Every finding on record at NHC Healthcare, Anniston

Based on interviews, record review, review of a facility policy titled Patient Protection and Response Policy for Allegations/Incidents of Abuse, Neglect, Misappropriation of Property and Exploitation, review of Facility Reported Incidents (FRIs) received by the State Agency, and review of the facility's investigative files, the facility failed to protect the rights of residents to be free from abuse perpetrated by other residents of the facility. Specifically, on 05/22/2023 Resident Identifier (RI) #237 was physically abused by RI #239 when facility staff witnessed RI #239 grab RI #237's wrists and pull RI #237 from a recliner onto the floor and punch RI #237 multiple times. The facility failed to prevent this from occurring as staff members were aware RI #239 was annoyed with RI #237 yelling and RI #239 had already told RI #237 to shut up, earlier in the night. RI #237 was assessed with redness and bruising to the right wrist. RI #237 told staff after the incident, he/she had been attacked and wanted the police. Facility staff said, the abuse against RI #237 would have made someone in that situation feel hurt, scared, and upset. Further, on 08/15/2023 RI #288 was physically abused by RI #290 when RI #290 struck RI #288 in the face and chest. After the incident RI #288 was seen crying and told staff he/she had been hit. Witnesses of the incident said it was physical abuse and someone in that situation would have felt terrified, upset, angry, and hurt. The facility failed to prevent this from occurring when just minutes prior to this incident RI #290 had used an electronic hand sanitizer as a weapon to swing at staff and had aggressively pushed a rollator (rolling walker) into staff and toward another resident. The facility further failed to substantiate RI #288 was physically abused by RI #290. This deficient practice was cited as a result of the investigation of complaint/report numbers AL00044297 and AL00045279 and affected RI #237 and RI #288, two of five residents sampled for abuse. Findings include: A facility policy titled Patient Protection and Response Policy for Allegations/Incidents of Abuse, Neglect, Misappropriation of Property and Exploitation, with a revision date of 02/01/2023, documented the following: . DEFINITION POLICY Abuse, Neglect, Misappropriation of Patient Property and exploitation . will not be tolerated by anyone, including . patients . The patient has the right to be free from abuse, neglect, . The center administrator is responsible for assuring that patient safety, including freedom from risk of abuse or neglect, holds the highest priority. DEFINITIONS: Abuse: the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Willful, as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. Physical Abuse: includes hitting, slapping, pinching and kicking. It also includes controlling behavior through corporal punishment. PREVENTION POLICY . A. The center will provide supervision and support services designed to reduce the likelihood of abusive behaviors. All supervisory partners who receive reports of and/or identify inappropriate behaviors will take immediate steps to correct such behaviors. C. Patients with needs and behaviors that might lead to conflict with partners or other patients will be identified by the Care Planning team, with interventions and follow through designed to minimize the risk of conflict. The interventions designed to meet the needs of such patients will include but will not be limited to 1. Identification of patients whose personal histories render them at risk for abusing other patients or partners, 2. Assessment of appropriate intervention strategies to prevent occurrences, 3. Monitoring the patient for any changes that would trigger abusive behavior, . 1) On 05/22/2023 the State Agency received an Online Incident Report (FRI) from the facility alleging physical abuse when staff witnessed RI #239 grab RI #237 by the wrists and pull RI #237 onto the floor from a recliner and RI #239 punched at RI #237. RI #237 was admitted to the facility on [DATE] with diagnoses to include Cerebrovascular Disease, Vascular Dementia with Severe Agitation and History of Falling. RI #237's admission Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 03/08/2023 documented a Brief Interview for Mental Status (BIMS) score of six of 15, which indicated severely impaired cognition. RI #239 was admitted to the facility on [DATE] with diagnoses to include History of Traumatic Brain Injury, Disorders of Brain-Encephalomalacia, Depression, and History of Transient Ischemic Attack. The facility's investigative file included a report titled Opening Statement that documented: . On 5/22/23 at approximately 3:30am, . (RI #237) and (RI #239) were both up in the dayroom and had an altercation, and (RI #239) pulled (RI #237) out of the recliner and began hitting at (RI #237). Staff responded immediately and separated the two patients and took (RI #239) back to (his/her) room with staff supervision. MD (physician) was notified and orders were received to transfer (RI #239) to the adult . (psychiatric) unit . Calls were made to both patient's families and an immediate investigation was initiated. (RI #237) was assessed and it was noted that (he/she) had redness to (his/her) right ear and right wrist. The facility's investigative file also contained a form titled Incident Investigation Summary, dated 05/25/2023 signed by the Administrator (ADM) that documented: . Conclusion Summary: Physical abuse was substantiated . The facility investigative file contained a handwritten statement signed by Registered Nurse (RN) #5 dated 05/22/2023 that documented: On May 22, 2023 at 0340 (3:40 AM), Nurse from memory care unit called me down . due to rehab patient dragging memory care/long term patient to the floor from recliner and punching (him/her) multiple times up until 4 members of staff were able to get (him/her) off of them. I did not witness any of this. Upon speaking . (with) patient that was allegedly hit, patient states, I was pulled out my chair and attacked. I want the police. Upon speaking (with) patient that allegedly hit the other patient, patient states, I told (him) to shut up. I told y'all I can not take all this noise here. On 10/23/2024 at 2:23 PM RN #5 was asked about the incident with RI #237. RN #5 said, she had been called over to help with a resident who had pulled another resident to the floor, RI #237 was sitting in a chair, and she asked RI #237 what happened. RN #5 stated, RI #237 told her I was pulled out of a chair and attacked, I want the police. RN #5 said, she tried to call the abuse coordinator/Social Service Director (SSD) and could not reach her so she notified the Director of Nursing who said to separate the residents. RN #5 said, she then notified RN #4 to continue to try to notify the SSD, Administrator, physician, and families; and then RN #5 returned to her own hall. The facility's investigative file contained an undated handwritten statement signed by CNA #6 that documented: (RI #239) was in the day area and I saw (him/her) drag (RI #237) out of the recliner and start punching (RI #237) repeatedly. The Nurse, CNAs and I immediately went over and removed (RI #239) away from (RI #237) . On 10/23/2024 at 9:24 AM CNA #6 was asked what she remembered about the incident on 05/22/2023. CNA #6 said, she witnessed RI #239 rolling up to RI #237 and pulling RI #237 out of a recliner and RI #239 hit RI #237. CNA #6 said, she did not remember where RI #237 was hit but they separated the residents and took RI #239 to his/her room. CNA #6 said, what she witnessed would make someone in that situation feel hurt or scared. The facility's investigative file contained an undated handwritten statement signed by CNA #7 that documented: (RI #237) . was in the day area, and I seen (RI #239) pulled (RI #237) out of the recliner and start punching (him/her) repeatedly. It took all of us to pull (RI #239) off of (RI #237) and remove (him/her) from the room. We took (RI #239) to (his/her) room where a CNA had to sit with (him/her). On 109/23/2024 at 10:17 AM CNA #7 was asked what she remembered about the incident on 05/22/2023. CNA #7 said, both residents were in the dayroom and she saw (RI #237) on the floor and RI #239 was leaning over RI #237. CNA #7 said, staff immediately separated the residents. CNA #7 said, RI #237 did not complain of pain but wanted the staff to call the police. CNA #7 said what she witnessed was physical abuse and someone in that situation would feel upset. The facility's investigative file contained an undated handwritten statement signed by CNA #8 that documented: I witnessed (RI #237) was sitting in the day room in the recliner when (RI #239) pulled (him/her) out the recliner and proceeded to punch (him/her) multiple times me and other staff pulled (him/her) off and redirected patient . (RI #239) stated (RI #237) was annoying and I quote The Shit out of him. CNA #8 was unavailable for interview. The facility's investigative file contained an undated handwritten statement signed by CNA #9 that documented: I witnessed (RI #239) pull (RI #237) out of (his/her) chair and proceeded to punch (him/her) multiple times. It took 4 CNAs to pull (RI #239) off of (RI #237). CNA #9 was unavailable for interview. RI #237's nursing progress note dated 05/22/2023 electronically signed by RN #4 documented: . Pt (patient) had been in day room in recliner for most of this shift. Pt yelling out but when asked what (he/she) needs (he/she) states (he/she) doesn't know or that (he/she) needs to urinate, . Another patient rolled over to (RI #237) . My CNAS (Certified Nursing Assistant) reported to me that the patient pulled (RI #237) from recliner when I came around the corner I seen the patient punching (RI #237). Pt was stopped and separated . assessed for injuries. Redness noted to (R/right) wrist and Ear. A handwritten statement signed by RN #4 and dated 05/22/2023 documented: . (RI #237) was in recliner in the day room. Pt yells out often and was this night. (RI #239) told pt to shut up and stated the yelling was annoying. Moments later . (RI #239) was sitting in wheelchair speaking in normal tones to (RI #237). I was behind my (medication) cart when I heard my CNAs say Oh no and rushed out to day room. When I came around the corner I witnessed (RI #239) punching (RI #237) and (RI #237) was on the floor. CNAs stated to me that (RI #237) was pulled out of the chair by (RI #239). (RI #239) was removed and taken to room . Notified (physician/social services) and DON . verbal order to send pt (RI #239) out. On 10/23/2024 at 10:45 AM RN #4 was asked about the incident occurring on 05/22/2023 involving RI #237 and RI #239. RN #4 said, RI #237 who typically slept in the recliner started yelling out as he/she had a history of doing. RI #239 self propelled in wheelchair and yelled at RI #237 to shut up and RI #237 was annoying. RI #239 was re-directed to his/her room and a little while later, about an hour and a half, RI #239 came up the hall to the dayroom back toward RI #237, close to RI #237's chair. RN #4 said, the next thing she remembered was CNA #6 and CNA #8 jumped up from the desk and said, Oh no. RN #4 continued, she ran with them and saw RI #237 down on the floor and RI #239 leaning over RI #237 from the wheelchair punching at RI #237. RN #4 said, the incident she observed was physical abuse that would make someone in that situation feel upset and scared. The Abuse Coordinator (AC) was interviewed on 10/23/2024 at 3:19 PM. She stated RN #4 had reported the 05/22/2023 resident-on-resident altercation involving RI #237 and RI #239. The AC said, RN #4 had reported the incident to her, that the two residents had an altercation and RI #239 hit RI #237. The AC further concluded the incident was substantiated due to resident-on-resident abuse. On 10/26/2024 at 7:03 PM a follow up interview was conducted with the Abuse Coordinator and she was asked her professional opinion about what could have been done to prevent the abuse from occurring. The AC said, the nurse or the CNAs could have assessed for toileting needs, hunger, thirst, pain, or they could have offered quiet time in bed. The AC also said, the physician could have been notified or they could have called the family. The AC said, these things were not done. The Director of Nursing, (DON), was interviewed on 10/23/2024 at 4:30 PM. When asked if she recalled the resident-on resident altercation on 05/22/2023 involving RI #237 and RI #239, she said, yes. The DON confirmed the nurse had reported the incident to her, and that the two residents had an altercation and RI #239 hit RI #237. The DON stated this conclusion was physical abuse. On 10/26/2024 at 6:47 PM a follow up interview was conducted with the DON and she was asked her professional opinion about what could have been done to prevent the abuse from occurring. The DON said, the physician could have been notified of RI#237's behaviors and they could have taken RI #237 to his/her room for quiet time. The DON also said, the staff also could have assessed RI #237 for pain, hunger, thirst, toileting needs, or they could have called the family. The DON said, these things were not done. 47408 2) On 08/15/2023 the State Agency received an Online Incident Report (FRI) from the facility alleging physical abuse when RI #290 struck RI #288 on the left side of the face and upper stomach. RI #288 was readmitted to the facility on [DATE] and had diagnosis to include: Epilepsy and Dementia. RI #290 was admitted to the facility on [DATE] and had diagnosis to include: Parkinson's Disease and Dementia. Review of the facility investigative file revealed a report titled Opening Statement that documented: . At approximately 11:30am . (RI #290) . came out of (his/her) room . became difficult to redirect and proceeded to nurses station picked up the hand sanitizer and was trying to swing at partners (employees) and then wanted (his/her) phone. was given (his/her) phone . At approximately 12:30pm . (RI #290) . walked over to the day area where lunch was being served. (RI #288), stood from where (he/she) was seated and . (RI #290) walked over and struck (RI #288) on the cheek and then in the abdomen area. Staff was able to intervene and assist (RI #290) back to (his/her) room until the MD (physician) could be notified and was given orders to send (him/her) to the ER (emergency department) for evaluation. (RI #288) was assessed for injury and no injuries were noted other than a red area to (his/her) face . The facility's investigative file contained an undated report titled Conclusion which documented: . it was determined that physical abuse could not be substantiated. (RI #288) may have gotten up to hug (RI #290) . (he/she) reacted with physical aggression. A Witness Statement Form dated 08/15/2023 for RI #288, the victim, documented an incident type of physical and RI #288's statement as follows: . (RI #288) stated (he/she) hit me. (He/she) knew better . (RI #288) was crying. A facility . Body Audit Form . dated 08/15/2023 at 12:40 PM documented . Slight Redness to (L/left) Cheek . with a line drawn on the left side of the face on the figure on the form. A Witness Statement Form dated 08/15/2023, signed by Certified Occupational Therapy Assistant (COTA) #13 documented an incident type of Physical and COTA #13's statement as follows: . I was walking to a . room, when (RI #290) was walking out. The CNAs were moving beds. So I tried to redirect (him/her), but (he/she) became aggressive. (RI #290) started running (his/her) walker into me (and) pushing me away. (He/she) continues to be aggressive, so I backed away to let the CNAs handle it. During an interview on 10/24/2024 at 2:07 PM with COTA #13, she stated she did observe RI #290 push his/her rollator in the way of staff in the hall so they could not get by and when she tried to intervene, RI #290 pushed the rollator into her, so she stepped aside and reported to the nurse, but not sure which nurse. A Witness Statement Form dated 08/15/2023, signed by CNA #11 documented an incident type of Patient-on-Patient and CNA #11's statement as follows: . Between 11:30 am and 12:00 pm while the nurse and I were moving a patient . (in the patient's bed) through the hall . (RI #290) would not let us pass. A member of therapy tried to redirect (RI #290) and (RI #290) ramed (rammed) the bed with (his/her) walker and began to ram the therapist. (RI #290) grabbed the Sanitizer dispenser from the desk . and began to swing it. When we got it away from (RI #290), (he/she) asked for (his/her) phone. (He/she) calmed down and stood at the desk for awhile. (He/she) walked over to the Dayroom and stood for a few minutes. (RI #288) stood up to go to the table to eat lunch. When (RI #288) stood up, (RI #290) punched (RI #288) in the chest area and then again in the face. On 10/23/2024 at 4:20 PM CNA) #11 was asked about the incident on 08/15/2023. CNA #11 stated, a short time prior to the incident between RI #290 and RI #288, RI #290 displayed aggressive behavior by using an electronic hand sanitizer dispenser as a weapon against the staff when RI #290 was mad for some reason and began to swing the dispenser at her and a nurse. CNA #11 said, it took several staff to take the dispenser away from RI #290. CNA #11 said, then RI #290 appeared to calm down and went over to the dayroom where RI #288 was. CNA #11 said, this was about 30 minutes later and they were singing in the watch area and RI #288 came up an started talking loudly (RI #288 is deaf) and RI #290 stood up and punched RI #288 in RI #288's face and chest. CNA #11 said, this was physical abuse and it would make someone in that situation feel terrified, upset, and angry. A Witness Statement Form dated 08/15/2023, signed by CNA #12 documented an incident type of physical and CNA #12's statement as follows: . I was in the watch .(area) sitting in between (another resident and RI #288). (RI #290) came and sat beside (RI #288). (RI #288) may have thought (RI #290) was a friend and went in to hug (RI #290). (He/she) punched (RI #288) in the upper right side of (his/her) face and upper right side of chest. (RI #288) was taken to safety and (RI #290) was taken to room. On 10/23/2024 at 3:53 PM CNA #12 was asked about the incident on 08/15/2023. CNA #12 stated, while on the unit assisting with activities RI #288 came up to RI #290 and tried to give RI #290 a hug. CNA #12 stated, RI #290 hit RI #288 in the face and upper chest. CNA #12 said, this was physical abuse and it would make someone in that situation feel angry. A Witness Statement Form dated 08/15/2023, signed by Licensed Practical Nurse (LPN) #14 documented an incident type of assault and LPN #15's statement as follows: . Resident was standing with (his/her) walker in front of (him/her). The nurse . (with a cart) . the CNA needed to pass. The resident began using (his/her) wheelchair to stop the . nurse and CNA . The resident then attempted to us (his/her) walker to stop PT person (physical therapist). The resident used (his/her) walker to attempt to stop the stretcher (resident being moved to another room). When that did not work, the resident picked up a metal hand sanitizer object (that was at the desk) to throw. Staff was able to get the object from the resident. (The resident was continuing to stop the stretcher . the stretcher had a resident on it as well). There was the potential to hurt the other resident and staff. The next thing was the resident had remained in the day area hit another resident twice. Once in the face and once in the chest. We all came to assist in stopping any further problems. The resident with the walker continued to walk towards the hit resident. Resident sat in chair yet still was wanting to hit at staff and the other resident. The resident continued attempting to hit at, punch at, grimace at. We phoned for help . assisted to (his/her) room until transport came. On 10/24/2024 at 2:30 PM LPN #14 was asked about the incident on 08/15/2023. LPN #14 reviewed and agreed, that was her written statement, and said, the incident was physical abuse. During an interview on 10/24/2024 at 3:55 PM with Director of Nursing (DON), she stated she was called to the unit by nursing staff who reported RI #290 had hit RI #288 in the left side of the face and chest. The DON stated, after the incident RI #288 was crying and saying RI #290 had hit him/her and RI #290 knew better. The DON said, she asked RI #290 what happened and RI #290 just shook his/her head and mumbled. The DON said, the physician was notified, RI #290 was sent to the hospital for evaluation, was admitted and returned to the facility on [DATE]. The DON stated, she was not aware of the behaviors RI #290 displayed prior to the incident. The DON was asked what the facility could have done to prevent this from happening since RI #290 had displayed behaviors prior to the incident. The DON replied, they could have called the doctor for medication or could have sent to the hospital sooner or called the family to come sit with resident. The DON stated, the staff should have kept RI #290 away from other residents when he/she started having behaviors and the physician should have been notified when the behavior pattern began. The DON said, the incident was physical abuse and someone in that situation would feel upset, angry, and have hurt feelings.

Based on interviews, resident record reviews, review of the facility policy titled BEHAVIORAL HEALTH SERVICES, the facility failed to provide immediate and necessary behavioral interventions and supervision to prevent Resident Identifier (RI) #290, a resident exhibiting physically aggressive behaviors, from physically abusing RI #288. On 08/15/2023 RI #290 displayed physically aggressive behaviors toward the facility staff, ramming them with his/her walker and swinging at them with a dispenser for hand sanitizer. RI #290 was then allowed to walk into a day room area with other residents and staff who were preparing for lunch. RI #290 hit RI #288 in the face and chest. This affected RI #288 one of five residents reviewed for behaviors. Findings include: Cross-reference F 600. Review of a facility policy titled BEHAVIORAL HEALTH SERVICES, revised date of 2/2019, revealed the following: . The center must provide the necessary behavioral health care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care . Assessment of mental health needs of a patient is the responsibility of the interdisciplinary care plan team, including the physician or physician/extender . When additional professional evaluation and /or development of a treatment plan is recommended, the attending physician or physician extender may order a mental health consult. The observations and recommendations of mental health professionals are included in the patient's overall care plan . Persons identified as being in need of acute inpatient psychiatric care are . referred to appropriate treatment facilities. The center will ensure they have sufficient and competent staff to provide behavioral health services . On 08/15/2023 the State Agency received an Online Incident Report from the facility alleging physical abuse when RI #290 struck RI #288 on the left side of the face and upper stomach. RI #288 admitted to facility on 03/28/2023 with diagnosis Epilepsy, Down Syndrome, and Unspecified Dementia with Psychotic Disturbance. RI #290 was admitted to the facility on [DATE] with diagnosis Parkinson's Disease and Dementia, Behavioral Disturbance and Mood Disorder. The facility investigative file contained a report titled Opening Statement which documented: . At approximately 11:30am . (RI #290) . came out of (his/her) room . became difficult to redirect and proceeded to nurses station picked up the hand sanitizer and was trying to swing at partners (employees) and then wanted (his/her) phone. was given (his/her) phone . At approximately 12:30pm . (RI #290) . walked over to the day area where lunch was being served. (RI #290) walked over and struck (RI #288) on the cheek and then in the abdomen area. Staff was able to intervene and assist (RI #290) back to (his/her) room until the MD (physician) could be notified and was given orders to send (him/her) to the ER (emergency department) for evaluation. (RI #288) was assessed for injury and no injuries were noted other than a red area to (his/her) face . A Witness Statement Form dated 08/15/2023 for RI #288, the victim, documented an incident type of physical and RI #288's statement as follows: . (RI #288) stated (he/she) hit me. (He/she) knew better . (RI #288) was crying. Review of a facility . Body Audit Form . dated 08/15/2023 at 12:40 PM documented . Slight Redness to (L/left) Cheek . with a line drawn on the left side of the face on the figure on the form. On 10/23/2024 at 4:20 PM CNA #11 who witnessed the incident said, was RI #290 displayed aggressive behavior by using an electronic hand sanitizer dispenser as a weapon against the staff when RI #290 was mad for some reason and began to swing the dispenser at her and a nurse. CNA #11 said, it took several staff to take the dispenser away from RI #290. CNA #11 said, then RI #290 appeared to calm down and went over to the dayroom where RI #288 was. CNA #11 said, about 30 minutes later they were singing in the watch area and RI #288 came up an started talking loudly (RI #288 is deaf) and RI #290 stood up and punched RI #288 in RI #288's face and chest. CNA #11 said, this was physical abuse and it would make someone in that situation feel terrified, upset, and angry. On 10/23/2024 at 3:53 PM an interview was conducted with CNA #12, and he stated while on the unit assisting with activities RI #288 came up to RI #290 and tried to give RI #290 a hug and RI #290 hit RI #288 in the face and upper chest. During an interview on 10/24/2024 at 3:55 PM with Director of Nursing (DON), she stated she was called to the unit by nursing staff who reported RI #290 had hit RI #288 in the left side of the face and chest. The DON stated RI #288 was crying and said RI #290 had hit him/her. The DON said, she asked RI #290 what happened and he/she just shook his/her head and mumbled. The physician was notified, and RI #290 was sent to the hospital for evaluation and was admitted to the hospital. The DON stated she was not aware of the behaviors RI #290 displayed prior to this incident. The DON was asked what the facility could have done to prevent this from happening since RI #290 had displayed behaviors just prior to this incident and she stated they could have called the MD for medication to calm him/her or to get him/her to the hospital sooner or called the family to come sit with resident. She further stated the staff should have kept RI #290 away from other resident when he/she started having behaviors and should have notified the physician when behavior pattern began.

Based on interviews, resident record review, review of a Facility Reported Incident (FRI) received by the State Agency, the facility's investigative file, and review of a facility policy titled PATIENT'S RIGHTS, the facility failed to ensure Resident Identifier (RI) #237's rights were honored on 05/22/2023 when RI #237 told facility staff he/she had been attacked and wanted to notify the police. Facility staff witnessed RI #239 grab RI #237's wrists, pull RI #237 out of a recliner onto the floor, and RI #239 threw punches at RI #237. The police were not notified of RI #237's request. This deficient practice affected one of 26 residents sampled and was cited as a result of the investigation of complaint/report number AL00044297. Findings include: On 05/22/2023 the State Agency received an Online Incident Report (FRI) from the facility alleging staff witnessed RI #239 grab RI #237 by the wrists, pull RI #237 onto the floor from a recliner, RI #239 was throwing punches at RI #237, and RI #237 had a bruise to the right wrist. A facility policy titled PATIENT'S RIGHTS dated 03/2024 documented: . we support the patient's right to live in an environment which is individualized for them. We strive to cultivate and sustain an excellent quality of life for each individual with person-centered care and services, by honoring and supporting each patient's preferences, choices, values and beliefs. RI #237 was admitted to the facility on [DATE], with diagnoses to include Cerebrovascular Disease, Vascular Dementia with Severe Agitation and History of Falling RI #237's admission Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 03/08/2023 documented a Brief Interview for Mental Status (BIMS) score of six of 15 which indicated severely impaired cognition. RI #239 was admitted to the facility on [DATE] with diagnoses to include History of Traumatic Brain Injury, Disorders of Brain-Encephalomalacia, Depression, and History of Transient Ischemic Attack. The facility investigative file contained a handwritten statement signed by Registered Nurse (RN) #5 dated 05/22/2023 that documented: On May 22, 2023 at 0340 (3:40 AM), Nurse from memory care unit called me down . due to rehab patient dragging memory care/long term patient to the floor from recliner and punching (him/her) multiple times up until 4 members of staff were able to get (him/her) off of them. I did not witness any of this. Upon speaking . (with) patient that was allegedly hit, patient states, I was pulled out my chair and attacked. I want the police. On 10/23/2024 at 2:23 PM RN #5 was asked about the incident with RI #237. RN #5 said, she had been called over to help with a resident who had pulled another resident to the floor, RI #237 was sitting in a chair, and she asked RI #237 what happened. RN #5 stated, RI #237 told her I was pulled out of a chair and attacked, I want the police. RN #5 said, she tried to call the abuse coordinator/Social Service Director (SSD) and could not reach her so she notified the Director of Nursing who said to separate the residents. RN #5 said, she then notified RN #4 to continue to try to notify the SSD, Administrator, physician, and families; and then RN #5 returned to her own hall. RN #5 said, she did not call the police, but tried to call the abuse coordinator. RN #5 said, the abuse coordinator and the Administrator were responsible for calling the police if warranted. The Abuse Coordinator (AC)/SSD was interviewed on 10/25/2024 at 3:15 PM. She stated, she did not recall any staff reporting that RI #237 requested the police. The AC said, anyone could have called the police for RI #237, including the Administrator and DON. The AC said, RI #237's rights were not honored if he/she requested the police be notified and the facility did not notify the police. On 10/26/2024 at 2:48 PM the Administrator (ADM) was asked about the incident involving RI #237. The Administrator said, the facility communicates with law enforcement by calling the police department directly or calling 911. The ADM said, the police were not notified of the incident between RI #237 and RI #239 on 05/22/2023 and she was not made aware RI #237 asked for the police.

Based on interviews, resident record review, review of facility polices titled, Patient Protection and Response Policy for Allegations/Incidents of Abuse, Neglect, Misappropriation of Property and Exploitation and INCIDENT AND ACCIDENT PROCESS, and review of the facility investigative files, the facility failed to thoroughly investigate incidents of resident-on-resident physical abuse for appropriate action to be taken to prevent further occurrences. On 05/22/2023 facility staff witnessed Resident Identifier (RI) #239 grab RI #237's wrists, pull RI #237 from a recliner onto the floor, and punch RI #237 multiple times. The facility failed to prevent this from occurring after RI #239 was annoyed with RI #237 yelling out and RI #239 had told RI #237 to shut up earlier in the night. RI #237 was assessed with redness and bruising to the right wrist. The facility investigation and witness statements the facility gathered from those present at the time the abuse occurred did not include any details describing how hard RI #237 was punched, how many times RI #237 was punched, where exactly RI #237 was punched, or how this could have been prevented. The investigative file also did not explain why it took four staff members to pull RI #239 off of RI #237, as explained by staff in their witness statements. Also, the investigative file did not explain why the local law enforcement were not notified of the abuse and of RI #237's wishes for the police to be notified. This failure had the potential to affect RI #237 and all residents residing on the facility's Memory Care Dementia Unit. This deficiency was cited as the result of the investigation of complaint/report #AL00044297. Findings include: Cross reference F 550, F 600, and F 609. 1.) A facility policy titled Patient Protection and Response Policy for Allegations/Incidents of Abuse, Neglect, Misappropriation of Property and Exploitation with an effective date of 02/01/2023, documented: . DEFINITION POLICY Abuse, Neglect, Misappropriation of Patient Property and exploitation, . will not be tolerated by anyone, including staff, patients, . or any other individual in this center. The patient has the right to be free from abuse, neglect . The center administrator is responsible for assuring that patient safety, including freedom from risk of abuse or neglect, holds the highest priority. A. INTERNAL INVESTIGATION POLICY 1. Policy All events reported as possible abuse, neglect, . will be investigated to determine whether the alleged abuse, neglect, . did or did not take place. The Administrator or Director of Nurses will determine the direction of the investigation once notified of alleged incident. The State Agency received an Online Incident Report (FRI) from the facility alleging physical abuse occurred on 05/22/2023 at 3:30 AM when facility staff witnessed RI #239 grab RI #237's wrists, pull RI #237 from a recliner onto the floor, and punch RI #237 multiple times. RI #237 was assessed with redness and bruising to the right wrist. The FRI report did not contain any information about the location, number, or intensity of the punches with which RI #247 was hit. RI #237 was admitted to the facility on [DATE], with diagnoses to include Cerebrovascular Disease, Vascular Dementia with Severe Agitation and History of Falling. RI #237's admission Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 03/08/2023 documented a Brief Interview for Mental Status (BIMS) score of six of 15, which indicated severely impaired cognition. RI #239 was admitted to the facility on [DATE] with diagnoses to include History of Traumatic Brain Injury, Disorders of Brain-Encephalomalacia, Depression, and History of Transient Ischemic Attack. The facility investigative file was reviewed and a report titled Opening Statement documented that on 05/22/2023 RI #239 pulled RI #237 out of the recliner and began hitting at RI #237, but there were not any details about the location, number, or intensity of the punches with which RI #247 was hit. Witness statements in the investigative files were reviewed as follows: A handwritten witness statement dated 05/22/2023, signed by Registered Nurse (RN) #5 documented RN #5 was called to help after a resident had been pulled from a recliner and punched multiple times by another resident, until four members of staff separated the residents. RN #5 did not witness the abuse but in her statement she documented part of her conversation with RI #237 after the incident took place as follows: . Upon speaking (with) patient that was allegedly hit, patient states. 'I was pulled out my chair and attacked. I want the police.' . The facility's investigative file contained an undated handwritten statement signed by CNA #6 that documented: (RI #239) was in the day area and I saw (him/her) drag (RI #237) out of the recliner and start punching (RI #237) repeatedly. The Nurse, CNAs and I immediately went over and removed (RI #239) away from (RI #237) . The statement did not contain the location, number, or intensity of the punches with which RI #247 was hit. On 10/25/2024 at 10:37 AM CNA #6 said, she did see RI #239 punch RI #237 repeatedly, but she could not remember the location, number, or intensity of the punches with which RI #247 was hit because it was long ago and happened so fast. CNA #6 also said, it did not really take four staff members to pull RI #239 off of RI #237, instead, two assisted RI #239 and two assisted RI #237. The facility's investigative file contained an undated handwritten statement signed by CNA #7 that documented: (RI #237) . was in the day area, and I seen (RI #239) pulled (RI #237) out of the recliner and start punching (him/her) repeatedly. It took all of us to pull (RI #239) off of (RI #237) and remove (him/her) from the room. We took (RI #239) to (his/her) room where a CNA had to sit with (him/her). The statement did not contain the location, number, or intensity of the punches with which RI #247 was hit. On 10/25/2024 at 10:59 AM CNA #7 said, she did see RI #239 punch RI #237 repeatedly, but she could not remember the location, number, or intensity of the punches with which RI #237 was hit because it was long ago and happened so fast. CNA #6 also said, it did not really take four staff members to pull RI #239 off of RI #237, instead they responded instantly to separate them. The facility's investigative file contained an undated handwritten statement signed by CNA #8 that documented: I witnessed (RI #237) was sitting in the day room in the recliner when (RI #239) pulled (him/her) out the recliner and proceeded to punch (him/her) multiple times me and other staff pulled (him/her) off and redirected patient . (RI #239) stated (RI #237) was annoying and I quote The Shit out of him. The statement did not contain the location, number, or intensity of the punches with which RI #237 was hit. CNA #8 was unavailable for interview during the survey. The facility's investigative file contained an undated handwritten statement signed by CNA #9 that documented: I witnessed (RI #239) pull (RI #237) out of (his/her) chair and proceeded to punch (him/her) multiple times. It took 4 (four) CNAs to pull (RI #239) off of (RI #237). The statement did not contain the location, number, or intensity of the punches with which RI #247 was hit. CNA #9 was unavailable for interview during the survey. RI #237's nursing progress note dated 05/22/2023 electronically signed by RN #4 documented: . Pt (patient) had been in day room in recliner for most of this shift. Pt yelling out but when asked what (he/she) needs (he/she) states (he/she) doesn't know or that (he/she) needs to urinate, . Another patient rolled over to (RI #237) . My CNAS (Certified Nursing Assistant) reported to me that the patient pulled (RI #237) from recliner when I came around the corner I seen the patient punching (RI #237). Pt was stopped and separated . assessed for injuries. Redness noted to (R/right) wrist and Ear., but the note did not contain the location, number, or intensity of the punches with which RI #237 was hit. On 10/23/2024 at 10:45 AM RN #4 was asked about the incident on 05/22/2023. RN #4 said, she did see RI #239 punching with fists but did not see actual contact as RI #237 was on the floor with RI #239 leaning over RI #237. RN #4 said she heard RI #237 say, RI #239 had hit him/her. The facility's investigative file also contained a form titled Incident Investigation Summary, dated 05/25/2023 signed by the Administrator (ADM) that documented: . Incident Summary: (RI #237 and RI #239) . were up in dayroom on 5/22/23. (RI #239) was observed pulling on (RI #237) and (RI #237) fell to floor (and RI #239) was punching (RI #237). Conclusion Summary: Physical abuse was substantiated ., but the form did not contain any documentation about the location, number, or intensity of the punches with which RI #237 was hit, nor did it explain how this could have been prevented or why it took four staff members to pull RI #239 off of RI #237, as explained by staff in their witness statements. The form also did not explain why local law enforcement agencies were not notified of the abuse even after RI #237 told staff he/she had been attacked and wanted the police. The Abuse Coordinator (AC) was interviewed on 10/26/2024 at 10:33 AM. The AC was asked where in the abuse investigation of RI #237 was the severity of the punches, the number of punches, and the location of the punches with which RI #237 was hit. The AC answered, there was not a statement in the investigation that indicated those details. The AC said, she did not know to ask those questions during an investigation. The AC said, those details would have been important to an investigation to indicate if the police should have been notified, they would have known exactly where the resident was hit and would have known who actually saw the contact made between the two residents. The Administrator (ADM) was interviewed on 10/26/2024 at 2:48 PM and was asked where in the abuse investigation of RI #237 was the severity of the punches, the number of punches, and the location of the punches with which RI #237 was hit. The ADM stated, in the investigation there was no indication of the severity, number, or location of punches to RI #237. The ADM said, to decide of what needs to be done for the resident, look what was leading up to the incident, what was observed and what may have been contributing factors to have a thorough investigation. The ADM said, she did not have an answer for why those details were not in the investigation and she did not think they were looking at the severity of the punches during the investigation. The ADM said, those details would be important to an investigation to determine the potential for any injury to the resident.

Based on interviews, review of Resident Identifier (RI) #237's medical record, review of a facility policy titled NEUROLOGICAL CHECKS, and an Online Incident Report (FRI), the facility failed to ensure Registered Nurse (RN) #4 documented assessment details in RI #237's medical record after a resident-on-resident incident on 05/22/2023. This had the potential to affect RI #237, one of 26 sampled residents and was cited as a result of the investigation of complaint/report number AL00044297. Findings include: On 05/22/2023 the State Agency received an Online Incident Report (FRI) from the facility alleging physical abuse when staff witnessed RI #237 being pulled to the floor and punched by another resident. RI #237 was admitted to the facility on [DATE], with diagnoses to include Cerebrovascular Disease, Vascular Dementia with Severe Agitation and History of Falling. Review of RI #237's medical record revealed vital signs were not documented as part of the assessment of RI #237 on 05/22/2023 after the incident. On 10/25/2024 at 10:59 AM Certified Nursing Assistant (CNA) #7, who was present during the incident on 05/22/2023, was asked about RI #237 being assessed on the morning of 05/22/2023. CNA #7 said, she and RN #4 assessed RI #237 and she took vital signs for RI #237, and she gave the vital signs to RN #4, but she did not know if they had been documented or not. On 10/25/2024 at 12:08 PM RN #4 said, on the morning of 05/22/2023, upon assessment RI #237 denied pain, CNA #7 measured his/her vitals while she, RN #4, performed visual assessment and performed neurological checks to document on the neurological check sheet. RN #4 said, she had RI #237 squeeze her hands, checked pupils, and asked RI #237 his/her name. RN #4 said, CNA #7 completed the vital signs and wrote it on a piece of paper. RN #4 said, she documented her assessment and RI #237's vital signs on the neurological check sheet form. RN #4 said, she was responsible for charting the vital signs in the computer. RN #4 said, she did not chart the vital signs in the computer but she did record them on the neurological check sheet. RN #4 said, the neurological check sheet was a paper form that was scanned into medical records. RN #4 said, the facility had not been able to locate the neurological check sheet that was completed that morning. On 10/25/2024 at 2:50 PM the Director of Nursing (DON) was asked about the neurological check sheet that was completed for RI #237 on 05/22/2023. The DON said, she was not able to locate the neurological check sheet. The DON said, when those sheets were completed by the nurses they went into a box on the units that went to Health Information Management and they were to be scanned into the resident's chart. The DON said, the vital signs and neurological checks were not recorded in the electronic medical chart for RI #237 but they should have been charted to be able to catch changes in the residents condition.

Based on resident record review, interviews, review of a facility policy titled Patient Protection and Response Policy for Allegations/Incidents of Abuse, Neglect, Misappropriation of Property and Exploitation, and review of the facility investigative files, the facility failed to report reasonable suspicion of a crime against residents who were physically abused to Local Law Enforcement for Resident Identifier (RI) #237 and RI #288. Specifically, on 05/22/2023 facility staff witnessed Resident Identifier (RI) #237 being pulled from a recliner by the wrists onto the floor and punched by RI #239. RI #237 was assessed with redness and bruising to the right wrist after the incident and RI #237 told staff who witnessed the physical abuse occur, he/she had been attacked and wanted the police. This incident was reported to the Director of Nursing (DON), Administrator (ADM) and Social Services Director/Abuse Coordinator (AC) but was not reported to the Local Law Enforcement. Further the facility failed to ensure the abuse policy specified: who was required to report the reasonable suspicion of crimes to law enforcement agencies; what crimes must be reported to law enforcement agencies; what constitutes serious bodily injury; and what the timeframe would be for reporting suspicion of crimes to law enforcement agencies. These deficient practices affected RI #237, one of five residents sampled for abuse. Findings include: Cross-reference F 550 and F 600. A facility policy titled Patient Protection and Response Policy for Allegations/Incidents of Abuse, Neglect, Misappropriation of Property and Exploitation, revised 02/01/2023, documented the following: . 6. REPORTING POLICY . It is the policy of this facility that abuse allegations . are reported per Federal and State law. The facility will ensure that all alleged violations involving abuse, . are reported immediately, . to the administrator of the facility. In addition, local law enforcement will be notified of any reasonable suspicion of a crime against a resident in the facility. The facility policy did not specify any of the following information about reporting suspicion of crimes against residents in the facility to local law enforcement agencies: who in the facility was required to report; what crimes must be reported; what constitutes serious bodily injury; and what the timeframe was for reporting suspicion of crimes against residents of the facility to local law enforcement. On 05/22/2023 the State Agency received an Online Incident Report (FRI) from the facility alleging physical abuse had occurred when staff witnessed RI #239 grab RI #237 by both wrists pulling RI #237 onto the floor from a recliner and then RI #239 was witnessed throwing punches at RI #237 as staff tried to intervene. The FRI also documented upon physical assessment RI #237 had bruises to the right wrist and a local law enforcement agency had not been notified of the incident. RI #237 was admitted to the facility on [DATE], with diagnoses to include Cerebrovascular Disease, Vascular Dementia with Severe Agitation and History of Falling RI #237's admission Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 03/08/2023 documented a Brief Interview for Mental Status (BIMS) score of six of 15, which indicated severely impaired cognition. RI #239 was admitted to the facility on [DATE] with diagnoses to include Personal History of Traumatic Brain Injury, Disorders of Brain-Encephalomalacia, Depression, and Personal History of Transient Ischemic Attack. The facility's investigative file also contained a form titled Incident Investigation Summary, dated 05/25/2023 and signed by the Administrator (ADM) that documented: . Conclusion Summary: Physical abuse was substantiated . RI #237's nursing progress note dated 05/22/2023 electronically signed by RN #4 documented: . Pt (patient) had been in day room in recliner for most of this shift. Another patient rolled over to (RI #237) . CNAS (Certified Nursing Assistant) reported to me that the patient pulled (RI #237) from recliner when I came around the corner I seen the patient punching (RI #237). Pt was stopped and separated . assessed for injuries. Redness noted to (R/right) wrist and Ear. During an interview on 10/23/2024 at 10:45 AM, RN #4 was asked if she recalled the incident on 05/22/2023 when RI #239 pulled RI #237 from a recliner onto the floor and began punching RI #237 multiple times. RN #4 said yes, she did recall that day, and that CNA #6 saw the altercation between RI #237 and RI #239. RN #4 said, the incident was reported to the Director of Nursing, the Administrator, and Abuse Coordinator/SSD. The Director of Nursing, (DON), was interviewed on 10/23/2024 at 4:30 PM. When asked if she recalled the resident-on resident altercation on 05/22/2023 involving RI #237 and RI #239, she said, yes. The DON confirmed the nurse had reported the incident to her, the two residents had an altercation, and the conclusion was physical abuse. The DON was asked when the facility notified the police of an incident of abuse. The DON replied, that was handled through the Administrator. On 10/26/2024 at 10:33 AM the Abuse Coordinator (AC) was asked about criminal reports to law enforcement. The AC said, the police would determine what a crime was. The AC said, the chief at the local police department would be the person to contact for reporting crimes. The AC said, the facility had not made any criminal reports to local law enforcement in the last year. When asked what types of abuse would be reported to law enforcement, the AC stated, any that involve reasonable suspicion of a crime against a resident. On 10/26/2024 at 8:39 PM in a follow up interview with the AC said, she had not communicated with local law enforcement about what a crime was and what incidents should be reported to law enforcement. The Administrator (ADM) was interviewed on 10/23/2024 at 5:18 PM and was asked about the conclusion of the investigation of the incident involving RI #237 and RI #239. The ADM said, physical abuse did occur. The ADM, said, law enforcement was not notified of the incident. In a follow up interview with the ADM on 10/26/2024 at 2:48 PM she was asked about criminal reports to law enforcement. The ADM said, anybody could determine what a crime was. The ADM was asked about communication with law enforcement for reporting and she replied, 911 could be called or the police department could be called directly to talk with police or the chief. The ADM said, the facility had not made any reports to local law enforcement in the last year. When asked what types of abuse would be reported, the ADM said, any suspicions of a crime. The ADM said, in this case the police had not been called and the concern of not calling the police to report suspicion of a crime was the police would not have the opportunity to determine if a crime occurred. In second follow up interview with the ADM on 10/26/2024 at 7:12 PM, she was asked when she had communicated with local law enforcement about what a crime was and what incidents at the facility should be reported. The ADM said, last year she had spoke with the chief. The ADM said, the communication with the chief was not documented. The facility did not have evidence of communication with local law enforcement about what was considered a crime and what was to be reported to local law enforcement.

Based on interviews, review of medical records, the facility's policy titled Testing Plan and the facility's agreement with (Name) Emergency Medical Services, the facility failed to ensure the contracted transportation company employees that provided non-emergent transportation to Resident Identifier (RI) #1, RI #2, RI #3, and RI #4, were tested for COVID-19 in accordance with the facility's testing requirements. This deficient practice affected RI #1, RI #2, RI #3 and RI #4, four of four residents who are routinely transported non-emergently to [MEDICAL TREATMENT]. Findings include: The facility's policy titled Testing Plan dated October 2020, documented [MEDICAL CONDITION] testing can be used to inform additional IPC (Infection Prevention and Control) actions necessary to keep [DIAGNOSES REDACTED]-CoV-2 (Severe Acute Respiratory Syndrome Coronavirus 2) out of facilities, detect COVID-19 cases quickly, and stop transmission . Keeping COVID-19 out . Testing for partners will be completed per CMS (Centers for Medicare & Medicaid Services) Guidance wit the review of the County Positivity Rate and Outbreak status of center reviewed on weekly basis. This weekly testing will include any individual that contracts with the center to provide care. Some examples of individuals that contract with the center to provide care include hospice providers, physicians, nurse practitioners, psychiatric providers, contracted staff, interns, student, beauticians, barbers, lab technicians, regional and corporate partners, etc. The Letter of Agreement between (Name) Emergency Medical Services, Inc. and National HealthCare-Anniston signed by the facility's Administrator on 1/7/2008 indicated the facility has an agreement with (Name) Emergency Medical Services (EMS) to provide non-emergency medical transportation for the residents of the facility. RI #1 was admitted to the facility on [DATE] with a medical history to include [DIAGNOSES REDACTED]. RI #1's physician's orders [REDACTED]. RI #2 was admitted to the facility on [DATE] with an admission [DIAGNOSES REDACTED]. RI #2 has a medical history to include [DIAGNOSES REDACTED]. RI #2's physician's orders [REDACTED]. RI #3 was admitted to the facility on [DATE] with an admission [DIAGNOSES REDACTED]. RI #3 has a medical history to include [DIAGNOSES REDACTED]. RI #3's physician's orders [REDACTED]. RI #4 was admitted to the facility on [DATE] with a medical history to include [DIAGNOSES REDACTED]. RI #4's physician's orders [REDACTED]. During an interview on 10/14/2020 at 10:42 AM, Employee Identifier (EI) #1, the Administrator stated the facility does not use any other transportation companies; only use (Name) EMS. In an interview on 10/15/2020 at 3:28 PM, EI #1, the Administrator was asked if the facility was testing the transportation company that was used to transport facility residents to [MEDICAL TREATMENT]. EI #1 replied, the facility was currently using EMS to transport residents and not a transportation company. When asked if the EMS personnel were being tested by the facility, EI #1 stated no, the facility does not test EMS personnel and they had not received any COVID-19 test results of the EMS personnel. On 10/16/2020 at 8:18 AM, a telephone interview was conducted with the Deputy Director of the (Name) EMS. When asked if EMS personnel were tested for COVID-19, the Deputy Director stated they were not conducting COVID-19 testing of the EMS personnel. When asked if (Name) EMS provided routine transportation services for the residents of NHC Anniston, the Deputy Director said yes. In a follow-up interview on 10/16/2020 at 11:56 AM, EI #1, the Administrator was asked why EMS personnel would not meet the definition of facility staff since the facility has a contract with them to provide transportation services for the residents. EI #1 replied, they (EMS personnel) are deemed as facility staff, which is not how she deemed them as prior. However, this morning (10/16/2020), she contacted the (Name) EMS to make arrangements for EMS testing. EI #1 stated she reviewed the guidance with the Deputy Director, their proposed agreement and offered to provide the testing at the facility for the EMS personnel that provides non-emergency transportation for the residents of the facility.

Based on observations, interviews and review of the facility's policy titled CALL LIGHTS, the facility failed to ensure the resident call system was functioning on the 300 Hall from 7/20/2020 to 7/24/2020. During the 7:00 PM to 7:00 AM shift on 7/20/2020, a weather storm caused the system to not function. The staff in the facility during the storm failed to notify the facility's Administrator or Director of Maintenance at the time of the outage. The staff also failed to provide the residents who resided on the 300 Hall with an alternate means to call for assistance. The staff assigned to work the 300 Hall from 7/20/2020 to 7/23/2020, did not report the outage to the facility's Administrator or Director of Maintenance and they failed to follow-up with anyone to ensure the malfunctioning call system was being addressed. On 7/24/2020 around 8:30 AM, a staff member brought it to the attention of the Administrator and Director of Maintenance. The Director of Maintenance then rebooted the system and it was fully functioning in less than one minute. These failures affected all 10 residents who resided on the 300 Hall, one of four halls in the facility, and placed them in immediate jeopardy for serious injury, harm, death or impairment. According to a facility document dated 8/18/2020, and titled Census Detail by Level of Care for the time period 7/20/2020 to 7/24/2020, the facility had a total of 10 residents who resided on the 300 Hall. On 8/20/2020 at 1:08 PM, the Administrator, Corporate Vice President, and Assistant Regional Nurse were given a copy of the Immediate Jeopardy (IJ) template and notified of the finding of immediate jeopardy, past non-compliance in the area of Resident Call System, F919. Findings include: The facility's undated policy titled CALL LIGHTS documented PURPOSE: Center will provide each patient with a functioning call light . OBJECTIVE: A call light alerts the staff to respond to a patient's request for help . On 8/7/2020, the Alabama State Survey Agency received a complaint which alleged, the facility's call light system on the 300 Hall was struck during a storm on 7/20/2020 and no one reported the non-functioning call system to the facility's Administrator until 7/27/2020. Once the Administrator was notified, the Maintenance Director rebooted the system and it was functioning again. During an observation on 8/11/2020 beginning at 5:10 PM, all call lights on the 300 Hall were found to be functional; the lights illuminated over the resident's room door and were audible at the nurses' station. The facility's Daily Partner Time Collection Report for 7/20/2020 indicated Employee Identifier (EI) #1, a Licensed Practical Nurse (LPN) clocked in on 7/20/2020 at 6:58 PM and clocked out on 7/21/2020 at 7:00 AM. In an interview on 8/13/2020 at 7:10 AM, EI #1, an LPN was asked about the call lights not working in the facility. EI #1 replied, there was a storm and the call lights stopped working on Monday, 7/20/2020 during the third shift (11:00 PM to 7:00 AM). When asked what he did when he recognized the call system was not working, EI #1 stated he and the Certified Nursing Assistants (CNAs) conducted every 15 to 20 minutes rounds. According to EI #1, he reported to the oncoming nurse (later identified as EI #8, a LPN), that the call lights were not working, the staff had been making rounds and everyone was okay. EI #1 stated he didn't report it to anyone else and didn't record it in the maintenance log. EI #1 stated he figured maintenance would be in the facility in the morning and would fix it (call system). When asked how long the call system was not functioning, EI #1 stated he thought it was out until Friday (7/24/2020). When asked what he should have done when the call light system went out on the 300 Hall, EI #1 replied, he should have reported it on the maintenance log so that it could be addressed the next morning. In a follow-up telephone interview on 8/16/2020 at 8:54 AM, EI #1, a LPN, acknowledged he worked in the facility on 7/23/2020 during the 7:00 PM to 7:00 AM shift. When asked did he follow up with anyone on the call light system still being out, EI #1 stated he was told by EI #8 (LPN) that the call lights still were not working. EI #1 stated he thought someone was working on the system. The facility's Daily Partner Time Collection Report for 7/21/2020 indicated EI #8, a LPN clocked in on 7/21/2020 at 7:00 AM and clocked out at 6:44 PM. During a telephone interview on 8/13/2020 at 2:10 PM, EI #8 stated when she came on shift on 7/21/2020 a nurse reported to her the call light system was not working. EI #8 stated she was told a storm had come through and lightning struck the system. When asked if she reported to anyone that the call light system was not working, EI #8 stated she didn't report it to anyone because she thought it had already been reported. EI #8 was asked what was provided to the residents to alert the staff when care was needed. EI #8 replied, nothing that she knew of. When asked what should have been done, EI #8 answered, it should have been reported to maintenance or the Supervisor and bells be given to the residents. EI #8 stated the purpose of the call light system was to help the residents be able to call for help if they need assistance. According to the Daily Partner Time Collection Report, EI #8, a LPN worked in the facility on 7/22/2020 from 7:00 AM to 6:49 PM and on 7/23/2020 from 7:00 AM to 7:05 PM. In a follow-up interview on 8/15/2020 at 5:35 PM, EI #8, a LPN, was asked why she didn't follow-up on the status of the call light system not functioning. EI #8 stated she thought it was already reported. When asked why she didn't ask someone when the system would be fixed, EI #8 replied, she didn't know. In a telephone interview on 8/13/2020 at 3:40 PM, EI #9, a Certified Nursing Assistant (CNA) was asked how did she become aware the call light system was not working. EI #9 answered that she was working the night it went out. EI #9 stated there was a storm that started during the second shift (3:00 PM to 11:00 PM) that caused the call lights to not work. EI #9 stated the residents were not given any other devices to alert the staff of care needs; that she and other staff constantly checked on the residents. According to EI #9, the only resident that complained was Resident Identifier (RI) #2 and all he/she wanted to know was when the call lights would be working again. When asked how long the call light system was nonfunctional, EI #9 stated for about three to four days. EI #9 stated she didn't question anyone as to why the call lights were not working. On 8/11/2020 at 6:00 PM, RI #2 said a storm knocked the call system out but could not recall how long it remained out. RI #2 stated someone came to check on him/her at least every hour but was not sure how long that lasted. According to the Daily Partner Time Collection Report, EI #10, an LPN worked in the facility during the 7:00 PM to 7:00 AM shift on 7/20/2020, 7/21/2020, and 7/22/2020. During an interview on 8/13/2020 at 4:35 PM, EI #10, an LPN was asked how she became aware of the call light system not working. EI #10 stated she was working on the 400 Hall the night the storm hit and a resident, RI #2, informed her that he/she needed some ice and water and that the call lights were out. When asked if she questioned anyone as to why the call lights were not working, EI #10 stated she did not and thought it was just RI #2's call light that was not working. In an interview on 8/13/2020 at 11:25 AM, EI #2, a CNA was asked how she became aware the call light system was not working. EI #2 stated she worked on 7/21/2020 and was told there has been a storm on 7/20/2020, lightning struck the system and it was out. When asked what call lights were not working, EI #2 stated it was just the 300 Hall. EI #2 was asked if any residents complained about the call lights not working and she replied, RI #3. According to EI #2, RI #3 told her that the staff needed to get the darn lights back working. RI #3 could be heard beating on the walls to let the staff know he/she needed to go the bathroom. EI #2 stated she thought the problem was being taken care of and she didn't know it would drag out as long as it did. When asked how many days the call lights were out, EI #2 said about two to three days. In an interview on 8/11/2020 at 5:38 PM, RI #3 was asked about the call light system. RI #3 stated a while back it was out for a long time. RI #3 couldn't recall how long the system was not working. According to RI #3, lightning had struck one of the circuits. While the call lights were not working, the staff checked on the residents about every 10 minutes. In a follow-up interview on 8/12/2020 at 10:55 AM, RI #3 stated the call lights were out for approximately three days. On 8/12/2020 at 11:15 AM, a random audit of the facility's call light system throughout the building was completed. All call lights were found to be functional. On 8/13/2020 at 9:30 AM, a telephone interview was conducted with RI #1, a resident who resided on the 300 Hall. RI #1 was asked if he/she was aware the call light system was not working. RI #1 replied, yes, it went out on Monday (7/20/2020) during the storm. RI #1 explained that one of the CNAs passed his/her room and said the call lights were out. When asked what he/she was provided as an alternate means to alert the staff of help needed, RI #1 said he/she was to call out or yell in hopes of getting someone's attention. RI #1 acknowledged there was a telephone in the room; however, the telephone was not always within reach and he/she was not provided a telephone number to call. On 8/13/2020 at 12:23 PM, an interview was conducted with EI #12, a first shift (7:00 AM to 3:00 PM) CNA. EI #12 stated when she came into work on 7/21/2020, she was notified by a third shift staff that a storm had come through and the call light system was not working because it had been struck by lightning. EI #12 stated to her knowledge, only the call lights on the 300 Hall were affected. EI #12 stated she assumed the issue had been reported. On 8/14/2020 at 8:51 AM, an interview was conducted with EI #13, a 7:00 PM to 7:00 AM shift LPN who works on the 300 Hall. EI #13 stated she came in one afternoon and noticed the call lights were not working. EI #13 also stated that a CNA informed her the call lights were not working and had been out since the storm. EI #13 stated the residents were checked every 30 minutes to hour to see if they needed anything. EI #13 stated she assumed it had already been reported to maintenance. According to the Daily Partner Time Collection Report, EI #13 worked in the facility during the 7:00 PM to 7:00 AM shift on 7/21/2020, 7/22/2020 and 7/24/2020. In a follow-up interview on 8/15/2020 at 3:35 PM, EI #13, a LPN was asked why she did not follow-up on the status of the non-functioning call lights when she worked in the facility on 7/21/2020 and 7/22/2020. EI #13 replied, she thought they knew and there was a reason why it was not fixed yet. EI #13 stated she works at night and thought the day shift staff had notified maintenance or the Administrator. During an interview on 8/19/2020 at 1:03 PM and 1:05 PM, respectively with RI #6 and RI #7, both residents acknowledged they were aware of the call light system was not working and was told to call out/holler for help. Both residents stated they had no unmet needs as the result of the call lights not working. In an interview on 8/13/2020 at 6:10 PM, EI #3, an LPN acknowledged that she immediately notified the Administrator on 7/24/2020 after becoming aware that RI #1's call light was not working. According to EI #3, the Administrator then notified maintenance and the residents were given a bells to alert the staff if they needed assistance, During an interview on 8/14/2020 at 4:45 PM, EI #5, the Administrator was asked how she became aware the call light system on the 300 Hall was not functioning. EI #5 replied, EI #3 notified her via text message on Friday (7/24/2020) morning around 8:30 AM. When asked how long the call lights were out, EI #5 stated there was a storm on Monday, 7/20/2020 and apparently that was when the call lights stopped working. EI #5 stated she called the nursing staff about the call lights. According to EI #5, EI #10 reported she was as aware because a resident had asked for ice and water and EI #1 said the storm caused the call lights to go out on Monday, 7/20/2020. EI #1 then reported it to EI #8. EI #5 stated, everybody assumed that everybody knew and assumed it was being fixed. In a follow-up interview on 8/15/2020 at 6:45 PM, EI #5, the Administrator stated after she became aware the call lights on the 300 Hall were not working, she notified EI #4, the Director of Maintenance. According to EI #5, EI #4 was not aware and begun working to fix the system. During an interview on 8/14/2020 at 9:30 AM, EI #4, the Director of Maintenance acknowledged that he found out on Friday, 7/24/2020 that the call light system on the 300 Hall was not working due to a storm that came through on Monday, 7/20/2020. When asked what was done to address the problem, EI #4 stated he reset the call light system and it was functional within about a minute. EI #4 was asked what his understanding was as to how long the call light system was not working. EI #4 replied, from Monday 7/20/2020 to Friday, 7/24/2020. EI #4 stated after he reset the system, he checked all the call lights throughout the entire facility. ************************* After the facility's Administrator became aware of the non-functioning call light system on the 300 Hall, the following corrective actions were implemented: On 7/24/2020, all residents on the 300 Hall were provided with a bell or [MEDICATION NAME]. All residents who resided on the 300 Hall were interviewed and no concerns were voiced. The Director of Maintenance, EI #4, was notified on 7/24/2020. EI #4 reset the call light system and it was again functional. EI #4 also conducted a facility-wide audit of all the call lights in the facility and none were found to be not working. EI #4 implemented a twice per week monitoring of the facility's call light system. Staff education was provided on 7/27/2020 regarding the facility's back-up call light system process, to include notification of appropriate personnel. 1:1 staff education was provided to EI #1 and EI #8 regarding the procedure to follow when there is a call light outage. Twice per week monitoring of the facility's call light was implemented. The above corrective actions were reviewed by the facility's Quality Assurance committee. ************************* After review of the facility's corrective actions, observations, resident and staff interviews, the facility implemented corrective actions from 7/24/2020 to 7/27/2020, thus immediate jeopardy past non-compliance was cited. This deficiency was cited as a result of complaint/report number AL 761.

Based on observation, staff interview, record review, Centers for Disease Control and Preparedness (CDC) guidelines, review of the facility Infection Control Manual, and staff education materials the facility failed to ensure staff wore a gown, mask, gloves and eye protection, as required when caring for four (4) of four (4) residents (Resident #1, #2, #3 and #4). The facility also failed to ensure staff wore a gown, mask gloves and eye protection, as required when caring for residents with unknown COVID-19 status on one (1) of one (1) quarantine units; this failure had the potential to affect 43 unsampled residents on the unit. These failures occurred during a COVID-19 Pandemic. The findings include: 1) Resident #1 was admitted [DATE], discharged to acute care on 6/2720 and readmitted from acute care on 7/21/20 with [DIAGNOSES REDACTED]. Resident #2 was admitted [DATE], discharged to acute care on 7/11/20 and readmitted from acute care 7/16/20 with [DIAGNOSES REDACTED]. Resident #3 was admitted [DATE], discharged to acute care 7/15/20 and readmitted [DATE] with [DIAGNOSES REDACTED]. Resident #4 was admitted [DATE], discharged to acute care 7/2/20 and readmitted from acute care 7/22/20 with [DIAGNOSES REDACTED]. During an interview with the Administrator on 7/23/20 at 10:45 a.m., she stated the facility was not taking new admissions at the time due to having both staff and residents that had tested positive. She stated that all readmitted residents had to have a negative COVID-19 test within 72 hours of readmission. Once readmitted residents were on a 14 day quarantine and were monitored to ensure they remained symptom free before being moved off from the quarantine area on the 400 hall. The Administrator said that staff should wear masks, face shield and gloves when providing care to readmitted residents during the quarantine period. In addition, all staff throughout the facility were to wear universal masks and had face shields or other eye protection. Upon inquiry, the Administrator confirmed staff did not wear gowns when caring for readmitted residents during the 14 day quarantine period the resident developed symptoms of COVID-19. On 7/23/20 at 11:52 a.m. the rooms of Resident #1, #2, #3 and #4 were observed with the Administrator. Resident #1, #2 and #3 were in private rooms with the door closed and Resident #4 was in a semi-private room but did not have a roommate. The door to Resident #4's room was also closed. Staff working on the hall were observed to be wearing masks and face shields, or other eye protection. There were no isolation kits with gowns for donning observed in the hallways or near the resident room doors. There was no signage on the doors indicating these residents were on transmission based precautions. The infection control policies, procedures and plan related to COVID-19 Prevention, Preparedness and Response were requested during the survey. The facility did not provide a COVID-19 specific plan during the survey. They did provide excerpts from the facility Infection Control Manual revised 10/1/08. Review of these excerpts revealed they did not specifically address Transmission Based Precautions for readmitted residents who may have been exposed to an airborne communicable disease. Review of COVID-19 staff education power point presentations (undated) provided by the facility revealed staff were educated on the appropriate Personal Protective Equipment (PPE) to wear when caring for residents with confirmed or suspected COVID-19. However, the materials provided did not include any education regarding the appropriate PPE for readmitted residents during the 14 day quarantine period. Review of the CDC guidelines entitled, Responding to Coronavirus in Nursing Homes (COVID-19), dated April 30, 2020, revealed Create a plan for managing new admissions and readmissions whose COVID-19 status is unknown. Options include placement in a single room or in a separate observation area so the resident can be monitored for evidence of COVID-19. a single negative test upon admission does not mean that the resident was not exposed or will not become infected in the future. Newly admitted or readmitted residents should still be monitored for evidence of COVID-19 for 14 days after admission and cared for using all recommended COVID-19 PPE. Further review revealed the required COVID-19 PPE for readmitted residents was use of an N95 or higher-level respirator (or facemask if a respirator is not available), eye protection (i.e., goggles or a disposable face shield that covers the front and sides of the face), gloves, and gown. 2) Resident #5 was admitted [DATE] with [DIAGNOSES REDACTED]. Review of the Nursing Notes Dated 7/4/20 - 7/6/20 revealed Resident #5 had a temperature of 99.6 degrees Fahrenheit (F) on 7/4/20 and was put on droplet precautions. On 7/5/20 the Resident's temperature was and 99.1 and she also had a productive cough and COVID-19 testing was ordered. On 7/6/20 she was noted to have a poor appetite the results of her COVID-19 test were positive. On 7/6/20 Resident #5 was discharged to a COVID-19 treatment unit at the hospital. Resident #5 had been located on 200 hall. Resident #6 was admitted [DATE] with [DIAGNOSES REDACTED]. Resident #6 had been the roommate of Resident #5. Review of the Nursing Notes dated 7/11/20 revealed Resident #6 tested positive for COVID-19 and was discharged to a COVID-19 treatment unit at the hospital. Resident #7 was admitted [DATE] with [DIAGNOSES REDACTED]. Review of the Nursing Notes dated 7/6 /20 - 7/21/20 revealed Resident #7 had been asymptomatic but tested positive on 7/23/20 and was placed on droplet precautions in the private room he was already residing in on 200 hall. Resident #8 was admitted [DATE] with [DIAGNOSES REDACTED]. Review of the Nursing Notes dated 7/6/20 - 7/23/20 revealed that Resident #8 was asymptomatic but tested positive for COVID-19 on 7/21/20. Resident #8 was put on droplet precautions and was transferred from a semi private room on 200 hall to a private room on 200 hall; across from Resident #7. During an interview with the Administrator on 7/23/20 at 10:43 a.m., she stated that the facility had four (4) residents who had tested positive for COVID-19. Two (2) of these residents remained in the facility and two (2) had been transferred out to the hospital. The two (2) residents who remained in the facility had been asymptomatic but were tested because they resided on the 200 Hall and 14 days had passed since the first resident (Resident #5) on 200 Hall tested positive. They were testing for surveillance purposes. She stated that the facility had also tested residents on other units but so far the only positive residents had been on 200 hall and all residents had been tested at least once. Eleven staff members had also tested positive and two (2) of these staff had worked on 200 hall. The Administrator said that after Resident #5 tested positive for COVID-19 the facility closed that unit off from the rest of the facility using plastic barriers. The facility had dedicated staff working on that unit and the only way to enter and exit was through the door leading to what used to be the facility's Rehabilitation Gym. This room had a door to the exterior of the building through which staff had to enter and exit. The Rehabilitation Gym had been converted into a large anteroom where staff were screened; donned and doffed masks, gloves and face shields; and performed hand hygiene as needed before entering and when exiting through a plastic barrier to the 200 hall. Upon inquiry she stated both residents who were COVID-19 positive resided on this unit in private rooms at the end of a hall and that staff donned gowns and gloves as needed to go in and out of the COVID-19 positive isolation rooms. Upon further inquiry she indicated that gowns were not worn when caring for the other residents on 200 hall who had potentially been exposed to COVID-19. On 7/23/20 at 12:15 p.m. the 200 Hall was observed with the Director of Rehabilitation, who was acting in a Unit Leadership Role for the 200 Hall (COVID-19 positive and COVID-19 quarantine unit). Isolation kits containing PPE were observed outside the rooms of Resident #7 and #8. No other isolation kits were observed on the unit. Upon inquiry the Director of Rehabilitation conformed that gowns were not worn when providing care to the residents on the unit whose COVID-19 status was unknown. While all the residents on 200 Hall had previously tested negative for COVID-19, it had only been two days since Resident #7 and Resident #8 tested positive for COVID-19. During an interview with the Administrator on 7/24/20 at 3:22 p.m., she indicated she was unaware of the requirement for staff to wear gowns during a quarantine period when caring for residents who resided on the same unit as other residents had tested positive for COVID-19. The Administrator added the facility's implemented droplet precautions with full PPE including gowns, gloves, face shield and N95 masks only for when residents had symptoms of COVID-19 or were COVID-19 positive. In addition she said that Resident #9 (the previous roommate of Resident #8) had been placed on droplet precautions (with full PPE) as a preventive measure. During an interview with the Administrator and Regional Nurse on 7/24/20 at 3:40 p.m., the Regional Nurse stated that the facility was only using gowns for residents who were COVID-19 symptomatic or positive due to a shortage of PPE. The Administrator indicated the facility supply of gowns was at contingency capacity. Upon inquiry the Administrator confirmed the facility had a supply of cloth gowns available. Review of the facility census dated 7/23/20 revealed that in addition to Resident #7 and Resident #8 there were 44 residents on 200 Hall. This included Resident #9 who was on droplet precautions as noted above. Therefore there were a total of 43 residents who had potentially been exposed to COVID-19 that staff were providing care to without wearing all recommended PPE (gown). The facility policy and procedure regarding optimizing the supply of PPE in response to contingency or crisis capacity supplies was requested but not provided during the survey. During an interview with the Administrator on 7/24/20 at 3:22 p.m., she indicated the facility did not have a written policy on this subject. The facility policy and procedure regarding transmission based precautions for residents potentially exposed to COVID-19 and/or the procedures specifically in place for the residents on 200 Hall who were not already known to be COVID-19 positive was requested but not provided during the survey. Review of the CDC guidance entitled Responding to Coronavirus (COVID-19) in Nursing Homes dated April 30, 2020 revealed, when a resident is confirmed to have COVID-19, regardless of symptoms, they should be transferred to the designated COVID-19 care unit. In addition HCP (health care providers) should use all recommended COVID-19 PPE for the care of all residents on affected units (or facility-wide if cases are widespread); this includes both symptomatic and asymptomatic residents. Maintain Transmission-Based Precautions for all residents on the unit at least until there are no additional clinical cases for 14 days after implementation of all recommended interventions.

Based on observation, interviews, and a review of the facility policy titled, Handling Linen, the facility failed to ensure that a staff member changed gloves and washed hands between rooms while collecting dirty laundry. This deficient practice had the potential to affect 2 out of 3 residents who had soiled laundry removed from their rooms by a staff member. Findings include: A review of the facility policy titled, Handling Linen, with no date, revealed, Purpose: Designated partners will handle . soiled linen appropriately. Objective: Provide guidelines to ensure . safe handling of . soiled linen to prevent the spread of germs and infection. Dirty Linen Procedure 1. Remove soiled linen . 5. Remove glove and wash or use hand sanitizer. On 11/13/2019 at 08:39 AM, an observation was made of Employee Identifier (EI) #1 exiting a resident's room with a small container of dirty laundry and emptying it onto the upside-down lid on the laundry barrel located in the hall. EI #1 then returned the small container to the room, returned to the hall to the laundry barrel, then began going through the dirty clothing. EI #1 was wearing one glove to the left hand and no glove to the right hand. EI #1 handled the dirty clothing with both hands and used a marker (which was on the upside-down lid) to mark names in the clothing that required it. EI #1 then placed the clothing into the laundry barrel. EI #1 entered another resident's room wearing the same glove to the left hand, collected the small container of dirty clothes, emptied the small container onto the upside-down lid on the laundry barrel in the hall, and returned the small container to that room. EI #1 then looked at each garment noting if a name was present, a pair of pants from this pile was noted to be visibly soiled. EI #1 was observed touching the soiled pants with both hands. EI #1 then placed the soiled clothing into the laundry barrel and proceeded to the last room. Wearing the same glove to the left hand and no glove to the right hand, she repeated the previous actions. EI #1 did not utilize the hand sanitizer when exiting or entering the rooms. After these observations EI #1 was interviewed. EI #1 was asked why she had only one glove on. EI #1 stated she needed a clean hand to touch the doors and enter rooms. EI #1 was asked if she had kept the right hand clean. EI #1 stated she tried to, but she may have touched the dirty clothes with the right hand because it was hard not to. EI #1 was asked if she had changed the glove to the left hand and washed her hands between rooms. EI #1 replied she had not, she would change the glove if it became really soiled. EI #1 also stated she used the hand sanitizer on her right ungloved hand when leaving the last room. EI #1 was asked what their policy was for collecting dirty laundry. EI #1 stated they were taught to wear one glove and keep the other hand clean. EI #1 was then asked what would be the potential concern with wearing the same dirty glove, going room to room, collecting dirty laundry. EI #1 stated they could spread germs, it was an infection control concern. On 11/14/2019 at 01:39 PM, an interview with EI #2, Director of Nursing/ Infection Control was conducted. EI #2 was asked how a staff member should collect personal laundry from a resident's room, then continue to another room. EI #2 stated they would expect the staff member to pick the laundry from the room, dump into assigned container, wash hands if soiled or use hand sanitizer if not visibly soiled. EI #2 was asked if the staff member should wear gloves, and EI #2 replied they can, but if they do not they should wash their hands or use sanitizer. EI #2 was asked if staff should change gloves and wash hands after collecting soiled laundry from a resident's room. EI #2 stated yes, if the staff realized the laundry was soiled, they should wash their hands, then put on gloves. EI #2 continued to state when the gloves were removed they should wash their hands or use hand sanitizer.

Based on observation, interview, the (YEAR) Food Code, and the facility's policy titled, Refrigerator and Freezer Storage, the facility failed to ensure ice cream and frozen nutritional treats were maintained solidly frozen during storage and failed to prevent the potential for contamination from backflow of contaminated sewage by allowing a food preparation sink's drain pipe to extend into the floor drain, This had the potential to affect all residents receiving meals from the kitchen, 135 of 136 residents. Findings Include: I. Frozen Food The (YEAR) Food Code recommendations of the United States (U.S.) Public Health Service and the U.S. Food and Drug Administration included: . 3-501.11 Frozen Food. Stored frozen FOODS shall be maintained frozen. The Code of Federal Regulations, Title 21, Volume 2, revised (MONTH) 1, (YEAR), included: . PART 135 -- FROZEN DESSERTS Subpart B -- Requirements for Specific Standardized Frozen Desserts Sec. (Section) 135.110 Ice cream and frozen custard. (a) Description. (1) Ice cream is a food produced by freezing, while stirring, a pasteurized mix consisting of . dairy ingredients . The facility's policy Refrigerator and Freezer Storage, dated (MONTH) (YEAR), included: Guidelines: . 3. Frozen foods should remain solidly frozen during storage. At 7:30 PM on 9/17/18, during the initial kitchen tour with Employee Identifier (EI) #1 (the full-time Registered Dietitian) and EI #2 (the Dietary Manager), individual 4-ounce cups of ice cream and ice cream type nutritional treats were found not to be frozen solid in the Walk-in Freezer. The surveyor was able to press into the sides of the individual containers. The items checked and found to be soft included: two individual vanilla-flavor nutritional treat cups, four individual ice cream cups, and several individual vanilla-flavor ice cream cups in an opened box. II. Food Preparation Sink The (YEAR) Food Code recommendations of the U.S. Public Health Service and the U.S. Food and Drug Administration included: . 5-402.11 Backflow Prevention. (A) . a direct connection may not exist between the SEWAGE system and a drain originating from EQUIPMENT in which FOOD, portable EQUIPMENT, or UTENSILS are placed. At 8:00 PM on 9/17/18, during the initial kitchen tour with EI #1 and EI #2, a drain pipe from a food preparation sink was observed extending into a floor drain. On 9/19/18 at 10:45 AM, EI #1 confirmed that the sink with the drain pipe extending into the floor drain was a food preparation sink. When asked what would be the problem if sewage back-flowed into the food preparation sink, EI #1 said potential contamination of the food preparation sink.

Based on observation, interview, medical record review and a review of the facility's policy titled, MEDICATION ADMINISTRATION-GENERAL GUIDELINES, the facility failed to ensure a licensed staff did not a leave a medication cart unlocked, unattended and out of staff view. This affected one of four nurses and one of four medication carts observed during medication administration. Findings Include: A review of the facility's policy titled, . Medication Administration-General Guidelines, effective date: 6/2016, included . B. Administration . 15) During administration of medications, the medication cart is kept closed and locked when out of sight of the medication nurse . On 09/19/18 at 8:22 AM, Employee Identifier (EI) #5, Licensed Practical Nurse (LPN) was observed during a medication pass. After EI # 5 completed her pass she returned to the med cart and reconciled all med passed. She locked the cart and left the area to retrieve a piece of equipment. At 09/19/18 at 8:42 AM, EI #5 returned to the cart, obtained additional meds and water and reentered the resident's room, after knocking. On 09/19/18 at 8:44 AM, EI #13, LPN/Restorative Nurse, walked by the med cart, turned around, locked the cart and proceeded to walk away. EI #13 was stopped by the surveyor and asked what she had done. She stated, I locked the med cart. When EI #5 returned to the med cart she was informed by EI #13 that she locked the med cart. 09/19/18 at 10:19 AM, EI #13 was interviewed regarding the locking of the med cart. EI #13 was asked what she did to the med cart. She replied she locked it. EI #13 was asked when did she notice the med cart was unlocked. She replied when she passed by. EI #13 was asked what do you do when leaving a med cart unattended. She replied, lock it. EI #13 was asked if she was working the med cart. She replied, no ma'am. When asked why she locked it, EI #13 said because she walked by and noticed it was not locked. EI #13 was asked what should she have done since she was not working the med cart. EI #13 replied, stood and waited for her( med nurse) to come out. 09/19/18 at 10:20 AM, EI #5 was interviewed regarding her med cart not being locked at the time she left it. EI #5 was asked who was responsible for locking med carts when not in use. She replied, the nurse working it. When asked what was the purpose of locking the med cart, she replied, so nobody else could open it. EI #5 was asked what did she do with the med cart when she entered the resident's room to pass meds. She said she left it unlocked. EI #5 was asked was the med cart in her line of site at all times. She replied, no not when she went into resident's room. When asked what was the facility policy and procedure for med carts when not in use or out of line of site, EI #5 said, it has to be locked. When asked if she followed the policy and procedure, EI #5 said, no. EI #5 was asked what the potential harm when med carts were left unlocked and unattended. She replied, anybody could open the cart, potentially a resident.

Based on observation, interview, record review, and a facility policy titled, Nail Care, Cleaning and Trimming, the facility failed to ensure Resident Identifier (RI) # 92's toenails were not long, thick and curved, on two of four days of the survey. This effected 1 of 52 residents observed for (ADL'S) Activities of Daily Living care. RI #92 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. A review of RI #92's Quarterly Minimum Data Set (MDS) assessment, with a reference date of 08/22/2018, reflected the resident had a Brief Interview of Mental Status of 12/15, indicating moderate cognition impairment. The MDS also reflected the resident required extensive assistance of one person for personal hygiene care. A review of RI #92's Assessment Record form, with dates of 8/6, 8/13, and 8/20, was documented with a N (No) for thick mycotic nails. A review of the facility policy titled, Nail Care, Cleaning and Trimming, included the purpose, Designated partner will care for patients nails as needed- . If a patient has thick mycotic nails may need referral to MD (Medical Doctor)/ podiatrist. OBJECTIVE: Promotes dignity and cleanliness and prevents infections and injury to the skin. On 09/18/18 at 11:00 AM, RI #92 verbalized to the surveyor he/she wanted and needed their toe nails cut and asked the surveyor if she could cut the nails. The resident said he/she wanted to be next. RI #92 wanted to know if the person (staff from a salon) cutting the roommate's toe nails at that time could cut his/hers nails next. The surveyor observed RI #92's toe nails to be long, thick and several toe nails were curved toward the side. On 09/18/18 at 1:45 PM, the surveyor went with the Licensed Practical Nurse (LPN)/ Unit Manager, Employee Identifier (EI) #10, to assess the resident's toe nails. On 09/18/18 at 4:03 PM, the spouse of RI #92 reported to the surveyor the resident's toe nails had been that way since the resident was admitted (05/23/18). On 09/19/18 at 9:50 AM, RI #92 was observed in his/her room. The resident asked the surveyor if she was there to cut the resident's toe nails. The surveyor responded with, no ma'am. On 09/20/18 at 3:07 PM, Certified Nursing Assistant (CNA) EI # 11, was interviewed. She was asked if she assisted RI #92 with activity of daily living care and showers. EI # 11 said, yes. When asked if she had observed the resident's toe nails, EI #11 answered, yes. When asked how did the nails look, EI #11 replied they needed to be clipped. When asked who she reported it to, the CNA named the nurse she reported to. EI #11 said she did not report it to anyone else because the nurse she reported to was the resident's assigned nurse when working. When asked when she reported it to the nurse, EI #11 replied, about a week prior. On 09/20/18 at 3:18 PM, an interview was conducted with EI # 10. She was asked if she was aware of the resident's long curved toe nails. EI #10 replied she was as of Tuesday, 9/18/18, when she and the surveyor went to RI #92's room to look at the toe nails. When asked how the toe nails looked to the nurse, she replied, long and thick. EI #10 was asked if the resident needed nail care. She replied, yes. EI #10 was asked who was responsible for the resident's nail care. EI #10 replied, the nurse that does the skin assessment should be responsible, but anyone that the resident asked could provide the nail care. When asked if RI #92 asked her to cut her toe nails, EI #10 said the resident did, on 9/18/18. EI #10 was asked when did the resident get the toe nails cut. She replied, the day before on 9/19/18. When asked why the nails were cut on 9/19/18, instead of 9/18/19, EI #10 said due to the resident's thick nails she had to get a heavy emery board to file them. When EI #10 was asked what harm could be caused to RI #92 with the long thick toe nails, she replied, pain and possible sore feet.

Based on observations, interviews and a review of facility policy titled MACHINE WAREWASHING, the facility failed to ensure: 1) plates were air dried and free of a black spot before staff placed them into the warmer, and 2) forks and spoons were dry in the silverware rack and in a cloth wrapped napkin. This had the potential to affect 136 of 136 residents who received meals from the kitchen. Findings Included: A review of a facility policy titled MACHINE WAREWASHING, with a revised date of 1/2011 revealed: .Warewashing Machine Operation: . 11. Air-dry all items . Make sure all items are dry before stacking to prevent wet-nesting . 1) On 9/13/2017 at 9:15 a.m., the surveyor observed dietary staff pulling dishes from the dishmachine and putting them immediately into a plate warmer. A black spot was noted on one of the plates. The plates were stacked on top of each other with water spots, and placed in the plate warmer. On 9/13/2017 at 11:11 a.m., the surveyor observed two plates in the warmer with water spots. On 9/14/2017 at 9:50 a.m., the surveyor conducted an interview with (Employee Identifier) EI #4, Dietary Manager. EI #4 was asked what was in a plate in the warmer. EI #4 replied a black spot. EI #4 was asked what was the black spot. EI #4 replied, she did not know. EI #4 was asked what was the facility policy on how plates should dry. EI #4 replied, air dry. EI #4 was asked who was responsible for making sure plates were dry. EI #4 replied, dietary aide. EI #4 was asked when dishes came out of the dish machine and immediately placed in the warmer was there water in the plates. EI #4 replied, yes. 2) On 9/13/2017 at 11:11 a.m., the surveyor observed one spoon and six forks in the silverware canister wet. On 9/14/2017 at 3:00 p.m., the surveyor conducted an interview with EI #5, Dietary Aide. EI #5 said she saw a wet fork wrapped in a cloth napkin. EI #5 was asked what did the facility policy say about wet utensils/wet nesting. EI #5 replied, she did not know the procedures. EI #5 was asked how should utensils be allowed to dry. EI #5 replied, they did not tell her. EI #5 was asked what was the potential harm when giving residents wet utensils from a wet silverware rack. EI #5 replied, she did not know. EI #5 was asked who was responsible for making sure utensils were dry. EI #5 replied, the person that did the dishes. On 9/14/2017 at 10:10 a.m., the surveyor conducted an interview with EI #3, the Dietitian. EI #3 was asked what did the facility policy say about wet nesting of utensils. EI #3 replied, they should be allowed to air dry. EI #3 was asked what was the potential harm when giving residents wet utensils from a silverware rack. EI #3 replied, there was a chance for bacteria to grow. EI #3 was asked who was responsible for making sure utensils were dry. EI #3 replied, the aides that were wrapping the silverware.

Based on observation, record review and interview, the facility failed to ensure: 1) Dented cans were not stored with regular cans. 2) A dietary worker tempted food before serving on the tray line. This had the potential to affect 136 residents receiving meals from the kitchen. Findings Include: 1. A review of a facility policy titled, Safety & Sanitation Best Practice Guidelines with an original date 1/2011 revealed: Dry (Non-Perishable) Food Storage . 4) An area must be designated and labeled for dented can storage . Unacceptable dented cans include: side, top or bottom seam dent. On 8/23/2016 at 1:40 p.m., the surveyor and the dietary manager observed a six pound and six ounce can of white potatoes dented in the middle. On the same shelf, there was a four ounce can of tuna that was dented on the side at the top. On 8/25/2016 at 8:42 a.m., the surveyor conducted an interview with the dietary manager, EI #5 (Employee Identifier). EI #5 was asked what two cans were dented in dry storage. EI #5 replied, Tuna and potatoes. EI #5 was asked why were the cans on the shelf with regular cans. EI #5 replied, someone forgot to take them off the shelf. EI #5 was asked who was responsible for removing dented cans from the shelf. EI #5 replied, everybody. EI #5 was asked where are dented cans kept. EI #5 replied, on the self that is labeled dented cans. EI #5 was asked what was the facility policy on dented cans. EI #5 replied, they should be placed on the dented can shelf. EI #5 was asked what was the potential harm when dented cans were on the shelf with regular cans. EI #5 replied, it can seep out, dry out and spoil. 2. A review of a facility policy titled, Safety & Sanitation Best Practice Guidelines with a Original Date 1/2016 revealed: . Subject: INSERVICE: TIME/TEMPERATURE CONTROL THROUGHOUT FOOD . Serving: 2. Cold food should be held at 41 degrees or lower throughout the serving process. On 8/24/2016 at 11:40 a.m., the cook was plating. She did not take the temperature of a pan of vegetables that was poured into the pan already on the steam table. After the vegetables was poured into the steam tray container, she continued plating. On 8/25/2016 at 9:10 a.m., an interview was conducted with the cook, EI #6. EI #6 was asked did she take the temperature of the vegetables that was poured into the steam tray pan. EI #6 replied, no. EI #6 was asked why was it not tempted. EI #6 replied, she did not take it. EI #6 was asked when should she take the temperature of food on the tray line. EI #6 replied, before and after tray line starts. EI #6 was asked why should she take the temperature of food on the tray line. EI #6 replied, to make sure it reads the right temperature of 135 degrees and above for hot foods, and 41 degrees and below for cold food. EI #6 was asked what was the facility policy on taking the temperature of foods. EI #6 replied, she had to make sure the food was at the right temperature when being served to the residents. EI #6 was asked what was the potential harm when food items were not tempted before serving. EI #6 replied, she would not know if the temperature was right for the residents. On 8/25/2016 at 9:11 a.m., an interview was conducted with the dietary manager, EI #5. EI #5 was asked was new vegetables poured in with the old vegetables on 8/24/2016. EI #5 replied, yes ma'am. EI #5 was asked did the worker take the temperature of the food before it was poured into the old vegetables. EI #6 replied, no.

Based on record reviews and interview, the facility failed to ensure reference checks were completed on new employees. This had the potential to affect all residents living in the facility. Findings include: A review of personnel files revealed there were no reference checks completed for the following positions: ADON (Assistant Director of Nursing), two CNA's (Certified Nursing Assistant), one housekeeping and one RN (Registered Nurse). A review of a facility policy titled, Human Resources Policies and Procedures with a revision date of 08/01/1999 revealed the following: .Employment Process . E. For potential new hires the hiring management is responsible for verifying applicant information and conducting reference checks. On 08/25/2016 at 4:25 PM, an interview was conducted with EI (Employee Identifier) #1, Administrator. EI #1 was asked who was responsible for ensuring new hire employee references were checked. EI #1 stated the department head. EI #1 was asked when he reviewed the personnel files for the identified new employees, was he able to locate the reference checks in their personnel files. EI #1 stated no. EI #1 was asked why. EI #1 explained the reference checks either had not been completed or documented. EI #1 was asked what was the facility's policy for checking references for new hires. EI #1 said to check references on all new hires. EI #1 was asked was the facility's policy followed. EI #1 said no ma'am. EI #1 was asked should references have been checked for new hires identified. EI #1 said yes. EI #1 was asked what was the potential harm in not checking references for new hires. EI #1 said he did not believe there was any harm.

Based on observation, record review, and interview the facility failed to ensure a licensed staff member cleaned an overbed table or placed a barrier on the overbed table before placing the equipment on the table to perform a fingerstick blood sugar. This affected one of one resident observed for fingerstick blood during the survey. Findings Include: RI (Resident Identifier) #25 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. RI #25's most recent Quarterly MDS (Minimum Data Set) with a ARD (Assessment Reference Date) of 06/09/2016 revealed a BIMS (Brief Interview for Mental Status) score of 09 out of 15. This indicated RI #25 to be moderately impaired in cognition. A review of Fundamentals of Nursing, Eighth Edition of Pottter and Perry revealed the following: . Chapter 44, Nutrition, page 1037 . 7. Remove unused reagent strip from meter and place on a paper towel or clean, dry surface . On 08/24/2016 at 11:25 AM the surveyor observed EI (Employee Identifier) # 4 perform a fingerstick blood sugar on RI #25. When placing the supplies and equipment on the resident's overbed table, EI #4 did not clean the overbed table or put a barrier on the overbed table before placing the supplies on it. On 08/24/2016 at 11:10 AM and interview was conducted with EI #4 a licensed staff member. EI #4 was asked what she failed to do that AM when doing a fingerstick blood sugar on RI #25. EI #4 said she failed to put a barrier between the glucometer and the overbed table. EI #4 was asked why she failed to put down a barrier on the overbed table or clean it before putting supplies down on it. She said she really didn't think it was needed since the glucometer had just been cleaned before and after a procedure. EI #4 was asked what did the facility say about putting down a barrier or cleaning the overbed table prior to putting down supplies on it. She replied not sure, didn't think it was needed. EI #4 was asked what was the potential harm in failing to put down a barrier or cleaning an overbed table before putting supplies on it. She replied contamination, germs. On 08/25/2016 at 10:00 AM an interview was conducted with EI # 2, DON(Director of Nursing)/ Infection Control Nurse. EI #2 was asked if the facility had an Infection Control Committee. EI #2 replied yes. EI #2 was asked how often does the Infection Control committee meet. EI #2 said 1 time a month. EI #2 was asked who the members of the committee was. EI #2 said the Medical Director, Director of Nurses, the Assistant Director of Nurses, The Senior Leadership Team and anybody that just wants to come.

Based on interviews and record reviews the facility failed to ensure the sponsor for Resident Identifier (RI) # 2 was notified when the resident was sent to the hospital. This affected RI # 2, one of 24 sampled residents, and one of three closed charts reviewed. Findings included: The facility's policy titled,4.1 POLICIES AND PROCEDURES REGARDING CHANGE IN PATIENT STATUS, with a R/ (Revised date) of 3-7-11 stipulated: . B. Notification of Family/Legal Representative The charge nurse on duty is notified immediately of any change in a patient's condition. The charge nurse will then assess the patient's condition and notify the doctor and the patient's family/legal representative. The patient may not be transferred to the hospital without first notifying the family . If unable to contact the family, the patient will be transferred per doctor's orders, and efforts to reach the family will be continued and documented. C. Care of Patients in Emergency Situations The Charge Nurse will: 3. Notify the family or legal representative In the admissions booklet given to residents titled, PATIENT RIGHTS revealed revealed the following: . page 10 . Medical Condition .Your physician and family, legal representative or guardian will be notified of any unusual or sudden changes in your condition. RI #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. RI#2's Minimum Data Set assessment dated [DATE] documented the resident with a cognitive score of 8 out of 15 which meant the resident was moderately impaired for decision making skills. RI #2's functional status for Activities of Daily Living (ADL) such as transfer, personal hygiene and dressing required extensive assistance with two or more persons physical assist. A review of RI #2's medical chart on 8/24/16 at 4:00 PM, with the Registered Nurse (RN) Supervisor, Employee Identifier (EI) # 9, revealed RI #2 was transferred to the hospital on [DATE]. A Daily Nursing Note Report dated 7/22/2015 under the title: ADDITIONAL PERTINENT FACTS RELATED TO CARE PROVIDED ON SHIFT: documented While being transferred back to room from therapy, patient had [MEDICAL CONDITION] activity. Patient was responsive with unstable vital signs. Patient transported to (Name of) Hospital ER (emergency room ) via ambulance to be assessed. RN to call and check status of patient, if admitted or not. This note was signed by a RN, EI #10 on 7/22/15. There was a Multidisciplinary Note dated 7-22-15 with a stamped TRANSFERRED TO HOSPITAL with no other note. There was also a facility document titled, Dietary Progress Notes dated 7-22-15 with the stamped, TRANSFERRED TO HOSPITAL. There was a physician order [REDACTED]. Through the nurses notes and other notes, there was no documentation of the family or sponsor called when the resident was sent to the hospital on [DATE]. In an interview with RI #2's sponsor, on 8/24/16 at 12:35 AM, the sponsor stated the facility did not contact her or her husband when the resident was sent to the hospital. The sponsor stated the resident had three or four hospitalization s but she was not contacted on the first hospitalization . In an interview with EI #9 on 8/24/16 at 4:00 PM, she was asked, what do you do when a resident goes out to the hospital. EI #9 said, notify the family and get doctor's orders. In the search through the records the surveyor and EI #9 could not find any notification record for the family. In an phone interview on 8/25/16 at 10:25 AM with EI #10, she was asked if she could remember calling the sponsor for this hospitalization . EI #10 said she remembered the patient being sent out to the hospital, however, if it was not documented, she guess she did not notify the family. EI #10 said she usually does call, however, with the emergency of getting the resident to the hospital, getting the ambulance, she had forgotten to call the sponsor.

Based on record review and interview, the facility failed to ensure Resident Identifier (RI) #1, a resident with [MEDICAL CONDITION]( [MEDICAL CONDITION]) was discharged home with an adequate supply of blood thinner. This had the potential to affect one of three residents whose discharge medicines were reviewed during the survey. Findings Included: A review of a facility document titled, Discharge Process Instructions: revealed: .Phone in medications to pharmacy of choice (as needed) . Complete discharge summary and/or nurse note. RI #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #1 physician's orders [REDACTED]. On 8/25/2016 at 2:35 p.m., an interview was conducted with the ADON, (Assistant Director of Nursing), EI #3 (Employee Identifier). EI #3 was asked where in the notes did the nurse compare home medicine with medication being used at the facility. EI #3 replied, there was no nurse notes that indicated she compared medicines. EI #3 was asked when was a prescription given to the resident or family member for Eliquis during the discharge process. EI #3 replied, there was no documentation of that. EI #3 was asked when was Eliquis medicine given to the resident or family members during discharge. EI #3 replied there was no evidence of documentation that she saw. EI #3 was asked who called in a prescription for Eliquis for the resident during discharge. EI #3 replied, there is no documentation that it was called in. EI #3 was asked what should the discharge nurse had done when she went over the resident Eliquis medication. EI #3 replied, she should have asked the resident or family member if they needed any of these medication called into the pharmacy. EI #3 was asked where was it documented that she asked the resident of family member theese questions. EI #3 replied, there was no documentation that supported that. EI #3 was asked if RI #1 had a supply of Eliquis until he/she followed up with his/her provider. EI #3 replied, she was unaware that RI #1 had a supply. EI #3 stated according to the documentation in the chart, there was no notes that RI #1 had an adequate supply of Eliquis. On 8/25/2016 at 3:07 p.m., an interview was conducted with the DON (Director of Nursing), EI #2. EI #2 was asked where in the notes was it documented that the discharge nurse compared home medication to a list of medication at the facility. EI #2 replied it was not. EI #2 was asked when was a prescription given to the resident or family member for the medication Eliquis. EI #2 replied, it was not. EI #2 was asked when was a prescription called in for Eliquis during discharge. EI #2 replied, it was not. EI #2 was asked what should the discharge nurse have done when she went over the discharge medication. EI #2 replied, she should have verified that the medication was at the patient's home. If not, called in to the appropriate pharmacy. EI #2 was asked did the resident leave the facility with medication, a prescription or a call in prescription to the facility. EI #2 replied, not that I am aware of. On 8/25/2016 at 3:30 p.m., a telephone interview was conducted with EI #8, RN (Registered Nurse). EI #8 was asked do you remember RI #1. EI #1 replied, yes ma'am. EI #8 was asked did you discharge RI #1. EI #8 replied, she did not work on that hall but she discharge he/she that day. EI #8 was asked did you go over his/her medication. EI #8 replied yes ma'am. EI #8 was asked how did she know if he/she did not have adequate medication for Eliquis. EI #8 said the residents would tell us. When we discharge patients, we tell them which one to take and which one not to take. EI #8 was asked when she went over the discharge list did she know if the resident had medication to take home. EI #8 replied no ma'am. On 8/25/2016 at 9:40 a.m., a telephone interview was conducted with EI #7, Physician. EI #7 was asked do you remember RI #1. EI #7 replied he could not remember. EI #7 said he remembered the [DIAGNOSES REDACTED].#7 was asked did you write a prescription for RI #1. EI #7 replied, possible. EI #7 was asked why did he/she not leave the nursing home with medication. EI #7 replied, they should have at least given him/her one month supply or what was left. EI #7 was asked how long was he/she suppose to take the Eliquis. EI #7 replied, if it was his patient he would give five refills. If it was another physician's patient he would give a one month supply.

Based on observation and interview the facility failed to ensure a Certified Nursing Assistant (CNA) did not stand while feeding Resident Identifier (RI) #2 lunch on 9/2/15. This affected 1 of 13 sampled residents which meals were observed. Findings Include: RI #2 was readmitted to the facility 3/11/15 with [DIAGNOSES REDACTED]. On 9/2/15 at 12:45 PM, EI #7, a CNA was observed rolling RI #2 in the wheelchair to the room for lunch. EI (Employee Identifier) #7 backed the wheelchair in the room. EI # 7 Then stood on the resident 's right side and began to feed the lunch meal. EI #7 was observed from 12:45 PM until 1:10 PM standing to the right side of RI #2 feeding the lunch meal. On 9/2/15 at 1:15 PM an interview was conducted with EI # 7. EI #7 was asked how long she had been a CNA and how was she instructed to feed residents. EI #7 replied she had been a CNA for almost 3 years and she was taught to sit down when feeding a resident. EI #7 was asked what the harm would be in not sitting to feed a resident. EI #7 replied they cannot see her. EI #7 was then asked if standing over a resident to feed them could be considered a dignity issue. EI #7 replied yes.

Based on observations, interviews and record review the facility failed to ensure Resident Identifier (RI) #3, a resident with a history of falls, was provided adequate supervision after her personal chair alarm was discovered malfunctioning. RI #3 stood and fell when left unattended, and sustained a fracture to her right arm. Furthermore, the facility failed to ensure RI#12, another resident with a history of falls, had a Dycem pad in the seat of his wheelchair on two (2) of three (3) days of the survey. This affected two (2) of eleven residents sampled for falls. Findings include: 1. RI #3 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Updated [DIAGNOSES REDACTED]. A Quarterly Minimum Data Set (MDS) with the assessment reference date of 07/22/13, identified RI #3 as cognitively intact with a BIMS (Brief Interview Mental Status) score of 13 out of a possible 15. The MDS assessed RI #3 as requiring "Extensive assistance of one person physical assistance with most of her ADL (Activates of Daily Living skills)." That included bed mobility, transfers, dressing, bathing and personal hygiene. The MDS identified RI #3 for falls: "two with no injury and one with major injury - (bone fractures ...)." A review of RI #3's medical records and fall investigations, revealed RI #3 had 13 falls in the last year, and a history of falls before coming into the facility. The care plan interventions were reviewed on the falls and it was noted that on admission RI #3 had a "Falls Care plan" dated 07/24/12, which identified, "Bed/Chair alarms. Check activatin (activation) each shift and PRN (As needed)." The May 06, 2013 Falls Care Plan for RI #3's had "6/2/13 PBA (Personal Bed Alarm) and PCA (Personal Chair Alarm) for pt (patient) to prevent falls and 6/4/13 Fall mat beside bed and in lowest position." Both of these approaches were handwritten in as new approaches. The bed/chair alarms and the low bed were already on the care plans." According to the fall investigations, during the month of June 2013, RI #3 had a fall on June 6th, and on the 16th she had two falls. On 06/18/13, RI #3 had a fall which resulted in a fractured arm. The Facility's Post Falls Investigation dated 06/18/13 (for the 06/16/13 fall), identified the approaches as: "Lowbed in low position; bed/chair alarm; call light w/i (within) reach and personal items (within reach); fall mat beside bed, environment free of clutter." The physician's orders [REDACTED]." The Indication - Dx (diagnosis) of the physician's orders [REDACTED]." RI #3's Radiology Exam dated 6/18/13 from the local hospital documented, "Distal radial metaphysis is noted. Fracture extends to the articular surface of the radiocarpal joint. Essentially nondisplaced ulnar styloid fracture is noted. Diffuse osteopenia is present." The incident report dated 06/19/13 (for the fall on 6/18/13) documented, RI #3 had "7 falls in the last 30 days and 9 falls in the last 180 days." The witness statements from the Licensed Practical Nurse (LPN) and the Certified Nursing Assistant (CNA) were reviewed and they were both interviewed. RI #3 was interviewed on 08/07/13 at 11:15 AM. RI #3 was asked how she had the fall with the fracture. RI #3 said she got up out of her chair and turned around too fast. RI #3 said the alarms were not in place then. RI #3 told the surveyor she does not go to the dining room anymore because she spills food on herself since she had the cast and splint on her arm. A facility form titled "Investigation Report" dated 06/18/13 documented: "Incident: Pt (Patient) was in room sitting in chair. She tried to get up to rest room & (and) was unable to stand & fell . Pt hit (R) (right) side of head on door & was sent to hospital for eval (evaluation). Investigation: Pt was sitting in chair in room. Alarm was not in chair (wasn't working properly). Activity partner sat patient in chair and pt stated she would be ok, so pt was left in chair without alarm. Pt tried to go to RR (restroom) and fell . Pt struck head on right side of RR door ... Pt did have (R) distal Radius Fx (fracture) & returned from hospital c (with) splint and sling." On 08/08/13 at 6:30 PM, an interview was conducted with EI #7, RI #3's assigned CNA (Certified Nursing Assistant) on June 18, 2013. EI #7 stated RI #3's alarm was not working properly. EI #7 stated it would not sound when RI #3 stood up. EI #7 said instead of telling the nurse, she just went to Central Supply to get a new alarm. EI #7 said when she returned, RI #3 had fallen. The surveyor asked EI #7 was the activity partner still in the room when she left the resident. EI #7 stated no. The surveyor asked EI #7 why would she leave RI #3 knowing the alarm was not working. EI #7 said she guessed she was not thinking. The LPN (Licensed Practical Nurse), EI #5, assigned to care for RI #3 on June 18, 2013 was interviewed on 08/08/13 at 6:50 PM. The surveyor asked EI #5 if she knew that the CNA (EI #7) had left RI #3 alone? EI #5 said, "Yes, we had told her (EI #7) that RI #3's alarm was not working." EI #5 was asked how did you know the alarm was not working. EI #5 said the alarm was not going off when she (RI #3) got up. EI #5 was asked whose responsibility it was to replace the alarms when they are not working. EI #5 said it was anybody's responsibility. On 08/08/13 at 10:15 PM, the facility's DON (Director of Nursing), EI #1, stated the CNA, EI #7 had been counseled. EI #1 stated she told EI #7 she should never had left her (RI #3). 2. RI #12 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. RI #12's most recently Quarterly MDS with an ARD (Assessment Reference Date) of 05/09/13, identified RI #12 to have a BIMS score of 8, indicating moderate impairment. RI #12 was assessed to need extensive assistance with bed mobility, transfers, walking in the room and in the corridor, locomotion on and off the unit, with dressing, toilet use and personal hygiene. Under Section G; Functional Status, RI #12 was coded as not being steady, only able to stabilize with staff assistance with Moving from seated to standing position, Walking, Turning around, Moving on and off toilet and with Surface-to-surface transfer. Under Section J; Health Condition, RI #12 was identified to have had two or more falls during this assessment period. A review of RI #12's care plan titled "Fall: risk for r/t (related to) Hx (history) of falls ... generalized weakness ..." documented the following Approach: "... Dycem to chair ..." On 08/07/13 at 12:14 p.m., the surveyor observed RI #12 sitting in his wheelchair in the Family room on the unit where he resides. No cushion was observed in RI #12's wheelchair seat at this time. On 08/07/13 at 1:25 p.m., the surveyor observed a black cushion (Dycem) on top of a three drawer dresser in RI #12's room. On 08/07/13 at 5:08 p.m., RI #12 remained in his wheelchair with no Dycem in the seat of the wheelchair. On 08/08/13 at 7:05 a.m., the surveyor observed that the black cushion remained on top of the dresser drawer in RI #12's room. RI #12's assigned CNA (Certified Nursing Assistant) for the day stated the resident was already up when she came. On 08/08/13 at 7:15 a.m., the surveyor observed RI #12 sitting in his wheelchair on the unit where he resides. A restorative CNA helped RI #12 to stand and the resident took several steps. No Dycem was observed in the seat of the wheelchair at this time. On 08/08/13 at 5:47 p.m., the surveyor conducted an interview with the LPN (Licensed Practical Nurse) Restorative nurse, EI #11. The surveyor asked EI #11 who places cushions (Dycem) in the resident's wheelchairs when they are gotten out of bed. EI #11 stated the CNA or whoever gets the resident out of bed. On 08/08/13 at 6:15 p.m., the surveyor escorted EI #11 to RI #12's room. The surveyor showed EI #11 the black cushion on top of the three drawer dresser and asked EI #11, what was it. EI #11 stated a gel cushion. The surveyor asked EI #11 what was the device, which looked like a net, on top of the cushion, EI #11 stated a Dycem. The surveyor asked EI #11 where was RI #12's Dycem. EI #11 stated RI #12 was sitting on his Dycem. The surveyor accompanied EI #11 to the Family room where RI #12 was seated in his wheelchair. EI #11 assisted RI #12 to stand. There was no Dycem in the seat of RI #12's wheelchair at this time.