/17, Certified Nurse Aides (CNAs) #2 and #3 witnessed CNA #1 throw a partially filled pan of water from the foot of the bed onto Resident #1, splashing the water into the resident's face during a bed bath. However, the incident was not reported to the Facility Administrator until the following day (06/15/17). The findings include: A review of the facility's Abuse policy (dated November 2016) revealed abuse was defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. The policy further defined willful, as used in the definition of abuse, to mean the individual must have acted deliberately; not that the individual must have intended to inflict injury or harm. In addition, the policy identified that all allegations involving mistreatment, neglect, or abuse would be reported immediately to the Director of Nurses and/or Administrator of the facility. The policy further identified the following procedures for reporting abuse allegations: staff on the 7-3 shift should report any mistreatment, abuse, or neglect directly to the Unit Supervisor who would be responsible to inform the Assistant Director of Nurses or the Director of Nurses; staff on the 3-11 shift should report directly to the House Supervisor or the Charge Nurse; and the staff on the 11-7 shift should report directly to the Charge Nurse. The policy stated the Charge Nurse would be responsible to report immediately to the Director of Nurses who would notify the facility Administrator. Review of the medical record revealed the facility admitted Resident #1 on 11/20/14 with [DIAGNOSES REDACTED]. Review of the quarterly MDS assessment dated [DATE] revealed the facility assessed Resident #1 to have short and long-term memory deficits with moderately impaired decision-making skills. Review of the facility's initial investigation dated 06/15/17 and final investigation dated 06/21/17 revealed Certified Nurse Aide #2 reported to Registered Nurse (RN) #1 on 06/15/17, that she and CNA #3 witnessed CNA #1 throw a partially filled pan of water from the foot of the bed onto Resident #1 during a bed bath on 06/14/17 causing the water to hit the resident's abdomen and splash onto the resident's face. CNA #2 reported the resident was startled and gasped when the water hit him/her in the face. The investigation further revealed CNA #1 was suspended on 06/15/17 and an investigation was initiated. Continued review of the investigation revealed CNA #3 also verified the report made by CNA #2. In addition, the investigation further included an interview with the alleged perpetrator (CNA #1), who verified she tossed the water onto Resident #1, but stated she (CNA #1) did not mean to toss it so hard. According to the investigation summary, the facility concluded abuse did occur and CNA #1 was terminated from the facility. Interview on 07/05/17 at 12:05 PM, with RN #1 revealed CNA #2 came to her office on 06/15/17 and told her something had occurred that was bothering her. RN #1 stated CNA #2 reported she and CNA #3 were assisting CNA #1 with providing a bed bath for Resident #1 on 06/14/17 sometime between 7:00 PM and 8:00 PM. According to RN #1, CNA #2 stated after CNA #1 had bathed/rinsed the resident with a washcloth, the CNA (CNA #1) said they complained that we don't rinse well enough and threw the half-filled basin of water onto the resident while standing at the foot of the bed. RN #1 stated CNA #2 reported the water splashed from the resident's abdomen into his/her face and the resident was gasped while CNA #1 laughed. RN #1 further stated she asked CNA #2 if she had previously reported the incident to anyone else and the CNA said she had not reported the incident. RN #1 stated she immediately reported the incident to the DON and Administrator. Interview with CNA #3 on 07/05/17, at 1:50 PM, revealed she had been working at the facility for approximately one (1) month and she was with CNAs #1 and #2 during the bed bath for Resident #1 on 06/14/17. CNA #3 stated after CNA #1 had washed the resident, she (CNA #3) got clean water to rinse the resident in a basin and handed it to CNA #1 who was at the foot of the bed. CNA #3 stated CNA #1 then threw the pan of water onto Resident #1 and it bounced off the resident's chest and splashed into his/her face. The CNA said the resident was scared and screamed out; however, CNA #1 was laughing and saying this is how you get the soap off. According to CNA #3, CNA #1 then told them (CNA #3 and CNA #2) to change the bed linens and put lotion on the resident and she (CNA #1) left the room. CNA #3 stated she had been trained in orientation regarding reporting abuse; however, the CNA stated she did not report the incident to anyone because she was new and scared. Interview conducted with CNA #2 on 07/06/17, at 3:45 PM, confirmed she reported the incident to RN #1 on 06/15/17. CNA #2 stated the incident occurred on 06/14/17 and she had been trained to identify and report all allegations of abuse immediately to the charge nurse. However, CNA #2 stated she did not immediately report the incident because she was also a new employee and was afraid of CNA #1. The CNA stated the incident kept bothering her and she knew she should report it and that is why she told RN #1 the following day. Interview with the DON on 07/06/17, at 4:00 PM, revealed she was first informed of the incident on 06/15/17 when she received the report from RN #1. The DON stated the facility investigation was immediately initiated and CNA #1 was suspended pending further investigation. The Administrator confirmed in interview on 07/06/17, at 4:12 PM, that she was also informed of the incident on 06/15/17 by RN #1. The Administrator stated the facility investigation determined abuse did occur on 06/14/17 and CNA #1 was terminated from the facility on 06/19/17.

Based on interview, record review, and facility policy review, the facility failed to ensure services were provided in accordance with the written plan of care for one (1) of two (2) sampled residents (Resident #2) related to incontinence care. The facility developed a care plan for Resident #2 that required the assistance of two (2) staff persons with incontinence care and toileting needs. However, on 06/14/17 Certified Nurse Aide (CNA) #1 was observed to provide incontinence care for Resident #2 without assistance as directed by the written plan of care. The findings include: A review of the facility's Care Plan Policy and Protocol (dated November 2016) revealed the facility would develop a comprehensive care plan for each resident that included measurable objectives and timetables to meet the resident's medical, nursing, mental, and psychosocial needs identified in the comprehensive assessment. The policy further noted the Kardex would be utilized as a guide for the nurse aide to provide care on a daily basis. Review of the medical record revealed the facility admitted Resident #2 on 10/28/16 with [DIAGNOSES REDACTED]. According to the quarterly MDS assessment dated [DATE], the facility assessed Resident #2 to have severely impaired cognition, to be totally incontinent of bowel and bladder, and to require total assistance of two (2) staff persons for transfers and for toileting needs. A review of the comprehensive care plan dated 05/09/17 and the June 2017 Resident Kardex revealed facility staff would check the resident every two (2) hours and as necessary for incontinence care and two (2) staff persons would provide incontinence care for the resident. Interview with CNA #1 on 07/05/17, at 1:05 PM, revealed she observed Resident #2 with feces on him/her and provided incontinence care for the resident while two (2) other CNAs were providing incontinence care for Resident #2's roommate on 06/14/17. CNA #1 stated she had been trained to follow the Kardex for each resident and was aware Resident #2 required two (2) staff persons for incontinence care. However, CNA #1 stated she had been a CNA for twenty (20) years and felt like she could do it by herself. Interview with CNA #2 on 07/06/17, at 3:45 PM, revealed she had also been trained to follow the Kardex when providing resident care. CNA #2 stated the CNAs were responsible to check the Kardex at the beginning of each shift for any changes in resident care needs. CNA #2 further stated she was providing care for Resident #2's roommate when CNA #1 provided incontinence care for Resident #2 on 06/14/17 without assistance. Interview with LPN #1 on 07/05/17, at 3:55 PM, revealed the CNAs always read the Kardex for each resident at the beginning of each shift. LPN #1 stated she monitored the CNAs during rounds every shift to ensure the Kardex/care plan was being followed for each resident and would provide assistance if another nurse aide was not available.

Based on observation, interview, and review of the facility's resident rights it was determined the facility failed to ensure the right to privacy was accommodated during the resident group meeting held on 10/12/16 for eight residents, three (3) sampled and five (5) unsampled (Resident #3, Resident #10, Resident #19, Resident B, Resident C, Resident D, Resident E, and Resident F). Observations during the group meeting with the facility resident council revealed the meeting was being televised throughout the facility in the resident rooms. The findings include: Review of the facility's Resident Bill of Rights, not dated, revealed all residents at the facility would have the right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside of the facility. Further review revealed all residents would have the right to personal privacy which included visits and meetings of resident groups. Observation on 10/12/16 at 11:30 AM, while the surveyor was interviewing Resident #14 in his/her room, revealed the group meeting with the resident council was being broadcast in Resident #14's room and throughout the facility. Interview with Resident B and Resident F on 10/13/16 at 12:37 PM, revealed they were not aware the facility had streamed the group meeting on the televisions in the residents' rooms. Resident B and Resident F stated they felt like the facility should not have done that. Resident B stated, I didn't say anything I would take back, but it could make some of the nurses or other staff mad at us. Interview with the Activities Director on 10/13/16 at 12:42 PM, revealed the facility had the video camera set up to allow a live feed of the church service which had taken place just before the group meeting with the resident council. The Activities Director stated normally the preacher would have turned the video camera off; however, the preacher did not come today. The Activities Director stated, It would have ultimately been my responsibility to turn off the video camera, but I just forgot. Interview with the Director of Nursing (DON) on 10/13/16 at 5:52 PM, revealed she was not aware the video camera had been left on. The DON stated she would have expected for the Activities Director to have followed up to ensure the video camera had been turned off to allow for privacy for the residents.

Based on interview, record review, fall investigation review, and a review of policies and procedures, it was determined the facility failed to ensure services were provided to one of twenty-five sampled residents in accordance with the resident's plan of care (Resident #10). The facility failed to ensure that a care plan intervention for two staff persons to assist Resident #10 with transfers and toileting had been implemented in accordance with the resident's written plan of care. Resident #10 sustained a fall on 02/14/11, when one State Registered Nursing Assistant (SRNA) attempted to transfer the resident from a wheelchair to a standing position. The resident sustained [REDACTED]. The findings include: A review of the Fall Investigation for Resident #10 revealed on 02/14/11, State Registered Nurse Aide (SRNA) #5 assisted Resident #10 in his/her wheelchair to the sink, assisted the resident to stand without waiting for assistance from another staff person as indicated on the Resident's Kardex, and allowed the resident to hold onto the sink with both hands. The Fall Investigation further revealed the wheelchair was positioned directly behind the resident and the wheels on the wheelchair were locked in place. Based on the report, the SRNA attempted to change the resident's incontinence brief, from a standing position, and had reached to obtain and open a trash bag. When Resident #10 leaned to the right, the SRNA was unable to catch the resident, and the resident subsequently fell and struck his/her head on the bed. The Fall Investigation further revealed SRNA #5 stated she had known the resident required two persons for transfer and for toileting. A review of the facility's policy titled, "Resident Status Kardex," (no date) revealed it was the responsibility of the nurse to complete and update the Resident Status Kardex. The policy further revealed it was the responsibility of the SRNA to review the Kardex to ensure appropriate care was delivered to the resident, or if the SRNA had questions that pertained to the delivery of care of the resident. In addition, the policy revealed the Resident Status Kardex reflected the current needs of the resident. A review of the medical record for Resident #10 revealed the resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of the Fall Risk Assessment completed on 02/08/11, revealed the facility had assessed Resident #10 as a high risk for falls, with a score of 20. According to the assessment, a total score of greater than 10 indicated the resident was at a high risk for falls. A review of a Quarterly Minimum Data Set ((MDS) dated [DATE], revealed the facility assessed Resident #10 to require the assistance of two persons for transfers and toileting. Resident #10 was also assessed as incontinent of both bladder and bowel. In addition, based on documentation, the facility assessed Resident #10's cognition to be severely impaired. A review of the resident's care plan, dated 05/26/10 through 03/03/11, revealed Resident #10 had been assessed to have potential for injury. The care plan revealed Resident #10 had risk factors for injury that included an unsteady gait, a history of falls, and decreased mobility. A review of interventions related to the resident's risk for injury included two staff persons to transfer the resident to a wheelchair. In addition, a care plan dated 05/26/10 through 03/03/11, revealed Resident #1 also had been assessed to have a [DIAGNOSES REDACTED]. Interventions related to the care plan revealed two staff persons were to transfer the resident to a wheelchair, and two to three staff persons were to assist the resident with ambulation. A review of the Kardex in use by the SRNAs on 02/14/11, for Resident #10 revealed the resident required the assistance of two persons for toileting and transfers. The Kardex further revealed Resident #10 had been assessed as a high fall risk. A review of the nurse's notes for Resident #10 dated 02/14/11, at 1:45 PM, revealed the nurse had been called to the resident's room by SRNA #5. The nurse's notes revealed Resident #10 had fallen, was lying on the floor, and was observed to have a laceration to the right side of his/her hand. Continued review of the nurse's notes revealed the resident complained of right hip pain. The resident's physician was notified of the fall, and orders were received to transfer the resident to an acute care facility. The resident was diagnosed with [REDACTED]. An interview conducted on 06/30/11, at 9:00 AM, with SRNA #5 revealed the Kardex contained information that pertained to the level of care. The SRNA stated Resident #10 required the assistance of two persons for transfers and toileting. The SRNA stated the facility had adequate staff to provide care required by the residents, but she thought she could change the resident's incontinence brief by herself. The SRNA further stated, "I could have gotten another SRNA to assist with the transfer, but I don't have a reason why I did it by myself." An interview conducted with RN #5 on 06/30/11, at 9:30 AM, revealed she was responsible for the care for Resident #10 on 02/14/11. The RN stated SRNAs were expected to review the Kardex daily to ensure residents received care as assessed in the care plan. The RN also stated she made rounds every two hours to ensure the SRNAs provided care as planned in a written care plan for each resident. RN #5 further stated that on 02/14/11, the SRNA told her that she had attempted to transfer Resident #10 by herself and the resident had fallen. RN #5 informed the Clinical Coordinator of the resident's fall and that the SRNA had transferred the resident without assistance as required by the plan of care. An interview conducted with the Clinical Coordinator (CC) of the Whispering Pines Unit of the facility on 6/30/11, at 10:15 AM, revealed SRNAs were required to review the Kardex at the beginning of their shift to ensure they were aware of and provided care as planned for the residents. The CC further stated nurses were expected to make rounds every two hours to ensure care was provided as planned for residents. The CC also stated she made rounds on a daily basis to ensure care was provided. The CC stated SRNA #5 should not have attempted to transfer without assistance or change the resident's incontinence brief without assistance. Interviews conducted with SRNAs #6 and #7 on 6/30/11, at 1:35 PM and 1:40 PM, revealed information related to the resident's care was contained in the Kardex. The SRNAs also stated they were required to check the Kardex at the beginning of their shift. The SRNAs further stated the facility had provided in-services related to the use of the Kardex. SRNAs #6 and #7 confirmed Resident #10 required the assistance of two staff persons for toileting and for transfers. An interview with the Director of Nursing (DON) on 6/30/11, at 2:30 PM, revealed SRNAs were required to review the Kardex at the beginning of their shift to obtain information related to each resident's care needs. In addition, according to the DON, nurses were required to give SRNAs a verbal report related to each resident's plan of care, and to make rounds every two hours to ensure the appropriate level of care was being provided to the residents. The DON further revealed the CCs made rounds on a daily basis. The DON stated SRNA #5 should have waited for assistance to help with the provision of Resident #10's planned care needs. The DON provided documentation of an in-service provided by the facility on Kardexes held on 12/22/10. Based on documentation, SRNA #5 attended the in-service on 12/22/10.

Based on interview and a review of records, the facility's fall investigation, hospital records, and policies, it was determined the facility failed to ensure one of twenty-five sampled residents (Resident #10) received adequate supervision and assistance to prevent accidents. Resident #10 was assessed to be at a high risk for falls, and required two staff persons for safe transfers and toileting. The facility failed to ensure transfers were performed safely to prevent accidents/injuries to Resident #10. On 02/14/11, one staff person attempted to transfer Resident #10 in order to change the resident's incontinence brief. During the transfer, Resident #10 sustained a fall which resulted in a laceration to the forehead and a nondisplaced fracture of the right hip. The findings include: The Fall Investigation for Resident #1 revealed on 02/14/11, State Registered Nurse Aide (SRNA) #5 assisted Resident #10 to the sink in a wheelchair. SRNA #5 assisted Resident #10 to stand without waiting for assistance for assistance from another staff person, while the resident held onto the sink with both hands. The SRNA attempted to change the resident's incontinence brief while the resident was in a standing position. Based on the report, when the SRNA reached to obtain and open a trash bag, Resident #10 leaned to the right, the SRNA was unable to catch the resident, and the resident fell and struck his/her head on the bed. The Fall Investigation revealed SRNA #5 was aware the resident required two persons for transfer and for toileting. A review of the facility's Falls Prevention Program policy (no date) revealed staff was required to assess all residents for fall risk upon admission and with any change in condition, utilizing the Fall Risk Assessment Form. According to the policy, the resident's Kardex would be "flagged" to signify the resident was at high risk for falls. A review of the medical record for Resident #10 revealed the resident's [DIAGNOSES REDACTED]. The Fall Risk Assessment completed on 02/08/11, revealed the facility assessed Resident #10 as a high risk for falls, with a score of 20 which indicated the resident was at a high risk for falls. Based on the Quarterly Minimum Data Set ((MDS) dated [DATE], the facility assessed Resident #10 to require the assistance of two persons for transfers/toileting and was assessed to be incontinent of both bladder and bowel. In addition, based on documentation, the facility assessed Resident #10's cognition to be severely impaired. A review of Resident #10's care plan, dated 05/26/10 through 03/03/11, revealed facility staff had identified "problem" areas related to the resident's care that included the resident's [DIAGNOSES REDACTED]. The care plan revealed resident #10 had risk factors for injury that included an unsteady gait, a history of falls, and decreased mobility. A review of interventions listed on the care plan revealed two staff persons were to assist the resident when the resident was transferred to a wheelchair and two to three staff persons were to assist the resident with ambulation. The Kardex for Resident #10 utilized by staff on 02/14/11, revealed the resident had been assessed to require the assistance of two persons for toileting/transfers and had been "flagged" to indicate the resident was a high risk for falls. A review of the nurse's notes for Resident #10 dated 02/14/11, at 1:45 PM, revealed the nurse was called to the room by State Registered Nursing Assistant (SRNA) #5. According to the nurse's notes Resident #10 had fallen and was lying on the floor with a laceration observed on the right side of the resident's head. Resident #10 was also complaining of right hip pain. The physician was notified and orders were received for Resident #10 to be transported to an acute care facility. A review of the emergency room record for Resident #10 dated 2/14/11, revealed the resident had a one-half inch laceration to the right forehead and a right hip fracture. The resident required hospitalized from [DATE] until 02/17/11, for these injuries. The Discharge Summary from the acute care facility dated 02/17/11, revealed Resident #10 had sustained a right intertrochanteric (hip) nondisplaced fracture, and was assessed by the orthopedic surgeon who requested only symptomatic treatment be provided for the resident's hip fracture. According to the discharge summary the resident was to be discharged back to the nursing facility with Physical Therapy and Occupational Therapy provided. An interview conducted on 06/30/11, at 9:00 AM, with SRNA #5 revealed the Kardex contained information regarding the type of care that each resident had been assessed to require. The SRNA acknowledged Resident #10 required the assistance of two persons for transfers and toileting. The SRNA stated the facility had adequate staff to provide care required by the residents, but she thought she could change the resident's incontinence brief by herself. An interview conducted with RN #5 on 06/30/11, at 9:30 AM, revealed the RN was responsible for the care of Resident #10 on 02/14/11. According to the RN, the SRNAs were responsible to review the Kardex at the beginning of every shift to ensure residents received care as required on the plan of care. The RN reported making rounds at least every two hours to ensure the SRNAs provided care as planned for each resident. RN #5 stated the SRNA informed the RN on 02/14/11, that the SRNA had had attempted to transfer Resident #10 without the assistance of additional staff and the resident had fallen. The RN informed the Clinical Coordinator of the incident. An interview with the Clinical Coordinator (CC) on 6/30/11, at 10:15 AM, revealed the SRNAs were required to review the Kardex at the beginning of every shift to ensure they were aware of and provided care as planned for the residents. According to the CC, nurses were required to make rounds at least every two hours, and the CC was responsible to make rounds on a daily basis to ensure care was provided as required by the plan of care. The CC stated the SRNA should have obtained assistance from another staff person prior to transferring Resident #10. Interviews conducted with SRNAs #6 and #7 on 06/30/11, at 1:35 PM and 1:40 PM, revealed SRNAs were required to review the Kardex at the beginning of every shift. The SRNAs stated the facility provided in-services related to the use of the Kardex and that Resident #10 required the assistance of two staff persons for toileting and for transfers. The Director of Nursing (DON) stated in interview on 06/30/11, at 2:30 PM, the SRNAs were required to review the Kardex at the beginning of every shift to obtain information related to each resident's care needs and to check for any changes that had been added. According to the DON, nurses were required to give the SRNAs a verbal report related to each resident's plan of care every shift and to make rounds at least every two hours to ensure the appropriate level of care was provided to the residents. The DON stated SRNA #5 should have waited for assistance to help with the provision of Resident #10's planned care needs.