Every finding on record at Mountainview Nursing Home

Based on observation, interview, record review, and facility policy review, the facility failed to revise a comprehensive person-centered care plan to reflect the Resident's (R)1 current fall interventions for 1 of 3 sampled residents reviewed for falls. Findings include: Review of the facility's undated policy titled, Care Plans, Comprehensive Person-Centered, revealed, 11. Assessments of residents are ongoing and care plans are revised as information about the residents and residents' conditions change. 12. The interdisciplinary team reviews and updates the care plan: and included, d. at least quarterly, in conjunction with the required quarterly MDS [Minimum Data Set] assessment. Review of the facility policy titled, Fall Management, dated 05/19/2024, revealed under the heading, C. Intervention included, g. Update the resident's care plan. Review of R1's admission Record revealed the facility admitted R1 on 03/12/2025. According to the admission Record, the resident had a medical history that included but was not limited to diagnoses of Alzheimer's disease with early onset, emphysema, generalized muscle weakness, and contracture of the right and left knee. Review of R1's Annual MDS assessment with an assessment reference date (ARD) of 02/23/2026, revealed that R1 had a Brief Interview for Mental Status (BIMS) score of 00 out of 15, which indicated the resident had severe cognitive impairment. Review of R1's Order Summary Report, with active orders as of 05/28/2026, contained an order, dated 02/16/2026, for bed bolsters to define the parameter of the bed for safety. Review of R1's Order Summary Report, with active orders as of 05/28/2026, contained an order dated 03/11/2026, for two fall mats, for safety. Review of R1's Care Plan Report included a focus area initiated on 06/24/2025 and revised on 02/26/2026, that indicated the resident had an actual fall related to gait, balance problem. Interventions directed staff to increase staff monitoring (initiated 02/26/2026) and to conduct neurological checks, physical assessments, and vital signs as ordered by the physician (initiated 02/26/2026). The Care Plan Report revealed no focus area or interventions that included bed bolsters or fall mats. During an observation on 05/30/2026 at 9:20 AM, revealed R1 lying in bed on an air mattress with a perimeter defining overlay (a mattress overlay with raised/defined edges, sometimes referred to as bolsters), over the air mattress. Fall mats were observed on the floor on each side of the bed. During an interview on 06/10/2026 at 11:14 AM, Registered Nurse (RN)13 stated that since December 2025, she was responsible Monday through Friday to follow up on the nursing assessment after a fall to determine if the appropriate fall interventions were in place, and if the care plan was up to date with the interventions. RN13 stated that she reviewed and updated care plans along with the MDS staff. RN13 stated meetings were conducted each morning, Monday through Friday, to discuss falls, fall interventions, and interventions that should be added to the care plan. RN13 stated that the care plan should be updated at the same time as the meeting. She stated that the fall mats, bed in lowest position, and the bed perimeter defining mattress cover should all be included as interventions on R1's care plan. RN13 said she was not certain why the interventions were not on the resident's care plan, but that the interventions should be added. During an interview on 06/10/2026 at 11:35 AM, RN14 stated she was the MDS Coordinator and had started in that role the prior week. RN14 stated that when a fall occurred, the facility discussed the fall in the facility's clinical meeting with supervisors from each unit. RN14 stated she reviewed care plans within 48 hours of the clinical meetings to ensure the care plan had all the interventions. RN14 stated that the new process was developed because the facility had identified that care plans were not being updated consistently. During an interview on 06/12/2026 at 3:13 PM, the Assistant Administrator stated that care plans should be updated immediately after each fall and as needed. During an interview on 06/12/2026 at 3:34 PM, the Director of Nursing (DON) stated that she expected care plans to be updated immediately after a fall and as needed.During an interview on 06/12/2026 at 3:38 PM, the Staff Development Coordinator stated that the care plan should be updated immediately after an intervention was added and as needed.

Based on observation, interview, record review, and review of manufacturer guidelines, the facility failed to ensure a sheet was not applied in a manner that flattened the perimeter defined mattress cover which created the potential for accidents for 1 (Resident (R)1) of 3 sampled residents reviewed for falls. Findings include: Review of a document provided by the Maintenance Manager (MM) for a Posey Defined Perimeter Mattress Cover, revised on 09/07/2016, indicated, Wedge-shaped foam sections line the perimeter of the covers and help provide a gentle reminder to those lying in bed of the location of the mattress edges, and help provide a less restrictive environment than side rails. A graph on the document indicated Foam Sections - Height 4 (10 cm [centimeter).Review of R1's admission Record revealed the facility admitted R1 on 03/12/2025. According to the admission Record, the resident had a medical history that included but was not limited to diagnoses of Alzheimer's disease with early onset, emphysema, generalized muscle weakness, and contracture of the right and left knee.Review of R1's annual Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 02/23/2026, revealed that R1 had a Brief Interview for Mental Status (BIMS) score of 00 out of 15, which indicated the resident had severe cognitive impairment.Review of R1's Order Summary Report, with active orders as of 05/28/2026, contained an order, dated 02/16/2026, for bed bolsters to define the perimeter of the bed for safety. During an observation on 05/30/2026 at 9:20 AM, revealed R1 lying in bed on an air mattress with a defining perimeter mattress cover with wedge-shaped foam sections that lined the perimeter (commonly referred to as bolsters), over an air mattress. Further observation revealed a fitted sheet was covering the perimeter mattress cover and fall mats were observed on the floor on each side of the bed. During a concurrent observation and interview on 06/09/2026 at 12:00 PM, with the MM, R1's bed was observed with a perimeter mattress cover over an air mattress, and a fitted sheet covering the perimeter mattress cover. The bolsters of the defining perimeter mattress cover were flattened, and not in an upright position. R1 was not in their bed. The MM stated the fitted sheet should not be on the defining perimeter mattress cover because it caused the bolsters of the mattress cover to be flattened, potentially causing the fall intervention to be ineffective.During a concurrent observation and interview on 06/09/2026 at 12:21 PM, with the Staff Development Coordinator (SDC), R1's bed was observed with a fitted sheet covering the perimeter mattress cover. The SDC stated that the fitted sheet was not on the bed when they rounded earlier that morning at 5:30 AM and that staff were trained not to have a fitted sheet over the perimeter mattress cover because it could cause the bolster cushions to flatten.During an interview on 06/09/2026 at 12:20 PM, Certified Nursing Assistant (CNA)15 stated she was assigned to care for R1 that day (06/09/2026) for the 7AM to 3PM shift. CNA15 stated that when she arrived that morning around 7:00 AM, R1 was in bed, and a fitted sheet was on the bed. CNA15 said she was trained not to use a fitted sheet to cover an air mattress with a perimeter mattress cover in place. During an interview on 06/09/2026 at 3:00 PM, CNA16 stated she was assigned to care for R1 on the 11PM to 7AM shift the prior night. Per CNA16, when she arrived at 11:00 PM, R1 was in bed with a fitted sheet over the defining perimeter mattress cover. CNA16 stated she had applied a fitted sheet to the resident's bed over the perimeter mattress cover in the past and noticed that the bolsters of the perimeter mattress cover flattened and were not raised upright. CNA16 said she was trained not to use a fitted sheet over a perimeter mattress cover, but since a fitted sheet was already on the resident's bed, she left the fitted sheet on the bed.During a telephone interview on 06/10/2026 at 7:37 PM, Licensed Practical Nurse (LPN)1 said she was trained not to use a fitted sheet to cover a perimeter mattress cover.During an interview on 06/10/2026 at 4:25 PM, the Director of Nursing (DON) revealed she expected staff not to use a fitted sheet over the defining perimeter mattress cover because it caused the bolster cushions to be flat instead of being raised which defeated the purpose of the perimeter mattress cover.

Based on interview, record review, and facility policy review, the facility failed to ensure Resident (R)1 received adequate supervision to prevent an elopement on 11/01/25 at approximately 6:00 AM. Specifically, R1 was located by staff outside the facility lying on the ground. R1 was dressed in bedtime clothing (pajamas and slippers). According to weather reports on 11/01/25 at 5:55 AM, the weather was 36 Degrees Fahrenheit (F).On 11/07/25 at 1:34 PM, the survey team provided the Administrator and Assistant Administrator with a copy of the CMS IJ Template and informed the facility IJ existed as of 11/01/25. The IJ was related to 483.24 Quality of Care.On 11/07/25 at 4:12 PM, the facility provided an acceptable IJ Removal Plan. On 11/07/25 at 5:00 PM, the survey team validated the facility's corrective action and determined that the facility put forth due diligence in addressing this non-compliance. The SA is considering this IJ at Past Non-Compliance (PNC) as of 11/05/25.An Extended Survey was conducted in conjunction with the Compliant Survey, constituting substandard quality of care. Findings include:Review of the facility policy titled Elopement, Risk Prevention, and Management of Missing Residents revealed, The facility strives to promote resident safety and protect the rights and dignity of the residents. The facility maintains a process to assess all residents for risk for elopement, implement prevention strategies for those identified as an elopement risk, institute measures for resident identification at the time of admission, and conduct a missing resident procedure. Intervention: responding to an actual elopement. It is the responsibility of all staff, regardless of the department they work in, to respond to activated door alarms and to return residents to their units. When a resident is determined to missing: note the time and date the resident is/was determined missing; the staff member assigned to the unit where the resident residents verify that the resident has not signed out; the staff notify the Director of Nursing Services that a resident is missing; staff members in accordance with the facility's search team plan, conduct a thorough search to locate the resident.Review of R1's Face Sheet revealed R1 was admitted to the facility on [DATE] with diagnoses including but not limited to, Alzheimer's Disease, Dementia with psychotic mood disturbance, repeated falls, and unsteadiness on feet.Review of R1's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 09/28/25 revealed that R1 had a Brief Interview for Mental Status (BIMS) score of 8 out of 15, which indicated R1 had moderate cognitive impairment. Further review of the MDS revealed R1 did not exhibit wandering behaviors or other behavioral symptoms during the look-back period. Further review revealed, R1 utilizes a walker for mobility and requires supervision or touching assistance with walking and staff utilize a bed alarm - it was used less than daily to notify staff when movement is detected from R1.Review of R1's Physician Orders revealed an order dated 04/13/25 which stated, Ambulatory with rolling walker.Review of R1's Physician Orders revealed an order dated 07/08/25 which stated, Code alert related to wandering secondary to dementia.Review of R1's Physician Orders revealed an order dated 07/12/25 which stated, Bed alarm related to poor safety awareness secondary to falls.Review of R1's Progress Notes dated 11/01/25 at 8:20 AM revealed, This nurse was making patient rounds at approximately 6:10 AM and noted that the resident was not in her bed. This nurse then checked the resident's bathroom; she was not there. All Certified Nursing Assistants (CNAs) were summoned to assist in looking for [R1]. All other rooms were checked - no [R1]. This nurse then went to the back door where the resident was seen lying on the ground.Review of R1's Progress Notes dated 11/01/25 at 9:05 AM revealed Registered Nurse called to unit at 6:22 AM due to resident elopement. Resident discovered by Licensed Practical Nurse (LPN) in charge of care lying outside facility on the ground. 911 had already been activated, resident was supine covered in multiple blankets, resident was shivering with eyes closed. [R1] did open eyes to sound of nurse's voice but did not speak. Emergency Medical Services (EMS) arrival 6:40 AM, resident taken to local Emergency Department for evaluation and treatment, Director of Nursing (DON) notified by RN at 6:38 AM, Resident Representative notified by LPN left message.Review of R1's Progress Notes dated 11/02/25 at 8:50 PM Late entry, resident was alert to name and location. Resident was able to life [sic] her legs up, no injuries was noted at the time of her fall. Resident denies any pain at this time, resident was complaining of being cold.Review of R1's Quarterly Elopement assessment dated [DATE] revealed R1 scored a 0-elopement score indicating she was not at risk for elopement.Review of R1's Care Plan last revised on 10/22/25 revealed R1 is at risk for wandering and safety concerns. Interventions included, clearly identify resident's room and bathroom; code alert in place related to wandering; engage resident in purposeful activity; identify if there is a certain time of day/wandering/elopement attempts occur; implement a scheduled toileting program; schedule for regular walks/appropriate activity.Review of R1's Encounter Summary (local hospital) with an Encounter Date of 11/01/25, revealed the reason for visit was due to Trauma Level Three and Subdural Hematoma (SDH). Further review of the Encounter Summary revealed ED (emergency department) Notes which stated, [Registered Nurse] - 11/01/25 7:49 AM EDT: . Pt arrives via EMS from Mountain View nursing home where pt was found face down on the sidewalk in front of the building. Unknown when pt was last seen or how long they had been outside. [Registered Nurse] - 11/01/25 7:45 AM EDT: . Warm blankets applied for rectal temp of 92.8F. [Doctor] notified. Will apply [NAME] upon return from CT. [DO] - 11/01/25 7:28 AM EDT: Associated Order(s): Critical Care ED Provider First Contact Date and Time: 11/1/2025 7:24 AM . Clinical Impression SDH (subdural hematoma) (HCC) Primary Diagnosis Modifier: Acute with threat to life or bodily functions . Lab/Imaging/Data interpretation and additional Decision Making: I have independently interpreted/reviewed CT Head imaging, I agree with radiology read of: Acute right subdural hematoma contributing to up to 6 mm of leftward directed midline shift. Persistent left supraorbital and right frontal scalp hematomas. Furher review revealed the following Medical Decision Making, A [AGE] year old female with a history of anticoaglation (Eliquis) presented from a nursing facility with altered mental status of unknown baseline, found outside on the ground with multiple ecchymoses and a right forehead hematoma. She was noted to withdraw to pain but was otherwise minimally responsive. Imaging revealed an acuteright subdural hematoma with 6 mm lefward midline shift. She was hypothermic on arrival, and her case was managed in consultation with neursurgery and trauma teams. Differential diagnosis includes, but is not limited to: - Acute right subdural hematoma . - Hypothermia . - Metabolic or infectious encephalopathy . - Admint to neurotrauma ICU for close monitoring and management.During a phone interview on 11/06/25 at 12:47 PM, R1's Resident Representative (RR1) revealed that R1 is still in the hospital after eloping and falling outside of the facility on 11/01/25. RR1 stated, things were not looking good for [R1] and that she currently has not been able to speak and has intubated. RR1 mentioned that R1 had an alarm to notify staff when she moves but the alarm was attached to her walker and when R1 eloped from the facility she did not bring her walker outside because she is often forgetful due to her Alzheimer's. RR1 further stated the facility notified her of the incident and had been very honest about this incident. Staff even explained to her that they did hear an alarm go off around 4:00 AM but no one went outside to look, and they turned off the alarm which led to the resident being left unaccounted for until she was found around 5:30 AM. RR1 concluded that this was not the first time R1 was able to get outside of the building, which is why the facility was using alarms to notify when R1 moved.During a phone interview on 11/06/25 at 1:10 PM, Registered Nurse (RN)1 revealed that they are an agency nurse for the facility and mostly utilized as an RN supervisor/scheduler. RN1 stated that on 10/31/25 - 11/01/25, they were the supervisor for the night and assisted the North Unit Licensed Practical Nurse (LPN) with medication pass on 10/31/25. RN1 sated that she gave R1 her bedtime medications at around 7:45 PM and last saw the resident around 10:30 PM, when she saw the resident exhibiting wandering behaviors and redirected R1 by offering her a snack. RN1 stated that she last went to the North Unit around 1:30 AM to complete a round/patient check and saw R1 in bed asleep. After rounding RN1 notified the LPN that she was going to lunch and did not return to the unit until around 6:00 AM, when she was notified by the CNA's on the unit that something bad had happened and they needed her assistance. RN1 stated that she arrived to the North Unit she heard the door alarm sounding off and the door was open, when she went outside, she saw other staff members and R1 was lying on the ground shivering with blankets covering her. RN1 stated she went to notify the Director of Nursing (DON) on the situation and after the resident was transferred to the hospital, she began to ask staff on the North Unit how R1 was able to get outside. During this time is when staff stated that they heard an alarm sounding off around 3:30 AM - 4:00 AM but thought it was the fire alarm, but it was actually the door alarm. Staff turned off the door alarm but did not go outside to check at that time.During an interview on 11/06/25 at 1:49 PM, Certified Nursing Assistant (CNA)3 revealed that they are an agency CNA and on 10/31/25 - 11/01/25, was their first time working at the facility. CNA3 stated that she was asked to pick up a shift from her staffing company along with a friend/coworker. CNA3 stated, At first my friend/coworker and I were together working a different unit, but the supervisor pulled me, and I went to the North Unit, and [R1] was one of my assigned residents. The other staff gave me report and told me that [R1] was high fall risk and often wandered. I remember around 2:30 AM or 3:00 AM hearing an alarm go off but I was in a different resident's room providing care. During my rounds around 5:30 AM, I saw [R1] in the bathroom, but she didn't need help, so I went to check on my other residents. About 30 minutes later other staff started asking about where [R1] was and we later found her outside. When asked what the weather was like that morning CNA3 stated that it was very cold and dark outside, R1 had on bedtime clothing (pajamas and slippers). CNA3 stated that she could not recall hearing the door alarm sounding off when staff went to look for the resident outside and it was later rumored through staff to her that this was not the first time that R1 was able to get outside of the facility.During an interview on 11/06/25 at 3:10 PM, CNA2 revealed, On 10/31/25 I spoke with [CNA3] and completed a walk-through with her related to the residents she'd be assigned to for the shift. I emphasized the residents that were high risk for falls including [R1], informed [CNA3] that the bed alarm number 17 belonging to [R1] several times. During the shift I saw [CNA3] go into [R1's] room on several occasions to check on [R1] because her bed alarm was very active that night. Around 3:30 AM the fire alarm panel in the nurse's station on the North Unit went off. Because there was no fire, I tried to assist Licensed Practical Nurse [LPN1] (the nurse on duty) with fixing it but it did not work so I suggested we get help from maintenance. After that I went to go check on my assigned residents and during that time I noticed that the alarm was fixed/stopped alarming. When I finished my residents, I asked [LPN1] how the alarm was fixed and she said that another CNA had fixed the alarm. I didn't think much about the alarm after that and finished caring for my resident and around 6:30 AM I was informed that [R1] could not be located on the unit. After a few minutes staff found [R1] lying outside on the ground in a supine position. We quickly got her blankets and pillow for her head; her upper body had fallen in the grass area and her lower body was still on the sidewalk. [R1] was able to say her name but [R1] had some confusion and was saying that My cousin was calling me to come outside but we spoke with her until EMS came.During an interview on 11/06/25 at 3:42 PM, the DON revealed that the facility staff did not follow the facility protocol related to elopement. Staff have been re-educated related to elopement, reporting, and abuse and neglect. On 11/07/25 at 4:12 PM, the facility provided an acceptable IJ Removal Plan, which included the following:Summary of EventsStep One: On 11/01/2025, during the final rounds of the 7p to 7 a.m. shift, nursing staff entered the resident's room and found the resident's bed empty. The bathroom was also empty. LPN notified C.N.A.s that the resident was missing. After searching all the rooms, the Nurse exited the door and found the resident lying partly on the pavement and grass, on her right side.Nursing then turned resident on her back and spoke with her. The resident was alert and able to state her name and location, explaining she thought she had heard her cousin calling her outside. She had exited the building without her walker or code alert sensor. Staff covered her with blankets, supporting her head with a pillow, and remained with her until EMS transported her to Spartanburg Regional Medical Center. The DON, RP, and on-call were then notified. DON completed a 24-Hour Report to DPH Certification and Licensure on 11/01/2025. 5 Day Reportable was complete and sent back to the Certification and Licensure Divisions of DPH on 11/06/2025.Step Two: All residents have the potential to be affected by this deficient practice. Please see below for the list of training and in-services conducted by the facility regarding the incident that transpired on 11/01/2025.1. In-Service on Falls and Causes started on 11/02/2025 and completed on 11/05/2025.2. In-Service on Safety and Supervision started on 11/02/2025 and completed on 11/05/2025.3. Abuse and Neglect In-Service Training started on 11/02/2025 and was completed by 11/05/2025.4. Change in Resident Condition/Accidents and Incidents (Steps to Compliance) started on 11/02/2025 and was completed by 11/05/2025.5. Elopement In-Service and Training started on 11/02/2025 and was completed by 11/05/2025.6. In-Service and Training in reference to responding to Door Alarms were started on 11/03/2025 and completed on 11/05/2025.7. Door Alarm In-Service and Training conducted by Maintenance Director completed on 11/04/2025.8. In-Service on Choke Alarm completed by Maintenance Director 11/04/2025.9. Fire Drill In-Service Training was completed on 11/05/2025.Step Three: To prevent this from reoccurring, the Designee/Associate Administrator will educate ALL staff on Falls and Causes; Safety and Supervision of Residents; Abuse and Neglect; Change in Resident Condition; Elopement; Responding to Door Alarms; Door Alarms Checks (Maintenance), Choke Alarm, and Fire Drills. All employees will be educated on correct policies and procedures during orientation.Step Four: To monitor and maintain compliance, the Designee/Associate Administrator will complete an audit of in-services and training for the below: 1. Falls and Causes one X per week X one a month, and then monthly for 3 months. The Designee/ Associate Administrator will report the results of the monitoring to the QAPI committee for review for a minimum of three months.2. Safety and Supervision one X per week X one a month, and then monthly for 3 months. The Designee/ Associate Administrator will report the results of the monitoring to the QAPI committee for review for a minimum of three months.3. Abuse and Neglect one X per week X one a month, and then monthly for 3 months. The Designee/ Associate Administrator will report the results of the monitoring to the QAPI committee for review for a minimum of three months.4. Change in Resident Condition one X per week X one a month, and then monthly for 3 months. The Designee/ Associate Administrator will report the results of the monitoring to the QAPI committee for review for a minimum of three months.5. Elopement one X per week X one a month, and then monthly for 3 months. The Designee/ Associate Administrator will report the results of the monitoring to the QAPI committee for review for a minimum of three months.6. Responding to Door Alarms one X per week X one a month, and then monthly for 3 months. The Designee/ Associate Administrator will report the results of the monitoring to the QAPI committee for review for a minimum of three months.7. Door Alarm Checks one X per week X one a month, and then monthly for 3 months. The Designee/ Associate Administrator will report the results of the monitoring to the QAPI committee for review for a minimum of three months.8. Choke Alarms one X per week X one a month, and then monthly for 3 months. The Designee/ Associate Administrator will report the results of the monitoring to the QAPI committee for review for a minimum of three months.9. Fire Drills one X per week X one a month, and then monthly for 3 months. The Designee/ Associate Administrator will report the results of the monitoring to the QAPI committee for review for a minimum of three months.Date of Compliance: 11/05/2025

Based on observations, record review, interviews, and facility policy review, the facility failed to follow infection control guidelines during an medication administration observation for two of seven resident observations (Resident (R) 13 and R19), during an observation of PPE (Personal Protective Equipment) for one of three COVID-19 positive residents (R24), and during a dressing change for one of one resident observation (R74) of 24 sample resident. These failures had the potential for spreading infections including COVID 19 to the vulnerable population in the facility. Findings include: Review of the facility's undated policy titled, Policies and Procedures - Infection Prevention and Control revealed: Policy Statement. The facility adopted infection prevention and control policies and procedures are intended to help maintain a safe, sanitary, and comfortable environment and to help prevent and manage transmission of diseases and infections .Policy Interpretation and Implementation. 1. Infection prevention and control policies and procedures apply to all personnel, consultants, contractors, residents, visitors, and volunteers. 2. The objectives of the infection prevention and control policies and procedures are to: a. monitor, prevent, detect, investigate, and control infections in the facility; b. maintain a safe, sanitary, and comfortable environment for personnel, residents, visitors, and the general public; and c. provide evidence-based guidelines for infection prevention and control based on current best practices . 1. Review of R13's undated Face Sheet located under the Face Sheet tab in the electronic medical record (EMR) revealed the resident was admitted to the facility on [DATE] with the diagnoses of multiple sclerosis and with a recent diagnosis of gastrostomy tube placement. Review of R13's quarterly Minimum Data Set (MDS) located under the MDS Assessment tab in the EMR and with an Assessment Reference Date (ARD) of 09/01/24 revealed the resident was coded as having a feeding tube. Review of R13's Physician Orders located under the Physician Order tab in the hard chart of the medical record revealed an order, dated 01/19/23, which revealed Resident gets medications crushed and administered per tube. There were also physician orders for Ferrous Sulfate 220 mg (milligram) per five ml (milliliter) Give five ml by tube which was dated 08/28/24 and Vitamin D tablet 1,000 unit Give two tabs (2,000 unit) per tube daily. There was no order for Enhanced Barrier Precautions due to R13 having a gastrostomy tube. During an observation on 11/22/24 at 6:35 AM, Licensed Practical Nurse (LPN)9 prepared a Ferrous Sulfate liquid 220 mg and when pouring the liquid into the medicine cup, the right index finger of LPN9 touched the inside of the medicine cup. LPN9 proceeded to pour three tablets of Vitamin D into the lid of the bottle and while doing this, LPN9 touched two of the pills with her bare hands as she was pouring these into the medicine cup. LPN9 then applied gloves and stated, I have to stop touching these tablets with my hands. LPN9 was observed wearing gloves only during this medication administration using the gastrostomy tube. During an interview on 11/22/24 at 10:38 AM, Certified Nurse Aide (CNA)2 was asked if R13 was in Enhanced Barrier Precautions due to having a feeding tube and CNA2 stated, That's a good question. You wear PPE anytime they have stuff on the door, then you wear the PPE that is on the sign to take care of the resident. During an interview on 11/22/24 at 10:47 AM, CNA3 was asked if R13 was in Enhanced Barrier Precautions and CNA3 stated, No, but could you please explain this? 2. Review of R24's undated Face Sheet located under the Face Sheet tab in the EMR revealed the resident was admitted to the facility on [DATE] with diagnoses of cerebrovascular disease, chronic pain, and moderate protein-calorie malnutrition. Review R24's Physician Orders located under the Physician Order tab of the hard chart of the medical record revealed an order, dated 11/15/24, COVID positive. During an observation on 11/22/24 at 7:55 AM, the CNA4 donned (put on) an N95 mask, gloves, and a gown and entered into R24's room. On the outside of R24's door was an isolation sign for Contact Isolation and Droplet Precautions. CNA4 opened R24's door and exited into the hallway wearing her mask, gloves, and gown. CNA4 walked across the hallway and doffed (took off) the mask, gloves, and gown and placed these into a cardboard box lined with a red trash bag that was in the hallway. CNA4 stated, I forgot to take my PPE [Personal Protective Equipment] off before I came out of the resident's room. 3. Review of R19's undated Face Sheet located under the Face Sheet tab in the EMR revealed the resident was admitted to the facility on [DATE] with diagnoses of cerebral palsy and epilepsy. Review of R19's quarterly MDS located under the MDS Assessment tab in the EMR and with an ARD of 09/08/24 revealed the resident was coded as having a feeding tube. Review of R19's Physician Orders located under the Physician Order tab in the hard chart of the medical record revealed an order, dated 02/27/23, which stated, Resident gets medications crushed and administered per tube separately. There was no order for Enhance Barrier Precautions due to R19 having a feeding tube. During an observation and interview on 11/22/24 at 11:10 AM, Registered Nurse (RN)3 wore only gloves while administering medications to R19 by tube. When asked if she knew what Enhanced Barrier Precautions were, RN3 stated, It's for some residents in the nursing home setting, the nurse is to wear gown, gloves, and a mask. When asked when do you wear PPE, RN3 replied, During patient care. When asked if she should have worn a gown when administering medications by tube, RN3 stated, Yes. During an interview on 11/22/24 at 11:14 AM, when asked to explain what Enhanced Barrier Precautions was, CNA1 stated, It is when we do our PPE. When asked if R19 was in Enhanced Barrier Precautions and CNA1 replied, If the sign is on the door, then yes, he is but honestly I can go get the nurse to ask. During an interview on 11/22/24 at 11:18 AM, LPN4 was asked to explain what Enhanced Barrier Precautions was, the LPN4 replied, Some people are on this related to different stuff like contact isolation or dealing with bodily fluids, emptying a catheter, you would wear PPE. During an interview on 11/23/24 at 6:00 PM, the Director of Nursing (DON) stated, Anyone with a tube feeding, a Foley catheter, or dialysis shunt was in Enhanced Barrier Precautions (EBP). She stated when in EBP, the staff was to wear gown and gloves during direct care such as administering medications per tube, emptying a Foley catheter, or giving a bath. The DON stated the resident who was in Droplet and Contact Isolation, the staff were to don the mask, gown, and gloves prior to entering the resident's room and doff (take off) these items prior to exiting the resident's room. 4. Review of R74's undated Face Sheet located under the Face Sheet tab in the EMR revealed the resident was admitted to the facility on [DATE] with most recent diagnosis of sacral ulcer identified on 11/12/24. Review of R74's quarterly MDS located under the MDS Assessment tab in the EMR revealed the resident was at risk for developing a pressure ulcer. Review of R74's Physician Orders located under the Physician Order tab in the hard chart of the medical record revealed an order, dated 11/13/24, which revealed, Clean area to sacrum with Anasept. Pat dry. Apply hydrogel to area [sic] and cover with Opti foam. Change QD [every day] & [and] prn [as needed] until healed. During an observation on 11/22/24 at 9:56 AM, LPN2 was observed performing the dressing change to R74's sacral ulcer, the following failures were identified: -LPN2 cleaned the overbed table with Micro kill at 10:02 AM. At 10:03 AM, LPN2 cleaned the overbed table with an alcohol prep. At 10:05 AM, LPN2 placed the barrier on the overbed table before the table was dried from the alcohol prep. -LPN2 unfasten R74's brief and removed the dressing, then took out a wipe and wiped bowel movement from the anus in an upward motion up and around the wound. During an interview at 10:17 AM, LPN2 was asked what the dry time was for the Micro kill wipe that was used to clean the overbed table. LPN2 was observed reading the container and stated. The dry time is three minutes. LPN2 would not answer when asked if she waited for the dry time before the alcohol prep was applied to the overbed table. During an interview on 11/22/24 at 11:39 AM, the DON stated, The nurse is to wait the dry time for the Micro kill before a barrier is applied to the overbed table and you never wipe germs toward the wound, you wipe away from the wound.

Based on record review, interviews, and review of facility policy, the facility failed to ensure two of two residents (R) 18 and R85 of three reviewed for abuse was free from resident to resident physical and verbal abuse out of a total sample of 24 residents. This had the potential for the residents to sustain injuries from the altercation. Findings include: Review of the facility's undated policy titled, .Abuse and Neglect Management Policy Statement revealed Our residents have the right to be free from abuse, neglect, misappropriation of resident property, corporal punishment and involuntary seclusion. [Facility Name] does not condone any form of abuse and will continually monitor [Facility Name] policies, procedures, training programs, systems, etc. to assist in preventing resident abuse is committed to protecting our residents from abuse by anyone including, but not necessarily limited to facility staff, other residents, consultants, volunteers, and staff from other agencies providing services to our residents, family members, legal guardians, surrogates, sponsors, friends, visitors, or any other individual. [Facility Name] employs systems for screening, training, prevention, identification, investigation, protection and reporting abuse in order to provide a safe environment for our residents. Review of the Facility Reported Incident FRI report dated 08/06/24, submitted by the Director of Nursing (DON) revealed R85 took the TV remote from another resident. R18 verbally confronted R85 for his actions. R85 responded verbally to R18. R18 verbally chastised R85 for his actions. R85 then got up and hit R18 several times. R18 then ran R18's powerchair into R85. Staff intervened and R18 called 911 (emergency services). No injuries were noted at the time. R85 was placed on a 1:1 observation until further notice after completion of investigation. A review of the 5-day report submitted to the state survey agency revealed that on 08/06/24, at approximately 4:45 PM revealed the following; R85 and R18 were in the common area. Another resident had a remote control in their hand when R85 reached out and took the remote from the resident. The resident made no attempt to retrieve the remote and continued to watch TV. R18, who was seated in their powerchair proceeded to question R85 as to why he took the remote from the resident. R85 verbally responded to R18 by saying that it was none of R18's business and that they were all retards. R18 then attempted to chastise R85 for R85's actions and R85 then responded to R18 by jumping up from the couch and punching R18 on the side of R18's neck. R18 turned on his powerchair and proceeded to try and ram into R85, but R85 fell backwards on the couch and pulled his legs up out of the way of the chair. R18 pushed the couch to the opposite side of the common area. Then R85 jumped off of the couch and attempted to hit R85 again. Certified Nursing Assistant (CNA)4 had heard the commotion and went to the common area when she saw R85 and R18. While yelling for assistance, CNA4 turned off R18's powerchair and got between R85 and R18. R18 then called 911 and demanded that R85 be charged, but the deputy was informed of the incident and no charges were warranted; therefore, no case was opened. R85 was placed on 1:1 observation. R18 was told to stay away from R85. Body audits were conducted on the residents and no injuries were noted. Staff was in-serviced on resident-to-resident abuse via Zoom. The TV remote would be managed by the staff at all times. During an interview on 11/21/24 at 12:39 PM, R85 stated he could not recall the incident on 08/06/24 during which he had an altercation with R18. R85 stated he may have had a disagreement, but could not recall. During an interview on 11/20/24 at 3:20 PM, R18 stated he recalled his altercation with R85 and said R85 punched him in the face, and he said he tried to grab him by the arm, and he punched him a couple more times in the face. That is when CNA4 saw what was going on and tried to separate us. R85 sat for a minute and then got up and tried to start another fight. He stated, I took my wheelchair, and I pushed him down onto the couch and then I called the police. The facility smoothed things down with the police and told them the facility was going to handle the matter in-house. Neither of us was hurt and we did not need to go to the hospital. During an interview on 11/22/24 at 11:23 AM, agency Licensed Practical Nurse (LPN)4 stated she recalled there was an incident involving R18 and R85 a few weeks ago. LPN4 stated she was in the hall when one of the aides came and got her, that some residents were fighting. LPN4 said when she got to the common area, the fight was already over. LPN4 assessed R18 and checked his vitals. There was no bruising. R18 wanted to call 911. LPN4 stated she told R18 he could call 911 if he wanted to, which he did. When the police arrived, they talked to both R18 and R85. The police said there will be no charges. LPN4 recalled there was an in-service online about resident-to-resident abuse. LPN4 also stated she had undergone abuse training at least annually, and that abuse could be physical or verbal, including seclusion and misappropriation. During an interview on 11/22/24 at 6:16 PM, the Director of Nursing (DON) stated she recalled that R18 and R85 were in the common area. She confirmed the incident occurred and there was a resident-to-resident altercation between R85 and R18. The DON further that she submitted a report to the state survey agency and conducted staff training via Zoom (online).

Based on record review and interview, the facility failed to ensure a written copy of the baseline care plan was provided to the resident and/or responsible party (RP) within 48 hours for one of one resident (Resident (R) 261) reviewed for baseline care plans. This failure had the potential for residents and/or RP not to be informed of the plan of care. Findings include: Review of R261's undated Face Sheet located under the Face Sheet tab of the electronic medical record (EMR) revealed the resident was admitted on [DATE] with diagnoses which included epilepsy, anoxic brain damage, diabetes mellitus, and chronic pain. Review of R261's Progress Notes located under the Progress Notes tab in the hard copy of the medical record revealed a physician progress note, dated 10/30/24, which stated R261 had a Brief Interview for Mental Status (BIMS) score of 11 out of 15, which indicated R261 was moderately cognitively impaired. Review of R261's Acknowledgement of Receipt Admission Baseline Care Plan, dated 10/24/24 and located under the MDS tab in the hard copy of the medical record revealed there was no resident and/or RP's signature located on the signature line of this form. During a phone interview on 11/21/24 at 10:37 AM, Family Member (FM)1 stated, No one has reached out to me concerning his care plan at the facility. During an interview on 11/23/24 at 4:10 PM, the Director of Nursing (DON) stated, That would be social services that gets these signed. During a phone interview on 11/23/24 at 4:30 PM, the Social Services Director (SSD) stated, That was an oversight on my part. During an interview on 11/23/24 at 6:00 PM, the Assistant Administrator stated, She [SSD] told me she had made a mistake concerning the baseline care plan for this resident.

28306 Based on record review, interview, and facility policy review, the facility failed to develop a care plan for refusal of medications and meals for one (Resident (R)92) and failed to develop and implement a care plan for pressure ulcers for one of 24 sample residents R78. This failure had the potential for residents to have unmet care plan needs. Findings include: Review of the facility's policy titled, Care Plans, Comprehensive Person Centered, dated 2017, revealed . The comprehensive, person-centered care plan will: a. Include measurable objectives and timeframes; b. Describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being; c. Describe services that would otherwise be provided for the above, but are not provided due to the resident exercising his or her rights, including the right to refuse treatment . 1. Review of R92's undated Face Sheet located under the Face Sheet in the electronic medical record (EMR) revealed R92 was admitted to the facility on [DATE] with the diagnosis of atrial fibrillation, hypertension, and congestive heart failure. Review of R92's quarterly Minimum Data Set (MDS) located under the MDS Assessments tab in the EMR with an Assessment Reference Date (ARD) of 09/08/24 revealed R92 had short- and long-term memory loss and rarely or never made decisions. Review of R92's Medication Administration Record (MAR) dated November 2024 revealed the resident commonly refused or spit out her medication when administered by the nurse. Review of R92's Progress Note located under the Dietary tab in the hard chart of the medical record revealed a note, dated 10/21/24, which revealed .refusing medications .refuses meal at times . Review of R92's current Care Plan located under the MDS tab in the hard chart of the medical record revealed the resident had not been care planned for the refusals of medications and meals as documented by the dietician in the progress note, dated 10/21/24. During an interview on 11/23/24 at 2:47 PM, Licensed Practical Nurse (LPN)1 stated, I have her care planned for refusal of showers but nothing else, and we use our nursing judgement in feeding her now and going back to offer her the medications and snacks throughout the day. Some days are better than other days for this resident. When asked if these were areas that should have been care planned for this resident, LPN1 stated, Well, I mean I don't know, I guess it should. During an interview on 11/23/24 at 6:00 PM, the Director of Nursing (DON) stated, The care plan needs to reflect the current plan of care for this resident and if she has been refusing her medications and meals this should have been in her care plan. 2. Review of R78's Face Sheet located under the Face Sheet tab of the paper medical record revealed the resident was admitted to the facility on [DATE]. Review of the quarterly MDS with an ARD of 08/25/24 revealed a BIMS score of 15 out of 15 indicating which indicated the resident was cognitively intact. Review of the paper chart revealed a telephone order, dated 11/12/24, which revealed R78 had a wound on his sacral area and included orders for treatment to the sacral area. The telephone order revealed Clean area to sacrum with antiseptic. Pat dry apply hydrogel to area and cover with optifoam change qd [daily] and PRN [as needed] until healed. Review of R78's Care Plan located in the paper chart under the MDS did not contain a care plan related to a pressure sore. During an interview on 11/21/24 at 5:45 PM, the DON revealed she was not aware R78 had a pressure injury. She confirmed with the wound nurse that R78 did have a pressure injury. During an interview on 11/22/24 at 4:10 PM, the MDS Coordinator (MDSC) confirmed there was not a care plan written when the sacral wound was identified. She stated most care plans were updated by the nurses on the unit and someone missed updating R78's care plan.

Based on record review and interviews, the facility failed to ensure the care plan was revised to reflect an updated advanced directive status for one of one resident (Resident (R)92) reviewed for advanced directives. This failure had the potential for residents to have unmet care plan needs. Findings include: Review of R92's undated Face Sheet located under the Face Sheet tab of the electronic medical record (EMR) revealed the resident was admitted to the facility on [DATE] with the diagnosis of stroke, congestive heart failure, and major depressive disorder. Review of R92's quarterly Minimum Data Set (MDS) located under the MDS Assessments tab of the EMR with an Assessment Reference Date (ARD) of [DATE] revealed R92 had short- and long-term memory loss and rarely or never made decisions. Review of R92's Advance Directive located under the Advance Directive tab in the hard chart of the medical record revealed the daughter signed for a DNR (Do Not Resuscitate) on [DATE] with the admission paperwork that was completed. Review of R92's Physician Orders located under the Physician Order tab in the hard chart of the medical record revealed an order, dated [DATE], which revealed DNR [Do Not Resuscitate]. Review of R92's Care Plan, dated [DATE] and located under the MDS tab in the hard chart of the medical record, revealed a Problem as I want everything done for me in an emergency. Under Approach it stated, Make sure my wishes are on my chart. Let Pharmacy know and outside doctors know what I want. If I am unresponsive, call 911 and start CPR [Cardiopulmonary Resuscitation]. Notify my doctor and family. Review of R92's Care Plan Conference Summary, dated [DATE] and located under the MDS tab of the hard chart of the medical record, and under Adv Dir/Code Status was documented as a Full Code. There were no further care plan conferences documented in the medical record. During an interview on [DATE] at 2:20 PM, the Director of Nursing (DON) stated, The MDS nurse is to update the care plans with each MDS that she does. She will type out a new care plan and include any current interventions in it. The nurses on the floor will write in on these care plans with new interventions or new orders then MDS nurse prints this off and puts the care plan in the chart. During an interview on [DATE] at 2:35 PM, the MDS Coordinator (MDSC) stated, I was following what the care plan had said on wanting to be a full code. When asked if the orders had been reviewed to see if there were any updates to the resident's care plan that needed to be included, the MDSC stated, I don't remember if I reviewed the orders or not when I updated the care plan. The MDSC returned to the conference room and brought in care plan conference summaries for [DATE], [DATE], and [DATE]. The MDSC stated, These were in my office. During an interview on [DATE] at 2:30 PM, Licensed Practical Nurse (LPN)1 stated, The nurses on the floor are to write in the updates as the orders come in for the resident. Then the MDS nurse will review the care plan when she does the next MDS and type up a current care plan with the new orders and interventions that are still current. I don't see where this was done for this resident. During an interview on [DATE] at 6:00 PM, the DON stated, Those should be filed in the medical record and not kept in the MDS office.

Based on record review and interview, the facility failed to have collaboration of care with the dialysis center for one of one resident (Resident (R)38) reviewed for dialysis. This failure had the potential to put R38 at risk for lack of communication between the facility and the dialysis center. Findings include: Review of R38's undated Face Sheet located under the Face Sheet tab of the electronic medical record (EMR) indicated R38 was admitted to the facility on [DATE] with diagnosis of cerebrovascular accident, end stage renal disease, and chronic kidney disease, stage five. Review of R38's quarterly Minimum Data Set (MDS) located in the EMR under the MDS Assessment tab with an Assessment Reference Date (ARD) of 08/18/24 revealed the resident was coded as receiving dialysis services while a resident in the facility. Review of R38's Physician Order located in R38's hard chart of the medical record, under the Orders tab, revealed orders, dated 06/20/23, which revealed R38 had dialysis on Mondays, Wednesdays, and Fridays. Review of R38's Dialysis Communication Record located in the hard chart of the medical record under the Assessments tab, revealed the records, dated 10/25/24, 11/01/24, 11/11/24, 11/13/24, and 11/18/24, had documentation missing from the dialysis center for shunt site (which described the location, dressings, pain and change in condition), lab values which described the events during the course of treatment, medications given at dialysis, recommendations, and food/fluid intake along with missing signatures and dates. During an interview on 11/23/24 at 6:00 PM, the Director of Nursing (DON) and the Assistant Administrator were notified of the missing components on the Dialysis Communication Record for the above documented dates in R38's medical record. The DON stated, The nurse that receives this back from the dialysis center should call the center and get a report or fax them this sheet and get it completed. The nurse should document this in the progress notes.

Based on record review, interview, and facility policy review, the facility failed to ensure risk and benefits were explained to the resident and/or representative (RP) prior to the use of psychotropic medications and failed to ensure targeted behaviors and side effects were monitored for administered psychotropics for one of five residents (Resident (R)46) reviewed for unnecessary medications. This failure had the potential for excessive psychotropic administration and for the residents and/or representative not to be able to make an informed decision regarding the use of the psychotropic medications. Findings include: Review of the undated facility's policy titled, Antipsychotic/Psychotropic Medication Use, revealed . The attending physician and other staff will gather and document information to clarify a resident's behavior, mood, function, medical condition, specific symptoms, and risks to the resident and others .The attending physician will identify, evaluate and document, with input from other disciplines and consultants as needed, symptoms that may warrant the use of antipsychotic medications . The staff will observe, document, and report to the attending physician information regarding the effectiveness of any interventions, including antipsychotic medications . Review of R46's undated Face Sheet located under the Face Sheet tab in the electronic medical record (EMR) revealed R46 was admitted to the facility on [DATE] with diagnoses of anxiety and major depressive disorder. Review of R46's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/06/24 and located under the MDS Assessment tab in the EMR revealed the resident was coded as having short- and long-term memory loss with rarely or never making decisions. Mood symptoms present for little interest or pleasure in doing things and feeling down, depressed, or hopeless were all coded as a 9 which represented no response. The resident was marked as receiving antipsychotics on a routine basis and was taking an antidepressant. Review of R46's Physician Orders located in the hard chart of the medical record under the Physician Orders tab, revealed: -Order date: 02/09/24 Effexor ER [extended release] (anti-depressant) 150 mg (milligram) by mouth daily for anxiety and major depressive disorder. -Order date: 07/12/24 Risperidone (antipsychotic) 1mg by mouth at bedtime for severe major depressive disorder. This was an increased order. The original order for Risperidone 0.5 mg daily was dated 02/27/24. -Order date: 03/05/24 Trazodone (anti-depressant) 100 mg by mouth at bedtime for insomnia. -Order date: 07/08/24 Klonopin (anti-anxiety) 0.5 mg by mouth daily for anxiety. Review of R46's Care Plan, dated 05/29/23, and located in the hard chart of the medical record under the MDS tab, revealed a problem: I have .dementia with agitation and restlessness, I get confused at times. The approach was documented as Don't rush me give me time to speak. Let me do things [sic] I want to do. I like to watch TV, and [sic] do activities of choice. I prefer to stay in my room most of the time. Review of R46's Behavior Documentation and Daily Monitoring, dated October 2024 and November 2024 and located under the Assessments tab in the hard chart of the medical record, revealed either missing documentation of No Behavior This Shift/No Interventions Required and/or incomplete documentation of the behavior observed, what caused the behavior, factors that may have caused or exacerbated the behavior, factors that caused or intensified the behavior, illnesses or conditions that may have caused behavior problems, potential reaction to medications, refer to (name of facility) behavioral manual for behavior management interventions related to the specific behavior exhibited by the resident, and psychoactive medications the resident was currently receiving. Review of the Consent for Use of Psychoactive Medication Therapy located in the hard chart of the medical record revealed a consent for Risperidone, dated 02/27/24. This consent was signed by the RP of R46 on 02/27/24. There was no consent for Effexor ER, Klonopin, and Trazodone located in the hard chart of the medical record. During an interview on 11/23/24 at 2:30 PM, Licensed Practical Nurse (LPN)1 stated, There are no specific behaviors stated but we chart on the care plan when the resident exhibits behavior and what they were. When asked if LPN1 knew what each medication was given for and the specific behavior the LPN1 stated, No, we will chart what we see. When asked what side effects were being monitored for each of the medications the resident received the LPN1 stated, We will monitor lethargy or something like that but nothing specifically for each medication. During an interview on 11/23/24 at 6:00 PM, the Director of Nursing (DON) stated, We document the behaviors that we see but not specific behaviors that each of the medications are specifically administered for. The behavior monitoring sheet that we use should be marked each day if no behaviors were seen, the nurse will mark no behaviors or if there are behaviors the nurse will document what they are seeing. The care plans should reflect the behaviors that we are seeing and any interventions.

Based on observation, interview, and facility policy review, the facility failed to accurately check the insulin pen that was being used to administer insulin to one of one resident (Resident (R)14) administered insulin out of seven residents being observed during the medication administration task. This failure had the potential for bloodborne pathogens to infect residents by using a reusable insulin pen to a resident other than the resident that it had been ordered for. Findings include: Review of the undated facility's policy titled, Administering Medications, revealed .The individual administering the medication must check the label THREE (3) times to verify the right medication, right dosage, right time, and right method (route) of administration before giving the medication . During an observation of medication administration on 11/22/24 at 8:09 AM, the label on R14's Humalog insulin Kwik Pen read, Give 12 units every morning. The paper Medication Administration Record (MAR)located in a notebook on the medication cart for R14 matched the label for Humalog which was compared by the surveyor at the time of the preparation of the Humalog Kwik Pen. It was noted at that time, the name on the Humalog Kwik Pen was R101's name and not the name of R14 which the insulin was to be administered. Licensed Practical Nurse (LPN) 8 applied the alcohol prep to R14's left upper arm and uncapped the Humalog Kwik Pen. Before LPN8 was able to stick R14's arm with the insulin pen, the surveyor requested the nurse to stop and check the resident's name on the pen. LPN8 stated, It's [R14's] insulin. Again, the surveyor asked LPN8 to read the name on the label that was on the Humalog insulin Kwik Pen. LPN8 stated, It is [R101]. I need to take this out to the medication cart. The Humalog insulin was not administered to R14 at this time. LPN8 returned to the medication cart and stated, You have to check the medication to make sure it is for the right patient, it is the right dose, the right route, and the right time. During an interview on 11/22/24 at 8:17 AM, LPN5 stated, The nurse is to check to make sure it is for the right patient, right dosage, right route, and right frequency before giving the medication to the patient. During an interview on 11/23/24 at 6:00 PM, the Director of Nursing (DON) stated, The nurse checks each medication to make sure it is the correct patient that the medication is being given to.

Based on observation, interview, record review, and facility policy review, the facility failed to have a permanently affixed compartment to store narcotics in the medication refrigerator on two of three units (North and [NAME] Units) which involved three of five residents (Resident (R) 259, R2, and R11) reviewed for medication storage of 24 sample residents This failure had the potential for these medications to be diverted. Findings include: Review of the facility's undated policy titled, Storage of Medications read in part, .Schedule II-V controlled medications are stored in separately lock, permanently affixed compartments . 1. Review of R259's undated Face Sheet located in the electronic medical record (EMR) under the Face Sheet tab revealed this resident was admitted to the facility on [DATE]. During an observation of the medication storage room on the North unit on 11/22/24 at 6:57 AM with Licensed Practical Nurse (LPN) 9, in the unlocked medication refrigerator, there was a transparent plastic container with two locks on it which contained Lorazepam (anti-anxiety medication) 2mg/ml (milligram per milliliter) 20 ml bottle which contained a medication label on it for R259. LPN9 was asked if the plastic container that contained Lorazepam was permanently affixed to the refrigerator. LPN9 confirmed that this plastic container was not permanently affixed to the medication refrigerator. During an interview on 11/22/24 at 11:45 AM, LPN1 stated, Yes, you can take the plastic container with the Lorazepam out of the refrigerator. 2. Review of R2's undated Face Sheet located in the EMR under the Face Sheet tab revealed the resident was admitted to the facility on [DATE]. Review of R2's Physician's Order's located under the Physician Order tab in the hard chart of the medical record revealed an order, dated 08/21/24, for Lorazepam Injection 2mg/ml 0.25 ml (0.5 mg) intramuscular every two hours as needed for seizure. 3. Review of R11's undated Face Sheet located in the EMR under the Face Sheet tab revealed the resident was admitted to the facility on [DATE]. Review of R11's Physician Orders located under the Physician Order tab in the hard chart of the medical record revealed an order, dated 08/22/24, Lorazepam 2mg/ml One ml (Two mg) intramuscular every eight hours as needed for seizure. During an observation of the medication storage room on the [NAME] unit on 11/23/24 at 10:00 AM with LPN3, in the unlocked medication refrigerator, there was a transparent plastic container with two locks on it which contained single dose vials of Lorazepam as ordered for R2 and R11, which was not permanently affixed to the medication refrigerator. LPN3 confirmed that the transparent plastic container that contained the single doses of Lorazepam was not permanently affixed to the medication refrigerator. During an interview on 11/23/24 at 6:00 PM, the Director of Nursing (DON) stated she was not aware that the transparent plastic container in the medication refrigerator had to be permanently affixed to the refrigerator because it had Lorazepam in it.

Based on observations, interviews, and review of facility policy, the facility failed to ensure food items stored in 1 of 1 walk in refrigerator were properly labeled and dated to prevent the risk of food borne illness. Findings Include: Review of the facility policy titled, Food Purchasing and Inspection of Food Deliveries dated 2020 revealed Guidelines: All food items will be purchased from approved vendors and received according to the following guidelines. Procedure: 4 Inspect all deliveries carefully. Check for appropriate labeling, temperature, appearance, texture, odor, and other factors important for food safety. 6. Any unsafe food items will be refused or discarded immediately, and proper credit received per vendor policy. Review of the facility policy titled, Food Safety with an effective date of February 1, 2015, revealed Purpose: To ensure food is stored in a manner to prevent contamination and preserve the nutritional content of all items in the establishment. Procedure: 14. Refrigerated Food Storage: f. All foods should be covered, labeled, and dated. All foods will be checked daily . Review of the undated facility policy titled, Foods Brought By Family/Visitors revealed 11. Food brought by family/visitors that is left with the resident to consume later will labeled and stored in a manner that it is clearly distinguishable from facility-prepared food. 13. Perishable foods must be stored . Containers will be labeled with the resident's name, the item and the use by date. During the initial tour of the kitchen on 02/21/23 at 10:25 AM, the following concerns were identified in the walk-in refrigerator: A bulk container of cabbage with multiple heads of cabbage covered in a black moldy substance and a cake holder containing left over cake, undated and unlabeled. A follow up visit to the kitchen on 02/24/23 at 10:29 AM revealed 4 trays containing 20-25 slices of assorted cakes and pies, uncovered, unlabeled and undated. During an interview on 02/21/23 at 10:47 AM the Kitchen Manager (KM) confirmed the bulk container of cabbage with a black moldy substance and the cake holder with left over cake. The KM stated the cabbage was just delivered and was unsure about the cake holder. During an interview on 02/24/23 at 10:32 AM the Kitchen Manager (KM) revealed, the trays of cakes and pies not covered nor labeled. The KM stated, covering it will mess up the whip cream. The KM further stated there is no policy related to food storage, it's all in my head. I purchase, receive, look after the food.

Based on observation, interview, and facility policy, the facility failed to ensure an effective pest control program for the environment to remain free from pests in 2 of 3 units observed for pests. Findings include: Review of the facility's policy titled, Infection Prevention and Control Manual Pest Control revealed The facility maintains an effective pest control program to remain free of pests and rodents. Facility wide-pest control strategies are developed emphasizing kitchens, cafeterias, laundries, central sterile supply areas, loading docks, garbage storage areas, construction activities, and other regions prone to pest infestations. An observation and interview during Medication Administration on 2/22/23 at 8:15 AM in Resident (R)60's room with Licensed Practical Nurse (LPN)1 revealed 2 dead water bugs in the resident's room. LPN1 further stated that the bugs used to be worse and when the facility had to replace the roof, that's when they got real bad and they were flying everywhere. An observation on 2/22/23 at 2:50 PM of R12's bathroom revealed a spider and spider-web. Further observation of the bathroom revealed items in bags on the floor blocking the toilet with a black substance on the floor, wall, and toilet. A phone interview on 2/23/23 at 1:12 PM with R12's Resident Representative revealed I noticed some bagged items in her bathroom as well, but have not looked in there in a while because the resident does not use the bathroom anymore (incontinent), but I think those are some old clothes that the resident can no longer wear due to weight loss over the years. I visit R12 about 2 or 3 times a month and during my last few visits, there were several cockroaches crawling around in the resident's room. R12 told me that the bugs come out at night mostly and are in her bedroom and bathroom. An interview during the Resident Council Meeting by the state agency on 2/22/23 at 11:02 AM with 4 Residents in attendance revealed concerns with water bugs/roaches around the facility at night. An interview and record review on 2/28/23 at 1:00 PM with the Maintenance Director revealed that pest control comes to the facility on ce a month, every month, but was unaware of the resident's concerns of seeing pests at night.

Based on observation, record review, and interview, the facility failed to maintain a clean and clutter free environment in rooms [ROOM NUMBERS]. Review of 1 of 3 units observed for environment. Findings include: Review of a facility job description and specification for Housekeeping Assistant, last revised December 2015 revealed The Housekeeping Assistant assigned to the neighborhoods work under the direct supervision of the Executive Housekeeper, carrying out tasks designed to maintain the facility in a safe, clean orderly and attractive manner. Specific duties: 1.Clean all patient room daily including; cleaning lavatory, commode inside and out with Comet, with mop and clan rags daily. An observation and interview on 2/22/23 at 10:32 AM with Resident (R)9, who lives in room [ROOM NUMBER], revealed their bathroom, located in their room, with multiple bagged items filled with clothes and blankets. There were signs of dust and what appeared to be black mildew on the toilet and walls. R9 stated those bags have been in there for a few months now because those are clothes I don't wear anymore. I no longer use that bathroom so we just put my stuff in there but if they could go somewhere else or home with my family I wouldn't mind. The cleaning staff come into my room to clean every day but I'm not sure the last time they cleaned my bathroom. An observation on 2/22/23 at 10:36 AM with R12, who lives in room [ROOM NUMBER], revealed their bathroom, located in their room, with multiple bagged items filled with clothes. There were signs of dust and what appeared to be black mildew on the toilet and walls. R12 was not able to be interviewed. During interview with R12 on 2/22/23 at 10:37 AM revealed, it's roaches in my room and bathroom. A phone interview on 2/23/23 at 1:12 PM with R12's Resident Representative (RR) revealed I noticed some bagged items in her bathroom as well but have not looked in there in a while because the resident does not use the bathroom anymore (incontinent), but I think those are some old clothes that the resident can no longer wear due to weight loss over the years. I visit R12 about 2 or 3 times a month and during my last few visit there were several cock-roaches crawling around in the resident's room. R12 told me that the bugs come out at night mostly and are in her bedroom and bathroom. An observation and interview on 2/24/23 at 10:10 AM with Licensed Practical Nurse (LPN) 4 revealed, bagged clothing items and blankets blocking the toilet area and black substances on the floor, and toilet. LPN4 stated that she was unsure of what the black substance was. LPN4 thought it could be sewage and would ask housekeeping staff to clean the bathroom. An interview on 2/24/23 at 10:18 AM with Certified Nursing Assistant (CNA)1 revealed, housekeeping staff are responsible for cleaning the resident bathroom and rooms and they are only responsible for the resident's bed and clothes. An observation and interview on 2/27/23 at 10:43 AM with Housekeeping Staff (HS)1 revealed, the process for cleaning a bathroom with bagged clothing items is to pull the bagged items out of the restroom and begin to clean. HS1 stated I'm not sure the last time this restroom has been cleaned but we are expected to clean all resident bathrooms daily. HS1 further stated the residents' extra bagged clothing items will be kept in the maintenance storage room until the resident representative is able to come pick and Social Services is supposed to contact the residents' families about picking up the items. An interview with R9 on 2/27/23 at 10:45 AM revealed they were happy that someone was finally cleaning their bathroom. An interview on 2/28/23 at 9:40 AM with the Housekeeping Director revealed, staff are expected to clean resident bathrooms and rooms daily or as needed. There are a few residents that like to keep overflowing amounts of clothes and blankets in their room. The Social Worker is in the process of speaking with those residents' families to pick up the extra items to prevent unnecessary clutter in rooms so that housekeeping staff will be able to clean all areas without having to move excessive items around. R12's and R9's items are now being stored in the maintenance storage rooms until their families are able to pick up their items. An interview on 2/28/23 at 10:00 AM with Registered Nurse (RN)2 revealed Social services is now working with residents to encourage them to allow their families to pick up extra clothing items that are unable to be stored in their rooms.

Based on record reviews, interviews and review of the facility policy titled, Bed Hold and Return, the facility failed to ensure the resident or the resident's representative for Resident (R)91 and R43 received the bed hold and return policy upon transfer to the hospital or within a practicable amount of time after discharge to the hospital for 2 of 4 residents reviewed for hospitalization . Findings include: Review of the undated facility policy titled, Bed Hold and Return, states under Policy Statement, Our facility shall inform residents upon admission and prior to a transfer for hospitalization s or therapeutic leave of out bed-hold and return policy. The Policy Interpretation and Implementation, states, Number 1. Upon admission and when a resident is transferred for hospitalization or for therapeutic leave, the assigned social worker or designee will provide information concerning our bed-hold and return policy. Residents or RP (responsible party) will be notified of the transfer and reason for the transfer in writing and in a language that they understand. A copy of the notice will be sent to SC State Ombudsman's Office. Bed hold will be sent to the hospital with the transferring documentation. Number 2 states, When emergency transfers are necessary, the facility will provide the residents or the responsible party with information concerning our bed-hold and return policy within 72 hours of such transfer. Number 5 states, Medicaid residents whose bed-hold and return days have expired will be discharged from the facility but may return to the facility if they desire so and a bed is available. Review of R91's medical record revealed, on [DATE], R91 was discharged to the hospital for evaluation and treatment. A nurse's note states, A 10 day bed hold was put into place per Medicaid guidelines. Further review of the medical record revealed, a facility transfer and 10 day bed hold form, which included the date of the transfer to the hospital and a signature from the Director of Nursing (DON). No documentation was found on the form or in the medical record to ensure R91 or her personal representative received a copy of the 10 day bed hold and return form. An interview on [DATE] at 4:05 PM with Registered Nurse (RN)1 and Social Services Director (SSD), confirmed neither R91 or her responsible party had received a copy of the bed hold notification upon transfer to the hospital. RN1 stated, a copy goes in a packet of information with the resident to the hospital and is given to the hospital staff. The resident and the personal representative do not get a copy from the hospital staff. SSD stated that this is a Medicaid only facility and they do not have to do the Bed Hold. 42424 Review of R43's medical record under a nurse's note dated [DATE] at 11:55 AM revealed This nurse called by primary nurse to assess resident. Resident fell upon my arrival, the resident is lying flat on her back. Resident alert is able to move right but yells out is pain when and not able to straighten her leg. 911 called, resident alert and oriented x 3 with complaints of pain. Resident stated that she fell attempting to use restroom and did not call for help. Resident stable and waiting for Emergency Medical Staff (EMS) staff to arrive. Review of a follow up nurses note dated [DATE] at 12:45 PM revealed Spoke with R47 Resident Representative (RR) and informed of resident fall, resident admitted to hospital with diagnosis of right hip fracture. Review of R43's Transfer and 10-Day Bed Hold Form dated [DATE] revealed this letter is to inform you that are being sent to the hospital because (evaluation for fall/hip pain) . If you have to be admitted to any other other facility your bed hold will start (no date listed) and will be in effect for 10 days, it is the practice of the facility to continue to extend to you your current ability to remain a resident of the facility pending review of your current medical situation, length of hospitalization and facilities ability to provide the level of care required. Please be informed that the facility does not require any additional funds to hold a residents bed. If there is a need for a room change during the 10-day bed hold, the facility will inform you or your Personal Representative in writing of the desired change. Review of 43's Discharge Evaluation Plan of Care dated [DATE] revealed R43 was sent out to the hospital for evaluation and treatment. A 10 day bed hold was put in place under Medicaid guidelines. Further review revealed on [DATE] R43 went past her 10 day hold, she will be discharge on this date, her return is expected. An interview on [DATE] at 9:45 AM with Social Services revealed I thought because we are a Medicaid only facility we do not have to put an amount on the bed hold letter.

Based on record reviews and interview, the facility failed to ensure an OBRA assessment for Resident (R)5 was completed, accurate and transmitted timely for 1 of 1 residents reviewed for a Missing OBRA assessment. Findings include: Review on 02/23/23 at 3:04 PM of the CMS (Centers for Medicare and Medicaid Services) MDS 3.0 NH Final Validation, report for R5 revealed a target date of 11/12/22. A warning received after transmission states, Care Plan Completed Late: V0200B2 (CAA process signature date) is more that 14 days after the assessment reference date. The current record type, is Inconsistent record sequence. Under CMS sequencing guidelines, the type of assessment in this record does not logically follow the type of assessment in the record received prior to this one. Assessment Completed: The assessment completion date is more than 14 days after the assessment reference date. The target date on the last record identified for R5 was 08/29/22. During an interview on 02/23/23 at 03:30 PM with Minimum Data Set (MDS) assessment coordinator, she stated that she was not in the position of MDS Coordinator at the time of the assessment and the transmission. She stated she would look at it and resubmit the assessment.

Based on record reviews, interviews, and review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE], the facility failed to ensure the MDS was complete and accurate for Resident (R)78. Specifically, Section G was not coded for 2 person assist with bed mobility, dressing, eating, toilet use, personal hygiene and bathing resulting in a fall with a major injury for 1 of 3 residents reviewed for falls with major injury. Findings include: The facility admitted R78 with diagnoses including, but not limited to, psychosis, neuropathy of the right hand, dementia, cerebrovascular accident, osteoarthritis, anxiety and behaviors. Review of the medical record for R78 revealed a Certified Nursing Assistant (CNA) plan of care which indicated R78 was to be assisted with all activities of daily living by 2 persons. Must have 2 CNAs providing care at all times. Further review on 02/22/23 at 12:30 PM of the medical record for R78 revealed a incident/accident report dated 01/25/23 in which R78 fell from the bed, while one CNA was providing care. The report states, CNA was performing care when she rolled the resident to right side and he fell from the bed. His head made contact with the bedside dresser. R78 obtained a laceration to the right side of his forehead and was sent out to the emergency department. The conclusion on the incident accident report for root cause states, Proper protocols were not in place. Resident requires 2 person assist and only one CNA was completing care at the time of the incident. During an interview on 02/24/23 at 10:45 AM with CNA6, the CNA that was providing care when R78 fell from the bed, this surveyor asked if she was providing care by herself or if she had another CNA helping her and she stated it was just her by herself. When asked if she was aware that R78 was a 2 person assist with all activities of daily living, she stated that at that time, he was just a person assist. An interview on 02/24/23 at 1:03 PM with Licensed Practical Nurse (LPN)2 confirmed that R78 was a 2 person assist and had been since 08/17/22, when he was moved from the East Wing to the North Wing. The MDS Coordinator was not available for interview.

Based on review of facility policy, record review, and interviews, the facility failed to ensure a Preadmission Screen and Resident Review (PASARR) Level II was completed for 1 of 3 residents reviewed for PASARR. Specifically, Resident (R)4 did not have a PASARR Level II completed after a diagnosis of Mental Illness (MI). Findings Include: Review of an undated facility policy titled, Pre-Admission Screening Policy (PASAR), revealed, Residents admitted to Mountainview Nursing Home will have a pre-admission screening completed prior to admission to assess for the need for special services and to assure placement is appropriate. If there are no indicators when the level I assessment is completed, resident will be accepted for admission. If resident does have indicators of a need for further services, then a Level II assessment must be completed by the appropriate agency. Should we admit a resident who requires Level II services, this will be coordinated with the appropriate agency. Review of R4's Face Sheet revealed R4 was initially admitted to the facility on [DATE] with no diagnosis of a severe mental illness. R4 was readmitted to the facility on [DATE] with diagnosis including but not limited to bipolar disorder, psychosis, dementia, and Alzheimer's disease. Review of R4's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 05/01/22 revealed R4 was not assessed for a Brief Interview for Mental Status (BIMS) due to R4 being rarely or never understood. Further review of R4's MDS revealed under Section E - Behaviors, R4 presented potential indicators of psychosis due to hallucinations and delusions. Review of R4's Psychiatry Follow Up Notes dated 10/28/22, 11/29/22, and 01/13/23 revealed, ongoing management of [R4] severe bipolar disorder. Review of R4's PASSRR Level I Screening dated 07/12/18 under the MI section revealed No diagnosis of mental illness and no indicators of current behaviors. Further review under the section Recommendations and Information revealed, No further evaluation recommended. In an interview on 02/24/23 at 10:12 AM with the Social Worker (SW) revealed, If the resident was diagnosed with a severe mental illness after admission, a Level II PASARR would be requested. [R4] has not had a PASSAR [NAME] II completed, but should have one.

Based on record reviews, interviews, and review of the facility policy titled, Care Plans, Comprehensive Person-Centered, the facility failed to formulate and implement a comprehensive plan of care for Resident (R)78, which included 2 person assist with all activities of daily living. The facility additionally failed to formulate and implement a comprehensive plan of care for R32 for seizures, convulsions and epilepsy for 2 of 5 residents reviewed for unnecessary medications. Findings include: Review of the facility policy titled, Care Plans, Comprehensive Person Centered, revealed a policy statement which reads, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. The Policy Interpretation and Implementation, states, 1. The interdisciplinary team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident. Number 7 states, The comprehensive, person-centered care plan: a. Includes measurable objectives and timeframe's; b. describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. c. Includes the resident's stated goals upon admission and desired outcomes; d. Builds on the resident's strengths; and e. Reflects currently recognized standards of practice for problem areas and conditions. Number 9 states, Care plan interventions are chosen only after data gathering, proper sequencing of events, careful consideration of the relationship between the resident's problem areas and their causes, and relevant clinical decision making. Number 11 states, Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change. The facility admitted R78 with diagnoses including, but not limited to, psychosis, neuropathy of the right hand, dementia, cerebrovascular accident, osteoarthritis, anxiety and behaviors. Review on 02/22/23 at 12:25 PM of the medical record for R78 revealed a Certified Nursing Assistant (CNA) plan of care which indicated R78 was to be assisted with all activities of daily living by 2 persons. Must have 2 CNAs providing care at all times. Review on 02/22/23 at 1:12 PM of the medical record for R78, a plan of care dated 11/29/22 revealed no documentation to include the 2 person assist at all times when providing care. R78 has dementia with behaviors and a history of falls one in which he received a laceration to his forehead. Only one staff member was providing care when R78 fell out of bed and his head hit the bedside dresser. An interview on 02/24/23 at 1:03 PM with Licensed Practical Nurse (LPN)2, the North Hall Manager confirmed that R78 was a 2 person assist and had been since 08/17/22, when he was moved from the East Wing to the North Wing. An interview on 02/23/23 at 1:32 PM with Registered Nurse (RN)1 confirmed that the comprehensive plan of care for R78 did not include 2 person assist with activities of daily living. The facility admitted R32 with diagnoses including, but not limited to, nontraumatic subarachnoid hemorrhage, altered mental status, aggressive behaviors, dementia, convulsions and epilepsy. Review on 02/27/23 at 11:29 AM of the medical record for R32 revealed a comprehensive plan of care dated 12/21/22. The comprehensive plan of care did not include goals and interventions to include convulsions/seizures or epilepsy. An interview on 2/27/23 at 1:32 PM with RN1 confirmed that the comprehensive plan of care for R32 did not include convulsions, seizure nor epilepsy. The Care Plan Coordinator was not available for interview.

Based on interview, record review, and review of the facility's abuse policy, the facility failed to protect Resident #1 (R#1) from physical abuse by Certified Nursing Assistant #1 (CNA #1) for 1 of 1 reportables reviewed for abuse. Findings include: The facility submitted a 2-hour reportable to the South Carolina state agency on June 9, 2021 alleging CNA #1 had physically abused R#1 by pushing him/her down to the floor. Review of the 5-day report submitted to the state agency on June 14, 2021 indicated the facility substantiated CNA #1 had indeed pushed R#1 to the floor, which resulted in him/her obtaining an injury. Record review on June 24, 2021 at 11:15 am indicated R#1 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set, Brief Interview of Mental Status, R#1 scored a 99, indicating the resident was not cognitively intact. Review of x-ray results taken at the hospital on 6/9/2021 of the left hand indicated R#1 had a fracture in the distal radius and ulna. Review of the Police report dated 6/9/2021 at 20:50 indicated the responding Law Enforcement Officer ([NAME]) obtained a written statement from CNA #1 dated 6/9/2021 at 9:06 pm, which read, I was walking through the day room when (another resident's name) started pointing and yelling, S/he's in there!. I followed to where s/he was pointing and saw R#1 heading towards CNA #2 with his/her pants down. CNA #2 started telling him/her to turn around and I walked in and was trying to redirect him/her to the bathroom across the hall. As I was turning to get his/her paints up, R#1 swung at me then towards CNA #2 to attack him/her. CNA #3 then came from behind him/her as s/he was attempting to swing and s/he got off balance and fell . I was only in the room to help or assist. I was not there to hurt or cause harm to anyone. I have been working here since mid 2000s (2006-). I have never had a problem or an event that as founded as abuse. Additional findings on the police report indicated by the [NAME], Due to R#1's diminished mental state and no malicious intent to cause any harm to the resident by CNA #1, probable cause does not exist to believe that any crime of assault took place, therefore, no charges will be sought at this time . I informed CNA #1 that the DON requested s/he leave the premises and stood by while s/he gathered his/her belongings to leave. S/he provided a written, voluntary statement and left the premise without incident. On 6/24/2021, multiple attempts were made at 11:55 am, 1:00 pm, 1:45 pm and 2:30 pm via telephone to contact CNA #1 with no success. On 6/24/2021 at 12:41 pm, an interview with Licensed Practical Nurse (LPN) #1 revealed on 6/9/2021, R#1 has been walking around the unit with staff all day. S/he heard a staff member say, I got him, so s/he continued to pass medications. Meanwhile, s/he saw R#1 go into an empty room, unknowing that another staff member was in the room. S/he then saw CNA #1 enter the room and heard someone else saying, No, the bathroom is this way. LPN #1 then heard screaming and went to see what was happening. When s/he arrived, R#1 was on the ground holding up his/her arm and CNA #1 stated, S/he tried to punch me, I moved out of the way and s/he fell on his/her arm. LPN #1 then assessed R#1 for any other injuries, attempted to ice the arm, R#1 refused, called the Director of Nursing and the on-call provider. an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . LPN #1 contacted R#1's responsible party to alert them what had happened. S/he had noticed CNA #1 hanging around, but then did not see him/her anymore. After the incident, another LPN stated, CNA #2 came to him/her and stated R#1 had not actually fallen but was pushed by CNA #1. When asked if s/he had ever witnessed R#1 hit anyone, s/he replied s/he had only witnessed attempts, but never successful. However, s/he had never witnessed CNA #1 aggressive with any other staff or residents. When asked if s/he had been questioned by the responding [NAME] for a witness statement, s/he stated, no. An interview attempt was made to contact the responding [NAME] on 6/24/2021 at 1:27 pm. Upon contacting the local Sherriff's office, the secretary stated the [NAME] worked night shift and was sleep, so s/he could not provide a telephone number, only an email address. An email was sent requesting the [NAME] contact the State Agency with no success. During a telephone interview with CNA #3 on 6/24/2021 at 1:56 pm, s/he stated, I was coming out a room from doing patient care and heard R#1 raising his/her voice, while CNA #1 was raising theirs. I got R#1 to turn around and come with me so I could assist him/her to the restroom and that is when CNA #1 slapped R#1 on the butt like a child and jerked his/her pants up. At this time, R#1 turned around and started punching in the air. CNA #1 began cussing and antagonizing R#1, while CNA #2 was yelling for him/her to stop. R#1 turned around again to follow me out and that is when CNA #1 pushed him/her down and said, That's what you get. When LPN #1 arrived, CNA #1 was overtalking R#1 and said that s/he had fallen while trying to hit staff. When asked if [NAME] had obtained a witness statement from him/her, s/he replied, no. S/he also stated, R#1 does like to wander, so we typically just walk behind him/her at a close enough distance to give him/her space, but also to prevent a fall or injury from occurring. During an interview with LPN #2 on 6/24/2021 at 2:31 pm, s/he stated, It happened during change of shift. When I arrived to work, R#1 was being sent out to the hospital. I received a call from R#1's responsible party asking what had happened and I explained to him/her that I did not know and that they could call in the morning to speak to the DON. During an interview with CNA #4 on 6/24/2021 at 2:44 pm, s/he stated they did not witness the incident, but had only heard about it and began obtaining statements based on the directions of the DON so that it could be reported timely to DHEC. S/he ensured [NAME] escorted CNA #1 off the property and that all other staff and residents were safe. An interview with CNA #2 on 6/24/2021 at 3:00 pm revealed, I went into an empty room to make a phone call and R#1 followed me in the room stating s/he had to use the restroom. S/he attempted to urinate, that is when CNA #1 came in yelling at R#1. I told CNA #1 to leave R#1 alone and that I would clean it up. That is when s/he pushed him/her down. When asked if s/he had been questioned by the [NAME], s/he stated, no. S/he also stated CNA #1 stated to him/her, I was trying to protect you, but that's alright, I got you. Multiple other staff and residents were interviewed with no concerns related to abuse by CNA #1. The interviewed residents stated they often request him/her as their aide because of his/her kindness. Review of the grievance logs from January 2021 to June 2021 indicated no concerns noted from residents, staff, and/or family regarding concerns with abuse. Review of the Resident Council minutes from January 2021 to June 2021 also indicated no concerns related to abuse. Review of R#1's care plan dated 3/18/2021 indicated a problem area of mood and behaviors. It stated, I have dementia that is advanced with behaviors. I will urinate in random places in my room instead of going to the bathroom . The documented approaches are to make sure my behaviors are monitored and noted in my records at least daily including inventions, possible causes, etc., attempt to get me to do ADLs care including shower and changing clothes more than once if I refuse, give me extra time to complete daily tasks and have conversations . Review of the facility's abuse policy indicates, Elder Abuse involves, physical abuse- use of physical force that may result in bodily injury, physical pain, or impairment. Review of CNA #1's employee file that is kept for all agency staff indicated, s/he had received formal training on abuse for the elderly. A background check was reviewed and did not show any adverse findings or allegations against CNA #1.

Based on interview and record review, the Certified Nursing Assistant (CNA) #1 failed to follow the care plan of Resident (R) #1 related to behaviors, which resulted in R#1 being physically abused by CNA #1. Findings include: The facility submitted a 2-hour reportable to the South Carolina state agency on June 9, 2021 alleging CNA #1 had physically abused R#1 by pushing him/her down to the floor. Review of the 5-day report submitted to the state agency on June 14, 2021 indicated the facility substantiated CNA #1 had indeed pushed R#1 to the floor, which resulted in him/her obtaining an injury. Record review on June 24, 2021 at 11:15 am indicated R#1 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set, Brief Interview of Mental Status, R#1 scored a 99, indicating the resident was not cognitively intact. Review of x-ray results taken at the hospital on 6/9/2021 of the left hand indicated R#1 had a fracture in the distal radius and ulna. Review of the Police report dated 6/9/2021 at 20:50 indicated the responding Law Enforcement Officer ([NAME]) obtained a written statement from CNA #1 dated 6/9/2021 at 9:06 pm, which read, I was walking through the day room when (another resident's name) started pointing and yelling, S/he's in there!. I followed to where s/he was pointing and saw R#1 heading towards CNA #2 with his/her pants down. CNA #2 started telling him/her to turn around and I walked in and was trying to redirect him/her to the bathroom across the hall. As I was turning to get his/her paints up, R#1 swung at me then towards toward CNA #2 to attack him/her. CNA #3 then came from behind him/her as s/he was attempting to swing and s/he got off balance and fell . I was only in the room to help or assist. I was not there to hurt or cause harm to anyone. I have been working here since mid 2000s (2006-). I have never had a problem or an event that as founded as abuse. On 6/24/2021, multiple attempts were made at 11:55 am, 1:00 pm, 1:45 pm and 2:30 pm via telephone to contact CNA #1 with no success. On 6/24/2021 at 12:41 pm, an interview with Licensed Practical Nurse (LPN) #1 revealed on 6/9/2021, R#1 has been walking around the unit with staff all day. S/he heard a staff member say, I got him, so s/he continued to pass medications. Meanwhile, s/he saw R#1 go into an empty room, unknowing that another staff member was in the room. S/he then saw CNA #1 enter the room and heard someone else saying, No, the bathroom is this way. LPN #1 then heard screaming and went to see what was happening. When s/he arrived, R#1 was on the ground holding up his/her arm and CNA #1 stated, S/he tried to punch me, I moved out of the way and s/he fell on his/her arm. LPN #1 then assessed R#1 for any other injuries, attempted to ice the arm, R#1 refused, called the Director of Nursing and the on-call provider. an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . LPN #1 contacted R#1's responsible party to alert them what had happened. S/he had noticed CNA #1 hanging around, but then did not see him/her anymore. After the incident, another LPN stated, CNA #2 came to him/her and stated R#1 had not actually fallen but was pushed by CNA #1. When asked if s/he had ever witnessed R#1 hit anyone, s/he replied s/he had only witnessed attempts, but never successful. However, s/he had never witnessed CNA #1 aggressive with any other staff or residents. When asked if s/he had been questioned by the responding [NAME] for a witness statement, s/he stated, no. An interview attempt was made to contact the responding [NAME] on 6/24/2021 at 1:27 pm. Upon contacting the local Sherriff's office, the secretary stated the [NAME] worked night shift and was sleep, so s/he could not provide a telephone number, only an email address. An email was sent requesting the [NAME] contact the State Agency with no success. During a telephone interview with CNA #3 on 6/24/2021 at 1:56 pm, s/he stated, I was coming out a room from doing patient care and heard R#1 raising his/her voice, while CNA #1 was raising theirs. I got R#1 to turn around and come with me so I could assist him/her to the restroom and that is when CNA #1 slapped R#1 on the butt like a child and jerked his/her pants up. At this time, R#1 turned around and started punching in the air. CNA #1 began cussing and antagonizing R#1, while CNA #2 was yelling for him/her to stop. R#1 turned around again to follow me out and that is when CNA #1 pushed him/her down and said, That's what you get. When LPN #1 arrived, CNA #1 was overtalking R#1 and said that s/he had fallen while trying to hit staff. When asked if [NAME] had obtained a witness statement from him/her, s/he replied, no. S/he also stated, R#1 does like to wander, so we typically just walk behind him/her at a close enough distance to give him/her space, but also to prevent a fall or injury from occurring. An interview with CNA #2 on 6/24/2021 at 3:00 pm revealed, I went into an empty room to make a phone call and R#1 followed me in the room stating s/he had to use the restroom. S/he attempted to urinate, that is when CNA #1 came in yelling at R#1. I told CNA #1 to leave R#1 alone and that I would clean it up. That is when s/he pushed him/her down. When asked if s/he had been questioned by the [NAME], s/he stated, no. S/he also stated CNA #1 stated to him/her, I was trying to protect you, but that's alright, I got you. Review of R#1's care plan dated 3/18/2021 indicated a problem area of mood and behaviors. It stated, I have dementia that is advanced with behaviors. I will urinate in random places in my room instead of going to the bathroom . The documented approaches are to make sure my behaviors are monitored and noted in my records at least daily including inventions, possible causes, etc., attempt to get me to do ADLs care including shower and changing clothes more than once if I refuse, give me extra time to complete daily tasks and have conversations . During an interview with the Director of Nursing on 6/24/2021 at 3:30 pm, s/he confirmed CNA #1 did not follow the care plan or training provided in dealing with patients with dementia. S/he stated, R#1 should have been left alone if redirection was unsuccessful and approached at a later time.

Based on observations, interviews and record reviews, the facility staff failed to report a fall, delaying timely intervention, for one (Resident #1) of three sampled residents. Resident #1 sustained a distal femoral fracture as a result of the fall.The findings included: The annual Minimum Data Set (MDS), dated [DATE], indicated Resident #1's cognition was severely impaired, and s/he was totally dependent on staff for bed mobility, transfer, dressing, personal hygiene and toileting. The MDS also indicated Resident #1 had upper and lower extremity impairment (contractures) on both sides of her/his hands and arms. The MDS and the Care Area Assessment (CAA) did not indicate Resident #1 exhibited any behaviors of resisting care. Resident #1's care plan, updated on 04/02/2020, indicated Resident #1 had problems which included, activity of daily living (ADL) self-care performance deficit due to impaired mobility, left femoral fracture and decreased mobility. The goals were measurable. The interventions included: Resident #1 requires maximum staff assistance with transfers (a mechanical lift with 2-person transfer), s/he requires bed bolsters (long narrow pillow used for support). Resident #3, who was Resident #1's roommate, had a quarterly MDS, dated [DATE], that indicated the resident's cognition was intact. The resident had no behavioral symptoms noted. Review of the weekly body audit for Resident #1 beginning 05/04/2020 until 05/25/2020 revealed no new areas of concern. Review of restorative treatment record for the month of May 2020 revealed Resident #1 received range of motion on 05/27/2020 and 05/29/2020. Resident did not indicate any increased pain. Restorative note, dated 06/04/2020, revealed an attempt was made to do passive range of motion on the resident. The note indicated Resident #1 hit the Restorative Aide's (RA) hand due to pain in her/his left leg and yelled. The restorative aide stopped and reported her observation of the resident's pain to the nurse. A nurse's note, dated 06/04/2020, revealed the Director of Nursing (DON) was informed by Registered Nurse (RN) #1 that there was an unreported incident involving Resident #1 and two staff members, Licensed Practical Nurse (LPN) #2 and Certified Nurse Aide (CNA) #1. RN #1 gave the details to the DON that RA went to do therapy on Resident #1 and felt that Resident #1's leg looked more swollen than usual and he appeared to have increased pain. Resident #3, who was Resident #1's roommate, said to the RA that the resident had been dropped on Sunday 05/24/2020. The staff involved were LPN #2 and CNA #1. Review of the note further indicated the assessment of Resident #1 revealed the resident always had [MEDICAL CONDITION] of left extremity but the [MEDICAL CONDITION] was more than usual. The assessment also indicated the resident always had chronic pain with movement, but pain was more pronounced. The nurse indicated no other bruising or injury was noted by visual assessment. The Nurse Practitioner (NP) was notified and order for an x-ray was obtained. A review of the radiology report for Resident #1, dated 06/04/2020, revealed a distal femoral fracture. A review of the Medication Administration Record [REDACTED]. Review of the incident report, dated 06/04/2020, revealed Resident #1 was total care and transfer dependent using the mechanical lift. S/he was non-ambulatory and required a Broda chair (a high-backed wheelchair that can be tilted-in-space for positioning) when out of bed. Chronic [MEDICAL CONDITION] and pain in the left extremity were ongoing. S/he required two people for assistance and care. S/he received restorative therapy as ordered without any changes in plan until 06/04/2020. Resident #1 was yelling in a lot of pain during passive range of motion (PROM) provided by the RA. Resident #3 reported to the RA that s/he observed Resident #1 fall during incontinent care. S/he stated to the RA that LPN #2 and CNA #1 were in the room on 05/24/2020 between 4:00 PM and 4:30 PM rendering care. CNA #1 turned Resident #1 towards LPN #2, the bed bolsters moved, and the resident rolled out of bed onto her/his left side then rolled onto her/his back. They left the room and returned with the mechanical lift and used it to get Resident #1 off the floor and hit her/his knees on the bottom of the bed while getting her/him up. The incident report indicated no one was notified of the incident as per policy, no incident report was completed at the time of the incident, nothing was documented, and no notifications were made. Both LPN #2 and CNA #1 did not write any statements concerning the incident. They resigned on 05/25/2020 before Resident #1's fracture was discovered. The incident was witnessed by Resident #3 who was under the assumption that the two employees had reported it. The incident was never documented or reported by the two staff members. Review of the incident report, dated 06/04/2020, concluded both LPN #2 and CNA #1 failed to follow facility policy in caring for Resident #1 regarding fall prevention and resident safety. Both were negligent in the resident's care and the management of the fall. They never informed anyone of the fall or striking her/his knees on the bed while using the lift. Both returned to work as scheduled on 05/25/2020 and continued to leave the incident unreported. Both abruptly left their employment at the facility on 05/25/2020. The incident went unreported until 06/04/2020 when the RA observed an increase in [MEDICAL CONDITION] of the left extremity with an increase in pain that was not observed prior to the date of 06/04/2020 when the incident was reported by Resident #3. A physician's orders [REDACTED]. [MEDICATION NAME] 5 mg (milligrams) tab per gastric tube ([DEVICE]) every six hours was ordered to control the resident's pain. Physician's note, dated 06/08/2020, revealed an x-ray was ordered of the left hip and knee and showed a distal femur fracture. Resident #1 had pain and [MEDICAL CONDITION] in her/his left leg. The [DIAGNOSES REDACTED]. The note indicated the resident would follow-up with orthopedics. S/he scheduled his [MEDICATION NAME] 5 mg every six hours for pain control. During an interview on 06/15/2020 at 12:13 PM, the physician reported s/he was notified of Resident #1's fall on 06/04/2020 and s/he ordered an x-ray. S/he reported the results came back as a distal femoral fracture. The physician stated s/he could not explain the reason the fracture was not discovered before 06/04/2020. S/he reported the resident had chronic [MEDICAL CONDITION] and pain in her/his leg which could have masked the pain caused by the fracture on her/his leg. S/he reported the resident was started on pain medication and an orthopedic appointment was made. S/he reported the resident was not sent to the emergency room (ER) due to the duration of the time which had passed since the fracture occurred. S/he also stated the family also declined to send the resident to the ER. During an interview on 06/15/2020 at 12:20 PM, RN #1 stated the RA reported to her on 06/04/2020 that Resident #3 observed Resident #1 fall on the floor during incontinent care. The care was being provided by two staff members LPN #2 and CNA #1. S/he reported since 05/24/2020, no incident of fall of Resident #1 had been reported. RN #1 reported s/he completed an assessment of Resident #1's left knee on 06/04/2020 and noticed it was swollen more than usual and the resident was also in more pain than usual. RN #1 stated the doctor was notified about the findings of the assessment. The physician ordered an x-ray. The results came back as a distal femoral fracture. During an interview on 06/15/2020 at 1:30 PM, the RA reported Resident #1 received passive range of motion twice a week for the past two months. S/he reported Resident #1 always had chronic pain in her/his legs and hands. The RA reported on 06/04/2020 the resident had more pain in her/his left leg than usual. Resident #1 hit her/his arm as s/he was getting ready to touch her/his left leg to start her/his exercises. S/he noticed more swelling on the left leg that usual. S/he stopped the exercises. Resident #3 then reported to her/his that he observed Resident #1 fall while two staff members CNA #1 and LPN #2 were providing incontinent care. The RA stated s/he reported Resident #3's observations of the fall to RN #1 who completed an assessment on the resident's left leg. During an interview on 06/15/2020 at 2:00 PM, the DON stated s/he started an investigation on 06/04/2020 in reference to Resident #1's injury of unknown origin. S/he said it was reported to her that Resident #3 observed LPN #2 and CNA #1 drop Resident #1 on the floor during the incontinent care. The DON reported s/he completed the investigation of Resident #1's left knee on 06/04/2020. S/he said her conclusion was both LPN #2 and CNA #1 failed to follow facility policy in caring for Resident #1 regarding fall prevention and resident safety. The DON reported both staff members to the Nursing Board and Nurse Aide registry that they were negligent in the resident's care and the management of the fall. The DON further indicated both staff members abruptly left their employment on 05/25/2020 before they gave any statements. The DON stated s/he completed the 24-hour report and faxed the information to state agency on 06/05/2020, and 5-day report was completed and faxed on 06/10/2020. S/he reported that all the staff at the facility had been in-serviced in reference to immediately reporting incidents of accidents and making sure during incontinent care they make all adjustments and take all precautions prior to moving residents for their safety. During an interview on 06/15/2020 at 2:30 PM, the Administrator reported LPN #2 and CNA #1 failed to immediately report the incident of a fall which happened on 05/24/2020. S/he expected all the staff to immediately notify a supervisor about any incidents of falls. Resident #3 was unavailable for an interview. Observation on 06/15/2020 at 11:30 AM of the resident revealed s/he was in his room asleep. Her/His eyes were closed. LPN #2 and CNA #1 were called by phone, but they did not return the phone calls. Both staff terminated their employment with the facility on 05/25/2020. Corrective action for past noncompliance dated 06/15/20: How the corrective action will be accomplished for the resident affected: Resident #1 was total care and transfer dependent using the mechanical lift. S/he was non-ambulatory and required a Broda chair when out of bed. Chronic [MEDICAL CONDITION] and pain in the left extremity were ongoing. S/he required two people for assistance and care. He received restorative therapy as ordered without any changes in plan until 06/04/2020. Per Resident #3, LPN #2 and CNA #1 were in the room on 05/24/2020 between 4:00 PM and 4:30 PM rendering care. CNA #1 turned Resident #1 towards LPN #2, the bed bolsters moved, and s/he rolled out of bed onto his left side then rolled onto her/his back. Resident #1 incident was reported to RN #1 and assessment findings were documented and Nurse Practitioner (NP) notified. X-ray of the leg was ordered. Pain medication was ordered by Physician. How corrective action will be accomplished for those residents with the potential to be affected by the same practice: Review of other residents that could be potentially affected was completed 06/05/2020. No other residents were identified as being affected by the deficient practice. No other residents had any change in mobility, discolorations, acute [MEDICAL CONDITION] of extremities or increase in ortho pain. No other incidents were reported. - fall checklist to be initiated by nurse. -Complete incident reports -Complete form indicating fall/found on a floor report -Completing of fall intervention or potential high risk for falls- 06/05/2020 Measures in place to ensure practices will not occur: All staff was educated on Abuse and Neglect, Reporting Requirements and Reporting time frames. All direct care staff were educated on: Bed Bolster application and management, turning of residents. Lift use and resident safety during lift use and Fall Management. All nurses were educated on the completion of the Incident Report and Fall Management. Alert and oriented residents were educated on the immediate reporting of incidents they witness. Stressed that everyone is responsible for reporting. Care plan was reviewed.06/15/2020 How the facility plans to monitor and ensure correction is achieved and sustained: Activities staff will assist in checking with alert and oriented residents three times a week for six weeks for any incidents that they witnessed and check on reporting status. Body audits will be completed weekly and reviewed by charge nurse weekly for six weeks. Random bed bolster audits will be conducted three times a week for six weeks by the RN-Supervisor. Random lift use observations will be conducted three times a week for six weeks by charge nurse or RN Supervisor Findings of all audits will be reported to QAA and QAPI committee at next monthly meetings -06/10/2020 - ongoing As part of the validation process on 06/15/2020, the entire plan of correction was reviewed including re-education of staff and observations of Resident #1 being turned and repositioned during incontinent care at the facility. Interviews with the certified nurse aides and nurses revealed they were aware of checking safety parameters for residents and making sure all adjustments were made prior to moving residents. A review of the monitoring tools revealed that the facility had completed 100% of the in-service on 06/15/2020.

Based on observations, interviews and record reviews, the facility failed to ensure residents were safely turned and repositioned during incontinent care, resulting in a fall for one (Resident #1) of three sampled residents reviewed for accidents. As a result, the resident sustained [REDACTED]. The annual Minimum Data Set (MDS), dated [DATE], indicated Resident #1's cognition was severely impaired, and he was totally dependent on staff for bed mobility, transfer, dressing, personal hygiene and toileting. The MDS also indicated Resident #1 had upper and lower extremity impairment (contractures) on both sides of her/his hands and arms. The MDS and the Care Area Assessment (CAA) did not indicate Resident #1 exhibited any behaviors of resisting care. Resident #1's care plan, updated on 04/02/2020, indicated Resident #1 had problems which included, activity of daily living (ADL) self-care performance deficit due to impaired mobility, left femoral fracture and decreased mobility. The goals were measurable. The interventions included: Resident #1 requires maximum staff assistance with transfers (a mechanical lift with 2-person transfer), he requires bed bolsters (long narrow pillow used for support). Resident #3, who was Resident #1's roommate, had a quarterly MDS, dated [DATE], that indicated the resident's cognition was intact. The resident had no behavioral symptoms noted. Review of the weekly body audit for Resident #1 beginning 05/04/2020 until 05/25/2020 revealed no new areas of concern. Review of restorative treatment record for the month of May 2020 revealed Resident #1 received range of motion on 05/27/2020 and 05/29/2020. Resident did not indicate any increased pain. Restorative note, dated 06/04/2020, revealed an attempt was made to do passive range of motion on the resident. The note indicated Resident #1 hit the Restorative Aide's (RA) hand due to pain in her/his left leg and yelled. The restorative aide stopped and reported her/his observation of the resident's pain to the nurse. A nurse's note, dated 06/04/2020, revealed the Director of Nursing (DON) was informed by Registered Nurse (RN) #1 that there was an unreported incident involving Resident #1 and two staff members, Licensed Practical Nurse (LPN) #2 and Certified Nurse Aide (CNA) #1. RN #1 gave the details to the DON that RA went to do therapy on Resident #1 and felt that Resident #1's leg looked more swollen than usual and he appeared to have increased pain. Resident #3, who was Resident #1's roommate, said to the RA that the resident had been dropped on Sunday 05/24/2020. The staff involved were LPN #2 and CNA #1. Review of the note further indicated the assessment of Resident #1 revealed the resident always had [MEDICAL CONDITION] of left extremity but the [MEDICAL CONDITION] was more than usual. The assessment also indicated the resident always had chronic pain with movement, but pain was more pronounced. The nurse indicated no other bruising or injury was noted by visual assessment. The Nurse Practitioner (NP) was notified and order for an x-ray was obtained. A review of the radiology report for Resident #1, dated 06/04/2020, revealed a distal femoral fracture. A review of the Medication Administration Record [REDACTED]. Review of the incident report, dated 06/04/2020, revealed Resident #1 was total care and transfer dependent using the mechanical lift. He was non-ambulatory and required a Broda chair (a high-backed wheelchair that can be tilted-in-space for positioning) when out of bed. Chronic [MEDICAL CONDITION] and pain in the left extremity were ongoing. He required two people for assistance and care. He received restorative therapy as ordered without any changes in plan until 06/04/2020. Resident #1 was yelling in a lot of pain during passive range of motion (PROM) provided by the RA. Resident #3 reported to the RA that he observed Resident #1 fall during incontinent care. He stated to the RA that LPN #2 and CNA #1 were in the room on 05/24/2020 between 4:00 PM and 4:30 PM rendering care. CNA #1 turned Resident #1 towards LPN #2, the bed bolsters moved, and the resident rolled out of bed onto her/his left side then rolled onto her/his back. They left the room and returned with the mechanical lift and used it to get Resident #1 off the floor and hit her/his knees on the bottom of the bed while getting him up. The incident report indicated no one was notified of the incident as per policy, no incident report was completed at the time of the incident, nothing was documented, and no notifications were made. Both LPN #2 and CNA #1 did not write any statements concerning the incident. They resigned on 05/25/2020 before Resident #1's fracture was discovered. The incident was witnessed by Resident #3 who was under the assumption that the two employees had reported it. The incident was never documented or reported by the two staff members. Review of the incident report, dated 06/04/2020, concluded both LPN #2 and CNA #1 failed to follow facility policy in caring for Resident #1 regarding fall prevention and resident safety. Both were negligent in the resident's care and the management of the fall. They never informed anyone of the fall or striking her/his knees on the bed while using the lift. Both returned to work as scheduled on 05/25/2020 and continued to leave the incident unreported. Both abruptly left their employment at the facility on 05/25/2020. The incident went unreported until 06/04/2020 when the RA observed an increase in [MEDICAL CONDITION] of the left extremity with an increase in pain that was not observed prior to the date of 06/04/2020 when the incident was reported by Resident #3. A physician's orders [REDACTED]. [MEDICATION NAME] 5 mg (milligrams) tab per gastric tube ([DEVICE]) every six hours was ordered to control the resident's pain. Physician's note, dated 06/08/2020, revealed an x-ray was ordered of the left hip and knee and showed a distal femur fracture. Resident #1 had pain and [MEDICAL CONDITION] in her/his left leg. The [DIAGNOSES REDACTED]. The note indicated the resident would follow-up with orthopedics. He scheduled her/his [MEDICATION NAME] 5 mg every six hours for pain control. During an interview on 06/15/2020 at 12:13 PM, the physician reported he was notified of Resident #1's fall on 06/04/2020 and he ordered an x-ray. He reported the results came back as a distal femoral fracture. The physician stated he could not explain the reason the fracture was not discovered before 06/04/2020. He reported the resident had chronic [MEDICAL CONDITION] and pain in her/his leg which could have masked the pain caused by the fracture on her/his leg. He reported the resident was started on pain medication and an orthopedic appointment was made. He reported the resident was not sent to the emergency room (ER) due to the duration of the time which had passed since the fracture occurred. He also stated the family also declined to send the resident to the ER. During an interview on 06/15/2020 at 12:20 PM, RN #1 stated the RA reported to her/his on 06/04/2020 that Resident #3 observed Resident #1 fall on the floor during incontinent care. The care was being provided by two staff members LPN #2 and CNA #1. She reported since 05/24/2020, no incident of fall of Resident #1 had been reported. RN #1 reported she completed an assessment of Resident #1's left knee on 06/04/2020 and noticed it was swollen more than usual and the resident was also in more pain than usual. RN #1 stated the doctor was notified about the findings of the assessment. The physician ordered an x-ray. The results came back as a distal femoral fracture. During an interview on 06/15/2020 at 1:30 PM, the RA reported Resident #1 received passive range of motion twice a week for the past two months. She reported Resident #1 always had chronic pain in her/his legs and hands. The RA reported on 06/04/2020 the resident had more pain in her/his left leg than usual. Resident #1 hit her/his arm as she was getting ready to touch her/his left leg to start her/his exercises. She noticed more swelling on the left leg that usual. She stopped the exercises. Resident #3 then reported to her/his that he observed Resident #1 fall while two staff members CNA #1 and LPN #2 were providing incontinent care. The RA stated she reported Resident #3's observations of the fall to RN #1 who completed an assessment on the resident's left leg. Observation of Resident #1 on 06/15/2020 at 1:50 PM revealed two staff members in the resident's room assisting with repositioning the resident. No concerns were identified. During an interview on 06/15/2020 at 2:00 PM, the DON stated she started an investigation on 06/04/2020 in reference to Resident #1's injury of unknown origin. She said it was reported to her/his that Resident #3 observed LPN #2 and CNA #1 drop Resident #1 on the floor during the incontinent care. The DON reported she completed the investigation of Resident #1's left knee on 06/04/2020. She said her/his conclusion was both LPN #2 and CNA #1 failed to follow facility policy in caring for Resident #1 regarding fall prevention and resident safety. The DON reported both staff members to the Nursing Board and Nurse Aide registry that they were negligent in the resident's care and the management of the fall. The DON further indicated both staff members abruptly left their employment on 05/25/2020 before they gave any statements. The DON stated she completed the 24-hour report and faxed the information to state agency on 06/05/2020, and 5-day report was completed and faxed on 06/10/2020. She reported that all the staff at the facility had been in-serviced in reference to immediately reporting incidents of accidents and making sure during incontinent care they make all adjustments and take all precautions prior to moving residents for their safety. During an interview on 06/15/2020 at 2:30 PM, the Administrator reported LPN #2 and CNA #1 failed to immediately report the incident of a fall which happened on 05/24/2020. He expected all the staff to immediately notify a supervisor about any incidents of falls. Resident #3 was unavailable for an interview. Observation on 06/15/2020 at 11:30 AM of the resident revealed he was in her/his room asleep. Her/his eyes were closed. LPN #2 and CNA #1 were called by phone, but they did not return the phone calls. Both staff terminated their employment with the facility on 05/25/2020. Corrective action for past noncompliance dated 06/15/2020: How the corrective action will be accomplished for the resident affected: Resident #1 was total care and transfer dependent using the mechanical lift. He was non-ambulatory and required a Broda chair when out of bed. Chronic [MEDICAL CONDITION] and pain in the left extremity were ongoing. He required two people for assistance and care. He received restorative therapy as ordered without any changes in plan until 06/04/2020. Per Resident #3, LPN #2 and CNA #1 were in the room on 05/24/2020 between 4:00 PM and 4:30 PM rendering care. CNA #1 turned Resident #1 towards LPN #2, the bed bolsters moved, and he rolled out of bed onto her/his left side then rolled onto her/his back. Resident #1 incident was reported to RN #1 and assessment findings were documented and Nurse Practitioner (NP) notified. X-ray of the leg was ordered. Pain medication was ordered by Physician. How corrective action will be accomplished for those residents with the potential to be affected by the same practice: Review of other residents that could be potentially affected was completed 06/05/2020. No other residents were identified as being affected by the deficient practice. No other residents had any change in mobility, discolorations, acute [MEDICAL CONDITION] of extremities or increase in ortho pain. No other incidents were reported. - fall checklist to be initiated by nurse. -Complete incident reports -Complete form indicating fall/found on a floor report -Completing of fall intervention or potential high risk for falls- 06/05/2020 Measures in place to ensure practices will not occur: All staff was educated on Abuse and Neglect, Reporting Requirements and Reporting time frames. All direct care staff were educated on: Bed Bolster application and management, turning of residents. Lift use and resident safety during lift use and Fall Management. All nurses were educated on the completion of the Incident Report and Fall Management. Alert and oriented residents were educated on the immediate reporting of incidents they witness. Stressed that everyone is responsible for reporting. Care plan was reviewed.06/15/2020 How the facility plans to monitor and ensure correction is achieved and sustained: Activities staff will assist in checking with alert and oriented residents three times a week for six weeks for any incidents that they witnessed and check on reporting status. Body audits will be completed weekly and reviewed by charge nurse weekly for six weeks. Random bed bolster audits will be conducted three times a week for six weeks by the RN-Supervisor. Random lift use observations will be conducted three times a week for six weeks by charge nurse or RN Supervisor Findings of all audits will be reported to QAA and QAPI committee at next monthly meetings -06/10/20 - ongoing As part of the validation process on 06/15/2020, the entire plan of correction was reviewed including re-education of staff and observations of Resident #1 being turned and repositioned during incontinent care at the facility. Interviews with the certified nurse aides and nurses revealed they were aware of checking safety parameters for residents and making sure all adjustments were made prior to moving residents. A review of the monitoring tools revealed that the facility had completed 100% of the in-service on 06/15/2020.

Based on record review, interview and review of facility policy, the facility failed to report a violation involving neglect that resulted in serious bodily injury for Resident #4, 1 of 2 sampled residents reviewed for Accidents/Hazards. Resident #4 fell from the bed while receiving care and sustained a fractured femur. Cross Refer to F656 and F689 The findings included: The facility admitted Resident #4 with [DIAGNOSES REDACTED]. Record review of an Incident/Accident Report on 8/9/2018 at 1:52 PM, revealed on 5/23/2018 at 5:15 AM, Resident #4 fell from the bed while receiving incontinence care from Certified Nursing Assistant (CNA) #5. The report indicated the bed wheels were not in the locked position and the resident fell to the floor while being turned in the bed. The report also indicated the resident had pain and swelling to the right knee and right leg. Orders for x-rays of the right leg were given by the provider. Review of the Radiology Report, dated 5/23/2018, on 8/9/2018 at 3:00 PM, revealed Resident #4 sustained a [MEDICAL CONDITION] right femur. Review of the Resident Information Sheet (CNA care plan) on 8/9/2018 at 2:38 PM, revealed the resident required the assistance of 2 persons for positioning. Review of the Falling Leaf Program Care Plan on 8/9/2018 at 1:52 PM, revealed staff were to ensure to secure locks on beds. Review of the facility's investigation on 8/9/2018 at 3:00 PM, revealed CNA #5 failed to lock the wheels of the bed prior to performing care and failed to get another staff member to assist with turning and positioning the resident. During an interview with the Director of Nursing (DON) on 5/9/2018 at 2:36 PM, the DON stated s/he reported the incident to Licensure, but did not report it to the State Survey Agency. When asked why s/he did not report to the State Survey Agency, the DON stated s/he did not believe the incident rose to the level of neglect because it was an accident and unintentional. The DON also stated CNA #4 had been an outstanding employee the past 4-5 years. Review of the facility's Abuse and Neglect policy revealed when an alleged or suspected case of mistreatment or neglect is reported, the facility Administrator, or his/her designee, will immediately notify the State licensing/certification agency responsible for surveying/licensing the facility.

Based on record review and interview, the facility failed to follow the care plan for Resident #4, 1 of 2 sampled residents reviewed for Accidents/Hazards. While receiving personal care, Resident #4 fell from the bed. The bed wheels were not locked and the resident was not receiving the assistance of 2 persons, per the care plan. Cross Refer to F609 and F689 The findings included: The facility admitted Resident #4 with [DIAGNOSES REDACTED]. Record review of an Incident/Accident Report on 8/9/2018 at 1:52 PM, revealed on 5/23/2018 at 5:15 AM, Resident #4 fell from the bed while receiving incontinence care from Certified Nursing Assistant (CNA) #5. The report indicated the bed wheels were not in the locked position and the resident fell to the floor while being turned in the bed. The report also indicated the resident had pain and swelling to the right knee and right leg. Orders for x-rays of the right leg were given by the provider. Review of the Radiology Report, dated 5/23/2018, on 8/9/2018 at 3:00 PM, revealed Resident #4 sustained a [MEDICAL CONDITION] right femur. Review of the Falling Leaf Program Care Plan on 8/9/2018 at 1:52 PM, revealed staff were to ensure to secure locks on beds. Review of the Resident Information Sheet (CNA care plan) on 8/9/2018 at 2:38 PM, revealed the resident required the assistance of 2 persons for turning and positioning. Review of a written statement, dated 5/23/2018, by CNA #5, revealed while turning the resident during incontinence care, the bed began to roll and the resident fell from the bed. In addition, per the statement, the bed had not been locked. The statement did not indicate CNA #5 had another staff member assisting her/him during the incontinence care. Review of the facility's investigation on on 8/9/2018 at 3:00 PM, revealed CNA #5 failed to lock the wheels of the bed prior to performing care and failed to get another staff member to assist with turning and positioning the resident. During an interview with the Director of Nursing (DON) on 5/9/2018 at 2:36 PM, the DON confirmed the bed wheels were not locked prior to rendering care, per the care plan. The DON also confirmed a 2 person assist was not provided during care per the care plan.

Based on record review, interview and review of facility policy, the facility failed to ensure that Resident #4 received adequate assistance and supervision to prevent accidents, 1 of 2 sampled residents reviewed for Accidents/Hazards. Resident #4 fell from the bed while receiving care and sustained a fractured femur. Cross Refer to F609 and F656 The findings included: The facility admitted Resident #4 with [DIAGNOSES REDACTED]. Record review of an Incident/Accident Report on 8/9/2018 at 1:52 PM, revealed on 5/23/2018 at 5:15 AM, Resident #4 fell from the bed while receiving incontinence care from Certified Nursing Assistant (CNA) #5. The report indicated the bed wheels were not in the locked position and the resident fell to the floor while being turned in the bed. The report also indicated the resident had pain and swelling to the right leg. Record review of the Nurse's Notes on 8/9/2018 at 2:15 PM, revealed on 5/23/2018 the CNA called the nurse and reported the resident fell from bed while providing incontinence care. The resident was complaining of pain to the right knee. Swelling was observed to the right knee. An x-ray was ordered. The resident was transferred to the hospital after receiving the x-ray results. Review of the Radiology Report, dated 5/23/2018, on 8/9/2018 at 3:00 PM, revealed Resident #4 sustained a [MEDICAL CONDITION] right femur. Record review of the provider progress notes on 8/9/2018 at 2:20 PM, revealed a note from 6/1/2018 indicating the resident required surgical intervention to repair the fractured femur. Review of the facility's investigation on 8/9/2018 at 3:00 PM, revealed CNA #5 failed to adhere to resident safe handling. CNA #5 failed to ensure the bed wheels were locked prior to providing care and did not get assistance from another staff member prior to providing incontinence care. In addition, the investigation revealed Resident #4 was considered a total care resident and all total care residents should have 2 staff members assisting during care. Review of the personnel file for CNA #5 on 8/9/2018 at 2:43 PM, revealed no documentation to indicate CNA #5 had received training to carry out her/his duties prior to caring for Resident #4. The file did not reveal any disciplinary action related to resident care. Review of a written statement, dated 5/23/2018, by CNA #5 on 8/9/2018 at 3:00 PM, revealed while s/he was turning the resident during incontinence care, the bed began to roll and the resident fell from the bed. In addition, per the statement, the bed wheels had not been locked. The statement did not indicate CNA #5 had another staff member assisting her/him during the incontinence care. During an interview with the Director of Nursing (DON) on 5/9/2018 at 2:36 PM, the DON confirmed CNA#5 failed to ensure the bed wheels were locked prior to providing incontinence care. The DON also confirmed CNA #5 was providing care without assistance of another staff member. The DON stated it is facility policy to have 2 staff members provide incontinence care for total care residents. The DON stated Resident #4 was considered a total care resident. Regarding the personnel file, the DON stated s/he was certain the facility had provided the appropriate and necessary training and orientation for CNA #5. However, the DON stated the documentation to show this could not be located. The DON stated CNA #5 had been an outstanding employee for many years and had no disciplinary action related to patient care. Review of the facility's Use Of All Lift Devices And Turning of Residents policy revealed: -If your resident is unable to assist you when turning and/or unable to control their body movements, you are required to get the assistance of another person. -If you are unable to get assistance when needed, please inform the nurse. Do not move the resident alone.

Based on review of facility files and interviews, the facility failed to ensure each resident received adequate supervision to prevent accidents. Resident #1 and Resident #2 were noted to have falls while on the Falling Leaf Sitting Program. Resident #1 fell on [DATE] when the Helping Hand staff member sitting with residents left the common area unattended. Resident #2 was found on the floor on 3/9/16 in another resident's room. The CNA responsible for sitting with the residents in the common area had left the area to take a telephone call on his/her cell phone. Two of 2 residents on the Falling Leaf Sitting program reviewed for falls. The findings included: The facility reported a fall with injury for Resident #1 to the State Agency on 11/22/15. The facility investigation indicated Resident #1 fell in the common area on 11/21/15. The resident was scored as a moderate fall risk under the Falling Leaf guidelines. On 11/21/15, Resident #1 was in the common area with other residents who were being observed by a Helping Hand staff member as a part of the unit sitting schedule. The Helping Hand staff member went to the restroom and it was at that time Resident #1 fell . The fall was unwitnessed but the nurse, who was around the corner, heard the resident's alarm and went to investigate and found the resident on the floor. The resident was assessed by the supervisor and it was noted that the bridge of his/her nose was lacerated and discolored. The resident was sent to the hospital for evaluation and the 2 centimeter laceration was closed with Dermabond. The reportable incident also indicated the unit Resident #1 resided on had a sitting schedule for managing the residents with dementia that were at risk for falls. The Helping Hand staff member sitting with the residents went to the restroom without notifying another staff member. Review of Resident #1's Falling Leaf Program Care Plan dated 7/7/15 revealed the resident was a moderate fall risk. Interventions were documented on the care plan and included the Falling Leaf Program. The facility reported a fall with injury for Resident #2 to the State Agency on 3/10/16. The facility investigation indicated Resident #2 was observed on his/her face on the floor on 3/9/16. Resident #2 sustained a discoloration to the left side of his/her face that extended around the eye. Resident #2 had been identified as being at high risk for falls and was placed on the Falling Leaf Sitting program as a Red Leaf resident. Resident #2 ambulated with the use of a merry walker. The Falling Leaf Sitting program was designed to have a clinical staff member in the common area at all times to observe, manage and assist dementia residents in an effort to provide another layer of safety for them. CNA #1 was assigned to be in the common area but failed to fulfill his/her duties. CNA #1 abandoned his/her duties by delegating his/her responsibilities to a nonclinical staff member without approval from the manager or supervisor. CNA #1 told the nonclinical staff member that s/he had an important phone call that s/he had to take while holding his/her cell phone in his/her hand and left the area. The nonclinical staff member reported that CNA #1 was not in the common area during the incident. Another CNA walking down the hall noted Resident #2 in a resident room draped over his/her merry walker between the unit and the bed. Resident #2 had fallen and hit his/her head on the heating and air unit in the room. Review of Resident #2's Falling Leaf Program Care Plan dated 7/23/15 revealed the resident was a high fall risk. Interventions were documented on the care plan and included the Falling Leaf Program and constant observation. Review of the facility's Falling Leaf Program revealed the direct care staff will visually check all residents on the program frequently as determined by the team to ensure safety. Direct care staff is responsible for the resident at all times. When the assigned care giver is unable to safely observe and manage the safety of the resident, the caregiver must do a verbal hand off to another caregiver. Constant supervision is when there is someone who is continuously aware of the resident and is responsible for ensuring their safety. The caregiver may perform other duties within close proximity to the resident. Review of the facility's Sitting Schedule Guidelines revealed A CNA, Helping Hand or LPN MUST be present in the common area with the residents at ALL times. Residents are NEVER to be left unattended for ANY reason. Anyone that is an observer must report off to another observer when leaving the resident for any reason including bathroom breaks, . In an interview with the surveyor on 8/13/16 at approximately 6:00 PM, the Director of Nursing stated Resident #1 was on the North unit where the majority of dementia residents are. The facility started a sitting program, staff can sit in the common area and see all halls on the unit. The facility uses Helping Hands staff members for the program because they are sitting and can redirect residents. The Helping Hands are trained on how to redirect residents. In Resident #1's incident the Helping Hand staff member got up to go to the bathroom. The Helping Hand said s/he just went to the bathroom and thought that was okay. The Helping Hand staff member said s/he wasn't in there any time. The Director of Nursing stated Helping Hand staff members are all full time and have been at the facility for 4-5 years. The Director of Nursing stated the facility uses CNAs, Helping Hand staff members and nurses for the Falling Leaf Sitting program. In an interview with the surveyor on 8/13/16 at approximately 6:10 PM, the Director of Nursing stated Resident #2 was in a merry walker because s/he can walk but is not safe. CNA #1 was sitting at the time of the incident. Another CNA passed a resident's room and saw Resident #2 tipped over on the opposite side of the room. The resident was not in his/her room but another resident's room. The resident was caught in between the bed and the air conditioning unit. The merry walker had flipped over and Resident #2 was hanging on it. Resident #2 hit his/her face during the fall. CNA #1 was assigned to sit with the residents at the time of the incident. CNA #1 stated s/he got up because somebody called about a meal tray from dietary. CNA #1 stated s/he told the charge nurse s/he was going to get a tray. CNA #1 stated Resident #2 was in the common area when s/he left. After investigating the incident, they found out CNA #1's cell phone went off. CNA #1 told a housekeeper it was an important call and s/he was going to take it. CNA #1 got up and walked off. The housekeeper was sitting there and said s/he felt stuck because s/he knew about the program. The housekeeper noticed Resident #2 was not there about the the same time the CNA found him/her on the floor in the resident room and called for help.

On the day of the complaint inspection, based on record review and interviews, the facility failed to ensure that each resident received adequate supervision and assistance devices to prevent accidents. Resident #1 fractured his/her hip while ambulating without a Merry walker. 1 of 1 resident's reviewed for a fall. The findings included: The facility reported an allegation of neglect for Resident #1 related to a fall with a fracture. Review of the facility's Five-Day Follow-Up Report dated 5/20/14 indicated Certified Nurse Aide (CNA) #1 was in Resident #1' room providing care to another resident and observed the resident attempting to ambulate in the room. Resident #1 was to be in a Merry walker when out of bed but was not at this time. CNA #1 stated that s/he verbally reminded the resident to sit down but made no attempt to provide the Merry walker for him/her to use. Resident #1 was left unattended to ambulate in the room while CNA #1 returned his/her attention to another resident. CNA #1 reported that s/he turned around to find Resident #1 in the floor at which time s/he got the nurse. Review of the medical record revealed Resident #1 was admitted to the facility with [DIAGNOSES REDACTED]. Further review of the medical record revealed the Initial Minimum Data Set ((MDS) dated [DATE] coded Resident #1 as having a Brief Interview for Mental Status (BIMS) score of 4. The Initial MDS coded the resident as requiring limited assistance with transfers and supervision with ambulation on the unit. Resident #1 was coded as wandering 1-3 days during the assessment period. Review of Resident #1's care plan revealed at risk for falling related to poor safety awareness was identified as a problem area. Interventions and approaches to this problem area were documented on the care plan and included to give her verbal reminders not to ambulate/ transfer without assistance. Review of the Nurses' Notes dated 5/16/14 indicated Resident #1 was noted lying on the floor between the bed and the wall. Staff reports the resident transferred him/herself from the bed and was up standing looking in his/her closet. The resident was then noted lying on the floor. Staff reports the resident did not call for assistance. Resident #1 complained of back pain and left hip and femur pain. A 2 x 2 centimeter skin tear was noted on the resident's right elbow and a 4 x 2 centimeter skin tear was noted on his/her left elbow. Review of Resident #1's Physician's Telephone Orders dated 3/19/14 indicated the resident may use a Merry Walker ad lib on the neighborhood and nursing staff to monitor. Review of the Physician's Telephone Orders dated 5/16/14 revealed an order for [REDACTED]. Review of the Radiology Report dated 5/16/14 revealed Resident #1 had a left pelvic fracture. Review of the resident's admission History and Physical revealed the resident's functional status indicated s/he was able to ambulate with a Merry walker. Registered Nurse (RN) #1's facility-obtained statement dated 5/16/14 indicated s/he was paged to Resident #1's room. S/he found the resident on the floor by his/her bed. RN #1 assessed the resident for injuries and noted s/he had skin tears to his/her bilateral upper extremities and was complaining his/her back hurt. RN #1 asked CNA #1 what happened. CNA #1 stated s/he was finishing up caring for Resident #1's roommate when Resident #1 got out of the bed and was looking in his/her closet. CNA #1 told the resident to sit down. RN #1 asked CNA #1 why Resident #1 wasn't secured in the Merry walker and CNA #1 made no response. In an interview with the surveyor on 6/23/14 at approximately 11:45 AM, RN #1 stated that CNA #1 was in the room and Resident #1 was lying on the floor. RN #1 stated that Resident #1 was not safe to walk on his/her on. RN #1 stated that the resident's roommate should have been put on hold. In an interview with the surveyor on 6/23/14 at approximately 12:20 PM, Licensed Practical Nurse (LPN) #1 stated that s/he was across the hall from Resident #1's room and heard a commotion. S/he stepped into the room and saw the resident on the floor. LPN #1 stated Resident #1 gets up without assistance and the Merry walker was used to keep him/her safe. In an interview with the surveyor on 6/23/14 at approximately 2:10 PM, the Director of Nursing (DON) stated that RN #1 came back and let her know what happened. RN #1 told her that CNA #1 stated that Resident #1 was in his/her closet, s/he was providing care to the resident's roommate and couldn't leave. CNA #1 turned around and saw Resident #1 on the floor. The DON stated that Resident #1's roommate was alert and oriented and could have been left while CNA#1 attended Resident #1. The DON stated that CNA #1 had redirected Resident #1 by telling him/her to sit down and went back to taking care for the resident's roommate. The DON stated that Resident #1 is not that redirectable. CNA #1's facility-obtained statement dated 5/16/14 indicated s/he was getting the resident's roommate up to their chair. Resident #1 refused to sit down when s/he asked him/her. Resident #1's roommate was up on the side of the bed and CNA #1 was about to put him/ her in their chair. Resident #1 was in his/her closet pulling out clothes. When CNA #1 had the roommate standing up s/he turned around to put the resident in his/her chair and looked over to see Resident #1 had fallen to the floor. Review of the facility's Fall Management Policy revealed high risk to fall mitigation strategies included "providing assistance whenever a resident ambulates."