Every finding on record at Marquis Piedmont Post Acute Rehab

Based on observation, interview and record review it was determined the facility failed to ensure medications and biologicals were secured for 2 of 3 medication carts and 2 of 3 treatment carts reviewed for safe medication storage. This placed residents at risk for unauthorized access to medications. Findings include:The facility's 5/2010 Security of Medication Cart Policy specified the following: -The nurse must secure the medication cart during the medication hall to prevent unauthorized entry. -Medication carts must be securely locked at all times when out of the nurse's view. 1. On 4/6/26 at 12:02 PM a treatment cart was observed to be unlocked on the North Hall. The nurse was not in view of the cart. The treatment cart contained multiple drawers with resident care items, including insulin and insulin supplies, prescribed creams and lotions, wound care supplies, nebulizer medications and supplies, and shampoos and other treatment supplies. On 4/6/26 at 12:04 PM Staff 10 (LPN) confirmed the cart was unlocked and contained medications and treatment supplies. On 4/9/26 at 9:57 AM Staff 2 (DNS) stated it was her expectation all medication and treatment carts remain locked when not in use in accordance with the facility policy. 2. On 4/8/26 at 9:46 AM a medication cart was observed to be unlocked on the North Hall. The CMA was not in view of the cart. The medication cart contained multiple drawers with medications, including eye drops, inhalers, nasal sprays, resident prescribed medications, over-the-counter medications, and overflow medications. On 4/8/26 at 9:51 AM Staff 11 (CMA) confirmed the cart was unlocked and contained resident medications. On 4/9/26 at 9:57 AM Staff 2 (DNS) stated it was her expectation all medication and treatment carts remain locked when not in use in accordance with the facility policy. 3. On 4/10/26 at 9:18 AM a treatment cart was observed to be unlocked on the [NAME] Hall. The nurse was not in view of the cart. The treatment cart contained multiple drawers with resident care items, including insulin and insulin supplies, prescribed creams and lotions, wound care supplies, nebulizer medications and supplies, and shampoos and other treatment supplies. On 4/10/26 at 9:25 AM Staff 12 (LPN) confirmed the cart was unlocked and contained medications and treatment supplies. On 4/9/26 at 9:57 AM Staff 2 (DNS) stated it was her expectation all medication and treatment carts remain locked when not in use in accordance with the facility policy. 4. On 4/8/26 at 2:20 PM an unlocked medication cart was observed to the right of the social services office and left of room [ROOM NUMBER]. No staff were observed in view of the unlocked medication cart. On 4/8/26 at 2:22 PM a CNA walked pass the unlocked medication cart. On 4/8/26 at 2:22 PM Staff 11 (CMA) returned to the unlocked medication cart. Staff 11 acknowledged she left the medication cart unattended and unlocked. Staff 11 confirmed it was expected for medication carts to always be locked when unattended. Staff 11 confirmed the medication cart contained resident medications, insulin supplies. eye drops, and inhalers. On 9/9/26 at 9:57 PM Staff 2 (DNS) stated it was the expectation all medication carts remain locked when not in use in accordance with the facility policy.

Based on observation, interview and record review it was determined the facility failed to assess residents for safe self-administration of medication for 1 of 2 sampled residents (# 29) reviewed for self-administering medication. This placed residents at risk for an unsafe medication regimen. Findings include:Resident 29 was admitted to the facility in 12/2025 with diagnoses including depression and end stage renal failure. Resident 29's 12/17/25 admission MDS assessed her/him as cognitively intact. On 4/6/26 at 11:47 AM and 1:19 PM observations were made of an empty six pack of Imodium on Resident 29's dresser to the right of her/his bed. On 4/6/26 at 2:34 PM observations were made of an empty six pack of Imodium on Resident 29's dresser to the right of her/his bed and a small clear plastic pill cup which contained two capsule pills and three small tablet pills on her/his window counter. On 4/7/26 at 1:50 PM observation was made of an empty six pack of Imodium on Resident 29's dresser to the right of her/his bed. On 4/8/26 at 8:39 AM three individual empty pill packs were observed on Resident 29's sink counter and one on floor by her/his bed. A review of Resident 29's medical records on 4/8/26 at 11:26 AM did not provide any indication she/he was safe to self-administer her/his own medications. On 4/8/26 at 1:00 PM Staff 11 (CMA) walked into Resident 29's room, left a white tablet pill in a small clear plastic pill cup with Resident 29 and left the room. On 4/8/26 at 1:00 PM Resident 29 stated staff leave this pill with her/him to take after meals and often leave other pills for her/him to take later if she/he does not want to take them at the time. On 4/8/26 at 2:24 PM Staff 11 stated some residents had medications left at the bedside to self-administer and the MAR indicated if a resident was able to take medication without staff supervision. Staff 11 looked at the computer and confirmed Resident 29 did not have directions to allow staff to leave medications at her/his bedside. On 4/8/26 at 2:39 PM Staff 15 (Resident Care Manager) stated staff were expected to not leave any medications in a resident's room unless the resident was assessed with a Self-Administration Assessment to ensure they were safe to take medication without supervision. Staff 15 stated she frequently removed medications from Resident 29's room and Resident 29 was known to obtained over the counter medications from the community. Staff 15 confirmed Resident 29 did not have a Self-Administration Assessment, and the resident should not have any medications in her/his room to self-administer. On 4/9/26 at 10:01 AM Staff 2 (DNS) acknowledged all residents who wished to self-administer medications were expected to be assessed for safety and no medication should not be left at bedside without an assessment.

Based on observation, interview and record review the facility failed to protect the resident's right to be free from physical abuse for 1 of 1 (#11) sampled resident reviewed for abuse. This placed residents at risk for continued physical abuse. Findings include: Resident 11 was admitted to the facility in 2024 with diagnoses including dementia and hearing deficit.Resident 11's 10/9/25 Quarterly MDS assessed her/him as cognitively intact and received anticoagulant (blood thinner) medication daily.Resident 36 admitted to the facility in 11/2025 with diagnoses including diabetes and visual deficit.Resident 36's 11/30/25 admission MDS assessed her/him as cognitively intact.On 3/29/26 Staff 21 (LPN) initiated a Resident-to-Resident Event Assessment for an incident involving Resident 11 and Resident 36. The assessment revealed Resident 11 reported asking Resident 36 to turn down the television volume and was punched in the face on 3/29/26 at 7:50 PM, resulting in Resident 11 obtaining a bloody nose. Staff 21 cleaned up Resident 11's face, assessed her/him for injury and found no bruising or swelling. Staff 21 offered to move Resident 36 to another room and Resident 36 agreed. The Resident-to-Resident Event Assessment section completed by Staff 4 (RNCM) on 3/30/26 revealed on 3/29/26 Resident 11 entered Resident 36's room due to the television being loud. Resident 11 approached Resident 36 who was lying in bed and talking on her/his cell phone. Due to Resident 11's hearing impairment, she/he did not understand when Resident 36 told her/him to leave the room. The situation escalated and resulted in Resident 11 sustaining a bloody nose. Staff 4 assessed no long-term effects or physical harm.Progress notes from 3/30/26 through 4/1/26 revealed Resident 11 was placed on alert charting and assessed daily by Staff 14 (RN) and Staff 21. The resident had no injuries, bruising or swelling to the face/nose area. Resident denied any pain or discomfort to her/his face/nose area.The Resident-to-Resident Event Assessment revealed on 4/1/26 revealed the following: -Staff 5 (Social Services Director) met with Resident 11 regarding the interaction with Resident 36 on 3/29/26. Resident 11 told her the incident was a miscommunication between the two parties and stated no harm was intended by Resident 36. -Resident 11 stated the situation escalated due to a misunderstanding. Resident 11 would like to talk with Resident 36 in hope to clear things up and maybe become friends. -Resident 36 stated she/he was lying on her/his bed talking on her/his cell phone when Resident 11 came into her/his room. Resident 36 stated Resident 11 was yelling, demanded the television volume lowered and proceeded to grab at her/his cell phone. Resident 36 stated she/he became upset and ended up hitting Resident 11 on the face with the phone.On 4/6/26 at 10:04 AM Resident 11 stated she/he felt safe in the facility and with other residents. Resident 11 indicated she/he recalled the 3/29/26 incident with Resident 36. Resident 11 stated although she/he was hard of hearing, loud televisions annoyed her/him. Resident 11 was observed with no signs of bruising to the face.On 4/9/26 at 12:31 PM Staff 4 stated she interviewed Resident 11 and Resident 36 after the 3/29/26 incident. Staff 4 stated Resident 36 had a history of verbal aggression and talked rough. When Staff 4 interviewed Resident 36 she asked her/him to demonstrate the action made when Resident 11 was hit. Staff 4 reported Resident 36 demonstrated a tap to the face with the flinch in attempt to keep Resident 11 from taking her/his phone and the contact was not intentional. Staff 4 stated Resident 36 seemed more annoyed than angry when interviewed. Staff 4 reported she assessed Resident 11 who sustained a bloody nose due to the tap to the nose and because of anticoagulant medication use. Staff 4 stated Resident 11 had a history of bruising easily, but no bruising was observed after the 3/29/26 incident.On 4/9/26 at 2:44 PM Resident 36 stated approximately one week earlier, Resident 11 came into her/his room yelling about the television volume down and attempted to grab her/his cell phone. Resident 36 stated she/he resisted and unintentionally struck Resident 11 in the face and had no intent to harm. Resident 36 stated she/he just wanted Resident 11 to leave her/his room.On 4/10/26 at 2:25 PM Resident 11 stated she/he had a bloody nose from a misunderstanding with Resident 36. Resident 11 stated she/he was not hurt and just wanted to work it out with Resident 36 but she/he was not interested.On 4/10/26 at 11:30 AM Staff 1 (Administrator) acknowledged the facility expected all residents to be free from abuse. Staff 1 stated the facility immediately implemented interventions and corrective action was taken on 3/30/26 to ensure residents resident safety. Staff 1 concluded the incident was resident to resident abuse event and Resident 11 sustained a bloody nose due to Resident 36's flinch, which was not intentional. Staff 1 confirmed no resident-to-resident incidents had occurred since 3/30/36. The deficient practice was identified as Past Noncompliance based on the following:-On 3/30/26, the deficient practice was identified by the facility and was corrected when the facility completed a root cause analysis of the incident and there was a resident-to-resident abuse altercation: 1.Separated Residents 11 and 36 immediately and relocated Resident 36. 2.Initiated alert charting for both residents.Reviewed and updated both residents' care plans. 3.Completed audits for all residents with televisions and offered headphones for volume control. 4.Provided immediate staff education on 3/30/26 regarding signs of abuse, recognition of triggers, de escalation techniques, and reporting requirements. 5.Continued ongoing review through the QAPI Committee regarding abuse protocols.

Based on interview and record review it was determined the facility failed to provide notice of bed hold policies for 1 of 1 sampled resident (#4) reviewed for hospitalizations. This placed residents at risk for miscommunication of the discharge process. Findings include:Resident 4 was admitted to the facility in 2/2026 with diagnoses of congestive heart failure and epididymitis (inflammation of the tube at the back of the testicle). Resident 4's clinical record revealed the resident was transferred to the hospital on 4/3/26 for evaluation and treatment related to swelling of the scrotum. The resident's provider was notified, and orders were received to send Resident 4 to the hospital for further evaluation. Resident 4's clinical record did not contain documentation to indicate a written notice of the facility's bed hold policy was provided to Resident 4 or her/his representative. On 4/10/26 at 11:30 AM, Staff 2 (DNS) stated the charge nurse was responsible for providing the bed hold policy to residents when they were sent to the hospital. Staff 2 stated there was no documentation Resident 4 received a bed hold notice and it was her expectation the form was completed at the time of transfer. On 4/10/26 at 11:40 AM Staff 1 (Administrator) confirmed a bed hold policy was not completed for Resident 4 at the time of transfer.

Based on observation, interview and record review the facility failed to ensure nail care was provided for 1 of 5 sampled residents (#29) reviewed for ADLs. This placed residents at risk for unkept hygiene needs. Findings include: Resident 29 admitted to the facility in 12/2025 with diagnoses including diabetes and end stage renal failure.Resident 29's 12/17/25 admission MDS assessed her/him as cognitively intact.On 4/6/26 at 11:47 AM Resident 29 was observed with long pointed fingernails with dark substance under the nails. Resident 29 stated she/he required assistance to trim her/his fingernails due to her/his diabetes diagnosis. Resident 29 stated she/he would like her/his nails trimmed and had not been offered assistance.Record review of Resident 29's health record revealed no directions for staff to assist or offer to trim her/his fingernails and no documentation the fingernails had been completed.On 4/8/26 at 2:27 PM Staff 13 (CNA) stated he did not trim resident's fingernails if the resident was diabetic and only licensed nurses completed the task.On 4/8/26 at 2:29 PM Staff 14 (RN) stated residents who have a diabetic diagnosis could not trim their own fingernails in the facility and only a licensed nurse could trim the fingernails for health and safety reasons. On 4/8/26 at 2:39 PM, Staff 15 (Resident Care Manager) stated only a licensed nurse could trim Resident 29's fingernails and it was expected the plan of care would direct a licensed nurse to perform the task. Staff 15 reviewed Resident 29's health record and confirmed the resident did not have any plan directing a licensed nurse to assist the resident's fingernail trimming, nor any documentation indicating a nail trim was completed.On 4/9/26 at 10:01 AM Staff 2 (DNS) acknowledged it was the expectation for Resident 29 to have a plan of care to direct licensed nursed to trim her/his fingernails.

Based on observation, interview and record review it was determined the facility failed to provide care planned safety interventions for 1 of 7 sampled residents (#25) reviewed for accidents. This placed residents at risk for falls and injury. Findings include:Resident 25 was admitted to the facility in 8/2024 with diagnoses of dementia and anxiety disorder. A 3/16/26 Quarterly MDS revealed Resident 25 had a BIMS of 14, which indicated she/he was cognitively intact. A 3/27/26 fall care plan revealed Resident 25 was at high risk for falls due to acute medical conditions, stroke and history of falls. Fall preventions included no assistive devices at bedside, bed in lowest position and fall mat at bedside. Random observations from 4/6/26 through 4/9/26 from 8:00 AM to 4:00 PM revealed Resident 25 was observed in bed with her/his walker at bedside and within reach, the bed was not in the lowest position (approximately knee height), and no fall mat was in place.On 4/9/26 at 10:18 AM, Staff 17 (CNA) stated Resident 25 was a high fall risk and was to have no assistive devices at bedside, bed in the lowest position and a fall mat in place. Staff 17 entered the room, observed Resident 25 in bed, and confirmed her/his walker was within reach, the bed was not in the lowest position, and a fall mat was not in place. On 4/9/26 at 10:25 AM, Staff 16 (RN) stated Resident 25 was to have no assistive devices within reach, bed in the lowest position and a fall mat in place. Staff 16 entered the room, observed Resident 25 in bed, and confirmed her/his walker was within reach, the bed was not in the lowest position, and a fall mat was not in place. On 4/9/26 at 10:32 AM, Staff 4 (RNCM) confirmed Resident 25 was care planned to have no assistive devices within reach, her/his bed in the lowest position, and a fall mat at bedside. On 4/9/26 at 12:32 PM, Staff 2 (DNS) stated it was her expectation that staff follow and implement all care planned fall interventions.

Based on observation, interview and record review it was determined the facility failed to identify PTSD (Post Traumatic Stress Disorder) triggers, provide treatment and services to address distress related to PTSD for 1 of 1 sampled resident (#5) reviewed for behavior health. This placed residents at risk for unrecognized triggers and increased or worsening PTSD related symptoms. Findings include:A 5/2019 Trauma Informed Care Policy indicated staff completed assessments to gather how trauma impacts the residents care needs in triggers, approaches and person-centered care planning, duration and frequency of problematic behaviors or changes in behavior, cognition, or mood. Resident 5 was admitted to the facility on [DATE] with diagnoses including PTSD. A 3/23/26 admission MDS indicated Resident 5 had a BIMS score of 15 indicating the resident was cognitively intact. The Mood and Behavior CAA indicated the resident's psychosocial well-being would be addressed in her/his care plan with a goal of maintaining current level of functioning and to avoid complications. A 3/18/26 Care Plan did not address Resident 5's PTSD triggers or interventions. The Care Plan indicated the resident did not want to talk about PTSD diagnoses and she/he refused counseling services. A 3/18/26 Social Services admission form indicated Resident 5 scored a 15 out of 27 on the PHQ-2 to 9 assessment indicating moderate depression. The social services form did not address the residents PTSD diagnosis, triggers or interventions. Progress notes dated 3/22/26 at 12:56 PM, 3/23/26 at 12:02 PM and 3/27/26 at 5:37 PM indicated Resident 5 was distressed, had increased symptoms of anxiety and expressed mental health concerns. The resident requested to check in with Staff 5 (Social Services). A 3/24/26 Care Conference did not address Resident 5's PTSD diagnosis, triggers or interventions. A review of Resident 5's clinical record revealed no evidence the resident refused to discuss her/his PTSD diagnosis and no follow-up was completed with Staff 5. On 4/6/26 at 12:06 PM and 4/8/26 at 10:45 AM, Resident 5 stated staff did not address her/his PTSD diagnoses, triggers and interventions. Resident 5 stated staff offered counseling services upon admission, but staff did not follow up. Resident 5 stated she/he experienced childhood trauma including abandonment, sex trafficking, substance abuse, sexual and physical abuse. Resident 5 stated she/he was triggered by closed doors, windows, curtains, opened bathroom doors, perfumes, supplies with high alcoholic content, chicken pot pies and [NAME] tea. Resident 5 stated when doors were closed, she/he felt isolated, trapped and scared. Resident 5 stated prolonged exposure to PTSD related triggers increased anxiety and required medications to decrease symptoms. Resident 5 stated during a recent facility fire drill, staff closed the door, which resulted in her/him experiencing increased anxiety and isolation. Resident 5 stated the door remained closed until the fire drill ended and the resident was distressed for a couple of hours after the fire drill. An observation on 4/8/26 at 11:24 AM to 11:31 AM, Staff 7 (CNA) entered Resident 5's room and assisted her/him to the bedside commode. Staff 5 walked by and attempted to close the door. Resident 5 stated, Having the door and curtain opened for care is my preference. Staff 5 did not respond and she walked away. On 4/8/26 at 2:56 PM, Staff 22 (CNA) stated Resident 5 experienced claustrophobia and preferred to have the window open and the blinds up. Staff 22 stated Resident 5 was sensitive to scents but was unsure which scents caused distress. Staff 22 stated she was unaware Resident 5 had a PTSD diagnosis. Staff 22 stated Resident 5 was anxious when staff did not perform care in a manner the resident preferred. On 4/8/26 at 12:06 PM, Staff 7 stated she was unaware Resident 5 had a PTSD diagnosis and would refer to the care plan. Staff 7 stated Resident 5 was triggered by closed doors and hand sanitizer which caused her/him to become anxious. On 4/8/26 at 3:03 PM, Staff 5 stated she had not talked to Resident 5 about her/his PTSD diagnosis and had not addressed any triggers or interventions. Staff 5 stated she was unaware whether Resident 5 had any PTSD related triggers. She stated she had asked the resident upon admission if she/he wanted counseling services, but the resident refused, and she did not follow up. Staff 5 stated she did not complete a behavior assessment related to Resident 5's PTSD diagnosis. On 4/8/26 at 3:17 PM, Staff 20 (RN) stated she was unaware of Resident 5's PTSD diagnosis. She reported Resident 5 became triggered when staff closed her/his bedroom door and the resident was triggered when the fire alarm sounded, at which time the resident refused to close her/his bedroom door. Staff 20 stated the resident experienced panic attacks when triggered. She stated Resident 5's PTSD triggers and related interventions were not included in the resident's care plan and the resident had not received services related to PTSD. On 4/9/26 at 1:05 PM, Staff 4 (RNCM) stated she was aware Resident 5 had a PTSD diagnosis, but she did not address Resident 5's PTSD diagnosis, identify triggers or develop interventions. Staff 5 stated she avoided discussing PTSD because she believed mentioning the trauma could worsen the resident's anxiety. Staff 4 stated she focused on the resident's physical health versus mental health. On 4/10/26 at 9:20 AM, Staff 2 (DNS) stated she was aware of Resident 5's diagnosis of PTSD. Staff 2 stated staff did not re-approach the resident after she/he admitted and did not offer counseling services. Staff 2 stated she did not specially address the resident's PTSD because Resident 5's other mental health diagnoses overlapped. Staff 2 stated she was aware about Resident 5's preference to use the commode with the door open and staff were accommodating and left the door open. Staff 2 acknowledged Resident 5 did not receive counseling services or have a care plan addressing her/his PTSD diagnosis, associated triggers or interventions.

Based on observation, interview and record review it was determined the facility failed to provide dental services for 1 of 2 sampled residents (#9) reviewed for dental care needs. This placed residents at risk for inadequate provision of dental services. Findings include: Resident 9 was admitted to the facility in 3/2026 with diagnoses including end stage renal disease and type 2 diabetes.Resident 9's admission MDS dated [DATE] revealed she/he was cognitively intact and had no missing, cracked or decayed teeth.Resident 9's 3/12/26 Nursing admission Assessment indicated she/he had, no dental issues.Resident 9's care plan dated 3/16/26 indicated she/he required constant supervision and physical assistance to complete oral hygiene tasks.On 4/6/26 at 2:33 PM, Resident 9 was observed to have several broken and missing upper front teeth. Resident 9 stated she/he was missing most of her/his upper teeth and had cavities which made it challenging and sometimes painful to chew. Resident 9 stated staff never examined the inside of her/his mouth and did not ask about her/his dental health.On 4/8/26 at 3:09 PM Staff 18 (CNA) stated she did not assist Resident 9 with oral care but just reminded the resident to brush her/his teeth after meals.On 4/8/26 at 4:02 PM Staff 19 (CNA) stated she thought Resident 9 was independent to complete oral hygiene and she only reminded her/him to brush her/his teeth after meals.On 4/8/26 at 4:17 PM Staff 20 (LPN) stated CNAs assisted Resident 9 to brush her/his teeth after meals and she did not know if the resident had cavities or missing teeth.On 4/10/26 at 12:53 PM Staff 12 (LPN) stated Resident 9 was fairly independent and required set up assistance for oral care. Staff 12 stated she never assessed Resident 9's teeth and was not aware if she/he had missing teeth or cavities.On 4/10/26 at 2:29 PM Staff 2 (DNS) examined Resident 9's dentition and stated she/he had missing, cracked and decayed teeth which needed to be addressed. Staff 2 stated she expected dental health assessments to be complete and accurate so residents will receive the dental care they require.

Based on observation, interview, and record review it was determined the facility failed to ensure care plans were revised to accurately reflect the needs of residents for 1 of 4 sampled residents (#37) reviewed for nutrition and positioning. This placed residents at risk for receiving unneeded assistance. Findings include: Resident 37 was admitted to the facility in 5/2024 with diagnoses including stroke and a stage 4 pressure injury (a full thickness tissue loss with exposed bone, tendon or muscle). Resident 37's nutrition care plan, dated 5/3/24, and Restorative care plan, dated 6/3/24, indicated Resident 37 was at risk for nutritional deficits such as weight loss and decline in ROM to her/his hand. Interventions included: -1:1 total assistance for all meals and snacks. - Adaptive equipment was to be used including adaptive silverware, scoop plate, and an adaptive cup or coffee cup. - Staff were to put a splint in place in the resident's hand during the day for four hours, and at night, and were to to thoroughly wash and dry the resident's skin before splint application and removal. During observations of Resident 37 from 12/2/24 through 12/5/24, no splint was observed in the resident's hand. On 12/3/24 at 8:40 AM Resident 37 was observed in the dining room during the breakfast meal. Resident 37 was drinking from a regular cup without assistance, and without difficulty. No assistive devices were observed. No hand splint was observed. On 12/3/24 at 12:53 PM Staff 21 (LPN) stated Resident 37 consumed 50-75% of her/his meal and only required staff supervision and encouragement. On 12/4/24 at 3:03 PM Staff 17 (LPN) stated there was a change from 1:1 assistance with meals to providing meal supervision for Resident 37. Staff 17 was unaware of the care plan for use of a hand splint. On 12/5/24 at 12:44 PM Staff 4 (RNCM) stated the hand splint was discontinued because it caused pain to the resident. Staff 4 stated Resident 37 no longer needed 1:1 assistance with meals or adaptive equipment. Staff 4 confirmed resident's care plan was not updated related to use of a splint and nutritional assistance.

Based on observation, interview, and record review it was determined the facility failed to ensure enhanced barrier precautions (EBP) were followed for 1 of 1 resident (#37) reviewed for EBP. This placed residents at risk for exposure to infections. Findings include: The facility's undated Isolation - Categories of Transmission-Based Precautions policy indicated EBP were to be used for residents with catheters and complex wounds. The precautions included use of gloves and gowns while providing high contact care such as transfers, wound care, peri-care, and dressing assistance. Resident 37 was admitted to the facility in 5/2024 with diagnoses including stroke and stage 4 pressure injury (a complex wound). Resident 37's 5/3/24 care plan indicated she/he was at risk for infection due to a stage 4 pressure injury. Interventions included EBP. On 12/3/24 at 11:56 AM an observation of Resident 37's care revealed Staff 9 (CNA) and Staff 8 (NA) provided transfer assistance and personal hygiene without donning gowns. On 12/3/24 at 12:05 PM Staff 8 (NA) was unable to explain what EBP was required when providing care for Resident 37 and confirmed she did not wear a gown when providing care to the resident. On 12/3/24 at 12:11 PM Staff 9 (CNA) verbalized understanding of EBP and confirmed she did not wear a gown when providing care to the resident. On 12/3/24 at 1:49 PM another observation of Resident 37's care revealed Staff 9 (CNA) and Staff 19 (NA) provided transfer assistance to Resident 37 without donning gowns. On 12/3/24 at 2:00 PM Staff 19 (NA) was unable to explain what EBP was required when providing care for Resident 37 and confirmed she did not wear a gown when providing care to the resident. On 12/5/24 at 12:44 PM Staff 4 (RNCM) was provided with these findings. Staff 4 confirmed staff were to wear gloves and gowns during transfers and personal hygiene care for Resident 37.

Based on observation, interview and record review it was determined the facility failed to ensure there were sufficient nursing staff available to provide the necessary care and services to meet residents' needs in 1 of 1 facility reviewed for staffing. This placed residents at risk for unmet care needs. Findings include: On 9/24/24 the facility had a census of 51 residents. On 9/26/24, Staff 1 (Administrator) provided a list of residents who: -Required two-person mechanical lift transfers: 17; -Required two-person extensive or total assistance for bathing: 3; -Required two-person extensive or total assistance for toileting: 3; -Required two-person extensive or total assistance for dressing: 6; -Required one-to-one feeding: 3 -Had behavioral health needs which required monitoring: 50; -Were high fall risks: 28; -Were considered at risk for elopement: 1 and -Required bariatric care (body mass index greater than 40): 6. On 8/26/24 a public complaint was received by the State Agency which alleged staff were not able to provide care such as showers and care was not timely due to low staffing. On 9/24/24 at 10:26 AM and 9/26/24 at 12:30 PM Resident 17 stated she/he was not showered and her/his hair was not washed for three weeks. Resident 17 stated there were not enough staff to assist her at times, especially during mealtime. Resident 17 reported she/he required two staff to assist her/him with most care and it could be difficult for staff to find a second person to help. Resident 17 stated on 9/25/24 at 5:00 PM, she/he activated her/his call light for assistance and was finally assisted at 8:00 PM because staff were assisting residents at dinner and two staff were not available, thus she/he waited three hours before receiving assistance. On 9/26/24 at 9:10 AM Resident 24 stated the facility was understaffed. Resident 24 stated when she/he needed assistance, sometimes it takes a long time. Resident 24 stated at times, staff did not show up so there were not enough staff to provide timely care. On 9/26/24 at 8:36 AM Resident 24's call light was activated for one hour and one minute. On 9/26/24 at 10:05 AM Resident 22 stated the facility was often short-staffed. Resident 22 stated at times, she/he had to go to the bathroom right away and staff were supposed to assist her/him to the bathroom but sometimes it took too long so she/he went to the bathroom without assistance. On 9/24/24 at 2:19 PM Staff 4 (CNA) stated when staff did not show up or called out, it made it difficult to get care done. Staff 4 stated when the facility was short-staffed, it was difficult to get vital signs and showers completed, toileting done and to get residents up. Staff 4 stated everything had to be done fast instead of moving at the rate residents preferred. On 9/25/24 at 10:12 AM Staff 10 (CNA) reported staffing levels did not meet patient care needs. Staff 10 stated, at times, showers had to be skipped and when residents were unavailable for a shower or refused showering then showers could not be rescheduled due to staffing issues. Staff 10 stated CNA staff were frequently late arriving for their shifts which pushed back everything and resulted in CNAs having to hit the floor running. On 9/25/24 at 11:45 AM Staff 14 (CNA) stated the facility needed more staff because it was difficult to give good care because there was not enough time to do what I need to do. Staff 14 stated if a resident required two person assistance, they often had to wait until a second person was available. Staff 14 stated there were not enough staff, especially at mealtimes and staff were unable to make-up showers if a resident was unavailable, missed or refused a shower. On 9/26/24 at 2:00 PM Staff 16 (Staffing Coordinator) stated she staffed CNAs according the State's mandatory minimum staffing ratios and not to the acuity needs of the residents. On 9/27/24 at 9:52 AM Staff 1 (Administrator) confirmed staffing was based on the State's mandatory minimum staffing ratios and not the acuity needs of the residents. Staff 1 stated it was difficult to find enough staff and they had challenges with staff calling out and not showing up for assigned shifts.

Based on interview and record review it was determined the facility failed to ensure the Direct Care Staff Daily Report (DCSDR) postings were thoroughly completed or accurately reflected the number of staff working and their hours worked for 37 of 37 days reviewed for sufficient staffing. This placed residents at risk for incorrect staffing information. Findings include: Review of the 8/18/24 through 9/24/24 DCSDRs indicated the staff postings were incomplete or inaccurate on all 37 days reviewed. On 9/25/24 at 8:24 AM Staff 2 (DNS) acknowledged the 8/18/24 through 9/24/24 DCSDRs were not accurately completed and did not include the hours staff members worked on all 37 days reviewed.

Based on observation, interview and record review it was determined the facility failed to treat residents in a dignified manner for 1 of 3 residents reviewed for resident rights. This placed residents at risk for diminished quality of life. Findings include: This deficient practice was identified at past non-compliance in the area of 483.10 Resident Rights when the facility failed to provide an environment which promoted the maintenance of dignity and respect for residents' quality of life. On 2/20/24, the non-compliance was corrected when the facility completed a root cause analysis of the incident and determined Staff 19 treated residents in a manner which was undignified and disrespectful. The Plan of Correction included: 1. All staff were educated on resident rights, respect, dignity, abuse and neglect. 2. All staff completed written tests on their knowledge of resident rights from the education provided. 3. Dignity and respect audits were completed on residents. 4. The quality assurance committee reviewed audits and grievances with no further incidents. 5. Staff 19 no longer worked at the facility. Resident 18 admitted to the facility on [DATE] with diagnoses including diabetes (body does not produce insulin properly) and edema (fluid retention). Resident 18's 12/17/23 Quarterly MDS indicated a BIMS score of 15 (cognitively intact). Review of the 1/25/24 FRI revealed on 1/22/24 Resident 18 told Staff 20 (Social Services Director) about the night shift CNA, Staff 19 (Former CNA). Resident 18 stated she/he asked to be cleaned after a bowel movement and her/his assigned CNA, Staff 19, refused, and stated I'm not wiping your ass. Resident 18 then went to the charge nurse who also asked Staff 19 to provide care, Staff 19 still refused, stating that the resident could do it her/himself. The charge nurse switched CNA assignments and another CNA provided care to the resident shortly thereafter. On 9/25/24 at 3:05 PM Resident 18 confirmed the 1/22/24 incident with Staff 19. Resident 18 stated she/he did not feel abused but considered Staff 19's comment demeaning. Resident 18 stated she/he was provided care by other staff timely. On 9/26/24 at 10:58 AM Staff 20 acknowledged Resident 18 told him about Staff 19's comment and refusal to provide care. Staff 20 completed resident interviews of other residents Staff 19 was assigned to care for and found two other residents who reported Staff 19 had an attitude problem and made inappropriate comments in the past. On 9/26/24 at 2:08 PM Staff 1 (Administrator) stated she expected all residents to be treated with dignity and respect. Staff 1 stated the facility completed an investigation and found Staff 19 made rude comments to Resident 18 and two other residents. Staff 1 stated Staff 20 completed audits for resident dignity and respect before each monthly Quality Assurance meeting. The facility's implementation of corrective actions was verified through the survey process. Observations conducted throughout the facility 9/24/24 through 9/30/24 revealed no concerns in which the staff treated residents with disrespect or a lack of dignity.

Based on interview and record review it was determined the facility failed to ensure dependent residents received showers for 1 of 2 sampled residents (#17) reviewed for showers. This placed residents at risk for unmet needs and loss of dignity. Findings include: Resident 17 was admitted to the facility in 5/2024 with diagnoses including multiple sclerosis (a progressive neurological disorder) and morbid obesity (having a body mass index greater than 40). Resident 17's 9/6/24 Quarterly MDS indicated the resident had no cognitive impairment and was dependent for bathing/showering. The facility's 8/2024 shower schedule revealed Resident 17 was to receive showers twice a week, on Sundays and Thursdays. Resident 17's 8/2/24 through 8/31/24 bathing task logs indicated the resident received bathing on the following days: - 8/2, 8/9, 8/21, 8/28 and 8/31. Resident 17 received five out of nine scheduled showers. A review of Resident 17's Progress Notes from 8/1/24 through 8/31/24 revealed no documentation Resident 17 was provided with additional bathing opportunities when bathing was not provided. On 9/24/24 at 10:26 AM and 9/26/24 at 12:30 PM Resident 17 stated she/he was not showered and her/his hair was not washed for three weeks. Resident 17 reported she/he refused only one shower during the month of 8/2024, she/he was not provided with additional opportunities to shower and missed showers were not rescheduled. On 9/24/24 at 3:20 PM, 9/25/24 at 10:12 AM and 9/25/24 at 11:45 AM Staff 9 (CNA), Staff 10 (CNA) and Staff 14 (CNA) reported when showers were missed or refused, the resident's shower typically could not be rescheduled due to staffing issues. On 9/26/24 at 1:22 PM Staff 2 (DNS) reported there was a miscommunication regarding Resident 17's showers which resulted in missed showers. She stated her expectation was residents received a minimum of two showers a week, more if that was their preference. Staff 2 confirmed Resident 17 did not receive two showers each week during 8/2024. On 9/27/24 at 9:52 AM Staff 1 (Administrator) stated she expected nursing staff to document resident refusals in the resident's progress notes. Staff 1 stated residents should be offered the opportunity to reschedule their shower if the resident refused, was unavailable or missed a shower. Staff 1 confirmed there was no evidence Resident 17 was provided with additional showering opportunities if she/he refused or missed showers. Refer to F725.

Based on interview and record review, it was determined the facility failed to ensure residents were free from sexual abuse for 2 of 3 (#s 102 and 103) sampled residents reviewed for abuse. This placed other residents at risk for abuse. Findings include: The facility's abuse policy, revised 10/2020, defined sexual abuse as any form of nonconsensual sexual contact, including but not limited to unwanted or inappropriate touching .in the form of touching of the sexual or intimate parts for the purpose of arousing or gratifying the sexual desire of either party. 1. Resident 102 was admitted to the facility in 12/2019 with diagnoses including heart disease and chronic kidney disease. Resident 102's MDS Quarterly dated 10/6/22 revealed a BIMS score of 7, which indicated severe cognitive impairment. Resident 102's care plan dated 10/6/22 revealed she/he had a history of inappropriate sexual behavior, and exposed her/his chest area. Interventions included not seating Resident 102 with residents of the opposite gender unless staff were present at all times, not to leave her/him alone with Resident 104 or seat the residents next to each other. Resident 104 was admitted to the facility in 4/2022 with diagnoses including cerebral infarction (stroke) and Type 2 diabetes. Resident 104's MDS Quarterly dated 10/22/22 revealed a BIMS score of 4, indicating severe cognitive impairment. Resident 104's care plan dated 10/13/22 revealed she/he had a history of inappropriate sexual behavior, touched other residents of the opposite gender. Interventions included not seating Resident 104 with residents of the opposite gender and to supervise her/him in a group setting. A FRI was submitted to the state agency on 4/27/22 which revealed the following: On 4/27/22 at approximately 11:25 AM, Resident 102 and Resident 104 were observed to kiss in the dining room by Staff 13 (Former Kitchen Aide). A few minutes later Staff 13 observed Resident 102 had her/his shirt up and Resident 104 kissed Resident 102's breast. Staff separated the residents and placed them on alert monitoring. The facility's incident report and investigation dated 4/27/22 included written statements from staff who witnessed the incident. Staff 13's written statement dated 4/28/22 indicated he was in the dining room on 4/27/22 and observed the residents to kiss. Staff 13 left the room for a short period of time and when he returned to the dining room, he observed Resident 104 to kiss Resident 102's breast. Staff 13 immediately went to the nurse's station and told Staff 16 (RN) what occurred. Staff 16's written statement dated 4/27/22 revealed she was notified by Staff 13 who reported he saw Resident 104 kiss Resident 102's breast. Staff 16 immediately went to the dining room and observed the residents seated next to another but observed no sexual activity. Staff 16 checked in with the residents, left the dining room and three minutes later observed Resident 102 approach Resident 104 in her/his wheelchair. Resident 102 lifted up her/his shirt while approaching Resident 104. Staff 16 immediately intervened and took Resident 102 to her/his room. Staff 12's (Former DNS) written statement dated 4/27/22 revealed she was notified by staff approximately 20 minutes after the incident occurred. Staff 12 interviewed Resident 102 the same date after lunch and Resident 102 confirmed the incident occurred. Resident 102 told Staff 12 she/he had lifted her/his shirt up but after she/he touched me, I moved away (from Resident 104), I didn't want that. Resident 102 denied being upset about what occurred and no negative psychosocial outcomes were observed. Both resident's care plans were revised on 4/27/22 to reflect not seating either resident next to other residents of the opposite gender. Resident 104 was care planned to be supervised while in a group setting. On 11/29/22 at 10:30 AM, Witness 13 (Complainant) stated she was contacted by the facility on 4/27/22, was told Resident 102 was observed with her/his shirt up and another resident kissed Resident 102 on her/his chest. Observations were made of Resident 102 and Resident 104 from 11/29/22 through 12/1/22 with no concerns. Neither resident was interviewed due to their cognitive status. Staff 12 and Staff 13 were not interviewed due to no longer working at the facility. On 11/30/22 at 12:26 PM, Staff 16 confirmed she had written the statement on 4/27/22 and provided no additional information. On 12/1/22 at 3:00 PM, Staff 1 (Administrator) and Staff 2 (DNS) were notified of the findings of this investigation and provided no additional information. 2. Resident 103 was admitted to the facility in 7/2018 with diagnoses including Type 2 diabetes, schizophrenia and hypertension. Resident 103's MDS Quarterly dated 3/29/22 revealed a BIMS score of 99, indicating she/he was not assessed due to inability to complete the testing. Resident 103's care plan, revised 5/17/22 revealed she/he had anxiety and delusions as a result of her/his psychiatric disorders. Interventions were to provide standard behavioral interventions for the resident's delusions and other mental health behaviors. Resident 104 was admitted to the facility in 4/2022 with diagnoses including cerebral infarction (stroke) and Type 2 diabetes. Resident 104's MDS Quarterly dated 10/22/22 revealed a BIMS score of 4, indicating severe cognitive impairment. Resident 104's care plan dated 10/13/22 revealed she/he had a history of inappropriate sexual behavior, and inappropriately touched other residents of the opposite gender. Interventions included to not seat Resident 104 with residents of the opposite gender and to supervise her/him in a group setting. A FRI was submitted to the state agency on 5/2/22 which revealed the following: On 5/2/22 at 2:20 PM during an activity, Witness 15 was overheard by staff saying that's not nice which alerted staff present in the dining room to inquire about the statement. It was learned Resident 104 had touched Resident 103's breast. Resident 104 was removed from the dining area to the nurse's station. The facility's incident report and investigation dated 5/2/22 included written statements from staff involved in the incident. Staff 12 (Former DNS) was notified Resident 104 had touched Resident 103's breast during bingo. Staff 15 (Activities Director) had been present in the dining room and was immediately interviewed. She stated she overheard Witness 15 (Resident) say don't do that, it's not very nice and Resident 104 responded to Witness 15 to mind your own business. When Staff 15 asked what was not nice, Witness 15 advised her Resident 104 had touched Resident 103's breast. Resident 104 was immediately removed from the activity. Resident 103 and Resident 104 were interviewed by Staff 12 on 5/2/22 immediately afterward but neither recalled the incident. Witness 15 was interviewed on 5/2/22 at 2:29 PM by Staff 12. She recalled the incident and stated Resident 104 had her/his hands on top of Resident 103's breast. Observations were made of Resident 104 from 11/29/22 through 12/1/22 with no concerns. No observations were made of Resident 103 due to her/his discharge from the facility. Staff 12 was not interviewed due to no longer working at the facility. Staff 15 was interviewed on 12/1/22 at 11:26 AM and stated she was the only staff in the dininig room during bingo. She witnessed Resident 103 and Resident 104 hold hands and she frequently reminded them this was not appropriate. Staff 15 assisted another resident and turned away from Resident 103 and Resident 104, who were seated next to each other. When Staff 15 turned around, she saw Resident 104's hand on Resident 103's chest, separated the residents and notified the Social Services Director of the incident. Staff 15 revealed she was not aware of the 4/27/22 care plan change which indicated Resident 104 should not be seated next to residents of the opposite gender. On 12/1/22 at 3:00 PM, Staff 1 (Administrator) and Staff 2 (DNS) were notified of the findings of this investigation and provided no additional information.

Based on interview and record review it was determined the facility failed to ensure care plan interventions were implemented and followed for 1 of 3 sampled residents (#104) reviewed for care plans. This placed other residents at risk for unmet needs. Findings include: Resident 104 was admitted to the facility in 4/2022 with diagnoses including cerebral infarction (stroke) and Type 2 diabetes. Resident 104's MDS Quarterly dated 10/22/22 revealed a BIMS score of 4, indicating severe cognitive impairment. Resident 104's care plan initiated on 4/27/22 revealed she/he had a history of inappropriate sexual behavior and inappropriately touched other residents of the opposite gender. Interventions included to not seat Resident 104 with residents of the opposite gender and to supervise her/him in a group setting. . A FRI and investigation dated 5/2/22 revealed Staff 12 (Former DNS) was notified Resident 104 sat next to a resident of the opposite gender during bingo. Staff 15 (Activities Director) was present in the dining room and immediately intervened. Staff 15 was interviewed on 12/1/22 at 11:26 AM and revealed she was not aware of the 4/27/22 care plan which indicated Resident 104 should not be seated next to residents of the opposite gender. On 12/1/22 at 3:00 PM Staff 1 (Administrator) and Staff 2 (DNS) were notified of the findings of this investigation and provided no additional information.

Based on interview and record review it was determined the facility failed to ensure residents were free from significant medication errors for 1 of 3 sampled residents (#106) identified with a medication error. As a result, Resident 106 erroneously received an antidepresssant, a preventative blood clot medication, a preventative seizure medication and a vitamin on 10/8/20. The facility identified the noncompliance and immediately initiated a plan of correction which resulted in staff awareness and education to ensure accurate identification of residents and no further medication errors occurred. This incident was identified as meeting criteria for past noncompliance. Findings include: The facility's 10/2020 Administering Medications and Identifying and Managing Medication Errors and Adverse Consequences policy directed The staff and practitioner shall strive to minimize adverse consequenses by: -The staff shall report clinically significant adverse medication consequences and medication errors with adverse clinical consequences to the resident's Attending Physician immediately. -In the event of a clinically significant adverse medication consequence, nursing staff shall implement and follow any Physician orders, and shall monitor closely and document the resident's condition and response to any corrective interventions for at least the next 24 hours or as otherwise directed. -Nursing staff will document appropriately detailed accounts of any incidents on an appropriate report form. -The Medical Director, Director of Nursing Services, and the Consultant Pharmacist shall review medication errors and adverse medication consequenses as part of the facility's Quality Assurance process. Resident 106 was admitted to the facility in 9/2020 with diagnosis including displaced fracture of right femur, hypertension and dementia. On 10/8/20 at 8:30 AM Staff 17 (Former RN) erroneously administered Sertraline (an antidepressant drug) 50 mg, Eliquis (a preventative blood clotting drug) 5 mg, Gabapentin (an anti-seizure drug) 600 mg and calciferol (vitamin D) 25 mcg. Staff 17 evaluated Resident 106, notified Staff 4 (LPN) and the resident of the medication error. The physician was contacted immediately and directed Staff 4 and Staff 17 to monitor Resident 106 for adverse side effects. On 11/30/22 at 1:21 PM Staff 4 stated she was training a new RN when he became distracted and inadvertently walked into the wrong resident room and administered medications to the wrong resident. Staff 4 stated immediate education was provided to Staff 17, he was reeducated on medication administration, received in-service trainings on The Five Rights of Medication Administration and a competency checklist was completed. On 12/2/22 at 11:40 AM Staff 2 (DNS) confirmed the medication error occurred and Resident 106 was placed on alert charting and monitored for adverse side effects. Staff 2 stated a quality assurance process was immediately implemented which included staff not interrupting nurses or CMA's when preparing or passing medications. Additionally, training and reeducation took place and skills audits were conducted to ensure competency of nurses and CMA's. Interviews conducted from 11/29/22 through 12/2/22 between the hours of 8:30 AM and 4:30 PM with Staff 2, Staff 4, Staff 6 (LPN) and Staff 8 (LPN) indicated all staff were aware of The Five Rights of Medication Administration and stated it was expected and the proper procedure to identify the resident with a picture, the resident's name and birthdate prior to adminstration of medications. The situation met the criteria for past noncompliance as follows: 1. The incident indicated noncompliance at F760; 2. The noncompliance occurred after the exit date of the last standard recertification survey (3/2/20) and before the date of this survey (11/29/22); 3. There was sufficient evidence the facility corrected the noncompliance and was in substantial compliance with F760 as evidenced by: -No deficient practice found at F760 with additional sampled residents. On 12/2/22 at 12:45 PM Staff 1 (Administrator) and Staff 2 were notified of the findings of this investigation.

Based on interview and record review it was determined the facility failed to report an allegation of abuse for 1 of 3 sampled residents (#7) reviewed for abuse. This placed the residents at risk for abuse and neglect. Findings include: The 1/29/21 Facility's Abuse Prevention Program Policy Interpretation and Implementation form revealed: comprehensive policies and procedures have been developed to aid our facility in preventing abuse, neglect, or mistreatment of [REDACTED]. Resident 7 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The 12/2020 Annual MDS revealed Resident 7 had a BIMS score of 7 out of 15, indicating severe cognitive impairment. The 1/14/21 Care Plan revealed Resident 7 required constant supervision and assistance with dressing and physical assistance with bathing and personal hygiene. The 2/16/21 Progress Notes revealed Resident 7 alleged a staff member snatched her/his arm where she/he received the COVID-19 vaccination. Resident 7 also complained of right shoulder pain and an X-ray was ordered. The 2/17/21 late entry Progress Notes revealed Resident 7 said she/he was grabbed too hard. The 2/17/21 The Marquis Abuse/AE Investigation form revealed the following: -Resident 7 complained of right shoulder pain, stated a female staff member of color helped her/him and grabbed her/his arm, which made Resident 7 say ouch. Resident 7's roommate (Resident 8) overheard the resident say Ow, that hurt! after the staff left the room. Resident 8 reported the incident; -The Administrator and DNS were notified; -The investigation concluded abuse/neglect ruled out through investigation with observation and interviews. On 3/18/21 at 10:09 AM Resident 7 stated she/he could not recall the event or the staff member and felt safe at the facility. On 3/18/21 at 10:10 AM Resident 8 stated she/he did not recall the event and felt safe at the facility. On 3/29/21 at 10:45 AM Staff 1 (Administrator) stated she was aware of the physical abuse allegation, the facility conducted an investigation and ruled out abuse. The allegation had not been reported to the State Survey Agency as required.

Based on observation, interview and record review it was determined the facility failed to ensure proper hand hygiene in 1 of 1 dining rooms and failed to store food in a sanitary manner in 1 of 2 unit refrigerators. This placed the residents at risk for contamination and foodborne illness. Findings include: 1. Review of the facility's ,[DATE] Handwashing Policy revealed staff were to wash their hands after sneezing, facial touching, contact with contaminated objects, when changing tasks or doing activities that contaminate the hands. On [DATE] at 12:21 PM Staff 16 (Diet Aide) picked up a walkie talkie, scratched his forehead and continued prepping beverages without washing his hands. On [DATE] at 11:58 AM Staff 14 (Prep Server) sneezed while at the steam table, donned gloves and began plating food without washing her hands. On [DATE] at 12:02 PM Staff 15 (Diet Aide) rubbed his nose gloveless and continued prepping beverages without washing his hands. In an interview on [DATE] at 12:34 PM Staff 16 stated handwashing should be done after touching his face or dirty objects like a walkie talkie and agreed he should of washed his hands before serving beverages. In an interview on [DATE] at 1:32 PM Staff 14 stated she realized she forgot to wash her hands after sneezing and stated she should slow down and perform hand hygiene when necessary. In an interview on [DATE] at 7:35 AM Staff 15 stated staff should wash their hands after touching their face and he should have paid more attention and washed his hands before continuing to serve beverages. In an interview on [DATE] at 11:00 AM Staff 1 (Administrator) stated she expected all staff to practice proper hand hygiene in all departments and the facility policy regarding hand washing should be followed at all times. 2. Review of facility's ,[DATE] Resident Food Storage Policy revealed residents' food or beverage must be dated and discarded after three days when stored in the unit refrigerators. On [DATE] at 11:55 AM observation of a unit refrigerator revealed the following: -undated sandwich; -undated soups in bowls; -prepackaged Chef salad dated [DATE]; -yogurt dated [DATE]; -sliced cheese dated [DATE]. On [DATE] at 1:00 PM Staff 1 (Administrator) discarded all expired food items found in a North hall unit refrigerator. On [DATE] at 1:30 PM Staff 12 (Dietary Manager) stated he expected all food items stored in the North hall unit refrigerators to be dated and discarded after three days.

Based on interview and record review it was determined the facility failed to implement care plan interventions in the area of falls for 1 of 2 sampled residents (#22) who were reviewed for falls. This placed residents at risk for falls. Findings include: Resident 22 was admitted to the facility in 3/2019 with [DIAGNOSES REDACTED]. The Comprehensive Care Plan included the following toileting interventions: - Do not leave unattended in bathroom, - Constant supervision and physical assist for safety. The 5/31/19 Post Fall Assessment indicated on 5/28/19 Resident 22 was in the bathroom, the CNA left the room for several minutes and Resident 22 fell during the CNA's absence. In an interview on 2/25/20 at 10:35 AM, Witness 1 (Complainant) stated Resident 22 had been care planned for supervision at all times when toileting and on 5/28/19 the CNA left Resident 22 unattended in the bathroom which resulted in her/his fall. In an interview on 2/26/20 at 4:47 PM, Staff 4 (LPN Resident Care Manager) stated on 5/28/19 a CNA assisted Resident 22 to the bathroom with a walker, left the resident in the bathroom unattended and Resident 22 self-transferred and fell . Staff 4 stated the CNA did not follow the care plan. In an interview on 3/2/20 at 10:42 AM, Staff 2 (DNS) stated Resident 22 was care planned for supervision in the bathroom, the CNA left Resident 22 and Resident 22 fell . Staff 2 stated she expected nursing staff to always follow the care plan.

Based on interview and record review it was determined the facility failed to maintain acceptable parameters of nutritional status for 1 of 2 sampled residents (#43) reviewed for nutrition. As a result Resident 43 had a severe weight loss of 19% in less than one month. Findings include: Resident 43 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 43 had the following weights: 6/4/18 116 pounds 6/19/18 116.2 pounds 6/23/18 105 pounds 6/25/18 105.8 pounds 6/27/18 94.2 pounds 6/29/18 93.6 pounds 7/5/18 94.8 pounds 7/9/18 95.3 pounds A 6/26/18 Nutrition Weight Note indicated Resident 43 had a 10.2 pound weight loss resulting in an 8.8% weight loss. The note indicated Resident 43 had complained of nausea which was relieved by [MEDICATION NAME] (nausea medication) and staff reported they had noted the resident picking at her/his food and not eating much at times. Oral (PO) intakes had been variable since admission from 0-100% with most meals in the 26-75% range. The note indicated Staff 9 (Dietary Manager) had talked with the resident regarding meal choices and preference and further indicated a recommendation for an RD evaluation. A 7/3/18 Nutrition Weight Note indicated Resident 43 had a 20.7 pound weight loss resulting in 17.8% weight loss. Resident had a 10.5 pound weight loss from the last note on 6/26/18. The RD saw the resident on 6/29/18 and the recommended 2.0 kcal 120 ml BID with med pass and fluid enhancement program. The RD recommendations were implemented on 7/2/18. PO intakes had been variable with most meals in the 26-75% range. The 6/2018 and 7/2018 MARs indicated Resident 43 received the following: -[MEDICATION NAME] (medication that blocks the release of stomach acid) 40 mg once daily [MEDICAL CONDITION] 6/5/18 to 6/28/18 and [MEDICATION NAME] 40 mg twice daily from 6/28/18 to current (administered as ordered) -[MEDICATION NAME] (medication to help with digestion) 9000 units PRN for lactose intolerance when eating meals containing lactose (administered 2 times) -[MEDICATION NAME] 8 mg every 8 hours PRN for nausea (administered 31 times) On 7/6/18 at 12:39 PM Resident 43 stated she/he did not have a good appetite and had received chocolate health shakes which she/he liked. On 7/6/18 at 1:32 PM Staff 4 (RNCM) stated Resident 43 weighed 116 pounds when she/he was admitted and the first weight loss was identified on 6/23/18. She stated the resident weight meetings were held on Tuesdays, the resident was reviewed on 6/25/18 and the team suggested the RD assess her/him. She further stated the RD saw Resident 43 on 6/29/18 and made recommendations but the recommendations were not implemented until 7/2/18. She stated the physician was not notified of the weight loss until 7/2/18. On 7/10/18 at 1:42 PM Staff 10 (CNA) stated if a resident had a weight change the nurse was notified. State 10 stated if the resident needed to be re-weighed the nurse was present for the re-weigh, they determined if the weights were correct and what needed to be addressed. On 7/10/18 at 1:44 PM Staff 12 (RN) stated CNAs weighed the residents and if a resident had weight loss the physician was notified so a plan could be made to address the weight loss. She acknowledged Resident 43 had weight loss and often had stomach issues. She stated Resident 43 took [MEDICATION NAME] for nausea, [MEDICATION NAME] twice daily and [MEDICATION NAME] since she/he was lactose intolerant. On 7/10/18 at 1:56 PM Staff 9 (Dietary Manager) stated Resident 43 was on a regular diet and often complained of a sour stomach. She stated it was difficult to determine her/his meal intake because the resident would often only eat fruit and did not always take in protein. On 7/10/18 at 2:22 PM Staff 2 (DNS) acknowledged Resident 43's weight loss was noted on 6/23/18 and the RD did not see her/him until 6/29/18. She further acknowledged the RD recommendations of 2 kcal and fluid enhancement were not started until 7/2/18 and the physician was not notified of the weight loss until 7/2/18. She acknowledged the interventions and physician notification of the weight loss were not timely. On 7/11/18 at 9:42 AM Staff 13 (RD) stated she saw Resident 43 on 6/29/18. She stated she ordered to start 2 kcal and fluid enhancement on 6/29/18 and acknowledged those interventions did not start until 7/2/18. She acknowledged staff could have obtained a verbal order from the physician prior to 7/2/18.

Based on observation, interview and record review it was determined the facility failed to implement policy related to smoking for 2 of 2 sampled residents (#s 1 & 2) reviewed for smoking. Residents were at risk of injury and Resident 1 was involved in a fire and hospitalized due to a burn. The facility's December 2007 Smoking Policy included the following: "Any smoking-related privileges, restrictions, and concerns (for example, need for close monitoring) shall be noted on the care plan and all personnel caring for the resident shall be alerted to those issues.... The facility may impose smoking restrictions on residents at any time if it is determined that the resident cannot smoke safely with the available levels of support and supervision.... a. Residents without independent smoking privileges may not have or keep any types of smoking articles, including cigarettes, tobacco, etc., except when they are under direct supervision...." 1. Resident 1 was admitted to the facility in 2010 and had [DIAGNOSES REDACTED]. The 6/26/12 and 3/22/13 Smoking Assessments revealed Resident 1 was assessed to require supervision with smoking, to use a smoking apron, and the facility was to store tobacco and fire materials. The resident was placed on a smoking schedule due to non-compliance with use of the designated smoking area. The 12/21/12 Care Plan disclosed Resident 1 required smoking supervision, was to use a smoking apron and the facility was to store tobacco and fire materials. A 3/1/13 Progress Note revealed "Alerted by fell ow staff member resident directly outside SNF entrance, smoking." A 3/4/13 Progress Note indicated the resident's smoking schedule was reviewed with the resident, "as (Resident 1) is often noted by staff out smoking before breakfast." It noted the room/resident checks for smoking materials were to be done every shift. A 3/7/13 1:21 pm Progress Note disclosed Resident 1 "had been out outside, without a staff member and without a smoking apron, smoking." A 3/7/13 3:14 pm Progress Note disclosed "Later in the morning resident's CNA reported she saw resident smoking outside alone...LN checked resident's room for smoking materials x 2, removed a lighter from the resident's room." A 3/13/13 5:52 am Progress Note documented "Did find sitting on top of night stand, a clear blue lighter." A 3/13/13 3:16 pm Progress Note revealed Resident 1 went out at 9:15 am with a CNA and one cigarette. The CNA reported to Staff 4, LN, the resident refused to wear a smoking apron and had an extra cigarette. It was further noted a CNA reported to Staff 4 that she saw the resident outside, "smoking independently x 2." A 3/20/13 1:45 pm Progress Note indicated Resident 1 was "in and out of facility independently." A 3/21/13 10:43 pm Progress Note revealed a CNA reported he had observed Resident 1 outside smoking alone with no smoking apron. "Res did not ask this LN for any smoking materials this shift..." A 3/28/13 9:52 am Progress Note documented by Staff 1, Administrator, revealed at 9:30 am, Staff 1 observed the resident in the hallway outside his/her room. The resident had a sweatshirt on and the pocket was "pooched out and a pack of KOOL cigarettes was visible..." A 4/2/13 Incident Investigation Recap disclosed at around 2:45 pm, a visitor to the facility alerted a nurse that someone was calling for help outside the facility. Staff 2, RNCM, responded and saw smoke coming from the outdoor smoking area and flames coming from Resident 1. The fire was extinguished, 911 was called and the resident was transported to the hospital. It noted that at the time of the incident, the resident was smoking unsupervised. In interview on 4/2/13 at 1:45 pm Staff 10, CNA, stated she had observed Resident 1 to smoke outside, unsupervised "maybe two times a week" in the past six months. In interview on 4/4/13 at 2:00 pm, Staff 5, RN, stated on one occasion Staff 8, CNA, reported to her the resident had been outside smoking with no apron in place, which she documented. In interview on 4/4/13 at 2:21 pm, Staff 4, RN, stated "once or twice" someone reported to her the resident was smoking independently, and in previous room checks she found lighters on two occasions. In interviews on 4/4/13 at 2:38 pm and 4/5/13 at 9:39 am, Staff 2, RNCM, stated in the past she had observed smoking materials in the resident's sweatshirt. When asked how often she had observed the materials on the resident, Staff 2 stated, "only one time, since cracking down on (Resident 1)." Staff 2 stated approximately a month ago, she "went in first thing that morning at 6:30 am and right on the bedside table was a pack of cigarettes." Additionally, she had observed Resident 1 smoking independently for approximately three months. Staff 2 stated when staff observed the resident independently smoking, they were to ask the resident to put out the cigarette, get the resident safe and then report it to the charge nurse. In interview on 4/4/13 at 3:06 pm, Staff 8, CNA, stated on one occasion when he took Resident 1 out to smoke, the resident refused the smoking apron. Staff 8 stated after the resident refused the apron, he lit the cigarette and gave it to the resident. Staff 8 stated he reported the incident to Staff 5, RN. Staff 8 stated approximately one or two weeks ago, he observed Resident 1 smoking by himself/herself, which he reported "right away" to Staff 5. Additionally, "a couple of weeks ago" he observed Resident 1 put cigarettes in a metal box in his/her room, which he reported to nursing. Per Staff 8, with each reporting, he was told the information was going to be passed along to the DNS. Staff 8 stated he checked the resident for materials when putting the resident in bed, but not upon return to the facility. He did not check the resident for smoking materials "unless (Resident 1) has been gone for several hours." Refer to F323. 2. Resident 2 was admitted to the facility in 2009. The 2/20/13 Smoking Assessment noted the resident had functional limitations, required supervision with smoking, a smoking apron and the facility was to store the tobacco and fire materials. The 2/22/13 Care Plan noted the use of the smoking apron, supervised smoking and directed CNA staff to return smoking items to the charge nurse for storage once the resident had finished smoking. In interview on 4/4/13 at 6:23 pm, with Staff 1, Administrator and Staff 3, RNCM, they stated the resident's family member would provide the resident with cigarettes. The resident would turn the cigarettes over to staff, "but may have kept them a day or two." Staff 3 stated Resident 2's room had not previously been checked for smoking materials and on 4/2/13 he found an empty cigarette box in the resident's room. On 4/5/13 at 8:00 am, Resident 2 refused to be interviewed and no smoking materials were observed in the resident's room. In interview on 4/5/13 at 10:23 am, Staff 9, CNA, stated the resident had told her if a family member brought her/him cigarettes, then the resident would let the caregiver know about the cigarettes. Staff 9 stated Resident 2 used to keep a lighter in an empty cigarette pack in her/his room, which Staff 9 observed "maybe a month or so ago." When asked if Resident 2 was to have a lighter in her/his room, Staff 9 stated she did not know. When Staff 9 was asked if she had reported the lighter to anyone, she stated "I believe the nurses knew." In interview on 4/5/13 at 10:57 am, Staff 5, Evening RN, stated when a family member brought in cigarettes for Resident 2, the family member should have given them to "us." However, as recently as "a couple of days ago", the family member gave them to the resident. Staff 5 stated the cigarettes were turned into the nurse's station the next morning. In interview on 4/5/13 at 11:26 am Staff 13, CNA, stated she had observed a lighter in Resident 2's room "a couple of weeks ago." When asked if the resident was to have any smoking materials in her/his room, Staff 13 stated the resident could have the lighter, but staff had to get the cigarettes from the nurse. Staff 13 stated she did not know what the resident was care planned for regarding smoking materials. When asked if she had reported the lighter to anyone, Staff 13 stated "as far as I know, everybody knows about it." Refer to F323.

Based on observation, interview and record review it was determined the facility failed to provide adequate supervision for smoking for 2 of 2 sampled residents (#s 1 & 2) reviewed for smoking. Residents were at risk for injury, and Resident 1 was involved in a fire and hospitalized due to a burn. This was an immediate jeopardy situation and constituted substandard quality of care. Findings include: The facility's December 2007 Smoking Policy included the following: "Any smoking-related privileges, restrictions, and concerns (for example, need for close monitoring) shall be noted on the care plan and all personnel caring for the resident shall be alerted to those issues.... The facility may impose smoking restrictions on residents at any time if it is determined that the resident cannot smoke safely with the available levels of support and supervision.... a. Residents without independent smoking privileges may not have or keep any types of smoking articles, including cigarettes, tobacco, etc., except when they are under direct supervision...." 1. Resident 1 was admitted to the facility in 2010 and had [DIAGNOSES REDACTED]. The 6/26/12 and 3/22/13 Smoking Assessment revealed Resident 1 had functional limitations, a history of burned clothes/dropping ashes on himself/herself, falling asleep while smoking, attempted to hide his/her smoking materials or smoking activities, had a clinical condition that impacted smoking ability and received medication that may cause drowsiness. The resident was assessed to require supervision with smoking, to use a smoking apron, and the facility was to store tobacco and fire materials. The resident was placed on a smoking schedule due to non-compliance with use of the designated smoking area, and noted "ashes on powerchair." The 12/21/12 Care Plan disclosed Resident 1 required smoking supervision, was to use a smoking apron and the facility was to store tobacco and fire materials. A 3/1/13 Progress Note revealed "Alerted by fell ow staff member resident directly outside SNF entrance, smoking." The dangers of fire were explained to the resident noting the "resident would have no way to extinguish, putting (Resident 1) and fell ow residents in a great amount of danger...." A 3/4/13 Progress Note indicated the resident's smoking schedule was reviewed with the resident, "as (Resident 1) is often noted by staff out smoking before breakfast." It noted the room/resident checks for smoking materials were to be done every shift. "If materials are found, may consider switching to Q (every) 4 hour checks for safety." A 3/7/13 1:21 pm Progress Note disclosed Resident 1 "had been out outside, without a staff member and without a smoking apron, smoking." A 3/7/13 3:14 pm Progress Note disclosed "Later in the morning resident's CNA reported she saw resident smoking outside alone...LN checked resident's room for smoking materials x 2, removed a lighter from the resident's room." In-Service agendas for All Staff on 3/11/13, CNAs on 3/15/13 and Licensed Nurses on 3/18/13 noted the facility's smoking policy was addressed with staff. A 3/13/13 5:52 am Progress Note documented "Did find sitting on top of night stand, a clear blue lighter." A 3/13/13 3:16 pm Progress Note revealed Resident 1 went out at 9:15 am with a CNA and one cigarette. The CNA reported to Staff 4, LN, the resident refused to wear a smoking apron and had an extra cigarette. It was further noted a CNA reported to Staff 4 that she saw the resident outside, "smoking independently x 2." 3/20/13 1:45 pm Progress Note indicated Resident 1 was "in and out of facility independently." A 3/21/13 10:43 pm Progress Note revealed a CNA reported he had observed Resident 1 outside smoking alone with no smoking apron. "Res did not ask this LN for any smoking materials this shift..." A 3/28/13 9:52 am Progress Note documented by Staff 1, Administrator, revealed at 9:30 am, Staff 1 observed the resident in the hallway outside his/her room. The resident had a sweatshirt on and the pocket was "pooched out and a pack of KOOL cigarettes was visible..." At the time of the survey, there was no documented evidence the facility had updated the resident's care plan regarding safety checks, despite the multiple incidents of Resident 1 being observed smoking independently and/or with smoking materials. A 4/2/13 2:40 pm Progress Note revealed at 2:25 pm, a nursing student reported to Staff 4, RN, the resident had "passed out" during a transfer from the toilet to the wheelchair. The resident's blood pressure was "a little low" and he/she had an elevated blood sugar. A 4/2/13 Incident Investigation Recap disclosed at around 2:45 pm, a visitor to the facility alerted a nurse that someone was calling for help outside the facility. Staff 2, RNCM, responded and saw smoke coming from the outdoor smoking area and flames coming from Resident 1. The fire was extinguished, 911 was called and the resident was transported to the hospital. It noted that at the time of the incident, the resident was smoking unsupervised. A 4/4/13 OBC Ward Progress Note, the resident had sustained a third degree burn on the the thigh. In interview on 4/2/13 at 1:45 pm with Staff 10, CNA, when asked if she had observed any smoking materials in Resident 1's room, Staff 10 stated "no, but that doesn't mean they weren't there...(he/she) may hide them" Staff 10 stated the resident would leave the facility independently and had previously reported to her that he/she had obtained smoking materials. Staff 10 stated she only checked the resident's room for smoking materials if she saw them on the resident. Staff 10 stated she had observed Resident 1 to smoke outside, unsupervised "maybe two times a week" in the past six months. In the last month, the facility got "strict" with the resident. When asked why the change, Staff 10 stated the facility was "concerned (Resident 1) was a fire hazard..."the facility knew this would happen." Staff 10 stated prior to the incident on 4/2/13 at around 2:00 pm, while being transferred from the toilet, the resident fainted while in the lift. Staff 10 stated when she left the facility at the end of her shift at 2:30 pm, the resident was still in his/her room. In interview on 4/4/13 at 2:21 pm, Staff 4, RN, stated "once or twice" someone reported to her the resident was smoking independently. Staff 4 stated she did nothing with that report as the staff member "had already reported it to someone else." Staff 4 stated in previous room checks, she found lighters on two occasions, which she removed and noted in the record. Staff 4 stated on 4/2/13, at around 2:30 pm, it was reported to her Resident 1 was in his/her room and had passed out. Staff 4 stated she observed Resident 1 to be sitting in the powerchair at that time. In interview on 4/5/13 at 10:32 am, Witness 1, Student Nursing Instructor, stated around 2:30 pm, she had been informed the resident had passed out and she went to the resident's room. Witness 1 stated when she left the resident, the resident appeared sleepy and was in the powerchair. Witness 1 stated it was a very short time from when she left the resident and the resident had taken himself/herself out to the smoking area. In interviews on 4/4/13 at 2:38 pm and 4/5/13 at 9:39 am, Staff 2, RNCM, stated in the past she had observed smoking materials in the resident's sweatshirt. When asked how often she had observed the materials on the resident, Staff 2 stated "only one time, since cracking down on (Resident 1)." Staff 2 stated approximately a month ago, she "went in first thing that morning at 6:30 am and right on the bedside table was a pack of cigarettes." Staff 2 stated if CNAs observed Resident 1 returning from being off property and they had any "evidence" of smoking, such as ashes or smelled cigarette smoke on the resident, they were to alert the charge nurse. Additionally, she had observed Resident 1 smoking independently for approximately three months. Staff 2 stated when staff observed the resident independently smoking, they were to ask the resident to put out the cigarette, get the resident safe and then report it to the charge nurse. Staff 2 stated on 4/2/13 the resident had been in and out of the facility throughout the shift. At the end of her shift a visitor reported a resident was yelling for help. Staff 2 stated when she got to the resident, she saw flames coming from his/her leg. Staff 2 stated she pulled the resident from the wheelchair, there was a lit cigarette in the crease of the resident's wheelchair and the resident did not have the smoking apron in place. Staff 2 stated she did not check for any other smoking materials at that time. In interview on 4/2/13 at 4:13 pm, Staff 1, Administrator stated matches had been found at the site where the resident was at the time of the incident. In interview on 4/4/13 at 2:00 pm, Staff 5, RN, stated on one occasion Staff 8, CNA, reported to her the resident had been outside smoking with no apron in place, which she documented. Per Staff 5, Staff 8 informed her of the incident at the end of shift when the resident was in bed. Staff 5 described Resident 1 as declining and due to neuropathy, the resident might not have felt it when he/she first dropped the cigarette. Staff 5 stated after the incident on 4/2/13 at around 9:00 pm, while checking the resident's nightstand, she moved things around in the drawer and found a lighter in the corner of Resident 1's nightstand drawer. In interview on 4/4/13 at 3:06 pm, Staff 8, CNA, stated on one occasion when he took Resident 1 out to smoke, the resident refused the smoking apron. Staff 8 stated after the resident refused the apron, he lit the cigarette and gave it to the resident. Staff 8 stated he reported the incident to Staff 5, RN. Staff 8 stated approximately one or two weeks ago, he observed Resident 1 smoking by himself/herself, which he reported "right away" to Staff 5. Additionally, "a couple of weeks ago" he observed Resident 1 put cigarettes in a metal box in his/her room, which he reported to nursing. Per Staff 8, with each reporting, he was told the information was going to be passed along to the DNS. Staff 8 stated he checked the resident for materials when putting the resident in bed, but not upon return to the facility. He did not check the resident for smoking materials "unless (Resident 1) has been gone for several hours." Staff 8 stated prior to the staff meeting about smoking, he checked the resident's pocket and stored the materials in the resident's room. In consultation with survey agency managers on 4/4/13 at 4:26 pm, it was determined this incident was immediate jeopardy to residents' health and safety and constituted substandard quality of care. The facility was asked to submit and implement a written plan of correction to immediately protect residents from harm. On 4/4/13 at 7:10 pm, the facility provided an acceptable plan of correction to abate the immediate jeopardy situation. The facility posted signs at their main entrance and both nurse's stations notifying visitors regarding checking all smoking materials at the nurse's station. Upon return from the hospital, staff increased how often Resident 1 was checked for smoking materials, including upon return from outings. Staff were immediately in-serviced on the smoking policy and the specific care plans for those residents who smoked. 2. Resident 2 was admitted to the facility in 2009. The 2/20/13 Smoking Assessment noted the resident had functional limitations, required supervision with smoking, a smoking apron and the facility was to store the tobacco and fire materials. The 2/22/13 Care Plan noted the use of the smoking apron, supervised smoking and directed CNA staff to return smoking items to the charge nurse for storage once the resident had finished smoking. A 4/2/13 Progress Note indicated Staff 3, RNCM, spoke with Resident 2, who "agreed not to keep smoking materials including empty carton/pack of cigarettes in (Resident 2) room." In interview on 4/4/13 at 6:23 pm, with Staff 1, Administrator and Staff 3, RNCM, they stated the resident's family member would provide the resident with cigarettes. The resident would turn the cigarettes over to staff, "but may have kept them a day or two." Staff 3 stated Resident 2's room had not previously been checked for smoking materials and on 4/2/13 he found an empty cigarette box in the resident's room. On 4/5/13 at 8:00 am, Resident 2 refused to be interviewed and no smoking materials were observed in the resident's room. In interview on 4/5/13 at 10:23 am, Staff 9, CNA, stated the resident had told her if a family member brought her/him cigarettes, then the resident would let the caregiver know about the cigarettes. Staff 9 stated Resident 2 used to keep a lighter in an empty cigarette pack in her/his room, which Staff 9 observed "maybe a month or so ago." When asked if Resident 2 was to have a lighter in her/his room, Staff 9 stated she did not know. When Staff 9 was asked if she had reported the lighter to anyone, she stated "I believe the nurses knew." In interview on 4/5/13 at 10:57 am, Staff 5, RN, stated when a family member brought in cigarettes for Resident 2, the family member should have given them to "us." However, as recently as "a couple of days ago", the family member gave them to the resident. Staff 5 stated the cigarettes were turned into the nurse's station the next morning. In interview on 4/5/13 at 11:26 am Staff 13, CNA, stated she had observed a lighter in Resident 2's room "a couple of weeks ago." When asked if the resident was to have any smoking materials in her/his room, Staff 13 stated the resident could have the lighter, but staff had to get the cigarettes from the nurse. Staff 13 stated she did not know what the resident was care planned for regarding smoking materials. When asked if she had reported the lighter to anyone, Staff 13 stated "as far as I know, everybody knows about it."

Based on interview and record review it was determined the facility failed to provide adequate supervision to prevent injury for 1 of 3 residents (# 1) who required assistance to safely complete activities of daily living tasks. Resident 1 fell from a commode and sustained a [MEDICAL CONDITION] which required sutures. Findings include: Review of the Oregon State Board of Nursing, Authorized Duties and Standards for Certified Nursing Assistants [PHONE NUMBER] revealed, (6) Standards of Care for Certified Nursing Assistants. "In the process of client care the CNA shall consistently: (d) Follow the care plan as directed by the licensed nurse." Resident 1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. According to a 4/18/11 admission nursing assessment the resident was dependent for transfers and personal hygiene and required assistance to use the toilet. The assessment indicated the resident "appears very weak." According to an admission care plan the resident required "Two person total assistance for entire process, take to BR (bathroom), transfer on and off toilet, ensure safety, provide pericare/products, adjust clothing, wash hands." According to nursing notes and an incident investigation, on 4/19/11 at 8:20 pm the resident was found on the floor in her/his room. The resident was bleeding from her/his forehead. The facility documents indicated Staff 1, CNA, had placed the resident on the bedside commode and then left the room. The resident reached for toilet paper and fell forward. The resident was sent to the hospital and received sutures for a [MEDICAL CONDITION]. In an interview on 5/12/11 at 2:30 pm Staff 1 stated on 4/19/11 he and Staff 3, CNA, had assisted the resident on to the commode, left toilet paper 2-3 feet in front of the resident, and then left the room for approximately five minutes. Staff 1 stated when he returned to the resident's room the resident was on the floor. Staff 1 stated he could not recall what the care plan directed for supporting the resident in the bathroom. In an interview on 5/16/11 at 2:30 pm Staff 3, CNA, stated that on 4/19/11 she helped Staff 1 transfer the resident to the commode and then left the room. Staff 3 stated she was not assigned to the resident's hall the evening of 4/19/11 and did not know what the care plan had directed for supporting the resident in the bathroom. In an interview on 5/13/11 at 11:15 am Staff 3, DNS, stated a resident who was assessed to be weak and require two-person total assistance for toileting, should not be left alone on the commode. Refer to F-323

Based on interview and record review it was determined the facility failed to provide adequate monitoring to prevent injury for 1 of 3 residents (# 1) who required assistance to safely complete activities of daily living tasks. Resident 1 fell from a commode and sustained a forehead laceration which required sutures. Findings include: Resident 1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. According to a 4/18/11 admission nursing assessment the resident was dependent for transfers and personal hygiene and required assistance to use the toilet. The assessment indicated the resident "appears very weak." According to an admission care plan the resident required "Two person total assistance for entire process, take to BR (bathroom), transfer on and off toilet, ensure safety, provide pericare/products, adjust clothing, wash hands." According to nursing notes and an incident investigation, on 4/19/11 at 8:20 pm the resident was found on the floor in his room. The resident was bleeding from his forehead. The facility documents indicated Staff 1, CNA, had placed the resident on the bedside commode and then left the room. The resident reached for toilet paper and fell forward. The resident was sent to the hospital and received sutures for a forehead laceration. In an interview on 5/12/11 at 12:30 pm Staff 2, RNCM stated when the resident was admitted to the facility on [DATE] she/he required two-person assistance for toileting. In an interview on 5/12/11 at 2:30 pm Staff 1 stated on 4/19/11 he and Staff 3, CNA, had assisted the resident on to the commode, left toilet paper 2-3 feet in front of the resident, and then left the room for approximately five minutes. Staff 1 stated when he returned to the resident's room the resident was on the floor. Staff 1 stated he could not recall what the care plan directed for supporting the resident in the bathroom. In an interview on 5/16/11 at 2:30 pm Staff 3, CNA, stated that on 4/19/11 she helped Staff 1 transfer the resident to the commode and then left the room. Staff 3 stated she was not assigned to the resident's hall the evening of 4/19/11 and did not know what the care plan had directed for supporting the resident in the bathroom. In an interview on 5/13/11 at 11:15 am Staff 3, DNS, stated a resident who was assessed to be weak and require two-person total assistance for toileting, should not be left alone on the commode.