Every finding on record at Oaks on Parkwood Skilled Nursing Facility

Based on interviews, medical record review, review of a third-party complaint received by the State Agency (SA), and review of the facility's investigative file the facility failed to ensure a process was developed and implemented to ensure the doors leading into the kitchen from the main dining room were locked when the kitchen staff were not present. On 05/18/2025, one of the two doors leading from the main dining room into the kitchen was not locked after dietary staff left for the evening. Resident Identifier (RI #141) entered the kitchen through the unlocked door, secured two knives and stabbed him/herself five times in the chest/abdomen area. A facility staff member heard RI #141 in the kitchen and responded. RI #141 was sent to the hospital and evaluated, RI #141 was found to have five self-inflicted stab wounds located to the right chest, epigastric and left upper quadrant area. RI #141 was taken to the operating room (OR) for exploratory laparotomy (a surgical procedure that involves opening the abdomen to examine the internal organs) where he/she was found to have three knife stab wounds to the abdomen, laceration to the liver, colon injury, Omentum injury, Pneumomediastinum, Anterior mediastinal hemorrhage and a Diaphragm defect. According to facility and dietary staff the two doors leading into the kitchen from the dining room should be kept locked at all times when dietary staff left for the evening. Dietary staff members reported that the last dietary staff who left for the evening was responsible for locking the doors. An interview with the dietary staff member leaving last on 05/18/2025 revealed she was in a hurry and forgot to lock both doors. It was determined the facility's non-compliance with one or more requirements of participation had caused, or was likely to cause, serious injury, harm, impairment, or death to residents. The Immediate Jeopardy (IJ) was cited in reference to 483.25(d) Free of Accident Hazards/Supervision/Devices at a scope and severity of J. Following the incident on 05/18/2025, the dietary staffed remained responsible for locking the doors and no other staff monitored or checked to ensure the doors were locked until the next morning when dietary staff arrived for their shifts. It was approximately nine hours after dietary staff left for the night before they returned in the morning; thus, ongoing immediate jeopardy was cited. On 09/27/2025 at 1:33 PM, the Executive Director (ED), Director of Nursing (DON) and the Assistant [NAME] President of Senior Living Division were provided a copy of the IJ Template and notified of the findings of substandard quality of care at the Immediate Jeopardy level at F689 Free of Accidents Hazards/Supervision/Devices. The IJ began on 05/18/2025 and continued until 09/27/2025. On 09/28/2025 the Immediate Jeopardy was removed, F689 was lowered to the lower severity of no actual harm with a potential for more than minimal harm that was not immediate jeopardy, to allow the facility time to monitor and/or revise their corrective actions as necessary to achieve substantial compliance. This deficiency was cited as a result of the investigation of complaint/report number 2575010 and affected RI #141; one of five residents sampled for accidents.Findings Include:RI #141 was admitted to the facility on [DATE] and readmitted on [DATE]. RI #141's admission diagnoses included: Cerebral Infarction due to Thrombosis of Left Middle Cerebral Artery, Adjustment Disorder with Anxiety and Aphasis. RI #141's quarterly Minimum Data Set assessment with an Assessment Reference Date of 05/01/2025 assessed RI #141 as having impairment on one side of the upper extremities and no impairments to the lower extremities.On 07/28/2025 at 9:05 AM a third-party incident report was submitted to the SA Online Incident Reporting System. The report indicated RI #141 was ambulatory, had easy access to the kitchen and stabbed (him/herself) several times in a suicide attempt. The report further indicated RI #141 was taken to a local hospital and died two weeks later from the injuries.Review of the facility's Incident Report dated 05/18/2025 at 8:15 PM revealed the following about RI #141's incident: . Self Inflicted Injury.Incident Location: Kitchen.Incident DescriptionNursing Description: (initials of Certified Nursing Assistant [CNA] #25), CNA WAS WALKING DOWN THE HALLWAY AND HEARD SOMEONE CALLING FOR HELP. THEN SHE YELLED FOR ME SAYING (Registered Nurse (RN) Supervisor #26) I THINK ONE OF THE WORKERS IS LOCKED IN THE KITCHEN AND YELLING FOR HELP. SHE WENT IN THE KITCHEN WHERE THE YELLING WAS COMING FROM, TRIED THE FIRST DOOR IN THE KITCHEN, IT WAS LOCKED THEN SHE WENT TO THE SECOND DOOR AS I WAS COMIMG IN THE KITCHEN, I LOOKED IN THE DOOR AND SAW IT WAS ONE OF THE RESIDENTS (RI #141). I TOLD HER TO STAY WITH (HIM/HER) WHILE I ACTIVATE EMS (Emergency Medical System). RESIDENT ON FLOOR BETWEEN ICE MACHINE AND WALL NEAR DISH AREA. BLOOD WAS ALL OVER (HIS/HER) ABDOMEN, CLOTHES, SHOES AND FLOORResident Description: I ASKED (RI #141) DID YOU DO THIS ON PURPOSE, (SHE/HE) SAID YES I TRIED AND I COULDN'T EVEN DO THAT RIGHT. I WANTED TO END IT ALL.Immediate Action TakenDescription: I ACTIVATED EMS. I SCREAMED FOR (initial of RN #27), RN FOR HELP, HE CAME. I GOT GAUZE FOR THE BLEEDING. I SAW (initial of Licensed Practical Nurse [LPN] #29), LPN AND TOLD HER TO COME, HER RESIDENT WAS ON THE FLOOD BLEEDING. WE ASSESSED THE SITUATION TO SEE WHERE THE BLOOD WAS COMING FROM. (initial of CNA #25), CNA, WAS LOOKING AROUND TO SEE WHAT (HE/SHE) MIGHT HAVE HURT (HIM/HERSELF) ON AND SAW THE KNIVES ON THE COUNTER, 2 HAD BLOOD ON THEM (ONE WAS A CHEF'S KNIFE AND ONE WAS A FILET KNIFE. THE CHEF'S KNIFE HAD A SMALL AMOUNT OF BLOOD ON THE TIP AND THE. HANDLE. THE FILET KNIFE HAD BLOOD ALL OVER IT. ASSESSED FOR SOURCE OF BLEEDING. FOUND 5 STAB WOUNDS (2 TO RIGHT MID ABDOMEN, 2 TO UPPER MID ABDOMEN, AND 1 TO UPPER RIGHT CHEST). (initial of RN #27) AND I APPLIED PRESSURE TO THE AREAS AND REMAINED THERE UNTIL EMS ARRIVED. REPORT GIVEN TO PARAMEDICS. ASSESSED BY THEM. ASSISTED ONTO STRETCHER. LEFT FACILITY VIA (by way of) (name of ambulance service). TRANSPORTED TO (name of hospital) TRAUMA FOR SELF INFLICTED STAB WOUNDS. Injuries Observed at Time of Incident.Injury Location12) Chest14) AbdomenLevel of Pain: 10.Notes: X (times) 5 STAB WOUNDS; 1 TO RIGHT UPPER CHEST, 2 TO LEFT MID ABDOMEN, 2 TO UPPER MID ABDOMEN.Other InfoFOUND IN KITCHEN; DOORS TO THE KITCHEN WERE FOUND TO BE UNLOCKED WITHOUT STAFF PRESENT IN KITCHEN. Review of RI #141's Run Report revealed the following: . Incident SectionType of Service RequestedEmergency Response.Dispatch ComplaintHemorrhage/Laceration.Unit Arrived on Scene Date/Time 5/18/2025 20:52 (8:52 PM) .Patient Assessment SectionProvider's Primary ImpressionInjury - Injury of thorax (upper chest) .ComplaintsStabbing.Primary SymptomsHemorrhage.Other Associated symptomsPain.Narrative Section. DISPATCHED WITH (name of fire engine) 2 (name of nursing home) for (MALE/FEMALE) PATIENT. BLEEDINGAOS (ARRIVED ON SCENE) TO FIND 70 YO (YEAR OLD) (MALE/FEMALE) INCARE OF STAFF AND FD (FIRE DEPARTMENT) HAD SELF INFLICTED STAB WOUNDS X5 PATIENT WAS MOVED BY FD TO THE STRETCHER. REEVALUATED IN THE AMBULANCE PATIENT AOX3 (ALERT AND ORIENTED TIMES 3) WITH GCS (GLASGOW COMA SCALE) 14 PATIENT EXPOSED AND FOUND TO HAVE 1 STAB WOUND IN THE RIGHR CHEST 2 STAB WOUNDS DISTAL TO THE STERNUM AND 2 STAB WOUNDS TO THE LEFT EPIGASTRIUM VERY MINIMAL ACTIVE BLEEDING BANDAGES PLACED ON WOUNDS. TRANSPORTED TO (name of hospital) TRAUMA BAY.Review of a form titled ALABAMA UNIFORM INCIDENT/OFFENSE REPORT dated 05/18/2025 at 8:45 PM revealed the following: . Type of Incident or Offense.Attempted Suicide.NARRATIVEOn 05/18/2025 at approximately 2035 (8:35 PM) . Officers, responded to (nursing home) in reference to an attempted suicide. Upon arrival at approximately 2045 (8:45 PM). I (name of officer) spoke with (name of RN #26) (House Supervisor) at the (name of nursing home). (RN #26) stated that a patient at this facility was found stabbed approximately five (5) time in the chest and stomach area. This white (male/female) was identified as (name of RI #141). (RN #26) stated that when she found (RI #141) in the kitchen on the floor bleeding asking for help. (RN #26) stated that (RI #141) stated that he just wanted to end it all as (he/she) was on the floor crying.(RN #26) stated that the knife used was from the kitchen area. The knife was recovered and placed in into evidence locker #1.(RI #141) was transported by (name of ambulance service) to the hospital.Review of RI #141's History and Physicals from the hospital revealed the following: . Result Date/Time: 5/18/2025 23:08 (11:08 PM) .Basic InformationConsult Performed.Information Mode of arrival: Ambulance.Trauma alert: Level I.the patient is a [AGE] year-old (male/female) who came in as a level 1 by EMS following self-inflicted stab wounds. On arrival patient is not in a c-collar but able to say (his/her) name and verbally describe the event . Secondary notable for stab wounds to the right chest, epigastric, and left upper quadrant. Tenderness to palpation of the abdomen.History of Present IllnessMethod of InjuryStabbingDetails of stabbing Self-inflicted stab wounds, epigastric, left upper quadrant, right chest.Senior addendum: .Patient was transferred to the OR for surgical intervention, level 1.Progress Notes.70. (WHITE MALE/FEMALE) s/p (status post) multiple SI (SELF-INFLICTED) KSW (KNIFE STAB WOUNDS) x 5 to abdomen (right chest, epigastric, and left upper quadrant). Taken to OR for exploratory laparotomy. Pericardial window, transverse colon primary repair, hepatorraphy, traumatic hernia repair x2, incisional wound vac placement. Transfused 4x WB (Whole Blood) and 2xFFP (Fresh Frozen Plasma). Taken to PACU (Post-Anesthesia Care Unit) postop where (he/she) was sent for trauma scans and then admitted to TBICU (Trauma/Burn Intensive Care Unit) after CT images.History of Present Illness.InjuriesKSW x 3 to abdomenLiver lac (laceration)Colon injuryOmentum injuryPneumomediastinum hemorrhageDiaphragm defect.Review of RI #141's Extended Care Facility Transfer form from the hospital, dated 06/04/2025, revealed that RI #141 was discharged with orders for hospice care. RI #141's Progress Notes dated 06/04/2025 at 7:49 PM revealed the following RI #141 had20 staples down the middle of abdomen with 2 open wounds including Upper abdomen wound size 4x2 Lower abdomen wound size 1x1. One staple in right upper chest areaRI #141's ALABAMA CERTIFICATE OF DEATH documented that RI #141 died on [DATE]. On 09/23/2025 at 9:02 AM a telephone interview was conducted with CNA #25, who said on 05/18/2025 she had been on break and was coming back to the when she heard a faint 'help help' sound in the dining room. CNA #25 said there were two doors to enter the kitchen by and the sound was coming from the inside of the kitchen. CNA said she went to the first door and pushed it and the door was locked. CNA #25 said she pushed the second door open and saw RI #141 lying on his/her back covered in blood. CNA #25 said RI #141 was the only person in the kitchen. CNA #25 said RI #141 would have had to enter the kitchen through the second door because the first door was locked. CNA #25 said she did not think residents could enter the kitchen at all, and by that time, the kitchen staff had already gone. CNA #25 said to her knowledge the kitchen doors were kept locked at night. When asked did anyone say how RI #141 entered the kitchen that night, CNA #25 said the only thing was said was that the kitchen staff must have forgotten to lock the second door. CNA #25 said RI #141 would not have been able to enter the kitchen at night if the second door had been locked. Contained within the facility's investigative file was a typed statement given by RN supervisor #26, dated 05/18/2025, which revealed the following: (name of CNA #25) WAS WALKING DOWN THE HALLWAY AND HEARD SOMEONE CALLING FOR HELP. THEN SHE YELED FOR ME SAYING (RN #26) I THINK ONE OF THE WORKERS IS LOCKED IN THE KITCHEN AND YELLING FOR HELP. SHE WENT IN THE KITCHEN WHERE THE YELLING WAS COMING FROM, TRIED THE FIRST DOOR IN THE KITCHEN, IT WAS LOCKED THEN SHE WENT TO THE SECOND DOOR AS I WAS COMING IN THE KITCHEN. I LOOKED IN THE DOOR AND SAW IT WAS ONE OF THE RESIDENTS (RI #141) I TOLD HER TO STAY WITH (HIM/HER) WHILE I ACTIVATE EMS. I SCREAMED FOR (RN #27), FOR HELP, HE CAME. I GOT GAUZE FOR THE BLEEDING. I SAW (LPN [LICENSED PRACTICAL NURSE] #29) AND TOLD HER TO COME, HER RESIDENT WAS ON THE FLOOR BLEEDING. WE ASSESSED THE SITUATION TO SEE WHERE HE BLOOD WAS COMING FROM (name of another CNA) WAS LOOKING AROUND TO SEE WHAT (HE/SHE) MIGHT HAVE HURT (HIM/HERSELF) ON AND SAW THE KNIVES ON THE COUNTER, 2 HAD BLOOD ON THEM. ASSESSED FOR SOURCE OF BLEEDING. FOUND 5 STAB WOUNDS (2 TO RIGHT MID ABDOMEN, 2 TO UPPER MID ABDOMEN, AND 1 TO UPPER RIGHT CHEST). (name of RN #27) AND I APPLIED PRESSURE TO THE AREAS. I ASKED (RI #141) DID YOU DO THIS ON PURPOSE, (HE/SHE) SAID YES I TRIED AND I COULDN'T EVEN DO THAT RIGHT. I WANTED TO END IT ALL. EMS ARRIVED, REPORT GIVEN TO THEM. (HE/SHE) LEFT FACILITY VIA (name of ambulance company). TRANSPORTED TO (name of hospital) FOR TRAUMA. On 09/23/2025 at 10:17 AM a telephone interview was conducted with RN Supervisor #26. RN #26 said when she entered the kitchen RI #141 was on the floor in front of the ice machine. RN #26 said she had no idea which door RI #141 entered the kitchen from, but she entered the kitchen from the second door. RN #26 said she thought the kitchen doors were supposed to be locked. When asked the type injuries she observed on RI #141, RN #26 said she observed bleeding coming from RI #141's abdomen and chest area. RN #26 said RI #141 had five or six stab wounds, RI #141's shirt was saturated, and the bleeding was active. RN #26 said she and RN #27 applied pressure to RI #141's wounds and other staff were present to assist. RN #26 said blood was on the floor all around RI #141, and even on RI #141's shoes. RN #26 said there was a lot of blood everywhere. RN #26 said there were two knives on the counter behind the ice machine and the knives had blood on them as well. RN #26 said RI #141 was moaning and when she asked RI #141 if he/she did this RI #141 said 'yea and I could not even do that right.' RN #26 said the area RI #141 was observed in was for the dietary department only. RN #26 said to her knowledge she thought the doors were supposed to be locked when dietary staff left. On 09/25/2025 at 3:43 PM a telephone interview was conducted with RN #27. When asked what he could tell the surveyor about RI #141 being found in the kitchen on 05/18/2025, RN #27 said he was working on another unit that shift when CNA on the unit informed him someone was calling his name. RN #27 said it was RN #26 calling his name. RN #27 said RN #26 said kitchen was anyone in the kitchen, and kept saying kitchen, kitchen. RN #27 said he checked the first door leading into the kitchen and it was locked. RN #27 said he then looked through the window on the second door and that was when he saw RI #141 laying on the floor. RN #27 said he said oh my God and hollered for someone to call 911 now. RN #27 said RI #141 was laying on his/her left side and there was blood everywhere. RN #27 said there was blood on RI #141's pants, shirt, and shoes and RI #141 was even lying in blood. RN #27 said he saw lacerations on RI #141's stomach and upper chest. RN #27 said he thought there were about five lacerations. RN #27 said some of the lacerations were superficial but the one to RI #141's abdomen appeared to be the deep cut. RN #27 said they observed two knives on the counter after they assessed RI #141 and there was blood on both knives. RN #27 said the big knife had blood at the tip, and the curvy knife had blood all over it. RN #27 said RI #141 was in pain. RN #27 said he did not see any dietary staff in the kitchen. RN #27 said the kitchen doors should be kept locked when dietary staff was not in the kitchen at night 100% of the time.Contained within the facility's investigative file was a typed, undated signed statement given by RN #30, which revealed the following: At 7:30 pm this writer waved to (RI #141) as (he/she) passed by looking in the dining room. Later on in the shift I saw the nurses running to the dining room. When I observed resident was bleeding profusely from several puncture area to (his/her) abd (abdomen). The nurses were applying pressure dressing and trying to keep (RI #141) calm. This writer notified DON at 8:38 pm of resident condition . On 09/24/2025 at 4:24 PM an interview was conducted with RN #30. RN #30 said RI #141 had multiple stab wounds to his abdomen area because he/she had gotten into the kitchen and got a knife and stabbed him/herself. RN #30 said dietary staff should ensure the doors to the kitchen were locked. When asked should RI #141 have been able to enter the kitchen at night, secure a knife and stab him/herself, RN #30 said no.On 09/26/2025 at 9:12 AM an interview was conducted with the DON who said the facility's investigation determined RI #141 got the knife from the kitchen. The DON said RI #141 was able to enter the kitchen and get the knife through the door leading into the kitchen. The DON said the doors to the kitchen should be kept locked at night. The DON said RI #141 should not have been able to enter the kitchen if the doors were locked. The DON said the dietary company started an immediate action plan which included educating dietary staff on the importance of locking all the doors when leaving at night and now there was a log sheet in place for dietary staff to sign off that the doors were checked and locked to ensure an incident of this type will not occur again. The DON said the log sheet was checked each morning by the opening manager to ensure this had been done. On review of the dietary company's investigative file there was a sheet titled Incident Report: Kitchen Closing which revealed the following: Date of Incident: May 18thEmployee Involved: (Dietary Aide [DA] #31)Department: KitchenInterview done via phoneSummary:On the evening of May 18th, (DA #31) completed her routine kitchen closing responsibilities. This included locking the dining area doors and turning off the lights. (DA #31) reported that she exited the building through the front door of the main facility.However, during the subsequent night shift, it was discovered that one of the doors had inadvertently been left open. This oversight led to an incident during the night, the details of which have been documented separately.Corrective Action:(DA #31) has been informed of the necessity of thoroughly checking and securing all doors before leaving the premises. She has also been reminded to sign the log located at the back door as part of the closing protocol. Emphasis was placed on the importance of completing all steps in the checklist to ensure the safety and security of the facility. Employee Statement:(DA #31) stated that she had locked the dining room doors as required and exited via the front door. She acknowledged the importance of ensuring all entry points are secured before leaving and has committed to being more vigilant moving forward.Supervisor: (name of Former Food Service Director [FFSD])Date: 5/19/25. On 09/25/2025 at 11:26 AM a telephone interview was conducted with DA #31who said she usually worked from 12:00 PM to 8 or 8:30 PM. DA #31 said before 05/18/2025 the two doors leading into to the dining room from the kitchen were to be kept locked when dietary staff left for the night. DA #31 said there were three dietary staff who worked the evening shift on 05/18/2025 and she was the last one to leave that night. DA #31 said she forgot to lock one of the doors. On review of PM [NAME] #7, DA #7 and DA #31's timesheet, it was noted that DA #31 punched out last on the evening of 05/18/2025.On 09/25/2025 at 8:24 PM a telephone interview was conducted with the FFSD who said residents were allowed in the dining room [ROOM NUMBER] hours a day, but they were supposed to stop at the kitchen door. The FFSD said the two doors leading into the kitchen from the dining room should be kept locked with deadbolt lock when dietary staff left for the evening. On 09/27/2025 at 12:08 PM a phone interview was conducted with the Dietary Kitchen Supervisor (DKS) who said she had worked at the facility for less than two months. The DKS said she opened the kitchen at 5 AM Monday through Friday and arrived before other dietary staff. The DKS said she worked some weekends and usually worked 5 AM to 1:30 PM. The DKS said the dietary staff who opened the kitchen each morning, which was usually herself, was responsible for checking to ensure the doors in the kitchen were locked and the knives were locked up from the previous shift. The DKS said there was a log posted by the back door that she looked at to make sure the last person leaving had signed that the doors were locked the previous night. On 09/26/2025 at 11:11 AM an interview was conducted with the ED who said the DON told him the resident had harmed him/herself with a knife in the kitchen. The ED said the facility's investigation determined RI #141 got the knife from inside the kitchen. The ED said residents were not allowed to be in the kitchen and the doors leading to the kitchen should have been locked. The ED said it was not reported to the State Agency because the facility did not feel that the incident met the guidelines for reporting to the State Agency. The ED said the incident was an oversight by the dietary staff. The ED said following the incident, the dietary staff were monitoring the door locking before leaving the kitchen at night. When asked if the incident could have been prevented if that door had been locked, the ED said it could have possibly been prevented. On 09/27/2025 at 9:26 AM a follow-up interview was conducted with the ED. When asked was there a process the facility used to check that the doors had been locked when dietary staff left, the ED said that was something the facility had not been doing. On 09/27/2025 at 10:50 AM the ED was interviewed to clarify the facility's process to ensure the kitchen doors were locked each night. The ED said the logs signed by the dietary staff were maintained by the dining department and were reviewed by the opening manager every morning. ************************************************* The facility took immediate action to include: On 05/18/2025 at approximately 8:00 PM RI #141 was found in the kitchen with multiple self-inflicted stab wounds. On 05/18/2025 the facility started gathered statements from nursing staff relating to the incident involving RI #141. On 05/18/2025 at approximately 9:15 PM RI #141 was transported to the hospital. On 05/18/2025-Local Police notified of the incident involving RI #141. On 05/19/2025- All dietary staff were educated on the importance of locking all doors when leaving at night. On 05/19/2025-log sheet put in place for staff to sign off that all doors in kitchen were checked to ensure they were locked when dietary staff left the kitchen for the evening. 05/19/2025 A QAPI meeting was held to discuss the incident involving RI #141.05/23/2025-Interdisciplinary Team met for a QA weekly subcommittee meeting and discussed incident and current action plan.06/11/2025-Psych nurse practitioner assessed resident.06/04/2025 through 06/14/2025-inserviced performed with all nursing staff regarding meal safety precautions, medication safety precautions and warning signs of a possible suicide attempt.On 06/15/2025 Quality Improvement Monitoring plan: Self Harm and Mental Well Being (Resident Specific) started. To be monitor through QAPI.07/01/2025-monitoring log updated to include all knives must be secured in designated lock box at the end of working day.************************************************* On 09/27/2025 at 9:26 AM the ED revealed there was no process in place to ensure facility staff checked to ensure the doors were locked when dietary staff left for the evening.*************************************************On 09/27/2025, the facility submitted the following as their removal plan for the identified Immediate Jeopardy:F 689Issue IdentifiedFacility failed to have a process in place for checking to ensure the doors to the kitchen were locked after dietary staff leave for the eveningIssueFacility wideSteps to CorrectSigns will be posted on the kitchen doors stating, This door is to be locked at all times after kitchen closing.All Licensed nurses will be in-serviced by DON/designee, on ensuring and documenting kitchen doors, that residents have access to, are locked when dietary staff are leaving in the evening. Any issues identified will be reported immediately to the ED and/or DON. 09/27/25 in-services began for the 41 employed licensed nurses. On 9/27/25 39 of the 41 licensed nurses have been in-serviced. Any Licensed Nurse not in-serviced as of today will be in-serviced by the DON/designee prior to working their next scheduled shift.On 09/27/25 16 of the 16 dietary staff have been in-serviced to get a licensed nurse to come and verify the doors are locked before they leave the building. Any dietary staff not in-serviced today will be in-serviced prior to working their next scheduled shift.Dietary staff will come out and notify a licensed nurse when they are getting ready to leave the building. That licensed nurse will go with the dietary employee to ensure all kitchen doors, that resident has access to, are locked and will document on the kitchen door lock log.MonitoringED and/or DON/designee will check and sign the kitchen door lock log weekly x 4 weeks, then 2xmonth x 1 month, then monthly.The Kitchen door lock logs will be reviewed in the facility QAPI meetings monthly and will be placed in the QAPI binder in the ED office. *************************************************After reviewing the facility's immediate actions and information provided in their Removal Plan, interviewing staff, observing, and verifying the corrective actions had been implemented the Immediate Jeopardy was removed on 09/28/2025. The scope/severity level of F689 was lowered to the lower severity of no actual harm with a potential for more than minimal harm that was not immediate jeopardy, to allow the facility time to monitor and/or revise their corrective actions as necessary to achieve substantial compliance.

Based on interviews, resident record reviews, review of a facility policy titled Abuse, Neglect, and Exploitation, review of Facility Reported Incidents (FRIs) received by the State Agency, and review of the facility's investigative files, the facility failed to protect the residents' right to be free from physical and verbal abuse perpetrated by staff and residents. The facility further failed to supervise combative, agitated residents and wandering residents in a manner to prevent abuse of residents.Specifically:1.) The facility failed to protect Resident Identifier (RI) #137 from verbal abuse perpetrated by Nurse Aide Trainee (NAT) #17. On 05/04/2024 Certified Nursing Assistant (CNA) #16 witnessed RI #137 curse at NAT #17, then NAT #17 responded by calling RI #137 a bitch. Because CNA #16 failed to report the verbal abuse immediately, NAT #17 continued working his assigned schedule on 05/04/2024, 05/05/2024, and 05/06/2024; leaving RI #137 and other residents at risk of abuse. The verbal abuse was not reported by CNA #16 until 05/07/2024 after RI #137 alleged he/she had been physically abused. 2.) The facility failed to protect RI #74 and RI #142 from physical abuse perpetrated by each other, both residents with a history of inappropriate behaviors to include agitation, combativeness, resisting care and wandering. On 06/25/2024, CNA #35 witnessed RI #142 and RI #74 slap each other in the face.3.) The facility failed to protect RI #140 from verbal abuse perpetrated by RI #2, a resident with a history of verbally aggressive behaviors to include cursing and agitation. On 03/31/2025 RI #2 was found unsupervised in RI #140's room and began to yell and curse RI #2, refusing to leave RI #140's room. RI #140 pressed his/her call light and responded through the communication unit for the nurse to come and get RI #2 out of RI #140's room. The verbal altercation was overheard by LPN #22 over the room call button system and they heard RI #2 call RI #140 a bitch.These deficient practices affected four of eight residents sampled for abuse.These deficient practices was a result of the investigations of facility reported incident/complaint/report numbers 2620942, 468258, and 468255.Findings Include:Cross-Reference F607 and F609. Review of the facility's abuse policy titled Abuse, Neglect, and Exploitation with an effective date of 02/2020, revealed the following: IntroductionThe resident has the right to be free from verbal, sexual, physical, and mental abuse, corporal punishment .Definitions.Abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish . Willful, as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm.Verbal Abuse means the use of oral, written language that willfully includes disparaging and derogatory terms to patients or their families, or within hearing distance, regardless of their ability to comprehend, or disability . Physical Abuse includes but is not limited to, hitting, slapping, pinching, and kicking.Mistreatment is defined as inappropriate treatment . of a resident . 1.) On 05/07/2024 the State Agency received a FRI alleging abuse occurred after RI #137 reported to LPN #19 that the night before a male aide had entered his/her room and poked RI #137 on the forehead multiple times. RI #137 was admitted on [DATE] and readmitted on [DATE]. RI #137's Annual Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 04/25/2024 documented a Brief Interview for Mental Status (BIMS) score of 15 which indicated intact cognition. A review of the facility's investigative file revealed an Incident Summary signed by the Executive Director (ED) that documented . During our interview with (CNA #16) she stated that on the evening of May 5th . the evening prior to when (RI #137) stated that the incident happened . she was assigned to (RI #137). (CNA #16) stated that around 10:00pm 5/5/24 she asked (NAT #17) if he could come help her with (RI #137). (RI #137) started yelling and cussing at (NAT #17) saying Get away from me, you bitch! Get out of here! . (CNA #16) stated that at this point (NAT #17) called (RI #137) a bitch and not to talk to him that way. (CNA #16) stated that (NAT #17) slammed (RI #137's) TV into the wall. (CNA #16) told (NAT #17) at this time that she was fine, and that he could leave the room. (CNA #16) stated that . (RI #137) calmed down after (NAT #17) left the room. When asked to describe (NAT #17's) general interactions with residents she stated He is quick to snap, and if a resident is rude to him then he gives them back the same energy. (NAT #17) denied all allegations, . After a thorough investigation, we are not substantiating the allegation of physical abuse (poking in face) due to lack of corroborating evidence or witnesses. We will, however, (supersede) the allegation of physical abuse with a substantiated verbal abuse allegation. (NAT #17's) employment . has been terminated. On 09/24/2025 at 10:51 AM CNA #16 was asked about the incident involving RI #137. CNA #16 said, she called NAT #17 into RI #137's room to help turn RI #137. CNA #16 stated RI #137 called NAT #17 a bitch, then NAT #17 called RI #137 a bitch. CNA #16 stated she then asked NAT #17 to leave the room, but she had no knowledge of NAT #17 poking RI #137 in the forehead. CNA #16 stated she was upset to hear NAT #17 swear at RI #137, but she did not report it until she was asked about an incident involving RI #137. CNA #16 said, what she witnessed was verbal abuse. On 09/24/2025 at 12:32 PM a telephone interview was conducted with LPN #19 and he was asked about an incident that occurred around 05/06/2024 and he stated RI #137 told him that a CNA came into his/her room the night prior and poked him/her in the forehead and asked, are you not listening to me. LPN #19 stated he reported to the Director of Nursing (DON) and ED. On 09/25/2025 at 10:20 AM an interview was conducted with the ED, and he stated he was notified on 05/07/2024 at 11:45 AM by LPN #19 that RI #137 told him that the night prior about 10 PM, a male CNA came into his/her room and poked him/her in the forehead. The ED stated he did not substantiate physical abuse but did substantiate verbal abuse. The ED stated that during the investigation CNA #16 reported that she witnessed NAT #17 verbally abuse RI #137. On 09/25/2025 at 6:05 PM a follow-up interview was conducted with the ED, and he was asked how a reasonable person would feel being called a bitch. ED stated it would not be ideal; not good. On 09/26/2025 at 10:25 AM an interview was conducted with the Social Services Director (SSD) and she stated she was not contacted to evaluate RI #137 after an abuse allegation. The SSD stated she should have been contacted to evaluate RI #137. When asked how it would make a reasonable person feel being cursed at by a staff member, she stated frightened and or angry. After surveyor review of timecards and assignments for CNA #16 and NAT #17 it was determined the only night they worked together was 05/04/2024. 2.) On 06/25/2024 at 6:36 PM the State Agency received a FRI alleging physical abuse on the memory care unit when CNA #35 witnessed RI #142 slap RI #74 in the face; before CNA #35 could get to the residents to separate them, RI #142 slapped RI #74 in the face a second time. RI #74 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses to include: Alzheimer's Disease, Adjustment Disorder with Depressed Mood, and Anxiety Disorder. RI #74's Quarterly MDS with an ARD of 05/16/2024 documented a BIMS score of 5 out of 15 which indicated severe cognitive impairment. RI #74's departmental notes contained documentation of RI #74's behaviors on 06/17/2024 as follows: . Resident is displaying increase rage and anger. attempting to go in another resident's rooms. (he/she) ran into the room and tried to slam the door repeatedly on me. (He/She) proceeded to get upset point (his/her) finger in my face and swing on me. The resident screamed coming towards me and ran out slamming the door. RI #74's departmental notes contained an entry dated 06/25/2024 at 6:41 PM signed by Registered Nurse (RN) #36 that documented . writer called to dining area . Staff member verbalized that she pulled the two residents apart. Both residents noted to have red faces. Addendum .Resident was the one who was (hit) at the time of the altercation . RI #142 was admitted to the facility on [DATE] and had and had diagnoses to include Alzheimer's Disease and Dementia. RI #142's Quarterly MDS assessment with an ARD of 04/18/2024 documented a BIMS score of 0 of 15 which indicated severe cognitive impairment. RI #142's departmental notes documented RI #142 was discharged on 06/05/2024 for behavior of attempting to throw hot coffee on another resident, fighting staff and other residents, with unsuccessful redirection. RI #142 was readmitted to the facility on [DATE]. RI #142's care plan with a problem of potential for exhibiting behaviors of agitation, combativeness, and resisting care, with a review date of 06/19/2024 upon readmission, did not include any approaches for the level of supervision RI #142 required to protect other residents from being abused. RI #142's departmental notes dated 06/20/2024 documented RI #142 believed staff and other residents were trying to steal his/her money, was fussing at other residents, pulling on the chair of another resident, and trying to hit staff as they tried to assist RI #142. RI #142's departmental notes dated 06/23/2024 documented RI #142 was agitated, kicking, spitting, pushed the dining table, and shouted profanity to staff attempts to intervene. The facility investigative file contained an Incident Summary signed by the Executive Director (ED) that documented: . Neither resident could tell . what happened, . both were assessed . with no injuries . Following the incident, we were not able to gain any insight into what could have sparked the confrontation between the two residents. We know that the incident occurred, . we will not substantiate physical abuse. On 09/23/2025 at 4:11 PM CNA #35 stated she was in another resident's room doing resident care when she heard a commotion and witnessed RI #142, a combative resident, hit RI #74 in the face before she was able to intervene. CNA #35 said, both RI #142 and RI #74 were combative residents with bad behaviors. CNA #35 said, both residents slapped each other. CNA #35 said, someone should have seen it coming, there was not anyone with them at the time, and it could have been prevented if someone was watching the residents. On 09/25/2025 at 11:09 AM when the DON was first interviewed she said, she did not think the incident was abuse between RI #142 and RI #74, and she did not think there was anything that could have been done differently. On 09/25/2025 at 12:19 PM the DON reviewed the facility abuse policy and stated the definition of abuse was the willful infliction of injury, unreasonable confinement intimidation or punishment with resulting physical harm, pain, or mental anguish. The DON stated that physical abuse included hitting, slapping, pinching, and kicking. On 09/26/2025 at 3:59 PM a follow-up interview was conducted with the DON. The DON did not think the behavior affecting others or the abuse could have been prevented because she thought neither resident was exhibiting a change of condition or any new behavior at the time of the incident, and prior to the abuse on 06/25/2024 RI #142 did not require any change in supervision, even though RI #142 had aggressive behaviors toward others documented in departmental notes during the month of June 2024. 3) On 03/31/2025 the State Agency received a FRI alleging verbal abuse when RI #2 went into RI #140's room and began to yell and curse at RI #140. RI #140 asked RI #2 to leave the room, RI #2 refused to leave the room and continued to curse at RI #140. RI #140 pressed his/her call light and responded through the communication unit for the nurse to come and get RI #2 out of the room. RI #2 was admitted to the facility on [DATE] and readmitted on [DATE]. RI #2 had diagnoses to include Dementia, Unspecified Severity, With Other Behavioral Disturbance and Alzheimer's Disease. RI #2's Quarterly MDS with an ARD of 02/24/2025 documented his/her BIMS score was a 7 of 15 which indicated severe cognitive impairment. RI #140 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses to include Alzheimer's Disease, Adjustment Disorder with Depressed Mood and Dementia in Other Diseases Classified Elsewhere, Mild with Mood Disturbance. RI #140's Quarterly MDS assessment with an ARD of 01/24/2025 documented his/her BIMS score of a 15 of which indicated no impaired cognition.The facility investigative file contained a Incident Summary which documented: . On the evening of the incident, (RI #2) entered (RI #140's) room and began cursing at (RI #140). (RI #140) stated that (RI #2) called (him/her) a mother fucker and bitch among other things (he/she) could not recall. After failed attempts of asking (RI #2) to leave, (RI #140) . pressed the emergency call button. (LPN #22) utilized the communication unit at the nurse's station to see what was needed . (RI #140) responded . Come get (RI #2) out of my room! followed by (RI #2) cursing at (RI #140) multiple times. including specifically (RI #2) calling (RI #140) a bitch. At this point (LPN #22) immediately began walking towards the resident room. (RI #140) grabbed (RI #2's) wheelchair by the handles at this time to push (him/her) out of the room and to the nurse, however (RI #2) put (his/her) legs on the ground and pushed backwards. This action pinned (RI #140) between (RI #2's) wheelchair and (RI #140's) bed. (RI #140) stated I was really scared I was going to fall and get hurt, but (he/she) started leaving the room and thankfully I didn't. While discussing what actions to take moving forward, (RI #2) came out of (his/her) room and started yelling and cursing at staff. (RI #2) was already currently on behavior monitoring for being resistive and kicking/spitting/cursing at staff members. due to (RI #2's) behavioral history and current situation . resident to be sent to hospital . to . Geri-Psych (Geriatric-Psychiatric). After investigation, . (RI #2) came into the resident room intentionally and cursed at (RI #140). RI #2's departmental notes were reviewed for the month leading up to the verbal abuse and revealed RI #2 had behaviors of cursing staff, kicking staff, trying to trip staff, exhibiting anger and frustration, threatening to spit on staff, and calling residents names. Contained within the facility's investigative file was a nurse's progress note signed by LPN #22, dated 03/31/2025 which documented, . Writer answered call light . heard yelling and screaming. Writer heard resident . (RI #2), who was in . (RI #140's) room, say bitch . (I am) not going anywhere. On 09/24/2025 at 4:59 PM an interview was conducted with LPN #22 per phone. LPN #22 was asked about the incident involving RI #2 and RI #140 on 03/31/2025. She stated she remembered answering the call light for RI #140 and he/she said to come and get RI #2 out of his/her room. LPN #22 further documented she heard RI #2 say bitch I am not going anywhere. LPN #22 said if she documented the incident then that was what happened and it was considered verbal abuse when she heard RI #2 curse RI #140. LPN #22 further stated that a reasonable person's feelings would be hurt and would be upset. On 09/26/2025 at 9:01 AM the Social Services Director (SSD) was asked about the incident that occurred between RI #2 and RI #140. The SSD read the nurses progress note dated 03/31/2025 signed by LPN #22. The SSD stated LPN #22 documented that she was answering a call light for RI #140 and heard RI #2 say bitch I am not going anywhere, and RI #140 said come get him/her out of the room. The SSD further stated that when RI #2 said bitch, I am not going anywhere that was considered verbal abuse and that would make a reasonable person angry. The SSD reported RI #2's behaviors included foul language, being aggressive, yelling, cursing staff, and being demanding. On 09/26/2025 at 10:35 AM the ED was asked how he became aware of the incident that occurred between RI #2 and RI #140 on 03/31/2025. The ED stated, LPN #22 called him and told him that RI #2 had gone into RI #140's room. RI #140 alleged RI #2 cursed him/her and RI #140 asked RI #2 to leave the room. The ED stated the investigation determined that RI #2 did go into RI #140's room and called him/her a bitch and LPN #22 overheard it on the communication system. The ED further stated that when RI #2 cursed RI #140 that was considered verbal abuse. The ED said RI #2 had a history of behaviors and using foul language, but he did not know how the verbal abuse could have been prevented. A review of RI #2's care plans revealed they did not include the level of supervision RI #2 required to prevent RI #2 from abusing residents.

Based on record reviews, interviews and review of the facility's policy titled, Abuse, Neglect, and Exploitation, the facility failed to implement the abuse policy to ensure residents were protected from further abuse when a Nurse Aide Trainee (NAT) #17 continued working in the facility on 05/05/2024 and 05/06/2024 after he was witnessed verbally abusing Resident Identifier (RI) #137 on 05/04/2024. Certified Nursing Assistant (CNA #16) who witnessed NAT #17 call RI #137 a bitch, failed to report the abuse to anyone until she was questioned about another allegation on 05/07/2024. The facility failed to determine when the verbal abuse had occurred. After surveyor review of timecards and assignments for CNA #16 and NAT #17 it was determined the only shift they worked together and the witnessed verbal abuse of RI #137 was on 05/04/2024.This deficient practice affected RI #137 and created the potential for residents to experience ongoing abuse and placed residents in the facility at risk. This deficient practice was cited as a result of the investigation of complaint/intake number 468255.Findings Include:Review of the Facility Reported Incident (FRI), dated 05/07/2024, revealed on 05/07/2024 at 11:45 AM the Executive Director (ED) was notified by Licensed Practical Nurse (LPN) #19 that RI #137 told him the night prior a male CNA came into his/her room and poked him/her on the forehead multiple times. A review of the facility's policy titled Abuse, Neglect, and Exploitation, Effective Date 02/2020, revealed: The resident has the right to be free from verbal . abuse . Residents must not be subject to abuse by anyone . facility staff .DefinitionsVerbal Abuse means the use of oral.or gestured language that willfully includes disparaging and derogatory terms to residents. within their hearing distance.V. Response and Reporting of Abuse. The following outlines steps to be taken during an investigation:A. Respond to the needs of the resident and protect them from further incident.B. Notify the Director of Nursing and Executive Director or their designee.D. Report to State agency all alleged violations involving abuse . immediately but no later than 2 hours after forming the suspicion or allegations .F. Place the employee on leave from resident care immediately.IXExamples of ways to protect from harm during an investigation of abuse .G. Reassignment of nursing staffH. Time off for nursing staff.I. Involve clergy, social services, and counselors as appropriate .RI #137 was admitted to the facility on [DATE] and readmitted on [DATE]. RI #137's Annual Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 04/25/2024 documented a Brief Interview for Mental Status (BIMS) score of 15 of 15 which indicated intact cognition.Included in the facility's investigative file the ED interviewed Certified Nursing Assistant (CNA) #16 who stated she was assigned to RI #137 on the evening of 05/05/2024 and called NAT #17 into the room to help turn RI #137. CNA#16 stated RI #137 started yelling and cursing at NAT #17, saying Get away from me you bitch! Get out of here! CNA #16 stated NAT #17 called RI #137 a bitch, told him/her not to talk to him like that, and slammed the television (TV) into the wall. The administrator noted that RI #137 initially stated that NAT #17 was accompanied by a black lady with red braids, who was believed to be CNA #21. It was determined that CNA #21 did not work with NAT #17, and she did not work 3-11 shift on 05/06/2024. The ED stated he believed the incident occurred on 05/05/2024 when CNA #16 and NAT #17 were in the room together. On 09/24/2025 at 10:51 AM CNA #16 stated that on 05/06/2024 RI #137 called NAT #17 a bitch, then NAT #17 called RI #137 a bitch and slammed the TV into the wall. CNA #16 stated NAT #17 left the room, and she did not see NAT #17 poke RI #137 in the forehead. She stated she did not report the abuse when it occurred, and she should have reported it. She stated abuse should be reported as soon as it happened so it would not happen again or to the same person and for resident safety, and protection. A review of the facility staffing assignment sheet dated 05/04/2024 indicated NAT #17 and CNA #16 worked 3-11 shift and worked with the same residents. A review of the employee timecards indicated:The timecards indicated NAT #17 continued working in the facility and worked the following dates and times, after the witnessed abuse went unreported leaving RI #137 and all other residents in the facility unprotected from abuse by NAT #17: 05/04/2024 in at 2:51 PM and out at 10:57 PM05/05/2024 In at 2:59 PM and out at 10:56 PM05/06/2024 In at 2:57 PM and out at 10:55 PM The timecard indicated CNA #16 worked the following dates and times: 05/04/2024 In at 2:57 PM and out at 10:58 PM05/05/2024 In at 6:58 AM and out at 03:00 PM05/06/2024 was not scheduled or clocked in05/07/2024 In at 6:57 AM and out at 03:05 PM A review of NAT #17's personnel file indicated NAT #17 was hired by the facility on 02/21/2024 and completed abuse training on 02/27/2024. Further reviewed indicated NAT #17 was suspended on 05/07/2024 for Violation of Abuse, inappropriate and unprofessional behavior toward a resident and terminated on 05/14/2024. On 09/25/2025 at 2:53 PM the ED stated during an interview with CNA #16 on 05/07/2024 she alleged she witnessed NAT #17 verbally abuse RI #137 the night prior. He stated CNA #16 should have reported it immediately. The ED was asked about the concern of an employee not reporting an abuse allegation immediately and the ED stated if any time lapsed, they were not in compliance and needed to keep the resident safe and have effective reporting. On 09/25/2025 at 6:05 PM in a follow up interview with the he was asked to clarify when the incident of abuse occurred. The ED stated that he reviewed the timecards again and should have checked the timecards closer. The ED stated that CNA #16 did not work on 05/06/2024, but did work on 05/04/2024, 3-11 with NAT #17. The ED stated the incident had to occur on 05/04/2024 which was the only date that month that they worked together. The ED was asked what type of disciplinary action was done with CNA #16 for not reporting the incident and he stated Director of Nursing (DON) conducted a one on one with CNA #16 on reporting abuse.

Based on interviews, record review, and a facility policy titled Abuse, Neglect, and Exploitation the facility failed to ensure Certified Nursing Assistant (CNA) #16 immediately reported verbal abuse she witnessed on 05/04/2024 when Nurse Aide Trainee (NAT) #17 called Resident Identifier (RI) #137 a bitch. This incident was discovered by the facility during their investigation into an allegation of physical abuse reported on 05/07/2024 affecting RI #137, one of eight residents sampled for abuse. This deficient practice was cited as a result of the investigation of complaint/intake number 468255.Findings Include: Cross-reference F600 and F607. On 05/07/2024 at 11:45 AM the State Agency received a Facility Reported Incident (FRI) alleging physical abuse when Licensed Practical Nurse (LPN) #19 was informed by RI #137 that the night prior a male CNA came into his/her room and poked him/her on the forehead multiple times. A review of a policy titled Abuse, Neglect, and Exploitation with an effective date of 02/2020 documented: . IntroductionThe resident has the right to be free from verbal, sexual, physical and mental abuse, corporal punishment, and involuntary seclusion. D. Report to State agency all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property, immediately but no later than 2 hours from forming the suspicion or allegation. RI #137 was initially admitted to the facility on [DATE] and readmitted on [DATE]. RI #137's Annual Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 04/25/2024 documented a Brief Interview for Mental Status (BIMS) score of 15 which indicated intact cognition.A review of NAT #17 and CNA #16's timecards from May 2024 revealed the incident occurred on 05/04/2024 the only day the two employees worked together. On 09/25/2025 at 6:05 PM an interview was conducted with the Executive Director (ED) and he was asked to provide clarification regarding the timing of the abuse incident. The ED stated he had reviewed the timecards and acknowledged he should have looked at them more closely and confirmed that CNA #16 did not work on 05/06/2024, but she did work on 05/04/2024, from 3 PM to 11 PM with NAT #17. The administrator said that the incident would have taken place on 05/04/2024 as that was the only day in that month when they worked together.Review of the facility investigative file revealed an Incident Summary in which the facility determined physical abuse could not be substantiated. The Summary documented the facility did determine that NAT #17 was verbally abusive to RI #137 when he called RI #137 a bitch. Facility disciplinary actions included NAT #17's termination on 05/14/2024. On 09/24/2025 at 10:51 AM an interview was held with CNA #16, and she was asked about the incident involving RI #137. She said that she requested NAT #17 to help her provide care to RI #137, upon entering the room RI #137 used profanity toward NAT #17, referring to him as a bitch. CNA #16 said, in response NAT #17 called RI #137 a bitch. CNA #16 expressed that she viewed NAT #17's cursing at RI #137 as verbal abuse. CNA #16 said she did not report the incident immediately and it should have been reported when it was witnessed. CNA #16 said the importance of reporting abuse immediately was to ensure the safety and protection of the resident. On 09/25/2025 at 2:53 PM the ED was questioned regarding the verbal abuse allegation involving RI #137. The ED stated that CNA #16 should have reported the allegation immediately. The ED said that any delays in reporting abuse allegations would result in the facility being non-compliant and it was important to ensure resident safety.

Based on interviews, resident record review, review of a facility policy titled Behavior Management Program, review of a Facility Reported Incident (FRI) received by the State Agency and review of a facility investigative file, the facility failed manage Resident Identifier (RI) #136's behaviors in a manner to reduce agitation and prevent escalation of behaviors for RI #136 on 09/15/2024 when Registered Nurse (RN) #27 and Certified Nursing Assistant (CNA) #37 provided Activity of Daily Living (ADL) care to RI #136, a resident with Dementia with Behavior Disturbance and a history of aggressive and paranoid behavior. RN #27 and CNA #37 failed to implement behavior approaches during ADL care to provide a calm environment, allow RI #136 time alone, promote independence and a sense of control, when RI #136 verbally and physically resisted ADL care.The facility further failed to continue monitoring and review of RI #136's documented behaviors in August and September 2024 leading up to 09/15/2024 and failed to update RI #136's behavior approaches after 08/09/2024 when RI #136 was discontinued from review in weekly behavior monitoring meetings despite RI #136 exhibiting behaviors the facility staff were unable to manage.This deficient practice affected RI #136 one of two residents sampled for Behavioral Health Services and was cited as a result of an investigation of complaint number 468254.Findings Include:Findings Include:Cross-reference F744.On 09/15/2024 at 10:29 PM the State Agency received a FRI alleging RI #136 was combative with staff, CNA #37 and RN #27, on the morning of 09/15/2024 at 5:00 AM; and by the evening of 09/15/2024 RI #136's left hand was bruised and swollen. A facility policy titled Behavior Management Program with an effective date of 03/2018 documented: PURPOSE:Mental and psychosocial adjustment difficulties may be experienced by a resident, due to problems adapting to changes in life's circumstances.STANDARD:Residents who display mental or psychosocial adjustment difficulty should receive appropriate services, in an attempt to correct the problem. PROCESS: .2) Assessment should be conducted upon admission and with new, or worsen behaviors to identify potential underlying causes.3) Behavior monitoring may be done to determine behavior or an isolated event. 4) A resident centered behavior management plan or resident centered plan of care will be developed by the interdisciplinary team . RI #136 was admitted to the facility on [DATE] and readmitted on [DATE] and had diagnoses to include Severe Dementia that included Behavior Disturbance and Restlessness and Agitation. RI #136's quarterly Minimum Data Set (MDS) assessment with an Assessment Reference Date of 06/27/2024 documented a Brief Interview for Mental Status (BIMS) score of two out of 15 which indicated severe cognitive impairment. RI #136 had a care plan with an onset date of 07/25/2023, a review date of 07/08/2024, and a problem/need of exhibiting behaviors such as hitting at other residents, threatening to hit other residents, paranoid behavior, and hallucinations. Care plan approaches included guidance to nursing staff to redirect resident when behaviors were exhibited, notify Medical Director (MD) of significant changes in behavior, notify social services of any changes noted in mood or behaviors, document noted behaviors, praise resident for participation in care, after ensuring resident safety allow time alone, assess resident for unmet needs, encourage resident to assist to promote independence and sense of control; check on the resident to ensure the resident was resting, not agitated and calm between 3:00 and 5:00 AM; and if resident was agitated to remove to a quiet calm environment. The facility investigative file contained an Incident Summary signed by the facility's Executive Director (ED) that documented: On the afternoon of September 15th the nursing department noticed redness, bruising and swelling on the left hand of (RI #136). (RN #27) had worked with (RI #136) . the morning of the 15th. (DON) asked (RN #27) about (RI #136's) hand . (RN #27) stated that on his previous shift (RI #136) was very combative; including-kicking, swinging arms and trying to scratch staff members. (RN #27) stated that he went in the room with (CNA #37) to assist with care and (RI #136) was actively being combative . X-Rays were ordered by MD . The results of the X-Rays were negative and there were no fractures or dislocations noted . multiple staff members' statements that they have recently seen (RI #136) running into door frames in (his/her) wheelchair, being combative with staff . We interviewed (CNA #37), . (CNA #37) stated that (RN #27) told her to She's being too combative . Let's just get the pants on now . this is too much! . (RN #27) stated . I think she felt rushed because (RI #136) was being so combative . she tried to . pull (his/her) pants on too quickly and forcefully. He went on to say We were in a bad situation with (RI #136) and (CNA #37) could have handled things differently, . RI #136's nursing progress note entries were reviewed and documented aggressive/combative behaviors toward staff during ADL care from 08/11/2024 through 09/02/2024, prior to the incident, as follows: 8/11/2024 1:52 PM . RESIDENT COMBATIVE WITH STAFF DURING CARE, (RI #136) KICKED AND SCRATCHED (HIS/HER) CNA, WHILE PASSING BY THIS WRITER (HE/SHE) GRABED THE TIE ON MY SCRUB AND PULLED IT TRYING TO TEAR IT. HAD TO TRY HARD TO GET THE TIE/STRING OUT OF (HIS/HER) HAND AND INSTUCTED (HIM/HER) THAT THIS WASN'T NICE. 8/13/2024 6:03 AM . Resident combative . (with) staff this AM during brief change. Difficult to clean and change linen and resident. continues to kick . scratch at staff. Redirected to not to do so. Redirect failed. 8/14/2024 9:05 PM . staff alerted this writer to resident room . staff notified this writer that (he/she) kicked me in my side while I was assisting (him/her) to bed and changing (his/her) clothes . This writer and another CNA attempted to finish care for the resident behaviors continued with this writer and CNA . 8/16/2024 12:49 PM . Resident displayed aggressive behavior toward staff during perineal care on 3-11 tour. Resident made multiple attempts to try and (kick) CNA in the face. resident is lying supine position with legs up in the air swing (his/her) arms (trying) to hit CNA. Redirection unsuccessful . resident continued to scratch, hit, swat and (kick) staff. 8/31/2024 6:34 PM . Resident has been combative with shift. throwing punches at staff, kicking, (knocking) things away . CNA from shift on (08/30/2024) reported the resident scratched her and hit at her. 9/2/2024 7:11 AM . Resident noted to be combative hitting and kicking staff while trying to perform ADL care. Resident refused AM (medications). A review of Weekly behavior monitoring Sub Committee Meeting reports revealed RI #136 was discontinued from the monitoring and meetings after 08/09/2024 even though RI #136 continued to have ongoing aggressive combative behaviors toward staff. According to facility documentation of the meetings RI #136 was not included for discussion on 08/16/2024, 08/23/2024, 08/30/2024, 09/20/2024, or 09/27/2024. A review of the facility's investigative file revealed a handwritten statement from CNA #37 that documented: . Sunday, (09/15/2024) (RI #136) often becomes combative, violent, and aggressive with anyone who attempts to provide care, making it difficult for CAREGIVERS. During the last round of care, (RI #136) was waking up. (CNA #37) therefore asked (RN #27) for assistance. On approach, (RI #136) was upside-down lying-in bed. As (CNA #37) began to render care, (RI #136) became very agitated. (Kicking, biting, twisting, and YELLING DADDY!) . (RN #27) stated, (RI #136) is too combative. Let's just get the pants on now. This is too MUCH! On 09/23/2025 at 3:00 PM CNA #37 was asked about the incident involving RI #136. CNA #37 said, she no longer worked at the facility, and she had nothing to say about RI #136. CNA #37 verified the contents of her facility statement. On 09/24/2025 at 5:54 PM RN #27 was asked about the incident involving RI #136. RN #27 said, RI #136 had a history of hitting and being combative. RN #27 said, he went to help CNA #37 put pants on RI #136 and CNA #27 was rough with RI #136 and it made him uncomfortable. RN #27 said, he told CNA #37 whoa whoa (he/she) is older and fragile and you cannot handle (him/her) that way. RN #27 said, they continued putting pants on RI #136 even though RI #136 continued to be combative, everything went fast, and CNA #37 had been rough with RI #136. RN #27 said, RI #136's care plan guided staff to get help, give RI #136 a break, calm down and reapproach. On 09/25/2025 at 11:13 AM an interview was conducted with the Social Services Director (SSD) regarding RI #136's behaviors and the facility's process on behavior monitoring. The SSD said she was responsible for reporting resident behaviors every day in morning meeting and every Friday they discussed anyone on the behavior monitoring program in the weekly Sub Committee meeting. The SSD said behavior data was pulled for the week, and the team discussed who needed to be added or taken off, what changes were needed or additional interventions to be implemented. When asked about RI #136's behaviors, she said according to the progress notes RI # 136 was having hitting, kicking, combative aggressive behaviors on 08/11/2024, 08/16/2024, 08/31/2024 and 09/02/2024, and she would not be aware of them until the morning meeting, if the nurse communicated the information. When asked what interventions were in place to help guide staff in how to manage RI # 136's combative behavior, she said staff were to provide redirection, assess for unmet needs, allow the resident to control and participate and allow time for the resident to calm down. On 09/25/2025 at 2:53 PM an interview was conducted with the Director of Nursing (DON) regarding RI #136's combative behaviors and the incident on 09/15/2024. When asked about RI #136's behaviors, the DON said RI #136 exhibited aggressive combative behavior toward staff. The DON said RI #136 was on a Behavior Monitoring Program (BMP) through 08/09/2024. The DON said the BMPs were not typically ongoing, and unless there were issues, they would stop after a period of time. When asked if RI #136 was exhibiting behaviors after the 08/09/2024, the DON said, yes, according to the notes RI #136 continued to have behaviors of hitting, kicking, and scratching staff. The DON said interventions in place for staff to help deescalate RI #136's behaviors would be talk in a calm manner, allow time to calm and reapproach and provide redirection. When asked what could have been done to prevent the incident on 09/15/2024, the DON said staff should have let RI #136 calm down and reapproached at a later time. The DON said, she was not sure why RI #136 was not included on behavior monitoring after 08/09/2024 leading up to the incident on 09/15/2024.

Based on interviews, record review, review of a facility policy titled Medication, Oral/Sublingual Administration, review of a Facility Reported Incident (FRI) received by the Alabama State Survey Agency, and review of the facility's investigative file, the facility failed to ensure Resident Identifier (RI) #9, RI #10, RI #11, and RI #13 received their medications on the three to eleven (3-11) PM shift on 01/09/2023 as ordered by the physician. This deficient practice had the potential to affect four of four residents residing on the secured unit at the facility; which is one of three units at the facility. Findings include: Review of a facility policy titled Medication, Oral/Sublingual Administration, with an effective date of 05/2014, revealed the following: PURPOSE: To administer oral medications in an organized and safe manner. STANDARD: Medications are administered orally under the orders of the attending physician. The facility submitted an Online Incident Report to the Alabama Department of Public Health on 01/10/2023. The report alleged Abuse and Neglect for four residents, RI #9, RI #10, RI #11, and RI #13. A narrative summary of the incident was documented in the report as follows: . DON (Director of Nursing) left yesterday with keys to med (medication) cart that contained medications for a total of four residents. Staff attempted to contact DON, spoke to her to let them (her) know they did not have keys to the cart for those residents. DON did not offer to return to the facility or offer any remedy to obtaining spare key to the cart. DON brought keys back to the facility today. Four residents identified did not receive medications as ordered during that time. The facility Incident Summary for the incident dated 01/10/2023 documented the following: . Description of Incident On 01/09/2023, 3p-11p shift nurses could not locate the medication cart keys for the secured unit.(LPN #8) contacted . (Former DON) who had the keys to that unit on the 7a-7p shift. (Former DON) stated she had the keys; she had accidentally brought them home, and would bring them back in the morning when she came in for her shift. (Former DON) did not bring them back immediately per the facility protocol. This caused 4 residents not to receive their medications in a timely manner, none of these were critical medications. (Former DON) returned the keys on 1/10/2023 and the residents received their morning medications as ordered. A review of the facility's investigative file revealed a Resident Incident Report that documented the following; Name: (Names of RI #10, RI #9, RI #13, RI #11) . Incident Date: 1/9/23 . Category . (Medication checked) . Describe Injury: no injuries . Narrative of incident and description of injuries: . On 1/9/23 RN (name of former DON) left facility with narcotic/med cart keys and 4 residents did not receive medications that was scheduled on 3-11 & (and) 11-7 . 1) RI #9 was admitted to the facility on [DATE] and readmitted on [DATE] and had diagnoses to include Dementia with Behavioral Disturbances, Constipation, Adjustment Disorder with Anxiety and Insomnia. A review of RI #9's January 2023 Physician Orders revealed RI #9 had orders for Depakote DR 125 mg to be administered by mouth twice a day for Dementia with Behaviors, Buspirone HCL 10 mg to be administered by mouth three times a day for Adjustment Disorder with Anxiety, Senna 8.6 mg by mouth to be given at bedtime for Constipation and Trazodone 50 mg by mouth to be administered at bedtime for Dementia with Behavior Disturbances/Insomnia. A review of RI #9's January 2023 eMAR (electronic Medication Administration Record) revealed on 01/09/2023, during the 3-11 PM shift, RI #9 did not receive Depakote DR 125 mg and Buspirone HCL 7.5 mg at 5:00 PM and Senna 8.6 mg and Trazodone 50 mg at 9:00 PM as ordered by the physician. 2) RI #10 was admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses to include Vascular Dementia with Behavioral Disturbances, Bipolar Disorder, Post-Traumatic Stress Disorder, Hyperlipidemia, and Insomnia. A review of RI #10's January 2023 Physician Orders revealed RI #10 had orders for Lotrimin AF (Antifungal) 1% Cream twice a day until clear, PreserVision Areds Softgel one by mouth twice a day, Trileptal 150 mg 1/2 tab (75 mg) by mouth twice a day for Vascular Dementia with Behavioral Disturbances, Quetiapine 50 mg by mouth three times a day for Post-Traumatic Stress Disorder, Trazodone 50 mg by mouth at bedtime for Insomnia, Atorvastatin 40 mg by mouth every day for Hyperlipidemia, Melatonin 10 mg by mouth at bedtime for sleep and Tamsulosin 0.4 mg by mouth every day for Obstructive and Reflux Uropathy. A review of RI #10's January 2023 eMAR revealed on 01/09/2023, during the 3-11 PM shift, RI #10 did not receive Lotrimin AF 1% Cream, Trileptal 150 mg, PreserVision Areds Softgel and Quetiapine 50 mg at 5:00 PM, Tamsulosin 0.4 mg at 7:00 PM and Atorvastatin 40 mg, Melatonin 10 mg and Trazodone 150 mg at 9:00 PM as ordered by the physician. 3) RI #11 was admitted to the facility on [DATE], with a diagnosis of Hyperlipidemia. A review of RI #11's January 2023 Physician Orders revealed RI #11 had orders for Zetia 10 mg by mouth at bedtime for Hyperlipidemia. A review of RI #11's January 2023 eMAR revealed on 01/09/2023, during the 3-11 PM shift, RI #11 did not receive Atorvastatin 80 mg and Zetia 10 mg at 9:00 PM as ordered by the physician. 4) RI #13 was admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses to include Dementia with Behavioral Disturbances, Major Depressive Disorder, Vascular Dementia with Behavioral Disturbances, Alzheimer's Disease, Bipolar Disorder, Multiple Fractures of Ribs, Left Side, with Routine Healing and Hyperlipidemia. A review of RI #11's January 2023 Physician Orders revealed RI #11 had orders for Refresh Optive Gel eye drops instill one drop in each eye twice a day, Trileptal 150 mg by mouth twice a day for Unspecified Dementia with Behavioral Disturbances, Namenda 10 mg by mouth twice a day for Vascular Dementia with Behavioral Disturbances, Zyprexa 5 mg one by mouth at bedtime for Vascular Dementia with Behaviors, Atorvastatin 40 mg one by mouth at bedtime, Trazodone 50 mg by mouth at bedtime for Insomnia, Aricept 10 mg by mouth at bedtime for Alzheimer's Disease and Norco 7.5-325 mg one by mouth every 8 hours. A review of RI #11's January 2023 eMAR revealed on 01/09/2023, during the 3-11 PM shift, RI #11 did not receive Trileptal 75 mg, Namenda 10 mg, Refresh Optive Gel eye drops, at 5:00 PM, Aricept 10 mg, Atorvastatin 40 mg, Trazodone 50 mg and Zyprexa 5 mg at 9:00 PM, and Norco 7.5-325 mg at 10:00 PM and on 01/10/2023 at 6:00 AM as ordered by the physician. On 11/15/2023 at 3:06 PM, the surveyor conducted an interview with the 3-11 PM shift LPN who had contacted the former DON about not being able to locate the keys to the medication cart for the secured unit. When asked who she informed when the former DON said she was not bringing the keys back to the facility, the LPN said besides the nurse who was on that cart, no one. The LPN said the facility's protocol when the keys to a medication cart were not available was to notify the DON. The LPN said in this case the DON was the one who had the keys, and she was notified. The LPN said when the former DON said she was not bringing the keys back to the facility, she probably could have called someone above the DON or called maintenance to see if they had a master key or not. The LPN said she was given a one on one in-service, by the Assistant [NAME] Present of Clinical Compliance nurse, that anyone who takes the medication keys from the facility must bring them back immediately, and if someone takes the keys home and refuse to bring them back, call their supervisor, the executive administrator or the DON. When asked were the physician orders followed if the residents did not get their medications on the 3-11 PM shift, the LPN said if the residents did not receive their medications the physician orders were not followed. On 11/15/2023 at 4:23 PM, an interview was conducted with a RN unit manager of one of the other units at the facility. The RN unit manager said the former DON came in on 01/10/2023 and informed her the staff had called her and asked her to bring the medication cart keys for the secured unit back to the facility. When asked where should the medication cart keys be at all times, the RN unit manager said with the nurse on the shift. The RN unit manager said that would be the nurse responsible for those residents. The RN unit manager said there were four residents from the secured unit on her unit at that time. The RN unit manager said looking at the resident's eMARs, EI #13's missed his/her 5:00 PM dose of Trileptal, Namenda, and Refresh eye drops; 9:00 PM dose of Aricept, Atorvastatin, Trazodone and Zyprexa and 10:00 PM dose of Norco 7.5 mg, RI #9 missed his/her 5:00 PM dose of Depakote and Buspirone, 9:00 PM dose of Senna and Trazodone, RI #11 missed his/her 5:00 PM dose of Namenda and 9:00 PM dose of Atorvastatin and Zetia; and RI #10 missed his/her 5:00 PM dose of Lotrimin Antifungal cream, Trileptal, PreserVision Ares (vitamin) and Seroquel, 7:00 PM dose of Flomax and 9:00 PM dose of Atorvastatin, Melatonin and Trazodone. When asked were the physician orders followed when the residents did not receive their medications, the RN unit manager said no, they were not followed. The RN unit manager said when resident do not receive their medication as ordered by the physician, in this this situation, there could be a potential for increased anxiety and loss of sleep. The RN unit manager said those were the two big things with the medications that were missed. On 11/16/2023 at 8:25 AM, 10:43 AM and 3:34 PM unsuccessful telephone attempts were made to contact the former DON. On 11/16/2023 at 9:45 AM, an interview was conducted with the RN Assistant [NAME] President of Clinical Compliance nurse. When asked how she became aware of an incident back in January of 2023, where four residents on the secured unit did not receive their evening medications, the RN Assistant [NAME] President of Clinical Compliance nurse said she believed the RN Director of MDS (Minimum Data Set) and Clinical Assessments informed her. The RN Assistant [NAME] President of Clinical Compliance nurse said she could not remember the exact words, but she was told the former DON had taken the cart keys home and refused to bring them back. The RN Assistant [NAME] President of Clinical Compliance nurse said she was already at the facility when she was informed . The RN Assistant [NAME] President of Clinical Compliance nurse said the facility identified the residents that were affected, notified the Medical Director (MD), notified the families, the residents were monitored for adverse effects of not receiving their evening medications and none were noted, and began in-servicing the nurses and the Macs (Medication Attendants Certified) regarding not taking medication carts keys home and the procedure for returning the keys. The RN Assistant [NAME] President of Clinical Compliance nurse also said it was discussed that if someone had taken the keys home and refused to bring them back, they were to notify the executive director immediately. The RN Assistant [NAME] President of Clinical Compliance nurse said an investigation was completed and it was found the former DON did not follow facility protocol which was when you take the keys home or realize that you have them you should bring them back immediately. The RN Assistant [NAME] President of Clinical Compliance nurse said four residents from the secured unit did not receive their medications on the 3-11 PM shift on 01/06/2023. When asked were the physicians orders followed when the residents did not receive their medications on the 3-11 PM shift on 01/06/2023, the RN Assistant [NAME] President of Clinical Compliance nurse said on 01/09/2023, on that shift they were not followed. On 11/16/2023 at 11:50 AM, a telephone interview was contacted with the Medical Director/physician of the four residents who missed their medications on the 3-11 PM shift on 01/09/2023. The MD said he was notified of the incident back in January of 2023 where the DON took the keys to the medication cart on the secured unit home with her. The MD said if he ordered medications for a resident, he would expect the nurses to follow the orders. The MD said from what he recalled about the incident, no resident experienced any adverse reactions nor did any harm occur due to the residents missing their medication that one time. On 11/16/2023 at 2:16 PM, the surveyor conducted an interview with the RN Director of MDS and Clinical Assessments nurse. When asked when she became aware the former DON had taken the keys to the mediation cart for the secured unit home with her and refused to bring them back, the RN Director of MDS and Clinical Assessments nurse said it was a staff member who informed her of that. The RN Director of MDS and Clinical Assessments nurse said she immediately called her supervisor the Assistant [NAME] Present of Clinical Compliance nurse. The RN Director of MDS and Clinical Assessments nurse said there four residents affected by this and it was on the 3-11 PM shift that this occurred. When asked were the physician orders followed if the resident did not receive their medication on the 3-11 PM shift, the RN Director of MDS and Clinical Assessments nurse said no. The RN Director of MDS and Clinical Assessments nurse said it would be important to follow physician orders because the residents have their medications ordered for a certain purpose. This deficient practice was cited as a result of the investigation of complaint/report number AL00042958. ************************************************************* The facility took immediate action to correct the noncompliance by: 01/09/2023- Staff identified that the Director of Nursing left the building with the medication cart keys for the Arbor unit. Call was made to the Director of Nursing by staff and she refused to return to the facility with the keys. 01/09/2023-Four residents on the Arbor unit did not receive medication on the 3-11 shift as ordered by the physician. 01/10/2023- Director of MDS/Clinical Assessment SNF was notified that the Director of Nursing left the faciity on [DATE] with medication cart keys and refused to return to the facility after being contacted by staff. 01/10/2023- Medical Director and representatives for the residents were notified of the incident. 01/10/2023-No adverse reactions noted from residents not receiving medications. 01/10/2023- Incident report completed 01/10/2023- Reported to ADPH and investigation began. The Director of Nursing was suspended pending investigation. 01/11/2023- Director of Nursing terminated after investigation completed. 01/11/2023- Educated and in-serviced staff (MACs and NURSES) on appropriate actions if med cart keys were removed from the facility. IF MEDICATION KEYS ARE TAKEN OUT OF THE FACILITY 1. If you count the medication cart with the oncoming shift, there should be no reason to take the cart keys out of the facility and home with you. 2. If you take the medication cart keys home with you, you must bring them back immediately upon discovering you have them. 3. If someone from the previous shift, takes the medication cart keys home you need to notify them immediately to bring them back to the facility 4. If someone takes the keys home and refuses to bring them back you must notify, your supervisor or, your DON or, your Executive Director or, your nurse consultant. You must ensure the residents receive their medications. 01/12/2023- Quality Improvement Action Plan initiated. 02/22/2023- Incident was brought to QA meeting. 01/10/23 till Present - No further issues with medication cart keys being taken out of the facility. ******************************************************* After review and verification of the information provided in the facility's corrective action plan, inservice/education records, and the facility's investigation, as well as staff interviews, the survey team determined the facility implemented corrective actions from 01/09/2023 through 02/22/2023; thus past noncompliance was cited.

Based on interview, record review, and review of Oaks on Parkwood Highlands Rehabilitation and Skilled Nursing Facility Assessment 2021 the facility failed to ensure the Facility Assessment included an evaluation of the overall number of facility staff needed to ensure sufficient number of qualified staff were available to meet each resident's needs. This had the potential to affect 84 of 84 residents in the facility. Findings Include: A review of Oaks on Parkwood Highlands Rehabilitation and Skilled Nursing Facility Assessment 2021 revealed . III. Facility Assessment of Care Required by Resident Population . B. Staffing- Current staffing is stable from day to day and shift to shift is based on the normal and expected care needs of the residents on each unit. On 10/15/21 at 2:00 PM an interview was conducted with EI #1, Administrator. EI #1 was asked, how did the facility assessment include an evaluation of the overall number of facility staff needed to ensure sufficient number of qualified staff were available to meet each resident's needs. EI #1 replied, he met with the clinical services administrator (EI #2) and the admissions director before a resident was admitted and they decided whether the existing staff could meet the needs of the prospective residents. EI #1 was asked, why was there not a staffing grid that outlined census and number of staff needed to provide quality care in the facility assessment. EI #1 replied, the facility had a staffing grid, but it was not included in the facility assessment.

Based on observation, resident record review, interviews, and a facility policy titled Perineal Care (Incontinence Care) the facility failed to ensure: 1) Resident Identifier (RI) #2 was provided incontinent care or checked for incontinence on 10/13/21 from 7:42 AM until 2:00 PM. 2) RI #1 was provided incontinent care on 8/8/21 during 7:00 AM-3:00 PM shift before around lunch time and then found to have a wet brief, bowel movement in brief, and wet draw sheet. This deficient practice affected two of four residents sampled for incontinent care. Findings Include: A review of facility policy titled Perineal Care (Incontinent Care) with an effective date of 6/2014 revealed PURPOSE: Good perineal care helps prevent infection, irritation, and skin breakdown. STANDARD: Residents who are incontinent of urine or feces should receive perineal care as needed. 1.) RI #2 was admitted to the facility on [DATE] and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . RI #2's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 7/15/21 documented RI #2 had a Brief Interview for Mental Status (BIMS) score of seven which indicated RI #2 had severe cognitive impairment; and RI #2 was always incontinent of bowel and bladder and was totally dependent on staff for toileting and required extensive assistance with personal hygiene. A nursing note dated 8/25/21 at 9:15 PM titled Weekly Summary signed by EI #16 Licensed Practical Nurse (LPN) documented .Total care. Incont. (incontinent) of B/B (bowel and bladder) pericare (perineal care) given q2h (every two hours) and as needed. On 10/13/21 at 7:42 AM surveyor began continuous tracking of RI #2. RI #2 was dressed and in a broda chair with a gel cushion in the chair. RI #2 was continuously observed until 2:00 PM and was not provided incontinent care or checked for incontinence during that time. On 10/13/21 at 2:00 PM EI #6, CNA went into RI #2's room. EI #6 was asked, how often was RI #2's brief changed. EI #6 replied, every two hours. EI #6 was asked, when was the last time she checked RI #2's brief. EI #6 replied, she did not check RI #2 every two hours that day because there were only three CNAs that day. EI #6 was asked, when was the last time she checked RI #2 to see if he/she needed changing. EI #6 replied, she had not because she had to give showers. EI #6 was asked, how many residents was she caring for that day. EI #6 replied, 15. EI #6 was asked, what other care was she unable to give to residents that day. EI #6 replied, she had done most of it, but had not been able to go back and check and change every two hours. EI #2 was observed as she transferred RI #2 to the bed to provide incontinent care. RI #2's brief was noted to be dry and had two smears of bowel movement on it. EI #6 provided perineal care for RI #2. 2.) RI #1 was admitted to the facility on [DATE], readmitted on [DATE] and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . RI #1 was discharged on [DATE]. RI #1's quarterly Minimum Data Set (MDS) with an assessment reference date (ARD) of 6/21/2021, documented RI #1 had severly impaired cognition, was always incontinent of bowel and bladder, was totally dependent on staff for toileting, and required extensive assistance with personal hygiene. On 10/13/21 at 8:40 AM an interview was conducted with RI #1's sponsor. RI #1's sponsor reported that on 8/8/21 around 12:00 PM to 12:30 PM, upon arrival at the facility in RI #1's room, RI #1's meal tray was in front of RI #1, so the sponsor fed RI #1. After RI #1 finished lunch, the sponsor went to the nurses' desk and while returning to RI #1's room, EI #13, CNA reported that she did not know RI #1 was assigned to her. RI #1's sponsor reported that while assisting EI #13 with care for RI #1 the padding under RI #1 was observed to be black and it was obvious that RI #1 had not been cleaned and it was near 1:00 PM. On 10/14/21 at 9:50 AM an interview was conducted with EI #13. EI #13 was asked, what happened on 8/8/21. EI #13 reported that different nurses did the staffing, and she was assigned the same residents that she had the day before and was not assigned RI #1. EI #13 continued, around lunch time, she thought RI #1's sponsor came and asked someone why RI #1 was not up and out of bed; she did not remember who, but someone came and told her that she was assigned to provide care to RI #1. EI #13 was asked, when she was told that RI #1 was assigned to her, in what condition did she find RI #1. EI #13 replied, RI #1 was still in the bed, his/her brief was wet with urine, the draw sheet under RI #1 was wet with urine, but the fitted sheet was not wet; RI #1 did have bowel movement in brief also. EI #13 was asked, when was RI #1's brief changed before she was told RI #1 was assigned to her. EI #13 replied, it was not changed. EI #13 was asked, should it have been changed before she changed it around lunch. EI #1 replied, yes. EI #1 was asked, what would the potential harm be for a resident's brief not being changed until around lunch. EI #13 replied, the resident could have skin breakdown. On 10/14/21 at 5:50 PM an interview was conducted with EI #2, RN, Clinical Services Administrator, Director of Nursing (DON). EI #2 was asked, what knowledge did she have of 8/8/21 when the CNA assigned to RI #1's care was unaware that she was assigned to RI #1's care until around lunch that day. EI #2 replied that she was not aware. EI #2 was asked, when should a resident not receive incontinent care from the 7:00 AM to 3:00 PM shift CNA until around lunch and be found to have bowel movement and urine saturated through the brief to the draw sheet. EI #2 replied, never. EI #2 was asked, what was the concern with a resident not receiving incontinent care after 7:00 am until around lunch and be found to have bowel movement and urine saturated through brief to draw sheet. EI #2 replied, potential for skin breakdown.

Based on observation, interview, record review and review of facility policies titled, Medication, Oral/Sublingual Administration, Medication Administration Procedures Controlled Medication Administration, ADL Care, Documentation of Routine, and Meal, serving a (Tray), the failed to ensure: 1.) Nurses documented medication administration on the Electronic Administration Record (EMAR) for Resident Identifiers (RI) #6. This affected one of four resident EMARs reviewed for documentation. 2.) EI #5 signed out [MEDICATION(S)], a controlled medication, after she removed it from the medication card to administer to Resident Identifier (RI) #8. This affected one of two residents observed during medication administration. 3.) Meal intake was documented consistently per policy for RI #1, RI #2, RI #3, and RI #6. This affected four of four residents who were reviewed for meal intake. These deficient practices affected five of eight residents whose records were reviewed. Findings include: 1.) A review of policy titled Medication, Oral/Sublingual Administration with an effective date of 5/2014 revealed, PURPOSE: To administer oral medication in an organized and safe manner. 4. Administer medication . 7. Document on MAR (Medication Administration Record). RI #6 was admitted to the facility on [DATE] and readmitted on [DATE]. RI #6's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] [MEDICATION(S)] two times a day, [MEDICATION(S)] twice a day, [MEDICATION(S)] daily, Vitamin D3 daily, and [MEDICATION(S)] daily. A review of RI #6's EMAR (Administration Record) for the month of October 2021 revealed these five medications were not signed as administered for the morning dose on 10/13/21 at 9:00 AM. On 10/14/21 at 5:20 PM EI #4 RN was asked if she worked on the medication cart on hall one on 10/13/21 from 7:00 AM to 3:00 PM. EI #4 replied, yes. EI #4 was asked, if she gave medications to RI #6. EI #4 replied, yes. EI #4 was asked, why the 9:00 AM medications were not signed off for 10/13/21. EI #4 replied, probably because the EMAR was backed up. EI #4 was asked, what could happen if medications were given but not signed on EMAR as administered. EI #4 replied, anyone would have thought the medications were not administered. On 10/14/21 at 11:45 AM the medication cart on hall one was checked with EI #9, LPN and there was no medication left on the cart for RI #6 for 10/13/21. On 10/15/21 at 10:00 AM an interview was conducted with EI #2, Registered Nurse, Clinical Services Administrator, Director of Nursing. EI #2 was asked, what was the risk to the residents when medications were not documented as given. EI #2 replied, you would not know if it was administered or not and it could cause medical issues. EI #2 was asked, to review the EMAR and confirm RI #6 had five medications on 10/13/21 at 9:00 AM that were not signed as administered. EI #2 replied, yes. EI #2 was asked, when should a nurse document that medications were administered. EI #2 replied, immediately after administering the medication. EI #2 was asked why were nurses not documenting medications administered. EI #2 replied, moving too fast and not checking. 2.) A review of policy titled, Medication Administration Procedures Controlled Medication Administration dated 3/11 revealed, . Policy Medications included in the Drug Enforcement Administration (DEA) classification as controlled substances are subject to special handling, . recordkeeping in the facility in accordance with federal and state laws and regulations. Procedures . 3. When a controlled medication is to be administered, the licensed nurse removing the medication immediately enters the following information on the controlled drug record . A. Date and time of removal. B. Amount removed. C. Signature. RI #8 was readmitted to the facility on [DATE]. RI #8's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On 10/14/21 at 8:15 AM, an observation of medication administration was conducted with EI #5, Licensed Practical Nurse (LPN). During the observation EI #5 unlocked the medication cart, unlocked and opened the top left drawer, pulled out a card of medications, placed a pill in the medication cup, put the card back in the drawer, closed the drawer, and continued preparing medication for RI #8. EI #5 entered RI #8's room to administer the medications. During an immediate interview back at the medication cart, EI #5 was asked what was in the small, locked drawer. EI #5 replied, controlled drugs. EI #5 was asked what medication she gave to RI #8. EI #5 replied, [MEDICATION(S)] (a controlled medication). EI #5 was asked what a nurse should do when giving a controlled drug. EI #5 pointed to computer screen showing EMAR and stated, I just signed it out. EI #5 was asked where else should the [MEDICATION(S)] be signed out. EI #5 picked up a red notebook, opened it and signed out [MEDICATION(S)] for RI #8. In 10/14/21 at 8:45 AM, a second interview was conducted with EI #5. EI #5 was asked how medications should be given. EI #5 replied, sign out narcotics when you get it out of the cart. 3.) A review of facility policy titled ADL Care, Documentation of Routine with an effective date of 3/2020 revealed .PROCESS: The following are documented: A. Nutritional intake (meal intake, fluids with meals, and supplements with meals) . should be monitored and recorded daily on each shift within 2 hours of occurrence. A review of facility policy titled Meal, Serving a (Tray) with an effective date of 4/2018 revealed . PURPOSE: To assure meals are served in a manner to meet the nutritional needs of residents . PROCESS: . 8. Record the percentage of food consumed . If a supplement is ordered with meal, record separately from the fluids consumed with the meal and record number of fluids in CC's (Cubic Centimeters or Milliliter). RI #6 was admitted to the facility on [DATE] and readmitted on [DATE]. A review of RI # 6's meal intake record titled Meal Intake revealed no meal intake was documented 9/1/21 through 9/13/21, 9/15/21 through 9/22/21, 9/29/21 through 9/30/21, and 10/11/21 thru 10/13/21. On 10/13/21 at 6:02 PM an interview was conducted with EI #11, CNA after observing her pick up RI #6's meal tray. EI #11 was asked, did she document meal intake for residents after meals. EI #11 replied, no one had told her to. RI #1 was admitted to the facility on [DATE] and readmitted on [DATE]. RI #1 was discharged from the facility on 9/13/2021. A review of RI #1's meal intake record titled Percentage of meals consumed 7/1/2021 thru 9/13/2021, when RI #1 was discharged , revealed meal intake was recorded only on 7/5/21. On 10/14/21 at 8:15 AM an interview was conducted with EI #12, CNA regarding RI #1. EI #12 was asked, did she document RI #1's meal intake. EI #12 replied, that it depended on time and staffing whether meal intake documentation was completed, and she did not recall whether she documented RI #1's meal intake. On 10/14/21 at 9:50 AM an interview was conducted with EI #13, CNA regarding RI #1. EI #13 was asked, did CNAs document meal intake. EI #13 replied, yes, it was on the computer smart charting. EI #13 was asked, did the meal intake documentation always get completed. EI #13 said, no, not when they worked short. On 10/14/21 at 12:45 PM an interview was conducted with EI #14, CNA regarding RI #1. EI #14 was asked, did she document RI #1's meal intake. EI #14 replied, probably not. EI #14 was asked, why not. EI #14 replied, when staffing was short a nurse or two on that unit, the charting did not always get completed. RI #2 was admitted to the facility on [DATE]. A review of RI #2's meal intake record titled Meal Intake revealed no meal intake was documented 9/1/21 through 9/22/21, 9/25/21 through 9/27/21, and 10/6/21 through 10/13/21. RI #3 was readmitted to the facility on [DATE]. A review of RI #3's meal intake record titled Meal Intake revealed no meal intake was documented 9/1/21 thru 9/4/21, 9/6/21 thru 9/13/21, 9/15/21 through 9/22/21, on 9/29/21, 10/2/21 through 10/13/21. On 10/14/21 at 5:50 PM an interview was conducted with EI #2, RN, DON. EI #2 was asked, what was the facility's policy for documentation of resident's meal intake. EI #2 replied, meal intake should be documented after each meal. EI #2 was asked, what dates was the meal intake documentation was provided to the surveyor for RI #1, RI #2, RI #3, and RI #6. EI #2 replied, September and October (2021). EI #2 was asked, were RI #1, RI #2, RI #3, or RI #6's meal intake documented per policy for September or October. EI #2 replied, no. EI #2 was asked, why not. EI #2 replied, the CNAs failed to document. EI #2 was asked, what was the potential harm to residents when meal intake documentation was not completed consistently. EI #2 replied, it would be difficult to determine how much the resident ate.

Based on observation, interview, resident record review, review of a facility policy titled Medication, Self-Administration of Drugs, the facility failed to ensure Employee Identifier (EI) #5, a Licensed Practical Nurse (LPN), did not leave Resident Identifier (RI) #8's medications on an overbed table for the resident to self-administer the medications without determination if the practice of self-administration was safe for RI #8. This deficient practice affected one of two residents observed during medication administration. Findings include: A review of a facility policy titled, Medication, Self-Administration of Drugs with an effective date of 3/2020 revealed, PURPOSE: To ensure the resident has the right to self administer medications, when the interdisciplinary team has determined this practice is safe. Process: 1. Residents will not be permitted to self-administer medications, unless ordered by the attending physician, approved by the care planning team, and recorded on the care plan. RI #8 was admitted to the facility on [DATE] and readmitted on [DATE]. Review of RI #8's medical record revealed RI #8 was not ordered by the attending physician or care planned to self administer medications. On 10/14/21 at 8:15 AM, an observation of medication administration was conducted with EI #5. After placing medications in a medication cup EI #5 entered RI #8's room. EI #5 placed the medications and cup of water on the overbed table in front of RI #8, turned her back to RI #8 and walked out of the room. The surveyor observed RI #8 pick up the cup of medications, place them into his/her mouth, pick up the cup of water and swallow the medications. 10/14/21 at 8:45 AM, an interview was conducted with EI #5. EI #5 was asked what a nurse should do when administering medications. EI #5 replied, watch, and wait for the resident to take the medications. EI #5 was asked if she did that with RI #8. EI #5 replied, no. EI #5 was asked why not. EI #5 replied, because RI #8 liked his/her medications, and she knew he/she would take them. On 10/15/21 at 10:00 AM an interview was conducted with EI #2, Registered Nurse, Director of Nursing. EI #2 was asked, when a nurse took medications into a resident's room and left the medications on the bedside table and then left the room without watching the resident take the medications, was that self-administration of medications. EI #2 replied, yes. EI #2 was asked, what was the policy for self-administration of medications. EI #2 replied, it should be approved by the physician and the resident should be educated about the medications. EI #2 was asked, if RI #8 was approved for self-administration of medications. EI #2 replied, the facility did not have a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . EI #2 was asked, should the nurse leave medications for RI #8 to take unsupervised. EI #2 replied, no. EI #2 was asked, what was the potential harm to RI #8 when medications were left on the bedside table and then the nurse exited the room. EI #2 replied, RI #8 could have not taken the medications.

Based on observation, interviews, and resident record review the facility failed to ensure Resident Identifier (RI) #6's care planned intervention to have water at the bedside was implemented on 10/13/21 and 10/14/21, two of four days of the survey. This affected one of eight residents whose care plans were reviewed. Findings include: RI #6 was admitted to the facility on [DATE] and readmitted on [DATE] and had diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of RI #6's Care Plan revealed .Problem Onset: 05/31/2018 . (RI #6's name) has the potential for alteration in weight/nutrition/hydration . Approaches . Provide pitcher of water or cooler of thickened liquids at bedside and encourage and assist to obtain at each care round and med (medication) pass . On 10/13/21 at 12:17 PM an observation was made of RI #6's meal service. There were not any other liquids observed at the bedside other than liquids on the meal tray. There were not any fluids at the bedside after the meal tray was removed. The only liquids observed were on the meal tray. On 10/13/21 at 4:40 PM RI #6 was observed with no liquids at the bedside. On 10/13/21 at 5:24 PM a second meal observation was made for RI #6 and there were no liquids observed at the bedside. On 10/13/21 at 6:00 PM, Employee Identifier (EI) #11, Certified Nursing Assistant (CNA) was observed removing RI #6's meal tray and no liquids remained at the bedside. On 10/14/21 at 9:00 AM an observation was made of EI #12, CNA as she picked up RI #6's meal tray. There were no liquids observed at the bedside. An immediate interview was conducted with EI #12. EI #12 was asked, if RI #6 had a pitcher of water or thickened liquid in his/her room. EI #12 replied, no. EI #12 was asked if RI #6 should have had a pitcher of water or thickened liquids at the bedside. EI #12 replied, she did not know because she was not familiar with RI #6. EI #12 was asked, if it was on RI #6's care card to provide water or thickened liquid at bedside and offer during rounds. EI #12 replied, no. On 10/14/21 at 5:30 PM an interview was conducted with EI #4, Care Plan Manager. EI #4 was asked, what was the intervention related to hydration in RI #6's Potential for alteration in Weight/Nutrition/Hydration Care Plan. EI #4 replied, to provide pitcher of water or cooler or thickened liquid at bedside and assist to obtain at each care round and medication pass. EI #4 was asked, when should RI #6 have a water pitcher at the bedside. EI #4 replied, it should be there at all times. EI #4 was asked, what was the potential for harm when the water pitcher was not at the bedside at all times. EI #4 replied, the water pitcher was there to encourage staff to offer fluids to prevent dehydration, so RI #6 could potentially not be hydrated if it was not at the bedside.

Based on observations, interviews, record review, and review of facility policy titled Guidelines Wound Management the facility failed to ensure: 1) RI #2 a resident at risk of developing pressure injury was repositioned on 10/13/21 from 7:42 AM and 2:00 PM 2) RI #1 a resident at risk of developing pressure injury was repositioned on 8/8/21 during 7:00 AM to 3:00 PM shift before around lunch time; when RI #1 was provided care he/she was found to have a wet brief, bowel movement in brief, and wet draw sheet. This deficient practice affected two of four residents sampled for receiving timely incontinent care. Findings include: A facility policy titled Guidelines Wound Management with an effective date on 11/2019 documented .CARE PLAN . Interventions for prevention . PREVENTION . Preventative measures in place . 1.) RI #2 was admitted to the facility on [DATE] and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . RI #2's Minimum Data Set (MDS) with assessment reference date (ARD) of 7/15/21 documented RI #2 had a Brief Interview for Mental Status (BIMS) score of seven which indicated RI #2 had severe cognitive impairment; and RI #2 had limited range of motion in the upper and lower extremity on one side, required extensive assistance for transfer, was always incontinent of bowel and bladder, and was at risk for pressure ulcer development. A review of RI #2's Care Plan for Potential for skin breakdown . RELATED WEAKNESS/DECREASED MOBILITY S/P (status post [MEDICAL RECORD OR PHYSICIAN ORDER] . On 10/13/21 at 7:42 AM RI #2 was observed dressed and transferred by a CNA into a broda chair with a gel cushion in the chair and was continuously observed until 2:00 pm. RI #2 was not provided incontinent care, did not reposition self, and was not provided assistance to reposition at any time between 7:42 AM and 2:00 PM. On 10/13/21 at 2:00 PM EI #6, CNA went into RI #2's room and she was asked about care provided to RI #2. EI #6 stated, she did not check RI #2 every two hours that day because there were only three CNAs that day and she had done most her work that day, but had not been able to go back and check and change every two hours. EI #2 was observed as she transferred RI #2 to the bed. On 10/15/21 at 10:00 AM a follow-up interview was conducted with EI #2. EI #2 was asked, on 9/13/21, when it was observed that RI #2 was provided AM care at 7:42 AM and he/she sat in his/her chair without being checked or changed or repositioned until 2:00 PM at which time the CNA placed him/her in bed, what was the risk to the resident in this case. EI #2 replied, skin breakdown and pressure injury. EI #2 was asked, was RI #2 at risk of developing pressure injury. EI #2 replied, yes. 2.) RI #1 was admitted to the facility on [DATE] and readmitted on [DATE] and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . RI #1 was discharged from the facility on 9/13/21. A review of RI #1's Care Plan for Potential for skin breakdown related to incontinence, weakness and decreased mobility with a problem onset date of 7/1/19 revealed an approach to Assist/encourage to turn and reposition every 2 hours and prn (as needed) . RI #1's quarterly Minimum Data Set (MDS) with an assessment reference date (ARD) of 6/21/2021, documented RI #1 had severly impaired cognition, was always incontinent of bowel and bladder, required extensive assistance with bed mobility, and was at risk of developing pressure ulcers. On 10/13/21 at 8:40 AM an interview was conducted with RI #1's sponsor. RI #1's sponsor reported that on 8/8/21 he/she went to the facility around 12:00 to 12:30 PM to fed RI #1 lunch. RI #1's food tray was in front him/her and he/she fed RI #1. After RI #1 finished lunch, the sponsor went to nurses' desk and while returning to RI #1's room, EI #13, CNA reported that she did not know RI #1 was assigned to her. RI #1's sponsor reported he/she assisted EI #13 and the padding under RI #1 was black and it was obvious RI #1 had not been cleaned and it was near 1:00 PM. On 10/14/21 at 9:50 AM EI #13 was asked, what happened on 8/8/21. EI #13 reported she thought RI #1's sponsor asked someone why RI #1 was not up and out of bed that day. EI #13 stated, RI #1 was found still in the bed, wearing a brief wet with urine, the draw sheet under RI #1 was wet with urine, and RI #1 had a bowel movement in the brief also. EI #13 was asked, when was RI #1's brief changed before she was told RI #1 was assigned to her. EI #13 replied, it was not changed. EI #13 was asked, should it have been changed before she changed it around lunch. EI #1 replied, yes. EI #1 was asked, what would the potential harm be for a resident's brief not being changed until around lunch. EI #13 replied, the resident could have skin breakdown. On 10/14/21 at 5:50 PM an interview was conducted with EI #2, Registered Nurse, Clinical Services Administrator, Director of Nursing (DON). EI #2 was asked, what knowledge did she have of 8/8/21 when the CNA assigned to RI #1's care was unaware that she was assigned to RI #1's care until around lunch that day. EI #2 replied that she was not until that time when surveyor informed her. EI #2 was asked, when should a resident not receive incontinent care from the 7:00 AM to 3:00 PM shift CNA until around lunch and be found with a bowel movement and urine saturated through the brief to the draw sheet. EI #2 replied, never. EI #2 was asked, what was the concern with a resident not receiving incontinent care after 7:00 am and until around lunch and be found to have bowel movement and urine saturated through the brief to the draw sheet. EI #2 replied, potential for skin breakdown.

Based on observation, interview, resident record review, and review of the ALABAMA BOARD OF NURSING ADMINISTRATIVE CODE, the facility failed to ensure Employee Identifier (EI) #5, a Licensed Practical Nurse (LPN), did not prepare and administer medications to Resident Identifier (RI) #8 on 10/14/21 without practicing safety precautions. EI #5 did not verify the medications with the Electronic Medication Administration Record (EMAR) during preparation of the medications before administration of the medications to RI #8. EI #5 did not stay with RI #8 to ensure RI #8 consumed the medications. This deficient practice affected one of two residents observed during medication administration. Findings include: The Standards of Nursing Practice titled ALABAMA BOARD OF NURSING ADMINISTRATIVE CODE dated 3/31/21 documented . Medication Administration And Safety. (1) The registered nurse or licensed practical nurse shall have applied knowledge of medication administration and safety, including but not limited to: . (j) Safety precautions, including but not limited to: 1. Right patient. 2. Right medication. 3. Right time. 4. Right dose. 5. Right route. 6. Right reason. 7. Right documentation. RI #8 was readmitted to the facility on [DATE]. On 10/14/21 at 8:15 AM, an observation of medication administration was conducted with EI #5 LPN. The surveyor approached EI #5 who was standing at the medication cart. The surveyor explained to EI #5 the surveyor needed to observe a few medications being administered. EI #5 stated okay. EI #5 unlocked the medication cart, unlocked, and opened the top left drawer, pulled out a card of medication, placed a pill in a medication cup, put the card of medication back into the drawer, and closed the drawer. EI #5 made no effort to show the surveyor what medication she was giving. EI #5 opened a large drawer on the medication cart and got out three packets of prepackaged medications, opened the packets and placed pills into the medication cup with the other pill she got from the card in the locked drawer. Again, EI #5 made no effort to show the medications to the surveyor or tell the surveyor what she was giving to which resident. EI #5 was asked who the medications were for. EI #5 replied, RI #8. EI #5 did not sign onto the computer or pull up the Electronic Medication Administration Record (EMAR) prior to getting the medications out of the cart and did not verify the medications with the EMAR. EI #5 entered RI #8's room. RI #8 was sitting on the side of the bed with an overbed table in front of him/her. EI #5 placed the medications and cup of water on the overbed table in front of RI #8, turned her back to RI #8 and walked out of room. The surveyor observed RI #8 pick up the cup of medications and put them into his/her mouth, pick up the cup of water and swallow the medications. An immediate interview was conducted with EI #5 when the surveyor returned to the medication cart with EI #5. EI #5 was asked how she knew what medications to give if she did not look at the EMAR. EI #5 replied, I have them memorized. EI #5 was asked, what was the problem with not verifying the medications she was giving with the EMAR. EI #5 replied, she was there every day and knew if a resident had any order changes. EI #5 was asked what the potential harm to RI #8 was when the nurse was not looking at the EMAR. EI #5 replied, I am going by the MAR. EI #5 was asked, how could she be going by the EMAR when she had not signed onto the computer and pulled up the EMAR and looked at it. EI #5 proceeded to sign onto the computer and pull up the EMAR, pointed at it and stated, This is (RI #8's name) and he/she just got all these and proceeded to document medications as administered. EI #5 was asked why she did not verify the medications given to RI #8 with the EMAR before she gave them. EI #5 replied, if it had been someone she did not know she would have verified the medications with the EMAR. EI #5 said she knew it was not the right way to do it. EI #5 was asked why she did it that way if she knew it was not right. EI #5 replied, she did not know. On 10/14/21 at 8:45 AM, a second interview was conducted with EI #5 LPN and she was asked how medications should be given. EI #5 replied, verify the medications with the EMAR as they are being pulled. EI #5 was asked what were the five rights of medication administration. EI #5 replied, the right person, right med, right route, and right dose. EI #5 was asked how a nurse ensured she has followed the five rights of medication administration. EI #5 replied, by looking at the EMAR. EI #5 was asked when she looked at the EMAR when giving medications to RI #8. EI #5 replied, that she did not, not right then. EI #5 was asked why not. EI #5 replied, she knew what medications RI #8 got. EI #5 was asked what the potential negative outcome was for a resident when the nurse did not verify medications with the EMAR. EI #5 replied, the wrong medications could be given. EI #5 was asked what else a nurse should do when administering medications. EI #5 said, stand watch and wait for the resident to take the medication. When asked if she did that with RI #8, EI #5 said, no. When asked why not, EI #5 replied, because RI #8 liked to take medication and she knew RI #8 would take them. On 10/15/21 at 1:00 PM, an interview was conducted with EI #2, the Director of Nursing (DON) and EI #3, Director of Clinical Quality. EI #2 was asked what the nursing standard of practice for medication administration was. EI #2 replied, a prudent, fundamental nurse would follow the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . EI #2 was asked what the five rights of medication administration were. EI #2 replied, right resident, right time, right dose, right medication, right route. EI #3 was asked if the nurse practice act was used to develop the facility medication administration policy. EI #3 replied, yes. EI #3 was asked who developed the medication administration policy. EI #3 replied, the policy was developed by a corporate team of [NAME] Health Services (NHS). The team consisted of members from various disciplines including pharmacy and was reviewed annually and updated as needed. EI #2 was asked if EI #5 followed the nursing standard of practice for medication administration. EI #2 replied, no. EI #2 was asked what action the facility took. EI #2 replied, EI #5 was terminated and reported to the Board of Nursing.

Based on observation, interview, review of the facility's policies titled Food Preparation Principles and Menus, Cycle and Meal Schedule, and review of the facility's Diet Spreadsheet, the facility failed to ensure: 1.) the portion size for fruit juice as documented on the Diet Spreadsheet for Day 4 - Wednesday, dated 5/19/2021, was served to residents at breakfast; 2.) the portion size for Scalloped Potatoes and for Pureed Scalloped Potatoes as documented on the Diet Spreadsheet for Day 4 - Wednesday, dated 5/19/2021, was served to residents at lunch; and 3.) portion sizes were identified for Mixed Vegetables on the Diet Spreadsheet for Day 4 - Wednesday, dated 5/19/2021, for the lunch meal. This had the potential to affect 85 of 85 residents receiving meals from the kitchen. Findings include: During an interview with Resident Identifier (RI) #23 on 5/18/2021 at 11:42 AM, RI #23 reported the facility was serving smaller portion sizes for meals. During an interview with RI #31 on 5/18/2021 at 4:40 PM, RI #31 reported portion sizes for meals had decreased. A review of the facility's policy titled Food Preparation Principles, effective 6/2018, revealed the following: . PURPOSE: To assure that the nutritive value of food is not compromised. STANDARD: . Food should be prepared . in sufficient quantity; . PROCESS: 1. The cook, or designee, should prepare menu items following the written menus and recipes. A review of the facility's policy titled Menus, Cycle and Meal Schedule, effective 11/2019, revealed the following: . PURPOSE: To meet the nutritional needs of residents, in accordance with the dietary reference intakes of the Food and Nutrition Board of the National Research Council, standardized menus are utilized. PROCESS: . 8. Menu changes should be indicated on the menu, prior to meal service and be of equal nutritive value. 9. The reason for a menu deviation should be noted on the menu. During an observation of breakfast service on 5/19/2021 at 8:01 AM, pre-portioned commercially packaged 4-ounce (1/2 cup) juice cups were seen placed on resident trays. Upon reviewing the facility's Diet Spreadsheet for Day 4 - Wednesday, dated 5/19/2021, a 3/4 cup (6-ounce) serving of juice was documented to be served to residents receiving Regular Diets, Dental Soft (Mechanical Soft) Diets, Pureed Diets, and Finger Food Diets. On 5/19/2021 at 8:40 AM, the surveyor verified the juice containers were 4-ounce servings by the information on the labels. Also at this time, Employee Identifier (EI) #1, the Registered Dietitian (RD) and Director of Food & Nutrition Services, also verified they were 4-ounce juice servings. On 5/19/2021 at 8:50 AM, the surveyor looked throughout the kitchen for any posting of scoop/dipper sizes and equivalents, but did not see anything posted with that information. During an observation of lunch service on 5/19/2021 at 11:10 AM, EI #3, the AM Cook, used a #12 scoop/dipper (3 ounces) for the Scalloped Potatoes and a #10 scoop/dipper (3 3/4 ounces) for the Pureed Scalloped Potatoes. Upon reviewing the facility's Diet Spreadsheet for Day 4 - Wednesday, dated 5/19/2021, a 4-ounce spoodle was documented to be used for the Regular Diets and the Dental Soft (Mechanical Soft) Diets. A #8 scoop/dipper (4 ounces) was documented to be used for the Pureed Diets. Also, during the observation of lunch service on 5/19/2021 at 11:10 AM, EI #3, the AM Cook, was observed using a 3-ounce slotted spoodle to serve a mixture of vegetables (Broccoli/Squash/Green Beans/Red Bell Pepper), which she identified as Mixed Vegetables, from the trayline for the residents. EI #3 also used a #10 scoop to serve a pureed item that she identified as Pureed Mixed Vegetables. The facility's Diet Spreadsheet for Day 4 - Wednesday, dated 5/19/2021, was reviewed, but it did not document anything about Mixed Vegetables for lunch. A review of the facility's Week I (May 16th - 22nd) Menu revealed Mixed Vegetables for the Wednesday, 5/19/2021, lunch meal, but it did not include any further information about the Mixed Vegetables. EI #3, the AM Cook, was interviewed on 5/19/2021 at 1:31 PM. When asked how she knew what to prepare for meals, EI #3 said there was a menu posted on the wall. EI #3 was shown the Diet Spreadsheet for Day 4 - Wednesday with the Regular Diet, Dental Soft (Mechanical Soft) Diet, Pureed Diet, and Finger Food Diet menus and asked if this was what was posted for today. EI #3 said yes. When asked how she knew what scoops/dippers or spoodles or ladles to use to portion the food items, EI #3 said it was listed on the Diet Spreadsheet. EI #3 was reminded that a #12 scoop was used for Scalloped Potatoes at lunch, but the Diet Spreadsheet indicated a 4-ounce spoodle. When asked if she knew the scoop/dipper equivalent for a 4-ounce spoodle, EI #3 said, No. When asked if there was anything posted in the Kitchen to document what an equivalent scoop/dipper would be, EI #3 said, Not that I know of. EI #3 was reminded that a #10 scoop/dipper was used for the Pureed Scalloped Potatoes at lunch, but the Diet Spreadsheet indicated a #8 scoop/dipper. EI #3 said she used the #10 scoop/dipper because that is what she had. When asked if she had spoken to EI #2, the Dietary Manager, or EI #1, the RD, about it, EI #3 said no. EI #1, the RD and Director of Food & Nutrition Services, was interviewed on 5/20/2021 at 8:53 AM. EI #1 was asked why the juice portion served at breakfast on 5/19/2021 was less than the amount listed on the Diet Spreadsheet; a 1/2 cup (4-ounce) serving was used instead of a 3/4 cup (6-ounce) serving. EI #1 said they normally use four ounces, but agreed that what was served did not match what what was listed on the menu. EI #1 was asked if there was a scoop/dipper portion size chart or a scoop/dipper and spoodle conversion chart readily available in the Kitchen for staff to refer to for guidance. EI #1 said we don't have it posted, but portion sizes are posted on the spreadsheet and the spreadsheet is posted on the wall. EI #1 further said the proper food portion would correspond with the scoop/dipper or spoodle size that was listed on Diet Spreadsheet. EI #1 was asked why portion sizes were included for the menu items on the Diet Spreadsheet and if there was any importance in doing that regarding nutrition for the residents. EI #1 said portion sizes are included to make sure that the residents get the proper nutrients. Upon being asked what was the potential problem for residents if Kitchen staff did not adhere to the menu portion sizes, EI #1 said they won't eat enough, which would lead to potential weight loss and skin break down. When asked why a #10 scoop/dipper (3 3/4 ounces) was used for Pureed Scalloped Potatoes instead of a #8 scoop (4 ounces) as indicated on the Dietary Spreadsheet for lunch on 5/19/2021, EI #1 said it should be around 4 ounces and that it was a cook error. EI #1 was asked why a #12 scoop (3 ounces) was used for Scalloped Potatoes for lunch on 5/19/2021 instead of a 4-ounce spoodle, as indicated on the Dietary Spreadsheet, or else an equivalent #8 scoop (4 ounces). EI #1 said it was a cook error. EI #1 was asked why there was no information about Mixed Vegetables included on the Diet Spreadsheet for lunch on 5/19/2021. EI #1 said, more than likely, EI #2, the Dietary Manager, made an error when the Diet Spreadsheet was created. EI #1 further said the Diet Spreadsheet comes from the menu and mixed vegetables got omitted when the spreadsheet was created. EI #1 was asked what was the potential problem in not including the Mixed Vegetable information on the Diet Spreadsheet. EI #1 said the cooks look at the menu and use the Diet Spreadsheet for portions. EI #1 further said vegetables should be a 4 ounce portion size. EI #4, the Regional RD/Director of Nutritional Services, was interviewed on 5/20/2021 at 9:58 AM. When asked why are portion sizes included for the menu items on the Diet Spreadsheet, EI #4 said portion sizes are included on the spreadsheet to direct the server as to the correct portion to serve. When asked if portion size had any importance regarding nutrition for the residents, EI #4 said to insure that they meet the daily food recommendation for the day. EI #4 was asked what was the potential problem for residents if Kitchen staff did not adhere to the menu portion sizes. EI #4 said potentially they may not receive an adequate diet. This deficient practice was cited as a result of the investigation of complaint/report #s AL 351, AL 352, AL 353 and AL 354.

Based on observation, interviews, and review of a facility policy titled Food Preparation Principles, the facility failed to ensure residents received hot foods at palatable temperatures. This had the potential to affect 85 of 85 residents receiving meals in the facility. Findings include: Review of a facility policy titled Food Preparation Principles, effective 6/2018, revealed the following: . STANDARD: . Food . should be served . at proper temperatures. On 5/18/2021 at 5:52 PM, the surveyor observed Resident Identifier (RI) #6's supper meal. RI #6 received a bowl of chicken noodle soup with the meal. As RI #6 began to eat the soup, he/she reported to the surveyor the soup was cold. RI #6 said, Please stick your finger in it. I am not going to eat it. You can see I am telling the truth. The surveyor told RI #6 she would not put her finger in the soup, however, RI #6 could spoon some of the soup into the surveyor's hand. RI #6 did so and the surveyor observed the soup to be cool to touch. On 5/19/2021 at 8:48 AM, the surveyor observed RI #24's breakfast meal. RI #24 received a breakfast tray sixteen minutes after the cart arrived on the hall. RI #24 received two pancakes and coffee. RI #24 said the coffee was warm, but the pancakes were cold. RI #24 said he/she was not going to eat them. The surveyor asked, how could RI #24 tell it was cold. RI #24 replied he/she had touched it. RI #24 tried to hand the surveyor a pancake. The surveyor said to break a piece off and put it in her hand. RI #24 broke a piece off a pancake and placed it in the surveyor's hand. The surveyor observed the piece of pancake was cold to touch. A Group Meeting was conducted on 5/19/2021 at 10:00 AM, with a total of seven residents in attendance. During the meeting, six of seven residents complained of hot foods being served cold. An observation of lunch meal service was made on Wednesday, 5/19/2021. At 12:34 PM, a test tray requested by the surveyor was prepared. The test tray was the last tray placed on the last tray cart, that left the kitchen at 12:36 PM. The cart arrived on the hall at 12:38 PM. At 12:44 PM, three staff people began serving trays on the hall. There were 21 resident trays on the cart, plus the one test tray. At 12:46 PM, a 4th staff person began serving trays. At 1:10 PM, the last resident tray was served, 32 minutes after the cart arrived on the hall. At 1:12 PM on 5/19/2021, the test tray was sampled with Employee Identifier (EI) #1, the Registered Dietitian (RD) and Director of Food & Nutrition Services. At the time of the test tray, the Scalloped Potatoes measured 118 degrees Fahrenheit (F); they were not hot. The mixed vegetables were 114 degrees F and were also not hot. The chicken noodle soup measured 126 degrees, and was also not hot/palatable. The coffee was described as lukewarm, and was not at a palatable temperature. On 5/19/2021 at 1:23 PM, EI #1 said, All we can do is make sure the food is hot coming out of the kitchen. I cannot control how quickly the trays get passed out. On 5/19/2021 at 3:56 PM, an interview was conducted with EI #6, a Certified Nursing Assistant (CNA). EI #6 was asked why would food be cold when delivered to residents. EI #6 replied trays not being passed in a timely manner. EI #6 was asked how often was hot food served cold. EI #6 replied it could be often as it takes a while to get all the trays out. On 5/19/2021 at 4:44 PM, an interview was conducted with EI #7, another CNA. EI #7 was asked when should residents' food that should be hot be received cold. EI #7 replied, it should not. EI #7 was asked what was the harm in residents' food being delivered cold. EI #7 replied it would not taste good and may not be pleasant to eat. On 5/20/2021 at 8:12 AM, an interview was conducted with EI #5, the Director of Nursing. EI #5 was asked when should residents get cold food. EI #5 replied never. EI #5 was asked why would food be cold when arriving to a resident room, if it was adequate temperature when leaving the kitchen. EI #5 replied the staff on the hall not getting the tray to the resident timely. EI #5 was asked what should be done if a resident complains of cold food. EI #5 replied the staff should warm it or get something else. EI #5 was asked what would the harm be of cold food. EI #5 replied the resident would not want to eat it, bad taste, not good texture, and it could cause other issues. EI #1, the RD and Director of Food & Nutrition Services, was interviewed on 5/20/2021 at 8:53 AM. EI #1 stated she was aware residents had complained of hot foods being served cold. EI #1 was asked what had been done to ensure food and beverages were served hot, as appropriate. EI #1 said when food leaves the kitchen, it is at the correct temperature. Upon being asked if she had discussed the cold food problem with nursing, EI #1 said yes. EI #1 further stated nursing told her they would take care of it. When asked what was the potential problem in serving residents cold food and beverages that should be served hot, EI #1 said they may not eat it and this could lead to weight loss and skin break down. EI #4, the Regional RD/Director of Nutritional Services, was interviewed on 5/20/2021 at 9:58 AM. EI #4 was asked what had been done to ensure food and beverages were served hot, as appropriate. EI #4 said food was served at the proper temperature from the kitchen at all meals. When asked what was the potential problem in serving residents cold food and beverages that should be served hot, EI #4 said the potential problem with serving hot food at a cold temperature was that it may not meet the resident's expectations and possibly result in them not consuming the food. On 5/20/21 at 11:32 AM, a follow-up interview was conducted with EI #5, the Director of Nursing. EI #5 was asked how long should it take for trays to be passed once they reach the hall. EI #5 replied they should be passed immediately upon reaching the hall. EI #5 was asked what would timely be if trays arrived to the unit at 12:38 PM and last tray removed from the cart was at 1:10 PM. EI #5 replied all trays for those that can feed themselves should be delivered within 10 to 15 minutes, and then pass trays to those requiring assistance with meals. This deficient practice was cited as a result of the investigation of complaint/report #AL 354.

Based on interviews, record review, review of controlled drug records, and review of Potter and Perry's FUNDAMENTALS OF NURSING, the facility failed to ensure Resident Identifier (RI) #2 received his/her [MEDICATION NAME] 50 MCG/HR (microgram/hour) [MEDICATION NAME] every 72 hours as ordered by the physician. RI #2 missed two consecutive patches on 11/21/2020 and 11/24/2020. This deficient practice affected RI #2, one of three residents sampled for patch administration. Findings include: On 11/30/2020 the State Agency received a complaint alleging RI #2's [MEDICATION NAME] had not been changed as ordered by the physician. A review of Potter and Perry's, FUNDAMENTALS OF NURSING, Ninth Edition, with a copyright date of 2017, Chapter 23, Legal Implications in Nursing Practice, page 311, revealed: . Health Care Providers' Orders. The health care provider (physician or advanced practice nurse) is responsible for directing medical treatment. Nurses follow health care providers' orders unless they believe that the orders are in error . RI #2, was admitted to the facility on [DATE], and readmitted on [DATE] with [DIAGNOSES REDACTED]. Review of RI #2's Physician order [REDACTED]. Review of RI #2's annual Minimum Data Set assessment, with an Assessment Reference Date of 11/10/2020 revealed RI #2 was cognitively intact. During an interview with RI #2 on 12/3/2020 at 10:30 a.m., RI #2 stated he/she had gone nine days without the patch being changed. A review of RI #2's November 2020 Controlled Drug Record for the [MEDICATION NAME] 50 MCG/HR patches revealed no patches had been signed out of inventory for administration from 11/18/2020 until 11/27/2020, for a period of nine days. There was no documentation indicating the patch had been removed from inventory for administration on 11/21/2020 or 11/24/2020 as ordered by the physician. On 12/03/2020 at 5:30 p.m., an unsuccessful attempt was made by the surveyor to call Employee Identifier (EI) #4, the Licensed Practical Nurse (LPN) assigned to care for RI #2 on 11/21/2020. On 12/03/2020 at 5:55 p.m., the surveyor conducted a telephone interview with EI #2, the LPN assigned to care for RI #2 on 11/24/2020. The surveyor asked EI #2, where there would be evidence RI #2's [MEDICATION NAME] had been applied on 11/24/2020. EI #2 said on the Medication Administration Record [REDACTED]. EI #2 said if the patch was not applied, the physician's orders [REDACTED]. This deficiency was written as a result of complaint/report #AL 632.

Based on interviews, medical record review, and review of a facility policy titled ADL (Activities of Daily Living) Care, Documentation of Routine (SNF) (Skilled Nursing Facility), the facility failed to provide Resident Identifier (RI) #1, a resident dependent on staff for ADL care, baths/showers as scheduled on 11/13/2020 and 11/16/2020. This deficient practice affected RI #1, one of three residents sampled for ADL care. Findings Include: On 11/23/2020 the State Agency received a complaint alleging RI #1 had not received a bath in eight days. RI #1 was admitted to the facility on [DATE], and readmitted on [DATE], with a [DIAGNOSES REDACTED]. A review of RI #1's Customary Routine and Activities care plan, with a Problem Onset date of 11/09/2017, revealed RI #1 preferred a shower in the morning. A review of a facility policy titled ADL (Activities of Daily Living) Care, Documentation of Routine (SNF) (Skilled Nursing Facility), with an Effective date of 03/2020, revealed the following: . PROCESS: The following are documented: . B. Care provided per policy and residents individualized plan of care are documented each shift . RI #1's Quarterly Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 10/28/2020, revealed RI #1 required extensive assistance with personal hygiene and bathing. During an interview with RI #1's responsible party on 12/3/2020 at 1:52 p.m., RI #1's responsible party said RI #1 reported to her on 11/18/2020 he/she had not had a bath in eight days. A review of the Bath list for the unit RI #1 resided on revealed RI #1 was scheduled to receive baths/showers on Mondays, Wednesdays and Fridays. Review of BATH SHEETS for RI #1 from 11/10/2020 through 11/18/2020, during the time RI #1 complained of not receiving a bath, revealed only one sheet for RI #1, dated 11/11/2020 (Wednesday). This sheet indicated RI #1 had been provided a shower. There was no documentation of showers, bed baths or refusals for RI #1 for 11/13/2020 (Friday) or 11/16/2020 (Monday), RI #1's other two scheduled bath days. On 12/03/2020 at 3:01 p.m., the surveyor conducted an interview with Employee Identifier (EI) #3, the Certified Nursing Assistant (CNA) caring for RI #1 on 11/13/2020 and 11/16/2020. EI #3 stated RI #1 required total care and was scheduled for baths/showers on Mondays, Wednesdays, and Fridays. When asked where there would be evidence RI #1 had been given a bath or shower on those days, EI #3 said on the bath sheets. EI #3 said, looking at RI #1's bath sheets, she did not see evidence RI #1 had been given a bath or shower on those days. On 12/03/2020 at 4:17 p.m., a telephone interview was conducted with EI #1, the Director of Nursing (DON). When asked where CNAs would document they had provided a bath or shower to a resident, EI #1 said on the bath sheets. This deficiency was written as a result of complaint/report #AL 404.

Based on observations, interviews with staff, and a review of the (YEAR) United States (US) Food and Drug Administration (FDA) Food Code, the facility failed to consistently maintain the temperature of the final rinse water of the dish machine within recommended levels. This had the potential to affect all 122 residents for whom meals were prepared and served at the time of the survey. Based on observation, the facility also failed to consistently date and label food items, stored in the nursing unit refrigerators, that were provided to residents during activity. This affected one of three nursing unit refrigerators. Findings included: 1) DISHWASHING The (YEAR) United States Food and Drug Administration Food Code mandates under 4-501.112 Mechanical Warewashing Equipment, Hot Water Sanitization Temperatures. (A) .in a mechanical operation, the temperature of the fresh hot water SANITIZING rinse as it enters the manifold may not be more than 194 degrees F . In reference to the above regulation, the Food Code Annex explains, .When the sanitizing rinse temperature exceeds 194 degrees F at the manifold, the water becomes volatile and begins to vaporize reducing its ability to convey sufficient heat to utensil surfaces. On 07/18/19 at 9:32 AM, the surveyor watched staff process seven racks of dishes and utensils through the dish machine. Of the seven cycles observed, three cycles were processed above the recommended rinse temperatures, at 195, 196, and 196 degrees Fahrenheit. The Corporate Dietitian, EI #5, stated he would contact Maintenance to reduce the booster heater by five degrees. On 07/18/19 at 9:55 AM, the surveyor watched as staff processed a rack of dome lids at a final rinse temperature of 194 degrees F. The surveyor asked the dish machine operator, EI #4, how hot the rinse water would get. EI #4 stated the final rinse temperatures got up to 200 degrees F. 2) NURSING STATION REFRIGERATORS FOR RESIDENTS' FOOD STORAGE According to the (YEAR) United States (US) Food and Drug Administration (FDA) Food Code, it documented, 3-501.17 Ready-to-Eat, . Date Marking. (F) . refrigerated, Ready-To-Eat, . prepared and held . more than 24 hours shall be clearly marked to indicate the date or day by which the FOOD shall be consumed on the premises. discarded . a) ARBOR NURSING STATION On 07/18/19 at 4:08 PM, the surveyor requested to see the refrigerator used by staff to store residents' food on the locked unit. EI #7 (CNA) took the surveyor to the refrigerator, which included the following: 1) A cool whip container with a light colored creamy item, which the EI #7 identified as icing made by the Activities Dept. for an activity. The container had no name or date; 2) One 7 lb 6 oz container of strawberry topping with no date, identified by EI #7 as used by Activities for sundaes the previous week; 3) One 10 oz container of candy sprinkles, which EI #7 identified as used by Activities for sundaes, with no date and 4) One bottle of caramel sauce, with no name, identified by EI #7 as belonging to Activities. On 07/18/19 at 4:25 PM, the CNA (EI #7) was asked how the food items should be labeled. EI #7 responded, with name and date. When asked what problem might result from the lack of a name or date, EI #7 stated they would not know how long it had been there and to whom it belonged. EI #7 stated the food should be held no more than two to three days.

Based on interviews and a review of the Resident Centered Care Plan Meeting facility policy, the facility failed to ensure Resident Identifier (RI) #90 was invited to participate in his/her care plan meeting. This affected one of 22 sampled, in-house residents. Findings Include: The facility policy titled, . Resident Centered Care Plan Meeting with an effective date of 1/2018 included the following: .2.Resident centered care plan letters, emails and calls to responsible parties by SSD (Social Services Director) or designee should be done at least 2 weeks in advance. .4. The SSD or designee should set the tone of the meeting with the resident's representative and/or resident and advise them of the purpose of the meeting . .8. All IDCP (Interdisciplinary Care Plan) team members in attendance as well as the resident's representative and/or resident should sign the attendance form. RI #90 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. The resident's Brief Interview for Mental Status score totaled 15 (of a possible 15) on the most recent Minimum Data Set assessment of 07/18/19, indicating his/her cognition was intact. On 07/16/19 at 12:30 PM, the surveyor asked RI #90 if he/she had an interest in attending his/her care plan meeting. RI #90 conveyed he/she was interested, and has resided in the facility since March, but had not yet been invited to attend his/her care plan meeting. On 07/18/19 at 1:50 PM, the surveyor asked the Licensed Social Worker, Employee Identifier (EI) #3, to provide documentation to show RI #90 had been invited to his/her care plan meeting. EI #3 said she had no documentation. EI #3 explained the residents have been told at Resident Council meetings they can go to their care plan meetings, or their family members may tell them, or she would tell them. When asked if RI #90 attended Resident Council meetings, EI #3 said, Sometimes. EI #3 explained RI #90's sponsor (a cousin) received the notification of care plan meetings for RI #90, but the sponsor neither visits, nor has she attended a care plan meeting.

Based on interviews and record review, the facility failed to ensure Resident Identifier (RI) #2's Gender and Ethnicity was coded accurately on RI #2's Admission Minimum Data Set (MDS) assessment dated [DATE]. This affected 1 of 26 sampled residents whose MDS' were reviewed. Findings Include: RI #2 was admitted to the facility on [DATE]. A review of RI #2's Admission MDS assessment, with an Assessment Reference Date (ARD) of 03/28/19, coded RI #2 as being a Female under A0800 Gender. RI #2 was also checked as being Black or African American under A1000C Ethnicity. On 07/18/19 at 3:07 p.m., the surveyor asked RI#2 what was his/her race. RI #2 said white. On 07/18/19 at 3:28 p.m., the surveyor conducted an interview with Employee Identifier (EI) #10, a LPN (licensed Practical Nurse)/MDS Coordinator. The surveyor asked EI #10 what was the race of RI #2. EI #10 said the MDS says African American. When asked what race RI #1 was, EI #10 said she believed RI #2 was white. The surveyor asked EI #10 what was the issue with RI #2 being coded incorrectly. EI #10 said the resident could not be identified as the correct resident if someone was looking for him/her. On 07/18/19 at 4:29 p.m., the surveyor conducted an interview with EI #14, the Director of Admissions. When asked was she familiar with RI #2, EI #14 said yes. EI #14 said she must have accidentally clicked African American, but RI #2 was Caucasian. EI #14 said the issue with incorrectly inputting information would be the resident could be incorrectly identified.

Based on interviews and record reviews, it was determined the facility failed to ensure RI (Resident Identifier) #13, a resident identified on admission as at risk for falls and on a blood thinner, was continuously monitored by staff after a fall on 7/10/2013 that resulted in a Hematoma to the left eye, bleeding and a skin tear to the left arm. The facility failed to perform neuro checks (alertness, change in mental status, worsening of condition) to determine the neurological status of the resident. RI #13 was transported to the local hospital emergency room and admitted and diagnosed with [REDACTED]. In addition, the facility failed to put new interventions in place immediately after a fall on 7/13/13 for RI #7 and on 5/04/13 for RI #14. This affected 3 of 9 residents sampled for falls. Findings include: 1) RI #13 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #13's hospital record revealed the resident had a fall prior to admission to the facility on [DATE]. The resident was admitted to the hospital where he had 35-40 cc (cubic centimeter) of bloody joint fluid removed from the right knee and a steroid joint injection performed. The record also revealed, "...3. Joint Effusion and Hemarthrosis ...The patient has been unable to stand or walk without significant amount of assistance during hospital course... Medical evaluation of the patient concludes that patient is at high risk for fall, and may be inappropriate at this time to discharge to home..." After hospitalization , RI #13 was admitted to the facility for rehabilitation on 7/10/13. A review of RI #13's Physician's Orders indicated, "7/10/13 1110 (11:10) PM Send resident out to (name of hospital) E-R for eval (evaluation)- S/P (status [REDACTED]. (Verbal Order) (name of physician)/ (name of RN-(Registered Nurse) EI (Employee Identifier) #27)" A review of RI #13's Physician's Order, dated 7/10/13, revealed the resident had an order for [REDACTED]. A review of the facility's "Resident Incident Report" for RI #13 revealed, "Incident Type: Falls Date/Time 7/10/13 10:20 PM Type of Injury: Skin tear-superf (superficial) Incident reported by: EI #26 (LPN-Licensed Practical Nurse) Report Prepared by: EI #27 (RN) Incident Level: Non-Witnessed Narrative of incident and description of injuries: Staff entered (RI #13's name) and found him sitting on the floor beside his bed. Hematoma noted over left eye and bleeding, skin tear to left arm. (RI #13's name) asked what happened "I was going home to see my wife." Hematoma over left eye, skin tear to left arm Immediate Actions Taken: (RI #13's name) assessed and skin tear cleaned and dressed and was sent to (name of hospital) ER" An area of the incident report titled, "Resident Condition at Time of Incident," revealed Bedrails: blank Bed height: blank Mobility: Medical risk factors possibly related to incident: Fall History (box checked) Mental: Confusion/Disorientation (box checked)..." A review of "SENIOR HOUSING OCCURRENCE REPORT" revealed, "(RI #13's name) Date of Event: 7-10-13 Time: 10:20 PM Shift 3-11 Person Initiating Form: (EI #27 name) PERSON INVOLVED IN OCCURRENCE Resident (box checked) DESCRIPTION OF INJURY Hematoma-Left eye (box checked) Skin Tear- Left arm (box checked) TREATMENT ACTION V/S (Vital Signs) 130/90 (blood pressure), P (Pulse) 72, R (Respiration) 22, T (Temperature) 97.8 NOTIFICATION MD (Medical Doctor) Yes (box checked) Notification: Time 11:00 PM Date 7-10-13 Name of MD (EI #1) Notified by: (EI #27's name) via Fax ER (emergency room ) (box checked) Disposition: (name of hospital) Family Notified Yes (box checked) Time 10:25 PM Date: 7/10/13 Name of Family Member Notified (RI #13's spouse) Notified by (EI #27's name) Staff Assigned to Resident at time of incided: (EI #24's name-CNA- Certified Nursing Assistant) Charge Nurse on Duty: (EI #27's name) FOUND ON FLOOR/SURFACE (box checked) Sitting (box checked) Location: Bedroom (box checked) Ambulating: Without assistance (box checked)..." The "POST-INCIDENT ACTIONS" for RI #13 revealed, "Incident Type: Falls Date/Time: 7/10/2013 10:20 PM Type of Injury: Skin tear- superf Location: Resident room Narrative of incident: Staff entered (RI #13's name) room and found him sitting on the floor beside his bed. Hematoma noted over left eye and bleeding, skin tear to left arm. (RI #13's name) asked what happened "I was going home to see my wife." Immediate Post-Incident Action: (RI #13's name) was sent to the ER for evaluation and on return will review for intervention for prevent falls. Immediate Actions Taken: (RI #13's name) assessed and skin tear cleaned and dressed and was sent to (name of hospital)." A review of "Departmental Notes" revealed, "(RI #13's name) 7/10/2013 11:34 PM 1025 p.m. Notified by (EI #26), LPN that resident was on the floor in his bedroom. Upon entering bedroom observed resident sitting on floor beside his bed, also observed large hematoma over left eye with gash in center with bleeding noted. Also noted skin tear to left arm with dressing place. Asked patient what happen. patient stated he was going home to see his wife. On assessment ROM (Range of Motion) good to upper ext (extremity), with limited movement noted to lower ext. V/S b/p (blood pressure) 130/90, p 72, r 22, t 97.8. M.D. notified of fall via fax at this time. Call placed to resident's sponsor spoke with (name) (wife) informed her of resident having a fall with injuries, and that resident to be sent out to E-R for eval per facility's protocol. 11:00 p.m Resident's son and daughter-in-law at facility at this time stating per patient's wife request, patient to be sent to (name of hospital) for eval. Call 11:15 pm. Patient leaving facility via stretcher with 2 ambulance attendants with family at side. Prepared by: (EI #27's name)" At 5:38 PM on 7/16/13, EI #24 (CNA) was interviewed and asked if she worked on evening of 7/10/13 and she stated yes. She was asked if RI #13 had a fall on 7/10/13 and she stated yes. EI #24 stated that she saw RI #13 on the floor but did not see him fall. She indicated that she was charting down the hall and heard someone say, "Help me." She went to RI #13's room and he was sitting straight up on the floor with legs spread open. She stated that he had blood on his forehead and on his left arm, under his forearm. EI #24 stated she called for another CNA to come stay with resident while she went to get the nurse. She indicated EI #26 (LPN) came into RI #13's room and cleaned up the blood and tended to his wound on the forehead. She stated other nurses came down to his room. EI #24 stated RI #13's children came and stopped by the nurse's station and talked to the nurse about a hospital and they went down to his room. She stated when the son and daughter got there, the resident was alone and that no one was in there with the resident. EI #24 was asked why was the resident left alone and she stated she did not know why he was alone. She was asked if the nurse asked her to stay with the resident after his fall and she stated no. On 7/16/13 at 6:22 PM, EI #25 (LPN) was interviewed. She was asked if she worked the evening shift on 7/10/13. She stated that she did but was in orientation and was orienting with EI #26. She was asked if she cared for RI #13 on evening of 7/10/13 and she stated that she wasn't on that hall that night but the nurse she was with assisted the resident that night. EI #25 was asked what happened that night and she stated that she had taken the trash out and went to the restroom and when she came back in EI #26 was in RI #13's room. She stated that EI #26 was cleaning the blood off the resident and asking him questions. EI #25 stated that she assisted with cleaning the blood off the resident and cleaning his dentures. She indicated that RI #13 was still sitting on the floor while being cleaned up and that EI #26 placed steri-strips on RI #13's arm and then his nurse, EI #27, came into the room to assess him. EI #25 took his vitals and then went to the nurse's station where EI #27 was on the phone with the family and the ambulance to give her the vital signs of RI #13. EI #25 stated that she did not go back into RI #13's room after that. EI #25 was asked what injuries RI #13 had and she stated he had a skin tear to the left forearm and a gash above the left eyebrow and a hematoma. She was asked who stayed with the resident until the discharge and sent out by ambulance. She stated she did not know. EI #25 was asked if a resident should be left unattended after a fall and she stated no. She was asked why and she stated there was more risk for more injuries and there could still be some reaction after the fall and it could get worse. EI #25 was asked if a resident had a fall with obvious head injury should be left unattended. She stated no. She was asked why and she stated the resident could pass out anytime, blood could continuously flow, and don't want to leave an open wound unattended. On 7/17/13 at 12:02 P.M., EI #26 was interviewed and asked what happened to RI #13 on 7/10/13. She stated that a CNA came to her and said she needed a nurse on the rehab hall. The CNA told her a man was on the floor and was bloody. EI #26 stated when she entered the room, the resident was sitting on the floor by the bed. She was asked if RI #13 was bleeding. She stated there was blood on the floor, his leg, shirt, arm, and was running down his face and was on his lips. She was asked who was in the room with her at that time and she stated she had 2 trainees that were nurses. EI #26 stated the 2 trainees helped with cleaning up RI #13 and left out of the room when she left out. EI #26 was asked if the resident was attempting to get up off the floor after the fall on 7/10/13. She stated he was trying and that he was scooting. EI #26 stated the resident said he had to get up and get dressed because he knew they were calling his wife. She stated that she explained to RI #13 that the facility was sending him out to be evaluated to get his head checked since he hit his head. On 7/17/13 at 4:50 P.M., EI #27 was interviewed and asked what happened in regards to RI #13's fall on 7/10/13. She stated that a nurse from another hall, EI #26 reported to her that RI #13 was on the floor. She stated this was between 10:00 PM and 10:30 PM when she was told he was on the floor. EI #27 stated she went into his room to assess him. She indicated RI #13 was sitting on the floor. He had a hematoma and gash over his left eye. She stated that she explained to him that he needed to go to the hospital. EI #27 stated that any type of head injury the protocol was to send the resident out to the hospital. She stated that he was scooting across the floor saying he wanted to see his wife. EI #27 was asked what care was provided to RI #13 after his fall. She stated that she did ROM on arms and the lower extremities had limited movement and she didn't want him to move because he may have injury they did not know about. She stated that when she left the resident's room to go call the family, the nurse, EI #26, was still in the room with the 2 nurse trainees. EI #27 was asked if anyone was with the resident after she left his room and she stated she didn't know. EI #27 stated RI #13's son and daughter-in-law arrived to the facility and went to the resident's room. She indicated the son was yelling and she went down to room to see what was happening. EI #27 was asked if anyone else was in the room with the resident when she went back in. She stated no, only the son. She was asked if RI #13 was confused at that time. She stated he was confused about month, day, and year. EI #27 was asked if a resident had a head injury should someone have stayed with him until the ambulance arrived. She stated yes and that nurses know they should stay with the resident until the ambulance comes. EI #27 stated the first time she went out of the room, the nurse and 2 trainees were in there with him. After she assessed him and tried to get him to stay still, she left to go to the nurse's station to call the family and then call the ambulance. EI #27 indicated she was getting his paperwork together and that her back was to that hall so she could not see if anyone left out of his room. When she went back down to his room after the family arrived, because the son was yelling, she indicated only the son was in the room with the resident and the daughter-in-law was in the doorway. On 7/18/13 at 9:25 AM, the daughter-in-law of RI #13 was interviewed. She stated she and her husband (RI #13's son) went to the facility to check on the resident after the fall. She stated that EI #27 informed her that he was unattended and had been on the floor for 45 minutes. She indicated that EI #27 was not sure why RI #13 was not supervised or watched after the fall. The daughter-in-law stated the resident had a gash on eyebrow bone and a hematoma on top and bottom eyelid. She indicated he had a black eye and was bleeding. The daughter-in-law stated when she and RI #13's son went to his room, the resident was scooting around on the floor. The resident was alone in the room on the floor. At that time another nurse came down but indicated it was not EI #27. The daughter-in-law asked the nurse why nobody was with the resident and the person informed her that there had been someone with the resident but they left to go on break. The daughter-in-law did not know the staff person's name and indicated they were not wearing a badge. On 7/18/13 at 4:13 PM, EI #1 (Medical Doctor) was interviewed and asked about RI #13. He stated he did not recall the resident. EI #1 was asked if a resident had a head injury from the fall, what would he expect staff to do. He stated they should do neuro checks every 2 hours, make sure resident was alert, monitor vital signs, check to see if change in their mental status, and no worsening of their condition. EI #1 was asked if a resident should be left unattended after a fall with a head injury. He stated no because changes could happen immediately and they certainly shouldn't move the resident with a head injury due to making the injury worse. He indicated staff should check the resident, keep the resident safe, not move them if possible, look for any changes, notify the MD of incident, and get the resident to the hospital as quickly as possible. A review of the facility's policy and procedure titled, "Guidelines: Event Reports/Incident Reports, Effective date: 8/2012," revealed, "The following steps should be taken when an accident or incident occurs. It is understood that the severity of the situation will dictate staff's response, and that the nurse assessing the resident will need to exercise judgement when determining the order in which the items are to be completed. Procedure ...Take and record vital signs; conduct neurological checks if indicated; note medications resident was taking at time of incident; assess resident for signs of abuse and neglect..." A review of EI #s 26 and 27 statements regarding fall incident of RI #13 revealed no documentation of neuro checks or continuous monitoring of resident by staff until discharged out of the facility by ambulance. The nurse's notes revealed no documentation of neuro checks or continuous monitoring by staff of RI #13 after his fall with a head injury on 7/10/13. On 7/18/13 at 6:10 PM, EI #3 (DON-Director of Nursing) indicated she could not find documentation of neuro checks being done on RI #13. A review of RI #13's hospital record of admission after his fall at the facility revealed the resident had a fracture of the C-6 and C-7 (Cervical) of the neck. 2) A review of the facility policy titled, "Guidelines: Event Reports/Incident Reports (Investigation of Incidents and Completion of Reports)" (08/2012) revealed: "The following steps should be taken when an accident or incident occurs. ... Documentation ...Update care plan to reflect new interventions, and communicate new approaches to staff, including CNAs (Certified Nursing Assistants). If new equipment or supplies need to be ordered, communicate such at morning stand-up meeting. Assign responsibility for follow-up. The Charge Nurse is responsible for ensuring that interventions are implemented. ..." RI #14 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. RI #14's hospice "Nursing Comprehensive Update/Visit Note," dated 05/03/13, revealed she was oriented to person and place and moderately impaired with cognitive skills for daily decision-making. This note also showed the resident scored a 26 on the fall risk assessment. A score of 19 or greater indicates "Very High Risk" for falls. She was assessed as totally dependent on one person for transfers and ambulation. RI #14's care plan for "potential for falls" (from her 05/03/13 admission) revealed multiple approaches. The last two approaches were dated 05/06/13. RI #14's "Occurrence Report" revealed on 05/04/13 at 3:45 AM, she had a witnessed fall in the bathroom with no apparent injury. The "Witness Statement revealed: "...When standing, patient slipped as I (CNA/Certified Nursing Assistant, EI #7) was transferring her to commode, and I slowly sat her on the floor. ..." The "Summary of Investigation" revealed the root cause was transfer techniques. The intervention documented was: "Staff education about safe transfers." On 07/18/13 at 11:35 AM, the Assistant Administrator, EI (Employee Identifier) #6 handed the surveyor an inservice that was done regarding transfers on 05/17/13 in which EI #7 was in attendance. However, this was 13 days after the resident's fall. EI #6 was asked if this was the education that the incident report was referring to. She said she assumed it was; it was the only one she found. EI #6 said she could check EI #7's personnel record. The surveyor and EI #6 went to the Human Resources Manager (EI #8), who looked in the computer file and said there was no re-education in EI #7's file regarding transfers. On 07/18/13 at 6:12 PM, EI #7 was asked if she received any training after RI #14's fall on 05/04/13. She said she did, but could not remember the date. RI #14's care plan for "potential for falls" (from her 05/03/13 admission) revealed nothing new was added on 05/04/13 to try to prevent another fall. 3) RI #7 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. RI #7's Significant Change MDS (Minimum Data Set) assessment (dated 06/01/13) revealed she scored a five out of fifteen on the mental status interview, indicating she was severely cognitively impaired. The MDS also showed she required extensive assistance from one person for transfers and toileting, and limited assistance from one person for walking and locomotion. RI #7's care plan for potential for falls (dated 08/30/12) revealed multiple approaches. RI #7's "Occurrence Report" revealed she was found on the floor on 07/13/13 at 7:50 PM. The "Post-Incident Actions" revealed: "...(RI #7) stated I was trying to get a telephone up off the floor and fell . ..." The "Immediate Post-Incident Action" was: "Resident was referred to therapy for a reacher." The nurse's note dated 07/13/13 revealed the resident complained of right knee and shoulder pain, therefore x-rays were ordered. The radiology reports showed no fractures. RI #7's care plan for potential for falls revealed an approach dated 07/13/13: "X ray right shoulder and right knee." An approach dated 07/14/13 revealed: "OT (Occupational Therapy) consult for a reacher." There was no new intervention added immediately after the fall to try to prevent another fall. A review of RI #7's "Daily Care Guide" (which is used by CNAs to know what to do for the resident) dated 07/18/13 revealed the last new intervention was dated 05/01/13; nothing new after the fall. On 07/17/13 at 5:27 PM, the LPN (Licensed Practical Nurse) who was working with RI #7 at the time of her fall on 07/13/13 (EI #16), was asked who was responsible for putting a new intervention in place to try to prevent another fall. She said she thought the investigation team did that because they do the care plans and update them on the computer. EI #16 was asked if it was a weekend and the team was not at the facility. She replied, "I've never thought about that." EI #16 was asked if the reacher evaluation was an intervention by her or by the team. She said it might have been restorative or therapy. EI #16 was asked if any other intervention was implemented immediately after the fall on 07/13/13 to try to prevent another fall. She said there was not, they just talked to her, kept her company and gave her something to drink until she fell asleep. EI #16 was asked what the potential problem was with not having a new intervention after a fall. She said the person could fall again. EI #16 was asked if the resident could potentially get injured. She said she could. On 07/16/13 at 6:43 PM, a CNA (EI #17) was asked if she was aware that RI #7 fell Saturday 07/13/13. She said she heard the resident had fallen when she came back inside from being outside with another resident that particular shift. EI #17 was asked when she worked with RI #7 after that. She said she worked with her the next two days and was working with her today. EI #17 was asked if anything new was put in place since Saturday to try to prevent another fall. She responded, "Not that I'm aware of." On 07/16/13 at 6:50 PM, RI #7 was in her room in the bed. She was asked if she had a reacher. RI #7 asked what that was. After explaining it, she said she did not have one, but it sounded wonderful. There was no reacher visible in the resident's room. On 07/18/13 at 9:41 AM, the Care Plan Coordinator (EI #9) was asked who was responsible for putting a new intervention in place after a fall. She said the nurse on duty implements an immediate intervention and writes it on the care plan, then they have an IDT (Interdisciplinary Team) meeting to decide an approach to add. EI #9 was asked what they do if it is a weekend. She said they discuss it Monday morning. EI #9 was asked if care plan staff were at the facility on Saturdays. She said they were not. EI #9 was asked if she was aware that RI #7 fell on [DATE] and a new intervention was not put in place. She said she was not aware. EI #9 was informed that the concern was from Saturday to Wednesday the resident could have fallen again. She said she understood that there was a potential for another fall there. EI #9 was asked if they had an IDT meeting Monday (07/15/13) regarding RI #7's fall. She said they did. EI #9 was asked what was put in place until the reacher could be provided. She said only the x-ray. On 07/18/13 at 10:31 AM, the OT (EI #15) was asked if RI #7 had received a reacher. She said she evaluated her the day before (07/17/13) and she would be training her how to use it today (07/18/13). EI #15 said the reacher was not in place yet. EI #15 explained that she did not receive the referral until Tuesday (07/16/13). On 07/18/13 at 10:38 AM, the Director of Nursing (EI #3) was asked who was responsible for putting a new intervention in place after a fall to try to prevent another fall. She said it was a clinical effort. EI #3 explained that the nurse on the hall puts an intervention in place immediately, then they meet and discuss if they need to continue that approach or do something different. EI #3 was asked what the new intervention was for RI #7 after her 07/13/13 fall. She looked at the incident report (which included the care plan) and said she did not see one. EI #3 was asked what the potential harm was of not putting a new intervention in place. She said the potential for another fall. This deficiency was cited as a result of the investigation of complaint #AL 072 and #AL 287.

Based on observations, interviews and record reviews, the facility failed to implement the fall prevention plan of care for Resident Identifier (RI) # 25, who was cognitively impaired and at high risk for falls. The facility assessed RI #25's Attention Deficit [MEDICAL CONDITION] Disorder, poor safety awareness; [DIAGNOSES REDACTED]. Documentation in the facility's records, the resident's medical record, and interviews with staff members that provided care for RI #25 revealed RI #25 had a history of [REDACTED]. Additionally, the facility sent a 30 day discharge letter to the sponsor of RI #25 dated 10/15/12 indicating they would like to supplement the services of 24 hour sitters until RI #25 was discharged from the facility. According to RI #25's sponsor, she had received the letter informing her that the facility would be providing 24 hour sitters prior to RI #25's fall on 10/17/12. Interviews with EI#1, EI#2, EI#4 and EI#5 revealed the facility did not provide the sitters on the 11-7 shift as indicated in the 30 day discharge notice. On 10/17/12, at 6 AM, RI #25 sustained another fall. According to interviews with staff members on the shift when RI #25 fell , it was determined RI #25 was placed in a recliner chair by a Certified Nursing Assistant (CNA), Employee Identifier (EI) #6 before the shift (3 PM - 11 PM) ended. Two CNAs, EI # 1 and EI #2, working the 11 PM - 7 AM shift relieved EI #6 of his responsibilities. EI #2 stated she and EI #1 knew the chair alarm was not on the recliner RI #25 was sitting in during their shift. EI #6 stated he was unaware RI #25 utilized an alarm while up in the recliner. EI #5, the Licensed Practical Nurse (LPN) working the 11 PM - 7 AM shift on this night revealed RI #25 was making movements in her sleep as if she was attempting to stand. However, EI #5 stated she turned her back to RI #25 and walked towards the medication room to retrieve medication for another resident. EI #5 stated she heard a loud noise, turned around and observed RI #25 lying face down on the floor. EI #5 stated RI #25 had blood on her face from the bridge of her nose down. RI #25 was transported to the ER (emergency room ) by a local transport service for evaluation and treatment. Hospital records revealed RI #1 was diagnosed to have Facial Lacerations and a Subdural Hematoma. This deficient practice posed a serious and immediate threat to the health and safety of RI #25, one of five residents care plans reviewed for falls, and has the potential to affect all 11 residents on facility's secure/locked Dementia unit with a risk for falls. On 10/29/12 at 7:00 PM, the facility's Director of Clinical Quality for Senior Living, Director of Nursing, Vice President for Senior Living/Acting Administrator and Executive Director were notified of the findings of Immediate Jeopardy in the area of Services by Qualified Person/per Care Plan. After reviewing the facility's information provided in their Allegation of Credible Compliance (AOC), observing residents utilizing chair alarms, conducting interviews with staff at the facility and reviewing the facility's in-service sheets to determine if the facility implemented their AOC, the surveyor abated the Immediate Jeopardy. The immediate jeopardy began on 10/17/12 and was abated on 10/31/12. Findings Include: RI #25 was admitted to the facility on [DATE], and readmitted on [DATE], with [DIAGNOSES REDACTED]. RI #25's fall care plan with a Problem Onset date of 06/14/11, documents: "(Name of RI #25) has potential for falls related to use of medications, dx (diagnosis) of advanced dementia. Poor safety awareness. ambulates with head down, and charges forward. Hx (history) of multiple falls. ADHD (Attention Deficit [MEDICAL CONDITION] Disorder) [MEDICAL CONDITION], Poor safety awareness ambulates with head down and charges forward... Approaches: ... * 10/2/12 Chair Alarm ..." The facility completed a Significant Change MDS (Minimum Data Set), with an ARD (Assessment Reference Date) of 10/01/12. RI #25 was identified as having short and long term memory problems and severely impaired cognition. RI #25 needed extensive assistance with bed mobility, transfers, and walking in the room and in the corridor with the assistance of two. RI#25 was also assessed as requiring extensive assistance of one with locomotion on and off the unit. RI #25's balance during transitions and walking was coded as not steady, only able to stabilize with staff assistance with moving from seated to standing position, walking, turning around, moving on and off toilet and with surface-to-surface transfers. RI #25's functional limitation in range of motion was coded as having impairment on both sides of her upper and lower extremities. RI #25 was coded as having two or more falls with no injury, one fall with injury (except major) and one fall with major injury. NURSES NOTES for RI #25 documents: "10/4/12 at 420 (4:20) PM ... chair alarm and Bed alarm will be in place as care planned to decrease risk if fall due to unsteady gait and poor safety awareness if she (RI #25) were to get up ambulating without assistance ..." EI #11, an LPN who provides care to RI #25 on the 7 AM - 3 PM shift, was interviewed on 10/27/12 at 10:43 AM. EI #11 stated the intervention for RI #25 to have a chair alarm was put in place on 10/02/12. EI #10 stated she had also observed the chair alarm on the recliner in the past. EI #6 stated the chair alarm should have been on the recliner when RI #25 was in it. EI #10 stated, "... once she stood up", the chair alarm would have alerted staff RI #25 was attempting to get up unassisted. A review of RI #25's Daily Care Guide documents: "... INTERVENTIONS ... . 10/2/12 Chair Alarm (Role: CNA) 10/2/12 Chair Alarm (Role: LPN)." EI #6, the CNA who provided care to RI #25 on 10/16/12, 3 PM - 11 PM shift, was interviewed by phone on 10/25/12 at 5:46 PM. EI #6 stated he was unsure why he did not place the chair alarm in the recliner chair when he placed RI #25 in the chair. EI #6 stated, " ... I know we were trying to make her comfortable in the recliner. I do not normally work with her so I wasn't sure whether it (alarm) should be on the recliner or not." EI #6 stated the Daily Care Guide instructs staff on what type of care a resident requires. EI #6 stated he failed to look at RI #25's Daily Care Guide before providing care that day. EI #10, an LPN who provided care to RI #25 on the 3 PM - 11 PM shift on 10/16/12, was interviewed on 10/26/12 at 8:56 AM. EI #10 stated a chair alarm was placed on RI #25's recliner after she had the first fall. EI #10 stated RI #25 had an unsteady gait and leans her head forward and walks at a very fast pace when she leans forward. EI #10 stated it was not safe for RI #25 to be in the recliner without the alarm. EI #10 stated when RI #25 gets up and leans with her head forward, "... Getting up this way could cause her to fall if no one assist her up. If she has the alarm attached to her, it would alert staff she was attempting to get up." A "WITNESS STATEMENT" by EI #5, the LPN assigned to care for RI #25 on the 11 PM - 7 AM shift she fell [DATE], documents: "(Name of RI #25) was sitting in recliner in dayroom ... I got up from table and turned my back to walk into med room, when I heard something hit the floor. I turned around and (Name of RI #25) was on the floor. Assisted her into her scooter chair. She had a bleedy (bloody) face ... (Name of RI #25) was sent to ER @ (at) (name of local hospital)." EI #5, the LPN assigned to provide care to RI #25 on 10/17/12, 11 PM - 7 AM shift, was interviewed on 10/15/12 at 7:05 AM. EI #5 was asked to recall what occurred on the 10/17/12 during the 11 PM -7 AM regarding RI #25's fall. EI #5 stated RI #25 had attempted to get up out of the recliner, "... probably about five times" on the shift before falling. EI #5 stated RI#25 was making movements in the chair like she was trying to rise from the chair throughout her shift; however her eyes would be closed. EI #5 stated around 6:00 AM, RI #25 was sitting in a recliner in the dayroom. EI #5 stated the TV was on the in the dayroom and RI #25 appeared to be asleep. EI #5 stated she got up to obtain a medication for another resident and had her back turned for about " ... 10 -15 seconds ... " when she heard a noise. EI #5 stated she observed RI #25 on the floor, face down. EI #5 was asked if the chair alarm was in the recliner chair. EI #5 stated, "No..." EI #5 stated, "... I have been back there once and there was a chair alarm on the recliner. I'm guessing one should have been on it but there wasn't one on the recliner when she fell ..." On 10/31/12 at 8:20 AM EI# 5, EI #4, EI #8, and EI #19, Maintenance Director all went to the location of RI #25's fall on 10/17/12. Measurements were taken and it was determined that at the time of the fall, EI #5 was standing approximately 21 1/2 feet from the recliner where RI #25 had previously been sitting. RI#25 fell approximately 11 feet, 4 inches from the recliner. It was also determined that EI#5 was standing 10 feet, 21/2 inches from where RI#25 fell . The facility provided a "JOB DESCRIPTION" for the Licensed Practical Nurse dated April 1. 2009. Under the "Summary of Duties" section was documented the nurse would: "Provide direct care to residents as needed in accordance with care plan, policies and procedures, and nursing standards of care..." EI #1, the CNA who provided care to RI #25 on 10/17/12, 11 PM - 7 AM shift, was interviewed on 10/25/12 at 10:18 AM. EI #1 stated EI #6 placed RI #25 in the recliner chair before leaving the unit on his shift. EI #1 stated it would have been EI #6's responsibility of ensuring the chair alarm was in the resident's chair. EI #1 stated she did not realize the alarm was not in the recliner chair until after the resident had fallen. The surveyor showed EI #1 RI #25's Daily Care Guide and Fall care plan. The surveyor asked EI #1 if the chair alarm was on the Daily Care Guide and the fall care plan. EI #1 stated yes. EI #1 stated she was introduced to the Daily Care Guide after RI #25's second fall. EI #1 stated if she needed to know anything about a resident she could refer to the Care Guide. EI #2, another CNA who provided care to RI #25 on 10/17/12, 11 PM - 7 AM shift, was interviewed on 10/25/12 at 8:56 AM. EI #2 stated she and EI #1 worked together that night. EI #2 stated she was aware that RI #25 used the alarm in the "... recliner and another chair ..." EI #2 stated EI #6 took RI #25 to the bathroom around 11:00 PM before he left that night and placed RI #25 in the recliner. EI #2 stated around 1:30 AM or 2:00 AM, she and EI #1 took her to the bathroom then put her in bed. EI #2 stated the bed alarm " ... kept going off so we brought her back up to the front and put her in the recliner ... " EI #2 stated RI #25's bed alarm keep going off because, "...she wouldn't stay in bed... " EI #2 stated the chair alarm is usually kept in her chair but, "... it wasn't in her chair when we came on. It probably was in her scoot chair." EI #2 was asked did they look for the chair alarm. EI #2 stated, no. EI #2 stated, "We knew it wasn't there, that's why we stayed there all night." EI #2 was asked who was responsible for putting the chair alarm on the recliner. EI #2 stated, "(EI #6), he put her in the chair. Whoever put her in the recliner should take the alarm off the scoot chair and place it on the recliner." EI #2 stated the CNAs are responsible for ensuring the chair alarm is in the recliner. The surveyor asked EI #2 was RI #25 care planned to have an alarm on her chair (recliner). EI #2 stated yes. The facility provided a "JOB DESCRIPTION" for the Certified Nursing Assistant dated April 1, 2009. Under the "Summary of Duties" section was documented the CNA would: " Be responsible for providing residents with routine daily nursing care and services in accordance with the resident's assessment and plan of care and as directed ..." EI #4, the facility's DON (Director of Nursing), was interviewed by the surveyor on 10/26/12 at 12:14 PM. EI #4 stated after RI #25 fell on [DATE], the intervention for a chair alarm was put in place on 10/02/12. EI #4 stated she was the first one who pulled someone to sit with RI #25. EI # 4 stated the one-on-one sitting was to keep RI #25 safe. EI #4 stated the staff had been told (about sitting with RI #25 one-on-one) but it was not on the care guide. EI #4 stated the care guide basically tells the staff any interventions that are in place for the resident. The surveyor asked EI #4 if the chair alarm could have been placed on a recliner chair. EI #4 stated she thought the chair alarm was for the scoot chair RI #25 sat in. EI #4 stated she didn't recall the facility putting alarms on recliner chairs. EI #4 stated, "... I don't see how they would do that..." On 10/27/12 at 3:05 PM, the DON and ADON accompanied the surveyor to the Arbor unit. EI #11, the LPN working the Arbor unit at the time demonstrated how the chair alarm could be applied to the recliner chair. The surveyor observed the Bed-Check Basic Check chair alarm to have two pieces of Velcro attached to the back of the monitor box. There was a sensor pad that could be connected to the monitor box. EI #11 placed one of the pieces of Velcro onto the top of the recliner. The other piece of Velcro was affixed to the monitor box. EI #11 attached the two pieces of Velcro together and the monitor box was secured to the top of the recliner. EI #13, the facility's MDS Manager/Coordinator/Care Plan Coordinator, was interviewed on 10/30/12 at 12:46 PM. EI #13 stated the chair alarm being on a chair would sound, "...if the resident moved a certain way or tried to get up..." EI #13 stated the chair alarm could be placed on any type chair. The surveyor asked EI #13 would RI #25 having one-on-one sitters been an approach that was added to her Fall Preventive care plan. EI #13 stated she would think the person making that determination should have put it on the care plan. On 10/25/12 at 2:48 PM, the surveyor conducted an interview with EI #3, the facility's Occupational Therapist. The surveyor asked EI #3 if RI #25 was safe to be in a recliner. EI #3 stated not without someone closely supervising her. EI #3 stated RI#25 has a history per nursing and her observations of RI #25's attempts to stand and walk. EI#3 stated RI #25 required two person assistance to perform safe standing and walking. On 10/24/12 at 11:28 AM, the surveyor conducted a phone interview with the sponsor of RI #25. RI #25's sponsor said RI #25 had fallen several times at the facility. RI #25's sponsor said RI #25 was suppose to have 24 hour sitters and she had a letter from the facility telling her the facility was going to provide the sitters. RI #25's sponsor said, Tuesday night (10/16/12) when she was there, a CNA by the name of (name of RI #6) was sitting with RI #25. A review of the 30-day discharge notice for RI #25, dated 10/15/12, documents: "... We understand you will be utilizing some sitter services as she (RI #25) recuperates from Friday's dental procedure. We would like to supplement those services so that your mother has 24 hour sitter services during this 30 day time frame ..." On 10/28/12 at 2:56 PM, the surveyor conducted an interview with EI #7, the Director of Clinical Services. The surveyor informed EI #7, that in reviewing the facility's 30 day discharge notice for RI #25, the surveyor read that the facility wanted to supplement 24 hour sitters services for RI #25. The surveyor asked EI #7 what was the reason for the 24 hour sitters. EI #7 stated they wanted to make sure RI #25 was safe until she left. EI#7 stated they thought the sitters might be the best thing. EI #7 stated the facility had never done this before, had 24 hour sitters. EI#7 stated they had run out of options, approaches other than have someone sit with her at all times. When EI#7 was asked if the facility provided the 24 hour sitters EI#7 stated the facility had a contract for sitters to come starting the morning she fell . EI #7 stated when she talked to the nurses on the unit where RI #25 resided, she told them to make sure RI #25 was in close proximity at all times. EI #7 stated staff were told they needed to have someone watching RI #25, eyeballing her, having her close enough so they could see her at all times. EI #7 stated she knew RI #25 had been sleeping but that didn't matter. EI #7 stated she understood people woke up that's why it was said to keep RI #25 in eyesight at all times. EI #7 stated she thought she and the DON gave staff instructions about what was expected of them with RI #25. The surveyor asked EI #7, on the morning of 10/17/12, did RI #25 have an assigned person to do one-on-one care for her. EI #7 stated she didn't know. EI#7 stated she told the nurses that she wanted one person with her at all times. EI#7 stated she told them to be watching her at all times. The surveyor asked EI #7 was she made aware that the morning RI #25 fell face first to the floor she did not have her chair alarm on the recliner. EI #7 stated no one told her that. On 10/29/12 at 12:45 PM, the surveyor conducted an interview with EI #4, the facility's DON. EI #4 stated the person that sat with RI #25 on 7 AM - 3 PM and 3 PM - 11 PM, they had no other duties assigned to them. EI #4 stated 11 PM - 7 AM took turns and traded out with someone sitting with RI #25. EI #4 stated EI #5 had the option to pull staff from another unit. EI #4 stated the other two units at the facility each had three CNA's and EI #5 could have pulled from either one of them. The surveyor asked EI #4 when EI #5 went toward the medication room to get a medication for another resident, what should she have done as far as monitoring RI #25. EI #4 stated she could only attest to what she would have done in that situation. EI #4 started she would have called one of the CNAs and just had them stay there until she did what she needed to do right quick. EI #4 stated she would have expected EI #5 to do the same thing, to call for assistance. This deficiency was written as a result of the investigation of complaint/report #AL 736. Cross refer to F 323. ******************************************************** On 10/31/12 at 11:35 PM, the facility submitted an Allegation of Compliance as to how the facility would relieve the immediacy of F 282 This allegation of credible compliance is being submitted in compliance with specific regulatory requirements. The preparation and or execution of this allegation of compliance does not constitute admission of agreement by the provider of the facts alleged and conclusions set forth. Please accept this credible allegation of compliance as the facilities written credible allegation that the alleged deficiencies to be cited have been corrected by the date or dates indicated. 1. On 10/17/12 RI #25 was discharged to hospital related to the fall. 2. On 10/18/12 Employees #1, #2, and #5 were in-serviced on the utilization of the Daily Care Guide pertaining to fall prevention intervention. On 10/18/12 Employee #5 was in-serviced on following facility incident protocol for falls. On 10/22/12 Employee #5 was in-serviced on the 24 Hour Report and shift change report for communicating interventions for falls that were placed on plan of care that shift. On 10/28/12 MDS Manager and MDS Coordinator audited all residents with chair alarms care plans and specified the type of chair in which to apply an alarm. This audit also included checking to assure this information was on the resident ' s Plan of Care/ Daily Care Guide. There were no chair alarms in the dementia unit. The MDS Manager and MDS Coordinator also audited the residents care plans to ensure fall preventative care plan interventions were in place. No concerns were identified. On 10/29/12 Employee #6 was in-serviced on utilization of the Plan of Care/ Daily Care Guide pertaining to fall prevention interventions. 3. On 10/18/12 Nursing staff was in-serviced, by the Assistant Director of Nursing (ADON), on utilization of Care Plan/Daily Care Guides. All staff not attending this in-service will be in-serviced prior to their next shift to work. On 10/22/12 Licensed Nursing staff was in-serviced, by the Registered Nurse (RN) Unit Manager on communication of falls via the 24 Hour Report so information can be used to update the plan of care. All staff not attending this in-service will be in-serviced prior to their next shift to work. On 10/27/12 Nursing Management team (DON, ADON , Administrator in Training, MDS Manager, MDS Coordinator, Restorative Nurse, 3 Registered Nurse Unit Managers, Staffing Coordinator) was in-serviced by the Corporate RN regarding - Care Plans/Daily Care Guides for care plan fall interventions; and 24 hour shift reports for communicating fall interventions to oncoming shift. On 10/30/12 The Interdisciplinary Care Plan Team Members (Registered Dietician, Treatment Nurse, Social Service Assistant, 3 Registered Nurse Managers, Social Worker, MDS Manager, Activity Director, MDS Coordinator) completed a computerized in-service on Care Plans/Daily Care Guides. This in-service included a post-test which 100% passed. 4. On 10/27/12 the DON/designee began daily monitoring of the 24 Hour Shift report; investigation of falls; care plan interventions for falls and Plans of Care. No concerns have been identified at this time. On 10/27/12 DON/designee began weekly review of residents experiencing falls from 10/24-29/12 to ensure initial Care Plan interventions for falls were effective. Additional interventions were added as needed ******************************************************** On 10/30/12, the surveyor observed residents who had orders for chair alarms. Alarms were being utilized. On 10/30 12, inservice sheets were reviewed. Staff assigned to work the secure locked/unit names appeared on these inservice sheets On 10/31/12, staff were interviewed to ensure staff had received inservices on fall prevention, care plan/Daily Care Guides, 24 hour reporting and bed/chair alarms. All staff interviewed had been inserviced. After reviewing the facility's information provided in their Allegation of Credible Compliance (AOC), observing chair alarms being utilized, conducting interviews with staff at the facility, and reviewing the facility's inservice sheets to determine if the facility implemented their AOC, the surveyor abated the Immediate Jeopardy.

Based on observation, interviews and record review, the facility failed to ensure RI (Resident Identifier ) #25, a resident with severely impaired cognition, history of an unsteady gait, poor safety awareness, history of multiple falls with facial injuries and a [DIAGNOSES REDACTED]. In addition, the facility failed to utilize the chair alarm, per the resident's care plan for falls, which alerts staff when a resident is attempting to rise from the chair. On 10/17/12 during the 11 PM - 7 AM shift, RI #25 fell face first on the floor in the day/sitting room area on the facility's secure dementia unit when attempting to get out of a recliner unassisted. In an interview with EI (Employee Identifier) #2, a CNA (Certified Nursing Assistant), working the 11 PM - 7 AM shift when RI #25 fell , RI #25 did not have a chair alarm on the recliner she was sitting in, per the resident's care plan for falls. EI #2 stated, EI #6, the CNA assigned to sit with RI #25 on the 3 PM - 11 PM shift should have placed the chair alarm on the recliner when he transferred RI #25 to the recliner. In an interview with EI #6, EI #6 stated he saw the chair alarm on the scoot chair RI #25 was sitting in, but he did not know RI #25 was supposed to have the chair alarm on the recliner. According to EI #1, RI #25's assigned CNA on the 11 PM - 7 AM shift, when RI #25 gets up out of a chair she has her head down and walks at a fast pace. EI #1 stated if the chair alarm had been on the recliner, it would have alerted staff RI #25 was attempting to get up unassisted. On 10/15/12, the facility sent the resident's sponsor a 30 day discharge notice. Within the discharge notice the facility stated they wanted to supplement the daughter's sitter services so that RI #25 had 24 hour sitter services during the 30 day timeframe. According to EI #7, the facility's Director of Clinical Services, the facility wanted to make sure RI #25 was safe until she was discharged and having 24 hour sitters might be the best thing. In an interview with EI #3, the facility's Occupational Therapist, EI #3 stated RI #25 was not safe to be in a recliner without close supervision. According to EI #3, RI #25 had an unsteady gait and poor safety awareness. EI #3 stated from hers and the nurses' observations, EI #25 attempts to stand and walk unassisted. EI #3 stated RI #25 required two person assistance to perform safe standing and walking. An interview with EI #4, the facility's DON (Director of Nursing), revealed RI #25 had sustained two previous falls with facial injuries and staff had been instructed to keep RI #25 in visual sight at all times. The facility provided an additional staff person to sit with the resident on 10/15/12 on the 3 PM -11 PM shift, and on 10/16/12 on the 7 AM -3 PM shift and the 3 PM -11 PM shift. The facility did not provide an additional staff person to sit with the resident on the night shift (11 PM - 7 AM) of 10/15/12 or 10/16/12. On the night shift of 10/16/12 there was one LPN (Licensed Practical Nurse), EI #5, who had to work two units and two CNAs (EI #1 and EI #2) who worked exclusively on the dementia unit to provide care for 17 residents. EI #5, the LPN on the 11 PM - 7 AM shift revealed she turned her back to RI #25 to walk to the medication room to get a medication for another resident. EI #5 stated she heard a loud noise, turned around, and RI #25 was observed lying face down on the floor. EI #5 stated RI #25 had blood on her face from the bridge of her nose down. RI #25 was transported to a local ER (emergency room ) for evaluation and treatment. Review of RI #25's ER records revealed RI #25 had [DIAGNOSES REDACTED]. On 10/19/12, RI #25 had "right frontal Bur Hole" surgery (A burr hole for subdural hematoma is performed to remove a hemorrhage (blood clot) from around the surface of the brain) and was admitted to the SICU (Surgical Intensive Care Unit). This deficient practice posed a serious and immediate threat to the health and safety of RI #25, one of five residents sampled for falls, and has the potential to affect all 11 residents residing on the facility's secure unit who are at risk for falls. On 10/29/12 at 7:00 PM, the facility's Director of Clinical Quality for Senior Living, Director of Nursing, Vice President for Senior Living/Acting Administrator and Executive Director were notified of the findings of immediate jeopardy in the area of Accidents / Supervision. After reviewing the facility's information provided in their Allegation of Credible Compliance (AOC), observing residents utilizing chair alarms, conducting interviews with staff at the facility and reviewing the facility's in-service sheets to determine if the facility implemented their AOC, the surveyor abated the Immediate Jeopardy. The immediate jeopardy began on 10/17/12 and was abated on 10/31/12. Findings Include: RI #25 was admitted to the facility on [DATE], and readmitted on [DATE], with [DIAGNOSES REDACTED]. RI #25's fall care plan with a Problem Onset date of 06/14/11, documents: "(Name of RI #25) has potential for falls related to ... dx (diagnoses) of advanced dementia. Poor safety awareness. ambulates with head down, and charges forward. Hx (history) of multiple falls. ADHD (Attention Deficit Hyperactive Disorder) Hyperactivity, Poor safety awarness (awareness) ambulate with head down and charges forward ... Approaches: ... Assist resident with transfers and ambulation as needed ... * 10/2/12 Chair Alarm ..." According to a facility "WITNESS STATEMENT" by EI #16, the LPN assigned to care for RI #25 on the 7 AM - 3 PM shift on 9/17/12 the resident was "... walking in day area & (and) walked into another residents walker. Resident lost balance and landed in floor ... no s/s (signs/symptoms) of distress, bruising or scraped areas ..." According to a facility "WITNESS STATEMENT" by EI #18, a CNA assigned to care for RI #25 on the 7 PM - 7 AM shift on 9/17/12, the resident had a second fall on 9/17/12, and was found on the floor of the dining room laying on her right side with bleeding from her nose and mouth. A "POST-INCIDENT ACTIONS" report dated 9/17/12 at 7:40 PM documents that the resident "... received first aid and sent to ER (emergency room ) for evaluation, she returned with orders and at 3 PM (name of hospital ) ER phoned to direct admit resident due to fx (fracture) and cerebral hemorrhage ..." "NURSES NOTES" for RI #25 dated 9/21/12 at 3 pm documented the resident (RI #25) was readmitted to the facility from the hospital and had some "... caps missing off teeth .." and that the daughter stated "dentist will be to see resident and examine her mouth." The facility completed a Significant Change MDS (Minimum Data Set), with an ARD (Assessment Reference Date) of 10/01/12. RI #25 was identified as having short and long term memory problems and severely impaired cognition. RI #25 needed extensive assistance with bed mobility, transfers, and walking in the room and in the corridor with the assistance of two. RI#25 was also assessed as requiring extensive assistance of one with locomotion on and off the unit. RI #25's balance during transitions and walking was coded as not steady, only able to stabilize with staff assistance with moving from seated to standing position, walking, turning around, moving on and off toilet and with surface-to-surface transfers. RI #25's functional limitation in range of motion was coded as having impairment on both sides of her upper and lower extremities. RI #25 was coded as having two or more falls with no injury, one fall with injury (except major) and one fall with major injury. "Nurses Notes" for RI #25 documents: "10/1/12 9 AM, Resident will not stay seated. Attempting to run and charge when she's up. constantly standing up and being assisted to sit back down ... 10/1/12 10:30 AM Was notified resident had fallen ... resident has a skin tear to right hand and a laceration to chin and lip. A bridge came out of residents mouth. Resident has been constantly getting up all morning and would not stay seated and was ... almost running and charging head first... 10/1/12 at 9 pm, Resident returned to facility @ (at) 8:30 pm ...Three sutures to laceration on chin. Sutures to lip ... bruising noted to lip and chin area ..." 10/2/12 2:00 AM ... Sitter remains at bedside ... 10/02 (2012) 4:30 PM ... Sitter will remain c (with) resident for safety measures. Spoke with Sponsor ... regarding room change off secure unit to long term bed ... due to decline of meeting criteria to be on secure unit. Daughter declined room change due to choice of roommate not available (with) a certain resident. Spoke to ... ombudsman to schedule meeting with sponsor to assist with communication and mediation of appropriate placement of resident. All Department Heads will continue to monitor the situation ... 10/03/12 3:15 pm ... resident has sitter at side ... 10/4/12 6A ...sitter @ bedside ... 10/04/12 at 10:00 am, Resident daughter was in visiting with her (RI #25) at side in day area. Sitter at chair side ... Daughter adviced (advised) that today was sitter last day and she would be leaving at 5 pm. Resident daughter stated, "that (name of company that owns nursing home) would have to provide one on one care for her mother ... 10/04/12 at 3:40 PM, I (Director of Clinical Services, EI #7) met with (EI #3, Occupational Therapist) and asked about evaluation she did for (RI #25). I told her I was concerned about (RI #25's) safety when the sitter left and could we find something that would help prevent another fall ..." EI #3, the facility's Occupational Therapist, evaluated RI #25. EI #3 completed a form titled, "PLAN OF TREATMENT FOR OUTPATIENT REHABILITATION" with a start of care date of 10/3/12. Documentation on the form read, "... (RI #25) referred to O.T. (Occupational Therapy) by nursing (secondary to) several recent falls ... Eval (Evaluation): Pt (patient) sitting in a std. (standard) style chair @ (at) NH (Nursing Home). Exhibits bruises/edema c (with) (L) (left) side of mouth (secondary to) recent fall ... sitter ... states when pt. is awake, pt. attempts to stand/walk & (and) requires (A) (assistance) to walk safety (safely) ... difficult to re-direct exhibits poor safety awareness and unsteady gait... Pt would benefit from O.T. services for assessment of least restrictive device for safe, comfortable OOB (out of bed) sitting, pt/family/nursing educ (education), dev (develop) FMP (functional maintenance plan) ..." A "THERAPY PROGRESS NOTES" dated 10/3/12 documents a conversation between the therapist and the resident's daughter about options for out of bed sitting options between the use of a scoot chair (recommended by the therapist) and a geri-chair (preferred by the daughter). The daughter requested therapy wait a week due to RI #25 being in pain from the recent dental work and being groggy from the pain meds. A "Occupational Therapy Daily Note" dated 10/8/12 documents "... O.T. spoke with (RI# 25's daughter) today re (regarding) various chair options for pt. for safe OOB sitting. OT explained to daughter the differences between a 'scoot chair' and 'geri-chair.' Daughter agreed (with) therapist that pt. can be tried in a scoot chair initially for OOB sitting ..." On 10/25/12 at 2:48 PM, the surveyor conducted an interview with EI #3. The surveyor asked EI #3 was RI #25 safe to be in a recliner. EI #3 stated not without someone closely supervising her. EI #3 stated RI #25 has a history per nursing and her observations of her attempts to stand and walk. EI #3 stated RI #25 required two person assistance to perform safe standing and walking. "Nurses Notes" for RI #25 documents, "... 10/04/12 at 4:30 PM, received call from sponsor ... I (EI #8, Assistant Director Of Nursing/Unit manager of Arbor unit) review (reviewed) safety measures of bed alarm and chair alarm and to alert staff if resident ambulates ... 10/04/12 10:30 pm Resident asleep in recliner at this time. Concerned for safety without sitter present as resident continues to abruptly jump up to walk ... 10/5/12 9am Spoke with (RI# 25's daughter) ... we couldn't provide one on one care to resident ... 10/05/12 9:50 am, Resident stood up and lean (leaned) forward on CNA ... and almost fell and the other CNA ... had to help with the safety of resident and CNA ... 10/06/12 (7-3), Resident not wanting to remain in chair in day area. Resident pushing back in chair ... Resident attempting to get up leaning forward walking hasity (hasty) ... 10/08/12 at 10 am, Resident constantly up and down out of chair. Monitoring and watching for resident safety and others. Resident confused and require 2 person assist with ADL's (Activities of Daily Living) and one on one care is needed. Adviced (Advised) Manager and DON ... (Note written by EI #11) 10/09/12 at 7 (7:00) AM, Resident awake and up will not sit still lunges up to walk. Concern for safety ..." Nurses notes dated 10/10/12 at 4:00 PM documents a meeting was held with RI#25's two daughters, the DVP (Division Vice President) and the DON to discuss RI#25. This note documents that one of the daughters, "... wanted a guarantee her mom wouldn't fall. DVP advised her that due to residents advanced stage of dementia she would probably have falls again and there was no way to prevent that without restraining or sedating resident which was no quality of life & we would not do that, and that the facility did not provide one on one care & if the family wanted sitters at their own cost that was up to them. Family clearly voiced their understanding that resident could or would fall again. They voiced pleasure with the scoot chair therapy currently had their mom in. Resident is to have oral surg (surgery) Friday & post procedure will return to facility with family or sitter thru week end ... Agreed to meet in 2 weeks again (with) family to discuss progression." The facility completed a "Care Area Assessment (CAA) Summary" on RI #25 on 10/11/12. The "Analysis of Findings" section documents, "... (Name of RI #25) is at risk for falls due to impaired cognition ... unsteady gait, poor safety awareness, and a history of falls. (RI #25) does attempt to get up and move about with out assistance of staff she is on our dementia unit and staff does keep a close visual watch on her. She has had falls and fx. (fracture)..." The "Care Plan Considerations" section documents, "... has had falls this past quarter and injury has been identified and treated ..." "Nurses Notes" for RI #25 dated 10/12/12 at 12 PM document, " ... NPO ... because of oral surgery on today ... 10/12/12 at 8:00 PM "Resident returned from dentist around 3:15. Daughters with (RI#25) ... 10/12/12 at 8:45 PM ... sitter at bedside ..." Nurses Notes dated 10/13/12 at 2 AM, 4 AM, 6 AM document sitter at bedside. Nurses Notes dated 10/13/12 at 4 PM document there is no sitter present and the daughter is not present. A Progress Note by RI #25's physician at the nursing home dated 10/15/12, documents: "... Assessment And Plan: ... (Name of RI #25) continues to be an extreme high risk for falls due to her behaviors of charging forward with her head down ... unless the facility could place 2 staff members with her at all times she will continue to injure herself and possible others ..." The facility's Vice President/Acting Administrator, EI #9, sent a letter regarding RI #25 to her sponsor informing them of a decision to discharge the resident from the facility in 30 days. The letter dated 10/15/12, documents: "... This letter is notification of discharge of your mother, (RI #25) from the (name of the facility). This notice is effective no later than Friday, November 16, sooner if possible. This discharge is necessary for (RI #25's) welfare as her needs cannot be met by the facility. Dr. (name) has entered the order for discharge into her medical record ...We understand you will be utilizing some sitter services as (RI #25) recuperates from Friday's dental procedure. We would like to supplement those services so that your mother has 24 hour sitter services during this 30 day timeframe ..." On 10/28/12 at 2:56 PM, the surveyor conducted an interview with EI #7, the Director of Clinical Services. The surveyor informed EI #7, that in reviewing the facility's 30 day discharge notice for RI #25, the surveyor read that the facility wanted to supplement 24 hour sitters services for RI #25. The surveyor asked EI #7 what was the reason for the 24 hour sitters. EI #7 stated they wanted to make sure RI #25 was safe until she left. EI#7 stated they thought the sitters might be the best thing. EI #7 stated the facility had never done this before, had 24 hour sitters. EI#7 stated they had run out of options, approaches other than have someone sit with her at all times. When EI#7 was asked if the facility provided the 24 hour sitters EI#7 stated the facility had a contract for sitters to come starting the morning she fell . EI #7 stated when she talked to the nurses on the unit where RI #25 resided, she told them to make sure RI #25 was in close proximity at all times. EI #7 stated staff were told they needed to have someone watching RI #25, eyeballing her, having her close enough so they could see her at all times. EI #7 stated she knew RI #25 had been sleeping but that didn't matter. EI #7 stated she understood people woke up that's why it was said to keep RI #25 in eyesight at all times. EI #7 stated she thought she and the DON gave staff instructions about what was expected of them with RI #25. The surveyor asked EI #7, on the morning of 10/17/12, did RI #25 have an assigned person to do one-on-one care for her. EI #7 stated she didn't know. EI#7 stated she told the nurses that she wanted one person with her at all times. EI#7 stated she told them to be watching her at all times. The surveyor asked EI #7 was she made aware that the morning RI #25 fell face first to the floor she did not have her chair alarm on the recliner. EI #7 stated no one told her that. "Nurses Notes" for RI #25 documents: "10/15/12 at 1240 (12:40 PM) ...Will continue to monitor & resident is (in) visual sight ... 10/15/12 at 1:30 PM ... Staff has kept her (RI #25) within visual view all shift ... 10/15/12 at 7:30 (7:30 PM) ... Sitter @ side ..." On 10/27/12 at 3:12 PM, the surveyor conducted an interview with EI #16, the LPN assigned to care for RI #25 on 10/15/12 on the 3 PM - 11 PM shift. The surveyor asked EI #16 did RI #25 have a one-on-one sitter on her shift. EI #16 stated yes, EI #6. EI #16 stated she did not remember why RI #25 needed one-on-one but she knew RI #25 had a couple of previous falls. EI #16 stated the one-on-one sitter's responsibilities with RI #25 was strictly to keep RI #25 within his sight at all times and also to assist with her ADL's (Activities Of Daily Living). The surveyor asked EI #16 who did she give report to on that day. EI #16 stated to EI #5. EI #16 stated she told EI #5 that EI #6 was sitting with RI #25. EI #16 stated she did not recall if she said one-on-one. "Nurses Notes" continue to document: "10/15/12 at 11:30 PM ... Resident in sight of nurse and CNA's. Will continue to monitor ... 10/16/12 at 5p (5:00 PM) ... CNA @ chair side ..." On 10/26/12 at 4:43 PM, the surveyor conducted a phone interview with EI #10, the LPN assigned to care for RI #25 on 10/16/12 on the 3 PM - 11 PM shift. The surveyor asked EI #10 did RI #25 have a one-on-one sitter on her shift. EI #10 stated yes, EI #6. EI #10 stated EI #6 was responsible for sitting with RI #25. EI #10 stated EI #6 took RI #25 to the bathroom and the majority of the time he just sat there by her side. EI #10 stated EI #6 did not take care of any patient (resident) only RI #25. EI #10 stated when you do one-on-one you only have that patient. You would have no other responsibilities. The surveyor asked EI #10 who she gave report to. EI #10 stated she gave report to EI #5, the 11 PM - 7 AM LPN. The surveyor asked EI #10 did she tell EI #5 RI #25 needed a one-on-one sitter. EI #10 stated no, EI #5 had worked the night before as the nurse on the Arbor unit. EI #10 stated no one told her RI #25 was getting a one-on-one sitter for the 11 PM - 7 AM shift. The surveyor asked EI #10 where was RI #25 on her shift. EI #10 stated RI #25 was sitting in a scoot chair and had a chair alarm on the scoot chair. The surveyor asked EI #10 had she ever seen RI #25 in a recliner chair. EI #10 stated yes. The surveyor asked EI #10 had she seen a chair alarm on the recliner. EI #10 stated yes. The surveyor asked EI #10 how was the chair alarm attached to the recliner. EI #10 stated you would put the alarm pad in the seat of the recliner then put the alarm box on the top of the recliner. The surveyor asked EI #10 how was RI #25's gait. EI #10 stated very unsteady. EI #10 stated RI #25 used to walk erect and unassisted now she leans her head forward, and walks at a very fast pace while leaning forward. EI #10 stated she has known RI #25 to get up out of her recliner by herself and it was not safe for RI #25 to be in the recliner without her alarm. EI #10 stated RI #25 getting up with her head down could cause her to fall if no one assists her up. EI #10 stated if RI #25 has the alarm attached to her, it would alert staff she was trying to get up. EI #10 stated RI #25 is not aware of her safety needs. On 10/25/12 at 5:46 PM, the surveyor conducted a phone interview with EI #6, the CNA assigned to sit with RI #25 on 10/15/12 and 10/16/12 on the 3 PM - 11 PM shift. EI #6 confirmed he sat with RI #25 on these shifts. EI #6 stated when he left on 10/16/12, RI #25 was removed from her scoot chair and placed in a recliner. The surveyor asked EI #6 was the chair alarm placed on the recliner. EI #6 stated he didn't think so. EI #6 stated he normally did not work with RI #25 so he wasn't sure whether it should be on the recliner or not. On 10/24/12 at 11:28 AM, the surveyor conducted a phone interview with the sponsor of RI #25. RI #25's sponsor said RI #25 had fallen several times at the facility. RI #25's sponsor stated it was her impression that RI #25 was supposed to have 24 hour sitters and she had a letter from the facility telling her the facility was going to provide the sitters. RI #25's sponsor said on 10/16/12, Tuesday night, she observed a CNA (EI #6), sitting with her mother. The surveyor asked RI #25's sponsor the reason RI #25 was being discharged from the facility. RI #25's sponsor stated the facility told her they could no longer care for her. RI #25's sponsor stated the facility did send her a discharge letter that said they would provide 24 hour sitters until her mother was discharged . "Nurses Notes" for 10/17/12 at 7:30 AM, documents, "... At approximately 6:00 am, Resident was found in floor in dayroom. This writter (writer) had been sitting in dayroom at table across from resident. Writter got up to check on a med for another resident, as soon as writter turned around, she heard a noise, when writter turned around resident was lying in floor face down, CNA (EI #2) came from down the hall and saw resident on the floor, called for CNA (name of EI #1) to come assist. Resident was assisted into scooter chair. Blood was coming from mouth, nose, and chin. 911 was called to send ambulance. (Daughter) was notified of incident at 6:05 am. MD (medical doctor) on call was notified at 6:10 am and order to send out for evaluation was ordered. At approximately 6:30 am Fire and Rescue arrived to evaluate situation ... Resident had been in Recliner since writter (writer) had gotten on duty ... Resident was sent to (name of hospital) for evaluation." On 10/25/12 at 7:05 AM, the surveyor conducted an interview with EI #5, the LPN assigned to care for RI #25 on 10/16/12 on the 11 PM - 7 AM shift. The surveyor asked EI #5 did RI #25 have a fall on her shift. EI #5 stated, yes. EI #5 stated around 6:00 AM, RI #25 was sitting in a recliner in the dayroom and appeared to be asleep. EI#5 stated that the recliner was reclined all the way back most of the shift. EI#5 stated RI#25 would try to get up and push the foot rest down and that sometimes she would get the foot rest all the way down and sometimes she wouldn't. EI#5 stated they would leave it down sometimes because she would cross her legs and go to sleep and then after awhile they would recline her fully back. When asked how many times RI#25 attempted to get up, EI#5 stated about five times. EI#5 also stated that RI#25's eyes would still be closed when she attempted to get up. When asked if RI#25 was really asleep, EI# 5 stated she did not know. EI#5 stated those were the movements she was making throughout the shift (her eyes being closed and her raising up). EI #5 stated a resident asked for a medication and she got up from the table where she was sitting. EI #5 stated she turned her back to RI #25 to walk into the medication room. EI #5 stated as she got to the door of the medication room she heard a noise. EI #5 stated she turned around and observed RI #25 on the floor, face down. EI #5 stated RI #25 had a laceration to her chin and a laceration above her upper lip. EI #5 stated it appeared something could have been wrong with RI #25's nose but there was so much blood she could not tell. EI #5 stated RI #25 had blood on her face from the bridge of her nose down. EI #5 stated the CNAs, EI #1 and EI #2 assisted RI #25 off the floor. The surveyor asked EI #5 was RI #25 receiving one-on-one before she fell . EI #5 stated from her knowledge RI #25 had one-on-one on the 7 AM - 3:00 PM shift and the 3 PM - 11 PM shift. EI #5 stated it was after the fact that she found out RI #25 was to receive one-on-one for her shift, as well. EI #5 was asked if the facility increased staff to care for RI#25 after she fell on [DATE]. EI #5 stated there was no increase in staff on 10/15/12 for the 11 PM - 7 AM shift. EI #5 confirmed RI #25 did not have a chair alarm on the recliner on her shift. On 10/31/12 at 8:20 AM EI # 5, EI #4, EI #8, and EI #19, the Maintenance Director all went to the location of RI #25's fall on 10/17/12. Measurements were taken and it was determined that at the time of the fall, EI #5 was standing approximately 21 1/2 feet from the recliner where RI #25 had previously been sitting. RI #25 fell approximately 11 feet, 4 inches from the recliner. It was also determined that EI #5 was standing 10 feet, 2 1/2 inches from where RI #25 fell . On 10/27/12 at 8:00 AM, the surveyor conducted a second interview with EI #5, the LPN assigned to care for RI #25 on 10/16/12 on the 11 PM - 7 AM shift. The surveyor asked EI #5 how many times did she leave the secure unit on 10/17/12. EI #5 stated she recalled three times to go to Parkwood unit to do her rounds and to give the as needed medications. EI #5 was asked if RI #25 was left alone in the day room on 10/17/12. EI #5 stated she didn't know when she wasn't back there. EI #5 stated there was probably about 2 minutes where RI #25 was left alone. EI #5 stated she had to take RI #31 back to her room. The surveyor asked EI #5 would it have been possible for another staff (staff member) to watch RI #25 while she went to get the medication from the medication cart for the other resident. EI #5 stated the two CNAs back there (on the Arbor unit) were getting residents up so no one was around. EI #5 stated, "I probably could have asked one of them. No one was around." The surveyor asked EI #5 was it safe for RI #25 to ambulate by herself. EI #5 stated no because RI #25 would always end up in a charging position which leaned her more toward falling. The surveyor asked EI #5 when did she find out RI #25 was one-on-one. EI #5 stated the day she fell . The surveyor asked EI #5 what did one-on-one sitting mean to her. EI #5 stated it meant that the staff member that is assigned one-on-one care only is responsible for that one resident. EI #5 stated EI #16, the LPN assigned to care for RI #25 on 10/15/12, and EI #10, the LPN assigned to care for RI #25 on 10/16/12, did not inform her RI #25 needed one-on-one sitting. EI #5 stated when she saw EI #6 sitting with RI #25, she knew that RI #25 could get out of hand for two people who had other residents to take care of. EI #5 stated she thought EI #6 was there so the other CNA's could assist with the other residents. EI#5 stated had she known the resident needed one on one she would have pulled a CNA to sit with her. According to a facility "WITNESS STATEMENT" by EI #5 on 10/17/12 at 7:50 am, it was documented: "... I gave Midnight meds it took approx (approximately) 30 min (minutes) 1045 (10:45) - 1130 (11:30) pm ...When I left the unit she (RI #25) was resting in the recliner snoring c (with) eyes closed reclined half way with foot rest partially elevated. I returned to Arbor between 2 (2:00) - 215 (2:15) AM. I made rounds on all residents (name of RI #25) was in the recliner snoring c her head tilted back and eyes closed I left unit at 300 (3:00) AM and returned @ (at) 320 (3:20) AM and stayed till 345 (3:45) AM. I went to Parkwood to round I returned to Arbor at 5 AM I sat in common area with other residents at 520 (5:20) AM I escorted (RI #31) to her room and returned to day room ..." On 10/31/12 at 8:30 AM, a third interview was conducted with EI #5. The surveyor asked EI #5 was there an increase in staff on 10/16/12 on the Arbor unit on the 11 PM - 7 AM shift. EI #5 stated no. EI #5 stated there wasn't an alarm on the recliner and she did not realize it until RI #25 fell . On 10/25/12 at 10:18 AM, the surveyor conducted an interview with EI #1, the CNA assigned to care for RI #25 on the 11 PM - 7 AM shift on 10/16/12. EI #1 stated she was in a resident's room and she heard her name being called by EI #2. EI #1 stated when she came up to the dayroom she saw EI #2 and EI #5 standing over RI #25. EI #1 stated RI #25 was lying on the floor, face down. The surveyor asked EI #1 where was RI #25 when she first came on her shift. EI #1 stated RI #25 was in the scoot chair and another CNA (EI #6) was sitting with her. The surveyor asked EI #1 who placed RI #25 in the recliner on her shift. EI #1 stated EI #6 did before he left. The surveyor asked EI #1 did RI #25 have a chair alarm on the recliner on her shift. EI #1 stated no. EI #1 stated it would have been the CNA's responsibility to place the chair alarm on the recliner. EI #1 stated when EI #6 put RI #25 in the recliner the chair alarm should have been placed on the recliner and it wasn't. EI #1 stated she did not realize the chair alarm was not on the recliner until RI #25 fell . The surveyor asked EI #1 was RI #25 receiving one-on-one before she fell on [DATE]. EI #1 stated RI #25 did have someone on one-on-one before she fell on [DATE] and then it stopped. EI #1 stated the one-on-one started back and EI #6 was there when she came in on 10/16/12. EI #1 stated EI #6 was there at 7 PM and left at 11 PM. EI #1 stated one-on-one is when you have someone there with you constantly. EI #1 stated you can't leave the resident for any reason without telling someone else. The surveyor asked EI #1 did the facility increase staff (on 10/16/12 on the 11 PM - 7 AM shift). EI #1 stated no. EI #1 stated she and the same CNA worked. EI #1 stated RI #25 had a sitter up until 11 PM. EI #1 stated after that is was the two CNAs. On 10/25/12 at 8:56 AM, the surveyor conducted an interview with EI #2, the other CNA assigned to work the Arbor unit on 10/16/12 (11 PM - 7 AM shift/the shift RI #25 fell ). EI #2 stated RI #25 wouldn't be still that she was constantly moving, even in her sleep and needed one-on-one care. EI #2 stated when she first came on (on 10/16/12) RI #25 was sitting in her scoot chair and she had a sitter, EI #6. EI #2 stated EI #6 put