Every finding on record at NHC Healthcare - Clinton

Based on observation, interview, record review, and facility policy review, the facility failed to ensure medication was securely stored for 1 (Resident (R)100) of 10 residents reviewed for medication administration. Findings included: Review of a facility policy titled, Medication storage in the facility, revised on 02/25/2025, revealed, Medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier. The medication supply is accessible only to licensed nursing personnel, or staff members lawfully authorized to administer medications. The policy further indicated, C. All medications dispensed by the pharmacy are stored in the container with the pharmacy label. Review of R100's admission Record revealed the facility admitted R100 on 10/23/2021. According to the admission Record, the resident had a medical history that included but was not limited to diagnoses of gastro-esophageal reflux disease (or GERD is a chronic condition where stomach acid flows backward into the stomach and causes heartburn and other symptoms) without esophagitis (inflammation of the esophagus). Review of R100's Physician Order Report, dated 05/14/2026, revealed an active order started on 09/02/2025 for omeprazole (a medication to reduce stomach acid), delayed release capsule, 20 milligrams (mg), once a day at 6:00 AM. During an observation and concurrent interview on 05/14/2026 at 5:59 AM on Wing B, a blue-green capsule was observed in a medication cup on top of a medication cart in the hallway. The medication cart was unattended. Registered Nurse (RN)1 was in a resident room and arrived back at the medication cart at 6:03 AM. The RN stated that the medication in the unmarked medicine cup was omeprazole for R100. RN1 stated she was busy, and she had left the medication on the cart when she went to assist a resident who had their call light on. The observation revealed that RN1 opened the medication cart and placed the unmarked medicine cup in front of R100's other medications and locked the cart. RN1 stated that she could not throw out the medication because she would have to use the next dose, and they came in packs that were replaced weekly. RN1 stated she would give the medication to the resident at approximately 6:30 AM before she left the facility. During an observation of medication administration on 05/14/2026 at 6:43 AM, RN1 removed R100's previously opened medication in the unmarked medication cup from the drawer and administered the medication to the resident at 6:49 AM on 05/14/2026.During an interview on 05/14/2026 at 6:50 AM, Unit Manager (UM)3 stated that they would not put medication back in the cart to give to a resident later. During an interview on 05/14/2026 at 11:52 AM, the Infection Preventionist (IP) stated that staff received yearly skills training regarding medication administration and storage. She stated that the expectation was that opened medication did not go back in the medication cart. She stated staff should dispose of the medication. Per the IP, the pharmacy provided medications a week at a time; however, they could pull from the last dose in the pack and notify the pharmacy for a replacement if needed. During an interview on 05/14/2026 at 12:09 PM, the Director of Nursing (DON) stated that the expectation was to encourage residents to take their medication. She stated if the resident refused, staff should dispose of the medication and notify the physician. The DON stated that the facility had an emergency medication kit and a pharmacy close by, or they could pull from the resident's supply. During an interview on 05/14/2026 at 12:28 PM, the Administrator stated that he deferred any clinical expectations to the DON.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure staff wore the appropriate personal protective equipment (PPE) for 1 (Resident (R)139) of 3 residents who were on infection control precautions. Specifically, two staff failed to put on a gown and a face shield or goggles before entering R139's room, who was on droplet precautions. Findings included: Review of a facility policy titled, Droplet Precautions, revised March 2026, revealed, In addition to standard precautions, use droplet precautions for a patient known or suspected to be infected with microorganisms transmitted by droplets larger than 5 microns in size that can be transmitted through close respiratory or mucous membrane contact with respiratory secretions. Facemasks should be used upon entry into the patient room. The policy revealed, Based upon the pathogen or clinical syndrome, if there is a risk of exposure of mucous membranes or substantial spraying of respiratory secretions is anticipated, gloves and gown as well as goggles (or face shield in place of goggles) should be worn. The policy also revealed there should be an Appropriate Droplet Precaution sign [on the] door. Review of the facility's Droplet Precautions signage revealed, Everyone Must Make sure their eyes, nose and mouth are fully covered before room entry. According to the sign, a face shield or goggles should be worn. Review of R139's admission Record revealed the facility admitted R139 on 05/12/2026. According to the admission Record, the resident had a medical history that included but was not limited to diagnoses of pneumonia due to mycoplasma pneumoniae (a bacteria that causes lung infection), chronic obstructive pulmonary disease (COPD) with acute lower respiratory infection, and dependence on supplemental oxygen. Review of R139's Physician Order Report, for orders dated 04/14/2026 through 05/14/2026, revealed an active order started on 05/12/2026, for Isolation precautions: Droplet precautions for mycoplasma pneumonia. Review of R139's Care Plan, included a problem statement edited on 05/14/2026, that indicated the resident had ineffective breathing as evidenced by diagnoses of COPD with lower respiratory infection and pneumonia due to mycoplasma pneumonia with sepsis. Interventions directed staff to provide droplet isolation precautions (created 05/14/2026). During an observation and interview on 05/14/2026 at 6:32 AM, R139's call light was on. The observation revealed an enhanced barrier precaution (an infection control strategy that requires the use of gowns and gloves during high-contact resident care to prevent the spread of infection) sign was posted on the right side of the door frame. A door caddy that contained gowns, gloves, and surgical masks (no goggles/face shields were available) was also observed on the door. Registered Nurse (RN)1 was observed going into the resident's room wearing a surgical mask and gloves. When leaving, RN1 disposed of the mask and gloves in a red container at the door. During an interview, RN1 stated that the resident was on droplet precautions, and she was only required to wear a mask and gloves to enter the room. During an observation and interview on 05/14/2026 at 6:37 AM, Certified Nursing Assistant (CNA)2 responded to R139's call light. CNA2 donned a mask and gloves prior to entering the room. During an interview when CNA2, who exited the room, she stated that she was only required to wear a mask and gloves when entering the room. During an interview on 05/14/2026 at 11:41 AM, the Infection Preventionist (IP) stated R139 had pneumonia and there was a sign (droplet precautions) on their door the previous day. She stated that the resident moved to a different room on 05/13/2026 and the sign and supplies were moved with the resident; however, the IP did not know what had happened to the sign. She stated that staff were expected to enter the room wearing PPE. She stated that a gown, gloves, mask, and face shield/goggles must be worn when a resident was on droplet precautions. She stated that she knew goggles were not available at the resident's door; however, according to the IP, goggles were available 24 hours per day, seven days per week in central supply storage. During an interview on 05/14/2026 at 12:26 PM, the Director of Nursing (DON) stated that he expected staff to wear the appropriate PPE. During an interview on 05/14/2026 at 12:28 PM, the Administrator stated that he deferred any clinical questions to the DON.

Based on observation, record review, interview, and facility policy review, the facility failed to: 1. utilize the proper personal protective equipment (PPE) for enhanced barrier precautions (EBP) for one of three residents (Resident (R)7) reviewed for EBP; 2. Have EBP signage to convey a resident was on EBP for one of three residents reviewed for EBP (R51); 3. Utilize gloves when touching a pill during the observation of medication administration for one resident (R94) and; 4. Provide proper storage of clean basins for two residents (R59 and R79) out of a sample of 27 residents. Findings include: Review of the facility's Enhanced Barrier Precautions policy, updated February 2025, revealed, Providers and partners must wear gloves and a gown for the following high-contact patient care activities: . device care or use: central line, urinary catheter, feeding tube, . Review of the Centers for Disease Control and Prevention (CDC) website titled, Implementation of Personal Protective Equipment (PPE) Use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDROs) indicated, Post clear signage on the door or wall outside of the resident room indicating the type of Precautions and required PPE (e.g., gown and gloves). For Enhanced Barrier Precautions, signage should also clearly indicate the high-contact resident care activities that require the use of gown and gloves. 1. Review of R7's Face Sheet located in the Face Sheet tab of the electronic medical record (EMR) revealed R7 was admitted to the facility on [DATE], and had diagnoses which included but was not limited to: Dementia, encounter for attention to gastrostomy (an opening in the stomach for a feeding tube), and dysphasia (difficulty swallowing) following cerebral infarction (stroke). Review of R7's Care Plan under the RAI (Resident Assessment Instrument) tab of the EMR revealed a problem area of potential for aspiration with a PEG (feeding) tube with an approach created 09/05/24, Provide Enhanced Barrier Precautions. Review of R51's Orders tab of the EMR revealed orders, dated 03/21/25, indicated, check placement of the feeding tube by aspirating stomach contents and checking the mark on the tubing prior to feeding, flushes, or medications, administer Osmolite 1.5 formula at 50 milliliters (mL) per hour for 22 hours starting at 2:00 PM daily, and provide enhanced barrier precautions. During an observation on 04/02/25 at 2:06 PM, Licensed Practical Nurse (LPN)3 was observed in R7's room, without gloves or a gown, hanging an Osmolyte feeding container from a hook on a pole containing a pump (to regulate the amount of feeding infused per hour) next to the R7's bed. LPN3 then applied gloves, removed the feeding container, re-attached the tubing to it, hung the container back on the hook, and inserted the tubing through the pump to run the Osmolyte through. Once the tubing had the Osmolyte run through it, LPN3 attached the tubing to R7's feeding tube in her abdomen and started the feeding at 50 mL per hour. LPN3 wore no gown while she started the feeding. During an interview on 04/03/25 at 12:24 PM, LPN2 stated residents with tube feedings were on EBP. Gowns and gloves were worn by nurses when doing anything with the feeding tube, and certified nursing assistants (CNAs) wore gowns and gloves when providing any cares involving contact with the residents. During an interview on 04/03/25 at 12:28 PM, LPN3 reported R7 was on EBPs because of her feeding tube. LPN3 stated she was supposed to wear a gown and gloves when administering the tube feeding but had forgotten to on 04/02/25. During an interview on 04/03/25 at 3:18 PM, the Director of Nursing (DON) stated he expected staff to utilize EBP and wear gowns and gloves for any direct care of residents with emerging resistant bacteria and indwelling devices to include feeding tubes and catheters. A nurse was expected to wear a gown and gloves when administering formula through a feeding tube. 2. Review of R51's Face Sheet, located under Face Sheet tab in the EMR, indicated R51 was admitted to the facility on [DATE], with diagnosis including but not limited to: retention of urine, unspecified. Review of R51's General Order, located under Order tab in the EMR, dated 02/24/25, indicated, Enhanced Barrier Precautions. During an observation on 04/01/25 at 9:52 AM, R51 was observed sitting in his wheelchair with his urinary catheter bag hanging on the left side of his wheelchair. There was nothing observed to alert staff that the resident was on EBP prior to entering the resident's room. During an observation on 04/01/25 at 11:36 AM, there was nothing observed to alert staff that the resident was on EBP prior to entering the resident's room. During an observation and interview on 04/02/25 at 10:06 AM, LPN1 confirmed residents who have a urinary catheter should be on EBP. LPN1 stated EBP should be used when providing catheter care or changing clothes, and staff are to wear a gown and gloves. LPN1 confirmed there was no signage outside of R51's room to alert staff that the resident was on EBP however there had been one in the past. During an interview on 04/03/25 at 8:30 AM, the DON confirmed that a resident with a urinary catheter should be on EBP, and an EBP sign should be placed on the doorframe prior to entering the resident's room therefore staff are aware of what precautions to take. The DON confirmed that R51 did have a urinary catheter and should be on EBP. 3. Review of R94's Face Sheet, located under the Face Sheet tab in the EMR, indicated R94 was admitted to the facility on [DATE], with diagnoses including but not limited to: polyneuropathy. Review of R94's Prescription Order, located under the Orders tab in the EMR, indicated R94 was to receive pregabalin 75 milligrams (mg), one capsule, twice a day. During a medication observation on 04/01/25 at 9:40 AM, LPN2 was observed removing R94's blister package of pregabalin from the narcotic box. After removal, LPN2 popped one pill into her left hand, placing the medication into a clear medication cup. Afterwards, LPN2 placed the rest of R94's medications into the cup and gave all the medications to R94. During an interview on 04/02/25 at 10:15 AM, LPN2 confirmed that she popped the medication into her hand and stated that she should not have. During an interview on 04/03/25 at 8:40 AM, the DON confirmed that he expected medications to be popped into medication cups, and not hands. 4. Review of the Face Sheet found in R59's EMR under the Face Sheet tab revealed R59 was admitted to the facility on [DATE], with diagnoses including but not limited to: dementia and poly-osteoarthritis. Review of the Face Sheet found in R79's EMR under the Face Sheet tab revealed R79 was admitted to the facility on [DATE], with diagnoses including but not limited to: Alzheimer's disease and bilateral primary osteoarthritis of the knee. During an observation of R59 and R79's shared bathroom on 04/01/25 at 2:08 PM, revealed two grey plastic wash basins resting on top of toilet seat uncovered. Further observation revealed each basin had the residents' name on each one. During an observation on 04/01/25 at 2:09 PM, LPN6 stated, Usually the wash bins are stored above for each resident. LPN 6 stated the wash bins were on the toilet seat and they needed to go in the trash. During an interview on 04/03/25 at 5:51 PM, the DON stated, Typically don't like to store them (washbasin) in the bathroom but typically store in the closet. We would not store wash basin on the toilets. 42440 52322

Based on record review and interviews, the facility failed to accurately code the Minimum Data Set (MDS) assessment for one (Resident (R) 27) of one sampled resident reviewed for mood and behavior. Failure to code the MDS correctly has the potential to lead to inaccurate assessment and care planning of the resident. (Cross Reference F842) Findings include: Review of the Resident Assessment Instrument (RAI) Manual, dated 10/01/19, indicated, . It is important to note here that information obtained should cover the same observation period as specified by the Minimum Data Set (MDS) items on the assessment and should be validated for accuracy (what the resident's actual status was during that observation period) by the IDT (Interdisciplinary Team) completing the assessment . Review of R27's Resident Face Sheet, located under the Resident tab of the electronic medical record, indicated the resident was admitted to the facility on [DATE]. A review of R27'sMinimum Data Set (MDS) assessments, located under the MDS tab of the EMR, revealed: R27's admission MDS, with an Assessment Reference Date (ARD) of 09/22/22, indicated the resident had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated the resident was cognitively intact. The assessment recorded the resident had a diagnosis of Post Traumatic Stress Disorder (PTSD). R27's quarterly MDS, with an ARD of 12/21/22, indicated the resident had a BIMS score of 15 out of 15, which indicated the resident was cognitively intact. The assessment recorded the resident had a diagnosis of PTSD. R27's quarterly MDS, with an ARD of 03/14/23, indicated the resident had a BIMS score of 15 out of 15, which indicated the resident was cognitively intact. The assessment recorded the resident had a diagnosis of PTSD. R27's quarterly MDS, with an ARD of 05/30/23, indicated the resident had a BIMS score of 15 out of 15, which indicated the resident was cognitively intact. The assessment recorded the resident had a diagnosis of PTSD. R27's annual MDS, with an ARD of 08/21/23, indicated the resident had a BIMS score of 15 out of 15, which indicated the resident was cognitively intact. The assessment recorded the resident had a diagnosis of PTSD. During an interview on 08/29/23 at 12:45 PM, R27 denied having a diagnosis of PTSD. The resident stated she had the diagnosis of bi-polar and had this diagnosis for a long time. During an interview on 08/30/23 at 1:05 PM, Social Services (SS)1 stated R27 had a long mental health history. During an interview on 08/30/23 at 1:51 PM, SS1 stated it was a coding issue for R27 to be recorded as having the diagnosis of PTSD. The Regional Health Information Manager (HIM) was present during this interview and stated the MDS coding was supposed to be accurate.

Based on interviews, record review, and policy review, the facility failed to maintain an accurate medical record for one resident (Resident (R) R27) of one sampled resident reviewed for mood and behavior. The facility entered an inaccurate diagnosis of Post Traumatic Stress Disorder (PTSD) during the length of R27's stay at the facility. Findings include: Review of a policy provided by the facility titled, Introduction to Documentation for Inpatient Medical Records, dated October 2021, indicated . It is the responsibility of each health care center to establish and maintain comprehensive records which accurately reflect all aspects of the organization . Observations, events, assessments/evaluations, treatments, services, and patient responses are accurately recorded and authenticated . Review of R27's electronic medical record (EMR) titled, Resident Face Sheet, located under the Resident tab, indicated the resident was admitted to the facility on [DATE]. Review of R27's EMR titled nursing Progress Notes, dated 08/30/23 at 4:20 PM, indicated . Reviewed resident's inpatient and hospital records interviewed the resident and resident RP [representative] and interviewed the resident's NP [nurse practitioner] and requested that she review resident's inpatient and hospital records related to the diagnosis of PTSD. Resident and RP both report they were not aware of resident ever being diagnosed with PTSD previously and have no knowledge of diagnosis. Resident's NP reviewed record and reported that she is unable to locate the origin/indication of when or why diagnosis of PTSD was initiated from hospital and based on resident and RP statements regarding diagnosis and resident not exhibiting symptoms of PTSD throughout frequent stays at the facility. NP gave order to invalidate diagnosis of PTSD. During an interview on 08/30/23 at 5:13 PM, the Director of Nursing stated he spoke with the resident and RP, and there was never a diagnosis of PTSD. The DON stated he did not know how it was generated.

Based on record review, observations, interviews, and review of the facility assessment, the facility failed to ensure two Certified Nursing Assistants (CNA) 1 and CNA8 were competently trained to properly don (put on) personal protective equipment (PPE). CNA1 was observed to enter one resident's (Resident (R) R162) room, who was unvaccinated, a new admission, under droplet precautions, and considered a Person Under Investigation (PUI) for potential COVID-19 exposure, without first donning required PPE. CNA8 was observed to exit R164's room who was also a new admission, on quarantine, unvaccinated, and under droplet precautions, without wearing proper PPE. Findings include: Review of a document provided by the facility titled Job Description. Certified Nursing Assistant, dated 07/01/09, indicated . Attend in-service programs, as assigned, to learn procedures and develop skills and meet state requirements. Review of a document provided by the facility titled Facility Assessment Tool, dated 11/19/21, indicated . Starting with the hiring process, potential employees complete an application and watch the better way video, which is our commitment and standard for delivering customer service. Once a partner is hired, they attend a center orientation, in which many topics are covered. Some of the topics include: The better way, 5 Step service recovery, falls, transfer training, abuse and neglect, fire and life safety, infection control. 1. The Director of Nursing (DON) reported CNA1 was hired on 05/19/93. Review of a document provided by the facility titled Questionnaire for Users of N95 Respirators, dated 10/28/20, indicated CNA1 was able to use a N95 face mask. Review of a document provided by the facility titled Skills fair inservice [sic] training, dated 09/21/21, indicated CNA1 attended an inservice [sic] on PPE. During an interview on 12/20/21 at 12:07 PM, CNA1 stated there were plenty of PPE supplies for her to use. CNA1 was observed to stand on the outside of R162's room. CNA1 had a surgical mask on and a gown. The door to R162's room was closed and had a Centers for Disease Control and Prevention (CDC) poster for droplet precautions on the outside of the door. At 12:13 PM, CNA1 performed hand hygiene with alcohol-based hand sanitizer and donned gloves and took a face shield from the PPE container, which hung the outside door R162's room. CNA1 took R162's lunch tray into the room. At 12:17 PM, CNA1 doffed (took off) her gloves and face shield. CNA1 then took the face shield and placed it into the PPE container hanging from R162's door. CNA1 did not sanitize the face shield prior to placing this item back into the PPE container. CNA1 then took off her gown and face mask and disposed of these items, in a trash container located in the resident's room. CNA1 then walked, without PPE on, to the resident's bathroom, located in the back of the room to wash her hands. At 12:18 PM, CNA1 donned a fresh face mask. CNA1 stated she always wore a surgical mask when entering a quarantined resident room. 2. The DON reported CNA8 was hired on 11/04/21. Review of a document provided by the facility titled Personal Protective Equipment (PPE) Competency Validation, dated 11/04/21, indicated CNA8 was provided training on donning and doffing PPE. This form failed to indicate CNA8 was competent to don a N95. During an observation on 12/21/21 at 9:09 AM, CNA8 exited R162's room and confirmed she performed personal care on the resident, applied lotion, and fed the resident breakfast. CNA8 was observed wearing a surgical mask. During an interview on 12/21/21 at 9:26 AM, when asked about the same face shield being used by multiple staff, the DON stated PPE should be for individual use. During an interview on 12/21/21 at 9:43 AM, the Infection Control Preventionist (ICP) stated staff were to don a N95 mask prior to entering a PUI/quarantined room. The ICP stated CNA8 had not gone through orientation on the use of a N95 nor was CNA8 provided a N95 face mask. During an interview on 12/22/21 at 1:52 PM, the ICP confirmed once again CNA8 was not provided a fit test for the use of a N95. The ICP stated CNA1 had been trained on the use of a N95. Cross reference: F880 Infection Control.

Based on observations, interviews, review of facility policies, and review of Centers for Disease Control and Prevention (CDC) COVID-19 guidance, the facility failed to ensure two Certified Nursing Assistants (CNA) 1 and CNA 8 and one Nursing Assistant (NA) 5 donned (put on) proper personal protective equipment (PPE) prior to providing care to two of two residents (Residents (R) R162 and R164) under quarantine who were new admissions, unvaccinated, and potentially exposed to COVID-19 while previously hospitalized . Findings include: Review of a policy provided by the facility titled Testing Plan, dated 09/02/20, indicated the unvaccinated resident should have a negative COVID-19 test prior to admission, placed in a designated area/room, and placed on droplet precautions. Review of a policy provided by the facility titled Core Principles of COVID-19 Infection Control, dated 10/01/20, indicated .Appropriate staff use of Personal Protective Equipment (PPE). Review of the Centers for Medicare & Medicaid Services (CMS), website https://data.cms.gov/covid-19/covid-19-nursing-home-data, the community positivity rate on 12/05/21 indicated a high rate of transmission at 6.74 percent. Review of CDC guidance, dated 09/10/21, indicated . If [CONDITION(S)]-CoV-2 infection is not suspected in a patient presenting for care (based on symptom and exposure history), HCP working in facilities located in counties with substantial or high transmission should also use PPE as described . NIOSH-approved N95 or equivalent or higher-level respirators should be used for . Facilities could consider use of NIOSH-approved N95 or equivalent or higher-level respirators for HCP working in other situations where multiple risk factors for transmission are present. One example might be if the patient is unvaccinated, unable to use source control, and the area is poorly ventilated . Eye protection (i.e., goggles or a face shield that covers the front and sides of the face) should be worn during all patient care encounters . 1. Review of an undated document provided by the facility titled Resident Face Sheet, indicated R162 was admitted to the facility on [DATE]. At the time of admission R162 was unvaccinated and was placed under quarantine for possible exposure to COVID-19. During an interview on 12/20/21 at 8:34 AM, the Bookkeeping Director stated R162 was an unvaccinated new admission and was under quarantine. During a random observation conducted on 12/20/21 at 12:07 PM, CNA1 was observed outside of R162's room. The door to R162's was shut and had a CDC poster on the door which indicated droplet precautions PPE were to be applied prior to entering into the room. CNA1 was observed wearing a gown and a surgical (disposable) mask. At 12:13 PM, CNA1 performed hand hygiene, with alcohol-based hand sanitizer, and then donned gloves. At 12:15 PM, CNA1 donned a face shield and was handed the lunch meal tray for R162. CNA1 then took the tray into R162's room and shut the door. At 12:17 PM, CNA1 opened R162's door and doffed (took off) her gloves and gown and took off the face shield and placed it back into the PPE container that hung from the resident's door. CNA1 then doffed her surgical mask while in the resident's room. CNA1 then walked to the resident's bathroom located in the back of the room. At 12:18 PM, CNA1 exited the room and donned a fresh surgical mask. CNA1 was asked what type of mask she dons prior to entering a quarantined room, and CNA1 stated she always wore a surgical mask. 2. Review of a document provided by the facility undated titled Resident Face Sheet, indicated R164 was admitted to the facility on [DATE]. At the time of admission R164 was unvaccinated and was placed under quarantine for possible exposure to COVID-19. During a random observation on 12/21/21 at 9:08 AM, NA5 was observed standing outside of R164's room. The door to R164's was shut and had a CDC poster on the door which indicated droplet precautions PPE were to be applied prior to entering into the room. NA5 was observed wearing a gown, surgical face mask, and gloves. During an observation at 9:09 AM, CNA8 came out of R164's room. CNA8 had on a surgical mask not an N95 mask. CNA8 placed the face shield back into the PPE holder. CNA8 stated she only sanitized the padding of the face shield. Observation of the face shield included padding that goes around the top of the shield and touches the forehead of the wearer. The plastic shield was attached to the padding and the plastic shield covered the front of the wearer's face. CNA8 stated she used alcohol-based hand sanitizer to sanitize the padding and confirmed she did not sanitize the plastic shield. NA5 was observed to retrieve the same face shield from the PPE container that CNA8 previously used and entered R164's room. NA5 did not sanitize the plastic face covering of the face shield. During an interview on 12/21/21 at 9:43 AM, the Infection Control Preventionist (ICP) stated staff were to use N95 masks. The ICP stated the face shield was to be sanitized between use. The ICP stated NA5 and CNA8 were newer employees and had completed orientation but did not get an assigned N95 mask yet. During an interview on 12/21/21 at 10:02 AM, the ICP stated new unvaccinated admissions were to have a negative COVID-19 test prior to admission. Review of a document provided by the facility titled [MEDICATION(S)] Health Greenville Memorial Hospital Laboratory, dated 12/01/21, indicated R162 had a negative COVID-19 test. Review of a document provided by the facility titled [MEDICATION(S)] Health Greenville Memorial Hospital Laboratory, dated 12/05/21, indicated R164 had a negative COVID-19 test. During an interview on 12/22/21 at 5:52 PM, the Director of Nursing (DON) stated staff do not need to wear a N95 face mask since unvaccinated residents were tested for COVID-19 prior to admission. The DON stated staff only needed to wear a surgical mask and a face shield. The DON did not present a professional source for this information during the interview. Review of Centers for Disease Control (CDC) guidance, dated 09/10/21, indicated . In general, all unvaccinated residents who are new admissions and readmissions should be placed in a 14-day quarantine, even if they have a negative test upon admission . HCP caring for them should use full PPE (gowns, gloves, eye protection, and N95 or higher-level respirator) .

Based on review of facility files and interview, the facility failed to ensure each resident remained free from neglect. Certified Nurse Aide (CNA) #1 transferred Resident #1 without the assistance of another staff member or lift as required. Resident #1 fell and sustained a femur fracture. One of three residents reviewed for neglect. The findings included: Review of Resident #1's medical record revealed a Nurses' Note dated 9/18/18 at 2:00 PM indicated resident resting in bed quietly. Range of motion within normal limits. Facial grimacing is observed when performed on right lower leg. Awaiting company to do x-rays in facility. Review of Resident #1's Post Falls Nursing assessment dated [DATE] revealed at 11:00 AM resident found on floor. CNA reports while assisting resident in shower resident's knees buckled and resident slid on floor. Assessed for injury and finished shower. Then assisted resident back to bed. Resident complained of pain to right leg, as needed Tylenol administered for pain. At time of fall resident was transferring to/from shower chair. X-ray ordered for right hip down to right foot. Review of the care plan revealed Resident #1 requires extensive assist per staff to complete transfers was identified as a problem area. Interventions and approaches to this problem area were documented on the care plan and included assistance per 2 staff and use of mechanical lift to complete all transfers. Review of the Radiology Report results for Resident #1 dated 9/18/18 revealed oblique [MEDICAL CONDITION] femur. In an interview with the Surveyor on 11/29/18 at approximately 11:45 AM, Licensed Practical Nurse (LPN) #1 stated s/he went to the bathroom and realized CNA #1 had dropped Resident #1 in the floor. There was a shower chair and the resident's wheelchair in the shower room with no additional equipment. The CNA was trying to transfer the resident from his/her wheelchair to the shower chair. CNA #1 was transferring the resident by him/herself, that was against the care plan. The resident required two person assist for transfers. CNA #1 should have had a second person but did not. LPN #1 asked CNA #1 why s/he did not wait for him/her, because s/he would have come and helped. CNA #1 said s/he was doing it by him/herself. CNA #1 was terminated because of this incident. LPN #1 stated the residents have care plans in their closets that have the information on transfer status. LPN #1 went and looked at the care plan in Resident #1's closet and it had two person assist for transfers. CNA #1 was assigned to that group and worked with Resident #1 regularly. CNA #1 said s/he didn't know the resident was going to buckle, CNA #1 did know s/he was supposed to have a second person. In an interview with the Surveyor on 11/29/18 at approximately 12:25 PM, the Director of Nursing and Administrator were asked about the incident. They stated the Unit Manager came and talked with the administrator at the time of the incident. The Unit Manager explained the situation, that the resident had fallen, and they were sending Resident #1 out. The Unit Manager talked to the administrator about the CNA #1 not following Resident #1's plan of care and that CNA #1 would be terminated. The Administrator stated they did not complete an investigation, because they knew what happened. In an interview with the Surveyor on 11/29/18 at approximately 12:27 PM, the 100-Unit Manager stated CNA #1 used the emergency call light in the shower room for assistance. When they got there the resident was in the floor with CNA #1 in the shower with him/her. CNA #1 said s/he was preparing the resident for a shower, when s/he went to transfer the resident the resident had a bowel movement while transferring and that caused him/her to slide down. CNA #1 was in the shower room by him/herself, s/he should have another staff. The Unit Manager talked with CNA #1 and s/he said s/he was trying to get the resident's shower done. The Unit Manager looked at the resident's care plan on the closet door and it indicated s/he required two person assist for transfers. In an interview with the Surveyor on 11/29/18 at approximately 12:30 PM, the Administrator stated s/he did not report the incident to the State Survey Agency because there was nothing to report. There did not need to be an investigation. The CNA knew what the protocol was and s/he chose not to do it.

Based on review of facility files and interview the facility failed to implement written policies and procedures that prohibit and prevent neglect. Certified Nurse Aide (CNA) #1 transferred Resident #1 without the assistance of a staff member and mechanical lift per the resident's plan of care. Resident #1 fell during the transfer and sustained a femur fracture. One of three residents reviewed for neglect. The findings included: Review of the POS [REDACTED]. CNA reports while assisting resident in shower resident's knees buckled and resident slid on floor. Assessed for injury and finished shower. Then assisted resident back to bed. Resident complained of pain to right leg, as needed Tylenol administered for pain. At time of fall resident was transferring to/from shower chair. X-ray ordered for right hip down to right foot. Review of Resident #1's care plan revealed resident requires extensive assist per staff to complete transfers was identified as a problem area. Interventions and approaches to this problem area were documented on the care plan and included assistance per 2 staff and use of mechanical lift to complete all transfers. Review of the Radiology Report results for Resident #1 dated 9/18/18 revealed oblique [MEDICAL CONDITION] femur. In an interview with the Surveyor on 11/29/18 at approximately 11:45 AM, Licensed Practical Nurse (LPN) #1 stated s/he went to the bathroom and realized CNA #1 had dropped Resident #1 in the floor. CNA #1 was transferring the resident by him/herself, that was against the care plan. The resident required two person assist for transfers. In an interview with the Surveyor on 11/29/18 at approximately 12:25 PM, The Administrator stated they did not complete an investigation, because they knew what happened. In an interview with the Surveyor on 11/29/18 at approximately 12:27 PM, the 100-Unit Manager stated CNA #1 was in the shower room by him/herself, s/he should have another staff. In an interview with the Surveyor on 11/29/18 at approximately 12:30 PM, the Administrator stated there did not need to be an investigation. The CNA knew what the protocol was, and s/he chose not to do it. Review of the facility's Patient Protection and Response Policy revealed the center administrator is responsible for assuring that patient safety, including from risk of abuse or neglect, holds the highest priority. The policy defined neglect as the failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. The policy indicated the center will provide supervision and support services designed to reduce the likelihood of abusive behaviors. In order for all care needs to be met, the nursing supervisors will provide the needed assistance when notified by fell ow partners of the inability to complete their assignments. Review of the facility's Patient Protection and Response Policy revealed any patient event that is reported to any partner by patient, family, other partner or any other person will be considered an allegation or either abuse, neglect, misappropriation of patient property or exploitation if it meets any of the following criteria: any patient or family complaint of physical harm, pain or mental anguish resulting from the actions of others; any complaint of deprivation by an individual caregiver of goods and services necessary to attain or maintain physical, mental, and psychological well-being to include toileting issues. Review of the facility's Patient Protection and Response Policy revealed procedures that the investigation is conduced immediately under the following circumstances: when it is identified that an alleged incident may have occurred, as soon as any partner has knowledge and reports an alleged event. When there is a question as to whether to conduct an investigation, it is best to do so. External reporting to the state survey and certification agency and all other state required agencies will follow federal, individual state laws, and licensure regulations.

Based on review of facility files and interview, the facility failed to ensure that all alleged violations involving neglect are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, to the State Survey Agency. Certified Nurse Aide (CNA) #1 was noted to neglect Resident #1 by transferring the resident without assistance per the resident's plan of care. Resident #1 fell during the transfer and sustained a femur fracture. One of three residents reviewed for neglect. The findings included: The Surveyor requested to see all reportable incidents upon entering the facility on 11/29/18. Review of the information provided revealed no report was made to the State Agency for Resident #1. On 9/18/18 CNA #1 transferred Resident #1 without the assistance of another staff member or mechanical lift. Resident #1 fell during the transfer and sustained a femur fracture. The facility did not report the incident to the State Survey Agency. In an interview with the Surveyor on 11/29/18 at approximately 12:25 PM, the Director of Nursing and Administrator were asked about the incident. They stated the Unit Manager came and talked with the Administrator at the time of the incident. The Unit Manager explained the situation, that Resident #1 had fallen and they were sending him/her out. The Unit Manager talked to the Administrator about the CNA #1 not following Resident #1's plan of care and that CNA #1 would be terminated. The Administrator stated they did not complete an investigation, because they knew what happened. In an interview with the Surveyor on 11/29/18 at approximately 12:30 PM, the Administrator stated s/he did not report the incident to the State Survey Agency because there was nothing to report. There did not need to be an investigation. The CNA knew what the protocol was and s/he chose not to do it. Review of the facility's Patient Protection and Response Policy revealed all allegations of possible neglect will be immediately assessed to determine the appropriate direction of the investigation. All alleged violations and all substantiated incidents will be reported immediately to the administrator and to other officials in accordance with state and federal law (including to the state survey and certification agency). All events reported as possible neglect will be investigated to determine whether the alleged 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.

Based on review of facility files and interview the facility failed to investigate and prevent neglect. Certified Nurse Aide (CNA) #1 transferred Resident #1 without the assistance of a staff member and mechanical lift per the resident's plan of care. Resident #1 fell during the transfer and sustained a femur fracture. The facility did not complete an investigation and document the findings. One of three residents reviewed for neglect. The findings included: Review of the POS [REDACTED]. CNA reports while assisting resident in shower resident's knees buckled and resident slid on floor. Assessed for injury and finished shower. Then assisted resident back to bed. Resident complained of pain to right leg, as needed Tylenol administered for pain. At time of fall resident was transferring to/from shower chair. X-ray ordered for right hip down to right foot. Review of Resident #1's care plan revealed resident requires extensive assist per staff to complete transfers was identified as a problem area. Interventions and approaches to this problem area were documented on the care plan and included assistance per 2 staff and use of mechanical lift to complete all transfers. Review of the Radiology Report results for Resident #1 dated 9/18/18 revealed oblique [MEDICAL CONDITION] femur. In an interview with the Surveyor on 11/29/18 at approximately 11:45 AM, Licensed Practical Nurse (LPN) #1 stated CNA #1 was transferring the resident by him/herself, that was against the care plan. The resident required two person assist for transfers. In an interview with the Surveyor on 11/29/18 at approximately 12:25 PM, The Administrator stated they did not complete an investigation, because they knew what happened. In an interview with the Surveyor on 11/29/18 at approximately 12:30 PM, the Administrator stated there did not need to be an investigation. The CNA knew what the protocol was, and s/he chose not to do it. Review of the facility's Patient Protection and Response Policy revealed procedures that the investigation is conduced immediately under the following circumstances: when it is identified that an alleged incident may have occurred, as soon as any partner has knowledge and reports an alleged event. When there is a question as to whether to conduct an investigation, it is best to do so. External reporting to the state survey and certification agency and all other state required agencies will follow federal, individual state laws, and licensure regulations.

Based on review of facility files and interviews, the facility failed to implement a comprehensive person-centered care plan for each resident. Certified Nurse Aide (CNA) #1 transferred Resident #1 without following the resident's plan of care. Resident #1 fell during the transfer and sustained a femur fracture. One of three residents reviewed for care plans. The findings included: Review of Resident #1's Post Falls Nursing assessment dated [DATE] revealed at 11:00 AM resident found on floor. CNA reports while assisting resident in shower resident's knees buckled and resident slid on floor. Assessed for injury and finished shower. Then assisted resident back to bed. Resident complained of pain to right leg, as needed Tylenol administered for pain. At time of fall resident was transferring to/from shower chair. X-ray ordered for right hip down to right foot. Review of Resident #1's care plan revealed resident #1 requires extensive assist per staff to complete transfers was identified as a problem area. Interventions and approaches to this problem area were documented on the care plan and included assistance per 2 staff and use of mechanical lift to complete all transfers. Review of the Radiology Report results for Resident #1 dated 9/18/18 revealed oblique [MEDICAL CONDITION] femur. In an interview with the Surveyor on 11/29/18 at approximately 11:45 AM, Licensed Practical Nurse (LPN) #1 stated s/he went to the bathroom and realized CNA #1 had dropped Resident #1 in the floor. There was a shower chair and the resident's wheelchair in the shower room with no additional equipment. The CNA was trying to transfer the resident from his/her wheelchair to the shower chair. CNA #1 was transferring the resident by him/herself that was against the care plan. The resident required two person assist for transfers. CNA #1 should have had a second person but did not. LPN #1 asked CNA #1 why s/he did not wait for him/her, because s/he would have come and helped. CNA #1 said s/he was doing it by him/herself. CNA #1 was terminated because of this incident. LPN #1 stated the residents have care plans in their closets that have the information on transfer status. LPN #1 went and looked at the care plan in Resident #1's closet and it had two person assist for transfers. CNA #1 was assigned to that group and worked with Resident #1 regularly. CNA #1 said s/he didn't know the resident was going to buckle, CNA #1 did know s/he was supposed to have a second person. In an interview with the Surveyor on 11/29/18 at approximately 12:27 PM, the 100-Unit Manager stated CNA #1 used the emergency call light in the shower room for assistance. When they got there the resident was in the floor with CNA #1 in the shower with him/her. CNA #1 said s/he was preparing the resident for a shower, when s/he went to transfer the resident the resident had a bowel movement while transferring and that caused him/her to slide down. CNA #1 was in the shower room by him/herself, s/he should have another staff. The Unit Manager talked with CNA #1 and s/he said s/he was trying to get the resident's shower done. The Unit Manager looked at the resident's care plan on the closet door and it indicated s/he required two person assist for transfers.

Based on record review and interview, the facility failed to ensure that a resident with documentation of an allergy to a [MEDICAL CONDITION] medication did not receive the [MEDICAL CONDITION] medication until clarification was made regarding the allergy. Resident #38 was given [MEDICATION NAME] on 10/11/18 through 10/16/18 with documentation throughout the medical record that the resident had an allergy to [MEDICATION NAME]. One of five sampled residents reviewed for unnecessary medications. The findings included: The facility admitted Resident #38 on 10/17/15 with [DIAGNOSES REDACTED]. A review of the medical record on 10/16/18 at approximately 9:14 AM revealed a large allergy sticker on the inside tab of the medical record that identified [MEDICATION NAME] as an allergy for Resident #38. Further record review revealed a physician's orders [REDACTED]. There was no documentation to address the resident's documented [MEDICATION NAME] allergy. A review of the nurse practitioner's progress reports dated 10/02/18 and 10/11/18 did not address the resident's allergy to [MEDICATION NAME]. A nurse's note dated 10/11/18 at 4:50 PM revealed the nurse practitioner made rounds and a new order was received and processed for [MEDICATION NAME] 25 milligrams every day at 2 PM and 9 PM. There was nothing in the nurse's note to indicate the resident's documented allergy to [MEDICATION NAME] was addressed. A review the resident's history and physical on admission in (YEAR) identified [MEDICATION NAME] as an allergy for the resident. The monthly cumulative physician's orders [REDACTED]. The monthly Medication Administration Record [REDACTED]. A review of the comprehensive care plan updated 8/21/18 indicated under risk of [MEDICAL CONDITION] medications as an approach Ensure that no meds containing [MEDICATION NAME] are administered. Allergy noted on record and IMAR. A review of the MAR for (MONTH) (YEAR) indicated Resident #38 received [MEDICATION NAME] 25 milligrams as ordered on [DATE] through 10/16/18. There was on documentation to address the allergy to [MEDICATION NAME]. An interview on 10/16/18 at approximately 2:40 PM revealed Licensed Practical Nurse (LPN) #1 reviewed the medical record and confirmed there was no documentation to address the resident's documented allergy to [MEDICATION NAME] although the medication was given. LPN #1 stated he/she would find out why the [MEDICATION NAME] was given with the documented allergy to [MEDICATION NAME] and let the surveyor know. In an interview on 10/16/18 at approximately 2:53 PM, LPN #1 informed the surveyor the he/she had spoken with the nurse practitioner who would provide an addendum to his/her 10/11/18 progress note. An interview on 10/16/18 at approximately 3:49 PM with Registered Nurse (RN) #1 confirmed there was nothing in the medical record to address the [MEDICATION NAME] given to Resident #38 with documented allergy to [MEDICATION NAME]. RN #1 stated he/she spoke to the family today and the family stated they did not feel resident had a true allergy to [MEDICATION NAME]. RN #1 stated the nurse practitioner would discontinue the allergy to [MEDICATION NAME] today. A review of the medical record on 10/17/18 at approximately 9:04 AM revealed a nurse's note dated 10/16/18 that the family was notified to get clarification of allergy to [MEDICATION NAME] and the nurse practitioner was informed of the family's response that [MEDICATION NAME] was not a true allergy.

Based on observations and interviews, the facility failed to ensure that residents who eat in their rooms had meals delivered to the rooms in a sanitary manner. Staff observed removing food trays from covered food cart and delivering meals to residents rooms with rolls, cornbread, cakes and/or bread pudding uncovered on 1 of 3 units observed. ( Unit 100) The findings included: During random lunch observation ON 7/23/17 at approximately 12:01 PM, staff was observed removing food trays from a covered food cart and delivered food trays to resident rooms with rolls and bread pudding uncovered. Staff was observed walking from room 130 to room 125 with roll and bread pudding uncovered. Residents in rooms 128 and 135 received roll and bread pudding that was not covered. Little clear plastic lids were noted on top of food cart but staff did not use the tops to cover the foods that were not covered prior to removing them from the food cart. There were three hallways on Unit 100. During random lunch observation on 7/24/17 at approximately 11:57 AM staff was observed removing food trays from a covered food cart and delivered food trays to residents rooms with cornbread and cake uncovered Staff was observed passing more than 2 resident rooms while delivering food trays. There were three hallways on Unit 100. An interview on 7/24/17 at approximately 12:09 PM with the facility's Certified Dietary Manager (CDM)confirmed the rolls, cornbread, cake and bread pudding were not covered for room delivery. The CDM stated when staff deliver food trays directly from the food cart all food did not have to covered. The CDM further stated he/she will review the facility policy to address how many rooms staff should pass when delivering food trays uncovered. An interview on 7/24/17 at approximately 12:13 PM with Certified Nursing Aide (CNA) #1 confirmed he/she had delivered food trays to resident rooms with foods uncovered. The CNA further stated they usually deliver food trays to resident rooms with breads, cakes/desserts uncovered. An interview on 7/24/17 at approximately 1:25 PM with the Director of Nursing (DON) with the CDM present revealed the facility did not have a policy related to food tray delivery to rooms with foods uncovered. The DON stated staff should not deliver foods trays to rooms with food uncovered no more than two doors away from the residents rooms. An interview on 7/24/17 at approximately 3:30 PM with the DON with the CDM present revealed the facility had an in-service within the past three months related to meal delivery. The in-service provided was not dated and did not address foods being covered during meal delivery. The DON stated the in-service was from a customer service standpoint for freshness and appropriate temps.

On the days of the Recertification Survey, based on record review and interview, the facility failed to revise the care plans to reflect falls and/or new interventions to prevent future falls for Residents # 7, #10, #11 and #19, 4 of 8 residents reviewed for revision of care plans following falls. The findings included: The facility admitted Resident #7 with [DIAGNOSES REDACTED]. On 1/8/14 at 3:21 PM, review of the record revealed Post Falls Nursing Assessments dated 10/10/13, 10/17/13, 10/27/13, 11/17/13, and 12/16/13 and 12/18/13. The fall on 12/18/13 resulted in an overnight hospitalization for a Subdural Hematoma. Further review revealed the 10/17/13 Post Falls Nursing Assessment listed hip protectors as one of the new interventions initiated. The intervention was not listed on the interim care plan dated 10/7/13 or on the the Comprehensive care plan dated 10/22/13. Continued review revealed on the 10/27/13 Post Falls Nursing Assessment, the intervention listed was to "Teach pt (patient to rise slowly from seated/ lying position." The intervention was not included on the care plan. The 11/17/13 Post Falls Nursing Assessment listed "Clear walking pathways" as an intervention following a fall on 11/16/13 which was not a new intervention as the care plan already stated to maintain a safe environment. Additional review revealed a Post Falls Nursing assessment dated [DATE] at 4:45 AM. The Post Falls Nursing Assessment indicated the "immediate interventions" that "were initiated to prevent future falls" was a "walking assessment or wheel chair assessment." There was no evidence this new intervention was completed. Review of the care plan revealed neither the walking/ wheel chair assessment or any other interventions had been added to prevent future falls following the 12/16/13 fall. Injuries that were documented as a result of the resident's repeated falls included: 10/27/13 Skin tear to back of head. 10/31/13 Blood noted on forehead. 11/16/13 Bruise inner thigh and outer left eye. 12/18/13 Hospital admission post fall, closed head trauma, subdural hematoma. During an interview on 1/9/14 at 12:25 PM, the Director of Nursing (DON) confirmed the hip protectors were not on the care plan. The DON further stated that the interventions listed on the Post Falls Nursing Assessment were suggestions and not necessarily interventions to be implemented, like "brainstorming." During the interview with the DON, s/he confirmed educating the resident "to rise slowly from seated/ lying position" was not listed on the care plan. The DON also confirmed that maintaining "clear walking pathways" was essentially the same as "Maintain safe environment," an intervention that was already on the care plan dated 10/22/13. During the interview, the DON stated the resident was non-ambulatory and a wheelchair assessment would have been done, not a walking assessment. S/he stated the assessment in the record was dated 10/7/13 and further stated that therapy would have reviewed the assessment already completed but would not have documented another assessment if there were no changes. When asked how reviewing an assessment that was completed 2 months prior to the fall would prevent future falls, the DON did not respond. The DON also stated that therapy would not have been in the facility at the time of the fall, 4:45 AM, to complete an assessment. The DON confirmed the resident was attempting to "to see what time it was" when s/he fell . Registered Nurse (RN) #3, who was present during the interview, stated that the resident had 2 illuminated clocks, one on each side of the bed and that the nurse immediately made sure both were visible from the bed. The DON confirmed that was not listed on the Post Falls Nursing Assessment or the care plan and that neither the wheel chair assessment or any other intervention were added to the care plan. RN #3 stated that, during business hours, a "Code Star" is paged over head for any falls. The fall team responds to the page to assist with the investigation in determining the root cause of the fall. After hours, the nurse initiates an investigation and enters the information into the computer. The Unit Manager checks the log daily to see if any falls occurred after hours and reports to the fall team to continue the investigation. Review of the "Memorandum" dated 11/1/12 related to the "Code Star" program revealed "1. Monday through Friday during regular business hours: If a resident experiences a fall, the nurse will PAGE "CODE STAR" FOLLOWED BY THE LOCATION OF THE RESIDENT WHO HAS FALLEN. Once paged members of the management team will respond to assist you in assuring that the resident is safe and to investigate the cause of the fall, weather (sic) it was avoidable or not, and in determining intervention(s) to assist in preventing future falls. 2. After normal business hours and on weekends: If a resident experiences a fall, the nurse must complete the Post Fall Investigation (See attached form) and then call (the Administrator)." The Post Fall Nursing Assessment was not included in the forms attached to the Memorandum provided by the facility for review. The Memorandum did not include instructions that new interventions to prevent future falls were required after the root cause of the fall was determined. The facility admitted Resident #19 with [DIAGNOSES REDACTED]. On 1/9/14 at approximately 1:32 PM, record review revealed a Post Falls Nursing assessment dated [DATE] that indicated the "CNA (Certified Nursing Assistant) was transferring Resident from W/C (wheel chair) to shower chair and resident became weak and her knees buckled and CNA lowered (the resident) to floor." The Post Falls Nursing Assessment had no "immediate interventions" that "were initiated to prevent future falls" listed. Review of the 7/23/13 care plan revealed on 8/13/13 an intervention had been added to the care plan to "use gait belt (with) all transfers." Review of the 10/15/13 and 1/7/14 care plans revealed the gait belt was not listed as an intervention. During an interview on 1/9/14 at 2:37 PM, the Director of Nursing stated it was a standard fall precaution to use a gait belt for all transfers. The DON confirmed that it was not on the care plan but stated it would be on the CNA care plan. At 2:40 PM, review of the CNA Care plan revealed "use gait belt for car transfers" which was confirmed by the DON at that time. The facility admitted Resident #10 with [DIAGNOSES REDACTED]. Walking, and Lack of Coordination Record review on 1/8/14 at 11:45 AM revealed Resident #10 had fallen on 10/19/13 at 5:35 AM. According to the Post Falls Nursing Assessment, the bed alarm had activated alerting staff, and upon entry to the room, they found the resident beside the bed on his/her hands and knees. There were no injuries noted. According to the assessment, a concave mattress was initiated to prevent future falls. Under additional comments, it was noted that the resident had gripper socks and upon getting the resident up, the socks were still slipping on the floor. The assessment documented that a low bed and alarm was in use and the resident had been wearing footwear. There was no mention that floor mats were in place at the time of the fall. A review of the High-Risk Patient Selection Form (fall risk assessment) revealed the resident had fallen on 10/19/13. It did not include information of any interventions currently in place or that any new interventions had been added to the care plan. A review of Nurse's Notes dated 10/21/13 revealed the resident was assisted to bed with the bed in the lowest position; bed alarm in use, and fall mats down. Another note dated 10/21/13 revealed the resident's [MEDICATION NAME] had been increased to four times a day related to the resident's increased tremors. A review of therapy notes dated 10/21/13 revealed that the resident had recently been fitted for a new pair of diabetic shoes. Observation of the resident's room on 1/9/14 at 9:42 AM revealed floor mats were beside the bed along with a bed alarm. There was no concave mattress visible. A review of the CNA (Certified Nursing Assistant) care plan on the resident's dresser door on 1/9/14 at 10:03 AM with CNA #1 revealed the bed alarm was an intervention in use for falls. There was no mention that fall mats were needed. CNA #1 verified that fall mats were in use for the resident and should have been added to the CNA care plan. A review of the Comprehensive Care Plan dated 12/24/13 revealed information that the resident was at risk for falls and had a fall on 10/19/13 without injury. Approaches listed included the bed alarm. However, there was no mention of a concave mattress or fall mats as interventions for falls and/or injury prevention. A review of the previous comprehensive care plan dated 10/1/13 revealed the previous care plan included the same interventions as the 12/24/13 care plan; with no new interventions added after the fall and no mention of a concave mattress or fall mats. During an interview on 1/9/14 at 9:55 AM, Licensed Practical Nurse (LPN) #1 verified the comprehensive care plan did not include fall mats as an intervention. LPN #1 verified there was no concave mattress in use for the resident and stated that the nurse had added the concave mattress to the Post Falls Nursing Assessment as a suggestion; and that a decision had been made not to use it. The facility admitted Resident #11 with [DIAGNOSES REDACTED]. Record review on 1/9/14 at 12:45 PM revealed Resident #11 had fallen on 12/11/13 at 2:00 PM. According to the Post Falls Nursing Assessment, the resident was being assisted to the wheelchair from the bed by therapy and 1 other staff member when the resident's legs gave out and the resident had to be lowered to the floor. There were no injuries noted. The assessment documented that "Other" immediate interventions had been initiated to prevent future falls. Under "Additional Comments" it was noted the resident was lifted with a mechanical lift. A review of the High-Risk Patient Selection Form (fall risk assessment) revealed the resident had been admitted on [DATE]. The assessment had not been updated to include information that the resident had fallen on 12/11/13 or that any new interventions had been added to the care plan. A review of December 2013 therapy notes revealed the resident required the use of a mechanical lift for transfers and that therapy was working with the resident on safe transfers with gait training and therapeutic exercises. A review of the Comprehensive Care Plan dated 12/24/13 revealed information that the resident was at risk for falls, had no fall history noted, and included approaches that the resident required the "Assistance of staff with all transfers". The Care Plan had not been updated to include the fall on 12/11/13 and did not include information that the resident required the use of a mechanical lift for transfers. During an interview on 1/9/14 at 12:55 PM, Licensed Practical Nurse (LPN) #1 verified the comprehensive care plan did not include information that the resident had fallen or that s/he required the use of a mechanical lift. Registered Nurse (RN) #4 reviewed the fall assessment with the surveyor and stated that the assessment was updated quarterly and it was "probably due for an update".

On the days of the Recertification Survey, based on record review and interview, the facility failed to implement new interventions to prevent future falls for Resident # 7, I of 8 residents reviewed for falls. The findings included: The facility admitted Resident #7 with [DIAGNOSES REDACTED]. On 1/8/14 at 3:21 PM, review of the record revealed Post Falls Nursing Assessments dated 10/10/13, 10/17/13, 10/27/13,11/17/13, and 12/16/13 and on 12/18/13, Resident #7 had a fall resulting in an overnight hospitalization for a Subdural Hematoma. Further review revealed the 10/17/13 Post Falls Nursing Assessment listed hip protectors as one of the new interventions initiated. The intervention was not listed on the interim care plan dated 10/7/13 or on the the Comprehensive care plan dated 10/22/13. During an interview on 1/9/14 at 12:25 PM, the Director of Nursing (DON) confirmed the hip protectors were not on either of the care plans. The DON further stated that the interventions listed on the Post Falls Nursing Assessment were suggestions and not necessarily interventions to be implemented, "brainstorming." Continued review revealed on the 10/27/13 Post Falls Nursing Assessment, the intervention listed was to "Teach pt (patient) to rise slowly from seated/ lying position." During the interview with the DON, s/he confirmed the intervention was not listed on the care plan. The 11/16/13 Post Falls Nursing Assessment listed "Clear walking pathways" as an intervention following a fall on 11/16/13. During the interview on 1/9/13, the DON confirmed that maintaining clear walking pathways was essentially the same intervention as "Maintain safe environment," an intervention that was already on the care plan dated 10/22/13. Additional review revealed a Post Falls Nursing assessment dated [DATE] at 4:45 AM. The Post Falls Nursing Assessment indicated the "immediate interventions" that "were initiated to prevent future falls" was a "walking assessment or wheel chair assessment." No assessment could be located in the chart since the initial assessment dated [DATE]. Review of the care plan revealed the intervention was not listed. During the interview on 1/9/13, at 12:35 PM, the DON stated the resident was non-ambulatory and a wheelchair assessment would have been done, not a walking assessment. The DON reiterated that the interventions listed on the Post Falls Nursing Assessment were suggestions, not necessarily interventions. S/he confirmed the only assessment in the record was dated 10/7/13 and further stated that therapy would have reviewed the assessment already completed but would not have documented another assessment if there were no changes. When asked how reviewing an assessment completed 2 months prior to the fall would prevent future falls, the DON did not respond but confirmed that the wheelchair assessment was not on the care plan. The DON also stated that therapy would not have been in the facility at the time of the fall, 4:45 AM, to complete an assessment. The DON confirmed the resident was attempting "to see what time it was" when s/he fell . Registered Nurse (RN) #3, who was present during the interview, stated the resident had 2 illuminated clocks, one on each side of the bed and that the nurse immediately made sure both were visible from the bed. The DON confirmed that was not listed on the Post Falls Nursing Assessment or the care plan and that no other intervention were added to the care plan. The DON also stated that s/he would have expected that the intervention to ensure the clocks were visible from the bed to have been implemented pending the completion of the investigation. RN #3 also stated that, during business hours, a "Code Star" is paged overhead for any falls. The fall team would then respond to the page to assist with the investigation in determining the root cause of the fall. After hours, the nurse is expected to initiate an investigation and enter the information into the computer. The Unit Manager is expected to check the log daily to see if any falls occurred after hours and report to the fall team to continue the investigation. Review of the "Memorandum" dated 11/1/12 related to the implementation of the "Code Star" program revealed "1. Monday through Friday during regular business hours: If a resident experiences a fall, the nurse will PAGE "CODE STAR" FOLLOWED BY THE LOCATION OF THE RESIDENT WHO HAS FALLEN. Once paged members of the management team will respond to assist you in assuring that the resident is safe and to investigate the cause of the fall, weather (sic) it was avoidable or not, and in determining intervention(s) to assist in preventing future falls. 2. After normal business hours and on weekends: If a resident experiences a fall, the nurse must complete the Post Fall Investigation (See attached form) and then call (the Administrator)." The Post Fall Nursing Assessment that was in the record for Resident #7 was not included in the forms attached to the Memorandum provided by the facility for review.

On the days of the Recertification Survey, based on interviews and record review, the facility failed to hold the administration of insulin, as ordered, for a FSBS (Finger Stick Blood Sugar) less than 130 for Resident # 2, and nursing staff failed to follow Physician ordered parameters for medications and hold 7 doses of [MEDICATION NAME] for a pulse rate less than 60 for Resident #11. (2 of 15 residents reviewed for medication monitoring and accurately dispensing per order.) The findings included: The facility admitted Resident # 2 with [DIAGNOSES REDACTED]. On 1/7/14, review of the cumulative monthly physician's orders [REDACTED]." On 1/8/14 at 2:53 PM, review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Further review revealed Resident # 2 received insulin on 15 of those days. Additional review of the December, 2013 MAR indicated [REDACTED]. On 1/9/14 at approximately 12:30 PM, review of the October 2013 MAR indicated [REDACTED]. Further, there was no documentation of the results of the FSBS on 3 days, 10/10/13-10/12/13, that the resident received the insulin. During an interview on 1/9/14 at 10:40 AM, Registered Nurse (RN) # 5 failed to confirm or deny the accuracy of the information on the MAR. RN # 5 stated that corrections to the MAR indicated [REDACTED]. The RN further stated that FSBSs and other insulin orders were not checked as frequently, usually monthly. The RN stated that s/he would check with Medical Records for any additional corrections. No further information was provided by the RN or Medical Records of any additional corrections. During an interview on 1/9/14 at 11:40 AM, the Director of Nursing (DON) confirmed there was "an issue" with the FSBS and insulin administration for Resident # 2. The DON stated the order to hold the insulin for a FSBS less than 130 was different than most of the facility's other FSBS orders. The facility admitted Resident #11 with [DIAGNOSES REDACTED]. Review on 1/8/14 at 4:05 PM of the December 2013 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The entry included information to hold the medication if the pulse was less than 60. Further review revealed that nursing staff had initialed 7 entries in December 2013 that indicated the [MEDICATION NAME] had been given with a documented pulse less than 60. On 12/7/13 and 12/8/13 at 9:00 AM the medication was administered with the resident's pulse documented as having been 59 and 58 respectively. The medication was also administered on 12/11/13 at 9:00 AM with a documented pulse of 53, 12/12/13 at 9:00 AM with a documented pulse of 58, 12/12/13 at 9:00 PM with a documented pulse of 54, 12/14/13 at 9:00 AM with a documented pulse of 53, and on 12/16/13 at 9:00 AM with a documented pulse of 58. During an interview on 1/9/14 at 10:40 AM, Licensed Practical Nurse (LPN) #1 verified the above documentation on the December 2013 Medication Record. A review of Nurse's Notes on 1/9/14 at 12:45 PM revealed an entry dated 12/27/13 which stated that the Physician had made rounds with orders given to discontinue the [MEDICATION NAME] ER as recommended by the Pharmacy. A review of the Pharmacist's "Note to Attending Physician/Prescriber" dated 12/23/13 revealed that due to concerns that the resident's pulse was less than 60 seven times in December, and because documentation indicated the resident's medications may be crushed; the Pharmacist wanted the Physician to evaluate the [MEDICATION NAME] for a possible dose reduction and/or whether it would be appropriate for a change to the immediate release form. The Physician agreed with the pharmacy recommendation and the medication was discontinued on 12/27/13.

On the days of the survey, based on record reviews and interviews, the facility failed to provide services in accordance with professional standards of practice for 1 of fifteen sampled residents reviewed for accurate documentation medication administration. A nurse incorrectly documented that [MEDICATION NAME] was not due to be administered to Resident #10 on 12/27/13 and failed to administer the medication as ordered. The findings included: The facility admitted Resident #10 with [DIAGNOSES REDACTED]. According to the Nurse's Notes, [MEDICATION NAME] 20 mg every other day was ordered because the resident's lower extremities were noted to be swollen on 12/18/13. Record review on 1/8/14 at 4:10 PM of the December 2013 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. According to the documentation, [MEDICATION NAME] had been given every other day starting 12/19/13 and was due to be administered on 12/27/13. The record indicated that on 12/27/13, the [MEDICATION NAME] had not been administered. According to nursing documentation on the Medication Record, the reason for changing the status was that the medication was due to be administered every other day; and was due on 12/28/13. However, continued review of the record revealed no documentation to clarify why the medication shouldn't have been administered on 12/27/13 since the last documented dose of the medication prior to this had been on 12/25/13. According to the MAR indicated [REDACTED]. The next dose of [MEDICATION NAME] the resident received was on 12/30/13. During interviews on 1/9/14 at 10:20 AM and 10:35 AM, LPN #1 and Registered Nurse (RN) #4 verified the above documentation.

On the days of the survey, based on interview, record review, and review of facility policies, the physician was not notified of Resident #125's refusal of medications to include [MEDICAL CONDITION] medications. The resident had two [MEDICAL CONDITION] for which the refusal of the medications may have been a contributing factor. (1 of 1 residents reviewed with [MEDICAL CONDITION]) The findings included: Record review on 10/16/12 at approximately 2:24pm revealed a hospital discharge summary for Resident # 125, dated 7/9/12 which included a [DIAGNOSES REDACTED]. Review of the October 2012 physician's cumulative orders revealed orders for [MEDICATION NAME] 500mg (milligram) tablet (take 1 twice daily) and [MEDICATION NAME] 100mg capsule (take 2 capsules (200mg) twice a day). Review of Laboratory (lab) reports revealed at the time of discharge (7/9/12) from the hospital the [MEDICATION NAME] acid ([MEDICATION NAME]) level was slightly low at 32 (Normal range is 50ug/dl (micrograms/deciliter) - 100ug/dl), but the [MEDICATION NAME] level was normal at 12.3. Further review of Lab reports revealed: [MEDICATION NAME] ([MEDICATION NAME]) level on 9/4/12 of 11.7 and on 9/12/12 - 5.3 (low) (Normal range 10 ug/dl - 20 ug/dl) and [MEDICATION NAME] Acid level on 9/4/12 of 17 (low) and on 9/12/12 - 13 (low) with no change in orders for [MEDICATION NAME] or [MEDICATION NAME] to be given. Review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Review of the October 1 through 15, 2012 MAR indicated [REDACTED]. This medication was refused for a total of 12 times out of a possible 30. The October 2012 MAR indicated [REDACTED]. This medication was refused for a total of 10 times out of a possible 30. Further record review revealed the resident had a [MEDICAL CONDITION] on 10/8/12 and on 10/15/12. Interview on 10/17/12 at approximately 10:16am with Licensed Practical Nurse (LPN) #1 indicated that nursing was aware of the resident refusing to take medication and that this could lead to a low blood level of the medications. Review of nursing notes did not indicate that the physician had been made aware of the refusal of 4 doses [MEDICAL CONDITION] medications before the [MEDICAL CONDITION] on 10/8/12 and refusal of a total of 22 doses before the [MEDICAL CONDITION] of 10/15/12. Further review of the record revealed on 10/9/12 a request was faxed to the physician concerning "Res. refuses pills most of the time. We have [MEDICATION NAME] and [MEDICATION NAME] in liquid form which ...accepts in juice. Could we change [MEDICATION NAME] and [MEDICATION NAME] to liquid?". Interview on 10/18/12 at approximately 9:47am with Registered Nurse (RN) #1 indicated that there had been no follow up to the lack of response from the physician concerning the requested change. RN # 1 stated: "Should have followed up with a phone call within a day or two of the original request.". Interview on 10/18/12 at approximately 9:54am with the resident's primary physician indicated that was not aware of the refusal of medications and s/he confirmed that the refusal of medications would cause a decrease in blood level and could contribute to [MEDICAL CONDITION] occurring. Review of Facility policy titled "Notification of MD Regarding Changes in Status" revealed under the section titled "Procedures", "2. Notify physician of significant changes in status. A. Non-urgent change 1. Fax physician to inform of assessment findings. Mark on fax form immediate response requested. . . B. Urgent/Emergent change 1. Call physician immediately to report urgent /emergent changes in resident's status."

On the days of the survey, based on interview, record review, and policy review, the facility failed to provide services that met professional standards of quality as evidenced by nursing staff performing CPR (Cardiopulmonary Resuscitation) while Resident #125 was having a [MEDICAL CONDITION], not documenting the provision of CPR, and by staff not giving medication for agitation per physician's orders [REDACTED]. The findings included: Interview on [DATE] at approximately 10:41am with Registered Nurse (RN) #2 and the Director of Nursing indicated that on [DATE] Resident #125 had a [MEDICAL CONDITION]. RN #2 described the [MEDICAL CONDITION] as "heavy, stiff, shaking, head jerking, stiff as a board." While the resident was in the state of [MEDICAL CONDITION] RN #2 had the resident lifted from the floor, placed on a wheelchair as the resident "could not get in wheelchair due to the [MEDICAL CONDITION]", taken to the resident's room and placed in the bed. S/he attempted to take a pulse, could not get a pulse, and began CPR as s/he did not know the resident's code status at that time. When asked why s/he could not get pulse, RN # 2 stated s/he "couldn't get pulse because the resident was seizuring so hard". Record review on [DATE], at approximately 2:24pm revealed no documentation in the physician's progress notes or the nursing progress notes of CPR being performed on the resident. When RN #2 was asked if s/he had documented the CPR s/he stated no s/he had not. In addition, RN #2 stated that while there was no documentation of contacting the physician and informing him of the [MEDICAL CONDITION] and provision of CPR, s/he had in fact contacted the physician. At the time of the interview ,a request was made for a copy of the facility's [MEDICAL CONDITION] policy/protocol. At approximately 11:15am the Director of Nursing stated that the facility did not have a [MEDICAL CONDITION] policy/protocol; that the facility followed nursing standards of practice. Review of Clinical Nursing Skills & Techniques, 7th Edition; Perry, Anne Griffin; Potter, Patricia A.; 2006; pp,[DATE] states "Implementation 1. When [MEDICAL CONDITION] begins, . . . 2. Position patient safely. If standing or sitting, guide patient to floor and protect head by cradling in nurse's lap or placing a pad under head. Do not lift patient from floor to bed while [MEDICAL CONDITION] is in progress." Review of the [MEDICAL CONDITION] Foundation, Managing [MEDICAL CONDITION], Standard First Aid states "CPR should not be given during a [MEDICAL CONDITION]". Review of Facility policy titled "Notification of MD Regarding Changes in Status" revealed under the section titled "Procedures", "2. Notify physician of significant changes in status. A. Non-urgent change 4. Document in Nurses' Notes assessment findings and notification of physician. . . B. Urgent/Emergent change 5. Document in Nurse's Notes assessment findings, notification of physician and orders received." Record review on [DATE] for Resident #125 revealed Nursing notes dated [DATE] which stated "2a Staff entered room to assist res(ident) with care. Res (resident) was holding a handful of own hair in hand. Res denies pain. Res hit @ (at) staff when staff attempted to assist res with care.". "7:30/a Res has been pulling out hair this morning by the handful . . .Paged MD on call". "11:15 Did not receive a call from MD, so nurse called office . . .still pulling hair out.". "3p Called MD office again . . .still pulling hair out by handsfuls.". [DATE] 11:00am "..... Family Practice called about res. Dr. .... has new order for [MEDICATION NAME]. Orders received and processed. Res behavior is decreased @ present.". Further review revealed a physician's orders [REDACTED]. Review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Interview on [DATE] at approximately 11:02am with Licensed Practical Nurse (LPN) #1 confirmed that [MEDICATION NAME] had not been given when the resident was pulling her hair out. LPN # 1 indicated that they use [MEDICATION NAME] for" when resident jumps up and goes running down the hall". Interview on [DATE] at approximately 9:54am with the resident's primary physician indicated that the resident's pulling out her hair was a sign of agitation and he would certainly approve the use of [MEDICATION NAME] for this behavior.

On the day of the complaint inspection based on observations, record review, interviews and review of the facility Patient Protection and Response Policy for Allegations/Incidents of Abuse, Neglect and Misappropriation of Property, the facility failed to implement written policies and procedures to prevent neglect. Resident #1 was transferred inappropriately on 3/7/2011 resulting in injury. The incident was not reported or throughly investigated until 3/16/2011. The Certified Nursing Assistant (CNA) continued to work from the date of the incident until 3/16/2011. The findings included: The facility admitted Resident #1 on 4/20/2004 with [DIAGNOSES REDACTED]. Review of the Care Plan revealed a problem area of falls with approaches including "... 2 person transfer." Review of the CNA Care Plan revealed "... Transfer: Extensive x 2." Review of the Nurse's Notes revealed on 3/8/2011 at 12 AM, "Bruise noted to R (right) and L (left) lower legs... Denies pain or discomfort. Dr. notified." Further review revealed the bruises remained to the bilateral lower legs through April 7 to April 9, 2011. Treatment continued to the resident's legs during that time. Review of the Incident Report dated 3/7/2011 and confirmed by the Director of Nurses documented bruising to legs. Under the "describe what happened" area only an asterisk was present. The DON stated that asterisk meant there was documentation however she was unable to obtain that documentation because the incident report was closed out and she did not have access. Under comments the CNA was counseled because Resident #1 was a 2 person transfer. Review of the 24 Hour Report dated 3/16/2011 revealed the incident occurred on 3/7/2011. The description of events stated, "On 3/16/2011 the resident's family reported that the resident sustained [REDACTED]." During an interview on 4/12/2011, CNA #1 stated that she was working on 3/7/2011 and was assigned to Resident #1. She stated that she transferred Resident #1 by herself. However, she stated on 3/7/2011 she asked for help from CNA #5. CNA #1 stated that on 3/18/2011 the Administrator informed her that she was "let go" because she transferred Resident #1 by herself. Review of the "as worked schedule" revealed CNA #1 was assigned to Resident #1 on 3/7/2011. CNA #1 was also assigned to work on 3/10, 3/14-3/16/2011, after the incident had been reported to administration on 3/7/2011. Review of the Time Card revealed CNA #1 worked from 7 AM to 3:03 PM on 3/7/2011. CNA #1 also worked 3/10 from 7 AM to 3 PM; 3/14 from 7 AM to 3 PM; 3/15 from 7 AM to 3 PM and 3/16 from 7:04 AM to 11:28 AM. Review of the 5 Day Report dated 3/23/2011 revealed corrective actions put in place were "inservice all current staff on abuse and neglect. Coordinate an inservice for all caregivers with therapy on transfers." The Summary was "We feel that (Resident #1's) bruises were caused by a CNA (CNA #1) not following the CNA Care p\Plan for (Resident #1) and performed a transfer by herself." An inservice was conducted on 3/28/2011 regarding Abuse/Neglect. The staff present in the building attended the inservice. No other staff members were inserviced. An inservice was conducted on 4/7/2011 regarding transfers. Eight staff members attended. During an interview on 4/12/2011, the Administrator and DON stated that the injury occurred on 3/7/2011. Both stated that they were aware of the injury and were aware that the injury was a result of CNA #1 improperly transferring Resident #1. The Administrator confirmed that the incident was not reported or investigated until 3/16/2011 when the family member stated that the injury was caused by abuse. The Administrator further stated that he did not think the fact that CNA #1 transferred the resident improperly and that the transfer caused injury to Resident #1 was neglect. The Administrator confirmed the inservice related to proper transfers only had 8 staff members in attendance. During an interview on 4/12/2011 at 5 PM, Resident #1's responsible party (RP) stated that the CNAs were rough with Resident #1. She also stated that on 3/7/2011 she reported the bruising to Resident #1's legs to the nurse. The RP stated that she was aware that CNA #1 transferred Resident #1 by herself. She then stated that the Administrator was aware of the incident on 3/8/2011. The RP stated that the Administrator informed her that he would investigate and suspend CNA #1. The RP stated that CNA #1 continued to care for Resident #1 after the Administrator assured her that he was investigating the incident. On 3/16/2011, the RP stated that Resident #1's legs looked bad and that she met with the Administrator immediately. She stated that the Administrator looked at the resident's legs and re-opened the investigation, terminated the CNA and reported the CNA to the registry. Review of the facility Patient Protection and Response Policy for Allegations/Incidents of Abuse, Neglect and Misappropriation of Property revealed the following: "Neglect: the failure to provide the goods and services necessary to avoid physical harm, mental anguish or mental illness." "Protection: Patients will be protected from harm during an investigation. Partners suspected of taking actions that would cause potential harm to a patient or other partners will be immediately placed on administrative leave pending the result of investigation." "Reporting: All allegations of possible abuse, neglect or misappropriation of patient property will be immediately assessed to determine the appropriate direction of the investigation. External reporting to the stated survey and certification agency and all other stated required agencies will follow Federal, individual State laws and licensing regulations." "Investigation: The investigation is conducted immediately under the following conditions: i. when it is identified that an alleged incident may have occurred, ii. as soon as any partner has knowledge and reports an alleged event."

On the day of the complaint inspection based on observations, record review, review of the facility Abuse Policy, and interviews, the facility failed to ensure one of four residents were transferred appropriately. Resident #1 transferred by a Certified Nursing Assistant (CNA) inappropriately resulting in injury to Resident #1's legs. The findings included: The facility admitted Resident # 1 on 4/20/2004 with [DIAGNOSES REDACTED]. Observation of Resident #1 on 4/12/2011 revealed the resident up in a wheelchair at the nurses' station socializing with other residents. Resident #1 had long sleeves and arm protectors in place as well as leg protectors. Review of the Care Plan revealed a problem area of fall with approaches including "... 2 person transfer." Review of the CNA Care Plan revealed "... Transfer: Extensive x 2." Review of the Nurses' Notes for 3/8/2011 at 12 AM stated, "Bruise noted to R (right) and L (left) lower legs... Denies pain or discomfort. Dr. notified." Further review revealed the bruises remained to the bilateral lower legs through April 9, 2011. Treatment continued to the resident's legs during that time. Review of the physician's orders [REDACTED]." A telephone order was written on 3/16/2011 to "apply Polymen non adhesive to bruises to bilateral legs (lower) wrap with kling until bruises healed." Review of the Incident Report dated 3/7/2011 and confirmed by the Director of Nurses documented bruising to legs. Under the "describe what happened" area only an asterisk was present. The DON stated the asterisk meant there was documentation however she was unable to obtain that documentation because the incident report was closed out and she did not have access. Under comments the CNA was counseled because resident was a 2 person transfer. Review of the 24 Hour Report dated 3/16/2011 revealed the incident occurred on 3/7/2011. The description of events stated, "On 3/16/2011 the resident's family reported that the resident sustained [REDACTED]." Review of the 5 Day Report dated 3/23/2011 revealed corrective actions put in place were "inservice all current staff on abuse and neglect. Coordinate an inservice for all caregivers with therapy on transfers." The Summary was "We feel that (Resident #1's) bruises were caused by a CNA not following the CNA Care Plan for (Resident #1) and performed a transfer by herself." During an interview on 4/12/2011, CNA #1 stated that she was working on 3/7/2011 and was assigned to Resident #1. She stated that she transferred Resident #1 by herself. However, she stated on 3/7/2011 she asked for help from CNA #5 (Review of the time care for CNA #5 showed she was not working 3/7/2011). CNA #1 stated that on 3/18/2011 the Administrator informed her that she was "let go" because she transferred Resident #1 by herself. During an interview the Physical Therapy Director stated that all residents were evaluated annually and as needed for appropriate transfers. She stated that Restorative Aides, CNAs and Nurses all report to therapy regarding each resident's transfer capabilities. She also stated that therapy makes the recommendations as to what type of transfer and the degree of assistance required. She further stated that she expected all therapy recommendations to be followed at all times. During an interview on 4/12/2011, the Administrator and DON stated the injury occurred on 3/7/2011. Both stated they were aware of the injury and were aware that the injury was the result of CNA #1 improperly transferring Resident #1. The Administrator confirmed that the incident was not reported or investigated until 3/16/2011 when the family member stated that the injury was caused by abuse. The Administrator further stated that he did not think the fact that CNA #1 transferred the resident improperly and that the transfer caused injury to Resident #1 was neglect. During an interview on 4/12/2011 at 5 PM, Resident #1's responsible party (RP) stated that the CNAs were rough with Resident #1. She also stated that on 3/7/2011 she reported the bruising to Resident #1's legs to the nurse. The RP stated that she was aware that CNA #1 transferred Resident #1 by herself. She then stated that the Administrator was aware of the incident on 3/8/2011. The RP stated that the Administrator informed her that he would investigate and suspend CNA #1. The RP stated that CNA #1 continued to care for Resident #1 after the Administrator assured her that he was investigating the incident. On 3/16/2011, the RP stated that Resident #1's legs looked bad and that she met with the Administrator immediately. She stated that the Administrator looked at the resident's legs and re-opened the investigation, terminated the CNA and reported the CNA to the registry. Review of the facility's Abuse Policy and Procedure revealed the following: "Neglect: the failure to provide the goods and services necessary to avoid physical harm, mental anguish or mental illness." "Protection: Patients will be protected from harm during an investigation. Partners suspected of taking actions that would cause potential harm to a patient or other partners will be immediately placed on administrative leave pending the result of investigation." "Reporting: All allegations of possible abuse, neglect or misappropriation of patient property will be immediately assessed to determine the appropriate direction of the investigation. External reporting to the stated survey and certification agency and all other stated required agencies will follow Federal, individual State laws and licensing regulations." "Investigation: The investigation is conducted immediately under the following conditions: i. when it is identified that an alleged incident may have occurred, ii. as soon as any partner has knowledge and reports an alleged event."