Every finding on record at Life Care Center of Centerville

Based on policy review, medical record review, facility investigation review, and interview, the facility failed to provide evidence that all alleged violations of abuse were thoroughly investigated for 4 of 4 (Resident #48, #54, #58, and #59) sampled residents reviewed for abuse. The findings include: 1. Review of the facility's policy titled, Abuse-Protection of Residents reviewed 6/17/2024, revealed The facility will ensure that all residents are protected from physical and psychosocial harm during and after the investigation .methods to ensure the protection of residents during an investigation may include but not limited to Responding immediately to protect the alleged victim and integrity of the investigation Examining the alleged victim for any sign of injury, including a physical examination or psychosocial assessment if needed Immediate notification of the alleged victim's practitioner and the family or responsible party Removal of access by the alleged perpetrator to the alleged victim and that ongoing safety and protection is provided for the alleged victim and, as appropriate, other residents Notification of the alleged violation to other agencies or law enforcement authorities Evaluation of whether the alleged victim feels safe and if the he/she does not feel safe, taking immediate steps to alleviate the fear, such as room relocation, increased supervision Monitor the alleged victim and other residents at risk . Review of the facility's policy titled, Abuse-Identification of Types, reviewed 6/17/2024, revealed Sexual abuse a non-consensual sexual contact of any type with a resident Facility staff should report any suspected abuse, neglect, or exploitation .Sexual abuse is non-consensual sexual contact of any type with a resident, as defined at have the capacity to consent sexual contact is nonconsensual if the resident Appears to want the contact to occur but lacks the cognitive ability to consent . Review of the facility's policy titled, Abuse-Conducting an Investigation, reviewed 6/17/2024, revealed It is the policy of this facility that allegations of abuse (abuse, neglect, mistreatment, including injuries of unknown source, exploitation, and misappropriation of property) are promptly and thoroughly investigated. The facility will prevent further abuse, neglect, exploitation and mistreatment from occurring while the investigation is in progress; and take appropriate corrective action as a result of the investigation findings. Residents have the right to live at ease in a safe environment without the fear of retaliation when allegations are reported Following identification of alleged abuse, the resident (s) receive prompt medical attention as necessary and the resident are protected during the investigation to prevent recurrence The alleged victim will be examined for any sign of injury, including a physical examination or psychosocial assessment When an incident or suspected incident of resident abuse and/or neglect, injury of unknown source, exploitation, or misappropriation of resident property is reported, the administrator/designee will investigate the occurrence the investigation would include but is not limited to Conducting observations of alleged victims .Conducting interviews with the alleged victim and representative, alleged perpetrator, witnesses, practitioner Conducting record review for pertinent information related to the alleged violation .such as progress notes The written summary of the investigation should include but not limited to A review of the Incident Report An Interview with the person(s) reporting the incident Interviews with any witnesses to the incident An interview with the resident, if appropriate .a review of the resident ' s medical record .an interview with the employee(s) .a review of the employee's file Interviews with staff members on all shifts having contact with the resident at the time of the incident Interviews other residents who received care or services from the alleged perpetrator A review all circumstances surrounding the incident If the accused individual is an employee, the alleged perpetrator will be removed from resident care areas immediately and placed on suspension pending results of the investigation. Retaliation by staff is abuse, regardless of whether harm was intended, and must be cited If the accused abuser is another resident, the resident must be separated while investigating the incident. Interventions must be implemented to assure the safety of all residents .Any investigation of alleged resident sexual abuse must start with a determination of whether the sexual activity was consensual on the part of the resident. A resident's apparent consent to engage in sexual activity is not valid if it is obtained from a resident lacking the capacity to consent .The administrator or their designee will keep the resident and/or his/her representative informed of the progress of the investigation. The alleged victim will be protected from retaliation .The administrator or designee will inform the resident, physician, and/or resident representative of the results of the investigation and the corrective action taken. Emotional support and counseling will be provided to the resident during and after the investigation, as needed . Review of the facility's policy titled, Abuse-Reporting and Response-No Crime Suspected, reviewed 6/17/2024, revealed Ensure all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately but not later than 2 hours after the allegation is made, if the event that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the event that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides jurisdiction in long-term care facilities) All associates are mandated to immediately report suspected resident abuse and /or neglect to their immediate supervisor and/or facility representative All residents, families, resident representatives and visitors are encouraged to immediately report incidents of suspected resident abuse and/or neglect to facility administration .When an incident of resident abuse is suspected, the incident must be reported to the supervisor regardless of the time lapse since the incident occurred. The supervisor notifies the director of nursing and the executive director of the alleged incident All alleged violations .must be reported to the administrator of the facility and to other officials in accordance with State Law through established procedures .the facility should retain documentation of the report .The supervisor and /or charge nurse will illicit the following information .the name of the resident involved in the incident .date and time the incident occurred .where the incident took place .name(s) of the person(s) committing or involved in the incident .name(s) of any witnesses to the incident .type of abuse and /or neglect that was committed additional information that may be pertinent to the incident .the nurse will complete and sign the Incident Report and notify the physician and the resident's representative of the occurrence . Review of the facility's policy titled, Incident and Reportable Event Management, reviewed 9/14/2023, revealed Ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately but no later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) Event Management includes, but is not limited to , the following types of events Alleged Abuse Sexual, Physical, Verbal, Mental, or Exploitation . 2. Review of the medical record revealed Resident #48 was admitted revealed resident was admitted to the facility on [DATE], with diagnoses including Chronic Obstructive Pulmonary Disease, Diabetes, Hypertension, Heart Failure, Alzheimer's Disease, and Depression. Review of Nurse's Note dated 7/19/2024, revealed Weekly summary: Resident is alert and oriented x [times] 3 and is pleasant and cooperative with staff. Is able to make some needs known and some are anticipated . Resident is incontinent of B&B [bowel and bladder] and requires assist of staff for peri care and brief changes. Requires assistance for all transfers to and from bed, wheelchair and toilet. Once in wheelchair requires assist of staff for to propel in room and hallways. Attends activities desired. Requires assist with bed mobility . Review of the quarterly Minimum Data Set (MDS) dated [DATE], revealed a Brief Interview of Mental Status (BIMS) score of 12 indicating Resident #48 was moderately cognitively impaired. Resident was dependent on staff with assistance in toileting and required max assistance of staff with performing transfers. Resident was assessed as always regarding incontinence with bowel and bladder. Review of the Care plan dated 9/3/2024, revealed .The resident has episodes of urinary and bowel incontinence .Will have no skin breakdown r/t [related to] urinary incontinence. Assist with toileting as needed. BM [Bowel Movement] protocol as ordered PRN [as needed]. Medications as ordered. Peri-care as needed . During an observation and interview in the Resident's room on 9/10/2024 at 3:53 PM, Resident #48 stated that CNA D is hateful to he when she has a bowel movement in her brief. Resident reported that CNA D scolded resident for being incontinent of stool by stating that it is ridiculous, and the Resident should have called for assistance to use bedpan or go to the bathroom. Resident #48 stated she reported the incident to Licensed Practical Nurse (LPN) B several weeks ago. During an interview on 9/10/2024 at 4:04 PM, the Administrator was asked if she was aware of Resident #48's concerns or complaint regarding CNA D. The Administrator stated No. The Administrator was informed that Resident #48 voiced a complaint regarding CNA D being hateful and, gets mad at the Resident's bowel incontinence and the Resident reported CNA D made comments that it was ridiculous. The Administrator stated I haven't heard of this. I will go talk to the DON [Director of Nursing] and we will go talk to the Resident. Review of Social Services Note dated 9/10/2024, revealed ED [Executive Director] and SS [Social Services] met with resident regarding her CNA [Certified Nurse Aide] complaint. Resident was upset with CNA because of her tone, feeling that CNA tells her what to do. Resident said she likes her CNA and does not want her to be removed from her care. CNA spoken to. SS [Social Services] will follow up with resident. During an interview on 9/10/2024 at 5:08 PM, CNA D was asked if she was aware of any complaints regarding Resident #48. CNA D stated the Resident complains about, . me asking her to use the bedpan or go to the bathroom. CNA D stated that Resident #48 can use the bedpan or go to the bathroom when she wants to. CNA D was asked if she has the credentials to determine if a resident can do that or not. CNA D stated, No, I don't. CNA D was asked if she was aware that residents can have a decline in their toileting abilities and incontinence frequency. CNA D stated, Yes. During an interview on 9/11/24 at 4:23 PM, the Administrator was asked regarding the status of the investigation regarding Resident #48's concerns. The Administrator stated that she and the SS spoke with the Resident and asked if she was having any issues with any of the staff. The Resident reported that CNA D talked mean to her. The Administrator was asked, when the investigation was started. The Administrator stated, I did not start an investigation since we spoke with the Resident . The Administrator was asked if the CNA should have been reassigned until an investigation was complete. The Administrator stated, Yes. 3. Review of the medical record revealed Resident #54 was admitted to the facility on [DATE], with diagnoses including Diabetes, Acute Cholecystitis, Muscle Weakness, Reduced Mobility, Dementia, Depression, Chronic Pain, Long Term Use of Anticoagulant, Obesity, and Abnormality of Gait and Mobility. Review of a facility's Behavior Note dated 3/13/2024, revealed .Resident noted to have inappropriate verbal behaviors towards female staff Review of a facility's Behavior Note dated 6/7/2024 revealed, Resident noted this shift to be trying to kiss [Resident #58] another resident in hopes [Hopes Place (secure unit)], resident redirected and later separated r/t [related to] continuing with same behavior Review of the quarterly Minimum Data Set (MDS) dated [DATE], revealed Resident #54 has a Brief Interview of Mental Status (BIMs) of 3, which indicate the resident has cognitive impairment, required moderate and maximal assistance for Activities of Daily Living skills (ADLs), with active diagnoses of Non-Alzheimer ' s Dementia and the use of an antidepressant medication. Review of a facility's Behavior Note dated 8/14/2024 revealed, Resident noted to be kissing another female resident. Residents separated and staff doing 1:1 [one on one] with female resident Review of a (Psychiatric Evaluation Note) dated 8/19/2024 revealed .Staff did report that he was seen kissing a female resident on 8/14/2024 . Review of the Care Plan dated 8/20/2024, revealed Resident #54 was care planned for ADL self care deficit, at risk for communication problems and difficulty understanding others and making self understood, at risk of impaired cognitive ability /impaired thought process. The Resident did not have a care plan for behaviors. Review of a facility's Event Note, for Resident #54 dated 9/10/2024, after the survey team had notified the Administrator of the alleged kissing between the two Residents revealed .DON was made aware of alleged issue that occurred on 8/14/2024 between resident and male resident. Male resident was heard calling this resident over to him. This resident was then seen approaching resident and bent down. Nurse only seen back of residents' head at this time. Residents were then separated and 1:1 was provided until behaviors resolved. Local law enforcement, Ombudsman, Psych services, DON, ED, MD [Medical Director], RVP [Regional [NAME] President], RDCS [Regional Director of Clinical Services] and residents conservator .were all notified of alleged issues . The facility began an investigation after questioned by the survey team. 4. Review of the medical record revealed Resident #58 was admitted to the facility on [DATE], with diagnoses including Dementia, Anxiety, Depression, and Cognitive Communication Deficit. Review of the quarterly MDS dated [DATE], revealed Resident #58 was severely cognitive impaired and required moderate assistance from staff for ADL's care. Review of the Care plan revised 6/13/2024, confirmed Resident #58 was dependent on staff for meeting emotion, intellectual, physical and social needs related to cognitive deficits, and had self-care performance deficits, at risk for elopement due to wandering, behavior problems or wandering and confusion due to diagnosis of dementia, impaired cognitive ability, impaired thought process due to dementia, impaired ability to understand others and impaired ability to make self understood, at risk for elopement due to wandering, and at risk for change in mood or behavior due to anxiety, depression, and dementia, and the use of antidepressants. Review of the medical record revealed the facility failed to initiate an investigation into the incident when Resident #54 attempted to kiss Resident #58 on 6/7/2024 and when Resident #54 and Resident #58 were observed kissing on 8/14/2024 until 9/10/2024 after it was brought to their attention on 9/8/2024. During an interview on 9/10/24 at 8:33 AM, LPN F, confirmed she was the nurse assigned to the unit on 6/7/2024 and on 8/14/2024, when Resident #54 attempted to kiss Resident #58 and again when they were witnessed kissing on 8/14/2024. LPN F confirmed that she reported the incident to the Director of Nursing (DON). LPN F was asked what was done after she reported the incident to the DON. LPN F confirmed that she tried to keep the Residents separated as much as possible. LPN F stated she does not recall if she notified the family representatives at that time. LPN F confirmed that they should have been notified at that time. LPN F confirmed she did not complete an incident report, and it should have been one completed at the time of the incident. LPN F confirmed these sexual inappropriate behaviors should not occur. LPN F was asked if she witnessed behaviors of sexual inappropriateness what should be done. LPN F stated that it should be reported to the DON, and they would talk about it and decide what should be done. LPN F was asked is Resident #54 and #58 have the cognition to give consent for a kiss. LPN F stated, I don't think so LPN F was asked should this be reported as an allegation of abuse. LPN F stated, Yes. During an interview on 9/10/24 at 8:08 AM, the Administrator confirmed she was the Abuse Coordinator, and any allegation of abuse should be immediately reported to her, the DON, and ADON in her absence. The Administrator confirmed when there is an allegation of abuse, statements from both staff and residents are obtained, the medical record is reviewed of the involved residents and an investigation is started. The Administrator was asked how sexual abuse and behaviors differentiated. The Administrator stated if there is a sexual allegation, the resident would be sent to the hospital to be evaluated. The Administrator was asked were you aware of the incident that occurred on 6/7/2024 when Resident #54 attempted to kiss Resident #58 and then again on 8/14/2024 when it was witnessed them kissing. The Administrator stated she was aware of the Residents holding hands but was not aware of the 6/7/2024 or the 8/14/2024 kissing incidents. During an interview on 9/10/24 at 4:14 PM, the DON stated she was the Abuse Coordinator for the facility and any allegation should be reported to her. The DON the kissing between the two Residents should be investigated and depending on the outcome of the investigation will you let you know if it was abuse or not. Review of the medical record revealed that Resident #59 was admitted to the facility on [DATE] with diagnoses including Anemia, Anxiety, Hypothyroidism, Encephalopathy, and Malnutrition. 5. Review of the medical record revealed that Resident #59 was admitted to the facility on [DATE], with diagnoses including Anemia, Anxiety, Hypothyroidism, Encephalopathy, and Malnutrition. Review of the quarterly MDS dated [DATE], revealed a BIMS score of 15 indicating Resident #59 was cognitively intact. Resident required max assistance of staff to perform toileting, bathing, bed mobility, and transfer activities. Resident was assessed as always incontinent of bowel and bladder. During an observation and interview in the Resident's room on 9/9/2024 at 2:41 PM, Resident #59 stated that CNA C was not truthful when saying she had refused care when she had not refused care. Resident #59 stated CNA C was rough when providing assistance and was rude when she had brought water into her room. Resident #59 stated the above incidents occurred about a month ago however she could not recall exact dates. Resident #59 stated she reported these incidents to Director of Nursing (DON) last Friday. Resident #59 was emotional and crying at times when talking during interview. During an interview on 9/9/2024 at 3:18 PM, the DON reported that she spoke with Resident #59 on 9/6/2024 and the Resident reported that CNA C lied about her refusal to accept ADL care. The DON stated the Resident requested CNA C not be assigned to her. There was no documentation of a facility investigation into the alleged abuse of Resident #59 until the surveyor team requested the investigation. The facility began the investigation during the survey on 9/11/24. Refer to 609 49269

Based on policy review, medical record review, observation, and interview, the facility failed to report allegations of abuse to State Agency, Ombudsman, Adult Protective Services, and Law Enforcement for 4 of 4 (Resident #48, #54, #58, and #59) sampled residents reviewed for allegations of abuse. The findings include: 1. Review of the facility's policy titled, Abuse-Protection of Residents dated 6/17/2024, revealed The facility will ensure that all residents are protected from physical and psychosocial harm during and after the investigation .methods to ensure the protection of residents during an investigation may include but not limited to Responding immediately to protect the alleged victim and integrity of the investigation .Examining the alleged victim for any sign of injury, including a physical examination or psychosocial assessment if needed .Immediate notification of the alleged victim's practitioner and the family or responsible party Removal of access by the alleged perpetrator to the alleged victim and that ongoing safety and protection is provided for the alleged victim and, as appropriate, other residents Notification of the alleged violation to other agencies or law enforcement authorities Evaluation of whether the alleged victim feels safe and if the he/she does not feel safe, taking immediate steps to alleviate the fear, such as room relocation, increased supervision .Monitor the alleged victim and other residents at risk . Review of the facility's policy titled, Abuse-Identification of Types dated 6/17/2024, revealed Sexual abuse a non-consensual sexual contact of any type with a resident Facility staff should report any suspected abuse, neglect, or exploitation Sexual abuse is non-consensual sexual contact of any type with a resident, as defined at have the capacity to consent sexual contact is nonconsensual if the resident Appears to want the contact to occur but lacks the cognitive ability to consent . Review of the facility's policy titled, Abuse-Conducting an Investigation dated 6/17/2024, revealed It is the policy of this facility that allegations of abuse (abuse, neglect, mistreatment, including injuries of unknown source, exploitation, and misappropriation of property) are promptly and thoroughly investigated. The facility will prevent further abuse, neglect, exploitation and mistreatment from occurring while the investigation is in progress; and take appropriate corrective action as a result of the investigation findings. Residents have the right to live at ease in a safe environment without the fear of retaliation when allegations are reported Following identification of alleged abuse, the resident (s) receive prompt medical attention as necessary and the resident are protected during the investigation to prevent recurrence The alleged victim will be examined for any sign of injury, including a physical examination or psychosocial assessment .When an incident or suspected incident of resident abuse and/or neglect, injury of unknown source, exploitation, or misappropriation of resident property is reported, the administrator/designee will investigate the occurrence the investigation would include but is not limited to Conducting observations of alleged victims .Conducting interviews with .the alleged victim and representative, alleged perpetrator, witnesses, practitioner Conducting record review for pertinent information related to the alleged violation such as progress notes The written summary of the investigation should include but not limited to A review of the Incident Report .An Interview with the person(s) reporting the incident Interviews with any witnesses to the incident An interview with the resident, if appropriate .a review of the resident's medical record .an interview with the employee(s) .a review of the employee's file Interviews with staff members on all shifts having contact with the resident at the time of the incident Interviews other residents who received care or services from the alleged perpetrator A review all circumstances surrounding the incident If the accused individual is an employee, the alleged perpetrator will be removed from resident care areas immediately and placed on suspension pending results of the investigation. Retaliation by staff is abuse, regardless of whether harm was intended, and must be cited If the accused abuser is another resident, the resident must be separated while investigating the incident. Interventions must be implemented to assure the safety of all residents .Any investigation of alleged resident sexual abuse must start with a determination of whether the sexual activity was consensual on the part of the resident. A resident's apparent consent to engage in sexual activity is not valid if it is obtained from a resident lacking the capacity to consent .The administrator or their designee will keep the resident and/or his/her representative informed of the progress of the investigation. The alleged victim will be protected from retaliation .The administrator or designee will inform the resident, physician, and/or resident representative of the results of the investigation and the corrective action taken. Emotional support and counseling will be provided to the resident during and after the investigation, as needed . Review of the facility's policy titled, Abuse-Reporting and Response-No Crime Suspected dated 6/17/2024, revealed Ensure all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately but not later than 2 hours after the allegation is made, if the event that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the event that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides jurisdiction in long-term care facilities) All associates are mandated to immediately report suspected resident abuse and /or neglect to their immediate supervisor and/or facility representative All residents, families, resident representatives and visitors are encouraged to immediately report incidents of suspected resident abuse and/or neglect to facility administration. When an incident of resident abuse is suspected, the incident must be reported to the supervisor regardless of the time lapse since the incident occurred. The supervisor notifies the director of nursing and the executive director of the alleged incident .All alleged violations .must be reported to the administrator of the facility and to other officials in accordance with State Law through established procedures .the facility should retain documentation of the report The supervisor and /or charge nurse will illicit the following information .the name of the resident involved in the incident .date and time the incident occurred where the incident took place name(s) of the person(s) committing or involved in the incident name(s) of any witnesses to the incident type of abuse and /or neglect that was committed .additional information that may be pertinent to the incident the nurse will complete and sign the Incident Report and notify the physician and the resident's representative of the occurrence . Review of the facility's policy titled, Incident and Reportable Event Management dated 9/14/2023, revealed Ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately but no later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) Event Management includes, but is not limited to , the following types of events .Alleged Abuse .Sexual, Physical, Verbal, Mental, or Exploitation 2. Review of the medical record revealed Resident #48 was admitted to the facility on [DATE], with diagnoses including Chronic Obstructive Pulmonary Disease, Diabetes, Hypertension, Heart Failure, Alzheimer's Disease, and Depression. Review of the quarterly Minimum Data Set (MDS) dated [DATE], revealed a Brief Interview of Mental Status (BIMS) score of 12, indicating Resident #48 was moderately cognitively impaired, dependent on staff with assistance in toileting and required max assistance from staff with performing transfers and incontinent both bowel and bladder. Review of the Care plan dated 9/3/2024, revealed .The resident has episodes of urinary and bowel incontinence .Assist with toileting as needed. BM [Bowel Movement] protocol as ordered PRN [as needed] .Peri-care as needed . Review of Social Services Note dated 9/10/2024, revealed ED [Executive Director] and SS [Social Services] met with resident regarding her CNA [Certified Nurse Aide] complaint. Resident was upset with CNA because of her tone, feeling that CNA tells her what to do. Resident said she likes her CNA and does not want her to be removed from her care. CNA spoken to. SS [Social Services] will follow up with resident. During an observation and interview in the resident's room on 9/10/2024 at 3:53 PM, Resident #48 stated that CNA D is hateful to her when she has a bowel movement in her brief. Resident reported that CNA D scolded resident for being incontinent of stool by stating that it is ridiculous, and that resident should have called for assistance to use bedpan or go to the bathroom. Resident stated that she reported the incident to Licensed Practical Nurse (LPN) B several weeks ago. During an interview on 9/11/2024 at 4:23 PM, the Administrator was asked if allegations of abuse are reported. The Administrator stated, Yes. The Administrator was asked if Resident #48's allegation of verbal/mental abuse should be reported. The Administrator stated, I did not think so . 3. Review of the medical record revealed Resident #54 was admitted to the facility on [DATE], with diagnoses including Diabetes, Acute Cholecystitis, Muscle Weakness, Reduced Mobility, Dementia, Depression, Chronic Pain, Long Term Use of Anticoagulant, Obesity, and Abnormality of Gait and Mobility. Review of a facility's Behavior Note dated 3/13/2024, revealed, Resident noted to have inappropriate verbal behaviors towards female staff . Review of a facility's Health Status Note dated 5/15/2024, revealed, Resident then began making inappropriate comments to staff X [times] 2, Stating, Climb in bed so I can [expletive] on ya [you]. This nurse educated resident on not talking to staff in that manner, staff is here to help him, but not with those needs; Redirection was unsuccessful, again resident made profane comments to CNA Staff X 2 reminded resident that we are not here to be talked to that way Review of a facility's Behavior Note dated 6/7/2024, revealed, Resident noted this shift to be trying to kiss [Resident #58] another resident in hopes [Hopes Place (secure unit)], resident redirected and later separated r/t [related to] continuing with same behavior Review of the quarterly MDS dated [DATE], revealed Resident #54 has a BIMs of 3, which indicate the resident has cognitive impairment, required moderate to maximal assistance for Activities of Daily Living skills (ADLs), with active diagnoses of Non-Alzheimer's Dementia and the use of an antidepressant medication. Review of a facility's Behavior Note dated 8/14/2024, revealed, Resident noted to be kissing another female resident. Residents separated and staff doing 1:1 [one on one] with female resident Review of a Psychiatric Evaluation Note dated 8/19/2024 revealed .Staff did report that he was seen kissing a female resident on 8/14/2024 . Review of the Care Plan dated 8/20/2024 revealed Resident #54 was care planned for needing assistance for Activities of Daily Living (ADL) care and no care plan for behaviors. Review of a facility's Event Note dated 9/10/2024, revealed .DON [Director of Nursing] was made aware of alleged issue that occurred on 8/14/2024 between resident and male resident. Male resident was heard calling this resident over to him. This resident was then seen approaching resident and bent down. Nurse only seen back of resident's head at this time. Residents were then separated and 1:1 was provided until behaviors resolved. Local law enforcement, Ombudsman, Psych services, DON, ED, MD [Medical Director], RVP [Regional [NAME] President], RDCS [Regional Director of Clinical Services] and residents conservator .were all notified of alleged issues . The facility failed to provide documentation the State Agency, Adult Protective Services, Ombudsman, and family representatives were notified when Resident #54 attempted to kiss Resident #58 on 6/7/2024 and when Residents #54 and #58 were observed kissing on 8/14/2024. 4. Review of the medical record revealed Resident #58 was admitted to the facility on [DATE], with diagnoses including Dementia, Anxiety, Depression, and Cognitive Communication Deficit. Review of the quarterly MDS dated [DATE], revealed Resident #58 was severely cognitive impaired and required moderate assistance from staff for ADL's care. Review of the Care plan revised 6/13/2024, revealed Resident #58 was dependent on staff for meeting emotion, intellectual, physical and social needs related to cognitive deficits, and had self-care performance deficits, at risk for elopement due to wandering, behavior problems or wandering and confusion due to diagnosis of dementia, impaired cognitive ability, impaired thought process due to dementia, impaired ability to understand others and impaired ability to make self understood, at risk for elopement due to wandering, and at risk for change in mood or behavior due to anxiety, depression, and dementia, and the use of antidepressants. Review of a facility's Event Note dated 9/10/2024, revealed DON was made aware of alleged issue that occurred on 8/14/2024 between resident and male resident. Male resident was heard calling this resident over to him. This resident was then seen approaching resident and bent down. Nurse only seen back of the residents [resident's] head at this time. Residents were then separated and 1:1 was provided until behaviors resolved. Local law enforcement, Ombudsman, Psych services, DON, ED, MD, RVP, RDCS, and residents [resident's] conservator .were all notified of alleged issues . The facility failed to provide documentation that State Agency, Adult Protective Services, Ombudsman, and family representatives were notified when Resident #54 attempted to kiss Resident #58 on 6/7/2024 and when Residents #54 and #58 were observed kissing on 8/14/2024. 5. During an interview on 9/10/24 at 8:33 AM, LPN F confirmed she was the nurse assigned to the unit on 6/7/2024 and on 8/14/2024 when Resident #54 attempted to kiss a female resident and again when they were witnessed kissing on 8/14/2024. LPN F confirmed the female resident was Resident #58. LPN F confirmed that she reported the incident to the DON. LPN F was asked what was done after she reported the incident to the DON. LPN F stated that she tried to keep the residents separated as much as possible. LPN F stated she does not recall if she notified the family representatives at that time. LPN F stated the family representatives should have been notified at that time. LPN F confirmed she did not complete an incident report, and one should have been completed at the time of the incident. LPN F stated that Resident #54 has not had this type of behavior toward any other female residents but has said sexual inappropriate things to female therapy staff. LPN F stated these sexual inappropriate behaviors should not occur. LPN F was asked if she witnessed behaviors of sexual inappropriateness what should be done. LPN F stated that it should be reported to the DON, and they would talk about the it and decide what should be done. LPN F stated she was unsure what was done about the sexual inappropriateness, and they try to keep the residents separated as much as possible. LPN F was asked is Resident #54 and #58 have the cognition to give consent for a kiss. LPN F stated, I don ' t think so . LPN F was asked should this be reported as an allegation of abuse. LPN F stated, Yes. During an interview on 9/10/24 at 8:08 AM, the Administrator confirmed she was the Abuse Coordinator, and any allegation of abuse should be immediately reported to her, the DON, and Assistant Director of Nursing (ADON) in her absence. The Administrator confirmed when there is an allegation of abuse, statements from both staff and residents are obtained, the medical record is reviewed of the involved residents and an investigation is started. The Administrator was asked how if there was differentiated actions with sexual behaviors. The Administrator stated that if there is a sexual allegation, the resident would be sent to the hospital to be evaluated. The Administrator was asked it they were aware of the incident that occurred on 6/7/2024 when Resident #54 attempted to kiss Resident #58 and then again on 8/14/2024 when it was witnessed them kissing. The Administrator confirmed she was aware of the incident when the Resident was seen holding hands with a Resident but was not aware of the 6/7/2024 or the 8/14/2024 occurrence of the Residents kissing. The Administrator was asked what was discussed with the Resident with a BIMs of 3. The Administrator stated they try to redirect the Resident. The Administrator was asked who was called if the Resident with a BIMs of 3 was his own Power of Attorney. The Administrator stated, I will have to check to make sure who we called . The Administrator confirmed that the occurrence on 6/7/2024 was not reported to State Agency, the Ombudsman, or Adult Protective Services. The Administrator stated she was unsure if she was notified of the kissing which occurred on 8/14/2024 between Resident #54 and #58. The Administrator confirmed the kissing occurrence on 8/14/2024 should have been reported and investigated when it occurred. The Administrator was asked what the nurse should have done when she had been made aware of the kissing between the two Residents. The Administrator confirmed the nurse should have reported the allegation to her or the DON or any supervisor. The Administrator confirmed that the family should have been notified as well as the physician and psychiatric services. During an interview on 9/10/24 at 4:14 PM, the DON confirmed she was the Abuse Coordinator for the facility and any allegation should be reported to her. The DON stated that if in immediate danger the staff should provide safety and start an investigation and witness, resident and staff statements should be obtained, and it should be reported the State Agency, local law enforcement, and the family, as well as APS and the Ombudsman. The DON was asked how she determined if it was a behavior or sexual abuse. The DON stated by the Resident's BIMs score and if the Resident has a history and medical diagnoses. The DON was asked if residents with a BIMs of 2 or 3, which is severe cognitive impairment, were observed kissing, would that be a behavior or an allegation of sexual abuse. The DON stated, I would say that is a behavior . The DON was asked should that be reported as an allegation of sexual abuse. The DON stated, No because it is a behavior . The DON confirmed she was unaware of the incident on 6/7/2024 when Resident #54 was attempting to kiss Resident #58 and then when on 8/14/2024 Residents #54 and #58 were observed kissing and before today she was unaware Resident #54 was having sexual inappropriate behaviors. The DON was asked what has been done regarding the above allegations. The DON stated that this was a behavior, and nothing has been done. The DON confirmed she has not called the Residents' family or made any psychiatric recommendations. The DON confirmed that nothing additional has been put into place to ensure Resident #58 or any other resident's safety. The DON stated she would have to pull the facility's policy to see what it says about reporting of sexual abuse. The DON was asked if a resident who was not cognitively intact to give consent be kissed by another resident, should that be reported as an allegation of sexual abuse. The DON stated, No. The facility failed to report allegation of sexual abuse on 8/14/2024 when Resident #58, a cognitively impaired female resident, who wasn't able to give consent, was kissed by a male resident, Resident #54. 6. Review of the medical record revealed that Resident #59 was admitted to the facility on [DATE], with diagnoses including Anemia, Anxiety, Hypothyroidism, Encephalopathy, and Malnutrition. Review of the quarterly MDS dated [DATE], revealed a BIMS score of 15 indicating Resident #59 was cognitively intact. Resident required max assistance of staff to perform toileting, bed mobility, and transfer activities. Resident was assessed as always incontinent of bowel and bladder. During an observation and interview in the Resident's room on 9/9/2024 at 2:41 PM, revealed Resident #59 stated that CNA C was rude saying she refused care when she didn't. Resident #59 stated that CNA C was rough when assisting with care and when CNA C brought water to her room. Resident #59 stated these incidents occurred about a month ago, couldn't recall exact dates and stated that she reported to incident to Director of Nursing (DON) last Friday. Resident #59 was emotional and crying at times when talking during interview. During an interview on 9/9/2024 at 3:18 PM, the DON reported that she spoke with Resident #59 on 9/6/2024 and resident reported that CNA C lied about her refusal of ADL assistance. The DON stated the Resident has requested CNA C not be assigned her care. The DON stated the Resident has frequent complaints. The facility failed to report the allegation of abuse in a timely manner when Resident #59, who is cognitively intact, reported that CNA C had been rough during care and was rude. 49269

Based on facility policy review, observation and interview the facility failed to ensure medications were properly stored when opened and undated medications were found in 1 of 6 medication storage areas (West Hall #1 Medication Cart). Findings include: Review of the facility's policy titled Storage and Expiration Dating of Medications, Biologicals dated 8/7/2023, revealed .Facility should ensure that medications and biologicals are stored in an orderly manner in cabinets, drawers, carts .Once any medication or biological package is opened .Facility should staff should record date opened on the primary medication container [vial, bottle, inhaler] .Facility should ensure that the medications and biologicals for each resident are stored in the containers in which they were originally received . Observation of the [NAME] Hall #1 Medication Cart on 9/11/2024 at 10:02 AM, revealed the following medications opened, unlabeled and undated medications loose in the medication cart drawer. a. ProAir inhaler b. Albuterol Sulfate inhaler During an interview on 9/11/2024 at 10:02 AM, Licensed Practical Nurse (LPN) A confirmed that the inhalers should be dated and labeled with the resident ' s name. During an interview on 9/12/2024 at 8:45 AM, the Director of Nursing (DON) was asked if medications in the medication storage areas should be labeled and dated. The DON confirmed that all medications should be labeled with the resident's name and dated.

Based on policy review, observation, and interview, the facility failed to ensure food was stored, prepared, and served under sanitary conditions as evidenced by a dirty meat slicer, wet nesting of trays, dirty cups, dirty skillets and a plastic container of food sitting on the floor in the kitchen. The facility had a census of 71, with 71 of those residents receiving a meal tray from the kitchen. The findings include: 1. The facility's .Food and Nutrition Services Manual, revised 1/11/2017 documented, .associates are trained in the .cleaning and sanitation of all equipment and utensils .All items are air dried before storing . 2. Observation in the Kitchen on 2/3/2020 at 9:15 AM, showed a dirty meat slicer on the kitchen counter. During an interview on 2/3/2020 at 9:17 AM, the Certified Dietary Manager (CDM) was asked when should the meat slicer be cleaned. The CDM stated, .after use . The CDM was asked was the meat slicer clean. The CDM stated, No. Observation in the Kitchen on 2/4/2020 at 11:25 AM, showed 11 wet trays stacked together. During an interview on 2/4/2020 at 11:28 AM, the Registered Dietician (RD) was shown the water on the meal trays and was asked what this was. The RD stated,Wet nesting. The RD was asked should there be wet nesting. The RD stated, No. Observation in the West Hall during dining on 2/4/2020 at 12:23 PM, showed 3 dirty cups stored with the clean cups on a tray on top of the meal cart. Observation in the Kitchen on 2/5/2020 at 9:05 AM, showed 2 dirty skillets. One skillet had dried white film around the inside of the skillet and the other skillet had dried yellow substance inside of the skillet. The dirty skillets were stored with the clean pots and pans. Observation in the Kitchen on 2/5/2020 at 3:10 PM, showed a large plastic container of salsa on the floor being used to prop the door open in the storage room. During an interview on 2/5/2020 at 3:14 PM, the CDM was asked what was inside the cups that was on the meal cart. The CDM stated, .one had a dirty napkin in it .one looked like coffee creamer .the other one probably coffee . The CDM was asked should dirty cups be stored with clean cups. The CDM stated, .nothing should be mixed with the clean .didn't take tray off after use .didn't check it . The CDM was asked what was on the two dirty skillets that were stored with the clean skillets. The CDM stated, .one looked like dried eggs . The CDM was asked should the salsa have been in the floor. The CDM stated, No.

Based on policy review, medical record review, and interview, the facility's Registered Dietician (RD) failed to do an admission dietary assessment for Resident #46. The findings include: Review of the facility's policy titled, Claxton Dietetic Solutions, dated 10/10/2018, showed, .New Admits must be charted on by day 14 of admission . The review of the medical record, showed Resident #46 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Weights and Vital Summary dated 2/5/2020, showed the following weights for Resident #46: 1/7/2020 171.1 lbs, 1/8/2020 166 lbs. 1/28/2020 164 lbs. There was no weight between 1/8/2020 and 1/28/2020. The Assistant Director of Nursing provided a weight of 160 pounds that was obtained on 2/4/2020. The facility was unable to provide an admission RD assessment for Resident #46. During an interview conducted on 2/5/2020 at 8:47 AM, the RD was asked when a dietary admission assessment should be performed. The RD stated, I have 14 days from admission. The RD was asked when the assessment was done. The RD stated, Yesterday (2/4/2020), after (Named Surveyor) gave me a list of people . This was 35 days after Resident #46 was admitted .

Based on the policy review, medical record review, and interview, the facility failed to assess and monitor weights for 1 of 5 sampled residents (Resident #46) reviewed for nutrition. The findings included: Review of the facility's policy titled, Weight and Heights, dated 11/18/2019, showed .All residents are weighed within 24 hours of admission and weekly for 4 weeks . Review of the facility's policy titled, Claxton Dietetic Solutions, dated 10/10/2018, showed, .New Admits must be charted on by day 14 of admission .What your dietary manager should be providing you at each visit .RD (Registered Dietitian) referral list with new admits . Review of the facility's policy titled, Changes in Resident's Condition or Status, dated 4/15/2019, showed, .This facility will notify the .primary care provider .consult with the residents physician .Notification of Changes .A significant change in resident's physical .status . Review of the facility's policy titled, Resident at Risk (RAR) Meeting, dated 1/22/2019, showed, .This facility conducts a weekly resident at risk meeting to review the residents who have been identified with nutritional .hydration problems .concerns or who have an identified risk factor that may lead to nutritional .hydration issues . Review of the medical record, showed Resident #46 had a [DIAGNOSES REDACTED]. Review of the Admission assessment dated [DATE], showed the facility did not obtain Resident #46's weight when she was admitted . Review of the Care Plan dated 1/3/2020, showed Resident #46 had a nutritional problem, with an intervention of, .Observe for and report to MD .significant weight loss: 3lbs (3 pounds) in 1 week .Provide and serve diet as ordered, Regular texture with thin consistency . Review of the physician's orders [REDACTED]. Review of the Weights and Vital Summary dated 2/5/2020, showed the following weights for Resident #46: 1/7/2020 171.1 lbs, 1/8/2020 166 lbs. 1/28/2020 164 lbs. There was no weight between 1/8/2020 and 1/28/2020. The Assistant Director of Nursing (ADON) provided a weight of 160 pounds that was obtained on 2/4/2020. Review of the physician's orders [REDACTED].House Supplement, Frozen in the afternoon, Give 4 oz. (ounces). Document % (percent) taken/ With lunch . Observation and interview conducted in Resident #46's room on 2/5/20 at 11:25 AM, showed Resident #46 was weighed using a lift and weighed 161 pounds. Certified Nursing Assistant (CNA) #1 and #2 confirmed Restorative CNAs are responsible for weekly and monthly weights, and the admission nurse and CNA do the admission weights. During an interview conducted on 2/5/2020 at 8:47 AM, the Registered Dietitian (RD), confirmed the admission assessment was not done timely. The RD stated, I have 14 days from admission to see a new admission, I saw her 2/4/2020 after the survey team asked about her .I realized she did not have an assessment . During an interview conducted on 2/5/2020 at 9:58 AM, the Certified Dietary Manager (CDM) confirmed she was responsible for reporting the admissions and weights to the RD. The CDM confirmed she failed to print out the RAR data prior to 1/1/2020. The CDM failed to include Resident #46, who was admitted on [DATE], on the RAR. The CDM confirmed the RD was new to the facility and she had not gone over the facility weight monitoring process with the RD. The CDM confirmed weekly weights were not performed per policy. During an interview conducted on 2/5/2020 at 10:47 AM, the ADON confirmed the admission weight was missed, and stated, We do the admission weight within 24 hours, and then they are weighed weekly . The ADON confirmed it was the responsibility of the charge nurse to get the admission weight and stated Resident #46 was missed. During an interview conducted on 2/5/2020 at 12:04 PM, the ADON was asked if the weight loss was reported to the physician. The ADON stated, I'm not aware the weight loss was reported (Named Licensed Practical Nurse (LPN) #1) did not know their was a 5 pound weight loss in 1 day. She should have been discussed weekly in RAR . She confirmed the RAR committee did not discuss Resident #46 in the RAR meetings until (MONTH) 16, 2020, and stated, I just don't know how she was missed . The ADON was asked if the physician was notified. The ADON stated, I saw no documentation he was notified .He should have been notified .Care plan stated to call, we need to follow the care plan. I was not aware until you (surveyor) pointed it out to me on the care plan .

Based on medical record review and interview, the facility failed to revise the Care Plan for nutritional supplements for 1 of 5 sampled residents (Resident #46) reviewed for weight loss and nutrition. The findings include: Review of the medical record, showed Resident #46 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED].House Supplement, Frozen in the afternoon, Give 4 oz. (ounces). Document % (percent) taken/ With lunch . Review of the Care Plan dated 1/3/2020, showed Resident #46 had a nutritional problem with an intervention of, .Provide and serve diet as ordered, Regular texture with thin consistency . There was no documentation that the Care Plan was updated to include the new house supplement order. During an interview on 2/5/2020 at 12:04 PM, the Assistant Director of Nursing (ADON) confirmed that the care plan was not revised to reflect nutritional supplements.

Based on medical record review and interview, the facility failed to ensure Minimum Data Set (MDS) assessments were completed accurately for percutaneous endoscopic gastrostomy (PEG) tube use and [MEDICAL TREATMENT] for 2 of 20 sampled residents (Resident #18 and #21) reviewed. The findings include: 1. Review of the medical record, showed Resident #18 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Review of the significant change MDS assessment dated [DATE] and the admission MDS assessment dated [DATE], showed Resident #18 was cognitively impaired. A feeding tube, nasogastric, or abdominal PEG tube was not checked as being present. The physician's orders [REDACTED].Enteral Feed Order four times a day Give 250 cc (cubic centimeters) Free H2O (water) QID (4 times per day) via PEG tube During an interview conducted on 2/5/2020 at 4:44 PM, the MDS Nurse confirmed Resident #18 had a PEG tube and should have been marked as yes on both of the MDS assessments. 2. Review of the medical record, showed Resident #21 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A physician's orders [REDACTED].[MEDICAL TREATMENT] patient .Send to [MEDICAL TREATMENT] on Monday, Wednesday, and Friday . Review of the annual MDS assessment dated [DATE], showed Resident #21 was cognitively impaired and [MEDICAL TREATMENT] was coded as No. During an interview conducted on 2/4/2020 at 4:18 PM, the MDS Nurse confirmed the MDS assessment was not coded correctly for [MEDICAL TREATMENT].

Based on the policy review, medical record review, and interview, the facility failed to notify the physician when a weight loss occurred for 1 of 5 sampled residents (Resident #46) reviewed for nutrition. The findings include: Review of the facility policy's titled, Changes in Resident's Condition or Status, dated 4/15/2019, showed .This facility will notify the .primary care provider .consult with the resident physician .Notification of Changes .A significant change in resident's physical .status . Review of the medical record, showed Resident #66 had a [DIAGNOSES REDACTED]. Review of the Care Plan dated 1/3/2020, showed Resident #46 had a nutritional problem with an intervention of, .Observe for and report to MD (Medical Doctor) .3lbs (3 pounds) in 1 week . Review of the Weights and Vital Summary dated 2/5/2020, showed the following weights for Resident #46: 1/7/2020 171.1 lbs, 1/8/2020 166 lbs. 1/28/2020 164 lbs. Review of the medical record, showed there was no documentation that the physician was notified of Resident #46's weight loss. During an interview conducted on 2/5/2020 at 12:04 PM, the Assistant Director of Nursing (ADON) confirmed the physician was not notified of Resident #46's weight loss.

Based on policy review, medical record review, observation, and interview, the facility failed to ensure 1 of 5 (Licensed Practical Nurse (LPN) #3) nurses followed the facility policy and the physician orders [REDACTED]. The findings include: 1. The facility's Medication Enteral Tubes . policy dated 11/2017 documented, .8. Verify tube placement .Insert a small amount of air into the tube with the syringe and listen to stomach with stethoscope for gurgling sounds . 2. Medical record review revealed Resident #34 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Physician order [REDACTED].Enteral Feed Order every shift Verify PEG tube placement by auscultation of 20 cc (cubic centimeters) of air prior to administration of meds, flushes . Observations in Resident #34's room on 4/3/19 at 12:25 PM, revealed LPN #3 administered PEG medications without confirming PEG placement by auscultation. Interview with LPN #3 on 4/3/19 at 3:55 PM, in the Lobby, outside the Director of Nursing Office, LPN #3 was asked did you auscultate for PEG placement prior to administering PEG medication. LPN #3 stated, No I didn't .I forgot my stethoscope.

Based on policy review, medical record review, observation, and interview, the facility failed to promote and maintain resident dignity when 1 of 23 (Licensed Practical Nurse (LPN) #1) staff members stood over a resident while assisting the resident with their meal, and when 1 of 5 (LPN #2) nurses exposed a resident during insulin administration. The findings include: 1. The facility's Dignity policy with a revision date of 6/17/08 documented, .All Residents are treated in a manner and in an environment that maintains and enhances each resident's dignity and respect . 2. Observations in Resident #60's room on 4/1/19 at 11:51 AM, revealed LPN #1 standing over Resident #60 while assisting the resident with her meal. Interview with the Director of Nursing (DON) on 4/3/19 at 7:21 PM, in the Administrator Office, the DON was asked if it was appropriate for staff to stand over residents to assist them with meals. The DON stated, .they should be seated at eye level, face to face . 3. Medical record review revealed Resident #66 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Observations in the Activity Room in the secured unit on 4/3/19 at 11:36 AM, revealed LPN #2 raised Resident #66's shirt, exposing his abdomen, and administered an insulin injection, with 3 other residents sitting in the room. Interview with the DON on 4/3/19 at 7:35 PM, in the Administrator office, the DON was asked if it was appropriate for staff to raise a resident's shirt and administer an insulin injection in front of other residents. The DON stated, .no, ma'am .should have been brought to his room for administration .

Based on policy review, medical record review, observation, and interview, the facility failed to assess 2 of 2 (Resident #65 and #73) for self-administration of medications. The findings include: 1. The facility's Self-Administration of Medication policy with a revision dated of 9/6/17 documented, .Each resident who desires to self-administer medication is permitted to do so if the facilities (facility's) interdisciplinary team has determined the practice would be safe for the resident and other residents in the facility .If the resident desires to self-administer medication, an order for [REDACTED]. 2. The facility's Respiratory Medication Administration policy dated 12/3/18 documented, .Nebulizer therapy .Remain with the patient and continue the treatment until the nebulizer begins to sputter .Monitor the patient's heart rate and respiratory status during the procedure to detect adverse reactions to the medication .Complications .Nebulized particulates can irritate the mucosa in some patients and cause [MEDICATION NAME] and dyspnea . 3. Medical record review revealed Resident #65 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Care Plan dated 3/2/19 documented, .has an ADL (Activities of Daily Living) self-care performance deficit r/t (related to) dx (diagnosis) of [MEDICAL CONDITION] and asthma with SOB (shortness of breath) upon exertion, and LE (left extremity) weakness r/t (related to) hx (history) [MEDICAL CONDITION] .Interventions .need for assist with personal care start 3/27/19 .has shortness of breath upon exertion r/t [MEDICAL CONDITION], allergies and asthma .Interventions .Administer medications/nasal inhalers as ordered . The Care Plan did not address self-administration of medications. The Physician order [REDACTED].[MEDICATION NAME]-[MEDICATION NAME] .inhale orally via nebulizer every 12 hours for wheezing .every 6 hours as needed for shortness of breath . Review of the Physician order [REDACTED]. Observations in Resident #65's room on 4/2/19 at 11:02 AM, revealed Resident #65 sitting in her wheelchair with her eyes closed and wearing a nebulizer mask. The nebulizer was on. There was no staff present in the room. The facility was unable to provide an interdisciplinary team assessment for self-administration of medications. 4. Medical record review revealed Resident #73 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Care Plan dated 3/2/19 documented, .has an ADL self-care performance deficit r/t DOE (Dyspnea on Exertion) d/t (due to) .[MEDICAL CONDITION]/Asthma, [MEDICAL CONDITION] and [DIAGNOSES REDACTED] .Recent hx of Pneumonia with [MEDICAL CONDITION] .Interventions .need for assist with personal care start 4/1/19 .Administer medications and inhalers as ordered . The Care Plan did not address self-administration of medications. The Physician order [REDACTED].[MEDICATION NAME]-[MEDICATION NAME] .inhale orally via nebulizer three times a day . Review of the Physician order [REDACTED]. Observations in Resident #73's room on 4/1/19 at 11:46 AM and 11:50 AM, revealed Resident #73 sitting in her wheelchair wearing a nebulizer mask with visible mist coming from the mask. The nebulizer was on. There was no staff present in the room. The facility was unable to provide an interdisciplinary team assessment for self-administration of medications. Interview with the DON on 4/3/19 at 7:21 PM, in the Administrator Office, the DON was asked if residents should self-administer medications. The DON stated, .don't do self-administration here. That was not appropriate.

Based on policy review, medical record review, observation, and interview, the facility failed to maintain privacy and confidentiality of resident medical records for 1 of 45 (Resident #50) sampled residents. The findings include: The facility's Health Insurance Portability and Accountability Act (HIPPA) Privacy and Security Training Acknowledgement form with a revision date of 1/29/2008 documented, .(Named Facility) has a legal and ethical responsibility to safeguard the privacy and security of all residents and to protect the confidentiality of their health information Medical record review revealed Resident #50 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Observations in the West Hall on 4/3/19 at 6:13 PM, revealed Resident #50's Medication Administration Record [REDACTED]. The resident's name and medications could be seen on the computer monitor screen. Interview with the RN Supervisor on 4/3/19 at 6:13 PM, in the West Hall, the RN Supervisor was asked if a resident's personal health information should be visible on the computer monitor when the medication cart was unattended. The RN Supervisor stated, No, ma'am definitely not .

Based on policy review, medical record review, observation, and interview, the facility failed to ensure 2 of 5 (Licensed Practical Nurse (LPN) #3 and #2) nurses administered medications with a medication error rate of less than 5 percent (%). A total of 2 errors were observed out of 29 opportunities, resulting in an error rate of 6.89%. The findings include: 1. The facility's Respiratory Medication Administration policy dated 12/3/18 documented, .This facility will utilize the following Lippincott procedures .Lippincott Procedures-Metered-dose inhaler use . The Lippincott Procedures - Metered dose inhaler use procedure dated 2/15/19 documented, .Metered-dose inhaler (MDI) use .Assess the patient's breath sounds to obtain a baseline for comparison .When administering inhaled quick-relief medications .wait about 15 to 30 seconds between inhalations . 2. Medical record review revealed Resident #19 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Physician order [REDACTED].[MEDICATION NAME] 120 INHALATIONS 160-4.5 MCG .2 puffs inhale orally two times a day .WAIT 30 SECONDS BETWEEN PUFFS . Observations in Resident #19's room on 4/3/19 at 8:07 AM, revealed LPN #3 administered 1 puff of a [MEDICATION NAME] inhaler, waited 10 seconds, and then administered the second puff. The administration of the second inhalation of the [MEDICATION NAME] 10 seconds after the first inhalation resulted in medication error #1. Interview with the Director of Nursing (DON) on 4/3/19 at 8:30 PM, in the DON Office, the DON was asked how long a nurse should wait between administering 2 puffs of a single inhalation medication. The DON stated, One minute. 3. The GERIATRIC MEDICATION HANDBOOK, thirteenth edition, page 45, documented, .[MEDICATION NAME] .ONSET .15 min (minutes) .ADMINISTRATION .15 minutes prior to meals . 4. Medical record review revealed Resident #66 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Physician order [REDACTED].[MEDICATION NAME] 100 U/1ML (milliliters) UNIT .Inject as per sliding scale: .151 - 200 = 2 .subcutaneously before meals and at bedtime . Observations in the Activity Room in the Secure Unit on 4/3/19 at 11:36 AM, revealed LPN #2 administered 2 units of [MEDICATION NAME] to Resident #66 subcutaneously. Resident #66 did not receive a meal tray or a substantial snack until 12:21 PM, 45 minutes after receiving the insulin. This resulted in medication error #2. Interview with LPN #2 on 4/3/19 at 3:57 PM, at the Secure Unit Nurses' Station, LPN #2 was asked how soon a resident should receive food after receiving a fast-acting [MEDICATION NAME]injection. LPN #2 stated, .30 minutes. LPN #2 confirmed that she failed to administer a meal tray or substantial snack until 12:21 PM (45 minutes after Resident #66 received the insulin).

Based on review of the GERIATRIC MEDICATION HANDBOOK provided by the American Society of Consultant Pharmacists, medical record review, observation, and interview, the facility failed to ensure 1 of 5 (Licensed Practical Nurse (LPN) #2) nurses administered medications free of significant medication errors. LPN #2 failed to administer insulin within the proper time frame related to food intake for Resident #66, which resulted in a significant medication error. The findings include: 1. The GERIATRIC MEDICATION HANDBOOK, thirteenth edition, page 45, documented, .[MEDICATION NAME] .ONSET .15 min (minutes) .ADMINISTRATION .15 minutes prior to meals . 2. Medical record review revealed Resident #66 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Physician order [REDACTED].[MEDICATION NAME] 100 U/1ML (milliliters) UNIT .Inject as per sliding scale: .151 - 200 = 2 .subcutaneously before meals and at bedtime . Observations in the Activity Room in the Secure Unit on 4/3/19 at 11:36 AM, revealed LPN #2 administered 2 units of [MEDICATION NAME] to Resident #66 subcutaneously. Resident #66 did not receive a meal tray or a substantial snack until 12:21 PM, 45 minutes after receiving the insulin. This resulted in a significant medication error. Interview with LPN #2 on 4/3/19 at 3:57 PM, at the Secure Unit Nurses' Station, LPN #2 was asked how soon a resident should receive food after receiving a fast-acting [MEDICATION NAME]injection. LPN #2 stated, .30 minutes. LPN #2 confirmed that she failed to administer a meal tray or substantial snack until 12:21 PM (45 minutes after Resident #66 received the insulin).

Based on policy review, medical record review, observation, and interview, the facility failed to ensure practices to prevent the potential spread of infection were followed when 1 of 1 (Registered Nurse (RN) #1) nurse failed to perform proper hand hygiene and contaminated a resident's bed during wound care, and when 1 of 1 (Certified Nursing Assistant (CNA) #1) staff member failed to clean a nebulizer mask after use. The findings include: 1. The facility's Hand Washing policy with a revision date of 11/11/16 documented, .Procedure .Turn off the water faucet without contaminating the clean hands .by using a paper towel . 2. Medical record review revealed Resident #46 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Observations in Resident #46's room on 4/2/19 at 11:25 AM, revealed RN #1 performed wound care to Resident #46's sacral pressure ulcer. RN #1 performed improper hand hygiene twice during wound care when she turned off the water faucet using her bare hands. RN #1 also moved a trash bag containing soiled dressings from the floor to the bed after wound care. Interview with RN #1 on 4/3/19 at 5:15 PM, in the Training Room, RN #1 was asked how she should wash hands. RN #1 stated, .wash hands with soap .pat dry .use a new paper towel to turn off the water . RN #1 was asked if it was appropriate to move a trash bag with soiled dressings from the floor to the bed. RN #1 stated, Definitely not acceptable. 3. The facility's Respiratory Medication Administration policy dated 12/3/18 documented, .Nebulizer therapy .After treatment .Rinse the nebulizer with sterile water and allow it to air-dry, or discard it after the treatment .Complications .include infection from contaminated equipment . 4. Medical record review revealed Resident #73 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Observations in Resident #73's room on 4/1/19 at 11:54 AM, revealed Resident #73 handed her nebulizer mask to CNA #1 and told her it (the breathing treatment) was finished. CNA #1 took the mask from Resident #73, placed it in a plastic bag without cleaning it, and placed the nebulizer on the bedside table. Interview with the Director of Nursing (DON) on 4/2/19 at 12:50 PM, in the Training Room, the DON was asked what staff should do with the nebulizer mask after use. The DON stated, The mask should be cleaned out, dried, and put back in the bag and put with the machine .it should definitely be cleaned after use.

Based on medical record review and interview, the facility failed to accurately assess residents for height, anticoagulant medication use, and activities of daily living (ADL) for 3 of 24 (Resident #31, #54, and #81) sampled residents reviewed. The findings include: 1. Medical record review revealed Resident #31 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed a height of 66 inches. Review of the NUTRITIONAL DATA COLLECTION/assessment dated [DATE] revealed a height of 68 inches. Interview with MDS Coordinator #1 in the Training Room, the MDS Coordinator #1 was asked if the MDS height was accurate. MDS Coordinator #1 stated, It was miscoded .he is 68 inches. 2. Medical record review revealed Resident #54 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly MDS assessment dated [DATE] revealed Resident #54 had received an anticoagulant medication for 7 day of the 7 day look back period. Review of the Physician order [REDACTED]. Interview with MDS Coordinator #1 on 4/2/19 at 5:05 PM, in the Training Room, MDS Coordinator #1 confirmed that the MDS dated [DATE] was coded incorrectly. 3. Medical record review revealed Resident #81 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the 14 day MDS assessment dated [DATE] revealed Resident #81 required extensive assistance with bed mobility and toilet use. Review of the quarterly MDS assessment dated [DATE] revealed Resident #81 was totally dependent on staff for bed mobility and toilet use. Interview with MDS Coordinator #1 on 4/2/19 at 3:59 AM, in the Training Room, MDS Coordinator #1 was asked about the difference in each of these MDS's related to ADLs. MDS Coordinator #1 confirmed that the 2/26/19 MDS had been coded incorrectly for ADLs.

Based on policy review, medical record review, observation and interview, the facility's Quality Assessment and Assurance Committee (QAA) failed to have an effective ongoing quality program that identified developed, implemented and monitored appropriate plans of action to for falls. The failure to ensure an effective fall prevention system resulted in actual harm for Resident #30. The facility failed to ensure interventions were implemented when Resident #30 fell and sustained a [MEDICAL CONDITION] that required surgical interventions. The findings included: 1. The QAA Committee failed to ensure that services were provided in accordance with each resident's written plan of care related to falls. Refer to F282 2. The QAA Committee failed to ensure the facility's fall prevention program was effective and the fall management policy was implemented. Refer to F323. 3. Interview with administrator on 05/24/17 1:20 PM, in administrators office, the Administrator was asked if she had looked at falls or fall interventions in QA. The Administrator stated .No . The administrator was asked is there anything specific for fall interventions. The administrator stated, .when resident changes rooms their adaptive equipment is not being moved with them . The failure of the facility to implement appropriate interventions for a resident with severe cognitive abilities and failure to place non-skid strips to both sides of the bed when the resident was transferred to a new room, and failure to implement new interventions after each fall resulted in Resident #30 falling and sustaining a right femur fracture. The facility's failure to implement fall interventions resulted in Resident #30 sustaining a right femur fracture after a fall which caused actual harm to the Resident #30. Refer to F282 and F323

Based on policy review, medical record review and interview the facility failed to implement written care plans related to falls and behavior for 1 of 5 (Resident # 30) sampled residents reviewed of the 10 residents reviewed that had falls with injuries and 1 of 5 (Resident #95) residents reviewed for unnecessary medication which resulted in the resident receiving potentially unnecessary medications. The facility failed to implement Resident #30's fall interventions, Resident #30 fell and sustained a fracture requiring surgery. The findings included: 1. The facility's FALL MANAGEMENT policy documented, .promote patient safety and reduce patient falls by proactively identifying, care planning and monitoring of patients' fall indicators .Pertinent Regulatory Requirements .Based on comprehensive assessment of a patient, the facility must ensure that patients receive treatment and care in accordance with professional standard of practice, the comprehensive person-centered care plan, and the patient's choice. The patient environment remains as free of accident hazards as is possible and each patient receives adequate supervision and assistance devices to prevent accidents .Avoidable Accident: means that an accident because the facility has failed to: .Implement interventions, including supervision, consistent with a patient's needs, goals, plan of care and current standards of practice in order to reduce the risk of an accident; and/or, Monitor the effectiveness of the interventions and modify the interventions as necessary, in accordance with current standards of practice .The interdisciplinary team will review, revise, if indicated, ALL patients fall management care plans upon completion of each comprehensive, significant change and quarterly MDS (Minimum Data Set assessment), upon a fall event and as needed thereafter. Care plan revisions will be made at this time as indicated .Patient Fall Management Care Planning .equally important as an accurate and thorough patient assessment for fall indicators is application of the interdisciplinary team's critical thinking skills to determine which fall indicators most significantly impact the patient's potential for falls and implementing person centered care plans with interventions that mitigate the potential for falls. Development and implementation of the patients fall management are(care) plans is the ongoing responsibility of the interdisciplinary team .The patient's fall management care plan will be revised as indicated . The facility's policy Psychopharmacological Medication Management documented, .for unnecessary medication use documented behavioral interventions are individualized non-pharmacological approaches including direct care and activities that are provided as part of a supportive physical and psychosocial environment and are directed toward preventing, relieving and or accommodating a patients distressed behavior. Non-pharmacological interventions refers to approaches to care that do not involve medications generally directed towards stabilizing a resident's mental, physical, and psychosocial well being. The policy included each patient receives only those psychopharmacological medications in doses and for the duration clinically indicated to treat the resident's assessed condition and appropriate diagnosis. Non-pharmacological interventions such as behavioral interventions are considered and used when indicated instead or in addition to psychopharmacological medication . 2. Medical record review revealed Resident #30 was admitted to the facility on [DATE] and readmitted [DATE] (Post fracture and surgical intervention) with [DIAGNOSES REDACTED]. The significant change in status Minimum Data Set ((MDS) dated [DATE] revealed Resident #30 had moderately impaired cognitive skills, short term and long term memory problems, required extensive assistance with 2 person physical assist with transfers and toilet use and a fall since the previous assessment. Review of the fall risk evaluations revealed the resident was high risk (10 or greater) on 12/15/16 with a score of 16, 12/31/16 with a score of 17, 1/9/16 with a score of 16, 1/13/17 with a score of 26, 2/2/17 with a score of 28 and 3/17/17 with a score of 28. The care plan dated 12/27/16 revealed the resident was at risk for injury related falls due to impaired mobility, impaired cognition and .non-compliance at times with calling for assistance to ambulate .Resident has impaired cognitive skills .Score of 6 on the BIMS (Brief Interview for Mental Status) (MDS) (12/22/16) indicating severe cognitive impairment . The intervention approaches to prevent injury related falls were to remind resident and reinforce safety awareness, educate/remind resident to request assistance prior to ambulation and appropriate footwear. Review of the falls care plan revealed the following intervention approaches: 12/31/16-every one hour safety checks for 24 hours. 1/6/17-Non-skid footwear on at all times. 1/13/17-every one hour safety checks and non-skid strips to both sides of bed. 3/17/17-every 1 hour safety checks for 24 hours. Review of INCIDENT FOLLOW-UP & RECOMMENDATION Form documented the following falls: 12/31/16 at 11:30 AM-Resident reported she fell and her knee hurts. The intervention was to ensure Non Skid Foot wear while out of bed. 1/13/17 at 12:30 AM-Resident found sitting beside bed, states I was trying to get dressed .No injury . Add non-skid strips to Both sides of bed and non-skid footwear at all times instead of slippers. 1/13/17 at 5:45 AM-Resident was attempting to transfer/ambulate unassisted and fell to floor No obvious injury. Add non skid strips to both sides of bed. 3/17/17 at 2:00 AM-Resident fell at 12:00 PM beside bed while attempting to get up to use the bathroom, skin tears to right upper extremity and left extremity and bruise to right hip. The intervention was add non skid strips, quarter side rails and non skid footwear. 5/2/17 at 12:00 PM-Resident fell beside her bed while attempting to get up to use the bathroom. The intervention, clear pathways will be established for the left side of this residents bed. Record review of the progress note dated 5/2/17 at 4:32 PM revealed the revealed the resident was on the floor. The resident stated was trying to get up and go to the bathroom and slid off bed. The note documented, .Resident has order for non skid strips to both sides of bed but not in place d/t (due to) recent room change. The Radiology Interpretation of X-Ray of right hip dated 5/2/17 documented .IMPRESSION .Acute Subcapital fracture to the proximal right femur . Interview with Licensed Practical Nurse (LPN) #2 on 5/24/17 at 9:42 AM, at the West Hall Nurses station, LPN #2 was asked if Resident #30 had non-skid strips on both sides of her bed. LPN #2 stated, .No . Interview with the Director of Nursing (DON) on 5/24/17 at 12:40 PM, in the DON office, the DON was asked if it is appropriate to establish interventions for fall prevention but not implement the interventions. The DON stated .No, it is not . The DON was asked if a resident has a care plan that includes an intervention of nonskid strips on both sides of the bed, should the resident have the non-skid strips in place. The DON stated . yes . Interview with the DON on 5/24/17 at 11:38 PM, in the Training Room, the DON was asked how the every 1 hour rounds prevent falls. The DON stated, There should be another intervention in place during the 1 hour checks. I was not aware they were using that as an intervention repeatedly every 1 hour rounds would not prevent a resident from falling but are designed to help identify factors that could lead to a fall, implementation of interventions should be done during grand rounds . Interview with the DON on 5/24/17 at 12:01 PM, in DON office, the DON was asked if it was an appropriate intervention to include resident education or re-education for a resident that has a BIMS score of 6 (severely impaired cognitively). The DON stated, No, educating or re-educating a resident with a BIMS score of 6 is inappropriate The DON was asked was it appropriate to establish interventions in the care plan but not implement the interventions. The DON stated, No it is not. The DON was asked if a resident has a care plan that includes an intervention of nonskid strips beside the bed would she expect the resident to have the strips in place following a room change. The DON stated, Yes, I would. The facility failed to ensure appropriate interventions were developed and implemented for Resident #30. The resident fell , sustained a fracture that required surgical interventions resulting in actual harm. 3. Medical record review revealed Resident #95 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE] documented, the resident has memory problems and his cognition is moderately impaired with behavioral symptoms not directed toward others to include physical symptoms such as hitting or scratching self, pacing, rummaging or verbal/vocal symptoms like screaming or disruptive sounds. This behavior was noted to occur 1 to 3 days during this assessment period. The Behavior care plan dated 11/1/16 documented .has a history of agitation during care related to his [DIAGNOSES REDACTED].goal would not harm others secondary to his behaviors .(non-pharmacological interventions) staff are to explain care that is being provided in advance and in terms that the resident understands .to approach in a calm manner and divert attention as needed, remove the resident from situations and take the resident to another location as needed .staff are to assist with participation in activity programs .provide one on one and re-directional activities as needed .observe for behavior episodes and attempt to determine the underlying cause of the behavior by considering the location, time of day, persons involved .to ensure safety and re-approach the resident later when he becomes less agitated . The physician order [REDACTED].[MEDICATION NAME] ([MEDICATION NAME]) 0.5 milligrams, give ½ (half) tablet by mouth as needed two times a day for generalized anxiety disorder. The February 2017 Medication Administration Record [REDACTED]#95 without evidence of any non-pharmacological interventions attempted prior to the administration of the medication in accordance with the care plan. The March 2017 MAR indicated [REDACTED]#95 without evidence of non-pharmacological interventions attempted prior to the administration of the medication in accordance with the care plan. The April 2017 MAR indicated [REDACTED]. The May 2017 MAR indicated [REDACTED]#95 without evidence of non-pharmacological interventions attempted prior to the administration of the medication in accordance with the care plan. The nurse's progress notes did not document that the staff attempted any non-pharmacological interventions prior to administration of [MEDICATION NAME] on these dates in February, March, April and May 2017 according to the current care plan. Interview with Licensed Practical Nurse (LPN) #5 on 5/23/17 at 2:45 PM, in Hope's Place unit, LPN # 5 verified that if a resident exhibits behavior they should attempt non-pharmacological interventions prior to administering anti-anxiety medications according to the care plan. Interview with LPN #4 on 5/24/17 at 7:45 AM, LPN #4 was asked how she deals with a resident that receives [MEDICATION NAME]. LPN #4 stated .if a resident becomes agitated and has a prn order for [MEDICATION NAME] I give the [MEDICATION NAME] . LPN #4 did not mention signing the behavior monitoring tool or how she would attempt non-pharmacological interventions prior to giving the prn [MEDICATION NAME] antianxiety medication. Interview with LPN # 3 on 5/24/17 at 10:45 AM, in Hope's Place unit, LPN #3 was asked what interventions would be attempted prior to administering an anti-anxiety medication. LPN #3 stated .the medication would be an intervention . LPN #3 failed to identify the need to attempt non-pharmacological interventions that would be attempted prior to administering medications in accordance with the care plan.

Based on policy review, medical record review, review of the Incident Follow-Up & Recommendation Form and interview, the facility failed to ensure care plan interventions were appropriate, in place and implemented to prevent falls and injury for 1 of 5 (Resident # 30) sampled residents reviewed of the 10 residents reviewed that had falls with injuries. The failure to implement interventions resulted in actual harm when Resident #30 sustained a fractured femur requiring surgery. The findings included: 1. The facility's FALL MANAGEMENT policy documented, .promote patient safety and reduce patient falls by proactively identifying, care planning and monitoring of patients' fall indicators .Based on comprehensive assessment of a patient, the facility must ensure that patients receive treatment and care in accordance with professional standard of practice, the comprehensive person-centered care plan, and the patient's choice. The patient environment remains as free of accident hazards as is possible and each patient receives adequate supervision and assistance devices to prevent accidents .Avoidable Accident: means that an accident because the facility has failed to: .Implement interventions, including supervision, consistent with a patient's needs, goals, plan of care and current standards of practice in order to reduce the risk of an accident; and/or, Monitor the effectiveness of the interventions and modify the interventions as necessary, in accordance with current standards of practice .The interdisciplinary team will review, revise, if indicated, ALL patients fall management care plans upon completion of each comprehensive, significant change and quarterly MDS (Minimum Data Set assessment), upon a fall event and as needed thereafter. Care plan revisions will be made at this time as indicated .Patient Fall Management Care Planning .equally important as an accurate and thorough patient assessment for fall indicators is application of the interdisciplinary team's critical thinking skills to determine which fall indicators most significantly impact the patient's potential for falls and implementing person centered care plans with interventions that mitigate the potential for falls. Development and implementation of the patients fall management are(care) plans is the ongoing responsibility of the interdisciplinary team .The patient's fall management care plan will be revised as indicated . 2. Medical record review revealed Resident #30 was admitted to the facility on [DATE] and readmitted [DATE] with [DIAGNOSES REDACTED]. Review of the Fall Risk Evaluation form revealed the resident was a high fall risk on 12/15/16 with a score of 16. High fall risk was the score of 10 or higher. The admission MDS dated [DATE] revealed Resident #30 was severely impaired cognitively, required extensive assistance with 1 person physical assist with transfers and extensive assistance with 2 person physical assist with toileting. Review of the Fall Risk Evaluation forms revealed the resident was a high fall risk with a score on 1/9/16 of 16, 1/13/17 of 26 and 2/2/17 of 28. The significant change in status Minimum Data Set ((MDS) dated [DATE] revealed Resident #30 had moderately impaired cognitive skills, short term and long term memory problems, required extensive assistance with 2 person physical assist with transfers and toilet use and a fall since the previous assessment. Review of the Fall Risk Evaluation form revealed the resident was a high fall risk with a score on 3/17/17 of 28. The Significant change MDS dated [DATE] revealed Resident #30 was severely impaired cognitively, required extensive assistance with 2 person physical assist with transfers and toilet use and a fall since the previous assessment. The care plan dated 12/27/16 documented, .Problems .At risk for fall related injury due to impaired mobility, impaired cognition .non-compliance at times with calling for assistance to ambulate .Resident has impaired cognitive skills .Score of 6 on the BIMS (Brief Interview for Mental Status) (MDS) (12/22/16) indicating severe cognitive impairment . Approaches .Remind resident and reinforce safety awareness .Educate/remind resident to request assistance prior to ambulation .appropriate footwear .Review of the falls care plan dated 12/31/16 and revised on 12/31/17 documented .Approaches .every one hour safety checks x (for) 24 hrs (hours) .1/6/17-Non-skid footwear on at all times .1/13/17-every one hour safety checks .non-skid strips to both sides of bed .3/17/17-q(every) 1 h(hour) safety (checks) x 24 hrs .5/2/17-Add non-skid strips to both sides of bed to new room (new room number) . The care plan interventions to educate/remind Resident #30 to request assistance was not effective for this severely cognitively impaired resident and labeled the resident as being non-compliant because she did not call for assistance when she was severely cognitively impaired with long and short term memory problems. Review of INCIDENT FOLLOW-UP & RECOMMENDATION Form documented the following: a. 12/31/16 at 11:30 AM Summary .Resident reported she fell and her knee hurts .Summary fell and hit her knee .INTERVENTION Non Skid Foot wear while oob (out of bed) . The 12/27/16 care plan had previously documented the implementation of appropriate foot wear. b. 1/13/17 at 12:30 AM Summary .Resident found sitting beside bed, states I was trying to get dressed .No injury .Non-skid strips to Both sides of bed .INTERVENTION .Non-skid footwear at all times instead of slippers . The 12/27/16 care plan had previously documented the implementation of appropriate foot wear. c. 1/13/17 at 5:45 AM Summary .Resident was attempting to transfer/ambulate unassisted and fell to floor No obvious injury .INTERVENTION .Add non skid strips to both sides of bed .Date initiated .1/13/17 . d. 3/17/17 at 2:00 AM .Summary .Resident fell @12:00 PM beside bed while attempting to get up to use the bathroom .Skin tears to R(right) UE (Upper Extremity) & LE (Left Extremity) & bruise to R hip .INTERVENTION .Add non skid strips to new room effective 5/2/17 ¼ side rails, non skid footwear . The intervention of non skid strips should have already been implemented in accordance with the 1/13/17 fall and care plan interventions. e. 5/2/17 at 12:00 PM .Summary .fell .beside bed while attempting to get up to use the bathroom .INTERVENTIONS .Clear pathways will be established for the left side of this residents bed . The progress note dated 5/2/17 at 4:32 PM documented, .Resident was found on floor .Resident stated was trying to get (up) and go to the bathroom and slid off bed .Resident has order for non skid strips to both sides of bed but not in place d/t/ recent room change .N.O.(New order) to add skid strips to both sides of bed effective today 5-2-17 .X-ray results received .fracture to the proximal right femur noted . The intervention of non skid strips should have already been implemented in accordance with the 1/13/17 fall and care plan interventions. The Radiology Interpretation of X-Ray of right hip dated 5/2/17 documented .IMPRESSION .Acute Subcapital fracture to the proximal right femur . Observations in Resident #30's room on 5/23/17 at 3:21 PM, revealed Resident #30 in the bed awake and she stated, I need to go to the bathroom. Observations in Resident #30's room on 5/24/2017 at 8:18 AM revealed, Resident #30 up in a wheelchair. The call light was out of her reach. Interview with LPN #2 on 5/24/17 at 9:42 AM, at the East Hall nurses station, LPN #2 was asked if he was familiar with Resident #30. LPN #2 stated, .yes when she was admitted she was on the secure unit, I took care of her back there and also on the East Hall when she was moved last month . LPN #2 was asked if the resident had nonskid strips beside her bed when she was on the secured unit. LPN #2 stated, Yes, I believe she did . LPN #2 was asked when the resident was moved from the secured unit to the East Hall, if the nonskid strips were placed on each side of the bed in the resident's new room. LPN #2 stated' No, I don't think so . Interview with LPN #3 on 5/24/17 at 10:02 AM, at the East Hall nurses station, LPN #3 was asked to tell this surveyor about Resident #30's care prior to her femur fracture. LPN #3 stated, .before she broke her hip she was able to get to the bathroom with little assistance she was sometimes unsteady but would go to the bathroom on her own . LPN #3 was asked if the resident was capable of using the call light to ask for assistance to ambulate to the bathroom. LPN #3 stated, She would press the call light frequently, sometimes she would call out for help by saying HEY, take me to the bathroom LPN #3 was asked if the resident would always use the call light. LPN #3 stated, .sometimes she would, sometimes she was confused . Interview with Registered Nurse (RN) #2 on 5/24/17 at 10:21 AM, in the MDS office, RN #2 was asked who determines what the [DIAGNOSES REDACTED]. RN #2 stated, That would be the ADON (Assistant Director of Nursing) and the DON are the ones that determine what [DIAGNOSES REDACTED].>Interview with DON 5/24/2017 at 10:35 AM, in the DON office, the DON was asked how the [DIAGNOSES REDACTED].>Interview with the Medical Records Director on 5/24/17 at 10:45 AM, in the Medical Records Office, the Medical Records Director was asked how a resident's medical [DIAGNOSES REDACTED]. The Medical Records Director stated, When we get a referral, the hospital documentation is given to me and I pull out all of the [DIAGNOSES REDACTED]. The Medical Record Director was asked who determined the [DIAGNOSES REDACTED]. The Medical Record Director stated, I did. The Medical Records Director was asked where the [DIAGNOSES REDACTED]. The Medical Records Director stated, I don't know where that [DIAGNOSES REDACTED]. The Medical Records Director was asked if the hospital documentation reviewed for readmission on May 9 included a medical [DIAGNOSES REDACTED]. The Medical Records Director stated, No it did not. Interview with the DON on 5/24/17 at 11:38 PM, in the Training Room, the DON was asked how the every 1 hour rounds prevent falls. The DON stated, There should be another intervention in place during the 1 hour checks. I was not aware they were using that as an intervention repeatedly every 1 hour rounds would not prevent a resident from falling but are designed to help identify factors that could lead to a fall, implementation of interventions should be done during grand rounds . Interview with the DON on 5/24/17 at 12:01 PM, in DON office, the DON was asked if it was an appropriate intervention to include resident education or re-education for a resident that has a BIMS score of 6 (severely impaired cognitively). The DON stated, No, educating or re-educating a resident with a BIMS score of 6 is inappropriate The DON was asked was it appropriate to establish interventions in the care plan but not implement the interventions. The DON stated, No it is not. The DON was asked if a resident has a care plan that includes an intervention of nonskid strips beside the bed would she expect the resident to have the strips in place following a room change. The DON stated, Yes, I would Interview with the Director of Nursing (DON) on 5/24/17 at 12:40 PM, in the DON office, the DON was asked if it is appropriate to establish interventions for fall prevention but not implement the interventions. The DON stated .No, it is not . The DON was asked if a resident has a care plan that includes an intervention of nonskid strips on both sides of the bed, should the resident have the non-skid strips in place. The DON stated . yes . The facility failed to implement fall interventions and implement effective fall interventions for Resident #30. On 5/2/17 Resident #30 fell , sustained a fracture that required surgery resulting in actual harm.