Every finding on record at Jefferson County Nursing Home

Based on medical record review and interview, the facility failed to follow a Physician's order for routine blood test for 1 resident (Resident #11) of 5 residents reviewed for routine blood test. The findings include: Review of the medical record revealed Resident #11 was admitted to the facility on [DATE] with diagnoses including Atrial Fibrillation, Hyperlipidemia, Bipolar Disorder, Diabetes Mellitus Type 2, and Anemia. Review of a Physician's order for Resident #11 dated 5/31/2022, revealed .Routine labs: CBC [Complete Blood Count- a blood test that measures amounts and sizes of red blood cells, hemoglobin, white blood cells and platelets], CMP [Comprehensive Metabolic Panel- a blood test that measures proteins, enzymes, electrolytes, and minerals in the body], magnesium [Magnesium level- a blood test that measures the amount of magnesium in the blood], lipid [Lipid panel- a blood test that measures the fats in the blood], vitamin D [Vitamin D level- a blood test that measures the amount of Vitamin D in the blood], ferritin [Ferritin level- a blood test that measures the amount of iron stored in the blood], TIBC [Total Iron Binding Capacity- a blood test that measures the bloods ability to attach and carry iron], folate [Folate level- a blood test that measures the amount of folate in the blood], valporic acid [Valproic Acid level- a blood test that measures the amount of the anticonvulsant drug in the blood] , Hgb A1C [Hemoglobin A1c- a blood test that measures the average blood glucose level in the blood for the past 3 months] (January and July) . Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #11 scored a 15 on the Brief Interview for Mental Status (BIMS) assessment which indicated the resident was cognitively intact. Review of the medical record for Resident #11, revealed no results for the following blood test CBC, CMP, Magnesium level, Lipid Panel, Vitamin D level, Ferritin level, TIBC, Folate level, Valproic Acid level, or Hemoglobin A1c for January 2025 or July 2025. Review of a comprehensive care plan for Resident #11 revised 10/3/2025, revealed . Dx [diagnosis] of Hyperlipidemia .monitor labs values [blood test] as directed and notify md/np [Doctor of Medicine/ Nurse Practitioner] of results .HX [history] OF DVT's [Deep Vein Thrombosis] .Monitor laboratory values .Diagnosis of Diabetes .Schedule labs as ordered and report results . Dx of Anemia .Obtain and monitor lab/diagnostic work as ordered .resident is on diuretic therapy .Report pertinent lab results to MD .The resident uses psychotropic medications .Depakote [medication used to treat seizures and mood disorders] levels as ordered and report to MD .Monitor lab values as directed by MD/NP . During an interview on 12/11/2025 at 11:22AM, the Assistant Director of Nursing (ADON) confirmed Resident #11 had a Physician's order for the following routine blood test CBC, CMP, Magnesium level, Lipid Panel, Vitamin D level, Ferritin level, TIBC, Folate level, Valproic Acid level, and Hemoglobin A1c level to be obtained every January and July. The ADON confirmed she could not locate any results of the following blood test CBC, CMP, Magnesium level, Lipid Panel, Vitamin D Level, Ferritin level, TIBC, Folate level, Valproic Acid level, or Hemoglobin A1c for Resident #11 for the month of January 2025 or July 2025. The ADON further confirmed the facility failed to follow a Physician's order for Resident #11. During an interview on 12/11/2025 at 11:51 AM, the Nurse Practitioner stated it was his expectation for facility staff to follow all Physician's orders. The Nurse Practitioner stated he was familiar with Resident #11. The Nurse Practitioner stated in his professional opinion Resident #11 did not experience any negative outcome such as a decline in health status or hospitalization as a result of the facility not following the Physician's order to obtain routine blood test.

Based on review of facility policy, review of medical records, observation, and interview the facility failed to offer hand hygiene assistance prior to meals for 5 residents (Residents #28, #111, #162, #40, and #78) on 1 of 7 units observed for meal tray distribution.The findings include: Review of the facility's policy titled, HANDWASHING POLICY, dated 5/20/2025, revealed .Hand hygiene is any method that removes microorganisms from the hands .Upon beginning of the meal, residents .should perform hand hygiene . Review of the medical record revealed Resident #28 was admitted to the facility on [DATE] with diagnoses including Unspecified Lack of Coordination, Reduced Mobility, Need for Assistance with Personal Care, and Cognitive Communication Deficit. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #28 scored a 12 on the Brief Interview for Mental Status (BIMS) assessment which indicated the resident was moderately cognitively impaired. Resident #28 required set up or clean-up assistance with eating and substantial/maximal assistance for personal hygiene. Review of Resident #28's comprehensive care plan revised on 9/3/2025, revealed .REQUIRES SUBSTANTIAL ASSISTANCE AND SUPERVISION WITH BATHING, GROOMING . Review of Resident #28's comprehensive care plan dated 12/4/2025, revealed .COGNITIVE DEFICITS .WITH PERIODS OF CONFUSION . During an observation on 12/8/2025 at 12:15 PM, Certified Nursing Assistant (CNA) A delivered the lunch meal tray to Resident #28. CNA A delivered the tray, donned gloves, set up Resident #28's lunch meal tray, doffed the gloves, sanitized the hands, and exited the room without offering hand hygiene assistance to Resident #28. Review of the medical record revealed Resident #111 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including Dysphagia, Need for Assistance with Personal Care, and Cognitive Communication Deficit. Review of the annual MDS assessment dated [DATE], revealed Resident #111 scored a 13 on the BIMS assessment which indicated the resident was cognitively intact. Resident #111 required set up or clean up assistance for eating and was dependent on staff for personal hygiene. Review of Resident #111's comprehensive care plan revised 9/8/2025, revealed .DEPENDENT ASSISTANCE AND SUPERVISION WITH BATHING, GROOMING .Provide assistance for daily care and hygiene . Review of Resident #111's comprehensive care plan revised on 12/5/2025, revealed .COGNITIVE DEFICITS . During an observation on 12/8/2025 at 12:16 PM, CNA A delivered the lunch meal tray to Resident #111. CNA A delivered the tray, donned gloves, set up Resident #111's meal tray, doffed the gloves, sanitized the hands, and exited the room without offering hand hygiene assistance to Resident #111. Review of the medical record revealed Resident #162 was admitted to the facility on [DATE] with diagnoses including Chronic Obstructive Pulmonary Disease and Encounter for Palliative Care. Review of Resident #162's Admit/Readmit Screener dated 12/4/2025, revealed Resident #162 was oriented to person and time only. Review of Resident #162's Baseline Care Plan dated 12/4/2025, revealed .Requires 1 Person assist with all adl [Activities of Daily Living] care . Review of Resident #162's care plan dated 12/4/2025, revealed .COGNITIVE DEFICITS .NEEDS ASSISTANCE WITH DECISION MAKING .NEW admission TO FACILITY UNDER THE SERVICES OF [HOSPICE COMPANY] RESPITE . During an observation on 12/8/2025 at 12:22 PM, CNA A delivered the lunch meal tray to Resident #162. CNA A delivered the tray, donned gloves, set up Resident #162's tray, doffed the gloves, sanitized the hands, and exited the room without offering hand hygiene assistance to Resident #162. Review of the medical record revealed Resident #40 was admitted to the facility on [DATE] with diagnoses including Chronic Obstructive Pulmonary Disease, Need for Assistance with Personal Care, and Delusional Disorders. Review of Resident #40's comprehensive care plan revised on 7/14/2025, revealed .episodes of paranoia with periods of delusions/hallucinations . Review of Resident #40's comprehensive care plan revised on 10/10/2025, revealed .Provide assistance for daily care and hygiene . Review of the quarterly MDS assessment dated [DATE], revealed Resident #40 scored a 3 on the BIMS assessment which indicated the resident had severe cognitive impairment. Resident #40 required setup or clean-up assistance for eating and was dependent on staff for personal hygiene. During an observation on 12/8/2025 at 12:24 PM, CNA A delivered the lunch meal tray to Resident #40. CNA A delivered the meal tray, donned gloves, set up Resident #40's tray, doffed the gloves, sanitized the hands, and exited the room without offering hand hygiene assistance to Resident #40. Review of the medical record revealed Resident #78 was admitted to the facility on [DATE] with diagnoses including Muscle Weakness, Need for Assistance with Personal Care, and Cognitive Communication Deficit. Review of Resident #78's comprehensive care plan revised on 10/22/2025, revealed .Provide assistance for daily care and hygiene . Review of the quarterly MDS assessment dated [DATE], revealed Resident #78 scored a 13 on the BIMS assessment which indicated the resident was cognitively intact. Resident #78 required setup or clean-up assistance for eating and was dependent on staff for personal hygiene. Review of Resident #78's comprehensive care plan dated 10/23/2025, revealed .COGNITIVE DEFICITS . During an observation on 12/8/2025 at 12:26 PM, CNA A delivered the lunch meal tray to Resident #78. CNA A donned gloves, set up the tray, doffed the gloves, sanitized the hands, and exited the room without offering hand hygiene assistance to Resident #78. During an interview on 12/8/2025 at 12:35 PM, CNA A stated residents were to be offered hand hygiene assistance prior to meals with a sanitizing wipe or hand sanitizer. CNA A confirmed she had not offered hand hygiene assistance prior to meals for Residents #28, #111, #162, #40, and #78. During an interview on 12/8/2025 at 12:44 PM, the Director of Nursing (DON) confirmed staff were to offer hand hygiene assistance to all residents prior to meals with hand sanitizer, sanitizing wipes, or offer assistance to wash hands with soap and water.

Based on review of facility policy, review of medical records, observations, and interviews, the facility failed to complete dialysis communication records for 1 resident (Resident #55) of 3 residents reviewed for dialysis. The findings include: Review of the facility's undated policy titled, Hemodialysis [treatment for kidney failure] Policy and Guidelines, revealed .The licensed nurse will communicate to the dialysis facility via [by] .written format, such as a dialysis communication form . Medical record review revealed Resident #55 was admitted to the facility on [DATE] with diagnoses including End Stage Renal Disease with Dependence on Renal Dialysis, Functional Quadriplegic, Obesity, and Diabetes. Review of a Physician's Progress note for Resident #55 dated 8/21/2025, revealed the resident began dialysis treatments while residing at another long term care facility and was to continue dialysis services long term. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #55 scored a 15 on the Brief Interview for Mental Status (BIMS) assessment which indicated the resident was cognitively intact. Further review revealed the resident received dialysis services. Review of a comprehensive care plan for Resident #55 dated 8/14/2025, revealed the resident had a Dialysis Care Plan. Review of the Physician's Orders for Resident #55 dated 10/1/2025, revealed .Complete Dialysis [communication] sheet before and after dialysis . During an interview and observation on 12/8/2025 at 11:00 AM, Resident #55 stated he went to dialysis services three days a week. The resident further stated he takes a dialysis notebook with communication sheets with him when he received dialysis services. During an observation and interview on 12/9/2025 at 7:50 AM, Licensed Practical Nurse (LPN) B stated Resident #55 was scheduled for dialysis today. LPN B stated dialysis communication sheets were left in a notebook behind the nurses' desk. Residents were assessed by the nurse prior to leaving the facility for dialysis and upon return using the dialysis communication sheet. Review of the Dialysis communication sheets for Resident #55 revealed the post dialysis assessments were not completed on the dialysis communication sheets on the following dates: 11/1/2025, 11/4/2025, 11/6/2025, 11/8/2025, 11/11/2025, 11/20/2025, 11/22/2025, 11/29/2025, 12/2/2025, and 12/6/2025. During an interview on 12/11/2025 at 11:15 AM, the Director of Nursing (DON) stated it was the facility's expectation to complete the dialysis communication sheet prior to dialysis treatment and upon return to facility. The DON confirmed dialysis communication sheets for Resident #55 had not been completed.

Based on facility policy review, medical record review and interview, the facility failed to resubmit a Pre-admission Screening and Resident Review (PASARR) timely after a new mental health diagnosis was added for 4 residents (Residents #3, #40, #43, and #143) of 8 residents reviewed for PASRR (PASARR). The findings include: Review of the facility's undated policy titled, PASRR POLICY, revealed .ensure that individuals with a mental disorder .receives care and services in the most integrated setting .All applicants to this facility will be screened for serious mental disorders .Any level II [2] resident who experiences a significant change in status will be screened via [by] submitting a new level I [1] PASRR . Review of Resident #3's Notice of PASRR Level I Screen Outcome dated 8/3/2023 (prior to admission to the facility), revealed .No PASRR Level II Required .DIAGNOSIS .No mental health diagnosis is known or suspected . It was noted the resident had a diagnosis of dementia/neurocognitive disorder. Review of the medical record revealed Resident #3 was admitted to the facility on [DATE] with diagnoses including Hemiplegia and Hemiparesis affecting Left Non-Dominant Side, Muscle Weakness, and Vascular Dementia. Review of Resident #3's medical record revealed a diagnosis of Adjustment Disorder with Mixed Anxiety and Depressed Mood was added on 11/15/2023. Review of Resident #3's comprehensive care plan initiated on 9/6/2024, revealed .RESIDENT HAS IMPULSE DISORDER . Review of Resident #3's medical record revealed a diagnosis of Impulse Disorder was added on 9/16/2024. Review of Resident #3's comprehensive care plan initiated on 2/20/2025, revealed .RESIDENT RECEIVES PSYCHOTROPIC MEDICATIONS [medications to control mental health disorders] . Review of a significant change Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #3 scored a 4 on the Brief Interview for Mental Status (BIMS) assessment which indicated the resident had severe cognitive impairment. The resident exhibited no behavioral symptoms during the 7-day lookback period. Resident #3's active diagnoses included Non-Alzheimer's Dementia, Anxiety Disorder, Depression, and Psychotic Disorder. Review of the medical record for Resident #3 revealed no evidence a new PASRR had been submitted when new diagnoses of Adjustment Disorder with Mixed Anxiety and Depressed Mood (11/15/2023) and Impulse Disorder (9/16/2024) were added. During an interview on 12/9/2025 at 2:40 PM, the Admission's Registered Nurse (RN) confirmed Resident #3's Level I PASRR dated 8/30/2023, showed no mental health diagnoses were known or suspected and confirmed a new PASRR had not been submitted for Resident #3 when new diagnoses of Adjustment Disorder with Mixed Anxiety and Depressed Mood and Impulse Disorder were added. Review of Resident #40's Notice of PASRR Level I Screen Outcome dated 1/3/2025 (prior to admission to the facility), revealed .No PASRR Level II Required .DIAGNOSIS .No mental health diagnosis is known or suspected . It was noted the resident had a diagnosis of dementia/neurocognitive disorder. Review of the medical record revealed Resident #40 was admitted to the facility on [DATE] with diagnoses including Chronic Obstructive Pulmonary Disease, Reduced Mobility, and Dementia. Review of the medical record for Resident #40 revealed a diagnosis of Delusional Disorders was added on 1/13/2025. Review of the comprehensive care plan for Resident #40 dated 1/14/2025, revealed .uses psychotropic medications r/t [related to] Paranoia/delusions . Review of the comprehensive care plan for Resident #40 dated 1/16/2025, revealed .Periods of delusions/paranoia. Started on Zyprexa [antipsychotic medication] 1/14/2025 . Continued review revealed .Cognitive Deficits and DX [diagnosis] of Dementia . Review of the comprehensive care plan for Resident #40 dated on 1/17/2025, revealed .History of Episodes of paranoia with periods of delusions/hallucinations . Review of the medical record for Resident #40 revealed a diagnosis of Anxiety was added on 2/5/2025, and Psychosis Not Due to a Substance or Known Physiological Condition was added on 3/2/2025. Review of the comprehensive care plan for Resident #40 dated 4/22/2025, revealed .RESIDENT HAS .DEMENTIA .ANXIETY . Review of the quarterly MDS assessment dated [DATE], revealed Resident #40 scored an 8 on the BIMS assessment which indicated the resident had moderate cognitive impairment. Resident #40 exhibited no behavioral symptoms. Resident #40's active diagnoses included Non-Alzheimer's Dementia, Anxiety Disorder, and Psychotic Disorder. Review of the quarterly MDS assessment dated [DATE], revealed Resident #40 scored a 3 on the BIMS assessment which indicated the resident had severe cognitive impairment. Resident #40 exhibited no behavioral symptoms. Resident #40's active diagnoses included Psychosis, Non-Alzheimer's Dementia, Anxiety Disorder, and Psychotic Disorder. Review of the medical record for Resident #40 revealed no documentation a new PASRR had been submitted to the State Designated Authority for Resident #40 after the mental health diagnoses of Delusional Disorder, Anxiety Disorder, and Psychosis were added to the medical record. During medical record review an interview on 12/9/2025 at 2:37 PM, the Admissions RN stated PASRRs were looked at upon admission and compared to the hospital records for diagnoses. After admission, if there are any changes in mental health diagnoses, the MDS Coordinator would be responsible to resubmit the PASRR when the quarterly MDS assessments were completed. The Admissions Nurse confirmed Resident #40's PASRR dated 1/3/2025 revealed the resident had diagnosis of dementia and no mental health diagnoses were suspected. Resident #40 had a new diagnosis of Delusional Disorder added on 1/13/2025, a new diagnosis of Anxiety added on 2/5/2025, and a new diagnosis of Psychosis added on 3/2/2025. The Admissions RN confirmed a new PASRR had not been submitted timely to include Resident #40's new diagnoses. Review of the medical record revealed Resident #43 was admitted to the facility on [DATE] with diagnoses including Dementia, Depression, and Anxiety. Review of the PASRR Notice of Exclusion from PASRR for Resident #43 dated 6/12/2023, revealed .Your neurocognitive disorder (dementia) is the primary focus of your care .If you have certain kinds of changes in your physical or mental health, you may need a new Level II evaluation .The nursing facility must submit a new Level I screening .to see if a new PASRR evaluation is needed .Anxiety Disorder (current Diagnosis) .Depression (current Diagnosis) .Does the individual have a diagnosis of dementia/neurocognitive disorder .Yes .SMI [Severe Mental Illness] is suspected .You were 'Ruled out' from further assessment through the PASRR Program .Dementia will likely be the primary focus of behavioral health treatment . Review of the medical record for Resident #43 revealed a diagnosis of Impulse Disorder was added on 6/15/2023. Review of a Physician's order for Resident #43 dated 9/29/2025, revealed .Divalproex Sodium [a medication used to treat Seizure disorder or Mood disorder] .125 MG [milligrams] .Give 1 capsule by mouth two times a day for impulse control disorder . Review of a Psychiatry Note for Resident #43 dated 10/13/2025, revealed .depakote [a medication used to treat Seizure disorder or Mood disorder] 125mg po [by mouth] BID [twice per day] .impulse control disorder . Review of Resident #43's comprehensive care plan dated 11/11/2025, revealed .RESIDENT HAS .IMPULSE DISORDER .Administer medications as ordered .RESIDENT RECEIVES PSYCHOTROPIC MEDICATIONS . Review of a quarterly MDS assessment dated [DATE], revealed Resident #43 scored an 8 on the BIMS assessment which indicated the resident had moderate cognitive impairment. Resident #43 exhibited no behavioral symptoms. Resident #43's active diagnoses included Non-Alzheimer's Dementia, Anxiety Disorder, Depression, and Impulse Disorder. Review of the medical record for Resident #43 revealed no documentation a new PASRR had been submitted to the State Designated Authority after the diagnosis of Impulse Control Disorder was added to the medical record. Review of the Notice of PASRR Level 1 Screen Outcome for Resident #143 dated 7/28/2025 (prior to admission to the facility), revealed PASRR Level II Onsite Evaluation required .Current diagnosis Major Depression .Rational: Your Level 1 screen shows you have evidence of serious mental illness .A level II evaluation will be initiated . Review of the PASRR Notice of Exclusion from PASRR for Resident #143 dated 8/4/2025 (prior to admission to the facility), revealed .Your neurocognitive disorder (Dementia) is the primary focus of your care . Review of the medical record revealed Resident #143 was admitted to the facility on [DATE], with diagnoses including Major Depressive Disorder with Severe Psychotic Symptoms, Dementia, Anxiety Disorder, and Parkinsons Disease. Review of the medical record for Resident #143 revealed the diagnoses of Paranoid Personality Disorder and Hoarding Disorder were added on 8/11/2025. Review of the Psychiatric Nurse Practitioner (NP) note for Resident #143 dated 8/25/2025, revealed the resident was assessed and treated for Hoarding Disorder, Anxiety, Paranoia/Delusions, Dementia, and Depression. Review of the comprehensive care plan for Resident #143 dated 8/26/2025, revealed, .resident has episodes of delusions and paranoia .resident has Depression and Anxiety with episodes of agitation and psychosis .cognitive deficits r/t Dementia . Review of the quarterly MDS assessment dated [DATE], revealed Resident #143 scored a 10 on the BIMS assessment which indicated the resident had moderate cognitive impairment. Resident #143 exhibited no behaviors. Further review revealed active diagnoses included Major Depressive Disorder, Dementia, Parkinsons Disease, Anxiety Disorder, and Psychotic Disorder. Review of the medical record for Resident #143 revealed no documentation a new PASRR had been submitted to the State Designated Authority after the mental health diagnoses of Hoarding and Paranoid Personality Disorder were added to the medical record. During a medical record review and interview on 12/11/2025 at 10:55 AM, Licensed Practical Nurse (LPN) MDS Assistant reviewed the medical record and PASRR for Resident #43 and #143. The LPN MDS Assistant confirmed Resident #43 had received a new mental health diagnosis of Impulse Control Disorder on 6/15/2023. The LPN MDS Assistant confirmed the PASRR for Resident #43 dated 6/12/2023 did not include the diagnosis of Impulse Control Disorder. The LPN MDS Assistant confirmed Resident #143 had received new mental health diagnoses of Hoarding and Paranoid Personality Disorder on 8/11/2025. The LPN MDS Assistant confirmed the PASRR for Resident #143 dated 8/4/2025 did not include the diagnoses of Hoarding and Paranoid Personality Disorder. The LPN MDS Assistant further confirmed the facility failed to submit a new PASRR Level I screen when Resident #43 and #143 received new mental health diagnoses.

Based on review of facility policy, review of medical records, and interview, the facility failed to revise the comprehensive care plan for 1 resident (Resident #117) of 29 residents reviewed for care plans. The findings include:Review of the facility's policy titled, CARE PLAN IMPLEMENTATION AND PROCESS, revised 6/4/2025, revealed .Comprehensive Care Plan .reviewed every 90 days or changes .be made as needed . Review of the medical record revealed Resident #117 was admitted to the facility on [DATE] with diagnoses including History of Falling, Cerebral Infarction, and Muscle Weakness. Review of a facility incident report for Resident #117 dated 5/17/2025, revealed .Un-witnessed Fall .Resident Description: I was trying to go to the bathroom and lost balance .reminded res [Resident] that she must use her call light and she stated she would .No injuries observed at time of incident .Ambulating without Assist .Hi [High] visibility Tape to call light . Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #117 scored a 14 on the Brief Interview for Mental Status (BIMS) assessment which indicated the resident was cognitively intact. The resident required supervision or touching assistance from staff with toileting hygiene and transfers. The resident required partial/moderate staff assistance with personal hygiene. Review of a facility incident report for Resident #117 dated 11/2/2025, revealed .Un-witnessed Fall .Resident observed on her bathroom floor .Gait imbalance .Weakness .Ambulating without Assist .[intervention] 3 in 1 toilet [bedside toilet placed over the toilet] . Review of a comprehensive care plan for Resident #117 dated 12/9/2025, revealed .RESIDENT REQUIRES TOUCHING/ PARTIAL ASSISTANCE .1 PERSON .TRANSFERS .RESIDENT AT INCREASED RISK FOR FALLS/TRAUMA . Further review revealed the comprehensive care plan was not revised to include the high visibility tape to the call light and 3 in 1 toilet. During an observation on 12/11/2025 at 9:18 AM, revealed there was bright yellow tape to the base of Resident #117's call light. Further observation revealed a 3 in 1 toilet placed over the toilet in Resident #117's restroom. During an interview on 12/11/2025 at 9:22 AM, the Assistant Director of Nursing (ADON) stated Resident #117 had experienced a fall on 5/17/2025 and the intervention included high visibility tape to Resident #117's call light to assist in reminding Resident #117 to use her call light to alert staff for assistance with transfers. The ADON further stated Resident #117 had experienced a fall on 11/2/2025 and the intervention included for Resident #117 to receive a 3 in 1 toilet. The ADON confirmed the facility failed to revise the comprehensive care plan for Resident #117 to include the fall interventions of high visibility tape to Resident #117's call light and for Resident #117 to receive a 3 in 1 toilet.

Based on review of facility policy, medical record review, review of facility investigation and interview the facility failed to ensure 1 resident (Resident #1) of 3 sampled residents was transferred with the use of a mechanical lift which resulted in a fracture to Resident #1's right femur and harm for Resident #1. The findings included: Review of a facility policy Resident Lifting Policy effective 9/18/1997 showed .[facility] will be considered a 'LIFT FREE FACILITY' .mechanical lifts will be provided to do all types of lifting and transferring of residents . Medical record review revealed Resident #1 was admitted to the facility on [DATE] with diagnoses including Dementia, Mood Disorder, Foot Drop Right and Left Feet and [CONDITION(S)]. Medical record review of the quarterly Minimum Data Set (MDS) dated [DATE] showed Resident #1 had a Brief Interview for Mental Status (BIMS) score of 7 which indicated the resident was severely cognitively impaired. The resident was totally dependent for transfers with 2-person assist. Resident #1 was only able to stabilize with staff assistance for surface-to-surface transfers between bed and chair or wheelchair. Medical record review of Resident #1's comprehensive care plan dated 7/10/2019 showed Resident #1 required .total assistance with the following activities of daily living [ADLS]: bed mobility, transfers, bathing, grooming/hygiene, dressing, toileting, and eating. Non-ambulatory. Has contracture to right hand, bilateral foot drop. Maxi lift [a mechanical lift with the use of a sling that is placed underneath a resident, the sling is attached to a mechanical lift which allows the resident's weight to be lifted and the resident can then be transferred to a different location] for transfers . Medical record review of a nurse note dated 11/9/2022 at 3:34 PM showed .POA [Power of Attorney] notified of c/o [complaint of] increased pain to RLE [Right Lower Extremity]. Physician Assistant [PA] assessed resident. New orders received .Resident resting in bed at this time . Medical record review of a Radiology Report dated 11/9/2022 at 6:10 PM showed .Conclusion: Recent distal femoral fracture . Medical record review of a nurse note dated 11/9/2022 at 7:14 PM showed the radiology report was received at the facility, the PA was notified and ordered Resident #1 be sent to the hospital for an orthopedic evaluation and the POA was notified. Medical record review of the hospital History and Physical dated 11/9/2022 confirmed Resident #1 was admitted to the hospital with a right femur fracture. Review of a facility investigation dated 11/9/2022 showed the facility initiated an immediate investigation after Resident #1 was discovered to have a distal femur fracture. The facility's investigation revealed Certified Nurse Assistant (CNA) #1 dressed Resident #1 for breakfast and requested assistance from CNA #2 to transfer Resident #1 using the mechanical lift. CNA #2 entered Resident #1's room and told CNA #1 she would show her how to transfer the resident. CNA #2 sat Resident #1 up on the side of her bed, placed her arms around the resident's waist, picked the resident up and sat her over into her wheelchair without the use of the mechanical lift. The resident bent her right knee during the transfer and her leg was caught underneath her buttocks. CNA #1 told CNA #2 the resident's leg was underneath her. CNA #2 lifted the resident up by placing her arms around her waist and CNA #1 straightened the resident's leg. CNA #2 sat the resident back down in the wheelchair and the resident's feet were placed on the wheelchair's footrest. Resident #1 did not express pain at the time of the incident. CNA #2 told CNA #1 she had reported the transfer incident to the nurse, but investigation revealed CNA #2 did not report the incident. Registered Nurse (RN) #1 noted [CONDITION(S)] to Resident #1's right knee and an x-ray of the right knee was ordered. The x-ray results showed a recent right femur fracture. Resident #1 was transferred to the hospital for treatment. Interview on 11/15/2022 at 8:45 AM with the Administrator confirmed the facility began an investigation immediately when they became aware of the fracture to Resident #1's right femur. Statements were obtained from all staff that had provided care for Resident #1 for the previous 24 hours. The witness statements revealed CNA #2 had transferred Resident #1 improperly and the resident's right leg was caught underneath her as she was placed in her wheelchair. During an interview on 11/15/2022 at 10:05 AM CNA #1 confirmed she was aware Resident #1 required the use of a lift to transfer Resident #1. CNA #1 stated CNA #2 entered Resident #1's to assist with the transfer and told CNA #1 she would show her how it was done. CNA #2 then sat Resident #1 up on the side of the bed, placed her arms around the resident's waist, picked her up and sat her down in her wheelchair. CNA #1 stated Resident #1 bent her right leg during the transfer and CNA #2 sat the resident down with the resident's right leg bent underneath her. CNA #1 stated CNA #2 seemed rushed. CNA #1 stated she then took Resident #1 to the dining room and assisted her with breakfast and on the way back to Resident #1's room the resident complained of knee pain and CNA #1 reported the complaint of pain to Licensed Practical Nurse (LPN) #1. CNA #1 stated when she transferred Resident #1 to provide incontinence care before the end of her shift at 2:00 PM Resident #1 continued to complain of knee pain, and she then reported the pain to the supervisor Registered Nurse (RN) #1. Interview on 11/15/2022 at 11:10 AM with LPN #1 confirmed he was Resident #1's nurse on 11/9/2022 and confirmed CNA #1 reported the resident's complaint of knee pain. LPN #1 stated it was time for Resident #1's routine pain medications, so he administered the medication to Resident #1. LPN #1 stated he was unaware of the incorrect transfer of Resident #1 and was not informed by CNA #2 of the incident. Continued interview with LPN #1 revealed RN #1 later reported to him Resident #1 continued to complain of knee pain and RN #1 and the PA assessed the resident's right knee and it appeared swollen. They applied scheduled topical pain cream to Resident #1's bilateral knees and the PA ordered an x-ray to the right knee. During a telephone interview on 11/16/2022 at 10:45 AM with RN #1 revealed CNA #1 reported Resident #1 complained of continued knee pain later in the CNA's shift on 11/9/2022. Continued interview confirmed RN #1 and the PA assessed the resident 's knee and it appeared swollen. The PA ordered an x-ray of the right knee due to the swelling and the increased complaints of knee pain. RN #1 stated she was not aware of the incorrect transfer at the time she and the PA assessed Resident #1. Interview on 11/16/2022 at 11:05 AM with the Director of Nursing (DON) confirmed CNA #2 did not follow Resident #1's care plan for transfers which resulted in a fracture to Resident #1's right femur. Interview with CNA #2 on 11/16/2022 by phone at 2:00 PM confirmed CNA #2 was aware Resident #1 required the use of a mechanical lift for transfers and had not used one when she transferred Resident #1 from the bed to the wheelchair.

Based on medical record review, review of facility investigation and interview the facility failed to ensure 1 resident (Resident #1) of 3 sampled residents was transferred according to the comprehensive care plan which resulted in a fracture to Resident #1's right femur and harm for Resident #1. The findings included: Medical record review revealed Resident #1 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Medical record review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #1 had a Brief Interview for Mental Status (BIMS) score of 7 which indicated the resident was severely cognitively impaired. The resident was totally dependent for transfers with 2-person assist. Medical record review of Resident #1's comprehensive care plan dated 7/10/2019 showed Resident #1 was totally dependent on staff for all activities of daily living (ADLs) and for transfers . Maxi lift [a mechanical lift with the use of a sling that is placed underneath a resident, the sling is attached to a mechanical lift which allows the resident's weight to be lifted and the resident can then be transferred to a different location] . Medical record review of a nurse note dated 11/9/2022 at 3:34 PM showed Resident #1's Power of Attorney (POA) was notified of an increase in pain to Resident #1's right lower extremity and the Physician Assistant (PA) had ordered an x-ray. Medical record review of a Radiology Report dated 11/9/2022 at 6:10 PM showed Resident #1 had sustained a fracture .Conclusion: Recent distal femoral fracture . Medical record review of the hospital History and Physical dated 11/9/2022 confirmed Resident #1 was admitted to the hospital with a right femur fracture. Review of a facility investigation dated 11/9/2022 showed the facility initiated an immediate investigation after Resident #1 was discovered to have a distal femur fracture. The facility's investigation revealed Certified Nurse Assistant (CNA) #1 had requested assistance from CNA #2 to help transfer Resident #1 from the bed to her wheelchair. Investigation review revealed CNA #2 entered Resident #1's room, sat Resident #1 up on the side of the bed and without the use of the mechanical lift, CNA #2 placed her arms around Resident #1's waist, picked the resident up and sat the resident down in the wheelchair. The facility's investigation revealed Resident #1's right leg was caught underneath her buttocks during the transfer. Further review revealed CNA #2 told CNA #1 she had reported the incident to a nurse, however she did not. During an interview on 11/15/2022 at 10:05 AM CNA #1 confirmed she was aware Resident #1 required the use of a mechanical lift to transfer Resident #1 to her wheelchair however stated CNA #2 seemed rushed and transferred the resident without the use of the mechanical lift. Interview on 11/16/2022 at 11:05 AM with the Director of Nursing (DON) confirmed CNA #2 did not follow Resident #1's care plan for the use of a mechanical lift for transfers which resulted in a fracture to Resident #1's right femur. Interview with CNA #2 on 11/16/2022 at 2:00 PM by phone confirmed CNA #2 was aware Resident #1 required the use of a mechanical lift for transfers and had not used one when she transferred Resident #1 from the bed to the wheelchair.

Based on facility policy review, observation, and interview the facility failed to maintain a sanitary kitchen with open to air food items/unsealed food items in 1 of 2 bread racks. The facility failed to maintain kitchen equipment in a sanitary manner in 1 of 1 kitchen. The facility failed to maintain a sanitary kitchen with open to air/unsealed food items, not placed in a container after opened, in 1 of 2 food preparation tables. The facility failed to maintain a sanitary kitchen with open to air/unsecured, undated with an open date, and undated food items with a use by date in 1 of 1 walk in freezers. The facility failed to maintain a sanitary kitchen with open to air/unsealed, undated with an open date, undated with a use by date in 1 of 1 walk in refrigerators in 1 of 1 kitchen potentially affecting 114 of 116 residents. The findings include: Review of the facility's policy, Food Storage, dated 3/25/2012, revealed .Food is stored and prepared in a clean safe sanitary manner .Purpose .To minimize contamination and bacteria .All food items opened should have open date and be sealed . Review of the facility's policy, Dry Food Storage, dated 3/26/2012, revealed .Purpose .To ensure dry food is stored in a safe, sanitary manner to ensure the best food quality .Open food items will be stored in clean, dry, sealed containers with contents noted and opened dates . Review of the facility's policy, Cold Storage Area, dated 4/1/2021, revealed .Cold food(s) will be stored under safe and sanitary conditions .Date, label, and properly secure all products removed from original containers with all items labeled stating the contents inside, the date opened, and the appropriate use-by date . Review of the facility's policy, Equipment Cleaning, undated, revealed .Purpose .To ensure food safety .All equipment including drawers, trays, and surfaces should be clean and free of debris . During an observation on 8/15/2022 at 10:23 AM, of the bread rack, in the kitchen with the Dietary Manager (DM) revealed: -3 slices of whole wheat bread in a clear plastic bag, open to air/unsealed, and available for resident use. -1 hamburger bun in a clear plastic bag, open to air/unsealed, and available for resident use. -8 slices of white bread in a plastic bag, open to air/unsealed, and available for resident use. During an interview on 8/15/2022 at 10:26 AM, the Dietary Manager (DM) confirmed the bread on the bread rack was available for resident consumption and was open to air and unsealed. The DM confirmed the facility failed to maintain a sanitary kitchen with open to air and unsealed food-items available for resident use. During an observation on 8/15/2022 at 10:33 AM, of the crumb tray under the grill, in the kitchen, with the DM revealed scattered brown food debris and a white powdered substance scattered throughout the crumb tray. During an interview on 8/15/2022 at 10:35 AM, the DM stated the crumb tray should be cleaned every time the grill was used by the dietary staff. The DM confirmed the facility failed to maintain a sanitary kitchen with an unclean crumb tray containing food debris and a powdered substance. During an observation on 8/15/2022 at 10:40 AM, of the metal shelf, at the food preparation table, in the kitchen, with the DM revealed: -1 five-pound white bag of grits approximately 1/2 full open to air/unsealed, not placed in a container after opened, and available for resident use. -1 one-pound box of light brown sugar approximately 3/4 full open to air/unsealed, not placed in a container after opened, and available for resident use. During an interview on 8/15/2022 at 10:45 AM, the DM stated the grits and brown sugar should have been placed in a container after opened by the dietary staff. The DM confirmed the facility failed to maintain a sanitary kitchen with food items opened to air/unsealed and not placed in a container after opened by the dietary staff. During an observation on 8/15/2022 at 10:56 AM, of the walk-in freezer, in the kitchen, revealed one 5-pound bag of tater tots in a white plastic bag open to air/unsecured, undated when opened, and not dated with a use by date. During an interview on 8/15/2022 at 11:00 AM, the DM confirmed the facility failed to maintain a sanitary kitchen with tater tots, open to air/unsecured, undated when opened, and undated with a use by date. The DM confirmed the food was available for resident use. During an observation on 8/15/2022 at 11:02 AM, of the walk-in refrigerator, in the kitchen, revealed a 5-pound plastic bag of shredded lettuce approximately 1/2 full, open to air/unsealed, undated when opened, undated with a use by date, and available for resident use. During an interview on 8/15/2022 at 11:02 AM, the DM confirmed the facility failed to maintain a sanitary kitchen with the shredded lettuce open to air/unsealed, undated when opened, undated with a use by date, and available for resident use.

Based on review of the Centers for Disease Control (CDC) guidance, review of the facility policy, review of facility documentation, observation, and interview, the facility failed to ensure 1 of 1 COVID-19 (an infectious disease caused by the [CONDITION(S)]-CoV-2 virus) unvaccinated staff observed donned appropriate Personal Protective Equipment (PPE) to ensure precautions were taken to properly prevent COVID-19 transmission to 5 of 113 residents in the facility. The findings include: Review of the CDC guidance titled, Interim Infection Prevention and Control Recommendations to Prevent [CONDITION(S)]-CoV-2 Spread in Nursing Homes, dated 2/2/2022, showed .HCP [health care personnel] who are not up to date with all recommended COVID-19 doses .Residents .cared for by HCP using an N95 or higher-level respirator . Review of the facility policy titled, COVID-19 Vaccination Policy, dated 4/22/2022, showed .to help reduce the risk residents and staff have of contracting and spreading COVID-19 .Staff who receive an exemption to the COVID-19 vaccine will be subject to additional precautions which includes [include] .Requiring unvaccinated staff to use .N-95 [respiratory protective device designed to achieve a very close facial fit and very efficient filtration of airborne particles] . Review of the facility's COVID-19 Staff Vaccination Status for Providers document showed Certified Nursing Assistant (CNA) #2 had a COVID-19 religious vaccination exemption. Review of facility test reporting showed CNA #2 had a negative COVID-19 test at the beginning of shift on 8/17/2022. Review of CNA #2's resident assignment for 8/17/2022, revealed the CNA was assigned to care for 5 residents (#92, #30, #100, #107 and a newly admitted resident) on the same hall. Resident #92 was admitted on [DATE] with Non-Traumatic [CONDITION(S)]. The resident was fully vaccinated and had received the booster for Covid-19. During an observation on 8/17/2022 at 9:00 AM, CNA #2 wore a surgical mask and was not wearing an N-95 mask as she exited Resident #92's room. During an interview on 8/17/2022 at 9:10 AM, CNA #2 confirmed she was unvaccinated, and .I am supposed to wear an N-95 . in the facility. CNA #2 stated she was had asthma symptoms at the beginning of the shift, supervisor was informed, and testing was performed for COVID-19 on the morning of 8/17/2022. CNA #2 stated a N-95 mask was not worn because of shortness of breath. During an observation and interview on 8/17/2022 at 9:20 AM, the Infection Preventionist confirmed CNA #2 was not wearing an N-95 mask, and there were no shortages of N-95 masks in the facility. The Infection Preventionist stated it was expected unvaccinated staff wear a N-95 at all times in the facility.

Based on the facility policy review, medical record review, observation, and interview, the facility failed to complete an assessment for self-administration of medications by the interdisplinary team for 1 resident (Resident #141) of 27 residents observed. The findings include: Review of the facility policy titled, Resident Self Administration Policy, dated 6/7/2022, revealed .In order for a resident to be considered for self-administration of medication .assessment will be performed by a nursing team member to ensure that the resident is safe to administrator and the medication is safe to be administered .if assessment meets criteria, an order will be obtained from medical provider, a lock box will be provided for resident in room with a key . Resident #141 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #141's care plan dated 4/28/2022, showed no documentation for self-administration of medications. Review of Resident #141's Minimum Data Set quarterly assessment dated [DATE], showed Brief Interview of Mental Status score was 13 which indicated resident was cognitively intact, and resident was independent with eating. During an observation on 8/15/2022 at 10:13 AM, showed Normal saline nasal spray (spray used to moisten inside of nose) and Oymetazoline nasal solution (medication spray to relieve nose stuffiness) nose spray at bedside for resident use. During an interview on 8/15/2022 at 11:45 AM, the Director of Nursing (DON) confirmed the medications were at the resident's bedside for resident use and should not have been stored in the resident's room. The DON stated Resident #141 had not been assessed for self-administration of medications.

Based on review of facility policy, facility documentation, and interview, the facility failed to ensure confidentialiy of resident record for 1 resident (#5) of 5 residents reviewed for resident records. The findings include: Review of the facility's Policy titled, .HIPPA POLICY last reviewed 1/10/2022 showed .To maintain the confidentiality of our residents record (paper/electronic file) . Confidential Information includes but is not limited to PHI [Protected Health Information], any information about patients .any patient records . Review of the medical record showed Resident #5 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] showed Resident #1's Brief Interview of Mental Status (BIMS) score was 11 indicating the resident had moderate cognitive impairment. Review of facility documentation showed .March 8, 2022 [Resident #1's daughter] requested medical records from us for her mother. The daughter stated that she received information that did not belong to her mother. After investigation and review of the records, there was one piece of paper (pharmacy recommendation) included in her mother's information that belonged to [Resident #5] . Review of a pharmacy recommendation document for Resident #5 showed .Date 3/1/22 Patient Name: [Resident #5] Patient Full Address [Resident #5's address] . During an interview on 4/12/2022 at 12:45 PM, the Assistant Administrator stated .[Resident #1's daughter] called on the 8th [3/8/2022] .and reported that she had received someone else's medical record .we went through the medical records that were sent to her to see what exactly she was talking about and there was one paper that was in there it was a pharmacy recommendation for [Resident #5] .it was sent and I instructed her to destroy the document and that it was not intended for her .

Based on facility policy review, medical record review, facility fall investigation review, and interview, the facility failed to ensure devices utilized to prevent falls were properly working for 1 resident (Resident #1) of 3 residents reviewed for falls. The facility's failure to ensure an assistive device was properly functioning resulted in multiple fractures and actual Harm to Resident #1. The findings include: Review of the Facility Policy, Fall Intervention Protocol, revised 9/15/2020, showed, .fall interventions is considered a team effort, with all three shifts and all departments actively participating and communicating. This is all in an effort to create the safest environment possible for our resident . Record review showed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Care Plan dated 2/5/2019 showed .Potential for falls R/T (related to) unsteady gait, weakness and dementia. Hx (history) of recent falls .I will be free from injurious falls over the next 90 days .Pad alarm to bed, and wheelchair . Review of the Care Plan eCare Tasks (Kardex), undated, showed .chair pad and attendant alarm (patient safety alarm) . Review of the Physician Orders List revealed an order dated 7/6/2020, .ALARMS: Bed Alarm, Chair Alarm . Review of the quarterly Minimum Data Set ((MDS) dated [DATE], showed Resident #1 had severe cognitive impairment. She required extensive assistance of 1 staff member for transfers and toileting, and limited assistance of 1 staff member for walking. The resident used a walker or wheelchair for mobility. The resident used a bed and chair alarm daily. Review of the Morse Fall Risk assessment dated [DATE], showed a fall risk score of 40, indicating the resident was at low risk for falls. Review of the facility's fall investigation dated 9/5/2020, showed Resident #1 had an unwitnessed fall on 9/5/2020 at 3:45 PM. The resident got up unassisted from a wheelchair and was found on her left side on the floor, in front of the bathroom of another resident's room. The resident sustained [REDACTED]. The resident was transported to the emergency room . Further review of the fall investigation revealed, .freq. (frequently) gets up unassisted .Alarm to w/c (wheelchair) - in place, not sounding at time of fall . Review of the hospital emergency room documentation dated 9/5/2020, showed .Diagnosis .Nondisplaced Type II dens fracture (fracture in the neck) .Fracture of orbital floor, left side (eye socket fracture) .Maxillary fracture (mid-face fracture) . Further review revealed the resident was transferred to another hospital for treatment. Interview with the Director of Nursing (DON) on 10/22/2020 at 9:25 AM, confirmed Resident #1 had a fall on 9/5/2020 during change of shift from day shift to evening shift. The fall occurred while the nurses were giving report from one shift to the other. The resident had wheeled herself in a wheelchair to another resident's room and fell in front of the bathroom door. Licensed Practical Nurse (LPN) #1 had worked the day shift (7:00 AM-3:00 PM) and LPN #2 worked the evening shift (3:00 PM-11:00 PM) shift. The Weekend Supervisor also worked that day. During an interview on 10/22/2020 at 10:05 AM, LPN #1 stated she had last seen Resident #1 right before she went to give report to the evening shift nurse. The resident was sitting in front of the nurse's station. LPN #1 was giving report to the evening shift nurse (LPN #2) in the medication room at the time of the fall. When they had finished report and came out of the medication room, she heard a faint help coming from down the hall. LPN #1 went down the hall and found Resident #1 lying on the floor in another resident's room in front of the bathroom door. LPN #1 stated Resident #1 was found 2 rooms down from Resident #1's own room. LPN #1 stated the resident was a fall risk and interventions used at the time included: keeping her in eyesight, toileting schedule every 2 hours, offering snacks, and if she wanted to go to bed the staff would assist her to lie down. LPN #1 stated the resident required one person assistance with transfers, but would sometimes try to get up without assistance. At the time of the fall, Resident #1 had her non-skid socks on and a chair pad alarm. The chair alarm did not sound at the time of the fall, but was on the chair. LPN #1 stated the resident had been confused and had been wheeling herself in a wheelchair, roaming the hall earlier in the day, which was normal for the resident. LPN #1 stated Resident #1 had been found lying on her left side with blood coming from her nose, a scrape on her cheek, and a laceration on her forehead. During a phone interview on 10/22/2020 at 11:38 AM, Certified Nursing Assistant (CNA) #2 confirmed she had worked the day and evening shifts on 9/5/2020. CNA #2 stated Resident #1 had wheeled herself around in her wheelchair during the day, but that was normal for the resident. CNA #2 stated she had last seen the resident wheeling herself in the hallway before the CNA entered a room to answer a call light. When CNA #2 came out of the room from answering the call light, she was notified of the fall. CNA #2 stated Resident #1 did have an alarm on her wheelchair, but the alarm did not sound at the time of the fall. CNA #2 stated the resident was at risk for falls. During a phone interview on 10/22/2020 at 12:54 PM, CNA #3 confirmed she worked the evening shift on 9/5/2020. CNA #3 stated she had seen Resident #1 in her wheelchair, in the hallway, less than 30 minutes prior to the fall. CNA #3 had been putting linen in the rooms and walked around the nurse's station when she heard someone saying help. CNA #3 went to the resident and found her lying in the floor in another resident's room. CNA #3 stated no alarm sounded at the time of the fall. CNA #3 stated Resident #1 was at risk for falls with interventions including: fall mats, nonskid socks, and the resident to be monitored in the hallway. During a phone interview on 10/22/2020 at 2:12 PM, the Weekend Supervisor stated she was outside with a family member at the time the fall occurred. When she entered the room, the resident was on her side and she was bleeding from the nose and mouth. She stated the fall occurred at change of shift and there were 2 nurses and several CNAs on the unit at the time of the fall. The Weekend Supervisor stated the resident was at risk for falls. During a phone interview on 10/22/2020 at 2:23 PM, LPN #2 confirmed she had just started work on 9/5/2020 and had been in the medication room with LPN #1 to receive report. When the nurses came out of the medication room, LPN #1 heard someone yell out and found Resident #1 lying on the floor. LPN #2 stated the chair alarm was not sounding at the time of the fall. During an interview on 10/22/2020 at 3:08 PM, the Nurse Practitioner (NP) confirmed the resident would attempt to get up unassisted. The NP stated the resident had a physician's order for a chair alarm and it was her expectation for orders to be followed. The NP confirmed the chair alarm should have alarmed at the time of the fall. During an interview and review of the facility's fall investigation on 10/22/2020 at 3:30 PM, the DON confirmed Resident #1 had frequently attempted to get up unassisted and confirmed the alarm did not sound at the time of the fall on 9/5/2020. The DON stated the facility completed an investigation, but did not determine the reason the alarm did not sound.

Based on medical record review, facility fall investigation review, and interview, the facility failed to follow the care plan for fall interventions to prevent a fall for 1 resident (Resident #1) of 3 residents reviewed for falls. The facility's failure to ensure the care plan was implemented resulted in Resident #1 sustaining multiple fractures and actual Harm to the resident. The findings include: Record review showed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident was discharged from the facility on 9/10/2020. Review of Resident #1's care plan dated 2/5/2019, showed, .Potential for falls R/T (related to) unsteady gait, weakness and dementia. Hx (history) of recent falls .I will be free from injurious falls over the next 90 days .Pad alarm to bed, and wheelchair . Review of the Care Plan eCare Tasks (Kardex - summary of resident needs/information), undated, showed, .chair pad and attendant alarm (patient safety alarm) . Review of the quarterly Minimum Data Set ((MDS) dated [DATE], showed Resident #1 had severe cognitive impairment. She required extensive assistance of 1 staff member for transfers and toileting, and limited assistance of 1 staff member for walking. Resident #1 used a walker or wheelchair for mobility. The resident used a bed and chair alarm daily. Review of the Morse Fall Risk assessment dated [DATE], showed a fall risk score of 40, indicating the resident was at low risk for falls. Review of the facility's fall investigation dated 9/5/2020 showed Resident #1 had an unwitnessed fall on 9/5/2020 at 3:45 PM. The resident got up unassisted from a wheelchair and was found on her left side, on the floor, in front of the bathroom in another resident's room. The resident sustained [REDACTED]. The resident was transported to the emergency room . Further review of the fall investigation revealed, .freq. (frequently) gets up unassisted .Alarm to w/c (wheelchair) - in place, not sounding at time of fall . Review of the hospital emergency room documentation dated 9/5/2020, showed .Diagnosis .Nondisplaced Type II dens fracture (fracture in the neck) .Fracture of orbital floor, left side (eye socket fracture) .Maxillary fracture (mid-face fracture) . Further review revealed Resiident #1 was transferred to another hospital for treatment. During an interview on 10/22/2020 at 10:05 AM, Licensed Practical Nurse (LPN) #1 stated when she and LPN #2 had finished report and came out of the medication room, she heard a faint help coming from down the hall. LPN #1 went down the hall and found Resident #1 lying on the floor in another resident's room, in front of the bathroom door. LPN #1 stated the chair alarm did not sound at the time of the fall, but was on the chair. During a phone interview on 10/22/2020 at 11:38 AM, Certified Nursing Assistant (CNA) #2 confirmed she had worked the day and evening shifts on 9/5/2020. CNA #2 stated she had last seen the resident wheeling herself in the hallway before the CNA entered a room to answer a call light. When the CNA came out of the room from answering the call light, she was notified of the fall. CNA #2 stated Resident #1 did have an alarm on her wheelchair, but the alarm did not sound at the time of the fall. During a phone interview on 10/22/2020 at 12:54 PM, CNA #3 confirmed she worked the evening shift on 9/5/2020. CNA #3 stated she had seen Resident #1 in her wheelchair, in the hallway, less than 30 minutes prior to the fall. CNA #3 had been putting linen in the rooms and walked around the nurse's station when she heard someone saying help. CNA #3 found Resident #1 lying on the floor in another resident's room. CNA #3 was unable to recall if Resident #1 had an alarm on her wheelchair on that date, but no alarm sounded at the time of the fall. During a phone interview on 10/22/2020 at 2:23 PM, LPN #2 stated she had just started work on 9/5/2020 and had been in the medication room with LPN #1 to receive report. When the nurses came out of the medication room, LPN #1 heard someone yell out and found Resident #1 lying on the floor. LPN #2 confirmed the chair alarm was not sounding at the time of the fall. During an interview on 10/22/2020 at 3:30 PM, the Director of Nursing confirmed the chair pad alarm, which was an intervention on Resident #1's care plan to prevent falls, was not functioning on 9/5/2020 when Resident #1 had a fall and sustained multiple fractures.

Based on review of the facility policy, observation, and interview, the facility failed to properly date and label frozen food items available for resident consumption for 1 of 3 Cottage kitchens, potentially affecting 29 of 30 residents; failed to maintain refrigerated food items in a sanitary manner in 3 of 3 nourishment rooms; and failed to maintain the sanitation of 2 of 3 ice machines, potentially affecting 115 of 116 residents. The findings include: Review of the facility policy Food Labeling and Dating Guidelines for Cold Storage, undated, revealed .Items must have a label stating the contents inside .foods that are removed from their original packaging should be labeled with the date it was received and expiration date or use by date . Review of the facility policy Food Brought into Facility, dated 12/6/16, revealed .Outside foods requiring storage and refrigeration must be dated, labeled and stored per facility and state guidelines . Review of the facility policy Personal Food Storage, dated 10/3/17, revealed .Food Brought in by outside sources will be monitored .All food and beverages brought in by outside sources will be labeled and dated .Food .in the original containers .unopened will be labeled with resident name and date received . Review of the facility policy Ice Machine Policy, undated, revealed .Ice machine will be cleaned according to manufacturers recommendations quarterly this will be completed by maintenance department . Observation with the Certified Dietary Manager (CDM) on 9/16/19 at 2:05 PM, of the Franklin Cottage pantry freezer, revealed the following items had been removed from their original package and placed in ziplock bags: 4 individual pieces of 6 ounce of tilapia fillets, undated and unlabeled. 2 gallon-sized bags of beef fingers, undated and unlabeled. 1 gallon-sized bag of chicken breasts, unlabeled. 1 gallon-sized bag of catfish fillets, undated and unlabeled. 1 gallon-sized bag of hot dogs, undated and unlabeled. 1 gallon-sized bag containing a 4 pound meatloaf, unlabeled. 1 gallon-sized bag of pollock fillets, undated and unlabeled. 1 four pound bag of rope sausage, undated and unlabeled. 1 gallon-sized bag of Philly cheese steaks, undated and unlabeled. 1 gallon-sized bag of ham, undated and unlabeled. 1 gallon-sized bag of breaded pork chops, undated and unlabeled. 1 gallon-sized bag of drumsticks, undated. 1 three or 4 pound package of meatballs, opened. Interview with the CDM on 9/16/19 at 2:25 PM, in the Franklin Cottage pantry, confirmed, .It should all be dated and labeled . Observation and interview with the CDM on 9/17/19 at 3:41 PM, in the Unit 100 hallway nourishment room, revealed: (1)- Chocolate Peanut Butter Silk Pie with ¼ of pie remaining in the refrigerator dated 9/15/19. (1)- Butterfinger Pie with ¼ of pie remaining in the refrigerator dated 9/15/19. The CDM confirmed the pies had been brought in by family members and had not been labeled with resident names. Observation and interview with the CDM on 9/17/19 at 3:48 PM, in the Unit 200/300 hallway nourishment room, revealed: (1)- 10 ounce jar of orange marmalade in the refrigerator opened and undated. (1)- 32 ounce box of chicken broth in the refrigerator opened and undated. (4)- 4 ounce cups of mandarin oranges in the refrigerator. (1)- boxed frozen meal of Alfredo pasta with chicken and broccoli in the freezer. (8)- 4.6 ounce cans of small hotdog sausages in the cabinet. The CDM confirmed food items above were brought in by family/visitors and had not been labeled with resident name/room number and dated when opened. Observation and interview with the CDM on 9/17/19 at 3:57 PM, on the 400 hallway nourishment room, revealed: (1)- 8 fluid ounce bag of squeezable mayonnaise opened and undated. The CDM confirmed the food item above had been brought in by family/visitors and had not been labeled with resident name/room number and dated when opened. Observation and interview with the CDM on 9/17/29 at 4:00 PM, on the Unit 400 hallway nourishment room, revealed the ice chest machine with a blackish gray substance to the inside tray below the ice maker. The CDM confirmed the ice chest machine was dirty. Observation and interview with the CDM on 9/17/19 at 4:07 PM, on the Unit 100 hallway nourishment room, revealed the ice chest machine with a blackish gray substance to the inside tray below the ice maker. The CDM confirmed the ice chest machine was dirty. Interview with the Director of Nursing (DON) on 9/17/19 at 4:10 PM, in the DON's office, confirmed his expectation was for food to be labeled.

Based on review of standards for nursing practice, facility policy review, medical record review, and interview, the facility failed to assess the vascular access for 1 resident (#54) of 2 residents who received [MEDICAL TREATMENT] of 45 residents sampled. The findings include: Review of Nursing Management (Springhouse): (MONTH) 2010- Volume 41-Issue 10- pg 47 revealed .Caring for a patient's vascular access for [MEDICAL TREATMENT] .to protect and preserve the vascular access and avoid complications .Assess for patency (absence of blockage) at least every 8 hours . Review of the facility policy for Post [MEDICAL TREATMENT] Care revised 6/2018 revealed the post-[MEDICAL TREATMENT] nursing assessment includes .Assessment of dressing site for bleeding .Assessing [MEDICAL TREATMENT] catheter .dry and intact dress . Medical record review revealed Resident #54 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Quarterly Minimum (MDS) data set [DATE] revealed a Brief Interview for Mental Status score of 14 indicating the resident was cognitively intact. Further review revealed the resident received [MEDICAL TREATMENT]. Medical record review of the care plan dated 1/1/17 revealed the resident required [MEDICAL TREATMENT] 3 times a week and had an AV (arteriovenous) shunt (access site for [MEDICAL TREATMENT]) in the right arm. Further review revealed .CHECK COLOR AND TEMP OF THE FINGERS AND PULSES ON THE ACCESS ARM FOR ADEQUATE CIRCULATION, AND MONITOR FOR S/S (signs and symptoms) OF INFECTION TO ACCESS SITE .MONITOR SHUNT FOR BLEEDING , AND DO NOT TAKE BLOOD PRESSURE IN THE ACCESS ARM Medical record review revealed no documentation of assessment of the vascular access. Interview with the Director of Nursing (DON) on 9/19/18 at 9:47 AM, in the conference room, confirmed the facility failed to monitor the vascular access for Resident #54.

Based on policy review, medical record review, facility documentation review, and interview the facility failed to complete a thorough investigation for 1 resident (#247) of 26 residents reviewed for abuse of a total of 45 sampled residents. The findings include: Review of the facility policy Abuse, Neglect, Misappropriation Protocol revealed .The individual conducting the investigation will possibly include some or all of the following steps, depending upon the circumstances: .Interview the person(s) reporting the incident .witness reports will be reduced to writing. Witnesses will be required to sign and date such reports . Medical record review revealed Resident #247 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of facility documentation dated 7/27/18 revealed .charge nurse reported that resident (Resident #247) was in altercation with another resident (Resident #248). Residents wheel chairs became tangled up CNA (certified nursing assistant) separated residents Nurse reports that no contact was witnessed between residents nurse assessed resident (#247) from head to toe with no visible red marks, bruising, or scratches . Interview with the Quality Assessment (QA) nurse on 9/19/18 at 7:48 AM, at the 300 hall nurse's desk, revealed the QA nurse was asked by the Director of Nursing (DON) to complete the investigation on 7/27/18 of the residents. Continued interview revealed the QA nurse was not told or aware initially of Resident #247 being struck by Resident #248 on 7/27/18. Interview revealed the facility became aware of the resident to resident contact between Resident #247and #248 when visited by local police department. Interview with CNA #1 on 9/19/18 at 8:14 AM, by phone, revealed the CNA observed the two residents' wheelchairs tangled up, and observed Resident #248 hitting Resident #247 in the back 3 times. Continued interview revealed the residents were separated and the CNA reported to the Charge Nurse what had happened. Interview with the Charge Nurse on 9/19/18 at 8:27 Am, by phone, revealed the Charge Nurse assessed both the residents with no visible marks, or bruising present. Continued interview revealed the Charge Nurse seperated the residents and reported the incident to the DON. Interview with the Administrator and DON on 9/19/18 at 1:33 PM, in the Administrators office, revealed the Administrator and DON were informed of the incident and initially thought residents only got wheelchairs stuck together until visited by the local police department. Continued interview confirmed the facility failed to complete a thorough investigation, and failed to follow the facility policy for Abuse investigations.

Based on medical record review, observation, and interview, the facility failed to implement a bladder retraining program, after a decline in urinary continence, for 2 (#77 and #117) residents of 3 residents reviewed for urinary incontinence of 27 residents reviewed. The findings included: Medical record review revealed Resident #77 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the admission Minimum Data Set ((MDS) dated [DATE] revealed the resident was always continent of urine. Medical record review of the quarterly MDS dated [DATE] revealed the resident was frequently incontinent of urine. Medical record review of the Bowel and Bladder assessment dated [DATE] revealed the resident scored a 14 indicating the resident was a candidate for a toileting schedule and the resident's voiding pattern was to be established. Interview with Licensed Practical Nurse (LPN)/MDS nurse #1, on 8/23/17 at 8:35 AM, in the MDS office, revealed LPN #1 had completed the Bowel and Bladder Assessment form dated 6/4/17 and gave the completed form to the Unit Manager for further action. Observation and interview with Resident #77 on 8/23/17 at 9:55 AM, in the resident's room, revealed the resident lying on the bed. Interview with the resident revealed the resident was sometimes aware of the need to void. Interview with Registered Nurse (RN)/Unit Manager (#1) on 8/23/17 at 9:00 AM, at the nursing station revealed RN #1 had referred the resident to therapy to screen for toileting after receiving the Bowel and Bladder Assessment from LPN #1. Interview with the Rehabilitation Manager on 8/23/17 at 9:10 AM, at the nursing station revealed the therapy department had not received a referral to screen the resident for a toileting program. Interview with RN #1 on 8/23/17 at 9:20 AM, at the nursing station, confirmed a bladder retraining program had not been developed for Resident #77. Medical record review revealed Resident #117 was admitted to the facility 4/12/15 with [DIAGNOSES REDACTED]. Medical record review of the Annual MDS dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) score of 15 indicating the resident was independent in cognitive skills for daily decision making, and was occasionally incontinent of urine. Medical record review of the Quarterly MDS dated [DATE] revealed the resident had a BIMS score of 15, and was frequently incontinent of urine. Medical record review of the Bowel and Bladder assessment dated [DATE] revealed . total score 15 .Score 21-15-Good candidate for individual training . Observation and interview on 8/23/17 at 8:50 AM, with the resident in the resident's room revealed the resident seated in a wheelchair. Interview with the resident revealed was sometimes aware of the need to void. Interview with the Rehabilitation Manager on 8/23/17 at 9:10 AM, at the Nursing Station, confirmed the therapy department did receive a referral for Resident #117, but an individualized bladder retraining program had not been developed for the resident.

Based on facility policy review, medical record review and interview, the facility failed to investigate and report to the state Survey and Certification agency an injury of unknown origin for 1 resident (#231), of 4 residents reviewed for injuries, of 30 residents reviewed. The findings included: Review of the facility policy Abuse Prevention Policy revised 7/1/14 revealed .The facility will promote policies and procedures to prohibit and prevent mistreatment, neglect and abuse of residents .This would include self- injurious behaviors .or heavy care or totally dependent on staff .Also procedures that identify events, incidents, patterns or trends that may constitute abuse include suspicious bruising, skin tears, injuries of unknown origin .The facility will ensure that all substantiated violations involving mistreatment, neglect, or abuse are reported to the State of Tennessee within three (3) days from the date of occurrence following a thorough investigation . Medical record review revealed Resident #231 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Continued review revealed the resident was discharged from the facility on 2/12/14. Review of the Admission Minimum (MDS) data set [DATE] revealed Resident #231 had a Brief Interview for Mental Status (BIMS) score of , indicating the resident had moderate cognitive impairment. Continued review revealed the resident required extensive assistance with Activities of Daily Living including transfers, bed mobility, dressing and toilet use. Medical record review of an X-ray report dated 10/2/14 revealed subacute nondisplaced fractures of the left tibia and fibula. Medical record review of a second X- ray report dated 10/2/15 revealed an X-ray was performed of resident's left ankle and foot with 3 views. Continued review revealed no fracture or dislocation was identified. Continued review revealed diffuse [MEDICAL CONDITION] changes noted. Extensive soft tissue [MEDICAL CONDITION] was identified. Medical record review of the Physician order dated 10/3/14, revealed an order to get a bone scan related to osteo[DIAGNOSES REDACTED] and an orthopedic consult as soon as possible. Further interview revealed the injury was of unknown origin. Medical record review of a physician progress notes [REDACTED]. Continued review revealed plans to get orthopedic consult as soon as possible and a bone scan. Medical record review of an Orthopedic Consult dated 10/8/14 revealed .He (Resident #231) presents with pain and fracture on the left side .He states that the symptoms have been acute traumatic and began on 10/2/14 .He states that the symptoms began as a result of a fall. Continued review revealed the Resident #231 had a short leg well-padded and molded cast placed on lower left leg. Further review revealed the resident had a left tibia/fibula fracture. Interview with Family Nurse Practitioner #1 in the DON office on 10/6/15 at 1:17 PM revealed the resident had several diseases that put the resident at risk for fractures. Continued interview revealed Resident #231 had [MEDICAL CONDITIONS], Diabetes, [MEDICAL CONDITION], and [MEDICAL CONDITION]. Continued interview revealed the resident was diagnosed with [REDACTED]. Further interview revealed she was aware of fracture on 10/2/14 Continued interview revealed she was unaware of how resident developed the fracture. Interview with the Administrator on 10/6/15 at 3:35 PM, in the Administrators Office confirmed the facility failed to investigate and report to the state an injury of unknown origin.

Based on review of facility policy, medical record review, observation and interview the facility failed to ensure Isolation Precautions were maintained to prevent cross contamination for 2 residents ( #154, #183) of 4 residents win Isolation Precautions, of 30 sampled residents. The findings included: Review of facility policy, Isolation Precaution, Categories of, revised date April 2001, revealed .In addition to Standard Precautions, Contact Precautions must be implemented for a resident known or suspected to be infected or colonized with microorganisms that can be transmitted by direct contact with the resident or indirect contact with environmental surfaces or patient-care items in the resident's environment. Examples of infections requiring Contact Precautions include, but are not limited to: .Clostridium Difficile (C-Diff) .Gloves and Handwashing 1. In addition to wearing gloves as outlined under Standard Precautions wear gloves (clean, nonsterile) when entering the room. 2. During the course of caring for a resident, change gloves after having contact with infective material that may contain high concentrations of microorganisms (fecal material and wound drainage). 3. Remove gloves before leaving the room and wash hands immediately with an antimicrobial agent or a waterless antiseptic agent. 4. After glove removal and handwashing, ensure that hands do not touch potentially contaminated environmental surfaces or items in the resident's room .Gown 1. In addition to wearing a gown as outlined under Standard Precautions, wear a gown (clean, non-sterile) when entering the room if you anticipate that your clothing will have substantial contact with the patient, environmental surfaces, or items in the patient's room; If the resident is incontinent; or if the resident has diarrhea, an ileostomy, a colostomy, or wound drainage not contained by a dressing . Medical record review of a Physicians Progress Note dated 10/5/15 revealed, Resident #154 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Observation of Certified Nurse Assistant (CNA) #1 on 10/5/15 at 12:30 PM, revealed CNA #1 entered the residents room wearing gloves and delivered a meal tray. Further observation revealed CNA #1 removed the gloves, left the room and applied new gloves without sanitizing her hands. Interview with CNA #1 on 10/5/15 at 12:35 PM, outside the residents room confirmed CNA #1 failed to sanitize her hands after removing soiled gloves. Medical record review revealed Resident #183 was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the 5 day MDS dated [DATE] Section H. revealed .frequently incontinent of bowel . Observation of CNA #1 on 10/06/15 at 8:50 AM revealed CNA #1 was in Resident #183's room, not wearing an isolation gown, was seated in a chair at bedside, feeding the resident who was lying in the bed. Interview with Licensed Pratrical Nurse (LPN) #1 on 10/6/15 at 8:40 AM, in her office, confirmed she would expect staff to wash hands between contact with residents and after removing gloves. Continued interview revealed she would expect staff to wear gloves when entering isolation rooms. Interview with LPN #1 on 10/6/15 at 8:50 AM, in the hallway outside of residents room, revealed she would expect CNA #1 to wear a gown while seated in resident isolation room due to risk of contamination. Interview with the Director of Nursing (DON) on 10/06/15 at 8:55 AM, in the front entrance lobby, confirmed staff should wash hands between contact with residents and after removal of gloves. Continued interview revealed, would expect staff to wear gloves and gowns and when providing care to residents with[DIAGNOSES REDACTED] per facility policy and confirmed the facility policy was not followed.

Based on medical record review, observation, and interview, the facility failed to ensure safety devices were on and functioning for two (#207, #7) residents of four residents reviewed for falls of twenty-nine residents reviewed. The facility's failure to ensure the use of a gait belt resulting in HARM for resident #207. The findings included: Resident #207 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Care Plan dated May 29, 2014, revealed the problem of falls and the approaches included "Use gait belt when assisting with transfers and ambulation." Medical record review of the Minimum Data Set (MDS) with a reference date of June 17, 2014, revealed the resident had severely impaired eyesight, did not have impaired cognition, required extensive assist for transfers and ambulation, used a walker, and balance was not steady during transitions and walking. Medical record review of a Physical Therapy Plan of Care dated July 2, 2014, revealed "...Balance, Static Standing...Requires handheld support and moderate assistance to amintain position...Balance, Dynamic Standing...Unable to accept challenge or or move without loss of balance...Balance, Fall Risk...High risk...Cognition, Functional Limitations...safety limited by need for assist in transfers, gait...contact guard assist (contact with patient due to unsteadiness)...backwards trunk lean...deficits during turning..." Medical record review of a written notification to the Medical Director dated July 8, 2014, revealed, "Resident fell walking from bathroom. Resident hit the back of resident's head. C/o (complained of) lower back pain...transfer to ER (emergency room ) for evaluation..." Medical record review of the ER physician's orders [REDACTED]." Medical record review of a radiology report of the XR LUMBAR SPINE dated July 8, 2014, revealed, "There is a subtle deformity of the superior endplate of L1 (lumbar vertebra #1), new from recent CT study. This is most compatible with a minimal compression fracture. The remaining lumbar vertebrae are normally maintained in height. IMPRESSION: Subtle superior endplate compression fracture of L1, new from CT study of 2 June 2014. Multilevel degenerative changes..." Medical record review of the physician's orders [REDACTED]. Review of facility policy, Gait Belt Policy, revealed, "All employees must use a gait belt when transferring any resident whom does not require a lift for transfers. This includes, but not limited to, transferring to W/C (wheelchair), toilet, bed, or ambulating in the hallway." Medical record review of a Nursing - Therapy Referral form dated July 8, 2014, revealed "...Resident ambulating with walker and fell backwards...No shoes or socks on..." Observation of the resident on July 21, 2014, at 8:40 a.m., and on July 23, 2014, at 8:45 a.m., revealed the resident sleeping in bed. Observation of the resident on July 23, 2014, from 12:15 p.m., until 12:40 p.m., revealed the resident seated at the bedside eating lunch. Interview with the resident, at the time of the observation, revealed the resident had continued to have plans to return home at the end of therapy. Interview revealed the resident believed therapy "was going well." Interview on July 22, 2014, at 4:00 p.m., with the Director of Nursing (DON), in the conference room revealed the Certified Nurse Assistant (CNA) #1 was not using a gait belt when assisting the resident to the bathroom. Continued interview confirmed the proper use of the gait belt included holding the gait belt as a resident transferred and ambulated. Further interview revealed the DON stated CNA #1, "...let go of the resident to move the call light cord off of the floor...in the way..." Interview with the Physical Therapist at 8:30 a.m., on July 23, 2014, in the conference room revealed, "...we share our assessments with nursing...the problems with (the resident) maintaining balance was addressed with the rolling walker and the gait belt being held by the person helping...for some reason the CNA broke contact with (the resident)...sometimes the balance problems cause (resident) to lean to the side and sometimes to the back...fell backwards...held therapy for a week...did well last week when we resumed..." Interview with the Unit 1 Charge Nurse, at the nursing station on July 23, 2014, at 9:25 a.m., confirmed "All the residents are suppose to be transferred and ambulated with a gait belt...they are taught to use a gait belt with all transfers...each CNA has one given to them..." Interview with CNA #1 by telephone on July 23, 2014, at 9:10 a.m., revealed CNA #1 answered the bathroom call light, did not apply a gait belt, assisted the resident to the bed with resident using walker, and let go of the resident when stooping down to move the call light cord from the resident's pathway. Interview with the Medical Director by telephone on July 23, 2014, at 9:35 a.m., revealed, "If the CT the radiologist was comparing the lumbar x-rays to was done in June 2014, then I think you would have to conclude the compression fracture was related to the fall." Resident #7 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the fall risk assessment dated [DATE] and June 4, 2014, revealed the resident was a high risk for falls. Medical record review of the Care Plan reviewed on March 11, 2014, revealed "...Low bed at HS (bedtime) Bed pad alarm..." Review of the facility investigation dated March 31, 2014, revealed "...Resident attempted to transfer from bed to chair without assist resulting in a fall. No signs injury...Alarm not sounding at the time. Sitter educated to turn alarms on when putting resident to bed...Staff education on make sure alarms are on and properly working..." Observation on July 22, 2014, at 1:00 p.m. revealed the resident lying on the low bed with mat on the floor and the pressure pad alarm on the bed. Interview on July 22, 2014, at 2:30 p.m., with the DON, in the conference room confirmed the alarm was not turned on at the time of the fall on March 31, 2014. C/O #