Every finding on record at Irvine Nursing and Rehabilitation Center

Based on interview, record review, and review of the facility's policy, the facility failed to provide food served at a safe and appetizing temperature to ensure resident satisfaction and safety for 5 out of 17 residents who attended the Resident Group Meeting held on 02/12/2025 at 1:20 PM. Five interviewable residents (Resident (R)4, R7, R38, R69, and R291) selected by the facility in a resident group meeting all expressed concerns about the facility's food, which included hot food being served cold. Observation of a test tray with the Dietary Manager (DM) revealed hot food temperatures were below 135 degrees Fahrenheit (F)and cold foods were above 41 degrees F. An interview with the DM revealed the hot foods on the test tray should be served at 135 degrees F, at a minimum, and the cold foods/beverages should have been below 41 degrees F. The findings include: A review of the facility's policy titled Food: Preparation, revision dated 02/2023, revealed that All foods will be held at appropriate temperatures, greater than 135 degrees Fahrenheit (F) (or as state regulation requires) for hot holding, and less than 41 degrees F for cold food holding. A review of the facility's policy titled Meal Distribution, revision dated 02/2023, revealed that Meals are transported to the dining locations in a manner that ensures proper temperature maintenance, protects against contamination, and delivers in a timely and accurate manner. A review of the facility's policy titled Food: Quality and Palatability revised 02/2023, revealed that Foods will be palatable, attractive, and served at a safe and appetizing temperature. During the resident group meeting held on 02/12/2024 at 01:20 PM, with interviewable residents selected by the facility, all five residents (R4, R7, R38, R69, and R291) expressed concerns about the facility's food. The interviews were as follows: -R38 stated food was the big issue at the facility, adding that the facility always serves her food cold. -R291 stated, Food is always cold by the time I get it. -R7 and R69 stated sometimes food items are cold. -R4 stated, I have to eat snacks that my family brings because the food is too cold from the kitchen. The facility provided the Resident Council Minutes from 09/09/2024 through 02/04/2025. The minutes revealed that residents expressed concerns about the food during the resident council meeting on 02/04/2025. Residents further stated, [NAME] top Hall trays are cold when they are passed out to them. On 02/13/2024 at 12:30 PM, a State Survey Agent (SSA) performed an observation of a lunch tray pass conducted on the [NAME] Hall unit. After the staff served the last resident tray, the Dietary Manager (DM), alongside the District Dietary Manager (DDM), obtained the food temperature on the test tray. Per observation, the floor staff completed the tray pass in 18 minutes. Continued observation revealed the temperature results of the test tray food were as follows: cheese pizza was 112.9 degrees F, verified by the DM; the fruit cocktail was 45 degrees F, verified by the DM; the salad was 62.5 degrees F, verified by the DM. During an interview with the DDM at the time of observation, he stated meals needed to be served at an appropriate temperature for food palatability, resident satisfaction, and resident safety to prevent foodborne illness, scalding, and burns. The DDM further stated the nursing staff did not deliver meals to the residents promptly. During an interview on 02/13/2025 at 3:00 PM, the Administrator stated she was aware of residents' food complaints. Although, the Administrator stated she had educated staff on meal service, the facility had failed to monitor to ensure food temperatures were within the required ranges and foods were palatable.

Based on interview, record review, and review of the facility's policy, it was determined the facility failed to ensure the security and confidentiality of medical records for one of twenty-nine (29) sampled residents, Resident 4 (R4). Medical information including the patient's name and medical symptoms were given to a family member of R4's physician. The findings include: Observation, on 02/12/2025 at 11:55 PM, revealed Registered Nurse (RN) 1 call Physician 1's home phone number to report R4's complaint of chest pain. Review of the facility's policy, Change of Condition Standard of Practice, dated 07/2020, revealed the policy purpose was to ensure all interested parties were informed of the resident's change in health status so a treatment plan could be developed which was in the best interest of the resident. Further review revealed the facility would immediately (as soon as possible/no longer than twenty-four (24) hours) consult the resident's physician, nurse practitioner, or physician assistant when there was a significant change in the resident's physical status (a deterioration in health status in either life-threatening conditions or clinical complications). Review of Resident 4's (R4) Admission Face Sheet revealed the facility admitted R4 on 10/24/2023 with diagnoses which included cerebral infarction, transient cerebral ischemic attack, and atrial fibrillation (an irregular heartbeat). During an interview, on 02/13/2025 at 12:10 AM, RN1 stated she had called Physician 1's home phone number and spoke with Physician 1's daughter to give report on R4. During further interview, RN1 stated Physician 1's daughter was not a medical professional (nurse, nurse practitioner, physician assistant, or physician), but was a smart sweet girl who was knowledgeable and helped Physician 1. During continued interview, RN1 stated she normally did not give report to a physician's family member, but Physician 1's daughter stated she would take report and relay it to Physician 1. Additionally, RN1 stated she should not have given report to Physician 1's daughter as she was not a trained medical profession because she may have given incorrect information regarding R4 to Physician 1 regarding the patient's condition. During an interview, on 02/13/2025 at 3:45 PM, the Director of Nursing (DON) stated only a physician, physician assistant, or nurse practitioner should be notified of a change in a resident's condition because information might not be relayed to the medical provider correctly, and it would be a violation of the Health Insurance Portability and Accountability Act of 1996 (HIPPA) to give information regarding a resident to someone other than the medical provider. During an interview, on 02/13/2025 at 4:35 PM, the Administrator stated staff should never relay a resident's medical information to a physician's family member because information could be relayed incorrectly to the physician. During an interview, on 02/13/2025 at 5:13 PM, Physician 1 stated RN1 did relay R4's medical information to his daughter on 02/12/2025 around 11:55 PM, and his daughter relayed the information to him and he called RN4 back a short time later with an order to send R4 to the emergency room (ER) for complaints of chest pain. He further stated his daughter had worked for him when he had a medical practice a few years ago, but was not a trained medical professional and did not work for him currently.

Based on interview, record review, and review of the facility's policy, it was determined the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for one of twenty-nine (29) sampled residents, Resident 4 (R4). The findings include: Observation, on 02/12/2025 at 11:30 PM, revealed Registered Nurse (RN) 1 obtained vital signs and a glucometer (blood sugar) check for R4 without washing her hands before or after obtaining vital signs and the glucometer check. Further observation revealed RN1 exited R4's room into the hallway while wearing gloves and unlocked and reached into a drawer of the treatment cart while wearing the soiled gloves, then reentered R4's room wearing the same soiled gloves. Continued observation revealed RN1 placed a bottle of glucometer strips on R4's bed while obtaining R4's glucometer check, then picked up the bottle of glucometer strips and placed it in her pocket. Review of the facility's policy, Infection Control, undated, revealed the facility's infection control policies and practices were intended to facilitate maintaining a safe, sanitary and comfortable environment and to help prevent and manage transmission of diseases and infections. Continued review of the policy revealed the objectives of the infection control policies and procedures were to prevent infections in the facility. Review of Resident 4's (R4) Admission Face Sheet revealed the facility admitted R4 on 10/24/2023 with diagnoses which included cerebral infarction, transient cerebral ischemic attack, and atrial fibrillation (an irregular heartbeat). During an interview, on 02/13/2025 at 12:10 AM, RN1 stated she had received Infection Control Training in the facility which was provided at least annually, and she thought the last in-service on Infection Control was about 2 weeks ago. She further stated she should have washed her hands before checking vital signs, between checking the vital signs and the glucometer check, and after finishing the glucometer check. She continued to state she should not have left the room wearing gloves. Additionally, she stated it was important to use proper handwashing technique and the proper use of gloves to prevent the spread of any germs or infections from one resident to another resident. During an interview, on 02/13/2025 at 3:45 PM, the Director of Nursing (DON) stated she expected all staff to perform proper handwashing technique and the proper use of personal protective equipment (PPE), including gloves, to prevent the spread of infection between residents. During an interview, on 02/13/2025 at 4:35 PM, the Administrator stated staff should follow the facility's policies and procedures, including the Infection Control Policy, for the safety of the residents.

Based on interviews, record review, and review of the facility's policy, the facility failed to allow residents to call for staff assistance through a communication system that relays the call directly to a staff member from each resident's bedside. During observations on the 2/12/2025 night shift, call lights for Resident (R) 23, R26, and R67 were found lying under the bed, behind a chair on the floor, and clipped to the privacy curtain, and all were out of reach for the residents to call for assistance. The findings include: The facility resident council meeting was held on 02/12/2025 at 1:20 PM, with 4 out of seventeen residents who attended voicing the following concerns about call lights: R291 revealed, We can't get any help during the night. The workers sit at their desks or stand in the hallway talking on their cell phones all night. R69 revealed, They hide our call lights at night, so we can't reach them. R7 revealed, They tell us not to ring our call bells and To go back to bed if we get up. Observation of R26 on 02/12/2025 at 11:04 PM revealed that staff had left the call light cord loosely draped around the bedrail, with the call light device dangling just above the floor. When the SSA entered the room for observation, resident 26 called out for help. An interview with R26 during the observation revealed that R26 was calling out for help because R26 said he was thirsty, hungry, and wanted a snack. Observation of R67 on 02/12/2025 at 11:15 PM revealed that the call light device was attached and wrapped in the center privacy curtain that divides the room, out of reach of R67, while she was lying in her bed. Observation of R23 on 02/12/2025 at 11:20 PM revealed that R23 was lying awake in the bed while the call light device was under the bedside chair on the floor out of R23's reach. An interview with State Registered Nursing Assistant (SRNA) #14, on 02/12/2025 at 11:14 PM, revealed that the call light cord should be within reach of the residents and the call light not being accessible to the resident increases the risk of them getting hurt trying to take care of their needs alone. An interview with SRNA #12 on 02/12/2020 at 11:18 PM revealed that staff had moved the call light during R26's care and forgotten to place it back within the resident's reach. Further interviews revealed that SRNA # 12 stated that the residents use the call light system to communicate their needs to us. If the resident can't reach the call light, it increases the risk of them getting hurt trying to get things alone. An interview with the facility Educator on 02/11/25 at 2:50 PM revealed the call light issue has been an ongoing problem that the residents have been voicing for a while. A review of R26's Plan of care revealed that the resident has a history of falls, and having his call light in reach is listed as an intervention. A review of Resident Council minutes for the time range of 09/09/2024 through 02/04/2025 revealed the following: On 11/5/2024 at 2 PM, Residents were concerned about call lights, and the Social Worker informed them that audits and education were in place. On 01/07/25 at 2 PM, a Resident voiced that staff was not answering the call lights promptly. The social worker told the council the staff was being educated again on answering call lights promptly. On 02/04/2025 at 2 PM, Residents voiced they were still having issues with the night shift not answering call lights promptly. A review of the facility's Grievance / Concern Form revealed a grievance was filed on the following dates by residents or a family member for the time range of 09/01/2024 through 02/10/2025 concerning call bells not being answered timely:12/02/2024,12/27/2024,01/24/2025, and 02/04/2025 A review of a grievance form dated 12/02/2025 revealed that R61 had called her family and stated that she needed assistance to go to the bathroom. She had rung the call light for over an hour, but the staff had not responded. R61's family drove to the facility to inform staff that the resident required assistance. The resident was found soiled with feces, and the call light remained activated with no staff response. The resident did not receive staff assistance until prompted by the family member. Although the Administrator stated in an interview on 02/13/2025 at 3 PM that she was aware of the problem and educated staff regarding staff answering call lights promptly, the facility continued to receive resident complaints and grievances regarding staff's failure to answer call lights promptly on 1/07/25, 01/24/2025, and 02/04/2025.

F641 Based on observation, interview and record review, the facility failed to ensure that each resident recived an assessment that accurately reflected the resident's status. Record review revealed a diagnosis of paraphilia had been entered on Resident (R) 6's admission face sheet on 06/29/2024. Review of the hospital discharge History and Physical (H&P) and the facility's admission H&P did not listed paraphilia as a diagnosis for R6. The findings include: Review of facility's policy titled Comprehensive Care Plans Standard of Practice dated 10/2020 revealed the comprehensive care plan was based on a thorough asessment that includes, but was not limited to the Minimum Data Set (MDS). Added review revealed areas of concern triggered during the resident assessment were evaluated using specific assessment tools, including Care Area Assessments. Observation during initial tour of facility on 12/09/2024 at 11:50 AM revealed R6 was in bed. During an interview at this time, R6 was unable to carry on conversation with exception of answering yes and no questions. Observation on 12/10/2024 at 2:20 PM revealed R6 resting in bed. Observation on 12/19/2024 at 11:15 AM revealed R6 up in wheelchair in hallway. Review of a hospital History and Physical (H&P) for R6 dated 06/26/2024 revealed diagnoses which did not include paraphilia. Added review of the H&P revealed R6 was neurologically alert but disoriented, did not include any sexually inappropriate behavior and was electronically signed by the provider on 06/26/2024 at 1:00 PM. Review of e-mail documentation from the facility's Admission Coordinator (AC) dated 06/28/2024 at 10:05 AM, revealed correspondence stating that R6 was a very sweet guy, was confused, did not get up independently/wander, and family couldn't care for R6 at home. The documentation did not include any sexually inappropriate behavior for R6. Review of an attached document in the e-mail titled Hospital On-Site Information dated 06/28/2024, revealed under Behaviors/Combativeness Section Revealed R6 did not have any inappropriate behaviors of combativeness. Review of R6's face sheet revealed the facility admitted R6 on 06/29/2024 with diagnoses to include Alzheimer's disease, depression, paraphilia, and dementia. Review of R6's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 07/04/2024 revealed the resident had a Brief Interview for Mental Status (BIMS) score of six (6) out of fifteen (15) which indicated the resident was severely cognitively impaired. Review of the Quarterly MDS with an ARD of 11/01/2024 revealed R6 had a BIMS score of seven (7) out of fifteen indicating resident remained severely cognitively impaired. Review of R6's MDS Assessment Section E Behavior with ARD of 07/04/2024 and 11/01/2024, revealed inappropriate sexual behavioral symptoms were not exhibited by R6. Review of the Admission History and Physical Examination dated 07/01/2024 revealed the medical history for R6 did not include paraphilia and the document was electronically signed by the Primary Care Physician (PCP) on 07/14/2024 at 3:27 PM. During an interview with State Registered Nurse Aide (SRNA)4 on 12/10/2024 at 1:42 PM, he stated he had not seen or heard of any inappropriate behavior from R6. During an interview with SRNA12 on 12/12/2024 at 2:42 PM, SRNA12 stated she had seen R6 holding hands and touching shoulders of R2 but there was no other behaviors. When asked why she had made the sexually inappropriate entry to R6's chart, SRNA12 stated that was the only entry in the Kiosk that fit the behavior. During an interview with SRNA13 on 12/17/2024 at 3:06 PM, SRNA13 stated he had not observed any inappropriate sexual behavior or verbalization from R6. In an interview with SRNA15 on 12/18/2024 at 2:26 PM, SRNA15 stated she had seen R6 in the dining room a lot and had never witnessed any inappropriate behavior from R6 toward other residents. During interview with SRNA16 on 12/18/2024 at 10:20 AM, SRNA16 stated she had provided the 1:1 staff supervision all night with R6 on 10/20/2024 after the allegation of sexual abuse. When asked if R6 exhibited any inappropriate behavior or language, SRNA16 stated no, R6 actually slept most of the night. During an interview with SRNA7 on 12/11/2024 at 1:44 PM, SRNA7 stated she had not witnessed R6 having any inappropriate behavior. SRNA8 stated in interview on 12/11/2024 at 1:56 PM, he had not seen any inappropriate interactions between R6 and female residents. During an interview with Licensed Practical Nurse (LPN)4 on 12/17/2024 at 2:24 PM, LPN4 stated she had not seen R6 touching anyone inappropriately. During interview with the Unit Manager (UM) on 12/11/2024 at 1:02 PM, the UM stated R6 had not had any inappropriate behavior of touching other residents prior to 10/20/2024 when R6 had his hand between the legs of R3. During interview with the MDS nurse on 12/18/2024 at 9:40 AM she stated she shared the workload of the MDS Coordinator, and her tasks included entries in the MDS when residents were admitted to the facility. The MDS Nurse stated some of the information she viewed for MDS entries were diagnoses included in the discharge summaries. The MDS Nurse stated those diagnoses were then pulled over to the resident face sheets by the computerized system. When MDS nurse was asked where R6's diagnosis of paraphilia came from, she stated the diagnosis of paraphilia for R6 had been keyed in wrong when the admission information was entered. The MDS Nurse was unsure if the facility had a system in place to ensure that each resident's admission diagnoses were entered correctly. During an interview with the MDS Coordinator on 12/12/2024 at 12:38 PM, the MDS Coordinator stated he has held that position for almost one (1) year. When asked what tasks the MDS Coordinator was responsible for he stated the MDS Coordinator was responsible to enter the baseline care plans, reviews orders, and perform revisions of care plans. The MDS Coordinator was unsure how the entry for inappropriate sexual behaviors was placed on R6's careplan on 06/29/2024. The MDS Coordinator stated in interview at 10:24 AM on 12/18/2024, he thought the Unit Manager did a three (3) day look back to ensure resident diagnoses had been keyed in correctly and stated his concern would be if a wrong diagnosis was placed in the resident record, direct care would possibly be provided incorrectly. During interview with the Social Service Director (SSD) on 12/10/2024 at 3:05 PM, the SSD stated she had heard that R6 liked to pat residents but had not witnessed any behavior. During an interview with the facility Administrator on 12/19/2024 at 12:46 PM, the Administrator stated she was unsure if a wrong diagnosis entered could have an impact on care, treatment, or care planning of residents. The Administrator added she expected facility staff to assure tasks were performed correctly assuring quality of care of residents. During interview with the Director of Nursing (DON) on 12/12/2024 at 11:28 AM, the DON stated she had never seen R6 inappropriately touching other residents other than patting them on hands, arms, back, or shoulder. The DON stated in interview on 12/18/2024 at 4:08 PM that entering a wrong diagnosis for R6 or any resident would be concerning since treatment or changes in treatment could occur reflective of the diagnosis. In an interview with the Primary Care Provider (PCP) on 12/17/2024 at 12:31 PM, the PCP stated he was unaware of a diagnosis of paraphilia for R6 and was unsure where it came from, adding he didn't recall a history of paraphilia related to R6. During continued interview with the PCP on 12/19/2024 at 10:22 AM, the PCP stated if a misdiagnosis was made, his concern would be adding extra medications/polypharmacy and extra medications need to be limited. The PCP added the medications added to R6's regiment possibly reflective of paraphilia were pretty benign and no side effects had been reported to him, nor had he made any observations of R6 declining during visits. During an interview with R6's family member (FM) on 12/18/2024 at 10:51 AM, the FM stated R6 had never had any inappropriate flirtatious behavior of grabbing or feeling of women. The FM stated he visits with R6 three (3) to four (4) times monthly and has never seen any unusual behavior adding the facility takes real good care of R6. During interview with the Psychiatric Nurse Practitioner (NP) on 12/13/2024 at 1:02 PM, the NP stated she was seeing R6 after one of the nurses told her R6 had sexually inappropriate behaviors. The NP denied witnessing any sexually inappropriate behaviors from R6. The NP stated she had witnessed R6 holding hands with a female resident. The NP stated touching and patting other residents could be a sign of paraphilia, but she knew nothing about R6's prior history and was going by what facility staff had reported to her.

The facility failed to have a system in place to develop and implement a care plan with individualized person-centered interventions, to include adequate supervision and monitoring for one (1) of three (3) residents, Resident 6 (R6). R6 was observed by staff to display behaviors of touching and patting the hands, arms, shoulders, and backs of female residents shortly after admission to the facility on [DATE]. Review of the comprehensive care plan for R6 revealed this behavior had not been addressed in the care plan and there were no person-centered specific interventions in place regarding these behaviors. The findings include: Review of facility's policy titled Comprehensive Care Plan dated 10/2020 revealed the purpose of the policy was to have an individualized care plan that included measurable objectives and timetables to meet the resident's medical, nursing, mental, and psychosocial needs. The policy stated the Comprehensive Care Plan (CCP) was based on a thorough assessment that included, but was not limited to the Minimum Data Set (MDS), was designed to identify problem areas and incorporate risk factors associated with identified problems. The policy revealed assessments of residents were ongoing and care plans were required to be revised as the resident's condition changed, when a significant change occurred in the resident's medical condition or when an outcome was not met. Observation during the initial tour of the facility on 12/09/2024 at 11:50 AM revealed R6 was in bed. During an interview at this time, R6 was unable to carry on conversation with exception of answering yes and no questions. Observation on 12/10/2024 at 2:20 PM revealed R6 was resting in bed. Observation on 12/19/2024 at 11:15 AM revealed R6 was up in wheelchair in the hallway. Review of R6's face sheet revealed the facility admitted R6 on 06/29/2024 with diagnoses to include Alzheimer's disease, depression, paraphilia, and dementia. Review of R6's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/30/2024, revealed the resident had a Brief Interview for Mental Status (BIMS) score of seven (7) of fifteen (15), which indicated the resident was severely cognitively impaired. Review of R6's CCP included the resident desired affection from peers (i.e. sitting too close together, holding hands, touching or patting arms and hands) dated 08/16/2024 with an intervention to redirect R6 as needed; however, no review or outcome of the intervention was found. Review of the problem list in the CCP for R6 dated 08/19/2024 included the resident displayed sexually inappropriate behaviors with an intervention for staff to monitor and redirect the resident as needed; however, no review or outcome of the behaviors or interventions were found. Continued review of the CCP for R6 revealed on 10/20/2024, the problem list included inappropriate touching of female residents with interventions implemented to remove R6 from the area, provide 1:1 staff supervision for R6 with fifteen-minute checks of R6 initiated on 10/21/2024; however, no review or outcome of the intervention were found. In an interview with SRNA3 on 12/10/2024 at 2:33 PM, she stated R6 had behaviors of touching other residents on the arms/hands/shoulders about one (1) to two (2) months ago. During interview with the Social Service Director (SSD) on 12/10/2024 at 3:05 PM, the SSD stated she had heard that R6 liked to pat other residents but had not witnessed any behavior. During an interview with State Registered Nurse Aide (SRNA)2 on 12/10/2024 at 3:28 PM, SRNA2 stated R6 had behaviors of touching/patting other residents on the arms/hands/shoulders not long after R6 was admitted to facility. During interview with the Unit Manager (UM), on 12/11/2024 at 1:02 PM, the UM stated she had seen R6 rubbing other residents' arms at times. In an interview with Licensed Practical Nurse (LPN)2 on 12/11/2024 at 1:02 PM, LPN2 stated the purpose of resident care plans was so staff would be aware of the care to be provided to each resident and the interventions were guides for the care to be provided for each resident. SRNA7 stated in interview on 12/11/2024 at 1:44 PM that she had witnessed R2 kissing R's jaw on one occassion. SRNA8 stated in interview on 12/11/2024 at 1:56 PM, he had not seen any inappropriate sexual interactions between R6 and other female residents adding he at one time had seen R6 tapping R2's shoulder. During an interview with SRNA12 on 12/12/2024 at 2:42 PM, SRNA12 stated she had seen R6 holding hands and touching the shoulders of R2 but there was no other behaviors. When asked why she had made the sexually inappropriate entry in R6's medical record, SRNA12 stated that was the only entry in the Kiosk that fit the behavior. During interview with the Psych Nurse Practitioner (NP) on 12/13/2024 at 1:02 PM, the NP stated she had witnessed R6 holding hands with a female resident. During an interview with SRNA11 on 12/17/2024 at 3:38 PM, SRNA11 stated she had been advised about R6's touching other residents in verbal report and was just told to supervise R6. During an interview with Licensed Practical Nurse (LPN)4 on 12/17/2024 at 2:24 PM, LPN4 stated she had not seen R6 touching anyone inappropriately. LPN4 added she had seen R6 holding hands with R2 at times. LPN 4 stated new interventions should be added to CCP for any resident and reported to the next shift verbally. When asked if she added interventions to the CCP, she stated she does as needed. In an interview with SRNA15 on 12/18/2024 at 2:26 PM, SRNA15 stated R6 was in the dining room a lot, but she had never seen any inappropriate behavior from him toward other residents. During interview with the Director of Nursing (DON) on 12/12/2024 at 11:28 AM, the DON stated she had seen R6 patting other residents on the hands, arms, back, or shoulder at times. In additional interview with the DON on 12/18/2024 at 4:08 PM, the DON stated the importance of resident care plans was to assure all staff understood the care to be provided for each residents to include the nurse aides. The DON added assessments, reviews, and care planning were on-going for all residents. During an interview with the MDS Coordinator on 12/12/2024 at 12:38 PM, the MDS Coordinator stated he was unsure if the staff nurses placed interventions on care plans for problems identified with residents, adding he reviewed physician orders each day and placed interventions on the resident CCP. When asked how the nurse aides were made aware of the care needs for each resident, he stated they would look in the Kiosk. The MDS Coordinator added that care plans were in place to direct resident care and if the interventions in the Kiosk or CCP were incorrect, this would incorrectly guide the care of residents.

During initial facility observations, a dark discolored area was noted to be under the stairwell of the facility where the wall meets the floor on the ground floor in a non-resident area. During interviews and record reviews, there was no documentation that an outside certified entity or lab inspected the area for identification of the discoloration. The findings include: Review of the facility policy titled Resident Rights Standard of Practices dated 04/2024, revealed the facility was to ensure the right for residents to have a safe, clean, comfortable, and homelike environment. Review of the facility policy titled Water Intrusion and Mold Remediation Policy and Procedure, no date given, revealed the purpose of the policy was to identify and mitigate the growth of fungi including mold within all facilities. Added review of the policy revealed the definition of mold was a simple microscopic fungus found virtually everywhere including ceiling tiles, carpet, drywall, porous surfaces, and wood. Review of health effects listed in the facility policy stated health problems could occur when a simple microscopic fungus entered the air and was inhaled in large numbers. Continued review of the facility policy revealed identification of mold or moisture problems included the appearance of discoloration ranging from white to orange and from green to brown to black and should be reported to the Supervisor, the Administrator, and the Plant Operations Manager. During an initial facility tour observation on 12/10/2024 at 09:50 AM, with the Maintenance Director present, revealed a non-resident area under the stairwell on the ground floor to have a dark discoloration between the floor and the wall in a corner approximately one (1) inch tall. Additional observation revealed the Rehabilitation Unit to be located on first floor in the same area. During a brief interview at that time the Maintenance Director stated a sample of the substance had not been sent out for evaluation but added a friend had performed a moisture test of the area under the stairwell and there was no moisture noted. When asked what that meant, he stated if there was no moisture, then there was no mold. When asked for copies of an inspection, he stated there were none that he was aware of. Review of a facility document titled Facility Inspection 7-18-2024 revealed maintenance performed a walk through inspection and did not identify any findings regarding water intrusion at the facility. Review of the facility document, no title given, revealed the Regional Plant Operations (RPOD) Director had visited the facility on 07/18/2024 to investigate the discolored wall under the staircase. Added review revealed the RPOD performed a moisture reading on the wall and the reading was under four (4) percent (%). Continued review revealed no organic matter was found, scraping did not dislodge any material from the discolored area and recommendations were to prime and paint the wall. Review of the facility document titled Mold under stairs 7-18-2024 revealed the RPOD had been to the facility, performed a moisture test which read four (4) percent (%) and determined mold could not live without water. Added review of the document revealed the Maintenance Director (MD) and (RPOD) had determined the area was just a discolored wall. Added review revealed the whole wall was bleached and when dried a mold destroyer paint was applied. During interview with the Regional Plant Operation Director (RPOD) on 12/12/2024 at 9:54 AM, he stated facility maintenance contacted him in July of this year about the discoloration on the wall under the stairwell at the facility. He stated his conclusion after scrapings and a moisture reading of less than four (4) percent (%) revealed the area was not mold, only a dirty wall and concrete wearing through paint. When asked what he was expecting by performing scrapings of the area, he stated if it was an organic matter/mold there would be flakes falling onto the white piece of paper he had held under the area for samples adding there were none. He added in interview he recommended the whole wall under the stairwell be primed and painted. When asked if there had been any water intrusion at the facility, he stated none was reported to him. When asked about inspections for water related issues, he stated facility Maintenance performed regular inspections and the surveyor should ask him for reports. When asked if he had any concerns at the facility regarding mold, he stated he did not. In an additional interview, he stated he did not hold any formal certification for identifying mold or inspection. During an additional interview on 12/12/2024 at 2:03 PM, with the Maintenance Director, he stated his tasks included performing facility inspections every month to check the overall condition of the facility. He stated the last one was for the month of November and there were no concerns with the building. When asked if there was a form or any type of documentation of inspections, he said there were not adding he only documented any concerns he found. When asked again about the discolored area under stairwell, he stated he had received a few complaints in July about the area under the stairwell and had contacted the RPOD. He added per recommendations after inspection of the RPOD, he bleached the wall and applied a coat of water-based paint to the entire area. When asked why the area close to the floor was still discolored after painting, he stated he had avoided that area to prevent getting paint on the floor. He stated the RPOD was the only one who had performed an inspection of the area. During an interview with Housekeeping on 12/17/2024 at 9:02 AM, she stated there had been a report of a discolored area under the stairwell about four (4)-five (5) months ago and she had reported this to maintenance. She added housekeeping doesn't do anything with concerns of mold other than reporting to maintenance. During an interview with the Health Department Environmentalist on 12/17/2024 at 9:40 AM, he stated the first step for any concerns of mold would be to first identify it by an outside lab. When asked if a moisture test would indicate the presence of mold, he stated again, the only way to determine if mold was present was to have an outside lab company perform testing. When asked if bleaching and painting the area was sufficient if it was mold, he added that was not recommended. When asked if mold could grow on cement blocks, he stated it could. During an interview with the Director of Nursing (DON) on 12/18/2024 at 4:08 PM, she stated she had not received any reports of mold under the stairwell other than the concern that was reported in July of this year. She stated there had been no increase in any respiratory illnesses in staff or residents since July. During an interview with the Administrator on 12/19/2024 at 12:46 PM, she stated she had been the Administrator of the facility since March of 2023 and her tasks included oversight of the day-to-day operations of the facility in all departments including maintenance. She added her expectations of maintenance were to report any concerns regarding the building to her and she could not recall any concerns reported from maintenance regarding the discolored area. When asked if there had been an outside lab or entity contacted for identification of the discolored area under the stairwell, she stated she felt if this was a concern, maintenance would have addressed it.

Based on observation, interview and record review it was determined the facility failed to ensure the person centered care plan was reviewed/revised after falls occurred for one (1) of three (3) sampled residents (Resident #1). Review of Resident #1's record and staff interviews revealed the resident experienced six (6) falls in the facility from 10/08/2020 through 11/07/2020. Further record review and interviews with staff revealed the facility failed to review/revise Resident #1's care plan after falls occurred to ensure effective interventions were implemented to prevent further falls. Resident #1 sustained a laceration to the forehead/scalp during the fall on 10/27/2020 and this laceration was reopened four (4) more times during subsequent falls. Resident #1's emergency room (ER) record dated 11/07/2020, revealed the resident's previous laceration was an open wound area with no skin available for closure and would likely have to heal by secondary intent and will take months and if not longer if the resident continued to fall and the area becomes ripped and/or torn open. The residents ER record also indicated the area to his/her forehead now measures 3-1/2 centimeters (cm) X 3 centimeters in width and was 2 millimeters in depth, and the record also revealed the physician documented, the area is going to have a very poor cosmetic result. The findings include: Interview with the Director of Nursing (DON), on 11/19/2020 at 10:00 AM, revealed the facility had no policy related to care plan review/revision. However, the DON stated resident care plans should be reviewed/revised and new interventions added/implemented after resident falls occurred. The DON stated the facility followed the Resident Assessment Instrument (RAI) Manual related to resident care plan. Observation of Resident #1, on 11/17/2020 at 11:20 AM, revealed a dark red (scab like area) and faded brown bruising to the right side of the resident's forehead. The right side of Resident #1's face was swollen and bruised (green/brown in color) and faded bruising (blue/brown in color) was observed to the bridge of the resident's nose. The left side of the resident's face had faded blue/brown bruising. Observation of the resident's neck revealed scattered, dark red bruising under the resident's chin and to the left side of his/her neck. Review of Resident #1's medical record revealed the facility initially admitted him/her on 12/07/2012, and the residents' current diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #1's Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #1 required the assistance of one (1) staff member to walk in his/her room and to transfer. The assessment also indicated the resident's daily decision making skills were severely impaired, and his/her Brief Interview for Mental Status (BIMS) score was 99, which indicated Resident #1 was not interviewable. The MDS also indicated Resident #1 had sustained one (1) fall with injury (except major), during the assessment period. Review of Resident #1's Comprehensive Care Plan, last reviewed/revised on 11/07/2020, revealed staff identified on 02/04/2020, the resident was at risk for injury related to falls, secondary to diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Facility staff had set a goal for Resident #1 to not have a significant injury related to falls through the next review. Care plan interventions effective 02/04/2020 directed staff to: encourage the resident to wear grippy (non-skid) socks as he/she would allow; have grab bars to the resident's bed; ensure a safe environment free of clutter as much as possible; ensure placement of scoop mattress with perimeter opening; and, place a sign in Resident #1's room to encourage the resident to call for assistance as necessary. Review of Resident #1's Fall Management forms, revealed on 10/27/2020 at 8:00 AM, the resident was found lying on the floor, next to his/her bed with a face towel beside the resident. Blood was running down the right side of the resident's face and blood was also observed on the resident's right arm. The resident had a one and one-half (1-1/2) inch laceration to the right side of the head and a two (2) inch skin tear was observed to Resident #1's right forearm. Review of the form revealed the intervention implemented after this fall was for staff to ensure the resident was wearing non-skid foot wear (which was already in place). Record review provided no evidence Resident #1's care plan was reviewed and revised to include a new intervention after the fall occurred on 10/27/2020. Review of Resident #1's medical record indicated the resident was transferred and evaluated in the ER after the fall on 10/27/2020. Review of Resident #1's ER record dated 10/27/2020, revealed the resident had a contusion of the scalp and a skin tear to the resident's right elbow. The ER record indicated a surgical and a pressure dressing was applied to Resident #1's forehead wound and steri-strips and a bandage was applied to the skin tear on his/her right elbow. The record also indicated Resident #1 was transferred back to the Nursing Home, with no new orders on 10/27/2020. Review of Resident #1's nurse's notes, timed at 2:22 PM on 10/28/2020, revealed the resident sustained [MEDICAL RECORD OR PHYSICIAN ORDER] . Interview with the DON, on 11/19/2020 at 10:00 AM, revealed the IDT team had discussed Resident #1's fall which occurred on 10/27/2020. He stated the intervention implemented after this fall was for staff to ensure Resident #1 had on non-skid socks; however, the DON acknowledged this intervention had previously been implemented in attempts to prevent falls for the resident. He stated the IDT discussed resident's falls and interventions during the morning meetings conducted Monday-Friday, which included interventions that had already been implemented. The DON also stated he was not sure how the team missed identifying that this intervention had already been added to the residents care plan, and acknowledged Resident #1's care plan was not reviewed/revised to include new interventions after the fall occurred on 10/27/2020, but stated it should have been. Per the DON, the IDT was aware the resident was non-complaint with wearing the non-skid socks. Review of Resident #1's Fall Management forms, revealed at 4:43 AM on 10/28/2020 (less than 24 hours later), the resident was found lying on his/her bathroom floor in a supine position (on his/her back). The form indicated Resident #1's laceration, which had occurred during a previous fall, had opened to his/her right forehead. The form indicated bleeding was observed to his/her right forearm, and the resident was again transferred to the hospital for evaluation and treatment. The form indicated the root cause of Resident #1's fall, was that he/she was lying on the bathroom floor. Review of Resident #1's ER record, revealed on 10/28/2020 Resident #1 was evaluated for a head laceration and was diagnosed with an Acute UTI, and Laceration of forehead. The record also indicated Resident #1 was prescribed [MEDICATION(S)] (an antibiotic) for an abnormal urinalysis and was transferred back to the nursing home on 10/28/2020. Continued review of the Fall Management Form for 10/28/2020 and review of Resident #1's care plan revealed the facility revised the resident's plan of care to include a check for UTI (Urinary Tract Infection), even though the resident had already been diagnosed with a UTI at the hospital. There was no documented evidence the facility revised the resident's care plan with interventions to address the resident getting up unassisted in an effort to prevent further falls. Interview with the DON, on 11/19/2020 at 10:00 AM, confirmed the facility evaluated the resident for a possible urinary tract infection, but did not implement any interventions to prevent falls. Review of Resident #1's Fall Management forms, revealed on 10/31/2020 at approximately 8:30 AM, Resident #1 had an unwitnessed fall in his/her room. Resident #1 was observed sitting on the side of the bed and blood was observed on Resident #1's face/shirt, on the floor, and at the foot of his/her bed. The form indicated Resident #1 was transferred to a local hospital to be evaluated after the fall. Review of Resident #1's hospital record indicated on 10/31/2020, he/she was evaluated in the ER for a head laceration and a fall. Review of the ER documentation also revealed this is actually the fourth fall this month the patient has had and unfortunately the third fall within four days. The ER record stated the resident had a full healing stellate laceration to the right forehead with hematoma. The ER documentation also stated this is an old laceration from four days ago which has been opened up twice already. ER documentation revealed there was nothing suturable to this area. Resident #1's ER record also revealed the culture report had resulted and was reviewed related to his/her urine collected on 10/28/2020, and the previously ordered antibiotic was changed to [MEDICATION(S)] and the resident was again transferred back to the nursing home. According to the Fall Management Form, staff determined the root cause of Resident #1's fall was due to the resident not wearing non-skid socks. Again, the intervention was for staff to ensure the resident was wearing non-skid footwear, even though this intervention had not been effective in preventing falls. There was no evidence the facility reviewed/revised the resident's care plan with interventions to prevent further falls. Interview with the DON, on 11/19/2020 at 10:00 AM, revealed the IDT team discussed Resident #1's fall which occurred on 10/31/2020 and he was not sure if they identified the intervention implemented for this fall, was already in place or not and confirmed the care plan was not revised to prevent further falls. Review of Resident #1's Fall Management forms revealed, on 11/06/2020 at 11:00 PM, he/she was sitting on the floor, next to his/her bed and Resident #1 informed staff he/she was going to the bathroom. Further review of the form revealed Resident #1 had voided in the floor and had hit his/her head on the bedside table, where the resident was previously injured. The form stated the area was bleeding and new areas were observed to Resident #1's right eye and old bruising was observed to his/her face, head and eye on the right side and a skin tear was observed to Resident #1's right elbow. The resident complained to staff that his/her head hurts and the resident was transferred to a local hospital again, to be evaluated. Further review of Resident #1's hospital record dated 11/06/2020, revealed he/she was evaluated for frequent falls and Lacerations: Stitches. The ER record provided no description on what specific care was provided to Resident #1; however, documentation revealed Resident #1 needed an appointment to return for suture removal. Resident #1 was transferred back to the facility on [DATE]. Continued review of Resident #1's Fall Management Form dated 11/06/2020 revealed staff determined the root cause of the fall, was previous frequent falls. Further review of the form revealed no evidence that staff implemented any new interventions to prevent falls for Resident #1. Interview with the DON, on 11/19/2020 at 10:00 AM, revealed the IDT team discussed Resident #1's 11/06/2020 fall, and determined the root cause was the need for toileting. However, the facility failed to revise the resident's plan of care to include direction for staff to increase the resident's supervision to ensure the resident's safety while using the bedside commode. The DON stated the alarm had been implemented before, in attempts to prevent Resident #1 from falling and stated it was not effective. However, he stated the team felt Resident #1 had a change in condition related to being diagnosed with a urinary tract infection, and hoped the resident wouldn't notice the alarm and we thought it might work. Review of Resident #1's Fall Management forms revealed he/she had another fall on 11/07/2020 at 6:20 AM. The form indicated SRNAs heard an alarm going off and immediately went to the resident's room. However, the form stated the nurse was unable to hear the alarm sounding from the nurse's station. Resident #1 was observed sitting on his/her couch singing with a baby doll in his/her arms. The form also stated blood was visible to the right top of Resident #1's head, where the sutures from the previous fall were located. The form also stated Resident #1 told staff he/she tripped as he/she was going to feed the baby. Resident #1 was again transferred and evaluated at a local hospital. Documentation on the 11/07/2020 Fall Management form indicated Resident #1 was unsteady on his/her feet and the root cause of the fall was that staff could not hear the alarm sounding to possibly prevent him/her from falling when he/she got up unassisted. The intervention was to move Resident #1 closer to the nurse's station. However, the care plan did not provide direction to staff regarding supervision to prevent further falls. Interview with the Minimum Data Set (MDS) Coordinator on 11/19/2020 at 11:40 AM revealed she attended the IDT Monday-Friday meetings when falls were discussed in an attempt to identify trends and care plans were reviewed/revised. She also stated staff were required to revise resident care plans after falls occurred, to implementing a different intervention in attempts to prevent further falls. The MDS nurse stated she recalled discussing Resident #1's falls; however, stated she did not recall identifying any trends or reviewing/revising the resident care plan with the same interventions (non-skid socks) that were already in place for the resident. Interview with Licensed Practical Nurse (LPN) #1, on 11/17/2020 at 2:20 PM and with Registered Nurse (RN) #1 at 3:20 PM on 11/17/2020 revealed nurses were required to conduct root cause analysis and listing an intervention to the fall investigation in attempts to prevent further falls. However, the LPN and RN stated staff nurses were not responsible for reviewing/revising resident care plans with the newly implemented interventions. Continued interview with the DON, on 11/19/2020 at 10:00 AM, revealed nurses were required to conduct root cause analysis and implement new interventions when residents experienced falls. The DON also stated falls were reviewed during the Monday-Friday meetings and care plans were also reviewed and revised at that time. According to the DON, the IDT should look at previous interventions to ensure they were not already in place; and should determine if interventions were effective, before reviewing and revising care plans. The DON stated the facility had not identified that Resident #1's care plan had not been reviewed and revised after each fall, nor that non-skid socks had been the intervention to prevent falls on two (2) occasions, even though the interventions was already in place and not effective. Interview with the Administrator, on 11/19/2020 at 12:25 PM, revealed she expected that Resident #1's care plan should have been reviewed/revised and new interventions implemented every time the resident sustained [MEDICAL RECORD OR PHYSICIAN ORDER] Review of Resident #1's hospital record revealed on 11/07/2020 the resident was evaluated in the ER with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the ER record revealed a CT (Computed Tomography) scan of Resident #1's head was completed and review of the results indicated the resident had a large scalp hematoma. The ER record indicated Resident #1 continually injures the right side of his/her head, and he/she had an area that was chronically being reopened. The ER record stated the resident had an area that was closed as well as possible yesterday (11/06/2020) with 4-0 [MEDICATION(S)] to the fascia and then also had a skin repair with 4-0 nylon. The record also indicated on 11/07/2020, Resident #1 had completely opened the wound again and his/her right orbital and forehead area was swollen with a large hematoma however this is chronic and has been ongoing for a month. Hospital documentation also revealed the residents' previous laceration was now just an open wound area with no skin available for closure and would likely have to heal by secondary intent and will take months and if not longer if he/she continued to fall and the area becomes ripped and/or torn open. The ER record also indicated the area to Resident #1's forehead now measures 3-1/2 centimeters (cm) X 3 cm in width and was 2 millimeters in depth, and the area is going to have a very poor cosmetic result. ER documentation also stated the area was closed as best as possible with 3 Dermabond and then pressure dressing placed because the wound still continued to ooze slightly through the Dermabond itself. The record stated Resident #1 was transferred back to the nursing home on 11/07/2020.

Based on observation, interview, record review, and review of the facility's policy, it was determined the facility failed to ensure one (1) of three (3) sampled residents (Resident #1) received adequate supervision and assistive devices to prevent accidents. Interviews with staff and review of Resident #1's record revealed the resident experienced six (6) falls in the facility from 10/08/2020 through 11/07/2020 that occurred late night/early morning from 11:00 PM to 8:30 AM. The facility failed to educate nursing staff on root cause analysis in order to ensure effective interventions were developed and put in place to prevent further falls. Further, observation on 11/17/2020 revealed the facility failed to implement fall interventions (bed alarm and non-skid socks) for Resident #1. The observation also revealed Resident #1 had various stages of bruising to the resident's forehead, nose, face and neck. The resident sustained a one and one-half (1.5) inch laceration to the forehead/scalp on 10/27/2020 and sustained repeated injury to the same area of the forehead during four (4) subsequent falls. Review of the emergency room (ER) record dated 11/07/2020, revealed the resident's previous laceration was an open wound area with no skin available for closure and would likely have to heal by secondary intent and will take months and if not longer if he/she continued to fall and the area becomes ripped and/or torn open. The ER record also stated the area to Resident #1's forehead now measures 3-1/2 centimeters (cm) by 3 cm in width and was 2 cm in depth, and the area is going to have a very poor cosmetic result. The findings include: Review of the facility's, Accidents and Incident Policy, dated June, 2019, revealed the purpose of the facility processes was to ensure the facility environment was as free from accident hazards, over which the facility had control, and that each resident received adequate supervision and assistive devices to prevent avoidable accidents. The policy indicated incidents and accidents were investigated by the IDT (interdisciplinary team) and the team was required to identify hazards and risks, and implement interventions to reduce hazards and risks for facility residents. The IDT team was also required to monitor for implemented interventions effectiveness and modify those interventions when necessary. The policy also stated the IDT would review risks, appropriate interventions and trends at least weekly for residents with falls and other accident related injuries. The residents' care plan and nurse aide care card were also required to be updated as interventions were implemented. Interview with the Director of Nursing (DON), on 11/19/2020 at 10:00 AM, revealed when a fall occurred, the staff nurse determined the root cause, and put an intervention in place that the individual nurse believed would prevent further falls. The DON stated the IDT then reviewed the Fall Management Form during the next IDT meeting Monday through Friday, to ensure the fall was investigated and appropriate interventions were in place. He also stated during the IDT meetings, the team reviewed/revised resident care plans, to indicate the newly implemented interventions to prevent further falls for facility residents. Observation conducted on 11/17/2020 at approximately 11:20 AM, revealed Resident #1 was ambulatory without assistance in his/her room. Resident #1's call bell was observed on the floor, and he/she was wearing house shoes. Yellow non-skid socks were observed on the resident's bedside table. Continued observation of Resident #1, on 11/17/2020 at 11:20 AM, revealed a dark red (scab like area) and faded brown bruising was observed to the right side of the resident's forehead. The right side of the resident's face was swollen and bruised (green/brown in color) and faded bruising (blue/brown in color) was also observed to the bridge of Resident #1's nose. The left side of Resident #1's face also had faded bruising, blue/brown in color. The resident's neck region had scattered dark red bruising to the front (area under the residents chin) and to the left side of his/her neck. Further observations of Resident #1, on 11/17/2020 at 12:55 PM and 2:00 PM, revealed the resident was sitting up on the side of his/her bed, no pad alarm was observed on the residents bed, the resident's call bell remained on the floor, and the yellow non-skid socks remained on his/her bedside table. Review of Resident #1's medical record revealed the facility initially admitted the resident on 12/07/2012, and the resident's current diagnoses included Dementia with Behavioral Disturbances, [CONDITION(S)]-severe with psychotic features, Difficulty Walking and Muscle Weakness. Review of Resident #1's Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed the resident required the assistance of one (1) staff member to transfer and/or walk in his/her room. According to the MDS, Resident #1's daily decision making skills were severely impaired, and his/her Brief Interview for Mental Status (BIMS) score was 99 which indicated the resident was not interviewable. The MDS also indicated Resident #1 had one (1) fall with injury (except major), during the assessment period. Review of Resident #1's Comprehensive Care Plan, last reviewed/revised on 11/07/2020, revealed on 02/04/2020, staff identified the resident was at risk for injury related to falls, secondary to diagnoses which included Alzheimer's/Dementia, history of Falls, Shuffling Gait, Functional Decline and Generalized Weakness. Staff's goal for Resident #1 was that the resident have no significant injury related to falls through the next review. Further review of Resident #1's care plan revealed on 02/04/2020 staff implemented the following fall interventions which included: encourage him/her to wear grippy socks (non-skid socks) as the resident would allow, ensure a safe environment free of clutter as much as possible, grab bars to his/her bed, scoop mattress with perimeter opening and to place a sign in the resident's room to encourage him/her to call for assistance as necessary. On 05/13/2020, the facility revised the resident's care plan to include an intervention for a pressure alarm to the resident's bed per family demand, as the resident would allow. Review of Resident #1's Fall Management form dated 10/08/2020 at 1:30 AM, revealed Resident #1 had rolled out of bed, which resulted in an abrasion to the right side of his/her forehead and an abrasion to his/her right elbow. Continued review of the form indicated the root cause of the fall was the resident was too close to the side of the bed and the intervention implemented after the fall, was staff should reposition the resident as he/she would allow away from the edge of the bed. Resident #1 was transferred and evaluated in the local emergency room (ER) on 10/08/2020 and returned the same day, with no new orders. The fall management form did not address whether the pressure alarm was in place at the time of the fall and/or whether the alarm sounded, nor whether the resident was wearing non-skid socks. Interview with Registered Nurse (RN) #1, on 11/17/2020 at 3:20 PM, the nurse who completed the fall form above, revealed nurses were required to complete a root cause analysis when falls occurred in the facility, and implement a new intervention in an attempt to prevent further falls. However, the RN stated she had not been trained on conducting root cause analysis of falls, nor had the facility trained nurses to evaluate fall interventions for effectiveness. The RN stated she was familiar with Resident #1 and the resident frequently took his/her fall alarm apart, turned it off or hid it in his/her room. She also stated the resident refused to wear non-skid socks most of the time. Continued review of Resident #1's care plan revealed the resident's pressure alarm was discontinued on 10/20/2020. Interview with the DON on 11/19/2020 at 10:00 AM, revealed the alarm was discontinued because the resident constantly removed and hid the alarm and they believed the alarm agitated the resident. Review of Resident #1's Fall Management forms revealed on 10/27/2020 at 8:00 AM, Resident #1 was observed lying on the floor next to his/her bed with a face towel beside the resident. Continued review revealed blood was running down the right side of the resident's face and blood was also on the resident's right arm. The form revealed the resident had a one and one-half (1-1/2) inch laceration to the right side of the resident's head and a two (2) inch skin tear to the resident's right forearm. Continued review of Resident #1's medical record the resident was transferred to the local hospital after the fall on 10/27/2020 and was evaluated in the ER. Review of the resident's ER record dated 10/27/2020, revealed Resident #1 had a contusion of the scalp and a skin tear on his/her right elbow. The ER record also indicated a surgical and a pressure dressing was applied to the resident's forehead wound and steri-strips and a bandage was applied to the skin tear on the residents right elbow. Resident #1 was transferred back to the facility with no new orders. According to Resident #1's Nurse's Note, dated 10/28/2020 at 2:22 PM, the resident had a scalp laceration and had sutures placed in the ER, on 10/27/2020 as a result of the fall. Continued review of the 10/27/2020 Fall Management Form for Resident #1 revealed no indication the nurse who completed the form attempted to determine the root cause of this fall and the intervention implemented after the fall was to ensure Resident #1 was wearing non-skid foot wear. However, according to the resident's care plan, non-skid footwear had been in place since 02/04/2020 and was not effective in preventing falls. Interview with the Director of Nursing (DON), on 11/19/2020 at 10:00 AM, revealed the IDT team reviewed Resident #1's 10/27/2020, fall and determined the root cause of the fall was the resident's decreased safety awareness. He stated staff were to ensure the resident had on non-skid socks even though this intervention should have already been implemented for the resident. The DON stated a therapy screen was also requested for the resident; however, therapy was not initiated because Resident #1 had just been discontinued from therapy on 10/21/2020 due to his/her refusal to participate. Continued review of Resident #1's Fall Management forms indicated on 10/28/2020 at 4:43 AM (less than 24 hours later), the resident was found lying on his/her bathroom floor in a supine positron (on his/her back). The form indicated the resident's laceration to the right forehead from the previous fall had opened and bleeding was noted to the resident's right forearm. Resident #1 was again transferred to the hospital for evaluation and treatment. According to the form, the root cause of the resident's fall was that he/she was lying on his/her bathroom floor. There was no evidence an investigation of the fall was conducted to identify hazards and risks as required by the facility's policy. Review of Resident #1's ER record dated 10/28/2020, revealed the resident was evaluated for a head laceration and was diagnosed with an Acute UTI, and Laceration of forehead. The ER record revealed the resident was prescribed [MEDICATION(S)] (an antibiotic) for an abnormal urinalysis and was transferred back to the facility on [DATE]. According to the facility's Fall Management Form, even though Resident #1 was diagnosed with a UTI at the ER, the facility's intervention was to request a urine test to check for UTI (Urinary Tract Infection). Further review of Resident #1's care plan dated 02/04/2020 revealed the facility identified the resident had occasional urinary incontinence and required assistance with toileting. The facility developed an intervention to assist the resident with incontinence care/toileting as indicated. Interview with the DON, on 11/19/2020 at 10:00 AM, revealed the IDT team had discussed Resident #1's fall, which occurred on 10/28/2020, and the only intervention implemented was to evaluate the resident for a possible urinary tract infection. He also stated the team determined the root cause of this fall was toileting because the resident was found on the bathroom floor and felt the resident being diagnosed with a UTI was the causative factor. Subsequently, no other interventions were implemented to address the resident's toileting needs and no further actions were taken to prevent further falls for Resident #1. Resident #1's Fall Management forms revealed on 10/31/2020, at approximately 8:30 AM, the resident had an apparent unwitnessed fall in his/her room. The resident was observed sitting on the side of his/her bed with blood was on the resident's face and shirt, and areas of blood on the floor and at the foot of his/her bed. Resident #1 was transferred to a local hospital to be evaluated. Staff documented the root cause of the resident's fall was due to not wearing non-skid socks and the new intervention was for staff to ensure the resident was wearing non-skid footwear, even though this intervention was already in place and had not been effective in preventing previous falls. Review of Resident #1's hospital record revealed the resident was evaluated in theER on [DATE] for a fall and head laceration. ER documentation indicated this is actually the fourth fall this month the patient has had and unfortunately the third fall within four days. The record indicated the resident had a full healing stellate laceration (a tear in the skin due to [MEDICATION(S)] trauma) to the right forehead with hematoma. The ER documentation also revealed this is an old laceration from four days ago which has been opened up twice already. ER documentation also indicated there was nothing suturable to this area. Resident #1's ER record indicated the culture report had resulted and was reviewed related to his/her urine collected on 10/28/2020, and the previously ordered antibiotic was changed to [MEDICATION(S)] and the resident was transferred back to the facility. Continued review of the 10/31/2020 Fall Management form, revealed staff documented the root cause of the resident's fall was due to not wearing non-skid socks. Although the intervention had been in place since at least February 2020 and had not been effective in preventing previous falls, the new intervention was for staff to ensure the resident was wearing non-skid footwear. Continued interview with the DON, on 11/19/2020 at 10:00 AM, revealed the IDT team reviewed Resident #1's 10/31/200 fall, and determined the root cause of the fall was from not wearing non-skid socks. He stated he was not sure if they identified the intervention implemented for this fall, was already in place and had been ineffective. However, he stated there was no evidence that any new interventions had been implemented in attempts to prevent further falls for Resident #1 as a result of the 10/31/2020 fall. Review of Resident #1's Fall Management forms revealed on 11/06/2020 at 11:00 PM, Resident #1 was observed sitting on the floor, next to his/her bed. The resident informed staff he/she was going to the bathroom. Further review revealed the resident had voided in the floor and he/she had hit his/her head on the bedside table, where the resident was previously been injured. The area was bleeding and new areas were observed to his/her right eye and old bruising was observed to his/her face, head and eye on the right side, and a skin tear to the right elbow. Resident #1 informed staff his/her head hurts and the resident was transferred to a local hospital again, to be evaluated. The facility documented that the root cause of the fall was previous frequent falls, and there was no evidence the facility investigated the cause/root cause of the resident's fall as required by the facility policy. Review of Resident #1's hospital record dated 11/06/2020, revealed the resident was evaluated for frequent falls and Lacerations: Stitches. Review of the ER record provided no description on what specific care was provided to the resident; however, revealed the resident needed an appointment to return for suture removal. Resident #1 was transferred back to the facility on [DATE]. Continued review of Resident #1's care plan revealed on 11/05/2020, the facility revised the care plan with a new intervention for a bedside commode. However, there was no evidence the facility identified or addressed the resident's need for assistance with toileting and/or how a bedside commode would prevent further falls related to toileting needs. Interview with the DON, on 11/19/2020 at 10:00 AM, revealed the IDT team discussed Resident #1's fall which occurred on 11/06/2020. Per the DON, the team determined the root cause of the resident's fall was the need for toileting and a bedside commode was provided to the resident. The team also decided to add a pressure alarm back to the resident's bed. The DON stated he was aware the alarm had been implemented before, in attempts to prevent the resident from falling and was not effective. However, he stated the team felt the resident had a change in condition related to being diagnosed with a urinary tract infection, and hoped the resident wouldn't notice the alarm and we thought it might work. Further review of Resident #1's Fall Management forms revealed the resident had another fall the next day, 11/07/2020 at 6:20 AM. The form indicated SRNA's heard an alarm going off and immediately went to the residents' room. However, the form stated the nurse was unable to hear the alarm sounding from the nurse's station. Resident #1 was observed sitting on his/her couch singing with a baby doll in his/her arms. The form indicated blood was visible to the right top of his/her head, where the sutures from the previous fall were located. The form also stated the resident informed staff he/she tripped as he/she was going to feed the baby. Resident #1 was transferred and evaluated again at a local hospital. Documentation on the Fall Management form revealed the resident was unsteady on his/her feet and the root cause of the fall was determined to be that staff could not hear the alarm sounding to possibly prevent a fall when the resident got up unassisted. The facility developed an intervention to move the resident closer to the nurse's station. Interview with Licensed Practical Nurse (LPN) #1, on 11/17/2020 at 2:20 PM, the nurse who completed the fall form above, revealed nurses were required to complete a root cause analysis when falls occurred, and implement a new intervention in attempts to prevent further falls. However, LPN #1 stated she had not been trained on how to conduct root cause analysis of falls, and no training had been conducted related to interventions to prevent falls. Review of Resident #1's hospital record revealed the resident was evaluated in theER on [DATE] with diagnoses of Multiple Falls, Closed Head Injury and Facial Laceration. Review of the ER record revealed a CT (Computed Tomography) scan of Resident #1's head, was completed and the review of the results indicated the resident had a large scalp hematoma. The ER record indicated the resident continually injures the right side of his/her head, and the resident had an area that was chronically being reopened. The record indicated Resident #1 had an area that was closed as well as possible yesterday (11/06/2020) with 4-0 [MEDICATION(S)] to the fascia and then also had a skin repair with 4-0 nylon. The 11/07/2020 ER record indicated the resident had completely opened the wound again and his/her right orbital (eye area) and forehead area was swollen with a large hematoma however this is chronic and has been ongoing for a month. Hospital documentation further revealed the resident's previous laceration was now just an open wound area with no skin available for closure and would likely have to heal by secondary intent and will take months and if not longer if he/she continued to fall and the area becomes ripped and/or torn open. The ER record also stated the area to Resident #1's forehead now measures 3-1/2 centimeters (cm) by 3 cms in width and was 2 cm in depth, and the area is going to have a very poor cosmetic result. ER documentation also indicated the area was closed as best as possible with 3 Dermabond (skin glue) and then pressure dressing placed because the wound still continued to ooze slightly through the Dermabond itself. Resident #1 was transferred back to the facility on [DATE]. Interview with Licensed Practical Nurse (LPN) #1, on 11/17/2020 at 2:20 PM, revealed she was assigned to care for Resident #1 from 7AM-7PM on 11/17/2020. The LPN stated Resident #1's pad alarm was on his/her bed and functioned properly at approximately 10:00 AM on 11/17/2020. However, the LPN stated she had not checked the resident's alarm since 10:00 AM and was not aware there had not been one on the residents' bed since approximately 11:20 AM on 11/17/2020. LPN #1 stated nurses were required to ensure care plan interventions to prevent falls were in place once during the shift, and nurse aides should also be checking fall alarms for placement, and to ensure they were working properly during their rounds on the residents, every two (2) hours. The LPN had not identified that the residents call bell had been on the floor, and not in reach of the resident, since approximately 11:20 AM or that the resident had not had non-skid socks on as care planned to prevent further falls on 11/17/2020. LPN #1 stated Resident #1 had a shuffled gait and behaviors of removing his/her fall alarms, and refusing to wear non-skid socks since a while back. Interview with State Registered Nurse Aide (SRNA) #1, on 11/17/2020 at 2:10 PM, revealed she was assigned to care for Resident #1 during the day shift 7AM-3PM, on 11/17/2020. She stated the resident's call light should be in reach of the resident at all times, so if assistance was needed, the resident could alert staff. SRNA #1 stated staff had to keep a close eye on Resident #1 because he/she had experienced frequent falls and had behaviors of removing, taking apart, and/or hiding his/her fall alarm. The SRNA also stated fall alarms should be checked to ensure they were in place and working properly when two hour rounds were conducted; however, SRNA #1 stated she had not checked Resident #1's alarm to ensure it was in place and working properly at all during the day shift on 11/17/2020. Interview with SRNA #3, on 11/18/2020 at 12:20 PM, revealed she cared for Resident #1 frequently. The SRNA stated the resident turned his/her fall alarm off, removed his/her non-skid socks and would not use a bedside commode, as the resident preferred to ambulate to the bathroom. The SRNA also stated Resident #1 could not remember to use his/her call bell to ask for assistance; therefore, you have to check on the resident frequently because he/she was unpredictable. Interview with SRNA #2, on 11/18/2020 at 12:00 PM, revealed she also cared for Resident #1 frequently and stated the resident always hid the fall alarm, took it apart or turned it off. The SRNA also stated Resident #1 removed his/her non-skid socks, and the resident's gait was unsteady and it was not safe for him/her to ambulate without assistance. SRNA #2 stated to be safely cared for, Resident #1 needed one one one supervision. She stated, That's all that will help the resident because he/she was non-compliant with all interventions the facility had in place to prevent falls for the resident. Interview with RN #2, on 11/18/2020 at 1:00 PM, revealed she had cared for Resident #1 in the facility and the resident removed his/her non-skid socks frequently. According to the RN, if the resident sees you putting an alarm on the resident would get mad, aggravated at the alarms and would throw them at staff. The RN stated she did not think the alarms were an effective fall intervention for Resident #1 because they agitated the resident. RN #2 stated nurses were required to make rounds at least once a shift, to ensure fall interventions were in place in attempts to prevent falls in the facility. She also stated nurses were responsible to conduct root cause analysis of falls, and implement new interventions in attempts to prevent further falls for facility residents; however, she had not been trained on root cause analysis or on evaluating interventions for effectiveness and the the need for revisions to prevent falls. Contained interview with the DON, on 11/19/2020 at 10:00 AM, revealed he expected nurse aides to ensure fall interventions were in place every time they were in the resident's room. He also stated Resident #1's fall interventions that had been implemented in attempts to prevent further falls for the resident, should have been in place as required when observations were conducted by the surveyor on 11/17/2020. Further interview with the DON revealed he had not identified any trends with Resident #1's falls related to the time of day the falls occurred, nor had the facility identified that the same fall interventions were being implemented even though they were not effective at preventing falls. The DON stated he had identified that IDT was not always agreeable with the staff nurses' root cause analysis; however, no actions had been taken to ensure appropriate root cause analysis was conducted to identify hazards and risks, and implement interventions to reduce those hazards and risks as required by facility policy. Interview with the Administrator, on 11/19/2020 at 12:25 PM, revealed she attended IDT meetings where falls were discussed most of the time. She stated no concerns had been identified with Resident #1's falls, which included interventions or trends before the state agency investigation initiated on 11/17/2020. She also stated she expected staff to implement new interventions when each fall occurred, in attempts to keep residents safe and potentially prevent further falls in the facility and expected staff to ensure interventions were implemented.

Based on observation, interview and record review, it was determined the facility failed to implement a comprehensive person-centered care plan for one (1) of three (3) sampled residents (Resident #1). The facility assessed Resident #1 to be at risk for falls and developed care plan interventions to prevent falls that included a bed alarm and non-skid socks. However, observations of Resident #1 on 11/17/2020 revealed the facility failed to implement the fall care plan interventions for Resident #1. Further record review revealed the resident experienced falls on 10/08/2020, 10/27/2020, 10/28/2020, 10/31/2020, 11/06/2020, and 11/07/2020; in which the resident sustained [MEDICAL RECORD OR PHYSICIAN ORDER] . The findings include: Interview with the Director of Nursing (DON), on 11/19/2020 at 10:00 AM, revealed the facility had no policy related to care plan implementation. However, the DON stated staff were expected to implement resident care plans as outlined. The DON stated the facility followed the Resident Assessment Instrument (RAI) Manual related to resident care plan. Review of Resident #1's medical record revealed the facility initially admitted the resident on 12/07/2012, and his/her current diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #1's Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed he/she required the assistance of one (1) staff member to walk in his/her room and to transfer. The MDS also indicated Resident #1's daily decision making skills were severely impaired, and the residents Brief Interview for Mental Status (BIMS) score was 99 which indicated Resident #1 was not interviewable. Resident #1's MDS also indicated he/she had one (1) fall with injury (except major), during the assessment period. Review of the Resident #1's Fall Management forms revealed the resident experienced falls on 10/08/2020, 10/27/2020, 10/28/2020, 10/31/2020, 11/06/2020, and 11/07/2020. Further review revealed the resident sustained [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #1's Comprehensive Care Plan, last reviewed/revised on 11/07/2020, revealed staff identified on 02/04/2020, that Resident #1 was at risk for injury related to falls, secondary to diagnoses, which included a history of falls, Generalized Weakness, Alzheimer's/Dementia, Shuffling Gait and Functional Decline. The facility's goal was for Resident #1 to have no significant injury related to falls through the next review. According to the care plan, on 02/04/2020, staff implemented an intervention to encourage the resident to wear grippy (non-skid) socks as he/she will allow, and revised on 10/31/2020 for the resident to have non-skid footwear at all times as the resident would allow. Further review revealed the facility revised Resident #1's care plan again on 11/06/2020 with an intervention for a pressure alarm to the bed and chair. Review of the Nurse Aide Resident Care Profile Card dated 11/09/2020 revealed Resident #1 required a pressure alarm to his/her chair and bed. Review of Resident #1's Treatment Administration Record (TAR) dated November 2020, revealed nursing staff was required to monitor to ensure the resident's bed/chair alarm was present and functioning once per shift (7AM-7PM and 7PM-7AM). According to the documention, LPN #1 had not documented that Resident #1's alarm was present and functioning on 11/17/2020 for the 7AM-7PM shift. Observation of Resident #1, on 11/17/2020 at 11:20 AM, revealed the resident was ambulating without assistance in his/her room, and no alarm was sounding to alert staff that he/she was ambulating without assistance. The residents call bell was on the floor, and Resident #1 was wearing house shoes. Yellow non-skid socks were observed on his/her bedside table. Continued observations on 11/17/2020 at 12:55 PM and 2:00 PM revealed Resident #1 was sitting up on the side of the bed and no pad alarm was observed on the resident's bed as care planned. Resident #1's call bell remained on the floor and his/her yellow non-skid socks were still on the bedside table. Interview with Licensed Practical Nurse (LPN) #1, on 11/17/2020 at 2:20 PM, revealed she was assigned to care for Resident #1 from 7AM-7PM on 11/17/2020. LPN #1 revealed she checked Resident #1's pad alarm placement and function at approximately 10:00 AM on 11/17/2020, but had not documented the check on the Resident's treatment record. The LPN stated she had not checked Resident #1's alarm since 10:00 AM and was not aware it had not been one on his/her bed since approximately 11:20 AM on 11/17/2020, as outlined in his/her plan of care. The LPN stated nurses were responsible to ensure care plan interventions to prevent falls were in place once during the shift, and it was the nurse aides responsibility to ensure the fall alarms were in place and functioned properly, during their rounds every two (2) hours. LPN #1 stated she had not identified that Resident #1's call bell had been in the floor, and not in reach of the resident, since approximately 11:20 AM or that Resident #1 had not had non-skid socks on as care planned to prevent further falls on 11/17/2020. According to LPN #1, Resident #1 had a shuffled gait and behaviors of removing his/her fall alarms, and refusing to wear non-skid socks since a while back. The LPN stated Resident #1's care plan interventions should have been implemented as required on 11/17/2020. According to the LPN, if the care plan interventions were not implemented, the resident could sustain further falls. Interview with State Registered Nurse Aide (SRNA) #1, at 2:10 PM on 11/17/2020 revealed she was assigned to care for Resident #1 during the day shift 7AM-3PM, on 11/17/2020. SRNA #1 stated the resident's call light should be in reach of the resident at all times, so the resident could alert staff, if assistance was needed. SRNA #1 stated staff had to keep a close eye on Resident #1 because the resident had frequent falls and took apart, removed and/or hid his/her fall alarm. SRNA #1 stated fall alarms should be checked to ensure they were in place and working properly when every two hour rounds were made; however, the SRNA stated she had not checked Resident #1's alarm to ensure it was in place and working properly, at all during the day shift on 11/17/2020. The SRNA stated if care plan interventions were not implemented, the resident could fall again. Continued interview with the DON, on 11/19/2020 at 10:00 AM, revealed nurses were required to ensure fall interventions were in place in an attempt to prevent falls and keep residents safe, at least once a shift. The DON stated nurse aides should ensure fall interventions were in place every time they were in the resident's room. He stated Resident #1's fall interventions should have been in place as required when observations were conducted by the surveyor on 11/17/2020. The DON stated staff nurses and administrative nurses, which included himself, were required to make rounds during the day to ensure care plans had been implemented for facility residents and he had not identified any concerns with care plan implementation. Interview with the Administrator, on 11/19/2020 at 12:25 PM, revealed no concerns had been identified with Resident #1's care plan interventions, or implementation of those interventions before prior to 11/17/2020. The Administrator indicated she expected staff to ensure interventions were implemented, in attempts to prevent accident hazards in the facility. She stated she made routine rounds daily in the facility, however was not observing for care plan implementation when her rounds were conducted.

Based on observation, interview, record review, and facility policy review it was determined the facility failed to ensure one (1) of twenty-one (21) sampled residents was provided appropriate care and services related to a dressing change for a Peripherally Inserted Central Catheter (PICC). A PICC is a catheter that enters the body through the skin (percutaneously) at a peripheral (situated away from the center) site, extends to the superior vena cava (a central venous trunk), and stays in place (dwells within the veins) for days or weeks. The findings include: Review of the facility policy titled, PICC Line Care, dated 06/25/2020, revealed, Dressing change: should be done every 7 days and PRN using clear occlusive dressing. Further review of the policy revealed, Apply new securement device and new dressing. Furthermore, Scrub the hub for 15 seconds, let dry completely, and replace with new cap. Review of the facility in-service titled PICC Line Care, dated 06/25/2020, revealed that Registered Nurse (RN) #1 had signed review of the policy. Review of the package, Central Line Dressing Change, from Medline Industries, expiration date 02/28/2022, revealed the kit did not contain a securement device or a needleless endcap. Record review revealed the facility admitted Resident #63 on 04/15/2019 with [DIAGNOSES REDACTED]. Review of Resident #63's Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) score of 12 indicating moderate cognitive impairment. Review of Resident #63's Physician orders revealed an order for [REDACTED]. Review of Resident #63's Care plan, dated 09/11/2020, revealed under the problem of risk of infection that the resident had an intervention for PICC line placed, care as ordered/indicated. Observation on 10/07/2020 at 1:29 PM revealed Registered Nurse (RN) #1 retrieved the Central Line Dressing Change kit and proceeded to change the dressing. However, RN #1 did not change the stabilization device or the needleless endcap. Interview with RN #1 on 10/08/2020 at 10:07 AM revealed the RN did not change the stabilization device or the needleless endcap. The RN stated she got confused because the Central Line Dressing Change kit was different and did not contain the stabilization device or the needleless endcap. Interview on 10/08/2020 at 11:05 AM with the Central Supply staff revealed she was in charge of ordering the dressing change kit. However, she stated she had found the packet online and showed the picture to RN #1 who said that was the right kit. Interview on 10/08/2020 at 3:58 PM with the Director of Nursing (DON) revealed the Central Line Dressing Change kit did not contain the stabilization device or the needleless endcap. He further stated that the central supply person was new to the job. When the supply clerk was told to order the dressing change kit, the clerk had pulled a kit up online and showed it to a nurse who had verified that it was the correct kit. The DON stated they went to the hospital to get stabilization devices and endcaps to use until the right kits were delivered. He further stated there was only one (1) PICC line in the facility at this time. The DON acknowledged that there would be a concern with the PICC line moving and the line becoming infected without changing the stabilization device or the needleless endcap.

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 01/21/2020, the facility discharged Resident #1 while the resident was hospitalized but failed to provide the resident and the resident's Power of Attorney (POA) with a written discharge notice. The findings include: Review of the facility's policy, Transfer or Discharge Documentation Standard of Practice, dated October 2017, revealed when a resident is transferred or discharged from the facility an appropriate notice will be provided to the resident and/or legal representative. Review of Resident #1's medical record revealed the resident was readmitted to the facility on [DATE]. On 0[DATE]20, the facility documented that Resident #1 had displayed aggressive behaviors, and the facility arranged for the resident to be transferred to a psychiatric hospital for evaluation/treatment on 0[DATE]20. Review of a Bed Hold Notification dated 01/13/2020 revealed the family requested the facility to place a bed hold for Resident #1 to be able to return to the facility upon discharge from the hospital. Interview with the Power of Attorney (POA) for Resident #1 on 0[DATE]20 at 1:10 PM revealed approximately three (3) weeks ago in January 2020 he was notified by the hospital that the facility refused to allow Resident #1 to return to the facility and the facility had already given Resident #1's room to another resident. Interview with the Ombudsman for the facility on 02/20/2020 at 8:15 AM revealed she had not been notified of Resident #1's discharge by the facility. Interview with the Administrator on 0[DATE]20 at 4:45 PM revealed the facility had sent a previous discharge notice to Resident #1's POA in November 2019; however, the facility had rescinded the discharge notice in December 2019. She revealed that the reason she had not sent another discharge notice was because it was just a piece of paper and Resident #1's physician had refused to treat the resident, and the facility was unable to readmit the resident due to having no treating physician.

Based on interview, record review, and facility's policy review, the facility failed to ensure one (1) of three (3) sampled residents (Resident #1) was permitted to return to the facility after a hospital stay. The findings include: Review of the facility policies, Transfer or Discharge Documentation Standard of Practice, dated October 2017, and Bed Hold Notice Prior to Transfer, dated November 2016, revealed the policies did not address permitting residents to return to the facility when the resident was ready to be discharged from the hospital. The Bed Hold Notice Prior to Transfer policy did state, The facility Standard of Practice regarding bed hold periods to include permitting residents to return. Review of Resident #1's medical record revealed the facility readmitted the resident on 11/15/2019 with [DIAGNOSES REDACTED]. Review of a Nurse's Note dated 0[DATE]20 (time was not specified) revealed Resident #1 was transferred to the hospital for a behavioral stay. Further review of the resident's record revealed no evidence of a discharge notice being sent to the resident or to the resident's representative. Interview with the Power of Attorney (POA) for Resident #1 on 0[DATE]20 at 1:10 PM revealed approximately three (3) weeks ago in January 2020 he was notified by the hospital that the facility refused to allow Resident #1 to return to the facility and the facility had already given Resident #1's room to another resident. Interview with the Ombudsman for the facility on 02/20/2020 at 8:15 AM revealed she had spoken to the Administrator on 0[DATE]20 concerning the behavioral incident Resident #1 had on 0[DATE]20. She revealed the facility had issued a Discharge Notice to Resident #1's Power of Attorney (POA) in November of 2019; however, the facility rescinded the Discharge Notice and allowed the resident to stay at the facility. The Ombudsman further revealed she had not been notified of Resident #1's discharge in January 2020 by the facility. Interview with the Administrator on 0[DATE]20 at 4:45 PM revealed they had initially informed the hospital that the facility would allow Resident #1 to return to the facility after the resident's hospital stay. She revealed Resident #1's physician refused to accept/treat the resident if the resident returned to the facility. The Administrator stated the facility only has two (2) physicians and the other physician also refused to accept/treat Resident #1. The Administrator stated the facility has no other place to send (Resident #1) and (he/she) was at the hospital and that's where we left (him/her). The Administrator revealed that when Resident #1 was being discharged from the hospital, the facility did have resident beds available. Interview with Resident #1's Primary Care Physician (PCP) on 0[DATE]20 at 1:47 PM revealed Resident #1 was combative and harmful to himself/herself and to others. The physician stated, I have tried numerous times to talk to the resident's family about having Resident #1 transferred to a geriatric psychiatric unit; however, the family has always refused. Resident #1's PCP revealed she did not refuse to provide care for the resident when he/she was a resident at the facility but after the resident went to the hospital, she did refuse to provide services for Resident #1 if the resident returned to the facility.

Based on observation, interview, record review, review of the facility investigation, and review of the facility policy it was determined the facility failed to ensure residents were free from misappropriation of narcotic pain medications for two (2) of three (3) sampled residents (Resident #1 and Resident #2). Record review and interviews revealed staff failed to conduct a narcotic count on 12/14/2019 during the 7:00 PM shift change as required per the facility policy. When the narcotic count was conducted on 12/15/2019 at 7:00 AM staff identified that one (1) [MEDICATION NAME] tablet (narcotic pain medication) was missing for Resident #1. Further, on 12/20/2019 staff identified that two (2) [MEDICATION NAME] tablets (narcotic pain medication) were also missing for Resident #2. According to the facility investigation, staff were unable to locate the residents' missing narcotic pain medications. The findings include: Interview with the Administrator on 01/17/2020 at 4:00 PM revealed the facility had no policy related to misappropriation of resident property. However, she stated residents should remain free from misappropriation of their personal property, which included medications, in the facility. Review of the facility policy titled Medication Administration Controlled Substances, dated May 2016, revealed at each shift change a physical inventory of controlled medications should be conducted by two (2) licensed clinicians and documented on the audit record. The policy also stated any discrepancy in the controlled substance medication count should be reported to the Director of Nursing (DON) immediately and thoroughly investigated. If the DON was not able to find the missing medications throughout the investigation, any missing medications would be replaced for the resident. Review of Resident #1's record revealed the facility admitted the resident on 05/02/2019 with [DIAGNOSES REDACTED]. Resident #1's quarterly Minimum Data Set Assessment ((MDS) dated [DATE] revealed the resident's cognitive skills for daily decision-making were severely impaired and he/she had no Brief Interview for Mental Status (BIMS) score recorded on the assessment, which indicated the resident was not interviewable. The MDS also indicated Resident #1 required extensive assistance of two (2) staff members for bed mobility and toileting. Review of the MDS also revealed Resident #1 was on a scheduled pain medication and had not exhibited any signs of pain during the assessment period. Continued review of Resident #1's record revealed the resident had a physician order for [REDACTED].#1's record also revealed he/she was transferred to the hospital and later admitted related to a change in condition on 12/14/2019. Review of the facility investigation revealed Registered Nurse (RN) #1 and Licensed Practical Nurse (LPN) #1 failed to conduct a narcotic count at 7:00 PM at shift change on 12/14/2019 as required. The investigation also revealed both nurses were terminated from the facility on 12/18/2019. Further review of the investigation revealed RN #1 was responsible for Resident #1's narcotics during the 7AM-7PM shift on 12/14/2019. An interview was attempted with RN #1 during the investigation on 01/17/2020; however, attempts to reach RN #1 were unsuccessful. An interview was also attempted with LPN #1 during the investigation on 01/17/2020 and attempts to contact the LPN were unsuccessful. However, LPN #1 had provided a written statement that indicated she had failed to conduct the shift change narcotic count with RN #1 as required at 7:00 PM on 12/14/2019. Continue review of the investigation and Resident #1's narcotic sheet revealed one (1) [MEDICATION NAME]/[MEDICATION NAME] ([MEDICATION NAME]) 10-325 mg tablet was discovered missing during the 7:00 AM narcotic count on 12/15/2019. 2. Review of Resident #2's record revealed he/she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #1's significant change MDS dated [DATE] revealed the resident's BIMS score was seven (7) which indicated he/she was cognitively impaired. The MDS also revealed he/she required extensive assistance of two (2) staff members for bed mobility and transfers. Resident #2's MDS also revealed he/she had not exhibited any signs of pain during the assessment period. Further review of Resident #2's record revealed the resident had physician orders for staff to administer [MEDICATION NAME]/[MEDICATION NAME] ([MEDICATION NAME]) 5-325 mg by mouth twice daily in November 2019. Further review of the record revealed Resident #2 experienced a change in condition and was transferred to the hospital and was later admitted on [DATE]. Resident #2's record also indicated the resident did not return from the hospital until 11/29/2019. Review of the investigation and Resident #2's narcotic sheet revealed two (2) [MEDICATION NAME]/[MEDICATION NAME] ([MEDICATION NAME]) 5-325 mg tablets had been signed out for the resident on 11/28/2019 (while the resident was at the hospital). Continued review of the investigation revealed one (1) signature was not legible and the facility was unable to determine who signed the narcotic sheet. The other signature was completed by RN #3 and RN #3 informed the Administrator that she did not recall signing out the medication for Resident #2. An interview was attempted with RN #3 during the investigation; however, attempts to reach the RN were unsuccessful. Interview with Resident #2 on 01/17/2020 at 3:00 PM revealed the resident voiced no concerns related to pain or narcotic pain medication administration in the facility. Interview with the Administrator on 01/07/2020 at 4:00 PM revealed she was notified that Resident #1 was missing a [MEDICATION NAME] after the narcotic count was conducted on 12/15/2019 at 7:00 AM. She stated RN #1 was not in the facility when the discrepancy was identified on 12/15/2019; however, LPN #1 remained in the facility after the discrepancy was identified, and the LPN acknowledged she had failed to conduct the narcotic count with RN #1 at the 7:00 PM shift change on 12/14/2019 as required. The Administrator stated that due to the identified concerns with narcotics in the facility, audits were being conducted daily and on 12/20/2019 staff identified that narcotic medications had been signed out for Resident #2 while he/she was out of the facility. Per the Administrator, one (1) signature dated 11/28/2019 belonged to RN #3; however, the RN informed the Administrator that she did not recall removing the narcotic for Resident #2 while he/she was out to the hospital. The Administrator also stated there was another signature, which indicated another [MEDICATION NAME] tablet was also removed for the resident on 11/28/2019; however, she was unable to determine who signed the narcotic record. The Administrator stated she was unable to determine what happened to the narcotic medications that belonged to Resident #1 or Resident #2.

Based on interview and record review it was determined the facility failed to develop written policies and procedures related to the prevention and investigation of allegations of misappropriation of resident property in the facility. Interviews and record reviews conducted on 01/17/2020 revealed staff identified that narcotic medications that belonged to Resident #1 and Resident #2 were missing. Even though an investigation was conducted, staff were unable to determine what happened to the resident's narcotic pain medication. Refer to F600. The findings include: Interview with the Administrator on 01/17/2020 at 4:00 PM revealed the facility had not developed policies and/or procedures related to the prevention and investigation of allegations of misappropriation of resident property. Review of the facility's investigation and Resident #1's narcotic sheet revealed one (1) [MEDICATION NAME]/[MEDICATION NAME] ([MEDICATION NAME]) 10-325 mg tablet was discovered missing during the 7:00 AM narcotic count on 12/15/2019. Further review of the facility investigation revealed Registered Nurse (RN) #1 and Licensed Practical Nurse (LPN) #1 failed to conduct a narcotic count at 7:00 PM at shift change on 12/14/2019 as required. The investigation also revealed both nurses were terminated from the facility on 12/18/2019. Review of the facility investigation and Resident #2's narcotic sheet revealed two (2) [MEDICATION NAME]/[MEDICATION NAME] ([MEDICATION NAME]) 5-325 mg tablets had been signed out for the resident on 11/28/2019 (while the resident was at the hospital). Continued review of the investigation revealed one (1) signature was not legible and the facility was unable to determine who signed the narcotic sheet. The other signature was completed by RN #3 and RN #3 informed the Administrator that she did not recall signing out the medication for Resident #2. The facility was unable to determine how Resident #1 and Resident #2's medication was misappropriated. Interview with the Administrator on 01/17/2020 at 4:00 PM revealed she reviewed the regulatory requirements when concerns were identified related to misappropriation of resident property in the facility. She also stated she was unable to determine what happened to Resident #1 and Resident #2's narcotic medications. The Administrator also stated residents should remain free from misappropriation of their personal property, which included medications, in the facility.

Based on interview, record review, and policy review, it was determined the facility failed to ensure that residents diagnosed with [REDACTED].#1). Review of the facility investigations revealed Resident #1 had wandered into other resident rooms and had exhibited aggressive behaviors and, as a result, had been involved in three (3) resident-to-resident abuse allegations since October 2019. Review of the resident's care plan and interviews with staff revealed the facility had failed to implement interventions in attempts to divert the resident's ongoing behavioral symptoms in the facility. The findings include: Review of the facility policy titled Dementia-Clinical Protocol, last revised in October 2010, revealed the policy did not address management or intervention options related to residents with Dementia that exhibit behaviors in the facility. Interview with the Administrator on 11/07/19 at 11:20 AM revealed the facility policy related to residents with dementia was vague and provided no direction on how to care for residents diagnosed with [REDACTED]. Review of Resident #1's record revealed the resident was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the most recent Minimum Data Set Assessment ((MDS) dated [DATE] revealed Resident #1 had exhibited physical and verbal behavioral symptoms directed toward others, as well as wandering behaviors, one (1) to three (3) days during the assessment period. Staff assessed the resident to be severely cognitively impaired and was unable to complete a Brief Interview for Mental Status (BI[CONDITION]) during the assessment period, which indicated the resident was not interviewable. Review of Resident #1's comprehensive care plan last reviewed/revised on 10/15/19 revealed staff identified that the resident wandered into other residents' rooms and rummaged through other residents' personal belongings. Continued review of the care plan revealed staff also identified that Resident #1 was verbally and physically hostile toward staff and other residents. Further review of Resident #1's care plan revealed staff were to offer a rummage tray, a baby doll, and a radio to the resident to divert his/her behaviors when they occurred. The care plan also indicated staff were to encourage group activities as well as brief walks in the facility courtyard, in attempts to divert the resident's behaviors. Review of the facility investigations revealed on 10/14/19 Resident #1 wandered into another resident's room and had the other resident's eye glasses in his/her hand; when the other resident attempted to retrieve his/her personal belongings, Resident #1 slapped the other resident on the mouth. Both residents were assessed to have no injuries after the altercation occurred. Resident #1 was provided with an increased level of supervision for approximately forty-eight (48) hours following the incident. Further review of the investigations revealed on [DATE] Resident #1 wandered into another resident's room and attempted to take a blanket; and when the other resident attempted to retrieve the blanket from Resident #1, he/she slapped the other resident on the shoulder. Both residents were assessed to have no injuries after the altercation occurred. Resident #1 was provided with an increased level of supervision until he/she was later transferred for an inpatient psychiatric stay on 10/21/19. Review of Resident #1's medical record revealed he/she returned from the psychiatric stay and was readmitted to the facility on [DATE]. Continued review of the resident's record provided no evidence that any new interventions were implemented when he/she was readmitted to the facility. Further review of the investigations revealed on 10/30/19 (approximately 24 hours after readmission) Resident #1 was observed to be verbally hostile toward his/her roommate and was observed to place a pillow over his/her roommate's head. Both residents were assessed to have no injuries after the incident occurred. Resident #1 was provided with an increased level of supervision and was again transferred for an inpatient psychiatric stay. Resident #1 was out of the facility during the investigation in an inpatient psychiatric unit, and was unable to be interviewed or observed. Interview with State Registered Nurse Aide (SRNA) #1 on 11/06/19 at 10:30 AM revealed Resident #1 frequently wandered into other residents' rooms and rummaged through their personal belongings, and staff are unable to keep up with his/her whereabouts in the facility. The SRNA also stated the resident was verbally and physically aggressive toward staff and was difficult to redirect at times, when behaviors were identified. However, SRNA #1 stated she had never seen or been trained to utilize a rummage tray, baby doll, or radio in attempts to redirect the resident from wandering into other residents' personal space. SRNA #1 also stated she had never been directed to take Resident #1 to the courtyard for walks, as outlined in the resident's plan of care. The SRNA stated behaviors are reported to the nurse. Interview with SRNA #2 on 11/06/19 at 1:30 PM revealed Resident #1 is constantly going in and out of other residents' rooms. The SRNA stated behaviors were reported to the nurses, and the SRNA stated they just tell us to redirect him/her. SRNA #2 also stated Resident #1 was difficult to redirect and would hit and curse staff at times when staff attempted to redirect the resident when behaviors occurred. SRNA #2 stated she had never observed or been trained to utilize a rummage tray, radio, or baby doll in attempts to redirect the resident from wandering into other residents' personal space. The SRNA also stated she had not been trained or directed to take Resident #1 to the courtyard for walks, as outlined in his/her care plan. Interview with Licensed Practical Nurse (LPN) #1 on 11/06/19 at 4:00 PM revealed Resident #1 exhibited behaviors that were unpredictable and hard to manage. The LPN stated she had observed Resident #1's aggressive behaviors as well as wandering in and out of other residents' rooms. LPN #1 stated she was not aware that a rummage box, a baby doll, or walks in the courtyard were interventions that staff should have implemented when he/she exhibited behaviors. LPN #1 also stated she felt Resident #1 just slipped through the cracks. Interview with the Unit Manager (UM) on 11/06/19 at 3:05 PM revealed resident behaviors were monitored daily Monday-Friday in the morning meetings. The UM stated he was responsible to make rounds daily and ensure care plan interventions were implemented for facility residents. The UM stated he was aware of Resident #1's ongoing behaviors; however, he was not aware that the resident's care plan directed staff to utilize a baby doll, a rummage box, or walks in the courtyard when he/she exhibited behaviors. The UM also stated Resident #1's behaviors were unpredictable and intrusive to other residents in the facility and acknowledged that the facility had not implemented appropriate interventions to manage Resident #1's exhibited behaviors. Interview with the MDS Coordinator on 11/06/19 at 4:15 PM revealed resident behaviors were discussed daily in the Monday-Friday morning meeting, and care plans were reviewed/revised at that time. The MDS Coordinator also stated Resident #1's ongoing behaviors had been discussed in the morning meetings, and new interventions had been implemented in attempts to redirect the resident's behaviors. She stated she was not responsible to ensure care plan interventions were implemented for the residents; however, she stated staff were expected to implement interventions as outlined in the resident's plan of care. Interview with the Activity Director on 11/06/19 at 2:30 PM revealed behaviors are discussed in the clinical meeting conducted Monday-Friday. She stated she recalled discussions related to Resident #1's behaviors, as well as resident-to-resident incidents that have occurred. However, she stated she had not reevaluated Resident #1 after aggressive events occurred, in attempts to determine if any other diversional activities could be provided to the resident. Interview with the Social Services Director (SSD) on 11/07/19 at 9:45 AM revealed she ran a daily behavior report in the clinical meeting conducted Monday-Friday, and behaviors were discussed at that time. The SSD also stated resident care plans were reviewed/revised during the morning meeting related to identified behaviors. She stated Resident #1's ongoing behaviors had been discussed and new interventions had been added to his/her plan of care. However, she acknowledged direct care staff had not been trained on when or how to utilize newly implemented interventions in attempts to redirect his/her ongoing behaviors exhibited in the facility. Interview with the Director of Nursing (DON) on 11/07/19 at 10:50 AM revealed residents should have care plans developed and interventions implemented related to behaviors they exhibited in the facility. She stated concerns related to Resident #1's ongoing behaviors had been discussed in the clinical meetings conducted Monday-Friday, and new interventions had been added to the resident's care plan. However, the DON had not identified that direct care staff were not trained on newly added interventions and was not aware Resident #1's care plan had not been implemented in attempts to manage the resident's ongoing behaviors. Interview with the Administrator on 11/07/19 at 11:20 AM revealed the SSD ran a behavior report daily in the morning meetings, and resident care plans were reviewed and revised at that time. She stated she expected the UM to inform direct care staff when new interventions had been implemented for facility residents. She also stated the UM was expected to monitor and ensure interventions that were implemented were effective in the management of residents' behaviors. The Administrator stated she had not identified that direct care staff had not been trained when to utilize and/or implement new interventions for Resident #1, and stated, We didn't communicate well to direct care staff.

Based on observations, interview, and review of the facility's policies, it was determined the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for five (5) of seven (7) residents reviewed for medication administration pass (Resident #19, Resident #79, Resident #383, Resident #384 and Resident #385). Observation of medication administration on 04/04/19 revealed staff member failed to perform proper hand hygiene technique prior to preparation of medications, before entering resident's room and prior to exiting resident's rooms during medication pass on West Unit. The findings include: Review of the facility's policy titled, Medication Administration-General Guidelines, dated 09/2018, revealed staff would wash their hands with soap and water and apply gloves prior to administration of any topical (skin), ophthalmic (eye), enteral (by mouth), [MEDICATION NAME] (some means other than by mouth or rectal, usually intravenously or injection), rectal or vaginal medications. Further review of the policy revealed staff were to wash their hands with soap and water again following the administration of medications and after any resident contact. Review of the facility's policy titled, Handwashing/Hand Hygiene, dated 04/2012, revealed the facility recognized hand hygiene as the primary means to prevent the spread of infection. Further review of the facility's Handwashing/Hand Hygiene Policy revealed, all personnel would be trained and regularly in-serviced on the importance of hand hygiene in preventing the transmission of health-care associated infections. Further policy review revealed, unless hands were visibly soiled, the preferred method of hand hygiene was with an alcohol-based hand rub. Continued review of the facility's policy revealed staff were to use an alcohol-based hand rub prior to preparing or handling medications, donning gloves and following removal of gloves and contact with residents. Review of the facility's policy titled, Infection Control Program Standard of Practice, dated 09/2017 and revised on 11/2017, revealed the purpose of the facility's policy was to provide appropriate education for staff and residents concerning infection control. Further policy review revealed the facility would monitor and provide infection isolation precautions as directed by The Center for Disease Control and Prevention (CDC) Long Term Care recommendations and as per regulatory guidelines. 1. Review of Resident #383's clinical record revealed, the facility admitted the resident on 03/25/19 with [DIAGNOSES REDACTED]. Review of the Admission Minimum Data Set (MDS) Assessment, dated 04/01/19, revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) Score of five (5) out of fifteen (15), which indicated the resident was severely cognitively impaired. Further review of the Admission MDS revealed the facility assessed the resident to require physical assistance of one (1) for all ADLS. Observation of medication administration performed by Kentucky Medication Aide (KMA) #2, on 04/04/19 at 1:18 PM, revealed KMA #2 sanitizing hands with alcohol-based rub and preparing Resident # 383's medications. Further observation revealed KMA #2 placing the Requip 0.5 Milligram (mg) one (1) Tablet and [MEDICATION NAME] 100 mg two (2) capsules whole in to a small medication cup of applesauce, taking care not to touch the resident's medications. Continued observations revealed KMA #2 then entered Resident # 383's room and administered the medications to the resident with a spoon and exited the resident's room. KMA #2 failed to wash or sanitize his hands prior to signing off the electronic Medication Administration Record [REDACTED]. 2. Review of Resident 384's clinical record revealed the facility admitted the resident on 03/22/19 with [DIAGNOSES REDACTED]. Review of the Admission MDS Assessment, dated 04/04/19, revealed the facility had assessed the resident as having a BIMS score of fifteen, which indicated the resident was cognitively intact. Further review of the Admission MDS revealed the resident required the assistance of one (1) with transfers and toileting. Observation of KMA #2 preparing medication for Resident #384, on 04/04/19 at 1:28 PM, revealed the KMA failed to perform hand hygiene prior to preparing Resident #384's medication. Further observation revealed the KMA opened the [MEDICATION NAME] 100 mg one (1) Tablet, [MEDICATION NAME] 500 mg- one (1) Tablet and placed both tablets in to a cup. Continued observations revealed KMA #2 failed to wash/sanitize his hands prior to entering the resident's room to administer the medications and prior to exiting the resident's room following the administration of the resident's medications. Additional observation revealed KMA #2 returned to the medication cart and electronically signed out both medications on the MAR. 3. Review of Resident #385's clinical record revealed the facility admitted the resident on 04/03/19 with [DIAGNOSES REDACTED]. Observation of KMA #2, on 04/04/19 at 1:34 PM, administering Resident #385's medications revealed the KMA obtained personal alcohol-based hand rub from his medication cart and sanitized hands and prepared the medications. Further observations revealed KMA #2 attempted to document his signature in the electronic record, by electronically flagging [MEDICATION NAME] 800 mg one (1) capsule had been pulled from the locked drawer but due to a frozen display screen, which the KMA advised happens frequently with the computer system currently in place, was unable to do. Continued observation revealed KMA #2 then knocked on the door, and entered the resident's room with the medication, without washing or sanitizing hands. Additional observation revealed KMA #2 administered the medication to Resident #385 and exited the room, again without sanitizing or washing hands prior to exiting the resident's room. KMA #2 then pushed the medication cart away from the resident's doorway, up to the middle of West Wing Unit, to the front of the nursing station to document his signature regarding the narcotic medication he had just administered. 4. Review of Resident 79's clinical record revealed the facility admitted the resident on 03/27/19 with [DIAGNOSES REDACTED]. Review of the Admission MDS Assessment revealed the facility assessed the resident to have a BIMS score of 99, which indicated the resident to have severe cognitive impairment. Further review of the Admission MDS Assessment revealed the facility assessed the resident to require extensive physical assistance of two (2) with bed mobility, transfers and personal hygiene. Observation of KMA #2, on 04/04/19 at 1:42 PM, revealed KMA continuing to review electronic medical records for residents requiring ordered medications at this time. Further observations revealed KMA #2 taking the medication cart to Resident 79's and sitting the cart in front of the resident's door to prepare medications. Continued observations revealed KMA #2 sanitizing hands with alcohol-based hand rub, preparing medication and taking medications to resident's room. Additional observations revealed the KMA collected all of the following medications Calphron 667 mg two (2) Tablets, [MEDICATION NAME] 40 mg one (1) Tablet, and Nephro-Vite one (1) Tablet and placed the tablets in to a medication cup. KMA #2 then poured the tablets from the medication cup, into a bag, crushed the tablets in to a fine powder, and placed it into a small amount of applesauce. Further observations revealed KMA #2 administered the applesauce mixture as a bolus to the resident. Resident #79 accepted the medications without difficulty and drank a small amount of water afterwards. KMA #2 then documented administration of the medication without washing or sanitizing his hands. 5. Review of Resident #19's clinical record revealed the facility readmitted the resident on 10/19/17 with [DIAGNOSES REDACTED]. Review of the Annual MDS Assessment, dated 01/16/19, revealed the facility assessed the resident as having a BIMS score of fifteen (15) out of fifteen (15), which indicated the resident was cognitively intact. Further review of the MDS revealed the facility assessed the resident as requiring extensive physical assist of two (2) with bed mobility, dressing, personal hygiene and toilet use. Observation of KMA #2, on 04/04/19 at 1:48 PM, administering medications to Resident #19 revealed the KMA sanitized his hands prior to preparing the resident's medications. Further observations revealed KMA #2 prepared [MEDICATION NAME] HCL 10 mg one (1) Tablet and documented the medication in the electronic medication record. Continued observations revealed the KMA entered the resident's room and administered the resident's medications without sanitizing or washing hands after touching computer. Additional observations revealed KMA #2 exited the resident's room following administration of resident's medication without washing or sanitizing hands and documented the administration on the electronic medical record (MAR). Interview with KMA #2, on 04/04/19 at 1:51 PM, revealed he had been employed with the facility for over fifteen years and was familiar with the Infection Control and Prevention Policy as well as the Hand Hygiene Policy. Further interview with the KMA revealed he should wash/sanitize his hands prior to administration of every resident's medication, between each resident contact, before entering each resident's room, prior to exiting a resident's room and any time he touches his computer to document in the electronic Medication Administration Record. Interview with LPN, West Wing Unit Manager (WW UM), on 04/04/19 at 3:43 PM revealed she had been employed with facility for three (3) years as staff nurse prior to serving in her current role as a Unit Manager for the last four (4) months and was familiar with facility policies and procedures. Further interview revealed she expected staff to wash/sanitize hands and don gloves with each resident contact, prior to preparing medications for each resident, again prior to administration of each resident's medications, prior to entering and exiting resident's rooms and any time staff are in doubt of the need to wash or sanitize hands. Continued interview revealed hand hygiene was important to prevent the potential spread of germs, disease or illness to residents, visitors, staff and others in the facility and her staff are aware of this. Additional interview with West Unit Manager revealed she ensures staff are adhering to policy by making unit rounds, reviewing physician orders [REDACTED]. Interview with Director of Nursing DON/Infection Control Nurse, on 04/04/19 at 4:36 PM, revealed the KMA should have washed/sanitized his hands prior to entering and exiting every resident's room during medication administration. Further interview revealed the DON expected the KMA to have washed/sanitized his hands prior to preparation of each resident's medications and following the administration of each resident's medication. The DON reported hand washing was the most effective way to ensure illness, infection, disease, germs and bacteria are not transferred throughout the building potentially causing sickness. Continued interview revealed she expected staff to utilize proper hand hygiene with all resident care. Interview with Licensed Nursing Home Administrator (LNHA), on 04/04/19 at 4:22 PM and 5:10 PM, revealed she expected staff to wash and/or sanitize hands between each resident's care to prevent spread of germs and illness to residents staff and others in facility. Further interview with the LNHA revealed staff were to wash/sanitize hands prior to preparation of medications, prior to entering a resident's room, prior to exiting a resident's room and following administration of resident medications and following any direct resident contact.

Based on observation, interview and review of the facility's Policy, it was determined the facility failed to meet professional standards of practice for one (1) of thirty-two (32) sampled residents (Resident # 77). During inspection of the Nurses Medication Cart on [DATE], observation revealed Resident #77 had Humalog Insulin with an opened date of [DATE], an expiration date twenty-eight (28) days after opening, and the insulin was still being used for Resident #77 fourteen (14) days after the expiration date of [DATE]. The findings include: Review of the facility's Policy titled, 4.1 Storage of Medication, from Nursing Care Center Pharmacy Policy and Procedure Manual-copyright 2007 PharMerica Corp, revealed Medications and biologicals are stored properly, following manufacturer's or provider pharmacy recommendations, to maintain their integrity and to support safe effective drug administration. Further review of the 4.1 Storage of Medication policy revealed insulin products should be stored in the refrigerator until opened. Continued review of the policy revealed to note the date on the label for insulin vials and pens when first used and that the opened insulin vial may be stored in the refrigerator or at room temperature. The policy stated to refer to section 9.10-Medications with Shortened Expiration Dates. Review of the policy Section 9.10 Appendix of Resources Medications with Shortened Expiration Dates, dated ,[DATE], from Nursing Care Center Pharmacy Policy and Procedure Manual-copyright 2007 PharMerica Corp, revealed Humalog insulin was to be refrigerated until dispensed. Further review revealed the vial, expires twenty-eight (28) days after first use or removal from the refrigerator, whichever comes first. Record review revealed the facility admitted Resident #77 to the facility on [DATE] and Resident #77 was re-admitted on [DATE], with [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED]. Review of Resident #77's Medication Administration Record [REDACTED]. Observation of the Nursing Medication Cart with LPN #4, on [DATE] at 1:41 PM, revealed Humalog 100 unit per ml vial for resident #77 was observed dated opened [DATE] with a pink sticker stating to discard 28 days after opening. Interview with LPN #4, on [DATE] at 1:41 PM during the time of the observation, revealed Resident #77 had been receiving the Humalog Insulin. Continued interview with LPN #4 revealed Humalog Insulin was good for twenty-eight (28) days after it was opened. LPN #4 stated that Resident #77 may have another bottle of Humalog Insulin in the refrigerator, and upon checking the refrigerator, LPN #4 stated Resident #77 did have another bottle of Humalog Insulin in the refrigerator, which had not been opened. Continued interview with LPN #4 revealed she does not know why the expired Humalog for Resident #77 had not been removed from the medication cart upon the twenty-eight (28) day expiration. Further interview with LPN #4 revealed the Humalog Insulin would not be as effective when administered after the twenty-eight (28) day expiration. LPN #4 stated the Humalog Insulin for Resident #77 was already reordered, and should have been placed in the medication cart and used for the resident and she was unsure why the expired Humalog Insulin for Resident #77 was still in the medication cart being administered to the resident. Interview with the Unit Coordinator, on [DATE] at 1:59 PM, revealed the facility followed recommendations the pharmacy placed on the vial. Further interview revealed the facility would go by the date on the pink sticker, dated opened [DATE]. The Unit Coordinator further stated the facility should follow manufacturer recommendations, and the pharmacy relays this information to the facility. Continued interview with the Unit Coordinator revealed the facility staff that looked at Resident #77's Humalog Insulin should have seen it was expired after twenty-eight (28) days, and the expired insulin should have been discarded and new medication ordered and used for the resident. Further interview with the Unit Coordinator revealed Humalog Insulin that was administered after it had been opened for twenty-eight (28) days would not be as effective. Interview with the Director of Nursing (DON), on [DATE] at 5:24 PM, revealed insulin is dated once opened, then discarded according recommendations in the pharmacy issued policy for insulins. Continued interview with the DON revealed Humalog Insulin expired in twenty-eight (28) days per the Medications with Shortened Expiration Dates policy. The DON further stated it was her expectation and that the facility staff should have reordered Resident #77's Humalog Insulin within two (2) weeks of expiration and then pulled the expired Humalog Insulin when expired, discarded it, and began use of the new vial. Continued interview with the DON revealed using Humalog Insulin after the twenty-eight (28) day expiration could affect the Humalog Insulin level of effectiveness, and stated the Humalog could be less effective. Further interview with the DON revealed it was her expectation that staff follow the facility's policy and procedures and staff should abide by pharmacy recommendations. Interview with the Administrator, on [DATE] at 5:43 PM, revealed the facility followed the policy for Medications with Shortened Expiration Dates, which was provided by PharMerica, the facility's pharmacy. Continued interview with the Administrator revealed Humalog Insulin expired twenty-eight (28) days after opening. Further interview with the Administrator revealed potential outcomes to continuing to administer Humalog Insulin after the twenty-eight (28) day expiration were that the Humalog Insulin could become less effective, losing strength and may not control Resident #77's blood sugar. In addition, the Administrator indicated she was not aware Resident #77 had a new, unopened bottle in the refrigerator. Continued interview with the Administrator revealed it was her expectation that staff follow physician's orders [REDACTED]. Further interview with the Administrator revealed staff should have opened the Humalog Insulin, dated it, and then followed the pharmacy guidelines. The Administrator stated staff should have removed Resident #77's Humalog Insulin from the medication cart when it expired after the twenty-eight (28) days and opened the new vial of Humalog insulin for resident #77.

Based on interview, record review, and review of facility policy, it was determined the facility failed to develop and implement a comprehensive person-centered care plan for one (1) of three (3) sampled residents (Resident #2). The facility admitted Resident #2 to the facility on [DATE], utilizing an abdominal binder to secure his/her Jejunostomy tube. However, the facility failed to develop a care plan to direct staff how to care for the resident related to the Jejunostomy tube. The findings include: Interview with the Director of Nursing (DON) on 03/19/19 at 7:55 PM, revealed the facility utilized the Resident Assessment Instrument (RAI) Manual as a guide for developing resident care plans. Review of the RAI Process dated (MONTH) (YEAR) revealed the facility was responsible to assess and address all care issues relevant to individual residents. Further review revealed the care plan should include measurable objectives and timeframes, and must describe services that would be provided to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. The policy further stated the facility would revise care plans on an ongoing basis to reflect changes in the resident. Review of Resident #2's medical record revealed the facility admitted the resident on 01/02/19 with [DIAGNOSES REDACTED]. Review of the Admission Nursing notes for Resident #2 revealed the resident utilized an abdominal binder to prevent dislodgement of the Jejunostomy tube. Review of Resident #2's Minimum Data Set (MDS) assessment dated [DATE] revealed the facility assessed the resident to be severely cognitively impaired, to require the assistance of two (2) staff persons for transfers and bed mobility, and to be at high risk for skin breakdown. Review of the Baseline Care Plan, developed for Resident #2 on 01/02/19, revealed the facility failed to implement interventions that addressed the resident's utilization of the abdominal binder and interventions to prevent skin breakdown related to the binder. Interviews on 03/19/19 with State Registered Nurse Aide (SRNA) #1 at 3:00 PM and SRNA #2 at 5:30 PM revealed they frequently provided care to Resident #2, and had always removed the abdominal binder in order to wash and dry the resident's skin. However, the SRNAs stated they just know to perform that intervention, stating interventions for caring for Resident #2 related to the abdominal binder had never been listed on the resident's plan of care. Interview with LPN #2 on 03/19/19 at 5:15 PM revealed any resident care need should be listed on the resident's care plan and staff should review the care plan prior to providing care to the resident. Interview with the Administrator and Director of Nursing on 03/19/19 at 7:55 PM revealed all resident care needs should be listed on the resident's care plan. The Administrator stated the admitting nurse was responsible to develop a baseline care plan upon a resident's admission to the facility and resident care plans were discussed and updated daily in the morning meetings. The Administrator stated the abdominal binder that was utilized to secure Resident #2's J-tube should have been listed on the care plan along with interventions instructing staff on the care to provide the resident related to the abdominal binder.

Based on interview, review of employee personnel files, and review of the facility's policy, it was determined the facility failed to implement written policies that prohibited mistreatment, neglect, and abuse of residents. Review of three (3) of three (3) employee files (Employees #1, #2, and #3) revealed the facility failed to conduct a pre-employment screening of the Adult Misconduct Registry. The findings include: Review of the facility's policy and procedure titled Abuse Prohibition Standards of Practice, not dated, revealed the facility developed and implemented written policies and procedures that prohibited and prevented abuse, neglect, and exploitation of residents. Continued review revealed the facility would screen potential employees which included conducting a Misconduct Registry screening for all potential non-licensed staff. Review of Employee #1's personnel record revealed the facility hired the employee on 03/05/18; however, there was no documented evidence the facility conducted an Adult Misconduct Registry check prior to hiring Employee #1. Review of Employee #2's personnel record revealed the facility hired the employee on 03/16/18; however, there was no documented evidence an Adult Misconduct Registry check was completed prior to the date of hire. Review of Employee #3's personnel record revealed the facility hired the employee on 03/23/18; however, there was no documented evidence the facility conducted an Adult Misconduct Registry check prior to hiring the employee. Interview with the Administrator on 05/16/18 at 2:30 PM and 3:43 PM revealed Employee #1, Employee #2, and Employee #3 were contracted non-licensed employees. Continued interview with the Administrator revealed the contracted agency was responsible for completing all pre-employment screenings and for maintaining their own personnel records. Additional interview with the Administrator revealed she was not aware the contracted agency was not conducting a check of the Adult Misconduct Abuse Registry for all their employees. However, further interview with the Administrator revealed since the contracted staff provided services to the residents in the facility she was responsible for ensuring all required checks were completed.