Every finding on record at Noxubee County Nursing Home

Based on staff interview and record review the facility failed to timely revise and implement a comprehensive, person-centered care plan for one (1) of eight (8) residents at risk for aspiration and choking risk. Resident #1. The facility's failure to revise the care plan and provide supervision on [DATE] at 11:20 AM, resulted in serious injury and death for Resident #1, who had a documented aspiration/choking risk. Resident #1 was not provided supervision while eating when staff served his lunch meal and stepped away from the table. Resident #1 began choking and required transfer to the emergency department where he was intubated and air lifted to another hospital for a higher level of care. Resident #1 expired after being taken off the ventilator on [DATE]. During the investigation, the SA identified Immediate Jeopardy (IJ) which began on [DATE] when Speech Therapy evaluated Resident #1 and recommended close supervision while eating.42 CFR 483.21 (b)(1) Comprehensive Care Plans (F657)- Scope/Severity J.This situation placed Resident #1 and other residents at risk for aspiration or choking in a situation that caused and was likely to cause serious injury, serious harm, serious impairment, or death.The SA notified the facility's Administrator of the IJ on [DATE] at 9:36 AM, and provided the Administrator with the IJ templates.The facility submitted an acceptable Removal Plan on [DATE], in which they alleged all corrective actions to remove the IJ was completed on [DATE], and the IJ removed on [DATE].The SA validated the Removal Plan on [DATE] and determined the IJ and SQC was removed on [DATE], prior to exit. Therefore, the scope and severity 42 CFR 483.21 (b)(1) Comprehensive Care Plans (F657) for were lowered from a J to a D while the facility develops a plan of correction to monitor the effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings Included:Record review revealed that the facility did not have a policy for updating and revising care plans.Record review of a Speech Therapy (ST) Note, dated [DATE], revealed recommendations for Resident #1 to have close supervision while eating. The recommended strategies included cyclic ingestion technique [two to three (2-3) sips per bite], small sips and bites, rate modification and general swallow techniques/precautions upright posture during meals.Record review of the care plan revealed Plan comments: Swallowing study shows risk for choking.I feed myself in the dining room after set-up only. Interventions included up in dining room for meals, will tolerate by mouth (PO) without signs/symptoms of aspiration, do not allow me to have straws, drink from cup, and serve mechanical soft with pureed meat diet. Review of the care plan revealed that it did not contain any information about the ST recommendations or the resident needing close supervision.Interview with the Minimum Data Set (MDS) nurse on [DATE] at 4:00 PM stated that the point of the care plan is for staff to know how to take care of residents. She stated that the nurse receiving recommendations or new orders is responsible for updating the care plan. She verified that Resident #1's care plan was not revised with the new ST recommendations for close supervision during meals, but that it should have been.Removal PlanThe facility failed to implement known swallowing safety interventions and close meal supervision on [DATE] at 11:20 A.M., for Resident #1 who had a documented aspiration/ choking risk, resulting in respiratory compromise and death, and failed to revise the comprehensive care plan for Resident #1 who was at risk for aspiration and choking, to include Speech Therapy (ST) recommendation for precautions and supervision to prevent aspiration and choking.Corrective Actions:1.On [DATE] at approximately 11:20 A.M., Licensed Practical Nurse (LPN) #1 noted Resident #1 had a panicked look on his face, yelled help and grabbed his chest. LPN #1 immediately identified the resident was choking and initiated back blows and called for help.2.On [DATE] at approximately 11:21 A.M., additional staff arrived, lowered Resident #1 to floor and abdominal thrusts initiated. Although Resident had a faint pulse, attempts to clear the airway were unsuccessful.3.On [DATE] at 11:45 A.M., Resident #1 placed on stretcher and transported to local hospital emergency room (ER) via Registered Nurse (RN) #1, LPN #2, and LPN #3.4.On [DATE] at 11:45 A.M., Attending Physician was notified by the Charge Nurse regarding the incident, current resident's condition and an order was received to transfer to local ER.5.On [DATE] at 11:50 A.M., Resident # 1 's Responsible Party (RP) was notified of incident and transfer to local ER. RP reported that he would meet Resident # 1 at the ER.6.On [DATE] at 3:30 P.M., Resident #1 had a Laryngeal Mask Airway (LMA) inserted in local ER and transferred to outside hospital.7.On [DATE] at 3:30 P.M., RP was present in the ER and was made aware of Resident # 1's transfer to outside hospital.8.On [DATE] at 1:30 P.M. the incident was reported to the Mississippi Dept of Health (MSDH) via the hotline.9.On [DATE] at 8:30 AM., the facility conducted a Quality Assurance (QA) meeting attended by Minimum Data Set (MDS) Coordinator, Medical Director, Administrator, Infection Control /Staff Education/Quality Assurance Nurse, RN #2, Director of Therapy Services and ST and Dietary Manager. The QA Committee reviewed the incident, identified root causes, and approved systemic corrective actions. Root Cause Analysis identified inadequate communication of ST recommendations, failure of supervision interventions during mealtime, and failure to revise resident care plans.10.Systemic corrective action implemented by Director of Therapy Services, MDS Coordinator, ST, and Infection Control/Staff Education/Quality Assurance Nurse on [DATE] for identification of residents with swallowing deficits, aspiration precautions or speech therapy recommendations and assessment for supervision needed.11.Systemic corrective action implemented by MDS Coordinator and Infection Control/Staff Education/Quality Assurance Nurse on [DATE] for review of ST recommendations to ensure any recommendations are immediately implemented and incorporated into resident care plans and electronic care systems.12.QA Committee adopted new policy for Care Plan Revisions upon Status Change to provide a consistent process for reviewing and revising the care plan for those residents experiencing a status change. Policy implemented on [DATE].13.QA Committee adopted new policy on Communication to make sure that therapy and nursing communicate any changes to a resident's diet/any needed equipment or any other change that is necessary to meet the resident's needs. Policy implemented on [DATE].14.Audits conducted by Infection Control/Staff Education/Quality Assurance Nurse and Director of Therapy Services to identify residents with swallowing precautions on [DATE] with 7 residents identified. Infection Control/Staff Education/Quality Assurance Nurse continued audit to ensure interventions are implemented consistently for lunch meal and the Charge Nurse will monitor meals for breakfast and supper and report to Infection Control/Staff Education/Quality Assurance Nurse any findings.15.Monitoring system implementation to ensure residents requiring direct meal supervision received supervision during meals.16.Staff education conducted by Infection Control/Staff Education/Quality Assurance Nurse regarding supervision requirements, aspiration precautions, choking prevention and implementation of swallowing interventions for those residents identified with swallowing deficits or aspiration precautions or per speech therapy recommendations and updating resident care plans with interventions. In-service conducted by Infection Control/Staff Education/Quality Assurance Nurse with nursing staff which refers to RN's, LPN's and Certified Nurse Assistants (CNA's), on [DATE]. No nursing staff will be allowed to work until education is completed.17. The facility alleged that all corrective measures were implemented on [DATE] and the immediate jeopardy was removed on [DATE].The SA validated on [DATE], through interview and record review that all corrective actions had been implemented as of [DATE], and the IJ was removed as of [DATE] prior to exit.

Based on review of facility investigation, staff interviews and record review the facility failed to provide adequate supervision and assistance during meals for one (1) of eight (8) residents at risk for aspiration and choking risk. Resident #1. The facility's failure to provide supervision on 5/4/26 at 11:20 AM, resulted in serious injury and death for Resident #1, who had a documented aspiration/choking risk. Resident #1 was not provided supervision while eating when staff served his lunch meal and stepped away from the table. Resident #1 began choking and required transfer to the emergency department where he was intubated and air lifted to another hospital for a higher level of care. Resident #1 expired after being taken off the ventilator on 5/8/26. During the investigation, the State Agency (SA) identified Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC), which began on 4/27/26 when Speech Therapy evaluated Resident #1 and recommended close supervision while eating.The IJ and SQC existed at:42 CFR(s) 483.25(d)(1)(2) Accidents (F689) Scope/Severity J.This situation placed Resident #1 and other residents at risk for aspiration or choking in a situation that caused and was likely to cause serious injury, serious harm, serious impairment, or death.The SA notified the facility's Administrator of the IJ and SQC on 5/12/26 at 9:36 AM and provided the Administrator with the IJ templates.The facility submitted an acceptable Removal Plan on 5/12/26, in which they alleged all corrective actions to remove the IJ and SQC were completed on 5/12/26, and the IJ removed on 5/13/26.The SA validated the Removal Plan on 5/13/26 and determined the IJ and SQC was removed on 5/12/26, prior to exit. Therefore, the scope and severity for 42 CFR(s) 483.25(d)(1)(2) Accidents (F689) were lowered from a J to a D while the facility develops a plan of correction to monitor the effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings Included:Record review revealed that the facility did not have a policy related to supervision and monitoring to prevent accidents.Record review of the facility investigation revealed that on 5/4/26 at approximately 11:20 AM, staff served Resident #1 his lunch tray and stepped away from the table. Moments later, Resident #1 then yelled help and Licensed Practical Nurse #1 (LPN) saw that the resident had a panicked look on his face and placed his hand on his chest. LPN #1 realized that the resident was choking and immediately went to the resident and began back blows and called for help. Additional staff entered the dining room, the resident was assisted to the floor, and abdominal thrusts were initiated. Staff were unable to clear Resident #1's airway so he was transferred to the local emergency room. The physician and responsible party (RP) were notified. In the emergency room, the resident presented not breathing with a slow thready pulse. He was intubated in the emergency room and was transferred to another hospital for a higher level of care.Record review of a Long Term Care (LTC) Note, dated 4/24/26, for Resident #1 revealed Speech Therapy (ST) was consulted due to the resident having increased coughing during meals.Record review of a Speech Therapy Note, dated 4/27/26, revealed recommendations for Resident #1 to have close supervision while eating. The recommended strategies included cyclic ingestion technique [two to three (2-3) sips per bite], small sips and bites, rate modification and general swallow techniques/precautions upright posture during meals. ST notes also indicated that Resident #1 scored a nine (9) out of 30 on the Standardized Mini-Mental State Examination (SMMSE), indicating that the resident is severely cognitively impaired.Record review of a LTC Note, dated 4/29/26, for Resident #1 revealed that during dinner the resident began to cough and choke. The resident coughed up a large amount of food. Before the nurse could identify what, the resident choked on, he began to immediately eat again and choked again. Resident was able to cough up the food, and the nurse identified the food item as a dinner roll and had it removed from the resident's diet.Record review of a ST Note, dated 4/30/26 revealed that the nurse reported Resident #1's choking incident that occurred on 4/29/26 and ST reiterated that the resident required close supervision precautions to the nurse.Record review of hospital triage note, dated 5/4/26, for Resident #1 revealed resident arrived cyanotic, unresponsive, was not breathing and staff was unable to obtain a pulse. Cardiopulmonary Resuscitation (CPR) was initiated.Record review of Final Report from the local emergency room (ER) dated 5/4/26, for Resident #1 revealed that resident was being transported to a higher level of care via helicopter related to posturing after post choking cardiac arrest and possibly had anoxic brain injury.Record review of LTC Note dated 5/8/26, for Resident #1 revealed that the resident's RP notified the facility that the resident passed away at 5:22 PM on 05/08/26 after being removed from the ventilator.Interview with LPN #1 on 5/11/26 at 2:30 PM, she verified that she and the staff in the dining room were aware that Resident #1 was at risk for aspiration and choking and were aware of ST recommendations to prevent aspiration and choking. She verified that the resident required repetitive cues to follow the recommendations from the speech therapist. She further stated that his short-term memory was bad, and you can tell him to take small bites and he will but then he will go right back to taking large bites. She stated that she had repositioned the resident and instructed him to take small bites, chew and then swallow. She then stepped away to check on other residents. Another resident had asked her for fluids and when she went to get the fluids Resident #1 called out and put his hand on his chest and was choking. She stated she immediately initiated back blows to attempt to dislodge the food and called for help. She verified additional staff assisted resident to the floor and began abdominal thrust, but they were unsuccessful in clearing his airway; so, the resident was transferred to the ER.On 5/11/26 at 2:36 PM, an observation with LPN #1, revealed the location that Resident #1 was sitting in dining room at the time of incident and she verified that he was sitting at the table that was facing the wall and staff were unable to see his face. There were two (2) Certified Nursing Assistants (CNA) sitting with other residents at a table diagonally across from where the resident was and this put Resident #1's back to the CNAs.Interview on 5/11/26 at 2:45 PM with ST revealed Resident #1 was at risk for aspiration and choking. Her recommendations were for Resident #1 to have close supervision while eating. She indicated that this meant that the staff should be present one on one with the resident to ensure that he is following his recommended strategies to prevent aspiration and choking. She verified the recommended strategies included 2 to 3 sips per bite, small sips and bites, rate modification and general swallow techniques/precautions, and upright posture during meals. She verified the resident required consistent cues to perform safe swallowing due to his impaired cognition. She stated she notified the Hall Nurse and Charge Nurse of the recommendations so they can enter them into the system to ensure that staff are aware.Interview with the Administrator (ADM) on 5/11/26 at 3:30 PM she agreed that Resident #1 should have received close supervision and consistent cueing during meals.Interview with the ADM on 5/12/26 at 8:45 AM, she verified there were no orders or communications in the system regarding the ST recommendations for Resident #1.Interview on 5/12/26 at 10:15 AM with CNA #2 verified that she was working in the dining room at lunch on 5/4/26. She stated she passed out trays and then sat down to assist another resident to eat. She stated that she was aware of Resident #1's need for cues and supervision. She stated usually someone is with him while he eats. She verified that from where she was sitting, she could not see the resident eating because his back was to her. She verified that no one was at the table with the resident. She stated he called out and it was noted that he was choking. She verified she assisted the nurse in moving the resident and providing care until he was transferred out.Telephone interview on 5/12/26 at 12:28 PM, with Charge Nurse #1 (CN) she stated that she did not receive any ST recommendations for Resident #1 on 4/27/26. She stated that ST spoke to the Hall Nurse. She further verified that she works in the dining room at times and is aware of the supervision and cues that the resident required for eating safely.Record review of demographics form revealed the facility admitted Resident #1 on 12/2/24.Record review of Diagnosis and Problems list revealed Resident #1 had a diagnosis of Cerebrovascular Accident and Difficulty Swallowing.Removal PlanThe facility failed to implement known swallowing safety interventions and close meal supervision on 05/04/26 at 11:20 A.M., for Resident #1 who had a documented aspiration/ choking risk, resulting in respiratory compromise and death, and failed to revise the comprehensive care plan for Resident #1 who was at risk for aspiration and choking, to include Speech Therapy (ST) recommendation for precautions and supervision to prevent aspiration and choking.Corrective Actions:1.On 05/04/26 at approximately 11:20 A.M., Licensed Practical Nurse (LPN) #1 noted Resident #1 had a panicked look on his face, yelled help and grabbed his chest. LPN #1 immediately identified the resident was choking and initiated back blows and called for help.2.On 05/04/26 at approximately 11:21 A.M., additional staff arrived, lowered Resident #1 to floor and abdominal thrusts initiated. Although Resident had a faint pulse, attempts to clear the airway were unsuccessful.3.On 05/04/26 at 11:45 A.M., Resident #1 placed on stretcher and transported to local hospital emergency room (ER) via Registered Nurse (RN) #1, LPN #2, and LPN #3.4.On 05/04/26 at 11:45 A.M., Attending Physician was notified by the Charge Nurse regarding the incident, current resident's condition and an order was received to transfer to local ER.5.On 05/04/26 at 11:50 A.M., Resident # 1 's Responsible Party (RP) was notified of incident and transfer to local ER. RP reported that he would meet Resident # 1 at the ER.6.On 05/04/26 at 3:30 P.M., Resident #1 had a Laryngeal Mask Airway (LMA) inserted in local ER and transferred to outside hospital.7.On 05/04/26 at 3:30 P.M., RP was present in the ER and was made aware of Resident # 1 's transfer to outside hospital.8.On 05/04/26 at 1:30 P.M. the incident was reported to the Mississippi Dept of Health (MSDH) via the hotline.9.On 5/12/26 at 8:30 AM., the facility conducted a Quality Assurance (QA) meeting attended by Minimum Data Set (MDS) Coordinator, Medical Director, Administrator, Infection Control /Staff Education/Quality Assurance Nurse, RN #2, Director of Therapy Services and ST and Dietary Manager. The QA Committee reviewed the incident, identified root causes, and approved systemic corrective actions. Root Cause Analysis identified inadequate communication of ST recommendations, failure of supervision interventions during mealtime, and failure to revise resident care plans.10.Systemic corrective action implemented by Director of Therapy Services, MDS Coordinator, ST, and Infection Control/Staff Education/Quality Assurance Nurse on 05/12/26 for identification of residents with swallowing deficits, aspiration precautions or speech therapy recommendations and assessment for supervision needed.11.Systemic corrective action implemented by MDS Coordinator and Infection Control/Staff Education/Quality Assurance Nurse on 05/12/26 for review of ST recommendations to ensure any recommendations are immediately implemented and incorporated into resident care plans and electronic care systems.12.QA Committee adopted new policy for Care Plan Revisions upon Status Change to provide a consistent process for reviewing and revising the care plan for those residents experiencing a status change. Policy implemented on 05/12/26.13.QA Committee adopted new policy on Communication to make sure that therapy and nursing communicate any changes to a resident's diet/any needed equipment or any other change that is necessary to meet the resident's needs. Policy implemented on 05/12/26.14.Audits conducted by Infection Control/Staff Education/Quality Assurance Nurse and Director of Therapy Services to identify residents with swallowing precautions on 05/12/26 with 7 residents identified. Infection Control/Staff Education/Quality Assurance Nurse continued audit to ensure interventions are implemented consistently for lunch meal and the Charge Nurse will monitor meals for breakfast and supper and report to Infection Control/Staff Education/Quality Assurance Nurse any findings.15.Monitoring system implementation to ensure residents requiring direct meal supervision received supervision during meals.16.Staff education conducted by Infection Control/Staff Education/Quality Assurance Nurse regarding supervision requirements, aspiration precautions, choking prevention and implementation of swallowing interventions for those residents identified with swallowing deficits or aspiration precautions or per speech therapy recommendations and updating resident care plans with interventions. In-service conducted by Infection Control/Staff Education/Quality Assurance Nurse with nursing staff which refers to RN's, LPN's and Certified Nurse Assistants (CNA's), on 05/12/26. No nursing staff will be allowed to work until education is completed.17. The facility alleged that all corrective measures were implemented on 05/12/26 and the immediate jeopardy was removed on 05/13/26.The SA validated on 5/13/26, through interview and record review that all corrective actions had been implemented as of 5/12/26, and the IJ was removed as of 5/13/26 prior to exit.

Based on observation, resident and staff interviews, record review, and facility policy review, the facility failed to ensure Activities of Daily Living (ADLs) with incontinent care was provided for one (1) of 17 sampled residents. Resident #45 Findings include: Record review of facility policy titled Quality of Care undated revealed, .The policy of the facility is to establish a minimum acceptable level of daily care, which shall include and involve the maximum utilization of the resident's capabilities, while providing the necessary assistance to accomplish the following: . Toileting .Staff is to check and change incontinent residents every 2 hours and prn (as needed) . On 6/09/25 at 10:20 AM, during an observation and interview revealed Resident #45 lying in her bed visibly upset and stated, It has been almost three hours that I have been sitting in a poopy diaper the last time my diaper was changed was on the night shift. Resident #45 further revealed, I have put my call light on several times this morning. They come in and ask me what I need, and I tell them I need my diaper changed because I have had a bowel movement and they turn the call light off and say they will get my aide. An observation from the hallway on 6/9/25 at 10:32 AM ,revealed Resident #45's call light was pressed and came on and Certified Nurse Aide (CNA) #1 entered the room, the call light was turned off, and CNA #1 exited the room within approximately fifteen (15) seconds. CNA #1 went down the hall and around a corner, then returned to the hall and began to pass ice and water to other rooms. An interview on 6/9/25 at 10:36 AM, Resident #45 revealed I turned on my call light, and the aide came in and asked me what I needed. I told her that I needed to be changed because I had a bowel movement. She told me, 'Okay,' and then turned off the call light, telling me she would let my aide know. During an interview on 6/9/25 at 10:45 AM, CNA #2 revealed she is assigned to the resident today and confirmed she started her shift at 6:45 AM and did her rounds on the resident this morning but the resident didn't say if she was wet or needed to be changed, she will usually let us know when she needs changing so I didn't change her. So, I moved on to the other hall and was giving a bed bath, and two aides came and told me that Resident #45 needed to be changed. She confirmed that she had not provided incontinent care to Resident #45 this morning because she was not wet when she initially made her rounds this morning. During an interview on 6/09/25 at 10:50 AM, CNA #3 revealed she went into Resident #45's room about 9:00 AM to see if she was ready for her whirlpool bath. The resident said she had to have a brief change first because she had a bowel movement. CNA #3 revealed, I then went and told her assigned aide, (Proper name of CNA #2), that the resident needed to be changed. CNA #3 revealed I am also able to provide incontinent care and I should have changed her brief instead of making her wait longer. In an interview on 6/9/25 at 11:10 AM, the Director of Nurses (DON) revealed the resident has had some complaints about her call light not being answered in a timely manner. He revealed that it is his expectation that residents receive incontinent care at least every 2 hours or more and for Resident #45 to be left soiled without being cleaned up for that amount of time is unacceptable. In an interview on 6/11/25 at 3:25 PM, the Administrator revealed that residents are supposed to receive incontinent care every two hours and as needed. She revealed that the CNAs should have made their rounds every two hours and provided care and should have changed the resident instead of turning the light off and not providing the care she needed. Record review of the Revenue Cycle Face sheet revealed the facility admitted Resident #45 on 10/09/2023 with medical diagnoses that included Acute kidney failure, Heart failure, and Depression. Record review of Resident #45's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 4/3/2025 Section H: Resident is always incontinent of urinary and bowel continence. Section C revealed a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident is cognitively intact.

Based on staff interview, record review, and facility letterhead review, the facility failed to monitor residents for side effects of anticoagulant medication use for two (2) of five (5) medication reviews. Resident #27 and Resident #56 Findings include: Record review of facility letterhead signed by the Administrator and dated 6/12/25 revealed, (Proper name of nursing home) does not have a policy on anticoagulant monitoring. Resident #27 Record review of Resident #27's Orders revealed an order dated 8/26/24 for Apixaban (Eliquis) 5 milligram oral tablet) .BID (two times daily). During an interview on 6/10/25 at 3:40 PM, Licensed Practical Nurse (LPN) #3 revealed Resident #27 received an anticoagulant medication and acknowledged awareness of the risk of anticoagulant medication use and the need to observe for bruising or bleeding. She revealed there was not an area in the computer documentation to prompt the nurses to monitor or to document that the resident was monitored for bleeding or bruising. During an interview on 6/11/25 at 10:10 AM, the Registered Nurse/Minimum Data Set (RN/MDS) acknowledged Resident #27 received an anticoagulant medication and monitoring for side effects had not been documented. She revealed the nurses should observe for bleeding and bruising and report if noted, but there was no documentation to prompt the nurses to monitor this routinely or verify this was done. She confirmed that residents receiving an anticoagulant medication should be monitored due to their risk for bleeding and this was not done. An interview with the Director of Nursing (DON) on 6/11/25 at 12:05 PM, revealed Resident #27 received an anticoagulant medication that could cause excessive bleeding and needed to be monitored for bleeding and bruising. He revealed that monitoring would help ensure the resident was evaluated and treated promptly to prevent complications. He confirmed the facility failed to monitor a resident on an anticoagulant medication for bleeding and/or bruising and document their observations. Record review of Resident #27's Revenue Cycle Face sheet revealed an original admission date of 8/26/24 with the most recent admit date of 5/6/25 and diagnoses that included Venous thrombosis and Embolism. Resident #56 An interview and observation on 06/11/25 at 9:50 AM, with LPN #2 revealed that they were supposed to pay close attention to the residents on anticoagulants. She revealed that they looked at labs, monitored for bleeding or bruising throughout the shift to make sure they didn't have any side effects of taking the blood thinners. An observation revealed LPN #2 pull Resident #56's information up on the computer screen on the medication cart and she confirmed that there was no documentation of monitoring for anticoagulant side effects for him and stated, I don't know why it's not getting done. An interview with RN #1, revealed that there was not a monitoring section for anticoagulants in their system. She revealed that the nurses were supposed to monitor for side effects of anticoagulants and if they noticed anything abnormal, they were to document it. RN #1 confirmed that Resident #56 was on an anticoagulant and there was no documentation found where the nurses monitored for side effects and also confirmed that inadequate monitoring placed the resident at risk for bleeding. Record review of Resident #56's Revenue Cycle Face Sheet revealed an admission date of 05/16/25 and that he had diagnoses that included Peripheral Vascular Disease and Atrial Fibrillation. Record review of Resident #56's Orders revealed an order dated 05/16/25 for Apixaban 5 mg (milligrams) by mouth twice a day and there was no order to monitor for bruising or bleeding. Record review of Resident #56's Medication Administration Record (MAR) for June 2025 revealed that he received Apixaban 5 mg (milligrams) orally bid (two times a day) and there was no monitoring tool in place for staff to monitor for signs of bleeding or bruising with the anticoagulant.

Based on observation, interview, and facility policy review the facility failed to utilize protective barriers to prevent possible contamination and spread of bacteria during two (2) of five (5) resident medication administration observations. Resident #1 and Resident #43. Findings Include: Review of the facility policy, Administration of Eye Drops or Ointments Policy with revision date of 04/24/23 revealed, Eye medications are administered as ordered by the physician and in accordance with professional standards of practice .5. Administration: a. Remove medication cap and place on clean, dry surface (i.e. tissue or paper towel) to prevent contamination Resident #1 An observation on 06/11/25 at 8:20 AM, during Resident #1's medication pass revealed Licensed Practical Nurse (LPN) #1, removed Timolol eye drop bottle from the box and placed it on the overbed table with no barrier in use and had not sanitized the overbed table prior to placing the eye drop bottle on the table. LPN #1 administered the eye drops, placed the eye drop bottle back on the overbed table and then returned it to the medication cart. An interview on 06/11/25 at 8:30 AM, with LPN #1 confirmed that she did not place the eye drop bottle on a barrier and that she had placed it directly on the overbed table while she administered Resident #1's other medications. LPN #1 revealed that not utilizing a barrier with the bottle of eye drops could cause spread of germs and cross contamination and she should not have placed the eye drops on the dirty surface. Record review of Resident #1's Revenue Cycle Face Sheet revealed an admission date of 10/15/1991 and that she had diagnoses that included Cerebral Palsy, Ocular Hypertension of the Right Eye, and Unspecified Keratoconus of the Right Eye. Record review of Resident #1's Orders revealed an order dated 06/11/24 for Timolol Ophthalmic 0.5% solution to instill one drop in the right eye daily. Resident #43 An observation on 06/11/25 at 8:50 AM, during Resident #43's medication pass, revealed LPN #1 removed the Systane eye drop bottle from the box, she administered the eye drops and then placed the eye drop bottle on the overbed table with no barrier in use and had not sanitized the table prior to placing the medication there. LPN #1 administered Resident #43's other medications, picked up the eye drop bottle from the overbed table and returned it to the medication cart. An interview on 06/11/25 at 8:58 AM, LPN #1 revealed that she did not clean the overbed table prior to setting the eye drop bottle down and confirmed that she should have placed it on a barrier. She stated, I forgot. LPN #1 revealed that not using a protective barrier and by placing the eye drops directly on the overbed table, could cause the spread of germs and cross contamination. She revealed that she would make sure she used a protective barrier going forward. An interview on 06/11/25 at 9:54 AM, with the Director of Nursing (DON), revealed that the nurses were supposed to use protective barriers when providing care including during medication administration. He confirmed that LPN #1 placing Resident #1 and Resident #43's eye drop bottles on the overbed table during medication administration without a barrier was an infection control issue and it could cause the spread of germs and bacteria. Record review of Resident #43's Revenue Cycle Face Sheet revealed an admission date of 06/28/23 and that she had diagnoses that included Alzheimer's Disease and Major Depressive Disorder. Record review of Resident #43's Orders revealed an order dated 10/30/24 for Systane Complete Optimal Dry Eye Relief ophthalmic solution (ocular lubricant) to instill one drop both eyes two times a day.

Based on observation, resident and staff interviews, record review, and facility policy review, the facility failed to implement a person-centered care plan for providing incontinent care for one (1) of the 18 care plans reviewed. Resident #45 Findings include: Record review of facility policy titled Quality of Care undated revealed, Each resident shall receive optimal care to attain and/or maintain the highest mental and physical functional status as defined by the comprehensive assessment and plan of care. Additionally, the resident will receive the appropriate interventions to maintain or to improve his/her abilities. Record review of Resident #45's care plan, updated 4/9/25 revealed Plan Comments: I am incontinent of bowels . Outcomes .I will be kept clean & dry of incontinent bowel .Interventions .Provide incontinence/pericare after each incontinent episode . Record review of Resident #45's care plan, updated 4/9/25 revealed Plan Comments: I have a potential for complications associated with urinary incontinence .Outcomes .I will be kept clean, dry, & comfortable daily .Interventions . Provide peri-care after each incontinent episode .Assess me every 2 to 3 hrs (hours) and PRN (as needed) for incontinent episodes . During an observation and interview on 6/09/25 at 10:20 AM, revealed Resident #45 lying in her bed visibly upset and stated, It has been almost three hours that I have been sitting in a poopy diaper the last time my diaper was changed was on the night shift. Resident #45 further revealed, I have put my call light on several times this morning. They come in and ask me what I need, and I tell them I need my diaper changed because I have had a bowel movement. They turn the call light off and say they will get my aide but they never come back. During an interview on 6/10/25 at 2:30 PM, the Registered Nurse (RN) Minimum Data Set (MDS) Coordinator revealed she is responsible for developing the care plans. She revealed that the care plans are developed individually for each resident, so the staff will know how to care for that resident's specific needs. She confirmed Resident #45's care plan was not being followed regarding her incontinence care, and it should have been. Record review of the Revenue Cycle Face sheet revealed the facility admitted Resident #45 on 10/09/2023 with medical diagnoses that included acute Kidney Failure, Heart Failure, and Depression. Record review of Resident #45's MDS with an Assessment Reference Date (ARD) of 4/3/2025 Section H: Resident is always incontinent of urinary and bowel continence. Section C revealed a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident is cognitively intact.

Based on staff interviews and record review, the facility failed to ensure an as needed (PRN) psychotropic hypnotic medication for insomnia was limited to 14 days or to an appropriate time frame approved by the provider for one (1) of five (5) medication reviews. Resident #20 Findings include: Record review of facility letterhead signed by the Administrator and dated 6/12/25 revealed, (Proper name of facility) does not have a policy on stop dates for psychotropic drugs. Record review of Resident #20's Orders revealed an order dated 4/17/25 for Zolpidem 5 milligram oral tablet .every night at bedtime PRN for insomnia. Record review of Consultant Pharmacist Recommendation to Physician dated 4/23/25, revealed, Ambien 5 mg (milligrams) qhs (every night at bedtime) PRN (as needed) for insomnia. May we extend the above order for 6 months? The physician's response was, Agree .Cont (continue) it 6 months. During an interview on 6/11/25 at 10:10 AM, Registered Nurse/Minimum Data Set Coordinator (RN/MDS) revealed Resident #20 had a psychotropic hypnotic medication ordered as needed (PRN) for insomnia and this order did not have the required stop date. She stated any PRN psychotropic medication should have a 14 day stop date or another date approved by the physician. She stated the pharmacist recommended the medication be extended for six months and the provider approved this recommendation, but it was overlooked by the facility staff and was not entered into the resident's orders. An interview with the Director of Nursing (DON) on 6/11/25 at 12:05 PM, revealed any PRN psychotropic medication should have a stop date of 14 days or longer if approved by the physician to ensure psychotropic PRN medication use is monitored and not extended if unnecessary. He stated Resident #20 was on a psychotropic hypnotic medication at bedtime as needed. He acknowledged the pharmacist made a recommendation for a six month stop date which was approved by the provider and the facility failed to enter this date into the resident's orders. He confirmed the facility failed to have the required stop date for a resident receiving a PRN hypnotic psychotropic medication. Record review of Resident #20's Revenue Cycle face sheet revealed the resident was admitted to the facility on [DATE] with diagnoses that included insomnia.

Based on observation, resident and staff interviews, and facility policy review, the facility failed to address a grievance regarding answering a call light and providing Activities of Daily Living (ADL) care in a timely manner for one (1) of the 17 sampled residents. Resident #45 Findings include: A review of the facility policy titled Policy Statement Filing Grievances/Complaints with a revision date of 3/17/17 revealed, .Staff will assist in completing and filing a grievance or complaint when such requests are made. Grievances include, but are not limited to, resident care, treatment, abuse, neglect .2. Grievances can be filed orally, in writing, or anonymously .4. Grievances will be responded to within 5 working days of the date the grievance was filed. Immediate action will be taken on grievances where alleged violations of any resident rights are reported to prevent further potential violations . An observation and interview on 6/09/25 at 10:20 AM, revealed Resident #45 lying in her bed and she was visibly upset. Resident #45 stated, It has been almost three hours that I have been sitting in a poopy diaper. The last time my diaper was changed was on the night shift. Resident #45 further revealed, I have put my call light on several times this morning. They come in and ask me what I need, and I tell them I need my diaper changed because I have had a bowel movement, then they turn the call light off and say they will get my aide. She revealed they need to take care of me instead of turning my light out and leaving. Resident #45 revealed that she had previously spoken with the Director of Nursing (DON) about this issue, and he is aware. She stated, I tried to talk with the DON last week, but he never got back with me. She became tearful and stated, I feel so useless. I'm not able to do anything for myself, and I'm at the mercy of everyone else. I haven't spoken to the Administrator because she has a lot on her plate to deal with. During an interview on 06/09/25 at 11:10 AM, the DON revealed that Resident #45 had some complaints about her call light not being answered on time in the past and having to wait to be changed. He confirmed that he had not formally written up a grievance to ensure the problem was addressed and a follow-up had not been conducted to see if her grievance was corrected. In an interview on 6/11/25 at 9:10 AM, the Administrator revealed that she is the grievance officer and confirmed that no formal grievance had been written regarding the resident's concerns and complaints. She revealed the residents' complaint should have been written up as a grievance so that we could have addressed it and followed up to ensure it was resolved. Record review of the Revenue Cycle Face sheet revealed the facility admitted Resident #45 on 10/09/2023 with medical diagnoses that included acute Kidney Failure, Heart Failure, and Depression. Record review of Resident #45's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 4/3/2025 revealed a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident is cognitively intact.

Based on observation, staff interview and facility policy review the facility failed to maintain a clean and homelike environment as evidenced by a dirty air conditioning unit in one (1) of 30 rooms observed. room [ROOM NUMBER]. Findings Include: Review of the facility policy, Routine Cleaning and Disinfection with revision date of February 2023, revealed, It is the policy of this facility to ensure the provision of routine cleaning and disinfection in order to provide a safe, sanitary environment and to prevent the development and transmission of infections to the extent possible . An observation on 06/09/25 at 11:23 AM and on 06/11/25 at 2:55 PM, in room [ROOM NUMBER], revealed a dirty air conditioning unit that had a damp, black substance scattered on the plastic slats on the front panel. There were also scattered food particles and dried crumbs on the front lower part of the thermostat section of the air conditioner unit. An observation in room [ROOM NUMBER] and interview with Licensed Practical Nurse (LPN #2) on 06/11/25 at 3:00 PM, confirmed that there was a black substance scattered throughout the front slats of the air conditioner unit. She revealed that the black substance looked like mildew, and this could cause respiratory issues for the resident if not taken care of and cleaned. She also confirmed that scattered food particles and crumbs were on the front lower part of the thermostat section and stated, It needs to be cleaned. During an observation in room [ROOM NUMBER] and interview with Director of Nurses (DON) on 06/11/25 at 3:10 PM, he confirmed the damp, black substance on the front panel of the air conditioner and the food particles and crumbs on the anterior right section under the thermostat control. The DON revealed that the black substance on the air conditioner looked like mildew and that this could cause respiratory problems. He also confirmed that by leaving the air conditioner dirty, they failed to ensure that they maintained a clean homelike environment for the residents. On 06/11/25 at 4:55 PM, an interview with the Maintenance Director, revealed that sometimes the residents eat their meals near the air conditioning units and would drop food in the units. He revealed that they removed the front panels of the air conditioner units three times a year and as needed, and cleaned them out good. He confirmed that the air conditioner unit in room [ROOM NUMBER], was left dirty and needed to be cleaned.

Based on observation, interview, and facility policy review, the facility failed to ensure medications were stored properly in a secure manner in the medication cart for one (1) of five (5) medication administration observations. Findings Include: Review of the facility policy titled Medication Storage, undated, revealed .1. General Guidelines: c. During a medication pass, medications must be under the direct observation of the person administering medications or locked in the medication storage area/cart . An observation on 06/11/25 at 9:05 AM, revealed a medication card of Lasix tablets on top of an unattended medication cart. An observation revealed Licensed Practical Nurse (LPN) #1 walked away from the medication cart down to the end of the hall in the sitting area and assisted a resident in a wheelchair to her room to receive her medications. An interview on 06/11/25 at 9:15 AM with LPN #1 revealed that medications were supposed to be locked up in the the medication carts when unattended. She confirmed that she left the Lasix 40 milligram (mg) medication card face down on the medication cart while she walked down the hall to get a resident to come to her room. LPN #1 confirmed that medications should never be left on top of the cart and by doing so could allow someone to come up to the cart, grab the medicine and possibly take something they were not supposed to have. An interview on 06/11/25 at 9:54 AM, with the Director of Nursing (DON), revealed that leaving medications unattended on top of the medication cart was unacceptable practice and was a safety issue. He revealed that a resident could walk by and take the medications and could possibly take something they were not supposed to take. He confirmed that medications were supposed to be within sight of the person administering the medications or be locked in the medication cart.

Based on staff interview, record review and facility policy review the facility failed to accurately complete a Minimum Data Set (MDS) assessment as evidenced by the presence of a pressure ulcer not being indicated on the assessment for one (1) of 16 MDS assessments reviewed. Resident #50 Findings Include: Review of the facility policy titled, MDS 3.0 Completion with an implementation date of 6/14/21 and no revision date revealed under the Policy .Residents are assessed, using a comprehensive assessment process, in order to identify care needs and to develop an interdisciplinary care plan. An interview on 10/18/23 at 8:45 AM, with Registered Nurse (RN)/Treatment Nurse #1 revealed that Resident #50's pressure ulcer was facility acquired and was currently still receiving treatment to the heel that started in July of this year. Review of Resident #50's physicians orders revealed an order dated 7/27/23 to Paint left (L) heel Deep Tissue Injury (DTI) with betadine for one week. Review of Resident #50's MDS assessment with an Assessment Reference Date (ARD) of 8/21/23 revealed in Section M that the resident did not have a pressure ulcer. A telephone interview on 10/18/23 at 2:00 PM, with the MDS nurse revealed she saw the order dated 7/27/23 for pressure ulcer treatment for Resident #50 but failed to mark the resident having a pressure ulcer on her MDS assessment. An interview on 10/19/23 at 10:30 AM, with the Administrator confirmed that Resident #50 had a facility acquired deep tissue injury with an order for treatment dated 7/27/23 and should have been included on the residents 8/21/23 MDS quarterly assessment and it was not. She revealed the purpose of the MDS assessment is to gather all the information regarding the care and to make sure we are giving the residents the care they need and deserve. Record review revealed that Resident #50 was admitted to the facility on [DATE] with medical diagnoses that did not include pressure ulcer. This review revealed the resident's admitting diagnoses include Type 2 Diabetes Mellitus without complications.

Based on observation, staff interview, record review and facility policy review the facility failed to implement a care plan regarding the placement of hand rolls per physician's order for one (1) of 16 care plans reviewed. Resident #29 Findings include: Review of the facility policy titled, Comprehensive Care Plans with an implementation date of 6/14/21 revealed, Policy .It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a residents medical, nursing, and mental and psychosocial needs . Record review of Resident #29's care plan with an onset date of 9/3/23 revealed, I am at risk for pressure ulcers related to poor body control/positioning, poor cognition, contractures to right and left hand . Approaches . Resident to wear hand roll in bilateral hands on at 9 AM and off at 3 PM to help prevent further contracture . On 10/16/23 at 11:33 AM, observation revealed Resident #29's hands were contracted bilaterally. No hand rolls were in place to bilateral hands. In an interview on 10/17/23 at 4:13 PM, Registered Nurse (RN) #1 revealed Resident #29's hand rolls were applied two and a half (2-1/2) hours late today. An interview on 10/18/23 at 3:10 PM with Certified Nurse Assistant (CNA) #1 revealed she does have access to the resident's care plans and the purpose of the care plan was to make sure we know the care the resident needs., An interview on 10/18/23 at 3:15 PM with RN #1 revealed that with Resident #29's hand rolls not being applied to the resident per the physician's order would mean that the resident's care plan was not implemented. An interview on 10/18/23 at 3:22 PM with the Director of Nurses (DON) confirmed that Resident #29's care plan was not implemented when the hand rolls were not applied on Monday and part of Tuesday of this week. He stated that the hand rolls not being applied could lead to further contractures. In an interview on 10/19/23 at 9:40 AM, with the Administrator confirmed that Resident #29's care plan was not implemented because the resident's hand rolls were not applied on 10/16/23 from 9 AM-3 PM and not until 11:30 AM on 10/17/23. Record review of Resident #29's Face Sheet revealed the resident was admitted to the facility on [DATE] with medical diagnoses that included Contracture, Right Hand and Contracture, Left Hand. Record review of Resident #29's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 8/28/23 revealed in Section C a Brief Interview for Mental Status (BIMS) score of 99, which indicated the resident is severely cognitively impaired.

Based on observation, staff interview and record review, the facility failed to place hand rolls on a resident with contractures for one (1) of 25 residents reviewed with contractures. Resident #29 Findings include: Review of the typed documentation on facility letterhead dated 10/19/23 and signed by the Administrator revealed, We have no policy on splints or hand rolls. An observation on 10/16/23 at 11:33 AM revealed Resident #29 had contracted hands bilaterally with no splints. An observation on 10/17/23 at 11:15 AM revealed Resident #29 lying in bed; hands contracted bilaterally with no splints or hand roll. Record review of Resident #29's Physician Orders revealed an order dated 10/14/21 for resident to wear hand roll in bilateral hands, on at 9 AM and off at 3 PM, to help prevent further contracture. An interview on 10/17/23 at 3:05 PM, with Licensed Practical Nurse (LPN) #1 revealed Resident #29's hand rolls are supposed to be applied by the treatment nurse and are documented on the Treatment Administration Record. An observation and interview on 10/17/23 at 3:10 PM, with Registered Nurse (RN)/Treatment Nurse #1 and LPN #1 revealed Resident #29 lying in bed with hands contracted bilaterally with a hand roll applied to the right hand. This observation revealed the hand roll on the left hand was secured with Velcro around the resident's wrist, but the roll was hanging free and not inserted into the resident's contracted hand. An interview with RN #1 revealed it is her responsibility to apply the resident's hand rolls daily at 9 AM and remove them at 3 PM. She stated that she knows she did not apply the resident's hand rolls today until about 11:30 AM and that the purpose of the hand rolls is to prevent the resident's hands from further contracture. An interview on 10/17/23 at 4:13 PM, with RN #1 revealed she was late applying Resident #29's hand rolls because the Certified Nursing Assistants (CNAs) were giving the resident a bath between 8 AM-9 AM. She admitted the hand rolls were applied 2 1/2 hours late and stated that applying the hand rolls late would result in the resident not having them on the amount of time daily that was physician ordered and could lead to worsening contractures. An interview on 10/18/23 at 12:15 PM, with LPN #2 revealed she was Resident #29's treatment nurse on 10/16/23 and did not apply the hand rolls because she could not find them. She stated that she had asked other staff about the missing hand rolls and went to laundry but did not find them. She stated that laundry was going to look for them, but they were not found before her shift ended at 3 PM. She stated that normally she would have just used a rolled-up hand towel in place of the missing hand rolls but was not sure that was ok. She confirmed that she did not ask her supervisor if it would be ok to use a rolled-up hand towel but should have. She revealed the purpose of the resident's hand rolls is to prevent further contracture of the resident's hands or skin breakdown. An interview on 10/18/23 at 3:22 PM, with the Director of Nurses (DON) confirmed that Resident #29's hand rolls not being applied properly could lead to further contractures or skin breakdown. An interview on 10/19/23 at 9:40 AM, with the Administrator confirmed that Resident #29's hand rolls not being applied could have led to skin issues for the resident. Record review of Resident #29's Face Sheet revealed the resident was admitted to the facility on [DATE] with medical diagnoses that included Contracture, Right Hand and Contracture, Left Hand. Record review of the quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 8/28/23 revealed in Section C a Brief Interview for Mental Status (BIMS) score of 99, which indicated the resident is severely cognitively impaired.

Based on observations, facility policy review, record reviews, and staff interviews the facility failed to prevent the likelihood of infection, as evidenced by failure to change the water flush bag and feeding tube bag every 24 hours for one (1) of six (6) residents reviewed with a Percutaneous Endoscopic Gastrostomy (PEG) tube. Resident #35 Findings Include: Record review of facility policy titled, Gastrostomy Tube Feedings Continuous Feeding Per Pump, dated 12/21/21, revealed . 6. Bottles of formula and/or feeding bags are to be changed every 24 hours . An observation on 06/06/22 at 1:38 PM revealed Resident #35's PEG tube feeding bag was empty and a filled water flush bag. Both bags were hanging on the PEG feeding pump pole and was labeled with the date of 6/4/22 on each bag. An observation and interview on 6/6/22 at 1: 45 PM, with the Licensed Practical Nurse, (LPN)#1 confirmed she worked on 6/4/22 on the 7:00 AM to 3:00 PM shift. She confirmed that the date on the water flush bag and that the date on the empty PEG tube feeding bag that were presently hanging on the PEG feeding pump was 6/4/22. She revealed it was her handwriting on the two (2) PEG feeding set up bags and revealed that she had labeled the 2 PEG feeding set up bags on 6/4/22 at 6:00 PM when she started Resident #35's PEG tube feeding. LPN #1 revealed she did not work on 6/5/22. She reported that she had returned to work today and did not look at the date on the 2 bags that were presently hanging on the PEG feeding pump. LPN #1 reported that LPN #2 worked the 3:00 PM to 11:00 PM shift on 6/5/22 and would have been the one assigned to change the water flush bag and PEG tube feeding bag. LPN #1 confirmed that an infection could occur if the new formula for the PEG tube feeding for 6/5/22 was poured in the used bag dated 6/4/22. LPN #1 confirmed that a new feeding set up was to be hung on the PEG feeding pump each time the PEG feeding was started. An observation and interview on 6/6/22 at 02:55 PM, with the Director of Nursing (DON) confirmed the date of 6/4/22 on the PEG tube feeding and water flush bags that were presently hanging on the feeding pump in Resident #35's room. The DON revealed the PEG tube feeding set up should have been changed when the PEG tube feeding was started on 6/5/22 at 6:00 PM. She reported the PEG tube feeding bag and the water flush bag dated 6/4/22 should not have been used for the PEG tube feeding on 6/5/22 for Resident #35. The DON revealed that by not using a new PEG tube set up could have possibly caused Resident #35 to become ill. A telephone interview on 6/8/22 at 10:17 AM, with LPN #2 confirmed that she worked the 3:00 PM to 11:00 PM shift on 6/5/22 and that she did not change the PEG tube feeding bag and the water flush bag dated for 6/4/22. She revealed she used the PEG tube feeding set up dated 6/4/22 and added new formula for Resident #35's PEG tube feeding to the PEG tube feeding bag dated for 6/4/22. She revealed she did not need to add more water to the water flush bag dated 6/4/22 because it already had enough in it to supply the needed amount of water flush to Resident #35. She confirmed that she did pour the new PEG tube feeding into the PEG tube feeding set up bag dated 6/4/22 at 6:00 PM on 6/5/22 because there was a PEG tube feeding set up already hanging on the feeding pump. She also revealed that she did sign off the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . LPN #2 also revealed the infection control standards and process to set up PEG tube feeding, for a resident included using a new PEG tube feeding set up, with new bags. She confirmed that she knew she should not have used the PEG tube feeding bags from the previous PEG tube feeding set up dated 6/4/22. An interview on 6/8/22 at 10:40 AM, with the Staff Development Nurse revealed LPN #2 had attended two Infection Control in-services that provided education regarding infection control related to PEG tube care set up and monitoring and LPN #3 had attended one in-service. A telephone interview on 6/9/22 at 06:23 AM with LPN #3, confirmed she worked the 11:00 PM-7:00 AM shift on 6/5/22 and did not check the dates on the PEG tube feeding set up during that shift. LPN #3 revealed she did monitor the water flush and the PEG tube feeding all night and signed off on the care task on the MAR. LPN #3 confirmed that she should have checked the date on the PEG tube feeding set up to confirm that it had been changed for that date. Record review of infection control in-services titled, Infection control regarding PEG tube care, set up, and monitoring, dated 5/19/21 and 4/27/22 revealed LPN #2's signature on both dates and LPN #3's signature was noted on the 4/27/22 in-service. Record review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] @ (at) 70 ML/HR (milliliters/hour) X 12 hours from 6 PM - 6 AM per G-Tube via pump . with 150 CC (cubic centimeters) water every 4 hours via pump. Record review of the Gastrostomy Tube section of the MAR, dated 6/5/22, revealed LPN #2's initials was documented for completion of the task of starting the PEG tube feeding at 06:00 PM and initialed for completion of the task on continuous water flush for the 3-11 shift. Record review of the Gastrostomy Tube section of the MAR, dated 6/5/22, revealed LPN #3's initials was documented for completion of the task of monitoring the water flush and PEG tube feeding for the 11:00 PM to 7:00 AM shift. Record review of the Face Sheet for Resident #35 revealed an admitted [DATE]. Record review of the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] .

Based on observation, staff interview, and facility policy review, the facility failed to maintain an effective pest control program as evidenced by, flies observed in the kitchen for three (3) of three (3) tours of the kitchen. The facility policy titled, Pest Control Program, dated 02/2020, revealed, It is the policy of this facility to maintain an effective pest control program that eradicates and contains common household pests and rodents.Definition: Effective pest control program is defined as measures to eradicate and contain common household pest( e.g.bed bugs, lice, roaches, ants, mosquito's, flies, mice, and rats . Facility will maintain a report system of issues that may arise in between scheduled visits with the outside pest service and treat as indicated. Facility will utilize a variety of methods in controlling certain seasonal pest, i.e. flies. These will involve indoor and outdoor methods that are deemed appropriate by the outside pest service and the state and federal regulations . The policy titled, Pest Control, dated 08/17, revealed In order to maintain a safe sanitary environment, a pest management program is used to prevent pests from entering the food and nutrition service department and to implement measures to eliminate any pest infestations .Procedure:b). All windows and vents are screened. Patch and replace when needed.c.) Self-closing devices on all outside doors .e.) Keep all exterior openings closed tightly. f )If flies are a problem, consider installing air curtains above or alongside the exterior doors . An observation, on 5/11/21 at 10:35 AM, of the kitchen revealed four (4) flies located on a pole connected to the food service steam table, one (1) fly flying around kitchen and one (1) fly located on the side of a cabinet, a total of six (6) flies. An observation, on 05/11/21 at 10:45 AM, revealed the kitchen door leading to the outside of the building was propped open approximately two (2) and one half (½) inches with a piece of red brick.The DM closed the door. An observation, on 05/11/21 at 11:30 AM, of the kitchen revealed nine (9) flies located on a pole connected to the food service steam table, two (2) flies in the air and one (1) fly located on the side of a cabinet in the kitchen, a total of twelve (12) flies. An observation, on 05/11/21 at 11:35 AM, revealed the outside door was propped open again two (2) and one half (1/2) inches open with a piece of red brick. An observation, on 05/12/21 at 11:30 AM, of the kitchen revealed two flies moving around on the pole connected to the food service steam table with food in containers on the table for meal time tray prep. During an interview on 05/11/21 at 10:50 AM, with the Dietary manager (DM), she stated that her staff knew better than this.(propping doors open). The DM removed the brick and closed the door. The DM stated that leaving this door open could cause bugs to come inside. An interview on 5/11/21 at 2:00 PM, with the DM revealed a fly bug light would help. The DM stated that the facility has one but, it is out of order. The DM also stated that she has seen what looks like a roach in the dish room on the floor a few times. An interview on 5/11/21 at 2:45 PM, with Dietary Staff (DS) #1 revealed that the staff leaving outside door propped open could allow anything to come in; dogs, cats, flies,or anything. An interview on 05/11/2021 at 4:30 PM, with Housekeeping/Maintenance (#2) revealed the facility uses a pest control company that comes to spray at least monthly and will make extra visits if called between the monthly visits. An interview on 05/12/2021 at 08:45 AM, with Housekeeping/Maintenance (HM) #1, confirmed the fly trap in the kitchen was not working at the time of survey. HM #1stated they usually do not turn the door fan on until it is fly season. When asked how you determine fly season he reported usually when the weather gets warm. Most of the time the door fans are usually turned on around March. He stated he was not aware the fan was not turned on. An interview, on 05/12/21 at 11:35 AM, with DS #1, confirmed two flies located on the pole connected to the food service steam table. She stated that she guessed the light had not had time to get all the flies that were here yesterday. An interview, on 05/12/2021 at 12:10 PM, with the Administrator (ADM), revealed she had not previously been aware of the problems in the kitchen until yesterday. The ADM stated that she was not aware of flies in the kitchen, or staff propping the outside door open. The Administrator stated that flies in the kitchen could spread disease.

Based on observation, staff interview and facility policy review, the facility failed to provide a clean and sanitary kitchen for two (2) of three (3) tours of the dietary department. The facility policy titled Storage of Refrigerated Food,dated ,d+[DATE] revealed, The facility ensures the quality and safety and sanitation of refrigerated foods through accepted storage practices .5. All open foods are labeled with common name of food, date stored and use- by- date. 6. Time and temperature control (TCS) foods held at forty-one (41) degrees Fahrenheit or lower may be stored for seven (7) days. The facility policy titled Employee Work Practices, dated ,d+[DATE] revealed Food service employees shall follow sanitary practices to prevent the spread of foodborne illnesses .4. Food service employees are not allowed to eat or drink in the food and nutrition services department except when tasting food to evaluate quality. A drink from a covered container with a straw may be used if kept out of the food preparation area. The policy titled, Food Storage Labeling, dated ,d+[DATE], revealed The facility will ensure the safety and quality of food by following good storage and labeling procedures .1. All food items must be labeled with the date they are received . Time and temperature control (TCS) foods can be stored for seven days if held at forty-one (41) degrees Fahrenheit or lower. On [DATE] at 10:35 AM, an observation with the Dietary Manager (DM) revealed one half (½) gallon opened container of buttermilk with an expiration date of [DATE]. A five (5)-pound container of sour cream one eighth (,d+[DATE]th) full, and two un-opened 5-pound containers of cream cheese.One of the containers of cream cheese had a best if used by date of [DATE] and the second container of cream cheese had a best if used by date of [DATE]. On [DATE] at 11:45 AM, an observation of the food prep tabletop in the kitchen revealed an open container of energy drink. Dietary Staff #2 confirmed the opened can of energy drink belonged to her and that she should not have it in the food prep area. On [DATE] at 2:00 PM, an interview with the DM revealed the out of date items could contribute to a foodborne illnesses, lack of taste quality, and possible loss of appetite and that the expired items should have been discarded. On [DATE] at 2:15 PM, an interview with Dietary staff #2 revealed that having personal open cans of drink in the kitchen could result in a spill and could spread germs. Dietary staff #2 confirmed she was not supposed to have personal food or drink in the kitchen. On [DATE] at 3:50 PM, in an interview with RegisteredNurse (RN) #1 confirmed there had not been any outbreaks of foodborne illnesses in the facility. On [DATE] at 12:10 PM, in an interview with the Administrator revealed she had not previously been aware of the problems in the kitchen, such as, outdated foods in refrigerator until yesterday.

Based on staff interview, record review, and facility policy review, the facility failed to convey the trust fund monies within 30 days of discharge for one (1) of two (2) residents sampled for discharge process (Resident #55). There were 16 residents in the total survey sample. The facility returned Resident #55's trust fund balance 60 days after discharge from the facility. Findings included: Review of Policy and Procedures on Resident Rights, revised 3/7/18, revealed the facility would refund the family or estate within 30 days of a resident death. The policy did not address when a resident discharged to the community. Review of Resident #55's Face Sheet, dated 3/11/19, revealed the resident was admitted into the facility on [DATE], with [DIAGNOSES REDACTED]. Review of Social Services Notes dated 3/8/19, revealed Resident #55's family came to see social services on 3/6/19, to discuss discharge plans for Resident #55. Resident was to be discharged on [DATE], with family. Review of physician's orders [REDACTED]. Review of Resident Trust Fund Statement (undated) indicated that Resident #55 was discharged [DATE]. The statement noted Resident #55 had a trust fund balance of $23.31 on 5/1/19. The statement noted a withdrawal on 5/3/19. Interview with the Business Office Manager (BOM) on 5/16/19 at 9:59 AM, revealed that there was a balance of $120 in Resident #55's account. The BOM stated that she called the family in (MONTH) to see if they wanted to apply the trust fund balance to the money owed but didn't hear back from them. The family did not respond to her call regarding the balance. The balance was refunded on 5/3/19. Further interview with the BOM on 5/16/19 at 10:35 AM, revealed that she normally refunded monies in the trust fund within 30 days, but she felt this was a special circumstance, so she did not refund it on time. The BOM stated that the facility's Policy and Procedures on Resident Rights should be updated to address residents discharged to the community.

Based on observation, staff interview, record review and facility policy review, the facility failed to accurately code a Minimum Data Set (MDS) for Resident #1 related to the use of a restraint and for Resident #11 related to a Urinary Tract Infection [MEDICAL CONDITION]. This is for two (2) of 24 MDS's reviewed. Findings Included: Review of facility policy titled, MDS Active [DIAGNOSES REDACTED]. Code only if all the following are met: Physician [DIAGNOSES REDACTED]. Laboratory findings. Current medication or treatment for [REDACTED]. Review of the facility policy titled, MDS Physical Restraints, dated October 2015, noted Evaluate whether the resident can easily and voluntarily remove any manual method or physical or mechanical device, material, or equipment attached or adjacent to his or her body. If the resident cannot easily and voluntarily do this, continue with the assessment to determine whether or not the manual method or physical device restrict freedom of movement or restrict the resident's access to his or her own body. Resident #11: Record review for Resident #11 revealed a MDS dated [DATE]. Section I2300 was checked for a UTI in the last 30 days. Record review of Resident #11's medical record did not reveal laboratory findings, a physician's order, sign or symptoms of a UTI or current treatment for [REDACTED]. Interview on 08/30/16 at 1:45PM, with Registered Nurse #1, who is also the MDS Nurse, confirmed that a UTI was checked in section I2300 of the 08/08/16 MDS and stated, He had a UTI on the 05/11/16 MDS assessment and I just failed to take it off on the 08/08/16 MDS assessment. I'll correct it and resubmit that MDS. It was just an oversight on my part. Resident #11 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The most recent MDS was completed on 08/08/16, and revealed a staff assessment indicating the resident is rarely or never understood and had moderately impaired cognitive skills. RESIDENT #1 During an observation on 08/29/16 during initial flash tour of the residents, Resident #1 was sitting in the dining room during meal time with a secured full lap tray adjacent to her wheelchair arms and buckled in the back of the wheelchair behind the residents back. The lap tray was against her upper abdomen under her breasts. The resident was eating her pureed liquid diet out of cups that were sitting atop of the lap tray. Record review on 08/29/16 of Resident #1's MDS dated [DATE], in Section P for Restraint use, 0 was marked indicating a restraint is not used in bed or used while up in chair or out of bed. During an interview at 12:30 PM on 08/29/16, RN #1 stated, We don't consider that a restraint, she has had it forever and she can't get up anyway. Record review revealed a care plan for At risk for falls, dated 07/13/16 through the next 90 days that noted, check lap tray every 30 minutes and release every 2 hours. Interview with the Administrator on 08/30/16 at 3:15 PM, revealed, We went back and got a doctor's order and consent from the family yesterday after you had questioned us about it (restraint). We weren't trying to not look at it as a restraint. I guess we were thinking she couldn't get up anyway if she wanted to so we didn't feel like it was restraining her. Resident #1 was admitted to the facility on [DATE], with diagnoses, which included [MEDICAL CONDITION] and Generalized Anxiety Disorder. The most recent MDS with an ARD of 7/06/16, indicated Resident #1 had severe cognitive impairment per staff assessment.

Based on observation, record review, staff interview, and facility policy review, the facility failed to keep a clean and sanitary environment as evidenced by unpackaged food items, packaged food items, sticky substance, and non-food items on the floor of the walk-in freezer for two (2) of three (3) kitchen tours. Findings include: Review of the facility's policy titled, Cleaning Instructions Cleaning Freezers, undated, revealed For walk-in freezers, mop floors, wash walls and ceilings at least every 3 - 6 months as needed. Store all foods at least 6 inches from floor. On 5/4/16 at 10:20 AM, the initial tour in the kitchen with the Dietary Manager (DM) revealed the following in the walk-in freezer: 1. A dark frozen, sticky substance, approximately four (4) inches by three (3) inches, located on the floor, 12 inches from the back wall. 2. A box of 24 blueberry muffins with the plastic wrap on the top torn open, located on the floor between the back and left wall. 3. Two (2) pieces of loose plastic wrap, one (1) four (4) inch piece of torn box tape, one (1) container of strawberry mighty shake, 1 container of orange sherbet, and five (5) loose tater tots located on the floor, on the right side, under the metal rack. 4. Ten (10) loose butter beans, one (1) container of prune juice, three (3) containers of strawberry mighty shakes, and 1 orange sherbet located under the front wall metal rack. 5. One (1) black permanent marker, 1 sealed plastic package of sliced ham, 1 unopened box of cornbread dressing, a four (4) inch by six (6) inch torn piece of box and an eight (8) inch long piece of box tape was noted, on the floor, under the metal rack against the left wall. 6. On the left side of the freezer on the floor, a six (6) inch by three (3) inch medium to light brown substance was noted. On 5/4/16 at 10:20 AM an interview with the DM revealed, the walk-in freezer is cleaned on Thursdays after the groceries are put up. She and the Kitchen Supervisor monitor the freezer often and she had not looked on the floor under the metal racks. The DM did confirm the food and nonfood items noted on the floor. On 5/5/16 at 9:20 AM a tour of the walk-in freezer with the DM revealed the following: 1. A four (4) by three (3) inch dark brown frozen substance was located on the floor, approximately 12 inches from the back wall. 2. A six (6) by two (2) inch piece of cardboard and a five (5) inch long piece of torn box tape were noted on the floor under the metal shelving against the left wall. 3. A medium brown sticky substance approximately six (6) by three (3) inches was noted on the floor, at the outer edge of the metal rack, against the left wall. On 5/5/16 at 9:20 AM an interview with the DM revealed, she checked the walk-in freezer last Thursday and did not notice items on the floor. DM stated any time any staff enters the freezer they should pick up, clean up and straighten up any items immediately. The DM stated she is not sure how long some of the items had been on the floor. She stated she and the Kitchen Supervisor should check the freezer better and more often. On 5/6/16 at 11:40 AM an interview with the DM revealed, cleaning the walk-in freezer was not included on the weekly cleaning schedule. No specific staff is assigned to monitor the walk-in freezer and it is the responsibility of all staff that enters the freezer to see that it is clean and straight. The DM could not find any documentation of an inservice covering cleaning of the freezer. The DM and the Kitchen Supervisor are responsible for seeing that the freezer is clean and straight. On 5/6/16 at 11:55 AM an interview with the Kitchen Supervisor revealed, she usually checks the walk-in freezer after the groceries are put up on Thursdays. She is responsible for checking the freezer but all staff should pick up and clean up any issues found while they are in the freezer. On 5/6/16 at 2:00 PM an interview with the Administrator (ADM) revealed, before 5/4/16 she had been aware of the issues in the freezer and understood a new cleaning schedule had been made to correct the problems. The DM had reported to her the items found on the walk-in freezer floor during the initial tour on 5/4/16.

Based on observation, staff interview, record review and policy review, the facility failed to ensure the potential for spread of infection were maintained by not properly cleaning of a resident during incontinent care for one (1) of one (1) resident observed during care (Resident #8) and staff returning items to the medication cart and the medication room after Accuchecks for two (2) of two (2) Accuchecks observed (Resident #6 and Unsampled Resident H). Findings include: Resident #8 Record review revealed Resident #8 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the Minimum Data Set, dated dated [DATE], revealed a Brief Interview for Mental Status score of 99, which indicated that Resident #8 was not able to complete the interview. Observation and interview with Certified Nurse Aide (CNA) #1 of incontinent care with assistance from Licensed Practical Nurse (LPN) #1 on 6/13/13 at 2:10 p.m. revealed Resident #8 was incontinent of bowel and bladder. LPN #1 washed her hands, placed towels on the table and donned gloves. CNA #1 got soapy water in wash tub, Resident #8 position on back, as CNA #1 wiped with wet soapy towel from front to back (pubic area), water changed to rinse water and area wiped using same technique, water changed to soapy water, resident position on right side with assistance from LPN #1 pad removed and changed to clean pad using rolling from side to side. Resident #8 was positioned on the right side as CNA #1 wiped left buttock and then right buttock, changed water to clean, said I don't have enough towels can I go get some more? LPN #1 stated, "You can't; but, I can", removed gloves, sanitized her hands before leaving the room and returned with towels, sanitized her hands and donned gloves. CNA #1 continued to care for Resident #8 as bowel movement was observed on towel during wiping, CNA #1 changed water rinsed and pat dry area. CNA #1 was asked if Resident #8 clean, CNA #1 just looked and lifted her shoulders up, and LPN #1 raised Resident #8 left buttock area to expose a large soft formed stool. There was no observation of wiping between the buttocks during incontinent care. Review of Resident #8 care plan revealed, resident was incontinent of bowel and bladder. At risk for UTI (urinary tract infection) r/t (related to) hx (history) of UTI dated 03/19/13. Review of the facility's "Urological Care, Perineal Care Female" policy, not dated, noted, "Change different area of the washcloth, separate buttocks and wash area from front to back." This policy did not address making cleaning the resident before ending care. Unsampled Resident H Record review revealed Unsampled Resident H was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Observation of an Accucheck on 6/12/13 at 12:20 p.m. revealed Licensed Practical Nurse (LPN) #3 carried supplies (glucometer, container of glucose strips, one (1) small sharp container, and lancet, container of Clorox wipes, alcohol wipes and band-aids) into Unsampled Resident H's room. After the Accucheck was completed, the used lancet was placed in the sharps container; the used Clorox wipes, alcohol wipe and used gloves were placed in a red bag and placed in the trash on the side of the medication cart. The glucometer was cleaned. The container of glucose strips were returned to case and put in top drawer of medication cart. The Clorox wipes were placed on side of the medication cart and a small sharp container was placed in bottom drawer of medication cart. Review of Unsampled Resident H June 2013 physician's orders [REDACTED]." Interview with Licensed Practical Nurse (LPN) #3 on 6/13/13 at 1:50 p.m. confirmed putting the glucose strips container back in the case after the Accucheck; and placing the Clorox wipes on the cart and the sharps container in the medication cart. Review of the facility's "Blood Glucose Testing" policy, not dated, did not address storage of unused supplies after use. Resident #6 Record review revealed Resident #6 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the Minimum Data Set, dated dated [DATE], revealed a Brief Interview for Mental Status score of 13, which indicated Resident #6 was cognitively intact. Observation of the Accucheck on 6/13/13 at 10:55 a.m. revealed Licensed Practical Nurse (LPN) #2 carried supplies (two (2) lancets, one (1) container of glucose strips, one (1) glucometer, one (1) small sharps container, one (1) container of Clorox wipes, alcohol wipes, two (2) band-aids and one (1) small red bag) into Resident #6's room. After the Accucheck was completed, the used lancet and one (1) not used was disposed of in the sharps container; the used gloves, alcohol wipes, and used Clorox wipes were placed in red bag and disposed of in trash can. The Glucometer was returned to case in the medication cart. The sharps container and Clorox wipes were carried to the medication room and placed on the counter. Review of Resident #6 June 2013 physician's orders [REDACTED]. Interview with Licensed Practical Nurse #2 on 6/13/13 at 11:05 a.m. acknowledged bringing out Clorox wipes and sharp container out of Resident #6's room and placing them in the medication room.

Based on observation, record review, staff interview, Physician interview, and policy and procedure reviews, the facility failed to adequately assess, investigate, and implement appropriate interventions to prevent falls and injuries to one (1) of three (3) resident's reviewed which resulted in an improper transfer. This is for Resident #2. Findings Include: Observation on 9/9/11 at 11:30 a.m. revealed that Resident #2 was sitting in a wheel chair in the dining room. Resident #2 had a splint in place to his left arm and hand and his fingers were swollen. Resident #2 had no positioning devices and had no restraints at the time of observation. Observation on 9/9/11 at 4:30 p.m. revealed that Resident #2 was sitting alone in the front lobby of the facility sleeping in his wheelchair. Resident #2 had a splint applied to his left arm and hand and his fingers were swollen. Resident #2 was leaning to the left with his head down, and chin touching his chest. Resident #2 had no positioning devices and had no restraints in place. Record review revealed that Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) with assessment reference dates 03/08/11, 06/06/11, and 08/30/11, documented that Resident #2 was moderately impaired in cognitive skills and had both short and long term memory problems. The MDS dated [DATE], 06/06/11, and 08/30/11, documented that Resident #2 was transferred via a stand up mechanical lift with the assistance of one (1) person/staff. Record review revealed that Resident #2 had contractures to his lower and upper extremities. Resident #2 was unable to stand and had poor body control and had poor safety awareness. Review of the Nursing Progress Notes signed by the MDS Coordinator dated 3/8/11 read: " Resident is a [AGE] year old (describes Resident #2). He is alert and oriented x 2. He has impaired vision. He wears glasses daily. He refused the interview. That is very typical of this particular resident. He needs assistance with ADL ' s. He is total x 1 with bed mobility, transfer, dressing, toilet use, personal hygiene, and bathing. He is limited x 1 with locomotion. He is extensive x 1 with eating. He is transferred per stand up lift. He is unsteady for any type of transfer without staff assistance. He has contractures to the left upper and lower extremities. This was the side affected by his traumatic brain injury years ago. He receives PROM with daily care. He wears a splint to the left hand to prevent further contractures. His primary mode of locomotion is his wheelchair. He is incontinent of bowel and bladder. He wears diapers while up to the chair. Incontinence care is performed every two hours." Record review revealed that Resident #2 had the following four (4) documented incident/accident reports: January 30, 2011 at 3:00 p.m. "Resident #2 was sitting in a wheel chair in the lobby surrounded by other Residents and some visitors, nurse at the nursing station was called to the lobby by visitors stating Resident #2 had fallen out of the wheel chair. Resident #2 was observed lying on the floor on his left side his eyeglasses were hanging from a piece of skin from the laceration observed to his left eyebrow area. Resident #2 was able to answer to his name. First aid was rendered and Resident #2 was transferred on to a stretcher per the staff and sent to the emergency room (ER) for evaluation. Resident #2 received a laceration over his left eyebrow and the (ER) placed stitches in the laceration." The nurses noted on 1/31/11 " Resident exhibiting no (signs and symptoms) S/S of pain, no active bleeding noted from upper L (left) eye, sutures intact swollen and hematoma to lower eye, resident can open eye with no drainage." The accident report dated 1/30/11 stated: "Resident is alert with confusion. Resident is not a frequent faller. Resident is to be monitored by staff for any drownsiness and offer resident to go to bed if any sleepiness and drownsiness is noted. Resident went to ER for laceration and had to have sutures. PT (physical therapy) to eval. (evaluate) and treat as indicated." Record review revealed that Resident #2 did not have an updated and/or revised care plan after thie fall with injury on 1/30/11. The facility did not document any in-services with staff regarding Resident #2 after the fall with a head injury. On May 21, 2011 at 12:00 a.m. (midnight) "Resident #2 was found on the floor of his room beside his bed. There were no witnesses to the incident and Resident #2 was not able to tell the staff what happened. The incident report for Resident #2 dated 5/21/11 documented that " Resident observed in floor beside his bed in a kneeling position. Resident was unable to tell the nurse how and why he was on the floor. Resident is alert with periods of confusion. Resident is not considered a frequent faller, free of falls for over 6 months. Has landing strip in place. On 5/20/11 resident had new order for air loss mattress. After fall air mattress was assessed and noted to shift resident weight as it inflates and deflates. Team recommends ? SR (side rails) up x 4 while in bed, bed gap protectors to SR (side rails) all for bed parameters/falls prevention. Air mattress settings were also checked and all noted to be WNL (Within Normal Limits). PT (Physical Therapy) to screen. " The incident report dated 5/21/11 documented in the vital signs section of the report that Resident #2 was " unable to stand. " The care plan for Resident #2 was not revised and/or up-dated following the un-witnessed fall on 5/21/11. There were no new interventions for Resident #2 documented after the un-witnessed fall on 5/21/11. The facility failed to assess and evaluate to help prevent future accidents and incidents for Resident #2. On June 15, 2011 at 10:00 a.m. a third (3rd) incident/accident report for Resident #2 stated: "The incident report dated 6/15/11 documented that Resident #2 was in the process of being transferred from the wheel chair to the "stand-up" mechanical lift when he hit his right leg on the wheel chair and/or lift and caused a skin tear to his right shin." The facility incident report documented that Resident #2 received a one (1) centimeter skin tear to the right shin with a " scant " amount of bleeding noted. The incident report documented that the Certified Nursing Assistance (CNA ' s) were informed to be careful upon transporting and make sure that resident ' s upper and lower extremities were in a safe place to prevent skin tears upon transfers. The incident report documented " Should resident become agitated during transfers staff is to allow resident to calm down and try transfer at a later time. Treatment done as ordered to S/T (skin tear) x 7 days (for 7 days). " There were no assessments to ensure that the stand up lift was the appropriate device for transfers. The care plan for Resident #2 was not reviewed and/or revised for the appropriate activities of Daily Living (ADL) care after the injury of 6/15/11. On August 8, 2011 at 8:00 p.m. the Nursing Note revealed that Resident #2 was found on the floor in his room face down in a pool of blood. The incident report for 8/8/11 documented that Resident #2 was found on the floor in his room face down. Resident #2 received a head injury with bleeding from his head and a trip to the (ER) where staples were placed in his head by the (ER) physician. The incident report dated 8/8/11 documented " Resident is alert with confusion. Resident slid to floor causing ? (Right) eye laceration. Cleaned by (name) staff. Transported to ER (emergency room ). PT (Physical Therapy) to screen. ? SR (side rails) up x 4 with protectors (gap) in place. Resident is not a frequent faller and makes no attempts to get up on his own. " The incident report dated 8/8/11 also documented " paralysis to all extremities except R (Right) hand. " The Physician's progress note dated 8/10/11 stated " fell lacerated forehead. Closed in ER. Not in pain. Is slowly going down physically. " Review of the Physical Therapy (PT) screening that was documented in the medical record of Resident #2 dated 8/12/11 stated: " Too confused to benefit from any Rehab (PT) at this time point. " Review of the care plan for Resident #2 was not reviewed and/or revised after the un-witnessed fall resulting in a head injury on 8/8/11. There were no fall assessments completed by the facility that related to the specific incident of Resident #2 on 8/8/11. Interview on 9/8/11 at 4:55 p.m. with the Licensed Practical Nurse (LPN#2) revealed that she was the Charge Nurse on 8/8/11 at 8:00 p.m. (LPN #2) stated that (CNA#1) had called her to the room of Resident #2 due to her finding Resident #2 on the floor. (LPN #2) stated that (CNA #1) had told her that Resident #2 had fallen out of his wheel chair and had hit his head. (LPN #2) arrived to Resident #2 ' s room and found him lying on the floor with blood on his clothes and on the floor. LPN#2 stated that Resident #2 had a laceration over his eye brow and was sent to the ER for evaluation. LPN #2 stated that CNA #1 told her that she had been in Resident #2's room prior and that he was sitting in his wheel chair. CNA #1 had left Resident #2's room to go to the cart on the hall way to gather linens and upon return CNA#1 found Resident #2 near his bed in the floor bleeding with a head injury and immediately came and got LPN #2. Interview on 9/9/11 at 1:30 p.m. with the Director of Nursing (DON) confirmed that Resident #2 did have a fall with a head injury on 1/30/11 in which Resident #2 had to go to the ER and received sutures. DON confirmed that Resident #2 was currently transferred with a stand up mechanical lift and that on 6/15/11 he received a skin tear to the shin while a CNA was transferring him from his wheel chair to a stand up mechanical lift. DON stated that Resident #2 was injured on 8/8/11 as a result of an un-witnessed fall. DON stated that Resident #2 was sent to theER on [DATE] for a laceration to his forehead and staples were applied. DON confirmed that Resident #2 had an un-witnessed fall with no injury on 5/21/11. DON confirmed that the facility had no fall logs and had no falls committees formally organized in the facility. DON confirmed that the facility did not have falls assessments after each of the incidents/accidents, and falls with injury that Resident #2 had received. The DON stated that the interventions from March 2011 had not been brought forward to the June 2011 care plan for Resident #2. DON stated that the facility had no " Kardex " system and had no ADL care plans for the CNA's to follow. DON stated that the facility had no written system for assignments to be given to CNA's to follow for the care of Residents. DON stated that the instructions for care of each Resident, was passed on verbally to the CNA's. DON stated that the MDS did not reflect the falls of Resident #2 but that they corrected the MDS of 8/25/11 to reflect the fall on 8/8/11. The DON stated that Resident #2 had not had any seizure activity to her knowledge. Interview on 9/9/11 at 1:30 p.m. with Registered Nurse (RN #2) revealed that Resident #2 was not ambulatory and was not independently weight bearing. RN #2 stated that she had documented and signed the MDS assessments on 3/8/11; 6/6/11; and 8/30/11. RN#2 stated that Resident #2 did have contractures and that he did wear a splint to his left arm and hand. Resident #2 is easily agitated and does have verbal out bursts. Interview on 9/9/11 at 4:25 p.m. with the Physician revealed that he was the treating Physician for Resident #2 and was also Medical Director for the facility. The interview with the Physician revealed that he was not aware of the fact that the facility was not thoroughly assessing and evaluating Resident #2 after each of his falls and incidents. Physician stated that he attended the Quality Assurance meetings regularly and that he did not recall specific discussion in reference to Resident #2 and his falls. Physician stated that from now on he will make sure that the facility follows up and places new interventions after all falls and incidents. Physician stated that he was very familiar with Resident #2 and that he had greatly declined. Interview on 9/9/11 at 4:35 p.m. with (CNA#2) revealed that she had not witnessed the fall of Resident #2. CNA #2 stated that she had been alone in Resident #2's room assisting with Resident #2's roommate and that while she was in Resident #2's room he had been sitting in his wheel chair. CNA #2 stated that she had left the room and that upon her return she found Resident #2 lying on the floor, face down, with blood on the floor and on his clothes. CNA #2 stated that there was a large amount of blood on Resident #2's clothes and on the floor so she ran to get the nurse. CNA #2 stated that there was no other CNA assigned to assist her to assist with Resident #2. CNA #2 stated that she was alone with Resident #2 and was assigned to his care on 8/8/11. The facility policy and procedure entitled " Falls Policy and Procedure " dated revised 03/15/2010 read: " (12). Appropriate interventions will be implemented and documented on the Incident Report. (13). All falls are to be taken to Care Plan. (14). With each fall, fall assessment will be updated. (15). Order to be obtained per MD for evaluation per therapy (PT & OT to eval and tx (treat) as indicated). (16). Therapy department will be notified of fall next business day. " The un-dated facility policy and procedure entitled " Mechanical Lifts (Stand-Up Lift) " stated "Description of equipment: The stand-up lift is for semi-dependent weight bearing residents. The Stand-up lift transfers someone from a sitting position to help with pivot transfers during toileting, changing clothes, and repositioning. Before using the Stand-up lift, ask the following: Can the resident bear weight on at least one leg? Does the resident have any upper body strength? Does the resident have reasonable cognitive abilities? Is the resident combative? The facility did not follow its policies and procedures for falls and for the use of a stand-up lift. Resident #2 was not appropriate for the use of the stand-up lift. The facility's failure to appropriately and adequately assess and to intervene after each incident caused harm and injury to Resident #2.