Every finding on record at Hillcrest Health and Rehabilitation Center

Based on interview, record review, facility document review, and facility policy review, the facility failed to protect the residents' right to be free from abuse other residents for 2 (Resident #10 and Resident #38) of 5 residents reviewed for abuse.Findings included: A facility policy titled, “Abuse, Neglect, Misappropriation and Exploitation Policy,” revised 01/2018, indicated, “Our facility does not condone or tolerate resident abuse (this includes verbal abuse, sexual abuse, physical abuse and mental abuse), neglect, misappropriation or exploitation under any circumstances by anyone, including staff members, other residents, consultants, volunteers, staff of other agencies serving or visiting the resident, family members, legal guardians, sponsors, friends, or other individuals.” 1. Record review revealed a document titled “admission Record” indicated the facility admitted Resident 10 on 04/03/2024. According to the admission Record, the resident had a medical history that included diagnoses of anxiety disorder and major depressive disorder. An annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 03/04/2025, revealed Resident 10 had a Brief Interview for Mental Status (BIMS) score of 11, which indicated the resident had moderate cognitive impairment. Resident 10’s “Care Plan Report,” included a focus area initiated 12/10/2024, that indicated the resident had a potential for alteration in sleep cycle due to a history of insomnia for which the resident received medication. Interventions directed staff to provide a calm environment for the resident as much as possible. Record review of a document titled “admission Record” indicated the facility admitted Resident #19 on 07/23/2021. According to the admission Record, the resident had a medical history that included diagnoses of Parkinson’s disease, major depressive disorder and insomnia. An annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 01/08/2025, revealed Resident 19 had a Brief Interview for Mental Status (BIMS) score of 7, which indicated the resident had severe cognitive impairment. The MDS also indicated Resident #19 had no wandering behaviors and exhibited no physical behaviors directed toward others. Resident 19’s “Care Plan Report,” included a focus area initiated 11/07/2023 that indicated the resident had a physical altercation with another resident. Interventions directed staff to move the resident to another room where the bathroom had only one entrance to avoid any confusion. Record review of a facility document titled, “Initial Report,” dated 03/28/2025, revealed an alleged incident of resident-to-resident physical abuse that occurred on 03/28/2025 at 5:35 AM. Per the Initial Report, Resident 19 was in an adjoining bathroom and got confused and exited out the wrong bathroom door into Resident 10’s room, where Resident 10 was sleeping. The Initial Report revealed Resident 19 hit Resident #10. The Initial Report revealed Resident 10 had a small laceration above their right eyelid. The Initial Report revealed both residents were evaluated for any injuries and sent to emergency room (ER) for an evaluation. A facility document titled, “Final Report/5 Day Follow-up,” dated 04/02/2025, revealed Resident 19 was assessed in the ER and reviewed by psychiatry, who felt that the incident was due to ongoing confusion as a result of the resident’s dementia. The report revealed the facility placed Resident 19 on one-on-one (1:1) supervision and moved the resident to new room where they did not have to share a bathroom with another resident/room. Per the report, Resident 19 was seen by in-house psychiatry and medication changes were made. The report revealed Resident 10 had a superficial laceration and bruising to the left eyebrow that did not require repair. During an interview on 08/20/2025 at 9:30 AM, Resident 10 stated they remembered being hit in the face, but they did not remember any other information, just that they were punched. During an interview on 08/20/2025 at 9:48 AM, Registered Nurse (RN) 7 stated he understood that Resident 19 thought Resident 10 was in Resident 19’s bed. RN 7 stated Resident 19 then punched Resident 10 in the face. During a telephone interview on 08/20/2025 at 12:49 PM, RN 15 stated that when Resident 19 was in their bathroom, the resident must have gotten confused and went out the wrong bathroom door into Resident 10’s room and thought Resident 10 was in Resident 19’s bed. During a telephone interview on 08/20/2025 at 1:35 PM, State Registered Nurse Aide (SRNA) 16 stated she was completing rounds and heard Resident 19 in the bathroom and went down to the room and found Resident 19 in Resident 10’s room. SRNA 16 stated it appeared that Resident 19 got confused while in the adjoining bathroom and came out into Resident 10’s room and thought Resident 10 was in Resident 19’s bed. SRNA 16 stated she then saw Resident 10’s eye had a small laceration/scratch on the eyebrow area. SRNA 16 stated both residents were sent to the ER for an evaluation. During an interview on 08/20/2025 at 3:52 PM, RN 17 stated that she was notified by SRNA 16 that Resident 19 was found in Resident 10’s room. RN 17 stated when she entered the room, she found Resident 10 had a small amount of blood on their face, and the resident said that someone had hit them in the face. RN 17 stated Resident 10 had a laceration on their eyebrow. During an interview on 08/22/2025 at 3:35 PM, the Administrator stated she knew the incident happened between Resident 10 and Resident 19 but believed Resident 19 was confused and thought someone was in their bed. 2. An “admission Record” revealed the facility admitted Resident 71 on 01/30/2023. According to the admission Record, the resident had a medical history that included diagnoses of dementia, mild intellectual disability, and depression. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 06/04/2025, revealed Resident 71 had a Brief Interview for Mental Status (BIMS) score of 5, which indicated the resident had severe cognitive impairment. Resident 71's “Care Plan Report,” included a focus area initiated 04/04/2024, that indicated the resident had the potential for an alteration in mood/behavior and was noted with physical aggression, screaming, threatening, cursing, and frustration. Interventions directed staff to administer medications as ordered, observe and record any alterations in mood/behaviors, psychiatric consult as ordered, if resistant to care allow the resident to calm down and then reapproach, and invite the resident to activities of choice. An “admission Record” revealed the facility admitted Resident 38 on 12/30/2005. According to the admission Record, the resident had a medical history that included diagnoses of bipolar disorder, dementia, major depressive disorder, and anxiety disorder. A quarterly MDS, with an ARD of 08/11/2025, revealed Resident 38 had a BIMS score of 10, which indicated the resident had moderate cognitive impairment. An “Initial Report” dated 07/19/2025 revealed an allegation of resident-to-resident abuse that occurred on 07/19/2025 at 11:40 AM between Resident 71 and Resident 38. The report revealed the incident was witnessed by State Registered Nurse Aide (SRNA) 3. The report revealed Resident 71 slapped Resident 38 on the right side of their face and knocked their glasses off. Per the report, Resident 71 was immediately removed to their room by Registered Nurse (RN) 4 to calm down. During an interview on 08/20/2025 at 9:49 AM, SRNA 3 stated that she had witnessed the altercation between Resident 71 and Resident 38. She stated that the residents were in front of the nursing station on the [NAME] Unit. SRNA 3 stated that Resident 71 appeared to get upset that their chair was touching Resident 38’s chair and they were unable to go around the other resident. She stated Resident 71 backed up a little and slapped Resident 38 in the face. SRNA 3 stated Resident 38’s glasses fell off their face as a result. During an interview on 08/20/2025 at 10:23 AM, RN 4 stated that Resident 71 had episodes of anger. He stated that he did not directly witness the slap but removed Resident 71 to the resident’s room after the incident. During an interview on 08/20/2025 at 10:38 AM, LPN 5 stated that she was present during the altercation between Resident 38 and Resident 71 but did not witness Resident 71 making contact with Resident 38. She stated that she checked Resident 38’s jaw, which was a little red, but the redness went away in approximately an hour. She stated Resident 38 did not have a bruise, and there were no scratches. She stated that R 71 had a history of cursing when they did not get what they wanted. She stated that she reported the incident to the Director of Nursing (DON). Resident 71 was observed ambulating independently in their wheelchair on 08/20/2025 at 11:50 AM on the [NAME] Unit. During an interview on 08/20/2025 at 11:54 AM, R 71 indicated they did not recall the incident that involved hitting R 38 but did know a resident by that name. R 71 denied ever striking another resident. During an interview on 08/18/2025 at 2:21 PM, R 38 indicated that they recalled R 71 hitting them. R 38 indicated that they did not feel safe in the facility because of that. The DON was interviewed on 08/20/2025 at 11:19 AM. She stated that she recalled the incident with Resident 38 and Resident 71, and the abuse had been verified.

Based on interview, record review, document review, and facility policy review, the facility failed to ensure staff reported an allegation of abuse timely to the Director of Nursing and/or Administrator for 2 (Resident #38 and Resident #81) of 4 sampled residents reviewed for abuse.Findings included: The facility policy titled, “Abuse, Neglect, Misappropriation and Exploitation Policy,” revised 01/2018, indicated, “All allegations involving suspected abuse, neglect, misappropriation or exploitation including injuries of an unknown source or misappropriation of resident property shall be reported immediately, but not later 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do no result in serious bodily injury, to the Director of Nursing and/or the Administrator of the facility. The Director of Nursing, Administrator or Designee shall report such allegations to appropriate state and federal agencies, including law enforcement, as required.” 1. An “admission Record” revealed the facility admitted Resident #81 on 09/12/2022. According to the admission Record, the resident had a medical history that included a diagnosis of atherosclerotic heart disease. An annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/27/2024, revealed Resident #81 had a Brief Interview for Mental Status (BIMS) of 12, which indicated the resident was cognitively intact. A review of progress notes dated 07/06/2025 at 2:57 AM indicated, “[Resident #81] stated to CNA (State Registered Nurse Aide [SRNA] #1) that hospital staff was mean to [Resident #81] during [Resident #81’s] admission and asked CNA where [Resident #81] could purchase a gun.” The progress note was entered by Registered Nurse (RN) #2. During an interview on 08/21/2025 at 8:43 AM, SRNA #1 stated she took care of Resident #81 on 07/05/2025. She stated Resident #81 told her that something had happened to Resident #81 at the hospital, and Resident #81 had a bruise on the top of their left hand. Resident #81 stated they wanted a gun for protection, and she told Resident #81 the resident did not need a gun for protection, and she would keep Resident #81 safe. Resident #81 then said to her, “Look at my hand and look at what they did to me at the hospital.” She reported it to RN #2, who was the nurse on duty that night, as soon as Resident #81 made the allegation to her. She could not remember what time it was when Resident #81 made the allegation of something happening at the hospital. During an interview on 08/20/2025 at 10:15 AM, RN #2 stated a SRNA came and told her what Resident #81 had said. Resident #81 told the SRNA that Resident #81 had been abused at the hospital. She made sure Resident #81 was safe, then she called the on-call nurse and told her what Resident #81 had reported as well. She could not remember who the SRNA was or who the on-call nurse was to whom she talked. The on-call nurse told her to leave a nurse's note for the social worker, and the social worker would talk to Resident #81. She stated she had received abuse training. She stated she would report any allegation of abuse to the on-call nurse or to a supervisor. She stated she was always supposed to report it immediately. She stated the on-call nurse told her just to make the note since the allegation of abuse did not involve any of their staff nor did it happen in the facility. During an interview on 08/20/2025 at 10:55 AM, MDS #11 could not remember what time RN #2 had called her on the night of 07/05/2025 and vaguely remembered what RN #2 had told her that Resident #81 had reported. She stated it was something about Resident #81 wanting a gun for protection because Resident #81 was worried about being robbed and about something that occurred at the hospital. She stated RN #2 told her that she had ensured Resident #81 was safe. She told RN #2 if Resident #81 was okay just to watch Resident #81 and make Resident #81 feel safe and comfortable. She did not report it to anyone else at that time. She could not remember if she ever reported it to anyone else. MDS #11 stated she had received abuse training. She stated she was supposed to report any allegation of abuse immediately by contacting the DON and/or Administrator. During an interview on 08/19/2025 at 2:20 PM, the Director of Social Services stated the allegation of abuse was reported to her by a staff member on July 8th. She stated a progress note dated 07/06/2025 at 2:57 AM revealed Resident #81 had reported the allegation to a CNA who reported it to RN #2 at that time. She talked to Resident #81 on 07/08/2025 sometime that morning, and Resident #81 told her that Resident #81 was at the hospital, and a man and two women came into the resident’s room, and the man held him down while the two women hit him on the hand over and over. She called the hospital on [DATE] and reported the allegation to a case manager. During a follow-up interview on 08/20/2025 at 10:46 AM, Director of Social Services stated they were reviewing the nurse’s note during their morning meeting on 07/08/2025 when they came across the note RN #2 had entered regarding Resident #81. The Administrator and Director of Nursing (DON) became aware during the morning meeting of the allegation of abuse made by Resident #81. She stated she had received abuse training, and she was to report abuse immediately. She stated she would report any allegation of abuse to the DON or Administrator. During an interview on 08/22/2025 at 1:51 PM, the DON stated they expected all staff to report abuse as soon as it happened. They had two hours to report abuse to the state in their initial report. When the allegation Resident #81 had made came to her that Resident #81 had been abused at the hospital, they wanted to know who, so she sent the Director of Social Services to talk to Resident #81 and get details while she started their initial report. She stated she was made aware of the allegation on 07/10/2025 and did not remember what time exactly. She stated there was obviously a breakdown somewhere, and staff did not report it properly on the morning of 07/06/2025. She did not remember becoming aware of the allegation on 07/08/2025 during the morning meeting. She would expect any allegation of abuse to be reported immediately and within two hours to the state. During an interview on 08/22/2025 at 2:18 PM, the Administrator stated that once abuse was reported the residents were protected first. They separated them, assessed them, and made sure they were safe. If it was reported to or witnessed by an aide, the aide would report it to the nurse, and the nurse would report it to a supervisor. It would then get reported to the Administrator or the DON. All staff should report any allegation of abuse immediately. After any allegation of abuse was reported, they had two hours to submit their initial report to the state survey agency and five days before the final report. She stated she could not remember when she was made aware of the allegation made by Resident #81. After she reviewed Resident #81’s file, she stated she was out sick during that time. She stated the DON had called her, but she did not recall any details. She would expect every staff member to report any allegation of abuse immediately so they could start their investigation. She did not know why the allegation made by Resident #81 was not reported timely. 2. An admission Record revealed the facility admitted Resident #71 on 01/30/2023 with diagnoses that included dementia, mild intellectual disability, and depression. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 06/04/2025, revealed Resident #71 had a Brief Interview for Mental Status (BIMS) score of 5, which indicated the resident had severe cognitive impairment. An admission Record revealed the facility admitted Resident #38 on 12/23/2024 with diagnoses that included bipolar disorder, dementia, major depressive disorder, and anxiety disorder. A quarterly Minimum Data Set (MDS), with an ARD of 05/13/2025, revealed Resident #38 had a BIMS score of 12, which indicated the resident had moderate cognitive impairment. Review of the “Long Term Care Facility – Self-Reported Incident Form Initial Report” indicated an allegation of resident-to-resident abuse was witnessed by State Registered Nurse Aide (SRNA) #3 on 07/19/2025 at 11:40 AM between Resident #71 and Resident #38. The incident was reported to the Administrator on 07/19/2025 at 2:39 PM. The facility reported the incident to the state agency on 07/19/2025 at 3:49 PM, which was not within the two-hour regulatory timeframe. During an interview on 08/20/2025 at 9:49 AM, SRNA #3 stated that she had witnessed the altercation between Resident #71 and Resident #38. She stated it was in front of the nursing station on the [NAME] Unit. Resident #71 appeared to get upset that they were unable to get around the other resident, so repositioned their own wheelchair and slapped Resident #38 in the face. Resident #38’s glasses fell off their face as a result. The event occurred during meal time, and several other staff were present offering feeding assistance to various residents and passing trays. She stated she made the nurse aware of the incident. During an interview on 08/20/2025 at 10:23 AM, Registered Nurse (RN) #4 stated that Resident #71 had episodes of anger. He stated that he did not directly witness the slap, but removed Resident #71 to the resident’s room. He stated that he let the assigned nurse, Licensed Practical Nurse (LPN) #5, process the situation and handle reporting the abuse to administration. In an interview on 08/20/2025 at 10:38 AM, LPN #5 stated that she was present during the altercation between Resident 38 and Resident #71 but did not witness the Resident #71’s hand make contact with Resident #38’s face. She stated that she checked Resident #38’s jaw, which was a little red, but the redness went away in approximately an hour. It did not bruise and there were no scratches. She stated that Resident #71 had a history of cursing when they did not get what they wanted. She stated that she did report the incident to the Director of Nursing (DON), but it may have been over an hour after the incident occurred. She stated that she did receive abuse training and had been educated to report abuse immediately. She stated the reason she took longer to report was due to becoming occupied with another person. Resident #71 was observed ambulating independently in their wheelchair on 08/20/2025 on the [NAME] Unit. Resident #71 was interviewed on 08/20/2025 at 11:54 AM. They indicated they did not recall the incident that involved hitting Resident #38 but did know a resident by Resident #38’s name. Resident #71 denied ever striking another resident. Resident #38 was interviewed on 08/18/2025 at 2:21 PM. Resident #38 indicated that they did recall Resident #71 hitting them. During an interview on 08/22/2025 at 1:51 PM, the DON stated that she expected all staff to report abuse as soon as it happened. She stated the facility had two hours to report abuse to the state in their initial report. She would expect any allegation of abuse to be reported immediately and within two hours to the state. In a follow-up interview on 08/22/2025 at 3:16 PM, the DON stated that the incident with Resident #71 and Resident #38 was reported to her late, so she informed the Administrator (ADM) that she would be unable to report the incident timely. The nurse who reported to her was educated after the fact about reporting. She reiterated that she expected staff to report immediately. In an interview on 08/22/2025 at 2:18 PM, the ADM stated that once abuse was reported, the resident was protected first; they separated the residents, assessed them, and made sure they were safe. If abuse was reported to or witnessed by an aide, the aide would report it to the nurse, and the nurse would report it to a supervisor. It would then get reported to the ADM or the DON. After any allegation of abuse was reported, the facility had two hours to submit the initial report to the state agency and five days to submit the final report. She stated she would expect every staff member to report any allegation of abuse immediately so they could start their investigation. In a follow-up interview on 08/22/2025 at 3:58 PM, the ADM stated that it did not meet expectations for an incident that occurred and was witnessed at 11:40 AM to be reported to the state agency at 3:49 PM the same day. She stated she was not sure why the allegation was reported late.

Based on interview, record review, and facility document and policy review, the facility failed to provide evidence of a thorough abuse investigation for an allegation of resident-to-resident abuse involving 1 (Resident #71) of 4 residents reviewed for dementia care and 1 (Resident #38) of 6 residents reviewed for abuse. Specifically, after staff witnessed Resident #71 slap Resident #38 on the face on 07/19/2025, the facility failed to ensure all potential witnesses to the incident were identified and interviewed and interviews or assessments of other residents who may have had contact with Resident #71 were conducted during the investigation to determine if other residents may have also been affected.Findings included: A facility policy titled, Abuse, Neglect, Misappropriation and Exploitation Policy, last revised on 01/2018, indicated, ABUSE AND/OR RESIDENT NEGLECT INVESTIGATION 1) When an incident or suspected incident of resident abuse or neglect is reported, the Administrator or Director of Nursing will appoint a representative to investigate the incident. 2) A thorough investigation shall be completed. 3) Results of the investigation may be documented in an Investigative Summary report format or on a Resident Abuse Investigation Report Form. 4) For resident to resident altercations: -Separate and ensure both residents are protected from further harm -Assess both residents for injuries -Provide appropriate medical attention as needed -Contact family, doctor, Administrator -Interview both residents, if interviewable, and document in an Investigative Summary report format -Review the resident's medical record for signs that led up to the event -Interview any witnesses to the incident.During an interview on 08/22/2025 at 2:18 PM, the Administrator (ADM) stated that during an abuse investigation, facility staff would also conduct interviews with other residents who had a Brief Interview for Mental Status (BIMS) score of 8 or above (those with moderate cognitive impairment and those that were cognitively intact) and conduct skin assessments on residents with a BIMS score below 8 (those with severe cognitive impairment).An admission Record revealed the facility admitted Resident #71 on 01/30/2023. According to the admission Record, the resident had a medical history that included diagnoses of dementia, mild intellectual disability, and depression.A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 06/04/2025, revealed Resident #71 had a Brief Interview for Mental Status (BIMS) score of 5, which indicated the resident had severe cognitive impairment.Resident #71's Care Plan Report included a focus area, initiated 04/04/2024, that indicated the resident had the potential for an alteration in mood/behavior and was noted with physical aggression, screaming, threatening, cursing, and frustration. Interventions directed staff to administer medications as ordered, observe and record any alterations in mood/behaviors, psychiatric consult as ordered, if resistant to care allow the resident to calm down and then reapproach, and invite the resident to activities of choice.An admission Record revealed the facility admitted Resident #38 on 12/30/2005. According to the admission Record, the resident had a medical history that included diagnoses of bipolar disorder, dementia, major depressive disorder, and anxiety disorder. A quarterly MDS, with an ARD of 08/11/2025, revealed Resident #38 had a BIMS score of 10, which indicated the resident had moderate cognitive impairment.An Initial Report, dated 07/19/2025, revealed an allegation of resident-to-resident abuse occurred on 07/19/2025 at 11:40 AM between Resident #71 and Resident #38. The report revealed Resident #71 slapped Resident #38 on the right side of their face and knocked their glasses off. The report revealed the incident was witnessed by State Registered Nurse Aide (SRNA) #3. The report did not reflect any other identified witnesses.A Final Report/5 Day Follow-Up revealed the facility's investigation included an interview with one witness (SRNA #3), an interview with the alleged perpetrator (Resident #71), and an interview with the alleged victim (Resident #38). The 5 Day Follow-Up report indicated that the altercation occurred in an area utilized by some residents for meals and was within sight of any staff coming and going through the area; however, the facility's investigation documentation revealed no evidence of attempts to identify or interview additional potential witnesses. The investigation documentation further revealed there was no evidence that interviews or skin assessments of other residents who may have had contact with Resident #71 were conducted during the investigation to determine if other residents may have also been affected.During an interview on 08/20/2025 at 9:49 AM, SRNA #3 stated that she had witnessed the altercation between Resident #71 and Resident #38. She stated the incident occurred in front of the nursing station on the [NAME] Unit during mealtime, and several other staff were present, offering feeding assistance to various residents and passing trays.During an interview on 08/20/2025 at 10:23 AM, RN #4 stated that at least five other staff were present as witnesses to the altercation that occurred on 07/19/2025.The Director of Nursing (DON) was interviewed on 08/20/2025 at 11:19 AM. The DON stated that she recalled the incident with Resident #38 and Resident #71. She further stated that she did not interview or assess other residents who may have had contact with the alleged perpetrator.

Based on observation, interview, and facility document review, the facility failed to ensure 2 of 3 (Resident #42 and Resident #56) sampled residents received nail care to promote their personal hygiene. Findings included: An undated facility document titled, Protocol for Nail Care indicated, Nail care for all residents that do not have a diagnosis of Diabetes will have nail care provided as needed with AM [morning] care.1. An admission Record indicated the facility admitted Resident #42 on 09/27/2022. According to the admission Record, the resident had a medical history that included dementia and anxiety disorder.A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 01/16/2025, revealed Resident #42 was severely impaired for daily decision making and had short-term or long-term memory problem per a staff assessment of mental status (SAMS). The MDS indicated Resident #42 required supervision or touch assistance for personal hygiene.Resident #42's Care Plan Report included a focus area initiated on 02/21/2024 that indicated the resident was unable to meet or maintain activities of daily living (ADLs) due to diagnosis of Alzheimer's dementia with impaired cognitive and aging process. Interventions directed staff to assist with grooming daily as needed.During an observation on 08/18/2025 at 3:04 PM, Resident #42 was observed to have long, dirty fingernails.During an observation on 08/19/2025 at 8:05 AM, Resident #42 was observed to have long, dirty fingernails.During an interview on 08/20/2025 at 9:50 AM, Registered Nurse (RN) #7 said that staff were to trim and/or clean fingernails as part of their bath/showers or as needed. RN #7 stated he was not aware that Resident #42 had long, dirty fingernails. RN #7 stated staff should be trimming the residents' nails on their shower/bath days and as needed.During an interview on 08/20/2025 at 10:01 AM, State Registered Nurse Assistant (SRNA) #8 stated staff were to trim or clean the residents' fingernails with every bath/shower and as needed. SRNA #8 stated Resident #42 did like to pick at the sore on their nose, and their fingernails needed to be trimmed and cleaned. SRNA #8 stated she had no reason why she did not trim or clean Resident #42's fingernails.During an observation on 08/21/2025 at 11:35 AM with SRNA #9, she confirmed Resident #42 had long, dirty fingernails.During an interview on 08/21/2025 at 11:40 AM, SRNA #9 said that part of a resident's ADL care was trimming the resident's fingernails. SRNA #9 stated she knew that Resident #42 had long, dirty fingernails that needed to be trimmed and cleaned, but she had not offered to trim Resident #42's fingernails.An observation on 08/21/2025 at 4:05 PM revealed Resident #42 continued to have long, dirty fingernails.During a telephone interview on 08/22/2025 at 8:56 AM, Resident #42's family member (resident representative) #12 stated she did want staff to keep Resident #42's fingernails trimmed and cleaned as needed. She stated that keeping Resident #42's fingernails clean and trimmed could minimize the risk of infections and also could minimize the damage to the resident's nose.During an interview on 08/22/2025 at 2:59 PM, the Director of Nursing (DON) stated the staff knew they had to keep the residents' nails trimmed. The DON stated the staff had been in-serviced to trim/clean the residents' fingernails on their bath/shower days.During an interview on 08/22/2025 at 3:35 PM, the Administrator stated she expected the staff to cut and clean the residents' fingernails.2. An admission Record indicated the facility admitted Resident #56 on 12/01/2015. According to the admission Record, the resident had a medical history that included muscle weakness, age-related nuclear cataract, other lack of coordination, and anxiety disorder.An annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 06/18/2025, revealed Resident #56 had severe impairment in cognitive skills for daily decision-making and short-term and long-term memory problem per a staff assessment of mental status (SAMS). The MDS indicated the resident was dependent on staff with all activities of daily living (ADLs).Resident #56's Care Plan included a focus area initiated on 01/30/2024 that indicated the resident was unable to meet/maintain ADLs due to cognitive/physical deficits. Interventions directed staff to assist for grooming/personal hygiene and required total assist for all ADLs.During an observation on 08/18/2025 at 11:14 AM, Resident #56 had long fingernails on both hands.During an interview on 08/20/2025 at 9:50 AM, RN #7 stated staff were to trim and clean the residents' fingernails on their bath/shower days or as needed. RN #7 stated he was not aware that Resident #56 had long fingernails. RN #7 stated that Resident #56 did have contracted hands and that their nails did need to be clean and trimmed to prevent them from going into the palm of their hands.An observation on 08/21/2025 at 10:31 AM revealed Resident #56 had long fingernails.During an interview on 08/21/2025 at 11:17 AM, MDS Coordinator (MDS) #10 stated she was told by the Administrator that Resident #56's fingernails needed to be trimmed; she said they did trim Resident #56's fingernails. MDS #10 confirmed Resident #56's fingernails were jagged, long, and needed to be trimmed.During an interview on 08/21/2025 at 11:21 AM, MDS #11 stated Resident #56's fingernails were jagged and long and needed to be trimmed. MDS #11 stated she came to trim the resident's fingernails after the Administrator told them the surveyor had mentioned the resident's fingernails.During an interview on 08/21/2025 at 11:40 AM, State Registered Nurse Assistant (SRNA) #9 stated trimming fingernails was part of providing ADL care to the residents on their shower days or as needed. SRNA #9 stated Resident #56 had long fingernails. SRNA #9 stated she had not offered to trim Resident #56's fingernails.During a telephone interview on 08/22/2025 at 9:10 AM, Resident #56's guardian, RP #13, said she wanted the staff to monitor the resident's fingernails and keep them trimmed.During an interview on 08/22/2025 at 2:59 PM, the Director of Nursing (DON) stated the staff knew they had to keep the residents' nails trimmed. The DON stated the staff had been in-serviced to trim/clean the residents' fingernails on their bath/shower days.During an interview on 08/22/2025 at 3:35 PM, the Administrator stated she expected the staff to cut and clean the residents' fingernails.

Based on observation, interview, record review, and review of the facility's policies, the facility failed to provide a safe, clean, comfortable, and homelike environment for two of nine sampled residents (Resident (R)8, and R42). Observations revealed the shared bathrooms in rooms 226, 228, 227, 221, and 223 had strong urine odor and two sampled residents complained of urine odors in their bathrooms. The findings include: Review of the facility's Protocol for Housekeeping Services (PHS) policy, not dated, revealed the housekeeping and maintenance services would ensure to maintain a sanitary, orderly, and comfortable interior environment. Review of the facility's Resident Rights (RR) policy, not dated, revealed residents had a right to share concerns regarding their stay at the facility. During observation on 08/14/2024, at 9:13 AM, room [ROOM NUMBER]'s bathroom presented with a strong urine odor. The private bathroom had a commode and shower, with a strong urine odor. During observation on 08/16/2024, at 9:15 AM, room [ROOM NUMBER]'s bathroom presented with a strong urine odor. Residents in room [ROOM NUMBER] shared a bathroom with residents in room [ROOM NUMBER]. Resident's in room [ROOM NUMBER] shared a bathroom with residents in room [ROOM NUMBER] and the bathroom presented with a strong urine odor. Record review revealed Resident(R)8 was admitted to the facility on [DATE] with diagnoses of chronic obstructive pulmonary disease, vascular dementia, anxiety and osteoarthritis. Record review of R8's brief interview of mental status (BIMS) was 15/15, indicating no cognitive impairment. During an interview on 08/16/2024 at 10:20 AM, with R8, she stated that her bathroom smelled bad. R8 stated she had reported the smell to housekeeping and the aides. R8 continued to state that housekeeping would come every day to clean the bathroom, but it still smelled bad. She further stated the bathroom stinks, and it had smelled bad for months. She rated the smell a ten on a scale of one to ten with ten being the worst she had ever smelled. Record review revealed R42 had been admitted to the facility on [DATE], with diagnoses of gout, dementia, hypertension, adjustment disorder for depression after the passing of his wife. Record review of R42's BIMS was 15/15 indicating no cognitive impairment. During interview on 08/13/2204 at 10:12 AM, with R42 he stated that he used the bathroom all the time and the bathroom smelled. He further stated he was used to the smell. He stated housekeeping cleaned every day and the bathroom still smelled of urine. On 08/15/2024 at 2:54 PM, during the interview with housekeeping/ laundry supervisor (HLS) she stated she was aware of the urine odors coming from the bathrooms. During further interview she stated she would try to find the cause of odors and address them, because she knew the strong urine smell would make residents uncomfortable and they would complain. HLS further stated urinals cause a lot of odors and were discarded as needed. She further stated other causes of urine odor could be the high-rise commode may need changed to a low rise commode, a commode seal might leak, or a high-rise screw on top commode extender may need changed. HLS continued to state that she was responsible to take any issue she had with needed repairs to the Administrator and the Administrator would let maintenance know to do needed repairs. She further stated there was no cleaning log, she went through and checked the rooms herself and would re-clean the rooms if she found odors. However, she further stated it could be hard to get rid of the urine odor despite trying several cleaning and disinfecting chemicals. 08/15/2024 at 3:25 PM, interview with Maintenance Director (MD) he stated he had replaced the seals, with a rubber gasket on the commode in room [ROOM NUMBER] last week, and when a seal leaked it would smell of urine. He further stated that HLS would let the Administrator know when a commode seal would need replaced and then the Administrator would let him know to replace it. 08/16/2024 at 10:30 AM interview with Administrator she stated she would visit residents but did not usually go into the restrooms and was not aware of the odors. The Administrator was taken to the bathrooms with odors, and she stated the bathrooms had a strong urine odor. She further stated her expectations were to have a homelike environment free of urine odors.

Based on observation, interview, record review and facility policy review, the facility failed to label and store drugs and biologicals in accordance with accepted principles. Observations, on 08/13/2024 at 3:49 PM, 08/14/2024 at 3:39 PM, 3:43 PM, and 4:05 PM, revealed a medication cart on the [NAME] Hall unlocked during medication pass. Residents, staff and visitors were observed passing by the cart. Additional observation, on 08/14/2024, revealed a medication cart on the [NAME] Hall with multi-dose bottles without an open date. The findings include: Review of the facility's policy titled Medication Storage in the Facility, dated June 2023 revealed medications and biologicals were to be stored safely, securely, and properly, following the manufacturer's recommendations or those of the supplier. The medication supply should be accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. Observation on 08/13/2024 at 3:49 PM, on 08/14/2024 at 3:39 PM, 3:43 PM, and 4:05 PM noted a medication cart on the [NAME] Hall, unlocked and unattended by staff during medication pass. Residents, staff, and visitors were observed to be passing by the medication cart. Licensed Practical Nurse #1 ( LPN1) was noted to be responsible for the medication cart. Observation of the medication cart on 08/13/2024 at 9:23 AM on the [NAME] Back Hall revealed Simply Thick an easy mix (a thickener) without an open date, Lactulose (a laxative) 10g/15mL (10 gram/15 milliliter) 32-ounce bottle opened without an open date; and, a 10g/15mL 16-ounce bottle opened without an open date. Further observation revealed Lidocaine Gel (an oral numbing gel) not labeled with a resident's name or open date. Observation of the medication room on 08/14/2024 at 2:29 PM on the East Hall revealed viral transport tubes/swabs dated 06/02/2024; 3 central line dressing kits dated 09/30/2019; 24-gauge intravenous (IV) with an expiration date of 06/03/2023; and, 1 sixteen ounce bottle of hydrogen peroxide, with an expiration date of 11/2023. During interview with Licensed Practical Nurse #1 (LPN1) on 08/14/2024 at 5:33 PM, she stated she realized she had failed to lock the medication cart. She further stated she did not realize she left the medication cart unlocked 4 times. LPN1 stated that failing to lock the medication cart could allow someone to get the medications from the cart (residents, staff, and/or visitors) and could cause harm if they took the medications. She further stated not labeling medications when opened could possibly cause harm to residents by giving expired medications. LPN1 stated that multi-dose medications could only be kept for thirty days after opening. Interview on 08/14/2024 at 5:55 PM with Nurse Consultant 1, she stated the facility did not have a policy for multi-dose bottle storage, but they should always be dated when opened. During an interview with RN3 on 08/15/2024 at 2:29 PM she stated she was not sure who was responsible for ensuring medical supplies were discarded when expired. She stated the supplies may not be as effecttive for use if expired. During interview with the Director of Nursing (DON) on 08/16/2024 at 4:47 PM, she stated it was very important for all medication and treatment carts to be locked when unattended due to the risk of a resident getting into the cart and getting medications which they could be allergic to and cause them harm. The DON further stated it was important to not use expired products as it also cause harm. She stated she expected anything opened to have a date on it so other staff knew when it had been opened to prevent harm to the residents. The DON stated she expected all nurses to lock the carts when unattended. During interview with the Administrator on 08/16/2024 at 5:16 PM, she stated she expected all staff to date medications or supplements when opened to prevent risks to the residents. The Administrator stated she expected all nurses to lock medication carts when they leave the cart to prevent residents, other staff, or visitors from getting into the medication carts. The Administrator stated she expected all nursing staff to look at the expiration dates on supplies and to discard any expired supplies due to the possibility of the supplies not being sterile. She further stated it could cause harm if residents, staff, and/or visitors got into unlocked medication carts.

Based on observation, interview, record review and facility policy, the facility failed to maintain proper infection control to prevent the development and transmission of communicable diseases and infections. The facility failed to use enhanced barrier precautions when providing personal resident care and wound care. Staff failed to clean shared resident equipment. In addition, the facility failed to ensure residents' urinals were stored in a clean matter to prevent contamination. The findings include: Review of the facility's policy, titled Protocol for Enhanced Barrier Precautions, revised 03/2024, revealed enhanced barrier precautions (EBP) were indicated for nursing home residents who have an infection or known colonization with a multi-drug resistant organism (MDRO) when contact precautions did not otherwise apply. Continued review of the policy revealed EBP included the use of a gown and gloves during high-contact resident care activities, including dressing, bathing or showering, performing transfers, changing linens, providing hygiene, changing a resident's brief or assisting them with toileting, direct care of an indwelling medical device, such as a central line, urinary catheter, feeding tube, or tracheostomy, and when performing wound care on any skin opening that requires a dressing. 1. Observation on 08/16/2024 at 9:12 AM of R1's wound care, by Licensed Practical Nurse (LPN) 2 revealed no gown was donned (put on) during the wound care. Continued observation revealed State Registered Nursing Assistant #12 (SRNA12) provided urinary catheter care without donning a gown. Further observation revealed SRNA13 assisted with turning and repositioning the resident during care without donning a gown. During an interview on 08/16/2024 at 9:42 AM, with SRNA12, she stated she realized immediately that she forgot to wear a gown and I was nervous. SRNA12 stated she had been trained on infection control by the Infection Preventionist (IP) and knew that a gown was required with any contact care being provided to a resident in enhanced barrier precautions. She stated by not following precautions she could contaminate other residents, and the reason for precautions was to keep residents and staff safe. During an interview on 08/16/2024 at 9:49 AM with LPN 2 who provided the wound care, she stated she had been trained on EBP, by the Infection Preventionist. She stated she was aware she should have worn a gown while providing hands on care to a resident in EBP, as well as gloves. She stated that they were very nervous with State Survey Agency (SSA) observing and forgot to gown. LPN2 stated she had been trained by the IP on all infection control precautions. She stated they must follow precautions to prevent cross contamination to other residents and or staff. During an interview on 08/16/2024 at 4:00 PM with the Infection Preventionist (IP), she stated staff were aware that a yellow tag by the name on the door alerted them that the resident was on EBP precautions and Personal Protective Equipment (PPE) was on the backside of door, which included gowns and gloves. The IP stated staff had been educated that for hands on care for residents in EBP they must use a gown and gloves. She stated EBP were implemented when a resident had a Foley (brand of indwelling catheter) wound, and/or a gastrostomy tube, or essentially any artificial opening or wound of the skin. The IP stated she provided in-services quarterly and/or as needed. She stated she did not have any formal audits in place and if she was rounding on the floor and saw an infection control issue she addressed it verbally at that time. The IP stated she made rounds when she had the opportunity, but there was no set time. She stated that her expectation was for the staff to always follow infection control measures. The IP stated she did track infections using the McGreer (is a set of guidelines used to identify infections in long term care facilities) criteria and tracks antibiotics. She further stated she was responsible for oversight for infection prevention, including education, tracking of antibiotic use, and cleaning of reusable equipment. She stated that by not following appropriate infection control it could cause a risk to the residents by cross contamination. 2. During an interview with Administrator on 08/16/2024 at 5:17 PM she stated the facility did not have a policy outlining the protocol for cleaning residents' care items after use. Observation on 08/13/2024 at 3:05 PM of SRNA5 (State Registered Nurse Aide) 5 and SRNA 6 removing the Hoyer (brand of mechanical lift) from the nurse's station on the 100 Hall and moving it into R83's room to assist the resident from the bed to the wheelchair. Observation revealed staff did not clean the Hoyer lift prior to use. After transferring the resident to his wheelchair, SRNA5 removed Hoyer lift from R 83's room and rolled it back to the 100 Hall nurse's station. The SRNA placed it next to the armoire and walked away from the Hoyer lift without cleaning the equipment. During an interview on 08/13/2024 at 3:31 PM with SRNA6 he stated the policy for cleaning equipment was to wipe down with Purple Top wipes after each use Observation on 08/13/2024 at 3:42 PM of SRNA 7 and SRNA 8 using the In-Bed scale to weigh R 16 in her bed. The IN-Bed scale was brought into R 16's room. A mat was removed from the side of the scale and was placed under R 16 without cleaning prior to use. SRNA 7 and SRNA 8 weighed R 16, returned her to her bed, removed the mat from underneath her, rolled the mat up without cleaning it, and placed it back onto the mobile bed scale. The scale was then removed from R 16's room and place in the 100 Hall nurse's station, behind the Hoyer lift. SRNA 7 and SRNA 8 went to assist another resident without cleaning the In-Bed scale. During an interview on 08/13/2024 at 4:09 PM with SRNA 7, she stated she was not aware of a policy that required staff to clean the In-Bed scale after each use. She stated, I have only been working here a month. They may have talked about it during orientation. I can go and ask someone, if you need me to. She stated if the mat gets soiled, we will wipe it down before placing it on the scale. She also stated by not cleaning the mat and equipment, it would not keep residents safe. Observation on 08/16/2024 at 10:12 AM revealed SRNA14 and SRNA2 taking the Hoyer lift from the nurse's station on the 100 Hall, assisting a resident, and returning the lift to the nurse's station without cleaning it. During an interview on 08/16/2024 at 10:34 AM with SRNA14 she stated she had only been working at the facility for a couple of weeks. She stated she did not know about a policy for cleaning the Hoyer lift or In-Bed scale either before or after use. During an interview on 08/16/2024 at 2:37 PM with the Infection Control (IP)/Staff Development Coordinator (SDC) she stated, We do not provide training for staff on cleaning the Hoyer lift or the In-Bed scale. She stated to her knowledge, the facility did not have a policy for cleaning the Hoyer lift or In-Bed scale. The IP/SDC stated there was not a cleaning schedule for equipment. She stated the lack of cleaning could put residents at risk for becoming exposed to infectious organisms. The IP/SDC stated employees were required to pass a skills test before providing resident care. She stated competency skills were assessed yearly. During an interview on 08/16/2024 at 4:45 PM with the Director of Nursing (DON) she stated the facility did not have a policy for cleaning the Hoyer lift of In-Bed scale currently. She stated she has discussed this with the Administrator, and they are working to develop an equipment cleaning policy. During an interview on 08/16/2024 at 5:17 PM with the Administrator, she stated her expectation of staff using Hoyer lifts and In-Bed scale would be they properly use them to assist residents and the equipment was properly cleaned after use with each resident. She also stated the implications of staff not properly cleaning equipment could endanger residents to possible germs and bacteria. She stated the facility did not currently have a cleaning policy for the Hoyer lift or In-Bed scale. 3. During initial tour of the facility on 08/13/2024, observations of bathrooms in rooms [ROOM NUMBERS] revealed unbagged bedpans and urinals sitting on the floor with no names on the devices. Continued tour of the facility on 08/13/2024 revealed the bathroom in room [ROOM NUMBER] had 2 unbagged urinals with dark color urine hanging on the rail. During an interview with the Director of Nursing (DON) on 08/16/2024 at 4:47 PM, she stated it was very important for the residents to have a homelike environment. The DON stated the bedpans and urinals should be cleaned after each use and changed at least weekly. The DON stated bedpans and urinals should be in a bag and not stored on the floor as the risk for the residents could be the spread of bacteria. During an interview with the Administrator on 08/16/2024 at 5:16 PM, she stated she expected any bedpans or urinals would be stored in a bag and not on the floor. She stated the risk would be the spreading of bacteria. The Administrator stated she expectation was if a bedpan or urinal was on the floor, then the staff would throw that item away and get another one. 49050 49360

Based on observation, interview, record review and a review of the facility policy it was determined the facility failed to implement the comprehensive person-centered care plan developed for two (2) of three (3) sampled residents (Resident #2 and Resident #3) consistent with resident's needs. The facility assessed and determined Resident #2 required assistance for ambulation in the facility to minimize the risk of the resident sustaining falls and injuries. However, the facility failed to ensure all staff were knowledgeable regarding the resident's assessed needs and failed to ensure the intervention of assisting the resident with ambulation, which was detailed on the resident's Kardex, was implemented. Observations on 03/01/2021 and staff interviews revealed the resident ambulated about the facility, without staff assistance. Subsequently, Resident #2 sustained multiple falls in the facility from 11/11/2021 through 02/28/2021, including two falls, which resulted in serious injury. On 11/16/2020, staff found Resident #2 on the floor of his/her room with blood observed on the resident and on the floor. The facility transferred the resident to the hospital, where he/she was diagnosed with [REDACTED]. On 11/21/2020 at 8:00 AM, staff found Resident #2 lying on the floor next to the bed. Staff transferred the resident to the hospital where he/she was diagnosed with [REDACTED]. The facility assessed Resident #3 as cognitively impaired and required the assistance of one (1) staff for transfers and transitioning from a seated to a standing position. Review of Resident #3's Kardex, not dated, revealed staff were to provide the assistance of one with transfer, toileting, and ambulation. However, on 01/07/2020 Resident #3 fell in the day dining room while attempting to stand unassisted from a wheelchair and sustained a head contusion (bruise). The facility implemented an intervention to put the resident in a regular chair; however, there was no evidence the intervention was implemented. The resident sustained [REDACTED]. In addition, Resident #3 sustained unwitnessed no injury falls while attempting to stand unassisted on 02/17/2020, 06/10/2020. Interviews with staff revealed they could not implement the resident's care plan and provide the required assistance because the resident attempted to transfer/stand without staffs' knowledge. Further review of an Incident Report, dated 08/30/2020 at 12:00 AM, revealed staff found Resident #3 lying on the floor of his/her room, in front of a wheelchair and assessed the resident to have an external rotation and shortening of the left leg. Hospital record review revealed Resident #3 was diagnosed with [REDACTED]. The findings include: Review of the facility policy titled Protocol for Care Planning, not dated, revealed all residents would have a care plan developed by the Interdisciplinary Team, based on the resident's individual needs, assessments and goals. The policy also stated the resident's care plan would be reviewed/updated on at least a quarterly basis when the MDS (Minimum Data Set) assessments were completed. The policy also directed staff to update care plans with changes in conditions, physician orders and on an as needed basis. However, further review of the policy provided no direction to staff on ensuring resident care plans were implemented in the facility. Interview with the Director of Nursing (DON), on 03/03/2021 at 3:50 PM, revealed the clinical care team reviewed all falls, during the morning meetings Monday-Friday, to ensure resident's had appropriate interventions implemented to prevent further falls from occurring. The DON also stated the Clinical Coordinators reviewed/revised resident care plans during the morning meetings, to include the newly implemented interventions after fall discussions occurred. She also stated she expected staff to follow the residents' care plan, when providing resident care in the facility. 1. Review of Resident #2's medical record revealed the facility admitted the resident on 11/10/2021 with [DIAGNOSES REDACTED]. Review of Resident #2's admission Minimum Data Set (MDS) assessment dated [DATE], revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of four (4), indicating the resident was cognitively impaired and required assistance of one (1) staff member with walking and transfers. Review of Resident #2's Comprehensive Care Plan reviewed/revised on 02/28/2021, revealed Resident #2 had a potential for falls with injury due to Decreased Mobility, Muscle Weakness, Lack of Coordination, Difficulty Walking and Impaired Standing Balance. Further review of the fall care plan revealed the resident also had cognition and short term memory deficits, impaired decision making skills, does not recognize his/her physical limitations nor the need for assistance to prevent injury. Review of interventions developed by the facility to prevent falls for Resident #2 included encouraging the resident to ask for assistance as needed, encourage the resident to call for assistance with transfers as needed due to impaired standing balance, encourage the resident to wear non-skid socks/slippers at all times, encourage/assist the resident to get out of bed daily, and assist the resident with transfers/ambulation as needed. However, the care plan does not specify how staff were to determine when the resident needed assistance or did not need assistance, what to do if the resident does not understand to ask for assistance. Review of Resident #2's Kardex (utilized by staff to care for residents), not dated, revealed the resident required assistance of one (1) staff member with transfers and ambulation in the facility. Observations on 03/01/2021 at 11:30 AM revealed Resident #2 was walking around at the front entrance area of the facility without staff assistance. At approximately 1:35 PM Resident #2 was ambulating in the hallway with no staff assistance, and had to grab hold of the handrail for stabilization and at 3:45 PM, Resident #2 was walking around at the nurse's station without assistance from staff. Review of a Resident Incident Report, dated 11/11/2020 at 6:35 PM, revealed staff found Resident #2 at the doorway of another resident's room and became upset when re-directed by staff. The report indicated the resident began to try to hit the staff, lost his/her balance and fell . The staff sent the resident to the hospital for treatment and the resident was diagnosed with [REDACTED]. The facility determined the cause of the fall was that the resident lost his/her balance. However, there was no evidence in the report the facility identified staff had not implemented interventions related to ambulation assistance. Interview with the Clinical Coordinator (CC) #1, on 03/02/2021 at 3:10 PM, revealed she determined the root cause of Resident #2's fall on 11/11/2020 was because the resident was confused and lost his/her footing and fell . However, according to the CC, she had not considered the resident ambulating without assistance in the facility was a contributing factor of the fall. Interview with State Registered Nurse Aide (SRNA) #4, on 03/02/2021 at 11:40 AM, revealed Resident #2 had ambulated independently in the facility since admission, and stated the residents gait was always unsteady. Although SRNA #4 stated she was aware of the facility's requirement to review each resident's Kardex prior to providing care for the resident, she stated she was unaware that the resident's Kardex directed staff to assist the resident with transfers and walking. Record review of Incident Report, dated 11/16/2020 at 4:30 AM, revealed staff found Resident #2 on the floor of his/her room behind the door with blood present on the resident, floor and foot of bed. The staff transferred Resident #2 to the hospital where the resident was diagnosed and treated for [REDACTED]. Resident #2 received treatment and the hospital transferred the resident back to the facility. Continued interview with CC #1, on 03/03/2021 at 2:30 PM, revealed she reviewed and revised Resident #2's care plan after the fall to include a night light for the resident to see better when up. However, the CC stated she again did not recognize the fact that the resident was getting up unassisted and walking around unsupervised when the resident had been assessed to require the assistance of staff for transfers and ambulation. Therefore, she implemented no interventions related to supervision of the resident Review of a Resident Incident Report, dated 11/21/2020 at 8:00 AM, indicated staff found Resident #2 lying on the floor next to the bed. Resident #2 was unable to tell staff how the fall occurred, but the resident's roommate stated the resident had gotten up, walked around the bed, lost balance and fell on to the floor. Staff transferred Resident #2 to the hospital where the resident was diagnosed with [REDACTED]. Continued interview with CC #1, on 03/03/2021 at 2:30 PM, revealed after reviewing Resident #2's fall that occurred on 11/21/2020, she implemented an intervention for staff to get the resident up out of bed for breakfast. However, she stated again she had not recognized or considered the resident transferring and ambulating unassisted was a causative factor for the fall. Review of a Resident Incident Report, dated 02/28/2021 at 8:20 AM, indicated staff found Resident #2 face down on the floor at the nurse's station. The resident was unconscious for three (3) to four (4) minutes and had a raised bloody area to the right side of the head. The staff transferred the resident to the hospital for evaluation and the resident's final [DIAGNOSES REDACTED]. Further review of the incident report revealed the belt from the resident's robe was found lying adjacent to the resident at the time of the fall, and therefore the facility theorized that the resident had tripped on the belt. Therefore, the intervention implemented by staff was to have the belt sewn to the robe. However, there was no documented evidence the facility identified staff had not provided the assessed assistance with ambulation to prevent a fall or accident. Continued interview with RN #1, on 03/02/2021 at 1:05 PM, revealed she recognized that Resident #2's gait got increasingly unbalanced the more the resident was up walking. However, RN #1 was not aware that Resident #2 required assistance with transfers and walking. RN #1 also stated there was no way for staff to know when the resident would get up unassisted, but stated she has always tried to assist the resident when she observed the resident staggering. On 03/02/2021 at 12:30 PM, interview with SRNA #6, revealed Resident #2's gait got more unsteady when the resident got tired from walking. However, the SRNA stated she had not realized that the resident's Kardex directed staff to assist the resident with transfers and ambulation, even though she knew she was supposed to review each resident's care plan each day prior to providing care to the resident. On 03/03/2021 at 3:50 PM, interview with the DON, revealed resident falls were reviewed daily in the Monday-Friday morning meetings to ensure among other things that the resident's care plans had been reviewed and revised to include appropriate interventions to prevent further falls. The DON stated Resident #2's falls were discussed in the morning meetings and she was aware that the resident transferred and ambulated without assistance. However, the DON was not aware the resident had been assessed to require supervision and staff were not following the resident's care plan when the resident was allowed to transfer and ambulate independently. Interview with the Administrator, on 03/03/2021 at 3:50 PM, revealed she had also reviewed Resident #2's care plan but had not identified that the resident was assessed to require staff assistance to safely ambulate in the facility. 2. Review of Resident #3's medical record revealed the facility admitted the resident on 09/02/2016 with [DIAGNOSES REDACTED]. Review of Resident #3's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #3 had a Brief Interview for Mental Status (BIMS) score of three (3), indicating the resident was cognitively impaired. In addition, the assessment indicated the resident required the assistance of one (1) staff for transfers and the assistance of one (1) staff when transitioning from a seated to a standing position. Review of Resident #3's care plan revealed the facility defied the resident had the potential for falls due to [MEDICAL CONDITION]/dizziness, episodes of confusion, short term memory deficits, impaired decision making, impaired standing balance, and due to requiring assistance with transfers. The facility's goal was for the resident to have decreased falls/injuries. The facility developed interventions that included assisting the resident with transfers and walking as needed. Review of Resident #3's Kardex, not dated, revealed staff were to provide the assistance of one with transfer, toileting, and ambulation. Observation of Resident #3, on 03/01/2021 at 11:25 AM, revealed the resident was awake and sitting up in a wheelchair in his/her room. Record review of an Incident Report, dated 01/07/2020 at 10:20 AM, revealed Resident #3 fell in the day dining room while attempting to stand unassisted from a wheelchair and hit his/her head on a table leg. According to the report, another resident witnessed Resident #3's fall. Staff transferred Resident #3 to the ER for further evaluation. Continued review of the report revealed the resident sustained [REDACTED]. Review of Resident #3's Care plan dated 12/02/2020, revealed the intervention initiated after the fall on 01/07/2020, was for staff to place the resident in a regular chair while in the dining room. In addition, continued review of the resident's care plan revealed the intervention of placing Resident #3 in a regular chair while in the dining room was discontinued, but a discontinuation date nor rational for discontinuing the intervention was not provided. Review of an incident report, dated 01/20/2020 at 8:00 PM, revealed Resident #3 fell again in the dining room. Staff observed the resident standing next to his/her wheelchair, leaned onto a dresser, and slid down onto the floor. Further review revealed the intervention implemented was to remind the resident not to attempt to stand from wheelchair unassisted and the facility revised the resident's care plan on 12/02/2020 instructing staff to encourage the resident to call for assistance due to impaired standing balance. Interview with the CC #2, on 03/03/2021 at 1:05 PM, revealed the facility was unaware of when or why the intervention related to placing the resident in a chair while in the dining room was discontinued. Therefore, the facility was unable to say if the resident should have been in a regular chair on 01/07/2020, prior to the fall on 01/20/20. Interview with RN #2, on 03/02/2021 at 2:10 PM, revealed she was working on 01/20/2020, when Resident #3 fell . She stated Resident #3 got up from the wheelchair unassisted and fell . The RN was aware the resident's care plan required staff to assist the resident; however, RN# 2 stated Resident #3 frequently attempted to get up from wheelchair without letting staff know, even when reminded to do so. Continued review of Incident Reports revealed the resident sustained [REDACTED]. On 02/17/2020 at 12:10 AM, Resident #3 was found on the floor of his/her room. The resident told staff he/she was going home. The resident sustained [REDACTED]. According to another Incident Report, on 06/10/2020 at 5:45 PM, staff found the resident sitting on his/her buttocks in the doorway of his/her room. Further review revealed the resident had no injuries from the fall. Interview with SRNA #5, on 03/02/2021 at 12:10 PM, revealed she was aware that Resident #3 required assistance with transfers and walking; however, she stated staff could not always assist the resident because the resident was confused, non-compliant, and frequently attempted to get up unassisted without staff knowledge. Record review of an Incident Report, dated 08/30/2020 at 12:00 AM, revealed the resident sustained [REDACTED]. The report revealed staff found Resident #3 lying on the floor of his/her room in front of a wheelchair. The staff assessed the resident to have an external rotation and shortening of the left leg. Further review revealed staff transferred the resident to the hospital for further evaluation and treatment. Review of a hospital record dated 08/30/2020, revealed Resident #3 was diagnosed with [REDACTED]. Interview with State Registered Nurse Aide (SRNA) #4 on 03/02/2021 at 11:40 AM, revealed Resident #3 was attempting to transfer from the bed to the wheelchair unassisted when the fall occurred. SRNA stated Resident #3's care plan required staff to assist the resident to transfer or stand; however, the SRNA stated Resident #3 would forget to ask for assistance and frequently attempted to get up unassisted. On 03/03/2021 at 12:00 PM, interview with LPN #1, revealed she heard a loud noise on 08/30/2020 and found Resident #3 on the floor near his/her bed with the wheelchair by the bed. She stated it was evident the resident's hip was broken. LPN #1 stated unless staff happened to observe Resident #3 attempting to get up, staff had no way of no way of knowing they needed to assist the resident. LPN #1 stated the resident just gets up. On 03/03/2021 at 3:50 PM, interview with the Director of Nursing (DON), revealed the DON acknowledged that when a care plan intervention was added or discontinued from a care plan the date and/or rational for the change or discontinuation was not always documented. However, she stated that the facility had not identified the practice to be problematic or a concern in the facility. The DON revealed she was aware of the number of falls Resident #3 had sustained from the wheelchair and staff attempted to keep the resident in an area where close supervision was possible. On 03/03/2021 at 3:50 PM, an interview with the Administrator, revealed she tracked/trended falls in the facility through incidents reports and review of a list of previous and current interventions. The Administrator stated the facility had not identified any concerns with fall interventions or implementation of interventions for Resident #3.

Based on observation, interview, record review and review of facility policy it was determined the facility failed to ensure two (2) of three (3) sampled residents (Resident #2 and Resident #3) received adequate supervision to prevent accidents and falls were thoroughly investigated. The facility assessed Resident #2 as cognitively impaired, unsteady, and required extensive assistance of one (1) staff member for transfers and ambulation. The facility failed to identify Resident #2 had been assessed to require the assistance of staff for transfers and ambulation and allowed Resident #2 to ambulate unsupervised around the facility. Resident #2 experienced six (6) falls from 11/11/2021 through 02/28/2021, as a result of the falls the resident sustained [REDACTED]. Although the facility reviewed each fall sustained by Resident #2, the facility failed to ensure interventions were implemented to prevent further falls. In addition, on 11/15/2020, staff discovered a raised area on the resident's forehead. However, the facility failed to conduct an investigation in an attempt to determine the cause of the injury so further injury did not occur. The facility assessed Resident #3 as cognitively impaired and to require the assistance of one (1) staff for transferring and transitioning from a seated to a standing position. Review of a Fall Risk Evaluation dated 11/20/2019, revealed the facility assessed Resident #3 to be at a high risk for falls. Additionally, Resident #3 sustained nine (9) falls from 01/07/2020 to 02/22/2021. Six (6) of the nine (9) falls the resident experienced were from the wheelchair without staff assistance. On 08/30/2020, Resident #3 fell from his/her wheelchair and sustained a [MEDICAL CONDITION]. However, the facility failed to to identify a pattern or trend of the resident's falls from the wheelchair, without staff assistance, and therefore failed to implement interventions to prevent further falls for the resident. The findings include: Review of the facility's policy Falls Prevention Program not dated, revealed the facility goals were to identify all residents who were at high risk for falls and to alter their environment and put interventions in place, to reduce the risk of falls or injuries. The policy also stated interventions would be based on the causative factor of the fall. In addition, the policy stated when the cause of the fall was identified, an intervention would be implemented to eliminate or reduce the possibility of the fall recurring, or attempt to reduce possible injuries. Interview with the Director of Nursing (DON), on 03/03/2021 at 3:50 PM, revealed nurses would identify the root cause of a resident fall and implement interventions at that time to prevent further falls for the resident. The DON stated the Clinical Coordinators were responsible to thoroughly investigate, determine the root cause, and ensure the facility had implemented interventions to prevent further falls from occurring. The DON stated the Clinical Care Team discussed every resident fall during the morning meetings conducted Monday-Friday to ensure the nurse had completed the root cause analysis and that interventions implemented were effective to prevent further falls for the resident. 1. Review of Resident #2's medical record revealed the facility admitted the resident on 11/10/2020 with [DIAGNOSES REDACTED]. Review of Resident #2's admission Minimum Data Set (MDS) assessment dated [DATE], revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of four (4), indicating the resident was cognitively impaired, unsteady, and required extensive assistance of one (1) staff member for transfers and ambulation. The assessment also indicated the resident was only able to stabilize self with assistance when moving from a seated to a standing position and when walking. In addition, the assessment revealed Resident #2 had experienced falls with major injury since admission to the facility. Review of Resident #2's Comprehensive Care Plan reviewed/revised on 02/28/2021, revealed the resident was at risk for falls due to Muscle Weakness, Lack of Coordination, Difficulty Walking, Impaired Standing Balance and Decreased Mobility. In addition, the care plan revealed two (2) of the falls resulted in significant injury, on 11/16/2020, the resident sustained [REDACTED]. Continued review of Resident #2's Care Plan revealed the staff assisted the resident with ambulation only as needed, however, the resident's Kardex (utilized by direct care staff to care for the resident) revealed the resident required the assistance of one (1) staff member with transfers and ambulation. Observations on 03/01/2021 at 11:30 AM, revealed Resident #2 was ambulating in the front entrance area of the facility without staff assistance. Continued observations on 03/01/2021 also revealed at approximately 1:35 PM, the resident was walking without staff assistance in the hallway, and had to grab hold of a handrail in the hallway in order to stabilize self. Additional observation on 03/01/2021, revealed Resident #2 was walking adjacent to the nurse's station, but no staff was assisting the resident. Review of a Resident Incident Report, dated 11/11/2020 at 6:35 PM, revealed Resident #2 sustained a fall in the doorway of another resident's room attempting to hit staff with an isolation supply box, while staff attempted to redirect Resident #2 out of the peer's doorway. Continued review of the report revealed staff transferred the resident to the emergency room (ER) for further evaluation and treatment. Subsequently, review of the ER record for Resident #2 dated 11/11/20, revealed the hospital diagnosed the resident with a hematoma (collection of blood outside of blood vessels) to the lower back skull. Continued review of the Incident Report, dated 11/11/20, revealed the root cause of Resident #2's fall was loss of balance and the intervention implemented to prevent further falls was to allow the resident to calm and re-approach, and utilize a [MEDICATION NAME] air freshener for a calming effect. Continued review of the report revealed no indication the facility investigated the reason Resident #2 was upset, outside another resident's room removing an isolation box or trying to hit staff. In addition, the root cause did not identify staff had not provided the assessed assistance required with transfers or ambulation. Interview with Clinical Coordinator (CC) #1, on 03/02/2021 at 3:10 PM, revealed she had been trained to do fall investigations and conduct root cause analysis for falls that occurred in the facility. The CC stated she was responsible to ensure the nurse had thoroughly investigated the fall, completed a root cause analysis, and initiated interventions to prevent further falls from occurring. The CC stated she had determined the root cause of the fall sustained by Resident #2 on 11/11/2020 was because the resident was confused and lost his/her balance while attempting to strike staff. Therefore, the CC stated she implemented the intervention of allowing the resident to calm down and using a [MEDICATION NAME] air freshener for a calming effect. However, the CC was unable to state how those specific interventions would help with preventing Resident #2 from disturbing or injuring a peer in their own room or preventing the resident from striking and injuring staff. In addition, the CC stated she had failed to consider the resident ambulating without assistance as a possible cause for the fall. Review of another Resident Incident Report for Resident #2, dated 11/15/2020 at 8:00 PM, revealed staff discovered a knot on the right side of the resident's forehead, documenting the area as soft, light blue around edges, pink in center. Continued review of the report revealed Licensed Practical Nurse (LPN) #2 documented the resident was unable to explain how the injury occurred, but that LPN #3 stated it was not present 45 minutes prior when the nurse had administered the resident's medication. Further review of the report revealed LPN #2 documented the root cause of the resident's injury as NA (not applicable). However, further review of the incident report revealed when CC #1 had reviewed the incident report, she documented the raised area on the resident's forehead was the result of the resident's previous fall on 11/11/2020, four (4) days prior. Therefore, the facility did not conduct an investigation to determine the cause of the raised area to the resident's head and as a result, implemented no interventions to prevent other injuries to the resident. Interview with LPN #2, on 03/02/2021 at 8:05 PM, revealed she completed the incident report on 11/15/2020, but was not the nurse assigned to the resident. The LPN stated she completed the report because the nurse aides had reported finding a knot on the right side of the resident's forehead, and the resident's primary nurse was busy caring for another resident. LPN #2 stated the area to the resident's forehead was very visible, soft to palpate and appeared to be a new area. LPN #2 stated she observed the area, with the resident's primary nurse (LPN #3), who stated she had assessed the resident approximately forty-five (45) minutes earlier during medication administration and the area was not there. However, LPN #2 stated that she nor LPN #3 initiated an investigation to determine how Resident #2 received the injury. Interview with State Registered Nurse Aide (SRNA) #4, on 03/02/2021 at 11:40 AM, revealed she cared for Resident #2 after the resident's fall on 11/11/2020, and did not observe any injury to the resident's forehead. However, days later when she reported to work, she observed a knot on the residents' forehead, but did not know how it occurred. Continued interview with Clinical Coordinator (CC) #1, on 03/02/2021 at 3:10 PM, revealed she reviewed the incident report dated 11/15/2021, but did not question why an investigation was not initiated to determine the cause of the resident's injury, because she knew the injury was from the fall the resident had four days prior. Therefore, the CC stated she did not interview staff working with the resident on 11/15/2020. In addition, the CC stated she had not reviewed the hospital documentation made for Resident #2 on 11/11/2020, which contained no evidence the resident had sustained an injury to the forehead during the fall. Interview with LPN #3, on 03/02/2021 at 7:45 PM, revealed she was assigned to care for Resident #2 on 11/15/2020. The LPN stated she was with another resident when LPN #2 informed her that the resident had a knot on the forehead. LPN #3 stated she knew the area was not present on Resident #2, 45 minutes prior, because she had assessed the resident when administering medication. However, LPN #3 stated she did not attempt to find the cause of the injury to the resident. LPN #3 also stated no one had questioned her regarding the 11/15/2020 incident until interviewed by the surveyor. Review of the Incident Report, dated 11/16/2020 at 4:30 AM, revealed staff found Resident #2 lying behind the room door on his/her right side against the closet with blood observed on the resident's hands and face. The report also stated staff found blood at the foot of the resident's bed and described the floor of the room as soiled with blood. The report stated staff last observed Resident #2 in the bed at 4 AM, and the resident was unable to tell staff what had occurred. Per the report, the resident's non-skid socks were in place, the bed was in low position and the resident's call light was not on. The report also detailed a hematoma to the right side of Resident #2's head and a bloody nose. The staff transferred the resident to the ER for further evaluation and treatment, where according to the hospital record, the resident was diagnosed a large scalp hematoma in the right parietal area with a small area of soft tissue swelling overlying the right forehead, and a comminuted depressed bilateral nasal bone fracture with associated soft tissue swelling. In addition, the resident required two (2) sutures to a laceration on the resident's nose. After treatment, the hospital transferred Resident #2 back to the facility. Continued review of the incident report on 11/16/2020, revealed staff failed to identify a root cause of Resident #2's fall. However, staff implemented a night light for better visualization, but failed to consider that the facility assessed the resident to need staff assistance for transfers and ambulation and should not be encouraged to get up unassisted. In addition, there was no evidence to indicate the facility considered that the resident was cognitively impaired and just because the call light was in reach of the resident, did not ensure the resident could remember the purpose or function of the call light or that he/she should use it to summons staff for assistance. In addition, the report did not identify staff did not provide the assessed assistance with transfer or ambulation. Continued interview with LPN #2, on 03/02/2021 at 8:05 PM, revealed she was caring for Resident #2 when the resident fell on [DATE]. LPN #2 stated the nurses were supposed to attempt to identify the root cause when a resident fall occurred, however, stated she was unable to determine a root cause of the resident's fall on 11/16/2020, because the fall was not witnessed. The LPN stated she assumed the resident lost his/her balance since the resident was found on the floor. The LPN stated she did not implement any new interventions to prevent further falls for Resident #2, such as increased supervision or distraction techniques because the supervisors do the interventions the next day. The LPN was unable to recall any training she had received regarding how to investigate a resident fall or determine the root cause of a fall. Interview with CC #1, on 03/03/2021 at 2:30 PM, revealed staff nurses were responsible for identifying the root cause, when a resident sustained [REDACTED]. However, the CC acknowledged the floor nurses usually do not attempt to implement interventions and she does it the next day at the morning meeting. The CC stated she had never considered that if the floor nurses were not implementing interventions at the time of the falls, how the facility was ensuring that resident remained safe and did not sustain additional falls until the CC could initiate additional interventions at the next morning meeting. The CC stated she was the staff that implemented the night light for Resident #2 after the resident fell on [DATE], because she determined the resident could not see when he/she got out of bed. Review of the Incident Report, completed by Registered Nurse (RN) #1, dated 11/17/2020 at 7:05 PM, revealed staff found Resident #2 lying face down on the floor of his/her room. The residents head was toward the bathroom and the resident's legs were under the edge of the bed. Staff assessed the resident to have no injuries. Continued review of the incident report revealed the resident's bed was in a Higher than sitting position. RN #1 determined the root cause of the fall was that the resident had tripped on the wheel located underneath the bed. The report also stated to prevent further falls, the therapy department measured and marked the wall in the resident's room for proper bed height. In addition, the report did not identify the staff had not provided the assessed assistance for transfer or ambulation. Interview with RN #1, on 03/02/2021 at 1:05 PM, revealed nurses were responsible to determine the root cause of falls when they occurred in the facility. However, the RN stated, we don't put interventions in place, the supervisors do that. RN #1 determined the root cause of Resident #2's fall on 11/17/2020, was that the resident tripped over the bed wheel, because the resident's foot was turned toward the wheel of the bed when found. RN #1 also stated the residents' bed was a little higher than it should have been, and acknowledged the resident at times messed with the bed remote, raising the bed. RN #1 stated Resident #2's gait gets increasingly unbalanced the longer the resident remained up ambulating. In addition, the RN stated she was not sure if Resident #2 required assistance for ambulation. RN #1 stated there was no way for staff to know when the resident gets up, but that she tries to help the resident when she sees him/her staggering. Interview with CC #1, on 03/03/2021 at 2:30 PM, revealed she reviewed Resident #2's fall that occurred on 11/17/2020. The CC stated she implemented the intervention to have therapy to mark the resident's wall to identify the appropriate bed height. However, the CC was unable to explain how Resident #2 was going to recognize the mark on the wall was were the bed height should be kept for safety, if the resident was unaware of what the bed remote was for and had a decrease in safety awareness. The CC stated, Looking back that intervention was probably not appropriate considering the resident's cognitive status. The CC also acknowledged the resident messing with the remote and inadvertently adjusting the bed height, to an unsafe level, had not been addressed. Review of the Incident Report, dated 11/21/2020 at 8:00 AM, revealed staff found Resident #2 lying in the floor next to the bed. The resident was unable to tell staff how the fall occurred, but the resident's roommate informed staff the resident had gotten up and walked around the bed, lost balance, and tried to use the curtain to stabilize and fell on the floor. The report indicated the resident had non-skid socks on at the time of the fall. The report stated Resident #2 complained of pain to the left shoulder and elbow; and staff transferred the resident to the ER for further evaluation and treatment. Review of the ER record for Resident #2 revealed the resident sustained [REDACTED]. Further review of the incident report revealed staff failed to identify a root cause of Resident #2's fall, nor that staff had not provided the assessed assistance with transfers or ambulation. An additional facility incident report, dated 02/28/2021 at 8:20 AM, revealed staff found Resident #2 face down on the floor at the nurse's station. The report indicated the resident had a loss of consciousness for approximately three (3) to four (4) minutes and had a raised bloody area to the right side of the head. Staff transferred the resident to the ER. Review of the ER record revealed the hospital diagnosed the resident with a hematoma to the scalp, two (2) small superficial lacerations, and returned the resident to the facility. Further review of the incident report indicated the fall was not witnessed, but the root cause was determined to be the belt from the resident's robe was on the floor next to the resident and that possibly the resident tripped over the belt. The intervention implemented to prevent further falls for Resident #2 was to have the belt stitched to the resident's robe. However, the report had not identified staff had not provided the required assessed need of assistance with ambulation or transfers. Interview with State Registered Nurse Aide (SRNA) #4, on 03/02/2021 at 11:40 AM, revealed she frequently provided care to Resident #2 and he/she ambulated independently in the facility and had done so since admission. The SRNA described the resident's gait as unsteady and stated the resident would bump into walls at times, and made comments to staff about the ground moving. Interview with Physical Therapy Assistant (PTA) #1, on 03/04/2021 at 10:10 AM, revealed she provided care to Resident #2 when the facility initially admitted the resident. The PTA stated when she worked with the resident in November 2020, the resident had decreased safety awareness and required safety reminders when the resident was up walking, going to the bathroom or maneuvering around obstacles in the environment. PTA #1 also stated the resident would get up and go quickly and had to be told to slow down, but that it was difficult to keep the resident on task. The PTA also stated the resident's gait had a lateral lean, which remained when discharged from therapy services in December 2020. Interview with Physical Therapist #1, on 03/03/2021 at 9:30 AM and on 03/04/2021 at 9:55 AM, revealed he received a request to evaluate Resident #2, on 03/01/2021, due to a fall the resident had on 02/28/2021. The PT evaluated the resident as requested on 03/01/2021 and stated the resident absolutely required assistance to transfer and ambulate safely in the facility. The PT stated the resident had dementia and an excessive left lateral sway when walking. He also stated the resident required hands on assist to ensure safety when the resident was ambulating in the room or in the hallways of the facility. Continued interview the Physical Therapist revealed that residents were referred for a therapy evaluation after a fall, but if the resident was already participating in therapy they would just continue the treatment plan that was in place and not reevaluated. Interview with the Director of Nursing (DON), on 03/03/2021 at 3:50 PM, revealed she expected nurses to identify the root cause of falls when they occurred in the facility and staff were to implement interventions at that time. The DON stated falls were discussed daily in the Monday-Friday morning meetings and the Clinical Coordinators were responsible to ensure falls were thoroughly investigated. In addition, a root cause analysis was conducted and staff had implemented interventions to prevent further falls from occurring. The DON also stated she attended the morning meetings and discussed falls with the Clinical Coordinators. The DON stated she had discussed Resident #2's falls and was aware the resident ambulated/transferred without assistance from staff but had not identified that the resident was coded on the MDS to require the assistance of one (1) staff member. The DON stated Resident #2's falls were discussed in the morning meetings, but no concerns had been identified with actions taken to prevent further falls for the resident. Interview with the Administrator, on 03/03/2021 at 3:50 PM, revealed she tracked and trended all falls that occurred in the facility. The Administrator also stated she had reviewed Resident #2's falls and had not identified any concerns with root cause analysis or appropriate interventions being implemented to prevent further falls for Resident #2. The Administrator stated she had not identified that the resident required the assistance of staff with ambulation in the facility. 2. Review of Resident #3's clinical record revealed the facility admitted on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #3's quarterly MDS assessment dated [DATE], revealed Resident #3 had a Brief Interview for Mental Status (BIMS) score of three (3), indicating the resident was cognitively impaired and required the assistance of one (1) staff for transferring and transitioning from a seated to a standing position. Review of a Fall Risk Evaluation dated 11/20/2019, revealed the facility assessed Resident #3 to be at a high risk for falls. Review of incident report, dated 01/07/2020 at 10:20 AM, revealed Resident #3 fell in the day dining room while attempting to stand unassisted from the wheelchair and hit his/her head on a table leg and was sent to the ER for further evaluation. Review of the ER record revealed the resident sustained [REDACTED]. However, the investigation report had no documented evidence staff had identified Resident #3 was not provided the required assistance of one (1) staff for transferring and transitioning from a seated to a standing position in order to prevent a fall. Review of incident report, dated 01/20/2020 at 8:00 PM, revealed Resident #3 again fell in the dining room while standing next to a wheelchair. The report indicated the resident leaned onto a dresser, and then slid down onto the floor. Further review revealed the facility determined the root cause of the fall to be the resident's confusion and standing unassisted from wheelchair. The intervention implemented was to remind the resident not to attempt to stand up from the wheelchair unassisted. Interview with RN #2, on 03/02/2021 at 2:10 PM, revealed she was working on 01/20/2020, when Resident #3 fell . She stated on 01/20/2020, Resident #3 got up from the wheelchair unassisted and slid to the floor while leaning on a dresser in dining area. Although the intervention initiated was to remind the resident not to get up unassisted, RN #2 stated Resident #3 frequently attempted to get up from wheelchair without letting staff know, even when reminded to do so. Interview with Clinical Coordinator #1, on 03/02/2021 at 3:10 PM, revealed Resident #3 was frequently confused and stated that confusion was not an appropriate root cause for a fall. The Clinical Coordinator further stated that if staff did not appropriately identified the root cause of a resident fall, then the care plan interventions implemented may not be inappropriate. Review of incident report, dated 02/08/2020 at 2:45 PM, revealed Resident #3 again fell in the dining room while attempting to stand up from the wheelchair and fell forward bending the resident's glasses and causing an abrasion (scrape) to the resident's right eye. Further review revealed the facility determined the root cause of the fall to be attempting to stand up unassisted from a wheelchair with increased weakness from a sitting to standing position. Continued review revealed an intervention for staff to check the resident's orthostatic blood pressure for three (3) days and encourage the resident to call for assistance with transfers. However, there was no indication as to why the resident was sitting in a wheelchair and not a regular chair as implemented on 01/07/2020. In addition, the report had no documented evidence the investigation identified staff failed to provide the required the assistance of one (1) staff for transferring and transitioning from a seated to a standing position. Continued review of Resident #3's clinical record, dated 02/08/2020-02/11/2020, revealed the resident's orthostatic blood pressure checks had been within normal limits. However, there was no evidence the facility went back and reviewed the fall again to determine other possible causative factors since the resident's blood pressures had not been the probable cause of the fall. Review of incident report, dated 02/17/2020 at 12:10 AM, revealed Resident #3 had an unwitnessed fall and was found in the floor of his/her room. The resident sustained [REDACTED]. Further review revealed no documented evidence the facility identified staff failed to provide the required the assistance of one (1) staff for transferring and transitioning from a seated to a standing position to prevent a fall. Review of incident report, dated 06/10/2020 at 5:45 PM, revealed Resident #3 was found by staff in the doorway of his/her room sitting on buttocks. Further review revealed the resident had no injuries from the fall. Although the facility failed to identify the root cause of the fall, interventions initiated were to obtain a urinalysis and complete blood count (CBC) from the resident and for staff to provide the resident with additional assistance during increased confused state. However, review of the clinical lab urinalysis and CBC obtained on 06/10/2020, and reported to the facility on [DATE], revealed the laboratory results were within normal limits with no evidence of infection. However, there was no evidence the facility re-evaluated the resident's fall, which occurred on 06/10/2020, to determine other possible causative factors of the resident's confusion and fall in order to implement interventions to prevent further falls. Review of another incident report, dated 08/30/2020 at 12:00 AM, revealed staff found Resident #3 lying in the floor of his/her room in front of a wheelchair. The staff assessed the resident to have an external rotation and shortening of the left leg. Further review revealed staff transferred the resident to the hospital for further evaluation and treatment. The facility determined the root cause of the fall to be the resident attempted to transfer to a wheelchair without assistance, and placed a sign in the wheelchair to remind resident not to get up without assistance. However, there was no evidence found to indicate the facility considered the intervention had not been effective in preventing falls for the resident in the past, or an explanation as to how it would prevent falls for the resident in the future. Review of a hospital record dated 08/30/2020, revealed Resident #3 was diagnosed with [REDACTED]. Interview with State Registered Nurse Aide (SRNA) #4, on 03/02/2021 at 11:40 AM, revealed she was working on 08/30/2020, when Resident #3 fell . She stated Resident #3 was attempting to transfer from the bed to the wheelchair unassisted when the fall occurred. Continued interview with the SRNA revealed Resident #3 required the assistance of one staff to transfer or stand and frequent reminders to use the call bell if he/she wanted to get up. However, the SRNA stated Resident #3 would forget to ask for assistance and frequently attempted to get up unassisted. Interview with LPN #1, on 03/03/2021 at 12:00 PM, revealed she had cared for Resident #3 and was present when the resident fell on [DATE]. The LPN stated she heard a loud noise on 08/30/2020 and found Resident #3 on the floor near his/her bed with the wheelchair by the bed. She stated it was evident the resident's hip was broken. LPN #1 stated unless staff happened to observe Resident #3 attempting to get up, staff have no way of knowing the resident was attempting to get up unassisted. LPN #1 stated the resident just gets up. LPN #1 stated after a resident fall, the nurse was responsible to complete an incident report, put safety interventions in place for the resident, and put the completed incident report in the supervisor's basket for review. LPN #1 stated she had not received training specific to determining the root cause analysis of a fall. Continued review of the incident report completed, on 08/30/2020, after Resident #3's fall, revealed the facility determined the root cause of the fall sustained by Resident #3 was because the resident was attempting to transfer to the wheelchair without assistance, and the intervention initiated was placing a sign in the resident's wheelchair as a reminder not to stand up without assistance. However, there was no evidence found to indicate the facility considered the resident's cognitive status when implementing the intervention as a means to prevent further falls for the resident. Interview with Clinical Coordinator #2, on 03/03/2021 at 1:05 PM, revealed placing a sign in the wheelchair to remind Resident #3 not to get up unassisted was not an appropriate intervention at that time based on Resident #3's cognitive status. Review of incident report, dated 12/10/2020 at 11:30 AM, revealed staff discovered Resident #3 in his/her room sitting on the floor in front of his/her wheelchair and stated to staff I was going for a walk. Further review of the report revealed the resident sustained [REDACTED].

Based on observations, interviews, and record review, the facility failed to identify and isolate residents to properly prevent the spread of COVID-19 for two (2) of three (3) sampled residents. (Resident #2 and Resident #3). Observations and interviews revealed the facility failed to isolate Resident #2 and Resident #3 after returning to the facility from emergency room (ER) visits as outlined in the facility's policy. Observations also revealed housekeeping staff failed to don appropriate Personal Protective Equipment (PPE) when cleaning an isolation room on 03/03/2021. Findings include: Review of facility policy titled, COVID-19: Protocol for Resident out for Facility Appointments and Quarantine, dated November 2020, revealed when a resident must go out of the facility for a physician consult, ER visit, follow-up, diagnostic procedure, etc., the resident would be placed in quarantine for the duration of fourteen (14) days. Review of the facility's policy titled, Infection Prevention and Control Program, undated, revealed to prevent the spread of infection, the facility would isolate any resident when it was determined necessary and if placed in contact or droplet precaution isolation and a PPE door caddy/cart would be placed at the door of the resident's room. Further review revealed the appropriate contact/droplet instruction sheet would be placed in the treatment book and in front of the nurse aide Kardex. Interview with Administrator, on 03/03/2021 at 6:50 PM, revealed staff entering a resident's rooms, in which the resident was in droplet precautions, was required to wear an N-95 mask, a face shield, a gown to cover their clothing and gloves. She also stated staff had to remove all the PPE and perform hand hygiene prior to exiting the room and re-entering the facility hallways. 1. Review of Resident #3's medical record revealed the facility admitted the resident on 09/02/2016 with [DIAGNOSES REDACTED]. Review of Resident #3's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the facility assessed the resident to be cognitively impaired. Continued review of Resident #3's medical record revealed the resident went out to the emergency room (ER) on 02/22/2021 at 5:55 PM, for evaluation after a fall and returned to the facility on [DATE] at 10:25 PM by ambulance. Review of Nursing Notes, dated 02/23/2021 at 8:10 AM, revealed Resident #3 was to be placed on isolation precautions per the facility's policy for two (2) weeks (02/22/2021 thru 03/08/2021) as a COVID-19 precaution. Review of Resident #3's Kardex on 03/01/2021 at 1:30 PM, revealed isolation precautions were not noted on the resident's Kardex, and an isolation instruction sheet was not in front of Resident #3's Kardex. Observation of Resident #3 on 03/01/2021 at 11:25 AM, revealed the resident was up in a wheelchair in his/her room. Continued observation revealed there was no isolation signage or PPE cart present on or at the resident's door. Further observation revealed the resident exited the room via wheelchair and propelled down the hallway to the community day area wearing a mask under the mouth and nose. Although staff were in the resident care area, none of the staff encouraged the resident to wear the mask properly. Further observations of Resident #3, on 03/01/2021 at 3:15 PM, revealed the resident in the hallway continuing to wear the facemask below the mouth and nose. Further observation revealed the resident propelled to the community day area, and interacted with staff. However, none of the staff encouraged Resident #3 to wear the mask appropriately. Continued observation of Resident #3, on 03/02/2021 at 10:00 AM, revealed the resident was resting in bed with no signage or PPE equipment at or on the resident's door. Observation of Resident #3's room, on 03/03/2021 at 10:10 AM, revealed a PPE caddy was on the room door with a droplet precaution identifier. Further observations revealed Resident #3 was not in the room, however, housekeeping staff was cleaning the room wearing only gloves and an N95 facemask. After completing the cleaning in Resident #3's room, the housekeeping staff exited the room with the same mask on. Further observation revealed that although the housekeeper removed the gloves, she failed to perform hand hygiene prior to exiting the room. The housekeeper then stood in the doorway of the neighboring resident's room, and spoke to another staff member, before entering a supply closet at the end of the hallway. Interview with the Housekeeper, on 03/03/2021 at 10:25 AM, revealed housekeeping staff was trained on the proper use of PPE, hand hygiene, and disinfection of reusable PPE. The Housekeeper stated she did not notice the PPE caddy and signage prior to entering Resident #3's room. She stated she should have donned full PPE prior to entering the room for cleaning. The housekeeper stated if staff did not wear appropriate PPE, cross contamination could occur as well as possible spread of infection to other residents and staff. 2. Review of Resident #2's medical record revealed the facility admitted the resident on 11/10/2021 with [DIAGNOSES REDACTED]. Review of Resident #2's admission Minimum Data Set (MDS) assessment, dated 11/22/2021, revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of four (4), indicating the resident was cognitively impaired. Continued review of Resident #2's medical record revealed staff transferred the resident to the ER, on 02/28/2021 after a fall, and the resident returned to the facility later that same day. However, further review of the resident's medical record including nursing notes and Kardex, revealed no evidence that staff placed the resident on isolation precautions as outlined in the facility's policy. Observations conducted of Resident #2's room, on 03/01/2021 at 11:35 AM, and again on 03/02/2021 at 9:55 AM, revealed no evidence a PPE cart or signage was on or at the resident's door. Observations conducted of Resident #2, on 03/01/2021 at 11:30 AM, revealed the resident was ambulatory in the front entrance area of the facility, with no facemask in place, and in contact with peers and staff. However, none of the staff members offered to obtain or encouraged the resident to use of a facemask. Further observations on 03/01/2021 at 1:35 PM and 3:45 PM, revealed Resident #2 was ambulatory in the facility hallway and at the nurse's station with other residents and staff present. However, none of the staff offered to obtain or encouraged the resident to wear a facemask. Interview with Registered Nurse (RN) #2, on 03/01/2021 at 2:10 PM revealed she was caring for Resident #3 on 02/22/2021 and Resident #2 on 02/28/2021 when the residents returned from the ER after fall evaluations. The RN stated the on call nurse or the Unit Coordinator (UC) was supposed to notify the infection control nurse when a situation occurred that required a resident to be isolated. Therefore, she did not check to ensure staff had placed signage or a PPE cart at or on the residents' doors. Interview with Unit Coordinator (UC) #2, on 03/04/2021 at 6:15 PM, revealed she was aware that the residents had been sent out to the ER, but did not realize staff had not placed the residents in isolation after returning. The UC stated she could notify the infection control nurse, but she usually notified the Administrator when a resident went to ER or out of facility. The UC stated if staff did not follow proper infection control practices, COVID-19 infection was a big risk. Interview with Infection Control Nurse, on 03/01/2021 at 3:40 PM, revealed she could not recall if staff notified her when Resident #3 and Resident #2 went out of the facility to the ER or when the residents returned. In addition, the Infection Control Nurse stated the facility had trained all housekeeping staff on proper PPE requirements. The infection Control Nurse stated that the facility discussed isolation in the morning meetings held daily Monday through Friday. However, she stated the exact number or specific residents in isolation each day was not specifically discussed. Interview with Director of Nursing (DON), on 03/03/2021 at 3:50 PM, revealed the UC's were responsible for surveillance of isolation precautions and ensuring that the proper signage and equipment was in place. She stated the Infection Control Nurse was responsible for monitoring and surveillance of isolated residents. The DON stated she had not identified that the facility failed to place Resident #2 and Resident #3 in isolation upon return from the ER. Interview with Administrator, on 03/04/2021 at 6:50 PM, revealed the facility had not identified any concerns with nursing staff or housekeeping staff not wearing appropriate PPE or staff failing to place residents in isolation when warranted.

Based on interview, record review, and facility policy review, it was determined the facility failed to protect one (1) of three (3) sampled residents (Resident #1) from misappropriation of property. State Registered Nurse Aide (SRNA) #1 routinely obtained money from Resident #1's locked box to buy food for the resident. However, the SRNA failed to follow the facility's policy related to purchasing items for residents. The findings include: Review of the facility's policy and procedure, Abuse, Neglect, Misappropriation and Exploitation Policy, revised (MONTH) (YEAR), revealed misappropriation of resident property was defined as the deliberate misplacement, exploitation, wrongful, temporary, or permanent use of a resident's belongings or money without the resident's consent. A review of the facility's protocol for purchases, undated, revealed all purchases made by facility staff with resident funds would be preapproved by the resident. Further review of the procedure revealed purchased items would be delivered to the business office when purchased and supervisory staff or a designee would confirm that the items purchased matched items listed on the receipt. In addition the policy stated that items purchased on behalf of the resident would be given to the resident on the date of purchase and be witnessed by two staff members and the resident would sign a purchase form for verification that the resident had authorized the purchase and received the items. A review of Resident #1's medical record revealed the facility admitted the resident on 01/15/19, with [DIAGNOSES REDACTED]. Review of Resident #1's Minimum Data Set (MDS) assessment dated [DATE], revealed the facility assessed the resident to be cognitively intact with a Brief Interview for Mental Status (BIMS) score of 14. Review of a facility investigation revealed on 07/26/19, Resident #1 alleged SRNA #1 took $2,900.00 of Resident #1's money from a locked drawer in the resident's room which the resident kept money in. However, the investigation revealed no documentation or any evidence of any receipts for purchases made by SRNA #1 for Resident #1. Interview with Resident #1 on 08/05/19 at 12:45 PM revealed the resident had $2,900.00 which he/she kept in a locked drawer in his/her room. Further interview with Resident #1 revealed he allowed SRNA #1 to have a key to the drawer so she could remove money from the drawer to purchase items for the resident. However, Resident #1 stated the SRNA did not bring receipts back after purchasing items for the resident. Interview with SRNA #1 on 08/05/19 at 1:20 PM revealed the SRNA did have a key to Resident #1's drawer, and would remove money to purchase food for the resident when she was going to lunch, and would bring the food items back to Resident #1 along with a receipt and change. Further interview with SRNA #1 revealed she was aware of the facility policy for making purchases for residents. However, she did not follow the facility policy regarding making purchases for Resident #1 because she was buying food for the resident because the resident would not eat the food at the facility. SRNA #1 denied taking money from the resident's drawer without the resident's consent, including $2,900.00. An interview with the Administrator on 08/06/19 at 12:57 PM revealed she became aware of the allegation on 07/26/19, when Resident #1 reported that SRNA #1 had taken money from him/her. According to the Administrator SRNA #1 should have followed the facility policy regarding making resident purchases. However, the facility could not substantiate that the SRNA took $2,900.00 of the resident's money. According to the Administrator SRNA #1 remains suspended awaiting outcome of the law enforcement investigation.

Based on observation, interview, record review, and review of the Resident Assessment Instrument (RAI) User's Manual, it was determined the facility failed to ensure the Minimum Data Set (MDS) assessment accurately reflected the resident's status for one (1) of twenty-seven (27) sampled residents (Resident #49). Resident #49 was admitted to hospice services on 04/25/19. However, review of the resident's Minimum Data Set (MDS) assessment dated [DATE] revealed hospice services was not coded on the assessment. The findings include: Interview with the Director of Nursing (DON) on 06/27/19 at 3:38 PM, revealed the facility utilized the Long Term Care Facility Resident Assessment Instrument 3.0 User's Manual, dated (MONTH) (YEAR), as a resource for completion of MDS assessments. Review of the Long Term Care Facility Resident Assessment Instrument 3.0 User's Manual revealed the facility had to complete a Significant Change in Status Assessment when a terminally ill resident enrolled in a hospice program and remained a resident in the facility. Further review of the manual revealed the facility had to complete the assessment within fourteen (14) days from the date hospice services was elected. Continued review of the manual revealed the facility must code the Significant Change in Status Assessment to reflect that the resident had elected to receive hospice services. A review of Resident #49's medical record revealed the facility admitted the resident on 06/28/11, with [DIAGNOSES REDACTED]. Review of physician's orders [REDACTED]. Review of hospice communication sheets revealed Resident #49 continued to receive hospice services as of 06/27/19. Although review of a Significant Change in Status MDS assessment for Resident #49, dated 05/01/19, revealed the facility completed the assessment, the facility failed to code the assessment to indicate the resident was receiving hospice services. Interview on 06/27/19 at 3:52 PM with the MDS Nurse that completed the Significant Change in Status MDS assessment dated [DATE] revealed the hospice selection should have been coded, stating it was human error, a typo. Interviews on 06/27/19 at 3:18 PM with the MDS Coordinator and at 3:38 PM with the Director of Nursing (DON) revealed the assessment should have been coded to reflect that the resident was receiving hospice services. The DON further stated she and a corporate staff member randomly audit MDS assessments, but have not identified any concerns related to accuracy.

Based on observation, interview, record review and policy review it was determined the facility failed to ensure one (1) of twenty-seven (27) (Residents were free from significant medication errors. Observation of medication administration on 06/26/19 revealed staff mixed [MEDICATION NAME] and [MEDICATION NAME] insulins in the same syringe and administer to Resident #99. The findings include: Review of facility's policy titled Medication Administration Policy, not dated, revealed should there be any doubt concerning the administration of medication to a resident, the physician's orders [REDACTED]. Review of the [MEDICATION NAME] (a long acting insulin) package insert revealed, Do not dilute or mix [MEDICATION NAME] with any other insulin or solution. In addition, review of the [MEDICATION NAME]package insert revealed, [MEDICATION NAME] may be mixed with neutral [MEDICATION NAME] Hagedorn (immediate acting insulins) insulin preparations ONLY. Review of Resident #99's medical record revealed the facility admitted the resident on 05/10/19 with [DIAGNOSES REDACTED]. Review of Resident #99's physician orders [REDACTED]. In addition, the resident had physician orders [REDACTED]. Review of Resident #99's Minimum Data Set (MDS), dated [DATE], revealed the resident had a Brief Interview for Mental Status (BIMS) score of 14, indicating the resident was cognitively intact. Observation and interview on 06/25/19 at 9:07 AM with Resident #99 revealed the resident sitting on the edge of the bed watching television. Interview with Resident #99 revealed the resident voiced no concerns with insulin administration. Observation on 06/26/19 at 8:35 AM of Licensed Practice Nurse (LPN) #2 preparing medication for Resident #99 revealed the LPN removed fifteen (15) units of [MEDICATION NAME] from the medication vial via syringe, and then utilized the same syringe to remove six (6) units of [MEDICATION NAME]from the vial, mixing the insulins together. The LPN was then observed to administer the mixed insulins to Resident #99. Interview on 06/26/19 at 3:56 PM with LPN #2 revealed she realized that she had made a mistake with the insulin right about lunchtime. She stated she called the physician and received orders to check the resident's blood sugar every hour for the next six hours. Continued interview with the LPN revealed the resident's blood sugar had been monitored as ordered, and no concerns had been noted. LPN #2 stated she was nervous and got confused when mixing the insulin. She said, I do realize I made a mistake by mixing the insulins, and will never mix [MEDICATION NAME] with anything again. A subsequent interview with Resident #99 on 06/26/19 at 4:03 PM revealed the resident was lying in bed with eyes open watching television. When asked how he/she was feeling the resident responded, I'm feeling fine; I don't know why everyone keeps asking me that. Interview on 06/27/19 at 4:06 PM with the Director of Nursing (DON) revealed she expected nurses to follow physician orders [REDACTED]. The DON stated the physician was notified of the incident and Resident #99 had suffered no ill effects.

Based on interview, record review, and review of facility policy it was determined the facility failed to ensure an allegation of abuse was reported immediately to the administrator of the facility and other state agencies for one (1) of three (3) sampled residents (Resident #1). Review of the facility's investigation revealed Nurse Aide in Training (NATR) #1 was observed to call Resident #1 a [***] and smack the resident on the arm on 07/09/18. The facility administrator and state agencies were not notified of the incident until the following day, 07/10/18. The findings include: Review of the facility's policy titled Abuse, Neglect, Misappropriation and Exploitation Policy, last revised (MONTH) (YEAR), stated abuse was the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. Further review revealed physical abuse included hitting, slapping, pinching, and kicking. The policy stated all allegations involving suspected abuse would be reported immediately, but not later than two hours after the allegation was made, to the Director of Nursing and/or the Administrator of the facility. Further review revealed the Director of Nursing, Administrator, or Designee would report such allegations to appropriate state and federal agencies, including law enforcement, as required. Review of Resident #1's medical record revealed the facility admitted the resident on 03/18/14 with [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set (MDS) assessment, dated 06/08/18, revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of fourteen (14), indicating the resident was cognitively intact and interviewable. Review of a facility investigation, dated 07/10/18, revealed on the evening of 07/09/18, Nurse Aide in Training (NATR) #2 observed NATR #1, call Resident #1 a [***] and smack the resident on the right forearm. Further review of the investigation revealed Resident #1 confirmed the incident occurred and stated he/she was not hurt. Further review of the investigation revealed NATR #2 stated she reported the incident to Registered Nurse (RN) #1 immediately after the incident occurred; however, she stated she may have been unclear when reporting the incident to the nurse. The investigation stated NATR #1 was terminated due to the incident. Interview with Resident #1 on 07/23/18 at 1:00 PM revealed NATR #1 was a smart aleck and they got into it. The resident reported the NATR hit the resident on the arm, but it did not hurt the resident. The resident stated the NATR had not been back in the resident's room since the incident occurred. Interview with NATR #2 on 07/23/18 at 4:15 PM revealed on 07/09/18 at approximately 9:30-9:45 PM, she observed NATR #1 call Resident #1 a [***] and smack the resident's arm during care. Further interview revealed she reported the incident to RN #1 when she left the resident's room; however, she was unsure if the RN understood the events of the incident. The NATR stated I think (RN #1) thought the resident hit the aide, not the other way around. The NATR stated she reported the allegation again the following day to the nurse aide Supervisor and Facility Administrator. Interview with RN #1 on 07/23/18 at 3:57 PM revealed she was unaware of the incident. The RN stated she would have reported the incident to the Administrator if she had been made aware. Interview with NATR #1 was not conducted due to inability to contact the staff member. Interview with the Administrator and Director of Nursing (DON) on 07/24/18 at 2:20 PM, revealed facility staff were expected to immediately report any allegations of abuse or neglect. Further interview revealed NATR #1 was terminated related to the incident.

Based on observation, interview, record review, and facility policy review, it was determined the facility failed to ensure one (1) of three (3) sampled residents (Resident #2) received respiratory care as required by the resident's comprehensive person-centered care plan. Observation of Resident #2 on 02/14/18 at 10:43 AM revealed the [MEDICAL CONDITION] care and suctioning provided by Licensed Practical Nurse (LPN) #1 was provided without washing and sanitizing her hands prior to beginning the procedure and sterile technique was not followed throughout the procedure. The findings include: Review of the facility's [MEDICAL CONDITION] care policy (undated) revealed handwashing should be done before starting and the policy described a sterile technique for performing the procedure. Review of Resident #2's medical record revealed the facility admitted the resident on 10/11/12, with [DIAGNOSES REDACTED]. Review of Resident #2's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of 99, indicating the resident was not interviewable, and the resident received respiratory and [MEDICAL CONDITION] care. Review of Resident #2's comprehensive plan of care revealed an intervention dated 05/08/17 to provide [MEDICAL CONDITION] care every shift and as needed, and suctioning as needed, as ordered by the physician. Observation of Resident #2's [MEDICAL CONDITION] care on 02/14/18, at 10:43 AM through 11:01 AM revealed LPN #1 failed to wash and sanitize her hands prior to beginning the procedure of [MEDICAL CONDITION] care and suctioning. Further observation revealed LPN #1 donned sterile gloves and proceeded to suction the resident three (3) times using a [MEDICAL CONDITION] kit. After completing the suctioning procedure she removed the inner cannula from the resident's [MEDICAL CONDITION]. She removed her gloves, discarding the gloves and her contaminated supplies with her bare hands, failing to wash her hands again after the suctioning procedure. She then opened a second sterile packaged [MEDICAL CONDITION] kit, opened the barrier sheet placing it on the table, donned sterile gloves, and proceeded to pick up a new disposable inner cannula from the sterile field to insert into the resident's [MEDICAL CONDITION] site. LPN #1 was stopped at that point and asked if she had washed her hands; her response was, It was sterile, but you are right, I did not wash my hands and I did touch the cannula. LPN #1 then discarded all supplies and washed her hands. LPN #1 touched her nose with her left hand, donned sterile gloves, and completed the [MEDICAL CONDITION] care. Interview with the Director of Nursing (DON) and Administrator on 02/14/18 at 4:30 PM revealed LPN #1 had been trained on [MEDICAL CONDITION] care and sterile technique. They stated LPN #1 should have washed and sanitized her hands at the beginning of the procedure, during the procedure, and when completing the procedure. Further interview revealed that LPN #1 should have maintained a sterile process during the procedure.

Based on interview, record review, and review of the facility's policy, it was determined that the facility failed to provide one (1) of three (3) sampled residents (Resident #1) with a written discharge notice. On 12/11/17, the facility initiated discharge procedures for Resident #1 but failed to issue the resident a notice of discharge. The findings include: Review of the facility's policy titled Transfer and Discharge Rights, not dated, revealed the resident and/or family would be given a thirty (30) day written notice in advance of the facility discharging a resident. Review of Resident #1's medical record revealed the resident was readmitted to the facility on [DATE]. On 12/11/17, the facility documented that Resident #1 had displayed maladaptive behaviors, and the facility arranged for the resident to be transferred to a psychiatric hospital for evaluation/treatment. Review of a Bed Hold Notification dated 12/11/17 for Resident #1 revealed the family was notified of Resident #1 being transferred out of the facility to the hospital on [DATE] but refused to privately pay to hold Resident #1's bed in the facility. Interview with the facility's Administrator on 01/10/18 at 1:45 PM revealed that due to Resident #1's family refusing to privately pay to hold Resident #1's bed, the facility discharged the resident on 12/11/17. However, the facility failed to issue the resident or the resident's family a notice of discharge. The Administrator stated the facility viewed the family's refusal to pay to hold Resident #1's bed as a resident initiated discharge, and therefore did not believe a written notice of discharge was required to be issued.

Based on interview, record review, and the facility's policy review it was determined that the facility failed to readmit (1) of three (3) sampled residents (Resident #1) back to the facility after the resident was discharged from a psychiatric hospital. On 12/18/17, the hospital psychiatric unit contacted the facility in an attempt to discharge Resident #1 back to the facility. However, the facility refused to readmit Resident #1 back to the facility. The findings include: Review of the facility's policy titled Bed Hold, revision date of November 2016, revealed when a resident was returning to the facility from a transfer stay the resident would be permitted to return to an available bed. Review of facility Daily Census Forms for 12/18/17 and 12/19/17 revealed the facility had empty beds. Review of Resident #1's medical record revealed he/she was readmitted to the facility on [DATE]. On 12/11/17, Resident #1 was transferred to a psychiatric hospital after display of maladaptive behaviors. Interview with the Social Services Director (SSD) from the psychiatric hospital on [DATE] at 4:55 PM revealed on 12/18/17 the hospital contacted the facility in an attempt to discharge the resident back to the facility. A request was made by the facility to the psychiatric unit for the progress notes regarding Resident #1's stay in the psychiatric unit. The psychiatric unit faxed the information to the facility and attempted again on 12/19/17 to discharge Resident #1 back to the facility. The SSD revealed she was told by the Admissions and Billing Director that Resident #1 did not have a bed because the family had refused to privately pay for the resident's bed to be held in the facility. Further interview with the hospital's SSD revealed Resident #1 had not displayed any behavioral issues while admitted to the psychiatric hospital. Interview with the Director of Nursing on 01/10/18 at 10:55 AM revealed she did not remember seeing any information from the psychiatric unit concerning Resident #1. She revealed the Minimum Data Set (MDS) Nurses review referral forms and if there are no changes in the resident's behavior, or if no bed is available, the facility does not readmit the resident. Interview with the MDS Nurse on 01/10/18 at 11:30 AM revealed she could not remember reviewing Resident #1's referral form. The MDS Nurse stated that if there were any concerns with a resident returning to the facility the DON made the decision regarding whether the resident could return to the facility. An interview with the facility's Administrator on 01/10/18 at 1:45 PM revealed that to her knowledge someone at the facility had reviewed Resident #1's record from the psychiatric hospital and made the decision to not allow the resident to return to the facility, despite the facility having available beds.

Based on observation, interview, record review, and facility policy review, it was determined the facility failed to develop a comprehensive plan of care for four (4) of twenty-four (24) sampled residents (Resident #3, Resident #4, Resident #6, and Resident #14) to address securing urinary catheters to prevent trauma or injury. The findings include: Review of the facility policy titled, Care Plan Policy and Protocol, revised August 2012, revealed the facility would develop a comprehensive care plan for each resident that included measurable objectives and timetables to meet the resident's medical, nursing, and mental/psychosocial needs that were identified in the comprehensive assessment. 1. Review of the medical record for Resident #3 revealed the resident was admitted by the facility on 11/01/12, with [DIAGNOSES REDACTED]. Review of the most current annual Minimum Data Set (MDS) assessment for Resident #3, dated 12/13/16, revealed the resident had a Brief Interview for Mental Status (BIMS) score of 3, which indicated the resident was severely cognitively impaired and was therefore not interviewable. The MDS also revealed the resident had an indwelling urinary catheter. Observation of indwelling urinary catheter care for Resident #3 was observed on 01/18/17, at 9:20 AM. State Registered Nursing Assistant (SRNA) #5 was observed to provide the care. The observation revealed Resident #3's indwelling urinary catheter was not secured prior to catheter care being conducted. SRNA #5 also failed to secure the catheter after the care was completed. Review of Resident #3's comprehensive plan of care with a revision date of 12/13/16 revealed the resident had no interventions developed to address securing the resident's indwelling urinary catheter to prevent trauma or injury. 2. Review of Resident #4's medical record revealed the facility readmitted the resident on 10/18/16 with [DIAGNOSES REDACTED]. Review of Resident #4's significant change Minimum Data Set (MDS) assessment dated [DATE] revealed the facility assessed the resident to have a BIMS score of 6 indicating the resident was severely cognitively impaired. Further review revealed the resident was assessed to require the use of an indwelling urinary catheter related to [MEDICAL CONDITION]. Observation of indwelling urinary catheter care on 01/17/17 revealed CNA #2 did not secure the indwelling urinary catheter tubing to the resident's thigh to prevent pain or injury while cleaning the catheter tubing. Review of the Comprehensive Care Plan for Resident #4 dated 07/15/16 revealed the resident had a care plan related to utilizing an indwelling urinary catheter. However, review of the implemented interventions revealed the facility had not developed interventions related to staff ensuring the resident's catheter was anchored appropriately to prevent trauma or injury. 3. Review of Resident #6's medical record revealed the facility admitted the resident on 10/11/12, with [DIAGNOSES REDACTED]. Review of a significant change Minimum Data Set assessment for Resident #6 dated 10/12/16, revealed the facility had assessed the resident to be severely cognitively impaired and was therefore not interviewable. The MDS also revealed the resident had an indwelling urinary catheter. Review of Resident #6's monthly physician orders dated 01/01/17 revealed a physician's order for the resident to have an indwelling urinary catheter to a bedside drainage bag. Observation of indwelling urinary catheter care performed by SRNA #6 for Resident #6 on 01/17/17, at 1:30 PM, revealed the resident's catheter was not secured prior to initiation of care. Additionally, the SRNA failed to anchor the resident's catheter after the care had been performed. Review of Resident #6's plan of care dated 04/20/16 revealed no interventions had been implemented to address anchoring or securing the resident's indwelling urinary catheter to prevent trauma or injury. 4. Review of the medical record revealed the facility admitted Resident #14 on 09/08/15 with [DIAGNOSES REDACTED]. Review of Resident 14's Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a BIMS score of 15, indicating the resident was cognitively intact. Further review of the MDS revealed the resident utilized an indwelling urinary catheter. Observation on 01/17/17 at 1:35 PM revealed Resident #14's urinary catheter was not anchored or secured. Review of Resident #14's comprehensive plan of care with a revision date of 11/27/16 revealed the resident had no interventions developed to address anchoring or securing the resident's indwelling urinary catheter to prevent trauma or injury. Interview with the MDS Coordinator on 01/18/17, at 4:00 PM, revealed she was responsible for developing plans of care for residents. However, the MDS Coordinator stated she had not included interventions on care plans for residents who utilize Foley catheters to ensure staff was anchoring or securing the catheters. The MDS Coordinator stated she just expected staff to do it. Interview with the Director of Nursing (DON) on 01/18/17, at 4:45 PM, revealed interventions should have been developed for residents with indwelling urinary catheters to address the securing of the catheters to prevent trauma or injury. The DON stated she had not identified any concerns with plans of care not addressing the securing of urinary catheters to prevent trauma or injury.

Based on observation, interview, and record review it was determined the facility failed to ensure residents received the appropriate care and services related to securing indwelling urinary catheters to prevent trauma or injury for four (4) of twenty-four (24) sampled residents (Resident #3, Resident #4, Resident #6, and Resident #14). Observations during indwelling urinary catheter care for Resident #3, Resident #4, Resident #6, and Resident #14 revealed staff was observed to not secure the residents' indwelling urinary catheters after performing catheter care. The findings include: Review of the facility's policy titled Giving Catheter Care, undated, revealed staff was required to secure an indwelling urinary catheter after performing urinary catheter care. 1. Review of the medical record for Resident #3 revealed the resident was admitted by the facility on 11/01/12, with [DIAGNOSES REDACTED]. Review of the most current annual Minimum Data Set (MDS) assessment for Resident #3 dated 12/13/16 revealed the resident had a Brief Interview for Mental Status (BIMS) score of 3 which indicated the resident was severely cognitively impaired and was therefore not interviewable. The MDS also revealed the resident had an indwelling urinary catheter. Observation of indwelling urinary catheter care for Resident #3 was conducted on 01/18/17, at 9:20 AM. State Registered Nursing Assistant (SRNA) #5 was observed to provide the care. The observation revealed Resident #3's indwelling urinary catheter was not secured prior to catheter care being conducted. SRNA #5 also failed to secure the catheter after the care was completed. Interview conducted with SRNA #5 on 01/18/17, at 1:15 PM, revealed she had been trained by the facility to secure urinary catheters to the resident's leg to prevent trauma or injury. The SRNA stated she was unsure why she had not secure the resident's urinary catheter, but should have. Interview with Registered Nurse (RN) #1 on 01/18/17, at 1:20 PM, revealed all urinary catheters were required to be secured to the resident to prevent trauma or injury. RN #1 stated she had not identified that Resident #3's indwelling urinary catheter had not been secured as required. 2. Review of Resident #4's medical record revealed the facility readmitted the resident on 10/18/16 with [DIAGNOSES REDACTED]. Review of the significant change MDS assessment dated [DATE] revealed the facility assessed the resident to have a BIMS score of 6 indicating severe cognitive impairment. Further review revealed the resident was assessed to require the use of an indwelling urinary catheter related to [MEDICAL CONDITION]. Observation of indwelling urinary catheter care on 01/17/17 at 1:50 PM revealed SRNA #2 did not secure the indwelling urinary catheter tubing to the resident's thigh to prevent pain or injury after the catheter care was performed. Interview with SRNA #2 on 01/17/17 revealed she routinely secured the resident's catheter tubing to the bed linens and not the resident's thigh. SRNA #2 stated she thought that was acceptable because the resident does not move much. Interview with the Director of Nursing (DON) on 01/18/17 at 4:45 PM revealed urinary catheters should be secured to the resident's thigh utilizing a leg anchor band. 3. Review of Resident #6's medical record revealed the facility admitted the resident on 10/11/12, with [DIAGNOSES REDACTED]. A review of Resident #6's significant change MDS assessment dated [DATE] revealed the facility assessed the resident to be severely cognitively impaired, and therefore not interviewable. The MDS also revealed the resident had an indwelling urinary catheter. A review of the monthly physician orders [REDACTED]. Observation of SRNA #6 performing indwelling urinary catheter care for Resident #6 on 01/17/17, at 1:30 PM, revealed the indwelling urinary catheter was not secured prior to the catheter care. SRNA #6 also failed to secure the catheter to prevent trauma or injury after completing catheter care for Resident #6. An interview conducted with SRNA #6 on 01/17/17, at 2:00 PM, revealed she had been trained by the facility to secure urinary catheters to the resident's leg to prevent trauma or injury but was nervous and failed to secure the catheter. Interview with Licensed Practical Nurse (LPN) #2 on 01/18/17, at 2:15 PM, revealed staff was required to secure indwelling urinary catheters to residents' legs to prevent trauma or injury. The LPN stated she was not aware that Resident #6's catheter had not been secured as required. 4. Review of Resident #14's medical record revealed the facility admitted the resident on 09/08/15, with [DIAGNOSES REDACTED]. Review of Resident #14's Minimum Data Set (MDS) assessment dated [DATE] revealed the facility assessed the resident to have a BIMS score of 15. Further review revealed the resident had an order for [REDACTED]. Observation of indwelling urinary catheter care on 01/17/17 at 1:35 PM and 01/18/17 at 9:14 AM revealed the indwelling urinary catheter tubing was not secured to prevent pain or injury after completion of the care. Interview with Resident #14 on 01/17/17, at 1:35 PM, revealed his/her catheter anchor band had come off a few days ago and staff had not replaced it. Interview conducted with SRNA #4 on 01/18/17, at 1:15 PM, revealed she had been trained by the facility to secure urinary catheters to the resident's leg to prevent trauma or injury. The SRNA stated she was unsure why she had not replaced the anchor band and secured Resident #14's indwelling urinary Foley catheter as required. An interview with the Director of Nursing on 01/18/17, at 4:45 PM, revealed staff was to ensure that each resident who utilized an indwelling catheter had the catheter appropriately secured to prevent injury or trauma.

Based on observation, interview, and record review, it was determined the facility failed to ensure four (4) of twenty-four (24) sampled residents (Resident #1, Resident #6, Resident #12, and Resident #20) received proper treatment and care related to receiving special services. Residents #1, #12, and #20 were observed to not receive oxygen as ordered by the physician. In addition, Resident #6's [MEDICAL CONDITION] care was not performed utilizing sterile technique. The findings include: Review of the facility's policy titled Setting Up For Oxygen Administration, undated, revealed the policy did not address oxygen administration. 1. Review of Resident #1's medical record revealed the facility admitted the resident on 06/18/13 with [DIAGNOSES REDACTED]. Review of Resident #1's Minimum Data Set (MDS) assessment dated [DATE] revealed the facility assessed the resident to be cognitively impaired and unable to be interviewed. Review of Resident #1's physician's orders [REDACTED].#1 to be administered oxygen at two (2) LPM. Observations of Resident #1 on 01/16/17 at 11:55 AM, 3:10 PM, 4:10 PM, and 5:40 PM revealed the resident was receiving oxygen at 1.5 LPM. 2. Review of Resident #12's medical record revealed the facility admitted the resident on 06/10/16 with [DIAGNOSES REDACTED]. Review of Resident #12's MDS assessment dated [DATE] revealed the facility assessed Resident #12 to have a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident was cognitively intact. Review of physician's orders [REDACTED]. Observations of Resident #12 on 01/16/17 at 3:15 PM and 01/17/17 at 1:40 PM revealed the resident was not wearing oxygen. 3. Review of Resident #20's medical record revealed the facility admitted the resident on 11/15/16 with [DIAGNOSES REDACTED]. Review of Resident #20's MDS assessment dated [DATE] revealed the facility assessed Resident #20 to have a BIMS score of 12, which indicated the resident had moderate cognitive impairment. Review of Resident #20's Physician order [REDACTED]. Interview with Registered Nurse (RN) #1 on 01/18/17 at 1:08 PM revealed the nurses monitor oxygen each shift and as needed. Further interview with RN #1 revealed oxygen was adjusted to the correct flow rate if needed during the shift. RN #1 stated she had not identified any residents with oxygen at the wrong flow rate. Interview with the Clinical Coordinator/Licensed Practical Nurse (LPN) #1 on 01/18/17 at 12:48 PM revealed oxygen administration was monitored by the nurse every shift by making rounds. She stated she was not aware that oxygen was not being administered as ordered. Interview with the Director of Nursing (DON) on 01/18/17 at 12:52 PM revealed nurses monitor oxygen each shift and she reviewed physician orders [REDACTED]. [REDACTED]. 4. Review of the facility's policy titled, [MEDICAL CONDITION] Care, undated, revealed the disposable inner cannula was to be replaced prior to the nurse changing her gloves. Review of Resident #6's medical record revealed the facility admitted the resident on 10/11/12, with [DIAGNOSES REDACTED]. A review of Resident #6's significant change Minimum Data Set (MDS) assessment dated [DATE] revealed the facility assessed the resident to be severely cognitively impaired and therefore not interviewable. The MDS also revealed the resident had a [MEDICAL CONDITION]. A review of the monthly physician orders [REDACTED]. Observation of [MEDICAL CONDITION] care for Resident #6 on 01/17/17, at 2:00 PM, revealed LPN #2 was observed to provide [MEDICAL CONDITION] care and discarded her sterile gloves. The LPN was then observed to wash/sanitize her hands and apply nonsterile gloves. The LPN then removed the resident's disposable inner cannula, opened a new disposable inner cannula, and placed it in the resident's [MEDICAL CONDITION], while wearing the nonsterile gloves. Interview with LPN #2 on 01/18/17, at 2:15 PM, revealed she had not been taught to use sterile gloves to change a resident's disposable inner cannula. The LPN stated she was not sure what the facility's policy on [MEDICAL CONDITION] care contained. An interview with the Director of Nursing on 01/18/17, at 4:45 PM, revealed staff was required to use sterile technique to change a disposable inner cannula for a resident with a [MEDICAL CONDITION]. The DON stated she had not identified any concerns with sterile technique not being maintained with [MEDICAL CONDITION] care.