Every finding on record at Owenton Healthcare and Rehabilitation

Number of residents sampled: Number of residents cited: Based on interview, record review, document review, and facility policy review, the facility failed to protect the resident's right to be free from physical abuse by another resident for two (Resident (R) 60 and R70) of three sampled residents reviewed for abuse. Resident-to-resident abuse occurred in two different incidents. On 10/02/2025, R60 swatted R70 and made contact with the resident's chest. On 10/27/2025, R65 hit R60 on the shoulder. Findings included: A facility policy titled, Abuse, Neglect and Exploitation, reviewed 06/2025, revealed, Policy: It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. Per the policy, Abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish, which can include.certain residents to resident altercations. The policy specified, Physical Abuse includes, but it not limited to, hitting, slapping, punching, biting, and kicking. 1. Review of a Resident Face Sheet revealed the facility admitted R60 on 12/04/2018. According to the Resident Face Sheet, the resident had a medical history that included a diagnosis of dementia with agitation. An annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 11/19/2025, revealed R60 had a Brief Interview for Mental Status (BIMS) score of 9/15, which indicated the resident had moderate cognitive impairment. A Resident Face Sheet revealed the facility admitted R70 on 09/09/2013. According to the Resident Face Sheet, the resident had a medical history that included a diagnosis of Alzheimer's disease. An annual MDS, with an ARD of 09/02/2025, revealed R70 had a BIMS score of 11/15, which indicated the resident had moderate cognitive impairment. Review of a facility Initial Report dated 10/02/2025, revealed after an activity, R70 backed up into R60 with her wheelchair and R60 reached out with her upper extremity, swatted, and made contact with R70's chest. Per the Initial Report, both residents were immediately separated and R60 was placed on 1:1 supervision while the investigation was initiated. The facility's Final Report/5 Day Follow-Up, dated 10/07/2025, revealed at the conclusion of the investigation, it was verified that the alleged incident did occur. According to the Final Report/5 Day Follow-Up, Activities Assistant (AA) 5 witnessed the incident. During an interview on 01/14/2026 at 11:16 AM, AA5 stated at the time of the incident, the residents were waiting for their smoke break when R70 backed into R60's wheelchair, and R60 placed her hand on R70's shoulder as if to let R70 know she needed to stop backing up. AA5 stated that, based on her training and experience, she would consider what she witnessed to be physical abuse. During an interview on 01/14/2026 at 11:53 AM, the Director of Nursing (DON) stated she was not at the facility at the time of the incident; however, she felt the incident between R60 and R70 did rise to the level of physical abuse. The DON stated she would expect residents to be free from abuse and feel safe in the facility. During an interview on 01/14/2026 at 12:06 PM, the Administrator stated she would expect residents to be free of abuse and kept safe in the facility. 2. A Resident Face Sheet revealed the facility admitted R60 on 12/04/2018. According to the Resident Face Sheet, the resident had a medical history that included a diagnosis of dementia with agitation. Review of an annual MDS, with an ARD of 11/19/2025, revealed R60 had a BIMS score of 9/15, which indicated the resident had moderate cognitive impairment. R60's Care Plan included a problem statement, initiated 10/02/2025, that indicated the resident had episodes of increased aggressive behavior towards others. A Resident Face Sheet revealed the facility admitted R65 on 12/26/2023. According to the Resident Face Sheet, the resident had a medical history that included diagnoses of dementia, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. A quarterly MDS, with an ARD of 10/24/2025, revealed R65 had a BIMS score of 3/15, which indicated the resident had severe cognitive impairment. Review of a facility Initial Report, dated 10/27/2025, revealed R60 and R65 were in the center hallway when they began to have a verbal disagreement. Per the Initial Report, R65 used their hand to make contact with R60's left upper extremity. The Initial Report indicated the incident was witnessed by Certified Nursing Assistant (CNA) 3. The facility's Final Report/5 Day Follow-Up, dated 10/07/2025, stated that During an interview with CNA [CNA3], she reported that she overheard a verbal disagreement between [R60] and [R65] in the middle hallway of the facility. She stated that when she rounded the corner, she witnessed [R65] use [their] hand to make contact with [R60] left upper extremity and [R60] begin to yell at [R65]. At that time, she reports that she separated the residents immediately and reported the incident to the DON [Director of Nursing] and Admin [Administrator]. During an interview on 01/13/2026 at 12:01 PM, CNA3 stated she was walking to the shower room and heard some yelling. CNA3 stated she saw R65 forcefully hit R60 in the shoulder and R60 said, Don't you [expletive] hit me. According to CNA3, from what she witnessed that day based on her abuse training, she would consider what R65 did to R60 to be physical abuse. During an interview on 01/14/2026 at 11:53 AM, the DON stated she felt the incident between R65 and R60 did rise to the level of physical abuse. The DON stated she would expect residents to be free from abuse and feel safe in the facility. During an interview on 01/14/2026 at 12:06 PM, the Administrator stated she would expect residents to be free of abuse and kept safe in the facility.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure one (R) 4) of two sampled residents reviewed for nutrition received their diet as ordered. R4, who was at nutritional risk, failed to receive his physician-ordered therapeutic diet for additional protein and fortified foods. Findings included: Review of a facility policy titled, Therapeutic Diet Orders, reviewed 06/2025, indicated, Policy: The facility provides all residents with foods in the appropriate form and/or the appropriate nutritive content as prescribed by a physician, and/or assessed by the interdisciplinary team to support the resident's treatment/plan of care, in accordance with his/her goals and preferences. The policy specified, 5. Dietary and nursing staff are responsible for providing therapeutic diets in the appropriate form and/or the appropriate nutritive content as prescribed. Review of a resident demographic record revealed the facility admitted R4 on 11/28/2019. According to the resident demographic record, the resident had a medical history that included diagnoses of quadriplegia and Stage IV pressure ulcer of the sacral region. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/16/2025, revealed R4 required set-up or clean-up assistance with eating, had no weight loss or gain, and was on a therapeutic diet. R4's Care Plan included a problem statement, initiated 07/05/2022, that indicated the resident was at nutritional risk related to a diagnosis of diabetes mellitus and altered skin integrity. Interventions directed the staff to provide the resident with his diet as ordered. R4's physician orders revealed an order dated 12/29/2025, for a regular, fortified foods, and double portion protein diet. During an observation of meal service on 01/14/2026 at 12:18 PM, R4's lunch meal tray consisted of 6 ounces (oz) of beef stew, peas, a biscuit, a piece of cake, an 8 oz glass of tea, and 2% milk. During an interview on 01/14/2026 at 12:26 PM, the Certified Dietary Manager (CDM) stated residents with orders for double portions of protein should receive 8 oz of beef stew, and for fortified foods, the resident should receive fortified mashed potatoes. Per the CDM, if R4 was only provided 6 oz of beef stew, the resident did not get a double portion of protein. In addition, if the resident received peas, he did not get the fortified food for that meal, which was fortified mashed potatoes. During an interview on 01/16/2026 at 8:51 AM, the Registered Dietician (RD) confirmed R4 had orders for a regular diet with fortified foods and a double portion of protein. The RD stated she expected the dietary staff to follow the resident's therapeutic diet order and provide R4 with a double portion of protein and the fortified food item for each meal to prevent weight loss. During an interview on 01/16/2026 at 9:51 AM, the Director of Nursing (DON) stated R4 was ordered a therapeutic diet of double portion protein and fortified foods to promote wound healing and decrease weight loss. The DON stated that although R4 had not experienced any weight loss, she expected the staff to make sure the resident received his ordered diet During an interview on 01/16/2026 at 10:24 AM, the Administrator stated she expected residents to receive their therapeutic diet as ordered.

Based on interview, record review, and review of the facility's policy, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice for 1 of 3 sampled residents, (Resident (R)3). R3 began vaginal treatment with Monistat 7 (antifungal vaginal cream) for a yeast infection on 11/29/2024. R3 had complaints of pain and discomfort. The facility transferred R3 to a hospital on 12/06/2024. At the hospital, R3 had a computed tomography (CT) scan performed which revealed the resident had a foreign object present in her vaginal canal, which was later determined to be a Monistat vaginal cream applicator. R3 stated the whole situation was unnecessary, caused her unnecessary pain and was humiliating. The findings include: Review of the facility's policy titled, Provision of Quality Care, revised 02/01/2024, revealed based on comprehensive assessments, the facility was to ensure residents received treatment and care by qualified persons in accordance with professional standards of practice, the comprehensive person-centered care plans, and the resident's choices. Further review revealed each resident was to be provided care and services to attain or maintain his/her highest practicable physical, mental, and psychosocial well-being. Review of the facility's policy titled, Medication Administration, revised 02/20/2024, revealed medications were administered by licensed nurses, or other staff who were legally authorized to do so in the state, as ordered by the physician and in accordance with professional standards of practice. Additional review revealed medications were to be administered as ordered in accordance with the manufacturer's specifications. Review of the facility's policy titled, Specific Medication Administration Procedures, dated 05/2022, revealed vaginal medications were to be administered in a safe, accurate, and effective manner. Review of the Monistat 7 package insert revealed the directions for use included removal of the applicator after insertion of the cream medication. Further review revealed the applicator was to be washed after each use. Review of the Face Sheet for R3 revealed the facility admitted the resident on 11/19/2023. R3's diagnoses included muscle weakness, polyneuropathy, and urinary tract infection (UTI). Review of the Annual Minimum Data Set (MDS) Assessment with an Assessment Reference Date (ARD) of 11/23/2024, revealed the facility assessed R3 with a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated the resident was cognitively intact. Further MDS review revealed the facility assessed R3 for bilateral lower extremities (BLE) impairment, dependent for toileting hygiene, and urinary incontinence. Review of R3's progress note, dated 11/27/2024, revealed the resident complained of inner vaginal pain/itching, inner labia pain/itching, and stated she had green discharge coming from her vagina. Per review, an assessment was performed by nursing staff and revealed R3 had redness to the vaginal area with no bleeding, and her urine was documented as clear yellow. Continued review revealed the physician and Unit Manager (UM) were notified, and orders were received for Diflucan (medication used to treat fungal and yeast infections) for treatment of a yeast infection. Further review revealed the Diflucan was discontinued on that date due to interactions with R3's other medications. Review of R3's progress note, dated 11/28/2024, revealed the physician ordered Monistat 7 with a vaginal applicator for treatment of a yeast infection. Review of R3's physician's orders revealed an order dated 11/29/2024, for Monistat 7 cream 2%: one applicator vaginally at bedtime for acute candidiasis of vulva and vagina. Review of the progress notes dated 11/29/2024, revealed the treatment with Monistat 7 had been initiated at bedtime per the physician's orders. Review of R3's, Medication Administration Record (MAR), dated 11/29/2024 - 12/04/2024, revealed the Monistat 7 was administered to R3 daily at bedtime 11/29/2024 - 12/02/2024. Further review revealed R3 refused administration on 12/03/2024 and 12/04/2024. Review of R3's progress notes dated 12/01/2024 revealed Monistat 7 was administered with slight discomfort noted during administration. Review of R3's progress note dated 12/02/2024 at 2:58 AM, revealed no adverse effects noted from Monistat (administration) and no complaints from resident. Review of R3's progress note dated 12/03/2024, revealed the resident complained of vaginal pain and discomfort and was assessed by nursing with findings of no bleeding, some edema to the labia, and a whitish discharge. Continued review revealed R3 refused administration of the Monistat 7 and continued to complain of vaginal pain. Per review, the on-call physician was notified, and orders were received for a urinalysis and blood work the following morning. Further review revealed R3's routine oxycodone (narcotic pain medication) was administered for pain with documented effectiveness. Review of R3's urinalysis and bloodwork collected on 12/04/2024 revealed positive findings for a UTI. Review of R3's progress note dated 12/04/2024, revealed the resident refused administration of the Monistat 7 and continued to complain of pain and told staff she felt injured. Per review, staff assessed R3 and observed redness and white patches to her vaginal area, but no sign of injury. Continued review revealed Tylenol was administered to the resident and was documented as effective. Review of R3's progress note dated 12/05/2024, revealed R3 started the antibiotic for a urinary tract infection (UTI) and the Monistat 7 had been discontinued. Further review revealed no additional documented complaints of pain or discomfort on 12/05/2024. Review of R3's progress notes dated 12/06/2024, revealed at 10:30 AM, R3 requested to speak to the Director of Nursing (DON) and asked to be sent to the emergency room (ER) for evaluation because of her vaginal pain and discomfort. Per review, R3 reported she had vaginal pain since the evening of 12/02/2024, after the nurse administered the vaginal medication. Further review revealed R3's husband took her to the hospital. Review of R3's progress note dated 12/07/2024, revealed the resident returned to the facility accompanied by her brother after evaluation at a hospital. Per review, R3 told staff she felt much better after the tube was removed from her at the ER. Review of the ER records revealed R3 presented with complaints of pain to the vaginal area and a three-day history of UTI symptoms. Per review, a computed tomography (CT) scan was performed and showed an indeterminate 12 centimeter (cm) cylindrical foreign body about the vaginal canal. Further review revealed when the foreign body was removed it was determined to be a Monistat applicator. Review of the facility's investigation revealed the facility was unable to definitively determine the staff member who inserted R3's (Monistat) medication. Continued review revealed immediate education for proper administration of Monistat 7 was provided to all nursing staff on 12/07/2024. Per review, the facility also reviewed all active medications in the facility on 12/07/2024, with no other residents identified who required vaginally administered medication. Additionally, review revealed the Nurse Practitioner (NP) and Medical Director were notified on 12/07/2024. In interview with the contract Pharmacist 1 on 12/24/2024 at 8:58 AM, she stated Monistat 7 was administered vaginally via a plunger type applicator and the applicator was then removed. She stated the directions for Monistat 7 medication for R3 were sent with the medication to the facility. Pharmacist 1 stated, in her opinion, the vaginal applicator was a foreign body and was not intended to remain in the resident. She further stated the applicator was not sterile and posed a risk for infection as well as the potential for pain if left in the vaginal canal. During interview with contract Pharmacist 2 on 12/27/2024 at 12:26 PM, he stated the Monistat 7 sent to the facility for R3 had been for a seven day supply. He stated the Monistat included one reusable applicator that was a plunger type system. In interview with R3 on 12/26/2024 at 9:52 AM, she stated initially both she and nursing staff thought she had a yeast infection, so the vaginal medication was started on 11/29/2024 and given at bedtime. R3 stated she experienced no problems until the evening of 12/02/2024, when Registered Nurse (RN) 1 inserted the medication. She stated she felt like RN 1 had been a little anxious and had heard her say she hoped she had gotten it (the Monistat 7) in the right place as she walked out of the room. R3 said afterwards she had vaginal pain and reported the pain to nursing staff. She stated the pain continued and a urine sample was taken that came back positive for an infection. R3 explained her pain had been attributed to the UTI and she was placed on an antibiotic on 12/05/2024. She stated on 12/06/2026, she asked the DON for transport to the ER because she still had pain and discomfort. R3 stated at the hospital a CT scan was performed which showed something inside her and when the doctor removed the object, it was a plastic applicator. R3 stated when she returned to the facility, staff apologized, and the Administrator informed her all nurses had been retrained on administration of medications with a vaginal applicator. In additional interview with R3 on 12/27/2024 at 1:37 PM, she stated the whole situation was unnecessary, caused her unnecessary pain and had been humiliating to go through. In interview with family member (FM) 2 on 12/26/2024 at 10:53 AM, he stated he had been at the ER with R3. He stated he had the actual item that was removed from R3 in his possession. In interview with Certified Nursing Assistant (CNA) 1 on 12/26/2024 at 11:46 AM, she stated she was familiar with R3 and had taken care of her the day prior to her ER visit. She stated R3 complained of pain to her vaginal area that day when she tried to help her get up out of bed, and she left the resident in bed and notified nursing immediately. In interview with Licensed Practical Nurse (LPN) 1 on 12/26/2024 at 12:31 PM, she stated Monistat 7 was not a common medication used at the facility. She stated if she was unfamiliar with a particular medication, she asked her Unit Manager (UM) or another nurse for help. LPN 1 stated after R3 returned from the hospital, nursing was given an in-service on administration of vaginal medications that included confirmation that the applicator or device was intact and not left in the resident. In interview with the Administrator on 12/26/2024 at 3:02 PM, she stated no other residents were currently ordered Monistat, and that it was not a commonly administered medication at the facility. She stated an investigation was conducted after the hospital notified them of finding the applicator in R3. In interview with the UM on 12/26/2024 at 3:06 PM, she stated on 12/04/2024, R3 complained of vaginal pain, and she assessed the resident for signs of injury, but none were noted. She stated R3 had not complained of constant pain; however, seemed to have more discomfort when she was moved or transferred. The UM further stated R3's urinalysis had returned positive for UTI and an antibiotic was ordered, so the resident's pain had been attributed to the UTI. In interview with LPN 2 on 12/26/2024 at 3:22 PM, she stated she had not administered medication vaginally with an applicator since she had worked at the facility. She stated she had taken care of R3 on 11/27/2024, when the resident complained of pain and itching around her vaginal area. LPN 2 reported she notified the physician and received orders for Diflucan. She stated she only worked on an as needed (PRN) basis; however, the DON contacted her two or three weeks ago regarding getting education related to administration of Monistat and any other vaginally inserted medications. LPN 2 stated a vaginal applicator was always removed after administration of the medication. In interview with LPN 3 on 12/26/2024 at 3:30 PM, she stated she cared for R3 when she returned from the hospital and the resident had no complaints of pain at that time. LPN 3 stated medications with applicators were rarely used at the facility; however, if she was unsure or unfamiliar with a medication, she asked her supervisor or co-worker before administrating the medication. She stated the DON provided an in-service about two weeks ago that addressed proper administration of Monistat and other vaginally inserted medications. LPN 3 stated some of the applicators were prefilled and others were filled by nursing prior to administration. She further stated, regardless of how medication was supplied, once administered the applicator was removed from the resident. In interview with RN 2 on 12/26/2024 at 3:46 PM, she stated she cared for R3 on 12/03/2024 and the resident had been in pain; however, the pain seemed to be with movement and not constant. RN 2 stated after the hospital report was received, the DON provided an in-service to all the nurses on how to administer Monistat. In interview on 12/26/2024 at 5:23 PM with RN 4, she stated she worked the evening of 12/03/2024; however, she had not administered the Monistat to R3. RN 4 stated R3 complained of pain to her vaginal and lower abdominal areas and refused the medication. RN 4 stated she notified the on-call physician and orders were received for a urinalysis and bloodwork for the following morning. She stated R3 received scheduled pain medication, and it had been administered that evening, and the resident slept all night with no complaints of pain. RN 4 stated she had not been assigned to care for R3 anymore until after the resident returned from the hospital. She stated the DON had since provided an in-service on the proper administration of vaginal medications with an applicator. In interview with CNA 3 on 12/26/2024 at 5:36 PM, she stated on 12/03/2024, R3 had complained of vaginal pain while she was in the resident's room. CNA 3 stated she notified nursing right away. She stated she had not been assigned to R3's care anymore until the resident returned from the hospital. In interview with CNA 4 on 12/26/2024 at 5:47 PM, she stated she had been present in R3's room on 12/02/2024, when RN 1 administered the Monistat 7 to the resident. She stated R3 expressed discomfort after RN 1 administered the medication; however, she was not able to say for certain if the Monistat applicator was removed or not. In interview with RN 1 on 12/26/2024 at 6:23 PM, she stated she had given R3 her evening medications around 9:00 PM on 12/02/2024, and she administered the Monistat 7 at that time. RN 1 stated she instructed R3 to take a deep breath when the applicator was inserted to minimize discomfort. She stated after the cream was injected, she removed the applicator. RN 1 stated R3 complained of discomfort and pain at the time of administration of the Monistat 7. She stated however, she was not surprised as the resident had complaints of pain already and the actual yeast infection with the dryness was painful. RN 1 stated she was made aware R3 had gone to the hospital and an applicator was found inside of her. She stated she tried to apologize to R3 that the incident happened. RN 1 stated shortly after that incident, nursing received an in-service by the DON on how to properly insert medication with a vaginal applicator. She stated she had never administered Monistat 7 prior to R3's, and she asked a colleague about it before she gave it to the resident. In interview on 12/27/2024 at 9:52 AM with the DON, she stated R3 initially complained of vaginal pain in late November which appeared to be related to a yeast infection. She stated the physician was contacted and Diflucan was ordered, but the Diflucan interacted with some of R3's other medications, so it was discontinued and replaced with Monistat 7. The DON stated the medication was given the evening of 12/02/2024 and R3 complained of pain to her vaginal and abdominal areas on 12/03/2024. She explained the UM assessed R3 and reported redness and inflammation to the resident's vaginal area; however, that was expected due to her yeast infection. The DON stated there were no reported signs of injury, so nursing continued to monitor the resident's pain. She stated R3's pain continued and the nurse on duty the night of 12/03/2024 contacted the on-call doctor and received orders for bloodwork and urinalysis for 12/04/2024. The DON reported R3's urinalysis returned positive and the resident was started on an antibiotic on 12/05/2024. She stated R3 already received scheduled oxycodone for pain and had PRN Tylenol ordered. In continued interview on 12/27/2024 at 9:52 AM, the DON stated R3 requested to see her on 12/06/2024 and asked to go to the hospital for evaluation of her pain. She stated she was notified on 12/07/2024, there had been a foreign object found in R3's vaginal canal after the hospital report was received. The DON stated she went to the facility immediately and developed an education plan for nursing staff. She stated all the nurses had been inserviced on the proper way to administer medication with a vaginal applicator. The DON stated Monistat was not a common medication given at the facility; however, all nurses had now received education on the topic. The DON stated it was her expectation that nursing staff referred to the package insert for any over the counter (OTC) medication that were unfamiliar to them. She stated they could also contact her anytime day or night for questions or concerns. In an additional interview on 12/30/2024 at 1:42 PM with the DON, she stated the facility followed their policies and procedures and referenced [NAME] for professional standards of care, which was located at the nurse's station. In additional interview with the Administrator on 12/27/2024 at 9:17 AM, she stated obviously they acknowledged a foreign body had been left in R3; however, after their investigation they were not able to definitively determine which staff member was responsible for doing that. The Administrator stated all the nurses reported they removed the applicator after administration of the medication to R3. She stated as soon as the hospital report was received on 12/07/2024, the DON immediately began education with the nurses on proper administration of vaginal applicator medications. In interview with the Administrator on 12/30/2024 at 1:45 PM, she stated it was her expectation all staff followed professional standards of care. She stated each resident was unique with different needs, and it was her expectation staff followed physician's orders and the resident's plan of care (POC) for the safety and well-being of the residents.

Based on observation interview and review of facility policy, it was determined the facility failed to provide special adaptive equipment and utensils for residents who needed them when consuming meals and snacks for 5 of 15, out of 28 sampled residents, (R)1, R5, R22, R76, and R64. The findings include: Review of the facility policy titled, Adaptive Self Feeding Devices, undated, revealed the use of adaptive, self-help feeding devices was encouraged when determined to be helpful to the resident. Continued review revealed the dietary department was responsible for all sanitizing of adaptive utensils after each use and for placing the devices on the meal trays as needed. 1. Review of the Resident Face Sheet for R1 revealed the facility admitted the resident to the facility on [DATE], with diagnoses to include: chronic obstructive pulmonary disease (COPD), type 2 diabetes, and dysphagia. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed the facility assessed R1 to have a Brief Interview for Mental Status (BIMS) score of thirteen out of fifteen, indicating the resident was cognitively intact. Review of the physician order for R1 dated 03/20/2024, revealed an order for the resident to have a regular mechanical soft diet. Continued review of the order revealed R1 was to have a divided plate and sip cup lid. Review of R1's Comprehensive Care Plan dated 06/23/2022, revealed a focus for nutritional risk related to receiving a mechanically altered diet and a diagnosis of dysphagia. Continued review revealed interventions dated 06/23/2022, included providing diet as ordered; and providing a divided plate and spouted lid with meals. Observation on 08/07/2024 at 12:30 PM, of the meal tray card for R1 revealed the resident was to have a sip lid cup. However, further observation revealed no sip lid cup on the resident's meal tray. 2. Review of the Resident Face Sheet for R5 revealed the facility admitted the resident on 02/27/2024, with diagnoses to include: cerebral palsy, unspecified intellectual disabilities and dysphagia. Review of the Quarterly MDS assessment dated [DATE], revealed the facility assessed R5 as having severe cognitive impairment and as rarely or never understood. Continued review of the MDS revealed R5 the facility also assessed the resident as a dependent diner and to be fed by staff. Review of the physician order dated 03/14/2024, revealed orders for R5 to receive a regular pureed diet with honey thick liquids. Additionally, review of the order revealed R5 was to have a small coated spoon, and double meat portions with every meal. Review of R5's Comprehensive Care Plan dated 08/09/2022, revealed a focus problem for the resident as at risk for nutritional status related to a history of being underweight, pureed diet and honey-thick liquids for diagnosis of dysphagia. Further review revealed interventions which included: providing a pureed diet with double meat portions; and for staff to provide adaptive equipment that included a small spoon. Observation on 08/06/2024 at 12:17 PM, revealed R5 was being fed by staff in the dining room during the noon meal. Review of R5 meal tray card revealed a small coated spoon was to be used. However, further observation revealed staff using a regular spoon to feed R5, and not the small, coated spoon. 3. Review of R22's Resident Face Sheet, revealed the facility admitted the resident on 01/27/2018, with diagnoses that included: Parkinson's Disease, dementia, and schizophrenia. Review of the Significant Change in Status MDS assessment dated [DATE], revealed the facility assessed R22 as having a BIMS score of seven out of 15, indicating severe cognitive impairment. Continued MDS review revealed the facility additionally assessed R22 as dependent on staff for eating. Review of the physician's order dated 6/20/2022, revealed R22's diet was regular, puree with a plate guard and built-up utensils; double meat portions; and magic cups (frozen dessert that adds protein and calories) with lunch and dinner. Review of R22's Comprehensive Care Plan dated 06/20/2022, revealed the resident was at risk for malnutrition related to dementia, dysphasia and abnormal labs. Continued review revealed the interventions included staff providing R22's diet as ordered with double meat portions, a plate guard and built up utensils. Observation of R22 on 08/06/2024 at 12:17 PM, in the dining room, revealed the resident was being fed by staff. Review of the meal tray card revealed R22 was to have a plate guard and built up utensils. However, further observation revealed those devices were not in place and being used. 4. Review of F76's Resident Face Sheet, revealed the facility admitted the resident on 06/07/2024, with diagnoses to include; schizophrenia, fracture of the left femur, and protein calorie malnutrition. Review of the Quarterly MDS assessment dated [DATE], revealed the facility assessed R76 as being severely cognitively impaired and as rarely or never understood. Review of R76's physician's order dated 08/01/2024, revealed the resident was to receive a mechanical soft diet with magic cups at lunch and dinner. Additionally, review of the order revealed R76 was to have a divided plate and double portions. Review of R76's Comprehensive Care Plan dated 06/07/2024, revealed a focus for nutritional status related to a diagnosis of severe protein-calorie malnutrition. Continued review revealed the interventions included: providing diet as ordered; magic cup with lunch and dinner. However, further review revealed R76's care plan had not been updated to include the interventions for a divided plate or double portions. 5. Review of R64's Resident Face Sheet, revealed the facility admitted the resident on 02/21/2024, with diagnoses of cerebral infarction due to embolism, dysphagia, and hemiplegia and hemiparesis following cerebral vascular disease. Review of the Quarterly MDS assessment dated [DATE], revealed the facility assessed R64 to have a BIMS score of five out of 15, indicating severe cognitive impairment. Continued MDS review revealed the facility assessed R64 as dependent on staff for eating. Review of R64's physician's order dated 08/05/2024, revealed the resident was to have a mechanical soft diet, house shakes at lunch and dinner, and a scoop plate. Review of R64's Comprehensive Care Plan dated 02/22/2024, revealed a focus for nutritional status as at risk for alteration of nutritional status related to obesity, and difficulty with diet. Further review revealed interventions that included providing diet as ordered. However, further review revealed R64's ordered scoop plate, nor the house shakes were documented on the care plan. Observation of R64 in the dining room on 08/06/2024 at 12:17 PM, revealed the resident did not have the ordered scoop plate. Additionally, review of R64's meal tray card revealed no documentation noting the scoop plate as ordered. In an interview with Certified Nursing Assistant (CNA) 5 on 08/09/2024 at 9:15 AM, she stated she checked the residents' tray cards before taking the tray into a resident's room. CNA 5 stated if she noted the card said the resident needed a magic cup or special utensils and it was not on the tray, she notified or went to the kitchen and requested the item. She stated sometimes the kitchen was out of the requested item, or the utensils had been thrown away. CNA 5 further stated she did not know the reason utensils would thrown away. During interview with CNA 6 on 08/09/2024 at 9:20 AM, she stated she looked at the tray card when taking the meal tray to the resident, and if it was missing an item, she notified the kitchen. She stated sometimes a resident card said they needed a divide plate; however, their food would be served on a regular plate. CNA 6 further stated she would not take that plate back to the kitchen and went ahead and served it to the resident. In an interview with Dietary Aide (DA) 1 on 08/09/2024 at 10:15 AM, she stated she worked on the tray line during meals preparing residents' trays. She stated she reviewed the meal tray card and read aloud what the resident was supposed to have. The DA stated she said, Regular, divided plate if a resident was supposed to have a divided plate. She further stated she had been employed for eight months and had never seen a small spoon used for any resident. In an interview with DA 2 on 08/09/2024 at 10:18 AM, she stated when on the tray line the tray cards were all read out loud. She stated the cook or whoever was serving food knew what to give the resident. DA 2 stated the assistive devices or supplements were usually located at the bottom of the tray line. In an interview with the Dietary Manager (DM) on 08/09/2024 at 10:24 AM, she stated she had been the dietary manager for approximately three weeks. She stated changes with residents' diets were communicated to the kitchen from nursing staff using a communication slip. The DM stated she was responsible for updating the tray meal cards; however, she was still in training and learning the facility's process. She stated the meal tray card was to be read out loud so the server knew what type of diet to served and what (if any) assistive devices to place on the tray. The DM stated there were newer staff in the kitchen and she had reeducated those staff on making sure they read the tray cards. She further stated on occasion, nursing staff did come to the kitchen and request items if they were not on the resident's tray. In an interview with the Regional Training Manager on 08/09/2024 at 10:29 AM, he stated it was the Dietary Manager's responsibility to update meal tray cards when changes came in from nursing or therapy services. He stated the Dietary Aides or whoever was working the tray line were to read the cards out loud so the server knew what diet to serve and what devices to utilize. The Regional Training Manager further stated he realized there were errors on Tuesday (08/06/2024) and having new staff contributed to errors as the new staff were nervous. In an interview with the Director of Nursing (DON) on 08/09/2024 at 4:18 PM, she stated nursing staff was responsible for communicating changes with diets and assistive devices to the kitchen staff. She stated she thought the Dietary Manager was responsible for updating the meal tray cards to include assistive devices and any nutritional supplements. The DON further stated if items were not on a resident's tray at meal time she expected the CNA to retrieve the items from the kitchen. During an interview with the Administrator on 08/09/2024 at 4:32 PM, she stated she was aware issues with the dietary department. She stated the current Dietary Manager was the third one in the facility in a year. The Administrator stated she expected the kitchen staff as well as the nursing staff to be aware of what was on residents' meal tray cards. She stated the kitchen staff were to ensure residents' assistive devices and nutritional supplements were in place on the meal trays. The Administrator further stated she expected nursing staff to go to the kitchen and ask for anything that was missing from the tray cards or trays.

Based on observation, interview, record review and review of facility policy, it was determined the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights that included measurable objectives and timeframes for 7 of 28 sampled residents (R). R1, R5, R22, R36, R61, R64 and R76 were observed in the dining room consuming meals without the assistive devices or nutritional supplements they had been care planned to receive. The findings include: Review of the facility policy titled, Comprehensive Care Plans, revised on 02/28/2024, revealed it was the policy of the facility to develop and implement a comprehensive person-centered care plan for each resident to meet the resident's medical, physical, mental and psychosocial needs. 1. Review of the Face Sheet for R1 revealed the facility admitted the resident on 07/01/2005, with diagnoses to include; chronic obstructive pulmonary disease (COPD), type 2 diabetes, and dysphagia. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of thirteen out of fifteen indicating R1 was cognitively intact. Review of the 03/20/2024, physician's order revealed an order for R1 to have a regular mechanical soft diet with special instructions that read divided plate and sip cup lid. Review of R1's Comprehensive Care Plan dated 06/23/2022, revealed a focus problem for nutritional risk related to a diagnosis of dysphagia and receiving a mechanically altered diet. Review further revealed interventions dated 06/23/2022, which included providing R1's diet as ordered, and providing a divided plate and spouted lid with meals. Observation on 08/07/2024 at 12:30 PM, revealed R1's meal tray contained a tray card noting the resident was supposed to have a sip lid cup and a divided plate. However, further observation revealed the divided plate and the sip lid cup were not on R1's meal tray. 2. Review of the Face Sheet for R5 revealed the facility admitted the resident on 02/27/2024, with diagnoses to include: dysphagia, cerebral palsy, and unspecified intellectual disabilities. Review of the Quarterly MDS assessment dated [DATE] revealed the facility completed an assessment and assessed R5 to have severe cognitive impairment and as rarely or never understood. Further MDS review revealed R5 was assessed as a dependent diner and was to be fed by staff. Review of the physician's order for R5 dated 03/14/2024, revealed the resident was to receive a regular pureed diet with honey thick liquids. Additionally, review of the order further revealed special instructions that stated R5 was to have a small coated spoon, and double meat portions were to be sent with every meal. Review of R5's Comprehensive Care Plan dated 08/09/2022, revealed a focus problem indicating the resident was at risk for nutritional status related to a history of dysphagia, being underweight, and receiving a pureed diet and honey-thick liquids. Further review revealed interventions which included: providing a pureed diet with double meat portions; and for staff to provide adaptive equipment that included a small spoon. Observation on 08/06/2024 at 12:17 PM, revealed R5 was in the dining room being fed by staff during the noon meal and the resident's meal tray contained a tray card. Review of R5's meal tray card revealed a small coated spoon was to be used. However, further observation revealed staff were using a regular spoon to feed R5, not the small coated spoon as per the care plan. 3. Review of the Face Sheet for R22 revealed the facility admitted the resident on 01/27/2018, with diagnoses that included, dementia, schizophrenia, and Parkinson's Disease. Review of a Significant Change in Status MDS assessment dated [DATE], revealed the facility assessed R22 to have a BIMS score of seven out of 15, indicating severe cognitive impairment. Continued review of the MDS revealed R22 was dependent on staff for eating. Review of the physician's order dated 6/20/2022, revealed R22's diet was regular, pureed. Continued review revealed special instructions for a plate guard and built-up utensils, double meat portions, and magic cups with lunch and dinner. Review of R22's Comprehensive Care Plan dated 06/20/2022, revealed the resident was at risk for malnutrition related to dysphasia, abnormal labs, and dementia. Continued review revealed interventions for staff to provide R22's diet as ordered with double meat portions, a plate guard and built up utensils. Observation of R22 on 08/06/2024 at 12:17 PM, in the dining room, revealed the resident was being fed by staff. Observation of R22's meal tray revealed a meal tray card noting the resident was to have a plate guard and built-up utensils. However, further observation revealed those devices were not in use for R22. 4. Review of the Face Sheet for R76 revealed the facility admitted the resident on 06/07/2024, with diagnoses to include: protein calorie malnutrition, fracture of the left femur, and schizophrenia unspecified. Review of the Quarterly MDS assessment dated [DATE], revealed the facility completed an assessment of R76 and assessed the resident as having severe cognitive impairment and as rarely or never understood. Review of the physician's order dated 08/01/2024, for R76 to receive a mechanical soft diet with magic cups at lunch and dinner, a divided plate, and double portions. Review of R76's Comprehensive Care Plan dated 06/07/2024, revealed a focus problem for nutritional status related to a diagnosis of severe protein-calorie malnutrition. Further review revealed the interventions included: providing R76's diet as ordered, and the magic cup with lunch and dinner. However, further review of the care plan revealed it had not been updated to include the divided plate or double portions. Observation in the assisted dining room, on 08/06/2024 at 12:17 PM, revealed R76's meal tray contained a tray card which read divided plate and double portions. However, further observation revealed the divided plate was not in use for R76, and the double portions, magic cup or other supplement were not present on the resident's meal tray. 5. Review of R36's Face Sheet revealed the facility admitted the resident on 03/02/2021, with diagnoses of dysphagia, gastroesophageal reflux disease (GERD) and COPD. Review of the Quarterly MDS assessment dated [DATE], revealed R36 had been assessed as being rarely or never understood. Continued review of the MDS revealed R36 was dependent on staff for eating. Review of the physician's order for R36 dated 05/30/2024, revealed an order for a pureed diet with honey thick liquids and a magic cup at lunch and dinner. Review of the Comprehensive Care Plan dated 06/11/2022, revealed R36 was at risk for nutritional status related to dysphagia, dementia, and significant weight gain. Review further revealed interventions which included providing R36's diet as ordered with magic cups at lunch and dinner. Observation on 08/06/2024 at 12:17 PM, revealed R36 was not served the magic cup as care planned. 6. Review of R61's Face Sheet revealed the facility admitted the resident on 07/03/2024, with diagnoses to include: dementia, chronic stage 3 kidney disease, and Alzheimer's Disease. Review of the Admission MDS assessment dated [DATE], for R61 revealed the facility assessed the resident to have a BIMS score of three, indicating the resident had severe cognitive impairment. Further review of the MDS revealed R61 was assessed as dependent on staff for eating. Review of the physician's order for R61 dated 07/15/2024, revealed a diet order for a mechanical soft diet. Additional review revealed the order included special instructions for finger foods, fruit and cottage cheese with lunch and dinner, and a magic cup with lunch and dinner as per the family's request. Review of the Comprehensive Care Plan dated 07/03/2024, revealed a problem for R61's nutritional status as at risk for alteration in nutritional status related to dementia, poor appetite and poor intakes. Continued review revealed the interventions included providing R61's diet as ordered. However, further review revealed there was no documentation of an intervention noting R61 was to have fruit and cottage cheese, finger foods or nutritional supplements, such as a magic cup. Observation on 08/06/2024 at 12:17 PM, of R61 in the dining room, revealed the facility failed to provide the resident's fruit and cottage cheese, magic cup or an alternative supplement on the meal tray. 7. Review of R64's Resident Face Sheet revealed the facility admitted the resident on 02/21/2024, with diagnoses of dysphagia, hemiplegia and heriparesis following cerebral vascular disease, and cerebral infarction due to embolism. Review of the Quarterly MDS assessment dated [DATE], revealed the facility assessed R64 to have a BIMS score of five indicating severe cognitive impairment. Continued MDS review revealed R63 was dependent on staff for eating. Review of R64's physician's order dated 08/05/2024, revealed the resident was to receive a mechanical soft diet, a scoop plate, and house shakes at lunch and dinner. Review of the Comprehensive Care Plan dated 02/22/2024, revealed a focus problem for R64's nutritional status as at risk for alteration of nutritional status related to difficulty with diet, and obesity. Continued review revealed the interventions included providing R64's diet as ordered. However, further review revealed no documentation of the scoop plate or house shakes noted on the care plan. Observation in the dining room on 08/06/2024 at 12:17 PM, revealed neither R64's scoop plate or house shake were provided for the resident. Additionally, observation of R64's meal tray revealed a tray card which did not indicate R64's need for a scoop plate. In interview with Certified Nursing Assistant (CNA) 1 on 08/06/2024 at 12:24 PM, she stated assistive devices were on the residents' care profile. She stated CNA's had access to residents' care plans in Matrix (facility's charting system) and reviewed it when charting in Matrix. In interview with CNA 5 on 08/09/2024 at 9:15 AM, she stated she checked residents' tray cards before taking their tray into their room. She stated she thought supplements and assistive devices were on the residents' care profiles. CNA 5 further stated the care profile was reviewed where she charted. During interview with CNA 6 on 08/09/2024 at 9:20 AM, she stated she reviewed residents' care profiles/plans daily. She stated if a resident was to have an assistive device it should be on their care plan. In interview with the former Registered Dietitian (RD) on 08/09/2024 at 4:00 PM, she stated she had been the person responsible for updating residents' care plans. She stated she had not worked at the facility for over a month. She stated assistive devices were to be on the residents' care plans, as well as any supplements ordered. During an interview with the Director of Nursing on 08/09/2024 at 4:17 PM, she stated she or the Assistant Director of Nursing (ADON) usually initiated a new resident's baseline care plan. She stated the MDS Nurse was then responsible for completion of the resident's comprehensive care plan. The DON stated each department updated and revised their own section of residents' care plans. She stated the RD, up until her last day, had updated residents' dietary or nutrition care plans. Per the DON's interview, it was her expectation for staff to follow residents' care plans. She stated CNAs could review residents' care plans in the facility's Electronic Medical Record (EMR). The DON further stated if items were not available on residents' tray cards, such as supplements or devices, she expected nursing staff to go to the kitchen and request those items. In an interview with the Administrator on 08/9/2024 at 4:32 PM, she stated she expected residents' care plans to be implemented and followed. She further stated the care plan guided residents' care and staff had to be aware of it to follow the care a resident needed.

Based on observation, interview, and record review, it was determined the facility failed to accommodate food preferences for 5 of 7 sampled residents (R) 61, R36, R22, R76 and R64. Observation during the noon meal service on 08/06/2024 at 12:17 PM, revealed the facility failed to provide residents with their nutritional supplements and double portions as ordered by the physician. The findings include: 1. Review of the Face Sheet located in R61's medical record revealed the facility admitted the resident on 07/03/2024, with diagnoses that included; dementia, Alzheimer's Disease with late onset, and chronic kidney disease stage 3. Review of the Admission Minimum Data Set (MDS) Assessment for R61 dated 07/07/2024, revealed the facility assessed the resident as having a Brief Interview for Mental Status (BIMS) score of three out of 15, indicating severe cognitive impairment. Review of the MDS further revealed the facility assessed the resident as dependent on staff for eating. Review of a physician's order for R61 dated 07/15/2024. revealed a diet order for a mechanical soft diet. Review further revealed special instructions included: finger foods; fruit and cottage cheese with lunch and dinner; and a magic cup (frozen dessert for increased protein and calories) with lunch and dinner per family's request. Review of the Comprehensive Care Plan for R61 dated 07/03/2024, revealed a nutritional status problem noting the resident was at risk for alteration in nutritional status related to poor appetite and intakes, and a history of dementia. Continued review revealed the interventions included, providing R61's diet as ordered. However, review further revealed no documentation of the fruit and cottage cheese, finger foods or nutritional supplements R61 was ordered to receive. Observation on 08/06/2024 in the dining room at 12:17 PM, revealed R61's meal tray contained a tray card. Review of the tray card revealed no documentation noting R61 was to have finger foods or fruit and cottage cheese at lunch and dinner, but did include the magic cup. Further observation revealed however, the magic cup was not provided on R61's meal tray. 2. Review of the Face Sheet located in R36's medical record revealed the facility admitted the resident on 03/02/2021, with diagnoses which included dysphagia, chronic obstructive pulmonary disease (COPD) and gastroesophageal reflux disease. Review of the Quarterly MDS Assessment for R36 dated 05/20/2024, revealed the facility assessed the resident as being rarely or never understood, and dependent on staff for eating. Review of a physician order for R36 dated 05/30/2024, revealed a diet order for a pureed diet with honey thick liquids and a magic cup at lunch and dinner. Review of the Comprehensive Care Plan for R36 dated 06/11/2022, revealed a risk for nutritional status problem related to diagnosis of dysphagia, significant weight gain, and dementia. Review further revealed interventions that included providing R36's diet as ordered and magic cups at lunch and dinner. Observation on 08/06/2024 at 12:17 PM, revealed however, R36 was not served a magic cup or other supplement as ordered and care planned. 3. Review of the Face Sheet located in R22's medical record revealed the facility admitted the resident on 01/27/2018, with diagnoses that included schizophrenia, dementia, and Parkinson's disease. Review of a Significant Change in Status Minimum Data Set (MDS) assessment dated [DATE], revealed R 22 had a Brief Interview for Mental Status (BIMS) score of seven of fifteen indicating severe cognitive impairment. Continued review of the MDS revealed R 22 dependent on staff for eating. Review of a physician's order for R22 dated 06/20/2022, revealed a diet order for a regular, pureed diet. Further review revealed R22 was to have a plate guard and built-up utensils, double meat portions, and a magic cup with lunch and dinner. Review of the Comprehensive Care Plan for R22 dated 06/20/2022, revealed the resident was at risk for malnutrition related to dysphasia, dementia, and abnormal labs. Further review revealed interventions that included staff were to provide diet as ordered with double meat portions, a plate guard and built up utensils and supplements as ordered. Observation on 08/06/2024 at 12:17 PM, of R22 in the dining room, revealed staff were feeding the resident. Continued observation revealed R22's meal tray contained a tray card. Review of the tray card revealed R22's order for double meat portions and the magic cup were not documented on the card. Observation further revealed R22 had no magic cup or other nutritional supplement on the meal tray, and no double portion of meat. 4. Review of the Face Sheet located in R76's medical record revealed the facility admitted the resident on 06/07/2024, with diagnoses that included schizophrenia, protein calorie malnutrition, and fracture of the left femur. Review of the Quarterly MDS assessment dated [DATE], revealed the facility assessed R76 as having severe cognitive impairment and was rarely or never understood. Review of the physician's order for R76 dated 08/01/2024, revealed an order for a mechanical soft diet with magic cups at lunch and dinner, a divided plate and double portions (of food). Review of the Comprehensive Care Plan for R76 dated 06/07/2024, revealed a problem for nutritional status related to a diagnosis of severe protein-calorie malnutrition. Continued review revealed the interventions included; providing the diet as ordered and magic cup with lunch and dinner. However, further review of the care plan revealed it had no been updated to include the ordered divided plate or double portions. Observation in the assisted dining room of R76 on 08/06/2027 at 12:17 PM, revealed the resident's meal tray contained a tray card. Review of the tray card revealed no indication that double portion were to be served. Further observation revealed R76 was not served double portions and did not have a magic cup as ordered. 5. Review of the Face Sheet located in R64's medical record revealed the facility admitted the resident on 02/21/2024, with diagnoses that included dysphagia, hemiplegia and hemiparesis following cerebral vascular disease, and cerebral infarction due to embolism. Review of the Quarterly MDS assessment dated [DATE], revealed the facility assessed R64 to have a BIMS score of five out of 15, indicating severe cognitive impairment. Review further revealed the facility assessed R64 as dependent on staff for eating. Review of physicians order for R64 dated 08/05/2024, revealed an order for a mechanical soft diet, house shakes at lunch and dinner and use of a scoop plate. Review of the Comprehensive Care Plan for R64 dated 02/22/2024, revealed a problem for nutritional status for the resident as at risk for alteration of nutritional status related to obesity, and difficulty with diet. Further review revealed the interventions included providing R64's diet as ordered. Additional review revealed however, the ordered scoop plate or house shakes were noted on the care plan. Observation in the dining room of R64 on 08/06/2024 at 12:17 PM, revealed the resident's meal tray contained a tray card. Review of the tray card revealed R64 was to have a house shake, 4 ounces. Further observation revealed however, the house shake was not provided. In interview with Certified Nursing Assistant (CNA) 1 on 08/06/2024 at 12:24 PM, she stated if residents' necessary items were not present on their meal tray, but were noted on the card, she typically let the kitchen staff know. She further stated she should have informed dietary staff that residents were missing items. In interview with CNA 5 on 08/09/2024 at 9:15 AM, she stated she checked residents' tray cards before taking their tray into their room. CNA 5 stated if a magic cup or special utensils were not on the tray, she notified the kitchen or went to the kitchen to request the missing item(s). She further stated sometimes the kitchen ran out of items; however, provided something else for the resident. During interview with CNA 6 on 08/09/2024 at 9:20 AM, she stated she looked at a resident's tray card when taking the tray to the resident. CNA 6 stated if the meal tray was missing a food or drink she usually notified the kitchen. She stated sometimes a regular plate would be on the resident's meal. CNA 6 further stated however, she did not take the plate back to the kitchen and went ahead and served it to the resident. In interview with Dietary Aide (DA) 1 on 08/09/2024 at 10:15 AM, she stated she worked on the tray line preparing residents' trays during meals. The DA stated she reviewed the meal tray cards and read aloud what the resident was supposed to have. She stated she would say whatever the supplement was to include house shakes, or magic cups. The DA stated the facility sometimes ran out of magic cups because they were hard to get, but there was a list of alternatives that could be sent for a resident. In interview with DA 2 on 08/09/2024 at 10:18 AM, she stated on the tray line tray cards were read out loud. DA 2 stated the cook or whoever was serving knew what to give the residents. She stated the assistive devices or supplements were usually located at the bottom of the tray card. In interview with the Dietary Manager (DM) on 08/09/2024 at 10:24 AM, she stated she had been the facility's DM for approximately 3 weeks. The DM stated changes occurring with resident diets were communicated to the kitchen from nursing staff using a communication slip. She stated she was responsible for updating residents' tray cards, but she was still learning that process and was still in training. Per the DM's interview, the facility was out of the magic cups nutritional supplements that week; however, she had gone to a sister facility to obtain some. She further stated it was important for residents to receive their nutritional supplements, as not providing the supplements could contribute to weight loss in the residents. In interview with the former Registered Dietitian (RD) on 08/09/2024 at 11:48 AM, she stated nutritional supplements should always be provided as ordered to the residents. She stated she had emailed the DM, as well as the DON, a list of supplements that could be used for substitutions if magic cups and house supplements were not available. The RD stated residents could be offered puddings, ice creams, yogurts, anything that would allow for extra calories. She further stated the facility sometimes did not have magic cups due to shortages, but other supplements were provided in its place. In interview with the Director of Nursing (DON) on 08/09/2024 at 4:18 PM, she stated nursing staff were responsible for communicating changes with residents' diets to the dietary staff. She stated the RD typically recommended residents' supplements and she thought the DM was responsible for updating residents' tray cards to include any nutritional supplements. The DON stated if items were not on the tray at meal time she expected the CNA to retrieve the necessary items from the kitchen. She stated if supplements were not available, there was a list of items that could be offered for substitutes such as pudding, yogurt and ice cream. The DON further stated she did not know if the current DM was aware of the substitute list. During an interview with the Administrator on 08/09/2024 at 4:32 PM, she stated she was aware of issues with the dietary department. She stated the current DM was the third DM the facility had employed in a year. The Administrator stated she expected kitchen staff, as well as nursing staff to be aware of what was on the meal tray cards. She stated kitchen staff were to ensure all assistive devices and nutritional supplements were in place on residents' meal trays. The Administrator further stated she expected nursing staff to go to the kitchen and ask for anything that was missing on the tray card.

The facility failed to ensure all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property, were reported immediately, but not later than 2 hours after the allegation was made for 3 of 23 sampled residents (R)2, R48, R86. The findings include: Review of the facility policy titled, Resident Rights dated 01/02/2020, and revised 02/16/2024, revealed the facility ensured all staff were educated on the rights of residents and the responsibility of the facility to properly care for its residents. Further review of the policy revealed the resident had the right to be treated with respect and dignity. Review of the facility policy titled, Abuse, Neglect, and Exploitation reviewed/revised 08/2023, revealed the facility was to protect the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prevented abuse. Continued review revealed the abuse prohibition plan included reporting of all alleged violations to the State Agency immediately, but not later than two hours after the allegation was made, if the event involved abuse. Further review revealed reports would not be made later than 24 hours if the allegation had not involved abuse and did not result in serious bodily injury. 1. Review of the medical record for R48 revealed the facility admitted the resident on 01/13/2022, with diagnoses including dementia, depression, anxiety, and psychotic disorder with delusions. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed the facility assessed R48 with a Brief Interview for Mental Status (BIMS) score of zero out of 15, indicating the resident was severely cognitively impaired. Review of the facility's investigation for an incident on 11/18/2023 at 7:50 PM, revealed staff witnessed R85 strike R48 on top of the head, with no assessed physical injury. Further review revealed the facility had not emailed the initial report to the State Survey Agency (SSA) until 11/20/2023 at 9:43 AM. In interview on 08/09/2024 at 3:39 PM, the Administrator stated she was the only employee responsible to report abuse to the State Agency. She stated she had access from home to report on those occasions when she was not in the facility at the time of the allegation. The Administrator stated she had two hours to make the initial report of an allegation to the SSA. She stated she tried multiple times to email the SSA the initial report of the incident that occurred on 11/18/2023 at 7:50 PM; however it failed to send a couple of times. In continued interview she stated she did not have records of the failed email attempts. The Administrator additionally stated she was not aware she could fax the initial reports (to the SSA) as well. 2. Review of the facility investigation for an incident that occurred on 10/25/2023 at around 11:45 AM, revealed R86 made an allegation of physical abuse against Certified Nursing Assistant (CNA) 8. Continued review revealed R86 reported the CNA hitting his/her leg. Further review revealed the facility had not emailed the initial report of the incident to the SSA until 10/25/2023 at 5:16 PM. In interview with the Administrator on 08/09/2024 at 3:39 PM, she stated R86 had not experienced any serious bodily injury and therefore, she had 24 hours to report to the SSA. She further stated she could not recall who told her she did not have to report incidents of abuse within two hours. 50000 3. Review of the facility face sheet for R2 revealed the facility admitted him on 05/08/2015, with diagnoses of traumatic brain injury, paraplegia, and aphasia. Review of the Annual Minimum Data Set (MDS) assessment dated [DATE], revealed the facility assessed R2 to have a BIMS score of 14 out of 15, indicating intact cognitive function. Further MDS review revealed the facility had not assessed R2 to exhibit any behavioral symptoms of physical, verbal or rejection of care and as dependent on staff for care needs. Review of the facility initial incident report dated 12/27/2023, for an incident that occurred on 12/26/2023 at 4:40 PM, revealed CNA 3 and CNA 4 witnessed CNA 2 using foul language and being verbally rude to R2 while providing his care. Per review, R2 had held onto his shirt and would not let go of it while CNA 2 was providing his care. Continued review revealed however, the allegation of abuse was not reported to the Administrator until 12/27/2023 at 10:30 AM. Further review revealed the Administrator had not submitted the initial report of the incident to the SSA until 12/27/2023 at 4:41 PM. Review of the facility's final report/5 day follow up investigation information revealed CNA 3's and CNA 4's witness statements dated 12/27/2023, which noted they overhead CNA 2 say to R2 you're not going to fucking hit me with that. Let go or I will break your fucking hand. Interview on 08/09/2024 at 2:57 PM with the Director of Nursing (DON) revealed she began employment with the facility on 12/04/2023. The DON stated suspected abuse was immediately reported to the Abuse Coordinator who was also the Administrator. She stated the Administrator was responsible to send information of abuse allegations to the State Agency. In interview on 08/09/2024 at 4:00 PM, the Administrator stated the incident involving R2 occurred during an evening shift, and she was not notified until the following morning of the incident by the SSD. The Administrator stated after the SSD informed her an investigation was immediately initiated. She further stated she reported the incident to the required agencies within 2 hours of finding out about the incident. The Administrator additionally stated at the time she believed the facility was following the CMS guidelines for reporting due to there not being any physical injury or harm to R2.

Based on interview, record review and review of facility policy, the facility failed to prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation was in progress for 1 of 23 sampled residents (R), R86. The findings include: Review of the facility policy titled, Abuse, Neglect, and Exploitation reviewed/revised 08/2023, revealed the facility was to protect the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prevent abuse. Continued review revealed instances of abuse of residents could cause harm, pain, or mental anguish, and the facility was to make efforts to ensure all residents were protected during an investigation. Review of the facility investigation for an incident involving R86 on 10/25/2023 at around 11:30 AM, revealed the resident alleged Certified Nursing Assistant (CNA) 8 hit his/her leg. Continued review revealed the facility sent the CNA home for the day. Further review revealed education for CNA 8 on resident rights, signed by the aide on 10/27/2023. Additional review revealed the facility's final report/5-day follow-up was signed on 10/28/2023 and emailed to the State Survey Agency (SSA) on 10/29/2023. Review of the facility's, Assignment Sheet dated 10/26/2023 and 10/27/2023 revealed CNA 8 was scheduled to work on the other unit in the facility, even though review of the facility's investigation revealed it was not completed until 10/28/2023. Review of the Timecard for CNA 8 revealed the aide clocked out of work at 12:06 PM on 10/25/2023 (The date of the incident). Continued review of the timecard revealed CNA 8 worked 12 hour shifts on 10/26/2023 and on 10/27/2023. In interview on 08/08/2024 at 4:19 PM and on 08/09/2024 at 10:43 AM, the Administrator stated CNA 8 was suspended the rest of her shift on the day the allegation was made. The Administrator also stated CNA 8 was then moved to the other unit in the facility to work. (However, review of the facility investigation revealed it was not completed until 10/28/2023.) In interview on 08/09/2024 at 11:11 AM, CNA 8 stated she went on break after changing R86 and was informed of the allegation when she returned from break. She further stated she was taken off R86's hall and came back to work the next day on the other unit. On 08/09/2024 at 2:57 PM interview with the Director of Nursing (DON) revealed if the facility received an allegation of abuse and the staff member was working, the employee was removed from the floor immediately and suspended during the investigation, usually for three days. She stated the purpose of the investigation was to find more evidence and determine if the abuse occurred. The DON further stated the staff member was suspended during the investigation to prevent the individual from continuing to abuse residents or retaliate against someone who reported. She also stated the Administrator was the facility's Abuse Coordinator. In additional interview with the Administrator on 08/09/2024 at 3:39 PM, she stated when she received the abuse allegation she sent CNA 8 home for the day and initiated the investigation. She stated the investigation lasted three days from start to finish. The Administrator stated once the interviews for the investigation were completed the aide was allowed to return to work on the facility's other unit. She stated she did not feel CNA 8 abused the resident or anyone else. The Administrator further stated the facility investigation had not been completed when CNA 8 returned to work on 10/26/2024.

Based on observation, interview, and review of the facility's policies, the facility failed to ensure its staff performed hand sanitation measures and maintained appropriate infection control measures during medication administration for 3 out of 39 sampled residents (R47, R52, R16, R57), which placed residents at increased risk for healthcare-associated infections (HAI). The findings include: Review of the facility's policy titled, Infection Prevention and Control, dated 09/03/2021 and revised 02/21/2024, revealed all hand hygiene was to be performed in accordance with the facility-established hand hygiene procedures. Review of the facility policy titled, Medication Administration Guidelines dated May 2022 for medication administration the general guidelines noted the person administering medication was to adhere to good hand hygiene, to include washing hands thoroughly. Observation on 08/08/2024 at 9:30 AM, revealed two hand sanitizer dispensers located at each end of the resident hallways available for staffs' use. Observation on 08/08/2024 at 10:12 AM, of medication administration by Registered Nurse (RN) 1 revealed the RN failed to wash or sanitize her hands between administering medications to R16 and R57. Observation also revealed RN 1 placed all medications in her bare hands before putting them into the medication cup for administration. Further observation revealed RN 1 did not disinfect the top of the cart's surface or place a barrier on top of the cart while preparing the residents' medications. Even though hand sanitizer dispensers were available at the end of the hallway, observation revealed RN 1 failed to utilize sanitizer prior to preparing the residents' medications. Observation on 08/07/2024 at 10:25 AM, during medication administration for R47, revealed Licensed Practical Nurse (LPN) 2 failed to sanitize her hands before she opened medication Lasix 40 milligram (mg) blister pack over a medication cup; however, the medication dropped onto the medication cart where no barrier was located or disinfection of the cart occurred. LPN 2 was observed to pick the Lasix tablet up and place it into the medication cup for administration. Even though hand sanitizer dispensers were available at the end of the hallway, observation revealed LPN 2 failed to utilize the sanitizer after R47's medication administration and before she prepared the next resident's medication. Observation on 08/07/2024 at 10:28 AM, of medication administration for R52, revealed LPN 2 failed to sanitize her hands before she opened the resident's Vitamin D3 over the medication cup; however, dropped one of the two tablets onto the top of the cart with no barrier in place. Continued observation revealed LPN 2 picked the tablet up off the cart and placed it in the cup with R52's other medications for administration. Further observation revealed LPN 2 had not disinfected the top of the cart. During an interview with LPN 2 on 08/07/2024 at 10: 30 AM, she stated it was important for her to disinfect her hands with alcohol gel or soap and water to keep infection risks down. She further stated she had been nervous and overlooked that step, but was aware of that expectation. During an interview after her medication administration, RN 1 on 08/08/2024 at 11:10 AM, she stated she should have washed her hands or used sanitizer before medication administration. She further stated she had sanitizer in her pocket; however, just forgot to use it. During an interview on 08/09/2024 at 2:57 PM, with the Director of Nursing (DON), she stated she expected nurses to wash their hands or use hand sanitizer before each medication administration. She stated hand sanitizer was located on the walls of each resident care area. The DON further stated there were also smaller bottles of sanitizer available.

Based on observation, interview, record review, and review of the facility's policies, it was determined the facility failed to ensure one (1) of seven (7) sampled residents, Resident #4, was provided with specialized person-centered care and services to address his/her known history of trauma and known psychosocial adjustment difficulties with life at the long-term care facility. On 02/09/2021, Resident #4 told the Social Services Director (SSD), he/she had oral sex with a direct care staff member, Licensed Practical Nurse (LPN) #4. Due to the resident's report, the facility immediately initiated an investigation. However, Resident #4 had a known history of making inappropriate (sexual in nature) comments about male direct care staff. The facility's staff knew the resident used social media to post inappropriate sexual comments and photos, asked staff members' assistance with his/her use of social media, asked staff to take nude pictures of him/her, and became easily irritated with direct care staff, at times refusing care. The findings include: Review of the facility's policy titled, OPS416 Person-Centered Care Plan, revised 07/01/2019, revealed person-centered care meant the focus was on the patient as the locus of control and to support the patient in making his/her own choices and having control over his/her daily life. Policy review also revealed the purpose of developing a plan of care was for the patient to attain and maintain his/her highest practicable physical, mental and psychosocial well-being, to eliminate or mitigate triggers that could cause re-traumatization of the patient, and to promote positive communication between the patient, resident representative, and the team to obtain input. The purpose was to ensure effective communication and optimize clinical outcomes. Review of the facility's policy titled, 2.0 Abuse Prohibition, Numeral 4, revised 08/01/16, revealed the facility must take actions to prevent abuse, neglect, and exploitation, including identifying, correcting, and intervening in situations in which abuse, neglect, exploitation, and/or misappropriation of property would more likely occur. Review of Resident #4's Admission Record revealed the facility admitted the resident, on 08/24/2018, with [DIAGNOSES REDACTED]. Prior to admission, Resident #4 experienced [MEDICAL CONDITIONS] due to a Heroin overdose, and upon admission, he/she had a [MEDICAL CONDITION] in place to support his/her ability to breathe; he/she was weaned from the [MEDICAL CONDITION] (trach) tube by March of 2019. Resident #4 continued to depend on a suprapubic catheter for urinary elimination. Interview with Resident #4's State Appointed Guardian, on 02/26/2021 at 8:50 AM, revealed prior to admission, Resident #4 had a history of [REDACTED]. She said Resident #4 was younger than most residents were in long-term care, and she thought the resident's young age, paired with confinement to the nursing home, had contributed to the resident's known depression and feelings of loneliness. She stated the resident was very sexual before his/her accident, and she said the resident's current situation prevented her from having the full freedom to do many of the things a person his/her age would normally be able to do. Resident #4's guardian stated the facility's former Social Services Director (SSD) told her that Resident #4's Facebook account was locked for a while in April of 2020, due to some inappropriate social media activity. The guardian stated Resident #4 was under the care of Psychiatric Services at the facility related to his/her history of substance abuse, depression, and anxiety. However, the guardian stated the resident's counselor told her in April 2020, the resident had not shown much interest in participating in those offered services. Review of an Investigation Report, initiated by the facility on 02/09/2021, revealed, on 02/09/2021, Resident #4 told the facility's Social Services Director (SSD), that he/she had a sexual relationship that involved oral sex with Licensed Practical Nurse (LPN) #4. The resident stated the affair was consensual. Resident #4 told the SSD that the oral sex began soon after he/she had weaned from his/[MEDICAL CONDITION](March 2019), and the affair ended in November 2020. Observation of Resident #4, on 02/22/2021 at 1:40 PM, revealed the resident wore splints on both of his/her hands for bilateral wrist contractures and had a urinary collection bag in place at the bedside. In addition, the resident was neatly dressed and groomed, and a staff person was feeding the resident. Interview with Resident #4, on 02/25/2021 at 11:02 AM, revealed he/she had oral sex with LPN #4. Resident #4 said she felt badly after it happened, and he/she did not tell anyone for a long time; but, he/she recently told everyone. Resident #4 stated LPN #4 promised him/her certain things, did not follow through with his promises, and that made the resident angry. Interview with the SSD, on 02/25/2021 at 11:55 AM, revealed, on 02/09/2021, Resident #4 told her that he/she had oral sex with LPN #4. She said the resident requested to speak to her and told her when his/her [MEDICAL CONDITION] (trach) tube was removed, he/she started having oral sex with LPN #4. The SSD said she was not sure why the resident waited to report this because she saw Resident #4 almost every day when making rounds on the 200 Hallway. The SSD said she informed Resident #4 that that she would have to report this information to the Center Executive Director (CED). The SSD stated Resident #4 had a history of [REDACTED]. She said she thought staff tried to keep an eye on Resident #4 because he/she often talked about having a mate and wanting sex. The SSD said the resident's guardian directed staff to remove Resident #4's I-pad, on 11/25/2020, due to his/her inappropriate use of social media, and she documented this action in the resident's progress notes. The SSD said Resident #4 became very angry when his/her I-pad use was suspended, and she and the Center Nurse Executive (CNE) tried to talk with Resident #4 to discuss why the guardian wanted staff to remove the I-pad. The SSD stated Resident #4's mood would change frequently, he/she would be belligerent toward staff, and he/she would at times refuse care. Review of Resident #4's Progress Note, dated 11/25/2020 at 12:22 PM, and documented by the SSD, revealed Resident #4's State Guardian had staff remove the resident's I-pad because the resident was ordering lines of credit, taking nasty pictures of him/herself and sending them to people via social media, and was posting about having sex. The note also revealed the resident was making false claims about the facility and was causing drama by trying to get friends to take him/her from the facility. Continued review of Resident #4's Progress Notes, from 10/01/2020 to 02/09/2021, revealed, on 10/05/2020, the resident complained that he/she thought he/she would be better off dead than to have to live in the nursing facility. Also, the resident stated he/she just wanted to go home and see his/her friends and family. The SSD was the author of the progress note and documented the resident did not identify a means or method toward self-harm, and the resident was followed by psychiatric services. The SSD also documented the resident would be incapable of self-harm due to his/her disabilities, including bilateral hand/wrist contractures and the need for total care. Review of the Psychiatric Advanced Practice Registered Nurse (APRN)'s Documentation of Visits, revealed she visited Resident #4 related to his/her [DIAGNOSES REDACTED]. The Psychiatric APRN documented visits on 01/22/2020, 02/18/2020, 02/26/2020, 05/19/2020, 08/18/2020, 10/13/2020, 01/08/2021, and 02/02/2021. Review of Resident #4's Therapeutic Services Note, dated 02/02/2021, revealed the Psychiatric (Psych) APRN documented Resident #4's clinical record had notes that described the resident's behaviors. The note revealed Resident #4 lost use of his/her tablet after sending nude photos and posting inappropriate things to his/her Facebook account. The Psych APRN's note also revealed the resident continued with episodes of screaming, yelling, and crying, however, that was the resident's baseline behavior. The note indicated the SSD tried to remind the resident that he/she would get the I-Pad back in March 2021. Documentation of a Psych APRN visit, dated 02/18/2020, revealed Resident #4 stated, I don't get along with people, and I want to go home. During the visit, the resident also told the APRN that his/her son had shot himself about a year before he/she took the drug overdose that caused his/her own physical disabilities. Interview with the Psych APRN, on 03/02/2021 at 1:03 PM, revealed she provided counseling services at least quarterly for Resident #4. She stated Resident #4 was impulsive and used poor judgment. She stated those qualities could be associated with the resident's history of [MEDICAL CONDITION]. She said Resident #4's perception of reality was not always accurate. The Psych APRN said she had a hard time determining if what the resident told her was true, so she would ask staff how they interpreted the resident's behaviors. The Psych APRN said she recently saw Resident #4, on 02/16/2021, and the first thing the resident said to her was, My mind is all messed up. She stated the resident's guardian asked staff to remove his/her I-pad for a time, due to the sexually inappropriate content the resident shared on Facebook, during the fall of 2020. The Psych APRN stated Resident #4 had not talked with her about a sexual relationship with a male staff member. She said she thought the direct care staff tried to redirect the resident when he/she made inappropriate comments. Interview with LPN #4, on 02/26/2021 at 9:29 AM, revealed Resident #4 required time-consuming care when he/she was dependent on a [MEDICAL CONDITION] for breathing and with the resident's ongoing need for the supra-pubic catheter for elimination, and he was often assigned to the resident. LPN #4 stated he heard from other staff members that Resident #4 made inappropriate sexual comments about him, and he heard the resident say he/she was horny and needed a sex partner. LPN #4 said he was glad when the resident moved to another hallway, and he denied ever having oral sex with Resident #4. Interview with the Minimum Data Set (MDS) Coordinator, on 03/02/2021 at 9:52 AM, revealed Resident #4 sent her a Facebook Friend request and she accepted it. She stated she saw inappropriate pictures the resident posted to his/her Facebook timeline. The MDS Coordinator stated the pictures and comments the resident was posting were very sexual and involved nudity. In description of the content she saw, the MDS Coordinator said Resident #4 posted a picture of a naked man with a large penis and scrotum. She said the resident also posted a comment with the picture, and the comment was something like he/she would love to ride that, how about you? The MDS Coordinator stated the resident would post other highly sexual comments on his/her Facebook timeline. She offered the following as an example: She said the resident posted the comment, You are not a real woman if you cannot take it up your ass. Continued interview with the MDS Coordinator, on 03/02/2021 at 9:52 AM, revealed she was unsure of when, but she thought she saw Resident #4's inappropriate Facebook posts in early to mid-Fall of 2020. She stated she reported what she saw at the facility's next Morning Staff Meeting. The MDS Coordinator stated she was concerned other residents or their family members might be Facebook friends with Resident #4 and would see the offensive posts. The MDS Coordinator stated she passed her phone around at the Morning Meeting so attendees could see what the resident posted. The MDS Coordinator said the CNE was at the meeting and said the facility would have to notify Resident #4's guardian. The MDS Coordinator stated she deleted Resident #4 as a Facebook friend because she did not want to see the inappropriate posts. However, neither the MDS Coordinator, SSD, Psych APRN, CNE, CED, nor any other attendees of the Morning Staff Meetings could provide evidence the facility ordered additional services to address Resident #4's psychosocial/sexual issues. Review of Resident #4's Comprehensive Care plan revealed the resident's care plan included a focus area, developed on 02/05/2020, by the former SSD, to address the resident's verbal outbursts directed to others, that included an abusive language pattern, confrontational verbal behaviors, and poor coping skills. However, a care plan focus area addressing Resident #4's sexually inappropriate behaviors related to disinhibition due to [MEDICAL CONDITION], was not developed, until 02/16/2021 by the MDS Coordinator, and by the SSD, on 02/18/2021. Both dates were after the resident's (02/09/2021) report that he/she had a long-standing consensual sexual relationship with LPN #4 and after the resident's inappropriate sexual behaviors and language. It was documented in this care plan focus area that the resident took nude photos and posted them online, was posting lewd photos of men on his/her social media profile, and posted comments about having sex once he/she was able to go home or have visitors. Further review revealed care plan interventions included having two (2) staff members at all times when providing Resident #4's care; no male caregivers; and exploring the resident's history and available medical records for sexual abuse, sexual dysfunction, inappropriate sexual behavior, deviant sexual practices, or vulnerability to sexual victimization. However, there were no new or increased services provided to Resident #4 to address his/her psychosocial concerns. Interview with the CNE, on 03/02/2021 at 1:53 PM, revealed she thought Resident #4 had trouble adjusting to life since admission to the facility. She stated Resident #4 was probably trying to deal with his/her current disabilities and adjustment to a lifestyle in a long-term care facility. She said the resident may have realized this could be his/her living arrangement for the remainder of his/her life. The CNE said Resident #4 was alert and oriented, but he/she was still vulnerable. She stated Resident #4's sexually explicit behaviors escalated during the summer of 2020, with his/her use of social media. The CNE stated staff was working with the resident in regard to his/her angry outbursts but that was probably not sufficient for addressing Resident #4's unique situation as a younger resident facing his/her current disabilities, with ongoing needs for services in a long-term care facility. Interview with the Center Executive Director (CED), on 03/01/2021 at 3:36 PM, revealed the facility's Interdisciplinary Team (IDT) was responsible for ongoing resident assessment and developing a resident's care plan that addressed their unique circumstances and need of services, including psychosocial. The CED stated staff should identify each resident's unique circumstances, and develop care plans, with the facility providing needed services to address each resident's needs.

Based on observation, interview, record review, and review of the facility's policy, it was determined the facility failed to develop and implement a person-centered care plan to address known sexually inappropriate behaviors, for one (1) of seven (7) sampled residents, Resident #4. Resident #4 had a known history of making inappropriate (sexual in nature) comments about male direct care staff, using social media in inappropriate (sexual) ways, asking staff members' assistance with his/her use of social media, and asking staff to take nude pictures of him/her. This information about the resident was known by facility staff prior to 02/09/2021, when the resident told the Social Services Director (SSD) that he/she had a sexual relationship with a staff member. However, a care plan to address his/her inappropriate sexual behaviors was not developed until 02/16/2021. The findings include: Review of the facility's policy titled, OPS416 Person-Centered Care Plan, revised 07/01/2019, revealed person-centered care meant to focus on the patient as the center of control and to support the patient in making his/her own choices and having control over his/her daily life. Additionally, the policy revealed a comprehensive, individualized care plan would be developed within seven (7) days after completion of the comprehensive assessment and would include measurable objectives and timetables to meet a patient's medical, nursing, nutrition, and mental and psychosocial needs identified in the comprehensive assessments. In addition, the care plan must be customized to each individual patient's preferences and needs. The policy stated the care plan would be reviewed and revised as needed, in order to reflect responses to care, and changing needs and goals. Review of Resident #4's Admission Record revealed the facility admitted the resident, on 08/24/2018, with [DIAGNOSES REDACTED]. Per record, prior to admission, Resident #4 experienced [MEDICAL CONDITIONS], due to a Heroin overdose, with subsequent placement of a [MEDICAL CONDITION] to support his/her ability to breathe. Per record, Resident #4 had a [MEDICAL CONDITION] upon admission to the facility, but he/she was weaned from the [MEDICAL CONDITION] by March 2019; Resident #4 continued to depend on a suprapubic catheter for urinary elimination. In addition, per record, Resident #4 had a court-appointed State Guardian. Interview with the State Guardian, on 02/26/2021 at 8:50 AM, revealed, prior to admission, Resident #4 had a history of [REDACTED]. She said Resident #4 was younger than most residents in a long-term care setting, and she thought the resident's young age, paired with confinement to the nursing home, had contributed to the resident's known depression and feelings of loneliness. She said the resident's current situation prevented her from having the full freedom to do many of the things a person his/her age would normally be able to do. Review of Resident #4's Annual Minimum Data Set (MDS) Assessment, dated 01/07/2021, revealed Resident #4 had a Brief Interview for Mental Status (BIMS), cognitive assessment within the MDS assessment, score of fifteen (15) out of a possible 15, indicating he/she was interviewable and cognitively intact. Review of the facility's Investigation Report, initiated by the facility on 02/09/2021, revealed that on 02/09/2021, Resident #4 told the facility's Social Services Director (SSD) that he/she had experienced a consensual sexual relationship with a male staff person, Licensed Practical Nurse (LPN) #4, which involved oral sex. The resident stated the oral sex began soon after he/she had weaned from his/[MEDICAL CONDITION](March 2019) and that the affair ended in November 2020. Per report, Resident #4 stated LPN #4 promised to buy him/her gifts, leave his/her spouse, and take him/her to his home and care for him/her. Continued review of the investigation revealed the facility's Human Resources (HR) Staff Person conducted an interview with Resident #4, and the resident stated oral sex with LPN #4 occurred when the LPN would administer his/her medications. Per report, the resident told the HR Staff Person he/she did not reveal the affair earlier because he/she did not think anyone would believe it, and he/she thought LPN #4 might treat him/her differently if he/she told anyone. Per the investigation, Resident #4 said he/she decided to report the affair now because he/she was angry with LPN #4, and LPN#4 did not follow through with his promises. Observation of Resident #4, on 02/22/2021 at 1:40 PM, revealed the resident wore splints on both of his/her hands related to bilateral wrist contractures, and a urinary collection bag was in place at the bedside. In addition, Resident #4 was neatly dressed and groomed, and a staff person was feeding the resident. Interview with Resident #4, on 02/25/2021 at 11:02 AM, revealed he/she had oral sex with LPN #4. Resident #4 said it made him/her feel bad when it happened. The resident stated he/she did not tell anyone for a long time, but recently he/she told everyone. Resident #4 stated LPN #4 promised to bring him/her gifts, but the LPN did not follow through with the promises and that made him/her angry. Resident #4 said he/she did not think LPN #4 still worked at the facility because he/she heard LPN #4 did something to another staff person. Resident #4 said the situation made him/her feel bad, and he/she told no one about the relationship until recently. Interview with the SSD, on 02/25/2021 at 11:55 AM, revealed on 02/09/2021, Resident #4 told her that he/she had oral sex with LPN #4. She said the resident requested to speak to her, and when she entered the room, Resident #4 asked if LPN #4 still worked at the facility. The SSD said she told the resident she was not sure about that. The SSD said Resident #4 told her when his/her [MEDICAL CONDITION] was removed, he/she started having oral sex with LPN #4. The SSD said she was not sure why the resident waited to report this because she saw Resident #4 almost daily. The SSD stated Resident #4 told her that LPN #4 had promised to give him/her gifts and that he loved him/her. The SSD said she informed Resident #4 she would have to report this information to the Center Executive Director (CED). The SSD stated the next day, Resident #4 also told her LPN #4 had promised to take him/her to his home and take care of him/her. In addition, the SSD stated, prior to a room change in the Fall of 2020, Resident #4 lived in room [ROOM NUMBER], which was on the hallway where LPN #4 worked most of the time. The SSD stated LPN #4 told the Center Nurse Executive (CNE) he was uncomfortable taking care of Resident #4 because of the comments he/she made about him to other staff members. Continued interview with the SSD, on 02/25/2021 at 11:55 AM, revealed room [ROOM NUMBER] was on a very busy pass-through hall at the facility, and Resident #4 often yelled at staff and other residents passing by his/her room. The SSD said if there was a sexual relationship between Resident #4 and LPN #4, she did not see how staff or other residents would not have discovered it over the long time span described by Resident #4. The SSD stated she had not witnessed LPN #4 exhibiting inappropriate behaviors toward residents. Per interview, she said LPN #4 was a good nurse and took time to talk to all residents. The SSD stated she thought it was possible that Resident #4 had a crush on LPN #4. Further, she stated Resident #4 spoke to several staff members about his/her anger toward LPN #4 because he/she thought LPN#4 was giving extra attention to a new staff person who started working at the facility in the Fall of 2020. Interview with the HR Staff Person, on 02/25/2021 at 11:20 AM, revealed she stayed with Resident #4 when Adult Protective Services (APS) Personnel interviewed the resident on 02/23/2021. She stated she did so because of the resident's difficulties with articulating his/her words. In addition, she stated Resident #4 provided the same account of his/her allegation that he/she had previously reported to facility staff. Continued interview revealed Resident #4 told APS Personnel he/she thought LPN #4 eventually started showing more attention to another staff person and that made him/her angry; so, their relationship ended in November of 2020. Interview with LPN #4, on 02/26/2021 at 9:29 AM, revealed he no longer worked at the facility. LPN #4 said after Resident #4 was weaned from his/her [MEDICAL CONDITION], he/she began making inappropriate comments to other staff about him. He stated Resident #4 asked other staff to shave his/her perineal area for him (LPN #4). LPN #4 stated Resident #4 would say he/she was horny and needed a sex partner. LPN #4 stated he reported Resident #4's inappropriate comments to the 200 Hallway Unit Manager (UM) and to the Center Nurse Executive (CNE). He said they told him to limit the amount of time he spent in Resident #4's room. However, LPN #4 stated that was difficult to do because the resident required time consuming care for his/her suprapubic catheter. He stated Resident #4's comments became more frequent after he/she obtained an Internet-Pad (I-Pad), and he thought the inappropriate comments began about Christmas 2019 or January 2020. LPN #4 stated the resident could have felt closer to him because he was often his/her assigned nurse when he/she had many more care needs. Further, LPN #4 stated he was glad when the resident moved to another hallway. LPN #4 denied ever engaging in oral sex acts with Resident #4. Interview with State Registered Nurse Aide (SRNA) #5, on 02/28/2021 at 1:17 PM, revealed Resident #4 had an I-pad and a Facebook account. She stated she could not remember the exact day, but the resident asked her to delete a picture from his/her Facebook account of a naked male with large genitals exposed. SRNA #5 said she deleted the photo as requested by the resident. She stated Resident #4's State Guardian suspended the resident's use of the I-Pad in November 2020, and so she probably assisted the resident with the picture removal before then. SRNA #5 stated she did not report this to any of the nurses or other facility leadership. Interview with SRNA #6, on 02/28/2021 at 3:45 PM, revealed she heard Resident #4 had asked staff members to take pictures of his/her naked breasts, but she could not remember if the resident had asked her to take pictures of that nature. SRNA #6 stated, in a casual conversation with Resident #4, the resident very graphically described the appearance of LPN #4's genitalia. SRNA #6 stated that conversation with the resident occurred just after the resident reported his/her alleged sexual relationship with LPN #4. Interview with the Minimum Data Set (MDS) Coordinator, on 03/02/2021 at 9:52 AM, revealed Resident #4 sent her a Facebook Friend request and she accepted it. She stated she personally saw Resident #4 was posting comments and pictures of a sexual nature to his/her Facebook timeline, and the pictures included male nudity. The MDS Coordinator stated Resident #4 posted a picture of a naked man with a large penis and scrotum. She stated the resident also posted a comment with the picture, which was something like he/she would love to ride that, how about you? The MDS Coordinator stated Resident #4 would post other highly sexual comments on his/her Facebook page. The MDS Coordinator offered the following as an example: She said the resident posted the statement, You are not a real woman if you cannot take it up your ass. Continued interview with the MDS Coordinator, on 03/02/2021 at 9:52 AM, revealed she was unsure of exactly when, but she thought she saw the photos/posts in early to mid-Fall of 2020. She stated at the next Morning Staff Meeting she reported what Resident #4 was posting on Facebook. The MDS Coordinator stated she was concerned other residents or their family members might be Facebook friends with Resident #4 and would see the posts. The MDS Coordinator stated she passed her phone around at the Morning Meeting so attendees could see what the resident posted. The MDS Coordinator stated the CNE was at the meeting, and said Resident #4's State Guardian would be notified. The MDS Coordinator said Resident #4 posted about having a relationship with a new partner almost daily, and the partners were going to come to the facility to pick him/her up and take care of him/her. The MDS Coordinator stated she deleted Resident #4 as a Facebook friend because she did not want to see the resident's posts. The MDS Coordinator said she was in Resident #4's room when the CNE spoke to the resident about the Facebook posts. In addition, she stated the CNE told the resident she had to report the posts to his/her State Guardian. The MDS Coordinator stated Resident #4's response was that it was his/her account, and the activity on it was not hurting anyone. Continued interview with the MDS Coordinator, on 03/02/2021 at 9:52 AM, revealed pertinent information for care plan development would come from varied sources of information including the clinical record, nurses' documenation in the progress notes, as well as interviews with direct care staff. She stated she thought the SSD, who usually participated in the development of behavioral type care plans, would also review progress notes going back at least ninety (90) or ninety-two (92) days, as well as any other behavior-associated documents. The MDS Coordinator stated she could also review and revise behavioral management care plans, as needed. However, neither the MDS Coordinator, licensed nurses, nor the SSD developed a focus area and interventions to address Resident #4's psychosocial issues, most importantly, those intended to focus on the resident's inappropriate sexual behavior. Continued interview with Resident #4's State Guardian, on 02/26/2021 at 8:50 AM, revealed she had been the resident's guardian since March 2020. The State Guardian stated she temporarily suspended Resident #4's I-Pad use, beginning on 11/25/2020, because of the resident's inappropriate use of social media. She said Resident #4 was giving the nursing facility bad press, and some of the resident's friends threatened to come take him/her from the facility, due to the things he/she was posting. She stated the facility's former social worker also reported Resident #4 was posting inappropriate photos of a sexual nature on Facebook. The State Guardian stated she had a virtual visit with Resident #4, on 09/10/2020, and discussed the nude pictures he/she had posted on Facebook. The State Guardian stated Resident #4's response was that it was his/her account and his/her right to post as he/she wanted to post. The State Guardian stated she advised Resident #4 not to ask staff for assistance with his/her Facebook account. Further, the State Guardian stated she thought Resident #4 was also sending pictures through private messages to a friend, of the opposite sex, from middle school years. The State Guardian stated she did not suspend Resident #4's I-Pad privileges after the September 2020 virtual meeting. She stated the intent of that meeting was to provide Resident #4 with a warning, and she had hoped the resident would change his/her behavior. The State Guardian said, on 10/05/2020, the facility's SSD contacted her with Resident #4's request for the purchase of sex toys. The State Guardian stated she did not authorize that purchase. Review of Resident #4's Progress Notes, from 10/01/2020 to 12/01/2020, revealed on 10/05/2020, the SSD documented she e-mailed Resident #4's State Guardian because the resident requested sex toys and inquired about how the facility should comply with the request. Continued review of the Progress Notes revealed, on 11/25/2020, the SSD documented the resident's State Guardian had staff remove the resident's I-Pad because the resident was ordering lines of credit; taking nasty pictures of him/herself and sending them to people via social media; and was posting about having sex. The note also revealed the resident was making false claims about the facility and was causing drama by trying to get friends to take him/her from the facility. However, a care plan focus area addressing Resident #4's sexually inappropriate behaviors related to disinhibition due to [MEDICAL CONDITION], was not developed, until 02/16/2021, by the MDS Coordinator and, on 02/18/2021, by the SSD. Both dates were after the resident's (02/09/2021) report that he/she had a long-standing consensual sexual relationship with LPN #4. It was documented in the care plan focus area that the resident took nude photos and posted them online, posted lewd photos of men on his/her social media profile, and posted comments about having sex once he/she was able to go home or have visitors. Care plan interventions included having two (2) staff members at all times when providing Resident #4's care; no male caregivers; and exploring the resident's history and available medical records for sexual abuse, sexual dysfunction, inappropriate sexual behavior, deviant sexual practices, or vulnerability to sexual victimization. Continued interview with the MDS Coordinator, on 03/02/2021 at 9:52 AM, revealed she was not sure why Resident #4's care plan for inappropriate sexual behaviors was not developed until 02/16/2021, but she confirmed her name was listed as the staff member who created the care plan on that day. Additional interview with the SSD, on 02/25/2021 at 12:30 PM, revealed she reviewed Resident #4's care plan, after Resident #4 reported he/she had a sexual relationship with LPN #4. She stated she noted the care plan did not contain a focus area for addressing the resident's sexual comments and behaviors, so she developed the plan on 02/18/2021. The SSD said she was not sure why Resident #4's care plan did not include interventions for addressing the sexual behavior, prior to 02/09/2021, because she thought staff tried to keep an eye on Resident #4 for any sexually specific behaviors. The SSD stated the resident often talked about having a boyfriend and wanting sex. Interview with the CNE, on 03/02/2021 at 1:53 PM, revealed in the Fall of 2020 (she was not sure of an exact date), a staff member reported viewing inappropriate pictures and posts made by Resident #4 via his/her Facebook account. The CNE said she told the former SSD that Resident #4's guardian would need to be notified. The CNE stated Resident #4 should have had a care plan component, prior to February 2021, that addressed his/her sexual behaviors. She said she honestly thought that particular focus area was in the resident's care plan prior to 02/16/2021. The CNE stated perhaps we were so heavily focused on protecting residents from COVID-19, we may not have been keenly focused on this particular resident's issue. The CNE stated a care plan component for Resident #1's sexual behaviors should have been in place to ensure all members of the Interdisciplinary Team (IDT) and direct caregivers were aware of the best approaches to use when responding to the resident's sexual behaviors and comments. The CNE stated she thought Resident #4's sexual behaviors started escalating during the Summer of 2020, when the resident increased his/her use of social media. In addition, the CNE stated she was aware Resident #4 was having a relationship, in November 2020, via social media with someone outside the facility. Interview with the Center Executive Director (CED), on 03/01/2021 at 3:36 PM, revealed any time a resident experienced a change of condition, including behavior changes, the care plan should be developed or revised to address the changing care needs or behavior(s). He stated licensed nurses could revise a resident's care plan when they thought it was necessary, and Unit Manager(s) and the Interdisciplinary Team (IDT) members would review the changes to ensure they were appropriate based on the resident's change in behavior or condition.

Based on observation, interview, record review, and facility policy review it was determined the facility failed to ensure one (1) of three (3) sampled residents (Resident #1) was free from resident to resident physical abuse. On 06/26/2020, staff discovered Resident #1 slumped over in bed bleeding with a one (1) centimeter laceration to the head. The findings include: Review of the facility's Abuse Prohibition policy, revised 07/01/2019, revealed abuse was defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, injury, or mental anguish. Willful, as used in the definition of abuse, meant the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. Review of the clinical record revealed the facility admitted Resident #1 on 04/12/2019 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Quarterly Minimum Data Set (MDS), dated [DATE], revealed Resident #1 was totally dependent upon staff for bed mobility, transfers, and hygiene. Review of the Social Service Progress Note, dated 06/29/2020, revealed the facility assessed Resident #1 with a Brief Interview for Mental Status score of five (5), which indicated the resident was not interviewable. Observation of Resident #1, on 07/08/2020 at 5:16 PM, revealed the resident was seated in bed with a scoop mattress and padded side rails. The resident held the side rail and rocked side to side. Interview during observation revealed Resident #1 could not recall how he/she sustained the head laceration. Interview with Patient Care Attendant (PCA) #3, on 07/14/2020 at 11:29 AM, revealed when she answered Resident #2's call light (who shared a room with Resident #1) and entered the room she saw Resident #1 was a bloody mess. She stated she asked the resident what happened, but he/she just looked at her and would not say anything. According to PCA #3, the privacy curtain between the beds was open and Resident #2 was leaning over in bed, and his/her reacher device was lying on the floor between the beds. The Aide stated she noticed the reacher device looked a little wet when she placed it on the over bed table, but she did not know what the wet substance was at the time. The PCA stated she immediately notified Registered Nurse (RN) #1 of Resident #1's injuries. Further interview with PCA #3 revealed Resident #1 rocked back and forth in bed and she knew it aggravated Resident #2. According to PCA #3, Resident #1 rocked back and forth in the bed with his/her shoulder blades, but not his/her head. Interview with PCA #2, on 07/14/2020 at 4:26 PM, revealed she entered Resident #1's room and the resident was covered in blood from the head to waist. She stated there was a cut on the resident's head. The PCA stated the roommate (Resident #2) reported the resident kept hitting his/her head over and over on the side rail. PCA #2 stated Resident #1 scratched his/her back by holding on to the side rail and moving side to side. According to the PCA, Resident #2 usually kept the bedside table over the foot of the bed so he/she could reach things. The surveyor attempted to interview Registered Nurse (RN) #1, on 07/14/2020 at 8:45 AM; however, the nurse did not return the call. Review of the Nursing Progress Notes, dated 06/26/2020, revealed staff discovered Resident #1 in bed with the top of his/her head covered in blood and blood running down his/her face. The note revealed the nurse observed a laceration to the top left side of the resident's head, a small laceration beneath the right eye, a large bruise with minor swelling to the left side of the resident's neck extending up behind the left ear, a bruise to the top of the right thigh, and a skin tear to the top of the right forearm. Further review revealed the facility transferred Resident #1 to the hospital for further evaluation. Interview with Licensed Practical Nurse (LPN) #1, on 07/14/2020 at 8:47 AM, revealed Resident #1's nurse called her to assist with care the evening of the incident. LPN #1 stated Resident #1 was covered with blood when she arrived to the room. She stated she applied pressure to the head laceration; however, she could not get the bleeding to stop. LPN #1 stated the resident's shirt was saturated with blood, and when she cut his/her shirt off, she noticed a huge bruise and swelling to the left side of the resident's neck starting at the shoulder extending up behind the left ear. She stated the scalp laceration was located on the mid to back left side of the resident's head. LPN #1 stated the resident would not answer when asked about what happened. She revealed staff collected Resident #2's reacher device from his/her bed, and stated there were red specks on the end that appeared to be blood. Review of the facility's investigation and photographs of Resident #2's reacher device revealed a scattered, dark reddish substance located on both sides of the grasping end. Review of the emergency room Discharge Summary, dated 06/26/2020, revealed Resident #1 sustained a one (1) centimeter laceration to the left side of the head at the crown. The laceration was repaired with skin adhesive and the resident was discharged back to the facility. Further interview with LPN #1 revealed she and PCA #4 checked on Resident #1 the following day and asked the resident how he/she got the knot on his/her head. According to LPN #1, the resident stated another resident hit him/her on the head with those things that extend you can grab things with. The resident did not say who the person was that hit him/her. She stated Resident #1 routinely held on to the side rail and wiggled back and forth to scratch his/her back; however, she had never seen the resident thrash back and forth. The LPN further revealed Resident #1's side rails were padded for safety. Interview with PCA #4, on 07/14/2020 at 9:31 AM, revealed she checked on Resident #1 the day after the incident, asked the resident what happened to his/her head, and the resident stated I didn't do it. According to PCA #4, the resident made an open and close motion with his/her hand and stated another resident hit him/her on the head with that thing you extend to get things. The resident stated the person hit him/her because he/she was making noises. The PCA revealed Resident #1 said a person's name, but she could not understand the resident. Interview with the Social Services Director (SSD), on 07/14/2020 at 11:08 AM, revealed she interviewed Resident #1 regarding the injuries he/she sustained on 06/26/2020. The SSD stated Resident #1 stated (he/she) hit me with that nutcracker thing and moved his/her hands in a grasping motion. The SSD stated the resident did not identify who hit him/her. Review of Resident #2's clinical record revealed the facility admitted the resident on 12/17/18 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Quarterly MDS, dated [DATE], revealed the facility assessed the resident with a BIMS score of fifteen (15) and determined he/she was interviewable. Further review of the MDS revealed the resident exhibited no behavioral symptoms. Interview with Resident #2, on 07/08/2020 at 4:46 PM, revealed he/she woke up to a noise, and saw Resident #1's head was bloody, and called for staff. According to Resident #2, the resident had been rocking around in bed violently, he/she reported the concern to a PCA, and was told Resident #1 had the right to do that. Interview PCA #4, on 07/14/2020 at 9:31 AM, revealed Resident #2 sometimes got frustrated when he/she did not get his/her way. She stated she was not aware of any physical aggression. Review of the Psychotherapy Progress Note, dated 01/08/2020, revealed the clinician questioned the possibility of [CONDITION(S)] (TIA) versus cardiovascular event which may have precipitated Resident #2's alleged aggression towards his/her roommate. Review of the Nursing Progress Note, dated 06/25/2020, revealed Resident #2 was verbally aggressive during care and the nurse notified the Director of Nursing (DON). Review of the Psychiatry Progress Note, dated 06/30/2020, revealed diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The note revealed the resident had been seclusive, withdrawn, and exhibited verbal aggression on 06/25/2020. Interview with the Unit Manager for the 100 Hall, on 07/16/2020 at 10:51 AM, revealed Resident #2 exhibited self-directed behaviors; however, she was not aware of behaviors directed at other residents or staff. She stated staff documented resident behavior(s) on individual behaviors sheets as they occurred. The Unit Manager stated any new behaviors should be reported to the physician. Interview with the UM for 200 Hall, on 07/14/2020 at 3:36 PM, revealed Resident #2 exhibited self-harm and manipulative behaviors. She stated she was not aware of behaviors or aggression directed at other residents; however, Resident #2 was particular about roommates. According to the UM, the resident had issues with roommates in the past about the television, room temperature, or if he/she felt they made too much noise. She stated she was not aware of any concerns related to Resident #1. Further interview with the SSD, on 07/14/2020 at 11:08 AM, revealed she interviewed Resident #2 multiple times following the incident; however, she did not ask directly about Resident #1's injuries. According to the SSD, Resident #2 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . Interview with the Director of Nursing (DON), on 07/16/2020 at 11:37 AM, revealed Resident #2 sometimes cussed at staff; however, she was not aware of any threats or assault of another resident. She stated she questioned Resident #2 about the incident and stated he/she vehemently denied assaulting Resident #1. Review of the Behavior Monitoring and Intervention Flowsheets for January through July 2020 revealed Resident #2 exhibited no behaviors. Interview with the Advanced Practice Registered Nurse (APRN), on 07/14/2020 at 4:12 PM, revealed she evaluated Resident #2 after the incident and stated the resident reported his/her roommate (Resident #1) moved to the other side of the building because he/she made too much noise. The APRN stated Resident #2 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . Interview with the Administrator, on 07/15/2020 at 1:29 PM, revealed he interviewed Resident #2 who stated he/she pressed the call light to notify staff Resident #1 hit his/her head on the side rail. The Administrator stated he also interviewed other residents and staff who reported they did not see or hear anything on the evening of the incident.

Based on observation, interview and review of facility Policy, it was determined the facility failed to prepare and store food under sanitary conditions. Observation on [DATE], during initial kitchen tour, revealed two (2) beverage pitchers were not labeled or dated, the ingredient bins had dry dusty food particles on the outside and the kitchen had a general dusty appearance. In addition, observation revealed the Manager in Training was not using correct procedure to to measure the sanitizer in the pot and pan sink. Continued observation of the kitchen on [DATE], revealed two (2) holes in the back wall over the back prep table. In addition, the floors to the base boards appeared soiled; window sills were dusty; walls throughout the kitchen needed paint, and paint was peeling off the wall near the hand sink. Further, the exhaust hood fire extinguisher pipes were dusty; the pot and pan rack over the prep table was dusty; the ceiling vents were dusty; and the top shelf of the prep table was dusty and had a greasy feel. Additionally, interviews with Dietary Staff on [DATE], revealed they were not knowledgeable of how to properly use the Quat Sanitizer, and were mixing Bleach with the Sanitizer. Furthermore, observation on [DATE] of the nourishment refrigerator on the 100 unit, revealed one (1) chocolate and four (4) strawberry 4 ounce (oz.) Sysco supplements were not dated. Moreover, observation on [DATE] of the nourishment refrigerator on the 200 unit, revealed eight (8) 4 oz. Sysco Vanilla shakes were not dated. Also, there was medical gauze dressing on the floor in a container; a bowl of bagged potato chips in the sink; and a wet washcloth on the sink. The findings include: Review of facility Policy, titled Food Handling, dated [DATE], revealed foods are stored, prepared and served in a safe and sanitary manner in order to prevent bacterial contamination and the possible spread of infection. Cold food that remains under refrigeration during service should be covered, labeled, dated with use by dates, and served by use by date. Review of the Dietary Detail Cleaning Schedule dated [DATE] to [DATE], revealed the Dietary Aides were responsible to clean the prep table top, bottom and shelves under the table; the Morning Aides were responsible to clean walls on Mondays; the Morning Cook was responsible to clean the wall behind the three (3) compartment sink on Wednesday and on Saturday; the Morning Dietary Aides were to clean all tables and floors; and the afternoon Dietary Aides were to clean all shelves on Saturday. However, there was no directive related to cleaning the cooks pot and pan rack, the window sills, the ingredient bins and areas behind the equipment. Review of the Quat Sanitizer instructions, revealed ECO-Lab Three Compartment Sink Sanitizer is an Environmental Protection Agency (EPA)registered, concentrated, no rinse Quat sanitizer that is effective across a dilution range of 0.25 - 0.67 ounce (oz.) per gallon of water. It provides a wider sanitization range with maximum convenience. It is an easy spray and wipe, mop bucket or third sink sanitizer application with no rinsing required. Continued review revealed dilute with water to obtain proper Parts per Million (PPM) to sanitize against different pathogens includes Escherichia coli, Staphylococcus aureas, Campylobactor jejuni, Escherichia coli 0157:H7, [DIAGNOSES REDACTED] pneumonia, Listeria monocytogenes, Salmonella [DIAGNOSES REDACTED]esuis, Shigella sonnei, Yersinia [MEDICATION NAME] and [MEDICATION NAME] sakazakii on food contact surfaces. Review of the Clorox Bleach Safety Data Sheet (SDS), dated [DATE] revealed: reacts with other household chemicals, or products containing ammonia to produce hazardous irritating gases, such as chlorine and other chlorinated compound. 1. Observation on [DATE] at 9:30 AM, during initial tour of the kitchen, revealed two (2) beverage pitchers were not labeled or dated. One (1) pitcher was ¼ full of a white liquid substance and one (1) pitcher was ¼ full of a dark liquid substance. In addition, the ingredient bins had dry dusty food particles on the outside and the kitchen had a general dusty appearance. Additionally, the Dietary Manager in Training was observed trying to measure the sanitizer in the pot and pan sink by dragging the test strip quickly through the sanitizer. However, he did not hold the test strip in the sanitizer long enough to register the strength of the sanitizer until Surveyor intervention. Interview with the Manager in Training during the observation, revealed he was unaware he needed to dip the test strip in the sanitizer and hold it there long enough for it to register. Observation of the kitchen on [DATE] at 12:00 PM, during lunch tray line revealed two (2) holes in the back wall over the back prep table. In addition, the floors to the base boards appeared soiled; window sills were dusty; walls throughout the kitchen needed paint, and paint was peeling off the wall near the hand sink. Further, the exhaust hood fire extinguisher pipes were dusty; the pot and pan rack over the prep table was dusty; and the ceiling vents were dusty. In addition the top shelf of the prep table was dusty and had a greasy feel. Interview on [DATE] 10:40 AM, with Dietary Aide #1, revealed staff was to label and date the beverage pitchers daily. She further revealed she was only responsible for cleaning the microwave, toaster and counters and explained further the method of sanitizing the kitchen. She stated she used sanitizer water from the dish room combined with bleach to pour into the red sanitizing buckets in order to clean kitchen surfaces and equipment. She stated it was important to properly sanitize the equipment and counter surfaces to prevent cross contamination. Interview on [DATE] at 10:48 AM, with Dietary Aide #2, revealed the beverage pitchers were to be labeled and dated daily. Per interview, if beverage pitchers were not labeled or dated, the contents of the pitchers should be thrown out because staff would not know how long the beverage had been in the pitcher. Further interview revealed she was responsible for cleaning the dish room, floor, and the counters in the kitchen. She stated she used the sanitizer from the dish room and added a little bleach to the sanitizer buckets in order to clean these areas. Interview on [DATE] at 10:54 AM, with Cook #1, revealed the beverage pitchers were to be labeled and dated daily and changed daily. Continued interview revealed she was responsible to clean the grill, steam table, and the cooks areas and signed off on the matrix for cleaning when completed. Cook #1 stated she sometimes cleaned the ingredient bins. Per interview, she also cleaned the windowsills, pot and pan rack and top shelf above the cooks table. Per interview, it was important to clean and sanitize the kitchen in order to prevent cross contamination of the food. Additional interview revealed she used the pot and pan sink sanitizer mixed with bleach for real greasy messes. Further interview revealed if the kitchen was not properly sanitized this could cause cross contamination of the surfaces. Further interview on [DATE] at 11:01 AM, with the Dietary Manager in Training, revealed the beverage pitchers were to be changed daily, cleaned and sanitized for the next day. Per interview, the beverage pitchers should be labeled and dated daily in order for staff to be knowledgeable of the expiration date. Further interview revealed there was an assigned cleaning list for the AM (morning) and PM (evening) staff, and staff was to sign when the work was completed. Per interview, Maintenance staff assisted with cleaning of the ceiling during non-production hours. Further, Dietary Staff was responsible to clean all reachable areas in the kitchen, as dust could fall into the food and cause cross contamination. Continued interview revealed the holes in the wall could allow pests to enter the kitchen and peeling paint could be a concern as debris could get into the food. Additional interview with the Dietary Manager in Training, revealed staff was to use the three (3) compartment sink Quat Sanitizer or the dish room Quat Sanitizer to sanitize the pots, pans and kitchen surfaces. Per interview, the Quat test strips were available to test the sanitizer in the pot and pan sink and in the red sanitizer buckets to ensure it was at appropriate PPM and effective. Further, this Quat Sanitizer was not to be mixed with bleach as this could cause the mixture to be toxic and not effective for sanitizing food contact surfaces. Interview on [DATE] at 11:17 AM, with the District Manager, revealed staff was to label and date the pitchers of fluids daily. Per interview, the leftover beverages in the pitchers was to be thrown out, washed and new beverages added to the pitchers daily. Further, if the pitchers were not dated, staff would not know when the beverages were prepared and needed to be discarded. Continued interview revealed Dietary Staff had a cleaning list with specific areas assigned to be cleaned in the kitchen. Upon completion of the cleaning task, staff was to sign the cleaning list to indicate the cleaning had been completed. The District Manager stated the dust in the kitchen over the production areas could fall into the food and cause cross contamination, and the holes in the kitchen wall could allow rodents and bugs to enter. Further interview revealed the kitchen did need repainting. Additional interview with the District Manager, revealed the sanitizer from the pot and pan sink was used for sanitizing the kitchen, and the sanitizer from the dish machine was used to clean stainless steel. Per interview, some staff preferred bleach and water to clean and sanitize the kitchen. The District Manager stated sanitizer and bleach were not to be mixed together because this would change the effects of the sanitizer on the food contact surfaces and allow for cross contamination of bacteria. Interview on [DATE] at 2:45 PM, with the Maintenance Director, revealed he cleaned the kitchen vents and changed air filters once monthly as scheduled during non-production times and another cleaning was not due until next month. Further, Dietary Staff was responsible for cleaning all the other areas of the kitchen. He stated the holes in the wall could allow pests to enter and the walls needed to be repaired. Interview on [DATE] at 4:00 PM, with the Director of Nursing (DON), revealed dietary staff should label and date all foods with the date of expiration. Per interview, the kitchen should be properly cleaned and sanitized to protect against the potential for food borne pathogens. Further, the kitchen should be free of dust or debris in the air which could contaminate food. Additional interview revealed the holes in the kitchen wall could allow pests to enter and contaminate food products. 2. Interview on [DATE] at 1:21 PM with the Administrator, revealed there was no facility policy related to labeling and dating food in the nourishment refrigerator. Observation on [DATE] at 12:35 PM, of the nourishment refrigerator on the 100 unit, revealed one (1) chocolate and four (4) strawberry 4 ounce (oz.) Sysco supplements were not dated. Observation on [DATE] at 12:40 PM, of the nourishment refrigerator on the 200 unit, revealed eight (8) 4 oz. Sysco Vanilla shakes were not dated. In addition, there was medical gauze dressing on the floor in a container; a bowl of bagged potato chips in the sink; and a wet washcloth on the sink. Interview on [DATE] at 2:00 PM, with State Registered Nurse Assistant (SRNA) #11, who was working the 100 unit, revealed the supplements were placed into the nourishment refrigerator when the residents refused them. Per interview, staff should date all supplements prior to putting them into the refrigerator in order for staff to know the date of expiration. Interview on [DATE] at 2:05 PM, with SRNA #4, who worked the 100 unit, revealed if supplements were not dated, they should be discarded immediately. Interview on [DATE] at 2:30 PM, with SRNA #5, who was working the 200 unit, revealed if supplements were not dated, they should be discarded. Interview on [DATE] at 2:35 PM, with Licensed Practical Nurse (LPN) #5, who worked the 200 unit, revealed supplements should be labeled and dated to ensure they were not expired. LPN #5 stated staff should throw out any expired, unlabeled or undated foods and contact Dietary. Per interview, staff should not remove the label or date on the supplements before placing them in the nourishment refrigerator. Interview on [DATE] at 2:40 PM, with the Unit Manager #2 for the 200 unit, revealed if a resident refuses a supplement, the SRNA should notify the nurse. Per interview, the label and date information should remain on the supplement if it was placed in the nourishment refrigerator and if the supplement was not labeled or dated, it should be thrown out. Further, there should be no medical equipment items kept in the nourishment room. Continued interview revealed the washcloth should not have been left on the back of the sink in the nourishment room, but should have been placed into the soiled linen room. Interview on [DATE] at 4:00 PM, with the Director of Nursing (DON), revealed nursing staff should label and date all supplements stored in the nourishment refrigerator to ensure it was discarded upon expiration. Further, there should not have been a wet washcloth left on the sink in the nourishment room and medical supplies should not have been left on the floor in the nourishment room as the nourishment room needed to be clean and sanitary. Interview on [DATE] at 4:23 PM, with the Administrator, revealed the beverage pitchers in the reach-in refrigerator of the kitchen should have been labeled and dated. Further interview revealed it was his expectation for staff to follow the cleaning schedule in the kitchen in order for the kitchen to be clean and sanitary at all times. Per interview, the dust build up in the kitchen allowed for the possibility of dust to get into the food causing cross contamination. In addition, the holes in the kitchen allowed for the potential for pests to enter the kitchen and contaminate food products. Further interview revealed it was his expectation for the kitchen staff to be knowledgeable of how to properly use the sanitizer. Additional interview with the Administrator, revealed it was his expectation for the 100 and 200 units to properly label and date all supplements stored in the nourishment refrigerators to ensure they were discarded upon expiration. Further, the wet washcloth should not have been left on the back of the sink in the nourishment room and medical supplies should not have been stored in the nourishment room on the floor, as this was not sanitary.

Based on observation, interview, and record review, it was determined the facility failed to develop and implement a Comprehensive Care Plan (CCP) for each resident, that includes measurable objectives and timeframes to meet a resident's needs for four (4) of twenty-two (22) sampled residents (Residents #9, #33, #42, #56). Resident #9's Monthly (MONTH) 2019 physician's orders [REDACTED]. However, there was no documented evidence the facility developed the CCP to include interventions related to the left resting hand splint. Additionally, the resident was discharged from Physical Therapy (PT) on 10/17/19, with recommendations to transition to the Restorative Nursing Program (RNP) in order to maintain current level of function with bed mobility, and bilateral lower extremity (BLE) Active Range of Motion (AROM). However, there was no documented evidence the facility developed or implemented the CCP related to transfers, bed mobility, or BLE AROM. (Refer to F-688) Resident #33's CCP, revised 09/05/19, revealed interventions for Restorative transfers, Restorative bed mobility and Restorative Range of Motion (ROM) related to cognitive loss/dementia and functional deterioration. However, there was no documented evidence the facility implemented the Plan of Care during (MONTH) and (MONTH) 2019. (Refer to F-688) In addition, Resident #33's CCP, revised 09/05/19, was not developed to include the medical symptom to justify the use of restraint, interventions related to the frequency or circumstance in which the restraint was to be used, interventions for ongoing evaluations for the restraint to ensure it was the least restrictive device or effective for this resident to prevent accidents/incidents; or interventions to address potential complications. (Refer to F 604). Additionally, per Resident #33's CCP, the resident was not to be left unsupervised in the Joy Room (dining room). However, observation on 10/29/19, at 1:30 PM, revealed Resident #33 was sitting in the joy room (dining room) in his/her wheelchair at a table, and there was no staff in the joy room. Resident #42 was discharged from Occupational Therapy (OT) on 09/15/19, with recommendations to transition to a RNP for bilateral upper extremity (BUE) AROM and BLE transfer training. However, there was no documented evidence the facility developed or implemented the CCP related to AROM to BUE and BLE transfer training. (Refer to F-688). Resident #56's CCP revised 01/29/19, revealed interventions for Restorative bed mobility and Restorative ROM related to cognitive loss/dementia and functional deterioration; however, there was no documented evidence the facility implemented the Plan of Care during (MONTH) and (MONTH) 2019. (Refer to F-688) The findings include: Review of the facility's Person Centered Care Plan Policy, revised 07/01/19, revealed a person center care plan will include measurable objective and timetables to meet the resident's physical, psychosocial and functional needs. Additionally, the care plan process will include a resident's personal preferences. Further, the Care Plan will describe the services to be provided to maintain or attain the residents' highest practicable physical, mental, and psychosocial wellbeing; include identified problem areas; and aid in preventing or reducing decline in functional status/level. 1. Review of Resident #9's clinical record revealed the facility admitted the resident on 11/28/16 with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) Assessment, dated 10/17/19, revealed the facility assessed Resident #9 as having a Brief Interview for Mental Status (BIMS) score of fifteen (15) out of fifteen (15) indicating intact cognition. Further, the facility assessed the resident as requiring extensive assistance of one (01) staff for bed mobility and extensive assistance of two (02) staff for transfers. Per the MDS Assessment, the resident was assessed as having Functional Limitation in Range of Motion (ROM) to (01) upper and one (1) lower extremity. Review of the Monthly (MONTH) 2019 physician's orders [REDACTED]. Review of the Physical Therapy (PT) Discharge Summary, dated 10/17/19, revealed recommendations for Resident #9 to transition to a Restorative Nursing Program (RNP) to maintain current level of function with bed mobility, and bilateral lower extremity (BLE) Active Range of Motion (AROM). However, record review revealed there was no documented evidence the Resident #9's CCP was developed to include interventions for the left resting hand splint as per the physician's orders [REDACTED]. 2. Review of Resident #33's clinical record revealed the facility admitted the resident on 12/28/18 with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) Assessment, dated 08/26/19, revealed the facility assessed Resident #33 as having a BIMS score of ninety-nine (99) and having both short and long term memory problems. Further, the facility assessed the resident as requiring total assistance of two (02) staff for all Activities of Daily Living (ADLS). Per the Assessment, this resident had Functional Limitation in Range of Motion (ROM) bilaterally to upper and lower extremities. Per the MDS Assessment, the resident last received therapy on 05/30/19. Review of the Comprehensive Care Plan (CCP), revised 09/05/19, revealed Resident #33 required Restorative Transfer: The resident demonstrated deficit in transferring related to Cognitive loss/Dementia and Functional Deterioration. The goal revealed the resident would safety transfer from bed to chair for ninety-two (92) days. Interventions initiated on 02/22/19 included: providing verbal cues for sequencing and to lock the wheelchair; placing transfer surface as close as possible and free from obstacles; ensuring surfaces are stable; and cueing patient for transfer techniques. Additional review of the CCP, revised 09/05/19, revealed Resident #33 required Restorative Bed mobility: The resident demonstrated deficit in positioning self in bed related to Cognitive loss/Dementia and Functional Deterioration. The goal revealed the resident would achieve maximum level of independence related to moving in bed for ninety-two (92) days. The interventions initiated on 02/22/19 included; standby assist with rolling side-to-side, supine to so sit and sit to supine. Further review of the CCP, revised 09/05/19, revealed Resident #33 required Restorative Range of Motion: The resident demonstrated loss in ROM in bilateral upper extremities related to Cognitive loss/Dementia and Functional Deterioration. The goal revealed contractures would be prevented and skin integrity would be maintained for ninety-two (92) days. The interventions initiated on 02/22/19 included: AROM to upper extremities; teach resident and family to perform the ROM exercises; and provide reminders, supervision or actual physical assist to move extremity. However, record review revealed there was no documented evidence the facility implemented the CCP related to interventions to maintain current functional status: transfers, bed mobility, and ROM, for (MONTH) or (MONTH) 2019. 3. Review of Resident 42's clinical record revealed the facility admitted the resident on 10/22/07 with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) Assessment, dated 09/06/19, revealed the facility assessed the resident as having a BIMS score of twelve (12) out of fifteen (15) which indicated moderate cognitive impairment. Additionally, the facility assessed the resident as requiring extensive assist of two (2) persons for transfers and as having Functional Limitation in Range of Motion to one (01) lower extremity. Review of the Occupational Therapy Discharge Summary, dated 09/15/19, revealed the resident was discharged with recommendations to transition to the Restorative Nursing Program (RNP) in order to maintain current level of function with Active Range of Motion (AROM) to bilateral upper extremities (BUE) and BLE transfer training. However, there was no documented evidence the facility developed or implemented the CCP related to AROM to BUE and BLE transfer training. 4. Review of Resident #56's clinical record revealed the facility admitted the resident on 03/19/19 with [DIAGNOSES REDACTED]. Review of the CCP, revised 01/29/19, revealed Resident #56 required Restorative Bed mobility: The resident demonstrated deficit in positioning self in bed related to Cognitive loss/Dementia and Functional Deterioration. The goal revealed the resident would achieve maximum level of independence related to moving in bed for ninety-two (92) days. The interventions initiated on 01/29/19 included; moderate assist rolling side to side and raise head of bed to approximately forty-five (45) degrees so resident can pull self up into long sitting position with minimal assist. Further review of the CCP, revised 01/29/19, revealed Resident #56 required Restorative Range of Motion: The resident demonstrated loss in ROM in bilateral upper extremities related to Cognitive loss/Dementia and Functional Deterioration. The goal revealed the resident would be able to move bilateral lower extremities through normal ROM without discomfort for ninety-two (92) days. The interventions initiated on 01/29/19 included: support above and below the joint; provide pain medications as needed; explain each step prior to doing it; teach patient to perform the ROM exercises; and for Passive ROM provide move joint slowly and gently, never force past resistance, avoid fast movements or stretching. Review of the Significant Change Minimum Data Set (MDS) Assessment, dated 10/25/19, revealed the facility assessed Resident #56 as having a BIMS score of three (03) indicating severe cognitive impairment. Also, the facility assessed the resident as requiring extensive assistance of two (02) staff for bed mobility and requiring total assistance for all other ADLS. Per the MDS Assessment, the facility assessed the resident to have Functional Limitation in Range of Motion (ROM) of one (1) lower extremity and as not receiving therapy or RNP. However, record review revealed there was no documented evidence the facility implemented the CCP related to Restorative Nursing for bed mobility and ROM in (MONTH) or (MONTH) 2019. Interview with Licensed Practical Nurse (LPN) #2, on 10/30/19 at 1:35 PM, revealed the CCP should be a current, accurate reflection of the residents because it was used by the interdisciplinary team (IDT) and direct care givers to ensure residents received safe quality care to meet their needs. She stated if residents had physician's orders [REDACTED]. Additionally, she stated it was important the CCP was implemented related to RNP and residents were provided necessary care and devices to ensure residents maintained their highest level of function, and wellbeing and to prevent and/or decrease risk for complications such as contracture, skin breakdown, and pain. Further interview with LPN #2, revealed the facility was in between RNP staff at this time as the Restorative Nurse had accepted the Interim Unit Manager position for the 100 hallway and it had been several weeks since the RNP program had been placed on hold. Interview with State Registered Nursing Assistant (SRNA) #2, on 10/30/19 at 2:00 PM (restorative aide for the 200 hallway) revealed she used the CCP as a reference in providing care to the residents. Additionally, the CCP should be developed to include all treatment and services the residents required and the CCP should be followed to ensure each resident's needs were met. Further interview revealed she was the Restorative Aide for the 200 hallway Unit, but during the last two (02) months she had not been assigned to complete RNP duties, but was assigned to work as a direct care SRN[NAME] Further, the RNP services and treatments were not being administered to the residents as per the Care Plans. Interview with the Therapy Director, on 10/31/19 at 11:15 AM, revealed the RNP Plan of Care was based on a nursing referral with noted decline in function or a referral from the therapy department after skilled therapy to maintain gains made in therapy. Per interview, the Therapist would complete a form on discharge and choose a program based on individual resident needs. That form was given to Restorative Nurse and who would develop the RNP and train the Restorative Aides to implement the RNP plan based on the referral. Further, she expected a RNP Plan to be implemented by nursing to maintain the highest level of independence for residents. Additional interview revealed she had identified a cycle over the last several months where residents were not getting RNP and she had discussed her concerns with Administration related to residents declining without the RNP. Interview with the Interim Unit Manager, 100 hallways, on 10/31/19 at 2:25 PM (previous Restorative Nurse) revealed the CCP should be developed and implemented by nursing staff to meet the needs of the individual residents. Per interview, following the care plan ensured optimal care, and progress towards meeting the residents' care needs. Additionally, the Restorative Nurse was responsible to develop the RNP Plan of Care based on therapy recommendations. Further, the Restorative Aides were responsible to implement the RNP Plan of care. Interview with the Director of Nursing (DON), on 10/31/19 at 3:05 PM, revealed if there were recommendations in place from therapy, the facility was responsible and accountable to develop and implement the RNP Plan of Care. Additionally, if there was a RNP Plan of care developed the facility was responsible and accountable to implement the RNP Plan of Care. Per interview, it was very important to ensure residents received effective, safe care, and to reduce complications. Further, if there was a physician's orders [REDACTED]. Additional interview revealed LPN #2 was responsible for the facility's RNP since the previous Restorative Nurse took the position of Unit Manager for the 100 hallway, in (MONTH) 2019. However, the DON stated she had identified that LPN #2 was not effective and was not able to maintain the RNP while working as a direct care nurse. She stated she hired a new Restorative Nurse last week. Further interview revealed she was aware the RNP in the facility had not been maintained for residents over the last few months, and the CCPs were not being developed or implemented related to RNP. 5. Review of Resident #33's clinical record revealed the facility admitted the resident on 12/28/18 with [DIAGNOSES REDACTED]. Review of Resident #33's physician's orders [REDACTED]. Review of Resident #33's Restrictive Device Consent, dated 02/11/19, revealed a self-releasing alarming seatbelt had been ordered by as part of the resident's overall plan of care. Additionally, the medical reason for use was poor safety awareness and impulse control. Per the Consent, the restraint was to be used when up in the wheelchair. Additional review revealed the Consent included risk versus benefits and was signed by the resident's representative. Review of Resident #33's Restraint Release Reduction Assessment, dated 08/23/19, revealed the resident had inconsistent response to the trial and recommendations were to continue the seatbelt alarm while the resident was up in the wheelchair related to impaired cognition, inability to follow safety measures, and unstable independent ambulation. Review of Resident #33's Quarterly Minimum Data Set (MDS) Assessment, dated 08/26/19, revealed the facility assessed the resident as having both short and long term memory loss. Further, the facility assessed the resident as requiring total assistance of two (02) staff for bed mobility, transfers, and toileting. Additional review revealed the resident did not ambulate and required total assistance of one (01) staff for locomotion in the wheelchair. Per the MDS Assessment, the resident had unsteady balance, only able to stabilize with staff assistance during transition from surface to surface. Further review revealed a chair and bed alarm was used daily and the resident used no physical restraints. Review of Resident #33's Comprehensive Care Plan (CCP), revised 09/05/19, revealed the resident was at risk for falls related to cognitive loss, lack of safety awareness, impaired mobility, and falls. The goal revealed the resident would have no falls with injury for ninety (90) days. The interventions included, but were not limited to: nonskid socks, 12/31/18; pressure alarm to wheelchair and bed to alert staff of unsafe attempts to self-transfers, 01/11/19; resident not to be left alone in Joy room (dining room) without staff supervision, 02/05/19; self releasing seatbelt with alarm, check and release every two (02) hours and as needed, 02/14/19; and resident to sit in high traffic areas after lunch, 05/19/19. However, the CCP was not developed to include the need to complete ongoing evaluations related to the self-releasing alarming seat belt to ensure this was an effective intervention for this resident, or to ensure the device was not a restraint. Additionally, the CCP was not developed to address the medical symptom to justify the use of restraint, the frequency or circumstance when to use the restraint; or interventions to address potential complications. Interview with Licensed Practical Nurse (LPN) #2, on 10/30/19 at 1:35 PM, revealed Resident #33's CCP should have been developed to include ongoing evaluations of the alarming seat belt, the medical symptom to justify the use of restraint, the frequency or circumstance when to use the restraint and interventions to address potential complications. Per interview, these criteria would ensure the restraint was an effective intervention for this resident, and the least restrictive device. Observation on 10/29/19, at 1:30 PM, revealed Resident #33 was sitting in the joy room (dining room) in his/her wheelchair at a table. Continued observation revealed there were no staff in the joy room (dining room). However, per the CCP, the resident was not to be left unsupervised in the Joy Room (dining room). Additional interview with the Director of Nursing (DON), on 10/31/19 at 3:05 PM, revealed Resident #33's CCP should have been developed to include the medical symptom to justify the use of restraint, the frequency or circumstance in which the restraint was to be used, ongoing evaluations of the alarms to ensure the alarms were the least restrictive devices or were appropriate or effective for this resident to prevent accidents/incidents, and interventions to address potential complications of the restraint. Furthermore, she stated she expected the CCP to be implemented related to not leaving the resident unsupervised in the Joy Room (dining room). Interview with the Administrator on 10/31/19 at 4:06 PM, revealed he expected the facility policy and regulations to be followed related to developing and implementing the CCP. Further, he expected nursing staff to develop care plans and provide services and treatment as per the individualized written plans related to restorative nursing. Additional interview with Administrator, revealed Resident #33's CCP should have been developed with further interventions related to restraint use as per regulation, and the resident's CCP should have been implemented related to not leaving the resident in the joy room unattended.

Based on observation, interview, record review, and review of facility Policy, it was determined the facility failed to ensure a resident with limited mobility received appropriate services, equipment, and assistance to maintain or improve mobility with the maximum practicable independence unless a reduction in mobility is demonstrably unavoidable for four (04) of five (05) residents reviewed related to Limited Range of Motion (ROM) out of twenty-two (22) sampled residents (Resident # 9, Resident #33, Resident #42, and Resident #56). Resident #9's Monthly (MONTH) 2019 physician's orders [REDACTED]. In addition, the resident was discharged from Physical Therapy (PT) on 10/17/19, with recommendations to transition to a Restorative Nursing Program (RNP) to maintain current level of function with bed mobility, and bilateral lower extremity (BLE) Active Range of Motion (AROM). However, there was no documented evidence the facility implemented the RNP related to interventions to maintain current functional status: bed mobility, BLE AROM or splints, in (MONTH) or (MONTH) 2019. (Refer to F-656) Resident #33's Comprehensive Care Plan (CCP), revised 09/05/19, revealed the resident required RNP for transfers, bed mobility and Range of Motion (ROM) related to cognitive loss/dementia and functional deterioration. However, there was no documented evidence the facility implemented the RNP related to transfers, bed mobility and ROM to maintain the resident's functional status in (MONTH) or (MONTH) 2019. (Refer to F-656) Resident #42 was discharged from Occupational Therapy on 09/15/19, with recommendations to transition to a RNP for bilateral upper extremity (BUE) AROM and BLE transfer training. However, there was no documented evidence the facility implemented the RNP related to AROM and transfers to maintain the resident's functional status in (MONTH) or (MONTH) 2019. (Refer to F-656) Resident #56's Comprehensive Care Plan (CCP), revised 01/29/19, revealed the resident required RNP for bed mobility and Range of Motion (ROM) related to cognitive loss/dementia and functional deterioration. However, there was no documented evidence the facility implemented the RNP related to bed mobility and ROM in order to maintain the resident's functional status in (MONTH) or (MONTH) 2019. (Refer to F-656) Furthermore, review of the RNP Binders, for the 100 and 200 hallways, revealed forty-one (41) residents with RNP Plans dated (MONTH) 2019. However, there was no documented evidence the services were provided as per the RNP Plans. Additionally, there was no documented evidence of (MONTH) 2019 RNP Plans. The findings include: Review of the facility Restorative Nursing Policy, revised 03/15/16, revealed residents would receive Restorative Nursing care as needed to promote and maintain optimal physical, mental, and psychosocial functioning. Additionally, Restorative Nursing consisted of nursing interventions that may not be accompanied by formalized rehabilitation services. Continued review revealed the goals and objectives of restorative were individualized and resident centered, and would be outlined in the resident's Care Plan. Further, the RNP would be implemented per the specifics on the Care Plan. Per the Policy, the RNP would be documented daily on the Restorative Nursing Record. 1. Review of Resident #9's Medical Record, revealed the facility admitted the resident on 11/28/16 with [DIAGNOSES REDACTED]. Interview with Resident #9, on 10/29/19 at 9:30 AM, revealed he/she had not received RNP after being recently discharged from therapy. Further, the resident was concerned that he/she would decline in functional status and his/her goal to maintain gains made in therapy would not be met without RNP services Review of Resident #9's Quarterly Minimum Data Set (MDS) Assessment, dated 10/17/19, revealed the facility assessed the resident as having a Brief Interview for Mental Status (BIMS) score of fifteen (15) out of fifteen (15) indicating intact cognition. Additionally, the facility assessed the resident as requiring extensive assistance of one (01) staff for bed mobility and extensive assistance of two (02) staff for transfers. Per the Assessment, the resident had Functional Limitation in Range of Motion (ROM) to (01) upper and one (1) lower extremity. Per the MDS Assessment, the resident last received therapy on 10/17/19. Review of Resident #9's Monthly (MONTH) 2019 physician's orders [REDACTED]. Review of Resident #9's Physical Therapy (PT) Discharge Summary, dated 10/17/19, revealed recommendations for the Resident to transition to a RNP to maintain current level of function with bed mobility, and bilateral lower extremity (BLE) Active Range of Motion (AROM). However, there was no documented evidence the facility implemented a RNP Plan of Care with interventions to maintain current functional status: bed mobility, BLE AROM or splints, in (MONTH) or (MONTH) 2019. Review of the Restorative Binder, dated (MONTH) 2019, for the 200 hall where Resident #9 resided, revealed a RNP for this resident related to Passive ROM to left upper and lower extremities and AROM to right upper and lower extremities six (06) to seven (07) days a week; and splint to left hand up to four (04) to six (06) hours a day six (06) to seven (07) days a week. However, there was no documented evidence these interventions were implemented for Resident #9 as there were no staff initials or signatures. Review of Resident #9's Progress Notes, dated 10/01/19 through 10/30/19 revealed no documented evidence of a RNP Plan. 2. Review of Resident #33's Medical Record, revealed the facility admitted the resident on 12/28/18 with [DIAGNOSES REDACTED]. Observation of Resident #33, on 10/29/19 at 9:22 AM, 1:00 PM and 4:00 PM; and on 10/30/19 at 9:00 AM; revealed the resident was in bed lying on his/her back, in high fowlers position. Further observation on 10/31/19 at 1:30 PM, revealed the resident was in the dining room seated in a high back wheelchair with an alarming seat belt across his/her lap. Review of Resident #33's Quarterly Minimum Data Set (MDS) Assessment, dated 08/26/19, revealed the facility assessed the resident as having both short and long term memory problems. Additionally, the facility assessed the resident as requiring total assistance of two (02) staff for all Activities of Daily Living (ADLS). Per the Assessment, the resident had Functional Limitation in Range of Motion (ROM) bilaterally to upper and lower extremities. Further, per the MDS Assessment, the resident last received therapy on 05/30/19. Review of Resident #33's Monthly (MONTH) 2019 physician's orders [REDACTED]. Further review revealed current orders for self-releasing seat belt to wheelchair when up, release every two (02) hours and for meals, dated 02/11/19. Review of Resident #33's Comprehensive Care Plan (CCP), revised 09/05/19, revealed the resident required Restorative Transfer: The resident demonstrated deficit in transferring related to Cognitive loss/Dementia and Functional Deterioration. The goal stated the resident would safety transfer from bed to chair for ninety-two (92) days. Interventions initiated on 02/22/19 included: provide verbal cues for sequencing and to lock the wheelchair; place transfer surface as close as possible and free from obstacles; ensure surfaces are stable; and cue patient for transfer techniques. Additional review of Resident #33's CCP, revised 09/05/19, revealed the resident required Restorative Bed mobility: The resident demonstrated deficit in positioning self in bed related to Cognitive loss/Dementia and Functional Deterioration. The goal stated the resident would achieve maximum level of independence related to moving in bed for ninety-two (92) days. Interventions initiated on 02/22/19 included; standby assist with rolling side-to-side, supine to so sit and sit to supine. Further review of Resident #33's CCP, revised 09/05/19, revealed the resident required Restorative Range of Motion: The resident demonstrated loss in ROM in bilateral upper extremities related to Cognitive loss/Dementia and Functional Deterioration. The goal was to prevent contractures and maintain skin integrity for ninety-two (92) days. Interventions initiated on 02/22/19 included: AROM to upper extremities; teach resident and family to perform the ROM exercises; and provide reminders, supervision or actual physical assist to move extremity. Review of the Restorative Binder, for the 200 hall where Resident #33 resided, revealed a RNP dated (MONTH) 2019, for this resident to receive Active ROM to bilateral upper and lower extremities ten (10) repetitions each, six (06) to seven (07) days a week; and self feeding-setup assist/verbal cues and divided plate two (02) to three (03) times a day, six (06) to seven (07) days a week. However, there was no documented evidence the services were provided as per the RNP as there were no staff initials or signatures. Further, there was no documented evidence of a RNP completed for Resident #33 for (MONTH) 2019. In addition, there was no documented evidence the facility implemented a RNP Plan of Care related to transfers, and bed mobility to maintain his/her functional status in (MONTH) or (MONTH) 2019. Review of Resident #33's Progress Notes, dated 10/01/19 through 10/30/19 revealed no documented evidence of a RNP Plan. 3. Review of Resident #56's Medical Record, revealed the facility admitted the resident on 03/19/19 with [DIAGNOSES REDACTED]. Observation of Resident #56, on 10/29/19 at 9:32 AM, revealed the resident was lying flat in bed on his/her back, in a low bed with a wedge under the left flank and right knee. Additional observation, on 10/29/19 at 12:30 PM, revealed the resident was in the dining room sitting in a geri chair. The resident slid down in the chair multiple times and two (02) staff repositioned him/her. Review of Resident #56's CCP, revised 01/29/19, revealed the resident required Restorative Bed mobility: The resident demonstrated deficit in positioning self in bed related to Cognitive loss/Dementia and Functional Deterioration. The goal stated the resident would achieve maximum level of independence related to moving in bed for ninety-two (92) days. Interventions initiated on 01/29/19 included; moderate assist rolling side to side and raise head of bed to approximately forty-five (45) degrees so resident can pull self up into long sitting position with minimal assist. Further review of Resident #56's CCP, revised 01/29/19, revealed the resident required Restorative Range of Motion: The resident demonstrated loss in ROM in bilateral upper extremities related to Cognitive loss/Dementia and Functional Deterioration. The goal stated the resident would be able to move bilateral lower extremities through normal ROM without discomfort for ninety-two (92) days. Interventions initiated on 01/29/19 included: support above and below the joint; provide pain medications as needed; explain each step prior to doing it; teach patient to perform the ROM exercises; and for Passive ROM provide move joint slowly and gently, never force past resistance, avoid fast movements or stretching. Review of Resident #56's Significant Change Minimum Data Set (MDS) Assessment, dated 10/25/19, revealed the facility assessed the resident as having a BIMS score of three (03) indicating severe cognitive impairment. Additionally, the facility assessed the resident as requiring extensive assistance of two (02) staff for bed mobility and requiring total assistance for all other ADLS. Per the MDS Assessment, the facility assessed the resident as having Functional Limitation in Range of Motion (ROM) of one (1) lower extremity. Further, per the MDS Assessment, the resident had not received therapy or RNP. Review of Resident #56's Monthly (MONTH) 2019 physician's orders [REDACTED]. Review of the Restorative Binder, for the 200 hall where Resident #56 resided, revealed no documented evidence of a RNP Plan including ROM or bed mobility, for (MONTH) or (MONTH) 2019 for this resident. Review of Resident #56's Progress Notes, dated 10/01/19 through 10/30/19 revealed no documented evidence of a RNP Plan. Further, there was no documented evidence the facility implemented a RNP Plan of Care related to bed mobility and ROM to maintain his/her functional status in (MONTH) or (MONTH) 2019. 4. Review of Resident 42's Medical Record revealed the facility admitted the resident on 10/22/07 with [DIAGNOSES REDACTED]. Review of the Quarterly MDS Assessment, dated 09/06/19, revealed the facility assessed the resident as having a BIMS score of twelve (12) out of fifteen (15) indicating moderate cognitive impairment. Additionally, the facility assessed the resident as requiring extensive assist of two (2) persons for transfers and as having Functional Limitation in Range of Motion (ROM) to one (01) lower extremity. Review of Resident #42's Occupational Therapy Discharge Summary, dated 09/15/19, revealed discharge recommendations for caregiver assist with Activities of Daily Living (ADL) and follow up with RNP addressing BUE AROM and BLE transfer training. However, there was no documented evidence the facility implemented a RNP Plan of Care with interventions to maintain current functional status related to AROM and transfers. Review of the Restorative Binder, for the 100 hall where Resident #42 resided, revealed the RNP for this resident dated 09/2019 included Active Range of Motion (AROM) to Bilateral Upper Extremities (BUE) and Bilateral Lower Extremities (BLE) ten to fifteen (10-15) repetitions each for six (6) to seven (7) days per week; transfer training five to ten (5-10) repetitions daily for six (6) to seven (7) days per week; and minimum assist with transfers chair to toilet, toilet to chair, chair to bed and bed to chair. Additional review revealed there was no documented evidence the facility implemented the RNP related to AROM and transfers to maintain the resident's functional status as there was no staff initials or signatures. In addition, there was no documented evidence the resident participated in a RNP as per the 09/15/19 OT recommendations, in (MONTH) or (MONTH) 2019. 5. Furthermore, review of the RNP Binders, for the 100 and 200 hallways, revealed forty-one (41) residents with RNP Plans dated (MONTH) 2019. However, there was no documented evidence the services were provided as per the RNP Plans. Additionally, there was no documented evidence of (MONTH) 2019 RNP Plans. Interview with Licensed Practical Nurse (LPN) #2, on 10/30/19 at 1:35 PM, revealed she had worked at the facility for ten (10) years. Per interview, the facility was in between RNP staff at this time as the Restorative Nurse had accepted the Interim Unit Manager position for the 100 hallway and the Restorative Aides were working as direct care aides. Additionally, it had been several weeks since the RNP program had been placed on hold. Further, Restorative aides received specific training on RNP services as opposed to direct care aides and Restorative Aides were usually assigned to implement the RNP set by the Restorative Nurse based on therapy referral. LPN #2 stated, only the Restorative Aides were knowledgeable of the RNP Plans and where and how to document on the Restorative Nursing Record. Additional interview with LPN #2, revealed there was no current RNP Plans in the Restorative binder because there had been no Restorative Nurse to complete them. However, LPN #2 stated it was important to implement and maintain a RNP program to ensure residents kept their highest level of function, and wellbeing. Further, the RNP program was important to ensure quality of care and quality of life and prevent and/or decrease risk for complications such as contractures, skin breakdown, and pain. Interview with State Registered Nursing Assistant (SRNA) #2, on 10/30/19 at 2:00 PM, revealed she was the Restorative Aide for the 200 hallway Unit. She stated during the last two (02) months she had not been assigned to complete RNP duties, but was assigned to work as a direct care SRN[NAME] Per interview, there was no longer a Restorative Nurse to implement or make changes to the RNP plans. Continued interview revealed there had been no updates to the RNP plans and the (MONTH) RNP Plans were not developed and placed in the RNP Binders on the units. Per interview, the RNP services and treatments were not being administered to the residents. Further, it was important to provide RNP services and treatments to residents to maintain their functional level and prevent declines such as contractures, pain, or skin breakdown. Interview with the Therapy Director, on 10/31/19 at 11:15 AM, and at 2:15 PM, revealed at times the therapy department discharged residents with recommendations to transition to the RNP after skilled therapy to maintain gains made in therapy. Per interview, a Therapist would complete a form on discharge and choose a program based on individual resident needs. That form was given to the Restorative Nurse who would train the Restorative Aides to implement the RNP plan based on the referral. Additionally, she expected a RNP plan to be implemented by nursing in order to ensure residents maintained their highest level of independence. Continued interview with the Therapy Director, revealed she had identified a cycle over the last several months where residents were not getting RNP and she had discussed her concerns related to residents declining without the RNP to Administration. Per interview, a nurse was recently hired for the RNP, as of last week. Further, it was her expectation that Resident #9 have a RNP in place, per therapy discharge recommendations on 10/17/19. In addition, she stated Resident #56 should have a functional maintenance plan to maintain mobility and ROM since he/she was comfort care now. Additionally, she stated Resident #33's RNP Plan should have been implemented per the CCP. Further interview revealed Resident #42 was discharged from the therapy program and was to transition to the RNP to assist with transition and continuity of resident care and the restorative nurse was notified of the change in programs for this resident. Interview with the Interim Unit Manager, for the 100 hallway, on 10/31/19 at 2:25 PM, revealed she had been in this role since 08/02/19 and had previously been responsible for the RNP two (02) days a week. Per interview, she was not aware of who was responsible for the RNP after she took her new role in August; however, the RNP services and treatment had been integrated into direct care over the last few months and the regular SRNAs were providing RNP services. Continued interview revealed she could not ensure the RNP services and treatments were being administered per the RNP Plans because there was no documented evidence of the services being provided. Additional interview with the Interim Unit Manager, for the 100 hallway, revealed she expected Restorative Nursing to be provided to all residents with identified needs to prevent and decrease risk for decline in function and maintain ROM. Continued interview revealed a resident with recommendations for RNP should have a RNP Plan in place and services and treatment should be provided by Restorative Aides, and documented in the Restorative Nursing Record, kept in the Restorative Binders on each unit. Further, RNP Plans were important in order to ensure residents maintained their capabilities of self-care, and current function and enabled staff to determine when a decline in self care had occurred. Interview with the Director of Nursing (DON), on 10/31/19 at 3:05 PM, revealed she expected RNP services and treatment to be provided to residents per the facility policy to prevent and decrease risk for decline in functional status. Additionally, she expected residents with recommendations for RNP to have a RNP Plan in place and services and treatments to be administered and documented by nursing staff per the Plan. Further interview revealed LPN #2 was responsible for the facility's RNP since the previous Restorative Nurse took the position of Unit Manager for the 100 hallway, in (MONTH) 2019. However, she had identified that LPN #2 was not effective and was not able to maintain the RNP while working as a direct care nurse. Therefore, she stated she had hired a new Restorative Nurse last week. Further, she was aware the RNP in the facility had not been maintained for residents over the last few months. Interview with the Administrator, on 10/31/19 at 4:06 PM, revealed he expected the facility policy and procedures to be maintained related to the RNP. Further, he expected nursing staff to provide services and treatment as per the individualized written plans and as per therapy recommendations related to restorative nursing. Additional interview revealed the RNP was important to ensure residents receive necessary care to meet their needs and maintain the highest quality of life.

Based on observation, interview, and review of facility Policy, it was determined the facility failed to ensure each resident receives food and drink that is palatable, attractive, and at a safe and appetizing temperature. Observation of the test tray conducted on the 200 unit at the lunch meal service on 10/31/19, revealed the hot foods were not hot, the cold foods were at room temperature, and some food items were not palatable. In addition, interviews with Resident #29 and #49, revealed foods were not served at appropriate temperatures and was not palatable. The findings include: Review of the facility Food Handling Policy, dated 10/01/15, revealed temperature control for food safety must maintain an internal temperature of forty one ( 41) degrees Fahrenheit or lower, and one hundred forty five (145 ) degrees Fahrenheit or higher while being held for service. Further review revealed during transportation of food from the kitchen to the dining room/resident room, care is to be taken to keep hot food hot, and cold food cold, and food protected from contamination. Interview with Resident #29, on 10/29/19 at 9:45 AM, revealed quality of food in the facility was poor. Further, menu items he/she ordered arrived either late, or at the wrong temperature and was not palatable. Continued interview revealed the majority of residents he/she conversed with had the same opinions concerning the food. The resident stated he/she resided on the 200 unit and ate meals in his/room. Resident #29 was assessed by the facility in a Quarterly Minimum Data Set (MDS) Assessment, dated 08/04/19, as having a Brief Interview for Mental Status of a fifteen (15) out of fifteen (15) indicating the resident was cognitively intact. Interview with Resident #49 on 10/29/19 at 10:15 AM, revealed food service in the facility continued to decline. Per interview, food arrived to his/her room late, incorrectly prepared, and hot foods were no longer hot, while foods needing to be cold were served warm. Further interview revealed the resident had voiced concerns to Administration. The resident verified he/she resided on the 200 unit and ate meals in his/room. Resident #49 was assessed by the facility in a Quarterly Minimum Data Set (MDS) Assessment, dated 08/02/19, as having a Brief Interview for Mental Status of a fifteen (15) out of fifteen (15) indicating the resident was cognitively intact. Observation of lunch meal service on 10/29/19 at 12:00 PM, revealed meals were delivered to the dining rooms first, then followed by separate meal carts going to both the 100 unit and 200 unit. Further observation revealed meals were not contained in a hot box, but did have a protective covering enclosing the trays. The meal trays were organized by room number, and were labeled with resident information and diet specifics. Observation and Food Test Tray testing conducted 10/31/19 at 12:15 PM, on the 200 unit, revealed servings of mixed fruit, Vegetable soup, Lemonade, Potato Salad, and a Roast Beef Sandwich. A temperature was obtained for each separate item and taste tested . The findings included mixed fruit registering at seventy (70) degrees Fahrenheit; Vegetable soup registering at one hundred fifty-two (152) degrees Fahrenheit with a bland taste; Lemonade registered at fifty four (54) degrees Fahrenheit with a cool taste; Potato Salad registered at sixty nine (69) degrees Fahrenheit with good taste, but was too warm to hold integrity; and Roast Beef Sandwich registered at one hundred thirty four (134) degrees Fahrenheit and was not hot to taste. Interview with State Registered Nurse Aide (SRNA) #1, on 10/31/19 at 1:30 PM, revealed SRNAs were responsible for delivering trays to resident rooms. Once trays arrived to the units, they were dispersed to residents in order by room number. Per interview, residents had complained that hot foods were delivered cold and the food did not taste good. Further interview revealed if residents complained about the food, they would get a replacement food item or meal tray. Interview with the Director of Nursing (DON), on 10/31/19 at 2:00 PM, revealed there could be concerns for food borne pathogens if food items were served at improper temperatures. Further, there was the potential of nutritional decline for residents as an unintended consequence of serving food items at improper temperature, or serving food items that were not palatable to residents. Interview with the Assistant Dietary Manager, on 10/31/19 at 3:00 PM, revealed foods served hot should remain hot, and foods meant to be served cold should remain cold. Further interview revealed food temperatures were obtained on the steam table, the food was plated and prepared on the meal tray, and then served to residents in the dining room and on the units. Per interview, food was covered at all times while being transported and the facility did not utilize hot boxes. Additional interview revealed residents had the right to be served foods at proper temperatures and periodic training was conducted with dietary staff to address dietary failures. Per interview, the Assistant Dietary Manager would be implementing new policies and methods to improve food quality. Interview with the District Dietary Manager, on 10/31/19 at 3:30 PM, revealed there was no particular Point of Service policy related to food temperatures; however, food temperatures should be maintained from preparation to delivery. Per interview, food served that was not palatable or served at incorrect temperatures could lead to possible foodborne illness or nutritional decline in residents. Continued interview revealed temperatures should be continually monitored and maintained, and Corporate would need to look into the concern of foods not holding temperatures. Interview with the Administrator, on 10/31/19 at 4:00 PM, revealed it was his expectation that all foods served be palatable and at correct temperatures for both hot and cold foods. Per interview, this was a resident's right and the facility must honor resident rights. Additional interview revealed incorrect food temperatures and poor food quality posed the potential for food borne illness and nutritional decline in residents who were vulnerable.

Based on observation and interview, it was determined the facility failed to provide maintenance services necessary to maintain a safe clean and comfortable environment for the 100 unit residents. Observation of the 100 unit hall ceiling vents from rooms 101 through 115, on 10/29/19, 10/30/19, and 10/31/19, revealed dust accumulation. The findings include: Review of the facility Resident Rights under Federal Law Policy, undated, revealed residents had the right to a safe, clean, comfortable and homelike environment including, but not limited to receiving treatment and supports for daily living safety. The Center must provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior. Observation on 10/29/19 at 12:30 PM; 10/30/19 at 10:00 AM; and 10/31/19 at 2:00 PM, revealed dust accumulation in the ceiling vents of the 100 unit hall from rooms 101 through room [ROOM NUMBER]. Interview on 10/31/19 at 2:45 PM, with the Maintenance Director, revealed the vents were cleaned on a monthly basis, and the air filters were changed monthly as well. Per interview, if the vents were dusty, this could affect the air quality for residents who could not breathe well. Further interview revealed there should not have been an accumulation of dust on the vents. Interview on 10/31/19 at 4:00 PM, with the Director of Nursing (DON), revealed the vents were scheduled to be cleaned regularly to promote cleaner air quality for residents with respiratory and/or chronic [MEDICAL CONDITION] disease. Interview on 10/31/19 at 4:39 PM, with the Administrator, revealed the dust accumulation in vents in the hallway could be an allergen or air quality issue for residents.

Based on observation, interview, record review, and review of facility Policy, it was determined the facility failed to ensure each resident was free from any physical restraints imposed for purposes of discipline or convenience, and not required to treat the resident's medical symptoms, for one (01) of one (1) sampled resident reviewed for restraints out of twenty-two (22) sampled residents (Resident # 33). The facility initiated a self-releasing alarming seatbelt to Resident #33's wheelchair as a fall intervention, on 02/11/19. However, there was no documented evidence they physician's orders [REDACTED]. In addition, observation on 10/29/19, revealed Resident #33 was sitting in the joy room (dining room) in his/her wheelchair at a table, with no staff in the room. The residents self-releasing seatbelt wiring was underneath the wheelchair arm. At the State Surveyor's request, Licensed Practical Nurse (LPN) #1 released the seatbelt; however, it did not sound. The facility failed to identify the alarming seatbelt restraint was not working properly. (Refer to F-656) The findings include: Review of the facility Use of Restraints Policy, revised 07/01/18, revealed patients have the right to be free from physical restraints imposed for purposes of discipline or convenience, and not required to treat the resident's medical symptoms. Additionally, when a restraint was indicated, the least restrictive device would be used for the least amount of time and the ongoing evaluation to determine the need for the restraint would be documented per state regulations. Further, there would be documentation identifying the medical symptom being treated and an order for [REDACTED]. Review of Resident #33's Medical Record, revealed the facility admitted the resident on 12/28/18 with [DIAGNOSES REDACTED]. Review of Resident #33's physician's orders [REDACTED]. Review of Resident #33's Restrictive Device Consent, dated 02/11/19, revealed a self-releasing alarming seatbelt had been ordered by the Physician as part of the resident's overall plan of care. Additionally, the medical reason for use was poor safety awareness and impulse control. Further, the restraint was to be used when up in the wheelchair. Continued review revealed the Consent included risk versus benefits and was signed by the resident's representative. Review of Resident #33's Restraint Release Reduction Assessment, dated 08/23/19, revealed over eight (08) shifts the resident's response to release/reduction was unsuccessful. The resident attempted to self-transfer frequently, and staff were unable to redirect. Per the Assessment, the resident required increased supervision; attempted unsafe transfer; leaned forward when the seatbelt was released; and attempted to stand on his/her own. Further, the Assessment concluded the resident had inconsistent response to the trial and recommendations were to continue the seatbelt alarm while the resident was up in the wheelchair related to impaired cognition, inability to follow safety measures, and unstable independent ambulation. Review of Resident #33's Quarterly Minimum Data Set (MDS) Assessment, dated 08/26/19, revealed the facility assessed the resident as having both short and long term memory problems. Additionally, the facility assessed the resident as requiring total assistance of two (02) staff for bed mobility, transfers, and toileting. Continued review revealed the resident did not ambulate and required total assistance of one (01) staff for locomotion in the wheelchair. Per the Assessment, the resident had unsteady balance, only able to stabilize with staff assistance during transition from surface to surface. Continued review revealed a chair and bed alarm was used daily and the resident used no physical restraints. Review of Resident #33's Comprehensive Care Plan (CCP), revised on 09/05/19, revealed the resident was at risk for falls related to cognitive loss, lack of safety awareness, impaired mobility, and falls. The goal stated the resident would have no falls with injury for ninety (90) days. Interventions included, but were not limited to: nonskid socks, 12/31/18; pressure alarm to wheelchair and bed to alert staff of unsafe attempts to self-transfers, 01/11/19; resident not to be left alone in Joy room (dining room) without staff supervision, 02/05/19; self releasing seatbelt with alarm, check and release every two (02) hours and as needed, 02/14/19; and resident to sit in high traffic areas after lunch, 05/19/19. (Refer to F-656) Review of the Treatment Administration Record (TAR), dated (MONTH) 2019, revealed each shift, nurses checked the function of the alarming seatbelt every two (02) hours. Observation on 10/29/19, at 1:30 PM, revealed Resident #33 was sitting in the joy room (dining room) in his/her wheelchair at a table. Continued observation revealed there were no staff in the joy room. The resident's self-releasing seatbelt wiring was underneath the wheelchair arm. At the State Surveyor's request, LPN #1 released the seatbelt; however, it did not sound. Further, LPN #1 acknowledged staff had failed to identify the alarm on the seatbelt restraint was not working properly until this time. Interview with LPN #2, on 10/30/19 at 1:35 PM, revealed she had worked at the facility for ten (10) years. Per interview, the alarming seat belt was used for Resident #33 because he/she attempted to self-transfer and had a history of [REDACTED]. Continued interview revealed Resident #33's physician's orders [REDACTED]. Further, it was a big safety concern that Resident #33's alarming seatbelt did not alarm on 10/30/19 because if the seatbelt was not working properly and the facility did not identify the malfunction, the resident's safety could not be ensured. Interview with State Registered Nursing Assistant (SRNA) #2, on 10/30/19 at 2:00 PM, revealed Resident #33's seatbelt was used to reduce falls and was to be worn when the resident was up in the wheelchair. Per interview, the resident would attempt to self-transfer and lose his/her balance and fall. Additionally, the seatbelt was released at meals and every two (02) hours. Further, it was important for the seatbelt to be functioning properly to alert staff if the resident tried to get out of the wheelchair, as the resident could potentially sustain a fall. Interview with the Director of Nursing (DON), on 10/31/19 at 3:05 PM, revealed she expected the facility policy related to restraints to be followed. Per interview, Resident #33's alarming seatbelt was a long term intervention the Interdisciplinary Team determined would reduce the resident's risk for falls. Additionally, she expected the physician's orders [REDACTED]. Further, she expected the alarming seatbelt to function properly and staff to identify any issues with the function of the restraint timely. Interview with the Administrator, on 10/31/19 at 4:06 PM, revealed he expected the facility policy and regulation related to restraints to be followed. Additionally he expected restraints to FUNCTION PROPERLY. Per interview, the physician's orders [REDACTED].

Based on interview, record review, review of facility Policy, and review of the Centers for Medicare and Medicaid Services (CMS), Resident Assessment Instrument (RAI) Manual 3.0, it was determined the facility failed to ensure the Comprehensive Care Plan (CCP) was reviewed and revised by an interdisciplinary team composed of individuals who have knowledge of the resident and his/her needs for two (02) of twenty-two (22) sampled residents (Resident #33 and Resident #56). Resident #33 sustained a fall on 10/18/19 and the Fall Investigation revealed a fall floor mat was placed on the favored side of the bed; however, there was no documented evidence which side of the bed was the favored side (left/right) or that the Care Plan was revised to include this intervention. Further, there was no documented evidence of a Root Cause Analysis of the fall in the investigation or in the medical record in order to revise the Care Plan with appropriate interventions to prevent falls of the same nature. (Refer to F-689) Further, Resident #56 sustained a fall on 10/12/19, and the Fall Investigation revealed roll bolsters would be placed on the bed. However, there was no documented evidence the Care Plan was revised to include this intervention. In addition, there was no documented evidence of a Root Cause Analysis of the fall in the investigation or in the medical record in order to revise the Care Plan with appropriate interventions to prevent falls of the same nature. (Refer to F-689) The findings include: Review of the facility's Person Centered Care Plan Policy, revised 07/01/19, revealed a person center care plan will include measurable objective and timetables to meet the resident's physical, psychosocial and functional needs. Additionally, the care plan process will include a resident's personal preferences. Further, the Care Plan will describe the services to be provided to maintain or attain the residents' highest practicable physical, mental, and psychosocial wellbeing; include identified problem areas; and aid in preventing or reducing decline in functional status/level. Review of the facility's Falls Management Policy, revised on 11/01/19, revealed residents experiencing a fall will receive appropriate care and investigation of the cause. Further, the practice standards included reviewing and revising the Care Plan. Review of the Centers for Medicare and Medicaid Services, Resident Assessment Instrument (RAI) Manual 3.0, dated (MONTH) (YEAR), revealed the care plan must be reviewed and revised periodically, and the services provided or arranged should be consistent with each resident's written plan of care. Continued review of the Manual, revealed the care plan was driven not only by identified resident issues and/or conditions, but also by a resident's unique characteristics, strengths, and needs. Furthermore, a care plan based on a thorough assessment and effective clinical decision making, was compatible with current standards of clinical practice that provide a strong basis for optimal approaches to quality of care and quality of life needs of individual residents. A well developed and executed assessment and care plan: re-evaluates the resident's status at prescribed intervals (quarterly, annually, or if a significant change in status occurs) using the RAI and then modifies the individualized care plan as appropriate and necessary. 1. Review of Resident #33's clinical record revealed the facility admitted the resident on 12/28/18 with [DIAGNOSES REDACTED]. Review of Resident #33's Quarterly Minimum Data Set (MDS) Assessment, dated 08/26/19, revealed the facility assessed the resident to have both short and long-term memory problems. Further, the facility assessed the resident as requiring extensive assistance or total assist of two (02) staff for bed mobility, transfers, and toileting. Additional review revealed the resident did not ambulate and required total assistance of one (01) staff for locomotion in the wheelchair. Per the MDS Assessment, the resident had unsteady balance, and was only able to stabilize with staff assistance during transition from surface to surface. Continued review revealed the resident had sustained falls since the prior assessment; one (01) non-injury and two (02) injury falls. Review of the Comprehensive Care Plan (CCP), revised 09/05/19, revealed Resident #33 was at risk for falls related to cognitive loss, lack of safety awareness, impaired mobility, and falls. The goal revealed the resident would have no falls with injury for ninety (90) days. The interventions included, but were not limited to: nonskid socks, 12/31/18; pressure alarm to wheelchair and bed to alert staff of unsafe attempts to self-transfers, 01/11/19; resident not to be left alone in Joy room (dining room) without staff supervision, 02/05/19; self releasing seatbelt with alarm, check and release every two (02) hours and as needed, 02/14/19; and resident to sit in high traffic areas after lunch, 05/19/19. Review of Resident #33's Fall Investigation, dated 10/18/19, revealed the bed alarm was sounding and the resident was noted on the floor next to the bed. Further review revealed the resident sustained [REDACTED]. Additional review revealed the resident was transferred back to bed after an assessment. Per the Investigation, a fall floor mat was placed on the favored side of the bed; however, the investigation did not specify which side of the bed the mat was to be placed. In addition, there was no documented evidence of contributing factors of the fall, specifics of the fall or the Root Cause Analysis of the fall in the investigation or in the medical record in order to revise the care plan with relevant, consistent, and individualized interventions to prevent falls of the same nature. There was no documented evidence the CCP was revised to include the intervention for a floor fall mat to the favored side of the bed, status [REDACTED]. 2. Review of Resident #56's clinical record revealed the facility admitted the resident on 03/19/19 with [DIAGNOSES REDACTED]. Review of Resident #56's Significant Change Minimum Data Set (MDS) Assessment, dated 09/25/19, revealed the facility assessed the resident as having a BIMS score of three (03) which indicated severe cognitive impairment. Further, the facility assessed the resident as requiring extensive assistance of two (02) staff for bed mobility and requiring total assistance for all other ADLS. Per the MDS Assessment, the facility assessed the resident as not being able to stabilize without staff assistance during surface to surface transfers, and as sustaining no falls. Additional review of the MDS Assessment, revealed the facility assessed the resident as having no falls since the previous assessment. Review of the Comprehensive Care Plan (CCP), revised 07/18/19, revealed Resident #56 was at risk for falls related to cognitive loss, lack of safety awareness, impaired mobility, high-risk medication and falls. The goal revealed the resident would have no falls with injury through the next review. The interventions included, but were not limited to: offer/assist with urinal/commode as requested, 12/06/18; place on get up list to help prevent resident from attempting to get out of bed, 04/04/19; approach resident in a calm manner, 04/19/19; place floor mat next to right side of bed when resident is in bed to help prevent injury, 04/19/19; wheelchair cushion replaced that attaches to wheelchair with clip, 09/06/19; and offer food and snack 08/28/19. Review of the Fall Investigation, dated 10/12/19, revealed Resident #56 sustained an unwitnessed fall. Additional review revealed the resident was found on the floor, on the fall mat, and bolsters were placed on the bed. However, the investigation did not address factors of the fall, specifics of the fall or the Root Cause Analysis of the fall in the investigation or in the medical record in order to revise the care plan with relevant, consistent, and individualized interventions to prevent falls of the same nature. There was no documented evidence the CCP was revised to include the intervention for roll bolsters to the bed, status [REDACTED]. Interview with Licensed Practical Nurse (LPN) #2, on 10/30/19 at 1:35 PM, revealed the residents' Care Plan was to be revised with an immediate intervention to ensure resident safety and provide necessary care after a fall. Interview with the Director of Nursing (DON), on 10/25/19 at 10:45 AM, revealed she expected the RAI Manual Guidelines to be followed to ensure the CCP was revised as necessary. Additionally, she expected the CCP to be revised after each fall event for all residents to ensure the facility was providing safe, necessary care. Per interview, the facility changed their Electronic Medical Record systems and the process in which the facility investigated and reviewed fall events changed. She further stated she was new to this role and until this week, she had been unsure of the process to follow up on an investigation. Per interview, the facility failed to revise the CCP after the Fall Investigations. Interview with the Administrator, on 10/25/19 at 12:18 PM, revealed he expected the CCP to be revised with interventions after fall events per RAI guidelines. Further interview revealed it was important to ensure the CCP was revised to include fall interventions status [REDACTED].

Based on observation, interview, record review, and review of facility Policy, it was determined the facility failed to ensure adequate supervision and assistive devices to prevent accidents for two (02) of four (4) sampled residents reviewed for falls out of twenty-two (22) sampled Residents (Resident #33 and Resident #56). Resident #33 sustained a fall on 10/18/19 from his/her bed, and received a skin tear injury. The Fall Investigation revealed a fall floor mat was placed on the favored side of the bed; however, there was no documented evidence which side of the bed was the favored side (left/right) or that the Care Plan was revised to include the intervention to place a fall mat on the favored side of the bed. In addition, there was no documented evidence of contributing factors of the fall, specifics of the fall or the Root Cause Analysis of the fall in the investigation or in the medical record in order to implement interventions to prevent falls of the same nature. (Refer to F-657) Further, Resident #56 sustained a non-injury fall on 10/12/19, from his/her bed. The Fall Investigation revealed roll bolsters would be placed on the bed. However, there was no documented evidence the Care Plan was revised to include the intervention to place the roll bolsters on the bed, status [REDACTED]. In addition, there was no documented evidence of contributing factors of the fall, specifics of the fall or the Root Cause Analysis of the fall in the investigation or in the medical record in order to implement interventions to prevent falls of the same nature. (Refer to F-657) The findings include: Review of the facility's Falls Management Policy, revised on 11/01/19, revealed residents determined to be at risk for falls will receive appropriate interventions to reduce risk and minimize injury. Additionally, residents experiencing a fall will receive appropriate care and investigation of the Cause of the fall. Per Policy, the purpose was to reduce the risk for falls and minimize the actually occurrence of the falls and to address injury and provide care for a fall. Further, the practice standards included assessing for fall risk; developing, reviewing and revising the Care Plan; documenting the accident/incident; and conducting a post fall review. 1. Review of Resident #33's medical record revealed the facility admitted the resident on 12/28/18 with [DIAGNOSES REDACTED]. Interview with the Director of Nursing on 10/31/19 at 3:05 PM, revealed the Nursing Quarterly Notes were what the facility utilized as a Fall Risk Assessment. Review of the Nursing Documentation Note, dated 08/25/19, revealed the resident had a history of [REDACTED]. Review of Resident #33's Quarterly Minimum Data Set (MDS) Assessment, dated 08/26/19, revealed the facility assessed the resident as having both short and long-term memory problems. Additionally, the facility assessed the resident as requiring extensive assistance of two (02) staff or total assistance of two (02) staff for bed mobility, transfers, and toileting. Continued review revealed the resident did not ambulate and required total assistance of one (01) staff for locomotion in the wheelchair. Per the Assessment, the resident had unsteady balance, and was only able to stabilize with staff assistance during transition from surface to surface. Continued review revealed the resident had falls since the prior assessment; one (01) non-injury and two (02) injury falls. Further review revealed the resident utilized daily use of a chair and bed alarm and the resident used no physical restraints. Review of Resident #33's Comprehensive Care Plan (CCP), revised 09/05/19, revealed the resident was at risk for falls related to cognitive loss, lack of safety awareness, impaired mobility, and falls. The goal stated the resident would have no falls with injury for ninety (90) days. Interventions included, but were not limited to: nonskid socks, 12/31/18; pressure alarm to wheelchair and bed to alert staff of unsafe attempts to self-transfers, 01/11/19; resident not to be left alone in Joy room (dining room) without staff supervision, 02/05/19; self releasing seatbelt with alarm, check and release every two (02) hours and as needed, 02/14/19; and resident to sit in high traffic areas after lunch, 05/19/19. Interview with the Director of Nursing, on 10/31/19 at 3:05 PM, revealed the Fall Risk Management Assessment (FRMA) was the facility Post Fall Assessment. However, the FRMA could not be printed out of the Electronic Medical Record. Further, she copied and pasted the information into a Word Document. Review of the Word Document, dated 10/18/19, untimed, revealed Resident #33 was in his/her room in bed, the bed alarm sounded and the nurse went into the resident's room to find the resident on the floor sitting beside his/her bed. Additionally, blood was noted to the resident's right arm from a skin tear; the skin tear was cleansed and a dressing was applied. Continued review revealed the nurse and the aide transferred the resident back to the bed. Further, a floor mat was placed on the favored side of the bed. However, the favored side of the bed was not identified. Review of Resident #33's Fall Investigation, dated 10/18/19, untimed, revealed the bed alarm was sounding and the resident was noted to be on the floor next to the bed. Additional review revealed the resident had a skin tear to his/her right arm and treatment was applied. Continued review revealed the resident was transferred back to bed after an assessment. Further, a fall floor mat was placed on the favored side of the bed; however, there was no specification related to which side of the bed. In addition, there was no documented evidence of contributing factors of the fall, specifics of the fall or the Root Cause Analysis of the fall in the investigation or in the medical record in order to implement relevant, consistent, and individualized interventions to prevent falls of the same nature. Additionally, further review of the (CCP), revised 09/05/19, revealed there was no documented evidence the Care Plan was revised to include the fall intervention for the floor fall mat to the favored side of the bed, status [REDACTED]. 2. Review of Resident #56's medical record revealed the facility admitted the resident on 03/19/19 with [DIAGNOSES REDACTED]. Review of the Nursing Documentation Note, dated 09/06/19, revealed the resident had a history of [REDACTED]. Review of Resident #56's Significant Change Minimum Data Set (MDS) Assessment, dated 09/25/19, revealed the facility assessed the resident as having a BIMS score of three (03) indicating severe cognitive impairment. Additionally, the facility assessed the resident as requiring extensive assistance of two (02) staff for bed mobility and requiring total assistance for all other Activities of Daily Living (ADLS). Per the MDS Assessment, the facility assessed the resident as not being able to stabilize without staff assistance during surface to surface transfers, and as having no falls. Further, per the MDS Assessment, the resident had no falls since the previous assessment. Continued review revealed the resident used no physical restraints. Review of Resident #56's Comprehensive Care Plan (CCP), revised on 07/18/19, revealed the resident was at risk for falls related to cognitive loss, lack of safety awareness, impaired mobility, high-risk medication and falls. The goal stated the resident would have no falls with injury through the next review. Interventions included, but were not limited to: offer/assist with urinal/commode as requested/needed, 12/06/18; place on get up list to help prevent resident from attempting to get out of bed, 04/04/19; approach resident in a calm manner, 04/19/19; place floor mat next to right side of bed when resident is in bed to help prevent injury, 04/19/19; wheelchair cushion replaced that attaches to wheelchair with clip, 09/06/19; and offer food and snack 08/28/19. Review of the Word Document, dated 10/12/19, untimed, revealed Resident #56 was in his/her room in bed, and the aide notified the nurse who then went into the room. Additionally, the nurse observed the resident's head and upper extremities were off the mat, and lower extremities were on the mat. Continued review revealed there was no apparent injury. Further, roll bolsters were put in place. Review of Resident #56's Fall Investigation, dated 10/12/19, untimed, revealed the resident had an unwitnessed fall. Additional review revealed the resident was found on the floor, on the fall mat. Further, bolsters were placed on the bed. However, there was no documented evidence of contributing factors of the fall, specifics of fall or the Root Cause Analysis of the fall in the investigation or in the medical record in order to implement relevant, consistent, and individualized interventions to prevent falls of the same nature. Additionally, review of the CCP, revealed no documented evidence it was revised to include the intervention to roll bolsters to the bed status [REDACTED]. Interview with Licensed Practical Nurse (LPN) #2, on 10/30/19 at 1:35 PM, revealed she had worked at the facility for ten (10) years. Additionally, direct care nurses completed the FRMA with each fall. Per interview, the purpose of completing FRMA was to track falls and keep an ongoing timeline of falls (circumstances and interventions that have been effective in the past) for the residents to ensure safety and provide necessary care. Continued interview revealed it was important to complete a thorough assessment of a fall event to include contributing factors of the fall events, and specifics of falls because the assessments were used to determine the Root Cause Analysis (RCA) and necessary in order to implement an intervention to prevent falls of the same nature. Further, the care plan was revised with an immediate intervention by the direct care nurse and the Unit Manager followed up to ensure the most appropriate intervention was revised to the care plan. Continued interview revealed Resident #33 and Resident #56 had a history of [REDACTED]. Interview with the Director of Nursing (DON), on 10/31/19 at 3:05 PM, revealed she expected the facility policy on Falls Management to be followed. Per interview, she expected staff to complete a thorough investigation of the cause of the fall, to include contributing factors, and specifics of a fall event to ensure the interdisciplinary team could review that data and determine the Root Cause Analysis of the fall event. Continued interview revealed completing a thorough assessment of each fall event ensured a safe environment to all residents. Further, since (MONTH) 2019, the facility was using a new fall assessment, the FRM[NAME] Continued interview revealed the FRMA needed to be edited to include areas for contributing factors, specifics of the falls and a Root Cause to be documented. Per interview, the facility nurses also needed training on documenting resident fall events to include specific data and contributing factors of fall events because there was not consistent documentation. Additional interview revealed there was a morning meeting Monday through Friday and falls were discussed for the previous twenty-four (24) hours or after a weekend which included the Administrator, DON, Unit Managers, and Therapy. However, she stated Resident #33 and Resident #56's falls were evidently not discussed in these morning meetings as there was no root cause identified and no new interventions care planned. Interview with the Administrator, on 10/31/19 at 4:06 PM, revealed he expected regulations and facility policies to be followed in order to prevent accidents and injuries. Additionally, he expected the staff to complete a thorough assessment post fall to determine the cause of the fall. Further, he expected the revision of the care plan to include an appropriate intervention to prevent accidents/injuries or falls of the same nature.