Every finding on record at Pine Hill Rehabilitation and Wellness Center

Based on observations and interviews, the facility failed to ensure Laundry Staff (LS) #13 handled clean clothing in the laundry department in a manner to prevent cross-contamination on 03/06/2024 when LS #13 was observed folding clean resident clothing. This was observed while LS #13 folded clean laundry from one cart of clothing and repeatedly and systematically held the clean clothing against her body and her scrub top while she folded the clean resident clothing. Findings include: On 03/06/2024 at 05:16 PM during an observation of the laundry department with the Environmental Service Director (ESD) #6, LS #13 picked up a pair of pink sweatpants from the unfolded clean laundry cart, placed her right hand inside one of the pant legs up to her shoulder to turn the pants inside out. LS #13 did not have on a clean gown or covering over her clothing. LS #13 held the pink pants against her scrub shirt on her chest and stomach. LS #13 placed the folded pink pants on the table with the other clean folded clothes. LS #13 picked a pair of green pants out of the clean laundry cart with her right hand and then held the green pants in her left hand, placing her right arm all the way down to the end of one of the pants legs while the green pants were touching her bare arm, bare hand, and scrub top and then pulled the pants leg out, and did the same on the other side of pants. LS #13 then put the green pair of pants against her scrub top and chest and folded the green pants. LS #13 placed the green pants on the clean table. LS #13 then picked up a pair of leopard print pajama pants out of the laundry cart. LS #13 put her right bare arm down one of the pant legs touching her bare arm, bare hand and all the way up to her shoulder touching her scrub top sleeve. LS #13 then folded the pajama pants touching her chest and scrub top, folded the pants, and placed them on the clean table. On 03/06/2024 at 05:20 PM during an interview with LS #13 she stated she had been holding the clothing up against her chest. LS #13 stated that she should not have held clean laundry up against her chest. LS #13 that holding the clothing up against her chest could cause a risk of cross contamination. On 03/06/2024 at 05:23 PM during an interview with ESD #6, she stated, she saw LS #13 was putting the clean clothing up against herself and touching her clothing with the clean clothing. ESD #6 stated, holding clean laundry up against LS #13's body and clothing could cause cross-contamination. On 03/07/2024 at 11:00 AM Infection Preventionist (IP) #4 stated, clean laundry should be held away from the body. IP #4 stated, holding clean linen up against the body can cause contamination. IP #4 stated, to prevent cross-contamination the clean linen should be held away from the body and not touch anything dirty with the clean.

Based on interviews, resident record review, and review of a facility policy titled COMPREHENSIVE PERSON CENTERED CARE PLANS the facility failed to ensure Resident Identifier (RI) #109 had the opportunity to attend and participate in care plan meetings at least quarterly since June 2023. This deficient practice affected RI #109, one of 49 residents for whom care plans were reviewed. Findings include: A facility policy titled COMPREHENSIVE PERSON CENTERED CARE PLANS dated 03/2018 revealed the following: . PROCEDURE: . 4. The Interdisciplinary Team along with the resident and/or Resident Representative will identify resident problems, needs, strengths, life history, preferences, and goals . 7. The Comprehensive Person Centered Care Plan can be reviewed and/or revised at quarterly intervals in conjunction with the completion of MDS (Minimum Data Set) quarterly, significant change and annual assessments . RI #109 was admitted to the facility on [DATE] and readmitted on [DATE]. A review of RI #109's most recent quarterly MDS, with an Assessment Reference Date (ARD) of 02/20/2024, revealed RI #109 scored a 15 on the Brief Interview for Mental Status assessment which indicted RI #109 was cognitively intact. On 03/04/2024 at 12:31 PM RI #109 was asked about attending care plan meetings. RI #109 said, he/she had not attended a care plan meeting lately. A review of RI #109's INTERDISCIPLINARY CARE PLAN TEAM ATTENDANCE document revealed RI #109 had not had a care plan meeting since 06/2023, over eight months ago. Further review of RI #109's MDS assessments revealed other quarterly assessments dated 08/23/2023 and 11/21/2023 had been completed since June 2023. 03/06/2024 at 5:51 PM, an interview was conducted with the Social Service Director (SSD). The SSD said, the purpose of the care plan meeting was to have the resident and/or responsible party to come in to review the resident's care plans. When asked how often care plan meetings were held for the resident, the SSD said, quarterly. The SSD said, according to RI #109's Interdisciplinary Care Plan Team Attendance sheet, the last time RI #109 had a care plan meeting was June of 2023 and two meetings had not been done. The SSD said, it would be important to ensure care plan meetings were held for the resident so that the resident and family would know what was going on with the resident. The SSD said, it would be the responsibility of her department to ensure care plan meeting were being conducted.

Based on interviews, observations, and review of facility policies titled CONTROLLED MEDICATIONS ADMINISTRATION and MEDICATION ADMINISTRATION -GENERAL GUIDELINES the facility failed to ensure the Interim Director of Nursing (IDON) #2, Licensed Practical Nurse (LPN) #10, LPN #11, and LPN #12 documented Oxycodone/Acetaminophen on the electronic Medication Administration Record for Resident Identifier (RI) #473. This affected one of 31 sampled residents. Findings include: The facility policy with a reviewed date of 1/15, titled CONTROLLED MEDICATIONS ADMINISTRATION revealed, . PROCEDURE: . 6. When administering controlled medication, the authorized personnel record the administration on the MAR and enters all of the following information on the Controlled Drug Record: a. Date and time of administration b. Amount administered c. Signature of the person preparing the dose d. Quantity reconciled The facility policy with a HISTORY date of 1/15, titled MEDICATION ADMINISTRATION -GENERAL GUIDELINES revealed, . PROCEDURE: . 11. The resident's MAR/TAR is initialed by the person administering a mediation, in the space provided under the date, and on the line for that specific medication dose following medication administration. Initials on each MAR/TAR are verified with a full signature in the space provided or on the signature log. 12. Placing an initial in the space provided on the MAR also indicates that the nurse who administered the medication is observing for side effects. 13. When PRN medications are administered, the following documentation is provided: a. Date and time of administration, dose, route of administration (if other than oral), and, if applicable, the injection site. b. Complaints or symptoms for which the medication was given. c. Results observed from giving the dose and the time results were noted. d. Resident pain evaluation per facility policy, if applicable. e. Signature or initials of person recording administration and signature or initials of person recording effects, if different person administering. RI #473 was admitted to the facility on [DATE], readmitted on [DATE], and discharged on [DATE] and had diagnoses to include: Cognitive communication deficit, Chronic pain syndrome, and Other psychoactive substance abuse, uncomplicated. A review of the facility form titled CONTROLLED DRUG RECORD revealed that Oxycodone-Acetaminophen 7.5-325 milligram (mg) was removed from the narcotic locked box and signed out on 01/14/2024 by IDON #2, 01/16/2024 and 01/22/2024 by LPN #10, 01/13/2024, 01/17/2024, 01/18/2024 by LPN #12, 01/20/2024 at 08:40 AM and 04:43 PM, 01/23/2024, 01/25/2024 at 05:30 PM, 01/26/2024 at 09:00 AM, 01/31/2024 at 09:00 AM, and 02/02/2024 by LPN #11. A review of the facility EMAR for RI #473 revealed that on 01/14/2024, 01/16/2024, 01/22/2024, 01/13/2024, 01/17/2024, 01/18/2024, 01/20/2024 at 08:40 AM and 04:43 PM, 01/23/2024, 01/25/2024 at 05:30 PM, 01/26/2024 at 09:00 AM, 01/31/2024 at 09:00 AM, and 02/02/2024 Oxycodone-Acetaminophen was not documented as given. On 03/07/2024 at 11:33 AM an interview was conducted with IDON #2. IDON #2 stated that she did sign out an Oxycodone 7.5/325 mg on 01/14/2024 for RI # 473 on the Controlled Drug Record but did not sign the EMAR. IDON #2 stated that the correct procedure when pulling a controlled medication was to sign the controlled medication record at the time the medication was pulled from the locked box and the EMAR signed when the medication was given. On 03/07/2024 at 02:02 PM an interview was conducted with LPN #10. LPN #10 stated that she signed the controlled medication record but did not sign the EMAR. She stated that she pulled and administered the Oxycodone on 01/16/3034 and 01/22/2024. On 03/07/2024 at 02:27 PM an interview was conducted with LPN #12. LPN #12 stated that she had signed the Controlled drug record for RI #473 for pulling Oxycodone 7.5/325 mg on 01/13/2024, 01/17/2024, and 01/18/2024. LPN #12 stated that she did not sign the EMAR on those days for administering the Oxycodone to RI #473. LPN #12 stated that she did administer the Oxycodone on 01/13/2024, 01/17/2024, and 01/18/2024. LPN #12 stated that she should have documented the Oxycodone as given. LPN #12 stated that there was a risk of not knowing when the medication was given if it was not documented on the EMAR. On 03/07/2024 at 03:03 PM a follow-up interview with LPN #11 was conducted. LPN #11 stated that she pulled Oxycodone 7.5/325 mg for RI #473 and administered on 01/20/2024 at 08:40 AM, 01/20/2024 at 04:43 PM, 01/23/2024 at 09:00 AM, 01/25/2024 at 11:00 AM, 01/25/2024 at 05:30 PM, 01/26/2024 at 9:00 AM, 01/26/2024 at 01:30 PM, 01/27/2024 at 08:35 AM, 01/27/2024 at 02:40 PM, 01/29/2024 at 10:00 AM, 01/31/2024 at 09:00 AM, 01/31/2024 at 05:00 PM, and 02/02/2024 at 02:00 PM. LPN #11 stated that she did not chart administered on the EMAR on 01/20/2024 at 08:40 AM, 01/20/2024 at 04:43 PM, 01/23/2024 at 09:00 AM, 01/25/2024 at 05:30 PM, 01/26/2024 at 9:00 AM, 01/26/2024 at 01:30 PM, 01/31/2024 at 09:00 AM, and 02/02/2024 at 02:00 PM. LPN #11 stated that the days that were not documented on the EMAR, the Oxycodone was given to RI #473. LPN #11 stated that the risk of not documenting on the EMAR would not show when the Oxycodone was given. On 03/07/2024 at 03:52 PM an interview was conducted with Clinical Operations Nurse (CON) #3. CON #3 stated that per facility policy when documenting controlled medication, the narcotic sheet and the EMAR should be documented on. CON #3 stated that when a controlled medication is given it should be documented on the EMAR. CON #3 stated that not documenting the Oxycodone on the EMAR looked like the medication was not administered.

Based on observations, interviews, record review, and review of a facility policy titled, MEDICATION STORAGE, the facility failed to ensure: 1) the medication refrigerator on the Memory Care Unit was kept between 36 degrees F and 46 degrees F; and 2) the medication room door was closed and locked and/or supervised on the memory care unit. These deficient practices had the potential to affect Resident Identifier (RI) #110 and all 36 residents on the Memory Care Unit. Findings include: RI #110 was admitted to the facility on [DATE] with diagnosis of Type II Diabetes Mellitus without complications. RI #110 had a physician order dated 12/20/2022 for the administration of Insulin Aspart 100 unit/ml accucheck with sliding scale before meals and at bedtime (AC/HS). A review of a facility policy titled, MEDICATION STORAGE, dated 01/2015 revealed: POLICY All drugs . must be stored securely and following . per facility policy. Procedure . 8. Medications requiring refrigeration must be stored between 36 degrees F and 46 degrees F in a refrigerator . On 03/07/2024 at 10:58 AM, the Memory Care Unit medication refrigerator was observed. The temperature record or log posted on the front of the refrigerator for March 2024 was an equipment temperature log, which included: . Temperatures: Refrigerator . 41 . or below . On 03/07/2024 at 12:06 PM, an interview was conducted with Licensed Practical Nurse (LPN) #10. LPN #10 stated the refrigerator in the medication room temperature was at 30 degrees. LPN #10 stated the refrigerator for medications temperature should be between 36 to 46 degrees. LPN #10 stated there was a concern that the medication could freeze with a refrigerator temperature of 30 degrees. LPN #10 stated there was Novolog Insulin 100 units per milliliter in the refrigerator. On 03/07/2024 at 12:09 PM, an interview was conducted with the Memory Care Unit Manager (MUM) #5. The MUM #5 stated there was Novolog insulin in the refrigerator. The MUM #5 stated the temperature log was documented at 30 degrees on the dates for March. The MUM #5 stated the instruction sheet for the Novolog insulin was to keep the medication at 36 to 46 degrees. The MUM #5 said the insulin could freeze if kept at 30 degrees. The MUM #5 stated there could be a risk that medication would not be effective if kept at 30 degrees. A review of a facility policy titled, MEDICATION STORAGE, with a revised date of 01/31/2023 revealed: POLICY . 1. Medication rooms, carts and medication supply rooms . kept locked at all time . On 03/07/2024 at 12:00 PM, the Memory Care Unit medication supply room was observed by two surveyors with the door propped open with a door stop and no licensed personnel present. On 03/07/2024 at 12:05 PM, an observation was made of LPN #10 returning to the Memory Care Unit medication supply room, where the door was open with the door stop. On 03/07/2024 at 12:06 PM, an interview was conducted with LPN #10. LPN #10 stated she left the medication supply room door open because she had just stepped out down the hallway. LPN #10 stated there was a sign on the door to keep the medication supply door locked at all times. On 03/07/2024 at 17:18 PM, an interview was conducted with the Registered Nurse, Interim Director of Nursing (IDON). The IDON stated the medication refrigerator should be between 36 to 46 degrees. The IDON said there was a concern of the refrigerator temperature being 30 degrees, and this was not in guidelines. The IDON stated there was a risk if the medication gets too cold it could freeze and the frozen medication could cause a risk of an adverse reaction. The IDON stated the medication supply room was supposed to be closed at all times. The IDON stated there was a risk of anyone going into the medication supply room. The IDON further stated even when housekeeping goes in the medication supply room a licensed personnel should be in the room with them per policy.

Based on an observation, interviews, record review and review of a facility policy titled, PRESCRIBER MEDICATION ORDERS, the facility failed to address Consultant Pharmacist recommendations for Resident Identifier (RI) #4 in a timely manner. The Nurse Practitioner (NP) responded to the recommendation on 02/05/2024, but the facility failed to implement the NP's response. A month later during the survey on 03/06/2024, RI #4 was observed receiving a one milligram Haldol tablet. This deficient practice affected RI #4, one of five residents sampled for the medication regimen review. Findings include: Review of a facility policy titled, PRESCRIBER MEDICATION ORDERS dated 08/2016, revealed the following: . 2. a. Each medication order is documented in the resident's medical record . The order is recorded on the physician order sheet . b. 4. When a new order changes an existing order, the old order will be discontinued, according to facility policy. For eMAR, . order changes will be discontinued or added to the eMAR electronically . RI #4 was admitted to the facility on [DATE] and readmitted on [DATE], with a diagnosis of Psychotic Disorder with Hallucinations due to known Physiological Condition. According to RI #4's March 2024 Physician Orders, RI #4 had been receiving Haloperidol (Haldol) 1 mg tablet one (1) tablet by mouth twice a day since 07/24/2023 for the diagnosis of Psychotic Disorder with Hallucinations due to known Physiological Condition. A review of the Consultant Pharmacist Communication to Physician form dated 01/23/2024, revealed: . Please consider the discontinuation, or taper and D/C (discontinue) of Haloperidol 1 mg BID (twice a day). The NP's written response dated 02/05/2024, was to change the Haldol to 0.5 mg twice a day. A review of RI #4's February and March 2024 EMARs revealed RI #4 continued to receive the Haldol 1 mg twice a day. On 03/06/2024 at 9:53 AM, the surveyor observed RI #4 receive morning medications to include a one mg Haldol tablet. On 03/07/2024 at 2:54 PM, a telephone interview was conducted with the Consultant Pharmacist. The Consultant Pharmacist said he visited the facility once a month typically and one of his job responsibilities was to do medication regimen reviews. The Consultant Pharmacist said a big part of that review was to review GDRs (Gradual Dose Reductions). The Consultant Pharmacist said he brings any irregularities to the attention of the unit manager or Director of Nursing (DON) to follow up with the physician or NP. The Consultant pharmacist said he sends a letter to the facility for the physician, and the DON gives the letter to the physician and the physician will respond to the GDR by saying he or she agrees or do not agree. The Consultant Pharmacist said if the physician agrees with the recommendation an order is written. When asked who writes the order, the Consultant Pharmacist said it may be the physician or NP. On 03/07/2024 at 4:18 PM, a telephone interview was conducted with the NP. The NP said once a recommendation is made by the Pharmacist, she or the physician will write the recommendation as an order to be carried out on the Consultant Pharmacist Communication to Physician form. The NP said she would then give the form to the DON to transcribe the order onto the physicians order form. When asked, when she wrote on the Consultant Pharmacist Communication to Physician form for RI #4's Haldol to be changed to 0.5 mg PO (by mouth) BID on 02/05/2024, would she have expected that order to have been implemented by this time, the NP said yes. On 03/07/2024 at 5:16 PM, an interview was conducted with Infection Preventionist (IP)/Licensed Practical Nurse (LPN). When asked who would have been responsible for transcribing onto the physicians order form the order to change RI #4's Haldol to 0.5 mg twice a day, the LPN said the DON was ultimately responsible for ensuring the order was placed on the physicians order. The LPN said the order should have been transcribed onto the physicians order form within 24 hours of receiving the order. The LPN said orders should be implemented in a timely manner because they were physician orders.

Based on interviews, review of the RECORD OF MEDICATION DESTRUCTION - NON CONTROLLED MEDICATIONS sheets and review of a facility policy titled . MEDICATION DESTRUCTION ., the facility failed to ensure all of the RECORD OF MEDICATION DESTRUCTION - NON CONTROLLED MEDICATIONS sheets contained the two required signatures. This deficient practice affected 26 pages from non-controlled destruction records dated January 2023 through January 2024 reviewed during the survey. Findings include: Review of a facility policy titled, . MEDICATION DESTRUCTION . dated 10/2022 revealed the following: . RESPONSIBILITY: All Licensed Nursing Personnel / Director of Nursing Services PROCEDURE: . 3. Two nurses are to witness the destruction and sign on the Record of Medication Destruction -- Non-Controlled Medication sheet . On 03/07/2024 at 8:43 AM, a review was done of the Non-Controlled Medication Drug Destruction sheets for 2023. One RECORD OF MEDICATION DESTRUCTION - NON CONTROLLED MEDICATIONS sheet for April 2023 did not have the required two signatures for two of the five medications destroyed on this sheet. One RECORD OF MEDICATION DESTRUCTION - NON CONTROLLED MEDICATIONS sheet for August 2023 did not have the two required signatures for six of the six medications destroyed on this sheet. Further review of the RECORD OF MEDICATION DESTRUCTION - NON CONTROLLED MEDICATIONS revealed 26 sheets with no date of destruction. On 03/07/2024 at 2:54 PM, a telephone interview was conducted with the Consultant Pharmacist. The Consultant Pharmacist said medication destruction was attempted at least once a month at the facility. When asked how many signatures were required on the non-controlled medication destruction sheets, the Consultant Pharmacist said two. The Consultant Pharmacist said there should be two signatures on these sheets because the two signatures were proof of the people who were there that verified the destruction of the medication. When asked why should there be a date on the medication destruction sheets, the Consultant Pharmacist said, because that would indicate when the medication destruction took place. On 03/07/2024 at 5:16 PM, an interview was conducted with the Licensed Practical Nurse (LPN) #4. When asked how many signatures should there be on the non- controlled drug medication record sheets, LPN #4 said two. LPN #4 said it was usually the Unit Manager and Assistant Director of Nursing but it could be any two nurses. LPN #4 said it would be important to ensure the required signatures were on the sheets because both are witnessing the medication was destroyed and the amount was correct. LPN #4 said, there should also be a date as to when the destruction occurred. LPN #4 said, looking at the non-controlled destruction records, April 2023 had two missing signatures, August 2023 had only one signature; and January, March, June, July and September of 2023; and January of 2024 had no date as to when the medications were destroyed.

Based on interview, review of a Facility Reported Incident (FRI) received by the Alabama Department of Public Health Online Incident Reporting System, and review of a facility policy titled, . ABUSE PREVENTION'' the facility failed to ensure an allegation of physical abuse was reported to the state agency within two hours on 08/29/2022 when Resident Identifier (RI) #94 was yelled at and slapped by RI #368. This deficient practice affected RI #94, one of 31 sampled residents, and one of five FRIs reviewed. Findings include: Review of a facility policy titled, ABUSE PREVENTION, with a History date of 10/2022, revealed the following: . POLICY: The facility is committed to protecting the residents from abuse by anyone including, but not necessarily limited to: facility staff, other residents . DEFINITIONS: . d) Physical Abuse: This includes but is not limited to hitting, slapping, pinching and kicking . REPORTING: . Alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source . are reported immediately, but not later than 2 hours after the allegation is made . RI #94 was admitted to the facility on [DATE]. RI #368 was admitted to the facility on [DATE]. The Alabama Department of Public Health Online Incident Reporting System received a report of physical abuse on 08/29/2022 at 9:53 AM, over three hours after the alleged abuse had been witnessed at 6:40 AM. On 03/07/2024 at 10:01 AM, an interview was conducted with the current Executive Director (ED)/Abuse Coordinator. The ED said that was her position since 03/08/2023 and she was asked about the incident that occurred on 08/29/2022. The ED said, the incident occurred at 6:40 AM and it was reported to ADPH at 9:53 AM. The ED said, it was not reported timely within two hours.

Based on an observation, interviews and review of the RESIDENT BILL OF RIGHTS, the facility failed to ensure the eMAR (electronic Medication Administration Record) screen was closed, and did not reveal personal information concerning Resident Identifier (RI) #149. This deficient practice affected RI #149; and was observed on 03/04/2024, during the morning medication pass. Findings include: Review of the facility's RESIDENT BILL OF RIGHTS, with a History date of 01/2023, revealed the following: . A. Facility residents shall have the right to: . 33. To personal privacy and confidentiality in his or her . personal and medical . records . RI #149 was admitted to the facility on [DATE]. On 03/04/2024 at 10:25 AM, the privacy screen to an eMAR on top of a medication cart was left open, where anyone walking by could observe RI #149's patient information and medications. On 03/04/2024 at 10:26 AM, a Certified Nursing Assistant (CNA)/Medication Assistant Certified (MAC) returned to the medication cart. The MAC said it would be important to ensure the privacy screen was closed when you leave the medication cart for privacy of the resident's information. The MAC said she probably got distracted or something and left it opened. When asked how she would ensure the privacy screen was closed when she left the medication cart, the MAC said she would click on the privacy button and the screen would close down. On 03/07/2024 at 5:30 PM, an interview was conducted with Licensed Practical Nurse (LPN) #4. The LPN said when the nurse was away from the medication cart the privacy screen should be closed so the resident's information was not showing. LPN #4 said, it would be a privacy concern when the eMAR screen was left open and anyone walking by could observe the resident's information.

Based on interviews, resident record review, and review of a facility policy titled, NOTIFICATION OF A CHANGE IN A RESIDENT'S STATUS, the facility failed to notify Resident Identifier (RI) #217's representative, who was the guardian, and RI #217's physician when RI #217 left the faciity on [DATE] by wheelchair van transportation. This deficient practice affected RI #217, one of three residents sampled for notification of change. Findings include: Review of a facility policy titled, NOTIFICATION OF A CHANGE IN A RESIDENT'S STATUS dated 11/2017, revealed the following: POLICY: The attending physician . and the resident representative will be notified of a change in a resident's condition, per standards of practice . RI #217 was admitted to the facility on [DATE] and readmitted to the facility on [DATE], and discharged from the facility on 02/17/2023. A review of RI #217's FACE SHEET listed RI #217's sister as the responsible party. A review of a legal document titled, . LETTERS OF GUARDIANSHIP . revealed the following: . Letters of Guardianship of (RI #217's name) are hereby granted to (RI #217 sister's name) . The document was signed by the PROBATE JUDGE on 10/29/2019. RI #217's departmental notes documented a nursing entry dated 02/17/2023 at 7:18 AM as follows: . RESIDENT WAS PICKED UP FOR DOCTOR'S APPT. (appointment) THIS MORNING BY (non-emergency medical) TRANSPORTATION PAPERWORK SENT WITH RESIDENT. This note was signed by Licensed Practical Nurse, (LPN) #18. There was no documentation of the resident's responsible party/guardian or physician being notified of the resident being transported from the the facility. On 03/06/2024 at 9:29 AM, a telephone interview was conducted with RI #217's responsible party/guardian. She confirmed that she was the residents' legal guardian and she was not notified of RI #217 leaving the facility on 02/17/2023. The responsible party/guardian stated, she was notified after the resident was transported to a family member's house from the facility. On 03/06/2024 at 4:35 PM, an interview was conducted with the Social Service Director (SSD). The SSD confirmed RI #217 was discharged from the facility on 02/27/2023 and that the resident's sister was his/her guardian. She further stated a guardian makes decisions on behalf of the resident. When asked how was RI #217 able to leave the facility on 02/17/2023, the SSD stated, she did not know, but the resident should not have left the facility without the guardian's consent. The SSD said, the resident's sister should have been notified. On 03/07/2024 at 8:36 AM, a telephone interview was conducted with LPN #18. She stated RI #217 left the faciity on [DATE] because she assumed RI #217 had a doctor's appointment. When asked how would she know if RI #217 had a doctor's appointment, LPN #18 stated, it would be on the calendar at the nurses station. She further stated, she did not look at the calendar at the nurse's station nor did she call anyone to verify if RI #217 had a doctor's appointment. LPN #18 stated, later that day she found out RI #217 did not have a doctor's appointment and had went home. When asked if she notified the resident's responsible party/guardian that RI #217 had left the facility, LPN #18 said, No ma'am. LPN #18 said, she should have notified RI #217's responsible party/guardian. On 03/07/2024 at 2:33 PM, an interview was conducted with Licensed Practical Nurse (LPN) Unit Manager, (UM) #8. UM #8 said, the resident's sister was RI #217's responsible party/guardian. She stated, the purpose of a guardian was to oversee the resident and help with decision making. When asked why RI #217 was allowed to leave the facility on 02/17/2023 without the guardian's consent, UM #8 said, she did not know. The UM said, the guardian should be notified about everything related to the resident and the guardian should have been contacted (notified) the day RI #217 left. On 03/07/2024 at 7:50 PM, a follow-up interview was conducted with the SSD. The SSD was asked when there was a change in the resident's condition, a resident transfers from the facility to the hospital, home or another facility who should be notified. The SSD said the sponsor/guardian and the doctor. The deficiency was cited as a result of the investigation of complaint/report number AL00043585.

Based on record review, interviews, and the Payroll Based Journal (PBJ) Report, the facility failed to report accurate staffing data from July 1, 2023-September 2023 to the Center for Medicare and Medicaid Services (CMS). The PBJ report generated for the quarter of 07/01/2023 documented, .This Staffing Data Report identified area of concern that will be triggered metric . Excessively Low Weekend Staffing Triggered = Submitted Weekend Staffing data is excessively low . On 03/07/2024 at 5:23 PM, an interview was conducted with Executive Director (ED). The ED was asked why did the facility trigger for excessively low weekend staffing for the 4th Quarter, (July 1-September 30) 2023. She said because the therapy department was not there on the weekends, unless they had an evaluation that needed completed, the facility have the core nursing staffing, dietary and housekeeping on weekends. The ED was asked how do staff who normally work during the week, are coded to work on the weekends. The ED said, they are coded the same as what their job tile was during the week. On 03/07/2024 at 7:13 PM, an interview was conducted with the [NAME] President (VP) of [NAME] Company. The VP was asked if she aware that the facility had a one star rating and excessively low weekend staffing on the PBJ report for the 4th Quarter of 2023. She said she was aware of the facility's one star rating, but not the excessively low weekend staff. When asked why did the facility trigger for excessively low weekend staffing for the 4th quarter of 2023. She said Human Resources (HR) was not coding staff accurate in the right department to ensure they are counted in the hands on nursing (working on the floor). If they do not put in the right code for hands on nursing, PBJ will not pick it up. The VP was asked who was responsible for knowing about the excessively low weekend data and what will the facility do to correct this issue. The VP said, they will reeducated the Human Resources (HR) staff to ensure the staff have the right code when working on the floor and have the staffing person (coordinator) double check to make sure their hours are code accurately to reflect when they work on the floor.

Based on interviews, review of the facility's online reports to the State Agency and a facility policy titled, ABUSE PREVENTION, the facility failed to ensure an allegation of sexual abuse reported by Employee Identifier (EI) #6, Registered Nurse (RN), was reported to the state agency within two hours. This affected one out of six reports of abuse reviewed. Findings include: The facility's policy titled, ABUSE PREVENTION, last revised 05/2022, revealed: .REPORTING: . Alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later that 2 hours after the allegation is made, if the events that cause the allegation involve abuse . to the administrator of the facility and to other officials (including State Survey Agency, APS (Adult Protective Services), and local law enforcement as required). Review of the facility's online report to the State Agency revealed complaint # 3, an allegation of sexual abuse occurred on 08/31/2022 at 11:00 PM. The allegation of sexual abuse was not reported to the State Agency until 09/01/2022 at 8:30 AM. In an interview on 09/07/2022 at 4:36 PM, EI #6, RN, stated two Certified Nursing Assistants (CNAs) reported to her that EI #7, CNA, was doing something sexual to a resident. EI #6 sent EI #7 home. EI #6 called EI #2, Director of Nursing. In a follow-up interview on 09/08/2022 at 4:15 PM, EI #6, RN, clarified that she called EI #2 on 08/31/2022 at 10:09 PM. EI #6 stated she told EI #2 that two CNAs thought EI #7, CNA, did something sexually inappropriate. In an interview on 09/08/2022 at 12:50 PM, EI #2, DON, stated he became aware of the allegation of sexual abuse on 08/31/2022 at 10:00 PM when he received a call stating two CNAs thought a resident had been touched inappropriately. EI #2 stated abuse was to be reported within two hours. This deficient practice was cited as a result of the investigation of complaint/report #AL 028.

Based on record review, interviews and a facility policy titled Comprehensive Person Centered Care Plans the facility failed to ensure two staff members provided care to Resident Identifier (RI) # 1's according to the care plan. This affected one of five sampled residents whose care plans were reviewed. Findings Includes A review of the policy, last revision date 3/18 titled, Comprehensive Person Centered Care Plans documented the following: .Each resident will have a person centered plan of care to identify problems, needs, strengths, preferences, and goals that will identify how the interdisciplinary team will provide care RI # 1 was readmitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . RI # 1's most recent quarterly minimum data set (MDS) with an assessment reference date (ARD) of 7/15/22 documented RI # 1 was total dependence for Personal hygiene: self-performance and two persons physical assist for personal hygiene: support provided. RI # 1's care plan documented: .12/21/2021 .Assist me with dressing, toileting, bathing, and personal hygiene . RI # 1 daily care guide documented Activities of Daily living assistance as total dependence-two person assist. The abuse investigation summary dated 9/6/22 involving RI # 1 documented: .On 8/31/22 between 9 and 10 pm C.N.A. EI # 7 was providing ADL care for RI # 1, to include incontinence care. EI # 7 was providing care alone in the room with RI # 1 .EI # 7 was noted providing routine care for RI # 1, he was attempting care without assistance . A telephone interview was completed with Employee Indentifer (EI) # 7, Certified Nursing Assistant (CNA) on 9/7/22 at 5:18PM. EI # 7 explained he provided patient care to include Peri Care to RI # 1 on 8/31/22. EI # 7 was asked if any other employees were in the room when he provided care to RI # 1. EI # 7 stated no, not initially but two other cna's came in the room but did not assist with RI # 1's care. An interview was completed with EI # 1, Administrator on 9/8/22 at 5:02 PM. EI # 1 was asked about the incident involving RI # 1 on 8/31/22. EI # 1 explained that EI # 7 explained he was providing patient care to RI # 1 on 8/31/22. He explained that RI # 1 was a two person assist but he explained how he provided care with only one person. An interview was completed with EI # 8, MDS Manager on 9/9/22 at 4:04 PM. EI # 8 was asked how many staff needed to be present when providing care to RI #1. EI # 8 stated he/she was a two person assist due to he/she being unable to move or assist in any way. EI # 8 was asked if RI # 1's care plan and care guide addressed the need to have two staff present. EI # 8 stated the care plan stated that he needed assistance with care and the care guide stated he needed two staff present when care is being provided. EI # 8 was asked if only one person was in the room when care was provided was the care plan followed. EI # 8 stated no, he/she would need two staff present. EI # 8 was asked the difference between the care plan and care guide. EI # 8 stated the care guide is more detailed and more accessible to the staff. EI # 8 was asked what was the importance of following the care plan. EI # 8 stated to make sure the resident was being taken care of properly. An interview was completed with EI # 2, Director of Nursing (DON) on 9/9/22 at 4:11 PM. EI # 2 was asked according to the MDS how many people were required to care for RI # 1. EI # 2 stated he was a two person assist. EI # 2 was asked how many staff provided care to RI # 1 on 8/31/22. EI # 2 stated just one person EI # 7. EI # 2 was asked how many people should have been in the room providing care to RI # 1 on 8/31/22. EI # 2 stated two people and he was unsure why only one person was in the room. EI # 2 was asked if the care plan or care guide was followed concerning providing care to RI # 1 on 8/31/22. EI # 2 stated no, it was not followed. EI # 2 was asked the importance of following the care plan or care guide. EI # 2 stated it would tell you what type of care was needed so the resident could be properly cared for.

Based on interviews, record reviews, a review of Potter and Perry, Fundamentals of Nursing, NINTH EDITION, and facility's policies titled, Clean Dressing Change, Medication Administration-General Guidelines, and How to document in RAIMAX, the facility failed to ensure: 1) Employee Identifier (EI) #5 documented wound treatments for Resident Identifier (RI) #5 on 08/19/2022, Treatment Administration Records (TAR). 2) EI #4 documented Activity of Daily Living (ADL) was documented correctly on May 3rd, 5th, 7th, 10th, 12th, 19th, 21st, 24th, 26th, and 31st in the medical record for RI #3. This affected RI #3 and RI #5, two of eight residents sampled for documentation. Findings Include: A review of Potter and Perry's Fundamentals of Nursing, NINTH EDITION, page 370, revealed the following: .Chapter 26 Documentation and Informatics .Informatics and Information Management in Health Care .A nurse's electronic or handwritten signature on an entry in a record designates accountability for the contents of that entry . Review of facility's policy titled, Dressing Change, with a review date of 10/2009, revealed: .26. Document on treatment sheet . Review of facility's document titled, How to document in RAIMAX, with a revised date of 11/2010 revealed: . to record the resident's self-care performance in activities of daily living . The ADL Self Performance and Support answers are documented on the kiosk . 1) RI #5 was admitted to the facility on [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . RI #5's TAR for August 2022 documented, . Clean sacrum with wound cleaner. Apply [MEDICATION(S)] to wound bed and lightly pack with normal saline moisten gauze and cover with [MEDICATION(S)] daily. Order Date- 08/18/2022 . A review of the August 2022 TAR revealed missing documentation for wound care on 08/19/2022. On 09/08/2022 at 10:34 AM, an interview was conducted with EI #5, Registered Nurse (RN)/Wound Treatment Nurse. EI #5 stated she was assigned to RI #5 on 08/19/2022 and provided wound treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . On 09/09/2022 at 12:57 PM, an interview was conducted with EI #2 RN/Director of Nursing (DON). EI #2 stated that wound care was not documented on 08/19/2022 and he did not know why it was not documented. EI #2 stated that the risk of not documenting wound care treatment was they would not know if it was provided or not. EI #2 stated that wound care should have been documented on 08/19/2022. 2) RI #3 was admitted to the facility on [DATE] and had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . RI #3's ADL for May 3rd, 5th, 7th, 10th, 12th, 19th, 21st, 24th, 26th, and 31st of 2022 documented, Activity did not occur for bathing. On 09/09/2022 at 10:43 AM, an interview was conducted with EI #4, CNA. EI #4 stated that she charts if the residents have a shower, total care, or independent. EI #4 stated that she would chart activity did not occur if it was not their shower day. EI #4 stated that RI #3's bath days were Tuesdays, Thursdays, and Saturdays. EI #4 was asked if she bathed RI #3 on May 3rd, 5th, 7th, 10th, 12th, 19th, 21st, 24th, 26th, and 31st since she charted for ADL/bathing as Activity did not occur. EI #4 stated she gave RI #3 a bath on those dates. EI #4 was asked, why she did not chart correctly on the ADL sheet documentation, and she stated she might have hit the wrong button. EI #4 was asked, what was the risk of not charting accurately the care of the residents. EI #4 replied, it looked like the care was not done. On 09/09/2022 at 12:57 PM, an interview was conducted with EI #2, RN/DON. EI #2 stated that the CNAs were to document in RAIMAX if they gave a full bath, partial bath or no bath. EI #2 was asked, what did Activity did not occur mean. EI #2 replied, the activity did not occur during that shift. EI #2 was asked, according to the bathing documentation, how many baths did RI #3 receive between 05/01/2022 and 06/06/2022. EI #2 replied, four. EI #2 was asked, how many baths were RI #3 supposed to receive during that period. EI #2 replied, a bath was to be given every Tuesday, Thursday, and Saturday. EI #2 was asked, what was the risk of not documenting according to policy for ADL care. EI #2 replied, it looked like RI #3 did not get a bath on May 3rd, 5th, 7th, 10th, 12th, 19th, 21st, 24th, 26th, and 31st. This deficiency was cited as a result of investigations AL 022 and AL 029.

Based on medical record review, interviews, and review of the manufacturer's information for the Sunbeam Hospitality Hair Dryer, the facility failed to ensure Employee Identifier (EI) #5, a Certified Nursing Assistant (CNA), did not place a hair dryer on Resident Identifier (RI) #14's abdomen causing RI #14 to sustain multiple blisters. On 4/23/2021 during the first shift (7:00 AM to 3:00 PM), RI #14 complained of being cold and asked EI #5, the CNA, to place the hair dryer on him/her. Without regard of the risks and potential hazards, the CNA did so. EI #5 propped the hair dryer up and covered it with a blanket. When another CNA, EI #6, came in during second shift (3:00 PM to 11:00 PM), RI #14 asked EI #6 to remove the hair dryer as he/she was beginning to get hot. EI #6 stated when she removed the bed covers, she noticed RI #14's skin was red and there were multiple blisters on the resident's legs, thighs, stomach, and arms. This deficient practice placed RI #14, one of four sampled residents reviewed for accidents, in immediate jeopardy, as it was likely to result in serious injury, serious harm, serious impairment, or death. On 9/15/2021 at 6:10 PM, the Administrator, Director of Nursing Services, and Clinical Operations Nurse Consultant were notified of the findings of substandard quality of care at the immediate jeopardy level in the area of Quality of Care/Free of Accident Hazards/Supervision/Devices, F689. Findings include: On 9/7/2021, the Alabama Department of Public Health (ADPH) received a complaint regarding RI #14. The reporter stated RI #14 sustained some bad [CONDITION(S)] that were open, pink sores on the right side of his/her body, arm, breast, torso, and inner thigh because EI #5 left a hair dryer turned on under the resident's blanket because the resident said he/she was cold. RI #14 was admitted to the facility on [DATE] with a medical history including [CONDITION(S)], C (cervical) 5-C7 incomplete, Cognitive Communication Deficit, and Type Two Diabetes Mellitus. Review of RI #14's Quarterly Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 2/22/2021, revealed RI #14 had a Brief Interview for Mental Status (BIMS) score of 15, indicating he/she was cognitively intact. This assessment also indicated RI #14 required extensive to total assistance of two plus people for all Activities of Daily Living (ADLs). Review of RI #14's Weekly Skin documentation dated 4/23/2021 at 10:33 AM, revealed at the time of the assessment RI #14 was only noted to have two old scars and a diabetic ulcer to the left lateral ankle. There was no documentation of any pre-existing [CONDITION(S)] on RI #14's body. Review of RI #14's Departmental Notes revealed, . 4/23/2021 6:05 PM Nurse summoned to shower resident has some reddened areas on (his/her) abdomen. (RI #14) stated (he/she) doesn't know what happened. New order for silvergel cream per (according) tx (treatment) nurse. The note was made by EI #3, Licensed Practical Nurse (LPN). Review of a document titled, Physician's Telephone Order, with order date: 4/23/2021 6:07 PM, revealed: . Order Text: APPLY SILVERGEL TO ABDOMEN AND BILATERAL BREAST REDDENED AREAS DAILY . On 9/9/2021 at 11:37 AM, an interview was conducted with RI #14. RI #14 was asked what he/she could recall about a staff member using a hair dryer to warm him/her up. RI #14 stated he/she asked EI #5, CNA, to warm him/her with the hair dryer. RI #14 stated EI #5 put the hair dryer on his/her stomach. When asked if the hair dryer caused any injuries, RI #14 stated yes, the hair dryer made a blister. When asked how long the hair dryer was blowing on him/her, RI #14 said, he/she did not remember. On 9/9/2021 at 2:47 PM, an interview was conducted with EI #5, CNA. During the interview EI #5 confirmed she used the hair dryer to warm RI #14 up. EI #5 said she propped the hair dryer up on top of some towels on RI #14's abdomen, and when she came back to work the next day, she was told RI #14 had a blister. On 9/11/2021 at 1:52 PM, a follow-up telephone interview was conducted with EI #5. EI #5 stated RI #14 could not do for him/herself and that he/she required total care. EI #5 was asked is RI #14 could move either arm or either leg. EI #5 said no, but he/she could throw his/her elbows out some but was still total care. EI #5 was asked when she placed the hair dryer on RI #14 on 4/23/2021. EI #5 said maybe 2:00 PM, during her last round. EI #5 was asked if she told any other staff that she had placed the hair dryer on RI #14. EI #5 said no. EI #5 stated that she only used the hair dryer one time to warm the resident because she was cold and shivering. Review of the manufacturer's information for the Sunbeam Hospitality Hair Dryer documented the following: .IMPORTANT SAFETY INSTRUCTIONS . basic safety precautions should always be followed .WARNING-To reduce risk of [CONDITION(S)], electrocution, fire or injury to persons: 1. Close supervision is necessary when this appliance is used by, on or near invalids or disabled persons . 2. Use this appliance only for its intended use as described in this manual . 9. Do not direct hot air toward eyes or other heat-sensitive areas . On 9/10/2021 at 6:48 PM, a telephone interview was conducted with EI #6, Nursing Assistant (NA). EI #6 was asked what she could recall about a hair dryer and RI #14 on 4/23/2021. EI #6 said at the start of her shift (3:00 PM to 11:00 PM) she answered RI #14's call light. EI #6 stated, when she entered RI #14's room, she heard something and pulled the blanket back and discovered the hair dryer blowing. EI #6 was asked what she saw on RI #14's skin. EI #6 said blisters. EI #6 was asked about the location and size of the blisters. EI #6 stated there were three on his/her stomach, one on each leg and some on his/her arms. EI #6 described most of the blisters as small, but stated the one on RI #14's stomach was bigger. EI #6 was asked what she did when she saw the hair dryer. EI #6 said she asked RI #14 why the hair dryer was under there and RI #14 said that a CNA on the morning shift put it there. EI #6 stated that she cut the dryer off, put it in a drawer and told the charge nurse. EI #6 was asked who the nurse was. EI #6 stated she thought it was EI #4, Licensed Practical Nurse (LPN)/Unit Manager (UM). EI #6 was asked if EI #4 looked at RI #14. EI #6 said yes. EI #6 said they put some cream on him/her. On 9/11/2021 at 10:59 AM, a follow-up telephone interview was conducted with EI #6. EI #6 was asked where the hair dryer was positioned when she found it. EI #6 stated it was facing RI #14 under the covers and it was blowing towards his/her upper body. EI #6 was asked what speed the hair dryer was on when she found it. EI #6 stated she could not remember, but it was hot. EI #6 was asked if RI #14 complained about the hair dryer. EI #6 stated RI #14 said it was getting hot and that a day shift CNA put it there. On 9/10/2021 at 8:00 PM, a telephone interview was conducted with EI #7, NA. EI #7 was asked if she recalled an incident with RI #14 involving a hair dryer. EI #7 said yes. EI #7 was asked who found the hair dryer on RI #14. EI #7 said EI #6, NA, found it. EI #7 was asked how long the hair dryer was on RI #14. EI #7 said that RI #14 did not say, but by the time she saw him/her around 3:45 PM, there were blisters everywhere and she called out to EI #4, LPN/UM, to come in the shower room to look at RI #14. EI #7 said EI #4 called EI #3, LPN, to come look at RI #14 and they got some medicine to put on him/her. On 9/11/2021 at 11:54 AM, an interview was conducted with EI #4, LPN/UM. EI #4 was asked if EI #7 called her to the shower room and showed her blisters on RI #14. EI #4 said that EI #7 showed her red areas across RI #14's stomach. EI #4 said she called EI #3, who was the treatment nurse at that time, to come assess RI #14. EI #4 was asked what EI #3 did when she saw RI #14. EI #4 stated EI #3 said it was bad and they had to get something to put on it. On 9/9/2021 at 4:03 PM an interview was conducted with EI #3, LPN. When asked how she became aware of the reddened areas to RI #14's abdomen, EI #3 stated at the time the incident occurred she was the wound nurse, and someone came to get her when RI #14 was in the shower. EI #3 said when she got to the shower, she observed reddened areas to RI #14's upper abdomen. When asked how many areas she observed, EI #3 stated she could not recall, but said she called the doctor to get treatment orders. On 9/15/2021 at 10:10 AM, an interview was conducted with EI #9, LPN. EI #9 was asked what she could tell me about an incident with RI #14 and a hair dryer. EI #9 stated when she came in for her shift on 4/23/2021, EI #4/LPN/UM, told her there had been an incident earlier in the day with a hair dryer and RI #14 had gotten blisters. When asked where the blisters were located, EI #9 stated the blisters were on both of RI #14's breasts, one or two on RI #14's stomach and one on RI #14's arm. EI #9 was asked if any of the areas contained fluid. EI #9 said yes, they kept fluid in them for about two weeks after it happened, and she did not think they were ever going to burst. ************************************************ On 9/15/2021 at 6:10 PM, the facility submitted a Removal Plan which documented: *The Medical Director/attending physician for RI #14 was notified on 9/15/2021 at 6:20 PM of the Immediate Jeopardy level deficiency for F689 accident hazards. *An emergency Quality Assurance Performance Committee meeting was held on 9/15/2021 at 6:30 PM . *The facility completed one-on-one in-service education with EI #5 that all equipment must be used only for purposes it was intended. If any resident asks for items to be used for any other purposes, administrative staff are to be immediately notified. *The facility initiated in-service education with staff starting 9/11/2021 and continuing through 9/16/2021 with all facility staff regarding all equipment must be used only for purposes it was intended. If any resident asks for items to be used for any other purposes, administrative staff are to be immediately notified. Any staff who has not completed this education as of 9/16/2021, will not be allowed to work until they complete education . *Social Services met with RI #14 on 9/15/2021 at 8:12 PM and communicated that the hair dryer cannot be used to warm him/her - only to dry his/her hair . *The care plan for RI #14 has been updated to instruct staff not to use hair dryer to warm resident .on 9/15/2021 at 8:30 PM . *The facility completed 100% audit of each resident's room to identify any potentially hazardous equipment and removed items as needed 9/15/2021 at 9:00 PM . *An emergency Quality Assurance Committee meeting was held on 9/15/2021 at 6:30 PM to review the facility immediate jeopardy removal plan which included in-service education related to only using equipment for its intended purpose, reporting any request to Administrative staff to use in non-intended manner . Completed on 9/17/2021 ************************************************ After review the facility's information provided in their Removal Plan and verifying the immediate actions had been implemented, the scope/severity level of F689 was lowered to a D level on 9/17/2021, to allow the facility time to monitor and/or revise their corrective actions as necessary to achieve substantial compliance. This deficiency was cited as a result of the investigation of complaint/report number AL 525.

Based on interviews, record review, review of facility policy titled, Subject: Laboratory Tests, and review of a complaint received by the State Agency, the facility failed to ensure the results of Resident Identifier (RI) #2's CMP and CBC was received in a timely manner after RI #2 was ordered a CMP and CBC on 6/22/21. On 6/26/21 resident was discharged from the facility. This affected RI #2 one of two residents sampled for laboratory services. Findings include: Review of a facility policy titled Subject: Laboratory Tests, with a History date of 11/17, revealed the following: Policy: . Lab tests are completed as ordered by the physician or physician extender (Nurse Practitioner, Physician Assistant or Clinical Nurse Specialist). Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] .Procedure: 1. Licensed Nurse, or designee, shall obtain the labs ordered by the physician or physician extender; or labs to be done routinely per policy and enter this information on the Lab Scheduling/Tracking Form, indicating resident, room number, month and approximate date lab work is due to be obtained, and when the results have been received.7. Any labs not obtained as indicated will be rescheduled by the Licensed Nurse. RI #2 was admitted to the facility on [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of RI #2's Physician Orders: dated 6/22/21 revealed the following, . collect CBC, CMP . On 7/29/21 at 4:34 PM, a follow up Interview with Employee Identifier (EI) #1 RN, Director of Nursing (DON) was conducted. EI #1 was asked, did RI #2 have an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . EI #1 was asked, was the lab order completed. EI #1 replied, we do not have the results, no it was not complete. EI #1 was asked, why wasn't it completed. EI #1 replied, we are still looking into why it was not complete. EI #1 was asked, what was the process of insuring labs are completed. EI #1 replied, the nurse takes it off and puts a lab order, and puts a requisition into the lab binder and the lab tech picks it up and if he is unable to get the lab he alerts the charge nurse by letting the charge nurse know he was not able to get the lab from that specific resident. EI #1 was asked, what was the possible of negative outcome of not completing the ordered blood work for RI #2. EI #1 replied, to know the lab work prior to treatment. EI #1 was asked, did you sign off that lab order. EI #1 replied, yes. EI #1 was asked, did you fill out a requisition for the lab. EI #1 replied, yes, and put it in the binder. EI #1 was asked, what happen to the requisition. EI #1 replied, he did not know. On 7/26/21 at 4:26 PM a follow up interview was conducted with EI #2 CRNP. EI #2 was asked, did you order a CBC and CMP on 6/22/21. EI #2 replied, yes. EI #2 was asked, why did you order it. EI #2 replied, trying to see if there was dehydration, and what EI #2's white count was. EI #2 was asked, when would you expect for it to be completed. EI #2 replied, if not that day then the next morning. EI #2 was asked, it appears it was not done do you know why it was not done. EI #2 replied, no. EI #2 was asked, do you think that would have caused EI #2 to decline. EI #2 replied, no.

Based on observations and interview, the facility failed to ensure residents that resided on the memory care unit were not served food in disposable, Styrofoam, or plastic ware. This deficient practice all the residents who resided on the memory care unit, one of three units in the facility. Findings include: During the lunch meal observation on the memory care unit on 5/17/2021 beginning at 12:15 PM, 18 residents were observed using disposable cups and service ware. During the breakfast meal observation on 5/18/2021 at 8:35 AM, 21 residents were in the dining room. The staff was observed serving the residents with plastic ware. The residents had Styrofoam cups with juice and thin plastic cups for water. During an interview with Employee Identifier (EI) #1, the Dietary Manager and EI #2, the Regional Dietician, on 5/19/2021 at 2:15 PM, EI #1 stated she was not aware that disposable ware was a dignity issue.

Based on observations and interview, the facility failed to ensure the dining area of the memory care unit was clean and sanitary. This deficient practice was observed on the memory care unit, one of three units within the facility. Findings include: During an observation of the dining area on the memory care unit on 5/17/2021 at 1:23 PM, the floor was dirty and sticky. There were areas of spills, yellow and brown in color, that had dried to the floor. There were used gloves on the floor in front of the serving area. The cupboard and drawers were dirty, contained crumbs and dried food debris. During an observation of the dining area on the memory care unit on 5/18/2021 at 8:35 AM, the condiment holder was dirty, contained crumbs and debris. The floor was sticky with dark and yellow spots on the floor. The beverage service cart had dried spills down the sides of the cart. On 5/19/2021 at 8:50 AM, an interview with Employee Identifier (EI) #3, the housekeeper was conducted. EI #3 stated she worked three days a week on the memory care unit, cleaning the rooms daily along with the lobby where the residents watch television. EI #3 stated she normally cleaned the dining area after breakfast around 10:00 AM and then again after lunch around 3:00 PM. According to EI #3, for the last couple of days, the staff have brought the residents into the dining room early and she did not have enough time to clean between meals. EI #3 stated she didn't know why the floor was sticky.

Based on interviews, record review, the facility's Resident Incident Report, review of a document titled, Online Incident Reporting System Report, and review of a facility policy titled, ABUSE PREVENTION, the facility failed to follow the Abuse policy to ensure resident to resident altercations involving Resident Identifier (RI) #'s 1, 2, 3, 4,6, 7, 10, 11 were identified as abuse. This deficient practice affected RI #'s 1, 2, 3, 4, 6, 7, 10 and 11, eight of ten residents reviewed for resident to resident altercations. Findings Include: Review of a facility policy titled, ABUSE PREVENTION, dated 11/17, revealed the following: POLICY: The facility is committed to protecting the residents from abuse by anyone including . other residents . DEFINITIONS: a) Abuse: Willful infliction of injury . d) Physical Abuse: This includes but is not limited to hitting, slapping, pinching and kicking . PR[NAME]EDURE: [NAME] STEPS TP PREVENT, DETECT AND REPORT: .IDENTIFICATION: 1. Identify events, such as suspicious bruising of residents, occurrences, patterns, and trends that may constitiute abuse; and to determine the direction of the investigation . 1) RI #10 was admitted to the facility on [DATE] and was readmitted on [DATE], with [DIAGNOSES REDACTED]. RI #10's most recent Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 5/16/2019, identified RI #10 as having a Brief Interview for Mental Status (BIMS) score of six, indicating severely impaired cognition. RI #11 was admitted to the facility on [DATE] and was readmitted on [DATE], with a [DIAGNOSES REDACTED]. RI#11's Quarterly MDS assessment with an ARD of 6/28/2019, identified RI #11 as having a BIMS score 14, indicating he/she was cognitively intact. A review of a document titled, Online Incident Reporting System Reportk dated 7/5/2019, revealed the following information: . Incident Type . Select Category: Physical Abuse . Incident Detail . Name(s) of resident(s) involved: (RI #11) and (RI #10) . Name of suspected offender(s): (RI# 10) . Narrative summary of incident: Residents were in hallway. (RI #10) kicked (RI #11). (RI #11) struck (RI #10) . A facility Resident Incident Report form for RI #10, dated 7/5/2019, revealed the following: Category Physical Contact . Describe Injury: none Location of Occurrence: Unit Lobby . Incident Reported by: (Employee Identifier (EI) #8, RN) . Narrative of incident and description of injuries . Notified by staff that the resident and coresident were arguing. Residents were separated. Resident stated I didn't do anything to (him/her), (he/she) hit me when I was passing by (him/her). No injuries noted. Resident returned to (his/her) room. DON (Director of Nursing) notified. On 11/13/2019 at 4:36 PM, the surveyor attempted to call EI #8. No contact made. On 11/14/2019 at 9:29 AM, the surveyor attempted to call EI #8. No contact made. On 11/14/2019 at 11:32 AM, the surveyor attempted to call EI #8. No contact made. On 11/14/2019 at 10:49 AM, the surveyor conducted an interview with EI #1, the DON. EI #1 stated the incident occurring between RI #10 and RI #11 on 7/5/2019, happened at 7:50 PM. EI #1 stated, according to the narrative summary of the incident, on the Online Incident Report sent to the State Agency, RI #10 and RI #11 were in the hallway and RI #10 kicked RI #11. EI #1 stated, then RI #11 struck RI #10. When asked, according to the five day summary, was this considered a resident on resident altercation, EI #1 stated it was. The surveyor asked EI #1 what type of abuse was kicking and striking. EI #1 stated physical. The surveyor asked EI #1, in the facility's five day report, why was the incident not substantiated as abuse. EI #1 stated it was a misunderstanding on the facility's part of what the definition of abuse was. EI #1 stated according to the regulations under the definition of willful, the intentions have to be deliberate, not that the individual intended to inflict injury. When asked if RI #10 deliberately kicked RI #11, EI #1 stated yes. When asked if RI #11 deliberately struck RI #10, EI #1 stated yes. 2) RI #6 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. RI #6's Quarterly MDS assessment with an ARD of 6/13/2019, identified RI #6 as having a BIMS score of three, indicating severely impaired cognition. RI #7 was admitted to the facility on [DATE] and readmitted on [DATE], with [DIAGNOSES REDACTED]. RI #7's Quarterly MDS assessment with an ARD of 6/5/2019, identified RI #7 as having a BIMS score of four, indicating severely impaired cognition. A review of a document titled, Online Incident Reporting System Report, dated 06/27/2019, revealed the following information: . Incident Type . Select Catogory: Physical Abuse . Incident Detail . Name(s) of resident(s) involved: (RI #7) and (RI #6) . Name of suspected offender(s): (R1#6) . Narrative summary of incident: Staff heard resident comotion. Staff noted (RI #6) strike (RI #7) . A facility Resident Incident Report form for RI #7, dated 6/27/2019, revealed the following: . Incident Type: Res (Resident)-Res-physical Type of Injury: None . Location: Hallway on unit . Narrative of incident and description of injuries: CNA (Certified Nursing Assistant) reported to the nurse that (RI #7) and another resident was trying to pass one another and the other resident became upset and hit (RI #7) with closed hand on (his/her) right ear and (RI #7) hit the other resident on (his/her) right cheek bone. Staff separated residents immediately. On head to toe assessment there was some redness to right ear with no pain or discomfort noted. No other injuries notied . On 11/13/2019 at 3:30 PM, EI #4, a Licensed Practical Nurse was interviewed. When asked about the incident between RI #6 and RI #7 on 6/27/2019, EI #4 said she heard a commotion. EI #4 stated she assisted in separating RI #6 from RI #7. EI #4 stated she assessed RI #6 and RI #7 for injuries and noticed redness to RI #7's ear. On 11/13/2019 at 4:50 PM, EI #7, a CNA was interviewed. EI #7 said RI #6 was walking down the hall going towards the dining room. EI #7 said RI #7 was rolling in his/her wheelchair towards the dining room. EI #7 said RI #6 was standing beside RI #7 looking down at RI #7. EI #7 said RI #6 then swung his/her right hand down and hit RI #7 on the top of the head. EI #7 said she called EI #6, the nurse and EI #6 came down the hall and redirected RI #6. On 11/14/2019 at 10:49 AM, EI #1 was interviewed. EI #1 stated he was made aware of the incident between RI #6 and RI #7 that occurred on 6/27/2019 at 6:40 PM. The surveyor asked EI #1, according to the narrative summary of the incident on the Online Incident Report sent to the State Agency, what occurred. EI #1 said the staff heard commotion and observed RI #6 strike RI #7. EI #1 stated, according to the five day summary, this incident was considenered a resident-on-resident altercation. EI #1 stated the initial report did not say RI #7 hit RI #6 but this information was discovered during the investigation. EI #1 stated striking/hitting is physical abuse. When asked why the incident was not substantiated as abuse in the five day report, EI #1 stated there was a misunderstanding of the term willful. EI #1 stated that RI #6 deliberately struck RI #7 and RI #7 deliberately struck RI #6. (3) RI #1 was admitted to the facility on [DATE], and readmitted on [DATE], with a [DIAGNOSES REDACTED]. A Quarterly MDS assessment with an ARD of 5/27/2019, revealed RI #1 had a BIMS score of eight, indicating moderately impaired cognition. RI #4 was admitted to the facility on [DATE], with a [DIAGNOSES REDACTED]. An Admission MDS assessment with an ARD of 7/18/2019, revealed RI #4 had short and long term memory problems and severely impaired cognition. A review of a document titled Online Incident Reporting System Report, dated 06/26/2019, revealed the followng information: . Incident Type . Select Catogory: Physical Abuse . Incident Detail . Name(s) of resident(s) involved: (RI #1) and (RI #4) . Name of suspected offender(s): (RI #4) . Narrative summary of incident: Residents in dining room at evening meal time, (RI #4) struck (RI #1) . On 11/13/2019 at 11:29 AM, the surveyor conducted a telephone interview with RI #1's sponsor. The surveyor asked RI #1's sponsor if she remembered the incident between RI #1 and RI #4 on 6/26/2019. RI #1's sponsor stated yes. RI #1's sponsor said RI #4 was ambulatory and very confused. RI #1's sponsor said RI #4 came to the table and tried to take RI #1's food. RI #1's sponsor said RI #1 swatted at RI #4 and RI #4 hit RI #1. When asked how staff handled the incident, RI #1's sponsor stated RI #4 and RI #1 were separated, and staff made sure RI #1 was ok. On 11/14/2019 at 7:27AM, an interview was conducted with EI #3, the Registered Charge Nurse working on the evening of 6/26/2019. EI #3 was asked what she could tell the surveyor about the incident between RI #1 and RI #4 that occurred on 06/26/2019. EI #3 stated RI #1 was sitting with the sponsor in the dining room. EI #3 stated RI #4 walked up to the table where RI #1 and the sponsor were sitting. EI #3 said she heard a noise and turned and saw RI #1's sponsor blocking RI #4 from hitting RI #1. EI #3 said RI #1's sponsor stated RI #4 had just just slapped RI #1. EI #3 said the CNAs separated the residents. EI #3 stated RI #1's face was observed and no injuries were noted. On 11/14/2019 at 10:49 AM, an interview was conducted with EI #1, the DON. EI #1 stated the incident between RI #1 and RI #4 was reported to the State Agency on 6/26/2019 at 6:42 PM. EI #1 stated RI #1 and RI #4 were in the dining room at the evening meal time and RI #4 struck RI #1. When asked what type of abuse was striking/hitting, EI #1 responded physical. EI #1 was asked why the incident was unsubstantiated as abuse in the facilty's five day report. EI #1 stated it was a misunderstanding. EI #1 agreed that according to information gathered, RI #4 deliberately struck RI #1 and this was considered a resident to resident altercation. (4) RI #2 was admitted to the facility on [DATE], with a [DIAGNOSES REDACTED]. An Annual MDS assessment with an ARD of 5/10/2019, revealed RI #2 had a BIMS score of eight, indicating moderately impaired cognition. A review of a document titled, Online Incident Reporting System Report, dated 06/27/2019, revealed the following information: . Incident Type . Select Catogory: Physical Abuse . Incident Detail . Name(s) of resident(s) involved: (RI #2) and (RI #4) . Name of suspected offender(s): (RI #4) . Narrative summary of incident: (RI #4) walked in (RI #2's) room and picked up one of (RI #2's) shirts. When (RI #2) attempted to get the shirt from (RI #4), (RI #4) struck (RI #2) . On 11/14/2019 at 10:49 AM, an interview was conducted with EI #1. EI #1 stated the incident between RI #2 and RI #4 on 6/27/2019, was reported to the State Agency around 12:15 PM. EI #1 stated it was reported that RI #4 walked into RI #2's room and picked up one of his/her shirts and when RI #2 tried to get it, RI #4 struck him/her. When asked what type of abuse was striking/hitting, EI #1 responded physical. EI #1 was asked why this incident was unsubstantiated as abuse in the facility's five day report. EI #1 stated it was a misinterpretation of the definition of willful. EI #1 agreed that according to information gathered, RI #4 deliberately struck RI #2. (5) RI #3 was admitted to the facility on [DATE], with a [DIAGNOSES REDACTED]. An Annual MDS assessment with an ARD of 6/13/2019, revealed RI #3 had a BIMS score of three, indicating severly impaired cognition. A review of a document titled, Online Incident Reporting System Report, dated 06/28/2019, revealed the following information: . Incident Type . Select Catogory: Physical Abuse . Incident Detail . Name(s) of resident(s) involved: (RI #3) and (RI #4) . Name of suspected offender(s): (R1 #4) . Narrative summary of incident: (RI #3) was sitting (in) the common area on unit. (RI #4) walked up to (RI #3) and struck (him/her). (RI #3) struck back at (RI #4) . A facility Resident Incident Report form for RI #3, dated 6/28/2019, revealed the following: Category Physical contact . Describe Injury: none Location of Occurrence: Unit lobby . Resident Condition at Time of Incident . Narrative of incident and description of injuries . Responded to noise in the front lobby when staff reported another resident hit (him/her) on the arm and then (his/her) face and this resident hit (him/her) back on (his/her) arm . Prepared by: (EI #5, LPN Unit Manager) . On 11/13/2019 at 5:15 PM, an interview was conducted with EI #5. EI #5 said she responded to a noise in the common area on the unit. EI #5 said when she arrived, she was told RI #4 was hitting at staff and RI #3. EI #5 said the residents were separated and RI #4 was redirected. On 11/14/2019 at 10:49 AM, an interview was conducted with EI #1. EI #1 stated he became aware of the incident between RI #3 and RI #4 on 6/28/2019, about 2:31 PM. EI #1 stated it was observed that RI #3 was sitting in the common area on the unit, when RI #4 walked up and struck RI #3 and RI #3 struck RI #4 back. When asked what type of abuse was striking/hitting, EI #1 responded physical. EI #1 was asked why the incident was unsubstantiated as abuse in the facility's five day report, EI #1 stated there was a misinterpretation of what willful was. EI #1 agreed that according to information gathered RI #4 and RI #3 deliberately struck each other. On 11/14/2019 at 11:55 AM, an interview was completed with EI #2, the Administrator/Abuse Coordinator. EI #2 was asked what type of abuse was hitting, striking and kicking. EI #2 stated all three would be considered physical, and resident to resident altercations were considered abuse. EI #2 agreed when a cognitively impaired resident willfully and deliberately hit or kicked another resident it was abuse. EI #2 stated the resident to resident altercations involving RI #'s 1, 2, 3, 4, 6, 7, 10 and 11 should have been substantiated as physical abuse. On 11/14/2019 at 2:14 PM, a second interview was conducted with EI #2. The surveyor asked EI #2 what were her responsibilities as the Abuse Coordinator. EI #2 stated she was responsible for reviewing facility reports, logs and investigations. This deficiency was written as a result of th einvestigation of complaint/report #AL 988 and #AL 032.

Based on interviews, record review, review of a facility policy titled, Abuse Prevention, review of the facility's investigative file and review of information from the Alabama Department of Public Health's (ADPH) Online Reporting System, the facility failed to ensure Resident Identifiers (RI) #'s 11, 92, 270 and 272 were not missing narcotic medications. These incidents occurred on two occasions, [DATE] and [DATE]. This deficient practice affected RI #'s 11, 92, 270 and 272, four of four residents who were observed for narcotic medication and resided on two of four units at the facility. Findings Include: A review of a facility policy titled Abuse Prevention, with a history date of ,[DATE], revealed the following: . DEFINITIONS: . g) Misappropriation of Resident Property: The deliberate misplacement, exploitation, or wrongful temporary or permanent use of a resident's belongings or money with or without the resident's consent . (1) RI #270 was admitted to the facility on [DATE], with a [DIAGNOSES REDACTED]. A review of RI #270's (MONTH) (YEAR) Physician order [REDACTED]. [MEDICATION NAME] SULF ER (Extended Release) 30 MG (milligrams) TABLET 1 TABLET BY MOUTH EVERY 12 HOURS . A review of an ADPH Online Facility Reported Incident dated [DATE], revealed the following: . Incident Type . Misappropriation of Resident Property . Incident Detail . Narrative summary of incident: While preparing to discharge (RI #270) after short stay skilled rehabilitation it was identified that narcotic medication, [MEDICATION NAME] Sulf (Sulfate) ER (Extended Relief) 3 (30 mg), was 28 short based on the count . On [DATE] at 8:58 a.m., the surveyor conducted an interview with Employee Identifier (EI) #3, the RN (Registered Nurse) Staff Development Coordinator. The surveyor asked EI #3 when was she made aware that residents had missing narcotics. EI #3 said there were three residents with concerns (RI #11, #92, #270) and she found out about RI #270 when a RN was trying to order medications for a couple of residents who were out of their narcotics. EI #3 said RI #270 was discharging home on the day the discovery was made and RI #270's [MEDICATION NAME] ER 30 mg tablet was one of the narcotics she was attempting to reorder. EI #3 said she showed the RN how to reorder the narcotics. EI #3 said she left the unit and when she came back to the desk the RN and the Director of Nursing (DON), EI #2, were in conversation because the Pharmacy said they were not sending that refill because RI #270 should have seven to ten days of the medication left. EI #3 said at that point facility staff began to search for the narcotics. The surveyor asked EI #3 did the facility determine what happened to the narcotics. EI #3 said no, other than they were gone. EI #3 said the facility attempted to drug screen the RN, but she left the building and never came back. The surveyor asked EI #3 what was put in place to ensure an incident like that one would not reoccur. EI #3 said inservices were done and the surveyor would have to ask the DON, EI #2. When asked what type incident would this be considered, EI #3 said misappropriation of a resident's property. On [DATE] at 4:52 p.m., the surveyor conducted an interview with EI #2. The surveyor asked EI #2 when was he made aware that RI #270 had missing [MEDICATION NAME] ER tablets. EI #2 it would have been on RI #270's discharge date . EI #2 said a RN came to him and said RI #270 did not have his/her medications to go home with. EI #2 said pharmacy informed him that a 28 day supply had already been sent over (on (MONTH) 1st) and RI #270 should still have some tablets to go home with. When asked were the narcotics ever located, EI #2 said no. EI #2 said the incident was reported to ADPH as misappropriation. (2) A review of an undated facility form titled (Name of Facility) Missing Controlled Drug Record from the facility's investigative file revealed RI #272 was dispensed 60 [MEDICATION NAME]-APAP 7XXX,[DATE] milligrams tablets on [DATE], and found to have 52 missing tablets during the facility's investigation. RI #272 was admitted to the facility on [DATE], and readmitted on [DATE] with a [DIAGNOSES REDACTED]. A review of RI #272's (MONTH) (YEAR) Physician order [REDACTED]. . [MEDICATION NAME] 7XXX,[DATE] TABLET GIVE ONE (1) TABLET BY MOUTH EVERY 4 HOURS AS NEEDED . On [DATE] at 3:59 p.m., an interview was conducted with EI #2. EI #2 was asked when was it discovered that RI #272's narcotics we missing. EI #2 said it was discovered on [DATE], when the consultant nurse did her visit after RI #9 and RI #11's narcotics went missing. EI #2 was asked when RI #272 expired. EI #2 said [DATE]. EI #2 was asked what procedure was in place for storing/destroying narcotic medication when a resident expired. EI #2 said the narcotics were usually picked up on Thursdays, but with the holiday season, the facility got off track with that. EI #2 was asked where were RI #272's narcotics stored. EI #2 said they were still in the narcotic box on the cart. EI #2 was asked where/when should they have been destroyed. EI #2 said that was the correct place to store them, they just got off track removing them from the narcotic box and destroying them. EI #2 was asked if that was reported to ADPH. EI #2 said it was. EI #2 was asked what type incident this was considered to be and he said misappropriation. (3) A review of an ADPH Online Facility Reported Incident with a Date and time of incident of [DATE], revealed the following: . Subject Category: Misappropriation of Resident Property . Name(s) of resident(s) involved: (RI #11 and RI #92) . Narrative summary of incident: Two resident's narcotic cards unaccounted for . A review of an undated facility form titled (Name of Facility) Missing Controlled Drug Record from the facility's investigative file revealed RI #11 was dispensed 90 [MEDICATION NAME]-APAP 7XXX,[DATE] milligrams tablets on [DATE], and found to have 76 missing tablets. RI #11 was admitted to the facility on [DATE], and readmitted on [DATE] with a [DIAGNOSES REDACTED]. A review of RI #11's (MONTH) (YEAR) Physician order [REDACTED]. . [MEDICATION NAME] 7XXX,[DATE] TABLET GIVE ONE (1) TABLET BY MOUTH Q4H (every 4 hours) AS NEEDED FOR PAIN . On [DATE] at 8:46 a.m., a telephone interview was conducted with EI #11, RN. EI #11 was asked if she was familiar with RI #11. EI #11 said she did not remember. EI #11 was asked when was she made aware he/she had missing narcotics. EI #11 said some time (MONTH) she was called to the DON's office and asked if she had added or taken away from a narcotic sheet. EI #11 was asked if she altered the narcotic sheet and she said no. EI #11 was asked if she cared for RI #11 during the time the narcotics were missing and she said she did not specifically remember him/her. EI #11 was asked if the facility ever determined what happened to the narcotics. EI #11 said not that she was aware of. EI #11 was asked what procedure was in place to ensure narcotic medications were accounted for at all times. EI #11 said when the shift is started, the oncoming and off going nurse count the medication and compare it against what was in the narcotic book. EI #11 was asked if she was still employed by the facility at this time and she stated she left a little after the incident. On [DATE] at 8:58 a.m., an interview was conducted with EI #3. EI #3 was asked did the facility determine what happened to the narcotics. EI #3 said no. EI #3 was asked what procedure the facility had in place to ensure narcotics were accounted for. EI #3 said the nurses count at shift change and two nurses had to sign when narcotics were brought into the facility. (4) A review of an undated facility form titled (Name of Facility) Missing Controlled Drug Record from the facility's investigative file revealed RI #92 was dispensed 60 [MEDICATION NAME]-APAP ,[DATE] milligrams tablets on [DATE], and was found to have 45 missing tablets. RI #92 was admitted to the facility on [DATE], with a [DIAGNOSES REDACTED]. A review of RI #92's (MONTH) (YEAR) Physician order [REDACTED]. . [MEDICATION NAME] ,[DATE] TABLET GIVE 1 TABLET BY MOUTH EVERY 12 HOURS AS NEEDED . On [DATE] at 8:46 a.m., a telephone interview was conducted with EI #11, RN. EI #11 was asked if she was familiar with RI #92. EI #11 said she did not remember. EI #11 was asked when was she made aware he/she had missing narcotics. EI #11 said some time (MONTH) she was called to the DON's office and asked if she had added or taken away from a narcotic sheet. EI #11 was asked if she altered the narcotic sheet and she said no. EI #11 was asked if she cared for RI #92 during the time the narcotics were missing and she said she did not specifically remember him/her. EI #11 was asked if the facility ever determined what happened to the narcotics. EI #11 said not that she was aware of. EI #11 was asked what procedure was in place to ensure narcotic medications were accounted for at all times. EI #11 said when the shift is started, the oncoming and off going nurse count the medication and compare it against what was in the narcotic book. EI #11 was asked if she was still employed by the facility at this time and she stated she left a little after the incident. On [DATE] at 8:58 a.m., an interview was conducted with EI #3. EI #3 was asked did the facility determine what happened to the narcotics. EI #3 said no. EI #3 was asked what procedure the facility had in place to ensure narcotics were accounted for. EI #3 said the nurses count at shift change and two nurses had to sign when narcotics were brought into the facility. This deficiency was cited as a result of the investigation of complaint/report #AL 123.

Based on observation, interview and record review, the facility failed to ensure staff did not stand while feeding Resident Identifier (RI) #59 the breakfast meal on 02/13/19. This deficient practice affected RI #59, one of five residents observed requiring assistance at meal time. Findings Include: RI #59 was admitted to the facility on [DATE], and readmitted on [DATE], with [DIAGNOSES REDACTED]. RI #59's Quarterly Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 12/17/18, assessed RI #59 as having short and long term memory problems with severely impaired cognitive skills for daily decision making and needing extensive assistance with eating. On 02/13/19 at 8:04 a.m., the surveyor observed Employee Identifier (EI) #8, a LPN (Licensed Practical Nurse) Unit Manager, standing while feeding RI #59 the breakfast meal. On 02/14/19 at 1209, the surveyor asked RI #59 if he/she minded staff standing while feeding him/her. RI #59 did not respond to the question. On 02/14/19 at 12:40 p.m., the surveyor conducted an interview with EI #8. The surveyor asked EI #8, what position was she in when the surveyor observed her feed RI #59 on 02/13/19. EI #8 said she was standing. The surveyor asked EI #8 how should staff be positioned when feeding the resident. EI #59 said staff should be sitting. When asked the type issue it could be considered when staff stood while feeding a resident, EI #8 said a dignity.

Based on interviews, record review, and document review, the facility failed to ensure Employee Identifier (EI) #1, a Certified Nursing Assistant (CNA) followed Resident Identifier (RI) #8's care plan to transfer RI #8 with a two-person assist and Marisa Lift on 06/25/2015. According to RI #8's incident report, EI #1 attempted to transfer the resident without any assistance. EI #1 stated during the transfer, the resident's weight shifted and the resident was lowered to the floor. As a result of this incident, RI #8 sustained a laceration to the right knee, which measured 15 centimeters (cm) long and 0.3 cm wide; swelling to the left forearm; a knot and bruising to the left thigh; a bruise to the right thigh and bruising and swelling to the right thumb and 5th finger. RI #8 was transferred to a local emergency room , where the resident received eight staples to close the laceration/wound. This affected RI #8, one of three sampled residents reviewed for falls. Findings include: The facility's undated policy titled, SUBJECT: CARE PLANS revealed Policy: Each resident will have a plan of care to identify problems, needs and strengths that identify how the interdisciplinary team will provide care . DEFINITIONS . Care Plan - Contains services provided, preference, ability, and care level guidelines.Pocket Care Guide - part of the Comprehensive Care Plan and used as the tool to make staff aware of the resident's daily care needs. RI #8 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. RI #8's at risk for falls care plan, with a problem onset date of 02/25/2015, included an approach of . * 2 person assist transfer with marisa lift . RI #8's Annual Minimum Data Set, with an assessment reference date of 05/25/2015, revealed RI #8 was totally dependent on staff for transfers. RI #8's undated Daily Care Guide revealed TRANSFER MARISSA LIFT X 2 ASSIST . RI #8's Resident Incident Report dated 06/25/2015 at 2:40 PM, documented, . Narrative incident and description of injuries: This nurse called to room per CNA. Resident noted on floor in supine position with blood noted under right leg. CNA in room stated while attempting to transfer resident, resident's weight shifted and (resident) was lowered to the floor (going down on right knee) . Laceration noted to right knee. 15cmlong (centimeters long) x (by) 0.3 cm wide. left right thigh noted. Right thumb and 5th finger noted with bruising and swelling . Head to toe assessment. Assessed for pain, Lift sheet placed under resident and resident placed in bed per (by) staff x 4. Pressure dressing to right knee, steri strips to left arm, PRN (as needed) pain med (medication) administered. MD and Responsible party notified. Transferred to ER (emergency room ) for further evaluation . RI #8's DISCHARGE SUMMARY from the local ER indicated RI #8 arrived at the emergency roiagnom on [DATE] at 4:13 PM with a chief complaint of Fall; Wound/laceration to right knee . An ER document indicated RI #8's wound was closed with eight staples. On 07/29/2015 at 10:00 AM, a phone interview was conducted with EI #1, the CNA who attempted to transfer RI #8 on 6/25/15. EI #1 was asked to describe the incident that occurred on 06/25/2015. EI #1 stated, I transferred RI #8 from the Geri chair to the bed, as I went to lift RI #8 up RI #8's body went down and leg buckled up under (her/him). EI #1 further stated, she could not hold RI #8 anymore and eased RI #8 down to the floor. EI #1 was asked, how did she know if a resident was a one-person or two-person assist for transfer. EI #1 said, look at the pocket care guide which was located at the nurses' station in a folder. EI #1 was asked, what was the purpose of the pocket care guide. EI #1 said, it told the staff how to care for the resident. EI #1 was asked, did she know RI #8 was a two-person assist with a Marisa lift. EI #1 said, yes. When asked if she followed RI #8's care plan, EI #1 said no. EI #1 was asked what was the harm of not following the care plan and pocket care guides for RI #8. EI #1 said, accidents happen. When asked if this accident could have been avoided, EI #1 said yes. On 07/29/2015 at 10:45 AM, and interview was conducted with EI #2, a Licensed Practical Nurse (LPN). EI #2 was asked to describe the incident that occurred on 06/25/2015 regarding RI #8. EI #2 said, she was called to RI #8's room and noted resident on the floor. According to EI #2, EI #1 told her she was transferring RI #8 back to bed, RI #8 started to go down, so she (EI #1) lowered RI #8 down to the floor. When asked, how was RI #8 to be transferred, EI #2 stated RI #8 was a two-person assist transfer with a lift. On 07/29/2015 at 3:55 PM, EI #3, the Registered Nurse (RN) Unit Manager, was asked how did a CNA know the type of assistance a resident required. EI #3 said the pocket care guide at the nurses station provided this information. After looking at RI #8's care plan, EI #3 acknowledged RI #8 was to be transferred by two people. On 07/29/2015 at 4:20 PM, an interview was conducted with EI #4, the Director of Nurses (DON) was asked what did RI #8's care plan say regarding transfer. EI #4 said, Two person assist with Marisa lift. This deficiency was cited as a result of the investigation of complaint/report number AL 672.

Based on interviews, record review and document review, the facility failed to ensure Resident Identifier (RI) #8 was transferred by two people with a Marisa lift on 06/25/2015. According to RI #8's Incident Report, Employee Identifier (EI) #1, a Certified Nursing Assistant (CNA) transferred the resident without any assistance. EI #1 stated during the transfer, RI #8's weight shifted and the CNA was unable to hold RI #8. As a result of this fall, RI #8 sustained a laceration to the right knee, which measured 15 centimeters (cm) long and 0.3 cm wide; swelling to the left forearm; a knot with bruising to the left thigh; a bruise to the right thigh with bruising and swelling to the right thumb and 5th finger. The physician was notified and gave orders to transfer the resident to the emergency room (ER) for further evaluation. According to the ER record, RI #8 required eight staples to close the laceration to the resident's right knee. This affected RI #8, one of three sampled residents reviewed for falls. Finding include: The facility's undated policy titled, SUBJECT: ACCIDENT & INCIDENT DOCUMENTATION & INVESTIGATION revealed Policy: . An incident is defined as an occurrence which is not consistent with the routine operation of the facility or the routine care of a particular resident . The facility's undated document titled, In Service Monthly. Instructor's Guide, Fall Prevention, Purpose of the Inservice The purpose of this inservice is to describe the actions a nurse aide should take to help prevent falls among nursing home residents. Introduction .The resident's care plan will tell you what actions you as a nurse aide need to take in order to help prevent falls while providing daily care . Student Program Guide Fall Prevention.Examples of devices that help prevent falls: 1. Gait belt and special transferring equipment . RI #8 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. RI #8's at risk for falls care plan, with a problem onset date of 02/25/2015, included an approach of . * 2 person assist transfer with marisa lift . RI #8's Annual Minimum Data Set with an assessment reference date of 05/25/2015 revealed RI #8 was totally dependent on staff for transfers. RI #8's Resident Incident Report dated 06/25/2015 at 2:40 PM revealed: . Narrative incident and description of injuries: This nurse called to room per CNA. Resident noted on floor in supine position with blood noted under right leg. CNA in room stated while attempting to transfer resident, resident's weight shifted and (resident) was lowered to the floor (going down on right knee) . Laceration noted to right knee. 15cmlong (centimeters long) x (by) 0.3 cm wide. left right thigh noted. Right thumb and 5th finger noted with bruising and swelling . Head to toe assessment. Assessed for pain, Lift sheet placed under resident and resident placed in bed per (by) staff x 4. Pressure dressing to right knee, steri strips to left arm, PRN (as needed) pain med (medication) administered. MD and Responsible party notified. Transferred to ER (emergency room ) for further evaluation . RI #8's DISCHARGE SUMMARY from the local ER indicated RI #8 arrived at the emergency roiagnom on [DATE] at 4:13 PM with a chief complaint of Fall; Wound/laceration to right knee . An ER document indicated RI #8's wound was closed with eight staples. On 07/29/2015 at 10:00 AM, a phone interview was conducted with EI #1, the CNA who attempted to transfer RI #8 on 06/25/2015. EI #1 was asked to describe the incident that occurred on 06/25/2015. EI #1 stated, I transferred RI #8 from the Geri chair to the bed, as I went to lift RI #8 up RI #8's body went down and leg buckled up under (her/him). EI #1 further stated, she could not hold RI #8 anymore and eased RI #8 down to the floor. EI #1 was asked, how did she know if a resident was a one-person or two-person assist for transfer. EI #1 said, look at the pocket care guide which was located at the nurses' station in a folder. EI #1 was asked, what was the purpose of the pocket care guide. EI #1 said, it told the staff how to care for the resident. EI #1 was asked, did she know RI #8 was a two-person assist with a Marisa lift. EI #1 said, yes. When asked if she followed RI #8's care plan, EI #1 said no. EI #1 was asked what was the harm of not following the care plan and pocket care guides for RI #8. EI #1 said, accidents happen. When asked if this accident could have been avoided, EI #1 said yes. On 07/29/15 at 10:45 AM, and interview was conducted with EI #2, a Licensed Practical Nurse (LPN). EI #2 was asked to describe the incident that occurred on 06/25/2015 regarding RI #8. EI #2 said, she was called to RI #8's room and noted resident on the floor. According to EI #2, EI #1 told her she was transferring RI #8 back to bed, RI #8 started to go down, so she (EI #1) lowered RI #8 down to the floor. When asked, how was RI #8 to be transferred, EI #2 stated RI #8 was a two-person assist transfer with a lift. This deficiency was cited as a result of the investigation of complaint/report number AL 672.

Based on observation, interview and record review, the facility failed to ensure Resident Identifier (RI) #4 did not sustain a fall with head injury, requiring more than first aid treatment, by leaving her unsupervised and out of view of staff. RI #4 was identified as high risk for falls and had one on one supervision at the time she was left unattended in her room. RI #4 sustained a hematoma to the left side of her face and forehead which resulted in the resident being sent out to the hospital for further evaluation. The facility also failed to attempt to determine causal factors for the two non injurious falls RI #4 had prior to the fall with injury. Findings include: The facility's document for "Accident & Incident Documentation & Investigation, date P & P 1/12" was provided. The Policy included, ... "Accidents and incidents will be analyzed for trends or patterns to enable the facility to enhance preventive measures to reduce the occurrence of incidents... . If an incident occurs then the interventions should be tailored to fit the underlying cause." RI #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the facility's "Fall: Morse Fall Scale" form, dated 9/20/13, revealed RI #4 was assessed for fall risk. The first (9/20/13) and second (9/25/13) evaluations both assessed RI #4 as high risk. The action indicated to "implement high risk fall prevention interventions." Review of the facility's Instant Care Plan, date 9/20/2013 "Risk" checked and "Fall/Trauma" checked and written in "Found on floor 9/25/13" Fall precaution was checked and "Circle: Bed/chair alarm..." (chair alarm circled date 9/25/13). A review of RI #4's Admission Minimum (MDS) data set [DATE] revealed RI #4's Brief Interview for Mental Status score of 5, indicating severe impairment in cognition. The MDS documented RI #4 required extensive assistance with bed mobility, transfer, walk in corridor, locomotion on and off the unit, and toileting. The MDS also documented RI #4's balance with walking; with turning around while walking; with moving on and off toilet; and surface to surface transfer was not steady and only able to stabilize with staff assistance. The MDS also revealed RI #4 had a history of [REDACTED]. A review of RI #4's care plan with a problem onset date of 09/25/13 revealed the following: "...Risk for additional falls, resident constantly gets up out of w/c (wheelchair) thinking she can walk ..." . Planned approaches included: Path free of clutter, Chair alarm when up in wheelchair, bed in low position and call light in reach. A review of the facility's Resident Incident Reports revealed the following: "... 9/25/13 08:30 AM ... Narrative of incident and description of injuries: Upon entering room resident assessed sitting on her buttocks on the floor in front of the dresser, ROM (range of motion) to upper and lower extremities without difficulty, without any injuries or bruises assessed. ... Activity at time: From chair w/o (without) asst (assistant) ...Immediate Post-Incident Action: Chair alarm applied ..." A review of the facility's Resident Incident Reports revealed the following: "... 10/05/13 07:00 PM ... Narrative of incident and description of injuries: Resident was sitting at desk in wheelchair and was occupied with a puzzle. Chair alarm in place and functional. Chair alarm activated and resident standing beside wheelchair. Unable to reach resident prior to falling on her right hip and shoulder. Resident did not hit her head when she fell . ROM performed without difficulty. Resident assisted off the floor and made comfortable in wheelchair, chair alarm in place. Denies pain or discomfort. no injuries noted ... Activity at time: From chair w/o asst ... Immediate Post-Incident Action: Location checks Q (every) 30 minutes ..." A review of the facility's Resident Incident Reports revealed the following: "...10/06/13 02:20 PM ... Narrative of incident and description of injuries: CNA (Certified Nursing Assistant) notified RN (Registered Nurse) that resident was on the floor, alarm sounding. Resident assessed for injuries, hematoma noted to left eyebrow. Resident assisted off the floor and made comfortable in bed. ROM done to upper and lower extremities, tolerated well. Hematoma above left eyebrow ... Activity at time: From chair w/o asst ... Immediate Post-Incident Action Therapy to assesss (assess) for lap buddy Immediate Actions Taken: Assessed injuries, assisted off the floor and made comfortable in bed, x-rays ordered and sent to emergency room for evaluation due to x-rays being inconclusive." The facility submitted a copy of the EMS Transport Report for the the transfer to the hospital on [DATE] which documented the "Chief Complaint: Fall with Head and Hip Injury". A review of the facility's interview with EI #5 (the CNA) revealed the following: "On 10/6/13 at 1:30 PM I went in (RI #2's) room to get her up and the sitter (staff member) came in the room and asked me to change her (RI #4). I told her I would be with her as soon as I got through with (RI #2). She brought (RI #4) into the room and left. I pulled the privacy curtain and continued doing (RI #2) and me and (RI #2) heard a noise alarm sounding and I pulled the curtain back and (RI #4) was on the floor. I went and got the RN ..." On 10/8/13 at 9:15 AM, RI #4 was observed lying in bed with her breakfast tray in front of her on the over bed table. The resident had a large bruise to the left eye, side of eye and forehead above the eye. When asked how she hurt her eye, her roommate RI #2 spoke up and said RI #4 had only been in the facility a couple of weeks and had frequent falls. The hurt face happened over the previous weekend. The roommate also said the resident had sitters but she did not have them anymore. On 10/10/13 at 10:30 AM, the Administrator, Director of Nursing and the Clinical Operation Nurse were located in the Administrator's office. The Administrator was asked if they had a policy to address high risk fall preventions - per the fall risk form. The Clinical Operation Nurse spoke out and said they assess for causal factors of the falls and develop interventions from the causal factors. On 10/10/13 at 1:45 PM, EI #5, Certified Nursing Assistant (CNA) was interviewed. She was asked to explain what happened the day RI #4 sustained the injury to her face. EI #5 said that day after lunch, RI #2, RI #4's roommate, wanted to get up so she went in the room to provide care. EI #5 said the curtain was pulled and the sitter for RI #4, a staff member, knocked on the door and said it was time to check RI #4. EI #5 said she told the other staff okay and she then pushed the resident in the room and closed the door. EI #5 said the curtains were closed and 2-3 minutes later she heard the alarm. She stopped with RI #2 and went to RI #4. EI #5 said the resident was on the floor and she (CNA) went to the door and hollered for help. EI #5 said she did not see an injury at that time because the resident had hit the floor on her head and the left side of her face was on the floor. EI #5 said a CNA and the nurse came in and the nurse assessed the resident and the resident answered the nurse and was alert. The nurse and CNA placed RI #4 back in the chair and they then took the resident to toilet. EI #5 said staff toileted the resident and she would hold her urine until she was taken to the toilet. On 10/10/13 at 3:00 PM, EI #11, CNA who sat with RI #4, was interviewed. She was asked when she began sitting 1on 1 with RI #4 and for how long. She replied at 8:00 AM on 10/5/13 from 8:00 AM until 2:00 PM. EI #11 was asked why was she assigned one on one with RI #4. She said because the resident was getting up and down unassisted and needed someone to watch her. EI #11 was asked to explain what happened with the fall. EI #11 said she took the resident back to her room so the other CNA could dry the resident and she (EI #11) was going to lunch at 2:00 PM. She said the other CNA was going to check and clean the resident. EI #11 said she was going to the hall to work the 3-11 shift at 2:30 - 10:30 PM. EI #11 said they could not leave the resident unless they had someone to cover for them and EI #5 told her to bring the resident to her and she would change her and watch her while EI #11 went to lunch. EI #11 said RI #4 required 1 person toileting assist. The CNA said EI #5 was in the resident's room when she returned to the room and told her to go on to lunch and she was there with the resident. On 10/10/13 at 4:47 PM, EI #4, LPN was interviewed regarding the 10/05/13 fall RI #4 sustained. He was asked based on what happened, did he determine what was the cause of the fall. He said he did not know. He was asked did he ask the resident. EI #4 said no. On 10/10/13 at 5:30 PM, EI #12, LPN was interviewed regarding the observation of RI #4 on the floor in her room on 09/25/13. EI #12 was asked if she asked the resident why she was trying to get up out of bed. EI #12 said when she saw the resident she was getting up and down, up and down. The LPN was asked did she ask the resident why she was trying to get up. EI #12 said she did not ask the resident any questions.