Every finding on record at Hartland Park Health & Rehabilitation

Based on observation, interview, review of a manufacturer's recommendations, and review of the facility's documents, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety, which had the potential to affect all 138 current residents.1. Observations of the kitchen on 06/29/2026 and 06/30/2026 revealed poor lighting throughout the kitchen production area and grease on the floor near the door of the dry storage room. Further, review of the facility's documents revealed issues with cleanliness in the kitchen from 04/29/2026 to 06/08/2026.2. Observation of two of three nourishment rooms on 06/30/2026 revealed the Combs Unit nourishment refrigerator contained a Med-Plus supplement, which was opened but not dated. Also, the [NAME] Unit nourishment refrigerator contained a Med-Plus supplement, which was opened and dated 05/12/2026.The findings include:The State Survey Agency (SSA) Surveyor requested from the Dietary Director, on 07/02/2026 at 4:00 PM, a policy addressing the labeling and dating of food products related to the nourishment refrigerators. The Dietary Director stated she had to request the policy, but the facility did not provide the policy as of exit on 07/02/2026 at 7:30 PM.Review of the facility's documents Daily/Weekly/Cleaning Schedule, dated 05/31/2026 to 06/06/2026, 06/07/2026 to 06/13/2026, 06/21/2026 to 06/27/2026, and 06/28/2026 to 07/04/2026, revealed beverage carts were not documented as being cleaned.Review of the Pest Control Customer Service Report, dated 04/29/2026, revealed the finding of the kitchen with debris, and the action needed was to clear the debris and sanitize the kitchen.Review of the Pest Control Customer Service Report, dated 05/07/2026, revealed the finding of the kitchen with grease build up by and under the dish area, and the action needed was to clean the area.Review of the Pest Control Customer Service Report, dated 05/18/2026, revealed the finding of the kitchen areas need to be addressed, and the action needed was to address the sanitation issue. Review of the Pest Control Customer Service Report, dated 06/08/2026, revealed the finding of the action needed was for the kitchen to be cleaned again under the dishwasher, under the cook steam line, and under the carts.Review of the manufacturer's recommendations for storage of Med-Plus supplement, revealed they included after opening, consume the product within four days if properly refrigerated. 1. a. Observation during the initial kitchen tour on 06/29/2026 at 1:42 PM revealed poor lightening in the production area of the kitchen and grease on the floor near the dry storage, beside the ingredient bin.b. Observation of the supper tray line in the kitchen on 06/29/2026 at 5:15 PM revealed poor lightning in the production area and grease remained on the floor.c. Observation of the kitchen on 06/30/2026 at 8:52 AM revealed the kitchen lighting was still low, and grease remained on the floor near the dry storage.d. Observation of the kitchen on 06/30/2026 at 3:21 PM revealed the lighting was still low, and grease was still on the floor near the dry storage. Continued observation revealed three of five beverage carts, by the tray line, with full clear beverage pitchers placed onto a wet puddled surface.2. a. Observation on 06/30/2026 at 3:35 PM of the nourishment refrigerator on the Combs Unit revealed a Med-Plus supplement opened and undated.b. Observation on 06/30/2026 at 3:58 PM of the [NAME] Unit nourishment refrigerator revealed a Med-Plus supplement opened, one-half full, and dated 05/12/2026.During an interview with the Dietary Director on 06/30/2026 at 3:21 PM, she stated the light needed a new ballast and maintenance needed to replace it.During an interview with the Maintenance Director on 07/01/2026 at 8:05 AM, he stated the Dietary Director just texted him about a light being out. He stated the kitchen needed to be brighter for safety and to clean the kitchen.During an additional interview with the Dietary Director on 07/02/2026 at 4:00 PM, she stated she could not do anything about the lighting in the kitchen. She stated the area near the dry storage was the water leaking from the freezer, and she mopped the area daily. Observation with the Dietary Director of the area of the water leak revealed it was behind the area identified with grease. She demonstrated the area she mopped for the water and the location of the water behind the dry storage door and the ingredient bin was not the same location as the grease in front of the ingredient bin and dry storage door. She stated the Dietitian took the medication administration supplements to the unit nourishment refrigerators. She stated the supplement had a label and date when stocked in the nourishment refrigerator. She stated she did not know the beverage carts were wet, and the beverage carts should be dry. She stated she knew the staff cleaned the kitchen even though it was not documented.During an interview with the Director of Nursing (DON) on 07/02/2026 at 6:05 PM, she stated Dietary provided the medication administration supplement with the date delivered to the unit nourishment refrigerators. She stated the supplement should be marked with the opened date and used within three days, and if any was remaining, it should be thrown away. She stated if any supplement was opened and undated it should be thrown away. She stated the utility carts needed a dry surface to prevent any potential concerns with the food being served. She stated the grease remaining on the kitchen floor was a hazard for the staff. During an interview with the Administrator on 07/02/2026 at 6:15 PM, she stated Dietary delivered the medication administration supplement to the unit nourishment refrigerators with a date, and it could only be used for three days after it was opened. She stated she expected the kitchen to be clean and well lit, and the utility carts should be dry to prevent gnats.

Based on observation, interview, record review, and review of the facility's policy, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent and control the development and transmission of communicable diseases. The facility failed to identify and correct problems related to infection prevention practices that had the potential to affect all residents in three of the three sampled shower rooms.Observations on 07/02/2026 of the [NAME], [NAME], and Combs Units Spa revealed the shower areas were used to store clean linens, which were uncovered, and shared resident use equipment. Also observed were dirty linens in the area and residents' personal items stored on the linen storage shelf.The findings include: Review of the facility's policy titled, Infection Control, reviewed 01/21/2026, revealed infection control policies and practices were intended to facilitate maintaining a safe, sanitary, and comfortable environment. According to the policy, the facility would establish and monitor environmental infection prevention and control practices in accordance with the Centers for Disease Control and Prevention (CDC) guidelines and state requirements. 1. Observation of the [NAME] Unit Spa on 07/02/2026 at 2:30 PM revealed the shower area was being used as storage for shared resident equipment, resident items, and linens. Two mechanical lifts, a powered wheelchair, a shower stretcher, a bedside chair, and other resident care equipment were stored in the shower area near the shower stalls. A powered wheelchair was positioned adjacent to an electrical outlet with the charging unit and power cord on the floor. The unit was plugged in. There was a hair dryer, plugged into an electrical outlet, resting on the powered wheelchair. On the floor, used tissues and a washcloth were observed near the wheelchair. Continued observation of the [NAME] Unit Spa on 07/02/2026 at 2:30 PM revealed clean towels, sheets, and other linens were stored on an open wire shelving unit without a protective cover. Linens were stacked above and around the resident care equipment and supplies. Additional resident care items, including basins, incontinence supplies, storage bins, and equipment accessories, were stored beneath the shelving on the floor. Residents' personal belongings, including clothing, shoes, and other items, were stored in a crate and a storage bin, hanging from wall hooks, and on the shower floor. A separate storage area contained numerous residents' personal belongings, including clothing, jackets, shoes, and other items, stored on open shelving, hanging from wall hooks, and in plastic crates. Clothing items were stored with several hanging and touching the floor.2. Observation of the [NAME] Unit Spa on 07/02/2026 at 2:45 PM revealed two mechanical lifts, a shower stretcher, multiple wheelchairs, a shower chair/commode, and a bedside chair were stored in the shower area. A black bag containing soiled towels was hanging from the shower stretcher. The equipment occupied a significant portion of the available space.Continued observation of the [NAME] Unit Spa on 07/02/2026 at 2:45 PM revealed clean towels, sheets, and other linens were stored uncovered on open wire shelving. Multiple lift slings hung from the shelving. A laundry basket containing linens, storage bins, basins, incontinence supplies, and other resident care supplies were stored on and beneath the shelving. A baby doll was observed on a lower shelf among the stored linens and supplies. A Wet Floor caution sign was stored behind a mechanical lift. The lift was obstructing access to the linen shelf. Residents' personal belongings, including clothing hanging on a towel bar, clothing on the floor, and personal belongings stored with resident equipment were in the shower area. A wheelchair had towels draped over the back and seat. Additional resident equipment and supplies were stored throughout the room, contributing to a congested environment.3. Observation of the Combs Unit Spa on 07/02/2026 at 3:20 PM revealed a shower chair, shower stretcher, mechanical lift, portable vital signs machine, and resident care supplies stored throughout the room. A mechanical lift was positioned in front of the shower stretcher, reducing the available space within the shower area. A linen storage rack contained clean towels, sheets, and other linens. The protective blue cover over the linen rack was open, leaving clean linens exposed. A bedside commode was used to store multiple transfer slings, with an inflatable shampoo basin placed on top of them. Multiple transfer slings were draped over a shower chair and touched the floor. Additional slings were hanging from a wall-mounted rack. Additionally, a multi-drawer plastic storage unit was used to store the resident's clothing. Various items, including supplies and slings, were stacked on top of the drawer unit, while additional items were hanging from the sides of the unit.During an interview with Certified Nursing Assistant (CNA) 10 on 07/02/2026 at 3:25 PM, she stated each staff member was responsible for cleaning the shower area after providing resident care. CNA10 stated clean towels should remain covered to prevent cross-contamination. She stated staff should place used towels, washcloths, and the resident's personal items in a bag after use and should not leave them on the shower room floor. CNA10 stated maintaining a clean environment was important to prevent the spread of germs. During an interview with Licensed Practical Nurse (LPN) 9 on 07/02/2026 at 3:15 PM, she stated housekeeping performed routine cleaning of the shower room. She stated nursing staff cleaned the shower after each resident's use and maintained the area throughout the day. LPN9 stated each shift ensured the shower was clean after the shift ended. When the State Survey Agency (SSA) Surveyor asked about the condition of the shower room, LPN9 stated she did not know why various items were stored in the same room where residents bathed. She stated storing linen uncovered in the bathroom created an unsanitary condition and posed a risk for cross-contamination. LPN9 stated staff should not store personal resident items and shared resident care equipment in the shower area because moisture and splashes from resident bathing could contaminate these items. She stated the presence of stored equipment and personal items in the shower created an unclean appearance for residents receiving showers and raised infection prevention and control concerns.During an interview with the Maintenance Director on 07/02/2026 at 2:30 PM, he stated nursing staff cleaned the shower room and reported maintenance concerns through the facility's work order system. The Maintenance Director stated leaving electrical items plugged in or storing electrical equipment with charging units in the shower area posed a safety concern. He stated electrical equipment should not be left plugged in or charging in the shower room due to the presence of water and moisture in the area. He stated it was important to maintain a safe environment.During an interview with the Infection Preventionist/Staff Development Coordinator (IP/SDC) on 07/02/2026 at 4:41 PM, she stated she had identified concerns with storing shared equipment, linens, and resident-use items in the shower areas during a walk-through. She stated the shower rooms were not an appropriate location for storing those items. Additionally, the IP/SDC stated uncovered linens, wet towels, wet washcloths, mechanical lift accessories, and other equipment stored in the shower areas created infection prevention concerns. The IP/SDC stated resident care items should not be stored in a manner that would contaminate them or create an unsanitary environment. The IP/SDC stated the shower rooms should not be used as storage areas. She stated maintaining a clean, sanitary, and safe environment was important for the safety and well-being of all residents and for preventing cross-contamination and the spread of disease. During an interview with the Director of Nursing (DON) on 07/02/2026 at 6:02 PM, she stated she was concerned regarding the cleanliness and the storage of shared equipment, uncovered linens, resident items, clothing, and other supplies in the facility's shower rooms. She stated linen should be covered, and equipment should not remain in the shower room during resident care. She stated the shower rooms were not intended for storage, although equipment could be moved temporarily to keep hallways clear. The DON stated a clean and sanitary environment promoted the health, safety, and well-being of residents. She stated keeping the room free of unnecessary items, clean, and linens covered was important to prevent the spread of infection.During an interview with the Administrator on 07/02/2026 at 6:32 PM, she stated she did not have an explanation for why equipment was being stored in the shower rooms. She stated it was important to have a clean, sanitary, and safe shower room for the safety and well-being of the residents and staff. The Administrator stated a clean environment prevented the spread of infections.

Based on observation, interview, and review of the facility's document and policy, the facility failed to ensure a safe, functional, sanitary, and comfortable environment for resident rooms and shower rooms. The facility failed to identify and correct problems related to the residents' environment that had the potential to affect all residents that used three of the three sampled shower rooms and all residents that resided on the [NAME] Unit Hallway 1 and Hallway 2.Observation on 07/02/2026 revealed there were two holes on the right side of the [NAME] 2 Hallway, directly above the baseboard. One hole was approximately four inches long, and the other was approximately one inch long. Additional observation on 07/02/2026 revealed there was a hole approximately four inches long on the left side, above the baseboard, in the [NAME] 1 Hallway, between rooms A1 and A3.Observations on 07/02/2026 of the [NAME], [NAME], and Combs Units Spa revealed the shower areas were also used to store shared resident use equipment and supplies. Also observed were dirty linens in the area; residents' personal items stored on the linen storage shelf; and chipped, peeling, and worn non-skid coating on the shower stall tile.The findings include: Review of the facility's policy titled, Resident Rights, revised 07/18/2025, revealed the resident had the right to voice grievances. Per the policy, the facility must make prompt efforts to resolve any grievances residents might have. Review of the facility's document Resident Council Minutes, dated 03/31/2026, revealed the Maintenance Director attended the meeting. According to the Resident Council meeting minutes, residents identified Multiple Residents Need Maintenance as an issue. The documented action taken stated, Work orders. 1. Observation on 07/02/2026 at 12:08 PM revealed there were two holes on the right side of the [NAME] 2 Hallway, directly above the baseboard. One hole was approximately four inches long, and the other was approximately one inch long. Additional observation on 07/02/2026 at 3:10 PM revealed in the [NAME] 1 Hallway between Rooms A1 and A3, there was a hole approximately four inches in length on the left side above the baseboard. 2. Observation of the [NAME] Unit Shower Room Spa on 07/02/2026 at 2:30 PM revealed staff used it as storage for shared resident equipment, resident belongings, and resident care supplies, as well as the residents' shower room. Two mechanical lifts, a powered wheelchair, a shower stretcher, a bedside chair, and other resident care equipment were stored near the shower stalls, reducing the available space within the shower room. A powered wheelchair was positioned adjacent to an electrical outlet with the charging unit and power cord on the floor. The wheelchair remained plugged in. A hair dryer rested on the powered wheelchair while plugged into a nearby electrical outlet. Tissues and a wet washcloth were thrown on the floor beside the wheelchair. The white tiled floor inside both shower stalls had multiple areas where the black non-skid coating was peeling, chipping, and worn, creating an inconsistent walking surface which could reduce slip resistance and pose a potential safety hazard for residents and staff. Shelving units contained resident supplies, storage bins, basins, incontinence supplies, and equipment accessories. The supplies and equipment appeared disorganized and were stored throughout the shower room. Residents' personal belongings, including clothing, shoes, and other items, were stored in crates and storage bins, on wall hooks, and on the shower room floor. 3. Observation of the [NAME] Unit Shower Room Spa on 07/02/2026 at 2:45 PM revealed staff stored two mechanical lifts, a shower stretcher, multiple wheelchairs, a shower chair/commode, and a bedside chair throughout the shower room. The stored equipment occupied a substantial portion of the available shower area. Shelving units contained resident supplies, storage bins, basins, incontinence supplies, equipment accessories, and other resident belongings. The supplies and equipment appeared disorganized throughout the room. A baby doll was placed on a lower shelf among the residents' belongings. A Wet Floor caution sign remained stored behind a mechanical lift, which obstructed access to the shelving. Residents' personal belongings, including clothing hanging from a towel bar, clothing on the floor, and personal belongings stored with resident equipment, remained throughout the shower room. The white-tiled floor in both shower stalls had multiple areas where the black non-skid coating was peeling, chipping, and worn, creating an inconsistent walking surface. 4. Observation of the Combs Unit Shower Room Spa on 07/02/2026 at 3:20 PM revealed the shower chair, the shower stretcher, a mechanical lift, a portable vital signs machine, and resident care supplies stored throughout the shower room. A mechanical lift was positioned directly in front of the shower stretcher, reducing the available space within the shower area. A bedside commode, wall-mounted rack, and a multi-drawer storage unit were used to store transfer slings, resident supplies, and residents' clothing. Supplies and equipment appeared disorganized and were stacked on, around, and hanging from the storage units throughout the shower room. The white-tiled floor in both shower stalls had multiple areas where the black non-skid coating was peeling, chipping, and worn. Additionally, mechanical lift pads were stored on the wall, on top of a storage container, and on a toilet chair, under an inflatable hair shampooing basin.During an interview with Family Member (F) 3 on 07/02/2026 at 2:45 PM, she stated she remained concerned about the overall cleanliness of the facility, the disrepair observed throughout the facility, and the condition of the shower area. F3 stated the shower room appeared dirty, and the floor appeared covered in mold. She stated portions of the floor were chipped and peeling. Additionally, F3 stated the shower rooms were overcrowded with resident supplies and equipment, making it difficult to provide resident showers and creating a safety concern during bathing. She stated the condition of the shower area did not appear clean or well maintained. She stated she was concerned for the safety of the residents and staff. During an interview with the Maintenance Director on 07/02/2026 at 2:30 PM, he stated leaving electrical items plugged in or storing electrical equipment with charging units in the shower area posed a safety concern. He stated electrical equipment should not be left plugged in or charging in the shower room due to the presence of water and moisture in the area. He stated it was important to maintain a safe environment. During an additional interview with the Maintenance Director on 07/02/2026 at 4:43 PM, he stated all maintenance concerns submitted through the facility's work order system generated service requests with an expected completion time of four to five days. He stated weekly reports generated each Monday identified outstanding work orders and flagged those exceeding 30 days. He stated the facility evaluated his performance based on the timely completion of work orders. He stated he had one maintenance assistant and had interviewed an additional applicant that day, intending to hire a second full-time maintenance assistant. During an interview with the Director of Nursing (DON) on 07/02/2026 at 4:51 PM, the DON stated she expected staff to repair holes in walls promptly. When the State Survey Agency (SSA) Surveyor asked whether 24 hours would be an appropriate timeframe, the DON stated, Yes. She stated she expected staff to repair holes in the walls within 24 hours. The DON stated she had not received any complaints from residents regarding the condition of the building. During an additional interview with the DON on 07/02/2026 at 6:02 PM, she stated staff submitted maintenance work orders when they identified environmental concerns or building damage. She stated maintaining the physical environment remained important because the facility served as the residents' home and should remain safe, clean, and as homelike as possible. The DON stated she remained concerned about the condition of the resident shower rooms, including their cleanliness and the storage of equipment within the rooms. She stated staff did not intend the shower rooms for storage, although they occasionally placed equipment there temporarily to keep hallways clear. Furthermore, the DON also stated she had concerns regarding the deteriorated non-skid floor surface in all shower rooms. She stated staff had recently discussed the issue because the deteriorated surface appeared discolored, and residents could mistake it for mold. She stated the facility should correct the condition of the shower room floors to provide a safe, clean, and comfortable environment for residents and staff. During an interview with the Administrator on 07/02/2026 at 6:32 PM, she stated her responsibilities included overseeing the facility's daily operations, ensuring regulatory compliance, monitoring staffing levels, and managing the facility's budget. She stated she had concerns regarding the shower rooms, and she could not explain why staff stored equipment in those areas. She stated storing equipment in the shower rooms reduced available space and detracted from the homelike environment. Additionally, the Administrator stated staff had previously discussed the deteriorated non-skid floor surface. She stated the facility had previously attempted to address the flooring; however, the remaining peeling surface prompted residents to mistake it for mold, and the facility should correct the condition.

Based on observation, interview, record review, review of the facility's job description, and review of the facility's policies, the facility failed to promote and maintain resident dignity for 2 of 52 sampled residents, Resident (R) 1 and R101. 1. During an interview with R101 on 06/29/2026, he stated staff did not respond in a timely manner to his call bell for toileting assistance, resulting in a fecal incontinent episode, which embarrassed and humiliated him. 2. During observations on the Combs Unit on 06/29/2026, 06/30/2026, and 07/01/2026, R1 had a suprapubic catheter connected to a urine-meter drainage bag. The urine collection bag hung on the right side of the bed and was not covered with a dignity bag cover, leaving it visible to others.The findings include: Review of the facility's undated policy titled, Dignity, revealed each resident would be cared for in a manner that promoted and enhanced the resident's well-being, satisfaction with life, self-worth, and self-esteem. The policy further stated staff was expected to promote and maintain each resident's dignity and assist residents by promptly responding to a resident's request for toileting assistance and by ensuring urinary catheter bags remained covered. Review of the facility's policy titled, Activities of Daily Living (ADLs), reviewed 07/18/2025, stated, Residents will be provided with care, treatment, and services appropriate to maintain or improve their ability to carry out activities of daily living (ADLs). Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming, and personal and oral hygiene. The policy further stated appropriate care and services would be provided for residents who were unable to carry out ADLs independently, with the consent of the resident in accordance with the plan of care, including hygiene support and assistance with elimination (toileting). Per the policy, residents shall be assisted with toileting as needed, and residents who were incontinent of bladder or bowel would be provided care in a timely manner. Review of the facility's job description Certified Nursing Assistant, reviewed 01/2026, revealed the Personal Nursing Care Responsibilities included assisting residents with bathing, grooming, hygiene, placement of adaptive equipment, keeping residents dry, and assisting residents with bowel and bladder functions. 1. a. Review of R101's admission Record, found in the resident's electronic medical record (EMR) under the Profile tab, revealed the facility admitted the resident on 05/19/2026 with diagnoses to include ankylosing spondylitis of multiple sites in spine, chronic inflammatory demyelinating polyneuritis, and bilateral primary osteoarthritis of knee. Review of R101's admission Minimum Data Set [MDS], with an Assessment Reference Date (ARD) of 05/29/2026, found in the resident's EMR under the MDS tab, revealed the facility assessed the resident to have a Brief Interview for Mental Status [BIMS] score of 15 out of 15, indicating the resident was cognitively intact. Continued review of the MDS revealed R101 was always incontinent [no episodes of continent bowel movements]. Review of R101's Care Plan Report, dated 05/19/2026, found in the resident's EMR under the Care Plan tab, revealed a focus for requiring toileting assistance, initiated on 05/19/2026, for staff to support R101 in remaining as clean and dry as possible.During an interview with R101 on 06/29/2026 at 1:47 PM, he stated the Certified Nursing Assistants (CNA) responded to his call light in about 30 minutes to an hour last night, and he felt humiliated and embarrassed being dirty and not able to do anything about it. He stated he thought he got pretty good care, but the staff got busy and sometimes did not respond as quickly as he would prefer. He stated having a roommate to know he was waiting and dirty made it worse on him. b. Review of R33's admission Record, found in the resident's EMR under the Profile tab, revealed the facility admitted the resident on 05/21/2026 with diagnoses to include myasthenia gravis with (acute) exacerbation, traumatic subdural hemorrhage, and acute bronchitis. Review of R33's admission MDS, with an ARD of 05/25/2026, found in the resident's EMR under the MDS tab, revealed the facility assessed the resident to have a BIMS score of 15 out of 15, indicating the resident was cognitively intact. During an interview with R33, R101's roommate on 06/29/2026 at 1:53 PM, he stated he could confirm the time frame that R101 waited for assistance with toileting during the night shift on 06/28/2026. R33 stated R101 waited forever and I felt sorry for him. I was right here next to him while he waited. During an interview with CNA6 on 06/29/2026 at 2:30 PM, he stated staff was to answer the call lights as soon as possible. During an interview with Unit Manager (UM) 1 on 07/02/2026 at 11:55 AM, she stated she expected all staff to answer call lights. She stated she kept her office door open so she could see the staff respond to call lights. She stated responding timely to call lights was important to make certain the resident was okay and to help with whatever they needed. She stated delayed care could result in harm to the resident. During an interview with the Infection Preventionist/Staff Development Coordinator (IP/SDC) on 07/02/2026 at 4:25 PM, she stated staff was trained on dignity and activities of daily living (ADLs) upon hire, in the moment, and at least annually. During an interview with the Director of Nursing (DON) on 07/02/2026 at 5:55 PM, she stated she expected all staff to answer call lights and to support the CNAs. She stated responding to call lights timely was important to maintain the residents' dignity. She stated skin issues could develop from delaying toileting care. She stated staff was trained to answer the call lights timely. During an interview with the Administrator on 07/02/2026 at 3:22 PM, she stated she expected staff to respond within five minutes to call lights or as soon as possible. She stated anyone could answer a call light, but the light should not be turned off without getting the resident's needs met. The Administrator stated the facility expected staff to provide care to preserve dignity and promote respect. She stated staff received consistent training through the SNF Clinic platform, and they had an annual Skills Fair where return demonstrations were required for all the tasks. 2. Review of R1's admission Record, found in the resident's EMR under the Profile tab, revealed the facility admitted the resident on 01/02/2025 with diagnoses to include neuromuscular dysfunction of the bladder, hydronephrosis, and pseudarthrosis after fusion.Review of R1's admission MDS, with an ARD of 06/15/2026, found in the resident's EMR under the MDS tab, revealed the facility assessed the resident to have a BIMS score of 15 out of 15, indicating the resident was cognitively intact. Continued review of the MDS revealed R1 had an indwelling suprapubic catheter.Review of R1's Care Plan Report, dated 04/25/2026, found in the resident's EMR under the Care Plan tab, revealed a focus for a urinary catheter, initiated on 06/11/2025, that directed staff to maintain the catheter by using a dignity cover.a. Observation of R1 on 06/29/2026 at 1:30 PM revealed the resident's urinary drainage bag was attached to the bed frame while the dignity cover hung beside the bag. However, staff did not place the urinary drainage bag inside the dignity cover. The drainage bag remained visible from the hallway.During an interview with R1 on 06/29/2026 at 1:30 PM, she stated the CNAs emptied the urinary catheter drainage bag throughout the day. When asked by the State Survey Agency (SSA) Surveyor about the use of a dignity cover, she stated she was not aware whether one was in place. However, the resident stated if a dignity bag cover were available, she would prefer to have one to provide privacy.b. Observation of R1 on 06/30/2026 at 9:39 AM revealed staff secured the resident's urinary drainage bag to the bed without a dignity cover in place. Continued observation outside of R1's room revealed the staff had left the urinary catheter drainage bag visible to individuals passing by the room. c. Observation outside R1's room on 07/01/2026 at 8:30 AM revealed the resident's urinary catheter drainage bag was visible to individuals outside the resident's room. The catheter drainage bag was not in the dignity bag cover.During an interview with CNA2 on 07/01/2026 at 8:30 AM, she stated staff placed dignity covers over urinary catheter drainage bags to maintain resident privacy and dignity unless the resident or family requested not to use a cover. CNA2 further stated staff monitored residents with catheters during care and rounds to ensure the dignity covers remained in place. She stated she was unsure why R1 did not have a dignity bag cover. CNA2 stated it was important to replace the cover after providing catheter care to protect R1's dignity and privacy. During an interview with Licensed Practical Nurse (LPN) 4 on 07/01/2026 at 3:00 PM, she stated CNAs kept urinary catheter drainage bags covered with dignity covers to protect the resident's privacy. LPN4 further stated she checked to ensure drainage bags remained covered during nursing rounds. She stated she was not sure why R1's catheter bag was not covered. LPN4 stated urinary bag covers were important to maintain privacy and resident dignity. During an interview with the Director of Nursing (DON) on 07/02/2026 at 6:02 PM, she stated she expected to keep urinary catheter drainage bags covered with a dignity cover to maintain resident dignity and privacy. The DON stated the facility attempted to keep dignity covers in stock and replace them as soon as possible when residents returned from the hospital or were admitted without one. She stated nursing leadership rounded daily and should have noticed R1's urinary drainage bag was not covered. She stated providing a cover for the urinary drainage bag was important to maintain the resident's dignity.During an interview with the Administrator on 07/02/2026 at 6:32 PM, she stated she was concerned that uncovered catheter bags had been observed on multiple occasions. She stated that it should have been identified during nursing rounds. The Administrator stated the facility expected staff to ensure urinary catheter drainage bags remained covered to preserve dignity and protect the resident's privacy.

Based on observation, interview, record review, and review of the facility's document and policy, the facility failed to have a process to prevent expired medications from being available for resident use and failed to provide pharmaceutical services to meet the needs of each resident for 1 of 52 sampled residents, Resident (R) 78. Observation of the medication refrigerator on the [NAME] Unit on 07/02/2026 at 10:06 AM revealed R78 had one unopened vial of lorazepam 20 milligrams per 10 milliliters with an expiration date of 06/2026. Review of the pharmacy shipping manifest revealed a delivery date of 07/01/2026.The findings include:Review of the facility's policy titled, Medication Storage, revision date 07/18/2025, revealed the facility shall store drugs in a safe, secure, and orderly manner to include not using drugs that were outdated. Observation of the medication refrigerator on the [NAME] Unit on 07/02/2026 at 10:06 AM revealed R78 had one unopened vial of lorazepam 20 milligrams per 10 milliliters (used to treat active seizures) with an expiration date of 06/2026. Review of R78's admission Record, found in the resident's electronic medical record (EMR), revealed the facility admitted the resident on 01/03/2022 with diagnoses to include cerebral palsy, epilepsy, and Down syndrome.Review of R78's Comprehensive Care Plan [CCP], initiated on 01/03/2022, revealed the resident was identified for risk of adverse reactions related to requiring anticonvulsants for treatment related to epilepsy with interventions to receive medications as ordered. Further review revealed the CCP identified R78 as at risk for neurological complications to include seizures with an intervention to administer medication as ordered.Review of R78's Orders revealed an order placed on 04/14/2026 for Ativan (lorazepam) Injection Solution 2 milligrams (mg) per milliliter (ml), inject 2 mg intramuscularly (IM) every 24 hours as needed for seizure and could repeat in 2 hours if not effective.Review of R78's June and July 2026 Medication Administration Record (MAR) revealed no doses of Ativan had been administered during the month of June 2026 or the month of July 2026, through 07/02/2026.Review of the pharmacy's Shipping Manifest, dated 07/01/2026 at 11:16 PM, revealed two medications were listed with one being lorazepam 20 mg per 10 ml vial with quantity of 10 ml for R78. Licensed Practical Nurse (LPN) 8 signed the manifest for 07/01, with no year or time given.Review of the Controlled Drug Record for the expired vial of lorazepam revealed R78 had not received any doses from the vial. The State Survey Agency (SSA) Surveyor attempted to reach LPN8 by telephone on 07/02/2026 at 3:59 PM but was unsuccessful. During an interview with the Pharmacist from the providing pharmacy on 07/01/2026 at 11:20 AM, he stated he was a licensed pharmacist and the Director of the pharmacy services that provided pharmaceutical services to the facility. When asked if he was aware of R78's lorazepam being expired, he stated he was made aware by the facility earlier. When asked how that happened, he stated the pharmacy had not pulled the expired medications from the refrigerator, and they were still stored in the refrigerator at the pharmacy prior to the delivery. He stated the pharmacy's staff should have removed the expired medications to ensure no expired medications were taken to the facility. He stated all medications delivered to the facility were sealed in a plastic vinyl bag, and the accepting staff checked the manifest of medications delivered. When asked if they checked the medications for the expiration dates, he stated only the manifest was presented to them at the time of the delivery, and staff was never asked to check expiration dates since there were so many medications. He stated it was a pharmacy error.During an interview with the Director of Nursing (DON) on 07/02/2026 at 1:36 PM, she stated an administered expired medication could cause harm to the resident. She stated when medications were delivered from the pharmacy, staff checking in the medications did not typically check all the medications for the expiration dates since there was such a large bulk of medications. The DON stated pharmacy had just delivered the medications around midnight on 07/01/2026. She stated night shift checked all the medications each night on all the carts for expiration dates.During an interview with the Administrator on 07/02/2026 at 3:35 PM, she stated her tasks included making sure the facility followed all regulations, and she depended on the DON for the clinical side of things. When asked about the expired lorazepam for R78, she stated the new vial had just literally been delivered early that morning, and no medication had been given from the vial. She stated her expectation was for each staff member giving medications to check the expiration date prior to administering. She stated night shift performed audits on all the medications in all the carts for expiration dates and would remove them if they were expired.

Based on observation, interview, record review, and review of the facility's policy, the facility failed to ensure drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles for 2 of 52 sampled residents, Resident (R) 98 and R130. 1. Observation of the [NAME] Hall Insulin Cart on 07/02/2026 at 10:00 AM revealed R98's insulin lispro KwikPen and Lantus 100 units/milliliter insulin pen did not have the original pharmacy label. 2. Observation of the [NAME] Hall Insulin Cart on 07/02/2026 at 10:00 AM revealed R130's insulin degludec U-100 pen and insulin lispro KwikPen did not have the original pharmacy label.The findings include:Review of the facility's policy titled Medication Storage, revised 07/18/2025, revealed medications were stored in their original pharmacy issue packaging and containers. According to the policy, medications with missing, incomplete, improper, or incorrect pharmacy labels must be returned to the pharmacy for proper labeling before being stored or used.1. During an observation on 07/02/2026 at 10:00 AM of the [NAME] Hall Insulin Cart revealed R98's insulin lispro KwikPen and Lantus 100 units/milliliter insulin pen were without the original pharmacy label. Both pens had a handwritten pink label with designated spaces for the resident's name and the date the pen was opened. Further observation revealed staff had handwritten R98's name on the label with a marker; however, the resident's name was not easily legible due to the limited space provided on the label. No other resident-specific identifying information from the original pharmacy label was present on the handwritten label.2. During an observation on 07/02/2026 at 10:00 AM of the [NAME] Hall Insulin Cart revealed R130's insulin degludec U-100 pen and insulin lispro KwikPen were missing the original pharmacy label. Both pens had a handwritten pink label with designated spaces for the resident's name and the date the pen was opened. Further observation revealed staff had handwritten R130's name on the label with a marker; however, the resident's name was not easily legible due to the limited space provided on the label. No other resident-specific identifying information from the original pharmacy label was present on the handwritten label.During an interview with Licensed Practical Nurse (LPN) 3 on 07/02/2026 at 10:00 AM, she stated the pharmacy dispensed medication pens with the original pharmacy label attached to each pen. She stated the label included the resident's name. LPN3 further stated if the original pharmacy label fell off, clinical staff replaced it with a handwritten label containing designated spaces for the resident's name and the date the pen was opened. She stated maintaining the original pharmacy label ensured staff could accurately identify the medication for safe administration.During an interview with the Pharmacy Director on 07/02/2026 at 11:20 AM, he stated the pharmacy dispensed insulin pens in a labeled plastic bag. He stated when an order included three insulin pens, the pharmacy placed all three pens in the bag with a large pharmacy label on the outside. He further stated the pharmacy also affixed a smaller label containing the resident's identifying information to each insulin pen. The Pharmacy Director stated if an individual's insulin pen's original pharmacy label was missing, staff should return the medication to the issuing pharmacy for proper labeling and storage before use. According to the Pharmacy Director, each individual's insulin pen label might include the resident's name, other resident-specific identifying information, the medication name, the medication dosage and strength, and the medication expiration date. When the State Survey Agency (SSA) Surveyor asked whether an individual insulin pen would ever lack a resident-specific label, the Pharmacy Director stated that it should not occur, except in the limited circumstance in which staff removed a pen from an emergency kit for single-dose use. He stated staff should not return an emergency kit pen to stock and should discard it after use. He further stated individual labeling enabled staff to identify the resident to whom the insulin pen belonged during storage and use and helped to prevent medication errors. During an interview with the Director of Nursing (DON) on 07/02/2026 at 6:02 PM, she stated insulin pens should have pharmacy labels identifying the correct resident, medication, and dose. She stated if a label was missing, staff should address it and ensure the pen was properly labeled or returned, as appropriate. She further stated individual labeling of medications helped to prevent medication errors. During an interview with the Administrator on 07/02/2026 at 6:32 PM, she stated original pharmacy labels ensured clinical staff identified the correct resident and medication and followed medication administration rights. She stated if a pharmacy label came off an insulin pen, staff should return the pen or otherwise address it in accordance with facility policy.

Based on observation, interview, record review, and review of the facility's documents and policy, the facility failed to maintain an effective pest control program so that it remained free of pests. This deficient practice had the potential to affect all of the facility's 133 current residents.Observations on 04/22/2026 and 04/23/2026 revealed a widespread gnat infestation in the common areas, conference room, hallways, laundry room, medication cart trash can, and dirty utility room. Gnats were observed emerging from drains in the laundry room and kitchen. Further observations in the kitchen revealed debris and organic buildup in drains, cracks in flooring holding debris, inadequate cleaning of hard-to-reach areas, standing water, and excessive moisture as primary breeding sources. Additionally, the facility failed to follow through with recommended cleaning and pest control treatments. The findings include:Review of the facility's policy titled, Pest Control, undated, revealed the facility maintained a pest control program intended to keep the building free of insects and rodents, which included the use of contracted pest control services, documentation of inspections and treatments, prohibition of accumulated garbage, encouragement to report pest sightings, and staff responsibility for proper storage of items to discourage pests.Review of the facility's documents Work Orders, dated 03/01/2026 through 03/31/2026 and had been closed, revealed one report of gnats found in common areas and on all nursing units.Review of the facility's documents Work Orders, dated 04/01/2026 through 04/22/2026 and had been closed, revealed one report of bugs facility wide.Review of the Service Reports, dated 01/14/2026 through 04/17/2026 and from the pest control company, revealed open actions from previous services remained ongoing with unresolved environmental concerns in the kitchen and adjacent areas. Findings included repeated documentation of drain debris, standing water in the kitchen and dishwashing areas, debris accumulation in the kitchen areas, and moisture related issues. Further review revealed these conditions were consistently identified across multiple service reports and remained pending for correction by the facility.Review of R17's admission Record revealed the facility admitted the resident on 10/06/2021, with diagnoses to include chronic osseous and subluxation stenosis, polyneuropathy, and hypertensive chronic kidney disease. Review of R17's comprehensive Minimum Data Set [MDS], found in the resident's Electronic Health Record (EHR), with an Assessment Reference Date (ARD) of 03/21/2026, revealed the facility assessed the resident to have a Brief Interview for Mental Status [BIMS] score of 12 out of 15, indicating the resident had moderate cognitive impairment.Review of R18's admission Record revealed the facility admitted the resident on 07/01/2024, with diagnoses to include acute respiratory failure with hypoxia, type 2 diabetes mellitus with diabetic chronic kidney disease, and unspecified severe protein-calorie malnutrition.Review of R18's quarterly MDS, found in the resident's EHR, with an ARD of 03/11/2026, revealed the facility assessed the resident to have a BIMS score of 15 out of 15, indicating the resident was cognitively intact.1. Observation of the conference room on 04/22/2026 at 8:50 AM revealed several gnats were observed flying around.2. Observation of Combs Hall, a resident hall, on 04/22/2026 at 9:05 AM revealed multiple gnats were observed flying around residents and on surfaces throughout the hall.3. Observation of the laundry room on 04/22/2026 at 9:25 AM revealed multiple gnats were observed flying in this area. The gnats were observed coming out of the washing machine discharge drain.4. Observation of Combs Hall on 04/22/2026 at 11:20 AM revealed several gnats were observed flying inside the medication cart trash can.5. Observation of the Combs Hall dirty utility room on 04/22/2026 at 11:33 AM revealed gnats were present in the room, particularly in and around a mop bucket containing stagnant water with a rancid odor.6. Observation of the kitchen on 04/22/2026 at 2:25 PM revealed wet dust, dirt, and debris had accumulated behind and around the ice machine and juice cart, including wet debris such as food crumbs, sugar packets, and other trash items. Moisture saturated these areas, leaving surfaces visibly wet. Cracked, loose, and broken floor tiles were noted near the ice machine drain and in the dish room, with food debris lodged within and beneath the damaged tiles. Further observation revealed standing water collected beneath the tiles and pooled around the ice machine drain. Gnats were present near the ice machine drain and throughout the kitchen. Additionally, the Dietary Manager was observed pouring vinegar into the ice machine drain.Further observation of the kitchen on 04/22/2026 at 2:25 PM revealed standing water in the spray room, dish room, along walls, and in corners. Water spread from the spray room into other areas of the kitchen, leaving the floor wet throughout. Following the lunch service, staff used a hose mounted sprayer to clean the floors, which contributed to water accumulation. Additionally, observation behind and underneath kitchen equipment revealed scattered food debris on the floor, including small particles and residue extending into hard to reach areas. These areas did not appear recently or thoroughly cleaned.7. Additional observation of the kitchen on 04/23/2026 at 10:49 AM revealed wet tile flooring with visible standing water across multiple areas. The floor appeared recently sprayed; however, water remained pooled rather than fully removed, creating a wet and unsanitary surface. Observation of the floor drain revealed accumulation of debris within and around the drain, including paper fragments and organic material. The drain grate was broken in half. Only part of the drain grate was visible and did not cover the drain and revealed trapped debris beneath the grate, including additional waste material and residue. The drain surface and surrounding grout appeared soiled with buildup. Gnats were present in and near the drain and flying around other areas of the kitchen. During an interview with the Dietary Manager on 04/22/2026 at 2:25 PM, she stated she had ongoing concerns with gnats for multiple weeks. The Dietary Manager stated a pest control service provided treatment two times per month, and kitchen staff performed routine cleaning weekly and as needed. The Dietary Manager stated dirt and debris should be removed to prevent accumulation. She stated staff used a hose-mounted spray system designed to dispense floor cleaner or disinfectant through the water stream to clean the floor in all areas of the kitchen. She stated she poured vinegar down drains between visits to reduce the gnat infestation. During a telephone interview with the Pest Control Service Representative on 04/22/2026 at 2:42 PM, he stated gnats originated from drains, cracks, and crevices containing organic debris and moisture, which served as breeding sources. The representative stated routine cleaning practices were ineffective when debris remained, as water and cleaning solutions pushed material into floor cracks and around drains, worsening conditions. The representative further stated pouring vinegar down drains would not eliminate the infestation, as it did not remove organic buildup or kill larvae and might attract gnats rather than resolve the source. The representative stated he had repeatedly identified and documented these conditions and provided recommendations, including removal of debris and proper drain maintenance; however, these recommendations were not consistently implemented, resulting in ongoing gnat activity.During an interview with the Pest Control Account Manager (PCAM) on 04/23/2026 at 12:15 PM, he stated the facility had pest activity, specifically gnats, originating from drains, cracks, and crevices in flooring, which served as breeding areas. He stated debris accumulation and moisture, found in inaccessible areas, particularly behind equipment, contributed to conditions conducive to that. He stated elimination of the source through environmental cleaning and maintenance was the primary intervention. The PCAM stated pest control services had been provided since approximately 03/2025, typically at least twice monthly, with ongoing communication to address concerns. He stated the facility's compliance with pest control recommendations was inconsistent, noting recommendations to remove debris and address sanitation issues were not always completed. Furthermore, he stated equipment components such as drain traps were not routinely cleaned, and environmental cleaning often improved only after issues became more apparent. During continued interview with the PCAM on 04/23/2026 at 12:15 PM, he stated contributing factors included debris buildup in cracks and flooring, lack of routine cleaning behind equipment, standing water or improperly maintained mop buckets, inconsistent cleaning practices in non-visible areas, inadequate cleaning of hard to access areas, lack of routine maintenance of drains and traps, and operational and leadership turnover impacting continuity of environmental practices. The PCAM stated pest control staff routinely documented findings with photographs and reports and communicated deficiencies to facility staff after inspection and service. He stated the facility was provided with a Service Report at each visit outlining required actions to prevent further infestation. Furthermore, he stated many action items remained undone by the facility and carried over to subsequent service reports.During an interview with Resident (R) 17 on 04/23/2026 at 2:50 PM, he stated gnats were present in the building and were most often observed during meal services. He stated he did not want gnats around him while he ate his meal.During an interview with R18 on 04/23/2026 at 2:50 PM, she stated gnats were always flying around. She stated they were annoying, and she did not like them near her or especially around her food. During an interview with the [NAME] President of Operations (VPO) on 04/23/2026 at 10:16 AM, he acknowledged gnats had been observed throughout the building, including in the kitchen and utility areas. Regarding kitchen sanitation, pest control, and the facility's environment, the VPO stated the dietary kitchen was clean and maintained an established cleaning schedule. Furthermore, he stated pest control services were provided by a local company. He stated reports from the pest control provider had identified ongoing concerns with debris in the kitchen and other areas, contributing to gnat activity. However, he stated the facility followed all recommendations communicated during each service call. When asked about expectations for maintaining a sanitary environment, the VPO stated pest control recommendations were generally followed, though specific monitoring and verification processes were not clearly defined during the interview. He stated he was surprised when informed observations identified debris behind and under equipment, and that did not align with expectations of cleanliness. He did not provide a clear process in the kitchen to ensure consistent removal of debris from hard to reach areas or to verify effectiveness of cleaning practices.During an interview with the Director of Maintenance (DM) on 04/23/2026 at 2:11 PM, he stated the facility had some issues with gnats, especially in the kitchen. He stated the facility had contracted with a pest control company who did semi-monthly visits to control the infestation. He stated following the pest control company's service recommendations was important to maintain a safe and sanitary environment.During an interview with the Director of Nursing (DON) on 04/24/2026 at 11:05 AM, she stated concerns with pests should be directed to nursing leadership who would then notify the DM to input a work order. She stated issues with insects and pests had been communicated to the DM through the facility's TELS work order system. The DON stated mop buckets should be emptied immediately after use. She further stated trash should be removed from medication carts when medication administration was completed. Additionally, the DON stated she expected staff to follow the chain of command related to reporting insects. She stated it was her expectation that staff maintained a clean, safe, and sanitary environment for the health and well-being of the residents and staff.During an interview with the Administrator on 04/24/2026 at 11:25 AM, she stated it was her expectation for kitchen staff to use a shop vac, fan, or squeegee, to ensure all standing water was removed. She stated staff was expected to remove all debris off the floor before cleaning the floor. She stated they should not sweep debris down the drains. Additionally, the Administrator stated following the pest control company's recommendation was important to reduce gnats in the building. Furthermore, the Administrator stated adherence to established cleaning procedures was required to ensure a clean, safe, and sanitary environment.

Based on record review, interview, and review of the facility's policy, the facility failed to provide specialized rehabilitative services for 1 out of 5 residents reviewed for therapy services, Resident (R) 21.Review of R21's Service Log Matrix revealed R21 did not receive physical therapy (PT) or occupational therapy (OT) on 08/28/2025 and 09/04/2025.The findings include: Review of the facility's policy titled, Scheduling Therapy Services, dated 01/01/2025, revealed, Therapy services shall be scheduled in accordance with the resident's treatment plan.Review of R21's admission Record revealed the facility admitted R21 on 08/25/2025 with diagnoses of muscle weakness and unsteadiness on feet.Review of R21's admission Minimum Data Set [MDS], dated 08/28/2025, revealed the facility assessed the resident to have a Brief Interview for Mental Status [BIMS] score of 14 out of 15, which indicated R21 was cognitively intact.Review of R21's Care Plan, date initiated 08/26/2025, revealed R21 had a focus of Rehabilitation: the resident has been admitted to the facility for rehabilitation and requires assistance with their activities of daily living, with interventions listed as skilled OT and skilled PT. Review of R21's Orders revealed PT and OT were ordered on 08/25/2025 to eval and treat as indicated. Further review revealed, Physical Therapy to treat five times a week for 30 days to include therapeutic exercises, therapeutic activity, gait training, neuromuscular reeducation, wheelchair management, group therapeutic procedure, and training to address diagnosis of weakness.Review of R21's OT Evaluation and Plan of Treatment, dated 08/26/2025, revealed the treatment had a frequency of five times a week, daily, for 60 days. The certification period was 08/26/2025 to 10/24/2025.Review of R21's PT Evaluation and Plan of Treatment, dated 08/29/2025, revealed the treatment had a frequency of five times a week, daily, for 30 days. The certification period was 08/26/2025 to 09/24/2025.Review of R21's Service Log Matrix, revealed R21 did not have individual PT or OT documented as being completed on 08/28/2025 or 09/04/2025.During an interview on 04/22/2026 at 5:32 PM with R21's representative, she stated the resident would have a certain number of minutes of physical therapy, and she had R21 keep track of his minutes. She stated R21 was not getting his allotted amount of time. She stated therapy was not getting tailored to his specific needs. She stated the family escalated things to transfer him to another facility for PT because they expressed concerns, and nothing improved. She stated R21 was weaker when he left the facility than when he entered. She stated R21 transferred to another facility for PT and was there an additional two weeks before returning home.During an interview on 04/22/2026 at 6:58 PM with R21, he stated he did not receive any physical therapy the first week and only received it the second week after he told them that he knew what it was. However, he stated it was not very good therapy. He stated the facility was not organized and was reactive instead of proactive. He stated when he received the PT, it was only for 30 to 40 minutes. He stated they had him participate in group therapy and counted that as his PT. He stated the PT was not tailored to his needs, and he made the facility aware that he did not want group therapy. He stated he felt like the facility thought he was an old man who did not know the difference.During an interview on 04/23/2026 at 9:42 AM with the Director of Rehabilitation (DOR), she stated evaluations typically depended on when the order was entered. She stated, if it was ordered during the week, then it was done on the following morning. She stated, if the order was placed during the weekend, then the resident was evaluated the following Monday. She stated a staff member would do the evaluation to determine the resident's deficits and determine what the plan of care needed to include. She stated R21 was evaluated on 08/26/2025, and his deficits with goals were lower extremity strength, activity tolerance, bed mobility, ambulation, and stairs. She stated residents received group therapy twice during their stay. She stated if a resident requested to not do group therapy, then they would stop and just do individual therapy. She stated his allotted minutes by the insurance company would be for physical therapy and occupational therapy combined. She stated residents had a 72-hour care plan meeting to go over the goals. During an additional interview on 04/23/2026 at 12:05 PM with the DOR, she stated R21 missed PT/OT on two different occasions, 08/28/2025 and 09/04/2025. The DOR stated she did not know why, and the reason was not documented. She stated the reason for missing PT/OT was typically documented. She stated she could not find any documentation for those two dates. She stated the plan of care was for five days a week, and R21 only received PT/OT three out of five days for two consecutive weeks. She stated any type of therapy was important to maximize reaching the resident's goals.During an interview on 04/24/2026 at 9:36 AM with the Director of Nursing (DON), she stated it was her understanding that if a resident missed therapy of any type for any reason, then staff would try to work them in at another time so they did not miss any therapy they might need. She stated that it was important for residents to reach their goals and to be able to go home.The State Survey Agency (SSA) Surveyor unsuccessfully attempted to contact the previous Administrator (Administrator at the time of the complaint) on 04/24/2026 at 10:54 AM by telephone.During an interview on 04/24/2026 at 12:02 PM with the current Administrator, she stated it was her expectation that residents received the therapy they were supposed to receive to reach their maximum potential.

Based on interview, record review, and review of the facility's policy, the facility failed to develop a resident centered behavioral care plan for 1 of 6 sampled residents, Resident (R) 1.From 08/09/2025 to 10/16/2025, R1 had food seeking behaviors that were not addressed timely on the behavioral care plan. Refer to F743.The findings include:Review of the facility's policy titled, Care Planning-Comprehensive Person-Centered, not dated, revealed the facility would develop and implement a comprehensive person-centered care plan for each resident that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs as identified throughout the comprehensive Resident Assessment Instrument (RAI) process. The comprehensive care plan would incorporate identified problem areas, incorporate risk factor associated with identified problems, and promote resident safety. Continued review revealed a behavior intervention plan (BIP) might be developed when a resident exhibited behavior that placed the resident at risk. The BIP would be incorporated into the resident's comprehensive care plan. The BIP would clearly identify the behaviors being addressed, interventions/approaches to reduce behaviors, and expected outcomes.Review of R1's admission Record revealed the facility initially admitted the resident on 09/28/2022. The facility most recently readmitted the resident on 10/18/2025. R1's admitting diagnoses were Parkinson's disease and esophageal obstruction.Review of R1's quarterly Minimum Data Set [MDS], with an Assessment Reference Date (ARD) of 09/11/2025, revealed the facility assessed the resident to have a Brief Interview for Mental Status [BIMS] score of zero out of 15, which indicated severe cognitive impairment.Review of R1's Comprehensive Care Plan [CCP], with date initiated of 03/28/2025 and revision date of 05/30/2025, revealed, under the focus of behaviors, the resident had behaviors of rejected care and services; refused meals; had hallucinations; made false allegations; had anxiety, irritability, and anger; picked at skin; and wrapped rubber bands around stump. Further review revealed the goal, initiated on 03/28/2025, revised on 07/31/2025, and with a target date of 01/19/2026, was for the resident's behaviors not to bother other residents. Review of the interventions, dated 03/28/2025, revealed for staff to monitor behavior episodes and attempt to determine the underlying cause by considering location, time of day, persons involved, and situations. However, the nutrition interventions were not updated for R1's current behaviors of trying to obtain and eat regular foods, which were not allowed on his pureed diet, after the 08/09/2025, 09/19/2025, and 10/16/2025 incidents.Review of R1's Physician's Orders, dated 07/30/2025 with an end date of 09/12/2025, revealed an order for a consistent carbohydrate diet (CCHO), pureed texture with regular thin consistency (liquid). Further review revealed the same diet was ordered for R1 on 09/21/2025 (an active order). Review of R1's Nurse Progress Note, dated 08/09/2025 at 8:51 AM and written by Registered Nurse (RN) 1, revealed the resident was lying in bed with his head elevated. Per the note, the resident was eating a granola bar, which was half gone, and the resident allowed the nurse to remove the granola bar. Per the note, RN1 asked the resident how he received the granola bar, and R1 stated to RN1, I have my connections. In an interview with the Activities Director on 10/21/2025 at 2:32 PM, she stated, during an activity on 09/19/2025 at 2:00 PM, R1 and R2 were watching a movie in the dining room with other residents and staff. She stated popcorn was offered to R2, and R2 shared his popcorn with R1. She stated the activities staff saw R1 with popcorn, and as they moved toward him, he started to cough. She stated staff took R1 to the nurses' station, and R1 had emesis. She stated R1 was offered water and could not swallow. In an interview with Certified Nurse Aide (CNA) 2, from Unit B, on 10/22/2025 at 1:08 PM, she stated R1 did wander occasionally over to Unit B. She stated she was present in the joint Unit B-C dining room, on 10/16/2025, at the assisted residents table when R1 visited with the male residents that sat there. She stated the male residents left the table, and she went to bring R1 to his assisted table for his food when he grabbed the pineapple off one of the male residents' trays. She stated she was not aware the resident would grab regular food off another resident's tray. Review of R1's three documents Hospital Discharge summary, dated [DATE], 09/21/2025, and 10/18/2025 revealed R1 was readmitted to the hospital, after each incident, with vomiting and the inability to swallow liquids. Per the summaries, R1 had an esophageal obstruction, chronic dysphagia, chronic esophageal strictures, and gastroesophageal reflex disease (GERD). Each time, Gastroenterology was consulted. R1 had an EGD on 10/17/2025 with removal of food from the upper esophagus as well as dilation of the esophagus. In continued interview with Certified Nurse Aide (CNA) 2, from Unit B, on 10/22/2025 at 1:08 PM, she stated R1 resided on Unit C, and she did not know where to find care plan information on Unit C. She stated she did not receive any information in report concerning R1's behavior of trying to obtain regular food. In an interview with the Licensed Practical Nurse (LPN) Minimum Data Set (MDS) Coordinator on 10/22/2025 at 10:10 AM, she stated CCPs were updated quarterly or as needed for a change. She stated the Unit Manager could update the care plan. She stated she attended the interdisciplinary morning meeting and made changes to the care plan. She stated the other disciplines were responsible to make changes to their specific care plan area and make the changes timely. In an interview with the Director of Nursing (DON) on 10/23/2025 at 10:29 AM, she stated care plans were updated in the interdisciplinary team clinical meeting and as needed, too. She stated the different disciplines could update the care plan as needed. She stated R1's care plan should have been updated in 09/2025. She stated the Quality Assurance and Performance Improvement (QAPI) committee, at their meeting, discussed the event with R1 and formulated a plan of action. In an interview with the Administrator on 10/22/2025 at 2:32 PM, she stated she had been informed about the events of R1 choking on food. She stated the CCP interventions should be to pick up trays before R1 could collect food off another resident's tray; and R1 to sit with staff supervision at the assisted table at meals, and the daughter, when she visited, would take him over to the male residents table to talk with his friends. She stated R1's daughter voiced no concern to them and stated he just had dementia. She stated R1's Activity Care Plan intervention should be not to give popcorn. She stated the concern with R1's non-compliance in food choices resulted in hospital stays.

Based on interview, record review, review of the facility's information sheet, and review of the facility's policy, the facility failed to monitor and provide ongoing assessment as to whether the care approaches were meeting the needs/behaviors of the resident for 1 of 6 sampled residents, Resident (R) 1.Interview and record review revealed on 08/09/2025, R1 obtained granola from an unknown source; on 09/19/2025, R1 obtained popcorn from another resident during an activity; and on 10/16/2025, R1 obtained pineapple from another resident's tray. The foods obtained were not allowed on the resident's ordered pureed diet.Refer to F656The findings include:Review of the facility's information sheet Pureed, not dated, revealed the standard texture for that diet resembled that of mashed potatoes or applesauce. Per the sheet, achieving that desired texture was most effectively done by pureeing foods in a food processor rather than a blender. The sheet stated the diet was appropriate for individuals experiencing swallowing difficulties, reluctance to chew, painful chewing with dentures or natural teeth, mouth pain due to lesions, or transitioning to solid foods after removal of a feeding tube. It stated a Speech Pathologist conducted swallowing evaluations for residents. Review of the facility's policy titled, Care Planning-Comprehensive Person-Centered, not dated, revealed a behavior intervention plan (BIP) might be developed when a resident exhibited behavior that placed the resident at risk. The BIP would be incorporated into the resident's comprehensive care plan. Further review revealed the BIP would clearly identify the behaviors being addressed, interventions/approaches to reduce behaviors, and expected outcomes. Review of R1's admission Record revealed the facility initially admitted the resident on 09/28/2022, and the facility most recently readmitted R1 on 10/18/2025. R1's admitting diagnoses included Parkinson's disease and esophageal obstruction.Review of R1's quarterly Minimum Data Set [MDS], with an Assessment Reference Date (ARD) of 09/11/2025, revealed the facility assessed the resident to have a Brief Interview for Mental Status [BIMS] score of zero out of 15, indicating severe cognitive impairment. Review of R1's Comprehensive Care Plan [CCP], with date initiated of 03/28/2025 and revision date of 05/30/2025, revealed, under the focus of behaviors, the resident had behaviors of rejected care and services; refused meals; had hallucinations; made false allegations; had anxiety, irritability, and anger; picked at skin; and wrapped rubber bands around stump. However, the interventions were not updated for R1's current behaviors of trying to obtain and eat regular foods, which were not allowed on his pureed diet, after the 08/09/2025, 09/19/2025, and 10/16/2025 incidents.Review of R1's Physician's Orders, dated 07/30/2025 with an end date of 09/12/2025, revealed an order for a consistent carbohydrate diet (CCHO), pureed texture with regular thin consistency (liquid). Further review of R1's Physician's Orders with an active/revision date of 09/21/2025, revealed the same order was renewed. 1. Review of R1's Nurse Progress Note, dated 08/09/2025 at 8:51 AM and written by Registered Nurse (RN) 1, revealed the resident was lying in bed with his head elevated. Per the note, the resident was eating a granola bar, which was half gone, and the resident allowed the nurse to remove the granola bar. The note stated RN1 told the resident the granola bar was not appropriate for his ordered diet, and she encouraged oral fluids. Per the note, RN1 asked the resident how he received the granola bar, and R1 stated to RN1, I have my connections. The note stated the nurse practitioner was notified, with no new orders received. It also stated R1's Power of Attorney (POA) was notified. In an interview with RN1 on 10/22/2025 on 1:37 PM, she stated she entered R1's room early before breakfast. She stated R1 was lying over the bed with a granola bar. She stated she took the granola from him, and R1 had just started to eat the granola bar.Review of R1's Nurse Progress Note, dated 08/09/2025 at 9:10 PM and written by Licensed Practical Nurse (LPN) 3, revealed the resident was trying to use the urinal, so the nurse provided privacy and left. Per the note, when the nurse returned, she noted blood around R1's gastrostomy tube site. The note revealed LPN3 called the provider and the POA, and R1 was sent to the emergency room (ER). Review of R1's Hospital Discharge summary, dated [DATE], revealed his diagnoses were food impaction of the esophagus, esophageal stenosis, dementia, Parkinson's disease, esophageal stent, with the most recent stent placement 05/24/2025, with PEG (gastrostomy) tube replacement. The computed tomography (CT) scan revealed an impaction of the esophageal stricture, reportedly due to him being given access to granola bars, which were not part of his prescribed diet. Per the summary, R1 was discharged on a full liquid diet for 48 hours with advancement to pureed diet thereafter.2. In an interview with the Activities Director on 10/21/2025 at 2:32 PM, she stated, during an activity on 09/19/2025 at 2:00 PM, R1 and R2 were watching a movie in the dining room with other residents and staff. She stated popcorn was offered to R2, and R2 shared his popcorn with R1. She stated the activities staff saw R1 with popcorn, and as they moved toward him, he started to cough. She stated staff took R1 to the nurses' station, and R1 had emesis. She stated R1 was offered water and could not swallow. She stated the physician was contacted, and R1 was sent to the emergency room (ER). Review of R1's Hospital Discharge summary, dated [DATE] revealed R1 was admitted with an esophageal stricture, and a gastroenterologist was consulted. Per the summary, R1 had an esophagogastroduodenoscopy (EGD) for dilatation of the esophageal stricture. R1 was discharged on 09/21/2025 back to the facility tolerating a pureed diet. In continued interview with the Activities Director on 10/21/2025 at 2:32 PM, she stated the type of snacks offered varied for different activities, such as a birthday party, Bingo, a coffee corner, or a movie. She stated the textured diets included chocolate/vanilla pudding and applesauce at every event. She stated the activities staff had a copy of the diet sheet from Point Click Care (PCC, a computer software), and all the aides had a copy. She stated the activities staff received training during the orientation process for diet textures to understand the types of food residents could have during an activity. She stated the resident on a pureed diet could have pudding, applesauce, ice cream, and chocolate pie, the pudding portion. She stated 09/19/2025 was the first time she saw R1 take popcorn offered from another resident. 3. Review of the facility's menus revealed pineapple was served on 10/16/2025 at the supper meal for regular diets. The menu for the pureed diet stated applesauce was served. In an interview with Certified Nurse Aide (CNA) 2, from Unit B, on 10/22/2025 at 1:08 PM, she stated R1 resided on Unit C but did wander occasionally over to Unit B. She stated she was present in the joint Unit B-C dining room at the assisted residents table when R1 visited with the male residents that sat there. She stated the male residents left the table, and she went to bring R1 to his assisted table for his food when he grabbed the pineapple off one of the male residents' trays. She stated she was not aware the resident would grab regular food off another resident's tray. Review of R1's Hospital Discharge summary, dated [DATE], revealed R1 was readmitted with vomiting and the inability to swallow liquids. Per the summary, R1 had an esophageal obstruction, chronic dysphagia, chronic esophageal strictures, and gastroesophageal reflex disease (GERD). Per the summary, Gastroenterology was consulted, and R1 had an EGD on 10/17/2025 with removal of food from the upper esophagus as well as dilation of the esophagus. In an interview with Registered Nurse (RN) 1 on 10/22/2025 at 1:35 PM, she stated R1 took items off trays, and other residents liked to share food. She stated R1 was active and moved around the unit, moving around tables in the dining room. She stated he sat at the assist table and was provided cues as needed. She stated he was known to hide food from trays into his prothesis. She stated R1 took off his leg in the dining room, and staff found cookies in his leg. She stated R1 required constant supervision. In an interview with the Registered Dietitian (RD) Licensed Dietitian (LD) on 10/22/2025 at 4:00 PM, she stated she was made aware of the incidents when R1 was offered or asked for foods from other residents. She stated R1 had an esophageal stricture and had the esophageal area stretched as needed. She stated foods not allowed on a pureed diet included popcorn, a granola bar, and pineapple. In an interview with the Speech Therapist on 10/21/2025 at 1:33 PM, she stated she had seen R1 for cognition and speech. She stated, at the time of the evaluation, she was not aware there were any concerns with R1's swallowing. She stated she asked the daughter about that, and she told her there were no concerns with his swallowing. She stated a Speech reevaluation was done on 10/02/2025, and there were no concerns for swallowing. She stated with R1, all foods were pureed, with no whole foods allowed on the diet. She stated she followed the orders from the Hospital Discharge Summary for R1 to follow a pureed diet. In an interview with the Director of Nursing (DON) on 10/22/2025 at 3:00 PM, she stated R1 did not move around as much as he used to. She stated he took himself to the dining room (DR) and would return. She stated she was told RN1 found a granola bar in his room and got it away from him. She stated the incident about the popcorn occurred while doing activities, and activities reported that to nursing. She stated the Activity Director instructed the residents not to share food with others. She stated R1 was quick to take food off the other residents' trays when the opportunity was available at the other or his own table. She stated he liked to sit with his male resident friends, and they would offer him food. The DON stated they had educated staff that R1 needed to stay at the assist table to be monitored, and staff was to sit and supervise him. The DON stated R1's last esophageal stent placement was on 05/22/2024, and R1 had received several esophageal dilatations over the years as his esophagus needed to be stretched. In an interview with the Administrator on 10/22/2025 at 2:32 PM, she stated she had been informed about the events of R1 choking on food. She stated the CCP interventions should be to pick up trays before R1 could collect food off another resident's tray; and R1 to sit with staff supervision at the assisted table at meals, and the daughter, when she visited, would take him over to the male residents table to talk with his friends. She stated R1's daughter voiced no concern to them and stated he just had dementia. She stated R1's Activity Care Plan intervention should be not to give popcorn. She stated the concern with R1's non-compliance in food choices and staff not preventing it resulted in hospital stays.

5. Review of R2's Face Sheet, found in R2's EMR, revealed the facility admitted R2 on [DATE] with diagnoses including cerebral palsy, epilepsy, and anxiety. Review of R2's quarterly MDS, with an ARD of [DATE], revealed the facility assessed the resident to have a BIMS score of zero out of 15, indicating severe cognitive impairment. When requested from the facility on [DATE], [DATE], and [DATE], a copy of R2's Advance Directive was not provided. However, a document Hospitality Guide Acknowledgement was provided, which was signed by R2's resident representative on [DATE]. The State Survey Agency (SSA) Surveyor attempted to interview R2's representative by telephone on [DATE] at 2:39 PM but was unsuccessful. 6. Review of R92's Face Sheet, found in R92's EMR, revealed the facility admitted the resident on [DATE] with diagnoses including depression, diabetes, and dementia. Review of R92's quarterly MDS, with an ARD of [DATE], revealed the facility assessed the resident to have a BIMS score of 14 out of 15, indicating R92 was cognitively intact. Review of R92's Care Plan, dated [DATE], revealed the R92 had an Advance Directive, with a goal of the Advance Directive would be honored through the care plan's next review. Further review revealed interventions listed were to honor the resident's Advance Directives per physician orders and to periodically review them. When requested from the facility on [DATE], [DATE], and [DATE], a copy of R92's Advance Directive was not provided. However, a document Hospitality Guide Acknowledgement was provided, which was signed by R92's Power-of-Attorney (POA) on [DATE]. During an interview on [DATE] at 9:17 AM with R92's representative, she stated a copy of R92's Advance Directive had been provided to the facility, but she was unsure of the date. During an interview on [DATE] at 2:39 PM with the Social Services Director (SSD), she stated it was important to have a resident's current Advance Directive information because a resident's wishes should be supported by the facility. She further stated it was important for the facility to honor the resident's wishes. During an interview with the Director of Medical Records (DMR) on [DATE] at 10:32 AM, she stated during the admission process, residents were allowed to provide a Power of Attorney (POA) or a Living Will. She stated she asked every resident about any Advance Directives during the admission conference, and if one was in place, she requested a copy at that time. She stated if she did not receive a copy of the Advance Directive, she contacted the family to make an additional request. The DMR stated Advance Directives were also discussed at the quarterly care plan meetings by the SSD. During an interview with the Director of Nursing (DON) on [DATE] at 5:45 PM, she stated during the admission process, residents or their representatives indicated their Advance Directives, including their preferences regarding cardiopulmonary resuscitation (CPR) or do not resuscitate (DNR) orders. She stated these preferences were documented in their medical record. The DON stated having Living Wills or POAs included in the EMR were important to ensure that residents' wishes were honored. During an interview with the Administrator on [DATE] at 6:30 PM, she stated the facility emailed the Hospitality Guide to the resident's representatives, and the representatives were to review all the information, electronically sign it, and send it back to the facility. She stated she expected the facility to obtain and retain the Advance Directive upon admission. However, she stated if the Advance Directive was not received at that time, the team would discuss the resident's wishes during the 72-hour meeting. The Administrator stated if the resident or their representative did not provide an Advance Directive, the facility would follow up with them during the quarterly care plan meeting. She stated the importance of having an Advance Directive was to ensure the resident's wishes were respected and to enable staff to honor the resident's plan of care when they were no longer able to communicate their needs. Based on interview, record review, and review of the facility's policies, the facility failed to inform and provide written information to all adult residents concerning the right to accept or refuse medical or surgical treatment and at the resident's option, formulate an Advance Directive for 6 of 28 sampled residents, Resident (R) 2, R12, R40, R85, R92, and R131. The findings include: Review of the facility's policy titled, Advance Directives, dated [DATE], revealed Advance Directives was written instruction, such as a Living Will or Durable Power-of-Attorney (POA) for healthcare, recognized under State Law (whether statutory or as recognized by the courts of the State), relating to the provision of healthcare when the individual was incapacitated. Further review revealed upon admission, the resident would be provided with information concerning the right to refuse or accept medical or surgical treatment and to formulate an advance directive if he or she chose to do so. Per the policy, facility staff should verify the resident's wishes regarding cardiopulmonary resuscitation (CPR). Review of the facility's policy titled, [Facility Name], Hospitality Guide, no date, revealed the resident had the right to be informed of, and participate in, his or her treatment, including the right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an Advance Directive. Per the policy, the facility must comply with the requirements specified in code of federal regulations (CFR) part 489, subpart I (Advance Directives). This included a written description of the facility's policies to implement Advance Directives and applicable State law. 1. Review of R40's Face Sheet, found in R40's electronic medical record (EMR), revealed the facility admitted the resident on [DATE] with admitting diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, other lack of coordination, and atherosclerotic heart disease of native coronary artery without angina pectoris. Review of R40's annual Minimum Data Set [MDS], with an Assessment Reference Date (ARD) of [DATE], revealed the resident had a Brief Interview for Mental Status [BIMS] score of 15 out of 15, which indicated the resident was cognitively intact. Review of R40's Advance Directives, found in R40's EMR under the miscellaneous tab, revealed R40 had signed the [State] Emergency Services Do Not Resuscitate [DNR] document on [DATE]. However, there was no documentation of R40's Power of Attorney (POA) or Living Will present in the resident's EMR. When requested from the facility on [DATE] at 2:19 PM, a copy of R40's Advance Directive was not provided. However, a document Hospitality Guide Acknowledgement was provided, which was dated [DATE]. Further review revealed a family member of R40 signed the document, and there was no POA or Living Will with the document. During an interview on [DATE] at 8:25 AM with R40, she stated R40's family member signed the admission paper work with a DNR. R40 stated she could not remember if the facility inquired about a POA or Living Will. 2. Review of R85's Face Sheet, found in R85's EMR, revealed the facility admitted the resident on [DATE] with admitting diagnoses including Alzheimer's dementia, unspecified; immunodeficiency, unspecified; and epilepsy, unspecified, not intractable, with status epilepticus. Review of R85's annual MDS, with an ARD of [DATE], revealed the resident had a BIMS score of two out of 15, which indicated severe cognitive impairment. Review of R85's Advance Directives, found in R85's EMR under the miscellaneous tab, revealed R85 had signed the [State] Emergency Services DNR document on [DATE]. However, there was no documentation of R85's POA or Living Will present in the resident's EMR. When requested from the facility on [DATE] at 2:19 PM, a copy of R85's Advance Directive was not provided. However, a document Hospitality Guide Acknowledgement was provided, which was dated [DATE]. Further review revealed R85's FM4 signed the document, and there was no POA or Living Will with the document. 3. Review of R131's Face Sheet, found in R131's EMR, revealed the facility admitted the resident on [DATE] with admitting diagnoses including hypertensive heart disease with heart failure, paroxysmal atrial fibrillation, and atherosclerotic heart disease of native coronary artery without angina pectoris. Review of R131's annual MDS, with an ARD of [DATE], revealed the resident had a BIMS score of three out of 15, which indicated severe cognitive impairment. When requested from the facility on [DATE] at 2:19 PM, a copy of R131's Advance Directive was not provided. However, a document Hospitality Guide Acknowledgement was provided, which was dated [DATE]. Further review revealed R131's FM1 signed the document, and there was no POA or Living Will with the document. 4. Review of R12's Face Sheet, found in R12's EMR, revealed the facility admitted the resident on [DATE] with admitting diagnoses including dementia, cerebral infarction, and aphasia. Review of R12's annual MDS, with an ARD of [DATE], revealed the resident had a BIMS score of zero out of 15, which indicated severe cognitive impairment. Review of R12's Advance Directives, found in R12's EMR under the miscellaneous tab, revealed R12 had full-code status; however, there was no documentation of an Advance Directive or Living Will. Further review of R12's EMR revealed there was no documentation in the resident's chart showing the facility reviewed the Advance Directive policy or provided written information regarding the right to create an Advance Directive. Review of the document Hospitality Guide Acknowledgement, found in R12's EMR and dated [DATE], revealed the resident's representative's (RR) signature line included the POA's initials with the word verbal noted in parentheses beside the initials. During an interview with R12's Power of Attorney (POA) on [DATE] at 9:12 AM, he stated he did not remember receiving any written information regarding his right to create an Advance Directive, nor does he recall signing any related documents. He stated R12 was a full-code and did not have an Advance Directive in place. Additionally, R12's POA stated the facility's staff had not informed him about his right to establish an Advance Directive.

Based on observation, interview, record review, and review of the facility's policies, the facility failed to store drugs and biologicals in the packaging, containers, or other dispensing systems in which they were received for 2 out of 28 sampled residents, Resident (R) 52 and R36 and 2 out of 7 medication carts, Cart 1 and Cart 2 on the Combs unit. The findings include: Review of the facility's policy titled Medication Administration, dated 09/2018, revealed, Medications are to be administered at the time they are prepared, and the resident is always observed after administration to ensure that the dose was completely ingested. Once removed from the package/container, unused medication doses shall be disposed of according to the nursing care center policy. Review of the facility's policy titled, Medication Storage, undated, revealed the nursing staff shall be responsible for maintaining medication storage and preparation areas in a clean, safe and sanitary manner, and drugs and biologicals shall be stored in the packaging, containers or dispensing systems in which they are received. 1. Observation on 06/10/2025 at 9:52 AM revealed R52 had five unidentified pills sitting on the bedside table. Review of R52 admission Record, in the electronic medical record (EMR), revealed the facility admitted the resident on 08/06/2021 with diagnoses of rheumatoid arthritis, hypertension, and anxiety. Review of R52's quarterly Minimum Data Set [MDS], with an Assessment Reference Date (ARD) of 04/28/2025, revealed the facility assessed the resident to have a Brief Interview for Mental Status [BIMS] score of 13 out of 15, indicating intact cognition. During an interview on 06/10/2025 at 9:52 AM with R52, she stated she was not sure what the medications were for or when or where they came from. She stated she thought they could have been vitamins. She also stated she was not sure how long they had been on the bedside table. During an interview on 06/10/2025 at 10:00 AM with Registered Nurse (RN) 1, she stated she was unsure what the unidentified pills were that were found on R52's bedside table. She stated she thought they were from the previous night. During an interview on 06/12/2025 at 3:40 PM with the Nurse Practitioner (NP), she stated she received a call yesterday from staff regarding R52 self-administering medications and was okay with that decision because she had worked with R52 for three years. She stated, She [R52] pretty much takes care of herself. The NP stated R52 is going to do what she wants to do. If she doesn't take them then that's on her because she makes her own decisions. When asked if other residents would be safe to find medications left out, the NP stated, I suppose not. When asked what could happen if another resident walked into R52's room and took medications that did not belong to them, she stated depends on what medication it is, and it could cause an adverse response. She stated her expectation of staff was to follow facility policy and standards of care. 2. Observation on 06/11/2025 at 8:15 AM of the Combs Unit Medication Cart 2 revealed 12 loose pills in the bottom of the second drawer. During an interview on 06/11/2025 at 8:15 AM with Licensed Practical Nurse (LPN) 4, she stated she was not sure how so many pills were at the bottom of the drawer, but sometimes they fell out of the blister packs. When asked what the concern would be about the loose pills, she stated someone could give the wrong medication. She then stated she would not give medication from the bottom of the drawer. She stated loose pills could mean a resident was charged for something they did not receive. 3. Observation on 06/11/2025 at 8:21 AM revealed RN1 prepared R36's medications by placing them into a medication cup and then placing the cup into the medication cart. Medications were not administered until 9:00 AM. 4. Observation on 06/11/2025 at 9:06 AM of the Combs Unit Medication Cart 1 revealed an unidentified, pinkish-colored tablet in a cup in the back of the top drawer. During an interview on 06/11/2025 at 9:06 AM, Kentucky Medication Aide (KMA) 1 stated the pill was a Midodrine (used to treat hypotension) for R35. She stated it fell from the package, and she did not want to waste it. She then stated she would put it back in the drawer, then corrected herself, and decided to waste it. When asked what the concern would be about leaving the medication loose in the cart without proper identification, she stated there was no way for someone to know for sure what it was or who it was for. She also stated the dose might be forgotten in the back of the drawer. During an interview on 06/13/2025 at 5:47 PM with the Director of Nursing (DON), she stated it was her expectation that staff who were administering medications verified the residents swallowed the medication. She stated this was important to ensure medications were taken at the correct time. She stated if a resident did not swallow the medicine and set it in the room, it would be a concern if another resident came into the room. She also stated staff should waste medications appropriately. She stated it was important to take care in removing medications from the cart because it wasted medications the resident had paid for. During an interview on 06/13/2025 at 6:31 PM with the Administrator, she stated it was her expectation that staff followed professional standards and guidelines to ensure residents were getting the appropriate medications at the correct time.

Based on observation, interview, record review, review of the Centers for Disease Control and Prevention (CDC) guidelines, and review of the facility's policies, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections affecting 4 of 28 sampled residents, Residents (R) 1, R12, R22, and R68. Additionally, the deficient practice of not handling trash and linens appropriately and failure to perform hand hygiene and wear appropriate personal protective equipment (PPE) had the potential to affect all 139 current residents. Observation on 06/10/2025 of R12's room revealed an opened package of skin wipes and gloves on the sink. R12's respiratory equipment supplies, including a mask and tubing, as well as a single denture, were drying on a stained towel on a table located in the resident's bathroom. Additional observation on 06/10/2025 revealed Certified Nurse Aide (CNA) 1 was at the bedside, holding a brief, with her uniform pressed against R12. CNA1 was not wearing the appropriate personal protective equipment (PPE) for providing direct care in an enhanced barrier precaution (EBP) room. Observation on 06/10/2025 revealed the Restorative Aide ambulated R68 with a gait belt to the dining room, then removed the gait belt from R68 and placed the gait belt in her pocket without cleaning it. Observation on 06/11/2025 revealed Licensed Practical Nurse (LPN) 2 performed a blood sugar fingerstick for R22. LPN2 failed to follow any infection control practices while performing the procedure and failed to properly clean and disinfect the blood glucose meter before storage. Observation on 06/11/2025 revealed R1's indwelling urinary catheter collection bag was anchored under her recliner, and the bottom surface of the collection bag was touching the ground. Continued observation revealed LPN2 repositioned R1's catheter collection bag without first donning (putting on) PPE. Additionally, LPN2 did not perform hand hygiene before she sat at the nurses' station to type on the computer. The findings include: Review of the Centers for Disease Control and Prevention (CDC) Guidelines titled, Core Infection Prevention and Control Practices for Safe Healthcare Delivery in All Settings, dated 04/12/2024, revealed hand hygiene should be performed immediately before providing resident care and after care was completed. It stated staff should ensure the proper selection and use of PPE based on the nature of the patient interaction and potential for exposure to blood, body fluids, and/or infectious materials. Review of the facility's policy titled, Infection Control Program [ICP], undated, revealed the facility maintained an infection prevention and control program designed to address surveillance, prevention, and control of disease and infection that was consistent with CDC guidelines. Review of the facility's policy titled Enhanced Barrier Precautions [EBP], dated 03/38/2024, revealed staff would implement EBP precautions in conjunction with standard precautions to include targeted gown and glove use during high contact care activities for residents known or suspected to be infected with multi drug-resistant organisms (MDRO). Review of the facility's policy titled, Point of Care Blood Glucose Meters/PT/INR Meters Use and Cleaning, dated 03/11/2019, revealed the facility would maintain processes to prevent the spread of infection and disease and to ensure that point of care devices were utilized safely when used on multiple residents by properly cleaning the devices between each resident. Review of the facility's competency titled Assure Platinum Blood Glucose Cleaning and Disinfecting Competency, dated 02/01/2024, revealed the blood glucose meter must be cleaned and disinfected after each use. According to the instructions, this should be done using a disinfectant or germicide registered with the Environmental Protection Agency (EPA) and approved for healthcare settings. Additionally, the competency guidelines stated that to clean the meter, a disinfectant cloth should be used to wipe its surface to remove the blood and other bodily fluids. To disinfect the meter, a fresh disinfectant cloth should be used to wipe the entire surface and ensure that it remained wet for the recommended contact time according to manufacturer's instructions. Review of the Sani-Cloth Germicidal Wipe package instructions revealed to thoroughly clean and disinfect, the glucometer surface must be thoroughly wet and allow treated surfaces to remain wet three minutes, then air dry. Review of the facility policy's titled, Cleaning and Disinfecting Resident Care Items and Equipment, dated 10/01/2021, revealed reusable items were cleaned and disinfected or sterilized between residents. Review of the facility's policy titled, Gait Belt Policy Staff Acknowledgement, undated, stated gait belts must be laundered as necessary and must be clean at all times. 1.a. Observation of R12's room on 06/10/2025 at 9:15 AM revealed an opened package of skin wipes and gloves on the sink. On the floor, there were two plastic bags containing linen and trash. Further observation revealed R12's respiratory equipment supplies, including a mask and tubing, as well as a single denture, were drying on a stained towel on a table located in the resident's bathroom. b. Observation of CNA1 on 06/10/2025 at 9:32 AM revealed she was at R12's bedside, holding a brief, with her uniform pressed against the resident's bed. The CNA was wearing gloves. She stated to R12, Let's change your brief. CNA1 was not wearing a gown when she touched R12 and began high-contact direct care to R12 who was in EBP. Review of an admission Record, found in R12's electronic medical record (EMR), revealed the facility admitted the resident on 04/03/2024 with diagnoses including dementia, cerebral infarction, and aphasia. Review of R12's quarterly Minimum Data Set [MDS], with an Assessment Reference Date (ARD) of 04/03/2025, revealed the resident had a Brief Interview for Mental Status [BIMS] score of 00 out of 15, which indicated severe cognitive impairment. Review of an Order Summary Report, found in R12's EMR, revealed the resident was placed on EBP related to a gastrostomy-tube and wounds on 04/19/2025. During an interview with CNA1 on 06/10/2025 at 9:32 AM, she stated she was going to get a gown. She stated there should be gowns in the hall. However, she stated there were none when she looked. CNA1 stated gowns were also kept in the shower room. When asked why she did not don a gown before she provided direct care, she stated, I wasn't providing direct care. CNA1 stated she received ICP training upon hire and had received periodic in-service training. She stated it was important to follow infection control to help everyone from getting sick. During an interview with Unit Manager (UM) 1 on 06/10/2025 at 10:05 AM, she stated there was one PPE container on each hall for staff to use for EBP rooms. She stated staff should wear the appropriate PPE in EBP and isolation rooms. She stated a gown and gloves were necessary when providing any type of high-contact direct care for a resident under EBP. She stated according to CDC guidelines, changing briefs was considered high-contact resident care. Additionally, UM1 stated clean equipment should not be stored in the bathroom as this was unsanitary. Instead, she stated it should be cleaned, dried, and placed in a bag to prevent cross-contamination. The UM stated following ICP practices was important for the health and safety of all residents and staff. 2. Observation of the A-Hall on 06/10/2025 at 9:26 AM revealed two bags of laundry and trash were outside of a room on the floor in the hall. 3. Observation of CNA3 on 06/10/2025 at 9:39 AM revealed she was holding a bag of dirty linen and then doffed (took off) her gloves. She did not perform hand hygiene. The CNA pushed a wheelchair holding the contaminated trash bag against the wheelchair. She disposed of the trash in the dirty utility room, but did not perform hand hygiene before she continued to move the wheelchair. During an interview with CNA3 on 06/10/2025 at 9:39 AM, she stated she should not wear gloves in the hall. She stated she should have doffed her gloves and performed hand hygiene before she exited the room. She stated she should have performed hand hygiene after disposing of the contaminated trash. CNA3 stated she received training on infection control policies and procedures during orientation and multiple in-service trainings. CNA3 further stated that following ICP was important to prevent the spread of infection and cross-contamination. 4. Observation of the A-Hall on 06/10/2025 at 9:42 AM revealed Housekeeper (HSK) 1 was holding a clean privacy curtain over her shoulder. The curtain was dragging on the ground as she walked down the hall. Continued observation revealed HSK1 began to hang the curtain. During an interview with HSK1 on 06/10/2025 at 9:42 AM, she stated she was unaware the curtain was dragging on the floor and believed a bag was covering the curtain. When asked if she should hold clean linen against her person, she did not respond. When questioned why dragging a clean item on the floor could pose an infection control issue, she stated that it could spread germs. When asked if she had received ICP training, she stated, Yeah, and walked away. During an interview with the Environmental Services Supervisor (EVS) on 06/13/2025 at 8:05 AM, she stated HSK1 should not have dragged the curtain through the hall or against her person. She stated the housekeeper should not hang a contaminated curtain. She stated her staff had received ICP training, and it was her expectation that all housekeeping staff followed facility policy related to ICP to prevent the spread of infection. 5. Observation of Room A5 on 06/10/2025 at 9:58 AM revealed wash cloths on the floor. Also, clean linen was piled on top of the vanity and in the sink. During continued interview with Unit Manager (UM) 1 on 06/10/2025 at 10:05 AM, she stated linen and trash should not be left on the floor or on any surfaces in the room or hallway. She stated staff was trained to only bring in the necessary linen and to remove trash and contaminated linen after care was completed. The UM stated it was her expectation that nursing staff should conduct audits of resident rooms to ensure they were kept clean and tidy to prevent the spread of infection. UM1 stated she could not explain why the rooms were unkempt. 6. Observation of CNA4 on 06/10/2025 at 11:30 AM revealed she entered and exited three resident rooms, who residents were gone (A16, A21, and A23), while carrying a large black garbage bag and collecting water pitchers and cups for disposal. CNA4 did not wear gloves while handling the dirty pitchers, cups, straws, and trash. Furthermore, CNA4 did not perform hand hygiene between rooms. During an interview with CNA4 on 06/10/2025 at 11:30 AM, she stated every Tuesday she changed the pitchers and cups in all the resident rooms. She stated she should have worn gloves, especially when touching straws, and should have performed hand hygiene. CNA4 stated she was not aware she could not take a contaminated bag in and out of rooms. 7. Observation on 06/10/2025 at 12:07 PM revealed the Restorative Aide ambulated R68 with a gait belt to the dining room, then removed the gait belt from R68 and placed the gait belt in her pocket without cleaning it. Review of an admission Record, found in R68's EMR, revealed the facility admitted the resident on 01/20/2020 with diagnoses including hypertension, anxiety, and depression. Review of R68's quarterly MDS, with an ARD of 04/24/2025, revealed the BIMS could not be performed because of memory problems. During an interview on 06/10/2025 at 12:25 PM with the Restorative Aide, she stated she used her own gait belt and wiped it down with purple wipes between uses. She stated wipes were kept at the nurses' stations, and she kept it in her pocket. She stated if she needed a second one, then she could get another one from the therapy department. She stated that storing it in her pocket before and after cleaning could contaminate it. 8. Observation of CNA3 on 06/10/2025 at 3:30 PM, revealed she walked down the A-Hall holding a bag of contaminated linen and a bag of trash. CNA3 did not doff her gloves or perform hand hygiene prior to leaving the room and going into the hallway. During an interview with CNA3 on 06/10/2025 at 3:30 PM, she stated, I already told you I shouldn't wear gloves in the hall. When asked why she did not doff the gloves and perform hand hygiene, she stated she was not finished with what she was doing. CNA3 then walked away from the State Survey Agency (SSA) Surveyor. 9. Observation of CNA3 on 06/11/2025 at 7:35 AM revealed CNA3 transported a bag of dirty linens with gloved hands down the hall while pushing a wheelchair. After disposing of the trash in the dirty utility room, the CNA removed her PPE, however she did not perform hand hygiene before she continued to push the wheelchair down the hall. During an interview with CNA3 on 06/11/2025 at 7:39 AM, she stated she should not wear contaminated gloves in the hall due to cross contamination. When asked about the importance of hand hygiene and PPE use, she stated they were important to prevent germs from spreading. 10. Observation of CNA4 on 06/11/2025 at 7:40 AM revealed she walked down the A-Hall holding a contaminated pair of gloves and a bag of dirty linen. 11. Observation of LPN2 perform a fingerstick on 06/11/2025 at 7:50 AM revealed she took her supplies into R22's room and placed the lancet, blood glucose meter (glucometer), and the testing strip on the bedside table without first placing a barrier. Without performing hand hygiene, LPN2 donned gloves. LPN2 stuck the resident's finger with a lancet and then placed the lancet on the bedside table without a barrier. She obtained the drops of blood on the test strip and took an alcohol wipe and wiped blood from R22's finger and discarded it directly on the bare table. Further observation revealed LPN2 discarded the lancet and test strip, removed her gloves and did not perform hand hygiene before she exited the room. LPN2 placed the contaminated glucometer on the medication cart without a barrier. She then wiped the contaminated glucometer with one SaniCloth Prime wipe for 6.8 seconds and placed it on a tissue. She then put the glucometer in the medication cart drawer on top of other glucometers. She did not wear gloves or perform hand hygiene. Review of an admission Record, found in R22's EMR, revealed the facility admitted R22 on 05/04/2022 with diagnoses that included type 2 diabetes, cerebral palsy, and neuropathic bladder. Review of R22's annual MDS, found in R22's EMR, with an ARD of 05/21/2025, revealed a BIMS score of six out of 15, which indicated the resident was severely cognitively impaired. Review of an Order Summary Report, found in R22's EMR, revealed the resident was placed on EBP related to a urinary catheter and colostomy. During an interview with LPN2 on 06/11/2025 at 8:00 AM, she stated she left the glucometer on top of the cart to dry. When asked what the proper kill/dwell-time was for the disinfectant wipes she used, she stated she was taught to wipe the glucometer clean and let it dry for three to five minutes. When asked to explain what kill/dwell time meant, LPN2 was unable to explain. Continued interview revealed LPN2 reviewed the Sani-Cloth Germicidal Wipe instructions and stated the object must remain wet for a full three minutes and then be left to air dry for complete disinfection to take place. LPN2 further stated she had received training to perform fingersticks and clean and disinfect glucometers and had passed competencies during her orientation period at the facility. During an interview with the Infection Preventionist/Staff Development Coordinator (IP/SDC) on 06/11/2025 at 8:15 AM, she stated she had been in her position since March 2025. She stated she had not seen any major issues of staff failing to perform ICP to include hand hygiene or wearing appropriate PPE. She stated nursing leadership recently performed an infection control audit, and the staff performed procedures with no issues. The IP/SDC stated nurses needed to focus on the product instructions to know the exact kill-time for that particular product. The IP/SDC stated following ICP was important to prevent the spread of infection and cross contamination. Furthermore, she stated all staff received infection control training upon hire, and it was reviewed many times throughout the year. 12. Observation on 06/11/2025 at 8:09 AM revealed Registered Nurse (RN) 1, when administering medications, touched all medications with hands and without performing hand hygiene consistently and did not clean the blood pressure (BP) cuff between use on multiple residents. During an interview on 06/11/2025 at 9:07 AM with RN1, she stated Honestly, I don't clean the BP cuff between residents unless I have a resident in contact [precautions]. However, she stated cleaning it between uses would decrease the risk of cross contamination. She stated hand hygiene and not touching residents' medications with bare hands would also decrease the risk of cross contamination. 13. Observation on 06/11/2025 at 9:15 AM revealed CNA8 and CNA9 were observed going into Room C8 with a Hoyer lift (a mechanical lift used to transfer residents between surfaces shared between residents). When they exited, the Hoyer was placed in the hallway without being cleaned. During an interview on 06/11/2025 at 9:42 AM with CNA8, she stated, We might've thought each other cleaned it. She stated that cleaning between resident use decreased risks of contamination. During an interview on 06/12/2025 at 2:05 PM with CNA9, she stated she thought CNA8 had cleaned the Hoyer lift when they were finished using it. She stated this should be done between resident use for sanitation because staff did not want to spread germs. During an interview on 06/13/2025 at 6:31 PM with the Administrator, she stated it was her expectation for staff to clean shared equipment per policy, and they should not be touching residents' medications without hand hygiene and donning gloves to decrease any risks that could arise. 14. Observation of the dumpster on 06/11/2025 at 12:53 PM revealed infectious trash with used gloves, clear plastic bags opened with used briefs, and dirty gowns lying on the ground around the trash compactor dumpster. Observation of the same area on 06/11/2025 at 4:35 PM revealed the area still had the same debris scattered around the trash compactor dumpster. During an interview with the Maintenance Director on 06/13/2025 at 1:23 PM, the Director stated the maintenance department was responsible to take out the red barrel/ hazmat trash. The Director stated other trash was housekeeping's responsibility to take to the trash compactor. The Director stated the trash on the ground was a concern because of the potential for cross contamination. During an interview with the Environmental Services Supervisor (EVS) on 06/13/2025 at 11:33 AM, she stated nursing took the trash out of the residents' rooms to the soiled utility room. Then, she stated housekeeping took the trash to the dumpster. She stated there was an infection control concern for cross contamination with trash lying on the ground. She stated it was maintenance's responsibility to clean up the dumpster area. She stated the dumpster was emptied every week on Wednesday. During an interview with the Director of Nursing (DON) on 06/13/2025 at 4:40 PM, she stated the CNAs took the residents' rooms trash to the dirty utilities, and housekeeping emptied it to the dumpster. She stated her expectation was for all staff to pick up trash off the ground and dispose of it properly into the dumpster. During an interview with the Administrator on 06/13/2025 at 4:43 PM, she stated her expectation for staff was to discard trash into the dumpster. 15. Observation of the [NAME] Unit on 06/11/2025 at 3:30 PM revealed R1's catheter collection bag was anchored under her recliner, and the entire bottom surface of the collection bag was touching the ground. Further observation revealed that LPN2 repositioned R1's catheter collection bag without donning PPE first. Additionally, LPN2 did not perform hand hygiene before sitting down at the nurses' station to type on the computer. Review of an admission Record, found in R1's EMR, revealed the facility admitted the resident on 01/03/2022 with diagnoses including cerebral palsy, epilepsy, and neuromuscular dysfunction of the bladder. Review of R1's quarterly MDS, with an ARD of 04/08/2025, revealed a BIMS, was not assessed because the resident was rarely or never understood. Review of an Order Summary Report, found in R1's EMR, revealed the resident was placed on EBP related to a urinary catheter on 04/28/2025. During an interview with LPN2 on 06/11/2025 at 3:35 PM, she stated the collection bag should not touch the ground due to cross contamination. When asked if there was a concern when she touched the urine collection bag of a resident on EBP, LPN2 stated, That's not my resident; I didn't know they were on EBP. When asked if it was ever acceptable to touch a urine drainage bag without PPE, she replied, No. Furthermore, when asked what additional steps she should have taken after providing care to R1, she stated she should have immediately performed hand hygiene. During an interview with the IP/SDC on 06/11/2025 at 4:15 PM, she stated urine collection bags should not touch the ground due to cross contamination. She stated the facility had suspended LPN2 for failure to consistently follow facility ICP policies. She stated LPN2 had completed her three week orientation and had passed her competencies, but there were continued concerns with her inability to retain training/education and perform appropriate ICP. During additional interview on 06/13/2025 at 8:11 AM with the IP/SDC, she stated all competencies were audited at hire and bi-annually. She stated skill audits for nurse aides covered bathing, hair and nail care, brief change, mechanical lift transfer, and gait belts. She stated EBP education was done on-line and in-person. She stated the facility now stored PPE in the hall to provide better accessibility for staff. She stated every time a policy was changed, staff were re-educated. She stated staff was educated on the meaning of the dot next to the resident's name in the hall; told to use a face shield when emptying the catheter bag or providing catheter care; and should know contact precaution and PPE's and droplet precaution. She stated she expected staff to provide safe care, and failure to do so was not from a lack of training. During additional interview with the IP/SDC on 06/13/2025 at 10:23 AM, she stated the facility adhered to the CDC's guidelines and followed the facility's infection prevention and control policies. She stated all EBP rooms had a red dot on the door leading into the room next to the resident's name on precautions. She stated that transmission based precaution (TBP) rooms had signs on the doors leading into the room. The IP/SDC stated gowns and gloves must be worn whenever staff entered an EBP room if they provided high-level care. She stated staff should remove gloves when contaminated or after care and perform hand hygiene before they exited a resident's room. She stated new PPE should be donned if they provided additional care. According to the IP/SDC, all staff members received education related to ICP. The IP stated nursing staff should follow the facility's policies and manufacturer's guidelines to clean and disinfect the glucometer. Additionally, the IP/SDC stated she was unsure why staff did not follow EBP and infection control practices despite being educated on the importance of ICP. She stated all staff members were trained upon hire in the use of PPE and isolation precautions, including EBP. The IP/SDC stated it was her expectation that all staff adhered to the facility's policies and procedures to help prevent the spread of infections. She stated it was important for the health and safety of the residents. During an interview with the Nurse Practitioner on 06/12/2025 at approximately 3:00 PM, she stated it was her expectation that staff performed infection control and prevention processes when caring for the residents. She stated it was important to prevent the spread of infection and maintain the residents' safety and well-being. During an interview with the Director of Nursing (DON) on 06/13/2025 at 5:50 PM, she stated staff received ICP training during orientation and then annually. She stated the UMs rounded on their units frequently, ideally at least once in the morning and once in the afternoon and possibly even more often than twice a day. The DON stated UMs should actively oversee their units, assist staff as needed, and consistently monitor staff activities. She stated while they might not be present on the unit for extended periods, nursing leadership should engage with staff and monitor conditions while they were there. She stated it was her expectation that staff would reach out for guidance whenever they had questions. The DON stated, I expect them to come to us if they need clarification. Additionally, the DON stated cleaning and disinfecting shared equipment was important to prevent the spread of infection. Furthermore, she stated it was her expectation that nurses were competent in performing procedures such as glucose monitoring, ensuring they not only performed the procedures correctly but also adhered to infection control protocols while doing so. She stated it was her expectation that all staff adhered to the facility's ICP policies and followed CDC guidelines at all times to prevent the spread of infection and to maintain the safety and well-being of the residents. During an interview with the Administrator on 06/13/2025 at 6:32 PM, she stated staff should adhere to ICP protocols, including EBP, to protect both residents and staff from the spread of infections. Additionally, she stated staff should be educated and complete their competencies. The Administrator stated it was her expectation that all staff followed ICP policies. Furthermore, she stated nurse managers were expected to round as often as needed to oversee staff to ensure they were wearing the correct PPE and following facility policy. The Administrator stated it was her expectation that staff performed hand hygiene between resident care and followed established CDC guidelines and standards of care related to ICP. She stated nursing staff should adhere to all facility policies and procedures, along with CDC recommendations, for infection control during glucose checks and the cleaning and disinfection of shared equipment. She stated ICP was important for the safety and well-being of both residents and staff.

Based on observation, interview, record review, and review of the facility's policy, the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promoted maintenance or enhancement of his or her quality of life, recognizing each resident's individuality for 2 of 28 sampled residents, Resident (R) 1 and R16. 1. Observation on 06/10/2025 of R1 revealed her indwelling urinary catheter collection bag was full of urine and not covered. The collection bag could be seen from the hallway. 2. Observation on 06/10/2025 of R16 revealed Licensed Practical Nurse (LPN) 2 administered an insulin injection to R16, in her abdomen, while the resident was seated in her wheelchair at the medication cart in the hallway. There were multiple residents and staff within sight of R16 at the time. The findings include: Review of the facility's policy titled, Resident Rights, dated 11/01/2024, revealed each resident had the right to personal privacy and to be treated with respect and dignity. 1. Review of R1's Face Sheet, found in R1's electronic medical record (EMR), revealed the facility admitted the resident on 01/03/2022 with diagnoses including cerebral palsy, epilepsy, and neuromuscular dysfunction of the bladder. Review of R1's quarterly Minimum Data Set [MDS], with an Assessment Reference Date (ARD) of 04/08/2025, revealed a Brief Interview for Mental Status [BIMS], was not assessed because the resident was rarely or never understood. Further review revealed R1 had an indwelling urinary catheter because of neuromuscular dysfunction of the bladder. Review of R1's Comprehensive Care Plan [CCP], dated 04/09/2025, revealed R1 would be free from complications from catheter use through the review period of 07/07/2025. Further review of the CCP revealed the facility care planned the resident as having a catheter. Interventions, dated 04/09/2025, included to maintain a catheter privacy bag. Observation of R1 on 06/10/2025 at 9:58 AM revealed there was no dignity cover for the resident's indwelling urinary catheter collection bag. Also, the collection bag was full of urine and could be seen from the hallway. During an interview with Unit Manager (UM) 1 on 06/10/2025 at 10:00 AM, she stated the facility used dignity bag covers, and she did not know why R1's catheter collection bag was uncovered. The UM stated the catheter collection bag should be covered to protect the dignity of the resident. 2. Review of R16's Face Sheet, found in R16's EMR, revealed the facility admitted the resident on 11/22/2022 with diagnoses including hemiplegia and hemiparesis, cerebral infarction, and type 2 diabetes mellitus. Review of R16's quarterly MDS, with an ARD of 05/23/2025, revealed a BIMS, score of zero out of 15, which indicated the resident had severe cognitive impairment. Observation of R16 on 06/10/2025 at 11:25 AM revealed LPN2 administered an insulin injection to R16 in her abdomen while the resident was seated in her wheelchair, which was positioned next to the medication cart in the hallway. During the administration of the injection, there were other residents and staff present in the hallway. During an interview with LPN2 on 06/10/2025 at 11:28 AM, she stated she was aware she could not administer medication in the dining or activity rooms. However, she stated since the injection was given in the hallway near the medication cart, she believed it was appropriate to proceed with the administration. LPN2 stated she did not provide privacy for the resident while administering the insulin injection. She stated she should have taken the resident to her room to ensure privacy. LPN2 stated it was important to provide privacy to protect the resident's dignity. During an interview with the Director of Nursing (DON) on 06/13/2025 at 5:45 PM, she stated nurses should not administer medications in the hallway. The DON further stated it was her expectation that staff treated every resident with dignity. Additionally, she stated providing privacy was essential for safeguarding each resident's dignity. During an interview with the Administrator on 06/13/2025 at 6:30 PM, she stated it was her expectation that staff provided each resident with privacy during care. She stated it was important to protect the resident and ensure dignity.

Based on observation, interview, record review, and review of the facility's policy, the facility failed to keep residents free from misappropriation for 1 out of 3 sampled residents for misappropriation, Resident (R) 92. The findings include: Review of the facility's policy titled, Abuse, dated 10/01/2021 and revised on 10/20/2022, defined misappropriation as the deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of the resident's belongings or money without the resident's consent. The policy also stated, The resident has the right to be free from misappropriation of resident's property. Observation on 06/11/2025 at 8:26 AM revealed Registered Nurse (RN) 1 used MiraLAX (a laxative), belonging to R92, and administered it to R95. Review of R92's admission Record, found in R92's electronic medical record (EMR), revealed the facility admitted the resident on 03/14/2022 with diagnoses of fibromyalgia, type 2 diabetes, and constipation. Review of R92's quarterly Minimum Data Set [MDS], with an Assessment Reference Date (ARD) of 05/13/2025, revealed the facility assessed the resident to have a Brief Interview Mental Status [BIMS] score of 14 out of 15, indicating R92 was cognitively intact. Review of R92's Physician's Orders, dated 05/07/2025, revealed R92 had an order for MiraLAX 17 grams every 12 hours as needed (PRN) for constipation. Review of R92's Medication Administration Record (MAR) for June 2025, revealed R92 had not received any doses of MiraLAX from 06/01/2025 to 06/13/2025. Review of R95's admission Record, found in R95's EMR, revealed the facility admitted the resident on 12/02/2022 with diagnoses of spinal stenosis, constipation, and depression. Review of R95's quarterly MDS, with an ARD of 04/04/2025, revealed the facility assessed the resident to have a BIMS score of 14 out of 15, indicating R95 was cognitively intact. Review of R95's Physician's Orders, dated 05/11/2024, revealed R95 had an order for MiraLAX 17 grams every morning for constipation. Review of R95's MAR, for June 2025, revealed R95 had received a dose of MiraLAX every morning from 06/01/2025 to 06/12/2025. During an interview on 06/11/2025 at 9:07 AM with RN1, she stated R95 was missing his MiraLAX, and it had been reordered by pharmacy the morning of 06/11/2025. She stated, when ordered early enough, it came within 24 hours. She stated she used R92's MiraLAX so R95 did not miss a dose. RN1 stated a medication should not be shared between residents. During an interview on 06/13/2025 at 5:47 PM with the Director of Nursing (DON), she stated when a medication was missing or empty, she expected staff to follow up with pharmacy and to reorder as needed. She stated staff was expected to call the provider to see if the medication should be held, administered late, or changed to something else that might be available. She stated her expectation was that staff did not borrow medications from another resident because they belonged to that specific resident, and we don't want to take things from another resident. During an interview on 06/13/2025 at 6:31 PM with the Administrator, she stated her expectation was that staff did not borrow another resident's medications, but they should notify the provider for direction on what steps should be taken. She stated, The issue is that you shouldn't borrow from another resident.

Based on observation, interview, record review, and review of the facility's policy, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for 4 of 28 sampled residents, Resident (R) 2, R17, R36, and R47. The findings include: Review of the facility's policy titled, Care Planning-Comprehensive Person-Centered, undated, revealed the facility would develop and implement a comprehensive person-centered care plan for each resident that included measurable objectives and time frames to meet the residents medical, nursing, and mental and psychosocial needs as identified throughout the comprehensive resident assessment instrument (RAI) process. The policy defined person-centered care meant to focus on the resident as the locus of control and support the resident in making their own choices and having control over their daily lives. 1. Observation on 06/11/2025 at 9:45 AM revealed R36 was sleeping in bed with an indwelling urinary catheter leg bag noted to be strapped to the resident's leg. Review of R36's admission Record, found in R36's electronic medical record (EMR), revealed the facility admitted R36 on 10/12/2023 with a diagnoses of seizures, obstructive and reflux uropathy, and overactive bladder. Review of R36's quarterly Minimum Data Set [MDS], with an Assessment Reference Date (ARD) of 04/02/2025, revealed the facility assessed the resident to have a Brief Interview for Mental Status [BIMS] score of 15 out of 15, indicating the resident was cognitively intact. Review of R36's Physician's Orders, dated 11/15/2023, revealed R36 had an order for an indwelling urinary catheter. Review of R36's Care Plan revealed the indwelling urinary catheter was initially care planned on 11/15/2023. However, further review revealed the Care Plan was not updated until 06/10/2025 to add R36's preference for a leg bag. During an interview on 06/10/2025 at 10:01 AM with Registered Nurse (RN) 1, she stated R36 had always preferred his leg bag. During an interview on 06/10/2025 at 3:37 PM with Certified Nurse Aide (CNA) 6, she stated R36 always kept his leg bag on and would not use a regular urinary collection bag when he was in bed. During an interview on 06/11/2025 at 8:21 AM with R36, he stated he was having an episode of low sodium and imagining things. He was unable to answer questions related to his indwelling urinary catheter and preference for the leg bag at the time of the interview. 2. Observation on 06/11/2025 at 2:19 PM revealed R47 lying in bed sleeping. R47 had a colostomy. Review of R47's admission Record, found in R47's EMR, revealed the facility readmitted R47 on 08/27/2024 with a colostomy after a bowel resection done for a colovesicular fistula which caused frequent urinary tract infections and sepsis. Review of R47's quarterly MDS, with an ARD of 05/24/2025, revealed the facility assessed the resident to have a BIMS score of 13 out of 15, indicating R47 was cognitively intact. Review of R47's Physician's Orders, dated 09/12/2024 and 12/16/2024, revealed an order for ostomy care. Review of R47's Care Plan, dated 01/27/2025, revealed this was the first time R47 was care planned for an alteration in elimination related to a need for a colostomy, even though the resident returned to the facility on [DATE] with a colostomy. During an interview on 06/11/2025 at 2:19 PM, R47 stated she had the colostomy done last August. She stated the staff cared for her colostomy. During an interview on 06/10/2025 at 3:45 PM with Licensed Practical Nurse (LPN) 3, she stated R47 had a colostomy prior to being admitted to the facility. During additional interview with LPN3 on 06/12/2025 at 2:13 PM, she stated care plans were worked on by the MDS Nurse. She stated nurses were expected to update care plans when the MDS Nurse was not in the building. During an interview on 06/13/2025 at 7:45 AM with the MDS Nurse, she stated nurses updated care plans, and the MDS nurse reviewed them. During additional interview on 06/13/2025 at 10:41 AM with the MDS Nurse, she stated R47 should have been care planned for her colostomy upon her readmission in August 2024. The MDS nurse stated R47 did not have a colostomy when she originally came into the facility, and she was sent to the hospital and then returned with the colostomy in August 2024. She stated upon readmission, the nurse missed updating the care plan, and she did not recall if it was mentioned in their daily meetings. She stated she discovered it was missing from R47's Care Plan in January 2025, and she added it at that time. She stated the risk of not having it there was the resident might not receive the proper care. 3. Observation on 06/12/2025 at 1:49 PM revealed R17 was sleeping in bed with an indwelling urinary catheter leg bag noted to be strapped to the resident's leg. Review of R17's admission Record, found in R17's EMR, revealed the facility admitted the resident on 04/08/2025 with a diagnoses of Alzheimer's disease, anxiety, and hypertension. Review of R17's admission MDS, with an ARD of 04/12/2025, revealed the facility assessed the resident to have a BIMS score of two out of 15, indicating the resident was severely cognitively impaired. Review of R17's Physician's Orders, dated 04/15/2025, revealed an order for an indwelling urinary catheter. Review of R17's Progress Note, dated 05/20/2025, revealed R17 now had a leg bag for the catheter because the resident got up to go to the restroom and ripped the catheter out. Review of R17's Care Plan revealed the indwelling urinary catheter was initially cared planned on 04/08/2025 and revised on 05/01/2025. However, further review revealed the Care Plan was not updated to add R17's preference for a leg bag until 06/10/2025. During an interview on 06/10/2025 at 4:55 PM with R17's representative, she stated R17 was not voiding properly and required an indwelling urinary catheter to be placed. She stated R17 would forget about the catheter, and she accidentally pulled it out twice. She stated she and the facility decided to try a leg bag, and since changing to the leg bag, R17 had not pulled it out anymore. She stated she could not remember the exact date the decision was made to only use a leg bag. During an interview on 06/12/2025 at 1:49 PM with CNA10, she stated R17 wore the leg bag all the time. During an interview on 06/12/2025 at 2:00 PM with LPN5, she stated R17 had the indwelling urinary catheter placed for urinary retention. She stated she was unsure of the exact date the leg bag was placed. She stated the resident was care planned for the leg bag. During continued interview on 06/13/2025 at 10:41 AM with the MDS Nurse, she stated R17 should have been care planned sooner for the leg bag to decrease her risk of infection. During an interview on 06/13/2025 at 2:08 PM with LPN1, she stated she could not remember the date R17 was switched to a leg bag. She stated updating the care plan was a team effort, and she was not sure why it was not done. She stated it was important to keep care plans updated so staff was aware of how to care for residents. She stated the risk of always using the leg bag was that it might not drain properly and lead to an infection. 4. Review of R2's admission Record, found in R2's EMR, revealed the facility admitted the resident on 02/23/2022 with diagnoses of cerebral palsy, epilepsy, and anxiety. Review of R2's quarterly MDS, with an ARD of 04/24/2025, revealed the facility assessed the resident to have a BIMS score of zero out of 15, indicating severe cognitive impairment. Review of R2's Care Plan revealed she was not care planned for activities until 06/12/2025. Activities was added to the Care Plan with a focus of the resident prefers to participate in activities such as 1:1 activities, reading books, watching television programs in room, music therapy. During an interview on 06/12/2025 at 8:39 AM with the Activities Director, she stated R2 did not come out of her room for activities because she remained in bed all the time. She stated R2's family member preferred to do activities with R2. She stated R2 was a part of a program where she received music therapy every other week at the bedside. She stated she could add a temporary 1:1 for activities to work with R2 while her family member was hospitalized . She stated she would call R2's representative about activities. During an interview on 06/13/2025 at 1:53 PM with the Activities Aide, he stated he did bedside activities with R2, who was responsive to music and enjoyed being read to. He stated he had been doing them while her family member had been hospitalized . He stated when R2's family member was at the facility, the Activities Aides stopped by R2's room to visit and to make sure the resident had some sort of activity. He stated he usually did independent activities, but in a meeting with his Director yesterday, they discussed making R2's activities 1:1 while her family member was not present to ensure that R2 received at least 15 minutes a day. The State Survey Agency (SSA) Surveyor attempted to interview R2's representative by telephone on 06/11/2025 at 2:39 PM but was unsuccessful. During an interview on 06/13/2025 at 5:47 PM with the Director of Nursing (DON), she stated everyone was responsible for updating care plans to make sure they were up-to-date with the care being provided. She stated care plans were discussed in the staff interdisciplinary morning meetings to ensure there were no delays in care planning. She stated the morning meeting process was changed in March 2025 to eliminate things being missed on the care plan. She stated activities should be assessed upon admission and updated quarterly and as needed to make sure they kept residents engaged and involved for their psychosocial well-being. During an interview on 06/13/2025 at 6:31 PM with the Administrator, she stated it was her expectation that care plans were developed when there were changes to the resident's condition or care. She stated fully developed care plans were important to ensure the facility was providing care the residents needed.

Based on observation, interview, record review, review of a Centers for Disease Control and Prevention (CDC) website, and review of the facility's policy, the facility failed to ensure a resident who was fed by enteral means received the appropriate treatment and services to prevent complications of enteral feeding including but not limited to aspiration pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities, and nasal-pharyngeal ulcers for 1 of 1 sampled residents with enteral feeding, Resident (R) 2. The findings include: Review of the facility's policy titled, Enteral Tube Feeding via Continuous Pump, dated 10/01/2021, revealed residents receiving enteral feedings should have their head of bed (HOB) positioned 30 to 45 degrees (Semi-Fowlers position) for feeding, unless medically contraindicated. Review of the CDC's guidance at www.cdc.gov, Guidelines for Preventing Health-Care--Associated Pneumonia, 2003, Prevention of Aspiration Associated with Enteral Feeding, revealed, In the absence of medical contraindication(s), elevate at an angle of 30-45 degrees of the head of the bed of a patient at high risk for aspiration (e.g., a person receiving mechanically assisted ventilation and/or who has an enteral tube in place). Observation on 06/10/2025 at 9:18 AM and 06/11/2025 at 9:10 AM revealed R2 was lying in bed with her tube feeding infusing, and the head of bed (HOB) was not elevated to help decrease the risk of aspiration. Review of R2's admission Record, found in the electronic medical record (EMR), revealed the facility admitted the resident on 02/23/2022 with diagnoses of cerebral palsy, epilepsy, and dysphagia. Review of R2's quarterly Minimum Data Set [MDS], with an Assessment Reference Date (ARD) of 04/24/2025, revealed a Brief Interview for Mental Status [BIMS] score of zero out of 15, indicating R2 was severely cognitively impaired. Review of R2's Care Plan, initiated on 09/11/2023 and revised on 01/29/2024, revealed R2 was care planned for impaired gastrointestinal status related to feeding tube, gastroesophageal reflux disease (GERD), and history of constipation. Review of R2's Physician's Orders, dated 05/31/2024, revealed an order for enteral feeding every day related to dysphagia. During an interview on 06/11/2025 at 9:10 AM with Licensed Practical Nurse (LPN) 4, she stated residents receiving tube feeding should have the HOB be elevated 35 to 40 degrees. She stated R2 had pain and yelled out when her head was elevated, so she raised her head of bed slowly throughout the shift. During an interview on 06/13/2025 at 8:12 AM with the Infection Preventionist/Staff Development Coordinator(IP/SDC), she stated staff should follow the facility's policies and CDC guidelines on HOB placement for residents receiving enteral feedings. During an interview on 06/13/2025 at 5:47 PM with the Director of Nursing (DON), she stated it was her expectation that the HOB angle for any resident receiving tube feedings was to be kept at 30 degrees or greater to decrease the risk of aspiration. During an interview on 06/13/2025 at 6:31 PM with the Administrator, she stated it was her expectation for staff to follow professional standards when administering tube feedings to residents.

Based on interview and record review, the facility failed to consistently provide respiratory treatments twice daily as ordered for 1 of 28 sampled residents, Resident (R) 12. Review of R12's digital respiratory therapy log on 06/12/2025 at 7:40 PM, revealed multiple missed treatments over the past month. The findings include: On 06/12/2025, a verbal request was made for the facility's Respiratory Policy. However, the facility did not provide the State Survey Agency (SSA) Surveyor with the requested document. Review of an admission Record, found in R12's electronic medical record (EMR), revealed the facility admitted the resident on 04/03/2024 with diagnoses including dementia, cerebral infarction, and aphasia. Review of R12's quarterly Minimum Data Set [MDS], with an Assessment Reference Date (ARD) of 04/03/2025, revealed the resident had a BIMS score of zero out of 15, which indicated severe impairment. Review of an Order Summary Report, for May 2025 and June 2025 and found in R12's EMR, revealed the resident was ordered use of the Volara System (used for lung expansion therapy and the mobilization of secretions) as tolerated for 10 to 20 minutes with sodium chloride inhalation every day and night shift. Review of the Volara device's digital history therapy log on 06/12/2025 at 7:43 PM revealed a history of the days and time the respiratory treatment was administered to R12. Further review revealed the facility failed to provide R12 with 22 respiratory treatments between 05/15/2025 and 06/12/2025. The dates were as follows: 05/17/2025 AM dose; 05/18/2025 PM dose; 05/24/2025 PM dose; 05/25/2025 AM and PM doses; 05/26/2025 PM dose; 05/27/2025 PM dose; 05/28/2025 PM dose; 05/29/2025 PM dose; 05/31/2025 AM dose; 06/01/2025 PM dose; 06/02/2025 AM and PM doses; 06/03/2025 PM dose; 06/04/2025 PM dose; 06/05/2025 PM dose; 06/06/2025 PM dose; 06/08/2025 AM dose; 06/09/2025 PM dose; 06/10/2025 PM dose; 06/11/2025 PM dose; and 06/12/2025 PM dose. Review of a Progress Note, found in R12's EMR, dated 06/11/2025 at 2:35 PM, revealed a chest x-ray was ordered due to wheezing lung sounds. During an interview with R12's Power-of-Attorney (POA) on 06/12/2025 at 9:13 AM, he stated he was concerned because his mother did not receive her Volara respiratory therapy as prescribed by her pulmonologist. He stated the nursing staff was inconsistent in providing her evening treatments. Additionally, he stated on 06/11/2025, his mother experienced increased congestion and began wheezing, which necessitated a chest x-ray. He stated R12 tended to develop increased congestion when she did not consistently receive her respiratory treatments. During an interview with the Respiratory Therapist (RT) on 06/13/2025 at 2:16 PM, she stated the Volara respiratory treatment controlled R12's secretions by providing an aerosol treatment in a delivery system to enhance therapy effectiveness. She stated the system was indicated for the treatment and prevention of increased secretions and to soften R12's bronchi (tubes in the lungs). She stated the respiratory treatments were very important to mobilize R12's secretions. She stated the resident's pulmonologist ordered the treatments for twice daily. She stated she would provide the treatments when she was in the building from Monday to Thursday. She stated nursing was responsible for administering treatments when she was not available, including during nights and weekends. The RT stated it was her expectation that the specific treatment orders written by a provider were followed and administered to the resident. During an interview with the Nurse Practitioner on 06/12/2025 at approximately 3:00 PM, she stated it was her expectation that nurses administered medication as ordered by the provider. She stated following provider orders was important to maintain the resident's health, quality of life, and ensure their well-being. During an interview with the Administrator on 06/13/2025 at 5:50 PM, she stated it was her expectation for nursing staff to follow provider orders as written to maintain the health and well-being of the resident.

Based on interview, record review, and review of the State Operations Manual (SOM), the facility failed to store food in a safe manner in a nourishment refrigerator on 1 of 3 resident units, the [NAME] Unit. The findings include: Review of the SOM definitions revealed the Danger Zone meant food temperatures above 41 degrees Fahrenheit (F) and below 135 degrees F that allowed the rapid growth of pathogenic microorganisms that could cause foodborne illness. Potentially Hazardous Foods (PHF) or Time/Temperature Control for Safety (TCS) Foods held in the danger zone for more than 4 hours (if being prepared from ingredients at ambient temperature) or 6 hours (if cooked and cooled) might cause a foodborne illness outbreak if consumed. Review on 06/12/2025 at 2:50 PM of the Refrigerator Temperature Log for the [NAME] Unit, dated June 2025, revealed documentation of multiple dates the temperatures were measured above 41 degrees F. Further review revealed on 06/03/2025, the temperature was recorded as 46 degrees F; on 06/04/2025, the temperature was recorded as 42 degrees F; on 06/05/2025, the temperature recorded was 48 degrees F; and on 06/06/2025, the temperature recorded was 46 degrees F. During an interview on 06/12/2025 at 2:53 PM with Certified Nurse Aide (CNA) 2, she stated she was not sure but thought the temperature range should be between 35 degrees F and 45 degrees F. She stated if the refrigerator was not working, she would contact the maintenance person or the nurse. She stated food that was not kept at the proper temperature could spoil and cause the residents to get sick. During an interview on 06/12/2025 at 3:04 PM with Licensed Practical Nurse (LPN)/Unit Manager (UM) 1, she stated she thought the temperature range for the unit nutrition refrigerator should fall between 36 degrees F and 46 degrees F. She stated it was the responsibility of night shift staff to record the temperatures and to ensure the safety of the contents, but it was her responsibility to make sure it had been done. She stated if the food was not kept at the right temperature, food could spoil, and residents could get sick as a result. During an interview on 06/13/2025 at 5:07 PM with the Director of Nursing (DON), she stated she expected the night shift staff to monitor and record temperatures of the nutrition room refrigerators and to ensure the safety of its contents. She stated if there was a concern about the working condition of the refrigerator, staff was expected to reach out to maintenance or to notify their supervisor for further direction. She stated the appropriate refrigerator temperature was no greater than 41 degrees F. During an interview on 06/13/2025 at 6:10 PM, the Administrator stated it was her expectation that the staff would monitor and document the refrigerator temperatures and report any concerns to their supervisor. She stated if food got too warm, it could cause it to spoil and could cause the residents to get sick.

Based on observation, interview, record review, and review of the facility's policy, the facility failed to develop or implement 2 of 36 sampled residents' Comprehensive Care Plans (CCP), Resident (R) 124 and R36. R124 returned from the hospital and reported pain, but she did not receive ordered pain medication for approximately 21 hours after it was ordered, despite care planning to administer medications per orders. (Cross Reference F689) R36's CCP was not developed with interventions to address the resident's and family's non-compliance with R36's current diet order. The findings include: Review of the facility's Comprehensive Care Plan policy, revised on 06/30/2022, revealed a comprehensive person-centered care plan was developed and implemented for each resident, consistent with a resident's rights that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs. 1. Review of R124's Admission Facesheet revealed the facility readmitted the resident on 03/01/2024 at 12:30 PM from the hospital, with diagnoses of new fracture of the right and left femur (upper leg), not requiring surgery. Review of R124's quarterly Minimum Data Set (MDS), with an assessment reference date (ARD) of 03/08/2024, revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of 15 of 15, indicating the resident was cognitively intact. Review of R124's Physician's Orders revealed Oxycodone 5 mg every 12 hours as needed (PRN) for pain was ordered on 03/01/2024 at 2:00 PM. Oxycodone 15 mg scheduled every six hours was ordered on 03/02/2024 at 4:52 AM. Review of R124's CCP, initiated on 10/05/2023, revealed the resident was at risk for pain. Interventions were to administer medications per orders. Review of Resident 124's pain scores, on a scale of 0 to 10, with 10 being the highest, revealed on 03/01/2024 at 3:10 PM, the pain score was 5/10; on 03/02/2024 at 9:49 AM, the pain score was 8/10; on 03/02/2024 at 1:24 PM, the pain score was 8/10; and on 03/02/2024 at 5:40 PM, the pain score was 5/10. Review of R124's Medication Administration Record (MAR) revealed R124 received 15 mg of Oxycodone on 03/02/2024 at 12:00 PM and 6:00 PM and 5 mg of Oxycodone on 03/02/2024 at 9:15 PM. Further review revealed R124 did not receive Oxycodone 5 mg PRN for pain on 03/01/2024 at 3:10 PM; on 03/02/2024 at 9:49 AM; on 03/02/2024 at 1:24 PM; and on 03/02/2024 at 5:40 PM. 32635 2. Review of R36's Admission Facesheet revealed the facility admitted the resident on 04/27/2024 with diagnoses including dysphagia, oropharyngeal phase, and major depression. Review of R36's annual MDS, with an ARD of 07/22/2024, revealed the facility assessed the resident to have a BIMS score of 15 of 15, which indicated the resident was cognitively intact. Review of R36's Physician's Orders, dated 04/27/2024, revealed a controlled carbohydrate diet, pureed texture, regular fluid, and thin consistency was ordered. Review of R36's CCP, with the admitted [DATE], revealed the area of focus, resident had dental problems related to missing teeth, dated 11/28/2023. The goal was for the resident to be free of infection, pain, or bleeding in the oral cavity through the next review date of 10/22/2024. The interventions were for a dietary consult as needed, encourage the resident to complete oral care, monitor for changes in nutritional status related to dental, and refer to dental services; the date initiated was 11/23/2023. Further review revealed no focus on the resident's/family's non-compliance with diet and education of the resident or family on the prescribed diet. Observation on 08/14/2024 at 2:23 PM revealed R36 had one small empty potato chip bag, one small full potato chip bag, and an opened package of saltine crackers on her bedside table. In an interview with R36 on 08/14/2024 at 2:24 PM, she stated she had no coughing or choking on regular food and could not eat hard-cooked hamburgers or chicken. She stated she did not pass the swallowing test at the hospital. She stated her family brought her food. In an interview with R36's daughter on 08/14/2024 at 3:59 PM, she stated the facility told them it was okay to bring in food; they monitored her. She stated R36 did not have dentures and hard-to-chew meats was difficult. She stated R93, the resident's spouse, brought food to the resident. She stated R36 tolerated fish, baked beans, and cauliflower and ate a regular texture diet before her recent hospital admission on 04/22/2024. In an interview with Certified Nurse Assistant (CNA) 11, Central Supply on 08/14/2024 at 3:52 PM, she stated she was not familiar with the resident's diet. However, she stated the family had a picnic with the resident and would bring food to the resident. In an interview with Speech 1 on 08/14/2024 at 2:24 PM, she stated the family brought food to the resident. She stated she educated the family on the resident's texture diet. She said she reassessed the resident in 07/2024, and the resident stated she wanted to remain on the puree diet because some foods were hard to swallow. In an interview with the B Unit Manager on 08/16/2024 at 2:39 PM, she stated speech evaluated the resident's diet texture. She stated R36's family members brought food to the resident, such as on the resident's birthday. She stated the food consisted of fried chicken, green beans, and mashed potatoes. She stated staff educated the family on the diet to prevent choking. She stated R36's spouse lived at the facility and brought R36 food. She stated R36's care plan should address the diet texture, the resident's non-compliance, and the family's non-compliance with bringing regular-texture food to R36. During interview with the MDS Coordinator on 08/16/2024 at 2:59 PM, she stated she followed the Resident Assessment Instrument manual when she developed a care plan. She stated nurses could make changes to the care plan. She stated she attended the morning meetings and discussed readmissions and any updates or changes. She stated care plans should be immediately changed and should reflect the resident's care accurately. During interview with the Director of Nursing (DON) on 08/14/2024 at 3:11 PM, she stated the resident's care plan should be fully developed, implemented, and followed to meet the resident's care needs. In an interview with the Administrator on 08/16/2024 at 3:30 PM, she stated changes in resident care were discussed in the clinical morning meeting, and the accuracy of the CCP depended on the MDS assessment. She stated she expected staff to develop and implement care plans to meet the resident's needs.

Based on interview, record review, and review of the facility's policies, the facility failed to administer prescribed pain medications timely for 1 of 2 sampled residents, Resident (R) 124. R124 returned to the facility on [DATE] at 12:30 PM, and orders were written for Oxycodone 5 milligrams (mg) every 12 hours as needed (an opioid pain medication) and Oxycodone 15 mg every six hours, for R124's fracture of the right and left femur. Observations and interviews revealed two Oxycodone 5 mg and two Oxycodone 5 mg/325 mg acetaminophen (a non-narcotic pain medication) were available in the medication emergency box, however, staff were unaware the medications were available to the resident. In addition, R124 first expressed pain to staff on 03/01/2024 at 3:10 PM. However, R124 did not receive Oxycodone until 03/02/2024 at 12:00 PM, approximately 21 hours after R124 had pain documented. (Cross Reference F656) The findings include: Review of the facility's policy titled, Ordering and Receiving Controlled Medications, dated 01/2023, revealed in an emergency situation, verbal authorization could be given by the prescriber to the pharmacist for a new order. Review of the facility's policy titled, Medication Administration, revised 01/17/2023, revealed medications were administered by licensed nurses, or other staff who were legally authorized to do so, as ordered by the physician and in accordance with professional standards of practice. Review of R124's Facesheet revealed the facility readmitted the resident on 03/01/2024 at 12:30 PM from the hospital, with diagnoses of new fracture of the right and left femur (upper leg), not requiring surgery. Review of R124's quarterly Minimum Data Set (MDS), with an assessment reference date (ARD) of 03/08/2024, revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of 15 of 15, indicating the resident was cognitively intact. Review of the Physician's Orders revealed Oxycodone 5 mg every 12 hours as needed for pain was ordered on 03/01/2024 at 2:00 PM. Oxycodone 15 mg scheduled every six hours was ordered on 03/02/2024 at 4:52 AM. Review of R124's Medication Administration Record (MAR) revealed R124 received 15 mg of Oxycodone on 03/02/2024 at 12:00 PM and 6:00 PM and 5 mg of Oxycodone on 03/02/2024 at 9:15 PM. Further review revealed R124 did not receive Oxycodone 5 mg PRN for pain on 03/01/2024 at 3:10 PM; on 03/02/2024 at 9:49 AM; on 03/02/2024 at 1:24 PM; and on 03/02/2024 at 5:40 PM. Review of Resident 124's pain scores, on a scale of 0 to 10, with 10 being the highest, revealed on 03/01/2024 at 3:10 PM, the pain score was 5/10; on 03/02/2024 at 9:49 AM, the pain score was 8/10; on 03/02/2024 at 1:24 PM, the pain score was 8/10; and on 03/02/2024 at 5:40 PM, the pain score was 5/10. During interview with R124 at the time of the observation, she stated she was a nurse and had worked at several places. She stated she had experienced back pain all her life, and she had been receiving pain medication for a long time. She stated sometimes when she came back from the hospital, it might take 24 hours before she received any pain medication. She stated this happened four months ago. She further stated she did not remember being offered an as needed Oxycodone and was in a lot of pain. The resident stated she could not remember the 03/01/2024 incident off hand. However, when asked specific questions about the incident she stated during that time the pain was sharp, hitting the muscles. She said she did not get to sleep until 2:00 AM. During interview with Registered Nurse (RN) 4 on 08/14/2024 at 9:29 AM, she stated she did not remember the incident that occurred on 03/01/2024. Review of the schedule for 03/01/2024 revealed RN4 was the nurse who admitted R124. When specifically asked if she remembered the resident being in extreme pain, she said she did not think so. When asked if there was pain medication available in the emergency medication box, she stated she did not know. She stated in the admission process for a resident, she received a discharge summary that listed the medications. She stated she called the provider and went over the list of medications from the hospital, and she reviewed them with the provider. She stated, for a controlled medication, the process was filling out a prescription request form, and faxing the form to the provider's office. She stated the hospital sometimes sent the prescription request form. During interview with the provider's Office Manager on 08/14/2024 at 1:56 PM, she stated she reviewed the office records, and they did not receive any prescription faxes on 03/01/2024. She stated, on 03/02/2024 at 6:29 AM the Advanced Practice Registered Nurse (APRN) requested six Oxycodone 5 mg tablets, and a nurse from the facility called the office at 9:50 AM requesting the medication be shipped immediately. The Office Manager also stated Oxycodone 5 mg was shipped at 10:38 AM, and the medication got to the facility at 1:09 PM on 03/02/2024. During interview with the Assistant Director of Nursing (ADON) on 08/14/2024 at 2:05 PM, she stated she expected the nursing staff to give pain medication when a resident was in pain. During interview with the Director of Nursing (DON) on 08/14/2024 at 2:16 PM, she stated she expected nursing staff to give pain medication when a resident was in pain. She stated a medication could be given from the emergency medication box if needed, and a prescription would need to be faxed to the pharmacy when the medication was used. She stated she was not sure if Oxycodone 5 mg was available in the emergency medication box. At the time of the interview, she checked the emergency medication box and stated Oxycodone 5 mg was available. Review of the list of medications in the emergency medication box revealed the box contained Oxycodone 5 mg tablets and Oxycodone-acetaminophen 5-325 mg tablets. However, the sheet did not document how many tablets were in the box. During interview with the Pharmacist on 08/16/2024 at 3:12 PM, he stated the emergency medication box contained two Oxycodone 5 mg tablets and two Oxycodone-acetaminophen 5-325 mg tablets. During interview with the APRN on 08/15/2024 at 12:21 PM, she stated she did not remember the incident on 03/01/2024. She stated the process when a resident transferred from the hospital was to review the medications with the nurse. She stated the nurse then entered the orders in the computer, and pharmacy reviewed the orders and sent the medications. She stated she knew R124 had chronic pain. During interview with the Administrator on 08/15/2024 at 3:32 PM, she stated she expected staff to follow the facility's policies.

Based on observation, interview, record review, and review of the facility's policies, it was determined the facility failed to establish and maintain an infection prevention and control (IPC) program designed to provide a safe, sanitary, and comfortable environment and to help prevent and control the development and transmission of communicable diseases. The facility also failed to implement interventions per the Centers' for Medicare and Medicaid Services (CMS), the Centers for Disease Control and Prevention (CDC), and the Kentucky Department for Public Health (Health Department) State guidelines for COVID-19 for fifteen (15) out of one-hundred fourteen (114) sampled residents (Residents #2, #4, #9, #10, #12, #13, #14, #15, #16, #17, #18, #19, and #20). Observations, on 09/07/2021 and 09/08/2021, of multiple areas and multiple staff members revealed staff members were not following the facility's policy and the CDC's guidelines for appropriate wearing of personal protective equipment (PPE) and correct hand hygiene. The facility's failure to maintain an infection prevention and control program where residents were not unnecessarily exposed to COVID-19 has caused or is likely to cause serious injury, harm, impairment or death to a resident. Immediate Jeopardy was identified, on 09/10/2021, and was determined to exist on 09/07/2021, at 42 CFR 483.80 Infection Prevention and Control (F-880) at a Scope and Severity (S/S) of a K. The facility was notified of the Immediate Jeopardy on 09/10/2021. The facility provided an acceptable Immediate Jeopardy Removal Plan, on 09/10/2021, alleging removal of the IJ on 09/11/2021. The State Survey Agency determined the IJ had been removed on 09/11/2021, as alleged, prior to exit on 09/10/2021, with remaining non-compliance at a S/S of a E while the facility develops and implements a Plan of Correction and the facility's Quality Assurance (QA) monitors to ensure compliance with systemic changes. The findings include: Review of the facility's policy titled, Personal Protective Equipment, last reviewed 08/13/2020, revealed PPE included gloves, gowns, face protection (facemasks, goggles, face shields, and respirators), and should be used as part of Standard Precautions regardless of a resident's suspected or confirmed infection status. Hand hygiene was to be performed immediately before donning (putting on) gloves and immediately after removing gloves. Furthermore, gloves, gowns, and masks were not to be reused. Per the policy, the outside of face protection equipment, including masks and goggles/face shields, were contaminated, and staff was to keep hands away from the face. Additionally, the sequence of doffing (removing) PPE was as follows: gloves, gown, perform hand hygiene, goggles or face shield, then mask. Staff should then perform hand hygiene immediately after removing all PPE. Review of the facility's policy titled, Hand Hygiene, last reviewed 05/07/2019, revealed staff would perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. The policy stated alcohol-based hand rub (ABHR) and washing hands with soap and water were the two (2) methods for hand hygiene. Further review revealed the clinical indications for the use of hand hygiene included immediately before touching a patient, after touching a patient or the patient's immediate environment, after hands touched contaminated surfaces, and immediately after PPE removal. Per the policy, hand hygiene was to be performed immediately before donning gloves and immediately after removing gloves. Review of the facility's policy titled, Infection Prevention and Control Program (IPC), revised 08/20/2020, revealed the facility followed recommended Standard and Transmission-Based Precautions (TBP), and environmental cleaning, to prevent the transmission of organisms within the facility. Further review revealed, while in the facility, personnel were required to adhere strictly to established IPC policies, including: hand hygiene; appropriate use of PPE; and TBP where indicated. Review of the facility's policy titled, Transmission-Based Precautions, revised 08/13/2020, revealed residents who were known or suspected to be infected or colonized with infectious organisms would be placed in contact, droplet, or airborne isolation under the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Per the policy, donning PPE upon room entry and discarding before exiting the room was done to contain pathogens. Review of the CDC's Strategies for Optimizing the Supply of Eye Protection, updated 12/22/2020, revealed in a healthcare setting, eye protection was used to protect staff from exposure to respiratory secretions from residents on Droplet Precautions and for all encounters when there was moderate to substantial community transmission of COVID-19. Per the CDC, reusable eye protection (face shield and goggles) should be cleaned and disinfected after each patient encounter. Per the directive, manufacturer's instructions for cleaning PPE should be followed; however, if instructions were not available, health care providers (HCP) should wear a clean pair of gloves and wipe the inside and then outside of the face shield/goggles using an approved disinfectant solution, let dry fully, remove gloves, and use hand hygiene. Review of the CDC's Core Infection Prevention and Control Practices for Safe Healthcare Delivery in All Settings -Recommendations of the HICPAC, revision date 01/01/2021, revealed, during a COVID-19 outbreak, staff would wear eye protection (face shield or goggles) until the facility went fourteen (14) days without a new resident or staff positive case. Per the directive, a staff member must always wash hands when removing any mask or after touching his/her mask or face. Furthermore, it stated the facility was expected to adhere to the CDC's Core Principles, which included: screening all who entered the facility; proper hand hygiene; appropriate staff use of PPE; use of masks to cover the mouth and nose; and social distancing. During the Entrance Conference, on 09/07/2021, the facility identified four (4) staff members positive for COVID-19 and five (5) residents to be positive, with one resident (1) admitted to the hospital on 09/06/2021. On 09/08/2021, three (3) additional residents were identified to be positive for COVID-19. On 09/09/2021, six (6) additional residents were identified to be positive for COVID-19. Observation of the Restorative Aide (RA), on 09/07/2021 at 1:08 PM, revealed the RA was on the Combs Unit and was not wearing a face shield or goggles. Observation of Certified Nurse Aide (CNA) #1, on 09/07/2021 at 1:21 PM, on the [NAME] Unit, revealed CNA #1 was not wearing a face shield or goggles. CNA #1 was speaking with other staff members, standing by a dietary cart. Interview with CNA #1, on 09/07/2021 at 1:23 PM, revealed, when asked by the State Survey Agency (SSA) Surveyor why she was not wearing her mask, CNA #1 stated, I'm just on my break. Observation of the COVID-19/Transitional Unit, on 09/07/2021 at 1:25 PM, revealed the COVID-19 isolation rooms were the last seven (7) of fourteen (14) rooms on the Combs 1 Hall. Doors into the unit were closed with a sign on the door, which stated visitors needed to stay in the room of the person they were visiting. The sign also stated should they need assistance, they should ring the call bell. There was a yellow, plastic expandable gate separating the Transitional end of the hall from the COVID-19 isolations rooms. Further observation revealed the unit was staffed with a non-dedicated aide and a nurse, who cared for COVID-19 positive and COVID-19 negative residents. It was observed, the staff members on the unit were free to walk in and out for breaks and get supplies. Observation of the COVID-19/Transitional Unit, on 09/07/2021 at 1:30 PM, revealed Registered Nurse (RN) #1, who was assigned to the COVID-19/Transitional Unit, was not wearing her mask or goggles. Her goggles were on top of her head. Further observation revealed RN #1 placed her mask and then her goggles on when she saw the State Survey Agency (SSA) Surveyor. Furthermore, RN #1 did not use ABHR after touching her mask and goggles. Interview with RN #1, on 09/07/2021 at 1:35 PM, revealed she usually wore her goggles, when she was in resident care areas. She stated it was the facility's policy to wear goggles and a facemask while in resident care areas. She stated she did not realize she did not use ABHR after touching her mask and goggles. RN #1 stated she had received education on PPE and hand hygiene training upon hire. She further stated that she received periodic in-services regarding IPC training and COVID-19 updates. RN #1 stated that training was completed and monitored for compliance through Relias, a training software. Additional interview with RN #1, on 09/09/2021 at 3:23 PM, revealed she had been employed at the facility for nine (9) months. She stated, the PPE policy changes all the time. Yesterday, I wore a new gown each time I went into any room. Per the interview, RN #1 stated goggles and masks were to be worn in the hallway. Further interview revealed she did not clean her goggles after exiting each COVID-19 isolation room. She further stated that she wiped off the medication cart at the end of the shift and emptied the medication cart's trash receptacle, but she denied double bagging trash on the cart. When asked what PPE needed to be worn when performing [CONDITION(S)] care, she stated, I'm not sure about what PPE to wear, but I wear a gown, surgical mask, goggles, and gloves, when performing care for a non-COVID-19 positive resident. Interview with the Respiratory Therapist (RT), on 09/09/2021 at 2:50 PM, revealed when performing [CONDITION(S)] care, he donned full PPE, and used an N-95 mask with a face shield. The RT stated that when he was not in the facility, the nursing staff performed suctioning or [CONDITION(S)] care. He stated that all nurses had been taught to wear full PPE and an N-95 mask with a face shield when suctioning a resident or doing [CONDITION(S)] care. Interview with the Administrator, on 09/07/2021 at 3:30 PM, revealed there were seven (7) COVID-19 isolation rooms located behind a yellow, plastic expandable gate, which was the COVID Zone. The remaining seven (7) rooms on the unit were designated as transitional rooms and were non-isolation rooms. The Administrator stated these rooms were used for residents admitted for a short stay. According to the Administrator, the entire unit was considered a clean unit with COVID-19 isolation rooms. The facility staffed the unit with one (1) CNA and one (1) RN, who provided care for residents in both the COVID-19 isolation rooms, and the non-isolation transitional rooms. Furthermore, the Administrator stated it was the facility's policy to wear goggles/facemask while in resident care areas. When entering a TBP room, staff were required to wear an N-95 mask and goggles/facemask; and, in all administrative areas of the building, a surgical mask was required. Additional interview with the Administrator, on 09/08/2021 at 8:00 AM, revealed all staff received IPC and hand hygiene training upon hire. The Administrator stated staff continued to receive periodic in-services regarding IPC training and COVID-19 updates. She stated training was completed and monitored for compliance through Relias training software. Per the interview, all staff was monitored for compliance by Nursing Management (Director of Nursing (DON), Assistant Director of Nursing (ADON), Staff Development Coordinator (SDC), Infection Preventionist (IP), and Unit Managers). The Administrator stated, if Nursing Management observed noncompliance, they would stop and educate. Observation of the DON, on 09/07/2021 at 1:40 PM, revealed she was in a resident care area not wearing goggles. The DON entered the COVID-19/Transitional Unit without donning goggles. Further observation revealed the DON failed to perform hand hygiene when she exited the unit. Observation of CNA #2, on 09/07/2021 at 1:55 PM, revealed she was wearing her mask below her nose. During the interview, CNA #2 continued to adjust the mask. She did not use ABHR after adjusting her mask. CNA #2 stated she was trained on the proper hand hygiene techniques and when to use hand hygiene. She further stated she had been educated on how to wear PPE appropriately. Per the interview, she stated she was adjusting her mask because the mask always slipped down. Observation of RN #1, on 09/08/2021 at 9:00 AM, on the COVID-19/Transitional Unit, revealed RN #1 was wearing goggles on top of her head. Observation of Licensed Practical Nurse (LPN) #3, on 09/08/2021 at 9:20 AM, revealed LPN #3 preparing medications at the medication cart. LPN #3 was assigned to Resident #2, who was COVID-19 positive. However, LPN #3 was not dedicated to Resident #2 only; she also provided care to other residents on the [NAME] unit. Further observation revealed LPN #3 was not wearing goggles. Her N-95 mask and face shield were lying without a barrier on the computer stand attached to the medication cart. Interview with LPN #3, on 09/08/2021 at 9:20 AM, revealed when she provided care to Resident #3, she wore an N-95 mask over her surgical mask. She stated it was facility procedure to wear goggles/face shields in resident care areas. She stated she brought her N-95 mask and face shield out of the room and placed it on the stand on the cart. LPN #3 stated she did not place her N-95 in a brown paper bag for storage per facility practice. She further stated, she did not doff the contaminated surgical mask worn under the N-95 mask. Telephone interview with the Local Health Department (LHD) contact, on 09/09/2021 at 11:00 AM, revealed it was her recommendation that surgical masks were not worn under or over an N-95 mask. Interview with the DON, on 09/08/2021 at 10:29 AM, revealed staff should don PPE in the hall and doff PPE inside the resident's room and dispose of contaminated PPE in the receptacle inside the room. The DON further stated that the N-95 masks should be placed in a brown paper bag after use. She stated staff was educated to wipe their facemasks and goggles/face shields with a disinfectant wipe. Further interview revealed that each N-95 mask could be worn up to five (5) times, before it must be discarded. Additional interview with the Administrator, on 09/08/2021 at 10:21 AM, revealed that historically, the facility discouraged the practice of double-masking because it compromised the integrity of the N-95 mask. Observation of RN #2, on 09/08/2021 at 9:10 AM, revealed she entered and exited Room #B34, #B26, #B28, and #B30 without using ABHR before or after entering and exiting the rooms. RN #2 was observed touching the beds, door handles, and doors when in the rooms. Observation of signage on Room #B25, on 09/08/2021 at 9:18 AM, revealed Room #B25 was designated a TBP room. A yellow sign on the door stated to Keep Door Closed, however, the door was open. LPN #7, Unit Manager, stated Resident #10 (resided in Room #B25) was in TBP due to his/her roommate testing positive for COVID-19. Observation of LPN #3, on 09/08/2021 at 9:27 AM, revealed she was not wearing goggles, even after her interview with the SSA Surveyor and stating it was the facility's procedure to wear goggles/face shields in resident care areas. Observation of LPN #4, on 09/08/2021 at 9:24 AM, revealed LPN #4 was in Room #B7 administering medications to Resident #11. The PPE sign located outside the room instructed those who entered to wear an N-95 mask, gown, goggles, and gloves. LPN #4 was wearing a surgical mask; however she had not donned a gown or gloves before providing care to Resident #11. LPN #4's goggles were on the top of her head. In addition, when LPN #4 exited Room #B7, she was holding a contaminated plastic drink cup, which she disposed of in the trash receptacle on the medication cart. Further observation revealed she failed to perform hand hygiene after exiting the room. Interview with LPN #4, on 09/08/2021 at 9:24 AM, revealed she washed her hands before exiting Resident #11's room; however, the SSA Surveyor did not observe hand hygiene upon exit or after disposing of the contaminated plastic cup used by the resident. When interviewed related to what PPE she should wear in the TBP room, she stated she should have worn full PPE. When asked what type of TBP Resident #11 was in, LPN #4 stated she did not know the resident was was in droplet precaution quarantine because he/she was a 14-day new admission. Interview with LPN #7, [NAME] Unit Manager, on 09/08/2021 at 9:28 AM, revealed all staff in resident care areas should be wearing goggles/face shield and a surgical mask. Further interview revealed Resident #11 had been admitted , on 09/07/2021, and was placed under a 14-day quarantine as a new admission. LPN #7 further stated, upon admission, this resident did not have proof he/she was fully vaccinated. She stated the facility was waiting for documentation from the facility where the resident was just discharged . LPN #7 further stated staff should be wearing full PPE (gown, gloves, mask, goggles/face shield) while providing care to Resident #11. Observation of RN #1, on 09/08/2021 at 9:35 AM, who was assigned to the Combs COVID-19/Transitional Unit, revealed she was standing outside of the Combs COVID-19/Transitional Unit, near the nurse's station on the Combs Unit. Further observation revealed RN #1 was with two (2) other staff members within two (2) to three (3) feet of each other. RN #1 was not wearing a mask and her goggles were on the top of her head. Interview with RN #1, on 09/08/2021 at 9:35 AM, who was assigned to the COVID-19/Transitional Unit, revealed when interviewed related to her not wearing appropriate PPE, RN #1 stated, I was just taking a break. When asked what PPE she should wear while on a resident care units, she stated goggles and a surgical mask. RN #1 placed her mask and goggles on, but did not use ABHR before entering the COVID-19/Transitional unit. Additional interview with RN #1, on 09/09/2021 at 3:23 PM, revealed she came off of the COVID-19/Transitional Unit into other areas of the facility up to five (5) or six (6) times a day to take her breaks. Observation of CNA #3, on 09/08/2021 at 9:48 AM, who was assigned to the COVID-19/Transitional Unit, revealed she came in and out of the unit two (2) times to get supplies from the Combs nurse's station. In addition, at this time, it was observed that RN #1 was not wearing goggles on the COVID-19/Transitional Unit. Telephone interview with the Local Health Department (LHD) contact, on 09/09/2021 at 11:00 AM, revealed it was her recommendation that staff assigned to the COVID-19 Unit did not come on and off of the unit. Observation, on 09/08/2021 at 10:00 AM, of the [NAME] Unit, which was the locked Dementia Care Unit, revealed CNA #9 was at the nurse's station desk. None of the staff were wearing goggles. Two (2) staff members had masks below their noses. CNA #9 yelled for staff to put on their goggles and masks when she saw the SSA Surveyor walk in the room. Interview with CNA #9, on 09/08/2021 at 5:23 PM, revealed it was the facility's policy to wear surgical masks and goggles while in resident care areas. Observation of the Speech-Language Pathologist (SLP), on 09/08/2021 at 9:05 AM, on the [NAME] Unit, revealed the SLP walked out of room [ROOM NUMBER] without doffing her contaminated gloves. The SLP walked down the hall and into the nurse's station. When she came out, she had doffed her gloves. Interview with the SLP, on 09/08/2021 at 9:10 AM, revealed she had three (3) residents that she was treating on the [NAME] Unit. She stated she was a contracted employee through an outside rehab agency. The SLP stated she had received education on doffing gloves before exiting a room. The SLP apologized and said she had forgotten to remove her gloves in the resident's room. In addition, she stated she had received in-service training on PPE use and hand hygiene. Telephone interview with the Local Health Department (LHD) contact, on 09/09/2021 at 11:00 AM, revealed she was not aware of the facility's breeches in the IPC practices and that staff assigned to the COVID-19 Unit walked freely throughout the facility. She stated it was her recommendation that the staff on the COVID-19 unit did not come on and off of the unit. Observation of the facility's front lobby, on 09/09/2021 at 1:15 PM and 2:00 PM, revealed the Receptionist was not wearing a mask. The Receptionist was talking with another staff member behind the front desk. Interview with the Receptionist, on 09/09/2021 at 2:00 PM, revealed that masks were to be worn while in the administrative areas, and goggles were to be worn when in resident care areas. She denied not having her mask on, and stated she wore her mask at all times, except to answer the phone. Observation of CNA #5, on 09/09/2021 at 5:59 PM, who was assigned to the COVID-19/Transitional Unit, revealed he failed to perform hand hygiene when in a COVID-19 isolation room. Further observation revealed CNA #5 failed to don and doff PPE appropriately between five (5) COVID-19 positive isolation rooms when serving meal trays to residents. Additionally, CNA #5 failed to perform hand hygiene between the first two (2) isolation rooms; and then used alcohol-based hand rub (ABHR) on gloved hands between the remaining three (3) isolation rooms. Observation of LPN #1, on 09/09/2021 at 6:00 PM, who was assigned to the COVID-19/Transitional Unit, revealed she failed to clean her goggles after exiting a COVID-19 isolation room. Interview with LPN #1, on 09/09/2021 at 6:30 PM, revealed she had received IPC and hand hygiene training upon hire. She further stated she received periodic in-services regarding IPC training and COVID-19 updates. In addition, LPN #1 stated training was completed and monitored for compliance through Relias training software. Interview with the DON, on 09/10/2021 at 1:00 PM, revealed she was responsible for assuring all agency staff were trained appropriately. She stated agency staff precepted with a seasoned staff member and/or unit managers, and peers monitored performance. She stated, if an agency staff member did not meet expectations, he/she did not continue to work at the facility. Per the interview, the DON stated that all of nursing management was responsible for staff performance, and they needed to be aware and observant of the staff's performance. The DON stated she expected that unit managers would do resident rounds every hour and work with staff to enhance resident care. Interview with the Medical Director, on 09/10/2021 at 1:25 PM, revealed he was new to the facility but was very involved in resident care and IPC policy development. He stated he was aware of the current COVID-19 cases within the facility. He stated that staffing remained a great concern, which was not an isolated problem at this facility, but existed in most healthcare facilities, especially since the COVID-19 pandemic began. Interview with the Administrator, on 09/10/2021 at 1:25 PM, revealed the Interdisciplinary Team (IDT) consisting of the Administrator, DON, Social Worker (SW), Dietary Manager, Activities Director, and Physical Therapy Director, met every morning to discuss matters involving resident care, IPC, and COVID-19 updates. Additional interview with the DON, on 09/10/2021 at 7:49 PM, revealed it was her expectation that all nursing staff follow IPC policies and CDC guidelines for the safety of residents and staff. Per the interview, the DON stated following IPC procedures and the facility's policies was important to prevent the spread of infection. Additional interview with the Administrator, on 09/10/2021 at 7:49 PM, revealed it was her expectation that IPC guidelines were to be maintained at all times in the facility. The Administrator stated she expected staff to wear the appropriate PPE for the situation and to don and doff PPE correctly. Additionally, she reported it was her expectation that hand hygiene was performed per facility policy and CDC guidelines. She stated following the facility's policies was important to decrease the potential spread of infection and COVID-19. The facility provided an acceptable Immediate Jeopardy Removal Plan, on 09/10/2021, that alleged removal of the Immediate Jeopardy (IJ) on 09/11/2021. The facility implemented the following: 1. On 09/10/2021, the facility's nurse management team (Director of Nursing (DON), Assistant Director of Nursing (ADON), Staff Development Coordinator (SDC), and Regional Infection Preventionist (RIP)) identified that all residents had the potential to be affected. Therefore, the facility would dedicate space for a COVID-19 Care Unit, which was physically separated by a temporary zippered barrier wall, from other rooms on the Combs 1 Unit. In addition, the facility would use a dedicated staff for the unit. 2. Staff, including agency personnel, were re-educated by nurse management on appropriate usage and storage of PPE to include gloves, gown, eye protection, and face masks. This included return demonstration to assure understanding. Education was done, on 09/07/2021 through 09/10/2021. 3. Staff, including agency personnel, were re-educated by nurse management on transmission based precautions including signage, usage of PPE, proper handwashing performance during meal services, donning and doffing of PPE, location of alcohol-based hand rub (ABHR) dispensers, and proper storage of N95 masks. This included return demonstration to assure understanding. Education was done, on 09/07/2021 through 09/10/2021. 4. Staff, including agency personnel, were re-educated by nurse management on proper handwashing performance during meal services, with a questionnaire and quiz given and reviewed by nurse management to assure understanding or need for further education. Education began on 09/10/2021. 5. Additional education was provided by nurse management for proper glove usage, location of eyewear cleaning stations, and proper doffing measures. Education began on 09/10/2021. 6. A Quality Assurance Performance Improvement (QAPI) Meeting was held, on 09/10/2021, to review education and inservicing content. Department heads, including the Administrator, DON, Nurse Managers, and other department heads will monitor for compliance to PPE use and wear, and staff utilizing the unit to doff PPE after exiting a TBP room by direct observation and daily rounding. The State Survey Agency validated the implementation of the facility's Immediate Jeopardy Removal Plan as follows: 1. Interview with the Administrator, DON, ADON, SDC, and RIP, on 09/10/2021 at 7:49 PM, revealed they identified that all residents had the potential to be affected. Observation, on 09/10/2021 at 8:30 PM, revealed the facility created a dedicated COVID-19 Care Unit on the Combs 1 hall. The COVID-19 Care Unit was physically separated from other rooms on Combs 1, by a temporary zippered barrier wall. In addition, the facility was staffing the unit with a dedicated staff: one (1) RN or LPN, and one (1) CNA, who would not work on both the COVID-19 Care Unit and other units during the same shift. To the extent possible, there was restricted access of ancillary personnel (e.g., dietary) to the unit. Meals were handed through the plastic barrier. An environmental services (EVS) staff member would be dedicated to the COVID-19 Care Unit. All dedicated staff would enter through a clean area where staff doffs PPE. Staff exited the facility through the back stairwell, where a clean station was available for hand hygiene. Interview with LPN #1 and CNA #8, on 09/10/2021 at 8:30 PM, revealed they had been assigned as dedicated staff to the COVID-19 Care Unit. Both received re-education on transmission based precautions including signage, usage of PPE, proper handwashing performance during meal services, donning and doffing of PPE, location of alcohol-based hand rub (ABHR) dispensers, and proper storage of N95 masks by nursing management. LPN #1 and CNA #8 stated they were required to demonstrate donning and doffing PPE and hand hygiene. Both stated they did not leave the unit during their shift, except on breaks, in which they exited though the back stairwell. Meals were passed through the zipper barrier. Observation revealed both LPN #1 and CNA #8 performing proper hand hygiene technique. The staff was wearing the appropriate PPE. 2. Observation, interview, and record review, on 09/10/2021, revealed nursing management completed re-education of all scheduled staff on appropriate usage and storage of PPE to include gloves, gown, eye protection, and face masks. Further observation revealed training by nursing management, which included return demonstration from staff. Education began on 09/07/2021 through 09/10/2021. Record review revealed education sheets, sign-in logs, and the posttest were completed by staff during the day and evening shifts prior to being allowed to work to assure understanding or the need for further education. Interview with the DON and Administrator, on 09/10/2021 at 7:49 PM, revealed the weekend Nurse Manager would reeducate all remaining staff prior to his/her shift. No staff member would be allowed to work until his/her re-education was completed. 3. Interviews with CNA #6, CNA #7, LPN #7, LPN #8, LPN #9, and RN #4, on 09/10/2021, between 5:43 PM and 6:48 PM, revealed they were re-educated by nurse management on transmission based precautions including signage, usage of PPE, proper handwashing performance during meal services, donning and doffing of PPE, location of alcohol-based hand rub (ABHR) dispensers, and proper storage of N95 masks. Observations of training by nursing management, on 09/10/2021, revealed they included return demonstration from staff. SSA Surveyors observed an in-service provided by the unit manager and ADON, which provided re-education and return demonstration of donning and doffing full PPE and hand hygiene. Record review revealed education sheets, sign-in logs, and posttests were completed by day and evening staff, and graded by nursing management, prior to being allowed to work to assure understanding or the need for further education. Interview with the DON and Administrator, on 09/10/2021 at 7:49 PM, revealed the weekend Nurse Manager would reeducate all remaining staff prior to his/her shift. No staff member would be allowed to work until his/her re-education was completed. 4. Interviews with CNA #6, CNA #7, LPN #7, LPN #8, LPN #9, and RN #4, on 09/10/2021, between 5:43 PM and 6:48 PM, revealed they were re-educated by nurse management on proper handwashing performance during meal services, with a questionnaire and quiz, which was reviewed by nurse management. Record review revealed education sheets, sign-in logs, and posttests were completed by day and evening staff, and graded by nursing management, prior to staff being allowed to work. Interview with the DON, on 09/10/2021 at 7:49 PM, revealed staff, including agency personnel, were re-educated by nurse management on proper handwashing performance during meal services, with questionnaire and quiz, and reviewed by the facility nurse management to assure understanding or the need for further education. Interview with the DON and Administrator, on 09/10/2021 at 7:49 PM, revealed the weekend Nurse Manager would reeducate all remaining staff prior to his/her shift. No staff member would be allowed to work until his/her re-education was completed. 5. Interviews with CNA #6, CNA #7, LPN #7, LPN #8, LPN #9, and RN #4, on 09/10/2021, between 5:43 PM and 6:48 PM, revealed scheduled staff received re-education, provided by nurse management, on the proper glove usage, location of eyewear cleaning station, with doffing measur [TRUNCATED]

Based on interview, record review, review of facility Policy, and review of the Centers for Medicare and Medicaid Services, Resident Assessment Instrument (RAI) Manual 3.0, it was determined the facility failed to review and revise the Comprehensive Care Plan for two (2) of six (6) sampled residents (Resident #3 and #5). Although Resident #3 was assessed by the facility as requiring the assistance of two (2) staff for transfers and two (2) staff for toileting according to the Quarterly Minimum Data Set (MDS) assessment dated [DATE], the Comprehensive Plan of Care, which was revised 03/01/17, did not indicate how many staff were required to transfer or toilet the resident. Also, review of the Nurse Aide Care Plan dated May 2017, and June 2017 up through 06/05/17, revealed one (1) staff was required for transfers with the use of a gait belt and there was no intervention stating how many staff were required to toilet the resident. On 06/03/17, State Registered Nurse Assistant (SRNA) #1 attempted to transfer Resident #3 independently, from the bedside commode to the bed, and the resident fell to the floor. Resident #3 sustained a Large Skin Tear to the Left Arm, and a Left Femoral Neck Fracture requiring orthopedic surgery, on 06/05/17. (Refer to F-323) In addition, Resident #5 was assessed by the facility as requiring the assistance of two (2) staff for dressing according to the Quarterly MDS Assessment, dated 03/24/17. However, the Comprehensive Plan of Care revised 05/17/17, and the Nurse Aide Care Plan dated June 2017, did not address how many staff were needed to assist the resident with dressing. On 06/13/17, Resident #5 experienced a fall from the bed to the floor while SRNA #7 was assisting the resident with undressing by taking off the resident's shoes, unassisted by a second staff member. Resident #5 did not sustain injuries related to this fall. (Refer to F-323) The findings include: Review of the facility's policy titled Care Plans-Comprehensive, revised 10/07/10, revealed an individualized Comprehensive Care Plan included measurable objectives and timetables to meet the resident's medical, nursing, and mental and psychological needs developed for each resident. Continued review of the policy, revealed the purpose of the care plan was to aid in preventing or reducing declines in the resident's functional status and/or functional levels. Further review of the policy, revealed care plans were revised as changes in the resident's condition dictate. Further review revealed care plans were reviewed at least quarterly and more often as indicated. Review of the Centers for Medicare and Medicaid Services, Resident Assessment Instrument (RAI) Manual 3.0, dated October 2016, revealed the care plan must be reviewed and revised periodically, and the services provided or arranged should be consistent with each resident's written plan of care. Additionally, the facility must maintain all resident assessments completed within the previous fifteen (15) months in the resident's active record and use the results of the assessments to develop, review, and revise the resident's comprehensive plan of care. Continued review of the CMS Manual, revealed the care plan was driven not only by identified resident issues and/or conditions but also by a resident's unique characteristics, strengths, and needs. Furthermore, a care plan based on a thorough assessment, effective clinical decision making, was compatible with current standards of clinical practice that provide a strong basis for optimal approaches to quality of care and quality of life needs of individual residents. A well developed and executed assessment and care plan: re-evaluates the resident's status at prescribed intervals (quarterly, annually, or if a significant change in status occurs) using the RAI and then modifies the individualized care plan as appropriate and necessary. 1. Review of Resident #3's clinical record revealed the facility admitted the resident on 02/08/17 and readmitted the resident on 04/10/17, with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) Assessment, dated 03/24/17, revealed the facility assessed Resident #3 as having a Brief Interview for Mental Status (BIMS) score of thirteen (13) out of fifteen (15), which indicated the resident was cognitively intact. Further review of the MDS, revealed the facility assessed the resident to require extensive assistance of two (2) persons for physical assist with transfers and toileting. Review of the Comprehensive Care Plan revised 03/01/17, revealed Resident #3 was at risk for injury from falls related to the resident's ambulation status, and balance. The Care Plan goal stated safety and manage risks for falling. There were several interventions which included observe for unsteady gait and balance and assist as needed; therapy/restorative screens and treatments as ordered. However, the Comprehensive Care Plan did not indicate how many staff members were required to assist the resident with transfers or toileting to prevent falls. (The Comprehensive Plan of Care was not revised related to the need for two (2) staff to assist with transfers until 06/03/17, after the resident sustained [REDACTED]. Review of the Nurse Aide Care Plan dated May 2017, and 06/01/17 through 06/05/17, revealed Resident #5 was to be transferred with the assistance of one (1) staff member and a gait belt, and did not specify how many staff were required to toilet the resident. (The Nurse Aide Care Plan was not revised to two (2) assist with transfers and elimination until 06/05/17). Review of the Facility's Incident Report, dated 06/03/17, revealed on 06/03/17 at 3:45 PM, Resident #3 sustained a fall while being transferred from the commode to the bed. Per the Report, the resident complained of left hip pain and also sustained a laceration to the left forearm. Further review revealed the resident was incontinent at time of the incident and the level of assistance at the time of the fall was one (1) assist. The results of the investigation revealed, after review of the information there were no factors, the resident's legs buckled and that contributed to the fall. The Falls Report was signed by the Director of Nursing (DON) on 06/04/17. Review of Resident #3's Nurse's Note, dated 06/03/17 at 3:45 PM, completed by Registered Nurse (RN) #1, revealed SRNA #1 notified RN #1 of the resident's fall. According to the Note, upon entering the room, the resident was on the floor and the resident complained of left hip pain, was yelling out in pain and had a skin tear on the left forearm. Continued review of the Note, revealed the DON and the resident's Power of Attorney (POA) were notified. The Note stated the resident was transferred to the hospital emergency room by Emergency Medical Services (EMS) at 4:06 PM. Review of SRNA #1's Statement, dated 06/03/17, revealed SRNA #1 was assisting Resident #3 to the bedside toilet from the bed. According to the Statement, she assisted the resident up and let him/her sit on the side of the bed until he/she was ready to stand. Continued review revealed when the resident said he/she was ready, SRNA #1 helped him/her stand and the resident's leg buckled and he/she fell to the floor. Review of Resident #3's the Hospital Discharge Summary, dated 06/07/17, revealed the resident was admitted to the hospital on [DATE] after a fall. Continued review revealed the resident was found to sustain a Left Femoral Neck Fracture and a Large Skin Tear to the Left Arm. Additional review revealed the resident was underwent surgery on 06/05/17 and was status [REDACTED]. Interview with Resident #3, on 06/29/17 at 11:25 AM, revealed he/she was transferred by one (1) staff member the day he/she fell . Per interview, the aide assisted him/her to the bedside commode, and he/she remained on the commode until SRNA #1 made his/her bed. Further interview revealed when he/she stood, and was assisted with being transferred back to the bed, his/her leg gave out and before he/she knew it, he/she was on the floor. Resident #3 stated he/she landed on his/her left side and it was painful. The resident stated he/she recalled staff asking him/her if he/she could move his/her left leg and when he/she reported to staff that he/she could not, staff called EMS. Additional interview with Resident #3, revealed he/she had always required two (2) staff to assist him/her with transferring; however, the day before the fall the Administrator spoke to him/her and asked if he/she wanted to have an assist of one (1) staff for transfers, since it took awhile for two (2) staff to respond to his/her call lights. Resident #3 revealed he/she thought he/she could be transferred with one (1) staff, thus when the Administrator talked to him/her about the level of assistance needed, he/she agreed to have one (1) person to assist with his/her transfers. Resident #3 further stated the Administrator or nursing staff did not assess him/her to determine if he/she was safe to complete his/her transfers with one (1) staff assistance. Interview with State Registered Nurse Aide (SRNA) #1, on 06/28/17 at 5:30 PM, revealed she was assigned to Resident #3 on 06/03/17, on the Breckinridge Unit. and reviewed the resident's Nurse Aide Care Plan prior to providing care to the resident. She stated the Nurse Aide Care Plan specified the resident required one (1) assist with transfers and did not specify how many staff was required for toileting. Per interview, she transferred Resident #3 by herself to the bedside commode, but when transferring the resident back into the bed, the resident fell . SRNA #1 stated she thought the resident's knee gave out. Per interview, she was following the resident's Nurse Aide Care Plan and would have had another person with her to assist with the resident's transfer had she known the resident required two (2) people with transfers. She stated the resident's Nurse Aide Care Plan should have been updated to state two (2) assist with transfers. Interview with SRNA #3, on 06/29/17 at 3:08 PM, revealed she had been assigned to Resident #3 in the past and thought the resident had always been care planned for an assist of two (2) staff for transfers. SRNA #3 revealed it had been awhile since she worked with the resident, but stated it would not have been safe to transfer the resident with one (1) assist because he/she was often weaker after returning from [MEDICAL TREATMENT] clinic. The State Survey Representative made phone calls in an attempt to reach Registered Nurse (RN) #1, who was assigned to the resident on 06/03/17 at the time of the fall. The calls were attempted on 06/28/17 at 6:01 PM and 6:30 PM; however, a message could not be left for a return call. Interview with Licensed Practical Nurse (LPN) #1, on 06/28/17 at 6:03 PM, revealed she was working on the Combs Unit when Resident #3 fell on the Breckinridge Unit on 06/03/17. She stated RN #1 asked her to assist with the fall and the incident paperwork because RN #1 was new to the facility and was unsure as to how to handle falls. She further stated the resident was on the floor, calling out in pain, so she called Emergency Medical Services (EMS) and made the notifications. She further revealed she looked at the resident's Nurse Aide Care Plan and noticed the resident was care planned for one (1) assist with transfers and she then updated the Comprehensive Care Plan and the Nurse Aide Care Plan to state two (2) assist with transfers. Per interview, Resident #3 had resided on the Combs unit previously, and was care planned to be an assist of two (2) for transfers at that time. She stated she was not sure when the resident became an assist of one (1) with transfers. Interview with LPN #3, on 06/29/17 at 4:51 PM, revealed was often assigned to Resident #3 on the Breckinridge Unit. Per interview, the resident always needed an assist of two (2) with transfers, even before the fall on 06/03/17. LPN #3 stated the resident attended [MEDICAL TREATMENT] three (3) times a week and was weak and fragile. LPN #3 further stated she was not aware of a time in which the resident required one (1) assist for transfers. She stated she had not reviewed the resident's Care Plan, but revealed it should have reflected an assist of two (2) people with transfers. Further interview with LPN #4, revealed the Comprehensive Care Plans were based on the MDS Assessments and the Care Plans drove the care for the residents. LPN #4 stated it was important to develop/revise the care plans with the proper interventions and follow the plan of care for the safety of the residents. Interview with LPN #2/Breckinridge Unit Manager, on 06/30/17 at 10:20 AM, revealed as Unit Manager she would ensure the Comprehensive Care Plan and the Nurse Aide Care Plan matched, then monitor a staff member to ensure they implemented the residents' plan of care as instructed on the residents' Care Plan. When questioned as to why Resident #3's Comprehensive Care Plan had no intervention to state how many staff were needed to transfer or toilet Resident #3, and the Nurse Aide Care Plan did not state how many staff were needed to toilet the resident, she revealed she had not checked Resident #3's Care Plans, but should have. Per interview, she did not check to ensure the Care Plans matched the MDS Assessments for transfers, or toileting as she did not have access to the the MDS Assessments. Further interview with LPN #2/Breckinridge Unit Manager, revealed Resident #3 had previously resided on the Combs Unit and when the resident moved to the Breckinridge Unit he/she was an assist of one (1) for transfers until sustaining the fall on 06/03/17. Per interview, on 04/25/17 she had to assist the aide with the resident due to the resident almost falling. She revealed the resident needed an assist of two (2) that day. However, she further stated even after the resident almost fell on [DATE], she did not recognize the need to revise the Comprehensive Care Plan to two (2) assist with transfers because she had always known the resident to be a one assist. Interview with Registered Nurse (RN) #2/MDS Coordinator, on 06/30/17 at 12:19 PM, revealed the Comprehensive Care Plans were to be developed/revised from the MDS Assessment. Further interview revealed all the residents' Comprehensive Care Plans were recently revised to indicate the amount of staff required to perform bed mobility/repositioning and transfers by LPN #4/MDS Coordinator. After reviewing Resident #3's Quarterly MDS assessment dated [DATE], she stated the resident was coded on the MDS for two (2) to assist with transfers and toileting on the MDS, and the Comprehensive Care Plan should have been revised to state two (2) assist for transfers and toileting. Further interview revealed the care plan was vague. Per interview, the Care plan was very important because it was about the care for the residents. Interview with Licensed Practical Nurse (LPN) #4/MDS Coordinator, on 06/30/17 at 12:56 PM, revealed in revising and updating the residents' care plans on 04/24/17 and 04/25/17, she did not check the MDS to ensure they matched the Comprehensive Care Plans. She further stated she only compared the Comprehensive Care Plans with the Nurse Aide Care Plans to determine that these care plans matched. Per interview, the number of staff needed to assist a resident with Activities of Daily Living (ADL's) such as transfers and toileting was important and needed to be on the Comprehensive Care Plan and the Nurse Aide Care Plan and the facility was working to correct that problem through completing the Provision of Audits which was a tool utilized to ensure staff were following the Care Plan. However, she further stated it was not important to ensure the Comprehensive Care Plan and the MDS Assessment correlated as far as the number of staff needed to assist with ADL's, because the residents' level of function may change between assessment periods for the MDS Assessments. Interview with the Director of Nursing (DON), on 06/30/17 at 2:21 PM, revealed Resident #3's Comprehensive Care Plan did not match the Nurse Aide Care Plan because the facility was in the process of updating/revising Care Plans during the period in which the resident fell . Further interview revealed it would not have been her expectation for the MDS Assessments to correlate with the Comprehensive Care Plans and the Nurse Aide Care Plans because the nurses were revising the care plans based on the Provision of Care Audits and not on the MDS Assessments. She explained the Provision of Audits was was a tool used to to monitor that staff were adhering to the Plan of Care for transfers and repositioning through observation of care. Further interview revealed she was not sure if the Comprehensive Care Plan was driven by the MDS, and relied on her nurses, therapy, and staff when it came to care planning. She stated after the fall on 06/03/17, the IDT recognized Resident #3's Comprehensive Care Plan and Nurse Aide Care Plan needed to be revised related to having two (2) staff to transfer, and two (2) staff to toilet the resident. Interview with the Administrator, on 06/30/17 at 4:56 PM, revealed the MDS Assessment, Comprehensive Care Plan, and Nurse Aide Care Plan were to correlate and there should be documented evidence to support the change of assistance needed if the Care Plan did not match the MDS. He stated he talked to Resident #3 a few days before the fall on 06/03/17 about transfers and the resident preferred to be an assist of one (1) due to long waits for two (2) staff to assist him/her. He stated he checked the resident's Nurse Aide Care Plan and he/she was care planned for one (1) assist with transfers. However, further interview revealed the MDS was coded for the resident to require two (2) assist with transfers and he could not locate documented evidence in the resident's record which supported the need for the resident's one (1) assist with transfers. He stated, Resident #3's Care Plan and Nurse Aide Care Plans should have been revised for two (2) staff to assist with transfers and toileting as per the MDS prior to the resident's fall with Fracture. 2. Review of Resident #5's closed medical record revealed the facility admitted the resident on 07/16/16 with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) Assessment, dated 03/24/17, revealed the facility assessed the resident as to have severe cognitive impairment. Further review revealed the facility assessed the resident as requiring extensive assistance with two (2) staff for dressing, which included how the resident puts on, fastens and takes off all items of clothing Review of Resident #5's Comprehensive Care Plan, revised 05/17/17, revealed the resident had a problem of Self-care Activities of Daily Living deficit related to cognitive deficits, deconditioning, impaired range of motion, and weakness. The Care Plan goal stated the resident would be dressed and groomed appropriately. On 06/07/17, a new intervention was added stating the resident required total assistance with dressing; however, there was no intervention stating how many staff were required to assist the resident with dressing. Review of the Nurse Aide Care Plan, dated June 2017, revealed the resident required total assistance with dressing; however, did not specify how many staff were required to assist the resident with dressing. Review of the facility's Incident Report, revealed the fall incident occurred on dated 06/13/17 at 10:30 PM. Per the Report, SRNA #7 had Resident #5 sitting on the edge of the bed and was taking off the resident's shoes off when he/she slid off the edge of the bed with no apparent injures. Per the Report, the staff member was re-educated by therapy related to transfers and assist. Continued review of the Comprehensive Care Plan and Nurse Aide Care Plan, revealed on 06/13/17 a new intervention was added for the resident to be prepared for getting up or going to bed, lying down, not while sitting on the side of the bed. However, the Care Plans were not revised to state two (2) staff for assistance with dressing. Review of the Nurse's Note, dated 06/12/17 at 10:30 PM, completed by LPN #3, revealed SRNA #7 called the nurse (LPN #3) to Resident #5's room. According to the Note, the resident was observed sitting on the floor on his/her buttocks and SRNA #7 was holding the resident. Continued review revealed an assessment was completed with no apparent injury noted. Interview with SRNA #7, on 06/27/17 at 4:38 PM, revealed Resident #5 required two (2) assist with transfers because the resident had a history of [REDACTED]. Further interview revealed on 06/13/17, the day of the incident, she asked SRNA #8 to assist her with transferring the resident into the bed. She stated SRNA #8 assisted her with transferring the resident to the bed with the mechanical lift and then left the room. She further stated she began to take off the resident's shoes and the resident leaned over to one (1) side and fell off the bed. Per interview she was unaware the resident was assessed to require two (2) staff to assist with undressing as the Nurse Aide Care Plan which she used as a reference I providing care was not specific. Continued interview with SRNA #7, revealed she had been assigned to the resident prior to the incident, but did not realize he/she had gotten weak on his/her side. SRNA #7 revealed she was not re-educated related to the incident. Interview with SRNA #8, on 07/03/17 at 12:32 PM, revealed on 06/13/17, SRNA #7 asked her to assist with transferring Resident #5 to bed. She stated she assisted SRNA #7 with transferring the resident to the bed with the mechanical lift, and then left the room with Resident #5 sitting on the edge of the bed and SRNA #7 bent over taking off the resident's shoes. She stated she did not observe the actual fall. Interview with LPN #3, on 06/29/17 at 4:51 PM, revealed she was assigned to Resident #3 on on 06/13/17, the day the resident fell . She stated SRNA #7 and SRNA #8 assisted the resident to bed and then SRNA #8 left the room. Further interview revealed Resident #5 slipped off the edge of the bed as SRNA #7 was taking off the resident's shoes. She stated Resident #3 was not injured. LPN #3 revealed the resident had a stroke and he/she was flaccid on his/her right side. She stated if the MDS stated the resident needed two (2) assist for dressing, then the Comprehensive Care Plan and Nurse Aide Care Plan should have been revised to reflect this. Interview with RN #3, on 06/28/17 at 3:43 PM, revealed she had worked with Resident #5 and was familiar with the resident's care. RN #3 stated the Comprehensive Care plans were developed and revised through the MDS Assessment. Further interview revealed MDS Nurses developed/revised the care plans; however, the nursing staff also could revise the care plans. After reviewing Resident #5's MDS dated [DATE], RN #3 revealed the resident's Comprehensive Care plan and SRNA Care Plan should have been revised to state the resident needed two (2) persons to assist with dressing. Interview with the Breckinridge Unit Coordinator/LPN #2, on 06/30/17 at 10:20 AM, revealed Resident #5 resided on the Breckinridge Unit and she audited the resident's care on 04/25/17, 05/05/17, and the week of May 15-19, 2017. She stated the audits revealed the resident was assessed to need two (2) assist with transfers and repositioning. She revealed she did not observe staff getting the resident ready in the morning during the audits, and only asked staff to tell her when they had completed dressing the resident. She further stated she then observed his/her transfers and repositioning. Continued interview with the Unit Coordinator, revealed she should have observed staff dress the resident so she could have re-educated staff and revised the Care Plan for resident to have two (2) staff to assist when dressing the resident. Further interview revealed the Comprehensive Care Plan and the SRNA care plan should have been revised with an intervention for two (2) staff to assist the resident with dressing. Interview with the ADON on 06/30/17 at 1:15 PM, regarding Resident #5's fall on 06/13/17, revealed Resident #5's Comprehensive Care Plan and Nurse Aide Care Plan was not specific enough to indicate the level of assistance needed for his/her care, related to accomplishing different tasks including dressing, but should have been. She stated it was important that the care plans were revised for the safety of the residents and the intervention for two (2) staff to dress the resident should have been added to the Comprehensive Care Plan and the Nurse Aide Care Plan, especially after the fall occurred. The ADON stated the care plans mapped out the care that should be provided to the resident. Interview with LPN #4/MDS Coordinator, on 06/30/17 at 12:56 PM, revealed she was not certain how many staff were needed to assist Resident #5 with dressing and undressing. However, after reviewing the documentation related to the resident's fall, she stated the Care Plan should have been revised for two (2) staff to assist with dressing. Interview with the Director of Nursing (DON), on 06/30/17 at 2:21 PM, revealed Resident #5's MDS was coded as the resident requiring two (2) persons to assist with dressing, but the resident did not necessarily need two (2) people to assist him/her with getting dressed. She further stated because of the resident's weakness on one side, the level of assistance and number of staff needed to dress the resident depended on whether the resident was having a good or bad day. Further interview revealed resources used to develop/revise the Residents' Comprehensive Care Plans included Discharge Summaries from the hospital, Therapy Notes, physician's orders [REDACTED]. were assigned to the residents. Per interview, the SRNA's would often tell her if they needed more assistance with a resident and she would put in a therapy referral. The DON stated she was not certain if the MDS was a resource used to Develop/revise the Comprehensive Care Plans. Further interview with the Administrator on 06/30/17 at 4:51 PM, revealed Resident #5 was recently assessed for dressing, thus his/her Comprehensive Care Plan and Nurse Aide Care Plan should have been revised with an intervention for two (2) staff to assist with dressing as per the MDS Assessment. The Administrator further stated he expected the facility Care Plan Policy to be followed related to revising care plans for the residents safety.

Based on interview, record review, review of the facility's Policy, and review of the Centers for Medicare and Medicaid Services, Resident Assessment Instrument (RAI) Manual 3.0, it was determined the facility failed to ensure services were provided in accordance with each resident's written Comprehensive Plan of Care for one (1) of six (6) sampled resident (Resident #5). Resident #5's Comprehensive Care Plan, revised 05/11/17, revealed the resident was to have his/her Pull Tab Alarm (device that attaches to the person and alarms when the person attempts to get up unassisted) attached while lying in the bed; however, on 05/26/17, State Registered Nurse Aide (SRNA) #2 detached the resident's pull alarm to dress the resident, then went to obtain assistance with a transfer, without re-attaching the alarm. Resident #5 fell from the bed sustaining a Hematoma, Slight Concussion, and Laceration requiring sutures from the fall on 05/26/17. (Refer to F-323) The findings include: Review of the facility's Policy titled Care Plans-Comprehensive, revised 10/07/10, revealed an individualized Comprehensive Care Plan includes measurable objectives and timetables to meet the resident's medical, nursing, and mental and psychological needs developed for each resident. Continued review of the policy, revealed the purpose of the care plan was to aid in preventing or reducing declines in the resident's functional status and/or functional levels. Review of the Centers for Medicare and Medicaid Services, Resident Assessment Instrument (RAI) Manual 3.0, dated October 2016, revealed the Comprehensive Care Plan is an interdisciplinary communication tool and must include measurable objectives and time frames and must describe the services to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. Further review revealed the services provided or arranged must be consistent with each resident's written Plan of Care. Review of Resident #5's closed medical record revealed the facility admitted the resident on 07/16/16 with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS), revealed the facility assessed the resident as having severe cognitive impairment. Review of the resident's Falls Comprehensive Care Plan revised 05/17/17, revealed the resident was a risk for falls related to acute process, ambulation/elimination status, balance, and history of falls. The goal was to safety and manage risks for falling with interventions including call light in reach; therapy/restorative screens/treatments as ordered and pull alarm while in bed. Review of the Nurse Aide Care Plan dated May 2017, revealed an intervention for a pull alarm when in bed. Review of the Facility's Incident Report, signed by the Assistant Director of Nursing (ADON), on 05/26/17, revealed on 05/26/17 at 5:20 PM, SRNA #2 needed to get Resident #5 up for the evening meal, left the room to get help, and heard a loud thump. According to the Report, SRNA #2 re-entered the room, and found the resident lying on the floor beside the bed with a large hematoma and lacerations to the head. Per the Report, the care plan interventions prior the fall included pull alarm on bed; however, the report did not state if the pull alarm was in place at the time of the fall. The Report further revealed the investigation concluded immediate education was implemented. Review of the Statement, dated 05/26/17, written by SRNA #2, revealed Resident #5 was attempting to get out of bed and she went to get her hall partner to assist with transferring the resident. Further review revealed while walking towards the Nurse's Station she heard a loud thump, walked back into the resident's room and saw the resident in the floor. Review of the Nurse's Note, dated 05/26/17 at 5:20 PM, completed by Licensed Practical Nurse (LPN) #3, revealed SRNA #2 was going to get Resident #5 up for the evening meal, left the room to get assistance, and heard a loud thump. According to the Note, upon SRNA #2 re-entering the resident's room, the resident was found lying on his/her stomach on the floor beside the bed. Further review of the Note, revealed when the resident was turned over there was a large amount of blood on the floor and a large hematoma to the right side of the resident's forehead, a laceration to the right side of the resident's head and two (2) small lacerations to the top of the resident's head. Continued review of the Note, revealed the resident was transferred out by Emergency Medical Services (EMS), leaving the facility at 5:30 PM. Per the Note, the hospital contacted the facility at 9:30 PM to report the resident would be returning back to the facility and the resident had sustained a concussion and had staples placed to the laceration in back of the head. Interview with State SRNA #2, on 06/28/17 at 9:09 AM, revealed she was assigned to Resident #5 on 05/26/17. She stated she was waiting on her hall partner, SRNA #5, to assist her with transferring the resident from the bed to the wheelchair. Per interview, she dressed the resident while she waited on her hall partner to come to the room to assist with the resident's transfer and she took off the residents bed pull tab alarm, which was attached to the resident. She stated she dressed the resident, then assisted the resident to lye down in the bed. She further stated she left the room to get her hall partner and while she was out of the room the resident fell off the bed and on to the floor. Per interview, the resident hit the bedside table and there was a laceration on his/her head. SRNA #2 revealed she notified LPN #3 who assessed the resident and called American Medical Response (AMR). Further interview with SRNA #2, revealed she had not attached the pull tab alarm to the resident before leaving the room, as per the resident's Care Plan. Interview with LPN #3, on 06/29/17 at 4:51 PM, revealed she was the nurse assigned on 05/26/17 at the time of Resident #5's fall. She stated SRNA #2 and SRNA #6 told her Resident #5 was on the floor in his/her room lying on his/her stomach. She further stated the resident's head was noted to have a laceration and hematoma. Per interview, she called LPN #2/Unit Coordinator to call AMR and to get the paperwork ready while she applied pressure to the resident's head. She stated the resident was transferred to the hospital and treated in the emergency room . Further interview revealed the hospital called and told her the resident would be sent back to the facility and had a mild concussion. LPN #3 revealed SRNA had not followed the Care Plan as she had not attached the resident's pull tab alarm to the resident prior to exiting the room. Interview with SRNA #6, on 06/30/17 at 10:04 AM, revealed as she was leaving(NAME)Unit and walking towards the Breckinridge Unit she heard a thump. Per interview, she did not know what room it was, so she went from room to room until she got to Resident #5's room. She stated SRNA #2 arrived at the same time she arrived to the room. Per interview, she did not hear an alarm go off and was not familiar with the resident enough to discuss his/her care plan. Interview with LPN #2/Unit Manager for Breckinridge Unit, on 06/30/17 at 10:20 AM, verified Resident #5 resided on the Breckinridge unit at the time of the fall on 05/26/17. She stated after the fall, she reviewed the circumstances surrounding the fall and educated SRNA #2 regarding making sure Resident #5's pull alarm was in place. She further stated SRNA #2 should have followed the Care Plan and ensured the resident's pull alarm was in place prior to exiting the resident's room as this was a safety intervention. Interview with the Assistant Director of Nursing (ADON), on 06/30/17 at 1:15 PM, revealed she worked the day of Resident #5's fall on 05/26/17. Per interview, she assisted LPN #3 with assessing the resident and getting the resident out to the hospital. Further interview with the ADON, revealed she completed the Facility's Incident Report and had written staff education under the immediate interventions implemented, but did not recall what the re-education was about. Interview with the Regional Director of Operation, on 06/30/17 at 7:45 PM, revealed through the investigation of Resident #5's fall on 05/25/17, it was recognized SRNA #2 did not follow the resident's Care Plan and ensure the pull alarm was in place prior to exiting the room, and SRNA #2 received education related to this. Interview with the Director of Nursing (DON), on 06/30/17 at 2:21 PM, revealed the facility was currently monitoring the care of the residents through Provision of Care Audits. She stated the facility was observing staff to ensure they were following the Nurse Aide Care Plan, with the Audits, thus it would have been her expectation that the care plan would have been followed related to ensuring the pull alarm was in place for Resident #5. Interview with the Administrator on 06/30/17 at 4:56 PM, revealed Resident #5's Care Plan should have been followed related to ensuring Resident #5's pull alarm was in place.

Based on interview, record review, review of the facility's Incident Reports, and review of the facility's Falls-Clinical Protocol Policy, it was determined the facility failed to ensure the residents receive adequate supervision and assistive devices to prevent accidents for two (2) of six (6) sampled residents (Residents #3 and #5). Resident #3 was assessed by the facility to require the assistance of two (2) staff for transfers and two (2) staff for toileting according to the Quarterly Minimum Data Set (MDS) assessment dated [DATE]. On 06/03/17, the Comprehensive Plan of Care, which was revised 03/01/17, did not indicate how many staff were required to transfer the resident, or toilet the resident. Review of the Nurse Aide Care Plan dated May 2017, and June 2017 up through 06/05/17, revealed one (1) staff was required for transfers with the use of a gait belt and there was no intervention stating how many staff were required to toilet the resident. On 06/03/17, a State Registered Nurse Assistant (SRNA) #1 attempted to transfer Resident #3 independently, from the bedside commode to the bed, the resident fell to the floor. Resident #3 suffered a Large Skin Tear to the Left Arm, and a Left Femoral Neck Fracture and underwent orthopedic surgery, on 06/05/17. (Refer to F-280) Resident #5's Comprehensive Care plan, revised 05/17/17, revealed the resident was at risk for falls with an intervention for a pull alarm while in bed (device that attaches to the resident that alarms when the resident attempts to get up unassisted). On 05/26/17, SRNA #2 removed the resident's pull alarm while assisting the resident to get dressed, and assisted the resident to lye down in bed. SRNA #2 then failed to re-attach the resident's pull alarm prior to exiting the room. After SRNA #2 exited the room, Resident #5 fell off the bed and sustained a Hematoma, Concussion, and Lacerations to the back of his/her head requiring sutures. (Refer to F-282) In addition, Resident #5 was assessed by the facility to require the assistance of two (2) staff for dressing according to the Quarterly MDS Assessment, dated 03/24/17. However, on 06/13/17, the Comprehensive Plan of Care and the Nurse Aide Care Plan did not address how many staff were needed to assist the resident with dressing. On 06/13/17, Resident #5 experienced a fall from the bed to the floor while SRNA #7 was assisting the resident with undressing by taking off the resident's shoes, unassisted by a second staff member. Resident #5 did not sustain injuries related to this fall. (Refer to F-280) The findings include: Review of the facility's Falls-Clinical Protocol Policy, revised April 2016, revealed the goals of the plan of care may include, but was not limited to reduction of falls, minimize injury from falls, and/or prevent falls while maintaining and/or improving resident abilities and quality of life. The policy further revealed interventions should be developed and implemented per the assessed needs. Additional items to remember when developing the plan of care include: resident's abilities and deficits; balance (sitting/standing); adaptive equipment needs; and proper use of mechanical lifts and transfer devices. In addition, interventions for direct care givers should be placed on the State Registered Nurse Aide (SRNA) Care Card or similar format. The care plan and SRNA care plan should be updated as interventions change. Continued review of the facility's Policy, revealed staff would monitor and document the individuals' response to interventions intended to reduce falling or the consequences of falling. Residents would be reviewed through the Standards of Care after new interventions were implemented to determine if effective or revision was necessary. 1. Review of Resident #3's medical record revealed the the facility admitted the resident on 02/08/17 and readmitted the resident on 04/10/17, with [DIAGNOSES REDACTED]. Per the Facility's Fall Risk Evaluation, dated 02/08/17, the resident was assessed to be at high risk for falls. Review of the Quarterly Minimum Data Set (MDS) Assessment, dated 03/24/17, revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of thirteen (13) out of fifteen (15), which indicated the resident was cognitively intact. Continued review of the MDS, revealed the facility assessed the resident to require extensive assistance of two (2) persons for physical assist with transfers and toileting. Review of the Comprehensive Care Plan revised 03/01/17, revealed Resident #3 was at risk for injury from falls related to ambulation status, and balance. The goal stated safety and manage risks for falling. There were several interventions including: observe for unsteady gait and balance and assist as needed; therapy/restorative screens and treatments as ordered. However, the Comprehensive Care Plan did not state how many staff members were required to assist the resident with transfers or toileting to prevent falls. (The Comprehensive Care Plan was not revised related to the need for two (2) staff to assist with transfers until 06/03/17, after the resident sustained [REDACTED]. Review of the Nurse Aide Care Plan dated May 2017, and June 2017 for the period of 06/01/17 through 06/05/17, revealed Resident #5 was to be transferred with the assistance of one (1) staff member and a gait belt, and did not state how many staff were required to toilet the resident. (The Nurse Aide Care Plan was not updated to two (2) assist with transfers and elimination until 06/05/17). Review of the Facility's Incident Report, dated 06/03/17, revealed on 06/03/17 at 3:45 PM, Resident #3 fell while being transferred from the commode to the bed. Per the Report, the resident complained of left hip pain and sustained a laceration to the left forearm. Per review, the resident was incontinent at time of the incident and the level of assistance at the time of the fall was one (1) assist. The results of the investigation stated, after review of the information there were no factors, the resident's legs buckled and that contributed to the fall. The Falls Report was signed by Director of Nursing (DON) on 06/04/17. Review of the Nurse's Note, dated 06/03/17 at 3:45 PM, completed by Registered Nurse (RN) #1, revealed SRNA #1 notified RN #1 of Resident #3's fall. Per the Note, upon entering the room, the resident was on the floor and the resident complained of left hip pain, was yelling out in pain and had a skin tear on the left forearm. Further review of the Note, revealed the DON and the resident's Power of Attorney (POA) was notified. Per the Note, the resident was transferred to the hospital emergency room by Emergency Medical Services (EMS) at 4:06 PM. Review of SRNA #1's Statement, dated 06/03/17, revealed SRNA #1 was assisting Resident #3 to his/her bedside toilet from the bed. Per the Statement, she assisted the resident up and let him/her sit on the side of the bed until he/she was ready to stand. Further review revealed when the resident said he/she was ready, SRNA #1 helped him/her stand and the resident's leg buckled and he/she fell to the floor. Review of the Hospital Discharge Summary, dated 06/07/17, revealed Resident #3 was admitted to the hospital on [DATE] after a fall. Further review revealed the resident was found to sustain a Left Femoral Neck Fracture and a Large Skin Tear to the Left Arm. Additional review revealed the resident was underwent surgery on 06/05/17 and was status [REDACTED]. Interview with Resident #3, on 06/29/17 at 11:25 AM, revealed he/she was transferred by one (1) staff member the day of the fall. The resident revealed the aide assisted him/her to the bedside commode, and he/she remained on the commode until SRNA #1 made his/her bed. Continued interview revealed when he/she stood, and was assisted with being transferred back to the bed, his/her leg gave out and before he/she knew it, he/she was on the floor. The resident stated he/she landed on his/her left side and it was painful. Per interview, the resident recalled staff asking him/her if he/she could move his/her left leg and when he/she reported to staff that he/she could not, staff called EMS. Further interview with Resident #3, revealed he/she had always required two (2) staff to assist him/her with transferring; however, the day before the fall the Administrator spoke to him/her and asked if he/she wanted to have an assist of one (1) staff for transfers, since it took awhile for two (2) staff to respond to his/her call lights. Resident #3 stated he/she thought he/she could be transferred with one (1) staff, thus when the Administrator talked to him/her about the level of assistance needed, he/she agreed to have one (1) person to assist with his/her transfers. Resident #3 stated the Administrator or nursing staff did not assess him/her to determine if he/she was safe to complete his/her transfers with one (1) staff assistance. Interview with State Registered Nurse Aide (SRNA) #1, on 06/28/17 at 5:30 PM, revealed she was somewhat familiar with Resident #3. She stated she was the aide assigned on the Breckinridge Unit, to work with the resident on 06/03/17, and reviewed the resident's Nurse Aide Care Plan prior to caring for the resident. She stated the Nurse Aide Care Plan stated the resident required one (1) assist with transfers and did not specify how many staff was required for toileting. Per interview, she transferred the resident by herself to the commode, but when transferring the resident back into his/her bed, the resident fell . SRNA #1 revealed she thought the resident's knee gave out. Further interview revealed she was following the resident's Nurse Aide Care Plan and would have had another person with her to assist with the resident's transfer had she known the resident required two (2) people with transfers. Interview with SRNA #3, on 06/29/17 at 3:08 PM, revealed she had worked with Resident #3 in the past and thought he/she had always been care planned for an assist of two (2) staff for transfers. SRNA #3 stated it had been awhile since she worked with the resident, but stated it would not have been safe to transfer the resident with one (1) assist because he/she was often weaker after returning from dialysis. The State Survey Representative attempted phone calls to Registered Nurse (RN) #1, who was assigned to the resident on 06/03/17 at the time of the fall. Calls were attempted on 06/28/17 at 6:01 PM and 6:30 PM; however, a message could not be left for a return call. Interview with Licensed Practical Nurse (LPN) #1, on 06/28/17 at 6:03 PM, revealed she was working on the Combs Unit at the time Resident #3 fell on the Breckinridge Unit on 06/03/17. She stated RN #1 asked her to assist with the fall and the incident paperwork since RN #1 was new to the facility and was unsure as to how to handle falls. She stated the resident was on the floor, calling out in pain, so she called EMS and made the needed notifications. She further stated she looked at the resident's Nurse Aide Care Plan and noticed the resident was care planned for one (1) assist with transfers and she then updated the Comprehensive Care Plan and the Nurse Aide Care Plan to state two (2) assist with transfers. LPN #1 stated Resident #3 had resided on the Combs unit previously, and was care planned to be an assist of two (2) for transfers at that time. She stated she was not certain when the resident became an assist of one (1) with transfers. Interview with LPN #3, on 06/29/17 at 4:51 PM, revealed she often cared for Resident #3 on the Breckinridge Unit. She stated the resident always needed an assist of two (2) with transfers, even before the fall on 06/03/17. LPN #3 revealed the resident attended Dialysis three (3) times a week and was weak and fragile. LPN #3 stated she was not aware of a time in which the resident required one (1) assist for transfers. Per interview, she had not reviewed the resident's Care Plan, but stated it should have reflected an assist of two (2) people with transfers. Continued interview with LPN #4, revealed the Comprehensive Care Plans were based on the MDS Assessments and the Care Plans drove the care for the residents. She stated it was important to develop/revise the care plans with the proper interventions and follow the plan of care for the safety of the residents. Interview with LPN #2/Breckinridge Unit Manager, on 06/30/17 at 10:20 AM, revealed as Unit Manager she would ensure the Comprehensive Care Plan and the Nurse Aide Care Plan matched, then monitor a staff member to ensure they implemented the residents' plan of care as instructed on the residents' Care Plan. When questioned as to why Resident #3's Comprehensive Care Plan had no intervention to state how many staff were needed to transfer or toilet Resident #3, and the Nurse Aide Care Plan did not state how many staff were needed to toilet the resident, she stated she had not checked Resident #3's Care Plans, but should have. Further interview revealed she did not check to ensure the Care Plans matched the MDS Assessments for transfers, or toileting as she did not have access to the the MDS Assessments. Continued interview with LPN #2/Breckinridge Unit Manager, revealed Resident #3 had previously resided on the Combs Unit and when the resident moved to the Breckinridge Unit he/she was an assist of one (1) for transfers until he/she sustained the fall on 06/03/17. Further interview with the Unit Manager, revealed on 04/25/17 she had to assist the aide with the resident due to the resident almost falling. She stated the resident needed an assist of two (2) that day. However, she stated even after the resident almost fell on [DATE], she did not recognize the need to update the Comprehensive Care Plan to two (2) assist with transfers because she had always known the resident to be a one assist. Interview with Registered Nurse (RN) #2/MDS Coordinator, on 06/30/17 at 12:19 PM, revealed the Comprehensive Care Plans were developed/revised from the MDS Assessment. Continued interview revealed all the residents' Comprehensive Care Plans were recently revised to indicate the amount of staff required to perform Bed Mobility/Repositioning and Transfers by LPN #4/MDS Coordinator. After reviewing Resident #3's Quarterly MDS assessment dated [DATE], she stated the resident was coded for two (2) to assist with transfers and toileting on the MDS, and should have been Care Planned for two (2) assist for transfers and toileting. Continued interview revealed the care plan was vague. Per interview, the Care plan was very important because it was about the care for the residents. Interview with Licensed Practical Nurse (LPN) #4/MDS Coordinator, on 06/30/17 at 12:56 PM, revealed in revising and updating the residents' care plans on 04/24/17 and 04/25/17, she did not check the MDS to ensure they matched the Comprehensive Care Plans. She stated she only compared the Comprehensive Care Plans with the Nurse Aide Care Plans to determine that these care plans matched. She further stated the number of staff needed to assist a resident with Activities of Daily Living (ADL's) such as transfers and toileting was important and needed to be on the Comprehensive Care Plan and the Nurse Aide Care Plan and the facility was working to correct that problem through completing the Provision of Audits which was a tool utilized to ensure staff were following the Care Plan. However, she stated it was not important to ensure the Comprehensive Care Plan and the MDS Assessment correlated as far as the number of staff needed to assist with ADL's, because the residents' level of function may change between assessment periods for the MDS Assessments. Interview with the Director of Nursing (DON), on 06/30/17 at 2:21 PM, revealed Resident #3's Comprehensive Care Plan did not match the Nurse Aide Care Plan because the facility was in the process of updating/revising Care Plans during the period in which the resident fell . Continued interview revealed it would not have been her expectation for the MDS Assessments to correlate with the Comprehensive Care Plans and the Nurse Aide Care Plans because the nurses were revising the care plans based on the Provision of Care Audits and not on the MDS Assessments. She explained the Provision of Audits was was a tool used to to monitor that staff were adhering to the Plan of Care for transfers and repositioning. Further interview revealed she was not certain if the Comprehensive Care Plan was driven by the MDS, and relied on her nurses, therapy, and staff when it came to care planning. When asked if a root cause analysis was done related to the resident's fall, she revealed falls were addressed in the morning meeting by the Interdisciplinary Team (IDT). She stated after the fall on 06/03/17, the IDT recognized Resident #3's Comprehensive Care Plan and Nurse Aide Care Plan needed to be updated related to having two (2) staff to transfer, and two (2) staff to toilet the resident. Interview with the Administrator, on 06/30/17 at 4:56 PM, revealed the MDS Assessment, Comprehensive Care Plan, and Nurse Aide Care Plan were to correlate with one another and there should be documented evidence to support the change of assistance if the Care Plan did not match the MDS. He stated he talked to Resident #3 a few days before the fall on 06/03/17 about his/her transfers and the resident preferred to be an assist of one (1) due to long waits for two (2) staff to assist him/her. Per interview, he checked the resident's Nurse Aide Care Plan and he/she was care planned for one (1) assist with transfers. However, further interview with the Administrator, revealed the MDS was coded for the resident to require two (2) assist with transfers and he could not locate documented evidence in the resident's record which supported the need for the resident's one (1) assist with transfers. He stated, Resident #3's Care Plan and Nurse Aide Care Plans should have had interventions for two (2) staff to assist with transfers and toileting as per the MDS. 2. Review of Resident #5's closed medical record revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) Assessment, dated 03/24/17, revealed the facility assessed the resident as having severe cognitive impairment and as having no falls since admission or since last Assessment. Review of the residents Fall Risk Evaluation dated 05/26/17, revealed the resident was at high risk for falls. Review of the Comprehensive Plan of Care, revised 05/17/17, revealed the resident was at risk for falls related to ambulation/elimination status, balance cognition, gait and history of falls. The goal stated resident safety and manage risk for falling. There were several interventions listed including call light in reach; therapy/restorative screens/treatments as ordered; and pull alarm when in bed. Review of the Nurse Aide Care Plan dated May 2017, revealed an intervention for a pull alarm when in the bed. Review of the Facility's Incident Report, signed by the Assistant Director of Nursing (ADON), dated 05/26/17, revealed on 05/26/17 at 5:20 PM, SRNA #2 needed to get Resident #5 up for the evening meal, left the room to get help, and heard a loud thump. Per the Report, SRNA #2 re-entered the room, and found the resident lying on the floor beside the bed with a large hematoma and lacerations to the head. According to the Report, the care plan interventions prior the fall included pull alarm on bed; however, the report did not state if the pull alarm was in place at the time of the fall. Further review of the Report revealed the investigation concluded immediate education was implemented. Review of the Statement, dated 05/26/17 written by SRNA #2, revealed the resident was attempting to get out of bed and she went to get her hall partner to assist with transferring the resident. Further review revealed when walking towards the Nurse's Station she heard a loud thump, walked back into the resident's room and saw the resident in the floor. Review of the Nurse's Note, dated 05/26/17 at 5:20 PM, completed by LPN #3, revealed SRNA #2 was going to get Resident #5 up for the evening meal, left the room to get assistance, and heard a loud thump. Per the Note, upon SRNA #2 re-entering the resident's room, the resident was found lying on his/her stomach on the floor beside the bed. Further review of the Note, revealed the resident was lying with his/her face turned towards the door and when the resident was turned over there was a large amount of blood on the floor and a large hematoma to the right side of the resident's forehead, a laceration to the right side of the resident's head and two (2) small lacerations to the top of the resident's head. Per the Note, the resident was transferred out by EMS, leaving the facility at 5:30 PM. Continued review of the Note, revealed the hospital contacted the facility at 9:30 PM to report the resident would be returning back to the facility and the resident had sustained a concussion and had staples placed to the laceration in back of the head. Interview with State SRNA #2, on 06/28/17 at 9:09 AM, revealed she cared for Resident #5 on the day of the incident, on 05/26/17. Per interview, Resident #5 required two (2) assist with transfers and she was waiting on her hall partner, SRNA #5, to assist her with transferring the resident from the bed to the wheelchair. Further interview revealed she thought she would dress the resident while she waited on her hall partner to come to the room to assist with the resident's transfer so she took off the residents bed pull tab alarm, which was attached to the resident, dressed the resident, then assisted the resident to lye down in the bed. She further stated she left the room to get her hall partner and while she was out of the room the resident fell off the bed and on to the floor. She stated the resident hit the bedside table and there was a laceration on his/her head. SRNA #2 stated she notified LPN #3 who assessed the resident and called American Medical Response (AMR). Continued interview with SRNA #2, revealed she had not attached the pull tab alarm to the resident before leaving the room, as per the resident's Care Plan. Interview with LPN #3, on 06/29/17 at 4:51 PM, revealed she was the nurse assigned on 05/26/17 at the time of the resident's fall. She stated SRNA #2 and SRNA #6 told her Resident #5 was on the floor in his/her room lying on his/her stomach. She stated the resident's right arm was bent funny, and when they got him/her off the arm, she noticed the blood on the floor and the laceration and hematoma on the resident's head. She further stated she called LPN #2/Unit Coordinator to call AMR and to get the paperwork ready while she applied pressure to the resident's head. Per interview the resident was transferred to the hospital and treated in the emergency room . Continued interview revealed the hospital called and told her the resident would be sent back to the facility and had a mild concussion and new physician's orders [REDACTED].#3 revealed SRNA had failed to follow the Care Plan as she had not attached the resident's pull tab alarm to the resident prior to exiting the room. Interview with SRNA #6, on 06/30/17 at 10:04 AM, revealed she was leaving Amelia Unit and walking towards the Breckinridge Unit when she heard a thump. She stated she did not know what room it was, so she went from room to room until she got to Resident #5's room. She further stated SRNA #2 arrived at the same time she arrived to the room. Continued interview revealed she did not hear an alarm go off and was not familiar with the resident enough to discuss his/her care plan. However; she stated the resident could get hurt if the care plan was not followed. Interview with LPN #2/Unit Manager for Breckinridge Unit, on 06/30/17 at 10:20 AM, revealed Resident #5 resided on the Breckinridge unit at the time of the fall on 05/26/17. She stated after the fall, she reviewed the circumstances surrounding the fall and did education with SRNA #2 related to the need to ensure the pull alarm was in place. She stated SRNA #2 should have ensured the resident's pull alarm was in place prior to exiting the resident's room as it was a safety intervention. Interview with the Assistant Director of Nursing (ADON), 06/30/17 at 1:15 PM, revealed she worked the day of Resident #5's fall on 05/26/17. She stated she assisted LPN #3 with assessing the resident and getting the resident out to the hospital. Continued interview with the ADON, revealed she completed the Facility's Incident Report and had written staff education under the immediate interventions implemented, but did not recall what the re-education was about. Interview with the Regional Director of Operation, on 06/30/17 at 7:45 PM, revealed through the investigation of Resident #5's fall on 05/25/17, it was recognized SRNA #2 did not ensure the resident's pull alarm was in place prior to exiting the room, and SRNA #2 received education related to this. 3. Continued review of Resident #5's Quarterly Minimum Data Set (MDS) Assessment, dated 03/24/17, revealed the facility assessed the resident as requiring extensive assistance with two (2) staff for dressing, which included how the resident puts on, fastens and takes off all items of clothing. Review of Resident #5's Comprehensive Care Plan, revised 05/17/17, revealed the resident had a problem of Self-care Activities of Daily Living deficit related to cognitive deficits, deconditioning, impaired range of motion, and weakness. The goal stated the resident would be dressed and groomed appropriately. On 06/07/17, a new intervention was added stating the resident required total assistance with dressing; however, there was no intervention stating how many staff were required to assist the resident with dressing. Review of the Nurse Aide Care Plan, dated June 2017, revealed the resident required total assistance with dressing; however, did not specify how many staff were required to assist the resident with dressing. Review of the facility's Incident Report, revealed the incident occurred on dated 06/13/17 at 10:30 PM. Per the Report, SRNA #7 had Resident #5 sitting on the edge of bed and was taking off his/her shoes off when the resident slid off the edge of the bed with no apparent injures. Continued review of the Report, revealed the staff member was re-educated by therapy related to transfers and assist. Further review of the Comprehensive Care Plan and Nurse Aide Care Plan, revealed on 06/13/17 a new intervention was added for the resident to be prepared for getting up or going to bed, lying down, not while sitting on the side of the bed. Review of the Nurse's Note, dated 06/12/17 at 10:30 PM, completed by LPN #3, revealed SRNA #7 called the nurse (LPN #3) into Resident #5's room. Per the Note, the resident was observed sitting on the floor on his/her buttocks and SRNA #7 was holding the resident. Further review revealed an assessment was completed with no apparent injury noted. Interview with SRNA #7, on 06/27/17 at 4:38 PM, revealed Resident #5 required two (2) assist with transfers due to a stroke on the left side. Continued interview revealed on 06/13/17, the day of the incident, she asked SRNA #8 to assist her with transferring the resident into the bed. She stated SRNA #8 assisted her and left the room with the mechanical lift they had used to transfer the resident to the bed. She further stated she began to take off the resident's shoes when the resident leaned over to one (1) side and fell off the bed. Continued interview revealed she was unaware the resident was assessed to require two (2) staff to assist with undressing as the Nurse Aide Care Plan was not specific. Further interview with SRNA #7, revealed she had been assigned to the resident prior to the incident, but did not realize he/she had gotten weak on his/her side. SRNA #7 stated she was not re-educated related to the incident. Interview with SRNA #8, on 07/03/17 at 12:32 PM, revealed on 06/13/17, SRNA #7 asked her to assist with assisting Resident #5 to bed. She stated she assisted SRNA #7 with transferring the resident to the bed with the mechanical lift, and left the room with Resident #5 sitting on the edge of the bed and SRNA #7 bent over taking off the resident's shoes. She further stated she left the room to put the lift up and did not observe the actual fall. Interview with LPN #3, on 06/29/17 at 4:51 PM, revealed she was assigned to Resident #3 on on 06/13/17, the date of the fall. She stated SRNA #7 and SRNA #8 assisted the resident to bed and SRNA #8 left the room. Continued interview revealed Resident #5 slipped off the edge of the bed as SRNA #7 was taking off the resident's shoes. She stated the resident was not injured. LPN #3 stated the resident had a stroke and he/she was flaccid on his/her right side. She revealed if the MDS stated the resident needed two (2) assist for dressing, then the intervention should have been on the resident's Comprehensive Care Plan and Nurse Aide Care Plan. Interview with RN #3, on 06/28/17 at 3:43 PM, revealed she had worked with Resident #5 and was familiar with his/her care. RN #3 stated the Comprehensive Care plans were developed through the MDS Assessment. Continued interview revealed MDS Nurses developed/revised the care plans; however, the nursing staff also revised the care plans. After reviewing Resident #5's MDS dated [DATE], RN #3 stated the resident's Comprehensive Care plan and SRNA Care Plan should have reflected the need for the resident to have two (2) persons to assist with dressing. Interview with the Breckinridge Unit Coordinator/LPN #2, on 06/30/17 at 10:20 AM, revealed Resident #5 resided on the Breckinridge Unit and she audited the resident's care on 04/25/17, 05/05/17, and the week of May 15-19, 2017 and the documented audits, revealed the resident was assessed to need two (2) assist with transfers and repositioning. She stated she did not observe staff getting the resident ready in the morning during the audits, and only asked staff to tell her when they had completed dressing the resident. She stated she then observed his/her transfers and repositioning. Further interview with the Unit Coordinator, revealed she should have observed staff dress the resident so that she could have re-educated staff and care planned for the need for two (2) staff to assist when dressing the resident. Continued interview revealed the Comprehensive Care Plan and the SRNA care plan should have had interventions for two (2) staff to assist the resident with dressing. Interview with the ADON on 06/30/17 at 1:15 PM, regarding Resident #5's fall on 06/13/17, revealed the resident's Comprehensive Care Plan and Nurse Aide Care Plan was not specific enough to indicate the level of assistance needed for his/her care, related to accomplishing different tasks including dressing, but should have been. She stated it was important that the care plans were revised and updated for the safety of the residents and the intervention for two (2) staff to dress the resident should have been added to the Comprehensive Care Plan and the Nurse Aide Care Plan, especially after the fall. The ADON stated the care plans were important because they mapped out the care that should be provided to the resident. Interview with LPN #4/MDS Coordinator, on 06/30/17 at 12:56 PM, revealed she was not certain how many staff were needed to assist Resident #5 with dressing and undressing. Further interview with the MDS Coordinator, revealed the facility ut(TRUNCATED)

Based on interview, and record review, it was determined the facility failed to ensure the Comprehensive Plan of Care was reviewed and revised for one (1) of three (3) sampled residents (Resident #1). Although Resident #1's Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed the facility assessed the resident as requiring the assistance of two (2) staff for bed mobility and toileting, the Comprehensive Care Plan initiated 08/15/16, was not revised with interventions for two (2) staff for bed mobility and toileting. Additionally, the Certified Nursing Aide (CNA) Care Plan dated April 2017, was not specific in stating how many staff was required for incontinence care/ toileting for Resident #1. On 04/23/17, a Certified Nursing Assistant (CNA) independently repositioned Resident #1 in the bed in order to provide incontinence care, and left the resident unattended to obtain a brief and linens. Resident #1 rolled out of the bed on to the floor and sustained a Laceration above the Left Eye, a [MEDICAL CONDITION] Fifth toe, and a Contusion of the Left Knee. The findings include: Post Survey phone interview on 06/01/17 at 9:00 AM, with the Director of Nursing (DON), revealed the facility did not have a policy related to revision of Care Plans. She stated the Minimum Data Set Coordinators were responsible for revising the Comprehensive Care Plans with the Admission, Quarterly, Annual and Significant Change MDS. Further interview revealed the interdisciplinary team was responsible for updating the Care Plans in the morning meetings Monday through Friday if there were changes in a resident's condition or with new physician's orders [REDACTED]. Review of Resident #1's medical record revealed the facility admitted the resident on 05/21/14 with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) Assessment, dated 03/13/17, revealed the facility assessed Resident #1 as having both long and term memory loss, and as requiring extensive assistance of two (2) person physical assist with toileting, and bed mobility. Continued review revealed the facility assessed the resident as always incontinent of bowel and bladder. Review of the Comprehensive Care Plan initiated 08/15/16, with the next subsequent review/revision date of 05/16/17, revealed Resident #1 was at risk for injury/falls due to cognition, history of falls, medications, and musculoskeletal impairment. The goal stated safety and manage risks for falling and the interventions included: dependent on staff for mobility; and perimeter mattress. Although the MDS assessment dated [DATE], revealed the resident required extensive assistance of two (2) person physical assist with bed mobility, the Comprehensive Care Plan was not revised to state how many staff members were required to assist the resident with bed mobility/re-positioning. Continued review of the Comprehensive Care Plan initiated 08/15/16, with the next subsequent review/revision date of 05/16/17, revealed Resident #1 had alteration in urinary elimination related to unable to toilet self with a goal stating manage and improve incontinence and prevent complications. The interventions included assist with toilet per CNA Care Plan. Although the MDS assessment dated [DATE], revealed the resident required extensive assistance of two (2) person physical assist with toileting, the Comprehensive Care Plan was not revised to state how many staff members were required to assist the resident with elimination needs and the CNA Care Plan did not specify how many staff was required to assist the resident with incontinence care/toileting Review of Resident #1's CNA Care Plan dated April 2017, revealed under the Section titled Repositioning, two (2) staff were required. Further review under the Section titled Elimination revealed the resident was incontinent of bowel and bladder, requiring check and change every two (2) to three (3) hours. However, the CNA Care Plan did not specify how many staff members were required to assist Resident #1 with toileting/elimination. Review of the facility Incident Report, dated 04/23/17, revealed at 5:35 AM, Resident #1 rolled out of bed to the floor stating he/she was getting up. Per the Report, the resident had a laceration above the left eye and complained of pain to the area; and remained alert. Further review revealed 911 was called and the resident was sent to the hospital. However, review of the Statement written and signed by the Assistant Director of Nursing (ADON) on 04/25/17 at 11:45 AM, revealed when the ADON phoned CNA #4 and asked her to come in and review camera footage with Administration to explain what occurred, CNA #4 told the ADON she forgot to tell something earlier. Per the Statement, CNA #4 then told the ADON, when she turned Resident #1 to his/her side, she realized she needed more linen and left the resident on his/her side while she left the resident's room to obtain the linen. According to the Statement, when she re-entered the resident's room, the resident had rolled over on to the floor. Review of the facility's Final Report/ Investigation of Resident #1's fall dated 04/28/17, revealed in the original Incident Report it was noted that when questioned as to how the resident fell , the resident stated I was trying to get out of bed. However, through further investigation, it was discovered the resident was unable to perform bed mobility per self. According to the Report/Investigation the ADON reviewed camera footage which revealed an aide (CNA #4) going into Resident #1's room and exiting to retrieve linen from the linen cart. Per the Report/Investigation, the aide then returned to the resident's room and shortly after, the nurse responded to the room. Continued review, revealed the aide (CNA #4) was interviewed a third time and admitted when she was in Resident #1's room, she left to get a brief and left the resident on his/her side on the side of the bed. Review of the Hospital Discharge Summary, dated 04/23/17, revealed Resident #1 was diagnosed with [REDACTED]. Telephone interview with CNA #4, on 05/16/17 at 2:50 PM, revealed on 04/23/17 she was assigned to Resident #1, and was not very familiar with the resident. She stated on 04/23/17 she had rolled the resident over to his/her side and was getting ready to perform incontinence care when she realized she did not have the supplies needed. CNA #4 stated she went out to the hall to get the supplies and as she was re-entering the room she heard Resident #1 fall. CNA #4 revealed she had not asked for help prior to repositioning the resident in order to perform incontinence care, stating, I can change {him/her} by myself. Continued interview revealed she always reviewed her assigned residents CNA Care Plans at the start of the shift, but had not realized at the time of the incident the resident required two (2) staff for providing incontinence care. Telephone interview with CNA #5, on 05/17/17 at 1:37 PM, revealed she was familiar with Resident #1, and had cared for the resident in the past. Per interview, she was aware the resident required two (2) staff to assist with incontinence care and repositioning, and she would always get another staff member to assist . Post Survey telephone interview with LPN #2, on 05/18/17 at 2:25 PM, revealed she was assigned to Resident #1 on 04/23/17 at the time of the fall and was standing at the medication cart when she heard a loud noise. She stated she questioned CNA #4 who was in the hallway, about the noise and the CNA walked immediately to Resident #1's room and found the resident on the floor. Per interview, LPN #2 immediately assessed Resident #1, and called 911 to transport the resident to the hospital for evaluation. Continued interview, revealed knowing how many staff were needed to assist the resident with Activities of Daily Living (ADL's) was key to preventing injuries with residents and staff was to refer to the CNA Care Plan for the amount of staff required for ADL's. LPN #2 verified Resident #2 required two (2) staff to assist with bed mobility and incontinence care prior to the fall on 04/23/17 and CNA #4 should have requested assistance. Interview with MDS Coordinator #1 and #2, on 05/17/17 at 12:27 PM and 2:18 PM, revealed specifics regarding level of assistance required for ADLs was found on the CNA Care Plans; however, the Comprehensive Care Plans were not revised to include this information because the nurses and CNA's followed the CNA Care Plan. MDS Coordinator #2 revealed Resident #1's Comprehensive Care Plan was not revised to include how many staff were needed to assist the resident with bed mobility, repositioning or incontinence care. MDS Coordinator #2 further revealed Resident #1's CNA Care Plan dated April 2017, was not specific as to assistance required with toileting/incontinence care under the Elimination Section. Interview with the ADON, on 05/17/17 at 1:20 PM, revealed generally the Comprehensive Care Plan was not revised to include how many staff was required to assist resident's with ADL's because specific needs regarding assistance with ADL's was updated to the CNA Care Plan monthly, with falls, and with significant changes. She stated the CNA Care Plan was currently a paper version found at the nurses' station of each unit and was updated as needed in morning meetings. Further interview revealed per Resident #1's CNA Care Plan, the resident required two (2) to assist with repositioning, but the CNA Care Plan was not updated to state how many staff were required for elimination/toileting needs. She revealed the resident sustained [REDACTED]. Interview with the Director of Nursing (DON), on 05/17/17 at 2:00 PM, revealed if a resident was assessed on the MDS as requiring extensive or total assistance, this was to be converted to two (2) person-assist on the CNA Care Plan. She further revealed this information related to the level of assistance required should match the Comprehensive Care Plan because the Comprehensive Care Plan was generated from the MDS Assessment. Per interview, the MDS Coordinators were responsible for revising the Comprehensive Care Plans. Further interview revealed Resident #1's Comprehensive Care Plan was not revised with specific interventions related to the need for two (2) staff to assist with bed mobility and incontinence care and the CNA Care Plan was not revised to state how many staff were required to toilet the resident. She confirmed only one (1) staff member was assisting the resident with positioning and incontinence care on 04/23/17, resulting in a fall with injury. Interview with the Administrator, on 05/17/17 at 2:18 PM, revealed it was important for staff to adhere to the level of assistance dictated by the Care Plan when providing care. Per interview the facility tried to ensure the CNA Care Plans were revised to be specific as to how many staff were required for ADL's. He further stated he realized the facility's Comprehensive Care Plans were based on a template, and were not revised to be specific and individualized in that respect.

Based on interview, record review and review of the facility's Policy, Incident Report and Investigation, it was determined the facility failed to ensure each resident received adequate supervision to prevent accidents for one (1) of three (3) sampled residents (Resident #1). Resident #1 was assessed by the facility to require the assistance of two (2) staff for bed mobility and toileting according to the Quarterly Minimum Data Set (MDS) assessment dated [DATE]. However, the Comprehensive Care Plan initiated 08/15/16, was not specific as to how many staff was required to assist the resident for bed mobility and toileting. In addition, the Certified Nursing Aide (CNA) Care Plan dated April 2017, was not specific in stating how many staff was required for incontinence care/ toileting. On 04/23/17 Certified Nursing Assistant (CNA) #4 independently repositioned Resident #1 in the bed in order to change his/her brief, and left the resident unattended while she left the room to obtain a brief and linens. Resident #1 rolled out of the bed sustaining a Laceration above the Left Eye, a Fracture of the Right Fifth Toe, and a Contusion of the Left Knee. The findings include: Review of the facility's Policy titled Falls - Clinical Protocol, dated February 2013, revealed the Minimum Data Set (MDS) Assessment would be utilized to develop the Comprehensive Plan of Care to minimize falls and injuries from falls. Further review revealed interventions should be implemented per the assessed needs, and interventions for direct care givers should be placed on the Certified Nursing Assistant (CNA) Care Card or similar format. Review of Resident #1's medical record revealed the facility admitted the resident on 05/21/14 with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) Assessment, dated 03/13/17, revealed the facility assessed Resident #1 as having both long and term memory loss, and as requiring extensive assistance of two (2) person physical assist with toileting, and bed mobility. Further review revealed the facility assessed the resident as always incontinent of bowel and bladder. Review of the Comprehensive Care Plan initiated 08/15/16, with the next review/revision date of 05/16/17, revealed Resident #1 was at risk for injury/falls related to cognition, history of falls, medications, and musculoskeletal impairment. The goal stated safety and manage risks for falling. There were several interventions including: dependent on staff for mobility and perimeter mattress. However, the Comprehensive Care Plan did not state how many staff members were required to assist the resident with bed mobility to prevent falls. Continued review of the Comprehensive Care Plan initiated 08/15/16, with the next review/revision date of 05/16/17, revealed Resident #1 had alteration in urinary elimination related to unable to toilet self with a goal stating manage and improve incontinence and prevent complications. There were several interventions including assist with toilet per CNA Care Plan. However, neither the Comprehensive Care Plan or the CNA Care Plan specified how many staff was required to safely assist the resident with incontinence care/toileting. Review of Resident #1's CNA Care Plan dated April 2017, revealed under the Section titled Repositioning, two (2) persons were required. Further review under the Section titled Elimination revealed the resident was incontinent of both bowel and bladder, requiring check and change every two (2) to three (3) hours, and was high risk for falls. However, the CNA Care Plan did not state how many staff were required to assist the resident with toileting/elimination. Review of Resident #1's Fall Risk Evaluation, dated 04/23/17, revealed the resident's risk factors for falls included: history of falls; required assistance with elimination; confined to chair; not able to attempt balance without physical help; eighty-five (85) years of age or older; health condition; and medications. Continued review of the Evaluation revealed a score of eighteen (18) for the resident with a score of ten (10) or greater indicating at risk for falls. Review of the facility Incident Report, dated 04/23/17, revealed at 5:35 AM, Resident #1 rolled out of bed to the floor stating he/she was getting up. Per the Report, the resident had a laceration above the left eye and complained of pain to the area; and remained alert. According to the Report, 911 was called and the resident was sent to the hospital. Review of the Witness Statement, signed by Licensed Practical Nurse (LPN) #2, undated and untimed, revealed LPN #2 was in the hallway when she heard a loud thump . Further review revealed CNA #4 was in a resident room and heard the noise also. Per the Statement, CNA #4 found the resident on the floor. Review of the Witness Statement, signed by CNA #4, dated 04/23/17 and untimed, revealed CNA #4 was in a room with another resident and heard a thumping noise. Per the Statement, when CNA #4 checked Resident #1's room, she found Resident #1 on the floor. However, review of the Statement written and signed by the Assistant Director of Nursing (ADON) on 04/25/17 at 11:45 AM, revealed when the ADON phoned CNA #4 and asked if she could come in and review camera footage with Administration to explain what occurred, CNA #4 told the ADON she forgot to tell something earlier. According to the Statement, CNA #4 then told the ADON, when she turned Resident #1 to his/her side, she realized she needed more linen and left the resident on his/her side while she left the resident's room to get the linen. Per the Statement, when she re-entered the resident's room, the resident had rolled over on to the floor. Review of the facility's Final Report/ Investigation of Resident #1's fall dated 04/28/17, revealed in the original Incident Report it was noted that when questioned as to how the resident fell , the resident stated I was trying to get out of bed. Upon further investigation, it was discovered the resident was unable to perform bed mobility per self. Per the Report/Investigation the ADON reviewed camera footage which revealed an aide (CNA #4) going into Resident #1's room and exiting to retrieve linen from the linen cart. According to the Report/Investigation, the aide then returned to the resident's room and shortly after, the nurse responded to the room. Further review, revealed the aide (CNA #4) was interviewed a third time and admitted when she was in Resident #1's room, she left to get a brief and left the resident on his/her side on the side of the bed. Review of the Hospital Discharge Summary, dated 04/23/17, revealed Resident #1 was diagnosed with [REDACTED]. Telephone interview with CNA #4, on 05/16/17 at 2:50 PM, revealed she was assigned and caring for Resident #1 on 04/23/17 at the time the fall occurred; however, was not very familiar with the resident as she had only cared for the resident a few times. She stated she had rolled Resident #1 over to his/her side and was getting ready to perform incontinence care when she realized she did not have the supplies needed. She stated she went out to the hall to get the supplies and as she was coming back into the room she heard Resident #1 fall. CNA #4 confirmed a second staff member was not with her on 04/23/17, while attempting to perform incontinence care for Resident #1. CNA #4 stated I can change {him/her} by myself. However, she stated if the CNA Care Plan stated the resident required two (2) person assist for repositioning, she should have had someone else helping her with the resident's incontinence care because changing a brief required repositioning. Further interview revealed she always reviewed her assigned residents CNA Care Plans and wrote down their needs on a paper at the start of the shift, but had not realized at the time of the incident the resident required two (2) staff for providing incontinence care. Telephone interview with CNA #5, on 05/17/17 at 1:37 PM, revealed she was familiar with Resident #1, and had cared for the resident in the past. She stated she was aware the resident required two (2) staff to assist with incontinence care and repositioning, and she would always get another staff member to help . Post Survey telephone interview with LPN #2, on 05/18/17 at 2:25 PM, revealed she was assigned to Resident #1 on 04/23/17 at the time of the fall. She stated she was standing at the medication cart and heard a loud noise and questioned CNA #4 who was in the hallway, about the noise. She further stated CNA #4 walked immediately to Resident #1's room and found the resident on the floor. LPN #2 stated she then immediately assessed Resident #1, and called 911 to transport the resident to the hospital for evaluation. Per interview, after the incident administrative staff asked her to give a statement. Further interview revealed knowing how many staff were needed to assist the resident with Activities of Daily Living (ADL's) was key to preventing injuries with residents. Per interview, staff was to refer to the CNA Care Plan for the amount of staff required for ADL's. LPN #2 confirmed Resident #2 required two (2) staff to assist with bed mobility and incontinence care and CNA #4 should have asked for assistance on 04/23/17. She further stated she constantly monitored and supervised the CNAs as they provided care and was available to assist the CNAs in providing care if they requested assistance. Interview with the Amelia Unit Manager, on 05/16/17 at 1:26 PM, revealed she was very familiar with Resident #1, and was aware the resident was able to move his/her arms and legs, but was unable to get out of bed. She stated she knew that something was not right when she initially heard the resident fell out of bed while trying to get out of bed on {his/her} own. Subsequent interview on 05/17/17 at 11:52 AM, with the Amelia Unit Manager, revealed Resident #1 had always been a two (2) person-assist with bed mobility and incontinence care in order to prevent falls and it was important all staff were aware of resident care needs for safety. Interview with MDS Coordinator #1 and #2, on 05/17/17 at 12:27 PM and 2:18 PM, revealed specifics regarding level of assistance required for ADLs was found on the CNA Care Plan, but not on the Comprehensive Care Plan because the CNAs as well as the nurses referred to the CNA Care Plan. MDS Coordinator #2 stated Resident #1's CNA Care Plan was not specific as to assistance required with toileting/incontinence care under the Elimination Section, but did state two (2) staff was needed to reposition the resident under the Repositioning Section. Per interview with MDS Coordinator #2, staff should realize if two (2) staff were needed to reposition the resident, they would need two (2) staff for incontinence care also, since this task required repositioning. Interview with the ADON, on 05/17/17 at 1:20 PM, revealed specific resident needs regarding assistance with ADL's were updated to the CNA Care Plan monthly, with falls, and with significant changes. Per interview, the CNA Care Plan was currently a paper version found at the nurses' station of each unit and was updated as needed in morning meetings. She stated per Resident #1's CNA Care Plan, the resident required two (2) to assist with repositioning at the time of the fall on 04/23/17. However, she confirmed the resident was repositioned for incontinence care with the assist of one (1) staff on 04/23/17, as per her written Statement from her interview with CNA #4 on 04/25/17. Interview with the Director of Nursing (DON), on 05/17/17 at 2:00 PM, revealed the residents' safety was always to come first and staff should follow assistance levels which were based on resident needs. Continued interview revealed if a resident was assessed on the MDS as requiring extensive or total assistance, this was to be converted to two (2) person-assist on the CNA Care Plan. She stated this information related to the level of assistance required should match the Comprehensive Care Plan. Further interview revealed Resident #1 did not have two (2) staff assisting with bed mobility and toileting/ incontinence care on 04/23/17 as per the Comprehensive Assessment, which resulted in the fall with injury. Interview with the Administrator, on 05/17/17 at 2:18 PM, revealed staff should adhere to the level of assistance dictated by the Care Plan when providing care, especially for resident safety. Continued interview revealed the facility's CNA Care Plans were to be individualized and specific as to how many staff were required for ADL's; and he realized the facility's Comprehensive Care Plans were based on a template, and were not specific in that respect. Continued interview revealed it was important for staff to be aware of resident needs for safety reasons.

Based on interview, review of the Administrator's Job Description, and review of the Plan of Correction (POC) for the 05/17/17 Abbreviated Survey, it was determined the facility's Administration failed to have an effective system in place to ensure Comprehensive Care Plans were revised and failed to have an effective system in place to ensure supervision to prevent accidents. The facility's Administration failed to ensure the facility maintained substantial compliance per the facility's POC as evidenced by repeat deficiencies at 42 CFR 483.25 Accidents/Hazards (F-323) and 42 CFR 483.20 (F-280) Resident Assessment (F-323). The findings include: Review of the facility's Job Description for Administrator, undated, revealed the Administrator was responsible for the efficient and profitable operation of the facility. Continued review revealed the Administrator would be in compliance with the facility policies and State and Federal rules and regulations, in providing the highest quality of care possible. Per the Job Description, the Administrator was responsible for directing and guiding the activities of clinical, administrative and service departments; implementing control systems to ensure accountability of all departments; ensure all employees receive orientation and ongoing training to meet the quality goals of the organization; act as chairperson of the facility's Performance Improvement Committee; and monitor the facility's staff in the execution of their compliance-related functions. Resident #3 was assessed by the facility to require the assistance of two (2) staff for transfers and toileting according to the Quarterly Minimum Data Set (MDS) assessment dated [DATE]. The Comprehensive Plan of Care, dated 03/01/17, did not indicate how many staff were required to transfer, or to toilet the resident. The Nurse Aide Care Plan, dated May 2017, through 06/05/17, revealed one (1) staff was required for transfers with the use of a gait belt and did not indicate how many staff were needed to toilet the resident. On 06/03/17, a State Registered Nurse Assistant (SRNA) attempted transferring the resident independently from the bedside commode to the bed and the resident sustained [REDACTED]. Resident #3 sustained a Left Femoral Neck Fracture and a Large Skin Tear to the Left Arm. Additionally, Resident #5 was assessed by the facility to require the assistance of two (2) staff for dressing per the Quarterly MDS Assessment, dated 03/24/17; however, the Comprehensive Plan of Care and the Nurse Aide Care Plan did not address how many staff were needed to assist the resident with dressing. On 06/13/17, Resident #5 sustained a fall from the bed to the floor while SRNA #7 was independently helping the resident undress by taking off the resident's shoes. Resident #5 did not sustain injuries related with this fall. Review of the facility's Plan of Correction (POC) for the Abbreviated Survey completed on 05/17/17, with a compliance date of 06/13/17, revealed all clinical staff was re-educated on following resident care plans related to transfers, bed mobility, and safety to prevent falls by 05/06/17 by the Staff Development Coordinator. However, during the the Revisit Survey, review of the POC in-service sign-in sheets for education related to following the individualized Care Plan which was submitted for review, as compared to the Employee Roster, revealed only a portion of the staff signed as receiving the inservice. Further review of the POC, revealed the Interdisciplinary Team (IDT) including the Unit Managers, Wound Care Nurse, Therapy manager, Dietary manager, Plant Operations Director, and Administrator were re-educated by the DON on 06/02/17, regarding Comprehensive Care Plans and Nurse Aide Care Plans should reflect the care needs of the resident. However, the facility could submit no documented evidence the IDT had received this inservice prior to 06/02/17 or after. Interview with the DON, on 06/30/17 at 2:21 PM, revealed the QA committee met which was made up of mostly management staff on 06/01/17, and the education related to how the Comprehensive Care Plans and Nurse Aide Care Plans were to reflect the care needs of the resident was discussed in that meeting. However, review of the QA Committee Agenda Minutes dated 06/01/17, did not reflect education provided related to the Care Plans. Further review of the POC, revealed by 06/12/17, the Staff Coordinator provided re-education to the MDS Coordinators regarding updating the Comprehensive Care Plans with the MDS Assessment. However, interview with the Staffing Development Coordinator (SDC), on 06/30/17 at 1:30 PM, revealed she had not provided this inservice to the MDS Coordinators. Review of the Sign In Sheet, dated 06/12/17, revealed when completing an MDS, the MDS Coordinators were to ensure that the Comprehensive Care Plan was being reviewed and updated with the MDS Assessment. Further review revealed there was no name to indicate the person who completed the training. Interview with the DON, on 06/30/17 at 2:21 PM, revealed she completed the MDS Coordinator in-service, but had not signed the in-service form. Further interview revealed resources used to develop/revise the residents' Comprehensive Care Plans included Discharge Summaries from the hospital, Therapy Notes, physician's orders [REDACTED]. However, when asked if the education provided to the MDS Coordinators included revising the Care Plans utilizing the MDS Assessment as a guide for how many staff were required to assist residents related to their functional status, she revealed she was not certain if the MDS was a resource used to develop/revise the Comprehensive Care Plans. Interview with LPN #4/MDS Coordinator, on 06/30/17 at 12:56 PM, revealed per the POC, the MDS Coordinators were to ensure the Comprehensive Care Plans matched the Nurse Aide Care Plans, and the MDS Assessment related to the level of assistance the residents required. Further interview revealed the QA plan; however, was to complete the Provision of Care Audits to ensure the aides were following the Nurse Aide Care Plan, and to see how much assistance the resident's required with bed mobility, transfers, and toileting. She stated the number of staff needed to provide care was care planned, through observation, not through review of the MDS, which would often change based on the residents' condition. Per the POC, by 06/08/17, the MDS Coordinators would revise all current care plans to indicate the amount of staff required to perform bed mobility, repositioning, and transfers. However, review of the POC binder revealed no documented evidence the current Care Plans were revised on 06/08/17. Further review of the POC, revealed by 06/12/17, the Unit Managers, MDS Coordinators and DON would complete a house wide audit to monitor that the Nurse Aide Care Plans matched the Comprehensive Care Plans. Review of the Audits revealed the Audits were completed on 04/24/17 and 04/25/17 by utilizing the Provision of Audits form. However, further review revealed there was no further housewide Audit completed to ensure the Nurse Aide Care Plans matched the Comprehensive Care Plans. According to the POC, the Provision of Audits was a form used to monitor that staff were adhering to the Care Plan (by observation) for transfers, repositioning, and toileting. Per the POC, the Unit Managers would complete a Provision of Care Audit on ten (10) residents a week starting 04/25/17 and weekly thereafter. These audits were to include validating the Comprehensive Care Plan and the Nurse Aide Care Plan matched, and were also to include review of the residents' latest MDS to ensure the assessed needs were in the Plan of Care. The POC further revealed the MDS assessment may not match the Comprehensive and Nurse Aide Care Plan if there was functional improvements or declines. Review of the Provision of Care Audits dated 04/24/17, and ongoing, revealed audits were completed weekly for ten (10) residents a week and were ongoing for the three (3) facility Units. Review of the Audit, revealed the residents' care was to be monitored in congruence with the Plan of Care. The interventions which were audited included: ensuring the Comprehensive Care Plans matched the Nurse Aide Care Plan; and review of the resident's fall interventions, repositioning, bed mobility, transfers, toileting, and skin protection. However, review of the facility's Provision of Care Audits, revealed no documented evidence the facility reviewed the resident's MDS Assessment to compare with the Comprehensive Care Plans on any of the three (3) units. In addition, the shift and/or name of staff monitored was not documented on the Combs and Breckinridge Audits. Interview with the DON, on 06/30/17 at 2:21 PM, revealed it was her expectation that all clinical staff would have received the inservice related to following the Care Plan as per the POC, and she was not sure why all staff had not received the inservice. Further interview revealed the MDS Coordinators and Unit Managers updated all the residents' Comprehensive Care Plans and Nurse Aide Care Plans to meet the assessed needs of the residents during the audit on 04/24/17 and 04/25/17; however, did not revise the current Comprehensive Care Plans after April 2017 and prior to 06/08/17 as per the POC. Additional interview revealed a facility wide audit was not completed after 04/24/17 and prior to 06/12/17 to monitor that the Nurse Aide Care Plans matched the Comprehensive Care Plans as per the POC. Continued interview with the DON, revealed the MDS Coordinators did not revise the Comprehensive Care Plans after 04/25/17 and the house wide audit was not done to compare the Nurse Aide Care Plan with the Comprehends Care Plan after 04/24/17, because the Unit Managers were completing ongoing Provision of Audits which was a tool utilized to observe SRNAs to ensure they were following the Nurse Aide Care Plan when providing care and also to ensure the SRNA Care Plans matched the Comprehensive Care Plans. She further stated the Unit Managers were to let her know so she could revise the Comprehensive Care Plans and Nurse Aide Care Plans if there were questions about the level of assistance a resident would need with care, and they were to confer with the MDS Coordinator if they had questions about the MDS Assessments or Care Plans. Additional interview with the DON, revealed she compared the Unit Manager Provision of Audits with the Comprehensive Care Plans and the Nurse Aide Care Plans. She stated the Unit Managers selected ten (10) residents weekly to watch their care, thus through this process the Comprehensive and Nurse Aide Care Plans would have been updated related to the assistance residents required with ADL's or per their functional status and the Comprehensive Care Plans and the Nurse Aide Care Plans would match by the dates as outlined in the POC. Per interview, the facility was not utilizing the MDS with the Provision of Care Audits, as per the POC, because the residents' condition could change between MDS Assessments. Interview with the Administrator, on 06/30/17 at 4:51 PM, revealed he was unaware staff had not followed the Plan of Correction. He stated it was his expectation that one-hundred (100%) of the clinical staff would have been re-educated related to following the resident's Care Plans. Further interview revealed he was not aware the Staff Development Nurse had not trained the MDS Nurses related to the Comprehensive Care Plans were to be revised according to the MDS Assessment. He stated the Staff Development Coordinator was part of the QA Committee, but had not been attending the meetings and this was an oversight to leave her off the list of managers who attended. He further stated he was unaware MDS Nurses did not refer to the MDS when addressing/revising the Comprehensive Care Plan and the Nurse Aide Care Plan. Continued interview with the Administrator, revealed he was unaware the Comprehensive Care Plans were not revised by the MDS Nurses by 06/08/17 and was unaware the housewide audit to ensure the Comprehensive Care Plans matched the Nurse Aide Care Plans was not completed by 06/12/17, as per the POC. He stated he should have been informed if there was a change in the POC. Further interview with the Administrator, revealed it was his job to oversee the operations of the building, to work with different department heads and ensure they had the resources they needed to do their job. He stated he was responsible for the resident care and worked closely with the Director of Nursing (DON) to ensure she had the resources available as the regulations stipulated. He further stated it was his job to regularly review the Federal and State Regulations to ensure the safety and care of the residents. Additionally, he stated he was over the Quality Assessment Performance Improvement (QAPI) committee, adding he would rely on expert opinions, but ultimately, he made the final decisions. Furthermore the Administrator stated he ensured the POC was being carried out by asking staff if they completed their task, but did not validate the documentation completed by staff to ensure all task were done, as outlined in the POC.

Based on observation, interview, record review and review of the facility's policies and the facility's Plan of Correction (POC) for the Abbreviated Survey of 05/17/17, it was determined the facility failed to maintain Quality Assessment and Assurance (QA) Program that developed and implemented effective plans of action to correct quality deficiencies. This was evidenced by repeat deficiencies from the Abbreviated Survey, conducted on 05/17/17, related to the facility's failure to have an effective system in place to ensure adequate supervision to prevent accidents at 42 CFR 483.25 Accidents/Hazards (F-323), and failure to ensure Comprehensive Care Plans were revised at 42 CFR 483.20 (F-280) Resident Assessment. During the Revisit Survey conducted 06/30/17, the following examples of continued non-compliance were identified: Resident #3 was assessed by the facility to require the assistance of two (2) staff for transfers and two (2) staff for toileting according to the Quarterly Minimum Data Set (MDS) assessment dated [DATE]; however, the Comprehensive Plan of Care, dated 03/01/17, did not indicate how many staff were required to transfer, or toilet the resident. The Nurse Aide Care Plan, dated May 2017, through 06/05/17, revealed one (1) staff was required for transfers with the use of a gait belt and did not indicate how many staff were needed to toilet the resident. On 06/03/17, a State Registered Nurse Assistant attempted to transfer the resident independently from the bedside commode to the bed and the resident sustained [REDACTED]. Resident #3 suffered a Left Femoral Neck Fracture and a Large Skin Tear to the Left Arm. (Refer to F-280 and F-323) Furthermore, Resident #5 was assessed by the facility to require the assistance of two (2) staff for dressing according to the Quarterly MDS Assessment, dated 03/24/17; however, the Comprehensive Plan of Care and the Nurse Aide Care Plan did not address how many staff were needed to assist the resident with dressing. On 06/13/17, Resident #5 sustained a fall from the bed to the floor while SRNA #7 was independently assisting the resident with undressing by taking off the resident's shoes. Resident #5 did not sustain injuries related to this fall. (Refer to F-280 and F-323) The findings include: Review of the Quality Assurance Performance Improvement (QAPI) Plan Policy, revised December 2016, revealed the facility would develop, implement, and maintain an ongoing, facility-wide Quality Assessment and Performance Improvement Program designed to monitor and evaluate the quality of resident care, pursue methods to improve care quality, promote overall building safety, and resolve identified problems. Continued review of the policy, revealed Quality Assurance (QA) was the process of meeting quality standards and assuring the care reaches an acceptable level. Performance Improvement (PI) was continuously analyzing the facility's performance and developing the systematic efforts to improve it; also known as Quality Improvement. Further review revealed the primary purpose of the Quality Assessment and Performance Improvement Plan (PIP) was to: provide means to identify and resolve present and potential negative outcomes related to resident, employee and visitor safety; and to establish and implement plans to correct deficiencies, and to monitor the effects of these action plans on resident outcomes. The Policy further stated the Administrator was responsible for assuring that the facility's Quality Assessment and Performance Improvement Program complied with federal, state, and local regulatory agency requirements. Review of the facility's Plan of Correction (POC) for the Abbreviated Survey completed on 05/17/17, with a compliance date of 06/13/17, revealed all clinical staff were re-educated on following resident care plans related to transfers, bed mobility, and safety to prevent falls beginning 04/25/17 and completed on 05/06/17 by the Staff Development Coordinator. However, during the the Revisit Survey concluded 06/30/17, review of the POC in-service sign-in sheets for education related to following the individualized Care Plan for transfers, bed mobility, safety, and diet, submitted for review revealed only a portion of the staff signed as receiving the inservice. The facility was unable to find and submit all the Sign In Sheets. Interviews with Licensed Practical Nurse, (LPN) #6 on 6/29/17 at 11:30 AM, LPN #7, on 06/29/17 at 11:35 AM, SRNA #3, on 6/29/17 at 1:45 PM, LPN #8 on 06/29/17 at 1:50 PM, and LPN #3, on 06/29/17 at 4:51 PM, revealed they did not remember any in-services related to care plans in the last three (3) months. Interview with the Staffing Development Coordinator (SDC), on 06/30/17 at 1:30 PM, revealed she attempted to re-educate all the employees on ensuring the SRNA's were following the care plans, but was unable to complete the re-education with one-hundred (100%) percent of the staff and thought she may have educated approximately seventy-five (75%) percent of the staff. Additionally, she stated the Director of Nursing (DON) instructed her to complete the in-service for the staff and she was unaware all clinical staff were to have been inserviced on this. Further interview with the SDC, revealed she was not aware she was to attend the QA meetings, and the POC was not discussed with her. Further review of the POC, revealed the Interdisciplinary Team (IDT) including the Unit Managers, Wound Care Nurse, Therapy manager, Dietary manager, Plant Operations Director, and Administrator were re-educated by the DON on 06/02/17, regarding Comprehensive Care Plans and Nurse Aide Care Plans should reflect the care needs of each resident. However, the facility could submit no documented evidence the IDT received this inservice prior to 06/02/17 or after. Interview with the DON, on 06/30/17 at 2:21 PM, revealed the QA committee met which was made up of mostly management staff on 06/01/17 and the POC was discussed in that meeting including information related to how the Comprehensive Care Plans and Nurse Aide Care Plans were to reflect the care needs of the resident. However, review of the QA Committee Agenda Minutes dated 06/01/17, did not reflect education provided related to the Care Plans. Further review of the POC, revealed by 06/12/17, the Staff Coordinator would provided re-education to the Minimum Data Set (MDS) Coordinators regarding updating the Comprehensive Care Plans with the MDS Assessment. Interview with the Staffing Development Coordinator (SDC), on 06/30/17 at 1:30 PM, revealed she had not provided this inservice to the MDS Coordinators. Review of the Sign In Sheet, dated 06/12/17, revealed the MDS Coordinators re-education related to updating the care plans lasted thirty (30) minutes. Further review revealed when completing an MDS, the MDS Coordinators were to ensure that the Comprehensive Care Plan was being reviewed and updated with the MDS Assessment. Continued review revealed the Administrator signed the in-service; however, there was no name to indicate the person who completed the training. Interview with Registered Nurse (RN) #2/Minimum Data Set (MDS) Coordinator, on 06/30/17 at 12:19 PM, revealed she was aware the MDS Coordinators were to ensure the MDS was in line with the Comprehensive Care Plan, and the Comprehensive Care Plan matched the SRNA care plans. Interview with LPN #4/MDS Coordinator, on 06/30/17 at 12:56 PM, revealed per the POC, the MDS Coordinators were to ensure the Comprehensive Care Plans matched the Nurse Aide Care Plans, and the MDS Assessment related to the level of assistance the residents would require. Continued interview revealed the QA plan; however, was to complete the Provision of Care Audits to ensure the aides were following the Nurse Aide Care Plan, and to see how much assistance the resident's required with bed mobility, transfers, and toileting. Further interview revealed the number of staff needed to provide care was care planned, through observation, not through review of the MDS, which would often change based on the residents' condition. Interview with the DON, on 06/30/17 at 2:21 PM, revealed she completed the MDS Coordinator in-service because the Staff Development Coordinator was out, but had not signed the in-service form with her signature. Further interview revealed resources used to develop/revise the residents' Comprehensive Care Plans included Discharge Summaries from the hospital, Therapy Notes, physician's orders [REDACTED]. The DON stated the SRNAs would often tell her if they needed more assistance with a resident and she would put in a therapy referral. However, when asked if the education provided to the MDS Coordinators included revising the Care Plans utilizing the MDS Assessment as a guide for how many staff were required to assist residents related to their functional status, she stated she was not certain if the MDS was a resource used to develop/revise the Comprehensive Care Plans. According to the POC, by 06/08/17, the MDS Coordinators would revise all current care plans to indicate the amount of staff required to perform bed mobility, repositioning, and transfers. However, review of the POC binder provided by the facility revealed no documented evidence the current Care Plans were revised on 06/08/17. Interview with Registered Nurse (RN) #2/Minimum Data Set (MDS) Coordinator, on 06/30/17 at 12:19 PM, revealed she attended the QA meetings and the plan was to review all the care plans on the floor. Further interview revealed though the POC stated she would ensure the MDS Assessments matched the Comprehensive Care Plans, and the Nurse Aide Care Plans, she was not involved with the process as outlined in the POC. She stated the MDS Assessments had to be completed in a timely manner and she was completing MDS's while LPN #4/MDS Coordinator took on the responsibility of auditing the Care Plans. Interview with LPN #4/MDS Coordinator, on 06/30/17 at 12:56 PM, revealed she only updated Care Plans on 04/24/17 and 04/25/17 and did not ensure all Care Plans were updated on 06/08/17 or afterward as per the POC. She stated the Unit Managers were using the Provision of Audits to observe staff implementing care to ensure the Nurse Aide Care Plan was being followed and they were to revise the Care Plans from the audits if they saw a discrepancy in the care provided and the care the resident should receive. She stated the Unit Managers did not utilize the MDS Assessments for these Audits. She stated she would provide guidance if the Unit Managers had questions about the MDS Assessments and Care Plans. Further review of the POC, revealed by 06/12/17, the Unit Managers, MDS Coordinators and DON would complete a house wide audit to monitor that the Nurse Aide Care Plans matched the Comprehensive Care Plans. Review of the Audits revealed these Audits were completed on 04/24/17 and 04/25/17 by utilizing the Provision of Audits form. However, review of the Audits revealed there was no further housewide Audit completed to ensure the Nurse Aide Care Plans matched the Comprehensive Care Plans. Per the POC, the Provision of Audits was a form used to monitor that staff were adhering to the Care Plan (by observation) for transfers, repositioning, and toileting. According to the POC, the Unit Managers would complete a Provision of Care Audit on ten (10) residents a week starting 04/25/17 and weekly thereafter. These audits were to include validating that the Comprehensive Care Plan and the Nurse Aide Care Plan matched. These audits were also to include review of the residents' latest MDS to ensure the assessed needs were in the Plan of Care. The POC further stated the MDS assessment may not match the Comprehensive and Nurse Aide Care Plan if there was functional improvements or declines. Review of the Provision of Care Audits dated 04/24/17 and ongoing, revealed audits were completed weekly for ten (10) residents a week and were ongoing for each of the three (3) facility Units. Per the Audit, the residents' care was to be monitored in congruence with the Plan of Care. The interventions being audited included ensuring the Comprehensive Care Plans matched the Nurse Aide Care Plan; and review of the resident's fall interventions, repositioning, bed mobility, transfers, toileting, and skin protection. However, review of the facility's Provision of Care Audits revealed no documented evidence the facility reviewed the resident's MDS to compare with the Comprehensive Care Plans on any of the three (3) units. In addition, the shift and/or name of staff that was monitored was not documented on the Combs and Breckinridge Audits. Interview with SRNA #2 who worked the the Breckenridge Unit, on 06/28/17 at 9:09 AM, revealed she was not observed or monitored while providing care for the residents. Post survey interview with SRNA #7, who worked the Breckenridge Unit, on 07/07/17 at 12:30 PM, revealed she had not been monitored or audited by the Unit Manager and/or MDS Nurse while providing care to the residents Review of Resident #3's Provision of Care Audit, audited on the Breckinridge Unit, revealed the resident was audited on 04/24/17 and 04/25/17 and was not audited after that date. Per review the Provision of Care Audit was checked as the resident requiring (1) person for transfers; however, on 04/25/17, the resident was checked as requiring two (2) persons to assist with transfers. Continued review of the Provision of Care Audit, revealed there was no documented evidence the resident was assessed again after that date. Review of Resident #3's Quarterly MDS assessment dated [DATE], revealed the resident was assessed as requiring two (2) staff to assist with toileting, and transfers. However, review of the resident's fall Comprehensive Care Plan, dated 03/01/17, revealed as of 06/03/17, there was no specification related to how many staff were to assist with transfers or toileting. Review of the Nurse Aide Care Plan dated May 2017, and June 2017 through 06/05/17, revealed one (1) staff was required for transfers with the use of a gait belt and there was no intervention stating how many staff were required to toilet the resident. On 06/03/17, a State Registered Nurse Assistant (SRNA) #1 was attempting to transfer Resident #3 independently, from the bedside commode to the bed, and the resident fell to the floor sustaining injuries including a Left Femoral Neck Fracture and a Large Skin Tear to the Left Arm. Interview with the Breckenridge Unit Coordinator/LPN #2, on 06/30/17 at 10:20 AM, revealed she had only audited Resident #3 two (2) times for the Provision of Care Audits, acknowledging she was to select ten (10) residents to audit weekly. She stated she did not revise the resident's care plan when the resident was audited as needing assist of two (2) persons for transfers, per the Provision of Care audits, because the resident had days in which he/she did better than others. She stated the resident needed a two (2) person assist in the past, but since he/she was a one (1) assist when he/she moved to the Breckinridge Unit about two (2) months ago, she kept the level of assist one (1) person on the Nurse Aide Care Plan and did not revise the Comprehensive Care Plan related to transfers or toileting. She further stated she had not audited the resident after 04/25/17 because she randomly audited residents and had no system to ensure all residents were being audited at intervals. Review of Resident #5's Provision of Care Audit, revealed the resident was audited on 04/25/17, 05/05/17, and 05/19/17. Per review, the Provision of Care Audit was checked as the resident requiring the assist of two (2) staff for transfers, and assist of two (2) staff for bed mobility, and the Audit did not include observing the resident for assistance needed with dressing. Review of the resident's Quarterly MDS Assessment, dated 03/24/17, revealed the resident required two (2) staff to assist with transfers, and bed mobility. However; review of the residents's Comprehensive Care Plan, revealed it was not revised until 06/07/17, to include an assist of two (2) for transfers and bed mobility. In addition, Resident #5 was assessed by the facility to require the assistance of two (2) staff for dressing according to the Quarterly MDS Assessment, dated 03/24/17. However, on 06/13/17, the Comprehensive Plan of Care and the Nurse Aide Care Plan did not address how many staff were needed to assist the resident with dressing. On 06/13/17, Resident #5 experienced a fall from the bed to the floor while SRNA #7 was assisting the resident with undressing, taking off the resident's shoes, without a second staff member. Resident #5 sustained a fall with no injuries. Continued interview with the Breckenridge Unit Coordinator/LPN #2, on 06/30/17 at 10:20 AM, revealed she audited Resident #5's care on 04/25/17, 05/05/17, and the week of May 15-19, 2017. She stated Resident #5 required two (2) persons to assist with repositioning and transfers as per the audits; however, the Care Plan plan was not revised for two (2) staff to transfer and reposition the resident until 06/07/17. Further interview revealed she did not observe staff getting the resident ready in the morning during the audits, and only asked staff to tell her when they had completed dressing the resident. She stated she then observed his/her transfers and repositioning. Per interview, she should have observed staff dress the resident so that she could have re-educated staff and care planned for the need for two (2) assist when dressing the resident on the Comprehensive Care Plan and the Nurse Aide Care Plan. Additional interview with Breckenridge Unit Coordinator/LPN #2, revealed per the POC, she was to ensure the residents' Comprehensive Care Plans, and Nurse Aide Care Plans matched, however; she stated she failed to do this and therefore, there was conflicting information related to Resident's #3, and #5's Comprehensive and Nurse Aide Care Plans. She further stated she was to compare the Care Plans with the MDS Assessments while completing the Provision of Care Audits; however, she had no access to the MDS Assessments. so she was not reviewing them as part of the audit. Continued interview revealed she attended the QA meetings and during the last meeting the committee reviewed the POC to ensure the safety of the residents. She stated she had a clear understanding of how to implement the POC, which included ensuring the SRNAs were following the residents Nurse Aide Care Plans by monitoring the care staff provided with the Provision of Care Audit. However, she revealed she could not provide names, times, and/or shifts in which she conducted the Provision of Care Audits, and stated that information should have been on the Audits to to validate the audits were completed. Further interview revealed the Provision of Care Audits were used in the QA meetings to see if there was a concerns with the care provided to the residents and no concerns came out in the QA meetings related to the Provision of Care Audits. Interview with the DON, on 06/30/17 at 2:21 PM, revealed the QA committee met once a month and the POC was discussed during the QA Committee meetings. She stated it was her expectation that all clinical staff would have received the inservice related to following the Care Plan as per the POC, and she was not sure why all staff had not received the inservice. Continued interview with the DON, revealed the MDS Coordinators and Unit Managers updated all the residents' Comprehensive Care Plans and Nurse Aide Care Plans to meet the assessed needs of the residents during the audit on 04/24/17 and 04/25/17. She stated the MDS Coordinators did not revise the current Comprehensive Care Plans after April 2017 and prior to 06/08/17 as per the POC. She further stated a facility wide audit was not completed after 04/24/17 and prior to 06/12/17 to monitor that the Nurse Aide Care Plans matched the Comprehensive Care Plans as per the POC. Further interview with the DON, revealed the MDS Coordinators did not revise the Comprehensive Care Plans after 04/25/17 and the house wide audit was not done to compare the Nurse Aide Care Plan with the Comprehends Care Plan after 04/24/17 because the Unit Managers were completing ongoing Provision of Audits which was a tool utilized to observe SRNAs to ensure they were following the Nurse Aide Care Plan when providing care and also to ensure the SRNA Care Plans matched the Comprehensive Care Plans. She stated the Unit Managers were to let her know so she could revise the Comprehensive Care Plans and Nurse Aide Care Plans if there were questions about the level of assistance a resident would need with care, and they were to confer with the MDS Coordinator if they had questions about the MDS Assessments or Care Plans. Continued interview with the DON, revealed she compared the Unit Manager Provision of Audits with the Comprehensive Care Plans and the Nurse Aide Care Plans. She further stated the Unit Managers selected ten (10) residents weekly to watch their care, thus through this process the Comprehensive and Nurse Aide Care Plans would have been updated related to the assistance residents required with ADL's or per their functional status and the Comprehensive Care Plans and the Nurse Aide Care Plans would match by the dates as outlined in the POC. She further stated the facility was not utilizing the MDS with the Provision of Care Audits, as per the POC, because the residents' condition could change between MDS Assessments. Interview with the Administrator, on 06/30/17 at 4:51 PM, revealed he was unaware staff had not followed the plan that was out lined in the Plan of Correction. Continued interview revealed it was his expectation that one-hundred (100%) of the clinical staff would have been re-educated related to following the resident's Care Plans. Further interview with the Administrator, revealed he was not aware the Staff Development Nurse had not trained the MDS Nurses related to the Comprehensive Care Plans were to be revised according to the MDS Assessment. He stated though the Staff Development Coordinator was part of the QA Committee, she had not been attending the meetings and it was an oversight to leave her off of the list of managers who attended. He stated he was not aware MDS Nurses did not refer to the MDS when addressing/revising the Comprehensive Care Plan and the Nurse Aide Care Plan. Further interview with the Administrator, revealed the DON met with him and the IDT team members on 06/01/17 during the QA Meeting and discussed the Provision of Care Audits. Per interview, in the meeting they discussed they were to utilize the Provision of Care Audits in comparing the care provided by observation with the Nurse Aide Care Plan. He stated then they were to update the Comprehensive Care Plan with the Nurse Aide Care Plan since the Nurse Aide Care Plan would indicate the most recent assessment of care provided. However, he stated he was unaware the Comprehensive Care Plans were not revised by the MDS Nurses by 06/08/17 and was unaware the housewide audit to ensure the Comprehensive Care Plans matched the Nurse Aide Care Plans was not completed by 06/12/17, as per the POC. He stated he should have been informed if there was a change in the POC. Additional interview with the Administrator, revealed it was his job to oversee the operations of the building, to work with different department heads and ensure they had the resources they needed to do their job. He continued by stating he was responsible for the resident care and worked closely with the Director of Nursing (DON) to ensure she had the resources available as the regulations stipulated. Per interview, it was his job to regularly review the Federal and State Regulations to ensure the safety and care of the residents. Furthermore, he stated he was over the Quality Assessment Performance Improvement (QAPI) committee, adding he would rely on expert opinions, but ultimately, he made the final decisions. The Administrator stated he ensured the POC was being carried out by asking staff if they completed their task, but did not validate the documentation completed by staff to ensure all task were done, as outlined in the POC.